Heart Failure and Starting Strength/Barbell Prescription

[blakegoodman]

Hey Mr. Rippetoe, I originally posted this over on the Starting Strength Staff Coaches Q&A and it was suggested by Mr. Hill that I post it here instead. I know you've said you like working with Master's level trainers, and your input would be greatly appreciated. I was also hoping to maybe get the attention of Dr. Sullivan or any of the other docs you've worked with as well if at all possible. I've tidied up a few things, but otherwise the post is the same as the SSC Q&A post.

I'm posting to talk to anyone who has experience working with people diagnosed with heart failure. A little background: I'm posting about my father, age 57.5, who used to be an amateur power lifter from about age 17 to 30, but quit due to us ingrate kids and work. The only number I remember him talking about was benching 425lbs at a weight of around 200-210lbs, but he used to squat and deadlift pretty heavy too. I'm an emergency medicine physician about to graduate residency, so know something about acute disease processes but am out of my depth on long-term care.

My dad was diagnosed with atrial fibrillation back on the the 9th of this month, and his ECHO that day showed LVEF ~30% and the perfusion/stress showed diminished perfusion to the inferior heart wall. We had a wedding that weekend, so my dad's cardiologist and I opted for outpatient rate control with carvedilol and amiodarone, but his symptoms continued to worsen, and he was admitted 3/12 with a-fib in rapid ventricular response. They diuresed about 8lbs off him and did a heart cath, which showed 80% stenosis to the LAD and LVEF 25%, a drug-eluting stent was placed with near complete reperfusion. He converted out of a-fib into sinus at that time but brady'd down and got hypotensive, but came out after a few minutes, and has since been feeling mostly better. Still on Coreg and amiodarone, and currently in the process of getting evaluated for "cardiac rehab" at a decent local healthplex.

His medical history is thus: hypertensive, diabetic, hypercholesterolemia, due to a combination of genetics, high-stress work, and for years eating like he was still a lifter despite not lifting. He was diagnosed around 35 and kinda-sorta followed his prescribed medical regimen, but really only started taking things seriously in the last 5 years. As far as his new-onset heart failure (orthopnea, dyspnea on exertion, palpitations, etc), it sounds like we've pinned down the severe worsening to sometime between Feb 14 and Feb 21, but he had some shortness of breath, palpitations, and exercise intolerance going back about 4 months, although he was still walking several miles or biking ~10 miles every couple of days up until mid-February.

I'll be honest. My dad was the one who got me into lifting, and even though I stopped for a long time, I'm back into it thanks to Starting Strength and everyone involved here. I'm a believer, I think this stuff works, and I think it could help my dad. I've asked hospitalists around my workplace and they seem to think that he could rehab his heart function a decent amount, especially considering the relatively acute onset. I'm looking for any guidance that y'all might have to offer regarding training, aside from the standard "What the cardiologist says is Word of God," which is obviously true **wink wink nudge nudge**. He does seem to have a good team of doctors, so I really don't think that's an issue. My dad wants to lift weights again. I think it will be good for him. I was just hoping someone might be able to give us some place to start. Right now, I'm thinking that's an empty bar.

[Mark Rippetoe]

Dr. Sullivan has dealt with this topic in his Greysteel videos: YouTube But we'll ask him to comment.

[David Kirkham]

I am not Doc Sully or one of the other good Docs on this forum. You can take my comments for whatever...

I had a major heart attack 4 years ago and I lift hard regularly now and do light bike 15 minutes 3 X week. So, that is n1. (I understand that's not the same as heart failure).

For n2 I'll comment on my brother. I won't go into all the details and I'm just skimming the story here...but it may be relevant.

My brother called me quite sick one morning and I went to his house to see him. When I found him he was near death, as his diabetes had gotten away from him. He was admitted to the ICU with a 15% ejection fraction in cardiogenic shock, ketogenic shock, septic shock, and rhabdomylosis on top of everything else. I gave 4 DNR's that day, one to the cardiologist who simply looked at me and replied, "Good."

He was so weak he couldn't even turn over. They pulled 52 liters off of him over 18 days...52 liters. When he got some of his strength back we started with weights. At first I smuggled in 1 pound dumbells, but I knew he needed a bar. Knowing I couldn't smuggle in an Olympic length bar past security (he couldn't lift one anyway) I made him a 4 foot, 4 pound aluminum bar and then I smuggled it into the hospital. Every 2 days I smuggled in more weights, 2 pounds at at time. We lifted at night when there was less chance of nurses being around. We lifted and pressed around his monitors and wires--one day he got tangled and I told him, "Stay with it. Stay with it! STAY WITH IT!" He finished the mentally (not physically) challenging rep. Eventually I got him back home and we continued training. He lost a leg during that stay, but he is now independent and can transfer on his own in and out of his wheel chair. His ejection fraction is back to almost 40% now. The bar saved my brother.

As for your dad, I'd recommend an empty bar and LP with very judicious addition of weight. Finally, I'd recommend some light cardio to keep him feeling good along with weights. Rowing and bike are both concentric so it's easy on recovery. The bar builds your strength and cardio builds your spirit--combined they are sunshine to the soul. Finally, UP the protein and CUT the fat. Excess weight is the killer in heart failure.

[Jonathon Sullivan]

I'm assuming the OP is posting an entirely speculative scenario in the interests of academic discussion and also to pimp and befuddle Poor Old Dr. Sullivan. The following is offered in the same speculative, entirely hypothetical spirit, because what kind of idiot gives medical advice over the interwebz? Certainly not I.

It sounds like his decompensation was due primarily to ischemia and a-fib, both of which worked together to embarrass cardiac output and result in heart failure. With conversion to sinus and reperfusion of the LAD territory, his CO should be up and his failure substantively resolved. He should be cleared for exercise soon ("cardiac rehab"). I would let them do their precious cardiac rehab until, you know, Medicare won't pay for any more. It won't hurt him, it will help him get some exercise tolerance back, and most importantly it will be in a controlled environment. Once he's cleared for exercise on his own, he can start with the empty bar and go slowly. It would be best if, at the start, he lifted in the presence of a promising young EM physician who can check his pulse from time to time to insure he's not sliding back into an irregular rhythm or getting inappropriately diaphoretic and pale and...well, you know. Progress slowly and judiciously, especially at first, and be on the lookout for red flag symptoms. Give him only one completely sedentary day a week: he's either lifting or he's walking all six other days. He has to take his meds, obviously, and and make all of his followups. He needs to be patient and careful.

But yes. Resistance training has been studied in the setting of patients with chronic HF. It appears to be safe and beneficial. If he can lift weights, he should lift weights. It helps that he wants to.

This post is offered for ejumacational and infotainment purposes only and does not constitute medical advice for any particular person, patient, disease or condition. Sullydog is not your doctor, and he doesn't want to be your doctor, and in fact he's happy to report that for the last year he hasn't been anybody's doctor. He's just a coach now, so what could he possibly know about hearts and kidneys and all those other gross organs and diseases? Eww. Do what your doctor says. He went to med school and you didn't. Actually, I guess you did, but he still knows more...than you do. He's like...a God. Just ask him; he'll tell you.

[ERdocDD]

I wish I could stop seeing patients, and coach!
Your hypothetical sounds like good advice... hypothetically, of course!

Blake,
I had an MI in Jan- posted on this board. One stent, normal EF.
Started SS over with empty bar- was afraid of how the metoprolol would make me feel with heavy weights and valsalva.

Empty bar then Fast forward 3 months.
Squat = 255
Bench = 210
Press = 130
DL = 285

Not the best numbers, but I like to look at them and say “Not bad for a guy who just had a heart attack”

Listen to what the body wants and needs at first. Medications are probably the biggest rate limiter.

And yes, I always have it in the back of my mind that my heart will explode, or I will blow my stent out of my chest.
But time and experience will get me over those fears.

Good luck to your dad, and to you in your career! Make sure to limit stress where you can.

[blakegoodman]

Doc, thanks so much for the input in this academic and instructive, wholly hypothetical case. It's very encouraging to hear there's hope in such situations, as long as one stays disciplined. I'll be sure to keep this information in mind as I continue my medical training for the multitude of heart failure patients I will see, and apply it individually only when appropriate and in a monitored setting. Thanks for brightening my day. Now to finish this shift and hit the gym myself!

[David Kirkham]

Started SS over with empty bar- was afraid of how the metoprolol would make me feel with heavy weights and valsalva.

Metoprolol makes my head spin. I finally gave it up. I've almost passed out pressing several times. Standing up was crazy. Lisinopril isn't nearly as bad on me.

Empty bar then Fast forward 3 months.
Squat = 255
Bench = 210
Press = 130
DL = 285

Not the best numbers, but I like to look at them and say “Not bad for a guy who just had a heart attack”

Those numbers are damn impressive for anyone walking around post MI. I remember those numbers well--everyone does. Friday I will Squat 355, Press 205, and Dead lift 405. You can get reasonable numbers (I'm 51) even post MI. Just keep lifting. I D.O.N.T miss. Matt thought I was going to be a typical Gold's Gym member but I even trained on Christmas Day. I'm getting my money's worth out of Matt in SSOC! (Just kidding, he wants dedicated lifters and they push you to keep lifting). If you don't have a coach, call Matt and he will set up up with a great coach. Coach Graham is perfect for me.

I always have it in the back of my mind that my heart will explode, or I will blow my stent out of my chest.
But time and experience will get me over those fears.

It took me years to do a Jesus rep. I wish I would have faced those demons sooner. I Jesus rep all the time now with no worries. Though, admittedly, I have a VERY hard time seeing Jesus when I squat...it just scares the shit out of me. It's just the cards we have been dealt. Yes...it takes time.

Make sure to limit stress where you can.

I absolutely need to do better on this one.

[blakegoodman]

Thanks to everyone for the stories and advice, much appreciated. Can't wait to talk to my dad tomorrow. Shift ran long, residency duties are lame, yadda yadda.

As for the stress, weight training has been great therapy. Last fall was rough but finally got back into barbell training after almost 10 years, and while my numbers aren't great yet, I am so much happier in all other aspects of life, and I'm lifting more than I ever was to boot and still going up. I'll try to remember to post progress on my dad every once in a while for posterity.

[ERdocDD]

My MI anniversay is 1/11/19
My goal is to DL 405 by that date.

[LimieJosh]

But yes. Resistance training has been studied in the setting of patients with chronic HF. It appears to be safe and beneficial. If he can lift weights, he should lift weights. It helps that he wants to.

Systolic blood pressure rises acutely during isometric muscle actions. That provides a clinical problem to people with blockages significant enough than they need to keep their rate-pressure product down (essentially SBP), or who have compromised ability to generate force sufficient to eject blood in the face of increased preload (SBP). The reason that is relevant to us is that the SBP excursion is directly related to the % of maximum voluntary contraction of the isometric action. Essentially, the weaker your skeletal muscles are, the more your already compromised heart will be unable to cope with activities of daily living. You do not need to worry about hitting a 200lbs press, but doing enough so that you remove yourself from the ranks of being objectively weak is possibly the best thing a heart patient can do for their heart.