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[Literature Review: Cardiac Care]
American Journal of Physical Medicine & Rehabilitation
Issue: Volume 79(3), May/June 2000, pp 292-297
Copyright: 2000 Lippincott Williams & Wilkins, Inc.
Publication Type: [Literature Review: Cardiac Care]
ISSN: 0894-9115
Accession: 00002060-200005000-00012
Keywords: Implantable Cardioverter Defibrillator, Exercise Testing
Prescribing Exercise Training for Patients with Defibrillators
Lampman, Richard M. PhD; Knight, Bradley P. MD
Author Information
From the Department of Surgery (RML), St. Joseph Mercy Hospital; the Department of Physical Medicine and Rehabilitation (RML), Cardiac Electrophysiology
Laboratory (BPK), and the Division of Cardiology (BPK), Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan.
Reprints: All correspondence and requests for reprints should be addressed to: Richard M. Lampman, PhD, St. Joseph Mercy Hospital, Department of Surgery, 5333
McAuley Drive, Suite RHB#2111, Ann Arbor, MI 48106.
Disclosures: Performed at St. Joseph Mercy Hospital and the University of Michigan Medical School, Ann Arbor, Michigan.
ABSTRACT

Patients with an implantable cardioverter defibrillator (ICD) often refrain from physical exercise for fear of
precipitating a life-threatening arrhythmia or receiving an ICD shock. However, most of these patients are able to
safely exercise if they are provided appropriate clinical guidelines. This review describes the factors that enter
into the development of an exercise program for patients with an ICD.


Routine exercise training has many physical and mental health benefits and can usually be safely enjoyed by
most patient populations.1 Patients with an implantable cardioverter defibrillator (ICD) would benefit from
exercising but often are apprehensive and avoid even mild physical activity for fear of triggering an arrhythmic
event, which could result in syncope and/or an ICD shock. It has been reported that 63% of young ICD recipients
studied worried about engaging in exercise.2

Data supporting the effectiveness of ICD therapy for sudden death prevention have greatly increased the use
of these devices.3-5 However, little is known regarding exercise therapy in this unique patient population. Only a
few case reports exist regarding exercise training in patients with an ICD who are undergoing cardiac
rehabilitation.6, 7 The purpose of this article is to outline a clinical approach for helping patients with an ICD to
begin systematically and to maintain an individualized exercise program that minimizes the risks and maximizes the
health benefits of routine exercise. Issues specific to ICD function and to patients with structural heart disease
must be considered.

Usual Cautionary Advice and Benefits of Routine Exercise

Restrictions for patients with ICD on exercise are usually general rather than specific. Patients are restricted
from heavy lifting or ipsilateral arm raising above the head for 6 wk after the procedure to avoid lead
dislodgement. After this period, patients should be encouraged to be physically active. Patients are often
cautioned to limit their activities and to follow guidelines suggested by their physicians curtailing activity if any of
the following symptoms occur: shortness of breath, lightheadedness, chest pain, etc. Competitive athletics are
not usually recommended and may be contraindicated in the case of high-intensity competitive and/or contact
sports. Although these are reasonable cautionary measures, they tend to restrict physical activity rather than to
encourage safe, routine exercise. Routine exercise training when medically advised establishes realistic goals and
optimal training protocols to help ensure patient safety.

A routine exercise program will enhance the ability of each patient with an ICD to perform activities of daily
living, participate in recreational activities, and in some cases, engage in competitive sports. The medical benefits
for these patients include the following: reduced risk factors for cardiovascular disease, reduced fatigue,
improved endurance, increased muscular strength, enhanced sense of well-being, and reduced perceived stress.
It is important that physicians show concern and compassion for the patient's special needs and concerns,
emphasize the benefits of routine exercise, and provide reassurance that routine exercise can be safely
performed when done appropriately.

Review of ICD Function

An exercise physiologist or physical therapist should have a fundamental understanding of ICD function.
Implantable defibrillators have been designed to reliably terminate ventricular tachyarrhythmias by delivering a
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Implantable defibrillators have been designed to reliably terminate ventricular tachyarrhythmias by delivering a
shock to the heart. However, current ICD models can be programmed to deliver a burst of rapid pacing (anti-
tachycardia pacing) during ventricular tachycardia. This pacing technique can only be used to terminate
relatively slow ventricular tachycardias but can also avoid the need for a painful shock. Current ICDs also provide
back-up bradycardia pacing.

Heart rate remains the primary method of tachycardia detection. The ICD diagnoses ventricular
tachyarrhythmias when the heart rate exceeds a programmable "cut-off" rate and then delivers therapy. The cut-
off rate is selected on an individual basis, depending on the slowest ventricular tachycardia. The exercise
physiologist or physical therapist should know the programmed device's cut-off rate for each patient participating
in an exercise training program. A problem arises when a nonlife-threatening tachycardia, such as sinus
tachycardia or atrial fibrillation, with a rapid ventricular rate exceeds the cut-off rate of the ICD, and the patient
receives unnecessary therapy. Current devices have sophisticated algorithms used to distinguish sinus tachycardia
from ventricular tachycardia based on its gradual onset or atrial fibrillation from ventricular tachycardia based on
its irregularity. However, inappropriate therapy continues to be a common problem for ICD recipients.

Patient Evaluation

Determination of Underlying Cardiac Function. The presence and severity of underlying heart disease have
an impact on exercise prescriptions and on the expectations regarding improvement in health and well-being.
Therefore, it is important to determine the baseline functional status and severity of ventricular dysfunction
before prescribing an exercise program. Implantable defibrillator recipients are a heterogeneous group. A
majority of patients with ventricular tachyarrhythmias has left ventricular dysfunction. A recent multicenter trial,
the Antiarrhythmic versus Implantable Defibrillators (AVID) study, included 500 patients treated with an ICD.5
Patients studied had a mean age of 65 yr and were mostly men (78%) with coronary artery disease (81%). The mean
left ventricular ejection fraction was 0.32, and one-half of the patients had symptomatic congestive heart failure.
Noncoronary causes of ventricular dysfunction among ICD recipients include nonischemic dilated cardiomyopathy,
hypertrophic cardiomyopathy, valvular disease, and congenital heart disease.

Patients with significant structural heart disease are usually limited to lower intensity physical activities.
Furthermore, patients with certain types of heart disease should be restricted from strenuous exertion. These
include right ventricular dysplasia, hypertrophic cardiomyopathy with obstruction, and severe pulmonary
hypertension. In contrast, a few patients with ICD have no identifiable structural heart disease. These patients
have primary rhythm abnormalities, such as long Q-T syndrome and primary ventricular fibrillation. Patients with
normal left ventricular function would be expected to have an exercise tolerance typical of the normal
population. However, some of these arrhythmias are catecholamine-dependent and can be triggered with
exercise. Therefore, consultation with the patient's electrophysiologist is important before prescribing an
exercise program for these patients.

Some patients with an ICD may wish to participate in competitive sports. The 26th Bethesda Conference in
1994 provided guidelines regarding eligibility for competition in athletes with cardiovascular abnormalities.8 The
guidelines state that ICD recipients with or without structural heart disease should not participate in moderate or
high-intensity competitive athletics. Low-intensity competitive sports that do not constitute a significant risk of
trauma to the defibrillator are permissible if 6 mo have passed since the last ventricular arrhythmia requiring
intervention.

Baseline Physiologic Testing. Patients with an ICD should undergo a standard graded exercise tolerance test
9-13 before starting an exercise program. The exercise test provides physiologic parameters for appropriately
devising an individual exercise program, can detect exercise-induced arrhythmias, and can provide reassurance to
the patient that exercise is safe.14, 15 A standardized exercise testing protocol should be followed during
baseline testing, using either a motor driven treadmill or cycle ergometer.9-13 Good clinical judgment should be
used in deciding an appropriate test according to a patient's ability and limitations. Ideally, the test chosen
should be one that elicits a maximum cardiorespiratory (maximum heart rate) response before a patient is limited
by peripheral skeletal muscle fatigue. The protocol by Bruce et al.10 has been used in many published reports, is
brief, and has normative values published for heart rate, blood pressures, and oxygen uptake ([latin capital V with
dot above]O
2
). Other well-established tests are available,9-13 and Pollack 11 reported a comparative analysis of
four different maximal exercise testing protocols for serial and maximal heart rate, [latin capital V with dot
above]O
2
, and ECG determinations. Ramping protocols have recently gained popularity for overcoming limitations
of multistage exercise tests.12 Although pharmacologic stress tests, such as a dobutamine echocardiogram or an
adenosine thallium test, are useful for the noninvasive detection of coronary artery disease, they do not provide
the appropriate hemodynamic parameters for use in prescribing an individualized exercise prescription.9, 13-16
Measured maximum oxygen uptake ([latin capital V with dot above]O
2 max
) is the best objective measure of the
functional capacity among patients with heart disease and provides useful information for the exercise
physiologist or physical therapist. Oxygen uptake can be estimated from the exercise hemodynamic data or
external workload achieved.

The tachycardia rate cut-off point and the sequence of therapies of the ICD should be recorded, and the
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The tachycardia rate cut-off point and the sequence of therapies of the ICD should be recorded, and the
patient's electrophysiologist should be notified before starting an exercise test in a patient with an ICD. If the
cut-off rate is below the age-predicted maximum heart rate, then the ICD should be programmed off during the
exercise test so that the patient can exercise to his or her fullest capacity without being at risk for
inappropriate shocks.17

Defibrillator therapy can be programmed off either by using a special programmer or by the application of a
doughnut magnet over the device. Deactivating the ICD with a programmer, if one is available, is the preferred
deactivation method before an exercise test for two reasons. First, many defibrillators are only temporarily
deactivated when a magnet is applied. Therefore, the magnet would need to be taped over the device while
patient is exercising to assure that inappropriate therapies are not given for sinus tachycardia. This would be
cumbersome and might interfere with the exercise test results. Second, the programmer allows the defibrillator
to be programmed to a special mode, referred to as a "monitor-only" mode, by which tachycardia therapy will not
be delivered but tachycardia detection is still programmed on. In this mode, the device will acquire data during
exercise, such as the rate of onset of the tachycardia, which can be used later if programming algorithms are
needed to discriminate ventricular tachycardia from sinus tachycardia.

It is important to remember that the usual resuscitation equipment must be available during an exercise test
in a patient who has the ICD temporarily programmed off in the event that external defibrillation is needed. If the
patient exercises to maximum capacity and the heart rate does not exceed the cut-off rate of the ICD, then the
patient can be reassured that similar levels of exertion at home will not result in inappropriate shocks. Further
assurance that ICD recipients can exercise safely and routinely can be obtained from ICD support groups.18

If a patient unexpectedly exceeds the cut-off rate during an exercise test while the device is active, the
patient might receive inappropriate shocks. If this were to occur, the heart rate should fall below the cut-off
rate when exercise is stopped. However, if shocks continue to be delivered and are confirmed to be
inappropriate, therapy from the device should be suspended. This can be accomplished by applying a magnet over
the device, which suspends therapy after approximately 30 sec. If the cut-off rate is exceeded, the options for
the electrophysiologist include programming discriminating detection algorithms, starting a medication to reduce
the maximum heart rate, or limiting exercise.

If a patient receives a shock during exercise training in an unmonitored environment, the patient should
contact his or her electrophysiologist to arrange for interrogation of the ICD to confirm that the shocks were
appropriate and to re-evaluate the exercise prescription. The delivery of multiple shocks should be treated as an
emergency.

Medications. Patients with an ICD are frequently treated with multiple cardiac medications. For this reason,
these patients should be both tested and trained on their current pharmacologic agents and they should be both
tested and trained at the same time each day. Many are prescribed a [beta]-adrenergic receptor antagonist for
ventricular rate control during atrial fibrillation, hypertension, long Q-T syndrome, arrhythmia prophylaxis, and/or
angina. Whether placed on a nonselective [beta]-blocker or a [beta]
1
-selective or one that possess intrinsic
sympathomimetic activity,19-22 these drugs should not adversely affect the response to acute exercise 23-25 or
to physical training, even if a patient desires to be a competitive athlete.26 Because [beta]-blocking drugs
decrease resting heart rate and maximal exercise heart rate, myocardial contractility, and blood pressure, these
drugs have a major influence on an exercise prescription when it is based on an exercise heart rate response and
should not be withheld when the patient undergoes an exercise stress test. [beta]-Blockers with
sympathomimetic activity have more of an effect on exercise heart rate than on resting heart rate but may
influence an exercise prescription if cardiac reserve is used in formulating the exercise prescription. Also,
because [beta]-blockers may vary in their pharmacologic effects during the day, it is optimal for exercise sessions
to take place at a regular time of day and similar to the time that the standard exercise test was administered.27

Amiodarone hydrochloride is a commonly prescribed antiarrhythmic drug for patients with an ICD to reduce
the number of appropriate ICD therapies and inappropriate therapies for atrial fibrillation. This drug has been
shown to improve significantly the exercise time during standard exercise testing in patients with congestive
heart failure,28 to increase left ventricular ejection fraction, and to improve exercise capacity.29

Verapamil, diltiazem, sotalol, amiodarone, and many antiarrhythmic agents influence resting and exercise
heart rates and must be considered when devising a patient's individualized exercise prescription.30 Because the
physiologic response to acute exercise is complex, involving many organ systems, these medications may have
metabolic or physiologic effects that may limit endurance time while performing moderate- to high-intensity
physical activities. Patients prescribed diuretics should not exercise in conditions of extreme heat and should be
checked periodically for hypokalemia, which may provoke arrhythmias, if significant increases in the frequency,
intensity, or time of exercise are made.

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Elements and Components of an Exercise Prescription

Mode of Activity. Body positioning during exercise is an important consideration for some patients, especially
for those with compromised cardiac function. Stroke volume and end-diastolic volume change little from rest in a
normal person during supine exercise. During upright exercise, both parameters increase and plateau within 3-5
min. In a patient with cardiac dysfunction, left ventricular filling pressure tends to increase more during supine
exercise compared with upright exercise. In patients with angina, supine cycling, compared with the same
identical submaximal work in the upright position, results in a higher heart rate and angina develops at a lower
rate pressure product for a given amount of work; the ST segment depression may be greater because of the
greater left ventricle volume.9 Therefore, if a patient has a history of ventricular arrhythmias provoked by
ischemia or heart failure exacerbations, it is recommended that upright exercise training (walking, biking, stair
climbing) exercises be performed rather than prolonged supine activities (recumbent cycling, swimming). Those
patients with preserved ventricular function should be able to participate in most physical activities.

Warm-Up and Cooldown. The pre- and postexercise periods are important times to warm-up thoroughly and
to cooldown appropriately. A warm-up period of easy physical activity for 3-5 min allows for proper cardiovascular
adjustments, may minimize the risk for exercise-induced cardiovascular complications (ischemia, arrhythmias), and
reduces a patient's perception of fatigue. Also, during the postexercise period, a mild cooldown period may
eliminate the potential for ischemic or arrhythmic responses and allows the cardiovascular system to more slowly
return to normal resting conditions.

Frequency, Intensity, and Time. Three intensity levels of aerobic exercise have been proposed (Table 1)
when initially prescribing exercise for patients and are based on the patient's clinical status and initial physical
fitness level.1 Participation at each level can improve health and functional capacity. Levels I, II, and III are
classified, respectively, as follows: adjuvant health training (a low level of effort intensity used to assist medical
treatment); health training/recreation (a moderate level of effort intensity used to improve health risk factors
and to participate in recreational activities); and fitness training/sports (a fairly high intensity of effort necessary
for competitive sports-a patient with an ICD and free of significant heart disease may stay with 70-80% of maximum
heart rate and participate in low-intensity competitive sports).

TABLE 1 Exercise training levels (modified from Lampman
1
)
If percent heart rate reserve is used in determining an appropriate exercise training heart rate in patients
not having ischemia or significant arrhythmias, 50-75% of heart rate reserve added to the resting heart rate
([maximum heart rate - resting heart rate] 50% - 75% + resting heart rate) has been purposed.9 Recent work
suggests that it cannot be assumed that percent heart rate reserve provides equivalent intensities to %[latin
capital V with dot above]O
2 max
but that percent heart rate reserve is an indicator of a percentage of the
difference between resting and [latin capital V with dot above]O
2 max
.31, 32 Anaerobic threshold measures,
obtained either by determining this value by expired gas analysis 33 or by estimating it using double product,34
may also prove valuable in determining an appropriate exercise training intensity.

Patients can graduate from the less vigorous to the most strenuous levels as they progress or stay at a level
that is safe and appropriate, depending on their medical status. The optimal length of time for each exercise
session is from 20 to 30 min but may be as long as an hour.

ECG Monitoring

Patients with normal cardiac function and no history of exercise-induced arrhythmias should be able to
follow the exercise prescription without ECG monitoring but may consider initially to undergo a monitored
cardiac rehabilitation program to assure safety and freedom from inappropriate shocks during exercise. Those
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cardiac rehabilitation program to assure safety and freedom from inappropriate shocks during exercise. Those
with left ventricular dysfunction should be treated as any other cardiac patient going through Phase I and II
cardiac rehabilitation.35 ECG monitoring during exercise, although important for detecting arrhythmias, also helps
a patient to develop a sense of perceived exertion (the patient's perception of the difficulty of the activity) and
may be beneficial in building a patient's confidence in their ability to exercise safely. A Holter monitor may be
worn by a patient when first engaging in more vigorous activities because conditions may differ from those during
a standardized progressive exercise tolerance test, resulting in altered hemodynamic and electrophysiologic
responses. For those wishing to electronically monitor their heart rate response to exercise, accurate heart rate
monitoring devices (Polar Vantage NV) are commercially available. Such a device can provide a constant monitor
of heart rate responses during an entire exercise session. In the absence of such a device, patients should be
taught to palpate their peripheral pulse to determine if they are achieving and staying within their target heart
rate.

Assessing a Patient's Progress

Unless signs and symptoms are present, patients without structural heart disease and those with
compromised cardiac function usually can be followed through routine clinical visits. At these visits, the physician
can discuss how and whether the patient's exercise prescription needs to be revised and whether additional
electrophysiologic or exercise stress testing is necessary. It is usually beneficial to initially contact patients via
phone calls the first few weeks or months to discuss any medical concerns and to offer encouragement to help
patients adhere to their exercise programs.

CONCLUSIONS

Physicians caring for patients with an ICD for control of life-threatening arrhythmias have a unique
opportunity to encourage and direct exercise through an individualized exercise prescription. The individualized
exercise prescription must be tailored based on knowledge of the presence and severity of the underlying heart
disease and the programmed heart rate at which ICD therapy is delivered. It is clear that more research is
necessary in the area of exercise testing and training for patients with an ICD. We are presently conducting
clinical research to determine the safety and objective benefits of exercise in patients with a defibrillator.

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Key Words: Implantable Cardioverter Defibrillator; Exercise Testing


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