Get more exercise," the edict which Dr. Paul Dudley White presented to President Dwight D. Eisenhower only 13 weeks after his attack of coronary thrombosis, confused and alarmed a good many people. Actually, Dr. White was acting on a new and little publicized theory which is putting an end to the bleak years of invalidism formerly endured by heart attack victims. In the opinion of many specialists today, physical activity, at work or play, if properly supervised, is the best treatment after a heart attack.
This idea is directly contrary to generations of thought and practice, and some physicians are still prescribing the don't-move-a-muscle therapy. But more and more the doctors are convinced that, by carefully graduated exercise coronary patients can return to an active life (see box for recommended sports).
There are extraordinary examples of this as well as less spectacular ones. A 19-year-old high school athlete trained for the half-mile run after a heart attack and two years later won a national championship. A 43-year-old coronary piloted a plane as high as 15,000 feet about a year after his attack and then went on to take up skiing at 5,000 feet in St. Moritz and at 8,000 feet on the Zugspitze in Bavaria. These examples are exceptional, and not to be used as guides, but they do show that the heart is stronger than was once believed.
How much exercise and when will of course differ for every patient, depending on the extent of the damage to his heart and his rate of recovery. These are determined by the doctor's study of electrocardiograms, blood sedimentation rates and other tests.
But the one person who can decide whether the rate of exercise is being stepped up too rapidly is the patient, who will feel warning symptoms if the convalescent heart is overtaxed. These danger signals are fatigue, shortness of breath or a feeling of tightness in the chest. If any of these occur, he must immediately stop exercising, and rest. But doctors would encourage him to try again later.
In no sense a do-it-yourself program, the schedule of gradually increased physical effort starting a few days after the attack must be determined by the physician every step of the way. In general, a person with small to moderate heart damage can expect to follow roughly the schedule in the chart on page 46, which was compiled from the opinions of leading heart authorities throughout the country.
Today, even during the first weeks when he may not be permitted to sit up in his hospital bed, the patient usually is told to do some mild exercises while reclining: wiggle toes and ankles, bend his knees, roll gently from one side of the bed to the other. This increases the return of blood to the heart and helps maintain proper muscle tone.
During the early weeks of recovery further very mild exercise is allowed. This must be carefully controlled (see chart) in order to give scar tissue time to form where the normal tissue died from lack of blood during the attack. Exertion too early may create an aneurysm, a weak spot in the heart wall that pulsates with each heartbeat and never becomes firm. Strong scar tissue is generally present no later than six weeks following the attack.
When the patient has progressed to the last phase on the chart (three to four months following the attack) he usually is ready to begin taking part in a mild sport. Sometimes he can go back to his old favorite, if it wasn't something like football, which he might as well forget. Tennis, however, might be permissible—some doctors will okay a return to it, if the patient plays only doubles. Other physicians feel that tennis is a game that cannot be played at a slow pace, and they rule out even doubles.
The best sports to pursue after a heart attack are hiking, golf, fishing (of the gentler variety), bowling, swimming (backstroke, for instance, demands low energy), and horseback riding, provided the person knew how to ride before he became ill. Even hunting is permitted, depending on the severity of conditions the hunter will have to face, such as weather, the number of unaccustomed heavy clothes required and so forth.
Casting all rules aside, some "weak-hearted" people have thrown themselves into just about every sport, including elephant hunting and skiing. One diehard from Texas defiantly kept up sailing for 14 years after doctors told him to keep still the rest of his life, but this gay attitude is not officially recommended. Dr. White had a patient still playing golf in his 80s who had had a heart attack 25 years before.
A program of graduated exercise should be started after a heart attack even by a patient whose greatest muscle strain before the attack consisted of walking from his office desk to the office-building elevator. Since exercise improves the circulation, it has even greater value—within limits—for the damaged than for the normal heart. Dr. Louis N. Katz of Michael Reese Hospital in Chicago, a former president of the American Heart Association, says: "I would encourage more active exercise [for the person who had not done any prior to his attack] but by training. Life is full of emergencies; a man in training is more able to meet them."
THE FLABBY BODY
The nonexerciser, following a training program, of course is faced with conditioning his flabby body to unaccustomed exertion after his attack as well as assessing the ability of his healing heart. The person who was athletic before his attack, on the other hand, can return to sports more rapidly and participate more vigorously because his muscles are in good shape to begin with.
But even choosing the right sport and taking it on with the proper step-by-step conditioning won't help the patient along the road back to normal living if participating in sports upsets him emotionally. That is why, in the list of suggested sports for people who have had heart attacks, doctors stress those which are noncompetitive. Says Dr. Katz: "It's not the form of exercise, but the rate, length and emotional overtone. While a good sport is out to win, he's a better sport if he takes a loss." Under the duress of excitement and drive to win, the heart patient may not be willing to stop when he feels the danger signals, and getting angry or excited just by itself is bad for his heart, whether it happens when he is actively hooking a fish or passively listening over the radio to his alma mater lose a football game. A good theme song for the recovering patient might well be that old swing tune of the '30s: T' ain't what cha do, it's the way that cha do it.
Another point the would-be sportsman must keep in mind, in addition to watching for danger signals, gradually working up his endurance and maintaining his emotional equilibrium, is never to indulge in his favorite sport on a full stomach. Of course, since the coronary must keep his weight down, he ought not to have a full stomach, but nonetheless he should wait at least an hour after meals before exerting himself. He should also be especially careful of hunting or walking in the cold, because low temperatures tend to make the arteries tighten up, thereby forcing the heart to pump harder.
Some doctors say ruefully that the greatest difficulty they have in returning patients to their former world of sports is combating the patient's own negative attitude toward exercise. Fear of exertion is still widespread; even those who may have enjoyed fishing regularly and felt it increased their health and happiness pre-attack are afraid to begin it again post-attack. Those who always thought exercise was "fine for the other fellow" can see no reason to subject themselves to it after their heart has been damaged.
Dr. Joseph B. Wolffe, Chief of Medicine at Valley Forge Heart Institute and Hospital, Fairview Village, Pa., sometimes resorts to a kind of suggestion therapy to persuade his heart patients to exercise. In the corridors of the institute, patients are often seen walking up and down flailing their arms about as if performing some weird ritual. Asked what they are doing, they answer cheerily: "I just took my pill, and it won't work unless I exercise." The pill is usually a vitamin, which, of course, would be just as beneficial if consumed while in bed.
Dr. Wolffe, who also heads a clinic in Philadelphia, moved to the hilly country 20 miles outside the city in 1951 for the purpose of opening a heart institute where patients would have room to move about during treatment and convalescence. The entire place is designed with that in mind. The grounds are graded in slopes and terraces that require different degrees of exertion, and Dr. Wolffe firmly refused to install any elevators in the buildings. Dr. Wolffe, now president of the new American College of Sports Medicine, was one of the earliest doctors to raise doubts about the value of restricting physical activity for coronary cases. As far back as 1926 he wrote in the Archives of Internal Medicine of encouraging his patient "to know he can indulge in physical activity" on a gradually increasing schedule.
THE "ARMCHAIR METHOD"
In that same year, Dr. Harold Feil, now clinical professor emeritus of cardiology at Western Reserve University School of Medicine, pointed out that some cardiacs can lead active lives. A decade later (1937) Dr. Samuel A. Levine, clinical professor of medicine at Harvard Medical School, was among the first to treat acute coronary thrombosis by what was later dubbed the "armchair method"—getting the patient out of bed and into a chair not later than one week after his attack. (In 1952 he and Dr. Bernard Lown reported in The Journal of the American Medical Association on the impressive recovery of 73 patients with acute coronary thrombosis after they were taken out of bed and placed in chairs.)
But it took World War II to convince some heart specialists that they should alter their opinions. The combination of a need to vacate military hospital beds plus a manpower shortage in critical jobs that were physically strenuous forced the medical profession to re-examine its entrenched beliefs about keeping heart patients inactive. Dr. Henry I. Russek, 44-year-old consultant cardiologist at the U.S. Public Health Service Hospital in Stat-en Island, today tells how amazed he and his colleagues were at the sudden exodus in 1941 of hundreds of men between 60 "and about 110" from Sailors' Snug Harbor, the island's home for aged sailors. These men, who had been drearily sitting around waiting to die, were suddenly in demand at their former jobs in the merchant marine. Back they thronged, coronary conditions and all, and successfully performed physical work they hadn't done since their younger days. And in the process they were happier than they had been in years, had no heart complications and lost their "cardiac neurosis," the paralyzing fear that they would die immediately if they did anything more energetic than rest in a chair for 24 hours a day.
Inexplicable cases like these sailors who refused to be buried alive made doctors take another look at the cardiac patient. Certainly the cost of complete rest was high. Immobilized patients complained of everything from weakness, poor circulation and shortness of breath to temporary paralysis of muscles that were beginning to atrophy from disuse. Their depression and apathy at being endlessly restricted and their dread of the slightest movement were definitely detrimental to their general recovery. They lacked the will to get well, that mysterious unknown quantity of the effect of the emotions on the body which often can tip the scale between good and poor health.
The results of the American Heart Association Work Classification Units opened physicians' eyes still further to the possibility of restoring the heart patient to an active life. In these clinics, located all over the country, the capacity of the recovered heart could be measured objectively by new laboratory tests, and teams of cardiologists, social workers and vocational counselors stood ready to help the patient take his first step in returning to normal life—finding a job he could safely handle.
Dr. Howard A. Rusk and his associate Dr. Joseph G. Benton, at the Institute of Physical Medicine and Rehabilitation of the New York University-Bellevue Medical Center in New York reported that, except for extremely heavy labor, almost all the physical activities required to perform a job appeared to be within the capacity of most people with heart disease.
Dr. Herman K. Hellerstein, head of the classification unit in Cleveland, found that in a four-year period, 75% of 535 cardiacs representing all occupations had been returned to their jobs.
Clinical evidence showed that the heart, even when damaged, was sturdier than doctors had believed possible. Dr. Carleton B. Chapman and Dr. Robert S. Fraser of the University of Minnesota tested men from the ages of 45 to 60 who had at least six months previously suffered the death of that part of the heart muscle which had been deprived of blood (a condition known as myocardial infarction). Tests were made while the men were at rest, and again after 10 minutes of walking on a treadmill going three miles per hour at a 5% grade. The doctors found there was no significant difference between the performance of the men with damaged hearts and another control group of the same age who had normal hearts. At the National Institutes of Health in Bethesda, Md. recently Drs. Thomas N. P. Johns and Byron J. Olson found that rats with coronary thrombosis could tolerate exercise just as well as those with normal hearts. Although it's hard for people to be overjoyed that a human heart is similar to a rat's, this experiment was good news for the heart attack victim, since it suggested that the heart (of men and rat) probably has the reserve strength for a good comeback when it gets in trouble.
In addition to these hints that they might be on the wrong track in confining patients to life in an easy chair, heart specialists noticed in their own patients that emotional upsets—anger, compulsive competitive drive, intense excitement—were the real culprits that threatened the recovery of the mending heart. These emotions could erupt while the patient was just watching a baseball game on TV, or playing an apparently quiet game of cards—or fuming at not being permitted to do anything. As Dr. Roy W. Scott of Cleveland, eminent heart authority, put it: "I'd much rather let a heart patient play golf than become upset in a poker game. He could be seriously disturbed by drawing a full house on an opening hand." Dr. Harry Gold, professor of clinical pharmacology at Cornell University Medical College, joined the chorus. Said he: "We must shift our emphasis in advising patients from limitations on their physical activity. We must convince them that in rage and anger, when they are endeavoring to kill someone else, they are actually accomplishing just the opposite—they are killing themselves."
And so sports for the heart attack victim, if done noncompetitively, became recognized as a safety valve for emotions. As Dr. White said about Eisenhower, "These diversions in the way of golf and painting have been very vital, I think, for his health.... They're a good antidote for nervous tension and mental overwork."
PRESIDENT EISENHOWER gets the feel of his clubs again on White House lawn.
PATIENTS AT THE VALLEY FORGE HEART INSTITUTE NEAR PHILADELPHIA, SUPERVISED BY A NURSE, ENJOY A THERAPEUTIC GAME OF BALL
GROVER W. MUELLER, physical education consultant to Valley Forge Heart Institute, leads exercises designed to help patients with damaged hearts resume normal lives.
SUGGESTED EXERCISE SCHEDULE AFTER AN ATTACK
FIRST TO 3RD WEEK
Stay in bed, wiggle toes. Roll body gently while reclining
3RD TO 4TH WEEK
Sit up in bed supported by as many pillows as desired
5TH TO 6TH WEEK
Sit up in a chair, for gradually increased lengths of time
6TH TO 7TH WEEK
Walk about on one floor, slowly increasing distance covered
7TH TO 8TH WEEK
Start climbing up and down stairs, gradually increasing the number of steps attempted
8TH TO 12TH WEEK
Take short daily walk outside when weather is not too cold
12TH TO 16TH WEEK
Begin to engage in some mild sport done gently, like golf with the aid of a motor cart