ExRx for Valvular Heart Disease
By Jennifer Green, MS
|Jennifer Green, NCHPAD Visiting Information Specialist|
There are two chief causes: congenital, or those conditions present at birth and acquired, which are defined as conditions owing to lifestyle, infection, and aging, among many other factors. The foremost causes of valvular heart disease (VHD) comprise of rheumatic fever, congenital defects, infection, and aging. The presence of symptoms can be diverse and depend on four varying areas:
- The valves involved
- The condition of the valve
- The severity of the lesions
- The presence of coronary artery disease, myocardial dysfunction, or other organ system disease
In the early stages of VHD, symptoms can habitually be mistaken for those of other conditions, such as fatigue, heart palpitations, chest pain, and blood pressure changes. Over time, these symptoms become more severe and can include excessive or extreme fatigue, inexplicable coughing, shortness of breath, and swollen legs or feet. Along with assorted signs and symptoms, there are a variety of forms of valvular heart disease, which includes mitral valve prolapsed, mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonic stenosis, and pulmonic regurgitation. If you are unfamiliar with these various conditions, it may be beneficial to do some research on your own before training a client with one of these conditions.
The degree to which VHD affects the exercise response depends on the form and severity of the lesions and valves involved. Physical activity is generally accepted and encouraged for this population as it can facilitate improvements in overall quality of life as well as resilience to perform activities of daily living. Only when VHD progresses to the point of causing resting or exertional symptoms or compromised hemodynamics is exercise contraindicated.
Classically, dynamic, low- to moderate-intensity physical activity is suggested in asymptomatic patients with all forms of mild valvular heart disease. Aerobic activities should make use of large muscle groups and focus on improving functional capacity, muscle function, and performing ADLs with decreases in symptoms. Exercise programming should focus on 4-7 days/week of aerobic activity at 20- to 60-minute sessions at a target heart rate of 40% to 80% VO2max. If using RPE, the intensity should be focused between 11 and 16 on a 20-point scale. A longer warm-up and cool-down are suggested; each should last 10 to 15 minutes.
Strength training should be performed 2 to 3 days per week and focus on improving muscle function and increasing strength for vocational and avocational activities. An exercise program should include 4 to 8 exercises focusing on large muscle groups for each strength training session, with 12 to 15 repetitions and 2 to 4 sets. Flexibility training is also important and should be done at least 3 days per week to a position of mild discomfort, making sure to hold each stretch for 10 to 30 seconds. It is important to emphasize to your client that these movements should be slow and controlled. The goal of this portion of the exercise prescription should be to increase ROM.
Clients with valvular heart disease may be taking at least one type of medication. It will be important to research what types of medications they are taking and how those drugs may affect their participation in exercise. Exercise induced symptoms should be taken into account when choosing activities and creating your program. Also, if after reviewing a client's medical history, is determined that he or she has symptomatic aortic stenosis or pulmonic stenosis note that this is an absolute contraindication to exercise testing and refer the client to his or her physician. If it is determined after the health and medical history that a client has significant aortic stenosis or pulmonic stenosis, strength training should be avoided.
ACC/AHA. (2006). 2006 guideline for the management of patients with valvular heart disease. Circulation, 114, e84-e231.
Simmonds, M. J., Ph.D., PT, MCSP, & Derghazarian, T. P. (2009). Muscular dystrophy. In J. L. e. a. Durstine (Ed.), ACSM's exercise management for persons with chronic diseases and disabilities (3rd ed., p. 306). Champaign, IL: Human Kinetics.
Thompson, W. R., Ph.D., FACSM, Gordon, N. F., M.D., Ph.D., MPH, FACSM, & Pescatello, L. S., Ph.D., FACSM (Eds.). (2010). ACSM's guidelines for exercise testing and prescription (8th ed.). Baltimore: Lippincott Williams & Wilkins.
Vahanian, A., Baumgartner, H., Bax J., et al. (2007). Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J., 28(2), 230-268.
Please send any questions or comments to Jennifer Green at firstname.lastname@example.org.