February 2021 Issue

Focus on Fitness: Safe Fitness With CHDs
By Jennifer Van Pelt, MA
Today’s Dietitian
Vol. 23, No. 2, P. 50

February is National Heart Month. In the context of exercise for improving heart health, congenital heart disorders (CHDs) often are overlooked. The most common type of birth defect, CHDs affect approximately 40,000 infants born each year in the United States. Over the last decade or so, medical and surgical advances in the treatment and repair of CHDs have increased survival to adulthood. The Centers for Disease Control and Prevention estimates that about 1 million children and 1.4 million adults are currently living with a CHD.

However, a paradigm shift regarding exercise for children and adults with CHDs is occurring. Until recently, physicians generally hesitated to recommend exercise and may even have advised restricted physical activity due to concerns about sudden cardiac death or other severe cardiac complications. As more children with CHDs have reached adulthood, the medical community has realized that sedentary lifestyle and poor cardiorespiratory fitness have contributed to obesity, atherosclerotic heart disease, and diabetes in this patient population. These comorbidities further stress the heart and circulatory system. Over the last several years, evidence has shown that exercise is safe and effective for the majority of those with CHDs. And, research into the adverse effects of exercise has shown that sudden cardiac death during exercise is rare; in fact, sudden cardiac death often has occurred during rest.1-3 Professional medical societies have noted that the benefits of appropriate exercise for those with CHDs outweigh the risk and have issued updated guidelines in response to this evidence.1-6

Regular physical activity for children and adults with CHDs is important for benefits beyond heart health and weight management, including reduced risk of cancer, osteoporosis, hypertension, and dementia, as well as improvements in mental health and quality of life. In 2013, the American Heart Association noted that “physical activity is a broader concept that incorporates all types of physical movement, not solely those designated as exercise (planned, repetitive physical activity designed to increase fitness). Given that health benefits will accrue from physical activity of moderate intensity, the health benefits of a physically active lifestyle are within reach of nearly all patients with CHD.”4

Despite the paradigm shift in exercise recommendations, the majority of children and adults with CHDs aren’t getting enough physical activity. Children and parents who received physician guidance against exercise due to safety concerns often fear exercise as adults.1 Encouragement, support, and appropriate guidance are key factors for increasing exercise adherence. In a small October 2020 study, researchers interviewed adults with CHDs regarding physical activity. They found that those who had experienced support and were encouraged to exercise as children were more likely to be physically active as adults. If they lacked support for regular physical activity during childhood, they were less likely to exercise as adults.7 Researchers are hopeful that identification of barriers to activity and increasing evidence on the benefits of exercise will increase awareness among health care providers, allied health professionals, and patients about the importance of regular physical activity for those with CHDs.

Best Practices
Exercise guidelines for those with CHDs are similar to general exercise guidelines in terms of overall physical activity goals. However, because there are so many different CHDs that affect cardiac functioning in varying ways, specific recommendations for exercise need to be individualized based on the type of CHD, comorbidities, clinical status, physical capabilities, and interests of the patient. Before starting exercise, cardiopulmonary exercise testing is required to assess capabilities and formulate individual exercise plans for those with CHDs. Structured cardiopulmonary rehabilitation programs are beneficial but often underused in this population due to program availability and insufficient physician referrals. Those with CHDs should also receive counseling regarding the importance of reducing sedentary behavior and engaging in daily physical activity appropriate for their condition.1,3,4,6

According to clinical guidelines, most adults with a CHD can safely perform regular moderate exercise multiple times weekly, and most children and adolescents can safely perform 60 minutes of daily physical activity, unless the type of CHD requires limitations.3,5 The Adult Congenital Heart Association recommends gentle exercises for 25 minutes two to three days per week, increasing intensity only as able and only every month. Muscle strengthening exercise can be performed two to three times per week, using light weights or doing bodyweight movements that don’t require straining.8

Low- to moderate-intensity aerobic activities appropriate for most children and adults include walking, jogging, swimming, cycling, cardio equipment (eg, elliptical, stair climber), and any other physical activity similar in intensity (eg, household/yard work, recreational sports/games, dancing). Flexibility and mind-body training should also be performed and might include tai chi/qigong, gentle yoga, stretching, and meditation. For some individuals, more vigorous aerobic activity may be possible and appropriate, and should be discussed with their health care providers.2

Competitive sports for children may be of interest or concern for parents. A backyard recreational soccer game may be appropriate and encouraged for most children with CHDs. However, competitive soccer—and the training associated with it—may be higher risk due to the higher intensity of activity and structured playing/training conditions. In 2015, the American Heart Association and American College of Cardiology published a scientific statement on competitive athletics for those with CHDs.9 In 2020, the European Society of Cardiology, in collaboration with specialty sports, pediatric, and congenital cardiology groups, published recommendations for participation in competitive sports for adolescents and adults with CHDs.10

The number and variety of CHDs and their effects are too great to include specific recommendations for each here. Detailed recommendations for physical activity based on CHD type can be found in guidelines and reviews cited in the references accompanying this article.2,6,9,10

Generally, any patient with a CHD who has had a successful surgical repair with no ventricular dysfunction, arrhythmia, or aortic dilation, and who has normal pulmonary artery pressure, can aim for the same daily physical activity goals as those for adults and children without a CHD. Some CHDs that require limited physical activity and specific restrictions include any that involve the following2,9,10:

• systemic ventricular systolic dysfunction;
• systemic ventricular outflow tract obstruction;
• hemodynamically significant arrhythmias;
• aortic dilation;
• hypoxia;
• moderate to severe pulmonary hypertension;
• exertional syncope;
• anticoagulant medications; and
• pacemakers or implantable cardiac defibrillators.

For example, those with mildly diminished ventricular function may be limited to low- and medium-intensity sports. Those with exertional syncope (loss of consciousness during activity) should be counseled to avoid sports and activities that would endanger themselves or others if an event occurs, such as horseback riding, rock climbing, gymnastics, and diving. Those with implanted devices should be advised to avoid activities that have a high likelihood of body contact to the chest, such as contact martial arts, boxing, football, and ice hockey. Guidelines provide a comprehensive classification of sports by intensity and parameters based on required power and endurance in terms of cardiac output, heart rate, blood pressure, and other clinical metrics affected by CHDs.2,9,10

The shift to encouraging exercise for children and adults with CHDs is a welcome change that will improve long-term health. With evidence- and guideline-informed recommendations, health care providers can help clients with CHDs devise a safe, effective plan for regular physical activity.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

1. Powell AW. Exercise in congenital heart disease: a contemporary review of the literature. Heart Mind. 2018;2(3):61-64.

2. de Ferranti SD, Krieger EV. Physical activity and exercise in patients with congenital heart disease. UpToDate website. https://www.uptodate.com/contents/physical-activity-and-exercise-in-patients-with-congenital-heart-disease. Updated May 5, 2020. Accessed November 22, 2020.

3. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(14):e637-e697.

4. Longmuir PE, Brothers JA, de Ferranti SD, et al. Promotion of physical activity for children and adults with congenital heart disease: a scientific statement from the American Heart Association. Circulation. 2013;127(21):2147-2159.

5. Selamet Tierney ES. The benefit of exercise in children with congenital heart disease. Curr Opin Pediatr. 2020;32(5):626-632.

6. Tran D, Maiorana A, Ayer J, et al. Recommendations for exercise in adolescents and adults with congenital heart disease. Prog Cardiovasc Dis. 2020;63(3):350-366.

7. Bay A, Lämås K, Berghammer M, Sandberg C, Johansson B. Enablers and barriers for being physically active: experiences from adults with congenital heart disease [published online October 30, 2020]. Eur J Cardiovasc Nurs. doi: 10.1177/1474515120963314.

8. Adult Congenital Heart Association. Exercise and adult congenital heart disease. https://www.achaheart.org/media/1973/qandaexercise2017.pdf

9. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2343-2349.

10. Budts W, Pieles GE, Roos-Hesselink JW, et al. Recommendations for participation in competitive sport in adolescent and adult athletes with congenital heart disease (CHD): position statement of the Sports Cardiology & Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J. 2020:41(43):4191-4199.