Returning to pre-surgery levels of exercise

[slb5418]

Hi there, new member here. I had a bicuspid aortic valve replacement in March '22 at age 31 with an On-X valve and have been working towards my previously levels of fitness.

Prior to surgery, I was primarily interested in powerlifting and had decent numbers of around 180kg squat, 250kg deadlift, 130kg bench press at a weight near 80kg.

Following surgery, I followed all of the guidelines. No lifting until 8 weeks post-op. Took it easy for the next few months. I did cardiac rehab for a couple of months and they "graduated" me early after about 8 weeks of 2 sessions per week. At that time I could only jog in short bursts of a few minutes until my heart rate reached fairly high levels ~160 bpm and a BP in the 180's or so.

My surgeon gave me no restrictions past 6 months and since about 7 months post op until now I've been gradually increasing my weight. My squat is near 150kg for 5 reps at this point, deadlift at 200kg for 3 and bench press around 95kg for 4. I am mindful of my effort and don't go to nearly the level as I previously did, stopping shy of "grinding" reps and have also changed my technique from a valsalva maneuver to where I do not hold my breath through a movement, but exhale on the concentric portion of the lift.

I'm also running at this time, and want that to be a bit more of a priority considering the circumstances. I run 3 times a week and try to maintain my heart rate within a "moderate range" of the 140's to 150's. On occasion, I do want to push myself a bit to the 160's and nearing 170 (I think my max heart rate is likely near 190 based on 220-age and my general feeling in these ranges, I think that checks out). I've been able to increase my mileage to slow 3-5 mile runs throughout the week near an 11:00 pace and my best was a 4 mile effort at ~9:30 pace which had my heart rate solidly around 170.

As my weights increase and my running volume increases, I can't help but feel slightly anxious about what I'm doing. I feel fine physically doing all of this. I like pushing myself a bit and I don't feel as though I'm overdoing it, but I'm curious as to the risks of continuing this. From what I've read, most of the concerns are related to other health problems such as aneurysm or dissection. Both of which were not problems for me when I had my replacement. Am I at a greater risk with the On-X valve if everything else regarding my heart is healthy?

I'd like to continue increasing running volume weekly with the ultimate goal of completing a half marathon perhaps later this year and a marathon late 2024. Are there additional risks when running long distances on an On-X valve?

I've also been reading in other posts that the 1.7 INR range for On-X valve may not be the best idea. I self monitor now and was typically keeping it in that range, but I think I'm going to increase that to the 2.5 range. Is there a relation between INR and exercise intensity? i.e. is it better to maintain a higher INR to reduce the risk of clotting/TE events and does exercise intensity have any affect on that risk?

Another question is regarding HR. My resting HR since surgery has been quite high. I know afib is a common occurrence but now being ~1 year out I'd expected to be closer to my old levels, especially considering my fitness level improving. I regularly notice my resting HR in the 80s and even 90s where in the past, it was 60s and 70s. I think this may be related to stress and anxiety, especially health/fitness related stress and anxiety. I was prescribed 10mg propranolol as needed to help with anxiety, and find I can usually just take 5mg and it helps me. Related to that - I sometimes find my workouts go smoother if I've taken a 5mg propranolol that day. I think it calms my nerves related to exercise so it has both a mental and obvious physical effect on my HR and BP. Is this okay to do? are there risks involved with taking a beta blocker and running or weight lifting, even at such a low dose?

There is a lot to unpack here, so my thanks to anyone who has read all of it. I plan on discussing some of these things with my cardiologist at my 1 year appointment. Unfortunately, I feel like the guidance has been fairly vague so far and from what I read here there is a very large spectrum of guidance as well. Looking forward to hearing some opinions.

 

[d333gs]

Hi slb , welcome to the board, those lift numbers are impressive! Your weight is 80kg?
Resting heart rate:
Mine was also higher by about 15 beats per minute. At one year post surgery my average is dropping and now , I guess when I sleep,the average is 54 according to my apple watch. But just sitting here now and typing it is at 75 which to me seems high. Pre surgery it would be 59 or 60.I used to be able to slow it by relaxing and breathing but the heart now seems more autonomous and does what it wants regardless of what I want. I don't have a mechanical valve so I can't comment in on that. But in regards to past physical performance, everything came back better than it was in about 6 months.

 

[slb5418]

Hi slb , welcome to the board, those lift numbers are impressive! Your weight is 80kg?
Resting heart rate:
Mine was also higher by about 15 beats per minute. At one year post surgery my average is dropping and now , I guess when I sleep,the average is 54 according to my apple watch. But just sitting here now and typing it is at 75 which to me seems high. Pre surgery it would be 59 or 60.I used to be able to slow it by relaxing and breathing but the heart now seems more autonomous and does what it wants regardless of what I want. I don't have a mechanical valve so I can't comment in on that. But in regards to past physical performance, everything came back better than it was in about 6 months.

Hi d333gs, thanks for the welcome. Yes my body weight was around 80kg then and I’m trying to be closer to 75kg now to be in a slightly healthier weight range and focus more on cardio.

Thanks for sharing your experience with HR. Hopefully I see some similar progress now that I’m about a year out from surgery.

And I agree, my performance is nearing what it used to be now, but I’m a little apprehensive to go to my previous weights and cardio volume.

 

[pellicle]

Hi

returning to exercise is a good thing. Its very much an individual thing (not least) because of the variations in the main parameters

• how fit you were before sugery
• how old you are
• what happened to you in surgery (like, "welcome to your pacemaker")

So:

Are there additional risks when running long distances on an On-X valve?

I see two ways to look at this question, I don't know which angle you had

1. causal link: does having a mechanical valve cause risks in exersize
2. associated link: does exersize alter my INR

So, the answer is always "it depends" and so principle #1 is test and know thyself.

I know 99% of the time the answer is

• exersize does you good
• you are not really limited in exercise (eg this woman climbed Mt Everest, if you think that's not exersicise and didn't require a ton of that in prepartory training then you have the wrong idea about climbing).
• people return to better than where they were when they left off
• people (yes members here) do long distance running and high impact hard cadio like juijitsu ...

but I think I'm going to increase that to the 2.5 range. Is there a relation between INR and exercise intensity?

that's wise

what relation are you asking about?

• Does INR need to be in a place to support it? or
• does exercise intensity effect INR for your dose?

in that order
Yes, INR needs to be on target (in your case 2.5)

It may change in response to commencement of training but will then likely return to where it was as your body adapts to the new training regime. The best thing there is: Test and Know thyself and keep a steady hand on the adjustment tiller.

Another question is regarding HR. My resting HR since surgery has been quite high. I know afib is a common occurrence but now being ~1 year out I'd expected to be closer to my old levels, especially considering my fitness level improving. I regularly notice my resting HR in the 80s and even 90s where in the past, it was 60s and 70s.

Your heart is a muscle and a complex nervous system. OHS is sorta like your kid pulling the CPU out of your computer and changing the RAM. Its entirely likely it won't work nicely for a while.

So everyone has some level of new resting rate and it settles over time. I was 120 (with beta blockers) for the first month, and it took till nearly 6 months before I was nordic pole running (no, not walking) with my wife on the beach.

Push yourself gently, be guided by what you feel and if you can get a Garmin and a HR strap and be both guided by and informed by the HR and what happens (including recovery rate) and your own knowledge of what that was like in the years pre surgery.

Best Wishes

 

[slb5418]

Hi pellicle, thank you for your reply and your reassurance.

that's wise

what relation are you asking about?

• Does INR need to be in a place to support it? or
• does exercise intensity effect INR for your dose?

in that order
Yes, INR needs to be on target (in your case 2.5)

Yes, I was referring to the former. More specifically, is it more dangerous to have an INR of 1.7 than 2.5 while exercising at various intensity levels, i.e. powerlifting three times a week and running three times a week.

Your heart is a muscle and a complex nervous system. OHS is sorta like your kid pulling the CPU out of your computer and changing the RAM. Its entirely likely it won't work nicely for a while.

So everyone has some level of new resting rate and it settles over time. I was 120 (with beta blockers) for the first month, and it took till nearly 6 months before I was nordic pole running (no, not walking) with my wife on the beach.

This is very true. I was taken aback by my condition in the first few weeks. Considering my former fitness level I thought I'd be in decent shape after a few weeks. It wasn't really my experience. I was hoping that at a year mark I would have a better fitness level, but patience is a virtue.

Push yourself gently, be guided by what you feel and if you can get a Garmin and a HR strap and be both guided by and informed by the HR and what happens (including recovery rate) and your own knowledge of what that was like in the years pre surgery.

I rely very much on my trusty Garmin watch and HR strap and do keep in mind my former fitness levels. I do recognize that my HR is quite a bit higher on a run and just in general.

Do you have any insight into beta blockers and exercise? If i've had a beta blocker before lifting or running, my numbers are obviously lower. This feels more normal for me as the numbers are more in line with my pre-surgery numbers. But obviously the numbers are medically reduced. I guess my question would be if that's a bad idea and it's actually masking my actual effort or if it's beneficial and helps my ticker stay in check - HR and blood pressure wise.

 

[pellicle]

Do you have any insight into beta blockers and exercise?

I take (as mentioned in another thread) metoprolol tartrate due to its half life:

https://www.valvereplacement.org/threads/metprolol-tartrate-side-effects.888984/#post-922965
I have a different attitude to personal titration than others express here. Apparently its wrong to do this knowingly because you'll come to harm if your doctor doesn't get involved, but if you just stop taking it because you are hopeless or forget then you won't come to harm.

My Dr specifically asked me what dose would I like to take (when he was writing out the script). But apparently my Dr sees something in me that others here don't.

So don't follow what I say, because I'm not a doctor and its wrong.

HTH

 

[slb5418]

I take (as mentioned in another thread) metoprolol tartrate due to its half life:

https://www.valvereplacement.org/threads/metprolol-tartrate-side-effects.888984/#post-922965
I have a different attitude to personal titration than others express here. Apparently its wrong to do this knowingly because you'll come to harm if your doctor doesn't get involved, but if you just stop taking it because you are hopeless or forget then you won't come to harm.

My Dr specifically asked me what dose would I like to take (when he was writing out the script). But apparently my Dr sees something in me that others here don't.

So don't follow what I say, because I'm not a doctor and its wrong.

HTH

I’m of a similar opinion.

I was on metoprolol post surgery as well. My cardio actually took me off of it when I was complaining about light headedness, especially when getting up quickly from a seated position.

Still not sure if it was blood pressure related, hydration issue, or just my heart acting up after OHS. I do pay more attention to my water intake and sodium and feel that’s been helpful for any light-headedness I feel (I sweat a lot during workouts).

Anyway, it’s months later and I have the propranolol prescribed which I don’t find any negative side effects from. Just the intended effect of lowering my HR to a comfortable level, especially while under stress.

I’m going to bring it up with him and see if he has a strong opinion for or against it.

 

[tom in MO]

I can't help much, but have some simple ideas.

INR does not impact exercise either positively or negatively from what I've read and been told. Rest easy on that subject. Change your INR based upon your anticoagulation needs not exercise. Per my mechanical valve, when I was released from cardio rehab, I was told I could do anything, but in exercising don't hold my breath. You do that already.

If you are anxious about your heartrate during exercise, it will go up. Particularly if you are clinically diagnosed with anxiety and can take medication for it. You can exercise w/o monitoring and exercise based solely upon how your whole body feels. Try ignoring your heartrate particularly if you don't need to take action on your results. I find relaxation techniques help with my anxiety. You might want to try that before exercising.

 

[Timmay]

I had an On-X replacement in May of ‘22.

I have not returned to my previous fitness levels. My previous fitness levels was benchpressing (freeweights of course) my own body weight 10 times … slow and with perfect form. I would also run 2 miles at around an 11 minute pace.

My goal was to bench 61kg (135lbs) for 10 slow reps with good form at the 6 month mark … and then work toward my body weight bench at around 8 months. I achieved the first goal of 10 reps at 135lbs with meticulous, slow form. However, within a couple days things weren’t feeling right. No pain. BP, Heart Rate, O2, etc were all great. But my heart was “thumping” hard like it did a month after surgery.

Talked to my cardiologist. Stopped working out but stepped up my walking. 10,000 steps a day. Got a echo and X-ray 2 months later and everything looks great. Started my workout again and after 1 week (3 days of extremely light weights), I could feel my heart wanting to thump harder again. So - at this point - whatever. I don’t NEED to lift weights like I did. I’m continuing to do my walking … throwing in jogs from time to time. I’ll up my jogging as the weather is warming. I’m doing some dumbbell curls at my desk during the day. And I’ll just keep things like that for awhile.

Why am I saying all of this? A couple reasons.

First - listen to your body. There is literally no reason to push yourself too hard. Take your time. Listen listen listen.

Second - for new people who might read this - don’t underestimate how different we all are. Me being “in shape” before surgery means nothing in comparison to another member being “in shape”. We can’t all strive to the same goals. We’re different people. Additionally, being younger truly is an advantage during the healing process. You youngins heal so much quicker (stereotypically speaking).

FWIW, after surgery my heart rate has been about 10-15bpm higher than pre-surgery. That said, I’m currently on a downward trend where my resting heart rate is now only 5bpm higher.

Oh - and for me - I would never ever target a 1.7 INR. At a minimum my target is 2.5. That said - my actual target is 3.

T

 

[pellicle]

Good Morning

Still not sure if it was blood pressure related,

which is perhaps the major application of metoprolol, so could well have been.

Either way I think your plan to bring it up on your next meeting with the cardio is good.

Best Wishes

 

[pellicle]

Hi

Oh - and for me - I would never ever target a 1.7 INR. At a minimum my target is 2.5. That said - my actual target is 3.

its interesting how the old hands tend to prefer the middle of the bathtub.
This older article from 2004 (so yes, its the first 40 years of INR by now)
International Normalized Ratios (INR): the first 20 years
has this reference in it

Limitations of INR​

Although the ISI corrects for major differences in PT results between test systems (reagent/coagulometer combinations), persistent INR disagreement between results with different test systems is frequently observed.​

seems familiar to me

it also has this chestnut:

... It was shown by Cannegieter et al. (1995) [86] that there is a dramatic increase in bleeding events at INR > 5.0 and of thrombotic complications at low INR < 2.0 (see Fig. 11).​

Fig 11 pasted for your convenience

looks also somehow familiar and not unlike a cross section of a bath tub

Good Morning from Oz

 

[Woodcutter]

I'll share a quote from the Chapter entitled "Treatment Options For Athlete Arrhythmia" in "The Haywire Heart" by Case/Mandrola/Zinn.

"All the commonly prescribed heart-rhythm drugs blunt cardiac performance.
Patients and doctors mistakenly call these side effects, but there's nothing side about them. They are effects. When you give a patient a blocker of adrenaline (a beta-blocker), you expect a reduction in maximum heart rate. That reduces performance. When you give a person a calcium channel blocker, you reduce the strength of the heart's contraction. That, too, reduces sports performance. Nonathletic patients may not notice the reduction in cardiac performance from these drugs. But athletes often do."

The referenced book is about arrhythmia's and an intended audience are those middle-aged endurance athletes that develop these issues later in life. As a lifelong endurance runner I recognize much of it. For me personally, when I was on metoprolol, it dropped my maximum heart rate 20-30 bpm.

As far as resting heart rate, I'd say my post surgery rate stabilized about 10 bpm higher than pre-surgery and it took 12 mos to get there.

As many have noted, we are all unique individuals ..... while sharing some commonalities!

Lastly, I'll offer that what is being asked of the heart during lifting is quite different than during a distance run. I've never been a lifter so I'll make the crude comparison of a sprint vs. a marathon. Both do use muscles, fuel, oxygen but definitely different.

 

[slb5418]

I can't help much, but have some simple ideas.

INR does not impact exercise either positively or negatively from what I've read and been told. Rest easy on that subject. Change your INR based upon your anticoagulation needs not exercise. Per my mechanical valve, when I was released from cardio rehab, I was told I could do anything, but in exercising don't hold my breath. You do that already.

If you are anxious about your heartrate during exercise, it will go up. Particularly if you are clinically diagnosed with anxiety and can take medication for it. You can exercise w/o monitoring and exercise based solely upon how your whole body feels. Try ignoring your heartrate particularly if you don't need to take action on your results. I find relaxation techniques help with my anxiety. You might want to try that before exercising.

Good to hear regarding INR. I just wanted to make sure I wasn’t at some sort of risk over the past few months when I’ve been exercising with a lower INR.

Regarding the second point, I also find that to be true. I hope I can get to that point where I can exercise without my strap but for now I feel somewhat reliant on it. I think I’d feel more anxious without it!

I’ve been meaning to start implementing some relaxation techniques, so I agree that’d be helpful.

Thanks for your input.

 

[slb5418]

I had an On-X replacement in May of ‘22.

I have not returned to my previous fitness levels. My previous fitness levels was benchpressing (freeweights of course) my own body weight 10 times … slow and with perfect form. I would also run 2 miles at around an 11 minute pace.

My goal was to bench 61kg (135lbs) for 10 slow reps with good form at the 6 month mark … and then work toward my body weight bench at around 8 months. I achieved the first goal of 10 reps at 135lbs with meticulous, slow form. However, within a couple days things weren’t feeling right. No pain. BP, Heart Rate, O2, etc were all great. But my heart was “thumping” hard like it did a month after surgery.

Talked to my cardiologist. Stopped working out but stepped up my walking. 10,000 steps a day. Got a echo and X-ray 2 months later and everything looks great. Started my workout again and after 1 week (3 days of extremely light weights), I could feel my heart wanting to thump harder again. So - at this point - whatever. I don’t NEED to lift weights like I did. I’m continuing to do my walking … throwing in jogs from time to time. I’ll up my jogging as the weather is warming. I’m doing some dumbbell curls at my desk during the day. And I’ll just keep things like that for awhile.

Why am I saying all of this? A couple reasons.

First - listen to your body. There is literally no reason to push yourself too hard. Take your time. Listen listen listen.

Second - for new people who might read this - don’t underestimate how different we all are. Me being “in shape” before surgery means nothing in comparison to another member being “in shape”. We can’t all strive to the same goals. We’re different people. Additionally, being younger truly is an advantage during the healing process. You youngins heal so much quicker (stereotypically speaking).

FWIW, after surgery my heart rate has been about 10-15bpm higher than pre-surgery. That said, I’m currently on a downward trend where my resting heart rate is now only 5bpm higher.

Oh - and for me - I would never ever target a 1.7 INR. At a minimum my target is 2.5. That said - my actual target is 3.

T

You’re absolutely right and I agree. I try to keep myself in check and always listen to my body in this healing period. So far, everything is going relatively well and my strength and fitness are slowly and surely returning. Maybe I’ll never reach my previous levels, but that’s fine.

It’s funny you mention your incident where you felt like your heart was “thumping”. I think what led me here seeking advice was a similar experience. Last weekend I had a 4 mile race and that’s where I pushed myself a little more than I have since surgery. Since then, I have a similar feeling to what you’ve described. I think I just need to be more conscious of what my body is telling me and keep it within reason.

It also seems common that people have elevated heart rates for a while and I’ve heard multiple anecdotes about the ~1 year mark, so maybe that will hold true for me.

Cheers.

 

[slb5418]

I'll share a quote from the Chapter entitled "Treatment Options For Athlete Arrhythmia" in "The Haywire Heart" by Case/Mandrola/Zinn.

"All the commonly prescribed heart-rhythm drugs blunt cardiac performance.
Patients and doctors mistakenly call these side effects, but there's nothing side about them. They are effects. When you give a patient a blocker of adrenaline (a beta-blocker), you expect a reduction in maximum heart rate. That reduces performance. When you give a person a calcium channel blocker, you reduce the strength of the heart's contraction. That, too, reduces sports performance. Nonathletic patients may not notice the reduction in cardiac performance from these drugs. But athletes often do."

The referenced book is about arrhythmia's and an intended audience are those middle-aged endurance athletes that develop these issues later in life. As a lifelong endurance runner I recognize much of it. For me personally, when I was on metoprolol, it dropped my maximum heart rate 20-30 bpm.

As far as resting heart rate, I'd say my post surgery rate stabilized about 10 bpm higher than pre-surgery and it took 12 mos to get there.

As many have noted, we are all unique individuals ..... while sharing some commonalities!

Lastly, I'll offer that what is being asked of the heart during lifting is quite different than during a distance run. I've never been a lifter so I'll make the crude comparison of a sprint vs. a marathon. Both do use muscles, fuel, oxygen but definitely different.

Thank you! I’ve heard that a lot from my scouring of the internet, that avid runners hated beta blockers because they couldn’t get their heart rate up.

In my post surgery experience, I’ve paradoxically enjoyed running on them more (only a very small dose).

For example, an “easy” effort run these days in the mid 10’s pace can get my heart rate to the 150s. That same run if I’ve taken a 5mg propranolol has me in the low 140s, and generally feeling more at ease. There may be a mental attribution to this as I see my HR at 140 and feel “better” about it. But perhaps I’m just masking my body’s actual effort. That’s kind of what I was curious about.

 

[spartangator]

Just wanted to say welcome SLB. I was about the same age at my procedure and work through many of the same questions. To add another vote to @pellicle's advice about the chest strap, I've found great utility there, mostly to set a cap on my HR during workouts so I can be smarter.

Also, recently, my GP suggested using the strap to check heart-rate variability a few times a day as a check on stress levels and well-being, and that's been insightful, too (if you have a strap, there are free apps that'll measure HRV for you).

Welcome to the other side. Here's to a life of health.

 

[pellicle]

Here's to a life of health.

I'll drink to that!!