Recommendations Regarding Lifestyle and Work in Patients with Thoracic Aortic Disease
Establishing clear life style goals for patients with thoracic aortic disease is important in improving long-term health and reducing the risk of both fatal and nonfatal complications. Since regular aerobic exercise, low fat and low salt diet, and achieving ideal body weight are tied to the ability to effectively control blood pressure, cholesterol and associated aortic stress, providing patients with clear life style targets is important. Avoidance of tobacco is also critical since it is linked not only with the development of thoracic aortic disease but is highly linked to aortic rupture. Avoidance of cocaine or other stimulating drugs such as methamphetamine is equally important as sudden surges in blood pressure and pulse attributed to such agents has been described as a trigger for aortic catastrophes.
The prescription of exercise represents an interesting dilemma in the management of patients with thoracic aortic disease. Since it is thought that the sudden increases in dp/dT and systemic blood pressure associated with physical and mental stress may be a trigger for aortic dissection in many patients, the concept of avoiding such stresses makes sense. [Maron BJ, Chaitman BR, Ackerman MJ, Bayes de Luna A, Corrado D, Crosson JE, Deal BJ, Driscoll DJ, Estes NA, Araujo CG, Liang DH, Mitten MJ, Myerburg RJ, Pelliccia A, Thompson PD, Towbin JA, Van Camp SP, for the Working Groups of the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention, and Councils on Clinical Cardiology and Cardiovascular Disease in the Young. Circulation. 2004; 109: 2807-2816.] However, maintaining a regular routine of aerobic exercise has day-to-day benefits in helping patients achieve ideal blood pressure, heart rate, and body weight. Moreover, many patients simply enjoy engaging in sports such as tennis, basketball, golf, bike riding, etc., and wish to continue in such activities if at all possible.
There is no outcomes data, and scant data of any variety for that matter, to indicate how much exercise is safe or beneficial for patients with thoracic aortic disease. However, aerobic exercise, sometimes referred to as dynamic exercise, is associated with only a modest increase in mean arterial pressure, [M. A. Williams, W. L. Haskell, P. A. Ades, E. A. Amsterdam, V. Bittner, B. A. Franklin, M. Gulanick, S. T. Laing, and K. J. Stewart. Resistance Exercise in Individuals With and Without Cardiovascular Disease: 2007 Update: A Scientific Statement From the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation 2007; 116: 572 - 584] and aortic dissection rarely occurs during aerobic exercise. Consequently, most experts believe that aerobic exercise, particularly when a patient's heart rate and blood pressure are well controlled with medications, is beneficial overall. Nevertheless, if patients wish to engage in vigorous aerobic exercise, such as running or basketball, one might consider performing a symptom limited stress test to ensure that the patient does not have a hypertensive response to exercise.
Conversely, with isometric exercise, there is a significant increase in mean arterial pressure. When the Valsalva maneuver is used for the lifting of heavy weights, there is a superimposed increase in intrathoracic pressure, followed by an often dramatic increase in systemic arterial pressure, [Williams] with systolic pressures reaching 300 mmHg or more. [Palatini P , Mos L, Munari L, et al. Blood pressure changes during heavy-resistance exercise. J Hypertens Suppl 1989;7:S72-73.] As a result, most experts believe that heavy weight lifting or competitive athletics involving isometric exercise may trigger aortic dissection and/or rupture and should therefore be avoided. [Hatzaras I, Tranquilli M, Coady M, Barrett PM, Bible J, Elefteriades JA. Cardiology 2007;107:103-106] Working with patients on an individualized basis to streamline these goals based on insufficient data can be challenging. For patients who are very much interested in maintaining some sort of weight lifting program, choosing sets of repetitive light weights appears to make more sense than permitting heavy weight lifting. [Williams] For example, instead of bench-pressing 200 lb, one might recommend selecting much lighter weights done in repetitive sets in order to minimize the hemodynamic consequences. Patients often ask exactly how much weight it is permissible to lift. Unfortunately, it is not possible to provide a blanket answer to that question, as it all depends on the patient's size, muscular strength, physical fitness, and how the weight is actually lifted. Rather than try to define a numerical limit, it may be more appropriate and useful to explain that patients can lift whatever weight they can comfortably lift without having to "bear down" or perform the Valsalva maneuver; indeed, any activities of any kind that require the Valsalva maneuver would best be avoided.
In addition to the physiologic stress of exercise, one should also recognize that in certain sports or recreational activities, sudden stress or trauma to the thorax can potentially precipitate aortic rupture and/or dissection. Thoracic stress or trauma can occur during competitive football, ice hockey, or soccer, or may result from a skiing accident, a fall while water skiing, etc. Therefore, experts often advise patients with thoracic aortic disease to avoid these types of sports. [Nataf P, Lansac E. Heart 2006;92;1345-1352]
In addition to the importance of setting clear lifestyle goals with patients with thoracic aortic disease, it is absolutely essential to emphasize the importance of adherence to their medications, especially to beta blockers and other antihypertensive agents. Patients who suddenly discontinue their medications because they fail to obtain a refill or perhaps forget their medications at home when travelling, may find themselves in a hypertensive crisis with a potentially catastrophic result.
Moreover, even patients who are compliant with their medications may find that their blood pressure may rise fluctuate between routine visits to the doctor, resulting in months of excessive hypertension. Therefore, patients may achieve more consistent control of their hypertension if they regularly track their heart rate and blood pressure with a home monitoring system. In addition, by regularly tracking their weight and activity profile they can provide their physician and other care members with accurate data with which to make adjustments in medication and lifestyle going forward.
In terms of work, patients with thoracic aortic disease generally can function normally in most types of occupations. The exception is any job involving heavy physical and manual labor accompanied by extreme isometric exercise (e.g., lifting heavy boxes in a stockroom, carrying furniture up and down stairs, etc.) As with the heavy weight lifting described above, this type of unusual sudden stress on the aorta is thought to predispose to a higher chance of triggering either aortic rupture or aortic dissection. Therefore, when patients have a vocation in which such extreme lifting might be required, it is important to discuss the details of their daily job responsibilities and to prescribe avoidance of activities that might put them at risk. In some cases patients can readily avoid such heavy lifting on the job, but in many cases a letter from a physician explaining the restrictions may be required.
Finally, it is important that patients with thoracic aortic disease recognize that aortic disease is usually a lifelong condition that puts them at future risk for acute aortic syndromes. Even those who have received advanced surgical or endovascular therapy must understanding that their aortic disease has not been "cured" by the interventions. Educating them about what to do in the event of the sudden onset of chest, back or abdominal pain, or the sudden development of an ischemic complication (i.e., neurologic or limb) and the critical nature of getting to an emergency department promptly, is of the utmost importance. It is similarly important that those who live with or care for such patients understand what action needs to be taken should concerning symptoms arise.