Despite enormous progress in understanding factors that lead to cardiac conditions, heart attacks are still the major cause of death in the United States. With the transformation of people's attitudes about fitness, a heart attack does not have to lead to a life of fear and despair. Cardiac rehabilitation programs are designed to help cardiac patients achieve an improved state of health, actually making them stronger than they were prior to their heart attacks.

WHO IS A CARDIAC PATIENT?
A cardiac patient may be defined as someone who has:

1. had a heart attack and has received some type of cardiac surgery.
2. had a heart attack and has not received surgery.
3. been diagnosed as "high risk" for coronary artery disease (CAD).

In addition, there are countless others who would fit the category of "high risk" for CAD (those who have a family history of premature CAD, who live a sedentary lifestyle, who currently smoke, who are obese, who are hypertensive and/or diabetic, and who have low HDL cholesterol), but who remain undiagnosed.

WHAT IS A CARDIAC REHABILITATION PROGRAM?
Cardiac rehabilitation programs are not exclusively for those patients who have had a heart attack and/or heart surgery. They are for any person who is a cardiac patient, or is considered "high risk" for CAD. Cardiac rehabilitation programs are offered by many hospitals, some universities and colleges and many public exercise facilities (such as YMCAs). They are designed to improve a person's health and cardiovascular condition to the point where the individual is able to participate in recreational activities and exercise at whatever level he or she desires. A cardiac rehabilitation program is divided into four phases:

Phase 1: Inpatient

This takes place in the hospital after a person has had a heart attack and/or surgery. It will include education, a supervised exercise program, dietary recommendations and some level of exercise.

This also takes place in the hospital or clinic, or as an "out-patient" and lasts for two to three months. Same content as Phase 1, but more participatory.

This phase is medically supervised and will last six to nine months. It is designed to develop the conditioning level of the patient beyond the level prior to hospitalization. The patient has now returned to his/her previous employment and/or daily routine.

This phase will last for the rest of a person's life, and is supervised by non-medical personnel (e.g., exercise physiologists, dietitians and fitness practitioners and other exercise specialists). It includes extensive exercise, stress reduction, dietary planning and periodic exercise testing.

APPROPRIATE EXERCISES
Years ago, exercise of any sort was considered a radical way to treat cardiac patients who have had surgery or not. Now it is not only a rational approach to rehabilitation, it is a mandatory part of any good cardiac rehab program.

Exercises in Phases 1 and 2 are primarily aerobic activities using stations such as stationary bicycles, treadmills, stair stepping and rowing machines. During Phase 1 and even the early stages of Phase 2, resistance weight training may not be the best form of exercise as it may elevate blood pressure. In the earliest stages of Phase 3, exercises that include stopping and starting, handball or racquetball for instance, are not recommended. By the time a person has moved into Phase 4, weight training is appropriate, as are most forms of aerobic activity, such as walking, swimming and cycling. In the latter stages of Phase 4, other strenuous activities, such as tennis, can be introduced.

CARDIAC MEDICATIONS AND EXERCISE
Some cardiac patients may be on heart or blood pressure medications. Since some cardiac and hypertensive drugs slow down the heart, it is important to anticipate a slower heart rate when exercising or performing exercise testing. One goal of cardiac rehabilitation is for the patient to become drug-free.

Blood pressure elevates during exercise. When exercise is routinely and consistently performed, the heart becomes conditioned and the circulatory system improves. It is important to design the exercise program to be vigorous enough to elevate blood pressure and heart rate to the proper levels. The worst thing a cardiac patient can do is be inactive.

OVERCOMING PSYCHOLOGICAL FACTORS FOR A CARDIAC PATIENT
In the past, post-surgical patients rested in the hospital for weeks and then were sent home to rest — sometimes for months. Fear of another heart attack after surgery due to exercise is now diminished. In fact, most people begin a mild exercise program from day one. The faster a cardiac patient becomes involved in a healthy lifestyle, the greater are the chances of living a full and vital life. Questions and concerns continue about exercising in the heat, especially during the late summer period when intense heat and high humidity are commonplace.

Overdoing it, with exercise or any type of strenuous physical activity, can cause serious problems -- possibly even fatalities. Mid-afternoon heat and humidity present an environmental condition that all exercisers of any age and conditioning level should carefully consider before they begin to exercise outdoors.

To exercise in the heat, a person should evaluate the potential heat/stress danger that results from the combination of temperature and humidity.

The combination of temperature and humidity is the Temperature Humidity Index (THI). This figure is usually reported on radio and/or TV weather forecasts, or can be obtained by contacting the Weather Bureau. Based on the THI, judgements can be made for the amount and type of exercise a person can safely perform in the heat.

The following table represents the recommended exercise options at various THIs with humidity greater than or equal to 60%:

Over 80 degrees F

Swimming/water activities only.

77.6-80.0 degrees F

Light calisthenics. No more than a few laps of easy jogging. Swimming is a preferred activity.

75.1-77.5 degrees F

Only very slow jogging and light calisthenics for all exercisers. Be alert for distress signs such as getting pale or overly red in the face.

72.6-75.0 degrees F

Reduce distance and intensity of running. Overweight individuals should limit activity to easy calisthenics and slow jogging.

70-72.5 degrees F

No sweatsuits or warmups. Overweight individuals should reduce activity.

Below 70 degrees F

No danger to exercise.

Heart rate can serve as a good indicator of exercise tolerance in the heat. On a day of high heat and humidity, training heart rate will be achieved at lesser than usual physical exertion. Therefore, it is prudent to measure your heart rate when exercising in the heat, as it is an excellent indicator of how tolerant you are. If your heart rate is above the usual for a given amount of exercise, or if you achieve your training heart rate very quickly, the exercise you are performing, under the current temperature and humidity conditions, is too severe and you should slow down or stop.

Slow progression of your outdoor exercise routine will aid your acclimation to exercising in the heat. However, when it is hot and humid, go swimming or seek the controlled environment of an air-conditioned exercise facility.

HYDRATION
The body's need for water is only second in importance to its need for oxygen. Water accounts for approximately 55-60% of our adult body weight and approximately 70% of infant weight. A 10% loss of body water may pose a significant health risk, while 20% of body water loss may result in death. Aerobic exercise involves the generation of internal heat through performance of muscular work. As the core temperature rises, an increased amount of cardiac output (the volume of blood pumped by the heart in one minute) is delivered to the skin so heat can be dissipated in the form of sweating. Heat is lost principally through evaporation of sweat from the body's surface, which cools the individual at the price of losing vital circulating fluids. Prolonged strenuous exercise invariably leads to dehydration, which may lead to headaches, muscle cramps, lightheadedness, fatigue, confusion, lethargy, and persistent elevated body temperature. Advanced stages of heat exhaustion from exercise may lead to coma and even cardiac arrhythmias and sudden death. These rare and extreme hazards can be prevented by knowing ways to avoid dehydration and hyperthermia (elevated body temperature) during exercise.To make certain you are consuming enough fluids to adequately hydrate your body, it is recommended that you drink 8-10 glasses of fluids daily (eight ounces per glass). Drink before, during, and after exercise and don't rely on your thirst mechanism to tell you how much fluid you need. Avoid items which contain caffeine (e.g., coffee, soft drinks and tea) or alcohol (e.g., beer, wine, etc.) for these can increase urine production and fluid loss.

HEAT INJURY PREVENTION
The following are actions to be taken to help prevent dehydration and hyperthermia during exercise.

1. Adequate hydration before exercise is the best prevention. Come to your exercise session well hydrated, passing clear-colored urine every two to four hours. Consume 8-10 ounces of water, 10-20 minutes before beginning a light workout.
2. Insist on warming up. The warm-up phase of exercise gradually increases your body temperature allowing the sweat mechanism to kick into place.
3. When exercising for one hour or more, take breaks to consume additional water. Recommended intake is three ounces every 20 minutes.
4. Avoid salt tablets. Sweat is composed primarily of water lost from the tissues in a greater proportion than losses of sodium and chloride. This means that the body is under pressure to correct the imbalance. For this reason, additional salt or salt tablets are undesirable prior to or after strenuous exercise. An individual should rely on the use of water alone to prevent heat injury or thermal stress.
5. Wear clothing that allows evaporation and ventilation. Appropriate dress during exercise is another important consideration in the prevention of heat stress. This involves dressing in light, loose-fitting clothing during hot weather exercise, especially on humid days when the sweating mechanism is less efficient.
6. On very hot days, stay indoors or in the shade. Exercising in full sun increases the risk of heat injury. Covering the head guards against the sun's radiant energy and protects one from dehydration as well as sunburn.
7. If you become overheated, moisten your skin by sponging or spraying with water to assist in the cooling process. Fans may aid evaporation. Such cooling measures provide a form of external sweating, which helps to dissipate heat without using internal fluid resources for evaporation.
8. Avoid the use of saunas, steam rooms and hot tubs immediately following exercise -- they can compound the problem of fluid depletion. Dizziness and fainting are not uncommon in saunas after strenuous exercise sessions.

WHAT IS STRESS?
Stress is your reaction to stressors -- conditions or events causing stress. Stressors can be external (getting a divorce; losing your job; moving to a new home; sitting in a dentist's chair) or internal (feeling frustrated; lacking direction; or having a negative outlook).

Stress is the specific response of the body to any demand made upon it. Reactions to stressors can be as varied as the stressors themselves.

Stress is considered the culprit in compulsive overeating, loss of appetite, hyperactivity, lethargy, depression, mania, and high and low blood pressure. Researchers have documented its role in accelerated aging, accidents, viral infections, ulcers, heart attacks and cancer.

People who have a Type A behavior pattern -- a high pressure, "deadline" personality -- were once thought to be prone to stress-related diseases such as high blood pressure and heart disease. But recent studies show individuals with Type A behavior pattern and who actually get the job done aren't the victims of stress disorders. Another study revealed anger, hostility, cynicism, mistrust, negative thinking and risk of heart disease have a far worse affect on physical health than Type A behavior patterns.

Stress is not all bad, but too little stress can make life drab and unstimulating, while too much stress may result in chronic fatigue, tension, and a variety of other aliments.

RECOGNIZING YOUR STRESS REACTION
Physically, we respond to stress the same way human beings always have. The physiological stress response begins with the senses recognizing a threat. The brain makes a quick decision, either "fight or flight," and then sends messages to the body. The hypothalamus alerts the adrenal glands for an immediate outpouring of adrenaline, a hormone which raises heart rate, increases respiration and redirects blood flow to the limbs from the viscera. The pupils of the eyes dilate, the mouth gets dry, the stomach stops digesting and the body is prepared for strength, speed and power. Adrenaline surges are meant to be a life-saving measure. The physical process that may save your life, however, can also take a physical toll if triggered too frequently, especially if triggered by events that don't call for physical exertion.

IDENTIFYING YOUR RESOURCES
Although you can enhance your skills for coping with stress, you should take an inventory of the number of stressful situations in your daily life. Eliminate the stressors you can, while also identifying the resources in your life.

Relationships
They can be either a source of stress or stress-release. Often they're both. Discover how certain relationships are value-adding components in your life. Do you appreciate warmth, sincerity, affection? Do your relationships reflect that?

Work
Engaging, fulfilling and rewarding work has a high degree of positive stress and very little negative stress. If you're not currently in a job or career that meets these criteria, then make sure your non-working hours are pleasantly spent.

Personal Time
Time for personal rejuvenation can give you the energy and fortitude to face crisis or beat boredom.

Recreation
Add a selection of enjoyable activities to your life. Investigate those dreams you've been carrying around for a while.

PERSONAL COPING SKILLS
Relaxation
One myth about relaxing is that it's the same as collapsing -- in front of the TV, for example. We now know that a stupor or "vegging out" is not deeply relaxing. Practicing intentional relaxation states such as progressive, step-by-step muscular tension destressors that revitalize the body and mind are highly recommended. Take a stretch-and-stress reduction class to learn this head-to-toe method. Then practice it at home or work whenever needed.

Rest
Getting optimum sleep is another coping strategy. Less than six hours of sleep per 24 hours can be linked to anxiety states, psychological disorders, chronic fatigue and emotional turmoil.

Meditation
Meditation is an ancient source of stress-release that triggers deep relaxation and clarity of mind. Some experts recommend 20 minutes a day. Others suggest simply meditating with slow breathing for a few minutes to break a stressful pattern. Traditional meditation techniques are a way of letting go and expanding your awareness.

Good Nutrition
Much has been written about the possibility of certain foods acting as physical stressors. Caffeine, refined sugars and foods high in saturated fats are usually linked to a lifestyle that carries the burden of other stress-filled patterns. There is still no hard data that states a candy bar can create added stress in your life. But it's generally accepted that unhealthy eating habits zap your vitality, and deplete your defense against illness and burn-out.

Exercise
Regular aerobic exercise (at least 20-30 minutes a session, three to four times per week) is one of the body's best defenses against negative stress. Make sure you're doing some type of exercise that you thoroughly enjoy, and approach it with a relaxed frame of mind. A "do or die" attitude about exercise can possibly block its positive benefits. Aerobic exercises, such as dancing, walking, running, cross-country skiing or swimming, can help metabolize stress hormones in the body. Common sense should be applied to exercise to avoid strain or overuse injury. An excessive amount of exercise or an exercise intensity beyond your physical capacity can itself act as a severe physical stressor. The welcomed rest between sessions should be considered part of your stress management program.

Imagery
Autogenic relaxation is a technique of self-regulated mental imagery developed over 50 years ago. In a relaxed, seated position with eyes closed, invite yourself to experience warmth and heaviness throughout your body. Let go of all tension and worry as you feel warmth and heaviness fill your neck and shoulders. After working your way from head-to-toe take a few minutes to enjoy the deep relaxation before returning to an alert state.

Prioritizing
Give your demands and activities a priority rating. Focus on what needs to be done now from your "to do" list, and block out sufficient time. Avoid focusing only on problems. Make sure a few recreational stress-release activities are at the top of your list, too.

Assertiveness Training
All the best intentions for planning and organizing your life are cast to the wind if you never learn to say "no." There will always be people and situations that place unreasonable demands on your time. You have a right and the ability to organize your time any way you choose. What are the risks? Are there any benefits? What guidelines are there so I know when I can exercise safely?

Deciding whether or not to work out if you don't feel well can be a difficult decision. You want to stay in shape, get the benefits of exercise, but you also don't want to impede your recovery from the illness. You want that cold, flu, or run-down feeling to go away as quickly as possible. What should you do?

What are the risks?
One major risk of exercising when ill is heatstroke and heat exhaustion. These conditions can occur when an individual is healthy and working out in very hot, humid conditions. However, when you are sick or feverish, the body doesn't deal with overheating as well as usual and therefore you run an increased risk of heatstroke, which can be fatal.

Another major risk of exercising when ill is the rare, but potential risk of developing a viral infection of the heart muscle, known as viral myocarditis. This condition, which can lead to heart failure, heart transplant, or even death, is believed to be associated with having a virus in your body and continuing to overexert yourself. Viral myocarditis is a condition we all want to prevent, if at all possible.

A third risk is making whatever illness you are suffering from worse by exercise. If you have bronchitis, for example, the stress of exercise, and the temporary dip in the immune system that has been documented to occur with strenuous exercise could lead to a worsening of the bronchitis or the development of a pneumonia (a serious lung infection). Sometimes that extra day or two without exercise will actually allow you to heal faster and get back to full strength faster than if you workout sooner than you should.

Another concern is if you participate in a sport or activity where other people are close by there is the potential for transmitting your infectious illness. This can occur with direct touch, and less often with coughing, spitting, or contaminated towels and water bottles.

How can I prevent these problems?
Well, one way is never to exercise except when you feel perfectly well, but obviously this is not a perfect solution. More realistically, you should avoid exercise completely when you have a fever, muscle aches, shakes, chills, or vomiting. These symptoms are often present when a viral or bacterial infection is at its peak, or when the germ is present in high amounts in the blood stream. By avoiding exercise with these symptoms, you drastically reduce the risk of that viral infection you are suffering from infecting the heart muscle. Also, you reduce the risk of dehydration and overheating by waiting until your body can better handle temperature changes.

Second, use the "below-the-neck" rule. Don't exercise if you have significant symptoms below the neck such as abdominal cramps, chest pain or tightness, severe diarrhea, or a cough that feels like it's "in your chest". Don't exercise if you are wheezing significantly or short of breath at rest or with mild exertion such as walking. On the other hand, exercise is probably safe with upper respiratory symptoms such as a runny nose, stuffy nose, sneezing, or scratchy throat.

Are there any benefits to exercise when ill?
If you're at the very end of a cold, sinus infection, or flu, you may find that light exercise is a natural "pick-me-up" after a period of recuperation. This mood elevation can be a positive way to cope with the "moping" feeling often associated with recovering from a viral illness. Also, many individuals report that they get a temporary, but substantial decongestant effect from exercise and are able to bring up whatever phlegm is lingering in their nose or chest at the end of an illness.

Certainly, the longer you go without exercise, the more you lose some of the fitness you have achieved. Sometimes light exercise can help prevent some of the cardiovascular and strength and flexibility losses associated with inactivity. However, it takes a week or two for these losses in fitness to become significant for most people.

What changes should I make when I choose to exercise while ill?
If you do decide that you feel well enough to exercise, be sure to follow your body's reaction to exercise rather then working out based upon your expectations of how far or how fast you "should" be going. Start slow, ease into exercise. Choose a lower than usual intensity for your first workout. Select an easier intensity on the stationary bike, run slower, or take a beginner's aerobics class if you're usually at an intermediate level. Lower the number of repetitions and the amount of weight that you lift.

Warm up with a brisk walk, don't rush yourself, allow time between segments of your workout. The overall workout time should also be reduced by about one third to one half depending on how you feel and how long you were inactive. STOP if you feel miserable!

Are there any vital signs I can monitor?
Your body will tell you if you're overdoing it. Telltale signs include: a high resting pulse rate, an unusually high pulse rate response to relatively light exercise, and the rapid onset of fatigue. If you notice your urine is more yellow or darker than usual either before or after your workout, pay attention to fluid intake. Drink a lot of water or electrolyte drink and AVOID dehydration.

Check your pulse rate (see exercise intensity Card). If your usual morning resting pulse rate is 60 and you're at 80 on a given day while recovering from the flu, consider postponing your first workout or exercising very lightly. Also monitor the effect of exertion on your pulse rate and avoid exercising toward the peak of your usual range if you're not up to par.

Summary
In short, use common sense when deciding whether to exercise when you're sick. Remember the "below-the-neck" rule and drink plenty of fluids. If your body says "no" or "stop," listen to it.

Asthma is a manageable condition for both adults and children. Treatment for children focuses on the reduction or elimination of triggers and proper use of the medications. Asthma affects approximately one in every ten children and is the most common chronic illness today. Asthma in children causes different problems than it does in adults. Children with asthma may have to make some drastic lifestyle changes that can alter the child’s entire life. Children have small airways that can become inflamed or blocked more easily than in adults. For this reason, the symptoms are more pronounced and serious. The major signs are wheezing during a respiratory illness and coughing at night. Other signs are:

• Rapid and noisy breathing
• Concaved chest
• Congestion or tightness in the chest
• Shortness of breath
• Less stamina than a non-asthmatic child

WHAT TRIGGERS ASTHMA?
Triggers are those situations or substances that bring on asthma symptoms in individuals with this condition. These triggers vary widely from person to person, depending upon the situation. In young children, triggers are often colds and other upper-respiratory infections. The list of triggers includes, but is not limited to, allergens, viral respiratory infections, aspirin, occupational hazards, physical exertion, food additives and cigarette smoke. Any of the above, alone or in combination, may trigger an asthma attack. Learning what triggers an asthmatic attack may be the key to the treatment for managing the asthma.

USE OF BRONCHODILATORS AND OTHER MEDICATIONS
There have been great strides in the treatment of asthma over the last several years. In the past, the main focus was on treating bronchospasm. Bronchodilators were used to relieve the breathlessness, wheezing, coughing and chest tightness of acute attacks. This led asthmatics to believe that if they carried a bronchodilator with them, their asthma was under control. However, this was not necessarily the case. Scientists have recently discovered the underlying reason for asthma is inflammation and swelling of the linings of the airways. In fact, if the inflammation is left untreated, it could lead to permanent lung damage. Always address any questions or concerns with your health care provider.

Anti-inflammatory drug treatment, even when no symptoms are present, is the best treatment for managing asthma. Corticosteroids (inhaled, oral or injected forms) are the most common anti-inflammatories. Inhaled corticosteroids are by far the safest method, acting to reduce and prevent inflammation in the airways of the lungs. Corticosteroids are members of the cortisone family and can have side effects, especially when taken over prolonged periods of time or taken improperly. Anti-leukotrines and leukotrine modifiers are very effective anti-inflammatory medication in the prevention of inflammation. Although there is no one best medication for asthmatics, doctors can tailor treatment to meet the individual needs of their patients. Whatever a physician prescribes, remember to follow closely the prescription amounts and frequency. Physicians generally advise patients not to skip doses when symptom-free and that they should not increase the dosage beyond what is prescribed when symptoms are present. Check with your physician for advice.

Bronchodilator drugs are used to manage symptoms once they occur. Bronchodilators can prevent symptoms of exercise-induced asthma if properly taken 15 minutes prior to exercise. They open blocked airways, as well as relax the muscles surrounding the airways that tighten and block the flow of air in and out of the lungs. Although they provide rapid relief of severe symptoms, their role is being reassessed. They tend to mask reactions, allowing the asthmatic to tolerate irritants that can cause permanent damage to the lungs. Overuse may provide a false sense of security. However, with proper use, they still play a valuable role in managing asthma symptoms. Remember to always closely follow the prescription amounts and frequency.

If a primary care physician cannot control the asthma with prescribed treatment, then consult an asthma specialist. In almost every case, a specialist can provide an aggressive treatment program that will prevent or relieve symptoms.

CAN A CHILD PARTICIPATE IN EXERCISE?

Exercise is one of the best things you can do for asthma. For many years, those with asthma were discouraged from exercising. A common myth was that asthmatics were "sick" and not capable of engaging in sports or exercise programs. This increased the risk for many asthmatics, especially children, to become overweight. Today, studies show those with asthma can, and actually should, exercise. However, asthmatics must be monitored by a physician initially, since unregulated exercise often leads to exercise-induced asthma. As a good rule, the simple fact that asthma may trigger symptoms is not a reason for asthmatics to forego exercise if their physician approves a plan of physical activity. Measures can be taken to reduce, or prevent, the onset of these symptoms.

WHAT TYPES OF ACTIVITIES SHOULD BE INCLUDED IN AN EXERCISE PROGRAM FOR AN ASTHMATIC?

As previously stated, exercise is an important element for asthma management. Swimming has been cited as one of the best modes of activity for asthmatics due to the warm, humid conditions in most pool situations. Running and continuous exertion are much harder on the asthmatic than swimming or other less demanding sports or activities. Therefore, any activity calling for continuous vigorous running could prove to be too stressful. Exercise that is sporadic, occurring in short intervals, rather than sustained, is recommended. However, when the asthma is well managed, a person may be able to participate in any exercise activity as approved by their doctor.

EXERCISING SAFELY WITH ASTHMA

With effective management, a person with asthma can participate safely in virtually any exercise activity. It is important for those with asthma to know their triggers and remember to exercise responsibly. Below is a list of helpful hints for exercising safely with asthma.

• Consult a physician before beginning the exercise program.
• Begin slowly and gradually increase intensity and/or duration. Do not push too quickly in an effort to accomplish too much too soon (this could actually jeopardize the health of the asthmatic).
• Set realistic goals (don’t compromise health in an effort to push beyond personal limits).
• Always allow sufficient warm-up and cool-down. These are important, especially if symptoms are triggered by exercise.
• Exercise in appropriate weather. Remember that excessively hot, humid weather, air pollution, and cold, dry weather can trigger asthma symptoms.
• If seasonal symptoms are a problem, be aware that extra medication may be needed during those times of the year.
• Ensure that medications are taken as prescribed and are available for those instances when exercise-induced asthma symptoms occur.

note: This information was derived from various medical publications, the American Asthma Association and the American Lung Association.