admitted to cardiac rehabilitation programs after acute coronary syndromes, episodes of acute congestive heart failure, and cardiac revascularization. A common clinical problem in these patients is to decide whether to start or continue physical training or not, given the risk of pulmonary embolism. Until definite evidence becomes available, careful patient selection and inpatient supervision may avoid the a priori withdrawal of such an important core component of cardiac rehabilitation programs

Ambrosetti, M.

Pedretti, R. F. E.

Salerno, M.

Tramarin, R.

walter ageno

Monaldi Archives for Chest Disease

Undetermined

Marco Ambrosetti

Mario Salerno

Walter Ageno

Roberto Tramarin

Roberto FE Pedretti

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Monaldi Arch Chest Dis2005; 64: 24-26 ORIGINAL ARTICLEThere is convincing evidence that structured pro-grams of cardiac rehabilitation (CR) favourably im-prove the clinical course of cardiovascular diseases,and their provision is now considered a standard ofcare for patients suffering from a variety of chronicand post-acute conditions. CR is currently indicatedfor all patients with a diagnosis of acute myocardialinfarction (MI), patients who have undergone coro-nary artery bypass graft surgery (CABG), percuta-neous transluminal coronary angioplasty (PTCA) orcardiac transplantation, patients with chronic stableangina, chronic heart failure (CHF), intermittent clau-dication (IC), and subjects at high risk for cardiovas-cular disease.1Several of these conditions are significantly as-sociated with an increased risk of venous throm-boembolism (VTE). Data from a large registry ofUnited States patients2 show that diagnosis of deepvein thrombosis (DVT) is common in inpatientswith cardiovascular disease, and is even more com-mon than in inpatients with neurologic disease or in-patients with cancer. The overall estimated inci-dence of DVT after MI is 24%, although the in-creasing use of combined antithrombotic therapiessuch as thrombolytics and heparins in these patientsmight have progressively reduced such rates.3 CHFalso predisposes to VTE with a reported incidenceof approximately 20% in the absence of antithrom-botic prophylaxis during hospitalization for acutedecompensation (3). Among surgical conditions, ap-proximately 20% of patients undergoing CABG de-velope DVT before discharge.4The clinical problemPhysical training (PT) has a pivotal role amongthe core components of CR programs and several clin-ical trials have been published indicating the safetyand efficacy of PT in stable coronary artery disease(CAD), CHF, and IC.6-8 Walking, cycling, and calis-thenics are widely applied as the modality of exercise,and intensities of 60-80% heart rate reserve and 60-80% of the predetermined peak heart rate are oftenprescribed. In addition, musculoskeletal flexibility andmovement coordination are encouraged. In the case ofconcomitant DVT, these modalities of exercise havethe potential to both worsen DVT symptoms and in-crease the risk of subsequent pulmonary embolism(PE). Because of venous obstruction and reflux, out-flow cannot match inflow under conditions of in-creased muscle blood flow during exercise, thus pro-moting fluid transudation from the capillaries into theinterstitial space and impairing leg muscle perfusion.As a consequence, patients may experience exercise-induced leg swelling and muscle fatigue. Exercise canalso theoretically cause the breakup of a proximal clotand thus the embolization to the lungs. This is gener-ally the leading reason for stopping PT in patients withconcomitant DVT. In 1992 the Task Force of theWorking Group on Cardiac Rehabilitation of the Eu-Is physical training contraindicated in patients with deep vein thrombosis during cardiac rehabilitation?Il training fisico è controindicato nei pazienti con trombosi venosa profonda durante riabilitazione?Marco Ambrosetti, Mario Salerno, Walter Ageno°, Roberto Tramarin, Roberto FE PedrettiDivision of Cardiology, IRCCS Fondazione Salvatore Maugeri, Tradate, Italy.°Department of Internal Medicine, University of Insubria, Varese, Italy.Corresponding author: Dr Marco Ambrosetti; Division of Cardiology; IRCCS Fondazione Salvatore Maugeri; Via Roncaccio 16, I-21049 Tradate (VA), Italy; E-mail address: mambrosetti@fsm.itABSTRACT: Is physical training contraindicated in patientswith deep vein thrombosis during cardiac rehabilitation? M.Ambrosetti, M. Salerno, W. Ageno, R. Tramarin, RFE Pedretti.Deep vein thrombosis is a potential complication in patientsadmitted to cardiac rehabilitation programs after acute coro-nary syndromes, episodes of acute congestive heart failure, andcardiac revascularization. A common clinical problem in thesepatients is to decide whether to start or continue physical train-ing or not, given the risk of pulmonary embolism. Until definiteevidence becomes available, careful patient selection and inpa-tient supervision may avoid the a priori withdrawal of such animportant core component of cardiac rehabilitation programs.Keywords: deep vein thombosis, cardiac rehabilitation,physical training.Monaldi Arch Chest Dis 2005; 64: 24-26.25DEEP VEIN THROMBOSIS AND PHYSICAL TRAININGropean Society of Cardiology included the presence of“active or recent thrombophlebitis” among absolutecontraindications to prescription of PT in patients withCAD, CHF, and cardiac surgery.9 In 2001, the Work-ing Group on Cardiac Rehabilitation & Exercise Phys-iology and Working Group on Heart Failure of the European Society of Cardiology listed “throm-bophlebitis” among absolute contraindications to PTin patients with stable CHF.7However, we believe that there is still inadequateevidence to support these recommendations and thatthe need to categorically avoid or stop PT in all DVTpatients irrespective of clinical symptoms severity,clots localization and morphology, response to an-tithrombotic therapy, cardiopulmonary status, patientcompliance, and any other variable related to the indi-vidual risk of VTE is debatable.Challenges in considering physical exercise in observations DVTIn our opinion, several observations give plausi-bility to the hypothesis that in selected patients withDVT PT may be safely continued. Indeed, it is possi-ble to hypothesize that: 1) exercise could ameliorateDVT symptoms by increasing the calf muscle pump,reducing the hydrostatic pressure gradient required foredema formation; 2) exercise could reduce venous sta-sis and consequently prevent recurrent or progressivethrombosis; and 3) several mechanisms involved inthe documented beneficial effect of PT in patients withIC (such as redistribution of blood flow, changes inblood rheology, metabolic changes, changes in skele-tal muscle morphology, and changes in pain percep-tion) could also be favourable for patients with DVT.In the recent past, DVT patients were commonlyplaced at bed rest for up to ten days after diagnosis;more recently, clinical practice has shifted towardsearlier ambulation. Although strong evidence to sup-port this strategy is still lacking, a large proportion ofopinion leaders in the field of VTE believe that earlyambulation leads to a more rapid resolution of DVTsymptoms and is sufficiently safe once appropriate an-tithrombotic therapy has been started. Strategies and evidenceA recent review by Aldrich and Hunt10 identi-fied only 3 controlled clinical trials11-13 and 1 largeprospective uncontrolled study14 that focused on theissue of early ambulation after DVT (table 1). Therewere no significant differences concerning the oc-currence of PE in early ambulating patients com-pared with the bed rest groups. All studies suggest-ed that, after careful evaluation, DVT patients canambulate early in the absence of an increased risk ofPE. Although not specified, it is also reasonable toassume that clinical studies evaluating the outpatientmanagement of DVT with low molecular weight he-parin (LMWH) included early ambulation, or atleast did not promote bed rest at home. Given thesafety of LMWH administered at home,15 we can ar-gue that ambulation was correspondingly safe.However, early ambulation and compression thera-py cannot be considered as structured PT activities. Wesought evidence from the medical literature to identifystudies addressing the efficacy and safety of PT in theacute management of DVT patients, especially in thecardiovascular setting. A series of MEDLINE databasesearches were performed using the following MedicalSubject headings: deep vein thrombosis, pulmonary em-bolism, venous thromboembolism, exercise, physicaltraining, and cardiac rehabilitation. This strategy yield-ed no study that we considered relevant to answer theabove question. We only found one article by Kahn etal16 in which treadmill exercise was shown not to wors-en post-thrombotic symptoms, although no convincingevidence was found regarding the adoption of PT im-mediately after diagnosis of DVT.At the institute of Tradate of the SalvatoreMaugeri Foundation, we performed two clinical stud-ies evaluating the postoperative incidence of DVT inan unselected17 and a selected18 population of CABGpatients entering CR. Overall, 67 (18%) had DVT.Proximal and isolated distal DVT cases were respec-tively 13% (9 cases) and 87% (58 cases) of the wholeDVT population. Forty-three DVT cases (64%) werediagnosed at admission, while 4 cases (6%) were di-agnosed after a structured PT program was started.Table 1. - Studies evaluating early mobilization in patients with deep venous thrombosis (DVT)Author, year Patients evaluated Strategy after diagnosis of DVT Development of PEAschwenden11, 2001 69 LMWH, early ambulation >4h/d, and ES 14%60 LMWH and immobilization for 4d 10%Schellong12, 1999 63 LMWH/OA, early ambulation, and ES 22%59 LMWH/OA, immobilization for 8d, and ES 17%Partsch13, 2000 15 LMWH, early ambulation 13%15 LMWH, early ambulation, and ES 7%15 LMWH and immobilization 7%Partsch14, 2001 1,289 LMWH/OA, early ambulation, and ES 14% in proximal DVT, 3% in isolated distal DVTDevelopment of Pulmonary Embolism (PE) was evaluated by V/Q scan on day 4 in study 11, on day 9 in study 13, and on day 10in studies 12,14.Legend: DVT: deep vein thrombosis; ES: elastic stockings, LMWH: low molecular weight heparin, OA: oral anticoagulants.26M. AMBROSETTI ET AL.These findings indicate that DVT may frequently oc-cur in CABG patients during CR and most often isconfined to the calf veins. In the case of DVT diag-nosed during CR, our policy attributes to the treatingphysician the decision to initiate/continue or to stopthe PT program after careful patient evaluation. Thekey elements providing an objective basis for the clin-ical decision are medical history, assessment of car-diopulmonary status, clots localization, ultrasono-graphic surveillance, and initiation of appropriate an-ticoagulation therapy. In the case of a decision favour-ing PT, patients with distal isolated DVT receive exer-cise training with an optimal intensity of 80% of peakVO2 (or peak heart rate) as detected by treadmill ex-ercise stress test, while patients with proximal DVTreceive low workload exercise (12 Borg Scale) in theabsence of cardiac stress testing. The standard dura-tion of the program is at least 3 weeks. For the purposeof this review, we analysed the safety of such a policyin terms of the occurrence of clinically evident PEamong patients enrolled in the two studies. Of 67 pa-tients considered, 2 (3%) did not have PT prescribedbecause of concomitant acute congestive heart failure(1 case) and an absolute contraindication to an-tithrombotic therapy (1 case). The incidence of PE at1 month in DVT patients in whom PT was not con-traindicated was 3% (2 cases). Both PE cases occurredwithin day 2 after diagnosis of DVT. In one case a sin-gle low workload PT session was administered afterprescription of anticoagulants and elastic stockings.ConclusionsRecent challenges in the treatment of DVT andlimited experiences suggest the hypothesis that DVTmay not represent an absolute contraindication tosome degree of PT activity during the inpatient phaseof CR. In this perspective, the evaluation of the indi-vidual patient profile and the use of PT like a drug perse are crucial to ensure a safe management. In ouropinion, the absence of respiratory symptoms, a stableclot, and the institution of appropriate anticoagulationmay favour the decision to start or to continue PT af-ter diagnosis of DVT. However, such a decision needsto be tailored to clinical circumstances, available fa-cilities, and local expertise. Controlled trials of struc-tured PT in patients with acute DVT are warranted toprovide definite recommendations. Riassunto La trombosi venosa profonda può complicare ildecorso riabilitativo di pazienti con esiti di sindromecoronarica acuta, scompenso cardiaco e rivascola-rizzazione coronarica. In questi casi la decisione cir-ca l’opportunità di iniziare o proseguire il previstoprogramma di training fisico può essere problemati-ca, stante il potenziale rischio di embolizzazione deitrombi periferici a livello del circolo polmonare.Sebbene corpose evidenze non siano al momento di-sponibili, l’appropriata selezione dei pazienti e l’at-tenta supervisione clinica potrebbero evitare l’aprio-ristica rinuncia a uno dei principali componenti deiprogrammi di riabilitazione cardiologica.Parole chiave: trombosi venosa profonda, riabi-litazione cardiologia, training fisico.References1. Giannuzzi P, Saner H, Bjornstad H, et al. Secondary pre-vention through cardiac rehabilitation. Position paper ofthe working group on cardiac rehabilitation and exercisephysiology of the European Society of Cardiology. EurHeart J 2003; 24: 1273-1278.2. Goldhaber SZ, Tapson VF. A prospective registry of5,451 patients with ultrasound-confirmed deep veinthrombosis. Am J Cardiol 2004; 93: 259-262.3. Geerts WH, Heit JA, Clagett GP, et al. Prevention of ve-nous thromboembolism. Chest 2001; 119 (suppl 1):132S-175S.4. Goldhaber SZ, Hirsch DR, MacDougall RC, et al. Pre-vention of venous thrombosis after coronary artery by-pass surgery (a randomized trial comparing two mechan-ical prophylaxis strategies). Am J Cardiol 1995; 76: 993-996.5. Prandoni P, Bilora F, Marchiori A, et al. An associationbetween atherosclerosis and venous thrombosis. N Engl JMed 2003; 348: 1435-1441.6. Joliffe JA, Rees K, Taylor RS, et al. Exercise-based reha-bilitation for coronary heart disease. The Cochrane Li-brary, Volume (Issue 3) 2001.7. Working group on cardiac rehabilitation & exercise phys-iology and working group on heart failure of the Euro-pean Society of Cardiology. Recommendations for exer-cise training in chronic heart failure patients. Eur Heart J2001; 22: 125-135.8. Gardner AW, Poehlman ET. Exercise rehabilitation pro-grams for the treatment of claudication pain. JAMA 1995;274: 975-980.9. Recommendations by the Working Group on Cardiac Re-habilitation of the European Society of Cardiology. Long-term comprehensive care of cardiac patients. Eur Heart J1992; 13 (suppl C): 1C-45C.10. Aldrich D, Hunt DP. When can the patient with deep ve-nous thrombosis begin to ambulate? Phys Ther 2004; 84:268-273.11. Aschwanden M, Labs KH, Engel H, et al. Acute deepvein thrombosis: early mobilization does not increase thefrequency of pulmonary embolism. Thromb Haemost2001: 85: 42-46.12. Schellong SM, Schwarz T, Kropp J, Prescher Y,Beuthien-Baumann B, Daniel WG. Bed rest in deep veinthrombosis and the incidence of scintigraphic pulmonaryembolism. Thromb Haemost 1999; 82 (suppl 1): 127-129. 13. Partsch H, Blattler W. Compression and walking versusbed rest in the treatment of proximal deep venous throm-bosis with low molecular weight heparin. J Vasc Surg2000; 32: 861-869. 14. Partsch H. Therapy of deep vein thrombosis with lowmolecular weight heparin, leg compression and immedi-ate ambulation. Vasa 2001; 30: 195-204.15. Levine MN, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at homewith unfractionated heparin administered in the hospitalfor proximal deep-vein thrombosis. N Engl J Med 1996;334: 677-681.16. Kahn SR, Azoulay L, Hirsch A, Haber M, Strulovitch C,Shrier I. Acute effects of exercise in patients with previ-ous deep venous thrombosis. Impact of the postthrombot-ic syndrome. Chest 2003; 123: 399-405.17. Ambrosetti M, Salerno M, Zambelli M, Mastropasqua F,Tramarin R, Pedretti RFE. Deep vein thrombosis amongpatients entering cardiac rehabilitation after coronaryartery bypass surgery. Chest 2004; 125: 191-196.18. Ambrosetti M, Salerno M, Pedretti RFE. TVP dopoBPAC: Resa di una policy operativa di screening valida-ta su base osservazionale. It Heart J 2003; 4 (suppl 1):25S (abstract).

Is physical training contraindicated in patients with deep vein thrombosis during cardiac rehabilitation?

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Is physical training contraindicated in patients with deep vein thrombosis during cardiac rehabilitation?

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