Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 93: Is snow shoveling safe for the cardiac patient?
What might seem like a simple task in the winter months could lead to devastation without the right education. What do we need to consider to keep our patients with heart disease safe?
The concern lies in the compounding effect. The effect of cold weather on the cardiopulmonary system, age, comorbidities, and aerobic capacity all play a role in determining safety.
Join me as we dive into HR response, MET levels, predictive equations, and much more.
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Multihead Snow Shovel
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Rachele Burriesci:We have sun today. This is probably the first day that we've had like the sun shining and we have some relatively warm weather, for right now it's 40 degrees out, just about getting a little bit of melting, which is nice, because we still have driveways that are completely frozen over and I think, just as a New Yorker who has the expectation to clear driveways and make sure your sidewalks are passable, it's actually quite surprising how little people shovel here. We just actually went for a walk I think it was yesterday and we took the main subdivision block to get back to. The house has not been touched one time, so now it's frozen footstep marks. It was quite an adventure to go that route, so it's getting better out there, but still we're a week out, or more than a week out, week and a half out, and we're still pretty poor sidewalk type stuff for the walking pedestrian, pretty poor sidewalk type stuff for the walking pedestrian. The roads have been okay for a little bit. So this actually brings me to something I was thinking about quite a bit last week while I was shoveling and snow blowing and using all sorts of devices to clear the snow, and it's a question that I got pretty frequently in cardiac rehab, especially in the winter months, because this is one of those big questions. Right, can I get back to shoveling snow? So the question really is is it safe for patients with heart disease to shovel snow, to use a snowblower? That whole picture. The answer is going to be the one that everyone hates, and that is it depends. It depends on a number of different factors and we're going to get into that today.
Rachele Burriesci:But, similar to mowing a lawn, we really need to consider the met level of activity that is occurring with snow shoveling. And then you have to compound that with the effects of being out in cold weather. And if you haven't heard my last podcast episode, I talked about the effects of the cardiopulmonary system in cold weather. So, just as a recap, our lungs are affected by cold temps, typically when we're temperatures less than 30 degrees. I highly recommend that, if you're going to be outside, that you cover your nose and mouth, that you aim to breathe in through your nose, because it's a built-in humidification and warmification center.
Rachele Burriesci:But even still, the changes are bronchoconstriction of the airways. Changes are bronchoconstriction of the airways, irritation of the lung tissues, increased inflammation within the lungs and dehydration of the lungs, which actually can potentially decrease immune function. So we have some things that can really stir up problems for our patients who are asthmatics, who have episodes of triggering events. Cold weather can be one of those triggers. Our patients with lung disease, especially things like emphysema, chronic bronchitis, may be more affected, may have higher rates of exacerbation in the winter.
Rachele Burriesci:On the heart side of things, cold weather affects the vessels, similar to the airways. It causes constriction, just like pipes in the house. So if we're creating vasoconstriction within the lungs, we're going to put more pressure on the right side of our heart, just like pulmonary hypertension. If we have cold weather, we're vasoconstricting to basically maintain core temperature, with that effect leading to increased heart rate and increased blood pressure. So in cold weather you can expect your heart rate and blood pressure to be elevated.
Rachele Burriesci:Now comes the question of well, can I shovel snow? It really depends on your level of heart disease. Have you had a recent event? For instance, a lot of my patients in cardiac rehab just recently had an MI, just recently had a sternotomy, post-cabg. Those things really do make a huge difference in that decision making. If you have longstanding chronic heart disease, hypertension, but maybe haven't had an MI or a heart failure exacerbation or something like a cabbage, the conversation may be a little different or maybe not.
Rachele Burriesci:And then we also have to consider resting vital signs. What is your resting heart rate? What is your resting blood pressure and what types of medications are you on? Are you on something like a beta blocker. That blunts your response and we won't be able to see that heart rate change. Things to talk about, right? So I talked about MET levels in the conversation about mowing the lawn, so if you want, go back to that episode as well.
Rachele Burriesci:But again, a little summary. A MET is a metabolic equivalent and basically it's a number to guesstimate oxygen consumption. And at rest we have this number that we would consider our normal resting metabolic rate, which will change based on age, sex, weight, height if you're pregnant, your body temp and all sorts of things. But we do have some roundabout estimate numbers that basically say at rest you're consuming one met level of activity which is equivalent to 3.5. And I'm going to always I always get my units wrong, so I'm just gonna make sure I get it right 3.5 milliliters per kilogram, per minute of oxygen. So at rest we're typically running at one met level oxygen consumption to run our vital organs and then, depending on what type of activity we're doing, they can be rated by a met level.
Rachele Burriesci:So from a PT perspective, speaking to your patients in METS can be a great education point. Now I'm not saying to explain to them how to convert the formula and basically tell them how many kilograms per milliliter of minute of oxygen consumption that they're performing. In theory you could do that right. So if we rest at 3.5 and we're performing a five met level activity, we're going to have 17.5 milliliters per kilogram per minute of oxygen consumption, essentially five times the amount of energy consumption than at rest. That might be too much information in the sense that it doesn't, you know, equate to anything substantial, and I think that's where people maybe feel like they don't use meds. I like it because it gives us numbers and goals and we can correlate it to different tests. For instance, if we're talking about a patient who's in cardiac rehab, this is a really great way to discuss. Are you ready to fill in the blank?
Rachele Burriesci:Whatever the activity is, when you enter and exit cardiac rehab, you typically perform a sub-max exercise stress test like a Bruce protocol. When they perform that Bruce protocol, they're doing what's called a symptom-limited stress test, meaning they're going to stop the test when the patient becomes symptomatic, which typically in this situation would be angina or the patient quits. So you have a true max heart rate. You can actually see the METs that were achieved on that test. So, best case scenario you have a pre and a post and you can see max heart rate and METs achieved. Let's say they achieved three METs on their test. That was their max effort, best effort. They were able to achieve three METs.
Rachele Burriesci:So when you get into a conversation about is snow shoveling safe, you can pull up the compendium which I will link in the show notes and show them that at this point, based on what you have accomplished in cardiac rehab or whatever the situation might be, that snow shoveling is six months. So that would be twice the capacity that they were able to perform. So I mean that would be a simple this isn't a safe activity for you. The new compendium is awesome. I'm going to link it again below Use it. It has literally everything and they've actually updated it where it's broken down into the adult compendium, elderly, and there's a young adolescent compendium and it has all sorts of activities, everything from gaming to mowing the lawn to snow shoveling, snowshoeing, skiing, basketball, golf, you name it gardening, different levels of gardening, right?
Rachele Burriesci:So it's just a really easy way to say this is what you're capable of doing based on the test you performed and this is what you're doing now and this is what you're doing now. So, for instance, snow shoveling at moderate intensity for an adult is about six met levels. For the elderly they don't have it based on moderate or vigorous, they have it simply as vigorous and it's eight met. So, again, likely, you're more than twice the capacity that you're currently performing. That's a simple yes. No, that's not a. It depends right. You can literally see in black and white this is what you can perform three METs. This is the level of activity. It takes to perform this activity in this situation snow shoveling.
Rachele Burriesci:If you don't have a Bruce protocol, things like six-minute walk test do have formulas to help convert VO2 max. Any time you're using an equation, it's going to over or underestimate. The equations get you close, but they're not perfect. The test itself usually is better, but you could still use MET as a way to determine safety, and the reason is is because we know that one MET level of activity is going to result in a change in heart rate and blood pressure is going to result in a change in heart rate and blood pressure. So for every one met level of activity you perform, you can expect an increase in heart rate by 10 to 12 beats per minute and an increase in blood pressure by 8 to 12 millimeters of mercury. So 10 is a happy number, right. For every one met level of activity you can expect at least 10 increase in heart rate and 10 in blood pressure. So again, the question is where does the person rest? Okay, and then the next question is what is their max heart rate? And so, again, if you don't have a test like a Bruce protocol, there are a number of equations that you can perform to get close, to get in a ballpark.
Rachele Burriesci:We all know 220 minus age. It is not the most advanced of the equations that exist, but it's still being used and it's still pretty close. Tanaka is probably more commonly used across the board for healthy adults. So 220 minus age is 220 minus the person's age, and that's going to give you max heart rate. From that you can either determine a percent max heart rate or heart rate reserve, which is the Karvonen formula. Essentially, if you do 220 minus age, all you're going to do then is, for instance, let's start at the top, if a person's 90 years old, you do 220 minus 90, which is going to give you 130. That's the person's max heart rate. In order to determine moderate intensity, we say around 60 to 80 percent you would do that by times 0.6, which will get you 78, or by 0.8, which will give you 104. So it gives you a nice range. And this is what we do in cardiac rehab. We have max heart rate achieved from the test and then we determine what moderate intensity range is for exercising, and so you have that right.
Rachele Burriesci:If you're using Tanaka, tanaka is a little bit different. It's 208 minus and then in parentheses, 0.7 times age. And with Tanaka what is most apparent in heart rate max is that it underestimates the older age. But as you come down in age it actually gets super close. So just for an example, at the 90-year-old age group, 220 minus age puts your max heart rate at 130. Tanaka puts it at 145. For an 80-year-old max heart rate would be 140, with 220 minus age, with Tanaka 152. At 70 years old, 220 minus age gives you a max heart rate of 150, while Tanaka gives you 159. So you can see that gap is already starting to close. At 60 years old, 220 minus age puts your max heart rate at 160, while Tanaka is 166. At 50, it goes from 170 to 173. And at 40 years old, 180 and 180. So you can see why 220 minus age has lasted for so long is because it's pretty close, but it does definitely underestimate older age compared to other equations.
Rachele Burriesci:So you can use heart rate max that's what we did in cardiac rehab or you can use the Karvonen method, and what's interesting about the Karvonen method is that it tries to incorporate. It doesn't try, it does. It incorporates resting heart rate into the equation. So typically when you do the Karvonen formula to the equation, so typically when you do the Karvonen formula, your range is going to be higher than that of heart rate max. But there's different percentages with heart rate reserve. If you're going to do heart rate reserve, moderate intensity is around 40 to 70% I think they say 40 to 69% while heart rate max is 60 to 80 and vigorous is higher. So same thing preference, what you use. My advice is to be consistent across the board so that you're familiar with the formulas that you're using on a daily basis and you know, do your research too. Maybe I'll do an episode just on the differences between formulas as well. I do like a heart rate max and then a percent of that.
Rachele Burriesci:Like I said, we use that in cardiac rehab and for a quick and dirty, especially for easy math. The 220 minus age is a good way to get you know the ball moving with that. To get you know the ball moving with that. So when we're thinking about heart rate max and we're thinking about activity levels, mets is a great way to just do like a quick and dirty assessment. So we said snow shoveling can be around. There's actually two met levels for snow shoveling. One is 5.3 and one is 6.0, depending on which source you're looking at. And then vigorous is 7.5. So anywhere between 5 and 7.5 is your range and that's higher in the elderly, that's higher in the elderly.
Rachele Burriesci:So essentially, just based on those quick numbers, you can assume heart rate could increase between 50 and 75 beats per minute. Adding that to resting heart rate is going to give you an idea of where that person is going to be exercising. At what intensity? Are they at moderate intensity? Are they at vigorous intensity? Are they near max intensity? This is a good way to have conversation with your patients. Instead of saying you're going to be expending 17.5 milliliters per kilogram per minute of oxygen consumption, that's not going to go very far. But if you say you rest, your heart rate rests at 90, your heart rate rests at 100, and we can expect you to increase between 50 and 75 beats per minute with snow shoveling. Beats per minute with snow shoveling, that's going to put you at around 150 beats per minute, which would be greater than 80% for most people in that group that we went through. That's going to help them understand that it's not safe, right?
Rachele Burriesci:If you have a patient who has I have some numbers written down blood pressure right, if your blood pressure is 140 over 80, you could potentially expect to have an increase in your blood pressure up to 182 over 80 to up to 204 over 80. Those are really high numbers, right? Those numbers start to put you in the red zone for safety. Compound that with known heart disease, history of heart attack, history of heart failure, history of hypertension what have you? It increases your risk and so there is a higher risk for mortality and morbidity in the winter months for heart attack and stroke. So this isn't really a light situation, it's really a safety situation. Now, if you have a healthy, active adult, that is very different than having the same age person with a pretty significant comorbidity list. It's going to increase their risk. Compound that with the cold weather that may already increase their resting heart rate, their resting blood pressure. So it just kind of primes the system to be a little bit more elevated anyway.
Rachele Burriesci:So the answer to the simple question is can I safely snow shovel? It truly depends. It depends on your comorbidities, it depends on your recent history. How long ago was your last heart attack? How long ago did you have a cabbage and have a sternotomy? What is your exercise capacity right? Did you do a stress test recently, either to rule something out or just because what is your max heart rate on a stress test? That's the best option. If you don't have that option, then you can go and use the formulas.
Rachele Burriesci:How active is your patient? Do they exercise on a daily basis? What does that exercise look like? At what intensity are they exercising? At what heart rate are they maintaining for how much time? And I think time is also a piece that we need to consider. When you go and shovel snow, it's not a five-minute activity, right? Depending on the size of a driveway, depending on the size of a walkway, depending on how many steps, depending on do you have a corner lot? Are you uphill? All of those things really enhance time.
Rachele Burriesci:If you do have patients that have no choice, right, because I heard that quite a bit. I have no choice. I don't have any help. No one's coming to shovel me out. What can I do Then? You have to really start thinking strategically. Can they perform a warmup inside prior to attempting to shovel? How many minutes can they sustain X heart rate? Maybe you have them do one or two passes, go inside, right, it could be really extreme and tedious, but that would be a better option than risking heart attack, stroke, urgency or emergency of blood pressure. It depends on how you know. Is your patient going to listen to the advice or are they going to do it anyway and you're going to give them the best option?
Rachele Burriesci:The reason why this really came up in my mind, besides the fact that I was shoveling snow, we had a pretty big snowstorm and we stayed at my mother-in-law's house to potentially make it to work, which I talked about last week Next door to my mother-in-law is a neighbor who is 90, 92 years old. We've seen him kind of slow down over the years. He's no longer mowing his lawn. We've seen him kind of slow down over the years. He's no longer mowing his lawn. He's had some incidents, you know, driving his car and he doesn't have a lot of family and his family is older. I think his daughters are in their 70s, right? So when we were shoveling my mother-in-law out, I was like, does anyone come and help him? And so the answer is no. So I went and I shoveled out his snow, because we had 12 inches of snow and, as I told you before, if you don't do it right away, it starts freezing up. So it was a little thing that I could do to potentially help this guy have access to his house, because he also receives Meals on Wheels. So how are people going to get in and out if they can't access the front door, the driveway, et cetera, et cetera?
Rachele Burriesci:But I'm thinking about this person as if it's my patient. What happens if he does then attempt to clear a path? Right? What risk does that put him at? Well, he's at 90 years old, so let's use the 220 minus age. That means his max heart rate is around 130 beats per minute. I know nothing about the man's history so I don't know where he rests at, nor do I know his comorbidities, but 60 to 80 percent at that age would be between 78 and 104. As I said, the 220 minus age does underestimate that range. If I was to use Tanaka it would increase it to 87 to 116. So still not a huge heart rate change. So still not a huge heart rate change. If we're snow shoveling and we put it on the low end let's say moderate intensity, five met levels we can expect 50 beats to increase or 50 millimeters of mercury. It's quite significant depending where you start. Let's say he has a heart rate of 60, right, if he does a 50 met level or 55 met level activity and increases him by 50, we're ready at like 110, which would make him over 80%. That is significant. That increases the risk. Then you add time to the factor, it increases the risk.
Rachele Burriesci:And we won't even get into the balance aspect. I know I briefly mentioned it last week, but it is a piece of the concern. Right, as a PT, as a cardiopulmonary PT, I don't just worry about the cardiopulmonary aspect of it. I actually just had a mobile client the other day. She's got some lung shortness of breath stuff happening. That's resolving and we also have some balance issues, which kind of was the spurring point of all of the issues. And when I left she asked if I could walk out with her because she needed to get to the car left. She asked if I could walk out with her because she needed to get to the car and there was, you know, ice and a patch of snow and so just like guarding to handle that. You really can see the risk in such a short span of time. So when you start doing things like snow shoveling it's just going to exacerbate that risk. But that's a whole different issue.
Rachele Burriesci:But MET levels can be a wonderful way to help your patients understand safety and that's how I always used it. Not so much the oxygen consumption piece Some people do like that information you could give a little bit and kind of explain what a MET means bit and kind of explain what the you know what a MET means, but really the piece of it is the expectation of activity and the level of safety that comes with that. With one MET level of activity we can increase our heart rate by 10 to 12 beats per minute. We can increase our blood pressure by 8 to 12 millimeters of mercury. What does that mean in respect to where your resting heart rate, resting blood pressure, is? What is your level of exercise capacity? How much intensity can you exercise for what amount of time? That all plays a role in this conversation and if you can show that you know you rest at 140 over 80, that means you can expect your blood pressure to go up to 180 over 80, or maybe even 200 over 80, not even taking into account what diastolic might do in this situation. That could be enough information to say, you know what, maybe this activity isn't safe for me anymore, and so it's just another way to create expectation and also to create goals.
Rachele Burriesci:For a lot of our patients in cardiac rehab, especially our younger guys that were 50, 60 years old, this was something that they wanted to get back to, something that they had to do, especially in Michigan we we got a lot of snow that they were able to contribute in their household, and so let's, let's use the 60 year old for an example. Using 220 minus age, that would put their max heart rate at 160, 60 to 80% of that is 96 to 128 beats per minute heart rate. So, again right, using, let's say again, 60, we're going to be at 110-ish, on the low end to probably near 120. So you're going to be right in that 60 to 80% intensity range. This could be a good goal for that patient. While you're in rehab, you are monitoring their heart rate, response to activity and the amount of time that they're performing said activity for safely, without shortness of breath, angina and things of that nature. The other piece I didn't mention yet, which I've mentioned in previous episodes, is if you have a patient who has known angina, you have a patient with stable angina. This is a good question, good conversation for them. They've likely done some sort of stress test at some point. Probably good to know when, because if it was 10 years ago, maybe not as relevant, but if they just completed cardiac rehab and they know that their angina threshold is, let's say, at 140 beats per minute, you want to stay 10 under that. So that's going to also play a role in understanding what MET level activity this person could accomplish.
Rachele Burriesci:The one last piece I wanted to talk about, which I did not mention earlier, was the option of using like a snowblower. So a snowblower on the adult compendium is 2.5 METs. That is a much more reasonable expectation. Now we're talking an increase in 25 beats per minute. Give or take right. But you always have to ask more questions and again, these are things you learn while you're doing them yourself.
Rachele Burriesci:So we bought my mother-in-law this snow thrower. I think it was awesome. We were going to get it last year. We held out, we weren't sure. We did a whole bunch of research looking at this type of device. She doesn't really have the space for a snowblower and her driveway and sidewalk doesn't really require a snowblower, but it would be nice for her to have something other than a snow shovel in these situations. Right, she's getting older, she lives by herself. These are things that we worry about if we can't come and help. I'm going to put the link below. We got her the Ego Power Plus I think it's called shovel, power shovel. That's what it's called Ego Power Plus power shovel. This thing was awesome. Now, one thing I will say. It is a little bit heavy, so the weight of it is something you need to consider, but it decreased the time that it took to move 12 inches of snow. You did not have to lift and throw, you just had to push, so that was much easier, um, and it was actually really easy to use. The one thing I would say is that it's a little bit heavy, so if you were trying to lift throughout, that could add to the met level activity, but I'd be curious if this is something that gets added later on.
Rachele Burriesci:Snow blowers are also not all the same. So when we got back to our house I used the snow blower because we don't have the power shovel yet and it's too big for like most snowstorms, but was very thankful to have it in this one. It definitely decreased the time and everything to do it. But the machine itself is heavy to pull and push and if it's not running it doesn't have self-propel. So every now and again it will turn off and you can't use the pull cord because it's too cold and then you have to lug this machine maybe down a block. All of those things are scenarios to consider when you're having these conversations with your patient.
Rachele Burriesci:My neighbor across the street their snowblower doesn't have a self-propel. I actually never even thought about it until we had the conversation. They had a three foot deep, like wide by whatever. Their driveway width is like 12 feet wide by three feet height snow bank at the end of their driveway and they had done their whole driveway and they looked like they were heading in and I was like well, they're definitely still not going to be able to get out. So I went up to them and asked if they needed some help and they said absolutely. They couldn't get through that much snow with the self-propel. Again, they're older, they're in their mid-60s, they're still pretty active, they go walking every day and you can tell that this was really a higher level activity, even using the snowblower. So the point of that is the snowblower is easier than snow shoveling, but it is still going to require energy consumption, it's still going to increase heart rate, blood pressure, it's still going to be a time factor in their level of intensity. So it's not something to just skip over and say, oh, snow blowing should be fine.
Rachele Burriesci:Ask that follow-up question Is it a self-propel right? Like questions that we don't always know to ask until you start doing activities yourself and if you've never done the activity before, because that happens all the time as a PT. Ask follow-up questions of things that you know revolve around this level of activity, right, and also ask about help. Do they have access to help? And also ask about help. Do they have access to help? Because sometimes people just don't want to ask for it and maybe now this will give them the opportunity to do that.
Rachele Burriesci:So snow blowing, also 2.5 METs, so definitely lesser of an activity, lesser of an oxygen consumption than snow shoveling, but it's still going to increase heart rate, blood pressure by about 25. It's not a non-activity. And again you have to think about the temperature. The temperature is going to compound that effect. Low temps are going to cause vasoconstriction which causes increased heart rate, increased blood pressure. It also helps stimulate the RAS system, which is the kidney's attempt to help with cardiac output. So you start to get water retention and more vasoconstriction. So for your heart failure patients this could be detrimental because it starts to spur that system and you have another component of vasoconstriction from the angiotensin 2. Just another cause of heart rate blood pressure to increase.
Rachele Burriesci:So these are the things that when you get asked these questions and the immediate knee-jerk reaction is to say it depends. Knee-jerk reaction is to say it depends. This is why it depends. It really does. I know it's one of those annoying answers, but it truly depends on the person. No two patients are the same. No two comorbidity lists are the same. Resting heart rate, exercising capacity what level of VO2 max can they achieve? What level of met level can they achieve? What level of heart rate max can they achieve is going to differ across the board. And then add age to that right. All of these things matter when you're giving the answer Black and white, no white, no, black and white, yes. To me is actually more of a concern than saying it depends, and this is one of those situations.
Rachele Burriesci:All right, if you have any questions, reach out to me, let me know. If this helped you in any way, let me know. I'm going to drop you some links below the compendium so that you can start looking at met level activity. I'm going to throw down that ego power plus snow shovel because that thing was awesome and I will be getting one myself. And don't forget about that, jane link. If you're interested, use Cardiopalm 1MO at the time of sign up to save you some monies on your account. All right, you have a wonderful day. Whatever you have to do, get after it.
