Safely Returning To Exercise After Aortic Dissection For Former Recreational Triathlete

HISTORY: A 58-year-old male, former recreational triathlete, and without history of hypertension or aneurysm presented for exercise counseling 18 months after emergent repair of an ascending aortic dissection and an unrepaired descending aortic dissection. Post-dissection, the patient was asymptomatic, but he was advised to curtail exercise training by his care team. The patient gained >40 lb and developed hypertension despite dietary modifications and new pharmacotherapy (ACE inhibitor, beta blocker, and calcium channel blocker). PHYSICAL EXAMINATION: BMI 36 kg/m2. Resting BP 156/102 mmHg. HR 66 bpm. Regular rate and rhythm, normal S1 and S2. No murmur or bruit. Symmetric pulses. DIFFERENTIAL DIAGNOSIS: 1.Obesity 2.Essential hypertension 3.Obstructive sleep apnea 4.Renal artery stenosis TEST AND RESULTS: CT Chest Angiogram: Ascending aortic graft and aortic arch reconstruction noted. Descending aortic dissection extending from the aortic arch to iliac arteries without cerebral, mesenteric, or renal involvement. No change compared to post-operative imaging. Coronary Angiogram: Normal coronary arteries. WORKING DIAGNOSIS: Multifactorial hypertension due to obesity and sedentarism TREATMENT AND OUTCOMES: The patient consulted with an exercise physiologist and was prescribed a physician-approved 12-week exercise training program (ExT). AEROBIC: 3 sessions/week; HR <110 bpm, RPE 11; 15-20 min/session. Progression to 30 min/session, then to 4-5 sessions/week. RESISTANCE: Lightweight exercises (30% 1RM, systolic BP <150 mmHg) avoiding substantial isometric component, 1-2 times/week. At one-year follow-up, resting BP was 135/84 mmHg, weight decreased 12 lb. No exertional symptoms or complications were reported. ExT revised to 45 min/day of aerobic exercise (HR <110 bpm, RPE 11) with integrated short duration moderate intensity intervals (4 min at HR <110 bpm, RPE 11 then 1 min at HR 112-118 bpm, RPE 12, 4-5 repetitions) on 1-2 days/week.At sports cardiology clinic, the patient performed supervised treadmill exercise. After warm-up, the patient completed 3 min at 3 mph then 1 min at 4.5 mph (0% grade) repeated four times without complication. BP <154/78 mmHg; HR <101 bpm (3 mph) and <121 bpm (4.5 mph). No symptoms were reported. Patient was advised to continue aerobic and resistance ExT.