Bob Underwood, MD (Host): The Heart Center at Children's Health provides a comprehensive continuum of care for children with congenital heart disease, and it has the first and only exercise cardiology program in North Texas. This is Pediatric Insights Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research.

I'm your host, Dr. Bob Underwood, and today we'll discuss the importance of physical activity for children with congenital heart disease. With us today is Pediatric Cardiologist at Children's Health and Assistant Professor at UT Southwestern, Dr. Katherine Hansen. Dr. Hansen, thank you so much for joining us today.

Katherine Hansen, MD: Thank you, Dr. Underwood for having me. I'm really excited to chat with you about this topic.

Host: Yeah, this is exciting information. I really do think so. And so can you tell us a little bit about the exercise cardiology program? What are some of the services that it provides?

Katherine Hansen, MD: So the exercise and sports cardiology program at Children's Health is new just this year within our Heart Center and really it provides exercise testing and counseling for youth with cardiac conditions, as well as evaluation of all types of athletes who might have cardiac concerns.

And as part of this program, we offer the Cardiac Fitness Program, which is a structured and supervised three month exercise training program designed to improve both physical and mental fitness for kids and teens with heart disease.

Host: So how do you assess individual exercise tolerance in children with heart conditions?

Katherine Hansen, MD: Well, I think of exercise capacity and tolerance pretty broadly, and there's really many ways to assess how kids are able to exercise. I do start with really taking a thorough history, and what I'm trying to do is understand a child's experience with exercise and sport. And their mindset towards exercise. As well as the activities that they find fun and engaging because this will inform how I provide exercise counseling. Of course, how the patient's family and friends engage in physical activity and exercise is really essential to understand as well. And I think it's important to make the distinction between exercise and physical activity.

You know, the structured exercise is important and something that we should advocate for and provide resources for our patients to be able to do. But it's also important to understand how our patients play. And how physical activity is integrated into their daily life. For those patients who do exercise, I do spend quite a bit of time understanding the type of exercise they're doing as well as the frequency, intensity, duration.

So in that exercise history, I really dive deep. However, we know that asking someone if they exercise is not really sufficient and not always accurate. So I do think of more objective measures as really essential to this kind of exercise evaluation as well. And the best test to assess cardiopulmonary fitness or exercise capacity is a cardiopulmonary exercise test, also known as a CPET or metabolic stress test.

And this test really provides much more objective data about how well the heart, the lungs, the muscles, and the brain actually work together to do vigorous exercise. And I also use that to inform my counseling. Plus, if there's abnormalities on that test, it can point us towards what kinds of maybe previously underappreciated pathologies might be contributing to an exercise limitation.

Host: Sure. Now I like the way that you talked about the mental capacity for the exercise too. It's bringing in like almost a holistic approach to the exercise program.

Katherine Hansen, MD: Oh, definitely. I mean, we think about as doctors and as people who think about physiology, I think, we think about kind of the nuts and bolts of how well are the lungs working? How well does the heart pump blood? How well does the muscle actually take oxygen and turn that into energy that the muscles can then use to perform work? But what I find, one of the things I find super interesting is how does the brain perceive the signals that the body is giving to the brain to decide when to stop exercising? And that becomes really interesting and somewhat complicated in patients who have heart disease because as you might expect their whole life, we've been asking them about, oh, is your heart racing?

Are you short of breath? Are you sweating? And these are all things that are normal responses to exercise, but you can appreciate from the patient's perspective that we've been asking them their whole life about these symptoms in a way that would probably lead them to think that these are alarm signs or something that signals that there's a problem with their heart.

So I think how, especially patients with heart disease, might perceive some of these signals becomes really interesting when we ask them to exercise.

Host: Yeah, it's phenomenal. So let's talk about the safety and the health benefits of exercise for these patients. So, why is exercise so important for patients with congenital heart disease? And are there any particular recommended activity guidelines?

Katherine Hansen, MD: I think back a little bit to the historical context because in children with heart disease, as I kind of alluded to, the patient, the family, and the school, and really the medical providers might have concerns about what the patient's heart might do with exercise and whether or not symptoms of exercise are actually symptoms of something wrong with the heart.

And, if you think about all of this starting at a really early age, this can lead to reduced engagement in physical activity, which I believe can have a snowball effect, leading to what I call the cycle of sedentariness. And of course, sedentariness has really important medical and psychosocial effects, both in the short term and long term. And all of this is important to understand the historical context because 20 years ago, as cardiologists, we weren't really sure what the effects of quote unquote, stressing an already stressed heart through exercise might be. So we took a more conservative approach and often restricted exercise for patients, even you know without

 specific data to support that those patients should not exercise. But we're now seeing how many of these patients struggle in adulthood, including, but really not limited to issues related to obesity and comorbid conditions like coronary artery disease, so acquired heart disease. And as you might've gathered, I think there's a lot of psychosocial morbidity related to being told to sit on the sidelines, both of exercise, but also of life.

So we're recognizing more and more that, these kinds of known downsides to sedentariness, are actually huge and probably outweigh the small theoretical risk of a sudden event occurring during an exercise, which is really what most people are primarily worried about.

 So overall, we've over the decades gathered that these very, very small theoretical risks of something bad happening while you exercise are very small and very rare. But what's really common is the downsides of sedentariness. So that's kind of where the data is pointing us towards in terms of safety and health benefits. But that being said, there are certain heart diseases where we do have to be thoughtful about the types of exercise we recommend and promote.

We still have limited data, especially in pediatric and general heart disease populations to definitively say that we know the perfect dose and the perfect type of exercise that is most beneficial and what the risk is for certain other types of exercise. So I see one of my roles as an exercise cardiologist, as being able to apply a physiologic framework to risk assessment and doing this in a way that's not restrictive, but is actually more promotional, in a safe and effective way that helps patients really establish these lifelong healthy habits. So an example of this might be that a patient who's on a blood thinner, contact sports might not be the best fit for them, or patients with severe aortic root dilation doing kind of these single rep, max power cleans might not be the best for them either, but together, I think hopefully we can figure out what a healthy and fun exercise routine looks like for that individual based on, their values, their preferences, their life, but also their physiology.

Host: That's terrific information. So, how does the program, and you, kind of alluded to this just a little earlier, is how does a program like this set patients up for success as they enter adulthood?

Katherine Hansen, MD: We all know that exercise is important. We kind of say this is like a blanket statement, right? But I think it is important to really be specific about the ways that we know, based on evidence that it's important across a really broad range of health and all kinds of benefits, right?

We know that it reduces the risk of all cause mortality, reduces the risk of cardiovascular disease later in life, hypertension, type 2 diabetes, high levels of cholesterol, and certain cancers. Your bone healh is benefited by it, obviously weight loss can be something that can be a benefit in adults, but also things like improved sleep and cognition I think is really important for our kids, thinking about what kind of activity they're engaging in and how that might actually affect their performance at school.

And then the mental health benefits in terms of reducing risk of depression and anxiety and really just improving overall quality of life. Plus, the kind of social benefits of community building. There's no medicine that does all this. So I think it's really important to be explicit about all the ways that it helps our patients. And in our cardiac fitness program, which is that intensive exercise training program for kids with heart conditions that I talked about; we recognize that exercise is this great platform to actually practice life skills.

So we've worked to formalize this through a mental skills curriculum that's integrated into the exercise. But I think for anybody, dedication to an exercise routine really, you can get these broad range of benefits. And the more we can establish those healthy habits, both for the patient, but also for the family; the earlier in life, the more opportunity I think we'll have to benefit from those positive effects, both in the short term and in the long term, as we learn how to be healthy adults.

Host: Sure. So, how do we get patients into this program? How can physicians refer patients?

Katherine Hansen, MD: Yeah, great question. We, have a referral to cardiology order, within EPIC, and you can basically check a box for exercise cardiology as one of the options, and so really that referral will be to me to do kind of an exercise consult, and then depending on the issues at hand, whether it's this patient has, um, cardiac risk factors and needs more specific exercise counseling. They need support and education regarding exercise promotion, or, I think they might be a good fit for an exercise test. And I want someone to help me kind of interpret those results for the family. And finally, the Cardiac Fitness Program, if you think that that actually might be a great fit for the patient, then those are all things we can do as part of that exercise consult.

Host: That's phenomenal. It really is. And so what's your hope for the future of the program? You said it's, you know, early and just getting underway. What are your hopes for the future?

Katherine Hansen, MD: Well, I think broadly, my hope is that we think of exercise as medicine, just like any other medicine, that actually it's important to consider this as part of the kind of medical therapy that's really essential to helping our kids live the best possible life that they can given their diseases.

So I think, we're hoping to expand the utility of our exercise program in terms of the diagnostics and therapeutics that we support other physicians with and support our patients with. But really I think thinking of it as a really an essential medicine, just like the rest of the therapies we provide.

Host: Yeah, absolutely phenomenal and very beneficial. Anything else that you'd like to share?

Katherine Hansen, MD: Yeah, you know, I think it'd be of interest potentially to the audience to know that really this, exercise is medicine concept, of course, it's much bigger than just me. And there's many folks across the country and across the world and across a range of medical disciplines who recognize that this needs to be expanded and even formalized.

So we're actually working to start an academy of exercise medicine. And with that are applying for ACGME approval for an exercise medicine diagnostics and therapeutic fellowship for folks are in medical training and want to learn more about this. But I think with that, you know, the components that we provide within exercise and sports cardiology program, I think are relevant beyond the walls of cardiology. Certainly the physical and mental skills that we train as part of the cardiac fitness program might be beneficial to a wide range of patients. So I would love to partner with anyone who has this as their interest and wants to help explore this further in other pediatric populations.

Host: And people can learn more about the only exercise cardiology program in North Texas at childrens.com/heart. So, Dr. Hansen, thanks for your time today. Thanks for being on with us.

Katherine Hansen, MD: Thank you, Dr. Underwood. I really appreciate it.

Host: And thanks to our audience for listening to Pediatric Insights, Advances, and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at Childrens.com. And if you found this podcast helpful, please rate, review, and share the episode.

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