Returning to Running After a Heart Attack: A Week-by-Week Guide

A heart attack (also known as a myocardial infarction) can be a life-altering, not only physically, but emotionally, and psychologically.  It is well established that exercising after after a heart attack increases strength, stamina, and energy levels, controls risk factors that may contribute to coronary artery disease, improves atrial elasticity, and restores confidence.  Overall, engaging in regular exercise has been shown to significantly lower the risk of dying from a heart related cause and to lower repeat hospitalization rates.  That said, one of the most common challenges people face in recovery is not knowing what level of exercise is safe, and if there are any restrictions when it comes to resuming daily life.

Throughout my 20 years in hospital-based cardiac rehabilitation I have had countless cardiac patients describe being provided blanket advice to limit lifting to 10 pounds and to avoid overly exerting themselves when discharged from hospital.  Although well intentioned, this non-specific advice coupled with delays or an inability to access cardiac rehabilitation has consequences as everyday tasks like walking the dog, climbing stairs, or even carrying groceries can suddenly feel uncertain.  Many people who were previously active suddenly find themselves sedentary, not because they want to be, but because they’re unsure what kind of activity is appropriate or safe.

For those who exercised regularly before their heart event, a big question looms large:

“When can I go back to exercising—or even just return to my usual routine?”

This guide is designed to answer that question with science-based, practical advice, walking you through the critical first weeks of recovery. Whether you’re a recreational runner, training for longer distances, or just trying to get back to feeling normal again, you’ll learn:

• What common issues following a heart attack may increase the risk of complication during exercise

• What your heart function means for recovery

• How commonly prescribed heart medications affect exercise

• The vital role of exercise testing and professional guidance

Note, if you are recovering from open heart surgery such as a bypass or valve replacement you may find many of the tips in the blog useful, however, you should also review my blog on returning to golf after open heart surgery onlineexerciseclinic.com/blog/golf-after-heart-surgery as it covers chest wall healing guidelines.  If you are seeking information of why exercise is important for heart health please review my blog onlineexerciseclinic.com/blog/why-is-exercise-good-for-our-heart.

What is a Heart Attack?

A heart attack, also known as a myocardial infarction, occurs when there is a blockage in one of the coronary arteries—the vessels responsible for delivering oxygen-rich blood to the heart. These blockages are usually caused by a buildup of plaque (a mix of fat, cholesterol, and other substances) that can rupture and form a clot, cutting off blood flow.

When blood—and therefore oxygen—can’t reach part of the heart, the affected heart muscle begins to die.  Heart tissue damage can ensue, and the extent of that damage depends on how long the artery is blocked and where in the heart the blockage occurs.

• If the blockage occurs in an artery supplying the left ventricle (the main pumping chamber), it can reduce the heart’s ability to effectively pump blood to the body, affecting ejection fraction (explained below) and overall cardiac output.

• If it affects the right ventricle, which pumps blood to the lungs, it may lead to issues with blood oxygenation and fluid balance.

• A heart attack can also cause arrhythmias (irregular heartbeats), conduction disturbances, or even heart failure, depending on the extent of the damage and pre-existing heart health.

Understanding the type, location, and severity of your heart attack is critical to designing a safe and effective exercise plan during recovery.

Key Considerations Before You Start Running Again

1. Left Ventricular Function

Your heart is divided into four chambers, with the left ventricle being the main pumping chamber responsible for sending oxygen-rich blood to the rest of your body. After a heart attack, some of the muscle tissue in the left ventricle may be damaged, which can reduce its pumping strength. We assess this using a measure called ejection fraction (EF).  Most commonly assess by echocardiography but may also be determined during an angiogram, the EF is a measure of what percentage of blood the left ventricle pumps out with each heartbeat.

Here’s what the numbers mean:

• Normal EF: 50–70%

• Most cardiology guidelines (including the AHA, ACC, and ESC) define EF ≥50% as normal, with values over 55% considered ideal or well-preserved.

• Borderline low or mildly Reduced EF: 40–49%

• Moderately reduced: 30-40%

• Severely reduced: < 30%

An impaired EF may lead to shortness of breath, fatigue, dizziness, and an increased risk of irregular heart rhythms, especially during physical exertion.  Those with a severely reduced EF at at high risk for arrhythmias and heart failure symptoms. Having an impaired EF doesn’t mean you can’t exercise—but it does mean exercise may need to be carefully prescribed and monitored.

It should be noted that may individuals who present with an impaired EF at the time of their heart attack may see it fully or partially recover with time and medications.

2. Residual coronary artery disease

Residual coronary artery disease refers to additional blockages in the coronary arteries that were not treated at the time of the heart attack. These blockages may limit blood flow during physical activity, leading to chest pain, shortness of breath or other symptoms of intolerance.

Most individuals who experience a heart attack undergo a angiogram where a dye is injected into the coronary arteries to evaluate potential blockages.  Often, the culprit lesion (the blockage responsible for the heart attack) is opened during the procedure and a stent is inserted to maintain the artery.  This is called an angioplasty.  If necessary, other arteries that are determined to block blood flow may also be stented, however, more minor blockages may be left alone.  It is important to understand your angiogram results to know if you have any residual blockages that may limit blood flow to your heart.

3. Arrhythmias

Some individuals are prone to arrhythmias after a heart attack as a result of the damage or scaring to the heart muscle.  This scar tissue doesn’t conduct electrical signals normally and disruption in the signals can cause the heart to beat abnormally fast, slow, or in an irregular manner.  Some arrhythmia are completely benign while others can result in significant consequences to your health.  Arrhythmias can be triggered or worsened by exercise and potentially result in symptoms of palpitations, dizziness, exercise intolerance, or in worst cases a cardiac arrest.

4. Symptoms

Some heart patients continue to experience symptoms of chest discomfort, dizziness, shortness of breath, palpitations, or excessive fatigue after being discharged from hospital.  If you experience any of these issues or other symptoms you should discuss them with your physicians and/or health care team.

All of the issues above can potentially complicate your return to running, however, an exercise test (also known as a stress test) can evaluate how your heart responds to exercise and help determine if any of these are limiting factors.

Medical Clearance and Stress Testing: Where to Start

Why You Need Medical Clearance First

You should be engaged in light to moderate physical activity once discharged from hospital.  Ideally 30 minutes of daily walking, stationary cycling, or another exercise that produces a mild increase in your breathing.  At this time, however, the intensity should not drive your breathing to a level where it limits your ability to carry on a conversation.

Before resuming a moderate to high-intensity exercise program (where breathing is significantly challenged and heart rate is significantly elevated), your should review your medical status with your cardiologist and ideally undergo exercise testing.  When speaking with your cardiologist or healthcare team it is important to get an understanding of:

• The extent of your heart muscle damage

• Your ejection fraction

• Any complications like arrhythmias or heart failure

The Critical Role of Exercise Testing

Undergoing an exercise test or stress test is crucial in identifying any lingering cardiovascular concerns before resuming a more intense exercise program.  One of the primary goals of this test is to rule out contraindications to exercise, such as exercise-induced arrhythmias, abnormal blood pressure responses, or residual ischemia (areas of the heart that may not be getting enough oxygen during exertion).

Just as importantly, exercise testing gives us a clear picture of your current exercise tolerance—how your heart and body respond to physical stress. This data allows us to develop a personalized, safe, and effective exercise prescription tailored to your unique physiology and stage of recovery.

Exercise testing is typically conducted on a stationary bike or treadmill. While under the supervision of a cardiologist and while wearing an ECG you exercise at progressively harder levels of exertion until you reach the point of fatigue or the test is stopped.

At the Online Exercise Clinic we specialize in helping you understand your stress test results and using them to design a safe and effective exercise programs for our clients.

What If You Had a Stent Inserted? Understanding Angioplasty and Exercise Safety

Many people recovering from a heart attack undergo a procedure called angioplasty, where a stent (a tiny mesh tube) is inserted into a blocked coronary artery to restore blood flow. If you’ve had a stent placed, you might wonder: Can I exercise with a stent? Could it move or dislodge?

The reassuring answer is: No, a stent cannot move or become dislodged from exercise. Once implanted, the stent becomes part of your artery wall. Your body begins to heal over it, and it remains securely in place—even during moderate to vigorous exercise.

Understanding Your Medications

Post-heart attack, most people are prescribed several medications to reduce the risk of another cardiac event. These medications are crucial—but some may also affect how your body responds to exercise.

1. Beta Blockers (e.g., Metoprolol, Bisoprolol)

• Purpose: Reduce heart rate and blood pressure; prevent arrhythmias.

• Exercise Implication: Your heart rate will be lower than expected, even during exertion.

2. Blood Thinners (e.g., Clopidogrel, Warfarin, Apixaban)

• Purpose: Prevent blood clots in damaged vessels or stents.

• Exercise Implication: Increased bruising or bleeding risk. Avoid contact sports or high-risk balance activities.

3. ACE Inhibitors / ARBs (e.g., Ramipril, Lisinopril, Valsartan)

• Purpose: Lower blood pressure and reduce heart strain.

• Exercise Implication: May cause dizziness, especially when standing quickly or after exertion.

4. Calcium Channel Blockers (e.g., Amlodipine, Diltiazem)

• Purpose: Lower blood pressure, manage chest pain.

• Exercise Implication: Similar to ACE inhibitors, may blunt blood pressure response. Watch for light-headedness.

5. Aspirin

• Purpose: Reduces clot formation.

• Exercise Implication: Same considerations as other blood thinners—monitor for unusual bruising.

6. Statins (e.g., Atorvastatin, Rosuvastatin)

• Purpose: Lower LDL cholesterol and reduce cardiovascular risk.

• Exercise Implication: Some users report muscle aches or cramps, especially during or after exercise. If symptoms are significant, consult your physician

A Week-by-Week Exercise Plan After a Heart Attack

If you were active before your heart attack your recovery doesn’t mean you need to stop moving.  Many people who were regularly active prior to their heart attacks are discharged home with relatively preserved fitness levels and typical hospital guidelines for exercise progression can feel unnecessarily slow and disengaging.

Imagine you were running 3 times weekly prior to your heart attack, you’re hospitalized for 2 days, and receive a stent and new mediations prior to going home.  Your heart function is preserved, no evidence of arrhythmias, and you feel well.  It’s only been 2 days and you fitness level has not changed but you’ve been instructed by your healthcare team to walk 10 minutes 3 times daily and limit lifting to 10 pounds.

That said, we need to start slow and make sure that you are feeling well and in the absence of a stress test progress towards more intense activity levels.  Progressing safely and gradually is key.

Understanding Effort: The RPE Scale

Before we dive in, let’s talk about how to measure exercise intensity safely. One of the best tools we use is the Rate of Perceived Exertion (RPE)—a 0 to 10 scale that helps you tune into how hard your body feels it’s working.

Here’s how it works:

• 0 = Rest (sitting on the couch)

• 1–2 = Very light (gentle movement, easy to breathe and talk)

• 3–4 = Light (you can talk comfortably, barely breaking a sweat)

• 5–6 = Moderate (breathing is deeper, talking becomes a little harder)

• 7–8 = Vigorous (talking in full sentences is difficult)

• 9–10 = Maximum effort (not recommended during recovery)

The goal is to train in RPE 5-7 by the end of the program

Heart Rate Guidance—Even with Beta Blockers

Some heart medications (like beta blockers) can blunt your heart rate response, making it harder to use heart rate as a guide to measure exercise intensity.  If you’re interested in using heart rate to gauge your intensity (start in week 6) it is best to use the heart rate that corresponds to a noticeable challenge to your breathing as the bottom of your training range (even if the heart rate is substantially lower they what you are use to). The stress test is ideal to determine if there is an upper limit that your heart rate should not exceed.

An 8-Week Post-Heart Attack Exercise Plan for Runners with Preserved Fitness Levels

⚠️ IMPORTANT DISCLAIMER

This plan assumes that you’ve been medically cleared and have completed a stress test.

This plan is generic and should be tailored to individual needs based on cardia function, risk stratification (low, moderate, high), comorbidities, medications, symptoms, and stress test results. Always seek guidance from your physician and an Exercise Physiologist.

You should stop exercising and consult your healthcare team if you experience any symptoms or signs of exercise intolerance.

Note that if stress test results are available the Online Exercise Clinic can skip the weekly progression and immediately tailor a program to your medical status, fitness level, and personal goals.

Warming Up and Cooling Down is Essential

We’ve all been told about the importance of warming-up before and cooling down after exercise, but how many of actually do it?  Once medically cleared, exercise following a heart attack is generally safe, however the majority of issues occur in the transitions to and from exercise.

Warming up and cooling down are critical components of a running program for individuals with heart conditions, especially those on medications like beta blockers or other heart rate-lowering and antihypertensive drugs.

A proper warm-up gradually increases heart rate and blood flow to the muscles, allowing the cardiovascular system time to adapt. This is particularly important for those on medications that blunt the heart’s ability to respond quickly to exercise demands. Without this gradual transition, the heart rate may lag behind the body’s activity level, leading to symptoms like dizziness, lightheadedness, and especially premature fatigue. Additionally, peak heart rates tend to be lower on these medications, which can reduce high-intensity performance—making a progressive warm-up even more essential to optimize performance.

On the other end, cooling down is equally important. Antihypertensives can amplify blood vessel dilation during exercise, increasing the risk of venous pooling—where blood collects in the lower limbs rather than returning efficiently to the heart. Abruptly stopping exercise can lead to a sudden drop in blood pressure and result in pronounced dizziness, lightheadedness, or feeling faint. A structured cool-down keeps muscle contractions active, promoting venous return, and allowing blood pressure and heart rate to normalize more safely.

All exercise sessions should be preceded and ended by a progression 10 minute warm-up and cool-down.

Week 1 – Getting Started (Day 3–7 post-MI, if cleared)

Even if you fitness level is preserved we it is recommended to begin gradually to make sure that you are feeling well.  This week is a feeling-out period to make sure you remain asymptomatic and are adjusting well to your medications.

• RPE: 3–4

• Duration: 20–30 minutes

• Type: Walking on level ground or treadmill

• Frequency: Daily, or 5–6 days/week

• Goal: Accumulate 100–150 min/week, reintroduce movement, assess tolerance

• Resistance training: None yet

While resistance training has enormous benefits for heart health it is important not to rush into it too early after a heart attack.

Your initial focus should be on aerobic (cardiovascular) exercise, such as walking, cycling, or using a recumbent elliptical. These forms of exercise are most effective at improving your heart’s ability to pump blood, restore endothelial function, reduce resting heart rate, and improve blood pressure regulation.

Week 2 – Challenge Breathing Slightly

• RPE: 4–5

• Duration: 30–40 minutes

• Type: Brisk walking, slight incline treadmill

• Frequency: 5–6 days/week

• Goal: Begin to push into moderate intensity at short intervals

• Resistance training: Begin light full-body routine 2x/week.  1-2 sets of 12–15 reps (opt for increased repetitions over weight).  Avoid breath holding while lifting (commonly know as the Valsalva manoeuvre).  Initially avoid over body or body weight lifting such as prone bench press, shoulder press and chin-ups and they can spike blood pressure and can induce some dizziness while on anti-hypertensive medications.

Week 3 – Introduce Intervals

• RPE: 5–6 (peaking at 6)

• Duration: 30–45 minutes

• Type: Walking with 2–3 bouts of light jogging or incline brisk walking (1–2 minutes each)

• Frequency: 5–6 days/week

• Continue to progress resistance training program keeping with 1-2 sets of 12-15 reps.

Week 4 – Reintroduce Jogging

• RPE: 6 (some sessions may peak at 7)

• Duration: 35–50 minutes

• Type: 2–3 rounds of 3–5 minutes of jogging; rest of session walking briskly

• Frequency: 5 days/week

• Continue to progress resistance training program keeping with 1-2 sets of 12-15 reps.

Week 5 – Establish Consistent Aerobic Load

• RPE: 5–7

• Duration: 40–60 minutes

• Type: Jogging up to 20 minutes continuous, or 1:1 jog-walk intervals

• Frequency: 5–6 days/week

• Continue to progress resistance training program

Week 6 – Push Aerobic Threshold

• RPE: 6–7

• Duration: 45–60 minutes

• Type: 20–30 minutes of jogging

• Frequency: 5–6 days/week

• Key focus: Use HR and RPE to push into the zone where breathing is laboured but sustainable

• Resistance training: Progress program and consider adding third set for large muscle groups

Week 7 – Build Variety and Intensity

• RPE: 6–7

• Duration: 50–60 minutes

• Type: Jog 25–35 minutes or alternate 3 min jog / 1 min walk x 10

• Optional: Low-level hill or intervals

• Continue to progress resistance training program as tolerated

Week 8 – Restore Confidence

• RPE: 6–7, occasionally 8 on short bursts

• Duration: 50–65 minutes

• Type: Continuous jog up to 40 minutes if tolerated; or intervals at higher RPEs for short periods (e.g., 30s–1min surges)

• Goal: Return to near pre-MI training pattern, while staying within safe exertion levels

• Resistance training: Continue 2–3x/week, progress based on goals

Your Comeback Starts Here

Returning to running after a heart attack is not only possible—it can be an empowering part of your recovery when approached with care, structure, and medical guidance. By understanding how your heart has changed, respecting the role of medications, and gradually building back fitness with the support of an exercise professional, you can safely reclaim your activity. Remember, progress will look different for everyone. The key is consistency, patience, and listening to your body. Whether you’re jogging around the block or training for longer distances, each step forward is a sign of progress. Always prioritize safety, stay in close communication with your healthcare team, and know that with the right plan, the path back to running is well within reach.

The information in the blog is provided for informational and educational purposes only and does not constitute medical advice.  The information is not a substitute for professional medical advice, diagnosis, or treatment.  For questions please follow up with your healthcare professional.