How to Exercise Safely With a Pacemaker, According to a Cardiologist

If you recently got a pacemaker due to arrhythmia (an irregular heartbeat), heart failure or bradycardia (a heart that beats too slowly), you might have concerns about getting back into exercise. It may seem like working out with a pacemaker is off the table, but it's actually highly encouraged.

"Everyone who has a heart condition benefits from exercise. There are really very few reasons somebody with a heart condition cannot exercise. Exercise is medicine and has tremendous health-promoting and healing powers for the heart," Jonathan H. Whiteson, MD, vice chair for Rusk Rehabilitation Clinical Operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health, says.

That said, there are a few things to keep in mind. Here, experts share guidelines for working out with a pacemaker.

Before you start any workout program, doctors recommend doing an exercise stress test on a treadmill. Doing a stress test allows you to understand how safe the heart is as you do more activities, Dr. Whiteson says.

"As you walk faster and steeper on a treadmill, we will understand how the heart is working, if there are any abnormal heart rhythms and how the blood pressure is responding, as well as any symptoms," he says. "We want to make sure when we tell someone to go and exercise that we're not blind to what might happen."

If you reach a certain intensity in your workout and notice a symptom, or maybe your blood pressure stops rising or there are some extra heartbeats, then you know to exercise below that intensity. From there, your doctor can determine the right training intensity for your workouts.

One common way is using the Borg rating of perceived exertion (RPE) scale. The Borg scale goes from 6 to 20, with 6 being no exertion at all and 20 max exertion.

Generally, people with pacemakers who are easing into a workout routine should start with light activity; this feels like a comfortable walk down a flat road, so you're not necessarily breathing heavily and can keep going. As you rebuild your fitness, you can increase the intensity.

"As [patients] are exercising, we ask them to rate their exertion. And if it's light, then we ask them to increase it. If it's very hard, we ask them to decrease it. If it's somewhat hard in that range of 12 to 14, that's where we want them to be," Dr. Whiteson says.

Anything in the 12 to 14 range is considered to be moderate intensity. At this intensity, you should be able to maintain a conversation of brief sentences.

You should avoid aggressively moving the arm on the same side as the device or lifting it overhead and to the side for the first four to six weeks, William Brown, MD, a cardiologist at Memorial Hermann in Houston, Texas, says. This means avoiding rigorous arm exercises during cardio, strength training and yoga.

"The device is typically implanted below the collarbone and the leads are inserted into the subclavian vein (a deep vein that carries oxygen-poor blood from your upper extremities to your heart) and down to the heart. It takes about 4 to 6 weeks for them to set in. So before this time, there is a risk of dislodgment with certain movements," Dr. Brown says.

A pacemaker is typically implanted on the left side of the chest under the collarbone, so you especially want to avoid vigorous movement on your left arm. Aggressive movement at your shoulder or chest after your procedure can also cause bleeding and cause a hematoma (pocket of blood) to form, as well as increase the risk of infection. You want to minimize shoulder movement to allow the area to heal, Dr. Whiteson says.

However, you can still move your fingers, hands and wrists. A little bit of shoulder movement is also OK to prevent stiffness.

"People have heard of what's called a frozen shoulder, where there's some discomfort and it's very difficult to move the arm and rotate it at the shoulder or elevate it. We don't want that to happen either, so we don't want zero movement," Dr. Whiteson says.

Because you want to avoid aggressive pulling and pushing arm movements during the first four to six weeks, that means some common cardio machines, like the rowing machine, ski erg and elliptical, are off limits.

However, walking outside or on the treadmill — even though you are swinging your arms forward and back — or outdoor cycling or an indoor bike are all good forms of exercise for the first six weeks.

Once your doctor has cleared you for other types of exercise, your cardio options open up. Generally, most cardio exercises are OK as long as you're working out below the threshold in which heartbeat irregularities or symptoms start to crop up.

Swimming and bike riding or indoor cycling are all excellent ways to get your body moving at a low or moderate intensity, says Holly Roser, CPT, a certified trainer based in San Mateo, California, who works with clients with pacemakers.

"If you become short of breath, dizzy or lightheaded, take a break. Exercise in short intervals can be just as effective as a single longer encounter," Dr. Brown says. "I always recommend a period of a warmup and slowly increasing activity levels as tolerated."

To help ensure you're training within the right heart rate zone, you can wear a heart rate monitor, smartwatch or fitness tracker. This will help you get a sense of what your heart rate is during exercise and correlate it with how you're feeling. And if you experience symptoms or are unsure how to increase your intensity or activity level, reach out to your cardiologist.

"We don't want people to be overly concerned about their heart rate. Of course, we don't want it too slow or too fast, but there's a relatively broad window where the heart rate is safe. And if something is very different, like if I'm doing light exertion, but my heart rate is 140, and normally when I do light exertion, it's only at 100, that's a reason to stop exercising and call your cardiologist," Dr. Whiteson says.

When it comes to high-intensity interval training (HIIT), it's going to vary from person to person.

"It's not absolutely contraindicated, but I would say someone who is interested in high-intensity or vigorous activity should check with their doctor first," Dr. Brown says.

Again, you want to avoid overhead and lateral arm exercises during the first four to six weeks after getting your pacemaker. But after that, resistance training using light weights, resistance bands or even your own body weight is the best route.

Although resistance training is recommended for maintaining strong muscles and bones, people with pacemakers need to be cautious about lifting heavy weights. In fact, it's best to avoid heavy weightlifting, especially in the upper body, Dr. Brown says.

That's because heavy resistance training can increase blood pressure a lot, which isn't recommended for people with heart conditions. Lifting heavy weights might also mean you're employing certain breathing techniques, like the Valsalva maneuver, that can cause changes in blood pressure.

"A lot of people push themselves hard to build muscle. But it's not necessarily healthy for the heart. Heavy weight training is not a heart-healthy activity, but we can do strength training for tone, strength and definition by using lighter weights and higher repetitions," Dr. Whiteson says.

Doing 16 or more reps of an exercise at a lighter weight is a great way to build strength and sculpt muscles — but not build muscle mass. You can do a 20-minute circuit of lunges, squats, push-ups, glute bridges and rows, for instance, Roser says. Just make sure to take long breaks between sets and stick with light dumbbells or resistance bands.

Seated exercises are also a good option for people with pacemakers because if you feel dizzy or faint, at least you're already sitting on a chair and can stop working out, Dr. Whiteson says.

Doing body-weight and light resistance-training exercises, like yoga, Pilates, barre and tai chi are all safe for people with pacemakers. However, people with heart conditions should generally avoid hot yoga classes — or any kind of heated exercise — because the heat can dilate blood vessels and cause a lot of sweating, which has been associated with people fainting, Dr. Whiteson says.

If you're starting a yoga routine, start slow and modify poses if you have to. Be mindful of how you're feeling holding the poses and take note of dizziness to help prevent falls, Dr. Brown says.

Working out two to three days a week for 15 to 20 minutes of light or moderate-intensity activity is a good start for anyone who's easing back into fitness, Dr. Whiteson says. But ultimately, the goal for people with pacemakers is to be able to get in 150 to 300 minutes of moderate-intensity aerobic activity per week, as recommended by the physical activity guidelines for Americans.

In addition, aim to do at least two days of moderate-intensity strength training, using light weights, per week. You want to train all major muscle groups, including your upper and lower body and core.

Note that "activity" doesn't always necessarily mean dedicated exercise. You can take a 15-minute walk at a moderate pace in the morning for your work commute or while running errands, for instance. So if you do this several times a day, the minutes can quickly add up.

If you're ever unsure about what types of exercises are best for you or how to progress your workouts safely, reach out to your cardiologist. Some people who have pacemakers may qualify for cardiac rehabilitation, so they'll also work under the guidance of a specialist who can prescribe the appropriate exercises.