Start, as always, with a talk with your doctor. Heart problems differ from individual to individual, and no one knows your heart’s needs—your baseline condition and improvement targets—better than your doctor. You need to be safe as you start this program.

Any aerobic activity—that is, any form of exercise that raises your heart rate—will make your heart stronger in time. The more often you do it, the more fit your heart and blood vessels will be. The secret is to keep doing it. Most people, with or without heart disease, who start an exercise program don’t keep at it.

As many as half of all people who begin an exercise program have given it up within six months. When you have heart disease, you don’t have that luxury. This isn’t about losing weight or looking good; this is about staying alive. How do you ensure you’ll still be going strong—in fact, stronger—after six months?

Simple, really: choose an exercise activity you really like, do well or can learn easily, and feel safe doing. Better yet, choose several. Make sure they can fit into your schedule and are affordable. Then make them part of your life. Give exercise priority and acknowledge its critical role in your recovery.

Some people like nothing better than to step onto a treadmill, get up to their target pace, and just go. Other people find treadmills tedious, every minute drudgery. If that’s the case for you, give yourself something else to think about as you work your muscles and your heart.

Listen to music. Watch a video. If that doesn’t help, switch to another activity. Hate gyms and exercise machines? Fine. Go dancing. Or swimming. Or cycling. The point is that it simply doesn’t matter what you do to increase your aerobic activity; what matters is that you do it—a lot— and that you don’t give it up.

Choosing an activity you enjoy helps a lot. So does having an exercise partner. For one thing, it’s nice to have company. For another, the days your partner doesn’t feel like exercising will probably not be the same days you don’t feel like it. On those days, you can each encourage the other.

Nothing is quite like peer pressure to keep you on your toes. Researchers have found other techniques that can help you stick to the task as well. For example, starting out with supervision helps you stay with the program over the long term. Images of your exercise goals will also help keep you on track.

And committing, reminding and rewarding yourself, and focusing on what you are accomplishing turn out to be even more important than having fun or getting social support. Don’t underestimate the value of walking. Brisk walking is the most commonly prescribed form of aerobic activity for beginners. Almost anyone can do it, almost anywhere.

Apart from a comfortable pair of shoes or sneakers, it requires no special equipment. It is, after all, something the human species is uniquely designed to do. You can do it alone, with a friend, or with a dog. It works: a recent study showed that brisk walking was associated with a marked reduction in the risk of heart disease. Note the word “brisk” here, however; ambling along casually does not do much to help your heart.

How Much Exercise Is Enough?

Good question. For most of us, the answer is, it’s never “enough.” Our lives are such today that we almost never get enough exercise to be as healthy and fit as we could be, or should be. Short of this ideal, however, here’s what health experts agree will help fight heart disease:

• How often? At least three days a week of structured exercise, though every day is better. In addition, you should gradually increase the physical activity in your daily routine.

• How long? At least thirty minutes of aerobic activity every time you exercise. If you don’t have thirty consecutive minutes, you can break it up into two fifteen-minute, or three ten-minute blocks.

• How hard? Hard enough to get your heart rate up. Only then are you strengthening your cardiovascular system. To calculate your target heart rate for exercising, use the formula on page 47. Here’s another gauge: you’re working hard enough if you break into a sweat.

A recent study found that exercise vigorous enough to cause you to sweat is related to reduced risk of stroke. How hard is too hard? Use the “talk test.” If you can carry on a conversation while exercising, you’re fine; if you can’t, or if you’re struggling to get out a sentence, chances are you need to slow down a bit (unless you are training to be an elite athlete).

• Know when to stop. If exercise begins to cause pain in your chest, arms, jaws, or stomach, sudden light-headedness or dizziness, cold sweats, nausea, vomiting, or weakness, call your doctor. If the symptoms persist after resting for five minutes, get medical help right away.

Beyond the Guideline Basics

The programs described here constitute the basic exercise regimen recommended by the American Heart Association/American College of Cardiology guidelines. Think of it as the bare minimum that will improve your condition.

But the latest research suggests that a more comprehensive exercise program, involving longer aerobic conditioning as well as strength training, will produce greater benefits, not just for your heart but for your entire body. And that goes for people in every age group, including the elderly. Here’s the basic structure:

• Warm up (5 to 10 minutes). Do a low-level aerobic exercise (casual walking, slow treadmill, etc.) to increase cardiovascular activity and warm up muscles.

• Aerobic exercise (20 to 60 minutes). Walk briskly, jog, cycle, swim, do aerobic dancing, use a treadmill, stair climber, cross trainer, rower, or other exercise machine to elevate pulse to target heart rate. Begin gradually and increase the length of the workout over time to increase endurance (see page 170 for how to use an Exercise Log to chart your progress).

• Cool down (5 to 10 minutes). Continue aerobic activity but at a gradually lower level of intensity. Many aerobic exercise machines build in a cool-down period automatically.

• Stretching (5 to 10 minutes). Gently stretch each major muscle group.

• Strength training (15 to 30 minutes). Use weight-lifting machines, free weights, exercise bands (available from many doctors and clinics), or simply your own body for resistance (sit-ups, squats, push-ups, leg lifts) to do strength exercises for each major muscle group. Rotate muscle groups so that you do not work the same muscles on consecutive days.

• Final streching (5 to 10 minutes). Strength training can shorten muscles and tendons even as it strengthens them. Spend a few minutes gently stretching again at the end of your workout. Stretch slowly and hold each stretch for ten seconds. Don’t bounce.

Remember to always consult your doctor before beginning an exercise program.

Know Your Target Heart Rate

When you exercise, your pulse, also called your heart rate, increases. To get the most from aerobic exercise, you should aim to increase your pulse to what’s known as its “target rate,” a figure between 60 and 80 percent of your heart’s maximum rate per minute. What’s your maximum heart rate per minute?

Well, that varies, but a rough rule of thumb is to subtract your age from the number 220. If you’re 60 years old, then, your maximum heart rate is 160 beats per minute and your target rate is in a zone between 96 and 128. But some medications, including so-called “beta-blockers,” keep your heart rate low, so if you use these drugs, check with your doctor before estimating your target rate for exercise.

Frequently Asked Questions

How do I now if it's safe for me to exercise?

You don’t. But your doctor does. Before you begin any exercise program, consult your doctor. Your doctor may even recommend you take an exercise stress test to define your capacity to exercise. It isn’t just safer to consult your doctor first, it’s smart. It gives your doctor a chance to help you tailor the program to meet your specific needs, and to help you establish reasonable expectations.

What’s more, it gives you and your doctor an opportunity to establish fitness milestones against which to measure your progress. And measurable progress is a great motivator. If your doctor is not skilled at developing an exercise regimen, then he or she should refer you to someone who is.

Is it better to exercise longer or harder?

Longer is generally better than harder, but in the end both are important. If you spend too little time at it, you’re not increasing your endurance. If you spend too little effort on it, you’re not increasing your strength. And you need to do both.

Here’s an example: one study found that walking 3 to 4 miles an hour—that is, briskly enough to raise your heart rate—was as effective at lowering your risk of heart disease as vigorous exercise. But easy walking, the kind that does not increase your heart rate, had little effect. Their conclusion? How hard you walk—your pace—is as important as how long you walk.

How do I know if I'm exercise too much?

Do your joints or muscles hurt? Then you’re probably exercising too hard, or too long. A certain amount of discomfort is normal; after all, these are muscles and body parts you haven’t used much for a while. But if the discomfort is debilitating, or if it discourages you from keeping at it, then you’re overdoing it.

You may need to change the exercise you are doing. Also, getting fit again takes time, no matter what the magazines at the supermarket checkout stand claim. Be patient, be persistent, but be prudent, too; gradually increase how long and how hard you work out.

What about those people who have heart attacks while exercise?

Yes, it’s been known to happen. But rarely. And rarely to people who are exercising prudently. People who suffer heart problems when doing aerobic exercises or lifting weights are often individuals who have been inactive for years and then throw themselves into strenuous workouts, instead of starting off slowly and building up gradually.

The warning signs for heart trouble caused by overexercise are the same as those for heart trouble not triggered by exertion. But if you exercise prudently and regularly, the benefits far outstrip the risks.

What about weight lifting?

The most important form of exercise for your heart is aerobic. But weight lifting and other muscle-strengthening exercises (push-ups, sit-ups, squats, etc.) can also benefit your heart as well as your overall health. A recent study showed that men who weight-trained for at least thirty minutes per week had a 20 percent lower risk of heart disease.

We also know that weight training can improve your endurance in aerobic workouts and reverse the atrophy, or weakening, of your muscles from years of inactivity—or simply advancing age. There is persuasive evidence that weight lifting increases bone density as well, in men and women alike.

Most experts recommend that you do strength training at least twice a week, alternating with or complementing your aerobic workouts. But like everything else, this is best done in moderation.

How can I tell if the exercise is working?

It’ll be obvious after a while. Your sense of vigor will grow and, as your physical health improves, your mental health will improve as well, partly because exercise releases “feel-good” chemicals in your brain. You’ll also notice very real changes in the health of your heart.

Your resting heart rate will decrease, and you’ll return to your resting heart rate after exertion much more quickly. Your blood pressure will decrease, too. Initially, you may lose weight, which lessens the burden on your cardiovascular system. Don’t be surprised, however, if after a while your weight increases a little even though your measurements are decreasing. Strong muscle weighs more (though it takes up less space) than fat.

What if I stop exercise?

You may, and for any number of reasons. Most people have lapses, so don’t worry about it. Focus instead on how to get back into the groove again as soon as you can. If you stopped out of boredom, devise a new routine.

Find an exercise partner. If you stopped for any reason, remember that you can’t expect to go back and pick up where you left off. Muscles weaken quickly, even in an athlete, so start slowly and gradually build up to the level you reached before you stopped—and then keep going!

What about watching television?

Television watching likely contributes to much of the sedentary behavior in our society. A study of 50,000 women found that their risk of obesity and diabetes could be predicted by the amount of time that they watched television. For each additional two hours a day of watching television, the participants had a 23 percent increase in the risk of obesity and a 14 percent increase in the risk of diabetes.

The investigators estimated if Americans adopted a more active lifestyle with fewer than ten hours a week of television, then the incidence of obesity would drop 24 percent and diabetes would have a 34 percent reduction.