This was told to me by the trainer of my gym. She has a client who...

This was told to me by the trainer of my gym. She has a client who... While, uh, joining gym. I'll tick the box which said, "Do you have any implants?" And when asked, she said she has, uh, she's 36 years old, female. She has an implant in the heart. But she refused to tell for what purpose. And, uh, also suggested that the cardiologist gave her exercise, uh, clearance. The issue is whenever she... even when she does her warm-ups, she feels like 20. And feels dizzy and dizziness. Maybe she'll have to rest for a while and then continue the work. And she also gets dizziness while doing stomach exercises. So what should the trainer do? The patient is not willing to reveal, uh, much information regarding her health status. Revealing what her condition actually is. No, there has been multiple episodes of her having fainting episodes, even during warm, warm-ups. What should the trainer do? What actually is happening with the patient, make, uh, to the client? What is your advice?

Reading File

Finding Sources

Searching the Web

cardiac implant ICD pacemaker exercise gym safety guidelines syncope dizziness trainer

Reading File

Finding Sources

I now have enough information to give a thorough, well-sourced answer. Let me compile this.

Situation Analysis: What's Likely Happening

This 36-year-old woman has a cardiac implant (most likely a pacemaker or an ICD - Implantable Cardioverter Defibrillator), has cardiologist-granted exercise clearance, yet experiences repeated near-syncope and syncope even during warm-ups. This is a serious red flag that overrides the cardiologist's general clearance.

What Types of Cardiac Implants Exist in a 36-Year-Old?

The most common reasons a young woman might have a cardiac implant are:

Pacemaker - for slow heart rhythms (bradycardia, AV block, sick sinus syndrome, congenital heart block)
ICD (Implantable Cardioverter-Defibrillator) - for life-threatening arrhythmias (e.g., Long QT Syndrome, hypertrophic cardiomyopathy, prior cardiac arrest, ARVC, Brugada syndrome, CPVT)
CRT device (Cardiac Resynchronization Therapy) - less likely at 36 but possible in heart failure
Implantable Loop Recorder - a monitoring device (no therapy function - less likely to cause symptoms)

Given that she has recurrent syncope during exercise, the two most medically significant possibilities are an ICD or a pacemaker with an underlying arrhythmic condition.

What Is Likely Causing the Syncope During Warm-Up?

Several mechanisms are possible, all serious:

1. Pacemaker Syndrome When a single-chamber ventricular pacemaker fires, it loses AV synchrony. The atria contract against closed valves, causing a sudden drop in cardiac output, hypotension, dizziness, near-syncope, and syncope. As per Braunwald's Heart Disease (15th ed.), pacemaker syndrome affects 3-30% of patients and manifests with "fatigue, dyspnea, dizziness, neck pulsations, chest pain, and hypotension." Exercise can worsen this, as the heart rate demand rises but the device may not respond appropriately.

2. Chronotropic Incompetence If the pacemaker or the heart itself cannot increase rate appropriately with exercise (i.e., cannot respond to increased physical demand), cardiac output drops, causing dizziness and fainting. Goldman-Cecil Medicine notes that "exercise intolerance caused by poor heart rate response" is a classic feature of pacemaker-related bradyarrhythmias.

3. ICD Discharge or Arrhythmia Detection During Exercise If she has an ICD, physical exertion raises heart rate. If her native heart rate approaches the ICD's detection threshold (the programmed rate at which the ICD fires a shock), the device may deliver therapy - or she may be experiencing the underlying VT/VF that triggered the ICD implant in the first place. Exercise-induced arrhythmias (especially in conditions like CPVT - Catecholaminergic Polymorphic Ventricular Tachycardia, Long QT, or HCM) are notoriously triggered by catecholamine surges from physical activity and emotional stress.

4. Vasovagal Response Augmented by Her Underlying Condition The syncope during abdominal exercises specifically suggests a Valsalva-like mechanism - bearing down or straining increases intrathoracic pressure, reduces venous return, drops cardiac output, and can precipitate syncope. This is particularly dangerous in someone with underlying arrhythmic vulnerability.

What the Trainer Should Do

Immediate Actions

STOP all exercise sessions until the cardiologist is re-contacted. The fact that she is having multiple syncopal episodes even during warm-ups means the original exercise clearance is no longer valid or was given under different circumstances. This is not a "push through it" situation - it is a medical emergency waiting to happen. A person losing consciousness in a gym on hard flooring, near equipment, can sustain serious injury.
Document every episode. The trainer should keep a written log of every episode - what exercise was being done, how many minutes in, what the symptoms were, how long recovery took, and any abnormalities noted. This documentation should be passed on to the cardiologist.
Do not allow exercise alone. If sessions continue at all (against recommendation), the client must never be left unattended. A trained first-aider must be present and the gym must have a defibrillator (AED) accessible and staff trained to use it.
Do not allow Valsalva-provoking exercises. Abdominal exercises involving breath-holding, crunches, leg raises, and any movement that increases intraabdominal pressure should be completely suspended. This is already triggering syncope.
Ask the client to share the device ID card. Cardiac implant patients are issued a device identification card listing the device type, manufacturer, model, programmed settings, and the implanting physician's contact details. The trainer has a right - and a duty of care obligation - to request this information in a fitness/wellness setting. The client does not need to explain her diagnosis, but sharing the device card is a reasonable, non-invasive safety request.

Communication With the Client

The trainer should have a direct, non-confrontational conversation:

"I care about your safety. You've fainted more than once here during warm-ups, and that tells me something is happening that I'm not equipped to manage on my own. I'm not asking you to tell me your diagnosis - but I need to know that your cardiologist is aware of what's happening here, and ideally I'd need some guidance from them on what your safe exercise heart rate range is and what warning signs to watch for."

The trainer's liability exposure is real. If a client suffers cardiac arrest and the trainer continued training them despite known, repeated syncopal episodes, there are serious professional and legal consequences.

Re-Clearance Requirements From the Cardiologist

Before continuing, the trainer should request (ideally in writing) from the cardiologist:

The safe target heart rate range for exercise
The ICD detection/trigger rate (if applicable) - exercise HR must stay at least 10 bpm below this threshold per ACSM and cardiology guidelines
Whether Valsalva-type exercises are cleared
What to do if the client loses consciousness (including whether AED use is appropriate - ICDs can sometimes interfere with AED interpretation)
Whether the client's recent symptoms (syncope during warm-up) have been reported to and reviewed by the cardiologist

The Core Clinical Point

A cardiologist saying "you can exercise" does not mean "you can do whatever you want at a gym." It typically means low-to-moderate, supervised activity with heart rate monitoring. Repeated syncope during warm-ups is categorically abnormal and almost certainly means:

The device settings need to be re-evaluated (device clinic visit required)
The underlying cardiac condition may be getting worse
OR the exercise intensity, even at warm-up level, is exceeding what the heart/device can safely handle

As the Heart Rhythm Charity (UK) guidelines on exercise with ICDs state: "Prior to starting or returning to physical exercise, these patients should be clinically stable, with their ICD settings customised and adequately programmed." Repeated syncope = not clinically stable for exercise.

Summary for the Trainer

Action	Priority
Stop exercise until cardiologist re-evaluates	IMMEDIATE
Document all syncope episodes and report them to the client/cardiologist	IMMEDIATE
Request device ID card and safe HR range from cardiologist	Before resuming
Ensure AED on-site and first-aider present during any future sessions	Ongoing
Never allow Valsalva/breath-holding exercises	Permanent restriction until cleared
Never allow solo/unattended exercise	Permanent until cleared

The trainer's job is fitness coaching, not cardiac risk management. But when a client is fainting repeatedly on their watch, stopping and referring back to the medical team is not just best practice - it is the ethical and legal minimum.

Which exercises are more dangerous for this patient, push exercises or pull exercises? Or, uh, exercises where weight is taken from below to upwards, like in barbell curls. Is there anything like that?

Finding Sources

Searching the Web

push vs pull exercises pacemaker ICD cardiac implant upper body lead dislodgement safety overhead pressing

Great - I have what I need. Here's a thorough breakdown:

Push vs. Pull vs. Curl - Which Is More Dangerous for This Patient?

The answer depends on two separate risks that stack on top of each other: hemodynamic risk (what happens to blood pressure and cardiac output) and mechanical risk (what happens to the device leads). For this patient, both matter.

Risk 1 - Hemodynamic (The Real Killer Here)

The primary concern with any resistance exercise in a cardiac implant patient is breath-holding and straining - the Valsalva maneuver. When you bear down against a closed glottis (hold your breath during exertion), you:

Increase intrathoracic pressure sharply
Compress the great veins returning blood to the heart
Drop venous return and cardiac output
Cause a sudden drop in blood pressure
This triggers dizziness, near-syncope, and syncope

As confirmed in Costanzo's Physiology (7th ed.) and Ganong's Review of Medical Physiology: "there is an increase in intrathoracic pressure, which decreases venous return to the heart... producing a decrease in cardiac output." In someone whose heart is already struggling to maintain output (due to a device-dependent arrhythmia or structural condition), this is especially dangerous.

Which exercises produce the most Valsalva?

Exercises that are hardest, require maximum effort, or involve a "push" against gravity or resistance are where people most naturally hold their breath. The ranking from most to least Valsalva-prone:

Exercise Type	Valsalva Risk	Why
Heavy overhead press (shoulder press)	Very High	Max effort, chest/thorax compressed, arms above heart
Barbell bench press (heavy)	Very High	Loads placed on thorax, strong breath-hold tendency
Deadlift / Romanian deadlift	Very High	Entire body bracing, ground-up load
Squat (barbell, heavy)	High	Core brace + breath hold for stability
Barbell curl (as you described)	Moderate-High	Particularly on the concentric (lifting) phase with heavy weight
Pull-ups / lat pulldown	Moderate	Less tendency to Valsalva than push, but still possible
Cable rows / seated row	Moderate	Manageable if breathing is coached
Light dumbbell exercises, bands	Low	Easier to maintain rhythmic breathing

So to directly answer your question: PUSH exercises are generally more dangerous than PULL exercises for the hemodynamic reason, because push movements (overhead press, bench press, push-ups at heavy resistance) generate greater intrathoracic pressure, provoke more Valsalva, and are harder to breathe through compared to pull movements.

Barbell Curls - Where Do They Fit?

Barbell curls are a curl/bi pattern, not strictly push or pull in the compound sense, but the movement of lifting weight from low to high (concentric phase) creates a moderate Valsalva risk especially when:

The weight is heavy (near max effort)
The person holds their breath to "brace" the lift
The elbows are driven forward, engaging the shoulder and raising the arms

For this patient specifically, the arm elevation component adds a second risk (explained below).

Risk 2 - Mechanical Risk to the Device Leads

Cardiac device leads (the wires from the device to the heart) run from the device (usually implanted under the left clavicle/pectoral area) through the subclavian vein into the heart. These leads are anchored in the heart muscle but can be stressed or dislodged by:

Overhead arm movements - especially raising the elbow above shoulder height on the same side as the device
Aggressive shoulder/pectoral stretching or pulling
Heavy pectoral exercises - bench press creates direct mechanical compression and movement over the device site
High-repetition vigorous arm cycling (like swim stroke motions)

Per ACSM guidelines: "avoid lifting the elbow above shoulder height or lifting more than 10-15 pounds to allow the leads to stabilize." This is most relevant in the early post-implant period but remains relevant in someone with device complications.

Which exercises stress the leads most?

Exercise	Lead Stress Risk	Why
Overhead shoulder press	Highest	Elbow driven above shoulder, arm fully elevated, direct stress on subclavian entry point
Pull-ups / lat pulldown	High	Full shoulder extension pulls the arm/shoulder girdle, tugs on the lead entry point
Upright row	High	Elbows raised laterally to shoulder height or above
Barbell curl (heavy, full ROM)	Moderate	Forward shoulder flexion at the top of the movement
Bench press	Moderate	Horizontal movement, but pectoral activation can pull on device pocket
Cable row / seated row	Lower	Elbows stay below shoulder, less stress on subclavian region
Leg press, squats	Negligible	No upper body involvement

Combined Danger Ranking for THIS Patient

Combining both hemodynamic and mechanical risk:

Overhead press (barbell or dumbbell) - most dangerous: max Valsalva + max lead stress
Heavy bench press - very dangerous: Valsalva + direct load over device site
Pull-ups / heavy lat pulldown - dangerous: significant shoulder range of motion stressing the lead
Upright row - dangerous: elbows go above shoulder height
Barbell curls (heavy) - moderately dangerous: Valsalva + end-range shoulder flexion
Seated cable rows, light resistance band work - lower risk if breathing is maintained

The Single Most Important Rule

For a patient with a cardiac implant who is having syncopal episodes, the exercise type matters less than two universal rules:

Never hold your breath during any exercise. Exhale on the effort, every single rep, no exceptions. This eliminates most of the Valsalva risk across all exercise types.
Keep weight light enough that holding breath is not tempting. If the weight forces a breath-hold to complete the rep, the weight is too heavy for this patient.

If those two rules cannot be maintained - which in a patient who is fainting even during warm-ups is very questionable right now - no resistance training should be happening at all until she has a fresh cardiology review with her current symptoms reported.

This is a shared conversation. Sign in to Orris to start your own chat.