Exercise Capacity in Chronic Heart Failure

Login or register to view PDF.
Abstract

Heart failure (HF) affects more than 5 million people and has an increasing incidence and cost burden. Patients note symptoms of dyspnea and fatigue that result in a decreased quality of life, which has not drastically improved over the past decades despite advances in therapies. The assessment of exercise capacity can provide information regarding patient diagnosis and prognosis, while doubling as a potential future therapy. Clinically, there is acceptance that exercise is safe in HF and can have a positive impact on morbidity and quality of life, although evidence for improvement in mortality is still lacking. Specific prescriptions for exercise training have not been developed because many variables and confounding factors have prevented research trials from demonstrating an ideal regimen. Physicians are becoming more aware of the indices and goals for HF patients in exercise testing and therapy to provide comprehensive cardiac care. It is further postulated that a combination of exercise training and pharmacologic therapy may eventually provide the most benefits to those suffering from HF.

Disclosure
The authors have no conflicts of interest to declare.
Correspondence
Gina G Mentzer, MD, 200 Davis HLRI, 473 W 12th Ave, Columbus, OH 43210. E: gina.mentzer@osumc.edu
Citation
US Cardiology Volume 9 - Issue 1 - Spring 2012;2012:9(1):57-60
Correspondence
Gina G Mentzer, MD, 200 Davis HLRI, 473 W 12th Ave, Columbus, OH 43210. E: gina.mentzer@osumc.edu

Pages

Heart failure (HF) affects more than 5 million people, representing 2 % of the population.1,2 At 40 years of age, the lifetime risk of developing HF, regardless of gender, is one in five, with an incidence of 10 per 1,000 population after the age of 65 years.1,3 Despite efforts focused toward primary prevention of HF in the areas of hypertension (HTN), diabetes, obesity, use of cardiotoxic chemotherapies, and ischemic coronary artery disease (CAD), there continues to be an increasing incidence. Seventy-five percent of HF patients have antecedent HTN, and a sedentary lifestyle furthermore places them at high risk of developing HF.1 This disease is of major economic significance, with an estimated cost of $34.8 billion in direct and indirect health-related care in the US in 2008.4 The majority of this economic burden is related to hospitalizations and readmissions: a third of patients are readmitted within 90 days and the number of hospitalizations has tripled from 1,274,000 in 1979 to 3,860,000 in 2004.1,3 From a patient’s perspective, HF remains fairly unrecognized as a deadly disease, although it has a mortality rate that prevails over that of many cancers, reaching 50 % within five years from the time of first diagnosis.1,5
Regardless of the etiology of HF, congestive features, dyspnea and fatigue are the leading limiting symptoms that determine prognosis, quality of life, and use of tailored therapies.6 These symptoms limit exercise and may progress to pulmonary congestion and peripheral edema, creating a continual cycle of decompensation and hospitalization. If these symptoms could be quantified and placed in context, patients would not need to seek as much inpatient medical care and would be able to enjoy an overall better quality of life. Exercise capacity is one parameter with potential to be used in diagnosis, prognosis, and therapeutic measurements of chronic HF, and also as a therapy with the intent of improving symptoms.

Exercise Capacity in Diagnosis and Prognosis

In routine clinical care, physicians address blood pressure and lipid targets, nutrition, exercise, and obesity with patients as part of the primary prevention of cardiovascular (CV) disease. However, more emphasis needs to be placed on physicians identifying those at risk of HF who require intensified primary prevention practices and advanced therapies to prevent progression. In addition, this would need to include an assessment of exercise capacity, with each patient given a specific exercise prescription.7

Pages

References
  1. Roger VL, Go AS, Lloyd-Jones DM, et al., Heart Disease and Stroke Statistics–2012 Update: A Report From the American Heart Association, Circulation, 2012;125:e2-e220.
    Crossref | PubMed
  2. Hunt SA, Abraham WT, Chin MH, et al., A focused update into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult, Circulation, 2005;112:e154–235.
    Crossref | PubMed
  3. Fang J, Mensah GA, Croft JB, Keenan NL, Heart failure-related hospitalization in the U.S., 1979 to 2004, J Am Coll Cardiol, 2008;52:428–34.
    Crossref | PubMed
  4. Rosamond W, Flegal K, Furie K, et al., Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Circulation, 2008;117:e25–146.
    Crossref | PubMed
  5. Koelling TM, Chen RS, Lubwama RN, et al., The expanding national burden of heart failure in the United States: the influence of heart failure in women, Am Heart J, 2004;147:74–8.
    Crossref | PubMed
  6. Devroey D, Van Casteren V, Signs for early diagnosis of heart failure in primary health care, Vasc Health Risk Manag, 2011; 7:591–6.
    Crossref | PubMed
  7. Corrà U, Piepoli MF, Carré F, et al., Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation, Eur Heart J, 2010;31:1967–74.
    Crossref | PubMed
  8. Kitzman DW, Exercise intolerance, Prog Cardiovasc Dis, 2005;47:367–79.
    Crossref | PubMed
  9. Hsich E, Gorodeski EZ, Starling RC, et al., Importance of treadmill exercise time as an initial prognostic screening tool in patients with systolic left ventricular dysfunction, Circulation, 2009;119:3189–97.
    Crossref | PubMed
  10. Arena R, Myers J, Abella J, et al., Defining the optimal prognostic window for cardiopulmonary exercise testing in patients with heart failure, Circ Heart Fail, 2010;3:405–11.
    Crossref | PubMed
  11. Beckers PJ, Possemiers NM, Van Craenenbroeck EM, et al., Impact of exercise testing mode on exercise parameters in patients with chronic heart failure, Eur J Cardiovasc Prev Rehabil, 2011;March 4 [Epub ahead of print].
  12. Corrà U, Giordano A, Mezzani A, et al., Cardiopulmonary exercise testing and prognosis in heart failure due to systolic left ventricular dysfunction: a validation study of the European Society of Cardiology Guidelines and Recommendations (2008) and further developments, Eur J Cardiovasc Prev Rehabil, 2011; February 22 [Epub ahead of print].
  13. Vuckovic KM, Fink AM, The 6-min walk test: is it an effective method for evaluating heart failure therapies?, Biol Res Nurs, 2011;May 17 [Epub ahead of print].
  14. Pina IL, Apstein CS, Balady GJ, et al., Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention, Circulation, 2003;107:1210–25.
    Crossref | PubMed
  15. Gitt AK, Wasserman K, Kilkowski C, et al., Exercise anaerobic threshold and ventilatory efficiency identify heart failure patients for high risk of early death, Circulation, 2002; 106:3079–84.
    Crossref | PubMed
  16. Belardinelli R, Arrhythmias during acute and chronic exercise in chronic heart failure, Int J Cardiol, 2003;90:213–8.
    Crossref | PubMed
  17. Whellan DJ, O’Connor CM, Lee KL, et al., Heart failure and a controlled trial investigating outcomes of exercise training (HF-ACTION): design and rationale, Am Heart J, 2007;153:201–11.
    Crossref | PubMed
  18. Noble BJ, Clinical applications of perceived exertion, Med Sci Sports Exerc, 1982;14:406–11.
    Crossref | PubMed
  19. Whaley MH, Brubaker PH, Kaminsky LA, Miller CR, Validity of rating of perceived exertion during graded exercise testing in apparently healthy adults and cardiac patients, J Cardiopulm Rehabil, 1997;17:261–7.
    Crossref | PubMed
  20. Utter AC, Robertson RJ, Green JM, et al., Validation of the Adult OMNI Scale of perceived exertion for walking/running exercise, Med Sci Sports Exerc, 2004;36:1776–80.
    Crossref | PubMed
  21. Flynn KE, Lin L, Ellis SJ, et al., Outcomes, health policy, and managed care: relationships between patient-reported outcome measures and clinical measures in outpatients with heart failure, Am Heart J, 2009;158:S64–71.
    Crossref | PubMed
  22. Toste A, Soares R, Feliciano J, et al., Prognostic value of a new cardiopulmonary exercise testing parameter in chronic heart failure: oxygen uptake efficiency at peak exercise – comparison with oxygen uptake efficiency slope, Rev Port Cardiol, 2011;30:781–7.
    Crossref | PubMed
  23. Kim S, Yamabe H, Yokoyama M, Hemodynamic characteristics during treadmill and bicycle exercise in chronic heart failure: mechanism for different responses of peak oxygen uptake, Jpn Circ J, 1999;63:965–70.
    Crossref | PubMed
  24. Larsen AI, Aarsland T, Kristiansen M, et al., Assessing the effect of exercise training in men with heart failure; comparison of maximal, submaximal and endurance exercise protocols, Eur Heart J, 2001;22:684–92.
    Crossref | PubMed
  25. Meyer K, Samek L, Schwaibold M, et al., Physical responses to different modes of interval exercise in patients with chronic heart failure—application to exercise training, Eur Heart J, 1996;17:1040–7.
    Crossref | PubMed
  26. Daullxhiu I, Haliti E, Poniku A, et al., Predictors of exercise capacity in patients with chronic heart failure, J Cardiovasc Med (Hagerstown), 2011;12:223–5.
    Crossref | PubMed
  27. Jakovljevic DG, Seferovic PM, Nunan D, et al., Reproducibility of cardiac power output and other cardiopulmonary exercise indices in patients with chronic heart failure, Clin Sci (Lond), 2012;122:175–81.
    Crossref | PubMed
  28. Keteyian SJ, Brawner CA, Ehrman JK, et al., Reproducibility of peak oxygen uptake and other cardiopulmonary exercise parameters: implications for clinical trials and clinical practice, Chest, 2010;138:950–5.
    Crossref | PubMed
  29. Ingle L, Theoretical rationale and practical recommendations for cardiopulmonary exercise testing in patients with chronic heart failure, Heart Fail Rev, 2007;12:12–22.
    Crossref | PubMed
  30. Wielenga RP, Huisveld IA, Bol E, et al., Safety and effects of physical training in chronic heart failure, results of the Chronic Heart Failure and Graded Exercise study (CHANGE), Eur Heart J, 1999;20:872–9.
    Crossref | PubMed
  31. Whellan DJ, Nigam A, Arnold M, et al., Benefit of exercise therapy for systolic heart failure in relation to disease severity and etiology-findings from the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training study, Am Heart J, 2011;162:1003–10.
    Crossref | PubMed
  32. Coats AJ, Clinical utility of exercise training in chronic systolic heart failure, Nat Rev Cardiol, 2011;8:380–92.
    Crossref | PubMed
  33. Zuazagoitia A, Grandes G, Torcal J, et al., Rationale and design of a randomised controlled trial evaluating the effectiveness of an exercise program to improve the quality of life of patients with heart failure in primary care: the EFICAR study protocol, BMC Public Health, 2010;10:33.
    Crossref | PubMed
  34. Van der Meer S, Zwerink M, van Brussel M, et al., Effect of outpatient exercise training programmes in patients with chronic heart failure: a systematic review, Eur J Cardiovasc Prev Rehabil, 2011;May 18 [Epub ahead of print].
  35. Pina IL, Kokkinos P, Kao A, et al., Baseline differences in the HF-ACTION trial by sex, Am Heart J, 2009;158:S16–23.
    Crossref | PubMed
  36. Kitzman DW, Brubaker PH, Morgan TM, et al., Exercise training in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial, Circ Heart Fail, 2010;3:659–67.
    Crossref | PubMed
  37. Seebach R, Hensler D, Christle JW, et al., Exercise in heart failure – additional effect to medication?, Dtsch Med Wochenschr, 2011;136:836–40.
    Crossref | PubMed
  38. Elmariah S, Goldberg LR, Allen MT, Kao A, The effects of race on peak oxygen consumption and survival in patients with systolic dysfunction, J Card Fail, 2010;16:332–9.
    Crossref | PubMed
  39. Chien CL, Lee CM, Wu YW, Wu YT, Home-based exercise improves the quality of life and physical function but not the psychological status of people with chronic heart failure: a randomised trial, J Physiother, 2011;57:157–63.
    Crossref | PubMed
  40. Hwang R, Marwick T, Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis, Eur J Cardiovasc Prev Rehabil, 2009;16:527–35.
    Crossref | PubMed
  41. Tierney S, Mamas M, Woods S, et al., What strategies are effective for exercise adherence in heart failure? A systematic review of controlled studies, Heart Fail Rev, 2011;17:107–15.
    Crossref | PubMed
  42. Cowie A, Thow MK, Granat MH, Mitchell SL, A comparison of home and hospital-based exercise training in heart failure: immediate and long-term effects upon physical activity level, Eur J Cardiovasc Prev Rehabil, 2011;18:158–66.
    Crossref | PubMed
  43. Downing J, Balady GJ, The role of exercise training in heart failure, J Am Coll Cardiol, 2011;58:561–9.
    Crossref | PubMed
  44. Whellan DJ, O’Connor CM, Lee KL, et al., Heart failure and a controlled trial investigating outcomes of exercise training (HF-ACTION): design and rationale, Am Heart J, 2007;153:201–11.
    Crossref | PubMed
  45. Tierney S, Mamas M, Skelton D, et al., What can we learn from patients with heart failure about exercise adherence? A systematic review of qualitative papers, Health Psychol, 2011;30:401–10.
    Crossref | PubMed
  46. Piepoli MF, Guazzi M, Boriani G, et al., Exercise intolerance in chronic heart failure: mechanisms and therapies. Part I, Eur J Cardiovasc Prev Rehabil, 2010;17:637–42.
    Crossref | PubMed
  47. Piepoli MF, Conraads V, Corrà U, et al., Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation, Eur J Heart Fail, 2011;13:347–57.
    Crossref | PubMed
  48. Edelmann F, Gelbrich G, Dungen HD, et al., Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study, J Am Coll Cardiol, 2011;58:1780–91.
    Crossref | PubMed
  49. Pina IL, Cardiac rehabilitation in heart failure: a brief review and recommendations, Curr Cardiol Rep, 2010;12:223–9.
    Crossref | PubMed
  50. Austin J, Williams WR, Hutchison S, Patterns of fatigue in elderly heart failure patients measured by a quality of life scale (Minnesota living with heart failure), Eur J Cardiovasc Nurs, 2011;May 4 [Epub ahead of print].
  51. Domingo M, Lupon J, Gonzalez B, et al., Noninvasive remote telemonitoring for ambulatory patients with heart failure: effect on number of hospitalizations, days in hospital, and quality of life. CARME (CAtalan Remote Management Evaluation) study, Rev Esp Cardiol, 2011;64:277–85.
    Crossref | PubMed
  52. Flynn KE, Pina IL, Whellan DJ, et al., Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial, JAMA, 2009;301:1451–9.
    Crossref | PubMed
  53. Cattadori G, Schmid JP, Brugger N, et al., Hemodynamic effects of exercise training in heart failure, J Card Fail, 2011;17:916–22.
    Crossref | PubMed
  54. Gary RA, Cress ME, Higgins MK, et al., A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study, J Cardiovasc Nurs, 2011;September 9 [Epub ahead of print].
  55. Lloyd-Williams F, Mair FS, Leitner M, Exercise training and heart failure: a systematic review of current evidence, Br J Gen Pract, 2002;52:47–55.
    PubMed
  56. O’Connor CM, Whellan DJ, Lee KL, et al., Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial, JAMA, 2009; 301:1439–50.
    Crossref | PubMed
  57. Tavazzi L, Giannuzzi P, Physical training as a therapeutic measure in chronic heart failure: time for recommendations, Heart, 2001;86:7–11.
    Crossref | PubMed
  58. Burkhoff D, Parides M, Borggrefe M, et al., “Responder analysis” for assessing effectiveness of heart failure therapies based on measures of exercise tolerance, J Card Fail, 2009;15:108–15.
    Crossref | PubMed
  59. Georgiou D, Chen Y, Appadoo S, et al., Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure, Am J Cardiol, 2001;87:984–8; A4.
    Crossref | PubMed
  60. O’Connor CM, Whellan DJ, Wojdyla D, et al., Factors related to morbidity and mortality in patients with chronic heart failure with systolic dysfunction: the HF-ACTION predictive risk score model, Circ Heart Fail, 2012;5:63-71.
    Crossref | PubMed
  61. Pina IL, Oghlakian G, Boxer R, Behavioral intervention, nutrition, and exercise trials in heart failure, Heart Fail Clin, 2011;7:467–79.
    Crossref | PubMed