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Exercise Training for Heart Failure

What is exercise training for heart failure?

Heart failure causes symptoms such as shortness of breath and swelling that make physical activity difficult. In the past, women with heart failure were cautioned to avoid physical exertion; it was thought that bed rest could minimize symptoms and prevent the heart's function from getting worse.1 We now know that the opposite is true: for most patients, a supervised exercise program can improve heart failure symptoms, ability to perform physical tasks, and quality of life.2

How does exercise help treat heart failure?

Heart failure symptoms get worse with physical exertion, causing many women with heart failure to avoid physical activity as much as possible. While avoiding exertion may prevent discomfort for now, in the long term it will actually make your symptoms worse.

Lack of physical activity causes the muscles in the legs and arms to waste away ( atrophy), worsening symptoms like fatigue and making activities of daily living more difficult. Women with little physical activity also lose responsiveness in the blood vessels of their legs and arms, increasing the heart's workload.3 Lack of exercise also contributes to depression, which is common in women with heart failure and can contribute to worse outcomes.4

Exercise training improves the responsiveness of the blood vessels in the legs, giving you more energy and reducing the strain on the heart.5 Strength training builds up the muscles in your arms and legs, making everyday physical tasks easier. Heart failure patients who exercise regularly are better able to take in oxygen and distribute it through their body, making exercise easier and reducing shortness of breath.6 Exercise may also improve blood flow to the muscles and promote other beneficial chemical changes.7

Who benefits from exercise training?

Most women with mild or moderate heart failure symptoms caused by blood pumping problems (systolic heart failure) should participate in an exercise training program. Some women with severe heart failure symptoms (symptoms even at rest) may be able to participate in a limited program.2

In these women, exercise training can:8-10

  • Relieve heart failure symptoms
  • Increase the ability to perform physical tasks
  • Improve quality of life
  • Lower the chances of being hospitalized for heart failure

One trial of more than 2300 heart failure patients (28% were women) compared a combination of supervised and home exercise training with standard heart failure care. Patients in the exercise group had a 15% lower chance of dying of heart disease or being hospitalized for heart failure.9 Exercise patients also had fewer symptoms, fewer physical and social limitations, and a better quality of life.11 The benefits of exercise training seem to continue even after the program ends: in one study the exercise group was still doing better than the no-exercise group 8 months after participating in a 4-month training program.8

Is exercise training effective in women?

Yes. Women and men who participate in an exercise program have similar improvements in symptoms, physical and social limitations, and quality of life.11 One large study (more than 2300 patients, 28% were women) even found that there was a trend for improved survival and reduced hospitalizations in women who participated in an exercise program.9

Exercise training has primarily been studied in patients with blood pumping problems (systolic heart failure), but women with heart failure are more likely to have blood filling problems (diastolic heart failure). Although it needs to be confirmed in larger trials, one small study (42 patients, 11 women) found that patients with diastolic heart failure had a better quality of life and improved ability to exercise when they followed a training program, suggesting that even women with a normal ejection fraction can benefit from exercise.12

What does a typical exercise training program consist of?

Exercise training programs can vary widely, but they share a few basics features:

  • They are done in a monitored setting at a hospital or outpatient facility, supervised by a physical therapist who specializes in heart failure rehabilitation
  • There are 3 to 5 sessions a week, lasting anywhere from 6 weeks to 4 months
  • There is an endurance training component (such as walking) to improve your body's ability to use oxygen (cardiorespiratory fitness)
  • There is a muscle strength training component (using free weights or your own body weight)
  • You will start slowly and work up to 40% to 70% of your maximum exertion
  • Some programs may also incorporate nontraditional aerobic exercise, such as dancing or bicycling

To determine where to start, you may have an exercise test to find your maximum exercise capacity. During the test they may also measure the gases you breathe in and out to determine how well your body is using oxygen.

When your exercise training program ends, your doctor or physical therapist will tell you how much physical activity is safe, and will provide an exercise plan or physical activity recommendations for you to follow at home.

Some women may not be able to participate in a supervised exercise training program because they do not live close to a facility, cannot obtain transportation, or cannot pay for a structured program. For these women, a moderate-intensity home-based exercise program can relieve fatigue, improve emotional well-being, and even reduce the risk of hospitalization.12,13 Home-based programs may be less effective than supervised programs at improving your ability to exercise and quality of life, but they are better than no exercise at all.14

See also: Heart benefits of exercise

Can all women with heart failure benefit from exercise training?

Exercise training can help nearly all women with mild or moderate symptoms of heart failure. However, some women with severe heart failure may be too ill to tolerate an exercise program. Women who experience sudden worsening of heart failure symptoms or who have an inflammation or infection in the heart muscle should hold off on physical exertion until their doctor tells them it is safe.

Never start any kind of exercise regimen without first discussing it with your doctor: she or he will be able to recommend a safe level of physical activity. Your general health and the severity of your heart failure will determine how much exercise you can tolerate. Your doctor may recommend exercise testing to find out how much exertion your heart can safely handle.

Can exercise prevent heart failure in the first place?

If you do not have heart failure, you can lower your chances of developing heart disease, including heart failure, with just 30 minutes a day of moderate-intensity physical activity, such as brisk walking. Regular physical activity helps prevent you from developing conditions that lead to heart disease and heart failure, including high blood pressure, high cholesterol, diabetes, and obesity. Talk to your doctor before starting any exercise regimen.

For much more on how exercise affects your heart, see Exercise & Heart Disease Risk.

See also: Heart Failure Rehabilitation

References

  1. McDonald CD, Burch GE, Walsh JJ. Prolonged bed rest in the treatment of idiopathic cardiomyopathy. Am J Med. Jan 1972;52(1):41-50.
  2. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. Apr 14 2009;53(15):e1-e90.
  3. Sinoway LI. Effect of conditioning and deconditioning stimuli on metabolically determined blood flow in humans and implications for congestive heart failure. Am J Cardiol. Sep 9 1988;62(8):45E-48E.
  4. North TC, McCullagh P, Tran ZV. Effect of exercise on depression. Exerc Sport Sci Rev. 1990;18:379-415.
  5. Linke A, Schoene N, Gielen S, et al. Endothelial dysfunction in patients with chronic heart failure: systemic effects of lower-limb exercise training. J Am Coll Cardiol. Feb 2001;37(2):392-397.
  6. Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, Controlled Trial of Long-Term Moderate Exercise Training in Chronic Heart Failure : Effects on Functional Capacity, Quality of Life, and Clinical Outcome. Circulation. March 9, 1999 1999;99(9):1173-1182.
  7. Hambrecht R, Niebauer J, Fiehn E, et al. Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles. J Am Coll Cardiol. May 1995;25(6):1239-1249.
  8. Nilsson BB, Westheim A, Risberg MA. Long-term effects of a group-based high-intensity aerobic interval-training program in patients with chronic heart failure. Am J Cardiol. Nov 1 2008;102(9):1220-1224.
  9. 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. Apr 8 2009;301(14):1439-1450.
  10. McKelvie RS. Exercise training in patients with heart failure: clinical outcomes, safety, and indications. Heart Fail Rev. Feb 2008;13(1):3-11.
  11. 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. Apr 8 2009;301(14):1451-1459.
  12. Smart N, Haluska B, Jeffriess L, Marwick TH. Exercise training in systolic and diastolic dysfunction: effects on cardiac function, functional capacity, and quality of life. Am Heart J. Apr 2007;153(4):530-536.
  13. Oka RK, De Marco T, Haskell WL, et al. Impact of a home-based walking and resistance training program on quality of life in patients with heart failure. Am J Cardiol. Feb 1 2000;85(3):365-369.
  14. Dracup K, Evangelista LS, Hamilton MA, et al. Effects of a home-based exercise program on clinical outcomes in heart failure. Am Heart J. Nov 2007;154(5):877-883.

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