Cardiac rehabilitation in patients with heart failure
- Ileana L Piña, MD, MPH
Ileana L Piña, MD, MPH
- Professor of Medicine and Epidemiology/Population Health
- Albert Einstein College of Medicine
- Associate Chief of Cardiology for Academic Affairs
- Montefiore-Einstein Medical Center
Patients with heart failure (HF) often have limited exercise capacity because of dyspnea and fatigue . It was previously thought that this exercise limitation was due entirely to cardiac dysfunction, and that treatment with inotropes and vasodilators, such as angiotensin converting enzyme inhibitors and the combination of hydralazine and nitrates, would improve exercise capacity. (See "Inotropic agents in heart failure due to systolic dysfunction" and "ACE inhibitors in heart failure due to systolic dysfunction: Therapeutic use".)
Although these drugs can improve the cardiac output and, with certain vasodilators, patient survival, they may not acutely improve exercise tolerance [2-5]. Thus, factors in addition to the low cardiac output and reduced skeletal muscle blood flow must contribute to poor exercise tolerance and fatigue.
In the 1970s, exercise training of HF patients was discouraged due to concerns of worsening symptoms and detriment to the disease process itself. Early observations in the 1980s documented improvements in exercise function for patients with HF with a low rate of complications.
These observations were followed by a series of studies that demonstrated that significant biochemical and functional abnormalities in skeletal muscle are present in patients with HF and play a large role in the exercise intolerance . Inactivity is in part responsible, leading to muscle atrophy. In addition, skeletal muscle utilizes high-energy phosphates in an inefficient manner; as a result, lactic acid accumulates at a more rapid rate than in normal controls, contributing to muscle fatigue and limited exercise capacity. Skeletal muscle dysfunction can also involve the respiratory muscles, which may contribute to fatigue and dyspnea on exertion . These biochemical and functional abnormalities, when added to deconditioning, can result in even greater impact on physical function. (See "Skeletal muscle dysfunction and exercise intolerance in heart failure".)
The importance of skeletal muscle dysfunction provides part of the rationale for the use of cardiac rehabilitation in patients with HF. This topic will review the evidence demonstrating the benefit of cardiac rehabilitation in patients with mild to moderate (NYHA class II to III) heart failure (table 1) and make recommendations about an exercise prescription. Measurement of peak oxygen uptake (peak VO2) to assess exercise capacity and prognosis is discussed separately. (See "Exercise capacity and VO2 in heart failure".)
- Kokkinos PF, Choucair W, Graves P, et al. Chronic heart failure and exercise. Am Heart J 2000; 140:21.
- Wilson JR, Martin JL, Ferraro N. Impaired skeletal muscle nutritive flow during exercise in patients with congestive heart failure: role of cardiac pump dysfunction as determined by the effect of dobutamine. Am J Cardiol 1984; 53:1308.
- Wilson JR, Martin JL, Ferraro N, Weber KT. Effect of hydralazine on perfusion and metabolism in the leg during upright bicycle exercise in patients with heart failure. Circulation 1983; 68:425.
- Kugler J, Maskin C, Frishman WH, et al. Regional and systemic metabolic effects of angiotensin-converting enzyme inhibition during exercise in patients with severe heart failure. Circulation 1982; 66:1256.
- Wilson JR, Ferraro N. Effect of the renin-angiotensin system on limb circulation and metabolism during exercise in patients with heart failure. J Am Coll Cardiol 1985; 6:556.
- Walsh JT, Andrews R, Johnson P, et al. Inspiratory muscle endurance in patients with chronic heart failure. Heart 1996; 76:332.
- Kitzman DW, Hundley WG, Brubaker PH, et al. A randomized double-blind trial of enalapril in older patients with heart failure and preserved ejection fraction: effects on exercise tolerance and arterial distensibility. Circ Heart Fail 2010; 3:477.
- McKelvie RS, Teo KK, McCartney N, et al. Effects of exercise training in patients with congestive heart failure: a critical review. J Am Coll Cardiol 1995; 25:789.
- Belardinelli R, Georgiou D, Cianci G, Purcaro A. Effects of exercise training on left ventricular filling at rest and during exercise in patients with ischemic cardiomyopathy and severe left ventricular systolic dysfunction. Am Heart J 1996; 132:61.
- Liu JL, Irvine S, Reid IA, et al. Chronic exercise reduces sympathetic nerve activity in rabbits with pacing-induced heart failure: A role for angiotensin II. Circulation 2000; 102:1854.
- Roveda F, Middlekauff HR, Rondon MU, et al. The effects of exercise training on sympathetic neural activation in advanced heart failure: a randomized controlled trial. J Am Coll Cardiol 2003; 42:854.
- Braith RW, Welsch MA, Feigenbaum MS, et al. Neuroendocrine activation in heart failure is modified by endurance exercise training. J Am Coll Cardiol 1999; 34:1170.
- Hambrecht R, Fiehn E, Weigl C, et al. Regular physical exercise corrects endothelial dysfunction and improves exercise capacity in patients with chronic heart failure. Circulation 1998; 98:2709.
- Varin R, Mulder P, Richard V, et al. Exercise improves flow-mediated vasodilatation of skeletal muscle arteries in rats with chronic heart failure. Role of nitric oxide, prostanoids, and oxidant stress. Circulation 1999; 99:2951.
- Hambrecht R, Hilbrich L, Erbs S, et al. Correction of endothelial dysfunction in chronic heart failure: additional effects of exercise training and oral L-arginine supplementation. J Am Coll Cardiol 2000; 35:706.
- Wisløff U, Støylen A, Loennechen JP, et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation 2007; 115:3086.
- Adamopoulos S, Parissis J, Karatzas D, et al. Physical training modulates proinflammatory cytokines and the soluble Fas/soluble Fas ligand system in patients with chronic heart failure. J Am Coll Cardiol 2002; 39:653.
- Experience from controlled trials of physical training in chronic heart failure. Protocol and patient factors in effectiveness in the improvement in exercise tolerance. European Heart Failure Training Group. Eur Heart J 1998; 19:466.
- Belardinelli R, Georgiou D, Purcaro A. Low dose dobutamine echocardiography predicts improvement in functional capacity after exercise training in patients with ischemic cardiomyopathy: prognostic implication. J Am Coll Cardiol 1998; 31:1027.
- Belardinelli R, Georgiou D, Ginzton L, et al. Effects of moderate exercise training on thallium uptake and contractile response to low-dose dobutamine of dysfunctional myocardium in patients with ischemic cardiomyopathy. Circulation 1998; 97:553.
- Haykowsky MJ, Liang Y, Pechter D, et al. A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed. J Am Coll Cardiol 2007; 49:2329.
- Hambrecht R, Gielen S, Linke A, et al. Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial. JAMA 2000; 283:3095.
- Meyer K, Görnandt L, Schwaibold M, et al. Predictors of response to exercise training in severe chronic congestive heart failure. Am J Cardiol 1997; 80:56.
- 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 1999; 99:1173.
- Whellan DJ, Shaw LK, Bart BA, et al. Cardiac rehabilitation and survival in patients with left ventricular systolic dysfunction. Am Heart J 2001; 142:160.
- McKelvie RS, Teo KK, Roberts R, et al. Effects of exercise training in patients with heart failure: the Exercise Rehabilitation Trial (EXERT). Am Heart J 2002; 144:23.
- Otsuka Y, Takaki H, Okano Y, et al. Exercise training without ventricular remodeling in patients with moderate to severe left ventricular dysfunction early after acute myocardial infarction. Int J Cardiol 2003; 87:237.
- Radzewitz A, Miche E, Herrmann G, et al. Exercise and muscle strength training and their effect on quality of life in patients with chronic heart failure. Eur J Heart Fail 2002; 4:627.
- Tavazzi L, Ignone G. Short-term haemodynamic evolution and late follow-up of post-infarct patients with left ventricular dysfunction undergoing a physical training programme. Eur Heart J 1991; 12:657.
- Giannuzzi P, Temporelli PL, Corrà U, et al. Antiremodeling effect of long-term exercise training in patients with stable chronic heart failure: results of the Exercise in Left Ventricular Dysfunction and Chronic Heart Failure (ELVD-CHF) Trial. Circulation 2003; 108:554.
- Piña 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.
- Rees K, Taylor RS, Singh S, et al. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2004; :CD003331.
- Smart N, Marwick TH. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Am J Med 2004; 116:693.
- 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.
- Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with chronic heart failure delays ventilatory anaerobic threshold and improves submaximal exercise performance. Circulation 1989; 79:324.
- Meyer K, Schwaibold M, Westbrook S, et al. Effects of exercise training and activity restriction on 6-minute walking test performance in patients with chronic heart failure. Am Heart J 1997; 133:447.
- Tyni-Lenné R, Gordon A, Jansson E, et al. Skeletal muscle endurance training improves peripheral oxidative capacity, exercise tolerance, and health-related quality of life in women with chronic congestive heart failure secondary to either ischemic cardiomyopathy or idiopathic dilated cardiomyopathy. Am J Cardiol 1997; 80:1025.
- Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction. Hemodynamic and metabolic effects. Circulation 1988; 78:506.
- 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 1995; 25:1239.
- Coats AJ, Adamopoulos S, Radaelli A, et al. Controlled trial of physical training in chronic heart failure. Exercise performance, hemodynamics, ventilation, and autonomic function. Circulation 1992; 85:2119.
- Belardinelli R, Georgiou D, Scocco V, et al. Low intensity exercise training in patients with chronic heart failure. J Am Coll Cardiol 1995; 26:975.
- Belardinelli R, Georgiou D, Cianci G, et al. Exercise training improves left ventricular diastolic filling in patients with dilated cardiomyopathy. Clinical and prognostic implications. Circulation 1995; 91:2775.
- 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.
- Edelmann F, Gelbrich G, Düngen 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.
- Davies EJ, Moxham T, Rees K, et al. Exercise based rehabilitation for heart failure. Cochrane Database Syst Rev 2010; :CD003331.
- Davies EJ, Moxham T, Rees K, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail 2010; 12:706.
- Keteyian SJ, Leifer ES, Houston-Miller N, et al. Relation between volume of exercise and clinical outcomes in patients with heart failure. J Am Coll Cardiol 2012; 60:1899.
- Flynn KE, Piña 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.
- 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.
- Reed SD, Whellan DJ, Li Y, et al. Economic evaluation of the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) randomized controlled trial: an exercise training study of patients with chronic heart failure. Circ Cardiovasc Qual Outcomes 2010; 3:374.
- 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. Circulation 2009; 119:e391.
- Working Group on Cardiac Rehabilitation & Exercice Physiology and Working Group on Heart Failure of the European Society of Cardiology. Recommendations for exercise training in chronic heart failure patients. Eur Heart J 2001; 22:125.
- Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: A statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000; 102:1069.