Explainers

Chronic Heart Failure and Exercise: to Exercise, or Not to Exercise?


As we have already discussed, congestive heart failure (CHF) is not a disease but rather a cascade of events and ill-conceived compensatory efforts made by the body, and all therapists should understand that cascade in order to safely and effectively design exercises for the patient with heart failure (HF).

The role of the therapy and nursing care in the management of CHF is rapidly changing. Often, the patient who walks in the clinic door is not seeking therapy for management of heart failure; rather, heart failure is merely one of an ever-increasing string of ‘also have’ conditions or co-morbidities. It comes with the package.

Exercise recommendations for the CHF patient have evolved beyond recognition over the last 30 years. In 2010, and again in 2014 and 2016, the industry heavyweight Cochrane Collaboration weighed in on the matter (Taylor et al. 2014). In their Exercise Based Rehabilitation for Heart Failure document, the Cochrane team added ammunition to the argument that exercise was both safe, and reduced hospital readmissions.

What’s more, the growing body of evidence has demonstrated that the safety of exercise prescription is not limited to patients with a single kind of heart failure. Recent studies have demonstrated that – if cardiac exercise is properly administered and supervised – a huge spectrum of patients with HF can safely participate, including patients with both systolic and diastolic dysfunction, atrial fibrillation, pacemakers, implantable cardioversion devices, and post-cardiac transplantation.

Keep in mind that patients who are unstable or decompensated should not participate in exercise until stable; in fact, some programs will not permit patients to exercise until they have been stable for 3 months or more.

No matter the official diagnoses, no HF patient is considered appropriate for exercise training until they are evaluated and assessed for current physical status, medical regime, and exercise tolerance.

Typically, patients must undergo a physical assessment with particular attention paid to signs or symptoms related to heart failure, such as the presence of new heart sounds, lung crackles, weight gain, or oedema.

The program may even track brain naturetic peptide (BNP), renal function, and medications. Additionally, before the first exercise is prescribed or performed, patients must see a physical therapist for an evaluation of physical function and endurance.

Further Learning: Venous Thromboembolism Video Course

Chronic Heart Failure and Exercise Red Flags

Patients with CHF rank worse than patients with other forms of heart disease on overall morbidity and mortality. It is not strange, then, that exercise guidelines place chronic heart failure at the highest level of risk. However, recent systematic reviews have shown the overall adverse event rate to be quite low.

It becomes important, then, for healthcare professionals to be able to differentiate signs and symptoms that require emergency management, from common exertion signs and symptoms.

The most common signs and symptoms that crop up during exercise sessions include hypotension (typically after exercise), arrhythmias (both atrial and ventricular) and a general worsening of CHF symptoms (dyspnoea, swelling, etc). Many patients with CHF already experience vacillating levels of symptoms from day to day; when this is the case, it is harder to determine if any decline in status is due to the exercise program or the disease itself.

That said, there are multiple red flags that should never be ignored and indicate the onset of an unstable stage of heart failure (see list below). A sudden onset of shortness of breath not related to exercise (or likewise a change in the status of dyspnoea at rest) is certainly a call for medical attention.

Patients who cough up pink/frothy sputum or experience chest pain, dizziness or any indications of low perfusion (such as a change in skin colour or a decline in level of consciousness) should cease all exercise and seek emergency management. Individuals who show dramatic deterioration in circulation and oxygenation – such as shown by an arterial oxygen saturation <90% or systolic blood pressure <80-90mmHg – are likely in an unstable state, especially if they are coupled with subjective symptoms.

Unstable symptoms may include:

  • Dyspnoea: at rest/orthopnoea (change from baseline), sudden onset of shortness of breath (SOB), worsening SOB, exertional dyspnoea, gasping
  • Arterial oxygen saturation (SaO2) less than 90%
  • Coughing up pink/frothy sputum
  • Dizziness or syncope
  • Chest pain
  • Systolic blood pressure (BP) less than 80 to 90mmHg and symptomatic
  • Evidence of hypoperfusion (cyanosis, decreased level of consciousness, etc.)
Further Learning: Interpretation of Arterial Blood Gas Results Video Course

Classifying Chronic Heart Failure Patients for Exercise

Heart failure patients are unlike almost every other patient who participates in an exercise program. They require a thorough assessment by a professional who understands their specific disorder and can properly stratify their risk for harm. In other words, it becomes important to classify patients into group of those who can exercise and those for whom exercise would be contraindicated.

Why is the CHF patient a special risk? Think about all the interwoven factors that alter the heart failure patient’s responses to exercise.

Firstly, their body reacts differently to exertion; they do not experience the normal physiological and compensatory responses that are commonly seen during an exercise session.

Secondly, they are most probably on multiple medications, including beta blockers, ACE inhibitors and diuretics, all of which dramatically alter how their heart responds to exercise stimuli.

Thirdly, they may be under the influence of a pacemaker, implantable defibrillator or other device, which alters their capacity to respond to exercise.

Fourthly, HF is probably not the only game in town. Patients who have developed heart failure typically have a history of hypertension, coronary artery disease and/or diabetes. Each of these comorbidities brings its own special needs to the exercise table.

And finally, when working with the patient with CHF, the end result of choosing wrongly is pretty darn catastrophic. Many heart failure patients are at risk of sudden arrhythmias, sudden cardiac death and myocardial infarction at rest. These risks all (theoretically) elevate during exercise, although recent research shows little evidence of increased major medical incidences.

So what kind of exercise should the patient with CHF be pursuing? There continues to be one gold-standard: moderate-intensity endurance training. This training type continues to excel at improving the prognosis of heart patients including a reduction in mortality and a reduced rate of rehospitalization. Recently, clinicians pinned their hopes on a trial that seemed to show that high-intensity interval training would eclipse steady-state training. However, this hope seems to have been crushed by the SMARTEX study which showed that these results could not be reproduced. Resistance training should never be a “singular focus” for the patient with heart failure; it is inefficient in improving exercise capacity; however, if combined with an endurance regime, it can produce results in both vascular function and exercise capacity.

Conclusion

Historically, patients with CHF were advised to reduce activity or just plain “rest” as their symptoms worsened, but these recommendations have been rejected and replaced with exercise protocols for most patients. Recent research continues to bolster the pro-exercise position. Rarely, if ever, should today’s clinicians be advising stable CHF patients to take it easy. Once again, exercise rules the day!

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References

  • Ellingsen, Ø, Halle, M, Conraads, VM, Støylen, A, Dalen, H, Delagardelle, C, Larsen, A, Hole, T, Mezzani, A, Van Craenenbroeck, EM, Videm, V, Beckers, PJ, Christle, JW, Winzer, EB, Mangner, N, Woitek, F, Höllriegel, R, Pressler, AP, Monk-Hansen, T, Snoer, M, Feiereisen, P, Valborgland, T, Kjekshus, JK, Hambrecht, R, Gielen, S, Karlsen, T, Prescott, EB, Linke
    A, & the SMARTEX Heart Failure Study Group 2017, ‘High intensity interval training in heart failure patients with reduced ejection fraction’, Circulation, vol. 136, no. 13, viewed 26 September 2017, http://circ.ahajournals.org/content/early/2017/01/19/CIRCULATIONAHA.116.022924.short.
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  • Institute for Clinical Systems Improvement 2011, Heart Failure in Adults, ICSI, viewed 26 September 2017, https://guideline.gov/summaries/summary/47030
  • O’Connor, CM, Whellan, DJ, Lee, KL, Keteyian, SJ, Cooper, LS, Ellis, SJ, Leifer, ES, Kraus, WE, Kitzman, DW, Blumenthal, JA, Rendall, DS, Miller, NH, Fleg, JL, Schulman, KA, McKelvie, RS, Zannad, F, Pina, IL & HF-ACTION Investigators 2009, ‘Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial’, JAMA: the journal of the American Medical Association, vol. 301, no. 14, pp. 1439–50, viewed 26 September 2017, https://www.ncbi.nlm.nih.gov/pubmed/19351941.
  • Sagar, VA, Davies, EJ, Briscoe, S, Coats, AJ, Dalal, HM, Lough, F, Rees, K, Singh, S & Taylor, RS 2015, ‘Exercise-based rehabilitation for heart failure: systematic review and meta-analysis’, Open Heart, vol. 2, no. 1, viewed 26 September 2017, https://www.ncbi.nlm.nih.gov/pubmed/25685361.
  • Taylor, RS, Sagar, VA, Davies, EJ, Briscoe, S, Coats, AJ, Dalal, H, Lough, F, Rees, K & Singh, S 2014, ‘Exercise‐based rehabilitation for heart failure’, Cochrane Database of Systematic Reviews, viewed 26 September 2017, https://scholar.google.com/scholar?as_ylo=2013&q=Exercise+Based+Rehabilitation+for+Heart+Failure&hl=en&as_sdt=0,43
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