Can I exercise if I have heart failure?

Patients with heart failure may have limited exercise capacity because exercise can worsen dyspnea and fatigue. However, at the physiologic level, exercise improves peak oxygen uptake, hemodynamic function, autonomic function, peripheral vascular and muscle function, and exercise capacity.^1,2 Thus, over time and with continued effort, exercise allows individuals to exercise at higher workloads at lower heart rates and with less effort.³ Overall, a vast body of literature has shown that regular exercise is safe and associated with a number of benefits⁴ in heart failure. 

Exercise and Heart Failure Sub-Types 

Systematic reviews and meta-analyses have found that exercise training reduces mortality and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF).^5,6 The largest single trial, HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training),⁶ showed a reduction in the adjusted risk for cardiovascular mortality or heart failure hospitalization in the exercise group (hazard ratio [HR] 0.85, 95% confidence interval [CI] [0.74 – 0.99], p=0.03), as compared to standard care. In addition, a meta-analysis of 801 heart failure patients participating in 9 individual randomized controlled trials of exercising training found that exercise reduced mortality (HR 0.65, 95% CI, 0.46 – 0.92), hospitalizations, and was not was associated with harm.⁷ Quality of life and depression also improved. There is considerably less data on the role of physical training in heart failure with preserved ejection fraction (HFpEF). However, a few randomized controlled trials have found that physical training is a safe and effective intervention to improve symptoms, increase aerobic capacity and endurance, and generally improve self-reported physical quality of life as well.^8-11

Exercise Recommendations

Exercise is recommended for patients with stable New York Heart Association (NYHA) functional class II to III HFrEF and for patients with stable NYHA functional class II to III HFpEF (left ventricular ejection fraction [LVEF] ≥50%) or mid-range ejection fraction (LVEF 41% – 49%).¹² The term stable heart failure does not have a clear consensus definition but generally implies mild symptoms with no recent new or worsening symptoms. The recommendation for exercise training in patients with HFrEF is stronger than for patients with HFpEF, but that is because the data are not as robust for patients with HFpEF. There is not enough data at present to recommend exercise for patients with class NYHA functional class IV HF. Exercise requires that the patient be clinically stable, so the ideal time to start exercising after a hospitalization should be discussed with a physician. 

The mode of exercise should be one that requires the use of large muscle groups and aerobic exercises such as walking, jogging, or cycling. No universal prescription for a particular exercise regimen for HF patients exists. The results of HF-ACTION⁶ support past research and are consistent with the current American Heart Association recommendations¹² for adequate warm-up (10 – 15 minutes) and cool-down periods and three to five exercise sessions per week, with supplemental walking on non-training days. Since adults with heart failure tend to be older and have other comorbid conditions, the exercise modality chosen should not exacerbate existing musculoskeletal issues. Additionally, certain patients are considered at higher risk for cardiac complications during exercise, such as patients with NYHA functional class III or IV HF and those with an ejection fraction less than 30%; these patients should review any exercise plan with a healthcare provider.³  In addition to exercise training, guidelines suggest that patients with heart failure should also engage in self-care, or behaviors involved in monitoring and responding to symptoms and adhering to treatment.^{4, 13} Finally, for some patients with heart failure, cardiac rehabilitation exercise training may be indicated.⁵ Cardiac rehabilitation is a comprehensive approach to treatment, offering exercise therapy, lifestyle modifications, and nutritional information, and is considered a Class IIa (a reasonable treatment recommendation for which benefit outweighs risk) recommendation in the management of stable HF by the American Heart Association.¹²  

^References

1. Downing J, Balady GJ. The role of exercise training in heart failure. J Am Coll Cardiol. Aug 2 2011;58(6):561-9. doi:10.1016/j.jacc.2011.04.020
2. 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. Jul 2002;144(1):23-30. doi:10.1067/mhj.2002.123310
3. Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. Aug 20 2013;128(8):873-934. doi:10.1161/CIR.0b013e31829b5b44
4. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. Sep 22 2009;120(12):1141-63. doi:10.1161/circulationaha.109.192628
5. Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail. Dec 2013;1(6):540-7. doi:10.1016/j.jchf.2013.09.002
6. 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):1451-9. doi:10.1001/jama.2009.457
7. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ. 2004-01-24 2004;328(7433):189-0. doi:10.1136/bmj.37938.645220.ee
8. Kitzman DW, Brubaker PH, Morgan TM, Stewart KP, Little WC. Exercise training in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial. Circ Heart Fail. Nov 2010;3(6):659-67. doi:10.1161/circheartfailure.110.958785
9. 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. Oct 18 2011;58(17):1780-91. doi:10.1016/j.jacc.2011.06.054
10. Kitzman DW, Brubaker PH, Herrington DM, et al. Effect of endurance exercise training on endothelial function and arterial stiffness in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial. J Am Coll Cardiol. Aug 13 2013;62(7):584-92. doi:10.1016/j.jacc.2013.04.033
11. Smart NA, Haluska B, Jeffriess L, Leung D. Exercise training in heart failure with preserved systolic function: a randomized controlled trial of the effects on cardiac function and functional capacity. Congest Heart Fail. Nov-Dec 2012;18(6):295-301. doi:10.1111/j.1751-7133.2012.00295.x
12. 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. Mar 4 2003;107(8):1210-25. doi:10.1161/01.cir.0000055013.92097.40
13. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Oct 15 2013;62(16):e147-239. doi:10.1016/j.jacc.2013.05.019