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Heart Failure
Exercise Therapy for the Failing Heart—Harmful or Helpful?
Peter H Brubaker, PhD
Professor, Department of Health and Exercise Science, and
Executive Director, Healthy Exercise and Lifestyle ProgramS (HELPS), Wake Forest University, Winston-Salem
Abstract
Appropriately prescribed endurance exercise training has traditionally been contraindicated in patients with heart failure (HF). Despite 20 years
of positive findings, including improved exercise tolerance and quality of life, published guidelines and clinicians have been reluctant to
recommend this important therapy for HF patients. Results from the large, randomized controlled HF ACTION trial indicate that properly
prescribed and monitored endurance exercise training is well tolerated and results in numerous positive benefits for these patients. The impact
of endurance exercise training on morbidity and mortality in this high-risk population appears marginally positive, but many other positive
adaptations also occur, including the prevention of undesirable left ventricular remodeling. Emerging studies suggest that resistance and/or
high-intensity interval training may also be tolerable and beneficial in HF patients. Larger long-term studies of these novel interventions will
require further investigation before widespread application. There is a plethora of evidence to support and encourage the use of appropriately
prescribed endurance exercise training for stable HF patients.
Keywords
Heart failure, exercise physiology, left ventricular dysfunction, exercise intolerance, cardiac rehabilitation
Disclosure: The author has no conflicts of interest to declare.
Received: February 9, 2009 Accepted: February 27, 2009
Correspondence: Peter H Brubaker, PhD, Box 7628 Reynolda Station, Wake Forest University, Winston-Salem, NC 27109. E:
brubaker@wfu.edu
Heart failure (HF), most simply defined as the inability of the heart to comprehensive and provide recommendations for specific medical
meet the demands of the tissue, results in symptoms of fatigue or therapies, surgical interventions, and dietary modifications for each
dyspnea on exertion (progressing to dyspnea at rest), and is a costly stage of HF, one potentially important therapy—exercise/physical
and deadly disorder.
1
HF is the only cardiovascular disease entity activity—is noticeably absent. The absence of exercise therapy
where the incidence is currently increasing. In 1991 there were ‘just’ guidelines in this important document may lead to concern and/or
3.5 million reported cases of HF in the US; however, this number has confusion among clinicians regarding the safety and/or efficacy of
recently risen to 5 million.
2
While this represents a major burden now, exercise for HF patients. The purpose of this article is to summarize
the HF prevalence in the US is expected to double to 10 million by the already extensive and rapidly accumulating evidence
2030.
3
Much of the increase in prevalence can be attributed to the demonstrating that properly conducted exercise therapy is safe and
aging population, as the prevalence of HF increases from 2% in beneficial in stable HF patients.
individuals between 40 and 50 years of age to more than 10% in those
above 65 years of age.
2
Moreover, hospital admissions for HF in Pathophysiology and Consequences of
patients above 65 years of age has increased by 131%, from 348,886 Heart Failure
in 1980 to 807,082 in 2006.
2
Consequently, annual direct and indirect It is now widely accepted that HF is not a disease but rather a
treatment costs associated with managing this growing HF burden are pathophysiological ‘syndrome’ that occurs when there is significant left
a staggering $34 billion. While HF has become a major public health ventricular (LV) systolic and/or diastolic dysfunction
5
that leads to the
problem, unfortunately little has been done to establish systematic development of HF signs and symptoms. Whereas systolic dysfunction
screening efforts (such as those for breast or prostate cancer) to can be considered a defect in the ability of myofibrils to shorten against
detect this deadly disease at the earliest stage. HF is largely resistance, diastolic dysfunction results from an increased resistance to
preventable, primarily through control of blood pressure and other LV filling leading to an inappropriate upward shift of the diastolic
known vascular risk factors. The American College of Cardiology (ACC) pressure volume relation. Systolic dysfunction will result in elevated
and the American Heart Association (AHA) have developed an end-diastolic and end-systolic volumes, resulting in a reduced ejection
approach that emphasizes evolution and disease progression in HF to fraction, whereas diastolic dysfunction results in reduced end-diastolic
classify the disease into four stages.
4
While these guidelines are and end-systolic volumes, with a resultant normal or greater than
56 © TOUCH BRIEFINGS 2009
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