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Prof. Emeline M. Van Craenenbroeck
Heart failure (HF) is associated with undermining physical symptoms, resulting in a markedly decreased quality of life. Exercise intolerance, with pronounced fatigue and dyspnoea are key characteristics of the HF syndrome. Contra-intuitively at first sight, exercise training is one of the most efficacious ways to improve physical performance and quality of life, and to reduce morbidity and mortality. The recently launched 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure have incorporated a recommendation for regular aerobic exercise in patients with HF to improve functional capacity and symptoms and to reduce the risk of HF hospitalisation (Class I recommendation). However, there remains a considerable knowledge gap between these firm recommendations and the lack of practical guidelines on the prescription of exercise training. Either way, it is essential to tailor the prescribed exercise regimen to the patient’s HF phenotype and abilities, as well as to take their preferences into account. Active measures should be taken to increase dissemination of efficacy, safety and practical modalities for exercise training in HF to cardiologists, physiotherapists, regulatory organisations and patients. In such a way, more patients, including the elderly and frail HF patients, will find their way to cardiac rehabilitation centres.
More than 14 million Europeans suffer from heart failure (HF). Despite significant improvements in the treatment of HF, morbidity and mortality remain unacceptably high . In addition, the costs for HF care approach 2% of the healthcare expenditure in Western Europe. One of the hallmarks of HF is severe exercise intolerance with pronounced fatigue and dyspnoea, even at low workloads, resulting in a markedly decreased quality of life. However, the severity of exercise limitation in HF is not correlated to the extent of cardiac dysfunction alone. Peripheral disturbances such as impaired vasoreactivity, impaired skeletal muscle energy metabolism and functional iron deficiency are as important as cardiac function to determine exercise capacity .
Because exercise training tackles both central and peripheral disturbances, it is an attractive therapy from a pathophysiological point of view. Indeed, 25 years of research have demonstrated the numerous physiologic, musculoskeletal and psychosocial benefits of exercise training. These benefits are clinically translated into improved exercise capacity, improved quality of life and improved outcome in patients with HF. This article provides general information on the clinical evidence of exercise training in HF and includes practical advice on how to prescribe exercise to HF patients.
In contrast to the former belief, exercise training in HF patients has proven to be safe and has no adverse effect on left ventricular remodelling .
With regard to benefit on exercise capacity, a meta-analysis of 29 randomised controlled trials (RCT) including 848 patients revealed a mean improvement of VO2peak of 2.16 ml/kg/min . Although modest in absolute terms, this means an increase of 13% which translates into a considerably better quality of life . VO2peak is a strong and independent prognosticator in HF, and even small changes in VO2peak are associated with significantly improved outcomes . In addition to VO2peak, exercise training has positive effects on health-related quality of life. A meta-analysis of 13 RCT demonstrated that exercise training results in a clinically important improvement in the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) (mean difference: -5.8 points) .
The HF-ACTION trial randomised 2,331 patients (median age 59 yrs, 27-30% women) suffering from HF with reduced ejection fraction (HFrEF) either to three months of supervised aerobic exercise training at moderate intensity (three days/week, exercise capacity at 60-70% of heart rate reserve) or to usual care . This study showed in an intention-to-treat analysis that exercise training was associated with an 11% lower adjusted risk for all-cause mortality or all-cause hospitalisation and a 15% lower adjusted risk for cardiovascular mortality or HF hospitalisation.
The most recent Cochrane review of exercise training included 33 trials with 4,740 patients with HF (mainly HFrEF) with the HF-ACTION trial contributing approximately 50% . There was a trend towards a reduction in mortality with exercise in trials with >1 year of follow-up. Exercise training, when compared to usual care alone, reduced the rate of overall (25%) and HF-specific hospitalisation (39%).
The 2016 European Society of Cardiology heart failure guidelines  firmly recommend that:
Contraindications for participation in an exercise training programme are listed in Table 1 .
Table 1. Contraindications for exercise training in HF.
Early after acute coronary syndrome (2 days)
Acute systemic illness, fever
Untreated life-threatening cardiac arrhythmias
Uncontrolled diabetes mellitus or thyroid dysfunction
Acute heart failure
High degree atrioventricular block
Cerebrovascular or musculoskeletal disease preventing exercise testing or training
Acute myocarditis and pericarditis
Symptomatic aortic stenosis
Severe hypertrophic obstructive cardiomyopathy
Progressive worsening of heart failure symptoms in previous 3-5 days, NYHA Class IV
Significant myocardial ischaemia or arrhythmia during low-intensity exercise
The main characteristics of the most frequently applied training schemes in HF are shown in Table 2.
Table 2. Main characteristics of the most frequently applied training schemes in HF.
Continuous endurance training
Intensity 40-50% VO2peak until exercise duration of 10-15 minutes is achieved
Increase gradually to intensity 50-70-80% VO2peak.
Then increase session duration to 15-20-30 minutes
Session duration: 45-60 min
Interval endurance training
Start low intensity, e.g., 50% of VO2peak during 10 sec, for 5-10 min
Increase gradually the duration of the high-intensity interval (10-30 sec), and then increase the intensity (60-100%). Session duration: 15-30 min
Intensity <30% 1-RM.
Intensity: 30-50% 1-RM.
Intensity 40-60% 1-RM.
The potential benefits of exercise training after ICD implantation include acquaintance with device settings, instruction about physical activity (including arm movements), psychological support and improvement of exercise capacity. One single-centre study showed that exercise training on top of CRT doubled the improvement in exercise capacity and further improved haemodynamic measures and quality of life .
ICD and CRT-D patients should start exercise training under medical supervision and monitoring of heart rate. Exercise level and ICD programming should be adapted to keep the maximal heart rate 20 beats below the ICD intervention zone. The following patient information should be readily available to reduce the risk of incidents: 1) underlying heart disease and indication of ICD implantation; 2) triggers for arrhythmia (e.g., ischaemia) and the arrhythmic substrate; 3) the ICD intervention heart rate; 4) the tachy-therapy that will be delivered.
So far, only small single-centre trials have been performed in which exercise training has been evaluated as treatment for HFpEF. From a recent meta-analysis of eight intervention trials of exercise training in HFpEF , we learn that endurance training, either alone or in combination with strength training, has several benefits, including improvements in exercise capacity, as measured objectively by VO2peak , quality of life  and diastolic dysfunction .
It is worrying that women with HF are severely underrepresented in exercise intervention trials. Only four RCT (a total of 84 women), with the most recent study dating from 2005 , have specifically studied the efficacy of exercise training on health-related outcomes in women. Despite the low sample, and the single-centre design of these trials, the data indicate that aerobic exercise training and strength training significantly improve VO2peak, health-related quality of life and muscle strength, similarly to men. When it comes to hard endpoints, the sub-analysis of the HF-ACTION trial - stratified according to sex - is of particular interest . Aerobic training was associated with a 26% reduction in the combined endpoint in women (n=290 in exercise group), whereas there was no decrease in men (n=682 in exercise group).
This subanalysis provides proof of concept that women, although they achieved lower VO2peak at baseline and their training adherence was lower compared to men, may benefit even more from exercise training than men with regard to outcome.
A joint effort from clinicians and researchers should be made to achieve the following goals in the future:
Piepoli MF, Binno S, Corrà U, Seferovic P, Conraads V, Jaarsma T, Schmid JP, Filippatos G, Ponikowski PP; Committee on Exercise Physiology & Training of the Heart Failure Association of the ESC. ExtraHF survey: the first European survey on implementation of exercise training in heart failure patients. Eur J Heart Fail. 2015 Jun;17(6):631-8.
Emeline M. Van Craenenbroeck, MD, PhD
Cardiology Department, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
Address for correspondence:
Prof Dr Emeline M. Van Craenenbroeck
Cardiology Department, Antwerp University Hospital, Wilrijkstraat 10
B-2650 Edegem, Belgium
Tel: +32 3 8214672
Conflict of interest
The author has no conflicts of interest to declare.
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