Introduction

Christopher Larson, M.S.
Carol Ewing Garber, Ph.D., FACSM, RCEP
Department of Health Science
Bouvé College of Health Sciences
Northeastern University
Boston, MA

Heart failure is one of the most commonly diagnosed diseases today. Nearly five million Americans are affected by heart failure, with 550,000 new cases diagnosed each year (American Heart Association, 2005). With the advancing age and longer life span of our population, these numbers are likely to increase drastically. The price tag for treating heart failure will also rise in the future. The direct and indirect costs of heart failure for 2005 have been estimated at $27.9 billion (American Heart Association, 2005). As treatment for conditions contributing to heart failure, such as heart attacks and high blood pressure improve, it is expected more individuals will be diagnosed with heart failure.

The development of heart failure leads to many adverse effects on a person’s life. A decrease in physical function is the hallmark of heart failure. However, other factors such as depression and anxiety also have a great impact on the health of those with heart failure. Depression has an additive impact on an already decreased functional level. Individuals exhibiting clinical depression have more constant symptoms of heart failure, and greatly decreased functional status and quality of life (Sullivan et al., 2004). Anxiety also has a negative effect on the standard of living in heart failure individuals and usually is accompanied by depression (Jiang et al., 2004). These adverse changes resulting from depression and anxiety can be mediated by treatment by a mental health professional, which may include the implementation of certain antidepressive medications such as selective serotonin reuptake inhibitors (SSRIs)(Jiang et al., 2004). Changes in lifestyle including increasing physical activity and exercise, healthier diet, and a good support structure will also help symptoms of depression as well as improve the overall prognosis of heart failure (Jiang et al., 2004).

Pathology

Heart failure is the inability of the heart to pump blood in order to meet the metabolic demands of the body (Dyer & Fifer, 2003). In other words, heart failure is a decreased ability of the heart to move blood to the working muscles of the body to provide necessary oxygen and nutrients, as well as moving blood away from the working muscles to remove products produced from muscular work. This disease has numerous and complicated processes of development. Heart failure can occur from any cause that results in a weaker heart. Myocardial infarction (heart attack), hypertension (high blood pressure), diseases of the heart valves, heart abnormalities at birth (congenital heart disease), and various forms of heart inflammation (cardiomyopathy), resulting from causes such as high blood pressure, disease of the heart valves infections, alcohol abuse, or unknown causes, are some of the conditions which can gradually or abruptly decrease the strength and efficiency of the heart, possibly ending in heart failure (Dyer & Fifer, 2003). When heart failure begins, it is generally unknown to both the individual and the clinician. This occurs because there are many mechanisms the body uses to compensate for the failure of the ability of the heart to pump blood, allowing the deterioration of the heart to remain relatively unnoticed. Once heart failure begins to progress, more signs and symptoms present themselves. Shortness of breath and fatigue are the main symptoms of heart failure (Francis & Wilson Tang, 2003) These symptoms first begin to show with mild to moderate physical exertion, and eventually become present at rest. Further manifestations of heart failure present themselves in the later stages of the disease when the compensatory mechanisms are unable to fully mask the deterioration of the heart. Some of these signs and symptoms include edema (swelling, usually in the ankles and in the lungs in later stages of heart failure), difficulty breathing at night and while lying down (sometimes accompanied with pulmonary congestion), decreased urine output, and possibly abdominal discomfort (Dyer & Fifer, 2003). Symptoms and physical findings are used by clinicians to classify heart failure (Tables 1 and 2). The classification, reflecting the severity of disease, is used to guide medical treatment.

Table 1: New York Heart Association Classification of Heart Failure
Class I	No limitation of physical activity
Class II	Slight limitation of activity. Dyspnea and fatigue with moderate physical activity.
Class III	Marked limitations of activity. Dyspnea with minimal activity.
Class IV	Severe limitation of activity. Symptoms are present even at rest.

From: Lilly, LS. Ed. Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty. Baltimore, MD: Lippincott Williams and Wilkins, 2003.

Table 2: Stages of Heart Failure
Stage	Description
A	Patients at risk of developing heart failure. (patients with hypertension, hypercholesterolemia, diabetes, smokers, etc.)
B	Patients with diagnosed structural damage who have not yet developed symptoms of heart failure. (history of myocardial infarction, reduced ejection fraction, valvular complications)
C	Patients with diagnosed with structural damage and symptoms of heart failure.
D	Structural damage and marked heart failure symptoms even with intense medical treatment.

Adapted from: Hunt, SA, Baker, DW, Chin, MH, et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1955 Guidelines for the Evaluation and Management of Heart Failure). Circulation, 2001, 104:2996-3007.

Treatment of Heart Failure

With a multitude of causative factors associated with heart failure, initial treatment lies in correcting the responsible underlying condition. Repair of dysfunctional heart valves, treatment of severe high blood pressure, and reopening clogged coronary arteries through bypass surgery or angioplasty are a few examples of correcting such conditions (Dyer & Fifer, 2003). Some standard medications are also used in the treatment of heart failure. Angiotensin Converting Enzyme (ACE) inhibitors and beta-blockers are recommended as initial treatment in all classes of diagnosed heart failure (Hunt et al., 2001). These two pharmacological treatments reduce the workload of the heart. ACE inhibitors act upon the blood vessels away from the heart, causing them to dilate, and allowing for easier movement of blood throughout the body. Beta-blockers, such as metoprolol, are used in heart failure to reduce the heart rate by blunting overactive stress hormones seen with this disease (Dyer & Fifer, 2003; Hunt et al., 2001) Diuretics (water pills) are also used in heart failure to reduce the fluid overload commonly seen with a weak heart. All of these drugs decrease the amount of work on the heart, improving symptoms and function (Hunt et al., 2001). Digitalis (Digoxin) and other drugs that improve the heart's ability to contract may also be used in the treatment of more severe heart failure patients. Digoxin is usually reserved for patients in New York Heart Association Class II or III (Table 1) (Haji & Movahed, 2003). Digoxin may also be used in more clinically stable patients in the presence of certain abnormal heart rhythms such atrial fibrillation, because it can slow the fast heart rate (tachycardia) that is associated with these heart rhythms (Haji & Movahed, 2003).

Eating a low fat, heart healthy diet is recommended in treating heart failure (Grady et al., 2000). One of the most important dietary alterations in heart failure is the restriction of sodium intake. Sodium can increase fluid retention and may stimulate pulmonary congestion and ankle swelling and worsening of symptoms of heart failure. 2000 milligrams of sodium or less is usually recommended however this may be increased to 2300 milligrams in those with mild to moderate heart failure (Grady et al., 2000). People with heart failure may need to increase their intake of potassium, because some the water pills (diuretic) medications may cause excessive loss of this mineral, which is important for the function of the heart and other body tissues (Grady et al., 2000). Alcohol should also be restricted in heart failure. Alcohol reduces the heart's ability to contract, leading to further decreases in blood flow throughout the body (Grady et al., 2000). In severe heart failure, fluids may be restricted, as these can worsen pulmonary congestion and edema.

Reduction of cardiovascular risk factors such as high cholesterol, high blood sugar (diabetes), high blood pressure, and overweight is important for persons with heart failure, because these increase the chance of having a heart attack, which would worsen heart failure. Smoking cessation is strongly encouraged for individuals with heart failure to lessen the burden on the heart and to improve overall health. Another lifestyle modification is to incorporate a regular routine of physical activity and exercise. Remaining physically active will allow the individual with heart failure to combat the cycle of decreased physical function and help to prolong life.

Exercise Adaptations

The decreased physical function associated with heart failure presents a serious challenge to the individuals with heart failure. Shortness of breath and fatigue precipitates a more sedentary lifestyle, which leads to further decline in functional capacity and the ability to engage in activities of daily living. Exercise has been shown to lessen and possibly reverse the regression in functional status in heart failure for individuals with heart failure (Hambrecht et al., 2000). The mechanisms involved in achieving the goal of stabilizing or improving functionality through exercise are many, but surprisingly they do not include a great degree of improvements in the functioning of the heart itself (Pina et al., 2003; Fang & Marwick, 2003).

• Vascular Adaptations

  Most of the improvements in the functional status of the heart failure individuals with heart failure come from enhancements to body areas away from the heart. Adaptations to circulation are the most significant adaptations of exercise. Regular aerobic activity leads to a decrease in blood pressure in hypertensive individuals. This occurs through activation of certain chemicals in the body by the increased movement of blood through the vessels. The main chemical involved, known as nitric oxide, works to relax the smooth muscles of the blood vessels thus increasing the diameter of the vessels allowing easier movement of blood. It should also be noted this response remain at rest as well (Pina et al., 2003; Fang & Marwick, 2003).

  Another effect of aerobic activity on heart failure is the ability to reduce the increase in a hormone commonly referred to as adrenaline (epinephrine). Increased levels of adrenaline and its related hormone, noradrenaline (norepinephrine), cause the heart to beat at a faster pace and more strongly than necessary. Higher levels of adrenaline result in an increase in resting heart rate as well as submaximal heart rate leading to a decreased ability to achieve higher workloads. Exercise is able to control the increase in heart rate by diminishing the levels of these hormones circulating in the blood stream (Hambrecht et al., 2000; Pina et al., 2003).

• Skeletal Muscle Adaptations

  One of the major changes occurring with exercise training in heart failure is the adaptation of skeletal muscle. The process of heart failure results in considerable muscle wasting of skeletal muscle, consequently inducing more fatigue and loss of functional ability. As the heart declines in function, blood is not able to move blood adequately to tissues in a similar manner of a normal functioning heart. Oxygen delivery is subsequently decreased to the muscle, leading to muscle degeneration and decreased strength (Monchamp & Frishman, 2002). Consequently, individuals with heart failure may feel like they have just sprinted when in actuality they have only walked a short distance. This is caused because the muscle cells being utilized are those usually utilized for short fast movement such as sprinting, and is one of the main causes of increases in shortness of breath with minimal physical activity (Monchamp & Frishman, 2002).

  With regular aerobic exercise, blood flow is improved to the muscles, thus increasing the amount and availability of oxygen to the muscles (Fang & Marwick, 2003). Adaptations occur causing the muscle cells to take on a form more similar to those without heart failure. The muscles utilize oxygen more efficiently and waste products are removed more efficiently as well.

  Resistance training has been shown to be a safe and effective way to manage the persistent muscle loss seen with individuals with heart failure (Benton, 2005). It has been shown to improve musculoskeletal performance as well as improve the ability of the muscle to utilize oxygen (Pu et al., 2000). Improvements are seen with resistance training muscular and physical functioning without improving or negatively affecting cardiac function (Pu et al., 2000). Additionally, no negative outcomes have been reported during resistance exercise according to the literature reviewed (Benton, 2005; Pu et al., 2000).

Exercise Recommendations

There is a great deal of evidence confirming the benefits individuals with heart failure receive with exercise. Determining the type, intensity, duration, and frequency of that exercise will depend on the individual, as an individualized approach is always recommended. Every patient is different; therefore, virtually every exercise prescription should be different as well. Consultation with a clinical exercise physiologist or other qualified health professional is ideal for persons with heart failure to obtain an individualized exercise prescription. Individuals with heart failure are also encouraged to begin a new program of exercise in a medically-supervised cardiac rehabilitation program. These programs are available through many hospitals and other clinical settings, and provide the opportunity to receive an individualized exercise prescription and to exercise under professional supervision to ensure safety during exercise. Cardiac rehabilitation programs can help individuals with heart failure to learn how to exercise appropriately, and to gain confidence in their ability to exert themselves. Cardiac rehabilitation programs are not always available or practical for persons with heart failure, and it is possible in many cases to exercise in community settings such as a local "Y" or health club, or at home.

Following are some general recommendations on how to construct an exercise program for individuals with heart failure with the goal of improving functionality and overall health in mind.

• Type

  Aerobic training is the most frequently used and frequently studied mode of exercise training in heart failure. This mode includes activities such as walking, cycling, and swimming. For the more stable patients in mild to moderate heart failure (NYHA Class I and some in Class II), these exercises will be the most appropriate and beneficial. For those with more severe heart failure (NYHA Class II and Class III), more limited activity may have to be employed. For example, persons with severe heart disease may need to exercise while sitting down, rather than standing. A variety of exercise equipment is available for those patients who may have an extremely limited exercise capacity where even walking may be difficult. Recumbent cycles may be an option for individuals who are deconditioned because of the more comfortable seated position.

  Resistance training should also be incorporated into an exercise routine for individuals with heart failure. Exercise machines may be the safest type of resistance training for an individual with heart failure to participate in, especially in a minimally-supervised environment. Weight machines allow for more correct body movement and less chance of adverse musculoskeletal injuries to occur. Free weights are also beneficial to the heart failure patient, although this type of resistance exercise may require more supervision and instruction. Exercises involving resistance bands as well as the individual’s own body weight will also improve the functioning of their muscle and may be the most appropriate for beginning training. Resistance exercise should focus on all major muscle groups of the body including arms, legs, back, and abdominal areas.

• Intensity

  In an ideal exercise setting, the prescribed aerobic intensity for the individuals with heart failure should come from an assessment performed by a clinician. Aerobic intensity should be obtained from data collected from a maximal cardiorespiratory exercise test. Since most individuals with heart failure will be medically treated with beta-blockers, heart rate will not be a sufficient method of determining exercise intensity. Instead, using the peak oxygen uptake (VO2) measured during a cardiopulmonary exercise test can be used. Oxygen uptake is a measure that reflects the function of the body (heart, circulation, lungs and muscles) during exercise. It is used to quantify the maximal amount of exercise a person is able to do, and to identify the level of exertion a person can engage in comfortably and safely. The majority of studies conducted have shown that improvement in functional capacity occurs when a person exercises at 70% to 80% of their maximal oxygen uptake, although exercising at lower levels (60-70% maximal oxygen uptake) also can result in improvement (Pina et al., 2003). Intensity of exercise may have to be reduced for severely individuals who are deconditioned beginning an exercise program. Periodic reevaluation of peak oxygen uptake should also be done if resources are available.

  The ventilatory threshold, also called the anaerobic threshold, may also be used to prescribe exercise for individuals with heart failure. The ventilatory threshold is measured during a cardiopulmonary exercise test, and is the point when an individual's breathing begins to increase at a very fast rate. The ventilatory threshold reflects the energy needs of muscles during exertion, and a by product of the process of providing energy for contraction of the muscle, lactic acid (lactate). Individuals with heart failure exercise below their anaerobic threshold.

  A subjective measure of exercise intensity may be utilized by itself or in combination with other methods to ensure proper intensity during aerobic activity. The Borg Ratings of Perceived Exertion scale (RPE) is a measure of an individual's perception of the degree of difficulty of exertion.)(Table 3). The RPE scale is a commonly used tool to determine or confirm an individual’s exercise intensity. On a scale of 6 to 20, an RPE of 12 to 13 correlates well with the intensity of exercise recommended based on peak oxygen uptake and is generally well tolerated (Pina et al., 2003).

  Table 3: Borg Rating of Perceived Exertion (RPE) Scale
  6
  7	Very, very light
  8
  9	Very light
  10
  11	Fairly light
  12
  13	Moderately hard
  14
  15	Hard
  16
  17	Very hard
  18
  19	Very, very hard
  20	Exhaustion

  
  From: Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982; 14(5):377-81.

  Another less accurate method that may be utilized is the “talk test.” The talk test is if an individual can carry on a conversation during exercise, then s/he is exercising at a safe level. The talk test approximates the ventilatory threshold, and is the point when the individual with heart failure first begins to have difficulty breathing (Persinger et al., 2004). However, if the resources are available, it should not be used as a substitute for more objective measures of intensity (Rotstein et al., 2004).

  Resistance training intensity should ideally be taken from measures obtained from musculoskeletal strength assessment tests assessing the ability of maximum workload during one repetition (1RM), which is the maximum amount of weight a person can lift one time. When 1RM measures are available, intensity should be set at 30 to 40% of 1RM for upper body exercises and 50 to 60% of 1RM for lower body exercises (Pollock et al., 2000). This level may have to be adjusted depending on the current condition of the individual. The Borg RPE scale may also be utilized during resistance exercises. An RPE of 13 to 15 is an appropriate level for training and comfort for most individuals (Pollock et al., 2000). Depending on the severity of heart failure and the physical condition of the individual, RPE may need to be lowered to 11 to 13 at the onset of resistance training. When beginning resistance training, the major focus of the training should be put on proper technique. Slow, controlled movements should be encouraged. In all, individuals with heart failure, especially those with high blood pressure, an emphasis on proper breathing techniques while performing the exercises should be made. Breath holding during muscle contraction (Valsalva maneuver) should be avoided while performing resistance exercises, as this increases the work on the heart and can result in dizziness and fainting in people with heart failure.

  All exercise, whether aerobic or resistance exercise, should begin with a 5-10 minute warm up and end with a cool down. The warm up and cool down should consist of gentle (low intensity) aerobic exercise, such as slow walking or cycling, and flexibility exercises. The warm up prepares the body for exercise by allowing it to adapt to exertion, while the cool down prepares the body to return to activity that is more sedentary. Individuals with heart failure may need longer periods of time (10-15 minutes) to warm up and cool down, because it takes their heart and blood vessels longer to adjust to changes in the demands for oxygen and nutrients by the muscles.

• Duration

  Duration of aerobic activity should once again be personalized depending on the condition of the individual. For most stable individuals, an initial duration of 20 minutes is reasonable (Monchamp & Frishman, 2002). This level should be used as a guideline, but it may be necessary to start some patients with a lower duration as tolerable by their condition. It may be necessary to start with very short durations of exercise, such as 5 to 10 minutes, which can be performed one or more times per day as tolerated. Progression of duration should be encouraged and recent research shows 30-40 minutes as being sufficient for one bout of exercise (Monchamp & Frishman, 2002; Smart et al., 2003).

  Resistance training should last long enough to complete the prescribed amount of repetitions with all prescribed exercises. Repetitions should begin at 12-15. However, some individuals will be unable to start at this level because of deconditioning or health status, and they can begin with fewer repetitions, which may be as few as 3-5 repetitions at the appropriate intensity. Progression to more repetitions can be made as tolerated. These exercises should focus on all major muscle groups including upper body, lower body and abdominal each exercise session (Pollock et al., 2000).

• Frequency

  The minimum aerobic exercise training frequency should be 3 times per week. This frequency correlates with the minimum level where improvements have been seen with exercise with individuals with heart failure (Pina et al., 2003; Monchamp & Frishman, 2002). This would be easily accomplished in a structured exercise program meeting on a regular basis. Additional days of activity done at home are encouraged on days when not attending regular exercise sessions. The home-based exercise does not necessarily need to include activity at the intensity of prescribed exercise, but movement such as light walking or cycling is encouraged. For the severely- deconditioned individuals, a day of rest may be needed in order to recover from the previous days exercise (Pina et al., 2003). Resistance training frequency should be set at 2 to 3 times per week with at least one day rest between exercise sessions (Pollock et al., 2000).

  Conclusion

  Heart failure is a progressive debilitating condition. By increasing activity and performing regular exercise at an appropriate training level, individuals with heart failure can improve physical function and quality of life. There are many benefits of exercise for individuals with heart failure which include improving blood flow to skeletal muscle, decreasing sympathetic nervous system effects on heart rate, blood pressure, and blood flow, improving skeletal muscle efficiency, and improving pulmonary (lung) diffusion. Exercise does not improve heart function in individuals with heart failure. Professional guidance is recommended for individuals with heart failure before taking on an exercise program. Ideally, an individual should begin exercising in a medically supervised environment with staff knowledgeable on exercise and heart failure. If this is service is not available, a consultation with the individual’s physician is recommended before beginning the exercise program. Aerobic and anaerobic exercise with individuals with heart failure can be a safe and effective method for improving functional capacity and overall quality of life for individuals with heart failure.

  Books

  1. Lilly, LS (Eds.). (2003). Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty: Heart Failure. Baltimore, MD: Lippincott Williams and Wilkins.

  Journals

  1. Francis, GS, Wilson Tang, WH. (2003). Pathophysiology of Congestive Heart Failure. Reviews in Cardiovascular Medicine, 4(3), S14-S20.
  2. Hambrecht, R, Gielen, S, Linke, A, et al. (2000). Effects of Exercise Training on Left Ventricular Function and Peripheral Resistance in Patients with Chronic Heart Failure. Journal of the American Medical Association, 283(23), 3095-3101.
  3. Pina, IL, Apstein, CS, Balady, GJ, et al. (2003). Exercise and Heart Failure: A Statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention. Circulation, 107, 1210-1225.
  4. Fang, ZY, Marwick, TH. (2003). Mechanism of Exercise Training in Patients with Heart Failure. American Heart Journal, 145(5), 904-911.
  5. Grady, KL, Dracup, K, Kennedy, G, et al. (2000). Team Management of Patients with Heart Failure: A Statement for Healthcare Professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation, 102(19), 2443-2456.
  6. Monchamp, T, Frishman, WH. (2002). Exercise as a Treatment Modality for Congestive Heart Failure. Heart Disease, 4, 110-116.
  7. Sullivan, MD, Newton, K, Hecht, J, et al. (2004). Depression and health status in elderly patients with heart failure: a 6-month prospective study in primary care. The American Journal of Geriatric Cardiology, 13(5), 252-260.
  8. Jiang, W, Kuchibhatla, M, Cuffe, MS, et al. (2004). Prognostic Value of Anxiety and Depression in Patients with Chronic Heart Failure. Circulation, 110(22), 3452-3456.
  9. Haji, SA, Movahed, A. (2000). Update on digoxin therapy in congestive heart failure. American Family Physician, 62, 409-416.
  10. 13. Benton, MJ. (2005). Safety and efficacy of resistance training in patients with chronic heart failure: research-based evidence. Progress in Cardiovascular Nursing, 20(1), 17-23.
  11. Pu, CT, Johnson, MT, Forman, DE, et al. (2001). Randomized trial of progressive resistance training to counteract thy myopathy of chronic heart failure. Journal of Applied Physiology, 90, 2341-2350.
  12. Persinger, R, Foster, C, Gibson, M, et al. (2004). Consistency of talk test for exercise prescription. Medicine and Science in Sport and Exercise, 36(9), 1632-1636.
  13. Rotstein, A, Meckel, Y, Inbar, O. (2004). Perceived speech difficulty during exercise and its relation to exercise intensity and physiological responses. European Journal of Applied Physiology, 92(4-5), 431-439.
  14. Pollock, ML, Franklin, BA, Balady, GJ, et al. (2000). Resistance Exercise in Individuals with and without Cardiovascular Disease Benefits, Rationale, Safety, and Prescription: An Advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation, 101(8), 828-833.
  15. Smart N, Fang ZY, Marwick, TH. (2003). A Practical Guide to Exercise Training for Heart Failure Patients. Journal of Cardiac Failure, 9(1), 49-58.
  16. Wielenga, RP, Huisveld, IA, Bol, E, et al. (1999). Safety and effects of physical training in chronic heart failure: Results from the Chronic Heart Failure and Graded Exercise study (CHANGE). European Heart Journal, 20, 872-879.

  Reports

  1. American Heart Association. (2005). Heart Disease and Stroke Statistics – 2005 Update.
  2. Hunt, SA, Baker, DW, Chin, MH, et al. (2001). ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). .
  
  
  

  This fact sheet was last updated on 03-01-2007.

Add a Fact Sheet Section

Update this Fact Sheet
(edit sheet name, edit organizations, etc.)