Physical Training and Cardiac Rehabilitation in Heart Failure Patients
Regardless of advances in medical and interventional treatment of cardiovascular disease (CVD), a limited number of patients attend a cardiac rehabilitation (CR) programme on a regular basis. Due to modern therapies more individuals will be surviving an acute cardiovascular event, but the expected burden of chronic heart failure will be increasing worldwide.
However, both in high- and low-income countries, secondary prevention after an acute myocardial infarction or stroke has been implemented in less than a half of eligible patients.
Combined interventions are still needed to reduce decompensations, hospitalizations and mortality in heart failure patients from any origin. In addition to medical treatments, regular exercise has been demonstrated to improve metabolic and hemodynamic conditions in both asymptomatic risk factor carriers and cardiac patients. Risk factor control and exercise should gather together for an effective management of patients.
Exercise-based training is a core component of primary and secondary prevention. It should involve healthy carriers of cardiovascular risk factors, and patients with cardiomyopathy as well. The supposed attenuated effect of CR in the era of advanced revascularization and structural interventions is due to the heterogeneity of training models and physical training in the literature. Moreover, lifestyle modification, psycho-social challenges and patient’s compliance are potential confounders.
In this chapter the most recent evidences about training modalities and potential benefit of CR in heart failure patients are discussed.
KeywordsCardiac rehabilitation Cardiovascular disease Exercise Functional evaluation Heart failure Clinical outcomes Physical training
Cardiopulmonary Exercise Test
Chronic/Congestive Heart Failure
Carbon Dioxide Oxygen
Intracardiac Implantable Defibrillator
Inspiratory Muscle Training
Transcatheter Aortic Valve Implantation
Conflict of Interest
None to declare.
- Abell B, Glasziou P, Hoffmann T (2017) The contribution of individual exercise training components to clinical outcomes in randomised controlled trials of cardiac rehabilitation: a systematic review and meta-regression. Sports Med Open 3:19. https://doi.org/10.1186/s40798-017-0086-zCrossRefPubMedPubMedCentralGoogle Scholar
- Ambrosetti M, Doherty P, Faggiano P, Corrà U, Vigorito C, Hansen D et al (2017) Characteristics of structured physical training currently provided in cardiac patients: insights from the Exercise Training in Cardiac Rehabilitation (ETCR) Italian survey. Monaldi Arch Chest Dis 87(1):778. https://doi.org/10.4081/monaldi.2017.778.CrossRefPubMedGoogle Scholar
- Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al (2017a) Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. Issue 6. Art. No.: CD007130. https://doi.org/10.1002/14651858.CD007130.pub4.
- Arena R, Myers J, Williams MA et al (2007) Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation 116:329–343. https://doi.org/10.1161/CIRCULATIONAHA.106.184461CrossRefPubMedGoogle Scholar
- Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JA et al (2007) Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 115:2675–2682. https://doi.org/10.1161/CIRCULATIONAHA.106.180945CrossRefPubMedGoogle Scholar
- Belardinelli R, Capestro F, Misiani A, Scipione P, Georgiou D (2006) Moderate exercise training improves functional capacity, quality of life, and endothelium-dependent vasodilation in chronic heart failure patients with implantable cardioverter defibrillators and cardiac resynchronization therapy. Eur J Cardiovasc Prev Rehabil 13:818–825. https://doi.org/10.1097/01.hjr.0000230104.93771.7dCrossRefPubMedGoogle Scholar
- Borg G, Hassmen P, Langerstrom M (1984) Perceived exertion in relation to heart rate and blood lactate during arm and leg exercise. Eur J Appl Physiol 65:679–685Google Scholar
- Borghi-Silva A, Carrascosa C, Oliveira CC, Barroco AC, Berton DC, Vilaça D et al (2008) Effects of respiratory muscle unloading on leg muscle oxygenation and blood volume during high-intensity exercise in chronic heart failure. Am J Physiol Heart Circ Physiol 294(6):H2465–H2472. https://doi.org/10.1152/ajpheart.91520.2007CrossRefPubMedGoogle Scholar
- Commissioning guidance for rehabilitation. NHS England (2016). Publications Gateway Ref No. 04919Google Scholar
- Corrà U, Agostoni PG, Anker SD, Coats AJS, Crespo Leiro MG, de Boer RA et al (2017) Role of cardiopulmonary exercise testing in clinical stratification in heart failure. A position paper from the Committee on exercise physiology and training of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. https://doi.org/10.1002/ejhf.979.
- de Gregorio C, Magaudda L (2017) Blunt thoracic trauma and cardiac injury in the athlete: contemporary management. J Sports Med Phys Fitness. https://doi.org/10.23736/S0022-4707.17.07776-3.
- de Gregorio C, Patanè S, Buda D, Campisi A, De Luca G (2015) on behalf of the Local Healthcare Authority. Percorso diagnostico-terapeutico-assistenziale nello scompenso cardiaco nella provincia di Messina (2015). Messina (Italy) [Italian]; Single issue; Research Gate, pp 1–66. https://doi.org/10.13140/RG.2.1.1535.8807
- de Gregorio C, Dattilo G, Casale M, Terrizzi A, Donato R, Di Bella G (2016) Left atrial morphology, size and function in patients with transthyretin cardiac amyloidosis and primary hypertrophic cardiomyopathy. Comparative strain imaging study. Circ J 80(8):1830–1837. https://doi.org/10.1253/circj.CJ-16-0364CrossRefPubMedGoogle Scholar
- Goode KM, John J, Rigby AS, Kilpatrick ES, Atkin SL, Bragadeesh T et al (2009) Elevated glycated haemoglobin is a strong predictor of mortality in patients with left ventricular systolic dysfunction who are not receiving treatment for diabetes mellitus. Heart 95:917–923. https://doi.org/10.1136/hrt.2008.156646CrossRefPubMedGoogle Scholar
- Grace SL, Russell KL, Reid RD, Oh P, Anand S, Rush J, Cardiac Rehabilitation Care Continuity through Automatic Referral Evaluation (CRCARE) Investigators et al (2011) Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. Arch Intern Med 171:235–241. https://doi.org/10.1001/archinternmed.2010.501.CrossRefPubMedGoogle Scholar
- Hansen TB, Berg SK, Sibilitz KL, Søgaard R, Thygesen LC, Yazbeck AM et al (2015) Availability of, referral to and participation in exercise-based cardiac rehabilitation after heart valve surgery: results from the national Copen Heart survey. Eur J Prev Cardiol 22(6):710–718. https://doi.org/10.1177/2047487314536364CrossRefPubMedGoogle Scholar
- Hermann TS, Dall CH, Christensen SB, Goetze JP, Prescott E, Gustafsson F (2011) Effect of high intensity exercise on peak oxygen uptake and endothelial function in long-term heart transplant recipients. Am J Transplant 11:536–541. https://doi.org/10.1111/j.1600-6143.2010.03403.xCrossRefPubMedGoogle Scholar
- Hollings M, Mavros Y, Freeston J, Fiatarone Singh M (2017) The effect of progressive resistance training on aerobic fitness and strength in adults with coronary heart disease: a systematic review and meta-analysis of randomised controlled trials. Eur J Prev Cardiol 24(12):1242–1259. https://doi.org/10.1177/2047487317713329CrossRefPubMedGoogle Scholar
- Hunt SA (2006) American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005; 46(6):e1–82. Erratum in: J Am Coll Cardiol 47(7):1503–1505. https://doi.org/10.1016/j.jacc.2005.08.022
- James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J et al (2014) Evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the eighth Joint National Committee (JNC 8). JAMA 311:507–520. https://doi.org/10.1001/jama.2013.284427.CrossRefPubMedGoogle Scholar
- Kämpfer J, Yagensky A, Zdrojewski T, Windecker S, Meier B, Pavelko M et al (2017) Long-term outcomes after acute myocardial infarction in countries with different socioeconomic environments: an international prospective cohort study. BMJ Open 7(8):e012715. https://doi.org/10.1136/bmjopen-2016-012715CrossRefPubMedPubMedCentralGoogle Scholar
- Karagiannis C, Savva C, Mamais I, Efstathiou M, Monticone M, Xanthos T (2017) Eccentric exercise in ischemic cardiac patients and functional capacity: a systematic review and meta-analysis of randomized controlled trials. Ann Phys Rehabil Med 60:58–64. https://doi.org/10.1016/j.rehab.2016.10.007CrossRefPubMedGoogle Scholar
- Kervio G, Carre F, Ville NS (2003) Reliability and intensity of the six-minute walk test in healthy elderly subjects. Med Sci Sports Exerc 35:169–174. https://doi.org/10.1249/01.MSS.0000043545.02712.A7CrossRefPubMedGoogle Scholar
- Kivimäki M, Kuosma E, Ferrie JE, Luukkonen R, Nyberg ST, Alfredsson L et al (2017) Overweight, obesity, and risk of cardiometabolic multimorbidity: pooled analysis of individual-level data for 120,813 adults from 16 cohort studies from the USA and Europe. Lancet Public Health 2:e277–e285. https://doi.org/10.1016/S2468-2667(17)30074-9CrossRefPubMedPubMedCentralGoogle Scholar
- Kraal JJ, Van den Akker-Van Marle ME, Abu-Hanna A, Stut W, Peek N, Kemps HM (2017) Clinical and cost-effectiveness of home-based cardiac rehabilitation compared to conventional, centre-based cardiac rehabilitation: results of the FIT@Home study. Eur J Prev Cardiol 24(12):1260–1273. https://doi.org/10.1177/2047487317710803.CrossRefPubMedPubMedCentralGoogle Scholar
- Lampert R, Olshansky B, Heidbuchel H, Lawless C, Saarel E, Ackerman M et al (2013) Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation 127(20):2021–2030. https://doi.org/10.1161/CIRCULATIONAHA.112.000447CrossRefPubMedGoogle Scholar
- MacDonald MR, Eurich DT, Majumdar SR, Lewsey JD, Bhagra S, Jhund PS et al (2010) Treatment of type 2 diabetes and outcomes in patients with heart failure: a nested case-control study from the U.K. General Practice Research Database. Diabetes Care 33:1213–1218. https://doi.org/10.2337/dc09-2227CrossRefPubMedPubMedCentralGoogle Scholar
- McGregor G, Nichols S, Hamborg T, Bryning L, Tudor-Edwards R, Markland D et al (2016) High-intensity interval training versus moderate-intensity steady-state training in UK cardiac rehabilitation programmes (HIIT or MISS UK): study protocol for a multicentre randomised controlled trial and economic evaluation. BMJ Open 6:e012843. https://doi.org/10.1136/bmjopen-2016-012843CrossRefPubMedPubMedCentralGoogle Scholar
- Medvedofsky D, Mor-Avi V, Amzulescu M, Fernández-Golfín C, Hinojar R, Monaghan MJ et al (2017) Three-dimensional echocardiographic quantification of the left-heart chambers using an automated adaptive analytics algorithm: multicentre validation study. Eur Heart J Cardiovasc Imaging. https://doi.org/10.1093/ehjci/jew328.
- Mezzani A, Hamm LF, Jones AM, McBride PE, Moholdt T, Stone JA et al (2013) Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation. Eur J Prev Cardiol 20:442–467. https://doi.org/10.1177/2047487312460484CrossRefPubMedGoogle Scholar
- Noble BJ, Robertson RJ (1996) Perceived exertion. Human Kinetics, ChampaignGoogle Scholar
- O’Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, HF-ACTION Investigators et al (2009) Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 301:1439–1450. https://doi.org/10.1001/jama.2009.454.CrossRefPubMedPubMedCentralGoogle Scholar
- Osbak PS, Mourier M, Henriksen JH, Kofoed KF, Jensen GB (2012) Effect of physical exercise training on muscle strength and body composition, and their association with functional capacity and quality of life in patients with atrial fibrillation: a randomized controlled trial. J Rehabil Med 44:975–979. https://doi.org/10.2340/16501977-1039CrossRefPubMedGoogle Scholar
- Pathak RK, Elliott A, Middeldorp ME, Meredith M, Mehta AB, Mahajan R et al (2015) Impact of CARDIO-respiratory FITness on arrhythmia recurrence in obese individuals with atrial fibrillation: the CARDIO-FIT study. J Am Coll Cardiol 66:985–996. https://doi.org/10.1016/j.jacc.2015.06.488CrossRefPubMedGoogle Scholar
- Patwala AY, Woods PR, Sharp L, Goldspink DF, Tan LB, Wright DJ (2009) Maximizing patient benefit from cardiac resynchronization therapy with the addition of structured exercise training: a randomized controlled study. J Am Coll Cardiol 53:2332–2339. https://doi.org/10.1016/j.jacc.2009.02.063CrossRefPubMedGoogle Scholar
- Piepoli MF, Conraads V, Corrà U, Dickstein K, Francis DP, Jaarsma T et al (2011) Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Failure 13:347–357. https://doi.org/10.1093/eurjhf/hfr017CrossRefGoogle Scholar
- Piepoli MF, Corrà U, Adamopoulos S, Benzer W, Bjarnason-Wehrens B, Cupples M et al (2014) Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: A policy statement from the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21(6):664–681. https://doi.org/10.1177/2047487312449597CrossRefPubMedGoogle Scholar
- Pollock ML, Franklin BA, Balady GJ, Chaitman BL, Fleg JL, Fletcher B et al (2000) AHA Science Advisory. 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; position paper endorsed by the American College of Sports Medicine. Circulation 101:828–833CrossRefPubMedGoogle Scholar
- Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ et al (2016) 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 18(8):891–975. https://doi.org/10.1002/ejhf.592CrossRefPubMedPubMedCentralGoogle Scholar
- Pressler A, Christle JW, Lechner B, Grabs V, Haller B, Hettich I et al (2016) Exercise training improves exercise capacity and quality of life after transcatheter aortic valve implantation: a randomized pilot trial. Am Heart J 182:44–53. https://doi.org/10.1016/j.ahj.2016.08.007CrossRefPubMedGoogle Scholar
- Randolph TC, Hellkamp AS, Zeitler EP, Fonarow GC, Hernandez AF, Thomas KL et al (2017) Utilization of cardiac resynchronization therapy in eligible patients hospitalized for heart failure and its association with patient outcomes. Am Heart J 189:48–58. https://doi.org/10.1016/j.ahj.2017.04.001CrossRefPubMedGoogle Scholar
- Rauch B, Davos CH, Doherty P, Saure D, Metzendorf MI, Salzwedel A et al (2016) The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: a systematic review and meta-analysis of randomized and non-randomized studies – the Cardiac Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol 23:1914–1939. https://doi.org/10.1177/2047487316671181CrossRefPubMedPubMedCentralGoogle Scholar
- Sibilitz KL, Berg SK, Rasmussen TB, Risom SS, Thygesen LC, Tang L et al (2016) Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial. Heart 102(24):1995–2003. https://doi.org/10.1136/heartjnl-2016-309414CrossRefPubMedGoogle Scholar
- Squeri A, Censi S, Reverberi C, Gaibazzi N, Baldelli M, Binno SM et al (2017) Three-dimensional echocardiography in various types of heart disease: a comparison study of magnetic resonance imaging and 64-slice computed tomography in a real-world population. J Echocardiogr 15:18–26. https://doi.org/10.1007/s12574-016-0315-3CrossRefPubMedGoogle Scholar
- Steca P, Monzani D, Greco A, Franzelli C, Magrin ME, Miglioretti M et al (2017) Stability and change of lifestyle profiles in cardiovascular patients after their first acute coronary event. PLoS One 12(8):e0183905. https://doi.org/10.1371/journal.pone.0183905CrossRefPubMedPubMedCentralGoogle Scholar
- Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K et al (2004) Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 116:682–692. https://doi.org/10.1016/j.amjmed.2004.01.009CrossRefPubMedGoogle Scholar
- van Deel ED, de Boer M, Kuster DW, Boontje NM, Holemans P, Sipido KR et al (2011) Exercise training does not improve cardiac function in compensated or decompensated left ventricular hypertrophy induced by aortic stenosis. J Mol Cell Cardiol 50:1017–1025. https://doi.org/10.1016/j.yjmcc.2011.01.016CrossRefPubMedGoogle Scholar
- Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al (1995) Cardiac rehabilitation as secondary prevention. Agency for health care policy and research and national Heart, Lung, and Blood Institute. Clin Pract Guide 17:1–23Google Scholar
- WislØff U, Stoylen A, Loennechen JP, Bruvold M, Rognmo Ø, Haram PM et al (2007) Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation 115:3086–3094. https://doi.org/10.1161/CIRCULATIONAHA.106.675041CrossRefPubMedGoogle Scholar
- Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, NAM E 3rd (2015) Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 9: arrhythmias and conduction defects: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 66(21):2412–2423. https://doi.org/10.1016/j.jacc.2015.09.041CrossRefPubMedGoogle Scholar