Exercise in Specific Diseases: Heart Failure with Reduced Ejection Fraction

Abstract

Heart failure (HF) is a clinical syndrome defined by clinical symptoms and functional or structural cardiac abnormalities. Based on left ventricular ejection fraction, HF can be classified as reduced ejection fraction (HFrEF), mid-range ejection fraction (HFmrEF), or preserved ejection fraction (HFpEF). A hallmark feature of all of these forms of HF is reduced exercise capacity, measured as decreased peak exercise oxygen uptake (VO₂peak). Every HFrEF and HFmrEF patient must be treated with optimal pharmacological therapy. Beside medical treatment, HF patients benefit from a healthy lifestyle which includes daily physical activity and a structured exercise training programme. Aerobic exercise training improves VO₂peak and quality of life, and decreases hospitalization rates. The objective of this textbook chapter is to discuss the long-term benefits of exercise training and the optimal exercise prescription required to achieve these benefits in patients with HFrEF. In brief, an optimal exercise prescription includes exercising a minimum of 20 min each day at a moderate to high intensity, depending on their clinical status and exercise preferences. Exercise training should start with a short duration and low intensity during the first few weeks, which progressively increases over time while factoring patient tolerance and clinical status. HFrEF patients may also experience added benefits from the addition of resistance and respiratory training to basic aerobic training.

Review

1.1 Questions

• 1. A 65-year old patient with newly diagnosed HF with reduced ejection fraction asks you for training recommendations. He was told by his doctor in hospital that regular exercise can improve fitness and HF symptoms. So instead of taking the pills, which were also recommended by the doctor he wants to start exercising. What’s your advice for the patient?

• 2. The patient wants to know if he can start directly with the training program or if he has to do any additional testing. He was discharged from hospital 3 weeks ago and feels much better after being recompensated.

• 3. After the examinations you discuss the results with the patient. There are no contraindications starting physical exercise. The VO₂peak of 17 ml/kg/min shows a deconditioned physical status of the patient. The patient tells you that he has never done any sports in his life, but now he wants to start exercising to get fitter. A friend of him—also a HF patient—exercises every day a so called “high intensity training”. As a HIT takes less time than a moderate endurance training he would like to start tomorrow with that type of training. What’s your advice?

1.2 Answers

• 1. A structured exercise program improves fitness, reduce HF symptoms and improves left ventricular function in patients with HFrEF. Even mortality may be reduced in the longer term. Therefore you confirm the beneficial effects of regular physical exercise in HFrEF patients. But physical activity is always a supportive therapy and should be performed in addition to the medical therapy only. The patient should definitely continue taking the recommended HF medication and should thereafter start a structured training program.

• 2. As it is the first appointment of the patient in your clinic you will need medical information and perform medical examinations to rule out any contraindication for physical activity and to be able to give individual training recommendations. Beside medical history you will perform a clinical examination, an ECG and an echocardiography. In addition cardiopulmonary exercise testing will have to be performed by the patient in order to determine abnormalities under exercise as well as values of maximal exercise capacity for individual training recommendations.

• 3. In general a moderate aerobic training as well as a high intensity training is possible for HFrEF patients when contraindication are excluded. But for the beginning of an exercise program HFrEF patients should always start with low or moderate intensity adapted to the individual fitness level. For very deconditioned patients—like your HFrEF patient—who has never done any kind of sports before, a daily activity of 5–10 min of low intensity is enough for the beginning. This amount of activity may also be done twice or even more frequently per day. In the next weeks first the duration of exercise should be increased, later the intensity. Overall a HIT is not recommended for the next weeks, but may be possible when physical performance increases over time without a deterioration of HF symptoms. For deconditioned patients a supervised setting is recommended.