- Open Access
Exercise training in heart failure
Trialsvolume 1, Article number: 155 (2000)
Chronic heart failure (CHF) is a common condition with a poor prognosis. It is associated with poor exercise tolerance and debilitating symptoms. These symptoms appear to be associated with pathophysiological changes that occur systemically in the patient with CHF. Exercise training in carefully selected patients has been shown to be safe and to improve exercise capacity. Many of the pathophysiological abnormalities of CHF are improved by training. Some studies have suggested a possible improvement in morbidity and mortality with training. This review analyzes the controlled clinical trials of exercise training in CHF published to date.
Chronic heart failure is a common condition with a poor prognosis. It is associated with debilitating limiting symptoms even with optimal modern medical management. One of the most prominent symptoms of CHF is severe exercise intolerance with marked fatigue and dyspnea at low exercise workloads.
The severity of symptomatic exercise limitation varies between patients with CHF and appears to be unrelated to the extent of left ventricular systolic dysfunction at rest. Peripheral changes commonly occur in patients with CHF and have been implicated in the development of symptoms in this condition. The reason for fatigue in CHF has been more readily attributed to persistent vasoconstrictor drive, endothelial dysfunction, and a wide range of structural and functional abnormalities of skeletal muscle than to ventricular dysfunction per se . Similarly, dyspnea appears to be more closely related to enhanced ventilatory effort than pulmonary congestion in most well-treated non-edematous patients . This may be related to augmented reflex control systems, such as the arterial chemoreflexes and the muscle ergoreflexes (metaboreflexes) [3,4].
Interest has been shown in the possibility that some forms of exercise therapy, either localized or systemic, could benefit the peripheral manifestations of CHF and thereby modify the symptoms of patients with CHF. Recently it has even been suggested that regular training could have beneficial effects on disease progression and survival. This review looks at the controlled clinical trial evidence for the role of exercise therapy in the management of patients with CHF. It will concentrate on generalized exercise training programs and will not look at selective respiratory muscle training.
The beneficial effects of exercise training in cardiac patients without symptomatic heart failure have been well described and will not be reviewed here. This review focuses on the evidence for training as a therapeutic option in patients with stable symptomatic CHF and refers specifically to studies on post-infarct left ventricular dysfunction or selective muscle training where necessary.
Exercise training in chronic heart failure
Participation in an exercise program was historically considered to be ill-advised for patients with significant left ventricular impairment. Until the late 1980s, avoidance of physical exercise was the standard recommendation for all patients suffering from heart failure. This was initially challenged by uncontrolled studies that showed that selected patients with significantly impaired left ventricular function could increase their exercise tolerance after a period of exercise training [5,6,7]. There was no detectable deterioration in left ventricular function in patients included in these studies.
It was not until the end of the 1980s that reports were published showing that physical training could increase exercise capacity in patients with CHF. Sullivan and colleagues [8,9] found that patients with severe left ventricular dysfunction, some of whom had previously suffered heart failure, improved their maximal exercise performance after a prolonged regime of physical training. They demonstrated an increased blood flow to exercising muscle and an increased ability of skeletal muscle to extract oxygen from the nutritive blood flow. Ventilatory function was also improved, with a reduction in the respiratory exchange ratio at sub-maximal exercise and a delay in the anaerobic threshold. These authors showed no improvement in exercise cardiac output, so the training-induced benefits appeared to be mainly caused by peripheral adaptations.
The beneficial effects of training were confirmed in a controlled cross-over trial in 11 patients with stable class II-III CHF . These carefully selected patients could exercise without serious ventricular arrhythmias and had no other medical condition that limited their exercise tolerance. After baseline evaluation and familiarization with laboratory procedures, all patients completed 8 weeks of exercise training and 8 weeks without exercise in a randomized cross-over study. The training regime produced a 20–25% increase in exercise tolerance and peak oxygen consumption. There was also a significant reduction in questionnaire-rated symptoms attributable to heart failure and a coincident increase in the extent and ease of performing daily activities. Since these early reports, numerous trials of similar design have confirmed these benefits and have shown many additional advantages of training in patients with heart failure. The randomized trials of parallel group design are summarized in Table 1 and those of cross-over design are in Table 2.
Training for heart failure: development of an idea
The earliest reports of training patients with significant left ventricular impairment were case reports or small series. The first report of exercise training of patients with heart failure was in 1987, in Russia . This study compared the effects of exercise training with no exercise in post-myocardial infarction patients who showed clinical signs of heart failure. The training continued for 11 months and included exercise therapy, cycle ergometry and walking. The patients who exercised showed a considerable increase in physical working capacity, a more favorable hemodynamic response to stress, a higher stroke index, a reduced heart rate increment and a greater reduction in systemic peripheral resistance compared with the control patients.
Further physiological investigation of the training-induced improvements in exercise capacity was undertaken by Sullivan and colleagues [8,9]. This was closely followed in the early 1990s by the first randomized controlled trials of training in patients with chronic stable heart failure [10,12], which showed an increase in exercise capacity and improved symptomatic status.
In the rest of the 1990s, an increasing number of larger and better designed studies in patients with heart failure demonstrated a consistent increase in exercise capacity and a bewildering array of physiological benefits with exercise training. A summary of trials performed by a collaborative European group  and an overview of all trials published up to 1998  have shown a consistent 15–20% increase in exercise capacity in a broad range of patients with heart failure. The beneficial effects of training have included improvements in hemodynamic responses, myocardial perfusion, diastolic function, skeletal muscle function and histological and biochemical responses, ventilatory control, peripheral vascular and endothelial function and neurohormonal and autonomic function.
Global exercise capacity was improved even with only low intensity training by relatively small muscle groups, which shows the primary importance of peripheral training mechanisms in even severe heart failure . Although the majority of these training effects are likely to be beneficial for a patient with CHF, none of the trials to date has been designed specifically to address the question of prognosis or alteration in disease progression. The largest reported controlled trial  included almost 100 patients and showed a statistically significant improvement in survival and a statistically significant reduction in hospital readmissions for heart failure. The results of this study, however, must be regarded as an exciting possibility of benefit rather than proof. A sufficiently powered trial is required to evaluate the proposal that training may improve survival.
Although there are many reports of training, few have prospectively compared the elements of the training program. Important points that still need to be considered include the optimal frequency and intensity of training, the necessary duration for training effects and how long these effects last after cessation of a formal program. Other points that need to be addressed in future controlled trials include details of the most appropriate selection of patients, the elements of the training program and possible interactions with modern heart failure medications. Although cardiovascular medicine has greatly improved in the last decade as a result of randomized controlled trials of effective treatments, this oldest of physical therapies remains extremely difficult to evaluate. This is at least partly because our modern system of funding trials is firmly in favor of commercial patentable treatments. A program of government support for randomized non-commercial treatment trials is needed if these important questions and considerations are to receive a timely answer.
Drexler H, Coats AJ: Explaining fatigue in congestive heart failure. Annu Rev Med. 1996, 47: 241-256. 10.1146/annurev.med.47.1.241.
Clark A, Coats A: The mechanisms underlying the increased ventilatory response to exercise in chronic stable heart failure. Eur Heart J. 1992, 13: 1698-1708.
Piepoli M, Clark AL, Volterrani M, Adamopoulos S, Sleight P, Coats AJ: Contribution of muscle afferents to the hemodynamic, autonomic, and ventilatory responses to exercise in patients with chronic heart failure: effects of physical training. Circulation. 1996, 93: 940-952.
Chua TP, Clark AL, Amadi AA, Coats AJS: Relation between chemosensitivity and the ventilatory response to exercise in chronic heart failure. J Am Coll Cardiol. 1996, 27: 650-657. 10.1016/0735-1097(95)00523-4.
Letac B, Cribier A, Desplanches JF: A study of left ventricular function in coronary patients before and after physical training. Circulation. 1977, 56: 375-378.
Lee AP, Ice R, Blessey R, Sanmarco ME: Long-term effects of physical training on coronary patients with impaired ventricular function. Circulation. 1979, 60: 1519-1526.
Conn EH, Williams RS, Wallace AG: Exercise responses before and after physical conditioning in patients with severely depressed left ventricular function. Am J Cardiol. 1982, 49: 296-300.
Sullivan MJ, Higginbotham MB, Cobb FR: Exercise training in patients with severe left ventricular dysfunction: Hemodynamic and metabolic effects. Circulation. 1988, 78: 506-515.
Sullivan MJ, Higginbotham MB, Cobb FR: Exercise training in patients with chronic heart failure delays ventilatory anaerobic threshold and improves submaximal exercise performance. Circulation. 1989, 79: 324-329.
Coats AJS, Adamopoulos S, Meyer TE, Conway J, Sleight P: Effects of physical training in chronic heart failure. Lancet. 1990, 335: 63-66. 10.1016/0140-6736(90)90536-E.
Lipchenko AA, Fomin IL: Use of physical training in the rehabilitation of patients with post-infarct heart failure [in Russian]. Kardiologiia. 1987, 27: 48-52.
Coats AJS, Adamopoulos S, Radaelli A, McCance A, Meyer TE, Bernardi L, Solda PL, Davey P, Ormerod D, Forfar C, Conway J, Sleight P: Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation and autonomic function. Circulation. 1992, 85: 2119-2131.
European Heart Failure Training Group: Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the improvement in exercise tolerance. Eur Heart J. 1998, 19: 466-475. 10.1053/euhj.1997.0736.
Piepoli MF, Flather M, Coats AJ: Overview of studies of exercise training in chronic heart failure: the need for a prospective randomized multicentre European trial. Eur Heart J. 1998, 19: 830-841. 10.1053/euhj.1998.1041.
Koch M, Douard H, Broustet JP: The benefit of graded physical exercise in chronic heart failure. Chest. 1992, 101(suppl 5): 231S-235S.
Belardinelli R, Georgiou D, Cianci G, Purcaro A: Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999, 99: 1173-1182.
Jette M, Heller R, Landry F, Blumchen G: Randomized 4-week exercise program in patients with impaired left ventricular function. Circulation. 1991, 84: 1561-1567.
Belardinelli R, Scocco V, Mazzanti M, Purcaro A: Effects of aerobic training in patients with moderate chronic heart failure [in Italian]. G Ital Cardiol. 1992, 22: 919-930.
Kostis JB, Rosen RC, Cosgrove NM, Shindler DM, Wilson AC: Non-pharmacologic therapy improves functional and emotional status in congestive heart failure. Chest. 1994, 106: 996-1001.
Kiilavuori K, Toivonen L, Naveri H, Leinonen H: Reversal of autonomic derangements by physical training in chronic heart failure assessed by heart rate variability. Eur Heart J. 1995, 16: 490-495.
Hambrecht R, Niebauer J, Fiehn E, Kalberer B, Offner B, Hauer K, Riede U, Schlierf G, Kubler W, Schuler G: Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles. J Am Coll Cardiol. 1995, 25: 1239-1249. 10.1016/0735-1097(94)00568-B.
Belardinelli R, Georgiou D, Cianci G, Berman N, Ginzton L, Purcaro A: Exercise training improves left ventricular diastolic filling in patients with dilated cardiomyopathy. Clinical and prognostic implications. Circulation. 1995, 91: 2775-2784.
Hambrecht R, Fiehn E, Yu J, Niebauer J, Weigl C, Hilbrich L, Adams V, Riede U, Schuler G: Effects of endurance training on mitochondrial ultrastructure and fiber type distribution in skeletal muscle of patients with stable chronic heart failure. J Am Coll Cardiol. 1997, 29: 1067-1073. 10.1016/S0735-1097(97)00015-6.
Dubach P, Myers J, Dziekan G, Goebbels U, Reinhart W, Muller P, Buser P, Stulz P, Vogt P, Ratti R: Effect of high intensity exercise training on central hemodynamic responses to exercise in men with reduced left ventricular function. J Am Coll Cardiol. 1997, 29: 1591-1598. 10.1016/S0735-1097(97)82540-5.
Reinhart WH, Dziekan G, Goebbels U, Myers J, Dubach P: Influence of exercise training on blood viscosity in patients with coronary artery disease and impaired left ventricular function. Am Heart J. 1998, 135: 379-382.
Wielenga RP, Erdman RA, Huisveld IA, Bol E, Dunselman PH, Baselier MR, Mosterd WL: Effect of exercise training on quality of life in patients with chronic heart failure. J Psychosom Res. 1998, 45: 459-464. 10.1016/S0022-3999(97)00309-7.
Wielenga RP, Huisveld IA, Bol E, Dunselman PH, Erdman RA, Baselier MR, Mosterd WL: Safety and effects of physical training in chronic heart failure. Results of the Chronic Heart Failure and Graded Exercise study (CHANGE). Eur Heart J. 1999, 20: 872-879. 10.1053/euhj.1999.1485.
Callaerts-Vegh Z, Wenk M, Goebbels U, Dziekan G, Myers J, Dubach P, Haefeli WE: Influence of intensive physical training on urinary nitrate elimination and plasma endothelin-1 levels in patients with congestive heart failure. J Cardiopulm Rehabil. 1998, 18: 450-457. 10.1097/00008483-199811000-00008.
Willenheimer R, Erhardt L, Cline C, Rydberg E, Israelsson B: Exercise training in heart failure improves quality of life and exercise capacity. Eur Heart J. 1998, 19: 774-781. 10.1053/euhj.1997.0853.
Sturm B, Quittan M, Wiesinger GF, Stanek B, Frey B, Pacher R: Moderate-intensity exercise training with elements of step aerobics in patients with severe chronic heart failure. Arch Phys Med Rehabil. 1999, 80: 746-750.
Keteyian SJ, Brawner CA, Schairer JR, Levine TB, Levine AB, Rogers FJ, Goldstein S: Effects of exercise training on chronotropic incompetence in patients with heart failure. Am Heart J. 1999, 138: 233-240.
Quittan M, Sturm B, Wiesinger GF, Pacher R, Fialka-Moser V: Quality of life in patients with chronic heart failure: a randomized controlled trial of changes induced by a regular exercise program. Scand J Rehabil Med. 1999, 31: 223-228. 10.1080/003655099444399.
Hambrecht R, Gielen S, Linke A, Fiehn E, Yu J, Walther C, Schoene N, Schuler G: Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: a randomized trial. JAMA. 2000, 283: 3095-3101. 10.1001/jama.283.23.3095.
Adamopoulos S, Coats AJ, Brunotte F, Arnolda L, Meyer T, Thompson CH, Dunn JF, Stratton J, Kemp GJ, Radda GK, Rajagopalan B: Physical training improves skeletal muscle metabolism in patients with chronic heart failure. J Am Coll Cardiol. 1993, 21: 1101-1106.
Radaelli A, Coats AJ, Leuzzi S, Piepoli M, Meyer TE, Calciati A, Finardi G, Bernardi L, Sleigh P: Physical training enhances sympathetic and parasympathetic control of heart rate and peripheral vessels in chronic heart failure. Clin Sci (Colch). 1996, 91: 92-94.
Meyer K, Schwaibold M, Westbrook S, Beneke R, Hajric R, Lehmann M, Roskamm H: Effects of exercise training and activity restriction on 6-minute walking test performance in patients with chronic heart failure. Am Heart J. 1997, 133: 447-453.
Tyni-Lenne R, Gordon A, Jansson E, Bermann G, Sylven C: Skeletal muscle endurance training improves peripheral oxidative capacity, exercise tolerance, and health-related quality of life in women with chronic congestive heart failure secondary to either ischemic cardiomyopathy or idiopathic dilated cardiomyopathy. Am J Cardiol. 1997, 80: 1025-1029. 10.1016/S0002-9149(97)00597-3.
Ohtsubo M, Yonezawa K, Nishijima H, Okita K, Hanada A, Kohya T, Murakami T, Kitabatake A: Metabolic abnormality of calf skeletal muscle is improved by localised muscle training without changes in blood flow in chronic heart failure. Heart. 1997, 78: 437-443.
Taylor A: Physiological response to a short period of exercise training in patients with chronic heart failure. Physiother Res Int. 1999, 4: 237-249.
Owen A, Croucher L: Effect of an exercise programme for elderly patients with heart failure. Eur J Heart Fail. 2000, 2: 65-70. 10.1016/S1388-9842(99)00067-7.
Maiorana A, O'Driscoll G, Cheetham C, Collis J, Goodman C, Rankin S, Taylor R, Green D: Combined aerobic and resistance exercise training improves functional capacity and strength in CHF. J Appl Physiol. 2000, 88: 1565-1570.
Professor Coats is supported by the Viscount Royston Trust. Some of the work described in this manuscript was supported by the British Heart Foundation and the Peel Medical Research Trust.