Exercise for heart failure

People with heart failure feel better when they stay active. Years ago, patients were told to rest and give up activities. But, now, research shows that normal activity is safe for most people with heart failure. Being active may help relieve your symptoms. Activity helps your sense of well-being. You should be able to do the things you enjoy. Walking, light weight-lifting, and water exercises will help your muscles stay strong. These activities also will give you more energy.

Types and amount of exercise

Talk with your doctor before starting an exercise program. Also check with your doctor if you want to add or change activities. You may need to do some testing first.

  • Work towards 20-30 minutes of activity per day most days of the week
  • You don’t have to be active for 30 minutes straight
  • It’s okay to be active for three different 10-minute blocks throughout the day

You might be able to participate in a cardiac rehabilitation program. This is an exercise program especially for patients with heart problems. While you exercise, your blood pressure, heart rate, and other physical responses are watched closely. After the program, an exercise routine is provided to you.

Getting started

  • Increase your activity slowly. This is important if you have not been active regularly. This is also the case if you have stopped being active due to illness.
  • Pick a simple activity that you like. Do you like to walk or bike? Work in the garden? Go fishing, bowling, or swimming? Choosing an activity you like helps you stay with it.
  • Walking is always a good choice. It’s easy to find places to walk—indoors or outdoors. Begin by walking five minutes a day. Then, slowly add to the amount of time you walk each day. Also add to the number of days you walk.
  • Be sure to warm-up and cool-down when exercising
  • Never stop exercising all of a sudden and then sit or lie down, or stand still. This can make you feel dizzy or lightheaded. Walk around slowly before you stop.

Exercise tips

  • Use walking shoes that are comfortable and have good support
  • Wait at least one hour after eating to exercise. You may feel sick if you exercise on an empty or full stomach.
  • Avoid outdoor activities when it’s colder than 40 degrees or warmer than 80 degrees
  • Avoid activity when there is a lot of smog or humidity in the air n Exercise at a slow and steady pace
  • Avoid actions that need quick bursts of energy
  • Exercise when you have the most energy. For most people with heart failure, that is in the morning.
  • Think about exercising with a friend or family member. It’s easier to stay with it when you have a partner. It can be an enjoyable social time.
  • Don’t exercise if you feel more short of breath than usual
  • Don’t exercise if you feel very tired
  • Don’t exercise if you are sick or have a fever
  • Don’t exercise if you have chest pain or are making major medicine changes
  • Rest between activities. Don’t wait until you are worn out to rest. Go back and forth between rest time and active time.

How do I know if I’m overdoing it?

You may need to stop exercising if you have any of these signs:

  • Shortness of breath
  • Unable to talk or finish a sentence
  • Shortness of breath that doesn’t get better when you slow down or stop
  • Feeling dizzy or lightheaded
  • Chest pain, tightness, or pressure
  • Pain in your shoulders, arms, neck, or jaw
  • Skipped heart beats or uneven heart rate (pulse)
  • Feeling more tired or weak
  • Major sweating, upset stomach, or vomiting

If you have any of these symptoms while you are active, slow down. If they do not get better, stop the activity. Call 911 if your chest pain or symptoms do not go away.

Congestive heart failure (CHF) is a progressive cardiovascular disease with significant morbidity and mortality that affects an increasing amount of people worldwide. There are approximately 6.5 million people in the US, more than 14 million people in Europe, and 26 million people worldwide who are living with heart failure, and the prevalence continues to grow.1–3 In the US alone, there were 960,000 new cases of CHF diagnosed in 2017, and this is expected to continue to increase year on year in the ageing population. It has been estimated that by 2030, the prevalence in the US will exceed 8 million people.4

Along with the high disease prevalence, there is also a significant cost burden related to CHF. The annual worldwide cost of heart failure has been estimated to be US$108 billion, which is about 1–2% of the global healthcare budget.5 The US is responsible for about 28% of the global expenditure, while Europe accounts for about 7%.5,6 In an evaluation of US costs published in 2014, the direct and indirect costs of heart failure were calculated from publicly available resources to be about US$60.2 billion and US$115.4 billion, respectively, significantly higher than previous estimates.7 Given the significant disease prevalence and cost burden, it is essential that healthcare providers investigate multiple therapies to improve clinical outcomes for people with CHF.

Despite there being many evidence-based therapies that are endorsed by guidelines and have shown to reduce mortality rates and hospitalisations and improve quality of life (QoL) and symptoms, many patients with CHF remain dyspnoeic and fatigued with recurrent hospitalisations, a diminished exercise tolerance and a poor QoL.8 Many studies have shown numerous benefits of cardiac rehabilitation (CR) and exercise training in patients with heart failure, including a reduction in morbidity and mortality.9–11 Guidelines from the American College of Cardiology/American Heart Association, European Society of Cardiology and Canadian Cardiovascular Society have included evidence-based recommendations for the use of exercise in the management of CHF (Table 1).12–14 Additionally, given the data supporting the use of exercise in heart failure as well as the revised guidelines, the US Centers for Medicare & Medicaid Services (CMS) extended coverage for CR for patients with heart failure with a reduced ejection fraction (HFrEF) in 2014.15 Despite inclusion in guidelines and CMS coverage and numerous studies showing clinical benefit from exercise therapy and its safety, it has been underused by people with CHF. It is essential that healthcare providers understand the available literature regarding the safety and clinical benefits related to exercise in this population, as well as the barriers to participation and adherence to CR. It is important that patients are referred to CR programmes and they are encouraged to participate.

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Safety of exercise has been consistently demonstrated in patients with numerous types of clinical HF (Table 2). The Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) trial, which was the largest trial of exercise training in patients with HF with a reduced ejection fraction (HFrEF), investigated the efficacy and safety of exercise for these patients. This was a multicentre, randomised controlled trial that included 2,331 medically stable patients with HF with left ventricular ejection fraction (LVEF) ≤35% and New York Heart Association (NYHA) Class II–VI symptoms despite optimal medical therapy for 6 weeks. Exercise training was demonstrated to be well tolerated and safe for these patients.10 A meta-analysis of 33 trials (including HF-ACTION), involving 4,740 patients with HFrEF with an LVEF <40% and NYHA Class II or III, demonstrated no significant adverse effects of exercise in patients with HF.16 In an evaluation of outcomes for HF with preserved ejection fraction (HFpEF), a meta-analysis that included 276 patients with well-compensated heart failure in six randomised controlled trials demonstrated no major adverse effects of exercise training.17 A study of rehabilitation with 27 patients and another including 278 patients both demonstrated that exercise was safe for patients with acute decompensated HF (ADHF).18,19 The Rehabilitation ventricular assist device (Rehab-VAD) trial and the 2017 Cochrane review of exercise-based cardiac rehabilitation in heart transplant recipients demonstrated the safety of exercising with a LV assist device (LVAD) and orthotropic heart transplant (OHT), respectively.20,21

There has been investigation into the pathophysiology of exercise intolerance in patients with HF and the beneficial effects of exercise training. Mechanisms that may lead to decreased exercise capacity in this patient population include cardiac dysfunction, abnormalities in peripheral flow, endothelial dysfunction, skeletal muscle dysfunction, ventilatory deficits and abnormalities of autonomic nervous system function.22 Exercise capacity is best quantified by peak oxygen consumption (peak VO2) and many studies have demonstrated improvements in peak VO2 with exercise training.9,11,22–24 Additionally, exercise with moderate aerobic training has led to favourable effects on central haemodynamic function, sympathetic tone, peripheral vascular and skeletal muscle function, ventilatory efficiency with decreased dyspnoea and improved QoL.22,25,26

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Heart Failure with Reduced Ejection Fraction

The majority of studies investigating the effects of exercise on HF have been related to chronic HFrEF and have demonstrated beneficial clinical outcomes (Table 2). Exercise Training Meta-Analysis of Trials in Patients with Chronic Heart Failure (ExTraMATCH) was a 2004 meta-analysis of nine prospective randomised controlled trials comparing exercise training and usual care in patients with CHF related to LV dysfunction. Significant reductions in mortality and hospitalisations were demonstrated.27 Subsequent systematic reviews have also demonstrated a decrease in hospitalisations, but failed to show significant reductions in mortality.8,28

An updated Cochrane review in 2017, which examined 33 randomised controlled trials including 4,740 participants, predominantly with HFrEF and NYHA Class II and III, demonstrated a reduction in all-cause hospital admissions and HF-specific admissions in up to 12 months of follow-up. Additionally, there was an improved health-related QoL in the exercise training programme group compared with the control.16 There is also evidence to support cost–effectiveness of exercise-based rehabilitation based on two trials included in the review that was attributed to a reduction in hospital bed days.16 The HF-ACTION trial was included in this Cochrane review; it demonstrated safety and an improved QoL among CHF patients randomised to the exercise therapy group.10 Although there was a non-significant reduction in the risk of all-cause mortality and all-cause hospitalisation in this group of patients with chronic HFrEF, there was a risk reduction in the primary endpoint of death or hospitalisation of any cause when adjusted for highly prognostic predictors, including duration of the cardiopulmonary exercise test, LVEF, Beck Depression Inventory II score and a history of atrial fibrillation or flutter. Further sub-study analysis demonstrated that the volume of exercise was a logarithmic predictor of the primary outcome of all-cause mortality or hospitalisation and that there was significant benefit demonstrated from moderate exercise.29

Heart Failure with Preserved Ejection Fraction

Multiple studies have demonstrated safety and effectiveness of exercise for people with HFrEF to improve symptoms, aerobic capacity/endurance and QoL, although people with HFpEF have been under-represented in the studies. Given that HFpEF leads to about 50% of hospital admission for HF and that there is a lack of demonstrated benefit from pharmacotherapies in this patient population, investigation of other potential beneficial interventions for people with HFpEF is essential.16,17 In addition to demonstrating the safety of exercise with no major adverse effects reported in the 276 patients with well-compensated HFpEF in a meta-analysis that included six randomised controlled trials, it was suggested that exercise training improved cardiorespiratory fitness by an increase in peak VO2 and QoL.17 These improvements were noted to be unrelated to a significant change in the diastolic LV function.

The Exercise Training in Diastolic Heart Failure (Ex-DHF) pilot study was a randomised study involving 64 patients that compared supervised exercise or usual care and it demonstrated improvements in exercise capacity and health-related QoL.30 There have been no studies evaluating the effect of exercise on hospitalisations or mortality in the HFpEF population, and HFpEF was excluded from CMS coverage for CR in the most recent decision memo in 2014.15 The Ex-DHF trial, which is currently enrolling participants, is the first multicentre trial to evaluate the long-term effects of exercise on a composite outcome of all-cause mortality, hospitalisations, NYHA functional class, global self-rated heath, maximal exercise capacity, and diastolic function in HFpEF patients.31

Acute Decompensated Heart Failure

There is extremely limited data on the safety and clinical outcomes related to exercise therapy in people with ADHF, which is a leading cause of hospitalisation and is associated with significant morbidity, mortality, and healthcare costs, especially in older patients. These patients have been excluded from previous exercise training trials and the updated CMS memo for CR coverage from 2014.15

The Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) pilot study provided feasibility of an ongoing multicentre, randomised, attention-controlled trial funded by the National Institute of Health to evaluate the use of rehabilitation to improve physical function and reduce rehospitalisations for patients ≥60 years beginning in the hospital during an admission for ADHF (including HFrEF and HFpEF) and continuing for 12 weeks after discharge.18 This pilot study included 27 patients with admissions for ADHF that were randomised into a novel rehabilitation intervention group, focusing on improved balance, strength, mobility and endurance, an attention control group or usual care, and demonstrated feasibility, safety and a trend toward improved physical function and decreased hospitalisations in the intervention group. Given that this is a pilot study with a small sample size of the larger and randomised controlled trial (REHAB-HF) that is currently enrolling participants, the authors recommend caution in instituting immediate rehabilitation in older patients with ADHF.

The Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure (EJECTION-HF) trial was a multicentre randomised controlled trial in Australia that included 278 recently discharged CHF patients who were randomised to 24 weeks of supervised centre-based exercise therapy commencing within 6 weeks of discharge or standard care.19 Average time to initiation of CR in these patients was 43 days and there were no adverse events associated with the therapy, suggesting that exercise therapy in patients recently hospitalised with acute HF is safe and feasible. Adherence in the home exercise group was 75% at 3 months and 68% at 6 months, while the centre-based exercise group had poor adherence with only 43% of patients participating in ≥50% of the sessions. There was no difference in the primary outcome of all-cause death or readmissions, although there was a significant reduction in all-cause mortality in the exercise group (based on a small number of events), which should be interpreted with caution. The results of the REHAB-HF trial will provide additional insight into the benefit of early rehabilitation for patients with ADHF.

Left Ventricular Assist Devices

Patients that have been implanted with LVADs are reported to have improved survival, functional capacity and health status, although many continue to report exercise intolerance and heart failure symptoms. The Rehab-VAD trial is the largest prospective randomised trial of the beneficial effects of exercise on LVAD patients. It included 26 patients randomised to CR or usual care after implantation of an LVAD. It demonstrated that exercise was safe in the CR group with only one event (syncope) in more than 300 sessions, and showed an improved total treadmill time, muscle strength and improved health status (evaluated by the Kansas City Cardiomyopathy Questionnaire) with continuous flow LVADs compared with usual care.20 There was no difference in the peak VO2, which has been a marker of exercise capacity in people with CHF, although additional studies have suggested an improvement in VO2 with exercise therapy after VAD implantation.32 A recent study of 1,164 Medicare beneficiaries receiving LVADs demonstrated low participation in CR (30%). Of those who participated in CR, there was a decreased risk of hospitalisation and mortality at 1 year after multivariate adjustment with a 23% and 47% reduction, respectively, compared with those who did not participate in CR.33 This was not the primary outcome of this study and there were likely additional confounding variables, although it suggests potential clinical benefits and identifies a need for further studies to evaluate the value of exercise in people with LVADs (Figure 1A).

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Cardiac Transplantation

Although there have been significant improvements in OHTs over the past 40 years, long-term survival remains limited. Exercise capacity and health-related QoL in transplant recipients have been noted to be inferior compared with age-matched healthy people.34 In the past, transplant patients were advised not to exercise due to concerns of chronotropic incompetence in the denervated heart, although further studies have shown evidence of sympathetic reinnervation, which is associated with improved exercise capacity and may be improved by physical training.35 An updated Cochrane review in 2017 included ten randomised controlled trials with 300 patients who had OHTs demonstrated the safety of exercise therapy in transplant patients with only one reported adverse event. Nine studies compared exercising to control and one study compared high-intensity to moderate-intensity training.21 CR participation was associated with an improvement in peak VO2 and exercise capacity, although there was no significant improvement in health-related QoL in a 12-week period. There was no data to report hospitalisations or mortality benefit in these studies. Additional studies have demonstrated improvement of peak heart rate, ventilatory capacity, autonomic function and QoL with exercise training.36 In an evaluation of CR and readmission rates for 595 Medicare beneficiaries that received heart transplants in the US in 2013, 55% of patients were enrolled in CR. Participation in CR was associated with a 29% lower readmission risk at 1 year.36 Younger patients (aged 35–49 years) were significantly less likely to enrol in CR, and those that enrolled were likely to attend fewer sessions that patients older then 65 years. There have been no published studies investigating the effects on mortality of OHT patients who have participated in exercise training or CR. Given the significant benefits of CR and the CMS coverage of CR in orthotopic heart transplant patients that was approved in 2006, there should be a significant effort to improve uptake of CR in this patient population (Figure 1B).37

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CMS Coverage

In 2006, CMS published a decision that there was adequate evidence to approve coverage of CR for patients with an acute MI, coronary artery bypass graft, stable angina, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting, and heart or heart and lung transplant (Table 3).37 At that time, there was insufficient evidence to approve CR coverage for CHF patients. After numerous studies were published demonstrating benefit of exercise training for patients with HFrEF, the largest of which being HF-ACTION, CMS expanded coverage for stable, chronic HF defined as patient with an LVEF ≤35% with NYHA II–IV symptoms despite optimal medical therapy for at least 6 weeks without recent or planned hospitalisation or procedure.15 Specific CR coverage is not available for patients with HFpEF, ADHF or LVAD, although many LVAD patients are eligible for CR under the HFrEF indication, or by medical criteria for disability with LVEF ≤30% with symptoms affecting daily living.33 Although HFpEF patients represent a significant number of CHF patients and hospital admissions, and ADHF is a significant cause of morbidity, mortality and is a component of healthcare expenditures, there is currently no CMS coverage for CR for these patients. Additional studies, including the Ex-DHF trial for HFpEF and REHAB-HF trial for ADHF, are necessary to demonstrate safety and clinical benefit to encourage CMS coverage for CR.18,30,31

Uptake and Adherence

Despite numerous benefits and CMS coverage for many patients, there has been significant underuse of CR for people with CHF. An earlier study demonstrated that only 10.4% (12.2% HFrEF, 8.8% HFpEF) of 105,619 eligible patients with HF (48% with HFrEF, 52% with HFpEF) received a CR referral after hospitalisation for CHF.38 In the HF-ACTION trial with HFrEF patients, despite numerous methods to reinforce adherence, about 30% of those enrolled in the exercise arm exercised at or above the target goal.10 A retrospective study using the CMS and the Veterans Health Administration (VA) national data between 2007 and 2011 evaluated CHF patient enrolment in one or more sessions of CR. Of the 66,710 veterans and 243,208 Medicare beneficiaries hospitalised for HF, 2.3% and 2.6% respectively, attended one or more sessions of outpatient CR.39 The investigators noted that they were unable to determine the prevalence of HFrEF that would be eligible for CR in these populations by using the ICD-9 codes. Much of the US data was collected before CMS coverage expansion of HFrEF in 2014. For LVAD and OHT recipients with Medicare coverage, uptake of CR was 30% (of 1,164 LVAD patients) and 55% (of 595 OHT patients).33,36 In a 2010 European survey, it was reported that <20% of HF patients were participating in CR.40

There are many potential barriers involving either the healthcare system or patient adherence that influence the use of CR. The healthcare provider should understand that current guidelines, consensus statements and high-impact studies demonstrate the value of exercise training, in addition to confirming available CR sites with educated CR teams. Additionally, many patient factors, including socioeconomic factors, work conflicts, inadequate transportation, lack of reimbursement, significant symptoms, as well as patient attitude, beliefs and motivations, affect enrolment and adherence to CR.43 In many cases, there are multiple barriers that need to be addressed to significantly improve CR use in people with CHF.

Conclusion

CHF is an increasingly prevalent disease with significant morbidity and mortality despite optimal drug and device therapies. Exercise training and cardiac rehabilitation have demonstrated numerous benefits for people with CHF, including improved exercise capacity and QoL, in addition to improved clinical outcomes. Exercise has also been established as safe and feasible with HF and, in some studies, exercise therapy has demonstrated improved cost-efficiency in HF management. The majority of current studies and subsequent guidelines have been established based on the benefits of exercise in HFrEF patients, although further studies are necessary to evaluate clinical outcomes with exercise in different HF populations to drive expansion of the guidelines to include HFpEF, VAD and OHT patients. Despite numerous benefits in multiple HF groups, there is significant underuse of CR due to many barriers that need to be overcome. Healthcare providers should strongly consider referring their patients with CHF to CR and encouraging participation in and adherence to exercise training programmes.

A recent analysis of existing studies on patients with heart failure says that exercise helps patients deal with the disease, and that for certain patients, vigorous exercise can help even more.

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The benefits of exercise for people with heart failure are well known, but the focus on intense exercise is new.

After reviewing the study, Gordon Blackburn, PhD, Program Director of Cardiac Rehabilitation at Cleveland Clinic, cautioned that, “The patient has to be stable with their heart failure managed” before any kind of exercise regimen would get the go-ahead from physicians.

5.8 million Americans affected

The National Institutes of Health (NIH) says about 5.8 million people in the United States have heart failure. Having heart failure doesn’t mean that your heart has actually failed or stopped functioning, but rather that it cannot keep up with the demands your body puts on it, particularly during exertion or exercise.

Previous heart attacks, chronic high blood pressure, heart valve diseases, diabetes and certain infectious diseases and genetic defects can lead to heart failure. Advancing age is another cause of heart failure.

People who have early-stage heart failure might not notice any symptoms. More advanced heart failure can cause shortness of breath, extreme fatigue and sometimes, swollen ankles.

Vigorous activity improved heart function

Researchers from Australia’s University of New England in Armidale, New South Wales, found that heart failure patients who participated in a relatively vigorous exercise regimen had a 23 percent improvement in their heart function. That beat out the 7 percent improvement for patients who participated in less strenuous exercise programs.

Scientists measured peak oxygen consumption during exercise as an indicator of how well subjects’ hearts functioned.

The patients who worked out at an intense level experienced greater improvement in peak oxygen consumption than those who worked out at low or moderate levels. (Intensity of exercise was measured on a sliding scale: Athletes were assigned a more demanding workout than formerly sedentary patients.)

Lower your risk and increase your energy

Regular exercise helps heart failure patients in many fundamental ways:

  • Reduces heart disease risk factors and the chance of having future heart problems
  • Reduces risk of death when exercise capacity is increased
  • Improves circulation and helps the body use oxygen better
  • Helps increase energy levels so they can do more activities without becoming tired or short of breath
  • Improves muscle tone and strength
  • Improves balance and joint flexibility
  • Improves mood and strengthens mental health

People with heart failure who improve their exercise capacity by following a regular, guided regimen of exercise should “notice a decline in fatigue with their regular daily care and job-related tasks as well as recreational activities,” says Dr. Blackburn.

Use common sense and talk to your doctor

Although there are added benefits with higher-intensity exercise, patients with heart failure shouldn’t just run out and sign up for an Ironman competition after reading the study results. Dr. Blackburn says that patients in the study were watched over “in a supervised cardiac rehabilitation environment” and that the results “are…suggesting we can be more aggressive with exercise for these patients, but the program must be tailored to the individual and attention to management of the whole disease process is essential.”

“I would hate to think that someone with heart failure would go out and think, ‘I’m going to push myself as hard as I can,’” Dr. Blackburn cautions. “Patients should meet with their doctor and cardiac rehabilitation staff to design a safe exercise program that would provide the most benefit.”

How Heart Failure Patients Can Safely Exercise

Physical activity is important for everyone, even people living with heart failure.

Research, including a review of more than 30 trials published in January 2015 in the journal Open Heart, has shown that heart failure patients who follow an exercise-based cardiac rehabilitation program are less likely to be hospitalized, and report a better quality of life than those who do not.

“We know exercise helps chronic heart failure patients,” says David Taylor, MD, a cardiologist at the Cleveland Clinic in Ohio. “While these studies weren’t designed to show if the patients actually lived longer, staying out of the hospital is incredibly important, as is improved symptoms.”

Most patients will be referred to a cardiac rehab program by their doctors, where their heart rate, ECG, blood pressure, and other physical responses can be monitored while you exercise. “This is a great place to start an exercise program, especially for patients with heart problems,” says Amy Beitel, a physical therapist in the department of rehabilitation sciences at the Medical University of South Carolina in Charleston.

It also provides extra motivation for patients to work out. “If you have a scheduled time and you’re sort of forced to go, you’re much more likely to go than if you have a bicycle in your basement,” Dr. Taylor says

You can also chose to start exercising on your own. But remember that it’s important to speak to your doctor before beginning any form of exercise.

Once you get cleared by a physician, start out slow. “Begin exercising for only a few minutes at a comfortable rate,” Beitel says. “Then each day, slowly try to increase the length of time and the intensity of your workout.”

When increasing the duration or intensity of the workout, experts recommend using the “talk test”: If you are unable to carry out a conversation while exercising, then you’re most likely overdoing it.

The ideal target for patients with mild to moderate heart failure is 30 to 45 minutes of exercise five days a week, Taylor says.

RELATED: What is Heart Failure?

Getting Started On An Exercise Plan

When it comes to choosing a type of exercise, experts recommend that patients do physical activities they like the best, though sticking to low-impact activities, like walking, bicycling, or swimming, is best.

Beitel advises beginning each exercise with a warm up, such as marching in place for about five minutes and doing some upper body stretches. At the end of each session, cool down with some more stretching exercises.

“Never stop exercising all of a sudden and then sit or lie down, or stand still. This can make you feel dizzy or lightheaded,” she says. “Walk around slowly before you stop.”

Importantly, you should never exercise during times when your heart failure is not under control. If you notice any heart failure symptoms, including excessive shortness of breath, chest discomfort, palpitations that do not go away, or increasing fatigue, stop exercising and notify your doctor right away.

Beitel also offers these seven tips for exercising safely while living with heart failure:

  1. Avoid exercises that require or encourage holding your breath, such as pushups, situps, and isometric exercises.
  2. Wait at least one hour after eating to exercise.
  3. Avoid actions that need quick bursts of energy.
  4. Exercise when you have the most energy. For most people with heart failure, that is in the morning.
  5. Think about exercising with a friend or family member. It’s easier to stay with it when you have a partner, and it can be an enjoyable social time.
  6. Don’t exercise if you are sick or have a fever.
  7. Avoid exercising outdoors in extreme weather or high humidity.

Chronic Heart Failure and Exercise: to Exercise, or Not to Exercise?

As we have already discussed, congestive heart failure (CHF) is not a disease but rather a cascade of events and ill-conceived compensatory efforts made by the body, and all therapists should understand that cascade in order to safely and effectively design exercises for the patient with heart failure (HF).

The role of the therapy and nursing care in the management of CHF is rapidly changing. Often, the patient who walks in the clinic door is not seeking therapy for management of heart failure; rather, heart failure is merely one of an ever-increasing string of ‘also have’ conditions or co-morbidities. It comes with the package.

Exercise recommendations for the CHF patient have evolved beyond recognition over the last 30 years. In 2010, and again in 2014 and 2016, the industry heavyweight Cochrane Collaboration weighed in on the matter (Taylor et al. 2014). In their Exercise Based Rehabilitation for Heart Failure document, the Cochrane team added ammunition to the argument that exercise was both safe, and reduced hospital readmissions.

What’s more, the growing body of evidence has demonstrated that the safety of exercise prescription is not limited to patients with a single kind of heart failure. Recent studies have demonstrated that – if cardiac exercise is properly administered and supervised – a huge spectrum of patients with HF can safely participate, including patients with both systolic and diastolic dysfunction, atrial fibrillation, pacemakers, implantable cardioversion devices, and post-cardiac transplantation.

Keep in mind that patients who are unstable or decompensated should not participate in exercise until stable; in fact, some programs will not permit patients to exercise until they have been stable for 3 months or more.

No matter the official diagnoses, no HF patient is considered appropriate for exercise training until they are evaluated and assessed for current physical status, medical regime, and exercise tolerance.

Typically, patients must undergo a physical assessment with particular attention paid to signs or symptoms related to heart failure, such as the presence of new heart sounds, lung crackles, weight gain, or oedema.

The program may even track brain naturetic peptide (BNP), renal function, and medications. Additionally, before the first exercise is prescribed or performed, patients must see a physical therapist for an evaluation of physical function and endurance.

Further Learning: Venous Thromboembolism Video Course

Chronic Heart Failure and Exercise Red Flags

Patients with CHF rank worse than patients with other forms of heart disease on overall morbidity and mortality. It is not strange, then, that exercise guidelines place chronic heart failure at the highest level of risk. However, recent systematic reviews have shown the overall adverse event rate to be quite low.

It becomes important, then, for healthcare professionals to be able to differentiate signs and symptoms that require emergency management, from common exertion signs and symptoms.

The most common signs and symptoms that crop up during exercise sessions include hypotension (typically after exercise), arrhythmias (both atrial and ventricular) and a general worsening of CHF symptoms (dyspnoea, swelling, etc). Many patients with CHF already experience vacillating levels of symptoms from day to day; when this is the case, it is harder to determine if any decline in status is due to the exercise program or the disease itself.

That said, there are multiple red flags that should never be ignored and indicate the onset of an unstable stage of heart failure (see list below). A sudden onset of shortness of breath not related to exercise (or likewise a change in the status of dyspnoea at rest) is certainly a call for medical attention.

Patients who cough up pink/frothy sputum or experience chest pain, dizziness or any indications of low perfusion (such as a change in skin colour or a decline in level of consciousness) should cease all exercise and seek emergency management. Individuals who show dramatic deterioration in circulation and oxygenation – such as shown by an arterial oxygen saturation <90% or systolic blood pressure <80-90mmHg – are likely in an unstable state, especially if they are coupled with subjective symptoms.

Unstable symptoms may include:

  • Dyspnoea: at rest/orthopnoea (change from baseline), sudden onset of shortness of breath (SOB), worsening SOB, exertional dyspnoea, gasping
  • Arterial oxygen saturation (SaO2) less than 90%
  • Coughing up pink/frothy sputum
  • Dizziness or syncope
  • Chest pain
  • Systolic blood pressure (BP) less than 80 to 90mmHg and symptomatic
  • Evidence of hypoperfusion (cyanosis, decreased level of consciousness, etc.)
Further Learning: Interpretation of Arterial Blood Gas Results Video Course

Classifying Chronic Heart Failure Patients for Exercise

Heart failure patients are unlike almost every other patient who participates in an exercise program. They require a thorough assessment by a professional who understands their specific disorder and can properly stratify their risk for harm. In other words, it becomes important to classify patients into group of those who can exercise and those for whom exercise would be contraindicated.

Why is the CHF patient a special risk? Think about all the interwoven factors that alter the heart failure patient’s responses to exercise.

Firstly, their body reacts differently to exertion; they do not experience the normal physiological and compensatory responses that are commonly seen during an exercise session.

Secondly, they are most probably on multiple medications, including beta blockers, ACE inhibitors and diuretics, all of which dramatically alter how their heart responds to exercise stimuli.

Thirdly, they may be under the influence of a pacemaker, implantable defibrillator or other device, which alters their capacity to respond to exercise.

Fourthly, HF is probably not the only game in town. Patients who have developed heart failure typically have a history of hypertension, coronary artery disease and/or diabetes. Each of these comorbidities brings its own special needs to the exercise table.

And finally, when working with the patient with CHF, the end result of choosing wrongly is pretty darn catastrophic. Many heart failure patients are at risk of sudden arrhythmias, sudden cardiac death and myocardial infarction at rest. These risks all (theoretically) elevate during exercise, although recent research shows little evidence of increased major medical incidences.

So what kind of exercise should the patient with CHF be pursuing? There continues to be one gold-standard: moderate-intensity endurance training. This training type continues to excel at improving the prognosis of heart patients including a reduction in mortality and a reduced rate of rehospitalization. Recently, clinicians pinned their hopes on a trial that seemed to show that high-intensity interval training would eclipse steady-state training. However, this hope seems to have been crushed by the SMARTEX study which showed that these results could not be reproduced. Resistance training should never be a “singular focus” for the patient with heart failure; it is inefficient in improving exercise capacity; however, if combined with an endurance regime, it can produce results in both vascular function and exercise capacity.

Conclusion

Historically, patients with CHF were advised to reduce activity or just plain “rest” as their symptoms worsened, but these recommendations have been rejected and replaced with exercise protocols for most patients. Recent research continues to bolster the pro-exercise position. Rarely, if ever, should today’s clinicians be advising stable CHF patients to take it easy. Once again, exercise rules the day!

Small changes can make a big difference

Following recommendations about diet, exercise and other habits can help alleviate heart failure symptoms, slow your disease’s progression and improve your everyday life. In fact, people with mild to moderate heart failure often can lead nearly normal lives as a result. Important lifestyle changes may include:

Quitting smoking

Each puff of nicotine from tobacco smoke temporarily increases heart rate and blood pressure, even as less oxygen-rich blood circulates through the body. Smoking also leads to clumping or stickiness in the blood vessels feeding the heart.

People who quit smoking are more likely to have their heart failure symptoms improve.

Learn more about quitting smoking.

Maintaining or losing weight

Sudden weight gain or loss can be a sign that you’re developing heart failure, or that your heart failure is progressing. Weigh yourself at the same time each morning, preferably before breakfast and after urinating. Notify your healthcare professional if you gain three or more pounds in one day, five or more pounds in one week, or whatever amount you were told to report.

Learn more about maintaining a healthy weight.

Tracking your daily fluid intake

If you have heart failure, it’s common for your body to retain fluid. So your healthcare team may recommend limiting your liquid intake.

Many people are prescribed diuretics (water pills) to help them get rid of extra water and sodium to reduce their heart’s workload.

Talk with your doctor about how much liquid to drink every day.

Avoiding or limiting alcohol

If you drink alcohol, do so in moderation. This means no more than one to two drinks per day for men and one drink per day for women. Talk to your doctor about whether it’s OK for you to drink alcohol.

Learn more about alcohol and heart disease.

Avoiding or limiting caffeine

Consume only a moderate amount of caffeine per day, no more than a cup or two of coffee.

Learn more about caffeine and heart disease.

Eating a heart-healthy diet

Eat an overall healthy dietary pattern that emphasizes a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish, nuts and legumes, and non-tropical vegetable oils. Also, limit saturated fat, trans fat, cholesterol, sodium, red meat, sweets and sugar-sweetened beverages.

Being physically active

If you’re not physically active, talk to your doctor about starting an exercise regimen. Schedule physical activity at the same time every day so it becomes a regular part of your lifestyle. If moderate exercise isn’t possible for you, consider participating in a structured rehabilitation program.

Managing stress

Take 15 to 20 minutes a day to sit quietly, breathe deeply and think of a peaceful scene. Or try a class in yoga or meditation. (Check with your doctor first before undertaking a strenuous yoga class.) When you get angry, count to 10 before responding to help reduce your stress.

Learn more about managing stress.

Keeping track of symptoms

Report any changes that concern you to your healthcare professional.

Monitoring your blood pressure

Monitoring blood pressure at home, in addition to regular monitoring in a doctor’s office, can help control high blood pressure.

Chart your blood pressure readings over time. This can reveal trends and help to eliminate false readings.

Find out more about how healthy eating can lower your blood pressure with the DASH eating plan.

Getting adequate rest

To improve your sleep at night, use pillows to prop up your head. Avoid naps and big meals right before bedtime. Try napping after lunch or putting your feet up for a few minutes every couple of hours.

Learn about sleep apnea and heart disease.

Seeking support

Join a support group for people with heart failure and other heart conditions.

Contact local congregations and volunteer centers to find out about programs that provide meals, transportation and errand services for people who need assistance.

Avoiding flu and pneumonia with vaccinations

Flu and pneumonia pose greater dangers for people who have heart failure (or any heart condition) than for healthy people.

Pneumonia is a lung infection that keeps your body from using oxygen as efficiently as it should. Your heart has to work harder to pump oxygenated blood through the body. If you have heart failure, you should avoid putting this extra stress on your heart.

Ask your doctor or another healthcare professional about getting a yearly influenza (flu) vaccine and a one-time pneumococcal vaccine. (The latter guards against the most common form of bacterial pneumonia.)

Both vaccines are generally safe and seldom cause any severe reactions. It’s much riskier not to be vaccinated against flu and pneumonia. You might have some pain or swelling at the site of the shot (on the arm), but this will go away after a few days.

Read more about flu and pneumonia.

Following heart patient guidelines for sexual activity

Many people with heart failure can still be sexually active. Choose a time when you’re feeling rested and free from the day’s stresses.

Learn more about sex and heart disease.

Selecting appropriate clothing

Avoid tight socks or stockings, such as thigh-high or knee-high hose, that slow blood flow to the legs and cause clots. Avoid temperature extremes as much as possible, too. Dress in layers so that you can add or remove garments as needed.

Lifestyle changes worth making

Making some of these lifestyle changes can be easier said than done. But working these changes into your daily routine can make a real difference in your quality of life.

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