Prescribed inactivity no longer an answer to chronic heart failure
UNTIL the 1990s, if you were diagnosed with chronic heart failure (CHF), chances are your doctor would have strictly advised you to rest and keep your activity levels to a minimum. Thanks to research over the last decade, and particularly in the last year, that advice has shown to be greatly contradicted — physical activity is now considered a primary therapy.
People with CHF experience multiple physical and psychological symptoms that can impact on their quality of life. Despite recent advances in drug treatment, the mortality and morbidity rates amongst CHF patients remain high — approximately 65 per cent of patients die within 5 years of diagnosis.
They experience breathlessness and their daily activities are limited because of their restricted heart capacity. This can reduce the amount of physical activity they perform, which can further reduce fitness, making their symptoms worse. As a result, they become trapped in a vicious circle of inactivity and decreasing functional capacity.
However, patients who undergo moderate exercise training have better quality of life and improved survival rates. A 2004 meta-analysis based on nine randomised controlled trials encompassing 801 patients with CHF, which included a 705-day follow-up, revealed that physical training reduced mortality as well as hospital admission ( BMJ 2004;328:189).
Similarly, a 2002 review of studies investigating exercise in people with CHF, published in the British Journal of General Practice , revealed positive effects on cardiovascular function including oxygen uptake, resting pulse and blood pressure (2002;52:47-55). Moreover, patients reported a significant improvement in quality of life.
They reported reduced tiredness, reduced breathlessness, and an increased tolerance to physical activity. Regular exercise enabled patients to manage more of their daily tasks independently, reduce their depression and improve their general wellbeing. Interestingly, the effect on psychological state occurred independently of the effects on physical state.
But a recent Australian study showing the benefits of resistance training in chronic heart failure patients has raised the eyebrows of many specialists and researchers in chronic heart failure. In the trial, published in the Journal of Cardiac Failure (2007;13(2):79-85), CHF patients underwent three months of resistance training combined with brief aerobic exercise.
Earlier studies investigating strength train- ing and heart failure demonstrated an improvement in markers associated with survival and quality of life, but showed that aerobic fitness can also be significantly increased with strength training. Moreover, patients in the control group who did not exercise deteriorated at the same rate as the exercise group improved.
Clinical exercise physiologist and author of the Australian study, associate professor Steve Selig, said the major implication of this trial was that ‘‘ those who have heart failure and are considerably deconditioned are able to achieve aerobic benefits to improve their condition. A very interesting finding was that these benefits seem to occur to a much greater extent than they would within the healthy population.’’
It must be stressed that the research was in a clinical setting and supervised by accredited exercise physiologists. The programs were not mainstream strength training classes.
It is only in recent years that the psycholog- ical impact of CHF has been explored. Not surprisingly, people with CHF experience moderate levels of depression and heightened anxiety. It has been shown that the level of support and style of coping are important factors in the prognosis of the condition. This highlights the importance of strategies to improve patient exercise and lifestyle habits as a major part of better self-management.
The accumulating evidence supporting exercise in the management of heart failure is having a noticeable effect on the treatment approaches of cardiologists and other health professionals. Increasingly, people with heart failure are being encouraged to take up regular supervised exercise programs alongside their medication treatment. Chris Tzar is an exercise physiologist and director of the Lifestyle Clinic, Faculty of Medicine, University of NSW