Pre­scribed in­ac­tiv­ity no longer an an­swer to chronic heart fail­ure

The Weekend Australian - Travel - - Health -

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

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