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. 2004:(3):CD003331.
doi: 10.1002/14651858.CD003331.pub2.

Exercise based rehabilitation for heart failure

K Rees  1 , R S Taylor, S Singh, A J S Coats, S Ebrahim
Affiliations

Exercise based rehabilitation for heart failure

K Rees et al. Cochrane Database Syst Rev. 2004.

Update in

Abstract

Background: The prevalence of chronic heart failure is increasing, and increases with increasing age. Major symptoms include breathlessness and restricted activities of daily living due to reduced functional capacity, which in turn affects quality of life. Exercise training has been shown to be effective in patients with coronary heart disease and has been proposed as an intervention to improve exercise tolerance in patients with heart failure.

Objectives: To determine the effectiveness of exercise based interventions compared with usual medical care on the mortality, morbidity, exercise capacity and health related quality of life, of patients with heart failure.

Search strategy: We searched the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2001), MEDLINE (2000 to March 2001), EMBASE (1998 to March 2001), CINAHL (1984 to March 2001) and reference lists of articles. We also sought advice from experts.

Selection criteria: RCTs of exercise based interventions. The comparison group was usual medical care as defined by the study, or placebo. Adults of all ages with chronic heart failure. Only those studies with criteria for diagnosis of heart failure (based on clinical findings or objective indices) have been included.

Data collection and analysis: Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information.

Main results: Twenty-nine studies met the inclusion criteria, with 1126 patients randomised. The majority of studies included both patients with primary and secondary heart failure, NYHA class II or III. None of the studies specifically examined the effect of exercise training on mortality and morbidity as most were of short duration. Exercise training significantly increased VO(2) max by (WMD random effects model) 2.16 ml/kg/min (95% CI 2.82 to 1.49), exercise duration increased by 2.38 minutes (95% CI 2.85 to 1.9), work capacity by 15.1 Watts (95% CI 17.7 to 12.6) and distance on the six minute walk by 40.9 metres (95% CI 64.7 to 17.1). Improvements in VO(2) max were greater for training programmes of greater intensity and duration. HRQoL improved in the seven of nine trials that measured this outcome.

Reviewers' conclusions: Exercise training improves exercise capacity and quality of life in patients mild to moderate heart failure in the short term. There is currently no information regarding the effect of exercise training on clinical outcomes. The findings are based on small-scale trials in patients who are unrepresentative of the total population of patients with heart failure. Other groups (more severe patients, the elderly, women) may also benefit. Large-scale pragmatic trials of exercise training of longer duration, recruiting a wider spectrum of patients are needed to address these issues.

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References

References to studies included in this review

    1. Belardinelli R, Scocco V, Mazzanti M, et al. Effects of aerobic training in patients with moderate chronic heart failure. Giornale italiano di cardiologia. 1992;22(8):919–30. - PubMed
    1. 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(11):2775–84. - PubMed
    1. 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(9):1173–82. - PubMed
    1. Cider A, Tygesson H, Hedberg M, Seligman L, Wennerblom B, Sunnerhagen KS. Peripheral muscle training in patients with clinical signs of heart failure. Scandinavian Journal of Rehabilitation Medicine. 1997;29(2):121–7. - PubMed
    1. Coats A, Adamopoulos S. A cross-over comparison of outpatient physical training versus rest in the treatment of moderate to severe heart failure [abstract] Clinical Science. 1989;77(Suppl 21):19P.

References to studies excluded from this review

    1. Adamopoulos S, Ponikowski P, Cerquetani E, Piepoli M, Rosano G, Sleight P, et al. Circadian pattern of heart rate variability in chronic heart failure patients. Effects of physical training. European Heart Journal. 1995;16(10):1380–6. - PubMed
    1. Barnard KL, Adams KJ, Swank AM, Kaelin M, Kushnik MR, Denny DM. Combined high-intensity strength and aerobic training in patients with congestive heart failure. Journal of strength and conditioning research. 2000;14:383–8.
    1. Belardinelli R, Georgiou D, Scocco V, Barstow TJ, Purcaro A. Low intensity exercise training in patients with chronic heart failure. Journal of the American College of Cardiology. 1995;26(4):975–82. - PubMed
    1. Cohen-Solal A, Aupetit JF, Gueret P, Kolsky H, Zannad F, The VO2 French Study Group Can anaerobic threshold be used as an end-point for therapeutic trials in heart failure? Lessons from a multicentre randomized placebo-controlled trial. European Heart Journal. 1994;15(2):236–41. - PubMed
    1. Davey P, Meyer T, Coats A, Adamopoulos S, Casadei B, Conway J, et al. Ventilation in chronic heart failure: Effects of physical training. British heart journal. 1992;68(5):473–7. - PMC - PubMed

References to studies awaiting assessment

    1. Kayanakis JG, Page E, Aros F, Borau F. [Rehabilitation of patients with chronic cardiac insufficiency. Immediate and midterm effects]. [French] Presse Medicale. 1994;23(3):121–6. - PubMed

References to ongoing studies

    1. EXIST - Exercise Intervention Strategies in Heart Failure Trial. National Research Register, Publication ID N0201112792. Start date 01/07/2002, end date 31/12/2002.
    1. A randomised trial of exercise intervention for older patients with heart failure. National Research Register, Publication ID NO514100933. Start date 01/01/2001, end date 01/01/2004.

Additional references

    1. American Heart Association www.americanheart.org.
    1. Working Group on Cardiac Rehabilitation and Exercise Physiology and Working Group on Heart Failure of the European Society of Cardiology. Recommendations for exercise training in chronic heart failure patients. European Heart Journal. 2001;22:125–35. - PubMed
    1. The task force for the diagnosis and treatment of chronic heart failure. Guidelines for the diagnosis and treatment of chronic heart failure. European Heart Journal. 2001;22:1527–60. - PubMed
    1. Cochrane Heart Group [Accessed May 2004];Preferred method for handling continuous variables. http://www.epi.bris.ac.uk/cochrane/stats3.html.
    1. Conn EH, Williams RS, Wallace AG. Exercise responses before and after physical conditioning in patients with severely depressed left ventricular function. The American Journal of Cardiology. 1982;49:296–300. - PubMed

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