# Exercise as it relates to Disease/Exercise Prescription for Patients with Heart Failure

NOTE: For the purpose of this assignment, only resistance exercise prescription will be discussed.

## Background

Chronic Heart Failure (CHF) is a serious medical condition in which the heart is no longer able to pump enough blood to meet the body's needs. The most common cause of this inability to pump is caused by cardiac dysfunction that impairs the ability of the left ventricle to fill and/or eject blood, especially during exercise. These impairments often occur as a result of other heart problems such as myocardial infarction, ischaemic heart disease, hypertension and idiopathic dilated cardiomiopathy. Symptoms of CHF include breathlessness, tiring easily; particularly during exercise, irregular heart beat, oedema in the lower limbs and sudden weight gain as a result from this fluid retention.

#### Diagnosis

Patients who have some symptoms listed above should get appropriate diagnostic testing from their physician. There are several tests that can diagnose heart failure:
* Electrocardiogram (ECG) can be used to diagnose a myocardial infarction or arrythmias, which could either be the cause or exacerbate heart failure.
* Chest X-ray can show whether the heart is enlarged or if there is any fluid build up caused by the heart failing.
* Echocardiogram analyses ultrasound waves to create an image of the heart as it beats. This image allows the physician to see the blood flow of the heart, the heart's structure and how effectively it is working.
* Angiogram is a specialised Xray of your heart using an injected contrast dye. It looks for heart muscle or heart valve abnormalities or if coronary arteries are narrowed or blocked.

### Prevalence

According to the National Health Survey (NHS) conducted in 2007-8, it was estimated that approximately 263,000 people had heart failure, which equated to 1.3% of the Australian population at the time. This prevalence however, is likely under-reported as the information collated from the NHS was self-reported. Due to heart failure’s initial stages having mild symptoms, many people may have been unaware they had the condition at the time. Data from the NHS also found that CHF prevalence is higher in lower socio-economic groups and indigenous populations. In 2005, it was estimated that CHF may cost the Australian health care system over 1 billion dollars per year.

### NYHA Functional Capacity

The New York Heart Association (NYHA) has developed a table which categorizes the severity of a patients heart failure and their capacity to exercise.
| NYHA Class | How a patient with CHF feels during exercise |
| I | Patients with CHF but resulting in no limitation of physical activity. Ordinary physical activity doesn't cause undue fatigue, palpitation, dyspnea or anginal pain. |
| II | Patients with CHF resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain |
| III | Patients with CHF resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain |
| IV | Patients with CHF resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases. |

## Resistance Exercise as a form of Treatment

Prior to the 1980's, physicians typically recommended bed rest over exercise. Until the mid 1990's, resistance training (RT) was not recommended for patients with CHF due to concern for increases in wall tension and rate pressure product (RPP) caused by increases in blood pressure and afterload, which may cause acute myocardial insufficiency and/or accelerate chronic left ventricle remodelling. There are now training guidelines established that can assist in the prevention of increases in RPP during resistance training and the role and benefit of resistance training in CHF patients has been widely researched in the literature. Benefits of resistance training in this population includes:
* Improved muscle strength, endurance and function
* Improved exercise capacity
* improved quality of life
* increases in peak VO2
These physiological adaptations are not associated with overall reduced morbidity and mortality in this diseased population, however, they come with no apparent negative contraindications, suggesting some resistance exercise can only be beneficial.

#### Resistance Exercise Recommendations for Patients with Heart Failure

| Training Method | Mode | Intensity | Frequency | Duration | Progression |
| Resistance | Free weights and bands, fixed machines; 6-8 regional exercises, avoid free weights | Initiate program at 40% of 1RM; progress over time to 70%. RPE 10-15 | 1-2 times a week | 1 set of 12-15 reps of each muscle group worked | Increase load by 5-10%, or as tolerated |
It is widely recommended that for optimum benefits, a resistance training program should co-exist with an aerobic exercise program tailored for this population

#### Considerations for those with CHF

* Many CHF sufferers take beta-blocker medications, which will blunt their heart rate response to exercise. Therefore, when exercise testing with this population it is best to use an RPE scale as a determinant of exercise intensity.
* Many patients are physically inactive and have a low tolerance for activity. Exercise intensity should be progressively increased according to the patients abilities

## Further reading

* National Heart Foundation: Diagnosis and Management of Chronic Heart Failure
* American Heart Association: Heart Failure
* American Heart Association:Heart Failure Medications

## References

* ↑ American College of Cardiology Foundation/American Heart Association, 2013. ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 62(16), pp. 147-239.
* 1 2 National Heart Foundation, 2011. Diagnosis and Management of Chronic Heart Failure, Canberra: National Heart Foundation.
* 1 2 Hall, J. E. & Guyton, A. C., 2010. Guyton and Hall Textbook of Medical Physiology. 12th ed. Philadelphia: Saunders Elsevier.
* ↑ National Heart Foundation, 2010. Symptoms and Diagnoses. [Online] Available at: http://www.heartfoundation.org.au/your-heart/cardiovascular-conditions/Heart-failure/Pages/Symptoms-and-Diagnoses.aspx [Accessed 17 October 2013].
* 1 2 Australian Bureau of Statistics, 2009. 2007-8 National Health Survey: Summary of Results. Cat. no 4364.0., Canberra: ABS.
* ↑ Australian Institute of Health and Welfare, 2011. Cardiovascular Disease: Australian Facts 2011, Canberra: AIHW.
* ↑ National Heart Foundation and Access Economics Pty Limited, 2005. The Shifting Burden of Cardiovascular Disease in Australia, Canberra: National Heart Foundation.
* ↑ American Heart Association, 2013. Classes of Heart Failure. [Online] Available at: http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp [Accessed 1 October 2013].
* ↑ Adsett, J. & Mullins, R., 2010. Evidence Based Guidelines for Exercise and Chronic Heart Failure, Brisbane: Queensland Health.
* 1 2 3 4 Cameron, M., Selig, S. & Hemphill, D., 2011. Clinical Exercise: A Case-Based Approach. 1st ed. Chatswood: Elsevier Australia.
* 1 2 Jankowska, E. A. et al., 2008. The 12-week Progressive Quadriceps Resistance Training Improves Muscle Strength, Exercise Capacity and Quality of Life in Patients with Stable Chronic Heart Failure. International Journal of Cardiology, 130(1), pp. 36-43.
* 1 2 3 Levinger, I. et al., 2005. Resistance Training for Chronic Heart Failure Patients on Beta Blocker Medications. International Journal of Cardiology, 102(1), pp. 493-499.
* 1 2 Delagardelle, C. et al., 2002. Strength/Endurance Training Versus Endurance Training in Congestive Heart Failure. Medicine & Science in Sports & Exercise, 34(12), pp. 1868-1872.
* 1 2 3 4 5 6 Selig, S. E. et al., 2010. Exercise & Sports Science Australia Position Statement on Exercise Training and Chronic Heart Failure. Journal of Science and Medicine in Sport, 13(1), pp. 288-294.
* ↑ Thompson, P. D. et al., 2003. Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease. Circulation, 107(1), pp. 3109-3116.
* 1 2 Ehrman, J. K., Gordon, P. M., Visich, P. S. & Keteyian, S. J., 2009. Clinical Exercise Physiology. 2nd ed. Lower Mitcham: Human Kinetics.
* ↑ Keteyian, S. J., 2011. Exercise Training in Congestive Heart Failure: Risks and Benefits. Progress in Cardiovascular Diseases, 53(1), pp. 419-428.