Exercise in Heart Failure: Safe and Beneficial with Proper Precautions
Exercise training is recommended as safe and effective for patients with heart failure who are able to participate, and improves functional status with potential benefits for morbidity and mortality. 1
Benefits of Exercise in Heart Failure
Exercise training in heart failure patients provides multiple benefits:
- Improves exercise capacity and functional status 1
- Enhances quality of life 1
- Reduces ventilatory abnormalities 1
- Improves peripheral vascular, muscular and metabolic function 1
- May reduce sympathetic nervous system activity 1
- Potentially reduces hospitalization rates 1
Patient Selection and Safety Considerations
Not all heart failure patients should exercise without medical guidance. Exercise should be avoided in patients with:
Absolute Contraindications 1:
- Progressive worsening of exercise tolerance or dyspnoea over previous 3-5 days
- Significant ischemia at low workloads
- Uncontrolled diabetes
- Acute systemic illness or fever
- Recent embolism or thrombophlebitis
- Active pericarditis or myocarditis
- Moderate to severe aortic stenosis
- Regurgitant valvular disease requiring surgery
- Myocardial infarction within previous 3 weeks
- New onset atrial fibrillation
Relative Contraindications 1:
- Recent weight gain (>1.8 kg over 1-3 days)
- Concurrent dobutamine therapy
- Decrease in systolic blood pressure with exercise
- NYHA Class IV heart failure
- Complex ventricular arrhythmias
- Resting heart rate >100 beats/min
- Pre-existing comorbidities
Exercise Prescription for Heart Failure Patients
Before starting an exercise program, patients should meet these criteria 1:
- Compensated heart failure for at least 3 weeks
- Ability to speak without dyspnea (respiratory rate <30 breaths/min)
- Resting heart rate <110 beats/min
- Less than moderate fatigue
Recommended Exercise Approach:
Type of Exercise:
- Cycle ergometer training is ideal, especially for patients with severe exercise intolerance 1
- Walking, swimming, and calisthenics are also appropriate options
Intensity:
- Begin with low intensity (RPE 11-13)
- Gradually increase to moderate intensity (RPE 13-15) 1
Duration:
- Start with 20 minutes of prescribed intensity
- Include proper warm-up and cool-down periods 1
Frequency:
- Regular, consistent exercise sessions
- Ideally part of a cardiac rehabilitation program 1
Cardiac Rehabilitation Referral
The American College of Cardiology/American Heart Association strongly recommends referring heart failure patients to cardiac rehabilitation programs:
- Exercise training is a Class I recommendation (Level of Evidence: A) for heart failure patients 1
- Cardiac rehabilitation is considered useful (Class IIa, Level of Evidence: B) to improve functional capacity, exercise duration, quality of life, and mortality 1
- Referral to cardiac rehabilitation should be considered for all eligible heart failure patients 1
Clinical Pearls and Pitfalls
- Monitoring: Initial exercise sessions should be supervised with monitoring of heart rate, blood pressure, and symptoms 1
- Progression: Gradually increase exercise intensity and duration based on individual tolerance 1
- Medication Considerations: Beta-blockers may affect heart rate response to exercise; use perceived exertion to guide intensity 1
- Warning Signs: Patients should stop exercising if experiencing chest pain, dizziness, unusual shortness of breath, or irregular heartbeats
Conclusion
Exercise is not only safe but beneficial for stable heart failure patients when properly prescribed and monitored. The evidence strongly supports exercise as an important component of heart failure management, with improvements in functional capacity, quality of life, and potentially reduced hospitalizations. Patients should be referred to cardiac rehabilitation programs when possible for structured, supervised exercise training.