What are the best exercises for patients with New York Heart Association (NYHA) class 2-3 heart failure?

Best Exercises for NYHA Class 2-3 Heart Failure Patients

Cycle ergometer training is the most favorable aerobic exercise for NYHA class 2-3 heart failure patients, performed at 60-80% of peak heart rate for 20-40 minutes, 3-5 times per week, combined with low-intensity resistance training. 1

Primary Exercise Modality: Cycle Ergometry

Cycle ergometer training should be the foundation of your exercise prescription for these patients because it allows:

• Precise control of very low workloads for severely limited patients 1
• Exact reproducibility of prescribed intensity 1
• Continuous monitoring of heart rate, rhythm, and blood pressure during exercise 1
• Ideal application of interval training methods 1

This is particularly critical for patients with severe exercise intolerance, history of arrhythmias, frequent diuretic adjustments, obesity, or orthopedic/neurological limitations. 1

Exercise Prescription Parameters

Aerobic Training Intensity and Duration

• Intensity: 60-80% of peak heart rate or 60-70% of peak VO2 1, 2
• Duration: 20-40 minutes per session 1, 2
• Frequency: 3-5 times per week 1, 2
• Program length: Minimum 8 weeks, with optimal benefits continuing up to 6 months 1

The European Heart Failure Training Group demonstrated that training at 70-80% of peak heart rate for 20 minutes, 4-5 times weekly, produced significant improvements in peak VO2 (12-31% increases) without complications in NYHA class II (50% of patients) and class III (48% of patients). 1

Interval vs. Continuous Training

Interval training produces more pronounced effects on exercise capacity than steady-state training, particularly in patients with very low baseline aerobic capacity. 3 High-intensity interval training (HIIT) using 2-4 minute intervals improved peak VO2 by 17-52% in NYHA class II-III patients. 1, 4

For interval training:

• Use 2-4 minute work intervals at higher intensity 1, 4
• Follow with recovery periods 1
• This allows more intense peripheral muscle stimulation without greater cardiovascular stress 1

Walking as Alternative Aerobic Exercise

Walking offers broad applicability across exercise tolerance levels and is suitable when cycle ergometry is unavailable:

• Low speeds (<50 m/min): Requires only 0.3 W/kg tolerance, suitable for severely limited patients 1
• Moderate speeds (100 m/min): Requires 0.8-0.9 W/kg tolerance 1
• Duration: 30-60 minutes 5, 2
• Frequency: 3-5 days per week 5, 2

Home-based walking programs demonstrated 90% adherence with excellent safety profiles and improved fatigue, emotional function, and quality of life. 5

Resistance Training Component

Add low-intensity, high-repetition resistance training to the aerobic program for comprehensive benefits:

• Intensity: 50-70% of 1-repetition maximum 1
• Repetitions: 10-15 repetitions per set (corresponding to the 50-70% intensity) 1
• Sets: 1-2 sets per exercise 1
• Exercises: 4-6 exercises targeting major muscle groups of upper and lower extremities 1
• Frequency: 2 times per week 1

Resistance training produces striking strength increases of 100-200% even in elderly patients, allowing some to reduce dependence on walking aids, and addresses the profound skeletal muscle weakness that compounds functional decline in heart failure. 1

Inspiratory Muscle Training

Consider adding inspiratory muscle training (IMT) for patients with maximal inspiratory pressure ≤70% of predicted values:

• Frequency: Most or all days of the week 1
• Duration: ~30 minutes per session 1
• Intensity: At least 30% of static maximal inspiratory pressure 1
• Respiratory rate: 15-20 diaphragmatic breaths per minute 1

IMT significantly improves inspiratory muscle strength, aerobic capacity, quality of life, and perceived dyspnea, with minimal adverse event risk. 1 When combined with aerobic training, IMT produces greater improvements in aerobic capacity than aerobic training alone. 1

Critical Safety Requirements

Patients must meet strict stability criteria before starting exercise:

• Stable symptoms for at least 2 weeks 1
• No resting symptoms or postural hypotension 1
• Stable fluid balance (diuretic increases no more than once weekly) 1
• No evidence of congestion 1
• Stable renal function and normal/near-normal electrolytes 1

Exercise is contraindicated when:

• Systolic blood pressure <80 mmHg 1
• Resting heart rate <50 or >100 bpm 1
• Dressing and body care cause symptoms 1
• NYHA class IV with dyspnea at rest 1, 3

Activities to Avoid

Do not recommend these activities:

• Jogging: Requires minimum 1200 ml/min VO2 (1 W/kg body weight), exceeding capacity of most heart failure patients 1
• Swimming: Causes hydrostatic volume shift increasing left ventricular volume loading and pulmonary capillary wedge pressure; even slow swimming (20-25 m/min) produces cardiovascular stress equivalent to 100-150W cycling 1
• Outdoor cycling: Environmental factors (wind, slopes) make workload unpredictable and potentially excessive 1

Expected Outcomes

Patients completing this exercise prescription typically achieve:

• Peak VO2 improvements of 12-31% 1
• 6-minute walk distance increases of 37-143 meters 4, 6
• Improved quadriceps muscle strength (2.8 kg increase) 6
• Enhanced quality of life, particularly exercise tolerance and general health domains 5, 6
• Reduced sympathetic nervous system overactivation 2

Most improvement occurs by week 3 but continues up to 6 months with sustained compliance. 1 Supervision during at least the initial training period is mandatory, particularly for NYHA class III patients. 1, 3