The European Journal of Heart Failure 8 (2006) 97 – 101

www.elsevier.com/locate/heafai

The effect of physical training in chronic heart failure

Sólrún Jónsdóttira,b,c,*, Karl K. Andersenb, Axel F. Sigurðssonb, Stefán B. Sigurðssonc
a
Landspitali-University Hospital, Department of Physical Therapy, Reykjavik, Iceland
b
Landspitali-University Hospital, Department of Cardiology, Reykjavik, Iceland
c
University of Iceland, Fac. of Medicine, Reykjavik, Iceland

Received 22 September 2004; received in revised form 13 October 2004; accepted 5 May 2005
Available online 27 September 2005

Abstract

Background: Supervised cardiac rehabilitation programs have been offered to patients following myocardial infarct (MI), coronary artery
bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) for many years. However, limited information is available on the
usefulness of rehabilitation programs in chronic heart failure (CHF). The aim of our study was to evaluate the outcome of supervised physical
training on CHF patients by measuring both central and peripheral factors.
Methods: This was a prospective randomized study, including 43 patients with CHF, New York Heart Association (NYHA) class II or III,
mean age 68 years. After initial measurements of VO2peak, 6 min walk distance, muscle strength, plasma levels of atrial natriuretic peptide
(ANP) and brain natriuretic peptide (BNP), echocardiogram, measurements of pulmonary function and quality of life questionnaire, patients
were randomized to either a training group (n = 21) or a control group (n = 22). The training group had supervised aerobic and resistance
training program twice a week for five months. After the training program was completed, all measurements were repeated in both groups.
Results: No training related adverse events were reported. Significant improvement was found between groups in the six minute walk test
(+ 37.1 m vs. + 5.3 m, p = 0.01), work load on the bicycle exercise test (+ 6.1 W vs. + 2.1 W, p = 0.03), time on the bicycle exercise test (+ 41 s
vs. + 0 s, p = 0.02) and quadriceps muscle strength test (+2.8 kg. vs. + 0.2 kg., p = 0.003). Quality of life factors that reflect exercise tolerance
and general health, improved significantly in the training group compared to the control group. No other significant changes were found
between the two groups.
Conclusion: Supervised physical training as used in this study appears safe for CHF patients in NYHA class II or III. The improvement in
functional capacity observed in the training group seems to be related to peripheral factors rather than in central cardiovascular performance.
D 2005 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: CHF; Physical training; Vo2max; Exercise tolerance; 6 min walk test; Quality of life

1. Introduction Patients with heart failure generally have reduced

exercise capacity, and two of the main symptoms in heart
The syndrome of chronic heart failure has become one of failure are exercise intolerance and fatigue [7– 11]. Recently
the most common cardiovascular disorders in western more emphasis has been placed on the role of peripheral
societies [1,2]. Due to more effective treatment of cardio- factors as the cause of exercise intolerance in CHF. This is
vascular diseases, the number of patients living with heart in part due to the fact that, exercise capacity and left
failure is increasing [3]. In spite of advances in pharmaco- ventricular systolic function are poorly correlated [12,13].
logical treatment, prognosis in heart failure remains poor, While pharmacological therapy can improve central hemo-
and morbidity and mortality rates among patients with dynamics in CHF patients, corresponding improvements in
severe heart failure remain relatively high [4– 6]. exercise capacity are often delayed for weeks or even
months [12,14].
* Corresponding author. Landspitali-University Hospital, Department of
The aim of our study was to evaluate the effect of
Physical Therapy, Reykjavik, Iceland. physical training in chronic heart failure patients by
E-mail address: [email protected] (S. Jónsdóttir). measuring both central and peripheral factors. The results
1388-9842/$ - see front matter D 2005 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejheart.2005.05.002
98 S. Jónsdóttir et al. / The European Journal of Heart Failure 8 (2006) 97 – 101

will be of value in deciding whether chronic heart failure electronically braked upright bicycle ergometer (Sensor
patients should attend cardiac rehabilitation programs. Medics/Ergometrics 900). After a period of resting and
unloaded pedaling, work load was increased progressively
by either 5, 10 or 15 W/min until exhaustion was reached,
2. Methods or other symptoms that caused the patient to stop the test.
Heart rate and rhythm were recorded continuously by 12-
This was a prospective randomized study. The study was lead EKG, and blood pressure was assessed manually
approved by the Icelandic National Bioethic Committee. All every minute. The respiratory gas exchange was measured
participants signed a written informed consent prior to and recorded continuously by the breath by breath
inclusion in the study. The inclusion and exclusion criteria manouvre using mass flow ventilometry (Vmax Sensor-
are listed in Table 1. medics, Yorba Linda). Peak VO2 was determined as the
The study population was identified by screening VO2 value relative to body weight in ml/min/kg.,
approximately 500 patients who were hospitalized due to achieved at the patients peak work load on the bicycle.
heart failure in the Reykjavik area during a three year Gas analyzers and flow probes were calibrated before
period. Fifty-one patients were identified, but after the each test.
randomization process, eight patients withdrew consent for Minimum time for the test to be considered valid was 4
various reasons, so the study started with 43 patients. min cycling on the work load.
After initial measurements, patients were randomized to 6 min walk test. This was a standardized indoor 6 min
either a control group or a training group. Initial measure- walk test. Patients were instructed to walk as far as
ments consisted of cardiopulmonary exercise test on possible in 6 min. Four tests were performed each time,
ergometer bicycle, 6 min walk test, muscle strength test, the first two for the patient to get familiarized with the
measurements of ANP and BNP levels in plasma, dynamic procedure of the test and surroundings, and the second
spirometry, 2-D echocardiography and quality of life two were the actual tests, where the better (farther
questionnaire. The training group entered a supervised distance) was chosen. Blood pressure, heart rate, and
exercise program twice a week for five months. The control respiratory rate was measured and reported before and
group continued their previous level of physical activity, after each test.
which varied from performing little physical activity up to Muscle strength test. Muscle strength was measured in
taking a daily walk outdoors. All participants in the control skeletal muscle groups in upper and lower extremities
group were contacted via telephone once during the study using the Evient sequence equipment leg-press, arm-pull
period. After five months all measurements were repeated in and arm-press, and a quadriceps-bench for knee exten-
both groups. sion. The heaviest weight lifted once through a full range
of motion was the patient’s 1-repetition maximum
2.1. Measurements (1RM). Statistical analyses were performed on the muscle
strength data obtained from knee extension, musculus
Cardiopulmonary exercise test. The patients performed quadriceps.
a symptom limited cardiopulmonary exercise test on an Plasma ANP and BNP levels. Blood samples were
obtained to determine the plasma levels of atrial- and brain
natriuretic peptides. The samples were stored at 70 -C
Table 1 prior to analysis with a 19-IRMA ANP and BNP commer-
Inclusion and exclusion criteria for participation in the study
cial analysis kit.
Inclusion criteria: Spirometry. Forced vital capacity (FVC), forced expir-
CHF-diagnosis
On CHF medication
atory volume in one second (FEV1), and flow volume loop
Clinical symptoms of CHF were measured.
Clinically stable >3 months before study entrance Echocardiogram. Left ventricular ejection fraction
Fullfill one of the following criteria: (LVEF) was assessed with 2-D echocardiography (Acuson
- previous MI 128XP / 10c) using the biplane Simpsons method [15].
- hospitalized because of CHF
- lung oedema and cardiac enlargement on X-ray
Quality of life. Quality of life was measured with a valid
Icelandic quality of life questionnaire Heilsutengd lı́fsgæði
Exclusion criteria: [16]. It consists of 32 questions, sorted in 12 different
COPD categories. Each question gives scores from 1 to 10, the
Orthopedic disabilities scores within each category are added together and a
Psychiatric disabilities
Cancer
specific T-score is found. The higher the T-score, the better
Senility the self reported quality of life.
>80 years Rehospitalization. A retrospective assessment was made
CHF = Chronic heart failure; MI = Myocardial infarction; COPD = Chronic 12 and 28 months after study closure to record rehospita-
obstructive lung disease. lizations among the patients in our study.
 S. Jónsdóttir et al. / The European Journal of Heart Failure 8 (2006) 97 – 101 99

2.2. Training protocol Table 2

Baseline characteristics
Patients in the training group attended outpatient Control group Training group
(n = 22) (n = 21)
supervised physical training twice a week for five months.
Each session started with a 10 min warm-up period, either Age/year(TSD) 69(T5.3) 68(T6.6)
Male; Female 18; 4 16; 5
sitting or standing. It consisted of breathing exercises and
EF % (TSD) 40.6(T13.7) 41.5(T13.6)
free non-resistance arm and leg movements. This was 6 min walk 482(T70) 482(T75)
followed by 15 min of pedaling on a bicycle and 20 min of distance/meters(TSD)
circuit resistance training using Evient sequence equipment,
with free weights and elastic rubber-bands (Thera-bands). Etiology
IHD 16 (73%) 18 (85%)
Each session ended with a cool down for 5 min with
AF 4 (18%) 1 (5%)
stretching of the engaged muscle groups. The work load on Valvular 2 (9%) 1 (5%)
the bicycle started with 50% of the peak work load from the Hypertension 0 (0%) 1 (5%)
cardiopulmonary exercise test, and then gradually increased
for each individual as their endurance improved during the Drugs:
ACE-I 5 (23%) 8 (38%)
five months. The resistance in the circuit training started
Beta-blockers 14 (64%) 11 (52%)
with 20 – 25% of 1RM in the muscle groups involved, and Diuretics 19 (86%) 17 (81%)
most of the patients continued to be on the same resistance Statins 4 (18%) 8 (38%)
throughout the study, but a few were on 35– 40% of 1RM at Antiarrythmics 14 (64%) 10 (48%)
the end of the study. The training was supervised by A-II blockers and ARB 10 (45%) 13 (62%)
Aspirin 18 (82%) 20 (95%)
physical therapists. Blood pressure, pulse, oxygen satura-
Nitrates 8 (36%) 7 (33%)
tion, dyspnea, exertion and body weight were measured and
Data presented as mean values(TSD), number of patients and/or percentage.
reported in each session.
EF = Ejection fraction; IHD = Ischemic heart disease; AF = Atrial fibrillation;
In addition to the exercise program, the training group ACE-I = Angiotensin Converting Enzyme Inhibitors; A-II /ARB = Angio-
had three educational lectures, about nutrition, physical tensin II Receptor Blocker.
activity and relaxation.

2.3. Statistical analysis significant difference was found between groups in

VO2peak.
If not otherwise stated, the data is presented as 6 min walk test and muscle strength test. There was
mean T SD. Student’s t-test and Mann Whitney U-test were highly significant improvement in the training group
used to compare values within groups and between groups. compared to the control group in the distance walked on
Statistical significance was defined as p < 0.05. the 6 min walk test ( p = 0.01) and quadriceps muscle
strength ( p = 0.003) (Table 3).
ANP,BNP, LVEF and respiratory function. No significant
3. Results difference was found between groups in the ANP or BNP
concentration in plasma, left ventricular ejection fraction
Demographic data are shown in Table 2. The two groups (LVEF) (Table 3), FVC or FEV1. The mean FVC in the
were comparable at baseline for age, sex, EF, and distance control group at baseline was 3.69 L, and 3.62 L at study
walked on the 6 min walk test. Two patients were excluded closure and in the training group 3.52 L vs. 3.48 L (p = NS).
from the end of study assessment, one because of a car The mean FEV1 in the control group was 2.6 L both at
accident and the other withdrew consent. Both of these study entrance and study closure, and in the training group
patients were in the control group. 2.5 L both at study entrance and study closure (p = NS).
Cardiopulmonary test. Cardiopulmonary test data Quality of life. There was no significant difference
from three patients was excluded from the analysis as between groups in the total score of the quality of life
follows. Two patients in the control group because they questionnaire (Table 3). In the category of exercise capacity,
didn’t complete the minimum four minutes of work load there was significant change in the training group between
on the bicycle, and one patient in the training group measurements, the mean values were 44.0 T-scores at study
because the patient stopped the test early due to entrance vs. 50.2 T-scores at study closure (p = 0.001),
ventricular tachycardia. compared to the control group where the mean values at
Exercise time, and work load on the bicycle improved study entrance were 45.7 T-scores vs. 46.7 T-scores at study
significantly in the training group compared to the control closure (p = NS). This difference was also significant
group (Table 3). Seventeen out of twenty patients in the between groups ( p = 0.01).
training group (85%) that completed the bicycle test Rehospitalization. Twelve months after study closure,
increased their time and work load, compared to five out five patients from the control group and two from the
of twenty one patients in the control group (24%). No training group had been rehospitalized, this increased after
100 S. Jónsdóttir et al. / The European Journal of Heart Failure 8 (2006) 97 – 101

Table 3
Exercise capacity
Control group Training group Between groups
before – after p before – after p p
VO2(L/min) 1.45 (0.36) – 1.52 (0.39) ns 1.28 (0.40) – 1.27 (0.35) ns NS
VO2peak(ml/kg/min) 16.32 (3.10) – 16.87 (4.05) ns 14.92 (3.44) – 14.76 (3.02) ns NS
Exercise time(min) 8.9 (2.15) – 8.9 (2.18) ns 8.2 (2.60) – 9.1 (3.11) 0.01 0.02
Max.HR(beats/min) 122.8 (24.71) – 123.9 (25.59) ns 117.0 (26.33) – 121.1 (24.29) ns NS
Work load(W) 103.8 (25.97) – 104.1 (27.68) ns 88.3 (26.79) – 95.9 (30.36) 0.007 0.03
Work load/k.(W/kg) 1.2 (0.31) – 1.2 (0.38) ns 1.0 (0.31) – 1.1 (0.30) ns 0.04
LVEF(%) 41.5 (13.6) – 43.5 (11.1) ns 41.5 (13.5) – 45.6 (10.3) ns NS
ANP(ngr/L) 53.8 (36.33) – 54.8 (53.92) ns 58.1 (61.31) – 60.9 (40.90) ns NS
BNP(ngr/L) 122.2 (121.8) – 124.5 (154.7) ns 173.2 (180.4) – 171.7 (155.1) ns NS
6 min walk test(meters) 489.2 (66.33) – 494.60 (66.40) ns 489.3 (75.00) – 526.4 (71.90) 0.001 0.01
Muscle strength (kg) 12.8 (2.99) – 13.0 (2.99) ns 11.3 (3.8) – 14.1 (3.2) <0.0001 0.003
QoL (T-score) 42.50 (13.7) – 44.10 (14.04) ns 44.50 (10.4) – 47.55 (8.7) ns NS
Data shown are mean values (TSD). Statistical significance: p < 0.05.
Before are measures at the beginning of the study, and after at the study closure.
VO2 = Oxygen consumption; HR = Heart rate; LVEF = Left ventricular ejection fraction; ANP= Atrial natriuretic peptide; BNP= Brain natriuretic peptide.

twenty eight months, to eleven patients in the control group The lack of significant improvement in the quality of life
and seven from the training group. None of the rehospital- measurements in the training group is a disappointment. On
izations in the training group was due to worsening of heart the other hand, significant improvement in the question-
failure, three hospitalisations in the control group were due naire’s category of exercise capacity was found for the
to worsening heart failure. Two patients in the training training group compared to the control group, which is
group and two patients in the control group had died 28 congruent with other results of our study.
months after study closure. No adverse events occurred during the exercise training,
and all patients in the training group completed the five
month exercise program. Among the patients in the training
4. Discussion group that were rehospitalized within 12 or 28 months after
study closure, none was due to worsening of the heart
Some studies have shown improvement in VO2peak after failure. These facts can imply that supervised physical
exercise training [17 – 19] but others have not [12,20 – 22]. training is safe for CHF patients. Exercise tolerance and
In our study no significant improvement was found in muscle strength improved significantly in the training group
VO2peak, ejection fraction (EF) or ANP and BNP plasma compared to the control group. This outcome is considered
levels. This may imply that the training did not affect left favorable for these patients.
ventricular contractility or cardiac function in general, The lack of improvement in ANP and BNP plasma levels
marked by the atrial- and brain natriuretic peptide plasma in our study fits well with the lack of improvement in other
levels. We found significant improvement in the distance indices of cardiopulmonary function.
walked in the 6 min walk test, muscle strength, and time and
work load on the bicycle ergometer test. The six minute
walk test has been found to be of value in evaluating 5. Conclusion
functional capacity in patients with chronic heart failure
[23,24]. In some studies physical training has not been In conclusion, the main effect of this training program for
shown to improve the walk distance [25], but in others it has patients with CHF is on muscle strength and functional
[26,27]. The significant improvement in the training group capacity. Supervised exercise training can therefore be of
in exercise time, work load on the bicycle ergometer test and value for these patients. The intensity of the training must
distance walked in the 6 min walk test in our study indicates always be customized for each patient, and it must be born
an increase in functional capacity. The strength of the in mind that these patients have poor prognosis and should
quadriceps muscle also increased significantly in the train- be treated with extra care. Further studies are necessary to
ing group, compared to the control group. This occurred evaluate how peripheral improvement is achieved, without
even though the weight/resistance which the patients significant central changes.
worked against in the exercises, increased only slightly
during the five months of the exercise program. We used
isotonic-type resistance exercises, to avoid any training 6. Study limitations
related increase in haemodynamic burden, which has been
reported to be caused by isometric-type resistance exercises Our study has relatively small sample size and included
[28]. only CHF patients in NYHA functional class II or III with
 S. Jónsdóttir et al. / The European Journal of Heart Failure 8 (2006) 97 – 101 101

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