Exercise benefits all, but compliance an issue

As we become more effective at treating heart attacks and other forms of heart disease, patients with heart disease are living longer, and as they age, they may be at increased risk of developing heart failure. Currently about five million Americans have some degree of heart failure, and this number is projected to rise significantly as the baby boomer population ages.

Fortunately, over the last decade we’ve made major advances in treating the disease with medication. Until recently, exercise was not considered an option for these patients. Heart failure patients have damaged hearts that fail to pump blood adequately. Just as the severity of heart attacks varies, so does the severity of heart failure. People may experience relatively mild cases and feel discomfort only after vigorous exercise, or they may have trouble breathing and feel weak after walking across a room.

This study only reviewed trials that included patients who were able to enter exercise programs that entailed some level of aerobic effort. There are some severely ill patients who are not able to exercise enough to meet the study’s criteria, but most heart failure patients can exercise to some degree.

Customized programs safest approach
At the Yale Congestive Heart Failure program, we tailor our exercise recommendations to the specific needs and condition of each patient. Safety is a primary consideration. Patients with heart failure should always talk with their doctors about beginning a formal exercise program and seek their assistance on doing it safely.

There isn’t any one size fits all program. Some people with heart failure, including those with unusual heart rhythms, may need to be monitored during exercise. Others may be able to exercise safely at home after they have undergone a supervised training program. Stationary bicycles may be too strenuous for some. Swimming is usually not recommended since immersion in water can result in shifts in body fluids that can be detrimental for some patients.

We refer some patients to formal cardiac rehabilitation programs, but unless there’s underlying coronary artery disease, insurance programs may not cover exercise programs.

For many patients, a regular walking program is the safest solution. Walking at a comfortable pace three or four times a week can have a definite beneficial effect on how patients feel. Exercise is particularly important for heart failure patients since improved conditioning makes it possible for them to go about their normal daily routines more easily and helps them remain independent longer.

There’s no question that exercise is beneficial not just for heart failure patients, but for all of us. Exercise provides a host of physiological benefits, including improved blood vessel function and improved muscular function. Exercise may also improve the flow of oxygen to muscles and lower levels of hormones that can contribute to heart failure symptoms.

Motivation: a challenge for all
The challenge is motivation. Only about a half of our patients comply with our exercise recommendations. The national obesity epidemic is clearly related to a decrease in physical activity. Exercising just 40 to 50 minutes three or four times a week can help people shed up to 5 percent of their body weight without changing eating habits, but clearly, in spite of all of the positive press, most people aren’t exercising regularly.

Limitations of the study
The study in the BMJ does have some limitations. There were a relatively small number of patients (395) in the exercise group, fewer women (11.6%) and few patients who had other illnesses in addition to their heart failure. In addition, it may be that patients who comply with exercise programs tend to take better care of themselves overall. It’s difficult to draw any specific conclusions about outcomes from this research.

It’s clear we need larger, longer-term trials to clarify the role of exercise and how it affects outcomes in a wide variety of patients. The National Institutes of Health is currently conducting a large multicenter trial that hopefully will provide us with more definitive information. The Yale Congestive Heart Failure program is participating in this study.

Dr. Katz is the director of the Yale Congestive Heart Failure Program, a cardiologist at Yale-New Haven Heart Center and Yale-New Haven Hospital, and associate professor of internal medicine at Yale.