Exercise Helps in Heart Failure Regardless of Baseline Activity

Megan Brooks

November 30, 2018

Patients with stable chronic systolic heart failure (HF) benefit from aerobic exercise training (ET) regardless of their baseline level of physical activity, a secondary analysis of the HF-ACTION trial suggests.

"This message probably applies as well to patients across a wide range of baseline fitness levels, although we did not specifically address this question," Jerome L. Fleg, MD, National Heart, Lung, and Blood Institute, National Institutes of Health, told theheart.org | Medscape Cardiology. "Thus, patients with stable heart failure should be highly encouraged to participate in regular aerobic exercise, ideally via a supervised cardiac rehabilitation program."

The study was published online November 26 in JACC: Heart Failure.

The two authors of a linked editorial say this study "communicates a very important clinical message: all stable patients with chronic HF should be motivated to participate in ET programs, regardless of their habitual [physical activity] level."

Benefits for All

In the HF-ACTION trial, ET was associated with improved symptoms in patients with HF and reduced all-cause mortality and hospitalizations, as well as cardiovascular (CV) mortality and HF hospitalization.

ET consisted of a series of supervised walking or stationary cycling 3 days per week, followed by home-based exercise, ideally performed 5 days per week for 40 minutes per session at 60% to 70% of heart rate reserve.

The researchers used the HF-ACTION trial data to see if habitual baseline level of physical activity can predict benefits from ET programs. Of the 1494 study participants with complete baseline physical activity data, 742 received usual care and 752 received ET.

Exercise capacity — assessed with peak VO₂, cardiopulmonary exercise test duration, and 6-minute walk test distance — was higher for participants in the highest tertile for baseline physical activity than for those in the middle and lowest tertiles.

Patients in the highest tertile also had a more favorable clinical profile — including lower New York Heart Association functional class, lower Beck depression score, and lower atrial fibrillation prevalence — than patients in the lowest tertile.

Our results suggest a similar salutary response to exercise training regardless of baseline activity level.

High baseline physical activity also correlated with better clinical outcomes during long-term follow-up. Compared with the lowest physical activity tertile, the middle tertile had an 18% lower risk for CV death/CV hospitalizations, and the highest tertile had a 23% lower risk for CV death/HF hospitalizations in adjusted models.

Exercise capacity and clinical outcome responses to ET were "similar and largely nonsignificant" across baseline physical activity tertiles, with significant benefit of ET on exercise test duration for all tertiles.

In the ET group, significant benefits for cardiopulmonary exercise test duration after 3 and 12 months were observed in all tertiles of baseline physical activity. Further parameters of exercise capacity (VO₂ peak, 6-minute walk test distance) and clinical outcome responses to training were similar and largely nonsignificant across baseline physical activity tertiles.

ET in these stable chronic HF patients also proved safe, with no significant differences in CV event rates among the tertiles.

"Although some studies have examined the relation between baseline activity levels and response to exercise training in patients with stable coronary artery disease, this is the first study to our knowledge to examine this relation in patients with chronic heart failure," Fleg told theheart.org | Medscape Cardiology.

"Our results suggest a similar salutary response to exercise training regardless of baseline activity level," he added.

Long-term Compliance Challenging

However, it's challenging to institute ET programs that achieve long-term effects into clinical practice, Rainer Hambrecht, MD, and Harm Wienbergen, MD, Bremer Institute for Heart and Circulation Research, Klinikum Links der Weser, Bremen, Germany, note in their editorial. In the HF-ACTION trial, for example, adherence to ET was suboptimal, they point out.

Modern strategies — such as telemetric control of physical activity with wearable step counters and accelerometers and repeated interaction with others — can help to achieve better long-term results from ET programs, they write.

For example, in the recently published Intensive Prevention Program (IPP) trial, a novel program for MI patients coordinated by prevention assistants and using personal teaching and telemetric strategies for 12 months was significantly better than usual care in providing sustainable risk factor control and better quality of life, they note.

Hambrecht and Wienbergen say these types of programs "should be provided to all stable patients with HF, those who are sedentary as well as those who are already active in daily life."

The study by Fleg and colleagues "increases evidence for the concept that every HF patient, regardless of habitual [physical activity] level, profits from structured exercise interventions. This message should be communicated to the patients to enhance motivation and increase adherence to ET programs," the editorial writers conclude.

The study was supported by the National Heart, Lung, and Blood Institute. The authors and editorialists have disclosed no relevant financial relationships.

JACC: Heart Failure. Published online November 26, 2018. Abstract, Editorial

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