Exercise and Heart Failure
Tami Ward MS, APRN, NP-C, CHFN
October 10, 2013
I have no conflict of interest

Discuss reduced ejection fraction(HFrEF)
and preserved ejection fraction (HFpEF)
heart failure

Examine the role and recommendations of
exercise training in heart failure (HF)

Identify barriers and strategies to
overcome these barriers in the HF
population
Objectives


The definition of HF has now expanded to:
a. HF with reduced ejection fraction
(HFrEF, EF≤40%)
b. HF failure with preserved ejection fraction
(HFpEF EF ≥50%)
c. HFpEF, borderline (EF 41-49%)
d. HFpEF, improved (EF >40%)
Two Types of HF
Definition of Heart Failure
Classification
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
Ejection
Fraction
≤40%
Description
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

The number of patients with HF, as well as the cost to treat
patients with HF, is expected to increase in the future.

All causes of HF must be evaluated, with consideration of
multigenerational family histories and genetic testing.

Risk factors need to be continually addressed when
managing a patient with HF: hypertension, lipid disorders,
obesity, diabetes mellitus, tobacco use, and known
cardiotoxic agents.

There is a clear mortality benefit from using guidelinedirected medical therapy.
Important points regarding HF
management

Anticoagulation should not be used in patients with chronic HFrEF
with no risk factors (atrial fibrillation, thromboembolic event, or
cardioembolic source).

Aim for control of systolic and diastolic blood pressures, as well
as volume status, to treat HFpEF.

Re-evaluate patients with left ventricular EF ≤35%, New York
Heart Association class II-IV, left bundle branch block, and a QRS
≥150 ms for cardiac resynchronization therapy.

HF education, dietary restrictions, and exercise training should
be provided for all patients to enhance self-care.

A HF multidisciplinary team, including a palliative care team,
should be involved when treating patients with advanced HF.
Important points regarding HF
management
Classification of Heart Failure
A
B
C
ACCF/AHA Stages of HF
At high risk for HF but without structural
heart disease or symptoms of HF.
Structural heart disease but without signs
or symptoms of HF.
Structural heart disease with prior or
current symptoms of HF.
NYHA Functional Classification
None
I
I
II
III
IV
D
Refractory HF requiring specialized
interventions.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)
ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
STAGE D
Refractory HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· Control symptoms
· Patient education
· Prevent hospitalization
· Prevent mortality
Drugs for routine use
· Diuretics for fluid retention
· ACEI or ARB
· Beta blockers
· Aldosterone antagonists
Drugs for use in selected patients
· Hydralazine/isosorbide dinitrate
· ACEI and ARB
· Digoxin
In selected patients
· CRT
· ICD
· Revascularization or valvular
surgery as appropriate
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Exercise intolerance due to fatigue and
dyspnea most prominent
 Other S & S:

◦
◦
◦
◦
◦
◦
Paroxysmal nocturnal dyspnea
Orthopnea,
Edema
Worsening dyspnea with exertion or at rest
Tachycardia
Change in weight
Signs and Symptoms in HF
patients

Current Guidelines 2013:
◦ Class I
 Exercise training (or regular physical activity) is
recommended as safe and effective for patients
with HF who are able to participate to improve
functional status
(Level of Evidence: A)
◦ Class IIa
 Cardiac rehabilitation can be useful in clinically
stable patients with HF to improve functional
capacity, exercise duration, HRQOL, and mortality.
(Level of Evidence: B)
Role of Exercise Training in HF





Improvement in exercise capacity after
exercise training due to peripheral
adaptations (increased oxygen
extraction)
Improvement in quality of life
Reduced hospitalizations and mortality
Improved endothelial function
Reduction in catecholamine levels
Benefits with exercise and cardiac
rehabilitation

Three major risk factors: age, presence
of heart disease and intensity of
exercise
◦ Lowest incidence: walking, cycling and
treadmill walking
◦ Least active patients are higher risk
◦ In HF patients, most common events
include: post-exercise hypotension,
atrial and ventricular arrhythmias and
worsening HF symptoms
Risks to exercise






Weight gain > 3 lb in 1-3 days
Drop in systolic BP with exercise
(marked/symptomatic)
NYHA IV (can exercise selective patients)
Complex ventricular arrhythmias
Resting heart rate ≥ 100 bpm
Pre-existing unstable co-morbidities
Relative Contraindications to
Exercise in Stable HF Patients






Progressive worsening of exercise
intolerance (dyspnea at rest)
Ischemia is suspected
Severe AS or severe regurgitant
valvular disease
Acute systemic illness
New onset afib
Acute pericarditis/myocarditis/embolism
Absolute Contraindications to
Exercise with Stable HF
Patients
Aerobic activity such as walking or
cycling
 Frequency – 3-5 days a week or
most days
 Intensity – 55-80% heart rate
reserve with perceived exertion (1114)
 Duration of each session – start at 5
minutes if needed and progress to
30-60 minutes

Exercise Recommendations

Cycling
◦ Allows low level workloads
◦ Easily reproducible
◦ May be safer with orthopedic or balance problems





Walking
Swimming
yoga
Interval training
Flexibility and resistance training
Exercise Recommendations
Patient related
 Social and economic
 Healthcare team/system
 Condition and Therapy related

Barriers and possible solutions







Older age
Low level of education
Low socio-economic status
Minority status
Anxiety and depression
Logistical problems
Lack of motivation, lack of insight into
benefits and lack of time
Patient related Barriers
European Journal of Heart Failure (2012) 14, 451-458
Lack or resources and support
 Lack of reimbursement
 Transportation concerns

Social and Economic Barriers
European Journal of Heart Failure (2012) 14, 451-458
Lack of expertise with heart failure
 Lack of capacity
 Lack of referral
 Lack of education on the importance of
exercise

Healthcare team/system barriers
European Journal of Heart Failure (2012) 14, 451-458
Severity of symptoms
 Level of disability
 Rate of disease progression
 Impact of co-morbidities

Condition and Therapy Related
Barriers
European Journal of Heart Failure (2012) 14, 451-458

Patient related
◦ Optimize heart failure management; manage
co-morbid conditions
◦ Discuss activity at each visit to rehab
◦ Assess preferred mode of exercise
◦ Education; engage patient as partner in
exercise
◦ Screen for depression
Recommendations to overcome
barriers

System and therapy related
◦ Have referral system in place
◦ Educate providers
Recommendations to overcome
barriers

74 year-old male with history of coronary
artery disease; inferior STEMI 2010
(unsuccessful PCI)complicated with
cardiogenic shock and VT; initial EF 25%;
received single chamber ICD
◦
◦
◦
◦
◦
Hypertension
Hyperlipidemia
Osteoarthritis
Ischemic cardiomyopathy
insomnia
Case study

Social History
◦ Never used tobacco products
◦ No alcohol and substance abuse
◦ Retired lawyer

Family History
◦ Father died of sudden death – age 60

Surgical History
◦ Cataracts; ICD implant
Case Study

Medications
◦ Aspirin 81mg daily
◦ Carvedilol 12.5mg twice daily
◦ Lisinopril 20mg daily (now on study drug – NEP
inhibitor)
◦ Furosemide 40mg twice daily
◦ Potassium 20mEq daily
◦ Simvastatin 40mg daily
◦ Meloxicam as needed
◦ Trazadone 25mg at bedtime
◦ Nitroglycerine 0.4mg as needed
Case study
Case Study

Exercise history
◦ Swimmer in high school
◦ Lifeguard at the Officers Club Pool in the Army
Medical Core
◦ Cardiac rehab after STEMI
◦ Resumed swimming after MI
 U.S. Master’s
 Senior Olympics
9 Gold medals
in Kansas
Senior Meet September ‘13
“My Doctor said if I hadn’t been in such good physical
shape from swimming it very likely would have been a fatal
heart attack. Swimming or any kind of exercise saves
lives”.
Find strategies to get patients referred
and enrolled in your cardiac rehabilitation
program
 Use this opportunity to give disease
specific education to the HF patients
 Prescribing exercise for HF patients is
similar to patients without HF
 Partner with your providers to help keep
these patients out of the hospital with
close surveillance of their symptoms.

In Summary
 Thank
You!
Tamra.Ward@Alegent.org