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Exercise right prescription for heart failure patients

July 1, 1993

Exercise right prescription for heart failure patients

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DALLAS—Exercise is good medicine for heart failure patients—even while they await heart transplantation—according to a new statement from the American Heart Association published in a recent print issue of Circulation: Journal of the American Heart Association.

Heart failure is a bit of a misnomer. The heart does not completely fail, but rather its ability to pump blood to other organs is compromised. As a result, patients experience fatigue and can’t exercise without discomfort.

“It seems counterintuitive, but walking, biking, swimming, dancing—all kinds of aerobic exercises—can help improve the patient’s sense of well-being,” says Ileana Pina, M.D., chair of the writing group from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention that drafted the position statement.

Heart failure is soaring along with America’s aging population. In 2000, almost 5 million people were living with heart failure.

The writing group undertook a comprehensive review of medical literature on exercise in the heart failure patient. They conclude that it is safe, beneficial and improves patients’ quality of life. The position paper will guide health professionals to better understand the exercise limitations of heart failure patients and direct them to engage in physical activity.

According to Pina, exercise can help heart failure patients in several ways:

n It improves the tone and lining of the blood vessels. “That’s important because the lining often does not behave properly in heart failure patients,” she says.

n It drops levels of neurohormones such as adrenaline that are inappropriately elevated in people with heart failure and can contribute to symptoms. Often, a higher level of such neurohormones means a worse prognosis, Pina says.

n It improves the muscle’s ability to pull out oxygen, which it needs.

“Patients who exercise report they can do more before getting symptoms and that they can better perform activities of daily living such as making the bed or getting a newspaper,” says Pina, a professor of medicine at Case Western Reserve University and director of the heart failure and transplant program at University Hospitals of Cleveland.

Because previous studies do not agree on a universal exercise prescription for heart failure patients, an individualized approach is recommended.

n “The patient should start slowly and build up gradually,” Pina says. “We generally recommend 20 to 30 minutes of aerobic exercise three to five times a week.”

The most debilitated patients may need a longer warm-up period. Usually, a period of 10 to 15 minutes is recommended. A cardiac rehabilitation program can help establish a safe exercise routine, she says.

The most important thing, Pina says, “is never to sit back and do nothing. That’s what patients were told back in the ’50s, ’60s and ’70s, and even now, some doctors tell their patients they should rest. But there is no showing that resting helps a person’s condition.”

The American Heart Association statement, besides being a first step in getting heart failure patients back on track, also notes areas for future research, such as finding out how exercise impacts survival and if there is any subgroup of heart failure patients for whom exercise is dangerous.

Pina says a landmark trial to investigate these concerns would begin enrolling patients in March. In the study, 3,000 patients with Stage II to Stage IV heart failure will be randomly assigned either to enter a formal exercise program at a cardiac center or to receive education, including the advice on the need to stay active, without a formal program. Stage IV is the worst type of heart failure, with patients often unable to cross a room without discomfort.

“This will hopefully give us the answers we are seeking,” Pina says. “If exercise is shown to have a beneficial impact on survival and hospitalization rates, it will really be a cost-effective, low-tech approach to helping these patients.”

Other members of the writing group are Carl S. Apstein, M.D.; Gary Balady, M.D.; Romualdo Berlardinelli, M.D.; Bernard R. Chaitman, M.D.; Brian D. Duscha; Barbara J. Fletcher, R.N.; Jerome L. Fleg, M.D.; Jonathan N. Meyers, Ph.D.; and Martin J. Sullivan, M.D.

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