Abstract and Introduction
Abstract
The practical management of heart failure remains a challenge. Not only are heart failure patients expected to adhere to a complicated pharmacological regimen, they are also asked to follow salt and fluid restriction, and to cope with various procedures and devices. Furthermore, physical training, whose benefits have been demonstrated, is highly recommended by the recent guidelines issued by the European Society of Cardiology, but it is still severely underutilized in this particular patient population. This position paper addresses the problem of non-adherence, currently recognized as a main obstacle to a wide implementation of physical training. Since the management of chronic heart failure and, even more, of training programmes is a multidisciplinary effort, the current manuscript intends to reach cardiologists, nurses, physiotherapists, as well as psychologists working in the field.
Introduction
It has taken exercise training 20 years to evolve from an experimental setting to a Class I recommended non-pharmacological treatment for all stable heart failure (HF) patients. Patients clearly benefit from regular physical activity by tackling the hallmarks of the syndrome, such as early fatigue and dyspnoea with exertion. The positive effects in patients with HF and reduced ejection fraction (HFREF) have been well established since the 1990s. Evidence has recently emerged that HF patients with preserved ejection fraction (HFPEF) equally improve their physical capacity following exercise training.
There is robust evidence that chronic heart failure (CHF) patients who engage in exercise training increase their peak aerobic and submaximal exercise capacity, mainly by reversing peripheral abnormalities, such as endothelial dysfunction, skeletal muscle wasting, and ventilatory inefficiency. Despite initial concerns, aerobic exercise training also favourably affects left ventricular remodelling. Nevertheless, implementation in clinical practice is still very poor.
The delivery of compelling data on the effects on mortality, morbidity, safety, and quality of life, as well as on the feasibility, is instrumental to facilitate the transition from selective implementation to a more general adoption of exercise training.
Because most of the published randomized studies until recently reflect small single-centre experience, confirmation of the benefits of exercise training in CHF had to be derived from meta-analyses. Clearly, the results of the 'Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training' (HF-ACTION) trial were eagerly awaited. In this trial 2331 HF patients were randomized either to an aerobic exercise training or a usual care group in order to determine whether the intervention is able to reduce all-cause mortality or all-cause hospitalization and to improve quality of life. Disappointing at first sight, after a median follow-up of 30 months, exercise training led only to a non-significant 7% reduction in all-cause mortality or hospitalization. However, after adjustment for pre-specified major prognostic factors, the composite primary endpoint was significantly reduced by 11% [adjusted hazard ratio 0.89 (95% confidence interval) 0.81–0.99], P = 0.03).