Curr Heart Fail Rep DOI 10.1007/s11897-014-0204-x
SELF-CARE AND HEALTH OUTCOMES (T JAARSMA, SECTION EDITOR)
How Should We Advise Heart Failure Patients on Exercise and What Should We Tell Them? Ewa Piotrowicz & Piotr Orzechowski & Agnieszka Chrapowicka & Ryszard Piotrowicz
# Springer Science+Business Media New York 2014
Abstract The article discusses the problem of motivating and encouraging patients with heart failure to perform regular exercise training. Firstly, the benefits of exercise training are presented, and rational and convincing arguments justifying its implementation in heart failure patients are provided. Secondly, the issue of overcoming barriers to exercise training implementation is considered. Finally, the role of the medical team and family members in supporting patients with heart failure in long-term adherence to recommendations is defined and analyzed. In addition, the article presents various ways of performing exercise training easily. Keywords Heart failure . Exercise training . Counseling strategies
Introduction The beneficial effects of exercise training in heart failure patients are well established. That is why the current worldwide European Society of Cardiology and American Heart Association guidelines recommend exercise training as an important component of heart failure management (class I, level of evidence A) [1••, 2••, 3••]. Despite these facts, many heart failure patients remain physically inactive, and the implementation of cardiac rehabilitation in clinical practice is still very poor [4]. Why is it so? Unfortunately, there are numerous factors that hinder participation in rehabilitation E. Piotrowicz (*) : P. Orzechowski : A. Chrapowicka Telecardiology Center, Institute of Cardiology, Alpejska 42, 04-628 Warszawa, Poland e-mail: [email protected] R. Piotrowicz Department of Cardiac Rehabilitation and Noninvasive Electrocardiology, Institute of Cardiology, Warsaw, Poland
programs. Apart from those resulting from the healthcare system, and socioeconomic reasons, patient-related factors are crucial and most important [5••]. They include lack of patients’ awareness that cardiac rehabilitation is effective. For this reason, patients need to be motivated to practice exercise training to the extent that it would become part of their lifestyle. The article is devoted to the problem of motivating and encouraging patients with heart failure to carry out regular exercise training. The first section emphasizes the benefits of exercise training and we will try to provide rational and convincing arguments to justify its implementation in heart failure patients. In addition, we will present how to perform exercise training easily. Another issue to be discussed is overcoming barriers to exercise training implementation. Finally, it is necessary to define the role of the medical team and family members in supporting patients with heart failure in long-term adherence to recommendations.
Mechanisms by Which Exercise Training Is Beneficial in Heart Failure Patients Currently, physical inactivity is considered a major cardiovascular risk factor [1••, 2••, 3••, 4, 5••, 6, 7••, 8]. Based on published data, we know that in stable heart failure patients well-planned exercise training has beneficial effects on neurohumoral, inflammatory, metabolic, and central haemodynamic responses, as well as on endothelial, skeletal muscle, and cardiovascular function. These phenomena lead to functional capacity improvement, alleviation of symptoms (dyspnoea, fatigue, exercise intolerance), reducing disability, improved quality of life, and reduced hospitalization and mortality rates [6, 7••, 8–10]. All these benefits should be presented and explained to the patient in a simple manner.
Curr Heart Fail Rep
Table 1 contains topics to be discussed with the patients on the individual effects of exercise training and its benefits [10–27]. Apart from these advantages, physical training also has beneficial effects on comorbidities: hypertension, dyslipidemia, diabetes mellitus, obesity, depression, and thus is one of the means of reducing the risk factors [28–49]. Exercise training is a non-pharmacological recommendation in hypertension treatment combined with pharmacotherapy. Antihypertensive properties of regular exercise are well documented [32–40]. Moreover, training modifies lipid profile; in particular, it decreases serum level of triglycerides and has favorable effect on HDL cholesterol levels [28–31]. Training has significant influence on energy expenditure and energy intake (energy balance). The combination of proper training with effective diet is one of the recommended ways of reducing obesity and maintaining lower weight in the long term [41–47]. Published data showed that cardiac rehabilitation produces a significant decrease of glycated haemoglobin (HbA1c) and
thus sufficiently reduces the rate of complications related to non-insulin-dependent diabetes. In addition, exercise training leads to improvement of insulin sensitivity and the reduction of insulin resistance [2••, 48]. It also notably restores self-confidence by gradually limiting anxiety and reducing other depression symptoms. Mental disorders and mood swings, such as depression, are common sources of cardiovascular risk and negatively affect the prognosis after cardiovascular incidents [2••, 5••, 49]. Since physical training requires more endurance and general fitness, it is capable of having positive effects on radical lifestyle changes such as the cessation of smoking. Nevertheless, this mechanism is not obvious. Training has some similarities to smoking since both stimulate the central nervous system and the neurobiological processes in the brain (increasing beta-endorphin level). Training also has an effect on cognitive functioning in smokers (it reduces attentional bias to smoking images, for example) [2••, 50–52].
Table 1 Mechanisms to help explain the beneficial effects of exercise training in heart failure Beneficial effects of exercise training
How to explain this effect to the patient
Effects on ventilation
Heart failure negatively affects the respiratory system. Performing respiratory training may decrease fatigue and breathlessness. “The more you improve the work of your respiratory muscles and lungs, the more oxygen will be taken from the air and thus delivered to your heart, and by this you will make your heart work easier.” While the disease progresses, your muscles tend to become weaker and weaker. If you exercise, they will become stronger, their condition will be better, and you will be stronger too. Your coordination will improve, which will prevent you from falling and risking injuries and bone fractures. In heart failure, the body produces substances which promote inflammation. Regular exercise training creates an effect that stops these harmful substances from being produced. Your blood vessels are lined with endothelium, which makes a protective layer for deeper parts of the vessel wall. In normal conditions, the endothelium produces substances that make vessels dilate and consequently improve the blood flow and organ feeding. In heart failure this mechanism fails. Exercise training brings back the beneficial function of the endothelium. In heart failure, and especially with coexisting arrhythymia, your body is prone to produce tiny blood clots, which may block the blood flow in vessels and result in heart attack or stroke. Exercise training helps to prevent this. Normally, your body is controlled by both the sympathetic nervous system, which is responsible for stress, and the parasympathetic nervous system, which is responsible for relaxation. In heart failure, the work of these systems is impaired. Physical training allows you to restore a favorable balance between these two systems. If you have to mobilize and act effectively, you do it with ease, and when you need a rest, you can relax effectively! In this way, your action will be more efficient. Good functioning of the endothelium (as described above) enables vessels to dilate effectively which results in a better blood supply to the organs. Long-term physical training also leads to the formation of collateral circulation, a network of small vessels, which are a kind of “bridge” connecting the areas before and after stenotic vessels. Better functioning of the endothelium, better blood flow in coronary vessels, beneficial effect on the nervous system, optimal breathing - all this makes physical training reduce arrhythmia, which is perceived by you as “heart palpitations” All the beneficial effects of exercise training will make you more independent and self-sufficient despite the limitations resulting from the disease
Effects on skeletal muscle
Anti-inflammatory effects Effects on vascular endothelial function
Effects on blood clotting
Autonomic functional changes
Anti-ischemic effects
Antiarrhythmic effects
Reduction in age-related disability
Curr Heart Fail Rep
Safety
Table 2 Borg’s rating of perceived exertion scale
Patients should be reassured that exercise training in stable heart failure is safe. Published studies including data from HF-ACTION showed that among stable heart failure patients who were instructed to perform supervised exercise and, later on, were supposed to continue with a home-based unsupervised exercise training, the adverse event rate was comparable to that in the usual care group [1••, 2••, 3••, 7••, 53]. Therefore, these data proved that home-based physical training seems safe for heart failure patients [2••, 3••].
18 19 20
Planning Exercise Training Exercise training should be planned and performed in line with the current guidelines for heart failure patients [1••, 2••, 3••]. Yet, universal agreement on exercise prescription in heart failure does not exist. Thus, a tailored cardiac rehabilitation is recommended, with initial clinical evaluation (among others: lab test, 6-min walking test, cardiopulmonary exercise test), behavioural characteristics, personal goals, and preferences. Training protocols should include the following variables: type (endurance/resistance/ strength/respiratory), intensity (aerobic/anaerobic), method (continuous/interval), duration (time of session), frequency (number of sessions per day/per week) application (systemic/regional), control (supervised/telesupervised/ unsupervised), progression (consider low-level initially, increase if tolerated), and setting (hospital/out-patient/home-based). The following modalities have been introduced for heart failure patients: endurance aerobic, respiratory muscle, and resistance/strength training [2••, 3••, 51, 54].
Endurance Training . In this modality, patients are encouraged to perform a wide range of exercises, such as cycle ergometer, Nordic walking, and walking training[2••, 3••, 54]. The workload assigned to patients should be in line with individual effort tolerance and the following indications. Firstly, the rating of perceived exertion according to the Borg scale should be taken into account (10/20–14/20 are recommended, as indicated in Table 2) [55]. Secondly, the training heart rate is to be set for each patient individually and in accordance with parameters achieved in exercise tests (training heart rate range of 40–70 % HRR (HRR = difference between the basal and peak heart rate during exercise test) [1••, 2••, 3••]. Endurance training duration should be 30–60 min/day with a frequency of at least five sessions per week. The gradual increase of intensity, if tolerated, is the primary aim. The secondary goal is prolonging the exercise session [1••, 2••, 3••, 51, 54].
6 7 8 9 10 11 12 13 14 15 16 17
very, very light very light fairly light somewhat hard hard very hard very, very hard
Resistance/Strength Training In line with the recommendations, tailored resistance/strength training can be performed in heart failure patients. The initial recommended intensity is
SELF-CARE AND HEALTH OUTCOMES (T JAARSMA, SECTION EDITOR)
How Should We Advise Heart Failure Patients on Exercise and What Should We Tell Them? Ewa Piotrowicz & Piotr Orzechowski & Agnieszka Chrapowicka & Ryszard Piotrowicz
# Springer Science+Business Media New York 2014
Abstract The article discusses the problem of motivating and encouraging patients with heart failure to perform regular exercise training. Firstly, the benefits of exercise training are presented, and rational and convincing arguments justifying its implementation in heart failure patients are provided. Secondly, the issue of overcoming barriers to exercise training implementation is considered. Finally, the role of the medical team and family members in supporting patients with heart failure in long-term adherence to recommendations is defined and analyzed. In addition, the article presents various ways of performing exercise training easily. Keywords Heart failure . Exercise training . Counseling strategies
Introduction The beneficial effects of exercise training in heart failure patients are well established. That is why the current worldwide European Society of Cardiology and American Heart Association guidelines recommend exercise training as an important component of heart failure management (class I, level of evidence A) [1••, 2••, 3••]. Despite these facts, many heart failure patients remain physically inactive, and the implementation of cardiac rehabilitation in clinical practice is still very poor [4]. Why is it so? Unfortunately, there are numerous factors that hinder participation in rehabilitation E. Piotrowicz (*) : P. Orzechowski : A. Chrapowicka Telecardiology Center, Institute of Cardiology, Alpejska 42, 04-628 Warszawa, Poland e-mail: [email protected] R. Piotrowicz Department of Cardiac Rehabilitation and Noninvasive Electrocardiology, Institute of Cardiology, Warsaw, Poland
programs. Apart from those resulting from the healthcare system, and socioeconomic reasons, patient-related factors are crucial and most important [5••]. They include lack of patients’ awareness that cardiac rehabilitation is effective. For this reason, patients need to be motivated to practice exercise training to the extent that it would become part of their lifestyle. The article is devoted to the problem of motivating and encouraging patients with heart failure to carry out regular exercise training. The first section emphasizes the benefits of exercise training and we will try to provide rational and convincing arguments to justify its implementation in heart failure patients. In addition, we will present how to perform exercise training easily. Another issue to be discussed is overcoming barriers to exercise training implementation. Finally, it is necessary to define the role of the medical team and family members in supporting patients with heart failure in long-term adherence to recommendations.
Mechanisms by Which Exercise Training Is Beneficial in Heart Failure Patients Currently, physical inactivity is considered a major cardiovascular risk factor [1••, 2••, 3••, 4, 5••, 6, 7••, 8]. Based on published data, we know that in stable heart failure patients well-planned exercise training has beneficial effects on neurohumoral, inflammatory, metabolic, and central haemodynamic responses, as well as on endothelial, skeletal muscle, and cardiovascular function. These phenomena lead to functional capacity improvement, alleviation of symptoms (dyspnoea, fatigue, exercise intolerance), reducing disability, improved quality of life, and reduced hospitalization and mortality rates [6, 7••, 8–10]. All these benefits should be presented and explained to the patient in a simple manner.
Curr Heart Fail Rep
Table 1 contains topics to be discussed with the patients on the individual effects of exercise training and its benefits [10–27]. Apart from these advantages, physical training also has beneficial effects on comorbidities: hypertension, dyslipidemia, diabetes mellitus, obesity, depression, and thus is one of the means of reducing the risk factors [28–49]. Exercise training is a non-pharmacological recommendation in hypertension treatment combined with pharmacotherapy. Antihypertensive properties of regular exercise are well documented [32–40]. Moreover, training modifies lipid profile; in particular, it decreases serum level of triglycerides and has favorable effect on HDL cholesterol levels [28–31]. Training has significant influence on energy expenditure and energy intake (energy balance). The combination of proper training with effective diet is one of the recommended ways of reducing obesity and maintaining lower weight in the long term [41–47]. Published data showed that cardiac rehabilitation produces a significant decrease of glycated haemoglobin (HbA1c) and
thus sufficiently reduces the rate of complications related to non-insulin-dependent diabetes. In addition, exercise training leads to improvement of insulin sensitivity and the reduction of insulin resistance [2••, 48]. It also notably restores self-confidence by gradually limiting anxiety and reducing other depression symptoms. Mental disorders and mood swings, such as depression, are common sources of cardiovascular risk and negatively affect the prognosis after cardiovascular incidents [2••, 5••, 49]. Since physical training requires more endurance and general fitness, it is capable of having positive effects on radical lifestyle changes such as the cessation of smoking. Nevertheless, this mechanism is not obvious. Training has some similarities to smoking since both stimulate the central nervous system and the neurobiological processes in the brain (increasing beta-endorphin level). Training also has an effect on cognitive functioning in smokers (it reduces attentional bias to smoking images, for example) [2••, 50–52].
Table 1 Mechanisms to help explain the beneficial effects of exercise training in heart failure Beneficial effects of exercise training
How to explain this effect to the patient
Effects on ventilation
Heart failure negatively affects the respiratory system. Performing respiratory training may decrease fatigue and breathlessness. “The more you improve the work of your respiratory muscles and lungs, the more oxygen will be taken from the air and thus delivered to your heart, and by this you will make your heart work easier.” While the disease progresses, your muscles tend to become weaker and weaker. If you exercise, they will become stronger, their condition will be better, and you will be stronger too. Your coordination will improve, which will prevent you from falling and risking injuries and bone fractures. In heart failure, the body produces substances which promote inflammation. Regular exercise training creates an effect that stops these harmful substances from being produced. Your blood vessels are lined with endothelium, which makes a protective layer for deeper parts of the vessel wall. In normal conditions, the endothelium produces substances that make vessels dilate and consequently improve the blood flow and organ feeding. In heart failure this mechanism fails. Exercise training brings back the beneficial function of the endothelium. In heart failure, and especially with coexisting arrhythymia, your body is prone to produce tiny blood clots, which may block the blood flow in vessels and result in heart attack or stroke. Exercise training helps to prevent this. Normally, your body is controlled by both the sympathetic nervous system, which is responsible for stress, and the parasympathetic nervous system, which is responsible for relaxation. In heart failure, the work of these systems is impaired. Physical training allows you to restore a favorable balance between these two systems. If you have to mobilize and act effectively, you do it with ease, and when you need a rest, you can relax effectively! In this way, your action will be more efficient. Good functioning of the endothelium (as described above) enables vessels to dilate effectively which results in a better blood supply to the organs. Long-term physical training also leads to the formation of collateral circulation, a network of small vessels, which are a kind of “bridge” connecting the areas before and after stenotic vessels. Better functioning of the endothelium, better blood flow in coronary vessels, beneficial effect on the nervous system, optimal breathing - all this makes physical training reduce arrhythmia, which is perceived by you as “heart palpitations” All the beneficial effects of exercise training will make you more independent and self-sufficient despite the limitations resulting from the disease
Effects on skeletal muscle
Anti-inflammatory effects Effects on vascular endothelial function
Effects on blood clotting
Autonomic functional changes
Anti-ischemic effects
Antiarrhythmic effects
Reduction in age-related disability
Curr Heart Fail Rep
Safety
Table 2 Borg’s rating of perceived exertion scale
Patients should be reassured that exercise training in stable heart failure is safe. Published studies including data from HF-ACTION showed that among stable heart failure patients who were instructed to perform supervised exercise and, later on, were supposed to continue with a home-based unsupervised exercise training, the adverse event rate was comparable to that in the usual care group [1••, 2••, 3••, 7••, 53]. Therefore, these data proved that home-based physical training seems safe for heart failure patients [2••, 3••].
18 19 20
Planning Exercise Training Exercise training should be planned and performed in line with the current guidelines for heart failure patients [1••, 2••, 3••]. Yet, universal agreement on exercise prescription in heart failure does not exist. Thus, a tailored cardiac rehabilitation is recommended, with initial clinical evaluation (among others: lab test, 6-min walking test, cardiopulmonary exercise test), behavioural characteristics, personal goals, and preferences. Training protocols should include the following variables: type (endurance/resistance/ strength/respiratory), intensity (aerobic/anaerobic), method (continuous/interval), duration (time of session), frequency (number of sessions per day/per week) application (systemic/regional), control (supervised/telesupervised/ unsupervised), progression (consider low-level initially, increase if tolerated), and setting (hospital/out-patient/home-based). The following modalities have been introduced for heart failure patients: endurance aerobic, respiratory muscle, and resistance/strength training [2••, 3••, 51, 54].
Endurance Training . In this modality, patients are encouraged to perform a wide range of exercises, such as cycle ergometer, Nordic walking, and walking training[2••, 3••, 54]. The workload assigned to patients should be in line with individual effort tolerance and the following indications. Firstly, the rating of perceived exertion according to the Borg scale should be taken into account (10/20–14/20 are recommended, as indicated in Table 2) [55]. Secondly, the training heart rate is to be set for each patient individually and in accordance with parameters achieved in exercise tests (training heart rate range of 40–70 % HRR (HRR = difference between the basal and peak heart rate during exercise test) [1••, 2••, 3••]. Endurance training duration should be 30–60 min/day with a frequency of at least five sessions per week. The gradual increase of intensity, if tolerated, is the primary aim. The secondary goal is prolonging the exercise session [1••, 2••, 3••, 51, 54].
6 7 8 9 10 11 12 13 14 15 16 17
very, very light very light fairly light somewhat hard hard very hard very, very hard
Resistance/Strength Training In line with the recommendations, tailored resistance/strength training can be performed in heart failure patients. The initial recommended intensity is
