Primary Care Corner with Geoffrey Modest MD: Vigorous Exercise Helps Those with Heart Failure

By Dr. Geoffrey Modest

There was a recent systematic review/meta-analysis finding that in patients who have heart failure with reduced ejection fraction, vigorous exercise training significantly improved their quality of life (see DOI: 10.1159/000448088).
Details:

• 25 studies were included with 2385 participants (1223 exercising and 1162 controls) [of note, 8 of these studies had <30 patients, and 6 studies had >100]
• They used the Minnesota living with heart failure total score (MLWHF), a 6-part inventory, all graded 0 to 5, assessing physical and emotional symptoms. A 5-point change is considered clinically meaningful.
• They did not specifically define the different exercise groups, but an example of high-intensity is cycling 45 minutes at 90% peak work three days per week. An example of vigorous-intensity exercise was cycling for 30 minutes at 60-70% peak VO₂ three times a week. An example of moderate-intensity exercise was 15 minutes of cycling and 15 minutes of treadmill at 50% peak VO₂ three times a week.

Results:

• MLWHF total score was significantly reduced after high-intensity (mean difference -13.74, P=0.0004) and vigorous-intensity training (mean difference -8.56, P<0.0001). No difference with moderate-intensity training.
• Significant differences were noted with aerobic training (mean difference -3.87, p=0.01) and combined aerobic and resistance training (difference -9.82, p=0.001), but no difference with resistance training alone.

Commentary:

• There was concern many years ago that vigorous exercise might put too much stress on the heart in those with heart failure. This changed considerably over the past several years, as some of the above studies came out.
• Review of the forest plot in the above article, which displays the individual studies, found that in all 3 studies where high-intensity exercise was done there was statistically significant benefit; those looking at vigorous-intensity training were pretty consistently favoring the exercise group, with only one study finding statistically significant benefit in the control group (and, that study included only 60 patients, out of a total of 924 overall)
• This study, as well as some other recent ones, suggest that there is more general benefit with the combo of aerobic and resistance training (i.e., not just aerobic)
• So, I think this analysis confirms that we should encourage exercise in patients with heart failure and reduced ejection fraction, and that patients should anticipate improved physical and emotional symptoms as they progress to higher intensity exercise. Of course, those with potentially ischemic symptoms should have an appropriate workup prior to beginning an intensive exercise program.