Download Exercise In Chronic Heart Failure

Exercise In
Chronic Heart Failure
Aynsley Cowie
Senior I Physiotherapist, Ayr Hospital
PhD Student, Glasgow Caledonian
University
Overview
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Exercise intolerance in CHF
Effects of exercise
Evidence for exercise training
PhD
Practical implications & advice
to patients
Exercise Intolerance in
Chronic Heart Failure
Why is exercise
tolerance reduced?
Exercise
Intolerance
 peakVO2, due to:
– cardiac output response
– nutritive blood flow to skeletal
muscles
– skeletal muscle abnormalities
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 %type I fibres
mitochondria
capillary density
muscle fibre size
Exercise
Intolerance
Metabolic abnormalities
– early dependence on anaerobic metabolism
– muscle wasting
AEROBIC METABOLISM
ANAEROBIC METABOLISM
OXYGEN IN CELL
OXYGEN ABSENT
GLUCOSE
GLUCOSE
ENERGY
ENERGY
PYRUVATE
PYRUVATE
ENERGY
CO2 & H2O
NO ENERGY
LACTATE
Exercise
Intolerance
Early respiratory muscle de-oxygenation
& fatigue
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excessive ventilatory effort
inefficient ventilation
V/Q mismatch
higher breathing frequency
Acidity of blood
Early activation of muscle ergoreflex
  Health-related Quality of Life
Proposed Effects of
Exercise in Chronic Heart
Failure
Effects of Exercise
15-20%  peakVO2, due to:
– cardiac output response
• modest  in heart rate & stroke volume
• diastolic filling at peak exercise
– changes to skeletal muscle
• nutritive blood flow to skeletal muscles
• O2 extraction
• mitochondria
Effects of Exercise
Improved metabolic functioning
– reliance on anaerobic metabolism
ventilatory efficiency
 neuro-endocrine activity
 sympathetic nervous system activity
Effects of Exercise
Therefore:
• exercise tolerance
• symptom severity
• improved NYHA class
• improved quality of life
……….without:
•  in central haemodynamics
•  unfavourable LV remodelling
But, no clear evidence regarding effects on prognosis
Evidence to Support
Exercise Training in
Chronic Heart Failure
Evidence
• Patients historically advised to restrict
physical activity to reduce circulatory
demands
• Coats et al (1990): first RCT to conclude
that exercise actually improves fitness,
symptoms and quality of life of those
with CHF
Evidence
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NICE 5 (2003): Both aerobic & resistive exercise will
improve symptoms, exercise performance & quality of life
without deleterious effects on central haemodynamics
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SIGN 57 (2002): Patients with chronic heart failure
should considered for comprehensive cardiac rehabilitation
if they have limiting symptoms
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European Society of Cardiology (2001): Exercise
training…..can increase exercise capacity in compensated
stable chronic heart failure patients
Literature Search
Search Criteria:
• published in 2000 or more recently
• published in English
• evaluating a specific programme of
training
• including exercise capacity &/or
quality of life outcomes
45 studies found (August 2006)
Literature Search
7 studies were non-controlled, most conducted out with UK
Samples:
• Generally small but widely ranging (6-200), mean n=44
• Mean age ~60y
• Women tended to be excluded
• Most included those of NYHA II & III
Location:
• Most evaluated hospital-based programmes
• Home programmes as effective as hospital programmes
• None compared home versus hospital programmes
Literature Search
Mode:
• Most trials incorporated cycling in training
• Many very equipment-orientated
• Very few evaluated resistance training
• Those using home walking demonstrated least
improvement in exercise capacity
Literature Search
Frequency:
• 3 x week or more is required for benefit
Length:
• Should be at least 8 weeks
• None examine longer programmes / if effects are sustained
Duration:
• Conditioning of <30 minutes = least effect on exercise capacity
Intensity:
• 60-70% peakVO2 for best effect on exercise capacity
Literature Search
Conclusion:
• Small samples, excluding elderly and women
• Home walking programmes were least effective
• None compared effects of home- & hospital-based
exercise
• Training mode was equipment-orientated
• Most evidence advocates training at least 3 x week for
at least 30 minutes (plus warm-up and cool-down)
• Best outcomes achieved if intensity set to 60-70%
peakVO2
• Few evaluated resistance training
A Study Comparing Effects of Home and
Hospital-based Exercise on Exercise
Capacity and Quality of Life of Patients
with Chronic Heart Failure
Aims:
To determine effects of hospital- versus home-based
exercise training (versus “usual care”) on exercise capacity
and quality of life of patients with CHF
To determine patients’ perceptions of the effects of homeversus hospital-based exercise training
Design
Pre-test measurement
of exercise capacity &
quality of life
Randomisation
Hospital-based
exercise
Focus groups to
examine
perceptions of
effects of training
Home-based
exercise
Control group
Post--test measurement
of exercise capacity &
quality of life
Sample
n=60 (45)
Recruitment from Heart Failure Nurse Liaison Service &
Cardiology clinics
Inclusion Criteria:
• Diagnosis of LVSD by echo
• Sufficiently clinically stable for exercise (3-4 weeks)
• Willing to participate
Exclusion Criteria:
• Other life threatening illness
• Unable to participate due to major cognitive impairment
Contraindications
Absolute
• Progressive worsening of exercise tolerance / SOB over
past 3-5 days
• Significant ischaemia at low work rates
• Uncontrolled diabetes
• Acute systemic illness or fever
• Recent embolism / thromboembolism
• Active pericarditis / myocarditis
• Moderate to severe aortic stenosis
• Regurgitant valvular heart disease requiring surgery
• MI within past 3 weeks
• New onset AF
(European Society of Cardiology, 2001)
Contraindications
Relative
• >1.8kg in body mass over previous 1-3 days
• Concurrent dobutamine therapy
• Decrease in SBP with exercise
• NYHA class IV
• Complex ventricular arrhythmias at rest, or with exertion
• Supine resting heart rate >100bpm
• Pre-existing co-morbidities
• Poorly controlled AF
(European Society of Cardiology, 2001)
Exercise Interventions
Hospital-based:
• Physiotherapist led classes
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Home-based:
Prescribed by physiotherapist
DVD & home exercise booklet / diary & Heart rate monitor
3 follow-up phone calls from physiotherapist
Both:
• 8 weeks duration, 2 x week, 1 hour per session
• Each session: 15 minute warm-up, 30 minute functional
aerobic circuit exercises (interval training), 10 minute cool-down
Control:
• General physical activity advice
Outcomes
Exercise Capacity:
• Shuttle / 6 minute walk depending on pilot results
Quality of Life:
• Literature suggests generic & disease-specific questionnaire
• Minnesota Living with Heart Failure & SF-36 most valid &
reproducible
Perceptions of Effects of Exercise:
• Home- and hospital-exercisers kept separate
• 2-3 group of each (6-7 participants per group)
• Previous exercise experience, expectations, perceived effects of
exercise, barriers / facilitators, future exercise ambitions
Methodology
n=60 participants recruited
from Heart Failure Nursing
Service & Cardiology Clinics
Pre-test measurement of exercise capacity (by shuttle/6 minute walk) &
quality of life (Minnesota & SF-36)
Randomisation
8 weeks
Hospital-based
exercise
Control
Home-based
exercise
Post-test measurement of exercise
capacity (by shuttle/6 minute walk) &
quality of life (Minnesota & SF-36)
2 or 3 focus groups to examine
perceptions of effects of training
2 or 3 focus groups to examine
perceptions of effects of training
Plan…...
•Final amendments to be made for
ethics
•Data collection planned for Spring
2007-Spring 2008
Practical Implications for
Patients Attending
Rehabilitation
Advice for Patients
Patient Evaluation
• Referrals from clinics, cardiologists / other consultants, GPs
or other health professionals
• Good recruitment protocol with agreed criteria &
contraindications
• Heart failure must have been stable for around 3-4 weeks
• Patients of NYHA I to III are eligible - ?some stable class IVs
• No lower limit to ejection fraction
• Don’t wait for optimisation of medications
• Any arrhythmias should be as well controlled as possible
Patient Assessment
Subjective:
• Gauge “normal” heart failure symptoms
• Threshold for ICDs
• Status of up-titration
• Are they checking their weight regularly?
Objective:
• Weight if not self-monitoring
• BP and resting heart rate
• ?recent ECG
• Measurement of functional capacity
• Measurement of quality of life
Exercise Session
• Warm-up: 5-15 minutes
• Conditioning: 10-30 minutes aerobic
exercise alternated with active recovery
• Cool-down: 5-10 minutes
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Seated exercises where appropriate
Should be tailored to the individual
Resistance training can be included
Exercises will be symptom limited
Borg RPE rating should be 12-13
Borg RPE
6
7
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15
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20
No exertion
Very, very light
Very light
Light
Somewhat hard
Hard
Very hard
Very, very hard
Maximum exertion
Exercise Session
• May not be able to achieve target heart rate
• Heart rate may have to be adjusted as medications
(blockers) are up-titrated
Common problems
• Symptomatic low BP
– check drug dosages / timings
• Increase in symptoms
– ?overloaded (weight gain)
– ? blockers initiated or up-titrated
Exercise Session
Safety
• Higher risk patients - staff ratio should be 1:5
• Some patients may require 1:1
• SCD common
• Rare in CHF English CR programme (Wythenshawe)
N.B.
• Good and bad days - exercise prescription may change
(erratic attendance)
• Remember fluid restriction when encouraging intake
• Gout is common 2° to diuretics
Home Exercise
Too unfit for class?
• Short daily sessions of 5-15 minutes
• Simple programme (?e.g. chair programme / pedals)
• As fitness improves, increase duration of session &
reduce frequency to once per day
• Start to increase pace to brisk (12-13 on Borg scale)
• With further improvement, aim to gradually build up
to accumulation of 30 minutes moderate intensity
activity most days
General Physical
Activity Advice
• Do any activity that you enjoy & are used to doing,
unless you have been told otherwise
• Physical activity is safe if you start slowly & build up
gradually
• Always exercise within limits of your symptoms
• If you use GTN spray or tablets for relief of angina,
keep this to hand
• If you wish to try a new activity, it’s probably best
to check with a health professional first
General Physical
Activity Advice
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Remember you may have good & bad days
Avoid sudden bursts of intense activity
Always start & end your exercise at a lower pace
Take care when exercising in extremes of temperature,
or windy weather
• Avoid exercising directly after a large meal
General Physical
Activity Advice
• Rest if you have a sore throat, cold, flu, infection /
temperature, or if your heart failure suddenly worsened
• Restart your programme at an easier pace
• If you experience severe chest pain, undue shortness of
breath, palpitations, nausea, dizziness, or excessive
tiredness during exercise, do not continue - speak to your
GP or nurse about this!
Swimming
• Head-up immersion & hydrostatically-induced volume shift
• LV volume loading & heart volume
• Physiological effects for easy paced swimming =
intense cycling
• 2001 guidelines state that patients should refrain
• More recent advice: compensated patients can swim
• Swim if they are stable & are used to swimming highlight that abilities may be reduced in water (build
up gradually)
Thank You
Any Questions?
References &
Bibliography
ACPICR (2006) Standards for the Exercise Component of Phase III Cardiac
Rehabilitation. London: ACPICR
European Society of Cardiology (2001) Recommendations for Exercise Training
in Chronic Heart Failure Patients. European Heart Journal 22: 125-135
Coats et al (1990) Effect of Physical Training in Chronic Heart Failure. The
Lancet 335: 63-66
National Institute for Clinical Excellence (2003) Chronic Heart Failure. London:
Clinical Guideline No. 5
Scottish Intercollegiate Guidelines Network (2002) Cardiac Rehabilitation.
Edinburgh: SIGN 57
Pilot Study
A Study Comparing Validity & Reproducibility
of the Shuttle Walk Test and 6-minute Walk
Test in Chronic Heart Failure
Why?
• Inconsistent research examining validity and reproducibility
of the walking tests
• Literature lacks standardisation of methodology
• Most studies conducted out with United Kingdom
• Studies use small samples, excluding women and elderly
Pilot - Methodology
n=28 participants recruited from
Heart Failure Nursing Service
Randomly familiarised with 1 walking test
Treadmill cardio-pulmonary exercise test - STEEP protocol
6 x walking tests (3 x shuttle, 3 x 6 minute walk) - 1 per week
Participants undertake walking test familiarised with first
Comparisons
between data
from walking tests
& treadmill
ANALYSES OF
WALKING TESTS’
VALIDITY
Comparisons
between data from
3 attempts of each
walking tests
ANALYSES OF
WALKING TESTS’
REPRODUCIBILITY
Comparisons between
reproducibility of tests
familiarised with against those not
ANALYSES OF
EFFECTS OF
FAMILIARISATION
Pilot - Sample
Recruitment from Heart Failure Nurse Liaison Service
Inclusion Criteria:
• Diagnosis of LVSD by echo
• Sufficiently clinically stable for exercise
• Willing to participate
Exclusion Criteria:
• Other life threatening illness
• Unable to participate due to major cognitive impairment
Progress so far…..
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Recruitment slow!
Patients need to be optimised on medication
Problems with treadmill testing criteria - LBBB
Patients reluctant to enrol in “serial testing”, reluctant
to travel, reluctant to attend after 4.30pm
• Recruitment extended to include those attending
Cardiology clinics & attending for echo
Data on 7 patients collated to date!
Hope++ to complete by Spring 2007