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By Benjamin Jose Celestino Quito, M.D.

HEART FAILURE

It is a common misconception that patients with heart failure should avoid any type of exercise. A lot of heart failure patients often have a long line of medications that they need to be adherent. Most of them are dependent on diuretics to relieve symptoms and signs of congestion. If they are on long term diuretic therapy, these heart failure patients may have derangements in electrolyte balance such as hypokalemia. They often feel dehydrated and weak when they are over-diuresed. Often their quality of life is affected due to the symptoms that they experience. A sedentary lifestyle contributes to the development of heart failure. Some of them become depressed and would not exercise. They are unable to go back to their work or usual activities.

Thus, most of them suffer a low self-esteem. It is not only their heart that ails, but their total well being as well. Most of them are afraid to return to their usual activities of daily living. They need to be guided on the right type of exercise regimen that they should engage in.
According to the HF action trial reported at the 2008 AHA meeting, cardiac rehabilitation has shown to reduce overall morbidity and mortality. Cardiac rehabilitation has been shown to be safe in heart failure patients. Long-term exercise also have been shown to form collaterals, or new blood vessels. Patients with blocked vessels may benefit from this, for this could be a “natural bypass” tract for them, supplying blood to diseased areas of the heart.

The first rule before these patients start an exercise regimen is that they should be on optimal medical therapy. A heart failure patient usually has a standard regimen that they follow. They should not be in frank congestion. They should be able to lie flat in bed and have no dyspnea at rest.
The cause of the heart failure should also be determined. Generally, it could be ischemic or non-ischemic. In patients with ischemia, or “blocked arteries”, revascularization in the form of angioplasty or bypass might be recommended depending if there is an indication based on diagnostic findings. The Stanford Coronary Risk Intervention Project (SCRIP) revealed that the mean rate of plaque progression is decreased when exercise training is combined with risk factor modification. Some important risk factors that can be modified are smoking, alcohol drinking, and diet.

Among the non-ischemic causes are those with dilated cardiomyopathy. In simple terms, they have large hearts with decreased pumping action. Usually they have normal angiogram findings. No blocked arteries are involved.

Different centers have different programs and regiments for heart failure. At the Philippine Heart Center, supervised exercise training is being implemented. Patients usually engage in brisk walking sessions for approximately 30 minutes, depending on their exercise capacity. Then arm ergometry or “arm bicycle” is done for 15 minutes. Then, aerobic exercise are done by the patient, which is supervised by physical therapists. Patients should be encouraged to progressively increase exercise duration, as tolerated, until they are able tolerate one bout of 30 minutes or more. A treadmill stress test is usually done at middle of the session to assess functional capacity and progress.

For heart failure, a home-based program is usually not advised. There should be supervision by trained personnel who are well knowledgeable in handling emergency situations. High intensity exercises such as jogging and swimming should be avoided by heart failure patients. In jogging, the heart failure patient is exposed to different environmental factors such head wind, slopes, and temperature that may give added stress to the cardiovascular system. During swimming, there is a hydrostatically induced volume shift which increases left ventricular volume and pulmonary capillary wedge pressure. Thus, heart failure patients with problems in contraction (systolic dysfunction) and relaxation (diastolic dysfunction) should refrain from swimming. Heart failure patients should only undergo light to moderate exercises such as stretching, arm or leg ergometry, and brisk walking. The exercises should first be done in cardiac rehabilitation centers.

In summary, light to moderate exercises should be encouraged in heart failure patients. They must be properly advised by cardiac rehabilitation patients. They must be hemodynamically stable first, before they start an exercise program.

Based on evidence, cardiac rehabilitation is beneficial for cardiac rehabilitation patients. Thus, physicians and patients should be properly educated on the benefits of cardiac rehabilitation.