Exercise in chronic heart failure

Åsa CiderMed. Dr, leg sjukgymnast

SU/Sahlgrenska

Chronic heart failure (CHF) a syndrom without perfect definition

Prevalence

0,3 – 2% in different populations Increase with age 10 % vid 80 år

Prognosis

Five years survival 50%

Cowie et al. Eur Heart J

1999;18:208-25

Diagnosis

Symptoms of CHF, typical are dyspnoea and fatigue at rest and during exercise

Objective signs of heart dysfunction at rest

Improved by medication

Remme, Swedberg. Eur Heart J;

2001;22: 1527-60

Chronic heart failure (CHF)

Adapted from Andersson, 2002

Energy consumption

Nutrition deficit Cellular death

Vaso-constrictionSalt-water retention

Heart frequencyContractility

Cardiac hypertrofi

Sympathetic nervous systemRenin-angiotensine system

Cardiacfunction

Cardiac outputCardiac outputAfterloadPreload

Why ?

Should patients with CHF exercise?

Peripheral changes lead to deconditioning

Coats et al 1996

Effects of exercise in patients with chronic heart failure Increased VO2 and work rate Increased gait velocity Increased muscle function Reduced levels of sympathetic hormones Increased endothelial function Symptom reduction and increased quality

of life

Eur Heart J 2001;22:125-35.

Juenger et al. Heart 2002;87:235-41

QoL is reduced in Chronic heart failure (CHF)

Juenger et al. Heart 2002;87:235-41

Who?

Should all patients with CHF exercise?

Patients with CHF

Stable CHF

NYHA I-III

NYHA IV?Eur Heart J 2001;22:125-35.

Circulation 2003;107;1210-25

Cochrane;2004

How?

Should patients with chronic heart failure exercise?

Any bodily movement produced by skeletal muscles that result in energy expenditure.

A subset of physical activity that is planned, structured, repetitive, and purposeful in the sense that improvement or maintenance of physical fitness is the objective

Physical activity Exercise

Casparsen, C. Public health report. 1985

The principles of training

The principle of individuality

The principle of specificity

The principle of disuse

The principle of progressive overload

The principle of hard/easy

The principle of periodization

Wilmore and Costhill 2001

Overview of the Cardiovascular System

Factors Affecting Neural Control of Cardiovascular Function

(4-6x) C.O

(2-4x) HR

20-50%SV (at least 100ml)

Frank Starling mechanism of EDV and ESV

Contractility Peripheral vasodillation

Circulatory respones due to exercise in healthy persons

Adapted fromCirculation 2003;107;1210-25

<50% of normal C.O

Lower max HR

SV (limited to 50-60 ml)

Minimal preload reserve to EDV and/ or inability ESV

Contractility,Β-adrenergic responsiveness

Systemic vascular resistance

Sympathetic renin- angiotensin system

Arterial vasodillatation response to exercise

Circulatory respones due to exercise in patientes with CHF

Adapted fromCirculation

2003;107;1210-25

CHF and 2DM

More reduced physical performance

Adapted from: Guazzi. Am J Cardiol. 2002

Control CHF CHF and 2DM

Long term effects of exercise in CHF

Eur Heart J 2001;22:125-35Circulation 2003;107;1210-25Cochrane 2004 2004(3):CD003331

Effects VO2 max

Arbetsbelastning Six minutes walk VE

Stroke volume at rest and during exercise

Cardiac output at

work

Sympathetic activity

Ejection fraction

Heart frequency

rest

maximal

Blood pressure systolic

Rest

Work

BNP

TNFα

Fatigue

Dyspneoa

Muscle blood flow, oxidative capacity,

capillarisation

Endothelial

function

Muscle fiber area Muscle strength and

endurance

Quality if life Mortality Hospital admissions NYHA-class

Assessment of physical function

Exercise test

Six minute walk6MWT Submaximalt test Guyatt Can Med Assoc J 1985;132:919-23. Lipkin BMJ 1986;292:653-5 Korrelerar väl med V02 och överlevnad. Cahalin 1996;110:325-32. Reproducerbarheten varierar i olika studier. ”Takeffekt”

Referensekvation finns för friska Enright Am J Resp Crit Care 1998;158:1384-7.

Unilateral Shoulder flexion 0-90

3kg for men

2kg for women

20 contractions /minute

Cider et al. Eur J Cardiovasc nurs;2006

Isotonic unilateral heel lift

10 tilted wedge

head should meet the length measurer arm

30 lifts/minute

Isometric bilateral 90 shoulder abduction

with a one kg dumbell in each hand

Central circulatory traning

Peripheral muscle traning

Combined peripheral and central circulatory training

Respiratory-muscle traning

Land Water Eur Heart J 2001;22:125-35Circulation 2003;107;1210-25 Cochrane 2004(3):CD003331

Tai Chi

Electric stimulation

Central circulatory training

Endurance training: 40-80% of maximal V02

Interval training:Different protocols i.e. 30/60 s 10-45 minutes 2 times/week – every day 3 weeks-1 year

Rees K , Taylor RS, Singh S, Coats AJ, Ebrahim S. Exercise based rehabilitation

for heart failure. Cochrane Database Syst Rev 2004(3):CD003331.

Classification of intensity

Adapted efter American College of Sports Medicine 1998

Relative intensityRelative

intensity*

HFmax

%

VO2max

%

RPE Classificationof intensity

Muscular resistance

% MVC

< 35 < 20 <10 Very light <30

35-54% 20-39% 10-11 Light 30-49

40-59% 55-69% 12-13 Somewhat hard

50-69

60-84% 70-89% 14-16 Hard 70-84

>90% >85% 17-19 Very hard >85

100 100 20 Maximal 100

HFmax = Maximal heart frequncy, MVC= Maximal voluntary contraction, VO2max =Maximal oxygen uptake,

RPE= Rate of percieved exertion, (Borg´scale), 6-20 scale.*= Based on 8 till 12 repetitions for persons <50-60 years and 10-15 repetitions for persons 50-60 years.

Rate of Percieved Exertion (RPE)

6 -7 Very, very light8 -9 Very light10 -11 Light12 -13 Somewhat hard14 -15 Hard (heavy)16 -17 Very hard18 -19 Very, very hard20 Maximal

Category ratio 10 scale (CR10)

0 None0.30.5 Very, very light1 Very light1.52 Light2.53 Moderate45 Strong67 Very strong8910 Very, very strong11 Maximal

Rate of Percieved Exertion (RPE)

6 -7 Very, very light8 -9 Very light10 -11 Light12 -13 Somewhat hard14 -15 Hard (heavy)16 -17 Very hard18 -19 Very, very hard20 Maximal

Category ratio 10 scale (CR10)

0 None0.30.5 Very, very light1 Very light1.52 Light2.53 Moderate45 Strong67 Very strong8910 Very, very strong11 Maximal

Rate of Percieved Exertion (RPE)

6 -7 Very, very light8 -9 Very light10 -11 Light12 -13 Somewhat hard14 -15 Hard (heavy)16 -17 Very hard18 -19 Very, very hard20 Maximal

Category ratio 10 scale (CR10)

0 None0.30.5 Very, very light1 Very light1.52 Light2.53 Moderate45 Strong67 Very strong8910 Very, very strong11 Maximal

Borg 1998

Central circulatory training

Effects VO2max +1.6 mL x kg-1xmin-1(95% CI 2.82 to 1.49)

Exercise time +2.38 minutes (95% CI 2.85 to 1.9)

Work capacity +15.1 Watt (95% CI 17.7 to 12.6)

Walking distance +40.9 meters (95% CI 64.7 to 17.1)

sex minutes walk

Improvement of VO2max greater when exercise programmes had an higher

intensity and longer duration

Health related increased in several studies

quality of life

Rees K , Taylor RS, Singh S, Coats AJ, Ebrahim S. Exercise based rehabilitation

for heart failure. Cochrane Database Syst Rev 2004(3):CD003331.

Wasserman K et al, 1999

Some improtant factors for oxygen uptake

Peripheral muscle traning

A high relative load on individual muscle groups while maintaining low central circulatory stress levels

Gaffney et al 1982

Pulley exercise

Exercise with dumb- bells

Exercise in Quadriceps table

Repetitions Maximum (RM)

Repetitions, Repetitions, resistanceresistance and expected effectand expected effect

RepetitionsRepetitions 1 2 3 51 2 3 5 77 1010 2525 5050

Resistance inResistance in 100 95 90 85 80100 95 90 85 80 7070 5050 3030% of 1 RM% of 1 RM

EffectEffect maximal strengthmaximal strength muscle growthmuscle growth enduranceendurance

coordinationcoordination

Adapted from: Karlsson J, Thommé R et al 1998

Repetition Maximum

Repetitions, Repetitions, resistanceresistance and expected effectand expected effect

RepetitionsRepetitions 1 2 3 51 2 3 5 77 1010 2525 5050

Resistance inResistance in 100 95 90 85 80100 95 90 85 80 7070 5050 3030% of 1 RM% of 1 RM

EffectEffect maximal strengthmaximal strength muscle growthmuscle growth enduranceendurance

coordinationcoordination

Adapted from: Karlsson J, Thommé R et al 1998

Repetition Maximum

Peripheral muscle traning

35 -80% of one Repetition Maximum (1 RM) 2-7 times/week 15-60 minutes 8 weeks – 5 months

Delagardelle C, Feiereisen P. Eura Medicophys 2005;41(1):57-65.

Fiber recruitment in different intensities

Combined central circulatory andperipheral training

Ergometer and peripheral muscle training

3 times a week 60 minutes 3 months

Dellagarede 1999, Hare 1999, Maiorana 2001, Dellagarde 2002, Senden 2005

Hydrotherapy

Could it be incorporated in the rehabilitation of patients with chronic heart failure?

Cider et al Eur J Heart Fail.2003;5(4):527-35.Cider et al. Clin Physiol Funct Imaging. 2005;25(6):313-7.Cider et al. Eur J Heart Fail. 2006 May;8(3):308-13

Head-out of water immersion (33-34°C)

Central blood volume

Hydrostatic pressure

Adapted from Arborelius, 1972

Gabrielsen, 2001, Meyer, 2004, Cider 2006

Stroke volume

Cardiac output

Heart rate

Systemic vascular resistance

Cardiopulmonary receptors

Renin

Angiotensin II

Aldosteron

ANP

ADH

Sympathetic activity

Diureses

Respiratory muscle exercises

Inspiration and/or expiration exercises Duration/exercise occasion:15-30

minutes Frequency:6 times/day- 3 times/week Long term duration:6 weeks -3 months

Mancini 1995, Johnsson 1998, Martinez 2001, Laoutaris 2004, Dall‘Ago P 2006.

Other training modalities

Tai Chi Electric stimulation

Conclusion Exercise should be incoperated in the

medical treatment in CHF.

Central circulatory training improves VO2.

Peripheral muscle training improve sceletal muscle function.

Hydrotherapy improves VO2 as well as sceletal muscle function

Patient cases

Athens 2006

Svea 82 years

Ischemic heart diease 1995 ( myocardial infarction) CHF 1998, EF 40% Diabets type 2 1999 Polyneuropathy, problems with gait Depressed mood Exercise -ECG 40 w, need to stop due to dyspneoa and

leg fatigue

Olle, 44 years Cardiomyopathy 2005 EF 20% Used to be healthy Exercised occasionally the last 10 years, mostly

jogging and floorball

Exercise-ECG 200 w, no signs of ischemia, HFmax 130, BPmax 185/-. Discontinue due to leg fatigue

Leif 72 years

Ischemic heart disease since 20 years back, CHF since 4 years back PCI x 5 and CABG x 2 Suffering from angina while exercising Inoperable Exercise-ECG, Pronounced ST-changes at

50 w, HF 88, BP 140/-

Metabolic equivalent (MET)

1MET=1.0kcal(4.184kJ)/kg/h eller

3.5 mLO2 x kg-1x min-1

Lätt fysisk aktivitet:<3METs Moderat fysisk aktivitet: 3-6 METs Kraftig Fysisk aktivitet>6 METs

Ainsworth BE et al. Med Sci Sports Exerc 2002;32(Suppl):S498-S516.

<2METs

2METs

3METs

4Mets

5Mets

Resting EatingMoving in bedSitting on the edge of the bed

Adapted from: Woods Cardiac nursing; 2004

Standing and transfering to chairChair exercises

Self care Walking in room

Walking 3km/h indoors

Climbing a flight of stairs

Functional class

O2 cost mLO2 x kg-1x min-1

METS Bicycle Ergometer

watt

56.0 16 52.5 15 49.0 14 45.5 13

250

42.0 12 38.5 11 200 35.0 10 31.5 9 28.0 8

150

24.5 7

Normal and

functional- class I

21.0 6 100 2 17.5 5 75

14.0 4 10.5 3

3

7.0 2

50 25

4 3.5 1