Activity in Heart Failure

Payman Zamani, MD, MTRUniversity of Pennsylvania

Saturday September 26th, 2015

Overview

• The risks/consequences of NOT exercising• Heart failure (HF) and the body• Benefits of exercise in HF• How do I get started?

The Less You Do, The Less You CAN Do

Exer

cise

Cap

acity

(L

O2/

min

)

Days

Exercise Capacity (L O2/min)

Healthy College Kids for 21 days~30% reduction

Middle-Aged Healthy Men for 10 days

~15% reductionModified from Debusk et al. Circ 1983; 68: 245

Modified from Saltin et al. Circ 1968; 5 (S7); 1Convertino. Med Sci Sports Exer 1997; 29: 191

The Time to Get Moving is Now!Ch

ange

in E

xerc

ise

Capa

city

Days of Bed RestModified from Convertino. Med Sci Sports Exerc 1997; 29: 191

DAYS IN BED ABILITY TO EXERCISE

Inactivity & The Company It Keeps

Decreased cognitionDepression

Reduced muscle strengthFalls

Decreased Bone Density

Hogan, Mata, Carstensen. Psychol Aging 2013; 28: 587Wagner et al. Annu. Rev. Publ. Health 1992; 13: 451Buchner et al. Annu. Rev. Publ. Health 1992; 13: 469

http://smartonlinesuccess.com/arnold-schwarzeneggers-six-rules-for-success/Bone: Dream Designs. Freedigitalphotos.netBrain: Omega1982. Freedigitalphotos.net

Heart Failure Affects the Whole Body!LungsLungs

Poor transfer of oxygen

Diaphragm“steal” blood

Less flow to the gut

Less outputPoor redistribution to muscles

Heart and Vessels

Skeletal MuscleReduced strengthMore fatigableLess muscle mass

Poole et al. Am J Physiol Heart Circ Physiol 2012; 302: H1050

Less Ability to Exercise

Modified from:

Impact of Exercise in Heart Failure• Improved ability to exercise!• Heart:– Improved pumping function– Reduces heart size

• Muscles– Stronger and more efficient

• Improved Quality of Life• Fewer Hospitalization and deaths

Haykowsky et al. JACC 2007; 49: 2329Hambrecht et al. JACC 1995; 25: 1239

Magnusson et al. Eur H J 1996; 17: 1048Flynn et al. JAMA 2009; 301: 1451

O’Connor et al. JAMA 2009; 310: 1439Keteyian et al. JACC 2012; 60: 1899

Image from American Council on Science and Health website

Exercise Reduces Bad OutcomesDeath or Hospitalization for Any Reason

E

vent

Rat

e

-- Usual Care− Exercise Group

Time, years

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0 1 2 3

11% Reduction in Death/Hospitalization

for any reason

O’Connor et al. JAMA 2009; 310: 1439Keteyian et al. JACC 2012; 60: 1899

The more exercise you didThe greater the benefit!

Exercise and Safety• Safe in stable HF patients• When is it okay to exercise?– Symptoms are under control!• Not when decompensated/extra fluid• Not when feeling worse/different • Stable medications

– Listen to your body: slow and steady– Discuss exercise with your provider• Usually starts with an exercise test

O’Connor et al. JAMA 2009; 310: 1439Pina. Curr Cardiol Rep 2010; 12: 223

Ades et al. JACC HF 2013; 6: 540Accessed on 9/2/2015: HFSA.org: http://www.hfsa.org/hfsa-wp/wp/module-5/

Cardiac RehabilitationUnderutilized resource!

• Generally: 36 supervised sessions– 3x/week: 30 min of exercise + warm up/cool down– Follow heart rate and feelings of difficulty– Increase duration & # of sessions first, then intensity– Build confidence, strength

• Only ~12% of patients with HF referred!

Golwala et al. JACC 2015; 66: 917Pina. Curr Cardiol Rep 2010; 12: 223

Ades et al. JACC HF 2013; 6: 540

February 2014: Medicare approves cardiac rehabilitation for heart failure!

Conclusions• Activity is good!!!• Listen to your body, notify your provider of

changes• Provided that your HF is under control…

The time to start moving is now!!• Discuss exercise with your provider• Consider cardiac rehab• HFSA Website:

http://www.hfsa.org/hfsa-wp/wp/module-5/