1. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 7 Resistance-Training Strategies for Individuals with Chronic Heart Failure

2. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Heart Failure Defined Pathological state in which abnormality of cardiac function causes failure of heart to pump blood at rate commensurate with requirements of metabolizing tissues –Or to do so only from elevated filling pressure

3. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chronic Heart Failure Defined Multi-system syndrome with multiple pathological abnormalities that reduce exercise tolerance and contribute to functional disability Systolic dysfunction –Reduced pumping capacity

4. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Exercise Intolerance and Resistance Training Exercise tolerance –Inability to sustain sub-maximal level of exercise/activity Previously contraindication for resistance training Now included in conjunction with aerobic exercise

5. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Prevalence of Chronic Heart Failure Affects approximately 5 million individuals in US More than 550,000 individuals diagnosed each year

6. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Prevalence of Chronic Heart Failure At age 65, rate increases from 2 to 3 percent –Affecting one in 100 individuals Over age 80, affects more than 80 percent of individuals

7. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Economic Impact Most common cause of hospitalization for people age 65 or more Individuals unable to perform activities of daily living due to deconditioning, dyspnea, and fatigue Approximately $30 billion total direct cost annually

8. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Common Symptoms Muscle weakness Dyspnea on exertion General fatigue Cardiovascular (central) and muscular (peripheral) dysfunction contribute to symptoms of heart failure

9. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Etiologic Factors Ischemic heart disease –Underlying factor in approximately 60 percent of cases Hypertensive heart disease Valvular heart disease Variety of metabolic, infectious, and toxic agents

10. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. “Muscle Hypothesis” Connection between cardiovascular and skeletal muscle dysfunction contributes to symptoms of heart failure

11. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Effects of Chronic Heart Failure on Skeletal Muscle Reduces blood flow Increases blood lactate levels during exercise Increases fatigue rates Causes structural alterations in peripheral vasculature Causes muscle atrophy and loss of muscle strength/endurance

12. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Effects of Chronic Heart Failure at Muscular Level Reduces slow-twitch oxidative fibers –Type I Increases fast glycolytic fibers –Type IIB Reduces mitochondrial function

13. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Effects of Chronic Heart Failure at Muscular Level Increases inducible nitric oxide synthase (iNOS) and nitric oxide associated with down-regulation of mitochondrial creatine kinase expression

14. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Benefits of Resistance Training Increases skeletal muscle and endothelial function –Decreasing negative effects associated with “muscle hypothesis” Improves physical and psychosocial factors Decreases fatigue

15. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Benefits of Resistance Training Improves emotional function Increases functional ability Improves peripheral blood flow Decreases sympathetic activation Improves heart rate variability

16. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Benefits of Resistance Training May improve autonomic function Increases muscle mitochondria size Improves muscle strength and endurance –Allowing greater efficiency when performing activities of daily living

17. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Research Supports Resistance Training Cumulative research results indicate resistance training leads to increases in: –Muscular strength –Muscular endurance –Quality of life –Functional measures

18. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Research Limitations Choice of subjects has mainly been “younger” males at low to moderate risk –Age 40 to 60 Many studies not reproducible due to various factors

19. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Research Limitations Typical 12-week program may be insufficient to impact both neural and muscle adaptations Focus on localized training strategies not ideal for long-term compliance

20. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Design Considerations Individuals in highest risk level due to greater overall morbidity/mortality rates Extensive medical and physical activity history required prior to training

21. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Design Considerations Other co-morbidities –E.g., diabetes, age Degree of severity of heart failure –Use categorization system established by American Heart Association (AHA) and American College of Cardiology (ACC)

22. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Heart Failure Classification System Stage A –At risk for developing heart failure Stage B –Asymptomatic and free of structural abnormalities

23. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Heart Failure Classification System Stage C –Structural abnormalities with/without mild to moderate symptoms Stage D –Advanced structural concerns –Quite limiting symptoms

24. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. New York Heart Association (NYHA) Classification System Class I –Level of exertion that would elicit symptoms for normal person Class II –Symptoms with ordinary exertion Class III –Symptoms during less than ordinary exertion

25. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. New York Heart Association (NYHA) Classification System Class IV –Symptoms at rest Individuals with symptoms in Class II-IV also fall within AHA/ACC Stage C and D

26. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Drug Regimen Considerations Consider possible drug side effects when planning training Diuretics reduce blood volume and edema Vasodilators reduce blood pressure and systemic vascular resistance

27. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Drug Regimen Considerations Beta-adrenergic receptor blockers interrupt “toxic effects” of over-active sympathetic nervous system Digoxin may be used –Also controversial Antiplatelet and anticoagulation therapies Aldosterone antagonist

28. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Exercise Testing Requirements Physical examination Symptom-limited cardiopulmonary exercise test using modified Naughton protocol Resting echocardiogram

29. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Testing Protocol Stress applied during test should reflect combination of static and dynamic loads on heart occurring during resistance training Echocardiographic stress test using leg press simulates training session

30. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Testing Protocol Measure: –Heart rate –Blood pressure –End diastolic volume –End systolic volume –Stroke volume –Ejection fraction –Cardiac output

31. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Testing Protocol If all variables assessed within normal limits, resistance training likely to be safe Next step: –Maximal strength testing Measure muscle strength by 1 RM method for all exercises to be included in resistance training program

32. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Contraindications for Resistance Training Post-exercise hypotension Arrhythmias Worsening heart failure symptoms: –Weight gain of 1.5 to 2.0 kilograms (kg) over previous three to five days –Increased heart rate and dyspnea –Auscultatory findings of pulmonary edema

33. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Cautions Some individuals experience temporary increase in fluid accumulation two to six weeks after starting exercise Take care during lifting exercises due to possibly altered reflex response to positional changes

34. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Components Consider individual’s loss of muscular endurance –Contributes to up to 40 percent of exercise intolerance First 12 weeks: –Circuit training protocol –Eight weeks of machines followed by four weeks adding free weights

35. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Components First 12 weeks: –Use sequence with minimal rest between exercises 30 to 60 seconds –Perform approximately 8 to 12 repetitions of each exercise per circuit 50 to 80 percent of 1 RM –Progress to 3 sets of 8 repetitions at 80 percent of 1 RM

36. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Program Components Second 12-weeks: –Two, six-week cycles Cycle 1 at club Cycle 2 at both home and club Review sample 24-Week Program

37. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Additional Training Considerations Should be entire body progressive resistance training program Ensure adequate rest/recovery –Critical to optimal outcomes Understand how varied differences in training intensity prevent training plateaus

38. Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Additional Training Considerations Constantly supervise and spot Properly orientate individuals to each procedure and piece of equipment Perform intermittent monitoring of heart rate and blood pressure