1. Activity in Heart Failure
Payman Zamani, MD, MTR
University of Pennsylvania
Saturday September 26th, 2015

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

3. The Less You Do, The Less You CAN Do
Exercise Capacity (L O2/min)
Exercise Capacity
(L O2/min)
Days
Middle-Aged Healthy Men
for 10 days
~15% reduction
Healthy College Kids for 21 days
~30% reduction
Modified from Debusk et al. Circ 1983; 68: 245
Modified from Saltin et al. Circ 1968; 5 (S7); 1
Convertino. Med Sci Sports Exer 1997; 29: 191

4. The Time to Get Moving is Now!
 DAYS IN BED 
 ABILITY TO EXERCISE
Change in Exercise Capacity
Days of Bed Rest
Modified from Convertino. Med Sci Sports Exerc 1997; 29: 191

5. Inactivity & The Company It Keeps
Decreased cognition
Depression
Decreased Bone
Density
Reduced muscle strength
Falls
Hogan, Mata, Carstensen. Psychol Aging 2013; 28: 587
Wagner et al. Annu. Rev. Publ. Health 1992; 13: 451
Buchner et al. Annu. Rev. Publ. Health 1992; 13: 469
Bone: Dream Designs. Freedigitalphotos.net Brain: Omega1982. Freedigitalphotos.net

6. Heart Failure Affects the Whole Body!
Lungs
Poor transfer
of oxygen
Diaphragm
“steal” blood
Less flow to the
gut
Less output
Poor redistribution to
muscles
Heart and Vessels
Skeletal Muscle
Reduced strength
More fatigable
Less muscle mass
Less Ability to Exercise
Modified from:
Poole et al. Am J Physiol Heart Circ Physiol 2012; 302: H1050

7. 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
Image from:
Haykowsky et al. JACC 2007; 49: 2329
Hambrecht et al. JACC 1995; 25: 1239
Magnusson et al. Eur H J 1996; 17: 1048
Flynn et al. JAMA 2009; 301: 1451
O’Connor et al. JAMA 2009; 310: 1439
Keteyian et al. JACC 2012; 60: 1899
Image from American Council on Science and Health website

8. Exercise Reduces Bad Outcomes
Death or Hospitalization for Any Reason
11% Reduction in
Death/Hospitalization
for any reason
0.8
0.7
0.6
0.5
Event Rate
0.4
The more exercise you did
The greater the benefit!
0.3
2331 patients randomized to exercise therapy or not and followed for an average of 30 months
Looking specifically at: Death for any reason or being admitted to the hospital for any reason
When they analyzed the results and adjusted for important differences in the groups, they found an 11% reduction in these bad outcomes in the groups that were assigned to exercise therapy.
What’s even more interesting is that they also then took a deeper look into the exercise group  not surprisingly, those individuals that did the most exercise had the most benefit.
0.2
-- Usual Care
− Exercise Group
0.1 1 2 3
Time, years
O’Connor et al. JAMA 2009; 310: 1439
Keteyian et al. JACC 2012; 60: 1899

9. 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
HF Action: 36 supervised sessions (3/week for 3 months). Focused on aerobic exercise (walking, teadmill, cycling).
Started at minutes at 60% of resere, then duration increasedto 30-35% and intensity increased to 70% reserve
After 6 weeks, patients added on home sessions to work up towards 5 40 minute sessions per reserve
O’Connor et al. JAMA 2009; 310: 1439
Pina. Curr Cardiol Rep 2010; 12: 223
Ades et al. JACC HF 2013; 6: 540
Accessed on 9/2/2015: HFSA.org:

10. Cardiac Rehabilitation Underutilized 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!
Resistance training less beneficial and may not have the same benefits on remodeling.
Also, high intensity likely associated with higher risks. (Smart 2013; 18: e21)
February 2014: Medicare approves cardiac
rehabilitation for heart failure!
Golwala et al. JACC 2015; 66: 917
Pina. Curr Cardiol Rep 2010; 12: 223
Ades et al. JACC HF 2013; 6: 540

11. 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: