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Exercise for Heart Failure

"Lift heavy things as much as possible because if you don't use your going to lose it!"

HF is responsible for over 67,000 admissions in Wales and England per year and is the leading cause of admission in those aged over 65 years old. There are nearly 1 million people in the UK have HF but it is estimated that there are as many that have a damaged heart but are asymptomatic.

HF is a clinical syndrome that is commonly characterised by several key symptomatic traits such as shortness of breath, swelling in the lower legs with rapid short term weight gain and fatigue. These are primarily a result of an abnormality in the heart structure or function which results in a reduction in cardiac output and elevated pressure inside the heart which can occur at rest or during stress i.e. physical activity.

Medications are also a vital treatment option for those with HF. But as the evidence shows, exercise is also an effective, and therefore essential treatment. With exercise categorised as a class 1A recommendation, which is the same as some pharmacotherapy treatments, it is vital that this is not delayed or omitted in a person diagnosed with HF.

Sciency bit; The Fick principle says that VO2 is dependent on cardiac output multiplied by the A-VO2 difference. The Frank-Starling mechanism looks at the relationship between stroke volume (SV) and end diastolic volume (EDV). If SV increases due to an increase in blood entering the ventricles then this stretches the ventricle muscle fibers leading to an increased force of contraction in response. This mechanism relies heavily on both the right and left ventricle maintaining output equally.

This physiology in those with HF will inhibit optimal functioning resulting in a cascade of complications that contribute to worsening features of HF but also must be monitored when seeking to treat with interventions such as medications and especially physical activity. Physical activity will increase the requirement of this mechanism due increasing hear rate.

But, exercise for those with HF is not only safe but also highly effective in their management and potential recovery. The benefits are seen from reduced rates of hospitalisation, symptom control and improved quality of life. Improvements in fitness, stamina and quality of life are all evidenced in the literature.

There is increasing acknowledgement and awareness that the benefits of exercise on the structure and function of the heart and muscle mass have a very important role in the long term risk of HF. Long term studies show that exercise improves aerobic conditioning in those with HF. The effect that long term exercise has on those with chronic HF show a significant improvement in fitness even at the 10 year point!

The benefits of Resistance Training (RT) has previously been questioned in regards to its safety due to a potential increase in the haemodynamic burden that may result in a decrease of myocardial perfusion.

There is the need to exercise caution when assessing and prescribing an exercise programme that contains resistance training in those diagnosed with HF. This may be attributed to a reduced functional capacity and exercise tolerance. However, it is a safe and effective method to increase patient outcomes. Physiological mechanisms why resistance training may have been previously discouraged and not utilised as an exercise method suggested that increased strain on the myocardium during a concentric action and the increased afterload may have had an effect on increasing LV re-modelling. But, if prescribed intensities are adhered to within a progressively overload training programme then this is not the case.

Despite resistance training not traditionally expected to have an aerobic effect on heart rate and adaptive responses to its function the primary effect at increasing skeletal muscle is a key factor in supporting the impaired heart. By increasing the function of skeletal muscle and the efficiency of its mitochondria the requirement of the heart to supply oxygen will not be so great and thus reduced the workload or the impaired heart.

There are many organisations that suggest guidelines for resistance training. A lot of these are not fit for purpose in that they suggest a 'one size fits all' approach which limits specific individualised considersations. Some suggest waiting up to 5 weeks post MI or surgery but can be a low as 2 weeks post PCI. These guidelines for the prescription of resistance training in those with HF need to be applied be specially trained professionals who have experience and qualifications in both exercise physiology and clinical healthcare to achieve best patient outcomes. There should also be specific considerations for individuals who work within occupations that involve increased manual labour which would require an even more specific exercise prescription in order to benefit from resistance training exercise with the aim to facilitate a return to work as soon as possible.

It is essential that all those diagnosed with HF, regardless of aetiology, engage in resistance based exercises. Doing so with a specially trained and experienced healthcare professional will reduce any complications significantly improve health outcomes.

Lift heavy things as much as possible because if you don't use your going to lose it!

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