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Review Article Acta Cardiol Sin 2014;30:353-359

Cardiac Rehabilitation in Patients with
Heart Failure
Tieh-Cheng Fu,1,3,5 Shu-Chun Huang,2 Chih-Chin Hsu,1 Chao-Hung Wang3 and Jong-Shyan Wang4

Reduced exercise capacity negatively affects the ability of patients with heart failure (HF) to perform activities
required for daily life, further decreasing their independence and quality of life (QoL). Cardiac rehabilitation (CR)
can effectively improve aerobic fitness and overall health status in patients with HF. Low referral rate is an
important limitation that may impede successful CR, whereas the automatic referral and liaison strategies
performed by some healthcare providers manifestly increase the CR referral rate. However, there is still
controversy regarding the most effective exercise strategy for improving hemodynamic efficiency during daily
activities in the HF population. Aerobic interval training (AIT), that includes alternating high- and low-intensity
exercise sessions, may be a more effective modality for improving functional capacity than traditional moderate
continuous training (MCT) in patients with HF. A novel AIT regimen designed in our previous study may
substantially enhance the ability of ventilation-perfusion matching during exercise, which effects are accompanied
by an improved global and disease-specific QoL in HF patients. Conversely, the traditional MCT regimen may only
maintain these physiologic responses to exercise at pre-interventional status. By elucidating the relationship
between physical activity and hemodynamic property, this review attempts to provide a CR strategy for developing
suitable exercise prescription that ameliorates hemodynamic disturbance, further retarding the disease progression
and improving health-related QoL in patients with HF.

Key Words: Aerobic capacity · Heart failure · Hemodynamics · Rehabilitation

BENEFICIAL EFFECTS OF CARDIAC REHABILITATION ease nears, HF patients suffer a higher rate of morbidity
(CR) IN HEART FAILURE (HF) and have a generally poor prognosis.2 According to the
report in 2009, the hospitalization cost of HF in the
Cardiovascular disease is the second highest cause United States for those aged 65 years or older at $20.1
of mortality in the Taiwanese population, at approxi- billion.3 Hence, healthcare associated with HF subjects
mately 11.1%.1 As the end stage of cardiovascular dis- the medical system to a substantial burden.
CR is suitable for patients with acute myocardial
infarction (AMI), post myocardial revascularization or
Received: October 9, 2013 Accepted: December 20, 2013 cardiac transplantation, and also for those patients with
Department of Physical Medicine and Rehabilitation, Chang Gung stable chronic angina and chronic cardiac insufficiency.4
Memorial Hospital, Keelung; 2Department of Physical Medicine and
Rehabilitation, Chang Gung Memorial Hospital, Taoyuan; 3Heart Failure By modifying health behavior, this medical strategy can
Center, Division of Cardiology, Department of Internal Medicine, effectively improve physical and psychological well-
Chang Gung Memorial Hospital, Keelung; 4Healthy Aging Research being, help patients recover productive participation
Center, Graduate Institute of Rehabilitation Science; 5Graduate
Institute of Clinical Medical Sciences, College of Medicine, Chang and function in society, and further minimize disease
Gung University, Taoyuan, Taiwan. progression in patients with cardiovascular disorders.5
Address correspondence and reprint requests to: Prof. Jong-Shyan Additionally, CR also reduces the detrimental effects
Wang, Graduate Institute of Rehabilitation Science, Chang Gung
University, No. 259, Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 333, associated with cardiac events to prevent patients with
Taiwan. Fax: 886-3-211-8700; E-mail: HF from recurrent hospitalization, eventually reducing

353 Acta Cardiol Sin 2014;30:353-359

heart failure.13 referral rate for CR was markedly elevated in patients with coronary artery disease18 and in patients with AMI by 56% and 55%.12 There. DM.16 In Taiwan. smoking 14%~37% in Victoria. United States. percutaneous coronary angioplasty. 11 showed that 28.5 mg/dL Hypertension Reduction in blood pressure of 3. Australia.6-9 As a multidisciplinary intervention. HF. diabetes mellitus. the and contraindication for cardiac rehabilitation. Table 1 shows the overview of candidates The Guidelines (GWTG)” program was implemented. Canada. Blackburn cessation. ICD. anxiety. coronary artery bypass graft.4 mm Hg Smoking Higher levels of abstinence from smoking Obesity 6. and psychological aid.10 et al. only 18~33% of patients of meta-analyses demonstrated that CR with an em. or swollen lymph glands CABG. cardiac resynchronization therapy. Acta Cardiol Sin 2014. 19 The GWTG program IMPROVING CR REFERRAL AND PARTICIPATION paid attention to how first-line cardiologists refer eligi- ble patients to CR before discharge. received outpatient CR within six months following phasis on exercise therapeutics was associated with a coronary bypass graft or valvular surgery. Tieh-Cheng Fu et al. PTCA. indicated that only 11% of patients participated in Moreover.8% Dyslipidemia Increase in high-density lipoprotein of 2. myocardial infarction. somatization. recent MI (within 2 days). Although the overall Low referral and participation rates are critical is. this program actually re- sues in the successful delivery of CR. CAD. medication. CR referral rate was still low. MI. by the efficacy of physical exercise-based therapy. RCT 12 Effect of exercise training on cardiac risk factors DM Decrease in hemoglobin A1C of 0.9% of patients were referred to CR in Compared to usual care without exercise. and psychosocialstress 3 Contraindication of Cardiac Rehabilitation A recent significant change in the resting ECG suggesting significant ischemia. recent studies Alberta. have reported that the attendance rates of CR were CR involves exercise therapeutics. Sundararajan et al. hostility. accompanied by fever. implantable cardiac defibrillator.30:353-359 354 .14 In America. this review article focuses on current exercise transportation. a hospital-based CR program in the Cleveland Clinic trolling cardiovascular risk factors is mainly determined Foundation. ICD. even if these decrease of 20%-30% in the mortality rate.7-kg weight loss at 1 year Psychosocial health Decreases in depression. body aches. nutritional counseling.17 strategies in HF healthcare according to the opinion of a When the American Heart Association’s “Get with physiatrist. respectively. patients lived in modern cities with convenient mass fore. the ability of CR to succeed in eventually con.11. presented an improvement compared to earlier data.4/2. healthcare costs. or other acute cardiac event Unstable angina Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic HF Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Suspected or know dissecting aneurysm Acute systemic infection. coronary artery disease. RCT. 15 whereas Norris et al.12-15 Table 1.4. Overview of cardiac rehabilitation Candidate of cardiac rehabilitation CAD MI PTCA CABG HF Heart transplant Pacemaker.

OUES. these hospitalization. the studies of Gravely-Witte et in patients with arrhythmia or users of b-adrenergic al.20 and Grace et al. capacity and efficiency. the HFC in Keelung CGMH first integrated a novel bioreactance-based measurement (noninvasive continuous cardiac output monitoring system. which may reflect on underlying mechanisms of ity. respectively. an plied the automatic referral system to recruit core team abnormal pattern of respiration that consists of alter- members when patients were admitted.22-24 This test can The results of this study clearly demonstrated that the offer numerous physiologic parameters including ven. the ventilatory parameters obtained from CR referral rate by over 80%. anaerobic threshold. These aforementioned CPET may contain information about disease prognosis. Afterwards. periodic breathing. EPB. VeVCO2 slope. suppression of cerebral and muscle hemodynamics dur- tilatory.29 A subsequent investigation further found that less tients with cardiovascular disorders (Table 2). investigations support the proposition that physicians Peak oxygen consumption (VO2peak) and oxygen uptake and other healthcare providers including case managers efficiency slope (OUES) are the surrogates of exercise and physical therapists play important roles as modula. exercise-induced central and peripheral hemodynamic after.29 to and even > 90 % efficacy rate. blocker. angina pectoris.21 indicated that the automatic re. hemodynamic. a slope number over 34 may repre- Chang Gung Memorial Hospital (CGMH) effectively ap.28 Notably.5 L/min/m Predictor on composite events of rehospitalization and death in HF EPB prevalence­ . ing exercise were associated with ventilatory abnormal- ercise. the CPET can also provide highly reproducible ferral and liaison strategies performed by healthcare results of exercise performance and limitation.30:353-359 . 27 The V E -VCO 2 tors in early CR access and a successful CR referral sys. Parameters in CPET and its clinical implication Change in HF Cut-off value Clinical implication VO2max ¯ 14 cc/min/kg Aerobic capacity Functional fitness Prognosis prediction OUES ¯ (not yet) Surrogate of VO2max in submaximal exercise test Ve-VCO2 slope ­ 34 Exertional hyperventilation More powerful survival prediction than VO2max VO2 at AT ­ . maximal oxygen consumption. 355 Acta Cardiol Sin 2014. EXERCISE TESTING FOR HF near-infrared spectroscopy. the CR referral mechanism was able to achieve up changes. and automatic gas analysis to identify the involvement of ventilatory and cardiac- The cardiopulmonary exercise test (CPET) is a useful cerebral-muscle hemodynamic responses to exercise in tool to evaluate patient exercise capacity and exertional functional impairment in patients with HF (Figure 1). HF. VO2max. Keelung patients.26 Fur- providers and early outpatient education increased the thermore. oxygen uptake efficiency slope.5 L/min/m2 of peak cardiac index was a signifi- Table 2. CI.22. Aerobic capacity Functional fitness 2 CI ¯ 4.29 symptoms using objective measures. which reduced functional capacity in patients with exertional dyspnea. Exercise and Heart Failure On the other hand. minute ventilation versus carbon dioxide production slope. and fatigue in pa. has been recognized consequent education course and liaison work during during exercise in chronic HF patients. the Heart Failure Center (HFC). In Taiwan. slope is a powerful predictor of survival in cardiac tem. There. these eligible patients indices of ventilatory efficiency may be correlated with would refer to the rehabilitation department. and then started nating hyperpnea and hypopnea. NICOM). Recently. sent a worse prognosis. cardiac index (cardiac output/body surface area). exercise periodic breathing. and metabolic responses to ex. namely. Survival prediction Sleep apnea correlation AT. VO2. oxygen consumption.27 Besides.25 Even than 4.

superior to moderate continuous training (MCT) for enhancing ventilatory and central/peripheral hemo- dynamic responses to exercise in patients with HF.HRrest) + HRrest] triuretic peptide in cardiac myocytes. in patients with HF. lege of Sports Medicine (ACSM). and reduced expression of atrial na. ditionally. and functional impairment tify the involvement of ventilatory and cardiac-cerebral-muscle hemo- dynamic responses to exercise in patients with HF.33-35 Use of an animal model of post-infarction HF has sions for 12 weeks.41 Inspiratory muscle training may be beneficial for increasing inspiratory muscular strength cant predictor regarding the composite events of re. and metabolic equivalents during a Type of exercise graded exercise test. is a Keelung CGMH. individual exer.4 In the HFC in nating high. exercise intolerance. electrocardiogram (lower circle in right spiratory muscle performance is associated with dy- panel) and automatic gas analysis (upper circle of middle panel) to iden- spnea. inten. ing if they have chest pain or other cardiac symptom/ sity for at least 30 min. completing three weekly ses- HF.37 The authors’ for 3 min. and progression of exercise.32 In general. including heart rate (HR). duration. then a cool-down at 30% of VO2peak for Acta Cardiol Sin 2014.40 panel). alleviating dyspnea. exercise intensity is the ness.30 functional status in HF patients. This exercise regimen in outpatient car. primary factor when prescribing an exercise regimen to vascular disease. duration. vised hospital-based training programs on a bicycle ity than traditional endurance training in patients with ergonometer (Figure 2). The protect individuals against cardiovascular disease.4 to exercise. iso- metric or eccentric resistance exercise should be avoided (or performed with great care) because of the resultant Figure 1. the intensity of exercise has a diversity of Aerobic interval training (AIT). heart rate reserve (HRR). subsequently improving functional mobility in patients with HF. attenu. near-infrared spectroscopy (NIRS) (upper circle in right panel and Evidence to date strongly suggests that poor in- lower circle in middle panel). should be instructed to immediately stop exercise train- diac patients is typically performed at moderate inten. Ad- and rhythmic exercise using large muscles has been pro. and frequency of exercise EXERCISE PRESCRIPTION FOR HF According to recommendations by the Center for Disease Control and Prevention and the American Col- Exercise prescription aims to enhance physical fit. the Borg 6-to-20 scale is used to assess the posed to be part of an effective rehabilitation strategy RPE during each exercise session. However. optimal exercise prescription for an individual is based cise prescription comprise an appropriate type. NICOM) (left increase in cardiac afterload. patients for HF patients.39 This training may increase muscle mass and strength.42 Intensity. Tieh-Cheng Fu et al. an increased VO2peak of 11-36%. on an objective evaluation of the individual’s response sity. However. MCT comprised a warm-up at 30% of VO 2peak [» 30% ated hypertrophy.30:353-359 356 . and endurance. and improving hospitalization and death in HF patients. Integrated a novel bioreactance-based measurement (non- invasive continuous cardiac output monitoring system.4 The principal components of a systematic. » 30%·(HRpeak . frequency.and low-intensity exercise sessions. VO2.31 and has been associated with sign.4 Cardiac patients can use a HR/EKG Aerobic endurance training that comprises isotonic monitor to obtain the assigned intensity of exercise. that includes alter. rating of perceived exertion (RPE). st- rength training has been recommended to counter cachexia-related disability. the HF patients performed two super- more effective modality for improving functional capac. and ensure safety during exercise.38 In a recent development in HF rehabilitation. setting ranged from 40% to 80% VO2peak. promote health by reducing risk factors for cardio.36. The exercise protocol in traditional shown that AIT rescued impaired contractility. followed by continuous 60% of VO2peak (» 60% recent investigation also demonstrated that AIT was HRR) for 30 min.

an improved health- related QoL could exhibit a reduced potential for mor- tality in HF patients. Furthermore. The exercise session was by healthcare providers and early outpatient education terminated by a 3-minute cool-down period at 30% of can significantly increase the referral rate of CR. HF patients on optimal cardiovascular pharmaco- 3 min. exercise phase and cool-down phase. and subsequently improves psychosocial sta- tus in HF patients.30:353-359 . includ- ing warm-up phase. controversy persists regarding the type and vo- the same exercise duration. lume of CR that optimally promotes beneficial adapta- tively improved oxygen uptake efficiency by enhancing tions in ventilatory and hemodynamic functions. which may ac- ing intensity and progression of moderate continuous training (MCT) celerate physical deconditioning and the consequent (upper panel) aerobic interval training (AIT) (lower panel). 2 Successful CR is a valuable warm-up for 3 min at 30% of VO 2peak before exercise. and may and MCT decreased patient scores on the Minnesota have important implications for exercise training in HF Living with Heart Failure questionnaire. increasing incidence and prevalence.20 How- VO2peak. whereas only rehabilitation. This increases the ability of patients to cope with the physical demands of daily activity. Schematic figure of the content of exercise training. a novel AIT regimen has been logic therapy frequently remain burdened by dyspnea successfully applied to HF patients. 44 and simultaneously reduce the financial burden to the Taiwanese health care sys- tem.38 ing exercise. non-pharmacologic intervention for improving aerobic and five 3-minute intervals at 80% of VO 2peak (» 80% fitness and overall health status in patients with HF.2 How- ever. vicious cycle of numerous associated disorders.45 CONCLUSIONS HF is a major cardiovascular syndrome with an Figure 2. A possible explanation of the superior effects of AIT on these health-related QoL issues is that AIT ef- fectively enhances aerobic capacity and efficiency and relieves exercise intolerance.38. A novel hemodynamics and suppressed oxidative stress/inflam.38 Conversely. AIT regimen noted in our previous study may effectively mation associated with cardiac dysfunction in patients improve ventilatory and hemodynamic efficiencies dur- with HF. Although the two protocols were isocaloric at ever. and the train. From 2011 to date.46 HRR). Exercise and Heart Failure AIT significantly increased patient scores on the Short Form-36 Health Survey questionnaire of physical and mental dimensions. Each interval was separated by 3-minute exercise The automatic referral and liaison strategies performed at 40% of VO2peak (» 40% HRR). AIT rather than MCT effec. which comprised and exercise intolerance. the traditional MCT regimen may only HEALTH-RELATED QUALITY OF LIFE IMPROVED BY maintain these physiologic responses to a level of exer- CR cise similar to pre-interventional status. These findings provide a new insight into the larger effect of AIT on According to the authors’ investigations. both AIT ventilation-perfusion matching during exercise. 357 Acta Cardiol Sin 2014. which effects are accompanied by im- proved global and disease-specific QoL in patients with HF.43 These findings imply that AIT rather than MCT simultaneously improves generic and disease-specific quality of life (QoL) in patients with HF.

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