Congestive Heart Failure: A Literature Review

Heart failure is a multifaceted clinical syndrome caused by a functional or structural

cardiac condition that impairs ventricular filling or blood ejection into the systemic circulation; it
is, by definition, a failure to meet the systemic circulation demands (Malik et al., 2022). The
current global prevalence of congestive heart failure (CHF) is 64.34 million cases, affecting
approximately 6.2 million people in the United States from 2013 to 2016 (Malik et al., 2022).
Regardless of the cause and classification, the prevalence increases steeply with age
(Malik et al., 2022). In most cases, CHFs are caused by coronary artery disease (CAD) and
myocardial infarction, and CAD and diabetes mellitus have become the most common risk
factors (Malik et al., 2022). Hypertension, valvular heart disease, uncontrolled arrhythmia,
myocarditis, and congenital heart disease are all structural causes of CHF.
Shortness of breath is the most common symptom, but it may also include chest pain,
palpitations, anorexia, fatigue, and a recumbent cough due to orthopnea (Malik et al., 2022).
S3 gallop (third heart sound), pulsus alternans, and P2 (pulmonic closure sound) accentuation are
all cardiac findings in CHF patients (Malik et al., 2022), with an S3 gallop as the most significant
and early finding associated with the condition (Ali et al., 1999).
To diagnose heart failure, the commonly used Framingham Diagnostic Criteria for Heart
Failure require the presence of two major criteria or one major and two minor criteria
(King et al., 2012). Major criteria may include acute pulmonary oedema, cardiomegaly,
hepatojugular reflex, neck vein distention, paroxysmal nocturnal dyspnea or orthopnea,
pulmonary rales, S3 gallop, ≥ 4.5 kg weight loss in 5 days in response to treatment, central
venous pressure greater than 16 cm of water, and radiographic cardiomegaly, while minor
criteria can include ankle oedema, exertional dyspnea, hepatomegaly, nocturnal cough, pleural
effusion, tachycardia, and a decrease in vital capacity by one third the maximal value recorded
(Malik et al., 2022). The New York Heart Association (NYHA) functional classification for
symptoms is as follows: Class I: symptom onset with more than an ordinary level of activity;
Class II: symptom onset with an ordinary level of activity; Class III: symptom onset with
minimal activity; Class IIIa: no dyspnea at rest; Class IIIb: recent onset of dyspnea at rest; and
Class IV: symptoms at rest.
Exercise training is a nonpharmacological intervention used to mitigate the abnormal
pathophysiology of cardiac failure and its influence on clinical outcomes
(Belardinelli et al., 1995; Coats et al., 1992). Exercise training, in particular, has been shown to
produce significant improvements in a variety of clinically essential parameters, including
aerobic capacity (van Tol et al., 2006), quality of life (van Tol et al., 2006), cardiac function
(Tucker et al., 2019), and cardiac structure (Haykowsky et al., 2007). These changes have been
shown to improve clinical outcomes, with significant reductions in all-cause and cardiovascular
hospitalization, as well as, although the data is more uncertain, all-cause mortality
(O'Connor et al., 2009; Taylor et al., 2018). Exercise training improves myocardial perfusion in
CHF patients by reducing endothelial dysfunction, dilation of coronary vessels, and stimulation
of new vessel formation via intermittent ischemia (Bai et al., 2022).
The benefits of exercise training involve multiple organ systems, but the extent and
targets of exercise training vary depending on the protocol used (Ismail et al., 2013).
Furthermore, the frequency and dose of ET are intuitively and casually dependent on the
intensity. The two most widely studied exercise programs for congestive heart failure are
moderate-intensity aerobic training (MIT) and high-intensity interval training (HIIT).
MIT programs are widely used exercise-based cardiac rehabilitation programs for CHF.
A study on the effect of long-term moderate exercise training indicated a long-term improvement
in functional capacity and quality of life in CHF patients, which appears to translate into
favourable outcomes (Belardinelli et al., 1999). In this study, 99 subjects aged 59 ±14 years were
randomized into a group that underwent exercise training at 60% of peak V̇ O2 initially three
times per week for eight weeks and then twice a week for one year and another group that did
not exercise. The Minnesota Living With Heart Failure Questionnaire was used to assess the
quality of life in both groups, with trained patients improving significantly after two months and
remaining stable after the subsequent 12-month exercise training program and during follow-up.
There was no difference in thallium activity between the two groups at baseline or after
redistribution-reinjection. However, after two months in the trial, trained patients had a
significantly higher percentage of myocardial defects with improved thallium activity and
reversible defects with higher thallium uptake than control patients. Furthermore, 75% of trained
patients with ischemic heart disease had higher thallium uptake than only 2% of untrained
patients. Although no significant difference in the frequency of nonfatal cardiac events was
observed between the two randomized groups during the training or follow-up periods, patients
who improved their functional capacity after exercise training had a significantly lower rate of
hospital readmission for heart failure and a lower cardiac mortality rate. Although quality of life
improved with peak oxygen uptake, it was not an independent predictor of cardiac events.
Following moderate-intensity exercise training, the relatively higher functional capacity may
stimulate a more active lifestyle, which helps maintain a higher peak VO2. Further, this study
indicated that the improvement in myocardial perfusion might be due to vessel neoformation due
to intermittent ischemia or vasodilation of preexisting coronary vessels due to reduced
endothelial dysfunction. By prolonging exercise conditioning, all of the positive effects seen
after short-term physical training may persist and contribute to the maintenance of higher
myocardial perfusion.
While MIT was found to be effective in CHF in the mentioned randomized controlled
trial, HIIT appears to produce similar, if not more significant, benefits than MIT in some
comparative investigations. For example, in a most recent systematic review conducted by
Edwards et al. (2023), which compared HIIT with continuous MIT in patients with CHF, HIIT
was significantly more effective than MIT in improving peak VO2 and left-ventricular ejection
fraction (LVEF) in CHF patients. Peak VO2, which is directly proportional to VO2max, is the
highest value of VO2 obtained during an incremental or other high-intensity exercise test
designed to push the subject to the limit of tolerance (Cade et al., 2018), while LVEF is a
measure of left ventricular systolic function, or the ratio of the volume of blood in the ventricle at
the end of diastole to the fraction of chamber volume ejected in systole (Kosaraju et al., 2023).
While both MIT and HIIT appear to be effective, this review's findings suggest that HIIT is
superior in improving such parameters in heart failure, which may have more prognostic
implications.
The two studies stated herein describe how exercise training benefits CHF patients.
However, their implementation still shows varying results, favouring HIIT more than MIT. Peak
VO2 is the critical prognostic marker specifically for CHF patients. Previous research links a 6%
increase in peak VO2 to an 8% lower risk of heart failure hospitalization and a 7% lower risk of
all-cause mortality (Swank et al., 2012). Peak VO2 is determined primarily by the oxygen
transport and utilization systems, which include the respiratory, cardiovascular, and skeletal
muscle systems (Dun et al., 2019). The main reason for the difference in effects between these
two types of exercise training has been supported in many studies based on these parameters and
concerning oxygen uptake. For example, Tasoulis et al. (2010) found that a 12-week HIIT
program improved respiratory muscle function in elderly CHF patients, while Dunham and
Harms (2012) demonstrated that four weeks of both HIIT and MIT resulted in significant
increases in respiratory muscle function, with HIIT eliciting a more significant increase in
effects. Given these findings, HIIT has a greater potential than MIT to improve the pulmonary
system's ability to distribute oxygen to working muscles during exercise, which has important
implications for overall exercise capacity and tolerance in CHF patients.
On the cardiovascular system, it was recently discovered that a 10-sessionHIIT increased
peak cardiac output (Astorino et al., 2018), which complements previous research that has shown
improved resting stroke volume and cardiac output, peak exercise cardiac output, plasma
volume, and haemoglobin mass following a 6-week long-interval HIIT with effects greater in
HIIT than MIT (Matsuo et al., 2014). These studies suggest that HIIT may have a more
significant effect on improving cardiovascular system function than MIT and appears to be more
effective or at least comparable to MIT in increasing cardiovascular parameters, all of which
contribute to improved peak VO2.
On the muscular system, Tan et al. (2018) found that 18 sessions of short-interval HIIT
over six weeks increased the total number of type I and II muscle fibres, capillary density, and
cytochrome oxidase IV protein expression - a marker of skeletal muscle oxidative capacity.
Furthermore, it was demonstrated that HIIT improves skeletal muscle deoxygenation and the
content and activity of glucose and fat oxidative metabolism markers in patients with CHF
(Spee et al., 2016). This demonstrates that HIIT is an effective strategy for increasing skeletal
muscle total fibre amount and type proportions, capillary density, and mitochondrial content and
function.
These studies have shown the beneficial effects of exercise, both MIT and HITT and that
it can reduce the incidence of mortality in CHF patients while also improving quality of life and
cardiovascular fitness through peak oxygen uptake. While continuous MIT has traditionally been
used for an aerobic-based exercise program for CHF, HIIT produces similar or even superior
physiologic adaptations to MIT, assisting CHF patients in improving their risk factors, exercise
capacity, and exercise tolerance. However, it should be recognized that specific exercise
intensity should correspond to specific patients and conditions, considering subjective and
objective measures of exercise training intensity. In the case of CHF, exercise training using
HIIT can be safely implemented using low-intensity intervals for patients with low exercise
capacity and tolerance.
Continuous MIT has been implemented for 20 to 60 minutes, which is longer than HIIT,
which lasts 10 minutes on average. According to public health guidelines in the United States,
the average American should engage in at least 150 minutes of moderate physical activity per
week. While sustained exercise for that time has been shown to have benefits, only some people
have the time to devote to exercise. It is acceptable if a CHF patient finds HIIT uncomfortable or
prefers a longer, more steady exercise like MIT. The most important thing is that the patient
keeps moving throughout the week to comply with the physical activity recommendation. More
people engage in HIIT because it fits easily into their weekly schedule. As a result, they are more
likely to engage in a regular exercise program, which is essential for maintaining good health.
The main benefit of HIIT is that it stimulates the cardiovascular system faster by working
harder rather than longer, as with MIT. According to one of the most extensive randomized
controlled trials of HIIT, healthy older people can participate in these workouts safely; however,
MIT appears to be equally beneficial in terms of longevity (Stensvold et al., 2020).

REFERENCES:

Ali, A. S., Rybicki, B. A., Alam, M., Wulbrecht, N., Richer-Cornish, K., Khaja, F., Sabbah, H.
N., & Goldstein, S. (1999). Clinical predictors of heart failure in patients with first acute
myocardial infarction. American heart journal, 138(6 Pt 1), 1133–1139.
https://doi.org/10.1016/s0002-8703(99)70080-3
Astorino, T. A., Edmunds, R. M., Clark, A., King, L., Gallant, R. M., Namm, S., Fischer, A., &
Wood, K. A. (2018). Increased cardiac output and maximal oxygen uptake in response to
ten sessions of high intensity interval training. The Journal of sports medicine and
physical fitness, 58(1-2), 164–171. https://doi.org/10.23736/S0022-4707.16.06606-8
Bai, Y., Hua, B., Zhang, F., Zhou, W., & Deng, B. (2022). Effect of different intensity exercises
intervention on cardiovascular functions and quality of life on patients with chronic heart
failure: A protocol for systematic review and meta-analysis. Medicine, 101(2), e28554.
https://doi.org/10.1097/MD.0000000000028554
Belardinelli, R., Georgiou, D., Cianci, G., & Purcaro, A. (1999). Randomized, controlled
trial of long-term moderate exercise training in chronic heart failure. Circulation,
99(9), 1173–1182. https://doi.org/10.1161/01.cir.99.9.1173
Belardinelli, R., Georgiou, D., Cianci, G., Berman, N., Ginzton, L., & Purcaro, A. (1995).
Exercise training improves left ventricular diastolic filling in patients with dilated
cardiomyopathy. Clinical and prognostic implications. Circulation, 91(11), 2775–2784.
https://doi.org/10.1161/01.cir.91.11.2775
Cade, W. T., Bohnert, K. L., Reeds, D. N., Peterson, L. R., Bittel, A. J., Bashir, A., Byrne, B. J.,
& Taylor, C. L. (2018). Peak oxygen uptake (VO2peak) across childhood, adolescence
and young adulthood in Barth syndrome: Data from cross-sectional and longitudinal
studies. PloS one, 13(5), e0197776. https://doi.org/10.1371/journal.pone.0197776
Coats, A. J., Adamopoulos, S., Radaelli, A., McCance, A., Meyer, T. E., Bernardi, L., Solda, P.
L., Davey, P., Ormerod, O., &Forfar, C. (1992). Controlled trial of physical training in
chronic heart failure. Exercise performance, hemodynamics, ventilation, and autonomic
function. Circulation, 85(6), 2119–2131. https://doi.org/10.1161/01.cir.85.6.2119
Dun, Y., Smith, J. R., Liu, S., & Olson, T. P. (2019). High-intensity interval training in
cardiac rehabilitation. Clinics in Geriatric Medicine, 35(4), 469–487.
https://doi.org/10.1016/j.cger.2019.07.011
Edwards, J., Shanmugam, N., Ray, R., Jouhra, F., Mancio, J., Wiles, J., Marciniak, A.,
Sharma, R., & O'Driscoll, J. (2023). Exercise Mode in Heart Failure: A Systematic
 Review and Meta-Analysis. Sports medicine - open, 9(1), 3.
https://doi.org/10.1186/s40798-022-00549-1
Haykowsky, M. J., Liang, Y., Pechter, D., Jones, L. W., McAlister, F. A., & Clark, A. M. (2007).
A meta-analysis of the effect of exercise training on left ventricular remodeling in heart
failure patients: the benefit depends on the type of training performed. Journal of the
American College of Cardiology, 49(24), 2329–2336.
https://doi.org/10.1016/j.jacc.2007.02.055
Ismail, H., McFarlane, J. R., Nojoumian, A. H., Dieberg, G., & Smart, N. A. (2013). Clinical
outcomes and cardiovascular responses to different exercise training intensities in
patients with heart failure: a systematic review and meta-analysis. JACC. Heart
failure, 1(6), 514–522. https://doi.org/10.1016/j.jchf.2013.08.006
King, M., Kingery, J., & Casey, B. (2012). Diagnosis and evaluation of heart failure. American
family physician, 85(12), 1161–1168.
Kosaraju, A., Goyal, A., Grigorova, Y., & Makaryus, A. N. (2023). Left Ventricular Ejection
Fraction. In StatPearls. StatPearls Publishing.
Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022). Congestive Heart Failure. In StatPearls.
StatPearls Publishing.
Matsuo, T., Saotome, K., Seino, S., Shimojo, N., Matsushita, A., Iemitsu, M., Ohshima, H.,
Tanaka, K., & Mukai, C. (2014). Effects of a low-volume aerobic-type interval exercise
on VO2max and cardiac mass. Medicine and science in sports and exercise, 46(1), 42–
50. https://doi.org/10.1249/MSS.0b013e3182a38da8
O'Connor, C. M., Whellan, D. J., Lee, K. L., Keteyian, S. J., Cooper, L. S., Ellis, S. J., Leifer, E.
S., Kraus, W. E., Kitzman, D. W., Blumenthal, J. A., Rendall, D. S., Miller, N. H., Fleg,
J. L., Schulman, K. A., McKelvie, R. S., Zannad, F., Piña, I. L., & HF-ACTION
Investigators (2009). Efficacy and safety of exercise training in patients with chronic
heart failure: HF-ACTION randomized controlled trial. JAMA, 301(14), 1439–1450.
https://doi.org/10.1001/jama.2009.454
Spee, R. F., Niemeijer, V. M., Wijn, P. F., Doevendans, P. A., & Kemps, H. M. (2016). Effects
of high-intensity interval training on central haemodynamics and skeletal muscle
oxygenation during exercise in patients with chronic heart failure. European journal of
preventive cardiology, 23(18), 1943–1952. https://doi.org/10.1177/2047487316661615
Stensvold, D., Viken, H., Steinshamn, S. L., Dalen, H., Støylen, A., Loennechen, J. P., Reitlo, L.
S., Zisko, N., Bækkerud, F. H., Tari, A. R., Sandbakk, S. B., Carlsen, T., Ingebrigtsen, J.
E., Lydersen, S., Mattsson, E., Anderssen, S. A., Fiatarone Singh, M. A., Coombes, J. S.,
Skogvoll, E., … Wisløff, U. (2020). Effect of exercise training for five years on all cause
mortality in older adults—the generation 100 study: Randomised Controlled Trial. BMJ,
m3485. https://doi.org/10.1136/bmj.m3485
Swank, A. M., Horton, J., Fleg, J. L., Fonarow, G. C., Keteyian, S., Goldberg, L., Wolfel, G.,
Handberg, E. M., Bensimhon, D., Illiou, M. C., Vest, M., Ewald, G., Blackburn, G.,
Leifer, E., Cooper, L., Kraus, W. E., & HF-ACTION Investigators (2012). Modest
increase in peak VO2 is related to better clinical outcomes in chronic heart failure
patients: results from heart failure and a controlled trial to investigate outcomes of
 exercise training. Circulation. Heart failure, 5(5), 579–585.
https://doi.org/10.1161/CIRCHEARTFAILURE.111.965186
Tan, R., Nederveen, J. P., Gillen, J. B., Joanisse, S., Parise, G., Tarnopolsky, M. A., &Gibala, M.
J. (2018). Skeletal muscle fiber-type-specific changes in markers of capillary and
mitochondrial content after low-volume interval training in overweight women.
Physiological reports, 6(5), e13597. https://doi.org/10.14814/phy2.13597
Tasoulis, A., Papazachou, O., Dimopoulos, S., Gerovasili, V., Karatzanos, E., Kyprianou, T.,
Drakos, S., Anastasiou-Nana, M., Roussos, C., & Nanas, S. (2010). Effects of interval
exercise training on respiratory drive in patients with chronic heart failure. Respiratory
medicine, 104(10), 1557–1565. https://doi.org/10.1016/j.rmed.2010.03.009
Taylor, R. S., Walker, S., Smart, N. A., Piepoli, M. F., Warren, F. C., Ciani, O., O'Connor, C.,
Whellan, D., Keteyian, S. J., Coats, A., Davos, C. H., Dalal, H. M., Dracup, K.,
Evangelista, L., Jolly, K., Myers, J., McKelvie, R. S., Nilsson, B. B., Passino, C.,
Witham, M. D., … ExTraMATCH II Collaboration (2018). Impact of exercise-based
cardiac rehabilitation in patients with heart failure (ExTraMATCH II) on mortality and
hospitalisation: an individual patient data meta-analysis of randomised trials. European
journal of heart failure, 20(12), 1735–1743. https://doi.org/10.1002/ejhf.1311
Tucker, W. J., Beaudry, R. I., Liang, Y., Clark, A. M., Tomczak, C. R., Nelson, M. D., Ellingsen,
O., & Haykowsky, M. J. (2019). Meta-analysis of Exercise Training on Left Ventricular
Ejection Fraction in Heart Failure with Reduced Ejection Fraction: A 10-year
Update. Progress in cardiovascular diseases, 62(2), 163–171.
https://doi.org/10.1016/j.pcad.2018.08.006
van Tol, B. A., Huijsmans, R. J., Kroon, D. W., Schothorst, M., & Kwakkel, G. (2006). Effects
of exercise training on cardiac performance, exercise capacity and quality of life in
patients with heart failure: a meta-analysis. European journal of heart failure, 8(8), 841–
850. https://doi.org/10.1016/j.ejheart.2006.02.013
NOTE: REFERENCES IN BOLD ARE THE STUDIES IN REVIEW