February 2020 Issue

Focus on Fitness: Exercising With Heart Failure
By Jennifer Van Pelt, MA
Today’s Dietitian
Vol. 22, No. 2, P. 54

February is American Heart Month. Efforts to increase awareness and prevention have resulted in declining mortality rates for coronary artery disease (CAD), the most common type of heart disease. However, while mortality rates associated with heart attacks from CAD have decreased, mortality and prevalence of heart failure are increasing. Much of this increase is related to the overall aging of the US population, but heart failure also is increasing among younger adults due to higher rates of obesity and CVD in this age group.

According to the American Heart Association (AHA), the most current data, from 2016, indicate that approximately 6.2 million Americans over 20 years of age have heart failure—an increase from the 5.7 million estimated in 2012. In 2017, there were 960,000 new cases of heart failure diagnosed in the United States.

The AHA projects that the prevalence of heart failure will increase by almost 50% by 2030, with more than 8 million Americans aged 18 or older developing the disease. Medical costs of heart failure will increase by more than 127% by 2030.1

In heart failure, the heart’s performance is impaired—it doesn’t fill properly with blood and/or is unable to pump enough blood. Therefore, the body doesn’t get enough oxygen. Heart failure is a progressive condition, and the heart gets weaker over time. Some causes of heart failure include CAD, previous heart attack, heart valve or muscle disease, certain lung conditions, and substance abuse. Symptoms of heart failure include the following:

• increased shortness of breath/labored breathing (dyspnea) on exertion or lying down;
• fatigue and weakness;
• persistent coughing or wheezing;
• fluid retention leading to swelling in the lower extremities and/or weight gain; and
• reduced tolerance of exercise.

Patients with heart failure are staged based on the severity of their symptoms and degree of exercise limitations using the New York Heart Association (NYHA) Functional Classification, grouped as follows:

NYHA I: No symptoms or limitations during normal physical activity;
NYHA II: Mild symptoms and some limitations (eg, fatigue, dyspnea) during normal physical activity;
NYHA III: Marked limitations during normal or lighter-than-normal physical activity due to fatigue and dyspnea, but patient is comfortable at rest; and
NYHA IV: Severe limitations—unable to perform any physical activity without discomfort, and symptoms of heart failure even at rest.

Patients generally are evaluated with a six-minute walking test and other clinical tests to determine NYHA status, which will determine how they’re managed. Despite several medications and device-based treatments for heart failure, between 50% and 75% of those with heart failure will die within five years after diagnosis.2

Exercise is used not only to assess heart failure symptoms but also as a therapeutic intervention. A large body of high-quality published evidence supports the benefits of regular exercise for heart failure patients who are able to perform physical activity. Systematic reviews and meta-analyses have shown that exercise reduces risk of hospitalizations and mortality and improves quality of life and functioning for patients with heart failure.3,4

Cardiac rehabilitation—medically supervised exercise commonly prescribed after a heart attack—is recommended for patients with heart failure. Cardiac rehabilitation for a prescribed number of sessions helps patients learn how to exercise appropriately to manage their heart failure. Current guidelines from the AHA, American College of Cardiology, Heart Failure Association, Canadian Cardiovascular Society, and European Society of Cardiology recommend regular exercise for patients with stable chronic heart failure who are able to exercise to improve functional status, symptoms, and quality of life, as well as reduce hospitalization and mortality.3,5

Guidelines emphasize aerobic endurance exercise performed at moderate to vigorous intensity for up to 30 minutes at least five days a week. Resistance training on two to three days a week is recommended as a complement to aerobic exercise. Note that this intensity, duration, and frequency of exercise mirrors AHA recommendations for all American adults. Exercise guidelines for heart failure do emphasize that exercise must be individualized for each patient depending on their functional status, age, comorbidities, and preferences.5

Research published since these guidelines were established suggests that the type of exercise is less important than the patient’s engagement and commitment. A 2018 systematic review and meta-analysis of 40 studies (totaling 5,411 patients) found significant improvements in quality of life and physical functioning associated with regular exercise. The researchers evaluated different factors that might affect outcomes and found that type of exercise, intensity, level of supervision, and exercise setting didn’t affect the significant improvements in quality of life and physical functioning associated with regular exercise. Exercise programs in all studies in this review were structured to ensure patient engagement and adherence, leading researchers to conclude that engagement and adherence contributed to improvements for patients. The study included patients with all NYHA functional statuses; most patients were NYHA II or III.2

Other recently published systematic reviews and meta-analyses have reported the following regarding exercise and heart failure:

• Interval training, continuous aerobic exercise, strength training, and combined aerobic/strength interval training all improved quality of life and functioning.6
• Aquatic exercise (eg, swimming, water aerobics, water walking) was comparable to land-based exercise in improving exercise capacity, muscular strength, and quality of life for patients with stable heart failure.7
• Resistance/strength training alone or combined resistance/aerobic exercise improved quality of life, walking ability, and peak oxygen uptake.8
• Yoga significantly improved quality of life, exercise capacity, and clinical heart failure outcomes as much as aquatic exercise. In addition, yoga significantly reduced anxiety and depression.9
• Tai chi significantly improved walking distance, quality of life, and certain cardiac performance measures in patients with heart failure.10

Despite guideline recommendations and proven health benefits, only about 10% of heart failure patients are referred to cardiac rehabilitation after diagnosis or hospitalization for heart failure.11 Patients therefore aren’t receiving much-needed guidance and encouragement to jump-start an exercise program on their own. Regular exercise is severely underutilized in managing patients with heart failure.3-5

Research suggests that helping clients with heart failure recognize their barriers to regular exercise and find exercise activities that they enjoy might be more helpful than prescribing a traditional and generalized exercise regimen. Because those with heart failure often have other comorbidities, exercise activities should be appropriate for age and physical abilities. NYHA III and IV clients may require supervised exercise sessions. The safest exercise options for most clients with heart failure include aquatic exercise, walking, gentle or chair yoga, tai chi, and strength training with light handheld weights.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.


1. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics — 2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.

2. Palmer K, Bowles KA, Paton M, Jepson M, Lane R. Chronic heart failure and exercise rehabilitation: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2018;99(12):2570-2582.

3. Alvarez P, Hannawi B, Guha A. Exercise and heart failure: advancing knowledge and improving care. Methodist Debakey Cardiovasc J. 2016;12(2):110-115.

4. Morris JH, Chen L. Exercise training and heart failure: a review of the literature. Card Fail Rev. 2019;5(1):57-61.

5. Deka P, Pozehl B, Williams MA, Yates B. Adherence to recommended exercise guidelines in patients with heart failure. Heart Fail Rev. 2017;22(1):41-53.

6. Cornelis J, Beckers P, Taeymans J, Vrints C, Vissers D. Comparing exercise training modalities in heart failure: a systematic review and meta-analysis. Int J Cardiol. 2016;221:867-876.

7. Adsett JA, Mudge AM, Morris N, Kuys S, Paratz JD. Aquatic exercise training and stable heart failure: a systematic review and meta-analysis. Int J Cardiol. 2015;186:22-28.

8. Jewiss D, Ostman C, Smart NA. The effect of resistance training on clinical outcomes in heart failure: a systematic review and meta-analysis. Int J Cardiol. 2016;221:674-681.

9. Hägglund E, Hagerman I, Dencker K, Strömberg A. Effects of yoga versus hydrotherapy training on health-related quality of life and exercise capacity in patients with heart failure: a randomized controlled study. Eur J Cardiovasc Nurs. 2017;16(5):381-389.

10. Gu Q, Wu SJ, Zheng Y, et al. Tai chi exercise for patients with chronic heart failure: a meta-analysis of randomized controlled trials. Am J Phys Med Rehabil. 2017;96(10):706-716.

11. Golwala H, Pandey A, Ju C, et al. Temporal trends and factors associated with cardiac rehabilitation referral among patients hospitalized with heart failure: findings from Get With The Guidelines-Heart Failure Registry. J Am Coll Cardiol. 2015;66(8):917-926.