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NHLBI Working Group on Exercise Training as Therapy for Heart Failure
The National Heart, Lung, and Blood Institute convened a working group of experts on June 11, 2012 in Bethesda, Maryland to identify knowledge gaps and to suggest general approaches to filling those gaps for exercise training as a treatment for heart failure. The need for new effective strategies to improve outcomes for patients with heart failure is underscored by persistently high mortality, morbidity, health care utilization and costs associated with heart failure, with over 1.1 million U.S. heart failure hospitalizations in 2006 and an estimated direct and indirect cost in the U.S. of $39.2 billion in 2010.
Despite a variety of pharmacologic and device therapies for persons with chronic heart failure (HF), prognosis and quality of life (QOL) remain poor. Exercise intolerance is a major symptom in chronic HF patients (the primary symptom in persons with preserved ejection fraction -- HFpEF) and is a strong determinant of their reduced QOL. Exercise training (ET) improves exercise intolerance and QOL in patients with HF with reduced ejection fraction (HFrEF), and has become an accepted adjunct therapy for these patients based on a fairly extensive evidence base, including a number of mostly small randomized trials.
The NHLBI-funded HF-ACTION trial (O'Connor et al., JAMA 2009) compared a personalized supervised and home-based aerobic exercise program plus guideline-based pharmacologic and device therapy with guideline-based therapy alone in persons with HF and reduced ejection fraction (HF-rEF). The exercise arm showed a modest reduction in cardiovascular hospitalizations and mortality and improved QOL. However, problems with adherence in the exercise arm likely dampened the potential benefit. This landmark study leaves unanswered a number of key questions, including the role of exercise dose; the relative benefit of different types of aerobic exercise including interval training and resistance training relative to aerobic training; and optimization of adherence.
Also not addressed by HF-ACTION was the role of exercise training in persons with HFpEF, the fastest growing form of heart failure, which predominates among older persons and has a higher prevalence of women than does HFrEF. Given the lack of evidence-based therapies for HFpEF, in contrast to HFrEF, the potential benefit from exercise therapy may be greater and the need to find an effective therapy that much more urgent. The first published randomized trial of exercise training in HFpEF (Kitzman et al., Circulation Heart Failure 2010) showed a significant improvement in aerobic capacity (peak VO2) and other measures of fitness in such patients. This has now been confirmed by others, including a small multicenter study (Edelmann et al., Journal of the American College of Cardiology 2011).
Workshop participants were asked to identify knowledge gaps and to suggest general approaches in basic and clinical investigation to evaluate and translate the potential role of exercise training in the treatment of heart failure. They were asked to address the following questions:
The workshop participants will develop a meeting proceedings report for publication in a peer-reviewed cardiovascular journal.
Division of Cardiovascular Sciences
Lawton Cooper, MD, MPH
Jerome Fleg, MD
Last Updated: December 2012