Exercise intolerance in patients with chronic heart failure

doi:10.1016/S0033-0620(05)80011-8

Progress in Cardiovascular Diseases

Volume 38, Issue 1, July–August 1995, Pages 1-22

https://doi.org/10.1016/S0033-0620(05)80011-8 Get rights and content

Patients with chronic heart failure (CHF) experience significant morbidity because of dyspnea and fatigue with activities of daily living. Although central hemodynamic abnormalities are the hallmark of this disorder, investigators have not shown a relationship between left ventricular ejection fraction or exercise pulmonary capillary wedge pressure and exercise intolerance in this disorder. Recent studies have focused on the contributions of pulmonary abnormalities and alterations in peripheral vasomotor control and skeletal muscle in exercise intolerance in this disorder. Early anaerobic metabolism occurs in patients with CHF and appears to be caused by a combination of reduced skeletal muscle blood flow and decreased aerobic enzyme content in skeletal muscle. Atrophy in skeletal muscle and alterations in skeletal muscle fiber typing are accompanied by alterations in contractile function in skeletal muscle. These results suggest that exercise intolerance in patients with CHF is multifactorial, and that research efforts must consider central hemodynamic abnormalities, pulmonary abnormalities, and alterations in peripheral blood flow and skeletal muscle biochemistry and histology. The present review will explore current research in this area and develop a model for understanding exercise intolerance in CHF.

References (175)

SchockenDD et al.
Prevalence and mortality rate of congestive heart failure in the United States
J Am Coll Cardiol
(1992)
HigginbothamMB et al.
Determinants of variable exercise performance among patients with severe left ventricular dysfunction
Am J Cardiol
(1983)
FranciosaJA et al.
Lack of correlation between exercise capacity and indexes of resting left ventricular performance in heart failure
Am J Cardiol
(1981)
SzlachcicJ et al.
Correlates and prognostic implication of exercise capacity in chronic congestive heart failure
Am J Cardiol
(1985)
MetraM et al.
Assessment of peak oxygen consumption, lactate and ventilatory thresholds and correlation with resting and exercise hemodynamic data in chronic congestive heart failure
Am J Cardiol
(1990)
SimontonCA et al.
The ventilatory threshold: Quantitative analysis of reproducibility and relation to arterial lactate concentration in normal subjects and in patients with chronic heart failure
Am J Cardiol
(1988)
MyersJ et al.
Exercise testing
Cardiol Clin
(1993)
GravesJE et al.
Exercise testing in cardiac rehabilitation
Cardiol Clin
(1993)
GradmanAH et al.
Predictors of mortality in patients with heart failure
Cardiol Clin
(1994)
GorkinL et al.
Assessment of quality of life as observed from baseline data of the studies of left-ventricular dysfunction (SOLVD) trial quality of life substudy
Am J Cardiol
(1993)

YounisLT et al.

Prognostic value of exercise testing

Cardiol Clin

(1993)

IngramRH et al.

Respiratory changes during exercise in patients with pulmonary venous hypertension

Prog Cardiovasc Dis

(1976)

MassieBM

Exercise tolerance in congestive heart failure: Role of cardiac function, peripheral blood flow, and muscle metabolism and effect of treatment

Am J Med

(1988)

WilsonJR et al.

Exercise intolerance in patients with chronic left heart failure: Relation to oxygen transport and ventilatory abnormalities

Am J Cardiol

(1983)

SullivanMJ et al.

Central hemodynamic response to upright exercise in normal subjects: Stroke volume is augmented by similar mechanisms in men and women

Am J Cardiol

(1991)

WilsonJR et al.

Objective detection of muscle fatigue in patients with heart failure

Am J Cardiol

(1992)

ManciniDM et al.

Respiratory muscle deoxygenation during exercise in patients with heart failure demonstrated with near-infrared spectroscopy

J Am Coll Cardiol

(1991)

NeryLE et al.

Contrasting cardiovascular and respiratory responses to exercise in mitral valve and chronic obstructive pulmonary disease

Chest

(1983)

EichackerPQ et al.

Methacholine bronchial reactivity testing in patients with chronic congestive heart failure

Chest

(1988)

BruceRA et al.

Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease

Am Heart J

(1973)

FrancisGS et al.

Relationship of exercise capacity to resting left ventricular performance and basal plasma norepinephrine levels in patients with congestive heart failure

Am Heart J

(1982)

WeberKT et al.

Lactate production during maximal and submaximal exercise in patients with chronic heart failure

J Am Coll Cardiol

(1985)

SullivanMJ et al.

Central hemodynamic response to exercise in patients with chronic heart failure

Chest

(1992)

HammondHK et al.

Normal and abnormal heart rate responses to exercise

Prog Cardiovasc Dis

(1985)

SmithWM

Epidemiology of congestive heart failure

Am J Cardiol

(1985)

SullivanMJ

Congestive heart failure: Trends in epidemiology and therapy

GhaliJK et al.

Trends in hospitalization rates for heart failure in the United States, 1973–1986

Arch Intern Med

(1990)

BengeW et al.

Exercise capacity in patients with severe left ventricular dysfunction

Circulation

(1980)

WeberKT et al.

Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure

Circulation

(1982)

MarantzPR et al.

The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria

Circulation

(1988)

FransciosaJA et al.

Relation between hemodynamic and ventilatory responses in determining exercise capacity in severe congestive heart failure

Am J Cardiol

(1984)

WeberKT et al.

Cardiopulmonary Exercise Testing

(1986)

Cohen-SolalA et al.

Cardiopulmonary exercise testing in chronic heart failure

Heart Failure

(1994)

ManciniDM et al.

Value of peak oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure

Circulation

(1991)

BrooksSE et al.

Prognostic features in patients with congestive heart failure and selection criteria for cardiac transplantation

Mayo Clin Proc

(1992)

EvartCK et al.

Usefullness of self efficacy in predicting over-exertion during programed exercise in coronary artery disease

Am J Cardiol

(1986)

FrolicherESS et al.

Exercise testing

SullivanMJ et al.

Exercise training in patients with severe left ventricular dysfunction. Hemodynamic and metabolic effects

Circulation

(1988)

ElbornJS et al.

Reproducibility of cardiovascular parameters during exercise in patients with chronic heart failure

Eur Heart J

(1990)

DicksteinK et al.

Reproducibility of cardiopulmonary exercise testing in men following myocardial infarction

Eur Heart J

(1988)

HansonP

Exercise testing and training in patients with chronic heart failure

Med Sci Sports Exerc

(1994)

RectorTS et al.

Patients self assessment of their congestive heart failure

Heart Failure

(1987)

DubachP et al.

Cardiac rehabilitation for heart failure patients

Cardiology

(1989)

PackerM et al.

Which objective measurements parallel the courses of disease progression in patients with congestive heart failure

J Am Coll Cardiol

(1988)

Hlaff-NelsonCL et al.

Relation of clinical and angiographic factors to functional capacity as measured by Duke Activity Status Index

Am J Cardiol

(1991)

WassermanK

Coupling of exernal to cellular respiration during exercise: the wisdom of the body revisited

Am J Physiol

(1994)

BrooksGA

Anaerobic threshold: Review of the concept and directions for future research

Med Sci Sports Exerc

(1985)

MatsumuraN et al.

Determination of anaerobic threshold for assessment of functional state in patients with chronic heart failure

Circulation

(1983)

SullivanMJ et al.

Exercise training in patients with chronic heart failure delays ventilatory anaerobic threshold and improves submaximal exercise performance

Circulation

(1989)

WassermanK et al.

Detecting the threshold of anaerobic metabolism in cardiac patients during exercise

Am J Cardiol

(1964)

Cited by (138)

Mechanisms of Exercise Intolerance in Chronic Heart Failure With Preserved Ejection Fraction: Challenging the Traditional Hypothesis
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Chronotropic incompetence: rediscovering phenotypes in heart failure with preserved ejection fraction
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Citation Excerpt :
In patients with systolic HF, also known as HFrEF, peak HR and SV are reduced approximately 20% and 45%, respectively, compared with normal individuals.13,14 Peripheral factors contributing to reduced AVO2 difference, thence, peak Vo2, include reduced muscle mass, decreased mitochondrial density in exercising muscle, and peripheral vasoconstriction because of intrinsic abnormalities of smooth muscle vasodilation and neurohormonal factors.15,16 A similar constellation of peripheral abnormalities contributes to the age-associated decrease in AVO2 difference at peak exercise (Table 1).17
Heart Failure: Exercise-Based Cardiac Rehabilitation: Who, When, and How Intense?
2016, Canadian Journal of Cardiology
The primary chronic symptom in patients with clinically stable heart failure (HF) is reduced exercise tolerance, measured as decreased peak aerobic power (peak oxygen consumption [Vo₂]), and is associated with reduced quality of life and survival. Exercise-based cardiac rehabilitation (EBCR) is a safe and effective intervention to improve peak Vo₂, muscle strength, physical functional performance, and quality of life and is associated with a reduction in overall and HF-specific hospitalization in clinically stable patients with HF. Despite these salient benefits, fewer than one-tenth of eligible patients with HF are referred for EBCR after hospitalization. In this review, selection for and timing of EBCR for patients with HF, as well as exercise prescription guidelines with special emphasis on the optimal exercise training intensity to improve peak Vo₂, are discussed.
Le principal symptôme chronique des patients atteints d’insuffisance cardiaque (IC) stable sur le plan clinique est la diminution de la tolérance à l’effort que l’on évalue par la diminution de la puissance maximale aérobie (absorption maximale d’oxygène [Vo₂]) et qui est associée à la diminution de la qualité de vie et de la survie. La réadaptation cardiaque axée sur l’exercice physique (RCEP) est une intervention sûre et efficace pour améliorer la Vo₂, la force musculaire, la performance fonctionnelle physique et la qualité de vie, et est associée à une réduction de l’hospitalisation globale et liée à l’IC chez les patients atteints d’IC stable sur le plan clinique. En dépit de ces avantages notables, moins d'un dixième des patients admissibles atteints d’IC sont orientés vers la RCEP après l’hospitalisation. Dans cette revue, nous discutons sur le choix et le moment opportun de la RCEP des patients atteints d’IC, ainsi que sur les lignes directrices sur la prescription d’activité physique qui met un accent particulier sur l’intensité optimale de l’entraînement à l’effort pour améliorer la Vo₂ maximale.
Defining the System: Contributors to Exercise Limitations in Heart Failure
2015, Heart Failure Clinics
Functional evaluation of a physical training programme in myocardial infarction patients with severe left ventricular systolic dysfunction
2020, Revista Colombiana de Cardiologia
Evaluar la factibilidad y los efectos sobre la capacidad funcional de un programa de entrenamiento físico supervisado, aplicado en pacientes con disfunción sistólica severa del ventrículo izquierdo después de infarto agudo de miocardio.
Se estudiaron 37 pacientes, de ambos sexos y sin límites de edad, con diagnóstico de disfunción sistólica severa del ventrículo izquierdo, después de haber sufrido un infarto agudo de miocardio, que consecutivamente se incorporaron al programa ambulatorio del Centro de Rehabilitación del Instituto de Cardiología.
Se hicieron pruebas de esfuerzo máximas limitadas por síntomas con determinación de consumo de oxígeno, ecocardiogramas en reposo y ventriculografías isotópicas en reposo y esfuerzo a los 2, 8 y 18 meses de evolución, y un tiempo medio de seguimiento clínico de 4,1 años. A todos se les prescribió un régimen de entrenamiento físico moderado o intenso, durante un año como mínimo. Se consideró disfunción sistólica severa cuando la fracción de eyección del ventrículo izquierdo fue menor de 35%.
Todos los parámetros ergométricos que expresaron capacidad funcional incrementaron significativamente en la evaluación del octavo mes (p< 0,0005), permaneciendo invariables a los 18. La fracción de eyección del ventrículo izquierdo media en reposo inicial fue de 28,3 ± 5,3%, la cual no mostró variaciones significativas con el esfuerzo ni con otros estudios evolutivos. La mortalidad total y la morbilidad de la serie fueron de 10,5% y 47,3%, respectivamente.
El entrenamiento físico supervisado en pacientes infartados con disfunción sistólica severa de ventrículo izquierdo fue seguro y efectivo, y mejoró su calidad de vida, sin causar efectos negativos sobre la función ventricular.
To evaluate the feasibility and effects on the functional capacity of a supervised physical training programme carried out on patients with severe left ventricular systolic dysfunction after an acute myocardial infarction.
The study included a total of 37 patients, males and females of any age, with a diagnosis of severe left ventricular systolic dysfunction after having suffered an acute myocardial infarction. They were consecutively included into the ambulatory programme of the Institute of Cardiology Rehabilitation Centre.
Maximum effort tests, limited by symptoms, were performed to determine oxygen consumption. Echocardiograms were also performed at rest, with isotopic ventriculography at rest and then at 2, 8, and 18 months. The mean clinical follow-up was 4.1 years. They were all prescribed to a moderate or intense training programme for at least one year. Severe left ventricular systolic dysfunction was considered when the left ventricular ejection fraction was less than 35%.
All the ergometric parameters that expressed functional capacity increased significantly in the evaluation at 8 months (P< .0005), and remained at 18 months. The initial mean left ventricular ejection fraction at rest was 28.3 ± 5.3%, which showed no significant changes with effort or in the other evaluation times. The overall mortality and morbidity of the series was 10.5% and 47.3%, respectively.
Supervised physical training in patients after an acute myocardial infarction and with severe left ventricular systolic dysfunction was safe and effective, and improved the quality of life, without causing negative effects on ventricular function.

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^*: Supported by Grant No. HL-54314 from the National Heart, Lung, and Blood Institute, Bethesda, MD, and by General Medical Research Funds from the Veterans Administration Medical Center, Durham, NC. M.J.S. was supported by an established investigatorship from the American Heart Association.

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Exercise intolerance in patients with chronic heart failure*

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Prog Cardiovasc Dis

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Am Heart J

Am Heart J

J Am Coll Cardiol

Chest

Prog Cardiovasc Dis

Epidemiology of congestive heart failure

Am J Cardiol

Congestive heart failure: Trends in epidemiology and therapy

Trends in hospitalization rates for heart failure in the United States, 1973–1986

Arch Intern Med

Exercise capacity in patients with severe left ventricular dysfunction

Circulation

Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure

Circulation

The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria

Circulation

Relation between hemodynamic and ventilatory responses in determining exercise capacity in severe congestive heart failure

Am J Cardiol

Cardiopulmonary Exercise Testing

Cardiopulmonary exercise testing in chronic heart failure

Heart Failure

Value of peak oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure

Circulation

Prognostic features in patients with congestive heart failure and selection criteria for cardiac transplantation

Mayo Clin Proc

Usefullness of self efficacy in predicting over-exertion during programed exercise in coronary artery disease

Am J Cardiol

Exercise testing

Exercise training in patients with severe left ventricular dysfunction. Hemodynamic and metabolic effects

Circulation

Reproducibility of cardiovascular parameters during exercise in patients with chronic heart failure

Eur Heart J

Reproducibility of cardiopulmonary exercise testing in men following myocardial infarction

Eur Heart J

Exercise testing and training in patients with chronic heart failure

Med Sci Sports Exerc

Patients self assessment of their congestive heart failure

Heart Failure

Cardiac rehabilitation for heart failure patients

Cardiology

Which objective measurements parallel the courses of disease progression in patients with congestive heart failure

J Am Coll Cardiol

Relation of clinical and angiographic factors to functional capacity as measured by Duke Activity Status Index

Am J Cardiol

Coupling of exernal to cellular respiration during exercise: the wisdom of the body revisited

Am J Physiol

Anaerobic threshold: Review of the concept and directions for future research

Med Sci Sports Exerc

Determination of anaerobic threshold for assessment of functional state in patients with chronic heart failure

Circulation

Exercise training in patients with chronic heart failure delays ventilatory anaerobic threshold and improves submaximal exercise performance

Circulation

Detecting the threshold of anaerobic metabolism in cardiac patients during exercise

Am J Cardiol