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Older textbooks of cardiology cite the presence of heart failure as a contraindication to exercise testing. However, the heart failure syndrome is characterised by the presence of symptoms, and these are principally symptoms of exercise limitation caused by breathlessness and/or fatigue. Some form of exercise testing is essential to evaluate these symptoms. Similarly, textbooks until recently specified “rest” as one of the mainstays of heart failure management, but it is now clear that exercise training has some important benefits for heart failure patients. In this article, I will be discussing patients with chronic stable heart failure; there is no role for exercise in the management of patients admitted to hospital with acute heart failure.
Exercise has a number of possible uses in patients with chronic heart failure. Exercise testing can help: (1) establish the diagnosis and the underlying cause of heart failure; (2) assess severity of heart failure and stratify risk; (3) monitor the response to treatment; and (4) explore the pathophysiology of exercise limitation in heart failure. Finally, exercise can be used as a prescription for some heart failure patients to help reduce symptoms and possibly improve outcome.
In assessing patients complaining of exercise-induced symptoms, it is usually helpful to watch the patient exercising. Simple tests include a walk up and down the outpatient department corridor while watching for changes in ventilation and heart rate, and the development of symptoms. Simply adding pulse oximetry before and after the walk can help—patients who desaturate are highly likely to have pulmonary pathology underlying their breathlessness.
More formal exercise testing can be done using a large number of different exercise protocols. These can be broadly classed as maximal or submaximal tests. Maximal tests characteristically use incremental protocols on either a treadmill or a cycle, with encouragement to exercise to exhaustion. Which protocol …
* V˙e/V˙co2 = 863/Paco2 × (1−Vd/Vt), where 863 is a constant to standardise volume measurements, Paco2 is the arterial tension of carbon dioxide and Vd/Vt is dead space as a fraction of tidal volume.
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