Editorial
Exercise training in heart failure: effect on morbidity and mortality

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Introduction

It is well known that physical fitness is associated with reduced overall and cardiovascular mortality. A recent study from Erikssen et al. [1] has demonstrated that even small improvements in physical fitness are associated with reduced risk of death.

The potential value of cardiac rehabilitation (CR) with exercise in individuals with coronary artery disease was recognised nearly as early as the clinical description of the disease itself. In 1772 Heberden [2] noted that one of his patients with angina was ‘nearly cured’ after 6 months of sawing wood for half an hour a day.

CR is being increasingly applied to cardiac illnesses other than myocardial infarction: exercise training is a mainstay of CR in combination with a variety of other therapeutic procedures.

Section snippets

Cardiac rehabilitation in coronary artery disease

Cardiac rehabilitation exercise programme has become a routine procedure in the case of patients recovering after myocardial infarction, coronary artery bypass grafting, PTCA, or cardiac transplantation.

However, in patients with coronary heart disease CR with exercise training has not been definitively shown to improve morbidity and mortality. Only one of 22 randomized trials of cardiac rehabilitation with exercise training demonstrated a statistically significant cardiovascular mortality

Cardiac rehabilitation in chronic heart failure

Traditionally ET has been contra-indicated in patients with heart failure (CHF), because of the fear of further precipitating clinical conditions.

In a series of small trials, a number of groups have now shown that patients with severe left ventricular dysfunction can be safely entered into exercise training programs and that, by the usual indices of exercise responses in heart rate, ventilation and peak oxygen consumption, they can achieve a favourable training response. More recently,

Effect on morbidity and mortality

The literature to date includes only 500–600 patients reported as having taken part in randomized trials of exercise training in the setting of CHF. Against this background, any single-center report of a randomized trial of 99 patients is to be heartily welcomed, especially if it contains, as this study does, some of the valuable longer-term follow-up data lacking in many of the earlier reports. Belardinelli et al. randomized 99 patients with moderate-to-severe CHF to supervised exercise

Unanswered questions

Three major questions remain unanswered by the predominantly single-center studies that have been published to date:

  • 1.

    whether the training effects could be maintained over the long term;

  • 2.

    whether training is practicable in multiple medical settings outside enthusiastic specialist clinics; and

  • 3.

    whether training would have an effect on mortality or morbidity, either adverse or beneficial.

Thus, there remains the need for a large controlled prospective trial to assess the value of medically prescribed

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