ReviewRisks and Benefits of Exercise Training in Adults With Congenital Heart Disease
Section snippets
Assessment Before Exercise Training in CHD
As outlined in Table 1, a thorough assessment is required before recommending exercise training in patients with CHD, with the purpose of informing the counselling process, identifying those at high risk for exercise-induced adverse events, and providing evidence to reassure patients concerning safety.8 One study reported that education of adults with CHD regarding exercise is suboptimal, even in a specialist clinic, leading to frequent misconceptions about potential benefits and dangers.9 A
Benefits of Exercise Training in CHD
The overarching objectives of exercise training in patients with CHD are to improve health, exercise tolerance, and quality of life. Several studies in diverse populations of patients with surgically repaired CHD have reported improvements in exercise tolerance after various exercise training programs, including VO2 max, peak oxygen consumption, peak oxygen pulse, total treadmill walking time, heart rate recovery, walking distance, power output, and oxygenation of respiratory muscles.11, 12, 13
Fontan Circulation
In complex patients with a Fontan circulation, exercise intolerance is multifactorial. In addition to the absence of a subpulmonary pump that contributes to a blunted increase in stroke volume with exercise, chronotropic incompetence and underlying arrhythmias might further impair exercise capacity. Although patients with a Fontan circulation often report the absence of symptoms during activities of daily living, objective functional capacity is characteristically reduced. The initial increase
Systemic Morphologic Right Ventricle
In patients with a systemic morphologic right ventricle due to congenitally or surgically (D-TGA) corrected transposition of the great arteries with atrial redirection, exercise capacity is limited by the inability to increase cardiac output as a result of chronotropic incompetence,24 inadequate ventricular filling due to poor atrial transport (ie, with Mustard or Senning baffles),25 impaired function of the systemic right ventricle,26 and/or limited coronary flow reserve.27, 28, 29, 30, 31 In
Other
Improvements in aerobic capacity as a result of structured exercise training have also been reported in small series of adults with tetralogy of Fallot16 and pulmonary hypertension associated with CHD.33 Other benefits of exercise training include the prevention of acquired coronary artery disease for which patients with CHD are becoming increasingly susceptible as a result of their improved longevity. There is evidence, albeit inconsistent, to suggest that obesity is more prevalent in patients
Risks Associated With Exercise Training in CHD
Feared complications associated with exercise in patients with CHD include malignant arrhythmias, exercise-induced hypertension, aortic dissection, myocardial ischemia, heart failure exacerbation, worsening cyanosis, syncope, and sudden cardiac death.39 All elements of the clinical profile should be considered in determining risks. For example, high-impact sports might be associated with additional risks in patients receiving anticoagulation therapy or with implantable
Recommendations for Exercise Training in CHD
The Canadian Cardiovascular Society has not issued specific recommendations regarding exercise training in patients with CHD. In 2008, the American College of Cardiology/American Heart Association (AHA) management guidelines for adults with CHD recognized the importance of individualizing, and regularly updating, exercise prescription.39 The American College of Cardiology/AHA guidelines endorsed published recommendations for exercise defined by the 36th Bethesda conference on CHD.50 In
Conclusions
A wealth of observational literature supports a strong association between higher levels of physical activity and lower rates of obesity, hypertension, and cardiovascular disease, superior psychosocial outcomes, and improved survival. Although the literature regarding exercise in CHD is limited to a few studies on relatively small patient populations with short-term follow-up, results are consistent in showing that the anticipated benefits of exercise are applicable to the growing population
Funding Sources
Dr Khairy is supported by a Canada Research Chair in Adult Congenital Heart Disease and Electrophysiology.
Disclosures
The authors have no conflicts of interest to disclose.
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