Advertisement

Chronic Heart Failure and Exercise Rehabilitation: A Systematic Review and Meta-Analysis

Published:April 23, 2018DOI:https://doi.org/10.1016/j.apmr.2018.03.015

      Abstract

      Objective

      The aim of this systematic review was to identify the effect of specific exercise parameters on physical function and quality of life (QOL) in people with chronic heart failure living in the community.

      Data Sources

      A total of 5 electronic databases were searched for relevant studies published after 1994.

      Study Selection

      The screening process was completed by 2 independent researchers, with a third independent reviewer for conflict resolution. Studies were selected if they included only chronic hHart failure participants, and the sole intervention was a structured exercise training program in an outpatient or community setting.

      Data Extraction

      Two independent researchers completed the data extraction and qualiy assessment. Quality was assessed using the Physiotherapy Evidence Database and Grading of Recommendations Assessment, Development and Evaluation scales.

      Data Synthesis

      In total, 40 articles (n=5411) were included in the review for meta-analysis and meta-regression, including 27 randomized control trials and 13 cohort studies. Exercise was shown to have a positive effect on QOL outcomes (standardized mean difference 1.16; 95% confidence interval [CI], 0.76-1.56) with the most commonly used measure, the Minnesota Living with Heart Failure Questionnaire, showing a clinically significant change of 8.5 points. Physical function was improved postexercise intervention in the 23 included studies (standardized mean difference 0.89; 95% CI, 0.40-1.38), with a clinically significant change of 49.8 m seen in studies using the 6-minute walk test (95% CI, 26.52-73.13). These improvements were independent of study design, study quality, participant demographics, disease severity, and exercise prescription variables.

      Conclusion

      Exercise significantly improves QOL and physical function. Current evidence suggests that engagement with exercise is a more important factor in achieving improvement than how the exercise is performed. Future research should aim to identify and address barriers to engagement in exercise rehabilitation in this population.

      Keywords

      List of abreviations:

      CHF (chronic heart failure), CI (confidence interval), PEDro (Physiotherapy Evidence Database), QOL (quality of life), RCT (randomized control trial), SMD (standardized mean difference)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Inamdar A.A.
        • Inamdar A.C.
        Heart failure: diagnosis, management and utilization.
        J Clin Med. 2016; 5: 62
        • Gomez-Soto F.M.
        • Andrey J.L.
        • Garcia-Egido A.A.
        • et al.
        Incidence and mortality of heart failure: a community-based study.
        Int J Cardiol. 2011; 151: 40-45
        • Sahle B.W.
        • Owen A.J.
        • Mutowo M.P.
        • Krum H.
        • Reid C.M.
        Prevalence of heart failure in Australia: a systematic review.
        BMC Cardiovasc Disord. 2016; 16: 32
        • Piepoli M.F.
        • Conraads V.
        • Corra U.
        • et al.
        Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation.
        Eur. J Heart Fail. 2011; 13: 347-357
        • Cook C.
        • Cole G.
        • Asaria P.
        • Jabbour R.
        • Francis D.P.
        The annual global economic burden of heart failure.
        Int J Cardiol. 2014; 171: 368-376
        • Davies E.J.
        • Moxham T.
        • Rees K.
        • et al.
        Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis.
        Eur J Heart Fail. 2010; 12: 706-715
        • Sagar V.A.
        • Davies E.J.
        • Briscoe S.
        • et al.
        Exercise-based rehabilitation for heart failure: systematic review and meta-analysis.
        Open Heart. 2015; 2e000163
        • Painter P.
        • Stewart A.L.
        • Carey S.
        Physical functioning: definitions, measurement, and expectations.
        Adv Ren Replace Ther. 1999; 6: 110-123
        • Scharpf T.P.
        • Madigan E.A.
        Functional status outcome measures in home health care patients with heart failure.
        Home Health Care Serv Q. 2010; 29: 155-170
        • Group W.
        The World Health Organization quality of life assessment (WHOQOL): position paper from the World Health Organization.
        Soc Sci Med. 1995; 41: 1403-1409
        • Coelho R.
        • Ramos S.
        • Prata J.
        • Bettencourt P.
        • Ferreira A.
        • Cerqueira-Gomes M.
        Heart failure and health related quality of life.
        Clin Pract Epidemiol Ment Health. 2005; 1: 19
        • Chung M.L.
        • Moser D.K.
        • Lennie T.A.
        • Frazier S.K.
        Perceived social support predicted quality of life in patients with heart failure, but the effect is mediated by depressive symptoms.
        Qual Life Res. 2013; 22: 1555-1563
        • Norton K.
        • Norton L.
        • Sadgrove D.
        Position statement on physical activity and exercise intensity terminology.
        J Sci Med Sport. 2010; 13: 496-502
        • Lewinter C.
        • Doherty P.
        • Gale C.P.
        • et al.
        Exercise-based cardiac rehabilitation in patients with heart failure: a meta-analysis of randomised controlled trials between 1999 and 2013.
        Eur J Prev Cardiol. 2015; 22: 1504-1512
        • Taylor R.S.
        • Davies E.J.
        • Dalal H.M.
        • et al.
        Effects of exercise training for heart failure with preserved ejection fraction: a systematic review and meta-analysis of comparative studies.
        Int J Cardiol. 2012; 162: 6-13
        • Taylor R.S.
        • Sagar V.A.
        • Davies E.J.
        • et al.
        Exercise-based rehabilitation for heart failure.
        Cochrane Database Syst Rev. 2014;Apr; CD003331
        • van der Meer S.
        • Zwerink M.
        • van Brussel M.
        • van der Valk P.
        • Wajon E.
        • van der Palen J.
        Effect of outpatient exercise training programmes in patients with chronic heart failure: a systematic review.
        Eur J Prev Cardiol. 2012; 19: 795-803
        • Day M.L.
        • Mcguigan M.R.
        • Brice G.
        • Foster C.
        Monitoring exercise intensity during resistance training using the session RPE scale.
        J Strength Cond Res. 2004; 18: 353-358
        • Recovery CPfS
        PEDro score.
        (Available at:) (Accessed January 12, 2018)
        • Dijkers M.
        Introducing GRADE: a systematic approach to rating evidence in systematic reviews and to guideline development.
        KT Update. 2013; 1: 1-9
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        Lawrence Erlbaum Associates, Hillsdale1988
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Harbord R.M.
        • Higgins J.
        Meta-regression in Stata.
        Meta. 2008; 8: 493-519
        • Higgins J.
        • Thompson S.G.
        Controlling the risk of spurious findings from meta-regression.
        Stat Med. 2004; 23: 1663-1682
        • Gagnier J.J.
        • Moher D.
        • Boon H.
        • Bombardier C.
        • Beyene J.
        An empirical study using permutation-based resampling in meta-regression.
        Syst Rev. 2012; 1: 18
      1. Fu R, Vandermeer BW, Shamliyan TA, et al. Handling continuous outcomes in quantitative synthesis. PLoS Med 2013;21:6.

        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Adsett J.
        • Morris N.
        • Kuys S.
        • Hwang R.
        • Mullins R.
        • Khatun M.
        • et al.
        Aquatic exercise training is effective in maintaining exercise performance in trained heart failure patients: a randomised crossover pilot trial.
        Heart Lung Circ. 2017; 26: 572-579
        • Aksoy S.
        • Findikoglu G.
        • Ardic F.
        • Rota S.
        • Dursunoglu D.
        Effect of 10-week supervised moderate-intensity intermittent vs. continuous aerobic exercise programs on vascular adhesion molecules in patients with heart failure.
        Am J Phys Med Rehabil. 2015; 94: 898-911
        • Belardinelli R.G.
        • Gerogiou D.
        • Cianci G.
        • Purcaro A.
        10-Year exercise training in chronic heart failure: a randomized controlled trial.
        J Am Coll Cardiol. 2012; 60: 1521-1528
        • Bocalini D.S.
        • dos Santos L.
        • Serra A.J.
        Physical exercise improves the functional capacity and quality of life in patients with heart failure.
        Clinics (São Paulo). 2008; 63: 437-442
        • Borland M.
        • Rosenkvist A.
        • Cider A.
        A group-based exercise program did not improve physical activity in patients with chronic heart failure and comorbidity: a randomized controlled trial.
        J Rehabil Med. 2014; 46: 461-467
        • Brubaker P.H.
        • Moore J.B.
        • Stewart K.P.
        • Wesley D.J.
        • Kitzman D.W.
        Endurance exercise training in older patients with heart failure: results from a randomized, controlled, single-blind trial.
        J Am Geriatr Soc. 2009; 57: 1982-1989
        • Chrysohoou C.
        • Angelis A.
        • Tsitsinakis G.
        • Spetsioti S.
        • Nasis I.
        • Tsiachris D.
        • et al.
        Cardiovascular effects of high-intensity interval aerobic training combined with strength exercise in patients with chronic heart failure. A randomized phase III clinical trial.
        Int J Cardiol. 2015; 179: 269-274
        • Cider A.
        • Schaufelberger M.
        • Sunnerhagen K.S.
        • Andersson B.
        Hydrotherapy–A new approach to improve function in the older patient with chronic heart failure.
        Eur J Heart Fail. 2003; 5: 527-535
        • Cider A.
        • Tygesson H.
        • Hedberg M.
        • Seligman L.
        • Wennerblom B.
        • Sunnerhagen K.
        Peripheral muscle training in patients with clinical signs of heart failure.
        Scand J Rehabil Med. 1997; 29: 121-127
        • Collins E.
        • Langbein W.E.
        • Dilan-Koetje J.
        • Bammert C.
        • Hanson K.
        • Reda D.
        • et al.
        Effects of exercise training on aerobic capacity and quality of life in individuals with heart failure.
        Heart Lung. 2004; 33: 154-161
        • Corvera-Tindel T.
        • Doering L.V.
        • Woo M.A.
        • Khan S.
        • Dracup K.
        Effects of a home walking exercise program on functional status and symptoms in heart failure.
        Am Heart J. 2004; 147: 339-346
        • Dracup K.
        • Evangelista L.S.
        • Hamilton M.A.
        • Erickson V.
        • Hage A.
        • Moriguchi J.
        • et al.
        Effects of a home-based exercise program on clinical outcomes in heart failure.
        Am Heart J. 2007; 154: 877-883
        • Edelmann F.G.
        • Gelbrich G.
        • Dügen H.G.
        • Fröhling S.
        • Wachter R.
        • Stahrenberg R.
        • et al.
        Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study.
        J Am Coll Cardiol. 2011; 58: 1780-1791
        • Fayazi S.
        • Zarea K.
        • Abbasi A.
        • Ahmadi F.
        Effect of home-based walking on performance and quality of life in patients with heart failure.
        Scand J Caring Sci. 2013; 27: 246-252
        • Flynn K.E.
        • Piña I.L.
        • Whellan D.J.
        • Lin L.
        • Blumenthal J.A.
        • Ellis S.J.
        • et al.
        Effects of exercise training on health status in patients with chronic heart failure: findings from the HF-ACTION randomized controlled trial.
        JAMA. 2009; 301: 1451-1459
        • Gary R.A.
        • Cress M.E.
        • Higgins M.K.
        • Smith A.L.
        • Dunbar S.B.
        Combined aerobic and resistance exercise program improves task performance in patients with heart failure.
        Arch Phys Med Rehabil. 2011; 92: 1371-1381
        • Gary R.A.
        • Cress E.
        • Higgins M.K.
        • Smith A.L.
        • Dunbar S.B.
        A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study.
        J Cardiovasc Nurs. 2012; 27: 418-430
        • Gerovasili V.
        • Drakos S.
        • Kravari M.
        • Malliaras K.
        • Karatzanos E.
        • Dimopoulos S.
        • et al.
        Physical exercise improves the peripheral microcirculation of patients with chronic heart failure.
        J Cardioplum Rehabil Prev. 2009; 29: 385-391
        • Giannuzzi P.
        • Temporelli P.L.
        • Corrà U.
        • Tavazzi L.
        Antiremodeling effect of long-term exercise training in patients with stable chronic heart failure: results of the Exercise in Left Ventricular Dysfunction and Chronic Heart Failure (ELVD-CHF) Trial.
        Circulation. 2003; 108: 554-559
        • Gordon A.
        • Tyni-Lenné R.
        • Jansson E.
        • Kaijser L.
        • Theodorsson-Norheim E.
        • Sylven C.
        Improved ventilation and decreased sympathetic stress in chronic heart failure patients following local endurance training with leg muscles.
        J Card Fail. 1997; 3: 3-12
        • Jankowska E.A.
        • Wegrzynowska K.
        • Superlak M.
        • Nowakowska K.
        • Lazorczyk M.
        • Biel B.
        • et al.
        The 12-week progressive quadriceps resistance training improves muscle strength, exercise capacity and quality of life in patients with stable chronic heart failure.
        Int J Cardiol. 2008; 130: 36-43
        • Kavanagh T.
        • Myers M.G.
        • Baigrie R.S.
        • Mertens D.J.
        • Sawyer P.
        • Shephard R.J.
        Quality of life and cardiorespiratory function in chronic heart failure: effects of 12 months' aerobic training.
        Heart. 1996; 76: 42-49
        • Keteyian S.J.
        • Brawner C.A.
        • Schairer J.R.
        • Levine T.B.
        • Levine A.B.
        • Rogers F.J.
        • et al.
        Effects of exercise training on chronotropic incompetence in patients with heart failure.
        Am Heart J. 1999; 138: 233-240
        • Klocek M.K.
        • Kubinyi A.
        • Bacior B.
        • Kawecka-Jaszcz K.
        Effect of physical training on quality of life and oxygen consumption in patients with congestive heart failure.
        Int J Cardiol. 2005; 103: 323-329
        • Kulcu D.
        • Kurtais Y.
        • Tur B.
        • Gülec S.
        • Seckin B.
        The effect of cardiac rehabilitation on quality of life, anxiety and depression in patients with congestive heart failure. A randomized controlled trial, short-term results.
        Eura Medicophys. 2007; 43: 489-497
        • Larsen A.I.
        • Gjesdal K.
        • Hall C.
        • Aukrust P.
        • Aarsland T.
        • Dickstein K.
        Effect of exercise training in patients with heart failure: a pilot study on autonomic balance assessed by heart rate variability.
        Eur J Cardiovasc Prev Rehabil. 2004; 11: 162-167
        • Levinger I.
        • Bronks R.
        • Cody D.V.
        • Linton I.
        • Davie A.
        Resistance training for chronic heart failure patients on beta blocker medications.
        Int J Cardiol. 2005; 102: 493-499
        • Mandic S.
        • Tymchak W.
        • Kim D.
        • Quinney H.A.
        • Taylor D.
        • et al.
        Effects of aerobic or aerobic and resistance training on cardiorespiratory and skeletal muscle function in heart failure: a randomized controlled pilot trial.
        Clin Rehabil. 2009; 23: 207-216
        • Maria Sarullo F.
        • Gristina T.
        • Brusca I.
        • Milia S.
        • Raimondi R.
        • Sajeva M.
        • et al.
        Effect of physical training on exercise capacity, gas exchange and N-terminal pro-brain natriuretic peptide levels in patients with chronic heart failure.
        Eur J Cardiovasc Prev Rehabil. 2006; 13: 812-817
        • McKelvie R.S.
        • Teo K.K.
        • Roberts R.
        • McCartney N.
        • Humen D.
        • Montague T.
        • et al.
        Effects of exercise training in patients with heart failure: the Exercise Rehabilitation Trial (EXERT).
        Am Heart J. 2002; 144: 23-30
        • O'Connor C.M.
        • Whellan D.J.
        • Lee K.L.
        • Keteyian S.J.
        • Cooper L.S.
        • Ellis S.J.
        • et al.
        Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial.
        JAMA. 2009; 301: 1439-1450
        • Passino C.
        • Severino S.
        • Poletti R.
        • Piepoli M.F.
        • Mammini C.
        • Clerico A.
        • et al.
        Aerobic training decreases b-type natriuretic peptide expression and adrenergic activation in patients with heart failure.
        J Am Coll Cardiol. 2006; 47: 1835-1839
        • Pihl E.
        • Cider A.
        • Strömberg A.
        • Fridlund B.
        • Mårtensson J.
        Exercise in elderly patients with chronic heart failure in primary care: effects on physical capacity and health-related quality of life.
        Eur J Cardiovasc Nurs. 2011; 10: 150-158
        • Prescott E.
        • Hjardem-Hansen R.
        • Dela F.
        • Ørkild B.
        • Teisner A.S.
        • Nielsen H.
        Effects of a 14-month low-cost maintenance training program in patients with chronic systolic heart failure: a randomized study.
        Eur J Carbiovasc Prev Rehabil. 2009; 16: 430-437
        • Quittan M.
        • Sturm B.
        • Wiesinger G.F.
        • Pacher R.
        • Fialka-Moser V.
        Quality of life in patients with chronic heart failure: a randomized controlled trial of changes induced by a regular exercise program.
        Scand J Rehabil Med. 1999; 31: 223-228
        • Tyni-Lenné R.
        • Dencker K.
        • Gordon A.
        • Jansson E.
        • Sylvén C.
        Comprehensive local muscle training increases aerobic working capacity and quality of life and decreases neurohormonal activation in patients with chronic heart failure.
        Eur J Heart Fail. 2001; 3: 47-52
        • Ulbrich A.Z.
        • Angarten V.G.
        • Schmitt Netto A.
        • Sties S.W.
        • Bundchen D.C.
        • Mara L.S.D.
        • et al.
        Comparative effects of high intensity interval training versus moderate intensity continuous training on quality of life in patients with heart failure: Study protocol for a randomized controlled trial.
        Clin Trials and Regul Sci Cardiol. 2016; 13: 21-28
        • Webb-Peploe K.M.
        • Chua T.P.
        • Harrington D.
        • Henein M.Y.
        • Gibson D.G.
        • Coats A.J.
        Different response of patients with idiopathic and ischaemic dilated cardiomyopathy to exercise training.
        Int J Cardiol. 2000; 74: 215-224
        • Willenheimer R.
        • Rydberg E.
        • Cline C.
        • Broms K.
        • Hillberger B.
        • Oberg L.
        • et al.
        Effects on quality of life, symptoms and daily activity 6 months after termination of an exercise training programme in heart failure patients.
        Int J Cardiol. 2001; 77: 25-31
        • Wilson J.R.
        • Groves J.
        • Rayos G.
        Circulatory status and response to cardiac rehabilitation in patients with heart failure.
        Circulation. 1996; 94: 1567-1572
        • Wisløff U.S.
        • Støylen A.
        • Loennechen J.P.
        • Bruvold M.
        • Rognmo Ø.
        • Haram P.M.
        • et al.
        Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study.
        Circulation. 2007; 115: 3086-3094
        • Masaracchio M.
        • Hanney W.J.
        • Liu X.
        • Kolber M.
        • Kirker K.
        Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: a systematic review with metaanalysis.
        PLoS One. 2017; 12e0178295
        • McAlister F.E.
        • J
        • Wiebe N.
        • Rowe B.
        • et al.
        106 cardiac resynchronization therapy for congestive heart failure: summary.
        AHRQ Evidence Report Summaries. 2004; (Available: https://www.ncbi.nlm.nih.gov/books/NBK11907/. Accessed May 17, 2018)
        • Shoemaker M.J.
        • Curtis A.B.
        • Vangsnes E.
        • Dickinson M.G.
        Clinically meaningful change estimates for the six-minute walk test and daily activity in individuals with chronic heart failure.
        Cardiopulm Phys Ther J. 2013; 24: 21-29
        • Jordan J.E.
        • Briggs A.M.
        • Brand C.A.
        • Osborne R.H.
        Enhancing patient engagement in chronic disease self-management support initiatives in Australia: the need for an integrated approach.
        Med J Aust. 2008; 189: S9-S13
        • Conraads V.M.
        • Deaton C.
        • Piotrowicz E.
        • et al.
        Adherence of heart failure patients to exercise: barriers and possible solutions.
        Eur J Heart Fail. 2012; 14: 451-458
        • Moe G.W.
        • Ezekowitz J.A.
        • O'Meara E.
        • et al.
        The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: focus on rehabilitation and exercise and surgical coronary revascularization.
        Can J Cardiol. 2014; 30: 249-263
        • Green C.P.
        • Porter C.B.
        • Bresnahan D.R.
        • Spertus J.A.
        Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure.
        J Am Coll Cardiol. 2000; 35: 1245-1255
        • Middel B.
        • Bouma J.
        • de Jongste M.
        • van Sonderen E.
        • Niemeijer M.
        • van den Heuvel W.
        Psychometric properties of the Minnesota living with heart failure questionnaire (MLHF-Q).
        Clin Rehabil. 2001; 15: 489-500