© 2004 European Society of Cardiology
Does aerobic training lead to a more active lifestyle and improved quality of life in patients with chronic heart failure?
a Department of Rehabilitation Medicine Erasmus Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
b Thoraxcenter, Erasmus Medical Center Rotterdam, The Netherlands
* Corresponding author. Tel.: +31-10-4633178; fax: +31-10-4633843. E-mail address: h.j.g.vandenberg{at}erasmusmc.nl
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Abstract |
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 Top Abstract 1. Background2. Aims3. Methods and results4. Results5. ConclusionReferences |
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Background: Due to dyspnea and fatigue, patients with chronic heart failure (CHF) are often restricted in the performance of everyday activities, which gradually may lead to hypoactivity.
Aims: To assess whether aerobic training leads to a more active lifestyle and improved quality of life (QoL) in patients with CHF.
Methods: Patients with stable CHF (NYHA II/III; 59 (11) years) were randomly assigned to a training group (n=18; 3-month aerobic program above standard treatment) or control group (n=16; standard treatment without special advice for exercise). Measurements were performed on level of everyday physical activity (PA, novel accelerometry-based activity monitor) and QoL, and on several related parameters.
Results: Training did not result in a more active lifestyle or improved QoL, but improved (P<0.05) peak power (17%), 6-min walk distance (10%), muscle strength (13–15%) and depression (–1.3 unit). Changes in level of everyday PA were related to changes in peak VO2 (r=0.58, P=0.01) and knee extension strength (r=0.48, P=0.05).
Conclusions: At group level training did not result in a more active lifestyle or improved QoL. However, correlations between training-related changes in parameters suggest that aerobic training has the potential to increase levels of everyday PA in CHF.
Key Words: Exercise training • Heart failure • Everyday physical activity • Quality of life
Received June 26, 2003; Revised July 30, 2003; Accepted October 8, 2003
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1. Background |
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TopAbstract1. Background2. Aims3. Methods and results4. Results5. ConclusionReferences |
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Due to dyspnea and fatigue, patients with chronic heart failure (CHF) are at risk of developing a sedentary lifestyle [1,2], which may have detrimental effects on daily functioning, quality of life (QoL) [3] and prognosis [4]. Several studies have shown considerable improvements in exercise capacity after aerobic training in this patient group [5–8]. However, whether increased exercise capacity leads to increased levels of everyday physical activity (PA) in patients with CHF has not been studied objectively. A discrepancy may exist between the capacity of a patient (what a patient can do) and actual performance (what a patient really does).
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2. Aims |
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TopAbstract1. Background2. Aims3. Methods and results4. Results5. ConclusionReferences |
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To assess whether aerobic training leads to a more active lifestyle in CHF. Furthermore, effects on QoL and on several other parameters (exercise capacity, NYHA classification, fear of movement, satisfaction with everyday PA, feelings of being disabled, depression, anxiety) were established and relationships between changes in parameters were explored.
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3. Methods and results |
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TopAbstract1. Background2. Aims3. Methods and results4. Results5. ConclusionReferences |
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3.1. Subjects
Inclusion criteria: stable heart failure (primarily systolic dysfunction, NYHA class II/III); LVEF<40%; age 40–75 years; aetiology: ischemic heart disease, idiopathic dilated cardiomyopathy, hypertension, non-obstructive valvular disease. Exclusion criteria: exercise-induced ischaemia or arrhythmias, uncontrolled hypertension and exercise limitation due to chronic obstructive pulmonary disease. The investigation conforms with the principles outlined in the Declaration of Helsinki. The study was approved by the Medical Ethics Committee of the Erasmus Medical Center. Written informed consent was obtained from all patients.
3.2. Training protocol
Patients were randomized into a control group and training group. The control group received standard medical treatment without special advice for activities, whereas the training group participated in a 3-month training program (above standard treatment). Training was performed twice a week for 1 h. Training activities were predominantly aerobic and comprised cycling, walking and games. A target heart rate (HR) was individually calculated as: resting HR+(60% of the difference between resting HR and maximal HR).
3.3. Measurements: pre-treatment (t0) and post-treatment after 3 months (t3)
3.3.1. Level of everyday physical activity
For the assessment of everyday PA a novel activity monitor was used (AM, Temec Instruments, Kerkrade, The Netherlands; Fig. 1). The AM is based on long-term ambulatory monitoring of signals from body-fixed accelerometers from which duration, rate and moment of occurrence of static activities (lying, sitting, standing), dynamic activities (walking [including walking stairs and running], cycling, wheelchair-driving, general [non-cyclic] movement) and transitions between postures can be detected [9]. Furthermore, information on the variability of the acceleration signal (motility) can be obtained, which is related to the intensity of body-segment movements [10]. Validity studies in several patient groups (including CHF) have shown that the AM is valid to quantify mobility-related activities [9,11].
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Measurements with the AM were performed during two randomly selected consecutive weekdays (48-h measurement). To avoid measurement bias, the principles of the AM were explained to the subjects only after the measurements. Four ADXL202 uniaxial piezo-resistive accelerometers (Analog devices, Breda, The Netherlands, adapted by Temec Instruments, Kerkrade, The Netherlands) were used (attached to trunk and thighs). The accelerometers were connected to the AM, which was worn around the waist. Accelerometer signals were stored digitally on a PCMCIA flash card with a sampling frequency of 32 Hz. A detailed description of the sensor configuration and activity detection procedure has been described before [1,9,11]. Data of the AM measurement were calculated per day and averaged over 2 days.
3.3.2. Quality of life
QoL was assessed by the Dutch version [12] of the Minnesota Living with Heart Failure Questionnaire of Rector et al. [13]. In addition to a total score, sub-scores representing a physical dimension and an emotional dimension were calculated.
3.3.3. Other tests
Classification according to NYHA was performed by a cardiologist who was unaware of the randomization outcome.
Aerobic capacity was tested by a symptom-limited bicycle ergometer test (Lode, Groningen, The Netherlands) at a constant pedalling speed of 60 rpm with workload increments of 10 W min–1. HR, blood pressure and a 12-lead electrocardiogram were monitored during the test. Gas volume and gas concentrations were measured continuously using a breath-by-breath system (Oxycon Champion, Mijnhardt Oxycon Systems, Bunnik, The Netherlands). Aerobic capacity was defined as the mean oxygen uptake during the last 30 s of exercise (peak VO2, expressed per kilogram bodyweight).
Besides the symptom-limited exercise test, the submaximal 6-min walk test [14] was performed. Patients were instructed to walk as far as they could along a 25-m marked tape during a 6-min period.
Muscle strength of the extensor and flexor muscles of the knees was determined by an isokinetic device (Biodex® dynamometer, Shirley, NY), recording strength as torque in newton meter. Patients performed 10 maximal contractions at 180° s–1 with each leg. Peak torque (PT) was defined as the maximum torque generated by the subject throughout one series of repetitions.
Fear of movement and satisfaction with everyday PA were scored by visual analog rating scales, feelings of being disabled by a subscale of the Medical Psychological Questionnaire for Heart Patients [15], and depression and anxiety by the Hospital Anxiety and Depression Scale [16].
3.4. Statistics
Paired t-tests were used to assess differences between pre- and post-treatment measurements, unpaired t-tests (continuous data) and 
2-tests (categorical data) to test differences in (changes in) parameters between the study groups. Analysis of variance was used to correct for differences in baseline levels between training and control group. Using the Pearson correlation coefficient we investigated relationships between changes in level of everyday PA (operationalised by changes in duration of dynamic activities, as percentage of a 24-h period) and changes in QoL and between changes in these parameters and changes in the other studied parameters. A P-value 
0.05 was considered statistically significant.
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4. Results |
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TopAbstract1. Background2. Aims3. Methods and results4. Results5. ConclusionReferences |
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4.1. Subjects
Thirty-four patients participated (training group n=18, control group n=16). At baseline, weight and body mass index were significantly higher (P<0.01) in the control group than in the training group (Table 1).
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4.2. Effects of training on everyday physical activity and quality of life
Training attendance was 84 (16)%. At t0, the duration of dynamic activities, body motility and number of walking periods (>10 s) were significantly (P<0.05) lower in the control group than in the training group. There were no significant changes after 3 months in any of the parameters of the AM in both the training and control group, and there were also no significant differences in changes between both groups. QoL improved in the training group at the
=0.10 level, although not significantly different from the changes in the control group (Table 2).
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4.3. Effects of training on other parameters
With the exception of peak HR, VO2RER=1 (VO2 at point when respiratory exchange ratio equals unity; is an approximate marker of when anaerobic muscular metabolism is starting) and peak VE/VCO2, exercise capacity was significantly improved (P<0.01, P<0.05) after 3 months in the training group, with improvements ranging from 7% (peak VO2) to 17% (peak power). The training group also improved (P<0.05) on feelings of being disabled, depression and anxiety. Training effects were not significantly different between patients with beta-blockers and patients without beta-blockers. In the control group significant improvements were only seen on 6-min walk distance (3%, P<0.05). The changes were significantly different between the study groups for peak power (P=0.01), 6-min walk distance (P=0.02), extension and flexion PT (P=0.01 and P=0.03, respectively) and depression (P=0.05). Changes in peak VO2 and VO2RER=1 were different between study groups at the
=0.10 level (Table 3).
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4.4. Relationships between changes
Changes in peak VO2 were significantly related with changes in duration of dynamic activities (r=0.58, P=0.01; Fig. 2). In patients in whom peak VO2 had increased with more than 2 ml kg–1 min–1 after training (n=7), the duration of dynamic activities had significantly increased with 2.0 (1.2) (percentage of a 24-h period), corresponding with an increase of 29 min (P=0.005). Changes in extension PT were also related to changes in duration of dynamic activities (r=0.48, P=0.05; Fig. 2). There were no significant correlations between changes in duration of dynamic activities on the one hand and changes in QoL, or any other parameters on the other hand. Changes in QoL (total) were significantly related with changes in peak VE/VCO2 (r=0.69, P=0.003), changes in feelings of being disabled (r=0.50, P=0.04), and changes in anxiety (r=0.47, P=0.05).
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5. Conclusion |
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TopAbstract1. Background2. Aims3. Methods and results4. Results5. ConclusionReferences |
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Despite favourable effects on exercise capacity and depression, the aerobic training program at group level did not result in a more active lifestyle. However, the relationships found between training-related changes in level of everyday PA and changes in peak VO2 and muscle strength (extension PT) indicate that aerobic training has the potential to improve levels of everyday PA in CHF. This is supported by the finding that in the seven patients in whom peak VO2 had increased by more than 2 ml kg–1 min–1 after training, (a 2–3 ml kg–1 min–1 increase is considered a feasible result of training in CHF [6,8,17], the duration of dynamic activities had significantly increased by 29 min per 24-h period, which is a clinically relevant improvement. However, to achieve strong improvements in peak VO2 and muscle strength, and as a consequence probably a more active lifestyle, our training program has to be optimised (increase in training frequency and duration of the program, aerobic activities combined with interval and peripheral muscle training).
Training did not have a surplus value above standard treatment on QoL, but this may be due to the relatively small study population. Furthermore, no relationship was found between changes in level of everyday PA and changes in QoL. However, we did find a significant correlation (r=0.69, P=0.003) between training-related changes in peak VE/VCO2 and changes in QoL, suggesting that improved ventilatory efficiency may be a determinant of improved QoL in patients with CHF. Other potential determinants are improvements in feelings of being disabled and anxiety.
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Acknowledgements |
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We thank Yvonne Grubben and Han van Nieuwenhuizen (Department of Rehabilitation, Erasmus MC), and fellows and paramedics of the Ergometry Lab (Thoraxcenter, Erasmus MC) for performing the measurements and Martin Bulthuis, Jan-Willem de Korver, Hennie Gijzen-Mulders, and Robbart van Linschoten (Rotterdam Foundation for Cardiac Rehabilitation) for performing the training sessions. The study was financed by The Netherlands Heart Foundation, grant no. 1998B111 and the Rotterdam Foundation for Cardiac Rehabilitation.
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