Congestive heart failure is a series of conditions when cardiac output cannot meet the metabolic demand of the body. Approximately 5 million people in the United States have been diagnosed with Congestive Heart Failure (CHF). More than half a million people are diagnosed annually. Heart failure is mainly due to a structural or functional defect in the heart. The aim of this article is to talk about the role of physical therapy, and the importance of an exercise regime in patients with congestive heart failure.
Predisposing factors of CHF:
- Coronary artery disease
- Diabetes Mellitus
- Family history of heart failure
- Sedentary life style
Types of CHF:
There are two main types of CHF. It can be systolic dysfunction or diastolic dysfunction.
In systolic dysfunction, the ventricular wall does not let the myocardium contract effectively and ventricles are not able to pump blood out of the heart (eject) efficiently. This reduces the ejection fraction to 40% or below. Normal ejection fraction in a healthy individual is 60 % to 70%.
In diastolic dysfunction, the myocardium is unable to relax completely and thereby unable to have sufficient filling. The ejection fraction with this kind of heart failure is usually normal.
Signs and Symptoms of Congestive Heart Failure:
Cardinal symptoms of congestive heart failure are:
- Shortness of breath at rest or with activity
- Swelling or edema – mainly dependent edema
Clinical presentation is mainly associated with types of heart failure or heart dysfunction.
Diastolic heart failure presents with dyspnea, tachypnea, cough, wheezing, presence of abnormal heart sound S3, systolic murmur, hypoxemia, orthopnea, and peripheral edema ( in right ventricle involvement).
Systolic heart failure clinically demonstrates fatigue, angina, activity intolerance, decreases mental status, decreased urination, cool, pale, diaphoresis, hypoxia, desaturation on SpO2, cyanosis, and dyspnea.
Treatment options for CHF:
Drug therapy is usually combined with exercise therapy in attempt to delay the onset of symptoms. This also improves the quality of life and decreases mortality rate significantly. A primary care physician or a cardiologist prescribes the drug based on the stage or severity of heart failure. Types and number of drugs a patient can be on, also depends on physical symptoms, lifestyle and the tolerance level of a patient. Usually, the patients are on beta blockers and or ACE inhibitors. These will help to reduce heart rate, reduce blood pressure and mainly reduce the after load to the heart. The doctors may also prescribe diuretics to help reduce the edema.
As a physical therapist, you need to be aware of what kind of drug your patient is on and when they take it. The drugs changes vitals and affects the clinical presentation while in the rehab gym.
Exercise as treatment and prevention
Guidelines for exercise protocol with CHF
To this date, there are no specific guidelines developed for the physical therapist to follow in terms of CHF treatment. Plenty of research concludes that exercise is beneficial in the treatment of CHF. It helps to maintain functional level, improves quality of life, and thereby reduces the mortality rate significantly. Research supports aerobic exercises as well as resistance training for CHF. The key point here is to provide moderate intensity of exercise to gain the positive results. Many times, clinicians are nervous to push the patients to their moderate intensity level due to fatigue or exhaustion. We need to remember that fatigue is a cardinal symptom of CHF and it is not going anywhere. We just need to improve their functional activity tolerance so we can push the feeling of lethargy little away!
The research supports moderate intensity of exercises 3 to 5 times a week for 30 to 40 minutes. Exercise sessions should always include a warm up and a cool down period. Research does not show any significant difference in individuals who exercise 3 to 5 times /week vs 5 to 6 times/week.
Exercises for CHF:
Some examples of aerobic exercises are walking, jogging, running, aerobic dancing, cycling, stepping, cross country skiing, swimming, arm cycle ergometry, rowing, chair aerobics etc. Resistance training can be done with use of dumbbells, cuff and hand weights, elastic bands, barbells, hand held blades, Pilates table, punching bags, inflated balls, stability balls, variable resistance exercise machines ( BTE, cybex) etc. Please check my article on how to prescribe exercise to know more about different ways to determine resistance.
It is also very important to make sure your patients are safe while performing exercise. Personally, I don’t rely on age related measurement of maximum heart rate when it comes to clinically complicated patients like a patient with CHF. There are few ways to measure the intensity of heart rate and find a favorable range to be in. Heart rate can be measured by Karvonen method. Maximum heart rate should be between 60 % to 80% in order to achieve favorable results with CHF.
You can also check Borg scale of perceived rate of exertion (RPE) or modified RPE. This will help to know how severe the fatigue level is while performing exercises. Usually with CHF, you want your patient to be at 3 to 5 out of 10 on modified RPE or 11 to 15 out of 20 on RPE to be safe. Again, your patient may not be able to get to that point just in the first session of exercise. I am trying to give some general guidelines for exercise with CHF.
It is a good idea to measure blood pressure as well as heart rate while exercising. You want to see a linear relationship with heart rate as well as with systolic blood pressure and exercise resistance level or over load. As I mentioned above, I like to know what kind of medications my patients take. As that has an effect on their heart rate and blood pressure.
Termination of exercise session with CHF patients:
Exercise is a beneficial treatment tool for CHF but it needs to have the right response. A clinician needs to terminate the exercise session if they see the following signs:
- Decrease in heart rate with increase in workload
- Decrease in systolic BP of more than 10 mm of Hg with increase in workload
- Diastolic BP increase more than 20 mm of HG with increase in workload
- SpO2 measurement is below 80% with supplemental oxygen
- Patient requests to terminate the session
Contraindication of Exercise:
Even though exercise has beneficial effects on CHF patients, there are few criteria to be considered before placing any patient on exercise regime. Absolute contraindications are Unstable Angina and a recent significant change in resting ECG suggesting ischemia, MI or other acute cardiac event.
This article summaries major signs and symptoms of CHF. I tried to talk about general exercise guidelines and when it is time to stop the exercise. It is always a good idea to consult with your physical therapist and or physician to know more about type of heart failure and prognosis. As a clinician, it is also a good idea to be in touch with your patient’s doctor to make sure you both are working for the same goal for your patient.
Hope that helps!!
Guccione, A.A. Geriatric Physical Therapy; third edition.