The incidence of heart failure (HF) is increasing as the population ages. Pharmacotherapy is an important component of treatment and yields significant improvements in survival and quality of life. In recent decades, exercise has gradually become accepted as an intervention beneficial to patients with HF, but more information is needed to clarify the effects of exercise and optimize interventions. Therefore, a systematic review of randomized controlled trials published from 1966 to October 2006 was carried out via PubMed. About 69 trials were reviewed, which used as main outcome measures: (a) central hemodynamic parameters, (b) peripheral blood flow, (c) endothelial function, (d) activation of neurohormones and cytokine systems, (e) structure of and metabolism in skeletal muscles, and/or (f) quality of life. Study findings suggest that the favorable physiological responses to exercise might slow some of the pathophysiological progression of HF. However, most of the trials reviewed here were based on relatively small samples and selected participant groups, and the exercise programs varied widely. These limitations and inconsistencies need to be addressed through further studies. Furthermore, reliable strategies for maintaining the positive effects of exercise and extending them to patients' daily life and quality of life are scarce in these trials. These domains need further exploration through rationally designed, large-scale randomized controlled trials.
Austin, J., Williams, R., Ross, L., Moseley, L., & Hutchison, S. (2005). Randomized controlled trial of cardiac rehabilitation in elderly patients with heart failure. European Journal of Heart Failure, 7, 411-417.
2.
Belardinelli, R., Georgiou, D., Cianci, G., & Purcaro, A. (1999). Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: Effects on functional capacity, quality of life, and clinical outcome. Circulation, 99, 1173-1182.
3.
Beniaminovitz, A., Lang, C.C., LaManca, J., & Mancini, D.M. (2002). Selective low-level leg muscle training alleviates dyspnea in patients with heart failure. Journal of the American College of Cardiology, 40, 1602-1608.
4.
Braith, R.W., Welsch, M.A., Feigenbaum, M.S., Kluess, H.A., & Pepine, C.J. (1999). Neuroendocrine activation in heart failure is modified by endurance exercise training. Journal of the American College of Cardiology, 34, 1170-1175.
5.
Callaerts-Vegh, Z., Wenk, M., Goebbels, U., Dziekan, G., Myers, J., Dubach, P., et al. (1998). Influence of intensive physical training on urinary nitrate elimination and plasma endothelin-1 levels in patients with congestive heart failure. Journal of Cardiopulmonary Rehabilitation, 18, 450-457.
6.
Centers for Disease Control and Prevention. (2006). CDC: Heart failure fact sheet. Retrieved November 1, 2006, from http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf.
7.
Chong, A.Y., & Lip, G.Y. (2007). Viewpoint: The prothrombotic state in heart failure: A maladaptive inflammatory response? European Journal of Heart Failure, 9, 124-128.
8.
Cider, A., Schaufelberger, M., Sunnerhagen, K.S., & Andersson, B. (2003). Hydrotherapy-a new approach to improve function in the older patient with chronic heart failure. European Journal of Heart Failure, 5, 527-535.
9.
Cider, A., Tygesson, H., Hedberg, M., Seligman, L., Wennerblom, B., & Sunnerhagen, K.S. (1997). Peripheral muscle training in patients with clinical signs of heart failure. Scandinavian Journal of Rehabilitation Medicine, 29, 121-127.
10.
Collins, E., Langbein, W.E., Dilan-Koetje, J., Bammert, C., Hanson, K., Reda, D., et al. (2004). Effects of exercise training on aerobic capacity and quality of life in individuals with heart failure. Heart Lung, 33, 154-161.
11.
Colucci, W.S., & Braunwald, E. (2005). Pathophysiology of heart failure. In D. P. Zipes, P. Libby , R. O. Bonow, & E. Braunwald (Eds.), Heart disease: A textbook of cardiovascular medicine. (7th ed., pp. 509-538). Philadelphia, PA: Elsevier Saunders.
12.
Corvera-Tindel, T., Doering, L.V., Woo, M.A., Khan, S., & Dracup, K. (2004). Effects of a home walking exercise program on functional status and symptoms in heart failure. American Heart Journal, 147, 339-346.
13.
de Mello Franco, F.G., Santos, A.C., Rondon, M.U., Trombetta, I.C., Strunz, C., Braga, A.M., et al. (2006). Effects of home-based exercise training on neurovascular control in patients with heart failure. European Journal of Heart Failure, 8, 851-855.
14.
Delagardelle, C., Feiereisen, P., Autier, P., Shita, R., Krecke, R., & Beissel, J. (2002). Strength/endurance training versus endurance training in congestive heart failure. Medicine & Science in Sports & Exercise, 34, 1868-1872.
15.
Department of Health and Human Services [DHHS] ( 1996). Physical activity and health: A report of the surgeon general. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.
16.
Dimopoulos, S., Anastasiou-Nana, M., Sakellariou, D., Drakos, S., Kapsimalakou, S., Maroulidis, G., et al. (2006). Effects of exercise rehabilitation program on heart rate recovery in patients with chronic heart failure. European Journal of Cardiovascular Prevention and Rehabilitation, 13, 67-73.
17.
Dobsak, P., Novakova, M., Fiser, B., Siegelova, J., Balcarkova, P., Spinarova, L., et al. (2006). Electrical stimulation of skeletal muscles. An alternative to aerobic exercise training in patients with chronic heart failure? International Heart Journal, 47, 441-453.
18.
Dubach, P., Myers, J., Dziekan, G., Goebbels, U., Reinhart, W., Muller, P., et al. (1997). Effect of high intensity exercise training on central hemodynamic responses to exercise in men with reduced left ventricular function. Journal of the American College of Cardiology, 29, 1591-1598.
19.
Dziekan, G., Myers, J., Goebbels, U., Muller, P., Reinhart, W., Ratti, R., et al. (1998). Effects of exercise training on limb blood flow in patients with reduced ventricular function. American Heart Journal, 136, 22-30.
20.
Erbs, S., Linke, A., Gielen, S., Fiehn, E., Walther, C., Yu, J., et al. (2003). Exercise training in patients with severe chronic heart failure: Impact on left ventricular performance and cardiac size. A retrospective analysis of the Leipzig heart failure training trial . European Journal of Cardiovascular Prevention and Rehabilitation , 10, 336-344.
21.
Evangelista, L.S., Doering, L.V., Lennie, T., Moser, D.K., Hamilton, M.A., Fonarow, G.C., et al. (2006). Usefulness of a home-based exercise program for overweight and obese patients with advanced heart failure. American Journal of Cardiology, 97, 886-890.
22.
Fleg, J.L., Pina, I.L., Balady, G.J., Chaitman, B.R., Fletcher, B., Lavie, C., et al. (2000). Assessment of functional capacity in clinical and research applications: An advisory from the committee on exercise, rehabilitation, and prevention, Council on Clinical Cardiology, American Heart Association . Circulation, 102, 1591-1597.
23.
Fletcher, G.F., Balady, G.J., Amsterdam, E.A., Chaitman, B., Eckel, R., Fleg, J., et al. (2001). Exercise standards for testing and training: A statement for health care professionals from the American Heart Association . Circulation, 104, 1694-1740.
24.
Gielen, S., Adams, V., Linke, A., Erbs, S., Mobius-Winkler, S., Schubert, A., et al. (2005). Exercise training in chronic heart failure: Correlation between reduced local inflammation and improved oxidative capacity in the skeletal muscle. European Journal of Cardiovascular Prevention and Rehabilitation, 12, 393-400.
25.
Gielen, S., Adams, V., Mobius-Winkler, S., Linke, A., Erbs, S., Yu, J., et al. (2003). Anti-inflammatory effects of exercise training in the skeletal muscle of patients with chronic heart failure. Journal of the American College of Cardiology, 42, 861-868.
26.
Givertz, M.M., Golucci, W.S., & Braunwald, E. (2005). Clinical aspects of heart failure; Pulmonary edema, high-output failure. In D. P. Zipes, P. Libby, R. O. Bonow , & E. Braunwald (Eds.), Heart disease: A textbook of cardiovascular medicine. (pp. 539-569). Philadelphia, PA: Elsevier Saunders.
27.
Gordon, A., Tyni-Lenne, R., Jansson, E., Jensen-Urstad, M., & Kaijser, L. (1999). Beneficial effects of exercise training in heart failure patients with low cardiac output response to exercise - a comparison of two training models. Journal of Internal Medicine, 246(2), 175-182.
28.
Gordon, A., Tyni-Lenne, R., Persson, H., Kaijser, L., Hultman, E., & Sylven, C. (1996). Markedly improved skeletal muscle function with local muscle training in patients with chronic heart failure. Clinical Cardiology, 19(7), 568-574.
29.
Gottlieb, S.S., Fisher, M.L., Freudenberger, R., Robinson, S., Zietowski, G., Alves, L., et al. (1999). Effects of exercise training on peak performance and quality of life in congestive heart failure patients. Journal of Cardiac Failure, 5, 188-194.
30.
Hambrecht, R., Fiehn, E., Weigl, C., Gielen, S., Hamann, C., Kaiser, R., et al. (1998). Regular physical exercise corrects endothelial dysfunction and improves exercise capacity in patients with chronic heart failure. Circulation, 98, 2709-2715.
31.
Hambrecht, R., Fiehn, E., Yu, J., Niebauer, J., Weigl, C., Hilbrich, L., et al. (1997). Effects of endurance training on mitochondrial ultrastructure and fiber type distribution in skeletal muscle of patients with stable chronic heart failure. Journal of the American College of Cardiology, 29, 1067-1073.
32.
Hambrecht, R., Gielen, S., Linke, A., Fiehn, E., Yu, J., Walther, C., et al. (2000). Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial. Journal of the American Medical Association , 283, 3095-3101.
33.
Hambrecht, R., Hilbrich, L., Erbs, S., Gielen, S., Fiehn, E., Schoene, N., et al. (2000). Correction of endothelial dysfunction in chronic heart failure: Additional effects of exercise training and oral L-arginine supplementation. Journal of the American College of Cardiology , 35, 706-713.
34.
Hambrecht, R., Niebauer, J., Fiehn, E., Kalberer, B., Offner, B., Hauer, K., et al. (1995). Physical training in patients with stable chronic heart failure: Effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles. Journal of the American College of Cardiology, 25, 1239-1249.
35.
Hambrecht, R., Schulze, P.C., Gielen, S., Linke, A., Mobius-Winkler, S., Erbs, S., et al. (2005). Effects of exercise training on insulin-like growth factor-1 expression in the skeletal muscle of non-cachectic patients with chronic heart failure. European Journal of Cardiovascular Prevention and Rehabilitation, 12, 401-406.
36.
Harris, S., LeMaitre, J.P., Mackenzie, G., Fox, K.A., & Denvir, M.A. (2003). A randomised study of home-based electrical stimulation of the legs and conventional bicycle exercise training for patients with chronic heart failure. European Heart Journal, 24, 871-878.
37.
Haykowsky, M., Vonder Muhll, I., Ezekowitz, J., & Arm-strong, P. (2005). Supervised exercise training improves aerobic capacity and muscle strength in older women with heart failure . Canadian Journal of Cardiology, 21, 1277-1280.
38.
Hunt, S.A., Baker, D.W., Chin, M.H., Cinquegrani, M.P., Feldman, A.M., Francis, G.S., et al. (2001). ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: Executive summary a report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the 1995 guidelines for the evaluation and management of heart failure): Developed in collaboration with the International Society for Heart and Lung Transplantation; endorsed by the Heart Failure Society of America. Circulation, 104, 2996-3007.
39.
Johnson, P.H., Cowley, A.J., & Kinnear, W.J. (1998). A randomized controlled trial of inspiratory muscle training in stable chronic heart failure. European Heart Journal , 19, 1249-1253.
40.
Jonsdottir, S., Andersen, K.K., Sigurosson, A.F., & Sigurosson, S.B. (2006). The effect of physical training in chronic heart failure. European Journal of Heart Failure, 8, 97-101.
41.
Keteyian, S.J., Levine, A.B., Brawner, C.A., Kataoka, T., Rogers, F.J., Schairer, J.R., et al. (1996). Exercise training in patients with heart failure. A randomized, controlled trial. Annals of Internal Medicine, 124, 1051-1057.
42.
Kiilavuori, K., Naveri, H., Leinonen, H., & Harkonen, M. (1999). The effect of physical training on hormonal status and exertional hormonal response in patients with chronic congestive heart failure. European Heart Journal, 20, 456-464.
43.
Kiilavuori, K., Sovijarvi, A., Naveri, H., Ikonen, T., & Leinonen, H. (1996). Effect of physical training on exercise capacity and gas exchange in patients with chronic heart failure. Chest, 110, 985-991.
44.
Klocek, M., Kubinyi, A., Bacior, B., & Kawecka-Jaszcz, K. (2005). Effect of physical training on quality of life and oxygen consumption in patients with congestive heart failure. International Journal of Cardiology, 103, 323-329.
45.
Kobayashi, N., Tsuruya, Y., Iwasawa, T., Ikeda, N., Hashimoto, S., Yasu, T., et al. (2003). Exercise training in patients with chronic heart failure improves endothelial function predominantly in the trained extremities . Circulation Journal, 67, 505-510.
46.
Krupski, W.C. (1997). Platelets. In A. N. Sidawy, B. E. Sumpio, & R. G. Depalma (Eds.), The basic science of vascular disease (pp. 245-287). Armonk, NY : Futura Publishing.
47.
LeMaitre, J.P., Harris, S., Fox, K.A., & Denvir, M. (2004). Change in circulating cytokines after 2 forms of exercise training in chronic stable heart failure. American Heart Journal, 147, 100-105.
48.
Linke, A., Adams, V., Schulze, P.C., Erbs, S., Gielen, S., Fiehn, E., et al. (2005). Antioxidative effects of exercise training in patients with chronic heart failure: Increase in radical scavenger enzyme activity in skeletal muscle. Circulation, 111, 1763-1770.
49.
Linke, A., Schoene, N., Gielen, S., Hofer, J., Erbs, S., Schuler, G., et al. (2001). Endothelial dysfunction in patients with chronic heart failure: Systemic effects of lower-limb exercise training. Journal of the American College of Cardiology, 37, 392-397.
50.
Mann, D.L., & Bristow, M.R. (2005). Mechanisms and models in heart failure: The biomechanical model and beyond. Circulation, 111, 2837-2849.
51.
McKelvie, R.S., Teo, K.K., Roberts, R., McCartney, N., Humen, D., Montague, T., et al. (2002). Effects of exercise training in patients with heart failure: The exercise rehabilitation trial (exert). American Heart Journal, 144, 23-30.
52.
Meyer, T., Schwaab, B., Gorge, G., Scharhag, J., Herrmann, M., & Kindermann, W. (2004). Can serum NT-proBNP detect changes of functional capacity in patients with chronic heart failure? Zeitschrift fur Kardiologie, 93, 540-545.
53.
Moncada, S., & Higgs, A. (1993). The L-arginine-nitric oxide pathway. New England Journal of Medicine, 329, 2002-2012.
54.
Nuhr, M.J., Pette, D., Berger, R., Quittan, M., Crevenna, R., Huelsman, M., et al. (2004). Beneficial effects of chronic low-frequency stimulation of thigh muscles in patients with advanced chronic heart failure . European Heart Journal, 25, 136-143.
55.
Oka, R.K., De Marco, T., Haskell, W.L., Botvinick, E., Dae, M.W., Bolen, K., et al. (2000). Impact of a home-based walking and resistance training program on quality of life in patients with heart failure. American Journal of Cardiology, 85, 365-369.
56.
Oka, R.K., & Sanders, M.G. (2005). The impact of exercise on body composition and nutritional intake in patients with heart failure. Progress in Cardiovascular Nursing, 20, 148-154.
57.
Parnell, M.M., Holst, D.P., & Kaye, D.M. (2002). Exercise training increases arterial compliance in patients with congestive heart failure. Clinical Science , 102(Lond), 1-7.
58.
Passino, C., Severino, S., Poletti, R., Piepoli, M.F., Mammini, C., Clerico, A., et al. (2006). Aerobic training decreases b-type natriuretic peptide expression and adrenergic activation in patients with heart failure . Journal of the American College of Cardiology, 47, 1835-1839.
59.
Pina, I.L., Apstein, C.S., Balady, G.J., Belardinelli, R., Chaitman, B.R., Duscha, B.D., et al. (2003). Exercise and heart failure: A statement from the American heart association committee on exercise, rehabilitation, and prevention. Circulation, 107, 1210-1225.
60.
Pozehl, B., Duncan, K., Krueger, S., & VerMaas, P. (2003). Adjunctive effects of exercise training in heart failure patients receiving maximum pharmacologic therapy. Progress in Cardiovascular Nursing, 18, 177-183.
61.
Quittan, M., Sturm, B., Wiesinger, G.F., Pacher, R., & Fialka-Moser, V. (1999). Quality of life in patients with chronic heart failure: A randomized controlled trial of changes induced by a regular exercise program. Scandinavian Journal of Rehabilitation Medicine, 31, 223-228.
62.
Quittan, M., Wiesinger, G.F., Sturm, B., Puig, S., Mayr, W., Sochor, A., et al. (2001). Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure: A single-blind, randomized, controlled trial. American Journal of Physical Medicine & Rehabilitation, 80, 206-214.
63.
Reinhart, W.H., Dziekan, G., Goebbels, U., Myers, J., & Dubach, P. (1998). Influence of exercise training on blood viscosity in patients with coronary artery disease and impaired left ventricular function . American Heart Journal, 135, 379-382.
64.
Roveda, F., Middlekauff, H.R., Rondon, M.U., Reis, S.F., Souza, M., Nastari, L., et al. (2003). The effects of exercise training on sympathetic neural activation in advanced heart failure: A randomized controlled trial . Journal of the American College of Cardiology, 42, 854-860.
65.
Sabelis, L.W., Senden, P.J., Fijnheer, R., de Groot, P.G., Huisveld, I.A., Mosterd, W.L., et al. (2004). Endothelial markers in chronic heart failure: Training normalizes exercise-induced vwf release. European Journal of Clinical Investigation, 34, 583-589.
66.
Sabelis, L.W., Senden, P.J., Te Boekhorst, B.C., Hulzebos, H.J., Van De Wiel, A., Van Haeften, T.W., et al. (2004). Does physical training increase insulin sensitivity in chronic heart failure patients?Clinical Science , 106(Lond), 459-466.
67.
Sallis, J.F., & Owen, N. (1999). Measuring physical activity. In Physical activity and behavioral medicine (pp. 71-92). Thousand Oaks, CA: Sage Publication, Inc.
68.
Selig, S.E., Carey, M.F., Menzies, D.G., Patterson, J., Geerling, R.H., Williams, A.D., et al. (2004). Moderate-intensity resistance exercise training in patients with chronic heart failure improves strength, endurance, heart rate variability, and forearm blood flow. Journal of Cardiac Failure, 10, 21-30.
69.
Senden, P.J., Sabelis, L.W., Zonderland, M.L., Hulzebos, E.H., Bol, E., & Mosterd, W.L. (2005). The effect of physical training on workload, upper leg muscle function and muscle areas in patients with chronic heart failure . International Journal of Cardiology, 100, 293-300.
70.
Silva, M.S., Bocchi, E.A., Guimaraes, G.V., Padovani, C.R., Silva, M.H., Pereira, S.F., et al. (2002). Benefits of exercise training in the treatment of heart failure: Study with a control group. Arquivos Brasileiros de Cardiologia, 79, 351-362.
71.
Sturm, B., Quittan, M., Wiesinger, G.F., Stanek, B., Frey, B., & Pacher, R. (1999). Moderate-intensity exercise training with elements of step aerobics in patients with severe chronic heart failure. Archives of Physical Medicine and Rehabilitation, 80, 746-750.
72.
Sullivan, M.J., & Hawthorne, M.H. (1995). Exercise intolerance in patients with chronic heart failure. Progresss in Cardiovascular Disease, 38, 1-22.
73.
Swan, J.W., Walton, C., Godsland, I.F., Clark, A.L., Coats, A.J., & Oliver, M.F. (1994). Insulin resistance in chronic heart failure. European Heart Journal, 15, 1528-1532.
74.
Thom, T., Haase, N., Rosamond, W., Howard, V.J., Rumsfeld, J., Manolio, T., et al. (2006). Heart disease and stroke statistics-2006 update: A report from the American Heart Association statistics committee and stroke statistics subcommittee. Circulation, 113, e85-e151.
75.
Tyni-Lenne, R., Dencker, K., Gordon, A., Jansson, E., & Sylven, C. (2001). Comprehensive local muscle training increases aerobic working capacity and quality of life and decreases neurohormonal activation in patients with chronic heart failure. European Journal of Heart Failure, 3, 47-52.
76.
Tyni-Lenne, R., Gordon, A., Jensen-Urstad, M., Dencker, K., Jansson, E., & Sylven, C. (1999). Aerobic training involving a minor muscle mass shows greater efficiency than training involving a major muscle mass in chronic heart failure patients. Journal of Cardiac Failure, 5, 300-307.
77.
Tyni-Lenne, R., Gordon, A., & Sylven, C. (1996). Improved quality of life in chronic heart failure patients following local endurance training with leg muscles. Journal of Cardiac Failure, 2, 111-117.
78.
van den Berg-Emons, R., Balk, A., Bussmann, H., & Stam, H. (2004). Does aerobic training lead to a more active lifestyle and improved quality of life in patients with chronic heart failure?European Journal of Heart Failure, 6, 95-100.
79.
Vanhoutte, P.M. (1996). Endothelium-dependent responses in congestive heart failure. Journal of Molecular and Cellular Cardiology , 28, 2233-2240.
80.
Wielenga, R.P., Erdman, R.A., Huisveld, I.A., Bol, E., Dunselman, P.H., Baselier, M.R., et al. (1998). Effect of exercise training on quality of life in patients with chronic heart failure. Journal of Psychosomatic Research, 45, 459-464.
81.
Wielenga, R.P., Huisveld, I.A., Bol, E., Dunselman, P.H., Erdman, R.A., Baselier, M.R., et al. (1998). Exercise training in elderly patients with chronic heart failure. Coronary Artery Disease, 9, 765-770.
82.
Wielenga, R.P., Huisveld, I.A., Bol, E., Dunselman, P.H., Erdman, R.A., Baselier, M.R., et al. (1999). Safety and effects of physical training in chronic heart failure. Results of the chronic heart failure and graded exercise study (change). European Heart Journal, 20, 872-879.
83.
Willenheimer, R., Erhardt, L., Cline, C., Rydberg, E., & Israelsson, B. (1998). Exercise training in heart failure improves quality of life and exercise capacity. European Heart Journal, 19, 774-781.
84.
Willenheimer, R., Rydberg, E., Cline, C., Broms, K., Hillberger, B., Oberg, L., et al. (2001). Effects on quality of life, symptoms and daily activity 6 months after termination of an exercise training programme in heart failure patients. International Journal of Cardiology , 77, 25-31.
85.
Witham, M.D., Gray, J.M., Argo, I.S., Johnston, D.W., Struthers, A.D., & McMurdo, M.E. (2005). Effect of a seated exercise program to improve physical function and health status in frail patients > or = 70 years of age with heart failure. American Journal of Cardiology , 95, 1120-1124.
86.
Yeh, G.Y., Wood, M.J., Lorell, B.H., Stevenson, L.W., Eisenberg, D.M., Wayne, P.M., et al. (2004). Effects of tai chi mind-body movement therapy on functional status and exercise capacity in patients with chronic heart failure: A randomized controlled trial. American Journal of Medicine, 117, 541-548.
