Is exercise safe with heart failure?

Why is exercise recommended in heart failure?

Heart failure means the heart does not pump blood as effectively as it should, causing breathlessness, fatigue and reduced exercise tolerance. Inactivity makes muscles weaker and less efficient, which worsens symptoms.

UK guidance on chronic heart failure recommends offering a personalised, exercise-based cardiac rehabilitation programme to people with heart failure unless their condition is unstable 3.

What does the evidence show?

A Cochrane review of 60 trials with 8,728 adults with heart failure found that, in the short term, exercise-based cardiac rehabilitation likely reduced all-cause hospital admissions (15.9 per cent compared with 23.8 per cent) and improved quality of life, measured by a 7.39-point improvement on the Minnesota Living with Heart Failure questionnaire 1. There was no evidence of a difference in short-term all-cause mortality 1.

Effects appeared consistent across centre-based and home-based programmes, exercise doses, and aerobic training alone or combined with resistance training 1.

What did the HF-ACTION trial find?

The HF-ACTION trial randomised 2,331 medically stable outpatients with heart failure and reduced ejection fraction to aerobic exercise training plus usual care or usual care alone, with a median follow-up of 30 months 2. The combined rate of death or hospitalisation was 65 per cent with exercise and 68 per cent with usual care, a difference that was not statistically significant 2.

After adjusting for important baseline characteristics, exercise was associated with a modest reduction in death or hospitalisation (hazard ratio 0.89) 2. Adverse events were similar between groups. Exercise adherence fell from a median of 95 to 74 minutes per week over the first year 2, highlighting the challenge of maintaining exercise.

What kind of exercise is suitable?

Programmes usually begin with low to moderate intensity aerobic exercise, such as walking or stationary cycling, for short periods, gradually increasing duration before intensity. Light resistance exercises for the arms and legs improve muscle strength and daily function.

A simple guide is exercising at a level where breathing is faster but talking is still possible. Warm-up and cool-down periods are important.

What precautions are needed?

Before starting, a clinician assesses stability, medicines, heart rhythm and exercise capacity. People with devices such as pacemakers or implantable defibrillators may need specific heart rate limits.

Daily weight checks help detect fluid build-up. Avoid exercising in extreme heat, soon after a large meal or when unwell, and follow advice on fluid intake.

How do heart failure medicines affect exercise?

Some heart failure medicines slow the heart rate, which means heart rate may not rise as much during exercise. For this reason, clinicians often use how breathless or tired a person feels, rather than heart rate alone, to guide intensity.

Diuretics can cause dehydration or dizziness, and blood pressure medicines can cause light-headedness when standing quickly. Exercising at a consistent time relative to medicines, rising slowly and following fluid advice help reduce these effects.

How can I stay motivated to exercise long term?

Maintaining exercise is often harder than starting. Setting personal goals, such as walking to a local shop or playing with grandchildren, and tracking progress in a diary or phone app can help.

Group programmes, exercising with a friend or family member and regular follow-up with the heart failure team provide encouragement. If symptoms change, adjusting rather than abandoning the programme keeps people active.

When should exercise be stopped?

Stop exercising and seek advice for chest pain, severe breathlessness, dizziness, fainting, palpitations or unusual fatigue.

Contact your heart failure team if you notice increasing breathlessness at rest or lying flat, new ankle or abdominal swelling, or a weight gain of more than a couple of kilograms in a few days.

Frequently asked questions