Aerobic and resistance exercise in heart failure inpatients: a scoping review

Abstract

Exercise performance is an essential tool for managing heart failure. Although the benefits of exercise are well documented for people with chronic and stable heart failure, there is still no consensus on their prescription in patients hospitalized with acute heart failure undergoing clinical stabilization. The aim of this study is to identify the literature on exercise programs encompassing the components of aerobic and resistance training for hospitalized patients admitted for acute heart failure. A scoping review was conducted according to the proposed methodology of the Joanna Briggs Institute. Studies with adults over 18 years old, hospitalized, and diagnosed with acute heart failure who participated in aerobic and resistance exercise training programs during their hospital stay were included. Three studies met the inclusion criteria. One was a retrospective, observational analytical cohort study, in which the main outcome of the exercise program was improvement in the previous disabilities of the participants. The other two were multicenter randomized controlled studies that showed greater improvement in physical function, functional capacity, depression, quality of life, and frailty status in the intervention groups. The exercise prescriptions differed according to the principles of the exercise prescription—frequency of exercise, intensity of exercise, exercise time (duration), type (mode), exercise volume, and progression. It is too early to make recommendations based on evidence of the type structure of an exercise program with aerobic and strength-training components in this population. However, in the exercise programs of the reviewed studies, the predominance of light to moderate intensity and the importance of progressively increase the frequency and duration of the training sessions were demonstrated, with bicycle ergometers and walking being the most common types of aerobic exercises. It is recommended that investment and research in this area should continue with more methodologically robust studies.

Appendices

Appendix A. Search strategy

Data search: 2022/01/12

Scopus

Search	Query (“Title – Abstract AND Keyword”)	Results
1	TITLE-ABS-KEY (((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (resistance OR strength) AND (inpatient OR hospital*)))	178

Web of Science citation database

Search all databases	Query (“Topic”)	Results
1	TS = (((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (Resistance OR Strength) AND (Inpatient OR hospital*)))	129

Query (“Title” OR “Subject Terms” OR “Abstract”)	Databases	Results
TI (((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (Resistance OR Strength) AND (Inpatient OR hospital*))) OR SU (((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (Resistance OR Strength) AND (Inpatient OR hospital*))) OR AB (((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (Resistance OR Strength) AND (Inpatient OR hospital*)))	ClinicalTrials.gov	66
	MEDLINE	64
	MEDLINE with Full Text	64
	OpenAIRE	57
	Complementary Index	29
	CINAHL Complete	25
	Academic Search Complete	24
	Supplemental Index	18
	ScienceDirect	17
	OAIster	16
	Gale Health and Wellness	15
	SPORTDiscus with Full Text	13
	Directory of Open Access Journals	12
	SwePub	3
	Psychology and Behavioral Sciences Collection	2
	Digital Access to Scholarship at Harvard (DASH)	1
	SciELO	1
	Regional Business News	1
	MedicLatina	1
	OpenDissertations	1
	NARCIS	1
	SveMed +	1
	RCAAP	1

OpenGrey

Search		Results
1	((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (Resistance OR Strength) AND (Inpatient OR hospital*))	0

Google Scholar

Search		Results
1	((“Heart failure” OR “Cardiac Failure” OR “Myocardial Failure” OR “Heart Decompensation”) AND (aerobic OR endurance) AND (Resistance OR Strength) AND (Inpatient OR hospital*))	0

Appendix B. Studies ineligible following full-text review

• 1. Abolahrari-Shirazi, S., Kojuri, J., Bagheri, Z., & Rojhani-Shirazi, Z. (2018). Efficacy of combined endurance-resistance training versus endurance training in patients with heart failure after percutaneous coronary intervention: a randomized controlled trial. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 23, 12. https://doi.org/10.4103/jrms.JRMS_743_17

  Reason for exclusion: Ineligible context

• 2. Ambrosetti, M., Doherty, P., Faggiano, P., Corrà, U., Vigorito, C., Hansen, D., … Pedretti, R. F. E. (2017). Characteristics of structured physical training currently provided in cardiac patients: insights from the Exercise Training in Cardiac Rehabilitation (ETCR) Italian survey. Monaldi Archives for Chest Disease, 87(1). https://doi.org/10.4081/monaldi.2017.778

  Reason for exclusion: Ineligible concept

• 3. Braith, R. W., & Edwards, D. G. (2000). Exercise following heart transplantation. Sports Medicine (Auckland, N.Z.), 30(3), 171–192. https://doi.org/10.2165/00007256-200030030-00003

  Reason for exclusion: Ineligible context

• 4. Carvalho, T. de, Milani, M., Ferraz, A. S., Silveira, A. D. da, Herdy, A. H., Hossri, C. A. C., … Serra, S. M. (2020). Brazilian cardiovascular rehabilitation guideline—2020. Arquivos Brasileiros de Cardiologia, 114(5), 943–987. https://doi.org/10.36660/abc.20200407

  Reason for exclusion: Ineligible context

• 5. Coats, A. J. S. (2011). Clinical utility of exercise training in chronic systolic heart failure. Nature Reviews. Cardiology, 8(7), 380–392. https://doi.org/10.1038/nrcardio.2011.

  Reason for exclusion: Ineligible context

• 6. de Gregorio, C. (2018). Physical training and cardiac rehabilitation in heart failure patientS. Advances in Experimental Medicine and Biology, 1067, 161–181. https://doi.org/10.1007/5584_2018_144

  Reason for exclusion: Ineligible context

• 7. Fernandes, S. L., Carvalho, R. R., Santos, L. G., Sá, F. M., Ruivo, C., Mendes, S. L., … Morais, J. A. (2020). Pathophysiology and treatment of heart failure with preserved ejection fraction: state of the art and prospects for the future. Arquivos Brasileiros de Cardiologia, 114(1), 120–129. https://doi.org/10.36660/abc.20190111

  Reason for exclusion: Ineligible context

• 8. Gunn, E., Smith, K. M., McKelvie, R. S., & Arthur, H. M. (2006). Exercise and the heart failure patient: aerobic vs strength training–is there a need for both? Progress in Cardiovascular Nursing, 21(3), 146–150. https://doi.org/10.1111/j.0889-7204.2006.04678.x

  Reason for exclusion: Ineligible context

• 9. Jewiss, D., Ostman, C., & Smart, N. A. (2016). The effect of resistance training on clinical outcomes in heart failure: a systematic review and meta-analysis. International Journal of Cardiology, 221, 674–681. https://doi.org/10.1016/j.ijcard.2016.07.046

  Reason for exclusion: Ineligible context

• 10. Knocke, A. (2012). Program description: physical therapy in a heart failure clinic. Cardiopulmonary Physical Therapy Journal, 23(3), 46–48. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22993502

  Reason for exclusion: Ineligible context

• 11. Larsen, A. I. (2018). The muscle hypothesis in heart failure revised: “the multisite training approach”. European Journal of Preventive Cardiology, 25(12), 1252–1256. https://doi.org/10.1177/2047487318789225

  Reason for exclusion: Ineligible context

• 12. Lindgren, M., & Börjesson, M. (2021). The importance of physical activity and cardiorespiratory fitness for patients with heart failure. Diabetes Research and Clinical Practice, 176, 108,833. https://doi.org/10.1016/j.diabres.2021.108833

  Reason for exclusion: Ineligible context

• 13. Miche, E., Roelleke, E., Wirtz, U., Zoller, B., Tietz, M., Huerst, M., & Radzewitz, A. (2008). Combined endurance and muscle strength training in female and male patients with chronic heart failure. Clinical Research in Cardiology: Official Journal of the German Cardiac Society, 97(9), 615–622. https://doi.org/10.1007/s00392-008-0660-y

  Reason for exclusion: Ineligible context

• 14. Schindler, M. J., Adams, V., & Halle, M. (2019). Exercise in heart failure-what is the optimal dose to improve pathophysiology and exercise capacity? Current Heart Failure Reports, 16(4), 98–107. https://doi.org/10.1007/s11897-019-00428-z

  Reason for exclusion: Ineligible context

• 15. Takada, S., Kondo, T., Yasunaga, M., Watanabe, S., Kinoshita, H., Fukuhara, S., & Yamamoto, Y. (2020). Early rehabilitation in older patients hospitalized with acute decompensated heart failure: a retrospective cohort study: early rehabilitation and acute heart failure. American Heart Journal, 230, 44–53. https://doi.org/10.1016/j.ahj.2020.09.009

  Reason for exclusion: Ineligible context

• 16. Van Iterson, E. H., & Olson, T. P. (2017). Therapeutic targets for the multi-system pathophysiology of heart failure: exercise training. Current Treatment Options in Cardiovascular Medicine, 19(11), 87. https://doi.org/10.1007/s11936-017-0585-8

  Reason for exclusion: Ineligible context

• 17. Vuckovic, K. M., Piano, M. R., & Phillips, S. A. (2013). Effects of exercise interventions on peripheral vascular endothelial vasoreactivity in patients with heart failure with reduced ejection fraction. Heart, Lung and Circulation, 22(5), 328–340. https://doi.org/10.1016/j.hlc.2012.12.006

  Reason for exclusion: Ineligible context

Appendix C. Characteristics of included studies

Author(s), year of publication, country	Study objective(s)	Population and sample size	Frequency of the implemented exercise training program	Intensity of the implemented exercise training program	Time (duration) of the implemented exercise training program	Type of the implemented exercise training program	Volume of the implemented exercise training program	Rate of progression of the implemented exercise training program
Kitzman et al. (2021), USA [21]	To evaluate the effect of a multi-domain structured physical rehabilitation intervention the on the physical function and on the 6-month rate of rehospitalization for any cause	Patients ≥ 60 years hospitalized with acute decompensated heart failure N = 349 (experimental group: 175; control group: 174)	One session of exercise per day	Borg RPE scale (6 to 20), ≤ 12	Up to 45 min	Aerobic component: walking and bicycle ergometer; Resistance component: sit to stand, step-up and side step-up, calf raise, stand to squat, proprioceptive neuromuscular facilitation patterns, open chain standing upper and lower extremities exercises using theraband (hip abductors, hip flexors, hip extensors, knee flexors, knee extensors, shoulder press, shoulder abductors, elbow flexors, elbow extensors	Not described; Average number of sessions per participant of 1.8 sessions	Assessment of the participants’ functional performance level (levels 1 to 4, from lowest to highest)—In the aerobic component, the time at which each participant could walk continuously without stopping was counted, with level 1 corresponding to the ability to walk at the usual pace for less than 2 min, level 2 corresponding to the ability to walk at the usual pace for 2 or more min but less than 10 min, level 3 corresponding to the ability to walk at the usual pace for 10 min or more but less than 20 min, and level 4 corresponding to the ability to walk at the usual pace for 20 min or more. Regarding the resistance component, the participant’s ability to get up from a chair without hand support was evaluated, with level 1 corresponding to the inability of this action, level 2 corresponding to the ability to rise from a chair at least once, level 3 corresponding to the ability to rise from a chair five times between 15 and 60 s, and level 4 corresponding to the ability to rise from a chair five times in less than 15 s Aerobic component: level 1: 5–9 min, level 2: 10–19 min, level 3: 20–29 min, level 4: 30–35 min (the participant should be encouraged to exceed the goal duration if able and then progressed to the next level at the subsequent session); Resistance component: once the participant can perform 1 set of 10 repetitions for each exercise without exceeding the target RPE in 2 consecutive sessions, the resistance is to be increased; proprioceptive neuromuscular facilitation patterns will be assisted or resisted by the study therapist to match the participant’s ability (1 set of 10 reps.); therabands with increasing resistance
Reeves et al. (2017), USA [22]	To determine the feasibility, reasonableness, adherence and potential for efficacy of an intervention, as well as the potential safety, and to estimate the intervention effect size	Patients ≥ 60 years hospitalized with acute decompensated heart failure N = 27 (experimental group: 15; control group: 12)	The same data as in the study by Kitzman et al. (21)	The same data as in the study by Kitzman et al. (21)	The same data as in the study by Kitzman et al. (21)	The same data as in the study by Kitzman et al. (21)	Not described	The same data as in the study by Kitzman et al. (21)
Motoki et al. (2019), Japan [20]	To evaluate the impact of a cardiac rehabilitation intervention on disability and prognosis	Patients hospitalized with acute decompensated heart failure N = 171	Five sessions of exercise per week carried out during 2 weeks	Borg RPE scale (6 to 20 between the values 11 to 13 or target heart rate training zone between 30 and 50%	30 min	Aerobic component: walking and bicycle ergometer; Resistance component: squats, calf raises, and weight training	Not described	Progression from the first stage (“sitting up in bed, sit-to-stand motions, self-care, and walking within the ward) to the second stage (exercise with the aerobic and resistance components)