Findings by SBU Alert
Technology and target group
Exercise training is an established treatment method in the rehabilitation of patients with symptoms of coronary artery disease, eg, as myocardial infarction and angina. The aim of treatment is to increase the patients exercise capacity, which in the long term is presumed to help reduce morbidity and premature death. This approach has also been tested in the rehabilitation of patients with heart failure as a complement to other treatment, eg, medication. An estimated 200 000 individuals in Sweden suffer from heart failure. A prerequisite for starting an exercise training program is that the patients heart-failure status must be stable and that physical exertion does not lead to angina. The target group in Sweden is estimated to be approximately 50 000 individuals annually.
Results have been published from 15 randomized controlled studies that tested physical exercise as adjuvant therapy in the rehabilitation of severely ill patients with chronic heart failure. Together the studies included around 600 patients aged 50 to 70 years. The exercise programs were carried out under medical supervision. Various exercise methods were used, eg, walking and bicycle ergometer. The exercise sessions were repeated 2 to 3 times per week and continued between 1 and 6 months. Changes in exercise capacity, quality of life, morbidity, and mortality were used as outcome measures. All of the studies found that patients exercise capacity increased between 20 percent and 38 percent. Six of the nine studies that investigated quality of life found a better quality of life in the exercise group compared to the group that did not have a training program. Three other studies found no impact on quality of life. No definitive conclusions can be drawn concerning the extent to which exercise training influences cardiac complications or mortality.
There are no scientific studies showing evidence on the cost-effectiveness of the method.
There is moderate* evidence on the effects of exercise training, but no* evidence on its cost effectiveness. To render valid judgements concerning the effects of exercise training on heart failure, it is essential to use sufficiently large studies with long-range followup. It would be advantageous to study exercise training programs where patients could participate without special supervision. These studies should also address the health economic aspects.
*This assessment by SBU Alert uses a 4-point scale to grade the quality and evidence of the scientific documentation. The grades indicate: (1) good, (2) moderate, (3) poor, or (4) no scientific evidence on the subject.
This summary is based on a report prepared at SBU in collaboration with André Biskop, MD, Leningrad County Cardiology Hospital, St. Petersburg, Russia and Hans Persson, MD PhD, Danderyd Hospital, Stockholm. It has been reviewed by Prof. Mona Britton, Karolinska Institute and SBU, Stockholm.
Alert is a joint effort by the Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.
- Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation 1999;99(9):1173-82.
- Cider A, Tygesson H, Hedberg M, Seligman L, Wennerblom B, Sunnerhagen KS. Peripheral muscle training in patients with clinical signs of heart failure. Scand J Rehabil Med 1997;29(2):121-7.
- Dubach P, Myers J, Dziekan G, Goebbels U, Reinhart W, Vogt P et al. Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction: application of magnetic resonance imaging. Circulation 1997;95(8):2060-7.
- Giannuzzi P, Tavazzi L, Temporelli PL, Corra U, Imparato A, Gattone M et al. Long-term physical training and left ventricular remodeling after anterior myocardial infarction: results of the Exercise in Anterior Myocardial Infarction (EAMI) trial. EAMI Study Group. J Am Coll Cardiol 1993;22(7):1821-9.
- Giannuzzi P, Temporelli PL, Corra U, Gattone M, Giordano A, Tavazzi L. Attenuation of unfavorable remodeling by exercise training in postinfarction patients with left ventricular dysfunction: results of the Exercise in Left Ventricular Dysfunction (ELVD) trial. Circulation 1997;96(6):1790-7.
- Gottlieb SS, Fisher ML, Freudenberger R, Robinson S, Zietowski G, Alves L et al. Effects of exercise training on peak performance and quality of life in congestive heart failure patients. J Card Fail 1999;5(3):188-94.
- Hambrecht R, Gielen S, Linke A, Fiehn E, Yu J, Walther C et al. Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial. JAMA 2000;283(23):3095-101.
- Jette M, Heller R, Landry F, Blumchen G. Randomized 4-week exercise program in patients with impaired left ventricular function. Circulation 1991;84(4):1561-7.
- Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane Review). In: The Cochrane Library, Issue 1, 2001. Oxford: Update Software.
- Keteyian SJ, Brawner CA, Schairer JR, Levine TB, Levine AB, Rogers FJ et al. Effects of exercise training on chronotropic incompetence in patients with heart failure. Am Heart J 1999;138(2 Pt 1):233-40.
- Kiilavuori K, Sovijarvi A, Naveri H, Ikonen T, Leinonen H. Effect of physical training on exercise capacity and gas exchange in patients with chronic heart failure. Chest 1996;110(4):985-91.
- Koch M, Douard H, Broustet JP. The benefit of graded physical exercise in chronic heart failure. Chest 1992;101(5 Suppl):231S-235S.
- McKelvie RS, Teo KK, McCartney RS, Roberts RS, Costantini LA, Montague TJ, Humen DP, Guyatt GH, Yusuf S. Randomized controlled trial of exercise training in patients with congestive heart failure (EXERT). J Am Coll Cardiol. 1998;31(suppl A):1226-1231.
- Owen A, Croucher L. Effect of an exercise programme for elderly patients with heart failure. Eur J Heart Fail 2000;2(1):65-70.
- Quittan M, Sturm B, Wiesinger GF, Pacher R, Fialka-Moser V. Quality of life in patients with chronic heart failure: a randomized controlled trial of changes induced by a regular exercise program. Scand J Rehabil Med 1999;31(4):223-8.
- Specchia G, De Servi S, Scire A, Assandri J, Berzuini C, Angoli L et al. Interaction between exercise training and ejection fraction in predicting prognosis after a first myocardial infarction. Circulation 1996;94(5):978-82.
- Sturm B, Quittan M, Wiesinger GF, Stanek B, Frey B, Pacher R. Moderate-intensity exercise training with elements of step aerobics in patients with severe chronic heart failure. Arch Phys Med Rehabil 1999;80(7):746-50.
- Tyni-Lenne R, Dencker K, Gordon A, Jansson E, Sylven C. Comprehensive local muscle training increases aerobic working capacity and quality of life and decreases neurohormonal activation in patients with chronic heart failure. Eur J Heart Fail 2001;3(1):47-52.
- Tyni-Lenne R, Gordon A, Jansson E, Bermann G, Sylven C. Skeletal muscle endurance training improves peripheral oxidative capacity, exercise tolerance, and health-related quality of life in women with chronic congestive heart failure secondary to either ischemic cardiomyopathy or idiopathic dilated cardiomyopathy. Am J Cardiol 1997;80(8):1025-9.
- Wielenga RP, Erdman RA, Huisveld IA, Bol E, Dunselman PH, Baselier MR et al. Effect of exercise training on quality of life in patients with chronic heart failure. J Psychosom Res 1998;45(5):459-64.
- Wielenga RP, Huisveld IA, Bol E, Dunselman PH, Erdman RA, Baselier MR et al. Safety and effects of physical training in chronic heart failure. Results of the Chronic Heart Failure and Graded Exercise study. Eur Heart J 1999;20(12):872-9.
- Wielenga RP, Huisveld IA, Bol E, Dunselman PH, Erdman RA, Baselier MR et al. Exercise training in elderly patients with chronic heart failure. Coron Artery Dis 1998;9(11):765-70.
- Willenheimer R, Erhardt L, Cline C, Rydberg E, Israelsson B. Exercise training in heart failure improves quality of life and exercise capacity. Eur Heart J 1998;19(5):774-81.