Effects of exercise training in patients with heart failure: The Exercise Rehabilitation Trial (EXERT)

doi:10.1067/mhj.2002.123310

American Heart Journal

Volume 144, Issue 1, July 2002, Pages 23-30

https://doi.org/10.1067/mhj.2002.123310 Get rights and content

Abstract

Background The purpose of this study was to examine the effects of exercise training on functional capacity in patients with heart failure. Methods One hundred eighty-one patients in New York Heart Association class I to III, with ejection fraction <40% and 6-minute walk distance <500 meters, were recruited into a randomized, controlled, single-blind trial comparing 3 months of supervised training, then 9 months of home-based training with usual care. Results There was a significant increase in 6-minute walk distance at 3 and 12 months but no between-group differences. Incremental peak oxygen uptake increased in the exercise group compared with the control group at 3 months (0.104 ± 0.026 L/min vs 0.025 ± 0.023 L/min; P =.026) and 12 months (0.154 ± 0.074 L/min vs 0.024 ± 0.027 L/min; P =.081). Compared with the control group, significant increases were observed in the exercise group for arm and leg strength. No significant changes were observed in cardiac function or quality of life. Adherence to exercise was good during supervised training but reduced during home-based training. Conclusions Exercise training improves peak oxygen uptake and strength during supervised training. Over the final 9 months of the study, there was little further improvement, suggesting that some supervision is required for these patients. There were no adverse effects on cardiac function or clinical events. (Am Heart J 2002;144:23-30.)

Section snippets

Study design

A total of 181 patients were recruited from Hamilton, Ontario, and Edmonton, Alberta, Canada, into a randomized, controlled, single-blind trial (blinded end point evaluation; stratification by center) comparing prescribed exercise training with usual care, with outcome evaluations at 3 and 12 months. Evaluation and training protocols were standardized between centers. Patients were stable on standard medical therapy (angiotensin-converting enzyme inhibitors, diuretics, and digoxin as necessary)

Patients

There were 181 randomly assigned patients (91 in the control group and 90 in the exercise group). There were no differences between the control and exercise training groups with respect to age, resting ejection fraction, New York Heart Association class, cause of heart failure, or duration of heart failure (Table I).

. Baseline patient characteristics

Characteristic	Control (n = 91)	Exercise (n = 90)
Age (y)	66.1 ± 0.99	64.8 ± 1.1
Weight (kg)	80.5 ± 1.9	79.6 ± 1.8
Males/females (%)	80/20	82/18
NYHA-FC I/II/III

Discussion

To date, this is the largest study with the longest follow-up examining the effects of exercise training in patients with heart failure. There was a 9-month home-based training component as part of the 12 months of follow-up with blinded evaluation of patients on a range of clinically useful outcomes. Although there was no improvement in 6-minute walk distance, training did significantly increase both peak oxygen uptake and muscle strength immediately after the structured supervised training

Acknowledgements

We thank Ann Page, Dianne Tomson, and Lesly Hill for recruiting and helping to follow up the patients during the study. We also thank Chris Steffann and Tammy Levesque for secretarial assistance.

References (23)

RS McKelvie et al.
Effects of exercise training in patients with congestive heart failure: a critical review
J Am Coll Cardiol
(1995)
R Hambrecht et al.
Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles
J Am Coll Cardiol
(1995)
GH Guyatt et al.
How should we measure function in patients with chronic heart and lung disease?
J Chronic Dis
(1985)
LP Cahalin et al.
The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure
Chest
(1996)
K Meyer et al.
Effects of exercise training and activity restriction on 6-minute walking test performance in patients with chronic heart failure
Am Heart J
(1997)
JB Kostis et al.
Nonpharmacologic therapy improves functional and emotional status in congestive heart failure
Chest
(1994)
C Opasich et al.
Reproducibility of the six-minute walking test in patients with chronic congestive heart failure: practical implications
Am J Cardiol
(1998)
C Lucas et al.
The 6-minute walk and peak oxygen consumption in advanced heart failure: aerobic capacity and survival
Am Heart J
(1999)
SL Olsen et al.
Carvedilol improves left ventricular function and symptoms in chronic heart failure: a double-blind randomized study
J Am Coll Cardiol
(1995)
European Heart Failure Training Group
Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the improvement in exercise tolerance
Eur Heart J
(1998)

AJ Coats et al.

Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation and autonomic function

Circulation

(1992)

Cited by (266)

Exercise-based cardiac rehabilitation for left ventricular function in patients with heart failure: A systematic review and meta-analysis
2024, Current Problems in Cardiology
To evaluate the effect of exercise rehabilitation on the left ventricular (LV) function in patients with heart failure (HF).
PubMed, Cochrane Library and Embase were searched until May 2023. Randomized controlled trials (RCTs) providing data on changes in LV function, comparing exercise to no-exercise controls with HF of any type, were included.
A total of 16 studies including 1443 participants were included. LV end-diastolic diameter (LVEDD) was significantly improved in the exercise group [mean differences (MD), −2.67; 95 % confidence interval (CI) (−4.88, −0.46); P=0.02], but left atrial volume index (LAVI), left ventricular end-systolic diameter (LVESD), E/e′ E/A, end-diastolic volume (EDV), end-systolic volume (ESV), left ventricular ejection fraction (LVEF) and LV mass were unaltered compared to the non-exercise group. High intensity interval training (HIIT) or with moderate exercise (MT) led to improvement in LVEDD [MD, 3.62; 95 %CI (2.55, 4.69); P<0.00001], but not LAVI, E/e′ and E/A. Sensitivity and subgroup analyses showed that the location, the type of HF and study duration may be the source of heterogeneity in LVEF. Age appears to be a source of heterogeneity in EDV and ESV. The Egger test indicated no significant publication bias.
Exercise can partially improve LV function in patients with HF, with improvements appearing to be dependent on study quality, the type of HF, and race. However, there are some indicators that do not seem to improve or are even worse than the control group. Among all exercise modalities, HIIT shows the greatest benefit for HF patients.
Effect of combined aerobic and resistance training on peak oxygen consumption, muscle strength and health-related quality of life in patients with heart failure with reduced left ventricular ejection fraction: a systematic review and meta-analysis
2019, International Journal of Cardiology
The aim of this study was to investigate the effects of combined aerobic and resistance training on peak oxygen consumption (peak VO₂), minute ventilation/carbon dioxide production (VE/VCO₂ slope), muscle strength and health-related quality of life (HRQoL) in heart failure patients with reduced left ventricular ejection fraction (HFrEF).
We searched Cochrane, Pubmed, and PEDro (from the earliest date available to September 2018) for RCTs that evaluated the effects of combined aerobic and resistance training in HFrEF patients. Weighted mean differences (WMD), standardized mean difference (SMD), and 95% confidence interval (CI) were calculated.
39 studies met the study criteria, including 2008 patients, 14 compared combined aerobic and resistance training versus aerobic training, and 25 compared combined aerobic and resistance training versus control. Compared to aerobic training, combined aerobic and resistance training resulted in improvement in muscle strength SMD 0.7 (95% CI: 0.3 to 1.0 N = 167) and, HRQoL WMD –2.6 (95% CI: −5.0 to −0.1 N = 138). A nonsignificant difference in peak VO₂ and VE/VCO₂ slope was found for participants in the combined aerobic and resistance training group compared with aerobic training group. Compared to control, combined aerobic and resistance training resulted in improvement in peak VO₂ WMD 2.9 (95% CI: 1.6 to 4.4 N = 638), muscle strength SMD 0.64 (95% CI: 0.4 to 0.9 N = 315) and, HRQoL WMD –9.8 (95% CI: −15.2 to −4.5 N = 524).
Combined aerobic and resistance training improves peak VO₂, muscle strength and HRQoL and should be considered as a component of care of HFrEF patients.
Impact of Exercise Rehabilitation on Exercise Capacity and Quality-of-Life in Heart Failure: Individual Participant Meta-Analysis
2019, Journal of the American College of Cardiology
Previous systematic reviews have indicated that exercise-based cardiac rehabilitation (ExCR) for patients with heart failure (HF) has a beneficial effect on health-related quality-of-life (HRQoL) and exercise capacity. However, there is uncertainty regarding potential differential effects of ExCR across HF patient subgroups.
The authors sought to undertake an individual participant data (IPD) meta-analysis to: 1) assess the impact of ExCR on HRQoL and exercise capacity in patients with HF; and 2) investigate differential effects of ExCR according to a range of patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischemic etiology, ejection fraction, and exercise capacity.
A single dataset was produced, comprising randomized trials where ExCR (delivered for 3 weeks or more) was compared with a no exercise control group. Each trial provided IPD on HRQoL or exercise capacity (or both), with follow-up of 6 months or more. One- and 2-stage meta-analysis models were used to investigate the effect of ExCR overall and the interactions between ExCR and participant characteristics.
IPD was obtained from 13 trials for 3,990 patients, predominantly (97%) with reduced ejection fraction HF. Compared with the control group, there was a statistically significant difference in favor of ExCR for HRQoL and exercise capacity. At 12-month follow-up, improvements were seen in 6-min walk test (mean 21.0 m; 95% confidence interval: 1.57 to 40.4 m; p = 0.034) and Minnesota Living With HF score (mean improvement 5.9; 95% confidence interval: 1.0 to 10.9; p = 0.018). No consistent evidence was found of differential intervention effects across patient subgroups.
These results, based on an IPD meta-analysis of randomized trials, confirm the benefit of ExCR on HRQoL and exercise capacity and support the Class I recommendation of current international clinical guidelines that ExCR should be offered to all HF patients. (Exercise Training for Chronic Heart Failure [ExTraMATCH II]: protocol for an individual participant data meta-analysis; PROSPERO: international database of systematic reviews CRD42014007170)
Functional evaluation of a physical training programme in myocardial infarction patients with severe left ventricular systolic dysfunction
2020, Revista Colombiana de Cardiologia
Evaluar la factibilidad y los efectos sobre la capacidad funcional de un programa de entrenamiento físico supervisado, aplicado en pacientes con disfunción sistólica severa del ventrículo izquierdo después de infarto agudo de miocardio.
Se estudiaron 37 pacientes, de ambos sexos y sin límites de edad, con diagnóstico de disfunción sistólica severa del ventrículo izquierdo, después de haber sufrido un infarto agudo de miocardio, que consecutivamente se incorporaron al programa ambulatorio del Centro de Rehabilitación del Instituto de Cardiología.
Se hicieron pruebas de esfuerzo máximas limitadas por síntomas con determinación de consumo de oxígeno, ecocardiogramas en reposo y ventriculografías isotópicas en reposo y esfuerzo a los 2, 8 y 18 meses de evolución, y un tiempo medio de seguimiento clínico de 4,1 años. A todos se les prescribió un régimen de entrenamiento físico moderado o intenso, durante un año como mínimo. Se consideró disfunción sistólica severa cuando la fracción de eyección del ventrículo izquierdo fue menor de 35%.
Todos los parámetros ergométricos que expresaron capacidad funcional incrementaron significativamente en la evaluación del octavo mes (p< 0,0005), permaneciendo invariables a los 18. La fracción de eyección del ventrículo izquierdo media en reposo inicial fue de 28,3 ± 5,3%, la cual no mostró variaciones significativas con el esfuerzo ni con otros estudios evolutivos. La mortalidad total y la morbilidad de la serie fueron de 10,5% y 47,3%, respectivamente.
El entrenamiento físico supervisado en pacientes infartados con disfunción sistólica severa de ventrículo izquierdo fue seguro y efectivo, y mejoró su calidad de vida, sin causar efectos negativos sobre la función ventricular.
To evaluate the feasibility and effects on the functional capacity of a supervised physical training programme carried out on patients with severe left ventricular systolic dysfunction after an acute myocardial infarction.
The study included a total of 37 patients, males and females of any age, with a diagnosis of severe left ventricular systolic dysfunction after having suffered an acute myocardial infarction. They were consecutively included into the ambulatory programme of the Institute of Cardiology Rehabilitation Centre.
Maximum effort tests, limited by symptoms, were performed to determine oxygen consumption. Echocardiograms were also performed at rest, with isotopic ventriculography at rest and then at 2, 8, and 18 months. The mean clinical follow-up was 4.1 years. They were all prescribed to a moderate or intense training programme for at least one year. Severe left ventricular systolic dysfunction was considered when the left ventricular ejection fraction was less than 35%.
All the ergometric parameters that expressed functional capacity increased significantly in the evaluation at 8 months (P< .0005), and remained at 18 months. The initial mean left ventricular ejection fraction at rest was 28.3 ± 5.3%, which showed no significant changes with effort or in the other evaluation times. The overall mortality and morbidity of the series was 10.5% and 47.3%, respectively.
Supervised physical training in patients after an acute myocardial infarction and with severe left ventricular systolic dysfunction was safe and effective, and improved the quality of life, without causing negative effects on ventricular function.
Exercise-based cardiac rehabilitation for adults with heart failure
2024, Cochrane Database of Systematic Reviews
Exercise-based cardiac rehabilitation for adults with heart failure – 2023 Cochrane systematic review and meta-analysis
2023, European Journal of Heart Failure

View all citing articles on Scopus

^*: Supported by the Medical Research Council of Canada.

^**: Reprint requests: R. S. McKelvie, MD, PhD, FRCP(C), Hamilton Health Sciences Corporation, General Site, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada.

^★: E-mail: [email protected].

View full text

Clinical Investigations: Congestive Heart FailureEffects of exercise training in patients with heart failure: The Exercise Rehabilitation Trial (EXERT)*,**,★

Abstract

Section snippets

Study design

Patients

Discussion

Acknowledgements

J Am Coll Cardiol

J Am Coll Cardiol

J Chronic Dis

Chest

Am Heart J

Chest

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the improvement in exercise tolerance

Eur Heart J

Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation and autonomic function

Circulation

Clinical Investigations: Congestive Heart Failure
Effects of exercise training in patients with heart failure: The Exercise Rehabilitation Trial (EXERT)*,**,★