Long-term aerobic exercise maintains peak VO(2), improves quality of life, and reduces hospitalisations and mortality in patients with heart failure.

QUESTION

Does aerobic exercise improve peak VO(2), quality of life, all-cause mortality, and cardiovascular morbidity in patients with chronic heart failure with mild to moderate symptoms?

DESIGN

Randomised, controlled trial with blinded outcome assessment.

SETTING

Hospital and community settings in Italy.

PARTICIPANTS

Patients with chronic heart failure who were clinically stable, had a left ventricular ejection fraction < 40%, and the ability to exercise. Haemodynamically significant valvular heart disease, uncontrolled diabetes or hypertension, and renal insufficiency were exclusion criteria. One hundred and thirty-five patients enrolled in the study and 123 completed the protocol. Randomisation of 123 participants (78% male) allotted 63 to the exercise group and 60 to a usual care group.

INTERVENTIONS

Both groups received counselling on smoking cessation, stress reduction and diet. In addition, the intervention group participated in an exercise training program for 10 years. The program consisted of 3×1-hour sessions per week of aerobic exercise at 60% peak VO(2) at a hospital for 2 months under the supervision of a cardiologist and an exercise therapist, and 2 supervised 1-hour sessions at 70% peak VO(2) the rest of the year in a community setting. Patients were also encouraged to exercise at home at least once a week. Each exercise session included 40 minutes of aerobic activity (cycling and treadmill). The control group received usual care and were advised to continue their usual physical activities for no longer than 30 minutes each session.

OUTCOME MEASURES

The primary outcomes were functional capacity, measured by peak VO(2) as a percentage of predicted maximum VO(2), and quality of life over 10 years. Quality of life was measured using the 21-item Minnesota living with heart failure questionnaire (maximum score 105 points). Secondary outcomes were hospitalisations and cardiac mortality.

RESULTS

At 10-years, the exercise group had maintained a higher peak VO(2) as a percentage of predicted maximum VO(2) compared with the control group (mean difference 13%, 95% CI 11 to 15). Quality of life was significantly better in the exercise group than the control group at 12 months (by 15 points (95% CI 10 to 20) and this was sustained throughout the 10 year study period. The groups differed significantly on the relative risk (hazard ratios) of hospital readmission (0.6, 95% CI 0.3 to 0.8) and cardiac death (0.6, 95% CI 0.3 to 0.8) in favour of the exercise training group.

CONCLUSION

Moderate intensity supervised aerobic exercise for patients with chronic heart failure performed at least twice-weekly for 10 years maintains functional capacity at more than 60% predicted maximum VO(2). It also offers a sustained improvement in quality of life and a reduction in hospitalisations and cardiac mortality.