Physical Activity in the Prevention of Heart Failure

In 1988, Sullivan and colleagues from Duke University took a bold and novel step forward in the treatment of heart failure with the publication of their comprehensive seminal study of exercise training in 12 patients with heart failure (left ventricular ejection fraction 24±10%).1 Whereas exercise was previously proscribed in such patients, using invasive hemodynamic measurements, radionuclide angiography, and metabolic measures including gas exchange and lactate analysis, these intrepid investigators demonstrated that ambulatory patients with heart failure can significantly improve their exercise tolerance largely through training-induced changes that occur in the periphery. They concluded that exercise training “may represent a useful therapeutic option in stable patients [with heart failure].” This study served as a major stimulus for nearly 3 decades of subsequent research that has consistently demonstrated improvements in functional capacity, subjective symptoms, and quality of life with exercise training in patients who have heart failure.2–4 Mechanistic studies have uncovered changes that occur in the central and peripheral circulation, exercising muscles, autonomic nervous system, and other integrated systems that lead to such improvements. These studies have prompted the question: Does exercise training affect mortality among patients with heart failure and reduced ejection fraction? This important issue has since been addressed by the National Institutes of Health–funded, multicentered, randomized, and controlled Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) trial that measured the effects of exercise training on clinical outcomes in stable, medically optimized patients with heart failure and left ventricular ejection fraction 35%. After adjusting for prespecified predictors of mortality, a significant 11% reduction in the composite primary end point of all-cause mortality or all-cause hospitalization was found.5 Accordingly, exercise training is now recognized as a valuable adjunct in the therapeutic approach to the patient with stable heart failure, and is recommended by …