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to exercise, resulting in dyspnea. These symptoms make exercise an unpleasant experience and together with depressive mood status, lead to reduced physical activity. Thus, these patients continue with bed rest. This vicious cycle leads to further inactivity during hospitalization by patients with HF (Figure 1). In this way, patients with HF become exercise-intolerant and are less able to perform their activities of daily living (ADL). The mechanisms for skeletal myopathy in patients with HF are unknown. However, the beneficial effect of exercise training to improve skeletal myopathy in patients with HF demonstrates that this process is not irreversible.10 With the aging of society, the number of patients with cardiovascular diseases is increasing in developed countries. The number of elderly patients with HF in Japan is increasing explosively and predicted to reach 1.0 million by 2030.11 The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) demonstrated that elderly Japanese It has been a long time since bed rest was considered useful and exercise considered harmful for patients with heart failure (HF), in the belief that additional myocardial stress would cause further harm.1 Recently, however, exercise training has been shown to benefit patients with HF by improving their exercise tolerance and quality of life.2–5 Currently, exercise training is recommended in clinical guidelines for HF from Japan,6 Europe7 and the USA.8 Several studies have shown that skeletal myopathy, including impaired muscle energy metabolism, transition of fiber type toward fast twitch fibers, and muscle atrophy, contributes to exercise intolerance with symptoms such as fatigue and dyspnea, and to improvements in exercise tolerance following exercise training in patients with HF.9 Bed rest during hospitalization for worsening HF results in skeletal muscle myopathy. The skeletal muscle myopathy induces early fatigue and an increased ventilator response Article p 69

Hospitalization Deteriorates Performance of Activities of Daily Living by Super-Elderly Patients With Heart Failure