Study Shines Light on Activity and Exercise in Patients with Heart Failure

The positive effects of exercise training for patients with heart failure are well documented: exercise improves clinical symptoms and quality of life and reduces the risk of future clinical events. Although activity and exercise are beneficial to patients with heart failure, rationale for not adhering to an exercise plan is less well understood, as are perceptions about the benefits, motivators and barriers of exercising.

Two nurse scientists and two research nurses from Cleveland Clinic recently explored perceptions of physical activity and exercise in patients with chronic heart failure in a qualitative, descriptive single-center study. Results were published in September 2014 in the article “Understanding physical activity and exercise behaviors in patients with heart failure” in Heart & Lung: The Journal of Acute and Critical Care.

Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, decided to conduct the study after attending a research presentation at a national conference in which investigators found that less than half of patients enrolled in an exercise group actually carried out activity and exercise instructions as expected.

“I did a literature review and could not find research on factors associated with adherence to activity and exercise,” says Dr. Albert, ACNO, Office of Nursing Research and Innovation at Cleveland Clinic. “Since mortality and hospitalization rates for heart failure remain high – and since even low levels of activity and exercise improve clinical outcomes – I thought it would be important to design a research study to get some answers.”

Dr. Albert teamed with Office of Nursing Research and Innovation team members Jeanne Sorrell, PhD, RN, FAAN, a nurse scientist with expertise in qualitative research, and two research nurses: Jennifer Forney, MSN, RN and Ellen Slifcak, BA, RN, who assisted in interviewing patients and analyzing data. They interviewed 48 patients with heart failure and asked them questions about the value, benefits and barriers of exercise, plus what their physicians told them about exercise and why they did or did not exercise. Several themes emerged.

“The most important was that patients did not receive precise directions from doctors about not only what to do, but also how to exercise,” says Dr. Albert.

In light of these findings, Dr. Albert offers the following recommendations to patients with heart failure and their healthcare team and caregivers:

1. After hospital discharge, patients should increase activity by walking in the home and outside, if weather permits. It is important to stay conditioned; too much sedentary behavior should be avoided.
2. Patients should attend a cardiac rehabilitation program once stable and on optimal heart failure drug therapies (usually six or more weeks after hospital discharge).
3. Patients need to be educated and understand that moderate to vigorous exercises are recommended, including brisk walking, walking on a treadmill or riding a stationary bicycle. In general, patients should start light and build up to 30 minutes per day, five days per week.
4. Patients must complete five minutes of warm up exercises and five minutes of cool down exercises. These exercises can be completed when sitting in a chair or standing and usually involve exercising legs and arms to get blood flowing.
5. To ensure that activities are completed at the right level of exertion, use a simple test called the “Talk Test”:
   1. If patients can talk easily when walking, they should pick up their pace a little and make it less like strolling and more like exercise.
   2. If patients are a little short of breath but are still able to talk when walking, their pace is probably perfect for them.
   3. If patients cannot talk and walk at the same time, due to being too short of breath, they should take a one minute break and then start re-walking, but at a slower pace.
6. Help patients to understand that the more they are active and exercise, the more they will be able to do over time. Their muscles will become re-conditioned and they will have better quality of life and, possibly, survival.

As cited in the journal article, rationale for participating in activity and exercise in patients with heart failure is multi-dimensional. It’s often compounded by misperceptions or lack of information about the benefits of exercise. Dr. Albert and her peers concluded that healthcare providers must be more explicit in educating patients, and patients must have the opportunity to build confidence in their capabilities so they achieve the benefits of exercise.