Artigo 56 - Resistance Exercise Training in Patients With Heart Failure

8/11/2019 Artigo 56 - Resistance Exercise Training in Patients With Heart Failure

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Sports Med 2005; 35 (12): 1085-1103REVIEWARTICLE 0112-1642/05/0012-1085/$34.95/0

2005 Adis Data Information BV. All rights reserved.

Resistance Exercise Training inPatients with Heart FailureKonstantinos A. Volaklisand Savvas P. Tokmakidis

Department of Physical Education and Sport Science, Democritus University of Thrace,Komotini, Greece

Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10851. Modes and Methods of Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10872. Isometric Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10873. Dynamic Resistance Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10874. Combined Isometric/Dynamic Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10885. Isokinetic Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10886. Acute Responses during Resistance Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1088

6.1 Isometric Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10886.2 Dynamic Resistance Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1088

7. Adaptations of Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10897.1 Exercise Time and Peak Oxygen Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1089

7.2 Histological and Metabolic Adaptations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10917.3 Muscular Adaptations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1093

8. Vascular Function, Immunity and Autonomic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10939. Resistance Training Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1094

9.1 Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10959.2 Duration and Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10959.3 Mode of Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10959.4 Number of Repetitions/Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10959.5 Number of Exercises/Stations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10979.6 Intensity of Contraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10979.7 Safety Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10979.8 Lifting Technique/Musculoskeletal Injury Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1098

9.9 Determining Training Workloads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10989.10 Supervision of Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10989.11 Resistance Exercise Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10999.12 General Suggestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10999.13 Circuit Weight Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1099

10. Contraindications of Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109911. Clinical Implications of Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110012. Conclusions and Recommendations for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1100

The utility, safety and physiological adaptations of resistance exercise trainingAbstract

in patients with chronic heart failure (CHF) are reviewed and recommendationsbased on current research are presented. Patients with CHF have a poor clinical

status and impaired exercise capacity due to both cardiac limitations and peripher-


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1086 Volaklis & Tokmakidis

al maladaptations of the skeletal musculature. Because muscle atrophy has been

demonstrated to be a hallmark of CHF, the main principle of exercise programmes

in such patients is to train the peripheral muscles effectively without producing

great cardiovascular stress. For this reason, new modes of training as well as new

training methods have been applied. Dynamic resistance training, based on the

principles of interval training, has recently been established as a safe and effective

mode of exercise in patients with CHF. Patients perform dynamic strength

exercises slowly, on specific machines at an intensity usually in the range of

5060% of one repetition maximum; work phases are of short duration (60seconds) and should be followed by an adequate recovery period (work/recovery

ratio >1 : 2). Patients with a low cardiac reserve can use small free weights (0.5, 1

or 3kg), elastic bands with 810 repetitions, or they can perform resistance

exercises in a segmental fashion. Based on recent scientific evidence, the applica-

tion of specific resistance exercise programmes is safe and induces significanthistochemical, metabolic and functional adaptations in skeletal muscles, contrib-

uting to the treatment of muscle weakness and specific myopathy occurring in the

majority of CHF patients. Increased exercise tolerance and peak oxygen consump-

tion (VO2peak), changes in muscle composition, increases in muscle mass, altera-

tions in skeletal muscle metabolism, improvement in muscular strength and

endurance have also been reported in the literature after resistance exercise alone

or in combination with aerobic exercise. According to new scientific evidence,

appropriate dynamic resistance exercise should be recommended as a safe and

effective alternative training mode (supplementary to conventional aerobic exer-

cise) in order to counteract peripheral maladaptation and improve muscle strength,

which is necessary for recreational and daily living activities, and thus quality oflife, of patients with stable, CHF.

Patients with chronic heart failure (CHF) have a Traditionally, patients with CHF have been ad-

vised to avoid exercise because of the concerns thatpoor clinical status and impaired exercise capacitytheir condition would further deteriorate.[5]Howev-due both to cardiac limitations (significant left ven-er, since the late 1970s, several studies have indicat-tricular impairment) and to peripheral maladapta-ed that exercise training can induce favourable phys-tions of the skeletal musculature. The latter includeiological adaptations and improve symptoms,

the reduction of peripheral blood flow and impaired clinical outcome and quality of life of these pa-perfusion as well as deficiencies in skeletal muscle

tients.[6-12]The majority of these studies were basedfunction, morphology and metabolism. These skele-

on aerobic exercise, which was traditionally thetal muscle disturbances increase cardiovascular

main exercise mode in rehabilitation programmes.stress, deteriorate symptoms and reduce further ex-

Nowadays, new methods of exercise training (inter-ercise capacity.[1-3]Recently, it has been reported[4] val training) have been developed in order to allowthat muscle strength was a better predictor of long- heart failure patients to exercise at higher intensities-term survival than workload or peak oxygen con- and at lower cardiovascular stress, since most aresumption (VO2peak) in patients with severe conges- extremely deconditioned.[10,13]

tive heart failure, indicating the importance of main- Resistance exercise (and especially isometric or

taining a normal skeletal muscle mass in order to static exercise) was not routinely prescribed to pa-improve the outcome of these patients. tients with CHF because this type of exercise was

2005 Adis Data Information BV. All rights reserved. Sports Med 2005; 35 (12)


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Resistance Training in Heart Failure 1087

associated with undesirable and pathological cardio- Nevertheless, this approach has completely

changed[15] and nowadays resistance training hasvascular responses.[14,15] During the last decade,

been proven to be beneficial even for patients withhowever, increasing evidence indicated that dynam-

CHF.[17,18,32,33] For safety reasons, however, clini-ic resistance training alone[16-20]or in combination

cians should be aware of the appropriate prescrip-with aerobic exercise[21-28]is beneficial and counter-

tion (training methods and modalities) of resistanceacts the negative peripheral side effects seen in

training due to the high risk of these patients. Thesepatients with CHF. The present review examines the

issues, based on current literature, are further dis-utility, safety and physiological adaptations of resis-

cussed.tance exercise training in patients with CHF and,

based on current literature, presents evidence and2. Isometric Exerciserecommendations for resistance training.

During this form of contraction, force is generat-

1. Modes and Methods of ed without a change in muscle length. Muscle bloodResistance Training flow and oxygen delivery are compromised becausethe increase in intramuscular pressure compresses

arterial blood vessels. As isometric exercise exceedsResistance training in cardiac rehabilitation is70% of maximal voluntary contraction, there is abasically applied according to the principles of inter-complete obstruction of arterial flow, so that energyval training. During interval training, the workrequirements are met by anaerobic metabolism.[34]phases are of short duration (e.g. 3060 seconds)As a consequence, systolic blood pressure increasesand are followed by short recovery periods of theto maintain muscle perfusion; the mean arterial pres-same or longer duration; thus, interval training al-sure for isometric exercise is much higher for anylows heart failure patients to train at higher powergiven oxygen consumption (VO2) at equivalent dy-output with lower haemodynamic and left ventricu-namic exercise.[35] Thus, isometric work imposeslar stress compared with steady-state exercise.[10,29]

greater pressure than volume load on the left ventri-Patients perform dynamic strength exercises rhyth-cle, which is directly related to the intensity, themically on specific machines or use free weightsactivated muscle mass and the duration of contrac-activating different muscle groups every time. Ittion.[36-38] Based on the above, sustained or high-should also be pointed out that the induced muscularintensity isometric exercise has been considered un-contraction is primarily dynamic, which means thatsafe in patients with mild to severe left ventricularthe movement is carried out throughout the changesimpairment and congestive heart failure.of muscle length and not through the alteration of

muscular tension, as in the case during isometric3. Dynamic Resistance Exerciseexercise.[30]

This kind of training cannot be compared to During dynamic resistance exercise, force is pro-

strenuous training undertaken by weight-lifting ath- duced while the length of the muscle changes (short-

letes, where the basic characteristic is the high inten- ens during concentric action and lengthens during

sity (>90% of the one repetition maximum; 1RM). eccentric action). Dynamic exercise can be applied

Neither can it be compared to the strength training of against a constant resistance, as in the case of dumb-

body builders who perform many repetitions with bells or weighted bags, or against a variable resis-

sub-maximal intensity until exhaustion. This misin- tance using machine weights.[39]This kind of exer-

terpretation, along with the acute increase of blood cise has been established as the proper and safe

pressure caused by isometric exercise, has been the training mode of strength training in cardiac and

main reason leading to the contraindications of re- heart failure patients. Eccentric exercise, a specific

sistance training for patients with heart disease for type of muscular contraction, requires special equip-many years.[31] ment and is based on the lengthening rather than the



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shortening of the muscle mass involved.[39] The examined the effects of isokinetic resistance training

mechanical power output with this kind of muscle in patients with CHF.

action is three to four times higher than the output The above modes of resistance exercise can be

obtained with the usual type of muscle contraction theoretically applied in practice. Their indication

without affecting the metabolic and cardiovascular and appropriateness in patients with heart failure,

demands.[40] The type of exercise using eccentric however, based on the existing literature, are further

muscle action has been found to improve muscle discussed in sections 6 and 9.

strength and muscle mass without affecting the oxi-

dative capacity of muscle cells at the same level.[40] 6. Acute Responses duringAlthough the theoretical basis of this type of exer- Resistance Exercisecise is valid in patients with heart failure, there is

Resistance exercise was not routinely prescribedonly one study (and this is in patients with coronaryto patients with heart failure because this type ofartery disease [CAD]) that examines the acute

exercise has the potential to trigger ventricular ar-haemodynamic and metabolic responses during ec-rhythmia, pathological haemodynamic responses,centric exercise.[41] More studies concerning theventricular wall stress, decreased myocardial perfu-acute responses and the chronic adaptations of ec-sion and wall motion abnormalities.[14] The acutecentric exercise are needed in patients with CHF.cardiovascular responses expected during resistance

exercise, however, depend on a variety of factors,4. Combined Isometric/including the kind and intensity of muscular con-Dynamic Exercisetraction (rhythmic and dynamic vs static and isomet-

This type of exercise concerns the combination ric), the amount of muscle mass involved (i.e. largeof both dynamic and static contractions (e.g. weight- vs small muscle groups), the number of repetitions,loaded walking, weight-carrying, or vocational and the duration of contraction.[35,37,38]

work simulation).[30]In patients with cardiovascular

disease, the combined isometric/isotonic exercise is 6.1 Isometric Exercisewell tolerated and results in acceptable

When cardiovascular stress is measured duringhaemodynamic responses.[30,42,43] In patients withstatic exercise, undesirable haemodynamic altera-CHF, however, no research exists on the centraltions and an excessive level of myocardial pressurehaemodynamic changes that occur during combinedwork were observed[45-50] in patients with CHF.isometric/dynamic exercise. Therefore, recommen-These include decreases in cardiac output, strokedations of this form of exercise cannot be suggestedvolume and ejection fraction (EF), increases in sys-yet.tolic, mean arterial pressure and left-ventricular end-

diastolic pressure, and wall motion abnormalities,5. Isokinetic Exercisemitral regurgitation and dysrhythmia.[45-50]The pro-

Isokinetic resistance exercise requires specific tocols applied to the above studies, however, includedevices that allow the muscle to produce force at a sustained isometric contractions of small muscleconstant predetermined speed. The nature of con- groups to an intensity of 3050% of maximum vol-traction can be either concentric or eccentric. The untary contraction and lasted 35 minutes. Yet, suchadvantage of this type of exercise is that a homoge- exercise stimuli, do not exactly reflect the nature ofneous strength development can be reached daily activities.throughout the entire range of motion using different

angular velocities of the activated muscle groups.[39] 6.2 Dynamic Resistance ExerciseSeveral investigators used isokinetic machines to

evaluate maximal resistance in patients with On the other hand, favourable cardiovascular re-CHF.[4,17,22,44]No follow-up studies, however, have sponses were observed in recent studies where dy-



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namic contractions of large muscle groups were In a recent study, Werber-Zion et al.[55]demon-

strated the safety of resistance testing (1RM) andused during resistance exercise (table I).

training up to 60% of 1RM in patients with mild toHaemodynamic responses (heart rate, systolic blood

moderate left ventricular dysfunction using two-pressure and rate-pressure product) during single leg

dimensional echocardiography. During only thepress at 70% of 1RM were lower than those foundknee extension exercise (10 repetitions at 60% ofduring cycling exercise at 70% of VO2peak in pa-1RM) a slight but significant reduction in EF wastients with moderate CHF,[32] whereas similar re-observed during the final repetitions (see also tablesults were obtained during bilateral leg press andI).biceps curl exercises (at 40% of maximum voluntary

Based on existing knowledge, dynamic resis-contraction [MVC]) compared with submaximal cy-tance exercise performed using large muscle groupscling exercise in patients with more severe CHF.[51]

(bilaterally) or small muscle groups (unilaterally) atIn addition, there was no evidence of significantappropriate intensities (up to 10 repetitions at 70%deterioration in left ventricular function during re-

of 1RM) was well tolerated in patients with wellsistance exercises performed at 6070% of 1RM incompensated, stable CHF, since it generated stablepatients with stable CHF (mean EF: 35%, New Yorkleft ventricular function and acceptable haemody-Heart Association [NYHA] class: III).[52]Further-namic loads.more, Meyer et al.[33] investigated the safety and

tolerability of rhythmic resistance exercise regard-7. Adaptations of Resistance Traininging cardiac function in patients with heart failure

(mean EF: 26%) and observed increased left ventric- Resistance training in patients with CHF is asso-ular stroke work index and decreased systemic vas- ciated with increased exercise tolerance (exercisecular resistance during rhythmic double leg press time) and correction of skeletal muscle abnormali-exercise at 60% and 80% of maximum voluntary ties. This can be better achieved, however, when the

contraction (60-second work phase/120-second re- combination of resistance and aerobic exercise iscovery), suggesting left ventricular adaptability of used. Changes in muscle composition, increase ofthe failing heart to dynamic resistance exercise. muscle mass, alterations in skeletal muscle metabo-

lism, and improvement in muscular strength andData from our laboratory[56] confirm the above

endurance have also been reported by most investi-observations in patients with coronary heart disease

gators after resistance training alone or in combina-and show that dynamic resistance exercises per-tion with aerobic exercise.[16-28]formed at 40%, 60% and 80% of 1RM produced

much lower haemodynamic responses than those7.1 Exercise Time and Peakobtained during a stress test (figure 1).Oxygen Consumption

King et al.[53] reported that dynamic resistance

exercise using hand-held weights (unilateral arm Significant improvements in exercise timecurls at 50%, 65% and 80% of calculated 1RM) was (13%)[18]and maximal exercise capacity (10%, de-tolerated haemodynamically and clinically in pa- fined as the maximal watts tolerated on the cycle-tients with advanced heart failure (mean EF: 20%, ergometer)[16] without changes in VO2peak haveNYHA class III or IV). When the intensity of a been reported in patients with CHF after 8 weeks of

combined aerobic and resistance exercise circuit resistance training. In addition, a lower VO2 at

training session was compared with the exercise submaximal workloads (without improvement in

intensity of continuous aerobic exercise in patients VO2peak) has been observed after an 11-week resis-

with CHF (mean EF: 25%, NYHA class IIII), no tance training programme in patients with moderate

significant differences in oxygen demand or CHF (mean EF: 26%, NYHA class IIIII). Never-

haemodynamic responses were found (69% and theless, a significant increase in VO2peak (14.5%)68% of VO2peak, respectively).[54] was observed after 12 weeks of training using



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*

0

5

10

15

20

25

30

35

Bench

press

Lateral pull

down

Seated

rowing

Pec-deck Knee

extension

Leg curl Stress test

40% of 1RM

60% of 1RM

80% of 1RM

Rate-pressureproduc

t(103)

Fig. 1. Rate-pressure product during six different exercises and during stress testing in patients with coronary artery disease (reproduced

from Tokmakidis,[56]with permission). RM= repetition maximum; * p < 0.001.

weight collars in patients with CHF awaiting heart pared with resistance or aerobic training alone in

order to improve VO2peakin patients with CHF.transplantation.[19]

Comparative studies have shown that the combi-7.2 Histological and Metabolic Adaptationsnation of strength and aerobic exercise results in

better adaptations of VO2peakand exercise toleranceThere are few studies that have examined thethan aerobic training alone. Maiorana et al.[23] re-

adaptations in skeletal muscle histology and bio-ported increases in exercise time of 18.4% and inchemistry as a result of resistance training in pa-VO2peak of 13% following a 12-week circuittients with heart failure. Minotti et al.[60] wereweight-training programme in patients with CHF

among the first who observed improved oxidative(mean EF: 26%, NYHA class IIII). When a com-capacity of the skeletal musculature, as indicated bybined strength and aerobic training programme wasthe lower inorganic phosphate to phoshocreatineconducted for 24 weeks in outpatients with conges-ratio (Pi/PCr) during submaximal workload, after 1tive heart failure (mean EF: 36%, NYHA class 2.2 month of non-dominant wrist flexor training. In-0.1), an 18% increase of working capacity and acreases of cross-sectional area of quadriceps femoris10% increase in VO2peak was found.[21] Recently,(9%)[16]and muscle fibre area (9.5% for type 1 and

Selig et al.[28] reported a 21% improvement of13.6% for type 2 muscle fibres)[18]as well as signifi-

VO2peakin a prospective, randomised study after 3cant improvements in skeletal muscle oxidative ca-

months of a moderate-intensity resistance and aero-pacity (increase of citrate synthase activity by

bic exercise programme in patients with CHF (mean35%)[18]have been reported after resistance training.

EF: 27%, NYHA class IIIII). These improvements in skeletal muscle metabolismBased on the above observation, resistance exer- and histology were directly associated with changes

cise alone may[19]or may not[17,18]improve VO2peak, (13%) in the overall functional capacity measuredalthough the combination of strength and aerobic by the 6-minute walking test[18] (figure 2). Thetraining seems to induce significant adaptations in above oxidative adaptations observed after resis-VO2peak(table II). This is clinically important since tance training may be explained by the severeVO2peakin these patients strongly predicts quality of deconditioning of these patients. In addition, com-life and prognosis. In addition, the improvement in bined strength and endurance exercise preventedVO2peak is associated with enhanced survival in loss of hamstrings muscle mass during an interven-patients awaiting cardiac transplantation.[57]There- tion period of 26 weeks.[61]Despite these promising

fore, the combination of strength and aerobic exer- findings, however, further studies are required tocise is suggested as the best form of training com- establish the long-term histological and metabolic



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2005AdisDataInformation

BV.Allrightsreserved.

SportsMed2005;35(12)

Table II. Summary of trials of resistance training in patients with heart failure

Study (n, M/F, aetiology) EF (%)/NYHA Duration/frequency Intensity/type of training Muscular ad

class

Magnusson et al.[16] 6 28 8wk/3 days/wk AE at 6575% of HRpeak 24% of m(1996) strength

5 11.4 8wk/3 days/wk ST at 80% of 1RM 40% of m(3 CAD, 8 DCM) strength

Adams et al.[58] (1999) 18M 24 8wk ST at 6080% of 1RM plus AE 1517% oat 70% of HRpeak strength

Hare et al.[17](1999)a 9M (8 CAD, 1 26/IIIII 11wk/3 days/wk 3060 sec of ST at low 1740% oDCM) intensity strength

Delagardelle et al.[21] 11M/3F (7 CAD, 5 29/2.7 0.5 24wk/3 days/wk ST at 6080% of 10RM plus 1825% o(1999) DCM,1 HT, 1 VD) AE at 5075% of VO2peak endurance

Maiorana et al.[23] 13M (7 CAD, 6 26/IIII 8wk/3 days/wk ST at 5565% of 1RM plus AE 18% of m(2000) DCM) at 7085% of HRpeak strength

Barnard et al.[22](2000) 14M (10 CAD, 4 25 8wk/3 days/wk ST at 6080% of 1RM plus AE 1833% o

DCM) at 6080% of HRpeak strength

Grosse et al.[19] 11M/3F (5 CAD, 9 28/3.0 0.4 12wk/2 days/wk ST at 65% of 1RM 80102.4%(2001)a DCM) muscular en

Pu et al.[18](2001)a 9F (6 CAD, 2 36/2.2 0.1 10wk/3 days/wk ST at 80% of 1RM 43% of mDCM, 1 VD) strength

Tynni-Lenne et al.[20] 8M/8F (10 CAD, 6 30/IIIII 8wk/3 days/wk 2 25 reps until 13 on Borgs Not reported(2001)a DCM) scale using elastic bands

Selig et al.[28] (2004) 15M/4F (11 CAD, 27/2.4 0.5 12wk/3 days/wk 30 sec of ST at moderate 21% of m8 DCM) intensity strength and

muscular en

Levinger et al.[59] 8M 35 8wk/3 days/wk ST at 4080% of 1RM 18% of m(2005)a strength

a In these studies only ST was applied.

AE= aerobic training; CAD= coronary artery disease; DCM= dilated cardiomyopathy; EF= ejection fraction; F= female; HRpeak= peak h

NYHA= New York Heart Association; reps= repetitions; RM= repetition maximum; ST= strength training; VD= valve dysfunction; V

indicates increase.


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muscular endurance (range 18299%; see also fig-

ure 3). Even at high intensities, resistance training is

well tolerated and without cardiovascular abnormal-

ities or orthopaedic complications (table III). In the

study by Pu et al.,[18]who conducted a randomised

controlled trial to determine the efficacy of resis-

tance training at 80% of 1RM in older patients with

CHF, maximal muscle strength improved from

33.5% to 68% for different muscle groups, whereas

muscular endurance also increased by 299% after 10

weeks of training. Furthermore, it is important to

note that -blocker therapy did not inhibit strengthgains following resistance training in patients with

CHF.[59]

Maintaining a satisfactory level of strength in

these patients is very important, since it facilitates

the execution of daily activities and enhances their

quality of life. In patients with CHF, and especially

the elderly, the normal physiological (age-depen-

dent) type 2 fibre decrease adds to the CHF-induced

reduction of type 1 fibres.[63]Therefore, regular re-

sistance training programmes are very efficient in

counteracting these negative skeletal muscle abnor-

malities seen in CHF.

8. Vascular Function, Immunity andAutonomic Control

Decreased peripheral blood flow and impaired

120

a

100

80

60

40

20

0

20

40

60

Change

in6-minwalk(m)

1500

500 500

Change in type 1 muscle fibre area (/m3)

1500 2500

r = 0.612

p = 0.026

120

b

100

80

60

40

20

0

20

40

60 10 20 30 100

Change in muscle oxidative capacity (mol/g min)403020 706050

r = 0.570

p = 0.053

Fig. 2. Correlations between the improvement in functional capacity

and (a) the changes in type 1 muscle fibre area and (b) the

changes in muscle oxidative capacity after resistance training in

patients with chronic heart failure (reproduced from Pu et al.,[18]with

permission).perfusion are common in patients with CHF.[64]

There are also autonomic derangements in CHFadaptations of this type of training in patients with

patients, including excessive sympathetic activationCHF.

and depressed heart rate variability (HRV).[65] In

addition, impaired function of the vascular endothe-

7.3 Muscular Adaptations lium and both local and systematic inflammation

Patients with heart failure exhibit skeletal muscle

atrophy (muscle wasting) and impaired muscular

strength. Although it has been demonstrated that

aerobic training reverses the histochemical and met-

abolic abnormalities in skeletal muscle,[9,62]the im-

provements in muscle function (increases in muscu-

lar strength and endurance) can be obtained only

after specific resistance training programmes.

Indeed, resistance exercise training in patients

with CHF results in a significant improvement ofmuscular strength (range 1543%)[16-19,21-23] and

10

15

20

25

30

Curl-ups Modified

push-ups

Biceps-

curl

Semi-

squats

Stepping

40cm

Repetitions/30sec

Baseline

4wk

Fig. 3. Muscular endurance before and after 4 weeks of a com-

bined strength and aerobic training programme in patients with

chronic heart failure (data from our laboratory).



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Table III. Adverse events during resistance training in patients with chronic heart failure

Study No. of Age (y) EF (%)/NYHA Type of training Adverse events

patients class

Magnusson et al.[16](1996) 5 57 11 Segmental (localised) muscular Intermittent atrialtraining using free weights fibrillation (n = 1)

Hare et al.[17](1999) 9 63 26/IIIII Whole body training (CWT) None

Barnard et al.[22](2000) 14 55 25 Whole body training (CWT) None

Maiorana et al.[23](2000) 13 60 26/IIIII Whole body training (CWT) None

Pu et al.[18](2001) 16 77 36/2.2 Whole body training (CWT) None

Grosse et al.[19] (2001) 14 56 28/3.0 Segmental (localised) muscular None

training using hand-held weights

(weight collars)

Tynni-Lenne et al.[20] (2001) 16 63 30/IIIII Segmental (localised) muscular Increased oedema

training using elastic bands (n = 1)

Conraads et al.[26](2002) 23 57 27/IIV Whole body training (CWT) Not reported

Delagardelle et al.[27](2002) 10 56 27/2.7 Segmental (localised) muscular Nonetraining using machines and

dumb bells

Selig et al.[28] (2004) 19 65 27/2.4 Whole body training (CWT) Sudden death (n =

1), noncardiac

illness (n = 1)

CWT= circuit weight training; EF= ejection fraction; NYHA= New York Heart Association.

have been suggested to play an important role in the gramme in patients with CHF. Favourable effects on

pathogenesis and progression of disease.[66,67] circulating soluble tumour necrosis factor-recep-tors in patients with CHF due to CAD have beenPromising findings have recently been reported

reported after 4 months of combined aerobic/resis-indicating that resistance training alone[17,28]

or intance training, indicating the anti-inflammatory ef-combination with aerobic exercise[24,26]may correctfect of this type of exercise programme, but not inthe above abnormalities seen in patients with CHFthe case of idiopathic dilated cardiomyopathy.[26]relating to vascular function, immunity and auto-Furthermore, the same investigators[68]found that anomic control. In an uncontrolled study,[17] ancombined endurance/resistance training programme11-week resistance exercise training programme re-reduces the N-terminal fragment of brain natriureticsulted in a significant increase (69%) of basal fore-peptide, which reflects left ventricular diastolic wallarm blood flow. However, baroreflex sensitivitystress without evidence of adverse remodelling.showed a non-significant improvement and heartMore studies are needed, however, to fully clarifyrate variability was unchanged after training. Seligthe effects of resistance training on vascular andet al.[28] reported significant increases of forearmimmunity functions and autonomic control in pa-blood flow at rest (20%) and when stimulated bytients with CHF.submaximal exercise (24%) or limb ischaemia

(26%) in a prospective, randomised study of moder-

ate resistance training in 19 patients with CHF. In 9. Resistancecontrast to the study of Hare et al.,[17]Selig et al.[28] Training Recommendationsreported significant improvements in HRV in re-

sponse to resistance training. Maiorana et al.[24]used When prescribing resistance exercise training to

a randomised crossover design and provided evi- patients with CHF, caution should be taken to avoid

dence that indicated improvements in both endothe- pressure as well as volume overload of the left

lium-dependent and endothelium-independent vas- ventricle. This can be accomplished with short train-

cular function and peak vasodilatory capacity after a ing intervals stimulating the peripheral musclescombined resistance and aerobic training pro- without inducing high cardiovascular stress. In



11/19


2001, Meyer,[40]in an excellent review, stated that 9.2 Duration and Frequency

resistance training can be recommended whenWork phases during resistance training should be

small muscle groups are involved, using short bouts of short duration (60 seconds) and should be fol-of work phases and small number of repetitions,lowed by an adequate recovery period (work to

while Pina et al.[69]in the American Heart Associa-recovery ratio >1 : 2).[40] The recommended dura-

tion (AHA) scientific statement in 2003 reportedtion per session should range from 20 to 30 minutes

that small free weights (1, 2 or 5lb), elastic bands or(1520 minutes at the early stages of training) with a

repetitive isolated muscle training can be used.frequency of one to two times per week. Despite the

Nowadays, based on current literature evidence,frequency of training being three times per week in

more specific recommendations concerning thethe majority of studies,[16-18,21-23]we believe that a

characteristics of resistance training (intensity, dura- resistance training frequency of two times per weektion, frequency, number of repetitions, sets of exer- as a supplement to conventional aerobic training

cise, contraction intensity, exercise/recovery ratio) represents an optimal stimulus to obtain desirablecan be obtained. cardiovascular and muscular adaptations in patients

with CHF (table V).

9.1 Intensity9.3 Mode of Training

Patients with a very low cardiac reserve (for Of the available studies, six used wholeexample those awaiting heart transplantation) use body[17,18,22,23,28,58]and four used segmental muscu-small free weights (0.5, 1 or 3kg) with 810 repeti- lar training.[16,19-21] The former tended to recruittions,[19]whereas those in a better condition (NYHA patients with less severe left ventricular dysfunctionclass III) can perform resistance exercises at an (EF range: 2536% vs 1129%). Until official

intensity level of 5060% of 1RM using machine guidelines exist, we suggest whole body (bilateral)weights.[16,22] NYHA class IV patients should be resistance training for NYHA class I patients and

excluded from participation in resistance training segmental (unilateral) training for patients with

NYHA class IIIII (table V). Because there are onlyprogrammes. To minimise cardiovascular stress and

two studies[51,53] that have examined the acute ef-during the first weeks of the programme, trainingfects of resistance exercise in very severe CHFcan be performed in a segmental manner (unilateralpatients (NYHA class IV) using only two exercisesperformed exercises). During resistance exercise,(leg press and biceps curl) and because only onethe rate of perceived exertion should range fromintervention study has been conducted with thesefairly light to somewhat hard on the Borg scale topatients (NYHA class IV),[26] additional data arefatigue. It should be noted that even higher intensi-

required before resistance training can be recom-ties of resistance training (80% of 1RM) have beenmended for patients with very severe CHF.reported in the literature for CHF patients[16,18,22]

(see table I and table IV). Although this intensity has9.4 Number of Repetitions/Sets

been well tolerated, the majority of CHF patients

should exercise at lower intensities (i.e. start from In previous studies involving heart failure pa-40%) and reach about 60% for routine training pro- tients, 1015 repetitions of each exercise were per-gressively (table II and table V). There is a need, formed in 24 sets. Most often they were applied athowever, to differentiate intensity of training ac- intensities ranging from 60% to 80% of 1RM whencording to the severity and the clinical status of the segmental (localised) muscle training waspatients and in relation to the muscle mass involved used.[16,19,21] Similar training characteristics were

(segmental or whole body muscle training). This used (815 reps in 24 sets at 5080% of 1RM) inissue needs to be clarified in further studies. studies where the whole body training was pre-



12/19

2005AdisDataInformation

BV.Allrightsreserved.

SportsMed2005;35(12)

Table IV. Aetiology and severity (according to New York Heart Association [NYHA] classification) of the recruited patients with heart failur

studies

Study (year) Aetiology (n) NYHA class [n (%)] Program

Acute studies

McKelvie et al.[32](1995) 10 CAD Patients had NYHA class IIII (not specified) 2 10 re

Meyer et al.[33](1999) 7 CAD, 2 DCM Not reported 4 12 re

King et al.[53](2000) Not reported Patients had NYHA class IIIIV (not specified) 2 101plus 1

Green et al.[54](2001) 4 CAD, 2 DCM I: 3 (50) II: 1 (17) III: 2 (33) 1 15 re

Cheetham et al.[51](2002) 12 CAD 4 DCM, 1 viral Patients had NYHA class IIIIV (not specified) 2 100 aetiology

Karlsdottir et al.[52](2004) Not reported Patients had NYHA class III (not specified) 1 10 re

Werber-Zion et al.[55] (2004) 15 CAD Patients had NYHA class III (not specified) 1 15 rereps at 6

Intervention studies

Magnusson et al.[16](1996) 3 CAD, 8 DCM II: 5 (45.5) III: 5 (45.5) IV: 1 (9) 4 610

Adams et al.[58](1999) Not reported Not reported 2 812

Hare et al.[17](1999) 8 CAD, 1 DCM II: 5 (66) III: 4 (44) 3060 s

Delagardelle et al.[21](1999) 7 CAD, 5 DCM, 1 HT, 2.7 0.5 (not specified) 3 15 re1 VD

Maiorana et al.[23](2000) 7 CAD, 6 DCM Patients had NYHA class IIII (not specified) 15 reps

Barnard et al.[22](2000) 10 CAD, 4 DCM Not reported 2 812

Grosse et al.[19](2001) 5 CAD, 9 DCM 3.0 0.4 (not specified) 2 15 re

Pu et al.[18](2001) 6 CAD, 2 DCM, 1 VD I: 1 (11) II: 6 (67) III: 2 (22) 2 8 rep

Tynni-Lenne et al.[20](2001) 10 CAD, 6 DCM II: 11 (69) III: 5 (31) 2 25 re

Selig et al.[28](2004) 11 CAD, 8 DCM 2.4 0.5 (not specified) 30 sec o

a Commonly used exercises: leg extension, leg press, chest press, shoulder press, lateral pull-down, biceps curl.

CAD= coronary artery disease;DCM= dilated cardiomyopathy; HT= hypertension; MVC= maximum voluntary contraction;reps= repe

strength training; VD= valve dysfunction.


13/19


Table V. Circuit weight-training characteristics for patients with chronic heart failure reported in the literature and modified according to the

severity[16-23,26]

Characteristic Reported in the Recommendations

literature NYHA I NYHA IIIIIIntensity 5080% of 1RM 5060% of 1RM 4050% of 1RM

Repetitions 815 610 46

Number of stations 39 46 34

Sets 14 12 12

Duration of training 1530 min 1520 min 1215

Rest intervals between 12 min 60 sec or longer if necessary, (work/ 60 sec or longer if necessary,

exercises recovery ratio >1 : 2) (work/recovery ratio >1 : 2)

Speed of muscle contraction 36 sec 6 sec (3 for the eccentric and 3 for the 6 sec (3 for the eccentric and 3 for

concentric phase the concentric phase)

Frequency 23/wk 2/wk as a supplement to aerobic 12/wk as a supplement to aerobic

training training

Mode of training Whole body training Segmental training during the first Segmental training mainly, whole

segmental muscular training months, whole body training if tolerated body training rarely

thereafter

NYHA= New York Heart Association; RM= repetition maximum.

scribed.[17,18,22-24,26,27] There is a need to establish en, we suggest the available time for each repetition

precise guidelines concerning the number of repeti- during resistance exercise be 46 seconds (23 for

tions and sets depending on the severity and the the concentric phase and 23 for the eccentric

clinical status of patients and according to the train- phase).

ing mode and/or method chosen each time.

9.7 Safety Aspects9.5 Number of Exercises/Stations

Patients with CHF have a greater morbidity andThe number of exercises performed in each train-mortality than patients with other heart disease man-ing session depends on several factors: mainly theifestations. However, no adverse events occurredmuscular fitness level, the severity of left ventricularduring or immediately after resistance exercise test-impairment of the patient, and the type of resistanceing in patients with CHF.[18,33,51,52,55]Furthermore,training chosen (whole body or localised training)no ventricular arrhythmias, need for increased[table V]. In previous studies, the number of exer-drugs, increase in symptomatology were reportedcises most often prescribed was on average 46 andwithin the next few days after the resistance exerciseranged from one to nine exercises (table IV).[16-28]protocols of participating patients. Pu et al.[18] re-

ported that they performed 91 maximal strength9.6 Intensity of Contractiontests in their study without cardiovascular complica-

tions in nine women with severe CHF.Resistance exercises should be performed

through the maximum range of motion that does not From the long-term resistance training studies

elicit pain or discomfort. Each repetition must be conducted to date and including 139 patients with

performed at a slow tempo to elicit the training CHF, the overall rate of adverse events seems to be

effects (muscle hypertrophy) and to minimise stress low (table III). Furthermore, no differences were

overload of the left ventricle. In relevant studies found between the combined resistance and aerobic

where resistance testing and training were applied in training group compared with the aerobic group

patients with CHF, the time allowed for a complete alone.[22,27]Despite the fact that no adverse outcome

lift was 36 seconds.[23,27,33,51,54,55]According to cur- occurred during or after the experimental protocolsrent knowledge and until official guidelines are giv- in studies where patients with very severe CHF were



14/19


recruited,[51,53]we believe that resistance testing and

training should be avoided in patients with severe

CHF (NYHA class IV).

9.8 Lifting Technique/Musculoskeletal

Injury Risk

Attention should be given to and patients must be

trained in the correct lifting technique in order to

avoid Valsalvas manoeuvre. For this reason, they

must breathe out during weight lifting (concentric

phase) and inhale when the weight is lowered (ec-

centric phase). In healthy subjects who underwent

regular resistance training, Pollock et al.[70]

found anaverage of 2.2 minor muscle joint ligament injuries

per 1000 training hours. In the study by Barnard et

al.,[22]no injury or complaints of muscular soreness

occurred immediately after and the week following

maximal strength testing in patients with CHF. Con-

versely, four of the nine women with heart failure

(mean age: 77 years) in the study by Pu et al.[18]

developed mild intermittent musculoskeletal symp-

toms during 1RM testing. Therefore, patients with

orthopaedic limitations or at risk of musculoskeletal

injury, and especially those aged >65 years, should

avoid maximal strength testing.

Table VI. Contraindications for resistance training in patients with

heart failure according to the exclusion criteria applied in the rele-

vant studies

NYHA class IVHospitalisation for CHF within 2mo

Change of CHF therapy within 1mo

Worsening of exercise tolerance or symptoms of heart failure

during the previous 35 days

Increase of bodyweight within 24h more than 1kg

Unstable angina pectoris

Abdominal aortic aneurysm >4cm

Significant exercise-induced ischaemia (>3mm ST-segment

depression)

New onset of atrial fibrillation

Obstructive valvular disease

Severe pulmonary hypertension or other severe pulmonary

disease

Blood pressure decrease of >20mm Hg during exercise stress

test

Resting systolic BP >160mm Hg and diastolic BP >90mm Hg

Complex ventricular arrhythmias at rest or arrhythmias that

worsens with exercise

Third-degree atrioventricular block

Resting heart rate >100 bpm

Resting systolic BP >180mm Hg and diastolic BP >105mm Hg

Moderate to severe aortic stenosis

Recent embolism

Acute systemic illness or fever

Active pericarditis, myocarditis or endocarditis

BP = blood pressure; bpm = beats/minute; CHF = chronic heart

failure; NYHA= New York Heart Association.9.9 Determining Training Workloads

Various methods have been used to determine there is a need for standardised procedures to deter-training workloads during resistance training in pa- mine training workloads with respect to the differingtients with CHF. The most commonly used is the severity of heart failure patients.1RM method, which represents the maximal weight

lifted in one full range of motion. Another approach 9.10 Supervision of Trainingis to measure the maximum number of repetitions

performed before the prohibition of fatigue for the In the relevant studies, patients participated in the

completion of an additional repetition (3RM, 5RM, resistance training programmes under the supervi-

or 10RM).[31]From the existing studies, seven used sion of a physical therapist,[20]an exercise physiolo-

the 1RM method[16,18,22-24,26,27] and two used the gist,[23]a research assistant[16,18]or one cardiologist

10RM or the 15RM method[19,21]to assess the inten- and two physiotherapists.[21] Two studies gave no

sity of training in patients with CHF. Furthermore, information about training supervision,[22,28] while

in three studies[17,25,28]no maximal testing or other in one study resistance training took place at

strength evaluating procedure was reported. Al- home.[25]However, there is an absence of essential

though several studies demonstrate the safety of data regarding the type of supervision used in order

maximal testing in patients with CHF, it should be to prevent cardiovascular complications during

performed carefully, under medical supervision and training, since few studies give sufficient informa-with proper cardiovascular monitoring. However, tion. Patients must be monitored by continuous elec-



15/19


trocardiography, and blood pressure should be mea- warm-up and ended with 510 minutes of cool-

sured before and after training as well as randomly down. Stretching exercises of the neck, trunk and

during each resistance training session.[17,21] There the extremities must be included in each session

are no guidelines available yet on the optimal level during the warm-up and cool-down period. Before

of supervision required for resistance training in each training session, patients must be controlled for

CHF patients, and this issue needs further verifica- weight changes (increase of 1kg of bodyweighttion. Until then, we suggest physician supervision indicates early cardiac decompensation), existence

during resistance training for all heart failure pa- of oedema and changes in heart rhythm or resting

tients. blood pressure.[40] During resistance training, pa-

tients must be checked for the proper body position9.11 Resistance Exercise Equipment and lifting technique to avoid orthopaedic complica-

tions; dyspnoea, fatigue and overall well-being mustFor the development of muscular strength, a vari-

also be evaluated.

ety of resistance equipment exists such as machineweights, free weights (barbells and dumbbells), 9.13 Circuit Weight Trainingelastic bands, and hand, wrist or ankle weights.

According to the scientific basis for the recom-These resistance modalities have their advantages

mendations of resistance training outlined in theand disadvantages.[30,39]Machine weights are safe,

previous sections, circuit weight training (CWT)easy to learn and illustrate a reduced isometric com-

seems to be the most appropriate approach for pa-ponent. They are a gold standard of training for CHF

tients with CHF (see table V). During CWT, patientspatients. Of the free weights, the barbells demand an

perform dynamic strength exercises on specific ma-increased skill level and there is concern about safe-

chines rhythmically, activating different musclety, since they have an increased isometric compo-

groups every time. If machine weights are not avail-nent. They are not appropriate, therefore, for CHF

able, exercise stations can be developed using otherpatients. Dumbbells (or hand-held weights) are

resistance modalities (e.g. hand-held weights orstrongly recommended for the most deconditioned

elastic bands).patients at the initial stages of training, since they

allow a better isolation of single-joint exercises and It should be noted that most of the exercises

require a reduced level of technique. Elastic bands chosen can be performed in either a bilateral manner

are relatively inexpensive, and when properly ap- (using both limbs at the same time; whole body

plied they have the potential to ameliorate flexibili- training) or unilaterally according to the concept of

ty. Finally, ankle weights are not recommended, due localised muscle training (separately using only one

to their possible adverse haemodynamic response limb each time; segmental training). In patients with

and the increased risk of musculoskeletal injury in CHF, local muscle training allows close to maximal

some patients. The above suggestions are based skeletal muscle effort without pushing the impairedmainly on the results of studies conducted in healthy cardiac function to its limits,[40,73] thus facilitating

subjects and in patients with CAD and hyperten- the manifestation of the beneficial peripheral adap-

sion.[30,71,72]Further studies are needed to fully es- tations. Specific information concerning the training

tablish the haemodynamic response of resistance characteristics (e.g. intensity, duration, frequency,

exercise performed using different resistance train- number of repetitions, sets of exercise) can be found

ing modalities in patients with CHF. in table V.

9.12 General Suggestions 10. Contraindications ofResistance Training

Each training session should be preceded by

1015 minutes of light aerobic activities such as Generally, patients must be clinically stable andwalking, stationary cycling or light calisthenics for under stable pharmacological therapy for at least 2



16/19


months before they begin resistance exer- cle, histochemical, metabolic and functional abnor-

cise.[16,18,19,21]To the best of our knowledge, specific malities are possible throughout resistance training

contraindications for resistance training in patients programmes. Whether this hypothesis will result in

with heart failure have not been reported yet. How- an improvement of exercise tolerance, clinical status

ever, according to the exclusion criteria applied in and prolonged survival of patients with CHF needs

relevant studies, some suggestions can be made (see to be confirmed in future studies. Preliminary data

table VI). already exist, since some studies reported a decrease

in NYHA status after resistance training alone[19]or11. Clinical Implications of in combination with aerobic training[26,27]in patientsResistance Training with CHF. Oka et al.[25] reported that a moderate-

intensity home-based walking and resistance exer-Skeletal muscle mass appears to be a good pre-cise programme of 3 months duration was effectivedictor of VO2peakand minute ventilation/carbon di-in reducing symptoms and improving quality of lifeoxide release (V

E/VCO

2) slope independently of

(dyspnoea, fatigue, emotional function and per-age, NYHA class, sex, resting haemodynamic andceived control over symptoms) in patients with sta-neurohormonal activation.[74]It therefore seems im-ble, moderate heart failure (NYHA class IIIII).portant for patients with CHF to maintain a normal

skeletal muscle mass in order to avoid functional

impairment. Recently, Huelsmann et al.[4] docu- 12. Conclusions and Recommendationsmented the importance and the clinical implication for Future Researchof maintaining a normal skeletal muscle mass in

order to improve outcome in these patients. In their Based on recent scientific evidence, the applica-study, the isokinetic strength of the knee flexor tion of specific exercise programmes using dynamicmuscles was a better predictor of long-term survival resistance training is safe and induces significant(up to 60 months) in 122 patients with severe con- histochemical, metabolic and functional adaptationsgestive heart failure than workload or VO2peak(fig- in skeletal muscles of properly screened patientsure 4). with CHF (EF: 2030%, NYHA IIII).

Expanding the findings of the above studies, weTable IV provides detailed information regarding

can hypothesise that a reversal of the skeletal mus-the aetiology and severity of the recruited patients

who participated in various studies. Note that

NYHA classes II and III represent the most fre-

quently appearing subgroups of CHF patients and

that coronary artery disease was the primary cause

of CHF followed by dilated cardiomyopathy. No

studies have examined the applicability and adapta-

tions of resistance training with regard to the differ-

ent aetiology of CHF and further research is re-

quired on this topic.

Resistance training seems to contribute signifi-

cantly to the treatment of specific myopathy and

muscle weakness occurring in the majority of CHF

patients. Thus, multiple health-related and socioeco-

nomic benefits could be achieved when profession-

als involved in the rehabilitation process are aware

of the practical implications of resistance trainingand encourage patients to exercise regularly.

p < 0.01

>68 n = 49


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Artigo 56 - Resistance Exercise Training in Patients With Heart Failure

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