1. Chronic Heart Failure Quincy Waite

2. Definition Condition in which the heart is not efficient in order to meet the metabolic demands of the body. Systolic dysfunction Diastolic dysfunction Around two thirds of patients with heart failure have a history of ischemic heart disease, making it the leading cause of chronic heart failure. Heart failure is the leading reason for hospitalizations in people 65 years of age and older and the 5 year mortality rate of the newly diagnosed with HF is about 50%. However, continual advancements in the medical field have improved survival in middle aged patients.

4. Progression of Heart Failure 1.Index event occurs (ex. Myocardial infarction) causing damage to functioning cardiac myocytes. 1.Mechanisms are activated in order to keep patient asymptomatic of HF (adrenergic nervous system, renin-angiotensin system, and the cytokine system.) 1.Ongoing use of mechanisms causes secondary damage to the left ventricle over time leading to symptomatic HF.

5. Symptoms of Chronic HF 2 key symptoms: Shortness of breath o Orthopnea – difficulty breathing when lying flat o Paroxysmal nocturnal dyspnea – relieved by waking up to “catch their breath” Signs of fluid retention o Peripheral edema o Recent weight gain

6. Diagnosis Echocardiography and symptoms o Measure ejection fraction. Chronic HF patients have a ejection fraction of 30% or lower (compared to normal > 55%) Measuring BNP levels o Can also be utilized in order to prove increased BNP in the plasma due to heart failure This does not tell the whole story! Cardiac and systemic impact.

7. Diagnosis continued Graded exercise test is vital o Ventilatory efficiency and peak oxygen uptake o Both of these measurements can help distinguish whether medication or even cardiac transplant is appropriate.

8. Responses to Exercise Key differences in patients with chronic heart failure: During submaximal exercise HR increases, however abnormally decreases in peak exercise. Lower power output (due to inability to get blood to metabolically active muscles) Decrease in oxygen consumption at peak exercise

9. Medication With advancement in pharmacology, there have been fewer HF induced deaths and symptoms. Diuretics o Reduce cardiac preload, lessening intracardiac pressure and vascular congestion. Beta blockers o Slow HR, decrease afterload, increase myocardial perfusion, etc. Important in exercise capacity. Angiotensin-converting inhibitors & angiotensin-receptor blockers o Decrease afterload and BP

10. Other Therapy Cardiac transplantation is popular for patients with chronic heart failure. They are still high risk. Must continue to be treated for heart failure risk factors. (diabetes, obesity, hypertension, ischemic heart disease, etc. Responses to exercise in this population may differ.

11. Case Study 62 year old male Recently hospitalized and treated (2 weeks ago) for a myocardial infarction, hypertension, and ischemic cardiomyopathy Weight = 240 lbs; height = 71 inches Exercise history: avid golfer and bowler, however has been sedentary for 9 months. Family history: father died from myocardial infarction at 70 yrs FBG = 130 mg/dl; HDL = 30; LDL = 135 mg/dl Complains of shortness of breath frequently. Usually sleeps on 3 pillows. Current medications: furosemide, lisinopril, carvedilol Non-smoker Risk Stratification: After the assessment of this client and according to the ACSM guidelines, this patient would be considered at high risk as he is symptomatic. Medical exam required, exercise test required before ex., and medical supervision for ex. Test. Goals for Patient: Gradually improve their exercise capacity without deterring them from rehabilitation. Healthy behavior/lifestyle (low sodium diet, medication compliance etc.) Special Considerations: Actively asses BP during exercise due decrease of pressure and after due to hypotensive responses when on diuretics and ACE inhibitors. Also keep in mind that HR will be lower than expected due to Beta blockers.

12. Exercise Testing Usually heart failure is a contraindication to exercise testing, however in stable patients it is vital that cardiorespiratory function is assessed before working with patient. Testing: o Get resting measurements (BP with stethoscope, and HR with ECG) o Modified Naughton or Bruce protocol of 2-3 min per stage increasing the work rate by 10 to 15 every minute. o Terminate test when patient shows any sign of fatigue or dyspnea. o Measure peak oxygen uptake to define limits of cardio respiratory system using a cardiopulmonary cart.

13. Exercise Prescription Aerobic: o Cycle o 60% of HRR o 4 times/wk for 40 min Resistance: o Fixed machines to improve lower body strength and endurance (leg press, quad ex, hamstring curls) o 40 % of 1RM for 1 set of 12-15 reps o Once a week Flexibility o Only 30s holds of major muscles minutes before and after exercise.

14. Conclusion As more people are living longer than ever before, the diagnosis of heart failure is rapidly growing. By managing the disease with appropriate pharmacology, and adherence of regular exercise those affected by the disease can improve their quality of life while decreasing their risk of hospitalization or death.

15. References Corrà, U., Piepoli, M. F., Adamopoulos, S., Agostoni, P., Coats, A. J., Conraads, V., &... Ponikowski, P. P. (2014). Cardiopulmonary exercise testing in systolic heart failure in 2014: the evolving prognostic role. European Journal Of Heart Failure, 16(9), 929-941. doi:10.1002/ejhf.156 Ehrman, J., Keteyian, Steven J. (2003). Chronic Heart Failure. In Clinical exercise physiology (Third ed., pp. 259-276). Champaign, IL: Human Kinetics. Kearney, M. (2008). Chronic Heart Failure. Oxford: OUP Oxford. Mann, D. (1999). Mechanisms and Models in Heart Failure : A Combinatorial Approach. Circulation, 999-1008. Nicholson, C. (2014). Chronic heart failure: pathophysiology, diagnosis and treatment. Nursing Older People, 26(7), 29-38 10p. doi:10.7748/nop.26.7.29.e584 Chicago/Turabian: Author-DateChicago/Turabian: Author-Date