Intervention for Patients

with Congestive Heart

Failure
INTRODUCTION
The APTA Guide to Physical Therapist Practice, the management of patients with congestive
heart failure (CHF) falls under Pattern 6D: Impaired Aerobic Capacity/Endurance
Associated with Cardiovascular Pump Dysfunction or Failure. This classification specifically
addresses conditions where cardiovascular limitations affect a patient’s endurance and aerobic
capacity, as seen in CHF.

In this pattern, physical therapists focus on interventions to improve the patient’s aerobic
capacity and endurance. The goal is to enhance cardiovascular function, increase exercise
tolerance, and ultimately improve the patient’s quality of life.

Congestive Heart Failure- Anticipated Goals and

Expected Outcomes
● Physiological response to increased oxygen demand is improved.
● Self-management of symptoms is improved.
● Ability to perform physical tasks is increased.
● Behaviors that foster healthy habits, wellness, and prevention are acquired.
● Disability associated with acute or chronic illness is reduced.
● Risk of secondary impairments is reduced.
● Awareness and use of community resources is improved.
● Performance of and independence in ADL is increased.

Exercise Prescription
Exercise , once considered too risky for CHF patients, is now a cornerstone of treatment.
Research has shown that exercise is both safe and beneficial for individuals with CHF, providing
improvements in functional status, quality of life, exercise tolerance, and symptom relief.
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A comprehensive, multidisciplinary exercise approach for CHF might include:

1.Initial Assessment and Monitoring: A multidisciplinary team (including cardiologists,

physical therapists, and exercise physiologists) should perform a thorough physical exam,
review symptoms, and evaluate medications before each session. If the patient is
hemodynamically stable and in compensated CHF, a low-level exercise program can be initiated.

2.Aerobic Conditioning: Low-intensity aerobic exercise, like walking or stationary cycling, is

typically the starting point. The exercise intensity is gradually increased as tolerated, with
continuous monitoring to ensure stability. Regular aerobic exercise helps improve
cardiovascular function, systemic endurance, and overall energy levels.

3.Strength Training and Peripheral Adaptations: CHF impacts not only the heart but also
peripheral muscles and arteries, leading to issues like muscle fiber atrophy and reduced arterial
vasodilation capacity. Low-level resistance training for large muscle groups (such as legs and
arms) can help counteract muscle atrophy, improve peripheral adaptations, and enhance
circulation. Research suggests strength training can be safely integrated with proper
supervision.

4.Respiratory Muscle Training: CHF also affects respiratory muscles, contributing to

decreased endurance and increased dyspnea (shortness of breath). Respiratory muscle training
(e.g., inspiratory muscle training) can strengthen these muscles, reduce breathing difficulty, and
improve exercise tolerance.

5.Peripheral Endurance Training: Peripheral adaptations—targeting skeletal muscles and

their endurance—are critical in CHF management. Such training helps limit atrophy, supports
functional independence, and enhances the ability to perform ADLs (activities of daily living)
without excessive fatigue.

6.Symptom Monitoring and Self-Management: Patients are trained to self-monitor for

symptoms like excessive fatigue, dyspnea, and weight gain, which could indicate fluid retention
or worsening CHF. Educating patients on symptom management can improve safety and
encourage long-term adherence to exercise.

Criteria for Modification or Termination of Exercise in Patients with Heart

Failure

● Marked dyspnea or fatigue

● RR > 40 breaths/min
● Development of S3 heart sound
● Increase in pulmonary crackles
● Decrease in HR or BP of > 10 bpm or mm Hg respectively during steady state or
progressive exercise

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 ● Increase in the CVP by 10 mm of Hg
● Diaphoresis, pallor, or confusion

Criteria for Initiation of Exercise

● Compensated CHF
● Able to speak comfortably without signs of dyspnea with RR < 30 breaths/min
● Less than moderate fatigue
● CI > 2.0 L/min
● CVP < 10 mm Hg
● Crackles in less than one half of the lungs
● Resting heart rate < 120 bpm

Aerobic Exercise
In managing aerobic exercise for patients with CHF, the focus is on maintaining low intensity
and gradually increasing duration, as these patients require tailored guidelines to avoid undue
stress on the heart. Here’s how aerobic exercise is effectively prescribed and monitored in this
population:

1.Intensity Monitoring and Adjustments:

● Low-Intensity Approach: Aerobic exercises, like walking or cycling, should start at a low
intensity, progressing gradually in frequency, duration, and slight intensity as tolerated.
● Use of Dyspnea and RPE Scales: Because medications like beta-blockers interfere with
heart rate (HR) responses, traditional HR monitoring is unreliable. Instead, dyspnea
(breathlessness) and perceived exertion scales (like the Borg RPE scale) are used, with
intensity maintained at a “fairly light” rating.
● The Negative Treppe Effect: In healthy individuals, increased HR typically corresponds
with increased contractility (inotropy). In CHF patients, however, an elevated HR can
reduce cardiac force due to the “negative treppe effect.” Hence, HR increases are not
targeted for intensity adjustment.

2. Blood Pressure (BP) Monitoring for Cardiac Output (CO):

● BP Response: A key indicator of cardiac stability during aerobic activity is BP. If BP

drops during exercise, it suggests that CO (the heart’s ability to supply blood effectively)
is compromised.
● Adjusting Exercise Based on BP: For patients exhibiting a BP drop, aerobic intensity

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 should be minimized, with a shift in focus to other exercise modalities to support
cardiovascular health without increasing central cardiac stress.

3. Strength Training for Peripheral Adaptations:

● Peripheral Focus Over Central Stress: When aerobic capacity is limited, strength training
offers a path to increase endurance by targeting peripheral muscle adaptations. Training
peripheral muscles can help offset the heart’s limitations by improving oxygen use and
energy production directly within the muscle tissues.
● Mitochondrial and Muscle Efficiency: Strength training increases mitochondrial density
and the muscle’s ability to utilize blood and oxygen efficiently. This promotes energy
production at the muscle level, enabling patients to perform ADLs with less reliance on
the heart for increased output.

4. Aerobic and Strength Training Balance:

● Gradual and Monitored Approach: A careful balance between aerobic and strength
training, adjusted based on the patient’s response, creates a safe and effective exercise
regimen. This approach maximizes peripheral adaptations while minimizing undue
stress on the heart, leading to enhanced exercise capacity, better functional outcomes,
and improved quality of life.

These two key studies provide strong evidence for the positive impact of exercise on patients with
heart failure, showing measurable improvements in exercise capacity, cardiovascular function,
and quality of life. Here’s a closer look at each study and its findings:

1.Meta-Analysis by van Tol et al. (2006):

● Design and Scope: This meta-analysis included 35 randomized crossover trials involving
patients with systolic heart failure. On average, patients participated in aerobic exercise
sessions three times a week, lasting 60 minutes each, over a 12-week period.
● Key Findings:
○ 6-Minute Walk Distance: Patients increased their 6-minute walk distance by an
average of 46.2 meters, indicating enhanced functional capacity.
○ Oxygen Uptake (VO2 max): Across 31 studies with about 1,240 patients, maximum
oxygen uptake improved with an effect size of 2.06 mL/kg/min, reflecting better
aerobic capacity.
○ Cardiovascular Improvements: Exercise led to beneficial changes in resting
diastolic blood pressure, cardiac output, and heart rate. These indicators suggest
improved heart efficiency at rest.
○ Left Ventricular Ejection Fraction (LVEF): Patients demonstrated an increase in
LVEF, suggesting improved heart pumping ability and potentially a higher
tolerance for exercise intensity after the 12-week program.

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2. Systematic Review by Smart and Marwick (2004):

● Design and Scope: This review evaluated 81 studies with a total of 2,387 exercising
subjects, 1,197 of whom were in controlled trials, covering around 60,000 hours of exercise
training. Participants had a mean age of 59 years, and an average ejection fraction (EF) of
27%.
● Key Findings:
○ VO2 Max Improvement by Exercise Type:
■ Aerobic Exercise Alone (40 studies): VO2 max increased by an average of
16.5%, showcasing aerobic training’s strong impact on cardiovascular
endurance.
■ Strength Training Alone (3 studies): VO2 max increased by 9.3%,
indicating that even strength training alone can positively influence
aerobic capacity.
■ Combined Aerobic and Strength Programs (30 studies): VO2 max increased
by 15%, illustrating that combined training is effective, albeit slightly less
impactful than aerobic alone but more than strength alone.
○ Clinical Significance: An individual with a VO2 max of 15 mL/kg/min could
increase it to 17.4 mL/kg/min, equating to a 0.68 MET (metabolic equivalent)
improvement. Clinically, this improvement could make a meaningful difference,
enabling sustained walking on a flat surface—a crucial factor in daily functional
independence for patients with heart failure

Strength Training
Strength training has become an integral part of exercise plans for patients with heart failure
(HF), as it plays a key role in enhancing peripheral muscle strength, endurance, and functional
capacity. Light resistance exercises, as highlighted by research from Braith and Beck, are both
safe and beneficial for HF patients, allowing for effective strength gains without overburdening
the cardiovascular system. Here’s a closer look at how resistance training is structured for HF
patients and its associated benefits:

1.Safety and Structure of Resistance Training:

● Light Resistance Levels: HF patients benefit from low-intensity resistance exercises that
reduce cardiovascular stress while improving muscle function. Modalities like elastic
bands and light weights (typically 1-3 lbs) are commonly used to provide gentle
resistance that can be gradually increased as tolerated.
● Upper and Lower Extremity (UE and LE) Exercises: By including exercises for both UE

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 and LE, patients can achieve balanced strength gains that support functional
independence and mobility.

2.Benefits Outlined by Braith and Beck’s Review:

● Improved Muscle Morphology: Resistance training has been shown to improve skeletal
muscle size and structure, counteracting the muscle atrophy often associated with HF.
This leads to greater muscle efficiency and endurance, essential for daily activities.
● Enhanced Peripheral Muscle Function: Strengthening peripheral muscles reduces the
load on the heart during activity by enabling muscles to use oxygen more effectively,
which helps improve overall energy efficiency and reduce fatigue.

3.Clinical Guidelines for Resistance Exercise in HF:

● Starting Low and Gradually Progressing: Begin with minimal resistance and a
conservative number of repetitions (typically 1-2 sets of 10-15 repetitions), increasing
gradually based on the patient’s tolerance and symptoms.
● Frequency and Rest: Recommended 2-3 times per week with rest days between sessions
to allow muscle recovery.
● Monitoring for Safety: Patients should be carefully monitored for signs of overexertion,
such as shortness of breath or unusual fatigue, and the program should be adapted to
each individual’s current health status and response to exercise.

Resistance Training Recommendations for CHF Patients

NYHA Class Frequency Duration Intensity Sets Reps

2-3 days per 15-30 50%-60% of 1 2-3 6-15

Class I week minutes RM*

1-2 days per 12-15 40%-50% of 1 1-2 4-10

Class II-III week minutes RM*

*1 RM = 1 Repetition Maximum, the maximum weight the patient can lift for one repetition.

New York Heart Association (NYHA)

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Ventilatory Muscle Training
Ventilatory muscle training (VMT) plays an important role in managing heart failure (HF) by
strengthening the respiratory muscles, enhancing breathing efficiency, and reducing symptoms
such as shortness of breath and fatigue. Here’s an overview of the techniques and devices used in
VMT and their benefits for HF patients:

1. Diaphragmatic and Pursed-Lip Breathing:

● Diaphragmatic Breathing: This technique focuses on using the diaphragm more
effectively, which can help reduce the reliance on accessory muscles (such as the
neck and shoulder muscles). By shifting breathing to the diaphragm, patients reduce
the work of breathing and improve oxygen delivery efficiency.
● Pursed-Lip Breathing: Although commonly associated with COPD management,
pursed-lip breathing is also beneficial for HF patients. By slowing the respiratory
rate and creating a positive end-expiratory pressure, this technique helps prevent
airway collapse, making it easier to control breathlessness and enhancing
oxygenation.

2. Inspiratory Muscle Training (IMT) with a Threshold Inspiratory Muscle Trainer:

● Device and Mechanism: The threshold inspiratory muscle trainer is a handheld
device that provides resistance during inhalation. This resistance strengthens the
inspiratory muscles, especially the diaphragm, by requiring the muscles to work
harder to overcome the device’s pressure.
● Protocol for Use: A standard protocol includes setting the trainer at about 20% of
the patient’s maximal inspiratory pressure. HF patients generally use the device
three times daily, with sessions lasting from 5 to 15 minutes each. This routine
gradually strengthens the inspiratory muscles over time, leading to improvements
in maximal inspiratory pressure (MIP).

3. Benefits of VMT in Heart Failure:

● Enhanced Respiratory Muscle Strength: By increasing the strength of the inspiratory
muscles, patients improve their overall ventilatory capacity, making daily activities
easier and less tiring.
● Reduced Respiratory Rate and Improved Control of Breathlessness: Techniques like

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 pursed-lip breathing help control the respiratory rate and reduce dyspnea, or
breathlessness, which is especially valuable during physical activities.
● Improved Exercise Tolerance and Quality of Life: Strengthening respiratory muscles
can lead to enhanced exercise capacity, enabling HF patients to participate more
effectively in physical activities and improving their quality of life.

Activity Pacing and Energy Conservation Techniques

Patients with heart failure require activity pacing and energy conservation techniques to decrease
the workload on the heart. A few techniques that may be beneficial for patients include the
following:

● Recommending frequent rest intervals before they get tired.

● Participate in activities that require greater energy costs at times of the day when they have
the most energy.
● Plan ahead to decide activities that possibly may be avoided and delegated to others.
● Alternate easy and difficult tasks with rest intervals.
● Adjust the environment to make tasks easier and sit when feasible while doing strenuous
activity.

EDUCATION FOR PATIENTS WITH HEART DISEASE

For patients with heart disease, patient and family education develops along a continuum,
depending on the patient’s baseline status and readiness to attend to the information. The physical
therapist, along with other members of the health care team, must determine the patient’s and
family’s ability to understand and adhere to the information. Appropriate discharge or ongoing
outpatient topics to be addressed include the following.

1. Activity Guidelines. Patients (and family) need to be able to understand specific activity
guidelines, which include planned exercise sessions as well as leisure time and rests.
2. Self-Monitoring. Patients may monitor the intensity of their activity in a variety of ways;
two of the more common ways are palpating a pulse and RPE. Because many older patients
have decreased sensitivity in their palpation skills, the use of RPE may be easier and more
reliable. hose patients who are able to take a pulse or choose to invest in an HR monitor

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 may prefer to use those methods. Self-monitoring not only involves HR or RPE, but
awareness of other symptoms or signs that may suggest exercise intolerance, such as
lightheadedness, mental confusion, dyspnea, and inability to carry on a brief conversation
while performing an activity. Patients with CHF commonly use the dyspnea scale and the
Borg RPE Scale.
3. Symptom Recognition and Response. Being able to recognize their specific cardiac
symptoms and to know how to respond is a key component in patient education. Patients
should have written information regarding the action they should take when symptoms
occur, for example, when to call their physician or go to the hospital. Angina is the most
common symptom associated with coronary heart disease, whereas weight gain (2 lb over 1
to 2 days), dyspnea, LE edema, and increased pillows for sleep are common signs and
symptoms for CHF.
4. Nutrition. Patients commonly meet with a nutritionist to discuss their usual dietary habits
and to make recommendations when needed for a more heart-healthy diet. Most commonly,
patients with heart disease are instructed to reduce fat intake; patients with CHF are
instructed to monitor salt and fluid intake.
5. Medications. Patients receive written information regarding the desired action of their
medications, potential side effects, dosage, and timing of medications. Patients should also
know which non-prescription drugs such as cold, sinus, allergy, or anti-inflammatory
medications they should avoid because of possible interactions with prescription drugs.
Patients should also be encouraged to dis- close all herbal remedies and supplements that
they may be taking.
6. Lifestyle Issues. Many factors influence whether a patient will return to work after a
cardiac event. Many patients with CAD return to work if they were employed before their
event; patients with CHF are, in general, an older population when compared to patients
with CAD and therefore may have already retired.