Heart Failure During Physical Therapy Interventions

• 150 minutes per week of moderate-intensity physical activity (e.g., brisk walking) or 75 minutes per week of vigorous-intensity physical activity.
  • Level of Benefit: Improved peripheral muscle function, reduced mortality and event-free survival.
  • Harm Assessment: Possible injuries from participation in activity or falls.

Considerations: Patients should be encouraged to increase activity as much as possible to offset the adverse sequelae noted with inactivity.

• For patients across all settings along the continuum educate on:
  • Daily weight measurement
  • Recognition of signs and symptoms of an exacerbation using the Red-Green-Yellow Heart Failure Tool
  • Following a nutrition plan and medication management
    • Level of Benefit: Significant reduction in all-cause hospital and heart failure specific readmissions.
    • Harm Assessment: None.

Considerations: Shared decision-making is essential to understanding the patient’s priorities and maximize the utilization of the education provided.

• For patients with stable, New York Heart Association (NYHA) Class II–III heart failure with reduced ejection fraction (HFrEF), use the following parameters:
  • Time: 20–60 minutes
  • Intensity: 50–90% of peak oxygen uptake (VO₂) or peak work
  • Frequency: 3–5 times per week
  • Duration: at least 8–12 weeks
  • Mode: treadmill or cycle ergometer or dancing
    • Level of Benefit: Significant improvement in peak VO₂ proportional to training intensity where higher training intensities yield greater changes in peak VO, improved health related quality of life (₂HRQL) on the Minnesota Living with Heart Failure Questionnaire (MLHFQ), reduced all-cause and heart failure (HF) -related hospital admissions and hospital days.
    • Harm Assessment: No additional adverse events beyond usual care.

Considerations: Use clinical judgment in dosing aerobic exercise training in patients who are unstable/acutely decompensated or who have significant comorbidity

• For patients with stable, NYHA Class II–III HFrEF use the following parameters:
  • Time: >35 total minutes of 1–5 minutes of high intensity (>90%) alternating with 1–5 minutes at 40–70% active rest intervals, with rest intervals shorter than the work intervals
  • Intensity: >90 of peak VO₂ or peak work
  • Frequency: 2–3 times per week
  • Duration: at least 8–12 weeks
  • Mode: treadmill or cycle ergometer
    • Level of Benefit: Improved peak VO₂ above that achieved with moderate-to-vigorous intensity continuous exercise training.
    • Harm Assessment: Deaths and other adverse events were not different compared to controls and other exercise training intensities.

Considerations: Adherence is thought to be higher with shorter, higher intensity, interval-based sessions. Exclude patients for whom high intensity and high heart rates might be contraindicated (e.g., some types/settings of implantable cardiac defibrillators (ICDs), history of exercise-related adverse events, sub-optimally treated coronary artery disease).

• For patients with stable, NYHA Class II–III HFrEF use the following parameters:
  • Time: 45–60 minutes per session
  • Intensity: 60–80% one repetition maximum (1RM), 2–3 sets per muscle group
  • Frequency: 3 times per week
  • Duration: at least 8–12 weeks
    • Level of Benefit: Significant improvements in aerobic capacity, six minute walk distance (6MWD), HRQL on the MLHFQ, and muscle strength.
    • Harm Assessment: Transient musculoskeletal pain that may require adjustment of the exercises performed.

Considerations: Patients with NYHA Class IV were excluded from all trials. The absence of empirical data in those with severe decompensated disease makes it challenging to create specific guidelines on resistance training.

• For patients with stable, NYHA Class II–III HFrEF use the following parameters:
  • Time: 20–30 minutes of resistance training added to aerobic exercise training
  • Intensity: 2–3 sets per major muscle group, 60–80% 1RM
  • Frequency: 3 times per week
  • Duration: at least 8–12 weeks
    • Level of Benefit: Improved muscular strength and endurance and HRQL beyond that achieved with aerobic exercise training alone.
    • Harm Assessment: Transient musculoskeletal pain that may require adjustment of the exercises.

Considerations: Total exercise training time should be considered to ensure adherence.

• For patients with stable, Class II and III HFrEF with or without baseline inspiratory muscle weakness use a threshold inspiratory muscle trainer or similar device:
  • Time: 30 min/day or less if using higher training intensity (>60% maximum inspiratory pressure [MIP])» Intensity: >30% MIP
  • Frequency: 5–7 days/week
  • Duration: at least 8–12 weeks
    • Level of Benefit: Improved MIP, sustained MIP, exercise capacity measured by peak VO₂ and 6MWD.
    • Harm Assessment: No documented risks or harms.

Considerations: Consideration should be given to those individuals at risk for vocal fold dysfunction and pneumothorax, as well as those with markedly elevated left ventricular end diastolic volumes. Device cost can vary. Patient time to complete an intervention especially with lower training intensities and longer durations or when combined with other interventions, should be considered.

• For patients with stable, Class II and III HFrEF with or without baseline inspiratory muscle weakness use inspiratory muscle trainer in addition to aerobic exercise training using the following parameters:
  • Time: 30 min/day
  • Intensity: >30% MIP
  • Frequency: 5–7 days/week
  • Duration: at least 8–12 weeks
    • Level of Benefit: Improved MIP and HRQL beyond that achieved with aerobic exercise training alone.
    • Harm Assessment: Similar to inspiratory muscle training as noted above.

Considerations: Similar to inspiratory muscle training as noted above.

• For patients with stable NYHA Class II–III HFrEF using the following parameters:
  • Time: 30–60 minutes per session
  • Waveform: Biphasic symmetrical pulses at 15 to 50 hertz
  • Intensity: On/off time 2/5 seconds, pulse width for larger muscles of the lower extremity should be 200 to 700 µs and for small lower extremity muscles 0.5 to 0.7 ms, 20–30% of maximum voluntary contraction (MVC), intensity to muscle contraction
  • Frequency: 5–7 days/week
  • Duration: At least 5–10 weeks
    • Level of Benefit: Improved muscle strength and endurance, Peak VO₂, 6MWD and HRQL on MLHFQ.
    • Harm Assessment: No adverse events attributable to the neuromuscular electrical stimulation (NMES) intervention throughout the available evidence. Patients did experience mild self-limited cramps or muscle soreness. NMES units and electrodes can vary in cost but handheld devices can be just as powerful as larger NMES devices.

Considerations: Patient tolerance to electric stimulation varies, and intensity to at least visible muscle contraction is required to be effective for NMES. Patients with an implanted ICDs/pacemakers were excluded from all randomized trials.