(Dec 10, 2008 - Insidermedicine) On a recent trip to Atlanta we caught up with Dr. Rebecca Gary (PhD, RN), an assistant professor in the department of Adult and Elder Health Nursing at Emory University. Dr. Gary’s research is concerned with improving symptom severity and quality of life in patients with chronic cardiovascular disease.
If I had heart failure, whom should I see?
I think that it is important for heart failure patients to be seen by a cardiologist, I think that a lot of studies have shown that patients’ outcomes are improved if they are seeing a heart specialist. Certainly they can be followed by their primary care physician as well, but I think it’s really important that they see a cardiologist at least from time to time to follow their medication therapy and their progress. I think that certainly in terms of medication therapy cardiologists are more updated on what’s current in terms of the latest guidelines and recommendations.
Why is exercise important for heart failure patients?
I think the biggest reason why it is important is that it changes a lot of the peripheral vascular and the musculo skeletal adaptations that occur with heart failure. Patients with heart failure start out with 50% less cardiac output to begin with, and as a result their muscles are under-perfused, and as a result of that there are a lot of changes that occur. Exercise has been shown to change these changes that occur in the muscle, and from that the symptoms are thought to be predominantly due to the changes in the peripheral musculo-skeletal system and so by doing exercise, we’re hoping to change the histological, the chemical, and all of the changes that are occurring with the heart failure that causes greater symptoms, and increases disease severity in terms of stimulating certain neuro-hormones , catacolomines, all of these things have been shown to be reduced with exercise. All of the heart failure disease severity markers have been shown over time to decrease with exercise and so hopefully their heart failure is more stabilized and the patient is less symptomatic.
How much exercise is enough?
I have had patients in the past who have exercised too much; they think that more exercise is better, just like thinking that if one pill is good, maybe two would be better. I think that starting out very slowly and progressing very gradually up, and we’ve watched that carefully with their heart rate and their RPE, generally 20-30 minutes three times a week is what’s recommended for aerobic exercise. There really aren’t any guidelines for the resistance training yet but generally what’s being published in the literature for heart failure is twice a week, and doing upper body and lower body muscle training either the same or at different times, and having at least 24 to 48 hours between the resistance exercises.
If I had heart failure I would want a prescribed exercise program with specific directions and what my heart rate needed to be, what my RPE level needed to be, how much I needed to exercise per week and what I needed to watch out for. I think some patients know they’re going to get a little winded but they don’t know it’s ok to be a little winded; they are going to get winded as they progress their exercise and if they are not feeling well then they shouldn’t be exercising that day, but I would want something more defined than what you typically see now, because I think patients can progress. If I were a heart failure patient I would want my physical function tested every six months, or every year at least: do a six minute walk test, check my mood level, check my quality of life (how am I doing, how am I doing around the house), and this is a real indicator of how patients are feeling, you can really pick up on subtle changes in their symptoms as they progress.
In summary, I would certainly want to see a cardiologist, I would want to be on all of the medications that are within the guidelines of the AHA and ACC, and also exercise prescriptions, the equipment provided if it could be, and routine physical function performance test, and maybe some novel biomarkers to see if I am getting worse, or better.