05_guimaraes.p65

Physical activity profile in heart failure patients
from a Brazilian tertiary cardiology hospital
Guilherme Veiga Guimarães, Vitor Oliveira Carvalho, Unidade Clínica de Insuficiencia Cardíaca e Transplante do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da USP (InCor HC-FMUSP), Brazil Laboratório de Atividade Física e Saúde do Centro de Práticas Esportivas da Universidade de São Paulo (CEPEUSP), Brazil Abstract
Background: Physical activity (PA) has proven benefits in the primary prevention of heart
diseases such as heart failure (HF). Although it is well known, HF PA habits and physicians’
advice have been poorly described. The aim of this study was to investigate if physicians were
advising HF patients to exercise and to quantify patients’ exercise profiles in a complex
cardiology hospital.
Methods: All 131 HF patients (80 male, average age 53 ± 10 years, NYHA class I–V, left
ventricular ejection fraction 35 ± 11%, 35 ischemic, 35 idiopatic, 32 hypertensive and 29 with
Chagas disease) went to the hospital for a HF routine check-up. On this occasion, after seeing
the physician , we asked the patients if the physician had advised them about PA. Then, we
asked them to fill in the international physical activity questionnaire (IPQA) Short Form to
classify their PA level.
Results: Our data showed a significant difference between patients who had received any
kind of PA advice from physicians (36%) and those who had not (64%, p<0.0001). Using the
IPAQ criteria, of the 36% of patients who had received advice, 12.4% were classified as low
and 23.6% as moderate. Of the 64% of patients who did not receive advice, 26.8% were
classified as lowand 37.2% as moderate. Etiology (except Chagas), functional class, ejection
fraction, sex and age did not influence the PA profile.
Conclusions: Physicians at a tertiary cardiology hospital were not giving patients satisfactory
advice as to PA. Our data supports the need to strengthen exercise encouragement by physicians
and for complementary studies on this area. (Cardiol J 2010; 17, 2: 143–148)
Key words: heart failure, exercise, adherence, rehabilitation
Introduction
ty [1, 2]. Physical activity has shown benefits in theprimary prevention of chronic diseases and in the Physical activity profile has long been used as secondary treatment of heart diseases [3, 4].
a marker of health status. In some populations, Heart failure is considered to be the last stage exercise capacity is related to mortality and morbidi- of heart disease and is a cause of worldwide mor- Address for correspondence: Dr. Vitor Oliveira Carvalho, Av. Dr. Enéas de Carvalho Aguiar, 44, Laboratório de InsuficiênciaCardíaca, Bloco 1, 10 Andar, CEP: 05403-900 São Paulo, Brazil, tel: +55 11 30695419, e-mail: [email protected] Cardiology Journal 2010, Vol. 17, No. 2
tality and morbidity [5, 6]. It is characterized by Table 1. Baseline characteristics in heart failure
a persistent activation of the neurohormonal system [7], endothelial dysfunction [8, 9], exercise intolerance [10– –12], high mortality [13] and a poor quality of life [14].
The recommended treatment for heart failure (HF) patients is divided into non-drug and drug therapy. The non-drug treatment is based on diet, family orientation and physical activity [15]. Physi- cal activity is a safe and well tolerated method to decrease HF symptoms, neurohormonal activity, morbidity and mortality [5]. It is also important to increase quality of life and physical capacity, mak- ing the patients better able to perform satisfactori- The International Physical Activity Question- naire (IPAQ) [22] was developed in 1998 in Gene- va, Switzerland, by the International Consensus Group to evaluate physical activity level. It was validated in 2000 by 14 centers. In Brazil it was The aim of this study was to evaluate the phys- ical activity profile of HF patients and the physical activity advice given by their physicians in a tertia- ry cardiology hospital in Brazil. In addition, this study evaluated the influence of etiology, function- al class, ejection fraction, sex and age in the physi- LVEF — left ventricular ejection fraction; NYHA — New York HeartAssociation; ACE — angiotensin converting enzyme; A II — angio-tensin II antagonists; Ca — calcium channel Population
jective as possible with regard to their usual mean One hundred and thirty one patients with sta- daily physical activities. As soon as the question- ble HF were recruited from a Brazilian tertiary car- naire was answered, patients were classified by diology hospital. Stability was defined as no alter- physician advice and by the three levels of physical ations in medical therapy or change in HF symp- activity (IPAQ Short Form): low, moderate and toms for one month, and no myocardial infarction high. Individuals who did not meet the criteria for for three months. Baseline characteristics are the moderate or high categories were considered shown in Table 1. All patients had documented left to have a ‘low’ physical activity level.
ventricular ejection fraction (LVEF £ 45%, by Individuals who met at least one of the follow- echocardiography) and were on appropriate medical ing criteria were classified as moderate: a) three or therapy (angiotensin-converting enzyme inhibitors, more days of vigorous-intensity activity for at least diuretics, aldosterone antagonists, digoxin, and/or 20 min per day; b) five or more days of moderate- beta-blockers). Patients were excluded if they had any -intensity activity and/or walking for at least, neurological, orthopedic or peripheral vascular disease 30 min per day; c) five or more days of any combi- that could impair their physical activity profile.
nation of walking, moderate-intensity or vigorousintensity activities.
Study design
Individuals who met one of these following crite- All studied patients went to the hospital for ria were classified as ‘high’ level of physical activity: a HF routine check-up. On this occasion, after see- a) vigorous-intensity activity on at least three days, or ing the physician, we asked the patients if the phy- b) seven or more days of any combination of walking, sician had advised them about physical activity.
moderate-intensity or vigorous-intensity activities.
Then, we asked the patients to fill in the IPAQ Short This protocol was approved by the Ethical Form for a physical activity classification [11]. All Committee of the study institution. All patients patients were instructed to be as precise and ob- provided informed consent prior to participation.
Guilherme Veiga Guimarães et al., Cardiovascular rehabilitation
Statistical analysis
Table 2. International Physical Activity Question-
Results are given as mean ± standard devia- naire in heart failure patients (n = 131).
tion for continuous variables. The Kolmogorov- Low Moderate
-Smitnov test was used to check the data normality.
The Mann-Whitney test was used to compare vari- ables that did not exhibit a normal distribution. Mul- tivariate logistic regression analysis was used to assess the ability of sex, age, New York Heart As- sociation (NYHA) functional class and LVEF to in- fluence a patient’s physical profile. Data was ana- lyzed using Statistical Package for Social Sciences (SPSS) for Windows, v. 11.5 (SPSS Inc, Chicago, IL, USA). Statistical significance was p < 0.05.
Our data showed a significant difference be- tween patients who had been given any kind of phys- ical activity advice by physicians (36%) and those who had not (64%, p < 0.0001). Using the IPAQ cri- teria for physical activity, of the 36% of advised pa- tients, 12.4% were classified as low and 23.6% as NYHA — New York Heart Association; LVEF — left ventricular ejection moderate. From the 64% of patients who did not re- ceive advice, 26.8% were classified as low and 37.2%as moderate. None of the studied patients were clas-sified as high intensity level of physical activity.
Table 3. Physical activity orientation in heart
failure patients (n = 131).
Functional class
There was no significant difference in the NYHA functional classification between low and moderate intensity of physical activity profile (Ta- ble 2). Neither was there any significant difference between the advised and the non-advised group about physical activity (Table 3). NYHA functional class did not influence the patient’s physical activ- Etiology
There was no significant difference between low and moderate physical activity profile, except for those with Chagas disease (Table 2). There was also no significant difference between the advised and the non-advised group about physical activity, except for those with Chagas (Table 3).
NYHA — New York Heart Association; LVEF — left ventricular ejectionfraction Left ventricular ejection fraction
There was no significant difference between low and moderate physical activity profile (Table 2).
There was also no significant difference between Men had a greater physical activity level than the advised and the non-advised group about phys- women, but both sexes received poor advice about ical activity (Table 3). LVEF did not influence the physical activity. Sex did not influence the physical patient’s physical activity profile (Table 4).
Cardiology Journal 2010, Vol. 17, No. 2
Table 4. Multivariate logistic regression analysis
represent a paradigm change; but rather the accu- mulated knowledge is now so extensive that it isobligatory to implement it in HF treatment [13].
Variables
Patients with heart disease are, naturally, con- cerned about the appropriate intensity of exercise and its safety. A moderate training level improves functional capacity and provides long-term adher- ence. Physical activity can be quantified in terms of METs (metabolic equivalents), where one MET NYHA — New York Heart Association; LVEF — left ventricular ejection (3.5 mLO /kg/min) represents the rate of oxygen consumption by a normal average adult at rest [26].
Physical activity can also be categorized as light(< 4 METs), moderate (4 to < 6 METs), and vig- orous (> 6 METs). Moderate intensity activities There was no significant distribution among burn almost 150 Kcal daily or 1,000 Kcal weekly low and moderate physical activity levels in the [27]. Therefore, sedentary patients should be en- ranges of age 19 to 40 years (16 patients), 41 to couraged to increase their physical performance, 60 years (80 patients) and > 60 years (35 patients).
exercising with a light to moderate intensity, ex- Age did not influence the patient’s physical activi- pending 1,000 to 1,500 Kcal per week, which can be accomplished by a daily walk [28, 29].
The U.S. Center for Disease Control and Pre- Discussion
vention and the American College of Sports Medi-cine recommend at least 30 min of moderate inten- The aim of this study was to check if HF pa- sity physical activity per day on most days of the tients were advised by physicians to exercise, week. No data exists concerning the prognostic and to study the level of physical activity of the implications of different intensities or duration advised and non-advised groups. We found that training in HF patients. However, the evidence physicians at a tertiary cardiology hospital did not suggests that regular physical activity can favorably advise patients satisfactorily to perform physical activities. This goes against accepted worldwide Our data showed that 86% of the studied HF advice. Our results suggest that physicians’ treat- patients performed physical activity less than 150 min ment profiles are almost entirely characterized by in a week. A similar result (84 to 93%) was observed the prescription of drugs to improve symptoms.
in a healthy population in Latin America, in contrast None of the studied patients had a high intensity to a European healthy population (57%) [31]. How- physical activity profile, and only a few had ever, participation in physical activity programs is influenced by social experiences and cultural va- A modern cardiovascular rehabilitation pro- lues. It is an important consideration when planning gram provides lifestyle intervention, encouraging exercise programs for specific ethnic groups [32, patients to stop smoking, to eat healthy food, to 33]. Appropriate forms of exercise may contribute maintain a healthy body weight and to increase their exercise capacity. Finally, physicians ensure appro- Physical inactivity is pervasive: more than 60% priate prescribing and compliance with cardio-pro- of women and men do not engage in the recom- mended amount of physical activity, and 25% are A previous study showed that global indicators not active at all [36]. Similar levels of inactivity were of physicians’ adherence to guidelines treatment observed in our study. This is particularly unfortu- were associated with decreased rates of HF com- nate in HF patients, because physical activity is plications and delayed re-hospitalization [23].
safe, effective and associated with a better survival This is the first study to evaluate physical ac- and quality of life. Physical activity should be part tivity profile of HF patients in a tertiary cardiology hospital. Physical capacity and daily exercises are A study showed that an increase of 1% in the important to clinical outcomes in any chronic disease physical activity level was enough to improve qual- [24, 25]. These daily exercises are effective in HF ity of life, decrease hospitalizations and medical treatment, particularly when the drug therapy is costs (estimated US$ 7 million) [37]. After the be- optimized. In this context, exercise therapy does not ginning of a physical activity motivation program in Guilherme Veiga Guimarães et al., Cardiovascular rehabilitation
a large number of sedentary people, there was an 8. Maruo T, Nakatani S, Kanzaki H et al. Circadian variation of increase of 8% of men, and 5% of women, partici- endothelial function in idiopathic dilated cardiomyopathy. Am J pating [18]. However, our study showed that, even after a physician advises physical activity, most 9. Carvalho VO, Ciolac EG, Guimarães GV, Bocchi EA. Effect of exercise training on 24-hour ambulatory blood pressure moni- patients do not perform any kind of exercise.
toring in heart failure patients. Congest Heart Fail, 2009; 15: 1–5.
10. Ades PA, Savage PD, Brawner CA et al. Aerobic capacity in Limitation of the study
patients entering cardiac rehabilitation. Circulation, 2006; 133: This study was limited by the use of an indi- rect measure of physical activity. No physiological 11. Guimarães GV, Carvalho VO, Bocchi EA. Reproducibility of the or exercise measuring devices were used. No con- self-controlled six-minute walking test in heart failure patients.
firmatory sources (such as family contact) were 12. Carvalho VO, Pascoalino LN, Bocchi EA, Ferreira SA, used to validate self-reported activity levels either.
Guimarães GV. Heart rate dynamics in heart transplantation Patients were interviewed only once, after their patients during a treadmill cardiopulmonary exercise test: A pilot study. Cardiol J, 2009; 16: 254–258.
13. Bocchi EA, Cruz F, Guimarães G et al. Long-term prospective, randomized, controlled study using repetitive education at six- Conclusions
-month intervals and monitoring for adherence in heart failure outpatients. The REMADHE study. Circ Heart Fail, 2008; 1: Physicians did not advise their patients satis- factorily to perform physical activities in a tertiary 14. Carvalho VO, Guimarães GV, Carrara D, Bacal F, Bocchi EA.
cardiology hospital in Brazil. Etiology (except those Validation of the Portuguese Version of the Minnesota Living with with Chagas disease), functional class, ejection frac- Heart Failure Questionnaire. Arq Bras Cardiol, 2009; 93: 39–44.
tion, sex and age did not influence the physical activ- 15. Corra U, Giannuzzi P, Adamopoulos S et al. Executive summary ity profile. Our data supports the necessity of streng- of the position paper of the Working Group on Cardiac Rehabilita- tion and Exercise Physiology of the European Society of Cardio- thening exercise encouragement by physicians.
logy (ESC): Core components of cardiac rehabilitation in chronic heart failure. Eur J Cardiovasc Prev Rehabil, 2005; 12: 321–325.
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