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Exercise Rejuvenates Failing Hearts

Function Improves Regardless of Age

We typically lose muscle and gain fat with age; the process starts slowly and gains momentum over time, especially in sedentary individuals. Congestive heart failure (CHF) brings on additional problems; the heart loses the pumping power to meet the body’s demands. About 5.7 million adult Americans have CHF, according to the American Heart Association.   

Both age and heart disease leave people feeling weak and fatigued, debilitated and unable to meet the demands of daily living. It is well known that exercise counters muscle wasting as we age. Exercise is also prescribed for people with weak hearts. Nevertheless, there’s still a lot we don’t know about the reach of exercise. What mechanisms are involved, especially in older people? An unanswered question is when, if ever, exercise loses its effectiveness. Does a 70-year-old with CHF benefit as much as a younger sufferer?

German researchers designed a study to determine the effects of exercise in younger and in older patients with CHF. The results were published in the May 7, 2012, issue of the journal Circulation.

The study included 60 heart failure patients and 60 healthy people who did either four weeks of endurance exercise or no exercise. Half of the participants were 55 or younger (mean age 46) and half 65 or older (mean age 72). In both age groups, four 20-minute sessions (excluding warm-up and cooldown) of supervised exercise was performed four times a day five days a week, plus one 60 minute group exercise session. The 20-minute sessions were done on stationary bicycles at 70% of symptom-limited maximum oxygen uptake capacity.

Changes in leg strength and oxygen uptake capacity were measured. Biopsies were also taken from their leg muscles before and after exercise. Using the biopsies, the researchers measured the levels of muscle wasting enzymes and muscle building enzymes before and after exercise. Muscle inflammation was also measured.

The surprising results!

Age made no difference. Those aged 55 and younger increased the peak oxygen uptake by 26%, while those 65 and older did a bit better, increasing oxygen uptake capacity by 27%. (Healthy controls improved by 24% for those 55 or under and 19% for those 65 or over.) In addition, exercise slowed muscle wasting in the heart failure patients, improving their leg muscle strength and overall exercise capacity—regardless of age.

Exercise improved the anabolic-catabolic balance in the leg muscles of participants with failing hearts; anabolic activation was increased and catabolic activation was reduced. The healthy subjects already had a decent balance of muscle building and muscle wasting enzymes, while the balance was restored in the participants with CHF. “Exercise switches off the muscle-wasting pathways and switches on pathways involved in muscle growth, counteracting muscle loss and exercise intolerance in heart failure patients,” explained lead researcher Stephan Gielen, MD, deputy director of cardiology at the University Hospital, Martin Luther University of Halle, Germany.  

“Many physicians—and insurance companies—still believe that cardiac rehabilitation does not really help in old age. This study clearly falsifies this belief,” Dr. Gielen and his colleagues declared.

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What about the heart itself? Did the 4-week exercise program make it stronger? Nothing was said in the report about specific effects on the heart, but Stephan von Haehling. MD, PhD, DIC, addressed the issue in an editorial accompanying the study: “Exercise capacity…was improved in all heart failure patients randomized to exercise training, and it appears that these findings can be partly explained by increase in left ventricular ejection fraction.” (Ejection fraction is an index of heart function. It refers to the proportion of blood ejected during each ventricular contraction.) So it seems fair to assume that the exercise did make the failing hearts stronger. Stronger leg muscles would also add to the heart’s pumping capacity.  

Dr. von Haehling was considerably less positive about the long term benefits of the intervention: “One of the reasons for the impressive results of the…study is most probably the rather short duration on the therapeutic intervention—only 4 weeks. Unfortunately, clinical experience shows that patient’s enthusiasm usually declines with the duration of therapy, particularly when much more than taking a daily tablet is involved.”

That’s bound to be true when people are asked to exercise four times a day. Most people are unwilling to exercise 20 minutes a day, much less 20 minutes four times a day. That’s the practical problem I see in the German study. They don’t explain why it was necessary for participants to exercise four times a day—nor do they suggest how that regimen is likely to be carried on without supervision, when the patients are on their own. The study proves that exercise works marvelously well in patients with failing hearts, but not the odds of continuing success after the intervention. That apparently remains for future study.

Referring to the need for more studies, von Haehling quoted the English author Samuel John in 1709: “Great works are performed not by strength, but by perseverance.” The same can be said for exercise. To make it work you’ve got to keep doing it.

The researchers say the study is an essential first step in the development of “pharmaceutical intervention strategies aimed at blocking muscle catabolism.” In other words, they are hoping for a pill that provides the benefits of exercise. “For the present endurance training provides an excellent anabolic stimulus for both younger and elderly patients with heart failure and should be regarded as a key component of an anticatabolic treatment approach in heart failure patients of all age groups,” they added.

Reading between the lines, they believe that an exercise pill is the only realistic answer. While they’re waiting, exercise will have to do, at least for those willing to exercise regularly and help themselves.

I have some thoughts on that approach. First, an exercise pill is a pipe dream. It’s not going happen. Exercise is far more effective than any pharmaceutical substitute is likely to be. The focus should be on persuading heart failure patients to exercise; better yet persuade them to exercise before their heart fails, preventing heart failure from occurring.

How to do that? You’ve heard this before, but I’ll say it again. The only exercise program that people, including those with CHD, are likely to do regularly is one they enjoy. Doctors should urge their patients to experiment and find a regimen they enjoy. Walking is a good place to start for most people. Enjoyment combined with the added vigor provided by challenging their muscles and their heart just might be enough to keep them exercising. They’ll surprise—and please—their doctors; maybe even outlive them. 

I question whether you need to exercise in any prescribed way four times a day. One or two 20-minute walks a day will do wonders for sedentary people, including those with CHD, especially if they get up and move around from time to time during the rest of the day.

A recent study published in the British Medical Journal found that sitting more than three hours a day cuts life expectancy. Lead author, Peter Katzmarzyk, a researcher at the Pennington Biomedical Research Center in Baton Rouge, Louisiana, said no one knows how much we should be up, but we do know we are down too much. If you’ve been sitting for an hour, Dr. Katzmarzyk says you’ve been sitting too long.

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