By Harold L. Karpman, MD, FACC, FACP

Clinical Professor of Medicine, UCLA School of Medicine

Dr. Karpman reports no financial relationships relevant to this field of study.

SYNOPSIS: Physical inactivity in heart failure patients was associated with an increased risk of all-cause death and cardiac death but not with an increased risk of heart failure hospitalization.

SOURCE: Doukky R, Mangla A, Ibrahim Z, et al. Impact of physical inactivity on mortality in patients with heart failure. Am J Cardiol 2016;117:1135-1143.

The effect of complete physical inactivity on various cardiovascular outcomes in healthy subjects without heart failure (HF) is well established.1 However, the effect of physical inactivity on HF patients has been unclear. Researchers previously demonstrated that in subjects without established heart disease, physical inactivity and sedentary time were associated with an increased incidence of new onset HF.2,3

To determine the effect of physical inactivity on mortality in patients with HF, Doukky et al analyzed data from the Heart Failure Adherence and Retention Trial (HART), which was a multihospital, partially blinded, behavioral efficacy, randomized, controlled trial funded by the National Institutes of Health.5,6 The study, which enrolled patients from 10 centers in the Chicago metropolitan area, assessed the effect of self-management counseling vs. education alone on the primary outcome of death or HF-related hospitalization in patients with symptomatic HF. No subjects in HART were enrolled in cardiac rehabilitation or other structured exercise training programs. The primary outcome was all-cause death, and the secondary outcomes were cardiac death and HF hospitalization.

The analysis determined that inactive patients were observed to demonstrate a significant increase in the risk of all-cause death and cardiac death compared to partially active and fully active subjects and that the risk of all-cause death and cardiac death increased in stepwise patterns with decreasing activity level. However, the difference in the risk of HF hospitalization between groups was not statistically significant.

COMMENTARY

The Doukky et al analysis clearly demonstrates that physical inactivity in patients with chronic HF was associated with nearly twice the risk of all-cause death and cardiac death and that even modest leisure exercise was associated with survival benefit. Also interesting was the discovery that television screen time was associated with an incremental risk of all-cause death above and beyond exercise duration and a broad range of sociodemographic and clinical covariates.

A recent cohort study of 82,695 men aged > 45 years of age with no established heart disease demonstrated that sedentary behavior, defined as physical inactivity often associated with significant television viewing screen time, was associated with adverse cardiovascular outcomes.7,8

Doukky et al found that even modest leisure exercise was associated with a significantly reduced risk of all-cause death and cardiac death in patients with chronic HF, regardless of whether the ejection fraction was preserved or reduced. Of course, one must recognize that this study was nonrandomized by design, which slightly or even moderately weakens the final conclusions.

However, the results would certainly suggest that sedentary behavior in patients with HF is associated with increased risk of all-cause and cardiac death, but not with an increase in HF hospitalizations.

Clinicians should make every effort to encourage HF patients to exercise routinely and instruct them to avoid excessive periods of inactivity, such spending too much time in front of the television.

REFERENCES

  1. Proper KI, Singh AS, van Mechelen W, et al. Sedentary behaviors and health outcomes among adults: A systematic review of prospective studies. Am J Prev Med 2011;40:174-182.
  2. Andersen K, Mariosa D, Adami HO, et al. Dose-response relationship of total and leisure time physical activity to risk of heart failure: A prospective cohort study. Circ Heart Fail;7:701-708.
  3. Young DR, Reynolds K, Sidell M, et al. Effects of physical activity and sedentary time on the risk of heart failure. Circ Heart Fail 2014;7:21-27.
  4. Doukky R, Mangla A, Ibrahim Z, et al. Impact of physical inactivity on mortality in patients with heart failure. Am J Cardiol 2016;117:1135-1143.
  5. Powell L, Calvin JE Jr, Richardson D, et al. Self-management counseling in patients with heart failure: The heart failure adherence and retention randomized behavioral trial. JAMA 2010;304:1331-1338.
  6. Powell L, Calvin JE Jr, Mendes de Leon CF, et al. The Heart Failure Adherence and Retention trial (HART): Design and rationale. Am Heart J 2008;156:452-460.
  7. Stamatakis E, Hamer M, Dunstan DW. Screen-based entertainment time, all-cause mortality and cardiovascular events: Population-based study with ongoing mortality and hospital events follow-up. J Am Coll Cardiol 2011;57:292-299.
  8. Nang EE, Salim A, Wu Y, et al. Television screen time, but not computer use and reading time, is associated with cardio-metabolic biomarkers in a multiethnic Asian population: A cross-sectional study. Int J Behav Nutr Phys Act 2013;10:70.