Heart failure

Also called: Congestive heart failure; reduced or preserved ejection fraction

Exercise is the main treatment Strength

Breathlessness and exhaustion on effort because the heart cannot meet demand. The surprise is how much of the exercise intolerance comes from the skeletal muscle rather than the heart - and that part is trainable.

How common: Around 2% of adults and up to 10% of over-70s

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What it is

Heart failure means the heart cannot pump enough blood to meet the body's needs, either because it does not squeeze well enough or because it does not fill well enough. Both produce the same symptoms: breathlessness, fatigue and fluid retention.

What is less well known is that the exercise intolerance correlates poorly with how badly the heart is pumping. A large part of it comes from changes in the skeletal muscle itself - reduced mass, a shift toward fatigable fibre types, fewer mitochondria and impaired blood flow. That is the part exercise training addresses, and it is why supervised exercise improves symptoms and quality of life substantially in a condition that sounds as though rest would be the answer.

What it feels like

Breathless on exertion, and later at rest or lying flat
Waking at night breathless, or needing extra pillows
Exhausted out of proportion to what you have done
Swollen ankles and legs, worse by evening
Reduced exercise tolerance that has been declining over months

What causes it

Most people have more than one of these at once, and they feed each other. Read the list looking for the two or three that sound like your week rather than for the one true answer — the ones that describe you are the ones worth acting on.

Reduced cardiac output: The heart cannot increase its output enough to meet the demand of exercise, so oxygen delivery to working muscle falls short.
Skeletal muscle dysfunction: Muscle mass falls, fibre type shifts toward fatigable types, mitochondrial density drops and oxidative capacity falls. This accounts for a great deal of the exercise limitation and it responds to training.
Impaired blood flow to muscle: Endothelial dysfunction reduces the ability of vessels to dilate during exercise, so even the output that is available does not reach the muscle efficiently. Exercise improves endothelial function directly.
The ergoreflex: Signals from fatiguing muscle drive up ventilation and sympathetic activity out of proportion. Training the muscle reduces this reflex, which is one reason breathlessness improves without the heart changing.
Deconditioning from reduced activity: The symptoms lead to doing less, which produces muscle loss and worse capacity, which produces more symptoms. This loop is often the largest single contributor to how someone feels.
Underlying causes: Previous heart attack, long-standing high blood pressure, valve disease, atrial fibrillation, alcohol and some chemotherapy agents. Treating the cause is separate from and as important as training.
Fluid overload: Retained fluid in the lungs and legs directly worsens breathlessness and heaviness, and is why diuretics and daily weight monitoring matter.
Anaemia and iron deficiency: Both are common in heart failure and both worsen symptoms independently. Iron deficiency in particular is treatable and frequently missed.
Sleep apnoea: Common in heart failure, worsens it, and is under-diagnosed. Treating it improves cardiac function measurably.
Fear of exertion: Understandable and costly. Being frightened to exert a failing heart produces exactly the deconditioning that makes the symptoms worse.

Who tends to get it

Anyone with a previous heart attack or long-standing high blood pressure
People with valve disease or atrial fibrillation
Anyone with diabetes, which substantially raises the risk
Older adults, in whom heart failure with preserved ejection fraction is common
People with obesity or sleep apnoea

What makes it worse, and what settles it

Makes it worse

Complete rest and avoidance of exertion, which drives the muscle deconditioning
High salt intake and not monitoring daily weight, which allow fluid to build
Alcohol, which is directly toxic to heart muscle
Untreated sleep apnoea, anaemia or iron deficiency
Exercising unsupervised during an unstable period, which is when it genuinely is not safe

Settles it

Supervised exercise-based cardiac rehabilitation, which improves symptoms, quality of life and hospital admissions
Resistance training alongside aerobic work, which addresses the muscle dysfunction directly
Daily weight monitoring so fluid retention is caught early
Getting iron status checked, since deficiency is common and treatable
Taking the prescribed medications consistently, which are what change survival

What actually helps

The short version: Reduced cardiac output plus, importantly, peripheral skeletal muscle dysfunction that drives much of the exercise intolerance

Strength work: Legs: Quads; Glutes; Full Body - moderate-intensity resistance training is safe and recommended

Stretching: Full Body

Massage: Legs: Calves - light, upward strokes

Also worth doing: Supervised aerobic training; inspiratory muscle training; daily weight monitoring

What the evidence says: HF-ACTION and subsequent trials: exercise training reduces hospitalization and improves quality of life. Resistance training is safe and no longer contraindicated. Needs medical clearance and stable status.

The names above are the Targets qFIT tracks — the Muscle Guide explains what each one does, and Quick Add switches on the Exercises you already have.

No ready-made routine for this one yet

249 of the 267 problems here have a routine already built, and this is not one of them — usually because the work that helps is covered by a general routine rather than needing its own. What actually helps above names the muscles and the work involved, which is enough to put it together yourself.

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Get it checked if…

Weight gain of 2 kg in days, worsening breathlessness lying flat, or new ankle swelling means decompensation - stop and get reviewed before exercising

And whatever the body part: chest pain or unusual breathlessness on exertion; a fever alongside the pain; unexplained weight loss; pain that is constant and unrelated to how you move; new numbness, weakness or loss of bladder or bowel control; or one calf that is swollen, warm and painful. Any of those, stop and get assessed.

How it usually goes

Exercise training improves exercise capacity, symptoms and quality of life in heart failure and reduces hospital admissions - a large body of trial evidence supports it, and it is recommended in guidelines. It should be started under supervision, through a cardiac rehabilitation programme, and it works best alongside optimal medical treatment rather than instead of it. Exercise is not appropriate during an acute decompensation - new or rapidly worsening breathlessness, sudden weight gain or new swelling needs medical attention first.

Prevalence basis: Cardiology epidemiology

This is general information, not a diagnosis, and it cannot examine you. If it matches you, use it to ask better questions of a clinician rather than to replace one.

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