Current issues of ACP Journal Club are published in Annals of Internal Medicine


Exercise training reduced mortality and cardiac events and improved quality of life in chronic heart failure

ACP J Club. 1999 Sept-Oct;131:42. doi:10.7326/ACPJC-1999-131-2-042

Source Citation

Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized,controlled trial of long-term moderate exercise training in chronic heart failure. Effects on functional capacity, quality of life, and clinical outcome. Circulation. 1999 Mar 9;99:1173-82. [PubMed ID: 99169042]



In patients with chronic heart failure (CHF), can long-term exercise training reduce all-cause mortality and cardiac events and improve quality of life?


Randomized, unblinded, controlled trial with mean follow-up of 3.4 years.


A cardiology institute and hospital in Italy.


110 patients with stable CHF were screened, and 99 (mean age 55 y, 88% men) were studied. Other inclusion criteria were left ventricular ejection fraction ≤ 40% and sinus rhythm. Exclusion criteria were unstable angina, recent acute myocardial infarction, de-compensated CHF, hemodynamically important valvular heart disease, severe chronic pulmonary illness, uncontrolled hypertension, renal insufficiency, or orthopedic or neurologic limitations. Follow-up was 95%.


50 patients were allocated to exercise training. During the 8-week start-up period, exercise training was done 3 times/wk at 60% of peak VO2. For the next 12 months, patients exercised 2 times/wk at the same intensity. The 1-hour sessions were supervised by a cardiologist and included stretching exercises and cycling on an electronically braked cycle ergometer. 49 patients in the control group received no exercise training.

Main outcome measures

Mortality, cardiac events (CHF requiring hospitalization or medication changes, myocardial infarction, unstable angina, or cardiac death), and quality of life (Minnesota Living with Heart Failure questionnaire).

Main results

Analysis was by intention to treat. Patients in the exercise training group had fewer deaths (all deaths were cardiac deaths) (P = 0.01); fewer hospitalizations for CHF (P = 0.02); fewer cardiac events (P = 0.006) (Table); increased peak VO2 (P < 0.001) and thallium uptake (P < 0.001); and improved quality of life at 2, 14, and 26 months. The groups did not differ for unstable angina or acute myocardial infarction.


Exercise training for patients with chronic heart failure reduced mortality, hospitalization for heart failure, and cardiac events and improved quality of life.

Source of funding: Not stated.

For correspondence: Dr. R. Belardinelli, Via Rismondo 5, 60100 Ancona, Italy. FAX 39-071-36819.

Table. Exercise training vs no training for chronic heart failure (CHF)*

Outcomes at 26 mo Exercise No exercise RRR (95% CI) NNT (CI)
Death 18.0% 40.8% 55.9% (15 to 78) 5 (3 to 21)
All cardiac events 34.0% 75.5% 55.0% (33 to 71) 3 (2 to 5)
Hospitalizations for CHF 10.0% 28.6% 65.0% (15 to 86) 6 (3 to 32)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Patients with CHF commonly present with symptoms of dyspnea and fatigue associated with decreased exercise tolerance. Small randomized trials of short duration evaluating the role of exercise training in CHF have shown improvements in quality of life and functional capacity (1, 2). These improvements in functional capacity are associated with changes in skeletal muscle structure, function, and blood flow as well as with decreases in resting neurohormonal activation (1, 2).

The exercise training study by Belardinelli and colleagues is one of the largest and longest studies of patients with CHF. Compliance and follow-up were excellent, most likely because the study was hospital-based and included younger patients with symptoms of mild to moderate CHF. Improvements in functional capacity and quality of life corroborated the results of other smaller studies.

Although this study is the first to report decreased cardiac events in patients with CHF enrolled in an exercise training program, these results should be interpreted with caution because of the small sample size. This study is important because it shows the safety of exercise training in patients with CHF and provides evidence of an improvement in exercise performance in a hospital-based program. Larger studies to properly assess the effect of exercise training in CHF on mortality and morbidity are needed to confirm these promising results.

Catherine Demers, MD
Robert S. McKelvie, MD, PhDMcMaster UniversityHamilton, Ontario, Canada


1. McKelvie RS, Yusuf S. The rationale for exercise training patients with congestive heart failure. Congestive Heart Failure. 1997;3:26-34.

2. European Heart Failure Training Group. Experience from controlled trials of physical training in chronic heart failure. Protocol and patient factors in effectiveness in the improvement in exercise tolerance. Eur Heart J. 1998;19:466-75.