Exercise Training for the Patient with Heart Failure: Is Your Patient Ready?

The purpose of this paper is: (1) to briefly review the heart failure syndrome and the importance of exercise training, (2) to stimulate the reader to consider examining the motivation and readiness of the patient with heart failure to engage in exercise training, and (3) to provide strategies to accelerate the process of change to make necessary behavioral changes. The cardinal symptoms of patients with heart failure include chronic fatigue, exercise intolerance, and shortness of breath. Multiple compensatory mechanisms appear to contribute to these symptoms, making the management of the patient extremely challenging. The reason for the compensatory adaptations is to maintain cardiac output and arterial pressure, but eventually these adaptations contribute to maladaptive processes and worsening heart failure. Exercise training programs for the patient with heart failure have shown great success with significant physiological and clinical benefits. Unfortunately, participation in and adherence to exercise training programs is low, in part, due to a lack of understanding of the patient's motivation and readiness to change behavior. This paper describes a theoretical framework for understanding behavioral change, using the transtheoretical model (TTM). The TTM consists of 4 core constructs: (1) the stages of change, (2) processes of change, (3) decisional balance, and (4) self-efficacy. It is recommended that clinicians use these constructs in their attempts to increase physical activity participation. Data from our laboratory indicate that the majority of patients with heart failure are in the pre-action stages of participation in physical activity programs and have significantly reduced exercise tolerance. Consequently, the stage of change algorithm aids in the identification of patients at increased risk for complications and early mortality. Our data also identify that the 2 most important predictors for the TTM stage in patients with heart failure are the processes of change and self-efficacy. Using this information specific stage-matched strategies can be used to help move individuals toward the action stage. These strategies are outlined in the paper. To further understand the stage-matched approach toward physical activity promotion in the pre-action stages, 3 cases are presented of individuals with heart failure. It is hypothesized that ‘moving’ patients toward the active stages may ultimately contribute to the well-being of the patient and perhaps have an impact on health care costs associated with this disease.