Exergaming for heart failure: an idea so good it just ought to work

This article refers to ‘Effects of exergaming on exercise capacity in patients with heart failure: results of an international multicentre randomized controlled trial’ by T. Jaarsma et al., published in this issue on pages 114–124. In one of our Heart Failure News items in the Journal recently, I had the great pleasure to interview Tiny Jaarsma, full professor in nursing science at the Faculty of Medicine and Health Sciences of the University of Linköping (Sweden) and a professor in cardiovascular chronic care at the University Medical Center Utrecht (the Netherlands).1 Tiny is also coordinator of the ‘Patient care: management and delivery’ Committee of the Heart Failure Association (HFA) and co-chair of the HFA Task Force on Palliative Care. Tiny and colleagues have worked for many years on the consequences of chronic heart failure (HF) for patients and carers, developing, trialling and proving interventions that really matter to patients. Too often we are accused of being interested only in large trials of drugs designed only to improve mortality in HF, as if no other benefit, such as patient well-being mattered. Not Tiny and colleagues; they study difficult to prove interventions and strategies aimed to make the life of a HF sufferer better, not just longer. The paper of Tiny Jaarsma et al.2 in this issue of the Journal is one such, testing a really conceptually attractive intervention, that of computer gaming to increase habitual (and enjoyable) physical exercise activity at home in HF patients, and in doing so make it an enjoyable part of the daily life so the chance of prolonged participation is increased. Ever since the late 1980s we have challenged the dogma that patients should not exercise if they suffer HF, because of an increased risk. Many small trials challenged this, and it is indeed one of my proudest achievements to conduct the first randomised trial in HF patients of exercise training.3 It took only a few years before exercise was indeed recognised as treatment that should be recommended in most stable HF patients to achieve improved exercise capacity and to correct some aspects of pathophysiological disturbance.4 There were tantalising suggestions of improved outcomes, with fewer emergency hospitalisations for HF, and even a tendency to reduced mortality,5 but this was not an area where large scale funding to conduct large mortality and morbidity trials was easy to achieve. We managed only one, HF-ACTION, which came frustratingly close to proving the benefits statistically significant also for a mortality/morbidity endpoint.6 This has never been tested in this scale trial again,7 but if it had been funded to the extent of a major commercial drug trial I and many others believe exercise training would have achieved this milestone. Nonetheless it is a well-recognised treatment of significant patient value. The team of Tiny and her colleagues, and especially Massimo Piepoli, have been further developing exercise as a therapeutic intervention for HF patients, particularly the elderly. The issue we saw in HF-ACTION and in many other studies was that compliance with the exercise regime often petered out after several months, and there was a clear indication that only patients who continued to exercise were the training-induced benefits maintained.8, 9 Thus, the challenge was out to find a form of exercise intervention that patients would commit to, enjoy and hence persist with. In this regard, the concept of Tiny and colleagues has been so attractive. The computer game industry had developed games that were attractive, well designed and to a sense addictive, but which importantly also carried mental and physical activity in their conduct, that might be of benefit to an elderly HF sufferer. Exergaming can be described as a computer game which requires rigorous physical exercise, and thus is ideally suited to elderly HF patients who may live alone and who find it difficult to attend formal group exercise sessions. Exergaming has been tested previously in HF and also in post-bypass surgery patients as well as in healthy older volunteers.10-12 Benefits have included improved motor function, balance and cognitive function, better self-reported quality of life and well-being, and a high level of enjoyment. This trial investigated the effect of exergaming vs. a control intervention of motivational support in 605 HF patients (both with reduced and preserved ejection fraction). The primary endpoint was the change from baseline in a 6 min walk test (6MWT) over 3 months. Technically it was a negative trial, because the primary analysis (linear mixed effects model taking baseline values into account) revealed no significant effect for the intervention, despite the exergaming group showing improved 6MWT distances compared to controls at all time points: 3 months (454 ± 123 vs. 420 ± 127 m, P = 0.005), 6 months (452 ± 123 vs. 426 ± 133 m, P = 0.015) and 12 months (456 ± 122 vs. 420 ± 135 m, P = 0.004).2 This is disappointing, for we do need an exercise intervention that gets widely adopted by HF patients and which is attractive enough for them to continue with long term, but it does in no way suggest the intervention does not work, for there were clear signals of efficacy, in the 6MWT of the intervention group, in individual muscle group function and in patient-reported outcomes. This will not be the last exercise training study, nor indeed the last involving exergaming. As we have seen with the recent COVID-19 crisis, we need intervention that can be adhered to by patients, without the need for regular visits to hospital, and in this regard the work of Jaarsma and colleagues offers us some exciting possibilities to explore further, we just need to give non-pharmacological therapies the same chances as we do drug treatments, and that means more large-scale clinical trials. Conflict of interest: A.J.S.C. declares no conflicts related to this work. Outside of this work, in the last 3 years, A.J.S.C. declares having received honoraria and/or lecture fees from AstraZeneca, Bayer, Menarini, Novartis, Nutricia, Servier, Vifor, Actimed, Cardiac Dimensions, CVRx, Enopace, Faraday, Gore, Impulse Dynamics, Respicardia, Stealth Peptides, V-Wave, Corvia, Arena, ESN Cleer.