Heart failure and exercise adherence: A systematic review of controlled studies

Purpose: The benefits of exercise for people with stable heart failure (HF) are well known and include improved morbidity, mortality, quality of life and reduced hospitalisation. ESC guidelines recommend exercise for patients, but adherence to this component of HF management appears to be less well followed compared to other aspects of self-care. A systematic review was conducted to examine the effectiveness of strategies used to promote exercise adherence in patients with HF. Methods: A protocol was developed that included a list of eligibility criteria for study acceptance. Electronic databases were searched for relevant literature published between January 1980 and December 2010. Retrieved papers were also examined for additional eligible papers. Two authors were involved in the selection process (kappa 0.915), in assessing study quality and in data extraction. Disagreements were referred to a third reviewer. Results: Titles and abstracts of 3935 papers were examined, of which 50 were accessed in full and 11 were accepted for inclusion (reporting on nine separate studies). Of the included investigations, five had fewer than 100 subjects and six had a follow-up of 2-6 months. Six studies compared usual care to exercise with an adherence intervention. A theoretical framework underpinned adherence interventions in six investigations. Adherence was primarily self-reported or rated; only one study used an objective measure (pedometers). Heterogeneity of measures made synthesis or meta-analysis unfeasible. Positive outcomes appeared possible in the short-term from strategies such as exercise prescriptions, goal setting, feedback and problem solving. However, studies with follow-up 12 months or more found little difference in adherence rates between intervention and control arms. Conclusions: The review highlighted the lack of evidence for strategies that promote adherence to exercise in patients with HF, and the difficulty of sustaining physical activity in this group. Directions for future research are a primary outcome of the review.