ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Cardiac rehabilitation in patients with heart failure

Cardiac rehabilitation in patients with heart failure
Literature review current through: Jan 2024.
This topic last updated: Jan 18, 2023.

INTRODUCTION — Patients with heart failure (HF) often have limited exercise capacity because of dyspnea and fatigue [1]. Symptoms of exercise-induced dyspnea resemble those of deconditioning-related dyspnea, and these symptoms make patients fearful of being active and patients may interpret deconditioning as worsening of their disease. Exercise training improves functional capacity and quality of life in patients with HF.

A comprehensive cardiac rehabilitation program provides services including patient evaluation, exercise training, physical activity counseling, cardiovascular risk factor management, psychosocial support, and patient education (table 1), as discussed in detail separately (see "Cardiac rehabilitation programs"). This topic will focus on the exercise training component of cardiac rehabilitation in patients with HF. Measurement of peak oxygen uptake to assess exercise capacity is discussed separately. (See "Exercise capacity and VO2 in heart failure".)

RATIONALE — Although exercise training of HF patients was previously discouraged due to concerns of worsening symptoms and detriment to the disease process itself, evidence supports a role for exercise training in this population as a means of reversing cardiac and skeletal muscle abnormalities, and improving functional status, quality of life, and clinical outcomes [2]. (See 'Evidence on effects of exercise' below.)

It was previously thought that exercise limitation in patient with HF was due entirely to cardiac dysfunction. However, drugs that improve cardiac output may not acutely improve exercise tolerance [3-6]. Thus, factors in addition to the low cardiac output and reduced skeletal muscle blood flow contribute to poor exercise tolerance and fatigue.

Observations since the 1980s have documented improvements in exercise function for patients with HF with a low rate of complications. These observations were followed by a series of studies that demonstrated that significant biochemical and functional abnormalities in skeletal muscle are present in patients with HF and play a large role in the exercise intolerance [1]. Inactivity is in part responsible, leading to muscle atrophy. In addition, skeletal muscle utilizes high-energy phosphates in an inefficient manner; as a result, lactic acid accumulates at a more rapid rate than in normal controls, contributing to muscle fatigue and limited exercise capacity. Skeletal muscle dysfunction can also involve the respiratory muscles, which may contribute to fatigue and dyspnea on exertion [7]. These biochemical and functional abnormalities, when added to deconditioning, can result in even greater impact on physical function. The importance of skeletal muscle dysfunction provides part of the rationale for the use of cardiac rehabilitation in patients with HF.

The effects of exercise in patients with HF are discussed below. (See 'Evidence on effects of exercise' below.)

EXERCISE TRAINING RECOMMENDATIONS

Indications — The following indications for exercise training apply to patients with HF. Evidence for these recommendations is discussed below. (See 'Evidence on effects of exercise' below.)

For patients with stable New York Heart Association (NYHA) functional class II to III HF with reduced ejection fraction (left ventricular ejection fraction [LVEF] ≤40 percent; HFrEF), we recommend referral for exercise training. (See 'For heart failure with reduced ejection fraction' below.)

For patients with stable NYHA functional class II to III HF with preserved ejection fraction (LVEF ≥50 percent; HFpEF) or mid-range ejection fraction (LVEF 41 to 49 percent), we suggest referral for exercise training. (See 'For heart failure with preserved or mid-range ejection fraction' below.)

Similar recommendations for exercise training in patients with HF are included in major society guidelines [8-10]. The recommendation for exercise training in patients with HFrEF is stronger than for patients with HFpEF because the data are not as robust for patients with HFpEF, as discussed below. There are not enough data at present to recommend cardiac rehabilitation for patients with class IV HF. (See 'Evidence on effects of exercise' below.)

In the United States, the Centers for Medicare and Medicaid Services (CMS) provide coverage for cardiac rehabilitation services for patients with stable chronic HF with LVEF ≤35 percent and NYHA class II to IV symptoms despite treatment with optimal HF therapy for at least six weeks [11]. Stable is defined as no recent (≤6 weeks) or planned (≤6 months) major cardiovascular hospitalizations or procedures. Most United States insurers cover the sessions similarly to CMS.

Components of cardiac rehabilitation

General components — A cardiac rehabilitation program for patients with HF should include all components of such programs, including medical evaluation and baseline patient assessment, education concerning medication adherence, risk factor reduction including dietary recommendations, psychosocial support (which may include peer support), as well as exercise training and physical activity counseling [2]. The program should include assessment and management of barriers to adherence [12]. In addition to providing direct benefits, the closer monitoring of symptoms afforded by a supervised program may allow detection and treatment of worsening HF prior to those symptoms necessitating an emergency department visit or an admission, particularly if the cardiac rehabilitation team communicates with patients’ other care teams. The frequent contact with the rehabilitation team may also identify medication issues such as side effects and questions about meals with medications, all of which impact adherence.

The components of cardiac rehabilitation programs in patients with cardiac disease in accordance with recommendations by the European Society of Cardiology [13] and by the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation [14] are discussed in detail separately. (See "Cardiac rehabilitation programs".)

Exercise prescription — An appropriate exercise prescription, in parallel with a medication prescription, includes intensity (dose), duration (how long for each session), frequency (usually on a weekly basis), location (center- or home-based), type of activity, and very importantly, progression. Intensity can be specified as a heart rate, a speed and grade of a treadmill, or a rated perceived exertion scale (RPE) (table 2). Cardiac rehabilitation programs can be monitored or non-monitored. Examples of patients who may need intermittent or constant monitoring include those with atrial fibrillation and uncontrolled ventricular response or those with suspected exercise-induced ventricular ectopy.

A typical exercise prescription includes a three-day-per-week program with 30 to 40 minutes of aerobic activity at an intensity commensurate with 60 to 70 percent of heart rate reserve (maximum heart rate-resting heart rate) or an RPE of 15 to 17. Starting in a six- to eight-week program of supervised training will familiarize patients with a sense of activity and better quality of life and reassure them of the safety of exercise. An unsupervised home training program can overlap with supervised sessions and gradually become the preferred modality of exercise once the supervised program is complete [15]. Beta blockers are a component of current guideline-recommended treatment so the heart rate usually remains lower than the maximum by age. However, if the patient is stable and doing well, there are no data to show harm from allowing the heart rate to rise above 60 to 70 percent of heart rate reserve. Timing of oral administration of beta blocker may affect the heart rate. Generally, patients are instructed to take all their medications as directed even on the days they attend a rehabilitation session.

The approach described here can be used for both HFrEF and HFpEF. Patients may also have comorbidities that limit activity, such as chronic lung disease, and a consult with an exercise specialist may be particularly helpful for patients with comorbid conditions. One such example is identifying and addressing a need for supplemental oxygen during exercise sessions.

When patients are rehospitalized, they will lose functional capacity. Once a patient is euvolemic and discharged, exercise can resume safely. Return to rehabilitation may necessitate starting at a lower intensity of aerobic training and progressing gradually.

Types of exercise training — In cardiac rehabilitation programs for patients with HF, aerobic exercise training is dominant since evidence and experience is greatest for this type of activity. Some programs also include resistance training and inspiratory muscle training as limited evidence suggests that such programs are beneficial. In patients who have lost muscle mass, particularly in the upper extremities, resistance training will improve their ability to perform activities of daily living, since most self-care involves the arms. Older women may benefit greatly from adding small weights with arm exercises. Inspiratory muscle training will ultimately improve the intercostal muscles and may be most helpful in patients who have been intubated or have chronic lung disease in addition to HF. (See 'For heart failure with reduced ejection fraction' below.)

Aerobic exercise — Aerobic activity is defined by movement through space and includes treadmill walking, cycling, upper body ergometry, dancing, swimming, and playing sports. Other aerobic modalities that may be included are low-level group activities with stretching and movement. Some programs may also offer group walks within or outside the facility. Aerobic exercise blocks can alternate with intervals of rest. With a variety of training modalities, patients may remain more engaged and find exercise enjoyable.

Some patients may not be able to attend a formal program due to social issues, such as transportation. Nonetheless, activity can generally be prescribed such as walking 20 to 30 minutes daily at an intensity that feels moderate in effort. Periods of rest can be interspersed. Progression can occur by adding time to the initial 20 to 30 minutes or increasing the speed of walking. Walking can occur outside (weather and conditions permitting) or in the patient’s home, up and down stairs, or walking from room to room. Some shopping malls open early for the public to walk in a sheltered safe environment. Engaging the caregivers in supporting the patient will go a long way to encouraging adherence to the recommendation. Comfortable shoes and loose clothing are recommended. Activity should occur at times of day where the weather is not uncomfortable, and when the patient feels most energetic (ie, morning versus afternoon and not after meals). In the digital era, smartphone technology may be helpful both to monitor the patient’s activity and to assess changes in function. Technology tools may enhance patient participation in increased activity at home. More research is needed to assess the long-term benefits of technology as a substitute for center-based cardiac rehabilitation [16].

It is important to advise the patient that at the initiation of a program, they may feel fatigued, but that this fatigue will improve with time and not to be discouraged since activity is safe.

Resistance training — Exercise programs for patients with HF may include resistance training as well as aerobic exercise, although as noted below, evidence on resistance training in this population is more limited. Resistance training should be individualized by the rehabilitation team with monitoring of symptoms and blood pressure. Teaching the patient to breathe during a resistance activity is important to avoid the Valsalva maneuver, which may increase vascular resistance. Muscle conditioning can help patients for their activities of daily living. (See 'Resistance training' below.)

Inspiratory muscle training — Inspiratory muscle training has also been a part of individual rehabilitation programs given the respiratory symptoms of more advanced patients. (See 'Inspiratory muscle training' below.)

Safety considerations — Evaluation of patients prior to enrollment in an exercise program should include history and physical examination as well as exercise testing with electrocardiographic monitoring to screen for patients at high risk for adverse events (by evaluating for ischemia and significant arrhythmias), to help identify an exercise intensity training range, and evaluate any exercise limitations, such as muscular-skeletal conditions or angina [2]. Risk stratification for exercise in patients with heart disease is discussed separately. (See "Cardiac rehabilitation programs", section on 'Risk stratification for exercise'.)

The safety of symptom-limited exercise testing in patients with HFrEF was assessed in 2037 of the subjects enrolled in the HF-ACTION trial who performed 4411 exercise tests [17]. There were no deaths per 1000 exercise tests and 0.45 nonfatal major cardiovascular events per 1000 exercise tests. In HF-ACTION, patients who had an implantable cardioverter-defibrillator (ICD) had no adverse events or ICD firing during the exercise sessions, as the exercise training heart rate is usually below the firing rate for the device.

Meta-analyses of studies of patients with HFrEF have found no significant adverse effects of exercise in patients with HF [18-20]. HF-ACTION, the largest trial of exercise training in patients with HFrEF found that exercise training was well-tolerated and safe; results were consistent across subgroups, including age and etiology of HF [15]. Similarly, no significant adverse effects were found in a meta-analysis of nine randomized trials of exercise training in 348 patients with HFpEF [21].

EVIDENCE ON EFFECTS OF EXERCISE — Most of the studies on exercise in HF have included patients with HF with reduced ejection fraction (HFrEF) [22]. Much less data are available on patients with HF with preserved ejection fraction (HFpEF), although these patients can be as limited in their exercise capacity as those with HFrEF [23].

No ventilatory, hemodynamic, autonomic, or clinical factor at baseline predicts the outcome with exercise training in patients with HF [24]. An exception may be the presence of hibernating (ischemic and dysfunctional yet viable) myocardium as evidenced by a positive response to low-dose dobutamine. The presence of hibernating myocardium is predictive of an increase in functional capacity and fewer cardiac events during follow-up after moderate exercise training [25,26].

The type of exercise training may be important, although limited data are available on the effect of exercise type on hemodynamics and clinical outcomes [27].

For heart failure with reduced ejection fraction — Most of the evidence on the effects of exercise training in HF comes from studies of patients with HFrEF.

Aerobic training — Aerobic interval training has been the type of training best studied in patients with HF.

Effect on patient outcome — Evidence from randomized trials indicates that exercise training reduces hospitalizations in patients with New York Heart Association (NYHA) functional class II or III HFrEF [15,19].

A meta-analysis included 33 randomized controlled trials comparing exercise training and usual care in a total of 4740 patients with NYHA functional class II and III HF (predominantly HFrEF) [19]. The overall risk of bias of included trials was moderate. There were similar pooled mortality rates at one year in exercise and control groups (25 trials). Exercise training reduced the rate of overall hospitalization (15 trials, 1328 participants: relative risk [RR] 0.75, 95% CI 0.62-0.92) and HF-related hospitalization (12 trials, 1036 participants: RR 0.75, 95% CI 0.46-0.80).

The largest trial included in the meta-analysis was the HF-ACTION trial in which 2331 patients with left ventricular ejection fraction (LVEF) ≤35 percent and NYHA class II to IV HF (96 percent with NYHA class II or III symptoms) were randomly assigned to either a supervised exercise training program plus usual care or usual care alone (which included education and recommendation of regular exercise) [15]. Background medical therapy was optimized with greater than 90 percent use of angiotensin converting enzyme inhibitors/angiotensin II receptor blockers and beta blockers. Median follow-up was 30 months. Results included the following:

The primary composite end point was all-cause mortality or all-cause hospitalization. There was no significant difference in the primary end point upon analysis adjusted for HF etiology (hazard ratio [HR] 0.93, 95% CI 0.84-1.02).

However, analysis adjusted for major prognostic baseline factors and HF etiology revealed a modest but significant decrease in the primary end point with the exercise training program (HR 0.89, 95% CI 0.81-0.99). After adjustment for prognostic baseline covariates, there was also a significant reduction in cardiovascular mortality or HF hospitalizations (HR 0.85, 95% CI 0.74-0.99).

The trial demonstrated a high level of safety during and after the training sessions.

The economic analysis of HF-ACTION showed that more than one-half of costs were related to inpatient care, and that mean unadjusted direct medical costs were lower in the exercise group compared with control. However, taking into account travel costs, patient time, and parking, the cost advantage became nonsignificant [28]. However, the majority of patients with HF who are Medicare recipients may not be actively employed. By removing the payment for patient time, the cost advantage becomes significant.

Effect on functional status and quality of life — Exercise-based cardiac rehabilitation has a beneficial effect on functional status and health-related quality of life in patients with HF, including those who are older (>60 years) and those with frailty, as demonstrated by randomized trials comparing one to six months of exercise training with no exercise program [2,8,15,18,19,24,29]. For those patients with problems of balance, stability, and muscle weakness, a program that combines physical therapy with the aerobic training may improve mobility. Patient stability, stable balance, and strength are necessary to embark on aerobic mobility. The program could be initiated with physical therapy to improve stability, balance, and strength and transition to aerobic activities, performed with better balance and better strength. The beneficial effects of exercise may be seen with high or low levels of training.

The benefits of cardiac rehabilitation were illustrated by an individual participant data meta-analysis that included 13 randomized trials with a total of 3990 patients with HF (97 percent with LVEF <45 percent) comparing exercise-based cardiac rehabilitation (for three weeks or more) with a no exercise control group [30]:

At 12 months follow-up, there were significant improvements in six-minute walk test (mean increase 21.0 m, 95% CI 1.57-40.4) and Minnesota Living with HF score (mean improvement 5.9 [on a scale from 0 to 105], 95% CI 1.0-10.9). In the seven trials assessing peak VO2, this was nominally but not significantly increased with exercise training (mean 1.01 mL/kg/min, 95% CI -0.42 to 2.44).

No significant treatment interaction was observed across patient subgroups including age, sex, NYHA functional class (I/II versus III/IV), and HF etiology. Results were also similar for LVEF <45 percent and LVEF ≥45 percent, although confidence intervals were wide for patients with higher LVEFs given low numbers of participants in this group. Studies in patients with HFpEF are discussed below. (See 'For heart failure with preserved or mid-range ejection fraction' below.)

The largest trial in the meta-analysis, HF-ACTION, randomly assigned 2331 patients with reduced LVEF (≤35 percent) and NYHA class II to IV HF to a formal exercise program or control program [15]. The peak improvement in peak VO2 was modest, although statistically significant (0.6 versus 0.2 mL/kg/min in controls) both at 3 and 12 months, as was the improvement in six-minute walk distance at three months. The six-minute walk improvement at three months was attenuated at 12 months. In addition, there was a significant improvement in health status as measured by the Kansas City Cardiomyopathy Questionnaire, which occurred early and remained for the duration of the trial [31]. Adherence was less than predicted and may have affected the improvement in peak VO2.

The benefits of cardiac rehabilitation on physical function have also been demonstrated in older patients with HF who have a high burden of frailty:

In a trial (REHAB-HF) published after the meta-analysis cited above, 349 patients age 60 years or older who were recently hospitalized for HF (approximately half with LVEF <45 percent) were randomly assigned to usual care or a tailored cardiac rehabilitation program (36 sessions) [29]. In contrast with programs used in other trials, this program began in the hospital, focused primarily on balance and mobility training, and required minimal equipment. At baseline, 97 percent of the trial subjects were classified as prefrail or frail by the Fried criteria. At three months, patients in the cardiac rehabilitation group had higher levels of physical function (as measured by the Short Physical Performance Battery score) compared with those in the control group (8.3 versus 6.9 points). Rates of rehospitalization for any cause were similar between the groups.

Effect on depression — Depression is common among patients with HF and adversely impacts prognosis [32,33]. A meta-analysis of 16 randomized trials with 3226 patients with HF (mostly HFrEF) found that exercise training reduced symptoms of depression, and this antidepressive effect was consistent in patients under and over 65 years of age [34].

The largest included trial was the HF-ACTION trial in which the Beck Depression Inventory II was administered to 2322 patients [35]. At entry, 28 percent of patients had scores of 14 or higher, which is considered clinically significant. Exercise training modestly improved the depression scores compared with the control group at three months with a smaller response at one year.

Effect on hemodynamics and skeletal muscle — Exercise training improves measures of LV function and hemodynamics.

The effect of exercise training on cardiac structure and function was examined by a meta-analysis of randomized controlled trials of exercise training in chronic HF [36]. Aerobic training was associated with significant improvements in LVEF (weighted mean difference 2.6 percent), and end-diastolic and end-systolic volumes (weighted mean difference -11.5 mL and -12.9 mL, respectively) [36]. Improvements in cardiac output and exercise capacity with exercise may be related to improvements in diastolic function as manifested by increase in peak early diastolic filling rate of the LV at rest and during exercise [37].

Exercise training improves hemodynamics and muscle energetics so that oxygen utilization becomes more efficient, allowing a similar amount of work to be performed at a lower heart rate, rate-pressure product, and minute ventilation (indicating improved gas exchange). The lower rate-pressure product may permit patients to perform their daily tasks with fewer symptoms and less disability [2].

Exercise-induced improvements in hemodynamics may be mediated by reduction of autonomic and neurohumoral activation [38]. Exercise training reduces sympathetic tone and increases vagal tone at rest, thereby restoring autonomic cardiovascular control towards normal [39-41]; enhanced arterial baroreceptor sensitivity may contribute to this reduction [42,43]. This change in the sympathetic-parasympathetic balance is associated with lower resting heart rates [39,41,44-46]. Exercise training also reduces neurohumoral activity with decreased resting levels of angiotensin, aldosterone, vasopressin, and natriuretic peptide [42,47,48]. To the degree that these changes reduce systemic vascular resistance and cardiac afterload, they may lead to an improvement in cardiac performance [49]. (See "Natriuretic peptide measurement in heart failure".)

Exercise training also improves endothelial function as evidenced by increased basal endothelial nitric oxide formation and acetylcholine-mediated, endothelium-dependent vasodilation of the skeletal muscle blood vessels, possibly leading to an increase in exercise capacity [50,51]. Dietary supplementation with L-arginine, which also increases nitric oxide levels, improves endothelial function in patients with HF to a similar extent as exercise; both interventions together have additive effects [52]. Aerobic interval training improves flow-mediated vasodilation more than moderate continuous training [53].

In addition, exercise training reduces plasma levels of proinflammatory cytokines, including tumor necrosis factor alpha (TNF-α) and interleukin-6 and their soluble receptors; and apoptotic mediators, such as Fas and Fas ligand [54,55]. Such cytokines may have detrimental effects on cardiac function and skeletal muscle.

Exercise training can increase muscle oxidative capacity and reduces oxidative stress. In patients with HFrEF, exercise training improves oxygen utilization with increased activity of oxidative enzymes and an increase in mitochondrial content [47]. Such exercise-induced changes may improve the peak VO2 and delay the onset of anaerobic metabolism. Patients with the worse function seem to benefit the most. This observation is encouraging and should be shared with patients who may be hesitant or afraid [39].

Reduced sympathetic hyperactivation and improved endothelial dysfunction with exercise training contribute to improved muscle blood flow and clinical performance. However, the information available on the effects of exercise training on the distribution of fast and slow twitch fibers and capillary densities in HF are not consistent and may be related to intensity of training and length of time with HF.

Effect of intensity and volume of aerobic training — Most HF trials have studied moderate intensity (50 to 60 percent peak VO2 or 60 to 70 percent heart rate reserve) exercise, which has resulted in 4 to 31 percent increases in peak exercise capacity [2,15].

In an analysis from HF-ACTION of a subset of 959 patients who were randomized to the exercise arm and were event free for at least three months, the volume of exercise was inversely associated with the risk for clinical events, with only moderate levels (3 to 7 MET-h per week) of exercise needed to observe a clinical benefit [56]. This on-therapy analysis of HF-ACTION supports the use of regular exercise in the management of patients with HFrEF and supported approval by the Centers for Medicare and Medicaid of coverage for cardiac rehabilitation in HFrEF.

High-intensity training may provide some advantages over moderate-intensity training but evidence is limited. A meta-analysis including seven randomized trials comparing high-intensity training with moderate-intensity continuous training in clinically stable patients with HFrEF found greater improvements in exercise tolerance with high-intensity training but no significant effect on LVEF at rest [57]. A systematic review suggested that higher-intensity training in patients with HF may have a greater beneficial effect on peak oxygen consumption as a measure of cardiorespiratory fitness [58].

Resistance training — Resistance training has been less well studied in HF due to concerns about potential risks, although the available limited evidence suggests that resistance training is safe and beneficial.

Patients with chronic HF are known to have significant physical disability compared with age- and activity-matched controls due to deficits in both aerobic capacity and muscular strength [59,60]. Myocardial dysfunction induces neurohormonal, metabolic, and circulatory changes that result in an imbalance between anabolic and catabolic processes at the level of skeletal muscle, producing a progressive skeletal myopathy and ultimately a wasting syndrome. This myopathy contributes to the exercise intolerance observed in chronic HF.

There is growing evidence of benefit from resistance training in patients with HF. Most studies have included only patients with HFrEF [61,62] with a few studies focusing on patients with HFpEF [63,64]. However, evidence is limited in part by the highly variable interventions among studies, making conclusions about effect sizes unclear.

A meta-analysis of prospective studies (including those with quasi-randomized designed) comparing resistance training with lack of exercise training included 10 studies with a total of 240 participants with HFrEF [62]. Training was conducted over 8 to 24 weeks at intensity up to 80 percent of one repetition maximum (1RM). Resistance training significantly increased 1 RM (standardized change score = 0.60, 95% CI 0.43-0.77) and VO2 peak, as well as quality-of-life (measured by MLHFQ).

A meta-analysis of randomized controlled trials comparing resistance training (alone or combined with aerobic exercise) with sedentary controls included 27 studies with a total of 2321 participants with HFrEF [61]. Peak VO2 improved with combined exercise compared with control (1.43 mL/kg/min, 95% CI 0.63-2.23) as well as with resistance training compared with control (3.99 mL/kg/min, 95% CI 1.47-6.51). Quality-of-life measures (MLHFQ) were improved with combined training, but data were not available for resistance-only training. Six-minute walk distance improved with combined exercise as well as with resistance only training.

Resistance training alone did not affect LVEF; mortality, hospitalization, and resting systolic blood pressure comparisons were not available for resistance training alone.

A later meta-analysis of 59 trials with a total of over 500 patients with HFrEF, which included resistance training with or without an aerobic component, supports resistance training as it may offer benefits to functional capacity without worsening of LV function [65].

More limited data are available on the effects of resistance training in patients with HFpEF. A randomized trial of 64 patients with HF and preserved ejection fraction found that those who participated in endurance training plus a resistance training program (including bench press, leg press, latissimus pull down, and other exercises at intensities up to 65 percent of 1RM) experienced no adverse events while significantly improving their peak VO2, LV diastolic function, and overall physical function [63].

Inspiratory muscle training — Preliminary evidence suggests that inspiratory muscle training may improve exercise capacity in patients with chronic HF. Respiratory muscle weakness and deconditioning may worsen exercise tolerance and quality of life in patients with HF. Respiratory muscle training, or inspiratory muscle training, has improved muscle strength and endurance in patients with chronic obstructive pulmonary disease. (See "Respiratory muscle training and resting in COPD".)

A meta-analysis included nine randomized controlled trials comparing inspiratory muscle training with sham or control (education) with a total of 239 participants with chronic HFrEF (NYHA class II or III) [66]. The duration of therapy was 4 to 12 weeks. Inspiratory muscle training resulted in improvements compared with control in six-minute walk distance and peak oxygen consumption but there was considerable heterogeneity among the studies. Improvements were greater in patients with baseline inspiratory muscle weakness.

Combination training — Evidence from trials comparing combined exercise training with single modality training suggest that a program that combines exercise modalities may provide greater benefit than single-modality programs. Small randomized trials have found that addition of inspiratory muscle training to an exercise training program resulted in improvements, including reduced dyspnea [67], increases in peak oxygen uptake [68], reduction in NT-proBNP [67], increase in exercise time [69], and improved quality of life [67] compared with exercise training alone.

However, a systematic review found that aerobic plus strength training was not more effective than aerobic training alone in terms of VO2max [18]. There was some evidence that the benefit of aerobic exercise on LV volumes may be diminished or lost with the addition of strength training, but the authors felt that since the studies were limited, the evidence on combination training was inconclusive.

Despite widespread concern among physicians about harmful effects from the acute increase in afterload caused by resistance training, the available limited evidence suggests that combined aerobic and strength training in patients with HFrEF or HFpEF does not cause adverse effects [61,63]. In the meta-analysis of randomized trials of combined resistance and aerobic training in patients with HFrEF, there were no observed changes in resting systolic blood pressure, hospitalization rates, or LVEF [61].

Noting that most activities of daily life involve the upper extremities, an upper body strength training program could be beneficial to improve self-care and counteract the results of muscle atrophy with inactivity [36,70].

Exercise location — For patients with HF who can be adequately supervised using remote or no monitoring, cardiac rehabilitation may be performed at a center or at home. The main advantage of home-based programs is increased access to rehabilitation due to lower barriers to entry (eg, scheduling, transportation), while the main disadvantage is the lack of in-person monitoring and support [71]. Some remote rehabilitation programs are delivered by mobile phone applications.

Our approach is consistent with the American Heart Association’s approach [71].

However, there are no high-quality studies that describe the relative efficacy of center-based rehabilitation programs and home-based programs. One challenge to broadly studying the effect of home-based cardiac rehabilitation is the variability among the programs delivered [72]. There are also concerns that adherence to a home-based program may not be as high as to a center-based program. Systematic reviews and studies of programs that offer home-based cardiac rehabilitation include:

A systematic review of 17 randomized controlled trials with a total of 2172 participants concluded that there was generally no difference in outcomes at 12-month follow-up between home- and center-based cardiac rehabilitation [73]; mortality rates, cardiac events, and exercise capacity were similar with home- and center-based exercise. However, in this review, only five small trials with a total of 521 participants studied patients with HF (all with HFrEF).

In the HF-ACTION trial, patients were provided with exercise equipment to continue the program at home and used diaries, phone calls, and pulse monitors to track adherence. Adherence fell further when patients were transitioned to home [15,56].

For heart failure with preserved or mid-range ejection fraction — In patients with HFpEF (defined as HF with LVEF >50 percent), exercise training improves quality of life and cardiopulmonary fitness (eg, peak VO2), although the expected benefits are small [2,29,74,75]. (See 'Exercise prescription' above.)

A meta-analysis included six randomized controlled trials of exercise training in 276 patients with HFpEF [74]. Exercise training improved exercise capacity (peak VO2; weighted mean difference 2.72 mL/kg per minute, 95% CI 1.79-3.65) and Minnesota Living with HF score (weighted mean difference -3.97, 95% CI -7.21 to -0.72) compared with the control group. Ejection fraction and a measure of diastolic function (E/A ratio) were not significantly changed.

Subsequent randomized trials show conflicting results. As examples:

In a randomized trial of 100 patients with obesity and HFpEF comparing caloric restriction alone, exercise alone, and the combination of diet and exercise, there were significant increases in peak VO2 for diet (1.3 mL/kg/min), exercise (1.2 mL/kg/min), and the combined intervention of diet and exercise (2.5 mL/kg/min) [76]. However, there were no changes in health-related quality of life for either intervention.

In another randomized trial of 180 patients with HFpEF comparing high-intensity exercise and moderate continuous exercise with exercise advice, there was no difference in peak VO2 (defined as a peak VO2 difference of at least 2.5 mL/kg/min) between exercise advice and either of the exercise training groups, nor was there a difference in health-related quality of life [75].

Limited data are available in patients with HF with mid-range ejection fraction (HFmrEF), but similar effects likely occur in these patients.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Heart failure in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Recovery after coronary artery bypass graft surgery (The Basics)")

Beyond the Basics topics (see "Patient education: Recovery after coronary artery bypass graft surgery (CABG) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

For patients with stable New York Heart Association (NYHA) functional class II to III heart failure (HF) with reduced ejection fraction (left ventricular ejection fraction [LVEF] ≤40 percent; HFrEF), we recommend referral for exercise training (Grade 1B). (See 'Indications' above and 'For heart failure with reduced ejection fraction' above.)

For patients with stable NYHA functional class II to III HF with mid-range (LVEF 41 to 49 percent; HFmrEF) or preserved ejection fraction (LVEF ≥50 percent; HFpEF), we suggest referral for exercise training (Grade 2B). (See 'Indications' above and 'For heart failure with preserved or mid-range ejection fraction' above.)

For patients who are unable to attend formal cardiac rehabilitation programs, a home program of ambulation is an alternative option. (See 'Exercise training recommendations' above and 'Exercise location' above.)

Exercise training in compensated HF confers clinical and physiologic benefits. (See 'Evidence on effects of exercise' above.)

Exercise training in patients with compensated HFrEF reduces total and HF-related hospitalizations, improves exercise tolerance and health-related quality of life, and reduces symptoms of depression. (See 'For heart failure with reduced ejection fraction' above.)

Exercise training in patients with compensated HFpEF improves exercise tolerance and health-related quality of life, although the benefits are small. Limited data are available in patients with HFmrEF, but similar effects likely occur in these patients. Some patients with HFmrEF have had prior HFrEF with subsequent improvement in LVEF. Following the same recommendations as for HFrEF is reasonable. (See 'For heart failure with preserved or mid-range ejection fraction' above.)

Exercise training in screened patients with compensated HF is generally well-tolerated with very low risk of adverse events. (See 'Safety considerations' above.)

In cardiac rehabilitation programs for patients with HF, aerobic exercise training is dominant since evidence and experience is greatest for this type of activity. Some programs also include resistance training and inspiratory muscle training, as the available limited evidence suggests that such programs are beneficial. (See 'Types of exercise training' above and 'For heart failure with reduced ejection fraction' above.)

  1. Kokkinos PF, Choucair W, Graves P, et al. Chronic heart failure and exercise. Am Heart J 2000; 140:21.
  2. Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail 2013; 1:540.
  3. Wilson JR, Martin JL, Ferraro N. Impaired skeletal muscle nutritive flow during exercise in patients with congestive heart failure: role of cardiac pump dysfunction as determined by the effect of dobutamine. Am J Cardiol 1984; 53:1308.
  4. Wilson JR, Martin JL, Ferraro N, Weber KT. Effect of hydralazine on perfusion and metabolism in the leg during upright bicycle exercise in patients with heart failure. Circulation 1983; 68:425.
  5. Kugler J, Maskin C, Frishman WH, et al. Regional and systemic metabolic effects of angiotensin-converting enzyme inhibition during exercise in patients with severe heart failure. Circulation 1982; 66:1256.
  6. Wilson JR, Ferraro N. Effect of the renin-angiotensin system on limb circulation and metabolism during exercise in patients with heart failure. J Am Coll Cardiol 1985; 6:556.
  7. Walsh JT, Andrews R, Johnson P, et al. Inspiratory muscle endurance in patients with chronic heart failure. Heart 1996; 76:332.
  8. Piña IL, Apstein CS, Balady GJ, et al. Exercise and heart failure: A statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation 2003; 107:1210.
  9. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37:2129.
  10. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895.
  11. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=270 (Accessed on September 02, 2015).
  12. Forman DE, Sanderson BK, Josephson RA, et al. Heart Failure as a Newly Approved Diagnosis for Cardiac Rehabilitation: Challenges and Opportunities. J Am Coll Cardiol 2015; 65:2652.
  13. Working Group on Cardiac Rehabilitation & Exercice Physiology and Working Group on Heart Failure of the European Society of Cardiology. Recommendations for exercise training in chronic heart failure patients. Eur Heart J 2001; 22:125.
  14. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: A statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000; 102:1069.
  15. O'Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009; 301:1439.
  16. Thomas RJ, Beatty AL, Beckie TM, et al. Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY. J Cardiopulm Rehabil Prev 2019; 39:208.
  17. Keteyian SJ, Isaac D, Thadani U, et al. Safety of symptom-limited cardiopulmonary exercise testing in patients with chronic heart failure due to severe left ventricular systolic dysfunction. Am Heart J 2009; 158:S72.
  18. Smart N, Marwick TH. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Am J Med 2004; 116:693.
  19. Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014; :CD003331.
  20. Piepoli MF, Davos C, Francis DP, et al. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ 2004; 328:189.
  21. Leggio M, Fusco A, Loreti C, et al. Effects of exercise training in heart failure with preserved ejection fraction: an updated systematic literature review. Heart Fail Rev 2020; 25:703.
  22. Lavie CJ, Arena R, Swift DL, et al. Exercise and the cardiovascular system: clinical science and cardiovascular outcomes. Circ Res 2015; 117:207.
  23. Kitzman DW, Hundley WG, Brubaker PH, et al. A randomized double-blind trial of enalapril in older patients with heart failure and preserved ejection fraction: effects on exercise tolerance and arterial distensibility. Circ Heart Fail 2010; 3:477.
  24. Experience from controlled trials of physical training in chronic heart failure. Protocol and patient factors in effectiveness in the improvement in exercise tolerance. European Heart Failure Training Group. Eur Heart J 1998; 19:466.
  25. Belardinelli R, Georgiou D, Purcaro A. Low dose dobutamine echocardiography predicts improvement in functional capacity after exercise training in patients with ischemic cardiomyopathy: prognostic implication. J Am Coll Cardiol 1998; 31:1027.
  26. Belardinelli R, Georgiou D, Ginzton L, et al. Effects of moderate exercise training on thallium uptake and contractile response to low-dose dobutamine of dysfunctional myocardium in patients with ischemic cardiomyopathy. Circulation 1998; 97:553.
  27. Arena R, Cahalin LP, Borghi-Silva A, Phillips SA. Improving functional capacity in heart failure: the need for a multifaceted approach. Curr Opin Cardiol 2014; 29:467.
  28. Reed SD, Whellan DJ, Li Y, et al. Economic evaluation of the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) randomized controlled trial: an exercise training study of patients with chronic heart failure. Circ Cardiovasc Qual Outcomes 2010; 3:374.
  29. Kitzman DW, Whellan DJ, Duncan P, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med 2021; 385:203.
  30. Taylor RS, Walker S, Smart NA, et al. Impact of Exercise Rehabilitation on Exercise Capacity and Quality-of-Life in Heart Failure: Individual Participant Meta-Analysis. J Am Coll Cardiol 2019; 73:1430.
  31. Flynn KE, Piña IL, Whellan DJ, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009; 301:1451.
  32. Newhouse A, Jiang W. Heart failure and depression. Heart Fail Clin 2014; 10:295.
  33. Fan H, Yu W, Zhang Q, et al. Depression after heart failure and risk of cardiovascular and all-cause mortality: a meta-analysis. Prev Med 2014; 63:36.
  34. Tu RH, Zeng ZY, Zhong GQ, et al. Effects of exercise training on depression in patients with heart failure: a systematic review and meta-analysis of randomized controlled trials. Eur J Heart Fail 2014; 16:749.
  35. Blumenthal JA, Babyak MA, O'Connor C, et al. Effects of exercise training on depressive symptoms in patients with chronic heart failure: the HF-ACTION randomized trial. JAMA 2012; 308:465.
  36. Haykowsky MJ, Liang Y, Pechter D, et al. A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed. J Am Coll Cardiol 2007; 49:2329.
  37. Belardinelli R, Georgiou D, Cianci G, Purcaro A. Effects of exercise training on left ventricular filling at rest and during exercise in patients with ischemic cardiomyopathy and severe left ventricular systolic dysfunction. Am Heart J 1996; 132:61.
  38. Gademan MG, Swenne CA, Verwey HF, et al. Effect of exercise training on autonomic derangement and neurohumoral activation in chronic heart failure. J Card Fail 2007; 13:294.
  39. Hambrecht R, Niebauer J, Fiehn E, et al. Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles. J Am Coll Cardiol 1995; 25:1239.
  40. Coats AJ, Adamopoulos S, Radaelli A, et al. Controlled trial of physical training in chronic heart failure. Exercise performance, hemodynamics, ventilation, and autonomic function. Circulation 1992; 85:2119.
  41. Belardinelli R, Georgiou D, Scocco V, et al. Low intensity exercise training in patients with chronic heart failure. J Am Coll Cardiol 1995; 26:975.
  42. Liu JL, Irvine S, Reid IA, et al. Chronic exercise reduces sympathetic nerve activity in rabbits with pacing-induced heart failure: A role for angiotensin II. Circulation 2000; 102:1854.
  43. Roveda F, Middlekauff HR, Rondon MU, et al. The effects of exercise training on sympathetic neural activation in advanced heart failure: a randomized controlled trial. J Am Coll Cardiol 2003; 42:854.
  44. Tyni-Lenné R, Gordon A, Jansson E, et al. Skeletal muscle endurance training improves peripheral oxidative capacity, exercise tolerance, and health-related quality of life in women with chronic congestive heart failure secondary to either ischemic cardiomyopathy or idiopathic dilated cardiomyopathy. Am J Cardiol 1997; 80:1025.
  45. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction. Hemodynamic and metabolic effects. Circulation 1988; 78:506.
  46. Belardinelli R, Georgiou D, Cianci G, et al. Exercise training improves left ventricular diastolic filling in patients with dilated cardiomyopathy. Clinical and prognostic implications. Circulation 1995; 91:2775.
  47. Braith RW, Welsch MA, Feigenbaum MS, et al. Neuroendocrine activation in heart failure is modified by endurance exercise training. J Am Coll Cardiol 1999; 34:1170.
  48. Cipriano G Jr, Cipriano VT, da Silva VZ, et al. Aerobic exercise effect on prognostic markers for systolic heart failure patients: a systematic review and meta-analysis. Heart Fail Rev 2014; 19:655.
  49. Hambrecht R, Gielen S, Linke A, et al. Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial. JAMA 2000; 283:3095.
  50. Hambrecht R, Fiehn E, Weigl C, et al. Regular physical exercise corrects endothelial dysfunction and improves exercise capacity in patients with chronic heart failure. Circulation 1998; 98:2709.
  51. Varin R, Mulder P, Richard V, et al. Exercise improves flow-mediated vasodilatation of skeletal muscle arteries in rats with chronic heart failure. Role of nitric oxide, prostanoids, and oxidant stress. Circulation 1999; 99:2951.
  52. Hambrecht R, Hilbrich L, Erbs S, et al. Correction of endothelial dysfunction in chronic heart failure: additional effects of exercise training and oral L-arginine supplementation. J Am Coll Cardiol 2000; 35:706.
  53. Wisløff U, Støylen A, Loennechen JP, et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation 2007; 115:3086.
  54. Adamopoulos S, Parissis J, Karatzas D, et al. Physical training modulates proinflammatory cytokines and the soluble Fas/soluble Fas ligand system in patients with chronic heart failure. J Am Coll Cardiol 2002; 39:653.
  55. Smart NA, Steele M. The effect of physical training on systemic proinflammatory cytokine expression in heart failure patients: a systematic review. Congest Heart Fail 2011; 17:110.
  56. Keteyian SJ, Leifer ES, Houston-Miller N, et al. Relation between volume of exercise and clinical outcomes in patients with heart failure. J Am Coll Cardiol 2012; 60:1899.
  57. Haykowsky MJ, Timmons MP, Kruger C, et al. Meta-analysis of aerobic interval training on exercise capacity and systolic function in patients with heart failure and reduced ejection fractions. Am J Cardiol 2013; 111:1466.
  58. Ismail H, McFarlane JR, Nojoumian AH, et al. Clinical outcomes and cardiovascular responses to different exercise training intensities in patients with heart failure: a systematic review and meta-analysis. JACC Heart Fail 2013; 1:514.
  59. Josiak K, Jankowska EA, Piepoli MF, et al. Skeletal myopathy in patients with chronic heart failure: significance of anabolic-androgenic hormones. J Cachexia Sarcopenia Muscle 2014; 5:287.
  60. Volaklis KA, Tokmakidis SP. Resistance exercise training in patients with heart failure. Sports Med 2005; 35:1085.
  61. Jewiss D, Ostman C, Smart NA. The effect of resistance training on clinical outcomes in heart failure: A systematic review and meta-analysis. Int J Cardiol 2016; 221:674.
  62. Giuliano C, Karahalios A, Neil C, et al. The effects of resistance training on muscle strength, quality of life and aerobic capacity in patients with chronic heart failure - A meta-analysis. Int J Cardiol 2017; 227:413.
  63. Edelmann F, Gelbrich G, Düngen HD, et al. Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study. J Am Coll Cardiol 2011; 58:1780.
  64. Nolte K, Herrmann-Lingen C, Wachter R, et al. Effects of exercise training on different quality of life dimensions in heart failure with preserved ejection fraction: the Ex-DHF-P trial. Eur J Prev Cardiol 2015; 22:582.
  65. Santos FV, Chiappa GR, Ramalho SHR, et al. Resistance exercise enhances oxygen uptake without worsening cardiac function in patients with systolic heart failure: a systematic review and meta-analysis. Heart Fail Rev 2018; 23:73.
  66. Montemezzo D, Fregonezi GA, Pereira DA, et al. Influence of inspiratory muscle weakness on inspiratory muscle training responses in chronic heart failure patients: a systematic review and meta-analysis. Arch Phys Med Rehabil 2014; 95:1398.
  67. Adamopoulos S, Schmid JP, Dendale P, et al. Combined aerobic/inspiratory muscle training vs. aerobic training in patients with chronic heart failure: The Vent-HeFT trial: a European prospective multicentre randomized trial. Eur J Heart Fail 2014; 16:574.
  68. Winkelmann ER, Chiappa GR, Lima CO, et al. Addition of inspiratory muscle training to aerobic training improves cardiorespiratory responses to exercise in patients with heart failure and inspiratory muscle weakness. Am Heart J 2009; 158:768.e1.
  69. Laoutaris ID, Adamopoulos S, Manginas A, et al. Benefits of combined aerobic/resistance/inspiratory training in patients with chronic heart failure. A complete exercise model? A prospective randomised study. Int J Cardiol 2013; 167:1967.
  70. Jankowska EA, Wegrzynowska K, Superlak M, et al. The 12-week progressive quadriceps resistance training improves muscle strength, exercise capacity and quality of life in patients with stable chronic heart failure. Int J Cardiol 2008; 130:36.
  71. Thomas RJ, Beatty AL, Beckie TM, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation 2019; 140:e69.
  72. Wongvibulsin S, Habeos EE, Huynh PP, et al. Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review. J Med Internet Res 2021; 23:e18773.
  73. Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev 2015; :CD007130.
  74. Pandey A, Parashar A, Kumbhani DJ, et al. Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials. Circ Heart Fail 2015; 8:33.
  75. Mueller S, Winzer EB, Duvinage A, et al. Effect of High-Intensity Interval Training, Moderate Continuous Training, or Guideline-Based Physical Activity Advice on Peak Oxygen Consumption in Patients With Heart Failure With Preserved Ejection Fraction: A Randomized Clinical Trial. JAMA 2021; 325:542.
  76. Kitzman DW, Brubaker P, Morgan T, et al. Effect of Caloric Restriction or Aerobic Exercise Training on Peak Oxygen Consumption and Quality of Life in Obese Older Patients With Heart Failure With Preserved Ejection Fraction: A Randomized Clinical Trial. JAMA 2016; 315:36.
Topic 3472 Version 28.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟