More than 6.2 million Americans¹ have a heart that cannot pump enough blood through their body to support the health and function of their heart and other organs. This heart condition, known as heart failure, can be fatal, and in fact, in 2018 it was listed among the multiple causes of death on 42 percent² of death certificates in which cardiovascular disease was named as the underlying cause. 

The good news is that recent research indicates that heart failure can be reversed, and it doesn’t require drugs. There’s also more good news: even if you start to take care of your heart in middle age, you can still improve heart health and help improve heart failure.

Table of Contents

• What is heart failure
• Two types of heart failure
  • Diastolic
  • Systolic
• Symptoms of congestive heart failure
• Lifestyle
  • Food choices
  • Smoking
  • Alcohol
  • Sleep
  • Weight management
  • Stress Management
• Exercise: recent research
• Exercising when you’re young
• Summary

1. What is heart failure?

Heart failure often occurs when conditions such as coronary artery disease (most common cause), myocarditis, congenital heart disease, diabetes, obesity, or high blood pressure damage or weaken the heart to a point where the heart muscle fails to pump blood adequately. 

2. Two types of heart failure

There are two types of heart failure that have been identified: diastolic heart failure and systolic heart failure (aka congestive heart failure).

1. Diastolic – Diastolic heart failure involves thickening and stiffening of a formerly healthy left ventricle, which results in an accumulation of fluid in the lungs and swelling of the abdomen and legs.
2. Systolic – The abdomen, legs, liver, and lungs are congested and filled with blood. The left ventricle begins to lose the ability to pump blood from the heart to the aorta. This leads to a backup of blood in the heart and an enlarged heart and eventually failure of the right ventricle. 

An important term to remember when talking about heart failure is ejection fraction. This refers to how well the left ventricle (the heart’s main pumping chamber) pumps blood with each heartbeat. In some cases, the term also refers to the right ventricle.  

3. Symptoms of congestive heart failure

Symptoms of heart failure typically include:

• Shortness of breath when lying down or with activity
• Swelling in the feet, ankles, or legs
• Irregular or rapid heartbeat
• Reduced ability to exercise
• Fatigue
• Weakness
• Abdominal swelling
• Persistent cough with white or blood-tinged mucus
• Nausea
• Decreased alertness
• Trouble concentrating
• Rapid weight gain associated with fluid accumulation
• Lack of appetite. 

4. Lifestyle

Numerous lifestyle factors can contribute to heart failure, and modifying them can alleviate symptoms, slow the progression of the disease, and improve daily life, particularly among those with mild to moderate heart failure. The one factor we will focus on here is exercise, but first there are other issues to consider as well. For example:

• Food choices – Focus on fruits and vegetables, lean protein, low-fat dairy, beans and legumes, seeds, nuts, and healthy fats such as avocados, olive oil, and cold-water fish. Limit saturated fats, trans fats, salt, and sugar.
• Smoking – If you need help, talk to your physician, or seek help through other professional avenues
• Alcohol – A moderate amount (one drink daily for women, two for men) can be beneficial, but if you already have heart failure, drinking alcohol may make it worse.
• Sleep – Seven to eight hours every night is recommended. Poor sleep, including the presence of sleep apnea or insomnia, can increase your risk of heart failure. Establish a sleep routine, such as relaxing before bedtime, going to bed and getting up at the same time every day, and avoiding exposure to electronic devices before retiring. 
• Weight management – Carrying excess weight, especially extra abdominal fat, increases the risk of heart disease. 
• Stress management – Unmanaged stress kicks up cortisol levels, which in turn places an extra burden on the heart and other organs in the body. 

5. Exercise: recent research

Lack of sufficient exercise is another contributing factor to heart failure. In a 2018 study appearing in Circulation³, the authors reported that poor physical fitness in middle age is a significant risk factor for heart failure, especially “heart failure with a preserved ejection fraction.”

They go on to explain that “The development of heart failure with a preserved ejection fraction is likely mediated through increased left ventricular (LV) stiffness,” which is a result of being sedentary as one ages. 

The study involved 61 healthy, sedentary, middle-aged individuals (45 to 64; 48% male) who were randomly assigned to one of two groups:

• Anaerobic exercise that included basic yoga, weight training, and balance training three times a week
• Aerobic exercise four or more days a week at a moderate- to high-intensity level. 

In the exercise group, the training increased in frequency, duration, and intensity over time, and each participant had his or her own personalized trainer and training program.

Pre-study testing involved right heart catheterization, three-dimensional echocardiography, determination of left ventricular stiffness, and maximal oxygen uptake, which helps identify changes in fitness.

Fifty-three of the participants finished the study and demonstrated the following:

• Maximal oxygen uptake increased by 18 percent
• Left ventricular stiffness reduced, but there was no change among controls
• Participants who exercised showed an increase in left ventricular end-diastolic volume
• The authors concluded that regular exercise training may help protect against the risk of heart failure with a preserved ejection fraction 
• They also found that among people who didn’t have a history of exercise but who now exercised regularly, the left ventricles were stronger and less stiff, and their hearts were more youthful, suggesting that hearts can “retain plasticity” well into middle age.

An integral part of the exercise program, according to Benjamin D. Levine, MD⁴, one of the study’s authors, was a high-intensity workout known as 4×4 intervals.

This involves participants exercising at 95 percent of maximal ability for four minutes, followed by three minutes of active recovery. This routine is repeated four times. 

Overall, “We took these 50-year-old hearts and turned the clock back to 30- or 35-year-old hearts,” noted Levine. “And the reason they got so much stronger, and fitter was because their hearts could now fill a lot better and pump a lot more blood during exercise.”

The hearts of the participants in the control group, however, didn’t change.

6. Exercising when you’re young

This latest study went beyond what other research had shown: that people who exercise in their younger years and who continue with physical activity often have healthier, more youthful hearts.

One example appeared in the Journal of Physiology⁵, in which the authors evaluated older adults who had participated in more than 25 years of exercise.

They noted 4 to 5 days a week of exercise was “necessary to preserve youthful vascular compliance, especially of the large central arteries,” while more casual activity (2 to 3 times per week) “may be sufficient for middle-sized arteries…to minimize arterial stiffening with aging.” 

Summary

We have evidence that healthy middle-aged adults who have been sedentary can improve their heart health and protect against the risk of heart failure by taking up high-intensity exercise at this stage of their lives.

More specifically, this activity improves the strength and reduces the stiffness of the left ventricle, and essentially leaves them with a more “youthful” heart.

References

1. Heart failure. Centers for Disease Control and Prevention.

2. Virani SS et al. Heart disease and stroke statistics—2021 update: A report from the American Heart Association. Published online 2021 Jan 27 Circulation

3. Howden EJ et al. Reversing the cardiac effects of sedentary aging in middle age—a randomized controlled trial. Circulation 2018; 137(15):1349-60

4. Shibata S et al. The effect of lifelong exercise frequency on arterial stiffness. Journal of Physiology 2018 Jul; 596(14):2783-2795. 

5. Neighmond P. Hearts get “younger,” even at middle-age, with exercise. NPR 2018 Mar 12