Editorial Exercise training in congenital heart disease: Should we follow the heart failure paradigm? Georgios Giannakoulas ⁎, Konstantinos Dimopoulos Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, SW3 6NP, Sydney Street, London, UK abstract article info Article history: Received 11 June 2009 Accepted 13 June 2009 Available online 14 July 2009 Keywords: Congenital heart disease Exercise training Accelerometers Quality of life Exercise intolerance is common in adults with congenital heart disease (ACHD) and affects their prognosis and quality of life, thus becoming an important target for therapies. While exercise training has been widely studied in chronic heart failure, its safety and efficacy in ACHD remain unknown. The main obstacle in studies involving physical training and when prescribing exercise, is long-term compliance. Lifestyle changes through behaviour modification are difficult and require adequate physician and patient education on the benefits and types of exercise. Individualised counselling regarding physical training, exercise and sports should begin in early adolescence or even earlier, and exercise restriction is rarely indicated. Self-monitoring of physical activity through logs and the use of simple devices such as accelerometers may also enhance awareness and motivation. Physicians and nurses with adequate communication skills should assist ACHD patients in achieving a positive attitude towards physical activity and lifestyle modification. © 2009 Elsevier Ireland Ltd. All rights reserved. While exercise was traditionally contraindicated in cardiac dis- orders, including paediatric and adult congenital heart disease (ACHD), the general consensus nowadays is that keeping fit conveys long-term beneficial effects on both quality of life and long-term morbidity and mortality [1]. The effects of exercise training have been widely studied in chronic heart failure, in which numerous trials and meta-analyses have demonstrated a benefit in terms of improved outcomes [2–5]. Apart from delivering clinical benefits, exercise training programmes have resulted in a decrease in circulating tumour necrosis factor alpha (TNF-α) and proinflammatory cytokine levels, suggesting an effect on systemic inflammation and endothelial function [6,7]. Other studies, however, including the recently published HF-ACTION trial, the largest multicentre randomised controlled trial of exercise training in heart failure (n =2331), failed to demonstrate a benefit on mortality or mor- bidity [8]. Exercise intolerance is a common feature of acquired heart failure and ACHD and similarities in pathophysiology suggest that established heart failure therapies, including exercise training, might also be bene- ficial to ACHD patients. Decreased exercise capacity is common in ACHD, especially in patients with complex cyanotic disease or Eisenmenger syndrome but is present also in patients with simple lesions, such as atrial or ventricular septal defects (Table 1) [9,10]. Exercise intolerance is also a strong predictor of outcome and significantly affects quality of life, which may already be impaired due to psychosocial problems, thus be- coming an important target for therapies [11–13]. There are scarce data on the feasibility, safety and efficacy of exer- cise training programmes in ACHD patients [14]. In the current issue of the IJC, Dua et al. enrolled 50 patients with various types of ACHD in a 10-week training programme [15]. Physical activity in these patients proved safe and resulted in an increase in exercise capacity quantified both objectively (treadmill test duration, accelerometers) and subjec- tively (questionnaires). Regular exercise also improved quality of life scores, most likely through an increase in effort tolerance, which is fundamental for improving social integration and permitting employ- ment and sexual relations, especially in young ACHD patients. Few other studies have assessed the effect of exercise programmes in the ACHD population. In all cases, exercise training proved to be safe, while efficacy varied. In a Norwegian trial on 55 ACHD patients, there was a small improvement in exercise duration with regular dedicated training, compared to controls [16]. Another study demonstrated a borderline improvement in the aerobic capacity of 9 patients with tetralogy of Fallot undertaking moderate regular physical training, compared to 9 sedentary tetralogy patients [17]. Moalla et al. showed that a 12-week training programme of unloaded cycling in children with congenital heart disease resulted in an improvement in markers of submaximal cardiorespiratory performance, but not peak oxygen consumption [18]. Even patients with pulmonary hypertension, who are generally highly symptomatic, experience improvement in exer- cise endurance, symptomatic status and quality of life after carefully designed exercise training [19,20]. However, all these observations are limited by the short duration of training programmes and/or the small sample size. In the study by Dua et al., there was a 2 minute (18%) increase in median exercise time and a 25% increase in activity as recorded by International Journal of Cardiology 138 (2010) 109–111 ⁎ Corresponding author. Tel.: +44 2073518617; fax: +44 2073518629. E-mail address: G.Giannakoulas@rbht.nhs.uk (G. Giannakoulas). 0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.06.024 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard