250 PHYSICAL ACTIVITY IN CHF PATIENTS
Simple Methods of Assessing
Physical Activity in Patients with
Chronic Heart Failure
This article reviews simple, noninvasive ways to assess
physical activity in patients with chronic heart failure.
Six- or 9-minute walk tests appear to be useful not only for
selecting patients with relatively advanced heart failure
but also as prognostic screening tests. The Master-Borg
test (Master’s two-step testing and 10-point Borg scale) is
useful for assessing symptoms during exercise. Weekly
pedometer counts show that the level of activity in patients
with heart failure is dramatically less than in healthy
controls. Physical activity can be determined directly by an
ambulatory calorie counter that measures step scores and
energy expenditure using specific accelerometers. Careful
clinical interviewing regarding symptoms, together with
submaximal exercise testing and use of motion sensors, are
recommended as useful, simple, noninvasive alternatives
for assessing physical activity in this patient population.
(CHF. 2000;6:250–255) ©2000 by CHF, Inc.
Susumu Asakuma, MD; Mitsumasa Ohyanagi, MD;
Tadaaki Iwasaki, MD
From the First Department of Internal Medicine,
Hyogo College of Medicine, Nishinomiya, Japan
Address for correspondence/reprint requests:
Susumu Asakuma, MD, First Department of
Internal Medicine, Hyogo College of Medicine,
1-1, Mukogawa-cho, Nishinomiya 663–8501, Japan
Manuscript received June 22, 1999;
accepted September 16, 1999
CHF SEPTEMBER/OCTOBER 2000
Chronic heart failure is characterized by limitation
of physical activity due to development of fatigue
and dyspnea. This limitation is used clinically to
evaluate progression of disease and efficacy of thera-
py. Although such patients are assumed to be rela-
tively sedentary, activity levels vary considerably
among individuals with heart failure of similar
severity. Physical activity in such patients is difficult
to quantify because of a lack of sensitive and reliable
evaluation methods and because of variability
among persons with apparently similar pathophysi-
ology. Nevertheless, physical activity levels are im-
portant, because they reflect general well-being;
quality of life may also be used as a marker for treat-
ment efficacy.1–3 We review recent investigations of
simple, noninvasive ways to assess physical activity
in patients with chronic heart failure. Attributes of
these methods are compared in the Table.
Clinical Interviewing
Global Assessment. The approach most common-
ly used by physicians to evaluate physical activity is
careful questioning of the patient. Questions are
posed in general or global terms concerning physi-
cal activity in the course of daily living. Physicians
ask patients about palpitations, dyspnea and fa-
tigue, physical activity relative to that of other peo-
ple, the pretreatment course of the disease, and
effects of therapy. Physicians have long asked sim-
ple questions—about the patient’s ability to climb
stairs, for example—and this assessment has distin-
guished active treatment from placebo in several
controlled clinical trials.4,5 However, such a simple
determination may be biased by a patient’s or
physician’s awareness of physiologic changes char-
acteristic of a drug action. Assessment should there-
fore include not only history taking but also other
methods, such as time-limited walk distance tests.
Functional Classification. In 1928 the New York
Heart Association (NYHA) published a classification
for patients with cardiac disease based on clinical
severity and prognosis. Each NYHA Functional Class
PHYSICAL ACTIVITY IN CHF PATIENTS
can include a wide range of physical activity levels,
and changes during a patient’s course are not neces-
sarily reflected;6–8 nevertheless, this approach re-
mains the most widely used grading system for
common symptoms of cardiovascular disease. The
ninth edition, revised by the Criteria Committee of
the New York City Affiliate of the American Heart
Association, was released in March, 1994.9 A signifi-
cant change in this edition involves terms used for
the classes. Early editions referred to “functional ca-
pacity” and “therapeutic classification.” The terms
“cardiac status” and “prognosis” were substituted in
the seventh (1973) and eighth (1979) editions. How-
ever, since “functional capacity” is the wording most
physicians use, the committee readopted the term,
which is based on subjective assessment. The com-
mittee also added a category for objective assess-
ment, based on studies such as electrocardiograms,
stress tests, x-rays, echocardiograms, and various ra-
diological images. A patient with cardiac disease who
has not undergone such objective tests of cardiac
structure or function is classified as “undetermined.”
Submaximal Exercise Tests
Cardiopulmonary testing—including treadmill or
bicycle maximal exercise test, combined with con-
current measurement of respiratory gas exchange—
has gained acceptance as a more precise method for
objective functional assessment than history
taking. 10 Oxygen consumption (Vo 2), specifically
peak Vo2 (Vo2peak), is the parameter measured by
these expensive and cumbersome systems for evalu-
ating the functional status of patients with heart
failure. However, data obtained from maximal ex-
ercise may not be reproducible11 because of varia-
tions in patient (and physician) motivation and
end-point criteria for the exercise test. As an alter-
native to such laboratory exercise testing, we need a
TABLE. CHARACTERISTICS OF EACH METHOD OF PHYSICAL ACTIVITY ASSESSMENT IN PATIENTS
WITH HEART FAILURE
COST SIMPLICITY QUANTITATIVENESS
Symptom Global
assessment assessment - +++
NYHA class - +++
Submaximal Walk test - ++
exercise testing Step test - ++
Motion sensors Pedometers + +++
Activity monitors ++ +++
Maximal exercise VO2peak +++ + +++
testing AT +++ - +++
NYHA=New York Heart Association; VO2peak=maximal oxygen uptake; AT=anaerobic threshold.
CHF SEPTEMBER/OCTOBER 2000 251
simple, noninvasive, inexpensive, and safe method
for evaluating the exercise capacity and physical ac-
tivity of these patients. Thus, cardiologists are inter-
ested in objective information obtained from
submaximal rather than maximal exercise.12
Walk Tests. 6-Minute Walk Test. The 6-minute
walk test (6-MWT) is a suitable alternative and bet-
ter simulates daily activity than maximal exercise
testing in patients with heart failure. A form of the
6-MWT described by Guyatt et al 13,14 has shown
particular clinical relevance and ease of administra-
tion, and has become increasingly popular in recent
years. The 6-MWT is easy to use as a supplement to
clinical information. The test requires an enclosed
corridor, level, with a surface of at least 20 meters.
The patient is asked to cover as much ground as
possible in 6 minutes by walking continuously at a
self-determined walking speed, pausing to rest as
needed. Usually, patients are encouraged by physi-
cians at regular 30-second intervals during the test
to improve performance. Guyatt et al have reported
that this walking test correlated well with bicycle er-
gometry and almost as well with functional status
determined from questionnaires.
Investigators have concluded that the 6-MWT is
a good measure of functional capacity and activities
of daily living in patients with heart disease. The
prognostic value of the 6-MWT was first reported by
Bittner et al15 based on the study of left ventricular
dysfunction (SOLVD) registry data. The registry
substudy included 898 patients with chronic heart
failure who had been randomly selected from the
SOLVD registry database. These patients underwent
a detailed, noninvasive clinical evaluation including
6-MWT and were followed prospectively for a mean
of 242 days. Most 6-MWT participants had mild-to-
moderate chronic heart failure (NYHA Class I 35%
and Class II 47%, as opposed to Classes III and IV
CONCRETENESS EXTENT OF USE
- ++ +++
- ++ +++
+ +++ ++
+ +++ -
+ ++ +
++ ++ -
++ ++
+ +
252 PHYSICAL ACTIVITY IN CHF PATIENTS
14%); the mean left ventricular ejection fraction was
37%. Distance walked during the 6-MWT was in-
versely related to death and hospitalization rates for
chronic heart failure during follow up. Compared
with patients walking more than 450 meters, those
walking less than 300 meters had a 3.7-fold greater
risk of dying and a 14-fold greater risk of being hos-
pitalized for chronic heart failure.
Recently, Cahalin et al16 reported a series of 45
patients with advanced heart failure who underwent
a 6-MWT. These authors found that the distance
walked (<300 meters) predicted an increased likeli-
hood of death or pre-transplant hospital admission
within 6 months (p=0.04). However, the 6-MWT
did not predict long-term overall or event-free sur-
vival during a mean follow up period of 62 weeks.
Vo2peak was the best predictor of long-term overall
and event-free survival.
As usual, the 6-MWT was assessed simply by
walking in a corridor. In other studies,17,18 a modi-
fied 6-MWT, measuring distance with a pedometer,
has been shown to be useful in assessing physical
activity in large ambulatory populations. Roll, Ger-
main, and Bareiss19 studied 121 subjects with mild-
to-moderate heart failure (NYHA Class II or III).
Distance covered was measured by a pedometer ac-
cording to the formula d=y x 10 meters ÷ x, where
d is distance walked in meters, x is the number of
steps a subject requires to cover 10 meters, and y is
the total number of steps during the 6-minute peri-
od. This modified 6-MWT showed a strong trend
toward predicting cardiovascular mortality and
morbidity but was less predictive than Vo 2peak ,
which attained statistical significance. In patients
who performed in the lowest quartile (<370 me-
ters)—in particular, those covering <300 meters—
prediction by 6-MWT also was statistically significant.
These observations corresponded to findings of Bit-
tner et al15 in the SOLVD trial.
Based on data from several trials, the 6-MWT ap-
pears to be useful as a prognostic screening test to
select patients with relatively advanced heart fail-
ure. Prospective confirmation of this observation in
a heart failure trial, using a cut off value of <300
meters or 350 meters, would be valuable. If its relia-
bility is confirmed, the 6-MWT should serve as a
simple, practical way to identify patients with severe
heart failure.
9-Minute Walk Test. The 9-minute walk test
(9-MWT) is performed on a patient-powered tread-
mill with a 6°–7° incline. To better reproduce daily
activity, the patient can stop to take a brief rest dur-
ing the examination.20 This examination has shown
high reproducibility and allows easy differentiation
CHF SEPTEMBER/OCTOBER 2000
among patients with different degrees of functional
limitation. The 9-MWT has a clinical significance
very similar to that of Vo2peak, averaging 95±5% of
Vo2peak and showing a high correlation with Vo2peak
(r=0.79, p<0.005).21 A 6-MWT requires a long cor-
ridor, and additional parameters are difficult to
monitor; by contrast, the 9-MWT allows continuous
electrocardiographic and heart rate monitoring and
regular blood pressure monitoring. In two recent,
separate multicenter trials comparing a ß-blocking
agent to placebo, the 9-MWT was used together
with the 6-MWT to assess functional capacity.22,23
Kaddoura et al24 recently studied objective as-
sessment of severe heart failure using a 9-MWT.
Twelve patients (one in NYHA Class II, three in
Class III, and eight in Class IV) underwent a daily
9-MWT for 7 days and again at 6-week follow up.
The patients also completed a 24-item symptom
score questionnaire; patients’ body weight also was
measured. After treatment, there was a rapid, signif-
icant increase in total distance walked (mean±SEM
on admission, 54±27 meters; on day 2 174±54 me-
ters, p<0.05). These authors concluded that the 9-
MWT was a practical, inexpensive, and safe way to
objectively assess functional capacity. Moreover, it
provided some advantages over other indices of re-
sponse to therapy, such as symptom scores and
weight loss.
The 9-MWT and the 6-MWT are based on the
measurement of the distance walked during a fixed
time period. These tests are well accepted by pa-
tients, are easy to perform, and require no special
equipment other than a treadmill. These tests
should, therefore, see increased use as submaximal
protocols in studies of drug efficacy. However, as
discussed below, the walk tests actually appear to
measure maximal rather than submaximal func-
tional capacity. Whether these tests ultimately will
replace the current standard assessment of func-
tional capacity with gas exchange measurement has
yet to be determined.
Step Test. Walking distance tests such as the 6-MWT
and 9-MWT are useful measurements of physical ac-
tivity, but they do not assess symptoms during exer-
cise. Asakuma et al25 have used a simple method,
termed the Master-Borg test, for evaluating physical
activity of patients with chronic heart failure based
on self-evaluation of the sensation of dyspnea at a
constant workload. Sixty patients (NYHA Class I–III)
performed a symptom-limited treadmill exercise test
and subsequently performed Master’s two-step test
for 90 seconds. Maximal dyspnea during this test was
self-rated using the Borg 10-point scale. The work-
load in the Master-Borg test (15.2±1.6 mL/min/kg)
PHYSICAL ACTIVITY IN CHF PATIENTS
represents the ordinary activity level of the individual
more accurately than does maximal exercise testing.
Master-Borg scores ranged from 0–7 and correlated
with Vo2peak (r=-0.87) or anaerobic threshold (r=
-0.84). The reproducibility of this test was very good
(r=0.93, p<0.0001). These authors concluded that
this simple and inexpensive test accurately represent-
ed ordinary activity levels, related the sensation of
dyspnea to peak exercise tolerance, and could be
completed by most patients with heart failure. The
Master-Borg test is suitable for mild or moderate
heart failure, because it is limited not only by time
(90 seconds) but also exercise capacity (3–5 metabolic
units). This test also may be useful in assessing effica-
cy of treatment or cardiac rehabilitation.
Motion Detection
Pedometry. Pedometry records acceleration and de-
celeration of movement in one direction. A pedome-
ter is small, easy to wear, and inexpensive and has
been found to be useful in assessing physical activi-
ty.26 Daily activity levels, as measured by pedometry,
show that the level of activity in patients with heart
failure is dramatically less than in healthy controls.
Hoodless et al27 assessed a new shoe-mounted pe-
dometer and compared conventional with body-worn
pedometers in 10 normal volunteers and 17 patients
with chronic heart failure. According to both types of
pedometer, patients with chronic heart failure
showed a reduced level of activity compared with nor-
mal volunteers over a 1-week period (p=0.01). Walsh
et al28 examined the effects of 12 weeks of vasodilator
drug treatment on laboratory exercise tests in relation
to measurements of daily activity in 18 patients with
chronic heart failure. The weekly pedometer scores of
patients with heart failure were much lower than
those of controls (258±45 x 100 vs. 619±67 x 100
steps per week, p<0.001). Treatment for 12 weeks did
not change patient scores (261±42 x 100 steps per
week); in this context, pedometers measure only total
step number, providing no information about speed
of walking or rest periods.
Walsh et al 29 investigated whether weekly pe-
dometer scores had prognostic importance. Of their
84 patients with chronic heart failure who were fol-
lowed for a mean of 710 days, 44 died and three
underwent cardiac transplantation. Symptom-limit-
ed treadmill exercise capacity did not predict sur-
vival, but reduced weekly pedometer scores were
strong predictors of mortality (p<0.001). Other
variables affecting survival included resting cardiac
output, arterial blood pressure, diuretic require-
ments, NYHA Functional Class, increased bilirubin,
and hyponatremia (all at p<0.01).
CHF SEPTEMBER/OCTOBER 2000 253
These reports suggest that pedometer score is
very useful for both evaluating physical activity and
predicting outcome in heart failure patients. How-
ever, these scores do not reflect aspects of walking
intensity, such as speed of walking or rest periods.
Ambulatory Activity Monitors. Everyday physi-
cal activity of patients with chronic heart failure
may reflect their quality of life, but it is difficult to
measure objectively and may relate insufficiently to
exercise capacity determined by laboratory testing
or to activity logs and questionnaires.30 Physical ac-
tivity can be determined directly by ambulatory ac-
tivity monitors that measure not only step scores
but also energy expenditure using specific ac-
celerometers. Microprocessors and other techno-
logical advances have made accelerometry a viable
option in field settings.
Sato et al31 measured energy expenditure with a
compact ambulatory calorimeter, the Kenz Calorie
Counter® (Suzuken, Nagoya, Japan), equipped with
an acceleration sensor. The apparatus, which weighs
70 g and measures 79 x 64 x 18 mm, was designed to
detect the acceleration rate along the vertical axis at
the waist during body movements and to automati-
cally calculate energy expenditure from the product
of the acceleration rate and body weight. The calcu-
lated energy expenditure is integrated and stored in-
ternally. Energy expenditure measured by the
calorimeter correlated well with that estimated from
oxygen uptake (r=0.89). Sato et al measured daily
energy expenditure by calorimetry in 8 patients with
chronic heart failure who received the ACE inhibitor
ramipril for 24 weeks. These authors found that not
only exercise capacity but also energy expenditure
associated with daily activities increased significantly
after 24 weeks of therapy (p<0.01). The daily energy
expenditure increased with improvement in symp-
toms of heart failure—probably a reflection of in-
creased daily activity. These authors concluded that
calorimetric measurement of daily energy expendi-
ture is an effective and practical technique for quan-
tifying the effect of therapy on daily physical activity
in patients with chronic heart failure. Recently, the
calorimeter has been reduced in size (60 x 40 x 10
mm) and weight (42 g); it can now store data contin-
uously for up to 6 weeks, which can be downloaded
to a personal computer.32
Two commercially available accelerometers are
the Caltrac® and Tritrac® (Hemokinetics, Madison,
WI). Investigators have tested the reliability of the
Caltrac®, which senses vertical acceleration, during
a variety of exercises. Results from studies of walk-
ing and running activities have concluded that the
Caltrac is highly reliable, with reliability coefficients
254 PHYSICAL ACTIVITY IN CHF PATIENTS
(r) ranging from 0.7–0.98. 33 The Tritrac ® device
senses acceleration along three separate axes: verti-
cal, lateral-medial, and anterior-posterior.
Fehling et al34 compared the Caltrac® and Tritrac®
accelerometers with indirect calorimetry to assess
caloric expenditure in older adults at submaximal
work rates in treadmill walking and bench-stepping
exercises. The Caltrac® significantly overestimated
energy expenditure at the three treadmill work rates
(10%–52% difference, p<0.05) and underestimated
energy expenditure at the three stepping work rates
(-19%–28% difference). When energy expenditure
among the three work rates was compared, the Cal-
trac® was not sensitive to changes (increase in energy
expenditure) that occurred during graded treadmill
walking but did detect some changes in the stepping
exercise. The Tritrac® significantly underestimated
energy expenditure (p<0.05) for the three work rates
of both the treadmill and stepping exercise compared
with indirect calorimetry, but it successfully detected
differences in energy expenditure among work rates
during stepping exercise (p<0.05). These data indi-
cate that energy expenditure is affected by exercise
mode and intensity and that caution is warranted
when using accelerometers to quantify energy expen-
diture in older adults.
Overall, ambulatory activity monitors have shown
promise for use in clinical trials, especially when
used concurrently with self-reported activity as a val-
idation technique. This combination represents
valuable progress in measuring physical activity in
patients with chronic heart failure.
Conclusions
We have reviewed various methods for assessing
physical activity in patients with chronic heart fail-
ure. Unfortunately, physical activity itself is not a
homogeneous entity but includes different compo-
nents that sometimes are only weakly related. For
this reason, there exists no standard protocol to as-
sess everyday physical activity. However, careful
questioning of patients regarding their symptoms,
together with submaximal exercise testing and use
of motion sensors, are simple and useful noninva-
sive alternatives for assessing physical activity in pa-
tients with chronic heart failure.
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