Effects of Exercise Training on Depressive Symptoms in Patients With Chronic Heart Failure: The HF-ACTION Randomized Trial

Study Questions:

Does exercise training result in greater improvement in depressive symptoms compared with usual care among patients with heart failure, and is there an impact on clinical outcome?


HF-ACTION is a multicenter, randomized, controlled trial conducted in 2,322 stable patients treated for heart failure at 82 medical clinical centers in the United States, Canada, and France. Patients with a left ventricular ejection fraction ≤35%, New York Heart Association class I-IV heart failure, and who had completed the Beck Depression Inventory II (BDI-II) score were randomized to supervised aerobic exercise (goal of 90 minutes/week for months 1-3, followed by home exercise, with a goal of 120 minutes/week for months 4-12) or to education and usual guideline-based heart failure care. Main outcome measures were death or hospitalization due to any cause, and scores on the BDI-II at 3 and 12 months.


The median age was 59 years (interquartile range, 51-68; range, 19-91). The majority were white, men, married, and had achieved at least a high school education. About 50% were nonischemic. Over a median follow-up period of 30 months, 789 patients (68%) died or were hospitalized in the usual care group compared with 759 (66%) in the exercise group (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.81-0.99; p = 0.03). The median BDI-II score at study entry was 8, with 28% of the sample having BDI-II scores of 14 (threshold for mild clinical depression) or higher. Compared with usual care, exercise resulted in lower mean BDI-II scores at 3 months (exercise, 8.95 vs. usual care, 9.70; difference,−0.76; 95% CI,−1.22 to −0.29; p = 0.002) and at 12 months (exercise, 8.86 vs. usual care, 9.54; difference,−0.68; 95% CI,−1.20 to −0.16; p = 0.01). There was a significant association between BDI-II change score and risk of all-cause death or hospitalization (p = 0.02).


Compared with guideline-based usual care, exercise training resulted in a modest reduction in depressive symptoms, although the clinical significance of this improvement is unknown.


Worsening of depressive symptoms was associated with worse outcome in both the exercise and usual care groups. Heart failure patients should be assessed for depression (perhaps with the Patient Health Questionnaire-2), depression should be treated, and exercise is one of the methods to reduce depressive symptoms.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Exercise

Keywords: Depression, Follow-Up Studies, Chronic Disease, Health Resources, Exercise, Canada, New York, Cause of Death, France, Cardiology, Heart Failure, Stroke Volume, Confidence Intervals, United States

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