Endpoints of large-scale trials in chronic
heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with
heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of
heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous
iron supplementation in patients with
iron deficiency, and - with less certainty - testosterone in highly selected patients.
Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with
heart failure. Sinus rhythm may have some advantage when compared with
atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for
heart failure co-morbidities such as
sleep-disordered breathing,
diabetes mellitus,
chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using
angiotensin-converting enzyme inhibitors,
angiotensin receptor blockers, beta-blockers, and
mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with
ivabradine and with
sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for
heart failure with preserved ejection fraction are even less positive, only
sacubitril/valsartan and
spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art
heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for
heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in
heart failure are required.