Perindopril improves six minute walking distance in older patients with left ventricular systolic dysfunction: a randomised double blind placebo controlled trial

Mineralocorticoid antagonism: a novel way to treat sarcopenia and physical impairment in older people?

Dysregulation of the renin-angiotensin-aldosterone system has been associated with a number of age-related pathologies including hypertension, heart failure and chronic kidney disease. More recently, it has been suggested that alterations within the RAAS may contribute to the development of sarcopenia and subsequent decline in physical function. There is growing interest in developing interventions to prevent age-associated decline in muscle function. We postulate that inhibition of the RAAS with the mineralocorticoid antagonist spironolactone may have a role in countering the effects of physical impairment in older people by improving skeletal muscle function. Spironolactone may prevent skeletal myocyte apoptosis, improve vascular endothelial function and enhance muscle contractility by increasing muscle magnesium and sodium-potassium pumps. This article will review the literature underpinning the hypothesis that spironolactone may have a role in maintaining muscle function in older people.

Optimal management of sarcopenia

Sarcopenia is the progressive generalized loss of skeletal muscle mass, strength, and function which occurs as a consequence of aging. With a growing older population, there has been great interest in developing approaches to counteract the effects of sarcopenia, and thereby reduce the age-related decline and disability. This paper reviews (1) the mechanisms of sarcopenia, (2) the diagnosis of sarcopenia, and (3) the potential interventions for sarcopenia. Multiple factors appear to be involved in the development of sarcopenia including the loss of muscle mass and muscle fibers, increased inflammation, altered hormonal levels, poor nutritional status, and altered renin-angiotensin system. The lack of diagnostic criteria to identify patients with sarcopenia hinders potential management options. To date, pharmacological interventions have shown limited efficacy in counteracting the effects of sarcopenia. Recent evidence has shown benefits with angiotensin-converting enzyme inhibitors; however, further randomized controlled trials are required. Resistance training remains the most effective intervention for sarcopenia; however, older people maybe unable or unwilling to embark on strenuous exercise training programs.

The use of the Internet to remotely monitor patients with heart failure

Heart failure (HF) results in high hospitalization rates and healthcare costs. Telemonitoring of HF has been shown to result in improved outcomes but usually involves the use of expensive equipment. A more feasible alternative may be the use of a Web site. The purpose of this study is to investigate the use of a Web site designed for HF telemonitoring. Patients newly referred to a heart function clinic were screened for eligibility. Twenty participants were recruited and entered their weight and symptoms onto the Web site for 6 months. A nurse monitored the Web site for changes in participant health status and telephoned the participants as necessary. Self-care, quality of life, 6-minute walk test, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) were assessed. Interviews were conducted to assess intervention uptake. Seventeen participants completed the study. A significant change was observed on the maintenance subscale of the Self-Care of Heart Failure Index (p = 0.039). There was a trend toward improvement on the confidence subscale of the Self-Care of Heart Failure Index (p = 0.069), Minnesota Living With Heart Failure((R)) Questionnaire (p = 0.337), 6-minute walk test (p = 0.124), and NT-proBNP (p = 0.210). Participants and nurses demonstrated a favorable uptake of the Web site. A Web site that facilitates the telemonitoring of patients with HF was favorably accepted and its use in this pilot study was associated with improved self-care skills. However, further investigation is warranted in a larger study population.

The Effects of Vitamin D Supplementation on Physical Function and Quality of Life in Older Patients With Heart Failure

Background— Low 25-hydroxyvitamin D levels, commonly found in older patients with heart failure, may contribute to the chronic inflammation and skeletal myopathy that lead to poor exercise tolerance. We tested whether vitamin D supplementation of patients with heart failure and vitamin D insufficiency can improve physical function and quality of life.

Methods and Results— In a randomized, parallel group, double-blind, placebo-controlled trial, patients with systolic heart failure aged ≥70 years with 25-hydroxyvitamin D levels <50 nmol/L (20 ng/mL) received 100 000 U of oral vitamin D2 or placebo at baseline and 10 weeks. Outcomes measured at baseline, 10 weeks, and 20 weeks were 6-minute walk distance, quality of life (Minnesota score), daily activity measured by accelerometry, Functional Limitations Profile, B-type natriuretic peptide, and tumor necrosis factor-α. Participants in the vitamin D group had an increase in their 25-hydroxyvitamin D levels compared with placebo at 10 weeks (22.9 versus 2.3 nmol/L [9.2 versus 0.9 ng/mL]; P <0.001) and maintained this increase at 20 weeks. The 6-minute walk did not improve in the treatment group relative to placebo. No significant benefit was seen on timed up and go testing, subjective measures of function, daily activity, or tumor necrosis factor. Quality of life worsened by a small, but significant amount in the treatment group relative to placebo. B-type natriuretic peptide decreased in the treatment group relative to placebo (−22 versus +78 pg/mL at 10 weeks; P =0.04).

Conclusions— Vitamin D supplementation did not improve functional capacity or quality of life in older patients with heart failure with vitamin D insufficiency.

Clinical Trial Registration— www.controlled-trials.com. Identifier: ISRCTN51372896.

ACE-inhibition and physical function: results from the Trial of Angiotensin-Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study

OBJECTIVES

Aim of the present study was to evaluate whether an ACE inhibitor intervention is able to significantly improve physical performance and muscle strength in a sample of older persons.

DESIGN

Double-blind, cross-over, randomized, placebo-controlled trial.

SETTING

The Trial of Angiotensin-Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study.

PARTICIPANTS

Participants were 257 subjects aged 55 years and older with high cardiovascular risk profile.

INTERVENTION

Six months of fosinopril use versus placebo.

MEASUREMENTS

The Short Physical Performance Battery score (rescaled to obtain a continuous variable ranging from 0 to 3 points), and the hand grip strength were measured at the baseline visit, and after 6 and 12 months of follow-up. Paired t test analyses were performed to compare results of physical function measures after ACE inhibition and placebo interventions.

RESULTS

Mean age of the sample population was 65.97 (standard deviation 7.41) years old. No statistically significant difference was found at the Short Physical Performance Battery (P=.23) and hand grip strength (P=.57) results after ACE inhibition (2.113, standard deviation [SD] 0.284; and 37.044 kg, SD 12.993 kg, respectively) compared to placebo (2.096, SD 0.298; and 36.898 kg, SD 13.178 kg, respectively). No significant effects from ACE inhibition were also found when the 3 subtests composing the Short Physical Performance Battery (ie, 4-meter walking speed, balance, and chair stand tests) were separately analyzed. Consistent negative results were obtained after analyses were restricted to participants showing the highest compliance to treatment and/or receiving the maximum fosinopril dosage.

CONCLUSION

No significant modifications in physical performance and muscle strength were reported after 6 months of fosinopril use in older persons with high cardiovascular risk profile. Given these negative findings, it is possible that the beneficial effects of ACE inhibitors on physical function might be attributable to the activation of a virtuous cycle determined by an improved cardiovascular system. Further specifically designed studies are needed to confirm our findings, and expand them to different populations and ACE inhibitors. If our findings will be confirmed, the extracardiovascular properties of ACE inhibitors in older persons might be substantially resized.

Effect of perindopril on physical function in elderly people with functional impairment: a randomized controlled trial

BACKGROUND

Physical function and exercise capacity decline with age and are a major source of disability in older people. Recent evidence suggests a potential role for the renin-angiotensin system in modulating muscle function. We sought to examine the effect of the angiotensin-converting-enzyme (ACE) inhibitor perindopril on physical function in elderly people with functional impairment who had no heart failure or left ventricular systolic dysfunction.

METHODS

In this double-blind randomized controlled trial, participants aged 65 years and older who had problems with mobility or functional impairment were randomly assigned to receive either perindopril or placebo for 20 weeks. The primary outcome was the change in the 6-minute walking distance over the 20 weeks. Secondary outcomes were changes in muscle function, daily activity levels, self-reported function and health-related quality of life.

RESULTS

A total of 130 participants were enrolled in the study (mean age 78.7, standard deviation 7.7 years); 95 completed the trial. At 20 weeks, the mean 6-minute walking distance was significantly improved in the perindopril group relative to the placebo group (mean between-group difference 31.4 m, 95% confidence interval [CI] 10.8 to 51.9 m; p = 0.003). There was a significant impact on health-related quality of life: although the mean score for part 1 of the EQ-5D questionnaire deteriorated over time in the placebo group, quality of life was maintained in the perindopril group, for a between-group difference of 0.09 (p = 0.046). There were no significant differences between the 2 groups in the other outcomes.

INTERPRETATION

Use of the ACE inhibitor perindopril improved exercise capacity in functionally impaired elderly people who had no heart failure and maintained health-related quality of life. The degree of improvement was equivalent to that reported after 6 months of exercise training. (International Standard Randomised Controlled Trial Register no. ISRCTN67679521).

Effect of angiotensin-converting enzyme inhibition on skeletal muscle oxidative function and exercise capacity in streptozotocin-induced diabetic rats

Since exercise capacity is related to the mitochondrial respiration rate in skeletal muscle and both parameters are potentially modulated by the onset of diabetes and by inhibition of the angiotensin-converting enzyme (ACE), we investigated whether skeletal muscle oxidative functions and exercise capacities are impaired in chronic streptozotocin-induced diabetic (STZ) rats and whether ACE inhibition could reverse such abnormalities. The ACE inhibitor perindopril (2 mg kg(-1) day(-1)) was given for a period of 5 weeks to 7-month-old STZ rats (DIA-PE, n = 8) whose haemodynamic function, skeletal muscle mitochondrial function and exercise capacity were compared with those of untreated diabetic (DIA, n = 8) and control rats (CONT, n = 8). Increased arterial blood pressure (157 +/- 12 versus 130 +/- 6 mmHg, P < 0.05) and reduced exercise capacity (29 +/- 2 versus 91 +/- 2 min, respectively, P < 0.01) were observed in DIA compared with CONT. The oxidative capacity of the gastrocnemius muscle was significantly reduced in DIA compared with CONT rats (5.4 +/- 0.5 versus 10.6 +/- 0.7 micromol O(2) min(-1)(g dry weight)(-1), respectively, P < 0.001). Moreover, the coupling between oxidation and phosphorylation was significantly impaired in DIA (-52%, P < 0.001). Angiotensin-converting enzyme inhibition (ACEi) normalized blood pressure without improving mitochondrial function (4.3 +/- 0.8 micromol O(2) min(-1) (g dry weight)(-1) in DIA-PE rats) but reduced exercise capacity to even lower levels (10 +/- 1 min, P < 0.01). Exercise capacity correlated positively with blood pressure in DIA-PE (r = 0.79, P < 0.05). In experimental type 1 diabetic rats, both skeletal muscle mitochondrial respiration and exercise capacity are impaired. The ACEi failed to restore the muscular function and worsened exercise capacity. Further studies will be useful to determine whether an inadequate muscular blood flow secondary to the reduction in mean systemic blood pressure can explain these results.

Long-Term Follow-Up of Very Old Heart Failure Patients Enrolled in a Trial of Exercise Training

Little is known about how physical and psychological status changes with time in older heart failure patients. The authors followed up a cohort of 82 patients (mean age, 80.5 years) enrolled in a randomized controlled trial of exercise training in heart failure. Six-minute walk test, accelerometry, functional status, quality of life, anxiety, and depression were measured at baseline, 3 months, 6 months, and a mean of 19 months post-enrollment. There were no significant differences between the exercise and control groups at long-term follow-up. Six-minute walk distance declined by only 0.2 m/month in those attending final follow-up (vs 4.6 m/month in nonattenders; P=.03). Similar results were seen for other outcomes. Only a small proportion of the variance in change of any of the outcomes was explained by differences in baseline variables.

Clinical trials update from the joint European Society and World Congress of Cardiology meeting: PEP-CHF, ACCLAIM and the HHH study

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at the joint European Society and World Congress of Cardiology meeting held in Barcelona in September 2006. All reports should be considered as preliminary data, as analyses may change in the final publication. The PEP-CHF study suggests that perindopril improves symptoms and functional capacity and may reduce heart failure hospitalisations in patients with diastolic heart failure. Although immune modulation therapy failed to reduce the incidence of all-cause mortality and cardiovascular hospitalisations in the ACCLAIM study, the observed differences in outcome in some heart failure patients warrants further investigation. The HHH study failed to show a beneficial effect of telemonitoring over usual care in patients with heart failure but potentially important country interactions were observed.

Enhanced External Counterpulsation Improves Exercise Duration and Peak Oxygen Consumption in Older Patients With Heart Failure: A Subgroup Analysis of the PEECH Trial

The Prospective Evaluation of Enhanced External Counterpulsation in Congestive Heart Failure (PEECH) trial demonstrated that enhanced external counterpulsation (EECP) therapy increased exercise duration and improved functional status and quality of life without affecting peak oxygen consumption. The authors present data from a prespecified subgroup of elderly patients (65 years or older) enrolled in the PEECH trial. The 2 co-primary end points were the percentage of subjects with a >60-second increase in exercise duration and the percentage of subjects with a >1.25-mL/kg/min increase in peak volume of oxygen consumption. At 6-month follow-up, the exercise responder rate was significantly higher in EECP patients compared with controls (P=.008). Further, in contrast to the overall PEECH study, the EECP group demonstrated a significantly higher responder rate for peak oxygen consumption (P=.017). The authors conclude that an older subgroup of PEECH subjects confirms the beneficial effect of EECP in patients with chronic, stable, mild-to-moderate heart failure.

The 6-minute walk test predicts clinical outcome in Asian patients with chronic congestive heart failure on contemporary medical therapy: a study of the multiracial population in Singapore

BACKGROUND

We sought the value of the 6-min walk test (6MWT) in predicting morbidity and mortality in Asian patients with congestive heart failure (CHF).

METHODS

668 patients (Age 66+/-12 years, Ejection fraction 29+/-13%, NYHA I to IV) were prospectively followed up for 36+/-12 months. 386 patients (58%) took the 6MWT. Cardiac events, defined as the composite end-point of death or CHF readmission were documented.

RESULTS

188 patients (28%) reached the composite end-point (63 deaths, 125 readmissions). 6MWT distance was an independent predictor of cardiac events (quartile 1 vs quartile 4)(p=0.041), as were beta-blocker or spironolactone use (p=0.008 for both), diabetes (p=0.042), monthly income less than SGD$1000 (p=0.030), and NYHA class (class III vs class I)(p=0.003). A 6MWT distance <340 m predicted occurrence of cardiac events with a sensitivity of 69% and specificity of 48%.

CONCLUSIONS

The 6MWT is a safe and simple clinical tool, which could predict both morbidity and mortality in a large population of Asian patients with CHF of differing etiology and severity (169 words).

Sarcopenia – A Potential Target for Angiotensin-Converting Enzyme Inhibition?

Society is ageing. There has been a steady increase in the number of people aged 65 years and over throughout the 20th century and this trend is predicted to continue worldwide. This has resulted in an increase in the incidence of sarcopenia, which is a loss of muscle mass and function with age. Maintenance of muscular function into old age is critical to sustaining normal daily activity and functional independence. Sarcopenia is associated with increased morbidity and mortality. Till now most efforts to counteract sarcopenia have met with limited success. We postulate that targeting the renin-angiotensin system through angiotensin-converting enzyme (ACE) inhibition could play a role in countering sarcopenia. ACE inhibitors could work by preventing mitochondrial decline and improving endothelial function and muscle metabolism. We describe the literature to support our hypothesis that sarcopenia may be a potential therapeutic target for ACE inhibitors.

Short-Term Change in Distance Walked in 6 Min Is an Indicator of Outcome in Patients With Chronic Heart Failure in Clinical Practice

OBJECTIVES

The purpose of this study was to investigate the prognostic value of change in distance walked in 6 min in chronic heart failure (CHF).

BACKGROUND

The strongest indication for the 6-min walking test (6MWT) is for measuring the response to therapeutic interventions in patients with CHF. Whether the increase in distance walked after a therapeutic intervention translates into improved clinical outcome is largely unknwon.

METHODS

We studied 476 CHF patients with left ventricular systolic dysfunction who were referred to our institution for adjustment of heart failure therapy because of persisting or worsening symptoms. Adjustment of therapy involved four classes of drugs: angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, beta-blockers, loop diuretics, and aldosterone antagonists. A standardized 6MWT was performed at baseline and at discharge.

RESULTS

After 15.2 +/- 8 days, the distance walked increased from 326 +/- 107 m to 408 +/- 109 m (+25%; p = 0.001). During a mean follow-up of 23.9 months, 94 patients died and 12 patients underwent cardiac transplantation. Among a set of variables, New York Heart Association functional class (p = 0.02), serum creatinine concentration (p = 0.01), left ventricular ejection fraction (p = 0.002), distance walked at baseline (p = 0.0002), and change in distance walked (p = 0.002) were significant independent predictors of survival. When the patients were divided into two subgroups according to the median value of the distance walked at baseline, the increase in walking distance was significantly associated with survival only in the subgroup of patients who walked <340 m at baseline.

CONCLUSIONS

Our data indicate that repeating a 6MWT after drug intervention provides independent prognostic information in CHF patients with more compromised exercise capacity.

Predictors of exercise capacity and everyday activity in older heart failure patients

BACKGROUND

Exercise capacity and daily activity are key outcomes for older, frail heart failure patients. Little is known about the determinants of these outcomes in this patient group.

AIMS

To explore predictors of exercise capacity and daily activity in older, frail heart failure patients.

METHODS

Analysis of prospectively collected data from a cohort of 82 patients aged 70 years and over, enrolled in a randomised controlled trial of exercise in heart failure patients. Pathophysiological, demographic, psychological and social factors were analysed by multivariate regression to determine predictors of exercise capacity (6-min walk distance) and daily activity (daily accelerometer counts).

RESULTS

Between 49% and 55% of the variance in 6-min walk distance was explained by variables including New York Heart Association class, depression score, attitude to ageing and use of walking aids. Only 11% to 26% of the variance in accelerometer scores was explained by the model; 6-min walk distance was the only consistent predictor of daily activity.

CONCLUSIONS

Physical, psychological and attitudinal variables contribute to variance of the 6-min walk. Six-minute walk distance predicts a small amount of the variance in daily activity, but the majority of variance in daily activity remains unexplained and requires further investigation.

Six minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review

AIMS

The 6 min walk test (6MWT) is commonly used in clinical trials to assess treatments for heart failure, but its ability to distinguish between effective and ineffective treatments is questionable. The aim of this study is to investigate, using a systematic literature review, the utility of the 6MWT as a measure of the effectiveness of treatment in randomized controlled trials of heart failure.

METHODS AND RESULTS

A literature search was performed using Medline, EMBASE, CINAHL, and Biological abstracts for randomized controlled trials that measured 6MWT between 1988 and 31 May 2004. A significant increase in 6MWT distance was observed in only 9 of 47 randomized controlled trials of pharmacological therapy; 2 of 6 trials of ACE-inhibitors; 3 of 17 trials of beta-blockers; 1 of 4 trials of digoxin; one trial of ibopamine; one trial of l-arginine; one trial of beriberine; and one trial showed superiority of captopril over flosequinan. A significant increase in 6MWT was observed in four out of six placebo-controlled trials of cardiac resynchronization. Smaller pharmacological trials with fewer centres were more likely to be positive; six out of nine positive pharmacological trials had four or less participating centres, raising the possibility of publication bias. Pharmacological trials including patients with more severe heart failure were more likely to show a significant improvement with therapy than trials of milder heart failure. Five out of seven pharmacological trials that reported an improvement in symptoms also reported an improvement in 6MWT distance. Of 30 pharmacological trials, 29 that reported no improvement in symptoms also reported no improvement in 6MWT. Using mean values in these trials, the age of patients appeared a more important determinant of 6MWT distance than New York Heart Association classification.

CONCLUSION

The 6MWT has not yet been proven to be a robust test for the identification of effective pharmacological interventions although it appears useful for the assessment of cardiac resynchronization therapy. The results of the 6MWT were concordant with changes in symptoms, suggesting that it may be used as supportive evidence for symptom benefit. The test may be of greater value in patients with more advanced heart failure, where it may function as a maximal exercise test.

Exercise training as a therapy for chronic heart failure: can older people benefit?

Despite recent advances in pharmacological therapy, chronic heart failure remains a major cause of morbidity and mortality in older people. Studies of exercise training in younger, carefully selected patients with heart failure have shown improvements in symptoms and exercise capacity and in many pathophysiological aspects of heart failure, including skeletal myopathy, ergoreceptor function, heart rate variability, endothelial function, and cytokine expression. Data on mortality and hospitalization are lacking, and effects on everyday activity, depression, and quality of life are unclear. Exercise therapy for patients with heart failure appears to be safe and has the potential to improve function and quality of life in older people with heart failure. To realize these potential benefits, exercise programs that are suitable for older, frail people need to be established and tested in an older, frail, unselected population with comorbidities.