Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials

Talking the same language on patient empowerment: Development and content validation of a taxonomy of self-management interventions for chronic conditions

CONTEXT

The literature on self-management interventions (SMIs) is growing exponentially, but it is characterized by heterogeneous reporting that limits comparability across studies and interventions. Building an SMI taxonomy is the first step towards creating a common language for stakeholders to drive research in this area and promote patient self-management and empowerment.

OBJECTIVE

To develop and validate the content of a comprehensive taxonomy of SMIs for long-term conditions that will help identify key characteristics and facilitate design, reporting and comparisons of SMIs.

METHODS

We employed a mixed-methods approach incorporating a literature review, an iterative consultation process and mapping of key domains, concepts and elements to develop an initial SMI taxonomy that was subsequently reviewed in a two-round online Delphi survey with a purposive sample of international experts.

RESULTS

The final SMI taxonomy has 132 components classified into four domains: intervention characteristics, expected patient/caregiver self-management behaviours, outcomes for measuring SMIs and target population characteristics. The two-round Delphi exercise involving 27 international experts demonstrated overall high agreement with the proposed items, with a mean score (on a scale of 1-9) per component of 8.0 (range 6.1-8.8) in round 1 and 8.1 (range 7.0-8.9) in round 2.

CONCLUSIONS

The SMI taxonomy contributes to building a common framework for the patient self-management field and can help implement and improve patient empowerment and facilitate comparative effectiveness research of SMIs. Patient or public contribution. Patients' representatives contributed as experts in the Delphi process and as partners of the consortium.

Unveiling the role of exercise training in targeting the inflammatory paradigm of heart failure with preserved ejection fraction: a narrative review

Heart failure with preserved ejection fraction (HFpEF) is currently lacking an effective pharmacological treatment with impact on major outcomes such as hospitalization and mortality. Exercise training (EXT) is recognized as an important nonpharmacological tool, capable of improving exercise capacity and quality of life, and has even been associated with a reduction in hospitalization and cardiovascular mortality risk. However, this positive impact largely lacks a physiological explanation. The aim of this narrative review was to provide an overview of the available data supporting the hypothesis that the beneficial role of EXT in HFpEF might be due to its effects on targeting the inflammatory paradigm described for this disease. A comprehensive literature search was conducted using the PubMed-NCBI database. We reviewed the effects of EXT throughout each step of the pathophysiological pathway leading to HFpEF and found clinical and/or preclinical evidence supporting the reduction of systemic inflammation, endothelial dysfunction, microvascular rarefaction, and myocardial stiffness. We also highlighted some gaps in the knowledge or topics that deserve further clarification in future studies. In conclusion, despite the scarcity of clinical studies in this population, there is compelling evidence suggesting that EXT modulates crucial aspects of the inflammatory pathway described for HFpEF and future investigation on cellular and molecular mechanisms are encouraged.

Effects of exercise training in heart failure with preserved ejection fraction: an updated systematic literature review

Physical activity is associated with a lower risk of adverse cardiovascular outcomes, including heart failure (HF). Exercise training is a class IA level recommendation in patients with stable HF, but its impact is less clear in heart failure with preserved ejection fraction (HFpEF). The aim of this study was to analyze the effects of the exercise training on cardiovascular outcomes in patients with HFpEF. A systematic literature search was conducted on the main electronic databases, proceedings of major meetings, and reference lists of the identified studies, using specific terms for only English language studies published between 2000 and 2018. We followed the PRISMA to perform our review. Quality of studies was also assessed. The systematic review identified 9 studies on 348 patients, of moderate (n = 2) to good (n = 7) quality. The training consisted of a combination of supervised in-hospital and home-based outpatient programs, including aerobic exercise, endurance and resistance training, walking, and treadmill and bicycle ergometer. Most of the protocols ranged 12-16 weeks, with a frequency of 2-3 sessions weekly, lasting 20-60 min per session. There were significant improvements in peak oxygen uptake, 6-min walking test distance, and ventilatory threshold, whereas quality of life and echocardiographic parameters improved only in some studies. Endothelial function/arterial stiffness remained unchanged. No adverse events were reported. Appropriate exercise programs are able to get a favorable cardiovascular outcome in patients with HFpEF. This could also benefit in terms of quality of life, even if more controversial. Further researches are necessary.

Cardiac rehabilitation for coronary artery disease: latest updates

PURPOSE OF REVIEW

To summarize recent innovations in cardiac rehabilitation and provide a view towards the future of cardiac rehabilitation as it adjusts to the pressures of a global pandemic.

RECENT FINDINGS

Although cardiac rehabilitation has been shown to result in a mortality benefit, research continues to enumerate the benefits of cardiac rehabilitation to patient function and quality of life in a growing range of cardiovascular diseases. In addition, new methodologies and new models of cardiac rehabilitation have emerged with the goal of increasing patient referral and participation.

SUMMARY

Cardiac rehabilitation continues to evolve and adapt to serve a growing and diversifying number of patients with cardiovascular disease with the goal of both decreasing mortality and improving patient function.

Gender differences in the prevalence of frailty in heart failure: A systematic review and meta-analysis

OBJECTIVES

This study quantitatively synthesized literature to identify gender differences in the prevalence of frailty in heart failure (HF).

BACKGROUND

The intersection of frailty and HF continues to garner interest. Almost half of patients with HF are frail; however, gender differences in frailty in HF are poorly understood.

METHODS

We performed a literature search to identify studies that reported prevalence of frailty by gender in HF. Random-effects meta-analysis was used to quantify the relative and absolute risk of frailty in women compared with men with HF, overall, and by Physical and Multidimensional Frailty measures. Meta-regression was performed to examine the influence of study age and functional class on relative risk in HF.

RESULTS

Twenty-nine studies involving 8854 adults with HF were included. Overall in HF, women had a 26% higher relative risk of being frail compared with men (95% CI = 1.14-1.38, z = 4.69, p < 0.001, I2 = 76.5%). The overall absolute risk for women compared to men with HF being frail was 10% (95% CI = 0.06-0.15, z = 4.41, p < 0.001). The relative risk of frailty was slightly higher among studies that used Physical measures (relative risk = 1.27, p < 0.001) compared with studies that used Multidimensional measures (relative risk = 1.24, p = 0.024). There were no significant relationships between relative risk and either study age or functional class.

CONCLUSIONS

In HF, frailty affects women significantly more than men. Future work should focus on elucidating potential causes of gender differences in frailty in HF.

Exercise Intolerance in Heart Failure with Preserved Ejection Fraction

Exercise intolerance represents a typical feature of heart failure with preserved ejection fraction (HFpEF), and is associated with a poor quality of life, frequent hospitalizations, and increased all-cause mortality. The cardiopulmonary exercise test is the best method to quantify exercise intolerance, and allows detection of the main mechanism responsible for the exercise limitation, influencing treatment and prognosis. Exercise training programs improve exercise tolerance in HFpEF. However, studies are needed to identify appropriate type and duration. This article discusses the pathophysiology of exercise limitation in HFpEF, describes methods of determining exercise tolerance class, and evaluates prognostic implications and potential therapeutic strategies.

Psychosocial factors, mental health, and coordination capacity in patients with heart failure with preserved ejection fraction compared with heart failure with reduced ejection fraction

Aims

Patients with heart failure (HF) suffer from reduced quality‐of‐life (QoL). We aimed to compare QoL, depression, and anxiety scores among outpatients with preserved (HFpEF) and reduced (HFrEF) ejection fraction and non‐HF controls and its relationship to coordination capacity.

Methods and results

Fifty‐five participants were recruited prospectively at the University Hospital Jena, Germany (17 HFpEF, 18 HFrEF, and 20 non‐HF controls). All participants underwent echocardiography, cardiopulmonary exercise testing (CPET), 10 m walking test (10‐MWT), isokinetic muscle function and coordination tests, and QoL assessments using the short form of health survey (SF‐36), and hospital anxiety and depression scale (HADS). Furthermore, inflammatory biomarkers such as growth differentiation factor‐15 (GDF‐15) were assessed. Patients with HFpEF showed compared with HFrEF and non‐HF controls reduced QoL [mental component score (MCS): 43.6 ± 7.1 vs. 50.2 ± 10.0 vs. 50.5 ± 5.0, P = 0.03), vitality (VT): 47.5 ± 8.4 vs. 53.6 ± 8.6 vs. 57.1 ± 5.2, P = 0.004), and elevated anxiety (6.5 ± 3.2 vs. 3.3 ± 2.8 vs. 3.8 ± 2. 8, P = 0.02) and depression scores (6.5 [3.5–10.0] vs. 3.0 [1.0–6.5] vs. 2.0 [0.75–3.0], P = 0.01)]. After adjusting to multiple comparisons, anxiety remained higher in HFpEF patients compared with HFrEF (p_post‐hoc = 0.009). HFpEF and HFrEF patients showed reduced coordination capacity compared with non‐HF controls (P < 0.05). In a logistic regression, the presence of depression score ≥8 remained an independent factor for predicting reduced coordination capacity after adjusting for peak VO₂, GDF‐15, 10‐MWT, physical component score (PCS), and peak torque of the leg [odds ratio (OR): 0.1, 95% confidence interval (CI): 0.004–0.626, P = 0.02].

Conclusion

Outpatients with HFpEF had worse QoL and higher anxiety and depression scores compared with HFrEF and non‐HF controls. Depression is associated with reduced QoL and is an independent predictor for reduced coordination capacity.

Impaired skeletal muscle fatigue resistance during cardiac hypertrophy is prevented by functional overload- or exercise-induced functional capillarity

KEY POINTS

Capillary rarefaction is hypothesized to contribute to impaired exercise tolerance in cardiovascular disease, but it remains a poorly exploited therapeutic target for improving skeletal muscle performance. Using an abdominal aortic coarctation rat model of compensatory cardiac hypertrophy, we determine the efficacy of aerobic exercise for the prevention of, and mechanical overload for, restoration of hindlimb muscle fatigue resistance and microvascular impairment in the early stages of heart disease. Impaired muscle fatigue resistance was found after development of cardiac hypertrophy, but this impairment was prevented by low-intensity aerobic exercise and recovered after mechanical stretch due to muscle overload. Changes in muscle fatigue resistance were closely related to functional (i.e. perfused) microvascular density, independent of arterial blood flow, emphasizing the critical importance of optimal capillary diffusion for skeletal muscle function. Pro-angiogenic therapies are an important tool for improving skeletal muscle function in the incipient stages of heart disease.

ABSTRACT

Microvascular rarefaction may contribute to declining skeletal muscle performance in cardiac and vascular diseases. It remains uncertain to what extent microvascular rarefaction occurs in the earliest stages of these conditions, if impaired blood flow is an aggravating factor and whether angiogenesis restores muscle performance. To investigate this, the effects of aerobic exercise (voluntary wheel running) and functional muscle overload on the performance, femoral blood flow (FBF) and microvascular perfusion of the extensor digitorum longus (EDL) were determined in a chronic rat model of compensatory cardiac hypertrophy (CCH, induced by surgically imposed abdominal aortic coarctation). CCH was associated with hypertension (P = 0.001 vs. Control) and increased relative heart mass (P < 0.001). Immediately upon placing the aortic band (i.e. before development of CCH), post-fatigue test FBF was reduced (P < 0.003), coinciding with attenuated fatigue resistance (P = 0.039) indicating an acute arterial perfusion constraint on muscle performance. While FBF was normalized during CCH in chronic groups (P > 0.05) fatigue resistance remained reduced (P = 0.039) and was associated with reduced (P = 0.009) functional capillarity after development of CCH without intervention, indicating a microvascular limitation to muscle performance. Normalization of functional capillarity after aerobic exercise (P = 0.065) and overload (P = 0.329) in CCH coincided with restoration to control levels of muscle fatigue resistance (P > 0.999), although overload-induced EDL hypertrophy (P = 0.027) and wheel-running velocity and duration (both P < 0.05) were attenuated after aortic banding. These data show that reductions in skeletal muscle performance during CCH can be countered by improving functional capillarity, providing a therapeutic target to improve skeletal muscle function in chronic diseases.

Pathophysiology of Exercise Intolerance and Its Treatment With Exercise-Based Cardiac Rehabilitation in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is the fastest growing form of heart failure in the United States. The cardinal feature of HFpEF is reduced exercise tolerance (peak oxygen uptake, (Equation is included in full-text article.)O2peak) secondary to impaired cardiac, vascular, and skeletal muscle function. There are currently no evidence-based drug therapies to improve clinical outcomes in patients with HFpEF. In contrast, exercise training is a proven effective intervention for improving (Equation is included in full-text article.)O2peak, aerobic endurance, and quality of life in HFpEF patients. This brief review discusses the pathophysiology of exercise intolerance and the role of exercise training to improve (Equation is included in full-text article.)O2peak in clinically stable HFpEF patients. It also discusses the mechanisms responsible for the exercise training-mediated improvements in (Equation is included in full-text article.)O2peak in HFpEF. Finally, it provides evidence-based exercise prescription guidelines for cardiac rehabilitation specialists to assist them with safely implementing exercise-based cardiac rehabilitation programs for HFpEF patients.

Aerobic Exercise-Assisted Cardiac Regeneration by Inhibiting Tryptase Release in Mast Cells after Myocardial Infarction

Background

Cardiovascular disease (CVD) contributes critically to the mortality, morbidity, and economic problem of illness globally. Exercise is a share of everyone's life. Some evidence-based studies have frequently shown a progressive correlation between physical activity and good health.

Objective

The effects of daily exercise on cardiomyocyte size, collagen content (fibrosis), and releasing mast cells (MCsʼ) tryptase of the model of myocardial infarction (MI) were assessed.

Methods

40 rats were coincidentally spread into sham+inertia (control), sham+exercise, infarction+inertia, and infarction+exercise groups. An experimental model of acute MI was induced in infarction groups. One week after surgery, exercising groups were allowed to an aerobic exercise program for six weeks. At the endpoint of the study, all examinations were performed.

Results

We found lesser fibrosis in sham+exercise and infarction+exercise groups compared to sham+inertia and infarction+inertia groups, respectively (p = 0.023, p = 0.001). Also, infarction groups were significantly lower than sham groups (p < 0.05) and the infarction+exercise group was significantly lower than the infarction+inertia group (p < 0.05). The effect of exercise on MCs while increased MC density and degranulation occur at the site of fibrosis, we demonstrated that exercise decreases both total MC density and degranulation in both sham and infarction groups (p < 0.05). Immunohistochemistry examinations were significantly higher expression of MCsʼ tryptase in infarction groups than sham groups (p < 0.05, p < 0.0001).

Conclusion

Exercise improves fibrosis and cardiac function in both healthy and MI rats by inhibiting released MCsʼ tryptase.

Aspartate aminotransferase to alanine aminotransferase ratio is associated with frailty and mortality in older patients with heart failure

Frailty is a common comorbidity associated with adverse events in patients with heart failure, and early recognition is key to improving its management. We hypothesized that the AST to ALT ratio (AAR) could be a marker of frailty in patients with heart failure. Data from the FRAGILE-HF study were analyzed. A total of 1327 patients aged ≥ 65 years hospitalized with heart failure were categorized into three groups based on their AAR at discharge: low AAR (AAR < 1.16, n = 434); middle AAR (1.16 ≤ AAR < 1.70, n = 487); high AAR (AAR ≥ 1.70, n = 406). The primary endpoint was one-year mortality. The association between AAR and physical function was also assessed. High AAR was associated with lower short physical performance battery and shorter 6-min walk distance, and these associations were independent of age and sex. Logistic regression analysis revealed that high AAR was an independent marker of physical frailty after adjustment for age, sex and body mass index. During follow-up, all-cause death occurred in 161 patients. After adjusting for confounding factors, high AAR was associated with all-cause death (low AAR vs. high AAR, hazard ratio: 1.57, 95% confidence interval, 1.02–2.42; P = 0.040). In conclusion, AAR is a marker of frailty and prognostic for all-cause mortality in older patients with heart failure.

The importance of physical activity and cardiorespiratory fitness for patients with heart failure

The present review highlights current research on the importance of PA and fitness for patients with heart failure and recommendations with respect to heart failure phenotypes and special populations. Furthermore, the evidence for various exercise types and intensities/doses as an "exercise prescription", are discussed. The strong association between heart failure and traditional risk factors, physical inactivity and low fitness, underlines the importance of regular PA and exercise for prevention and treatment of heart failure. This is illustrated by cardiac stiffness which typically accelerates in middle-life and could be reversed by aerobic exercise. In patients with HFpEF, regular PA counteracts many of the changes observed, both metabolic and functional. Indeed, exercise-based cardiac rehabilitation has received a class 1A recommendation in current guidelines [1], in order to improve functional capacity, quality of life and lower the risk of rehospitalization. An individually tailored plan based on risk stratification, clinical assessment and cardiopulmonary exercise testing is encouraged before initiation of exercise training in patients with heart failure. In general, a combination of aerobic exercise and resistance training protocols is recommended (Table 1) [2], preferably throughout life. More studies are needed, regarding the role of PA and exercise in specific populations, such as frail patients with heart failure.

Relationships Between Objectively Measured Physical Activity, Exercise Capacity, and Quality of Life in Older Patients With Obese Heart Failure and Preserved Ejection Fraction

BACKGROUND

The relationship between physical activity (PA), exercise capacity, and quality of life (QOL) in obese heart failure with preserved ejection fraction is poorly understood.

METHODS AND RESULTS

This was an ancillary study to a clinical trial. Accelerometers were used to measure light PA, moderate to vigorous PA, total PA, PA energy expenditure, and steps. Peak VO₂, exercise time, and 6-minute walk distance, as well as QOL measures were obtained. Pearson correlations were performed to examine relationships between PA, exercise capacity, and QOL. Patients (n = 58) were 68.0 ± 5.7 years old, 78% female, 59% White, and obese (body mass index 39.1 ± 6.1 kg/m²). Patients had low levels of objectively measured PA as well as decreased exercise capacity and poor QOL. Light PA (r = 0.32, P = .014) and steps per day (r = 0.30, P = .022) were modestly correlated with peak VO₂. All PA variables were modestly correlated with exercise time (r = 0.33-0.49, all P < .02) and 6-minute walk distance (r = 0.25-0.48, all P < .01). None of the PA variables were correlated with QOL.

CONCLUSIONS

PA variables were modestly correlated with measures of exercise capacity and were not significantly correlated with QOL. Our findings indicate that PA, exercise capacity, and QOL assess different aspects of the patient experience in older obese patients with heart failure with preserved ejection fraction.

Cellular and molecular pathobiology of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) affects half of all patients with heart failure worldwide, is increasing in prevalence, confers substantial morbidity and mortality, and has very few effective treatments. HFpEF is arguably the greatest unmet medical need in cardiovascular disease. Although HFpEF was initially considered to be a haemodynamic disorder characterized by hypertension, cardiac hypertrophy and diastolic dysfunction, the pandemics of obesity and diabetes mellitus have modified the HFpEF syndrome, which is now recognized to be a multisystem disorder involving the heart, lungs, kidneys, skeletal muscle, adipose tissue, vascular system, and immune and inflammatory signalling. This multiorgan involvement makes HFpEF difficult to model in experimental animals because the condition is not simply cardiac hypertrophy and hypertension with abnormal myocardial relaxation. However, new animal models involving both haemodynamic and metabolic disease, and increasing efforts to examine human pathophysiology, are revealing new signalling pathways and potential therapeutic targets. In this Review, we discuss the cellular and molecular pathobiology of HFpEF, with the major focus being on mechanisms relevant to the heart, because most research has focused on this organ. We also highlight the involvement of other important organ systems, including the lungs, kidneys and skeletal muscle, efforts to characterize patients with the use of systemic biomarkers, and ongoing therapeutic efforts. Our objective is to provide a roadmap of the signalling pathways and mechanisms of HFpEF that are being characterized and which might lead to more patient-specific therapies and improved clinical outcomes.

Temporal Trends and Factors Associated With Cardiac Rehabilitation Participation Among Medicare Beneficiaries With Heart Failure

OBJECTIVES

The purpose of this study was to assess temporal trends and factors associated with cardiac rehabilitation (CR) enrollment and participation among Medicare beneficiaries after the 2014 Medicare coverage expansion.

BACKGROUND

CR improves exercise capacity, quality of life, and clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). In 2014, Medicare coverage for CR was expanded to include chronic HFrEF.

METHODS

Among Medicare beneficiaries from quarter (Q) 1 2014 to Q2 2016, 11,696 patients from 14,258 hospitalizations with primary discharge diagnosis of HF were identified. Patients with HF with preserved ejection fraction were excluded. Quarterly CR participation rates among hospitalized HF patients within 6 months of discharge were identified through outpatient administrative claims. The predictors of CR participation were assessed with the use of a multivariable logistic regression model that included patient- and hospital-level characteristics. A secondary analysis to assess participation rates of CR after outpatient encounters for HF was performed.

RESULTS

Overall, only 611 (4.3%) and 349 (2.2%) eligible patients participated CR after primary hospitalization or outpatient visit for HF, respectively. There was a modest, statistically significant increase in CR participation after HF admissions (2.8% in Q1 2014; 5.0% in Q2 2016; p < 0.001) without significant increase after outpatient visits for HF (2.6% to 3.8%; p = 0.21). Younger age, male sex, nonblack race, previous cardiovascular procedures, and hospitalization at hospitals with available CR facilities were all independently associated with CR participation.

CONCLUSIONS

CR participation among eligible Medicare beneficiaries with HFrEF was low with minimal increase since 2014 Medicare coverage decision. Sex, race, and institution-dependent variables were independent predictors of CR participation.

Salutary Acute Effects of Exercise on Central Hemodynamics in Heart Failure With Preserved Ejection Fraction

BACKGROUND

A warmup period of priming exercise has been shown to improve peripheral oxygen transport in older adults. We sought to determine the acute effects of priming exercise on central hemodynamics at rest and during a repeat exercise in heart failure with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

This is a post hoc analysis from 3 studies. Patients with HFpEF (n = 42) underwent cardiac catheterization with simultaneous expired gas analysis at rest and during exercise (20 W for 5 minutes, priming exercise). Measurements were then repeated at rest and during a second bout of exercise at a 20-W workload (second exercise). During the priming exercise, patients with HFpEF displayed dramatic increases in biventricular filling pressures and exercise-induced pulmonary hypertension. After the priming exercise at rest, biventricular filling pressures and pulmonary artery (PA) pressures were lower and lung tidal volume was increased. During the second bout of exercise, biventricular filling (PA wedge pressure, 29 ± 8 mm Hg at second exercise vs 32 ± 7 mm Hg at first exercise, P = .0003) and PA pressures were lower, and PA compliance increased.

CONCLUSIONS

This study shows that short duration, submaximal priming exercise attenuates the pathologic increases in filling pressures, improving pulmonary vascular hemodynamics at rest and during repeat exercise in patients with HFpEF.

Carvedilol and exercise combination therapy improves systolic but not diastolic function and reduces plasma osteopontin in Col4a3-/- Alport mice

There are currently no Food and Drug Administration-approved treatments for heart failure with preserved ejection fraction (HFpEF). Here we compared the effects of exercise with and without α/β-adrenergic blockade with carvedilol in Col4a3-/- Alport mice, a model of the phenogroup 3 subclass of HFpEF with underlying renal dysfunction. Alport mice were assigned to the following groups: no treatment control (n = 29), carvedilol (n = 11), voluntary exercise (n = 9), and combination carvedilol and exercise (n = 8). Cardiac function was assessed by echocardiography after 4-wk treatments. Running activity of Alport mice was similar to wild types at 1 mo of age but markedly reduced at 2 mo (1.3 ± 0.40 vs. 4.5 ± 1.02 km/day, P < 0.05). There was a nonsignificant trend for increased running activity at 2 mo by carvedilol in the combination treatment group. Combination treatments conferred increased body weight of Col4a3-/- mice (22.0 ± 1.18 vs. 17.8 ± 0.29 g in untreated mice, P < 0.01), suggesting improved physiology, and heart rates declined by similar increments in all carvedilol-treatment groups. The combination treatment improved systolic parameters; stroke volume (30.5 ± 1.99 vs. 17.8 ± 0.77 μL, P < 0.0001) as well as ejection fraction and global longitudinal strain compared with controls. Myocardial performance index was normalized by all interventions (P < 0.0001). Elevated osteopontin plasma levels in control Alport mice were significantly lowered only by combination treatment, and renal function of the Alport group assessed by urine albumin creatinine ratio was significantly improved by all treatments. The results support synergistic roles for exercise and carvedilol to augment cardiac systolic function of Alport mice with moderately improved renal functions but no change in diastole.NEW & NOTEWORTHY In an Alport mouse model of heart failure with preserved ejection fraction (HFpEF), exercise and carvedilol synergistically improved systolic function without affecting diastole. Carvedilol alone or in combination with exercise also improved kidney function. Molecular analyses indicate that the observed improvements in cardiorenal functions were mediated at least in part by effects on serum osteopontin and related inflammatory cytokine cascades. The work presents new potential therapeutic targets and approaches for HFpEF.

Multidomain Frailty in Heart Failure: Current Status and Future Perspectives

PURPOSE OF REVIEW

With a worldwide aging population, frailty and heart failure (HF) have become issues that need to be addressed urgently in cardiovascular clinical practice. In this review, we outline the clinical implications of frailty in HF patients and the potential therapeutic strategies to improve the clinical outcomes of frail patients with HF.

RECENT FINDINGS

Frailty has physical, psychological, and social domains, each of which is a prognostic determinant for patients with HF, and each domain overlaps with the other, although there are no standardized criteria for diagnosing frailty. Frailty can be targeted for treatment with various interventions, and recent studies have suggested that multidisciplinary intervention could be a promising option for frail patients with HF. However, currently, there is limited data, and further research is needed before its clinical implementation. Frailty and HF share a common background and are strongly associated with each other. More comprehensive assessment and therapeutic interventions for frailty need to be developed to further improve the prognosis and quality of life of frail patients with HF.

Invasive Hemodynamic and Metabolic Evaluation of HFpEF

Purpose of review

Heart failure with preserved ejection fraction (HFpEF) is a complex and heterogeneous condition of multiple causes, characterized by a clinical syndrome resulting from elevated left ventricular filling pressures, with an apparently unimpaired left ventricular systolic function. Although HFpEF has been long recognized as a distinct entity with significant morbidity for patients, its diagnosis remains challenging to this day. In recent years, few diagnostic algorithms have been postulated to aid in the identification of this condition. Invasive hemodynamic and metabolic evaluation is often warranted for the conclusive diagnosis and risk stratification of HFpEF, in patients presenting with undifferentiated DOE.

Recent findings

Rest and provoked hemodynamics remain the golden-standard diagnostic tool to unequivocally confirm the diagnosis of both established and incipient HFpEF, respectively. Cycle exercise hemodynamics is the paramount provocative maneuver to unveil this condition. Rapid saline loading does not offer a significant benefit over that of cycle exercise. Vasoactive agents can also uncover and confirm incipient HFpEF disease. The role of metabolic evaluation in patients presenting with idiopathic dyspnea on exertion (DOE) is of unparalleled value for those who have expertise in cardiopulmonary exercise test (CPET) interpretation; however, the average clinician who focuses solely on oxygen consumption will find it underwhelming. Invasive CPET stands alone as the ultimate diagnostic tool to discriminate between pulmonary, cardiovascular, and skeletal muscle disorders, and their respective contribution to DOE and exercise intolerance.

Summary

Several hemodynamic and metabolic parameters have demonstrated not only strong diagnostic value, but also predictive power in HFpEF. Additionally, these diagnostic methods have given rise to several therapeutic interventions that are now part of our clinical armamentarium. Regrettably, due to the heterogeneity and multicausality of HFpEF, none of the targeted interventions have been so far successful in decreasing the mortality burden of this prevalent condition.

Narrative review: the holy grail: update on pharmacotherapy for heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is the presence of clinical signs and/or symptoms of heart failure with a left ventricular ejection fraction (LVEF) ≥50%. Risk factors associated with this disease include hypertension, hyperlipidemia, atrial fibrillation (AF), obesity, diabetes and coronary artery disease (CAD). Despite the multiple risk factors identified for this condition, treatment and management remain challenging and a subject of ongoing research. Since a treatment approach that alters the natural course or lowers mortality for this disease has not been found, treating co-morbidities and symptom management is essential. From the comorbidities, hypertension is identified as the main risk factor for disease development. Thus, after congestive symptom control with diuretics, blood pressure (BP) management is considered one of the most important preventive measures and also a target for treatment. Amongst antihypertensives, angiotensin receptor blockers (ARBs) and aldosterone antagonists are the therapeutic agents used that have a role in reducing hospitalizations. Implantable monitoring devices have also been shown to reduce hospitalizations in comparison to standard heart failure therapies by allowing to tailor diuretic therapy based on ongoing hemodynamic data. In this manuscript we discuss pharmacologic strategies for HFpEF patients by risk factors, including those with and without a potential role.

Cardiac Rehabilitation for Patients With Heart Failure: JACC Expert Panel

Cardiac rehabilitation is defined as a multidisciplinary program that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Exercise training and other components of cardiac rehabilitation (CR) are safe and beneficial and result in significant improvements in quality of life, functional capacity, exercise performance, and heart failure (HF)-related hospitalizations in patients with HF. Despite outcome benefits, cost-effectiveness, and strong practice guideline recommendations, CR remains underused. Clinicians, health care leaders, and payers should prioritize incorporating CR as part of the standard of care for patients with HF.

Daily Consumption of a Specially Formulated Essential Amino Acid-Based Dietary Supplement Improves Physical Performance in Older Adults With Low Physical Functioning

We have investigated the hypothesis that nutritional supplementation of the diet in low-physical-functioning older individuals with a specially formulated composition based on essential amino acids (EAAs) would improve physical function as compared to supplementation with the same amount of whey protein. A third group of comparable volunteers were given nutrition education but no supplementation of the diet. After 6 weeks of whey protein supplementation (n = 32), there was no effect on the distance walked in 6 minutes, but the distance walked improved significantly from the pre-value after 12 weeks of whey supplementation. EAA consumption (n = 28) significantly improved walking distance at both 6 and 12 weeks. The distance walked at 12 weeks (419.0 ± 25.0 m) was 35.4 m greater than the pre-value of 384.0 ± 23.0 m (p < .001). The increase in distance walked by the EAA group was also significantly greater than that in the whey group at both 6 and 12 weeks (p < .01). In contrast, a decrease in distance walked was observed in the control group (n = 32) (not statistically significant, NS). EAA supplementation also improved grip strength and leg strength, and decreased body weight and fat mass. Plasma low-density lipoprotein concentration was significantly reduced in the EAA group, as well as the concentration of macrophage migration inhibitory factor. There were no adverse responses in any groups, and compliance was greater than 95% in all individuals consuming supplements. We conclude that dietary supplementation with an EAA-based composition may be a beneficial therapy in older individuals with low physical functional capacity. Clinical Trials Registration Number: This study was registered with ClinicalTrials.gov: NCT03424265-"Nutritional interventions in heart failure."

Potential Beneficial Effects of Dietary Protein Supplementation and Exercise on Functional Capacity in a Pilot Study of Individuals with Heart Failure with Preserved Ejection Fraction

Approximately half of heart failure patients in the US have heart failure with preserved ejection fraction (HFpEF). HFpEF impairs physical performance and thus reduces quality of life. Increasing dietary protein intake can increase lean body mass and physical performance in healthy elderly individuals, but the effect of a high-quality protein supplement, with or without a structured exercise program, has not been investigated in HFpEF patients. Twenty-three obese elderly HFpEF patients with grade 1 or 2 diastolic dysfunction were randomized into three groups: control, protein supplementation alone, and protein plus exercise. Protein supplementation involved providing sufficient whey protein so that total intake was 1.2 g protein/kg/day. The exercise intervention was 2 days of hydrotherapy and 1 day of gym sessions per week under supervision of a fitness expert. Physical parameters and functional tests were performed at baseline and at 12 weeks. Protein supplementation alone failed to improve physical performance. However, when combined with light exercise, there was significant improvement in some (6-minute walk, 10 m walking speed, quadriceps strength), but not all, physical function measurements. The results of this pilot study suggest that further exploration of potential interactive effects between protein supplementation and light exercise in individuals with HFpEF is warranted.

Mitochondrial Dysfunction and Heart Disease: Critical Appraisal of an Overlooked Association

The myocardium is among the most energy-consuming tissues in the body, burning from 6 to 30 kg of ATP per day within the mitochondria, the so-called powerhouse of the cardiomyocyte. Although mitochondrial genetic disorders account for a small portion of cardiomyopathies, mitochondrial dysfunction is commonly involved in a broad spectrum of heart diseases, and it has been implicated in the development of heart failure via maladaptive circuits producing and perpetuating mitochondrial stress and energy starvation. In this bench-to-bedside review, we aimed to (i) describe the key functions of the mitochondria within the myocardium, including their role in ischemia/reperfusion injury and intracellular calcium homeostasis; (ii) examine the contribution of mitochondrial dysfunction to multiple cardiac disease phenotypes and their transition to heart failure; and (iii) discuss the rationale and current evidence for targeting mitochondrial function for the treatment of heart failure, including via sodium-glucose cotransporter 2 inhibitors.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Cardiac Rehabilitation in Heart Failure

Heart failure (HF) is a complex clinical syndrome caused by a structural and/or functional cardiac abnormality, resulting in reduced organ perfusion. The goals of treatment in patients with HF are to improve functional capacity and quality of life, and to reduce mortality. Cardiac rehabilitation (CR) including exercise training is one of the treatment options, and current guidelines recommend CR as safe and effective for patients with HF. CR has been known to improve exercise capacity and quality of life, minimize HF progression, and lower mortality in patients with HF. Improvement of vascular endothelial function, activation of the neurohormonal system, increase of mitochondrial oxygen utilization in peripheral muscles, and increase of chronotropic responses are possible mechanisms of the beneficial effects of exercise-based CR in HF. Although CR has been shown to decrease morbidity and mortality, it is underutilized in clinical practice. Despite the existence of concrete evidence of clinical benefits, the CR participation rates of patients with HF range from only 14% to 43% worldwide, with high dropout rates after enrollment. These low participation rates have been attributed to several barriers, including patient factors, professional factors, and service factors. The motivation for participating in CR and for overcoming the patients' barriers for CR before discharge should be provided to each patient. Current guidelines strongly recommend applying a CR program to all eligible patients with HF.

Predicting maximal oxygen uptake from the 6 min walk test in patients with heart failure

Aims

A cardiopulmonary exercise (CPX) test is considered the gold standard in evaluating maximal oxygen uptake. This study aimed to evaluate the predictive validity of equations provided by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. in predicting peak VO₂ from 6 min walk test (6MWT) distance in patients with heart failure (HF).

Methods and Results

New York Heart Association Class I–III HF patients performed a maximal effort CPX test and two 6MWTs. Correlations between CPX VO_{2 peak} and the predicted VO_{2 peak}, coefficient of determination (R²), and mean absolute percentage error (MAPE) scores were calculated. P‐values were set at 0.05. A total of 106 participants aged 62.5 ± 11.5 years completed the tests. The mean VO_{2 peak} from CPX testing was 16.4 ± 3.9 mL/kg/min, and the mean 6MWT distance was 419.2 ± 93.0 m. The predicted mean VO_{2 peak} (mL/kg/min) by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. was 22.8 ± 8.8, 14.6 ± 2.1, 8.30 ± 1.4, and 16.6 ± 2.8. A significant correlation was observed between the CPX test VO_{2 peak} and predicted values. The mean difference (0.1 mL/kg/min), R² (0.97), and MAPE (0.14) values suggest that the Cahalin et al. equation provided the best predictive validity.

Conclusions

The equation provided by Cahalin et al. is simple and has a strong predictive validity, and researchers may use the equation to predict mean VO_{2 peak} in patients with HF. Based on our observation, equations to predict individual maximal oxygen uptake should be used cautiously.

Current Studies and Future Directions of Exercise Therapy for Muscle Atrophy Induced by Heart Failure

Muscle atrophy is a common complication of heart failure. At present, there is no specific treatment to reverse the course of muscle atrophy. Exercise training, due to the safety and easy operation, is a recommended therapy for muscle atrophy induced by heart failure. However, the patients with muscle atrophy are weak in mobility and may not be able to train for a long time. Therefore, it is necessary to explore novel targets of exercise protection for muscle atrophy, so as to improve the quality of life and survival rate of patients with muscular atrophy induced by heart failure. This article aims to review latest studies, summarize the evidence and limitations, and provide a glimpse into the future of exercise for the treatment of muscle atrophy induced by heart failure. We wish to highlight some important findings about the essential roles of exercise sensors in muscle atrophy induced by heart failure, which might be helpful for searching potential therapeutic targets for muscle wasting induced by heart failure.

Pulmonary haemodynamic effects of interatrial shunt in heart failure with preserved ejection fraction: a preclinical study

AIMS

The aim of this study was to evaluate the effect of the creation of a left-to-right interatrial shunt on pulmonary haemodynamics in rats with heart failure with preserved ejection fraction (HFPEF).

METHODS AND RESULTS

An interatrial communication (IAC) was created in 11 healthy rats (Lewis rats) and 11 rats which developed HFPEF (36-week-old spontaneously hypertensive rats [SHR]). Effects of the interatrial shunt were compared to 11 sham-operated Lewis and 11 sham-operated SHR. At 45 days post shunt, strain effect was observed in diastolic function (E/A ratio, p<0.001; isovolumetric relaxation time, p<0.001), left atrial volume (p=0.005) and pulmonary wall shear rate (WSR) (p=0.02) measured by Doppler echo. At sacrifice of the animals (60 days), a strain effect was also noted in elastin density (p=0.003) and eNOS protein expression (p=0.001). Interatrial shunt creation resulted in (i) an increase in pulmonary WSR (p=0.04) and a decrease in left atrial volume (p<0.001), (ii) an increase in elastin density (p<0.005), and (iii) an increase in eNOS protein expression (p=0.03).

CONCLUSIONS

Creation of a left-to-right atrial shunt in rats with HFPEF was effective in improving pulmonary haemodynamics. In addition, this study provides preliminary evidence of the potential risk of right volume overload and pulmonary hypertension due to atrial shunting.

Cardiovascular responses to rhythmic handgrip exercise in heart failure with preserved ejection fraction

Although the contribution of noncardiac complications to the pathophysiology of heart failure with preserved ejection fraction (HFpEF) have been increasingly recognized, disease-related changes in peripheral vascular control remain poorly understood. We utilized small muscle mass handgrip exercise to concomitantly evaluate exercising muscle blood flow and conduit vessel endothelium-dependent vasodilation in individuals with HFpEF (n = 25) compared with hypertensive controls (HTN) (n = 25). Heart rate (HR), stroke volume (SV), cardiac output (CO), mean arterial pressure (MAP), brachial artery blood velocity, and brachial artery diameter were assessed during progressive intermittent handgrip (HG) exercise [15-30-45% maximal voluntary contraction (MVC)]. Forearm blood flow (FBF) and vascular conductance (FVC) were determined to quantify the peripheral hemodynamic response to HG exercise, and changes in brachial artery diameter were evaluated to assess endothelium-dependent vasodilation. HR, SV, and CO were not different between groups across exercise intensities. However, although FBF was not different between groups at the lowest exercise intensity, FBF was significantly lower (20-40%) in individuals with HFpEF at the two higher exercise intensities (30% MVC: 229 ± 8 versus 274 ± 23 ml/min; 45% MVC: 283 ± 17 versus 399 ± 34 ml/min, HFpEF versus HTN). FVC was not different between groups at 15 and 30% MVC but was ∼20% lower in HFpEF at the highest exercise intensity. Brachial artery diameter increased across exercise intensities in both HFpEF and HTN, with no difference between groups. These findings demonstrate an attenuation in muscle blood flow during exercise in HFpEF in the absence of disease-related changes in central hemodynamics or endothelial function.NEW & NOTEWORTHY The current study identified, for the first time, an attenuation in exercising muscle blood flow during handgrip exercise in individuals with heart failure with preserved ejection fraction (HFpEF) compared with overweight individuals with hypertension, two of the most common comorbidities associated with HFpEF. These decrements in exercise hyperemia cannot be attributed to disease-related changes in central hemodynamics or endothelial function, providing additional evidence for disease-related vascular dysregulation, which may be a predominant contributor to exercise intolerance in individuals with HFpEF.

An evidence-based structured one-year programme to sustain physical activity in patients with heart failure in primary care: A non-randomized longitudinal feasibility study

Aim

The primary objective of this non-randomized feasibility study was to test a 1-year model programme for sustaining/increasing patients' motivation to perform daily physical activity.

Design

Non-randomized longitudinal feasibility study with a one-group repeated measures design.

Methods

The study took place at a primary care centre in mid-Sweden in 2017-2018. The model programme included individual and group-based support, individualized physical activity prescriptions, a wrist-worn activity tracker and an activity diary. The main outcomes were the participants' perceptions of programme feasibility and scores on the Exercise Self-Efficacy Scale.

Results

Seven patients were recruited. Six patients completed the programme that was perceived to imply learning, motivation and support. Compared with baseline, the median score of the Exercise Self-Efficacy Scale improved 3 months after participants completed the programme.

Diagnosis and Management of Patients with Heart Failure with Preserved Ejection Fraction (HFpEF): Current Perspectives and Recommendations

Heart failure with preserved ejection fraction (HFpEF) is a major global public health problem. Diagnosis of HFpEF is still challenging and built based on the comprehensive echocardiographic analysis. Currently, there are no universally accepted therapies that alter the clinical course of HFpEF. This review attempts to summarize the current advances in the diagnosis of HFpEF and provide future directions of the patients´ management with this very widespread, heterogeneous clinical syndrome.

Exercise Training in Patients With Heart Failure With Preserved Ejection Fraction: A Community Hospital Pilot Study

BACKGROUND

Patients with heart failure with preserved ejection fraction (HFpEF) experience poor exercise tolerance and quality of life. Little is known about the feasibility or effects of HFpEF exercise training (ET) in a community hospital setting.

OBJECTIVE

The aim of this study was to examine the feasibility and pilot data of a community-based HFpEF ET intervention.

METHODS

This was a single-group (n = 16), pretest-posttest, 9-week ET intervention. The Minnesota Living With Heart Failure Questionnaire, Patient Health Questionnaire-9, cardiopulmonary exercise test (peak VO2), and 6-minute walk test were used for evaluation.

RESULTS

Participants (n = 16) attended 88% of prescribed ET sessions and 94% completed all pretest-posttest assessments. Significant improvements in Minnesota Living With Heart Failure Questionnaire (P = .01), Patient Health Questionnaire-9 (P ≤ .01), exercise test time (P = .01) and 6-minute walk test (P = .001), but not in peak VO2 (P = .16), were found.

CONCLUSIONS

The ET intervention was feasible and safe, and findings support improved quality of life, depressive symptoms, and exercise tolerance. Larger controlled trials are warranted.

Effect of renin-angiotensin system inhibition on cardiac structure and function and exercise capacity in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials

Targeting the renin-angiotensin system (RAS) pathways has been considered a logical intervention for patients with heart failure with preserved ejection fraction (HFpEF), due to its hypothesized link to left ventricular (LV) remodeling. Although the effects of RAS inhibitors including angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) on LV structure and function and exercise capacity in HFpEF patients have been examined in multiple randomized controlled trials (RCTs), results are inconsistent due partly to limited power. We conducted a meta-analysis of RCTs on the effects of RAS inhibitors on LV structure and function as well as exercise capacity in HFpEF patients. The search of electronic databases identified 7 trials including 569 patients; 4 trials were on ACE-Is; 2 on ARBs; and 1 on DRIs. Follow-up duration ranged across trials from 12 to 52 weeks. The pooled analysis showed that RAS inhibitors significantly increased EF compared with control (weighted mean difference [95% CI] = 2.182 [0.462, 3.901] %). In contrast, RAS inhibitors did not significantly change the ratio of peak early to late diastolic mitral inflow velocities (weighted mean difference [95% CI] = 0.046 [- 0.012, 0.105]), early diastolic mitral annular velocity (0.327 [- 0.07, 0.725] cm/s), the ratio of early diastolic mitral inflow to annular velocities (0.291 [- 0.937, 1.518]), LV mass (- 6.254 [- 15.165, 2.656] g), or 6-min walk distance (1.972 [- 14.22, 18.163] m) compared with control. The present meta-analysis suggests that RAS inhibitors may increase LVEF in HFpEF patients.

Abnormalities of Skeletal Muscle, Adipocyte Tissue, and Lipid Metabolism in Heart Failure: Practical Therapeutic Targets

Chronic diseases, including heart failure (HF), are often accompanied with skeletal muscle abnormalities in both quality and quantity, which are the major cause of impairment of the activities of daily living and quality of life. We have shown that skeletal muscle abnormalities are a hallmark of HF, in which metabolic pathways involving phosphocreatine and fatty acids are largely affected. Not only in HF, but the dysfunction of fatty acid metabolism may also occur in many chronic diseases, such as arteriosclerosis, as well as through insufficient physical exercise. Decreased fatty acid catabolism affects adenosine triphosphate (ATP) production in mitochondria, via decreased activity of the tricarboxylic acid cycle; and may cause abnormal accumulation of adipose tissue accompanied with hyperoxidation and ectopic lipid deposition. Such impairments of lipid metabolism are in turn detrimental to skeletal muscle, which is hence a chicken-and-egg problem between skeletal muscle and HF. In this review, we first discuss skeletal muscle abnormalities in HF, including sarcopenia; particularly their association with lipid metabolism and adipose tissue. On the other hand, the precise mechanisms involved in metabolic reprogramming and dysfunction are beginning to be understood, and an imbalance of daily nutritional intake of individuals has been found to be a causative factor for the development and worsening of HF. Physical exercise has long been known to be beneficial for the prevention and even treatment of HF. Again, the molecular mechanisms by which exercise promotes skeletal muscle as well as cardiac muscle functions are being clarified by recent studies. We propose that it is now the time to develop more “natural” methods to prevent and treat HF, rather than merely relying on drugs and medical interventions. Further analysis of the basic design of and molecular mechanisms involved in the human body, particularly the inextricable association between physical exercise and the integrity and functional plasticity of skeletal and cardiac muscles is required.

Effects of exercise training on cardiac function, exercise capacity, and quality of life in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials

Left ventricular (LV) diastolic dysfunction is associated with the pathophysiology of heart failure with preserved ejection fraction (HFpEF) and contributes importantly to exercise intolerance that results in a reduced quality of life (QOL) in HFpEF patients. Although the effects of exercise training on LV diastolic function, exercise capacity, or QOL in HFpEF patients have been examined in randomized clinical trials (RCTs), results are inconsistent due partly to limited power with small sample sizes. We aimed to conduct a meta-analysis of RCTs examining the effects of exercise training on LV diastolic function and exercise capacity as well as QOL in HFpEF patients. The search of electronic databases identified 8 RCTs with 436 patients. The duration of exercise training ranged from 12 to 24 weeks. In the pooled analysis, exercise training improved peak exercise oxygen uptake (weighted mean difference [95% CI], 1.660 [0.973, 2.348] ml/min/kg), 6-min walk distance (33.883 [12.384 55.381] m), and Minnesota Living With Heart Failure Questionnaire total score (9.059 [3.083, 15.035] point) compared with control. In contrast, exercise training did not significantly change early diastolic mitral annular velocity (weighted mean difference [95% CI], 0.317 [- 0.952, 1.587] cm/s), the ratio of early diastolic mitral inflow to annular velocities (- 1.203 [- 4.065, 1.658]), or LV ejection fraction (0.850 [- 0.128, 1.828] %) compared with control. In conclusion, the present meta-analysis suggests that exercise training improves exercise capacity and QOL without significant change in LV systolic or diastolic function in HFpEF patients.

Management of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction is a highly heterogenous disease. There is emerging evidence that treatment should be tailored to the individual’s associated comorbidities

No current algorithms exist for the management of heart failure with preserved ejection fraction. Conventional therapies used in heart failure with reduced ejection fraction are yet to show a mortality benefit

Key treatment objectives include control of hypertension and fluid balance

Common comorbidities include coronary artery disease, atrial fibrillation, obesity, diabetes, renal impairment and pulmonary hypertension. These comorbidities should be considered in all patients and treatment optimised

Heart failure disease management: a systematic review of effectiveness in heart failure with preserved ejection fraction

AIMS

Heart failure with preserved ejection fraction (HFpEF) poses a substantial challenge for clinicians, but there is little guidance for effective management. The aim of this systematic review was to determine if there was evidence that disease management programmes (DMPs) improved outcomes for patients with HFpEF.

METHODS AND RESULTS

A systematic review of controlled studies in English or Greek of DMPs including patients with HFpEF from 2008 to 2018 was conducted using CINAHL, Cochrane, MEDLINE, and Embase. Interventions were assessed using a DMP taxonomy and scored for complexity and intensity. Bias was assessed using the Cochrane Collaboration tool. Initial and updated searches found 6089 titles once duplicates were removed. The final analysis included 18 studies with 5435 HF patients: 1866 patients (34%, study ranges 18-100%) had potential HFpEF (limited by variable definitions). Significant heterogeneity in terms of the population, intervention, comparisons, and outcomes prohibited meta-analysis. Statistically significant or positive trends were found in mortality, hospitalization rates, self-care ability, quality of life, anxiety, depression, and sleep, but findings were not robust or consistent. Four studies reported results separately for study-defined HFpEF, with two finding less positive effect on outcomes.

CONCLUSIONS

Varying definitions of HFpEF used in studies are a substantial limitation in interpretation of findings. The reduced efficacy noted in contemporary HF DMP studies may not only be due to improvements in usual care but may also reflect inclusion of heterogeneous patients with HFpEF or HF with mid-range EF who may not respond in the same way as HFrEF to individual components. Given that patients with HFpEF are older and multi-morbid, DMPs targeting HFpEF should not rely on a single-disease focus but provide care that addresses predisposing and presentation phenotypes and draws on the principles of comprehensive geriatric assessment. Other components could also be more targeted to HFpEF such as modification of lifestyle factors for which there is emerging evidence, rather than simply continuing the model of care used in HFrEF. Based on current evidence, HF DMPs may improve mortality, hospitalization rates, self-care, and quality of life in patients with HFpEF; however, further research specifically tailored to appropriately defined HFpEF is required.

[Lifestyle intervention in the primary prevention of cardiovascular diseases]

Cardiovascular diseases are the leading cause of death worldwide. Adherence to a healthy lifestyle lifelong is capable of significantly reducing the cardiovascular risk by up to 70% and is therefore a key component in primary prevention of cardiovascular disease. According to the European and American guidelines lifestyle interventions include not smoking, daily physical activity of ≥150 min/week at moderate intensity or 75 min/week for higher intensity physical activity, a cardioprotective nutrition (high proportion of unsaturated fatty acids, low amounts of saturated fatty acids and low salt intake), normal body weight (body mass index 20-25 kg/m²), arterial blood pressure <140/90 mm Hg (optimum <130/80 mm Hg), low-density lipoprotein (LDL)-cholesterol target values depending on the cardiovascular risk and a normal glucose metabolism in type 2 diabetes mellitus with adjustment of a HbA1c to <7%. Lifestyle measures with weight reduction and intensification of physical activity can improve the cardiometabolic risk factors. In this way reduction of the systolic and diastolic blood pressures by approximately 10-15 mm Hg, reduction of HbA1c by approximately 1 % and reduction of triglycerides by ca. 30-40 % are possible. The LDL-cholesterol and lipoprotein(a) levels cannot be easily influenced. Beyond the recommendations for a cardioprotective lifestyle, additional pharmacological therapy may have to be added depending on the cardiovascular risk profile.