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

Mechanisms of the Improvement in Peak VO2 With Exercise Training in Heart Failure With Reduced or Preserved Ejection Fraction

Heart failure (HF) is a major health care burden associated with high morbidity and mortality. Approximately 50% of HF patients have reduced ejection fraction (HFrEF) while the remainder of patients have preserved ejection fraction (HFpEF). A hallmark of both HF phenotypes is dyspnoea upon exertion and severe exercise intolerance secondary to impaired oxygen delivery and/or use by exercising skeletal muscle. Exercise training is a safe and effective intervention to improve peak oxygen uptake (VO_2peak) and quality of life in clinically stable HF patients, however, evidence to date suggests that the mechanism of this improvement appears to be related to underlying HF phenotype. The purpose of this review is to discuss the role of exercise training to improve VO_2peak, and how the central and peripheral adaptations that mediate the improvements in exercise tolerance may be similar or differ by HF phenotype (HFrEF or HFpEF).

A multinational qualitative investigation of the perspectives and drivers of exercise and dietary behaviors in people living with HIV

Globally, people living with HIV (PLWH) are at remarkably high risk for developing chronic comorbidities. While exercise and healthy eating reduce and mitigate chronic comorbidites, PLWH like many others, often fail to engage in recommended levels. We qualitatively examined the perspectives and contextual drivers of diet and exercise reported by PLWH and their health care providers. Two hundred and six participants across eight sites in the United States, Puerto Rico and Botswana described one overarching theme, Arranging Priorities, and four subthemes Defining Health, Perceived Importance of Diet and Exercise, Competing Needs, and Provider Influence. People living with HIV and their health care providers recognize the importance of eating a healthy diet and engaging in regular exercise. Yet there are HIV-specific factors limiting these behaviors that should be addressed. Health care providers have an important, and often underutilized opportunity to support PLWH to make improvements to their exercise and diet behavior.

Effects of 24-Week Aerobic and Resistance Training on Carotid Artery Intima-Media Thickness and Flow Velocity in Elderly Women with Sarcopenic Obesity

Aim: Sarcopenic obesity (SO) is closely associated with cardiovascular disease (CVD) in elderly women. Increases in body fat and decreases in muscle mass are closely associated with increased carotid intima-media thickness (CIMT). The aim of this study was to examine the influence of a 24-week aerobic and resistance training program on carotid parameters in SO.

Methods: Fifty elderly women (74.1 ± 6.1 years) with SO were randomly divided into an exercise group and a control group. The exercise group performed combined exercise over 24 weeks, consisting of resistance and aerobic training for 50–80 min, 5 times a week. Carotid variables were measured using B-mode ultrasound. The differences in the carotid variables and the relative changes between baseline and after 24 weeks were evaluated.

Results: In the analysis of variance (ANOVA) results, CIMT (p = 0.013), systolic flow velocity (p = 0.007), diastolic flow velocity (p = 0.006), and wall shear rate (p = 0.010) showed significant interactions. In paired t-test results of the exercise group, CIMT significantly decreased (p < 0.01) and systolic flow velocity (p < 0.01), diastolic flow velocity (p < 0.001), and wall shear rate (p < 0.05) significantly increased after 24 weeks.

Conclusion: The 24-week combined exercise effectively decreased CIMT and increased carotid flow velocity and wall shear ratio. Therefore, combined exercise is thought to contribute to the improvement of the risk of CVD in elderly women with SO.

Exercise Therapy for Older Heart Failure Patients

Both the aging process and heart failure (HF) syndrome are characterized by a dramatic reduction of aerobic capacity. Significant decreases in muscle mass and strength are also common. Few HF training studies have included meaningful numbers of older individuals, especially those greater than 80 years of age and older women with HF with reduced ejection fraction. The modest data available suggest similar benefits in older patients and excellent safety. Resistance training may provide additional benefit. Whether exercise training can reduce mortality, hospitalizations, and overall health care costs in older adults with HF awaits the outcome of adequately powered multicenter trials.

Physical Activity and Prognosis in the TOPCAT Trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist)

BACKGROUND

Physical activity (PA) is inversely associated with adverse cardiovascular outcomes in healthy populations, but the impact of physical activity in patients with heart failure (HF) with preserved ejection fraction is less well characterized.

METHODS

The baseline self-reported PA of 1751 subjects enrolled in the Americas region of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) was categorized as poor, intermediate, or ideal PA with American Heart Association criteria. PA was related to the primary composite outcome (HF hospitalization, cardiovascular mortality, or aborted cardiac arrest), its components, and all-cause mortality with the use of multivariable Cox models.

RESULTS

The mean age at enrollment was 68.6±9.6 years. Few patients met American Heart Association criteria for ideal activity (11% ideal, 14% intermediate, 75% poor). Over a median follow-up of 2.4 years, the primary composite outcome occurred in 519 patients (397 HF hospitalizations, 222 cardiovascular deaths, and 6 aborted cardiac arrests). Compared with those with ideal baseline PA, poor and intermediate baseline PA was associated with a greater risk of the primary outcome (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.28-3.28; HR, 1.95; 95% CI, 1.15-3.33, respectively), HF hospitalization (HR, 1.93; 95% CI, 1.16-3.22; HR, 1.84; 95% CI, 1.02-3.31), cardiovascular mortality (HR, 4.36; 95% CI, 1.37-13.83; HR, 4.05; 95% CI, 1.17-14.04), and all-cause mortality (HR, 2.95; 95% CI, 1.44-6.02; HR, 2.05; 95% CI, 0.90-4.67) after multivariable adjustment for potential confounders.

CONCLUSIONS

In patients with HF with preserved ejection fraction, both poor and intermediate self-reported PA were associated with higher risk of HF hospitalization and mortality.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT00094302.

Targeting Endothelial Function to Treat Heart Failure with Preserved Ejection Fraction: The Promise of Exercise Training

Although the burden of heart failure with preserved ejection fraction (HFpEF) is increasing, there is no therapy available that improves prognosis. Clinical trials using beta blockers and angiotensin converting enzyme inhibitors, cardiac-targeting drugs that reduce mortality in heart failure with reduced ejection fraction (HFrEF), have had disappointing results in HFpEF patients. A new “whole-systems” approach has been proposed for designing future HFpEF therapies, moving focus from the cardiomyocyte to the endothelium. Indeed, dysfunction of endothelial cells throughout the entire cardiovascular system is suggested as a central mechanism in HFpEF pathophysiology. The objective of this review is to provide an overview of current knowledge regarding endothelial dysfunction in HFpEF. We discuss the molecular and cellular mechanisms leading to endothelial dysfunction and the extent, presence, and prognostic importance of clinical endothelial dysfunction in different vascular beds. We also consider implications towards exercise training, a promising therapy targeting system-wide endothelial dysfunction in HFpEF.

Invited Commentary: Searching for the Perfect Measure of Diastolic Dysfunction-A Futile Exercise?

Heart failure with preserved ejection fraction (HFpEF) is common, recalcitrant to treatment, and associated with poor outcomes. Diastolic dysfunction (DD) is an independent predictor of HFpEF risk, associated clinical manifestations, and long-term outcomes. However, the usefulness of diastolic function assessment is limited by the heterogeneity in the existing definitions of DD. In this issue of the Journal, Rasmussen-Torvik et al. (Am J Epidemiol. 2017;185(12):1221-1227) have highlighted this problem by evaluating the prevalence and concordance of 4 established definitions of DD in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort. The authors demonstrate significant variability in prevalence of DD and its association with established risk factors across the different definitions. These findings suggest that the current 1-dimensional approach to HFpEF risk prediction based on noninvasive measures of diastolic function may not be optimal. Perhaps the future of HFpEF risk assessment lies in a multimodality approach that combines the relevant echocardiographic measures of diastolic function with blood-based biomarkers (such as N-terminal prohormone of brain natriuretic peptide (NT-proBNP)) and a measure of functional status (such as exercise capacity).

Epidemiology of heart failure with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) is a clinical syndrome associated with poor quality of life, substantial health-care resource utilization, and premature mortality. We summarize the current knowledge regarding the epidemiology of HFpEF with a focus on community-based studies relevant to quantifying the population burden of HFpEF. Current data regarding the prevalence and incidence of HFpEF in the community as well as associated conditions and risk factors, risk of morbidity and mortality after diagnosis, and quality of life are presented. In the community, approximately 50% of patients with HF have HFpEF. Although the age-specific incidence of HF is decreasing, this trend is less dramatic for HFpEF than for HF with reduced ejection fraction (HFrEF). The risk of HFpEF increases sharply with age, but hypertension, obesity, and coronary artery disease are additional risk factors. After adjusting for age and other risk factors, the risk of HFpEF is fairly similar in men and women, whereas the risk of HFrEF is much lower in women. Multimorbidity is common in both types of HF, but slightly more severe in HFpEF. A majority of deaths in patients with HFpEF are cardiovascular, but the proportion of noncardiovascular deaths is higher in HFpEF than HFrEF.

Exercise And Heart Failure: Advancing Knowledge And Improving Care

Exercise limitation is the hallmark of heart failure, and an increasing degree of intolerance is associated with poor prognosis. Objective evaluation of functional class (e.g., cardiopulmonary exercise testing) is essential for adequate prognostication in patients with advanced heart failure and for implementing an appropriate exercise training program. A graded exercise program has been shown to be beneficial in patients with heart failure and has become an essential component of comprehensive cardiac rehabilitation in these patients. An exercise program tailored to the patient's preferences, possibilities, and physiologic reserve has the greatest chance of being successful. Despite being safe, effective, and a guideline-recommended treatment to improve quality of life, exercise training remains grossly underutilized. Patient, physician, insurance and practice barriers need to be addressed to improve this quality gap.

Molecular Mechanisms Underlying Cardiac Adaptation to Exercise

Exercise elicits coordinated multi-organ responses including skeletal muscle, vasculature, heart, and lung. In the short term, the output of the heart increases to meet the demand of strenuous exercise. Long-term exercise instigates remodeling of the heart including growth and adaptive molecular and cellular re-programming. Signaling pathways such as the insulin-like growth factor 1/PI3K/Akt pathway mediate many of these responses. Exercise-induced, or physiologic, cardiac growth contrasts with growth elicited by pathological stimuli such as hypertension. Comparing the molecular and cellular underpinnings of physiologic and pathologic cardiac growth has unveiled phenotype-specific signaling pathways and transcriptional regulatory programs. Studies suggest that exercise pathways likely antagonize pathological pathways, and exercise training is often recommended for patients with chronic stable heart failure or following myocardial infarction. Herein, we summarize the current understanding of the structural and functional cardiac responses to exercise as well as signaling pathways and downstream effector molecules responsible for these adaptations.

Effect of Moderate-Intensity Exercise Training on Peak Oxygen Consumption in Patients With Hypertrophic Cardiomyopathy: A Randomized Clinical Trial

IMPORTANCE

Formulating exercise recommendations for patients with hypertrophic cardiomyopathy is challenging because of concern about triggering ventricular arrhythmias and because a clinical benefit has not been previously established in this population.

OBJECTIVE

To determine whether moderate-intensity exercise training improves exercise capacity in adults with hypertrophic cardiomyopathy.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial involving 136 patients with hypertrophic cardiomyopathy was conducted between April 2010 and October 2015 at 2 academic medical centers in the United States (University of Michigan Health System and Stanford University Medical Center). Date of last follow-up was November 2016.

INTERVENTIONS

Participants were randomly assigned to 16 weeks of moderate-intensity exercise training (n = 67) or usual activity (n = 69).

MAIN OUTCOMES AND MEASURES

The primary outcome measure was change in peak oxygen consumption from baseline to 16 weeks.

RESULTS

Among the 136 randomized participants (mean age, 50.4 [SD, 13.3] years; 42% women), 113 (83%) completed the study. At 16 weeks, the change in mean peak oxygen consumption was +1.35 (95% CI, 0.50 to 2.21) mL/kg/min among participants in the exercise training group and +0.08 (95% CI, -0.62 to 0.79) mL/kg/min among participants in the usual-activity group (between-group difference, 1.27 [95% CI, 0.17 to 2.37]; P = .02). There were no occurrences of sustained ventricular arrhythmia, sudden cardiac arrest, appropriate defibrillator shock, or death in either group.

CONCLUSIONS AND RELEVANCE

In this preliminary study involving patients with hypertrophic cardiomyopathy, moderate-intensity exercise compared with usual activity resulted in a statistically significant but small increase in exercise capacity at 16 weeks. Further research is needed to understand the clinical importance of this finding in patients with hypertrophic cardiomyopathy, as well as the long-term safety of exercise at moderate and higher levels of intensity.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01127061.

Supervised exercise training versus usual care in ambulatory patients with left ventricular assist devices: A systematic review

Implantation of left ventricular assist devices (LVAD) has increased because of improved safety profile and limited availability of heart transplantation. Although supervised exercise training (ET) programs are known to improve exercise capacity and quality of life (QoL) in heart failure (HF) patients, similar data is inconclusive in LVAD patients. Thus, we performed a systematic review on studies that incorporated supervised ET and measured peak oxygen uptake in LVAD patients. A total of 150 patients in exercise and 55 patients in control groups were included from 8 studies selected from our predefined criteria. Our systematic review suggests supervised ET has an inconsistent effect on exercise capacity and QoL when compared to control groups undergoing usual care. A quantitative sub-analysis was performed with 4 studies that provided enough data to compare peak oxygen uptake and QoL at baseline and at follow-up. After at least 6 weeks of training, LVAD patients undergoing supervised ET demonstrated significant improvement in exercise capacity (standardized mean difference [SMD] = 0.735, 95% Confidence Interval-[CI], 0.31-1.15 units of the standard deviation, P = 0.001) and QoL scores (SMD = 1.58, 95% CI 0.97-2.20 units of the standard deviation, P <0.001) when compared to the usual care group, with no serious adverse events with exercise. These results suggest that supervised ET is safe and can improve patient outcomes in LVAD patients when compared to the usual care.

Response to Endurance Exercise Training in Older Adults with Heart Failure with Preserved or Reduced Ejection Fraction

OBJECTIVES

To systematically examine the relative magnitude and predictors of responses to exercise training in older adult with heart failure (HF) with reduced ejection fraction (HFrEF), and preserved EF (HFpEF).

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Outpatient cardiac rehabilitation program.

PARTICIPANTS

Individuals with HF (24 HFrEF, 24 HFpEF) who underwent supervised exercise training.

MEASUREMENTS

The study included individual-level data from the exercise training arms of a randomized controlled trial that evaluated the effect of 16 weeks of supervised moderate-intensity endurance exercise training in older adults with chronic, stable HFpEF and HFrEF. Changes in peak oxygen uptake (VO_2peak ) in response to supervised training in individuals with HFpEF were compared with that of individuals with HFrEF. The significant clinical predictors of changes in VO_2peak with exercise training were assessed using univariate and multivariate regression models.

RESULTS

Training-related improvement in VO_2peak was higher in participants with HFpEF than in those with HFrEF (change: 18.7 ± 17.6% vs -0.3 ± 15.4%, P < .001). In univariate analysis, echocardiographic abnormalities in left ventricular structure and function and lower body mass index were associated with blunted response of VO_2peak with exercise training. In multivariate regression analysis using stepwise selection, submaximal exercise systolic blood pressure, and resting early deceleration time were independent predictors of change in VO_2peak .

CONCLUSION

The change in VO_2peak in response to endurance exercise training in older adults with HF differs significantly according to HF subtype, with greater VO_2peak improvement in HFpEF than HFrEF. These results suggest that the current Centers for Medicare and Medicaid Services policy excluding individuals with HFpEF from reimbursement from cardiac rehabilitation may need to be revisited.

Relationship Between Physical Activity, Body Mass Index, and Risk of Heart Failure

BACKGROUND

Lower leisure-time physical activity (LTPA) and higher body mass index (BMI) are independently associated with risk of heart failure (HF). However, it is unclear if this relationship is consistent for both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).

OBJECTIVES

This study sought to quantify dose-response associations between LTPA, BMI, and the risk of different HF subtypes.

METHODS

Individual-level data from 3 cohort studies (WHI [Women's Health Initiative], MESA [Multi-Ethnic Study of Atherosclerosis], and CHS [Cardiovascular Health Study]) were pooled and participants were stratified into guideline-recommended categories of LTPA and BMI. Associations between LTPA, BMI, and risk of overall HF, HFpEF (ejection fraction ≥45%), and HFrEF (ejection fraction <45%) were assessed by using multivariable adjusted Cox models and restricted cubic splines.

RESULTS

The study included 51,451 participants with 3,180 HF events (1,252 HFpEF, 914 HFrEF, and 1,014 unclassified HF). In the adjusted analysis, there was a dose-dependent association between higher LTPA levels, lower BMI, and overall HF risk. Among HF subtypes, LTPA in any dose range was not associated with HFrEF risk. In contrast, lower levels of LTPA (<500 MET-min/week) were not associated with HFpEF risk, and dose-dependent associations with lower HFpEF risk were observed at higher levels. Compared with no LTPA, higher than twice the guideline-recommended minimum LTPA levels (>1,000 MET-min/week) were associated with an 19% lower risk of HFpEF (hazard ratio: 0.81; 95% confidence interval: 0.68 to 0.97). The dose-response relationship for BMI with HFpEF risk was also more consistent than with HFrEF risk, such that increasing BMI above the normal range (≥25 kg/m2) was associated with a greater increase in risk of HFpEF than HFrEF.

CONCLUSIONS

Our study findings show strong, dose-dependent associations between LTPA levels, BMI, and risk of overall HF. Among HF subtypes, higher LTPA levels and lower BMI were more consistently associated with lower risk of HFpEF compared with HFrEF.

Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial: Design and rationale

BACKGROUND

Acute decompensated heart failure (ADHF) is a leading cause of hospitalization in older persons in the United States. Reduced physical function and frailty are major determinants of adverse outcomes in older patients with hospitalized ADHF. However, these are not addressed by current heart failure (HF) management strategies and there has been little study of exercise training in older, frail HF patients with recent ADHF.

HYPOTHESIS

Targeting physical frailty with a multi-domain structured physical rehabilitation intervention will improve physical function and reduce adverse outcomes among older patients experiencing a HF hospitalization.

STUDY DESIGN

REHAB-HF is a multi-center clinical trial in which 360 patients ≥60 years hospitalized with ADHF will be randomized either to a novel 12-week multi-domain physical rehabilitation intervention or to attention control. The goal of the intervention is to improve balance, mobility, strength and endurance utilizing reproducible, targeted exercises administered by a multi-disciplinary team with specific milestones for progression. The primary study aim is to assess the efficacy of the REHAB-HF intervention on physical function measured by total Short Physical Performance Battery score. The secondary outcome is 6-month all-cause rehospitalization. Additional outcome measures include quality of life and costs.

CONCLUSIONS

REHAB-HF is the first randomized trial of a physical function intervention in older patients with hospitalized ADHF designed to determine if addressing deficits in balance, mobility, strength and endurance improves physical function and reduces rehospitalizations. It will address key evidence gaps concerning the role of physical rehabilitation in the care of older patients, those with ADHF, frailty, and multiple comorbidities.

The future of pleiotropic therapy in heart failure. Lessons from the benefits of exercise training on endothelial function

A novel generation of drugs is introduced in the treatment of heart failure (HF). These drugs, including phosphodiesterase-5 inhibitors, guanylate cyclase stimulators and activators, share the feature that their action is either endothelial-mediated or substitutes for endothelial pathways, in particular the nitric oxide-cyclic guanosine monophosphate pathway, thereby influencing homeostatic balances in virtually each organ system in a pleiotropic fashion. Unfortunately, recent clinical trials with some of these drugs have shown disappointing results, at least in the setting of HF with a preserved ejection fraction. This suggests that their clinical use may require approaches that diverge from traditional pharmacological approaches, the latter often titrated on the effects of drugs on haemodynamic parameters or single biomarkers. In this paper we preconize that HF drugs with an endothelial profile should be applied conform to principles of endothelial physiology and systems pharmacology. This type of drug therapy should be viewed as a systems physio-pharmacological intervention and its clinical use accustomed to systems pharmacological principles, comparable to the systemic endothelial-mediated benefits induced by exercise training in HF. We will review the actions of these drugs and define criteria to which trials with these drugs should comply in order to increase chances of success.

Exercise-Based Rehabilitation for Heart Failure: Clinical Evidence

People with heart failure experience marked reduction in their exercise capacity which has detrimental effects on their activities of daily living, health-related quality of life, and ultimately their hospital ad-mission rate and mortality. Numerous cardiac rehabilitation studies have demonstrated functional benefits, improvement in quality of life and clinical outcomes from exercise training in patients with HFrEF. Based on evidences, the American College of Cardiology/American Heart Association, European Society of Cardiology, and National Institute for Health and Care Excellence(NICE) consistently recommend exercise-based cardiac rehabilitation(CR) as an effective and safe adjunct for patients with stable class II to III heart failure (HF) who do not have advanced arrhythmias and who do not have other limitations to exercise. This recommendation applies to patients with HFrEF as well as to patients with HFpEF besides patients with class IV HF, although the data are not as robust for patients with HFpEF. In this article, the clinical evidence on effects of exercise for HFrEF and HFpEF as well as end-stage heart failure were separately reviewed.

The Benefits of Exercise Training on Aerobic Capacity in Patients with Heart Failure and Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is defined as an inability of the ventricles to optimally accept blood from atria with blunted end- diastolic volume response by limiting the stroke volume and cardiac output. The HEpEF prevalence is higher in elderly and women and may be associated to hypertension, diabetes mellitus and atrial fibrillation. Severe exercise intolerance, manifested by dyspnea and fatigue during physical effort is the important chronic symptom in HFpEF patients, in which is the major determinant of their reduced quality of life. In this sense, several studies demonstrated reduced aerobic capacity in terms of lower peak oxygen consumption (peak VO₂) in patients with HFpEF. In addition, the lower aerobic capacity observed in HFpEF may be due to impaired both convective and diffusive O₂ transport (i.e. reduced cardiac output and arteriovenous oxygen difference, respectively).Exercise training program can help restore physiological function in order to increase aerobic capacity and improve the quality of life in HFpEF patients. Therefore, the primary purpose of this chapter was to clarify the physiological mechanisms associated with reduced aerobic capacity in HFpEF patients. Secondly, special focus was devoted to show how aerobic exercise training can improve aerobic capacity and quality of life in HFpEF patients.

Targeting Obesity and Diabetes to Treat Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a major unmet medical need that is characterized by the presence of multiple cardiovascular and non-cardiovascular comorbidities. Foremost among these comorbidities are obesity and diabetes, which are not only risk factors for the development of HFpEF, but worsen symptoms and outcome. Coronary microvascular inflammation with endothelial dysfunction is a common denominator among HFpEF, obesity, and diabetes that likely explains at least in part the etiology of HFpEF and its synergistic relationship with obesity and diabetes. Thus, pharmacological strategies to supplement nitric oxide and subsequent cyclic guanosine monophosphate (cGMP)-protein kinase G (PKG) signaling may have therapeutic promise. Other potential approaches include exercise and lifestyle modifications, as well as targeting endothelial cell mineralocorticoid receptors, non-coding RNAs, sodium glucose transporter 2 inhibitors, and enhancers of natriuretic peptide protective NO-independent cGMP-initiated and alternative signaling, such as LCZ696 and phosphodiesterase-9 inhibitors. Additionally, understanding the role of adipokines in HFpEF may lead to new treatments. Identifying novel drug targets based on the shared underlying microvascular disease process may improve the quality of life and lifespan of those afflicted with both HFpEF and obesity or diabetes, or even prevent its occurrence.

The challenge of frailty and sarcopenia in heart failure with preserved ejection fraction

Frailty is a clinical state in which there is an increase in an individual's vulnerability for developing increased dependency and/or mortality when exposed to stressors. Frailty is often accompanied by heart failure with preserved ejection fraction (HFpEF), and frailty is likely to affect its clinical features and outcomes. Frail patients with HFpEF are frequently associated with sarcopenia (ie, muscle loss and weakness), which is a major component of the pathophysiology of frailty. Sarcopenia is a systemic skeletal muscle disease that impairs the function of limb skeletal muscles, as well as respiratory muscles, and this results in further functional decline. In addition, sarcopenia may contribute to cardiovascular remodelling and dysfunction, leading to the development of HFpEF through several metabolic and endocrine abnormalities. Although there is no established strategy for frail patients with HFpEF, a multidisciplinary approach, including various types of muscular training and nutritional intervention, may provide beneficial effects for these patients.

Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?"

Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed.

Improvement in aerobic capacity during cardiac rehabilitation in coronary artery disease patients: Is there a role for autonomic adaptations?

Background It has been previously shown in patients with heart failure that exercise-based rehabilitation programmes may improve functional capacity and autonomic response. The aim of this study was to investigate this issue further by evaluating whether an association exists between autonomic adaptations and improvements of aerobic capacity in a general population of coronary artery disease patients undergoing cardiac rehabilitation. Methods Ninety consecutive patients (age 60 ± 11 years) attended a rehabilitation programme of moderate continuous training (25 ± 8 sessions, 2-3 sessions/week). Functional capacity expressed as oxygen uptake (peak VO₂) and autonomic function expressed as chronotropic response and heart rate recovery were evaluated by cardiopulmonary exercise tests before and after the rehabilitation programme. According to the expected mean increase in functional capacity, coronary artery disease patients were divided into two groups: those who improved peak VO₂ by more than 2.6 ml/kg/min (R group) and those who did not (NR group). Effects of the rehabilitation programme were compared in R and NR groups. Results The number and intensity of exercise sessions did not differ between R ( N = 39) and NR ( N = 51) groups. However, only R patients improved chronotropic response (R: from 45.1 ± 16.9% to 72.7 ± 34.1%, P < 0.01; NR: from 49.3 ± 18.6% to 48.2 ± 36.5%, P = NS) and heart rate recovery (R: from 16.9 ± 7.0 bpm to 21.0 ± 8.7 bpm, P < 0.01; NR: from 15.2 ± 9.9 bpm to 15.8 ± 8.5 bpm, P = NS). After training both chronotropic response and heart rate recovery were significantly higher in R than NR patients. Conclusions The improvement in aerobic capacity of coronary artery disease patients following exercise-based cardiac rehabilitation programmes is associated with positive adaptations of autonomic function.

Rehabilitation Enablement in Chronic Heart Failure-a facilitated self-care rehabilitation intervention in patients with heart failure with preserved ejection fraction (REACH-HFpEF) and their caregivers: rationale and protocol for a single-centre pilot randomised controlled trial

INTRODUCTION

The Rehabilitation EnAblement in CHronic Heart Failure in patients with Heart Failure (HF) with preserved ejection fraction (REACH-HFpEF) pilot trial is part of a research programme designed to develop and evaluate a facilitated, home-based, self-help rehabilitation intervention to improve self-care and quality of life (QoL) in heart failure patients and their caregivers. We will assess the feasibility of a definitive trial of the REACH-HF intervention in patients with HFpEF and their caregivers. The impact of the REACH-HF intervention on echocardiographic outcomes and bloodborne biomarkers will also be assessed.

METHODS AND ANALYSIS

A single-centre parallel two-group randomised controlled trial (RCT) with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention) or usual care alone (control) in 50 HFpEF patients and their caregivers. The REACH-HF intervention comprises a REACH-HF manual with supplementary tools, delivered by trained facilitators over 12 weeks. A mixed methods approach will be used to assess estimation of recruitment and retention rates; fidelity of REACH-HF manual delivery; identification of barriers to participation and adherence to the intervention and study protocol; feasibility of data collection and outcome burden. We will assess the variance in study outcomes to inform a definitive study sample size and assess methods for the collection of resource use and intervention delivery cost data to develop the cost-effectiveness analyses framework for any future trial. Patient outcomes collected at baseline, 4 and 6 months include QoL, psychological well-being, exercise capacity, physical activity and HF-related hospitalisation. Caregiver outcomes will also be assessed, and a substudy will evaluate impact of the REACH-HF manual on resting global cardiovascular function and bloodborne biomarkers in HFpEF patients.

ETHICS AND DISSEMINATION

The study is approved by the East of Scotland Research Ethics Service (Ref: 15/ES/0036). Findings will be disseminated via journals and presentations to clinicians, commissioners and service users.

TRIAL REGISTRATION NUMBER

ISRCTN78539530; Pre-results .

Growing Relevance of Cardiac Rehabilitation for an Older Population With Heart Failure

Cardiac rehabilitation (CR) is a comprehensive lifestyle program that can have particular benefit for older patients with heart failure (HF). Prevalence of HF is increasingly common among older adults. Mounting effects of cardiovascular risk factors in older age as well as the added effects of geriatric syndromes such as multimorbidity, frailty, and sedentariness contribute to the high incidence of HF as well as to management difficulty. CR can play a decisive role in improving function, quality of life, symptoms, morbidity, and mortality, and also address the idiosyncratic complexities of care that often arise in old age. Unfortunately, the current policies and practices regarding CR for patients with HF are limited to HF with reduced ejection fraction and do not extend to HF with preserved ejection fraction, which is likely undercutting its full potential to improve care for today's aging population. Despite the strong rationale for CR on important clinical outcomes, it remains underused, particularly among older patients with HF. In this review, we discuss both the potential and the limitations of contemporary CR for older adults with HF.

Diastolic heart failure: diagnosis and therapy

PURPOSE OF REVIEW

This article focuses on the recent findings in the diagnosis and treatment of diastolic heart failure (DHF) or heart failure with preserved ejection fraction.

RECENT FINDINGS

DHF has become the most common form of heart failure in the population. Although diastolic dysfunction still plays a central role, it is now understood that DHF is a very complex clinical entity with heterogeneous pathophysiology and significant contribution from extracardiac comorbidities. Alterations in ventricular-arterial coupling play a significant role in the impaired hemodynamic response to exercise seen in these patients. The absence of diastolic dysfunction at rest does not exclude the diagnosis of DHF. There has been little to no progress made in identifying evidence-based, effective, and specific treatments for patients with DHF. This may be because of the pathophysiological heterogeneity, incomplete understanding of DHF, and heterogeneity of patients included in clinical trials with variable inclusion criteria.

SUMMARY

The understanding of the phenotypic heterogeneity and multifactorial pathophysiology of DHF may lead to novel therapeutic targets in the future. Currently, the key to the treatment of DHF is aggressive management of contributing factors.

Cardiometabolic Syndrome and Increased Risk of Heart Failure

Approximately 50 % of patients with heart failure have diastolic heart failure (HFPEF) with the major predisposing risk factors age, inactivity, obesity, insulin resistance (IR), type-2 diabetes, and hypertension. The prognosis of HFPEF is comparable to that of systolic heart failure, but without any specific or effective treatment. This review presents a biomathematically corrected diagnostic approach for quantification of diastolic dysfunction (DD) via the age dependency of diastolic function. Pathophysiological mechanisms for DD in the cardiometabolic syndrome (CMS) are mainly based on downstream effects of IR including insufficient myocardial energy supply. The second section discusses therapeutic strategies for the control and therapy of CMS, IR, and the associated DD/HFPEF with a focus on dietary therapy that is independent of weight loss but improves all manifestations of the CMS and reduces cardiovascular risk.

Impact of Exercise Programs on Hospital Readmission Following Hospitalization for Heart Failure: A Systematic Review

Given persistently high 30-day readmission rates among patients hospitalized for heart failure, there is an ongoing need to identify new interventions to reduce readmissions. Although exercise programs can improve outcomes among ambulatory heart failure patients, it is not clear whether this benefit extends to reducing readmissions following heart failure hospitalization. We therefore conducted a systematic review of the literature to identify randomized controlled trials examining the impact of exercise programs on hospital readmissions among patients recently hospitalized for heart failure. We searched Ovid MEDLINE, EMBASE, and the Wiley Cochrane Library for studies that fulfilled pre-defined criteria, including that the exercise program pre-specify activity type and exercise frequency, duration, and intensity. Exercise interventions could occur at any location including within the hospital, at an outpatient facility, or at home. Among 1213 unique publications identified, only one study fulfilled inclusion criteria. This study was a single-site randomized controlled trial that consisted of a 12-week exercise program in a cohort of 105 patients with a principal diagnosis of HF at a metropolitan hospital in Australia. This study revealed a reduction in 12-month all-cause and cardiovascular-related hospitalization rates. However, inferences were limited by its single-site study design, small sample size, premature termination, and high risk for selection, performance, and detection bias. As no studies have built upon the findings of this study, it remains unknown whether exercise programs can improve readmission rates among patients recently hospitalized for heart failure, a significant gap in the literature.

An integrative review of physical activity/exercise intervention effects on function and health-related quality of life in older adults with heart failure

This paper reviews randomized, controlled trials (RCTs) that have used a physical activity/exercise intervention in older adults with heart failure and reported outcomes of physical function and/or health-related quality of life. An integrative review was necessary because a literature search indicated no reviews have been done regarding these outcomes which are deemed very important by the older adult population. Computerized database search strategies by authors between 2002 and 2015 resulted in 163 studies, with 12 meeting inclusion criteria. Interventions were performed in clinic and home-based, group and/or individual settings with durations from three to 12 months. Interventions were varied. Common methodological weaknesses of the studies include lack of theory guiding the intervention, small sample and low minority representation. Strengths included detailed intervention methods. There was a moderate effect of interventions with no reported adverse effects. Further work is essential to identify successful strategies to support older adults with heart failure to increase their physical activity levels.

The Effect of Exercise Training Intensity on Quality of Life in Heart Failure Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

To establish if exercise training intensity produces different effect sizes for quality of life in heart failure.

BACKGROUND

Exercise intensity is the primary stimulus for physical and mental adaptation.

METHODS

We conducted a MEDLINE search (1985 to February 2016) for exercise-based rehabilitation trials in heart failure using the search terms 'exercise training', 'left ventricular dysfunction', 'peak VO2', 'cardiomyopathy', and 'systolic heart dysfunction'.

RESULTS

Twenty-five studies were included; 4 (16%) comprised high-, 10 (40%) vigorous-, 9 (36%) moderate- and 0 (0%) low-intensity groups; two studies were unclassified. The 25 studies provided a total of 2,385 participants, 1,223 exercising and 1,162 controls (36,056 patient-hours of training). Analyses reported significant improvement in total Minnesota living with heart failure (MLWHF) total score [mean difference (MD) -8.24, 95% CI -11.55 to -4.92, p < 0.00001]. Physical MLWHF scorewas significantly improved in all studies (MD -2.89, 95% CI -4.27 to -1.50, p < 0.00001). MLWHF total score was significantly reduced after high- (MD -13.74, 95% CI -21.34 to -6.14, p = 0.0004) and vigorous-intensity training (MD -8.56, 95% CI -12.77 to -4.35, p < 0.0001) but not moderate-intensity training. A significant improvement in the total MLWHF score was seen after aerobic training (MD -3.87, 95% CI -6.97 to -0.78, p = 0.01), and combined aerobic and resistance training (MD -9.82, 95% CI -15.71 to -3.92, p = 0.001), but not resistance training.

CONCLUSIONS

As exercise training intensity rises, so may the magnitude of improvement in quality of life in exercising patients. Aerobic-only or combined aerobic and resistance training may offer the greatest improvements in quality of life.

The Effect of Cardiac Rehabilitation Exercise Training on Cardiopulmonary Function in Ischemic Cardiomyopathy With Reduced Left Ventricular Ejection Fraction

OBJECTIVE

To observe the effect and safety of cardiac rehabilitation (CR) exercise in ischemic cardiomyopathy and to compare the results between patients with preserved left ventricular ejection fraction (LVEF) and reduced LVEF.

METHODS

Patients with ischemic cardiomyopathy with LVEF <50% were included as subjects. The patients were classified into the preserved LVEF (pLVEF; LVEF 41%-49%) group and the reduced LVEF (rLVEF; LVEF ≤40%) group. Patients underwent hourly aerobic exercise training sessions with an intensity of 60%-85% of heart rate reserve, three times a week for 6 weeks. Graded exercise test and transthoracic echocardiogram were performed in all study patients before and after completion of the CR exercise program.

RESULTS

After completion of the CR exercise program, both groups (pLVEF, n=30; rLVEF, n=18) showed significant increases in LVEF and VO2max. In the pLVEF group, LVEF and VO2max increased from 45.1%±4.8% to 52.5%±9.6% (p<0.001) and from 24.1±6.3 to 28.1±8.8 mL/kg/min (p=0.002), respectively. In the rLVEF group, LVEF and VO2max increased from 29.7%±7.7% to 37.6%±10.3% (p<0.001) and from 17.6±4.7 to 21.2±5.1 mL/kg/min (p<0.001), respectively. Both groups completed their exercise program safely.

CONCLUSION

In both groups, patients with ischemic cardiomyopathy who completed a 6-week supervised CR exercise program demonstrated remarkable improvements in cardiopulmonary function. This result implies that neither of the two groups showed higher efficacy in comparison to each other, but we can conclude that CR exercise in the rLVEF group was as effective and safe as that in the pLVEF group.

Optimising self-care support for people with heart failure and their caregivers: development of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention using intervention mapping

BACKGROUND

We aimed to establish the support needs of people with heart failure and their caregivers and develop an intervention to improve their health-related quality of life.

METHODS

We used intervention mapping to guide the development of our intervention. We identified "targets for change" by synthesising research evidence and international guidelines and consulting with patients, caregivers and health service providers. We then used behaviour change theory, expert opinion and a taxonomy of behaviour change techniques, to identify barriers to and facilitators of change and to match intervention strategies to each target. A patient and public involvement group helped to identify patient and caregiver needs, refine the intervention objectives and strategies and deliver training to the intervention facilitators. A feasibility study (ISRCTN25032672) involving 23 patients, 12 caregivers and seven trained facilitators at four sites assessed the feasibility and acceptability of the intervention and quality of delivery and generated ideas to help refine the intervention.

RESULTS

The Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention is a comprehensive self-care support programme comprising the "Heart Failure Manual", a choice of two exercise programmes for patients, a "Family and Friends Resource" for caregivers, a "Progress Tracker" tool and a facilitator training course. The main targets for change are engaging in exercise training, monitoring for symptom deterioration, managing stress and anxiety, managing medications and understanding heart failure. Secondary targets include managing low mood and smoking cessation. The intervention is facilitated by trained healthcare professionals with specialist cardiac experience over 12 weeks, via home and telephone contacts. The feasibility study found high levels of satisfaction and engagement with the intervention from facilitators, patients and caregivers. Intervention fidelity analysis and stakeholder feedback suggested that there was room for improvement in several areas, especially in terms of addressing caregivers' needs. The REACH-HF materials were revised accordingly.

CONCLUSIONS

We have developed a comprehensive, evidence-informed, theoretically driven self-care and rehabilitation intervention that is grounded in the needs of patients and caregivers. A randomised controlled trial is underway to assess the effectiveness and cost-effectiveness of the REACH-HF intervention in people with heart failure and their caregivers.

Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure

The study aimed to gain consensus on key priorities for developing breathlessness rehabilitation services for patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). Seventy-four invited stakeholders attended a 1-day conference to review the evidence base for exercise-based rehabilitation in COPD and CHF. In addition, 47 recorded their views on a series of statements regarding breathlessness rehabilitation tailored to the needs of both patient groups. A total of 75% of stakeholders supported symptom-based rather than disease-based rehabilitation for breathlessness with 89% believing that such services would be attractive for healthcare commissioners. A total of 87% thought patients with CHF could be exercised using COPD training principles and vice versa. A total of 81% felt community-based exercise training was safe for patients with severe CHF or COPD, but only 23% viewed manual-delivered rehabilitation an effective alternative to supervised exercise training. Although there was strong consensus that exercise training was a core component of rehabilitation in CHF and COPD populations, only 36% thought that this was the 'most important' component, highlighting the need for psychological and other non-exercise interventions for breathlessness. Patients with COPD and CHF face similar problems of breathlessness and disability on a background of multi-morbidity. Existing pulmonary and cardiac rehabilitation services should seek synergies to provide sufficient flexibility to accommodate all patients with COPD and CHF. Development of new services could consider adopting a patient-focused rather than disease-based approach. Exercise training is a core component, but rehabilitation should include other interventions to address dyspnoea, psychological and education needs of patients and needs of carers.

Impaired Myocardial Bioenergetics in HFpEF and the Role of Antioxidants

Heart failure with preserved ejection fraction (HFpEF) is a significant cardiovascular condition for more than 50% of patients with heart failure. Currently, there is no effective treatment to decrease morbidity and mortality rates associated with HFpEF because of its pathophysiological heterogeneity. Recent evidence shows that deficiency in myocardial bioenergetics is one of the key pathophysiological factors contributing to diastolic dysfunction in HFpEF. Another known mechanism for HFpEF is an overproduction of free radicals, specifically reactive oxygen species. To reduce free radical formation, antioxidants are often used. This article is a summative review of the recent relevant literature that addresses cardiac bioenergetics, deficiency in myocardial bioenergetics, and increased reactive oxygen species associated with HFpEF and the promising potential use of antioxidants in managing this condition.

New Management Strategies in Heart Failure

Despite >100 clinical trials, only 2 new drugs had been approved by the US Food and Drug Administration for the treatment of chronic heart failure in more than a decade: the aldosterone antagonist eplerenone in 2003 and a fixed dose combination of hydralazine-isosorbide dinitrate in 2005. In contrast, 2015 has witnessed the Food and Drug Administration approval of 2 new drugs, both for the treatment of chronic heart failure with reduced ejection fraction: ivabradine and another combination drug, sacubitril/valsartan or LCZ696. Seemingly overnight, a range of therapeutic possibilities, evoking new physiological mechanisms, promise great hope for a disease that often carries a prognosis worse than many forms of cancer. Importantly, the newly available therapies represent a culmination of basic and translational research that actually spans many decades. This review will summarize newer drugs currently being used in the treatment of heart failure, as well as newer strategies increasingly explored for their utility during the stages of the heart failure syndrome.

Adiponectin resistance in skeletal muscle: pathophysiological implications in chronic heart failure

Skeletal muscle wasting is a common complication of chronic heart failure (CHF) and linked to poor patient prognosis. In recent years, adiponectin was postulated to be centrally involved in CHF-associated metabolic failure and muscle wasting. This review discusses current knowledge on the role of adiponectin in CHF. Particular emphasis will be given to the complex interaction mechanisms and the intracellular pathways underlying adiponectin resistance in skeletal muscle of CHF patients. In this review, we propose that the resistance process is multifactorial, integrating abnormalities emanating from insulin signalling, mitochondrial biogenesis, and ceramide metabolism.

Preventing heart failure: the role of physical activity

PURPOSE OF REVIEW

Heart failure prevention is an important public health goal. Increased physical activity and exercise may help to prevent heart failure, as they are associated with reduced heart failure incidence and potentially act through a variety of mechanisms to slow disease progression.

RECENT FINDINGS

Increased physical activity, higher cardiorespiratory fitness, and lower sedentary time are associated with reduced heart failure incidence. These associations are consistent for occurrence of heart failure with both preserved and reduced ejection fraction, the common subphenotypes of the condition. Physiologic cardiac and vascular remodeling occurs across the normal range of physical activity in the community, and regular exercise (four to five sessions per week) is necessary to mitigate age-associated reductions in ventricular compliance and cardiac mass.

SUMMARY

Greater physical activity, less sedentary time, and improved cardiorespiratory fitness are associated with reductions in heart failure risk. Various mechanisms may explain these findings, including: reducing the prevalence of standard and novel cardiovascular risk factors, inhibiting pathologic cardiovascular remodeling, promoting physiologic remodeling, and improving cardiac, neurohormonal, skeletal muscle, pulmonary, renal, and vascular performance. Future research is needed to elucidate the optimal timing, duration, and modality of physical activity and exercise training necessary to prevent the development of heart failure.

Aerobic Interval Training Elicits Different Hemodynamic Adaptations Between Heart Failure Patients with Preserved and Reduced Ejection Fraction

OBJECTIVE

This investigation explored how aerobic interval training influences central or peripheral hemodynamic response(s) to exercise in patients with heart failure (HF) with preserved ejection fraction (HFpEF) or those with HF with reduced ejection fraction (HFrEF).

DESIGN

One hundred twenty HF patients were divided into four groups: HFpEF and HFrEF with aerobic interval training (3-min intervals at 40% and 80% VO2peak for 30 mins/day, 3 days/wk for 12 wks) and general health care groups. Exercise hemodynamics in the heart, frontal cerebral lobe, and vastus lateralis muscle, and oxygenation in the frontal cerebral lobe and vastus lateralis muscle were measured before and after the intervention.

RESULTS

Aerobic interval training significantly (1) improved pumping function with enhanced peak cardiac power index in the HFrEF group and improved diastolic function with reduction of the E/E' ratio in the HFpEF group, (2) increased blood distribution to the frontal cerebral lobe/vastus lateralis muscle and O2 extraction by vastus lateralis muscle during exercise in the HFpEF group compared with the HFrEF group, (3) heightened VO2peak in both HFpEF and HFrEF groups and lowered the VE/VCO2 slope in the HFpEF group, and (4) increased the Short Form-36 physical/mental component scores and decreased the Minnesota Living with Heart Failure questionnaire score in both HFpEF and HFrEF groups.

CONCLUSIONS

Aerobic interval training effectively enhances cardiac hemodynamic response to exercise in HFrEF patients while increasing the delivery/use of O2 to exercising skeletal muscles and frontal cerebral lobe tissues in HFpEF patients, thereby improving global/disease-specific quality-of-life measures in these HF patients.