Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial

Focusing on microvascular function in heart failure with preserved ejection fraction

Heart failure is a prevalent global health issue. Heart failure with preserved ejection fraction (HFpEF), which already represents half of all heart cases worldwide, is projected to further increase, driven by aging populations and rising cardiovascular risk factors. Effective therapies for HFpEF remain limited, particularly due to its pathophysiological heterogeneity and incomplete understanding of underlying pathomechanisms and implications. Coronary microvascular dysfunction (CMD), characterized by structural and functional changes in the coronary microcirculation, is increasingly recognized as a significant factor in HFpEF even though the exact nature of their causal relationship is still unclear. This review explores prevalence, prognostic implications, and potential therapeutic targets for CMD in HFpEF. CMD's role in HFpEF might involve impaired coronary blood flow regulation, leading to myocardial ischemia, impaired relaxation, and/or adverse remodeling. Vice versa, increased wall stress in patients with HFpEF might elevate coronary resistances, further worsening microvascular perfusion. Finally, abnormalities in substrate metabolism might cause both CMD and HFpEF. Current treatments, including pharmacotherapy and device-based therapies, show limited success, highlighting the need for more targeted approaches. New possible therapies, such as the coronary sinus reducer device, may show promise in improving myocardial perfusion and function. However, further large-scale studies are required to elucidate the mechanistic links between CMD and HFpEF and to develop specialized treatments for distinct heart failure phenotypes.

Cardiac Rehabilitation and Heart Failure with Reduced Ejection Fraction: Pathophysiology, Benefits, and Precautions

Heart failure (HF) is a highly comorbid condition associated with significant mortality, despite advances in current medical management. Patients who suffer from HF represent a high needs disease care population in whom structured, long-term chronic disease care delivery models, such as cardiac rehabilitation (CR), have been shown to be highly cost effective in reducing hospitalizations and improving quality of life. HF with reduced ejection fraction affects a growing number of Canadians and health care costs secondary to this condition are increasing, with further increases over the next decade to be expected. CR is a guideline-directed medical therapy for patients living with HF with reduced ejection fraction, and with increasing numbers of HF patients across the world, there is a prescient need to revisit the benefits, safety, and the prescription of this intervention for the health care professionals who treat this condition. Certainly, there is a clinical need for HF practitioners to better understand the pathophysiological benefits of CR with respect to exercise training, as well as the prudent precautions required to facilitate the safe delivery of this highly cost-effective patient intervention.

Wearable device-measured moderate to vigorous physical activity and risk of degenerative aortic valve stenosis

BACKGROUND AND AIMS

Physical activity has proven effective in preventing atherosclerotic cardiovascular disease, but its role in preventing degenerative valvular heart disease (VHD) remains uncertain. This study aimed to explore the dose-response association between moderate to vigorous physical activity (MVPA) volume and the risk of degenerative VHD among middle-aged adults.

METHODS

A full week of accelerometer-derived MVPA data from 87 248 UK Biobank participants (median age 63.3, female: 56.9%) between 2013 and 2015 were used for primary analysis. Questionnaire-derived MVPA data from 361 681 UK Biobank participants (median age 57.7, female: 52.7%) between 2006 and 2010 were used for secondary analysis. The primary outcome was the diagnosis of incident degenerative VHD, including aortic valve stenosis (AS), aortic valve regurgitation (AR), and mitral valve regurgitation (MR). The secondary outcome was VHD-related intervention or mortality.

RESULTS

In the accelerometer-derived MVPA cohort, 555 incident AS, 201 incident AR, and 655 incident MR occurred during a median follow-up of 8.11 years. Increased MVPA volume showed a steady decline in AS risk and subsequent AS-related intervention or mortality risk, levelling off beyond approximately 300 min/week. In contrast, its association with AR or MR incidence was less apparent. The adjusted rates of AS incidence (95% confidence interval) across MVPA quartiles (Q1-Q4) were 11.60 (10.20, 13.20), 7.82 (6.63, 9.23), 5.74 (4.67, 7.08), and 5.91 (4.73, 7.39) per 10 000 person-years. The corresponding adjusted rates of AS-related intervention or mortality were 4.37 (3.52, 5.43), 2.81 (2.13, 3.71), 1.93 (1.36, 2.75), and 2.14 (1.50, 3.06) per 10 000 person-years, respectively. Aortic valve stenosis risk reduction was also observed with questionnaire-based MVPA data [adjusted absolute difference Q4 vs. Q1: AS incidence, -1.41 (-.67, -2.14) per 10 000 person-years; AS-related intervention or mortality, -.38 (-.04, -.88) per 10 000 person-years]. The beneficial association remained consistent in high-risk populations for AS, including patients with hypertension, obesity, dyslipidaemia, and chronic kidney disease.

CONCLUSIONS

Higher MVPA volume was associated with a lower risk of developing AS and subsequent AS-related intervention or mortality. Future research needs to validate these findings in diverse populations with longer durations and repeated periods of activity monitoring.

Effects of exercise based cardiac rehabilitation delivery modes on chronic heart failure: a systematic review and network meta-analysis

Chronic heart failure (CHF) represents one of the most severe and advanced stages of cardiovascular disease. Despite the critical importance of cardiac rehabilitation (CR) in CHF management, while studies have explored the effectiveness of various CR delivery modes and offered valuable context-specific insights, their relative efficacy remains inconsistent across different patient groups, healthcare environments, and intervention approaches. A clearer understanding requires comprehensive comparisons and in-depth analyses to address these variations. Systematic searches were conducted in databases including Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science, up to August 2024. Two researchers independently screened the literature according to strict inclusion criteria, extracted relevant data, and assessed the quality of included studies using Cochrane Collaboration tools and the Jadad scale. Subsequent pairwise and network meta-analyses were performed using statistical software, including Stata 17.0, to present the results graphically. The network meta-analysis included 9,552 articles, with 33 meeting the inclusion criteria and examining eleven different interventions. All interventions outperformed routine care. Combined CR with aerobic exercise and resistance training (HCR [AE + RE]) significantly improved Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores and 6-min walk test (6MWT) performance, and reduced rehospitalization rates [SUCRA = 96%]. Center-based cardiac rehabilitation (CBCR) with high-intensity interval training (HIIT) was the most effective in enhancing left ventricular ejection fraction (LVEF), while CBCR(AE) demonstrated the greatest improvement in peak oxygen uptake (Peak VO2) [RR = 3.64, 95% CI: 1.66-7.95]. Our analysis identifies HCR (AE + RE) as the most effective intervention for improving quality of life (MLHFQ), exercise capacity (6MWT), and reducing hospital readmissions. CBCR (HIIT) was optimal for enhancing cardiac function through improved LVEF, while CBCR (AE) effectively boosted peak VO2.PROSPERO: CRD42024517039, Review Completed not published.

The Effect of Dark Chocolate Consumption on Arterial Function in Endurance Male Runners: Prospective Cohort Study

Foods rich in polyphenols have beneficial effects on health. This study aimed to examine the impact of dark chocolate on endurance runners' arterial function. Forty-six male amateur runners, aged 25-55, participated. The initial assessments included clinical testing, arterial stiffness measurements, and a cardiopulmonary exercise test. The participants then consumed 50 g of dark chocolate (70% cocoa) daily for two weeks, maintaining their usual training routine. After this period, the baseline assessment was repeated. The results showed significant improvements. Pulse wave velocity decreased by 11.82% (p < 0.001), and augmentation index by 19.47% (p < 0.001). Systolic brachial blood pressure reduced by 2.12% (p < 0.05), diastolic by 2.79% (p < 0.05), and mean pressure by 2.41% (p < 0.05). Central arterial pressure also decreased, with systolic by 1.24% (p < 0.05), diastolic by 2.80% (p < 0.05), and mean pressure by 2.43% (p < 0.05). Resting heart rate increased by 4.57% (p < 0.05) and left ventricular ejection time decreased by 4.89% (p < 0.05), particularly in athletes over 40. Exercise time increased by 2.16% (p < 0.05), heart rate (max) by 1.15% (p < 0.05), VO2max by 2.31% (p < 0.05), and anaerobic threshold shifted by 6.91% (p < 0.001) in exercise time and 6.93% (p < 0.001) in VO2max. In conclusion, dark chocolate improves arterial function in endurance runners, enhancing vascular health.

Elevated meteorin-like protein from high-intensity interval training improves heart function via AMPK/HDAC4 pathway

High-intensity interval training (HIIT) has been found to be more effective in relieving heart failure (HF) symptoms, than moderate-intensity continuous aerobic training (MICT). Additionally, higher meteorin-like protein (Metrnl) levels are seen after HIIT versus MICT. We investigated whether Metrnl contributed to post-HF cardiac functional improvements, and the signaling pathways involved. 50 HF patients underwent MICT, and another 50, HIIT, which was followed by cardiac function and serum Metrnl measurements. Metrnl was also measured in both blood and skeletal muscle samples of mice with transverse aortic constriction-induced HF after undergoing HIIT. Afterward, shRNA-containing adenovectors were injected into mice, yielding five groups: control, HF, HF + HIIT + scrambled shRNA, HF + HIIT + shMetrnl, and HF + Metrnl (HF + exogenous Metrnl). Mass spectrometry identified specific signaling pathways associated with increased Metrnl, which was confirmed with biochemical analyses. Glucose metabolism and mitochondrial functioning were evaluated in cardiomyocytes from the five groups. Both HF patients and mice had higher circulating Metrnl levels post-HIIT. Metrnl activated AMPK in cardiomyocytes, subsequently increasing histone deacetylase 4 (HDAC4) phosphorylation, leading to its cytosolic sequestration and inactivation via binding with chaperone protein 14-3-3. HDAC4 inactivation removed its repression on glucose transporter type 4, which, along with increased mitochondrial complex I-V expression, yielded improved aerobic glucose respiration and alleviation of mitochondrial dysfunction. All these changes ultimately result in improved post-HF cardiac functioning. HIIT increased skeletal muscle Metrnl production, which then operated on HF hearts to alleviate their functional defects, via increasing aerobic glucose metabolism through AMPK-HDAC4 signaling.

Impact of exercise training on clinical outcomes and quality of life in chronic congestive heart failure: A systematic review and meta-analysis

BACKGROUND

Exercise training is a well-established intervention for patients with heart failure with reduced and preserved ejection fraction. Still, the evidence of its effects on mortality, hospitalization, and quality of life needs to be more conclusive. We aim to evaluate exercise training clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).

METHODS

We searched five databases and three clinical trial registries for RCTs that compared exercise training plus usual care versus usual care alone in congestive heart failure (CHF) patients. We extracted data on all-cause mortality, hospital admission, heart failure hospitalization, and health-related quality of life measured by the Minnesota Living with HF questionnaire (MLHFW) and other scales. We pooled the data using random-effects or fixed-effects models, depending on the heterogeneity of the outcomes. We performed subgroup analyses for patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).

RESULTS

We included 61 RCTs with 9062 participants. There was no mortality benefit, but exercise training improved health-related quality of life, reduced hospital admission at 12 months and longer follow-up, and reduced heart failure hospitalization. We observed substantial enhancement in health-related quality of life and a greater decrease in hospital admissions in the HFpEF group compared to the HFrEF group.

CONCLUSIONS

Despite the lack of mortality benefit, exercise training is a beneficial intervention for CHF patients, improving health-related quality of life and reducing hospitalization.

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, disrupts the heart's rhythm through numerous small re-entry circuits in the atrial tissue, leading to irregular atrial contractions. The condition poses significant health risks, including increased stroke risk, heart failure, and reduced quality of life. Given the complexity of AF and its growing incidence globally, exercise-based cardiac rehabilitation (ExCR) may provide additional benefits for people with AF or those undergoing routine treatment for the condition.

OBJECTIVES

To assess the benefits and harms of ExCR compared with non-exercise controls for people who currently have AF or who have been treated for AF.

SEARCH METHODS

We searched the following electronic databases: CENTRAL in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS BIREME, and two clinical trial registers on 24 March 2024. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) that investigated ExCR interventions compared with any type of non-exercise control. We included adults 18 years of age or older with any subtype of AF or those who had received treatment for AF.

DATA COLLECTION AND ANALYSIS

Five review authors independently screened and extracted data in duplicate. We assessed risk of bias using Cochrane's RoB 1 tool as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots and by using standard Chi² and I² statistics. We performed meta-analyses using random-effects models for continuous and dichotomised outcomes. We calculated standardised mean differences where different scales were used for the same outcome. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 RCTs involving a total of 2039 participants with AF. All trials were conducted between 2006 and 2024, with a follow-up period ranging from eight weeks to five years. We assessed the certainty of evidence as moderate to very low. Five trials assessed comprehensive ExCR programmes, which included educational or psychological interventions, or both; the remaining 15 trials compared exercise-only cardiac rehabilitation with controls. The overall risk of bias in the included studies was mixed. Details on random sequence generation, allocation concealment, and use of intention-to-treat analysis were typically poorly reported. Evidence from nine trials (n = 1173) suggested little to no difference in mortality between ExCR and non-exercise controls (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; 101 deaths; low-certainty evidence). Based on evidence from 10 trials (n = 825), ExCR may have little to no effect on SAEs (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; 28 events; low-certainty evidence). Evidence from four trials (n = 378) showed that ExCR likely reduced AF recurrence (measured via Holter monitoring) compared to controls (RR 0.70, 95% CI 0.56 to 0.88; I² = 2%; moderate-certainty evidence). ExCR may reduce AF symptom severity (mean difference (MD) -1.59, 95% CI -2.98 to -0.20; I² = 61%; n = 600; low-certainty evidence); likely reduces AF symptom burden (MD -1.61, 95% CI -2.76 to -0.45; I² = 0%; n = 317; moderate-certainty evidence); may reduce AF episode frequency (MD -1.29, 95% CI -2.50 to -0.07; I² = 75%; n = 368; low-certainty evidence); and likely reduces AF episode duration (MD -0.58, 95% CI -1.14 to -0.03; I² = 0%; n = 317; moderate-certainty evidence), measured via the AF Severity Scale (AFSS) questionnaire. Moderate-certainty evidence from six trials (n = 504) showed that ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) of the 36-item Short Form Health Survey (SF-36) (MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on the physical component summary measure was very uncertain (MD 1.75, 95% CI -0.31 to 3.81; I² = 52%; very low-certainty evidence). ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (peak oxygen uptake (VO2peak) and 6-minute walk test) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre compared to home-based, exercise dose, exercise only compared to comprehensive programmes, and aerobic training alone compared to aerobic plus resistance programmes. Using univariate meta-regression, there was evidence of significant association between location of trial and length of longest follow-up on exercise capacity.

AUTHORS' CONCLUSIONS

Due to few randomised participants and typically short-term follow-up, the impact of ExCR on all-cause mortality or serious adverse events for people with AF is uncertain. ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as the mental components of HRQoL. ExCR may improve AF symptom severity, episode frequency, and VO2peak. Future high-quality RCTs are needed to assess the benefits of ExCR for people with AF on patient-relevant outcomes including AF symptom severity and burden, AF recurrence, AF-specific quality of life, and clinical events such as mortality, readmissions, and serious adverse events. High-quality trials are needed to investigate how AF subtype and clinical setting (i.e. primary and secondary care) may influence ExCR effectiveness.

Redefining Management in Hypertrophic Cardiomyopathy: The Role and Challenges of Exercise Rehabilitation

Hypertrophic cardiomyopathy (HCM), a common genetic heart condition, is characterized by thickening of the left ventricle, which can result in a range of health issues, such as arrhythmias, heart failure, and sudden death. Despite traditional cautions against exercise in HCM patients due to potential exacerbation of symptoms and risk of sudden death, recent evidence suggests a paradigm shift toward the benefits of structured exercise rehabilitation. The pathogenesis of HCM, the physical and psychological effects of the illness on patients, and changing views on exercise as a therapeutic intervention are all covered in this review. Recent research shows that modest physical activity can considerably enhance functional ability, psychological health, and overall quality of life in individuals with heart failure without increasing the risk of unfavorable cardiac events, challenging earlier recommendations. Moreover, exercise rehabilitation has been shown to induce favorable myocardial remodeling and enhance cardiovascular fitness, suggesting a revaluation of exercise prescriptions tailored to individual patient profiles. Despite the promising role of exercise in managing HCM, this review also acknowledges the complexities of implementing rehabilitation programs, including the need for comprehensive patient assessment, personalized exercise regimens, and monitoring for potential complications. Future research should focus on optimizing exercise recommendations, understanding long-term outcomes, and integrating exercise rehabilitation into standard care protocols for HCM to foster a more holistic approach to patient management. Underscoring the necessity of a multidisciplinary strategy that balances the benefits of physical activity with the unique risks associated with HCM with the aim of improving patient outcomes through evidence-based, patient-centered care.

The treatment of chronic anemia in heart failure: a global approach

Chronic anemia is an independent risk factor for mortality in patients with heart failure (HF). Restoring physiological hemoglobin (Hb) levels is essential to increase oxygen transport capacity to tissues and improve cell metabolism as well as physical and cardiac performance. Nutritional deficits and iron deficiency are the major causes of chronic anemia, but other etiologies include chronic kidney disease, inflammatory processes, and unexplained anemia. Hormonal therapy, including erythropoietin (EPO) and anabolic treatment in chronic anemia HF patients, may contribute to improving Hb levels and clinical outcomes. Although preliminary studies showed a beneficial effect of EPO therapy on cardiac efficiency and in HF, more recent studies have not confirmed this positive impact of EPO, alluding to its side effect profile. Physical exercise significantly increases Hb levels and the response of anemia to treatment. In malnourished patients and chronic inflammatory processes, low levels of anabolic hormones, such as testosterone and insulin-like growth factor-1, contribute to the development of chronic anemia. This paper aims to review the effect of nutrition, EPO, anabolic hormones, standard HF treatments, and exercise as regulatory mechanisms of chronic anemia and their cardiovascular consequences in patients with HF.

Microvascular Dysfunction across the Spectrum of Heart Failure Pathology: Pathophysiology, Clinical Features and Therapeutic Implications

Coronary microvascular dysfunction (CMD) plays a crucial role across the spectrum of heart failure (HF) pathology, contributing to disease development, progression, and outcomes. The pathophysiological mechanisms linking CMD to HF are complex and still not completely understood and include chronic inflammation, oxidative stress, and neurohormonal activation. Despite the diagnostic and prognostic relevance in patients with HF, there is no specific therapeutic strategy targeting CMD to date. Moreover, the diagnosis of this clinical condition is challenging. In this review article, we aim to discuss the different clinical pathogenetic mechanisms linking CMD to HF across the different spectra of these diseases, their prognostic relevance, and the possible therapeutic targets along with the remaining knowledge gaps in the field.

Exercise Training and Rehabilitation in Cardiac Amyloidosis (ERICA) Study: Rationale and Design

Notwithstanding the dramatic improvement associated with Tafamidis in Heart Failure due to wild-type transthyretin cardiac amyloidosis (ATTRwt-CA), the effect of exercise training on ATTRwt-CA remains unexplored. We hereby present rationale and design of the Exercise training and Rehabilitation in Cardiac Amyloidosis study. This interventional, controlled study will randomize ATTRwt-CA patients into a control group and a training group. Primary endpoint will be the distance obtained at the 6-min walk test. Quality-of-life, peak oxygen consumption, left and right heart architecture and function, and natriuretic peptides will be secondary endpoints.

Delivering effective, comprehensive, multi-exercise component cardiac rehabilitation (CR) for chronic heart failure patients in low resource settings in sub-Saharan Africa: Queen Elizabeth Central Hospital-(QECH-CR) randomised CR study, Malawi

BACKGROUND

The delivery of Cardiac Rehabilitation (CR) and attaining evidence-based treatment goals are challenging in developing countries, such as Malawi. The aims of this study were to (i) assess the effects of exercise training/ CR programme on cardiorespiratory and functional capacity of patients with chronic heart failure (CHF), and (ii) examine the effectiveness of a novel, hybrid CR delivery using integrated supervised hospital- and home-based caregiver approaches.

METHODS

A pre-registered (UMIN000045380), randomised controlled trial of CR exercise therapy in patients with CHF was conducted between September 2021 and May 2022. Sixty CHF participants were randomly assigned into a parallel design-exercise therapy (ET) (n = 30) or standard of care (n = 30) groups. Resting hemodynamics, oxygen saturation, distance walked in six-minutes (6MWD) and estimated peak oxygen consumption (VO2 peak) constituted the outcome measures. The exercise group received supervised, group, circuit-based ET once weekly within the hospital setting and prescribed home-based exercise twice weekly for 12 weeks. Participants in both arms received a group-based, health behaviour change targeted education (usual care) at baseline, 8-, 12- and 16-weeks.

RESULTS

Most of the participants were female (57%) with a mean age of 51.9 ±15.7 years. Sixty-five percent (65%) were in New York Heart Association class III, mostly with preserved left ventricular ejection fraction (HFpEF) (mean Left Ventricular Ejection Fraction 52.9 ±10.6%). The 12-weeks ET led to significant reductions in resting haemodynamic measures (all P <0.05). The ET showed significantly higher improvements in the 6MWD (103.6 versus 13.9 m, p<0.001) and VO2 peak (3.0 versus 0.4 ml·kg-1·min-1, p <0.001). Significant improvements in 6MWD and VO2 peak (both p<0.001), in favour of ET, were also observed across all follow-up timepoints.

CONCLUSION

This novel, randomised, hybrid ET-based CR, delivered to mainly HFpEF patients using an integrated hospital- and home-based approach effectively improved exercise tolerance, cardiorespiratory fitness capacities and reduced perceived exertion in a resource-limited setting.

Exercise-based cardiac rehabilitation for adults with heart failure

BACKGROUND

People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting.

OBJECTIVES

To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes.

AUTHORS' CONCLUSIONS

This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

Effect of different intensity exercises on cardiopulmonary function and quality of life of patients with chronic heart failure : A systematic review and meta-analysis

BACKGROUND

Exercise-based cardiac rehabilitation has positive benefits for patients with chronic heart failure (CHF), but the choice of exercise intensity has been controversial. The aim of this systematic review and meta-analysis was to investigate the effects of different exercise intensities on cardiopulmonary function and quality of life (QoL) of patients with CHF.

METHODS

Randomized controlled trials (RCTs) of different exercise intensities applied to patients with CHF were searched in PubMed, Web of Science, the Cochrane Library, and Embase databases from inception to December 2021. Study selection and data extraction were performed simultaneously by two independent reviewers, using the Physiotherapy Evidence Database Scale (PEDro) for quality assessment of the included literature. The weighted mean differences (WMD) or standardized mean difference (SMD) were calculated by employing a fixed or random effects model. Other statistical analyses included subgroup analysis and sensitivity analysis. Quality of evidence was evaluated by the Grade of Recommendation, Assessment, Development, and Evaluation (GRADE) method.

RESULTS

Eight RCTs were included. Analyses reported no significant improvement in left ventricular ejection fractions (LVEF; WMD = 0.47, 95% CI [-4.10, 5.03], p = 0.841), peak oxygen uptake (peak VO2) (SMD = 0.38, 95% CI [-0.03, 0.80], p = 0.069) and 6‑min walking distance (6MWD) (WMD = 14.10, 95% CI [-9.51, 37.72], p = 0.242). Exercise interventions of varying intensity produced small-to-moderate beneficial effects on QoL (WMD = -4.99, 95% CI [-8.29, -1.68], p = 0.003), which appeared to be attenuated at long-term follow-up (WMD = 2.12, 95% CI [-2.91, 7.16], p = 0.409).

CONCLUSION

High-intensity exercise does not have a significant advantage over moderate-intensity exercise in improving cardiopulmonary function and aerobic capacity in patients with CHF. Beneficial changes in QoL from high-intensity exercise also appeared to decrease during long-term follow-up, indicating a cumulative effect of the efficacy of high-intensity exercise.

Strength training improves heart function, collagen and strength in rats with heart failure

BACKGROUND/OBJECTIVES

Myocardial infarction (MI) frequently leads to cardiac remodeling and failure with impaired life quality, playing an important role in cardiovascular deaths. Although physical exercise is a well-recognized effective non-pharmacological therapy for cardiovascular diseases, the effects of strength training (ST) on the structural and functional aspects of cardiac remodeling need to be further documented. In this study, we aimed to investigate the role of a linear block ST protocol in the rat model of MI.

METHODS AND RESULTS

After 6 weeks of MI induction or sham surgery, male adult rats performed ST for the following 12 weeks. The ladder-based ST program was organized in three mesocycles of 4 weeks, with one load increment for each block according to the maximal carrying load test. After 12 weeks, the infarcted-trained rats exhibited an increase in performance, associated with reduced cardiac hypertrophy and pulmonary congestion compared with the untrained group. Despite not changing MI size, the ST program partially prevented cardiac dilatation and ventricular dysfunction assessed by echocardiography and hemodynamics, and interstitial fibrosis evaluated by histology. In addition, isolated cardiac muscles from infarcted-trained rats had improved contractility parameters in a steady state, and in response to calcium or stimuli pauses.

CONCLUSIONS

The ST in infarcted rats increased the capacity to carry mass, associated with attenuation of cardiac remodeling and pulmonary congestion with improving cardiac function that could be attributed, at least in part, to the improvement of myocardial contractility.

High-Intensity Interval Training Is Associated With Improved 10-Year Survival by Mediating Left Ventricular Remodeling in Patients With Heart Failure With Reduced and Mid-Range Ejection Fraction

BACKGROUND

This study aimed to assess the left ventricular (LV) remodeling response and long-term survival after high-intensity interval training (HIIT) in patients with various heart failure (HF) phenotypes during a 10-year longitudinal follow-up.

METHODS AND RESULTS

Among 214 patients with HF receiving guideline-directed medical therapy, those who underwent an additional 36 sessions of aerobic exercise at alternating intensities of 80% and 40% peak oxygen consumption (V ̇ $$ \dot{\mathrm{V}} $$ O2peak) were considered HIIT participants (n=96). Patients who did not undergo HIIT were considered participants receiving guideline-directed medical therapy (n=118). Participants with LV ejection fraction (EF) <40%, ≥40% and <50%, and ≥50% were considered to have HF with reduced EF, HF with mid-range EF, and HF with preserved EF, respectively. V ̇ $$ \dot{\mathrm{V}} $$ O2peak, serial LV geometry, and time to death were recorded. In all included participants, 10-year survival was better (P=0.015) for participants who underwent HIIT (80.3%) than for participants receiving guideline-directed medical therapy (68.6%). An increased V ̇ $$ \dot{\mathrm{V}} $$ O2peak, decreased minute ventilation carbon dioxide production slope, and reduced LV end-diastolic diameter were protective factors against all-cause mortality. Regarding 138 patients with HF with reduced EF (P=0.044) and 36 patients with HF with mid-range EF (P=0.036), 10-year survival was better for participants who underwent HIIT than for participants on guideline-directed medical therapy. Causal mediation analysis showed a significant mediation path for LV end-diastolic diameter on the association between HIIT and 10-year mortality in all included patients with HF (P<0.001) and those with LV ejection fraction <50% (P=0.006). HIIT also had a significant direct association with 10-year mortality in patients with HF with LV ejection fraction <50% (P=0.027) but not in those with LV ejection fraction ≥50% (n=40).

CONCLUSIONS

Reversal of LV remodeling after HIIT could be a significant mediating factor for 10-year survival in patients with HF with reduced EF and those with HF with mid-range EF.

Left ventricle function and post-transcriptional events with exercise training in pigs

BACKGROUND

Standardized exercise protocols have been shown to improve overall cardiovascular fitness, but direct effects on left ventricular (LV) function, particularly diastolic function and relation to post-transcriptional molecular pathways (microRNAs (miRs)) are poorly understood. This project tested the central hypothesis that adaptive LV remodeling resulting from a large animal exercise training protocol, would be directly associated with specific miRs responsible for regulating pathways relevant to LV myocardial stiffness and geometry.

METHODS AND RESULTS

Pigs (n = 9; 25 Kg) underwent a 4 week exercise training protocol (10 degrees elevation, 2.5 mph, 10 min, 5 days/week) whereby LV chamber stiffness (KC) and regional myocardial stiffness (rKm) were measured by Doppler/speckle tracking echocardiography. Age and weight matched non-exercise pigs (n = 6) served as controls. LV KC fell by approximately 50% and rKm by 30% following exercise (both p < 0.05). Using an 84 miR array, 34 (40%) miRs changed with exercise, whereby 8 of the changed miRs (miR-19a, miR-22, miR-30e, miR-99a, miR-142, miR-144, miR-199a, and miR-497) were correlated to the change in KC (r ≥ 0.5 p < 0.05) and mapped to matrix and calcium handling processes. Additionally, miR-22 and miR-30e decreased with exercise and mapped to a localized inflammatory process, the inflammasome (NLRP-3, whereby a 2-fold decrease in NLRP-3 mRNA occurred with exercise (p < 0.05).

CONCLUSION

Chronic exercise reduced LV chamber and myocardial stiffness and was correlated to miRs that map to myocardial relaxation processes as well as local inflammatory pathways. These unique findings set the stage for utilization of myocardial miR profiling to identify underlying mechanisms by which exercise causes changes in LV myocardial structure and function.

Large lessons learned from small vessels: coronary microvascular dysfunction in HIV

PURPOSE OF REVIEW

Large cohort studies have consistently shown the presence of heart failure is approximately doubled among persons with HIV (PWH). Early studies of cardiovascular disease (CVD) in HIV were primarily focused on atherosclerotic burden, and we now have a greater understanding of large vessel disease in HIV. More recent studies have begun to inform us about small vessel disease, or coronary microvascular dysfunction (CMD), in HIV. CMD is recognized to be an important risk factor for adverse events related to heart failure, associated with cardiovascular mortality, and often presents without overt atherosclerotic disease.

RECENT FINDINGS

In this review, we highlight implications for CMD and relevant clinical studies in HIV. Inflammation and endothelial dysfunction, well known risk factors in HIV, may mediate the pathogenesis of CMD. Initial studies suggest that CMD worsens with ART initiation. Newer studies reveal CMD is present among well treated PWH without known CVD. In addition, myocardial flow reserve (MFR), a marker of CMD, is reduced in HIV similar to diabetes. There also appears to be sex differences, such that CMD is worse among women vs. men with HIV.

SUMMARY

Alterations in the coronary microvasculature may be an important mediator of subclinical myocardial dysfunction that deserves further clinical attention among PWH without known CVD.

Exercise-based cardiac rehabilitation for left ventricular function in patients with heart failure: A systematic review and meta-analysis

AIMS

To evaluate the effect of exercise rehabilitation on the left ventricular (LV) function in patients with heart failure (HF).

METHODS

PubMed, Cochrane Library and Embase were searched until May 2023. Randomized controlled trials (RCTs) providing data on changes in LV function, comparing exercise to no-exercise controls with HF of any type, were included.

RESULTS

A total of 16 studies including 1443 participants were included. LV end-diastolic diameter (LVEDD) was significantly improved in the exercise group [mean differences (MD), -2.67; 95 % confidence interval (CI) (-4.88, -0.46); P=0.02], but left atrial volume index (LAVI), left ventricular end-systolic diameter (LVESD), E/e' E/A, end-diastolic volume (EDV), end-systolic volume (ESV), left ventricular ejection fraction (LVEF) and LV mass were unaltered compared to the non-exercise group. High intensity interval training (HIIT) or with moderate exercise (MT) led to improvement in LVEDD [MD, 3.62; 95 %CI (2.55, 4.69); P<0.00001], but not LAVI, E/e' and E/A. Sensitivity and subgroup analyses showed that the location, the type of HF and study duration may be the source of heterogeneity in LVEF. Age appears to be a source of heterogeneity in EDV and ESV. The Egger test indicated no significant publication bias.

CONCLUSIONS

Exercise can partially improve LV function in patients with HF, with improvements appearing to be dependent on study quality, the type of HF, and race. However, there are some indicators that do not seem to improve or are even worse than the control group. Among all exercise modalities, HIIT shows the greatest benefit for HF patients.

The effect of resistance training on PCSK9 levels in patients undergoing cardiac rehabilitation after coronary artery bypass grafting: a randomized study

BACKGROUND

Resistance training is commonly recommended as part of secondary prevention for post-coronary artery bypass graft (CABG) patients in conjunction with aerobic exercise. Despite its potential benefits, there is currently a lack of studies investigating the impact of resistance training on proprotein convertase subtilisin kexin 9 (PCSK9).

AIM

To evaluate the effect of intensive resistance training on proprotein convertase subtilisin kexin 9 (PCSK9) levels among post-CABG patients undergoing cardiac rehabilitation (CR).

METHODS

In this prospective, open-label, randomized trial, 87 post-coronary artery bypass graft (CABG) patients were randomly assigned into two groups: moderate to high intensity resistance training and aerobic training (n = 44) or aerobic training alone (n = 43) for a total of 12 sessions. Changes in PCSK9 levels was determined as a primary endpoint, while secondary endpoints included changes in the six-minute walk test (6-MWT) results, aerobic capacity, WHO-5 well-being index, fasting blood glucose, and lipid profile. Both groups underwent intention-to-treat analysis.

RESULTS

Following completion of cardiac rehabilitation program, the intervention group demonstrated a significant decrease in mean PCSK9 levels when compared to the control group (β = -55 ng/ml, 95% CI -6.7 to -103.3, p = 0.026), as well as significant improvements in the 6-MWT result (β = 28.2 m, 95% CI 2.4-53.9, p = 0.033), aerobic capacity (β = 0.9 Mets, 95% CI 0.1-1.7, p = 0.021), and WHO-5 well-being index (β = 8.1, 95% CI 2.0-14.4, p = 0.011) in patients who received resistance and aerobic training. No statistically significant changes were observed in fasting blood glucose, cholesterol, LDL-C, HDL-C, and triglyceride levels.

CONCLUSION

Resistance training in CR significantly reduced PCSK-9 levels and increases patient's functional capacity and quality of life. (NCT02674659 04/02/2016).

Effect of Exercise Training on Peak Aerobic Power After Heart Transplantation: A Brief Review

Heart transplantation (HTP) is a life-saving therapy for selected individuals with end-stage refractory heart failure. Despite improvements in quality of life and survival, HTP recipients' peak aerobic power (peak VO2) remains up to 50% lower than age-matched healthy control subjects owing to abnormal cardiovascular and skeletal muscle function. Currently, little is known regarding the effect of exercise training (ET) to improve peak VO2 after HTP. This brief review aims to summarise existing evidence regarding the role of ET on peak VO2 and its determinants, highlights the upper limits of endurance performance in highly trained HTP athletes, and identifies areas for future HTP exercise rehabilitation research.

Comparative effect of different physical exercise training on exercise capacity and cardiac function in heart failure with preserved ejection fraction: a network meta-analysis-ExIC-FEp Study

AIMS

This network meta-analysis aimed to compare the effect of different types of physical exercise [endurance training, endurance/resistance training, and high-intensity interval training (HIIT)] on exercise capacity and cardiac function parameters in patients with heart failure with preserved ejection fraction.

METHODS AND RESULTS

A systematic search of the MEDLINE (via PubMed), Scopus, and Web of Science databases was conducted to identify experimental studies addressing the effect of different physical exercise training programmes on exercise capacity and cardiac function in heart failure with preserved ejection fraction. Comparative evaluation of the effect of exercise training type was performed by conducting a standard pairwise meta-analysis and a network meta-analysis for direct and indirect comparisons between exercise training types and controls/non-interventions. Eleven studies were included in the analysis showing that endurance training improves the main exercise capacity parameters (VO2peak, workload, exercise time, peak heart rate, VO2, and 6 min walk distance). Additionally, endurance/resistance training showed a significant effect on VO2peak, workload, early mitral annulus velocity, and early mitral/mitral annulus velocity ratio. Finally, HIIT showed a significant effect on VO2peak, VO2, and the early mitral/mitral annulus velocity ratio.

CONCLUSION

Our findings support the effect of three different types of physical exercise on exercise capacity, mainly VO2peak. Additionally, endurance/resistance training and HIIT could reverse left ventricular remodelling in patients with heart failure with preserved ejection fraction.

REGISTRATION

PROSPERO: CRD42021276111.

Determinants of Anaerobic Threshold at Each Stage of Renal Dysfunction in Patients With Heart Disease

Patients with heart disease have a low anaerobic threshold (AT), and the determinants of AT may differ, depending on the severity of renal dysfunction. This study aimed to verify the determinants of AT for each stage of renal function in patients with heart disease. We consecutively enrolled 250 patients with heart disease who underwent cardiopulmonary exercise testing in our institution. The patients were divided into 3 groups by their estimated glomerular filtration rate (eGFR): <45, 45 to 59, and ≥60 ml/min/1.73 m2. A multivariate linear regression analysis was performed to evaluate the independent determinants of AT for each group. In total, 201 patients were analyzed. AT decreased with the deterioration of renal function (eGFR <45, 10.9 ± 2.1 vs eGFR 45 to 59, 12.4 ± 2.5 vs eGFR ≥60, 14.0 ± 2.6 ml/min/kg, p <0.001). In the eGFR <45 group, left ventricular ejection fraction and hemoglobin were significantly associated with AT (β = 0.427, p = 0.006 and β = 0.488, p = 0.002, respectively). In the eGFR 45 to 59 and ≥60 groups, ΔPETO2 (end-tidal oxygen partial pressure from rest to AT) showed a significant association with AT (β = 0.576, p <0.001 and β = 0.308, p = 0.003, respectively). The determinants of AT depended on the stage of renal dysfunction in patients with heart disease. In conclusion, in the eGFR <45 group, the determinants of AT were left ventricular ejection fraction and hemoglobin, whereas in the eGFR 45 to 59 and eGFR ≥60 groups, the determinant of AT was ΔPETO2.

Physical Activity During Breast Cancer Therapy Associates With Preserved Exercise Capacity and Cardiac Function (WF97415)

Background

Cancer treatment increases cardiovascular disease risk, but physical activity (PA) may prevent cardiovascular disease.

Objectives

This study examined whether greater PA was associated with better submaximal exercise capacity and cardiac function during cancer therapy.

Methods

Participants included 223 women with stage I to III breast cancer (BC) before and 3 months after undergoing treatment and 126 control participants. Leisure-time PA (LTPA) was reported using the Godin-Shephard LTPA questionnaire. Cardiac function was assessed by cardiac magnetic resonance. Submaximal exercise capacity was determined by 6-minute walk distance.

Results

BC participants reported similar baseline LTPA scores (24.7; 95% CI: 21.7-28.0) as control participants (29.4; 95% CI: 25.0-34.2). The BC group declined to 16.9 (95% CI: 14.4-19.6) at 3 months relative to 30.8 (95% CI: 26.2-35.8) in control participants. Among BC participants, more LTPA was related to better exercise capacity (β ± SE: 7.1 ± 1.6; 95% CI: 4.0-10.1) and left ventricular (LV) circumferential strain (-0.16 ± 0.07; 95% CI: -0.29 to -0.02). Increased LTPA over the 3 months was associated with decreased likelihood of treatment-induced cardiac dysfunction according to LV circumferential strain classifications (OR: 0.98; 95% CI: 0.97-0.998). BC participants reporting insufficient LTPA according to PA guidelines exhibited deteriorations in exercise capacity (adjusted mean difference ± SE: -29 ± 10 m; P = 0.029), LV end-systolic volume (5.8 ± 1.3 mL; P < 0.001), LV ejection fraction (-3.2% ± 0.8%; P = 0.002), and LV circumferential strain (2.5% ± 0.5%; P < 0.001), but BC participants meeting LTPA guidelines did not exhibit these adverse changes.

Conclusions

PA declined during BC therapy; however, PA participation was associated with attenuated declines in exercise capacity and cardiac function that are often observed in this population. (Understanding and Predicting Breast Cancer Events After Treatment [WF97415 UPBEAT]; NCT02791581).

The Effects of Cardiac Rehabilitation including Nordic Walking in Patients with Chronic Coronary Syndromes after Percutaneous Coronary Interventions in Elective Mode

Background: Percutaneous coronary intervention (PCI) in patients with chronic coronary syndrome (CCS) is a worldwide method of coronary revascularisation. The aim of this study was to assess the immediate and long-term effects of Nordic Walking (NW) training added to a standard cardiac rehabilitation programme on physical activity (PA) and capacity and life quality, as well as selected proatherogenic risk factors. Methods: The studied group comprised 50 patients (considering exclusion criteria, 40 patients), aged 56-70, with CCS after elective PCI qualified them for a 6-weeks-long cardiac rehabilitation. The follow-up period lasted 4 months, and control visits occurred at 2 and 4 months. The studied patients were randomly divided into two groups: control group-standard cardiac rehabilitation programme and experimental group-standard cardiac rehabilitation programme additionally combined with NW training. Results: The cardiac rehabilitation programme in the experimental, compared to the control group, increased intense PA (from 731.43 ± 909.9 to 2740 ± 2875.96 vs. from 211.43 ± 259.43 to 582.86 ± 1289.74 MET min/week) and aerobic efficiency-VO2peak (from 8.67 ± 0.88 to 9.96 ± 1.35 vs. from 7.39 ± 2 to 7.41 ± 2.46 METs), as well as quality of life according to the WHOQOL-BREF questionnaire (from 3.57 ± 0.51 to 4.14 ± 0.36 vs. from 3.29 ± 0.47 to 3.57 ± 0.51 points). The walking distance assessed with the 6-min walk test did not differ between the groups before the beginning of the rehabilitation programme. Both at the I follow-up and II follow-up time points, a significant increase in the walking distance was noted in the control and experimental groups compared to baseline, and the difference between both groups was significant at the end of follow-up (378.57 ± 71.35 vs. 469.29 ± 58.07, p = 0.003). Moreover, NW had a positive effect on the modulation within selected biochemical risk factors of atherosclerosis, as well as subjective quality of life and well-being. Conclusions: Introducing NW training into the cardiac rehabilitation process proved to be a more effective form of therapy in patients with CCS treated via PCI, as compared to the standard cardiac rehabilitation programme alone.

Different exercise training intensities prevent type 2 diabetes mellitus-induced myocardial injury in male mice

Type 2 diabetes mellitus (T2DM) usually develop myocardial injury and that exercise may have a positive effect on cardiac function. However, the effect of exercise intensity on cardiac function has not yet been fully examined. This study aimed to explore different exercise intensities on T2DM-induced myocardial injury. 18-week-old male mice were randomly divided into four groups: a control group, the T2DM, T2DM + medium-intensity continuous training (T2DM + MICT), and T2DM + high-intensity interval training (T2DM + HIIT) groups. In the experimental group, mice were given high-fat foods and streptozotocin for six weeks and then divided into two exercise training groups, in which mice were subjected to exercise five days per week for 24 consecutive weeks. Finally, metabolic characteristics, cardiac function, myocardial remodeling, myocardial fibrosis, oxidative stress, and apoptosis were analyzed. HIIT treatment improved cardiac function and improved myocardial injury. In conclusion, HIIT may be an effective means to guard against T2DM-induced myocardial injury.

Mechanisms of trastuzumab induced cardiotoxicity - is exercise a potential treatment?

The use of the adjuvant therapeutic antibody trastuzumab in breast cancer is associated with a range of cardiotoxic side effects despite successfully reducing the severity of outcomes cancer patients,. The most common cardiac effect, a reduction in left ventricular ejection fraction (LVEF), is a known precursor to heart failure and often requires interruption of chemotherapy to avoid endangering patients further. An understanding of trastuzumab's cardiac-specific interactions is therefore critical in devising new methods to not only avoid permanent cardiac damage, but also prolong treatment time, and therefore effectiveness, for breast cancer patients. Increasingly, the use of exercise as a treatment has been indicated across the field of cardio-oncology due to encouraging evidence that it can protect against LVEF reductions and heart failure. This review explores the mechanisms of trastuzumab-mediated cardiotoxicity, as well as the physiological effects of exercise on the heart, in order to assess the suitability of exercise intervention for breast cancer patients on trastuzumab antibody-therapy. We furthermore draw comparison to existing evidence for exercise intervention as a cardioprotective treatment in doxorubicin-induced cardiotoxicity. Although preclinical evidence seems to support exercise-based approaches also in trastuzumab-cardiotoxicity, current clinical evidence is too limited to confidently recommend it as a treatment, largely owing to issues of adherence. Future studies should therefore examine how the variety and duration of exercise can be adjusted to improve treatment effectiveness at a more personalised level.

Effects of different exercise modalities on inhibiting left ventricular pathological remodeling in patients with heart failure with reduced ejection fraction: A systematic review and network meta-analysis

AIMS

To evaluate the effects of different exercise training modalities on inhibiting the left ventricular pathological remodeling in patients with heart failure with reduced ejection fraction (HFrEF) and screen out the optimal exercise modality.

METHODS

We performed a network meta-analysis based on the Frequentist model. Random-effect meta-analyses were used to estimate mean differences (MD) and 95 % confidence intervals.

KEY FINDINGS

25 randomized controlled trials (1284 patients) were enrolled in this study. Results revealed that: high-intensity interval training had the best effect in improving left ventricular ejection fraction (p-score = 0.93, MD: 6.44 (3.61 to 9.28)), reducing left ventricular end-diastolic diameter (p-score = 0.97, MD: -6.73 (-10.27 to -3.19)) and left ventricular end-systolic diameter (p-score = 0.97, MD: -9.33 (-14.90 to -3.76)). Combined aerobic training with resistance training and inspiratory muscle training had the best effect in improving maximal oxygen consumption (p-score = 0.90, MD: 5.19 (3.12 to 7.25)).

SIGNIFICANCE

Current evidence revealed that exercise training could effectively inhibit left ventricular pathological remodeling in patients with HFrEF. For efficacy, high-intensity interval training may have greater potential.

Ischemia With Nonobstructive Coronary Artery Disease: Concept, Assessment, and Management

In daily clinical practice, physicians often encounter patients with angina or those with evidence of myocardial ischemia from noninvasive tests but not having obstructive coronary artery disease. This type of ischemic heart disease is referred to as ischemia with nonobstructive coronary arteries (INOCA). INOCA patients often suffer from recurrent chest pain without adequate management and are associated with poor clinical outcomes. There are several endotypes of INOCA, and each endotype should be treated based on its specific underlying mechanism. Therefore, identifying INOCA and discriminating its underlying mechanisms are important issues and of clinical interest. Invasive physiologic assessment is the first step in the diagnosis of INOCA and discriminating the underlying mechanism; additional provocation tests help physicians identify the vasospastic component in INOCA patients. Comprehensive information acquired from these invasive tests can provide a template for mechanism-specific management for patients with INOCA.

Inflammatory pathways in heart failure with preserved left ventricular ejection fraction: implications for future interventions

Many patients with symptoms and signs of heart failure have a left ventricular ejection fraction ≥50%, termed heart failure with preserved ejection fraction (HFpEF). HFpEF is a heterogeneous syndrome mainly affecting older people who have many other cardiac and non-cardiac conditions that often cast doubt on the origin of symptoms, such as breathlessness, or signs, such as peripheral oedema, rendering them neither sensitive nor specific to the diagnosis of HFpEF. Currently, management of HFpEF is mainly directed at controlling symptoms and treating comorbid conditions such as hypertension, atrial fibrillation, anaemia, and coronary artery disease. HFpEF is also characterized by a persistent increase in inflammatory biomarkers. Inflammation may be a key driver of the development and progression of HFpEF and many of its associated comorbidities. Detailed characterization of specific inflammatory pathways may provide insights into the pathophysiology of HFpEF and guide its future management. There is growing interest in novel therapies specifically designed to target deregulated inflammation in many therapeutic areas, including cardiovascular disease. However, large-scale clinical trials investigating the effectiveness of anti-inflammatory treatments in HFpEF are still lacking. In this manuscript, we review the role of inflammation in HFpEF and the possible implications for future trials.

Coronary microvascular dysfunction: A review of recent progress and clinical implications

The coronary microcirculation plays a cardinal role in regulating coronary blood flow to meet the changing metabolic demands of the myocardium. Coronary microvascular dysfunction (CMD) refers to structural and functional remodeling of the coronary microcirculation. CMD plays a role in the pathogenesis of obstructive and non-obstructive coronary syndromes as well as myocardial diseases, including heart failure with preserved ejection fraction (HFpEF). Despite recent diagnostic advancements, CMD is often under-appreciated in clinical practice, and may allow for the development of novel therapeutic targets. This review explores the diagnosis and pathogenic role of CMD across a range of cardiovascular diseases, its prognostic significance, and the current therapeutic landscape.

Effects of Concurrent, Within-Session, Aerobic and Resistance Exercise Training on Functional Capacity and Muscle Performance in Elderly Male Patients with Chronic Heart Failure

BACKGROUND

The best format of exercise training (ET) in the setting of cardiac rehabilitation in patients with chronic heart failure (CHF) is still to be defined. Current guidelines recommend aerobic exercises, such as running and cycling, including some sessions per week of resistance exercise.

AIM

The aim of this study was to address the effectiveness of a concurrent exercise training program utilizing a circuit of sequential endurance and resistance exercises on functional capacity and muscular strength in patients with CHF.

METHODS

Ninety-five consecutive male patients (age 63.1 ± 6 years) with CHF (EF < 40%) in NYHA functional class II/III, were randomly assigned on 1:1 basis to a 12-week aerobic continuous training (AT) or concurrent CT), aerobic + resistance, training (CT), three times a week, with each session lasting 80 min. We used high quality, specifically designed ergometers, connected with each other and governed by a central console, and managed by a single physiotherapist. Before and after training all patients performed a symptoms-limited exercise test on a treadmill and a 6-min walking test (6MWT). Patients in the CT group also performed resistance exercises of upper and lower body.

RESULTS

The 6MWT and exercise duration at ergometric test increased significantly in both AT and CT groups, with the increase being greater in CT group (p < 0.001; ES = 0.13; p < 0.01; ES = 0.07). Muscular strength increased significantly in the CT group, particularly in the lower body muscular districts (p < 0.001). Quality of life improved in both groups, with a significantly greater improvement in the CT group (p < 0.05). No side effects leading to discontinuation of training were observed.

CONCLUSIONS

These findings indicate that concurrent, within-session training results in larger improvements in functional capacity, in addition to muscle performance, in patients with CHF, in comparison to single-mode aerobic training.

Cardiac rehabilitation in heart failure with severely reduced ejection fraction: effects on mortality

Thirty years ago, patients with low ejection fraction (EF) have often been excluded from rehabilitation programs due to concern about possibility of sudden death or other adverse cardiovascular events during exercise sessions. Recent studies have highlighted the fact that cardiac rehabilitation could improve exercise capacity, cardiac function, and health-related quality of life in congestive heart failure patients. This encouraged us to write a review article and update our latest knowledge about the outcome of rehabilitation program in patients with severely depressed cardiac function. We were particularly interested in effect of cardiac rehabilitation on exercise capacity, quality of life, vascular effects, neuro-hormonal changes, and mortality. We also conducted a mini-systematic review and meta-analysis on randomized controlled trials comparing exercise training with usual care in patients with severely reduced left ventricular ejection fraction, for the mortality subsection to obtain precise estimates of overall treatment benefit on mortality. It is our privilege to submit our manuscript for possible publication in your prestigious journal.

[Cardiac rehabilitation: investigation of efficacy, results, perspectives]

Previous research experience on cardiac rehabilitation programs as a part of general health care system has shown that they are an important part of the management of cardiovascular patients. Improving quality of life, reducing the severity of risk factors, increasing physical performance, slowing disease progression, decrease in morbidity and mortality indicate the clinical efficacy of cardiac rehabilitation and make it an integral part of therapeutic interventions. Heart rehabilitation is a 1st class recommendation in the majority of modern cardiovascular guidelines around the world.

Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.

Cognitive decline in heart failure: Biomolecular mechanisms and benefits of exercise

By definition, heart failure (HF) is a human pathological condition affecting the structure and function of all organs in the body, and the brain is not an exception to that. Failure of the heart to pump enough blood centrally and peripherally is at the foundation of HF patients' inability to attend even the most ordinary daily activities and progressive deterioration of their cognitive capacity. What is more, between heart and brain exists a bidirectional relationship that goes well beyond hemodynamics and concerns bioelectric and endocrine signaling. This increasingly consolidated evidence makes the scenario even more complex. Studies have mainly chased how HF impairs cognition without focusing much on preventive measures, notably cardio-cerebral health proxies. Here, we aim to provide a brief account of known and hypothetical factors that may explain how exercise can help obviate cognitive dysfunction associated with HF in its different forms. As we shall see, there is a stringent need for a deeper grasp of such mechanisms. Indeed, gaining this new knowledge will automatically shed new light on the inner workings of HF itself, thus resulting in more effective prevention and treatment of this escalating syndrome.

Relationship of arterial tonometry and exercise in patients with chronic heart failure: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Arterial stiffness is a common characteristic in patients with chronic heart failure (CHF), and arterial tonometric technologies related to arterial stiffness are novel and effective methods and have an important value in the diagnosis and prognosis of CHF. In terms of ameliorating arterial stiffness in patients with CHF, exercise training is considered an adjuvant treatment and also an effective means in the diagnosis and judgment of prognosis. However, there are huge controversies and inconsistencies in these aspects. The objective of this meta-analysis was to systematically test the connection of arterial tonometry and exercise in patients with CHF.

METHODS

Databases, including MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, were accessed from inception to 7 March 2022. The meta-analysis was then conducted, and trial sequential analysis (TSA) was performed jointly to further verify our tests and reach more convincing conclusions by using RevMan version 5.4 software, STATA version 16.0 software, and TSA version 0.9.5.10 Beta software.

RESULTS

Eighteen articles were included, with a total of 876 participants satisfying the inclusion criteria. The pooling revealed that flow-mediated dilation (FMD) was lower in basal condition [standardized mean difference (SMD): - 2.28%, 95% confidence interval (CI) - 3.47 to - 1.08, P < 0.001] and improved significantly after exercise (SMD: 5.96%, 95% CI 2.81 to 9.05, P < 0.001) in patients with heart failure with reduced ejection fraction (HFrEF) compared with healthy participants. The high-intensity training exercise was more beneficial (SMD: 2.88%, 95% CI 1.78 to 3.97, P < 0.001) than the moderate-intensity training exercise to improve FMD in patients with CHF. For augmentation index (AIx), our study indicated no significant differences (SMD: 0.50%, 95% CI - 0.05 to 1.05, P = 0.074) in patients with heart failure with preserved ejection fraction (HFpEF) compared with healthy participants. However, other outcomes of our study were not identified after further verification using TSA, and more high-quality studies are needed to reach definitive conclusions in the future.

CONCLUSIONS

This review shows that FMD is lower in basal condition and improves significantly after exercise in patients with HFrEF compared with healthy population; high-intensity training exercise is more beneficial than moderate-intensity training exercise to improve FMD in patients with CHF; besides, there are no significant differences in AIx in patients with HFpEF compared with the healthy population. More high-quality studies on this topic are warranted.

Effects of a Long-Term Wearable Activity Tracker-Based Exercise Intervention on Cardiac Morphology and Function of Patients with Cystic Fibrosis

Several studies have shown that patients with cystic fibrosis (CF), even at a young age, have pulmonary and cardiac abnormalities. The main complications are cardiac right ventricular (RV) systolic and/or diastolic dysfunction and pulmonary hypertension, which affects their prognosis. Exercise training (ET) is recommended in patients with CF as a therapeutic modality to improve physical fitness and health-related quality of life. However, questions remain regarding its optimal effective and safe dose and its effects on the patients’ cardiac function. The study aimed to provide a wearable activity tracker (WAT)-based ET to promote physical activity in CF patients and assess its effects on cardiac morphology and function. Forty-two stable CF individuals (aged 16.8 ± 3.6 years) were randomly assigned to either the intervention (Group A) or the control group (Group B). Group A participated in a 1-year WAT-based ET program three times per week. All patients underwent a 6-min walking test (6-MWT) and an echocardiographic assessment focused mainly on RV anatomy and function at the baseline and the end of the study. RV systolic function was evaluated by measuring the tricuspid annular plane systolic excursion (TAPSE), the systolic tricuspid annular velocity (TVS’), the RV free-wall longitudinal strain (RVFWSL), and the right ventricular four-chamber longitudinal strain (RV4CSL). RV diastolic function was assessed using early (TVE) and late (TVA) diastolic transtricuspid flow velocity and their ratio TVE/A. Pulmonary artery systolic pressure (PASP) was also estimated. In Group A after ET, the 6MWT distance improved by 20.6% (p < 0.05), TVA decreased by 17% (p < 0.05), and TVE/A increased by 13.2% (p < 0.05). Moreover, TAPSE, TVS’, RVFWSL, and RV4CSL increased by 8.3% (p < 0.05), 9.0% (p < 0.05), 13.7% (p < 0.05), and 26.7% (p < 0.05), respectively, while PASP decreased by 7.6% (p < 0.05). At the end of the study, there was a significant linear correlation between the number of steps and the PASP (r = −0.727, p < 0.01) as well as the indices of RV systolic function in Group A. In conclusion, WAT is a valuable tool for implementing an effective ET program in CF. Furthermore, ET has a positive effect on RV systolic and diastolic function.

Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis

Background

This review aimed to compare the relative effectiveness of different exercise-based cardiac rehabilitation (ExCR) delivery modes (centre-based, home-based, hybrid and technology-enabled ExCR) on key heart failure (HF) outcomes: exercise capacity, health-related quality of life (HRQoL), HF-related hospitalisation and HF-related mortality.

Methods and results

Randomised controlled trials (RCTs) published through 20 June 2021 were identified from six databases, and reference lists of included studies. Risk of bias and certainty of evidence were evaluated using the Cochrane tool and Grading of Recommendations Assessment, Development and Evaluation, respectively. Bayesian network meta-analysis was performed using R. Continuous and binary outcomes are reported as mean differences (MD) and ORs, respectively, with 95% credible intervals (95% CrI). One-hundred and thirty-nine RCTs (n=18 670) were included in the analysis. Network meta-analysis demonstrated improvements in VO₂peak following centre-based (MD (95% CrI)=3.10 (2.56 to 3.65) mL/kg/min), home-based (MD=2.69 (1.67 to 3.70) mL/kg/min) and technology-enabled ExCR (MD=1.76 (0.27 to 3.26) mL/kg/min). Similarly, 6 min walk distance was improved following hybrid (MD=84.78 (31.64 to 138.32) m), centre-based (MD=50.35 (30.15 to 70.56) m) and home-based ExCR (MD=36.77 (12.47 to 61.29) m). Incremental shuttle walk distance did not improve following any ExCR delivery modes. Minnesota living with HF questionnaire improved after centre-based (MD=−10.38 (−14.15 to –6.46)) and home-based ExCR (MD=−8.80 (−13.62 to –4.07)). Kansas City Cardiomyopathy Questionnaire was improved following home-based ExCR (MD=20.61 (4.61 to 36.47)), and Short Form Survey 36 mental component after centre-based ExCR (MD=3.64 (0.30 to 6.14)). HF-related hospitalisation and mortality risks reduced only after centre-based ExCR (OR=0.41 (0.17 to 0.76) and OR=0.42 (0.16 to 0.90), respectively). Mean age of study participants was only associated with changes in VO₂peak.

Conclusion

ExCR programmes have broader benefits for people with HF and since different delivery modes were comparably effective for improving exercise capacity and HRQoL, the selection of delivery modes should be tailored to individuals’ preferences.

Is Exercise Blood Pressure Putting the Brake on Exercise Rehabilitation after Acute Type A Aortic Dissection Surgery?

(1) Background: Exercise is recommended to improve physical fitness in patients recovering from acute type A aortic dissection (ATAAD). However, surgery corrects the diseased blood vessels and reduces the risk of ATAAD, but it does not redefine a safe exercise blood pressure (BP) threshold. This review aimed to discuss whether the safe threshold of exercise BP can be upregulated after ATAAD surgery to increase exercise intensity with additional benefits. (2) Data sources: The PubMed databases were searched with the keywords “type A acute aortic dissection surgery”, “exercise”, “BP”, “stress”, and variations of these terms. (3) Study selection: Data from clinical trials, guidelines, and recent reviews were selected for review. (4) Results: Regular exercise can be considered a cardioprotective intervention for aortic dissection patients by attenuating hemodynamic responses at rest and during exercise. Previous studies have mainly focused on moderate-intensity aerobic exercise. In practice, the exercise systolic BP of some patients was higher than 160 mm Hg without adverse events, which indicates that the training intensity may be underestimated for patients after ATAAD surgery. Limited studies suggest a light-to-moderate resistance training for selected patients because it may cause a greater increase in BP. (5) Conclusions: Moderate-intensity continuous aerobic exercise supplemented by low-intensity resistance training is appropriate for cardiac rehabilitation after ATAAD surgery. The BP increase based on the normal exercise BP response, corresponding to the moderate-intensity is relatively safe. For high-risk post-ATAAD patients, considering the overall volume of training, personalizing the exercise regimen to remain within “safe” BP limits, and avoiding excessive fluctuations in BP should be the primary considerations for exercise training.

A Contemporary Review of the Effects of Exercise Training on Cardiac Structure and Function and Cardiovascular Risk Profile: Insights From Imaging

Exercise is a commonly prescribed therapy for patients with established cardiovascular disease or those at high risk for de novo disease. Exercise-based, multidisciplinary programs have been associated with improved clinical outcomes post myocardial infarction and is now recommended for patients with cancer at elevated risk for cardiovascular complications. Imaging studies have documented numerous beneficial effects of exercise on cardiac structure and function, vascular function and more recently on the cardiovascular risk profile. In this contemporary review, we will discuss the effects of exercise training on imaging-derived cardiovascular outcomes. For cardiac imaging via echocardiography or magnetic resonance, we will review the effects of exercise on left ventricular function and remodeling in patients with established or at risk for cardiac disease (myocardial infarction, heart failure, cancer survivors), and the potential utility of exercise stress to assess cardiac reserve. Exercise training also has salient effects on vascular function and health including the attenuation of age-associated arterial stiffness and thickening as assessed by Doppler ultrasound. Finally, we will review recent data on the relationship between exercise training and regional adipose tissue deposition, an emerging marker of cardiovascular risk. Imaging provides comprehensive and accurate quantification of cardiac, vascular and cardiometabolic health, and may allow refinement of risk stratification in select patient populations. Future studies are needed to evaluate the clinical utility of novel imaging metrics following exercise training.

Physical Exercise Promotes a Reduction in Cardiac Fibrosis in the Chronic Indeterminate Form of Experimental Chagas Disease

Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is a neglected tropical disease and a health problem in Latin America. Etiological treatment has limited effectiveness in chronic CD; thus, new therapeutic strategies are required. The practice of physical exercises has been widely advocated to improve the quality of life of CD patients. The most frequent clinical CD manifestation is the chronic indeterminate form (CIF), and the effect of physical exercises on disease progression remains unknown. Here, in a CIF model, we aimed to evaluate the effect of physical exercises on cardiac histological, parasitological, mitochondrial, and oxidative metabolism, electro and echocardiographic profiles, and immunological features. To establish a CIF model, BALB/c and C57BL/6 mice were infected with 100 and 500 trypomastigotes of the Y T. cruzi strain. At 120 days postinfection (dpi), all mouse groups showed normal PR and corrected QT intervals and QRS complexes. Compared to BALB/c mice, C57BL/6 mice showed a lower parasitemia peak, mortality rate, and less intense myocarditis. Thus, C57BL/6 mice infected with 500 parasites were used for subsequent analyses. At 120 dpi, a decrease in cardiac mitochondrial oxygen consumption and an increase in reactive oxygen species (ROS) were detected. When we increased the number of analyzed mice, a reduced heart rate and slightly prolonged corrected QT intervals were detected, at 120 and 150 dpi, which were then normalized at 180 dpi, thus characterizing the CIF. Y-infected mice were subjected to an exercise program on a treadmill for 4 weeks (from 150 to 180 dpi), five times per week in a 30–60-min daily training session. At 180 dpi, no alterations were detected in cardiac mitochondrial and oxidative metabolism, which were not affected by physical exercises, although ROS production increased. At 120 and 180 dpi, comparing infected and non-infected mice, no differences were observed in the levels of plasma cytokines, indicating that a crucial biomarker of the systemic inflammatory profile was absent and not affected by exercise. Compared with sedentary mice, trained Y-infected mice showed similar parasite loads and inflammatory cells but reduced cardiac fibrosis. Therefore, our data show that physical exercises promote beneficial changes that may prevent CD progression.

Long Non-Coding RNAs in Cardiovascular Diseases: Potential Function as Biomarkers and Therapeutic Targets of Exercise Training

Despite advances in treatments and therapies, cardiovascular diseases (CVDs) remain one of the leading causes of death worldwide. The discovery that most of the human genome, although transcribed, does not encode proteins was crucial for focusing on the potential of long non-coding RNAs (lncRNAs) as essential regulators of cell function at the epigenetic, transcriptional, and post-transcriptional levels. This class of non-coding RNAs is related to the pathophysiology of the cardiovascular system. The different expression profiles of lncRNAs, in different contexts of CVDs, change a great potential in their use as a biomarker and targets of therapeutic intervention. Furthermore, regular physical exercise plays a protective role against CVDs; on the other hand, little is known about its underlying molecular mechanisms. In this review, we look at the accumulated knowledge on lncRNAs and their functions in the cardiovascular system, focusing on the cardiovascular pathology of arterial hypertension, coronary heart disease, acute myocardial infarction, and heart failure. We discuss the potential of these molecules as biomarkers for clinical use, their limitations, and how the manipulation of the expression profile of these transcripts through physical exercise can begin to be suggested as a strategy for the treatment of CVDs.

Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review

Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.

Optimizing Outcomes in Cardiac Rehabilitation: The Importance of Exercise Intensity

Exercise based cardiac rehabilitation (CR) is recognized internationally as a class 1 clinical practice recommendation for patients with select cardiovascular diseases and heart failure with reduced ejection fraction. Over the past decade, several meta-analyses have generated debate regarding the effectiveness of exercise-based CR for reducing all-cause and cardiovascular mortality. A common theme highlighted in these meta-analyses is the heterogeneity and/or lack of detail regarding exercise prescription methodology within CR programs. Currently there is no international consensus on exercise prescription for CR, and exercise intensity recommendations vary considerably between countries from light-moderate intensity to moderate intensity to moderate-vigorous intensity. As cardiorespiratory fitness [peak oxygen uptake (VO₂peak)] is a strong predictor of mortality in patients with coronary heart disease and heart failure, exercise prescription that optimizes improvement in cardiorespiratory fitness and exercise capacity is a critical consideration for the efficacy of CR programming. This review will examine the evidence for prescribing higher-intensity aerobic exercise in CR, including the role of high-intensity interval training. This discussion will highlight the beneficial physiological adaptations to pulmonary, cardiac, vascular, and skeletal muscle systems associated with moderate-vigorous exercise training in patients with coronary heart disease and heart failure. Moreover, this review will propose how varying interval exercise protocols (such as short-duration or long-duration interval training) and exercise progression models may influence central and peripheral physiological adaptations. Importantly, a key focus of this review is to provide clinically-relevant recommendations and strategies to optimize prescription of exercise intensity while maximizing safety in patients attending CR programs.

Sex-Specific Impacts of Exercise on Cardiovascular Remodeling

Cardiovascular diseases (CVD) remain the leading cause of death in men and women. Biological sex plays a major role in cardiovascular physiology and pathological cardiovascular remodeling. Traditionally, pathological remodeling of cardiovascular system refers to the molecular, cellular, and morphological changes that result from insults, such as myocardial infarction or hypertension. Regular exercise training is known to induce physiological cardiovascular remodeling and beneficial functional adaptation of the cardiovascular apparatus. However, impact of exercise-induced cardiovascular remodeling and functional adaptation varies between males and females. This review aims to compare and contrast sex-specific manifestations of exercise-induced cardiovascular remodeling and functional adaptation. Specifically, we review (1) sex disparities in cardiovascular function, (2) influence of biological sex on exercise-induced cardiovascular remodeling and functional adaptation, and (3) sex-specific impacts of various types, intensities, and durations of exercise training on cardiovascular apparatus. The review highlights both animal and human studies in order to give an all-encompassing view of the exercise-induced sex differences in cardiovascular system and addresses the gaps in knowledge in the field.

Exercise during Pregnancy: Developmental Programming Effects and Future Directions in Humans

Epidemiological studies show that low birth weight is associated with mortality from cardiovascular disease in adulthood, indicating that chronic diseases could be influenced by hormonal or metabolic insults encountered in utero. This concept, now known as the Developmental Origins of Health and Disease hypothesis, postulates that the intrauterine environment may alter the structure and function of the organs of the fetus as well as the expression of genes that impart an increased vulnerability to chronic diseases later in life. Lifestyle interventions initiated during the prenatal period are crucial as there is the potential to attenuate progression towards chronic diseases. However, how lifestyle interventions such as physical activity directly affect human offspring metabolism and the potential mechanisms involved in regulating metabolic balance at the cellular level are not known. The purpose of this review is to highlight the effects of exercise during pregnancy on offspring metabolic health and emphasize gaps in the current human literature and suggestions for future research.

Difference in Prognosis between Continuation and Discontinuation of A 5-Month Cardiac Rehabilitation Program in Outpatients with Heart Failure with Preserved Ejection Fraction

Background: Cardiac rehabilitation (CR) is a requisite component of care for patients with heart failure (HF). We aimed to evaluate the clinical outcomes in outpatients with HF with preserved ejection fraction (HFpEF) compared to those in patients with non-HFpEF who did and did not continue a 5-month CR program. Methods: 173 outpatients with HF who participated in a 5-month CR program were registered. We divided them into two groups: HFpEF (n = 84, EF 63 ± 7%) and non-HFpEF (n = 89, EF 31 ± 11%). We further divided the patients into those who continued the CR program (continued group) and those who did not (discontinued group) in the HFpEF and non-HFpEF groups. The clinical outcomes at 5 months were compared among the groups. Results: There were no significant differences in patient characteristics at baseline between the continued and discontinued groups in the HFpEF and non-HFpEF groups except for % diabetes mellitus in the non-HFpEF group. The rates of all-cause death and hospital admissions in the continued group in both the HFpEF and non-HFpEF groups were significantly lower than those in the discontinued group. The all-cause death and hospital admissions in each group were independently associated with the continuation of the CR program. Conclusions: The continuation of a 5-month CR program was associated with the prevention of all-cause death and hospital admissions in both the HFpEF and non-HFpEF groups.

The ergoreflex: how the skeletal muscle modulates ventilation and cardiovascular function in health and disease

The control of ventilation and cardiovascular function during physical activity is partially regulated by the ergoreflex, a cardiorespiratory reflex activated by physical activity. Two components of the ergoreflex have been identified: the mechanoreflex, which is activated early by muscle contraction and tendon stretch, and the metaboreflex, which responds to the accumulation of metabolites in the exercising muscles. Patients with heart failure (HF) often develop a skeletal myopathy with varying degrees of severity, from a subclinical disease to cardiac cachexia. HF‐related myopathy has been associated with increased ergoreflex sensitivity, which is believed to contribute to dyspnoea on effort, fatigue and sympatho‐vagal imbalance, which are hallmarks of HF. Ergoreflex sensitivity increases significantly also in patients with neuromuscular disorders. Exercise training is a valuable therapeutic option for both HF and neuromuscular disorders to blunt ergoreflex sensitivity, restore the sympatho‐vagal balance, and increase tolerance to physical exercise. A deeper knowledge of the mechanisms mediating ergoreflex sensitivity might enable a drug or device modulation of this reflex when patients cannot exercise because of advanced skeletal myopathy.