Combined endurance and muscle strength training in female and male patients with chronic heart failure

Establishing a cardiac training group for patients with heart failure: the "HIP-in-Würzburg" study

Background

Exercise training in heart failure (HF) is recommended but not routinely offered, because of logistic and safety-related reasons. In 2020, the German Society for Prevention&Rehabilitation and the German Society for Cardiology requested establishing dedicated “HF training groups.” Here, we aimed to implement and evaluate the feasibility and safety of one of the first HF training groups in Germany.

Methods

Twelve patients (three women) with symptomatic HF (NYHA class II/III) and an ejection fraction ≤ 45% participated and were offered weekly, physician-supervised exercise training for 1 year. Patients received a wrist-worn pedometer (M430 Polar) and underwent the following assessments at baseline and after 4, 8 and 12 months: cardiopulmonary exercise test, 6-min walk test, echocardiography (blinded reading), and quality of life assessment (Kansas City Cardiomyopathy Questionnaire, KCCQ).

Results

All patients (median age [quartiles] 64 [49; 64] years) completed the study and participated in 76% of the offered 36 training sessions. The pedometer was worn ≥ 1000 min per day over 86% of the time. No cardiovascular events occurred during training. Across 12 months, NT-proBNP dropped from 986 pg/ml [455; 1937] to 483 pg/ml [247; 2322], and LVEF increased from 36% [29;41] to 41% [32;46]%, (p for trend = 0.01). We observed no changes in exercise capacity except for a subtle increase in peak VO₂% predicted, from 66.5 [49; 77] to 67 [52; 78]; p for trend = 0.03. The physical function and social limitation domains of the KCCQ improved from 60 [54; 82] to 71 [58; 95, and from 63 [39; 83] to 78 [64; 92]; p for trend = 0.04 and = 0.01, respectively. Positive trends were further seen for the clinical and overall summary scores.

Conclusion

This pilot study showed that the implementation of a supervised HF-exercise program is feasible, safe, and has the potential to improve both quality of life and surrogate markers of HF severity. This first exercise experiment should facilitate the design of risk-adopted training programs for patients with HF.

Resistance exercise enhances oxygen uptake without worsening cardiac function in patients with systolic heart failure: a systematic review and meta-analysis

Recent literature suggests that resistance training (RT) improves peak oxygen uptake ([Formula: see text] peak), similarly to aerobic exercise (AE) in patients with heart failure (HF), but its effect on cardiac remodeling is controversial. Thus, we examined the effects of RT and AE on [Formula: see text] peak and cardiac remodeling in patients with heart failure (HF) via a systematic review and meta-analysis. MEDLINE, EMBASE, Cochrane Library and CINAHL, AMEDEO and PEDro databases search were extracted study characteristics, exercise type, and ventricular outcomes. The main outcomes were [Formula: see text] peak (ml kg^-1 min^-1), LVEF (%) and LVEDV (mL). Fifty-nine RCTs were included. RT produced a greater increase in [Formula: see text] peak (3.57 ml kg^-1 min^-1, P < 0.00001, I ² = 0%) compared to AE (2.63 ml kg^-1 min^-1, P < 0.00001, I ² = 58%) while combined RT and AE produced a 2.48 ml kg^-1 min^-1 increase in [Formula: see text]; I ² = 69%) compared to control group. Comparison among the three forms of exercise revealed similar effects on [Formula: see text] peak (P = 0.84 and 1.00, respectively; I ² = 0%). AE was associated with a greater gain in LVEF (3.15%; P < 0.00001, I ² = 17%) compared to RT alone or combined exercise which produced similar gains compared to control groups. Subgroup analysis revealed that AE reduced LVEDV (- 10.21 ml; P = 0.007, I ² = 0%), while RT and combined RT and AE had no effect on LVEDV compared with control participants. RT results in a greater gain in [Formula: see text] peak, and induces no deleterious effects on cardiac function in HF patients.

Creatinine excretion rate, a marker of muscle mass, is related to clinical outcome in patients with chronic systolic heart failure

AIMS

In chronic heart failure (CHF), low body mass as a reflection of low muscle mass has been associated with poor outcome. Urinary creatinine excretion rate (CER) is an established marker of muscle mass, but has not been investigated in CHF. This study aims to evaluate urinary CER as a marker of muscle mass in patients with CHF and establish the relationship with clinical outcome.

METHODS AND RESULTS

In 120 patients with CHF, we evaluated CER as determined by mean creatinine excretion rate in two consecutive 24-h urine collections. We evaluated the relationship between CER and clinical variables using linear regression. Finally, we evaluated the association between CER and clinical outcome. Mean age was 59 ± 12 years, and 80% were male. Mean CER was 1,383 mg/day (range 412-2,930). Independent predictors of CER were body surface area (BSA) (β = 0.404, P < 0.001), gender (β = -0.180, P = 0.029), log N terminal pro-brain natriuretic peptide (NTproBNP) (β = -0.172, P = 0.048) and age (β = -0.168, P = 0.035). During three years of follow-up, 33 patients (28%) developed a clinical endpoint, defined as the first occurrence of either all-cause death, heart transplantation, myocardial infarction, or hospitalization for heart failure during three years of follow-up. In Cox regression analyses, log CER was associated with the occurrence of the clinical endpoint independent of age, gender, BSA, glomerular filtration rate and urinary albumin excretion, [hazard ratio 7.67 (1.82-32.3) per log decrease], but not independent of NTproBNP [hazard ratio 3.66 (0.79-17.0), P = 0.098].

CONCLUSIONS

Low urinary CER is associated with smaller body dimensions and more severe heart failure and is associated with an increased risk of adverse outcome.

Functional and psychosocial effects of either a traditional dancing or a formal exercising training program in patients with chronic heart failure: a comparative randomized controlled study

OBJECTIVE

To compare the effects of traditional dancing with formal exercise training in terms of functional and cardiovascular benefits and motivation in patients with chronic heart failure.

DESIGN

Randomized controlled trial.

SETTING

Sports Medicine Laboratory.

SUBJECTS

Fifty-one Greek male patients aged 67.1±5.5 years with chronic heart failure of New York Heart Association (NYHA) class II-III, participated in an eight-month study.

INTERVENTIONS

They were randomly assigned to either training with Greek traditional dances (group A, n=18), formal exercise training (group B, n=16) or a sedentary control group (group C, n=17).

MAIN MEASURES

At entry and the end of the study all patients underwent cardiopulmonary exercise testing, functional ability assessment and quality of life evaluations. The Intrinsic Motivation Inventory was also used to assess participants' subjective experience.

RESULTS

After training group A showed increased peak oxygen consumption by 33.8% (19.5 vs. 26.1 ml/kg/min, p<0.05) and B by 32.3% (19.5 vs. 25.8 ml/kg/min, p<0.05), maximal treadmill tolerance by 48.5% (p<0.05) and by 46.4% (p<0.05), and a decreased Slope of expired minute ventilation for carbon dioxide output (VE/VCO2) slope by 18% (p<0.05) and 19.5% (p<0.05), respectively. Trained patients revealed significant improvement in the quality of life indices. Intrinsic Motivation Inventory was increased only in group A by 26.2% (3.08 vs. 3.87, p<0.05).

CONCLUSIONS

Exercise training in chronic heart failure patients with Greek traditional dances led to functional and cardiovascular benefits similar to formal exercise training and to a higher level of motivation.

Exercício resistido no cardiopata: revisão sistemática

INTRODUÇÃO: A perda de massa muscular secundária à idade e à inatividade física é clinicamente relevante na população cardíaca; contudo, a prescrição do exercício resistido dinâmico para esses pacientes apresenta-se inconclusiva na literatura. OBJETIVOS: Reunir informações e apresentar as principais diretrizes relacionadas à prescrição de exercícios resistidos em cardiopatas. MATERIAIS E MÉTODOS: Foi realizada busca sistemática de literatura, a partir das bases de dados LILACS, SciELO e MEDLINE, utilizando os seguintes descritores na língua portuguesa: força muscular, exercício isométrico, esforço físico, cardiopatia e coronariopatia, e seus correspondentes na língua inglesa (muscle strength, isometric exercise, physical effort, heart disease e artery coronary disease), os quais foram pesquisados separadamente e em cruzamentos, sendo considerados para esta revisão apenas artigos publicados entre 2005 e 2010. RESULTADOS E DISCUSSÃO: De um total de 806 artigos foram selecionados 22 para integrar a revisão, sendo 14 estudos classificados como artigos originais, 2 artigos de atualização da literatura e 6 artigos de revisão, além do capítulo 8 do livro intitulado Diretrizes do ACSM (American College of Sports Medicine) para os testes de esforço e sua prescrição, publicado em 2007. CONCLUSÃO: O exercício resistido, independente da variada metodologia utilizada na prescrição dos componentes específicos do treinamento, mostrou-se eficiente para aumentar a força muscular de membros superiores e inferiores em cardiopatas e sua aplicação pode ser considerada segura para esses pacientes, desde que prescrito corretamente.

Acute effects of muscular counterpulsation therapy on cardiac output and safety in patients with chronic heart failure

Our aim was to investigate acute effects of muscular counterpulsation (MCP) on hemodynamic parameters and to evaluate its safety in regard to myocardial integrity and interferences with implanted rhythm devices in patients with chronic heart failure (CHF). A total of 22 patients with CHF (16 male, 67.8 ± 9.5 years, New York Heart Association [NYHA] class II + III, left ventricular ejection fraction 29.6 ± 6.6%) were treated with MCP for 3 consecutive days for 45 min, while hemodynamic parameters were measured noninvasively by bioimpedance (Task Force Monitor). Laboratory control and a complete device testing were performed prior to the first and after the third treatment. In addition, continuous rhythm device interrogation was performed online during the first MCP application. During each application, a significant increase in cardiac output (CO; average change +2.08 ± 2.33 L/min, P < 0.05) was documented. This increase was due to a decrease of total peripheral resistance (-336 ± 530 dyn × s/cm(5) , P < 0.05), to an augmented stroke volume (+8.35 ±  20.86 mL, P = n.s.), and an increase in heart rate (+17.12 ± 21.12 bpm, P < 0.05). Cardiac markers and enzymes were within normal limits at all times and did not increase during treatment. MCP stimuli were monitored using surface electrocardiogram, and no abnormal sensing or pacing events occurred. MCP acutely improves CO in patients with stable CHF. No adverse influence on myocardial integrity was observed nor were any inappropriate sensing or pacing artifacts detected in patients with implanted rhythm devices.

Clinical utility of exercise training in chronic systolic heart failure

The volume of literature attesting to the clinical benefits of exercise training in patients with stable chronic heart failure (CHF) is substantial. Training can improve symptoms and exercise capacity, as well as reducing morbidity, mortality, and rates of emergency hospitalization. These benefits are apparent in all patients with stable CHF, irrespective of age or sex, or the etiology or severity of heart failure. Training regimens for patients with stable, systolic CHF should form part of a comprehensive heart-failure support effort and are best delivered using supervised in-hospital exercise combined with some training at home or in a group setting in community centers. In this Review, the modes and intensity of exercise training, selection of patients, duration of training effects, and other clinical guidance for using this treatment option are discussed.

Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles

OBJECTIVE

To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.

DESIGN

A critical review of the literature (1994-2009).

FINDINGS

The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8-80% depression; 6-74% anxiety) and chronic heart failure (10-60% depression; 11-45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co-morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co-morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co-morbid depression and anxiety, however, this is insufficient to guide recommendations.

CONCLUSIONS

The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi-faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety.

Resistance training increases 6-minute walk distance in people with chronic heart failure: a systematic review

QUESTION

Does resistance training, either alone or as an adjunct to aerobic training, improve cardiac function, exercise capacity and quality of life in people with chronic heart failure?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults with stable chronic heart failure.

INTERVENTION

Progressive resistance exercise training, alone or as an adjunct to aerobic training.

OUTCOME MEASURES

Cardiac function, exercise capacity and quality of life.

RESULTS

241 participants from eight trials performed 2 to 6 months of moderate-intensity resistance training (50-75% of 1RM). Most programs consisted of 5 to 6 exercises for large limb and trunk muscles with two sets of 8 to 12 repetitions, three times a week. Resistance training significantly increased 6-minute walk distance (WMD 52 m, 95% CI 19 to 85) but not peak oxygen consumption (WMD 1.4 ml/kg/min, 95% CI -0.3 to 3.1). When used as an adjunct to aerobic training, resistance training did not significantly alter left ventricular ejection fraction (WMD -0.5%, 95% CI -4.3 to 3.3), peak oxygen consumption (WMD -0.7 ml/kg/min, 95% CI -2.3 to 1.0), or Minnesota Living with Heart Failure Questionnaire scores (WMD -0.9, 95% CI -5.4 to 3.7), compared with aerobic training alone.

CONCLUSION

Resistance training increased 6-minute walk distance compared to no training, but had no other benefits on cardiac function, exercise capacity, or quality of life if used alone or as an adjunct to aerobic training in people with chronic heart failure. However, further high quality, large scale, randomised trials are needed.

Intervention study shows outpatient cardiac rehabilitation to be economically at least as attractive as inpatient rehabilitation

BACKGROUND

Since the late 1990 s, cost pressure has led to a growing interest in outpatient rehabilitation in Germany where predominantly inpatient rehabilitation has been provided. Taking into account the feasibility of a randomized design, the aim of this study was to compare outpatient and inpatient cardiac rehabilitation from a societal perspective.

METHOD

A comprehensive cohort design was applied. Costs during rehabilitation were measured using individual documentation of the rehabilitation centers. Economic end points were quality of life (EQ-5D), and total direct and indirect costs. A propensity score approach, integrated into a simultaneous regression framework for cost and effects, was used to control for selection bias. Bootstrap analysis was applied for assessing uncertainty in cost-effectiveness.

RESULTS

A total of 163 patients were included in the study (112 inpatients, 51 outpatients). As randomization was chosen by only 2.5% of participants, the study had to be analyzed as an observational study. Direct costs during inpatient rehabilitation were significantly higher by 600 euro (+/-318; p < 0.001) compared to outpatient rehabilitation (2,016 euro +/- 354 euro vs. 1,416 euro +/- 315), while there was no significant difference in health-related quality of life. Over the 12-month follow-up period, adjusted costs difference in total cost was estimated at -2,895 euro (p = 0.102) and adjusted difference in effects at 0.018 quality-adjusted life years (QALYs) (n.s.) in favor of outpatient treatment.

CONCLUSION

The ratio of mean cost over mean effect difference (incremental cost-effectiveness ratio) indicates dominance of outpatient rehabilitation, but at a considerable statistical uncertainty. However, outpatient rehabilitation cannot be rejected from an economic perspective.

Comparison of skeletal muscle strength between cardiac patients and age-matched healthy controls

The purpose of the present study was to compare muscular strength of knee extensors and arm flexor muscles of cardiac patients (n = 638) and healthy controls (n = 961) in different age groups. Isometric torques were measured in a sitting position with the elbow, hip, and knee flexed to 90(0). For statistical analysis, age groups were pooled in decades from the age of 30 to 90 years. Additionally, the influence of physical lifestyle prior to disease on muscular strength was obtained in the patients. For statistical analysis three-way ANOVA (factors age, gender, and physical activity level) was used.Both in patients and in controls a significant age-dependent decline in maximal torque could be observed for arm flexors and knee extensors. Maximal leg extensor muscle showed statistically significant differences between healthy controls and cardiac patients as well as between subgroups of patients: Physically inactive patients showed lowest torques (male: 148 +/- 18 Nm; female: 82 +/- 25 Nm) while highest values were measured in control subjects (male: 167 +/- 16 Nm; female: 93 +/- 17 Nm). In contrast, arm flexor muscles did not show any significant influence of health status or sports history.This qualitative difference between weight-bearing leg muscles and the muscle group of the upper extremity suggest that lower skeletal muscle strength in heart patients is mainly a consequence of selective disuse of leg muscles rather than any pathological skeletal muscle metabolism. Since a certain level of skeletal muscle strength is a prerequisite to cope with everyday activities, strength training is recommended as an important part of cardiac rehabilitation.