The role of exercise training on cardiovascular peptides in patients with heart failure: A systematic review and meta-analysis

The effects of early exercise on cardiovascular biomarkers in patients with congestive heart failure

BACKGROUND

Exercise training improves functional outcomes in chronic heart failure (HF), but the effects of early in-hospital physical activity on cardiovascular biomarkers and prognosis in acute congestive heart failure (AHF) patients remain unclear. This study investigated the short-term impact of early rehabilitation on prognostic biomarkers-high-sensitivity troponin T (hs-TnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), soluble suppression of tumourigenesis-2 (sST2), galectin-3 (Gal-3) and endothelin-1 (ET-1)-and evaluated associations with clinical outcomes.

METHODS AND RESULTS

A total of 118 hospitalized AHF patients (35 controls and 83 exercise group) underwent biomarker measurement before and after supervised rehabilitation using non-invasive cardiac output monitoring. Serum levels of NT-proBNP, hs-TnT, sST2, Gal-3, and ET-1 were analysed. Prognosis was assessed via 12-month follow-up for all-cause mortality. Statistical analysis included ANOVA for biomarker changes and Kaplan-Meier survival analysis. Post-intervention, NT-proBNP levels increased significantly in the exercise group (2900 ± 700 pg/mL to 3500 ± 760 pg/mL, P = 0.012), as did ET-1 (1.9 ± 0.4 pg/mL to 2.4 ± 0.5 pg/mL, P = 0.018). Hs-TnT, sST2 and Gal-3 showed no significant changes (all P > 0.05). Survival analysis demonstrated higher baseline hs-TnT [hazard ratio (HR) 2.1, 95% confidence interval (CI) 1.3-3.4] and greater NT-proBNP elevation post-exercise (ΔNT-proBNP HR 1.8, 95% CI 1.1-2.9) were independent predictors of mortality.

CONCLUSIONS

Early in-hospital exercise in AHF patients transiently elevates NT-proBNP and ET-1, indicative of acute haemodynamic stress, without altering myocardial injury or fibrosis markers (hs-TnT, sST2 and Gal-3). Elevated baseline hs-TnT and post-exercise NT-proBNP increases correlate with poorer survival, highlighting their prognostic value in risk assessment.

Monitoring the Effects of Cardiac Rehabilitation Programs in Heart Failure Patients: The Role of Biomarkers

Heart failure (HF) is characterized by poor exercise tolerance and reduced ability to perform routine daily activities. Cardiac rehabilitation (CR), which includes exercise training, has shown a role in improving cardiac remodeling, functional capacity and HF outcomes as a consequence of its beneficial effects on neurohormonal dysfunction, endothelial function, vascular tone and peripheral oxygen extraction. Although a multiparametric evaluation, including physical examination, blood sampling, echocardiographic and cardiopulmonary exercise testing parameters, is routinely performed during CR programs, the use of cardiac biomarkers, in particular natriuretic peptides (NPs), is still poorly adopted and characterized. In this article we analyze the potential role of biomarkers in monitoring the success of rehabilitation programs and the potential implications of their use in clinical practice. Indeed, NPs measurements might represent an important tool to modulate the rehabilitative interventions with a favorable cost-effectiveness profile.

The impacts of exercise interventions on inflammaging markers in overweight/obesity patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

Objectives

The purpose of this meta-analysis was to investigate the association of aerobic, resistance and concurrent exercises vs. control group on inflammaging markers [tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-1-beta, IL-8, and high sensitivity C-reactive protein (hs-CRP)] in overweight or obesity patients with heart failure (HF).

Methods

The databases of Scopus, PubMed, Web of Science and Google Scholar were searched until August 31, 2022 for exercise interventions vs. control group on circulating inflammaging markers in patients with HF. Only randomized controlled trial (RCT) articles were included. Standardized mean difference (SMD) and 95% confidence intervals (95%CIs) were calculated (registration code = CRD42022347164).

Results

Forty-six full-text articles (57 intervention arms and 3693 participants) were included. A significant reduction was occurred in inflammaging markers of IL-6 [SMD-0.205(95% CI:-0.332 to -0.078),p = 0.002] and hs-CRP [SMD -0.379 (95% CI:-0.556 to -0.202), p = 0.001] with exercise training in patients with HF. Analysis of subgroup by age, body mass index (BMI), type, intensity, duration of exercise and mean left ventricular ejection fraction (LVEF) revealed that there was a significant reduction in TNF-α for middle-aged (p = 0.031), concurrent training (p = 0.033), high intensity (p = 0.005), and heart failure with reduced ejection fraction (HFrEF) (p = 0.007) compared to the control group. There was a significant reduction in IL-6 for middle-aged (p = 0.006), overweight (p = 0.001), aerobic exercise (p = 0.001), both high and moderate intensities (p = 0.037 and p = 0.034), short-term follow-up (p = 0.001), and heart failure with preserved ejection fraction (HFpEF) (p = 0.001) compared to the control group. There was a significant reduction in hs-CRP for middle-aged (p = 0.004), elderly-aged (p = 0.001), overweight (p = 0.001), aerobic exercise (p = 0.001), concurrent training (p = 0.031), both high and moderate intensities (p = 0.017 and p = 0.001), short-term (p = 0.011), long-term (p = 0.049), and very long-term (p = 0.016) follow-ups, HFrEF (p = 0.003) and heart failure with mildly reduced ejection fraction (HFmrEF) (p = 0.048) compared to the control group.

Conclusions

The results confirmed that aerobic exercise and concurrent training interventions were effective to improve inflammaging markers of TNF-α, IL-6, and hs-CRP. These exercise-related anti-inflammaging responses were observed across ages (middle-aged and elderly-aged), exercise intensities, duration of follow-ups, and mean LVEFs (HFrEF, HFmrEF and HFpEF) in overweight patients with HF.

Impacts of Exercise Interventions on Inflammatory Markers and Vascular Adhesion Molecules in Patients With Heart Failure: A Meta-analysis of RCTs

Background

The aim of this meta-analysis was to investigate the effects of concurrent, aerobic, and resistance exercise on markers of inflammation and vascular adhesion molecules (high-sensitivity C-reactive protein [hs-CRP], interleukin [IL]-6, tumour necrosis factor-alpha [TNF-α], soluble intercellular adhesion molecule-1 [sICAM-1], soluble vascular cell adhesion molecule-1 [sVCAM-1], fibrinogen, IL-1-β, IL-10, IL-18, and E-selectin) in patients with heart failure (HF).

Methods

The PubMed, Scopus, Web of Science, and Google Scholar databases were searched for dates up to August 31, 2022. Randomized controlled trial studies for exercise interventions on circulating inflammatory and vascular adhesion markers in patients with HF were included. Standardized mean difference (SMD) and 95% confidence interval (CI) were calculated.

Results

A total of 45 articles were included. Exercise training significantly reduced hs-CRP (SMD -0.441 [95% CI: -0.642 to -0.240], P = 0.001), IL-6 (SMD -0.158 (95% CI: -0.303 to -0.013], P = 0.032), and sICAM-1 (SMD -0.282 [95% CI: -0.477 to -0.086], P = 0.005) markers. Analysis of subgroups revealed that a significant reduction occurred in hs-CRP level for the following subgroups: middle-aged, elderly, overweight status, aerobic exercise, concurrent training, both high and moderate intensity, and short-term, long-term, and very long-term follow-up, compared to a control group (P < 0.05). A significant reduction occurred in IL-6 and sICAM-1 levels for those in the following subgroups, compared to a control group (P < 0.05): middle-aged, aerobic exercise, moderate-intensity exercise, and short-term follow-up. A reduction in TNF-α level occurred for middle-aged patients, compared to a control-group (P < 0.05).

Conclusions

These exercise-related changes (improved inflammation and vascular adhesion markers) as clinical benefits in general, and for exercise-based cardiac rehabilitation in a more-specific format, improve clinical evolution and survival in patients with HF of different etiologies (registration number = CRD42021271423).

Lifestyle Modification in Heart Failure Management: Are We Using Evidence-Based Recommendations in Real World Practice?

The heart failure (HF) guideline's purpose is to assist medical professionals while treating patients with HF in accordance with the best current research. Many cases of HF are both, avoidable and treatable thanks to scientific trials. Management is, therefore, based on lifestyle changes, also called non-pharmacological treatment. These, based on lifestyle changes, should be recommended in every patient at risk for HF or with diagnosed of HF, but evidence in itself is scarce. DASH Diet could be clearly beneficial while Mediterranean diet doesn't have enough evidence at the present moment. Smoking should be stopped, and excessive amounts of alcohol drinking avoided, but there is no clinical trial nor registry performed on these aspects. A moderate salt restriction is better than a strict reduction. Exercise and cardiac rehabilitation are beneficial but there are no clear recommendations about type, duration, etc. Most of the evidence that we have in HF patients with obesity is contradictory. Finally, due to the high number of aged frail patients in HF lifestyle changes should be individualized, but again available data is scant. Therefore, due to the lack of current evidence, these gaps need to be considered and need new efforts on investigation in the next future.

The effect of moderate intensity aerobic exercise on cardiovascular function, cardiorespiratory fitness and estrogen receptor alpha gene in overweight/obese postmenopausal women: A randomized controlled trial

Objective

The purpose of this study was to examine the effect of 12 weeks of moderate intensity aerobic exercise on echocardiographic and cardiorespiratory fitness (CRF) parameters, lymphocyte estrogen receptor alpha (ERα) gene expression and sex hormones (17β-estradiol and progesterone) in overweight/obese postmenopausal women (OPMW).

Methods

Twenty-seven sedentary OPMW aged 45 to 65 years old were randomly assigned to exercise (EX, n = 14) and control (C, n = 13) groups. The EX group performed warm up-walking/jogging moderate intensity aerobic exercise program- recovery (60 min/day, 3 days/week at 70 % of maximal heart rate reserve for 12 weeks) while the C group participated in no intervention and maintained their daily physical activity level, sedentary normal lifestyle and dietary habits during 12-week. The lymphocyte ERα gene expression, serum levels of 17β-estradiol and progesterone, and CRF & echocardiographic parameters were measured at baseline and week-12.

Results

After 12-week, the increase in ERα gene expression (p = 0.009, estimate of effect size/Eta = 28.2 %), VO2max (p = 0.001, Eta = 53.4 %), walking-jogging time to exhaustion (WJTE) (p = 0.001, Eta = 55.1 %), metabolic equivalent of task (METs) (p = 0.001, Eta = 97.9 %), left ventricular ejection fraction (LVEF) (p = 0.001, Eta = 53.6 %), cardiac output (Q) (p = 0.036, Eta = 22.3 %), and cardiac index (p = 0.030, Eta = 22.5 %) were significantly higher in the EX group compared to the C group, whereas body fat (p = 0.023, Eta = 25.7 %), left ventricular end-systolic diameter (LVESD) (p = 0.013, Eta = 28.3 %), and mitral E-wave deceleration time (E-wave D time) (p = 0.007, Eta = 32.1 %) were significantly decreased.

Conclusions

The results suggested that moderate intensity aerobic exercise can be improved cardiac function such as LVEF, Q, cardiac index, LVESD, and E-wave D time, CRF, ERα-mRNA gene expression as well as maintained sex hormones among sedentary OPMW during menopause, as these positive cellular and molecular or physiological adaptations may be signs of cardioprotective effects by aerobic exercise.

The Related Metabolic Diseases and Treatments of Obesity

Obesity is a chronic disease characterized by the abnormal or excessive accumulation of body fat, affecting more than 1 billion people worldwide. Obesity is commonly associated with other metabolic disorders, such as type 2 diabetes, non-alcoholic fatty liver disease, cardiovascular diseases, chronic kidney disease, and cancers. Factors such as a sedentary lifestyle, overnutrition, socioeconomic status, and other environmental and genetic conditions can cause obesity. Many molecules and signaling pathways are involved in the pathogenesis of obesity, such as nuclear factor (NF)-κB, Toll-like receptors (TLRs), adhesion molecules, G protein-coupled receptors (GPCRs), programmed cell death 1 (PD-1)/programmed death-ligand 1 (PD-L1), and sirtuin 1 (SIRT1). Commonly used strategies of obesity management and treatment include exercise and dietary change or restriction for the early stage of obesity, bariatric surgery for server obesity, and Food and Drug Administration (FDA)-approved medicines such as semaglutide and liraglutide that can be used as monotherapy or as a synergistic treatment. In addition, psychological management, especially for patients with obesity and distress, is a good option. Gut microbiota plays an important role in obesity and its comorbidities, and gut microbial reprogramming by fecal microbiota transplantation (FMT), probiotics, prebiotics, or synbiotics shows promising potential in obesity and metabolic syndrome. Many clinical trials are ongoing to evaluate the therapeutic effects of different treatments. Currently, prevention and early treatment of obesity are the best options to prevent its progression to many comorbidities.