Meta-analysis of Exercise Training on Left Ventricular Ejection Fraction in Heart Failure with Reduced Ejection Fraction: A 10-year Update

Effect of Exercise Rehabilitation in Patients With Acute Heart Failure: A Systematic Review and Meta-analysis

BACKGROUND

Exercise rehabilitation is conducive to increasing functional ability and improving health outcomes, but its effectiveness in patients with acute heart failure (AHF) is still controversial.

PURPOSE

In this study, our aim was to systematically examine the efficacy of exercise rehabilitation in people with AHF.

METHODS

A search was conducted for randomized controlled trial studies on exercise rehabilitation in patients with AHF up to November 2021. Two investigators conducted literature selection, quality assessments, and data extractions independently. The primary outcome was 6-minute walk distance, and the secondary outcomes were left ventricular ejection fraction, quality of life, Short Physical Performance Battery, readmission, and mortality. RevMan (version 5.3) software was used for the meta-analysis.

RESULTS

Twelve studies with 1215 participants were included. Exercise rehabilitation significantly improved the 6-minute walk distance (mean difference [MD], 33.04; 95% confidence interval [CI], 31.37-34.70; P < .001; I2 = 0%), quality of life (MD, -11.57; 95% CI, -19.25 to -3.89; P = .003; I2 = 98%), Short Physical Performance Battery (MD, 1.40; 95% CI, 1.36-1.44; P < .001; I2 = 0%), and rate of readmission for any cause (risk ratio, 0.48; 95% CI, 0.26-0.88; P = .02; I2 = 7%), compared with routine care. However, no statistically significant effects on left ventricular ejection fraction (MD, 0.94; 95% CI, -1.62 to 3.51; P = .47; I2 = 0%) and mortality (risk ratio, 1.07; 95% CI, 0.64-1.80; P = .79; I2 = 0%) were observed.

CONCLUSIONS

Compared with routine care, exercise rehabilitation improved functional ability and quality of life, reducing readmission in patients with AHF.

Non-Pharmacological Interventions in Patients With Heart Failure With Reduced Ejection Fraction: A Systematic Review and Network Meta-analysis

OBJECTIVE

To determine the effectiveness of non-pharmacologic interventions and the additional benefits of their combination in patients with heart failure with reduced ejection fraction (HFrEF).

DATA SOURCES

We searched PubMed, Embase, and the Cochrane Clinical Trials Register from the date of database inception to April 22, 2023.

STUDY SELECTION

Randomized controlled trials involving non-pharmacologic interventions conducted in patients with HFrEF were included.

DATA EXTRACTION

Data were extracted by 2 independent reviewers based on a pre-tested data extraction form. The quality of evidence was assessed using the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation method.

DATA SYNTHESIS

A total of 82 eligible studies (4574 participants) were included. We performed a random-effects model within a Bayesian framework to calculate weighted mean differences (WMDs) and 95% credibility intervals. High or moderate certainty evidence indicated that high-intensity aerobic interval training (HIAIT) was best on improving 6-minute walk distance (6MWD; 68.55 m [36.41, 100.47]) and left ventricular ejection fraction (6.28% [3.88, 8.77]), while high-intensity aerobic continuous training (HIACT) is best on improving peak oxygen consumption (Peak VO2; 3.48 mL/kg•min [2.84, 4.12]), quality of life (QOL; -17.26 [-29.99, -7.80]), resting heart rate (-8.20 bpm [-13.32, -3.05]), and N-terminal pro-B-type natriuretic peptide (-600.96 pg/mL [-902.93, -404.52]). Moderate certainty evidence supported the effectiveness of inspiratory muscle training to improve peak oxygen consumption and functional electrical stimulation to improve QOL. Moderate-intensity aerobic continuous training (MIACT) plus moderate-intensity resistance training (MIRT) had additional benefits in Peak VO2, 6MWD, and QOL. This review did not provide a comprehensive evaluation of adverse events.

CONCLUSIONS

Both HIAIT and HIACT are the most effective single non-pharmacologic interventions for HFrEF. MIACT plus MIRT had additional benefits in improving peak oxygen consumption, 6MWD, and QOL.

Non-Pharmacological Treatment of Heart Failure-From Physical Activity to Electrical Therapies: A Literature Review

Heart failure (HF) represents a significant global health challenge that is still responsible for increasing morbidity and mortality despite advancements in pharmacological treatments. This review investigates the effectiveness of non-pharmacological interventions in the management of HF, examining lifestyle measures, physical activity, and the role of some electrical therapies such as catheter ablation, cardiac resynchronization therapy (CRT), and cardiac contractility modulation (CCM). Structured exercise training is a cornerstone in this field, demonstrating terrific improvements in functional status, quality of life, and mortality risk reduction, particularly in patients with HF with reduced ejection fraction (HFrEF). Catheter ablation for atrial fibrillation, premature ventricular beats, and ventricular tachycardia aids in improving left ventricular function by reducing arrhythmic burden. CRT remains a key intervention for selected HF patients, helping achieve left ventricular reverse remodeling and improving symptoms. Additionally, the emerging therapy of CCM provides a novel opportunity for patients who do not meet CRT criteria or are non-responders. Integrating non-pharmacological interventions such as digital health alongside specific medications is key for optimizing outcomes in HF management. It is imperative to tailor approaches to individual patients in this diverse patient population to maximize benefits. Further research is warranted to improve treatment strategies and enhance patient outcomes in HF management.

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.

Physiological and psychological outcomes of high intensity interval training in patients with heart failure compared to moderate continuous training and usual care: A systematic review with meta analysis

BACKGROUND

An important component of secondary prevention of CVD (including HF) is comprehensive cardiac rehab, including exercise. Novel, individualised approaches are needed to increase uptake and adherence to exercise programmes, one area offering potential is HIIT. HIIT has been shown to be both safe and effective for improving cardiovascular fitness in both coronary artery disease and HF patients.

OBJECTIVES

To provide a current and up to date evaluation of the physiological and psychological outcomes of HIIT in patients with HF compared to MCT and UC. Secondly to perform sub-group analyses comparing short and long HIIT protocols.

METHODS

A systematic review and meta-analysis of randomised controlled trials was undertaken. Medline, Embase, Scopus, CINAHL and SportDISCUS were searched up to July 2022. Trials were included if they carried out a HIIT intervention (defined at intensity ≥ 80% peak HR or ≥ 80% VO2peak) in HF patients (HFpEF or HFrEF) for at least 6 weeks. Comparator group was UC or MCT.

RESULTS

HIIT was shown to be superior to MCT and UC for improving VO2peak (HIIT mean improvement 3.1 mL.kg-1min-1). HITT was superior to MCT and UC for improving LVEF (HIIT mean improvement 5.7%). HIIT was superior to MCT and UC for improving HRQoL, using the MLHFQ (HIIT mean point change of -12.8). Subgroup analysis showed no difference between long and short HIIT.

CONCLUSION

HIIT improves VO2peak, LVEF and HRQoL in patients with HF, the improvements seen in VO2peak and LVEF are superior in HIIT compared to MCT and UC.

High intensity interval training vs. moderate intensity continuous training on aerobic capacity and functional capacity in patients with heart failure: a systematic review and meta-analysis

Background

Exercise training is commonly employed as a efficacious supplementary treatment for individuals suffering from heart failure, but the optimal exercise regimen is still controversial. The objective of the review was to compare the effects of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) on the exercise capacity, cardiac function, quality of life (QoL) and heart rate among patients with heart failure with reduced ejection fraction.

Methods

A systematic search was performed using the following eight databases from their inception to July 5, 2023: PubMed, Web of Science, Embase, Cochrane Library, Clinical Trials, China Knowledge Network, Wan fang Data, and the China Biology Medicine databases. The meta-analysis results were presented as mean difference (MD) and 95% confidence interval (CI). The Cochrane Risk of Bias tool was used for the included studies. The Grading of Recommendations Assessment, Development, and Evaluations was used to assess the certainty of evidence.

Results

Thirteen randomized controlled trials were included in the study. The results showed that HIIT had a significant positive effect on peak oxygen uptake (MD = 1.78, 95% CI for 0.80-2.76), left ventricular ejection fraction (MD = 3.13, 95% CI for 1.25-5.02), six-minute walk test (MD = 28.13, 95% CI for 14.56-41.70), and Minnesota Living with Heart Failure Questionnaire (MD = -4.45, 95% CI for -6.25 to -2.64) compared to MICT. However, there were no statistically significant differences observed in resting heart rate and peak heart rate.

Conclusions

HIIT significantly improves peak oxygen uptake, left ventricular ejection fraction, six-minute walk test, and Minnesota Living with Heart Failure Questionnaire in patients with heart failure with reduced ejection fraction. Additionally, HIIT exhibits greater effectiveness in improving peak oxygen uptake among patients with lower body mass index.

Systematic Review Registration

https://www.doi.org/10.37766/inplasy2023.7.0100, identifier (INPLASY2023.7.0100).

Exercise-based cardio-oncology rehabilitation for cardiotoxicity prevention during breast cancer chemotherapy: The ONCORE randomized controlled trial

BACKGROUND

Breast cancer (BC) treatment with anthracyclines and/or anti-human epidermal growth factor receptor-2 (HER2) antibodies is associated with an increased risk of cardiovascular disease complications, including cancer therapy-related cardiac dysfunction (CTRCD). While Cardio-Oncology Rehabilitation (CORe) programs including exercise have emerged to minimize these risks, its role in preventing CTRCD is unclear.

OBJECTIVES

We investigated the effectiveness of an exercise-based CORe program in preventing CTRCD [left ventricular ejection fraction (LVEF) drop ≥10% to a value <53% or a decrease >15% in global longitudinal strain (GLS)]. Secondary outcomes examined changes in cardiac biomarkers, physical performance including peak oxygen consumption, psychometric and lifestyle outcomes. Safety, adherence, and patient satisfaction were also assessed.

METHODS

This is a randomized controlled trial including 122 early-stage BC women receiving anthracyclines and/or anti-HER2 antibodies, randomized to CORe (n = 60) or usual care with exercise recommendation (n = 62). Comprehensive assessments were performed at baseline and after cardiotoxic treatment completion. The average duration of the intervention was 5.8 months.

RESULTS

No cases of CTRCD were identified during the study. LVEF decreased in both groups, but was significantly attenuated in the CORe group [-1.5% (-2.9, -0.1); p = 0.006], with no changes detected in GLS or cardiac biomarkers. The CORe intervention led to significant body mass index (BMI) reduction (p = 0.037), especially in obese patients [3.1 kg/m2 (1.3, 4.8)]. Physical performance and quality-of-life remained stable, while physical activity level increased in both groups. No adverse events were detected.

CONCLUSIONS

This study suggests that CORe programs are safe and may help attenuate LVEF decline in BC women receiving cardiotoxic therapy and reduce BMI in obese patients.

Supervised exercise training in patients with advanced heart failure and left ventricular assist device: A multicentre randomized controlled trial (Ex-VAD trial)

AIMS

Small studies and observations suggested that exercise training may improve peak oxygen consumption (peakVO2 ) in patients with advanced heart failure and left ventricular assist device (LVAD). We investigated whether in this patient group a supervised exercise training can improve exercise capacity.

METHODS AND RESULTS

In this multicentre, prospective, randomized, controlled trial, patients with stable heart failure and LVAD were randomly assigned (2:1) to 12 weeks of supervised exercise training or usual care, with 12 weeks of follow-up. The primary endpoint was the change in peakVO2 after 12 weeks (51 patients provided a power of 90% with an expected group difference in peakVO2 of 3 ml/kg/min). Secondary endpoints included changes in submaximal exercise capacity and quality of life. Among 64 patients enrolled (97% male, mean age 56 years), 54 were included in the analysis. Mean difference in the change of peakVO2 after 12 weeks was 0.826 ml/min/kg (95% confidence interval [CI] -0.37, 2.03; p = 0.183). There was a positive effect of exercise training on 6-min walk distance with a mean increase in the intervention group by 43.4 m (95% CI 16.9, 69.9; p = 0.0024), and on the Kansas City Cardiomyopathy Questionnaire physical domain score (mean 14.3, 95% CI 3.7, 24.9; p = 0.0124), both after 12 weeks. The overall adherence was high (71%), and there were no differences in adverse events between groups.

CONCLUSION

In patients with advanced heart failure and LVAD, 12 weeks of exercise training did not improve peakVO2 but demonstrated positive effects on submaximal exercise capacity and physical quality of life.

Efficacy and Safety of Moderate-Intensity Continuous Training on the Improvement of Cardiopulmonary Function in Patients After Transcatheter Aortic Valve Replacement (ENERGY): A Randomized Controlled Trial

OBJECTIVES

To investigate the effect of moderate-intensity continuous training (MICT) on the improvement of cardiopulmonary function for patients undergoing transcatheter aortic valve replacement (TAVR).

DESIGN

Randomized controlled study.

SETTING AND PARTICIPANTS

Between August 20, 2021, and February 28, 2022, a total of 66 patients after TAVR were screened for inclusion and randomly divided into the MICT and control groups at a ratio of 1:1. MICT was scheduled 3 times per week for 3 months in the intervention group. Patients in the control group received one-time advice on physical activity according to the current guideline.

METHODS

The primary endpoint was the 3-month change in peak oxygen consumption (peak VO2) assessed by cardiopulmonary exercise testing. The secondary endpoints included the 3-month change in 6-minute walk test (6MWT), the 12-Item Short Form Health Survey (SF-12), New York Heart Association (NYHA) class, echocardiographic parameters, and laboratory parameters.

RESULTS

After 3 months, the change in peak VO2 was higher in the MICT group than that in the control group (1.63 mL/kg/min, 95% CI 0.58-2.67, P = .003). Change in 6MWT (21.55 m, 95% CI 0.38-42.71, P = .046) was higher in the MICT group compared with the control group. A significant change in favor of MICT was also observed for low-density lipoprotein cholesterol (-0.62 mmol/L, 95% CI -1.00 to -0.23, P = .002). However, there were no significant changes in other echocardiographic indices, laboratory parameters, and SF-12 between the 2 groups (all P > .05).

CONCLUSIONS AND IMPLICATIONS

MICT had a positive effect on the cardiopulmonary function and physical capacity of patients after TAVR.

Exercise-based training programs for patients with chronic Chagas cardiomyopathy: A systematic review and meta-analysis

Background

We assessed the effects of exercise-based training programs (EBTP) in patients with chronic Chagas cardiomyopathy (CCC) through a systematic review and meta-analysis.

Methods

We conducted a search in Pubmed/Medline, Embase, Scopus, Web of Science, Cochrane Library, Virtual Health Library, and SciELO until January 2023. Randomized controlled trials (RCTs) and non-randomized intervention studies (NRIS) investigating the effects of EBTP in CCC patients were included. The primary outcomes were all-cause mortality, cardiovascular mortality, and health-related quality of life (HRQoL), and the secondary outcomes were exercise capacity by peak VO2, heart failure-related hospital admissions (HFRHA), and left ventricular ejection fraction (LVEF).

Results

The search strategy yielded 3617 studies. After removing duplicates and screening, eight studies (3 RCTs and 5 NRIS) involving 222 patients were included. Seven studies were conducted in Brazil. The age range was from 30 to 71 years, and 47.1% were male. Data on mortality, HRQoL, LVEF, and HFRHA were scarcely reported. The meta-analysis pooling four studies showed that the peak VO2 was significantly higher (mean difference 4.45, 95% confidence interval 3.50 to 5.39 mL/kg/min, I2 = 0%) in the EBTP group compared to the control group.

Conclusion

The evidence available was limited and heterogeneous. While EBTP has shown to improve HRQoL and exercise capacity, there is no conclusive information about the other proposed outcomes. These positive effects present an opportunity to provide treatment to CCC patients in low- and middle-income countries. Further studies are needed to ascertain the effects of EBTP on hard outcomes in this population.Registration number: CRD42022334060.

Effects of exercise during chemotherapy for breast cancer on long-term cardiovascular toxicity

OBJECTIVE

Animal data suggest that exercise during chemotherapy is cardioprotective, but clinical evidence to support this is limited. This study evaluated the effect of exercise during chemotherapy for breast cancer on long-term cardiovascular toxicity.

METHODS

This is a follow-up study of two previously performed randomised trials in patients with breast cancer allocated to exercise during chemotherapy or non-exercise controls. Cardiac imaging parameters, including T1 mapping (native T1, extracellular volume fraction (ECV)), left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), cardiorespiratory fitness, and physical activity levels, were acquired 8.5 years post-treatment.

RESULTS

In total, 185 breast cancer survivors were included (mean age 58.9±7.8 years), of whom 99% and 18% were treated with anthracyclines and trastuzumab, respectively. ECV and Native T1 were 25.3%±2.5% and 1026±51 ms in the control group, and 24.6%±2.8% and 1007±44 ms in the exercise group, respectively. LVEF was borderline normal in both groups, with an LVEF<50% prevalence of 22.5% (n=40/178) in all participants. Compared with control, native T1 was statistically significantly lower in the exercise group (β=-20.16, 95% CI -35.35 to -4.97). We found no effect of exercise on ECV (β=-0.69, 95% CI -1.62 to 0.25), LVEF (β=-1.36, 95% CI -3.45 to 0.73) or GLS (β=0.31, 95% CI -0.76 to 1.37). Higher self-reported physical activity levels during chemotherapy were significantly associated with better native T1 and ECV.

CONCLUSIONS

In long-term breast cancer survivors, exercise and being more physically active during chemotherapy were associated with better structural but not functional cardiac parameters. The high prevalence of cardiac dysfunction calls for additional research on cardioprotective measures, including alternative exercise regimens.

TRIAL REGISTRATION NUMBER

NTR7247.

The Pathophysiology and New Advancements in the Pharmacologic and Exercise-Based Management of Heart Failure With Reduced Ejection Fraction: A Narrative Review

Heart failure with reduced ejection fraction (HFrEF) is a clinical syndrome whose management has significantly evolved based on the pathophysiology and disease process. It is widely prevalent, has a relatively high mortality rate, and is comparatively more common in men than women. In HFrEF, the series of maladaptive processes that occur lead to an inability of the muscle of the left ventricle to pump blood efficiently and effectively, causing cardiac dysfunction. The neurohormonal and hemodynamic adaptations play a significant role in the advancement of the disease and are critical to guiding the treatment and management of HFrEF. The first-line therapy, which includes loop diuretics, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, hydralazine/isosorbide-dinitrate, and mineralocorticoid receptor antagonists (MRAs), has been proven to provide symptomatic relief and decrease mortality and complications. The newly recommended drugs for guideline-based therapy, angiotensin receptor/neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitors, soluble guanylate cyclase, and myosin activators and modulators have also been shown to improve cardiac function, reverse cardiac remodeling, and reduce mortality rates. Recent studies have demonstrated that exercise-based therapy has resulted in an improved quality of life, exercise capacity, cardiac function, and decreased hospital readmission rates, but it has not had a considerable reduction in mortality rates. Combining multiple therapies alongside holistic advances such as exercise therapy may provide synergistic benefits, ultimately leading to improved outcomes for patients with HFrEF. Although first-line treatment, novel pharmacologic management, and exercise-based therapy have been shown to improve prognosis, the existing literature suggests a need for further studies evaluating the long-term effects of MRA and ARNI.

Different Continuous Training Intensities Improve Echocardiographic Parameters, Quality of Life, and Functional Capacity in Heart Failure Patients with Reduced Ejection Fraction

Background

Multiple comorbidities and physiological changes play a role in a range of heart failure conditions and influence the most effective approach to exercise-based rehabilitation. This research aimed to examine and compare the outcomes of continuous training at three different intensities, focusing on left ventricular (LV) remodeling, functional capacity, and quality of life among patients with heart failure with reduced ejection fraction (HFrEF).

Methods

In this randomized control trial, a total of 60 male patients (average age: 54.33 ±2.35 years) with HFrEF were randomly allocated into three groups: 1) High-intensity continuous training group (HICT), 2) Moderate-intensity continuous training group (MICT), and 3) Low-intensity continuous training group (LICT). All the training was performed on a bicycle ergometer 3 times/week for 12 weeks. Echocardiographic parameters (left ventricular ejection fraction, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, N-terminal pro-B-type natriuretic peptide (NT-proBNP), quality of life (Minnesota Living with Heart Failure Questionnaire), and functional capacity (6-minute walking test) were assessed before and the end of the study.

Results

The HICT group demonstrated the greatest improvements in all measured variables when compared to the other two groups (P < 0.05). These findings were consistent across all measured outcomes.

Conclusion

It was determined that HICT appears to yield the most favorable outcomes in enhancing echocardiographic measures, NT-proBNP levels, quality of life, and functional capacity among HFrEF patients.

Effect of a Physical Exercise Program on the Inflammatory Response, Cardiac Functions, Functional Capacity, and Quality of Life in Patients with Sickle Cell Disease

INTRODUCTION

The beneficial effects of physical exercise on functional capacity and inflammatory response are well-known in cardiovascular diseases; however, studies on sickle cell disease (SCD) are limited. It was hypothesized that physical exercise may exert a favorable effect on the inflammatory response of SCD patients, contributing to an improved quality of life. This study aimed to evaluate the effect of a regular physical exercise program on the anti-inflammatory responses in SCD patients.

METHODS

A non-randomized clinical trial was conducted in adult SCD patients. The patients were divided into two groups: 1-Exercise Group, which received a physical exercise program three times a week for 8 weeks, and; 2-Control Group, with routine physical activities. All patients underwent the following procedures initially and after eight weeks of protocol: clinical evaluation, physical evaluation, laboratory evaluation, quality of life evaluation, and echocardiographic evaluation.

STATISTICAL ANALYSIS

Comparisons between groups were made using Student's t-test, Mann-Whitney test, chi-square test, or Fisher's exact test. Spearman's correlation coefficient was calculated. The significance level was set at p < 0.05.

RESULTS

There was no significant difference in inflammatory response between the Control and Exercise Groups. The Exercise Group showed an improvement in peak VO₂ values (p < 0.001), an increase in the distance walked (p < 0.001), an improvement in the limitation domain due to the physical aspects of the 36-Item Short Form Health Survey (SF-36) quality of life questionnaire (p = 0.022), and an increase in physical activity related to leisure (p < 0.001) and walking (p = 0.024) in the International Physical Activity Questionnaire (IPAQ). There was a negative correlation between IL-6 values and distance walked on the treadmill (correlation coefficient -0.444, p = 0.020) and the estimated peak VO₂ values (correlation coefficient -0.480; p = 0.013) in SCD patients in both groups.

CONCLUSIONS

The aerobic exercise program did not change the inflammatory response profile of SCD patients, nor did it show unfavorable effects on the parameters evaluated, and patients with lower functional capacity were those with the highest levels of IL-6.

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.

Functional outcome after cardiac rehabilitation and its association with survival in heart failure across the spectrum of ejection fraction

BACKGROUND

There is limited evidence regarding the effects of cardiac rehabilitation (CR) in patients with heart failure and preserved ejection fraction (HFpEF).

METHODS

We studied 1784 patients admitted to inpatient CR. The patients were grouped into HFpEF (EF≥0.50), HF with mildly reduced EF (HFmrEF; EF 41-49), and HF with reduced EF (HFrEF; EF≤0.40). A standardized 6-min walking test was performed at admission and discharge. Measures of functional outcome were: (1) absolute increase in 6-min walking distance (6MWD) from admission to discharge >50 m and (2) increase in 6MWD to ≥300 among the patients who walked <300 m at admission.

RESULTS

After adjustment, the patients with HFpEF or HFmrEF were as likely as those with HFrEF to achieve an increase in 6MWD >50 m (odds ratio 0.95 [95%CI 0.71-1.24; p=0.648] and 1.04 [95%CI 0.77-1.41; p=0.769], respectively) or an increase in 6MWD to ≥300 m (odds ratio 0.79 [95%CI 0.51-1.23; p=0.299] and 0.65 [95%CI 0.38-1.12; p=0.118], respectively). The adjusted hazard ratio of 5-year mortality for patients who achieved an increase in 6MWD >50 m was 0.60 (95%CI 0.51-0.71; p<0.001) and that for patients who achieved an increase in 6MWD at discharge to ≥300 m 0.61 (95%CI 0.48-0.79; p<0.001). In each EF group, both outcomes remained independently associated with improved survival.

CONCLUSIONS

Our data suggest that patients with HFpEF or HFmrEF are as likely as those with HFrEF to benefit from CR in terms of functional improvement. Functional improvement was independently associated with improved long-term survival, regardless of EF.

Effects of High-Intensity Interval Training on Central Blood Pressure: A Systematic Review and Meta-Analysis

Central blood pressure (cBP) is considered an independent predictor of organ damage, cardiovascular events and all-cause mortality. Evidence has shown that high intensity interval training (HIIT) is superior to moderate-intensity continuous training (MICT) for improving cardiorespiratory fitness and vascular function. However, the effects of these aerobic training modalities on cBP have not yet been properly reviewed.This meta-analysis aims to investigate to effects of HIIT versus MICT on cBP.We conducted a meta-analysis of randomized controlled trials that compared HIIT versus MICT on cBP. Primary outcomes were measures of central systolic blood pressure (cSBP) and central diastolic blood pressure (cDBP). Peripheral systolic blood pressure (pSBP) and diastolic blood pressure (pDBP), pulse wave velocity (PWV) and maximal oxygen uptake (VO2max) were analyzed as second outcomes. Meta-analysis of mean differences (MD) was conducted using the random effects model.Our study included 163 patients enrolled in six trials. We found that HIIT was superior to MICT in reducing the cSBP (MD = -3.12 mmHg, 95% CI: -4.75 to -1.50, p = 0.0002) and SBP (MD = -2.67 mmHg, 95% CI: -5.18 to -0.16, p = 0.04), and increasing VO2max(MD = 2.49 mL/kg/min, 95% CI: 1.25 to 3.73, p = 0.001). However, no significant differences were reported for cDBP, DBP and PWV.HIIT was superior to MICT in reducing the cSBP, which suggests its potential role as a non-pharmacological therapy for high blood pressure.

The Role of Exercise-based Cardiac Rehabilitation in Heart Failure

Exercise-based cardiac rehabilitation (EBCR) is a treatment modality for patients with heart failure (HF) that has withstood the test of time. It has continued to show benefits even in the current era of pharmacotherapeutics for HF. Participation in a multidisciplinary comprehensive EBCR programme reduces mortality and morbidity, has a multitude of physiological benefits, and improves cardiovascular risk factor control and quality of life. Despite this, historical barriers to enrolment and uptake remain. Strategies to overcome these, as well as alternative delivery methods of EBCR in HF patients, are emerging and include telerehabilitation, focus on special groups and emphasis on behavioural change. This review provides oversight on the modalities of exercise training in HF as well as their benefits and gives an overview of barriers to the utilisation of EBCR along with future progress in the field.

A Randomized, Controlled Trial of Resistance Training Added to Caloric Restriction Plus Aerobic Exercise Training in Obese Heart Failure With Preserved Ejection Fraction

BACKGROUND

We have shown that combined caloric restriction (CR) and aerobic exercise training (AT) improve peak exercise O2 consumption (VO2peak), and quality-of-life in older patients with obese heart failure with preserved ejection fraction. However, ≈35% of weight lost during CR+AT was skeletal muscle mass. We examined whether addition of resistance training (RT) to CR+AT would reduce skeletal muscle loss and further improve outcomes.

METHODS

This study is a randomized, controlled, single-blind, 20-week trial of RT+CR+AT versus CR+AT in 88 patients with chronic heart failure with preserved ejection fraction and body mass index (BMI) ≥28 kg/m2. Outcomes at 20 weeks included the primary outcome (VO2peak); MRI and dual X-ray absorptiometry; leg muscle strength and quality (leg strength ÷ leg skeletal muscle area); and Kansas City Cardiomyopathy Questionnaire.

RESULTS

Seventy-seven participants completed the trial. RT+CR+AT and CR+AT produced nonsignificant differences in weight loss: mean (95% CI): -8 (-9, -7) versus -9 (-11, -8; P=0.21). RT+CR+AT and CR+AT had non-significantly differences in the reduction of body fat [-6.5 (-7.2, -5.8) versus -7.4 (-8.1, -6.7) kg] and skeletal muscle [-2.1 (-2.7, -1.5) versus -2.1 (-2.7, -1.4) kg] (P=0.20 and 0.23, respectively). RT+CR+AT produced significantly greater increases in leg muscle strength [4.9 (0.7, 9.0) versus -1.1 (-5.5, 3.2) Nm, P=0.05] and leg muscle quality [0.07 (0.03, 0.11) versus 0.02 (-0.02, 0.06) Nm/cm2, P=0.04]. Both RT+CR+AT and CR+AT produced significant improvements in VO2peak [108 (958, 157) versus 80 (30, 130) mL/min; P=0.001 and 0.002, respectively], and Kansas City Cardiomyopathy Questionnaire score [17 (12, 22) versus 23 (17, 28); P=0.001 for both], with no significant between-group differences. Both RT+CR+AT and CR+AT significantly reduced LV mass and arterial stiffness. There were no study-related serious adverse events.

CONCLUSIONS

In older obese heart failure with preserved ejection fraction patients, CR+AT produces large improvements in VO2peak and quality-of-life. Adding RT to CR+AT increased leg strength and muscle quality without attenuating skeletal muscle loss or further increasing VO2peak or quality-of-life.

REGISTRATION

URL: https://ClincalTrials.gov; Unique identifier: NCT02636439.

Exercise Mode in Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

Optimising exercise prescription in heart failure (HF) with a preserved (HFpEF) or reduced (HFrEF) ejection fraction is clinically important. As such, the aim of this meta-analysis was to compare traditional moderate intensity training (MIT) against combined aerobic and resistance training (CT) and high-intensity interval training (HIIT) for improving aerobic capacity (VO₂), as well as other clinically relevant parameters.

METHODS

A comprehensive systematic search was performed to identify randomised controlled trials published between 1990 and May 2021. Research trials reporting the effects of MIT against CT or HIIT on peak VO₂ in HFpEF or HFrEF were considered. Left-ventricular ejection fraction (LVEF) and various markers of diastolic function were also analysed.

RESULTS

Seventeen studies were included in the final analysis, 4 of which compared MIT against CT and 13 compared MIT against HIIT. There were no significant differences between MIT and CT for peak VO₂ (weighted mean difference [WMD]: 0.521 ml min^-1 kg^-1, [95% CI] =  - 0.7 to 1.8, P_fixed = 0.412) or LVEF (WMD: - 1.129%, [95% CI] =  - 3.8 to 1.5, P_fixed = 0.408). However, HIIT was significantly more effective than MIT at improving peak VO₂ (WMD: 1.62 ml min^-1 kg^-1, [95% CI] = 0.6-2.6, P_random = 0.002) and LVEF (WMD: 3.24%, [95% CI] = 1.7-4.8, P_random < 0.001) in HF patients. When dichotomized by HF phenotype, HIIT remained significantly more effective than MIT in all analyses except for peak VO₂ in HFpEF.

CONCLUSIONS

HIIT is significantly more effective than MIT for improving peak VO₂ and LVEF in HF patients. With the exception of peak VO₂ in HFpEF, these findings remain consistent in both phenotypes. Separately, there is no difference in peak VO₂ and LVEF change following MIT or CT, suggesting that the addition of resistance exercise does not inhibit aerobic adaptations in HF.

The effect of exercise training and physiotherapy on left and right heart function in heart failure with preserved ejection fraction: a systematic literature review

The impact of exercise training and physiotherapy on heart function and pulmonary circulation parameters in heart failure with preserved ejection fraction (HFpEF) patients is uncertain. Hence, we performed a systematic review of published trials studying physical training in HFpEF population, with a focus on exercise and physiotherapy effect on left ventricular (LV), right ventricular (RV) morphological, functional, and pulmonary circulation parameters. We searched Cochrane Library and MEDLINE/PubMed for trials that evaluated the effect of exercise training and/or physiotherapy in adult HFpEF patients (defined as LVEF ≥ 45%), including publications until March 2021. Our systematic review identified eighteen articles (n = 418 trained subjects, 4 to 52 weeks of training) and covered heterogeneous trials with various populations, designs, methodologies, and interventions. Five of twelve trials revealed a significant reduction of mitral E/e' ratio after the training (- 1.2 to - 4.9). Seven studies examined left atrial volume index; three of them showed its decrease (- 3.7 to - 8 ml/m²). Findings were inconsistent regarding improvement of cardiac output, E/A ratio, and E wave DecT and uncertain for RV function and pulmonary hypertension parameters. For now, no reliable evidence about rehabilitation effect on HFpEF cardiac mechanisms is available. There are some hypotheses generating findings on potential positive effects to parameters of LV filling pressure (E/e'), left atrium size, cardiac output, and RV function. This encourages a broader and more complex assessment of parameters reflecting cardiac function in future HFpEF exercise training studies.

Exercise Training in Heart failure with Preserved and Reduced Ejection Fraction: A Systematic Review and Meta-Analysis

Background

While exercise training (ET) is an established tool in heart failure (HF), no research to date has analysed the efficacy of ET in both preserved (HFpEF) and reduced (HFrEF) ejection fraction phenotypes across the same clinically important parameters.

Methods

A comprehensive systematic search was performed to identify trials published between 1990 and May 2021. Controlled trials of adults reporting pre- and post-ET peak VO2, 6-min walk distance (6MWD), Minnesota Living with Heart Failure Questionnaire (MLHFQ), Kansas City Cardiomyopathy Questionnaire (KCCQ) and left ventricular ejection fraction (LVEF) were considered. Parameters of cardiac diastolic function, brain natriuretic peptides (BNP)/N-terminal prohormone of BNP (NTproBNP) and follow-up hospitalisation and mortality data were also analysed.

Results

Ninety-three studies (11 HFpEF and 82 HFrEF) were included in the final analysis, with a pooled sample size of 11,081 participants. HFpEF analysis demonstrated significant improvements in peak VO2 (weighted mean difference: 2.333 ml·min^-1·kg^-1, P_fixed < 0.001), 6MWD (WMD: 35.396 m, P_fixed < 0.001), MLHFQ (WMD: − 10.932, P_random < 0.001), KCCQ (WMD: 3.709, P_fixed = 0.037) and E/e′ (WMD: − 1.709, [95% CI] = − 2.91–0.51, P_random = 0.005). HFrEF analysis demonstrated significant improvements in peak VO2 (WMD: 3.050 ml·min^-1·kg^-1, P_random < 0.001), 6MWD (WMD: 37.299 m, P_random < 0.001), MLHFQ (WMD: − 10.932, P_random < 0.001), LVEF (WMD: 2.677%, P_random = 0.002) and BNP/NTproBNP (SMD: − 1.349, P_random < 0.001). Outcome analysis was only performed in HFrEF, which found no significant changes in hospitalisation, all-cause mortality or composite end-points.

Conclusion

ET significantly improves exercise capacity and quality of life in both HFpEF and HFrEF patients. In HFpEF patients, ET significantly improved an important index of diastolic function, with significant improvements in LVEF and NTproBNP/BNP seen in HFrEF patients only. Such benefits did not translate into significantly reduced hospitalisation or mortality after short-term follow-up.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00464-5.

The Preventive Role of Physical Activity in Systemic Sclerosis: A Cross-Sectional Study on the Correlation with Clinical Parameters and Disease Progression

Although exercise is associated with improved health in many medical conditions, little is known about the possible influences of physical activity (PA) habits pre- and post- a diagnosis of systemic sclerosis (SSc) on disease activity and progression. This cross-sectional study assessed, for the first time, self-reported pre- and post-diagnostic PA levels with the aim to verify if changes in these levels were correlated with demographic/anthropometric data (e.g., weight, height, gender, age, BMI), disease duration, diagnostic/clinical parameters (e.g., skin involvement, pulmonary hemodynamic/echocardiographic data, disease activity) related to disease activity and progression, and quality of life in a population-based sample of patients with SSc. Adult participants (n = 34, age 56.6 ± 13.3 years) with SSc (limited cutaneous SSc, lcSSc, n = 20; diffuse cutaneous SSc, dcSSc, n = 9; sine scleroderma SSc, n = 5) were enrolled at the Division of Rheumatology and Clinical Immunology of the Humanitas Research Hospital. All medical data were recorded during periodic clinical visits by a rheumatologist. Moreover, all subjects included in this study completed extensive questionnaires to evaluate their health-related quality of life (HRQOL), and others related to health-related physical activity performed before (PRE) and after (POST) the diagnosis of disease. The linear regression analysis has shown that either a high Sport_index or Leisure_index in the PRE-diagnostic period was correlated with lower disease duration in dcSSc patients. Physical load during sport activity and leisure time accounted for ~61.1% and ~52.6% of the individual variation in disease duration, respectively. In lcSSc patients, a high PRE value related to physical load during sporting activities was correlated with a low pulmonary artery systolic pressure (sPAP) and the POST value of the Work_index was positively correlated with the left ventricular ejection fraction (LVEF), and negatively with creatine kinase levels (CK). Interestingly, the univariate analysis showed that Work_index accounts for ~29.4% of the variance in LVEF. Our analysis clearly reinforces the concept that high levels of physical load may play a role in primary prevention-delaying the onset of the disease in those subjects with a family history of SSc-as well as in secondary prevention, improving SSc management through a positive impact on different clinical parameters of the disease. However, it remains a priority to identify a customized physical load in order to minimize the possible negative effects of PA.

The Effects of High-Intensity Interval Training on Exercise Capacity and Prognosis in Heart Failure and Coronary Artery Disease: A Systematic Review and Meta-Analysis

Objective

The purpose of this study is to compare the effects of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) on exercise capacity and several prognostic markers in patients with coronary artery disease (CAD) and heart failure (HF).

Methods

This systematic review is registered on the INPLASY website (number: INPLASY202080112). We conducted a comprehensive search in eight databases of literature before September 13, 2019. Trials comparing HIIT and MICT in participants with CAD or HF aged 52–78 years were included. Exercise capacity (peak oxygen consumption (peak VO₂)) and prognostic markers, such as the anaerobic threshold (AT), minute ventilation/carbon dioxide production (VE/VCO₂) slope, left ventricular ejection fraction (LVEF), and prognostic value of the predicted VO₂ max per cent (the predicted VO₂ peak (%)) were examined.

Results

A total of 15 studies were included comprising 664 patients, 50% of which were male, with an average age of 60.3 ± 13.2 years. For patients with CAD, HIIT significantly improved peak VO₂ values (95% CI 0.7 to 2.11) compared with MICT, but peak VO₂ values in patients with HF did not seem to change. For training lasting less than eight weeks, HIIT significantly improved peak VO₂ values (95% CI 0.70 to 2.10), while HIIT lasting 12 weeks or longer resulted in a modestly increased peak VO₂ value (95% CI 0.31 to 5.31). High-intensity interval training significantly increased the AT when compared with MICT (95% CI 0.50 to 1.48). High-intensity interval training also caused a moderate increase in LVEF (95% CI 0.55 to 5.71) but did not have a significant effect on the VE/VCO₂ slope (95% CI −2.32 to 0.98) or the predicted VO₂ peak (95% CI −2.54 to 9.59) compared with MICT.

Conclusions

High-intensity interval training is an effective therapy for improving peak VO₂ values in patients with CAD. High-intensity interval training in the early stage (eight weeks or fewer) is superior to MICT. Finally, HIIT significantly improved prognostic markers, including the AT and LVEF in patients with CAD and HF.

Short- and Long-Term Effects of High-Intensity Interval Training vs. Moderate-Intensity Continuous Training on Left Ventricular Remodeling in Patients Early After ST-Segment Elevation Myocardial Infarction—The HIIT-EARLY Randomized Controlled Trial

Aim

Due to insufficient evidence on the safety and effectiveness of high-intensity interval training (HIIT) in patients early after ST-segment elevation myocardial infarction (STEMI), we aimed to compare short- and long-term effects of randomized HIIT or moderate-intensity continuous training (MICT) on markers of left ventricular (LV) remodeling in STEMI patients receiving optimal guideline-directed medical therapy (GDMT).

Materials and Methods

Patients after STEMI (<4 weeks) enrolled in a 12-week cardiac rehabilitation (CR) program were recruited for this randomized controlled trial (NCT02627586). During a 3-week run-in period with three weekly MICT sessions, GDMT was up-titrated. Then, the patients were randomized to HIIT or isocaloric MICT for 9 weeks. Echocardiography and cardiopulmonary exercise tests were performed after run-in (3 weeks), end of CR (12 weeks), and at 1-year follow-up. The primary outcome was LV end-diastolic volume index (LVEDVi) at the end of CR. Secondary outcomes were LV global longitudinal strain (GLS) and cardiopulmonary fitness.

Results

Seventy-three male patients were included, with the time between STEMI and start of CR and randomization being 12.5 ± 6.3 and 45.8 ± 10.8 days, respectively. Mixed models revealed no significant group × time interaction for LVEDVi at the end of CR (p = 0.557). However, there was a significantly smaller improvement in GLS at 1-year follow-up in the HIIT compared to the MICT group (p = 0.031 for group × time interaction). Cardiorespiratory fitness improved significantly from a median value of 26.5 (1st quartile 24.4; 3rd quartile 1.1) ml/kg/min at randomization in the HIIT and 27.7 (23.9; 31.6) ml/kg/min in the MICT group to 29.6 (25.3; 32.2) and 29.9 (26.1; 34.9) ml/kg/min at the end of CR and to 29.0 (26.6; 33.3) and 30.6 (26.0; 33.8) ml/kg/min at 1 year follow-up in HIIT and MICT patients, respectively, with no significant group × time interactions (p = 0.138 and 0.317).

Conclusion

In optimally treated patients early after STEMI, HIIT was not different from isocaloric MICT with regard to short-term effects on LVEDVi and cardiorespiratory fitness. The worsening in GLS at 1 year in the HIIT group deserves further investigation, as early HIIT may offset the beneficial effects of GDMT on LV remodeling in the long term.

Physical Activity and Cardiac Function in Long-Term Breast Cancer Survivors: A Cross-Sectional Study

Background

Higher levels of physical activity are associated with a lower risk of cardiovascular disease in the general population. Whether the same holds for women who underwent treatment for breast cancer is unclear.

Objectives

The aim of this study was to evaluate the association between physical activity in a typical week in the past 12 months and cardiac dysfunction in breast cancer survivors.

Methods

We used data from a cohort of breast cancer survivors who were treated at ages 40 to 50 years (N = 559). The association between physical activity and global longitudinal strain (GLS) and left ventricular ejection fraction (LVEF) was evaluated using both linear and modified Poisson regression analyses adjusted for relevant confounders.

Results

In total, 559 breast cancer survivors were included, with median age of 55.5 years and a median time since treatment of 10.2 years. GLS was less favorable in inactive survivors (−17.1%) than in moderately inactive (−18.4%), moderately active (−18.2%), and active survivors (−18.5%), with an adjusted significant difference for active versus inactive survivors (β = −1.31; 95% CI: −2.55 to −0.06)). Moderately active (n = 57/130) and active survivors (n = 87/124) had significantly lower risks of abnormal GLS (defined as >−18%) compared with inactive survivors (n = 17/26) (RR: 0.65 [95% CI: 0.45-0.94] and RR: 0.61 [95% CI: 0.43-0.87], respectively). LVEF, in normal ranges in all activity categories, was not associated with physical activity.

Conclusions

In long-term breast cancer survivors, higher physical activity levels were associated with improved GLS but not LVEF, with the relatively largest benefit for doing any activity versus none. This finding suggests that increasing physical activity may contribute to cardiovascular health benefits, especially in inactive survivors.

Intermittent aerobic-resistance interval training versus continues aerobic training: Improvement in cardiac electrophysiologic and anthropometric measures in male patients post myocadiac infarction, a randomized control trial

Purpose

Exercise is a valuable intervention modality for patients post-myocardial infarction (MI). Aerobic and resistance training are both commonly used separately in cardiac rehabilitation. However, the effect of aerobic interval exercise combined with alternating sets of resistance training (super-circuit training, SCT) on cardiac electrophysiologic and anthropometric measures had not been thoroughly investigated.

Aim

The primary objective of this study was to compare the effectiveness of moderate-intensity continuous-aerobic training (CAT) vs. SCT on cardiac electrical measures (resting electrocardiographic, ECG; a nd heart rate variability, HRV) in patients’ post-MI presenting reduced left ventricular function. Second, to examine its effect on anthropometric measures.

Material and methods

Twenty-nine men post-MI with reduced left ventricular function were assigned randomly to either 12 weeks of CAT (n = 15) or SCT (n = 14). CAT group performed moderate-intensity activity. SCT group performed high-intensity exercise, alternating between resistance and aerobic training. Differences between CAT and SCT groups were done using independent t-tests, paired t-tests and effect size (ES).

Results

Participants in both groups improved their HRV measures (increase in HFnu; p < 0.05; ES > 0.51) and ECG (reduction in QT-dispersion; p < 0.05; ES > 0.51). Only the SCT group had significant improvements in waist circumference (p < 0.05).

Conclusion

Exercise improves cardiac electrical measures post-MI. However, in comparison to CAT, SCT may yield greater anthropometric changes. In order to have improvements in cardiac electrical stability, clinicians working with post-MI patients may use both CAT and SCT. However, SCT might result in greater improvements.

Physical Exercise Modalities for the Management of Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

ABSTRACT

Different physical exercise modalities have been widely studied in patients having heart failure with preserved ejection fraction (HFpEF) but with variably reported findings. We, therefore, conducted a systematic review and meta-analysis to evaluate whether the efficacy of physical activity in the management of HFpEF is related to exercise modalities. PubMed and Embase were searched up to July 2021. The eligible studies included randomized controlled trials that identified effects of physical exercise on patients with HFpEF. Sixteen studies were included to evaluate the efficiency of physical exercise in HFpEF. A pooled analysis showed that exercise training significantly improved peak oxygen uptake (VO2), ventilatory anaerobic threshold, distance covered in the 6-minute walking test, the ratio of early diastolic mitral inflow to annular velocities, the Short Form 36 physical component score, and the Minnesota Living with Heart Failure Questionnaire total score. However, the changes in other echocardiographic parameters including the ratio of peak early to late diastolic mitral inflow velocities, early diastolic mitral annular velocity, and left atrial volume index were not significant. Both high-intensity and moderate-intensity training significantly improved exercise capacity (as defined by peak VO2), with moderate-intensity exercise having a superior effect. Furthermore, exercise-induced improvement in peak VO2 was partially correlated with exercise duration. Physical exercise could substantially improve exercise capacity, quality of life, and some indicators of cardiac diastolic function in patients with HFpEF. A protocol of moderate-intensity exercise training lasting a longer duration might be more beneficial compared with high-intensity training for patients with HFpEF.

Exercise training differently improve cardiac function and regulate myocardial mitophagy in ischemic and pressure-overloaded heart failure mice

NEW FINDINGS

What is the central question of this study? The cardioprotective effects of different aerobic exercises on chronic heart failure with different etiologies and whether mitophagy is involved remain elusive. What is the main finding and its importance? Moderate-intensity continuous training may be the "optimum" modality for improving cardiac structure and function in ischemic heart failure, while both moderate-intensity continuous training and high-intensity interval training were suitable for pressure-overloaded heart failure. Various mitophagy pathways especially PRKN-dependent pathways participated in the protective effects of exercise on heart failure.

ABSTRACT

The cardioprotective effects of different aerobic exercises on chronic heart failure with different etiologies and whether mitophagy is involved remain elusive. In the current research, left anterior descending ligation and transverse aortic constriction surgeries were used to establish mice models of heart failure, followed by 8 weeks of moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT). The results showed that MICT significantly improved ejection fraction (P < 0.05) and fractional shortening (P < 0.05), mitigated left ventricular end-systolic dimension (P < 0.01), brain natriuretic peptide (P < 0.0001), and fibrosis (P < 0.0001), while HIIT only decreased brain natriuretic peptide (P < 0.0001) and fibrosis (P < 0.0001) for ischemic heart failure. Both MICT and HIIT significantly increased ejection fraction (P < 0.0001) and fractional shortening (MICT: P < 0.001, HIIT: P < 0.0001), reduced left ventricular end-diastolic and end-systolic dimension, brain natriuretic peptide (P < 0.0001), and fibrosis (MICT: P < 0.01, HIIT: P < 0.0001), even HIIT was better in reducing brain natriuretic peptide on pressure-overloaded heart failure. Myocardial autophagy and mitophagy were compromised in heart failure, exercises improved myocardial autophagic flux and mitophagy inconsistently in heart failure with different etiologies. Significant correlations were found between multiple mitophagy pathways and cardioprotection of exercises. Collectively, MICT may be the "optimum" modality for ischemic heart failure, both MICT and HIIT (especially HIIT) were suitable for pressure-overloaded heart failure. Exercises differently improved myocardial autophagy/mitophagy and multiple mitophagy-related pathways were closely implicated in cardioprotection of exercises for chronic heart failure. This article is protected by copyright. All rights reserved.

Exercise Training in Heart Failure With Reduced Ejection Fraction and Permanent Atrial Fibrillation: A Randomized Clinical Trial

BACKGROUND

Heart failure (HF) associated with atrial fibrillation (AF) increases patients' physical inactivity, worsening their clinical condition and mortality. Exercise training is safe and has clear benefits in HF. However, little is known about the effects of exercise training on heart failure patients with reduced ejection fraction and permanent atrial fibrillation (HFAF).

OBJECTIVE

To test the hypothesis that exercise training improves functional capacity, cardiac function, and quality of life in patients with HFAF.

METHODS

This randomized clinical trial was conducted at the Heart Institute. Patients with HFAF, LVEF ≤40% and resting HR ≤80 bpm were included in the study. Cardiopulmonary testing, echocardiography, autonomic, and quality of life assessment were performed before and after the 12-week protocol period.

RESULTS

Twenty-six patients, 58±1 years, were randomized to exercise training (HFAF-trained, n=13) or no training (HFAF-untrained, n=13). At baseline, no differences between groups were found. Exercise improved VO₂ peak, slope VE/VCO₂, and quality of life. HFAF-trained significantly decreased resting HR (from 73±2 to 69±2 bpm, P=.02) and recovery HR (from 148±11 to 128±9 bpm, P=.001). Concomitantly, LVEF increased (from 31±1 to 36±0.9 %, P=.01), LA decreased (from 52±1.2 to 47±1mm, P=.03), and LV-ESV and LV-EDV deceased (from 69±2 to 64±1.8 mL/m², and 99±2.1 to 91±2, P<.05, respectively). No changes were observed in the untrained group.

CONCLUSION

Exercise training can improve exercise capacity, quality of life, and cardiac function in patients with heart failure with reduced ejection fraction and permanent atrial fibrillation.

Exercise-Generated β-Aminoisobutyric Acid (BAIBA) Reduces Cardiomyocyte Metabolic Stress and Apoptosis Caused by Mitochondrial Dysfunction Through the miR-208b/AMPK Pathway

Objective

To explore the cardioprotective effects of exercise-derived β-aminoisobutyric (BAIBA) on cardiomyocyte apoptosis and energy metabolism in a rat model of heart failure (HF).

Methods

In male Sprague-Dawley rats (8-week-old), myocardial infarction (MI) was used to induce HF by ligating the left anterior descending branch of the coronary artery. In the Sham group, the coronary artery was threaded but not ligated. After HF development, Sham and HF rats were exercised 60 min daily, 5 days/week on a treadmill for 8 weeks (50–60% maximal intensity) and exercise-induced cardiac remodeling after MI were assessed using echocardiography, hematoxylin and eosin (H&E), Masson's Trichrome, and TUNEL staining for the detection of apoptosis-associated factors in cardiac tissue. High-throughput sequencing and mass spectrometry were used to measure BAIBA production and to explore its cardioprotective effects and molecular actions. To further characterize the cardioprotective effects of BAIBA, an in vitro model of apoptosis was generated by applying H₂O₂ to H9C2 cells to induce mitochondrial dysfunction. In addition, cells were transfected with either a miR-208b analog or a miR-208b inhibitor. Apoptosis-related proteins were detected by Western Blotting (WB). ATP production was also assessed by luminometry. After administration of BAIBA and Compound C, the expression of proteins related to apoptosis, mitochondrial function, lipid uptake, and β-oxidative were determined. Changes in the levels of reactive oxygen species (ROS) were assessed by fluorescence microscopy. In addition, alterations in membrane potential (δψm) were obtained by confocal microscopy.

Results

Rats with HF after MI are accompanied by mitochondrial dysfunction, metabolic stress and apoptosis. Reduced expression of apoptosis-related proteins was observed, together with increased ATP production and reduced mitochondrial dysfunction in the exercised compared with the Sham (non-exercised) HF group. Importantly, exercise increased the production of BAIBA, irrespective of the presence of HF. To assess whether BAIBA had similar effects to exercise in ameliorating HF-induced adverse cardiac remodeling, rats were treated with 75 mg/kg/ day of BAIBA and we found BAIBA had a similar cardioprotective effect. Transcriptomic analyses found that the expression of miR-208b was increased after BAIBA administration, and subsequent transfection with an miR-208b analog ameliorated both the expression of apoptosis-related proteins and energy metabolism in H₂O₂-treated H9C2 cells. In combining transcriptomic with metabolomic analyses, we identified AMPK as a downstream target for BAIBA in attenuating metabolic stress in HF. Further cell experiments confirmed that BAIBA increased AMPK phosphorylation and had a cardioprotective effect on downstream fatty acid uptake, oxidative efficiency, and mitochondrial function, which was prevented by the AMPK inhibitor Compound C.

Conclusion

Exercise-generated BAIBA can reduce cardiomyocyte metabolic stress and apoptosis induced by mitochondrial dysfunction through the miR-208b/AMPK pathway.

Cardiorespiratory Responses During High-Intensity Interval Training Prescribed by Rating of Perceived Exertion in Patients After Myocardial Infarction Enrolled in Early Outpatient Cardiac Rehabilitation

Objective: We aimed to determine the cardiorespiratory responses during, and adaptations to, high-intensity interval training (HIIT) prescribed using ratings of perceived exertion (RPE) in patients after myocardial infarction (MI) during early outpatient cardiac rehabilitation (CR).

Methods: We prospectively recruited 29 MI patients after percutaneous coronary intervention who began CR within 2 weeks after hospital discharge. Eleven patients (seven men; four women; age: 61 ± 11 yrs) who completed ≥24 supervised HIIT sessions with metabolic gas exchange measured during HIIT once weekly for 8 weeks and performed pre- and post- CR cardiopulmonary exercise tests were included in the study. Each HIIT session consisted of 5–8 high-intensity intervals [HIIs, 1-min RPE 14–17 (Borg 6–20 scale)] and low-intensity intervals (LIIs, 4-min RPE < 12). Metabolic gas exchange, heart rate (HR), and blood pressure during HIIT were measured.

Results: The mean oxygen uptake (V˙O₂) during HIIs across 88 sessions of HIITs [91 (14)% of V˙O_2peak, median (interquartile range, IQR)] was significantly higher than the lower limit of target V˙O₂ zone (75% of V˙O_2peak) recommended for the HII (p < 0.001). Exercise intensity during RPE-prescribed HIITs, determined as %V˙O_2peak, was highly repeatable with intra-class correlations of 0.95 (95% CI 0.86– 0.99, p < 0.001). For cardiorespiratory adaptations from the first to the last session of HIIT, treadmill speed, treadmill grade, treadmill power, V˙O_2HII, %V˙O_2peak, and V_E during HIIs were increased (all p < 0.05), while no difference was found for HR, %HR_peak and systolic blood pressure (all p > 0.05). V˙O_2peak increased by an average of 9% from pre-CR to post-CR. No adverse events occurred.

Conclusion: Our results demonstrate that HIIT can be effectively prescribed using RPE in MI patients during early outpatient CR. Participation in RPE-prescribed HIIT increases exercise workload and V˙O₂ during exercise training without increased perception of effort or excessive increases in heart rate or blood pressure.

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.

Economic Outcomes of Rehabilitation Therapy in Older Patients With Acute Heart Failure in the REHAB-HF Trial: A Secondary Analysis of a Randomized Clinical Trial

Importance

In the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a novel 12-week rehabilitation intervention demonstrated significant improvements in validated measures of physical function, quality of life, and depression, but no significant reductions in rehospitalizations or mortality compared with a control condition during the 6-month follow up. The economic implications of these results are important given the increasing pressures for cost containment in health care.

Objective

To report the economic outcomes of the REHAB-HF trial and estimate the potential cost-effectiveness of the intervention.

Design, Setting, Participants

The multicenter REHAB-HF trial randomized 349 patients 60 years or older who were hospitalized for acute decompensated heart failure to rehabilitation intervention or a control group; patients were enrolled from September 17, 2014, through September 19, 2019. For this preplanned secondary analysis of the economic outcomes, data on medical resource use and quality of life (via the 5-level EuroQol 5-Dimension scores converted to health utilities) were collected. Medical resource use and medication costs were estimated using 2019 US Medicare payments and the Federal Supply Schedule, respectively. Cost-effectiveness was estimated using the validated Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, which uses an individual-patient simulation model informed by the prospectively collected trial data. Data were analyzed from March 24, 2019, to December 1, 2020.

Interventions

Rehabilitation intervention or control.

Main Outcomes and Measures

Costs, quality-adjusted life-years (QALYs), and the lifetime estimated cost per QALY gained (incremental cost-effectiveness ratio).

Results

Among the 349 patients included in the analysis (183 women [52.4%]; mean [SD] age, 72.7 [8.1] years; 176 non-White [50.4%] and 173 White [49.6%]), mean (SD) cumulative costs per patient were $26 421 ($38 955) in the intervention group (excluding intervention costs) and $27 650 ($30 712) in the control group (difference, -$1229; 95% CI, -$8159 to $6394; P = .80). The mean (SD) cost of the intervention was $4204 ($2059). Quality of life gains were significantly greater in the intervention vs control group during 6 months (mean utility difference, 0.074; P = .001) and sustained beyond the 12-week intervention. Incremental cost-effectiveness ratios were estimated at $58 409 and $35 600 per QALY gained for the full cohort and in patients with preserved ejection fraction, respectively.

Conclusions and Relevance

These analyses suggest that longer-term benefits of this novel rehabilitation intervention, particularly in the subgroup of patients with preserved ejection fraction, may yield good value to the health care system. However, long-term cost-effectiveness is currently uncertain and dependent on the assumption that benefits are sustained beyond study follow-up, which needs to be corroborated in future trials in this patient population.

Plasma-Derived microRNAs Are Influenced by Acute and Chronic Exercise in Patients With Heart Failure With Reduced Ejection Fraction

Background: Exercise training improves VO₂peak in heart failure with reduced ejection fraction (HFrEF), but the effect is highly variable as it is dependent on peripheral adaptations. We evaluated changes in plasma-derived miRNAs by acute and chronic exercise to investigate whether these can mechanistically be involved in the variability of exercise-induced adaptations.

Methods: Twenty-five male HFrEF patients (left ventricular ejection fraction < 40%, New York Heart Association class ≥ II) participated in a 15-week combined strength and aerobic training program. The effect of training on plasma miRNA levels was compared to 21 male age-matched sedentary HFrEF controls. Additionally, the effect of a single acute exercise bout on plasma miRNA levels was assessed. Levels of 5 miRNAs involved in pathways relevant for exercise adaptation (miR-23a, miR-140, miR-146a, miR-191, and miR-210) were quantified using RT-qPCR and correlated with cardiopulmonary exercise test (CPET), echocardiographic, vascular function, and muscle strength variables.

Results: Expression levels of miR-146a decreased with training compared to controls. Acute exercise resulted in a decrease in miR-191 before, but not after training. Baseline miR-23a predicted change in VO₂peak independent of age and left ventricular ejection fraction (LVEF). Baseline miR-140 was independently correlated with change in load at the respiratory compensation point and change in body mass index, and baseline miR-146a with change in left ventricular mass index.

Conclusion: Plasma-derived miRNAs may reflect the underlying mechanisms of exercise-induced adaptation. In HFrEF patients, baseline miR-23a predicted VO₂peak response to training. Several miRNAs were influenced by acute or repeated exercise. These findings warrant exploration in larger patient populations and further mechanistic in vitro studies on their molecular involvement.

Effects of exercise training on diastolic and systolic dysfunction in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is a complex syndrome characterized by a progressive reduction of the left ventricular (LV) contractility, low exercise tolerance, and increased mortality and morbidity. Diastolic dysfunction (DD) of the LV, is a keystone in the pathophysiology of CHF and plays a major role in the progression of most cardiac diseases. Also, it is well estimated that exercise training induces several beneficial effects on patients with CHF.

AIM

To evaluate the impact of a cardiac rehabilitation program on the DD and LV ejection fraction (EF) in patients with CHF.

METHODS

Thirty-two stable patients with CHF (age: 56 ± 10 years, EF: 32% ± 8%, 88% men) participated in an exercise rehabilitation program. They were randomly assigned to aerobic exercise (AER) or combined aerobic and strength training (COM), based on age and peak oxygen uptake, as stratified randomization criteria. Before and after the program, they underwent a symptom-limited maximal cardiopulmonary exercise testing (CPET) and serial echocardiography evaluation to evaluate peak oxygen uptake (VO_2peak), peak workload (W_peak), DD grade, right ventricular systolic pressure (RVSP), and EF.

RESULTS

The whole cohort improved VO_2peak, and W_peak, as well as DD grade (P < 0.05). Overall, 9 patients (28.1%) improved DD grade, while 23 (71.9%) remained at the same DD grade; this was a significant difference, considering DD grade at baseline (P < 0.05). In addition, the whole cohort improved RVSP and EF (P < 0.05). Not any between-group differences were observed in the variables assessed (P > 0.05).

CONCLUSION

Exercise rehabilitation improves indices of diastolic and systolic dysfunction. Exercise protocol was not observed to affect outcomes. These results need to be further investigated in larger samples.

Resistance training in heart failure patients: a systematic review and meta-analysis

Aerobic training (AT) has been the primary mode of exercise training in cardiac rehabilitation. Historically, the reason for the prescription of AT was that it was speculated that although RT may be beneficial for some clinical outcomes, it may have an adverse effect on ventricular structure and function. However, RT has now made its way into current cardiac rehabilitation guidelines, including those directed towards patients with HF, albeit differences exist across institutions and guidelines. A systematic search of PubMed, EMBASE and Cochrane Trials Register on April 30, 2021, was conducted for exercise-based rehabilitation trials in HF. Randomised and controlled trials that reported on resistance training versus usual care or trials that directly compared RT to an AT intervention were included. Resistance training versus controls improves parameters of lower (SMD 0.76 (95%CI 0.26, 1.25, p = 0.003] and upper extremity muscle strength (SMD 0.85 (95%CI 0.35, 1.35), p = 0.0009], both key parameters of physical function throughout the lifespan. Importantly, RT in isolation, versus control, improves VO2peak [MD: 2.64 ml/kg/min (95%CI 1.67, 3.60), p < 0.00001] and 6MWD [MD: 49.94 m (95%CI 34.59, 65.29), p < 0.00001], without any detrimental effect on left ventricular parameters. Resistance training in HF patients is safe and improves parameters of physical function and quality of life. Where people with HF are unable to, or are not inclined to, partake in aerobic activity, RT alone is appropriate to elicit meaningful benefit.

Effect of exercise training on left ventricular remodeling in patients with myocardial infarction and possible mechanisms

BACKGROUND

A growing amount of evidence provides support for the hypothesis that acute myocardial infarction (AMI) patients should go through cardiopulmonary exercise testing (CPET) about 3-5 d after AMI is diagnosed, make reasonable exercising prescription, and conduct exercise training under guidance.

AIM

To investigate the effect of exercise training (ET) on left ventricular systolic function and left ventricular remodeling (LVRM) and to study the possible mechanisms of LVRM by the changes of matrix metallopeptidase 9 (MMP-9) and tissue inhibitor of metalloproteinases 1 (TIMP-1) in patients with acute ST-segment elevation myocardial infarction (STEMI).

METHODS

Sixty patients with first STEMI undergoing direct percutaneous coronary intervention from February 2008 to October 2008 were randomly assigned to an exercise group (n = 30) and a control group (n = 30). The levels of MMP-9 and TIMP-1 were measured in all patients at 1 d, 10-14 d, 30 d, and 6 mo after admission. Two-dimensional echocardiography and cardiopulmonary exercise testing were done in patients at 10-14 d and 6 mo after admission.

RESULTS

There was no significant difference in CPET at baseline between the exercise group and the control group. At 6 mo, the time of exercise, peak and anaerobic threshold values of O₂ uptake, and metabolic equivalents increased in both groups, but markedly increased in the exercise group. At baseline, there were no significant differences in left ventricular ejection fraction (LVEF) between the two groups. At 6 mo, LVEF increased in the exercise group, but not in the control group. At 6 mo, the percentage of patients with positive result of LVRM was 26.6% in the exercise group and 52.6% in the control group (P < 0.05). The levels of plasma MMP-9 and TIMP-1 and the ratio of MMP-9 to TIMP-1 in both groups had no significant difference at 1 d and 10-14 d after AMI, but at 30 d and 6 mo, the levels of plasma MMP-9 and TIMP-1 in the exercise group were significantly lower than those in the control group; the ratio of MMP-9 to TIMP-1 in the exercise group was significantly higher than that in the control group.

CONCLUSION

ET under supervision based on home condition in early and recovery stage of AMI can improve exercise cardiopulmonary function and prevent the LVRM. Therefore, it may reduce unfavorable remodeling response by decreasing the levels of plasma MMP-9 and TIMP-1 and adjusting the ratio of MMP-9 to TIMP-1 hereafter.

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.

Low-volume high-intensity interval training for cardiometabolic health

High-intensity interval training (HIIT) is characterised by short bouts of high-intensity submaximal exercise interspersed with rest periods. Low-volume HIIT, typically involving less than 15 min of high-intensity exercise per session, is being increasingly investigated in healthy and clinical populations due to its time-efficient nature and purported health benefits. The findings from recent trials suggest that low-volume HIIT can induce similar, and at times greater, improvements in cardiorespiratory fitness, glucose control, blood pressure, and cardiac function when compared to more traditional forms of aerobic exercise training including high-volume HIIT and moderate intensity continuous training, despite requiring less time commitment and lower energy expenditure. Although further studies are required to elucidate the precise mechanisms of action, metabolic improvements appear to be driven, in part, by enhanced mitochondrial function and insulin sensitivity, whereas certain cardiovascular improvements are linked to increased left ventricular function as well as greater central and peripheral arterial compliance. Beyond the purported health benefits, low-volume HIIT appears to be safe and well-tolerated in adults, with high rates of reported exercise adherence and low adverse effects.

Cardiac Rehabilitation for Patients With Heart Failure: JACC Expert Panel

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

The Feasibility of High-Intensity Interval Training in Patients with Intensive Care Unit-Acquired Weakness Syndrome Following Long-Term Invasive Ventilation

Background

Intensive care unit-acquired weakness syndrome (ICUAWS) can be a consequence of long-term mechanical ventilation. Despite recommendations of early patient mobilisation, little is known about the feasibility, safety and benefit of interval training in early rehabilitation facilities (ERF) after long-term invasive ventilation.

Methods and Results

We retrospectively analysed two established training protocols of bicycle ergometry in ERF patients after long-term (> 7 days) invasive ventilation (n = 46). Patients conducted moderate continuous (MCT, n = 24, mean age 70.3 ± 10.1 years) or high-intensity interval training (HIIT, n = 22, mean age 63.6 ± 12.6 years). The intensity of training was monitored with the BORG CR10 scale (intense phases ≥ 7/10 and moderate phases ≤ 4/10 points). The primary outcome was improvement (∆-values) of six-minute-walk-test (6 MWT), while the secondary outcomes were improvement of vital capacity (VC_max), forced expiratory volume in 1 s (FEV₁), maximal inspiratory pressure (PI_max) and functional capabilities (functional independence assessment measure, FIM/FAM and Barthel scores) after 3 weeks of training. No adverse events were observed. There was a trend towards a greater improvement of 6 MWT in HIIT than MCT (159.5 ± 64.9 m vs. 120.4 ± 60.4 m; p = .057), despite more days of invasive ventilation (39.6 ± 16.8 days vs. 26.8 ± 16.2 days; p = .009). VC_max (∆0.5l ± 0.6 vs. ∆0.5l ± 0.3; p = .462), FEV₁ (∆0.2l ± 0.3 vs. ∆0.3l ± 0.2; p = .218) PI_max (∆0.8 ± 1.1 kPa vs. ∆0.7 ± 1.3pts; p = .918) and functional status (FIM/FAM: ∆29.0 ± 14.8pts vs. ∆30.9 ± 16.0pts; p = .707; Barthel: ∆28.9 ± 16.0 pts vs. ∆25.0 ± 10.5pts; p = .341) improved in HIIT and MCT.

Conclusions

We demonstrate the feasibility and safety of HIIT in the early rehabilitation of ICUAWS patients. Larger trials are necessary to find adequate dosage of HIIT in ICUAWS patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00299-6.

Exercise-mitigated sex-based differences in aging: from genetic alterations to heart performance

The prevalence of cardiovascular diseases dramatically increases with age; therefore, striving to maintain a physiological heart function is particularly important. Our aim was to study the voluntary exercise-evoked cardioprotective effects in aged male and female rats, from genetic alterations to changes in heart performance. We divided 20-month-old female and male Wistar rats to control and running groups. After the 12-wk-long experimental period, echocardiographic measurements were performed. Afterwards, hearts were either removed for biochemical measurements or mounted into a Langendorff-perfusion system to detect infarct size. The following genes and their proteins were analyzed from heart: catechol-O-methyltransferase (Comt), endothelin-1 (Esm1), Purkinje cell protein-4 (Pcp4), and osteoglycin (Ogn). Recreational exercise caused functional improvements; however, changes were more prominent in males. Cardiac expression of Comt and Ogn was reduced as a result of exercise in aged males, whereas Pcp4 and Esm1 showed a marked overexpression, along with a markedly improved diastolic function. The key result of this study is that exercise enhanced the expression of the Pcp4 gene and protein, a recently described regulator of calcium balance in cardiomyocytes, and suppressed Comt and Ogn gene expression, which has been associated with impaired cardiac function. In addition, as a result of exercise, a significant improvement was observed in the size of infarct elicited by left anterior descending coronary artery occlusion. Our results clearly show that age and sex-dependent changes were both apparent in key proteins linked to cardiovascular physiology. Exercise-moderated fundamental genetic alterations may have contributed to the functional adaptation of the heart.NEW & NOTEWORTHY Voluntary exercise has proved to be an effective therapeutic tool to improve cardiac function in aged rats with clearly visible sex differences. Long-term exercise is associated with decreased Ogn and Comt expression and enhanced presence of Pcp4 and Esm1 genes. Sex-dependent changes were also observed in the expression of the cardiovascular key proteins. Fundamental alterations in gene and protein expression may contribute to the improvement of cardiac performance.