Chronic heart failure and exercise

Ten-year trends in non-surgical patients requiring intensive care: Long-term prognostic differences by year of admission

BACKGROUND

The aim of the present study is to elucidate prognostic impact of temporal trends of non-surgical patients requiring intensive care over a 10-year period.

METHODS AND RESULTS

A total of 4276 non-surgical patients requiring intensive care from 2012 to 2021 were enrolled. Patients' backgrounds, in-hospital management, and prognoses were compared between five groups [2012-2013 (n = 825), 2014-2015 (n = 784), 2016-2017 (n = 864), 2018-2019 (n = 939), and 2020-2021 (n = 867)]. During the study period, mean age significantly increased from 69 years in 2012-2013 to 72 years in 2020-2021. Mean Acute Physiology and Chronic Health Evaluation scores significantly increased from 10 points in 2012-2013 to 12 points in 2020-2021. The median duration of intensive care unit stays increased from 3 to 4 days. Kaplan-Meier survival curve analysis showed that survival rates during 30- and 365-days were significantly lower in 2020-2021 than in 2012-2013, but it was not significantly different by a Cox proportional hazards regression model in 30 days. A Cox proportional hazards regression model revealed that the risks of 365-day all-cause death were significantly higher in patients enrolled in 2016-2017 (HR: 1.324, 95 % CI: 1.042-1.680, p = 0.021), in 2018-2019 (HR: 1.329, 95 % CI: 1.044-1.691, p = 0.021), and in 2020-2021 (HR: 1.409, 95 % CI: 1.115-1.779, p = 0.004).

CONCLUSION

The condition of patients requiring intensive care is becoming more critical year by year, leading to poorer long-term prognoses despite improvements in treatment strategies. These findings emphasize the importance of additional care management after admission into non-surgical intensive care units, particularly for the aging society of Japan.

Effects of Synchronizing Foot Strike and Cardiac Phase on Exercise Hemodynamics in Patients With Cardiac Resynchronization Therapy: A Within-Subjects Pilot Study to Fine-Tune Cardio-Locomotor Coupling for Heart Failure

BACKGROUND

Despite advances in medical and cardiac resynchronization therapy (CRT), individuals with chronic congestive heart failure (CHF) have persistent symptoms, including exercise intolerance. Optimizing cardio-locomotor coupling may increase stroke volume and skeletal muscle perfusion as previously shown in healthy runners. Therefore, we tested the hypothesis that exercise stroke volume and cardiac output would be higher during fixed-paced walking when steps were synchronized with the diastolic compared with systolic portion of the cardiac cycle in patients with CHF and CRT.

METHODS

Ten participants (58±17 years of age; 40% female) with CHF and previously implanted CRT pacemakers completed 5-minute bouts of walking on a treadmill (range, 1.5-3 mph). Participants were randomly assigned to first walking to an auditory tone to synchronize their foot strike to either the systolic (0% or 100±15% of the R-R interval) or diastolic phase (45±15% of the R-R interval) of their cardiac cycle and underwent assessments of oxygen uptake (V̇o2; indirect calorimetry) and cardiac output (acetylene rebreathing). Data were compared through paired-samples t tests.

RESULTS

V̇o2 was similar between conditions (diastolic 1.02±0.44 versus systolic 1.05±0.42 L/min; P=0.299). Compared with systolic walking, stroke volume (diastolic 80±28 versus systolic 74±26 mL; P=0.003) and cardiac output (8.3±3.5 versus 7.9±3.4 L/min; P=0.004) were higher during diastolic walking; heart rate (paced) was not different between conditions. Mean arterial pressure was significantly lower during diastolic walking (85±12 versus 98±20 mm Hg; P=0.007).

CONCLUSIONS

In patients with CHF who have received CRT, diastolic stepping increases stroke volume and oxygen delivery and decreases afterload. We speculate that, if added to pacemakers, this cardio-locomotor coupling technology may maximize CRT efficiency and increase exercise participation and quality of life in patients with CHF.

Effects of traditional Chinese eight brocade exercise with same frequency and different durations on the quality of life, 6-min walk and brain natriuretic peptide in patients with chronic heart failure

BACKGROUND

Traditional Chinese eight brocade exercise (TCEBE) with same cycle and frequency and different durations has an effect on patients with chronic heart failure (CHF). However, relevant reports on the topic are lacking.

OBJECTIVE

This study aims to explore the differences of rehabilitation effect by conducting TCEBE with the same cycle and frequency and different single exercise time for patients with CHF.

METHODS

A total of 103 patients with CHF were randomly divided into long-time group (LTG), short-time group (STG) and control group (CG). The subjects in the three groups were given corresponding routine treatment. In addition, under the guidance of professional TCEBE coaches and nurses, TCEBE was conducted for 12 weeks (3 times/week) for LTG (60 min/time) and STG (30 min/time). Minnesota living with heart failure questionnaire (MLHFQ) was used, and 6-min walk (6MWK) and brain nautical peptide (BNP) were tested.

RESULTS

1) At 12 weeks, the comparison between groups obtained the following results: For the LTG, MLHFQ was less than that of the CG (P < 0.01), 6MWT was greater than that of the CG (P < 0.05), and 6MWT was greater than that of the STG (P < 0.05); for the STG, MLHFQ was less than that of the CG (P < 0.05); no significant difference in BNP was found among the three groups; 2) At 12 weeks and 0 weeks, the comparison obtained the following results: For the LTG, MLHFQ decreased by 37.7 %, and 6MWT increased by 46.7 % (P < 0.01); for the STG, MLHFQ decreased by 31.7 %, and 6MWT increased by 31.5 % (P < 0.01); for the CG, MLHFQ decreased by 14.6 %, and 6MWT increased by 19.7 % (P < 0.05); no significant change in BNP was found in each group.

CONCLUSION

TCEBE of two kinds of duration improves the quality of life and 6MWT of patients with CHF but has no positive effect on BNP. Compared with 30-min/time, 60-min/time further improves 6MWT in patients with CHF but has no additional benefit on quality of life.

Mechanism of Dyspnea during Exercise in Children with Corrected Congenital Heart Disease

This study will evaluate cardiorespiratory and peripheral muscle function and their relationship with subjective dyspnea threshold after the surgical correction of congenital heart disease in children. Thirteen children with surgically repaired congenital heart disease were recruited. Each participant performed an incremental exercise test on a cycle ergometer until exhaustion. Gas exchanges were continuously sampled to measure the maximal aerobic parameters and ventilatory thresholds. The functional capacity of the subjects was assessed with a 6 min walk test. At the end of the exercise test, isokinetic Cybex Norm was used to evaluate the strength and endurance of the knee extensor muscle in the leg. Dyspnea was subjectively scored with a visual analog scale during the last 15 s of each exercise step. Oxygen consumption measured at the dyspnea score/VO₂ relationship located at the dyspnea threshold, at which dyspnea suddenly increased. Results: The maximal and submaximal values of the parameters describing the exercise and the peripheral muscular performances were: VO₂ Peak: 33.8 ± 8.9 mL·min^-1·kg^-1; HR: 174 ± 9 b·min^-1; VEmax: 65.68 ± 15.9 L·min^-1; P max: 117 ± 27 W; maximal voluntary isometric force MVIF: 120.8 ± 41.9 N/m; and time to exhaustion Tlim: 53 ± 21 s. Oxygen consumption measured at the dyspnea threshold was related to VO₂ Peak (R² = 0.74; p < 0.01), Tlim (R² = 0.78; p < 0.01), and the distance achieved during the 6MWT (R² = 0.57; p < 0.05). Compared to the theoretical maximal values for the power output, VO₂, and HR, the surgical correction did not repair the exercise performance. After the surgical correction of congenital heart disease, exercise performance was impeded by alterations of the cardiorespiratory function and peripheral local factors. A subjective evaluation of the dyspnea threshold is a reliable criterion that allows the prediction of exercise capacity in subjects suffering from congenital heart disease.

The effectiveness of functional electrical stimulation of the legs in patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the effectiveness of functional electrical stimulation of the legs in patients with heart failure.

METHODS

Data were obtained from PubMed, Cochrane Library, and Embase databases until August 12, 2021. We included randomized controlled trials that evaluated the effects of functional electrical stimulation applied to the legs of patients with heart failure, namely changes in cardiopulmonary function, muscle strength, and quality of life.

RESULTS

In total, 14 randomized controlled trials (consisting of 518 patients) were included in our article. Pooled estimates demonstrated that functional electrical stimulation significantly improved peak oxygen consumption (peak VO₂; standardized mean difference = 0.33, 95% confidence interval = 0.07-0.59, eight randomized controlled trials, n = 321), 6-min walking distance (mean difference = 48.03 m, 95% confidence interval = 28.50-67.57 m, 10 randomized controlled trials, n = 380), and Minnesota Living with Heart Failure Questionnaire quality of life score (mean difference =  - 8.23, 95% confidence interval =  - 12.64 to - 3.83, nine randomized controlled trials, n = 383). Muscle strength of lower extremities was not significantly improved in the functional electrical stimulation group compared with that in the control group (standardized mean difference = 0.26, 95% confidence interval =  - 0.18 to 0.71, five randomized controlled trials, n = 218). Furthermore, the subgroup analysis revealed that functional electrical stimulation significantly improved peak VO₂, 6-min walking distance, and Minnesota Living with Heart Failure Questionnaire quality of life score in the heart failure with reduced ejection fraction and heart failure with preserved ejection fraction subgroups.

CONCLUSION

Functional electrical stimulation can effectively improve the cardiopulmonary function and quality of life in patients with heart failure. However, functional electrical stimulation did not significantly improve muscle strength in the legs.

The Prognostic Impact of Hospital Transfer after Admission due to Acute Heart Failure

The prognostic impact of transfer to another hospital among acute heart failure (AHF) patients has not been well elucidated.Of the 800 AHF patients analyzed, 682 patients were enrolled in this study for analysis. The subjects were divided into two groups according to their discharge location: discharge home (Group-H, n = 589) or transfer to another hospital for rehabilitation (Group-T, n = 93). The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and heart failure (HF) events (death, readmission-HF), in Group-T than that in Group-H (P < 0.001, respectively). A multivariate Cox regression model showed that Group-T was an independent predictor of 365-day all-cause death (hazard ratio: 2.618, 95% confidence interval [CI]: 1.510-4.538, P = 0.001). The multivariate logistic regression analysis showed that aging (per 1-year-old increase, odds ratio [OR]: 1.056, 95% CI: 1.028-1.085, P < 0.001), female gender (OR: 2.128, 95% CI: 1.287-3.521, P = 0.003), endotracheal intubation during hospitalization (OR: 2.074, 95% CI: 1.093-3.936, P = 0.026), and increased Controlling Nutritional Status score on admission (per 1.0-point increase, OR: 1.247, 95% CI: 1.131-1.475, P < 0.001) were associated with transfer to another hospital after AHF admission. The prognosis, including all-cause death, was determined to be significantly poorer in patients who were transferred to another hospital, as their activities of daily living were noted to lessen before discharge (n = 11) compared to others (n = 82).Elderly AHF patients suffering from malnutrition were difficult to discharge home after AHF admission, and transfer to another hospital only led to adverse outcomes. Appropriate rehabilitation during definitive hospitalization appears necessary for managing elderly patients in the HF pandemic era.

Multimorbidity patterns and risk of frailty in older community-dwelling adults: a population-based cohort study

BACKGROUND

the aim of this study was to examine the cross-sectional and longitudinal associations of different multimorbidity patterns with physical frailty in older adults.

METHODS

we used data from the Swedish National study on Aging and Care in Kungsholmen to generate a physical frailty measure, and clusters of participants with similar multimorbidity patterns were identified through fuzzy c-means cluster analyses. The cross-sectional association (n = 2,534) between multimorbidity clusters and physical frailty was measured through logistic regression analyses. Six- (n = 2,122) and 12-year (n = 2,140) longitudinal associations were determined through multinomial logistic regression analyses.

RESULTS

six multimorbidity patterns were identified at baseline: psychiatric diseases; cardiovascular diseases, anaemia and dementia; sensory impairments and cancer; metabolic and sleep disorders; musculoskeletal, respiratory and gastrointestinal diseases; and an unspecific pattern lacking any overrepresented diseases. Cross-sectionally, each pattern was associated with physical frailty compared with the unspecific pattern. Over 6 years, the psychiatric diseases (relative risk ratio [RRR]: 3.04; 95% confidence intervals [CI]: 1.59-5.79); cardiovascular diseases, anaemia and dementia (RRR 2.25; 95% CI: 1.13-4.49) and metabolic and sleep disorders (RRR 1.99; 95% CI: 1.25-3.16) patterns were associated with incident physical frailty. The cardiovascular diseases, anaemia and dementia (RRR: 4.81; 95% CI: 1.59-14.60); psychiatric diseases (RRR 2.62; 95% CI: 1.45-4.72) and sensory impairments and cancer (RRR 1.87; 95% CI: 1.05-3.35) patterns were more associated with physical frailty, compared with the unspecific pattern, over 12 years.

CONCLUSIONS

we found that older adults with multimorbidity characterised by cardiovascular and neuropsychiatric disease patterns are most susceptible to developing physical frailty.

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.

Exercise-Based Cardiac Rehabilitation Programs in Heart Failure Patients

Exercise training is recommended for patients with heart failure by major societies' guidelines. It improves exercise capacity and quality of life, reduces symptoms of depression, can improve survival, and reduce the risk for hospitalizations. Exercise-based cardiac rehabilitation can be offered with different modalities, such as continuous or interval aerobic training, resistance, and inspiratory muscle training. The intervention must follow an accurate evaluation of the patient's cardiovascular conditions and functional capacity. Despite the multiple benefits of exercise training, there is a lack of adherence to exercise-based programs, due to socioeconomic factors, patients' characteristics, and lack of referral.

Impact of cardiac rehabilitation programs on left ventricular remodeling after acute myocardial infarction: Study Protocol Clinical Trial (SPIRIT Compliant)

INTRODUCTION

While the role of early mobilization in the immediate postinfarction period has been well demonstrated, little is known in present about the link between early mobilization and reduction of systemic inflammation. At the same time, the impact of early mobilization on regression of left ventricular remodeling has not been elucidated so far.

MATERIAL AND METHODS

Here we present the study protocol of the REHAB trial, a clinical descriptive, prospective study, conducted in a single-center, with the purpose to analyze the impact of early mobilization in reducing left ventricular remodeling, the complication rates and mortality in patients who had suffered a recent acute myocardial infarction (AMI). At the same time, the study aims to demonstrate the contribution of early mobilization to reduction of systemic inflammation, thus reducing the inflammation-mediated ventricular remodeling. 100 patients with AMI in the last 12 hours, and successful revascularization of the culprit artery within the first 12 hours after the onset of symptoms in ST-segment elevation acute myocardial infarction or within first 48 hours in non ST-segment elevation AMI will be enrolled in the study. Based on the moment of mobilization after AMI patients will be distributed in 2 groups: group 1 - patients with early mobilization (<2 days after the onset of symptoms) and; group 2 - subjects with delayed mobilization after AMI (>2 days after the onset of symptoms). Study outcomes will consist in the impact of early mobilization after AMI on the ventricular remodeling in the post-infarction period, as assessed by cardiac magnetic resonance imaging, the rate of in-hospital mortality, the rate of repeated revascularization or MACE and the effect of early mobilization on systemic inflammation in the immediate postinfarction phase.

CONCLUSION

In conclusion, REHAB will be the first trial that will elucidate the impact of early mobilization in the first period after AMI, as a first step of a complex cardiac rehabilitation program, to reduce systemic inflammation and prevent deleterious ventricular remodeling in patients who suffered a recent AMI.

Effect of cardiac rehabilitation on cardiovascular risk factors in chronic heart failure patients

Introduction

Cardiac rehabilitation improves disease-related symptoms, quality of life, and clinical outcomes. This study was done to evaluate the effect of cardiac rehabilitation program on cardiovascular risk factors in chronic heart failure patients as well as functional capacity and health related quality of life.

Methods

The study was conducted on 80 Patients with chronic stable heart failure. All patients had full history and thorough physical examination. Body mass index (BMI), waist circumference, glycated hemoglobin (HbA1c), lipid profile, and echocardiography, all of which were done before and after recruitment in a 2 months cardiac rehabilitation program (through prescribed exercise training, 2 sessions/week for 2 months). The changes in functional capacity were evaluated by 6-min walk test (6MWT) and the changes in the health related quality of life were measured by Minnesota living with heart failure questionnaire (MLHFQ), both were done before and after the rehabilitation program.

Results

There was a highly significant reduction in the blood pressure, heart rate, BMI, waist circumference, the smokers' number and the glycated hemoglobin (HbA1c) (P < 0.01). However, there was no statistically significant reductions in low density lipoproteins (LDL), Triglycerides (P > 0.05). Highly significant improvements were noted in the functional capacity and the health related quality of life as evidenced by improvement in the 6MWT and the MLHFQ scores (total score, physical and psychological domains, P < 0.01).

Conclusion

Cardiac rehabilitation had a significant improvement of cardiovascular risk factors, functional capacity and Health related quality of life in patients with chronic heart failure.

An exploratory study on the efficacy and safety of a BCAA preparation used in combination with cardiac rehabilitation for patients with chronic heart failure

Background

Sarcopenia is generally complicated with patients with chronic heart failure (CHF) and its presence negatively affects the course of heart failure, however effective nutritional intervention had not been elucidated yet. The primary objective of this study is to explore whether the addition of a branched-chain amino acid (BCAA) preparation for cardiac rehabilitation (CR) of patients with CHF further improves cardiopulmonary functions, skeletal muscle functions, and metabolism in comparison with conventional CR.

Methods

This is a randomized, parallel-group comparative study. The elderly patients that were participated in CR and complicated with left ventricular systolic or diastolic dysfunction are randomized into two groups, CR + BCAA and CR. 20 weeks later, the second randomization is performed, which divide subjects into two groups with and without BCAA intervention without CR. Primary outcome measure is the rate of change of the anaerobic threshold workload from baseline to post-intervention. Secondary outcome include parameters of exercise capacity, cardiac function and psychological status.

Discussion

In the current study the effect of a promising new intervention, BCAA, will be assessed to determine whether its addition to CR improve exercise capacity in patients with heart failure, who are generally complicated with sarcopenia.

Trial registration

This clinical trial was registered with the University Hospital Medical Information Network—Clinical Trials Registry (UMIN–CTR; JPRN–UMIN R000022440).

Exercise-Based Rehabilitation for Heart Failure: Clinical Evidence

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

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Temporal Trends and Factors Associated With Cardiac Rehabilitation Referral Among Patients Hospitalized With Heart Failure: Findings From Get With The Guidelines-Heart Failure Registry

BACKGROUND

Current guidelines recommend cardiac rehabilitation (CR) in medically stable outpatients with heart failure (HF); however, temporal trends and factors associated with CR referral among these patients in real-world practice are not entirely known.

OBJECTIVES

The purpose of this study was to assess proportional use, temporal trends, and factors associated with CR referral at discharge among patients admitted with decompensated HF.

METHODS

Using data from a national Get With the Guidelines-Heart Failure registry, we assessed the temporal trends in CR referral among eligible patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) at discharge after HF hospitalization between 2005 and 2014. On multivariable analysis, we also assessed patient- and hospital-level characteristics that are associated with CR referral.

RESULTS

Among 105,619 HF patients (48% with HFrEF, 52% with HFpEF), 10.4% (12.2% with HFrEF, 8.8% with HFpEF) received CR referral at discharge. A significant increase in CR referral rates was observed among both HFpEF and HFrEF patients over the study period (ptrend <0.0001 for HFrEF, HFpEF, and overall). Compared with patients discharged without CR referral, patients referred for CR were younger, predominantly men, and more likely to receive evidence-based HF therapies at discharge. On multivariable analysis, younger age, fewer comorbid conditions, and in-hospital procedures such as coronary artery bypass grafting, percutaneous coronary intervention, and cardiac valve surgery were most strongly associated with CR referral.

CONCLUSIONS

Only one-tenth of eligible HF patients received CR referral at discharge after hospitalization for HF. The proportional use of CR referral is increasing over time among both HFrEF and HFpEF patients. Further strategies to improve physician and patient awareness in regard to the benefit of CR should be used to increase CR referral among patients with HF.

Perioperative Hypoalbuminemia Affects Improvement in Exercise Tolerance After Left Ventricular Assist Device Implantation

BACKGROUND

Although survival rates have improved for patients receiving implantable continuous flow left ventricular assist devices (I-CF LVAD), postoperative exercise tolerance levels are not necessarily satisfactory.

METHODS AND RESULTS

We enrolled 51 patients who had received an I-CF LVAD and underwent follow-up between 2006 and 2014; all patients underwent cardiopulmonary exercise testing 3 months following surgery: 26 (51%) patients achieved peak oxygen consumption (PV̇O2) ≥14 ml·kg(-1)·min(-1)and had significantly lower readmission rates for cardiovascular events than those with PV̇O2<14 ml·kg(-1)·min(-1)during 2 years of LVAD treatment (17 vs. 43%, P=0.033). Uni- and multivariate logistic regression analyses showed that the preoperative serum albumin (S-ALB) level was an independent predictor for PV̇O2≥14 ml·kg(-1)·min(-1)at 3 months (P=0.023, odds ratio 6.132). Patients with persistently normal S-ALB levels during the perioperative period had the lowest preoperative serum C-reactive protein level (S-CRP, 0.7±0.9 mg/dl), and the majority (77%) showed improved exercise tolerance. Conversely, patients with persistently low S-ALB levels during this period had the highest preoperative S-CRP level (2.8±1.2 mg/dl) and did not achieve the test endpoint.

CONCLUSIONS

Both pre- and postoperative low S-ALB impedes recovery of exercise tolerance after I-CF LVAD surgery, and this may be attributable to inflammatory responses caused by heart failure.

How should we advise heart failure patients on exercise and what should we tell them?

The article discusses the problem of motivating and encouraging patients with heart failure to perform regular exercise training. Firstly, the benefits of exercise training are presented, and rational and convincing arguments justifying its implementation in heart failure patients are provided. Secondly, the issue of overcoming barriers to exercise training implementation is considered. Finally, the role of the medical team and family members in supporting patients with heart failure in long-term adherence to recommendations is defined and analyzed. In addition, the article presents various ways of performing exercise training easily.

Cardiac remodeling and physical training post myocardial infarction

After myocardial infarction (MI), the heart undergoes extensive myocardial remodeling through the accumulation of fibrous tissue in both the infarcted and noninfarcted myocardium, which distorts tissue structure, increases tissue stiffness, and accounts for ventricular dysfunction. There is growing clinical consensus that exercise training may beneficially alter the course of post-MI myocardial remodeling and improve cardiac function. This review summarizes the present state of knowledge regarding the effect of post-MI exercise training on infarcted hearts. Due to the degree of difficulty to study a viable human heart at both protein and molecular levels, most of the detailed studies have been performed by using animal models. Although there are some negative reports indicating that post-MI exercise may further cause deterioration of the wounded hearts, a growing body of research from both human and animal experiments demonstrates that post-MI exercise may beneficially alter the course of wound healing and improve cardiac function. Furthermore, the improved function is likely due to exercise training-induced mitigation of renin-angiotensin-aldosterone system, improved balance between matrix metalloproteinase-1 and tissue inhibitor of matrix metalloproteinase-1, favorable myosin heavy chain isoform switch, diminished oxidative stress, enhanced antioxidant capacity, improved mitochondrial calcium handling, and boosted myocardial angiogenesis. Additionally, meta-analyses revealed that exercise-based cardiac rehabilitation has proven to be effective, and remains one of the least expensive therapies for both the prevention and treatment of cardiovascular disease, and prevents re-infarction.

Exercise training in chronic heart failure: mechanisms and therapies

Decreased exercise capacity negatively affects the individuals' ability to adequately perform activities required for normal daily life and, therefore, the independence and quality of life. Regular exercise training is associated with improved quality of life and survival in healthy individuals and in cardiovascular disease patients. Also in patients with stable heart failure, exercise training can relieve symptoms, improve exercise capacity and reduce disability, hospitalisation and probably mortality. Physical inactivity can thus be considered a major cardiovascular risk factor, and current treatment guidelines recommend exercise training in patients with heart failure in NYHA functional classes II and III. Exercise training is associated with numerous pulmonary, cardiovascular, and skeletal muscle metabolic adaptations that are beneficial to patients with heart failure. This review discusses current knowledge of mechanisms by which exercise training is beneficial in these patients.

Factors related to the improvement of quality of life at 6 months after discharge for myocardial infarction patients treated with percutaneous coronary intervention

OBJECTIVE

The purpose of this study was to evaluate the relationship between improvement of health-related quality of life (QOL) and participation in self-care activities and coronary risk factor management at 6 months after discharge for acute myocardial infarction (AMI) patients treated with percutaneous coronary intervention (PCI).

METHODS

A total of 118 patients were asked to complete the MOS 36-Item Short-Form Health Survey (SF-36) questionnaire at discharge and 6 months after discharge. The SF-36 consists of eight subscales: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health Perception (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). We examined self-care activities and coronary risk factor management and related factors from SF-36 scores to measure quality of life (QOL) at discharge and 6 months after discharge.

RESULTS

The PF and BP scores at 6 months after discharge were significantly higher than those at discharge. Increasing PF and BP scores indicated improvement in ability to perform physical activities and absence of intense bodily pain that would interfere with activities of daily living or work. Improvement of PF in AMI patients treated with PCI was related to performing exercise after discharge and absence of diabetes mellitus. However, there were no related factors for BP.

CONCLUSION

Our results indicated that exercise, as a self-care activity after discharge, for AMI patients treated with PCI may be related to the improvement of QOL.

Prognostic utility of T-wave alternans in a real-world population of patients with left ventricular dysfunction: the PREVENT-SCD study

BACKGROUND

The predictive value of T-wave alternans (TWA) for lethal ventricular tachyarrhythmia in patients with left ventricular (LV) dysfunction is controversial. Also, long-term arrhythmia risk of patients ineligible for the TWA test is unknown.

METHODS

This was a multicenter, prospective observational study of patients with LV ejection fraction ≤40% due to ischemic or non-ischemic cardiomyopathies, designed to evaluate the prognostic value of TWA for lethal ventricular tachyarrhythmia. The primary end point was a composite of sudden cardiac death, sustained rapid ventricular tachycardia (VT) or ventricular fibrillation (VF), and appropriate defibrillator therapy for rapid VT or VF.

RESULTS

Among 453 patients enrolled in the study, 280 (62%) were eligible for the TWA test. TWA was negative in 82 patients (29%), who accounted for 18% of the total population. The median of follow-up was 36 months. The 3-year event-free rate for the primary end point was significantly higher in TWA-negative patients (97.0%) than in TWA non-negative patients (89.5%, P = 0.037) and those ineligible for the TWA test (84.4%, P = 0.003). Multivariable analysis identified both non-negative TWA [hazard ratio (HR) 4.43; 95% confidence interval (CI) 1.02-19.2; P = 0.047) and ineligibility for the TWA test (HR 6.89; 95% CI 1.59-29.9; P = 0.010) to be independent predictors of the primary end point.

CONCLUSIONS

TWA showed high negative predictive ability for lethal ventricular tachyarrhythmia in patients with LV dysfunction, although the TWA-negative patients accounted for only 18% of the entire population. Those ineligible for the TWA test had the highest risk for lethal ventricular tachyarrhythmia.

No effect of group-based aerobic interval training on N-terminal pro- B-type natriuretic peptide levels in patients with chronic heart failure

OBJECTIVES

Exercise training might improve cardiac function as well as functional capacity in patients with chronic heart failure (CHF). N-terminal pro-B-type natriuretic peptide (NT pro-BNP), is associated with the severity of the disease, and has been reported to be an independent predictor of outcome in CHF. We evaluated the effect of a four months group-based aerobic interval training program on circulating levels of NT pro-BNP in patients with CHF. We have previously reported improved functional capacity in 80 patients after exercise in this exercise program.

METHODS

Seventy-eight patients with stable CHF (21% women; 70+/-8 years; left ventricular ejection fraction 30+/-8.6%) on optimal medical treatment were randomized either to interval training (n=39), or to a control group (n=39). Circulating levels of NT pro-BNP, a six minute walk test (6MWT) and cycle ergometer test were evaluated at baseline, post exercise, and further after 12 months.

RESULTS

There were no significant differences in NT pro-BNP levels from baseline to either post exercise or long-term follow-up between or within the groups. Inverse correlations were observed between NT pro-BNP and 6MWT (r=-0.24, p=0.035) and cycle exercise time (r=-0.48, p<0.001) at baseline. But no significant correlations were observed between change in NT pro-BNP and change in functional capacity (6MWT; r=0.12, p=0.33, cycle exercise time; r=0.04, p=0.72).

CONCLUSION

No significant changes in NT pro-BNP levels were observed after interval training, despite significant improvement of functional capacity.

Mechanisms by which exercise training benefits patients with heart failure

Clinical consequences of heart failure are fatigue, dyspnea, and progressive impairment of exercise tolerance. Regular exercise training is associated with health-improving effects. In patients with stable heart failure, exercise training can relieve symptoms, improve exercise capacity and quality of life, as well as reduce hospitalization and, to some extent, risk of mortality. Progressive exercise training is associated with pulmonary, cardiovascular, and skeletal muscle metabolic adaptations that increase oxygen delivery and energy production. This Review focuses on current knowledge of mechanisms by which progressive and moderate exercise training can have sustained beneficial effects on patients with heart failure.

Muscle wastage in heart failure: orphan of the heart failure

The patients with heart failure (HF) often exhibit some degree of muscle wasting restricted to the lower limbs. This loss of tissue may become more extensive in some patients, usually when their HF is more advanced, and may affect all body compartments. The underlying metabolic causes are very complex and differ from patient to patient. Three essential contributors are dietary deficiency and loss of nutrients through the digestive tract and metabolic dysfunction. The development of cachexia is an ominous sign and new drugs will be added into our therapeutic armamentarium to fight against cardiac cachexia in the near-future.

Benefits of exercise for community-dwelling older adults

This focused review highlights the benefits of exercise and physical activity for community-dwelling older adults. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the benefits of physical activity and exercise for older adults with regard to morbidity, mortality, and disability. It discusses the appropriate preexercise screening and evaluation procedures for older adults contemplating exercise. Last, it reviews the current literature on the benefits of varying modes of exercise to modify the most prevalent chronic medical conditions of late life, including arthritis, heart disease, diabetes, stroke, pulmonary disease, and osteoporosis.

OVERALL ARTICLE OBJECTIVE

To summarize the current knowledge regarding the therapeutic benefits of exercise for community-dwelling older adults.

Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure

This review discusses the scientific and clinical evidence for cardiac rehabilitation in patients who have undergone percutaneous revascularization, heart transplant, and heart valve surgery, and in patients with chronic heart failure. Across these diagnoses, regardless of age, there is considerable benefit of cardiac rehabilitation and supervised exercise training for increasing functional capacity, favorably modifying disease-related risk factors, decreasing symptoms, detecting signs and symptoms of disease before they become serious complications, and improving quality of life. The available evidence for this component of cardiovascular disease management, albeit not perfect, still warrants its more widespread application.

Exercise training in patients with chronic heart failure improves endothelial function predominantly in the trained extremities

The present study investigates whether lower-limb dominant exercise training in patients with chronic heart failure (CHF) improves endothelial function primarily in the trained lower extremities or equally in the upper and lower extremities. Twenty-eight patients with CHF were randomized to the exercise or control group. The exercise group underwent cycle ergometer training for 3 months while controls continued an inactive sedentary lifestyle. Exercise capacity (6-min walk test) and flow-mediated vasodilation in the brachial and posterior tibial arteries were evaluated. After 3 months, walking performance increased only in the exercise group (488+/-16 to 501+/-14 m [control]; 497+/-23 to 567+/-39 m [exercise, p<0.05]). The flow-mediated vasodilation in the brachial arteries did not change in either group (4.2+/-0.5 to 4.5+/-0.4% [control]; 4.3+/-0.5 to 4.6+/-0.4% [exercise]), but that in the posterior tibial arteries increased only in the exercise group (4.1+/-0.5 to 4.1+/-0.3% [control]; 3.6+/-0.3 to 6.4+/-0.6% [exercise, p<0.01]). Cycle ergometer training improved flow-mediated vasodilation in the trained lower limbs, but not in the untrained upper limbs. Exercise training appears to correct endothelial dysfunction predominantly by a local effect in the trained extremities.

Nurses's knowledge of heart failure education principles

OBJECTIVE

The goal of this study was to determine nurses' knowledge of heart failure (HF) self-management education principles.

DESIGN

The study was exploratory and descriptive and included a convenience sample.

SETTING

Research took place in a large midwestern health care system that included a university-based hospital, community hospitals, and home or palliative care.

SUBJECTS

Subjects included 300 nurses who provide care to patients with HF.

OUTCOME MEASURE

The outcome measures included overall and topic specific perceptions of basic information important to HF self-management. Topics included diet, fluids or weight, signs or symptoms of worsening condition, medications, and exercise.

INTERVENTION

A 20-item, true or false written survey was administered between February 2000 and April 2000.

RESULTS

Of the 300 nurses surveyed, 92% were registered nurses and 8% were licensed practical nurses; 38% worked in a large university-based hospital; 44% were employed at 5 community hospitals; and 18% worked in home or hospice-palliative care. Mean HF self-management knowledge score was 15.2 +/- 2.0. Registered nurses scored significantly higher than licensed practical nurses (15.3 vs 14.1; P =.004). Individual questions with overall scores <30% were related to dry or ideal weight in daily weight monitoring (24%), nonsymptomatic, low blood pressure (26%), and short-term dizziness when rising (19%). Individual question scores >30% and < or =75% were related to nonsteroidal anti-inflammatory inhibitor use (49%), potassium-based salt substitute use (52%), rest vs activity (72%), and lean delicatessen meat use in a low sodium diet (75%). In questions with scores <30%, nurses requested more information only 5% to 8% of the time. Overall analysis of variance indicated differences by work experience. HF nurses (primary population) scored higher than critical-care, medical-surgical, or telemetry floor nurses (16.2 +/- 1.7; 15.1 +/- 1.8; and 14.7 +/- 2.0, respectively; P <.001); home care nurses scored higher than hospital or palliative care nurses (15.9 +/- 1.5; 15.1 +/- 2.0; and 14.0 +/- 1.5, respectively; P =.006).

CONCLUSION

Nurses may not be properly educated in HF self-management principles and must be provided with the right information so they can improve the quality and amount of information they offer to patients. Nurses who are better prepared to educate patients with HF may be more likely to carry out this nursing function as a part of their daily job role.

[Rehabilitation modalities as a function of the severity of heart insufficiency]

After a review of the different central and peripherical factors limiting exercise capacity in chronic heart failure, the authors report the mechanisms of these increment with exercise training. The different indications for clinical training techniques of segmental training on a specific bench are discussed; but it appears that both aerobic and repetitive weight programs seem to have short term favorable and complementary effects.