Resting heart rate and the risk of hypertension and heart failure: a dose-response meta-analysis of prospective studies. J Hypertens. 2018;36:995-1004. [PMID: 29176508 DOI: 10.1097/hjh.0000000000001627]

Establishment of hypertension risk nomograms based on physical fitness parameters for men and women: a cross-sectional study

Objective

This study aims to establish hypertension risk nomograms for Chinese male and female adults, respectively.

Method

A series of questionnaire surveys, physical assessments, and biochemical indicator tests were performed on 18,367 adult participants in China. The optimization of variable selection was conducted by running cyclic coordinate descent with 10-fold cross-validation through the least absolute shrinkage and selection operator (LASSO) regression. The nomograms were built by including the predictors selected through multivariable logistic regression. Calibration plots, receiver operating characteristic curves (ROC), decision curve analysis (DCA), clinical impact curves (CIC), and net reduction curve plots (NRC) were used to validate the models.

Results

Out of a total of 18 variables, 5 predictors-namely age, body mass index, waistline, hipline, and resting heart rate-were identified for the hypertension risk predictive model for men with an area under the ROC of 0.693 in the training set and 0.707 in the validation set. Seven predictors-namely age, body mass index, body weight, cardiovascular disease history, waistline, resting heart rate, and daily activity level-were identified for the hypertension risk predictive model for women with an area under the ROC of 0.720 in the training set and 0.748 in the validation set. The nomograms for both men and women were externally well-validated.

Conclusion

Gender differences may induce heterogeneity in hypertension risk prediction between men and women. Besides basic demographic and anthropometric parameters, information related to the functional status of the cardiovascular system and physical activity appears to be necessary.

Effect of Presence versus Absence of Hypertension on Admission Heart Rate-Associated Cardiovascular Risk in Patients with Acute Coronary Syndrome

Background and Aims

Heart rate (HR) and hypertension are both important risk factors for adverse cardiovascular (CV) events in patients with established coronary artery disease (CAD). We sought to evaluate whether hypertension can modify the effect of admission HR on adverse CV events in patients with acute coronary syndrome (ACS).

Methods

A total of 1056 patients with ACS undergoing percutaneous coronary intervention (PCI) were analyzed. All patients were classified into three groups according to the tertiles of admission HR (T1: ≤66 bpm, n = 369; T2: 67–73 bpm, n = 322; and T3: ≥74 bpm, n = 365). The primary endpoint was defined as major adverse CV events (MACEs), including all-cause death, stroke, myocardial infarction, or unplanned repeat revascularization. The multivariate Cox regression model was performed to evaluate the association of admission HR with MACE stratified by hypertension.

Results

During the median follow-up of 30 months, a total of 232 patients developed at least one event. After adjusting for other covariates, elevated admission HR was significantly associated with an increased risk of MACE only in patients with hypertension (when T1 was taken as a reference, the adjusted HR of T2 was 1.143 [95% CI: 0.700–1.864] and that of T3 was 2.062 [95% CI: 1.300–3.270]); however, in patients without hypertension, admission HR was not associated with the risk of MACE (when T1 was taken as a reference, the adjusted HR of T2 was 0.744 [0.406–1.364] and that of T3 was 0.614 [0.342–1.101]) (P=0.025 for interaction).

Conclusions

In patients with ACS undergoing PCI, the association of elevated admission HR with an increased risk of MACE was present in individuals with hypertension but not in those without hypertension. This finding suggests a potential benefit of HR control for ACS patients when they concomitantly have hypertension.

Risk factors for asymptomatic echocardiographic abnormalities that predict symptomatic heart failure

Aims

Risk factors for asymptomatic echocardiographic abnormalities that predict symptomatic heart failure (HF) may provide insight into early mechanisms of HF pathogenesis. We examined risk factors associated with asymptomatic echocardiographic structural, systolic, and diastolic abnormalities, separately and in combination, and interactions between risk factors, in the prospective community‐based SCReening Evaluation of the Evolution of New HF (SCREEN‐HF) Study cohort of 3190 participants at increased risk of cardiovascular disease.

Methods and results

Inclusion criteria were age ≥ 60 years with one or more of hypertension, diabetes, ischaemic heart disease, valvular heart disease, abnormal heart rhythm, cerebrovascular disease, or renal impairment. Exclusion criteria were known HF, ejection fraction < 50%, or >mild valve abnormality. Structural, systolic, and diastolic echocardiographic abnormalities were defined according to the Atherosclerosis Risk in Communities study criteria, and risk factors for asymptomatic structural, systolic, and diastolic abnormalities were identified using logistic regression analysis. In multivariable analysis, increased body mass index (BMI), non‐steroidal anti‐inflammatory drug therapy, and alcohol intake were risk factors for isolated structural abnormality, whereas male gender, increased heart rate, atrial fibrillation (AF), angiotensin‐converting enzyme inhibitor therapy, and obstructive sleep apnoea were associated with a lower risk. Moreover, male gender, smoking, increased systolic blood pressure, and physical inactivity were risk factors for isolated systolic abnormality, whereas increased pulse pressure and antihypertensive therapy were associated with a lower risk. Furthermore, increased age, blood pressure, amino‐terminal pro‐B‐type natriuretic peptide level, and warfarin therapy (associated with AF) were risk factors for isolated diastolic abnormality, whereas increased heart rate and triglyceride level (associated with BMI) were associated with a lower risk. The association of increased heart rate with lower risk of structural and diastolic abnormalities was independent of β‐blocker therapy. Interactions between risk factors differed for structural, systolic, and diastolic abnormalities.

Conclusions

The different risk factors for asymptomatic structural, systolic, and diastolic abnormalities that predict symptomatic HF, and the interactions between risk factors, illustrate how these structural, systolic, and diastolic abnormalities represent unique trajectories that lead to symptomatic HF. Improved understanding of these trajectories may assist in the design of HF prevention strategies.

Prevalence and risk factors of hypertension among college freshmen in China

Hypertension is the leading single contributor to all-cause death and disability worldwide. However, there is scarce evidence on the prevalence and risk factors of hypertension for Chinese youth. This study aimed to investigate the prevalence of hypertension among Chinese college freshmen and to identify the influencing factors. We conducted a cross-sectional study of all freshmen from 2015 to 2017 at a university in Wuhan, China by physical examination and standard-structured questionnaire. The Pearson chi-square test was used to compare categorical variables. Forward stepwise logistic regression method was used in the multivariate analysis to identify independent predictors of hypertension in youth. A total of 12,849 participants were included, and the prevalence of hypertension of Chinese college freshmen was 4.3% (7.9% in men and 1.6% in women). Men had a higher risk of hypertension than women (odds ratio [OR]: 5.358, 95% confidence interval [CI]: 4.345-6.607, P < 0.001). Obese people were more likely to develop hypertension than those with normal body mass index (OR: 10.465, 95% CI: 8.448-12.964, P < 0.001). People with elevated resting heart rate (RHR) had a higher prevalence of hypertension (OR: 4.987, 95% CI: 3.641-6.832, P < 0.001). Staying up late (OR: 2.957, 95% CI: 2.482-3.523, P < 0.001), physical inactivity (OR: 4.973, 95% CI: 4.141-5.972, P < 0.001), living in urban district (OR: 1.864, 95% CI: 1.493-2.329, P < 0.001) and family history of cardiovascular diseases (CVDs) (OR: 2.685, 95% CI: 2.108-3.421, P < 0.001) were related to higher prevalence of hypertension in youth. Male, obesity, elevated RHR, physical inactivity and family history of CVDs were identified as important risk factors of hypertension in youth. These risk factors should be given more attention when designing and implementing the interventional programs.

Heart rate modulates the relationship of augmented systolic blood pressure with the blood natriuretic peptide levels

AIMS

Augmented central systolic blood pressure (cSBP), which is known to affect the cardiac afterload, is an independent risk factor for cardiovascular disease. While an inverse relationship is known to exist between the heart rate (HR) and the cSBP, it has not yet been clarified if the HR also modulates the association between the cSBP and the cardiac afterload. The present study was conducted to clarify whether the association of the cSBP with the serum levels of the N-terminal fragment B-type natriuretic peptide (NT-proBNP) differs between subjects with high and low HRs, using data obtained from the same subjects on two occasions (2009 and 2012) so as to confirm their consistency.

METHODS AND RESULTS

The radial augmentation index, systolic pressure at the second peak of the radial pressure waveform (SBP2), and serum NT-proBNP levels were measured and analysed in a worksite cohort of 2000 middle-aged men in 2009 and in 2012. The subjects were divided into three groups by the HR (i.e. ≤69, 70-79, and ≥80 b.p.m.). While the serum NT-proBNP levels were similar among the three groups, the radial augmentation index increased (from 61 ± 12% to 72 ± 13%, P < 0.01 in 2009 and from 61 ± 13% to 73 ± 12%, P < 0.01 in 2012) and the SBP1-2 decreased (from 18 ± 7 to 13 ± 7 mmHg, P < 0.01 in 2009 and from 19 ± 7 to 13 ± 6 mmHg, P < 0.01 in 2012) significantly with decreasing HR. After the adjustment, the SBP2 showed a significant association with the serum NT-proBNP levels in the overall study population [non-standardized coefficient (B) = 0.005, standard error (SE) = 0.001, P < 0.01 in 2009 (n = 2257) and B = 0.004, SE = 0.001, P < 0.01 in 2012 (n = 1986)]. In subgroup analyses, the SBP2 showed a significant association with the serum NT-proBNP levels [B = 0.004, SE = 0.002, P = 0.02 in 2009 (n = 1291) and B = 0.005, SE = 0.001, P < 0.01 in 2012 (n = 1204)] only in the subject group with an HR of ≤69 b.p.m.

CONCLUSIONS

In middle-aged Japanese men, the relationship between the cSBP and the cardiac afterload appears to differ depending on the HR; the results of our analysis showed that the relationship between the cSBP and the cardiac overload may be more pronounced and strongly significant in patients with low HRs as compared with patients with high HRs.

Waist circumference, waist-hip ratio, body fat rate, total body fat mass and risk of low back pain: a systematic review and meta-analysis

PURPOSE

To identify the associations between waist circumference (WC), waist-hip ratio (WHR), body fat rate (BFR), total body fat mass (BFM), and the risk of low back pain (LBP).

METHODS

We have searched PubMed through October 2020 for observational studies investigating the associations between WC, WHR, BFR, or total BFM and the risk of LBP. Random-effect models were used to calculate the summary risk estimates and corresponding 95% confidence intervals (95% CIs).

RESULTS

A total of fifteen studies with 92,936 participants were included, of which ten were related to WC, five were related to WHR, four were related to BFR, and four were related to total BFM. Pooled results indicated that high WC (odds ratio (OR) = 1.30, 95% CI 1.10-1.54) and WHR (OR = 1.33, 95% CI 1.00-1.76) were associated with an increased risk of chronic low back pain (c-LBP). High WC (OR = 1.18, 95% CI 1.03-1.34) was also associated with an increased risk of non-c-LBP. The risk of non-c-LBP increased by 23% (OR = 1.23, 95% CI 1.01-1.50) for every 10% increase in BFR, and for every 10 kg increase in total BFM, the risk of non-c-LBP increased by 24% (OR = 1.24, 95% CI 1.10-1.39).

CONCLUSION

Observational epidemiological evidence suggested that individuals with increased WC, WHR, BFR, or total BFM tended to have an increased risk of LBP, regardless of whether their body mass indexes were normal. Excessive fat mass was the essence of the process.

Elevated resting heart rate as a predictor of inflammation and cardiovascular risk in healthy obese individuals

The role of leukocyte inflammatory markers and toll like receptors (TLRs)2/4 in pathologies associated with elevated resting heart rate (RHR) levels in healthy obese (HO) individuals is not well elucidated. Herein, we investigated the relationship of RHR with expression of leukocyte-inflammatory markers and TLRs in HO individuals. 58-obese and 57-lean participants with no history of a major medical condition, were recruited in this study. In HO individuals, the elevated-RHR correlated positively with diastolic blood pressure, cholesterol, pro-inflammatory monocytes CD11b+CD11c+CD206- phenotype (r = 0.52, P = 0.0003) as well as with activated T cells CD8+HLA-DR+ phenotype (r = 0.27, P = 0.039). No association was found between RHR and the percentage of CD16+CD11b+ neutrophils. Interestingly, elevated RHR positively correlated with cells expressing TLR4 and TLR2 (CD14+TLR4+, r = 0.51, P ≤ 0.0001; and CD14+TLR2+, r = 0.42, P = 0.001). TLR4+ expressing cells also associated positively with the plasma concentrations of proinflammatory or vascular permeability/matrix modulatory markers including TNF-α (r = 0.36, P = 0.005), VEGF (r = 0.47, P = 0.0002), and MMP-9 (r = 0.53, P ≤ 0.0001). Multiple regression revealed that RHR is independently associated with CD14+TLR4+ monocytes and VEGF. We conclude that in HO individuals, increased CD14+TLR4+ monocytes and circulatory VEGF levels associated independently with RHR, implying that RHR monitoring could be used as a non-invasive clinical indicator to identify healthy obese individuals at an increased risk of developing inflammation and cardiovascular disease.

Autonomic Imbalance and Risk of Dementia and Stroke: The Framingham Study

Background and Purpose

The autonomic nervous system has been implicated in stroke and dementia pathophysiology. High resting heart rate and low heart rate variability indicate the effect of autonomic imbalance on the heart. We examined the associations of resting heart rate and heart rate variability with incident stroke and dementia in a community-based cohort of middle- and old-aged adults.

Methods

The study sample included 1581 participants aged >60 years and 3271 participants aged >45 years evaluated for incident dementia and stroke, respectively, who participated in the Framingham Offspring cohort third (1983–1987) examination and had follow-up for neurology events after the seventh (1998–2001) examination. Heart rate variability was assessed through the standard deviation (SD) of normal-to-normal RR intervals and the root mean square of successive differences between normal heartbeats from 2-hour Holter monitor. Participants were followed-up for stroke and dementia incidence from exam 7 to a maximum of 10 years. Cox regression models were used to assess the link of resting heart rate and heart rate variability with stroke and dementia risk while adjusting for potential confounders, and interactions with age and sex were assessed.

Results

Of the dementia (mean age, 55±6 years, 46% men) and stroke (mean age, 48±9 years, 46% men) samples, 133 and 127 developed dementia and stroke, respectively, during the follow-up. Overall, autonomic imbalance was not associated with dementia risk. However, age modified the associations such that SD of normal-to-normal intervals and root mean square of successive differences were associated with dementia risk in older people (hazard ratio [HR] [95% CI] per 1SD, 0.61 [0.38–0.99] and HR [95% CI] per 1SD, 0.34 [0.15–0.74], respectively). High resting heart rate was associated with increased stroke risk (HR [95% CI] per 10 bpm, 1.18 [1.01–1.39]), and high SD of normal-to-normal intervals was associated with lower stroke risk in men (HR [95% CI] per 1SD, 0.46 [0.26–0.79]) but not women (HR [95% CI] per 1SD, 1.25 [0.88–1.79]; P for interaction=0.003).

Conclusions

Some measures of cardiac autonomic imbalance may precede dementia and stroke occurrence, particularly in older ages and men, respectively.

Resting Heart Rate as a Cardiovascular Risk Factor in Hypertensive Patients: An Update

A large body of evidence has shown that resting heart rate (RHR) holds important prognostic information in several clinical conditions. In the majority of the general population studies, a graded association between RHR and mortality from all causes, cardiovascular (CV) disease, ischemic heart disease, and stroke has been observed. These associations appeared even stronger and more consistent in hypertensive patients. Studies performed with 24-hour ambulatory recording have shown that an elevated nighttime heart rate may confer an additional risk on top of office RHR. The mechanisms by which tachycardia alone or in association with sympathetic overactivity induces CV damage are well understood. Fast RHR is a strong predictor of future hypertension, metabolic disturbances, obesity, and diabetes. Several experimental lines of research point to high RHR as a main risk factor for the development of atherosclerosis, large artery stiffness, and CV disease. Elevated RHR is a common feature in patients with hypertension. Thus, there is a large segment of the hypertensive population that would benefit from a treatment able to decrease RHR. Improvement of unhealthy lifestyle should be the first goal in the management of the hypertensive patient with elevated RHR. Most clinical guidelines now recommend the use of combination therapies even in the initial treatment of hypertension. Although no results of clinical trials specifically designed to investigate the effect of RHR lowering in human beings without CV diseases are available, in hypertensive patients with high RHR a combination therapy including a cardiac slowing drug at optimized dose seems a sensible strategy. Tachycardia can be considered both as a marker of sympathetic overactivity and as a risk factor for cardiovascular events. In this sketch, the main cardiovascular and metabolic effects of increased sympathetic tone underlying high heart rate are shown. The link between tachycardia and cardiovascular events can be explained also by the direct hemodynamic action of heart rate on the arteries and the left ventricular (LV) wall.

Apolipoprotein-AI and AIBP synergetic anti-inflammation as vascular diseases therapy: the new perspective

Vascular diseases (VDs) including pulmonary arterial hypertension (PAH), atherosclerosis (AS) and coronary arterial diseases (CADs) contribute to the higher morbidity and mortality worldwide. Apolipoprotein A-I (Apo A-I) binding protein (AIBP) and Apo-AI negatively correlate with VDs. However, the mechanism by which AIBP and apo-AI regulate VDs still remains unexplained. Here, we provide an overview of the role of AIBP and apo-AI regulation of vascular diseases molecular mechanisms such as vascular energy homeostasis imbalance, oxidative and endoplasmic reticulum stress and inflammation in VDs. In addition, the role of AIBP and apo-AI in endothelial cells (ECs), vascular smooth muscle (VSMCs) and immune cells activation in the pathogenesis of VDs are explained. The in-depth understanding of AIBP and apo-AI function in the vascular system may lead to the discovery of VDs therapy.

One-year change in resting heart rate and subsequent risk of hypertension in healthy Chinese adults

BACKGROUND

Changes in baseline resting heart rate (RHR) appear to predict new-onset hypertension (NOH). However, RHR is a dynamic anthropometric parameter; thus, the association between changes in RHR and NOH requires further investigation.

METHODS

We studied 10 403 participants who were initially normotensive and who had at least one routine health examination at baseline and 1 year later during 2011-2016. We compared the RHR between the baseline and 1-year follow-up. We defined hypertension as SBP ≥140 mmHg or DBP ≥90 mmHg. Participants were divided into three groups: RHR decreased, RHR unchanged [from 0 to 10 beats per minute (bpm)], and RHR increased ≥10 bpm. Cox regression analysis was performed to calculate relative risk with 95% confidence intervals (CIs) for the association between NOH and RHR change.

RESULTS

During a mean follow-up period of 2.42 years, 1173 (11.28%) participants developed hypertension. After adjusting for age, sex, SBP, DBP, RHR and other confounders obtained at baseline, and compared with participants with unchanged RHR, participants with decreased RHR had a 17% decreased risk of NOH (adjusted hazard ratio: 0.83, 95% CI 0.73-0.95), whereas subjects with RHR that increased ≥10 bpm had a 23% increased risk of NOH (adjusted hazard ratio: 1.23, 95% CI 1.04-1.46).

CONCLUSION

A 1-year increase in RHR for initially normotensive subjects is an independent risk factor for subsequent hypertension.

Individual Differences in Cross-System Physiological Activity at Rest and in Response to Acute Social Stress

OBJECTIVE

Individual differences in long-term cardiovascular disease risk are related to physiological responses to psychological stress. However, little is known about specific physiological response profiles in young adults that may set the stage for long-term increased cardiovascular disease risk. We investigated individual differences in profiles of resting cardiovascular physiology and stress reactivity, combining parasympathetic, sympathetic, and hemodynamic measures.

METHODS

Participants (n = 744, 71% women, mean [standard deviation] age = 20.1 [2.4] years) underwent the Trier Social Stress Test, while blood pressure (systolic blood pressure, diastolic blood pressure), electrocardiograms (interbeat interval), and impedance cardiograms (preejection period, left ventricular ejection time) were recorded. Respiratory sinus arrhythmia was derived from the combination of the electrocardiogram and the impedance cardiogram. A three-step latent profile analysis (LPA) was performed on resting and reactivity values to derive clusters of individual physiological profiles. We also explored demographic and health behavioral correlates of the observed latent clusters.

RESULTS

For resting physiology, LPA revealed five different resting physiology profiles, which were related to sex, usual physical activity levels, and body mass index. Five cardiovascular stress reactivity profiles were identified: a reciprocal/moderate stress response (Cr1; 29%), and clusters characterized by high blood pressure reactivity (Cr2: 22%), high vagal withdrawal (Cr3; 22%), autonomic coactivation (parasympathetic nervous system and sympathetic nervous system; Cr4; 13%), and overall high reactivity (Cr5; 12%). Men were more likely to belong to the high reactivity (Cr5) cluster, whereas women were more likely to have autonomic coactivation (Cr4).

CONCLUSIONS

We identified five cardiovascular physiological reactivity profiles, with individuals displaying generalized hyperreactivity, predominant vagal withdrawal, autonomic coactivation, or blood pressure-specific hyperreactivity. Longitudinal studies are needed to determine whether these profiles are useful in early detection of individuals at high risk for cardiovascular disease.

Elevated heart rate and cardiovascular risk in hypertension

Epidemiological studies have shown that chronically elevated resting heart rate (HR) is significantly associated with organ damage, morbidity and mortality in a wide range of patients including hypertensive patients. Evidence is also available that an increased HR reflects sympathetic nervous system overdrive which is also known to adversely affect organ structure and function and to increase the risk of unfavourable outcomes in several diseases. The causal relationship between elevated HR, organ damage, and cardiovascular outcomes can thus be explained by its relationship with sympathetic cardiovascular influences although evidence of sympathetically-independent adverse effect of HR increases per se makes it more complex. Interventions that target HR by modulating the sympathetic nervous system have therefore a strong pathophysiological and clinical rationale. As most clinical guidelines now recommend the use of combination therapies in patients with hypertension, it might be desirable to consider as combination components drugs which lower HR, if HR is elevated such as, according to guideliines, when it is above 80 b/min.

Arterial hypertension in adults. Clinical guidelines 2020

Arterial hypertension in adults. Clinical guidelines 2020

Dose-response association of resting heart rate and hypertension in adults: A systematic review and meta-analysis of cohort studies

BACKGROUND

The association of resting heart rate (RHR) and hypertension in adults is unclear. We aimed to perform a meta-analysis of cohort studies to clarify the association.

METHODS

We searched PubMed and Embase from their inception to November 3, 2017, for published articles. We used a random effects model to combine study-specific relative risks (RRs) and 95% confidence intervals (CIs). We used restricted cubic spline functions to assess the dose-response relationship.

RESULTS

Nine cohort articles (12 independent studies) with 79,399 individuals and more than 26,380 incident cases of hypertension were included. The summary RR for hypertension was 1.09 (95% CI: 1.06-1.13) with each 10 bpm increment in RHR. The cubic spline model suggested that when compared with 55.5 beats per minute, the risk of hypertension significantly increased with increasing levels of RHR (Pnonlinearity = 0.059).

CONCLUSION

We found a linear dose-response association between RHR and incident hypertension in adults.

Respiratory training interventions improve health status of heart failure patients: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Prior studies indicate that doing breathing exercises improves physical performance and quality of life (QoL) in heart failure patients. However, these effects remain unclear and contradictory.

AIM

To determine the effects of machine-assisted and non-machine-assisted respiratory training on physical performance and QoL in heart failure patients.

METHODS

This was a systematic review and network meta-analysis study. A literature search of electronic databases was conducted for randomized controlled trials (RCTs) on heart failure. Respiratory training interventions were grouped as seven categories: IMT_Pn (inspiratory muscle training without pressure or < 10% maximal inspiratory pressure, MIP), IMT_Pl (inspiratory muscle training with low pressure, 10%-15% MIP), IMT_Pm (inspiratory muscle training with medium pressure, 30%-40% MIP), IMT_Ph (inspiratory muscle training with high pressure, 60% MIP or MIP plus aerobics), Aerobics (aerobic exercise or weight training), Qi_Ex (tai chi, yoga, and breathing exercise), and none. The four outcomes were heart rate, peak oxygen uptake (VO₂ peak), 6-min walking distance test (6MWT), and Minnesota Living with Heart Failure QoL. The random-effects model, side-splitting model, and the surface under the cumulative ranking curve (SUCRA) were used to test and analyze the data.

RESULTS

A total of 1499 subjects from 31 RCT studies were included. IMT_Ph had the highest effect sizes for VO₂ peak and 6MWT, IMT_Pm highest for QoL, and Qi_Ex highest for heart rate. Aerobics had the second highest for VO₂ peak, Qi_Ex second highest for 6MWT, and IMT_Ph second highest for heart rate and QoL.

CONCLUSION

This study supports that high- and medium-intensity machine-assisted training improves exercise capacity and QoL in hospital-based heart failure patients. After hospital discharge, non-machine-assisted training continuously improves cardiac function.