Exercise training prevents the deterioration in the arterial baroreflex control of sympathetic nerve activity in chronic heart failure patients

Efficacy and Safety of Hybrid Comprehensive Telerehabilitation (HCTR) for Cardiac Rehabilitation in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Backgrounds

Cardiovascular disease (CVD) is a serious condition that poses threats to patients' quality of life and life expectancy. Cardiac rehabilitation is a crucial treatment option that can improve outcomes for CVD patients. Hybrid comprehensive telerehabilitation (HCTR) is a relatively new approach. In the context of pandemics, HCTR can minimize the risk of cluster infections by reducing hospital visits while delivering effective rehabilitation care. This study is aimed at assessing the efficacy and safety of HCTR as a secondary prevention measure for CVD patients compared to usual rehabilitation care.

Methods

We searched PubMed, Embase, The Web of Science, The Cochrane Library, and PsychINFO for all related studies up to January 20, 2023. Two reviewers independently screened the titles and abstracts of potentially eligible articles based on the predefined search criteria. Data were analyzed using a comprehensive meta-analysis software (RevMan5.3).

Results

Eight trials, involving 1578 participants, were included. HCTR and usual rehabilitation care provide similar effects on readmission rates (odds ratio (OR) = 0.90 (95% CI 0.69-1.17), P = 0.43) and mortality (odds ratio (OR) = 1.06 (95% CI 0.72-1.57), P = 0.76). Effects on Short Form-36 Health Status Questionnaire (SF-36) score were also similar (SMD: 1.32 (95% CI-0.48-3.11), P = 0.15). Compared with usual rehabilitation care, HCTR can improve peak oxygen uptake (VO2 peak) (SMD: 0.99 (95% CI 0.23-1.74), P = 0.01) and 6-minute walking test (6MWT) (SMD: 10.02 (95% CI 5.44-14.60), P < 0.001) of patients.

Conclusions

Our findings indicate that HCTR is as effective as traditional rehabilitation care in reducing readmission rates and mortality and improving quality of life in patients with CVD. However, HCTR offers the added advantage of improving VO2 peak and 6MWT, measurements of cardiorespiratory fitness and functional capacity, respectively. These results suggest that HCTR can be a safe and effective alternative to traditional rehabilitation care, offering numerous benefits for CVD patients. Clinical Study Registration Number. This trial is registered with NCT02523560 and NCT02796404.

Physical capacity increase in patients with heart failure is associated with improvement in muscle sympathetic nerve activity

BACKGROUND

Exercise training improves physical capacity in patients with heart failure with reduced ejection fraction (HFrEF), but the mechanisms involved in this response is not fully understood. The aim of this study was to determine if physical capacity increase in patients HFrEF is associated with muscle sympathetic nerve activity (MSNA) reduction and muscle blood flow (MBF) increase.

METHODS

The study included 124 patients from a 17-year database, divided according to exercise training status: 1) exercise-trained (ET, n = 83) and 2) untrained (UNT, n = 41). MSNA and MBF were obtained using microneurography and venous occlusion plethysmography, respectively. Physical capacity was evaluated by cardiopulmonary exercise test. Moderate aerobic exercise was performed 3 times/wk. for 4 months.

RESULTS

Exercise training increased peak oxygen consumption (V̇O2, 16.1 ± 0.4 vs 18.9 ± 0.5 mL·kg-1·min-1, P < 0.001), LVEF (28 ± 1 vs 30 ± 1%, P = 0.027), MBF (1.57 ± 0.06 vs 2.05 ± 0.09 mL.min-1.100 ml-1, P < 0.001) and muscle vascular conductance (MVC, 1.82 ± 0.07 vs 2.45 ± 0.11 units, P < 0.001). Exercise training significantly decreased MSNA (45 ± 1 vs 32 ± 1 bursts/min, P < 0.001). The logistic regression analyses showed that MSNA [(OR) 0.921, 95% CI 0.883-0.962, P < 0.001] was independently associated with peak V̇O2.

CONCLUSIONS

The increase in physical capacity provoked by aerobic exercise in patients with HFrEF is associated with the improvement in MSNA.

Effects of the exercise training on skeletal muscle oxygen consumption in heart failure patients with reduced ejection fraction

AIMS

Skeletal muscle dysfunction is a systemic consequence of heart failure (HF) that correlates with functional capacity. However, the impairment within the skeletal muscle is not well established. We investigated the effect of exercise training on peripheral muscular performance and oxygenation in HF patients.

METHODS AND RESULTS

HF patients with ejection fraction ≤40% were randomized 2:1 to exercise training or control for 12 weeks. Muscle tissue oxygen was measured noninvasively by near-infrared spectroscopy (NIRS) during rest and a symptom-limited cardiopulmonary exercise test (CPET) before and after intervention. Measurements included skeletal muscle oxygenated hemoglobin concentration, deoxygenated hemoglobin concentration, total hemoglobin concentration, VO₂ peak, VE/VCO₂ slope, and heart rate. Muscle sympathetic nerve activity by microneurography, and muscle blood flow by plethysmography were also assessed at rest pre and post 12 weeks. Twenty-four participants (47.5 ± 7.4 years, 58% men, 75% no ischemic) were allocated to exercise training (ET, n = 16) or control (CG, n = 8). At baseline, no differences between groups were found. Exercise improved VO₂ peak, slope VE/VCO₂, and heart rate. After the intervention, significant improvements at rest were seen in the ET group in muscle sympathetic nerve activity and muscle blood flow. Concomitantly, a significant decreased in Oxy-Hb (from 29.4 ± 20.4 to 15.7 ± 9.0 μmol, p = 0.01), Deoxi-Hb (from 16.3 ± 8.2 to 12.2 ± 6.0 μmol, p = 0.003) and HbT (from 45.7 ± 27.6 to 27.7 ± 13.4 μmol, p = 0.008) was detected at peak exercise after training. No changes were observed in the control group.

CONCLUSION

Exercise training improves skeletal muscle function and functional capacity in HF patients with reduced ejection fraction. This improvement was associated with increased oxygenation of the peripheral muscles, increased muscle blood flow, and decreased sympathetic nerve activity.

Oscillatory Pattern of Sympathetic Nerve Bursts Is Associated With Baroreflex Function in Heart Failure Patients With Reduced Ejection Fraction

Sympathetic hyperactivation and baroreflex dysfunction are hallmarks of heart failure with reduced ejection fraction (HFrEF). However, it is unknown whether the progressive loss of phasic activity of sympathetic nerve bursts is associated with baroreflex dysfunction in HFrEF patients. Therefore, we investigated the association between the oscillatory pattern of muscle sympathetic nerve activity (LF_MSNA/HF_MSNA) and the gain and coupling of the sympathetic baroreflex function in HFrEF patients. In a sample of 139 HFrEF patients, two groups were selected according to the level of LF_MSNA/HF_MSNA index: (1) Lower LF_MSNA/HF_MSNA (lower terciles, n = 46, aged 53 ± 1 y) and (2) Higher LF_MSNA/HF_MSNA (upper terciles, n = 47, aged 52 ± 2 y). Heart rate (ECG), arterial pressure (oscillometric method), and muscle sympathetic nerve activity (microneurography) were recorded for 10 min in patients while resting. Spectral analysis of muscle sympathetic nerve activity was conducted to assess the LF_MSNA/HF_MSNA, and cross-spectral analysis between diastolic arterial pressure, and muscle sympathetic nerve activity was conducted to assess the sympathetic baroreflex function. HFrEF patients with lower LF_MSNA/HF_MSNA had reduced left ventricular ejection fraction (26 ± 1 vs. 29 ± 1%, P = 0.03), gain (0.15 ± 0.03 vs. 0.30 ± 0.04 a.u./mmHg, P < 0.001) and coupling of sympathetic baroreflex function (0.26 ± 0.03 vs. 0.56 ± 0.04%, P < 0.001) and increased muscle sympathetic nerve activity (48 ± 2 vs. 41 ± 2 bursts/min, P < 0.01) and heart rate (71 ± 2 vs. 61 ± 2 bpm, P < 0.001) compared with HFrEF patients with higher LF_MSNA/HF_MSNA. Further analysis showed an association between the LF_MSNA/HF_MSNA with coupling of sympathetic baroreflex function (R = 0.56, P < 0.001) and left ventricular ejection fraction (R = 0.23, P = 0.02). In conclusion, there is a direct association between LF_MSNA/HF_MSNA and sympathetic baroreflex function and muscle sympathetic nerve activity in HFrEF patients. This finding has clinical implications, because left ventricular ejection fraction is less in the HFrEF patients with lower LF_MSNA/HF_MSNA.

Effect of exercise training on cardiovascular autonomic and muscular function in subclinical Chagas cardiomyopathy: a randomized controlled trial

PURPOSE

Patients with chronic chagasic cardiomyopathy with preserved ventricular function present with autonomic imbalance. This study evaluated the effects of exercise training (ET) in restoring peripheral and cardiac autonomic control and skeletal muscle phenotype in patients with subclinical chronic chagasic cardiomyopathy.

METHODS

This controlled trial (NCT02295215) included 24 chronic chagasic cardiomyopathy patients who were randomized www.random.org/lists/ into two groups: those who underwent exercise training (n = 12) and those who continued their usual activities (n = 12). Eight patients completed the exercise training protocol, and 10 patients were clinically followed up for 4 months. Muscular sympathetic nerve activity was measured by microneurography and muscle blood flow (MBF) using venous occlusion plethysmography. The low-frequency component of heart rate variability in normalized units (LFnuHR) reflects sympathetic activity in the heart, and the low-frequency component of systolic blood pressure variability in normalized units reflects sympathetic activity in the vessels. The infusion of vasoactive drugs (phenylephrine and sodium nitroprusside) was used to evaluate cardiac baroreflex sensitivity, and a vastus lateralis muscle biopsy was performed to evaluate atrogin-1 and MuRF-1 gene expression.

RESULTS

The baroreflex sensitivity for increases (p = 0.002) and decreases (p = 0.02) in systolic blood pressure increased in the ET group. Muscle blood flow also increased only in the ET group (p = 0.004). Only the ET group had reduced resting muscular sympathetic nerve activity levels (p = 0.008) and sympathetic activity in the heart (LFnu; p = 0.004) and vessels (p = 0.04) after 4 months. Regarding skeletal muscle, after 4 months, participants in the exercise training group presented with lower atrogin-1 gene expression than participants who continued their activities as usual (p = 0.001). The reduction in muscular sympathetic nerve activity was positively associated with reduced atrogin-1 (r = 0.86; p = 0.02) and MuRF-1 gene expression (r = 0.64; p = 0.06); it was negatively associated with improved baroreflex sensitivity both for increases (r = -0.72; p = 0.020) and decreases (r = -0.82; p = 0.001) in blood pressure.

CONCLUSIONS

ET improved cardiac and peripheral autonomic function in patients with subclinical chagasic cardiomyopathy. ET reduced MSNA and sympathetic activity in the heart and vessels and increased cardiac parasympathetic tone and baroreflex sensitivity. Regarding peripheral muscle, after 4 months, patients who underwent exercise training had an increased cross-sectional area of type I fibers and oxidative metabolism of muscle fibers, and decreased atrogin-1 gene expression, compared to participants who continued their activities as usual. In addition, the reduction in MSNA was associated with improved cardiac baroreflex sensitivity, reduced sympathetic cardiovascular tone, and reduced atrogin-1 and MuRF-1 gene expression.

TRIAL REGISTRATION

ID: NCT02295215. Registered in June 2013.

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

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

Diet associated with exercise improves baroreflex control of sympathetic nerve activity in metabolic syndrome and sleep apnea patients

PURPOSE

We tested the hypothesis that (i) diet associated with exercise would improve arterial baroreflex (ABR) control in metabolic syndrome (MetS) patients with and without obstructive sleep apnea (OSA) and (ii) the effects of this intervention would be more pronounced in patients with OSA.

METHODS

Forty-six MetS patients without (noOSA) and with OSA (apnea-hypopnea index, AHI > 15 events/h) were allocated to no treatment (control, C) or hypocaloric diet (- 500 kcal/day) associated with exercise (40 min, bicycle exercise, 3 times/week) for 4 months (treatment, T), resulting in four groups: noOSA-C (n = 10), OSA-C (n = 12), noOSA-T (n = 13), and OSA-T (n = 11). Muscle sympathetic nerve activity (MSNA), beat-to-beat BP, and spontaneous arterial baroreflex function of MSNA (ABR_MSNA, gain and time delay) were assessed at study entry and end.

RESULTS

No significant changes occurred in C groups. In contrast, treatment in both patients with and without OSA led to a significant decrease in weight (P < 0.05) and the number of MetS factors (P = 0.03). AHI declined only in the OSA-T group (31 ± 5 to 17 ± 4 events/h, P < 0.05). Systolic BP decreased in both treatment groups, and diastolic BP decreased significantly only in the noOSA-T group. Treatment decreased MSNA in both groups. Compared with baseline, ABR_MSNA gain increased in both OSA-T (13 ± 1 vs. 24 ± 2 a.u./mmHg, P = 0.01) and noOSA-T (27 ± 3 vs. 37 ± 3 a.u./mmHg, P = 0.03) groups. The time delay of ABR_MSNA was reduced only in the OSA-T group (4.1 ± 0.2 s vs. 2.8 ± 0.3 s, P = 0.04).

CONCLUSIONS

Diet associated with exercise improves baroreflex control of sympathetic nerve activity and MetS components in patients with MetS regardless of OSA.

Exercise and heart failure: an update

The present update is dedicated to the evolution of the interaction between heart failure (HF) and exercise and how the scientific community has handled it. Indeed, on the one hand, HF is a leading cause of morbidity and mortality with a stable prevalence from 1998 onward varying between 6.3% and 13.3%. On the other hand, exercise is seen as a diagnostic and prognostic tool as well as a therapeutic intervention in chronic HF. More precisely, the knowledge, the clinical application, and the research interest on the mutual interactions between exercise and HF have different phases in disease progression: Before HF onset (past): exercise provides protective benefit in preventing HF (primary prevention). With HF present: exercise improvement with training provides benefits in HF (secondary prevention). The prediction of future in HF patients: exercise impairment, as a leading characteristic of HF, is used as a prognostic factor.

The autonomic nervous system as a therapeutic target in heart failure: a scientific position statement from the Translational Research Committee of the Heart Failure Association of the European Society of Cardiology

Despite improvements in medical therapy and device-based treatment, heart failure (HF) continues to impose enormous burdens on patients and health care systems worldwide. Alterations in autonomic nervous system (ANS) activity contribute to cardiac disease progression, and the recent development of invasive techniques and electrical stimulation devices has opened new avenues for specific targeting of the sympathetic and parasympathetic branches of the ANS. The Heart Failure Association of the European Society of Cardiology recently organized an expert workshop which brought together clinicians, trialists and basic scientists to discuss the ANS as a therapeutic target in HF. The questions addressed were: (i) What are the abnormalities of ANS in HF patients? (ii) What methods are available to measure autonomic dysfunction? (iii) What therapeutic interventions are available to target the ANS in patients with HF, and what are their specific strengths and weaknesses? (iv) What have we learned from previous ANS trials? (v) How should we proceed in the future?

Cardiac and peripheral autonomic control in restrictive cardiomyopathy

AIMS

Autonomic dysfunction determines the advance of dilated cardiomyopathy (DCM) and is related to poor outcomes. However, this autonomic imbalance is unknown in patients with restrictive cardiomyopathy (RCM) even though they have similar symptoms and poor quality of life as DCM patients have. The aim of this study was to evaluate if autonomic and neurovascular controls were altered in RCM patients.

METHODS AND RESULTS

Fifteen RCM patients, 10 DCM patients, and 10 healthy subjects were evaluated. Heart rate and blood pressure (BP) were recorded. Peripheral sympathetic activity [muscle sympathetic nerve activity (MSNA)] by microneurography and cardiac sympathetic activity by power spectrum analysis of heart rate variability. Spontaneous baroreflex sensitivity (BRS) was evaluated by the sequence method and forearm blood flow by venous occlusion plethysmography. Both cardiomyopathy groups had higher MSNA frequency (P < 0.001) and MSNA incidence (P < 0.001), higher cardiac sympathovagal balance (P < 0.02), reduced BRS for increase (P = 0.002) and for decrease in BP (P = 0.002), and lower forearm blood flow (P < 0.001) compared with healthy subjects. We found an inverse correlation between BRS for increase and decrease in BP and peripheral sympathetic activity (r = -0.609, P = 0.001 and r = -0.648, P < 0.001, respectively) and between BRS for increase and decrease in BP and cardiac sympathetic activity (r = -0.503, P = 0.03 and r = -0.487, P = 0.04, respectively).

CONCLUSIONS

The RCM patients had cardiac and peripheral autonomic dysfunctions associated with peripheral vasoconstriction. Nonetheless, the presence of normal ejection fraction underestimates the evolution of the disease and makes clinical treatment difficult. These alterations could lead to a similar cardiovascular risk as that observed in DCM patients.

Exercise training to reduce sympathetic nerve activity in heart failure patients. A systematic review and meta-analysis

OBJECTIVE

To determine the effects of exercise training on sympathetic nerve activity in heart failure patients.

METHODS

A systematic review was performed. An electronic search of MEDLINE, ProQuest, SciELO, SPORTDiscus, Rehabilitation and Sport Medicine Source, Cumulative Index to Nursing and Allied Health Literature, Tripdatabase, Science Direct and PEDrO was performed from their inception to February 2017. Clinical trials and quasi-experimental studies were considered for primary article selection. The studies should include patients diagnosed with chronic heart failure that performed exercise training for at least 4 weeks. Sympathetic nerve activity should be measured by microneurography before and after the intervention. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate risk of bias, and the quality of evidence was rated following the GRADE approach. Standardized mean differences (SMD) were calculated for control and experimental groups. Meta-analysis was performed using the random effects model.

RESULTS

Five trials were included. Overall, the trials had moderate risk of bias. The experimental group indicated a significant decrease in the number of bursts per minute (SMD -2.48; 95% CI -3.55 to -1.41) when compared to the control group. Meanwhile, a significant decrease was also observed in the prevalence of bursts per 100 beats in the experimental group when compared to the control group (SMD -2.66; 95% CI -3.64 to -1.69).

CONCLUSION

Exercise training could be effective in reducing sympathetic nerve activity in patients with heart failure. The quality of evidence across the studies was moderate. Future studies are necessary to confirm these results.

Sympathetic Activity in Patients With Secondary Symptomatic Mitral Regurgitation or End-Stage Systolic Heart Failure

OBJECTIVES

This study shows the impact of secondary mitral regurgitation (sMR) and transcatheter mitral valve repair (TMVR) with the MitraClip system on sympathetic nerve activity (SNA).

BACKGROUND

An increase in SNA is associated with worse outcomes and limited survival in patients with chronic heart failure (CHF).

METHODS

Twenty CHF-patients without relevant sMR and 30 CHF patients with symptomatic sMR were enrolled prospectively. All patients underwent standardized laboratory testing and microneurography. Sixteen patients from the sMR group underwent the MitraClip procedure; 10 patients after TMVR and 9 untreated sMR patients completed 6 months of follow-up.

RESULTS

Comparing groups according to presence of sMR, we found no differences in left ventricular dimensions, and serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and noradrenaline; sMR was associated with increased MSNA (106 ± 60 burst/min vs. 74 ± 48 burst/min, d = 0.58), an impaired sympathetic baroreflex gain (10 ± 7 burst/mm Hg vs. 5 ± 5 burst/mm Hg, d = 0.61), and a higher heart rate (90 ± 27/beats/min vs. 78 ± 12/beats/min, d = 0.58). TMVR led to improved New York Heart Association functional class (d > 0.05), reduced levels of NT-proBNP (5,251 ± 3,760 pg/ml vs. 3,710 ± 2,464 pg/ml; d = 0.58) improvement in 6-minute walk test (204 ± 33 m vs. 288 ± 45 m, d = 0.64), but unchanged levels of noradrenaline. TMVR decreased MSNA burst-frequency (130 ± 78 bursts/min vs. 74 ± 21 bursts/min; d = 0.58) and baroreflex gain (7 ± 4 burst/mm Hg vs. 4 ± 1 burst/mm Hg; d = 0.61).

CONCLUSIONS

In patients with CHF, concomitant sMR is associated with increased sympathetic nerve activity, which was independent from measured levels of NT-proBNP, noradrenaline, and left ventricular dimensions. Reduction of sMR with the MitraClip procedure reduced SNA and improved baroreflex gain, in line with improvements of functional capacity.

Visit-to-Visit Variability and Reduction in Blood Pressure After a 3-Month Cardiac Rehabilitation Program in Patients With Cardiovascular Disease

Visit-to-visit variability (VVV) in blood pressure (BP) has been shown to be a predictor of cardiovascular events. It is unknown whether CR can improve VVV in BP as well as reducing BP. We enrolled 84 patients who had cardiovascular disease (CVD) and participated in a 3-month CR program. We measured systolic and diastolic BP (SBP and DBP), pulse pressure (PP), and heart rate (HR) before exercise training at each visit and determined VVV in BP or HR expressed as the standard deviation of the average BP or HR. Patients who had uncontrolled BP at baseline and who did not change their antihypertensive drugs throughout the study period showed a significant reduction of both SBP and DBP with a decrease in PP after 3 months. Patients who did not change their antihypertensive drugs were divided into larger (L-) and smaller (S-) VVV in the SBP groups and L- and S-VVV in the DBP groups according to the average value of VVV in SBP or DBP. In the L-VVV in the SBP and DBP groups, VVV in SBP and DBP in the 1st month was significantly decreased after the 3rd month in both groups. HR at baseline was significantly decreased after 3 months. In addition, CR induced a significant increase in the level of high-density lipoprotein cholesterol (HDL-C) in blood. In conclusion, CR improved VVV in BP in patients with L-VVV in BP and evoked a significant reduction in HR and an increase in HDL-C. These effects due to the CR program may be cardioprotective.

Exercise training-induced modification in autonomic nervous system: An update for cardiac patients

Patients with cardiovascular disease show autonomic dysfunction, including sympathetic activation and vagal withdrawal, which leads to fatal events. This review aims to place sympathovagal balance as an essential element to be considered in management for cardiovascular disease patients who benefit from a cardiac rehabilitation program. Many studies showed that exercise training, as non-pharmacologic treatment, plays an important role in enhancing sympathovagal balance and could normalize levels of markers of sympathetic flow measured by microneurography, heart rate variability or plasma catecholamine levels. This alteration positively affects prognosis with cardiovascular disease. In general, cardiac rehabilitation programs include moderate-intensity and continuous aerobic exercise. Other forms of activities such as high-intensity interval training, breathing exercises, relaxation and transcutaneous electrical stimulation can improve sympathovagal balance and should be implemented in cardiac rehabilitation programs. Currently, the exercise training programs in cardiac rehabilitation are individualized to optimize health outcomes. The sports science concept of the heart rate variability (HRV)-vagal index used to manage exercise sessions (for a goal of performance) could be implemented in cardiac rehabilitation to improve cardiovascular fitness and autonomic nervous system function.

Clinical neurocardiology defining the value of neuroscience-based cardiovascular therapeutics

The autonomic nervous system regulates all aspects of normal cardiac function, and is recognized to play a critical role in the pathophysiology of many cardiovascular diseases. As such, the value of neuroscience-based cardiovascular therapeutics is increasingly evident. This White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology, pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases.