Personalized remotely guided preventive exercise therapy for a healthy heart (PRIORITY): protocol for an assessor-blinded, multicenter randomized controlled trial

Training-induced change of diastolic function in heart failure with preserved ejection fraction

AIMS

Exercise training improves aerobic capacity (V̇O2peak) in patients with heart failure and preserved ejection fraction (HFpEF), but underlying mechanisms remain unclear. We aimed to evaluate whether exercise training could improve systolic and diastolic function during exercise.

METHODS

This was a substudy of the multicentre Optimizing Exercise Training in HFpEF (OptimEx-Clin) trial, in which 180 patients with HFpEF were randomized 1:1:1 to guideline control, moderate continuous training or high-intensity interval training. All patients included at two out of five participating sites underwent exercise echocardiography at baseline and 3 months. Patients of both training groups were pooled and compared with guideline control.

RESULTS

A total of 61 patients (mean age 73 ± 7 years, 72% female) were included. At baseline, E/e' increased from 17.0 ± 5.7 to 19.5 ± 6.1 and systolic pulmonary artery pressure from 31 ± 8 to 51 ± 11 mmHg (both P < 0.001). Right ventricular function did not change significantly (maximal tricuspid annular plane systolic excursion 24.7 ± 4.0 mm, P = 0.051 vs. baseline). At 3 months, patients randomized to exercise training improved V̇O2peak (control +0.2, training +2.7 mL/kg/min, P = 0.006) and demonstrated small but significant improvements in exercise E/e' (control 21.7 ± 7.5 to 22.8 ± 9.2, training 18.3 ± 5.0 to 17.2 ± 4.1, P = 0.044). No significant changes were observed in ejection fraction, mitral or tricuspid annular plane systolic excursion, S', A' or systolic pulmonary artery pressure (P > 0.05). Changes in E/e' were not associated with the change in V̇O2peak.

CONCLUSIONS

In patients with HFpEF, exercise echocardiography revealed increases in filling pressures as well as a failure to augment right ventricular function during exercise. After 3 months of exercise training, HFpEF patients demonstrated a small improvement in diastolic function (exercise E/e'), but this did not explain the improved aerobic capacity.

Obesity-Related Phenotype of Heart Failure With Preserved Ejection Fraction: A Comprehensive Review

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome with an obesity-related phenotype gaining prominence amid the global obesity epidemic. This review explores the distinct pathophysiological mechanisms, diagnostic challenges, and management strategies associated with obesity-induced HFpEF. Obesity contributes to HFpEF through several key mechanisms, including increased blood volume, myocardial hypertrophy and fibrosis, systemic inflammation, and metabolic dysregulation. These factors collectively exacerbate diastolic dysfunction and elevate left ventricular filling pressures, hallmark features of HFpEF. Diagnosing HFpEF in obese patients is particularly challenging due to overlapping comorbidities such as hypertension and diabetes, as well as the reduced reliability of traditional biomarkers such as N-terminal pro-B-type natriuretic peptide. Advanced imaging techniques are crucial in assessing diastolic dysfunction and myocardial remodeling. Managing obesity-related HFpEF requires a comprehensive approach. Lifestyle modifications, including weight loss and exercise, form the cornerstone of treatment, complemented by pharmacological therapies such as sodium-glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists. Optimizing comorbidity management is essential, while emerging therapies targeting inflammation, fibrosis, and metabolic dysfunction, alongside precision medicine approaches, offer promising future advancements. This review underscores the need for inclusive clinical trials and personalized treatment strategies to improve outcomes in obesity-related HFpEF. A deeper understanding of this phenotype is crucial for developing targeted interventions that enhance patient care and quality of life. Integrating these insights into clinical practice can help optimize diagnostic accuracy, refine therapeutic approaches, and guide risk stratification for better patient management.

Shear wave elastography to unmask differences in myocardial stiffness between athletes and sedentary non-athletes

Aims

Myocardial stiffening naturally occurs with aging and contributes to diastolic dysfunction. Assessing myocardial stiffness non-invasively could improve the sensitivity of diastolic function evaluation in clinical practice. Shear wave (SW) elastography is a non-invasive tool for quantifying myocardial stiffness, where higher SW velocities indicate increased stiffness. We investigated whether SW elastography could detect differences in myocardial stiffness between athletes and sedentary non-athletes and, during exercise, reveal differences in operational stiffness that may indicate diastolic dysfunction.

Methods and results

We enrolled 20 master athletes (median age 60 [IQR 59-66] years) and 17 sedentary non-athletes (median age 58 [IQR 52-71] years). Standard exercise echocardiography revealed no significant differences in diastolic function between the groups. Additionally, ultra-high frame rate imaging was used to measure SW velocities after mitral valve closure (MVC) and aortic valve closure (AVC) at rest and during exercise. At rest, athletes had lower SW velocities after MVC compared to sedentary non-athletes (3.2 ± 0.4 m/s vs. 3.9 ± 0.7 m/s, respectively, P = 0.003). During exercise, SW velocities after AVC significantly increased in sedentary non-athletes but not in athletes (+1.6 ± 1.6 cm/s increase per 1% power output increase vs. 0.0 ± 0.8 cm/s, respectively, P = 0.006). An inverse correlation was found between the increase of SW velocity after AVC during exercise and VO2max (r = -0.51, P = 0.003).

Conclusion

SW elastography reveals reduced myocardial stiffness in athletes compared to sedentary non-athletes at rest and during exercise, which is not detected by conventional echocardiographic measurements. Exercise-induced changes in SW velocities after AVC may potentially serve as an early marker for detecting diastolic dysfunction.

Transforming the cardiometabolic disease landscape: Multimodal AI-powered approaches in prevention and management

The rise of artificial intelligence (AI) has revolutionized various scientific fields, particularly in medicine, where it has enabled the modeling of complex relationships from massive datasets. Initially, AI algorithms focused on improved interpretation of diagnostic studies such as chest X-rays and electrocardiograms in addition to predicting patient outcomes and future disease onset. However, AI has evolved with the introduction of transformer models, allowing analysis of the diverse, multimodal data sources existing in medicine today. Multimodal AI holds great promise in more accurate disease risk assessment and stratification as well as optimizing the key driving factors in cardiometabolic disease: blood pressure, sleep, stress, glucose control, weight, nutrition, and physical activity. In this article we outline the current state of medical AI in cardiometabolic disease, highlighting the potential of multimodal AI to augment personalized prevention and treatment strategies in cardiometabolic disease.

Effect of a home-based isometric handgrip training programme on systolic blood pressure in adults: A randomised assessor-blinded trial

OBJECTIVES

To evaluate the effects of 20 weeks of home-based isometric handgrip training (IHT) compared with usual care on systolic blood pressure (SBP) in adults.

DESIGN AND PARTICIPANTS

This was a randomised, controlled, assessor-blinded trial. Participants were randomised to either IHT (intervention group) or usual care (control group).

INTERVENTIONS

Participants randomised to the intervention group performed a session of 16 min of effective workout home-based IHT three times per week for 20 weeks. Participants randomised to the control group were asked to continue their daily activities as usual.

OUTCOMES

The primary outcome was the difference in SBP between groups over 20 weeks. Secondary outcomes were diastolic blood pressure, heart rate, handgrip strength, and self-administered home blood pressure measures.

RESULTS

Forty-eight adults (mean [SD] age, 64 [8] years) were included in this trial. The adjusted between-group mean difference in SBP was 8.12 mmHg (95% CI 0.24 to 16.01, p = 0.04) - favouring the usual care group. No differences between groups were found in any of the home blood pressure measurements.

CONCLUSIONS

This trial showed that 20 weeks of home-based isometric handgrip training was not superior compared to the usual care in lowering SBP.