Magnetic resonance imaging to assess the effect of exercise training on pulmonary perfusion and blood flow in patients with pulmonary hypertension

Exercised-based cardiac rehabilitation associates with lower all-cause mortality in patients with primary pulmonary hypertension

Background

Despite pharmacological therapies to improve outcomes of pulmonary hypertension (PH), poor long-term survival remains. Exercised-based cardiac rehabilitation (ExCR) may be an alternative strategy to improve prognosis. Therefore, using an electronic medical record (EMR) database, the objective of this study was to compare mortality between patients with primary PH with ExCR vs. propensity-matched PH patients without ExCR.

Methods

The retrospective analysis was conducted on February 15, 2023 using anonymized data within TriNetX, a global federated health research network. All patients were aged ≥18 years with primary PH recorded in EMRs with at least 1-year follow-up from ExCR. Using logistic regression models, patients with PH with an EMR of ExCR were 1:1 propensity score-matched with PH patients without ExCR for age, sex, race, and comorbidities, and cardiovascular care.

Results

In total, 109,736 patients with primary PH met the inclusion criteria for the control group and 784 patients with primary PH met the inclusion criteria for the ExCR cohort. Using the propensity score-matched cohorts, 1-year mortality from ExCR was proportionally lower with 13.6% (n = 101 of 744 patients) in the ExCR cohort compared to 23.3% (n = 174 of 747 patients) in the controls (OR 0.52, 95% CI 0.40-0.68).

Conclusion

The present study of 1,514 patients with primary PH suggests that ExCR is associated with 48% lower odds of 1-year mortality, when compared to propensity score-matched patients without ExCR.

Role of pulmonary perfusion magnetic resonance imaging for the diagnosis of pulmonary hypertension: A review

Among five types of pulmonary hypertension, chronic thromboembolic pulmonary hypertension (CTEPH) is the only curable form, but prompt and accurate diagnosis can be challenging. Computed tomography and nuclear medicine-based techniques are standard imaging modalities to non-invasively diagnose CTEPH, however these are limited by radiation exposure, subjective qualitative bias, and lack of cardiac functional assessment. This review aims to assess the methodology, diagnostic accuracy of pulmonary perfusion imaging in the current literature and discuss its advantages, limitations and future research scope.

Routine Rehabilitation as a Treatment Component for Patients With Pulmonary Arterial or Chronic Thromboembolic Pulmonary Hypertensions

PURPOSE

Patients with pulmonary hypertension (PH) have long been advised to avoid exercise in fear of deterioration in right-sided heart function. Since the 2009 European Society of Cardiology guidelines, rehabilitation in expert centers is considered to have a specific role in care of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We report routine rehabilitation effects in patients with PH as a component of real-life multimodal treatment.

METHODS

Patients with PAH or CTEPH were recommended for either in- or outpatient rehabilitation in addition to their usual care, unless there were practical problems or the patient declined. Assessment was conducted according to New York Heart Association classes, adverse events, 6 min-walk test, hemodynamics, and risk stratification after rehabilitation.

RESULTS

Forty-one patients, 61% female, age 60 ±18 yr were included between March 2010 and May 2019. No major adverse events or deaths related to progression of right-sided heart failure were reported. Nevertheless, 22% of participants suffered adverse events in most cases not linked with physical activity. Rehabilitation as add-on to medical therapy and/or arterial deobstruction improved New York Heart Association class: mean difference, -0.39 (95% CI, -0.68 to -0.10), 6-min walk test: mean difference, 80 m (95% CI, 46-114), and was associated with improved right-sided heart hemodynamics. The risk assessment grade improved by -0.25 points (95% CI, -0.44 to -0.06) after rehabilitation.

CONCLUSIONS

For patients with PAH or CTEPH, supervised rehabilitation as add-on to medical therapy and/or arterial deobstruction is safe and effective in improving patient and clinically related outcomes.

Imaging human lung perfusion with contrast media: A meta-analysis

PURPOSE

To pool and summarise published data of pulmonary blood flow (PBF), pulmonary blood volume (PBV) and mean transit time (MTT) of the human lung, obtained with perfusion MRI or CT to provide reliable reference values of healthy lung tissue. In addition, the available data regarding diseased lung was investigated.

METHODS

PubMed was systematically searched to identify studies that quantified PBF/PBV/MTT in the human lung by injection of contrast agent, imaged by MRI or CT. Only data analysed by 'indicator dilution theory' were considered numerically. Weighted mean (wM), weighted standard deviation (wSD) and weighted coefficient of variance (wCoV) were obtained for healthy volunteers (HV), weighted according to the size of the datasets. Signal to concentration conversion method, breath holding method and presence of 'pre-bolus' were noted.

RESULTS

PBV was obtained from 313 measurements from 14 publications (wM: 13.97 ml/100 ml, wSD: 4.21 ml/100 ml, wCoV 0.30). MTT was obtained from 188 measurements from 10 publications (wM: 5.91 s, wSD: 1.84 s wCoV 0.31). PBF was obtained from 349 measurements from 14 publications (wM: 246.26 ml/100 ml ml/min, wSD: 93.13 ml/100 ml ml/min, wCoV 0.38). PBV and PBF were higher when the signal was normalised than when it was not. No significant differences were found for PBV and PBF between breathing states or between pre-bolus and no pre-bolus. Data for diseased lung were insufficient for meta-analysis.

CONCLUSION

Reference values for PBF, MTT and PBV were obtained in HV. The literature data are insufficient to draw strong conclusions regarding disease reference values.

Exercise-based rehabilitation programmes for pulmonary hypertension

BACKGROUND

Individuals with pulmonary hypertension (PH) have reduced exercise capacity and quality of life. Despite initial concerns that exercise training may worsen symptoms in this group, several studies have reported improvements in functional capacity and well-being following exercise-based rehabilitation.

OBJECTIVES

To evaluate the benefits and harms of exercise-based rehabilitation for people with PH compared with usual care or no exercise-based rehabilitation.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 June 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people with PH comparing supervised exercise-based rehabilitation programmes with usual care or no exercise-based rehabilitation.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. exercise capacity, 2. serious adverse events during the intervention period and 3. health-related quality of life (HRQoL). Our secondary outcomes were 4. cardiopulmonary haemodynamics, 5. Functional Class, 6. clinical worsening during follow-up, 7. mortality and 8. changes in B-type natriuretic peptide. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included eight new studies in the current review, which now includes 14 RCTs. We extracted data from 11 studies. The studies had low- to moderate-certainty evidence with evidence downgraded due to inconsistencies in the data and performance bias. The total number of participants in meta-analyses comparing exercise-based rehabilitation to control groups was 462. The mean age of the participants in the 14 RCTs ranged from 35 to 68 years. Most participants were women and classified as Group I pulmonary arterial hypertension (PAH). Study durations ranged from 3 to 25 weeks. Exercise-based programmes included both inpatient- and outpatient-based rehabilitation that incorporated both upper and lower limb exercise. The mean six-minute walk distance following exercise-based rehabilitation was 48.52 metres higher than control (95% confidence interval (CI) 33.42 to 63.62; I² = 72%; 11 studies, 418 participants; low-certainty evidence), the mean peak oxygen uptake was 2.07 mL/kg/min higher than control (95% CI 1.57 to 2.57; I² = 67%; 7 studies, 314 participants; low-certainty evidence) and the mean peak power was 9.69 W higher than control (95% CI 5.52 to 13.85; I² = 71%; 5 studies, 226 participants; low-certainty evidence). Three studies reported five serious adverse events; however, exercise-based rehabilitation was not associated with an increased risk of serious adverse event (risk difference 0, 95% CI -0.03 to 0.03; I² = 0%; 11 studies, 439 participants; moderate-certainty evidence). The mean change in HRQoL for the 36-item Short Form (SF-36) Physical Component Score was 3.98 points higher (95% CI 1.89 to 6.07; I² = 38%; 5 studies, 187 participants; moderate-certainty evidence) and for the SF-36 Mental Component Score was 3.60 points higher (95% CI 1.21 to 5.98 points; I² = 0%; 5 RCTs, 186 participants; moderate-certainty evidence). There were similar effects in the subgroup analyses for participants with Group 1 PH versus studies of groups with mixed PH. Two studies reported mean reduction in mean pulmonary arterial pressure following exercise-based rehabilitation (mean reduction: 9.29 mmHg, 95% CI -12.96 to -5.61; I² = 0%; 2 studies, 133 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

In people with PH, supervised exercise-based rehabilitation may result in a large increase in exercise capacity. Changes in exercise capacity remain heterogeneous and cannot be explained by subgroup analysis. It is likely that exercise-based rehabilitation increases HRQoL and is probably not associated with an increased risk of a serious adverse events. Exercise training may result in a large reduction in mean pulmonary arterial pressure. Overall, we assessed the certainty of the evidence to be low for exercise capacity and mean pulmonary arterial pressure, and moderate for HRQoL and adverse events. Future RCTs are needed to inform the application of exercise-based rehabilitation across the spectrum of people with PH, including those with chronic thromboembolic PH, PH with left-sided heart disease and those with more severe disease.

Exercise Training in Pulmonary Hypertension: AN UPDATED SYSTEMATIC REVIEW WITH META-ANALYSIS

PURPOSE

Given that previous reviews on exercise training in pulmonary hypertension (PH) were largely based on a small number of randomized controlled trials (RCT), their conclusions are subject to bias. This review sought to identify the impact of exercise training on functional capacity and health-related quality of life (HRQoL) in PH using advanced statistical approaches such as meta-analysis by stratification according to study design.

REVIEW METHODS

Five databases were searched from January 2015 to April 2020 to update a previous review. Included articles had data extracted, risk of bias (ROB) assessed, and quality rating performed. Data were analyzed using meta-analysis with a random-effects model for 6-min walk test (6MWT) distance and HRQoL. Heterogeneity was explored using stratified meta-analysis, within patient correlation and meta-regression.

RESULTS

A total of 28 studies (11 RCT, 12 pre-/post-studies, 2 two-group non-RCT, and three case series) consisting of 1264 patients were included. Meta-analysis of six RCT demonstrated an improved 6MWT distance by 49.5 m (95% CI, 27.2-71.8: I2 = 73%; 254 participants; low-moderate ROB) with a low correlation coefficient of 0.34, while the 12 pre-/post-non-RCT showed an improvement of 68.36 m (95% CI, -86.78 to -49.94: I2 = 37%; 746 participants; high ROB) along with improvements in V˙ o2peak (weighted mean difference [WMD] = 3.03 mL/kg/min, 95% CI, 2.17-3.90: I2 = 0%, P = .82), and HRQoL (WMD = 2.74: 95% CI, -0.82 to 6.30). Metaregression showed that the benefit of exercise on 6MWT distance did not significantly vary across the trial study characteristics.

CONCLUSION

This updated review identified an additional body of evidence supporting the efficacy of exercise training on 6MWT distance and HRQoL in stable PH patients. These benefits appeared to be consistent across models of delivery.

Soluble epoxide hydrolase inhibitor, t-AUCB, improves salivary gland function by ameliorating endothelial injury

AIMS

Inhibitor of soluble epoxide hydrolase (t-AUCB) has been used in the experimental therapy of hypertension. This study aimed to investigate whether the secretion of submandibular glands (SMGs) altered in renal hypertensive rats, and to explore whether t-AUCB could improve the salivary secretion.

MAIN METHODS

2-kidney 1-clip Sprague-Dawley rats were used as renal hypertensive animals. t-AUCB treatment was given for 1 week after 8 weeks modeling. Blood pressure, blood perfusion and the secretion of SMGs, and endothelium-dependent relaxation of external maxillary artery were measured to investigate the effects of t-AUCB on the vascular tone and the secretion of SMGs in renal hypertensive rats. SMGs were collected for histological evaluation and the internal arteries were dissected for primary endothelial cells culture.

KEY FINDINGS

The blood perfusion and flow rate of SMGs in the renal hypertensive rats were significantly lower than those in the controls. Endothelium-dependent relaxation of the external maxillary artery and AMPK/Akt/eNOS signaling was impaired in hypertensive rats. The glandular morphology and the concentration of salivary ions did not change obviously. t-AUCB treatment ameliorated the secretion of SMGs, the blood perfusion, and the dysfunction of endothelium-dependent relaxation of the external maxillary artery by activating the AMPK/Akt/eNOS pathway in hypertensive rats.

SIGNIFICANCE

t-AUCB increases the blood perfusion through ameliorating dysfunction of endothelium-dependent relaxation of SMGs arteries and thus improves the hyposecretion of SMGs in hypertensive rats.

Exercise Rehabilitation Training in Patients with Pulmonary Hypertension: A Review

Pulmonary hypertension (PH) has a high morbidity and mortality. Despite the existing disease-targeted therapy, most patients with PH continue to suffer from difficulty in breathing, exercise intolerance, and reduced quality of life. Recently, a large body of research results has suggested that exercise rehabilitation training (ERT) seems to be a beneficial, safe, and cost-effective treatment for patients with PH. However, knowledge gaps still exist for a uniformly accepted ERT protocol, the modality, duration, intensity, and frequency of ERT in PH. The purpose of this review is to summarise the existing research evidence and knowledge, aiming to strengthen clinicians' awareness of the application of ERT in patients with PH. PubMed databases were systematically searched for eligible studies. Twelve (12) randomised controlled trials and other important studies documenting effectiveness, safety, and adverse events of ERT are summarised. Additionally, the modality, duration, intensity, and frequency of various types of ERT and future research directions are discussed. In summary, ERT is generally effective and safe for PH patients as an adjuvant treatment to disease-specific therapy. It can improve the exercise capacity and tolerance, skeletal and respiratory muscle performance, cardiopulmonary function, and quality of life of PH patients. In view of the occurrence of a small number of adverse events, we currently recommend a combination of in-hospital and home-based ERT under close supervision. In the future, more multi-centre randomised controlled studies are needed to evaluate the effectiveness and feasibility of long-term, community, or home-based ERT, as well as to explore the molecular mechanism behind it.

Pulmonary Arteriovenous Pressure Gradient and Time-Averaged Mean Velocity of Small Pulmonary Arteries Can Serve as Sensitive Biomarkers in the Diagnosis of Pulmonary Arterial Hypertension: A Preclinical Study by 4D-Flow MRI

(1) Background: Pulmonary arterial hypertension (PAH) is a serious condition that is associated with many cardiopulmonary diseases. Invasive right heart catheterization (RHC) is currently the only method for the definitive diagnosis and follow-up of PAH. In this study, we sought a non-invasive hemodynamic biomarker for the diagnosis of PAH. (2) Methods: We applied prospectively respiratory and cardiac gated 4D-flow MRI at a 9.4T preclinical scanner on three different groups of Sprague Dawley rats: baseline (n = 11), moderate PAH (n = 8), and severe PAH (n = 8). The pressure gradients as well as the velocity values were analyzed from 4D-flow data and correlated with lung histology. (3) Results: The pressure gradient between the pulmonary artery and vein on the unilateral side as well as the time-averaged mean velocity values of the small pulmonary arteries were capable of distinguishing not only between baseline and severe PAH, but also between the moderate and severe stages of the disease. (4) Conclusions: The current preclinical study suggests the pulmonary arteriovenous pressure gradient and the time-averaged mean velocity as potential biomarkers to diagnose PAH.

Outcome Measures Used in Studies of Rehabilitation in Pulmonary Hypertension

Rationale: The evidence base for rehabilitation in pulmonary hypertension is expanding, but adoption in clinical practice is limited.Objectives: The World Health Organization International Classification for Functioning, Disability and Health identifies three health domains: Body Functions/Structures, Activity and Participation in society. To ensure that the wider impact of rehabilitation in pulmonary hypertension is accurately assessed, it is important that study endpoints reflect all three domains.Methods: A systematic review of the literature was conducted to identify studies of rehabilitation in patients with pulmonary hypertension from 2006 to 2019.Results: Searches across five databases yielded 2,564 articles, of which 34 met eligibility criteria; 50 different outcome measures (mean = 5, minimum = 1, maximum = 9) were identified. When mapped onto the World Health Organization International Classification for Functioning, Disability and Health, 48% of instances of outcome usage were measures of Body Functions/Structure, 33% were measures of Activity, and 18% were measures of Participation. Measures of Participation were not included in seven studies (21%).Conclusions: Studies of rehabilitation in pulmonary hypertension have focused primarily on measures of Body Functions/Structure; the impact in other health domains is not well characterized. Greater inclusion of outcome measures reflecting Activity and Participation in society is needed to allow assessment of the wider impact of rehabilitation in patients with pulmonary hypertension.

Standardized exercise training is feasible, safe, and effective in pulmonary arterial and chronic thromboembolic pulmonary hypertension: results from a large European multicentre randomized controlled trial

AIMS

This prospective, randomized, controlled, multicentre study aimed to evaluate efficacy and safety of exercise training in patients with pulmonary arterial (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH).

METHODS AND RESULTS

For the first time a specialized PAH/CTEPH rehabilitation programme was implemented in 11 centres across 10 European countries. Out of 129 enrolled patients, 116 patients (58 vs. 58 randomized into a training or usual care control group) on disease-targeted medication completed the study [85 female; mean age 53.6 ± 12.5 years; mean pulmonary arterial pressure 46.6 ± 15.1 mmHg; World Health Organization (WHO) functional class II 53%, III 46%; PAH n = 98; CTEPH n = 18]. Patients of the training group performed a standardized in-hospital rehabilitation with mean duration of 25 days [95% confidence interval (CI) 17-33 days], which was continued at home. The primary endpoint, change of 6-min walking distance, significantly improved by 34.1 ± 8.3 m in the training compared with the control group (95% CI, 18-51 m; P < 0.0001). Exercise training was feasible, safe, and well-tolerated. Secondary endpoints showed improvements in quality of life (short-form health survey 36 mental health 7.3 ± 2.5, P = 0.004), WHO-functional class (training vs. control: improvement 9:1, worsening 4:3; χ2P = 0.027) and peak oxygen consumption (0.9 ± 0.5 mL/min/kg, P = 0.048) compared with the control group.

CONCLUSION

This is the first multicentre and so far the largest randomized, controlled study on feasibility, safety, and efficacy of exercise training as add-on to medical therapy in PAH and CTEPH. Within this study, a standardized specialized training programme with in-hospital start was successfully established in 10 European countries.

The benefit of exercise-based rehabilitation programs in patients with pulmonary hypertension: a systematic review and meta-analysis of randomized controlled trials

Several studies have suggested that exercise capacity and quality of life are reduced in patients with pulmonary hypertension, and exercise-based rehabilitation can improve exercise capacity and quality of life in patients with pulmonary hypertension. The aim of this study is to assess the efficacy and safety of exercise-based rehabilitation in patients with pulmonary hypertension through a meta-analysis of randomized controlled trials. We searched PubMed, Embase, Medline, and the Cochrane Central Register of Controlled Trials up to November 2018. All randomized controlled trials comparing exercise capacity and quality of life between patients undergoing exercise-based rehabilitation and those undergoing non-exercise training were included. Data were extracted separately and independently by two investigators, and discrepancies were arbitrated by the third investigator. We used the random-effects model to analyze the results, the GRADE to assess the risk of bias in the included studies, and I² statistic to estimate the degree of heterogeneity. Nine randomized controlled trials are included; however, only seven randomized controlled trials were able to extract data. Including inpatients and outpatients, the total number of participants was 234, most of whom were diagnosed as pulmonary artery hypertension. The study duration ranged from 3 to 15 weeks. The mean six-minute walking distance after exercise training was 51.94 m higher than control (27.65-76.23 m, n = 234, 7 randomized controlled trials, low quality evidence), the mean peak oxygen uptake was 2.96 ml/kg/min higher (2.49-3.43 ml/kg/min, n = 179, 4 randomized controlled trials, low-quality evidence) than in the control group. In conclusion, our finding suggests that an exercise-based training program positively influences exercise capacity in patients with pulmonary hypertension.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

High Right Ventricular Afterload during Exercise in Patients with Pulmonary Arterial Hypertension

The right ventricle (RV) is more sensitive to an increase in afterload than the left ventricle (LV), and RV afterload during exercise increases more easily than LV afterload. Pulmonary arterial hypertension (PAH)-specific therapy has improved pulmonary hemodynamics at rest; however, the pulmonary hemodynamic response to exercise is still abnormal in most patients with PAH. In these patients, RV afterload during exercise could be higher, resulting in a greater increase in RV wall stress. Recently, an increasing number of studies have indicated the short-term efficacy of exercise training. However, considering the potential risk of promoting myocardial maladaptive remodeling, even low-intensity repetitive exercise training could lead to long-term clinical deterioration. Further studies investigating the long-term effects on the RV and pulmonary vasculature are warranted. Although the indications for exercise training for patients with PAH have been expanding, exercise training may be associated with various risks. Training programs along with risk stratification based on the pulmonary hemodynamic response to exercise may enhance the safety of patients with PAH.

Long-Term Effect of an Exercise Training Program on Physical Functioning and Quality of Life in Pulmonary Hypertension: A Randomized Controlled Trial

The aim of this study was to evaluate the effects of a 6-month combined aerobic and strength exercise training program on functional and psychological aspects and health-related quality of life in patients with PH and to evaluate its longer-term impact. In total, 22 stable patients (mean age 53.9 ± 13.8, 13 female) with pulmonary hypertension of World Health Organization (WHO) class I-III participated in a nine-month study. They were randomly assigned into two groups: Group A participated in a 6-month combined aerobic and strength exercise training program, whereas Group B remained untrained. All patients underwent physical and psychological assessment at baseline and at month 6 (after completing the exercise program) and physical assessment after 9 months (3 months posttraining). After the 6-month exercise training program, patients of Group A significantly improved their physical (6MWD, STS 10 rep, STS 20 rep, TUG, lower limb strength, cardiopulmonary exercise time, METs, peak VO₂, VCO₂, and VE/VCO₂ slope) and psychological aspects (SF-36, STAI, and BDI). Between the two groups, differences were observed at the 6MWD (95% CI: 36.2-64.6, η² = 0.72), STS 10 rep (95% CI: 6.6-2.2, η² = 0.4), STS 20 rep (95% CI: 10.8-2.4, η² = 0.34), lower limb strength (95% CI: 7.2-3.6, η² = 0.38), cardiopulmonary exercise time (95% CI: 0.1-3.3, η² = 0.2), and VCO₂ (95% CI: 0.1-0.5, η² = 0.2). Additionally, psychological changes were noted at SF-36, PCS (95% CI: 3.6-14.8, η² = 0.35), MCS (95% CI: 1.3-16.1, η² = 0.22), TCS (95% CI: 1.3-16.1, η² = 0.22), and STAI (95% CI: 1.8-28.2, η² = 0.18). The favorable results of exercise were maintained at the 3-month posttraining follow-up assessment. No exercise-induced complications were observed throughout the study. In conclusion, a long-term exercise training program is a safe and effective intervention to improve functional status, psychological aspects, and health-related quality of life in patients with PH.

Walking for hypertension

BACKGROUND

Increased physical activity has been recommended as an important lifestyle modification for the prevention and control of hypertension. Walking is a low-cost form of physical activity and one which most people can do. Studies testing the effect of walking on blood pressure have revealed inconsistent findings.

OBJECTIVES

To determine the effect of walking as a physical activity intervention on blood pressure and heart rate.

SEARCH METHODS

We searched the following databases up to March 2020: the Cochrane Hypertension Specialised Register, CENTRAL (2020, Issue 2), Ovid MEDLINE, Ovid Embase, CINAHL, PsycINFO, SPORTDiscus, PEDro, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also searched the following Chinese databases up to May 2020: Index to Taiwan Periodical Literature System; National Digital Library of Theses and Dissertation in Taiwan; China National Knowledge Infrastructure (CNKI) Journals, Theses & Dissertations; and Wanfang Medical Online. We contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials of participants, aged 16 years and over, which evaluated the effects of a walking intervention compared to non-intervention control on blood pressure and heart rate were included.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Where data were not available in the published reports, we contacted authors. Pooled results for blood pressure and heart rate were presented as mean differences (MDs) between groups with 95% confidence intervals (CIs). We undertook subgroup analyses for age and sex. We undertook sensitivity analyses to assess the effect of sample size on our findings.

MAIN RESULTS

A total of 73 trials met our inclusion criteria. These 73 trials included 5763 participants and were undertaken in 22 countries. Participants were aged from 16 to 84 years and there were approximately 1.5 times as many females as males. The characteristics of walking interventions in the included studies were as follows: the majority of walking interventions was at home/community (n = 50) but supervised (n = 36 out of 47 reported the information of supervision); the average intervention length was 15 weeks, average walking time per week was 153 minutes and the majority of walking intensity was moderate. Many studies were at risk of selection bias and performance bias. Primary outcome We found moderate-certainty evidence suggesting that walking reduces systolic blood pressure (SBP) (MD -4.11 mmHg, 95% CI -5.22 to -3.01; 73 studies, n = 5060). We found moderate-certainty evidence suggesting that walking reduces SBP in participants aged 40 years and under (MD -4.41 mmHg, 95% CI -6.17 to -2.65; 14 studies, n = 491), and low-certainty evidence that walking reduces SBP in participants aged 41 to 60 years (MD -3.79 mmHg, 95% CI -5.64 to -1.94, P < 0.001; 35 studies, n = 1959), and those aged 60 years of over (MD -4.30 mmHg, 95% CI -6.17 to -2.44, 24 studies, n = 2610). We also found low certainty-evidence suggesting that walking reduces SBP in both females (MD -5.65 mmHg, 95% CI -7.89 to -3.41; 22 studies, n = 1149) and males (MD -4.64 mmHg, 95% CI -8.69 to -0.59; 6 studies, n = 203). Secondary outcomes We found low-certainty evidence suggesting that walking reduces diastolic blood pressure (DBP) (MD -1.79 mmHg, 95% CI -2.51 to -1.07; 69 studies, n = 4711) and heart rate (MD -2.76 beats per minute (bpm), 95% CI -4.57 to -0.95; 26 studies, n = 1747). We found moderate-certainty evidence suggesting that walking reduces DBP for participants aged 40 years and under (MD -3.01 mmHg, 95% CI -4.44 to -1.58; 14 studies, n = 491) and low-certainty evidence suggesting that walking reduces DBP for participants aged 41 to 60 years (MD -1.74 mmHg, 95% CI -2.95 to -0.52; 32 studies, n = 1730) and those aged 60 years and over (MD -1.33 mmHg, 95% CI -2.40 to -0.26; 23 studies, n = 2490). We found moderate-certainty evidence that suggests walking reduces DBP for males (MD -2.54 mmHg, 95% CI -4.84 to -0.24; 6 studies, n = 203) and low-certainty evidence that walking reduces DBP for females (MD -2.69 mmHg, 95% CI -4.16 to -1.23; 20 studies, n = 1000). Only 21 included studies reported adverse events. Of these 21 studies, 16 reported no adverse events, the remaining five studies reported eight adverse events, with knee injury being reported five times.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that walking probably reduces SBP. Moderate- or low-certainty evidence suggests that walking may reduce SBP for all ages and both sexes. Low-certainty evidence suggests that walking may reduce DBP and heart rate. Moderate- and low-certainty evidence suggests walking may reduce DBP and heart rate for all ages and both sexes.

Continuous Aerobic Exercise Prevents Detrimental Remodeling and Right Heart Myocyte Contraction and Calcium Cycling Dysfunction in Pulmonary Artery Hypertension

ABSTRACT

Pulmonary artery hypertension (PAH) imposes right heart and lung detrimental remodeling which impairs cardiac contractility, physical effort tolerance, and survival. The effects of an early moderate-intensity continuous aerobic exercise training on the right ventricle and lung structure, and on contractility and the calcium (Ca2+) transient in isolated myocytes from rats with severe PAH induced by monocrotaline were analyzed. Rats were divided into control sedentary (CS), control exercise (CE), monocrotaline sedentary (MS), and monocrotaline exercise (ME) groups. Animals from control exercise and ME groups underwent a moderate-intensity aerobic exercise on a treadmill (60 min/d; 60% intensity) for 32 days, after a monocrotaline (60 mg/kg body weight i.p.) or saline injection. The pulmonary artery resistance was higher in MS than in control sedentary (1.36-fold) and was reduced by 39.39% in ME compared with MS. Compared with MS, the ME group presented reduced alveolus (17%) and blood vessel (46%) wall, fibrosis (25.37%) and type I collagen content (55.78%), and increased alveolus (52.96%) and blood vessel (146.97%) lumen. In the right ventricle, the ME group exhibited diminished hypertrophy index (25.53%) and type I collagen content (40.42%) and improved myocyte contraction [ie, reduced times to peak (29.27%) and to 50% relax (13.79%)] and intracellular Ca2+ transient [ie, decreased times to peak (16.06%) and to 50% decay (7.41%)] compared with MS. Thus, early moderate-intensity continuous aerobic exercise prevents detrimental remodeling in the right heart and lung increases in the pulmonary artery resistance and dysfunction in single myocyte contraction and Ca2+ cycling in this model.

Exercise Training for Pulmonary Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Pulmonary hypertension (PH) is a chronic disease with a notable health burden; regular exercise may improve specific health outcome measures.

OBJECTIVE

The objective of this meta-analysis was to estimate the effectiveness of exercise training for PH patients.

DATA SOURCES

PubMed, CINAHL, SportDiscuss and Google Scholar databases and reference lists of included studies were searched.

STUDY SELECTION

The selection criteria were randomized controlled trials (RCTs) employing an exercise training intervention. Data were extracted from the entered studies for analysis. The primary outcomes were peak oxygen uptake (VO_2peak), anaerobic threshold (AT), 6-minute walk distance (6-MWD), and quality of life (QoL) measures (physical component score and mental component score). The analysis included 9 articles with a total of 302 participants: intervention (n = 154), and control (n = 148).

RESULTS

In the pooled analysis, improvements were seen in: VO_2peak, mean difference (MD) 2.79 ml/kg/min (95% CI 2.00 to 3.59, p < 0.00001); AT, MD 107.83 ml/min (95% CI 39.64 to 176.00, p = 0.002); and 6-MWD, MD 46.67 meters (95% CI 32.39 to 60.96, p < 0.00001). Differences were found in the SF-36 physical component score MD 3.57 (95% CI 2.04 to 5.10, p < 0.00001) and the SF-36 mental component score MD 3.92 (95% CI 1.92 to 5.91, p = 0.001).

CONCLUSION

This meta-analysis demonstrates exercise training has a beneficial effect on fitness, walking performance, and self-reported QoL in PH patients.

Effects of Different Types of Exercise Training on Pulmonary Arterial Hypertension: A Systematic Review

Pulmonary arterial hypertension (PAH) represents a chronic progressive disease characterized by high blood pressure in the pulmonary arteries leading to right heart failure. The disease has been a focus of medical research for many years due to its worse prognosis and limited treatment options. The aim of this study was to systematically assess the effects of different types of exercise interventions on PAH. Electronic databases were searched until July 2019. MEDLINE database was used as the predominant source for this paper. Studies with regards to chronic physical activity in adult PAH patients are compared on retrieving evidence on cellular, physiological, and psychological alterations in the PAH setting. Twenty human studies and 12 rat trials were identified. Amongst all studies, a total of 628 human subjects and 614 rats were examined. Regular physical activity affects the production of nitric oxygen and attenuates right ventricular hypertrophy. A combination of aerobic, anaerobic, and respiratory muscle training induces the strongest improvement in functional capacity indicated by an increase of 6 MWD and VO₂peak. In human studies, an increase of quality of life was found. Exercise training has an overall positive effect on the physiological and psychological components of PAH. Consequently, PAH patients should be encouraged to take part in regular exercise training programs.

Effects of upper extremity aerobic exercise training on oxygen consumption, exercise capacity, dyspnea and quality of life in patients with pulmonary arterial hypertension

BACKGROUND

Pulmonary and extrapulmonary impairments are prevalent in pulmonary arterial hypertension (PAH) which is a rare, chronic and progressive disease.

OBJECTIVES

To investigate the effects of upper extremity aerobic exercise training on exercise capacity, oxygen consumption, dyspnea and quality of life in patients with PAH.

METHODS

In a prospective, randomized controlled, double-blinded study, eleven patients in training group applied upper extremity aerobic exercise training (50-80% of maximal heart rate), 15-45 min/day, 3 days a week for 6 weeks and 11 patients in control group alternating active upper extremity exercises for the same period. Exercise capacity evaluated using six minute walk test (6MWT), oxygen consumption simultaneously measured during 6MWT using a portable instrument, dyspnea modified Borg scale and Modified Medical Research Council dyspnea scale and quality of life Short Form 36 Health Survey, before and after the exercise training.

RESULTS

Baseline characteristics of groups were similar (p>0.05). Dyspnea (p<0.001) and peak oxygen consumption (p = 0.031) were significantly improved in training group compared the controls. Dyspnea, exercise capacity, peak oxygen consumption, minute ventilation, tidal volume, end tidal carbon-dioxide pressure, and vitality, social functioning and role-physical were significantly improved within training group (p<0.05). Oxygen consumption at anaerobic threshold were significantly decreased within control group (p<0.05).

CONCLUSIONS

Upper extremity aerobic exercise training improves oxygen consumption, and decreases dyspnea perception. It is a safe and effective intervention in patients with PAH. (ClinicalTrials.gov registration: NCT02371733).

Attitudes towards exercise among medical specialists who manage patients with pulmonary hypertension

Exercise training was not traditionally recommended for patients with pulmonary hypertension. However, recent work has demonstrated that exercise improves endurance and quality-of-life in patients with pulmonary hypertension. Unfortunately, patients with pulmonary hypertension are often sedentary. While some studies have examined patient attitudes to exercise, none have investigated physician perspectives on exercise in patients with pulmonary hypertension. This multinational survey of physicians involved in treating patients with pulmonary hypertension sought to ascertain physician attitudes to exercise and physician-identified barriers and enablers of exercise in this patient population. We collected cross-sectional survey data from a cohort of 280 physicians, including rehabilitation physicians, cardiologists, respiratory physicians and rheumatologists. We found that overall, 86% physicians recommended exercise, in line with current guidelines, although there were differences in the rationale for prescribing exercise and in the type of exercise prescription. Barriers to exercise included patient-related factors, such as patient ill health preventing exercise; poor patient motivation and lack of understanding regarding the benefits of exercise. Systemic barriers included cost/funding issues and limited availability of appropriate services. Perceived enablers of exercise included access to appropriate programmes, provision of education and supportive treating clinicians. Further research is required to identify and implement interventions to promote physical activity in patients with pulmonary hypertension.

Effectiveness and safety of exercise training and rehabilitation in pulmonary hypertension: a systematic review and meta-analysis

Background

Pulmonary hypertension (PH) is a chronic progressive disease characterized by increasing pulmonary vascular resistance, poor prognosis and high disability rate. Although many targeted drugs for PH have been put to clinical use, most patients still have poor exercise tolerance and quality of life. Exercise training is considered to further improve exercise capacity and quality of life in patients with PH, but it has not been fully studied and utilized. The aim of this systematic review and meta-analysis is to evaluate the effectiveness and safety of exercise training in patients with PH.

Methods

A search was conducted for the meta-analysis using the databases PubMed, Embase, Cochrane Library, including literature published before December 2018. The primary outcome of this meta-analysis was a change in the 6-minute walk distance (6MWD). In addition, peak oxygen uptake (PeakVO₂), resting pulmonary arterial systolic pressure (PASP_rest), resting heart rate (HR_rest), peak exercise heart rate (HR_peak), oxygen uptake anaerobic threshold (VO₂ at AT), maximum workload and quality of life (QoL) were also assessed.

Results

A total of 651 patients in 17 studies were included. A meta-analysis showed that exercise training was associated with significant improvement in the 6MWD [weighted mean difference (WMD): 64.75 m (95% CI: 53.19–76.31 m, P<0.001)], peakVO₂ [WMD: 1.78 mL/min/kg (95% CI: 1.27–2.29 mL/min/kg, P<0.001)], HR_peak [WMD: 11.07 beats/min (95% CI: 8.04–14.11 beats/min, P<0.001)] and QoL measured by SF-36 questionnaire subscale scores. Furthermore, exercise training is well tolerated, and no major adverse event occurred related to exercise training.

Conclusions

Exercise training is associated with a significant improvement in exercise capacity, cardiorespiratory fitness and quality of life among patients with PH and proved to be safe for stable PH patients with optimization of medical therapy. However, more large-scale multicenter studies are needed to confirm the effectiveness and safety of exercise training in patients with PH.

The role of cardiopulmonary exercise testing and training in patients with pulmonary hypertension: making the case for this assessment and intervention to be considered a standard of care

Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

Exercise-Based Rehabilitation to Improve Exercise Capacity and Quality of Life in Pulmonary Arterial Hypertension

<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions-medications, surgery, education, nutrition, exercise-and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature. Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on people diagnosed with pulmonary arterial hypertension. Can exercise-based rehabilitation programs improve exercise capacity and quality of life in people with pulmonary arterial hypertension?

The role of rehabilitation in patients with pulmonary arterial hypertension

PURPOSE OF REVIEW

The current review summarizes the latest evidence of the effects of exercise training for pulmonary hypertension patients demonstrated by six randomized controlled trails and 20 further studies. As the availability of exercise training is still limited it is important to raise awareness of the body of evidence showing the benefit for the patients and the limitations.

RECENT FINDINGS

The effects of exercise training on exercise capacity, hemodynamics as well as quality of life are described as well as different settings and components of exercise training. Associated adverse events are critically reviewed and strategies for avoidance of these events discussed. Lastly, the most important issues of availability and reimbursement of a specialized exercise training program are examined and the future path is outlined to improve patient access.

SUMMARY

The latest publications on this topic strengthen the call for international multicenter randomized controlled trials to establish the feasibility of exercise training in different healthcare systems and to enhance patient access to these programs.

The Relationship between Hypertension and Cognitive Function Impairment in the Elderly

BACKGROUND:

Hypertension is still a health problem both in developed and developing countries. Hypertension can cause various complications; one of them is cognitive function impairment.

AIM:

This study aimed to look at the relationship of hypertension with cognitive function. This research can also be useful to help optimise the health of the elderly, maximise quality of life and avoid hypertension as a risk factor for cognitive impairment in the elderly at the Karya Kasih Nursing Homes, Medan from May to June 2018.

METHODS:

This research was carried out by analytic observational with cross-sectional research approach. In this study, 57 elderly from Karya Kasih Nursing Homes Medan who met the inclusion and exclusion criteria participated. Assessment of cognitive function used Mini-Mental State Examination (MMSE), Six Item Cognitive Impairment Test (6CIT) and Abbreviated Mental Test Score (AMT) instruments.

RESULT:

This study obtained a significant relationship between the history of hypertension with impaired cognitive function (p = 0.003). The results of the cognitive function examination with MMSE showed that among 57 elderly, 16 people (43.2%) were normal and 21 people (56.8%) had impaired cognitive function in the first degree hypertension group, besides that, 3 people were normal (15%) and 7 people (85%) had impaired cognitive function in the second degree hypertension group (p = 0.031). Based on the result of mild and severe cognitive function impairment, among 12 people (57.1%) and 9 people (42.9%) had a mild and severe cognitive function impairment, respectively, in first-degree hypertension. 3 people (17.6%) and 14 people (82.4%) had a mild and severe cognitive function impairment, respectively, in the second-degree hypertension (p = 0.013). The 6-CIT instrument also showed a significant relationship between the severity of hypertension and impaired cognitive function (p = 0.027), and there was no significant relationship with AMT instruments (p = 0.078).

CONCLUSION:

There was a relationship between the history or duration and degree of hypertension with cognitive dysfunction in the elderly at the Karya Kasih Nursing Home Medan.

Update on MR imaging of the pulmonary vasculature

Magnetic resonance imaging (MRI) plays an increasingly important role in the non-invasive evaluation of the pulmonary vasculature. MR angiographic (MRA) techniques provide morphological information, while MR perfusion techniques provide functional information of the pulmonary vasculature. Contrast-enhanced MRA can be performed at high spatial resolution using 3D T1-weighted spoiled gradient echo sequence or at high temporal resolution using time-resolved techniques. Non-contrast MRA can be performed using 3D steady state free precession, double inversion fast spin echo, time of flight or phase contrast sequences. MR perfusion can be done using dynamic contrast-enhanced technique or using non-contrast techniques such as arterial spin labelling and time-resolved imaging of lungs during free breathing with Fourier decomposition analysis. MRI is used in the evaluation of acute and chronic pulmonary embolism, pulmonary hypertension and other vascular abnormalities, congenital anomalies and neoplasms. In this article, we review the different MR techniques used in the evaluation of pulmonary vasculature and its clinical applications.

ERS statement on exercise training and rehabilitation in patients with severe chronic pulmonary hypertension

Objectives of this European Respiratory Society task force were to summarise current studies, to develop strategies for future research and to increase availability and awareness of exercise training for pulmonary hypertension (PH) patients.

An evidence-based approach with clinical expertise of the task force members, based on both literature search and face-to-face meetings was conducted. The statement summarises current knowledge and open questions regarding clinical effects of exercise training in PH, training modalities, implementation strategies and pathophysiological mechanisms.

In studies (784 PH patients in total, including six randomised controlled trials, three controlled trials, 10 prospective cohort studies and four meta-analyses), exercise training has been shown to improve exercise capacity, muscular function, quality of life and possibly right ventricular function and pulmonary haemodynamics. Nevertheless, further studies are needed to confirm these data, to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.

As exercise training appears to be effective, cost-efficient and safe, but is scarcely reimbursed, support from healthcare institutions, commissioners of healthcare and research funding institutions is greatly needed. There is a strong need to establish specialised rehabilitation programmes for PH patients to enhance patient access to this treatment intervention.

Exercise Training and Rehabilitation in Pulmonary Hypertension

Within the last years, exercise training and rehabilitation as add-on to medical treatment has become an emerging field in pulmonary hypertension. Owing to the beneficial effects of exercise training in pulmonary hypertension, the new European Respiratory Society/European Society of Cardiology guidelines for pulmonary hypertension recommended a supervised and closely monitored exercise and respiratory training/rehabilitation as add-on to medical therapy (class IIa, level of evidence B). In this article, different training modalities, effects of exercise training, possible pathobiological mechanisms of action, and future research questions are discussed.

Exercise rehabilitation programmes for pulmonary hypertension: a systematic review of intervention components and reporting quality

Objectives

To identify the components, and assess the reporting quality, of exercise training interventions for people living with pulmonary hypertension.

Design

Systematic review with analysis of intervention reporting quality using the Consensus on Exercise Reporting Template (CERT).

Data sources

Eligible studies in the Cochrane Systematic Review of exercise-based rehabilitation for pulmonary hypertension, updated with a new search of relevant databases from 1 August 2016 to 15 January 2018.

Eligibility criteria

Peer-reviewed journal articles of randomised and non-randomised controlled trials, and non-controlled prospective observational studies, investigating dynamic exercise training interventions in adult humans with diagnosed pulmonary hypertension, reporting on at least one physiological and/or psychosocial outcome.

Results

Interventions typically involved cycle ergometry and walking. They were delivered as 3-week inpatient, or outpatient and/or home-based programmes, lasting for 4–15 weeks. Components relating specifically to exercise prescription were described satisfactorily and in more detail than motivational/behavioural change strategies, adherence and fidelity. Mean CERT score was 13.1 (range 8–17) out of a possible maximum score of 19. No studies fully reported every aspect of an exercise intervention to the standard recommended by CERT.

Summary/conclusion

Considerable variability was evident in the components and reporting quality of interventions for exercise rehabilitation studies in pulmonary hypertension. Interventional studies using exercise training should pay greater attention to describing motivational/behavioural change strategies, adherence and fidelity. Detailed description of these parameters is essential for the safe and effective replication of exercise rehabilitation interventions for pulmonary hypertension in clinical practice.

Trial registration number

CRD42018085558.

Safe and effective exercise training for patients with pulmonary arterial hypertension: putting current evidence into clinical practice

INTRODUCTION

While there have been significant advances in the medical treatment of pulmonary arterial hypertension (PAH), life expectancy, and quality of life remain reduced in this disease. Strenuous exercise may be hazardous for PAH patients; however, several relatively small trials have confirmed that exercise training programs can be used safely and effectively as adjunctive treatment for selected patients. The use of exercise training is now recommended in consensus international PAH treatment algorithms; however, there is no published guideline detailing how this intervention should be carried out. Areas covered: This review describes the evidence available and evaluates its applicability to 'real life' clinical practice. The limitations of current evidence are acknowledged, and we discuss how the existing data can be applied to management of PAH patients in Australia, New Zealand, and countries with similar healthcare systems. Recommendations for PAH exercise training are proposed including patient selection, program structure and duration, training modalities, training intensity, supervision, monitoring, safety precautions, and outcome assessments. Expert commentary: It is recognized that knowledge gaps remain and further research is required into physiological mechanisms associated with improved exercise capacity, optimal outpatient exercise regimen, durability of benefit, and whether there is any disease-modifying effect or impact on long-term prognosis.

Pulmonary hypertension in chronic heart failure: definitions, advances, and unanswered issues

Pulmonary hypertension (PH) is a common and severe complication of heart failure (HF). Consequently, HF is the leading cause of PH. For many years, specialists have attempted to better understand the pathophysiology of PH in HF, to define its prevalence and its impact on prognosis in order to improve the therapeutic management of these patients. Nowadays, despite the recent guidelines published on the subject, several points remain unclear or debated, and until now, no study has demonstrated the efficacy of any treatment. The aim of this review is to report the evolution of the concepts on post‐capillary PH (diagnosis, prevalence, prognosis, and therapeutics). The main issues are raised, focusing especially on the link between structural alterations and haemodynamic abnormalities, to discuss the possible reasons for treatment failures and future potential targets.

Study protocol for a randomised controlled trial of exercise training in pulmonary hypertension (ExTra_PH)

Background

Exercise training is an integral component of evidence-based management programs for many chronic cardiac and respiratory conditions. Despite this, there are limited high-quality studies available on the significance of exercise training in pulmonary hypertension (PH). The aim of this study is to evaluate the short and long-term effectiveness of exercise training in PH patients in terms of exercise capacity, quality of life, cardiac function and disease progression.

Methods

This randomized control trial will aim to recruit 50 medically stable PH patients categorised as New York Heart Association functional classification II-III. Participants will be randomly allocated to either the supervised exercise training group or usual care group for the 8-week study period. Exercise training will be conducted in an outpatient setting. Measurements at baseline and following the 8-week study period include exercise capacity (6 min walk distance and cardiopulmonary exercise test), cardiac function (exercise cardiac magnetic resonance imaging [CMRI] and echocardiography), health-related quality of life (Cambridge Pulmonary Hypertension Outcome Review), adverse responses to exercise training and time to clinical worsening. In addition, participants will be followed up for a minimum of 2 year period from commencement of the study so as to monitor long-term clinical outcomes i.e. time to clinical worsening.

Discussion

This study will determine whether an 8-week outpatient based supervised exercise training program is safe and beneficial for medically stable PH patients in the short and long term. This will be the first study to examine the impact of exercise training on right heart function using exercise CMRI. Results from the study will contribute new knowledge in relation to the impact of exercise training on cardiac function, long-term prognosis and inform clinical practice guidelines for this patient population. Moreover, the study will add to our understanding regarding the efficacy of exercise training in individuals with PH in an outpatient setting.

Trial registration

Australia and New Zealand Clinical Trials Registry: ACTRN12616001467426. Registered 21st October, 2016.

Exercise training in patients with pulmonary and systemic hypertension: A unique therapy for two different diseases

Pulmonary hypertension is a potentially life-threatening condition. Given its evolving definition, the incidence and prevalence of the disease is difficult to define, but registries suggest an increased global awareness. The management of patients with pulmonary arterial hypertension is highly specialised and requires multi-disciplinary input from a range of healthcare professionals, including cardiologists, respiratory physicians, rheumatologists, rehabilitation physicians and cardio-pulmonary physiotherapists. Historically, exercise training in pulmonary hypertension has not been recommended because of safety concerns. However, an increasing number of studies have demonstrated the benefit of exercise training on exercise capacity, peak oxygen consumption and quality of life. Systemic hypertension is one of the most important risk factors for cardiovascular disease, and has been ranked as the leading cause for death and disability worldwide: therefore, adequate control of blood pressure is important for public health. Lowering of blood pressure and prevention of hypertension is in first instance preferable by lifestyle changes. These include weight loss, moderation of alcohol intake, a diet with increased fresh fruit and vegetables, reduced saturated fat, reduced salt intake, reduced stress, and, finally, increased physical activity. With regard to the latter, former guidelines predominantly recommended aerobic exercises such as walking, jogging, and cycling for lowering blood pressure. The main focus of this narrative overview paper is to briefly examine and summarize the benefit of exercise training in patients with pulmonary and systemic hypertension, suggest mechanisms by which exercise may improve symptoms and function and provide evidence-based recommendations regarding the frequency and intensity of exercise in these patients.

Exercise training in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is characterized by a continuous increase in pre-capillary pulmonary vascular resistance (PVR) with a progressive reduction of cardiac output (CO). Similar to what occurs in left heart failure (HF), this represents the initial phase of a syndrome characterized by the progressive development of dyspnea and fatigue with increasing deterioration of exercise tolerance. Although the therapies introduced in the last two decades have determined a significant improvement of the clinical conditions of PAH patients, they have a little impact on exercise capacity and prognosis. However, as previously demonstrated for HF, recent pilot studies have reported that physical and respiratory rehabilitation may have a specific role in the management of PAH. Despite potential risks, so far all studies agree that exercise training (ET) improves exercise capacity, quality of life (QoL), muscle function and pulmonary circulation. We will review the pathophysiological mechanisms underlying the functional incompetence of PAH patients, the effects of ET on clinical and functional parameters, the selection criteria for inclusion of patients in a training program, the suggested monitoring of beneficial effects or possible side effects induced by ET. Finally, we discuss of the possible exercise induced amelioration of prognosis in PAH.

A prescribed walking regimen plus arginine supplementation improves function and quality of life for patients with pulmonary arterial hypertension: a pilot study

Current evidence suggests that exercise training is beneficial in pulmonary arterial hypertension (PAH). Unfortunately, the standard supervised, hospital-based programs limit patient accessibility to this important intervention. Our proof-of-concept study aimed to provide insight into the usefulness of a prescribed walking regimen along with arginine supplementation to improve outcomes for patients with PAH. Twelve PAH patients (all women) in New York Heart Association (NYHA) functional class (FC) II (n = 7) or III (n = 5) and in stable condition for ≥ 3 months were enrolled. Patients performed home- and fitness-center- based walking at 65-75% heart rate (HR) reserve for 45 min, six sessions/week for 12 weeks. Concomitant L-arginine supplementation (6000 mg/day) was provided to maximize beneficial endothelial training adaptations. Cardiopulmonary exercise testing, 6-min walk testing (6MWT), echocardiography, laboratory studies, and quality of life (QoL) survey (SF-36) were performed at baseline and 12 weeks. Eleven patients completed the study (72 session adherence rate = 96 ± 3%). Objective improvement was demonstrated by the 6MWT distance (increased by 40 ± 13 m, P = 0.01), VO₂max (increased by 2 ± 0.7 mL/kg/min, P = 0.02), time-to-VO₂max (increased by 2.5 ± 0.6 min, P = 0.001), VO₂ at anaerobic threshold (increased by 1.3 ± 0.5 mL/kg/min, P = 0.04), HR recovery (reduced by 68 ± 23% in slope, P = 0.01), and SF-36 subscales of Physical Functioning and Energy/Fatigue (increased by 70 ± 34% and 74 ± 34%, respectively, P < 0.05). No adverse events occurred, and right ventricular function and brain natriuretic peptide levels remained stable, suggesting safety of the intervention. This proof-of-concept study indicates that a simple walking regimen with arginine supplementation is a safe and efficacious intervention for clinically stable PAH patients, with gains in objective function and QoL measures. Further investigation in a randomized controlled trial is warranted.

Australian and New Zealand Pulmonary Rehabilitation Guidelines

BACKGROUND AND OBJECTIVE

The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts.

METHODS

The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts.

RESULTS

The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary.

CONCLUSION

The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Effects of exercise training on pulmonary hemodynamics, functional capacity and inflammation in pulmonary hypertension

Pulmonary hypertension (PH) is characterized by severe exercise limitation mainly attributed to the impairment of right ventricular function resulting from a concomitant elevation of pulmonary vascular resistance and pressure. The unquestioned cornerstone in the management of patients with pulmonary arterial hypertension (PAH) is specific vasoactive medical therapy to improve pulmonary hemodynamics and strengthen right ventricular function. Nevertheless, evidence for a beneficial effect of exercise training (ET) on pulmonary hemodynamics and functional capacity in patients with PH has been growing during the past decade. Beneficial effects of ET on regulating factors, inflammation, and metabolism have also been described. Small case-control studies and randomized clinical trials in larger populations of patients with PH demonstrated substantial improvements in functional capacity after ET. These findings were accompanied by several studies that suggested an effect of ET on inflammation, although a direct link between this effect and the therapeutic benefit of ET in PH has not yet been demonstrated. On this background, the aim of the present review is to describe current concepts regarding the effects of exercise on the pulmonary circulation and pathophysiological limitations, as well as the clinical and mechanistic effects of exercise in patients with PH.

Randomised controlled trial examining the effect of an outpatient exercise training programme on haemodynamics and cardiac MR parameters of right ventricular function in patients with pulmonary arterial hypertension: the ExPAH study protocol

INTRODUCTION

Pulmonary hypertension (PH) is a potentially life-threatening condition characterised by elevated pulmonary artery pressure. Early stage PH patients are often asymptomatic. Disease progression is associated with impairment of right ventricular function and progressive dyspnoea. Current guidelines recommend exercise training (grade IIa, level B). However, many questions remain regarding the mechanisms of improvement, intensity of supervision and optimal frequency, duration and intensity of exercise. This study will assess the effect of an outpatient rehabilitation programme on haemodynamics and cardiac right ventricular function in patients with pulmonary arterial hypertension (PAH), a subgroup of PH.

METHODS AND ANALYSIS

This randomised controlled trial involves both a major urban tertiary and smaller regional hospital in New South Wales, Australia. The intervention will compare an outpatient rehabilitation programme with a control group (home exercise programme). Participants will be stable on oral PAH-specific therapy. The primary outcome measure will be right ventricular ejection fraction measured by cardiac MRI. Secondary outcomes will include haemodynamics measured by right heart catheterisation, endurance, functional capacity, health-related quality of life questionnaires and biomarkers of cardiac function and inflammation.

ETHICS APPROVAL AND DISSEMINATION

Ethical approval has been granted by St Vincent's Hospital, Sydney (HREC/14/SVH/341). Results of this study will be disseminated through presentation at scientific conferences and in scientific journals.

TRIAL REGISTRATION NUMBER

ACTRN12615001041549; pre-results.

Exercise-based rehabilitation programmes for pulmonary hypertension

BACKGROUND

Individuals with pulmonary hypertension (PH) have reduced exercise capacity and quality of life. Despite initial concerns that exercise training may worsen symptoms in this group, several studies have reported improvements in functional capacity and well-being following exercise-based rehabilitation in PH.

OBJECTIVES

To assess the efficacy and safety of exercise-based rehabilitation for people with PH. Primary outcomes were exercise capacity, adverse events during the intervention period and health-related quality of life (HRQoL). Secondary outcomes included cardiopulmonary haemodynamics, functional class, clinical worsening during follow-up, mortality and changes in B-type natriuretic peptide.

SEARCH METHODS

We searched the Cochrane Airways Specialised Register of Trials up to August 2016, which is based on regular searches of CINAHL, AMED, Embase, PubMed, MEDLINE, PsycINFO and registries of clinical trials. In addition we searched CENTRAL and the PEDro database up to August 2016 and handsearched relevant journals.

SELECTION CRITERIA

All randomised controlled trials (RCTs) focusing on exercise-based rehabilitation programmes for PH.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently. For binary outcomes, we calculated odds ratios and their 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

We included six RCTs and were able to extract data from five studies. The majority of participants were Group I pulmonary artery hypertension (PAH). Study duration ranged from three to 15 weeks. Exercise programmes included both inpatient- and outpatient-based rehabilitation that incorporated both upper and lower limb exercise. The mean six-minute walk distance following exercise training was 60.12 metres higher than control (30.17 to 90.07 metres, n = 165, 5 RCTs, low-quality evidence; minimal important difference was 30 metres), the mean peak oxygen uptake was 2.4 ml/kg/minute higher (1.4 to 3.4 ml/kg/min, n = 145, 4 RCTs, low-quality evidence) and the mean peak power in the intervention groups was 16.4 W higher (10.9 to 22.0 higher, n = 145, 4 RCTs, low-quality evidence). The mean change in HRQoL for the SF-36 physical component score was 4.63 points higher (0.80 to 8.47 points, n = 33, 2 RCTs, low-quality evidence) and for the SF-36 mental component score was 4.17 points higher (0.01 to 8.34 points; n = 33; 2 RCTs, low-quality evidence). One study reported a single adverse event, where a participant stopped exercise training due to lightheadedness.

AUTHORS' CONCLUSIONS

In people with PH, exercise-based rehabilitation results in clinically relevant improvements in exercise capacity. Exercise training was not associated with any serious adverse events. Whilst most studies reported improvements in HRQoL, these may not be clinically important. Overall, we assessed the quality of the evidence to be low. The small number of studies and lack of information on participant selection makes it difficult to generalise these results across the spectrum of people with PH.

Evidence on Exercise Training in Pulmonary Hypertension

Pulmonary hypertension (PH) is a chronic, debilitating condition which gravely affects exercise tolerance and quality of life. Though most therapies focus purely on medical intervention, there is a growing body of evidence to suggest the role and benefits of exercise training. This chapter discusses the various physiological basis for exercise intolerance observed in PH and highlights the rationale for exercise training. Recent evidence related to exercise training is summarized and potential pathways to suggest adaptations to exercise training are put forward. While keeping the paper applicable to clinicians, details on evaluating exercise intolerance, prescribing exercise and setting up rehabilitation centers for PH are discussed.

Aerobic exercise-related attenuation of arterial pulmonary hypertension: A right arrow targets the disease?

Characterized by progressive elevation of mean pulmonary artery pressure and pulmonary vascular resistance, pulmonary arterial hypertension (PAH) is an important health problem that contributes to right heart failure. Pulmonary arterial remodeling and constriction are two prominent features of PAH. It is a traditional view that increasing pulmonary blood flow and pressure, aerobic exercise does more harm than good to the pulmonary vasculature in PAH. However, recent studies have documented a potential benefit of low-intensity aerobic exercise for PAH patients. Here the current mini-review outlines the evidence and challenges for this additional tool in our armamentarium to combat this ominous disease.

MR phase-contrast imaging in pulmonary hypertension

Pulmonary hypertension (PH) is a life-threatening, multifactorial pathophysiological haemodynamic condition, diagnosed when the mean pulmonary arterial pressure equals or exceeds 25 mmHg at rest during right heart catheterization. Cardiac MRI, in general, and MR phase-contrast (PC) imaging, in particular, have emerged as potential techniques for the standardized assessment of cardiovascular function, morphology and haemodynamics in PH. Allowing the quantification and characterization of macroscopic cardiovascular blood flow, MR PC imaging offers non-invasive evaluation of haemodynamic alterations associated with PH. Techniques used to study the PH include both the routine two-dimensional (2D) approach measuring predominant velocities through an acquisition plane and the rapidly evolving four-dimensional (4D) PC imaging, which enables the assessment of the complete time-resolved, three-directional blood-flow velocity field in a volume. Numerous parameters such as pulmonary arterial mean velocity, vessel distensibility, flow acceleration time and volume and tricuspid regurgitation peak velocity, as well as the duration and onset of vortical blood flow in the main pulmonary artery, have been explored to either diagnose PH or find non-invasive correlates to right heart catheter parameters. Furthermore, PC imaging-based analysis of pulmonary arterial pulse-wave velocities, wall shear stress and kinetic energy losses grants novel insights into cardiopulmonary remodelling in PH. This review aimed to outline the current applications of 2D and 4D PC imaging in PH and show why this technique has the potential to contribute significantly to early diagnosis and characterization of PH.