Effects of Treatment on Exercise Tolerance, Cardiac Function, and Mortality in Heart Failure With Preserved Ejection Fraction (original) (raw)
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ESC heart failure, 2018
Heart failure with preserved ejection fraction (HFpEF) remains a common condition with no pharmacological treatment. Physical activity (PA) improves symptoms and quality of life (QoL), but no clear recommendations exist on PA in HFpEF patients. We investigated the association of PA (amount/intensity) on clinical phenotype in HFpEF. The Aldosterone in Diastolic Heart Failure trial investigated spironolactone vs. placebo in stable HFpEF patients. At baseline, all patients underwent detailed phenotypization including echocardiography, cardiopulmonary exercise testing, 6 minute walking test (6MWT), and QoL assessment (36-item Short-Form questionnaire). PA was assessed by a self-report questionnaire, classified in metabolic equivalents of task (MET) and analysed with regard to exercise capacity, diastolic function, and QoL. Four hundred twenty-two patients (52% women, age 67 ± 8 years, New York Heart Association II and III) were classified by weekly MET hours into a low (<70), middle ...
Exercise intolerance in heart failure with preserved ejection fraction: more than a heart problem
Journal of geriatric cardiology : JGC, 2015
Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF in older adults, and is increasing in prevalence as the population ages. Furthermore, HFpEF is increasing out of proportion to HF with reduced EF (HFrEF), and its prognosis is worsening while that of HFrEF is improving. Despite the importance of HFpEF, our understanding of its pathophysiology is incomplete, and optimal treatment remains largely undefined. A cardinal feature of HFpEF is reduced exercise tolerance, which correlates with symptoms as well as reduced quality of life. The traditional concepts of exercise limitations have focused on central dysfunction related to poor cardiac pump function. However, the mechanisms are not exclusive to the heart and lungs, and the understanding of the pathophysiology of this disease has evolved. Substantial attention has focused on defining the central versus peripheral mechanisms underlying the reduced functional capacity and exercise tolerance among ...
Journal of Clinical Exercise Physiology, 2020
Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of all heart failure (HF) cases and is the fastest growing form of HF in the United States. The cornerstone symptom of clinically stable HFpEF is severe exercise intolerance (defined as reduced peak exercise oxygen uptake, VO2peak) secondary to central and peripheral abnormalities that result in reduced oxygen delivery to and/or use by exercising skeletal muscle. To date, pharmacotherapy has not been shown to improve VO2peak, quality of life, and survival in patients with HFpEF. In contrast, exercise training is currently the only efficacious treatment strategy to improve VO2peak, aerobic endurance, and quality of life in patients with HFpEF. In this updated review, we discuss the specific central and peripheral mechanisms that are responsible for the impaired exercise responses as well as the role of exercise training to improve VO2peak in clinically stable patients with HFpEF. We also discuss the...
European Journal of Heart Failure, 2020
Endpoints of large-scale trials in chronic heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous iron supplementation in patients with iron deficiency, and-with less certainty-testosterone in highly selected patients. Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with heart failure. Sinus rhythm may have some advantage when compared with atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for heart failure co-morbidities such as sleep-disordered breathing, diabetes mellitus, chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with ivabradine and with sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for heart failure with preserved ejection fraction are even less positive, only sacubitril/valsartan and spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in heart failure are required.
Exercise Intolerance in Heart Failure With Preserved Ejection Fraction
Circulation, 2018
More than 50% of Americans with heart failure have preserved ejection fraction (HFpEF). Exercise intolerance is a hallmark of HFpEF, but the pathophysiology is not well understood. Diverse etiologies and incomplete mechanistic understanding have resulted in ineffective management strategies to improve the outcomes of HFpEF. Traditional therapies that have been beneficial in the treatment of heart failure with reduced ejection fraction (HFrEF), neurohormonal blockade in particular, have not been effective in treating HFpEF. In this review, we address underlying mechanisms of HFpEF and present the rationale supporting exercise as a component of comprehensive management.
Comparing methods for prescribing exercise for individuals with chronic heart failure
Journal of Exercise Physiology Online, 2005
This study examined the accuracy of current recommended guidelines for prescribing exercise intensity using the methods of percentage of heart rate reserve (%HRR), percentage of VO 2 peak (%VO 2 peak) and percentage of VO 2 reserve (%VO 2 R) in a clinical population of chronic heart failure (CHF) patients. The precision of prescription of exercise intensity for 45 patients with stable CHF (39:6 M:F, 65±9 yrs (mean±SD)) was investigated. VO 2 peak testing is relatively common among patients with cardiac disease, but the assessment of VO 2 rest is not common practice and the accepted standard value of 3.5 mL/kg/min is assumed in the application of %VO2R (%VO 2 R 3.5). In this study, VO 2 rest was recorded for 3 min prior to the start of a symptom-limited exercise test on a cycle ergometer. Target exercise intensities were calculated using the VO 2 corresponding to 50 or 80 %HRR, VO 2 peak and VO 2 R. The VO 2 values were then converted into prescribed speeds on a treadmill in km/hr at 1 %grade using ACSM's metabolic equation for walking. Target intensities and prescribed treadmill speeds were also calculated with the %VO 2 R method using the mean VO 2 rest value of participants (3.9 mL/kg/min) (%VO 2 R 3.9). This was then compared to the exercise intensities and prescribed treadmill speeds using patient's measured VO 2 rest. Error in prescription correlates the difference between %VO 2 R 3.5 and %VO 2 R 3.9 compared to %VO 2 R with measured VO 2 rest. Prescription of exercise Exercise Prescription For Individuals With CHF 10 intensity through the %HRR method is imprecise for patients on medications that blunt the HR response to exercise. %VO 2 R method offers a significant improvement in exercise prescription compared to %VO 2 peak. However, a disparity of 10 % still exists in the %VO 2 R method using the standard 3.5 mL/kg/min for VO 2 rest in the %VO 2 R equation. The mean measured VO 2 rest in the 45 CHF patients was 11 % higher (3.9±0.8 mL/kg/min) than the standard value provided by ACSM. Applying the mean measured VO 2 rest value of 3.9 mL/kg/min rather than the standard assumed value of 3.5 mL/kg/min proved to be closer to the prescribed intensity determined by the actual measured resting VO 2. These results suggest that the %HRR method should not be used to prescribe exercise intensity for CHF patients. Instead, VO 2 should be used to prescribe exercise intensity and be expressed as %VO 2 R with measured variables (VO 2 rest and VO 2 peak).
European Journal of Preventive Cardiology, 2019
Background: In heart failure with reduced left ventricular ejection fraction (HFrEF) patients the effects of exercisebased cardiac rehabilitation on top of state-of-the-art pharmacological and device therapy on mortality, hospitalization, exercise capacity and quality-of-life are not well established. Design: The design of this study involved a structured review and meta-analysis. Methods: Evaluation of randomised controlled trials of exercise-based cardiac rehabilitation in HFrEF-patients with left ventricular ejection fraction 40% of any aetiology with a follow-up of !6 months published in 1999 or later. Results: Out of 12,229 abstracts, 25 randomised controlled trials including 4481 HFrEF-patients were included in the final evaluation. Heterogeneity in study population, study design and exercise-based cardiac rehabilitation-intervention was evident. No significant difference in the effect of exercise-based cardiac rehabilitation on mortality compared to control-group was found (hazard ratio 0.75, 95% confidence interval 0.39-1.41, four studies; 12-months follow-up: relative risk 1.29, 95% confidence interval 0.66-2.49, eight studies; six-months follow-up: relative risk 0.91, 95% confidence interval 0.26-3.16, seven studies). In addition there was no significant difference between the groups with respect to 'hospitalization-for-any-reason' (12-months follow-up: relative risk 0.79, 95% confidence interval 0.41-1.53, four studies), or 'hospitalization-due-to-heart-failure' (12-months follow-up: relative risk 0.59, 95% confidence interval 0.12-2.91, four studies; six-months follow-up: relative risk 0.84, 95% confidence interval 0.07-9.71, three studies). All studies show improvement of exercise capacity. Participation in exercise-based cardiac rehabilitation significantly improved quality-of-life as evaluated with the Kansas City Cardiomyopathy Questionnaire: (six-months follow-up: mean difference 1.94, 95% confidence interval 0.35-3.56, two studies), but no significant results emerged for qualityof-life measured by the Minnesota Living with Heart Failure Questionnaire (nine-months or more follow-up: mean difference-4.19, 95% confidence interval-10.51-2.12, seven studies; six-months follow-up: mean difference-5.97, 95% confidence interval-16.17-4.23, four studies).
Heart Failure Reviews, 2019
Physical activity is associated with a lower risk of adverse cardiovascular outcomes, including heart failure (HF). Exercise training is a class IA level recommendation in patients with stable HF, but its impact is less clear in heart failure with preserved ejection fraction (HFpEF). The aim of this study was to analyze the effects of the exercise training on cardiovascular outcomes in patients with HFpEF. A systematic literature search was conducted on the main electronic databases, proceedings of major meetings, and reference lists of the identified studies, using specific terms for only English language studies published between 2000 and 2018. We followed the PRISMA to perform our review. Quality of studies was also assessed. The systematic review identified 9 studies on 348 patients, of moderate (n = 2) to good (n = 7) quality. The training consisted of a combination of supervised in-hospital and home-based outpatient programs, including aerobic exercise, endurance and resistance training, walking, and treadmill and bicycle ergometer. Most of the protocols ranged 12-16 weeks, with a frequency of 2-3 sessions weekly, lasting 20-60 min per session. There were significant improvements in peak oxygen uptake, 6-min walking test distance, and ventilatory threshold, whereas quality of life and echocardiographic parameters improved only in some studies. Endothelial function/arterial stiffness remained unchanged. No adverse events were reported. Appropriate exercise programs are able to get a favorable cardiovascular outcome in patients with HFpEF. This could also benefit in terms of quality of life, even if more controversial. Further researches are necessary.