Exercise Intolerance in Heart Failure With Preserved Ejection Fraction (original) (raw)
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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 ...
Mechanisms of Exercise Intolerance in Heart Failure With Preserved Ejection Fraction
Circulation Journal, 2014
Approximately half of patients with heart failure (HF) have a preserved ejection fraction (HFpEF), and with the changing age and comorbidity characteristics in the adult population, this number is growing rapidly. The defining symptom of HFpEF is exercise intolerance, but the specific mechanisms causing this common symptom remain debated and inadequately understood. Although diastolic dysfunction was previously considered to be the sole contributor to exercise limitation, recent studies have identified the importance of ventricular systolic, chronotropic, vascular, endothelial and peripheral factors that all contribute in a complex and highly integrated fashion to produce the signs and symptoms of HF. This review will explore the mechanisms underlying objective and subjective exercise intolerance in patients with HFpEF.
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...
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 ...
Journal of Cardiopulmonary Rehabilitation and Prevention, 2020
H eart failure (HF) is a major health care problem associated with high morbidity and mortality. 1 Currently, >6 million Americans ≥20 y of age have HF, and its prevalence is expected to increase by 46% by 2030. 1,2 Nearly half of all HF patients have preserved left ventricular (LV) ejection fraction (heart failure with preserved ejection fraction [HF-pEF]) and this phenotype is more common in older individuals, women, and those with a history of hypertension, obesity, and anemia. 1,3 Decreased exercise tolerance is a hallmark feature in clinically stable HFpEF patients and is associated with reduced quality of life (QoL). 4,5 Given the relationship between cardiorespiratory fitness (CRF; ie, peak oxygen uptake, • Vo 2peak) and survival, 6,7 an important goal of therapy should be to improve CRF in HFpEF patients. 8-12 Currently, exercise training is the only proven effective intervention to improve • Vo 2peak , aerobic endurance, and QoL in HFpEF patients. 4,10 Several recent meta-analyses have reported that endurance exercise training, performed alone or combined with resistance training, improves • Vo 2peak and 6-min walk test distance by 2.2 mL/kg/min and 33 m, respectively. 4,13,14 Accordingly, understanding the mechanisms responsible for reduced • Vo 2peak and its improvement with exercise training is critical to optimally improve functional capacity and QoL in HFpEF patients. In this brief review, the pathophysiology of exercise intolerance and the role of exercise training to improve • Vo 2peak in clinically stable patients with HFpEF are discussed. Further discussion of the mechanisms responsible for the exercise training-mediated increase in • Vo 2peak is provided, along with evidence-based exercise prescription guidelines for clinically stable HFpEF patients participating in an exercise-based cardiac rehabilitation (CR) program. PATHOPHYSIOLOGY OF EXERCISE INTOLERANCE IN HFpEF Appreciating the Fick principle for • Vo 2 is fundamental to understanding the pathophysiology of exercise intolerance in patients with HFpEF. Specifically, the Fick principle dictates that • Vo 2 = cardiac output (Q) × arterial-venous O 2 content difference (a-vO 2 Diff), with Q and the a-vO 2 Diff each having their own modulating factors that ultimately drive the highest achievable • Vo 2 at peak exercise (Figure). ROLE OF CARDIAC FUNCTION ON EXERCISE LIMITATIONS IN HFpEF The reduction in • Vo 2peak observed in patients with HFpEF is due, in part, to a reduction in cardiac function during exercise. Several independent laboratories have demonstrated that peak Q is 30-40% lower in patients with HF-pEF compared with control subjects. 16-19 Evidence to date suggests that chronotropic incompetence rather than stroke volume (SV) is a fundamental concern for the blunted Q response to peak exercise in patients with HFpEF. 16-18,20-22 Indeed, significant relationships between Q (independent of major reductions in SV) 18 and heart rate (HR) 20 with • Vo 2peak have previously been reported, even when matched for important comorbidities, 21 supporting that underlying chronotropic incompetence is a major contributor to reduced Q and subsequent reductions in • Vo 2peak in HFpEF. Despite the major role that HR plays on the severely reduced peak exercise • Vo 2 in patients with HFpEF, several impairments in left ventricular function have also been reported (Figure). Normally, LV relaxation is augmented during exercise to compensate for the reduction in filling
Clinical Utility of Exercise Training in Heart Failure with Reduced and Preserved Ejection Fraction
Clinical Medicine Insights: Cardiology, 2015
Reduced exercise tolerance is an independent predictor of hospital readmission and mortality in patients with heart failure (HF). Exercise training for HF patients is well established as an adjunct therapy, and there is sufficient evidence to support the favorable role of exercise training programs for HF patients over and above the optimal medical therapy. Some of the documented benefits include improved functional capacity, quality of life (QoL), fatigue, and dyspnea. Major trials to assess exercise training in HF have, however, focused on heart failure with reduced ejection fraction (HFREF). At least half of the patients presenting with HF have heart failure with preserved ejection fraction (HFPEF) and experience similar symptoms of exercise intolerance, dyspnea, and early fatigue, and similar mortality risk and rehospitalization rates. The role of exercise training in the management of HFPEF remains less clear. This article provides a brief overview of pathophysiology of reduced...
Circulation. Heart failure, 2016
Evidence-based therapies for heart failure (HF) differ significantly according to left ventricular ejection fraction (LVEF). However, few data are available on the phenotype and prognosis of patients with HF with midrange LVEF of 40% to 55%, and the impact of recovered systolic function on the clinical features, functional capacity, and outcomes of this population is not known. We studied 944 patients with HF who underwent clinically indicated cardiopulmonary exercise testing. The study population was categorized according to LVEF as follows: HF with reduced LVEF (HFrEF; LVEF<40%; n=620); HF with midrange ejection fraction and no recovered ejection fraction (LVEF was consistent between 40% and 55%; n=107); HF with recovered midrange ejection fraction (LVEF, 40%-55% but previous LVEF<40%; n=170); and HF with preserved LVEF (HFpEF; LVEF>55%; n=47). HF with midrange ejection fraction and no recovered ejection fraction and HF with recovered midrange ejection fraction had simila...
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.