Exercise Training for Heart Failure
1999; Lippincott Williams & Wilkins; Volume: 99; Issue: 9 Linguagem: Inglês
10.1161/01.cir.99.9.1138
ISSN1524-4539
Autores Tópico(s)Cardiovascular and exercise physiology
ResumoHomeCirculationVol. 99, No. 9Exercise Training for Heart Failure Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBExercise Training for Heart Failure Coming of Age Andrew J. S. Coats Andrew J. S. CoatsAndrew J. S. Coats From the National Heart and Lung Institute, Imperial College School of Medicine at Royal Brompton Hospital, London, UK. Originally published9 Mar 1999https://doi.org/10.1161/01.CIR.99.9.1138Circulation. 1999;99:1138–1140We have known for many years of the benefits of an exercise component in cardiac rehabilitation. It was initially thought that significant left ventricular impairment was a contraindication to participation in such programs. In fact, in heart failure, there was a vogue for and reports of the beneficial effects of prolonged bed rest.1 It is against this background that a few challenging reports emerged in the early 1980s that selected patients with significant left ventricular impairment had in fact participated in exercise programs and had achieved training responses with increased exercise capacity.234 It was not until the late 1980s, however, that the first reports of training patients with a history of chronic heart failure (CHF) emerged.56 Pioneering work from Duke University showed a significant enhancement in exercise capacity and ancillary physiological benefits, including reduced lactate production, improved use of ventilatory reserve, and increased leg blood flow during progressive exercise.56 This was quickly followed by the first prospective controlled trial of exercise training in CHF, an 11-patient crossover study of home-based exercise training using a cycle ergometer for 8 weeks versus a similar period of activity restriction.7 The result was an improvement in exercise capacity and an improvement in questionnaire-based heart failure–related symptoms. The era of training as a treatment of heart failure had begun.In the decade following these first reports, there have been a profusion of small trials and a long list of impressive physiological gains that could be achieved. These included increased peak oxygen consumption,8910 an increase in peak cardiac output (in some8 but not all trials), and improvement in the autonomic control of the circulation with a reduction in sympathetic nervous system activity and an enhancement in vagal activity.811 More recent reports have documented an increase in endothelial function12 and in skeletal muscle biochemical1314 and histological characteristics15 and improvements in patients' perceptions of their quality of life and symptom severity. These training benefits have been shown against a background of increasing interest in and realization of the importance of secondary peripheral manifestations of the syndrome of CHF.16 The importance of neurohormonal overactivity has been recognized for a decade, but the importance of other changes, such as altered and wasted skeletal muscle and a host of major metabolic disturbances in CHF, are only now being appreciated.17 These include insulin resistance, deficient insulin-like growth factor-1, immune activation and cytokine release, endothelial dysfunction, and baroreflex, chemoreflex, and muscle ergoreflex (metaboreflex) alterations, all of which have the capacity to worsen the symptoms and prognosis of the heart failure patient and all of which at least in theory might be improved by a customized training program. It is against this background that exercise training (given its diverse and metabolically powerful effects) is being viewed as an exciting potential therapy for stable CHF patients.The results of training in heart failure, however, have not been uniform. In the setting of a recent myocardial infarction, in particular, early reports stressed caution. Early fears that training after an MI in those with large infarcts could worsen left ventricular asynergy have not been confirmed by later, better-designed studies, which showed that these patients could train safely and improve their exercise capacity, as shown by the EAMI study group.18 In a second study by this group (ELVD), in fact, they actually showed an improvement in the harmful process of left ventricular remodeling by participation in a structured exercise rehabilitation program.19 It is easy to see how the chronic reduction in sympathetic tone could improve the remodeling process, and this may be more important in the long term than the short durations of the exercise necessary to achieve this increased fitness.Wilson et al20 described a proportion of his patients who either were unable to complete an exercise program or achieved no increase in exercise capacity from so doing. These patients seemed to be those with limiting cardiac output rather than those limited by secondary changes in the periphery, such as impaired peripheral vasodilatory capacity or impaired skeletal muscle function. This distinction is quite plausible, because training does appear to achieve the majority of its beneficial effects through peripheral mechanisms with little or no effect on resting left ventricular function. More recent reports have suggested that some patients with ischemic cardiomyopathy may be able to increase their collateral blood flow to the myocardium as measured by perfusion scanning. Similar results were also seen in the study by Belardinelli in this issue of Circulation, to which this editorial refers.21Three major questions remain unanswered by the predominantly single-center studies that have been published to date: (1) whether the training effects could be maintained over the long term, (2) whether training is practicable in multiple medical settings outside of enthusiastic specialist clinics, and (3) whether training would have an effect on mortality or morbidity, either adverse or beneficial. We have published our own experience of training in multiple units across several European countries with different healthcare systems and found that these differences were of less importance than such factors as the duration of training or the setting (in-hospital only, out-of-hospital, or a combination).22 It would appear that the type of training and the combination of some supervised and some unsupervised is, superficially at least, most likely to be associated with the largest increase in exercise capacity and that none of the patient factors studied (pathogenesis, NYHA class, left ventricular ejection fraction, or medication) appeared to predict the training response reliably.The literature to date includes only ≈500 to 600 patients reported as having taken part in randomized trials of exercise training in the setting of CHF. Against this background, any single-center report of a randomized trial of 99 patients is to be heartily welcomed, especially if it contains, as this study does, some of the valuable longer-term follow-up data lacking in many of the earlier reports. Belardinelli and colleagues randomized 99 patients with moderate to severe CHF to supervised exercise rehabilitation or control for a period of 14 months. They found a highly significant 18% greater increase in exercise capacity (peak oxygen uptake) in the trained group than in the control group, associated with improved indices of myocardial thallium uptake and increased quality-of-life questionnaire scores. With this trial and the as yet unpublished EXERT trial from Canada, the experience on training in CHF is growing at a rapid pace. A similarly large trial from another unit in Italy has also been completed, with heartening results on clinical outcomes (M. Volterrani, MD, Brescia, Italy, personal communication). We are also aware of similar initiatives either completed or nearing completion in the United States. Experience in this mode of therapy for CHF is therefore accumulating at a fast rate, and what is sorely needed now is definitive information on the impact of this treatment option on mortality and worsening of heart failure. The present report from Belardinelli and coworkers from a rehabilitation unit in eastern Italy gives heartening results, showing as it does statistically significant reductions in total all-cause mortality (9 versus 20 deaths; risk reduction, −63%; 95% CIs, 16% to 83%; P<0.01) and a similar effect on hospital readmissions for heart failure (5 versus 14; risk reduction, 71%; 95% CIs, 12% to 89%; P<0.02). This is not proof of a mortality reduction, because the trial clearly was not designed to be, nor could it ever have been, powered to show these effects reliably. The results do, however, give encouragement that we may now have sufficient trial data on which to make estimates of possible mortality effects of training in similar groups of patients. Furthermore, it now appears that a mortality trial of this nature is not impossible, should sufficient funding be found. We have proposed such a trial, and 2 working-group meetings have taken place to mount the initiative within Europe. We hope that like-minded North American units will form with the European group to make a mortality trial of training in CHF a reality before the millennium. It would be ironic if the group of patients initially denied the benefits of participation in cardiac rehabilitation programs formed the patient group who finally offered the rehabilitation community their first opportunity to prove a beneficial effect on mortality in a single prospectively designed mortality and morbidity trial. Much remains to be done and many unanswered questions remain, but the excellent work of Belardinelli and colleagues gives us an incentive to put exercise rehabilitation for heart failure to the test.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.FootnotesCorrespondence to Prof Andrew J.S. Coats, Viscount Royston Professor of Clinical Cardiology, National Heart and Lung Institute, Imperial College School of Medicine at Royal Brompton Hospital, Sydney St, London SW3 6NP, UK. E-mail [email protected] References 1 McDonald CD, Burch GE, Walsh JJ. Prolonged bed rest in the treatment of idiopathic cardiomyopathy. Am J Med.1972; 52:41–50.CrossrefMedlineGoogle Scholar2 Letac B, Cribier A, Desplanches JF. A study of left ventricular function in coronary patients before and after physical training. Circulation.1977; 56:375–378.CrossrefMedlineGoogle Scholar3 Lee AP, Ice R, Blessey R, Sanmarco ME. Long-term effects of physical training on coronary patients with impaired ventricular function. Circulation.1979; 60:1519–1526.CrossrefMedlineGoogle Scholar4 Conn EH, Williams RS, Wallace AG. Exercise responses before and after physical conditioning in patients with severely depressed left ventricular function. Am J Cardiol.1982; 49:296–300.CrossrefMedlineGoogle Scholar5 Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with chronic heart failure delays ventilatory anaerobic threshold and improves submaximal exercise performance. Circulation.1989; 79:324–329.CrossrefMedlineGoogle Scholar6 Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction: hemodynamic and metabolic effects. Circulation.1988; 78:506–515.CrossrefMedlineGoogle Scholar7 Coats AJS, Adamopoulos S, Meyer TE, Conway J, Sleight P. Effects of physical training in chronic heart failure. Lancet.1990; 335:63–66.CrossrefMedlineGoogle Scholar8 Coats AJ, Adamopoulos S, Radaelli A, McCance A, Meyer TE, Bernardi L, Solda PL, Davey P, Ormerod O, Forfar C, Conway J, Sleight P. Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation, and autonomic function. Circulation.1992; 85:2119–2131.CrossrefMedlineGoogle Scholar9 Hambrecht R, Niebauer J, Fiehn E, Kalberer B, Offner B, Hauer K, Riede U, Schlierf G, Kubler W, Schuler G. Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles. J Am Coll Cardiol.1995; 25:1239–1249.CrossrefMedlineGoogle Scholar10 Belardinelli R, Georgiou D, Scocco V, Barstow TJ, Purcaro A. Low intensity exercise training in patients with chronic heart failure. J Am Coll Cardiol.1995; 26:975–982.CrossrefMedlineGoogle Scholar11 Kiilavuori K, Toivonen L, Naveri H, Leinonen H. Reversal of autonomic derangements by physical training in chronic heart failure assessed by heart rate variability. Eur Heart J.1995; 16:490–495.CrossrefMedlineGoogle Scholar12 Hornig B, Maier V, Drexler H. Physical training improves endothelial function in patients with chronic heart failure. Circulation.1996; 93:210–214.CrossrefMedlineGoogle Scholar13 Minotti JR, Johnson EC, Hudson TH, Zuroske G, Murata G, Fukushima E, Cagle TG, Chick TW, Massie BM, Icenogle MV. Skeletal muscle response to exercise training in congestive heart failure. J Clin Invest.1990; 86:751–758.CrossrefMedlineGoogle Scholar14 Adamopoulos S, Coats AJ, Brunotte F, Arnolda L, Meyer T, Thompson CH, Dunn JF, Stratton J, Kemp GJ, Radda GK, Rajagopalan B. Physical training improves skeletal muscle metabolism in patients with chronic heart failure. J Am Coll Cardiol.1993; 21:1101–1106.CrossrefMedlineGoogle Scholar15 Hambrecht R, Fiehn E, Yu JT, Niebauer J, Weigl C, Hilbrich L, Adams V, Riede U, Schuler G. Effects of endurance training on mitochondrial ultrastructure and fiber type distribution in skeletal muscle of patients with stable chronic heart failure. J Am Coll Cardiol.1997; 29:1067–1073.CrossrefMedlineGoogle Scholar16 Clark AL, Poole Wilson PA, Coats AJS. Exercise limitation in chronic heart failure: the central role of the periphery. J Am Coll Cardiol.1997; 28:1092–1102.Google Scholar17 Anker SD, Chua TP, Ponikowski P, Harrington D, Swan JW, Kox WJ, Poole Wilson PA, Coats AJS. Hormonal changes and catabolic/anabolic imbalance in chronic heart failure: the importance for cardiac cachexia. Circulation.1997; 96:526–534.CrossrefMedlineGoogle Scholar18 Giannuzzi P, Tavazzi L, Temporelli PL, Corra U, Imparato A, Gattone M, Giordano A, Sala L, Schweiger C, Malinverni C. Long-term physical training and left ventricular remodeling after anterior myocardial infarction: results of the Exercise in Anterior Myocardial Infarction (EAMI) trial. EAMI Study Group. J Am Coll Cardiol.1993; 22:1821–1829.CrossrefMedlineGoogle Scholar19 Giannuzzi P. Attenuation of unfavorable remodeling by exercise training in postinfarction patients with left ventricular dysfunction: results of the Exercise in Left Ventricular Dysfunction (ELVD) trial. Circulation.1997; 96:1790–1797.CrossrefMedlineGoogle Scholar20 Wilson JR, Groves J, Rayos G. Circulatory status and response to cardiac rehabilitation in patients with heart failure. Circulation.1996; 94:1567–1572.CrossrefMedlineGoogle Scholar21 Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation.1999; 99:1173-1182.CrossrefMedlineGoogle Scholar22 European Heart Failure Training Group. Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the improvement in exercise tolerance. Eur Heart J.1998; 19:466–475.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Upadhya B, Edelmann F and Kitzman D (2020) Exercise in Specific Diseases: Heart Failure with Preserved Ejection Fraction Textbook of Sports and Exercise Cardiology, 10.1007/978-3-030-35374-2_45, (927-955), . Byku M and Mann D (2017) Neuromodulation of the Failing Heart Cardioskeletal Myopathies in Children and Young Adults, 10.1016/B978-0-12-800040-3.00019-4, (381-397), . Hussain S, Macaluso A and Pearson S (2016) High-Intensity Interval Training Versus Moderate-Intensity Continuous Training in the Prevention/Management of Cardiovascular Disease, Cardiology in Review, 10.1097/CRD.0000000000000124, 24:6, (273-281), Online publication date: 1-Nov-2016. 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Froelicher V, Hart L and Nichols A (2015) Highlights, The Physician and Sportsmedicine, 10.1080/00913847.1999.11439367, 27:11, (15-28), Online publication date: 15-Oct-1999. Petrella R (2015) Exercise for Older Patients With Chronic Disease, The Physician and Sportsmedicine, 10.1080/00913847.1999.11439372, 27:11, (79-104), Online publication date: 15-Oct-1999. March 9, 1999Vol 99, Issue 9 Advertisement Article InformationMetrics Copyright © 1999 by American Heart Associationhttps://doi.org/10.1161/01.CIR.99.9.1138 Originally publishedMarch 9, 1999 KeywordsEditorialsheart failureexercisePDF download Advertisement
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