A controlled trial of exercise rehabilitation after heart transplantation

Sexual counselling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

After a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as '… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences ….'(1(p4)) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.(2) Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.(3) ED and vaginal dryness may also be presenting signs of heart disease and may appear 1-3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care;(4) therefore, routine assessment of sexual problems and sexual counselling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.

Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation

Aerobic exercise intensity prescription is a key issue in cardiac rehabilitation, being directly linked to both the amount of improvement in exercise capacity and the risk of adverse events during exercise. This joint position statement aims to provide professionals with up-to-date information regarding the identification of different exercise intensity domains, the methods of direct and indirect determination of exercise intensity for both continuous and interval aerobic training, the effects of the use of different exercise protocols on exercise intensity prescription and the indications for recommended exercise training prescription in specific cardiac patients' groups. The importance of functional evaluation through exercise testing prior to starting an aerobic training program is strongly emphasized, and ramp incremental cardiopulmonary exercise test, when available, is proposed as the gold standard for a physiologically comprehensive exercise intensity assessment and prescription. This may allow a shift from a 'range-based' to a 'threshold-based' aerobic exercise intensity prescription, which, combined with thorough clinical evaluation and exercise-related risk assessment, could maximize the benefits obtainable by the use of aerobic exercise training in cardiac rehabilitation.

Effects of an acute, outpatient physiotherapy exercise program following pediatric heart or lung transplantation

This prospective interventional study investigated the impact of a three-month, ambulatory HA or HB, semi-individualized, PT-prescribed exercise program following pediatric HTx or LTx. SMW distance, strength, and flexibility were assessed at start and completion of the program and one yr after enrollment. Subjects received either an HB or HA exercise program three times per week. The cohort demonstrated clinically and statistically significant improvements in SMW distances at three months (425.7 ± 109.4-500.6 ± 93.6 m, p < 0.001) and at one yr (528.5 ± 66.6 m, p = 0.001), although there was no difference between the two groups at any time. Similar improvements were also observed in strength and flexibility measures. Correlates with higher SMW distance at three months and one yr included older age, male gender, and underlying diagnosis other than CHD. Male gender and diagnosis other than CHD were associated with a slower improvement in the SMW distance. This is the first report of institutionally based, outpatient exercise rehabilitation in the recovery following pediatric thoracic transplantation. We found similar improvements to HB interventions up to one yr after surgery. Further study of the role of exercise rehabilitation and long-term fitness outcomes is needed.

One year of high-intensity interval training improves exercise capacity, but not left ventricular function in stable heart transplant recipients: a randomised controlled trial

BACKGROUND

Heart transplant recipients have lower exercise capacity and impaired cardiac function compared with the normal population. High-intensity interval training (HIIT) improves exercise capacity and cardiac function in patients with heart failure and hypertension, but the effect on cardiac function in stable heart transplant recipients is not known. Thus, we investigated whether HIIT improved cardiac function and exercise capacity in stable heart transplant recipients by use of comprehensive rest- and exercise-echocardiography and cardiopulmonary exercise testing.

DESIGN AND METHODS

Fifty-two clinically stable heart transplant recipients were randomised either to HIIT (4 × 4 minutes at 85-95% of peak heart rate three times per week for eight weeks) or to control. Three such eight-week periods were distributed throughout one year. Echocardiography (rest and submaximal exercise) and cardiopulmonary exercise testing were performed at baseline and follow-up.

RESULTS

One year of HIIT increased VO 2peak from 27.7 ± 5.5 at baseline to 30.9 ± 5.0 ml/kg/min at follow-up, while the control group remained unchanged (28.5 ± 7.0 vs. 28.0 ± 6.7 ml/kg per min, p < 0.001 for difference between the groups). Systolic and diastolic left ventricular functions at rest and during exercise were generally unchanged by HIIT.

CONCLUSIONS

Whereas HIIT is feasible in heart transplant recipients and effectively improves exercise capacity, it does not alter cardiac systolic and diastolic function significantly. Thus, the observed augmentation in exercise capacity is best explained by extra-cardiac adaptive mechanisms.

High-intensity interval training improves peak oxygen uptake and muscular exercise capacity in heart transplant recipients

Heart transplant (HTx) recipients usually have reduced exercise capacity with reported VO(2peak) levels of 50-70% predicted value. Our hypothesis was that high-intensity interval training (HIIT) is an applicable and safe form of exercise in HTx recipients and that it would markedly improve VO(2peak.) Secondarily, we wanted to evaluate central and peripheral mechanisms behind a potential VO(2peak) increase. Forty-eight clinically stable HTx recipients >18 years old and 1-8 years after HTx underwent maximal exercise testing on a treadmill and were randomized to either exercise group (a 1-year HIIT-program) or control group (usual care). The mean ± SD age was 51 ± 16 years, 71% were male and time from HTx was 4.1 ± 2.2 years. The mean VO(2peak) difference between groups at follow-up was 3.6 [2.0, 5.2] mL/kg/min (p < 0.001). The exercise group had 89.0 ± 17.5% of predicted VO(2peak) versus 82.5 ± 20.0 in the control group (p < 0.001). There were no changes in cardiac function measured by echocardiography. We have demonstrated that a long-term, partly supervised and community-based HIIT-program is an applicable, effective and safe way to improve VO(2peak) , muscular exercise capacity and general health in HTx recipients. The results indicate that HIIT should be more frequently used among stable HTx recipients in the future.

Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation

Aerobic exercise intensity prescription is a key issue in cardiac rehabilitation, being directly linked to both the amount of improvement in exercise capacity and the risk of adverse events during exercise. This joint position statement aims to provide professionals with up-to-date information regarding the identification of different exercise intensity domains, the methods of direct and indirect determination of exercise intensity for both continuous and interval aerobic training, the effects of the use of different exercise protocols on exercise intensity prescription and the indications for recommended exercise training prescription in specific cardiac patients' groups. The importance of functional evaluation through exercise testing prior to starting an aerobic training program is strongly emphasized, and ramp incremental cardiopulmonary exercise test, when available, is proposed as the gold standard for a physiologically comprehensive exercise intensity assessment and prescription. This may allow a shift from a 'range-based' to a 'threshold-based' aerobic exercise intensity prescription, which, combined with thorough clinical evaluation and exercise-related risk assessment, could maximize the benefits obtainable by the use of aerobic exercise training in cardiac rehabilitation.

[Diagnosis, prevention and treatment of cardiac allograft vasculopathy]

The major limitation of long-term survival after cardiac transplantation is allograft vasculopathy, which consists of concentric and diffuse intimal hyperplasia. The disease still has a significant incidence, estimated at 30% five years after cardiac transplantation. It is a clinically silent disease and so diagnosis is a challenge. Coronary angiography supplemented by intravascular ultrasound is the most sensitive diagnostic method. However, new non-invasive diagnostic techniques are likely to be clinically relevant in the future. The earliest possible diagnosis is essential to prevent progression of the disease and to improve its prognosis. A new nomenclature for allograft vasculopathy has been published in July 2010, developed by the International Society for Heart and Lung Transplantation (ISHLT), establishing a standardized definition. Simultaneously, the ISHLT published new guidelines standardizing the diagnosis and management of cardiac transplant patients. This paper reviews contemporary concepts in the pathophysiology, diagnosis, prevention and treatment of allograft vasculopathy, highlighting areas that are the subject of ongoing research.

The relationship between physical activity and heart rate variability in orthotopic heart transplant recipients

AIMS AND OBJECTIVES

To investigate the relationship between physical activity and heart rate variability in orthotopic heart transplant recipients, to compare the difference in heart rate variability between patients one year after orthotopic heart transplant and healthy adults matched to the heart transplant recipients in terms of age, gender and physical activity levels.

BACKGROUND

Although physical activity affects the heart rate variability in patients with heart disease, there is a paucity of literature discussing the correlation between physical activity and heart rate variability among heart transplant recipients.

DESIGN

This was a descriptive and cross-sectional study.

METHODS

A total of 120 eligible subjects were divided into the orthotopic heart transplant recipient group (n = 60) and the healthy adult group (n = 60). The Seven-day Physical Activity Recall questionnaire was used to record the subjects' amount of physical activity per week. Heart rate variety parameters were determined by separate frequency domain components.

RESULTS

Results indicated heart transplant recipients' heart rate variety was significantly lower than that of healthy adults in terms of mean, sdr, total power (ms(2)), low frequency (ms(2)), low frequency (nu), high frequency (ms(2)) and low frequency/high frequency. Heart transplant recipients' heart rate variety including total power (ms(2)), low frequency (ms(2)) and high frequency (ms(2)) was 18·2, 2 and 7·2% of healthy controls, respectively; the amount of absolutely and relatively moderate physical activity was positively related to high frequency (ms(2)) and high frequency (nu), but was negatively related to low frequency/high frequency. High frequency (nu) increases while the total amount of weekly physical activity increases.

CONCLUSIONS

Results confirmed that the more the moderate physical activity performed, the better the patient's heart rate variability.

RELEVANCE TO CLINICAL PRACTICE

We suggest that clinical care providers have to encourage heart transplant recipients to engage in moderate physical activity.

Effects of exercise training in heart transplant recipients: a meta-analysis

OBJECTIVES

Muscle wasting and exercise intolerance are common in heart transplant recipients. Most studies on the effects of exercise training have used relatively small sample sizes and are heterogeneous in nature. The purpose of this meta-analysis was to systematically review the relevant studies and investigate the effects of exercise training on exercise capacity and muscle strength in heart transplant recipients.

METHODS

A systematic search was adopted from electronic databases and relevant references, using medical subject heading key words related to heart transplantation and exercise. Only randomized controlled trials with exercise intervention versus usual care were included. The data were expressed as the weighted mean differences with 95% confidence intervals (CIs).

RESULTS

Altogether 6 studies were included. Peak oxygen consumption (VO(2)) was reported in 4 trials (117 patients), and muscle strength was reported in 3 trials (67 patients). Peak VO(2) was significantly increased by 2.34 ml/kg/min (95% CI 0.63-4.05). One-repetition maxima of the chest press (23.28 kg, 95% CI 0.64-45.91) and leg press (28.84 kg, 95% CI 5.70-51.98) were significantly improved by exercise training.

CONCLUSION

Exercise training is recommended for heart transplant recipients to improve peak VO(2) and muscle strength despite the small number of trials included in this meta-analysis.

Availability, characteristics, and barriers of rehabilitation programs in organ transplant populations across Canada

Rehabilitation is receiving increasingly more attention from the medical community in the management of individuals' pre- and post-organ transplantation. A cross-sectional descriptive survey was administered to all known transplant programs across Canada to explore the availability, characteristics, and barriers of rehabilitation programs pre- and post-heart, lung, kidney, and liver transplantation. Of the 58 programs surveyed, 35 agreed to participate (nine heart, six lung, 13 kidney, seven liver), and six refused for a response rate of 71%. Twelve transplant programs that offered rehabilitation were identified (six heart, five lung, one liver). All rehabilitation programs identified included aerobic exercises, strength training, and education and involved a multidisciplinary team. The Six Minute Walk Test and the Medical Outcomes Short Form-36 questionnaire were the most commonly used outcome measures. In kidney and liver transplant programs, over 50% of respondents from these programs cited lack of funding, shortage of health care personnel, and a low volume of patients in a centralized region as barriers to providing rehabilitation programs. Rehabilitation can play an integral role in pre- and post-transplantation management, and barriers to access and provision of rehabilitation for organ transplant populations should be examined further.

Exercise therapy for cardiac transplant recipients

Heart transplantation (HT) is an attractive treatment for patients with terminal heart failure from a variety of causes. Survival at 1- and 5 years after HT averages 90% and 70%, respectively. The physiologic response to exercise is abnormal after HT presumably because the transplanted heart is surgically denervated, although a minority of patients demonstrate signs of partial cardiac reinnervation several months after surgery. The heart rate response to exercise is typically blunted, and exercise capacity is below average for most HT recipients. Multiple studies have demonstrated the benefits of exercise training (ET) after HT. Peak exercise oxygen uptake improves by an average of 24% after 2 to 3 months of ET. Resistance training results in increased skeletal muscle mass and strength. Early mobilization and low-level ET may begin in the hospital after extubation. Outpatient ET, ideally in a supervised environment for at least several weeks, should begin immediately after hospital dismissal. Exercise prescription for HT patients is similar to that for other patients who have undergone cardiothoracic surgery, with the exception of a target heart rate. Ratings of perceived exertion are useful for prescribing exercise intensity. Exercise training does not affect the frequency or severity of episodes of acute rejection. There are no data regarding the effect of ET on survival after HT.

Effect of high intensity exercise on peak oxygen uptake and endothelial function in long-term heart transplant recipients

Coronary allograft vasculopathy is a well-known long-term complication after cardiac transplantation. Endothelial dysfunction is involved and may be prevented by aerobic exercise. The purpose of this study was to examine whether high intensity aerobic exercise improves peak oxygen uptake (VO(2 peak) ) and endothelial function in heart transplant (HT) recipients. Twenty-seven long-term HT recipients were randomized to either 8-weeks high intensity aerobic exercise or no training. Flow mediated dilation of the brachial artery (FMD) was measured by ultrasound and VO(2 peak) by the analysis of expired air. Blood pressure and biomarkers were measured before and after 8 weeks. VO(2 peak) increased significantly in the exercise group (VO(2 peak) 23.9 ± 1.79 to 28.3 ± 1.63 mL/kg/min compared to controls (VO(2 peak) 24.6 ± 1.38 to 23.4 ± 1.58, p < 0.001 exercise vs. control).FMD increased in the exercise group compared to controls (8.3 ± 1.1% to 11.4 ± 1.2% vs. 5.6 ± 1.0% to 5.3 ± 1.7%, p = 0.024). No increase in nitroglycerin-induced vasodilation was observed. Systolic blood pressure fell in the exercise group (142 ±4.2 mmHg to127 ± 3.4 mmHg, p = 0.01) and was unchanged in controls (141 ± 4.2 mmHg to 142 ±6.4 mmHg, NS). High intensity aerobic exercise reduces systolic blood pressure and improves endothelial function in HT recipients.

Exploratory study on oxygen consumption on-kinetics during treadmill walking in women with systemic lupus erythematosus

OBJECTIVE

To determine whether oxygen consumption (V o(2)) on-kinetics differed between groups of women with systemic lupus erythematosus (SLE) and sedentary but otherwise healthy controls.

DESIGN

Exploratory case-control study.

SETTING

Medical school exercise physiology laboratory.

PARTICIPANTS

Convenience samples of women with SLE (n=12) and sedentary but otherwise healthy controls (n=10).

INTERVENTION

None.

MAIN OUTCOME MEASURES

V o(2) on-kinetics indices including time to steady state, rate constant, mean response time (MRT), transition constant, and oxygen deficit measured during bouts of treadmill walking at intensities of 3 and 5 metabolic equivalents (METs).

RESULTS

Time to steady state and oxygen deficit were increased and rate constant was decreased in the women with SLE compared with controls. At the 5-MET energy demand, the transition constant was lower and MRT was longer in the women with SLE than in controls. For a similar relative energy expenditure that was slightly lower than the anaerobic threshold, the transition constant was higher in controls than in women with SLE.

CONCLUSION

V o(2) on-kinetics was prolonged in women with SLE. The prolongation was concomitant with an increase in oxygen deficit and may underlie performance fatigability in women with SLE.

Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

Cardiac patients after an acute event and/or with chronic heart disease deserve special attention to restore their quality of life and to maintain or improve functional capacity. They require counselling to avoid recurrence through a combination of adherence to a medication plan and adoption of a healthy lifestyle. These secondary prevention targets are included in the overall goal of cardiac rehabilitation (CR). Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients. The CR approach is delivered in tandem with a flexible follow-up strategy and easy access to a specialized team. To promote implementation of cardiac prevention and rehabilitation, the CR Section of the EACPR (European Association of Cardiovascular Prevention and Rehabilitation) has recently completed a Position Paper, entitled 'Secondary prevention through cardiac rehabilitation: A condition-oriented approach'. Components of multidisciplinary CR for seven clinical presentations have been addressed. Components include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, weight control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. Cardiac rehabilitation services are by definition multi-factorial and comprehensive, with physical activity counselling and exercise training as central components in all rehabilitation and preventive interventions. Many of the risk factor improvements occurring in CR can be mediated through exercise training programmes. This call-for-action paper presents the key components of a CR programme: physical activity counselling and exercise training. It summarizes current evidence-based best practice for the wide range of patient presentations of interest to the general cardiology community.

L-arginine supplementation improves exercise capacity after a heart transplant

BACKGROUND

Endothelial dysfunction is associated with the decreased exercise capacity observed in heart-transplant (HTx) recipients. L-arginine supplementation (LAS) stimulates the nitric oxide (NO) pathway and restores endothelial function.

OBJECTIVE

We compared exercise capacity in healthy subjects and HTx patients and investigated whether chronic LAS might improve exercise capacity and NO/endothelin balance after an HTx.

DESIGN

Clinical, echocardiographic, and exercise characteristics were measured in 11 control subjects and 22 HTx recipients. In a prospective, double-blind study, the 22 HTx recipients performed a 6-min exercise [6-min-walk test (6MWT)] and a maximal bicycle exercise test before and after a 6-wk period of placebo intake or LAS. Endothelial function was measured by analyzing blood NO metabolites, endothelin, and the resulting NO/endothelin balance.

RESULTS

Exercise capacity decreased after transplantation. Unlike with the placebo intake, 6 wk of LAS improved quality of life in HTx recipients (mean +/- SEM Minnesota Score: from 15.3 +/- 1.3 to 10.6 +/- 1.1; P < 0.001) and their submaximal exercise capacity. The distance walked during the 6MWT increased (from 525 +/- 20 to 580 +/- 20 m; P = 0.002), and the ventilatory threshold during the incremental test was delayed by 1.2 min (P = 0.01). Central factors such as resting stroke volume, systolic pulmonary arterial pressure, cardiac systolodiastolic functions, and heart-rate reserve were not modified, but LAS significantly increased the NO:endothelin ratio (from 2.49 +/- 0.38 to 3.31 +/- 0.39; P = 0.03).

CONCLUSION

Oral LAS may be a useful adjuvant therapeutic to improve quality of life and exercise tolerance in HTx recipients.

Changes in exercise capacity induced by heart transplantation: prognostic and therapeutic implications

Survival and exercise performance are key targets of heart transplantation (HT). We designed this study to help in identifying (1) patients with chronic heart failure (CHF) at risk of poor exercise capacity after HT and (2) HT recipients presenting risk factors modifiable with exercise showing a potential impact on outcome. We enrolled 49 HT recipients (age 52 ± 12 years, 84% males) who underwent a cardiopulmonary exercise test before (9 ± 6 months) and after (20 ± 14 months) HT. In the CHF phase, lower peak oxygen consumption (VO(2) ) (odds ratio 0.69, P=0.017) independently predicted peak VO(2) improvement after HT. In the post-HT phase, body mass index (BMI) [adjusted hazard ratio (HR) 1.16, P=0.034] and VE (ventilation)/VCO(2) (carbon dioxide production) slope (adjusted HR 1.07, P=0.031) independently predicted mortality. In conclusion, CHF patients with only a moderate impairment of peak VO(2) are at a risk of failing to achieve a significant improvement of exercise performance after HT. In the post-HT phase, a BMI≥28 and/or a VE/VCO(2) slope ≥47 represent risk factors for death, which are potentially modifiable with exercise. Prospective randomized studies are needed to analyze the effects of training on functional capacity and outcome in the different subsets of HT recipients.

Exercise training after lung transplantation: a systematic review

BACKGROUND

Lung transplant recipients experience persistent impairments in exercise capacity and skeletal muscle function despite a vast improvement in lung function after transplantation. Exercise training may be beneficial in improving exercise capacity in lung transplant recipients. A systematic review was undertaken to examine the evidence for exercise training on functional outcomes in lung transplant recipients.

METHODS

Studies were identified by searching electronic databases and scanning reference lists. Only randomized controlled trials, controlled trials, and prospective cohorts were included in the review. Seven studies met the inclusion criteria. Study quality was assessed using the Physiotherapy Evidence Database, Jadad, and Downs scales.

RESULTS

The overall quality of studies was fair to moderate in assessing the effect of exercise training on maximal and functional exercise capacity, skeletal muscle function, and lumbar bone mineral density. Every study reported significant improvements in these outcomes. Some studies lacked randomization and/or a control group, so it was not possible to separate the effects of training with the natural recovery process after lung transplantation.

CONCLUSION

Some evidence was found to support that a period of structured exercise training could improve maximal and functional exercise capacity, skeletal muscle strength, and lumbar bone mineral density in lung transplant recipients. Further studies are needed to determine the potential for exercise training to optimize these functional outcomes and to develop optimal guidelines for exercise prescription in the lung transplant population.