6 min walk test is a strong independent predictor of death in outpatients with heart failure

Prognostic value of quality of life and functional status in patients with heart failure: a systematic review and meta-analysis

BACKGROUND

Functional health status is increasingly being recognized as a viable endpoint in heart failure (HF) trials. We sought to assess its prognostic impact and relationship with traditional clinical outcomes in patients with HF.

METHODS

MEDLINE and Cochrane central were searched up to January 2021 for post hoc analyses of trials or observational studies that assessed independent association between baseline health/functional status, and mortality and hospitalization in patients with HF across the range of left ventricular ejection fractions to evaluate the prognostic ability of NYHA class [II, III, IV], KCCQ, MLHFQ, and 6MWD. Hazard ratios (HR) with 95% confidence intervals were pooled.

RESULTS

Twenty-two studies were included. Relative to NYHA I, NYHA class II (HR 1.54 [1.16-2.04]; p < 0.01), NYHA class III (HR 2.08 [1.57-2.77]; p < 0.01), and NYHA class IV (HR 2.53 [1.25-5.12]; p = 0.01) were independently associated with increased risk of mortality. 6MWD (per 10 m) was associated with decreased mortality (HR 0.98 [0.98-0.99]; p < 0.01). A 5-point increase in KCCQ-OSS (HR 0.94 [0.91-0.96]; p < 0.01) was associated with decreased mortality. A high MLHFQ score (> 45) was significantly associated with increased mortality (HR 1.30 [1.14-1.47]; p < 0.01). NHYA class, 6MWD (per 10 m), KCCQ-OSS, and MLHFQ all significantly associated with all-cause mortality in patients with HF.

CONCLUSION

Identifying such patients with poor health status using functional health assessment can offer a complementary assessment of disease burden and trajectory which carries a strong prognostic value.

Functional limitation predicts mortality in heart failure with preserved ejection fraction

BACKGROUND

While the prognostic value of six-minute walking test (6MWT) in patients with heart failure (HF) and reduced ejection fraction has been firmly established, there are few or no data correlating the distance walked during 6MWT (6MWD) with mortality in patients with HF with preserved ejection fraction (HFpEF) METHODS: We studied 482 patients with HFpEF who had been admitted to inpatients cardiac rehabilitation. The primary outcome was 3-year all-cause mortality. The association between 6MWD and the primary outcome was assessed using multivariable models. Established risk markers were incorporated into the models.

RESULTS

174 patients died during the 3-year follow-up. Taking the highest tertile of 6MWD (≥360 m) as reference, the adjusted hazard ratio (HR) of the primary outcome was 2.23 (95 % CI 1.31-3.78; p = .003) for the patients in the intermediate tertile (241-359 m) and 4.94 (95 % CI 2.90-8.39; p < .001) for those in the lowest tertile (≤240 m). The annual mortality rate was 25.0 % in the lowest tertile, 10.9 % in the intermediate tertile, and 5.3 % in the highest tertile. When the distance walked was normalized for age, sex, and body mass index and expressed as percent-of-predicted walking distance, the adjusted HR was 1.30 (95 % CI 0.76-2.22; p = .331) for the patients in the intermediate tertile (58.2 % to 77.6 %) and 3.52 (95 % CI 2.12-5.85; p < .001) for those in the lowest tertile (≤58.1 %).

CONCLUSIONS

Our findings suggest that measuring functional capacity by evaluating the distance that a patient can walk over a period of 6 min provides important prognostic information in HFpEF.

Changes in 6-min walk test is an independent predictor of death in chronic heart failure with reduced ejection fraction

AIMS

Functional capacity provides important clinical information in patients with heart failure (HF) and reduced ejection fraction (HFrEF). The 6-min walk test (6MWT) is a simple and inexpensive tool for assessing functional capacity and risk. Although change in 6MWT is frequently used as a surrogate outcome in HF trials, the association with mortality is unclear. We aimed to assess the prognostic importance of changes in 6MWT.

METHODS AND RESULTS

Patients with chronic HFrEF referred to HF outpatient clinics in Norway completed a 6MWT at the first visit (baseline) and at a stable follow-up visit after treatment optimization (follow-up). Absolute and relative changes in 6MWT were analysed in association with mortality risk using Cox regression models and flexible cubic splines. The study included 3636 HFrEF patients aged 67.3 ± 11.6 years, 23% women, with left ventricular ejection fraction 30 ± 7%. At baseline, mean 6MWT was 438 ± 125 m, median N-terminal pro-B-type natriuretic peptide (NT-proBNP) 1574 (732-3093) ng/L, and 27% had New York Heart Association (NYHA) class III/IV. After optimization of guideline-directed medical therapy (median 147 [86-240] days), 6MWT increased by mean 40 ± 74 m, NT-proBNP decreased by median 425 (14-1322) ng/L, and NYHA class improved in 38% of patients. Patients with greater improvements in 6MWT were younger, with greater improvements in NYHA class (r = 0.27, p < 0.001) and larger reductions in NT-proBNP concentrations (r = 0.19, p < 0.001). After mean 845 ± 595 days, 419 (11.5%) patients were dead. Both absolute and relative changes in 6MWT were non-linearly associated with survival, attenuating as 6MWT increased. A 50 m increase in 6MWT was associated with a 17% lower mortality risk (hazard ratio 0.84, 95% confidence interval 0.77-0.90, p < 0.001) in the fully adjusted model, including changes in NYHA class, NT-proBNP concentrations, and other established risk factors. The associations were more pronounced in patients with lower baseline 6MWT and higher age.

CONCLUSION

Improvement in 6MWT in patients with HFrEF is associated with increased survival, independent of changes in NT-proBNP and NYHA class. These findings support 6MWT change as a surrogate outcome in HF trials.

Prognostic utility of B-type natriuretic peptide and 6-min walk test in patients with acute decompensated heart failure

BACKGROUND

We aimed to assess the utility of B-type natriuretic peptide (BNP) and 6-min walk test (6 MWT) together as predictors of re-hospitalization and mortality in acute decompensated heart failure (ADHF) patients.

METHODS

This prospective, observational, comparative study was conducted at a tertiary care center in India between October 2016 and March 2018. Patients (aged≥18 years) with ADHF and left ventricular systolic dysfunction were included in this study. The study group (N = 100 patients) consisted of patients undergoing a second BNP test along with the 6 MWT at the time of discharge and at 3-months of discharge. The control group (N = 100 patients) consisted of patients who did not undergo these tests at discharge and/or at 3-months of discharge. Study endpoints were re-hospitalization within 6-months, and in-patient and 6-month mortality.

RESULTS

Total 200 patients diagnosed with ADHF were enrolled. Mean age was 53.46 ± 10.12 years in the study group and 52.98 ± 9.88 years in the control group. ROC analysis of BNP level to predict re-hospitalization revealed AUC of 0.935 (p < 0.001) at admission, 0.915 (p < 0.001) at discharge, and 0.783 (p < 0.001) at 3-months. Similarly, at discharge, ROC analysis of 6 MWT to predict death gave AUC of 0.670 (p = 0.011), and at 3-months, it was 0.838 (p < 0.001). ROC analysis of BNP level to predict mortality showed AUC of 0.960 (p < 0.001) at admission, 0.947 (p < 0.001) after discharge, and 0.960 (p = 0.002) at 3-months.

CONCLUSION

BNP levels and 6 MWT have good prognostic utility in ADHF patients, and thus may be beneficial in making therapeutic adjustments and taking precautionary measures in these patients.

Assessment of cardiovascular risk and physical activity: the role of cardiac-specific biomarkers in the general population and athletes

The first part of this Inter-Society Document describes the mechanisms involved in the development of cardiovascular diseases, particularly arterial hypertension, in adults and the elderly. It will also examine how consistent physical exercise during adolescence and adulthood can help maintain blood pressure levels and prevent progression to symptomatic heart failure. The discussion will include experimental and clinical evidence on the use of specific exercise programs for preventing and controlling cardiovascular diseases in adults and the elderly. In the second part, the clinical relevance of cardiac-specific biomarkers in assessing cardiovascular risk in the general adult population will be examined, with a focus on individuals engaged in sports activities. This section will review recent studies that suggest a significant role of biomarkers in assessing cardiovascular risk, particularly the presence of cardiac damage, in athletes who participate in high-intensity sports. Finally, the document will discuss the potential of using cardiac-specific biomarkers to monitor the effectiveness of personalized physical activity programs (Adapted Physical Activity, APA). These programs are prescribed for specific situations, such as chronic diseases or physical disabilities, including cardiovascular diseases. The purposes of this Inter-Society Document are the following: 1) to discuss the close pathophysiological relationship between physical activity levels (ranging from sedentary behavior to competitive sports), age categories (from adolescence to elderly age), and the development of cardiovascular diseases; 2) to review in detail the experimental and clinical evidences supporting the role of cardiac biomarkers in identifying athletes and individuals of general population at higher cardiovascular risk; 3) to stimulate scientific societies and organizations to develop specific multicenter studies that may take into account the role of cardiac biomarkers in subjects who follow specific exercise programs in order to monitor their cardiovascular risk.

Effects of a physical therapist-driven individualized hybrid model of the exercise component of cardiac rehabilitation on patient outcomes: a prospective single group, time-series design

PURPOSE

The aim of this prospective single group, time-series study was to determine the feasibility, adherence, and effectiveness of an individualized physical therapist (PT)-driven hybrid model of the exercise component of cardiac rehabilitation (CR) that uses a novel intensity-recovery progression protocol (IRPP) and cardiac testing template (CTT) to assess achieved heart rate (HR) intensity, HR recovery, and intensity-recovery total to guide treatment.

METHODS

Assessment of a questionnaire, treadmill 6-min walk (6MW), 1-min sit-to-stand (1STS), 1-min step, and 1-min agility square tests were assessed on 100 participants. Compared to traditional CR the 36-visit 1:1 hybrid model was individualized using the IRPP program and CTT.

RESULTS

Adherence was 35% (timely) and 44% (overall) completion. The per-protocol analysis (PPA) and intent-to-treat (ITT) analysis suggest significant improvement in objective assessments baseline to visit 15 (PPA = 11 of 14) (ITT = 13 of 14), baseline to visit 30 (PPA = 12 of 14) (ITT = 12 of 14) and visit 15 to visit 30 (PPA = 9 of 14) (ITT = 10 of 14). Improvement beyond the minimal clinically important difference (MCID) was 94.3% in the 6MW and 91.4% in the 1STS.

CONCLUSIONS

The PT-driven IRPP program was feasible in terms of adherence and safety, showing significant improvement in a majority of assessments. Analysis of HR using the CTT may help clinical decision making for progression in CR.Implications for rehabilitationCardiac rehabilitation (CR) is an underutilized means of improving health for people recovering from cardiac surgery.People recovering from cardiac surgery have complex reasons for why they choose to enroll in, drop out from, or complete a CR program.Reporting of outcomes in CR and progression in intensity is not often individualized.An individualized physical therapist driven CR program using both subjective and objective assessments may be successful at improving adherence and effectiveness in this cohort.

Six-minute walk test as clinical end point in cardiomyopathy clinical trials, including ATTR-CM: a systematic literature review

Aim: The six-minute walk test (6MWT) is a common measure of functional capacity in patients with heart failure (HF). Primary clinical study end points in cardiomyopathy (CM) trials, including transthyretin-mediated amyloidosis with CM (ATTR-CM), are often limited to hospitalization and mortality. Objective: To investigate the relationship between the 6MWT and hospitalization or mortality in CM, including ATTR-CM. Method: A PRISMA-guided systematic literature review was conducted using search terms for CM, 6MWT, hospitalization and mortality. Results: Forty-one studies were identified that reported 6MWT data and hospitalization or mortality data for patients with CM. The data suggest that a greater 6MWT distance is associated with a reduced risk of hospitalization or mortality in CM. Conclusion: The 6MWT is an accepted alternative end point in CM trials, including ATTR-CM.

Longitudinal strain correlates with 6-minute walk distance whereas ejection fraction and diastolic parameters do not

BACKGROUND

Impaired functional capacity is a common symptom in patients with heart failure. Standard measures of left ventricular (LV) function, such as ejection fraction (EF) and LV diastolic parameters, do not correlate with measures of functional capacity. The aim of this study is to determine if measures of global and regional LV strain better correlate with 6-minute walk distance than does EF or measures of LV diastolic function.

METHODS

120 patients referred to a cardiology clinic for evaluation of known or suspected heart failure were approached for enrollment. Of those 120 patients, 58 had an echocardiogram within 3 months of enrollment with images adequate for regional and global strain assessment, had no contra-indication to exercise testing, and had no previously documented non-cardiac explanation for dyspnea on exertion. In those 58 patients, 6-minute walk distance was measured, LV EF was determined with Simpson's biplane method, and global and regional longitudinal strain were measured with TomTec Image Arena 4.5.1 software.

RESULTS

LV EF had no correlation with 6-minute walk distance (r = 0.22, p = 0.09) even when controlling for age, gender, and BMI (p = 0.07). No measures of LV diastolic function (including E velocity, Deceleration Time, e' annular velocities, or E/e') had a correlation with 6-minute walk distance. Multiple measures of global and regional LV longitudinal systolic function had a correlation with 6-minute walk distance. Longitudinal strain of the basal LV segments had the strongest correlation with 6-minute walk distance (r= -0.36, p = 0.005), and correlation persisted after controlling for age, gender, BMI, and systolic blood pressure (p = 0.004).

CONCLUSIONS

Longitudinal strain correlates with a measure of functional capacity, but LVEF and traditional measures of LV diastolic dysfunction do not. Measures of longitudinal strain, especially in basal LV segments, will likely be an important marker of clinically relevant LV function.

Evaluating the Potential of a Novel Metabolic Syndrome Severity Score to Inform Exercise Interventions for People with Complex Chronic Conditions

Aims: Exercise interventions positively affect numerous cardiometabolic risk factors. To better evaluate the health effects of exercise training, it may be more appropriate to evaluate risk factors together. The Metabolic Syndrome Severity Score (MetSSS) is a composite score representing cardiometabolic risk. Purpose: To evaluate the relationships between physical activity, neuromuscular fitness, exercise capacity, and the MetSSS in a heterogenous sample of people with complex chronic disease. Material and Methods: Fifty-three people with kidney or liver disease and at least one feature of the metabolic syndrome (MetS) were included. Pearson correlations were conducted between physical activity, neuromuscular fitness, exercise capacity, and the MetSSS. Linear regressions were performed for multi-level categorical variables. Independent variables with an association with MetSSS (P ≤ 0.2) were included in a multiple regression analysis. Results: The 6-minute walk test (6MWT) distance was inversely and independently associated with MetSSS [standardized beta coefficient (β) = -0.31, P = 0.04]. No relationship was found between MetSSS and physical activity or neuromuscular fitness. Mean 6MWT in the highest tertile was 550 m (range: 505-620 m) and 346 m (range: 233-408 m) in the lowest. The analysis showed a medium-large between-group effect for the difference in MetSSS for the lowest and highest tertile of 6MWT [Eta squared (η2) = 0.16, P = 0.01]. Conclusions: Exercise capacity was inversely and independently associated with MetSSS in people with complex chronic disease. Clinical trials with exercise interventions are needed to further investigate if improvements in exercise capacity result in clinically significant changes in the MetSSS.

Six-minute walk test distance at time of hospital discharge is strongly and independently associated with all-cause mortality following cardiac surgery

We investigated the impact of distance covered in the six-minute walk test (6mWT) before being discharged from the hospital after cardiac surgery on the risk of all-cause mortality. Our study included 1127 patients who underwent cardiac surgery and then took part in a standardised physiotherapist-supervised inpatient rehabilitation programme during 2007-2017. The percentage of the predicted 6mWT distance, and the lower limit of normal distance was calculated based on individual patients' age, sex, and body mass index. We used Cox regression with adjustment for confounders to determine multivariable-adjusted hazard ratios (HRs) for mortality. Over a median follow-up period of 6.4 (IQR: 3.5-9.2) years, 15% (n = 169) patients died. We observed a strong and independent inverse association between 6mWT distance and mortality, with every 10 m increase in distance associated to a 4% reduction in mortality (HR: 0.96, 95% CI 0.94-0.98, P < 0.001). Those in the top tertile for predicted 6mWT performance had a 49% reduced risk of mortality (HR: 0.51, 95% CI 0.33-0.79) compared to those in the bottom tertile. Patients who met or exceeded the minimum normal 6mWT distance had 36% lower mortality risk (HR: 0.64, 95% CI 0.45-0.92) compared to those who did not meet this benchmark. Subgroup analysis showed that combined CABG and valve surgery patients walked less in the 6mWT compared to those undergoing isolated CABG or valve surgeries, with a significant association between 6mWT and mortality observed in the isolated procedure groups only. In conclusion, the longer the distance covered in the 6mWT before leaving the hospital, the lower the risk of mortality.

Dapagliflozin cardiovascular effects on end-stage kidney disease (DARE-ESKD-2) trial: rationale and design

Purpose

Sodium glucose co-transporter 2 inhibitors (SGLT2i) remarkably reduced the incidence of hospitalization for heart failure and cardiovascular death of conservatively managed chronic kidney disease. We hypothesized that adding SGLT2i to standard treatment would yield cardiovascular benefits also in end-stage kidney disease (ESKD) individuals on dialysis.

Methods

The DARE-ESKD-2 Trial (NCT05685394) is an ongoing, single-center, open-label, controlled trial aimed at assessing the cardiovascular effects of dapagliflozin in ESKD on dialysis. Eligible patients are adults on renal replacement therapy for more than 3 prior to enrollment. Exclusion criteria encompass pregnancy, liver failure, and current use of a SGLT2i. After signing an informed consent form, participants are randomized 1:1 to either dapagliflozin 10mg PO plus standard treatment or standard treatment alone for 6 months. Echocardiogram, anthropometry, blood sample collection, 6-min walk test, gait speed, and Kansas City Cardiomyopathy Questionnaire (KCCQ), are performed at baseline and at study termination. Participants are contacted monthly during treatment for outcomes disclosure. The primary endpoint of our study is the between-groups differences in posttreatment changes in plasma levels of N-terminal pro-B natriuretic peptide. Secondary endpoints include the differences between groups in the changes of echocardiography measurements, cardiopulmonary tests performance, body composition. The incidence of safety endpoints will also be diligently compared between study arms.

Conclusion

The DARE-ESKD-2 trial will provide unprecedented data on the cardiovascular safety and efficacy of SGLT2i in ESKD individuals on dialysis. This study will pave the grounds for improving clinical outcomes of dialysis recipients.

Clinical Outcomes with GLP-1 Receptor Agonists in Patients with Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) reduce the risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM). However, there remains uncertainty about the efficiency of GLP-1 RAs in patients with heart failure (HF).

METHODS

Randomized placebo-controlled trials (RCTs) that reported the effect of GLP-1 RAs on prognosis in patients with HF were identified by searching databases. The primary outcome was defined as MACE. Trail Sequential Analysis (TSA) was used to evaluate the reality and authenticity.

RESULTS

Nine RCTs involving 8920 patients with HF were included. GLP-1 RAs significantly reduced the risk of MACE compared with placebo (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.77-0.98) in HF coexisting with T2DM. The benefit was not observed in all-cause death (HR 0.99, 95% CI 0.84-1.15), hospitalization for heart failure (HR 1.04, 95% CI 0.89-1.22), cardiovascular death (HR 0.95, 95% CI 0.79-1.16), myocardial infarction (HR 0.88, 95% CI 0.71-1.08), stroke (HR 1.03, 95% CI 0.75-1.43) and death or hospitalization for HF (HR 1.07, 95% CI 0.78-1.46). GLP-1 RAs did not improve the change in LVEF (mean difference [MD]): - 0.86, p = 0.12, left-ventricular end-diastolic volume (LVEDV) (MD: 3.54, p = 0.11), left-ventricular end-systolic volume (LVESV) (MD: 2.78, p = 0.07) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) (MD: - 140.36, p = 0.08). However, GLP-1 RAs significantly increased the change in the 6-min walk test (MWT) distance (MD: 19.74, p = 0.002). In the subgroup analyses, human GLP-1 RAs, but not nonhuman GLP-1 RAs, reduced the risk of MACE in patients with HF (p interaction = 0.11). Grading of Recommendations Assessment, Development and Evaluation (GRADE) showed moderate certainty for MACE, all-cause death and hospitalization for HF. Trail Sequential Analysis revealed that there may be a high possibility of false positive results for MACE.

CONCLUSION

Compared with placebo, GLP-1 RAs may reduce the risk of MACE in patients with HF coexisting with T2DM, with a more significant efficiency of human GLP-1 RAs. More RCTs are needed to assess the cardiovascular benefits of GLP-1 RAs in HF, regardless of T2DM.

REGISTRATION

The protocol for this meta-analysis is registered on PROSPERO [CRD42022357886].

Effects of new hypoglycemic drugs on cardiac remodeling: a systematic review and network meta-analysis

BACKGROUND

In recent years, the incidence of diabetes mellitus has been increasing annually, and cardiovascular complications secondary to diabetes mellitus have become the leading cause of death in diabetic patients. Considering the high incidence of type 2 diabetes (T2DM) combined with cardiovascular disease (CVD), some new hypoglycemic agents with cardiovascular protective effects have attracted extensive attention. However, the specific role of these regimens in ventricular remodeling remains unknown. The purpose of this network meta-analysis was to compare the effects of sodium glucose cotransporter type 2 inhibitor (SGLT-2i), glucagon-like peptide 1 receptor agonist (GLP-1RA) and dipeptidyl peptidase-4 inhibitor (DPP-4i) on ventricular remodeling in patients with T2DM and/or CVD.

METHODS

Articles published prior to 24 August 2022 were retrieved in four electronic databases: the Cochrane Library, Embase, PubMed, and Web of Science. This meta-analysis included randomized controlled trials (RCTs) and a small number of cohort studies. The differences in mean changes of left ventricular ultrasonic parameters between the treatment and control groups were compared.

RESULTS

A total of 31 RCTs and 4 cohort studies involving 4322 patients were analyzed. GLP-1RA was more significantly associated with improvement in left ventricular end-systolic diameter (LVESD) [MD = -0.38 mm, 95% CI (-0.66, -0.10)] and LV mass index (LVMI) [MD = -1.07 g/m2, 95% CI (-1.71, -0.42)], but significantly decreased e' [MD = -0.43 cm/s 95% CI (-0.81, -0.04)]. DPP-4i was more strongly associated with improvement in e' [MD = 3.82 cm/s, 95% CI (2.92,4.7)] and E/e'[MD = -5.97 95% CI (-10.35, -1.59)], but significantly inhibited LV ejection fraction (LVEF) [MD = -0.89% 95% CI (-1.76, -0.03)]. SGLT-2i significantly improved LVMI [MD = -0.28 g/m2, 95% CI (-0.43, -0.12)] and LV end-diastolic diameter (LVEDD) [MD = -0.72 ml, 95% CI (-1.30, -0.14)] in the overall population, as well as E/e' and SBP in T2DM patients combined with CVD, without showing any negative effect on left ventricular function.

CONCLUSION

The results of the network meta-analysis provided high certainty to suggest that SGLT-2i may be more effective in cardiac remodeling compared to GLP-1RA and DPP-4i. While GLP-1RA and DPP-4i may have a tendency to improve cardiac systolic and diastolic function respectively. SGLT-2i is the most recommended drug for reversing ventricular remodeling in this meta-analysis.

Association Between Knee Extension Strength and Functional Capacity After Intensive Care Unit Discharge: A 6-Mo Prospective Cohort Study

INTRODUCTION

Assessing functional improvement after intensive care unit discharge is particularly challenging. The aim of this study was to measure the association between (1) changes in knee extension muscle strength or quadriceps femoris and rectus femoris muscle thickness and (2) changes in functionality/function-related measurements in post-intensive care unit patients.

METHODS

This prospective cohort study included adult patients without previous disability, consecutively selected after intensive care unit discharge. Some parameters, such as Short-Form 36, 6-min walking test, 1-min sit-to-stand, and Short Physical Performance Battery, were measured at baseline and 3 and 6 mos after discharge. Correlations were assessed and regression models were built to assess the association between evolution in knee extension strength or muscle thickness and evolution in functional tests.

RESULTS

Thirty patients completed the follow-up. Moderate correlation was found between knee extension strength change and Short-Form 36 physical functioning (correlation coefficient [ ρ ] = 0.53), 6-min walking test ( ρ = 0.38), 1-min sit-to-stand ( ρ = 0.52), and Short Physical Performance Battery ( ρ = 0.38). Baseline values and changes in knee extension strength moderately predicted evolution in Short-Form 36 physical functioning ( r2 = 0.32, P = 0.006). Changes in muscle thickness were overall not associated with changes in functional variables.

CONCLUSION

Changes in knee extension muscle strength may inform on functional progression over time after intensive care unit discharge, although confirmatory studies are needed.

Prognostic implications of six-minute walking distance in patients with heart failure with preserved ejection fraction

BACKGROUND

The incremental prognostic value of the six-minute walking test over conventional risk factors has not been evaluated in an adequate number of patients with heart failure with preserved ejection fraction (HFpEF). Therefore, we aimed to examine its prognostic significance using data from the FRAGILE-HF study.

METHODS AND RESULTS

A total of 513 older patients who were hospitalized for worsening heart failure were examined. Patients were classified according to the tertiles of six-minute walking distance (6MWD): T1 (<166 m), T2 (166-285 m), and T3 (≥285 m). During the 2-year follow-up period after discharge, 90 all-cause deaths occurred. Kaplan-Meier curves showed that the T1 group had significantly higher event rates than the other groups (log-rank p = 0.007). Cox proportional hazard analysis revealed that the T1 group was independently associated with lower survival, even after adjusting for conventional risk factors (T3: hazard ratio 1.79, 95% confidence interval 1.02-3.14, p = 0.042). The addition of the 6MWD to the conventional prognostic model showed a statistically significant incremental prognostic value (net reclassification improvement 0.27, 95% confidence interval 0.04-0.49; p = 0.019).

CONCLUSIONS

The 6MWD is associated with survival in patients with HFpEF and has an incremental prognostic value over conventional well-validated risk factors.

Predictive equation for six-minute walk test in Indian children, adolescents, and adults

Background

Post-COVID residual dysfunction has been observed in a majority of people, with reduction in cardiopulmonary endurance emerging as a primary symptom. The Six-Minute Walk Test is a simple, reliable, and valid test that is used routinely on people with chronic respiratory dysfunction. In the current COVID-19 pandemic situation, reference values and a predictive equation developed from a large sample across a large age group, from 6 to 75 years, will enable one to establish goals of treatment for post-COVID rehabilitation.

Methods

Following institutional ethical clearance, we recruited 1369 participants for the study (685 females and 684 males). Participants were classified according to biological age into group 1 (6-12 years), group 2 (13-17 years), group 3 (18-40 years), group 4 (41-65 years), and group 5 (>65 years). Informed consent was sought and participants were screened using a health history questionnaire. Demographic features, namely, age, height, weight, and body mass index (BMI) were noted. The Six-Minute Walk Test was administered as per ATS guidelines. Clinical parameters, namely, pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, and rate of perceived exertion were recorded.

Results

The Six-Minute Walk Test (6MWT) was significantly influenced by age and gender (r = 0.257, P = 0.00 and r = 0.501, P = 0.00, respectively). Walking distance was longest in 13-17-year-old males, whereas females demonstrated a linear decline after 12 years. In each age group, males walked a greater distance than females. Stepwise linear regression analysis was used to derive the following predictive equation: 6MWT = 491.93 - (2.148 × age) + (107.07 × gender) (females = 0, males = 1).

Conclusion

The study confirmed variability of the Six-Minute Walk Test, with age and gender being predominant predictors. Reference values, equations, and percentile charts generated from the study can be utilised to guide clinical decision-making while exercise prescription for patients with post COVID dysfunction.

Population analysis of mortality risk: Predictive models from passive monitors using motion sensors for 100,000 UK Biobank participants

Many studies have utilized physical activity for predicting mortality risk, using measures such as participant walk tests and self-reported walking pace. The rise of passive monitors to measure participant activity without requiring specific actions opens the possibility for population level analysis. We have developed novel technology for this predictive health monitoring, using limited sensor inputs. In previous studies, we validated these models in clinical experiments with carried smartphones, using only their embedded accelerometers as motion sensors. Using smartphones as passive monitors for population measurement is critically important for health equity, since they are already ubiquitous in high-income countries and increasingly common in low-income countries. Our current study simulates smartphone data by extracting walking window inputs from wrist worn sensors. To analyze a population at national scale, we studied 100,000 participants in the UK Biobank who wore activity monitors with motion sensors for 1 week. This national cohort is demographically representative of the UK population, and this dataset represents the largest such available sensor record. We characterized participant motion during normal activities, including daily living equivalent of timed walk tests. We then compute walking intensity from sensor data, as input to survival analysis. Simulating passive smartphone monitoring, we validated predictive models using only sensors and demographics. This resulted in C-index of 0.76 for 1-year risk decreasing to 0.73 for 5-year. A minimum set of sensor features achieves C-index of 0.72 for 5-year risk, which is similar accuracy to other studies using methods not achievable with smartphone sensors. The smallest minimum model uses average acceleration, which has predictive value independent of demographics of age and sex, similar to physical measures of gait speed. Our results show passive measures with motion sensors can achieve similar accuracy to active measures of gait speed and walk pace, which utilize physical walk tests and self-reported questionnaires.

The Pre-Discharge Oxygen Uptake Efficiency Slope Predicts One-Year Cardiovascular Events in Acute Decompensated Heart Failure Patients

(1) Background: Heart failure is a complex disease leading to functional disability. Cardiopulmonary exercise testing (CPET) is the gold standard in assessing aerobic capacity and formulating function-based prognostic stratification; however, patients with acute heart failure after medical treatment usually remain with markedly reduced exercise capacity, leading to early termination of CPET with submaximal testing results. The current study aimed to assess the cardiorespiratory fitness and characteristics of CPET variables of patients after acute heart failure treatment and determine potential CPET variables with prognostic value. (2) Methods: We recruited patients during hospitalization after management of acute heart failure, and pre-discharge CPET was performed. All enrolled patients were followed for one year for major adverse cardiovascular events (MACE). (3) Results: 85 patients were enrolled, with average left ventricular ejection fraction of 30.52%, and peak oxygen consumption of 10.85 mL/min/kg at baseline. The one-year MACE was 50%. Oxygen uptake efficiency slope (OUES) was a significant event predictor, with lower one-year MACE in those with OUES ≥ 1.25 (p < 0.001). Cox regression analysis showed a 5.421-fold increased risk of MACE in those with OUES < 1.25 (p = 0.004). (4) Conclusions: The current results suggested OUES is a significant prognostic indicator in patients with acute heart failure. This also emphasized the critical role of CPET in patients with heart failure for prognostic stratification.

Systems Pharmacology-Based Strategy to Investigate Pharmacological Mechanisms of Total Flavonoids in Dracocephalum moldavica on Chronic Heart Failure

Heart failure (HF) is a clinical syndrome of cardiac insufficiency caused by abnormalities in cardiac structure and function that arise for various reasons, and it is the final stage of most cardiovascular diseases’ progression. Total flavonoid extract from Dracocephalum moldavica L. (TFDM) has many pharmacological and biological roles, such as cardioprotective, neuroprotective, anti-atherogenic, antihypertensive, anti-diabetic, anti-inflammatory, antioxidant, etc. However, its effect on HF and its molecular mechanism are still unclear. In this study, we used systems pharmacology and an animal model of HF to investigate the cardioprotective effect of TFDM and its molecular mechanism. Eleven compounds in TFDM were obtained from the literature, and 114 overlapping genes related to TFDM and HF were collected from several databases. A PPI network and C-T network were established, and GO enrichment analysis and KEGG pathway analysis were performed. The top targets from the PPI network and C-T network were validated using molecular docking. The pharmacological activity was investigated in an HFpEF (heart failure with preserved ejection fraction) mouse model. This study shows that TFDM has a protective effect on HFpEF, and its protective mechanism may be related to the regulation of proinflammatory cytokines, apoptosis-related genes, fibrosis-related genes, etc. Collectively, this study offers new insights for researchers to understand the protective effect and mechanism of TFDM against HFpEF using a network pharmacology method and a murine model of HFpEF, which suggest that TFDM is a promising therapy for HFpEF in the clinic.

A Mobile Application to Perform the Six-Minute Walk Test (6MWT) at Home: A Random Walk in the Park Is as Accurate as a Standardized 6MWT

The six-minute walk test (6MWT) provides an objective measurement of a person’s functional exercise capacity. In this study, we developed a smartphone application that allows cardiac patients to do a self-administered 6MWT at home on a random trajectory. In a prospective study with 102 cardiovascular disease patients, we aimed to identify the optimal circumstances to perform a smartphone-measured 6MWT, i.e., the best algorithm and the best position to wear the smartphone during the test. Furthermore, we investigated if a random walk is as accurate as a standardized 6MWT. When considering both the reliability and accuracy of the distance walked, the best circumstances to perform a standardized smartphone-measured 6MWT are wearing the smartphone in a strap around the patient’s arm and using an algorithm that relies on the processed step count data acquired from Google Fit. Furthermore, we demonstrated that a smartphone-measured walk along a random trajectory is as accurate to determine a cardiac patient’s functional exercise capacity as a standardized (smartphone-measured) 6MWT. We conclude this paper by presenting how our 6MWT application can be used in a home setting to remotely follow up on cardiac patients’ functional exercise capacity.

Effect of exercise on functional capacity in patients with advanced cancer: A meta-analysis of randomized controlled trials

PURPOSE

To determine the impact of exercise on functional capacity, measured through the "Six minutes walking test" (6MWT) in patients with advanced cancer stage.

METHODS

Systematic research on PubMed, Cochrane Library, and SportDiscus was conducted. Randomized controlled trials were eligible if they examined the effect of exercise on 6MWT.

RESULTS

Overall, a total of ten trials were included in the primary analysis. Compared to the controls, the exercise intervention was associated with an increase in functional capacity (+20.86 m; CI: -5.90 to 47.72, p = 0.12) although not reaching the statistical significance. Sensitivity analysis revealed an improvement for studies proposing a supervised exercise intervention towards the statistical significance. Few adverse events were associated with exercise training, and the median withdrawals rate was 17%.

CONCLUSIONS

Exercise may have a beneficial role on functional capacity in patients with advanced cancer, especially if supervised.

Home-based and remote functional exercise testing in cardiac conditions, during the covid-19 pandemic and beyond: a systematic review

BACKGROUND

With the change in healthcare to one that adopts a greater reliance on remote delivery, guidance regarding functional exercise testing, either in-person in the home or performed remotely, is urgently needed for people with cardiac conditions.

OBJECTIVES

To identify functional exercise tests that have been conducted in the home or remotely in patients with cardiac conditions.

DATA SOURCES

A search was undertaken across four electronic databases and grey literature for English language publications without time restrictions.

STUDY ELIGIBILITY CRITERIA

Studies of any designs were selected if they reported an exercise test conducted at home or remotely in patients with cardiac conditions.

STUDY APPRAISAL AND SYNTHESIS

Studies were independently screened and graded by two reviewers according to the Downs and Black checklist. A narrative synthesis of the included studies was undertaken.

RESULTS

Five studies (six articles) were included, with a total of 438 patients with cardiac conditions. Tests used at home or remotely were the 6-minute walk test (6MWT, five studies) and the timed up and go test (one study). No studies reported the use of step tests in the home or remotely. The 6MWTs were administered via a smartphone application, rope, videoconferencing and accelerometer and proved to be feasible, valid and reliable.

CONCLUSIONS

Despite a marked demand for home-based exercise programs, the 6MWT remains the most commonly administered functional exercise test for people with cardiac conditions. Surprisingly few studies have explored alternative tests for this patient population that may be more suitable for home or remote performance.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO: CRD42020219512.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Factors associated with lack of improvement in submaximal exercise capacity of patients with heart failure

AIMS

Improvement in exercise capacity is the primary goal of physical activity programmes for patients with heart failure (HF). Although activity programmes are effective for some patients, others do not benefit. Identifying factors related to a lack of improvement in submaximal exercise capacity may help us interpret findings and design new interventions. The aim of this study is to identify factors contributing to a lack of improvement in submaximal exercise capacity 3 months after physical activity advice or an exergame intervention in patients with HF. Additionally, we aimed to assess differences in lack of improvement in submaximal exercise capacity of patients whose baseline exercise capacity predicted a worse compared with better prognosis of HF.

METHODS AND RESULTS

This secondary analysis of the HF-Wii study analysed baseline and 3 month data of the 6 min walk test (6MWT) from 480 patients (mean age 67 years, 72% male). Data were analysed separately in patients with a pre-defined 6 min walking distance at baseline of <300 m (n = 79) and ≥300 m (n = 401). Among patients with a baseline 6MWT of ≥300 m, 18% had deteriorated submaximal exercise capacity. In the multiple logistic regression analysis, lower baseline levels of self-reported physical activity [odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60-0.97], lower baseline levels of cognitive function (OR = 0.87, 95%CI = 0.79-0.96) were significantly associated with lack of improvement in exercise capacity at 3 months. Not randomized to exergaming (OR = 0.63, 95%CI = 0.37-1.09) was likely (P = 0.097) to be associated with lack of improvement in exercise capacity at 3 months. Among the 79 patients with baseline 6MWT of <300 m, 41% (n = 32) did not improve 6MWT distance at 3 months. Independent predictors for the lack of improvement for 6MWT were New York Heart Association class III/IV (OR = 4.68, 95%CI = 1.08-20.35), higher levels of serum creatinine (OR = 1.02, 95%CI = 1.003-1.03), lower cognitive function (OR = 0.86, 95%CI = 0.75-0.99), and fewer anxiety symptoms (OR = 0.84, 95%CI = 0.72-0.98).

CONCLUSIONS

Lower self-reported physical activity and cognitive impairment predict lack of improvement in submaximal exercise capacity in HF patients. Patients who have a worse prognosis (score <300 m at the 6MWT) are often frail and gain less in exercise capacity. These patients may need a more comprehensive approach to have an effect on exercise capacity, including an individually tailored exercise programme with aerobic exercise (if tolerated) and strength exercises.

6 min walk test is a strong independent predictor of death in outpatients with heart failure

AIMS

The aim of this study was to examine the prognostic value of the 6 min walk test (6MWT) in a large cohort of outpatients with heart failure.

METHODS AND RESULTS

A total of 5519 outpatients with heart failure from the National Norwegian Heart Failure Registry (NNHFR), which is part of the Norwegian Cardiovascular Disease Registry, were included in this analysis. The NNHFR recommended the use of the 6MWT for prognostic assessment of all patients included in the registry. Patients were categorized according to the 6MWT: Category 1 walked the longest and Category 3 the shortest. During a median (25th-75th percentiles) follow-up of 24 (14-36), 12.9% of the patients died. Patients in Category 3 had the overall worst outcome than had patients in Categories 1 and 2. 6MWT used as a continuous variable was a highly significant independent predictor for mortality in a multivariate Cox regression model adjusted for 16 other variables with a hazard ratio of 0.979 [(95% confidence interval 0.972-0.986), P < 0.001]. The four most important predictors for mortality were active cancer in the last 5 years, age, 6MWT, and natriuretic peptides (all P < 0.001).

CONCLUSIONS

6MWT is a strong independent predictor of mortality in outpatients with HF. The findings support the use of the 6MWT in the prognostic assessment of patients with HF irrespective of HF aetiology.