Systematic review of the effect of aerobic and resistance exercise training on systemic brain natriuretic peptide (BNP) and N-terminal BNP expression in heart failure patients

Effect of rehabilitation on renal outcomes after acute kidney injury associated with cardiovascular disease: a retrospective analysis

BACKGROUND

Acute kidney injury (AKI) incidence is extremely high worldwide, and patients who develop AKI are at increased risk of developing chronic kidney disease (CKD), CKD progression, and end-stage kidney disease (ESKD). However, there is no established treatment strategy for AKI. Based on the idea that exercise has a stabilizing effect on hemodynamics, we hypothesized that rehabilitation would have beneficial renal outcomes in patients with AKI associated with cardiovascular disease. Therefore, the purpose of this study was to determine whether rehabilitation can stabilize hemodynamics and positively impact renal outcomes in patients with AKI associated with cardiovascular disease.

METHODS

In total, 107 patients with AKI associated with cardiovascular disease were enrolled in this single-center retrospective study and were either assigned to the exposure group (n = 36), which received rehabilitation at least once a week for at least 8 consecutive weeks, or to the control group (n = 71). Estimated glomerular filtration rate was assessed at baseline before admission, at the lowest value during hospitalization, and at 3, 12, and 24 months after enrolment. Trends over time (group × time) between the two groups were compared using generalized estimating equations. Moreover, congestive status was assessed by amino-terminal pro-B-type natriuretic peptide (NT-proBNP), and the effect of rehabilitation on congestion improvement was investigated using logistical regression analysis.

RESULTS

The time course of renal function after AKI, from baseline to each of the three timepoints suggested significant differences between the two groups (p < 0.01). However, there was no significant difference between the two groups at any time point in terms of percentage of patients who experienced a 40% estimated glomerular filtration rate reduction from that at baseline. The proportion of patients with improved congestion was significantly higher in the exposure group compared with that in the control group (p = 0.018). Logistic regression analysis showed that rehabilitation was significantly associated with improved congestion (p = 0.021, OR: 0.260, 95%CI: 0.083-0.815).

CONCLUSION

Our results suggest that rehabilitation in patients with AKI associated with cardiovascular disease correlates with an improvement in congestion and may have a positive effect on the course of renal function.

Resistance is not futile: a systematic review of the benefits, mechanisms and safety of resistance training in people with heart failure

Exercise offers many physical and health benefits to people with heart failure (CHF), but aerobic training (AT) predominates published literature. Resistance training (RT) provides additional and complementary health benefits to AT in people with CHF; we aimed to elucidate specific health benefits accrued, the mechanism of effect and safety of RT. We conducted a systematic search for RT randomised, controlled trials in people with CHF, up until August 30, 2023. RT offers several benefits including improved physical function (peak VO2 and 6MWD), quality of life, cardiac systolic and diastolic function, endothelial blood vessel function, muscle strength, anti-inflammatory muscle markers, appetite and serious event rates. RT is beneficial and improves peak VO2 and 6MWD, partly restores normal muscle fibre profile and decreases inflammation. In turn this leads to a reduced risk or impact of sarcopenia/cachexia via effect on appetite. The positive impact on quality of life and performance of activities of daily living is related to improved function, which in turn improves prognosis. RT appears to be safe with only one serious event reported and no deaths. Nevertheless, few events reported to date limit robust analysis. RT appears to be safe and offers health benefits to people with CHF. RT modifies the adverse muscle phenotype profile present in people with CHF and it appears safe. Starting slowly with RT and increasing load to 80% of 1 repetition maximum (RM) appears to offer optimal benefit.

Exercise training and high-sensitivity cardiac troponin-I in patients with heart failure with reduced ejection fraction

AIMS

The aims of this sub-study of the SMARTEX trial were (1) to evaluate the effects of a 12-week exercise training programme on serum levels of high sensitivity cardiac troponin I (hs-cTnI) in patients with moderate chronic heart failure (CHF), in New York Heart Association class II-III with reduced ejection fraction (HFrEF) and (2) to explore the associations with left ventricular remodelling, functional capacity and filling pressures measured with N-terminal pro brain natriuretic peptide (NT-proBNP).

METHODS AND RESULTS

In this sub-study, 196 patients were randomly assigned to high intensity interval training (HIIT, n = 70), moderate continuous training (MCT, n = 59) or recommendation of regular exercise (RRE), (n = 67) for 12 weeks. To reveal potential difference between structured intervention and control, HIIT and MCT groups were merged and named supervised exercise training (SET) group. The RRE group constituted the control group (CG). To avoid contributing factors to myocardial injury, we also evaluated changes in patients without additional co-morbidities (atrial fibrillation, hypertension, diabetes mellitus, and chronic obstructive pulmonary disease). The relationship between hs-cTnI and left ventricular end-diastolic diameter (LVEDD), VO2peak, and NT-proBNP was analysed by linear mixed models. At 12 weeks, Hs-cTnI levels were modestly but significantly reduced in the SET group from median 11.9 ng/L (interquartile ratio, IQR 7.1-21.8) to 11.5 ng/L (IQR 7.0-20.7), P = 0.030. There was no between-group difference (SET vs. CG, P = 0.116). There was a numerical but not significant reduction in hs-cTnI for the whole population (P = 0.067) after 12 weeks. For the sub-group of patients without additional co-morbidities, there was a significant between-group difference: SET group (delta -1.2 ng/L, IQR -2.7 to 0.1) versus CG (delta -0.1 ng/L, IQR -0.4 to 0.7), P = 0.007. In the SET group, hs-cTnI changed from 10.9 ng/L (IQR 6.0-22.7) to 9.2 ng/L (IQR 5.2-20.5) (P = 0.002), whereas there was no change in the CG (6.4 to 5.8 ng/L, P = 0.64). Changes in hs-cTnI (all patients) were significantly associated with changes in; LVEDD, VO2peak, and NT-proBNP, respectively.

CONCLUSIONS

In patients with stable HFrEF, 12 weeks of structured exercise intervention was associated with a modest, but significant reduction of hs-cTnI. There was no significant difference between intervention group and control group. In the sub-group of patients without additional co-morbidities, this difference was highly significant. The alterations in hs-cTnI were associated with reduction of LVEDD and natriuretic peptide concentrations as well as improved functional capacity.

Impact of high intensity interval and moderate continuous training on plasma ratios of ProBNP1-108/BNP1-32 and NT-pro-BNP1-76/BNP1-32 after coronary artery bypass grafting surgery

Background: ProBNP1-108/BNP1-32, and NT-pro-BNP1-76/BNP1-32 ratios are significant indices for predicting complications after coronary artery bypass grafting (CABG) surgery. However, the effect of aerobic training types on these biomarkers has not been fully understood. So, the current study aimed to determine the impact of aerobic interval and continuous training programs on plasma ratios of ProBNP1-108/BNP1-32 and NT-pro-BNP1-76/BNP1-32 after coronary artery bypass grafting surgery. Method: 36 patients were selected purposive (27 men and 9 women with mean of age 60.32 ± 5.81 years, height 164.64 ± 9.25 cm, weight 73.86 ± 14.23 kg, fat 32.30 ± 4.28, SBP 142.67 ± 6.49, DBP 84.5 ± 5.16 mmHg in seated position at rest situation and functional capacity of 7.08 ± 2.49 METs) and then divided randomly into three groups: control (C) group (without training program) moderate continuous training (MCT) and high intensity interval training (HIIT) (exercise training program was performed 3 days/week for 8 weeks) with intensities 65%-80% and 80%-95% of reserve heart rate in order. Blood samples were taken 48 h before the first session and 48 h after the last training session to measure the plasma levels of ProBNP1-108, corin enzyme, BNP1-32, and NT-pro-BNP1-76 using the enzyme-linked immunosorbent assay (ELISA) technique. Wilcoxin and kruskal wallis tests were used for analyzing data. Results: The plasma corin enzyme was increased, and the ratios of proBNP1-108/BNP1-32 and NT-pro-BNP1-76/BNP1-32 were reduced in both training groups in compared with control group (p = 0.004, p = 0000, p = 0.016, p = 0.003, p = 0.009, and p = 0.016) when there was no significant difference was found between training groups (p = 0.074, p = 450, and p = 0.295). Conclusion: Both high intensity interval training and moderate continuous training in compared with inactivity have positive effects on ratios of ProBNP1-108/BNP1-32, NT-pro-BNP1-76/BNP1-32 and could be effective to promote the health of coronary arteries and prevention of HF in post-CABG patients.

The role of exercise training on cardiovascular peptides in patients with heart failure: A systematic review and meta-analysis

Background

The purpose of this systematic review & meta-analysis was to determine the roles of aerobic, resistance or concurrent exercises vs. control (CON) group on B-type natriuretic peptide (BNP) and N-terminal-pro hormone BNP (NT-proBNP) in patients with heart failure.

Methods

The electronic databases of PubMed, Scopus, Web of Science, and Google Scholar were searched up to May 2022 for aerobic vs. CON, resistance vs. CON, and concurrent vs. CON studies on circulating (serum or plasma) levels of BNP and NT-proBNP in patients with heart failure. Non-randomized or randomized controlled trial studies were included. Standardized mean difference (SMD) and 95% confidence intervals (95% CIs) were calculated. This systematic review & meta-analysis was registered in PROSPERO at the University of York with the registration number [CRD42021271632].

Results

A total of 28 articles (37 intervention arms), 26 aerobic intervention arms, 3 resistance intervention arms, and 8 concurrent intervention arms were included. A total of 2563 participants (exercise groups = 1350 and CON groups = 1213) were included. Exercise training significantly decreased NT-proBNP marker [-0.229 (SMD and 95% CI: 0.386 to -0.071), p = 0.005], irrespective of overweight/obesity status. Analysis of subgroup by type of exercise training revealed that there was a significant reduction in the NT-proBNP marker for aerobic exercise group compared to the CON group [-0.336 (SMD and 95% CI: 0.555 to -0.105), p = 0.004], whereas concurrent exercise did not show significant changes in the NT-proBNP marker [-0.134 (SMD and 95% CI: 0.350 to 0.083), p = 0.227]. In addition, exercise training did not significantly change the BNP marker [-0.122 (SMD and 95% CI: 0.322 to 0.079), p = 0.235].

Conclusions

The results suggested that exercise training, especially aerobic exercise can be improved the NT-proBNP concentrations in patients with HF (irrespective of overweight/obesity status), which may be a sign of positive physiological adaptations to aerobic exercise.

Does group-based high-intensity aerobic interval training improve the inflammatory status in patients with chronic heart failure?

BACKGROUND

Chronic heart failure (CHF) is a multifaceted syndrome associated with endothelial dysfunction and increased inflammation. Despite the existing controversies regarding the appropriate training modality, it is widely accepted that supervised cardiac rehabilitation (CR) interventions lead to proinflammatory biomarkers reduction and cellular adhesion molecules in patients with CHF.

AIM

The aim of the study was to quantify the effects of 12-week group-based high-intensity aerobic interval training (HIAIT)/modified group-based HIAIT intervention (m-Ullevaal) vs. moderate continuous training (MICT) on serum levels of proinflammatory biomarkers.

DESIGN

Single-blind, two-arm, prospective randomized controlled trial conducted on CHF outpatients performing group-based CR interventions throughout a 12-week period.

SETTING

The setting of the study was the Medical Center of Outpatient Rehabilitation and Sports Medicine, Plovdiv, Bulgaria.

POPULATION

The population included a total of 120 outpatients of both genders, mean age of 63.73±6.68 years, with stable CHF (NYHA classes II to IIIB, were randomly assigned to HIAIT/ m-Ullevaal (N.=60) or to MICT (N.=60) group.

METHODS

Functional exercise capacity (FEC) of the eligible subjects was evaluated through 6-minute walk test (6MWT) and peak oxygen uptake. Blood samples were drawn at baseline, after 12 weeks follow-up for analyses of C-reactive protein (CRP), tumor necrosis factor-α (TNFα) and cellular adhesion molecules (CAM).

RESULTS

Significant decreases in the serum levels of CRP (P=0.029), TNF-α (P=0.036), and vascular cell adhesion molecule-1 (VCAM-1) (P=0.040), were observed after 48 training sessions in the group-based HIAIT/m-Ullevaal intervention, except for intercellular adhesion molecule-1 (ICAM-1), which was higher in the MICT (P=0.034). FEC was significantly inversely related to CRP (r=-0.72, P<0.05), and the levels of VCAM-1 (r=-0.68, P<0.05).

CONCLUSIONS

Both group-based CR interventions (HIAIT/m-Ullevaal and MICT) significantly reduced the serum levels of CRP, TNF- α, ICAM-1 and VCAM in patients with CHF. However, selected proinflammatory biomarkers changes and CAMs favorably decreased in the group-based HIAIT/m-Ullevaal intervention. The responses on serum levels of proinflammatory biomarkers and CAMs are dependent upon the type, intensity, and CR intervention duration.

CLINICAL REHABILITATION IMPACT

The group-based high-intensity aerobic interval training reduces significantly the proinflammatory biomarkers and cellular adhesion molecules in patients with chronic heart failure.

Effects of exercise training in heart failure with preserved ejection fraction: an updated systematic literature review

Physical activity is associated with a lower risk of adverse cardiovascular outcomes, including heart failure (HF). Exercise training is a class IA level recommendation in patients with stable HF, but its impact is less clear in heart failure with preserved ejection fraction (HFpEF). The aim of this study was to analyze the effects of the exercise training on cardiovascular outcomes in patients with HFpEF. A systematic literature search was conducted on the main electronic databases, proceedings of major meetings, and reference lists of the identified studies, using specific terms for only English language studies published between 2000 and 2018. We followed the PRISMA to perform our review. Quality of studies was also assessed. The systematic review identified 9 studies on 348 patients, of moderate (n = 2) to good (n = 7) quality. The training consisted of a combination of supervised in-hospital and home-based outpatient programs, including aerobic exercise, endurance and resistance training, walking, and treadmill and bicycle ergometer. Most of the protocols ranged 12-16 weeks, with a frequency of 2-3 sessions weekly, lasting 20-60 min per session. There were significant improvements in peak oxygen uptake, 6-min walking test distance, and ventilatory threshold, whereas quality of life and echocardiographic parameters improved only in some studies. Endothelial function/arterial stiffness remained unchanged. No adverse events were reported. Appropriate exercise programs are able to get a favorable cardiovascular outcome in patients with HFpEF. This could also benefit in terms of quality of life, even if more controversial. Further researches are necessary.

Intra-individual differences in the effect of endurance versus resistance training on vascular function: A cross-over study

We used a within‐subject, cross‐over design study to compare the impact of 4‐weeks' resistance (RT) versus endurance (END) training on vascular function. We subsequently explored the association of intra‐individual effects of RT versus END on vascular function with a single nucleotide polymorphism (SNP) of the NOS3 gene. Thirty‐five healthy males (21 ± 2 years old) were genotyped for the NOS3 rs2070744 SNP and completed both training modalities. Participants completed 12 sessions over a 4‐week period, either RT (leg‐extension) or END (cycling) training in a randomized, balanced cross‐over design with a 3‐week washout period. Participants performed peak oxygen uptake (peak VO₂) and leg‐extension single‐repetition maximum (1‐RM) testing, and vascular function assessment using flow‐mediated dilation (FMD) on 3 separated days pre/post‐training. Peak VO₂ increased after END (p < 0.001), while 1‐RM increased after RT (p < 0.001). FMD improved after 4‐weeks’ training (time effect: p = 0.006), with no difference between exercise modalities (interaction effect: p = 0.92). No relation was found between individual changes (delta, pre‐post) in FMD to both types of training (R² = 0.06, p = 0.14). Intra‐individual changes in FMD following END and RT were associated with the NOS3 SNP, with TT homozygotes significantly favoring only END (p = 0.016) and TC/CC tending to favor RT only (p = 0.056). Although both training modes improved vascular function, significant intra‐individual variation in the adaptation of FMD was found. The association with NOS3 genotype suggests a genetic predisposition to FMD adapting to a specific mode of chronic exercise. This study therefore provides novel evidence for personalized exercise training to optimize vascular health.

The role of cardiac rehabilitation using exercise to decrease natriuretic peptide levels in non-surgical patients: a systematic review

Exercise is recommended in patients with cardiac failure. In the perioperative patient, exercise is also gaining popularity as a form of prehabilitation. In this meta-analysis, we examine if exercise is able to reduce natriuretic peptide levels. Natriuretic peptide (NP) has strong prognostic ability in identifying patients who will develop adverse postoperative cardiovascular outcomes. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcomes were to determine whether exercise therapy was effective in reducing NP levels as compared to control group, the shortest time period required to reduce NP levels after exercise therapy, and whether reducing NP levels decreased morbidity and mortality. Full texts of 16 trials were retrieved for this review. Exercise therapy showed a significant reduction in natriuretic peptide levels between the intervention and control groups (SMD - 0.45, 95% CI - 0.88 to - 0.03) with significant heterogeneity between the included trials. This was also shown in the within a 12-week period.

Endurance Exercise Training Attenuates Natriuretic Peptide Release During Maximal Effort Exercise: Biochemical Correlates of the "Athlete's Heart"

Endurance exercise training (ET) stimulates eccentric left ventricular hypertrophy (LVH) with left atrial dilation. To date, the biochemical correlates of exercise-induced cardiac remodelling (EICR) remain incompletely understood. Collegiate male rowers (n = 9) were studied with echocardiography and maximal-effort cardiopulmonary exercise testing (MECPET) before and after 90 days of ET intensification. Mid-regional pro-atrial natriuretic peptide (MR-proANP), N-terminal pro B-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hscTn) were measured at rest, peak MECPET, and 60 minutes post-MECPET at both study time points. ET resulted in eccentric LVH (LV mass = 102 ± 8 vs. 110 ± 11 g/m², p=0.001; relative wall thickness = 0.36 ± 0.04 vs. 0.37 ± 0.04, p=0.103), left atrial dilation (74 ± 18 vs. 84 ± 15 mL, p<0.001), and increased exercise capacity (peak VO₂ = 53.0 ± 5.9 vs. 67.3 ± 8.2 ml/kg/min, p<0.001). LV remodelling was characterized by an approximate 7% increase in LV wall thickness but only a 3% increase in LV chamber radius. The magnitude of natriuretic peptide release, examined as percent change from rest to peak exercise, was significantly lower for both MR-proANP (115 [95, 127]% vs. 78 [59, 87]%, p=0.04) and NT-proBNP (46 [31, 70]% vs. 27 [25, 37]%, p=0.02) after ET. Rowing-based ET and corollary EICR appear to result in an attenuated natriuretic peptide response to maximal effort exercise. This may occur as a function of decreased cardiac wall stress after ET as seen by disproportionally higher ventricular wall thickening compared to chamber dilation.

Effect of exercise therapy on established and emerging circulating biomarkers in patients with heart failure: a systematic review and meta-analysis

Background

Biomarkers are important in the diagnosis, risk stratification and management of patients with heart failure (HF). The established biomarkers of myocardial stretch, brain natriuretic peptide (BNP) and amino (N) portion of BNP (NT-proBNP) have been extensively studied, and early analyses have demonstrated response to exercise training. Several other biomarkers have been identified over the last decade and may provide valuable and complementary information which may guide treatment strategies, including exercise therapy.

Methods

A systematic search of PubMed, EMBASE and Cochrane Trials Register to 31 October 2017 was conducted for exercise-based rehabilitation trials in HF. Randomised and controlled trials that reported biomarkers, BNP, NT-proBNP, soluble ST2, galectin-3, mid-regional atrial natriuretic peptide, mid-regional adrenomedullin and copeptin, were included.

Results

Forty-three studies were included in the systematic review, with 27 studies suitable for meta-analyses. Data pooling was only possible for NT-proBNP and BNP. Meta-analyses of conventional training studies demonstrated a statistically significant improvement in NT-proBNP (pmol/L); mean difference (MD) −32.80 (95% CI −56.19 to −9.42), p=0.006 and in BNP (pmol/L); MD −17.17 (95% CI −29.56 to −4.78), p=0.007. Pooled data of non-conventional training failed to demonstrate any statistically significant improvements.

Conclusion

Pooled data indicated a favourable effect of conventional exercise therapy on the established biomarkers, NT-proBNP and BNP; however, this was in contrast to a number of studies that could not be pooled. Limited evidence exists as to the effect of exercise training on emerging biomarkers.

Efficacy of combined endurance-resistance training versus endurance training in patients with heart failure after percutaneous coronary intervention: A randomized controlled trial

Background:

This study aimed to compare the effects of combined endurance-resistance training (CT) versus endurance training (ET) on some cardiovascular markers in patients with heart failure after percutaneous coronary intervention (PCI).

Materials and Methods:

The study applied a randomized, controlled design in which 75 patients with heart failure who had undergone PCI were randomly assigned to one of three groups: ET, CT, and control. The ET group performed ET for 45 min, three times a week for 7 weeks. The CT group performed the same ET for 30 min followed by a resistance exercise protocol. The control group received usual care. Functional capacity, N-terminal pro-brain natriuretic peptide (NT-pro BNP), and high sensitivity C-reactive protein (hs-CRP) levels were measured.

Results:

After the intervention, functional capacity was improved (P < 0.001) and NT-pro BNP level was significantly reduced (P = 0.004 in the CT group, P = 0.002 in the ET group). Hs-CRP level was significantly reduced only in the ET group (P = 0.030). The control group showed no significant changes in any cardiovascular parameters (P ≥ 0.05). Changes in functional capacity (P < 0.001) in both training groups were significantly different from the control group. No significant differences were found between the ET and CT groups regarding changes in all outcomes after exercise training (P ≥ 0.05).

Conclusion:

Exercise training is safe and feasible in post-PCI patients, even in those with reduced ejection fraction. CT was as effective as ET in reducing NT-pro BNP level and improving functional capacity in heart failure patients after PCI.

Eficácia do treinamento resistido na melhora da capacidade funcional e na qualidade de vida de pacientes com insuficiência cardíaca: uma revisão sistemática e metanálise

RESUMO Avaliou-se a eficácia do treinamento resistido (TR) na melhoria da capacidade funcional (CF) e na qualidade de vida (QV) de pacientes com insuficiência cardíaca (IC). Uma busca eletrônica foi realizada em bancos de dados (PubMed, MEDLINE, Scopus, Web of Science, CINAHL, LILACS e Cochrane), sem restrições de linguagem ou ano de publicação, utilizando como descritores “heart failure”, “resistance training”, “exercise tolerance”, “quality of life”, “fatigue”, “dyspnea” e “muscle strength”. Foram incluídos ensaios clínicos, com amostra composta por indivíduos com IC, classe funcional I, II ou III da New York Heart Association; idade média <65 anos, sedentários, clinicamente estáveis e farmacologicamente otimizados; com fração de ejeção (FE) <45% do predito. A intervenção deveria ser o TR exclusivo. A descrição dos aspectos metodológicos pelo risco de viés e uma metanálise com uma análise por subgrupo foram executados. Sete estudos foram incluídos para análise qualitativa. O nível de concordância (índice kappa - k) entre os pesquisadores foi k=0,74. A maioria dos estudos que avalia CF e QV mostrou aumento no VO2 pico (pico de consumo de oxigênio) e nas pontuações finais dos questionários de QV para o grupo de intervenção. Os resultados de CF possibilitaram uma metanálise, exibindo um aumento final de 0,52 (0,17-0,87) mL.kg-1.min-1 (mililitros.quilograma-1.minuto-1) no VO2 pico depois do TR, com baixa heterogeneidade. Contudo, limitações estatísticas e diversidade de intervenções foram evidenciadas após a análise por subgrupos. As limitações encontradas nos estudos selecionados ainda não permitem considerar o TR eficaz na melhoria da CF e da QV em pacientes com IC.

The Effects of Exercise on Cardiovascular Biomarkers: New Insights, Recent Data, and Applications

The benefit of regular exercise or physical activity with appropriate intensity on improving cardiopulmonary function and endurance has long been accepted with less controversy. The challenge remains, however, quantitatively evaluate the effect of exercise on cardiovascular health due in part to the amount and intensity of exercise varies widely plus lack of effective, robust and efficient biomarker evaluation systems. Better evaluating the overall function of biomarker and validate biomarkers utility in cardiovascular health should improve the evidence regarding the benefit or the effect of exercise or physical activity on cardiovascular health, in turn increasing the efficiency of the biomarker on individuals with mild to moderate cardiovascular risk. In this review, beyond traditional cytokines, chemokines and inflammatory factors, we systemic reviewed the latest novel biomarkers in metabolomics, genomics, proteomics, and molecular imaging mainly focus on heart health, as well as cardiovascular diseases such as atherosclerosis and ischemic heart disease. Furthermore, we highlight the state-of-the-art biomarker developing techniques and its application in the field of heart health. Finally, we discuss the clinical relevance of physical activity and exercise on key biomarkers in molecular basis and practical considerations.

Effect of exercise training on endothelial function in heart failure patients: A systematic review meta-analysis

OBJECTIVE

Endothelial dysfunction contributes to the development and progression of cardiovascular disease and heart failure (HF) and is associated with an increased risk of mortality. Flow-mediated dilation (FMD) is widely utilised to assess endothelial function and is improved with exercise training in heart failure patients. The aim of this meta-analysis is to quantify the effect of exercise training in patients with heart failure.

BACKGROUND

A large number of studies now exist that have examined endothelial function in patients with heart failure. We sought to add to the current literature by quantifying the effect of exercise training on endothelial function.

METHODS

We conducted database searches (PubMed, EMBASE, PROQUEST and Cochrane Trials Register to June 2016) for exercise based rehabilitation trials in heart failure, using search terms exercise training, endothelial function, flow-mediated dilation (FMD) and endothelial progenitor cells (EPCs).

RESULTS

The 16 included studies provided a total of 529 participants, 293 in an intervention and 236 in controls groups. FMD was improved with exercise training in exercise vs. control, SMD of 1.08 (95%CI 0.70 to 1.46, p<0.00001).

CONCLUSION

Overall exercise training improved endothelial function, assessed via FMD, and endothelial progenitor cells in heart failure patients.

The Effect of Exercise Training Intensity on Quality of Life in Heart Failure Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

To establish if exercise training intensity produces different effect sizes for quality of life in heart failure.

BACKGROUND

Exercise intensity is the primary stimulus for physical and mental adaptation.

METHODS

We conducted a MEDLINE search (1985 to February 2016) for exercise-based rehabilitation trials in heart failure using the search terms 'exercise training', 'left ventricular dysfunction', 'peak VO2', 'cardiomyopathy', and 'systolic heart dysfunction'.

RESULTS

Twenty-five studies were included; 4 (16%) comprised high-, 10 (40%) vigorous-, 9 (36%) moderate- and 0 (0%) low-intensity groups; two studies were unclassified. The 25 studies provided a total of 2,385 participants, 1,223 exercising and 1,162 controls (36,056 patient-hours of training). Analyses reported significant improvement in total Minnesota living with heart failure (MLWHF) total score [mean difference (MD) -8.24, 95% CI -11.55 to -4.92, p < 0.00001]. Physical MLWHF scorewas significantly improved in all studies (MD -2.89, 95% CI -4.27 to -1.50, p < 0.00001). MLWHF total score was significantly reduced after high- (MD -13.74, 95% CI -21.34 to -6.14, p = 0.0004) and vigorous-intensity training (MD -8.56, 95% CI -12.77 to -4.35, p < 0.0001) but not moderate-intensity training. A significant improvement in the total MLWHF score was seen after aerobic training (MD -3.87, 95% CI -6.97 to -0.78, p = 0.01), and combined aerobic and resistance training (MD -9.82, 95% CI -15.71 to -3.92, p = 0.001), but not resistance training.

CONCLUSIONS

As exercise training intensity rises, so may the magnitude of improvement in quality of life in exercising patients. Aerobic-only or combined aerobic and resistance training may offer the greatest improvements in quality of life.

The Effects of Exercise on Natriuretic Peptides in Individuals without Heart Failure

Cardiac natriuretic peptides (NPs) play an important role in the regulation of energy expenditure in skeletal muscle and adipose tissue. A systematic review on the effects of exercise on NPs in patients with heart failure reported that aerobic and resistance training reduced NPs; however, the effects of exercise on NPs and the underlying mechanism of exercise-induced NP secretion in subjects without heart failure remain unknown. In athletes and young, healthy subjects, the NP concentration at rest is not elevated, but strenuous endurance exercise significantly increases NPs. The exercise-induced increase in NPs may be caused by transient myocardial wall stress, cardiomyocyte metabolic changes, or neuroendocrinological response, which may have cytoprotective and growth-regulating effects on the heart. On the other hand, in elderly, overweight/obese subjects, and patients with hypertension, NP concentrations also increase during exercise; however, NP secretion may be more susceptible to cardiac stress compared to young, healthy individuals. Recent studies have shown that NPs are associated with thermogenesis in fat tissue and oxidative capacity in skeletal muscles. NPs may also have a protective role for skeletal muscle in humans, although further studies are warranted to elucidate the physiological mechanism of exercise-induced NP secretion.

Aerobic exercise effect on prognostic markers for systolic heart failure patients: a systematic review and meta-analysis

From previous systematic reviews and meta-analyses, there is consensus about the positive effect of exercise training on exercise capacity for systolic heart failure (HF); however, the effect on actual prognostic markers such as NTproBNP and minute ventilation/carbon dioxide production (VE/VCO2) slope has not been evaluated. The primary aim of the proposed study is to determine the effect of aerobic exercise training (AEX) on the VE/VCO2 slope and NTproBNP. The following databases (up to February 30, 2013) were searched with no language limitations: CENTRAL (The Cochrane Library 2013, issue 2), MEDLINE (from January 1966), EMBASE (from January 1980), and Physiotherapy Evidence Database (PEDro) (from January 1929). We screened reference lists of articles and also conducted an extensive hand search of the literature. Randomized controlled trials of exercise-based interventions with 2-month follow-up or longer compared to usual medical care or placebo were included. The study population comprised adults aged between 18 and 65 years, with evidence of chronic systolic heart failure (LVEF < 45 % and baseline NTproBNP > 300 pg/ml). Two review authors independently extracted data on study design, participants, interventions, and outcomes. We assessed the risk of bias using PEDro scale. We calculated mean differences (MD) or standardized mean differences between intervention and control groups for outcomes with sufficient data; for other outcomes, we described findings from individual studies. Eight studies involving a total of 408 participants met the inclusion criteria across the NTproBNP (5 studies with 191 patients) and VE/VCO2 slope (4 studies with 217 patients). Aerobic exercise significantly improved NTproBNP by a MD of -817.75 [95 % confidence interval (CI) -929.31 to -706.19]. Mean differences across VE/VCO2 slope were -6.55 (95 % CI -7.24 to -5.87). Those patients' characteristics and exercise were similar (frequency = 3-5 times/week; duration = 20-50 min/day; intensity = 60-80 % of VO2 peak) on the included studies. Moreover, the risk of bias across all studies was homogeneous (PEDro scale = 7-8 points). However, based on the statistical analysis, the heterogeneity among the studies was still high, which is related to the variable characteristics of the studies. Aerobic exercise may be effective at improving NTproBNP and the VE/VCO2 slope in systolic HF patients, but these effects are limited to a specific HF population meeting specific inclusion criterion in a limited number of studies. Future randomized controlled studies including diastolic and HF overleap with pulmonary diseases are needed to better understand the exact influence of AEX.

Management and outcomes of patients with reduced ejection fraction after acute myocardial infarction in cardiac rehabilitation centers

BACKGROUND

We aimed to describe the contemporary management of patients with systolic chronic heart failure (CHF) during a cardiac rehabilitation (CR) stay and present outcomes with focus on lipids, blood pressure, exercise capacity, and clinical events.

METHODS

Comparison of 3199 patients with moderately or severely impaired left ventricular ejection fraction (low EF, 13.3%) and 20,913 patients with slightly reduced or normal LVEF (normal EF, 86.7%) who underwent an inpatient CR period of about 3 weeks in 2009-2010.

RESULTS

Patients with low EF compared to those with normal EF were somewhat older (65.1 vs. 63.0 years, p < 0.0001), and more often had risk factors such as diabetes mellitus (39.7% vs. 32.0%, p < 0.0001) or other comorbidities. The overall rate of patients with regular physical activity of at least 90 minutes per week prior to CR was low overall (54.4%), and reduced in patients with low EF compared to those with normal EF (47.7% vs. 55.5%, p < 0.0001). The rate of patients that achieved lower LDL cholesterol (<100 mg/dl), total cholesterol (<200 mg/dl) and triglyceride (<150 mg/dl) values at discharge increased compared to baseline. Mean blood pressure was substantially lower in the low EF group compared to the normal EF group both at baseline (124/75 vs. 130/78 mmHg, p < 0.0001) and at discharge (119/72 vs. 124/74 mmHg, p < 0.0001). Maximum exercise improved substantially in both groups (at baseline 71 vs. 91 Watts, p < 0.0001; at discharge 85 vs. 105 Watts, p < 0.0001). Event rates during CR were low, and only 0.3% in the low EF group died. As limitations to this study, information on brain natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-pro BNP) and/or cardiac troponin were not documented, and no long-term information was collected beyond the 3-week CR stay.

CONCLUSIONS

Patients with CHF account for a considerable proportion of patients in CR. Also patients with moderate/severe EF benefited from participation in CR, as their lipid profile and physical fitness improved.

Physical therapy in heart failure with preserved ejection fraction: A systematic review

About 50% of patients with heart failure (HF) have preserved ejection fraction (HFpEF) which is especially common in elderly people with highly prevalent co-morbid conditions. HFpEF is usually defined as an ejection fraction equal to or greater than 50%, although some studies have used a limit as low as 40%. The prevalence of this syndrome is expected to increase over the next decades. The associated impact on mortality and hospital readmissions has made of this entity a major public health issue. Despite the fact that mortality and re-hospitalisation rates of HFpEF are similar to the syndrome of HF with reduced ejection fraction (HFrEF), currently there is no available evidence-based therapy as effective as is the case for HFrEF. Exercise intolerance is the principal clinical feature in HFpEF. The pathophysiological mechanisms behind impaired exercise capacity in these patients are complex and not yet fully elucidated. Current guidelines and consensus documents recommend the implementation of exercise training in HFpEF; however, they are based mostly on results from a few small trials evaluating surrogate endpoints such as exercise capacity and quality of life. The aim of this work was to review the current evidence that supports the effect of the different modalities of physical therapies in HFpEF.

Exercise counselling practices for patients with chronic kidney disease in the UK: a renal multidisciplinary team perspective

BACKGROUND

Patients with chronic kidney disease (CKD) have elevated cardiovascular disease (CVD) risk. Physical activity (PA) is a strong and independent CVD risk factor, and despite the fact that current clinical practice guidelines recommend simultaneous treatment of multiple risk factors for optimum management of CKD, PA is rarely addressed by renal care teams. The aim of this observational cross-sectional survey was to document current exercise/PA practices across renal units in the UK, and capture views and experiences regarding the provision of PA/exercise options for patients with CKD.

METHODS

An 18-item online survey questionnaire regarding exercise counselling practice patterns was administered to 565 multidisciplinary renal care professionals.

RESULTS

142 individuals (25% response rate) completed the questionnaire. Overall, 42% of respondents discussed and encouraged PA, but only 18 and 11% facilitated implementation of PA for their patients. Nephrologists (p < 0.003) were more likely to prescribe or recommend PA compared to professionals with a nursing background and believed that specific renal rehabilitation services, including an active PA/exercise component, should be available to all patients (p < 0.01). The most commonly reported barriers for the development and implementation of PA/exercise options included lack of funding, time, and knowledgeable personnel, such as physiotherapists or other exercise professionals.

CONCLUSION

Beliefs and attitudes towards PA amongst members of the renal multidisciplinary team are encouraging. However there is a big gap between believing in the benefits of PA and promoting/implementing PA for patient benefit. This gap needs to be minimised by at least trying to address some of the reported barriers.

Biomarkers of myocardial stress and fibrosis as predictors of mode of death in patients with chronic heart failure

OBJECTIVES

The aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure.

BACKGROUND

The 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown.

METHODS

HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP.

RESULTS

After a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure.

CONCLUSIONS

Clinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers.

The effects of exercise on cardiovascular biomarkers in patients with chronic heart failure

BACKGROUND

Exercise training is recommended for chronic heart failure (HF) patients to improve functional status and reduce risk of adverse outcomes. Elevated plasma levels of amino-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), and cardiac troponin T (cTnT) are associated with increased risk of adverse outcomes in this patient population. Whether exercise training leads to improvements in biomarkers and how such improvements relate to clinical outcomes are unclear.

METHODS AND RESULTS

Amino-terminal pro-brain natriuretic peptide, hs-CRP, and cTnT levels were assessed at baseline and 3 months in a cohort of 928 subjects from the HF-ACTION study, a randomized clinical trial of exercise training versus usual care in chronic HF patients with reduced left ventricular ejection fraction (<35%). Linear and logistic regressions were used to assess 3-month biomarker levels as a function of baseline value, treatment assignment (exercise training vs usual care), and volume of exercise. Linear regression and Cox proportional hazard modeling were used to evaluate the relations between changes in biomarker levels and clinical outcomes of interest that included change in peak oxygen consumption (peak VO2), hospitalizations, and mortality. Exercise training was not associated with significant changes in levels of NT-proBNP (P = .10), hs-CRP (P = .80), or detectable cTnT levels (P = .83) at 3 months. Controlling for baseline biomarker levels or volume of exercise did not alter these findings. Decreases in plasma concentrations of NT-proBNP, but not hs-CRP or cTnT, were associated with increases in peak VO2 (P < .001) at 3 months and decreased risk of hospitalizations or mortality (P ≤ .04), even after adjustment for a comprehensive set of known predictors.

CONCLUSIONS

Exercise training did not lead to meaningful changes in biomarkers of myocardial stress, inflammation, or necrosis in patients with chronic HF. Only improvements in NT-proBNP translated to reductions in peak VO2 and reduced risk of clinical events.

Neuro-hormonal effects of physical activity in the elderly

Thanks to diagnostic and therapeutic advances, the elderly population is continuously increasing in the western countries. Accordingly, the prevalence of most chronic age-related diseases will increase considerably in the next decades, thus it will be necessary to implement effective preventive measures to face this epidemiological challenge. Among those, physical activity exerts a crucial role, since it has been proven to reduce the risk of cardiovascular diseases, diabetes, obesity, cognitive impairment and cancer. The favorable effects of exercise on cardiovascular homeostasis can be at least in part ascribed to the modulation of the neuro-hormonal systems implicated in cardiovascular pathophysiology. In the elderly, exercise has been shown to affect catecholamine secretion and biosynthesis, to positively modulate the renin-angiotensin-aldosterone system and to reduce the levels of plasma brain natriuretic peptides. Moreover, drugs modulating the neuro-hormonal systems may favorably affect physical capacity in the elderly. Thus, efforts should be made to actually make physical activity become part of the therapeutic tools in the elderly.

Exercise training program characteristics and magnitude of change in functional capacity of heart failure patients

BACKGROUND

Intuitively higher exercise program volume may be the primary stimulus for physical adaptation. We sought to establish if aerobic exercise training program characteristics produced different effect sizes for change in cardiorespiratory fitness in heart failure patients.

METHODS

We conducted a MEDLINE search (1966 to 2012), for exercise based rehabilitation trials in heart failure, using the search terms 'exercise training, left ventricular dysfunction, peak VO2, cardio-myopathy and systolic heart dysfunction'. Forty seven studies were included, producing 54 intervention groups; 3 (6%) were high-, 29 (54%) vigorous-, 20 (37%) moderate- and 2 (3%) low- intensity groups, providing a total of 2285 exercising subjects and 2098 control subjects, totaling 4383 participants.

RESULTS

Peak VO2 increased by a mean difference of 3.3 ml kg(-1)min(-1) [95% CI 0.53 to 6.13, p=0.02] with high intensity training in exercise groups versus control, equating to a 23% improvement from baseline. The corresponding data for vigorous, moderate and low intensity were 8%, 13%; and 7% respectively. Weekly exercise energy expenditure >460 kcal was associated with a mean difference in peak VO2 of 2.6 ml kg(-1)min(-1) [95% CI 1.88 to 3.28, p<0.00001].

CONCLUSIONS

Our data suggest that high-intensity exercise, achieving at least 460 kcal weekly energy expenditure may elicit the greatest changes in cardiorespiratory fitness.

Clinical outcomes and cardiovascular responses to different exercise training intensities in patients with heart failure: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to establish whether aerobic exercise training intensity produces different effect sizes for fitness, adherence, event rates, mortality rates, and hospitalization rates in patients with heart failure.

BACKGROUND

Intuitively, greater exercise intensity is considered to result in higher risk for serious events, but intensity may be the primary stimulus for physical adaptation.

METHODS

A MEDLINE search (1985 to 2012) was conducted for exercise-based rehabilitation trials in heart failure, using the search terms "exercise training," "left ventricular dysfunction," "peak Vo2," "cardio-myopathy," and "systolic heart dysfunction." Seventy-four studies were included, producing 76 intervention groups; 9 (11.8%) were high-intensity, 38 (50%) vigorous-intensity, 24 (31.6%) moderate-intensity, and 5 (6.6%) low-intensity groups, providing a total of 3,265 exercising subjects and 2,612 control subjects.

RESULTS

Peak oxygen consumption increased by a mean difference of 3.33 ml·kg(-1)·min(-1) (95% confidence interval [CI]: 0.53 to 6.13 ml·kg(-1)·min(-1); p = 0.02) with high-intensity training in exercise groups compared with control groups, equating to a 23% improvement from baseline. For vigorous intensity, the mean difference was 2.27 ml·kg(-1)·min(-1) (95% CI: 1.70 to 2.84 ml·kg(-1)·min(-1); p < 0.00001), with an 8% weighted mean; for moderate intensity, the mean difference was 2.17 ml·kg(-1)·min(-1) (95% CI: 1.34 to 2.99 ml·kg(-1)·min(-1); p < 0.00001), with a weighted mean of 13%; and for low intensity, the mean difference was 1.04 ml·kg(-1)·min(-1) (95% CI: -2.50 to 4.57 ml·kg(-1)·min(-1); p = 0.57), with a weighted mean of 7%. In 123,479 patient-hours of training, not a single death was directly attributable to exercise.

CONCLUSIONS

As exercise training intensity rises, so may the magnitude of improvement in cardiorespiratory fitness, accompanied by lower study withdrawal in exercising patients. Total exercise time may be a confounder.

The role of B-type natriuretic Peptide testing in guiding outpatient heart failure treatment

OPINION STATEMENT

While heart failure (HF) treatment guidelines exist, there are significant gaps in their implementation owing in part to the lack of objective data to help guide clinicians in their medical decision-making. B-type natriuretic peptide (BNP) and its amino-terminal equivalent (NT-proBNP) are objective markers of HF prognosis, are useful to monitor response to treatment in outpatients with HF, and may have a role in "guiding" HF care as well. Successful BNP or NT-proBNP guided HF treatment requires regular attempts to reach and maintain target values (BNP ≤ 125 pg/mL or NT-proBNP ≤ 1000 pg/mL). This may be achieved through lifestyle modifications, exercise programs, medication adjustments, and therapeutic interventions shown to reduce morbidity and mortality in HF patients. Failure to achieve biomarker targets portends a worse prognosis, proportional to the lowest achieved natriuretic peptide concentration; in those with significant biomarker "nonresponse," prognosis is poor, and alternative therapeutic strategies should be considered.

Exercise preconditioning provides early cardioprotection against exhaustive exercise in rats: potential involvement of protein kinase C delta translocation

The objective of this study was to investigate the early cardioprotective effect of exercise preconditioning (EP) on the exhaustive exercise-induced myocardial injury in rats and the role of protein kinase C delta isoform (PKCδ) in EP. Rats were subjected to run on the treadmill for four periods of 10 min each at 30 m/min with intervening periods of rest of 10 min as an EP protocol. The exhaustive exercise was performed 0.5 h after EP. PKC inhibitor chelerythrine (CHE) was injected before EP. Our results showed that EP markedly attenuated the exhaustive exercise-induced myocardial ischemia/hypoxia, ultrastructural damage, high serum cTnI, and NT-proBNP levels. CHE injection before EP did not abolish the protection of EP. Both exhaustive exercise and EP produced a significant increase in PKCδ and p-PKCδ(Thr507) protein levels in cardiomyocytes. However, the immunostaining of p-PKCδ(Thr507) in EP cardiomyocytes was primarily localized to intercalated disks and nuclei while the exhaustive exercise-induced high level p-PKCδ(Thr507) was mainly distributed in the cytoplasm. Moreover, the high PKCδ and p-PKCδ(Thr507) levels in exhaustive exercise were significantly down-regulated by EP. CHE did not attenuate the expressions of PKCδ and p-PKCδ(Thr507). These results indicate that an appropriate activation and translocation of PKCδ may represent a mechanism whereby EP can exert an early cardioprotection against exhaustive exercise-induced myocardial injury.

Intermittent versus continuous exercise training in chronic heart failure: a meta-analysis

INTRODUCTION

We conducted a meta-analysis of randomized, controlled trials of combined strength and intermittent aerobic training, intermittent aerobic training only and continuous exercise training in heart failure patients.

METHODS

A systematic search was conducted of Medline (Ovid) (1950-September 2011), Embase.com (1974-September 2011), Cochrane Central Register of Controlled Trials and CINAHL (1981-September 19 2011). The search strategy included a mix of MeSH and free text terms for the key concepts heart failure, exercise training, interval training and intermittent exercise training.

RESULTS

The included studies contained an aggregate of 446 patients, 212 completed intermittent exercise training, 66 only continuous exercise training, 59 completed combined intermittent and strength training and 109 sedentary controls. Weighted mean difference (MD) in Peak VO2 was 1.04mlkg(-1)min(-1) and (95% C.I.) was 0.42-1.66 (p=0.0009) in intermittent versus continuous exercise training respectively. Weighted mean difference in Peak VO2 was -1.10mlkg(-1)min(-1) (95% C.I.) was -1.83-0.37 p=0.003 for intermittent only versus intermittent and strength (combined) training respectively. In studies reporting VE/VCO2 for intermittent versus control groups, MD was -1.50 [(95% C.I. -2.64, -0.37), p=0.01] and for intermittent versus continuous exercise training MD was -1.35 [(95% C.I. -2.15, -0.55), p=0.001]. Change in peak VO2 was positively correlated with weekly exercise energy expenditure for intermittent exercise groups (r=0.48, p=0.05).

CONCLUSIONS

Combined strength and intermittent exercise appears superior for peak VO2 changes when compared to intermittent exercise of similar exercise energy expenditure.

Individual patient meta-analysis of exercise training effects on systemic brain natriuretic peptide expression in heart failure

BACKGROUND

Brain natriuretic peptide (BNP) predicts exercise performance and exercise training may modulate BNP and its N-terminal portion (NT-pro-BNP), we therefore conducted an individual patient analysis of exercise training effects on BNP and NT-pro-BNP.

AIMS

To use an individual patient meta-analysis to relate changes in BNP, NT-pro-BNP, and peak VO(2); to link these changes to volume parameters of exercise training programmes (intensity etc.); and to identify patient characteristics likely to lead to greater improvements in BNP, NT-pro-BNP, and peak VO(2).

DESIGN

Individual patient meta-analysis.

METHODS

A systematic search was conducted of Medline (Ovid), Embase.com, Cochrane Central Register of Controlled Trials, and CINAHL (until July 2008) to identify randomized controlled trials of aerobic and/or resistance exercise training in systolic heart failure patients measuring BNP and/or NT-pro-BNP. Primary outcome measures were change in BNP, NT-pro-BNP, and peak VO2. Subanalyses were conducted to identify (1) patient groups that benefit most and (2) exercise programme parameters enhancing favourable changes in primary outcome measures.

RESULTS

Ten randomized controlled studies measuring BNP or NT-pro-BNP met eligibility criteria, authors provided individual patient data for 565 patients (313 exercise and 252 controls). Exercise training had favourable effects on BNP (-28.3%, p < 0.0001), NT-pro-BNP (-37.4%, p = < 0.0001), and peak VO(2) (17.8%, p < 0.0001). The analysis showed a significant change in primary outcome measures; moreover, change in BNP (r = -0.31, p < 0.0001) and NT-pro-BNP (r = -0.22, p < 0.0001) were correlated with peak VO(2) change.

CONCLUSION

Exercise training has favourable effects on BNP, NT-pro-BNP, and peak VO(2) in heart failure patients and BNP/NT-pro-BNP changes were correlated with peak VO(2) changes.

The effect of physical training on systemic proinflammatory cytokine expression in heart failure patients: a systematic review

Systemic inflammation is associated with cardiovascular disease, especially the end stages of heart failure (HF). The authors sought to determine by systematic review whether physical therapy reduces serum levels of pro-inflammatory cytokines in HF patients. Potential studies were identified from a systematic search of Medline (Ovid) (1950-October 2010), Embase.com (1974-current), Cochrane Central Register of Controlled Trials, CINAHL (1981-current), and Web of Science (2000-current). The search strategy included a mix of MeSH and free text terms for key concepts. A total of 11 studies were included, with 4 reporting a post-training reduction in tumor necrosis factor α (TNF-α), of which 3 used traditional aerobic or resistance exercise and 1 used functional electrical stimulation. Reduced post-training serum levels of interleukin 6 were reported by one exercise study. The one study that employed combined resistance and aerobic training only showed soluble receptors TNF-α1 and TNF-α2 to be lower. The one study of respiratory muscle training and two studies that employed electrical stimulation had limited effect on cytokines and peak maximal oxygen uptake. With the exception of one study, those therapies that employed ≥ 5 sessions per week lowered serum TNF-α. Our review data suggest that physical therapies employing ≥ 5 sessions per week are most likely to reduce serum levels of TNF-α in HF patients. No isolated study of resistance training has yet examined the relationship between muscle wasting, glycogen depletion, and the ability of exercise training to reverse both of these conditions in HF patients.

Exercise Training for Heart Failure Patients with and without Systolic Dysfunction: An Evidence-Based Analysis of How Patients Benefit

Significant benefits can be derived by heart failure patients from exercise training. This paper provides an evidence-based assessment of expected clinical benefits of exercise training for heart failure patients. Meta-analyses and randomized, controlled trials of exercise training in heart failure patients were reviewed from a search of PubMed, Cochrane Controlled Trial Registry (CCTR), CINAHL, and EMBASE. Exercise training improves functional capacity, quality of life, hospitalization, and systolic and diastolic function in heart failure patients. Heart failure patients with preserved systolic function (HFnEF) participating in exercise training studies are more likely to be women and are 5–7 years older than their systolic heart failure (CHF) counterparts. All patients exhibit low functional capacities, although in HFnEF patients this may be age related, therefore subtle differences in exercise prescriptions are required. Published works report that exercise training is beneficial for heart failure patients with and without systolic dysfunction.