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Wood N, Critchlow A, Cheng CW, Straw S, Hendrickse PW, Pereira MG, Wheatcroft SB, Egginton S, Witte KK, Roberts LD, Bowen TS. Sex Differences in Skeletal Muscle Pathology in Patients With Heart Failure and Reduced Ejection Fraction. Circ Heart Fail 2024; 17:e011471. [PMID: 39381880 PMCID: PMC11472905 DOI: 10.1161/circheartfailure.123.011471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 08/28/2024] [Indexed: 10/10/2024]
Abstract
BACKGROUND Women with heart failure and reduced ejection fraction (HFrEF) have greater symptoms and a lower quality of life compared with men; however, the role of noncardiac mechanisms remains poorly resolved. We hypothesized that differences in skeletal muscle pathology between men and women with HFrEF may explain clinical heterogeneity. METHODS Muscle biopsies from both men (n=22) and women (n=16) with moderate HFrEF (New York Heart Association classes I-III) and age- and sex-matched controls (n=18 and n=16, respectively) underwent transcriptomics (RNA-sequencing), myofiber structural imaging (histology), and molecular signaling analysis (gene/protein expression), with serum inflammatory profiles analyzed (enzyme-linked immunosorbent assay). Two-way ANOVA was conducted (interaction sex and condition). RESULTS RNA-sequencing identified 5629 differentially expressed genes between men and women with HFrEF, with upregulated terms for catabolism and downregulated terms for mitochondria in men. mRNA expression confirmed an effect of sex (P<0.05) on proatrophic genes related to ubiquitin proteasome, autophagy, and myostatin systems (higher in all men versus all women), whereas proanabolic IGF1 expression was higher (P<0.05) in women with HFrEF only. Structurally, women compared with men with HFrEF showed a pro-oxidative phenotype, with smaller but higher numbers of type I fibers, alongside higher muscle capillarity (Pinteraction<0.05) and higher type I fiber areal density (Pinteraction<0.05). Differences in gene/protein expression of regulators of muscle phenotype were detected between sexes, including HIF1α, ESR1, VEGF (vascular endothelial growth factor), and PGC1α expression (P<0.05), and for upstream circulating factors, including VEGF, IL (interleukin)-6, and IL-8 (P<0.05). CONCLUSIONS Sex differences in muscle pathology in HFrEF exist, with men showing greater abnormalities compared with women related to the transcriptome, fiber phenotype, capillarity, and circulating factors. These preliminary data question whether muscle pathology is a primary mechanism contributing to greater symptoms in women with HFrEF and highlight the need for further investigation.
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Affiliation(s)
- Nathanael Wood
- Faculty of Biological Sciences, School of Biomedical Sciences (N.W., A.C., M.G.P., S.E., T.S.B.), University of Leeds, United Kingdom
| | - Annabel Critchlow
- Faculty of Biological Sciences, School of Biomedical Sciences (N.W., A.C., M.G.P., S.E., T.S.B.), University of Leeds, United Kingdom
| | - Chew W. Cheng
- Leeds Institute of Cardiovascular and Metabolic Medicine (C.W.C., S.S., S.B.W., K.K.W., L.D.R.), University of Leeds, United Kingdom
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine (C.W.C., S.S., S.B.W., K.K.W., L.D.R.), University of Leeds, United Kingdom
| | | | - Marcelo G. Pereira
- Faculty of Biological Sciences, School of Biomedical Sciences (N.W., A.C., M.G.P., S.E., T.S.B.), University of Leeds, United Kingdom
| | - Stephen B. Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine (C.W.C., S.S., S.B.W., K.K.W., L.D.R.), University of Leeds, United Kingdom
| | - Stuart Egginton
- Faculty of Biological Sciences, School of Biomedical Sciences (N.W., A.C., M.G.P., S.E., T.S.B.), University of Leeds, United Kingdom
| | - Klaus K. Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine (C.W.C., S.S., S.B.W., K.K.W., L.D.R.), University of Leeds, United Kingdom
- Clinic for Cardiology, Angiology and Internal Intensive Care Medicine, RWTH Aachen University, Germany (K.K.W.)
| | - Lee D. Roberts
- Leeds Institute of Cardiovascular and Metabolic Medicine (C.W.C., S.S., S.B.W., K.K.W., L.D.R.), University of Leeds, United Kingdom
| | - T. Scott Bowen
- Faculty of Biological Sciences, School of Biomedical Sciences (N.W., A.C., M.G.P., S.E., T.S.B.), University of Leeds, United Kingdom
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2
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Sterczala AJ, Rodriguez‐Ortiz N, Feigel ED, Krajewski K, Martin BJ, Sekel NM, Lovalekar M, Kargl CK, Koltun KJ, Van Eck C, Flanagan S, Connaboy C, Wardle SL, O'Leary TJ, Greeves JP, Nindl BC. Skeletal muscle adaptations to high-intensity, low-volume concurrent resistance and interval training in recreationally active men and women. Physiol Rep 2024; 12:e15953. [PMID: 38490811 PMCID: PMC10942853 DOI: 10.14814/phy2.15953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/16/2023] [Accepted: 12/16/2023] [Indexed: 03/17/2024] Open
Abstract
This study compared the structural and cellular skeletal muscle factors underpinning adaptations in maximal strength, power, aerobic capacity, and lean body mass to a 12-week concurrent resistance and interval training program in men and women. Recreationally active women and men completed three training sessions per week consisting of high-intensity, low-volume resistance training followed by interval training performed using a variety upper and lower body exercises representative of military occupational tasks. Pre- and post-training vastus lateralis muscle biopsies were analyzed for changes in muscle fiber type, cross-sectional area, capillarization, and mitochondrial biogenesis marker content. Changes in maximal strength, aerobic capacity, and lean body mass (LBM) were also assessed. Training elicited hypertrophy of type I (12.9%; p = 0.016) and type IIa (12.7%; p = 0.007) muscle fibers in men only. In both sexes, training decreased type IIx fiber expression (1.9%; p = 0.046) and increased total PGC-1α (29.7%, p < 0.001) and citrate synthase (11.0%; p < 0.014) content, but had no effect on COX IV content or muscle capillarization. In both sexes, training increased maximal strength and LBM but not aerobic capacity. The concurrent training program was effective at increasing strength and LBM but not at improving aerobic capacity or skeletal muscle adaptations underpinning aerobic performance.
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Affiliation(s)
- Adam J. Sterczala
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
- Present address:
Human Engineering Research LaboratoriesVA Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Nathaniel Rodriguez‐Ortiz
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Evan D. Feigel
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Kellen T. Krajewski
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Brian J. Martin
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Nicole M. Sekel
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Mita Lovalekar
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Christopher K. Kargl
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Kristen J. Koltun
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Carola Van Eck
- Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Shawn D. Flanagan
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
- Present address:
Center for Lower Extremity Ambulatory ResearchRosalind Franklin University of Medicine & ScienceNorth ChicagoILUSA
| | - Christopher Connaboy
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
- Present address:
Center for Lower Extremity Ambulatory ResearchRosalind Franklin University of Medicine & ScienceNorth ChicagoILUSA
| | - Sophie L. Wardle
- Army Health and Performance ResearchArmy HeadquartersAndoverUK
- Present address:
Norwich Medical School, Faculty of Medicine and Health SciencesUniversity of East AngliaNorwichUK
| | - Thomas J. O'Leary
- Army Health and Performance ResearchArmy HeadquartersAndoverUK
- Present address:
Norwich Medical School, Faculty of Medicine and Health SciencesUniversity of East AngliaNorwichUK
| | - Julie P. Greeves
- Army Health and Performance ResearchArmy HeadquartersAndoverUK
- Present address:
Norwich Medical School, Faculty of Medicine and Health SciencesUniversity of East AngliaNorwichUK
- Present address:
Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
| | - Bradley C. Nindl
- Neuromuscular Research Laboratory and Warrior Human Performance Research CenterUniversity of PittsburghPittsburghPennsylvaniaUSA
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3
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Nijenkamp LLAM, Bollen IAE, Niessen HWM, dos Remedios CG, Michels M, Poggesi C, Ho CY, Kuster DWD, van der Velden J. Sex-specific cardiac remodeling in early and advanced stages of hypertrophic cardiomyopathy. PLoS One 2020; 15:e0232427. [PMID: 32369506 PMCID: PMC7199944 DOI: 10.1371/journal.pone.0232427] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/14/2020] [Indexed: 01/28/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most frequent genetic cardiac disease with a prevalence of 1:500 to 1:200. While most patients show obstructive HCM and a relatively stable clinical phenotype (stage II), a small group of patients progresses to end-stage HCM (stage IV) within a relatively brief period. Previous research has shown sex-differences in stage II HCM with more diastolic dysfunction in female than in male patients. Moreover, female patients more often show progression to heart failure. Here we investigated if differences in functional and structural properties of the heart may underlie sex-differences in disease progression from stage II to stage IV HCM. Cardiac tissue from stage II and IV patients was obtained during myectomy (n = 54) and heart transplantation (n = 10), respectively. Isometric force was measured in membrane-permeabilized cardiomyocytes to define active and passive myofilament force development. Titin isoform composition was assessed using gel electrophoresis, and the amount of fibrosis and capillary density were determined with histology. In accordance with disease stage-dependent adverse cardiac remodeling end-stage patients showed a thinner interventricular septal wall and larger left ventricular and atrial diameters compared to stage II patients. Cardiomyocyte contractile properties and fibrosis were comparable between stage II and IV, while capillary density was significantly lower in stage IV compared to stage II. Women showed more adverse cellular remodeling compared to men at stage II, evident from more compliant titin, more fibrosis and lower capillary density. However, the disease stage-dependent reduction in capillary density was largest in men. In conclusion, the more severe cellular remodeling in female compared to male stage II patients suggests a more advanced disease stage at the time of myectomy in women. Changes in cardiomyocyte contractile properties do not explain the progression of stage II to stage IV, while reduced capillary density may underlie disease progression to end-stage heart failure.
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Affiliation(s)
- Louise L. A. M. Nijenkamp
- Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- * E-mail:
| | - Ilse A. E. Bollen
- Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Hans W. M. Niessen
- Pathology and Cardiac Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Michelle Michels
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Corrado Poggesi
- Dipartimento di Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Firenze, Italy
| | - Carolyn Y. Ho
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Diederik W. D. Kuster
- Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Jolanda van der Velden
- Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
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4
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Gevaert AB, Adams V, Bahls M, Bowen TS, Cornelissen V, Dörr M, Hansen D, Kemps HM, Leeson P, Van Craenenbroeck EM, Kränkel N. Towards a personalised approach in exercise-based cardiovascular rehabilitation: How can translational research help? A 'call to action' from the Section on Secondary Prevention and Cardiac Rehabilitation of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2019; 27:1369-1385. [PMID: 31581819 DOI: 10.1177/2047487319877716] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The benefit of regular physical activity and exercise training for the prevention of cardiovascular and metabolic diseases is undisputed. Many molecular mechanisms mediating exercise effects have been deciphered. Personalised exercise prescription can help patients in achieving their individual greatest benefit from an exercise-based cardiovascular rehabilitation programme. Yet, we still struggle to provide truly personalised exercise prescriptions to our patients. In this position paper, we address novel basic and translational research concepts that can help us understand the principles underlying the inter-individual differences in the response to exercise, and identify early on who would most likely benefit from which exercise intervention. This includes hereditary, non-hereditary and sex-specific concepts. Recent insights have helped us to take on a more holistic view, integrating exercise-mediated molecular mechanisms with those influenced by metabolism and immunity. Unfortunately, while the outline is recognisable, many details are still lacking to turn the understanding of a concept into a roadmap ready to be used in clinical routine. This position paper therefore also investigates perspectives on how the advent of 'big data' and the use of animal models could help unravel inter-individual responses to exercise parameters and thus influence hypothesis-building for translational research in exercise-based cardiovascular rehabilitation.
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Affiliation(s)
- Andreas B Gevaert
- GENCOR Department, University of Antwerp, Belgium.,Department of Cardiology, Antwerp University Hospital (UZA), Belgium.,Heart Centre Hasselt, Jessa Hospital, Belgium
| | - Volker Adams
- Department of Molecular and Experimental Cardiology, TU Dresden, Germany
| | - Martin Bahls
- Department of Internal Medicine B, University of Greifswald, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Germany
| | - T Scott Bowen
- School of Biomedical Sciences, University of Leeds, UK
| | | | - Marcus Dörr
- Department of Internal Medicine B, University of Greifswald, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Germany
| | - Dominique Hansen
- Heart Centre Hasselt, Jessa Hospital, Belgium.,Faculty of Rehabilitation Sciences, Hasselt University, Belgium
| | - Hareld Mc Kemps
- Fitheid, Leefstijl, Ontwikkeling en Wetenschap (FLOW), Máxima Medical Centre, The Netherlands
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, University of Oxford, UK
| | - Emeline M Van Craenenbroeck
- GENCOR Department, University of Antwerp, Belgium.,Department of Cardiology, Antwerp University Hospital (UZA), Belgium
| | - Nicolle Kränkel
- Department of Cardiology, Charité Universitätsmedizin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
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5
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Effect of Qigong exercise on cognitive function, blood pressure and cardiorespiratory fitness in healthy middle-aged subjects. Complement Ther Med 2017; 33:39-45. [DOI: 10.1016/j.ctim.2017.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 04/25/2017] [Accepted: 05/24/2017] [Indexed: 11/22/2022] Open
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6
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Hirai DM, Musch TI, Poole DC. Exercise training in chronic heart failure: improving skeletal muscle O2 transport and utilization. Am J Physiol Heart Circ Physiol 2015; 309:H1419-39. [PMID: 26320036 DOI: 10.1152/ajpheart.00469.2015] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/23/2015] [Indexed: 01/13/2023]
Abstract
Chronic heart failure (CHF) impairs critical structural and functional components of the O2 transport pathway resulting in exercise intolerance and, consequently, reduced quality of life. In contrast, exercise training is capable of combating many of the CHF-induced impairments and enhancing the matching between skeletal muscle O2 delivery and utilization (Q̇mO2 and V̇mO2 , respectively). The Q̇mO2 /V̇mO2 ratio determines the microvascular O2 partial pressure (PmvO2 ), which represents the ultimate force driving blood-myocyte O2 flux (see Fig. 1). Improvements in perfusive and diffusive O2 conductances are essential to support faster rates of oxidative phosphorylation (reflected as faster V̇mO2 kinetics during transitions in metabolic demand) and reduce the reliance on anaerobic glycolysis and utilization of finite energy sources (thus lowering the magnitude of the O2 deficit) in trained CHF muscle. These adaptations contribute to attenuated muscle metabolic perturbations (e.g., changes in [PCr], [Cr], [ADP], and pH) and improved physical capacity (i.e., elevated critical power and maximal V̇mO2 ). Preservation of such plasticity in response to exercise training is crucial considering the dominant role of skeletal muscle dysfunction in the pathophysiology and increased morbidity/mortality of the CHF patient. This brief review focuses on the mechanistic bases for improved Q̇mO2 /V̇mO2 matching (and enhanced PmvO2 ) with exercise training in CHF with both preserved and reduced ejection fraction (HFpEF and HFrEF, respectively). Specifically, O2 convection within the skeletal muscle microcirculation, O2 diffusion from the red blood cell to the mitochondria, and muscle metabolic control are particularly susceptive to exercise training adaptations in CHF. Alternatives to traditional whole body endurance exercise training programs such as small muscle mass and inspiratory muscle training, pharmacological treatment (e.g., sildenafil and pentoxifylline), and dietary nitrate supplementation are also presented in light of their therapeutic potential. Adaptations within the skeletal muscle O2 transport and utilization system underlie improvements in physical capacity and quality of life in CHF and thus take center stage in the therapeutic management of these patients.
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Affiliation(s)
- Daniel M Hirai
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, São Paulo, Brazil; and
| | - Timothy I Musch
- Departments of Anatomy and Physiology and Kinesiology, Kansas State University, Manhattan, Kansas
| | - David C Poole
- Departments of Anatomy and Physiology and Kinesiology, Kansas State University, Manhattan, Kansas
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7
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Kitzman DW, Nicklas B, Kraus WE, Lyles MF, Eggebeen J, Morgan TM, Haykowsky M. Skeletal muscle abnormalities and exercise intolerance in older patients with heart failure and preserved ejection fraction. Am J Physiol Heart Circ Physiol 2014; 306:H1364-70. [PMID: 24658015 DOI: 10.1152/ajpheart.00004.2014] [Citation(s) in RCA: 219] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Heart failure (HF) with preserved ejection fraction (HFPEF) is the most common form of HF in older persons. The primary chronic symptom in HFPEF is severe exercise intolerance, and its pathophysiology is poorly understood. To determine whether skeletal muscle abnormalities contribute to their severely reduced peak exercise O2 consumption (Vo2), we examined 22 older HFPEF patients (70 ± 7 yr) compared with 43 age-matched healthy control (HC) subjects using needle biopsy of the vastus lateralis muscle and cardiopulmonary exercise testing to assess muscle fiber type distribution and capillarity and peak Vo2. In HFPEF versus HC patients, peak Vo2 (14.7 ± 2.1 vs. 22.9 ± 6.6 ml·kg(-1)·min(-1), P < 0.001) and 6-min walk distance (454 ± 72 vs. 573 ± 71 m, P < 0.001) were reduced. In HFPEF versus HC patients, the percentage of type I fibers (39.0 ± 11.4% vs. 53.7 ± 12.4%, P < 0.001), type I-to-type II fiber ratio (0.72 ± 0.39 vs. 1.36 ± 0.85, P = 0.001), and capillary-to-fiber ratio (1.35 ± 0.32 vs. 2.53 ± 1.37, P = 0.006) were reduced, whereas the percentage of type II fibers was greater (61 ± 11.4% vs. 46.3 ± 12.4%, P < 0.001). In univariate analyses, the percentage of type I fibers (r = 0.39, P = 0.003), type I-to-type II fiber ratio (r = 0.33, P = 0.02), and capillary-to-fiber ratio (r = 0.59, P < 0.0001) were positively related to peak Vo2. In multivariate analyses, type I fibers and the capillary-to-fiber ratio remained significantly related to peak Vo2. We conclude that older HFPEF patients have significant abnormalities in skeletal muscle, characterized by a shift in muscle fiber type distribution with reduced type I oxidative muscle fibers and a reduced capillary-to-fiber ratio, and these may contribute to their severe exercise intolerance. This suggests potential new therapeutic targets in this difficult to treat disorder.
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Affiliation(s)
- Dalane W Kitzman
- Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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8
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Rehn TA, Munkvik M, Lunde PK, Sjaastad I, Sejersted OM. Intrinsic skeletal muscle alterations in chronic heart failure patients: a disease-specific myopathy or a result of deconditioning? Heart Fail Rev 2013; 17:421-36. [PMID: 21996779 DOI: 10.1007/s10741-011-9289-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Chronic heart failure (CHF) patients frequently experience impaired exercise tolerance due to skeletal muscle fatigue. Studies suggest that this in part is due to intrinsic alterations in skeletal muscle of CHF patients, often interpreted as a disease-specific myopathy. Knowledge about the mechanisms underlying these skeletal muscle alterations is of importance for the pathophysiological understanding of CHF, therapeutic approach and rehabilitation strategies. We here critically review the evidence for skeletal muscle alterations in CHF, the underlying mechanisms of such alterations and how skeletal muscle responds to training in this patient group. Skeletal muscle characteristics in CHF patients are very similar to what is reported in response to chronic obstructive pulmonary disease (COPD), detraining and deconditioning. Furthermore, skeletal muscle alterations observed in CHF patients are reversible by training, and skeletal muscle of CHF patients seems to be at least as trainable as that of matched controls. We argue that deconditioning is a major contributor to the skeletal muscle dysfunction in CHF patients and that further research is needed to determine whether, and to what extent, the intrinsic skeletal muscle alterations in CHF represent an integral part of the pathophysiology in this disease.
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Affiliation(s)
- T A Rehn
- Institute for Experimental Medical Research, Oslo University Hospital, Ullevaal, Oslo, Norway.
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9
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Skeletal Muscle Adaptation in Response to Supervised Exercise Training for Intermittent Claudication. Eur J Vasc Endovasc Surg 2012; 44:313-7. [DOI: 10.1016/j.ejvs.2012.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 07/02/2012] [Indexed: 11/18/2022]
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10
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Swank AM, Horton J, Fleg JL, Fonarow GC, Keteyian S, Goldberg L, Wolfel G, Handberg EM, Bensimhon D, Illiou MC, Vest M, Ewald G, Blackburn G, Leifer E, Cooper L, Kraus WE. Modest increase in peak VO2 is related to better clinical outcomes in chronic heart failure patients: results from heart failure and a controlled trial to investigate outcomes of exercise training. Circ Heart Fail 2012; 5:579-85. [PMID: 22773109 DOI: 10.1161/circheartfailure.111.965186] [Citation(s) in RCA: 228] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The prognostic ability of a single measurement of peak oxygen uptake (VO(2)) is well established in patients with chronic heart failure. The relation between a change in peak VO(2) and clinical outcomes is not well defined. METHODS AND RESULTS This investigation determined whether an increase in peak VO(2) was associated with a lower risk of the primary end point of time to all-cause mortality or all-cause hospitalization and 3 secondary end points. In Heart Failure and a Controlled Trial to Investigate Outcomes of Exercise Training, an exercise training trial for patients with systolic heart failure, cardiopulmonary exercise tests were performed at baseline and ≈3 months later in 1620 participants. Median peak VO(2) in the combined sample increased from 15.0 (11.9-18.0 Q1-Q3) to 15.4 (12.3-18.7 Q1-Q3) mL·kg(-1)·min(-1). Every 6% increase in peak VO(2,) adjusted for other significant predictors, was associated with a 5% lower risk of the primary end point (hazard ratio=0.95; CI=0.93-0.98; P<0.001); a 4% lower risk of the secondary end point of time to cardiovascular mortality or cardiovascular hospitalization (hazard ratio=0.96; CI=0.94-0.99; P<0.001); an 8% lower risk of cardiovascular mortality or heart failure hospitalization (hazard ratio=0.92; CI=0.88-0.96; P<0.001); and a 7% lower all-cause mortality (hazard ratio=0.93; CI=0.90-0.97; P<0.001). CONCLUSIONS Among patients with chronic systolic heart failure, a modest increase in peak VO(2) over 3 months was associated with a more favorable outcome. Monitoring the change in peak VO(2) for such patients may have benefit in assessing prognosis.
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Affiliation(s)
- Ann M Swank
- Exercise Physiology Laboratory University of Louisville, Louisville, KY 40292, USA.
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11
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Nilsson KR, Duscha BD, Hranitzky PM, Kraus WE. Chronic heart failure and exercise intolerance: the hemodynamic paradox. Curr Cardiol Rev 2011; 4:92-100. [PMID: 19936283 PMCID: PMC2779357 DOI: 10.2174/157340308784245757] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 11/23/2007] [Accepted: 12/03/2007] [Indexed: 01/14/2023] Open
Abstract
Heart failure represents a major source of morbidity and mortality in industrialized nations. As the leading hospital discharge diagnosis in the United States in patients over the age of 65, it is also associated with substantial economic costs. While the acute symptoms of volume overload frequently precipitate inpatient admission, it is the symptoms of chronic heart failure, including fatigue, exercise intolerance and exertional dyspnea, that impact quality of life. Over the last two decades, research into the enzymatic, histologic and neurohumoral alterations seen with heart failure have revealed that hemodynamic derangements do not necessarily correlate with symptoms. This “hemodynamic paradox” is explained by alterations in the skeletal musculature that occur in response to hemodynamic derangements. Importantly, gender specific effects appear to modify both disease pathophysiology and response to therapy. The following review will discuss our current understanding of the systemic effects of heart failure before examining how exercise training and cardiac resynchronization therapy may impact disease course.
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Affiliation(s)
- Kent R Nilsson
- Department of Medicine, Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina, USA
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12
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Abstract
The volume of literature attesting to the clinical benefits of exercise training in patients with stable chronic heart failure (CHF) is substantial. Training can improve symptoms and exercise capacity, as well as reducing morbidity, mortality, and rates of emergency hospitalization. These benefits are apparent in all patients with stable CHF, irrespective of age or sex, or the etiology or severity of heart failure. Training regimens for patients with stable, systolic CHF should form part of a comprehensive heart-failure support effort and are best delivered using supervised in-hospital exercise combined with some training at home or in a group setting in community centers. In this Review, the modes and intensity of exercise training, selection of patients, duration of training effects, and other clinical guidance for using this treatment option are discussed.
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Affiliation(s)
- Andrew J Stewart Coats
- The Norwich Research Park, University of East Anglia, Colney Lane, Norwich, Norfolk NR4 7TJ, UK.
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Antunes-Correa LM, Melo RC, Nobre TS, Ueno LM, Franco FGM, Braga AMW, Rondon MUPB, Brum PC, Barretto ACP, Middlekauff HR, Negrao CE. Impact of gender on benefits of exercise training on sympathetic nerve activity and muscle blood flow in heart failure. Eur J Heart Fail 2010; 12:58-65. [PMID: 20023046 DOI: 10.1093/eurjhf/hfp168] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIMS We compared the effects of exercise training on neurovascular control and functional capacity in men and women with chronic heart failure (HF). METHODS AND RESULTS Forty consecutive HF outpatients from the Heart Institute, University of Sao Paulo, Brazil were divided into the following four groups matched by age: men exercise-trained (n = 12), men untrained (n = 10), women exercise-trained (n = 9), women untrained (n = 9). Maximal exercise capacity was determined from a maximal progressive exercise test on a cycle ergometer. Forearm blood flow was measured by venous occlusion plethysmography. Muscle sympathetic nerve activity (MSNA) was recorded directly using the technique of microneurography. There were no differences between groups in any baseline parameters. Exercise training produced a similar reduction in resting MSNA (P = 0.000002) and forearm vascular resistance (P = 0.0003), in men and women with HF. Peak VO(2) was similarly increased in men and women with HF (P = 0.0003) and VE/VCO(2) slope was significantly decreased in men and women with HF (P = 0.0007). There were no significant changes in left-ventricular ejection fraction in men and women with HF. CONCLUSION The benefits of exercise training on neurovascular control and functional capacity in patients with HF are independent of gender.
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Affiliation(s)
- Ligia M Antunes-Correa
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44 Cerqueira Cesar, São Paulo SP CEP 05403-904, Brazil
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14
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Abstract
Clinical consequences of heart failure are fatigue, dyspnea, and progressive impairment of exercise tolerance. Regular exercise training is associated with health-improving effects. In patients with stable heart failure, exercise training can relieve symptoms, improve exercise capacity and quality of life, as well as reduce hospitalization and, to some extent, risk of mortality. Progressive exercise training is associated with pulmonary, cardiovascular, and skeletal muscle metabolic adaptations that increase oxygen delivery and energy production. This Review focuses on current knowledge of mechanisms by which progressive and moderate exercise training can have sustained beneficial effects on patients with heart failure.
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15
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Implications of chronic heart failure on peripheral vasculature and skeletal muscle before and after exercise training. Heart Fail Rev 2008; 13:21-37. [PMID: 17955365 DOI: 10.1007/s10741-007-9056-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The pathophysiology of chronic heart failure (CHF) is typically conceptualized in terms of cardiac dysfunction. However, alterations in peripheral blood flow and intrinsic skeletal muscle properties are also now recognized as mechanisms for exercise intolerance that can be modified by therapeutic exercise. This overview focuses on blood delivery, oxygen extraction and utilization that result from heart failure. Related features of inflammation, changes in skeletal muscle signaling pathways, and vulnerability to skeletal muscle atrophy are discussed. Specific focus is given to the ways in which perfusion and skeletal muscle properties affect exercise intolerance and how peripheral improvements following exercise training increase aerobic capacity. We also identify gaps in the literature that may constitute priorities for further investigation.
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16
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Hsich E, Chadalavada S, Krishnaswamy G, Starling RC, Pothier CE, Blackstone EH, Lauer MS. Long-term prognostic value of peak oxygen consumption in women versus men with heart failure and severely impaired left ventricular systolic function. Am J Cardiol 2007; 100:291-5. [PMID: 17631085 DOI: 10.1016/j.amjcard.2007.02.096] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Revised: 02/13/2007] [Accepted: 02/13/2007] [Indexed: 10/23/2022]
Abstract
Although peak oxygen consumption (VO(2)) during exercise is frequently used to help predict optimal timing for heart transplantation, its long-term prognostic value in women is not known. We followed 2,105 adult patients with heart failure (HF) and with impaired left ventricular (LV) systolic function for 5 years, including 525 women (25%) who underwent metabolic stress testing between January 1995 and December 2002. Multivariable proportional hazards modeling related VO(2) to survival with adjustments for >30 confounders and with transplantation considered as a time-dependent covariate. During follow-up, 129 women (26%) died, as did 572 men (36%). There were 175 transplants, including 34 women. Women and men were similar in age (54 vs 55 years), but women were less likely to have coronary artery disease (28% vs 58%). Peak VO(2) was strongly predictive of time to death in women (adjusted hazard ratio [HR] for peak VO(2) decreasing from 15 to 14 ml/kg/min, 1.11, 95% confidence interval [CI] 1.05 to 1.18, p <0.0001) and in men (adjusted HR 1.12, 95% CI 1.08 to 1.16, p <0.0001). There was no gender interaction with peak VO(2) (p = 0.80), but for any given peak VO(2) women were at lower risk (adjusted HR for men compared with women 2.22, 95% CI 1.58 to 3.10, p <0.0001). A significant interaction was found between gender and presence of coronary artery disease (p for interaction 0.02); in women, those with ischemic cardiomyopathy had a worse survival for any given peak VO(2). In conclusion, in this large cohort, peak VO(2) predicted survival in women and men whether or not coronary artery disease was present, but an interaction was noted between coronary artery, gender, and survival.
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Affiliation(s)
- Eileen Hsich
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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17
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Li P, Waters RE, Redfern SI, Zhang M, Mao L, Annex BH, Yan Z. Oxidative phenotype protects myofibers from pathological insults induced by chronic heart failure in mice. THE AMERICAN JOURNAL OF PATHOLOGY 2007; 170:599-608. [PMID: 17255328 PMCID: PMC1851852 DOI: 10.2353/ajpath.2007.060505] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The fiber specificity of skeletal muscle abnormalities in chronic heart failure (CHF) has not been defined. We show here that transgenic mice (8 weeks old) with cardiac-specific overexpression of calsequestrin developed CHF (50.9% decrease in fractional shortening and 56.4% increase in lung weight, P<0.001), cachexia (37.8% decrease in body weight, P<0.001), and exercise intolerance (69.3% decrease in running distance to exhaustion, P<0.001) without a significant change in muscle fiber-type composition. Slow oxidative soleus muscle maintained muscle mass, whereas fast glycolytic tibialis anterior and plantaris muscles underwent atrophy (11.6 and 13.3%, respectively; P<0.05). In plantaris muscle, glycolytic type IId/x and IIb, but not oxidative type I and IIa, fibers displayed significant decreases in cross-sectional area (20.3%, P<0.05). Fast glycolytic white vastus lateralis muscle showed sarcomere degeneration and decreased cytochrome c oxidase IV (39.5%, P<0.01) and peroxisome proliferator-activated receptor gamma co-activator 1alpha protein expression (30.3%, P<0.01) along with a dramatic induction of the MAFbx/Atrogin-1 mRNA. These findings suggest that exercise intolerance can occur in CHF without fiber type switching in skeletal muscle and that oxidative phenotype renders myofibers resistant to pathological insults induced by CHF.
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Affiliation(s)
- Ping Li
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 4321 Medical Park Dr., Suite 200, Durham, NC 27704, USA
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18
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Kao A. The role of exercise therapy in the treatment of patients with systolic heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2006; 8:310-24. [PMID: 17038271 DOI: 10.1007/s11936-006-0052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The predominant benefits of exercise training in systolic heart failure have been seen with aerobic training, although some information exists for the beneficial effects of resistive training as well. Although men clearly benefit from exercise training, the effects of exercise in women are less clear. Most of the studies have used supervised training 3 to 5 days a week for 8 weeks to 6 months, with 30 to 60 minutes of exercise per session. However, home exercise has been reported in a few studies, and appears to be safe and possibly efficacious. The effects of training on mortality are unknown at this time, although no study has demonstrated increased adverse events associated with training. Exercise training should be recommended for patients with stable New York Heart Association class II to III heart failure.
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Affiliation(s)
- Andrew Kao
- Cardiovascular Consultants, Mid-America Heart Institute, 4330 Wornall Road, Suite 2000, Kansas City, MO 64111, USA.
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19
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Crespo Leiro MG, Paniagua Martín MJ. Insuficiencia cardiaca. ¿Son diferentes las mujeres? Rev Esp Cardiol 2006. [DOI: 10.1157/13091374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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20
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Abstract
The past 15 years of research involving patients with heart failure have provided a lot of new information regarding how exercise training lessens the exercise intolerance that is characteristic of these patients. Despite these new understandings, the prescription of regular exercise and rehabilitation in eligible patients is not embraced by all practitioners. Such reluctance may be due, in part, to concerns about either the safety of the treatment or the absence of multisite, randomized, controlled trial data that evaluates clinical end-points. This paper focuses on how exercise capacity is improved through training in patients with heart failure and suggests future considerations with respect to the study and application of this novel therapy.
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Affiliation(s)
- Steven J Keteyian
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA.
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21
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Harjola VP, Kiilavuori K, Virkamäki A. The effect of moderate exercise training on skeletal muscle myosin heavy chain distribution in chronic heart failure. Int J Cardiol 2006; 109:335-8. [PMID: 16458984 DOI: 10.1016/j.ijcard.2005.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2004] [Revised: 06/05/2005] [Accepted: 06/11/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND The myosin heavy chain (MHC) is altered in chronic heart failure (CHF), but the effect of exercise on MHC expression in CHF patients is not understood. The aim of the present study was to show the effect of aerobic exercise on MHC distribution in patients with CHF. METHODS Patients (n=17) with stable NYHA class I-III CHF were randomised into training and control groups. For a period of three months, the training group cycled on an ergometric cycle 3 times a week for 30 min, the control group continued as they did previously. Both a baseline and a final 3 month graded maximal exercise test and exercise endurance test with constant submaximal work load were performed. Muscle samples, obtained from vastus lateralis muscle at baseline and after 3 months from the 8 patients in the training group and the 9 in the control group, were analysed for MHC distribution using SDS-polyacrylamide gel electrophoresis. RESULTS Baseline MHC distributions were similar in both groups and training did not alter the MHC distribution. Exercise duration, at constant submaximal work load, improved from 14.9+/-7.1 to 26.9+/-9.6 min (p<0.01 for the change between the groups). Training did not improve peak oxygen consumption. CONCLUSION No correlation between the change in exercise capacity and MHC distribution appeared despite the significant improvement of exercise duration.
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Affiliation(s)
- Veli-Pekka Harjola
- Division of Emergency Care, Department of Medicine, Helsinki University Central Hospital, POB 340, FIN-00029 HUS, Finland
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Smart N, Marwick TH. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Am J Med 2004; 116:693-706. [PMID: 15121496 DOI: 10.1016/j.amjmed.2003.11.033] [Citation(s) in RCA: 306] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Accepted: 10/28/2003] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine the efficacy of exercise training and its effects on outcomes in patients with heart failure. METHODS MEDLINE, Medscape, and the Cochrane Controlled Trials Registry were searched for trials of exercise training in heart failure patients. Data relating to training protocol, exercise capacity, and outcome measures were extracted and reviewed. RESULTS A total of 81 studies were identified: 30 randomized controlled trials, five nonrandomized controlled trials, nine randomized crossover trials, and 37 longitudinal cohort studies. Exercise training was performed in 2387 patients. The average increment in peak oxygen consumption was 17% in 57 studies that measured oxygen consumption directly, 17% in 40 studies of aerobic training, 9% in three studies that only used strength training, 15% in 13 studies of combined aerobic and strength training, and 16% in the one study on inspiratory training. There were no reports of deaths that were directly related to exercise during more than 60,000 patient-hours of exercise training. During the training and follow-up periods of the randomized controlled trials, there were 56 combined (deaths or adverse events) events in the exercise groups and 75 combined events in the control groups (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.61 to 1.32; P = 0.60). During this same period, 26 exercising and 41 nonexercising subjects died (OR = 0.71; 95% CI: 0.37 to 1.02; P = 0.06). CONCLUSION Exercise training is safe and effective in patients with heart failure. The risk of adverse events may be reduced, but further studies are required to determine whether there is any mortality benefit.
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Affiliation(s)
- Neil Smart
- University of Queensland Department of Medicine, Princess Alexandra Hospital, Brisbane, Australia
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Jessup M, Piña IL. Is it important to examine gender differences in the epidemiology and outcome of severe heart failure? J Thorac Cardiovasc Surg 2004; 127:1247-52. [PMID: 15115978 DOI: 10.1016/j.jtcvs.2003.09.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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