Celiprolol augments the effect of physical exercise on insulin sensitivity and serum lipid levels in chronic heart failure

Nordic Walking Training Causes a Decrease in Blood Cholesterol in Elderly Women Supplemented with Vitamin D

OBJECTIVE

Different studies have demonstrated that regular exercise can induce changes in the lipid profile, but results remain inconclusive. Available data suggest that correction of vitamin D deficiency can improve the lipid profile. In this study, we have hypothesized that Nordic Walking training will improve lipid profile in elderly women supplemented with vitamin D.

METHODS

A total of 109 elderly women (68 ± 5.12 years old) took part in the study. First group [experimental group (EG): 35 women] underwent 12 weeks of Nordic Walking (NW) training combined with vitamin D supplementation (4,000 IU/day), second group [supplementation group (SG): 48 women] was only supplemented with vitamin D (4,000 IU/day), and third group [control group (CG): 31 women] was not subject to any interventions. Blood analysis of total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and 25-OH-D₃ was performed at baseline and after the 12 weeks of NW training. Additionally, a battery of field tests specifically developed for older adults was used to assess the components of functional fitness. The same blood analysis was repeated for the EG 6 months after the main experiment.

RESULTS

After 12 weeks of NW training and vitamin D supplementation, in the EG a decrease in TC, LDL-C, and TG was observed. In the SG, no changes in the lipid profile were observed, whereas in the CG an increase in the HDL-C level was noticed. Positive physical fitness changes were only observed in the EG.

CONCLUSION

Our obtained data confirmed baseline assumption that regular exercise induces positive alternations in lipid profile in elderly women supported by supplementation of vitamin D.

Metabolic remodelling in human heart failure

In addition to the typical abnormalities in myocardial structure and function, it is well established that the cardiac metabolism is abnormal in patients with heart failure (HF). Insulin resistance is a common co-morbidity in HF patients and also modulates cardiac metabolism in HF. The notion that an altered myocardial metabolism may contribute to the disease pathogenesis and optimizing it may serve therapeutic purposes underscores the importance of identifying the metabolic characteristics of HF patients. In this paper, the literature on the metabolic changes in human HF is reviewed, and the effects of metabolic modulators on patients with HF are discussed.

[Physical training with beta-blockers in chronic heart failure]

In patients with chronic heart failure, the efficacy of beta-blocker therapy on mortality and the multiple benefits observed with physical training justify the association of the both. The effects of betablockade on different systems solicited in the exercise, particularly on the cardiocirculatory response during exercise test, rise many questions about the impact of beta blocker treatment on the changes induced by physical training. The cardioselective and vasodilating properties of beta-blockers play a role. It seems that the improved performance assessed by peak oxygen uptake (peak VO2) resulting from physical training is not limited by the beta-blocker treatment in patients with chronic heart failure. Synergistic effects have been observed, but many issues remain unsolved.

Efeitos do treinamento resistido na lipoproteína de baixa densidade

Os benefícios da prática regular do exercício físico estão claramente estabelecidos na literatura. Entretanto, a escolha do tipo de exercício ideal pode ser mais salutar para indivíduos com doenças específicas e patologias associadas. O propósito desta revisão foi verificar se o treinamento resistido (TR) exerce alguma alteração no colesterol da lipoproteína de baixa densidade (LDL-C). Foram observadas grandes diferenças na literatura, dificultando uma conclusão em relação aos benefícios do TR nesta revisão. No entanto, foi visto que o TR pode ser promissor na redução dos níveis de LDL-C, principalmente em homens e mulheres adultos, em pacientes com diabetes mellitus tipo 1 e tipo 2 e em mulheres pré-menopausa, não mostrando diferenças na população idosa. Os autores concluem que o TR é uma boa opção de exercício físico para indivíduos, principalmente quando o treinamento aeróbio (TA) é contraindicado.

Decreased Myocardial Free Fatty Acid Uptake in Patients With Idiopathic Dilated Cardiomyopathy: Evidence of Relationship With Insulin Resistance and Left Ventricular Dysfunction

BACKGROUND

Results on myocardial substrate metabolism in the failing heart have been contradictory. Insulin resistance, a common comorbidity in heart failure patients, and medical therapy may modify myocardial metabolism in complex fashions. Therefore, we characterized myocardial oxidative and free fatty acid (FFA) metabolism in patients with idiopathic dilated cardiomyopathy (IDCM) and investigated the contributions of insulin resistance and beta-blocker therapy.

METHODS AND RESULTS

Nineteen patients with IDCM (age 58 +/- 8 years, ejection fraction 33 +/- 8.8%) and 15 healthy controls underwent examination of myocardial blood perfusion, oxidative and FFA metabolism using positron emission tomography and [(15)O]H(2)O, [(11)C]acetate and [(11)C]palmitate, respectively. Echocardiography was used to assess myocardial function, work, and efficiency of forward work. Insulin resistance was calculated using the homeostasis model assessment index (HOMA index) and the degree of beta-blockade was estimated with a beta-adrenoceptor occupancy test. IDCM patients were characterized by decreased cardiac efficiency (35 +/- 2 versus 57 +/- 12 mm Hg.L.g(-1), P < .0001) and reduced myocardial FFA uptake (5.5 +/- 2.0 versus 6.4 +/- 1.2 mumol.100 g(-1).min(-1), P < .05), but the FFA beta-oxidation rate constant was not changed. In the patients, myocardial FFA uptake was inversely associated with left ventricular (LV) ejection fraction (r = -0.63, P < .01), indicating that further depression of LV function induces an opposite switch to greater FFA uptake. The FFA beta-oxidation rate constant correlated positively with the HOMA index (r = 0.53, P < .05). In patients on beta-1 selective beta-blockers, beta-1 adrenoceptor occupancy correlated inversely with LV work, oxidative metabolism, and FFA uptake; similar relationships were not found in patients on nonselective beta-blocker.

CONCLUSIONS

Myocardial FFA metabolism is reduced in patients with IDCM. However, when LV function is further depressed and insulin resistance manifested, myocardial FFA uptake and oxidation are, in turn, upregulated. These findings may partly explain the discrepancies between previous studies about cardiac metabolism in heart failure.

Effect of Physical Training on Insulin Resistance in Patients With Chronic Heart Failure

BACKGROUND

The effect of physical training on insulin resistance (IR) in chronic heart failure (CHF) remains unclear.

METHODS AND RESULTS

Fourteen patients with CHF performed physical training using a bicycle ergometer; 9 patients (64%) were hyperinsulinemic and insulin resistant (HOMA IR > 1.97). Exercise tolerance increased (5.1 +/- 1.7 to 6.9 +/- 2.7 METs, p < 0.05) and heart rate at rest decreased (82 +/- 15 to 72 +/- 6, p < 0.05) in the IR group after physical training. Physical training also decreased the insulin level (15.1 +/- 5.6 to 9.8 +/- 2.6 microU/ml, p < 0.05) and HOMA IR (3.7 +/- 1.4 to 2.3 +/- 0.6, p < 0.05) in the IR group, but not in the 5 patients (36%) without IR or in 6 control patients.

CONCLUSION

Physical training can improve hyperinsulinemia and IR in patients with CHF.

Does Carvedilol Impair Insulin Sensitivity in Heart Failure Patients Without Diabetes?

BACKGROUND

An increased risk for impaired glucose tolerance or diabetes was shown in patients on beta-blockers, whereas alpha1 blockers seem to have favorable effects on glycemic profile. In this study, the metabolic effect of carvedilol in nondiabetic patients with chronic heart failure (CHF) was evaluated.

METHODS AND RESULTS

Twenty-eight nondiabetic CHF patients were enrolled. Before being started on carvedilol and on the highest tolerated dose, each patient underwent an oral glucose tolerance test and fasting insulin, glycohemoglobin, lipid concentrations were measured and insulin sensitivity indices (HOMA, ISI-gly, and ISI-composite) were calculated. An impaired glucose tolerance was found (2-hour glycemia 144 +/- 42 mg/dL), with a fasting glycemia at upper limits of normal (108 +/- 13 mg/dL) and no significant differences between basal and carvedilol treatment measurements. Fasting insulinemia significantly decreased during carvedilol treatment (13.6 +/- 7.3 versus 9.8 +/- 5.1 muU/mL; P = .022), with a reduction of the HOMA index (3.75 +/- 1.95 versus 2.73 +/- 1.47; P = 034) and an increase of the ISI-gly index (0.85 +/- 0.22 versus 1.03 +/- 0.31; P = .025). The lipoprotein profile did not significantly change.

CONCLUSION

Carvedilol might have some positive metabolic effects on increasing insulin sensitivity that would make it suitable for diabetic patients that have a worse prognosis than non diabetic patients with CHF.

Celiprolol, A Vasodilatory β-Blocker, Inhibits Pressure Overload–Induced Cardiac Hypertrophy and Prevents the Transition to Heart Failure via Nitric Oxide–Dependent Mechanisms in Mice

Background— The blockade of β-adrenergic receptors reduces both mortality and morbidity in patients with chronic heart failure, but the cellular mechanism remains unclear. Celiprolol, a selective β 1 -blocker, was reported to stimulate the expression of endothelial NO synthase (eNOS) in the heart, and NO levels have been demonstrated to be related to myocardial hypertrophy and heart failure. Thus, we aimed to clarify whether celiprolol attenuates both myocardial hypertrophy and heart failure via the NO-signal pathway.

Methods and Results— In rat neonatal cardiac myocytes, celiprolol inhibited protein synthesis stimulated by either isoproterenol or phenylephrine, which was partially suppressed by N G -nitro- l -arginine methyl ester (L-NAME). Four weeks after transverse aortic constriction (TAC) in C57BL/6 male mice, the ratio of heart weight to body weight (mg/g) (8.70±0.42 in TAC, 6.61±0.44 with celiprolol 100 mg · kg −1 · d −1 PO, P <0.01) and the ratio of lung weight to body weight (mg/g) (10.27±1.08 in TAC, 7.11±0.70 with celiprolol 100 mg · kg −1 · d −1 PO, P <0.05) were lower and LV fractional shortening was higher in the celiprolol-treated groups than in the TAC group. All of these improvements were blunted by L-NAME. Celiprolol treatment significantly increased myocardial eNOS and activated phosphorylation of eNOS. Myocardial mRNA levels of natriuretic peptide precursor type B and protein inhibitor of NO synthase, which were increased in the TAC mice, were decreased in the celiprolol-treated mice.

Conclusions— These findings indicated that celiprolol attenuates cardiac myocyte hypertrophy both in vitro and in vivo and halts the process leading from hypertrophy to heart failure. These effects are mediated by a selective β 1 -adrenergic receptor blockade and NO-dependent pathway.

Determinants of insulin sensitivity in chronic heart failure

OBJECTIVE

To describe the determinants of insulin sensitivity (IS) in chronic heart failure (CHF), we created a model in which the influence of lifestyle factors and etiology of heart failure on IS were incorporated concomitantly with age, left ventricular ejection fraction (LVEF) and parameters of body composition.

DESIGN

Observational cohort study.

SETTING

Outpatient clinic for chronic heart failure.

PATIENTS

Fifty-seven male CHF patients [NYHA class II-III, age 61+/-9 years, body mass index (BMI) 26.9+/-3.3 kg/m2 (mean+/-S.D.)].

INTERVENTIONS

Euglycemic hyperinsulinemic clamp, cycle ergometry, anthropometric measurements, LVEF and a physical activity questionnaire.

MAIN OUTCOME MEASURES

A model explaining the variance of IS in CHF.

RESULTS

IS was 18.2+/-8.6 microg.kg(-1).min(-1).mU(-1).l(-1), fasting insulin level was 15.9+/-11.0 mU/l and fasting glucose level was 5.5+/-0.6 mmol/l. Peak VO2 was 19.1+/-4.9 ml.kg(-1).min(-1) and LVEF 26.2+/-7.1%. IS was inversely associated with fasting insulin concentration (r=-0.50, P<0.001) and BMI (r=-0.54, P<0.001). After controlling for BMI, IS also revealed a correlation with age (r=-0.36, P<0.01). The model explained 60% of variance in IS: BMI contributed 20%, smoking 17%, age 17% and physical activity in daily life (DPA) 16% (all P<0.05) to the variance of IS, whereas LVEF (9%) and etiology of heart failure (8%) contributed moderately.

CONCLUSIONS

In CHF patients, IS is for a major part predicted by BMI, smoking, age, daily physical activity, LVEF and etiology of heart failure.

Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity

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.

Vasodilating beta-adrenoceptor blockers as cardiovascular therapeutics

beta-Adrenoceptor blocking agents (beta-blockers) have been established as therapeutics for treatment of patients with hypertension, ischemic heart diseases, chronic heart failure, arrhythmias, and glaucoma. However, their clinical use is limited because some patients are adversely affected by their side effects. The discovery of cardioselective (beta(1)-selective) blockers has overcome some of the problems. Current retrospective studies have revealed that vasodilating beta-blockers (so-called beta-blockers of the third generation) have advantages over the conventional type of beta-blockers in terms of minimizing the adverse effects and improving the disease-derived dysfunction, thus enhancing the quality of life variables. Some of the possible advantages include improvement of insulin resistance, decrease in low-density lipoprotein cholesterol in association with increase in high-density lipoprotein cholesterol, attenuation of bronchial asthma attack and respiratory dysfunction, alleviation of coronary vasospasm provocation, peripheral circulatory disturbances, and erectile dysfunction, and better patient compliance. Release of nitric oxide, antioxidant action, beta(2)-adrenoceptor activation, Ca(2+) entry blockade, and other mechanisms underlying the vasodilating action may be responsible for the beneficial therapeutic effects of these agents.

Exercise training improves insulin stimulated skeletal muscle glucose uptake independent of changes in perfusion in patients with dilated cardiomyopathy

OBJECTIVE

The purpose of the present study was to investigate the effects of a 5-month exercise training program on skeletal muscle perfusion and insulin sensitivity at rest and during exercise in patients with idiopathic dilative cardiomyopathy (DCM).

BACKGROUND

Patients with chronic heart failure are characterized by impaired insulin sensitivity and endothelial function. It is hypothesized that exercise training improves metabolism by enhancing perfusion in patients with heart failure.

METHODS

Fifteen DCM patients (New York Heart Association I-III) on stable medical therapy participated in the study. Patients were divided to receive either supervised strength and aerobic training (n=9, left ventricular ejection fraction [LVEF]=34 +/- 8%) for 5 months (3 times per week at an intensity of 70% of peak oxygen uptake [VO2]) or standard care (n=7, LVEF=36 +/- 6%) based on their living proximity to the exercise training site. Muscle blood flow, oxygen consumption, and glucose uptake were quantified using [15O]-water, [15O]-oxygen, [18F]FDG, and positron emission tomography (PET) during euglycemic hyperinsulinemia and 1-legged isometric exercise. PET studies were performed twice for each patient at the same individual workloads.

RESULTS

Exercise training improved exercise capacity by 27% (P<.001). Whole body insulin-stimulated glucose uptake enhanced by 23% (P<.05) and muscle glucose uptake by 53% (P<.05) in the trained group but tended to decrease in the untrained group. When studied using identical workloads, muscle glucose uptake in exercising muscles was enhanced by 55% (P<.05), whereas no changes were observed in muscle blood flow and oxygen uptake.

CONCLUSIONS

Exercise training counteracts the impaired insulin sensitivity caused by DCM. Training improves exercise capacity with a concomitant enhancement in whole body, resting, and exercising skeletal muscle glucose uptake. The improved insulin sensitivity is not explained by changes in muscle perfusion suggesting enhanced cellular glucose extraction.

Effect of beta-blockers on insulin resistance in patients with dilated cardiomyopathy

The aim of this study was to evaluate the effect of beta-blockers on insulin resistance in patients with dilated cardiomyopathy (DCM). A secondary aim was to determine the effect of this treatment on plasma concentrations of tumor necrosis factor-alpha (TNF-alpha) and to investigate the relationships between this adipocytokine and insulin resistance. Insulin resistance determined using the Homeostatic Model Assessment (HOMA), echocardiographic measurements and analysis of plasma TNF-alpha concentration were carried out in 47 patients with DCM without diabetes mellitus before and after 6 months of beta-blocker therapy. A reduction in left ventricular dimensions and an associated increase in ejection fraction occurred with beta-blocker. The treatment resulted in a significant decrease in insulin resistance (HOMA index: Baseline, 2.73+/-3.36 vs, Month 6, 1.58+/-1.33, p=0.0347). Beta-blockade was also associated with a decrease in plasma TNF-alpha concentration although no significant relationship between this change and the improvement in insulin resistance was observed. Beta-blocker therapy in patients with DCM improved not only cardiac function, but also insulin resistance. The mechanism of the change in insulin function remains unclear, but may be related to improvements in left ventricular function or an attenuation of the inhibitory effect of reduction in TNF-alpha on insulin signaling.

A practical guide to exercise training for heart failure patients

BACKGROUND

Exercise training has been shown to improve exercise capacity in patients with heart failure. We sought to examine the optimal strategy of exercise training for patients with heart failure.

METHODS

Review of the published data on the characteristics of the training program, with comparison of physiologic markers of exercise capacity in heart failure patients and healthy individuals and comparison of the change in these characteristics after an exercise training program.

RESULTS

Many factors, including the duration, supervision, and venue of exercise training; the volume of working muscle; the delivery mode (eg, continuous vs. intermittent exercise), training intensity; and the concurrent effects of medical treatments may influence the results of exercise training in heart failure. Starting in an individually prescribed and safely monitored hospital-based program, followed by progression to an ongoing and progressive home program of exercise appears to be the best solution to the barriers of anxiety, adherence, and "ease of access" encountered by the heart failure patient.

CONCLUSIONS

Various exercise training programs have been shown to improve exercise capacity and symptom status in heart failure, but these improvements may only be preserved with an ongoing maintenance program.

Rehabilitation of patients with congestive heart failure with or without beta-blockade therapy

BACKGROUND

Management of heart failure includes beta-blockade (betaB) therapy and cardiac rehabilitation. The aim of this study was to compare the exercise training response of patients with congestive heart failure (CHF) receiving betaB therapy with that of patients not receiving treatment.

METHODS AND RESULTS

Thirty-four consecutive patients with CHF were included in a 4-week training program at their ventilatory threshold (VT); 6 patients received betaB treatment and 18 did not. The patients underwent a cardiopulmonary exercise test before and after training. Oxygen uptake (VO(2)) at peak exercise and at VT increased in both groups (P < or =.0001) without any significant differences between the groups. The same results were found after adjustment to ejection fraction and VO(2) at the start of the training program. There was no difference in VT improvement, measured as a percentage of utilization of maximal oxygen uptake, between the groups. After training, heart rate and ventilation decreased (P < or =.0001) at submaximal levels in both groups without significant differences between the groups.

CONCLUSIONS

betaB therapy does not impair functional improvement induced by a rehabilitation program in patients with CHF. betaB therapy does not interfere with exercise training prescription if patient exercise evaluations are made at the time of therapeutic intake.