Exercise training as a therapy for chronic heart failure: can older people benefit?

The Efficacy and Safety of Xinmailong Injection in Patients with Chronic Heart Failure: A Multicenter Randomized Double-Blind Placebo-Controlled Trial

Objectives: Chronic heart failure (CHF) is a chronic and progressive disease with high incidence. The aim of this study was to evaluate the effectiveness and safety of Xinmailong injection (XI) on CHF patients with B-type natriuretic peptide (BNP) ≥200 ng/mL and left ventricular ejection fraction (LVEF) of ≤45%. Trial design: This is a randomized double-blind placebo-controlled trial. Settings: Hospitals. Subjects: One hundred patients with CHF were randomly divided into XI (n = 50) and control groups (n = 50). Intervention: The XI group was treated with standard treatment plus XI (100 mg/2 mL, intravenous drip infusion). The control group was treated with standard treatment plus equal amounts of XI placebo. The course of treatment was 5 days. Outcome measures: New York Heart Association (NYHA) functional class, LVEF, BNP, and 6-min walking distance were assessed for therapeutic effect. Results: NYHA functional classes and LVEF were better in the XI group than in the control (p < 0.01). BNP was significantly different after the treatments in both groups (p < 0.01), and compared with the control, BNP was reduced after XI treatment (p < 0.01). No deaths occurred in the course of this study. The number of adverse events between the two groups was not statistically different (p > 0.05). Conclusions: XI can alleviate the symptoms, improve heart function, and exercise tolerance in patients with CHF and is safe to use.

Feasibility of Conducting a 6-month long Home-based Exercise Program with Protein Supplementation in Elderly Community-dwelling Individuals with Heart Failure

Objective

Cardiac cachexia is a condition associated with heart failure, particularly in the elderly, and is characterized by loss of muscle mass with or without the loss of fat mass. Approximately 15% of elderly heart failure patients will eventually develop cardiac cachexia; such a diagnosis is closely associated with high morbidity and increased mortality. While the mechanism(s) involved in the progression of cardiac cachexia is incompletely established, certain factors appear to be contributory. Dietary deficiencies, impaired bowel perfusion, and metabolic dysfunction all contribute to reduced muscle mass, increased muscle wasting, increased protein degradation, and reduced protein synthesis. Thus slowing or preventing the progression of cardiac cachexia relies heavily on dietary and exercise-based interventions in addition to standard heart failure treatments and medications.

Methods

The aim of the present study was to test the feasibility of an at-home exercise and nutrition intervention program in a population of elderly with heart failure, in an effort to determine whether dietary protein supplementation and increased physical activity may slow the progression, or prevent the onset, of cardiac cachexia. Frail elderly patients over the age of 55 with symptoms of heart failure from UAMS were enrolled in one of two groups, intervention or control. To assess the effect of protein supplementation and exercise on the development of cardiac cachexia, data on various measures of muscle quality, cardiovascular health, mental status, and quality of life were collected and analyzed from the two groups at the beginning and end of the study period.

Results

More than 50% of those who were initially enrolled actually completed the 6-month study. While both groups showed some improvement in their study measures, the protein and exercise group showed a greater tendency to improve than the control group by the end of the six months.

Conclusion

These findings suggest that with a larger cohort, this intervention may show significant positive effects for elderly patients who are at risk of developing cardiac cachexia.

Treatment of heart failure in nursing home residents

Background

For the treatment of chronic heart failure (HF), both pharmacological and non-pharmacological treatment should be employed in HF patients. Although HF is highly prevalent in nursing home residents, it is not clear whether the recommendations in the guidelines for pharmacological therapy also are followed in nursing home residents. The aim of this study is to investigate how HF is treated in nursing home residents and to determine to what extent the current treatment corresponds to the guidelines.

Methods

Nursing home residents of five large nursing home care organizations in the southern part of the Netherlands with a previous diagnosis of HF based on medical records irrespective of the left ventricle ejection fraction (LVEF) were included in this cross-sectional design study. Data were gathered on the (medical) records, which included clinical characteristics and pharmacological- and non-pharmacological treatment. Echocardiography was used as part of the study to determine the LVEF.

Results

Out of 501 residents, 112 had a diagnosis of HF at inclusion. One-third of them received an ACE-inhibitor and 40% used a β-blocker. In 66%, there was a prescription of diuretics with a preference of a loop diuretic. Focusing on the residents with a LVEF ≤ 40%, only 46% of the 22 residents used an ACE-inhibitor and 64% a β-blocker. The median daily doses of prescribed medication were lower than those that were recommended by the guidelines. Non-pharmacological interventions were recorded in almost none of the residents with HF.

Conclusions

The recommended medical therapy of HF was often not prescribed; if prescribed, the dosage was usually far below what was recommended. In addition, non-pharmacological interventions were mostly not used at all.

Essential amino acids and exercise tolerance in elderly muscle-depleted subjects with chronic diseases: a rehabilitation without rehabilitation?

Exercise intolerance remains problematic in subjects with chronic heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). Recent studies show that supplemented essential amino acids (EAAs) may exert beneficial effects on CHF/COPD physical capacity. The results from 3 investigations (2 conducted on CHF and 1 on COPD subjects) served as the basis for this paper. The 3 studies consistently showed that elderly CHF and COPD improved exercise intolerance after 1–3 months of EAA supplementation (8 g/d). In CHF exercise capacity increased 18.7% to 23% (watts; bicycle test), and 12% to 22% (meters) in 6 min walking test. Moreover, patients reduced their resting plasma lactate levels (by 25%) and improved tissue insulin sensitivity by 16% (HOMA index). COPD subjects enjoyed similar benefits as CHF ones. They increased physical autonomy by 78.6% steps/day and decreased resting plasma lactate concentrations by 23%. EAA mechanisms explaining improved exercise intolerance could be increases in muscle aerobic metabolism, mass and function, and improvement of tissue insulin sensitivity (the latter only for the CHF population). These mechanisms could be accounted for by EAA's intrinsic physiological activity which increases myofibrils and mitochondria genesis in skeletal muscle and myocardium and glucose control. Supplemented EAAs can improve the physical autonomy of subjects with CHF/COPD.

Association between mental health and physical activity in patients with chronic heart failure

PURPOSE

Poor mental health (MH) is common in chronic heart failure (CHF) patients. No studies have reported a relation between MH status and objectively measured physical activity (PA) in CHF patients. The study aim was to determine self-reported MH-related differences associated with PA and target values of PA for improved MH in CHF outpatients.

METHODS

We divided 243 CHF outpatients (mean age 57.1 years) into two groups according to MH assessed by Short Form-36 score: high-MH (≥68 points) group (n = 148) and poor-MH (<68 points) group (n = 95). Average step count (steps) and energy expenditure on PA (EE) (kcal) per day for 1 week of PA were assessed by an accelerometer and compared between groups. PA resulting in high MH was determined by the receiver-operating characteristic (ROC) analysis.

RESULTS

PA correlated positively with MH in all patients (steps: r = 0.46, p < 0.001; EE: r = 0.43, p < 0.001). After adjusting for patient characteristics, steps and EE were significantly lower in the poor-MH versus high-MH group (5020.1 ± 280.7 versus 7174.1 ± 221.5 steps, p < 0.001; 133.9 ± 10.8 versus 215.9 ± 8.4 kcal, p < 0.001). Cut-off values of 5590.8 steps and 141.1 kcal were determined as PA target values associated with improved MH.

CONCLUSIONS

Poor MH status may reduce PA. Attaining PA target values may improve MH status of CHF outpatients.

Fit for prison: special population health and fitness programme evaluation

OBJECTIVE

To evaluate a health and fitness programme conducted within a New South Wales, Australia correctional facility for male inmates with a chronic illness.

DESIGN

A randomised control trial.

SAMPLE

Twenty male inmate participants with a chronic illness, two risk factors for developing a chronic illness or who were over the age of 40 years.

MEASUREMENTS

Pre and post programme health assessments that included resting blood pressure and heart rate, weight, body mass index, waist girth, peak flow measures, peripheral saturation of oxygen, blood glucose levels and 6 minute walk test.

INTERVENTION

A 12-week structured exercise programme focusing on cardio respiratory endurance, strength and flexibility training.

RESULTS

Statistically significant improvements in resting heart rate and endurance were found.

CONCLUSIONS

The health and fitness programme positively impacts on the health of inmates with a chronic illness. A further study with a larger sample size would be productive.

Pilot Study of an Exercise Intervention Suitable for Older Heart Failure Patients with Left Ventricular Systolic Dysfunction

Background: Most studies of exercise training for heart failure have been conducted on relatively young patients with little comorbidity. Such programmes are unsuitable for the majority of older frail heart failure patients.

Aims: To test the acceptability and tolerability of an outpatient exercise programme in older heart failure patients with comorbid disease.

Methods: 17 patients aged 70 years and over with left ventricular systolic dysfunction attended twice weekly group exercise classes for 12 weeks, focussing on endurance exercise and everyday functional tasks. Outcome measures were proportion of sessions attended; adverse events and reasons for non-attendance; six-minute walk, accelerometry, hospital depression and anxiety score, Guyatt quality of life scale, carer strain and satisfaction scores.

Results: 83% of sessions were attended; 80% of subjects attended at least 80% of allocated sessions. One adverse incident occurred in 324 person-sessions. Encouraging improvements were seen in six minute walk test (+ 19 m, p = 0.14) and in Functional Limitation Profile score (− 82 points, p = 0.02). 50% of informal carers attended at least one session. No increase in carer strain was noted.

Conclusions: Twice-weekly group exercise focussing on aerobic endurance and everyday functional tasks was acceptable and well-tolerated in this patient group.

Living with chronic heart failure: a review of qualitative studies of older people

AIM

This paper is a report of a systematic review of qualitative studies of how older people live with chronic heart failure.

BACKGROUND

Chronic heart failure is a global epidemic mainly affecting an ageing population. Understanding how older people live with this disease is important to help promote their adjustment to the distressing illness experience.

DATA SOURCES

Eligible studies published in 1997-2007 were identified from several databases (Medline, CINAHL, PsycINFO and Sociological Abstracts). A manual search was conducted of bibliographies of the identified studies and relevant journals.

REVIEW METHODS

Two researchers independently reviewed the studies and extracted the data. Key concepts from the papers were compared for similarities and differences. The transactional model of stress was used to guide data synthesis.

FINDINGS

Fourteen qualitative studies were identified. Most described the illness experiences of older people with chronic heart failure and associated coping strategies. There was some emerging work exploring the adjustment process. The findings indicated that living with chronic heart failure was characterized by distressing symptoms, compromised physical functioning, feelings of powerlessness and hopelessness, and social and role dysfunction. There were gender differences in the way the disease was conceived. Adjustment required patients to make sense of the illness experience, accept the prognosis, and get on with living with the condition.

CONCLUSION

Empowering older people to manage chronic heart failure, instilling hope and bolstering support system are means of promoting successful adjustment to the disease. Further research needs to explore the cultural differences in the adjustment process.

The relationship between exercise and hopelessness in prison

This paper reports on the relationship between the levels of self-reported physical exercise and mental well-being (as measured using the Beck Hopelessness Scale) in a cohort of 914 prisoners within New South Wales, Australia. A significant inverse relationship between self-reported exercise in minutes per week and hopelessness was identified. The need to include exercise as a factor in inmate health plans is discussed.

Non-Pharmacological Interventions in Older People with Heart Failure: Effects of Exercise Training and Relaxation Therapy

BACKGROUND

Effective management of heart failure relies on optimal use of non-pharmacological therapy alongside medical treatment. Yet, there is an inadequate use of non-pharmacological therapy in caring for older people with heart failure.

OBJECTIVE

To examine the effects of relaxation therapy and exercise training on psychological outcomes and disease-specific quality of life of older heart failure patients.

METHODS

Subjects undertook relaxation (n = 59), exercise training (n = 32) or received attention placebo (n = 62) for 12 weeks. The relaxation group attended two training sessions, one revision workshop, and continued with twice-daily taped-directed home relaxation practice, with support from the intervener through bi-weekly telephone contact, for 12 weeks. The exercise group undertook 12 weekly sessions of resistance training and aerobic exercise and thrice weekly home exercise. The control group received regular telephone calls for general 'greetings'.

RESULTS

The relaxation and exercise groups reported a significantly greater improvement in psychological [F(2, 149) = 6.69, p = 0.002] and various disease-specific quality of life outcomes [dyspnea: F(2, 149) = 5.72, p = 0.004; fatigue: F(2, 149) = 3.78, p = 0.25; emotion: F(2, 149) = 6.68, p = 0.001], compared with those who received the attention placebo. While relaxation therapy was more effective to reduce psychological distress, with depression in particular (p < 0.001), exercise therapy worked better to control fatigue symptoms (p = 0.03).

CONCLUSION

Relaxation therapy and exercise training are effective to improve the psychological and physical health of older heart failure patients. They should be used as an individual treatment modality, or as care components of a disease management program.

Effect of a seated exercise program to improve physical function and health status in frail patients > or = 70 years of age with heart failure

Eighty-two patients aged > or = 70 years with heart failure were randomized to a gentle, seated exercise program or to usual care. Six-minute walk distance and quality of life did not change between groups, but daily activity as measured by accelerometry increased in the exercise group relative to the control group.

Exercise as a treatment for depression in elders

PURPOSE

To describe the use of exercise when treating depression in elders and to discuss the data supporting the relationship between increased physical activity and decreased depression.

DATA SOURCES

Extensive review of recent scientific literature, both medical and gerontological in content.

CONCLUSIONS

Increasing physical activity markedly reduces depressive symptoms and is a safe adjunct or alternative to medication therapy.

IMPLICATIONS FOR PRACTICE

Exercise has numerous physical and psychological benefits to patients. Physical activity should be recommended to all patients of all ages.

Benefits of exercise for community-dwelling older adults

This focused review highlights the benefits of exercise and physical activity for community-dwelling older adults. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the benefits of physical activity and exercise for older adults with regard to morbidity, mortality, and disability. It discusses the appropriate preexercise screening and evaluation procedures for older adults contemplating exercise. Last, it reviews the current literature on the benefits of varying modes of exercise to modify the most prevalent chronic medical conditions of late life, including arthritis, heart disease, diabetes, stroke, pulmonary disease, and osteoporosis.

OVERALL ARTICLE OBJECTIVE

To summarize the current knowledge regarding the therapeutic benefits of exercise for community-dwelling older adults.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.

Lifestyle and dietary modification for prevention of heart failure

This article discusses the factors that contribute most to systolic and diastolic heart failure (HF): ischemic heart disease, hypertension,obesity, diabetes, and nephropathy. Diabetes often follows the insulin resistance syndrome in which obesity and hypertension are combined with dyslipidemia, and obesity is likely causal. Diabetes and hypertension are common causes of nephropathy, which in turn is a common precursor to HF. Insulin resistance, obesity,dyslipidemia, diabetes, and hypertension are risk factors for atherosclerotic coronary disease and left ventricular ischemia. Each is also a risk factor for diastolic dysfunction.

Encouraging exercise in older adults with congestive heart failure

Congestive heart failure (CHF) is a chronic medical problem commonly found in older adults. Management of CHF ideally should combine lifestyle modifications and medication management. Exercise prescriptions and encouraging patients with CHF to exercise can have a significant impact on management of symptoms as well as exacerbation of further disease. The recommended exercise program should ideally incorporate 10 to 15 minutes of warm-up with exercise durations of 20 to 30 minutes and a cool-down period generally repeating the warm up exercises. Exercise should be done at least 3 to 5 days per week and should include a combination of aerobic and resistance exercise. The HEART approach provides a useful guide to help motivate older adults with CHF to exercise regularly. In so doing, older adults with CHF will be helped to improve and maintain cardiac status, decrease the symptoms of CHF, and improve overall quality of life.

Exercise as a Time-conditioning Effector in Chronic Disease: a Complementary Treatment Strategy

Exercise has been widely believed to be a preventive and therapeutic aid in the treatment of various pathophysiological conditions such as cardiovascular disease and cancer. A common problem associated with such pathologies is cachexia, characterized by progressive weight loss and depletion of lean and fat body mass, and is linked to poor prognosis. As this syndrome comprises changes in many physiological systems, it is tempting to assume that the modulation of the psychoneuroimmunoendocrine axis could attenuate or even prevent cachexia progression in cancer patients. Cancer cachexia is characterized by a disruption in the rhythmic secretion of melatonin, an important time-conditioning effector. This hormone, secreted by the pineal gland, transmits circadian and seasonal information to all organs and cells of the body, synchronizing the organism with the photoperiod. Considering that exercise modulates the immune response through at least two different mechanisms-metabolic and neuroendocrine-we propose that the adoption of a regular exercise program as a complementary strategy in the treatment of cancer patients, with the exercise bouts regularly performed at the same time of the day, will ameliorate cachexia symptoms and increase survival and quality of life.

The implications of physical activity in patients with chronic heart failure

The clinical syndrome of chronic heart failure is increasingly prevalent. It can be considered a multiorgan disorder that may exert a negative physical and psychological influence on a patient. Medication and surgical intervention have important roles to play and have certainly improved both morbidity and mortality in this field, but clearly these interventions alone are not enough. Excessive resource utilization for this group of patients has provided added impetus to research into non-pharmacological interventions. These encompass dietary and other lifestyle measures, including smoking cessation and exercise. Exercise has been shown to favourably affect the functional capacity and quality of life. There is also emerging evidence that it reduces mortality. In the absence of contraindications, regular endurance exercise coupled with strength training is undoubtedly beneficial. As with other cardiovascular research, there is a trend towards recruiting middle-aged males. This effectively means that practitioners need to be cautious when evaluating and/or implementing research evidence. By addressing the implications of physical activity for deconditioned patients with chronic heart failure, a holistic therapeutic regimen is fostered. This has been shown to improve the quality of life of patients and to enhance the quality of service delivered to this patient group.

Health-related quality of life in elderly chinese patients with heart failure

Heart failure (HF) has a profound impact on patients' health-related quality of life (HRQL). Little is known about factors relating to HRQL in elderly Chinese HF patients. The objective of this cross-sectional correlational study was to identify the demographic, psychosocial, and clinical factors associated with HRQL in this group of patients. Cross-sectional data were obtained from a consecutive sample of hospitalized HF patients (n = 227) with measures of HRQL, psychological distress, perceived social support, and health perception. Functional status was measured with the New York Heart Association Classification (NYHA). In stepwise regression analysis, four variables, including psychological distress, health perception, NYHA classification, and educational level explained 51.8% (p =.01) of the variance in HRQL. These findings suggest that improving HRQL of HF patients entails improving their psychological status, functional status, and health perception.