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Kaluhiokalani JP, Wallace TE, Ahmadi M, Marchant ED, Mehling J, Altuhov S, Dorff A, Leach OK, James JJ, Hancock CR, Hyldahl RD, Gifford JR. Six weeks of localized passive heat therapy elicits some exercise-like improvements in resistance artery function. J Physiol 2024. [PMID: 39004886 DOI: 10.1113/jp286567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
The purpose of this study was to examine the effects of 6 weeks of localized, muscle-focused (quadriceps femoris) passive heat therapy (PHT) on resistance artery function, exercise haemodynamics and exercise performance relative to knee extension (KE) exercise training (EX). We randomized 34 healthy adults (ages 18-36; n = 17 female, 17 male) to receive either PHT or sham heating sessions (120 min, 3 days/week), or EX (40 min, 3 days/week) over 6 weeks. Blood flow was assessed with Doppler ultrasound of the femoral artery during both passive leg movement (PLM) and a KE graded exercise test. Muscle biopsies were taken from the vastus lateralis at baseline and after 6 weeks. Peak blood flow during PLM increased to the same extent in both the EX (∼10.5% increase, P = 0.009) and PHT groups (∼8.5% increase, P = 0.044). Peak flow during knee extension exercise increased in EX (∼19%, P = 0.005), but did not change in PHT (P = 0.523) and decreased in SHAM (∼7%, P = 0.020). Peak vascular conductance during KE increased by ∼25% in EX (P = 0.030) and PHT (P = 0.012). KE peak power increased in EX by ∼27% (P = 0.001) but did not significantly change in PHT and SHAM groups. Expression of endothelial nitric oxide synthase increased significantly in both EX (P = 0.028) and PHT (P = 0.0095), but only EX resulted in increased angiogenesis. In conclusion, 6 weeks of localized PHT improved resistance artery function at rest and during exercise to the same extent as exercise training but did not yield significant improvements in performance. KEY POINTS: Many for whom exercise would be most beneficial are either unable to exercise or have a very low exercise tolerance. In these cases, an alternative treatment to combat declines in resistance artery function is needed. We tested the hypothesis that passive heat therapy (PHT) would increase resistance artery function, improve exercise haemodynamics and enhance exercise performance compared to a sham treatment, but less than aerobic exercise training. This report shows that 6 weeks of localized PHT improved resistance artery function at rest and during exercise to the same extent as exercise training but did not improve exercise performance. Additionally, muscle biopsy analyses revealed that endothelial nitric oxide synthase expression increased in both PHT and exercise training groups, but only exercise resulted in increased angiogenesis. Our data demonstrate the efficacy of applying passive heat as an alternative treatment to improve resistance artery function for those unable to receive the benefits of regular exercise.
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Affiliation(s)
| | - Taysom E Wallace
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Mohadeseh Ahmadi
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Erik D Marchant
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Jack Mehling
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Stepan Altuhov
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Abigail Dorff
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Olivia K Leach
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Jessica J James
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Chad R Hancock
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Robert D Hyldahl
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
| | - Jayson R Gifford
- Department of Exercise Sciences, Brigham Young University, Provo, UT, USA
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Alpenglow JK, Bunsawat K, Francisco MA, Broxterman RM, Craig JC, Iacovelli JJ, Weavil JC, Harrison JD, Morgan DE, Silverton NA, Reese VR, Ma CL, Ryan JJ, Wray DW. α-Adrenergic regulation of skeletal muscle blood flow during exercise in patients with heart failure with preserved ejection fraction. J Physiol 2024; 602:3401-3422. [PMID: 38843407 PMCID: PMC11250769 DOI: 10.1113/jp285526] [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: 08/22/2023] [Accepted: 04/26/2024] [Indexed: 07/17/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) has been characterized by lower blood flow to exercising limbs and lower peak oxygen utilization (V ̇ O 2 ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}}}$ ), possibly associated with disease-related changes in sympathetic (α-adrenergic) signaling. Thus, in seven patients with HFpEF (70 ± 6 years, 3 female/4 male) and seven controls (CON) (66 ± 3 years, 3 female/4 male), we examined changes (%Δ) in leg blood flow (LBF, Doppler ultrasound) and legV ̇ O 2 ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}}}$ to intra-arterial infusion of phentolamine (PHEN, α-adrenergic antagonist) or phenylephrine (PE, α1-adrenergic agonist) at rest and during single-leg knee-extension exercise (0, 5 and 10 W). At rest, the PHEN-induced increase in LBF was not different between groups, but PE-induced reductions in LBF were lower in HFpEF (-16% ± 4% vs. -26% ± 5%, HFpEF vs. CON; P < 0.05). During exercise, the PHEN-induced increase in LBF was greater in HFpEF at 10 W (16% ± 8% vs. 8% ± 5%; P < 0.05). PHEN increased legV ̇ O 2 ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}}}$ in HFpEF (10% ± 3%, 11% ± 6%, 15% ± 7% at 0, 5 and 10 W; P < 0.05) but not in controls (-1% ± 9%, -4% ± 2%, -1% ± 5%; P = 0.24). The 'magnitude of sympatholysis' (PE-induced %Δ LBF at rest - PE-induced %Δ LBF during exercise) was lower in patients with HFpEF (-6% ± 4%, -6% ± 6%, -7% ± 5% vs. -13% ± 6%, -17% ± 5%, -20% ± 5% at 0, 5 and 10 W; P < 0.05) and was positively related to LBF, leg oxygen delivery, legV ̇ O 2 ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}}}$ , and the PHEN-induced increase in LBF (P < 0.05). Together, these data indicate that excessive α-adrenergic vasoconstriction restrains blood flow and limitsV ̇ O 2 ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}}}$ of the exercising leg in patients with HFpEF, and is related to impaired functional sympatholysis in this patient group. KEY POINTS: Sympathetic (α-adrenergic)-mediated vasoconstriction is exaggerated during exercise in patients with heart failure with preserved ejection fraction (HFpEF), which may contribute to limitations of blood flow, oxygen delivery and oxygen utilization in the exercising muscle. The ability to adequately attenuate α1-adrenergic vasoconstriction (i.e. functional sympatholysis) within the vasculature of the exercising muscle is impaired in patients with HFpEF. These observations extend our current understanding of HFpEF pathophysiology by implicating excessive α-adrenergic restraint and impaired functional sympatholysis as important contributors to disease-related impairments in exercising muscle blood flow and oxygen utilization in these patients.
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Affiliation(s)
- Jeremy K. Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, SLC, UT
| | - Kanokwan Bunsawat
- Department of Internal Medicine, Division of Geriatrics, University of Utah, SLC, UT
- Geriatric Research, Education, and Clinical Center, VAMC, SLC, UT
| | | | - Ryan M. Broxterman
- Department of Nutrition and Integrative Physiology, University of Utah, SLC, UT
- Department of Internal Medicine, Division of Geriatrics, University of Utah, SLC, UT
- Geriatric Research, Education, and Clinical Center, VAMC, SLC, UT
| | - Jesse C. Craig
- Department of Internal Medicine, Division of Geriatrics, University of Utah, SLC, UT
- Geriatric Research, Education, and Clinical Center, VAMC, SLC, UT
| | - Jarred J. Iacovelli
- Department of Nutrition and Integrative Physiology, University of Utah, SLC, UT
| | - Joshua C. Weavil
- Geriatric Research, Education, and Clinical Center, VAMC, SLC, UT
| | | | | | - Natalie A. Silverton
- Geriatric Research, Education, and Clinical Center, VAMC, SLC, UT
- Department of Anesthesiology, University of Utah, SLC, UT
| | - Van R. Reese
- Department of Internal Medicine, Division of Geriatrics, University of Utah, SLC, UT
| | - Christy L. Ma
- Department of Internal Medicine, Division of Cardiovascular Medicine, SLC, UT
| | - John J. Ryan
- Department of Internal Medicine, Division of Cardiovascular Medicine, SLC, UT
| | - D. Walter Wray
- Department of Nutrition and Integrative Physiology, University of Utah, SLC, UT
- Department of Internal Medicine, Division of Geriatrics, University of Utah, SLC, UT
- Geriatric Research, Education, and Clinical Center, VAMC, SLC, UT
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Hearon CM. α-Adrenergic regulation of blood flow in HFpEF: too much and not enough. J Physiol 2024; 602:3241-3242. [PMID: 38923435 DOI: 10.1113/jp286912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Affiliation(s)
- Christopher M Hearon
- Institute for Exercise and Environmental Medicine, University of Texas Southwestern Medical Center & Texas Health, Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern School of Health Professions, Dallas, Texas, USA
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Verwerft J, Foulkes S, Bekhuis Y, Moura-Ferreira S, Falter M, Hoedemakers S, Jasaityte R, Stassen J, Herbots L, La Gerche A, Haykowsky MJ, Claessen G. The Oxygen Cascade According to HFpEF Likelihood: A Focus on Sex Differences. JACC. ADVANCES 2024; 3:101039. [PMID: 39130052 PMCID: PMC11313028 DOI: 10.1016/j.jacadv.2024.101039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/06/2024] [Accepted: 05/01/2024] [Indexed: 08/13/2024]
Abstract
Background Women are at greater risk for heart failure with preserved ejection fraction (HFpEF). Objectives The aim of the study was to compare sex differences in the pathophysiology of exertional breathlessness in patients with high vs low HFpEF likelihood. Methods This cohort study evaluated consecutive patients (n = 1,936) with unexplained dyspnea using cardiopulmonary exercise testing and simultaneous echocardiography and quantified peak oxygen uptake (peak VO2) and its determinants. HFpEF was considered likely when the H2FPEF or HFA-PEFF score was ≥6 or ≥5, respectively. Sex differences were evaluated with the Student's t-test or Mann-Whitney U test and determinants of exercise capacity with a multivariable linear regression. Results The cohort included 1,963 patients (49% women and 28% [n = 555] with a high HFpEF likelihood). HFpEF likelihood did not impact the magnitude of sex differences in peak VO2 and its determinants. Overall, women had lower peak VO2 (mean difference -4.4 mL/kg/min [95% CI: -3.7 to -5.1 mL/kg/min]) secondary to a reduced O2 delivery (-0.5 L/min [95% CI: -0.4 to -0.6 L/min]) and less oxygen extraction (-2.9 mL/dL [95% CI: -2.5 to -3.2 mL/dL]). Reduced O2 delivery was due to lower hemoglobin (-1.2 g/dL [95% CI: -0.9 to -1.5 g/dL]) and smaller stroke volume (-15 mL [95% CI: -14 to -17 mL]). Women demonstrated increased mean pulmonary artery pressure/cardiac output slope (+0.5 mm Hg/L/min [95% CI: 0.3-0.7 mm Hg/L/min]) and left ventricular ejection fraction (+1% [95% CI: 1%-2%]), while they had smaller left ventricular end-diastolic volumes (-9 mL/m2 [95% CI: -8 to -11 mL/m2]) and mass (-12 g/m2 [95% CI: -9 to -14 g/m2]) and more often iron deficiency (55% vs 33%; P < 0.001). Conclusions Women with unexplained dyspnea had significantly lower peak VO2, regardless of HFpEF likelihood, attributed to both lower peak exercise O2 delivery and extraction. This suggests that physiologic sex differences, and not HFpEF likelihood, are an important factor contributing to functional limitations in females with exertional breathlessness.
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Affiliation(s)
- Jan Verwerft
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
| | - Stephen Foulkes
- Integrated Cardiovascular Exercise Physiology and Rehabilitation (iCARE) Lab, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Canada
- Heart, Exercise and Research Trials (HEART) Lab, St Vincent's Institute of Medical Research, Fitzroy, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Australia
| | - Youri Bekhuis
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Sara Moura-Ferreira
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
| | - Maarten Falter
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Sarah Hoedemakers
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
| | - Ruta Jasaityte
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
| | - Jan Stassen
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
| | - Lieven Herbots
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
| | - Andre La Gerche
- Heart, Exercise and Research Trials (HEART) Lab, St Vincent's Institute of Medical Research, Fitzroy, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Australia
| | - Mark J. Haykowsky
- Integrated Cardiovascular Exercise Physiology and Rehabilitation (iCARE) Lab, Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Canada
- Heart, Exercise and Research Trials (HEART) Lab, St Vincent's Institute of Medical Research, Fitzroy, Australia
| | - Guido Claessen
- Department of Cardiology, JESSA Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences/LCRC, UHasselt, Diepenbeek, Belgium
- Heart, Exercise and Research Trials (HEART) Lab, St Vincent's Institute of Medical Research, Fitzroy, Australia
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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5
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Hammer SM, Bruhn EJ, Bissen TG, Cifci G, Borlaug BA, Olson TP, Smith JR. Impaired Vastus Lateralis Blood Flow During Cycling Exercise in Heart Failure With Preserved Ejection Fraction. J Card Fail 2024:S1071-9164(24)00186-6. [PMID: 38777217 DOI: 10.1016/j.cardfail.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Shane M Hammer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; School of Kinesiology, Applied Health and Recreation, Oklahoma State University, Stillwater, OK
| | - Eric J Bruhn
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thomas G Bissen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Gizem Cifci
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Iacovelli JJ, Alpenglow JK, Ratchford SM, Craig JC, Simmons JM, Zhao J, Reese V, Bunsawat K, Ma CL, Ryan JJ, Wray DW. Statin administration improves vascular function in heart failure with preserved ejection fraction. J Appl Physiol (1985) 2024; 136:877-888. [PMID: 38385181 PMCID: PMC11286274 DOI: 10.1152/japplphysiol.00775.2023] [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: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by impaired vascular endothelial function that may be improved by hydroxy-methylglutaryl-CoA (HMG-CoA) reductase enzyme inhibition. Thus, using a parallel, double-blind, placebo-controlled design, this study evaluated the efficacy of 30-day atorvastatin administration (10 mg daily) on peripheral vascular function and biomarkers of inflammation and oxidative stress in 16 patients with HFpEF [Statin: n = 8, 74 ± 6 yr, ejection fraction (EF) 52-73%; Placebo: n = 8, 67 ± 9 yr, EF 56-72%]. Flow-mediated dilation (FMD) and sustained-stimulus FMD (SS-FMD) during handgrip (HG) exercise, reactive hyperemia (RH), and blood flow during HG exercise were evaluated to assess conduit vessel function, microvascular function, and exercising muscle blood flow, respectively. FMD improved following statin administration (pre, 3.33 ± 2.13%; post, 5.23 ± 1.35%; P < 0.01), but was unchanged in the placebo group. Likewise, SS-FMD, quantified using the slope of changes in brachial artery diameter in response to increases in shear rate, improved following statin administration (pre: 5.31e-5 ± 3.85e-5 mm/s-1; post: 8.54e-5 ± 4.98e-5 mm/s-1; P = 0.03), with no change in the placebo group. Reactive hyperemia and exercise hyperemia responses were unchanged in both statin and placebo groups. Statin administration decreased markers of lipid peroxidation (malondialdehyde, MDA) (pre, 0.652 ± 0.095; post, 0.501 ± 0.094; P = 0.04), whereas other inflammatory and oxidative stress biomarkers were unchanged. Together, these data provide new evidence for the efficacy of low-dose statin administration to improve brachial artery endothelium-dependent vasodilation, but not microvascular function or exercising limb blood flow, in patients with HFpEF, which may be due in part to reductions in oxidative stress.NEW & NOTEWORTHY This is the first study to investigate the impact of statin administration on vascular function and exercise hyperemia in patients with heart failure with preserved ejection fraction (HFpEF). In support of our hypothesis, both conventional flow-mediated dilation (FMD) testing and brachial artery vasodilation in response to sustained elevations in shear rate during handgrip exercise increased significantly in patients with HFpEF following statin administration, beneficial effects that were accompanied by a decrease in biomarkers of oxidative damage. However, contrary to our hypothesis, reactive hyperemia and exercise hyperemia were unchanged in patients with HFpEF following statin therapy. These data provide new evidence for the efficacy of low-dose statin administration to improve brachial artery endothelium-dependent vasodilation, but not microvascular reactivity or exercising muscle blood flow in patients with HFpEF, which may be due in part to reductions in oxidative stress.
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Affiliation(s)
- Jarred J Iacovelli
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - Stephen M Ratchford
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Jesse C Craig
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Jonah M Simmons
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
- Department of Chemistry, University of Utah, Salt Lake City, Utah, United States
| | - Jia Zhao
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Van Reese
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - D Walter Wray
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
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7
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Bunsawat K, Nelson MD, Hearon CM, Wray DW. Exercise intolerance in heart failure with preserved ejection fraction: Causes, consequences and the journey towards a cure. Exp Physiol 2024; 109:502-512. [PMID: 38063130 PMCID: PMC10984794 DOI: 10.1113/ep090674] [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: 07/12/2023] [Accepted: 11/22/2023] [Indexed: 04/04/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for over 50% of all heart failure cases nationwide and continues to rise in its prevalence. The complex, multi-organ involvement of the HFpEF clinical syndrome requires clinicians and investigators to adopt an integrative approach that considers the contribution of both cardiac and non-cardiac function to HFpEF pathophysiology. Thus, this symposium review outlines the key points from presentations covering the contributions of disease-related changes in cardiac function, arterial stiffness, peripheral vascular function, and oxygen delivery and utilization to exercise tolerance in patients with HFpEF. While many aspects of HFpEF pathophysiology remain poorly understood, there is accumulating evidence for a decline in vascular health in this patient group that may be remediable through pharmacological and lifestyle interventions and could improve outcomes and clinical status in this ever-growing patient population.
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Affiliation(s)
- Kanokwan Bunsawat
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical CenterSalt Lake CityUtahUSA
- Department of Internal Medicine, Division of GeriatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Michael D. Nelson
- Department of KinesiologyUniversity of Texas at ArlingtonArlingtonTexasUSA
| | - Christopher M. Hearon
- Department of Applied Clinical ResearchThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - D. Walter Wray
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical CenterSalt Lake CityUtahUSA
- Department of Internal Medicine, Division of GeriatricsUniversity of UtahSalt Lake CityUtahUSA
- Department of Nutrition and Integrative PhysiologyUniversity of UtahSalt Lake CityUtahUSA
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8
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Bunsawat K, Skow RJ, Kaur J, Wray DW. Neural control of the circulation during exercise in heart failure with reduced and preserved ejection fraction. Am J Physiol Heart Circ Physiol 2023; 325:H998-H1011. [PMID: 37682236 PMCID: PMC10907034 DOI: 10.1152/ajpheart.00214.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023]
Abstract
Patients with heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF) exhibit severe exercise intolerance that may be due, in part, to inappropriate cardiovascular and hemodynamic adjustments to exercise. Several neural mechanisms and locally released vasoactive substances work in concert through complex interactions to ensure proper adjustments to meet the metabolic demands of the contracting skeletal muscle. Specifically, accumulating evidence suggests that disease-related alterations in neural mechanisms (e.g., central command, exercise pressor reflex, arterial baroreflex, and cardiopulmonary baroreflex) contribute to heightened sympathetic activation and impaired ability to attenuate sympathetic vasoconstrictor responsiveness that may contribute to reduced skeletal muscle blood flow and severe exercise intolerance in patients with HFrEF. In contrast, little is known regarding these important aspects of physiology in patients with HFpEF, though emerging data reveal heightened sympathetic activation and attenuated skeletal muscle blood flow during exercise in this patient population that may be attributable to dysregulated neural control of the circulation. The overall goal of this review is to provide a brief overview of the current understanding of disease-related alterations in the integrative neural cardiovascular responses to exercise in both HFrEF and HFpEF phenotypes, with a focus on sympathetic nervous system regulation during exercise.
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Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Rachel J Skow
- Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, United States
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Jasdeep Kaur
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas, United States
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
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9
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Alpenglow JK, Bunsawat K, Francisco MA, Craig JC, Iacovelli JJ, Ryan JJ, Wray DW. Evidence of impaired functional sympatholysis in patients with heart failure with preserved ejection fraction. Am J Physiol Heart Circ Physiol 2023; 325:H806-H813. [PMID: 37566111 PMCID: PMC10659321 DOI: 10.1152/ajpheart.00450.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 08/12/2023]
Abstract
Exercising muscle blood flow is reduced in patients with heart failure with a preserved ejection fraction (HFpEF), which may be related to disease-related changes in the ability to overcome sympathetic nervous system (SNS)-mediated vasoconstriction during exercise, (i.e., "functional sympatholysis"). Thus, in 12 patients with HFpEF (69 ± 7 yr) and 11 healthy controls (Con, 69 ± 4 yr), we examined forearm blood flow (FBF), mean arterial pressure (MAP), and forearm vascular conductance (FVC) during rhythmic handgrip exercise (HG) at 30% of maximum voluntary contraction with or without lower-body negative pressure (LBNP, -20 mmHg) to increase SNS activity and elicit peripheral vasoconstriction. SNS-mediated vasoconstrictor responses were determined as LBNP-induced changes (%Δ) in FVC, and the "magnitude of sympatholysis" was calculated as the difference between responses at rest and during exercise. At rest, the LBNP-induced change in FVC was significantly lesser in HFpEF compared with Con (HFpEF: -9.5 ± 5.5 vs. Con: -21.0 ± 8.0%; P < 0.01). During exercise, LBNP-induced %ΔFVC was significantly attenuated in Con compared with rest (HG: -5.8 ± 6.0%; P < 0.05) but not in HFpEF (HG: -9.9 ± 2.5%; P = 0.88). Thus, the magnitude of sympatholysis was lesser in HFpEF compared with Con (HFpEF: 0.4 ± 4.7 vs. Con: -15.2 ± 11.8%; P < 0.01). These data demonstrate a diminished ability to attenuate SNS-mediated vasoconstriction in HFpEF and provide new evidence suggesting impaired functional sympatholysis in this patient group.NEW & NOTEWORTHY Data from the current study suggest that functional sympatholysis, or the ability to adequately attenuate sympathetic nervous system (SNS)-mediated vasoconstriction during exercise, is impaired in patients with heart failure with preserved ejection fraction (HFpEF). These observations extend the current understanding of HFpEF pathophysiology by implicating inadequate functional sympatholysis as an important contributor to reduced exercising muscle blood flow in this patient group.
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Affiliation(s)
- Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Michael A Francisco
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Jesse C Craig
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Jarred J Iacovelli
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - D Walter Wray
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Salt Lake City, Utah, United States
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Bunsawat K, Clifton HL, Ratchford SM, Vranish JR, Alpenglow JK, Haykowsky MJ, Trinity JD, Ryan JJ, Fadel PJ, Wray DW. Cardiovascular responses to static handgrip exercise and postexercise ischemia in heart failure with preserved ejection fraction. J Appl Physiol (1985) 2023; 134:1508-1519. [PMID: 37167264 PMCID: PMC10259865 DOI: 10.1152/japplphysiol.00045.2023] [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: 01/23/2023] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by reduced ability to sustain physical activity that may be due partly to disease-related changes in autonomic function that contribute to dysregulated cardiovascular control during muscular contraction. Thus, we used a combination of static handgrip exercise (HG) and postexercise ischemia (PEI) to examine the pressor response to exercise and isolate the skeletal muscle metaboreflex, respectively. Mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), and total peripheral resistance (TPR) were assessed during 2-min of static HG at 30 and 40% of maximum voluntary contraction (MVC) and subsequent PEI in 16 patients with HFpEF and 17 healthy, similarly aged controls. Changes in MAP were lower in patients with HFpEF compared with controls during both 30%MVC (Δ11 ± 7 vs. Δ15 ± 8 mmHg) and 40%MVC (Δ19 ± 14 vs. Δ30 ± 8 mmHg), and a similar pattern of response was evident during PEI (30%MVC: Δ8 ± 5 vs. Δ12 ± 8 mmHg; 40%MVC: Δ13 ± 10 vs. Δ18 ± 9 mmHg) (group effect: P = 0.078 and P = 0.017 at 30% and 40% MVC, respectively). Changes in HR, CO, and TPR did not differ between groups during HG or PEI (P > 0.05). Taken together, these data suggest a reduced pressor response to static muscle contractions in patients with HFpEF compared with similarly aged controls that may be mediated partly by a blunted muscle metaboreflex. These findings support a disease-related dysregulation in neural cardiovascular control that may reduce an ability to sustain physical activity in HFpEF.NEW & NOTEWORTHY The current investigation has identified a diminution in the exercise-induced rise in arterial blood pressure (BP) that persisted during postexercise ischemia (PEI) in an intensity-dependent manner in patients with heart failure with preserved ejection fraction (HFpEF) compared with older, healthy controls. These findings suggest that the pressor response to exercise is reduced in patients with HFpEF, and this deficit may be mediated, in part, by a blunted muscle metaboreflex, highlighting the consequences of impaired neural cardiovascular control during exercise in this patient group.
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Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Heather L Clifton
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Stephen M Ratchford
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Jennifer R Vranish
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, United States
- Department of Integrative Physiology and Health Science, Alma College, Alma, Michigan, United States
| | - Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - Mark J Haykowsky
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, United States
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Joel D Trinity
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Paul J Fadel
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, United States
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
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11
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Gevaert AB, Böhm B, Hartmann H, Goovaerts I, Stoop T, Van De Heyning CM, Beckers PJ, Baldassarri F, Mueller S, Oberhoffer R, Duvinage A, Haykowsky MJ, Wisløff U, Adams V, Pieske B, Halle M, Van Craenenbroeck EM. Effect of Training on Vascular Function and Repair in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:454-464. [PMID: 36892488 DOI: 10.1016/j.jchf.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/16/2022] [Accepted: 12/14/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND Exercise training improves peak oxygen uptake (V̇O2peak) in heart failure with preserved ejection fraction (HFpEF). Multiple adaptations have been addressed, but the role of circulating endothelium-repairing cells and vascular function have not been well defined. OBJECTIVES The authors investigated effects of moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT) on vascular function and repair in HFpEF. METHODS This study is a subanalysis of the OptimEx-Clin Study randomizing patients with HFpEF (n = 180) to HIIT, MICT, or guideline control. At baseline, 3, and 12 months, the authors measured peripheral arterial tonometry (valid baseline measurement in n = 109), flow-mediated dilation (n = 59), augmentation index (n = 94), and flow cytometry (n = 136) for endothelial progenitor cells and angiogenic T cells. Abnormal values were defined as outside 90% of published sex-specific reference values. RESULTS At baseline, abnormal values (%) were observed for augmentation index in 66%, peripheral arterial tonometry in 17%, flow-mediated dilation in 25%, endothelial progenitor cells in 42%, and angiogenic T cells in 18%. These parameters did not change significantly after 3 or 12 months of HIIT or MICT. Results remained unchanged when confining analysis to patients with high adherence to training. CONCLUSIONS In patients with HFpEF, high augmentation index was common, but endothelial function and levels of endothelium-repairing cells were normal in most patients. Aerobic exercise training did not change vascular function or cellular endothelial repair. Improved vascular function did not significantly contribute to the V̇O2peak improvement after different training intensities in HFpEF, contrary to previous studies in heart failure with reduced ejection fraction and coronary artery disease. (Optimizing Exercise Training in Prevention and Treatment of Diastolic Heart Failure [OptimEx-Clin]; NCT02078947).
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Affiliation(s)
- Andreas B Gevaert
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium; Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium. https://twitter.com/AndreasGevaert
| | - Birgit Böhm
- Department of Preventive Pediatrics, Technical University of Munich, Munich, Germany
| | - Haley Hartmann
- Department Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Inge Goovaerts
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Tibor Stoop
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Caroline M Van De Heyning
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium; Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Paul J Beckers
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium; Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium
| | - Flavia Baldassarri
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Stephan Mueller
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Renate Oberhoffer
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - André Duvinage
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Mark J Haykowsky
- College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Ulrik Wisløff
- Cardiac Exercise Research Group, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Volker Adams
- Heart Centre Dresden-University Hospital, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
| | - Burkert Pieske
- Department Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Martin Halle
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Emeline M Van Craenenbroeck
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium; Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
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12
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Sarma S, Brazile T. Balancing Expectations: Rehabilitation in Frail, Obese Patients With Heart Failure. JACC. HEART FAILURE 2022; 10:928-930. [PMID: 36456065 DOI: 10.1016/j.jchf.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Satyam Sarma
- Institute for Exercise and Environmental Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Tiffany Brazile
- Institute for Exercise and Environmental Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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