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

The impacts of exercise interventions on inflammaging markers in overweight/obesity patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

Objectives

The purpose of this meta-analysis was to investigate the association of aerobic, resistance and concurrent exercises vs. control group on inflammaging markers [tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-1-beta, IL-8, and high sensitivity C-reactive protein (hs-CRP)] in overweight or obesity patients with heart failure (HF).

Methods

The databases of Scopus, PubMed, Web of Science and Google Scholar were searched until August 31, 2022 for exercise interventions vs. control group on circulating inflammaging markers in patients with HF. Only randomized controlled trial (RCT) articles were included. Standardized mean difference (SMD) and 95% confidence intervals (95%CIs) were calculated (registration code = CRD42022347164).

Results

Forty-six full-text articles (57 intervention arms and 3693 participants) were included. A significant reduction was occurred in inflammaging markers of IL-6 [SMD-0.205(95% CI:-0.332 to -0.078),p = 0.002] and hs-CRP [SMD -0.379 (95% CI:-0.556 to -0.202), p = 0.001] with exercise training in patients with HF. Analysis of subgroup by age, body mass index (BMI), type, intensity, duration of exercise and mean left ventricular ejection fraction (LVEF) revealed that there was a significant reduction in TNF-α for middle-aged (p = 0.031), concurrent training (p = 0.033), high intensity (p = 0.005), and heart failure with reduced ejection fraction (HFrEF) (p = 0.007) compared to the control group. There was a significant reduction in IL-6 for middle-aged (p = 0.006), overweight (p = 0.001), aerobic exercise (p = 0.001), both high and moderate intensities (p = 0.037 and p = 0.034), short-term follow-up (p = 0.001), and heart failure with preserved ejection fraction (HFpEF) (p = 0.001) compared to the control group. There was a significant reduction in hs-CRP for middle-aged (p = 0.004), elderly-aged (p = 0.001), overweight (p = 0.001), aerobic exercise (p = 0.001), concurrent training (p = 0.031), both high and moderate intensities (p = 0.017 and p = 0.001), short-term (p = 0.011), long-term (p = 0.049), and very long-term (p = 0.016) follow-ups, HFrEF (p = 0.003) and heart failure with mildly reduced ejection fraction (HFmrEF) (p = 0.048) compared to the control group.

Conclusions

The results confirmed that aerobic exercise and concurrent training interventions were effective to improve inflammaging markers of TNF-α, IL-6, and hs-CRP. These exercise-related anti-inflammaging responses were observed across ages (middle-aged and elderly-aged), exercise intensities, duration of follow-ups, and mean LVEFs (HFrEF, HFmrEF and HFpEF) in overweight patients with HF.

Meta-Analysis of Physical Training on Natriuretic Peptides and Inflammation in Heart Failure

Physical training has been reported to attenuate myocardial stress and inflammation in heart failure (HF). We aimed to assess the impact of physical training on B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide (NT-proBNP), as well as biomarkers of inflammation-C-reactive protein, tumor necrosis factor α (TNF-α), and interleukins (ILs). A systematic electronic literature search was conducted up to May 2021 in PubMed, Cochrane Library, CINAHL, Embase, and SPORTDiscus to identify randomized clinical trials reporting associations between any formal physical training intervention and biomarker levels in patients with HF. Random-effects meta-analyses was used to calculate pooled correlations between physical training and blood biomarkers. Biomarker outcomes were expressed as mean difference or ratio of means and 95% confidence interval between the intervention and control groups, according to the normality of the data. A total of 38 trials were included in the final meta-analysis (2,652 randomized patients). Physical training was associated with decreased B-type natriuretic peptide (p = 0.02), NT-proBNP (p <0.01), C-reactive protein (p <0.00001), TNF-α (p = 0.03), IL-6 (p = 0.04), and IL-1β (p = 0.001). Aerobic continuous training was associated with a 35% reduction in NT-proBNP (p = 0.01); ≥150 min/week of exercise was associated with a greater reduction in TNF-α levels (p = 0.0004), and aerobic interval training was associated with lower IL-6 levels (p = 0.01). In conclusion, physical training in patients with HF is associated with beneficial effects on natriuretic peptides and biomarkers of inflammation because they were all reduced by the intervention.

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

Background

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

Methods

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

Results

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

Conclusions

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

•

Exercise intervention, especially aerobic training can be improved (decreased) NT-proBNP marker in patients with HF.

•

Exercise intervention cannot improve BNP marker in patients with HF.

•

Decreased NT-proBNP marker by aerobic exercise can be considered as a cardiac rehabilitation programme in patients with HF.

Evaluation of Qatar's First Cardiac Rehabilitation Program: A Brief Report

Background

There are few studies on the impact of cardiac rehabilitation (CR) in the Eastern Mediterranean Region (EMR), where the burden of risk factors and context is somewhat different from Western countries where much of the evidence is derived.

Objective

To evaluate patient engagement in, and outcomes associated with, participation in Qatar's first and only CR program, from inception.

Methods

This was a retrospective, observational study of patients referred to Heart Hospital's CR program from January 2013-September, 2018. The program offered 3 sessions/week over 6-12 weeks, depending on patient risk. An initial assessment was performed, and outcomes (i.e., functional capacity, risk factors, and psychosocial well-being (quality of life [SF-36] and depressive symptoms) were re-assessed post-program in those who did not drop-out. Session attendance was recorded.

Results

682 patients enrolled; they attended 77.6% of prescribed sessions; 554 (81.2%) completed the program and post-assessment. Improvements in functional capacity were statistically and clinically meaningful (METs 9.3 ± 3.3 pre and 11.1 ± 3.7 post; p < 0.001). There were significant improvements in body mass index (28.7 ± 5.2 kg/m² pre and 28.2 ± 5.4 post; p < 0.001), waist circumference (102.8 ± 13.0 cm pre and 101.8 ± 13.2 post; p < 0.001), low-density lipoprotein (LDL 1.9 ± 0.9 mmol/L pre and 1.6 ± 0.8 post; p = < 0.001), total cholesterol (3.6 ± 1.1 mmol/L pre and 3.3 ± 0.8 post; p < 0.001), systolic blood pressure (SBP 128.5 ± 17.7 mmHg pre and 123.7 ± 14.8 post; p < 0.001), hemoglobin A1c (6.8 ± 1.6% pre and 6.5 ± 1.3 post; p < 0.001) and depressive symptoms (Cardiac Depression Scale score 78.3 ± 23.9 pre and 66.3 ± 21.3 post; p < 0.001). Improvements on 7 of the 8 quality of life domains were also observed (all p < .05; e.g., physical functioning 68.2 ± 24.0 pre and 74.9 ± 24.4 post).

Conclusion

The new Qatari CR program is very engaging to patients, and resulted in clinically significant risk factors (LDL, SBP, and cholesterol) as well as functional capacity and health-related quality of life improvements, which likely translate to reduced morbidity and mortality.

A systematic review of rehabilitation in chronic heart failure: evaluating the reporting of exercise interventions

A large body of research supports the use of exercise to improve symptoms, quality of life, and physical function in patients with chronic heart failure. Previous reviews have focused on reporting outcomes of exercise interventions such as cardiorespiratory fitness. However, none have critically examined exercise prescription. The aim of this review was to evaluate the reporting and application of exercise principles in randomised control trials of exercise training in patients with chronic heart failure. A systematic review of exercise intervention RCTs in patients with CHF, using the Consensus on Exercise Reporting Template (CERT), was undertaken. The Ovid Medline/PubMed, Embase, Scopus/Web of Science, and Cochrane Library and Health Technology Assessment Databases were searched from 2000 to June 2020. Prospective RCTs in which patients with CHF were randomized to a structured exercise programme were included. No limits were placed on the type or duration of exercise structured exercise programme or type of CHF (i.e. preserved or reduced ejection fraction). We included 143 studies, comprising of 181 different exercise interventions. The mean CERT score was 10 out of 19, with no study achieving a score of 19. Primarily, details were missing regarding motivational strategies, home-based exercise components, and adherence/fidelity to the intervention. Exercise intensity was the most common principle of exercise prescription missing from intervention reporting. There was no improvement in the reporting of exercise interventions with time (R²  = 0.003). Most RCTs of exercise training in CHF are reported with insufficient detail to allow for replication, limiting the translation of evidence to clinical practice. We encourage authors to provide adequate details when reporting future interventions. Where journal word counts are restrictive, we recommend using supplementary material or publishing trial protocols prior to beginning the study.

Exercise Intensity in Patients with Cardiovascular Diseases: Systematic Review with Meta-Analysis

Exercise-induced improvements in the VO₂peak of cardiac rehabilitation participants are well documented. However, optimal exercise intensity remains doubtful. This study aimed to identify the optimal exercise intensity and program length to improve VO₂peak in patients with cardiovascular diseases (CVDs) following cardiac rehabilitation. Randomized controlled trials (RCTs) included a control group and at least one exercise group. RCTs assessed cardiorespiratory fitness (CRF) changes resulting from exercise interventions and reported exercise intensity, risk ratio, and confidence intervals (CIs). The primary outcome was CRF (VO₂peak or VO₂ at anaerobic threshold). Two hundred and twenty-one studies were found from the initial search (CENTRAL, MEDLINE, CINAHL and SPORTDiscus). Following inclusion criteria, 16 RCTs were considered. Meta-regression analyses revealed that VO₂peak significantly increased in all intensity categories. Moderate-intensity interventions were associated with a moderate increase in relative VO₂peak (SMD = 0.71 mL-kg^-1-min^-1; 95% CI = [0.27-1.15]; p = 0.001) with moderate heterogeneity (I² = 45%). Moderate-to-vigorous-intensity and vigorous-intensity interventions were associated with a large increase in relative VO₂peak (SMD = 1.84 mL-kg^-1-min^-1; 95% CI = [1.18-2.50], p < 0.001 and SMD = 1.80 mL-kg^-1-min^-1; 95% CI = [0.82-2.78] p = 0.001, respectively), and were also highly heterogeneous with I² values of 91% and 95% (p < 0.001), respectively. Moderate-to-vigorous and vigorous-intensity interventions, conducted for 6-12 weeks, were more effective at improving CVD patients' CRF.