Invited editorial commentary for American Heart Journal mechanisms of exercise training in heart failure with preserved ejection fraction: Central disappointment and peripheral promise

Cardiology and Geriatrics Sections, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC. Electronic address: .
American heart journal (Impact Factor: 4.46). 12/2012; 164(6):807-9. DOI: 10.1016/j.ahj.2012.09.002
Source: PubMed
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Available from: Mark J.F. Haykowsky, May 14, 2014
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    • "A single bout of strenuous exercise in a previously sedentary subject unleashes a broad array of cellular and molecular processes, which serve to quickly prepare for the next episode of physical exertion. The opposite can also occur quickly, as evidenced by the marked muscle atrophy and decline in exercise performance following forced bed rest in older individuals, which likely mimics the condition resulting from the frequent hospitalizations experienced by older HF patients (Kitzman and Haykowsky, 2012). "
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    ABSTRACT: A treatment based on an interatrial shunt device has been proposed for counteracting elevated pulmonary capillary wedge pressure (PCWP) in patients with heart failure and mildly reduced or preserved ejection fraction (HFpEF). We tested the theoretical hemodynamic effects of this approach using a previously validated cardiovascular simulation model. Rest and exercise hemodynamics, using primary data from 2 previous, independent studies of patients with HFPEF, were entered into the simulation. The effects of a shunt between the right and left atria (diameter up to 12 mm) were evaluated. The interatrial shunt lowered PCWP by ∼3 mmHg under simulated resting conditions (from 10 to 7 mmHg) and by ∼11 mmHg under simulated peak exercise conditions (from 28 to 17 mmHg). Left ventricular cardiac output decreased ∼0.5 L/min at rest and ∼1.3 L/min at peak exercise, with corresponding increases in right ventricular cardiac output. However, because of accompanying reductions in PCWP, increases in right atrial and pulmonary artery pressures were minimal. A majority of these effects were achieved with a shunt diameter between 8 and 9 mm. The direction of flow though the shunt was left-to-right in all conditions tested. The interatrial shunt reduced left-sided cardiac output with a marked reduction in pulmonary capillary pressure. This may reduce the propensity for heart failure exacerbations and allow patients to exercise longer, thus attaining higher heart rates and cardiac outputs with the shunt compared to no shunt. These results support clinical investigation of this approach and point out key factors necessary to evaluate its safety and hemodynamic effectiveness.
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    ABSTRACT: Background: Heart failure with preserved ejection fraction (HFPEF) is common and characterized by exercise intolerance and lack of proven effective therapies. Exercise training has been shown to be effective in improving cardiorespiratory fitness (CRF) in patients with systolic heart failure. In this meta-analysis, we aim to evaluate the effects of exercise training on CRF, quality of life, and diastolic function in patients with HFPEF. Methods and results: Randomized controlled clinical trials that evaluated the efficacy of exercise training in patients with HFPEF were included in this meta-analysis. Primary outcome of the study was change in CRF (measured as change in peak oxygen uptake). Effect of exercise training on quality of life (estimated using Minnesota living with heart failure score), and left ventricular systolic and diastolic function was also assessed. The study included 276 patients who were enrolled in 6 randomized controlled trials. In the pooled data analysis, patients with HFPEF undergoing exercise training had significantly improved CRF (mL/kg per min; weighted mean difference, 2.72; 95% confidence interval, 1.79-3.65) and quality of life (weighted mean difference, -3.97; 95% confidence interval, -7.21 to -0.72) when compared with the control group. However, no significant change was observed in the systolic function (EF-weighted mean difference, 1.26; 95% confidence interval, -0.13% to 2.66%) or diastolic function (E/A-weighted mean difference, 0.08; 95% confidence interval, -0.01 to 0.16) with exercise training in patients with HFPEF. Conclusions: Exercise training in patients with HFPEF is associated with an improvement in CRF and quality of life without significant changes in left ventricular systolic or diastolic function.
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