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Effects of device-guided slow breathing training on exercise capacity, cardiac function and respiratory patterns during sleep in male and female patients with chronic heart failure

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Abstract

INTRODUCTION Slow breathing training (SBT) has been proposed as new non-pharmacological treatment in chronic heart failure (CHF) patients. OBJECTIVES The aim of this study was to assess the effects of SBT on exercise capacity, haemodynamic parameters and sleep respiratory patterns in a relatively large sample of CHF patients. PATIENTS ABD METHODS A cross-over open study was conducted. The patients completed, in random order, 10-12 week periods of SBT with the RESPeRATE device (InterCure Ltd., Lod, Israel) with two fifteen-minute sessions of device-guided SBT each day reaching six breaths/minute and of standard care. Clinical data collection, polysomnography, echocardiography, six-minute walk test (6MWT) and laboratory tests were performed. RESULTS Ninety-six patients (74M, 22F) in NYHA class I-III, with average age of sixty-five years and an ejection fraction (EF) of 30.8% completed the study. Home-based SBT was safe. After training EF (31.3±7.3 vs. 32.3±7.7 %; P=0.030) and 6MWT distance (449.9 ± 122.7 vs. 468.3 ± 121.9 m; P <0.001) improved, apnea-hypopnea index decreased (5.6 (2.1; 12.8) vs. 5.35 (2.0; 10.8); P = 0.043). CONCLUSIONS SBT improved physical capacity and systolic heart function, it also diminished sleep disturbances. The results support the benefits of SBT as a novel component of cardiorespiratory rehabilitation programs in CHF.
POLISH ARCHIVES OF INTERNAL MEDICINE
2017; 127 (1)
8
programs based on physical exercise might prove
particularly beneficial. However, their use in clin
ical practice remains limited because of thetime
and resources needed to achieve asatisfactory
outcome. New nonpharmacologic home ‑based
treatment options may thus be of particular in‑
terest in this regard. Among these options, re
spiratory training aimed atslowing thebreath
ing rate, was proposed some years ago. Adevice
for slow breathing training (SBT) was developed
(RESPeRATE) in order to facilitate thepatient
in thepotentially difficult task of maintaining
INTRODUCTION Chronic heart failure (CHF) has
become one of themost widespread diseases and
aprincipal cause of morbidity and mortality, due
to thehigh prevalence of its main causes in ag
ing societies, namely, hypertension and coronary
heart disease.1,2 Despite unquestionable progress
in pharmacologic and device ‑based treatment,
themortality of CHF patients has only slight
ly improved in recent years,3,4 and frequent hos‑
pitalizations4 and poor quality of life5 of these
patients remain major health care issues. Espe‑
cially in this latter aspect, cardiac rehabilitation
ORIGINAL ARTICLE
Effects of device ‑guided slow breathing training
on exercise capacity, cardiac function, and
respiratory patterns during sleep in male and
female patients with chronic heart failure
KalinaKawecka ‑Jaszcz
1
, GrzegorzBilo
2,3
, TomaszDrożdż
1
, DorotaDębicka ‑Dąbrowska
1
,
GrzegorzKiełbasa
1
, GabriellaMalfatto
2
, KatarzynaStyczkiewicz
1
, CarolinaLombardi
2
,
AgnieszkaBednarek
1
, SabrinaSalerno
2
, DanutaCzarnecka
1
, GianfrancoParati
2,3
1 I Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
2 Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
3 Department of Medicine and Surgery, University of Milano ‑Bicocca, Milan, Italy
Correspondence to:
Prof. Kalina Kawecka‑Jaszcz,
MD, PhD, I Klinika Kardiologii
i Elektrokardiologii Interwencyjnej
orazNadciśnieniaTętniczego,
UniwersytetJagielloński,
Collegium Medicum,
ul. M. Kopernika 17, 31‑501 Kraków,
Poland, phone: +48 12 424 73 00,
e‑mail: mckaweck@cyf‑kr.edu.pl
Received: November 13, 2016.
Revision accepted:
January 10, 2017.
Published online: January 10, 2017.
Conflict of interest: none declared.
Pol Arch Intern Med. 2017;
127 (1): 8‑15
doi:10.20452/pamw.3890
Copyright by Medycyna Praktyczna,
Kraków 2017
KEY WORDS
chronic heart failure,
sleep apnea, slow
breathing training
ABSTRACT
INTRODUCTION
Slow breathing training (SBT) has been proposed as a new nonpharmacologic treatment
in patients with chronic heart failure (CHF).
OBJECTIVES
The aim of this study was to assess the effects of SBT on exercise capacity, hemodynamic
parameters, and sleep respiratory patterns in a relatively large sample of CHF patients.
PATIENTS AND METHODS
A crossover open study was conducted. Patients completed, in a random order,
10- to 12 -week SBT, with 2 15 -minute sessions of device -guided SBT each day, reaching 6 breaths/
min, and a 10- to 12 -week follow -up under standard care. Clinical data collection, polysomnography,
echocardiography, 6 -minute walk test (6MWT), and laboratory tests were performed.
RESULTS A total of 96 patients (74 men, 22 women) in New York Heart Association classes I–III, with
an average age of 65 years and an ejection fraction (EF) of 31%, completed the study. Home -based SBT
was safe. After training, EF and 6MWT distance improved (EF: 31.3% ±7.3% vs 32.3% ±7.7%; P = 0.030;
6MWT: 449.9 ±122.7 m vs 468.3 ±121.9 m; P <0.001), and the apnea–hypopnea index decreased
(5.6 [interquartile range (IQR), 2.1; 12.8] vs. 5.4 [IQR, 2.0; 10.8]; P = 0.043).
CONCLUSIONS
SBT improved physical capacity and systolic heart function; it also diminished sleep
disturbances. The results support the benefits of SBT as a novel component of cardiorespiratory reha-
bilitation programs in patients with CHF.
ORIGINAL ARTICLE Slow breathing training in patients with chronic heart failure 9
PATIENTS AND METHODS Study design e
study, performed in 2 cardiology departments
(Kraków, Poland and Milan, Italy), employed
acrossover open trial design where patients,
in arandom order, underwent a10‑ to 12 ‑week
SBT with theRESPeRATE device (InterCure Ltd.,
Lod, Israel) and a10‑ to 12 ‑week follow ‑up un
der standard care. Participants were identified
by local investigators in theperiod between 2012
and 2015, and were consecutively assigned to in
tervention sequence starting with either SBT or
standard care according to apreviously prepared
simple randomization list. In all patients, home
sleep study, echocardiography, 6‑minute walk test
(6MWT), and laboratory tests were performed
atbaseline and after each study phase (FIGURE 1).
Optimized pharmacologic treatment was main‑
tained throughout thestudy. estudy was per‑
formed in accordance with the1975 Declaration
of Helsinki for Human Research and approved
by theBioethical Committee of theparticipat
ing institutions: Jagiellonian University Bioeth‑
ical Committee and theEthics Committee of Is‑
tituto Auxologico Italiano. Patients were includ‑
ed only if they gave their written informed con‑
sent. estudy has been registered in thePolish
National Science Centre (number 2011/03/B/
NZ5/00 533).
Study population
Adult patients with CHF ful
filling thefollowing conditions were enrolled for
this study: NYHA classes I–III; left ventricular
EF (LVEF) lower than 40% in echocardiograph‑
ic study; stable clinical conditions with no car
diovascular interventions over theprevious 3
months; receiving stable pharmacologic treat
ment over theprevious 4 weeks; sinus rhythm
in 24 ‑hour Holter monitoring; and ability to per
form breathing exercises after supervised train‑
ing. Patients after heart transplantation, patients
who had received traditional cardiac rehabilita
tion within theprevious 3 months, and patients
presenting with serious chronic obstructive pul‑
monary disease, ventricular arrhythmias (tachy
cardia, fibrillation), or conduction abnormalities
(second‑ and third ‑degree atrioventricular block)
were excluded.
Slow breathing training (the RESPeRATE device)
In
thepresent study, patients were asked to under‑
go 2 separate 15 ‑minute sessions of device ‑guided
SBT with theRESPeRATE device throughout
the10‑ to 12 ‑week period of SBT. eprinciples
aconstant number of breaths. is device guides
thebreathing exercise through visual and acous
tic feedback, and its application has been recog‑
nized by theAmerican Heart Association as apo
tentially useful nonpharmacologic approach for
lowering blood pressure.6
euse of SBT has also been shown to be
afeasible treatment option in theframework of
thehome ‑based rehabilitation of patients with
C H F.
7
Our previously published data indicated
that it is safe and does not significantly affect
blood pressure values or theprevalence of ortho
static hypotension in these patients.8 Moreover,
preliminary data have demonstrated theuseful‑
ness of home ‑based rehabilitation in terms of im
proving both subjective (New York Heart Associ
ation [NYHA] class, breathlessness) and objective
(exercise capacity, pulmonary function, and ven
tricular EF) parameters.
9‑11
It was hypothesized
that thefavorable effects of SBT may be mediat‑
ed by improved baroreflex sensitivity and respi‑
ratory mechanics.9,1 0
Respiratory abnormalities, from shallow
breathing to Cheyne ‑Stokes periodicity, are
very frequent in advanced CHF and their pres
ence suggests apoor prognosis.12 In particular,
sleep ‑disordered breathing, mainly character
ized by thepresence of central apneas, is found
in up to 76% of patients with systolic and dia
stolic heart failure13 and, apparently, remains in
adose ‑dependent relationship with heart failure
severity.
14
Intervention with positive airway pres
sure devices was shown to reduce thenumber of
central apneas in CHF patients
15
and may improve
some clinical parameters.16 However, data from
arecent trial suggest that adaptive servoventila
tion treatment is associated with higher mortali
ty in CHF patients.17
Alternative therapeutic options to correct
sleep ‑disordered breathing in CHF thus remain
to be evaluated. In this context, no information
is available on whether atraining based on slow
breathing during theday may improve abnormal
patterns of respiration atnight.
In summary, previous data indicate that SBT
may be asimple and clinically useful adjunct to
cardiac rehabilitation in CHF patients but stron
ger evidence is needed to support its clinical use.
erefore, we performed this study to assess
theeffects of SBT on clinical variables, including
exercise capacity, hemodynamic parameters, and
respiratory patterns during sleep in arelatively
large sample of patients with CHF.
FIGURE 1 Study
design; group I, started
with slow breathing
training (SBT); group II,
started with standard
care
baseline
baseline
SBT
control
10–12 weeks 10–12 weeks
group I
group II
1st evaluation
1st evaluation
final evaluation
final evaluation
control
SBT
POLISH ARCHIVES OF INTERNAL MEDICINE
2017; 127 (1)
10
Six minute walk test
e6MWT was performed
in patients after a10 ‑minute resting period in
asitting position. Patients were asked to march
attheir own pace, on aflat and level surface in
anempty corridor. ey were informed about
theprogress of thetest on regular basis; atthe
end of the6 ‑minute period, thetotal distance
walked was measured. Atbaseline and after
thetest, blood pressure and oxygen saturation
were also measured.21
Statistical analysis Considering thepaucity of
similar studies in theliterature, thesample size
was determined based on SBP effects on EF ob‑
served in theprevious data from our group9: as
suming asample standard deviation of 8% and
acorrelation coefficient of 0.6 between EF be
fore and after theintervention, 103 patients were
needed to identify a2% difference in EF with
apower of 80%.
All data were analyzed using theStatistica PL
v.12.0 software (StatSoft, Tulsa, Oklahoma, Unit
ed States). Categorical variables were reported
as percentages, while continuous variables—as
means and standard deviations or median and
interquartile ranges when data distribution dif‑
fered from thenormal. eχ
2
test was applied
for all categorical variables. For continuous vari‑
ables, theanalysis of variance for repeated mea‑
sures was applied. If theassumptions were not
met, amultidimensional approach or theFried‑
man test was used. For statistically significant re
sults, detailed comparisons using theappropriate
post hoc testing (Tukey tests) were conducted. To
assess changes in only 2 measurements, thet test
for paired samples or theWilcoxon matched pairs
test was used. e results for which theP value
was lower than theassumed level of significance
α = 0.05 (P <0.05) were considered significant.
RESULT S
We included 110 patients (age, 23–87
years; 86 men and 24 women), of whom 14 did
not complete thestudy for thefollowing reasons:
2 sudden cardiac deaths; cardiac resynchroniza‑
tion therapy device implantation; 2 hospitaliza‑
tions (myocardial infarction and limb fracture);
alcohol addiction; overnight working; 4 changed
theplace of residence; 3 withdrew from further
participation in thestudy (health reasons were
excluded). Consequently, thetrial ended after 96
subjects completed thestudy (74 in Kraków, 22 in
Milan; age, 23–86 years; 74 men and 22 women).
Owing to aspecific study design (crossover
open trial), in order to verify theprobability of
asignificant carryover effect, we preliminarily as
sessed theinteractions between theintervention
sequence (SBT first vs control first) and theob‑
served effects, and found no significant interac‑
tions (P value always >0.4). us, theresults could
be safely pooled together.
eclinical characteristics of the patients are
shown in TABLE 1, separately for male and female
participants. Male participants had slightly high
er body mass index and more frequent ischemic
of functioning of this device were described previ
ously.
18
Briefly, after a“learning” phase of thepa
tient’s respiratory pattern, thedevice guides
thepatient’s breathing by means of amusical
pattern and gradually reduces breathing frequen
cy to 6 breaths/min, while maintaining adesired
inspiration/expiration time ratio.8
Echocardiography
Echocardiography was per
formed using Vivid 7 Pro (General Electric, Fair‑
field, Connecticut, United States), with a2.5 ‑MHz
probe by asingle experienced operator who was
blinded to thepatients’ allocation to experimen
tal groups. One ‑dimensional, two ‑dimensional,
pulse, and continuous Doppler, and pulsed ‑wave
tissue Doppler imaging methods incorporating
themeasurement of individual phases of mitral
annulus velocity were used. Each point of thepro
tocol was recorded for atleast 3 cardiac cycles dur
ing patients’ steady breathing. edata were re‑
corded, stored, and analyzed using theEcho ‑Pack
system (General Electric). EF was calculated using
theSimpson’s formula. In thepresence of tricus
pid regurgitation, thetricuspid regurgitation pres
sure gradient and thevalue of right atrial pressure
estimated on thebasis of thewidth and there‑
spiratory subsidence of thevena cava were used
to assess thesystolic pressure in theright ventri
cle. Right ventricular systolic pressure was calcu
lated by adding thevalues of tricuspid regurgita
tion pressure gradient and right atrial pressure.19
Home sleep study Home sleep study was per
formed with Embletta Gold, anambulatory over
night cardiorespiratory device (Embla, Broom
field, Colorado, United States), which recorded
nasal/oral airflow (via apressure cannula), chest
and abdominal wall movements (via inductive
belts), oxygen saturation (via afinger probe pulse‑
‑oximetry) and heart rate (via aCM5 device).
Abreathing event was defined as abnormal if:
1) acomplete cessation of airflow lasting more
than 10 seconds was present (apnea); or 2) are‑
duction in respiratory airflow greater than 50%
and lasting more than 10 seconds and associat‑
ed with adesaturation of 4% or higher (hypop‑
nea) occurred. Obstructive apneas were defined
by areduction of respiratory airflow of over 50%
for aminimum of 10 seconds, associated with par
adoxical thoracic and abdominal motion and ade
saturation of 4% or higher. Central apneas were
defined by theabsence/reduction of respirato
ry airflow for 10 seconds with anabsence of tho‑
racic and abdominal excursions and adesatura‑
tion of 4% or higher. eapnea–hypopnea index
(AHI) was defined as theaverage number of ap‑
neas and hypopneas per hour of sleep. Asleep‑
‑related breathing disorder was diagnosed when
theAHI was 5 or higher. Cheyne –Stokes respira
tion was characterized by the lack of air flow and
respiratory effort followed by hyperventilation in
acrescendo ‑decrescendo pattern.20
ORIGINAL ARTICLE Slow breathing training in patients with chronic heart failure 11
During thestudy, no patient reported safety
issues related to study procedures and no adverse
events attributable to theintervention occurred.
DISCUSSION Our study attempted to assess
anumber of clinically relevant parameters in arel
atively large sample of patients with CHF before
and after SBT. We indeed confirmed previous
findings showing that SBT may improve cardiac
function and functional performance. Further
more, our study investigated for thefirst time
theeffects of SBT on sleep ‑disordered breathing
in these patients.
Previous studies have suggested that slow
breathing or SBT may be auseful adjunct to
standard CHF treatment. Acute effects of slow
breathing in patients with heart failure were as‑
sessed by Bernardi et al,
10
who reported anin
crease in blood oxygenation levels and improved
exercise performance in participants who under
went 1 ‑month training. Improvement in blood ox
ygenation seems to be related to animproved re
spiratory mechanics with increased alveolar ven
tilation
10
as shown also by astudy in subjects ex
posed to hypoxia.22
einformation on thebeneficial effects of SBT
was further extended by apilot study by Parati
etal,
9
in which SBT was performed with thesame
device as was used in thepresent study. ese ef
fects included reductions in both theNYHA class
and sPAP, as well as improvement in EF, ventila‑
tory parameters, and quality of life.
Furthermore, Ekman et al
11
found animprove
ment in NYHA class and breathlessness after 1
month of SBT with theRESPeRATE device.
etiology and sleep apneas, both central and ob‑
structive. Of 96 patients, 20 had mild to mod
erate obstructive sleep apnea and 6 had mild to
moderate central sleep apnea. On theother hand,
there were no significant differences in baseline
characteristics according to theintervention se‑
quence (initial SBT versus initial control period).
emain clinical variables before and after
theperiod of SBT are presented in
TABLE 2
. We
observed asignificant reduction in global AHI
(from 5.6 [2.1–12.8] to 5.35 [2.0–10.8], P = 0.043),
and atrend for areduction in central apneas in
thewhole population (P = 0.16); central apne
as were significantly reduced in men (P = 0.039)
(even if themedian values were close to 0 due to
highly skewed distribution) but not in women
(P= 0.21). No significant changes in obstructive
apneas were observed (TABLE 2).
ere was asignificant improvement in LVEF
after SBT (31.3% ±7.3% vs 32.3% ±7.7%; P=
0.030), accompanied by areduction in end‑
‑diastolic diameter of theleft ventricle and atrend
for areduction in theE/A ratio, while no change
was observed in systolic pulmonary artery pres‑
sure (sPAP). eincrease in LVEF was more ev‑
ident in women (from 32.8% to 35.3%) than in
men (from 30.8% to 31.4%; P for interaction =
0.07), and in patients with NYHA class I (from
34.4% to 37.6%) compared with those with class
es II (from 31.1% to 32.5%) and III (from 30.2% to
28.9%; P for interaction = 0.018), while no effect
of CHF etiology was observed (TABLE 2).
e6MWT distance increased after SBT (449.9
±122.7m vs 468.3 ±121.9m; P <0.001;
TABLE 2
),
regardless of theintervention sequence (
FIGURE 2
).
TABLE 1 Baseline characteristics of study participants
Parameter All participants
(n = 96)
Male participants
(n = 74)
Female participants
(n = 22)
P value
age, y 64.5 (57.0–71.5) 64.5 (57.0–72.0) 64.5 (56.0–69.0) NS
BMI, kg/m226.4 (24.4–29.1) 26.9 (24.4–30.1) 25.0 (21.8–27.1) 0.036
NYHA class I–III, n 11/65/20 7/49/16 4/14/4 NS
EF, % 31.0 (25.0–37.0) 30.0 (25.0–36.0) 32.5 (27.0–38.0) NS
sPAP, mmHg 35.0 (30.0–44.5) 35.0 (30.0–45.0) 32.5 (30.0–44.0) NS
office SBP, mmHg 131.0 (118.0–140.0) 131.5 (118.5–140.3) 126.0 (112.0–138.0) NS
office DBP, mmHg 80.8 (72.0–87.0) 81.0 (74.3–87.3) 79.0 (68.5–85.0) NS
6MWT distance, m 440.0 (360.0–521.0) 459.0 (380.0–525.0) 410.0 (324.0–462.0) NS
AHI, 1/h 6.6 (2.6–14.2) 10.0 (3.0–16.0) 4.9 (1.0–6.6) 0.001
central AHI 0.1 (0.0–0.7) 0.1 (0.0–1.0) 0.0 (0.0–0.1) 0.048
obstructive AHI 2.0 (0.4–4.3) 2.3 (0.5–6.0) 1.0 (0.3–2.3) 0.038
ischemic
etiology, n (%)
67 (69.1) 56 (75.7) 11 (50) 0.021
β -blockers, n (%) 88 (91.7) 67 (90.5) 21 (95.5) NS
ACEI/ARB, n (%) 69 (71.9) 54 (73.0) 15 (68.2) NS
diuretics, n (%) 69 (71.9) 52 (70.3) 17 (77.3) NS
Data are presented as median (interquartile range) unless stated otherwise.
Abbreviations: 6MWT, 6 -minute walk test; ACEI, angiotensin -converting enzyme inhibitor; AHI, apnea–hypopnea index;
ARB, angiotensin receptor blocker; BMI, body mass index; DBP, diastolic blood pressure; EF, ejection fraction; NYHA,
New York Heart Association; NS, nonsignificant; SBP, systolic blood pressure; sPAP, systolic pulmonary artery pressure
POLISH ARCHIVES OF INTERNAL MEDICINE
2017; 127 (1)
12
ble effect on respiratory muscles.
23
Our results
are consistent with theresults of thestudy by
Parati etal,
9
although in thecurrent study thein
crease in LVEF was less pronounced (Parati etal
9
reported anincrease in LVEF from 32% ±6% to
In our study, we demonstrated that SBT led
to asignificant increase in LVEF in patients with
CHF. is improvement might be theresult of
increasing thesensitivity of baroreceptor reflex
and respiratory mechanics itself,
9
with apossi
TABLE 2 Key clinical variables before and after slow breathing training
Parameter All participants (n = 96) Male participants (n = 74) Female participants (n = 22)
before SBT after SBT P value before SBT after SBT P value before SBT after SBT P value
6MWT, m 449.9
±122.7
468.3 ±121.9 <0.001 461
(389–529)
480
(402–574)
<0.001 420 ±134 427 ±135 NS
sleep parameters
AHI, 1/h 5.6 (2.1–12.8) 5.4 (2.0–10.8) 0.043 7.2
(2.6–15.6)
6.5 (2.5–12.4) 0.013 4.0 ±4.3 4.8 ±4.8 NS
AI central 0.0 (0.0–0.7) 0.0 (0.0–0.6) NS 0.1 (0.0–1.1) 0.1 (0.0–0.7) 0.039 0.0
(0.0–0.1)
0.0
(0.0–0.4)
NS
AI obstructive 1.6 (0.4–4.1) 1.4 (0.5–4.6) NS 1.8 (0.5–5.3) 1.6 (0.4–5.2) NS 1.2 ±1.6 1.9 ±2.1 NS
echocardiography
LVEDd, mm 61 (56–65) 60 (56–66) 0.023 62 (58–66) 61 (57–67) 0.041 57 ±7 57 ±7 NS
LVESd, mm 49 (43–54) 49 (43–55) NS 50 (44–54) 50 (44–56) NS 45 (39–52) 43 (40–47) NS
E/A ratio 0.80
(0.65–1.44)
0.77
(0.67–1.20)
0.061 0.79
(6.4–1.45)
0.77
(0.63–1.22)
NS 1.08 ±0.56 0.95 ±0.40 NS
sPAP, mmHg 35 (29–43) 35 (28–40) NS 35 (27–43) 35 (27–40) NS 33 (30–38) 31 (30–43) NS
LVEF,% 31 ±7 32 ±8 0.030 31 ±7 31 ±7 NS 33 (26–38) 35 (32–40) 0.005
Data are presented as mean ± SD or median (interquartile range) as appropriate.
Abbreviations: AI, apnea index; E/A, early-to-late ventricular filling velocity ratio; LVEDd, left ventricular end -diastolic diameter; LVEF, left ventricular
ejection fraction; LVESd, left ventricular end -systolic diameter; SBT, slow breathing training; others, see TABLE 1
6MWT, m
420
baseline
440
after 12 weeks final
400
480
500
460
520
540
580
560
a
a
a
a
group I (P = 0.045)
group II (P <0.001)
FIGURE 2 Changes in
the 6 -minute walk test
(6MWT) distance
between study phases
and treatment sequences;
group I, started with slow
breathing training; group
II, started with standard
care; data presented as
mean ± standard error
a significant differences
ORIGINAL ARTICLE Slow breathing training in patients with chronic heart failure 13
having no central apneas). is was probably due
to thefact that our intervention was not specifi‑
cally aimed atreducing theburden of sleep apne
as but rather atassessing clinical effects of SBT in
arepresentative group of CHF patients followed
in rehabilitation programs. erefore, study par
ticipants had on average relatively mild CHF with
good functional performance (79% of patients
were classified as NYHA class II or lower), were in
stable conditions, and had only modestly elevat‑
ed body mass index (median, 26.4kg/m
2
). ere
fore, since theprevalence of both central and ob
structive sleep apneas was low, theconceivable
benefits of SBT were limited. Also in this case
we observed adifference between sexes; howev‑
er, contrary to what was observed for thechang‑
es in LVEF, animprovement in central apneas was
only evident in male participants, possibly due to
ahigher central apnea index atbaseline.
efinding of thehigher rate of central apne‑
as in men is in line with anincrease in theprev‑
alence of central apneas in patients with CHF
26
and in healthy subjects exposed to high altitude
where central apneas are common.27 As aconse‑
quence of our findings, we believe that astudy in
cluding specifically asample of patients with CHF
and sleep ‑disordered breathing would be justified.
Considering that anoptimization of heart failure
treatment may alleviate central sleep apnea,28,29
and in thewake of recent controversies regard‑
ing whether or not central sleep apnea should
be specifically targeted in heart failure patients,
anew therapeutic option targeting thepatho
physiological basis of central apneas might be of
particular interest.
In our previous analyses, we did not show sig‑
nificant changes in blood pressure values after
SBT.
8
eRESPeRATE device has been success
fully used to lower blood pressure in patients
with hypertension. elack of significant chang
es in blood pressure values in thestudied group
could be attributed to low prevalence of elevat
ed blood pressure.
Our data showed animprovement in exercise
capacity in the6MWT after SBT. According to
current guidelines, the6MWT is easy to admin‑
ister and provides strong indications for measur
ing theresponse to medical intervention in pa‑
tients with heart failure.
21
In ambulatory patients
with systolic heart failure, 6MWT provides prog
nostic utility comparable to that of cardiopulmo
nary exercise tests, which is thegold standard for
theassessment of exercise capacity in this group
of patients.30
The improvement in physical capacity on
thebasis of thebicycle cardiopulmonary exer
cise test in patients with heart failure treated
with monthly respiratory training was reported
by Bernardi et al.
10
After 1 month of respirato
ry muscle training, Mancini et al31 found anim‑
provement in exercise capacity based on there‑
sults of the6MWT. us far, only thepilot study
by Parati et al, which had similar duration and
thesame protocol as our study with theuse of
39% ±9%). Similarly, in our population, we did
not show apositive effect of SBT on thereduc
tion of sPAP. ese results differ from theresults
of thepilot study, where sPAP decreased from 49
±17mmHg to 38 ±9mmHg after 10 weeks of SBT.
ese discrepancies could be explained by
thefact that thepilot study included patients
with significantly higher baseline sPAP values:
thebaseline condition of more severely impaired
pulmonary hemodynamics could have amplified
apotentially favorable effect of slow breathing,
less evident in thecurrent study.9 On theother
hand, thecontrolled design of our study might
also have reduced theforeseeable bias of asmall
uncontrolled study. Indeed, our data are in agree
ment with theresults of astudy by Fox et al24 in
patients with pulmonary hypertension, in whom
6 weeks of exercise training led to asignificant im
provement in the6MWT distance despite non
significant changes in echocardiography param‑
eters such as stroke volume and sPAP. Interest
ingly, thebenefits in terms of LVEF improvement
were mostly evident in female participants and in
those with clinically milder CHF. Sex differences
in response to exercise training in patients with
CHF were previously reported by Pina et al,25 who
found greater benefits (measured by peak oxygen
consumption and 6MWT) in women than in men
with CHF. Although in our sample there was no
significant difference between men and women in
terms of achange in the6MWT distance, thefind
ing of improved LV function after SBT restrict
ed to female sex may further support theuseful
ness of rehabilitation techniques in this group.
Sleep ‑disordered breathing is commonly seen
in systolic and diastolic heart failure. Sleep ap
nea comprises several forms of sleep ‑disordered
breathing. Although thepathophysiology of cen
trally driven apneas differs considerably com
pared with that of obstructive sleep apnea, they
share multiple consequences. edifferential di
agnosis of the2 forms of sleep apnea is based on
polysomnographic studies where thepresence or
absence of respiratory movements distinguishes
obstructive from central episodes.Apparently,
there is adose ‑dependent relationship between
sleep disorders and theseverity of heart failure,
with agradual increase in central sleep apnea
occurrence along with theprogression of cardi
ac failure.14
In our study, theAHI score equaled 6.6 (in
terquartile range, 2.6–14.2) atbaseline. Never
theless, theuse of SBT resulted in anoverall im‑
provement in breathing stability during sleep as
theAHI modestly decreased after active treat
ment (TABLE 2).
We observed atrend towards areduced num‑
ber of central apneas and hypopneas (P = 0.16),
whereas no change was observed in obstructive
episodes. Arguably, theabsolute benefit in terms
of improvement in sleep ‑disordered breathing was
modest (the median central apnea index values
equal to 0 derived from ahighly skewed distribu
tion of this variable with numerous participants
POLISH ARCHIVES OF INTERNAL MEDICINE
2017; 127 (1)
14
thedesign of theresearch. TD, DD ‑D, GK, KS, CL,
AB, and SS were involved in data collection. GB,
TD, and GK analyzed thedata. KS and KK ‑J coor
dinated funding for theproject. All authors edited
and approved thefinal version of themanuscript.
Acknowledgments eauthors wish to thank Elis
abetta Lisi (Department of Medicine and Surgery,
University of Milano ‑Bicocca) and Jacek Wolf (De
partment of Hypertension and Diabetology, Med
ical University of Gdańsk) for their valuable sup
port in this study. estudy in theKraków cen‑
ter was supported by agrant of theNational Sci‑
ence Centre (no. UMO ‑2011/03/B/NZ5/00 533;
to KK‑J). epublishing of this article was fund
ed by agrant from theLeading National Research
Centre 2012–2017 to aFaculty of Medicine, Jagi
ellonian University Medical College.
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Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive servo-
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theRESPeRATE device, showed animprovement
in exercise capacity based on thebicycle cardio‑
pulmonary test.
9
emeta ‑analysis by Monte
mezzo et al32 of all studies on theuse of respira‑
tory rehabilitation in patients with heart failure
confirms its beneficial effects on physical per
formance and usefulness in clinical practice, al‑
though it should be emphasized thatthe number
of these studies is low.
Our study has several strengths. First, there‑
spiratory profile after SBT with RESPeRATE had
never been tested previously; second, thesam
ple size was larger than in most previous stud
ies
9,11
; third, thecontrolled design and theuse
of adevice designed for SBT (and approved by
theFood & Drug Administration for blood pres‑
sure lowering) followed astandardized exercise
protocol. Furthermore, this device implements
aseries of features that make theexercise eas
ier for thepatient, including theindividualized
acoustic guidance of breathing frequency, which
results in its gradual reduction, and visual feed‑
back on theexercise performance. is is impor‑
tant as self ‑maintenance of aconstant number of
breaths by thepatient is adifficult task, and rig‑
id breathing pacing could have anegative effect
on exercise performance.
ere are also afew limitations. First, thema
jority of enrolled patients were in NYHA class II,
thus theinformation on thetolerability and effi
cacy in more severe CHF is limited. Second, since
for practical reasons we implemented acrossover
rather than aparallel ‑group design, there might
have been acarryover effect; however, thelack
of interaction of theintervention sequence with
theobserved changes suggests that such anef
fect was not relevant. ird, astrict supervision
of exercise quality in patients’ homes was not
performed, and theobserved effect might have
been diluted by participants who were not com‑
pliant with thetraining. Fourth, we did not as
sess breathing pattern during daytime and there
fore have no data on thepresence of central ap‑
neas in theawake period.33 Finally, we could not
exclude thepossible influence of comorbidities
(eg, diabetes, hypertension) or drugs on there‑
sults, although pharmacotherapy was kept sta
ble during thestudy.
In conclusion, in patients with stable chronic
systolic heart failure, SBT improved physical ca‑
pacity and systolic left ventricular function, with
atendency to attenuate sleep disturbances, main
ly central apnea. elatter results support thehy
pothesis that central sleep apnea may represent
aconsequence of heart failure or anadaptation
mechanism to thecomplex neurohormonal ab
normalities observed in these patients. We be
lieve that device ‑guided SBT may be successfully
implemented as ahome ‑based rehabilitation tool
in patients with CHF, leading to improvements
in their clinical status and breathing patterns.
Contribution statement KS conceived theidea for
thestudy. KS, DC, KK ‑J, and GP contributed to
ORIGINAL ARTICLE Slow breathing training in patients with chronic heart failure 15
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... The effects of SLOWB training on blood pressure (BP) in chronic HF has been reported to be marginal with low incidence of orthostatic hypotension [49]. A recent study has demonstrated an improvement of physical capacity and systolic heart function with a tendency to attenuate sleep disturbances in chronic HF [50]. Although the currently available results with paced breathing are promising in chronic HF and the mechanistic rationale for the use of SLOWB is apparent, not all HF patients seemed to respond to this behavioural technique [48]. ...
... responders) compared to non-responders [48]. Findings from a recent study have demonstrated modest improvements in LVEF (31 ± 7 vs 32 ± 8%, P < 0.05), apnoea-hypopnea index (5.6 vs 5.4 events per hour, P < 0.05) and 6MWT (449.9 ± 122.7 vs 468.3 ± 121.9 m, P < 0.001) after 10-12 weeks of home passed breathing with the use of RESPeRATE in chronic HF [50]. ...
... Another important observation from this study is the absence of significant deterioration in echocardiographic parameters including LVEF, EDV and ESV following SLOWB home training suggesting no further progression of severe HFrEF. Moreover, in line with previous findings we observed an improvement in LVEF by 2 ± 5% at 3-month follow-up [50]. The effects on PWV were not observed in our study indicating no BP-dependent or BP-independent effects of SLOWB on large artery remodeling. ...
Article
Full-text available
Background: Slow breathing (SLOWB) alleviates symptoms of chronic heart failure (HF) but its long-term effects are unknown. We examined the acute and long-term impact of device-guided breathing on hemodynamics and prognostic parameters in HF patients with reduced ejection fraction (HFrEF). Methods and results: Twenty-one patients with HFrEF (23.9 ± 5.8%, SD ± mean) on optimal medical therapy underwent blood pressure (BP), heart rate (HR), HR variability, 6-min walk test (6MWT), cardiopulmonary exercise testing (CPET), and echocardiography measurements before and 3 months after SLOWB home training (30 min daily). After 3 months, all patients were assigned to continue SLOWB (Group 1) or no-SLOWB (Group 2). All tests were repeated after 6 months. Acute SLOWB (18 ± 5 vs 8 ± 2 breaths/min, P < 0.001) had no influence on BP and HR but improved saturation (97 ± 2 vs 98 ± 2%, P = 0.01). Long-term SLOWB reduced office systolic BP (P < 0.001) but not central or ambulatory systolic BP. SLOWB reduced SDNN/RMSSD ratio (P < 0.05) after 3 months. One-way repeated measures of ANOVA revealed a significant increase in 6MWT and peak RER (respiratory exchange ratio) from baseline to 6-month follow-up in group 1 (P < 0.05) but not group 2 (P = 0.85 for 6MWT, P = 0.69 for RER). No significant changes in echocardiography were noted at follow-up. No HF worsening, rehospitalisation or death occurred in group 1 out to 6-month follow-up. Two hospitalizations for HF decompensation and two deaths ensued in group 2 between 3- and 6-month follow-up. Conclusions: SLOWB training improves cardiorespiratory capacity and appears to slow the progression of HFrEF. Further long-term outcome studies are required to confirm the benefits of paced breathing in HFrEF.
... Some authors consider that VBE effectively improved quality of life, reducing symptoms associated with a variety of anxiety and depression [20,21]. VBE is also applied to treat cardiovascular complaints, such as primary hypertension [11,16], heart failure [19,22,23], arrhythmia [24], and so on. Kawecka-Jaszcz et al. [23] found that respiratory exercise combined with exercise rehabilitation for a period of 10-12 week in patients with chronic heart failure had a better effect on ejection fraction and 6-min walk test, but this study failed to observe the functional changes of autonomic nervous function. ...
... VBE is also applied to treat cardiovascular complaints, such as primary hypertension [11,16], heart failure [19,22,23], arrhythmia [24], and so on. Kawecka-Jaszcz et al. [23] found that respiratory exercise combined with exercise rehabilitation for a period of 10-12 week in patients with chronic heart failure had a better effect on ejection fraction and 6-min walk test, but this study failed to observe the functional changes of autonomic nervous function. Westerdahl et al. [25] showed that respiratory exercise for 2 weeks reduced systolic blood pressure in patients with coronary heart disease, but had no effect on heart rate and diastolic blood pressure, which may be closely related to the short intervention time. ...
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Full-text available
Background: At present, China has more than 11 million patients with stable coronary heart disease and this is becoming a major public health problem. The pathological changes of coronary heart disease can lead to dysfunction of the cardiac autonomic nervous system, which increases the risk of complications such as malignant arrhythmia (ventricular flutter, ventricular fibrillation, etc.), heart rate, systolic blood pressure, and rate-pressure product (RPP), which is highly correlated with myocardial oxygen consumption and indirectly reflects myocardial blood supply and oxygen consumption. Although the guidelines recommend that such patients take drugs to reduce heart rate and myocardial oxygen consumption, the clinical control of heart rate is still not ideal. Thus, in this trial, we will use voluntary breathing exercises as the strategy of exercise rehabilitation for patients with stable coronary artery disease (SCAD), in order to increase the vagus nerve activity and/or reduce the sympathetic nervous activity, help maintain or rebuild the balance of plant nerve system, improve the time-domain index of heart rate variability, reduce the burden on the heart, and relieve patients' anxiety and other negative emotions. Methods: This is a 6-month single-blind, randomized controlled clinical trial that will be conducted in the First Affiliated Hospital of Soochow University. A total of 140 patients who fill out the Informed Consent Form are registered and randomized 1:1 into the Voluntary Breathing Exercises (VBE)-based clinical trial monitoring group (n = 70) or the Routine follow-up group (n = 70). The VBE-based clinical trial monitoring group is given VBE training on the basis of conventional treatment and health education, while the control group received conventional health education and follow-up. The primary outcomes will be measured heart rate variability and RPP. Secondary outcomes will include changes in Self-rating Anxiety Scale, total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, weight, and body mass index. Discussion: This trial will carry out scientific respiratory exercise for patients with SCAD, which belongs to the category of active secondary prevention for patients, and changes from remedial to pre-protective. VBE is easy to operate and is not limited by time and place. It is important and meaningful to carry out VBE for patients with SCAD. This study will provide considerable evidence for further large-scale trials and alternative strategies for the rehabilitation nursing of patients with SCAD. Trial registration: Chinese Clinical Trials Registry, 1900024043 . Registered on 23 June 2019.
... Some authors consider that VBE effectively improved quality of life, reduced symptoms associated with a variety of anxiety and depression [20,21]. VBE is also applied to treat cardiovascular complaints, such as primary hypertension [11,16], heart failure [19,22,23], arrhythmia [24],and so on. Kawecka-Jaszcz K et al. [23] found that respiratory exercise combined with exercise rehabilitation for a period of 10 to 12 week in patients with chronic heart failure had a better effect on ejection fraction and 6-minute walk test, but this study failed to observe the functional changes of autonomic nervous function. ...
... VBE is also applied to treat cardiovascular complaints, such as primary hypertension [11,16], heart failure [19,22,23], arrhythmia [24],and so on. Kawecka-Jaszcz K et al. [23] found that respiratory exercise combined with exercise rehabilitation for a period of 10 to 12 week in patients with chronic heart failure had a better effect on ejection fraction and 6-minute walk test, but this study failed to observe the functional changes of autonomic nervous function. Westerdahl E et al. [25] showed that 2week respiratory exercise reduced systolic blood pressure in CHD patients, but had no effect on heart rate and diastolic blood pressure, which may be closely related to the short intervention time. ...
Preprint
Full-text available
Background: At present, China has more than 11 million patients with stable coronary heart disease, becoming a major public health problem. The pathological changes of coronary heart disease can lead to dysfunction of cardiac autonomic nervous system, which increases the risk of complications such as malignant arrhythmia (ventricular flutter, ventricular fibrillation, etc.), heart rate, systolic blood pressure, and rate-pressure-product (RPP), which is highly correlated with myocardial oxygen consumption and indirectly reflects myocardial blood supply and oxygen consumption. Although the guidelines recommend that such patients take drugs to reduce heart rate and myocardial oxygen consumption, the clinical control of heart rate is still not ideal. Thus, in this trial, we will use voluntary breathing exercises as the strategy of exercise rehabilitation patients with Stable coronary artery disease(SCAD), in order to increase the vagus nerve activity and/or reduce the sympathetic nervous activity, help maintain or rebuild the balance of plant nerve system, improve the time domain index of heart rate variability, reduce the burden on the heart, relieve patients' anxiety and other negative emotions. Methods: This is a 6 months single-blind, randomized controlled clinical trial that will be conducted in the First Affiliated Hospital of Soochow University. 140 patients who fill out the Informed Consent Form are registered and randomized 1:1 into the Voluntary Breathing Exercises(VBE)-based clinical trial monitoring group (n = 70) or the Routine follow-up group (n = 70). The VBE-based clinical trial monitoring group is given VBE training on the basis of conventional treatment and health education, while the control group received conventional health education and follow-up. The primary outcome will be measured heart rate variability(HRV) and rate-pressure product (RPP). Secondary outcomes will include changes in self-rating anxiety ccale (SAS), total cholesterol(TC),triglyceride(TG), high density lipoprotein (HDL-C),low density lipoprotein(LDL-C), weight and body mass index (BMI). Discussion: This trial will carry out scientific respiratory exercise for patients with stable coronary heart disease, which belongs to the category of active secondary prevention for patients, and changes from remedial to pre-protective. VBE is easy to operate, and is not limited by time and place. It is very important and meaningful to carry out VBE for patients with SCAD. This study will provide considerable evidence for further large-scale trials and alternative strategies for the rehabilitation nursing of patients with SCAD. Trial registration: This study is registered at Chinese Clinical Trials Registry.gov, ID:1900024043.Registered on 23 June 2019. Keywords: Breathing, Stable coronary artery disease, Heart rate variability, Blood pressure , Myocardial oxygen consumption
... Kawecha-Jaszcz et al. (17) found that the use of slow breathing device at home in patients with stable chronic systolic HF tended to reduce sleep disturbance and predominantly narrow central apnea, improve functional capacity and systolic left ventricular function. In one study, the authors stated that CPAP treatment titrated automatically at night in patients with OSA and CHF improved the daytime sleepiness, but did not improve other quality of life measures or severe CHF markers (Table 2) (18). ...
... As a result of the evaluations made in this study, treatment interventions for CHF patients with OSA and CSA included mostly CPAP (7-9,12,18) and ASV (10)(11)(12)(13)(14)(15)(16)22), as well as BIPAP (8), overdrive pacing (21), oxygen therapy with nasal cannula (6,19), slow breathing training (17) and exercise training (20). ...
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... It seems that this topic has been of interest to scientists for many centuries now, while Avicenna can be considered as the pioneer of clinical medicine and his hypotheses and theories have been corroborated by a significant number of recent studies. 5 Further studies on BH as an exercise and rehabilitation method, especially for elderly and disabled people, may be useful. ...
... We sincerely hope that our work meets these criteria. 5 ...
... It seems that this topic has been of interest to scientists for many centuries now, while Avicenna can be considered as the pioneer of clinical medicine and his hypotheses and theories have been corroborated by a significant number of recent studies. 5 Further studies on BH as an exercise and rehabilitation method, especially for elderly and disabled people, may be useful. ...
... We sincerely hope that our work meets these criteria. 5 ...
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ACC/AHA : American College of Cardiology/American Heart Association ACCF/AHA : American College of Cardiology Foundation/American Heart Association ACE : angiotensin-converting enzyme ACEI : angiotensin-converting enzyme inhibitor ACS : acute coronary syndrome AF : atrial fibrillation
Book
A modern definition of health goes beyond the biological dimension to encompass human functionality and well-being. Quality of life is one of the most popular health-related concepts and simultaneously reflects several dimensions of individual health. Health-related quality of life (HRQoL) is taken to include physical, psychological, and social aspects of positive well-being as well as negative effects of illness, treatment, and infirmity. Quality of life outcomes are now considered an important indicator of the success of both diagnostic and therapeutic procedures.In this book, recognized experts discuss the findings of various studies, including their own, regarding HRQoL in patients with cardiovascular diseases. The impact of the newest forms of medical treatment on well-being is considered in patients with arterial hypertension, coronary artery disease, heart failure, arrhythmias, and stroke as well as in patients who have undergone interventional procedures or have implantable cardiac devices. By summarizing established facts and presenting new data, this book will be an invaluable source of information for all practitioners in the field.
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Background: Adaptive servoventilation (ASV) is a new therapeutic modality to treat Sleep-Disordered breathing (SDB) especially for central sleep apnea associated with Cheyne-Stokes respiration, whereas the role of ASV in SDB patients with heart failure (HF) is controversial. The purpose of this study was to evaluate the effects of ASV on these patients through a meta-analysis of published data. Methods: A comprehensive literature search was performed to identify studies focused on ASV through databases, including PubMed, Medline, Embase, Cochrane Library and Web of science from 1950 to 2014. Parallel randomized controlled trials which compared ASV to other controls in HF and SDB patients with extractable data were meet our inclusion criteria. Random effects meta-analysis models were applied using RevMan 5.2. Results: Seven studies involving 301 patients were recruited in the meta-analysis. The weighted mean difference in apnea hyponea index (-17.73 events/h, 95% CI, -21.85 to -2.94) and left ventricular ejection fraction (MD: 4.68, 95% CI, 2.74 to 6.63) both favored ASV compared to control conditions. The urinary noradrenaline level (MD: -32.18, 95%CI: -44.07 to -20.09) was decreased, while the exercise capacity measured by 6-min walk distance (MD: 41.26, 95% CI, 17.06-65.45) was improved after ASV treatment. Whereas neither left ventricular end-diastolic diameter (LVEDD) nor Epworth sleepiness scale score significantly changed after ASV therapy. Conclusions: ASV is superior to other therapy, as it can result in good consequences for patients with SDB and improve their prognosis in cardiac function. Further studies will still be needed to assess the benefit of it. This article is protected by copyright. All rights reserved.