The effect of high-intensity training on ventilatory efficiency in chronic heart failure
MGJ Gademan1, J Myers1, K Brunner2, W Kottman2, C Boesch2, P Dubach2
1Palo Alto Veterans Affairs Medical Center/Stanford University, Palo Alto, United States of America, 2Kantosspital, Chur, Switzerland
Topic: Cardiovascular rehabilitation
Background: the oxygen uptake efficiency slope (OUES) is a relatively new measure of ventilatory efficiency which has prognostic value in chronic heart failure (CHF) patients. the OUES has the advantage that it is independent of exercise capacity achieved. Little is known regarding the effects of exercise training on OUES in CHF.
Hypothesis: High-intensity training improves the OUES in patients with CHF.
Methods: Fifty CHF patients were randomized to a 2-month high-intensity residential exercise training program (EXTR, N=24) or to a control group (CTRL, N=26). Before and after the study period, maximal cardiopulmonary exercise testing was performed. Peak oxygen uptake (VO2peak), VE/VCO2 slope, OUES, and minute-by-minute lactate responses were measured.
Results: Exercise training significantly increased VO2peak (23%), peak minute ventilation (23%), exercise time (29%) and peak workload (28%), whereas no improvements were observed in controls (p>0.05). these responses also improved at the lactate threshold (VO2peak 44%, minute ventilation 44%, exercise time 71% and workload 69%). the OUES increased by 11% in the EXTR group and 4% in the CTRL group (p=0.46 between groups). However, the within group change in the EXTR group was highly significant (p=0.003). At baseline, EXTR patients had an OUES that was 69% of the predicted value, and this improved to 78% after finishing the program (p within group=0.004). Conversely, no differences were observed in the VE/VCO2 slope.
Conclusions: In these relatively healthy CHF patients, high intensity training resulted in marked improvements in VO2peak, exercise time and workload. Training also improved the OUES but not the VE/VCO2 slope. Among measures of ventilatory inefficiency, the OUES may respond more favorably to exercise training than the VE/VCO2 slope. therefore, an improvement in the OUES may be a more achievable outcome from exercise training in relatively healthy CHF patients.
Gas exchange data
Exercise
Control
P value
group
group
between
groups
Pre Post
%change
Pre Post
% change
Peak
oxygen
Uptake
(ml/kg/min) 20.5
±
3.6 25.22
±
5.0 22.8∗
19.2
±
3.4 19.9
±
3.8 3.8 0.02
Peak
minute
Ventilation 60.1
±
12.8
73.9
±
15.5
23∗ 54.4
±
12.2
54.8
±
14.4
0.74
0.02
VE/VCO2
slope
32.2
±
4.8 31.9
±
4.7 –0.9 31.1
±
6.8 30.5
±
4.7 –2.6 0.83
OUES
1753
±
436 1957
±
204 11.6∗
1625
±
494 1690
±
427 4
0.46
∗P>0.01
within
groups.
P86
Gender Differences in Baseline Exercise Capacity and Improvements in Endurance Capacity in Phase III Cardiac Rehabilitation (CR)
B Bjarnason-Wehrens, S Schmitz, C Gebhard, E Mauch, G Montiel, C Knackstedt, G Predel
German Sport University Cologne, Cologne, Germany
Topic: Cardiovascular rehabilitation
When referred to phase II CR women are older and have lower exercise capacity than male patients. the aim of this study was to find out if this is also the case in phase III CR and if both gender have the same benefits of participation.
A sample of 88 patients (63.3 ± 10.1 yrs) with coronary artery disease, 63 men (62 ± 10 yrs), 23 women (66.7 ± 9.8 yrs p>0.05) participated twice a week for 60 minutes in an exercise based phase III CR. Before (T0) and after three months of participation (T1) exercise capacity was assessed by bicycle ergometry including measurement of lactic acid.
the results are summarised in Table 1. At the beginning of phase III CR exercise capacity was significantly lower in women than in men showing women to have 60% of maximum and 70% of relative exercise capacity of male patients. the results show significant improvements in exercise capacity in male patients only and a significant increase of work load at defined lactate levels in the presence of unchanged heart rates mediated by the CR in men as well as in women. these improvements are based on an improvement of aerobic endurance capacity associated with decrease of heart rate for a defined workload. Starting an exercise based CRhe clearly lower exercise capacity in female patients has to be taken into account. Women have the same benefits of participation.
study group
men
women
p-value
p-value
(1)
(2)
maximum ecercise capacity (watt)
T0 121.8±44.9
135.9±42.7
82.6±21.9
=0.001
T1 129.7±48∗∗
143.7±45.1∗∗
84.8±22.3
=0.001
0.271
relative exercise capacity (watt/kg/body weight)
T0 1.48±0.51
1.61±0.51
1.12±0.30
=0.001
T1 1.54±0.52∗
1.67±0.52∗
1.16±0.30
=0.001
0.568
work load on 2.5 mmol/l lactate level (watt)
T0 88.5±27.8
97.0±26.7
63.5±16.0
=0.05
T1 97.4±29.4∗∗
106.4±27.1∗∗
71.1±16.6∗
=0.05
0.810
work load on 3.0 mmol/l lactate level (watt)
T0 101.7±28.7
108.2±27.1
76.5±19.7
=0.05
T1 112.2±29.4∗∗
119.2±27.4∗∗
84.8±19.4∗
=0.05
0.810
heart rate on 2.5 mmol/l lactate level (beats/min)
T0 101.2±15.3
100.6±15.5
103.3±15.1
0.073
T1 101.7±16.7
101.3±15.8
102.6±19.6
0.073
0.889
heart rate on 3.0 mmol/l lactate level (beats/min)
T0 105.2±15.5
104.9±14.8
106.0±18.6
0.073
T1 107.1±17.3
107.0±15.6
107.6±23.6
0.073
0.889
∗p>0.05; ∗∗p>0.01 compared to T0; p-value (1) men versus women at T0 and at T1; p-value (2) men versus women changes during CR program.
P87
Determinants of exercise tolerance in adults with congenital heart disease
R Buys, W Budts, A Van De Bruaene, C Delecluse, A Stevens, L Vanhees
Catholic University of Leuven, Leuven, Belgium
Topic: Cardiovascular rehabilitation
Purpose: Grown Up patients with Congenital Heart disease (GUCH) have a lower exercise tolerance compared to normal controls, but data concerning the predictive factors of exercise tolerance are scarce. therefore this study focuses on the determinants of peak oxygen uptake (peak VO2) in adults with tetralogy of Fallot (TF), transposition of the great arteries (TGA) and coarctation of the aorta (COA).
Methods: 205 GUCH (98 COA, 57 TF, 50 TGA) who underwent echocardiography at rest followed by an exercise test until exhaustion, and who filled in questionnaires about physical activity and quality of life, were included in the study. Stepwise multiple regression analysis was used to assess the determinants of peak VO2. Following variables were included in the analysis: demographic data, pathology, age at correction, resting blood pressure, sports participation, SF-36 data and smoking. In subanalysis per patient group, echocardiographic-Doppler data and surgical correction data were also included.
Results: Peak VO2 averaged 79.8±14.8% of predicted normal values in COA, 72.4±15.1% in TF, and 64.4±13.8% in TGA. Gender, age, BMI, pathology and MET-hours of sports per week could explain 61,5% of the variance in peak VO2 in all patients. In TF, left ventricular mass index (LVMI), age at correction and perceived physical health were also related to peak VO2. the variance of peak VO2 in TGA was furthermore partly explained by perceived physical health, as well as the degree of right ventricular dilatation.
Conclusions: In GUCH, exercise tolerance is affected by the underlying heart defect, decreases with age, is positively related to BMI and physical activity, and male patients have a higher exercise tolerance. A higher LVMI and younger age at correction positively influence peak VO2 in TF. A decrease in right ventricular contractility in TGA negatively affects the exercise tolerance.
Determinants of peak VO2 in all patients
Variable
Partial r
β
p
Intercept
2458
Gender (0=male;1=female)
0,4712
–937
<.0001
Pathology (1=COA;2=TF;3=TGA)
0,0695
–204
<.0001
Sports participation (MET-hours/week)
0,0480
4,90
<.0001
Age (years)
0,0123
–13,7
<.05
Body mass index (kg/·)
0,0136
23,4
<.05
P88
Aerobic interval vs. aerobic interval and strength exercise training in CHF - Effects on aerobic exercise capacity and strength
L Karatzanos1, A Tasoulis2, V Agapitou1, D Koudoumas2, L Triantafyllou1, L Katsaros2, E Zerva1, S Nanas1
Purpose: Exercise training is an important means of rehabilitation in CHF patients, with aerobic and strength training being major components of a rehabilitation program. the effects of strength training inclusion in an aerobic regime, especially a high-intensity one, have not been adequately investigated. therefore, this study aimed at investigating the effects of two different regimes (aerobic interval vs. combined) on exercise capacity in CHF patients.
Method: Forty four CHF patients, 36 males / 8 females, [(M±S) age: 53.6±11.5 yrs, VO2peak 15.9±4.8 ml/kg/min] participated in an exercise training program for 12 weeks, 3 times/week Participants were randomly assigned to either aerobic (AER, n=20) or combined regime (COM, n=24), which included aerobic and strength training. Aerobic exercise was performed in interval type (30 sec exercise 60 sec rest) on cycle ergometers at intensity =100% VO2peak. Strength training involved exercises for various muscle groups, including the quadriceps. Both regimes were of the same duration. At the beginning and the end of the program, participants performed a maximum symptom-limited test to exhaustion to assess oxygen uptake at the peak (VO2peak) and the anaerobic threshold (VO2AT), the corresponding power outputs (Wmax and WAT), and a 2-resistance maximum test (2-RM, the maximum resistance to overcome with 2 repetitions) for each leg to assess quadriceps strength.
Results: the whole cohort improved (p>0.05) VO2peak (from 15.9±4.8 to 18.3±5.5 ml/kg/min), VO2AT (from 10.3±2.8 to 11.4±2.9 ml/kg/min), Wmax (from 101±38 to 119±42 watt), WA? (from 58±23 to 70±25 watt), and the 2-RM sum of the two legs (from 35.6±13.1 to 44.0±17.5 kg). In relation to between-group comparison, COM improved more than AER (p>0.05) in VO2peak (??R: from 16.4±4.2 to 17.8±4.7 ml/kg/min, COM: from 15.5±5.3 to 18.7±6.1 ml/kg/ min) and 2-RM sum (??R: from 35.9±12.6 to 39.2±13.2 kg, COM: from 35.3±13.9 to 48.0±19.7 kg). No between-group differences (p>0.05) were found on VO2AT (??R: from 10.4±2.5 to 11.2±2.8 ml/kg/min, COM: from 10.2±3.1 to 11.5±3.0 ml/kg/min), WA? (AER from 60±18 to 69±19 watt, COM: from 56±28 to 71±30 watt) and Wmax (AER: from 104±29 to 118±30 watt, COM: from 99±44 to 120±51 watt).
Conclusions: A combined rehabilitation program of aerobic interval and strength training, in comparison to an aerobic interval regime, induced at least similar improvements on aerobic parameters of functional and predictive value and greater enhancement of the maximum strength in CHF patients. Strength training is safe, well-tolerated, and can amplify the benefits of the CHF rehabilitation programs.
P89
Benefits of resistance training added to endurance training vs endurance training alone in elderly patients with heart failure and preserved left ventricular ejection fraction
G Caminiti, M Volterrani, G Marazzi, A Cerrito, A Arisi, V Cioffi, ME Lippi, G Rosano
IRCCS San Raffaele Pisana Hospital, Rome, Italy
Topic: Cardiovascular rehabilitation
Purpose: To asses if a combined training including resistance training (RT) and endurance training (ET) is more effective than ET alone in improving exercise tolerance and glucose metabolism of patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF).
Methods: thirthy-five patients with diagnosis of stable HF with preserved LVEF, median age 74+/–4 years; ejection fraction 58+/–9. NYHA functional class II-III were enrolled. Twenty pts were randomized to group A performing the combined training and 15 patients to group B (ET only), both on top of maximal medical therapy. At baseline and after 24 weeks all patients underwent exercise test, 6-minute walking test (6MWT), and assessment of quadriceps maximal isometric voluntary contraction (MVC) and peaktorque (PT). Insulin sensitivity was assessed by the Homeostatic Model Assesment (HOMA) index. RT was performed with an intensity setted at 50% pre-training MVC. and consisted of exercise involving muscle groups of the lower and upper limbs and torso. ET consisted on ciclying or walking at 60% of VO2. Both RT and ET were performed 3 times/week.
Results: Exercise training was well tolerated. No patients had adverse events during the follow up period. No patients withdrawn during the study period. After 24 weeks exercise time (Gr A = 88+/–21 sec, GrB = 62+/–17 sec; p 0.033) and distance walked at 6mwt (Gr A= 166+/–34m;Gr B, 103+/–29 m; p 0.027) improved in both groups with significant intergroups differences. Diastolic BP and rest HR significantly decreased in both groups without intergroups dfifferences. HR at peak of exercise had a greater increase in Gr A compared to Gr B (18 mmHg+/–2, p 0.04; e 9 bpm, p 0.01) Heart rate recovery at I min and HOMA index had a greater significant decrease in the A group (–18+/–5; 1.1+/–0.4 respectively) compared to B (–11+/–5; 0.61+/–0.2 respectively Patients of A group had a significantly higher increase of both MVC and PT than B group.
Conclusions: We demonstrated that combined training improves exercise tolerance, chronotropic competence and metabolic profile at a greater extent than ET alone in patients with HF and preserved LVEF.
P90
A high-intensity exercise program improves peak VO2 and reduces markers of systemic inflammation in cardiac transplant recipients: a randomized study
C Dall1, SB Christensen2, TS Hermann2, E Prescott1, F Gustafsson2
1Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark, 2Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
Topic: Cardiovascular rehabilitation
Purpose: Previous studies have shown that moderate intensity aerobic exercise improve peak VO2 in cardiac transplant recipients, but little is known about the safety and effect of high-intensity aerobic exercise initiated late after transplantation. the aim of this study was to examine the effect on peak VO2 and inflammatory plasma markers of an eight-week high-intensity aerobic training program in stable heart transplant recipients (>1 year after transplantation).
Methods and Materials: A total of 27 patients (5 women, mean age 50.5 +/– 14.9 years) with a mean post-transplant time of 6.9 +/– 4.7 years were randomized to either an eight-week high-intensity aerobic training programme (N=14), or control (N=13). Patients with recent rejection or significant allograft vasculopathy were excluded. Immunosuppression included cyclosporine/tacrolimus, an antiproliferative agent and in 70 % prednisone. the training was individualised, hospital-based and carried out as =80% of peak VO2 three times a week. Peak VO2 was measured on a cycle ergometer.
Results: No adverse events were recorded in the exercise group. Peak VO2 increased from 23,9 ± 6,7 to 28,3 ± 6,1 in the intervention group (p>0,05), but was unchanged in the controls 23.9 ± 4,9 to 23,4 ± 5,7(NS). Age, time from transplantation, baseline VO2 or comorbidities did not significantly predict improvement in peak oxygen uptake. Plasma hsCRP was reduced by 43% in the exercise group (1,41 ± 0,83 mg/L to 0,81 ± 0,59 mg/L (p=0,02)) whereas no change was seen in the control group. No change was found in the inflammation markers TNFalfa, IL6 and adiponectin. there was no significant correlation between improvement in peakVO2 and decrease in hsCRP.
Conclusion: Participation in high-intensity aerobic training long after cardiac transplantation is safe and significantly increases peak VO2 while reducing the inflammatory burden as demonstrated by the change in plasma levels of hsCRP.
P91
Maintaining physical fitness of patients with chronic heart failure: a randomized controlled trial
P J M Paul Jan MarieBeckers1, J Denollet2, N M Possemiers1, K Wuyts1, CJ Vrints1, V M Conraads1
1University of Antwerp Hospital (Edegem), Antwerp, Belgium, 2Tilburg University, CoRPS Center of Research on Psychology in Somatic diseases, Tilburg, Netherlands
Topic: Cardiovascular rehabilitation
Objective: To compare the effects after 1 year, of 3 different training advices, following a 6 months supervised cardiac rehabilitation period in patients with chronic heart failure (CHF).
Methods: Sixty-nine CHF patients were randomized, at the end of their rehabilitation period, either to Usual Care (UC) or to UC plus controlled Home Training (HT), prolonged Supervised Training (ST), or Preferred Training (PT). Treadmill cardio pulmonary exercise testing (CPET) was performed prior to rehabilitation, post-rehabilitation and thereafter at 3 monthly intervals during the 1 year follow-up. Sub-maximal exercise capacity (Oxygen consumption and workload at the respiratory compensation point [VO2RCP, WattRCP] and sub-maximal workload [SMW] efficiency [SMW/HR] at 70% of the initial maximal workload) was chosen as a primary endpoint, because health status in CHF patients depends largely on their ability to perform activities at a sub-maximal level.
Results: After 6 months of rehabilitation, the 4 groups (UC, HT, ST, PT) were comparable with regard to cardiac rehabilitation derived benefit, both at the sub-maximal and maximal level. Whereas exercise capacity during follow-up declined in both UC and HT patients, ST and especially PT patients maintained and even improved VO2peak and VO2RCP. However, only PT patients managed to maintain or even increase sub-maximal (WattRCP and SMW/HRratio) workload (p=0.045 and >0.0001 for interaction, respectively). Ventilatory-derived prognostic markers during CPET evolved similarly in the 4 subgroups.
Conclusion: the present study suggests that engagement in physical training of their own choice (preferred training), might be the optimal training modality for maintaining physical capacity in CHF patients.
P92
Predictors of six-minute walk test performance in heart failure patients.
G Pepera1, G Sandercock1, L Ingle2
1University of Essex, Colchester, United Kingdom, 2Leeds Metropolitan University, Leeds, United Kingdom
Topic: Cardiovascular rehabilitation
Background: the six-minute walk test (6-MWT) is a simple and safe measure used to evaluate functional capacity in chronic heart failure (CHF). the purpose of this study was to identify, routinely made clinical measures associated with 6-MWT performance and establish a reference equation to predict 6-MWT performance.
Methods: 71 CHF patients (82% males; mean age 76±9 years), enrolled in a chronic disease assessment programme completed the 6-MWT. Relationships between distance walked and potential predictors were assessed by multiple stepwise regression analysis. Multinomial logistic regression was performed to determine the factors associated with poor performance (=300 m) in 6-MWT. thresholds values identified for dependent (total distance 300 m) and independent variables (age >/>75; stature >/>1.72 m; BMI >/>25 kg m-2; LVEF >/>45 mm; step length >/>0.63 m). Odds ratios (ORs) with 95 % confidence intervals (CI) were calculated.
Results: Mean distance walked was 305 ± 123 m. In regression analysis, 42% of variance in walking distance was accounted for by age: Distance walked (6-MWT) = 762 + (–6 æ age), m. Logistic regression analysis showed that independent predictors of poor performance were: BMI = 25 kg m-2 (OR = 13.6, 95% CI = 1.6 118) and age = 75 years (OR = 4.8, 95% CI = 1.3 18) (Table I).
Conclusion: Clinical variables such as ventricular function are unrelated 6MWT performance in CHF patients. However, age and BMI are independent predictors of performance and should be accounted for when the 6MWT is used to assess heart failure patients functional capacity. these variables appear particularly important when walk test performance is used to categorise patients according to known prognostic cut points.
Logistic regression predicting likelihood of achieving less than 300m in 6-MWT.
Odds Ratio
95% C.I for Odds Ratio
P-value
Lower
Upper
Gender (male vs. female)
0.79
0.14
4.40
0.784
Age (older vs. younger)
4.89
1.29
18.20
0.020
Stature (short vs. tall)
1.23
0.31
4.85
0.763
BMI (overweight vs. normal weight)
13.61
1.56
118.47
0.018
Step length (short length vs. long step)
0.73
0.22
2.41
0.609
LVEF (poor LVEF vs. normal LVEF)
0.55
1.16
1.91
0.349
P93
the relationship of left atrial size with minute ventilation / carbon dioxide production slope in chronic heart failure
Y Shen, L Wang, HM Song, L Che, Q Zhang
Tongji Hospital Tongji University, Shanghai, People's Republic of China
Topic: Cardiovascular rehabilitation
Purpose: Left atrial diameter (LAD) is usually enlarged in patients with chronic heart failure (CHF). the minute ventilation - carbon dioxide production relationship (VE/VCO2 slope) has recently demonstrated prognostic significance in patients with heart failure, and in some studies, it has outperformed peak VO2. the aim of the current study was to investigate the association of LAD with VE/VCO2 slope.
Methods: Total of 74 patients were enrolled in the study, with 37 having congestive heart failure (LVEF0.55). Echocardiography was performed for each patient and LAD was measured. VE/VCO2 slope was assessed using the symptom-limited cardiopulmonary exercise testing. Multiply linear regression model was used to evaluate the association between LAD and VE/VCO2 slope.
Results: As expected, the study showed that the LAD was significantly enlarged in patients with CHF compared with controls [LAD: (43.24±6.52) mm vs (38.65±4.93) mm, p=0.001]; the VE/ VCO2 Slope in CHF patients was significantly increased compared with controls [VE/VCO2 Slope: (36.74±6.74) vs (30.73±5.09), p=0.000]. Multivariate linear regression analysis indicated that the patients VE/VCO2 Slope was significantly associated with LAD, however, the direction and/or strength of the associations varied in CHF and controls. VE/VCO2 slope correlates positively with the increase of LAD (P>0.0001) in CHF patients, while VE/VCO2 slope correlates negatively with the increase of LAD in control patients (p=0.009).
Conclusions: LAD might be valuable in predicting VE/VCO2 slope in CHF patients. there might be a turning point of the direction and/or strength of the associations of LAD with VE/VCO2 slope between CHF and without CHF.
P94
Safety and outcome of cardiac rehabilitation after Berlin Heart Incor left ventricle assist device implantation
FT Genta, M Tidu, F Bertolin, M Psaroudaki, E Favro, E Bosimini, PL Temporelli
Salvatore Maugeri Foundation, IRCCS - Institute of Turin, Turin, Italy
Topic: Cardiovascular rehabilitation
Purpose: As left ventricle assist device implantation (LVAD) as a “bridge to transplantation” is wide spreading in refractory heart failure (HF) patients due to heart donors shortage, we studied safety and outcome of residential cardiac rehabilitation (RCR) after Berlin Heart Incor LVAD.
Methods: Between March 2007 and April 2009 ten refractory HF patients (100% males, 50±8 years) because of idiopathic (40%) or ischemic (60%) dilated cardiomyopathy underwent RCR. All patients followed a 3 weeks supervised training program (TP) (20 minutes walking and up to 40 minute of cycling aerobic exercise daily session). NT-proBNP on admission and discharge, echocardiography, flow mediated dilation (FMD) by brachial Doppler ultrasound and 6-minute walking test at discharge were measured. Adverse events were recorded.
Results: All patients completed the TP; adverse events (a transient ischemic attack) occured in only one patient (10%); no device dysfunction occurred. Results are reported in the Table: of note, NT-proBNP significantly decreased at the end of the TP and far more patients tolerated beta-blockers; all patients had a satisfactory sub-maximal exercise and FMD before discharge. At a mean follow up of 1 year (range 6–30 months) 5 patients underwent heart transplantation and 5 patients are waiting graft at home.
Conclusions: RCR after Berlin Heart Incor LVAD is safe, well tolerated and associated with a significant reduction in HF prognostic markers (NT-proBNP) and good sub-maximal exercise capacity and endothelial function.
Admission
Discharge
p value
Clopidogrel AND Cardioaspirin AND Warfarin
100%
100%
NS
Implantable cardiac defibrillator
60%
60%
NS
Diuretic
70%
70%
NS
ACE-inhibitor
10%
30%
NS
Beta-blocker
10%
60%
>0.05
Amiodarone
60%
60%
NS
Ejection Fraction (%)
22±9
Flow Mediated Dilation (%)
10,3±3
6-minutes walking test (m)
325±57
NT-proBNP (pg/ml)
2502±1936
1835±1368
>0.05
P95
Efficacy of the cardiovascular rehabilitation in patients with congestive heart failure or after cardiac surgery
ENervo, E Menditto, E Lombardo, C Taglieri, S Piccolo, P Vallauri, M Peano, M Feola
Cardiovascular Rehabilitation-Heart Failure Unit, Fossano, Italy
Topic: Cardiovascular rehabilitation
Patients with congestive heart failure (CHF) or after cardiac surgery improved their clinical status after cardiovascular rehabilitation (CR). We analyzed in-hospital patients with CHF or after cardiac surgery admitted for CR with functional, echocardiographic and neuhormonal parameters at baseline and before discharge. Moreover neuropsychological tests attempting to investigate the psychological behaviour were performed.
Methods: All subjects underwent a complete neuropsychological examination consisting of the mini mental state examination (MMSE), anxiety and depression scale (HADS) and geriatric depression scale (GDS). the severity of CHF was evaluated with NYHA class, brain natriuretic peptide (BNP) plasma level (using the Biosite method) and transthoracic echocardiography for the evaluation of left ventricular ejection fraction (LVEF).
Results: Four hundred eighty-three patients admitted for cardiovascular rehabilitation (320 males; mean age 70 ys) entered this observational study. the mean NYHA class at admission was 2,46 ± 0,7, LVEF was 46,3 ± 14,2, mean BNP at admission proved to be 467,9 ± 526,1 pg/ml and 6min WT was calculated 320,5 ± 91,7 m. Patients were admitted for cardiovascular rehabilitation after coronary artery bypass (30%), after valve replacement (27%), myocardial infarction (54,2%) for CHF (55%). In 9,1% of subjects a pathological MMSE score (considered = 24) was determined.
At discharge NYHA class significantly reduced from 2,46 ± 0,7 to 1,67± 0,6 (p = 0,0001) and plasma BNP from 467,9 ± 526,1 pg/ml to 344,6 ± 388,5 pg/ml (p = 0,0001). the 6WT ameliorated from 320,5 ± 91,7m to 392,4± 93,2m (p = 0,0001). the neuropsycological tests demonstrated a clear improvement of anxiety and depression score at discharge (anxiety score 5,55 ± 3,6 vs 4,78 ± 2,9 (p = 0,0003); depression score 4,90 ± 3,5 vs 4,11 ± 3,05 (p = 0,0002) without a modification of MMSE (from 27,04 ± 3,24 to 26,92± 3,21 p = 0,5).
Conclusion: Cardiovascular rehabilitation in patients with CHF of after cardiac surgery usefully improved clinical performance and plasma BNP. In our population the benefits of CV ameliorated the depression and anxiety of mood without any influence in cognitive impairment.
P96
Effects of physical training in elderly patients with chronic heart failure (CHF): the TETRAC study
M Mariani1, S Pirelli1, R De Maria2
1Hospital of Cremona, Department of Cardiology, Cremona, Italy, 2CNR Clinical Physiology Institute, Niguarda Ca Granda Hospital, Milan, Italy
Topic: Cardiovascular rehabilitation
Purpose: We sougth to assess the impact of a structered physicaltraining program (PTP) delivered by trained nurses on quality of life (QoL) and exercise tolerance (ET) in clinically stable elderly CHF outpatients and to identify predictors of non compliance with the PTP prescribed. Study end points were changes in Minnesota Living With Heart Failure Questionnaire (MLWHFQ) scores and distance walked at the Six Minutes Walking Test (6minWT).
Methods: We enrolled in an open-label controlled trial 67 elderly patients (mean age 78 yrs) with systolic CHF (mean LVEF 30%). the etiology of CHF was ischemic in 49%, 76% were male, 40% were in NYHA class III, 76% had at least 1 comorbidility,80% took betablockers, 93% renin-angiotensin system inhibitors. Twenty subjects who declined participation served as controls (Group B). Out of 47 patients who accepted, 34 completed the scheduled 12-week training program (Group A) while 13 abandoned before week 6 (Group C). Data were compared at baseline, 6 and 12 weeks in the 3 groups by one-way analysis of variance (ANOVA).
Results: In Group A, ET (time p>0.001; group p>0.001; interaction p>0.001) and Qol (time p=0.032; group p>0.001; interaction p>0.001), improved significantly when compared to controls (B) and Group C (Figure). Number of comorbidities (OR 2.37, 95% CI 1.20–4.67, p=0.013) and kidney dysfunction (OR 7.22, 95% CI 1.39–37.5) were independently associated to program drop-out.
Conclusion: Our study confirms that in stable elderly CHF patients on optimal standard treatment, a nurse-managed PTP determines an improvement in exercise tolerance and quality of life. the use of simple and reliable tools without complex and costly diagnostic tests, the competence in clinical management of CHF patients and team working were the keys to program success.
P97
Hemodynamic response to one session of strength exercise with and without electrostimulation in heart failure patients: A randomized controlled trial
V Oliveira Carvalho1, JM Roque2, RARX Xavier1, EA Bocchi1, GV Guimaraes1, GV Guimaraes1
1Heart Institute (InCor) - University of Sao Paulo, Faculty of Medicine Clinics Hospital, Sao Paulo, Brazil, 2Instituto Sao Paulo (ISP), Sao Paulo, Brazil
Topic: Cardiovascular rehabilitation
Background: Studies have investigated the influence of the neuromuscular electrostimulation in the exercise/muscle capacity of patients with heart failure, but the hemodynamic overload has never been investigated.
Aim: to evaluate the heart rate, systolic and diastolic blood pressures in one session of strength exercises with and without neuromuscular electrostimulation (quadriceps) in heart failure patients and in healthy subjects.
Methods: Ten (50% male) heart failure patients and healthy subjects performed three sets of eight repetitions with and without neuromuscular electrostimulation randomly with one week of range. During all the protocol, the electromyography was performed to guarantee the electrostimulation effectiveness. the hemodynamic variables were measured in the resting, immediately in the end of each exercise set and in the recovery.
Results: Systolic and diastolic blood pressures did not change during each set of exercise to heart failure and controls. To controls, the heart rate concerning to the first (85±13bpm, p=0.002), second (84±10bpm, p>0.001) third (89±17, p>0.001) sets and recuperation (83±16bpm, p=0.012) were different compared to the resting (77bpm). Moreover, the recuperation was different to the third set (0.018). To heart failure, the heart rate concerning to the first (84±9bpm, p=0.041) and third (84±10bpm, p=0.036) sets were different compared to the resting (80±7bpm), but this increase of 4bpm is clinically irrelevant to heart failure. the protocol was well tolerated and no subjects referred muscle pain after 24hours.
Conclusion: One session of strength exercises with and without neuromuscular electrostimulation did not promote a clinically significant hemodynamic overload in heart failure patients and in healthy subjects.
P98
the relationship between heart rate and oxygen consumption in heart transplant recipients during a cardiopulmonary exercise test
V Oliveira Carvalho1, JM Roque2, LN Pascoalino1, EA Bocchi1, GV Guimaraes1
1Heart Institute (InCor) - University of Sao Paulo, Faculty of Medicine Clinics Hospital, Sao Paulo, Brazil, 2Instituto Sao Paulo (ISP), Sao Paulo, Brazil
Topic: Cardiovascular rehabilitation
Background: In healthy subjects, the percentage of heart rate reserve (%HRR) versus the percentage of oxygen consumption reserve (%VO(2)R) is the closest relationship between heart rate and VO(2) and it seems also to be true to heart failure patients only if they are under optimized beta-blocker therapy. AIM: To evaluate the closest relationship between heart rate and VO(2) (%peak heart rate versus %peak VO(2); %HRR versus %VO(2)R or absolute heart rate versus absolute VO(2)) in heart transplant recipients during a treadmill cardiopulmonary exercise test.
Methods: A total of 19 sedentary heart transplant recipients (5.4+/–3.3years after transplant) in a stable condition (for, at least, 3months), were recruited to perform a cardiopulmonary exercise test. the relationship between %HRR-%VO(2)R, %peak heart rate versus %peak VO(2) and absolute heart rate versus absolute VO(2) were tested.
Results: the strongest relationship was found between %HRR-%VO(2)R (r=0.95, p>0.0001), followed by %peak heart rate versus %peak VO(2) (r=0.91, p>0.0001) and absolute heart rate versus absolute VO(2) (r=0.67, p>0.0001). the mean regression line did not coincide with the line of identity in any group (p>0.0001 for all groups).
Conclusion: the %HRR versus %VO(2)R showed the closest relationship followed by %peak heart rate versus %peak VO(2) and absolute heart rate versus absolute VO(2). Despite this, the perfect reliability of the heart rate versus VO(2) was not found.
P99
Effects of exercise training on patients with CHF or COPD
M Jonasson1, M Gudjonsdottir2, E thoroddsen2, A E Karlsdottir1, A Kristjansdottir1, M Asgeirsdottir1, S B Sigurdsson2
1Reykjalundur-rehabilitation center, Mosfellsbaer, Iceland, 2Department of Physiology, University of Iceland, Reykjavik, Iceland
Topic: Cardiovascular rehabilitation
Introduction: Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) is an increasing health problem. Patients with CHF and COPD generally suffer from exercise intolerance due to breathlessness, fatigue or a combination of both.
Purpose: Evaluate the effects of a comprehensive inpatient rehabilitation program on exercise capacity, dyspnea and body weight in COPD and CHF patients.
Methods: 23 CHF patients, (21M/2F, 55,5±9,8 years, NYHA II-III, left ventricular ejection fraction = 35%) and 24 patients with COPD (10M/14F, 64,1±9,0years, GOLD 3&4) underwent a maximal incremental cycle exercise test pre- and post-rehabilitation with breath by breath measurements of VO2, VCO2 and V E. the average length of the program was 5.8 weeks (±1.1) with the focus on exercise training (2–4 exercise sessions per day), using a combination of endurance and strength training.
Results: See table.
Conclusions: Both COPD and CHF patients increased their exercise capacity after the rehabilitation program as V O2 max increased. this is supported by higher maximal oxygen pulse without decrease in heart rate reserve. Additionally, the dyspnea index increased in both groups after rehabilitation without the patients rating their dyspnea higher. BMI was unchanged in the COPD but decreased in the CHF group.
Response to training, CHF and COPD
Parameters
CHF
COPD
Pre
Post
Pre
Post
BMI (kg/m2)
31.1±4.6
30.3±4.0ç
23.8±5.9∗∗
23.3±4.1∗∗
WRmax (watts)
97±44
107±58ç
51±25∗∗
59±30∗ç
V O2max (L/min)
1.19±0.48
1.39±0.54Œ
0.72±0.29∗
0.81±0.34∗∗ç
V O2max (ml/kg/min)
11.9±4.1
14.3±4.6Œ
10.7±3.2
12.0±3.5ç
Oxygen pulse max (ml/beat)
10.4±3.8
11.9±3.7ç
5.9±2.2∗∗
6.7±2.8∗∗ç
Heart rate reserve (%)
32±21
32±21
21±9∗
22±10∗
Dyspnea indexO
0.44±0.16
0.51±0.11ç
0.82±0.15∗∗
0.93±0.17∗∗ç
Dyspnea Borg at max
4.8±2,6
5.2±2.6
5.7±2.4
5.5±1.8
∗p>0.05 COPD vs CHF; ∗∗p>0.0001 COPD vsCHF;çp>0.05 post vs pre; Œp>0.0001 post vs pre; O V Emax/ V Emax pred.; V E max predicted = FEV1 × 40.
P100
Impact of sleep related breathing disorders on health-related quality of life in chronic heart failure during cardiac rehabilitation
E Skobel
Center of cardiac and pulmonary rehabilitation, Aachen, Germany
Topic: Cardiovascular rehabilitation
Objective: Treatment opportunities in patients with severe chronic heart failure (CHF) (NYHA II-III, EF>30%) consists of medical therapy, heart transplantation or resynchronisation therapy (CRT), which is only suitable in patients with conduction-disturbances. Sleep related breathing disorders (SRBD) like obstructive apnoea (OSAS) or Cheyne-Stokes respiration (CSR) are common in CHF, associated with high mortality, effect on quality of life and high depression rate. But SRBD in CHF are poorly diagnosed and treated, because nocturnal dyspnoea and fatigue are common even without SRBD.
Methods: We report on 104 patients with known CHF (age 71±10 years, 14 women, EF 23±7%, VO2 peak 11.5ml/min/kg±2, NYHA III, all ischmemic heart disease, BMI 26±5) on optimized medical therapy based on current guidelines, who received a cardiac rehabilitation program. All patients were evaluated by the Pittsburgh Sleep quality index (PSQI) for daytime sleepiness and SF-36 for quality of life and Beck depression index (BDI).
Results: 87 % (91 pts) of these patients present an PSQI > 5 with a mean score of 9±3. First patients were evaluated by overnight screening (ApneaLink ResMed) and received polysomnography if the apnea/hypopnea-index (AHI) was >15/h. 51 pts (56%) were positively diagnosed for significant SRBD (AHI>15/h, mean 36±12). CSR was found in 20 patients and OSAS in 31 pts. Patients with HF and SRBD had lower quality of life than patients without SRBD and HF. Bodily pain, physical functioning and social functioning showed largest impairment in patients with HF and SRBD. Furthermore, elevated depression rates in correlation to the AHI were only observed in patients with SRBD.
Conclusion: As SRBD in CHF has effect on prognosis and quality of life, it ought to be early diagnosed and treated. Cardiac rehabilitation programs for CHF are one new possibility for diagnostics and treatment of SRBD in order to prevent progression of CHF.
P101
Impact of a long-term complex rehabilitation on cardiopulmonary data in patients with moderate to severe chronic heart failure
D Vasiliauskas1, L Jasiukeviciene1, A Kavoliuniene2, V Grizas1, R Kubilius2, L Leimoniene1, E Sulinskaite2, L Sakalauskaite2
1Institute of Cardiology, Kaunas, Lithuania, 2Kaunas Medical University Hospital, Department of Cardiology, Kaunas, Lithuania
Topic: Cardiovascular rehabilitation
the aim of the study: To evaluate the impact of a long-term aerobic, at interval exercise training and risk factor correction on cardiopulmonary data in patients with moderate to severe chronic heart failure.
Methods: One hundred sixty patients with moderate to severe chronic heart failure underwent spiroergometry and 2D echocardiography. they practice 6 month-term aerobic, at interval exercise training and risk factor correction programs. Measurements were repeated after 3 and 6 months. Eighty patients were studied as controls and used only drug treatment without rehabilitation programs.
Results: Spiroergometry showed that in rehabilitation group VO2peak (24.1±3.1 vs. 18.3±2.1 mL/kg/min.), METs (6.9±1.2 vs. 5.3±2.2), exercise time (7.8±0.9 vs. 6.2±1.1 min.), ventilatory equivalents, VE/VCO2 slope (24.4±3.5 vs. 35.1±3.2) and pCO2 (40.5±1.1 vs. 34.8±2.3 mmHg) after 6 months significantly (p>0.05) improved, compared to initial data, but not in controls. Echocardiography showed that systolic function significantly improved (EF 33.5±1.5 vs. 30.5±2.6 percent) and remodelling was arrested (LVEDD 65.0±9.1 vs. 60.8±4.8 mm, LA 59.6±7.9 vs. 53.5±5.3 mm after 6 months complex rehabilitation. there were no significant changes in control group. there were observed 14 vs. 32 cases of cardiac events in rehabilitation group compare to controls.
Conclusion: In patients with moderate to severe chronic heart failure successful rehabilitation should have these components: aerobic, at interval and long-term exercise training pattern with a consistent risk factor correction.
P102
Impact of long-term rehabilitation on interchanges of heart failure functional classes
D Vasiliauskas1, L Leimoniene1, L Jasiukeviciene1, R Karaliute2, L Oboleviciute2
1Kaunas Medical University Hospital, Department of Cardiology, Kaunas, Lithuania, 2Kaunas Medical University, Institute of Cardiology, Kaunas, Lithuania
Topic: Cardiovascular rehabilitation
Aim: To evaluate the impact of aerobic exercise training and risk factor correction on interchanges of heart failure (HF) functional classes in patients with moderate to severe chronic HF.
Methods: the study included 93 patients with moderate to severe HF (NYHA classes IIIV). they were get into rehabilitation (n=52) and control groups (n=41). Rehabilitation group patients practiced a long-term aerobic exercise training (AET) and risk factor correction program. Changes of HF functional classes were evaluated after 3, 6 and 12 months from baseline. the methodology for NYHA class interchanges implied the shift from one functional class to another with scoring it from 0 (worst change) to 10 points (best change).
Results: there were 34 (65.4 %) NYHA class III patients, 9 (17.3 %) class II, and 9 (17.3 %) class IV patients in rehabilitation group (p > 0.05, compared to controls). NYHA class improvement (evaluated in points from 0 to 10) was 4.9±0.2 (mean ± SE) points after 3 months, 5.7±0.3 points after 6 months and 6.0±0.3 points after 12 months in rehabilitation group, respectively − 3.7±0.3; 4.1±0.3 and 4.1±0.3 points in controls (p >0.05). there were 6 (11.5%) vs. 16 (39%) cases of cardiac events (p=0,001) and 1 (1.9%) vs. 5 (12.2%) cases of death (p=0,02) in rehabilitation group compared to control group.
Conclusions: Long-term AET and risk factor correction program improves (p>0.05) HF functional classes in patients with moderate to severe heart failure. Score system for evaluation of functional changes based on NYHA classification depicts objective dynamics of clinical state in patients with moderate to severe heart failure.
P103
Participation in community-based cardiac rehabilitation preserves physical function in elderly individuals
S Mandic, D Body, E Nye, M Williams
University of Otago, Dunedin, New Zealand
Topic: Cardiovascular rehabilitation
Purpose: Reduced physical activity with advancing age contributes to a decline in physical function and increasing disability in elderly individuals. Long-term effects of cardiac rehabilitation on age-related decline in physical function remain unknown. the purpose of this study was to examine physical activity patterns, physical function, functional capacity, and muscle strength in elderly individuals participating in ongoing community-based cardiac rehabilitation programs.
Methods: Forty-seven participants (32 males, 15 females; age: 71±7 years (range: 52 to 85)) were recruited from two community-based cardiac rehabilitation programs. Outcome measures included: 1) self-reported physical activity in the previous week assessed by New Zealand Physical Activity Questionnaire Short Form; 2) physical function measured using Short Physical Performance Battery (balance, gait speed and sit-to-stand tests); 3) functional capacity measured using the 6-Minute Walk Test (6-MWT) and 10-meter Shuttle Walk test and 4) lower extremity muscle strength and endurance assessed using a sit-to-stand test.
Results: the majority of participants met minimal physical activity guidelines for healthy adults in a previous week (87%). One third of participants reported engaging in at least 60 minutes of moderate intensity exercise on =5 days per week (31%). the average distance covered during the 6-MWT was 581±81m (range: 315 to 710). the average shuttle walk test duration was 8.1±1.9 min (range: 3.7 to 12 min) with a maximum achieved walking speed of 6.5±1.2 km/h (range: 3.6 to 8.5). Physical function score was 11.4±1.3 out of 12 (range: 6 to 12) with 34 participants (72%) demonstrating no impairment in physical function. Distance covered during the 6-MWT correlated to total weekly physical activity (r=.31, p=0.038), physical function score (r=.59, p>0.009), gait speed (r=.36, p=0.012), and lower extremity muscle strength and endurance (r=.38, p=0.012). Advancing age was associated with a decline in lower extremity muscle strength (r=-.37, p=0.019). No significant correlations were found between age and 6-MWT distance (r=-.24, p=0.105), physical function score (r=-.02, p=0.559), or weekly physical activity (r=-.06, p=0.686).
Conclusions: Long-term participation in ongoing community-based cardiac rehabilitation programs encourages regular physical activity and preserves physical function in elderly individuals. therefore, these programs may play a significant role in reducing disability and promoting independent living in elderly individuals.
