sheba medical center tel hashomer the leviev heart center exercise diego medvedofsky 2/2012

Sheba Medical CenterTel Hashomer The Leviev Heart Center

Exercise

Diego Medvedofsky 2/2012


Background• ~50% of pts with symptomatic HF

experience HFpEF

• Morbi-mortality is high and comparable to HF with reduced LVEF (HFrEF)

• In HFpEF no effective therapeutic strategies shown to be effective in large clinical trials


Background• In HFrEF exercise training (ET) improves

exercise capacity and reduces morbidity (Van Tol, Eur J Heart Fail 2006)

• HF-ACTION also demonstrated a benefit with ET in HFrEF (Piepoli, BMJ 2004, O’Connor, JAMA 2009)

• Conditions associated with HFpEF (endothelial dysfunction, systemic inflammation, metabolic sme) are improved by ET (Adamopoulos, Eur Heart J 2001, Boulé, JAMA 2001, Linke, JACC 2001)


ObjectivesTo determine whether structured exercise

training (ET) improves

– Exercise performnce

– LV diastolic FC

– Quality of life (QoL)

in pts with HF with preserved ejection fraction (HFpEF)


Methods• Prospective, multicenter, blind, RCT in

HFpEF

• NYHA II/III

• LVEF≥50%

• Sinus

• At least 1 of: overweight, DM, HTN, hyperlipidemia, smoking


Methods: Exclusion criteria

• Significant valvular disorders, pulmonary disease, angina, untreated CAD>50%, S/P MI, anemia, BP>150/100 mmHg, relevant arrhythmia, change in CV cardiovascular medication in previous 4 weeks


Methods• 64 pts (age 65±7, 56% female) with

HFpEF were prospectively randomized (2:1) to– From 1/2007-8/2007– Supervised endurance/resistance training in

addition to usual care (ET, n=44) – Usual care alone (UC) (n=20)


Intervention• Supervised, facility based training program

• Endurance and resistance (32 sessions)

• Weeks 1-4: aerobic endurance (cycling)

– Target HR of 50-60% of peak oxygen uptake (peak VO2) baseline


Intervention• From week 5:

– ↑ training freq and workload

– Added resistance training (bench press, leg press, leg curl, rowing machine, triceps dip, latissimus pull down)


Methods• Primary endpoint

– Change in peak VO2 after 3 months


Methods• Secondary endpoints

– Systolic and diastolic function– Effects on cardiac structure [LV mass index

(LVMI) and LA volume index (LAVI)]– QoL [Health Survey (SF-36) and Minnesota

Questionnaire (MLWHFQ)]– Serum biomarkers:

• NT-proBNP• PINP (serum procollagen type I-NP)


Results• Peak VO2

– The mean benefit of ET was 3.3 ml/min/kg (95% CI: 1.8 to 4.8, p<0.001), NNT 3.5

– Increase in 6 min walk of 24 m (<0.001)


Results• E/e' and LA volume index

– ↓ with ET, unchanged with UC

• The physical functioning score (36-Item Short-Form Health Survey)

– ↑ with ET, unchanged with UC


Safety• Brief episodes of palpitations (2)

• Dyspnea (3)

• Mild musculoskeletal discomfort (9)


Compliance• Training group - exercise sessions

– N=15 (34%) participated in >90%– N=23 (52%) in 70% to 90%– N=6 (14%) in <70%


Conclusions• 1ST multicenter, prospective RCT• Effects of supervised, structured ET on HFpEF pts– exercise capacity– diastolic function (atrial reverse remodeling and

improved LV diastolic function)– QoL

• Endurance/resistance ET over 3 months was a feasible, safe, and effective intervention


Limitations• Nature of ET interventions prohibits pure

blinding

• Small number of younger and middle aged pts in short-term follow-up


Background• Adults with congenital heart disease

(CHD) are at increased risk of mortality and morbidity

• Parameters of cardiopulmonary exercise testing (CPX) identified as strong predictors of mortality in adults with CHD

– guide clinicians in assessing prognosis and planning interventions


Investigation• Relation between CPX parameters

and their combination• may provide optimal prognostic info

on midterm survival in this population


Methods• 1375 pts w/adult (>14y) CHD (33±13 y)

– Retrospectively– CPX – Single center, 10 years (1999-2008)– All cause mortality

• Measured:– Peak oxygen consumption (peak VO2)– Ventilation/CO2 (VE/VCO2 slope)– HR reserve (peak - resting HR)


Cardiopulmonary Exercise Testing

• On a treadmill - modified Bruce protocol

• All patients were encouraged to exercise to exhaustion

• Respiratory mass spectrometer: ventilation, VO2, VCO2

• ECG: HR

• Manually sphygmomanometry: BP

• Pulse oximetry: O2 saturation


Simple:ASDVSDPDA

AO coartat

SO2<90%

I 51%II 39%

16%


BB, CCB ,AMIODAR


Results• Follow-up of 5.8 years

– 117 patients died:• HF 41• SCD 34• Perioperative 12• Inf 5• PE 1• Hemoptysis 1• Brain hemorrhage 1• Out of Hospital 21


Results


Results• Risk of death ↑ with:

– ↓ peak VO2– ↓ HR reserve– ↑ VE/VCO2 slope in noncyanotic pts

• Not predictive in cyanotic pts– Combination of peak VO2+HR reserve

• greatest predictive info• ↓ in pts with peak respiratory exchange

ratio <1.0

Sheba Medical CenterTel Hashomer The Leviev Heart Center)Neg chronotropic agents(


Conclusions• Peak VO2 and HR reserve data can be

used to generate estimates of 5-year survival across a wide spectrum of adults with CHD


Conclusions• CPX: strong prognostic info in adult pts

w/CHD

– Data useful for comparing the exercise capacity of a particular patient vs pts in the same diagnostic group


Limitations• Retrospective

• Part of routine evaluation

• Tertiary center

• Ed: patients terminated exercise before reaching their cardiovascular limit


THANKS

THANKS

sheba medical center tel hashomer the leviev heart center exercise diego medvedofsky 2/2012

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