Background In current ESC/EAPC guidelines, adding resistance training to endurance training is advised for patients with heart failure (HF), but the optimal intensity of the resistance training is unknown (40–80% of 1RM is advised). Purpose To investigate the effects of high- vs low-intensity resistance training as an adjunct to endurance training on: aerobic capacity (primary outcome), walking capacity, muscle strength and quality of life in patients with HF. Methods Forty patients with HF were consecutively recruited in the cardiac rehabilitation center of the Hospital East-Limburg in Belgium. Patients were block-randomized (by age and sex) by an independent researcher to receive maximally 45 supervised sessions (3x/week) of high-intense (HI: 3 exercises, 3x12 repetitions, 55–70%1RM) or low-intense resistance training (LI: 3 exercises, 3x22 repetitions, 35–40%1RM) as an adjunct to endurance training (30 min/session; 50–75% VO2max). The aerobic capacity (VO2max) was measured by a blinded assessor with a ramp cardiopulmonary cycling test (+5–30W/min). Walking distance was assessed with a 6-minute walk test (6MWT), maximal strength with 1RM (leg-press, pull-down and dip), and quality of life with the Minnesota questionnaire. An unpaired t-test, Mann-Whitney U test or ANCOVA were used for between-group analysis, and paired t-test or Wilcox sign-rank test for the within-group analysis. Results Both groups had similar baseline characteristics and training adherence (HI vs LI; 20 vs 20 subjects; Age: 62±9 vs 59±13 years; Sex: 76% vs 79%male; BMI: 27±58 vs 29±4 kg/m2; LVEF: 35±10 vs 38±6%; Adherence: 33±10 vs 36±10 sessions; p>0.05). There were no adverse events. Both groups had significant within-group improvements in aerobic and walking capacity (VO2max: LI (n=20) vs HI (n=19), p≤0.010; 6MWT distance: p≤0.007) (Figure 1), but these improvements did not differ between groups (VO2max: p=0.855; 6MWT distance: p=0.854). The LI group improved significantly more in muscle strength than the HI group (dip and leg-press: p<0.001). Although the LI group significantly improved in the quality of life (Minnesota score reduction: p=0.028), the quality of life did not differ between groups (Minnesota score: p=0.756). Conclusions Both low-and high-intense resistance training are similarly beneficial for improving aerobic and walking capacity in patients with HF. Surprisingly, low-intense resistance training seems superior to high-intense training in improving muscle strength. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Hasselt University
Aim To compare the cardiac function and pulmonary vascular function during exercise between dyspneic and non-dyspneic patients with type 2 diabetes mellitus (T2DM). Methods 47 T2DM patients with unexplained dyspnea and 50 asymptomatic T2DM patients underwent exercise echocardiography combined with ergospirometry. Left ventricular (LV) function (stroke volume, cardiac output, LV ejection fraction, systolic annular velocity (s’)), estimated LV filling pressures (E/e’), mean pulmonary arterial pressures (mPAP) and mPAP/COslope were assessed at rest, low- and high-intensity exercise with colloid contrast. Results Groups had similar patient characteristics, glycemic control, stroke volume, cardiac output, LV ejection fraction and E/e’ (p > 0.05). The dyspneic group had significantly lower systolic LV reserve at peak exercise (s’) (p = 0.021) with a significant interaction effect (p < 0.001). The dyspneic group also had significantly higher mPAP and mPAP/CO at rest and exercise (p < 0.001) with significant interaction for mPAP (p < 0.009) and insignificant for mPAP/CO (p = 0.385). There was no significant difference in mPAP/COslope between groups (p = 0.706). However, about 61% of dyspneic vs. 30% of non-dyspneic group had mPAP/COslope > 3 (p = 0.009). The mPAP/COslope negatively predicted V̇O2peak in dyspneic group (β= -1.86, 95% CI -2.75, -0.98; multivariate model R²:0.54). Conclusion Pulmonary hypertension and less LV systolic reserve detected by exercise echocardiography with colloid contrast underlie unexplained exertional dyspnea and reduced exercise capacity in T2DM.
Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation – Flanders (FWO) Introduction Approximately half of the heart failure population has heart failure with preserved ejection fraction (HFpEF), a chronic disease starting with cardiovascular risk factors such as hypertension, diabetes and obesity (stage A) which can further emerge in a structural heart disease without (stage B) or with (stage C) signs or symptoms. Structured exercise therapy is recommended as a Class IA intervention in national and international guidelines and, as such, should be offered to all patients. Yet, in current practice, exercise therapy is often only offered within a secondary prevention program. At present, there exists no comprehensive preventive care program that includes structured exercise for patients in the early stages of heart failure, when cardiovascular risk factors are present, but cardiac remodeling and dysfunction might still be reversible or even preventable. Purpose PRIORITY aims to investigate the use of remotely guided exercise therapy as a preventive clinical and cost-effective treatment in the HFpEF continuum. This includes both prevention of progression of asymptomatic diastolic dysfunction towards symptomatic HFpEF (= primary prevention) and delaying progression of symptomatic HFpEF (= secondary prevention). Methods A randomized controlled multicenter trial will be conducted in 450 patients (men and women, aged 35-80 years) with heart failure (n = 180 stage A, 180 stage B, 90 stage C). Participants are being recruited from 3 different hospitals and the general population during a 16-month period which started in September 2021. Patients will be randomized (1:1) to usual care or to the PRIORITY exercise intervention (i.e. a combination of supervised with remotely guided home-based training sessions). Training prescription is based on the EXPERT tool and includes person-tailored endurance and dynamic strength training. During one year, participants will receive 18 supervised exercise sessions supplemented with a structured progressive home-based exercise program. Outcomes will be assessed at baseline, 4 months, one and two-years. Primary outcome is the proportion of patients with a clinically relevant improvement in peak oxygen uptake at one-year. Secondary outcomes include vascular health, muscle metabolism, change in electrocardiographic parameters and physical fitness parameters (muscle strength, body composition). Further, big data of physical activity collected during the trial will be used to develop models using machine-learning algorithms which can predict physical activity uptake and changes in fitness to facilitate the creation of more personalized interventions and better tailored exercise prescription. Conclusion We anticipate that the PRIORITY study will contribute to better prevention of heart failure thanks to an early easily accessible person-tailored exercise intervention.
Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWO - Research Foundation – Flanders. Background Exercise is a key therapy for patients across all the stages of heart failure with preserved ejection fraction (HFpEF). Despite being a class I recommendation, the EUROASPIRE registry showed that only a third of patients is sufficiently active, with numbers being even lower among patients with symptomatic HFpEF (stage C). Knowledge of barriers and confidence to exercise is needed to increase the uptake of exercise and a physically active lifestyle. Objective To assess barriers to exercise and self-efficacy in patients along the continuum of HFpEF and to detect possible differences between patients in different HFpEF stages. Methods The first 60 patients (n = 20 HFpEF stage A, 20 HFpEF stage B, 20 HFpEF stage C) from the PRIORITY randomized controlled trial (PeRsonalIzed remOtely guided preventive exeRcIse therapy for a healThY heart) were included. Barriers to exercise and self-efficacy were evaluated using the Exercise Barrier Questionnaire and the Exercise Self-Efficacy Scale. Results Patients with HFpEF stage C were older (72 ± 9.41 years), more likely to be female (70%) and were less physically fit (peak VO2 14.09 ± 2.58 ml/min/kg) compared to patients with HFpEF stage A (63.5 ± 9.10 years, 40% women and peak VO2 21.43 ± 4.94 ml/min/kg) and stage B (70.5 ± 5.25 years, 40% women and peak VO2 17.84 ± 5.15 ml/min/kg). As shown in Figure 1, patients with HFpEF stage C reported more barriers to exercise compared to patients with HFpEF stage A or HFpEF stage B. In particular, 50% of HFpEF stage C reported that they would not exercise when they perceived the exercise as boring (vs A:21%, B:22%), not fun (vs A: 21%, B:21%), if supervised by a bad instructor (vs A:32%, B:33%) or during holidays (vs A:26%, B:17%). Almost 40% of patients with HFpEF stage C reported that having to exercise alone would be a barrier for them (vs A:11%, B:22%). As shown in Figure 2, patients with HFpEF stage C were less confident that they 1) could overcome barriers to exercise by finding appropriate exercise resources (A:0%, B:6%, C:11%), 2) would exercise when feeling tired (A:5%, B:24%, C:28%), 3) would exercise without family support (A:5%, B:6%, C: 17%) or 4) without professional support (A:11%, B:18%, C:17%). Conclusion Barriers to exercise and self-efficacy were rated differently by the 3 stages of HFpEF. Patients with more advanced stages of HFpEF experienced more challenges to be physically active.
Funding Acknowledgements Type of funding sources: None. Purpose To evaluate whether type 2 diabetes mellitus (T2DM) patients who suffer from unexplained exercise-induced dyspnea display cardiac dysfunction during exercise. Background Patients with type 2 diabetes mellitus (T2DM) frequently suffer from unexplained dyspnea. It is not fully understood whether these patients have a worse exercise capacity and cardiac dysfunction than non-dyspneic patients. If so, it would be clinically relevant to evaluate cardiac function in T2DM patients with unexplained dyspnea and initiate treatment accordingly. Methods 47 T2DM patients with unexplained dyspnea and 50 asymptomatic T2DM patients underwent echocardiography with simultaneous cardiopulmonary exercise testing (CPETecho). Left ventricular (LV) function (cardiac output, LV ejection fraction, stroke volume), estimated LV filling pressures (E/e’) and mean pulmonary artery pressures (mPAP) were assessed at rest, low- and high-intensity exercise by using colloid contrast. Breath-by-breath analyses were used to monitor exercise intensity and evaluate exercise capacity (V̇O2peak). Results The groups had similar characteristics and glycemic control (p>0.05). LV function and E/e’ were similar between groups during all stages of exercise (p>0.05). However, mPAP increased disproportionally (mPAP/CO > 3) during exercise in 62% of the patients with dyspnea. The mPAP/CO slope was significantly steeper in the patients with, as opposed to without dyspnea (Pinteraction=0.013). Moreover, a steeper mPAP/cardiac output slope (β= -1.86, 95% CI -2.75, -0.98) was an independent predictor of lower V̇O2peak (multivariate model R²:0.54). Conclusion In T2DM patients with unexplained exertional dyspnea, simultaneous cardiopulmonary exercise testing and echocardiography frequently reveal a reduced exercise capacity associated with exercise-induced pulmonary arterial hypertension. Dyspneic T2DM patients possibly have early left atrial and LV diastolic dysfunction. Timely preventive and therapeutic interventions may improve clinical outcomes in these patients.
Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Hasselt University Background Adding resistance training on top of endurance training is recommended in the rehabilitation of patients with heart failure. However, it is unknown which intensity of resistance training should be preferred. Purpose To compare the effects of the addition of high- vs. low-intensity resistance training on top of endurance training in patients with heart failure. Methods Nineteen patients with heart failure were block randomized (by gender and sex) in a combined high-intensity resistance and endurance group (HIG; n=8, age=61±12y, 7 males, LVEF=38±10%) vs. combined low-intensity resistance and endurance group (LIG; n=9, age=68±21y, 8 males, LVEF=38±13%). Patients trained 3x/week for 45 sessions. The resistance exercises were volume-matched between groups and consisted of three sets of leg press, pull down and dip exercises, separated by 30s of rest, done at 55-70% 1RM in HIG vs. 35-40% 1RM in LIG. Both groups did moderate-intense endurance training on a bicycle, cross-trainer, treadmill and arm ergometer for 30 min per training. Maximal oxygen consumption was evaluated with an incremental cardiopulmonary cycling test and muscle strength by 1-RM testing, while quality of life was assessed with the Minnesota questionnaire, and walking distance by a 6-minute walking test. Mann-Whitney U test was used for analyzing differences between groups in all variables and Wilcoxon signed-rank test for evaluating pre-post difference of the entire sample. P values <0,05 (2-tailed) were considered statistically significant. Results Training adherence was similar in both groups (LIG vs HIG: 41±6 vs 37±9 sessions, p=0,370; Table 1). Overall, the intervention improved maximal oxygen consumption, walking capacity and muscle strength (p<0,05), but the between-group changes in maximal oxygen consumption (LIG vs HIG: 3±2 vs 3±4 ml/kg/min, p=0,963), quality of life (LIG vs HIG: -8±23 vs -1±5 points, p=0,931) and muscle strength (LIG vs HIG: Dip 34±34 vs 18±20kg, p=0,481; Leg press, 66±87 vs 47±53kg, p=0,486; Pull down, 9±6 vs 9±7kg, p=0,574) were similar. Conclusion Adding either high- or low-intensity resistance training on top of endurance training seems equally effective for improving aerobic capacity and walking performance in patients with heart failure. The study is ongoing.
Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): research Foundation - Flanders (FWO) Introduction Cardiac dysfunction is highly prevalent in patients with type 2 diabetes mellitus (T2DM), leading to increased risk of cardiac morbidity and premature death. Previous research underscored the high prevalence of a disturbed global longitudinal strain (GLS), a marker to predict this cardiac dysfunction, in both symptomatic and asymptomatic T2DM patients. Exercise-based therapy is recommended in the management of patients with type 2 diabetes. However, it remains unclear i) which type of exercise therapy to have the biggest effect on GLS and ii) which factors modify the effect of exercise therapy on GLS. Purpose The PROTECTION study will i) investigate the impact of exercise volume and intensity on GLS to optimize exercise prescription in T2DM and will ii) assess which patient-specific factors influence the change in GLS and physical fitness as a result of exercise intervention in T2DM. Methods and analyses The PROTECTION study is composed of two work packages (WP). In WP 1, 100 T2DM adults (50% male, aged 30-75 years) will be randomized to a usual care group or one of the three supervised exercise intervention groups (see Table 1) for a duration of 26 weeks. Outcome measures will be performed at baseline, 13, 26 and 52 weeks of follow-up. The primary outcomes are GLS and cardiac dimensions. Secondary outcomes include health-related physical fitness, blood biomarkers and physical activity behavior. Data will be analyzed by two-way ANOVA repeated measures. A two-tailed P-value <0.05 will be considered statistically significant. Parallel with the randomized controlled trial, a longitudinal intervention study (WP2) involving 107 adults (50% male, aged 30-75 years) with T2DM will be conducted. All participants will engage in a supervised intervention for 26 weeks, including a high volume of moderate intense physical activity (see Table 1). The main objective of this work package is to define determinants of change in GLS during an exercise intervention. Moreover, the interaction between diet-exercise, habitual physical activity-exercise and phenotype-exercise on change in GLS will be studied in great detail. Patient-specific data will be analyzed by multivariate regression analysis. A two-tailed P-value <0.05 will be considered statistically significant. Conclusion It is anticipated that the PROTECTION study will contribute to a better understanding on i) which exercise characteristics are preferred to maximally improve GLS in T2DM and on ii) the determinants of the responsiveness of GLS and physical fitness to exercise in T2DM.
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