ERS statement on exercise training and rehabilitation in patients with severe chronic pulmonary hypertension

Abstract

Objectives of this European Respiratory Society task force were to summarise current studies, to develop strategies for future research and to increase availability and awareness of exercise training for pulmonary hypertension (PH) patients.An evidence-based approach with clinical expertise of the task force members, based on both literature search and face-to-face meetings was conducted. The statement summarises current knowledge and open questions regarding clinical effects of exercise training in PH, training modalities, implementation strategies and pathophysiological mechanisms.In studies (784 PH patients in total, including six randomised controlled trials, three controlled trials, 10 prospective cohort studies and four meta-analyses), exercise training has been shown to improve exercise capacity, muscular function, quality of life and possibly right ventricular function and pulmonary haemodynamics. Nevertheless, further studies are needed to confirm these data, to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.As exercise training appears to be effective, cost-efficient and safe, but is scarcely reimbursed, support from healthcare institutions, commissioners of healthcare and research funding institutions is greatly needed. There is a strong need to establish specialised rehabilitation programmes for PH patients to enhance patient access to this treatment intervention.

Treating Pulmonary Arterial Hypertension With Exercise: The Role of Rehabilitative Medicine

“…The issue of safety in PAH rehabilitation has recently been reviewed in detail by a European Respiratory Society task force. 7 The amalgamated study data suggest exercise-related safety issues in 4.6% of study participants. However, half of these (2.4%) were due to desaturation, which is a predictable consequence of the disease pathophysiology rather than an adverse effect of exercise training.…”

“…The N-terminal pro B-type natriuretic peptide (NT-proBNP) assay is a straightforward and widely available assay for detecting impaired cardiac function and hence has been extensively measured in rehabilitation studies in PAH. 7 Reassuringly, exercise training does not appear to lead to an increase in NT-proBNP. On the other hand, unlike other outcome measures such as 6MWT distance and QoL, there does not appear to be an improvement (ie, a reduction) in this biomarker with exercise training.…”

“…Quality of life (QoL) has principally been measured in the rehabilitation studies using a generic tool (the Short Form 36). 7,37 The analysis reported in the Cochrane review showed an improvement in several domains, namely physical role, vitality, and social function. Physical and mental composite scores were also improved.…”

“…Over 19 studies investigating rehabilitation in PH have now been published, usually but not always with similar results. 7 This body of work has provided much data on the efficacy and safety of exercise training in PAH and led to a Class IIa recommendation for this as a useful intervention in the 2015 European Society of Cardiology-European Respiratory Society guidelines. 8…”

“…8 Whilst there is a clear improvement in 6MWT distance, this is counterbalanced by the lack of fall in NT-proBNP. 7 The data on functional class and cardiac index are currently limited. It may be possible in the future to use one of the emerging risk scores 9 linked to survival to provide further information here.…”