Exercise in Patients With Pulmonary Arterial Hypertension

Desai, Smita; Channick, Richard N.

doi:10.1097/01.hcr.0000311502.57022.73

Cited by 53 publications

(42 citation statements)

References 33 publications

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“…37 However, clinicians have traditionally been skeptical about the use of exercise training and cardiopulmonary rehabilitation for management of chronic pulmonary hypertension because of concerns of exertional syncope and progressive right ventricular dysfunction with strenuous physical activity. [38][39][40] Contrary to these notions, our study findings provide comprehensive evidence in favor of efficacy and safety of exercise training in patients with pulmonary hypertension and highlight its potential role as an adjunct to medical therapy designed to alleviate symptoms in patients with pulmonary hypertension.We observed significant improvements in exercise tolerance, measured as 6MWD, with exercise training. Previous studies have established an association between 6MWD and long-term clinical outcomes in patients with pulmonary hypertension.…”

mentioning

confidence: 40%

Efficacy and Safety of Exercise Training in Chronic Pulmonary Hypertension

Pandey

Garg

Khunger

et al. 2015

Circ: Heart Failure

107

110

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P ulmonary hypertension is a chronic cardiopulmonary disorder characterized by progressive increasing pulmonary vascular resistance, leading to right ventricular heart failure. 1 Prevalence of pulmonary hypertension is estimated to be 10 to 15 cases per million with a mortality rate of 15% per year. 2 Over the past 2 decades, targeted pharmacological therapies have been effective in reducing disease progression and improving the survival rate among patients with pulmonary hypertension.3,4 However, most patients remain symptomatic with significant exercise intolerance and reduced quality of life despite being on optimal medical therapy. 5,6 Thus, there is an unmet need for adjunctive therapeutic strategies to improve exercise tolerance and quality of life among these patients. Clinical Perspective on p 1043Exercise intolerance in patients with pulmonary hypertension is associated with a reduced maximal oxygen uptake and early onset of anaerobic threshold, similar to patients with severe heart failure. 7 The decrease in pulmonary vasculature distensibility associated with pulmonary hypertension leads to marked increases in pulmonary arterial mean pressure during exercise. This results in reduced pulmonary blood flow and low cardiac output insufficient to meet the metabolic demands of exercise. [7][8][9] Furthermore, pulmonary hypertension patients have significant skeletal muscle abnormalities leading to impaired peripheral oxygen utilization. These central and peripheral abnormalities contribute significantly to the exercise intolerance and functional limitation in patients with pulmonary hypertension. 10,11 Exercise training has been shown to improve cardiorespiratory fitness, functional status, and clinical outcomes in patients with cardiopulmonary conditions, such as heart failure and chronic obstructive pulmonary disease (COPD). 12,13 Considering the overlap in the pathophysiological derangements Original Article© 2015 American Heart Association, Inc.Circ Heart Fail is available at http://circheartfailure.ahajournals.org DOI: 10.1161/CIRCHEARTFAILURE.115.002130Background-Exercise training has been shown to improve cardiorespiratory fitness, physical capacity, and quality of life in patients with cardiopulmonary conditions, such as heart failure and chronic obstructive pulmonary disease. However, its role in management of pulmonary hypertension is not well defined. In this study, we aim to evaluate the efficacy and safety of exercise training in patients with pulmonary hypertension. Methods and Results-We included all prospective intervention studies that evaluated the efficacy and safety of exercise training in patients with pulmonary hypertension. Primary outcome of this meta-analysis was a change in 6-minute walk distance. We also assessed the effect of exercise on peak oxygen uptake, resting pulmonary arterial systolic pressure, peak exercise heart rate, and quality of life. A total of 469 exercise-training participants enrolled in 16 separate training studies were included. In the pooled ana...

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confidence: 40%

Efficacy and Safety of Exercise Training in Chronic Pulmonary Hypertension

Pandey

Garg

Khunger

et al. 2015

Circ: Heart Failure

107

110

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“…3 Here, we demonstrate that exercise training in progressive PH can indeed be harmful in the case of a poorly adapted RV by augmenting pressure overload-associated RV inflammation.…”

Section: Worsened Survival After Training Associated With Enhanced Rvmentioning

confidence: 99%

“…3 First, the prognosis of PH patients improved with the introduction of various potent PH-specific medications in the last decades. 4 Second, several studies have demonstrated beneficial effects of training in patients with chronic obstructive pulmonary disease and with congestive heart failure, and training was beneficial even for the most severely affected patients (GOLD IV, New York Heart Association class IV) often suffering from secondary PH.…”

Section: Clinical Perspective On P 49mentioning

confidence: 99%

Opposite Effects of Training in Rats With Stable and Progressive Pulmonary Hypertension

et al. 2009

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Background-Exercise training in pulmonary arterial hypertension (PH) is a promising adjunct to medical treatment.However, it is still unclear whether training is beneficial for all PH patients. We hypothesized that right ventricular adaptation plays a pivotal role in the response to training. Methods and Results-Two different dosages of monocrotaline were used in rats to model stable PH with preserved cardiac output and progressive PH developing right heart failure. Two weeks after injection, PH was confirmed by echocardiography, and treadmill training was initiated. Rats were trained for 4 weeks unless manifest right heart failure developed earlier. At the end of the study protocol, all rats were functionally assessed by endurance testing, echocardiography, and invasive pressure measurements. Lungs and hearts were further analyzed in quantitative histomorphologic analyses. In stable PH, exercise training was well tolerated and markedly increased exercise endurance (from 25Ϯ3.9 to 62Ϯ3.9 minutes; PϽ0.001). Moreover, capillary density increased significantly (from 1.21Ϯ0.12 to 1.51Ϯ0.07 capillaries per cardiomyocyte; PϽ0.05). However, in progressive PH, exercise training worsened survival (hazard ratio, 2.7; 95% confidence interval, 1.1 to 14.2) and increased pulmonary vascular remodeling. In addition, training induced widespread leukocyte infiltration into the right ventricle (from 135Ϯ14 to 276Ϯ18 leukocytes per 1 mm 2 ; PϽ0.001). Conclusions-In our rat model, exercise training was found to be beneficial in stable PH but detrimental in progressive PH. Future studies are necessary to address the clinical implications of our findings. Key Words: capillaries Ⅲ exercise Ⅲ hypertension, pulmonary Ⅲ inflammation Ⅲ pulmonary heart disease P ulmonary arterial hypertension (PH) is characterized by progressive pulmonary vascular remodeling, which importantly increases right ventricular (RV) afterload, eventually leading to right heart failure and premature death. 1 Traditionally, PH patients were advised to limit physical activity because of risk of fatal cardiovascular compromise. 2 Clinical Perspective on p 49Recent developments, however, have challenged this view. 3 First, the prognosis of PH patients improved with the introduction of various potent PH-specific medications in the last decades. 4 Second, several studies have demonstrated beneficial effects of training in patients with chronic obstructive pulmonary disease and with congestive heart failure, and training was beneficial even for the most severely affected patients (GOLD IV, New York Heart Association class IV) often suffering from secondary PH. 5,6 Finally, in a recent clinical trial of 30 stable PH patients under optimized medical treatment, Mereles et al 7 reported marked improvement in exercise capacity and quality of life after exercise training.Although training might be a promising adjunct to medical treatment in PH, it remains to be elucidated whether exercise training is beneficial for all PH patients and what its effect is on RV function and remo...

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“…However, with the increase in medical treatment options in the last decennium, the prognosis has improved significantly, and the role of exercise training in patients with iPAH was reconsidered [3]. Recently, the first clinical trial on exercise training in patients with pulmonary arterial hypertension reported promising results of improved exercise capacity and quality of life [4].…”

mentioning

confidence: 99%

“…Traditionally, exercise training in iPAH patients was contraindicated due to the risk of sudden cardiac death [3]. However, with the increase in medical treatment options in the last decennium, the prognosis has improved significantly, and the role of exercise training in patients with iPAH was reconsidered [3].…”

mentioning

confidence: 99%

Effects of exercise training in patients with idiopathic pulmonary arterial hypertension

Man¹,

Handoko²,

Groepenhoff³

et al. 2009

European Respiratory Journal

203

202

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We determined the physiological effects of exercise training on exercise capacity and quadriceps muscle function in patients with idiopathic pulmonary arterial hypertension (iPAH).In total, 19 clinically stable iPAH patients (New York Heart Association II-III) underwent a supervised exercise training programme for the duration of 12 weeks. Maximal capacity, endurance capacity and quadriceps function were assessed at baseline and after 12 weeks. In 12 patients, serial quadriceps muscle biopsies were obtained.6-min walk distance and peak exercise capacity did not change after training. However, endurance capacity improved significantly after training, demonstrated by a shift of the anaerobic threshold to a higher workload (from 32¡5 to 46¡6 W; p50.003) together with an increase in exercise endurance time (p,0.001). Moreover, exercise training increased quadriceps strength by 13% (p50.005) and quadriceps endurance by 34% (p50.001).Training enhanced aerobic capacity of the quadriceps, by increasing capillarisation (1.36¡0.10 to 1.78¡0.13 capillaries per muscle fibre; p,0.001) and oxidative enzyme activity, especially of the type-I (slow) muscle fibres. No changes were found in cross-sectional area and fibre type distribution.Exercise training in iPAH improves exercise endurance and quadriceps muscle function, which is also reflected by structural changes of the quadriceps.

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Exercise in Patients With Pulmonary Arterial Hypertension

Cited by 53 publications

References 33 publications

Efficacy and Safety of Exercise Training in Chronic Pulmonary Hypertension

Efficacy and Safety of Exercise Training in Chronic Pulmonary Hypertension

Opposite Effects of Training in Rats With Stable and Progressive Pulmonary Hypertension

Effects of exercise training in patients with idiopathic pulmonary arterial hypertension

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