Exercise training in advanced heart failure patients: Discordance between improved exercise tolerance and unchanged NT-proBNP levels
Introduction
Exercise intolerance is a cardinal manifestation of congestive heart failure (CHF). In advanced heart failure, functional capacity is, by definition, so poor that patients become symptomatic during minimal effort or even at rest. Limitations imposed by low cardiac output and decreased oxygen supply to skeletal muscle are followed by muscle deconditioning and eventually atrophy [1], [2], [3], [4], [5].
In the past, physical activity was considered contraindicated in heart failure patients. Recent studies indicate that exercise training programs can produce symptomatic benefit and improve functional class in individuals with left ventricular dysfunction [6], [7]. A meta-analysis summarizing 9 studies in a total of 801 patients found a trend for improved longevity [8], [9]. Limited data exist, however, on the feasibility, safety and the clinical benefits of exercise in patients with advanced heart failure.
We initiated an exercise rehabilitation program for patients with advanced heart failure. CHF patients who became stable at NYHA functional class III on maximal medical therapy were encouraged to undergo exercise rehabilitation.
Levels of brain natriuretic peptide (BNP) or its amino-terminal fragment (NT-proBNP) were established in prospective studies as a principal neurohumoral prognostic indicator in heart failure patients [10], [11]. The objective of the current study was to explore whether exercise training is also associated with improved cardiovascular performance and the principal indicators of prognosis: maximal aerobic capacity (VO2max) and blood levels of the brain natriuretic hormone (NT-proBNP).
Section snippets
Methods
Consecutive outpatients with advanced CHF (New York Heart Association functional class III, stage D) were referred from the Heart Failure Clinic of our Heart Institute to the Cardiac Rehabilitation Institute, to participate in a supervised exercise and rehabilitation program according to preexisting guidelines [12], [13]. Patients included were in a stable clinical condition and on optimal medical therapy. Patients who underwent percutaneous or surgical intervention, acute myocardial
Results
Thirty advanced heart failure patients with systolic left ventricular dysfunction, who stabilized on NYHA functional class III on optimal medical therapy, were enrolled (Table 1). Eighty percent were males, 77% had heart failure of ischemic etiology. Nearly all were treated with angiotensin converting enzyme or angiotensin receptor blocker and the majority were on digoxin and beta-adreno-receptor blockers. Seven (23%) had chronic renal failure defined as serum creatinine ≥ 1.5 mg/dl.
The exercise
Discussion
Our study demonstrates the great merit of rehabilitation therapy in otherwise maximally treated and severely symptomatic patients with advanced heart failure. A relatively short period of exercise training was associated with a major improvement in functional capacity. While the 66% increase in the duration of treadmill exercise may be, at least in part, attributed to habituation, the 39% increase in the 6 min walking distance apparently reflects the net benefit of training. The significant
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2023, Experimental GerontologyCitation Excerpt :In addition, evidence shows that exercise training in patients with CHF mainly affects peripheral muscles, thus improving body function and may not have a considerable effect on serum BNP (Kokkinos et al., 2000). Other studies have shown that although exercise training can effectively improve 6MWT in patients with CHF, it will not affect the serum BNP level (Arad et al., 2008). These findings are consistent with the results of the present study.
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2019, Journal of CardiologyCitation Excerpt :The effort capacity was quantified using metabolic equivalent of task (METs) units, derived from ergometry tests executed according to the Bruce protocol, the modified Bruce, and the Belke protocol. The training protocol originally developed for a heart failure cohort was previously described [15]. Finally, each patient was contacted by telephone and requested to respond to questionnaires relating to their health status and functional capacity and post-rehabilitation.
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2012, International Journal of CardiologyCitation Excerpt :We found a relationship to worsened self-rated health, but the significance of this correlation was borderline and should be interpreted with care. Also other therapeutic strategies have been shown to differentially affect physical capacity and NTproBNP levels in heart failure patients [15]. According to the primary goal of the CIBIS-ELD trial, patients and physicians were blinded to the beta-blocker agent but not to the dose levels.
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2011, Journal of the American College of CardiologyCitation Excerpt :Furthermore, NT-proBNP levels have been described to be heavily influenced by comorbidities that were excluded in our study population (39). The fact that NT-proBNP levels did not reflect the improvement in physical function that has been described also in HFrEF, supports the recommended approach to use natriuretic peptides for a diagnosis of HFpEF only in conjunction with other parameters (18,39,40). Furthermore, it generates the hypothesis that NT-proBNP may not be an ideal stand-alone surrogate marker to evaluate the success of interventions in HFpEF.
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2011, American Journal of CardiologyCitation Excerpt :The mechanism leading to the association of PAD with poorer outcomes and lack of improvement with exercise training in a large HF population is unknown. Lack of improvement with exercise training has been separately described in the PAD and HF literatures and may relate to skeletal muscle abnormalities or a mixture of central and peripheral hemodynamic abnormalities.10–16 There are unfortunately no data on skeletal muscle changes or hemodynamic changes with exercise in this study.
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These authors contributed equally to this work.