Moderate continuous or high intensity interval exercise in heart failure with reduced ejection fraction: Differences between ischemic and non-ischemic etiology.

Background: Exercise for heart failure (HF) with reduced ejection fraction (HFrEF) is recommended by guidelines, but exercise mode and intensities are not differentiated between HF etiologies. We, therefore, investigated the effect of moderate or high intensity exercise on left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF) and maximal exercise capacity (peak VO2) in patients with ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM). Methods: The Study of Myocardial Recovery after Exercise Training in Heart Failure (SMARTEX-HF) consecutively enrolled 231 patients with HFrEF (LVEF ≤ 35 %, NYHA II-III) in a 12-weeks supervised exercise program. Patients were stratified for HFrEF etiology (ICM versus NICM) and randomly assigned (1:1:1) to supervised exercise thrice weekly: a) moderate continuous training (MCT) at 60-70 % of peak heart rate (HR), b) high intensity interval training (HIIIT) at 90-95 % peak HR, or c) recommendation of regular exercise (RRE) according to guidelines. LVEDD, LVEF and peak VO2 were assessed at baseline, after 12 and 52 weeks. Results: 215 patients completed the intervention. ICM (59 %; n = 126) compared to NICM patients (41 %; n = 89) had significantly lower peak VO2 values at baseline and after 12 weeks (difference in peak VO2 2.2 mL/(kg*min); p < 0.0005) without differences between time points (p = 0.11) or training groups (p = 0.15). Etiology did not influence changes of LVEDD or LVEF (p = 0.30; p = 0.12), even when adjusting for sex, age and smoking status (p = 0.54; p = 0.12). Similar findings were observed after 52 weeks. Conclusions: Etiology of HFrEF did not influence the effects of moderate or high intensity exercise on cardiac dimensions, systolic function or exercise capacity. Clinical Trial Registration­URL: http://www.clinicaltrials.gov. Unique identifier: NCT00917046.

[Care pathway for Covid-19 patients in a hospital in Luxembourg]. / Parcours de soins des patients atteints de la Covid-19 dans un centre hospitalier au Luxembourg.

The current care pathway for COVID-19 patients was set up at the Centre Hospitalier de Luxembourg following the experiences of the first wave. The role of the nurse in this pathway is fundamental: she coordinates care and the multidisciplinary team as well as the families, in addition to monitoring and treating the patients. Her tool is clinical reasoning, which is the guarantee of care adapted to the needs and expectations of the patients.

Exercise training and high-sensitivity cardiac troponin T in patients with heart failure with reduced ejection fraction.

AIMS: Whether an exercise training intervention is associated with reduction in long-term high-sensitivity cardiac troponin T (hs-cTnT) concentration (a biomarker of subclinical myocardial injury) in patients with heart failure with reduced ejection fraction (HFrEF) is unknown. The aims were to determine (i) the effect of a 12 week endurance exercise training intervention with different training intensities on hs-cTnT in stable patients with HFrEF (left ventricular ejection fraction ≤ 35%) and (ii) associations between hs-cTnT and peak oxygen uptake (VO2peak ). METHODS AND RESULTS: In this sub-study of the SMARTEX-HF trial originally including 261 patients from nine European centres, 213 eligible patients were included after withdrawals and appropriate exclusions [19% women, mean age 61.2 years (standard deviation: 11.9)], randomized to high-intensity interval training (HIIT; n = 77), moderate continuous training (MCT; n = 63), or a recommendation of regular exercise (RRE; n = 73). Hs-cTnT measurements and clinical data acquired before (BL) and after a 12 week exercise training intervention (12 weeks) and at 1 year follow-up (1 year) were analysed using multivariable mixed models. Baseline hs-cTnT was above the 99th percentile upper reference limit of 14 ng/L in 35 (48%), 35 (56%), and 49 (64%) patients in the RRE, MCT, and HIIT groups, respectively. Median hs-cTnT was 16 ng/L at BL, 14 ng/L at 12 weeks, and 14 ng/L at 1 year. Hs-cTnT was statistically significantly reduced at 12 weeks in a model adjusted for randomization group, centre and VO2peak , and after further adjustment in the final model that also included age, sex, creatinine concentrations, N-terminal pro-brain natriuretic peptide, smoking, and heart failure treatment. The mean reduction from BL to 12 weeks in the final model was 1.1 ng/L (95% confidence interval: 1.0-1.2 ng/L, P < 0.001), and the reduction was maintained at 1 year with a mean reduction from BL to 1 year of 1.1 ng/L (95% confidence interval: 1.0-1.1 ng/L, P = 0.025). Randomization group was not associated with hs-cTnT at any time point (overall test: P = 0.20, MCT vs. RRE: P = 0.81, HIIT vs. RRE: P = 0.095, interaction time × randomization group: P = 0.88). Independent of time point, higher VO2peak correlated with lower hs-cTnT (mean reduction over all time points: 0.2 ng/L per increasing mL·kg-1 ·min-1 , P = 0.002), without between-group differences (P = 0.19). CONCLUSIONS: In patients with stable HFrEF, a 12 week exercise intervention was associated with reduced hs-cTnT in all groups when adjusted for clinical variables. Higher VO2peak correlated with lower hs-cTnT, suggesting a positive long-term effect of increasing VO2peak on subclinical myocardial injury in HFrEF, independent of training programme.

Baseline and Exercise Predictors of V˙O2peak in Systolic Heart Failure Patients: Results from SMARTEX-HF.

PURPOSE: This study aimed to investigate baseline, exercise testing, and exercise training-mediated predictors of change in peak oxygen uptake (V˙O2peak) from baseline to 12-wk follow-up (ΔV˙O2peak) in a post hoc analysis from the SMARTEX Heart Failure trial. METHODS: We studied 215 patients with heart failure with left ventricular ejection fraction (LVEF) ≤35%, and New York Heart Association (NYHA) classes II-III who were randomized to either supervised high-intensity interval training with exercise target intensity of 90%-95% of peak heart rate (HRpeak) or supervised moderate continuous training (MCT) with target intensity of 60%-70% of HRpeak, or who received a recommendation of regular exercise on their own. Predictors of ΔV˙O2peak were assessed in two models: a logistic regression model comparing highest and lowest tertiles (baseline parameters) and a multivariate linear regression model (test/training/clinical parameters). RESULTS: The change in V˙O2peak in response to the interventions (ΔV˙O2peak) varied substantially, from -8.50 to +11.30 mL·kg·min. Baseline NYHA (class II gave higher odds vs III; odds ratio (OR), 7.1 (2.0-24.9); P = 0.002), LVEF (OR per percent, 1.1 (1.0-1.2); P = 0.005), and age (OR per 10 yr, 0.5 (0.3-0.8); P = 0.003) were associated with ΔV˙O2peak.In the multivariate linear regression, 34% of the variability in ΔV˙O2peak was explained by the increase in exercise training workload, ΔHRpeak between baseline and 12-wk posttesting, age, and ever having smoked. CONCLUSION: Exercise training response (ΔV˙O2peak) correlated negatively with age, LVEF, and NYHA class. The ability to increase workload during the training period and increased ΔHRpeak between baseline and the 12-wk test were associated with a positive outcome.

High-Intensity Interval Training in Patients With Heart Failure With Reduced Ejection Fraction.

BACKGROUND: Small studies have suggested that high-intensity interval training (HIIT) is superior to moderate continuous training (MCT) in reversing cardiac remodeling and increasing aerobic capacity in patients with heart failure with reduced ejection fraction. The present multicenter trial compared 12 weeks of supervised interventions of HIIT, MCT, or a recommendation of regular exercise (RRE). METHODS: Two hundred sixty-one patients with left ventricular ejection fraction ≤35% and New York Heart Association class II to III were randomly assigned to HIIT at 90% to 95% of maximal heart rate, MCT at 60% to 70% of maximal heart rate, or RRE. Thereafter, patients were encouraged to continue exercising on their own. Clinical assessments were performed at baseline, after the intervention, and at follow-up after 52 weeks. Primary end point was a between-group comparison of change in left ventricular end-diastolic diameter from baseline to 12 weeks. RESULTS: Groups did not differ in age (median, 60 years), sex (19% women), ischemic pathogenesis (59%), or medication. Change in left ventricular end-diastolic diameter from baseline to 12 weeks was not different between HIIT and MCT (P=0.45); left ventricular end-diastolic diameter changes compared with RRE were -2.8 mm (-5.2 to -0.4 mm; P=0.02) in HIIT and -1.2 mm (-3.6 to 1.2 mm; P=0.34) in MCT. There was also no difference between HIIT and MCT in peak oxygen uptake (P=0.70), but both were superior to RRE. However, none of these changes was maintained at follow-up after 52 weeks. Serious adverse events were not statistically different during supervised intervention or at follow-up at 52 weeks (HIIT, 39%; MCT, 25%; RRE, 34%; P=0.16). Training records showed that 51% of patients exercised below prescribed target during supervised HIIT and 80% above target in MCT. CONCLUSIONS: HIIT was not superior to MCT in changing left ventricular remodeling or aerobic capacity, and its feasibility remains unresolved in patients with heart failure. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00917046.

Effects of different training modalities on circulating anabolic/catabolic markers in chronic heart failure.

BACKGROUND: Muscle wasting in chronic heart failure (CHF) is a result of increased catabolism induced by proinflammatory cytokines like tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6), and decreased anabolism due to alterations in the insulin-like growth factor 1 (IGF-1)/growth hormone (GH) axis. The goal of this study was to analyze the effects of 3 different training modalities (endurance training, strength training, and combined strength and endurance training [CT]) on circulating cytokines, IGF-1, and GH levels. METHODS: Patients with CHF (N = 45), NYHA class II-III, left ventricular ejection fraction < 35%, were randomly assigned to 1 of 3 training modalities. They trained for 40 sessions, 3 times weekly. Fifteen CHF patients served as a control group. Blood samples were collected at baseline and 48 hours after the last training session. RESULTS: There was a significant decrease in circulating IL-6 with all 3 training modalities. Tumor necrosis factor α levels decreased in the training groups and reached statistical significance for the CT group. No change was observed in the control group. There was no difference between the 4 groups. When comparing all trained patients with the control group, the decrease in IL-6 was significant. Concerning IGF-1 and GH, there was no change with training and no change in the control group. CONCLUSION: Exercise training has no effects on circulating IGF-1 and GH. The decreases in cytokines are evident only when all trained patients are compared with the control group, independently of the modality of training intervention.

[25 years of organized ambulatory heart sport in Luxembourg. The development of a sustained rehabilitation model]. / 25 ans de sport pour Cardiaques a Luxembourg. Développement d'un modèle de rééducation durable.

After Second World War cardiovascular disease (CVD), especially coronary artery disease (CAD), turned out to be an epidemic in the western countries including the Grand-Duchy of Luxembourg, and accounted for nearly half of all deaths. A lot of strategies, among them treatment by physical activity, were developed to fight this challenge and, fortunately, a mortality regression of about 50 % could be achieved. Nowadays, eastern European countries and, more recently, China and India face an increasing CVD mortality. During the seventies ambulatory heart sport clubs, then labeled as, "coronary clubs" became very popular in Europe especially in West-Germany. Around 2000 there were more than 6000 heart sports groups in Germany. In 1984 a first group was founded in Luxembourg City (Centre) a, 1991 a second group started in Esch/Alzette (South) and in 2002 a third regional group in Ettelbruck (North) so that, by now, the 3 main public health districts of the Grand-Duchy of Luxembourg can offer regular ambulatory sports activities to almost all concerned cardiac patients in the country. The ambulatory heart sport groups of Luxembourg cooperate in a federated association allowing an integrated logistic organization. Since the beginning nineties cardiac rehabilitation became a field of interest to the university faculties and later of scientific societies, like the American Heart Association (AHA) and the European Society of Cardiology (ESC). New subgroups were founded and guidelines were published and renewed. The movement of ambulatory heart sport groups was more or less neglected in the prevention and rehabilitation activities of the scientific societies. Recently the ESC proposed a new definition of comprehensive CVD prevention and rehabilitation programmes as "coordinated, multifaceted interventions designed to optimize a cardiac patient's physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality". The responsible ESC cardiologists agree with the international community that fighting CVD risk factors is at least as important as the whole arsenal of modern heart surgery and interventional cardiology. The core activity of ambulatory heart sport groups remains physical activity, and nowadays 6 different activities can be offered (one activity each day of the week): exercise lesson, swimming, walking, cycling, Nordic Walking and water gymnastics On the other hand comprehensive prevention programs, especially concerning CVD risk factors are also endorsed by the ambulatory heart sport groups of Luxembourg via regular meetings, conferences, brochures and symposia. One advantage of the ambulatory heart sport movement in Luxembourg, in contrast to the German model, is the direct financial allowance of the health ministry, which permits a lifelong activity to all the active members. Another advantage is that all the regional groups are directed by clinical cardiologists knowing the patients very closely. One weak point is that only about 5-10% of all potential candidates adhere to the ambulatory heart sport groups but nearly 50% of the active members are practicing for more than 5 years. These regularly active patients are a positive selection of well committed cardiac patients who, most of the time, control CVD risk factors with scrutiny. The ESC has recommended creating so called "Heart Houses" where all the aspects of comprehensive prevention and rehabilitation can be offered. Their main concern is to develop a sustained strategy which is desperately missing for the moment. A lot of the active members of the heart sport groups of Luxembourg achieve such a sustained activity and, therefore, these heart sport groups can be considered as very cost effective models of sustained rehabilitation. After a 25 years activity the ambulatory heart sport movement of Luxemburg has reached the outstanding goal of being a center of sustained rehabilitation. Although such a goal was not really planned during the first 15 years of activity, the stamina of the active members set the movement into this direction.

Isokinetic versus one-repetition maximum strength assessment in chronic heart failure.

PURPOSE: Reduction in exercise capacity in patients with chronic heart failure (CHF) has been partially attributed to decreased muscle strength. Training studies reported important variations in strength increases during rehabilitation, ranging between 5% and 70% and depending on the measurement technique: isokinetic dynamometry or the one-repetition maximum (1RM) methods. Therefore, the question arises if both techniques assess the changes in muscle strength in a comparable way. METHODS: Thirty patients with CHF, New York Heart Association class II-III, with mean baseline VO2peak of 14.8 +/-3.0 mL x kg(-1) x min(-1) and mean baseline left ventricular ejection fraction of 23.5% T 5.5%, were assessed for knee extensor and knee flexor strength before and after 40 training sessions by isokinetic dynamometry and 1RM method. These two strength measurement techniques were compared using the Bland and Altman method for agreement. RESULTS: Knee extensor muscle strength increased by 7.4% and knee flexor strength increased by 18.7% if measured by isokinetic testing. With the 1RM method, knee extensor and flexor strength increased by 36% and 100%, respectively. Both techniques were not in agreement for muscle strength assessment; improvements were more important with the 1RM method. Furthermore, statistical analysis showed that the 1RM technique was overestimating strength increases in comparison with isokinetic evaluation, especially for higher strength levels. CONCLUSIONS: In the follow-up of exercise training programs in patients with CHF, isokinetic measurements should be preferentially used to limit bias between measurements at different times.

Reverse remodelling through exercise training is more pronounced in non-ischemic heart failure.

PURPOSE: Most training studies in patients with chronic heart failure (CHF) do not consider CHF aetiology in the interpretation of the results. About 60% of the patients in those studies have ischemic CHF (IHF) and 40% non-ischemic CHF (NHF). Recently, we conducted a randomized controlled trial to study three different training modalities in 60 patients with severe CHF, with a similar distribution of IHF and NHF patients. In the present post hoc analysis we compared the differences in training results between ischemic and non-ischemic patients. METHODS: Left ventricular ejection fraction (EF), end diastolic volume (EDV), end systolic volume (ESV), measured with radionuclide ventriculography (RNV) and echocardiography, NT-pro BNP, peak oxygen uptake (peak V(O)(2)), working capacity and muscular volume were analyzed before and after training in 45 patients training for 40 sessions, 3 times per week. Fifteen patients served as control group. The outcome was analyzed considering the aetiology of CHF, either ischemic or non-ischemic. RESULTS: There were no significant differences in improvements of peak V(O)(2), working capacity and muscular volume between IHF and NHF patients. In NHF patients, EF increased while EDV and ESV decreased after training. These parameters remained unchanged in IHF patients after training. NT-pro BNP decreased significantly in NHF patients and increased in IHF patients after training. In the control group, patients showed a mild improvement of EF and a decrease of NT-pro BNP. CONCLUSION: This post hoc analysis shows that training intervention is associated with significant reverse remodelling in NHF, but not in IHF patients, whereas V(O)(2) peak and muscle volume improve regardless of CHF aetiology. Future prospective studies are needed to confirm our findings.

[Ongoing medical problems in the anti-doping fight]. / Problèmes médicaux actuels de la lutte antidopage.

Over the last 20 years systematic doping has become a major threat for elite sport. So far, there is no clear information about the daily practice of doping. Repeated scandals and recent personal statements have added to our knowledge. Several more recent doping agents like Erythropoietin (EPO) and, probably, growth hormone (GH) enhance performance in a highly effective way and, together with the well known anabolic steroids (AAS), belong to the major doping categories. The introduction of EPO has really changed the paradigm in endurance sports allowing a good middle class athlete to become a champion. It is evident that doping practices are influenced by the possibilities of the anti-doping control system. Unethical, criminal medical doctors play a decisive role in the ongoing practice of major doping. Apart from the already mentioned substances AAS, EPO and GH several novel drugs appear on the horizon. They are highly effective and there is no doubt that they will be used in attempts to improve performance. During the last years, doping control systems have also been improved: EPO can now be detected in urine samples and the detection of AAS has also become much more sensitive. However GH hormone detection is not possible at the moment and this remains a major weakness of doping control. Other problems are the control procedures which are far from being optimal. In the future the quality of doping controls will be decisive and not only the quantity; controls will have to be "intelligent". The effective fight against doping in the next years will decide about the survival of elite sport.

Is strength training the more efficient training modality in chronic heart failure?

PURPOSE: An open, randomized, controlled study was designed to study the effects of exclusive strength training (ST) in patients with severe chronic heart failure (CHF) in comparison with conventional endurance (ET) and combined ET-ST training (CT). The hypothesis was that ST would at least be equal to ET or CT, because peripheral muscle atrophy and weakness play a key role in exercise limitation in CHF patients. METHODS: Three groups of 15 patients underwent ST, ET, or CT during 40 sessions, three times a week, for 45 min. Fifteen patients served as control group. Before and after intervention, left ventricular ejection fraction (LVEF), peak oxygen consumption (VO2peak), peak workload, thigh muscle volume, knee extensor strength, endurance, and quality of life (QoL) were assessed. RESULTS: All measured parameters improved significantly in the three training groups, except for knee extensor strength in ET. Training outcome was superior in all three training groups compared with the control group, but statistical significance was only reached for VO2peak and peak workload, thigh muscle volume, and knee extensor endurance. In contrast, knee extensor strength, LVEF, and QoL did not reach statistical significance. None of the training modalities proved to be superior to any other, although small differences between the three groups were observed. CONCLUSION: Independently of the training modality, intensive exercise training is efficient in increasing cardiac function, exercise capacity, peripheral muscle function, and QoL in CHF patients.

[Prescription of physical activity in cardiology: classical and new indications (a review based on evidence based data)]. / La prescription d'activité physique en cardiologie: indications classiques et nouvelles (revue a partir des données de la médecine factuelle).

Evidence based data of physical activity in primary prevention of coronary heart disease are excellent. For secondary prevention these data still are acceptable. Although it is an important new target group for physical therapy, there are so far no favourable data for exclusive training therapy in children or adolescents presenting a syndrome of obesity, sedentary lifestyle and bad nutrition. In nearly all the studies in this field physical activity is integrated in nutrition counselling and behavioural therapy. The following recommendations for public health can be made: Each adult should exercise at least half an hour and each child or adolescent one hour a day. Physical activity is the logical response to the sedentary lifestyle and hyper caloric food intake which are continuously spreading all over the world since 3 decades. It is an excellent therapy with nearly no side effects.

Strength/endurance training versus endurance training in congestive heart failure.

PURPOSE: The aim of this study was to compare the effects of endurance training alone (ET) with combined endurance and strength training (CT) on hemodynamic and strength parameters in patients with congestive heart failure (CHF). METHODS: Twenty male patients with CHF were randomized into one of two training regimens consisting of endurance training or a combination of endurance and resistance training. Group ET had 40-min interval cycle ergometer endurance training three times per week. Group CT combined endurance and strength training with the same interval endurance training for 20 min, followed by 20 min of strength training. Left ventricular function was assessed at baseline and after 40 training sessions by echocardiography and radionuclide ventriculography. Work capacity was measured with cardiopulmonary exercise test (CPX) and lactate determination. Strength was measured with an isokinetic dynamometer. RESULTS: After 40 sessions, the ET group improved functional class, work capacity, peak torque, and muscular endurance. However, peak O2 remained unchanged. Left ventricular ejection fraction (LVEF) and fractional shortening (FS) decreased, whereas left ventricular end-diastolic diameter (LVED) increased. The CT group improved NYHA score, working capacity, peak O2, and peak lactate; peak torque and muscular endurance, LVEF, and FS increased, whereas LVED decreased. Compared with ET, CT was significantly (P < 0.05) better in improving LV function. CONCLUSION: Combined endurance/strength training was superior to endurance training alone concerning improvement of LV function, peak VO2, and strength parameters. It appears that for stable CHF patients, a greater benefit can be derived from this training modality.