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Giovanni PulignanoGiovanni PulignanoAmbulatorio per lo Scompenso Cardiaco Ambulatorio per lo Scompenso Cardiaco
I UO Cardiologia /UTIC I UO Cardiologia /UTIC Dipartimento CardiovascolareDipartimento Cardiovascolare
Az.Osp. S.Camillo-ForlaniniAz.Osp. S.Camillo-Forlanini
41 Congresso di CardiologiaIncontri con gli esperti
Milano, 19 settembre 2007
“Gli aspetti che trascuriamo nel paziente con scompenso cardiaco:
Esercizio fisico e scompenso cardiacoEsercizio fisico e scompenso cardiaco
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Senni et al. On behalf of IN-CHF Investigators. Journal of Cardiac Failure Vol. 11 No. 4 2005
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?
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training
VO2
Esercizio e scompenso cardiaco
Fattori periferici e centrali
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Vasoconstriction Sympatho-excitation
Vagal- withdrawal
Skeletal and RespiratoryMyopathy
InactivityMalnutrition
PhysicalDeconditioning
Muscle FatigueDyspnoea
Modifications:•muscular structure•vascular structure•autonomic tone•muscular reflex
Reduced peripheralblood flow
Catabolic State
LV Dysfunction
Inactivity
Physical Training
M. Piepoli, 1997
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Mechanisms to augment cardiac output (C.O.) in (A) healthypersons without HF and (B) patients with HF.
Piña et al, Circulation March 4, 2003
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Cardio-Pulmonary eXercise (CPX) test
Healthy subject CHF patient
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Circulation 1993 87:VI-7
Relationship of LVEF and peak oxygen uptake
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Survival by peak VO2 in CHF
0 10 20 30 40 50 60 70
Time (months)
>>2121
16-2116-21
14-1614-16
<14<14
0
20
40
60
80
100
Pe
rce
nt
Su
rviv
al
n = 297p = 0.0002
Francis, Heart 2000 Florea, EHJ 2000
increase in peak VO2
decrease in peak VO2
0 5 10 15 20 25 30 35 40
100
80
60
40
20
0 Time (months)
Survival (%)
p < 0.05
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Ventilatory Inefficiency in CHF: VE/VCO2 slope
0
20
40
60
80
100
120
140
0 1 2 3 4 5 6VCO2 (L/min)
VE (L/min)
NormalModerate CHFSevere CHF
0
20
40
60
80
100
0 10 20 30 40 50 60 70Time (months)
< 27< 27
27-3327-33
34-4234-42
> 43> 43n = 297P < 0.0001
Survival
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Impaired Tolerance and Abnormal Responses to Exercise in CHF: Peripheral Factors
1. Blood flow ml/min reduced
2. Metabolism early lactic acid productionphosphate depletion
3. Function Weakness, increased fatigue
4. Morphology: Quantity Loss of muscle mass (or bulk)
Site Localised to legs or general abnormalityOrientation and fibre position
Quality Atrophy, damage and/or necrosis (apoptosis)Change of fibre type, myosin IIb
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Muscle Ergoreflex System: Anatomical Pathways
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0
25
50
75
100
CHF Control
Ergoreflex L/min%
*
0
1
2
3
4
CHF Control
Central - Chemoreflexl/min mmHg
*
0
0.25
0.5
0.75
1
1.25
CHF Control
*
Peripheral - Chemoreflexl/min/%SaO2
0
10
20
30
40
0
10
20
30
40
CHF Control CHF Control
Peak VO2ml/min/kg
*
*
VE/VCO2
Ponikowski, Piepoli et al Circulation. 2001;104:2324-2330.)
Neural Reflex Activation in Heart Failure
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Piepoli et al. Circulation 1996;93: 940
.
24
recovery (min.)rest exercise time (%)
circulatory occlusion
6
8
10
12
14
16
18
20
22
100 1 2 3 4 5 6 725 50 75rest
**** **
HEART FAILURE PATIENTS
Ven
tilat
ion
(l/m
in)
CONTROL SUBJECTS
Training: control handgripTraining: handgrip withPH-RCODetraining: handgrip withPH-RCO
recovery (min.)rest exercise time (%)circulatory occlusion
24
6
8
10
12
14
16
18
20
22
100 1 2 3 4 5 6 725 50 75rest
* * *
\
Effect of Exercise training on the Contribution of Muscle Ergoreflex to Exercise in Heart Failure vs Controls
DetrainingTraining
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Cicoira MA et al. JACC 2001
Massa muscolare scheletrica e tolleranza allo sforzo
Skeletal muscle mass independently predicts peak oxygen consumption and ventilatory response during exercise in
noncachectic patients with chronic heart failure
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• Piepoli et al Circulation 2006
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Modello fisiopatologico degli adattamentiindotti dal training fisico nello scompenso cardiaco
Belardinelli R, Agostoni PG.
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Studi randomizzati sugli gli effetti del training nei pazienti con insufficienza cardiaca cronica.
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Parametro Effetto del Training
VO2 picco + 12-26%
VO2 alla AT +
VE/CO2 ratio - 6-18%
Durata esercizio + 17%
Eur HF training Group . Eur Heart J 1998; 19:466-475
Pina IL. Circulation 2003; 107(8):1210-1225.
Principali adattamenti indotti dal trainingfisico nell’insufficienza cardiaca cronica.
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Principali adattamenti indotti dal trainingfisico nell’insufficienza cardiaca cronica.
• Adattamenti centrali
• Ridotta progressione di stenosi coronariche – (30-45)
• Dilatazione arteriosa coronarica endotelio-dipendente + (20-30)
• Aumento della diffusione polmonare + (10-20)
• Miglioramento della perfusione miocardica + (15-25)
• Miglioramento del rilasciamento diastolico + (15-28)
• Miglioramento della contrattilità + (15-25)
• Miglioramento della funzione sistolica globale + (10-15)
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Principali adattamenti indotti dal trainingfisico nell’insufficienza cardiaca cronica.
• Adattamenti periferici
• Miglioramento del flusso muscolare + (12-30)
• Aumento degli enzimi muscolari ossidativi + (15-30)
• Aumento del volume di densità mitocondriale + (15-25)
• Aumento delle fibre muscolari tipo I + (15-30)
• Dilatazione arteriosa endotelio-dipendente + (15-40)
• Attenuazione dell’ergoriflesso
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Effect of Exercise Training on Muscle Metabolism in CHF
Adamopoulos et al. Physical Training in Heart Failure. JACC 1993;21:1101-1106.
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Physical exercise increases in endothelium-dependent blood flow (A), whereas peripheral blood flow remained unchanged (B) in the control group. #P<0.05 vs beginning; *P<0.05 vs control.
Training corrects endothelial dysfunction and improves exercise capacity in CHF
Hambrecht et al. Circulation 1998;98:2709
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S. Adamopoulos European Heart Journal (2001) 22, 791–797
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Improvements in patents in the exercise group
Passino C et al. J Am Coll Cardiol 2006; 47:1835-1839.
End points Active group (% change)*
p*
Workload (W) +14 <0.001
Peak VO2 (mL/min/kg) +13 <0.001
LVEF (%) +9 <0.01
BNP (ng/L) -34 <0.01
NT-proBNP (ng/L) -32 <0.05
Norepinephrine (ng/L) -26 <0.01*Compared with control group, which showed no changes BNP=B-type natriuretic peptideNT-proBNP=amino-terminal pro-brain natriuretic peptide
Aerobic training decreases B-type natriuretic peptide expression and adrenergic activation in patients with heart failure
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• Conclusioni: in condizioni di stabilità, l’esercizio moderato, a lungo termine, non ha effetti negativi sul volume e sulla funzione del VS, ma anzi attenua il rimodellamento. Inoltre l’allenamento è sicuro ed efficace per aumentare la tolleranza all’esercizio e migliorare la qualità della vita.
Circulation. 2003; 108: 554-559
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Haykowsky et al. JACC Vol. 49, No. 24, 2007
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Training and quality of life in CHF
Afzal et al. Progress in Cardiovascular Diseases 1998
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Fattori predittivi di risposta positiva al training fisico nei pazienti con insufficienza cardiaca
Wilson JR et al. Circlation 1996; 94: 1767-72
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Belardinelli R, Circulation. 1999;99:1173-1182.)
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ExTraMATCH Collaborative. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH)
ExTraMATCH BMJ 2004;328:189
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K-M cumulative two year survival (top) and cumulative two year survival or free from admission hospital (bottom).
ExTraMATCH BMJ 2004;328:189
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death
.65 (.46 to .92)
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.72 (.56 to .93)
death/Admission
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HF-ACTION: Heart Failure: A Controlled Trial
Investigating Outcomes of Exercise TraiNing
• 5-year, 3,000-patient NYHA II-IV, EF<35% randomized trial,
• 50 U.S. and Canadian hospitals,
• first large-scale prospective trial designed to determine whether exercise can reduce mortality and hospitalizations for patients with HF or any other disease
• Ongoing enrolment
• >2000 pts, >> male, low mean age, mild peak VO2 impairment
Whellan DJ Am Heart J. 2007 Feb;153(2):201-11. Adams, Barcelona WCC 4 September 2006
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• “ Despite ..benefits, a limitation of these investigations was the primary focus on males <60 years with impaired left ventricular systolic function”.
• “Thus the role that exercise training may play in attenuating the HF-mediated decline in VO2peak in women >65 years of age with systolic or diastolic dysfunction remains unknown”.
HAYKOWSKYJ ournal of Cardiac Failure Vol. 10 No. 2 2004
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•Modalità•Durata•Frequenza•Intensità•Progressione•Sicurezza
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Relative and absolute contraindications
European Heart Journal (2001) 22, 125–135
Working Group Report
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• Aerobic exercise• Cycle ergometer• walking (<50-100 m/min)
• out-door cycling? jogging ? Swimming ?
• Calisthenic: flexibility, coordination, strength
• Resistance • rhythmic, ie. 1:1 rate • small muscle: single limb• small repetition: 60”ex/120”recovery• 50-80% max voluntary capacity
• Respiratory• inspiratory, (20-30% max capacity) 20-30min/d, 3-5 d/w• abdominal muscle• yoga
Modality of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
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Aerobic Exercise. Cycle ergometer:
Warm up 10’ – Conditioning phase 40’– Cool down 10’
• Interval training: short bouts of work phases followed by short recovery phases. • 30” exercise: 50-60% max ex capacity / 60” recovery (low load, 10W)• 10-12 work phases in 15-min training session• Max ex capacity: steep ramp test, 25W every 10”
• Steady-state training • 10-60 min /d, 3-7 d/w• 40-80% peak VO2 (or peak HR or perceived exertion by Borg scale)• <3METS, 2-3 sessions/d, 5-10 min; >3METS 3-5 sessions, 20-30min
Modality of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
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Aerobic Training: Phases of exercise progression
1. Initial stage:
- 10-15min, 40%-50% pkVo2,
2. Improvement stage (>15d):
- 15-20-30min, 50% -> 60% -> 70% pkVo2
3. Maintenance stage (>6m)
European Heart Journal (2001) 22, 125–135
Working Group Report
Modality of exercise training programme in CHF
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• Initial phase: in-hospital supervision• Pulmonary and cardiac O.E.• body weight and oedema• HR and BP monitoring• symptoms
• Maintenance Phase: combination of supervised/ unsupervised training• selected group of patients• to favour adherence to prescription
Safety of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
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Safety of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
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Eur J Cardiovasc Prev Riabil 2005; 12:321-325
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Conclusioni: Il training nel paziente con scompenso cardiaco stabile:
• Migliora la funzione vascolare periferica, muscolare e metabolica
• Migliora la funzione respiratoria e del sistema nervoso autonomo
• Questi effetti portano ad un significativo miglioramento della tolleranza all’esercizio e alla qualità della vita
• Nessun deterioramento significativo dell’emodinamica centrale
• Attenuazione dello sfavorevole rimodellamento del ventricolo sinistro
• Migliori risultati con esercizio aerobico, intensità moderata (60%), personalizzato, lunga durata (mesi), con supervisione specialistica.
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Conclusioni:Problemi
• Evidenza derivante da studi randomizzati con numero limitato di pazienti arruolati in centri altamente specializzati, >>maschi, età media 50-55 anni con interferenza di altri fattori (Hawthorne effect)
• Mancanza di dati relativi a pazienti con diversi modelli fisiopatologici (SC diastolico, cpt. valvolare)
• Diversità nei protocolli negli studi pubblicati
• Bassa prescrizione ACE/ARB, BB o CRT
• Risultati non sempre concordi in termini di QDV, tolleranza allo sforzo e sopravvivenza
• Scarsità di fattori (clinici, di funzione ventricolare, ecc.) predittivi di miglioramento durante programma riabilitativo
• Difficoltà organizzative
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Ponzo effect
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