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

Senni et al. On behalf of IN-CHF Investigators. Journal of Cardiac Failure Vol. 11 No. 4 2005

?

training

VO2

Esercizio e scompenso cardiaco

Fattori periferici e centrali

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

Mechanisms to augment cardiac output (C.O.) in (A) healthypersons without HF and (B) patients with HF.

Piña et al, Circulation March 4, 2003

Cardio-Pulmonary eXercise (CPX) test

Healthy subject CHF patient

Circulation 1993 87:VI-7

Relationship of LVEF and peak oxygen uptake

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

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

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

Muscle Ergoreflex System: Anatomical Pathways

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

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

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

• Piepoli et al Circulation 2006

Modello fisiopatologico degli adattamentiindotti dal training fisico nello scompenso cardiaco

Belardinelli R, Agostoni PG.

Studi randomizzati sugli gli effetti del training nei pazienti con insufficienza cardiaca cronica.

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.

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)

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

Effect of Exercise Training on Muscle Metabolism in CHF

Adamopoulos et al. Physical Training in Heart Failure. JACC 1993;21:1101-1106.

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

S. Adamopoulos European Heart Journal (2001) 22, 791–797

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

• 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

Haykowsky et al. JACC Vol. 49, No. 24, 2007

Training and quality of life in CHF

Afzal et al. Progress in Cardiovascular Diseases 1998

Fattori predittivi di risposta positiva al training fisico nei pazienti con insufficienza cardiaca

Wilson JR et al. Circlation 1996; 94: 1767-72

Belardinelli R, Circulation. 1999;99:1173-1182.)

ExTraMATCH Collaborative. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH)

ExTraMATCH BMJ  2004;328:189

K-M cumulative two year survival (top) and cumulative two year survival or free from admission hospital (bottom).

ExTraMATCH BMJ  2004;328:189

death

.65 (.46 to .92)

.72 (.56 to .93)

death/Admission

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

• “ 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

•Modalità•Durata•Frequenza•Intensità•Progressione•Sicurezza

Relative and absolute contraindications

European Heart Journal (2001) 22, 125–135

Working Group Report

• 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

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

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

• 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

Safety of exercise training programme in CHF

European Heart Journal (2001) 22, 125–135

Working Group Report

Eur J Cardiovasc Prev Riabil 2005; 12:321-325

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.

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

Ponzo effect