What is established? Risk of Benefit complica comp tion

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1 What s new in exercise training in CHF? Jean-Paul Schmid, MD, FESC Consultant Cardiologist, SpitalNetzBern Tiefenau Hospital, Dept. of Internal Medicine, Cardiology, Bern, Switzerland

2 What is established? Benefit Improvement of exercise capacity & QOL Risk of complication Negative remodeling Arrhythmias Decompen- sation

3 Exercise Training & LV Remodeling Haykowsky et al. JACC 2007;49:2329

4 peak VO 2 (l/min.) Muscle mass and exercise tolerance Mancini DM et al, Circulation 1992; 85: Toth MJ et al. Am J Cardiol 1997; 79: Control Heart failure Muscle mass (kg)

5 Effect of combined (AT & RT) vs. aerobic training alone in CAD pts VO 2 peak CT is more effective than AT in improving body composition, strength, and some indicators of cardiovascular fitness. Watt Marzolini S et al. European Journal of Preventive Cardiology : 81

6 BMJ 2004 Effect of exercise training on death or hospital admission

7 HF-ACTION All cause mortality

8 Exercise & morphologic changes in myocardium Weeks K et al. Physiology 26:97-105, 2011 Wassermann K et al. Circ 1997; 96(7):2221

9 Steep ramp test to set training intensity for intervall training Meyer K et al. Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures. Med Sci Sports Exerc 1997;29: W Seconds 30 s load / 60 s recovery

10 Active pause 60-70% 3 min Active pause 60-70% 3 min Active pause 60-70% 3 min Warm-up 60-70% 8 10 min Cool-down 60-70% 3 5 min High intensity training protocol on treadmill Interval Interval Interval Interval 85-95% 85-95% 85-95% 85-95% 4 min 4 min 4 min 4 min Intensity as % of max heart rate

11 Twenty-seven patients with stable postinfarction heart failure Optimal medical treatment Mean age: 75.5 ± 11.1 years Left ventricular ejection fraction: 29% VO 2 peak 13 ml/kg/min. moderate continuous training (70% of peak HR) vs. aerobic interval training (95% of peak HR) > 3 times per week for 12 weeks vs. control group (standard advice regarding physical activity)

12 Reversal of LV remodelling with high intensity training in HF patients Wisloff U et al.; Circ 2007; 115:3086

13 High intensity interval training

14 The 3-phase model General and local muscular aerobic endurance General anae- robic endurance Local muscular speed, endu- rance, power & elasticity Effect on cardiovascular system Binder R. et al. EJCPR 2008, 15:

15 Training prescription

16 Training prescription

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18 Inspiratory muscle training Train Air IMT threshold Power breath

19 Exercise limitation CHF pts: central vs periphery Reduced cardiac output and inadequate skeletal muscle flow vs. muscle deconditioning

20 Relation between exercise capacity (VO 2 max.) and LV-EF A. Cohen-Solal et al. Cardiac and peripheral responses to exercise in patients with chronic heart failure. European Heart Journal 1999;20:

21 Response to ex. training in pts with reduced cardiac output response Wilson JR et al. Circulation 1996;94:

22 Chronotropic reserve and respose to exercise training Optimal threshold Chi- square Hazard ratio 95% CI HR reserve (bpm) HR recovery (bpm) HR peak (bpm) HR reserve (%) ** * ** ** Schmid JP et al. Eur J Prev Cardiol * = p<0.05, ** = p<0.01, *** = p<0.001

23 Active Skeletal Muscle Mass and Cardio-pulmonary Reserve Jondeau G et al. Circulation 1992;86: ) 1356)

24 Cardiac contractility modulation effects on exercise capacity bi-phasic square wave pulse non-excitatory, relatively highvoltage electrical impulses applied during the myocardial absolute refractory period do not initiate a new contraction or affect activation sequence, but modify the entry of calcium into the cardiomyocyte and enhance its contractility Burri H. Cardiovascular Medicine 2013;16(10): aim to improve myofilament efficacy and enhance contractility by increasing the entry of calcium into the cardiomyocyte

25 Improvement of clinical parameters? Giallauria F. et al. 2014; 175 (2): peak VO 2 6-MWT MLWHFQ

26 Muscle limitation Peak VO 2 <15 ml/kg/min. (50 or 60% of pred.) yes no Central hemo- dynamic limitation VO AT < 30% VO 2 predicted HRR < 30 beats/min yes no no yes Improve aerobic capacity Improve muscle mass Improve aerobic capacity and endothelial function Improve central hemodynamics Combined: moderate resistance/ endurance training Resistance training high intensity (1-RM > 60%) Moderate aerobic endurance training (constant load) High intensity interval Training Cardiac contractility modulation

27 [W] 150 Steady State time [W] 150 Intervall time

28 How to guide exercise training in heart failure training Initial stage: Intensity: should be kept at a low level (40 50% of peak VO 2 ) increasing duration from 15 to 30 min, 2 3 times/ week according to perceived symptoms and clinical status for the first 1 2 weeks Low intensity interval training Combine with resistance training from the beginning Supervised, in-hospital training programme may be recommended, during the initial phases to verify: individual response & tolerability clinical stability

29 How to guide exercise training in heart failure training Improvement stage: Switch from low intensity interval training to constant work load training gradual increase of intensity (50, 60, 70-80% of peak VO2, if tolerated) is the primary aim Increase resistance training up to 60% of the 1-RM Add respiratory muscle training: min/day on 3 5 days/week minimum of 8 weeks starting at 30 35% 35% maximum inspiratory pressure up to 60% readjusting every 7 10 days Switch to high intensity exercise training if indicated Consider CRT/ cardiac contractility modulation in selected patients

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