Forgotten problems in HF PHYSICAL AND SEXUAL ACTIVITIES Massimo F Piepoli, MD, PhD, FESC, FACC Heart Failure Unit, Guglielmo da Saliceto Hospital, Piacenza m.piepoli@alice.it No disclosures Massimo Speaker F Piepoli
Physical Activity in CHF: Yesterday Speaker Massimo F Piepoli
Heart Failure Physical Activity and Exercise Training Regular, moderate daily activity is recommended for all patients with heart failure Class of recommendation I, level of evidence B Exercise training is recommended to all stable chronic heart failure patients. There is no evidence that exercise training should be limited to any particular HF patient subgroup (aetiology, NYHA class, LVEF or medication). Class of recommendation I, level of evidence A ESC Guidelines for the Diagnosis Speaker and Treatment of Acute and Chronic HF - 2008
Physical Activities in CHF Vagal Autonomic Sympathetic VO 2 Physical Activity
Similarity between Muscular Deconditioning and Heart Failure Haemodynamics Vascular resistance Resting Heart Rate Deconditioning Speaker Heart Failure Function Exercise Tolerance Neuroendocrine/autonomic Renin/angiotensin Sympathetic Vagal Activity Baroreflex sensitivity Skeletal Muscle Muscle Mass /bulk Mitochondrial Enzymes Oxidative Glycholytic Psychological Wellbeing Activity Scores
Cardiovascular Benefits of Exercise Anti-atherosclerotic Improved lipids Lower BPs Reduced adiposity Insulin sensitivity Inflammation Anti-thrombotic Platelet adhesiveness Fibrinolysis Fibrinogen Blood viscosity Anti-ischemic Myocardial O 2 demand Coronary flow Endothelial dysfunction Anti-arrhythmic Vagal tone Adrenergic activity HR variability
Exercise training and CHF. Increased Survival Reduced Hospitalisation M F Piepoli, Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ 2004;328:189 Speaker
Exercise training and CHF. ExTraMATCH Piepoli et al. BMJ 2004;328:189 Peak VO2 >15 ml/kg/min <15 ml/kg/min Speaker
Secondary prevention through cardiac rehabilitation. 2010 From Knowledge to Implementation. A Position Paper from the Cardiac Rehabilitation Section of the EACPR Exercise Training Prescriptions in CHF MODALITY: Dynamic aerobic exercise and endurance training regimens (cycling, walking, calisthenics) should be prescribed. Different training modalities (respiratory, strength INTENSITY: range of 60 to 80% of maximal HR or at 50-70% of peak VO2. Low intensity exercise training at 40-60% of peak VO2 TRAINING PERIOD: long-term exercise training periods should be pursued DURATION AND FREQUENCY OF THE TRAINING: The length and intensity of the exercise session should be gradually increased by 1-2 min with a goal of 30 min. In the maintenance phase, exercise is recommended for 20 to 60 min on 3 to 5 days/week. Speaker Piepoli et al. Eur Heart J 2010
Fantasy vs reality
HF patients undergoing Exercise-based Cardiac Rehabilitation in Europe: <20% ECRIS study. European Cardiac Rehabilitation Inventory Survey. Eur J Cardiov Prev Rehab 2010
Managing medical barriers to exercise in HF Cardiologists/GPs Inability to meet intensity and duration exercise requirements Arthritis ICD / CRT placement Following hospitalisation Barbour, Heart Fail Rev 2008
Managing non-medical barriers to exercise in HF Costing Lack of time Boredom Work conflicts Motivation Vacation/Holidays Social support Depression Barbour, Heart Fail Rev 2008
Physical Activity. Key role of the physician Assessment of physical activity level by history: readiness to change behaviour; self-confidence; barriers to increase physical activity, and social support in making positive changes. Recommend: A least 30-60 minutes/session of moderately intense aerobic activity, preferable daily, or at least 3-4/week; gradual increases in daily lifestyle activities over time, and how to incorporate it into daily routine Advice individualised physical activity according to age, habits, comorbidities, preferences and goal Speaker Piepoli et al. Eur Heart J 2010
Physical Activity. Key role of the physician Reassure regarding the safety of the recommended protocol Encourage the involvement in leisure activities, enjoyable and in group programme Educate on the risk of relapses and the need for its lifelong continuation. Expect outcomes: Improved psychosocial well-being, prevention of disability, improved prognosis Speaker Piepoli et al. Eur Heart J 2010
Exercise training and modern treatment options for CHF patients
Sexual Activity and Heart Failure
Sexual Activity: metabolic and haemodynamic demands In middle age CAD men Peak HR (117 bpm), BP 162/89 mmhg METs: 2-3 3-4 In severe CHF HR increases from 53 to 131 bpm RV Pressure from 38/8 to 101/21 mmhg
Sexual Activity and Heart Failure
Speaker 2010
International Journal of Cardiology 101 (2005) 83-90
Exercise training sessions 60 min sessions - 3 times/week x 8 weeks: 15 min stretching movements 45 min cycle training @ work-load (watts): 60% peak VO2
International Journal of Cardiology 101 (2005) 83-90 After 8 training Training Control P Peak VO 2, ml/kg/min 21.8±4.9 15.3±4.6 0.005 AT VO 2, ml/kg/min 14.1±3.8 9.6±1.8 0.001 Ventilation, L/min 64.2±15 46.1±12 0.005 Peak O 2 pulse, ml/beat 10.8 ±1.6 9.0 ±2 0.02 DVO 2 /DW, ml/min/w 8.7 ±0.6 7.5 ±1.0 0.01 Peak Work Rate, Watts 133±28 92±18 0.002 Resting HR, beats/min 76.4±14 86.7±17 0.001 Peak HR, beats/min 137 ±19 136 ±20 0.49 Peak SPB Pressure, mmhg 183±35 163±15 <0.001
Sexual Activity After 8 week Exercise Training Training Control P Men DOMAIN 1 1.63±2-0.72±2.3 0.003 DOMAIN 2 0.8±0.4 0.24±0.5 0.001 DOMAIN 3 3.73±1.4 2.38±1.1 0.001 All 6.17±3.2 1.96±3.2 <0.001 Partners DOMAIN 1 0.8±1.5-0.27± 1.5 0.02 DOMAIN 2 0.53±0.6 0.10±0.8 0.03 DOMAIN 3 3.5±0.8 2.65±0.9 0.004 All 4.87±2.5 2.48±0.3 <0.001 International Journal of Cardiology 101 (2005) 83-90 DOMAIN 1 = relationship with the partner; DOMAIN 2 = quality of penile erection; DOMAIN 3 = personal wellness. In normal individuals, the sum is 13.
% Diameter Change % Diameter Change Changes in the vasomotor response of the brachial artery after Exercise Training 8. *P=0.0001. * 30 4 15 0 0 trained control trained control Flow-mediated dilation NTG-mediated dilation International Journal of Cardiology 101 (2005) 83-90
D MHL Score Changes in Minnesota HF Living Score after Exercise Training 15 7.5 Training 0 * - 7.5 Control -15 Entry International Journal of Cardiology 101 (2005) 83-90 8 weeks
Sexual Activity and Heart Failure Initial assessment: Medical history [age, overall health motivational state] - Signs and symptoms of HF - Lab findings (chemistry, BNP) Low risk NYHA I, No symptom or cardiac event on sexual activity Most patients in this category Intermediate risk NYHA II, or LVEF <30% Moderate risk of symptom exacerbation with sexual activity High risk NYHA III or IV, severe, unstable High risk of symptom exacerbation with sexual activity Continue routine CHF therapy Advice to continue with sexual activity without testing No contraindication to ED if need Re-stratify into low- or high risk after exercise test [CPX], 6MWT, 2D-Echo Consider Exercise Training Stabilise underlying HF via therapy Advice to abstain from sexual activity. Reassess
Summary: Physical and Sexual Activities - Exercise intolerance as hallmark of HF - Benefit of moderate exercise training programme, - Promotion of Physical Exercise as a tool to maintain long term effect - Concerns on sexual activity - Multiple aetiology - Benefit of physical training programme via - increasing exercise capacity, and - endothelial function
Grazie Massimo F Piepoli, MD, PhD, FESC, FACC Div. Cardiologia, Ospedale Polichirurgico Guglielmo da Saliceto, Piacenza - m.piepoli@alice.it Speaker