A patient with heart failure and resynchronisation/ ICD: what is specific about training and exercise? Jean-Paul Schmid, MD Cardiovascular Prevention & Rehabilitation Division of Cardiology University Hospital, Bern, CH - Conflict of interest: nothing to declare -
ICD CRT/ (ICD) NYHA II to III Ex. capacity + to ++(+) Device = threat to exercise training NYHA III (to IV) Ex. capacity + Device = support to exercise training Dublin, 04MAY2012 2
Challange in ICD pts: Underlying heart disease Long QT - Syndrome Arrhthmogenic Right Ventricular Dysplasia Condition after heart transplantation Multifactorial/ unknown origin N = 121 data in file Hypertrophic Obstructive Cardiomyopathy (HOCM) Congenital anomalies Idiopathic dilative cardiopathy Hypertensive cardiopathy Ischaemic heart disease Dublin, 04MAY2012 3
ICD indications by clinical presentations: great heterogeneity Cardiac arrest, defined as signs of circulatory arrest requiring resuscitation (sudden cardiac death survivor), in the absence of a reversible trigger Electrocardiographically documented ventricular arrhythmia without symptoms or cardiac arrest Syncope without documented ventricular arrhythmia in the presence of heart failure Prophylactic indication (low ejection fraction, positive family history of sudden cardiac death, certain heart pathologies) Dublin, 04MAY2012 4
Continuum of ICD shock response Sears S, Conti J. Heart 2002;87:488 493 Quality of life & psychological functioning of ICD patients Dublin, 04MAY2012 5
% of patients Cardiovaskular Prevention und Rehabilitation, University Hospital (Inselspital) Bern Left ventricular function in ICD patients: from heart failure to athletic patients 25 Anthony Van Loo KV Mechelen 20 15 10 5 0 20 30 40 50 60 70 data in file University Hospital Bern/CH N = 121 Dublin, 04MAY2012 6
Susceptibility to arrhythmias during (high intensity) exercise the frequency and relative risk of life threatening arrhythmias or ICD shocks delivered during physical activity is unknown it is, however, likely that ICD shocks during exertion may occur exercise is also associated with atrial fibrillation and sinus tachycardia, which can trigger inappropriate ICD shocks Dublin, 04MAY2012 7
834 patients with an ICD Average training duration 9.6 weeks 10 ICD therapies (7 shocks) during training 182 ICD therapies (166 shocks) between exercise sessions Sedentary patients (control group) were more prone to ICD discharge Dublin, 04MAY2012 8
Indications for Exercise Testing Classical indications Diagnosis of ischemia Determination of exercise capacity Risk assessment (especially in heart failure patients) Differential diagnosis of exercise intolerance Chronotropic response Training recommendations ICD-related indications Peak heart rate response to exercise (Cave: HR on bicycle 10 to 20 beats lower than on treadmill) Exercise induced arrhythmias Heart rate at onset of arrhythmia Effectiveness of pharmacologic intervention Patient reassurance & exercise prescription Dublin, 04MAY2012 9
Cardiovaskular Prevention und Rehabilitation, University Hospital (Inselspital) Bern Precautions to take before the exercise test Know the underlying heart disease are there known triggers of arrhythmia in the individual patient (ischaemia, heart rate dependent arrhythmias,...) Know the reason for ICD implantation and whether the patient has already experienced shocks (under which circumstances?) Know the intervention cut-off rate and sequence of therapy (monitoring zone, antitachycardiac pacing, shocks) Determine the exercise test endpoint 10 to 20 beats below the intervention cut-off should be safe Instruct the medical staff how to react in case of an unexpected incident Dublin, 04MAY2012 10
Dublin, 04MAY2012 11
Endurance training following CRT Implantation CRT CRT & training (n=8) CRT without training (n=9) Conraads V, EJCPR 2007;13:818 825 Dublin, 04MAY2012 12
Endurance training following CRT HF = historical group + = exercise training - = no exercise training Conraads V, EJCRP 2007;13:818 825 Dublin, 04MAY2012 13
Conclusion Training in patients with ICD s is safe The risk of arrhythmias during exercise depends on the underlying heart disease The most important point to consider in ICD patients is to avoid inappropriate shocks due to a training heart rate exceeding the intervention rate of the device Some patients with ICD s suffer from anxiety and wrong believes about different aspects of living with an ICD, which should be specifically addressed Patients receiving a CRT s have a great potential to respond favorably to exercise training and constitute therefore a special target population Dublin, 04MAY2012 14
Consider CRT in non-responders to exercise training! Tabet J-Y. Circ Heart Fail 2008;1:220-6 Dublin, 04MAY2012 15