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Effect of Physical Training on Peak VO2 in HFpEF
Quick Takes
- In a randomized controlled trial of sedentary HFpEF patients with NYHA class II-III symptoms, high- and moderate-intensity training did not produce any clinically meaningful changes in peak VO2 compared to standard guideline-based physical activity counseling.
- Adherence to exercise training dropped off in both high- and moderate-intensity training when patients were switched from direct supervision to telemanagement.
- There were no changes in NT-proBNP or echocardiographic diastolic parameters between the three groups.
Study Questions:
Do different intensities of exercise training result in different changes to peak oxygen consumption (peak VO2), indices of left ventricular diastolic function, N-terminal pro–B-type natriuretic peptide (NT-proBNP), and quality of life (QOL) after 3 and 12 months in patients with heart failure and preserved ejection fraction (HFpEF)?
Methods:
This was a randomized trial with three groups of different exercise intensities conducted at five European centers. Sedentary patients with HFpEF with New York Heart Association (NYHA) class II-III symptoms were randomized to either high-intensity interval training, moderate continuous training, or control. The control group received one-time advice on physical activity per guidelines. For patients in the exercise groups, in-person supervised training was provided for the first 3 months followed by 9 months of telemedically supervised home-based training. The primary endpoint was change in peak VO2 at 3 months. Secondary endpoints included changes from baseline to 3 and 12 months in echocardiographic measures of diastolic function, NT-proBNP, QOL, and other cardiopulmonary stress test parameters.
Results:
A total of 180 patients were enrolled from 2014-2018. Mean age was 70 years, with 67% women. Mean body mass index (BMI) was 30 kg/m2. At 3 months, while peak VO2 was higher in the high-intensity interval training group and moderate continuous training group compared to control, this change was not clinically significant and did not persist at 12 months. There was no difference between high- and moderate-intensity groups. Change in NT-proBNP levels and echocardiographic parameters did not differ between groups. Changes in QOL domain at 3 months did not differ between the groups. However, at 12 months, change in QOL domain was higher in the moderate training group compared to control but did not differ between high-intensity training and control groups. In the first 3 months, 80.4% patients were adherent in the high-intensity training group and 76.4% in the moderate training group. Adherence dropped in the subsequent months with only 56% adherent patients in the high-intensity group and 60% in the moderate-intensity group at 12 months. There were no differences in incidence of serious and cardiovascular adverse events across three groups, with the most common event being acute coronary syndrome.
Conclusions:
In this randomized controlled trial of sedentary HFpEF patients, different intensities of exercise training were not associated with a clinically relevant improvement in peak VO2 compared to control. Adherence to training dropped off substantially when switching from in-person supervised to telesupervised training. There was no difference in change in NT-proBNP or echocardiographic diastolic parameters. However, QOL was better only in the moderate-intensity group compared to control at 12 months. Incidences of serious and cardiovascular adverse events were no different across the groups.
Perspective:
This trial does not support high- or moderate-intensity training in HFpEF patients compared to guideline-based physical activity. This may at least in part be due to poor long-term adherence to exercise training. While change in QOL was better at 12 months in the moderate-intensity training group compared to control, this finding should be considered exploratory. In addition, the exercise staff was not blinded to the treatment group, which can lead to bias. Nonetheless, the enrolled patient population is representative of real-world HFpEF patients and highlights struggles of ensuring continued adherence to regular physical activity, of any intensity, especially when patients are not directly supervised.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, ACS and Cardiac Biomarkers, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound, Exercise
Keywords: Acute Coronary Syndrome, Body Mass Index, Diastole, Echocardiography, Exercise, Exercise Therapy, Exercise Test, Heart Failure, Natriuretic Peptide, Brain, Oxygen Consumption, Quality of Life, Secondary Prevention, Stroke Volume
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