Exercise Rehabilitation in Heart Disease: the real “polypill” for primary and secondary prevention

Our society is currently at war against the ominous enemy of chronic disease. Chronic disease presents a heavy burden to society, in terms of both medical costs and human suffering. It is our perception that: 1) much of the medical community underpractises primary prevention as regards appropriate levels of physical activity for health, and 2) much of the research community undervalues the importance of understanding the physiological, genetic and clinical bases of diseases caused by physical inactivity. For many, exercise is viewed solely as a research or diagnostic tool and not as a true weapon against chronic disease. In reality, however, exercise attacks the roots of chronic disease, i.e. physical inactivity. The first step in a common “battle plan” is to convince the medical community that chronic disease is rooted in physical inactivity. In this review, we focus on the biological evidence to date showing how physical inactivity leads to chronic disease. One purpose of this review is to demonstrate that exercise, such as treadmill testing of humans for cardiac dysfunctions, is more than a diagnostic tool but part of disease management itself

The Walking Test: Use in clinical practice

Exercise Capacity is the expression of the cardiovascular and of metabolic organic efficiency and represents a important prognostic marker. The Six Minute Walking Test is adopted in the practice for exercise capacity evaluation in the normal subject as in pneumologic or cardiac rehabilitation programs, and in both pediatric and elderly ages. The aim of the work is to present a practical summary of the application of the six minutes walking test, according to the American Thoracic Society statement. We reviewed the various experiences of its application, and reported the indications, clinical interpretation parameters, relationship and correlation between functional and clinical parameters (hospitalization, quality of life, therapy and exercise control response and compliance), the basic and advanced protocol, the application modality, the reporting models, and the educational checklist

Summary Statement on Cardiopulmonary Exercise Testing in Chronic Heart Failure due to Left Ventricular Dysfunction Recommendations for Performance and Interpretation

Cardiopulmonary exercise testing (CPET) is a non-invasive tool that provides the physician with relevant information to assess the integrated response to exercise involving pulmonary, cardiovascular, haematopoietic, neuro-psychological, and skeletal muscle systems. Measurement of expiratory gases during exercise allows the best estimate of functional capacity, grade the severity of the impairment, objectively evaluate the response to interventions, objectively track the progression of disease, and assist in differentiating cardiac from pulmonary limitations in exercise tolerance. To achieve optimal use of this test in every day clinical practice, clarification of conceptual issues and standardization of CPET practices are necessary. Recently, a Statement on Cardiopulmonary Exercise Testing in Chronic Heart Failure due to Left Ventricular Dysfunction, by the Gruppo Italiano di Cardiologia Riabilitativa and endorsed by the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology, has been published. Here are resumed the cardinal points of the Statement: (1) Definition of Cardiopulmonary Exercise Testing Parameters for Appropriate Use in Chronic Heart Failure, (2) How to Perform Cardiopulmonary Exercise Testing in Chronic Heart Failure, (3) Interpretation of Cardiopulmonary Exercise Testing in Chronic Heart Failure and Future Applications

Muscle Ergoreceptor Overactivity Reflects Deterioration in Clinical Status and Cardiorespiratory Reflex Control in Chronic Heart Failure

Background In chronic heart failure (CHF), overactivation of ergoreceptors (afferents sensitive to the metabolic effects of muscular work) may be a link between peripheral changes, sympathetic overactivation, and increased hemodynamic and ventilatory responses to exercise. The relationship between ergoreceptors, autonomic changes, and the progression of the syndrome has not yet been studied. Methods and Results Thirty-eight stable CHF patients (age, 57±1 years; ejection fraction, 26±2%) were compared with 12 age-matched normal control subjects. The ergoreflex contribution to the ventilatory and hemodynamic responses to exercise, together with peripheral and central chemoreceptor sensitivity, arterial baroreflex sensitivity, plasma norepinephrine, epinephrine, and heart rate variability, were measured. Enhanced ergoreflex effects on ventilation (78±2% versus 50±8%), peripheral chemosensitivity (0.6±0.4 versus 0.2±0.1 L/min per percent Sa o 2 ), and central chemosensitivity (2.9±0.2 versus 2.0±0.2 L · min −1 · mm Hg −1 ) and an impaired baroreflex function (4.1±0.6 versus 9.1±5.6 ms/mm Hg) were confirmed in CHF compared with control subjects ( P <0.01 in all comparisons). Ergoreceptor overactivity was associated with a worse symptomatic state (NYHA class, P <0.05), lower exercise tolerance (peak V o 2 , P <0.05), and pronounced exercise hyperventilation (V̇ e /V co 2 , P <0.01). It was also a strong predictor of increased central chemosensitivity (independently of clinical parameters), baroreflex impairment, and sympathetic activation (plasma catecholamines and heart rate variability indexes; all P <0.05). In multivariate analysis, among all reflexes studied, the ventilatory component of the ergoreflex was the only independent predictor of peak V o 2 and V̇ e /V co 2 . Conclusions In CHF, overactivation of the ergoreflex is associated with abnormal cardiorespiratory reflex control, independently of clinical severity. Among impaired reflexes, overactivation of the ergoreflex is an important determinant of exercise hyperventilation and reduced exercise tolerance

[Standards and outcome measures in cardiovascular rehabilitation. Position paper GICR/IACPR].

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic problem in Italy. Costs and resources required are increasing in close correlation to both the improved quality of care and to the population ageing. There is an overwhelming evidence of the efficacy of cardiac rehabilitation (CR) in terms of reduction in morbidity and mortality after acute cardiac events. CR services are by definition multi-factorial and comprehensive. Furthermore, systematic analysis and monitoring of the process of delivery and outcomes is of paramount importance. The aim of this position paper promoted by the Italian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR) is to provide specific recommendations to assist CR staff in the design, evaluation and development of their care delivery organization. The position paper should also assist health care providers, insurers, policy makers and consumers in the recognition of the quality of care requirements, standards and outcome measure, quality and performance indicators, and professional competence involved in such organization and programs. The position paper i) include comprehensive CR definition and indications, ii) describes priority criteria based on the clinical risk for admission to both inpatient or outpatient CR, and iii) defines components and technological, structural and organizing requirements for inpatient or outpatient CR services, with specific indicators and standards, performance measures and required professional skills. A specific chapter is dedicated to the requirements for highly specialized CR services for patients with more advanced cardiovascular diseases

Monitoring functional capacity in heart failure.

This document reflects the key points of a consensus meeting of the Heart Failure Association of European Society of Cardiology (ESC) held to provide an overview the role of physiological monitoring in the complex multimorbid heart failure (HF) patient. This article reviews assessments of the functional ability of patients with HF. The gold standard measurement of cardiovascular functional capacity is peak oxygen consumption obtained from a cardiopulmonary exercise test. The 6-min walk test provides an indirect measure of cardiovascular functional capacity. Muscular functional capacity is assessed using either a 1-repetition maximum test of the upper and lower body or other methods, such as handgrip measurement. The short physical performance battery may provide a helpful, indirect indication of muscular functional capacity

Effects of exergaming on exercise capacity in patients with heart failure: results of an international multicentre randomized controlled trial

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Eligibility for vericiguat in a real‐world, contemporary heart failure population

Aims: Vericiguat is a soluble guanylate cyclase stimulator and improves survival in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and an increased risk of decompensation. As real-world data on how many patients could be eligible for vericiguat therapy derive from outdated registries, we aimed to assess eligibility in a prospective cohort of patients with HF. Methods and results: Data from consecutive HF patients undergoing an elective ambulatory visit at five university hospitals from 3 July to 28 July 2023 were collected. Independent investigators assessed which patients (i) met the eligibility criteria of the VICTORIA trial, (ii) complied with HF guideline recommendations, (iii) met regulatory agency criteria, or (iv) met criteria for refundability according to the Italian regulatory agency. Patients (n&nbsp;=&nbsp;346, 72% men, median age 69&nbsp;years) had HFrEF in 57% of cases, left ventricular ejection fraction&nbsp;&lt;&nbsp;45% in 68%, and New York Heart Association class II-IV symptoms in 76%. Patients meeting the eligibility criteria of the VICTORIA trial or European and American HF Guideline recommendations were 9% and 13%, respectively. Patients meeting Food and Drug Administration (FDA) or European Medicines Agency (EMA) label criteria were 19% and 17%, respectively. Drug costs would be covered by the Italian National Health System in 10% of patients [if a sodium-glucose cotransporter-2 inhibitor (SGLT2i) is not mandatory] or in 8% (if an SGLT2i is requested). Conclusions: In a real-world study, 9% of patients met the eligibility criteria of the VICTORIA trial, but up to 13% complied with guideline recommendations and up to 19% met FDA or EMA criteria. In Italy, drug costs would be covered by up to 10% of patients