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The Effect of Exercise Training Intensity on Quality of Life in Heart Failure Patients: A Systematic Review and Meta-Analysis

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Cecilia Ostman at Hunter New England Health
Cecilia Ostman
Daniel Lewis at John Hunter Hospital
Daniel Lewis
Neil A Smart at University of New England (Australia)
Neil A Smart
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Abstract and Figures

Objectives: To establish if exercise training intensity produces different effect sizes for quality of life in heart failure. Background: Exercise intensity is the primary stimulus for physical and mental adaptation. Methods: We conducted a MEDLINE search (1985 to February 2016) for exercise-based rehabilitation trials in heart failure using the search terms 'exercise training', 'left ventricular dysfunction', 'peak VO2', 'cardiomyopathy', and 'systolic heart dysfunction'. Results: Twenty-five studies were included; 4 (16%) comprised high-, 10 (40%) vigorous-, 9 (36%) moderate- and 0 (0%) low-intensity groups; two studies were unclassified. The 25 studies provided a total of 2,385 participants, 1,223 exercising and 1,162 controls (36,056 patient-hours of training). Analyses reported significant improvement in total Minnesota living with heart failure (MLWHF) total score [mean difference (MD) -8.24, 95% CI -11.55 to -4.92, p < 0.00001]. Physical MLWHF scorewas significantly improved in all studies (MD -2.89, 95% CI -4.27 to -1.50, p < 0.00001). MLWHF total score was significantly reduced after high- (MD -13.74, 95% CI -21.34 to -6.14, p = 0.0004) and vigorous-intensity training (MD -8.56, 95% CI -12.77 to -4.35, p < 0.0001) but not moderate-intensity training. A significant improvement in the total MLWHF score was seen after aerobic training (MD -3.87, 95% CI -6.97 to -0.78, p = 0.01), and combined aerobic and resistance training (MD -9.82, 95% CI -15.71 to -3.92, p = 0.001), but not resistance training. Conclusions: As exercise training intensity rises, so may the magnitude of improvement in quality of life in exercising patients. Aerobic-only or combined aerobic and resistance training may offer the greatest improvements in quality of life.
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Original Research
Cardiology 2017;136:79–89
DOI: 10.1159/000448088
The Effect of Exercise Training Intensity
on Quality of Life in Heart Failure Patients:
A Systematic Review and Meta-Analysis
Cecilia Ostman Daniel Jewiss Neil A. Smart
Schools of Rural Medicine and Science and Technology, University of New England, Armidale, N.S.W. , Australia
training (MD –8.56, 95% CI –12.77 to –4.35, p < 0.0001) but
not moderate-intensity training. A significant improvement
in the total MLWHF score was seen after aerobic training
(MD –3.87, 95% CI –6.97 to –0.78, p = 0.01), and combined
aerobic and resistance training (MD –9.82, 95% CI –15.71
to –3.92, p = 0.001), but not resistance training. Conclusions:
As exercise training intensity rises, so may the magnitude of
improvement in quality of life in exercising patients. Aerobic-
only or combined aerobic and resistance training may offer
the greatest improvements in quality of life.
© 2016 S. Karger AG, Basel
Introduction
Meta-analyses have shown exercise training to be ben-
eficial in heart failure patients in terms of improved car-
diorespiratory fitness and quality of life
[1, 2] . As heart
failure patients are severely de-conditioned, aerobic, re-
sistance or a combination of these exercise types will be
beneficial; however, aerobic exercise probably produces
the greatest improvements in physical measures of clini-
cal status such as peak V
O 2 [2] , left ventricular ejection
fraction
[3] , endothelial function [4] , and serum levels of
natriuretic peptides
[5] and pro-inflammatory cytokines
Key Words
Exercise intensity · Heart failure · Quality of life
Abstract
Objectives: To establish if exercise training intensity produc-
es different effect sizes for quality of life in heart failure.
Background: Exercise intensity is the primary stimulus for
physical and mental adaptation. Methods: We conducted a
MEDLINE search (1985 to February 2016) for exercise-based
rehabilitation trials in heart failure using the search terms
‘exercise training’, ‘left ventricular dysfunction’, ‘peak V
O 2 ’,
‘cardiomyopathy’, and ‘systolic heart dysfunction’. Results:
Twenty-five studies were included; 4 (16%) comprised
high-, 10 (40%) vigorous-, 9 (36%) moderate- and 0 (0%)
low-intensity groups; two studies were unclassified. The 25
studies provided a total of 2,385 participants, 1,223 exercis-
ing and 1,162 controls (36,056 patient-hours of training).
Analyses reported significant improvement in total Minne-
sota living with heart failure (MLWHF) total score [mean dif-
ference (MD) –8.24, 95% CI –11.55 to –4.92, p < 0.00001].
Physical MLWHF score
was significantly improved in all stud-
ies ( MD –2.89, 95% CI –4.27 to –1.50, p < 0.00001). MLWHF
total score was significantly reduced after high- (MD –13.74,
95% CI –21.34 to –6.14, p = 0.0004) and vigorous-intensity
Received: February 23, 2016
Accepted after revision: June 28, 2016
Published online: August 27, 2016
Assoc. Prof. Neil A. Smart
School of Science and Technology
University of New England
Armidale, NSW 2351 (Australia)
E-Mail nsmart2 @ une.edu.au
© 2016 S. Karger AG, Basel
www.karger.com/crd
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Background Previous systematic reviews and meta-analyses consistently show the positive effect of exercise-based rehabilitation for heart failure (HF) on exercise capacity; however, the direction and magnitude of effects on health-related quality of life, mortality and hospital admissions in HF remain less certain. This is an update of a Cochrane systematic review previously published in 2010. Objectives To determine the effectiveness of exercise-based rehabilitation on themortality, hospitalisation admissions, morbidity and health-related quality of life for people with HF. Review inclusion criteria were extended to consider not only HF due to reduced ejection fraction (HFREF or ’systolic HF’) but also HF due to preserved ejection fraction (HFPEF or ’diastolic HF’). Search methods We updated searches from the previous Cochrane review.We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue1, 2013) from January 2008 to January 2013. We also searchedMEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and PsycINFO (Ovid) (January 2008 to January 2013). We handsearched Web of Science, bibliographies of systematic reviews and trial registers (Controlled-trials.com and Clinicaltrials.gov). Selection criteria Randomised controlled trials of exercise-based interventions with six months’ follow-up or longer compared with a no exercise control that could include usual medical care. The study population comprised adults over 18 years and were broadened to include individuals with HFPEF in addition to HFREF. Exercise-based rehabilitation for heart failure (Review) 1 Copyright © 2017 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. Data collection and analysis Two review authors independently screened all identified references and rejected those that were clearly ineligible. We obtained fulltext papers of potentially relevant trials. 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Compared with control, exercise training reduced the rate of overall (15 trials, 1328 participants: RR 0.75; 95% CI 0.62 to 0.92, fixed-effect analysis) and HF specific hospitalisation (12 trials, 1036 participants: RR 0.61; 95% CI 0.46 to 0.80, fixed-effect analysis). Exercise also resulted in a clinically important improvement superior in the Minnesota Living with Heart Failure questionnaire (13 trials, 1270 participants: mean difference: -5.8 points; 95% CI -9.2 to -2.4, random-effects analysis) - a disease specific health-related quality of life measure. However, levels of statistical heterogeneity across studies in this outcome were substantial. Univariate meta-regression analysis showed that these benefits were independent of the participant’s age, gender, degree of left ventricular dysfunction, type of cardiac rehabilitation (exercise only vs. comprehensive rehabilitation), mean dose of exercise intervention, length of follow-up, overall risk of bias and trial publication date.Within these included studies, a small body of evidence supported exercise-based rehabilitation for HFPEF (three trials, undefined participant number) and when exclusively delivered in a home-based setting (5 trials, 521 participants). One study reported an additional mean healthcare cost in the training group compared with control of USD3227/person. Two studies indicated exercise-based rehabilitation to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs) and life-years saved. 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  • Mar 2015
  • Int J Evid Base Healthc
Several established tools are available to assess study quality and reporting of randomized controlled trials; however, these tools were designed with clinical intervention trials in mind. In exercise training intervention trials some of the traditional study quality criteria, such as participant or researcher blinding, are extremely difficult to implement. We developed the Tool for the assEssment of Study qualiTy and reporting in EXercise (TESTEX) - a study quality and reporting assessment tool, designed specifically for use in exercise training studies. Our tool is a 15-point scale (5 points for study quality and 10 points for reporting) and addresses previously unmentioned quality assessment criteria specific to exercise training studies. There were no systematic differences between the summated TESTEX scores of each observer [H(2) = 0.392, P = 0.822]. There was a significant association between the summated TESTEX scores of the three observers, with almost perfect agreement between observers 1 and 2 [intra-class correlation coefficient (ICC) = 0.93, 95% confidence interval (CI) 0.82-0.97, P < 0.001], observers 1 and 3 (ICC = 0.96, 95% CI 0.89-0.98, P < 0.001) and observers 2 and 3 (ICC = 0.91, 95% CI 0.75-0.96, P < 0.001). The TESTEX scale is a new, reliable tool, specific to exercise scientists, that facilitates a comprehensive review of exercise training trials.
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A group-based exercise program did not improve physical activity in patients with chronic heart failure and comorbidity: A randomized controlled trial
Article
Full-text available
  • Mar 2014
  • J REHABIL MED
Objective: To investigate how group-based exercise affects the levels of physical activity, physical fitness and health- related quality of life (HRQoL) in patients with chronic heart failure and comorbidities. Design: Randomized controlled trial. Patients: A total of 48 patients (10 women, 38 men), mean age 71 years (standard deviation 8 years), ejection fraction 27% (standard deviation 10%), and New York Heart Association functional class II-III. Methods: A bicycle test, 6-min walk test (6MWT) and muscle endurance tests were performed. Physical activity was assessed with a pedometer and the International Physical Activity Questionnaire (IPAQ), HRQoL was evaluated with the Short Form-36 (SF-36). Patients were randomized to control or intervention groups. Intervention consisted of an individually designed group-based exercise programme twice a week, for a period of 3 months. Subjects in the control group were asked to continue with their usual lives. Results: A total of 42 patients completed the study, and 6 dropped-out. Steps/day did not increase significantly after intervention (p = 0.351), but IPAQ score did (p = 0.008). Exercise tolerance (p = 0.001), 6MWT (p = 0.014), shoulder abduction (p = 0.028), heel lift (p < 0.0001) and HRQoL (p = 0.018) improved significantly in the intervention group compared with the control group. Conclusion: Group-based exercise did not improve the level of physical activity in patients with chronic heart failure and comorbidity; however, physical fitness and HRQoL were significantly improved.
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Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients With Heart Failure A Systematic Review and Meta-Analysis
Article
Full-text available
  • Dec 2013
The aim of this study was to establish whether aerobic exercise training intensity produces different effect sizes for fitness, adherence, event rates, mortality rates, and hospitalization rates in patients with heart failure. Intuitively, greater exercise intensity is considered to result in higher risk for serious events, but intensity may be the primary stimulus for physical adaptation. A MEDLINE search (1985 to 2012) was conducted for exercise-based rehabilitation trials in heart failure, using the search terms "exercise training," "left ventricular dysfunction," "peak Vo2," "cardio-myopathy," and "systolic heart dysfunction." Seventy-four studies were included, producing 76 intervention groups; 9 (11.8%) were high-intensity, 38 (50%) vigorous-intensity, 24 (31.6%) moderate-intensity, and 5 (6.6%) low-intensity groups, providing a total of 3,265 exercising subjects and 2,612 control subjects. Peak oxygen consumption increased by a mean difference of 3.33 ml·kg(-1)·min(-1) (95% confidence interval [CI]: 0.53 to 6.13 ml·kg(-1)·min(-1); p = 0.02) with high-intensity training in exercise groups compared with control groups, equating to a 23% improvement from baseline. For vigorous intensity, the mean difference was 2.27 ml·kg(-1)·min(-1) (95% CI: 1.70 to 2.84 ml·kg(-1)·min(-1); p < 0.00001), with an 8% weighted mean; for moderate intensity, the mean difference was 2.17 ml·kg(-1)·min(-1) (95% CI: 1.34 to 2.99 ml·kg(-1)·min(-1); p < 0.00001), with a weighted mean of 13%; and for low intensity, the mean difference was 1.04 ml·kg(-1)·min(-1) (95% CI: -2.50 to 4.57 ml·kg(-1)·min(-1); p = 0.57), with a weighted mean of 7%. In 123,479 patient-hours of training, not a single death was directly attributable to exercise. As exercise training intensity rises, so may the magnitude of improvement in cardiorespiratory fitness, accompanied by lower study withdrawal in exercising patients. Total exercise time may be a confounder.
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High intensity, interval exercise improves Quality of Life of patients with chronic heart failure: a randomized controlled trial.
Article
Full-text available
  • Sep 2013
  • QJM-INT J MED
The aim of this study was to evaluate the effect of high intensity, interval exercise on quality of life (QoL) and depression status, in chronic heart failure (CHF) patients. A randomized controlled trial (phase III). Of the 100 consecutive CHF patients (NYHA class II-IV, ejection fraction≤50%) that were randomly allocated to exercise intervention (n=50, high-intensity intermittent endurance training 30 sec at 100% of max workload, 30 sec at rest, for 45 min/day-by-12 weeks) or no exercise advice (n=50), 72 (exercise group, n=33, 63±9 years, 88% men, 70% ischemic CHF and control group, n=39, 56±11 years, 82% men, 70% ischemic CHF) completed the study. QoL was assessed using the validated and translated Minnesota Living with Heart Failure questionnaire. Depressive symptomatology was evaluated using the validated and translated Zung Depression Rating Scale (ZDRS). Maximal oxygen uptake (VO2max) and carbon dioxide production (VCO2max) were also measured breath-by-breath. Data analysis demonstrated that in the intervention group MLHFQ score was reduced by 66% (p=0.003); 6-minutes-walk distance increased by 13% (p<0.05), VO2maxlevel increased by 31% (p=0.001), VCO2max level increased by 28% (p=0.001) and peak power output increased by 25% (p=0.001), as compared with the control group. High intensity, systematic aerobic training, could be strongly encouraged in CHF patients, since it improves QoL, by favorably modifying their fitness level.
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Exercise Training in Patients With Heart Failure and Preserved Ejection Fraction: Meta-Analysis of Randomized Control Trials
Article
  • Nov 2014
Background: Heart failure with preserved ejection fraction (HFPEF) is common and characterized by exercise intolerance and lack of proven effective therapies. Exercise training has been shown to be effective in improving cardiorespiratory fitness (CRF) in patients with systolic heart failure. In this meta-analysis, we aim to evaluate the effects of exercise training on CRF, quality of life, and diastolic function in patients with HFPEF. Methods and results: Randomized controlled clinical trials that evaluated the efficacy of exercise training in patients with HFPEF were included in this meta-analysis. Primary outcome of the study was change in CRF (measured as change in peak oxygen uptake). Effect of exercise training on quality of life (estimated using Minnesota living with heart failure score), and left ventricular systolic and diastolic function was also assessed. The study included 276 patients who were enrolled in 6 randomized controlled trials. In the pooled data analysis, patients with HFPEF undergoing exercise training had significantly improved CRF (mL/kg per min; weighted mean difference, 2.72; 95% confidence interval, 1.79-3.65) and quality of life (weighted mean difference, -3.97; 95% confidence interval, -7.21 to -0.72) when compared with the control group. However, no significant change was observed in the systolic function (EF-weighted mean difference, 1.26; 95% confidence interval, -0.13% to 2.66%) or diastolic function (E/A-weighted mean difference, 0.08; 95% confidence interval, -0.01 to 0.16) with exercise training in patients with HFPEF. Conclusions: Exercise training in patients with HFPEF is associated with an improvement in CRF and quality of life without significant changes in left ventricular systolic or diastolic function.
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Exercise training for chronic heart failure (ExTraMATCH II): Protocol for an individual participant data meta-analysis
Article
  • Apr 2014
Patients with chronic heart failure (HF) experience a marked reduction in their exercise capacity, health-related quality of life, and life expectancy. Despite substantive evidence supporting exercise training in HF, uncertainties remain in the interpretation and understanding of this evidence base. Clinicians and healthcare providers seek definitive estimates of impact on mortality, hospitalisation and health-related quality of life, and which HF patient subgroups are likely to most benefit. The original Exercise Training Meta-Analysis for Chronic Heart Failure (ExTraMATCH) individual participant data (IPD) meta-analysis conducted in 2004 will be updated by the current collaboration (ExTraMATCH II), to investigate the effects of exercise training in HF. Randomised controlled trials have been identified from the updated 2014 Cochrane systematic review and the original ExTraMATCH IPD meta-analysis with exercise training of 3weeks' duration or more compared with a non-exercise control and a minimum follow-up of 6months. Particular outcomes of interest are mortality, hospitalisation and health-related quality of life plus key baseline patient demographic and clinical data. Original IPD will be requested from the authors of all eligible trials; we will check original data and compile a master dataset. IPD meta-analyses will be conducted using a one-step approach where the IPD from all studies are modelled simultaneously whilst accounting for the clustering of participants with studies. The information from ExTraMATCH II will help inform future national and international clinical and policy decision-making on the use of exercise-based interventions in HF and improve the quality, design and reporting of future trials in this field.
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Exercise training program characteristics and magnitude of change in functional capacity of heart failure patients
Article
  • Nov 2013
Intuitively higher exercise program volume may be the primary stimulus for physical adaptation. We sought to establish if aerobic exercise training program characteristics produced different effect sizes for change in cardiorespiratory fitness in heart failure patients. We conducted a MEDLINE search (1966 to 2012), for exercise based rehabilitation trials in heart failure, using the search terms 'exercise training, left ventricular dysfunction, peak VO2, cardio-myopathy and systolic heart dysfunction'. Forty seven studies were included, producing 54 intervention groups; 3 (6%) were high-, 29 (54%) vigorous-, 20 (37%) moderate- and 2 (3%) low- intensity groups, providing a total of 2285 exercising subjects and 2098 control subjects, totaling 4383 participants. Peak VO2 increased by a mean difference of 3.3mlkg(-1)min(-1) [95% CI 0.53 to 6.13, p=0.02] with high intensity training in exercise groups versus control, equating to a 23% improvement from baseline. The corresponding data for vigorous, moderate and low intensity were 8%, 13%; and 7% respectively. Weekly exercise energy expenditure >460kcal was associated with a mean difference in peak VO2 of 2.6mlkg(-1)min(-1) [95% CI 1.88 to 3.28, p<0.00001]. Our data suggest that high-intensity exercise, achieving at least 460kcal weekly energy expenditure may elicit the greatest changes in cardiorespiratory fitness.
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