giovanni pulignano ambulatorio per lo scompenso cardiaco i uo cardiologia /utic dipartimento...
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Giovanni PulignanoGiovanni PulignanoAmbulatorio per lo Scompenso Cardiaco Ambulatorio per lo Scompenso Cardiaco
I UO Cardiologia /UTIC I UO Cardiologia /UTIC Dipartimento CardiovascolareDipartimento Cardiovascolare
Az.Osp. S.Camillo-ForlaniniAz.Osp. S.Camillo-Forlanini
41 Congresso di CardiologiaIncontri con gli esperti
Milano, 19 settembre 2007
“Gli aspetti che trascuriamo nel paziente con scompenso cardiaco:
Esercizio fisico e scompenso cardiacoEsercizio fisico e scompenso cardiaco
Senni et al. On behalf of IN-CHF Investigators. Journal of Cardiac Failure Vol. 11 No. 4 2005
?
training
VO2
Esercizio e scompenso cardiaco
Fattori periferici e centrali
Vasoconstriction Sympatho-excitation
Vagal- withdrawal
Skeletal and RespiratoryMyopathy
InactivityMalnutrition
PhysicalDeconditioning
Muscle FatigueDyspnoea
Modifications:•muscular structure•vascular structure•autonomic tone•muscular reflex
Reduced peripheralblood flow
Catabolic State
LV Dysfunction
Inactivity
Physical Training
M. Piepoli, 1997
Mechanisms to augment cardiac output (C.O.) in (A) healthypersons without HF and (B) patients with HF.
Piña et al, Circulation March 4, 2003
Cardio-Pulmonary eXercise (CPX) test
Healthy subject CHF patient
Circulation 1993 87:VI-7
Relationship of LVEF and peak oxygen uptake
Survival by peak VO2 in CHF
0 10 20 30 40 50 60 70
Time (months)
>>2121
16-2116-21
14-1614-16
<14<14
0
20
40
60
80
100
Pe
rce
nt
Su
rviv
al
n = 297p = 0.0002
Francis, Heart 2000 Florea, EHJ 2000
increase in peak VO2
decrease in peak VO2
0 5 10 15 20 25 30 35 40
100
80
60
40
20
0 Time (months)
Survival (%)
p < 0.05
Ventilatory Inefficiency in CHF: VE/VCO2 slope
0
20
40
60
80
100
120
140
0 1 2 3 4 5 6VCO2 (L/min)
VE (L/min)
NormalModerate CHFSevere CHF
0
20
40
60
80
100
0 10 20 30 40 50 60 70Time (months)
< 27< 27
27-3327-33
34-4234-42
> 43> 43n = 297P < 0.0001
Survival
Impaired Tolerance and Abnormal Responses to Exercise in CHF: Peripheral Factors
1. Blood flow ml/min reduced
2. Metabolism early lactic acid productionphosphate depletion
3. Function Weakness, increased fatigue
4. Morphology: Quantity Loss of muscle mass (or bulk)
Site Localised to legs or general abnormalityOrientation and fibre position
Quality Atrophy, damage and/or necrosis (apoptosis)Change of fibre type, myosin IIb
Muscle Ergoreflex System: Anatomical Pathways
0
25
50
75
100
CHF Control
Ergoreflex L/min%
*
0
1
2
3
4
CHF Control
Central - Chemoreflexl/min mmHg
*
0
0.25
0.5
0.75
1
1.25
CHF Control
*
Peripheral - Chemoreflexl/min/%SaO2
0
10
20
30
40
0
10
20
30
40
CHF Control CHF Control
Peak VO2ml/min/kg
*
*
VE/VCO2
Ponikowski, Piepoli et al Circulation. 2001;104:2324-2330.)
Neural Reflex Activation in Heart Failure
Piepoli et al. Circulation 1996;93: 940
.
24
recovery (min.)rest exercise time (%)
circulatory occlusion
6
8
10
12
14
16
18
20
22
100 1 2 3 4 5 6 725 50 75rest
**** **
HEART FAILURE PATIENTS
Ven
tilat
ion
(l/m
in)
CONTROL SUBJECTS
Training: control handgripTraining: handgrip withPH-RCODetraining: handgrip withPH-RCO
recovery (min.)rest exercise time (%)circulatory occlusion
24
6
8
10
12
14
16
18
20
22
100 1 2 3 4 5 6 725 50 75rest
* * *
\
Effect of Exercise training on the Contribution of Muscle Ergoreflex to Exercise in Heart Failure vs Controls
DetrainingTraining
Cicoira MA et al. JACC 2001
Massa muscolare scheletrica e tolleranza allo sforzo
Skeletal muscle mass independently predicts peak oxygen consumption and ventilatory response during exercise in
noncachectic patients with chronic heart failure
• Piepoli et al Circulation 2006
Modello fisiopatologico degli adattamentiindotti dal training fisico nello scompenso cardiaco
Belardinelli R, Agostoni PG.
Studi randomizzati sugli gli effetti del training nei pazienti con insufficienza cardiaca cronica.
Parametro Effetto del Training
VO2 picco + 12-26%
VO2 alla AT +
VE/CO2 ratio - 6-18%
Durata esercizio + 17%
Eur HF training Group . Eur Heart J 1998; 19:466-475
Pina IL. Circulation 2003; 107(8):1210-1225.
Principali adattamenti indotti dal trainingfisico nell’insufficienza cardiaca cronica.
Principali adattamenti indotti dal trainingfisico nell’insufficienza cardiaca cronica.
• Adattamenti centrali
• Ridotta progressione di stenosi coronariche – (30-45)
• Dilatazione arteriosa coronarica endotelio-dipendente + (20-30)
• Aumento della diffusione polmonare + (10-20)
• Miglioramento della perfusione miocardica + (15-25)
• Miglioramento del rilasciamento diastolico + (15-28)
• Miglioramento della contrattilità + (15-25)
• Miglioramento della funzione sistolica globale + (10-15)
Principali adattamenti indotti dal trainingfisico nell’insufficienza cardiaca cronica.
• Adattamenti periferici
• Miglioramento del flusso muscolare + (12-30)
• Aumento degli enzimi muscolari ossidativi + (15-30)
• Aumento del volume di densità mitocondriale + (15-25)
• Aumento delle fibre muscolari tipo I + (15-30)
• Dilatazione arteriosa endotelio-dipendente + (15-40)
• Attenuazione dell’ergoriflesso
Effect of Exercise Training on Muscle Metabolism in CHF
Adamopoulos et al. Physical Training in Heart Failure. JACC 1993;21:1101-1106.
Physical exercise increases in endothelium-dependent blood flow (A), whereas peripheral blood flow remained unchanged (B) in the control group. #P<0.05 vs beginning; *P<0.05 vs control.
Training corrects endothelial dysfunction and improves exercise capacity in CHF
Hambrecht et al. Circulation 1998;98:2709
S. Adamopoulos European Heart Journal (2001) 22, 791–797
Improvements in patents in the exercise group
Passino C et al. J Am Coll Cardiol 2006; 47:1835-1839.
End points Active group (% change)*
p*
Workload (W) +14 <0.001
Peak VO2 (mL/min/kg) +13 <0.001
LVEF (%) +9 <0.01
BNP (ng/L) -34 <0.01
NT-proBNP (ng/L) -32 <0.05
Norepinephrine (ng/L) -26 <0.01*Compared with control group, which showed no changes BNP=B-type natriuretic peptideNT-proBNP=amino-terminal pro-brain natriuretic peptide
Aerobic training decreases B-type natriuretic peptide expression and adrenergic activation in patients with heart failure
• Conclusioni: in condizioni di stabilità, l’esercizio moderato, a lungo termine, non ha effetti negativi sul volume e sulla funzione del VS, ma anzi attenua il rimodellamento. Inoltre l’allenamento è sicuro ed efficace per aumentare la tolleranza all’esercizio e migliorare la qualità della vita.
Circulation. 2003; 108: 554-559
Haykowsky et al. JACC Vol. 49, No. 24, 2007
Training and quality of life in CHF
Afzal et al. Progress in Cardiovascular Diseases 1998
Fattori predittivi di risposta positiva al training fisico nei pazienti con insufficienza cardiaca
Wilson JR et al. Circlation 1996; 94: 1767-72
Belardinelli R, Circulation. 1999;99:1173-1182.)
ExTraMATCH Collaborative. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH)
ExTraMATCH BMJ 2004;328:189
K-M cumulative two year survival (top) and cumulative two year survival or free from admission hospital (bottom).
ExTraMATCH BMJ 2004;328:189
death
.65 (.46 to .92)
.72 (.56 to .93)
death/Admission
HF-ACTION: Heart Failure: A Controlled Trial
Investigating Outcomes of Exercise TraiNing
• 5-year, 3,000-patient NYHA II-IV, EF<35% randomized trial,
• 50 U.S. and Canadian hospitals,
• first large-scale prospective trial designed to determine whether exercise can reduce mortality and hospitalizations for patients with HF or any other disease
• Ongoing enrolment
• >2000 pts, >> male, low mean age, mild peak VO2 impairment
Whellan DJ Am Heart J. 2007 Feb;153(2):201-11. Adams, Barcelona WCC 4 September 2006
• “ Despite ..benefits, a limitation of these investigations was the primary focus on males <60 years with impaired left ventricular systolic function”.
• “Thus the role that exercise training may play in attenuating the HF-mediated decline in VO2peak in women >65 years of age with systolic or diastolic dysfunction remains unknown”.
HAYKOWSKYJ ournal of Cardiac Failure Vol. 10 No. 2 2004
•Modalità•Durata•Frequenza•Intensità•Progressione•Sicurezza
Relative and absolute contraindications
European Heart Journal (2001) 22, 125–135
Working Group Report
• Aerobic exercise• Cycle ergometer• walking (<50-100 m/min)
• out-door cycling? jogging ? Swimming ?
• Calisthenic: flexibility, coordination, strength
• Resistance • rhythmic, ie. 1:1 rate • small muscle: single limb• small repetition: 60”ex/120”recovery• 50-80% max voluntary capacity
• Respiratory• inspiratory, (20-30% max capacity) 20-30min/d, 3-5 d/w• abdominal muscle• yoga
Modality of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
Aerobic Exercise. Cycle ergometer:
Warm up 10’ – Conditioning phase 40’– Cool down 10’
• Interval training: short bouts of work phases followed by short recovery phases. • 30” exercise: 50-60% max ex capacity / 60” recovery (low load, 10W)• 10-12 work phases in 15-min training session• Max ex capacity: steep ramp test, 25W every 10”
• Steady-state training • 10-60 min /d, 3-7 d/w• 40-80% peak VO2 (or peak HR or perceived exertion by Borg scale)• <3METS, 2-3 sessions/d, 5-10 min; >3METS 3-5 sessions, 20-30min
Modality of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
Aerobic Training: Phases of exercise progression
1. Initial stage:
- 10-15min, 40%-50% pkVo2,
2. Improvement stage (>15d):
- 15-20-30min, 50% -> 60% -> 70% pkVo2
3. Maintenance stage (>6m)
European Heart Journal (2001) 22, 125–135
Working Group Report
Modality of exercise training programme in CHF
• Initial phase: in-hospital supervision• Pulmonary and cardiac O.E.• body weight and oedema• HR and BP monitoring• symptoms
• Maintenance Phase: combination of supervised/ unsupervised training• selected group of patients• to favour adherence to prescription
Safety of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
Safety of exercise training programme in CHF
European Heart Journal (2001) 22, 125–135
Working Group Report
Eur J Cardiovasc Prev Riabil 2005; 12:321-325
Conclusioni: Il training nel paziente con scompenso cardiaco stabile:
• Migliora la funzione vascolare periferica, muscolare e metabolica
• Migliora la funzione respiratoria e del sistema nervoso autonomo
• Questi effetti portano ad un significativo miglioramento della tolleranza all’esercizio e alla qualità della vita
• Nessun deterioramento significativo dell’emodinamica centrale
• Attenuazione dello sfavorevole rimodellamento del ventricolo sinistro
• Migliori risultati con esercizio aerobico, intensità moderata (60%), personalizzato, lunga durata (mesi), con supervisione specialistica.
Conclusioni:Problemi
• Evidenza derivante da studi randomizzati con numero limitato di pazienti arruolati in centri altamente specializzati, >>maschi, età media 50-55 anni con interferenza di altri fattori (Hawthorne effect)
• Mancanza di dati relativi a pazienti con diversi modelli fisiopatologici (SC diastolico, cpt. valvolare)
• Diversità nei protocolli negli studi pubblicati
• Bassa prescrizione ACE/ARB, BB o CRT
• Risultati non sempre concordi in termini di QDV, tolleranza allo sforzo e sopravvivenza
• Scarsità di fattori (clinici, di funzione ventricolare, ecc.) predittivi di miglioramento durante programma riabilitativo
• Difficoltà organizzative
Ponzo effect