Adnan Afzal

Exercise training in heart failure

Patients with heart failure challenge the clinician with a constellation of difficult clinical, pathophysiologic, and psychologic issues. As a result, until recently, exercise training was not considered a safe and effective treatment strategy to be used in these patients. However, in the past 10 years, data from both randomized and nonrandomized trials showed that regular exercise training in patients with stable Class II and III heart failure can safely improve exercise tolerance, attenuate an overactivated sympathetic nervous system, partially reverse skeletal muscle abnormalities, and enhance health-related quality of life. These outcomes are achievable with a relatively moderate dose of physical activity, such as 30 to 60 minutes of walking or cycling 3 to 5 days per week at an intensity equivalent to 60% to 70% of peak oxygen consumption. Sufficiently powered trials are needed to assess morbidity, mortality, and cost-effectiveness endpoints relative to exercise training in patients with heart failure.

Distal myocardial protection with intracoronary propranolol during percutaneous coronary intervention is widely applicable

Background: Myocardial necrosis (Ml) after percutaneous coronary intervention (PCI) IS associated with an increased incidence of late adverse outcomes. Methods: We conducted a prospective randomized. placebo-controlled trial in 150 PCI patients to determine whether intracoronary (IC) propranolol ( 0.015mglkg) decreases post PCI MI and in which subgroups this effect occurs. Results: Post -PCI Ml &K-MB > upper limit of normal) developed in 17% of IC propranolol pts (13/75) and 36% of placebo pts ( 27175) (p=O.Ol). The figure shows that this effect is widely applicable including the subgroup receiving prophylactic GP llbillla inhibitors (28% of pts) and chronic oral pre-PCI betablockers (64%). Factors associated with decreased risk of MI were IC propranolol (OR: 0.40, Cl: 0.17-0.91, p= 0.03) and prophylactic GP Ilb/llla use (OR: 0.41, Cl: 0.14-I .08, p= 0.08). IC propranolol decreased MIS in GP llblllla pts ( O%vs. 41%) and pts on chronic beta blockers ( 16% vs. 35%).Factors associated with increased Ml were age > 60 years old and mechanical complications during PCI. IC propranolol decreased MI risk in older pts (19% vs. 46%) and in patients with mechanical complications (41% vs. 61%). Conclusion: These data are consistent with IC propranolol being a broadly effective cardioprotective agent during PCI. *ak*n --