Eloy Domínguez

Physical therapy in heart failure with preserved ejection fraction: A systematic review:

About 50% of patients with heart failure (HF) have preserved ejection fraction (HFpEF) which is especially common in elderly people with highly prevalent co-morbid conditions. HFpEF is usually defined as an ejection fraction equal to or greater than 50%, although some studies have used a limit as low as 40%. The prevalence of this syndrome is expected to increase over the next decades. The associated impact on mortality and hospital readmissions has made of this entity a major public health issue. Despite the fact that mortality and re-hospitalisation rates of HFpEF are similar to the syndrome of HF with reduced ejection fraction (HFrEF), currently there is no available evidence-based therapy as effective as is the case for HFrEF. Exercise intolerance is the principal clinical feature in HFpEF. The pathophysiological mechanisms behind impaired exercise capacity in these patients are complex and not yet fully elucidated. Current guidelines and consensus documents recommend the implementation of exercise training in HFpEF; however, they are based mostly on results from a few small trials evaluating surrogate endpoints such as exercise capacity and quality of life. The aim of this work was to review the current evidence that supports the effect of the different modalities of physical therapies in HFpEF.

Peak Exercise Oxygen Uptake Predicts Recurrent Admissions in Heart Failure With Preserved Ejection Fraction

INTRODUCTION AND OBJECTIVESnHeart failure with preserved ejection fraction (HFpEF) is a highly prevalent syndrome with an elevated risk of morbidity and mortality. To date, there is scarce evidence on the role of peak exercise oxygen uptake (peak VO2) for predicting the morbidity burden in HFpEF. We sought to evaluate the association between peak VO2 and the risk of recurrent hospitalizations in patients with HFpEF.nnnMETHODSnA total of 74 stable symptomatic patients with HFpEF underwent a cardiopulmonary exercise test between June 2012 and May 2016. A negative binomial regression method was used to determine the association between the percentage of predicted peak VO2 (pp-peak VO2) and recurrent hospitalizations. Risk estimates are reported as incidence rate ratios.nnnRESULTSnThe mean age was 72.5 ± 9.1 years, 53% were women, and all patients were in New York Heart Association functional class II to III. Mean peak VO2 and median pp-peak VO2 were 10 ± 2.8mL/min/kg and 60% (range, 47-67), respectively. During a median follow-up of 276 days [interquartile range, 153-1231], 84 all-cause hospitalizations in 31 patients (41.9%) were registered. A total of 15 (20.3%) deaths were also recorded. On multivariate analysis, accounting for mortality as a terminal event, pp-peak VO2 was independently and linearly associated with the risk of recurrent admission. Thus, and modeled as continuous, a 10% decrease of pp-peak VO2 increased the risk of recurrent hospitalizations by 32% (IRR, 1.32; 95%CI, 1.03-1.68; P = .028).nnnCONCLUSIONSnIn symptomatic elderly patients with HFpEF, pp-peak VO2 predicts all-cause recurrent admission.

Sacubitril/valsartan and short-term changes in the 6-minute walk test: A pilot study

BACKGROUNDnImpaired exercise capacity is the most disabling symptom in patients with heart failure with reduced ejection fraction (HFrEF). Despite sacubitril/valsartan showing reduced long-term morbidity and mortality over enalapril in HFrEF, its effects on short-term functional capacity remain uncertain. We sought to evaluate the effects of sacubitril/valsartan on a 30-day six-minute walk test in eligible patients with HFrEF.nnnMETHODS AND RESULTSnFrom November 1, 2016 to February 1, 2017, a total of 58 stable symptomatic patients with HFrEF were eligible for sacubitril/valsartan and underwent 6-MWT before and 30days after initiation of sacubitril/valsartan therapy. A mixed-effects model for repeated-measures was used to analyze the changes. Mean age was 70±11years. 72.4% males, 46.6% with ischemic heart disease, and 51.7% on NYHA functional class III were included. The mean (SD) values of baseline LVEF and 6MWT were 30±7%, and 300±89m, respectively. The median (IQR) of NT-proBNP at baseline was 2701pg/ml (1087-4200). Compared with baseline, the 6-MWT distance increased significantly at 30days by 13.9% (+∆=41.8m (33.4-50.2); p<0.001).nnnCONCLUSIONSnIn this pilot study, sacubitril/valsartan was associated with an improvement in exercise tolerance in symptomatic patients with HFrEF.

Six-minute walk test in moderate to severe heart failure with preserved ejection fraction: Useful for functional capacity assessment?

This work was supported in part by grants from: Sociedad Espanola nde Cardiologia: Investigacion Clinica en Cardiologia, Grant SEC 2015 and Red de nInvestigacion Cardiovascular; Programa 7 (RD12/0042/0010) FEDER.

Inspiratory Muscle Training and Functional Electrical Stimulation for Treatment of Heart Failure With Preserved Ejection Fraction: Rationale and Study Design of a Prospective Randomized Controlled Trial.

Heart failure with preserved ejection fraction (HFpEF) has become the most prevalent form of heart failure in developed countries. Regrettably, there is no evidence‐based effective therapy for HFpEF. We seek to evaluate whether inspiratory muscle training, functional electrical stimulation, or a combination of both can improve exercise capacity as well as left ventricular diastolic function, biomarker profile, quality of life (QoL), and prognosis in patients with HFpEF. A total of 60 stable symptomatic patients with HFpEF (New York Heart Association class II–III/IV) will be randomized (1:1:1:1) to receive a 12‐week program of inspiratory muscle training, functional electrical stimulation, a combination of both, or standard care alone. The primary endpoint of the study is change in peak exercise oxygen uptake; secondary endpoints are changes in QoL, echocardiogram parameters, and prognostic biomarkers. As of March 21, 2016, thirty patients have been enrolled. Searching for novel therapies that improve QoL and autonomy in the elderly with HFpEF has become a health care priority. We believe that this study will add important knowledge about the potential utility of 2 simple and feasible physical interventions for the treatment of advanced HFpEF.

Clinical utility of cardiopulmonary exercise testing in patients with heart failure with preserved ejection fraction

Dr Corrà and colleagues review the prognostic role of cardiopulmonary exercise testing (CPET) in heart failure (HF) and consider individual patient characteristics, the modality of CPET execution, and newer clinical endpoints.1 Given the lack of well-evidenced information relevant to clinical prediction in particular subsets of the HF population [elderly people, women, obese patients, patients with HF with preserved ejection fraction (HFpEF), etc.], the proposed prognostic flowcharts based on CPET parameters are greatly appreciated and may be regarded as representing an excellent starting point for further research. In our opinion, there are some issues in patients with HFpEF that warrant further comment. It is a heterogeneous syndrome that is especially common in elderly people, women and patients with high numbers of co-morbidities. The incidence and prevalence of HFpEF are increasing and the financial burdens imposed by recurrent admissions have become alarming.2,3 This work1 highlights the utility of CPET as a tool for improving risk stratification using objective and functional parameters; however, information about the utility of

Heart rate response and functional capacity in patients with chronic heart failure with preserved ejection fraction: Heart rate response and functional capacity in patients with chronic HFpEF

The mechanisms of exercise intolerance in heart failure with preserved ejection fraction (HFpEF) are not yet elucidated. Chronotropic incompetence has emerged as a potential mechanism. We aimed to evaluate whether heart rate (HR) response to exercise is associated to functional capacity in patients with symptomatic HFpEF.

Early effects of empagliflozin on exercise tolerance in patients with heart failure: A pilot study.

Sodium‐glucose linked transporter 2 inhibition recently emerged as a promising therapy for reducing the risk of heart failure (HF) in patients with type 2 diabetes mellitus (T2DM). However, there is a lack of data endorsing its role in symptomatic HF patients. We sought to evaluate the short‐term effects of empagliflozin on maximal exercise capacity in these patients.

Inspiratory Muscle Function and Exercise Capacity in Patients With Heart Failure With Preserved Ejection Fraction.

BACKGROUNDnHeart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by impaired exercise capacity resulting from dyspnea and fatigue. The pathophysiological mechanisms underlying the exercise intolerance in HFpEF are not well established. We sought to evaluate the effects of inspiratory muscle function on exercise tolerance in symptomatic patients with HFpEF.nnnMETHODS AND RESULTSnA total of 74 stable symptomatic patients with HFpEF and New York Heart Association class II-III underwent a cardiopulmonary exercise test between June 2012 and May 2016. Inspiratory muscle weakness was defined as maximum inspiratory pressure (MIP)u2009u2009<70% of normal predicted values. Pearson correlation coefficient and multivariate linear regression analysis were used to assess the association between percent of predicted MIP (pp-MIP) and maximal exercise capacity [measured by peak oxygen uptake (peak VO2) and percent of predicted peak VO2 (pp-peak VO2)]. Thirty-one patients (42%) displayed inspiratory muscle weakness. Mean (standard deviation) age was 72.5u2009±u20099.1 years, 53% were women, and 35.1% displayed New York Heart Association class III. Mean peak VO2 and pp-peak VO2 were 10u2009±u20092.8u2009mL•min•kg and 57.3u2009±u200913.8%, respectively. The median (interquartile range) of pp-MIP was 72% (58%-90%). pp-MIP was not correlated with peak VO2 (r = -0.047, Pu2009=u2009.689) nor pp-peak VO2 (r = -0.078, Pu2009=u2009.509). Furthermore, in multivariable analysis, pp-MIP showed no association with peak VO2 (β coefficientu2009=u20090.01, 95% confidence interval -0.01 to 0.03, Pu2009=u2009.241) and pp-peak VO2 (β coefficientu2009=u2009-0.00, 95% confidence interval -0.10 to 0.10, Pu2009=u2009.975).nnnCONCLUSIONSnIn symptomatic elderly patients with HFpEF, we found that pp-MIP was not associated with either peak VO2 or pp-peak VO2.

Isolated Partial Congenital Absence of the Pericardium: A Familial Presentation

Congenital defects of the pericardium are uncommon heart abnormalities. Most of the patients are asymptomatic and are usually diagnosed incidentally. Complications are more common in partial absence than in complete absence of the pericardium; thus, this congenital defect should be identified because of the associated risk of sudden death. We report the first mention in the literature, to our knowledge, of a 3-generation familial presentation of isolated congenital partial absence of the pericardium with similar physical examination and radiological findings.