Nathalie Renaud

Benefits of exercise training in chronic heart failure

Exercise training performed in cardiac rehabilitation centres is an adjuvant therapy in chronic heart failure patients with left ventricular dysfunction; it decreases the deleterious consequences of chronic heart failure. Exercise training attenuates neurohormonal stimulation, the production of proinflammatory cytokines and natriuretic peptide overexpression. Trained patients showed a significant decrease in the peripheral organ injuries encountered in chronic heart failure, with a reduction in vascular resistance and improvements in endothelial dysfunction and the oxidative capacity of peripheral muscles, without a deleterious effect on left ventricular remodelling. Ultimately, exercise training leads to a notable improvement in ventilatory capacity. These beneficial effects are accompanied by improvements in symptoms at rest, exercise capacity and quality of life. Several training programmes are in current use: exercise training sessions always include endurance exercise performed either at a constant load intensity or with interval training, combining periods of exercise performed at high intensity with periods performed at low intensity. Most of the time, training programmes also include resistance training sessions, which improves large muscle strength. Exercise training programmes seem to have a favourable effect on prognosis, even if the results of Heart Failure: a Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) remain controversial, emphasizing the difficulty in monitoring observance and the importance of compliance with a long-term exercise training programme. Patients who do not improve their exercise capacity significantly after an exercise training programme have a poorer prognosis.

Low-Molecular-Weight Heparin as a Bridging Anticoagulant Early After Mechanical Heart Valve Replacement

Background— After mechanical heart valve replacement (MHVR), long-term use of unfractionated heparin is sometimes required because vitamin K antagonists (VKA) are temporarily contraindicated or because the time to reach the target international normalized ratio is long. The aim of this study was to investigate the feasibility of low-molecular-weight heparin treatment in these patients. Methods and Results— This work was conducted as a prospective study. We selected all patients (n=695) who underwent MHVR and were transferred to a postoperative cardiac rehabilitation center between January 2000 and January 2005. The study focused on patients who had not yet started VKA therapy or who had a below-target international normalized ratio despite VKA therapy. Unfractionated heparin was replaced by enoxaparin (100 IU/kg BID) until VKA treatment was fully effective. Two hundred fifty patients (60±11 years old) were enrolled 16±11 days after surgery (aortic valve replacement, n=190; mitral valve replacement, n=34; double valve replacement, n=26). Of these, 50% had permanent or transient atrial fibrillation, 40% had hypertension, 13% had diabetes, and 19% had a history of cardiac surgery. The mean duration of low-molecular-weight heparin treatment was 8.3±6.0 days. Patients were followed for 90 days, during which there were two major and three minor bleeding episodes and one transient ischemic attack. There were no cases of valve thrombosis and no deaths. Conclusions— After MHVR, one third of patients leave the cardiac surgery unit before VKA treatment is fully effective. Bridging anticoagulation therapy with enoxaparin appears to be feasible during this high-risk period for thromboembolism and could shorten the length of hospital stay.

Absence of Exercise Capacity Improvement After Exercise Training Program A Strong Prognostic Factor in Patients With Chronic Heart Failure

Background—Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results—In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (&dgr;PVo2) and in PVo2 expressed as a percentage of predicted PVo2 (&dgr;%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P<0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline (P<0.0001) and improvement in exercise capacity as assessed by &dgr;PVo2 and &dgr;%PPVo2 (P<0.0001). Multivariate analysis revealed B-type natriuretic peptide level and &dgr;%PPVo2 as only independent predictive factors of outcome (P=0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median &dgr;%PPVo2<6%) was 8.2 (P=0.0006). Conclusions—Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level.Background— Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results— In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (δPVo2) and in PVo2 expressed as a percentage of predicted PVo2 (δ%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P <0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline ( P <0.0001) and improvement in exercise capacity as assessed by δPVo2 and δ%PPVo2 ( P <0.0001). Multivariate analysis revealed B-type natriuretic peptide level and δ%PPVo2 as only independent predictive factors of outcome ( P =0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median δ%PPVo2<6%) was 8.2 ( P =0.0006). Conclusions— Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level. Received February 26, 2008; accepted September 23, 2008.

Nonsteroidal Anti-inflammatory Drug Treatment for Postoperative Pericardial Effusion: A Multicenter Randomized, Double-Blind Trial

BACKGROUND The incidence of asymptomatic pericardial effusion is high after cardiac surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in this setting, but no study has assessed their efficacy. OBJECTIVE To assess whether the NSAID diclofenac is effective in reducing postoperative pericardial effusion volume. DESIGN Multicenter randomized, double-blind, placebo-controlled study. (Clinical trials.gov registration number: NCT00247052) SETTING 5 postoperative cardiac rehabilitation centers. PATIENTS 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. INTERVENTION Random assignment at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. MEASUREMENTS The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P = 0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P = 0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. LIMITATION The sample was not large enough to find small beneficial effects of diclofenac or assess the cardiovascular tolerance of diclofenac. CONCLUSION In patients with pericardial effusion after cardiac surgery, diclofenac neither reduced the size of the effusions nor prevented late cardiac tamponade. PRIMARY FUNDING SOURCE French Society of Cardiology.

Determination of exercise training level in coronary artery disease patients on β blockers

Objectives To compare the intensity of three exercise training regimens. Background During a cardiac rehabilitation program coronary artery disease (CAD) patients should be trained at an intensity as close as possible to the ventilatory threshold (VT) level. The precise way to obtain this intensity of training during the sessions, however, remains unclear. Methods In stable β-blocked CAD patients, heart rate (HR) and workload (WL) at the VT were determined from a cardiopulmonary exercise test. The 3 following days, each patient performed (in a randomized order) one bicycle training session per day at an intensity determined by (i) HR at VT, (ii) WL at VT, (iii) patients feelings (14 on the Borg scale). HR, WL, systolic blood pressure, oxygen consumption (V O 2) and the respiratory exchange ratio were monitored during each session, to compare the intensity of each regimen. Results Twenty patients, 57 ± 10 years old were included. V O 2, WL, HR and systolic blood pressure were significantly higher in the sessions driven by feelings and WL, than in the HR-driven sessions. As respiratory exchange ratio remained less than 1, we can assume that there was no important and deleterious participation of anaerobic metabolism. Conclusion Classical training HR prescription could lead to undertrain CAD patients, although a training session prescription driven by the feelings or by the WL observed at VT allows the patients to train at a higher — but still aerobic — intensity.

Absence of Exercise Capacity Improvement After Exercise Training ProgramCLINICAL PERSPECTIVE

Background—Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results—In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (&dgr;PVo2) and in PVo2 expressed as a percentage of predicted PVo2 (&dgr;%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P<0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline (P<0.0001) and improvement in exercise capacity as assessed by &dgr;PVo2 and &dgr;%PPVo2 (P<0.0001). Multivariate analysis revealed B-type natriuretic peptide level and &dgr;%PPVo2 as only independent predictive factors of outcome (P=0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median &dgr;%PPVo2<6%) was 8.2 (P=0.0006). Conclusions—Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level.Background— Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results— In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (δPVo2) and in PVo2 expressed as a percentage of predicted PVo2 (δ%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P <0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline ( P <0.0001) and improvement in exercise capacity as assessed by δPVo2 and δ%PPVo2 ( P <0.0001). Multivariate analysis revealed B-type natriuretic peptide level and δ%PPVo2 as only independent predictive factors of outcome ( P =0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median δ%PPVo2<6%) was 8.2 ( P =0.0006). Conclusions— Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level. Received February 26, 2008; accepted September 23, 2008.

Greater prognostic value of peak VO2 after exercise training program completion in heart failure patients

BACKGROUND Exercise capacity, best reflected by peak exercise oxygen consumption (peak VO(2)), is a powerful prognostic factor in patients with chronic heart failure (CHF). However, the optimal time to assess exercise capacity for prognosis remains unclear and whether an exercise training program (ETP) to improve exercise capacity alters the prognostic value of cardiopulmonary exercise (CPX) testing variables in CHF is unknown. METHODS AND RESULTS CHF patients who underwent an ETP in two cardiac rehabilitation centers between 2004 and 2009 were prospectively included, and CPX testing was performed before and after ETP completion. We included 285 consecutive patients who underwent an ETP (19.4 ± 8.7 training sessions in 4 to 10 weeks), including segmental gymnastics and cycling sessions. During follow-up (12 months), 14 patients died, 6 underwent cardiac transplantation and 15 were hospitalized for acute heart failure. Univariate analysis and receiver operating characteristic (ROC) curve analysis showed that CPX variables, especially peak oxygen consumption and circulatory power (product of peak VO(2) × peak systolic blood pressure) before and after ETP completion predicted prognosis. However, CPX data obtained after ETP completion had the best prognostic value (area under the ROC curve = 0.79 ± 0.03 for peak VO(2) after ETP completion vs 0.64 ± 0.04 before ETP completion, p < 0.0001). The results did not change even when considering only deaths. CONCLUSION In patients with stable CHF who can exercise, the prognostic value of CPX data seems greater after versus before completion of a hospital-based ETP. Therefore, CPX capacity for prognostic purposes should at best be assessed after cardiac rehabilitation.

Heart rate recovery identifies high risk heart failure patients with intermediate peak oxygen consumption values

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The absence of exercise capacity improvement after exercise training program: a strong prognostic factor in patients with chronic heart failure

Background—Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results—In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (&dgr;PVo2) and in PVo2 expressed as a percentage of predicted PVo2 (&dgr;%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P<0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline (P<0.0001) and improvement in exercise capacity as assessed by &dgr;PVo2 and &dgr;%PPVo2 (P<0.0001). Multivariate analysis revealed B-type natriuretic peptide level and &dgr;%PPVo2 as only independent predictive factors of outcome (P=0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median &dgr;%PPVo2<6%) was 8.2 (P=0.0006). Conclusions—Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level.Background— Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results— In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (δPVo2) and in PVo2 expressed as a percentage of predicted PVo2 (δ%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P <0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline ( P <0.0001) and improvement in exercise capacity as assessed by δPVo2 and δ%PPVo2 ( P <0.0001). Multivariate analysis revealed B-type natriuretic peptide level and δ%PPVo2 as only independent predictive factors of outcome ( P =0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median δ%PPVo2<6%) was 8.2 ( P =0.0006). Conclusions— Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level. Received February 26, 2008; accepted September 23, 2008.

Absence of Exercise Capacity Improvement After Exercise Training ProgramCLINICAL PERSPECTIVE: A Strong Prognostic Factor in Patients With Chronic Heart Failure

Background—Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results—In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (&dgr;PVo2) and in PVo2 expressed as a percentage of predicted PVo2 (&dgr;%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P<0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline (P<0.0001) and improvement in exercise capacity as assessed by &dgr;PVo2 and &dgr;%PPVo2 (P<0.0001). Multivariate analysis revealed B-type natriuretic peptide level and &dgr;%PPVo2 as only independent predictive factors of outcome (P=0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median &dgr;%PPVo2<6%) was 8.2 (P=0.0006). Conclusions—Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level.Background— Exercise training is established as adjuvant therapy for chronic heart failure, but the prognostic value of improvement in exercise capacity after exercise training has never been evaluated. Methods and Results— In this prospective bicentric study, all chronic heart failure patients with left ventricular ejection fraction <45% who underwent an exercise training program in a cardiac rehabilitation center between January 2004 and September 2006 were consecutively included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (δPVo2) and in PVo2 expressed as a percentage of predicted PVo2 (δ%PPVo2) measured before and after the training program. We included 155 patients (54±12 years old, male 81%, left ventricular ejection fraction=29.5±7.1%). Patients underwent 20 (10–30) training sessions. PVo2 and %PPVo2 were significantly increased after the training program (14% and 13%, respectively, P <0.001 for both). After 16±6 months follow-up, 27 patients had a cardiac event (death [n=12], cardiac transplantation [n=5], hospitalization for acute heart failure [n=10]). Univariate analysis revealed that among 17 significant predictors of cardiac events, the 2 more powerful ones were level of B-type natriuretic peptide at baseline ( P <0.0001) and improvement in exercise capacity as assessed by δPVo2 and δ%PPVo2 ( P <0.0001). Multivariate analysis revealed B-type natriuretic peptide level and δ%PPVo2 as only independent predictive factors of outcome ( P =0.01). The risk ratio of cardiac events for nonresponse versus response to the training program (defined as median δ%PPVo2<6%) was 8.2 ( P =0.0006). Conclusions— Among patients with chronic heart failure, the lack of improvement in exercise capacity after an exercise training program has strong prognostic value for adverse cardiac events independent of classical predictive factors such as left ventricular ejection fraction, New York Heart Association class, and B-type natriuretic peptide level. Received February 26, 2008; accepted September 23, 2008.