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2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

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Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise

Heart failure (HF) is a global pandemic affecting at least 26 million people worldwide and is increasing in prevalence. HF health expenditures are considerable and will increase dramatically with an ageing population. Despite the significant advances in therapies and prevention, mortality and morbidity are still high and quality of life poor. The prevalence, incidence, mortality and morbidity rates reported show geographic variations, depending on the different aetiologies and clinical characteristics observed among patients with HF. In this review we focus on the global epidemiology of HF, providing data about prevalence, incidence, mortality and morbidity worldwide.

Global Public Health Burden of Heart Failure.

Aims Carotid–femoral pulse wave velocity (PWV), a direct measure of aortic stiffness, has become increasingly important for total cardiovascular (CV) risk estimation. Its application as a routine tool for clinical patient evaluation has been hampered by the absence of reference values. The aim of the present study is to establish reference and normal values for PWV based on a large European population. Methods and results We gathered data from 16 867 subjects and patients from 13 different centres across eight European countries, in which PWV and basic clinical parameters were measured. Of these, 11 092 individuals were free from overt CV disease, non-diabetic and untreated by either anti-hypertensive or lipid-lowering drugs and constituted the reference value population, of which the subset with optimal/normal blood pressures (BPs) (n = 1455) is the normal value population. Prior to data pooling, PWV values were converted to a common standard using established conversion formulae. Subjects were categorized by age decade and further subdivided according to BP categories. Pulse wave velocity increased with age and BP category; the increase with age being more pronounced for higher BP categories and the increase with BP being more important for older subjects. The distribution of PWV with age and BP category is described and reference values for PWV are established. Normal values are proposed based on the PWV values observed in the non-hypertensive subpopulation who had no additional CV risk factors. Conclusion The present study is the first to establish reference and normal values for PWV, combining a sizeable European population after standardizing results for different methods of PWV measurement.

Determinants of pulse wave velocity in healthy people and in the presence of cardiovascular risk factors

Mounting evidence has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease, all-cause mortality, and mortality rates attributable to various cancers. A growing body of epidemiological and clinical evidence demonstrates not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes mellitus, but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes. The purpose of this statement is to review current knowledge related to the association between CRF and health outcomes, increase awareness of the added value of CRF to improve risk prediction, and suggest future directions in research. Although the statement is not intended to be a comprehensive review, critical references that address important advances in the field are highlighted. The underlying premise of this statement is that the addition of CRF for risk classification presents health professionals with unique opportunities to improve patient management and to encourage lifestyle-based strategies designed to reduce cardiovascular risk. These opportunities must be realized to optimize the prevention and treatment of cardiovascular disease and hence meet the American Heart Association's 2020 goals.

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign: A Scientific Statement From the American Heart Association.

The study by Jehn et al. (2009) is interesting and adds important information to the discussion about the 6-min walking test as a sub-maximal exercise test in heart failure patients. The current study compared the cardiorespiratory responses during a 6-min walking test performed in a corridor with those during a maximal cycle ergometer exercise test in patients with three different stages of heart failure based on the peak oxygen uptake (VO2peak): group 1: [25.2 ml/kg per minute; group 2: between 17.5 and 25.2 ml/kg per minute and group 3: \17.5 ml/kg per minute. The authors concluded that heart failure patients with a VO2peak \17.5 ml/kg per minute reached higher levels of respiratory response during the 6-min walking test compared with patients with a VO2peak [25.2 ml/kg per minute. These data would benefit from being expressed relative to the responses to incremental exercise on the treadmill, rather than the cycle ergometer; i.e., treadmill walking being more closely related to walking test performance. In addition, the authors could have used the prognostic cutoff point for VO2peak in heart failure patients to divide the groups: 14 ml/kg per minute (Mehra et al. 2006), or more recently 12.5 ml/kg per minute (Guimaraes et al. 2009) instead of the 17.5 ml/kg per minute criterion. The discussion on the nature of the sub-maximal 6-min walking test is not new. Guimaraes et al. 2002 evaluated the cardiorespiratory response of 12 male heart failure patients (New York Heart Association functional class III and 15.4 ml/kg per minute) in a treadmill cardiopulmonary exercise test and in a 6-min walking test. The tests showed that the respiratory exchange ratio at end exercise was of the order of 1.0 (mean of 1.06). The respiratory exchange ratio during the 6-min walking test represented 94% of the peak respiratory exchange ratio reached in the cardiopulmonary exercise test. It is known that peak respiratory exchange ratio above 1.05 represents an effort near to the maximum in heart failure patients (Carvalho et al. 2009a, b). The study by Guimaraes contests, for the first time, the sub-maximal status of the classical 6-min walking test and proposes a new method to perform this test using the Borg Scale between ‘‘relatively easy’’ and ‘‘slightly tiring’’. This new method assures the 6-min walking test as sub-maximal. The Borg Scale is recognised as an important tool of self-monitoring and self-regulation of the exercise (Carvalho et al. 2009a, b). A second study (Guimaraes et al. 2008) showed that the 6-min walking test using the Borg Scale in heart failure patients is reproducible and once more that this methodology assures the 6-min walking test as sub-maximal. Thus, the study by Jehn et al. provided new perspectives for the evaluation of the 6-min walking test by taking into account the different cardiorespiratory responses on the different functional status of the heart failure patients.

Is the 6-min walking test a sub-maximal exercise test in heart failure patients?

Aerobic exercise improves central blood pressure and blood pressure variability among patients with resistant hypertension: results of the EnRicH trial

Age-related maximum heart rate among ischemic and nonischemic heart failure patients receiving β-blockade therapy.

FUNDAMENTO: Insuficiencia cardiaca (IC) esta associada com aumento da quimio-sensibilidade periferica e central em repouso, que pode estar correlacionada com um aumento na resposta ventilatoria durante exercicio. Entretanto, SUS sensibilidade na IC durante o exercicio ainda nao foi reportada. OBJETIVO: Testar se o estimulo dos quimiorreceptores centrais e perifericos em pacientes com IC pode modular respostas ventilatorias, cronotropicas e neurohormonais durante exercicio submaximo. METODOS: Investigamos a quimio-sensibilidade central e periferica em 15 pacientes com insuficiencia cardiaca (IC) e 7 controles normais (C), comparando a resposta durante 3 testes de caminhada de 6 minutos (TC6M), realizado em esteira ergometrica com: ar ambiente, em hipoxia e em hipercapnia (em ordem randomica). RESULTADOS: FR em ar ambiente nos grupos C e IC foi 17±2 e 22±2 (p<,0001); em hipoxia, foi 17±1 e 23±2 (p<,02); com CO25% foi 20±2 e 22±5 (p<,02). Volume tidal (VT) ou corrente em ar ambiente foi 1,25±0,17 e 1,08±0,19 (p<,01); em hipoxia 1,65±0,34 e 1,2±0,2(p<,0001); com CO25% 1,55±0,46 e 1,29±0,39 (p<,0001). Em repouso, o aumento na IC foi maior para VE (C 33±40%, IC 62±94%, p<,01), FC(C 7±10%, IC 10±10%, p<0,05) em repouso. Durante a hipoxia, o aumento durante o exercicio na IC foi maior para FR (C 1±4, IC 11±6,p<,05), FC (C 12±2, IC 14±3, p<,05), VE/VO2 (C -4±18%, IC 24±21%, p<,01), FC/VO2 (C -26±11%, IC 11±5%, p<,01), VE/DC (C 36±10%, 46±14, p<,05% ) and FC/DC (C 18±8%, HF 29±11, p<,01). Durante exercicio em hipoxia no grupo IC, o NO diminuiu e os niveis de IL-6 e aldosterona aumentaram. Os niveis neurohormonais permaneceram inalterados no grupo C. CONCLUSAO: A quimio-sensibilidade central e a periferica durante o exercicio estao aumentadas na IC e podem modular padroes respiratorios, cronotropicos cardiacos e atividade neurohormonal durante exercicio.

/pdf/quimiossensibilidade-durante-exercicio-na-insuficiencia-ic1fohkhj9.pdf

Guilherme Veiga Guimarães

Papers

Is the 6-min walking test a sub-maximal exercise test in heart failure patients?

Aerobic exercise improves central blood pressure and blood pressure variability among patients with resistant hypertension: results of the EnRicH trial

Age-related maximum heart rate among ischemic and nonischemic heart failure patients receiving β-blockade therapy.

Quimiossensibilidade durante exercício na insuficiência cardíaca: respostas ventilatórias, cronotrópicas e neurohormonais

Capacidade física em idosos submetidos a programa de condicionamento físico