Is serial determination of inspiratory muscle strength a useful prognostic marker in chronic heart failure
01 Apr 2008-European Journal of Preventive Cardiology (Eur J Cardiovasc Prev Rehabil)-Vol. 15, Iss: 2, pp 156-161
TL;DR: This is the first study to investigate the prognostic information of the changes of PImax over time, regarding both short-term and long-term morbidity and mortality in patients with stable CHF, and found neither the absolute nor the relative change of Pimax to be significant predictors for the primary and secondary endpoints.
Abstract: Background Little data exists on the prognostic role of inspiratory muscle strength (PImax) in chronic heart failure (CHF). Training studies, however, frequently use it as a therapeutic target and surrogate marker for prognosis. The prognostic value of changes of PImax that allow this extrapolation is unknown.Design Patients with stable CHF were prospectively included and 1-year and all-time event rates recorded for endpoint analysis.Methods In 158 patients (85% men; New York Heart Association functional class: 2.4 ± 0.6), PImax was measured along with clinical evaluations at two visits, the initial visit and the second visit, 6.4 ± 1.4 months apart. The mean follow-up was 59 ± 34 months.Results Overall, 59 patients (37%) reached the primary endpoint of death or hospitalization (endpoint positive), and overall mortality rate (secondary endpoint) was 26% (42 patients). PImax did not differ between endpoint-negative and endpoint-positive patients, both at the initial and at the second visit (8.3 ± 5.6 vs. 7...
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TL;DR: The results of trials with inspiratory muscle training (IMT) indicate that this intervention improves exercise capacity and quality of life, particularly in patients with CHF and IMW, and specific IMT and/or aerobic training are of practical value in the management of these patients.
Abstract: Inspiratory muscle weakness (IMW) is prevalent in patients with chronic heart failure (CHF) caused by left ventricular systolic dysfunction, which contributes to reduced exercise capacity and the presence of dyspnea during daily activities. Inspiratory muscle strength (estimated by maximal inspiratory pressure) has independent prognostic value in CHF. Overall, the results of trials with inspiratory muscle training (IMT) indicate that this intervention improves exercise capacity and quality of life, particularly in patients with CHF and IMW. Some benefit from IMT may be accounted for by the attenuation of the inspiratory muscle metaboreflex. Moreover, IMT results in improved cardiovascular responses to exercise and to those obtained with standard aerobic training. These findings suggest that routine screening for IMW is advisable in patients with CHF, and specific IMT and/or aerobic training are of practical value in the management of these patients.
110 citations
Cites background from "Is serial determination of inspirat..."
...The same group reported on the prognostic value of serial determination of PI max in patients with CHF [ 21 ]....
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Ludwig Maximilian University of Munich1, Stanford University2, Selly Oak Hospital3, The Ohio State University Wexner Medical Center4, University Hospitals Birmingham NHS Foundation Trust5, Imperial College London6, Salford Royal NHS Foundation Trust7, Boston Children's Hospital8, University of Münster9
TL;DR: The utility of MIP for the early evaluation of respiratory muscle strength, especially of the diaphragm, in patients with NMD and as a surrogate endpoint in clinical trials of therapies for NMD is supported.
Abstract: Respiratory muscle strength is a proven predictor of long-term outcome of neuromuscular disease (NMD), including amyotrophic lateral sclerosis, Duchenne muscular dystrophy, and spinal muscular atrophy. Maximal inspiratory pressure (MIP), a sensitive measure of respiratory muscle strength, one of several useful tests of respiratory muscle strength, is gaining interest as a therapeutic clinical trial endpoint for NMD. In this comprehensive review we investigate the use of MIP as a measure of respiratory muscle strength in clinical trials of therapeutics targeting respiratory muscle, examine the correlation of MIP with survival, quality of life, and other measures of pulmonary function, and outline the role of MIP as a clinically significantly meaningful outcome measure. Our analysis supports the utility of MIP for the early evaluation of respiratory muscle strength, especially of the diaphragm, in patients with NMD and as a surrogate endpoint in clinical trials of therapies for NMD.
61 citations
Cites background from "Is serial determination of inspirat..."
..., 2008 [54] CHF Prospective, singlearm study 158 No significant association...
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TL;DR: In CHF patients with IMW, IMT results in a significant increase in OUES, and there was a significant association between the changes in PImax and OUES.
Abstract: ■ PURPOSE: Inspiratory muscle training (IMT) improves exercise capacity and ventilatory responses to exercise in patients with chronic heart failure (CHF) with inspiratory muscle weakness (IMW). We analyzed the effects of IMT on the oxygen uptake efficiency slope (OUES) in this patient population. ■ METHODS: Thirty-two CHF patients with IMW (maximal inspiratory pressure [PImax] � 70% of predicted) were randomly assigned to either a 12-week program of IMT (IMT, n � 16) or placebo-IMT (P-IMT, n � 16). PImax and OUES were obtained before and after the intervention. ■ RESULTS: Inspiratory muscle training resulted in 115% increment in PImax (5.9 � 0.9 vs 12.7 � 0.9 kPa; P � .001) and in significant improvement in OUES (1,554 � 617 to 2,037 � 747 mL� 1 min� 1 O 2 /L min�1 of minute ventilation; P � .001). There were no significant changes in the P-IMT group. There was a significant association between the changes in PImax and OUES (r � 0.82, P � .01). ■ CONCLUSION: In CHF patients with IMW, IMT results in a significant increase in OUES.
54 citations
TL;DR: New insights are offered into the pathophysiological mechanisms of exertional dysPNoea in patients with chronic heart failure by exploring the potential role of the various constituents of the physiological response to exercise and particularly the role of abnormal ventilatory and respiratory mechanics responses to exercise in the perception of dyspnoea.
Abstract: Exertional dyspnoea is among the dominant symptoms in patients with chronic heart failure and progresses relentlessly as the disease advances, leading to reduced ability to function and engage in activities of daily living. Effective management of this disabling symptom awaits a better understanding of its underlying physiology.Cardiovascular factors are believed to play a major role in dyspnoea in heart failure patients. However, despite pharmacological interventions, such as vasodilators or inotropes that improve central haemodynamics, patients with heart failure still complain of exertional dyspnoea. Clearly, dyspnoea is not determined by cardiac factors alone, but likely depends on complex, integrated cardio-pulmonary interactions.A growing body of evidence suggests that excessively increased ventilatory demand and abnormal "restrictive" constraints on tidal volume expansion with development of critical mechanical limitation of ventilation, contribute to exertional dyspnoea in heart failure. This article will offer new insights into the pathophysiological mechanisms of exertional dyspnoea in patients with chronic heart failure by exploring the potential role of the various constituents of the physiological response to exercise and particularly the role of abnormal ventilatory and respiratory mechanics responses to exercise in the perception of dyspnoea in patients with heart failure.
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TL;DR: The normal range of values for the maximal inspiratory and expiratory pressures in males and females from 20 to 74 years of age was determined and there was no significant regression of Pi max or Pe max with age in subjects younger than 55 years.
Abstract: A method for determining maximal respiratory pressures is described. The test was easy to perform; reproducible results were obtained, and no complications were encountered in the 120 subjects studied. The normal range of values for the maximal inspiratory (Pi max) and expiratory (Pe max) pressures in males and females from 20 to 74 years of age was determined. There was no significant regression of Pi max or Pe max with age in subjects younger than 55 years. In subjects older than 55, Pe max in males and females and Pi max in females decreased with age. The application of the method is illustrated by the results obtained in 2 patients with neuromuscular disease.
1,863 citations
TL;DR: Meta-analysis of randomised trials to date gives no evidence that properly supervised medical training programmes for patients with heart failure might be dangerous, and indeed there is clear evidence of an overall reduction in mortality.
Abstract: Objective To determine the effect of exercise training on survival in patients with heart failure due to left ventricular systolic dysfunction.
Design Collaborative meta-analysis.
Inclusion criteria Randomised parallel group controlled trials of exercise training for at least eight weeks with individual patient data on survival for at least three months.
Studies reviewed Nine datasets, totalling 801 patients: 395 received exercise training and 406 were controls.
Main outcome measure Death from all causes.
Results During a mean (SD) follow up of 705 (729) days there were 88 (22%) deaths in the exercise arm and 105 (26%) in the control arm. Exercise training significantly reduced mortality (hazard ratio 0.65, 95% confidence interval, 0.46 to 0.92; log rank χ2 = 5.9; P = 0.015). The secondary end point of death or admission to hospital was also reduced (0.72, 0.56 to 0.93; log rank χ2 = 6.4; P = 0.011). No statistically significant subgroup specific treatment effect was observed.
Conclusion Meta-analysis of randomised trials to date gives no evidence that properly supervised medical training programmes for patients with heart failure might be dangerous, and indeed there is clear evidence of an overall reduction in mortality. Further research should focus on optimising exercise programmes and identifying appropriate patient groups to target.
1,007 citations
TL;DR: Regular physical training increases maximal exercise tolerance and delays anaerobic metabolism during submaximal exercise in patients with stable chronic heart failure and improved functional capacity is closely linked to an exercise-induced increase in the oxidative capacity of skeletal muscle.
536 citations
TL;DR: Hazard ratios and 95% confidence intervals for individual studies for effect of exercise training on risk of death and on risk for death and admission to hospital are shown.
Abstract: EDITOR—The figure shows the forest plots of the hazard ratios and 95% confidence intervals. The forest plots were removed during revision for reasons of space.
Fig 1
Hazard ratios and 95% confidence intervals for individual studies for effect of exercise training on risk of death and on risk of death and admission to hospital (full data available on bmj.com>)
As Metcalfe observes, in one fairly …
419 citations
TL;DR: In patients with CHF and inspiratory muscle weakness, IMT results in marked improvement in inspiratory Muscle strength, as well as improvement in functional capacity, ventilatory response to exercise, recovery oxygen uptake kinetics, and quality of life.
384 citations