title: Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Improved Exercise Tolerance and Quality of Life With Cardiac Rehabilitation of Older Patients After Myocardial Infarction: Results of a Randomized, Controlled Trial A randomised study of home-based electrical stimulation of the legs and conventional bicycle exercise training for patients with chronic heart failure. Superior Cardiovascular Effect of Aerobic Interval Training Versus Moderate Continuous Training in Heart Failure Patients: A Randomized Study Effect of Treadmill Testing and Exercise Training on Self-Efficacy in Patients with Heart Failure Effects of home-based exercise training on neurovascular control in patients with heart failure. Antiremodeling Effect of Long-Term Exercise Training in Patients With Stable Chronic Heart Failure: Results of the Exercise in Left Ventricular Dysfunction and Chronic Heart Failure (ELVD-CHF) Trial Effect of encouragement on walking test performance. Physical training reduces peripheral markers of inflammation in patients with chronic heart failure. Antioxidative Effects of Exercise Training in Patients With Chronic Heart Failure: Increase in Radical Scavenger Enzyme Activity in Skeletal Muscle Home‐based exercise training modulates pro‐oxidant substrates in patients with chronic heart failure The effect of physical training on skeletal muscle in patients with chronic heart failure. Home-based exercise improves functional performance and quality of life in women with diastolic heart failure. Exercise training in chronic heart failure: correlation between reduced local inflammation and improved oxidative capacity in the skeletal muscle Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study Usefulness of a home-based exercise program for overweight and obese patients with advanced heart failure. Effects of a home walking exercise program on functional status and symptoms in heart failure. Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: A randomized trial. Endothelial markers in chronic heart failure: training normalizes exercise-induced vWF release. Aerobic training decreases B-type natriuretic peptide expression and adrenergic activation in patients with heart failure. Effects of exercise training on heart rate recovery in patients with chronic heart failure. Effects of exercise training in patients with heart failure: the Exercise Rehabilitation Trial (EXERT). Reliability of the PEDro scale for rating quality of randomized controlled trials. Predictors of a sustained response to exercise training in patients with chronic heart failure: a telemonitoring study. Telephone Interventions by Nursing Students: Improving Outcomes for Heart Failure Patients in the Community Physical training in patients with chronic heart failure of ischemic origin: effect on exercise capacity and left ventricular remodeling Effect of a seated exercise program to improve physical function and health status in frail patients > or = 70 years of age with heart failure. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure The Rotterdam Study. Comparison of Quality of Life Measures in Heart Failure
abstract: BACKGROUND Case management is believed to promote continuity of care and decrease hospitalization rates , although few controlled trials have tested this approach . OBJECTIVE To assess the effectiveness of a st and ardized telephonic case-management intervention in decreasing re source use in patients with chronic heart failure . METHODS A r and omized controlled clinical trial was used to assess the effect of telephonic case management on re source use .  Patients were identified at hospitalization and assigned to receive 6 months of intervention ( n = 130 ) or usual care ( n = 228 ) based on the group to which their physician was r and omized .  Hospitalization rates , readmission rates , hospital days , days to first rehospitalization , multiple readmissions , emergency department visits , inpatient costs , outpatient re source use , and patient satisfaction were measured at 3 and 6 months . RESULTS The heart failure hospitalization rate was 45.7 % lower in the intervention group at 3 months ( P = .03 ) and 47.8 % lower at 6 months ( P = .01 ) . Heart failure hospital days ( P = .03 ) and multiple readmissions ( P = .03 ) were significantly lower in the intervention group at 6 months . Inpatient heart failure costs were 45.5 % lower at 6 months ( P = .04 ) . A cost saving was realized even after intervention costs were deducted . There was no evidence of cost shifting to the outpatient setting . Patient satisfaction with care was higher in the intervention group . CONCLUSIONS The reduction in hospitalizations , costs , and other re source use achieved using st and ardized telephonic case management in the early months after a heart failure admission is greater than that usually achieved with pharmaceutical therapy and comparable with other disease management approaches Background —Whether cardiac rehabilitation ( CR ) is effective in patients older than 75 years , who have been excluded from most trials , remains unclear . We enrolled patients 46 to 86 years old in a r and omized trial and assessed the effects of 2 months of post-myocardial infa rct ion ( MI ) CR  on total work capacity ( TWC , in kilograms per meter ) and health-related quality of life ( HRQL ) . Methods and Results —Of 773 screened patients , 270 without cardiac failure , dementia , disability , or contraindications to exercise were r and omized to outpatient , hospital-based CR ( Hosp-CR ) , home-based CR ( Home-CR ) , or no CR within 3 predefined age groups ( middle-aged , 45 to 65 years ; old , 66 to 75 years ; and very old , > 75 years ) of 90 patients each .  TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline , after CR , and 6 and 12 months later . Within each age group , TWC improved with Hosp-CR and Home-CR and was unchanged with no CR . The improvement was similar in middle-aged and old persons but smaller , although still significant , in very old patients . TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR .  HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients . Complications were similar across treatment and age groups . Costs were lower for Home-CR than for Hosp-CR . Conclusions —Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group . However , with lower costs and more prolonged positive effects , Home-CR may be the treatment of choice in low-risk older patients AIMS Recent guidelines recommend regular exercise in the management of patients with chronic heart failure ( CHF ) . This study was design ed to compare the safety and efficacy of conventional bicycle exercise and functional electrical stimulation ( FES ) of the legs as forms of home-based exercise training for patients with stable CHF . METHODS AND RESULTS Forty-six patients ( 38 male ) with stable NYHA Class II/III heart failure underwent a 6-week training programme using either a bicycle ergometer or electrical stimulation of the quadriceps and gastrocnemius muscles . In the bike group , significant increases were seen in 6-min walk ( 44.6 m , 95 % confidence interval ( CI ) 29.3 - 60.9 m ) , treadmill exercise time ( 110 s , 95 % CI 72.2 - 148.0 s ) , maximum leg strength ( 5.32 kg , 95 % CI 3.18 - 7.45 kg ) , and quadriceps fatigue index ( 0.08 , 95 % CI 0.04 - 0.12 ) following training . In the stimulator group , similar significant increases were seen following training for 6-min walk ( 40.6 m , 95 % CI 28.2 - 53.0 m ) , treadmill exercise time ( 67 s , 95 % CI 11.8 - 121.8s ) , maximum leg strength ( 5.35 kg , 95 % CI 1.53 - 9.17 kg ) , and quadriceps fatigue index ( 0.10 , 95 % CI 0.04 - 0.17 ) . Peak VO(2)did not change in either group following training , indicating a low-intensity regime . Quality of life scores improved following training when the bicycle and stimulator groups were considered together , but not when considered separately ( -0.43 , 95 % CI -8.13 to -0.56 ) . CONCLUSIONS FES produces beneficial changes in muscle performance and exercise capacity in patients with CHF . Within this study , the benefits were similar to those observed following bicycle training . FES could be offered to patients with heart failure as an alternative to bicycle training as part of a home-based rehabilitation programme Background — Exercise training reduces the symptoms of chronic heart failure . Which exercise intensity yields maximal beneficial adaptations is controversial . Furthermore , the incidence of chronic heart failure increases with advanced age ; it has been reported that 88 % and 49 % of patients with a first diagnosis of chronic heart failure are > 65 and > 80 years old , respectively . Despite this , most previous studies have excluded patients with an age > 70 years . Our objective was to compare training programs with moderate versus high exercise intensity with regard to variables associated with cardiovascular function and prognosis in patients with postinfa rct ion heart failure . Methods and Results — Twenty-seven patients with stable postinfa rct ion heart failure who were undergoing optimal medical treatment , including & bgr;-blockers and angiotensin-converting enzyme inhibitors ( aged 75.5±11.1 years ; left ventricular [ LV ] ejection fraction 29 % ; & OV0312;o2peak 13 mL · kg−1 · min−1 ) were r and omized to either moderate continuous training ( 70 % of highest measured heart rate , ie , peak heart rate ) or aerobic interval training ( 95 % of peak heart rate ) 3 times per week for 12 weeks or to a control group that received st and ard advice regarding physical activity . & OV0312;o2peak increased more with aerobic interval training than moderate continuous training ( 46 % versus 14 % , P<0.001 ) and was associated with reverse LV remodeling . LV end-diastolic and end-systolic volumes declined with aerobic interval training only , by 18 % and 25 % , respectively ; LV ejection fraction increased 35 % , and pro-brain natriuretic peptide decreased 40 % . Improvement in brachial artery flow-mediated dilation ( endothelial function ) was greater with aerobic interval training , and mitochondrial function in lateral vastus muscle increased with aerobic interval training only . The MacNew global score for quality of life in cardiovascular disease increased in both exercise groups . No changes occurred in the control group . Conclusions — Exercise intensity was an important factor for reversing LV remodeling and improving aerobic capacity , endothelial function , and quality of life in patients with postinfa rct ion heart failure . These findings may have important implication s for exercise training in rehabilitation programs and future studies Background : Self-efficacy is a person 's confidence in being able to successfully perform a specific activity or behavior . Self-efficacy has been shown to influence exercise capacity in patients post myocardial infa rct ion , but has not been fully explored in patients with heart failure ( HF ) . This study examined the impact of performance of a single treadmill exercise test and participation in a 3-month program of walking and resistance exercise on self-efficacy in HF patients . Methods : 24 patients were r and omized to either a home-based walking and resistance exercise program or usual care for 3 months . Prior to enrollment into the exercise program all participants performed a single treadmill exercise test with respiratory gas analysis .  Self-efficacy question naires were completed at 3 time points , 1 ) prior to performance of an exercise treadmill test ; 2 ) immediately after completing an exercise test ; and 3 ) at the end of a 3-month exercise program . Results : Self-efficacy for walking ( p = 0.07 ) , climbing ( p = 0.17 ) , lifting ( p = 0.73 ) and general activity ( p = 0.15 ) did not improve after performance of a single treadmill exercise test and usual care . However , self-efficacy for walking increased after 3 months of a walking and resistance exercise program . ( p = 0.04 ) . Conclusions : The findings from this study suggest that in patients with stable mild to moderate heart failure , self-efficacy is improved with participation in a home-based walking and endurance exercise program .  Self-efficacy is not enhanced by performance of a single treadmill exercise test and usual care BACKGROUND The effect of home-based exercise training on neurovascular control in heart failure patients is unknown . AIMS To test the hypothesis that home-based training would maintain the reduction in muscle sympathetic nerve activity ( MSNA ) and forearm vascular resistance ( FVR ) acquired after supervised training . METHODS AND RESULTS Twenty-nine patients ( 54+/-1.9 years , EF<40 % ) were r and omised into two groups : untrained control ( n=12 ) and exercise trained  ( n=17 ) . Both groups underwent assessment of Quality of Life ( QoL ) , MSNA , and forearm blood flow . The exercise group underwent a 4-month supervised training program followed by 4 months of home-based training . After the initial 4 months of training , patients in the exercise group showed a significant increase in peak VO(2 ) and reduction in MSNA , compared to the untrained group , but this was not maintained during 4 months of home-based training . In contrast , the decrease in FVR ( 56+/-3 vs. 46+/-4 vs. 40+/-2 U , p=0.008 ) and the improvement in QOL that were achieved during supervised training were maintained during home-based training . CONCLUSIONS Home-based training following supervised training is a safe strategy to maintain improvements in QoL and reduction in FVR in chronic heart failure patients , but is an inadequate strategy to maintain fitness as estimated by peak VO(2 ) or reduction in neurohumoral activation Background —The effects of exercise training ( ET ) on left ventricular ( LV ) remodeling in chronic heart failure are not definitively established , and the safety of ET in these patients is still debated . Methods and Results —This multicenter study investigated the long-term effect of moderate ET on LV remodeling , work capacity , and quality of life ( QoL ) in 90 patients with stable chronic heart failure caused by LV systolic dysfunction , r and omized to a 6-month ET program ( T , n=45 ) or a control group ( C , n=45 ) . All patients underwent resting echocardiography , a cardiopulmonary exercise test , 6-minute walking test , and QoL assessment at entry and after 6 months . At entry , end-diastolic ( EDV ) and end-systolic ( ESV ) volume , ejection fraction , work capacity , peak & OV0312;o2 , and walking distance were similar in the 2 groups . After 6 months , LV volumes diminished in T ( EDV , from 142±26 to 135±26 mL/m2 , P < 0.006 ; ESV , from 107±24 to 97±24 mL/m2 , P < 0.05 ) but increased in C ( EDV , from 147±41 to 156±42 mL/m2 , P < 0.01 ; ESV , from 110±34 to 118±34 mL/m2 , P < 0.01 ) . Ejection fraction improved in T ( P < 0.001 ) but was unchanged in C ( P = NS ) . Significant improvement in work capacity ( P < 0.001 ) , peak & OV0312;o2 ( P < 0.006 ) , walking distance ( P < 0.001 ) , and QoL ( P < 0.01 ) was observed in T but not in C ( P = NS ) . T showed a trend toward fewer ( P = 0.05 ) hospital readmissions for worsening dyspnea in the absence of other adverse cardiac events . Conclusions —In stable chronic heart failure , long-term moderate ET has no detrimental effect on LV volumes and function ; rather , it attenuates abnormal remodeling . Furthermore , ET is safe and effective in improving exercise tolerance and Walking tests , frequently used to document effects of treatment on exercise capacity , have never been st and ardised . We studied the effects of encouragement on walking test performance in a r and omised study that controlled for the nature of the underlying disease , time of day , and order effects . We r and omised 43 patients with chronic airflow limitation or chronic heart failure or both to receive or not receive encouragement as they performed serial two and six minute walks every fortnight for 10 weeks . Simple encouragement improved performance ( p less than 0.02 for the six minute walk ) , and the magnitude of the effect was similar to that reported for patients in studies purporting to show beneficial effects of therapeutic manoeuvres . Age and test repetition also affected performance . These results demonstrate the need for careful st and ardisation of the performance of walking tests , and suggest caution in interpreting studies in which st and ardisation is not a major feature of the study design AIMS Previous studies have shown an abnormal expression of cellular adhesion molecules and cytokines in chronic heart failure , which may be related to endothelial dysfunction characterizing this syndrome . Our study investigates the effects of physical training on serum activity of some peripheral inflammatory markers associated with endothelial dysfunction , such as granulocyte-macrophage colony-stimulating factor ( GM-CSF ) , macrophage chemoattractant protein-1 ( MCP-1 ) , soluble intercellular adhesion molecule-1 ( sICAM-1 ) and soluble vascular cell adhesion molecule-1 ( sVCAM-1 ) in patients with chronic heart failure . METHODS AND RESULTS Serum levels of GM-CSF , MCP-1 , sICAM-1 and sVCAM-1 were determined in 12 patients with stable chronic heart failure ( ischaemic heart failure : 6/12 , dilated cardiomyopathy : 6/12 , New York Heart Association : II-III , ejection fraction : 24+/-2 % ) before and after a 12-week programme of physical training in a r and omized crossover design . In addition , the functional status of chronic heart failure patients was evaluated by using a cardiorespiratory exercise stress test to measure peak oxygen consumption .  Physical training produced a significant reduction in serum GM-CSF ( 28+/-2 vs 21+/-2 pg . ml(-1 ) , P<0.001 ) , MCP-1 ( 192+/-5 vs 174+/-6 pg . ml(-1 ) , P<0.001 ) , sICAM-1 ( 367+/-31 vs 314+/-29 ng . ml(-1 ) , P<0.01 ) and sVCAM-1 ( 1247+/-103 vs 1095+/-100 ng . ml(-1 ) , P<0.01 ) as well as a significant increase in peak oxygen consumption ( 14.6+/-0.5 vs 16.5+/-0.5 ml . kg(-1)min(-1 ) , P<0.005 ) . A significant correlation was found between the training-induced improvement in peak oxygen consumption and percentage reduction in soluble adhesion molecules sICAM-1 ( r=-0.72 , P<0.01 ) and sVCAM-1 ( r=-0.67 , P<0.02 ) . CONCLUSION Physical training affects beneficially peripheral inflammatory markers reflecting monocyte/macrophage-endothelial cell interaction . Training-induced improvement in exercise tolerance is correlated with the attenuation of the inflammatory process , indicating that inflammation may contribute significantly to the impaired exercise capacity seen in chronic heart failure Background —In chronic heart failure ( CHF ) , cross-talk between inflammatory activation and oxidative stress has been anticipated in skeletal muscle ( SM ) . The role of the radical scavenger enzymes superoxide dismutase ( SOD ) , catalase ( Cat ) , and glutathione peroxidase ( GPX ) , which remove oxygen radicals , has never been assessed in the SM in this context . Moreover , it remains unknown whether exercise training augments the activity of these enzymes in CHF . Methods and Results —Twenty-three patients with CHF were r and omized to either 6 months of exercise training ( T ) or a sedentary lifestyle  ( C ) ; 12 age-matched healthy subjects ( HS ) were studied in parallel . Activity of Cat , SOD , and GPX was assessed in SM biopsies before and after 6 months ( 6 months ) . Oxidative stress was determined by measuring nitrotyrosine formation . SOD , Cat , and GPX activity was reduced by 31 % , 57 % , and 51 % , respectively , whereas nitrotyrosine formation was increased by 107 % in SM in CHF ( P<0.05 versus HS ) . In CHF , exercise training  augmented GPX and Cat activity in SM by 41 % ( P<0.05 versus before and group C ) and 42 % ( P<0.05 versus before and group C ) , respectively , and decreased nitrotyrosine production by 35 % ( from 3.8±0.4 % tissue area before to 2.5±0.3 % after 6 months ; P<0.05 versus before ) . Conclusions —The reduced activity of major antioxidative enzymes in the SM of CHF patients is associated with increased local oxidative stress  . Exercise training exerts antioxidative effects in the SM in CHF , in particular , due to an augmentation in activity of radical scavenger enzymes In chronic heart failure , oxidative stress is thought to lead to endothelial dysfunction . In this study , we assessed the effect of home‐based exercise training on variables of the NO and purine pathways BACKGROUND The improvement of exercise capacity in patients with chronic heart failure ( CHF ) by physical training has been connected with reversal of the abnormalities in muscle fiber distribution and with the reduced activity of the enzymes of oxidative metabolism in skeletal muscle . However , the change in fiber type distribution induced by training is controversial and in previous studies the activities of the rate-limiting enzymes of the metabolic pathways have not been measured . AIMS To examine the effect of dynamic training on percentage distribution of muscle fibers , on activities of the rate-limiting enzymes of the metabolic pathways and on electrophysiology in skeletal muscle . METHODS A total of 27 patients with stable CHF ( NYHA class II-III ) were r and omized to a training ( N=12 ) or a control ( N=15 ) group . The training group exercised on a bicycle ergometer for 30 min three times a week for 3 months using a load corresponding to 50 - 60 % of their peak oxygen consumption . This was followed by a 3-month training period at home according to personal instructions . The control group did not change its physical activities . We studied muscle histology and measured the activities of the rate-limiting enzymes of anaerobic glycolysis ( phosphofructokinase , PFK ) , glycogenolysis ( phosphorylase ) , citric acid cycle ( alpha-ketoglurate dehydrogenase , KGDH ) and fatty acid oxidation ( carnitinepalmitoyl transferase I and II , CPT I and II ) from biopsies of the vastus lateralis muscle at baseline and after 3 and 6 months . Muscle strength and strength endurance with surface EMG and macro EMG of the right knee extensors were also determined . RESULTS Exercise capacity , particularly submaximal , improved in the training group . The activity of PFK rose significantly but that of the other enzymes did not when compared with the change in the controls . Training had no effect on the percentage distribution of slow-twitch and fast-twitch muscle fibers or on capillary density around these fibers in skeletal muscle . Maximum voluntary force , strength endurance and the function of motor units remained unaffected . CONCLUSIONS Dynamic training results in improved exercise endurance in CHF . In skeletal muscle , the capacity of anaerobic glycolysis is increased but that of the citric acid cycle and fatty acid oxidation is not . Furthermore , the improvement in exercise endurance seems to be independent of changes in the percentage distribution of muscle fibers , capillarity or electrophysiological factors BACKGROUND Diastolic heart failure ( DHF ) is common in older women . There have been no clinical trials that have identified therapies to improve symptoms in these patients . A total of 32 women with New York Heart Association class II and III DHF ( left ventricular ejection fraction > 45 % and symptoms of dyspnea or fatigue ) were r and omized into a 12-week home-based , low-to-moderate intensity ( 40 % and 60 % , respectively ) exercise and education program ( intervention ) or education only program ( control ) . Methods and results The intervention group improved in the 6-minute walk test from 840 + /- 366 ft to 1043 + /- 317 ft versus 824 + /- 367 ft to 732 + /- 408 ft in the control group ( P = .002 ) . Quality of life also improved in the intervention group compared with the control group as measured by the Living with Heart Failure Question naire ( 41 + /- 26 to 24 + /- 18 vs 27 + /- 18 to 28 + /- 22 at 12 weeks , P = .002 ; 24 + /- 18 to 19 + /- 18 vs 28 + /- 22 to 32 + /- 27 at the 3-month follow-up , P = .014 ) and the Geriatric Depression Scale ( 6 + /- 4 to 4 + /- 4 vs 5 + /- 3 to 7 + /- 5 at 12 weeks , P = .012 ; 4 + /- 4 to 4 + /- 4 vs 7 + /- 5 to 7 + /- 5 at the 3-month follow-up , P = .009 ) . CONCLUSIONS Women with DHF exhibit significant comorbidities and physical limitations . Home-based , low-to-moderate intensity exercise , in addition to education , is an effective strategy for improving the functional capacity and quality of life in women with DHF . Further study is needed to assess the long-term effect of exercise on clinical outcomes Background Chronic heart failure ( CHF ) is accompanied by an inflammatory activation which occurs both systemically and in the skeletal muscle . Exercise training has been shown to reduce the local expression of cytokines and inducible nitric oxide synthase ( iNOS ) in muscle biopsies of CHF patients . INOS-derived NO can inhibit oxidative phosphorylation and contribute to skeletal muscle dysfunction in CHF . Design To investigate the correlation between changes in local iNOS expression associated with regular exercise and changes in aerobic enzyme activities in the skeletal muscle of patients with CHF . Twenty male CHF patients [ ejection fraction 25 % ( SE 2 ) , age 54 ( SE 2 ) years ] were r and omized to a training ( n = 10 ) or a control group ( C , n = 10 ) . Methods At baseline and after 6 months skeletal muscle iNOS expression was measured by real-time polymerase chain reaction . INOS protein and protein nitrosylation were assessed by immunohistochemistry . Cytochrome c oxidase ( COX ) activity was quantified electrochemically using the Clark oxygen electrode . Results Exercise training led to a 27 % increase in cytochrome c oxidase activity [ from 21.8 ( SE 3.2 ) to 27.7 ( SE 3.5 ) nmol O2/mg per min , P=0.02 versus baseline ] . Changes in iNOS expression and iNOS protein content were inversely correlated with changes in COX-activity ( r= −0.60 , P=0.01 ; r= −0.71 , P<0.001 ) . Conclusions The inverse correlation between iNOS expression/iNOS protein content and COX-activity indicates that local anti-inflammatory effects may contribute to improved muscular oxidative metabolism BACKGROUND Accurate data for prevalence rates for heart failure due to various causes , and for left-ventricular systolic dysfunction in all adults are unavailable . Our aim was to assess prevalence of left-ventricular systolic dysfunction and heart failure in a large representative adult population in Engl and . METHODS Of 6286 r and omly selected patients aged 45 years and older , 3960 ( 63 % ) participated in the study . They came from 16 r and omly selected general practice s. We assessed patients by  history and examination , electrocardiography , and echocardiography .  Prevalence of left-ventricular systolic dysfunction ( defined as ejection fraction < 40 % ) and heart failure was calculated for the overall population on the basis of strict criteria and , when necessary , adjudication by a panel . FINDINGS Left-ventricular systolic dysfunction was diagnosed in 72 ( 1.8 % [ 95 % CI 1.4 - 2.3 ] ) participants , half of whom had no symptoms . Borderline left-ventricular function ( ejection fraction 40 - 50 % ) was seen in 139 patients ( 3.5 % [ 3.0 - 4.1 ] ) . Definite heart failure was seen in 92 ( 2.3 % , [ 1.9 - 2.8 ] ) and was associated with an ejection fraction of less than 40 % in 38 ( 41 % ) patients , atrial fibrillation in 30 ( 33 % ) , and valve disease in 24 ( 26 % ) . Probable heart failure was seen in a further 32 ( 0.8 % [ 0.6 - 1.1 ] ) patients . In total , 124 ( 3.1 % [ 2.6 - 3.7 ] ) patients aged 45 years or older had definite or probable heart failure . INTERPRETATION Heart failure is often misdiagnosed or underdiagnosed in primary care . Our results suggest that assessment of left-ventricular function in patients with suspected heart failure could lead to more effective diagnosis and treatment of this disorder Exercise is an important behavior for long-term weight control in overweight and obese patients . However , little evidence exists confirming such findings in patients with advanced heart failure ( HF ) . Using a prospect i ve , experimental design , the effects of 24 weeks of a low-level , home-based walking program on weight loss were studied in overweight and obese ( body mass index > or = 27 kg/m(2 ) ) patients with advanced HF who were r and omized to exercise ( n = 48 ) and control ( n = 51 ) groups .  Weight changes between the 2 groups at baseline and 6 months were compared using repeated- measures analysis of variance . Patients were on average aged 53.3 + /- 10.1 years and predominantly male ( 75 % ) , Caucasian ( 57 % ) , and married ( 55 % ) . Most patients were in New York Heart Association class III or IV ( 67 % ) , with a mean ejection fraction of 25 % . Patients in the exercise group showed significant weight reduction from baseline to 6 months compared with those in the control group ( -6.37 + /- 11.7 vs -0.33 + /- 9.3 kg , p = 0.002 ) . No significant differences were noted between the 2 groups in 6-minute walk distance or depression , although the changes were in the anticipated direction . Modest weight losses of > 5 % were associated with cardiopulmonary exercise test-documented workload levels at 6 months ( r = 0.331 , p = 0.006 ) , as well as decreased depression ( r = -0.315 , p = 0.01 ) and hostility ( r = -0.355 , p = 0.005 ) . The number of hospital admissions was significantly smaller for patients in the exercise group compared with those in the control group ( 0.63 + /- 0.94 vs 1.07 + /- 0.95 , p < 0.05 ) . In conclusion , the findings demonstrate the beneficial effects of a low-level , home-based walking program on weight loss in overweight and obese patients with advanced HF BACKGROUND Hospital-based exercise programs using a bicycle ergometer or a combination of exercise modalities have shown positive benefits in heart failure , but may not be readily accessible to many patients . Thus , we sought to evaluate the effects of a 12-week home walking exercise program on functional status and symptoms in patients with heart failure . METHODS A r and omized controlled trial comparing a 12-week progressive home walking exercise program ( n = 42 ) to a " usual activity " control group ( n = 37 ) was conducted in patients with heart failure ( 78 [ 99 % ] male ; mean age 62.6 + /- 10.6 years ; ejection fraction 27 % + /- 8.8 % ; 63 [ 80 % ] New York Heart Association class II ; 15[20 % ] New York Heart Association class III-IV ) from a Veterans Affairs medical center and a university-affiliated medical center .  Functional status ( peak oxygen consumption via cardiopulmonary exercise testing , 6-minute walk test , the Heart Failure Functional Status Inventory ) , and symptoms ( Dyspnea-Fatigue Index score with a postglobal rating of symptoms ) were measured at baseline and 12 weeks . RESULTS No adverse events related to exercise training occurred . Overall mean compliance to training was 74 + /- 37 % . Peak oxygen consumption and the Heart Failure Functional Status Inventory were unchanged with training . Compared to the usual activity group , the training group had significantly longer walking distances measured by the 6-minute walk test ( 1264 + /- 255 vs 1337 + /- 272 feet , P = .001 ) , and improved postglobal rating of symptoms ( P = .03 ) . CONCLUSION In patients with heart failure , a progressive home walking exercise program is acceptable , increases walking distance , and decreases global rating of symptoms CONTEXT Exercise training in patients with chronic heart failure improves work capacity by enhancing endothelial function and skeletal muscle aerobic metabolism , but effects on central hemodynamic function are not well established . OBJECTIVE To evaluate the effects of exercise training on left ventricular ( LV ) function and hemodynamic response to exercise in patients with stable chronic heart failure . DESIGN Prospect i ve r and omized trial conducted in 1994 - 1999 . SETTING University department of cardiology/outpatient clinic in Germany . PATIENTS Consecutive sample of 73 men aged 70 years or younger with chronic heart failure ( with LV ejection fraction of approximately 0.27 ) . INTERVENTION Patients were r and omly assigned to 2 weeks of in-hospital ergometer exercise for 10 minutes 4 to 6 times per day , followed by 6 months of home-based ergometer exercise training for 20 minutes per day at 70 % of peak oxygen uptake ( n=36 ) or to no intervention ( control group ; n=37 ) . MAIN OUTCOME MEASURES Ergospirometry with measurement of central hemodynamics by thermodilution at rest and during exercise ; echocardiographic determination of LV diameters and volumes , at baseline and 6-month follow-up , for the exercise training vs control groups . RESULTS After 6 months , patients in the exercise training group had statistically significant improvements compared with controls in New York Heart Association functional class , maximal ventilation , exercise time , and exercise capacity as well as decreased resting heart rate and increased stroke volume at rest . In the exercise training group , an increase from baseline to 6-month follow-up was observed in mean ( SD ) resting LV ejection fraction ( 0.30 [ 0.08 ] vs 0.35 [ 0.09 ] ; P=.003 ) . Mean ( SD ) total peripheral resistance ( TPR ) during peak exercise was reduced by 157 ( 306 ) dyne/s/cm(-5 ) in the exercise training group vs an increase of 43 ( 148 ) dyne/s/cm(-5 ) in the control group ( P=.003 ) , with a concomitant increase in mean ( SD ) stroke volume of 14 ( 22 ) mL vs 1 ( 19 ) mL in the control group ( P=.03 ) . There was a small but significant reduction in mean ( SD ) LV end diastolic diameter of 4 ( 6 ) mm vs an increase of 1 ( 4 ) mm in the control group ( P<.001 ) . Changes from baseline in resting TPR for both groups were correlated with changes in stroke volume ( r=-0.76 ; P<.001 ) and in LV end diastolic diameter ( r=0.45 ; P<.001 ) . CONCLUSIONS In patients with stable chronic heart failure , exercise training is associated with reduction of peripheral resistance and results in small but significant improvements in stroke volume and reduction in cardiomegaly . JAMA . 2000 BACKGROUND Chronic heart failure ( CHF ) is characterized by endothelial dysfunction . Vascular endothelium is important for control of haemostasis and vasoregulation . The aim of the present study was to investigate plasma levels of several endothelial markers and the exercise-induced changes on these plasma levels in CHF patients . Subsequently , the effect of a 6-month training programme on these markers is described . MATERIAL S AND METHODS Twenty-nine male CHF patients ( NYHA II/III , age 60 + /- 8 year , body mass index 26.7 + /- 2.3 kg m(-2 ) , left ventricular ejection fraction 26.3 - 7.2 % ; mean + /- SD ) participated . Patients were r and omly assigned to a training or control group . Training ( 26 weeks ; combined strength and endurance exercises ) was four sessions/week : two sessions supervised and two sessions at home . Before and after intervention , anthropometry , endothelial markers ( haemostasis and vasoregulation ) , maximal workload and peak oxygen uptake were assessed . RESULTS Physical training positively affected maximal workload . Plasma levels of endothelial markers were not affected by physical training and not related to exercise tolerance . After training , stimulated ( maximal exercise ) plasma von Willebr and Factor ( vWF ) release was present , whereas at baseline this release was absent . CONCLUSION Physical training led to normalization of the stimulated plasma vWF release . Plasma levels of other endothelial markers were not affected by physical training either at rest or under stimulated ( maximal exercise ) conditions OBJECTIVES We sought to evaluate the effect of physical training on neurohormonal activation in patients with heart failure ( HF ) . BACKGROUND Patients with HF benefit from physical training . Chronic neurohormonal activation has detrimental effects on ventricular remodeling and prognosis of patients with HF . METHODS A total of 95 patients with HF were assigned r and omly into two groups : 47 patients ( group T ) underwent a nine-month training program at 60 % of the maximal oxygen uptake ( VO2 ) , whereas 48 patients did not ( group C ) . The exercise load was adjusted during follow-up to achieve a progressive training effect . Plasma assay of B-type natriuretic peptide ( BNP ) , amino-terminal pro-brain natriuretic peptide ( NT-proBNP ) , norepinephrine , plasma renin activity , and aldosterone ; quality -of-life question naire ; echocardiogram ; and cardiopulmonary stress test  were performed upon enrollment and at the third and ninth month . RESULTS A total of 85 patients completed the protocol ( 44 in group T , left ventricular ejection fraction [ EF ] 35 + /- 2 % , mean + /- SEM ; and 41 in group C , EF 32 + /- 2 % , p = NS ) . At the ninth month , patients who underwent training showed an improvement in workload ( + 14 % , p < 0.001 ) , peak VO2 ( + 13 % , p < 0.001 ) , systolic function ( EF + 9 % , p < 0.01 ) , and quality of life . We noted that BNP , NT-proBNP , and norepinephrine values decreased after training ( -34 % , p < 0.01 ; -32 % , p < 0.05 ; -26 % , p < 0.01 , respectively ) . Increase in peak VO2 with training correlated significantly with the decrease in both BNP/NT-proBNP level ( p < 0.001 and p < 0.01 , respectively ) . Patients who did not undergo training showed no changes . CONCLUSIONS Clinical benefits after physical training in patients with HF are associated with blunting of adrenergic overactivity and of natriuretic peptide overexpression BACKGROUND Heart rate recovery ( HRR ) is a marker of vagal tone that is associated with survival , but little is known about the effects of exercise training on HRR in patients with heart failure ( HF ) . METHODS Twenty-four patients with HF were r and omized to a 2-month residential rehabilitation program or to  usual care . Symptom-limited exercise testing was performed at baseline and at discharge from the program . Heart rate recovery was expressed as the decline in heart rate from peak exercise through 6 minutes into recovery . In addition , HRR recovery curves were normalized to a range of 1 at peak heart rate and 0 at 6 minutes and adjusted for differences in heart rate reserve , facilitating the comparison of recovery curve shapes between groups . RESULTS Mean peak oxygen uptake and oxygen uptake at the lactate threshold increased 26 % ( P < .05 ) and 39 % ( P < .001 ) , respectively , in the exercise group , whereas neither of these responses changed significantly among controls . Heart rate recovery was significantly more rapid in the exercise group after training ( main effect 12.6 vs 2.6 beat/min in the trained and control groups , respectively , P = .005 ) . The normalized curves showed that the largest improvement in recovery curve shape occurred in the exercise group , but most of the HRR improvement was accounted for by a widening of the difference between peak and resting heart rate . CONCLUSION Exercise training results in a faster HRR in patients with HF . Heart rate recovery , as a simple marker of autonomic function , is an easily acquired response that may be useful for evaluating patient outcomes in cardiac rehabilitation BACKGROUND The purpose of this study was to examine the effects of exercise training on functional capacity in patients with heart failure . METHODS One hundred eighty-one patients in New York Heart Association class I to III , with ejection fraction < 40 % and 6-minute walk distance < 500 meters , were recruited into a r and omized , controlled , single-blind trial comparing 3 months of supervised training , then 9 months of home-based training with usual care . RESULTS There was a significant increase in 6-minute walk distance at 3 and 12 months but no between-group differences . Incremental peak oxygen uptake increased in the exercise group compared with the control group at 3 months ( 0.104 + /- 0.026 L/min vs 0.025 + /- 0.023 L/min ; P = .026 ) and 12 months ( 0.154 + /- 0.074 L/min vs 0.024 + /- 0.027 L/min ; P = .081 ) . Compared with the control group , significant increases were observed in the exercise group for arm and leg strength . No significant changes were observed in cardiac function or quality of life . Adherence to exercise was good during supervised training but reduced during home-based training . CONCLUSIONS Exercise training improves peak oxygen uptake and strength during supervised training . Over the final 9 months of the study , there was little further improvement , suggesting that some supervision is required for these patients . There were no adverse effects on cardiac function or clinical events BACKGROUND AND PURPOSE Assessment of the quality of r and omized controlled trials ( RCTs ) is common practice in systematic review s. However , the reliability of data obtained with most quality assessment scales has not been established . This report describes 2 studies design ed to investigate the reliability of data obtained with the Physiotherapy Evidence Data base ( PEDro ) scale developed to rate the quality of RCTs evaluating physical therapist interventions . METHOD In the first study , 11 raters independently rated 25 RCTs r and omly selected from the PEDro data base . In the second study , 2 raters rated 120 RCTs r and omly selected from the PEDro data base , and disagreements were resolved by a third rater ; this generated a set of individual rater and consensus ratings . The process was repeated by independent raters to create a second set of individual and consensus ratings . Reliability of ratings of PEDro scale items was calculated using multirater kappas , and reliability of the total ( summed ) score was calculated using intraclass correlation coefficients ( ICC [ 1,1 ] ) . RESULTS The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters . The ICC for the total score was.56 ( 95 % confidence interval=.47-.65 ) for ratings by individuals , and the ICC for consensus ratings was.68 ( 95 % confidence interval=.57-.76 ) . DISCUSSION AND CONCLUSION The reliability of ratings of PEDro scale items varied from " fair " to " substantial , " and the reliability of the total PEDro score was " fair " to " good . BACKGROUND Exercise training ( ExT ) improves exercise capacity in chronic heart failure , but the results of home-based training have been variable . We sought the predictors of favorable outcome using a telemonitoring approach . METHODS Exercise capacity and quality of life ( QOL ) were assessed in 30 patients ( 28 men , age 64 + /- 8 years ) with symptomatic chronic heart failure and left ventricular ejection fraction < or = 35 % ( 28 % + /- 9 % ) undergoing 8 months of home ExT.  Patients were provided with heart rate monitors and exercise diaries after undergoing 4 months of hospital-based ExT. Weekly telephone contact was established and heart rate data were downloaded bimonthly . Changes in peak oxygen consumption per unit time ( V*O2 ) and QOL were compared between the 15 most and 15 least adherent patients defined by the number of hours per week at > 60 % maximum heart rate , observed during heart-rate monitoring . RESULTS Peak V*O2 increased by 26 % ( P < .001 ) after 4 months of hospital ExT , but this increase had fallen to 8 % ( P = .07 ) at 12 months ; only adherent patients ( n = 15 ) showed persistent improvement of peak V*O2 at 12 months ( P = .02 ) . Improvement in peak V*O2 at 12 months was associated with baseline peak V*O2 ( r = -0.61 , P < .001 ) and hours logged on the heart rate monitor ( r = 0.47 , P = .01 ) . Quality of life improvements were sustained at 12 months for the Minnesota Living with Heart Failure Question naire and Hare-Davis Depression Question naire . Nevertheless , QOL improvements achieved during the outpatient program were lost or attenuated at 12 months in nonadherent patients but were maintained in adherent patients . CONCLUSIONS Telemonitoring is feasible for following adherence to home ExT. Ongoing adherence is critical in obtaining sustained benefit from ExT in heart failure Community care for heart failure patients is difficult due to multiple comorbidities , polypharmacy , and advanced age of patients . Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in home and community setting s. The purpose of this study 1 was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of heart failure patients in the home . Senior students were paired with community nursing staff and assigned 2 heart failure patients to follow up by telephone calls for 12 to 14 weeks . Patients who received telephone interventions had fewer hospital readmissions ( 13 % ) than the comparison group ( 35 % ) . Patients in the telephone intervention group also had fewer overt heart failure symptoms as measured by the Minnesota Living With Heart Failure Question naire Background Physical training is a well-known complementary treatment for chronic heart failure ( CHF ) ; however , many aspects require further studies . One of them is the impact on remodeling of the left ventricle ( LV ) . The purpose of this study was to evaluate the effect of 6 months of training on LV , exercise capacity and safety issues in patients with ischemic CHF . Methods Fifty patients ( mean age 60.1 ± 9.2 years ) with ischemic CHF , New York Heart Association ( NYHA ) classification class II and III and left ventricular ejection fraction ( LVEF ) ≤ 35 % were r and omized into groups : undergoing 6-month training ( 25 patients ) and not trained ( 25 patients ) . In both groups at baseline and at 6 months a cardiopulmonary exercise test and magnetic resonance imaging ( MRI ) with evaluation of LV were performed . Training was limited by the achievement of 80 % of the predicted heart rate at VO2PEAK achieved at the baseline cardiopulmonary exercise test . Results All patients completed the 6-month observation . No serious adverse events were found in either group . Exercise capacity improved only in the trained group ( VO 2peak increased by 31 % ) . At 6 months in the trained group there was a tendency towards an improvement in some LV parameters : ejection fraction , end-diastolic volume and wall motion score index ( WMSI ) , whereas an opposite trend was seen in the controls ( P < 0.05 , P < 0.05 and P < 0.01 for comparison of LVEFs , end-diastolic volumes and WMSIs , respectively ) . Conclusions Six-month training in ischemic CHF patients is a safe modality . Training improves exercise capacity . There was no negative impact on LV morphology , and a trend towards improvement of functional parameters on MRI may suggest an anti-remodeling effect of training in patients with ischemic CHF . Eur J Cardiovasc Prev Rehabil 14 : 85 - 91 © 2007 The European Society of Eighty-two patients aged > or = 70 years with heart failure were r and omized to a gentle , seated exercise program or to usual care .  Six-minute walk distance and quality of life did not change between groups , but daily activity as measured by accelerometry increased in the exercise group relative to the control group AIMS To determine the prevalence , incidence rate , lifetime risk and prognosis of heart failure . METHODS AND RESULTS The Rotterdam Study is a prospect i ve population -based cohort study in 7983 participants aged > or = 55 .  Heart failure was defined according to criteria of the European Society of Cardiology . Prevalence was higher in men and increased with age from 0.9 % in subjects aged 55 - 64 to 17.4 % in those aged > or = 85 . Incidence rate of heart failure was 14.4/1000 person-years ( 95 % CI 13.4 - 15.5 ) and was higher in men ( 17.6/1000 man-years , 95 % CI 15.8 - 19.5 ) than in women ( 12.5/1000 woman-years , 95 % CI 11.3 - 13.8 ) . Incidence rate increased with age from 1.4/1000 person-years in those aged 55 - 59 to 47.4/1000 person-years in those aged > or = 90 . Lifetime risk was 33 % for men and 29 % for women at the age of 55 . Survival after incident heart failure was 86 % at 30 days , 63 % at 1 year , 51 % at 2 years and 35 % at 5 years of follow-up . CONCLUSION Prevalence and incidence rates of heart failure are high . In individuals aged 55 , almost 1 in 3 will develop heart failure during their remaining lifespan . Heart failure continues to be a fatal disease , with only 35 % surviving 5 years after the first diagnosis Background Although numerous health-related quality -of-life instruments are available to measure patients ’ quality of life , few studies have compared these measures directly to determine how they function in the same group of patients . Objective The purpose of this study was to empirically compare psychometric properties of the Chronic Heart Failure Question naire ( CHQ ) , the Minnesota Living with Heart Failure Question naire ( LHFQ ) , and the General Health Survey Short-form-12 ( SF-12 ) . Sample A convenience sample of 211 patients with heart failure completed baseline question naires ; 165 patients completed the entire 26-week study . Methods Patients completed telephone interviews at baseline and at 4 , 8 , and 26 weeks after baseline . To compare mode of administration , a subset of patients ( n = 173 ) completed face-to-face and telephone interviews . Results Patients reported low-to-moderate health-related quality -of-life overall . Reliability of the three instruments was satisfactory . Responsiveness to changing condition , as evaluated by analysis of variance , receiver operating curve characteristics , and the minimal clinical ly important difference method , indicated that the CHQ and LHFQ were more responsive to changing conditions than the SF-12 . No major differences were noted between the scores of the face-to-face interviews and the baseline telephone interviews . The LHFQ and SF-12 were easier and took less time to administer than the CHQ . Conclusions While all three instruments were reliable and valid , the CHQ and LHFQ were more sensitive than the SF-12 in detecting clinical ly important changes over time
target: Home-based exercise increased exercise capacity safely but did not improve quality of life in patients with chronic heart failure .
  It could therefore be used to improve the management of people with chronic heart failure who do not have access to hospital-based exercise
background: QUESTIONS Does home-based exercise improve exercise capacity and quality of life in people with chronic heart failure ?
  Is it safe ?