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Hamid Talebifard, Habib Asgharpour, Reza Rezaeeshirazi, Abdulamir Saiiari,
Volume 28, Issue 9 (12-2021)
Volume 28, Issue 9 (12-2021)
Abstract
Background & Aims: Heart failure (HF) is a complex clinical syndrome caused by various structural or functional abnormalities of the heart and impairs the capacity to fill the ventricles (1). The prevalence of this disease in Iran is reported 8%, the highest rate of which is in Khuzestan and Gilan provinces (6). Despite numerous treatments depending on the pathology of the disease and the patient's condition, the mortality rate after the diagnosis of HF is still high (7). Although the pathogenesis of HF is largely unclear, it is widely accepted that neurohormonal changes and inflammatory processes are involved in the structural and functional destruction of vital organs including the heart, kidneys, and lungs (2). One of the clinical complications of HF is pulmonary diseases. The association between HF and COPD has been extensively investigated in recent years. It has been shown that about 30% of patients with HF have COPD and a similar HF prevalence has been reported in a large population of patients with COPD (9, 10). Impairment of aerobic function due to negative cardiopulmonary and muscular interactions is an important determinant factor in exercise intolerance in the heart failure patients with COPD (12). Considering heart and pulmonary disorders and problems of lack of oxygen in different tissues of the body, also considering the role of exercise in improving cardiorespiratory function and improving oxygen delivery to the body, it seems that exercise is very useful for these patients. On the other hand, due to the low respiratory capacity in patients with HF, one of the treatment priorities for these patients is to increase lung capacity in these people. It has been shown that the use of breathing exercises can be a complementary therapy to improve pulmonary function in patients with HF (16). Despite the relationship between pulmonary disorders in HF, so far no research has been conducted to investigate the effect of simultaneous combined exercise training (aerobic-resistance) on improving the structure and function of the heart as well as pulmonary volumes in these people, which shows the necessity of the present research. Therefore, the aim of this study was to determine the effect of eight weeks of simultaneous combined training (aerobic- inhalation resistance) on cardiovascular and pulmonary functional volumes in men with HF.
Methods: In the present semi-experimental study, 20 men with heart failure referred to the Cardiac Rehabilitation Center of Imam Khomeini Hospital in Ahvaz were selected by snowball sampling method. Randomly were divided into 2 groups of 10 people including exercise training group (mean age: 47.5 ± 7.84; body mass index: 29.27 ± 1.99) and control group (mean age: 48.8 ± 8.03; body mass index 26.93 ± 2.14). The training intervention consisted of eight weeks of training in three sessions per week. The training program included increasing continuous aerobic exercise with 40-85% of the subjects' reserve heart rate; Inhalation resistance exercises were performed 5 minutes after aerobic exercises with an intensity of 40-70% of the training load. No training intervention was performed in the control group. Cardiovascular and pulmonary variables were measured 48 hours before and 48 hours after the intervention period. Dependent t-test and analysis of covariance were used for statistical analysis of the obtained data. Statistical analysis was performed using SPSS software version 26 and a significance level of P <0.05 was considered.
Results: In the study of intragroup changes, the results of dependent t-test showed that after exercise intervention, a significant decrease in the levels of systolic blood pressure and resting heart rate variables and a significant increase in SV, EF, VO2Peak, FVC and FEV1 variables were observed in the exercise group, but no significant difference was observed in diastolic blood pressure levels. In the control group, no significant difference was observed in any of the measured variables.
In examining intergroup changes, the results of covariance test showed that changes in systolic blood pressure and resting heart rate, SV, EF, VO2Peak, FVC and FEV1 were significant in the exercise group compared to the control group.
Conclusion: Due to the positive changes in cardiac function, which were seen as an increase in functional heart volumes (SV and EF) and a decrease in resting heart rate and systolic blood pressure, part of the improvement in exercise performance capacity (VO2Peak) can be attributed to cardiac adaptation to aerobic exercise (20). Also, after the training period, a significant decrease in resting heart rate was observed. Since high resting heart rate is associated with adverse consequences of HF with reduced mutations (23) and due to the increase in stroke volume after exercise, changes in resting heart rate can be justified. Other factors affecting the improvement of cardiorespiratory function include increased pulmonary functional volumes (FVC and FEV1) (24). FVC and FEV1 are two common indicators in assessing pulmonary function and are used in research and clinical therapy as indications for response to treatment and clinical research (28,29). Considering that the exercises used in the present study included both aerobic and inhalation resistance training exercises, so the increase in FVC and FEV1 volumes can be attributed to the interaction of the two training methods on increasing the strength of the respiratory muscles as well as the adaptations resulting from aerobic exercise. Overall, the results of the present study showed that a combination of continuous aerobic exercise and respiratory resistance training can improve cardiorespiratory function and performance capacity in men with heart failure through improving cardiovascular function by increase in cardiac function (SV and EF) and reduction in resting heart rate and systolic blood pressure with increased pulmonary function FVC and FEV1). Considering that one of the complications of chronic heart failure, in addition to structural and functional problems of the heart, is a decrease in pulmonary capacity as one of the serious complications of heart failure, so, a combination of aerobic exercise and respiratory resistance training can be used to reduce HF complications and cardiorespiratory rehabilitation in these people. In general, it can be said that combined training, including a combination of increasing aerobic training and inhalation muscles resistance training with improved cardiopulmonary function, plays an important role in the rehabilitation of patients with HF, and these patients can use this training protocol for cardiopulmonary rehabilitation and reduction in complications of the disease.
Hamid Talebifard, Habib Asgharpour, Reza Rezaee Shirazi, Abdulamir Saiiari,
Volume 29, Issue 10 (12-2022)
Volume 29, Issue 10 (12-2022)
Abstract
Background & Aims: Chronic hypertension causes structural and functional changes in the heart, ultimately leading to heart failure (HF), which further increases mortality and morbidit. HF is a complex clinical syndrome caused by various structural or functional abnormalities of the heart that impair the filling capacity of the ventricles. The findings of various trials have shown the association between long-term hypertension and HF. The association between hypertension and heart failure with preserved ejection fraction (H:FpEF) is well known, with left ventricular hypertrophy, arterial stiffness, and renal failure possibly contributing to this syndrome. 90% or more of patients with HFpEF in contemporary trials have a history of hypertension. Furthermore, many patients with HFpEF remain hypertensive, and concomitant treatment is one of the few recommended treatments for people with this heart failure phenotype. Recent evidence suggests that not only do many HFpEF patients remain hypertensive, but a significant proportion may have high blood pressure that is difficult to control, despite the use of multiple antihypertensive drugs. In fact, resistant hypertension appears to be as common in patients with HFpEF as in those with hypertension, affecting 10–20% of patients. Use of three antihypertensive drugs in different classes, including an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), a calcium channel blocker, and a diuretic, although there are differences between US and European guidelines. The Ang-(1-7)/ACE2/Mas axis is now considered a major mechanism that balances the vasoconstrictor effects of the classical RAS, which includes renin, ACE, Ang-2 and its receptors AT1 and AT2. Therefore, examining the enzymes of this axis can provide us with useful information in interventional research. Sports training programs are one of the basic elements in cardiac rehabilitation in patients with HF. In this regard, Tucker et al. reported in a meta-analysis of studies registered from 2007 to 2017 that moderate-intensity continuous exercise was an effective treatment for left ventricular remodeling in patients with HF who had clinically stable ejection fraction reduction. And improving performance in these patients; however, a research specifically aimed at determining the effect of increasing aerobic endurance training on variables related to blood pressure, especially the levels of Ang-1 and Ang-2 enzymes, as well as angiotensin-converting enzyme-2 (ACE-2) as one of the regulating enzymes Blood pressure was not done, which shows the necessity of the present research. According to the above, the aim of this study was to determine the effect of progressive aerobic continuous training on Ang-1, Ang-2 enzymes and ACE-2 in patients with heart failure.
Methods: In the present semi-experimental study, 20 men with heart failure referred to the Cardiac Rehabilitation Center of Imam Khomeini Hospital in Ahvaz were selected by snowball sampling method. Randomly were divided into 2 groups of 10 people including progressive aerobic continuous training group (mean age: 47.5 ± 7.84; body mass index: 29.27 ± 1.99) and control group (mean age: 48.8 ± 8.03; body mass index 26.93 ± 2.14). The training intervention consisted of eight weeks of training in three sessions per week. The training program included increasing continuous aerobic exercise with 40-85% of the subjects' reserve heart rate; No training intervention was performed in the control group. Blood variables were measured in fasting 48 hours before and 48 hours after the intervention period. To measure height and weight, the SECA scale and scale made in Germany were used. The blood samples of the patients were taken fasting and after blood pressure test. Enzyme-linked immunosorbent assay (ELISA) technique and Hangzhou Eastbiopharm kits were used to measure Ang I, Ang II and ACE-2 proteins. Dependent t-test and analysis of covariance were used for statistical analysis of the obtained data. Statistical analysis was performed using SPSS software version 26 and a significance level of P <0.05 was considered.
Results: The results of analysis of covariance test showed that after the intervention period of progressive aerobic continuous training, there were a significant increase in the level of Ang-1 (P < 0.001) and a significant decrease in the levels of Ang-2 (P < 0.001) and ACE-2 (P < 0.001) in the training group compared to the control group.
Conclusion: The results of the current research showed that after the intervention period, progressive aerobic continuous training caused a significant decrease in the levels of Ang-2 and a significant increase in the levels of Ang-1 and ACE-2. The renin-angiotensin system (RAS) plays an important role in cardiovascular physiology by regulating blood pressure and electrolyte balance. RAS is mainly regulated by both angiotensin-converting enzyme (ACE) and angiotensin-converting enzyme type 2 (ACE2). The classic ACE enzyme converts Ang I to Ang-2. In previous studies, it has been reported that ACE and Ang-2 levels increase in high blood pressure and increased afterload on the heart. Therefore, participating in aerobic activities in order to rehabilitate the heart can reduce the afterload on the heart and reduce blood pressure and Ang-2. Considering that exercise improves the sensitivity of baroreceptors, reduces stress and anxiety of Post HF patients, and reduces sympathetic activity. Considering the Ang-(1-7)/ACE2/Mas axis as a mechanism that balances the vasoconstrictor effects of the classical RAS, which includes renin, ACE, Ang-2 and its receptors AT1 and AT2; It seems that in Post HF patients, the reduction of ACE-2 to ACE ratio (ACE-2/ACE) is a more important factor that can moderate high blood pressure and heart complications caused by high blood pressure levels in HF patients; In our previous research, a significant decrease in systolic blood pressure and resting heart rate was observed in the exercise group compared to the control group; This improvement can be attributed to chronic cardiovascular adaptation to continuous aerobic exercise, including the increase of ACE2 and the decrease of Ang-2 compared to Ang-. According to the results of the present research, it can be said that rehabilitation exercises based on progressive aerobic continuous training through increasing ACE2 can modulate the renin-angiotensin system and reduce Ang-2 compared to Ang-1, and through the Ang-(1-7)/ ACE2/Mas can modulate blood pressure and reduce cardiovascular complications in patients with HF. It is likely that aerobic exercise regulates the local (cardiac) RAS to switch the ACE-Ang II-AT1R axis to the ACE2-Ang (1-7)-Mas receptor axis, And this setting inhibits cardiac regeneration in HF. which can probably justify the improvement of blood pressure and cardiovascular function in patients with HF.
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