Zusammenfassung
Körperliches Training bei stabiler chronischer Herzinsuffizienz ist neben pharmakologischen und nichtpharmakologischen Behandlungskonzepten eine in den aktuellen Leitlinien empfohlene und besonders bei eingeschränkter linksventrikulärer (LV) Funktion [“heart failure with reduced ejection fraction“ (HFrEF)] breit akzeptierte Therapieoption. Eine Vielzahl randomisierter Studien zu körperlichem Training bei HFrEF und eine wachsende Zahl von Studien zu Herzinsuffizienz mit erhaltener LV-Funktion [“heart failure with preserved ejection fraction“ (HFpEF)] belegen, dass die Belastungstoleranz, Symptomatik und Lebensqualität signifikant verbessert werden können. Ursächlich hierfür sind durch körperliches Training induzierte Verbesserungen der zentralen Hämodynamik, der Endothelfunktion, der Inflammation, der neurohumoralen Aktivierung, aber auch der Skelettmuskulatur. HF-ACTION, die größte randomisierte, kontrollierte Studie zu körperlichem Training, zeigte für Patienten mit HFrEF in Abhängigkeit von der Compliance einen positiven Effekt auf Mortalität und Hospitalisierungen. Bei HFpEF fehlen Studien zu den prognostischen Effekten von Training bislang. Neben der Compliance beeinflussen auch die gewählte Trainingsintensität und -modalität die Wirksamkeit von körperlichem Training. So scheinen eine höhere Intensität und ein zusätzlich zum aeroben Ausdauertraining durchgeführtes Krafttraining vorteilhaft zu sein. Individualisierte Trainingskonzepte sollten zukünftig dazu beitragen, eine langfristige Motivation zum körperlichen Training bei Herzinsuffizienz aufrechtzuerhalten.
Abstract
Exercise training in patients with chronic stable heart failure (HF) is a recommended and broadly accepted treatment strategy that is an integral part of an evidence-based management involving pharmacological and non-pharmacological therapies. There is ample scientific evidence that exercise training in HF with reduced (HFrEF) and with preserved ejection fraction (HFpEF) improves exercise capacity, HF symptoms and quality of life. This is due to an improvement of central hemodynamics, endothelial function, neurohumoral activation, skeletal muscle structure and function as well as a decrease in inflammatory markers. The largest randomized, controlled HF-ACTION study (Heart Failure-A Controlled Trial Investigating Outcomes of exercise TraiNing) demonstrated that exercise training results in a modest improvement of all-cause mortality and hospitalizations in HFrEF, depending on adequate compliance. Outcome data in HFpEF are lacking. Besides compliance, efficacy of exercise training is dependent on the intensity and type of exercise. Resistance and high intensity endurance training in addition to a standard aerobic exercise seem to be superior in improving the clinical status of HF patients. In the future, individualized exercise programs will help to improve long-term adherence to exercise training.
Literatur
Arbab-Zadeh A, Dijk E, Prasad A et al (2004) Effect of aging and physical activity on left ventricular compliance. Circulation 110:1799–1805
Arena R, Myers J, Guazzi M (2008) The clinical and research applications of aerobic capacity and ventilatory efficiency in heart failure: an evidence-based review. Heart Fail Rev 13:245–269
Belardinelli R, Georgiou D, Cianci G et al (2012) 10-year exercise training in chronic heart failure: a randomized controlled trial. J Am Coll Cardiol 60:1521–1528
Conraads VM, Beckers P, Vaes J et al (2004) Combined endurance/resistance training reduces NT-proBNP levels in patients with chronic heart failure. Eur Heart J 25:1797–1805
Davies EJ, Moxham T, Rees K et al (2010) Exercise training for systolic heart failure: cochrane systematic review and meta-analysis. Eur J Heart Fail 12:706–715
Downing J, Balady GJ (2011) The role of exercise training in heart failure. J Am Coll Cardiol 58:561–569
Edelmann F, Gelbrich G, Dungen HD et al (2011) Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study. J Am Coll Cardiol 58:1780–1791
Edelmann F, Stahrenberg R, Gelbrich G et al (2011) Contribution of comorbidities to functional impairment is higher in heart failure with preserved than with reduced ejection fraction. Clin Res Cardiol 100:755–764
Edelmann F, Stahrenberg R, Polzin F et al (2011) Impaired physical quality of life in patients with diastolic dysfunction associates more strongly with neurohumoral activation than with echocardiographic parameters: quality of life in diastolic dysfunction. Am Heart J 161:797–804
Flynn KE, Pina IL, Whellan DJ et al (2009) Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 301:1451–1459
Hambrecht R, Fiehn E, Yu J et al (1997) Effects of endurance training on mitochondrial ultrastructure and fiber type distribution in skeletal muscle of patients with stable chronic heart failure. J Am Coll Cardiol 29:1067–1073
Hambrecht R, Gielen S, Linke A et al (2000) Effects of exercise training on left ventricular function and peripheral resistance in patients with chronic heart failure: a randomized trial. JAMA 283:3095–3101
Haykowsky MJ, Timmons MP, Kruger C et al (2013) Meta-analysis of aerobic interval training on exercise capacity and systolic function in patients with heart failure and reduced ejection fractions. Am J Cardiol 111:1466–1469
Isaksen K, Morken IM, Munk PS et al (2012) Exercise training and cardiac rehabilitation in patients with implantable cardioverter defibrillators: a review of current literature focusing on safety, effects of exercise training, and the psychological impact of programme participation. Eur J Prev Cardiol 19:804–812
Ismail H, McFarlane JR, Dieberg G et al (2014) Exercise training program characteristics and magnitude of change in functional capacity of heart failure patients. Int J Cardiol 171:62–65
Keteyian SJ, Leifer ES, Houston-Miller N et al (2012) Relation between volume of exercise and clinical outcomes in patients with heart failure. J Am Coll Cardiol 60:1899–1905
Kitzman DW, Higginbotham MB, Cobb FR et al (1991) Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism. J Am Coll Cardiol 17:1065–1072
Kitzman DW, Little WC, Brubaker PH et al (2002) Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure. JAMA 288:2144–2150
Kraigher-Krainer E, Lyass A, Massaro JM et al (2013) Association of physical activity and heart failure with preserved vs. reduced ejection fraction in the elderly: the Framingham Heart Study. Eur J Heart Fail 15:742–746
Lloyd-Jones D, Adams RJ, Brown TM et al (2010) Heart disease and stroke statistics – 2010 update: a report from the American Heart Association. Circulation 121:e46–e215
Malfatto G, Branzi G, Osculati G et al (2009) Improvement in left ventricular diastolic stiffness induced by physical training in patients with dilated cardiomyopathy. J Card Fail 15:327–333
McMurray JJ, Adamopoulos S, Anker SD et al (2012) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 33:1787–1847
O’Connor CM, Whellan DJ, Lee KL et al (2009) Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 301:1439–1450
Paulus WJ (2010) Culprit mechanism(s) for exercise intolerance in heart failure with normal ejection fraction. J Am Coll Cardiol 56:864–866
Piepoli MF, Conraads V, Corra U et al (2011) Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail 13:347–357
Roveda F, Middlekauff HR, Rondon MU et al (2003) The effects of exercise training on sympathetic neural activation in advanced heart failure: a randomized controlled trial. J Am Coll Cardiol 42:854–860
Stoylen A, Conraads V, Halle M et al (2012) Controlled study of myocardial recovery after interval training in heart failure: SMARTEX-HF—rationale and design. Eur J Prev Cardiol 19:813–821
Swank AM, Horton J, Fleg JL et al (2012) Modest increase in peak VO2 is related to better clinical outcomes in chronic heart failure patients: results from heart failure and a controlled trial to investigate outcomes of exercise training. Circ Heart Fail 5:579–585
Vanhees L, Kornaat M, Defoor J et al (2004) Effect of exercise training in patients with an implantable cardioverter defibrillator. Eur Heart J 25:1120–1126
Wisloff U, Stoylen A, Loennechen JP et al (2007) Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation 115:3086–3094
Preßler A (2013) Training bei Herzinsuffizienz: Intervall oder Ausdauer? Herzmedizin 2:24–30
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Interessenkonflikt. F. Edelmann, V. Grabs und M. Halle geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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F. Edelmann und V. Grabs sind als gleichberechtige Erstautoren anzusehen.
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Edelmann, F., Grabs, V. & Halle, M. Trainingstherapie bei Herzinsuffizienz. Internist 55, 669–675 (2014). https://doi.org/10.1007/s00108-013-3429-y
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DOI: https://doi.org/10.1007/s00108-013-3429-y