Letter by Kambic et al Regarding Article, “A Randomized, Controlled Trial of Resistance Training Added to Caloric Restriction Plus Aerobic Exercise Training in Obese Heart Failure With Preserved Ejection Fraction”

HomeCirculation: Heart FailureVol. 16, No. 5Letter by Kambic et al Regarding Article, "A Randomized, Controlled Trial of Resistance Training Added to Caloric Restriction Plus Aerobic Exercise Training in Obese Heart Failure With Preserved Ejection Fraction" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Kambic et al Regarding Article, "A Randomized, Controlled Trial of Resistance Training Added to Caloric Restriction Plus Aerobic Exercise Training in Obese Heart Failure With Preserved Ejection Fraction" Tim Kambic, Frank Edelmann and Mitja Lainscak Tim KambicTim Kambic https://orcid.org/0000-0003-3571-7928 Cardiac Rehabilitation Unit and Department of Research and Education (T.K.), General Hospital Murska Sobota, Slovenia. , Frank EdelmannFrank Edelmann Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Germany (F.E.). DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany (F.E.). Berlin Institute of Health, Germany (F.E.). and Mitja LainscakMitja Lainscak Division of Cardiology (M.L.), General Hospital Murska Sobota, Slovenia. Faculty of Medicine, University of Ljubljana, Slovenia (M.L.). Originally published18 Apr 2023https://doi.org/10.1161/CIRCHEARTFAILURE.122.010401Circulation: Heart Failure. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 18, 2023: Ahead of Print To the Editor:Cardiac rehabilitation guideline recommendations1 and position statement documents2 penetrate clinical practice to a different extent, with resistance training (RT) being more at the lower end. In this context, the trial by Brubaker et al,3 which investigated the potential of RT on top of aerobic training and caloric restriction in heart failure with preserved ejection fraction is an important contribution to our understanding of rehabilitation structure, modalities, and duration.Generally viewed, RT is suggested as a constituent part of cardiac rehabilitation to improve various outcomes provided it is feasible within the rehabilitation facility.1,2,4 However, this was not replicated in the present trial,3 where the authors reported no additional benefits of RT on maximal aerobic capacity and lower limb muscle strength, and quality of life after 20 weeks of training. There can be many reasons for such observations and we would like to spotlight some of them. The authors used standard in-run phase of (very) low-load–RT (1 set of 8–12 repetitions/set at the intensity of 20%–30% of 1 repetition maximum [1-RM]) followed by a progressive low-load-to moderate load–RT (2 sets of 8–12 repetitions/set at the intensity of 40%–50% of 1-RM]) from 4th to 20th week. The loading of RT (number of sets and repetitions and training load) seems suboptimal and could potentially influence the muscle strength and hypertrophy outcomes. We think that the authors should be more ambitious in the training progression (eg, repetitions per set), especially after the in-run phase. To better apply available evidence at the time of the study,4 more optimal loading at the intensity of 40% to 50% of 1-RM would correspond to >20 repetitions (according to load-repetition relationship for RT),4 which is significantly more than delivered by the study protocol.3 Despite using multiple resistance exercises for upper and lower limbs, we also believe that extending the progression of RT to the upper end of moderate load–RT (50%–60% of 1-RM)4 or even to high-load–RT (>70% of 1-RM)2,4 could have provided additional muscle gains, especially since all patients tolerated baseline maximal efforts on isokinetic dynamometry. We understand the fear of potential oscillations in heart rate and blood pressure with high-load–RT (70%–80% of 1-RM), but this may not be substantiated anymore as recent studies in patients with coronary artery disease have demonstrated lower acute hemodynamic increase during exercise2 and a greater increase in muscle strength after 12 weeks5 when compared with low-load–RT. Although the exercise was relatively high (82%),3 we still think that the total load accumulated during cardiac rehabilitation was insufficient to elicit intervention superiority over aerobic training and caloric restriction alone.Although the study by Brubaker et al3 does not provide superior evidence for RT in heart failure with preserved ejection fraction, this should not discourage clinicians from adding RT into their cardiac rehabilitation structure for heart failure with preserved ejection fraction, especially for older, often sarcopenic or frail patients to increase physical activity. Rather, we should reconsider the RT structure, progression, and intensity, which should be addressed in future trials, with greater participation of male patients with heart failure with preserved ejection fraction.Article InformationSources of FundingThe study was supported by a research fellowship grant (630-72/2019-1) received by T. Kambic from the Slovenian Research Agency. Dr Lainscak is funded by the Slovenian Research Agency (grant J3-9292, Burden of cachexia and sarcopenia in patients with chronic diseases: epidemiology, pathophysiology, and outcomes; and grant J3-9284, Epidemiology, pathophysiology, and clinical relevance of anemia in chronic cardiopulmonary patients).Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 460.References1. Ambrosetti M, Abreu A, Corrà U, Davos CH, et al. Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary prevention and rehabilitation section of the European Association of Preventive Cardiology.Eur J Prev Cardiol. 2021; 28:460–495. doi: 10.1177/2047487320913379CrossrefMedlineGoogle Scholar2. Hansen D, Abreu A, Doherty P, Völler H. Dynamic strength training intensity in cardiovascular rehabilitation: is it time to reconsider clinical practice? A systematic review.Eur J Prev Cardiol. 2019; 26:1483–1492. doi: 10.1177/2047487319847003CrossrefMedlineGoogle Scholar3. Brubaker PH, Nicklas BJ, Houston DK, Hundley WG, Chen H, Molina AJA, Lyles WM, Nelson B, Upadhya B, Newland R, et al. A randomized, controlled trial of resistance training added to caloric restriction plus aerobic exercise training in obese heart failure with preserved ejection fraction.Circ Hear Fail. 2022; 16:xx–xx. doi: 10.1161/CIRCHEARTFAILURE.122.010161LinkGoogle Scholar4. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA, Gulanick M, Laing ST, Stewart KJ; American Heart Association Council on Clinical Cardiology. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association council on clinical cardiology and council on nutrition, physical activity, and metabolism.Circulation. 2007; 116:572–584. doi: 10.1161/CIRCULATIONAHA.107.185214LinkGoogle Scholar5. Kambic T, Šarabon N, Hadžić V, Lainščak M. Effects of high-load and low-load resistance training in patients with coronary artery disease: a randomized controlled clinical trial.Eur J Prev Cardiol. 2022; 29:e338. doi: 10.1093/eurjpc/zwac063CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2023Vol 16, Issue 5 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.122.010401PMID: 37070433 Originally publishedApril 18, 2023 PDF download Advertisement SubjectsAgingDiet and NutritionExerciseObesity