Impacto do exercício físico combinado na função diastólica de pacientes com insuficiência cardíaca e fração de ejeção reduzida
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Data
2016-02-25
Autores
Valadão, Tainá Fabri Carneiro [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
Os efeitos favoráveis de um programa de exercício físico combinado (EFC) em pacientes com insuficiência cardíaca (IC) e fração de ejeção ventricular esquerda reduzida (FEVER) são bem reconhecidos na literatura. Acredita-se que os efeitos benéficos do EF não se devam à melhora da FEVE. Por outro lado, alguns estudos apontaram para efeitos benéficos do EF na função diastólica do VE. Tendo em vista a importância da pressão de enchimento do VE na sintomatologia dos pacientes com IC, levantou-se a hipótese de que de que um programa de EFC e supervisionado é capaz de promover melhora na função diastólica em pacientes com IC com FEVE < 50%, e que esse efeito está associado à diminuição dos sintomas, refletindo em melhora da CF e da QV nesses pacientes. Objetivos: avaliar o efeito do EFC na função diastólica de pacientes com IC de FEVE reduzida e investigar se a melhora na função diastólica é fator associado à melhora dos sintomas, capacidade funcional e qualidade de vida desses pacientes. Metodologia: trata-se de um ensaio clínico prospectivo, randomizado e controlado, que incluiu pacientes com IC e FEVE <50%, acima de 18 anos. A amostra foi composta por 42 pacientes, distribuídos em 2 grupos pareados por idade e sexo: grupo controle (GC) n=20 - submetidos à prescrição já realizada nas consultas de rotina para prática de atividade física regular não supervisionada. Grupo intervenção (GI) n=22 - submetidos a um programa de exercício físico supervisionado composto por exercício aeróbico complementado por exercício de força 3 vezes por semana por 12 semanas. Os pacientes dos dois grupos foram submetidos inicialmente e após 12 semanas de pesquisa à avaliação clínica e física, teste de caminhada de 12 minutos, ecocardiograma transtorácico, avaliação do controle autonômico cardíaco e avaliação da QV. Análise estatística: Foi realizado teste “t” dos resultados das diferenças entre os momentos pós e pré protocolo comparando os dois grupos, ou de Mann Whitney para dados com distribuição não normal. Foi utilizado testes de correlação para associações de variáveis do mesmo grupo. Resultados: Em relação às variáveis clínicas, apenas a pressão arterial sistêmica no GI (p=0,022) apresentou diferença significativa em relação ao GC. Durante a avaliação inicial do estudo, o sintoma de dispneia estava presente em 60% no GC e 45% no GI, p=0,72, e dor torácica 30% no GC e 22% no GI, p=0,36. Ao final da pesquisa, tanto o sintoma de dispneia (10% no GI e 53% no GC, p=0,01) como de dor torácica (0,0% no GI e 20% no GC, p=0,02) diminuíram significativamente no GI e não se modificaram no GC. Em relação às variáveis ecocardiográficas morfofuncionais, foi observada diferença significativa apenas na variável fração de ejeção (p=0.049) no GI ao final do protocolo de pesquisa. Os voluntários do GI apresentaram melhora na CF, avaliada pelo VO2 de pico em METS em relação ao GC ao final do estudo (p=0,001). Ao término do protocolo, houve melhora significativa em quatro das oito dimensões do questionário de QV no GI em relação ao GC: Capacidade funcional (p<0,001), limitação física (p=<0,001), estado geral de saúde (p<0,001) e vitalidade (p<0,001). Também foi observada relação positiva entre a CF e três dimensões avaliadas no questionário SF-36: vitalidade (R=0,459, R2= 0,211 e P= 0,036), aspectos sociais (R= 0,510, R2= 0,260 e P= 0,018) e limitações por aspectos emocionais (R= 0,529, R2= 0,279 e P= 0,014). Em relação às análises do domínio de variabilidade de frequência cardíaca (VFC), foi observada melhora do componente parassimpático (banda de alta frequência em unidades normalizadas; p=0,016) e redução na banda de baixa frequência em unidades normalizadas no GI após o programa de exercício (p= 0,036) em ortostatia. O GC apresentou 3 pacientes com desfechos desfavoráveis (1 paciente com mortalidade cardiovascular e 2 pacientes com recém diagnosticada fibrilação atrial) e o GI não apresentou desfechos desfavoráveis ao longo do protocolo. (p=0,058). Discussão e Conclusão: Um programa de EFC supervisionado de 12 semanas em pacientes com ICFER é capaz de promover impacto favorável na sintomatologia, pressão arterial, tolerância ao exercício e QV, que independe de alterações morfofuncionais cardíacas. A função diastólica não parece ser fator principal nesses benefícios promovidos pelo exercício. O GI, submetido a programa de exercício físico combinado, teve tendência a menor número de desfechos desfavoráveis nesse período de protocolo, quando comparado ao Grupo Controle.
The favorable effects of a combined exercise program (CEP) in patients with heart failure (HF) and reduced left ventricular ejection fraction (RLVE) are well recognized in the literature. There is consensus that physical exercise (PE) improves quality of life (QOL) and functional capacity (FC) in patients with HF. It is believed that the beneficial effects of PE are not due to the improvement of LVEF. On the other hand, some studies indicated beneficial effects of PE on LV diastolic function. Given the importance of LV filling pressure in symptoms of HF patients, the hypothesis of this study was that an CEP supervised program should promote improvement in diastolic function in patients with HF with LVEF <50% and this effect may be associated with decreased symptoms, reflecting improvement in FC and QOL in these patients. Objective: evaluate the effect of ECF in diastolic function in patients with reduced LVEF IC and investigate whether the improvement in diastolic function is r associated with improvement in symptoms, functional capacity and quality of life of these patients. Methodology: Prospective clinical trial, randomized and controlled, which included patients with HF and LVEF <50%, above 18 years. The sample consisted of 42 patients, divided into two groups matched for age and sex: the control group (CG) n = 20 - submitted to prescription in clinical practice of regular physical activity, not supervised. Intervention group (IG) n = 22 - underwent a physical exercise program supervised composed of aerobic exercise supplemented by resistance exercise 3 times a week for 12 weeks. Patients in both groups were initially submitted and after 12 weeks of research to clinical and physical evaluation, 12-minute walk test, transthoracic echocardiography, assessment of cardiac autonomic control and QoL questionary. Statistical analysis: test "t" was performed of the results of the differences between after and before moments of protocol comparing the two groups, or Mann Whitney test for data with non-normal distribution. Correlation test was used for variable associations of the same group. Results: In relation to clinical variables, only the blood pressure in IG (p = 0.022) showed a significant difference to the CG.). During the initial evaluation of the study, the dyspnea symptom was present in 60% in the control group and 45% in IG, p = 0.72, and chest pain 30% in CG and 22% in IG, p = 0.36. At the end of the study, both the symptom of dyspnea (10% in IG and 53% in the control group, p = 0.01) and chest pain (0.0% in IG and 20% in the control group, p = 0.02) decreased significantly in IG and did not change in the CG. Regarding the morphological and functional echocardiographic variables, significant differences were observed only in ejection fraction variable (p = 0.049) in IG at the end of the research protocol. Patients of IG showed improvement in FC, as measured by peak VO2 in METS compared to CG at the end of the study (p = 0.001). At the end of the protocol, there was significant improvement in four of the eight dimensions of QOL questionnaire in IG compared to CG: physical functioning (p<0.001), physical role functioning (p<0.001), general health perceptions (p<0.001) and vitality (p<0.001). It was also observed positive relationship between the FC and three dimensions evaluated in the SF-36 questionnaire: vitality (R=0,459, R2= 0,211 e P= 0,036), social role functioning (R= 0,510, R2= 0,260 e P= 0,018) and emotional role functioning (R= 0,529, R2= 0,279 e P= 0,014). Regarding the analysis of heart rate variability domain (HRV), there was improvement of the parasympathetic component (high-frequency band in normalized units; p = 0.016) and reduction in the low frequency band in units normalized in GI after the program exercise (p = 0.036) in orthostatic position. The CG had 3 patients with unfavorable outcomes (1 patient with cardiovascular mortality and 2 patients with newly diagnosed atrial fibrillation) and IG group did not course with unfavorable outcomes during the protocol. (p = 0.058). Discussion and Conclusion: CEP program supervised for 12 weeks in patients with HFREF is able to promote favorable impact on symptoms, blood pressure, exercise tolerance and QOL, which is independent of heart morphological changes. Diastolic function is not the main responsible for these benefits promoted by the exercise. The IG group, tended to less unfavorable outcomes in this protocol period, when compared to the control group.
The favorable effects of a combined exercise program (CEP) in patients with heart failure (HF) and reduced left ventricular ejection fraction (RLVE) are well recognized in the literature. There is consensus that physical exercise (PE) improves quality of life (QOL) and functional capacity (FC) in patients with HF. It is believed that the beneficial effects of PE are not due to the improvement of LVEF. On the other hand, some studies indicated beneficial effects of PE on LV diastolic function. Given the importance of LV filling pressure in symptoms of HF patients, the hypothesis of this study was that an CEP supervised program should promote improvement in diastolic function in patients with HF with LVEF <50% and this effect may be associated with decreased symptoms, reflecting improvement in FC and QOL in these patients. Objective: evaluate the effect of ECF in diastolic function in patients with reduced LVEF IC and investigate whether the improvement in diastolic function is r associated with improvement in symptoms, functional capacity and quality of life of these patients. Methodology: Prospective clinical trial, randomized and controlled, which included patients with HF and LVEF <50%, above 18 years. The sample consisted of 42 patients, divided into two groups matched for age and sex: the control group (CG) n = 20 - submitted to prescription in clinical practice of regular physical activity, not supervised. Intervention group (IG) n = 22 - underwent a physical exercise program supervised composed of aerobic exercise supplemented by resistance exercise 3 times a week for 12 weeks. Patients in both groups were initially submitted and after 12 weeks of research to clinical and physical evaluation, 12-minute walk test, transthoracic echocardiography, assessment of cardiac autonomic control and QoL questionary. Statistical analysis: test "t" was performed of the results of the differences between after and before moments of protocol comparing the two groups, or Mann Whitney test for data with non-normal distribution. Correlation test was used for variable associations of the same group. Results: In relation to clinical variables, only the blood pressure in IG (p = 0.022) showed a significant difference to the CG.). During the initial evaluation of the study, the dyspnea symptom was present in 60% in the control group and 45% in IG, p = 0.72, and chest pain 30% in CG and 22% in IG, p = 0.36. At the end of the study, both the symptom of dyspnea (10% in IG and 53% in the control group, p = 0.01) and chest pain (0.0% in IG and 20% in the control group, p = 0.02) decreased significantly in IG and did not change in the CG. Regarding the morphological and functional echocardiographic variables, significant differences were observed only in ejection fraction variable (p = 0.049) in IG at the end of the research protocol. Patients of IG showed improvement in FC, as measured by peak VO2 in METS compared to CG at the end of the study (p = 0.001). At the end of the protocol, there was significant improvement in four of the eight dimensions of QOL questionnaire in IG compared to CG: physical functioning (p<0.001), physical role functioning (p<0.001), general health perceptions (p<0.001) and vitality (p<0.001). It was also observed positive relationship between the FC and three dimensions evaluated in the SF-36 questionnaire: vitality (R=0,459, R2= 0,211 e P= 0,036), social role functioning (R= 0,510, R2= 0,260 e P= 0,018) and emotional role functioning (R= 0,529, R2= 0,279 e P= 0,014). Regarding the analysis of heart rate variability domain (HRV), there was improvement of the parasympathetic component (high-frequency band in normalized units; p = 0.016) and reduction in the low frequency band in units normalized in GI after the program exercise (p = 0.036) in orthostatic position. The CG had 3 patients with unfavorable outcomes (1 patient with cardiovascular mortality and 2 patients with newly diagnosed atrial fibrillation) and IG group did not course with unfavorable outcomes during the protocol. (p = 0.058). Discussion and Conclusion: CEP program supervised for 12 weeks in patients with HFREF is able to promote favorable impact on symptoms, blood pressure, exercise tolerance and QOL, which is independent of heart morphological changes. Diastolic function is not the main responsible for these benefits promoted by the exercise. The IG group, tended to less unfavorable outcomes in this protocol period, when compared to the control group.
Descrição
Palavras-chave
Reabilitação cardiovascular, Pressão de enchimento do ventrículo esquerdo, Disfunção sistólica do ventrículo esquerdo, Qualidade de vida, Capacidade funcional, Cardiovascular Rehabilitation, Left ventricle filling pressure, Systolic left ventricular dysfunction, Quality of life, Functional capacity