A meta-analysis of the effects of exercise training on left ventricular remodeling following myocardial infarction: start early and go longer for greatest exercise benefits on remodeling

Mark Haykowsky, Jessica Scott, Ben Esch, Don Schopflocher, Jonathan Myers, Ian Paterson, Darren Warburton, Lee Jones, Alexander M Clark, Mark Haykowsky, Jessica Scott, Ben Esch, Don Schopflocher, Jonathan Myers, Ian Paterson, Darren Warburton, Lee Jones, Alexander M Clark

Abstract

Background: The effects of variations in exercise training on left ventricular (LV) remodeling in patients shortly after myocardial infarction (MI) are important but poorly understood.

Methods: Systematic review incorporating meta-analysis using meta-regression. Studies were identified via systematic searches of: OVID MEDLINE (1950 to 2009), Cochrane Central Register of Controlled Trials (1991 to 2009), AMED (1985 to 2009), EMBASE (1988 to 2009), PUBMED (1966 to 2009), SPORT DISCUS (1975 to 2009), SCOPUS (1950 to 2009) and WEB OF SCIENCE (1950 to 2009) using the medical subject headings: myocardial infarction, post myocardial infarction, post infarction, heart attack, ventricular remodeling, ventricular volumes, ejection fraction, left ventricular function, exercise, exercise therapy, kinesiotherapy, exercise training. Reference lists of all identified studies were also manually searched for further relevant studies. Studies selected were randomized controlled trials of exercise training interventions reporting ejection fraction (EF) and/or ventricular volumes in patients following recent MI (≤ 3 months) post-MI patients involving control groups. Studies were excluded if they were not randomized, did not have a 'usual-care' control (involving no exercise), evaluated a non-exercise intervention, or did not involve human subjects. Non-English studies were also excluded.

Results: After screening of 1029 trials, trials were identified that reported EF (12 trials, n = 647), End Systolic Volumes (ESV) (9 trials, n = 475) and End Diastolic Volumes (EDV) (10 trials, n = 512). Meta-regression identified that changes in EF effect size difference decreased as the time between MI and initiation of the exercise program lengthened, and increased as the duration of the program increased (Q = 25.48, df = 2, p < 0.01, R2 = 0.76). Greater reductions in ESV and EDV (as indicated by effect size decreases) occurred with earlier initiation of exercise training and with longer training durations (ESV: Q = 23.89, df = 2, p < 0.05, R2 = 0.79; EDV: Q = 27.42, df = 2, p < 0.01, R2 = 0.83). Differences remained following sensitivity analysis. Each week that exercise was delayed required an additional month of training to achieve the same level of benefit on LV remodeling.

Conclusions: Exercise training has beneficial effects on LV remodeling in clinically stable post-MI patients with greatest benefits occurring when training starts earlier following MI (from one week) and lasts longer than 3 months.

Figures

Figure 1
Figure 1
Flow of trials through the selection process.
Figure 2
Figure 2
EF effect size difference for individual trials categorized by time to exercise training and duration of training program.
Figure 3
Figure 3
ESV effect size difference for individual trials categorized by time to exercise training and duration of training program.
Figure 4
Figure 4
EDV effect size difference for individual trials categorized by time to exercise training and duration of training program.

References

    1. O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS, Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80:234–244.
    1. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA. 1988;260:945–950. doi: 10.1001/jama.260.7.945.
    1. Chow CK, Jolly S, Rao-Melacini P, Fox KAA, Anand SS. Association of Diet, Exercise, and Smoking Modification With Risk of Early Cardiovascular Events After Acute Coronary Syndromes. Circulation. 2010;121:750–758. doi: 10.1161/CIRCULATIONAHA.109.891523.
    1. White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wild CJ. Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction. Circulation. 1987;76:44–51.
    1. Giallauria F, Cirillo P, Lucci R, Pacileo M, De Lorenzo A, D'Agostino M, Moschella S, Psaroudaki M, Del Forno D, Orio F. et al.Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain natriuretic peptide. Eur J Cardiovasc Prev Rehabil. 2008;15:113–118. doi: 10.1097/HJR.0b013e3282f00990.
    1. Giallauria F, Galizia G, Lucci R, D'Agostino M, Vitelli A, Maresca L, Orio F, Vigorito C. Favourable effects of exercise-based Cardiac Rehabilitation after acute myocardial infarction on left atrial remodeling. Int J Cardiol. 2009;136:300–306. doi: 10.1016/j.ijcard.2008.05.026.
    1. Giannuzzi P, Temporelli PL, Corra U, Gattone M, Giordano A, Tavazzi L. Attenuation of unfavorable remodeling by exercise training in postinfarction patients with left ventricular dysfunction: results of the Exercise in Left Ventricular Dysfunction (ELVD) trial. Circulation. 1997;96:1790–1797.
    1. Jugdutt BI, Michorowski BL, Kappagoda CT. Exercise training after anterior Q wave myocardial infarction: importance of regional left ventricular function and topography. J Am Coll Cardiol. 1988;12:362–372. doi: 10.1016/0735-1097(88)90407-X.
    1. Kubo N, Ohmura N, Nakada I, Yasu T, Katsuki T, Fujii M, Saito M. Exercise at ventilatory threshold aggravates left ventricular remodeling in patients with extensive anterior acute myocardial infarction. Am Heart J. 2004;147:113–120. doi: 10.1016/S0002-8703(03)00521-0.
    1. Giannuzzi P, Tavazzi L, Temporelli PL, Corra U, Imparato A, Gattone M, Giordano A, Sala L, Schweiger C, Malinverni C. Long-term physical training and left ventricular remodeling after anterior myocardial infarction: results of the Exercise in Anterior Myocardial Infarction (EAMI) trial. EAMI Study Group. J Am Coll Cardiol. 1993;22:1821–1829. doi: 10.1016/0735-1097(93)90764-R.
    1. Dubach P, Myers J, Dziekan G, Goebbels U, Reinhart W, Vogt P, Ratti R, Muller P, Miettunen R, Buser P. Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction: application of magnetic resonance imaging. Circulation. 1997;95:2060–2067.
    1. Giallauria F, De Lorenzo A, Pilerci F, Manakos A, Lucci R, Psaroudaki M, D'Agostino M, Del Forno D, Vigorito C. Reduction of N terminal-pro-brain (B-type) natriuretic peptide levels with exercise-based cardiac rehabilitation in patients with left ventricular dysfunction after myocardial infarction. Eur J Cardiovasc Prev Rehabil. 2006;13:625–632. doi: 10.1097/01.hjr.0000209810.59831.f4.
    1. Giallauria F, Lucci R, De Lorenzo A, D'Agostino M, Del Forno D, Vigorito C. Favourable effects of exercise training on N-terminal pro-brain natriuretic peptide plasma levels in elderly patients after acute myocardial infarction. Age Ageing. 2006;35:601–607. doi: 10.1093/ageing/afl098.
    1. Koizumi T, Miyazaki A, Komiyama N, Sun K, Nakasato T, Masuda Y, Komuro I. Improvement of left ventricular dysfunction during exercise by walking in patients with successful percutaneous coronary intervention for acute myocardial infarction. Circ J. 2003;67:233–237. doi: 10.1253/circj.67.233.
    1. Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM. A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed. J Am Coll Cardiol. 2007;49:2329–2336. doi: 10.1016/j.jacc.2007.02.055.
    1. Glasziou P, Chalmers I, Altman DG, Bastian H, Boutron I, Brice A, Jamtvedt G, Farmer A, Ghersi D, Groves T. et al.Taking healthcare interventions from trial to practice. BMJ. 2010;341:c3852. doi: 10.1136/bmj.c3852.
    1. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12. doi: 10.1016/0197-2456(95)00134-4.
    1. Lipsey M, Wilson D. Practical meta-analysis. Sage Publications, Thousand Oaks, Ca; 2001.
    1. Jette M, Heller R, Landry F, Blumchen G. Randomized 4-week exercise program in patients with impaired left ventricular function. Circulation. 1991;84:1561–1567.
    1. Heldal M, Rootwelt K, Sire S, Dale J. Short-term physical training reduces left ventricular dilatation during exercise soon after myocardial infarction. Scand Cardiovasc J. 2000;34:254–260. doi: 10.1080/713783109.
    1. Grodzinski E, Jette M, Blumchen G, Borer J. Effects of a four-week training program on left ventricular function as assessed by radionuclide ventriculography. J Cardiopulmonary Rehabil. 1987;7:517–524.
    1. Ioannidis JPA, Patsopoulos NA, Evangelou E. Uncertainty in heterogeneity estimates in meta-analyses. BMJ. 2007;335:914–916. doi: 10.1136/bmj.39343.408449.80.
    1. Jugdutt BI. Prevention of ventricular remodelling post myocardial infarction: timing and duration of therapy. Can J Cardiol. 1993;9:103–114.
    1. Ehsani AA, Biello DR, Schultz J, Sobel BE, Holloszy JO. Improvement of left ventricular contractile function by exercise training in patients with coronary artery disease. Circulation. 1986;74:350–358.
    1. Belardinelli R, Georgiou D, Ginzton L, Cianci G, Purcaro A. Effects of moderate exercise training on thallium uptake and contractile response to low-dose dobutamine of dysfunctional myocardium in patients with ischemic cardiomyopathy. Circulation. 1998;97:553–561.
    1. Dubach P, Myers J, Dziekan G, Goebbels U, Reinhart W, Muller P, Buser P, Stulz P, Vogt P, Ratti R. Effect of high intensity exercise training on central hemodynamic responses to exercise in men with reduced left ventricular function. J Am Coll Cardiol. 1997;29:1591–1598. doi: 10.1016/S0735-1097(97)82540-5.
    1. Malfatto G, Facchini M, Bragato R, Branzi G, Sala L, Leonetti G. Short and long term effects of exercise training on the tonic autonomic modulation of heart rate variability after myocardial infarction. Eur Heart J. 1996;17:532–538.
    1. Vona M, Rossi A, Capodaglio P, Rizzo S, Servi P, De Marchi M, Cobelli F. Impact of physical training and detraining on endothelium-dependent vasodilation in patients with recent acute myocardial infarction. Am Heart J. 2004;147:1039–1046. doi: 10.1016/j.ahj.2003.12.023.
    1. Suaya JA, Stason WB, Ades PA, Normand SL, Shepard DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009;54:25–33. doi: 10.1016/j.jacc.2009.01.078.
    1. Piepoli M, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler A, Schmid J. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: Key components of the position paper from the CardiacRehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010;31:1967–1976.
    1. Dafoe W, Arthur H, Stokes H, Morrin L, Beaton L. Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation. Can J Cardiol. 2006;22:905–911.
    1. Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med. 2005;143:659–672.
    1. Kovoor P, Lee AK, Carrozzi F, Wiseman V, Byth K, Zecchin R, Dickson C, King M, Hall J, Ross DL. et al.Return to full normal activities including work at two weeks after acute myocardial infarction. Am J Cardiol. 2006;97:952–958. doi: 10.1016/j.amjcard.2005.10.040.
    1. Senaratne MP, Smith G, Gulamhusein SS. Feasibility and safety of early exercise testing using the Bruce protocol after acute myocardial infarction. J Am Coll Cardiol. 2000;35:1212–1220. doi: 10.1016/S0735-1097(00)00545-3.
    1. Parker k, Hauer T, Arena R, Lundberg D, Aggarwal S, Goodhart D, D. T. Attendance in an early discharge clinic with symptom limited maximal exercise testing is safe and improves cardiac rehabilitation participation among low-risk stemi patients. Eur J Cardiovasc Prev Rehabil. 2009;16
    1. Clark AM, Hartling L, Vandermeer B, McAlister FA. Secondary prevention program for patients with coronary artery disease: A meta-analysis of randomized control trials. Ann Int Med. 2005;143:659–672.
    1. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone J, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682–692. doi: 10.1016/j.amjmed.2004.01.009.
    1. Kotseva K, D W, De Backer G, De Bacquer D, Pyörälä K, Keil U. ftESG. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet. 2009;373:929–940. doi: 10.1016/S0140-6736(09)60330-5.
    1. Bjarnason-Wehrens B, McGee H, Zwisler AD, Piepoli MF, Benzer W, Schmid JP, Dendale P, Pogosova NG, Zdrenghea D, Niebauer J. et al.Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey. Eur J Cardiovasc Prev Rehabil. 2010;17:410–418. doi: 10.1097/HJR.0b013e328334f42d.
    1. Dalal HM, Zawada A, Jolly K, Moxham T, Taylor RS. Home-based versus centre based cardiac rehabiltiation: Cochrane systematic review and meta-analysis. BMJ. 2010;340:b5631.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner