ABC | Volume 110, Nº5, May 2018

Original Article Safety and Efficacy of Aerobic Exercise Training Associated to Non‑Invasive Ventilation in Patients with Acute Heart Failure Mayron F. Oliveira, 1,2 Rita C. Santos, 1 Suellen A. Artz, 1 Vanessa M. F. Mendez, 1 Denise M. L. Lobo, 1,3 Edileide B. Correia, 1 Almir S. Ferraz, 1 Iracema I. K. Umeda, 1 Priscila A. Sperandio 1 Instituto Dante Pazzanese de Cardiologia, 1 São Paulo, SP; Universidade de Fortaleza (UNIFOR) - Centro de Ciências da Saúde, 2 Faculdade Metropolitana da Grande Fortaleza (FAMETRO), 3 Fortaleza, CE – Brazil Mailing Address: Mayron Faria Oliveira • Avenida Dr. Dante Pazzanese, 500. CEP 04012-180, Vila Mariana, São Paulo, SP – Brazil E-mail: mayronfaria@hotmail.com Manuscript received July 25, 2017, revised manuscript September 27, 2017, accepted October 11, 2017 DOI: 10.5935/abc.20180039 Abstract Background: Exercise training (ET) improves functional capacity in chronic heart failure (HF). However, ET effects in acute HF are unknown. Objective: To investigate the effects of ET alone or combined with noninvasive ventilation (NIV) compared with standard medical treatment during hospitalization in acute HF patients. Methods: Twenty-nine patients (systolic HF) were randomized into three groups: control (Control - only standard medical treatment); ET with placebo NIV (ET+Sham) and ET+NIV (NIV with 14 and 8 cmH 2 O of inspiratory and expiratory pressure, respectively). The 6MWT was performed on day 1 and day 10 of hospitalization and the ET was performed on an unloaded cycle ergometer until patients’ tolerance limit (20 min or less) for eight consecutive days. For all analyses, statistical significance was set at 5% (p < 0.05). Results: None of the patients in either exercise groups had adverse events or required exercise interruption. The 6MWT distance was greater in ET+NIV (∆120 ± 72 m) than in ET+Sham (∆73 ± 26 m) and Control (∆45 ± 32 m; p < 0.05). Total exercise time was greater (128 ± 10 vs. 92 ± 8 min; p < 0.05) and dyspnea was lower (3 ± 1 vs. 4 ± 1; p < 0.05) in ET+NIV than ET+Sham. The ET+NIV group had a shorter hospital stay (17 ± 10 days) than ET+Sham (23 ± 8 days) and Control (39 ± 15 days) groups (p < 0.05). Total exercise time in ET+Sham and ET+NIV had significant correlation with length of hospital stay (r = –0.75; p = 0.01). Conclusion: Exercise training in acute HF was safe, had no adverse events and, when combined with NIV, improved 6MWT and reduce dyspnea and length of stay. (Arq Bras Cardiol. 2018; 110(5):467-475) Keywords: Exercise; Acute Heart Failure; Non-Invasive Ventilation; Physiotherapy; Rehabilitation. Introduction Heart failure (HF) is a complex syndrome characterized by reduced left ventricular function, skeletal myopathy and exercise intolerance. 1,2 Previous studies have shown evidences that exercise training (ET) can be an effective non‑pharmacological intervention for patients with chronic HF. 3-6 However, periods of acute/decompensated HF may occur, which represent the most frequent cause of hospitalization, 7 leading to long periods of bed rest and sarcopenia 8,9 and, consequently, complications during hospitalization. Acute HF patients show worsening pulmonary congestion, dyspnea, increased respiratory effort, exercise intolerance 10 and frequently, decreased alveolar ventilation, which results in blood shunting and hypoxemia. 11 In this context, noninvasive ventilation (NIV) has been widely used in acute HF cases to reduce dyspnea and improve oxygenation. 12,13 In addition, patients with chronic HF have displayed a progressive reduction in functional capacity and decreased exercise tolerance compared to healthy individuals, due to both cardiac disease and peripheral factors (endothelial dysfunction, inflammation, and increased neurohormonal activation). 14,15 Moreover, it has been already demonstrated that exercise with NIV in chronic HF increases exercise tolerance and reduces dyspnea and leg effort. 16,17 Several studies have shown that early exercise after admission can benefit critical patients in the intensive care unit 18,19 and patients with chronic obstructive pulmonary disease exacerbations. 20,21 These studies showed a reduction in length of stay and rehospitalization, as well as improved quality of life. However, ET in acute HF patients has been contraindicated and there have been no studies to evaluate the effects of cardiac rehabilitation on acute/ decompensated HF. Thus, despite extensively documented evidence regarding the benefits of exercise 5,22 and NIV combined with exercise 16 in chronic HF patients, the safety and effectiveness of aerobic ET in acute HF patients remains unknown. 467