ABC | Volume 110, Nº5, May 2018

Original Article Oliveira et al Exercise in acute heart failure Arq Bras Cardiol. 2018; 110(5):467-475 1. Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart failure. Nat Rev Cardiol. 2011; 8(1):30-41. doi: 10.1038/ nrcardio.2010.165. 2. Barretto AC, Santos AC, Munhoz R, Rondon MU, Franco FG, Trombetta IC, et al. Increased muscle sympathetic nerve activity predicts mortality in heart failure patients. Int J Cardiol. 2009;135(3):302-7. doi: 10.1016/j. ijcard.2008.03.056. 3. Negrao CE, Middlekauff HR. Exercise training in heart failure: reduction in angiotensin II, sympathetic nerve activity, and baroreflex control. J Appl Physiol (1985). 2008;104(3):577-8. doi: 10.1152/ japplphysiol.01368.2007. 4. Pina IL, Apstein CS, Balady GJ, Belardinelli R, Chaitman BR, Duscha BD, et al; American Heart Association Committee on exercise, rehabilitation, and prevention. Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation. 2003;107(8):1210-25. doi: https://doi.org/10.1161/01. CIR.0000055013.92097.40. 5. Belardinelli R, Georgiou D, Cianci G, Purcaro A. 10-year exercise training in chronic heart failure: a randomized controlled trial. J Am Coll Cardiol. 2012;60(16):1521-8. doi: 10.1016/j.jacc.2012.06.036. 6. McKelvie RS. Exercise training in patients with heart failure: clinical outcomes, safety, and indications. Heart Fail Rev. 2008;13(1):3-11. doi: 10.1007/s10741-007-9052-z. 7. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):1977-2016. doi: 10.1161/CIRCULATIONAHA.109.192064. 8. Little JP, Phillips SM. Resistance exercise and nutrition to counteract muscle wasting.ApplPhysiolNutrMetab.2009;34(5):817-28.doi:10.1139/H09-093. 9. Corcoran PJ. Use it or lose it--the hazards of bed rest and inactivity. West J Med. 1991;154(5):536-8. PMID: 1866946. References without workload (unloaded exercise). We chose this type of exercise because this is the first protocol of this type in acute HF patients, and the repercussions of the exercise were unknown. Also, we acknowledge that exercise groups performed the protocol during 8 days only, but such period was established based on the mean length of stay in our institution. Further studies on exercise and its main outcomes should be performed including the whole hospitalization period. In fact, this was the first study to perform aerobic exercise training in acute HF, so a reduced exercise protocol duration was necessary to check the viability and safety of aerobic exercise in this patient population. Our study raises new questions regarding exercise in acute HF. Further study protocols must be performed to confirm our data, including clinical outcomes as death and worsening HF, other exercise modalities (inspiratory muscle training, resistive, etc.) and how to perform the aerobic exercise prescription in acute HF, as recently demonstrated in chronic HF. 33 Clinical implications Our study provides evidences of the importance of aerobic exercise during hospitalization in acute HF patients. The findings of safety, reduced length of stay and increased exercise tolerance suggest aerobic exercise training as a new tool for the management of acute HF in combination with standard clinical therapy. Moreover, the enhance of the positive effects of aerobic exercise when combined to NIV, reinforce the relevance of our study, and opens new challenges to investigate the mechanisms of this strategy that contributes to better clinical outcomes in patients with decompensated HF. Conclusion Aerobic exercise is safe, improves the exercise tolerance and reduces hospital stay for decompensated HF patients. Moreover, NIV can enhance the effectiveness of aerobic exercise in these patients. These findings suggest that this simple tool associated with standard clinical therapy may be useful during hospitalization for the management of acute HF. Author contributions Conception and design of the research: Oliveira MF, Ferreira VM, Umeda IIK, Sperandio PA; Acquisition of data: Oliveira MF, Santos RC, Artz SA, Correia EB, Ferraz AS; Analysis and interpretation of the data: Oliveira MF, Santos RC, Artz SA, Ferreira VM, Lobo DML, Correia EB, Ferraz AS, Umeda IIK, Sperandio PA; Statistical analysis: Oliveira MF, Lobo DML; Writing of the manuscript: Oliveira MF, Santos RC, Artz SA, Ferreira VM; Critical revision of the manuscript for intellectual content: Lobo DML, Correia EB, Ferraz AS, Umeda IIK, Sperandio PA. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Instituto Dante Pazzanese de Cardiologia under the protocol number #3911. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 473