Impact of Chronotropic Incompetence and Correlation with Exercise Tolerance in Patients with Implantable Cardiac Devices Undergoing a Phase II Cardiac Rehabilitation Program
Main Article Content
Abstract
Objective: Since patients with implantable cardiac devices tend to develop chronotropic incompetence (CI) associated with the effect of the device itself or the pharmacological effect of the underlying disease, CI could act as a limiting factor in improving exercise tolerance in patients undergoing cardiac rehabilitation program, since an increase in HR is a crucial part in improving cardiac output as a central component of oxygen consumption (VO2). However, it has been observed that there could be other factors contributing to the improvement in exercise tolerance in these patients regardless of the presence of CI. The aim of this research is to clarify the effect of chronotropic incompetence on the improvement in exercise capacity in patients with implantable cardiac devices after a phase II cardiac rehabilitation program (CRP).
Methods: Quasi-experimental study applied to patients with implantable cardiac devices (ICDs, CRT, pacemakers) undergoing a supervised concurrent CRP, lasting 4-6 weeks, at an intensity between 65-80% of heart rate reserve (HRR), associated with kinesiotherapy sessions (with strength and endurance training and other biomotor qualities) and interdisciplinary intervention, education, and counseling. CI was calculated using the chronotropic response index, and METs-load measurement was performed at the beginning and at the end of the intervention.
Results: Forty patients with a mean age of 61.4 years were included, mostly male (29) 72.5%, (23) 57.5% diagnosed with heart failure, and regarding the type of device, pacemakers (20) 50%, implantable cardioverter-defibrillator (ICD) (12) 30%, and cardiac resynchronization therapy with defibrillator (CRT-D) (20) 8%, of the total patients (35) 87.5% presented chronotropic incompetence and only (5) 12.5% with normal chronotropic response at the end of the intervention. A significant decrease in the chronotropic response index from 0.70 to 0.47 (p <0.001) and a significant increase in METs-load from 5.47 to 9.35 (p <0.001) were found. The value of the differential between initial and final METs (delta-METs) was obtained for both groups, observing a significant increase between initial and final METs in favor of patients with CI (3.8 Vs 3.5, p<0.012) at the end of the intervention. A significant moderate negative correlation (r=-0.395, Spearman, p<0.012) was determined between the degree of CI and final METs-load.
Conclusions: It was observed that patients with implantable cardiac devices undergoing a CRP show an increase in exercise tolerance measured in METs, with an inversely proportional correlation to chronotropic incompetence.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
I. Marie Christine Iliou, Jean Christophe Blanchard, Aurélia Lamar-Tanguy, Pascal Cristofini, François Ledru. Cardiac rehabilitation in patients with pacemakers and implantable cardioverter defibrillators. Monaldi Archives for Chest Disease Cardiac Series. 2016;86:756.
II. Piepoli MF, Corrà U, Adamopoulos S, et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Eur J Prev Cardiol. 2014;21:664-81.
III. Haqeel A. Jamil, John Gierula, Maria F. Paton, Roo Byrom, Judith E. Lowry, Richard M. Cubbon, David A. Cairns, Mark T. Kearney, Klaus K. Witte. Chronotropic incompetence does not limit exercise capacity in chronic heart failure. J Am Coll Cardiol. 2016;67(16).
IV. Hobbs FD, Kenkre JE, Roalfe AK, et al. Impact of heart failure and left ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur Heart J. 2002;23:1867–76.
V. Smith, J., et al. (2024). Impact of resistance training versus aerobic training on stroke volume in patients with implantable cardiac devices: A literature review. Cardiac Rehabilitation Journal, 12(3), 45-56.
VI. Al-Najjar Y, Witte KK, Clark AL. Chronotropic incompetence and survival in chronic heart failure. Int J Cardiol. 2012;157:48–52.
VII. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction: hemodynamic and metabolic effects. Circulation. 1988;78:506–515.
VIII. Adamopoulos S, Coats AJ, Brunotte F, Arnolda L, Meyer T, Thompson CH, et al. Physical training improves skeletal muscle metabolism in patients with chronic heart failure. J Am Coll Cardiol. 1993;21.
IX. Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128:873-934.
X. Pavy B, Iliou MC, Vergès Patois B, et al. French society of cardiology guidelines for cardiac rehabilitation in adults. Arch Cardiovasc Dis. 2012;105:309-28.
XI. Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar 2009 - a World Society of Arrhythmia’s project. Pacing Clin Electrophysiol. 2011;34:1013-27.
XII. Hobbs FD, Kenkre JE, Roalfe AK, et al. Impact of heart failure and left ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur Heart J. 2002;23:1867–76.
XIII. Brubaker PH, Kitzman DW. Chronotropy: the Cinderella of heart failure pathophysiology and management. J Am Coll Cardiol HF. 2013;1:267–9.
XIV. Dresing TJ, Blackstone EH, Pashkow FJ, et al. Usefulness of impaired chronotropic response to exercise as a predictor of mortality, independent of the severity of coronary artery disease. Am J Cardiol. 2000;86:602–9.
XV. Wilkoff BL, Miller RE. Exercise testing for chronotropic assessment. Cardiol Clin. 1992;10:705–17.
XVI. Roberto F.E. Pedretti, Marie-Christine Iliou, Carsten W. Israel, Ana Abreu, Hielko Miljoen, Ugo Corra. Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA). Eur J Prev Cardiol. 2021;28:1736–1752.
XVII. Piepoli MF, Corrà U, Adamopoulos S, Benzer W, Bjarnason-Wehrens B, Cupples M, Dendale P, Doherty P, Gaita D, Höfer S, McGee H, Mendes M, Niebauer J, Pogosova N, Garcia-Porrero E, Rauch B, Schmid JP, Giannuzzi P. Secondary prevention in the clinical management of patients with cardiovascular diseases. Eur J Prev Cardiol. 2014;21:664–681.
XVIII. Raatikainen MJP, Arnar DO, Merkely B, Nielsen JC, Hindricks G, Heidbuchel H, Camm J. A decade of information on the use of cardiac implantable electronic devices and interventional electrophysiological procedures in the European Society of Cardiology countries: 2017 report of the European Heart Rhythm Association. Europace. 2017;19:ii1–ii90.
XIX. Ambrosetti M, Abreu A, Corrà U, et al. Secondary prevention through comprehensive cardiovascular rehabilitation: from knowledge to implementation. Update 2020. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology. Eur J Prev Cardiol. 2020;
doi:10.1177/2047487320913379.
XX. Conraads VM, Beckers PJ. Exercise training in heart failure: practical guidance. Heart. 2010;96:2025–2031.
XXI. Dunbar SB, Dougherty CM, Sears SF, Carroll DL, Goldstein NE, Mark DB, McDaniel G, Pressler SJ, Schron E, Wang P, Zeigler VL. Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families. Circulation. 2012;126:2146–2172.
XXII. Kjetil Isaksen, Ingvild Margreta Morken, Peter Scott Munk, Alf Inge Larsen. Exercise training and cardiac rehabilitation in patients with implantable cardioverter defibrillators: a review of current literature focusing on safety, effects of exercise training, and the psychological impact of programme participation. Eur J Prev Cardiol. 2012;19:804.
XXIII. Romualdo Belardinelli, Francesco Capestro, Agostino Misiani, Pietro Scipione, Demetrios Georgiou. Moderate exercise training improves functional capacity, quality of life, and endothelium-dependent vasodilation in chronic heart failure patients with implantable cardioverter defibrillators and cardiac resynchronization therapy. Eur J Cardiovasc Prev Rehabil. 2006;13:818–825.
XXIV. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction: hemodynamic and metabolic effects. Circulation. 1988;78:506–515.
XXV. Coats AJS, Adamopoulos S, Radaelli A, McCance A, Meyer TE, Bernardi L, et al. Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation, and autonomic function. Circulation. 1992;85:2119–2131.
XXVI. K. Fernández-Vaquero, A. (2005). Capítulo 16, Respuesta cardiaca al ejercicio. En: López-Chicharro, J., Fernández ,Vaquero, A. Fisiología del ejercicio, 3a. edición, pp. 321-330. Editorial Médica Panamericana.
XXVII. Parson, B. P. (2017). The potential role of contraction-induced myokines in the regulation of metabolic function for the prevention and treatment of type 2 diabetes. Frontiers in Endocrinology; 8:97. doi: 10.3389/fendo.2017.00097