Pulmonary Rehabilitation and Cardiovascular Disease

ABSTRACT

Chronic obstructive pulmonary disease (COPD) and heart disease often coexist. Both diseases share risk factors such as smoking and inactivity. Roughly 15 to 20% of patients referred to pulmonary rehabilitation suffer from some degree of heart failure. Heart failure complicates the presentation of COPD and is often the cause of death in COPD.

Exercise training as part of a comprehensive rehabilitation program is now recognized as a treatment for both COPD and congestive heart failure (CHF). It tackles the skeletal muscle abnormalities commonly seen in these diseases. The rehabilitation program that is offered to patients with COPD and coexisting CHF may need to be adapted in terms of the intensity and the components of self-management and counseling offered. This article discusses these adaptations.

KEYWORDS

Pulmonary rehabilitation - cardiac disease - systemic consequences

REFERENCES

• 1 Pitta F, Troosters T, Spruit M A, Probst V S, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2005;  171 972-977
• 2 van den Berg-Emons H, Bussmann J, Balk A, Keijzer-Oster D, Stam H. Level of activities associated with mobility during everyday life in patients with chronic congestive heart failure as measured with an “activity monitor”.  Phys Ther. 2001;  81 1502-1511
• 3 Gosker H R, Lencer N HMK, Franssen F M, van der Vusse G J, Wouters E F, Schols A M. Striking similarities in systemic factors contributing to decreased exercise capacity in patients with severe chronic heart failure or COPD.  Chest. 2003;  123 1416-1424
• 4 Zvezdin B, Milutinov S, Kojicic M et al.. A postmortem analysis of major causes of early death in patients hospitalized with COPD exacerbation.  Chest. 2009;  136 376-380
• 5 Mascarenhas J, Lourenço P, Lopes R, Azevedo A, Bettencourt P. Chronic obstructive pulmonary disease in heart failure: prevalence, therapeutic and prognostic implications.  Am Heart J. 2008;  155 521-525
• 6 Decramer M, Rennard S, Troosters T et al.. COPD as a lung disease with systemic consequences: clinical impact, mechanisms, and potential for early intervention.  COPD. 2008;  5 235-256
• 7 Topsakal R, Kalay N, Ozdogru I et al.. Effects of chronic obstructive pulmonary disease on coronary atherosclerosis.  Heart Vessels. 2009;  24 164-168
• 8 Watz H, Waschki B, Boehme C, Claussen M, Meyer T, Magnussen H. Extrapulmonary effects of chronic obstructive pulmonary disease on physical activity: a cross-sectional study.  Am J Respir Crit Care Med. 2008;  177 743-751
• 8a Rabe K F, Hurd S, Anzueto A et al.. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.  Am J Respir Crit Care Med. 2007;  176 532-555
• 9 Rutten F H, Cramer M J, Grobbee D E et al.. Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease.  Eur Heart J. 2005;  26 1887-1894
• 10 Witte K K, Clark A L. Why does chronic heart failure cause breathlessness and fatigue?.  Prog Cardiovasc Dis. 2007;  49 366-384
• 11 Koechlin C, Couillard A, Simar D et al.. Does oxidative stress alter quadriceps endurance in chronic obstructive pulmonary disease?.  Am J Respir Crit Care Med. 2004;  169 1022-1027
• 12 Swallow E B, Gosker H R, Ward K A et al.. A novel technique for nonvolitional assessment of quadriceps muscle endurance in humans.  J Appl Physiol. 2007;  103 739-746
• 13 Malaguti C, Nery L E, Dal Corso S et al.. Scaling skeletal muscle function to mass in patients with moderate-to-severe COPD.  Eur J Appl Physiol. 2006;  98 482-488
• 14 Allaire J, Maltais F, Doyon J F et al.. Peripheral muscle endurance and the oxidative profile of the quadriceps in patients with COPD.  Thorax. 2004;  59 673-678
• 15 Coronell C, Orozco-Levi M, Méndez R, Ramírez-Sarmiento A, Gáldiz J B, Gea J. Relevance of assessing quadriceps endurance in patients with COPD.  Eur Respir J. 2004;  24 129-136
• 16 Couillard A, Maltais F, Saey D et al.. Exercise-induced quadriceps oxidative stress and peripheral muscle dysfunction in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2003;  167 1664-1669
• 17 Serres I, Gautier V, Varray A, Préfaut C. Impaired skeletal muscle endurance related to physical inactivity and altered lung function in COPD patients.  Chest. 1998;  113 900-905
• 18 Wilson J R, Martin J L, Schwartz D, Ferraro N. Exercise intolerance in patients with chronic heart failure: role of impaired nutritive flow to skeletal muscle.  Circulation. 1984;  69 1079-1087
• 19 Saey D, Debigare R, LeBlanc P et al.. Contractile leg fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2003;  168 425-430
• 20 Decramer M, Gosselink R, Troosters T, Verschueren M, Evers G. Muscle weakness is related to utilization of health care resources in COPD patients.  Eur Respir J. 1997;  10 417-423
• 21 Swallow E B, Reyes D, Hopkinson N S et al.. Quadriceps strength predicts mortality in patients with moderate to severe chronic obstructive pulmonary disease.  Thorax. 2007;  62 115-120
• 22 Izawa K P, Watanabe S, Osada N et al.. Handgrip strength as a predictor of prognosis in Japanese patients with congestive heart failure.  Eur J Cardiovasc Prev Rehabil. 2009;  16 21-27
• 23 Sala E, Roca J, Marrades R M et al.. Effects of endurance training on skeletal muscle bioenergetics in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 1999;  159 1726-1734
• 24 Wagner P D. Skeletal muscles in chronic obstructive pulmonary disease: deconditioning, or myopathy?.  Respirology. 2006;  11 681-686
• 25 Bernard S, LeBlanc P, Whittom F et al.. Peripheral muscle weakness in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 1998;  158 629-634
• 26 Harrington D, Anker S D, Chua T P et al.. Skeletal muscle function and its relation to exercise tolerance in chronic heart failure.  J Am Coll Cardiol. 1997;  30 1758-1764
• 27 Decramer M, Lacquet L M, Fagard R, Rogiers P. Corticosteroids contribute to muscle weakness in chronic airflow obstruction.  Am J Respir Crit Care Med. 1994;  150 11-16
• 28 Spruit M A, Gosselink R, Troosters T et al.. Muscle force during an acute exacerbation in hospitalised patients with COPD and its relationship with CXCL8 and IGF-I.  Thorax. 2003;  58 752-756
• 29 Pitta F, Troosters T, Probst V S, Spruit M A, Decramer M, Gosselink R. Physical activity and hospitalization for exacerbation of COPD.  Chest. 2006;  129 536-544
• 30 Gosker H R, Wouters E F, van der Vusse G J, Schols A M. Skeletal muscle dysfunction in chronic obstructive pulmonary disease and chronic heart failure: underlying mechanisms and therapy perspectives.  Am J Clin Nutr. 2000;  71 1033-1047
• 31 Stassijns G, Lysens R, Decramer M. Peripheral and respiratory muscles in chronic heart failure.  Eur Respir J. 1996;  9 2161-2167
• 32 Filippatos G S, Tsilias K, Venetsanou K et al.. Leptin serum levels in cachectic heart failure patients: relationship with tumor necrosis factor-alpha system.  Int J Cardiol. 2000;  76 117-122
• 33 Creutzberg E C, Schols A M, Weling-Scheepers C A, Buurman W A, Wouters E F. Characterization of nonresponse to high caloric oral nutritional therapy in depleted patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2000;  161(3 Pt 1) 745-752
• 34 Agustí A G, Sauleda J, Miralles C et al.. Skeletal muscle apoptosis and weight loss in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2002;  166 485-489
• 35 Gosker H R, Kubat B, Schaart G, van der Vusse G J, Wouters E F, Schols A M. Myopathological features in skeletal muscle of patients with chronic obstructive pulmonary disease.  Eur Respir J. 2003;  22 280-285
• 36 Adams V, Jiang H, Yu J et al.. Apoptosis in skeletal myocytes of patients with chronic heart failure is associated with exercise intolerance.  J Am Coll Cardiol. 1999;  33 959-965
• 37 Gan W Q, Man S F, Senthilselvan A, Sin D D. Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis.  Thorax. 2004;  59 574-580
• 38 Barreiro E, Schols A M, Polkey M I ENIGMA in COPD project et al. Cytokine profile in quadriceps muscles of patients with severe COPD.  Thorax. 2008;  63 100-107
• 39 Vogiatzis I, Stratakos G, Simoes D C et al.. Effects of rehabilitative exercise on peripheral muscle TNFalpha, IL-6, IGF-I and MyoD expression in patients with COPD.  Thorax. 2007;  62 950-956
• 40 Rabinovich R A, Figueras M, Ardite E et al.. Increased tumour necrosis factor-alpha plasma levels during moderate-intensity exercise in COPD patients.  Eur Respir J. 2003;  21 789-794
• 41 Crul T, Spruit M A, Gayan-Ramirez G et al.. Markers of inflammation and disuse in vastus lateralis of chronic obstructive pulmonary disease patients.  Eur J Clin Invest. 2007;  37 897-904
• 42 Ventura-Clapier R, De Sousa E, Veksler V. Metabolic myopathy in heart failure.  News Physiol Sci. 2002;  17 191-196
• 43 Linke A, Adams V, Schulze P C et al.. Antioxidative effects of exercise training in patients with chronic heart failure: increase in radical scavenger enzyme activity in skeletal muscle.  Circulation. 2005;  111 1763-1770
• 44 Van Vliet M, Spruit M A, Verleden G et al.. Hypogonadism, quadriceps weakness, and exercise intolerance in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2005;  172 1105-1111
• 45 Kontoleon P E, Anastasiou-Nana M I, Papapetrou P D et al.. Hormonal profile in patients with congestive heart failure.  Int J Cardiol. 2003;  87 179-183
• 46 Jankowska E A, Biel B, Majda J et al.. Anabolic deficiency in men with chronic heart failure: prevalence and detrimental impact on survival.  Circulation. 2006;  114 1829-1837
• 47 Casaburi R, Bhasin S, Cosentino L et al.. Effects of testosterone and resistance training in men with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2004;  170 870-878
• 48 Janssens W, Lehouck A, Carremans C, Bouillon R, Mathieu C, Decramer M. Vitamin D beyond bones in chronic obstructive pulmonary disease: time to act.  Am J Respir Crit Care Med. 2009;  179 630-636
• 49 Hopkinson N S, Li K W, Kehoe A et al.. Vitamin D receptor genotypes influence quadriceps strength in chronic obstructive pulmonary disease.  Am J Clin Nutr. 2008;  87 385-390
• 50 Murakami S, Otsuki T, Maeda M et al.. Effects of vitamin D receptor gene polymorphisms on low-resistance training using exercise machines: the ‘Power Rehabilitation’ program.  Int J Mol Med. 2009;  23 81-88
• 51 Rees K, Taylor R S, Singh S, Coats A J, Ebrahim S. Exercise based rehabilitation for heart failure.  Cochrane Database Syst Rev. 2004;  (3) CD003331
• 52 Lacasse Y, Goldstein R, Lasserson T J, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease.  Cochrane Database Syst Rev. 2006;  (4) CD003793
• 53 Troosters T, Gosselink R, Decramer M. Short- and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial.  Am J Med. 2000;  109 207-212
• 54 O’Donnell D E, McGuire M, Samis L, Webb K A. General exercise training improves ventilatory and peripheral muscle strength and endurance in chronic airflow limitation.  Am J Respir Crit Care Med. 1998;  157(5 Pt 1) 1489-1497
• 55 Mador M J, Bozkanat E, Aggarwal A, Shaffer M, Kufel T J. Endurance and strength training in patients with COPD.  Chest. 2004;  125 2036-2045
• 56 Ortega F, Toral J, Cejudo P et al.. Comparison of effects of strength and endurance training in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2002;  166 669-674
• 57 Bernard S, Whittom F, Leblanc P et al.. Aerobic and strength training in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 1999;  159 896-901
• 58 Kobayashi N, Tsuruya Y, Iwasawa T et al.. Exercise training in patients with chronic heart failure improves endothelial function predominantly in the trained extremities.  Circ J. 2003;  67 505-510
• 59 Hambrecht R, Fiehn E, Weigl C et al.. Regular physical exercise corrects endothelial dysfunction and improves exercise capacity in patients with chronic heart failure.  Circulation. 1998;  98 2709-2715
• 60 Conraads V M, Beckers P, Bosmans J et al.. Combined endurance/resistance training reduces plasma TNF-alpha receptor levels in patients with chronic heart failure and coronary artery disease.  Eur Heart J. 2002;  23 1854-1860
• 61 Rabinovich R A, Ardite E, Troosters T et al.. Reduced muscle redox capacity after endurance training in patients with chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2001;  164 1114-1118
• 62 Piepoli M F, Davos C, Francis D P, Coats A J. ExTraMATCH Collaborative . Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH).  BMJ. 2004;  328 189
• 63 O’Connor C M, Whellan D J, Lee K L HF-ACTION Investigators et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial.  JAMA. 2009;  301 1439-1450
• 64 Puhan M, Scharplatz M, Troosters T, Walters E H, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.  Cochrane Database Syst Rev. 2009;  (1) CD005305
• 65 Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 2005;  172 19-38
• 66 Hunt S A, Abraham W T, Chin M H American College of Cardiology Foundation et al. 2009 focused update incorporated into the ACC/AHA 2005 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.  J Am Coll Cardiol. 2009;  53 e1-e90
• 67 Nici L, Donner C, Wouters E ATS/ERS Pulmonary Rehabilitation Writing Committee et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation.  Am J Respir Crit Care Med. 2006;  173 1390-1413
• 68 Vogiatzis I, Nanas S, Roussos C. Interval training as an alternative modality to continuous exercise in patients with COPD.  Eur Respir J. 2002;  20 12-19
• 69 Vogiatzis I, Terzis G, Nanas S et al.. Skeletal muscle adaptations to interval training in patients with advanced COPD.  Chest. 2005;  128 3838-3845
• 70 Puhan M A, Büsching G, Schünemann H J, VanOort E, Zaugg C, Frey M. Interval versus continuous high-intensity exercise in chronic obstructive pulmonary disease: a randomized trial.  Ann Intern Med. 2006;  145 816-825
• 71 Wisløff U, Støylen A, Loennechen J P et al.. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study.  Circulation. 2007;  115 3086-3094
• 72 Meyer K, Samek L, Schwaibold M et al.. Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures.  Med Sci Sports Exerc. 1997;  29 306-312
• 73 Dolmage T E, Goldstein R S. Effects of one-legged exercise training of patients with COPD.  Chest. 2008;  133 370-376
• 74 Emtner M, Porszasz J, Burns M, Somfay A, Casaburi R. Benefits of supplemental oxygen in exercise training in nonhypoxemic chronic obstructive pulmonary disease patients.  Am J Respir Crit Care Med. 2003;  168 1034-1042
• 75 Hawkins P, Johnson L C, Nikoletou D et al.. Proportional assist ventilation as an aid to exercise training in severe chronic obstructive pulmonary disease.  Thorax. 2002;  57 853-859
• 76 Casaburi R, Kukafka D, Cooper C B, Witek Jr T J, Kesten S. Improvement in exercise tolerance with the combination of tiotropium and pulmonary rehabilitation in patients with COPD.  Chest. 2005;  127 809-817
• 77 Eves N D, Sandmeyer L C, Wong E Y et al.. Helium-hyperoxia: a novel intervention to improve the benefits of pulmonary rehabilitation for patients with COPD.  Chest. 2009;  135 609-618
• 78 Probst V S, Troosters T, Pitta F, Decramer M, Gosselink R. Cardiopulmonary stress during exercise training in patients with COPD.  Eur Respir J. 2006;  27 1110-1118
• 79 Spruit M A, Eterman R M, Hellwig V, Janssen P, Wouters E, Uszko-Lencer N. Effects of moderate-to-high intensity resistance training in patients with chronic heart failure.  Heart. 2009;  95 1399-1408
• 80 Braith R W, Beck D T. Resistance exercise: training adaptations and developing a safe exercise prescription.  Heart Fail Rev. 2008;  13 69-79
• 81 Troosters T. Endurance versus strength training in chronic obstructive pulmonary disease, II: Resistance training.  Chron Respir Dis. 2004;  1 40-41
• 82 Levinger I, Bronks R, Cody D V, Linton I, Davie A. The effect of resistance training on left ventricular function and structure of patients with chronic heart failure.  Int J Cardiol. 2005;  105 159-163
• 83 Beckers P J, Denollet J, Possemiers N M, Wuyts F L, Vrints C J, Conraads V M. Combined endurance-resistance training vs. endurance training in patients with chronic heart failure: a prospective randomized study.  Eur Heart J. 2008;  29 1858-1866
• 84 Sillen M J, Speksnijder C M, Eterman R M et al.. Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with chronic heart failure or COPD: a systematic review of the English-language literature.  Chest. 2009;  136 44-61
• 85 Neder J A, Sword D, Ward S A, Mackay E, Cochrane L M, Clark C J. Home based neuromuscular electrical stimulation as a new rehabilitative strategy for severely disabled patients with chronic obstructive pulmonary disease (COPD).  Thorax. 2002;  57 333-337
• 86 Vivodtzev I, Pépin J L, Vottero G et al.. Improvement in quadriceps strength and dyspnea in daily tasks after 1 month of electrical stimulation in severely deconditioned and malnourished COPD.  Chest. 2006;  129 1540-1548
• 87 Myers J. Principles of exercise prescription for patients with chronic heart failure.  Heart Fail Rev. 2008;  13 61-68