Heart Failure
Relation of Angina Pectoris to Outcomes, Quality of Life, and Response to Exercise Training in Patients With Chronic Heart Failure (from HF-ACTION)

https://doi.org/10.1016/j.amjcard.2016.07.040Get rights and content

Angina pectoris (AP) is associated with worse outcomes in heart failure (HF). We investigated the association of AP with health-related quality of life (HRQoL), exercise capacity, and clinical outcomes and its interaction with exercise training in an HF population. We grouped 2,331 patients with HF with reduced ejection fraction in the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) trial of usual care ± exercise training according to whether they had self-reported AP by Canadian classification score. HRQoL and clinical outcomes were assessed by AP status. In HF-ACTION, 406 patients (17%) had AP at baseline (44% with Canadian classification score ≥II) with HF severity similar to those without AP. Patients with AP had similar baseline exercise capacity but worse depressive symptoms and HRQoL. AP was associated with 22% greater adjusted risk for all-cause mortality/hospitalizations, driven by hospitalizations. There was significant interaction between baseline AP and exercise training peak VO2 change (p = 0.019) but not other end points. Exercise training was associated with greater peak VO2 improvement after 3 months in patients with AP (treatment effect = 1.25 ml/kg/min, 95% CI 0.6 to 1.9). In conclusion, AP was associated with worse HRQoL and depressive symptoms. Despite greater peak VO2 improvement with exercise training, patients with AP experienced more adverse outcomes.

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Methods

HF-ACTION was a trial of exercise training versus usual care in 2,331 patients with EF ≤35% and New York Heart Association (NYHA) class II to IV symptoms despite optimal HF therapy for at least 6 weeks.9 Patients with major co-morbidities that could interfere with exercise training, including exercise-limiting AP, were excluded from HF-ACTION. In patients randomized to exercise training, the protocol included 36 supervised exercise sessions followed by home-based training for an additional

Results

From the HF-ACTION cohort, 406 of 2,331 patients (17%) had AP at baseline and worse NYHA class and depression but similar proBNP level compared with those without baseline AP (Table 1). Baseline exercise parameters were similar by AP status, but patients with AP had worse HRQoL scores (Table 2). Adherence rates to the exercise intervention at 3 months in patients with and without baseline AP were 51 of 186 (27%) versus 205 of 828 (25%), respectively (p = 0.45).

Baseline AP was associated with a

Discussion

In this study, ambulatory patients with HFrEF with AP had a 25% increased risk for all-cause hospitalization but no significant differences in all-cause or CV mortality over a follow-up period of 2.5 years. Depression was common (21%) in the overall HF-ACTION population, but patients with AP had increased prevalence and severity of depression along with worse HRQoL. Exercise training conferred similar benefits to patients with versus without AP. Several factors may account for the observed

Disclosures

Kishan S. Parikh, MD: none. Adrian Coles, PhD: none. Phillip J. Schulte: none. Robert Mentz, MD: NIH (U10HL110312), Amgen, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Gilead, Novartis, Otsuka, and ResMed; honoraria from HeartWare, Janssen, Luitpold Pharmaceuticals, Novartis, ResMed, and Thoratec; and has served on an advisory board for Luitpold Pharmaceuticals, Inc. William E. Kraus: none. Steven J. Keteyian, PhD: none. Jerome L. Fleg, MD: none. Ileana L. Piña, MD, MPH: none. Mona

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  • The contents of this manuscript are solely the responsibility of the authors and do not necessarily reflect the views of the National Institutes of Health or the Department of Health and Human Services.

    Funding was provided by Gilead Sciences. Work for the analysis was supported by grants U10HL110312 (Dr. Mentz) and 5T32GM086330-05 (Dr. Parikh) from NIH (Bethesda, MD). The HF-ACTION trial was funded by grants HL063747 and HL093374 from the National Heart, Lung, and Blood Institute (Bethesda, MD).

    See page 1215 for disclosure information.

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