Heart Failure and Sleep Apnea: Exercise Training and Continuous Positive Airway Pressure (CPAP)

• Cardiopulmonary exercise testing [ Time Frame: Two evaluations (baseline and 3 month) ] [ Designated as safety issue: Yes ]
  To evaluate changes from Baseline in functional capacity, after 3 months. All patients will realize a symptom limited, treadmill test with respiratory gas exchange analysis, according to Weber protocol. Heart rate and rhythm were monitored by 12-lead electrocardiogram. Blood pressure was determined by a mercury sphygmomanometer at rest and at the end of each stage. The self-perceived level of exertion (15-point Borg scale) was assessed at peak effort.
• Isokinetic strength and endurance [ Time Frame: Two evaluations (baseline and 3 month) ] [ Designated as safety issue: Yes ]
  To evaluate changes from Baseline in strenght and endurance of legs after 3 months. Strength and endurance of the knee extensors and flexors were measured using an isokinetic dynamometer, which modifies the speed and angle of movements. The test protocol consisted of a warm-up (five minutes on a cycle ergometer), three repetitions at 60degree/second (Maximal dynamic strength, peak torque - Nm) and 10 repetitions at 180degree/second (endurance, total work - J), followed by a cool-down (five minutes on a cycle ergometer).
• Quality of Life [ Time Frame: Two evaluations (baseline and 3 month) ] [ Designated as safety issue: Yes ]
  To evaluate changes from Baseline in quality of life after 3 months. Quality of life will be measure by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) that assesses disease-specific health-related quality of life by including the patient's perception of the effects of chronic heart failure and its treatment on daily life. And by 36-item Short-Form Health Survey (SF-36) that is a generic instrument to evaluate the quality of life.
• Sexual Function [ Time Frame: Two evaluations (baseline and 3 month) ] [ Designated as safety issue: Yes ]
  To evaluate changes from Baseline in sexual function after 3 months. Sexual function of men will be evaluate by the questionnaire Quociente Sexual Masculino (QS-M) and sexual function of women will be evaluate by the questionnaire Quociente Sexual Feminino (QS-F). Both questionnaires evaluate the sexual function of men and women in a comprehensive way to measure the elements of physical, emotional and relational.

Introduction. Heart failure is the result of primary ventricular dysfunction followed by neurohormorais changes, distribution of cardiac output, peripheral circulation, the skeletal and respiratory muscles, which determine their clinical and prognosis. Despite the advancement in treatment, morbidity and mortality remain high. Physical training appears as a therapeutic strategy, because most of its beneficial effects is by inducing changes in peripheral physiological changes resulting from heart failure. Associated factors that may contribute to its progression and worse prognosis, now beginning to be studied, such as sleep apnea, the diagnosis provides important prognostic information and a potential therapeutic option for these patients.

Objectives. Demonstrate the benefits of physical training for patients with heart failure and sleep apnea, and compare treatment with CPAP alone and associated with the exercise program. Will also be assessed risk and adherence to physical training.

Material and Methods. The design will be prospective, longitudinal, randomized consecutive patients. After screening and baseline evaluations the patients will be randomized into Group 1 (CPAP, n = 20), Group 2 (CPAP + Physical training, n = 20), Group 3 (Physical Training, n = 20) and Group 4 (Control without intervention, n = 20). Outcomes (baseline and 3 months): Quality of sleep (polysomnography), Quality of life (Minnesota and SF-36), sexual function (QS-M and QS-F) and functional capacity (cardiopulmonary exercise testing and isokinetic testing). Physical training: aerobic and resistance exercises three times a week for three months. CPAP therapy:after polysomnography for titration with ventilator servo-assisted, and outpatient follow monthly, for three months.

• Heart Failure
• Sleep Apnea Syndromes

• Other: Exercise training
  It consisted of three sessions/week, on non-consecutive days. The aerobic protocol consisted of a warm-up (strengthening exercises, 10 minutes), aerobic exercise (30 minutes in the first month and 45 minutes in the last two months) and cool-down (strengthening exercises, 10 minutes). The aerobic exercise intensity was established by heart rate levels that corresponded to anaerobic threshold, 10 heart rates down and 10 heart rates up, assessed by cardiopulmonary exercise testing. The strength training consisted of eight exercises attending the major muscle groups and the intensity was determined by 50-60% of one-repetition maximum (1-RM) and the progression of the training will be monthly: first month (a series of 12 repetitions with 50% 1-RM), second month (1 set of 15 repetitions with 60% 1-RM) and third months (2 sets of 10 repetitions with 60% 1-RM).
• Other: Control group
  No intervention within three months.
• Other: CPAP group
  The CPAP treatment will be according to protocol of the Department of Psychobiology. Titration will be perform after randomization with ventilation device servo-assisted so as to ensure positive pressure within the first 24 hours of treatment. The treatment will be for three months.
• Other: Exercise and CPAP group
  The patients randomized for this group will perform both Exercise protocol and CPAP treatment at the same time for three months.

• No Intervention: Control group
  Intervention: Other: Control group
• Experimental: Exercise group
  Intervention: Other: Exercise training
• Experimental: CPAP group
  Intervention: Other: CPAP group
• Experimental: Exercise and CPAP group
  Intervention: Other: Exercise and CPAP group

Inclusion Criteria:

• Age range 20-70 years
• New York Heart Association Class II-III
• Clinically stable for one month
• Ejection fraction <40%
• Peak VO2 <20 ml/kg/min
• Stable and optimized medical therapy at least one month before the study
• B-blocker therapy
• Clinical and polysomnographic diagnosis of sleep apnea (IAH>10)

Exclusion Criteria:

• Patients with previous treatment of sleep apnea
• New York Heart Association Class IV
• Clinical instability
• Poor adherence to drug treatment
• Myocardial infarction or revascularization within the past two months
• Unstable angina
• Symptomatic arrhythmias (pacemaker and defibrillator)
• Obstructive aortic or mitral valvular disease
• Hypertrophic cardiomyopathy
• Abnormal exercise testing
• Pulmonary arterial pressure >50mmHg
• Chronic obstructive pulmonary disease
• Intermittent leg claudication
• Musculoskeletal disorders or psychiatric disease that prevents the patient from understanding and following the exercise prescription safely