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High-intensity interval training early after heart transplantationTransplantoux symposium –Leuven 7.February 2020 Katrine Rolid
Disclosure statement
• I have no potential conflicts of interest to declare
What I will talk about today
•Brief introduction-history
•Exercise principles after heart transplantation
•The effect of high-intensity interval training early after HTx
•The decentralized exercise model-whatworked in the HITTS study
•Summary
Katrine Rolid
1967
1969
2008 First heart transplant recipient completed the Ironman (Triathlon)
Katrine Rolid
History of heart transplantation from short-term survival to the heart transplant athlete
First heart transplant
Hardangervidda. Cyclosporine
Why is exercise so important after heart transplantation
«Your exercise capacity is crucial for your life after a heart transplantation»
Peak oxygen uptake and self‐reported physical health are strong predictors of long‐term survival after heart transplantation
Yardley et al. 2016
Katrine Rolid
www.uio.no Websites university of Oslohttps://www.med.uio.no/klinmed/forskning/aktuelt/aktuelle-saker/2017/kondisen-din-avgjorende-for-livet-etter.html
Exercise-based cardiac rehabilitation afterheart transplantation
•Moderate continuous training is common
•High-intensity interval training (HIT) is safe, well tolerated and efficacious in maintenance HTx recipients
•What about HIT early after heart transplantation?
•Results from the HITTS (High-intensity Interval Training in De Novo Heart Transplant recipients in Scandinavia)
Katrine Rolid
Time since heart transplant, months0 3 122
Baseline tests
RandomizationFollow-up
tests
High-intensity interval training
Moderate intensity continuous training
Heart transplant
Recruitment
36
Follow-up tests
HITTS study
Endpoints
•Secondary endpoints• Muscle strength • Heart rate response • Cardiac function• Tolerability, safety and
adverse events• Body composition• Biomarkers • Hemodynamics• Health-related quality of life• Endothelial function
Katrine Rolid 8
Primary endpoint• Change in VO2peak
Cybex 6000, Isokinetic musclestrength
Bioimpedance
Exercise protocolsHIT MICT
Katrine Rolid 9
Illustration from : Design and rationale of the HITTS randomized controlled trial: Effect of High-intensity Interval Training in de novo Heart Transplant Recipients in Scandinavia. Nytrøen et al.(2016) American Heart Journal
The interventions
A) Three main exercise periods 2-3 sessions per week
B) Aerob exercise (HIT vs. MICT) and muscular strength training
C) All exercise was logged and monitored with a heart rate monitor
•Decentralized training
• Local physical therapists• Long-term follow-up
Katrine Rolid 10
Heart rate during HIT versus MICT
First period(mean HR±SD)
Last period(mean HR±SD)
HIT 124 ± 14 142 ± 17
MICT 111 ± 15 121 ± 16
Both groups performed a mean ± SD of 58 ± 22 sessions out of the 72 initially planned sessions as per protocol (81 %)
HIT
MIC
T
Katrine Rolid
Results published in Circulation (2019) https://doi.org/10.1161/CIRCULATIONAHA.118.036747Circulation. 2019;139:2198–2211
HTx baseline
HTx 1 year(same patient)
Normal curve(non-patient)
Example of heart rate (HR) improvement during the intervention period (HIT)
HR
HR
HR
1.int 2.int
1. 2. 3. 4.
1. 2. 3. 4.
Katrine Rolid
Results and figures published in Circulation (2019) https://doi.org/10.1161/CIRCULATIONAHA.118.036747Circulation. 2019;139:2198–2211
Results primary endpoint:Change in mean VO2peak
Mean changeVO2peak (mL/kg/min):
1.8 [0.05, 3.50]
Katrine Rolid
Results published in Circulation (2019) https://doi.org/10.1161/CIRCULATIONAHA.118.036747Circulation. 2019;139:2198–2211
HIT (N=37) MICT (N=41)
Variables Baseline 1-yr
Follow-up
Baseline 1-yr
Follow-up
Mean difference
between groups
[95% CI]
t-test
P value
Exercise / CPET
% of predicted
VO2peak
53 ± 12 67 ±15** 58 ± 13 67 ± 15** 5 [0, 9] 0.040*
VO2peak (L/min) 1.51 ± 0.40 2.03 ± 0.57** 1.65 ± 0.44 1.97 ± 0.58** 0.20 [0.04, 0.35] 0.014*
AT (L/min) 1.01 ± 0.26 1.44 ± 0.51** 1.14 ± 0.36 1.28 ± 0.50* 0.28 [0.08, 0.46] 0.005*
O2 pulse
(mL/beat)
11.8 ± 3.2 13.1 ± 3.3** 13.1 ± 3.4 13.6 ± 3.9 0.9 [-0.1, 1.9] 0.081
Katrine Rolid
Results published in Circulation (2019) https://doi.org/10.1161/CIRCULATIONAHA.118.036747Circulation. 2019;139:2198–2211
Change in muscular exercise capacity
Mean change Joule [95% CI]:
517 [129, 905]
Katrine Rolid
Results and figure published in Circulation (2019) https://doi.org/10.1161/CIRCULATIONAHA.118.036747Circulation. 2019;139:2198–2211
Tolerability, safety and adverse events
• There were no serious adverse events related to exercise in either of the groups during the intervention period
• Medical issues, not related to exercise, but which resulted in shorter or longer exercise-breaks during the 9-month long intervention period
• CMV infections and lung infections
• One ancle fracture, spinal compression fracture
• Hernia repair (abdominal and lingual)
• One arrhythmia (atrial flutter)
• One patient with elevated TnT and proBNP values (hospitalization)
• Rejection grade 1 and 2
• Musculoskeletal problems (back, knee, Achilles)
• Family related issues, not enough time to exercise
• Symptoms of depression, lack of motivation
Katrine Rolid
Success factors for HIT early after HTx
•A plausible explanation for this favorable benefit of HIT was that subjects in this study were able to perform the brief interval bouts at a very high intensity level ( Editorial. Tucker et al.)• 1:1 interaction , local physical therapist •Motivated participants (achievable) •Shared decision making •Close cooperation with transplant center •High compliance due to the systematic follow-up in
their own home environment• Long duration of intervention = better odds for life-
long healthy habits
Katrine Rolid
The decentralized rehabilitation model in Norway
Katrine Rolid
Challenges
• The target intensity during the first year
•Use Rated Perceived Exertion and heart rate monitor
•Duration of exercise bouts
• Start out with 1 -2 minutes, increase gradually
• Rest periods (The overeager participant)
• Recommend a resting day between the HIT sessions. Help them to keep a healthy balance
Katrine Rolid
Summary• HIT compared to MICT, resulted in a clinically meaningful and
statistically significant higher change in exercise capacity as assessed by VO2peak (25% vs. 15%)
• HIT compared to MICT resulted in a significantly higher anaerobic threshold and muscular exercise capacity
• Implementation of higher intensity training may optimize exercise results in de novo HTx recipients
• Close follow-up important
• Decentralized rehabilitation should start as early as possible
Katrine Rolid
Thank you for your attention
Run for organdonationOslo Marathonwww.organdonasjon
Katrine Rolid
