No Clinical Outcome Benefit With Aerobic Training Program in Cancer Patients With Heart Failure
In a retrospective analysis in the HF-ACTION trial reported in the Journal of Clinical Oncology, Jones et al found that a program of aerobic training did not reduce the rate of all-cause mortality or hospitalization in cancer patients with heart failure. Some evidence suggested that patients who were able to adhere to the program had improved outcomes.
Study Details
The study evaluated the primary endpoint of all-cause mortality or hospitalization among 47 patients randomly assigned to aerobic training and 43 to guideline-based usual care in the HF-ACTION trial. Patients had to have medically stable heart failure. The aerobic training program consisted of three supervised 20- to 45-minute sessions at 60% to 70% of heart rate reserve each week for 12 weeks followed by home-based sessions for 4 to 12 months.
The aerobic training and usual-care groups were generally balanced for age (mean, 66 years in both), sex (72% and 77% male), heart rate (mean, 70 and 72 bpm), blood pressure (mean, 115/70 and 117/69) New York Heart Association class (II for 60% and 67%, III for 36% and 33%), race/ethnicity (67% and 65% white, 28% and 33% African American), left-ventricular ejection fraction (mean, 24% and 28%), comorbid conditions (diabetes in 32% and 44%, previous myocardial infarction in 55% and 42%, hypertension in 51% and 65%, atrial fibrillation or flutter in 23% and 16%), and medications and devices (ACE inhibitors or angiotensin II receptor blockers in 96% and 93%, beta-blockers in 81% and 95%, aldosterone in 45% and 30%, loop diuretic in 68% and 77%, digoxin in 53% and 44%, implanted cardioverter-defibrillator in 43% and 35%, and biventricular pacemaker in 17% and 19%).
No Benefit
Median follow-up was 35 months. In intention-to-treat analysis, the rate of all-cause mortality or hospitalization at 2 years was 74% in the aerobic training group vs 67% in the usual-care group (adjusted hazard ratio [HR] = 1.11, P = .676), including a higher rate of cardiovascular mortality or cardiovascular hospitalization in the aerobic training group (67% vs 41%, adjusted HR = 1.94, P = .017). All-cause mortality was 11% in both groups, and cardiovascular mortality was 7% vs 3%. There were no differences between groups in any exercise capacity (VO2peak) or health-related quality-of-life outcomes.
Effect of Adherence?
During the supervised phase of aerobic training, 53% of patients were adherent to the program (achieved ≥ 90 minutes per week). Post hoc analysis showed that the rate of all-cause mortality or hospitalization was lower in adherent patients (66.1% vs 83.9%), including all-cause mortality in 4.0% vs 19.3%. No significant changes in exercise capacity were found in the adherent subgroup, with improvements in some quality-of-life measures being observed.
The investigators concluded, “In [intention-to-treat] analyses, [aerobic training] did not improve clinical outcomes in patients with cancer who had [heart failure]. Post hoc analyses suggested that patients not capable of adhering to the planned [aerobic training] prescription may be at increased risk of clinical events.”
Lee W. Jones, PhD, of Memorial Sloan Kettering Cancer Center, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by grants from the National Cancer Institute. The study authors reported no potential conflicts of interest.
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