What should be the focus in the management of patients with heart failure? The importance of peripheral vision

patients. Although all patients were treated with ACE inhibitors, none were using a beta-blocking agent or aldosterone antagonist. What was the degree of activation of the adrenergic nervous system and natriuretic peptide system? Were there differences in endothelin concentrations or perhaps more importantly, extent of cytokine activation? Obviously, central cardiac mechanisms may also be operative. As the authors state, preserved peak cardiac output could well be due to maintenance of an adequate heart rate response and superior venricular contractility in the asymptomatic group. Reliable measurements of contractility during exercise are difficult. However, substantial differences are unlikely in the presence of similar ejection fractions, enddiastolic dimensions, LVEDP and dP/dt at rest. Similarly, differences in the mechanics of pump function (exercise-induced diastolic dysfunction and mitral insufficiency) could contribute to symptoms in patients with severe left ventricular dilatation and systolic dysfunction. Now, why is this good news? Simply because peripheral function is easier to improve than myocardial function. Common sense would suggest that asymptomatic patients have preserved their exercise tolerance because they remain physically active. Extensive literature uniformly documents that various training protocols have been shown to improve not only exercise performance but also to reverse the skeletal muscle atrophy and fatigue with attenuated vasodilator capacity that characterizes symptomatic patients. The suggested mechanisms explaining improvement following training are multifactorial. Improvements in regional blood flow, capillary density, muscle bioenergetics, autonomic tone and neurohumoral status have been documented. This paper provides important evidence to support a hypothesis that deserves testing. A proper prospective evaluation of exercise training on morbidity and mortality in a broad group of symptomatic patients is the next step. Such an international effort is in the planning stages and currently recruiting centres. EXIST (Exercise Intervention in Stable Heart Failure Trial) is being led by Andrew Coats and Marcus Flather from the Royal Brompton and Harefield NHS Trust and the National Heart See page 392 for the article to which this Editorial refers