Effect of combined aerobic and resistance training on peak oxygen consumption, muscle strength and health-related quality of life in patients with heart failure with reduced left ventricular ejection fraction: a systematic review and meta-analysis Mansueto Gomes-Neto a,b,c,d, ⁎, André Rodrigues Durães b , Lino Sergio Rocha Conceição d,e , Leonardo Roever e , Cassio Magalhães Silva a,c , Iura Gonzalez Nogueira Alves c , Øyvind Ellingsen g,h , Vitor Oliveira Carvalho c,d,f a Physical Therapy Department, Federal University of Bahia – UFBA, Salvador, Bahia, Brazil b Programa de Pós-Graduação em Medicina e Saúde - UFBA, Salvador, BA, Brazil c Physiotherapy Research Group, UFBA, Brazil d The GREAT Group (GRupo de Estudos em ATividade física), Brazil e Federal University of Uberlândia, Department of Clinical Research, Brazil f Physical Therapy Department, Federal University of Sergipe - UFS, Aracaju, SE, Brazil g K.G. Jebsen Center for Exercise in Medicine, Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway h Department of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway abstract article info Article history: Received 21 December 2018 Received in revised form 14 February 2019 Accepted 22 February 2019 Available online 24 June 2019 Objective: The aim of this study was to investigate the effects of combined aerobic and resistance training on peak oxygen consumption (peak VO 2 ), minute ventilation/carbon dioxide production (VE/VCO 2 slope), muscle strength and health-related quality of life (HRQoL) in heart failure patients with reduced left ventricular ejection fraction (HFrEF). Methods: We searched Cochrane, Pubmed, and PEDro (from the earliest date available to September 2018) for RCTs that evaluated the effects of combined aerobic and resistance training in HFrEF patients. Weighted mean differences (WMD), standardized mean difference (SMD), and 95% confidence interval (CI) were calculated. Results: 39 studies met the study criteria, including 2008 patients, 14 compared combined aerobic and resistance training versus aerobic training, and 25 compared combined aerobic and resistance training versus control. Com- pared to aerobic training, combined aerobic and resistance training resulted in improvement in muscle strength SMD 0.7 (95% CI: 0.3 to 1.0 N = 167) and, HRQoL WMD –2.6 (95% CI: -5.0 to -0.1 N = 138). A nonsignificant difference in peak VO 2 and VE/VCO 2 slope was found for participants in the combined aerobic and resistance training group compared with aerobic training group. Compared to control, combined aerobic and resistance training resulted in improvement in peak VO 2 WMD 2.9 (95% CI: 1.6 to 4.4 N = 638), muscle strength SMD 0.64 (95% CI: 0.4 to 0.9 N = 315) and, HRQoL WMD –9.8 (95% CI: -15.2 to -4.5 N = 524). Conclusions: Combined aerobic and resistance training improves peak VO 2 , muscle strength and HRQoL and should be considered as a component of care of HFrEF patients. © 2019 Elsevier B.V. All rights reserved. 1. Background Heart failure (HF) is a major health care burden in the world [1]. Pa- tients with HF experience numerous symptoms that affect their quality of life and activities of daily living, such as dyspnea, fatigue, poor exercise tolerance and fluid retention. Patients with HF also have in- creased risk of hospital readmission and mortality [2,3]. Recently Cattadori et al., presented update to review the evolu- tion of the interaction between HF and exercise. They reported that exercise is a tool of primary prevention and therapy for HF patients [4]. Studies consistently reported that exercise training is a safe and effective intervention to improve exercise tolerance and quality of life in HF patients with reduced left ventricular ejection fraction (HFrEF) [5, 6]. Continuous aerobic exercise training, which is en- dorsed by current guidelines [7,8], is very important to improve International Journal of Cardiology 293 (2019) 165–175 ⁎ Corresponding author at: Physical Therapy Department, Universidade Federal da Bahia- UFBA, Instituto de Ciências da Saúde, Av. Reitor Miguel Calmon s/n - Vale do Canela, Salvador, BA CEP 40.110-100, Brazil. E-mail address: mansueto.neto@ufba.br (M. Gomes-Neto). https://doi.org/10.1016/j.ijcard.2019.02.050 0167-5273/© 2019 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard