Exercise Intervention as an Adjunct to Medical Therapy in Newly Diagnosed Patients With Pulmonary Arterial Hypertension

This study is designed to deliver a remotely supervised, home-based exercise programme to patients newly diagnosed with pulmonary arterial hypertension with a view to early optimisation of their condition. The design is a waitlist randomised controlled trial whereby participants will be randomised to an exercise intervention or control group, with the control group then going on to have access to the exercise programme after a 12-week delay. There will be further randomisation after completion of the exercise programme to determine if participants have access to support package aimed at improving adherence to exercise.

The study objectives are to evaluate:

• The incremental effect of an exercise programme on exercise capacity, quality of life and mental health
• The impact of an additional support package following completion of the exercise programme on adherence to exercise in the long term.

Methodology Patients will be recruited from the Scottish Pulmonary Vascular Unit and consented for the study at the time of diagnosis with pulmonary arterial hypertension.

Participants will be commenced on pulmonary vasodilator therapy as per standard of care decided by the clinical team, then will be reviewed 3 months later at outpatient clinic.

Half of participants will then be randomly assigned to an intervention group and the remaining half to a control group. The intervention group will start a 12-week home-based remotely supervised exercise programme while the control group continue on medical therapy alone to allow for comparison. After this 12 weeks, participants in both groups will be seen back in clinic for further review and data collection. The control group will then commence the exercise programme.

After each participant completes the exercise programme they will then be randomly assigned to either receive a support package from the research team, designed to improve adherence to exercise, or to act as a control group and continue with self-directed exercise. All participants will be reviewed one year after completing the exercise programme to review their adherence to exercise.

Data collection:

Data will be collected at standard of care outpatient clinic appointments (six-minute walk test results, EmPHasis-10 questionnaires, NT-proBNP test. Study questionnaires will also be checked at these visits (PHQ-9 and GAD-7 questionnaires at all visits, exercise adherence rating scale questionnaire at the final visits).

Smartwatches will also be worn by study participants and data will be collected on step count, exercise frequency and intensity, heart rate variability, sleep.

Qualitative data will be gathered from the participants by interview at the end of the exercise programme and following their follow-up phase to evaluate factors that helped or hindered exercise.

Exercise programme:

The exercise programme is carried out fully remotely and has been adopted from the PHAHB study by McCormack et al 2019 and includes induction training sessions (discussing the introduction to exercise equipment, the provided materials, exercise safety and demonstrations) and health coaching sessions (discussing various topics including benefits of exercise, goal setting, action planning, self-monitoring, identification and management of barriers to exercise, problem solving and feedback on behaviour).

There are three types of training activities in the programme which are aerobic training (either walking, cycling or a combination), resistance training (using body weight exercises, but may progress to using resistance bands or light weights) and respiratory training. These activities are built up gradually throughout the programme on an individualised basis over a 12-week period.

Exercise support package:

The exercise adherence package will consist of access to online exercise resources, monthly phone calls from the research team and a forum to allow participant discussion and encouragement.

Sample size: Recruitment target is 40 patients with a 1:1 randomisation to the intervention and control groups.

Inclusion criteria

• Aged 18-years-old and above
• Diagnosed with pulmonary hypertension (group I and non-operable group IV) by right heart catheterisation showing:

• a baseline mean pulmonary artery pressure >20mmHg
• pulmonary vascular resistance >2 Wood Units
• pulmonary capillary wedge pressure <15mmHg
• Able to provide written informed consent

Exclusion criteria

• Diagnosis with pulmonary hypertension of any other cause

• Group II (PH due to left heart disease)
• Group III (PH due to hypoxic lung disease)
• Operable group IV (PH due to chronic thromboembolic disease amenable to surgical treatment)
• Group V (unclear and/or multifactorial elements).
• Planned treatment with a research trial medication during the study timeframe
• Consenting clinician and/or patient concern regarding the patient's safety in performing a home-based exercise programme
• Patients with syncopal episodes felt to be related to pulmonary hypertension at time of exercise intervention initiation.
• Severe concurrent medical condition that would prevent participation in study procedures
• Life expectancy <3 months