Study of the Effects Caloric Restriction and Exercise Training in Patients With Heart Failure and a Normal Ejection Fraction
Phase: NA
Conditions: Heart Failure, Diastolic, Obesity
Sponsor: Wake Forest University Health Sciences

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Study Title: Study of the Effects of Caloric Restriction and Exercise Training II (SECRET II) 
 
Principal Investigator:  Dalane W. Kitzman 
 
Co-investigator(s):   Peter Brubaker, Barbara Nicklas, Denise Houston, Timothy Morgan, Greg 
Hundley, Anthony Molina, Mary Lyles, Jamehl Demons Shegog 
 
Sponsor or funding source: NIH 
 
IRB: 00032364 
 
ClinicalTrials.gov Identifier: NCT02636439 
 

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Amendment 51 
 
A limited dataset of demographics, clinical variables, and outcomes measures will be sent via 
encrypted files to Dr. Ambarish Pandey, MD at UT Southwestern. Additionally, deidentified 
extracted DNA samples will be sent for CHiP analyses. A Data Use Agreement and Material 
Transfer Agreement will be completed with the Office of Sponsored Programs.  
 

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Background, Rationale and Context 
Heart failure with preserved ejection fraction (HFpEF) is a relatively recently recognized disorder 
and the fastest growing form of HF.(170; 180)  HFpEF is nearly exclusively found in older 
persons, particularly women, in whom 90% of new HF cases are HFpEF.(85)  HFpEF is 
associated with markedly increased morbidity, mortality, and health care expenditures.(12; 86; 
136; 193)  Despite its importance, the prognosis of HFpEF is worsening, its pathophysiology is 
poorly understood, and other than diuretics no medications have proven effective.(170; 197; 
229) 
 
Exercise intolerance, with severe exertional dyspnea and fatigue during normal activities, is the 
primary manifestation of chronic HFpEF and a major cause of reduced quality of life (QOL).(28; 
125)  Our work has focused on understanding the pathophysiology of HFpEF and testing 
strategies to improve exercise intolerance.(8; 31; 96-98; 110; 118; 124; 125; 127; 128; 178; 190)  
Peak oxygen consumption during exercise (peak VO2) is a widely accepted primary outcome in 
HF trials,(9; 89) including older HFpEF patients,(89; 190) because it provides an objective, 
standardized, valid, reproducible measure of exercise intolerance,(11; 21; 190) is an 
independent predictor of QOL, hospitalizations and mortality, and is sensitive to interventions 
that improve the underlying abnormalities.(11; 63; 89; 127; 128)   
 
Peak VO2 is determined by the combined contributions of cardiac, arterial, and skeletal muscle 
function.(11)  As recently cited by others, our work has helped change the conventional 
paradigm of chronic HFpEF,(27; 115; 146; 197) by demonstrating that in addition to 
cardiovascular dysfunction, older HFpEF patients have multiple skeletal muscle abnormalities, 
including adipose infiltration, reduced muscle mass, capillary density, type 1 oxidative fibers, 
citrate synthase activity, and mitochondrial content and these strongly contribute to their 
severely reduced peak VO2.(94; 98; 100; 120; 164)  As first reported in a randomized trial by our 
group,(128) aerobic exercise training (AT) remains the only intervention that improves peak VO2 
in HFpEF.(116) Our work and others’ indicate that improvements in skeletal muscle function 
account for nearly all the improvement in peak VO2 with AT.(78; 99; 123; 127) This recent 
understanding of the key role of skeletal muscle abnormalities mirrors that of two other 
conditions related to HFpEF: aging and HF with reduced EF (HFrEF).  Loss of muscle is a major 
factor in the age-associated decline in peak VO2.(64)  Aging is also associated with reduced 
capillary density(48), accumulation of intermuscular adipose,(53; 187) and alterations in 
mitochondrial mass and function,(47; 186) all associated with reduced peak VO2, strength, and 
endurance(17; 133; 164; 187; 214; 215)  Furthermore, in HFrEF, decreased skeletal muscle 
mass, oxidative capacity, and mitochondrial content and function all contribute strongly to 
reduced peak VO2 and its improvement after AT, and are not due merely to deconditioning.(43; 
46; 56; 57; 73; 84; 93; 131; 142; 149; 150; 199; 212) 
 
Obesity is one of the strongest risk factors for development of HFpEF.(91; 121; 166; 182; 194) 
About 85% of older HFpEF patients are overweight/obese, twice the general aging population, 
making obesity a major yet under-recognized contributor to the HFpEF phenotype.(91; 182; 
196)  Increased adiposity markedly impairs physical function, skeletal muscle composition, and 
mitochondrial function,(23) as well as cardiovascular function.  In obese older adults, weight 
loss improves body composition and physical, cardiac, vascular, skeletal muscle, and 
mitochondrial function.(19; 44; 184; 213)  However, weight reduction therapy is controversial in 
HF patients because observational studies uniformly report that overweight/obese HF patients, 
including specifically HFpEF, appear to have better survival.(10; 45; 69; 91)  Recently surgical 
weight reduction was reported to prevent the onset of HF, and to improve peak exercise 
intolerance in HFrEF.(151; 200)  To date, there have been no published studies of dietary 
weight loss in any type of HF.  Our recently completed study challenges conventional HF 

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paradigms as the first dietary weight loss intervention for HFpEF.  It found that caloric restriction 
(CR) significantly improves peak VO2, other measures of exercise capacity and QOL. The 
improvements were related to reduced total and intermuscular fat and increased mitochondrial 
content.  CR and AT were additive and the combination of CR+AT produced robust 
improvements in peak VO2 and QOL. This suggests CR+AT as a novel treatment for the 1.8 
million patients with the overweight/obese HFpEF phenotype.   
 
However, 35% of the weight lost during CR in our HFpEF patients was muscle mass and this 
was not prevented by the combination with AT.  This is concerning because muscle mass is a 
major determinant of peak VO2 such that the loss of muscle mass may have limited even further 
increases in peak VO2 with CR+AT.  Although CR+AT strongly increased peak VO2, about 75% 
of the deficit in peak VO2 in HFpEF vs. controls remained, indicating ample opportunity for 
further improvement.(15)  Thus, a strategy that helps preserve muscle mass in the setting of 
CR+AT may further improve peak VO2 and its associated functional and QOL benefits for 
HFpEF.  Preserving muscle mass may also: 1) facilitate weight loss and its long-term 
maintenance since muscle mass is the strongest determinant of metabolic rate;(179; 205; 217; 
223) 2) address concerns about exacerbating aging and HF-related muscle loss which is 
strongly associated with increased disability, hospitalizations, and death;(7; 15; 62; 93; 219) and 
3) avoid worsened body composition(18) and reduced physical function that can occur with 
weight regain after CR when lost muscle mass is replaced disproportionately with fat mass.(14; 
15; 18)  These factors provide the rationale for retaining skeletal muscle during CR+AT.   
 
 
Multiple lines of evidence and our preliminary data indicate that resistance training (RT) could 
be an ideal addition to CR+AT for HFpEF.(184)  (1) RT reliably increases muscle mass, quality, 
strength, and function, significantly more than AT,(37) and specifically during CR.(36; 50; 74; 
76; 77; 101; 144; 184; 225)  We found that in older non-HF patients undergoing CR, RT reduced 
loss of lean mass by 47%, and enhanced body composition and physical function(198) - nearly 
identical to Frimmel et al who found that RT reduced loss of muscle mass by 48%.(74)  (2) In 
HFrEF, RT improves exercise capacity independent of cardiac function and to a similar degree 
as AT.(177)  In older men, RT significantly increased peak VO2 (+1.9 ml/kg lean/min) and was 
associated with increased type 1 fiber area, thigh muscle area, capillary density, and citrate 
synthase (all of which we have found deficient in HFpEF).(76; 77)  (3) RT and AT can have 
additive effects on peak VO2(20; 49; 144)  In HFrEF, the addition of RT to AT doubled the 
training-related increase in endurance.(20)  (4) RT also improves peak VO2 by mechanisms 
independent of muscle mass, including muscle mitochondrial function, blood flow, inflammation, 
and neuromuscular function.(50; 76; 77; 103; 201; 207; 226) Muscle mitochondrial function is a 
fundamental driver of peak VO2 and is reduced in older persons and in HFrEF,(50; 76; 77; 104; 
201; 207; 226) and is improved by RT in HFrEF.(226)  In diabetics, addition of RT to AT 
improves muscle mitochondrial content, function and oxidative capacity, resulting in increased 
peak VO2.(201)  Our preliminary data (Sections 3.D.4.) suggest that: a) muscle mitochondrial 
content is reduced in HFpEF, and b) is related to the increase in peak VO2 following CR+AT; c) 
mitochondrial respiratory function is reduced in obese older adults, and d) improves with RT.  
(5) RT and AT have complementary effects on muscle and cardiovascular function.(52; 92; 95; 
101; 103; 144; 157)  (6) Regimens adding RT to AT improve compliance.(50; 225)  These data 
provide a strong rationale for the addition of RT to AT during CR.   
 
However, RT has never been tested with CR in any type of HF.  Furthermore, there are few 
data regarding RT in HFpEF; a pilot study used a small dose of RT in combination with AT,(58) 
and another small study included just 3 HFpEF patients.(177)  Although initial concerns have 
been largely allayed regarding the potential effect of RT on left ventricular (LV) function in 
HFrEF,(135) there remains equipoise in HFpEF.  RT can significantly increase arterial stiffness 

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and LV hypertrophy(153; 225) a potential concern in HFpEF patients who often already have 
increased arterial stiffness and LV hypertrophy.(106; 124; 137; 230)   Therefore, it is important 
to rigorously test the efficacy and safety of adding RT to CR+AT, as we propose here using 
state-of-the-art methods. 
 
 
Objectives 
The primary aim is to conduct a randomized, controlled, single-blinded 20-week intervention 
trial of RT added to CR+AT in 84 overweight / obese (BMI > 28 kg/m2), older (age>60 years) 
HFpEF patients to test the following primary hypothesis: 
 
The addition of resistance training to CR+AT will improve peak VO2. 
The secondary aims of the study are to test the following secondary hypotheses: 
 
Resistance training added to CR+AT will improve retention of skeletal muscle mass.   
 
Resistance training added to CR+AT will improve skeletal muscle mitochondrial 
function. 
 
The improvement in peak VO2 with RT will be related to improved skeletal muscle 
mass and mitochondrial function, and accompanied by improved QOL.   
Peak VO2 (ml/min) will be assessed by expired gas analysis. Skeletal muscle mass will be 
measured as thigh muscle area by MRI and total lean mass by DXA.(94; 100) Mitochondrial 
function and indices of cell death will be assessed by respirometry, protein expression analyses, 
and enzyme activity assays.(23; 24; 209) QOL will be assessed by the KCCQ instrument. 
Muscle strength and quality, and cardiac and vascular function will also be assessed. 
 
Methods and Measures 
 
Design 
This is a randomized, controlled, single-blind clinical trial.  After baseline assessments, 84 
patients with HFpEF aged > 60 years will be randomly assigned to 1 of 2 groups: CR+AT or 
CR+AT+RT.  Outcomes will be assessed in blinded fashion at baseline and after the 20week 
intervention. The primary outcome is peak VO2 (in ml/min) by expired gas analysis during 
treadmill exercise to exhaustion. The secondary outcome of skeletal muscle mass will be 
measured by MRI and DXA. The secondary outcome of mitochondrial function will be assessed 
by respirometry, protein expression analyses, and enzyme activity assays on vastus lateralis 
muscle biopsy samples with RCR as a pre-planned, key outcome. Other measures will include: 
health-related QOL by the KCCQ instrument, SF-36,EuroQOL,and CES-D.  SPPB; lower 
extremity strength and power by isokinetic dynamometer; muscle quality; 6-min walk distance; 
thigh composition and LV and arterial function by MRI; and LV diastolic function by echo-
Doppler.   
 
 
 
Setting 
All study tests and procedures will be performed at Wake Forest School of Medicine and Wake 
Forest University Clinical Research Center.  Testing labs include the Cardiac Ultrasound and 
Stress Testing lab, Clinical Research Unit, Geriatric Research Center, and the Center for 
Magnetic Resonance Imaging. 
 
Subjects Selection Criteria 

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Eligible patients will have chronic, stable, well-compensated HFpEF with no changes in cardiac 
medications or symptoms and no hospitalizations or unscheduled visits for at least 6 weeks 
prior to enrollment; these criteria minimize status changes and study interruptions.(168)  To 
ensure safety for CR, patients will have a BMI > 28 kg/m2; this cutoff will still include ~75% of 
older HFpEF patients.  HFpEF will be defined using the 2013 ACC/AHA Guidelines and as 
previously described.(4; 96; 98; 100; 117-119; 124; 125; 127; 128; 181; 210)  The 4 key criteria 
include: clinical signs and symptoms of HF, a normal LV ejection fraction (>50%) by 
echocardiogram, LV diastolic dysfunction (> grade I)(59; 160) and no evidence of significant 
ischemic, valvular, pulmonary or other medical disorder to account for their symptoms.  As 
previously reported,(118; 125; 127; 128) clinical signs and symptoms of HF will be defined as 
either NHANES HF score of >3 (188) or by the Rich criteria.(185)  These criteria produce 
HFpEF patient characteristics similar to population-based studies(122; 211) and with severely 
reduced peak VO2.  Patients with contraindications to the assessments (exercise tests, MRI, 
muscle biopsy) or interventions will be excluded.  Final eligibility decisions will be made by a 
board-certified cardiologist with experience in HFpEF following the conclusion of all baseline 
assessments.   
 
Inclusion Criteria 
1. Clinical signs and symptoms of HF:  HF Clinical score ≥3 or Rich Criteria 
 
___________________Heart Failure Clinical Score (≥3 required)______________________ 
____________________Clinical Variables______________Score_____________ 
Dyspnea/difficulty breathing 
 
    Trouble with breathing (shortness of breath)  
       1 
    Hurrying on the level or up slight hill 
       1 
    At ordinary pace on the level? 
       2 
    Do you stop for breath when walking at own pace? 
       2 
    Do you stop for breath after 100 yards on the level? 
       2 
Physical examination 
 
    Heart rate (beats/min) 
 
    91 to 110 
       1 
    111+ 
       2 
Rales/crackles  
 
    Either lower lung field 
       1 
    Either lower and either upper lung field 
       2 
Jugulovenous distention 
 
    Alone 
       1 
    Plus edema 
       2 
    Plus hepatomegaly 
       2 
Chest x-ray film 
 
    Cephalization of pulmonary vessels 
       1 
    Interstitial edema 
       2 
    Alveolar fluid plus pleural fluid 
       3 
    Interstitial edema plus pleural fluid 
       3 
 
 
 
Or 
 
Rich Criteria 
- 
history of pulmonary edema, or 
- 
occurrence of 2 or more of the following with subsequent improvement with 
medical therapy and with no other identifiable cause: dyspnea on exertion, 

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paroxysmal nocturnal dyspnea, orthopnea, systemic edema, exertional 
fatigue. 
 
2. Preserved Ejection Fraction ≥50% 
3. LV diastolic dysfunction (≥ grade 1) 
4. Age ≥60 
5. BMI ≥28 
 
Exclusion Criteria 
 
Medical 
A. Valvular heart disease as the primary etiology of HF  
B. Significant change in cardiac medication or HF symptoms <6 weeks 
C. Hospitalization or urgent care visit <6 weeks 
D. Uncontrolled hypertension  
E. Uncontrolled diabetes  
F. Evidence of significant COPD defined as either: 
a. On continuous home oxygen therapy for COPD 
b. Hospitalization for COPD in last 6 months 
 
 
G. Recent or debilitating stroke 
 
H. Cancer or other noncardiovascular conditions with life expectancy less than 2 years 
I. Significant anemia (<10 gms Hgb) (eligibility will be determined by CBC) 
J. Significant renal insufficiency (eGFR < 30 ml/min/1.73 m2) (eligibility will be 
determined by comprehensive metabolic panel) 
K. Pregnancy-women of child bearing potential are excluded from participation in this 
study. 
 
Psychiatric disease- uncontrolled major psychoses, depressions, dementia, or personality 
disorder 
 
Other 
 
A. 
Plans to leave area within 1 year 
 
B. 
Refuses informed consent 
 
Screening Echocardiogram  
A. 
Left ventricular ejection fraction < 50% 
B. 
Significant valvular heart disease 
 
Exercise Test 
A. Evidence of significant ischemia 
B. Electrocardiogram: 1mm flat ST depression 
C. Stopped exercising due to chest or leg claudication or any reason other than 
exhaustion/fatigue/dyspnea 
D. Exercise SBP > 240 mmHg, DBP > 110 mmHg  
E. Unstable hemodynamics or rhythm  
F. Unwilling or unable to complete adequate exercise test 
 
Magnetic resonance imaging 
A. Indwelling metal-containing prosthesis (orthopedic, valvular, other) 
B. Pacemaker or defibrillator 
C. History of welding occupation (ocular metal debris) 
D. Uncontrollable claustrophobia 
E. Any other contra-indication to MRI 
 
Thigh muscle biopsy 
A. History of bleeding disorder 
B. Current anticoagulation 

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C. Contraindication to stopping aspirin for 1 week 
D. Allergy to topical anesthetic 
 
Sample Size 
Confidence in our estimates is enhanced because they are based on data from our recently 
completed factorial trial of CR and AT using the same patient population and primary outcome. 
The chosen sample size has adequate power for the primary and secondary aims and QOL.   
The effect of CR+AT on peak VO2 was 110.8 ml/min (7.6% relative effect) with a square root of 
the mean square error for the ANCOVA model being 107.5.  To have 90% power to detect a 
relative effect due to RT of 5.6% (absolute difference of 82.0 ml/min) in peak VO2 at the 0.05 
two-sided level of significance, the study requires 38 evaluable participants per group.  In our 
recent trial, the retention rate was excellent (93%), similar to our previously published trials in 
HFpEF.  To allow for up to 11% loss to follow-up, a total of 42 subjects per group (84 total) will 
be randomized.  In our recently completed study, we observed a 7.4 cm2 decrease in thigh 
muscle area measured by MRI in the CR+AT vs. control group. The square root of the mean 
square error was 5.98 using analysis of covariance.  With 76 evaluable subjects we will have 
80% power to detect if the decrease in muscle mass is reduced by 53% (e.g. a difference of 3.9 
cm2).  In our study of older, non-HF participants, RT had an effect of this magnitude on muscle 
retention during CR.(198).  We will confirm muscle retention with DXA measurement of total 
lean mass. In our recently completed study; we observed a 2.2 kg decrease (3.2% relative 
effect) (square root mean squared error of 28.47) providing 80% power to detect a 2.8% relative 
effect of RT. This sample size also allows adequate power for the secondary aim, mitochondrial 
function.  In our pilot study, RT increased respiratory control ratio (RCR) from 2.78 to 7.23 
(160% increase; mean square error of 6.372).  The sample size provides 80% power to detect a 
60% increase in RCR.  It also provides 80% power to detect a 10% relative difference in the 
KCCQ QOL score. The sample size also provides adequate power to detect increases in 
confirmatory measures of exercise capacity. In our recent study, we observed a 35.4%, 13.8%, 
and 13.9% increase in the AT+CR vs. control group in exercise time, VO2 reserve, and six-
minute walk distance respectively. The sample size provides 90% power to detect a 10%, 8%, 
and 6% increase in exercise time, VO2 reserve, and six-minute walk, respectively. We will also 
have 80% power to detect partial correlations as low as 0.30 at the 0.05 two-sided level of 
significance to examine independent relationships with peak VO2. 
 
Interventions  
Exercise training overview.  The exercise training regimens are based on our successful 
experience with aerobic training (AT) in 3 randomized trials in HFpEF patients,(127; 128; 156) 
and resistance training (RT) in 6 trials in older persons with disability due to conditions other 
than HF(60; 147; 148; 198)   These were effective for improving peak VO2, lean body mass, and 
QOL(22) and were safe. The exercises are based on ACSM and AHA guidelines for older 
persons and for HFrEF.(2; 65; 72; 225; 225)  The AT and RT interventions are individualized 
and progressive in nature, beginning at a low level and increasing based on specific milestones 
(Table 1) to safely deliver an optimal stimulus.  Both groups (AT-only and AT+RT) will meet 3 
times per week for 20 weeks. The total stimulus phase of the sessions for both groups will be 50 
minutes (30 min for AT and 20 min for RT). To keep the duration similar for both groups, 20 min 
of light chair-based range-of-motion, stretching, and flexibility maneuvers will be included at the 
end of the AT-only group sessions.  This attention /physical activity control will provide no 
resistance or aerobic activity. Warm-up and cool-down phases will be 5 min each with 
stretching, flexibility, and light walking for a total session time of 60 min for both groups.   
Table 1 
AT Regimen 
RT Regimen  

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Sessions will be conducted at the Wake Forest Clinical Research Center by Masters-level, 
Certified Clinical Exercise physiologists with medical supervision to ensure safety and a uniform, 
robust stimulus. This facility has been used for numerous clinical trials and has appropriate 
emergency equipment and response team, staff trained in BLS/ACLS.  To eliminate potential for 
cross-group contamination, the 2 groups will meet at different times.  
 
Aerobic exercise training. The AT prescription for each participant will be based on initial 
evaluations and stress testing results: heart rate reserve (HRR), peak VO2, RPE.  AT sessions 
will be similar for each group (AT only, and AT+RT) and include a walking circuit, and/or 
stationary cycling. Initial intensity will start at 40-50% of HRR, calculated by a standard 
formula(34) and increase gradually for the first 6-8 weeks until the participant can maintain ~60-
70% heart rate reserve for at least 20 minutes.  Exercise training intensity will be re-evaluated at 
least every 3 weeks by assessment of heart rate response during submaximal exercise.  
Depending on subject tolerance, the stimulus duration will progress to 30 minutes, performed 
continuously or as intermittent bouts.  When a subject can complete 30 minutes of continuous 
exercise, the AT intensity will be increased incrementally to 70-80%.  Periodic HR, rhythm, and 
blood pressure measures will be performed to ensure safety and compliance with the exercise 
prescription.  After completion of the AT phase, the AT-only group will perform the light chair-
based maneuvers described above for 20 min. In contrast, the AT+RT group will go on to the 20 
minute RT regimen described below.     
 
Resistance training.  Participants in AT+RT will have a short rest period before initiating the RT 
session.  The progressive RT intervention is designed to elicit adaptations resulting in increased 
skeletal muscle strength, mass, and quality.  Participants will exercise in small groups to allow a 
rotation/rest between machines and enhance the social environment.  All participants will first 
attend an orientation session where correct use of the equipment will be demonstrated.  Heart 
rate, blood pressure, and rhythm will be monitored before and after the RT session.(225)  We 
will use a gradual progression to allow participants to become familiar with the equipment, 
minimize muscle soreness and reduce potential for injury. We have had excellent safety using 
this approach. 
 
To optimize the resistance stimulus for maximal functional gain, the exercise prescription is 
based on a relative intensity level and will progress at a rate specific to each individual’s 
strength gain.  The RT regimen is based on AHA and ACSM guidelines for intensity, number of 
repetitions, number of sets, and frequency.(5; 225)  It will consist of 2 upper and 4 lower body 
exercises on Nautilus RT equipment which can accommodate different body sizes and allow 
small increments in resistance, both important considerations for low-functioning older HF 
patients.  As employed in studies of HFrEF,(29; 58; 61; 112; 143; 177; 192; 203; 208; 218) the 
RT exercises (and muscle groups affected) will be: leg curl (hamstrings), leg extension 
Intensity 
Initial: 40-50% 
HRR 
Goal: 70-80% 
HRR 
Initial: 20-30% 1-RM 
Goal: 70-80% 1-RM 
Amount 
Initial: ~15 
minutes 
Goal: 30 minutes 
Wk 1-3: 1 set of 8-12 reps 
Wk 4-20: Addition of 2nd set to volitional 
fatigue 
Type 
Walking, treadmill, 
cycling 
6 weight machines: leg curl, leg extension, 
leg press, calf raise, chest press, 
compound row 

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(quadriceps), leg press (multi-joint: knee extensors and hip flexors), calf raises (gastrocnemius), 
chest press (pectorals and triceps), and compound row (latissimus dorsi and biceps).  For the 
first 3 weeks, 1 set of 8-12 repetitions will be done on each exercise.  To deliver a progressive 
muscle stimulus, starting at week 4, a second set of each exercise performed to volitional 
fatigue will be added.  Participants will be instructed to complete the concentric phase of the 
movement in ~2-3 sec, pause briefly at the mid-point, and complete the eccentric phase in ~2-3 
sec with ~1-min rest between sets.  Using a 2:1 recovery-exercise ratio (1 min recovery after 30 
sec RT), the RT (12 total sets of RT exercises) will require ~20 minutes.   
The initial resistance (weight) setting on each piece of equipment will be based on the person’s 
one-repetition maximum (1-RM) tested on the machine. The 1-RM testing process is well 
described(2; 102; 225) and well-tolerated by older adults, including those with HFrEF.(177) 
During the first 3 weeks, the weight on each exercise will be 20-30% of participants’ 1-RM.  In 
addition to adding a 2nd set of each exercise, beginning at week 4, the resistance will increase to 
40-50% of 1-RM. For the remaining 20 weeks, if >12 repetitions are completed on the 2nd set in 
2 consecutive sessions, the weight will be increased for the next session. The 1-RM testing will 
be repeated every 4 weeks to assess gains in strength and help ensure optimal resistance 
settings. The goal will be to achieve 70-80% 1-RM for the last 8 weeks of the study. Amount of 
weight lifted, number of repetitions, and sets completed for each session will be recorded.(225) 
Our experience and others’ indicate this regimen will produce sufficient stimulus time & load 
progression to elicit the desired neuromuscular adaptations.(2; 80; 102)   
 
Adherence, retention, and intercurrent illness.  We will utilize multiple behavioral management 
strategies to create a positive exercise environment and ensure compliance, including promptly 
contacting participants who miss a session, scheduling makeup sessions, and individual 
counseling sessions with Dr. Brubaker to discuss strategies to promote attendance and limit 
obstacles to participation.  Using these strategies in 3 prior exercise trials in older HFpEF 
patients, we had excellent attendance (88%) and retention (87-93%). If a participant has a 
change in health status or intercurrent illness, Dr. Kitzman will communicate with the personal 
physician to determine suitability for returning to the intervention, and with Dr. Brubaker who will 
determine need for modifications to the exercise prescription. In prior studies, only 3% of 
patients had intercurrent illness requiring interruption of the intervention and all but 1% were 
able to return to complete the study.  If there is a substantial change in beta-blocker dosage, we 
will re-evaluate the heart rate range.  
 
Caloric restriction intervention. The caloric restriction intervention will be supervised by Denise 
Houston, PhD, RD, Co-I, in coordination with Linda Easter, MS, RD, LDN and conducted in 
accord with published recommendations for overweight/ obese older adults (213; 221) similar to 
our recent trial in obese older HFpEF patients.  A hypo caloric diet (lunch and supper daily, plus 
snacks), will be prepared by the CRU Metabolic Kitchen.  Portions are weighed individually. 
Menus will be provided to guide food selection and preparation of daily breakfasts, and 
participants will be reminded to consume only the items provided and to keep a log. Participants 
will pick up meals 3 times/week; in addition to this frequent staff contact, there will be weekly 
weigh-ins and progress review sessions, further ensuring safety.  Participants choose from a 
36-item menu, enhancing acceptance. We will employ several strategies to enhance 
compliance including weekly individual counseling sessions if diet records or inadequate weight 
loss suggest suboptimal compliance and allowance of 2 ‘free’ days/month. We have 
successfully conducted several weight loss trials in older adults, including our recently 
completed trial in HFpEF patients and achieved 99% meal compliance, consistent weight loss, 
with excellent safety and no adverse events.(16; 198)   
 

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The diet will be adjusted to achieve a 300 kcal/day deficit. Our preliminary data in this 
population indicate this is safe and when combined with exercise will produce a total weight loss 
of ~10.0 kg (about 9.5% body weight) over the 20-week intervention.  Individual calorie levels 
will be prescribed using measured RMR by indirect calorimetry(51) which in our preliminary 
study yielded an average daily intake of ~1650kcal/day.  To further ensure safety, no participant 
will receive less than 1100 kcal/day for women and 1300kcal/day for men, and total weight loss 
will be capped at 15% of body weight or a BMI of 25 kg/m2.  The tailored meals provide a 
balanced diet with <30% calories from fat and 1.2 g protein/kg/day.(13; 79; 162)    Overall, 
participants will receive ~1.5 gm protein/kg/day, ensuring adequate protein intake, consistent 
with recommendations for older adults undergoing weight loss(26; 55; 134; 154; 222) and the 
Dietary Reference Intake Standards for Macronutrients.(13; 162)  Per PROT-AGE 
recommendations,(13) patients with eGFR < 30 ml/min/1.73 m2 will be excluded. 
 
Outcome Measure(s) 
All outcomes assessments will be performed at baseline and following the 20-week intervention 
and will be assessed by observers blinded to intervention group assignment when feasible.  
Written, informed consent will be obtained from each subject by trained research staff using an 
IRB-approved consent form and study protocol.   
 
Exercise testing.  Exercise tolerance will be measured as peak VO2. The primary outcome will 
be determined during a progressive exercise test on a motorized treadmill according to 
standards established by the American Heart Association and as previously described in 
detail.(33; 83; 125; 176; 224)  The standardized extended modified Naughton protocol will be 
used which is well suited to older heart failure patients.(75; 227)  Expired gases will be 
measured with a MedGraphics (Minneapolis, MN) Ultima system following calibration for VO2, 
VCO2.(125; 155; 165)  Patients will be encouraged to give a maximal, exhaustive effort as 
judged by either an RER > 1.05 or >90% age predicted maximal heart rate.  Blood pressure, 
heart rate, and ECG will be continuously monitored. The tests will be administered by a 
Master’s-level exercise physiologist, and attended by a cardiologist.  We have administered > 
800 maximal exercise tests in older heart failure patients in clinical trials without a significant 
adverse event.  VO2 will be assessed by averaging the final three 15 sec averages, ventilatory 
threshold by the Wasserman method, and VE/VCO2 slope as previously described in detail in 
older patients with HFpEF in our laboratory.(32; 114; 125; 145; 155) 
 
Six-minute walk distance (6MWD).  The 6MWD test is a well-established outcome measure in 
HF.  It is valid and reproducible in patients with a wide range of physical function, predicts 
clinical events, and responds to interventions.(1; 54; 129; 195) We showed that it is as 
predictive of clinical events as exercise oxygen consumption,(70) and improves with AT, 
including in older HFpEF patients.(128; 167)  The 6MWD will be conducted by the method of 
Guyatt et al(90) at the first and last visits to the Wake Forest University Clinical Research 
Center utilizing a standardized script as previously reported.(1; 70; 71)  Total distance covered 
and number and duration of rests and symptoms will be recorded. 
 
Short physical performance battery (SPPB). The SPPB is a measure of physical function that 
incorporates three components: usual gait speed measured over 4 meters, timed repeated chair 
rise, and standing balance with progressively narrow base of support.  Each component is 
scored on a 0-4 scale and then summed to provide an overall score range of 0-12.  We will 
evaluate the overall SPPB as well as each component.  A change of 1 point in the overall SPPB 
score has been identified as representing a substantial change and 0.5 points as a small 
meaningful change.(172) 

Amendment 3 6/2/2022 
 
12 
 
Lower extremity muscle strength will be assessed as maximal isokinetic knee extensor strength 
(Newton-meters, Nm) in both legs using an isokinetic dynamometer (Biodex®) with the 
participant seated and the hips and knee flexed at 90°. For consistency, seat height and depth 
will be recorded and the best of 2 trials will be selected. Test-retest reliability of knee extensor 
maximal voluntary contraction is high among older adults.(38; 189)   
 
Hand grip strength will be measured in both hands using an adjustable grip strength 
dynamometer.(113)  The participant will be seated with the elbow at 90 degrees.  Two trials will 
be recorded for each hand.   
 
Body composition will be measured by dual-energy x-ray absorptiometry (DXA, Hologic Delphi 
QDR).(100) Scans will be analyzed by a certified DXA technician experienced in body 
composition measures in older adults.(100)  Whole body DXA estimates body and regional 
mass, lean mass, fat mass, and bone.  Percent lean mass will be calculated as lean mass / total 
mass x 100.  Total and appendicular skeletal muscle mass will be estimated using the 
Heymsfield method.(42)  Precision of our DXA lean mass measurements is excellent (CV = 
0.51%).  
 
Thigh muscle composition will be assessed by MRI on a 3.0 T Skyra scanner (Siemens) as 
previously described.1 The left thigh will be scanned using a cardiac phased array coil.  A scout 
view will be obtained by single phase, multi-slice coronal acquisition. The slices will be 10 mm 
thick with a 5-mm gap, with a 256 x 128 matrix, a 40-cm field of view, a 30 flip angle, an auto 
repetition time, and a minimum echo time. Images will be transferred to a dedicated image 
analysis workstation and the slice corresponding to a constant location of the mid-thigh will be 
selected.(111)  Cross-sectional areas of skeletal muscle (SM), intermuscular fat (IMF), and 
subcutaneous fat (SCF) will be measured using commercially available software (Tomovision, 
Montreal, Quebec).  This technique was been validated against cadaver specimens.(152) 
Duplicate tests from 10 random subjects analyzed in a blinded fashion yielded correlation 
coefficients for SM, IMF, and SCF of 0.99, 0.98, and 0.99 respectively, similar to others.(105) 
We will use fat-water separation by the Dixon method, recently shown to enhance precision of 
muscle mass measures.(228)  DXA provides total lean mass and is widely available; MRI 
provides regional thigh mass and is independent of fluid fluctuation which could affect DXA 
measurements.  
 
Muscle quality will be calculated as the ratios of knee extensor strength to thigh muscle area 
assessed by MRI (Nm/cm2) and leg lean mass assessed by DXA (Nm/kg lean mass).  Muscle 
quality for the upper extremity will be calculated using dynamometer grip strength and DXA arm 
lean mass. 
Health-related QOL. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a 23-item self-
administered questionnaire that quantifies physical function, symptoms, social function, and 
self-efficacy in HF patients.  It is a well-established survey that is valid and sensitive to physical 
and psychological effects from HF and its treatment, including with exercise in our previous 
trials of older HFpEF patients.(66; 68) KCCQ score is an independent predictor of exercise 
capacity,(66; 67) all-cause mortality, and cardiovascular death and hospitalization,(130) and is 
more sensitive to change than other QOL measures.(88; 202)  In addition, the SF-36, EuroQOL, 
MOCA and CES-D will be administered. 
LV structure / function and arterial function will be assessed by cardiac MRI (CMR) and echo-
Doppler as previously described.12,13,146,231  Although our hypotheses focus on skeletal muscle, 
assessing the effect of RT on cardiovascular function will allow us to examine safety and 

Amendment 3 6/2/2022 
 
13 
potential benefit. This can be accomplished in the same setting as thigh imaging with a single 
30-minute exam, minimizing participant burden and cost.  RT can increase LV mass while CR 
can decrease it; RT can also increase arterial stiffness.(153; 225) CMR is the most sensitive 
test for changes in LV mass.(108; 158) LV volumes, ejection fraction, and strain, aortic 
distensibility and left atrial (LA) volume will be measured using a Steady State Free Precession 
cine protocol(35; 40; 41; 106-108; 118; 138; 163; 216) and body coil.231  A stack of short axial 
images of the LV and LA will be obtained.(141)  Epicardial / endocardial borders will be traced 
using a semi-automatic method (QMASS 7.1, Medis) and LV and LA volumes will be calculated 
by Simpson's rule(25; 118; 163)  Circumferential LV strain will be assessed by myocardial tissue 
tagging(140) and analyzed using the Harmonic Phase technique.(82; 169)  Aortic distensibility 
will be measured using phase-contrast gradient-echo sequences.(39; 106; 109; 118)   
 
Echo-Doppler will be performed with a Phillips iE33 (Andover, MA) instrument according to ASE 
recommendations, as previously described.(118; 125; 126; 139; 220) Early mitral annulus 
velocity by tissue Doppler (Ea) reflects diastolic relaxation(161; 204) and ratio of peak early 
filling velocity (E) to Ea (E/Ea)  estimates LA pressure.(159; 204; 206) We’ve shown these 
outcomes correlate with peak VO2, have prognostic value, and respond to interventions.(81) We 
will assess carotid artery distensibility and carotid-femoral pulse-wave velocity as previously 
described.(118; 124; 127) Measures will be performed in triplicate by blinded personnel. 
 
Biomarkers:  B-type natriuretic peptide, an established biomarker of HF severity and treatment 
response, will be analyzed on baseline/follow-up frozen plasma using a standardized, commercial 
radioimmunoassay.(118; 125; 127; 128) 
 
Thigh muscle tissue will be obtained as previously described from the left vastus lateralis by 
percutaneous needle biopsy under local anesthesia using aseptic technique and a 6mm 
University College Hospital needle and a 60cc syringe for suction.  Over 700 muscle biopsies 
have been performed using this technique in older research participants, including HFpEF, with 
good tissue yields (161±79 mg, >100 mg in 83%) and no serious complications.(164) The 
portion intended for immunoblot analyses is harvested and immediately stored at -80°C.  The 
portion intended for respirometry will be processed as described below.  
 
Mitochondrial function will be examined comprehensively by analysis of key aspects of 
mitochondrial physiology (Table 2).  Measures for this exploratory aim were selected to be 
relevant to older, obese patients with HFpEF and the effects of RT.   
Mitochondrial Physiology 
Table 2.  Mitochondrial Outcome Assessments 
Respiratory Function 
 Respiratory control assessed with complex I, II and β-oxidation specific substrates (isolated 
mitos) 
 Respirometric kinetics and OXPHOS efficiency (Permeablized muscle fiber bundles- PmFBs) 
Content / Structure / 
Biogenesis 
 Content - citrate synthase activity; Expression of Porin, cardiolipin,Cox4, and Complexes I-V 
(Western blot); mitochondrial isolation yields  
 Structure – fiber type, cross-sectional area (histology); Mfn1, Mfn2, MFF, DRP1, Fis1, OPA1 
expression (Western blot) 
 Biogenesis - PGC1α, TFAM, SIRT3 expression (Western blot) 
Mitochondrial-Mediated 
Cell Death 
 Bcl-2, Bax, ICE, p53, Fas receptor protein, and Cyclophilin D expression (Western blot) 
 Susceptibility to calcium-induced mPTP opening (PmFBs) 
 Mitochondrial H2O2 emitting potential (PmFBs) 
 
Muscle biopsy yield in our preliminary studies in HFpEF averaged 138 mg, sufficient for 
completion of all proposed experiments;  20-30 mg of tissue to isolate mitochondria,(24) 10-15 
mg to prepare permeabilized fiber bundles (PmFB)(6), and the remainder (~100 mg) frozen for 
protein expression/histochemistry.   

Amendment 3 6/2/2022 
 
14 
 
Mitochondrial Respiratory Function will be assessed in parallel by complementary techniques 
using isolated mitochondria and PmFBs.(30; 173; 175) Isolated mitochondria (5 µg) will be 
assessed with the Seahorse Bioscience XF24 system as a higher throughput system to 
maximize screening for potential defects/changes in respiratory control at key points in the 
electron transport chain (ETC) or tricarboxylic acid (TCA) cycle as previously described.(209)  
Basal (state 2), ADP-stimulated (state 3), non-ADP-stimulated (state 4) and maximally 
uncoupled (+FCCP) respiration will be determined under substrate conditions that distinguish 
potential dysfunction at the level of (1) the PDH complex (pyruvate/malate) vs (2) the TCA cycle 
and/or complex I (glutamate/malate), (3) complex II (succinate/rotenone), (4) complex I + II 
(glutamate/malate/succinate), and (5) β-oxidation (palmitoyl-carnitine).  Data will be expressed 
as O2 consumption per mg mitochondrial protein. The PmFB approach will be used to determine 
in greater detail the kinetics of ADP-stimulated respiration (i.e., Km and Vmax) as previously 
described.(173; 174)  High-resolution respirometry (Oroboros Oygraph-2k, Innsbruck Austria) 
coupled with direct monitoring of ATP synthesis (fluorometrically) will be used to determine 
OXPHOS efficiency (ATP /O2 ratio) during respiration supported by glutamate/malate or 
succinate/rotenone.(87) All data will be expressed per mg dry weight and normalized for 
mitochondrial content. RCR, a key pre-planned outcome, will be calculated as the ratio of state 
3/state 4.(30)   
 
Mitochondrial Content, Structure, and Biogenesis.  Mitochondrial content will be assessed by 
immunoblot (Porin, cardiolipin, and COXIV) and enzyme activity analysis (citrate 
synthase).(132) Expression of Complex I-V of the ETC will be determined using the MitoProfile 
human antibody cocktail (Abcam, ab110411). Regulators of mitochondrial biogenesis (PGC1α, 
TFAM, and SIRT3) and mitochondrial dynamics (Mfn1, Mfn2, MFF, DRP1, Fis1, and OPA1) will 
be determined by Western blot.(191)   
 
Mitochondrial Mechanisms for Skeletal Muscle Loss, a phenomenon related to reduced peak 
VO2 in HFrEF(3) but never examined in HFpEF, will be assessed by using: 1) expression of 
Bax, ICE, p53, Fas receptor protein, and cyclophilin D as indices of programmed cell 
death;(171) 2) Bcl-2 as an index of protection against apoptosis; and 3) calcium retention 
capacity and H2O2 emission in PmFBs as indices of susceptibility to opening of the 
mitochondrial permeability transition pore and mitochondrial failure.(6; 173) 
 
Physical Activity will be assessed using two accelerometers, the Actigraph GT3X+ and the 
Lifecorder EX. The Actigraph monitor is a small device worn on the non-dominant wrist, and the 
Lifecorder monitors is a small device worn on the right hip, attached to the waistband. Both 
monitors assess variables related to physical activity: energy expenditure, steps, and physical 
activity duration, intensity, and frequency.  Participants will wear both devices for 7 continuous 
days during baseline and follow-up testing to assess changes in physical activity pre to post 
intervention. There are no risks associated with wearing an activity monitor. 
 
 
 
 
 
 
 
 
 
 

Amendment 3 6/2/2022 
 
15 
 
 
 
Study visit timeline. 
 
 
Analytical Plan 
The trial is a 2-arm, randomized, parallel design to test the effect of adding RT to the regimen of 
CR+AT shown as most beneficial in our recent trial.  Peak VO2 (ml/min) will be the primary 
outcome measure using an intention-to-treat analysis.  Analyses will be conducted using 
analysis of covariance (ANCOVA) with baseline peak VO2, age and gender as predefined 
covariates. Similar analyses will be done for the secondary outcomes, skeletal muscle mass 
and mitochondrial function, QOL, and other outcomes. Partial correlation analysis adjusting for 
age and gender will be done to correlate changes in peak VO2 with the other key outcomes of 
interest (muscle mass, mitochondrial function, and QOL). 
 
Data Management  
The REDCap (Research Electronic Data Capture) system will be used for this trial; as we have 
used this system previously, many data entry fields, screens, and data checks are in place.   
 
Human Subjects Protection 
 
Informed Consent 
Written informed consent will be obtained from each subject.  The study coordinator will 
obtain informed consent in private examination room.  Study staff will give adequate time for 
the participant to review the consent form and ask questions.  Each participant will be given 
a copy of the signed consent form. 
 
Confidentiality and Privacy 
Confidentiality will be protected by collecting only information needed to assess study 
outcomes, minimizing to the fullest extent possible the collection of any information that 
could directly identify subjects, and maintaining all study information in a secure manner.  To 
help ensure subject privacy and confidentiality, only a unique study identifier will appear on 
the data collection form.  Any collected patient identifying information corresponding to the 
unique study identifier will be maintained on a separate master log.  The master log will be 
kept secure, with access limited to designated study personnel.  Following data collection 
subject identifying information will be destroyed at the earliest opportunity, consistent with 
data validation and study design, producing an anonymous analytical data set.  Data access 
will be limited to study staff.  Data and records will be kept locked and secured, with any 
computer data password protected.  No reference to any individual participant will appear in 
reports, presentations, or publications that may arise from the study. 
Table 3.  Assessment Timeline                      Visit code 
SV 
BV1 
BV2 
BV3 
Interv. 
FV1 
FV2 
FV3 
Activity/assessment                                 Week number 
 
 
 
 
0-20 
 
 
 
Informed consent, screening, demographics, 
echocardiogram/Doppler, dietary interview 
X 
 
 
 
 
 
 
 
Physical exam, medical history, medication review 
X 
 
 
 
 
X 
 
 
RMR, Blood draw, questionnaires, Exercise test 
 
X 
 
 
 
X 
 
 
SPPB, Muscle strength, DXA & MRI scans 
 
 
X 
 
 
 
X 
 
Muscle biopsy 
 
 
 
X 
 
 
 
X 
Randomization and dietary education 
 
 
 
X 
 
 
 
 

Amendment 3 6/2/2022 
 
16 
 
 
Data and Safety Monitoring 
The principal investigator will be responsible for the overall monitoring of the data and safety 
of study participants.  The principal investigator will be assisted by other members of the 
study staff.  If during the study assessments, an incidental medical finding occurs, the 
principal investigator will be notified immediately.  Findings will also be reported to the 
patient’s personal physician for further determination of appropriate care. 
 
Although a DSMB was not required by NIH because it was deemed a low risk protocol, we 
have elected to utilize a DSMB for this study, the NIH-supported, Pepper Center DSMB, 
which successfully monitored the recently completed prior cycle of this project, which had a 
similar patient population, methods, and intervention.   This DSMB monitors all Pepper 
Center supported projects.  These DSMB members have appropriate expertise for this 
project and are:  Curt Furberg, MD (Chair); Paul Laurienti, MD, Jack Rejeski, PhD, Tim 
Howard, PhD, Douglas Case, PhD.   This plan has been approved by Dr. Steve Krichevsky, 
Director of the Aging Center and PI of the Wake Forest Pepper Center, and by the NIA 
program project officer and director.    
 
The DSMB will be charged with monitoring study-wide safety and clinical events on a regular 
basis (semi-annually).  In particular, the DSMB will review the following SAE’s and the 
following specific clinical and safety events: death, hospitalization, hospitalization/ 
observation unit stay lasting less than 24 hours, emergency room visit, urgent clinic visits, 
and adverse events occurring while the participant is performing the SECRET II intervention 
(including angina, syncope/presyncope, palpitations, symptomatic hypoglycemia and/or 
falls), cardiovascular events (including worsening heart failure, acute coronary syndrome, 
arrhythmia, and stroke), nursing home placement, and injury (or fall).  
 
 
Reporting of Unanticipated Problems, Adverse Events or Deviations 
Any unanticipated problems, serious and unexpected adverse events, deviations or protocol 
changes will be promptly reported by the principal investigator or designated member of the 
research team to the IRB and DSMB. 
 
 
 
Long-Term Follow-Up Visit 
The purpose of this long-term follow-up visit is to examine the long-term level of weight 
change (maintenance, continued loss, or regain) following a short-term weight-loss 
intervention and its effect on exercise capacity, physical function, quality of life, and body 
composition.  A long-term follow-up visit will be conducted to assess changes in weight, 
VO2peak, physical function, quality of life, and body composition.  All long-term follow-up 
visits will take place following the completion of the original study.  Further, the visit(s) will 
take place no sooner than 1 year following study intervention completion in any participant.  
Therefore, this long-term follow-up visit will occur between 8 months and 4 years following 
study intervention completion for each participant.   
The exercise testing, physical performance battery, health-related quality of life, body 
composition by DXA, and an MRI will be conducted.  In addition, physical activity monitoring, 
basic vital signs (height, weight, blood pressure) will be collected and a review and update 
of medical history will be performed to check for any possible or new contraindications to 
exercise testing.  The blood and stool sample will also be collected at this visit. 

Amendment 3 6/2/2022 
 
17 
This visit should take ~2-4 hours.  It may be done in 1 or 2 visits, depending on study 
participant desire.   
 
 
SECRET II Physical Activity Sub-Study (PASS)-COSMED K5 
 
Background  
The results of our Studies Examining Caloric Restriction and Exercise Trial (SECRET I) 
demonstrate that 20 weeks of moderate intensity aerobic exercise (AE) together with caloric 
restriction (CR) was safe and efficacious for individuals with heart failure and preserved ejection 
fraction (HFpEF) 1.  Despite many positive changes, the AE + CR combination resulted in a 
significant reduction of total muscle mass in these HFpEF patients 1. Therefore, we are currently 
examining the benefit of incorporating resistance exercise training (RE) to improve body 
composition and exercise capacity in participants with HFpEF in the SECRET II study.  
Moderate intensity AE is generally prescribed at 60-80% of the patient’s maximum oxygen 
consumption (VO2peak) as this level is a safe and effective for HF patients 2.  Since VO2 cannot be 
easily measured during AE or RE, heart rate (HR) is commonly used as a surrogate measure to 
regulate exercise intensity.  While previous research has shown that % HR and % VO2peak during 
AE are well correlated in clinical populations 3, this relationship has not been examined in 
HFpEF patients.  Performing AE at a low intensity (i.e. < 60% VO2peak) may fail to produce 
optimal physiological benefits, whereas performing AE at an intensity that is too high (i.e. > 80% 
VO2peak) may be intolerable and potentially dangerous to these HFpEF patients. Thus, it is 
important to ensure that HFpEF patients are performing AE and RT in the proper range of their 
% VO2peak to ensure their safety and to stimulate maximal physiological benefits.   
 
Measuring VO2 during ambulatory AE or RT was not possible until the development of the 
portable COSMED K5 system (see photo below).  This COSMED K5 system, obtained by the 
Health and Exercise Science (HES) department in 2016, can be used to measure VO2 outside of 
the lab environment, while patients are performing their normal activities, and/or AE and RE.  
This will be the first time such a measurement/study will be performed in HFpEF patients. 
 
In addition to examining the relationship between % VO2 and % HR during AE and RE in 
HFpEF patients, the COSMED K5 allows for the direct determination of energy expenditure (i.e 
kcals).  In addition to measuring the energy expenditure (in kcals) during AE, we can also 
determine the additional energy expenditure associated with preforming RE in these HFpEF 
patients.  It’s unknown if adding RE to AE will result in a significant increase in energy 
expenditure versus AE alone in HFpEF patients.  These findings will have important 
implications for weight loss and body composition changes and have not been assessed in 
HFpEF patients.  
 
Based on existing literature and direct experience we developed the following hypotheses; 
1. The average % HR will not be significantly different that the average % VO2peak 
during either the AT only or AT + RT sessions. 
2. The average physical activity energy expenditure (PAEE) during a typical exercise 
session AT or AT + RT will be significantly less than the recommended 300 kcal/day. 
3. AT + RT will result in significantly higher PAEE than AT alone. 
 

Amendment 3 6/2/2022 
 
18 
 
 
 
 
Methods.   
This research project would be conducted in HF patients that are already participating in the 
SECRET II study funded by the NIH and approved by WFUBMC IRB.   Participants in 
SECRET II are randomly assigned to two groups; CR + AE or CR+AE+RE. The SECRET II 
intervention is 20 weeks and will eventually enroll up to 90 HF patients over a 4 year period. 
This proposed sub-study would be conducted on 15-20 of the HFpEF patients already 
performing AE with/without RE in SECRET II study. All data collection for this sub-study 
would take place at the Health and Exercise Science Department’s Clinical Research Center 
under the supervision of Dr. Brubaker and will be stored on encrypted computers and/or in 
locked files/offices.   
 
Participants in SECRET II would be asked to voluntarily participate in two experimental 
sessions (one near the beginning and one near the end of their 20 week intervention). For each 
session the participants would wear the portable COSMED K5 system while performing their 
normal AE + RE exercise session.  Expired air will be collected continuously during the entire 
exercise session that lasts ~ 1 hr.  From the expired air collected by the COSMED K5 mask, the 
VO2 for each minute will be obtained and compared to HR values that are obtained from a wrist 
worn heart rate monitor (see photo below).  This data would allow us to determine if these 
HFpEF patients are at the appropriate intensity levels during AE + RE.  
 
Furthermore, since we will be able quantify the physical activity energy expenditure (PAEE 
measured in kcal) from the VO2 values obtained during both AE and AE + RE, we can compare 
the two groups to determine if there are additional metabolic costs associated with RT.  Finally, 
to determine the reliability of these measures (VO2, HR, and kcal) we will ask the first 5 
participants in the study to perform a second identical experimental session ~ 1 week after the 
first session.  
 
Risks. 
There are no additional risks, beyond those associated with AE and RE, for the volunteers in this 
sub-study.  Volunteering participants will perform their “normal” AE + RE session as part of 
SECRET II while wearing the COSMED K5 mask.  This mask comfortably covers the subject’s 
mouth/nose and allows, through a one-way valve system, for normal inhalation of room air and 
expiration to the analyzer.  If at any point the mask becomes uncomfortable to the participant, it 
will be removed and the experimental session will be terminated.   This is the same mask the 
participant wears during their baseline exercise test so they will already be familiar with it.   
 
References 
 
1. Kitzman DW, Brubaker P, Morgan T, Haykowsky M, Hundley G, Kraus WE, Eggebeen 
J, Nicklas BJ.  Effect of Caloric Restriction or Aerobic Exercise Training on Peak 
Oxygen Consumption and Quality of Life in Obese Older Patients With Heart 
Failure With Preserved Ejection Fraction: A Randomized Clinical Trial.  JAMA. 
2016 Jan 5;315(1):36-46. 

Amendment 3 6/2/2022 
 
19 
 
2. O'Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus 
WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, 
McKelvie RS, Zannad F, Piña IL; HF-ACTION Investigators.  Efficacy and safety of 
exercise training in patients with chronic heart failure: HF-ACTION randomized 
controlled trial. JAMA. 2009 Apr 8;301(14):1439-50.  
 
3. Joo KC, Brubaker PH, MacDougall A, Saikin AM, Ross JH, Whaley MH. Exercise 
prescription using resting heart rate plus 20 or perceived exertion in cardiac 
rehabilitation. J Cardiopulm Rehabil. 2004 May-Jun;24(3):178-84 
 
COSMED K5 
 
 
 
 
Garmen HR monitor 
 
 
 
References 
 
 
 
1.   ATS Statement: Guidelines for the Six-Minute Walk Test. Am J Respir Crit Care Med 
166: 111-117, 2002. 
 
2.  ACSM. ACSM's Guidelines for exercise testing and prescription.  Philadelphia: 
Lippincott Williams & Wilkins, 2013. 

Amendment 3 6/2/2022 
 
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3.  Adams V, Jiang H, Yu J, Mobius-Winkler S, Fiehn E, Linke A, Weigl C, Schuler G 
and Hambrecht R. Apoptosis in skeletal myocytes of patients with chronic heart failure 
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4.  American College of Chest Physicians HRSaISfHaLT. 2013 ACCR/AHA Guideline 
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XHT and Deswal A. Impact of Noncardiac Comorbidities on Morbidity and Mortality in 
a Predominantly Male Population With Heart Failure and Preserved Versus Reduced 
Ejection Fraction. J Am Coll Cardiol 59: 998-1005, 2012. 

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