bims-exemet Biomed News
on Exercise metabolism
Issue of 2021‒02‒21
fourteen papers selected by
Javier Botella Ruiz
Victoria University

  1. Nat Commun. 2021 02 15. 12(1): 1041
    Klein AB, Nicolaisen TS, Ørtenblad N, Gejl KD, Jensen R, Fritzen AM, Larsen EL, Karstoft K, Poulsen HE, Morville T, Sahl RE, Helge JW, Lund J, Falk S, Lyngbæk M, Ellingsgaard H, Pedersen BK, Lu W, Finan B, Jørgensen SB, Seeley RJ, Kleinert M, Kiens B, Richter EA, Clemmensen C.
      Growing evidence supports that pharmacological application of growth differentiation factor 15 (GDF15) suppresses appetite but also promotes sickness-like behaviors in rodents via GDNF family receptor α-like (GFRAL)-dependent mechanisms. Conversely, the endogenous regulation of GDF15 and its physiological effects on energy homeostasis and behavior remain elusive. Here we show, in four independent human studies that prolonged endurance exercise increases circulating GDF15 to levels otherwise only observed in pathophysiological conditions. This exercise-induced increase can be recapitulated in mice and is accompanied by increased Gdf15 expression in the liver, skeletal muscle, and heart muscle. However, whereas pharmacological GDF15 inhibits appetite and suppresses voluntary running activity via GFRAL, the physiological induction of GDF15 by exercise does not. In summary, exercise-induced circulating GDF15 correlates with the duration of endurance exercise. Yet, higher GDF15 levels after exercise are not sufficient to evoke canonical pharmacological GDF15 effects on appetite or responsible for diminishing exercise motivation.
  2. J Biol Regul Homeost Agents. 2021 Feb 17. 35(1):
    Zhou L, Chen SY, Han HJ, Sun JQ.
      Regular exercise induces intramuscular triglyceride accumulation with improved mitochondrial ability, but the mechanism remains unknown. The glycolytic product of exercise, lactate, has long been rec-ognized to suppress lipolysis and promote lipogenesis in adipocytes through inhibition of the cAMP-PKA pathway by activation of the G protein-coupled receptor (GPR81). However, whether lactate results in a similar process in skeletal muscle is unclear. Here, by using intramuscular injection of lactate to the gastrocnemius, the lipid metabolism effects were investigated in rat skeletal muscle. Firstly, the lactate-injection effect was verified by comparing changes in blood lactate levels from injection and exercise (30 min, 31 m/min, treadmill running). After five weeks of lactate intervention, intramuscular triglyceride levels in the gastrocnemius and the proportion of epididymis adipose mass to body weight increased. Chronic intramuscular injection of lactate elevated lactate receptor, GPR81, and reduced cAMP response element-binding (CREB) and P-CREB abundance in the gastrocnemius. Additionally, there was a significant decline in lipolytic-related proteins (AMPK, P-AMPK, P-HSL, CPT-1B, TGF-β2, SDHA) and a significant increase in fat synthesis proteins (SREBP-1C, PPAR-γ). Surprisingly, mitochondrial biomarkers (PGC-1α, CS) were also increased in the gastrocnemius, suggesting that chronic lactate might promote mitochondria biogenesis. Together, these results demonstrated that lactate may play a crucial role in triglyceride storage and mitochondria biogenesis in the skeletal muscle of rat.
    Keywords:  GPR81; Lactate; cAMP; intramuscular triglyceride; skeletal muscle
  3. J Transl Med. 2021 Feb 16. 19(1): 71
    Harper C, Gopalan V, Goh J.
      Skeletal muscle aging is associated with a decline in motor function and loss of muscle mass- a condition known as sarcopenia. The underlying mechanisms that drive this pathology are associated with a failure in energy generation in skeletal muscle, either from age-related decline in mitochondrial function, or from disuse. To an extent, lifelong exercise is efficacious in preserving the energetic properties of skeletal muscle and thus may delay the onset of sarcopenia. This review discusses the cellular and molecular changes in skeletal muscle mitochondria during the aging process and how different exercise modalities work to reverse these changes. A key factor that will be described is the efficiency of mitochondrial coupling-ATP production relative to O2 uptake in myocytes and how that efficiency is a main driver for age-associated decline in skeletal muscle function. With that, we postulate the most effective exercise modality and protocol for reversing the molecular hallmarks of skeletal muscle aging and staving off sarcopenia. Two other concepts pertinent to mitochondrial efficiency in exercise-trained skeletal muscle will be integrated in this review, including- mitophagy, the removal of dysfunctional mitochondrial via autophagy, as well as the implications of muscle fiber type changes with sarcopenia on mitochondrial function.
    Keywords:  Aging; Exercise; Mitochondria; Skeletal muscle
  4. Int J Sport Nutr Exerc Metab. 2021 Feb 17. pii: ijsnem.2020-0274. [Epub ahead of print] 1-8
    Shad BJ, Thompson JL, Mckendry J, Holwerda AM, Elhassan YS, Breen L, van Loon LJC, Wallis GA.
      The impact of resistance exercise frequency on muscle protein synthesis rates remains unknown. The aim of this study was to compare daily myofibrillar protein synthesis rates over a 7-day period of low-frequency (LF) versus high-frequency (HF) resistance exercise training. Nine young men (21 ± 2 years) completed a 7-day period of habitual physical activity (BASAL). This was followed by a 7-day exercise period of volume-matched, LF (10 × 10 repetitions at 70% one-repetition maximum, once per week) or HF (2 × 10 repetitions at ∼70% one-repetition maximum, five times per week) resistance exercise training. The participants had one leg randomly allocated to LF and the other to HF. Skeletal muscle biopsies and daily saliva samples were collected to determine myofibrillar protein synthesis rates using 2H2O, with intracellular signaling determined using Western blotting. The myofibrillar protein synthesis rates did not differ between the LF (1.46 ± 0.26%/day) and HF (1.48 ± 0.33%/day) conditions over the 7-day exercise training period (p > .05). There were no significant differences between the LF and HF conditions over the first 2 days (1.45 ± 0.41%/day vs. 1.25 ± 0.46%/day) or last 5 days (1.47 ± 0.30%/day vs. 1.50 ± 0.41%/day) of the exercise training period (p > .05). Daily myofibrillar protein synthesis rates were not different from BASAL at any time point during LF or HF (p > .05). The phosphorylation status and total protein content of selected proteins implicated in skeletal muscle ribosomal biogenesis were not different between conditions (p > .05). Under the conditions of the present study, resistance exercise training frequency did not modulate daily myofibrillar protein synthesis rates in young men.
    Keywords:  deuterated water; exercise frequency; muscle protein synthesis; skeletal muscle
  5. Front Physiol. 2020 ;11 596351
    Touron J, Costes F, Coudeyre E, Perrault H, Richard R.
      A characteristic feature of eccentric as compared with concentric exercise is the ability to generate greater mechanical loads for lower cardiopulmonary demands. Current evidence concurs to show that eccentric training translates into considerable gains in muscle mass and strength. Less is known, however, regarding its impact on oxygen transport and on factors to be considered for optimizing its prescription and monitoring. This article reviews the existing evidence for endurance eccentric exercise effects on the components of the oxygen transport system from systemic to mitochondria in both humans and animals. In the studies reviewed, specially designed cycle-ergometers or downhill treadmill running were used to generate eccentric contractions. Observations to date indicate that overall, the aerobic demand associated with the eccentric training load was too low to significantly increase peak maximal oxygen consumption. By extension, it can be inferred that the very high eccentric power output that would have been required to solicit a metabolic demand sufficient to enhance peak aerobic power could not be tolerated or sustained by participants. The impact of endurance eccentric training on peripheral flow distribution remains largely undocumented. Given the high damage susceptibility of eccentric exercise, the extent to which skeletal muscle oxygen utilization adaptations would be seen depends on the balance of adverse and positive signals on mitochondrial integrity. The article examines the protection provided by repeated bouts of acute eccentric exercise and reports on the impact of eccentric cycling and downhill running training programs on markers of mitochondrial function and of mitochondrial biogenesis using mostly from animal studies. The summary of findings does not reveal an impact of training on skeletal muscle mitochondrial respiration nor on selected mitochondrial messenger RNA transcripts. The implications of observations to date are discussed within future perspectives for advancing research on endurance eccentric exercise physiological impacts and using a combined eccentric and concentric exercise approach to optimize functional capacity.
    Keywords:  calcium; eccentric training; free radicals; mitochondria; oxygen consumption
  6. Appl Physiol Nutr Metab. 2021 Feb 16.
    Gaffney K, Lucero A, Macartney-Coxson D, Clapham J, Whitfield P, Palmer B, Wakefield S, Faulkner J, Stoner L, Rowlands DS.
      Skeletal muscle microvascular dysfunction and mitochondrial rarefaction feature in type-2 diabetes mellitus (T2DM) linked to low tissue glucose disposal rate (GDR). Exercise training and milk protein supplementation independently promote microvascular and metabolic plasticity in muscle associated with improved nutrient delivery, but combined effects are unknown. In a randomised-controlled trial, 24 men (55.6 y, SD5.7) with T2DM ingested whey protein drinks (protein/carbohydrate/fat: 20/10/3 g; WHEY) or placebo (carbohydrate/fat: 30/3 g; CON) before/after 45 mixed-mode intense exercise sessions over 10 weeks, to study effects on insulin-stimulated (hyperinsulinemic clamp) skeletal-muscle microvascular blood flow (mBF) and perfusion (near-infrared spectroscopy), and histological, genetic, and biochemical markers (biopsy) of microvascular and mitochondrial plasticity. WHEY enhanced insulin-stimulated perfusion (WHEY-CON 5.6%; 90%CI -0.1, 11.3), while mBF was not altered (3.5%; -17.5, 24.5); perfusion, but not mBF, associated (regression) with increased GDR. Exercise training increased mitochondrial (range of means: 40-90%) and lipid density (20-30%), enzyme activity (20-70%), capillary:fiber ratio (~25%), and lowered systolic (~4%) and diastolic (4-5%) blood pressure, but without WHEY effects. WHEY dampened PGC1α -2.9% (90%CI -5.7, -0.2) and NOS3 -6.4% (-1.4, -0.2) expression, but other mRNA were unclear. Skeletal muscle microvascular and mitochondrial exercise adaptations were not accentuated by whey protein ingestion in men with T2DM. Clinical Trial Registration Number: ACTRN12614001197628 Novelty Bullets: • Chronic whey ingestion in T2DM with exercise altered expression of several mitochondrial and angiogenic mRNA. • Whey added no additional benefit to muscle microvascular or mitochondrial adaptations to exercise. • Insulin-stimulated perfusion increased with whey but was without impact on glucose disposal.
  7. Acta Physiol (Oxf). 2021 Feb 19. e13620
    Vieira de Sousa Neto I, Fontes W, Prestes J, de Cassia Marqueti R.
      A significant number of studies have demonstrated that paternal exercise modulates future generations via effects on the sperm epigenome. However, comprehensive information regarding the effects of exercise performed by the father on different tissues and their clinical relevance has not yet been explored in detail. This narrative review is focused on the effects of paternal exercise training on various physiological systems of offspring. A detailed mechanistic understanding of these effects could provide crucial clues for the exercise physiology field and aid the development of therapeutic approaches to mitigate disorders in future generations. Non-coding RNA and DNA methylation are major routes for transmitting epigenetic information from parents to offspring. Resistance and treadmill exercise are the most frequently used modalities of planned and structured exercise in controlled experiments. Paternal exercise orchestrated protective effects over changes in fetus development and placenta inflammatory status. Moreover paternal exercise promoted modifications in the ncRNA profiles, gene and protein expression in the hippocampus, left ventricle, skeletal muscle, tendon, liver and pancreas in the offspring, while the transgenerational effects are unknown. Paternal exercise demonstrates clinical benefits to the offspring and provides a warning on the harmful effects of a paternal unhealthy lifestyle. Exercise in fathers is presented as one of the most logical and cost-effective ways of restoring health in the offspring and, consequently, modifying the phenotype. It is important to consider that paternal programming might have unique significance in the developmental origins of offspring diseases.
    Keywords:  epigenetic inheritance; offspring health; paternal transmission; physical activity
  8. Exp Physiol. 2021 Feb 19.
    Kindlovits R, Bertoldi JMCRJ, Rocha HNM, Bento-Bernardes T, Gomes JLP, de Oliveira EM, Muniz IC, Pereira JF, Fernandes-Santos C, Rocha NG, da Nóbrega ACL, Medeiros RF.
      NEW FINDINGS: What is the central question of this study? What are the mechanisms underlying the cardiac protective effect of aerobic training in the progression of a high fructose-induced cardiometabolic disease in Wistar rats? What are the main findings and their importance? At the onset of cardiovascular disease, aerobic training activates the p-p70s6k, ERK, and the IRß-PI3K-AKT pathways, without changing the miR-126 and miR-195 levels, therefore, providing evidence that aerobic training modulates the insulin signalling pathway. This data contributes to the understanding of the molecular cardiac changes that are associated with physiological left ventricular hypertrophy during the development of a cardiovascular disease.ABSTRACT: Introduction: During the onset of cardiovascular disease (CVD), disturbances in myocardial vascularisation, cell proliferation, and protein expression are observed. Aerobic training prevents CVD but the underlying mechanisms behind left ventricle hypertrophy are not fully elucidated.
    AIM: To investigate the mechanisms by which aerobic training protects the heart from left ventricle (LV) hypertrophy during the onset of a fructose-induced cardiometabolic disease.
    METHODS: Male Wistar rats were allocated into four groups (n = 8/group): Control Sedentary (C), Control Training (CT), Fructose Sedentary (F), and Fructose Training (FT). C and CT received drinking water, and the F and FT groups received d-fructose (10% water). After 2 weeks, the CT and FT rats were assigned to a treadmill training protocol at moderate intensity for eight weeks (60 min/day, 4 days/week). After ten weeks, LV morphological remodelling, cardiomyocyte apoptosis, microRNAs, and the insulin signalling pathway were investigated.
    RESULTS: The F group had systemic cardiometabolic alterations, which were normalised by aerobic training. The LV weight increased in FT, myocardium vascularisation decreased in F, and the cardiomyocyte area increased in CT, F, and FT. Regarding the protein expressions, total-IRß decreased in the F. The p-IRß and PI3K increased in the FT. The total-AKT and p-AKT increased in all of the groups. The p-p70s6k protein was higher in the CT, and the p-ERK increased in CT and FT. MiR-126, miR-195, and cardiomyocyte apoptosis did not differ among the groups.
    CONCLUSION: Aerobic training activates p-p70s6k and p-ERK, and during the onset of a cardiovascular disease, it can activate the IRß-PI3K-AKT pathway. This article is protected by copyright. All rights reserved.
    Keywords:  aerobic training; apoptosis; cardiac hypertrophy; dprotein synthesis; insulin signalling pathway
  9. Front Physiol. 2020 ;11 615038
    Memme JM, Hood DA.
      Mitochondrial dysfunction is common to many organ system disorders, including skeletal muscle. Aging muscle and diseases of muscle are often accompanied by defective mitochondrial ATP production. This manuscript will focus on the pre-clinical evidence supporting the use of regular exercise to improve defective mitochondrial metabolism and function in skeletal muscle, through the stimulation of mitochondrial turnover. Examples from aging muscle, muscle-specific mutations and cancer cachexia will be discussed. We will also examine the effects of exercise on the important mitochondrial regulators PGC-1α, and Parkin, and summarize the effects of exercise to reverse mitochondrial dysfunction (e.g., ROS production, apoptotic susceptibility, cardiolipin synthesis) in muscle pathology. This paper will illustrate the breadth and benefits of exercise to serve as "mitochondrial medicine" with age and disease.
    Keywords:  aging; cancer; exercise as medicine; mitochondrial quality control; skeletal muscle
  10. J Cell Physiol. 2021 Feb 15.
    Turner DC, Gorski PP, Seaborne RA, Viggars M, Murphy M, Jarvis JC, Martin NRW, Stewart CE, Sharples AP.
      Understanding the role of mechanical loading and exercise in skeletal muscle (SkM) is paramount for delineating the molecular mechanisms that govern changes in muscle mass. However, it is unknown whether loading of bioengineered SkM in vitro adequately recapitulates the molecular responses observed after resistance exercise (RE) in vivo. To address this, the transcriptional and epigenetic (DNA methylation) responses were compared after mechanical loading in bioengineered SkM in vitro and after RE in vivo. Specifically, genes known to be upregulated/hypomethylated after RE in humans were analyzed. Ninety-three percent of these genes demonstrated similar changes in gene expression post-loading in the bioengineered muscle when compared to acute RE in humans. Furthermore, similar differences in gene expression were observed between loaded bioengineered SkM and after programmed RT in rat SkM tissue. Hypomethylation occurred for only one of the genes analysed (GRIK2) post-loading in bioengineered SkM. To further validate these findings, DNA methylation and mRNA expression of known hypomethylated and upregulated genes post-acute RE in humans were also analyzed at 0.5, 3, and 24 h post-loading in bioengineered muscle. The largest changes in gene expression occurred at 3 h, whereby 82% and 91% of genes responded similarly when compared to human and rodent SkM respectively. DNA methylation of only a small proportion of genes analyzed (TRAF1, MSN, and CTTN) significantly increased post-loading in bioengineered SkM alone. Overall, mechanical loading of bioengineered SkM in vitro recapitulates the gene expression profile of human and rodent SkM after RE in vivo. Although some genes demonstrated differential DNA methylation post-loading in bioengineered SkM, such changes across the majority of genes analyzed did not closely mimic the epigenetic response to acute-RE in humans.
    Keywords:  DNA methylation; bioengineering; fibrin; gene expression; mechanical loading; skeletal muscle
  11. Int J Sport Nutr Exerc Metab. 2021 Feb 14. pii: ijsnem.2020-0222. [Epub ahead of print] 1-10
    Holwerda AM, Trommelen J, Kouw IWK, Senden JM, Goessens JPB, van Kranenburg J, Gijsen AP, Verdijk LB, van Loon LJC.
      Protein ingestion and exercise stimulate myofibrillar protein synthesis rates. When combined, exercise further increases the postprandial rise in myofibrillar protein synthesis rates. It remains unclear whether protein ingestion with or without exercise also stimulates muscle connective tissue protein synthesis rates. The authors assessed the impact of presleep protein ingestion on overnight muscle connective tissue protein synthesis rates at rest and during recovery from resistance-type exercise in older men. Thirty-six healthy, older men were randomly assigned to ingest 40 g intrinsically L-[1-13C]-phenylalanine and L-[1-13C]-leucine-labeled casein protein (PRO, n = 12) or a nonprotein placebo (PLA, n = 12) before going to sleep. A third group performed a single bout of resistance-type exercise in the evening before ingesting 40 g intrinsically-labeled casein protein prior to sleep (EX+PRO, n = 12). Continuous intravenous infusions of L-[ring-2H5]-phenylalanine and L-[1-13C]-leucine were applied with blood and muscle tissue samples collected throughout overnight sleep. Presleep protein ingestion did not increase muscle connective tissue protein synthesis rates (0.049 ± 0.013 vs. 0.060 ± 0.024%/hr in PLA and PRO, respectively; p = .73). Exercise plus protein ingestion resulted in greater overnight muscle connective tissue protein synthesis rates (0.095 ± 0.022%/hr) when compared with PLA and PRO (p < .01). Exercise increased the incorporation of dietary protein-derived amino acids into muscle connective tissue protein (0.036 ± 0.013 vs. 0.054 ± 0.009 mole percent excess in PRO vs. EX+PRO, respectively; p < .01). In conclusion, resistance-type exercise plus presleep protein ingestion increases overnight muscle connective tissue protein synthesis rates in older men. Exercise enhances the utilization of dietary protein-derived amino acids as precursors for de novo muscle connective tissue protein synthesis during overnight sleep.
    Keywords:  aging; collagen; injury
  12. Oxid Med Cell Longev. 2021 ;2021 4593496
    Matta L, Fonseca TS, Faria CC, Lima-Junior NC, De Oliveira DF, Maciel L, Boa LF, Pierucci APTR, Ferreira ACF, Nascimento JHM, Carvalho DP, Fortunato RS.
      Physical exercise is characterized by an increase in physical and metabolic demand in face of physical stress. It is reported that a single exercise session induces physiological responses through redox signaling to increase cellular function and energy support in diverse organs. However, little is known about the effect of a single bout of exercise on the redox homeostasis and cytoprotective gene expression of white adipose tissue (WAT). Thus, we aimed at evaluating the effects of acute aerobic exercise on WAT redox homeostasis, mitochondrial metabolism, and cytoprotective genic response. Male Wistar rats were submitted to a single moderate-high running session (treadmill) and were divided into five groups: control (CTRL, without exercise), and euthanized immediately (0 h), 30 min, 1 hour, or 2 hours after the end of the exercise session. NADPH oxidase activity was higher in 0 h and 30 min groups when compared to CTRL group. Extramitochondrial ROS production was higher in 0 h group in comparison to CTRL and 2 h groups. Mitochondrial respiration in phosphorylative state increased in 0 h group when compared to CTRL, 30 min, 1, and 2 h groups. On the other hand, mitochondrial ATP production was lower in 0 h in comparison to 30 min group, increasing in 1 and 2 h groups when compared to CTRL and 0 h groups. CAT activity was lower in all exercised groups when compared to CTRL. Regarding oxidative stress biomarkers, we observed a decrease in reduced thiol content in 0 h group compared to CTRL and 2 h groups, and higher levels of protein carbonylation in 0 and 30 min groups in comparison to the other groups. The levels returned to basal condition in 2 h group. Furthermore, aerobic exercise increased NRF2, GPX2, HMOX1, SOD1, and CAT mRNA levels. Taken together, our results suggest that one session of aerobic exercise can induce a transient prooxidative state in WAT, followed by an increase in antioxidant and cytoprotective gene expression.
  13. Front Physiol. 2020 ;11 604274
    Nederveen JP, Warnier G, Di Carlo A, Nilsson MI, Tarnopolsky MA.
      The benefits of exercise on health and longevity are well-established, and evidence suggests that these effects are partially driven by a spectrum of bioactive molecules released into circulation during exercise (e.g., exercise factors or 'exerkines'). Recently, extracellular vesicles (EVs), including microvesicles (MVs) and exosomes or exosome-like vesicles (ELVs), were shown to be secreted concomitantly with exerkines. These EVs have therefore been proposed to act as cargo carriers or 'mediators' of intercellular communication. Given these findings, there has been a rapidly growing interest in the role of EVs in the multi-systemic, adaptive response to exercise. This review aims to summarize our current understanding of the effects of exercise on MVs and ELVs, examine their role in the exercise response and long-term adaptations, and highlight the main methodological hurdles related to blood collection, purification, and characterization of ELVs.
    Keywords:  EV isolation; aerobic exercise; circulation; exerkine; exosome; extracellular vesicle; resistance exercise; size-exclusion chromatography
  14. ESC Heart Fail. 2021 Feb 20.
    Knuiman P, Straw S, Gierula J, Koshy A, Roberts LD, Witte KK, Ferguson C, Bowen TS.
      AIMS: Heart failure with reduced ejection fraction (HFrEF) induces skeletal muscle mitochondrial abnormalities that contribute to exercise limitation; however, specific mitochondrial therapeutic targets remain poorly established. This study quantified the relationship and contribution of distinct mitochondrial respiratory states to prognostic whole-body measures of exercise limitation in HFrEF.METHODS AND RESULTS: Male patients with HFrEF (n = 22) were prospectively enrolled and underwent ramp-incremental cycle ergometry cardiopulmonary exercise testing to determine exercise variables including peak pulmonary oxygen uptake (V̇O2peak ), lactate threshold (V̇O2LT ), the ventilatory equivalent for carbon dioxide (V̇E /V̇CO2LT ), peak circulatory power (CircPpeak ), and peak oxygen pulse. Pectoralis major was biopsied for assessment of in situ mitochondrial respiration. All mitochondrial states including complexes I, II, and IV and electron transport system (ETS) capacity correlated with V̇O2peak (r = 0.40-0.64; P < 0.05), V̇O2LT (r = 0.52-0.72; P < 0.05), and CircPpeak (r = 0.42-0.60; P < 0.05). Multiple regression analysis revealed that combining age, haemoglobin, and left ventricular ejection fraction with ETS capacity could explain 52% of the variability in V̇O2peak and 80% of the variability in V̇O2LT , respectively, with ETS capacity (P = 0.04) and complex I (P = 0.01) the only significant contributors in the model.
    CONCLUSIONS: Mitochondrial respiratory states from skeletal muscle biopsies of patients with HFrEF were independently correlated to established non-invasive prognostic cycle ergometry cardiopulmonary exercise testing indices including V̇O2peak , V̇O2LT , and CircPpeak . When combined with baseline patient characteristics, over 50% of the variability in V̇O2peak could be explained by the mitochondrial ETS capacity. These data provide optimized mitochondrial targets that may attenuate exercise limitations in HFrEF.
    Keywords:  Exercise; HFrEF; Lactate threshold; Skeletal muscle; V̇O2peak