Multivariable analysis of heart rate recovery after cycle ergometry in heart failure: exercise in heart failure

Purpose

The purpose of this study was to investigate the association between impairment in heart rate recovery (HR_rec) after cycle ergometry and prognostic markers in patients with heart failure (HF) compared with healthy controls.

Methods

Fifty patients with chronic HF (systolic HF, N = 30; diastolic HF, N = 20; mean age = 62 ± 12 years) and 50 healthy controls (N = 50; mean age = 66 ± 13 years) underwent 2-dimensional and M-mode echocardiography followed by cardiopulmonary exercise testing. Independent predictors of HR_rec at 1 and 2 minutes after exercise were analyzed by univariable and multivariable regression analyses, and receiver operating characteristics were performed to obtain area under the curve.

Results

In HF, left ventricular end-diastolic diameter (millimeters), left ventricular ejection fraction (%), N-terminal pro-brain natriuretic peptide (picograms/milliliter), peak oxygen uptake (VO₂peak [milliliters/kilogram/min]), and peak heart rate (HR_peak) showed a significant association with HR_rec (beats/min) in univariate regression analyses (P < .001), but only VO₂peak remained independently predictive of both HR_rec1 (P = .034) and HR_rec2 (P = .008) in the multivariable regression analyses. In controls, VO₂peak (P = .035) and HR_peak (P = .032) were significantly associated with HR_rec2 in univariate analyses only. Optimal cutoff values for discriminating HF versus non-HF based on HR_rec were 17.5 beats/min (sensitivity 92%; specificity 74%) for HR_rec1 and 31.5 beats/min (sensitivity 94%; specificity 86%) for HR_rec2. Optimal cutoff values for discriminating systolic HF versus diastolic HF were 12.5 beats/min (sensitivity 78%; specificity 80%) for HR_rec1 and 24.5 beats/min (sensitivity 82%; specificity 90%) for HR_rec2.

Conclusion

Impairment in after exercise HR_rec is significantly and independently associated with VO2peak in HF and thus might constitute a useful tool for assessing the degree of functional status during exercise rehabilitation.     

Left ventricular end‐diastolic volume predicts exercise capacity in patients with a normal ejection fraction

Background

Exercise capacity is a powerful predictor of all‐cause mortality. The duration of exercise with treadmill stress testing is an important prognostic marker in both healthy subjects and patients with cardiovascular disease. Left ventricular (LV) structure is known to adapt to sustained changes in level of physical activity.

Hypothesis

Poor exercise capacity in patients with a preserved LV ejection fraction (LVEF) should be reflected in smaller LV dimensions, and a normal exercise capacity should be associated with larger LV dimensions, irrespective of comorbidities.

Methods

This hypothesis was first tested in a cross‐sectional analysis of 201 patients with normal chamber dimensions and preserved LVEF who underwent a clinically indicated treadmill stress echocardiogram using the Bruce protocol (derivation cohort). The best LV dimensional predictor of exercise capacity was then tested in 1285 patients who had a Bruce‐protocol treadmill exercise stress test and a separate transthoracic echocardiogram (validation cohort).

Results

In the derivation cohort, there was a strong positive relationship between exercise duration and LV end‐diastolic volume deciles (r ² = 0.85; P < 0.001). Regression analyses of several LV dimensional parameters revealed that the body surface area–based LV end‐diastolic volume index was best suited to predict exercise capacity (P < 0.0001). In a large validation cohort, LV end‐diastolic volume was confirmed to predict exercise capacity (P < 0.0001).

Conclusions

Among patients referred for outpatient stress echocardiography who have a preserved LVEF and no evidence of myocardial ischemia, we found a strong positive association between LV volume and exercise capacity.     

Physical activity and sarcopenia

Physical activity can be a valuable countermeasure to sarcopenia in its treatment and prevention. In considering physical training strategies for sarcopenic subjects, it is critical to consider personal and environmental obstacles to access opportunities for physical activity for any patient with chronic disease. This article presents an overview of current knowledge of the effects of physical training on muscle function and the physical activity recommended for sarcopenic patients. So that this countermeasure strategy can be applied in practice, the authors propose a standardized protocol for prescribing physical activity in chronic diseases such as sarcopenia.     

Effect of exercise training in patients with an implantable cardioverter defibrillator.

AIMS: Little research exists on exercise performance and training in patients with an implemented cardioverter defibrillator (ICD) and only in a limited number of patients. This study aims to investigate the effect of exercise training in ICD patients in comparison to the effects in other cardiac patients without an ICD. METHODS AND RESULTS: 92 ICD patients were compared with a control group of 473 patients. A maximal cycle-spiroergometric test was performed until exhaustion before and after an ambulatory exercise training programme. Exercise training was offered 3 times a week for 3 months. The cut-off heart rate was set at (ICD detection rate -20 beats/min). At baseline, the ICD patients had a lower peak oxygen uptake (VO(2)) compared to the control group. Training effects were smaller for peak VO(2) (mL/min/kg) and oxygen pulse in the ICD group (18 vs. 27%, p = 0.006 and 11 vs. 17%, p = 0.016, respectively). Several appropriate shocks were delivered during (n = 5), and in between (n = 7), testing or training and one inappropriate shock during training. CONCLUSIONS: ICD patients can safely participate in an exercise training programme with favorable results. A randomised control study with evaluation of the physical and the psychosocial effects is warranted.     

运动疗法在2型糖尿病治疗中的作用

目的探讨运动疗法在2型糖尿病治疗中的作用。方法对30例中年2型糖尿病患者在饮食和口服降糖药物治疗的基础上采用运动疗法。具体方法为3次／d快步行走，运动量=总摄入热量-日常生活消耗量 1737．5kJ，以最大心率(Hrmax)的60％作为靶心率，治疗前后检测各项相关指标变化。结果运动治疗2周后，30例患者的血糖、体重指数(BMI)、果糖胺及甘油三酯均明显下降，且无并发症发生。结论运动疗法可降低中年2型糖尿病患者的血糖，改善血脂代谢，方法安全可行。     

Exercise therapy in patients with idiopathic inflammatory myopathies and systemic lupus erythematosus – A systematic literature review

Idiopathic inflammatory myopathies (IIM) and systemic lupus erythematosus (SLE) are inflammatory connective tissue diseases (CTDs) with common features of arthritis, muscle impairment, skin rash, and heart- and lung involvement. Exercise is becoming an important part of the treatment in patients with IIM and SLE; however, there is a need for evidence-based exercise recommendations on patient-relevant outcomes. To evaluate the evidence and to present evidence-based exercise recommendations on patient-relevant outcomes in patients with IIM and SLE. A systematic literature search of five databases was performed at two time points, 2016 going back all years, and an update in 2019. Inclusion criteria: RCTs including exercise, physical activity intervention, and patient-relevant outcomes. Systematic reviews and meta-analysis was also included. Grading of evidence was done according to the GRADE system. Five RCTs and 1 systematic review were identified in patients with IIM and eight RCTs, 6 systematic reviews, and 2 meta-analysis for patients with SLE. Aerobic exercise and resistance training on moderate-high intensity can improve aerobic capacity, muscle impairment, activity limitation, quality of life, and disease activity (limited evidence) in patients with established polymyositis (PM) and dermatomyositis (DM). Moderate-high intensity aerobic exercise can improve aerobic capacity (moderately strong evidence) and improve fatigue and depressive symptoms (limited evidence) without changing disease activity in patients with mild/inactive SLE with low/no organ damage. There is insufficient evidence for effects of exercise in patients with recent onset PM/DM and IBM. Exercise performed in line with American College of Sports Medicine recommendations can improve aerobic capacity, patient-reported outcomes in patients with nonactive PM/DM and mild/inactive SLE. More well-designed studies are needed to increase the scientific evidence. Studies with additional focus on evaluating effects of exercise in patients with higher disease activity, in patients with vital-organ involvement and in patients with IBM are needed.     

Prolonged recovery from exercise-induced asthma with increasing age in childhood

It has been suggested that children with asthma recover more quickly from exercise-induced bronchoconstriction than adults. On the basis of clinical observation we hypothesized that recovery rate from exercise-induced asthma (EIA) in childhood also decreases with age. In 14 children (aged 7–12 years) with a history of EIA, we measured spontaneous recovery from bronchoconstriction induced by two different stimuli: exercise and histamine. The children visited the laboratory three times. After a screening exercise test on the first visit, standardized bronchoprovocation tests with either exercise or histamine were performed on the following two visits in random order. The degree of bronchoconstriction induced by histamine was matched for that observed after exercise. During recovery, forced expiratory volume in 1 second (FEV₁,) was measured repeatedly up to 2 hours postchallenge. The recovery rate (% increase in FEV₁/min) was calculated from the linear slope of the time-response curve. Differences in recovery rate between the two stimuli were analyzed by paired t-test, and age-related differences were analyzed using multiple regression analysis. For the group as a whole, recovery rate was not different between the two stimuli (mean ± SD: 1.22±0.91 for exercise, and 1.46±0.65, for histamine, P = 0.31). However, the recovery rate for exercise-induced bronchoconstriction decreased significantly with age (r = ?0.74, P = 0.003), in contrast to the recovery rate for histamine (r = ?0.15, P = 0.60). Consequently, in the oldest age group (11–12 years, n = 5) recovery rate from exercise challenge was significantly slower than in the younger age group (7–10 years, n = 9), i.e., 0.54 2 0.17 and 1.60 f 0.93, respectively, P = 0.009, and slower than the recovery rate from histamine challenge: 0.54±0.17 and 1.33±0.54, respectively, P = 0.03. In the younger age group the recovery rates from exercise and histamine were not different (1.60 ± 0.93 and 1.54 ± 0.73, respectively, P = 0.83). We conclude that recovery from EIA in childhood decreases with increasing age. These data suggest that the mechanism of exercise-induced asthma in childhood changes with age. This might be due to changes in mediator production or response to mediator release. Pediatr Pulmonol. 1995; 20:177–183 . © 1995 Wiley-Liss, Inc.     

Exercise dependent complete left bundle branch block.

Eleven patients with an exercise dependent complete left bundle branch block (CLBBB) were followed-up over a period of 2-13 years (mean 6.5 +/- 3.8). Their ages ranged from 19 to 62 years (mean 48). Four patients complained of chest pain on effort and one of palpitations. All patients underwent a clinical examination, 12 lead ECG, routine blood tests, chest X-ray, a multistage exercise test, echo Doppler, radionuclide ventriculography with TC99 and 48-h Holter monitoring. Ten were submitted to a coronary angiography with left ventriculography. The ECG at rest displayed a normal ECG in seven patients and an incomplete left bundle branch block (ILBBB) in four patients. The onset heart rate (HR) of CLBBB ranged from 95-146 beats.min-1 (mean 123) and the offset HR75-135 (mean 102 beats.min-1). Coronary angiography showed three-vessel disease in two patients and an obstruction of the left anterior descending coronary artery (LAD) in the third. In the other seven patients all the investigations (including coronary angiography) were normal. During the follow-up period the HR at onset of CLBBB decreased from 145 beats.min-1 to 100 beats.min-1 in four patients but no coronary artery disease (CAD) could be proven at coronary angiography. In our series chest pain did not always signify the presence of CAD. We conclude, that in patients with exercise-dependent CLBBB the prognosis is good if no underlying heart disease can be detected. It appears from our limited experience that an exercise-dependent CLBBB at heart rate below 125 beats.min-1 does not by itself constitute a sign of CAD.     

High-sensitivity C-reactive protein levels and treadmill exercise test responses in men and women without overt heart disease

BACKGROUND:

C-reactive protein (CRP) is a marker of systemic inflammatory activity and may be modulated by physical fitness. Treadmill exercise testing is used to evaluate cardiovascular health through different variables including exercise capacity, heart rate and blood pressure responses. It was hypothesized that CRP levels are associated with these variables in men and women without overt heart disease.

METHODS:

A total of 584 asymptomatic subjects (317 [54.3%] women and 267 [45.7%] men) were enrolled in the present study and underwent clinical evaluation. CRP levels in men and women were examined relative to clinical characteristics and to variables of treadmill exercise testing: peak heart rate, exercise systolic blood pressure, exercise time, chronotropic reserve and heart rate recovery at the first and second minutes after exercise. Multivariate analysis was performed using a log-linear regression model.

RESULTS:

In women, exercise time on the treadmill exercise test (P=0.009) and high-density lipoprotein cholesterol levels (P=0.002) were inversely associated with CRP levels. Body mass index (P<0.001) and total cholesterol levels (P=0.005) were positively associated with CRP levels. In men, exercise time on the treadmill exercise test was inversely associated with CRP levels (P=0.015). Body mass index (P=0.001) and leukocyte count (P=0.002) were positively associated with CRP levels. CRP levels were not associated with peak heart rate, chronotropic reserve, heart rate recovery at the first and second minutes, or exercise systolic blood pressure.

CONCLUSIONS:

These findings contribute to the evidence that CRP is lower in individuals with better exercise capacity and demonstrate that this relationship is also apparent in individuals without overt heart disease undergoing cardiovascular evaluation through the treadmill exercise test. Lowering inflammatory markers may be an additional reason to stimulate sedentary individuals with low exercise capacity in the treadmill exercise test to improve physical conditioning through regular exercise.     

Prediction of mortality in patients without angina: use of an exercise score and exercise echocardiography.

BACKGROUND: Exercise testing has limited efficacy for identifying coronary artery disease (CAD) in the absence of anginal symptoms. Exercise echocardiography is more accurate than standard exercise testing, but its efficacy in this situation has not been defined. We sought to identify whether the Duke treadmill score or exercise echocardiography (ExE) could be used to identify risk in patients without anginal symptoms. METHODS: We studied 1859 patients without typical or atypical angina, heart failure, or a history or ECG evidence of infarction or CAD, who were referred for ExE, of whom 1832 (age 51+/-15 years, 944 men) were followed for up to 10 years. The presence and extent of ischaemia and scar were interpreted by expert reviewers at the time of the original study. RESULTS: Exercise provoked significant (>0.1mV) ST segment depression in 215 patients (12%), and wall motion abnormalities in 137 (8%). Seventy-eight patients (4%) died before revascularization, only 17 from known cardiac causes. The independent predictors of death were age (RR 1.1, p<0.0001), smoking, Duke treadmill score (RR 0.9, p<0.0001) and resting LV dysfunction (RR 1.9, p<0.04), but did not include ischaemia at ExE. Echocardiography was not predictive of outcome in subgroups with an intermediate or high risk Duke score, nor in patients with two or more risk factors. CONCLUSIONS: Patients without anginal symptoms have a low mortality, especially from cardiac causes. If such individuals undergo exercise testing and a resting echocardiogram, exercise echocardiography does not offer additional prognostic information.     

Cardiac rehabilitation and exercise therapy in the elderly: Should we invest in the aged?

Coronary heart disease (CHD) is the leading cause of death worldwide and becomes increasingly prevalent among patients aged 65 years and older. Elderly patients are at a higher risk for complications and accelerated physical deconditioning after a cardiovascular event, especially compared to their younger counterparts. The last few decades were privy to multiple studies that demonstrated the beneficial effects of cardiac rehabilitation (CR) and exercise therapy on mortality, exercise capacity, psychological risk factors, inflammation, and obesity among patients with CHD. Unfortunately, a significant portion of the available data in this field pertains to younger patients. A viable explanation is that older patients are grossly underrepresented in these programs for multiple reasons starting with the patient and extending to the physician. In this article, we will review the benefits of CR programs among the elderly, as well as some of the barriers that hinder their participation.     

Exercise induced complete atrioventricular block: Utility of exercise stress test

Exercise induced complete atrioventricular block (EIAVB) is a relatively uncommon condition. This phenomenon is clinically important because it can mimic symptoms of other cardiovascular conditions and may be associated with exercise intolerance and subsequent syncope. A 76 year old man with long-standing hypertension and diabetes mellitus presented with recurrent episodes of lightheadedness and syncope with physical activity. ECG showed sinus rhythm with first degree atrioventricular block. Echocardiography did not show any valvular disease causing his symptoms. Coronoary angiographic evaluation revealed non-obstructive coronary artery disease. Because of the exertional nature of his symptoms, a symptom-limited treadmill exercise test was performed which revealed EIAVB. A permanent dual chamber pacemaker was implanted and his symptoms resolved completely.     

Implementação Clínica de Diferentes Estratégias para Reabilitação Baseada em Exercícios em Receptores de Transplante de Rim e Fígado: Um Estudo Piloto

Background:Cardiovascular disease is among the leading causes of death in solid organ transplant recipients with a functional graft. Although these patients could theoretically benefit from exercise-based rehabilitation (EBR) programs, their implementation is a challenge.Objective:We present our initial experience on different delivery modes of a pilot EBR program in kidney and liver transplant recipients.Methods:Thirty-two kidney or liver transplant recipients were invited for a 6-month EBR program delivered at the hospital gym, community gym or at home, according to the patient’s preference. The significance level adopted was 5%.Results:Ten patients (31%) did not complete their program. Among the 22 who did, 7 trained at the hospital gym, 7 at the community gym, and 8 at home. The overall effect was an 11.4% increase in maximum METs (Hedges’ effect size g = 0.39). The hospital gym group had an increase in METs of 25.5% (g= 0.58, medium effect size) versus 10% (g= 0.25), and 6.5% (g= 0.20) for the community gym and home groups, respectively. There was a beneficial effect on systolic and diastolic blood pressures, greater for the hospital gym (g= 0.51 and 0.40) and community gym (g= 0.60 and 1.15) groups than for the patients training at home (g= 0.07 and 0.10). No significant adverse event was reported during the follow-up.Conclusion:EBR programs in kidney and liver transplant recipients should be encouraged, even if they are delivered outside a hospital gym, since they are safe with positive effects on exercise capacity and cardiovascular risk factors.     

Circulatory and Ventilatory Power: Characterization in Patients with Coronary Artery Disease

Background

Circulatory power (CP) and ventilatory power (VP) are indices that have been used for the clinical evaluation of patients with heart failure; however, no study has evaluated these indices in patients with coronary artery disease (CAD) without heart failure.

Objective

To characterize both indices in patients with CAD compared with healthy controls.

Methods

Eighty-seven men [CAD group = 42 subjects and healthy control group (CG) = 45 subjects] aged 40–65 years were included. Cardiopulmonary exercise testing was performed on a treadmill and the following parameters were measured: 1) peak oxygen consumption (VO₂), 2) peak heart rate (HR), 3) peak blood pressure (BP), 4) peak rate-pressure product (peak systolic HR x peak BP), 5) peak oxygen pulse (peak VO₂/peak HR), 6) oxygen uptake efficiency (OUES), 7) carbon dioxide production efficiency (minute ventilation/carbon dioxide production slope), 8) CP (peak VO₂ x peak systolic BP) and 9) VP (peak systolic BP/carbon dioxide production efficiency).

Results

The CAD group had significantly lower values for peak VO₂ (p < 0.001), peak HR (p < 0.001), peak systolic BP (p < 0.001), peak rate-pressure product (p < 0.001), peak oxygen pulse (p = 0.008), OUES (p < 0.001), CP (p < 0.001), and VP (p < 0.001) and significantly higher values for peak diastolic BP (p = 0.004) and carbon dioxide production efficiency (p < 0.001) compared with CG. Stepwise regression analysis showed that CP was influenced by group (R² = 0.44, p < 0.001) and VP was influenced by both group and number of vessels with stenosis after treatment (interaction effects: R² = 0.46, p < 0.001).

Conclusion

The indices CP and VP were lower in men with CAD than healthy controls.