Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology

Mechanisms of exercise as a preventative measure to muscle wasting

Skeletal muscle is the most abundant tissue in healthy individuals and it has important roles in health beyond voluntary movement. The overall mass and energy requirements of skeletal muscle require it to be metabolically active and flexible to multiple energy substrates. The tissue has evolved to be largely load dependent and it readily adapts in a number of positive ways to repetitive overload, such as various forms of exercise training. However, unloading from extended bed rest and/or metabolic derangements in response to trauma, acute illness, or severe pathology, commonly results in rapid muscle wasting. Decline in muscle mass contributes to multimorbidity, reduces function, and exerts a substantial, negative impact on the quality of life. The principal mechanisms controlling muscle mass have been well described and these cellular processes are intricately regulated by exercise. Accordingly, exercise has shown great promise and efficacy in preventing or slowing muscle wasting through changes in molecular physiology, organelle function, cell signaling pathways, and epigenetic regulation. In this review, we focus on the role of exercise in altering the molecular landscape of skeletal muscle in a manner that improves or maintains its health and function in the presence of unloading or disease.epigenetics; exercise; muscle wasting; resistance training; skeletal muscle.

Prevalence and Functional Implication of Silent Coronary Artery Disease in Marathon Runners Over 40 Years of Age: The MATCH-40 Study

BACKGROUND

Marathon participation is becoming increasingly popular among individuals ≥40 years of age. Little is known about the prevalence of subclinical coronary artery disease (CAD) and corresponding ischemia in this patient population. The study objectives are: (1) to characterize the prevalence of silent CAD in marathoners ≥ 40 years old using cardiac computed tomography angiography (CCT); and (2) if subclinical CAD was detected, to determine the functional significance of occult lesions by stress echocardiography (SE).

METHODS

Marathoners aged ≥ 40 years who completed a full marathon between 2018 and 2019 were recruited to undergo a prospective CCT. Coronary artery stenosis was graded as zero, mild (1%-49%), moderate (50%-69%), or severe (> 70%). All study participants diagnosed with mild-to-severe atherosclerotic CAD on CCT further underwent functional imaging with exercise treadmill SE.

RESULTS

A total of 65 individuals (53 ± 7 years, 65% males, 24 ± 3 kg/m2) underwent a prospective CCT within 12 months of marathon completion. Of the total study population, 13 participants (20%) were diagnosed with CAD, of whom 10 (77%) had mild disease, 1 (8%) had moderate disease, and 2 (15%) had severe disease by CCT. Despite the identification of subclinical CAD on CCT, none of the 13 patients had any evidence of inducible ischemia on SE.

CONCLUSIONS

This is the first study to incorporate both CCT and SE in the evaluation of subclinical CAD in marathoners ≥40 years old. Although the overall prevalence of anatomic CAD was 20%, there was no evidence of functional ischemia in this highly competitive cohort.

A Novel mHealth Monitoring System during Cycling in Elite Athletes

Background: Cycling is a very demanding physical activity that may create various health disorders during an athlete’s career. Recently, smart mobile and wearable technologies have been used to monitor physiological responses and possible disturbances during physical activity. Thus, the application of mHealth methods in sports poses a challenge today. This study used a novel mobile-Health method to monitor athletes’ physiological responses and to detect health disorders early during cycling in elite athletes. Methods: Sixteen high-level cyclists participated in this study, which included a series of measurements in the laboratory; health and performance assessments; and then application in the field of mHealth monitoring in two training seasons, at the beginning of their training period and in the race season. A field monitoring test took place during 30 min of uphill cycling with the participant’s heart rate at the ventilatory threshold. During monitoring periods, heart rate, oxygen saturation, respiratory rate, and electrocardiogram were monitored via the mHealth system. Moreover, the SpO₂ was estimated continuously, and the symptoms during effort were reported. Results: A significant correlation was found between the symptoms reported by the athletes in the two field tests and the findings recorded with the application of the mHealth monitoring method. However, from the pre-participation screening in the laboratory and from the spiroergometric tests, no abnormal findings were detected that were to blame for the appearance of the symptoms. Conclusions: The application of mHealth monitoring during competitive cycling is a very useful method for the early recording of cardiac and other health disorders of athletes, whose untimely evaluation could lead to unforeseen events.

Extracorporeal life support programme for out-of-hospital cardiac arrest during competitive sport events: the experience of the Volleyball Men's World Championship Final Six in Turin (Italy)

The high incidence of out-of-hospital cardiac arrest refractory to standard resuscitation protocols, despite precompetitive screening, demonstrated the need for a prehospital team to provide an effective system for life support and resuscitation at the Volleyball Men's World Championship. The evolution of mechanical circulatory support suggests that current advanced cardiovascular life support protocols no longer represent the highest standard of care at competitive sporting events with large spectator numbers. Extracorporeal life support (ECLS) improves resuscitation strategies and offers a rescue therapy for refractory cardiac arrest that can no longer be ignored. We present our operational experience of an out-of-hospital ECLS cardiopulmonary resuscitation team at an international sporting event.

[Effects of home-based strength training during COVID-19 lockdown in acute coronary syndrome]

INTRODUCTION AND OBJECTIVE

Cardiac rehabilitation has the highest level of recognition in medical guideline references. The rise of COVID-19 pandemic, particularly during the first months of strict containment, cause to temporally stop most of the ongoing programs. We studied the effects of an interdisciplinary phase II secondary prevention in patients diagnosed with a recent acute coronary syndrome with the use of new technologies, home-exercise and telemedicine.

METHODS

Between the 2nd and 11th of March 2020, we included 37 patients with recent acute coronary syndrome (76.4%), low-risk and preserved systolic function and underwent a 12-week treatment. A dynamic muscle toning with overload domiciliary training program was applied, in addition to nutritional counselling, as well as psychological and educational therapy.

RESULTS

Of the initial cohort, 30 patients finished. At the end of the program, we observed and increased functional capacity over the 6-min walking test (+47.13m; 95% CI: 32.82-61.45, P<.001), and improvement to the subjective feeling of dyspnoea on the modified Borg scale (-0.5 units; 95% CI: -0.76 to -0.24, P=.001), and an improvement over both initial and final training systolic blood pressure (-6.67mmHg; 95% CI: -10.98 to -2.35, P=.004) (-7mmHg; 95% CI: -12.86 to -1.14, P=.021). We also observed an increase in the level of physical activity during leisure time in the IPAQ questionnaire (+1162.93min/week; 95% CI: 237.36-2088.5, P=.016), and in the Mediterranean eating habits on the PREDIMED test (+2.1units; 95% CI: 1.32-2.28, P<.001).

CONCLUSIONS

After three months of a domiciliary cardiac rehabilitation program, patients increased their functional capacity, feeling of dyspnoea, blood pressure and eating habits. Domiciliary telemedicine cardiac rehabilitation program produces an improvement in the patient after acute coronary syndrome.

[Effects of an interdisciplinary program combining aerobic interval training and dynamic strength in acute coronary syndrome]

INTRODUCTION AND OBJECTIVES

Cardiac rehabilitation has the highest level of recognition in medical guideline references, however there are still little-explored training modalities. We study the effects of an interdisciplinary program after acute coronary syndrome (ACS) in phase II secondary prevention.

METHODS

Between January 2008 and December 2018, 439 patients with stable ischemic heart disease and preserved systolic function were included, as maximum 2 month after the ACS. A combined aerobic resistance training program in a variable continuous method and muscle toning with overload and/or ballast was applied, in addition to nutritional counseling and psychological-educational therapy for 12 weeks.

RESULTS

378 patients finished. The functional capacity increases in the incremental stress test (1.76 METS; CI 95%: 1.59-1.96, p < 0.001) and in the six minutes walking test (32.58 m; CI 95%: 29.24-35.92, p < 0.001). Leisure physical activity in IPAQ increased (763.27 min/week; CI 95%: 583.31-943.16, p < 0.001) and the time sitting during the week decreased (-28.85 min/day; CI 95%: -43.94 to -13.77, p < 0.001). Also, eating habits improved in PREDIMED (2.58 units; CI 95%: 1.43-3.73, p < 0.001), decreased body weight (-0.88 kg; CI 95%: -1.26 to -0.49, p < 0.001), the abdominal perimeter (1.57 cm; CI 95%: 2.23-0.90, p < 0.001) and adipose tissue (-0.80%; CI 95%: -1.10 to -0.51, p < 0.001).

CONCLUSIONS

An interdisciplinary program with high intensity variable continuous training combined with dynamic muscle toning increases functional capacity, the level of physical activity, improves body composition and eating habits in ACS patients.

Effects of medium- and long-distance running on cardiac damage markers in amateur runners: a systematic review, meta-analysis, and metaregression

BACKGROUND

To finish an endurance race, athletes perform a vigorous effort that induces the release of cardiac damage markers. There are several factors that can affect the total number of these markers, so the aim of this review was to analyze the effect of endurance running races on cardiac damage markers and to identify the factors that modify the levels of segregation of these cardiac damage markers.

METHODS

A systematic search of PubMed, Web of Science, and the Cochrane Library databases was performed. This analysis included studies where the acute effects of running races on cardiac damage markers (troponin I and troponin T) were analyzed, assessing the levels of these markers before and after the races.

RESULTS

The effects of running races on troponin I (mean difference = 0.0381 ng/mL) and troponin T (mean difference = 0.0256 ng/mL) levels were significant. The ages (R2 = 14.4%, p = 0.033) and body mass indexes (R2 = 14.5%, p = 0.045) of the athletes had a significant interaction with troponin I. In addition, gender, mean speed, time to finish the race, and type of race can affect the level of cardiac damage markers.

CONCLUSION

Endurance running races induce the release of cardiac-damage markers that remain elevated for at least 24 h after the races. In addition, young male athletes with high body mass indexes who perform races combining long duration and moderate intensity (i.e., marathons) release the highest levels of cardiac damage markers. Physicians should take into consideration these results in the diagnosis and treatment of patients admitted to the hospital days after finishing endurance running races.

Influence of exercise test on platelet function in patients with coronary arterial disease: A systematic review

BACKGROUND

Exercise test (ET) may have adverse effects on platelet function and induce acute thrombotic events in patients with coronary artery disease (CAD). The aim of this study is to investigate the platelet function and evaluate the risk of thrombotic events in CAD patients during ET.

METHODS

Pubmed, Embase, Cochrane Library, and Web of Science were searched for a systematic review from initiation to October 2019. The inclusion criteria were controlled clinical trails as study design; investigating platelet function in CAD patients during ET; with ET carried out by treadmill or bicycle ergometer; written in English. Included articles were screened based on title/abstract and full-text review by 2 independent reviewers. Platelet aggregation (PA), platelet surface expression of CD62p and PAC-1, plasma levels of platelet factor 4 (PF4) and beta-thromboglobulin (β-TG) were evaluated before and after ET.

RESULTS

Eighteen articles were included out of the 427 references initially identified. In most of the studies included ET was terminated because of limited symptoms. Prior to ET, no difference in platelet aggregation was observed in CAD patients compared with healthy controls in majority of the studies, with or without the treatment with Aspirin. Dual anti-platelet therapy suppressed adenosine diphosphate (ADP)-induced platelet aggregation at rest. After ET, platelet aggregation, the serum levels of β-thromboglobulin were found unchanged in majority of studies and platelet factor-4 were found unchanged in half of studies. The expression of platelet surface markers were elevated by ET in a few study.

CONCLUSION

Symptom-limited exercise test did not affect platelet function in patients with coronary artery disease; however exercise to higher intensity may induce platelet activation.

Does Exercise Influence the Susceptibility to Arterial Thrombosis? An Integrative Perspective

Arterial thrombosis is the primary cause of death worldwide, with the most important risk factors being smoking, unhealthy diet, and physical inactivity. However, although there are clear indications in the literature of beneficial effects of physical activity in lowering the risk of cardiovascular events, exercise can be considered a double-edged sword in that physical exertion can induce an immediate pro-thrombotic environment. Epidemiological studies show an increased risk of cardiovascular events after acute exercise, a risk, which appear to be particularly apparent in individuals with lifestyle-related disease. Factors that cause the increased susceptibility to arterial thrombosis with exercise are both chemical and mechanical in nature and include circulating catecholamines and vascular shear stress. Exercise intensity plays a marked role on such parameters, and evidence in the literature accordingly points at a greater susceptibility to thrombus formation at high compared to light and moderate intensity exercise. Of importance is, however, that the susceptibility to arterial thrombosis appears to be lower in exercise-conditioned individuals compared to sedentary individuals. There is currently limited data on the role of acute and chronic exercise on the susceptibility to arterial thrombosis, and many studies include incomplete assessments of thrombogenic clotting profile. Thus, further studies on the role of exercise, involving valid biomarkers, are clearly warranted.

Asian Pacific Society of Cardiology Consensus Recommendations for Pre-participation Screening in Young Competitive Athletes

Sports-related sudden cardiac death is a rare but devastating consequence of sports participation. Certain pathologies underlying sports-related sudden cardiac death could have been picked up pre-participation and the affected athletes advised on appropriate preventive measures and/or suitability for training or competition. However, mass screening efforts - especially in healthy young populations - are fraught with challenges, most notably the need to balance scarce medical resources and sustainability of such screening programmes, in healthcare systems that are already stretched. Given the rising trend of young sports participants across the Asia-Pacific region, the working group of the Asian Pacific Society of Cardiology (APSC) developed a sports classification system that incorporates dynamic and static components of various sports, with deliberate integration of sports events unique to the Asia-Pacific region. The APSC expert panel reviewed and appraised using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed, which were then put to an online vote. Consensus was reached when 80% of votes for a recommendation were agree or neutral. The resulting statements described here provide guidance on the need for cardiovascular pre-participation screening for young competitive athletes based on the intensity of sports they engage in.

Development of a Cadence-based Metabolic Equation for Walking

PURPOSE

This study aimed to develop cadence-based metabolic equations (CME) for predicting the intensity of level walking and evaluate these CME against the widely adopted American College of Sports Medicine (ACSM) Metabolic Equation, which predicts walking intensity from speed and grade.

METHODS

Two hundred and thirty-five adults (21-84 yr of age) completed 5-min level treadmill walking bouts between 0.22 and 2.24 m·s, increasing by 0.22 m·s for each bout. Cadence (in steps per minute) was derived by dividing directly observed steps by bout duration. Intensity (oxygen uptake; in milliliters per kilogram per minute) was measured using indirect calorimetry. A simple CME was developed by fitting a least-squares regression to the cadence-intensity relationship, and a full CME was developed through best subsets regression with candidate predictors of age, sex, height, leg length, body mass, body mass index (BMI), and percent body fat. Predictive accuracy of each CME and the ACSM metabolic equation was evaluated at normal (0.89-1.56 m·s) and all (0.22-2.24 m·s) walking speeds through k-fold cross-validation and converted to METs (1 MET = 3.5 mL·kg·min).

RESULTS

On average, the simple CME predicted intensity within ~1.8 mL·kg·min (~0.5 METs) at normal walking speeds and with negligible (<0.01 METs) bias. Including age, leg length, and BMI in the full CME marginally improved predictive accuracy (≤0.36 mL·kg·min [≤0.1 METs]), but may account for larger (up to 2.5 mL·kg·min [0.72 MET]) deviations in the cadence-intensity relationships of outliers in age, stature, and/or BMI. Both CME demonstrated 23%-35% greater accuracy and 2.2-2.8 mL·kg·min (0.6-0.8 METs) lower bias than the ACSM metabolic equation's speed-based predictions.

CONCLUSIONS

Although the ACSM metabolic equation incorporates a grade component and is convenient for treadmill-based applications, the CME developed herein enables accurate quantification of walking intensity using a metric that is accessible during overground walking, as is common in free-living contexts.

[Effect of a physical training program on the occurrence of exercise-induced arrhythmias in patients with heart disease]

Objective

Although physical training has been associated with an increase in survival, its role in reducing Exercise-induced arrhythmias (EIA) in patients with heart disease has not yet been dilucidated. We aim to compare the effect of physical training on the occurrence of EIA in patients with heart disease.

Methodology

We evaluated a retroprospective and self-controlled cohort of patients older than 18 years with heart disease who entered the cardiac rehabilitation program of the National Institute of Cardiology Ignacio Chávez in México, during January 2015 to December 2016. In all patients, cardiovascular risk was stratified, including a cardiopulmonary exercise test, which was also performed at the end of the program. The occurrence of arrhythmias was evaluated before and after the training program.

Results

160 patients were analyzed, of which 126 (79%) were male. The proportion of patients who developed EIA in the first exercise testing was 56% and in the second one was 48%. In the first group 35% of patients did not developed EIA in the second test. Of the 71 patients who did not present EIA at the beginning of the program, twenty (28%) presented arrhythmias at second test. In relation to the effect of the training program on the occurrence of arrhythmias, we could observe that it had a protective effect, with a RR = 0.49 (95% CI: 0.35-0.67, p <0.001).

Conclusion

In this study, physical training was associated with a decreased risk of developing EIA.

Neurologic complications of cardiac disease in athletes

Athletic participation at all levels of proficiency is an encouraged activity. Physicians evaluating athletes are tasked with assessing the benefits and risks of participating in vigorous physical activity and should engage in shared decision making with the athlete. Identifying the neurologic sequelae is an essential part of the assessment that is often not covered. This chapter will review the association of a wide range of cardiac disorders that can be related to or associated with subsequent neurologic sequelae, along with a brief overview of recommendations for management. Prevalent neurological complications of cardiac disease in athletes include stroke and seizures. There are also certain channelopathies that result in concurrent cardiac dysrhythmias and epilepsy. In addition, physiologic cardiac rhythm changes and the athlete's heart are discussed in the context of the differential diagnoses of subsequent cardiac and neurologic disease. The primary objective of this chapter is to prepare the physician for accurate recognition of cardiac disease in athletes that could result in neurologic complications if not diagnosed and managed early on.

The Cardiovascular Response to Interval Exercise Is Modified by the Contraction Type and Training in Proportion to Metabolic Stress of Recruited Muscle Groups

Background: Conventional forms of endurance training based on shortening contractions improve aerobic capacity but elicit a detriment of muscle strength. We hypothesized that eccentric interval training, loading muscle during the lengthening phase of contraction, overcome this interference and potentially adverse cardiovascular reactions, enhancing both muscle metabolism and strength, in association with the stress experienced during exercise. Methods: Twelve healthy participants completed an eight-week program of work-matched progressive interval-type pedaling exercise on a soft robot under predominately concentric or eccentric load. Results: Eccentric interval training specifically enhanced the peak power of positive anaerobic contractions (+28%), mitigated the strain on muscle’s aerobic metabolism, and lowered hemodynamic stress during interval exercise, concomitant with a lowered contribution of positive work to the target output. Concentric training alone lowered blood glucose concentration during interval exercise and mitigated heart rate and blood lactate concentration during ramp exercise. Training-induced adjustments for lactate and positive peak power were independently correlated (p < 0.05, |r| > 0.7) with indices of metabolic and mechanical muscle stress during exercise. Discussion: Task-specific improvements in strength and muscle’s metabolic capacity were induced with eccentric interval exercise lowering cardiovascular risk factors, except for blood glucose concentration, possibly through altered neuromuscular coordination.

Effect of moderate-intensity seated exercise on the management of metabolic outcomes in hypertensive individuals with or without exercise habits

Background

We aimed to evaluate the effect of moderate-intensity seated exercise on metabolic outcomes in hypertensive individuals with or without exercise habits.

Methods

Forty-two hypertensive individuals volunteered for this study and were classified into 3 groups by their habits and place for moderate-intensity exercise prior to this study: NONE (<2 days/week or no exercise; n = 13), HOME (≥30 min/day and ≥2 days/week at home; n = 15), and GYM (≥30 min/day and ≥2 days/week at a hospital gym; n = 14). They performed their daily activities as usual and seated exercise (stepping and stepping with trunk rotation; a range of 11–13 on the Borg rating of perceived exertion scale) for at least 15 min/day and at least 3 days/week for 12 weeks.

Results

Thirty-five participants (age: 67.7 ± 5.9 years) completed the study, and there was no difference among the 3 groups regarding weekly exercise. The homeostasis model assessment of insulin resistance (HOMA-IR) value in the NONE group was significantly higher than that in the GYM group at baseline (p < 0.05), but it decreased significantly after 12 weeks (from 2.2 ± 0.8 to 1.7 ± 0.7, p < 0.05). Changes in HOMA-IR in the NONE group after 12 weeks was greater than that in the HOME and GYM groups (both p < 0.01). The HOME and GYM groups showed no significant changes in any of the variables.

Conclusion

Moderate-intensity seated exercise may be an effective strategy to improve insulin resistance in hypertensive individuals without exercise habits.

Leisure-Time Physical Activity and Mortality in CKD: A 1999-2012 NHANES Analysis

BACKGROUND

For patients with CKD, evidence on the optimal dose of physical activity and possible harm with excessive exercise is limited. This study aimed to analyze the dose-response association between leisure-time physical activity (LTPA) and mortality in those with CKD and explore the optimal dose or possible harm associated with increased levels of LTPA.

METHODS

4,604 participants with CKD from the 1999 to 2012 National Health and Nutrition Examination Surveys with linked mortality data obtained through 2015 were classified into 6 groups: 0, 1-149, 150-299, 300-599, 600-899, and ≥900 min/week based on the total duration of the self-reported LTPA. Multivariable-adjusted Cox proportional hazards models were used to examine dose-response associations between LTPA and mortality.

RESULTS

During the median follow-up of 114 months, 1,449 (31%) all-cause deaths were recorded. Compared to the inactive group (0 min/week), we observed a 22% lower risk of all-cause mortality (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.63-0.97) among participants who performed 1-149 min per week for LTPA. The corresponding HRs and 95% CIs for all-cause mortality for 150-299 and 300-599 min/week of LTPA were 0.79 (0.64-0.97) and 0.74 (0.56-0.98). The benefit appeared to reach a threshold of a 43% (HR, 0.57; 95% CI, 0.36-0.91) lower risk of all-cause mortality among individuals performing 600-899 min/week for LTPA. Importantly, for ≥900 min/week of LTPA, the continued benefits were observed (HR, 0.62; 95% CI, 0.44-0.87).

CONCLUSION

LTPA was associated with lower mortality in those with CKD. The optimal dose was observed at the LTPA level of approximately 600-899 min/week, and there were still benefits rather than the excess risk with LTPA levels as high as ≥900 min/week. Therefore, clinicians should encourage inactive CKD patients to perform LTPA and do not need to discourage CKD patients who already adhere to long-term physical activity.

Effectiveness of physical activity prescription by primary care nurses using health assets: A randomized controlled trial

AIM

To evaluate the effectiveness of a 12-month multifactorial intervention by primary care nurses using health assets in increasing adherence to physical activity prescription (150 min/week) in patients with two or more cardiovascular risk factors.

BACKGROUND

Physical activity promotion is a priority and helps to decrease mortality risk due to cardiovascular diseases. However, adherence to the habitual physical activity prescription in primary healthcare settings is low.

DESIGN

Multicentre, single-blind, parallel randomized (in two different branches) clinical trial.

METHODS

In total, 263 participants from 20 primary healthcare centres in Mallorca completed the randomized controlled trial study (intervention group N = 128, control group N = 135). The intervention consisted in four visits and included a motivational interview and an individualized prescription of physical activity using health assets. Primary outcome measure was the number of participants performing at least 150 min of weekly physical activity. Secondary outcomes included physical activity level and physical fitness, Sense of Coherence, cardiovascular risk, sociodemographic data, trans-theoretical stage of change, sleep quality, and depression.

RESULTS

Adherence to the recommendation of at least 150 min of physical activity was higher in the intervention than in the control group (χ²  = 3.951, p = .047). However, this higher adherence did not suppose higher physical activity levels because no differences between groups were found in the total physical activity performed after intervention (t=-0.915, p = .361). At the end of the intervention participants randomized to the intervention group spent more time walking than participants in the control group (t = 2.260, p = .025).

CONCLUSION

The multifactorial intervention performed by primary care nurses induced a higher adherence to the 150-min of weekly physical activity recommendation.

IMPACT

Adherence to the usual physical activity prescription in primary care is low. Physical activity prescription performed by primary care nurses and based on health assets and motivational interview can help to increase physical activity levels of patients. The main finding of the present study was that prescription using this approach was shown to be effective, leading to a higher adherence in the intervention group. This intervention is feasible in the nurse's primary healthcare setting, thus it could be implemented as the main tool when exercise is prescribed.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN76069254.

Cardiorespiratory fitness assessment among firefighters: Is the non-exercise estimate accurate?

BACKGROUND

Minimum cardiorespiratory fitness (CRF) has been recommended for firefighters due to job requirements. Thus, it is important to identify accurate and readily available methods to assess CRF in this population. Non-exercise CRF estimates (NEx-CRF) have been proposed but this approach requires validation in this population.

OBJECTIVE

To evaluate the accuracy of a NEx-CRF, as compared to a field maximum exercise test, among career military firefighters of both genders using a comprehensive agreement analysis.

METHODS

We evaluated the accuracy of a NEx-CRF estimate compared to the Cooper 12 min running test among 702 males and 106 female firefighters.

RESULTS

Cooper and NEx-CRF tests yielded similar CRF in both genders (differences <1.8±4.7 ml/kg-1.min-1; effect size <0.34). However, NEx-CRF underestimated Cooper-derived CRF among the fittest firefighters. NEx-CRF showed moderate to high sensitivity/specificity to detect fit or unfit firefighters (71.9% among men and 100% among women). Among men, the NEx-CRF method correctly identified most firefighters with less than 11 METs or greater than 13 METs, but showed lower precision to discriminate those with CRF between 11-13 METs.

CONCLUSIONS

The NEx-CRF method to estimate firefighters' CRF may be considered as an alternative method when an exercise-based method is not available or may be used to identify those who require more traditional testing (CRF 11-13 METs).

Blunted blood pressure response to exercise and isolated muscle metaboreflex activation in patients with cirrhosis

We sought to test the hypothesis that the cardiovascular responses to isolated muscle metaboreflex activation would be blunted in patients with cirrhosis. Eleven patients with cirrhosis and 15 healthy controls were evaluated. Blood pressure (BP; oscillometric method), contralateral forearm blood flow (FBF; venous occlusion plethysmography), and heart rate (HR; electrocardiogram) were measured during baseline, isometric handgrip at 30% of maximal voluntary contraction followed by postexercise ischemia (PEI). Forearm vascular conductance (FVC) was calculated as follows: (FBF / mean BP) × 100. Changes in HR during handgrip were similar between groups but tended to be different during PEI (controls: Δ 0.5 ± 1.1 bpm vs. cirrhotic patients: Δ 3.6 ± 1.0 bpm, P = 0.057). Mean BP response to handgrip (controls: Δ 20.9 ± 2.7 mm Hg vs. cirrhotic patients: Δ 10.6 ± 1.5 mm Hg, P = 0.006) and PEI was attenuated in cirrhotic patients (controls: Δ 16.1 ± 1.9 mm Hg vs. cirrhotic patients: Δ 7.2 ± 1.4 mm Hg, P = 0.001). In contrast, FBF and FVC increased during handgrip and decreased during PEI similarly between groups. These results indicate that an abnormal muscle metaboreflex activation explained, at least partially, the blunted pressor response to exercise exhibited by cirrhotic patients. Novelty: Patients with cirrhosis present abnormal muscle metaboreflex activation. BP response was blunted but forearm vascular response was preserved. HR response was slightly elevated.

Ambient fine particulate matter pollution and years of life lost from cardiovascular diseases in 48 large Chinese cities: Association, effect modification, and additional life gain

Existing evidence on the associations between fine particulate matter (PM_2.5) and years of life lost (YLL) from cardiovascular diseases (CVD) is limited and inconclusive, and the role of potential modifiers, especially those at city-level, is not fully understood. In this study, a time-series study was conducted in 48 large Chinese cities from 2013 to 2017. Generalized additive model coupled with random effects model were used to estimate national-average associations of PM_2.5 with YLL. Effect modification by individual- and city-level characteristics obtained by linking with China Chronic Disease and Risk Factors Surveillance was explored. Moreover, additional life gain was evaluated under scenario where PM_2.5 concentration would be reduced. For 10 μg/m³ increase in PM_2.5 concentration at lag01 day, the relative increment of YLL was 0.22% from CVD, 0.20% from ischemic heart disease, 0.26% from stroke, 0.23% from hemorrhagic stroke, and 0.31% from ischemic stroke. Some associations were stronger in elder and less educated people, warm season, as well as cities characterized by higher temperature and prevalence of binge drinking and excess red meat intake, or lower PM_2.5 and prevalence of usual exercise. Additional life gain attributable to avoidable YLL from CVD was estimated to be 0.08 year if PM_2.5 concentration could fall to the standard recommended by World Health Organization (25 μg/m³). This large epidemiological investigation demonstrated robust evidence of short-term associations between PM_2.5 exposure and YLL from CVD. Potential modifiers should be considered to develop efficient intervention strategies. Implementation of more stringent standard is beneficial to alleviate YLL caused by PM_2.5.

Incidence, bystander emergency response management and outcomes of out-of-hospital cardiac arrest at exercise and sport facilities in Australia

OBJECTIVE

Despite growing emphasis on automated external defibrillators (AEDs) at sport venues in Australia, the risk of cardiac events at such locations is unknown. The aim of the present study was to investigate the incidence of out-of-hospital cardiac arrest (OHCA) at exercise and sport facilities (ESF) in Australia and the impact of effective bystander-initiated CPR and AED use on return of spontaneous circulation (ROSC) to hospital admission.

METHODS

Data were obtained from the Queensland Ambulance Service for the 8-year period between January 2007 and January 2015. Data were analysed using descriptive statistics, non-parametric correlational tests and logistic regression. The OHCA incidence rate (IR) for ESF categories was standardised for 100 000 participant-years.

RESULTS

Over the 8-year period, there were 250 OHCA events with a median age of 62 years (interquartile range 49-69) comprising mostly males (86.6%, n = 187). The risk of OHCA for 100 000 participants per year was highest at outdoor sports facilities (IR 5.1) followed by indoor sports or fitness facilities (IR 0.8). On arrival of paramedics, bystander-initiated CPR and AED was present at 12.4% (n = 31) of the cases achieving 33.3% (n = 9) ROSC to hospital admission. The odds of ROSC for effective CPR was 2.3 times the odds of ROSC for no CPR (P = 0.01).

CONCLUSION

These findings have implications for policy development by government agencies and major sport and exercise organisations to improve bystander CPR and AED. This can help to ensure that ESF can properly respond to cardiac emergencies to save lives.

[Effects of Physical Activity on Health]

Regular physical activity contributes to both maintaining and improving health, and is important for human development throughout the entire lifespan of a person. There is strong evidence for the beneficial effects of physical activity on health, in the areas of all-cause mortality, cancer, cardiovascular health, musculoskeletal health, metabolic health, and neurocognitive health. Physical activity includes any form of movement in which the contraction of skeletal muscles results in an increase in energy consumption. It is quantified and controlled via the frequency, duration, intensity, and weekly extent. All those forms of movement that improve health and in which the risk of injury is low are defined as health-enhancing physical activity. The Austrian recommendations for health-enhancing physical activity include endurance-oriented movement, plus strength and coordination training. Exercise is aimed at initiating adaptation processes, in order to improve functionality. Therefore, it has to be adapted to the different levels of individual performance ability, activity levels, and age, and should be carried out according to certain principles. Exercise leads to a positive change in physiological parameters, which in turn are closely linked to an improvement in the state of health. Through regular endurance-oriented and muscle-strengthening physical activity, far-reaching health effects can be achieved. Nevertheless, undesirable events can occur during activity, and the musculoskeletal and circulatory systems can be particularly affected. However, through adequate preparation, suitable equipment, and appropriate exercise, the personal and also the public health benefits of physical activity and sport can be increased.

Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease

AIMS

CoV-19/SARS-CoV-2 is a highly pathogenic virus that is causing a global pandemic with a high number of deaths and infected people. To contain the diffusion of infection, several governments have enforced restrictions on outdoor activities or even collective quarantine on the population. The present commentary briefly analyzes the effects of quarantine on lifestyle, including nutrition and physical activity and the impact of new technologies in dealing with this situation.

DATA SYNTHESIS

Quarantine is associated with stress and depression leading to unhealthy diet and reduced physical activity. A diet poor in fruit and vegetables is frequent during isolation, with a consequent low intake of antioxidants and vitamins. However, vitamins have recently been identified as a principal weapon in the fight against the Cov-19 virus. Some reports suggest that Vitamin D could exert a protective effect on such infection. During quarantine, strategies to further increase home-based physical activity and to encourage adherence to a healthy diet should be implemented. The WHO has just released guidance for people in self-quarantine, those without any symptoms or diagnosis of acute respiratory illness, which provides practical advice on how to stay active and reduce sedentary behavior while at home.

CONCLUSION

Quarantine carries some long-term effects on cardiovascular disease, mainly related to unhealthy lifestyle and anxiety. Following quarantine, a global action supporting healthy diet and physical activity is mandatory to encourage people to return to a good lifestyle routine.

Higher Body Mass Index Is Associated With Biochemical Changes in Knee Articular Cartilage After Marathon Running: A Quantitative T2-Relaxation MRI Study

Background:

More than 30 million individuals participate in marathon running every year worldwide. As the popularity of marathon running continues to increase, it is essential for the purposes of injury prevention to understand the effects of marathon running on the knee cartilage.

Purpose:

To investigate the immediate effects of marathon running on knee articular cartilage and to determine the relationship between body mass index and cartilage biochemical composition.

Study Design:

Descriptive laboratory study.

Methods:

T2-relaxation magnetic resonance imaging (MRI) of knees in 18 nonprofessional marathoners (mean age, 35.6 ± 6.4 years) was performed before and after a full-length marathon. Three-dimensional models of the knee articular cartilage were reconstructed and divided into different regions of interest. The 3-dimensional models were then applied to corresponding T2-relaxation MRI maps to calculate T2 values in each region of interest. The mean values of the T2-relaxation times in each region of interest before and after the marathon were compared by use of the paired Student t test. The Pearson correlation coefficient between T2 change and runner body mass index (BMI) was calculated.

Results:

Postmarathon T2-relaxation times were significantly higher than premarathon values for patellofemoral cartilage (32.6 ± 12.1 vs 34.1 ± 10.9 ms; P < .01) and medial tibial cartilage (35.6 ± 11.7 vs 34.6 ± 12.0 ms; P = .01). The greatest increase was observed in the anterior part of the medial tibial cartilage. No statistically significant changes were seen in the T2-relaxation times of the lateral tibial and femoral cartilage. Postmarathon T2-relaxation elevation in the anteromedial knee tibiofemoral joint cartilage strongly correlated with body weight (R = 0.6746; P = .03) and BMI (R = 0.6989; P = .001). Changes in T2-relaxation times did not correlate with marathon time, height, age, or sex in any regions of interest.

Conclusion:

Marathon running leads to immediate postmarathon elevated T2-relaxation values within knee articular cartilage, suggesting biochemical content alteration. Additionally, runners with higher BMI may have greater changes in cartilage biochemical composition after a marathon. Further studies should investigate whether these changes are sustained over time to determine the relationship between immediate biochemical changes in cartilage composition and cartilage degeneration.

Clinical Relevance:

Runners with a higher BMI may carry a higher risk of anteromedial tibiofemoral cartilage degeneration compared with runners with lower BMI.

Generalized Approach to Translating Exercise Tests and Prescribing Exercise

Although there is evidence supporting the benefit of regular exercise, and recommendations about exercise and physical activity, the process of individually prescribing exercise following exercise testing is more difficult. Guidelines like % heart rate (HR) reserve (HRR) require an anchoring maximal test and do not always provide a homogenous training experience. When prescribing HR on the basis of % HRR, rating of perceived exertion or Talk Test, cardiovascular/perceptual drift during sustained exercise makes prescription of the actual workload difficult. To overcome this issue, we have demonstrated a strategy for "translating" exercise test responses to steady state exercise training on the basis of % HRR or the Talk Test that appeared adequate for individuals ranging from cardiac patients to athletes. However, these methods depended on the nature of the exercise test details. In this viewpoint, we combine these data with workload expressed as Metabolic Equivalent Task (METs). We demonstrate that there is a regular stepdown between the METs during training to achieve the same degree of homeostatic disturbance during testing. The relationship was linear, was highly-correlated (r = 0.89), and averaged 71.8% (Training METs/Test METs). We conclude that it appears possible to generate a generalized approach to correctly translate exercise test responses to exercise training.

Inspiratory muscle strength training lowers blood pressure and sympathetic activity in older adults with OSA: a randomized controlled pilot trial

Previous work has shown lowered casual blood pressure after just 6 wk of inspiratory muscle strength training (IMST), suggesting IMST as a potential therapeutic in the prevention/treatment of hypertension. In this study, we assessed the effects of IMST on cardiovascular parameters in older, overweight adults diagnosed with moderate and severe obstructive sleep apnea (OSA). Subjects were randomly assigned to one of two interventions 1) high-intensity IMST (n = 15, 75% maximal inspiratory pressure), or 2) a control intervention (n = 10, 15% maximum inspiratory pressure). Subjects in both groups trained at home completing 30 training breaths/day, 5 days/wk for 6 wk. Pre- and posttraining measures included maximal inspiratory pressure, casual and ambulatory blood pressures, spontaneous cardiac baroreflex sensitivity, and muscle sympathetic nerve activity. Men and women in the high-intensity IMST group exhibited reductions in casual systolic (SBP), diastolic (DBP), and mean arterial blood pressures (MAP) [SBP: -8.82 ± 4.98 mmHg; DBP: -4.69 ± 2.81 mmHg; and MAP: -6.06 ± 1.03 mmHg; P < 0.002] and nighttime SBP (pre: -12.00 ± 8.20 mmHg; P < 0.01). Muscle sympathetic nerve activities also were lower (-6.97 ± 2.29 bursts/min^-1; P = 0.01 and -9.55 ± 2.42 bursts/100 heartbeats; P = 0.002) by week 6. Conversely, subjects allocated to the control group showed no change in casual blood pressure or muscle sympathetic nerve activity and a trend toward higher overnight blood pressures. A short course of high-intensity IMST may offer significant respiratory and cardiovascular benefits for older, overweight adults with OSA. For Clinical Trial Registration, see https://www.clinicaltrials.gov (Identifier: NCT02709941).NEW & NOTEWORTHY Older, obese adults with moderate-severe obstructive sleep apnea who perform 5 min/day high-intensity inspiratory muscle strength training (IMST) exhibit lowered casual and nighttime systolic blood pressure and sympathetic nervous outflow. In contrast, adults assigned to a control (low-intensity) intervention exhibit no change in casual blood pressure or muscle sympathetic nerve activity and a trend toward increased overnight blood pressure. Remarkably, adherence to IMST even among sleep-deprived and exercise-intolerant adults is high (96%).

Preconditioning by aerobic exercise reduces acute ischemic renal injury in rats

Acute kidney injury (AKI) can be defined as the sudden loss of renal function associated with structural changes in the kidneys. Currently, 13.3 million people die of AKI around the world. Normally aerobic exercise is used both as/for the treatment and prevention of high blood pressure, metabolic disease and Diabetes mellitus (DM). Nevertheless, exercise preconditioning must be a crucial resource in the prevention and mitigation of AKI. The aim of this study was to evaluate the effects of the exercise preconditioning on renal IR (ischemic/reperfusion) experimental model. Male Wistars rats were divided into three groups (n = 9): sham (S), ischemic/reperfusion (IR), exercise + ischemic/reperfusion (EX + IR). IR renal injury was induced by clamping the bilateral renal artery for 45 min. The rats were subjected to exercise 5 days a week for 4 weeks with progressive intensity and duration. The group treated with exercise preconditioning, showed additional improvements in various parameters, including serum creatinine, proteinuria, and decrease of the severity of the tubular injury and activated caspase‐3 levels (P < 0.05). The previous aerobic exercise‐induced renoprotection in the IR injury. We anticipate that the practice of physical exercise in healthy individuals can also be useful for the prevention and attenuation of AKI.

Cardiac baroreflex function and vascular reactivity recovery after aerobic exercise in patients with early cirrhosis

OBJECTIVE

To investigate the effects of aerobic exercise on the cardiac baroreflex function and vascular reactivity in patients with cirrhosis.

METHODS

Thirteen patients with cirrhosis were submitted to exercise and control intervention. At baseline and at 30 and 60 min following intervention, we evaluated cardiac baroreflex sensitivity (cBRS) and the baroreflex effectiveness index (BEI) using sequence technique. Vascular reactivity was assessed inducing reactive hyperemia before and 60 min after intervention.

RESULTS

At baseline, there was no difference (P interaction = 0.848) between exercise (from 3.0 ± 0.34 to 14.60 ± 1.06 ml/100ml/min) and control sessions (from 2.38 ± 0.10 to 13.73 ± 1.05 ml/100ml/min) regarding the increase in forearm blood flow during reactive hyperemia. However, this response was higher postexercise (from 3.38 ± 0.31 to 16.58 ± 1.58 ml/100ml/min) than postcontrol intervention (from 2.04 ± 0.23 to 11.98 ± 1.16 ml/100ml/min, P interaction < 0.001). BEI increased at 30- and 60-min postexercise (from 32 ± 7 to 42 ± 7 and 46 ± 7%), but not after control intervention (from 33 ± 6 to 31 ± 5 and 33 ± 7%, P interaction = 0.014). In contrast, cBRS decreased at 30-min postexercise (from 10.3 ± 1.9 to 8.2 ± 1.4 and 10.3 ± 2.1 ms/mmHg) and increased postcontrol intervention (from 7.9 ± 0.9 to 10.5 ± 1.5 and 10.3 ± 1.3 ms/mmHg, P interaction = 0.012).

CONCLUSION

The results suggest that a single bout of aerobic exercise improved cardiac baroreflex function and increased vascular reactivity in patients with early-stage cirrhosis.

An expanded repertoire of intensity-dependent exercise-responsive plasma proteins tied to loci of human disease risk

Routine endurance exercise confers numerous health benefits, and high intensity exercise may accelerate and magnify many of these benefits. To date, explanatory molecular mechanisms and the influence of exercise intensity remain poorly understood. Circulating factors are hypothesized to transduce some of the systemic effects of exercise. We sought to examine the role of exercise and exercise intensity on the human plasma proteome. We employed an aptamer-based method to examine 1,305 plasma proteins in 12 participants before and after exercise at two physiologically defined intensities (moderate and high) to determine the proteomic response. We demonstrate that the human plasma proteome is responsive to acute exercise in an intensity-dependent manner with enrichment analysis suggesting functional biological differences between the moderate and high intensity doses. Through integration of available genetic data, we estimate the effects of acute exercise on exercise-associated traits and find proteomic responses that may contribute to observed clinical effects on coronary artery disease and blood pressure regulation. In sum, we provide supportive evidence that moderate and high intensity exercise elicit different signaling responses, that exercise may act in part non-cell autonomously through circulating plasma proteins, and that plasma protein dynamics can simulate some the beneficial and adverse effects of acute exercise.

Adequately dosed aerobic physical activity in people with axial spondyloarthritis: associations with physical therapy

INTRODUCTION

This study aimed to compare the engagement in moderate- and vigorous-intensity PA in axSpA patients with and without current physical therapy (PT).

METHODS

In this cross-sectional study, a survey, including current PT treatment (yes/no) and PA, using the 'Short QUestionnaire to ASsess Health-enhancing PA' (SQUASH), was sent to 458 axSpA patients from three Dutch hospitals. From the SQUASH, the proportions meeting aerobic PA recommendations (≥ 150 min/week moderate-, ≥ 75 min/week vigorous-intensity PA or equivalent combination; yes/no) were calculated. To investigate the association between PT treatment and meeting the PA recommendations, odds ratios (OR) with 95% confidence intervals (95% CI) were estimated using logistic regression models, adjusting for sex, age, health status and hospital.

RESULTS

The questionnaire was completed by 200 patients, of whom 68%, 50% and 82% met the moderate-, vigorous- or combined-intensity PA recommendations, respectively. Ninety-nine patients (50%) had PT treatment, and those patients were more likely to meet the moderate- (OR 2.09 [95% CI 1.09-3.99]) or combined-intensity (OR 3.35 [95% CI 1.38-8.13]) PA recommendations, but not the vigorous-intensity PA recommendation (OR 1.53 [95% CI 0.80-2.93]). Aerobic exercise was executed in 19% of individual PT programs.

CONCLUSION

AxSpA patients with PT were more likely to meet the moderate- and combined-intensity PA recommendations, whereas there was no difference in meeting the vigorous-intensity PA recommendation. Irrespective of having PT treatment, recommendations for vigorous-intensity PA are met by only half of the patients. Implementation should thus focus on aerobic PA in patients without PT and on vigorous-intensity PA in PT programs.

Feasibility and safety of high-intensity interval training for the rehabilitation of geriatric inpatients (HIITERGY) a pilot randomized study

BACKGROUND

High-intensity interval training (HIIT) has been shown to be more effective than moderate-intensity continuous training (MICT) for the physical rehabilitation. However, data on its suitability for older hospitalized patients is scarce.

METHODS

Randomized controlled trial in a hospital setting. Inclusion of 100 patients, ≥65 years old, hospitalized for rehabilitation after an acute medical condition, in a two-week rehabilitation program of either four HIIT or three MICT sessions per week. Completion was defined as participation in all but two planned sessions accomplishing ≥50% of each session. We assessed: upper-limb muscle strength (handgrip isometric strength test), lower-limb muscle strength (quadriceps and ankle flexion and extension tests); gait speed and spatio-temporal parameters (instrumented walkway), and exercise capacity (6-min walk test). All adverse events were recorded as safety endpoints.

RESULTS

An intention-to-treat analysis showed a 44% completion rate for the HIIT group (95% CI, 30-59) and 77% for MICT (95% CI, 55-82). A modified intention-to-treat analysis restricted to patients who participated in ≥1 session showed an 88% completion rate in the HIIT group (95%CI, 69-97) and an 80% completion rate in MICT (95%CI, 65-90). The exercises most frequently undertaken were the pedal exerciser (54%) and the NuStep (32%). There were no significant differences in the various measures. No serious adverse events occurred.

CONCLUSION

A HIIT rehabilitation program for this population was feasible, safe and had a high adherence rate.

TRIAL REGISTRATION NUMBER

Clinicatrials.gov ID: NCT02318459. Trial registration date: November 7th, 2014. Retrospectively registered. This study adheres to the CONSORT guidelines.

Physical Activity and the Risk for Sudden Cardiac Death in Patients With Coronary Artery Disease

BACKGROUND

The association between leisure-time physical activity (LTPA) and the risk of sudden cardiac death (SCD) in coronary artery disease patients is not well known. We aim to assess whether there is an association between LTPA and the risk of SCD and non-SCD in patients with coronary artery disease.

METHODS

Patients with angiographically verified coronary artery disease (n=1946) underwent a clinical evaluation, including filling in an LTPA questionnaire and extensive risk profiling at the baseline. The patients were classified into 4 groups according to LTPA: (1) inactive; (2) irregularly active; (3) active, exercise regularly 2× to 3× weekly; (4) highly active, exercise regularly ≥4× weekly. Age, sex, body mass index, left ventricular ejection fraction, type 2 diabetes mellitus, history of myocardial infarction, Canadian Cardiovascular Society grading of angina pectoris class, and exercise capacity were used as covariates in the multivariate Cox regression analysis.

RESULTS

During follow-up (median 6.3 years), 52 SCDs and 49 non-SCDs occurred. Inactive patients had increased risk for SCD compared with active patients (hazard ratio, 2.45 [95% CI, 1.01-5.98]; P<0.05). A significant LTPA×Canadian Cardiovascular Society grading of angina pectoris class interaction was observed in SCD risk (P=0.019 in highly active patients). LTPA was not associated with SCD in patients with Canadian Cardiovascular Society grading of angina pectoris class 1 (n=1107, 18 events). Among patients with Canadian Cardiovascular Society grading of angina pectoris class 2 or higher (n=839, 34 events), increased risk for SCD was encountered in highly active patients (hazard ratio, 7.46 [95% CI, 2.32-23.9]; P<0.001) and inactive patients (hazard ratio, 3.64 [95% CI, 1.16-11.5]; P<0.05) as compared to active patients. A linear association was observed between LTPA and non-SCD; those with high LTPA had the lowest risk for non-SCD.

CONCLUSIONS

Inactive coronary artery disease patients had increased risk for SCD. In subgroup analysis among symptomatic patients, the risk of SCD was increased in highly active and inactive patients compared with active patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01426685.

Dietary and Biological Assessment of the Omega-3 Status of Collegiate Athletes: A Cross-Sectional Analysis

Omega-3 fatty acids (ω-3 FA) are associated with cardiovascular health, brain function, reduction of inflammation, and several other physiological roles of importance to competitive athletes. The ω-3 FA status of National Collegiate Athletic Association (NCAA) Division I athletes has not been well-described. The purpose of this study was to evaluate the ω-3 FA status of NCAA Division I athletes using dietary and biological assessment methodology. Athletes from nine NCAA Division I institutions from throughout the U.S. (n = 1,528, 51% male, 34 sports represented, 19.9 ± 1.4 years of age) completed a food frequency questionnaire (FFQ) to assess ω-3 FA from diet and supplements. Omega-3 Index (O3i) was evaluated in a sub-set of these participants (n = 298, 55% male, 21 sports represented, 20.0 ± 1.3 years of age) using dried blood spot sampling. Only 6% (n = 93) of athletes achieved the Academy of Nutrition & Dietetics’ recommendation to consume 500 mg DHA+EPA per day. Use of ω-3 FA supplements was reported by 15% (n = 229) of participants. O3i was 4.33 ± 0.81%, with no participants meeting the O3i benchmark of 8% associated with the lowest risk of cardiovascular disease. Every additional weekly serving of fish or seafood was associated with an absolute O3i increase of 0.27%. Overall, sub-optimal ω-3 FA status was observed among a large, geographically diverse group of male and female NCAA Division I athletes. These findings may inform interventions aimed at improving ω-3 FA status of collegiate athletes. Further research on athlete-specific ω-3 FA requirements is needed.

Modifiable Cardiovascular Risk, Hematopoiesis, and Innate Immunity

Unhealthy diet, lack of exercise, psychosocial stress, and insufficient sleep are increasingly prevalent modifiable risk factors for cardiovascular disease. Accumulating evidence indicates that these risk factors may fuel chronic inflammatory processes that are active in atherosclerosis and lead to myocardial infarction and stroke. In concert with hyperlipidemia, maladaptive immune system activities can contribute to disease progression and increase the probability of adverse events. In this review, we discuss recent insight into how the above modifiable risk factors influence innate immunity. Specifically, we focus on pathways that raise systemic myeloid cell numbers and modulate immune cell phenotypes, reviewing hematopoiesis, leukocyte trafficking, and innate immune cell accumulation in cardiovascular organs. Often, relevant mechanisms that begin with lifestyle choices and lead to cardiovascular events span multiple organ systems, including the central nervous, endocrine, metabolic, hematopoietic, immune and, finally, the cardiovascular system. We argue that deciphering such pathways provides not only support for preventive interventions but also opportunities to develop biomimetic immunomodulatory therapeutics that mitigate cardiovascular inflammation.

ISPRM/ESPRM guidelines on Physical and Rehabilitation Medicine professional practice for adults with obesity and related comorbidities

BACKGROUND

The World Health Organization (WHO) has declared obesity as the largest global chronic health problem in adults. In the last years, attention has been drawn to rehabilitative interventions for patients with obesity.

AIM

The aim of this manuscript is to provide Physical and Rehabilitation Medicine (PRM) physicians with evidence-based recommendations for the rehabilitation of patients with overweight or obesity and related comorbidities.

DESIGN

Evidence-based guidelines.

POPULATION

Adults with overweight or obesity.

METHODS

Guidelines were based on GRADE and WHO recommendations. A comprehensive search of the available evidence about rehabilitation treatments for obesity was performed, and 17 separate systematic literature reviews were conducted. For each outcome, estimates of the effects of rehabilitation treatments were computed and employed along with an assessment of quality of evidence, desirable and undesirable effects, values and preferences to formulate the recommendations. Recommendations were reviewed by a consensus expert panel using a modified Delphi process.

RESULTS

We strongly recommend providing comprehensive multiprofessional and multidisciplinary interventions including exercise, diet and behavioral or cognitive-behavioral therapy. The nutritional component of these treatments should include diets with either a high-protein or a low-fat content. It is strongly recommended to prescribe frequent moderate aerobic exercise. We strongly recommend providing cognitive-behavioral interventions as the behavioral component of rehabilitation programs.

CONCLUSIONS

PRM physicians should lead multidisciplinary teams providing comprehensive and individualized rehabilitation programs for patients with overweight or obesity. These guidelines were endorsed by the International Society of Physical and Rehabilitation Medicine (ISPRM) and by the European Society of Physical and Rehabilitation Medicine (ESPRM).

The effect of physical activity on dose-relationship between serum 25-hydroxyvitamin D and cardiovascular health events in older adults

BACKGROUND AND AIMS

Reverse J- or U-shaped associations between serum 25-hydroxyvitamin D (25[OH]D) concentrations and cardiovascular outcomes have been reported, which need clarifications in older adults. Physical activity, correlating with both serum 25[OH]D concentration and cardiovascular health, may have an effect on the dose-relationships.

METHODS AND RESULTS

At baseline, 2790 participants aged 65 years and over, free of vitamin D supplementation use, had assays for serum 25[OH]D concentrations and health related characteristics and measurements, were followed up for cardiovascular events and death by up to 7 and 15 years, respectively. The dose-response associations of serum 25[OH]D concentrations with cardiovascular events and mortality risk were examined using Cox regression models. After adjusting for physical activity and other covariates, serum 25[OH]D concentration was non-linearly associated with cardiovascular mortality risk (U-shaped, P = 0.009). According to the Institute of Medicine categories, the HR(95% CI) of cardiovascular mortality risk separately in deficient (<25 nmol/L), inadequate (25 to < 50 nmol/L) and potentially harmful (≥125 nmol/L) level was 1.67 (0.23, 12.01), 1.66 (1.25, 2.20) and 2.21 (0.30, 16.37), respectively. The risk of 25[OH]D inadequacy for cardiovascular mortality was significantly attenuated by increased physical activity, especially leisure activity (P for trend = 0.008 and 0.021, respectively). No significant finding was observed for incident cardiovascular events.

CONCLUSION

Both lower and higher serum 25[OH]D concentrations were associated with risk of cardiovascular mortality in Chinese community-dwelling older adults. Physical activity may attenuate the cardiovascular mortality risk of vitamin D inadequacy, but its role in individuals with higher 25[OH]D concentrations remains unclear.

Exposure to ambient fine particulate matter is associated with changes in fasting glucose and lipid profiles: a nationwide cohort study

BACKGROUND

Ambient fine particulate matter is a rising concern for global public health. It was recently suggested that exposure to fine particulate matter may contribute to the development of diabetes and dyslipidaemia. This study aims to examine the potential associations of ambient particulate matter exposure with changes in fasting glucose and lipid profiles in Koreans.

METHOD

We used the data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC), a nationwide database representative of the Korean population. A total of 85,869 individuals aged ≥20 years were included. Multiple regression analyses were conducted to assess the associations between exposure to particulate matter and changes in fasting glucose and lipid profiles at 2-year intervals after adjusting for confounders.

RESULTS

Significant associations were observed between an increase in interquartile range for particulate matter < 2.5 μm in diameter (PM_2.5) and elevated levels of fasting glucose and low-density lipoprotein cholesterol (p for trend = 0.015 and 0.010, respectively), while no association for particulate matter sized 2.5-10 μm in diameter (PM_10-2.5) was noted after adjusting for the other covariates. Sub-group analyses showed stronger associations in individuals who were older (≥60 years) or physically inactive.

CONCLUSIONS

Fine particulate matter exposure affects worsening fasting glucose and low-density lipoprotein cholesterol levels, with no evidence of an association for coarse particulate matter.

Hidden danger: A 22-years analysis of law enforcement deaths associated with duty-related illnesses (1997-2018)

Purpose –

Law enforcement is a dangerous profession not only due to assaults, accidents and homicides but also due to health risks. This study examined trends in the national frequency and rate of law enforcement jobrelated illness deaths in the United States over a 22-year period (1997-2018).

Design/methodology/approach –

Data were obtained from the National Law Enforcement Officers Memorial Fund (NLEOMF) on death frequencies related to health issues at work. Death rates were based on the total number of police officers in the United States [rate = (frequency/population at risk) × 100,000]. Trends were examined using standardized regression.

Findings –

A total of 646 deaths were attributed to job-related illness. There was a significant upward trend in overall job-related illness deaths (frequency analyses: β = 0.88, p < 0.0001; rate analyses: β = 0.82, p ≤ 0.0001) mainly driven by a significant increase in 911 cancer deaths (frequency analyses: β = 0.88, p < 0.0001; rate analyses: β = 0.88, p ≤ 0.0001). Nearly 82 percent of circulatory deaths were from a heart attack, with an average death age of 46.5 years.

Research limitations/implications –

Deaths were not included if they failed to meet medical requirements of the NLEOMF. The data are descriptive, do not estimate risk and should be interpreted cautiously.

Practical implications –

Police wellness programs may help to reduce the danger of deaths associated with job-related illness.

Originality/value –

This is among the first studies to examine frequency and rate of police health-related deaths due to job exposures.

Medical-Grade ECG Sensor for Long-Term Monitoring

The recent trend in electrocardiogram (ECG) device development is towards wireless body sensors applied for patient monitoring. The ultimate goal is to develop a multi-functional body sensor that will provide synchronized vital bio-signs of the monitored user. In this paper, we present an ECG sensor for long-term monitoring, which measures the surface potential difference between proximal electrodes near the heart, called differential ECG lead or differential lead, in short. The sensor has been certified as a class IIa medical device and is available on the market under the trademark Savvy ECG. An improvement from the user’s perspective—immediate access to the measured data—is also implemented into the design. With appropriate placement of the device on the chest, a very clear distinction of all electrocardiographic waves can be achieved, allowing for ECG recording of high quality, sufficient for medical analysis. Experimental results that elucidate the measurements from a differential lead regarding sensors’ position, the impact of artifacts, and potential diagnostic value, are shown. We demonstrate the sensors’ potential by presenting results from its various areas of application: medicine, sports, veterinary, and some new fields of investigation, like hearth rate variability biofeedback assessment and biometric authentication.

Acute cardiovascular responses to interval exercise: A systematic review and meta-analysis

Interval exercise training is increasingly recommended to improve health and fitness; however, it is not known if cardiovascular risk is different from continuous exercise protocols. This systematic review with meta-analyses assessed the effect of a single bout of interval exercise on cardiovascular responses that indicate risk of cardiac fibrillation and infarction compared to continuous exercise. Electronic databases Medline, CINAHL, Embase, Scopus and Cochrane were searched. Key inclusion criteria were: (1) intervals of the same intensity and duration followed by a recovery period and (2) reporting at least one of blood pressure, heart rate variability, arterial stiffness or function. Cochrane Risk of Bias tool and GRADE approach were used. Meta-analyses found that systolic blood pressure responses to interval exercise did not differ from responses to continuous exercise immediately (MD 8 mmHg [95% CI -32, 47], p = 0.71) or at 60 min following exercise (MD 0 mmHg [95% CI -2, 1], p = 0.79). However, reductions in diastolic blood pressure and flow-mediated dilation with interval exercise were observed 10-15 min post-exercise. The available evidence indicates that interval exercise does not convey higher cardiovascular risk than continuous exercise. Further investigation is required to establish the safety of interval exercise for clinical populations.

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.

High Intensity Interval training (HIIT) for people with severe mental illness: A systematic review & meta-analysis of intervention studies- considering diverse approaches for mental and physical recovery

There is a mortality gap of 15 to 20 years for people with severe mental illness (SMI - psychotic spectrum, bipolar, major depressive disorders). Modifiable risk factors include inactivity and low cardiorespiratory fitness (CRF). Exercise can improve mental and physical outcomes; optimal type and intensity of exercise for people with SMI has yet to be determined. High Intensity Interval training (HIIT) is an exercise with distinct cardio-metabolic advantages in other disease populations compared to traditional moderate intensity continuous training (MCT). We investigated the feasibility and efficacy of HIIT for people with SMI. Major electronic databases were searched, identifying HIIT studies for adults experiencing SMI.Data on feasibility, safety, study design, sample characteristics, and physical and psychological outcomes were extracted and systematically reviewed. Meta-analyses were conducted within group, pre and post HIIT interventions, and between group, to compare HIIT with control conditions. Nine articles were identified including three pre/post studies, one non randomised and five randomised trials, (366 participants, 45.1% female). HIIT appears as feasible as MCT, with few safety concerns. Following HIIT, there was a moderate improvement in CRF and depression. There was no difference between HIIT and MCT for adherence or CRF.HIIT improved depression more than MCT.

Leisure-Time Physical Activity and Mortality in CKD: A 1999–2012 NHANES Analysis

<b><i>Background:</i></b> For patients with CKD, evidence on the optimal dose of physical activity and possible harm with excessive exercise is limited. This study aimed to analyze the dose-response association between leisure-time physical activity (LTPA) and mortality in those with CKD and explore the optimal dose or possible harm associated with increased levels of LTPA. <b><i>Methods:</i></b> 4,604 participants with CKD from the 1999 to 2012 National Health and Nutrition Examination Surveys with linked mortality data obtained through 2015 were classified into 6 groups: 0, 1–149, 150–299, 300–599, 600–899, and ≥900 min/week based on the total duration of the self-reported LTPA. Multivariable-adjusted Cox proportional hazards models were used to examine dose-response associations between LTPA and mortality. <b><i>Results:</i></b> During the median follow-up of 114 months, 1,449 (31%) all-cause deaths were recorded. Compared to the inactive group (0 min/week), we observed a 22% lower risk of all-cause mortality (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.63–0.97) among participants who performed 1–149 min per week for LTPA. The corresponding HRs and 95% CIs for all-cause mortality for 150–299 and 300–599 min/week of LTPA were 0.79 (0.64–0.97) and 0.74 (0.56–0.98). The benefit appeared to reach a threshold of a 43% (HR, 0.57; 95% CI, 0.36–0.91) lower risk of all-cause mortality among individuals performing 600–899 min/week for LTPA. Importantly, for ≥900 min/week of LTPA, the continued benefits were observed (HR, 0.62; 95% CI, 0.44–0.87). <b><i>Conclusion:</i></b> LTPA was associated with lower mortality in those with CKD. The optimal dose was observed at the LTPA level of approximately 600–899 min/week, and there were still benefits rather than the excess risk with LTPA levels as high as ≥900 min/week. Therefore, clinicians should encourage inactive CKD patients to perform LTPA and do not need to discourage CKD patients who already adhere to long-term physical activity.