Exercise-based cardiac rehabilitation and parasympathetic function in patients with coronary artery disease: a systematic review and meta-analysis

Exercise-based cardiac rehabilitation for patients with coronary heart disease: a systematic review and evidence mapping study

INTRODUCTION

Exercise-based cardiac rehabilitation (CR) plays a critical role in coronary heart disease (CHD) management. There is a heritage in the effect of exercise-based CR with different exercise programs or intervention settings. This study developed an evidence matrix that systematically assesses, organizes, and presents the available evidence regarding exercise-based CR in CHD management.

EVIDENCE ACQUISITION

A comprehensive literature search was conducted across six databases. Two reviewers screened the identified literature, extracted relevant data, and assessed the quality of the studies. An evidence-mapping framework was established to present the findings in a structured manner. Bubble charts were used to represent the included systematic reviews (SRs). The charts incorporated information, exercise prescriptions, outcome indicators, associated P values, research quality, and the number of original studies. A descriptive analysis summarized the types of CR, intervention settings, influential factors, and adverse events.

EVIDENCE SYNTHESIS

Sixty-two SRs were included in this analysis, focusing on six exercise types in addition to assessing major adverse cardiovascular events (MACE), cost and rehabilitation outcomes. The most commonly studied exercise types were unspecified (28 studies, 45.2%) and aerobic (11 studies, 17.7%) exercises. All-cause mortality was the most frequently reported MACE outcome (22 studies). Rehabilitation outcomes primarily centered around changes in cardiac function (135 outcomes from 39 SRs). Only 8 (12.9%) studies were rated as "high quality." No significant adverse events were observed in the intervention group. Despite some variations among the included studies, most SRs demonstrated the benefits of exercise in improving one or more MACE or rehabilitation outcomes among CHD patients.

CONCLUSIONS

The proportion of high-quality evidence remains relatively low. Limited evidence is available regarding the effectiveness of specific exercise types and specific populations, necessitating further evaluation.

Association between arterial stiffness and autonomic dysfunction in participants underwent treadmill exercise testing: a cross-sectional analysis

Data on the impact of arterial stiffness on autonomic function are limited. We sought to investigate whether heart rate recovery (HRR), a predictor of autonomic function, is impaired in patients with increased arterial stiffness. A total of 475 participants (mean age 55.8 ± 11.1 years, 34.3% women) who underwent a treadmill exercise test (TET) for the evaluation of chest pain were retrospectively analyzed. All patients underwent brachial-ankle pulse wave velocity (baPWV) measurement on the same day. HRR was defined as the difference in heart rate from maximal exercise to 1 min of recovery. Participants with the lowest HRR tertile were older and had more cardiovascular risk factors than those with the highest HRR tertile. Simple correlation analysis showed that baPWV was negatively correlated with HRR (r =  - 0.327, P < 0.001). In multiple linear regression analysis, there was a significant association between baPWV and HRR, even after adjusting for potential confounders (β =  - 0.181, P < 0.001). In participants who underwent TET, baPWV was negatively correlated with HRR. The results of our study indicate a potential relationship between arterial stiffness and the autonomic nervous system.

Lifestyle Medicine as a Treatment for Resistant Hypertension

PURPOSE OF REVIEW

Approximately 10% of the adults with hypertension fail to achieve the recommended blood pressure treatment targets on 3 antihypertensive medications or require ≥ 4 medications to achieve goal. These patients with 'resistant hypertension' have an increased risk of target organ damage, adverse clinical events, and all-cause mortality. Although lifestyle modification is widely recommended as a first-line approach for the management of high blood pressure, the effects of lifestyle modifications in patients with resistant hypertension has not been widely studied. This review aims to provide an overview of the emerging evidence on the benefits of lifestyle modifications in patients with resistant hypertension, reviews potential mechanisms by which lifestyles may reduce blood pressure, and discusses the clinical implications of the recent findings in this field.

RECENT FINDINGS

Evidence from single-component randomized clinical trials demonstrated that aerobic exercise, weight loss and dietary modification can reduce clinic and ambulatory blood pressure in patients with resistant hypertension. Moreover, evidence from multi-component trials involving exercise and dietary modification and weight management can facilitate lifestyle change, reduce clinic and ambulatory blood pressure, and improve biomarkers of cardiovascular risk. This new evidence supports the efficacy of lifestyle modifications added to optimized medical therapy in reducing blood pressure and improving cardiovascular risk biomarkers in patients with resistant hypertension. These findings need to be confirmed in larger studies, and the persistence of benefit over extended follow-up needs further study.

Physical Activity in Long COVID: A Comparative Study of Exercise Rehabilitation Benefits in Patients with Long COVID, Coronary Artery Disease and Fibromyalgia

Exercise in long COVID is poorly studied. Nevertheless, exerciserehabilitation could improve cardiorespiratory, muscular and autonomic functions. We aimed to investigate improvement in physical and autonomic performances of long COVID patients (n = 38) after a 4-week exercise rehabilitation program (3 sessions/week) compared to two control groups composed of coronary artery disease (n = 38) and fibromyalgia patients (n = 38), two populations for whom exercise benefits are well known. Efficacy of exercise training was assessed by a cardiopulmonary exercise test, a handgrip force test, and a supine heart rate variability recording at rest before and after the rehabilitation program. Cardiorespiratory and muscular parameters were enhanced after exercise rehabilitation in the three groups (p < 0.001). No significant difference was observed for the autonomic variables. Through this comparative study with control groups, we confirm and reinforce the interest of caring for long COVID patients without post-exertional symptom exacerbation by exercise rehabilitation of both strength and endurance training, by personalizing the program to the patient and symptoms.

Effects of high-intensity interval training on vascular function in patients with cardiovascular disease: a systematic review and meta-analysis

Background: Exercise training improves endothelial function in patients with cardiovascular disease (CVD). However, the influence of training variables remains unclear. The aim of this study was to evaluate the effect of high-intensity interval training (HIIT), compared to moderate intensity training (MIT) and other exercise modalities (i.e., resistance and combined exercise), on endothelial function, assessed by arterial flow-mediated dilation (FMD) or endothelial progenitor cells (EPCs), in patients with CVD. Secondly, we investigated the influence of other training variables (i.e., HIIT protocol). Methods: The PICOS strategy was used to identify randomised and non-randomised studies comparing the effect of HIIT and other exercise modalities (e.g., MIT) on endothelial function in patients with CVD. Electronic searches were carried out in Pubmed, Embase, and Web of Science up to November 2022. The TESTEX scale was used to evaluate the methodological quality of the included studies. Random-effects models of between-group mean difference (MD) were estimated. A positive MD indicated an effect in favour of HIIT. Heterogeneity analyses were performed by the chi-square test and I 2 index. Subgroup analyses evaluated the influence of potential moderator variables. Results: Fourteen studies (13; 92.9% randomised) were included. Most of the studies trained 3 days a week for 12 weeks and performed long HIIT. No statistically significant differences were found between HIIT and MIT for improving brachial FMD in patients with coronary artery disease (CAD) and heart failure with reduced ejection fraction (HFrEF) (8 studies; MD+ = 0.91% [95% confidence interval (CI) = -0.06, 1.88]). However, subgroup analyses showed that long HIIT (i.e., > 1 min) is better than MIT for enhancing FMD (5 studies; MD+ = 1.46% [95% CI = 0.35, 2.57]), while no differences were found between short HIIT (i.e., ≤ 1 min) and MIT (3 studies; MD+ = -0.41% [95% CI = -1.64, 0.82]). Insufficient data prevented pooled analysis for EPCs, and individual studies failed to find statistically significant differences (p > .050) between HIIT and other exercise modalities in increasing EPCs. Discussion: Poor methodological quality could limit the precision of the current results and increase the inconsistency. Long HIIT is superior to MIT for improving FMD in patients with CAD or HFrEF. Future studies comparing HIIT to other exercise modalities, as well as the effect on EPCs and in HF with preserved ejection fraction are required. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier CRD42022358156.

Effects of Exercise on Circulating Extracellular Vesicles in Cardiovascular Disease

The evidence that physical exercise has multiple beneficial effects and is essential to a healthy lifestyle is widely accepted for a long-time. The functional and psychological changes promoted by exercise improve clinical outcomes and prognosis in several diseases, by decreasing mortality, disease severity, and hospital admissions. Nonetheless, the mechanisms that regulate the release, uptake, and communication of several factors in response to exercise are still not well defined. In the last years, extracellular vesicles have attracted significant interest in the scientific community due to their ability to carry and deliver proteins, lipids, and miRNA to distant organs in the body, promoting a very exciting crosstalk machinery. Moreover, increasing evidence suggests that exercise can modulate the release of those factors within EVs into the circulation, mediating its systemic adaptations.In this chapter, we summarize the effects of acute and chronic exercise on the extracellular vesicle dynamics in healthy subjects and patients with cardiovascular disease. The understanding of the changes in the cargo and kinetics of extracellular vesicles in response to exercise may open new possibilities of research and encourage the development of novel therapies that mimic the effects of exercise.

Physical activity alleviates negative effects of bedroom light pollution on blood pressure and hypertension in Chinese young adults

Excessive exposure to light at night (LAN) has become a serious public health concern. However, little is known about the impact of indoor LAN exposure on blood pressure, particularly among young adults. We aimed to investigate the effects of bedroom individual-level LAN exposure in real-world environment on blood pressure and hypertension among vulnerable young adults, and to evaluate the possible buffering effect of physical activity. In this cross-sectional study, a total of 400 healthy young adults aged 16-22 years were included. Bedroom LAN exposure was recorded at 1-min intervals for two consecutive nights using a TES-1339 R illuminance meter. Blood pressure was measured three times (8-11 a.m. in the physical examination day) in the seated position using an Omron HEM-7121 digital sphygmomanometer. A wrist-worn triaxial accelerometer (ActiGraph GT3X-BT) was used to assess physical activity for seven consecutive days. Each 1 lx increase of bedroom LAN intensity was associated with 0.55 mmHg-increase in SBP (95% CI: 0.15, 0.95), 0.30 mmHg-increase in DBP (95% CI: 0.06, 0.54), and 0.38 mmHg-increase in MAP (95% CI: 0.12, 0.65). Higher levels of LAN exposure were associated with increased risk of hypertension (LAN ≥ 3lx vs. LAN < 3lx: OR = 3.30, 95%CI = 1.19-9.19; LAN ≥ 5lx vs. LAN < 5lx: OR = 3.87, 95%CI = 1.37-10.98). However, these detrimental effects of bedroom LAN exposure on blood pressure and hypertension were not observed among young adults with high MVPA (≥2 h/day) level. MVPA can alleviate negative effects of bedroom LAN exposure on blood pressure and hypertension. Maintaining bedroom settings darkness at night may be an important strategy for reducing the risk of hypertension. Furthermore, for individuals living with high levels of indoor LAN exposure, regular physical activity may be a good option for preventing cardiovascular disease and hypertension.

Does Exercise Training Improve Cardiac-Parasympathetic Nervous System Activity in Sedentary People? A Systematic Review with Meta-Analysis

The aim of this study was to investigate the training-induced effect on cardiac parasympathetic nervous system (PNS) activity, assessed by resting heart rate variability (HRV) and post-exercise heart rate recovery (HRR), in sedentary healthy people. Electronic searches were carried out in PubMed, Embase, and Web of Science. Random-effects models of between-group standardised mean difference (SMD) were estimated. Heterogeneity analyses were performed by means of the chi-square test and I² index. Subgroup analyses and meta-regressions were performed to investigate the influence of potential moderator variables on the training-induced effect. The results showed a small increase in RMSSD (SMD₊ = 0.57 [95% confidence interval (CI) = 0.23, 0.91]) and high frequency (HF) (SMD₊ = 0.21 [95% CI = 0.01, 0.42]) in favour of the intervention group. Heterogeneity tests reached statistical significance for RMSSD and HF (p ≤ 0.001), and the inconsistency was moderate (I² = 68% and 60%, respectively). We found higher training-induced effects on HF in studies that performed a shorter intervention or lower number of exercise sessions (p ≤ 0.001). Data were insufficient to investigate the effect of exercise training on HRR. Exercise training increases cardiac PNS modulation in sedentary people, while its effect on PNS tone requires future study.

Heart Rate Variability-Guided Training for Improving Mortality Predictors in Patients with Coronary Artery Disease

The objective of this research was to investigate whether heart rate variability (HRV)-guided training improves mortality predictors to a greater extent than predefined training in coronary artery disease patients. Twenty-one patients were randomly allocated to the HRV-guided training group (HRV-G) or the predefined training group (PRED-G). They measured their HRV at home daily and trained three times a week for six weeks. Resting heart rate, isolated vagal-related HRV indices (i.e., RMSSD, HF, and SD₁), weekly averaged RMSSD, heart rate recovery, and maximum oxygen uptake were assessed before and after the training period. There was a statistically significant difference (p = 0.034) in the change in weekly averaged RMSSD in favor of the HRV-G, while no differences were found in the remaining analyzed variables (p > 0.050). Regardless of the training prescription method, exercise training decreased resting heart rate (p = 0.001; -4.10 [95% CI = -6.37--1.82] beats per minute (bpm)), and increased heart rate recovery at 2 min (p = 0.010; 4.33 [95% CI = 1.15-7.52] bpm) and maximum oxygen uptake (p < 0.001; 3.04 [95% CI = 1.70-4.37] mL·kg^-1·min^-1). HRV-guided training is superior to predefined training in improving vagal-related HRV when methodological factors are accounted for.

Cardiac Rehabilitation Improves Endothelial Function in Coronary Artery Disease Patients

Exercise-based cardiac rehabilitation may be an effective non-pharmacological intervention for improving endothelial function in coronary artery disease patients. Therefore, this systematic review with meta-analysis aimed to (a) estimate the training-induced effect on endothelial and vascular smooth muscle function, assessed by flow-mediated dilation and nitroglycerin-mediated dilation, respectively, in coronary artery disease patients; and to (b) study the influence of potential trial-level variables (i. e. study and intervention characteristics) on the training-induced effect on endothelial and vascular smooth muscle function. Electronic searches were performed in Pubmed, Scopus, and Embase up to February 2021. Random-effects models of standardised mean change were estimated. Heterogeneity analyses were performed by using the Chi ² test and I ² index. Our results showed that exercise-based cardiac rehabilitation significantly enhanced flow-mediated dilation (1.04 [95% confidence interval=0.76 to 1.31]) but did not significantly change nitroglycerin-mediated dilation (0.05 [95% confidence interval=-0.03 to 0.13]). Heterogeneity testing reached statistical significance (p<.001) with high inconsistency for flow-mediated dilation (I ² =92%). Nevertheless, none of the analysed variables influenced the training-induced effect on flow-mediated dilation. Exercise-based cardiac rehabilitation seems to be an effective therapeutic strategy for improving endothelial-dependent dilation in coronary artery disease patients, which may aid in the prevention of cardiovascular events.

Exercise Training and Interventions for Coronary Artery Disease

Coronary artery disease (CAD) may be considered a main cause of mortality and the prevalence of CAD is increasing nowadays, leading to high health costs in many countries. Despite the fact of the regression of the atherosclerotic plaque, the decrease in blood viscosity and the growth of collateral vessels have been proposed as improvements that CAD patients may obtain under exercise performance. Thus, the present narrative review aimed to carry out a brief specific analysis of the results achieved when performing endurance, strength or inspiratory muscle training. Exercise attenuates certain pathophysiological processes of this disease, such as endothelial dysfunction or the vulnerability of atherosclerotic plaques, and produces improvements in functional capacity and muscle strength, among others. Within the different exercise modalities, the most important parameter to be considered seems to be the total caloric expenditure, and not so much the modality itself. As such, in cardiac rehabilitation, when prescribing exercise, we should possibly focus on the modality that obtains more adherence in patients. To conclude, it must be highlighted that total caloric expenditure is not being taken into account when comparing interventions and this relevant information should be considered in future studies.

Effects of the Training of Aerobic Function on Clinical Symptoms and Quality of Life in Patients with Medium and Advanced Lung Cancer

Objective

To investigate the effects of the training of aerobic function on clinical symptoms and quality of life in patients with medium and advanced lung cancer.

Methods

The study objects were 84 patients with medium and advanced lung cancer who were treated in our hospital (July 2019-July 2021) and their materials were retrospectively reviewed. Depending on the different intervention modes, they were equally divided into control group (routine nursing intervention measures) and experiment group (training of aerobic function), with 42 cases in each group. The clinical symptoms and living quality were compared between the two groups.

Results

After intervention, affective meaning, behavior/severity, cognitive/mood, and sensory scores in both groups were decreased, and the various indexes in the experiment group were lower compared with the control group (P < 0.05). After intervention, the patients' clinical symptoms, such as pain, inappetence, insomnia, and dyspnea in the two groups were improved, and the experiment group achieved eminently better improvement compared with the control group (P < 0.05). After intervention, the walking distances in 6 minute walk test (6MWT) in both groups were increased, and the experiment group achieved observably longer walking distance compared with the control group (P < 0.05). After intervention, the patients' pulmonary function indexes of forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), and FEV1/FVC% level in the two groups were all improved, and the experiment group had signally better indexes compared with the control group (P < 0.05). After intervention, the patients' scores of Quality of Life Questionnaire-Core Questionnaire (QLQ-C30) in both groups were decreased, and the experiment group achieved much lower score compared with the control group (P < 0.05).

Conclusion

The training of aerobic function has obvious therapeutic effect on medium and advanced lung cancer. This training can mitigate the patients' cancer-related fatigue and clinical symptoms, improve their pulmonary function, and enhance their athletic ability and quality of life.

Effects of Exergaming in Patients with Cardiovascular Disease Compared to Conventional Cardiac Rehabilitation: A Systematic Review and Meta-Analysis

Background: Exercise-based cardiac rehabilitation (CR) programs are used for improving prognosis and quality of life in patients with cardiovascular disease (CVD). Nonetheless, adherence to these programs is low, and exercise-based CR programs based on virtual reality (i.e., exergaming) have been proposed as an alternative to conventional CR programs. However, whether exergaming programs are superior to conventional CR programs in patients with CVD is not known. Objective: This systematic review with meta-analysis was conducted to explore whether exergaming enhances exercise capacity, quality of life, mental health, motivation, and exercise adherence to a greater extent than conventional CR programs in patients with CVD. Method: Electronic searches were carried out in PubMed, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases up to June 2021. Meta-analyses were performed using robust variance estimation with small-sample corrections. The effect sizes were calculated as the mean differences (MD) or standardized mean differences (SMD) as appropriate. The SMD magnitude was classified as trivial (<0.20), small (0.20−0.49), medium (0.50−0.79), or large (≥0.80). Heterogeneity was interpreted based on the I2 statistics as low (25%), moderate (50%), or high (75%). Results: Pooled analyses showed no differences between exergaming and conventional CR programs for enhancing exercise capacity (i.e., distance covered in the six-minute walk test) (MD+ = 14.07 m (95% confidence interval (CI) −38.18 to 66.32 m); p = 0.426) and mental health (SMD+ = 0.17 (95% CI −0.36 to 0.70); p = 0.358). The results showed a small, statistically nonsignificant improvement in quality of life in favor of exergaming (SMD+ = 0.22 (95% CI = −0.37 to 0.81); p = 0.294). Moderate heterogeneity was found for exercise capacity (I2 = 53.7%), while no heterogeneity was found for quality of life (I2 = 3.3%) and mental health (I2 = 0.0%). Conclusions: Exergaming seems not to be superior to conventional CR programs for improving exercise capacity, quality of life, or mental health in patients with CVD.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.

SEARCH METHODS

We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.

DATA COLLECTION AND ANALYSIS

We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).  MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials;  NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).

AUTHORS' CONCLUSIONS

This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.

Stress and autonomic nerve dysfunction monitoring in perioperative gastric cancer patients using a smart device

Background

Heart rate variability (HRV), a sensitive marker of stress and autonomic nervous disorders, was significantly decreased in cardiovascular disease, inflammation, and surgical injury. However, the effect of radical gastrectomy on HRV parameters needs to be further investigated.

Methods

A prospective, observational study including 45 consecutive enrolled patients undergoing radical gastrectomy in our enhanced recovery after surgery (ERAS) programs was conducted. Frequency‐ and time‐domain parameters of HRV from 1 day prior to operation to 4 days postoperatively were continuously measured. Meanwhile, plasma cortisol and inflammatory markers were recorded and correlated to HRV parameters.

Results

Heart rate variability showed a solidly circadian rhythm. Anesthesia severely disturbed HRV parameters, resulting in a reduction of most of the HRV parameters. Frequency‐domain parameter (including VLF) and time‐domain parameters (including the SDNN, SDANN, and triangular index) of HRV demonstrated a significant reduction compared to preoperative values on the postoperative day 1 (Pod1), and these HRV parameters could return to baseline on Pod2 or Pod3, indicating surgical stress and autonomic nerve dysfunction existed in the early postoperative period. Inflammatory biomarkers were significantly elevated on Pod1 and Pod3. Plasma cortisol decreased significantly on Pod1 and Pod3. Both inflammatory biomarkers and plasma cortisol had no significant correlation with HRV parameters.

Conclusions

Compared with plasma cortisol and inflammation biomarkers, HRV is more sensitive to detect surgical stress and autonomic nervous dysfunction induced by radical gastrectomy in patients with gastric cancer.

Sacubitril/Valsartan Improves Autonomic Function and Cardiopulmonary Parameters in Patients with Heart Failure with Reduced Ejection Fraction

BACKGROUND

Heart rate recovery (HRR) is a marker of vagal tone, which is a powerful predictor of mortality in patients with cardiovascular disease. Sacubitril/valsartan (S/V) is a treatment for heart failure with reduced ejection fraction (HFrEF), which impressively impacts cardiovascular outcome. This study aims at evaluating the effects of S/V on HRR and its correlation with cardiopulmonary indexes in HFrEF patients.

METHODS

Patients with HFrEF admitted to outpatients' services were screened out for study inclusion. S/V was administered according to guidelines. Up-titration was performed every 4 weeks when tolerated. All patients underwent laboratory measurements, Doppler-echocardiography, and cardiopulmonary exercise stress testing (CPET) at baseline and at 12-month follow-up.

RESULTS

Study population consisted of 134 HFrEF patients (87% male, mean age 57.9 ± 9.6 years). At 12-month follow-up, significant improvement in left ventricular ejection fraction (from 28% ± 5.8% to 31.8% ± 7.3%, p < 0.0001), peak exercise oxygen consumption (VO_2peak) (from 15.3 ± 3.7 to 17.8 ± 4.2 mL/kg/min, p < 0.0001), the slope of increase in ventilation over carbon dioxide output (VE/VCO_{2 slope} )(from 33.4 ± 6.2 to 30.3 ± 6.5, p < 0.0001), and HRR (from 11.4 ± 9.5 to 17.4 ± 15.1 bpm, p = 0.004) was observed. Changes in HRR were significantly correlated to changes in VE/VCO_2slope (r = -0.330; p = 0.003). After adjusting for potential confounding factors, multivariate analysis showed that changes in HRR were significantly associated to changes in VE/VCO_2slope (Beta (B) = -0.975, standard error (SE) = 0.364, standardized Beta coefficient (Bstd) = -0.304, p = 0.009). S/V showed significant reduction in exercise oscillatory ventilation (EOV) detection at CPET (28 EOV detected at baseline CPET vs. 9 EOV detected at 12-month follow-up, p < 0.001). HRR at baseline CPET was a significant predictor of EOV at 12-month follow-up (B = -2.065, SE = 0.354, p < 0.001).

CONCLUSIONS

In HFrEF patients, S/V therapy improves autonomic function, functional capacity, and ventilation. Whether these findings might translate into beneficial effects on prognosis and outcome remains to be elucidated.