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Hybrid and Traditional Cardiac Rehabilitation in a Rural Area: A RETROSPECTIVE STUDY. J Cardiopulm Rehabil Prev 2023:01273116-990000000-00062. [PMID: 36880962 DOI: 10.1097/hcr.0000000000000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
PURPOSE Cardiac rehabilitation is a prescribed exercise intervention that reduces cardiovascular mortality, secondary events, and hospitalizations. Hybrid cardiac rehabilitation (HBCR) is an alternative method that overcomes barriers to participation, such as travel distance and transportation issues. To date, comparisons of HBCR and traditional cardiac rehabilitation (TCR) are limited to randomized controlled trials, which may influence outcomes due to supervision associated with clinical research. Coincidental to the COVID-19 pandemic, we investigated HBCR effectiveness (peak metabolic equivalents [peak METs]), resting heart rate (RHR), resting systolic (SBP) and diastolic blood pressure (DBP), body mass index (BMI), and depression outcomes (Patient Health Questionnaire-9 [PHQ-9]). METHODS Via retrospective analysis, TCR and HBCR were examined during the COVID-19 pandemic (October 1, 2020, and March 31, 2022). Key dependent variables were quantified at baseline (pre) and discharge (post). Completion was determined by participation in 18 monitored TCR exercise sessions and four monitored HBCR exercise sessions. RESULTS Peak METs increased at post-TCR and HBCR (P < .001); however, TCR resulted in greater improvements (P = .034). The PHQ-9 scores were decreased in all groups (P < .001), while post-SBP and BMI did not improve (SBP: P = .185, BMI: P = .355). Post-DBP and RHR increased (DBP: P = .003, RHR: P = .032), although associations between intervention and program completion were not observed (P = .172). CONCLUSIONS Peak METs and depression metric outcomes (PHQ-9) improved with TCR and HBCR. Improvements in exercise capacity were greater with TCR; however, HBCR did not produce inferior results by comparison, an outcome that may have been essential during the first 18 mo of the COVID-19 pandemic.
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Miyamoto T, Watanabe K, Fukuda K, Moritani T. Near-infrared Spectroscopy of Vastus Lateralis Muscle during Incremental Cycling Exercise in patients with Type 2 Diabetes. Phys Ther Res 2020; 23:23-30. [PMID: 32850275 DOI: 10.1298/ptr.e9984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/21/2019] [Indexed: 11/23/2022]
Abstract
PURPOSE It is clinically important to elucidate the precise mechanism of exercise intolerance in patients with type 2 diabetes (T2DM). The aim of this study was to examine whether there is a difference in the time course change of the oxygenation in the vastus lateralis (VL) muscle during submaximal incremental cycling exercise between patients with T2DM and age-matched healthy subjects. METHODS Nine elderly men with T2DM and 10 age-matched healthy men (CON) participated in this study. All participants performed an incremental cycling exercise.Total, deoxygenated and oxygenated hemoglobin/myoglobin in the VL muscle were assessed using near-infrared spectroscopy, and cardiorespiratory response was also evaluated during the exercise. RESULTS There were no significant differences in the time course changes of deoxygenated hemoglobin/myoglobin between groups ( p > 0.05). However, the oxygenated hemoglobin/myoglobin in T2DM was significantly higher than that in CON at an intensity above ventilatory threshold during the incremental cycling exercise ( p< 0.05). CONCLUSION This study suggests that patients with T2DM had early limitation of oxygen extraction and lower capacity of oxygenated myoglobin dissociation in the VL muscle. The fact that patients with T2DM showed different oxygen kinetics in a peripheral tissue from healthy subjects may partly explain the potential mechanisms of exercise intolerance in T2DM.
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Affiliation(s)
| | - Kohei Watanabe
- School of International Liberal Studies, Chukyo University
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Goulding RP, Roche DM, Scott SN, Koga S, Weston PJ, Marwood S. Limitations to exercise tolerance in type 1 diabetes: the role of pulmonary oxygen uptake kinetics and priming exercise. J Appl Physiol (1985) 2020; 128:1299-1309. [PMID: 32213117 DOI: 10.1152/japplphysiol.00892.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We compared the time constant (τV̇O2) of the fundamental phase of pulmonary oxygen uptake (V̇o2) kinetics between young adult men with type 1 diabetes and healthy control subjects. We also assessed the impact of priming exercise on τV̇O2, critical power, and muscle deoxygenation in a subset of participants with type 1 diabetes. Seventeen men with type 1 diabetes and 17 healthy male control subjects performed moderate-intensity exercise to determine τV̇O2. A subset of seven participants with type 1 diabetes performed an additional eight visits, in which critical power, τV̇O2, and muscle deoxyhemoglobin + myoglobin ([HHb+Mb], via near-infrared spectroscopy) kinetics (described by a time constant, τ[HHb+Mb]) were determined with (PRI) and without (CON) a prior 6-min bout of heavy exercise. τV̇O2 was greater in participants with type 1 diabetes compared with control subjects (type 1 diabetes 50 ± 13 vs. control 32 ± 12 s; P < 0.001). Critical power was greater in PRI compared with CON (PRI 161 ± 25 vs. CON 149 ± 22 W; P < 0.001), whereas τV̇O2 (PRI 36 ± 15 vs. CON 50 ± 21 s; P = 0.006) and τ[HHb+Mb] (PRI 10 ± 5 vs. CON 17 ± 11 s; P = 0.037) were reduced in PRI compared with CON. Type 1 diabetes patients showed slower pulmonary V̇o2 kinetics compared with control subjects; priming exercise speeded V̇o2 and [HHb + Mb] kinetics and increased critical power in a subgroup with type 1 diabetes. These data therefore represent the first characterization of the power-duration relationship in type 1 diabetes and the first experimental evidence that τV̇O2 is an independent determinant of critical power in this population.NEW & NOTEWORTHY Patients with type 1 diabetes demonstrated slower oxygen uptake (V̇o2) kinetics compared with healthy control subjects. Furthermore, a prior bout of high-intensity exercise speeded V̇o2 kinetics and increased critical power in people with type 1 diabetes. Prior exercise speeded muscle deoxygenation kinetics, indicating that V̇o2 kinetics in type 1 diabetes are limited primarily by oxygen extraction and/or intracellular factors. These findings highlight the potential for interventions that decrease metabolic inertia for enhancing exercise tolerance in this condition.
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Affiliation(s)
- Richie P Goulding
- School of Health Sciences, Liverpool Hope University, Liverpool, United Kingdom.,Japan Society for Promotion of Science, Tokyo, Japan.,Applied Physiology Laboratory, Kobe Design University, Kobe, Japan
| | - Denise M Roche
- School of Health Sciences, Liverpool Hope University, Liverpool, United Kingdom
| | - Sam N Scott
- University Department of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, University Hospital and University of Bern, Bern, Switzerland.,Team Novo Nordisk Professional Cycling Team, Atlanta, Georgia
| | - Shunsaku Koga
- Applied Physiology Laboratory, Kobe Design University, Kobe, Japan
| | - Philip J Weston
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Simon Marwood
- School of Health Sciences, Liverpool Hope University, Liverpool, United Kingdom
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Determining Cardiorespiratory Fitness With Precision: Compendium of Findings From the FRIEND Registry. Prog Cardiovasc Dis 2019; 62:76-82. [DOI: 10.1016/j.pcad.2018.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/23/2018] [Indexed: 02/07/2023]
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5
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Goit RK, Pant BN, Shrewastwa MK. Moderate intensity exercise improves heart rate variability in obese adults with type 2 diabetes. Indian Heart J 2017; 70:486-491. [PMID: 30170641 PMCID: PMC6116720 DOI: 10.1016/j.ihj.2017.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 01/14/2023] Open
Abstract
AIM The aim of this study was to determine the effect of moderate aerobic exercise on heart rate variability (HRV) in obese adults with type 2 diabetes. METHODS Forty-one obese adults with type 2 diabetes participated in this study. Anthropometric and metabolic parameters were measured, and resting electrocardiogram (ECG) for the HRV analysis at spontaneous respiration was recorded for 5 min in supine position before and after six months of supervised aerobic training given thrice-a-week. RESULTS The mean age, body mass index (BMI), and duration of diabetes of the study population were 44.1 ± 4.5 years, 30.94 ± 1.36 kg/m2, and 16.3 ± 2.7 years, respectively. In time domain variables, standard deviation of all RR intervals (SDNN), the square root of the mean of the sum of the squares of differences between adjacent RR intervals (RMSSD) and percentage of consecutive RR intervals that differ by more than 50 ms (pNN50) were significantly increased after exercise. In frequency domain variables, high frequency (HF) (ms2) and HF (nu) were significantly increased while low frequency (LF) (ms2) and LF/HF ratio were significantly decreased after exercise. But LF (nu) was unaffected after exercise. CONCLUSION This study suggests that thrice-a-week moderate intensity aerobic exercise for six months improves cardiac rhythm regulation as measured by HRV in obese adults with type 2 diabetes.
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Toprak MS, Ozturk ZG, Ekmekci OB, Ekmekci H, Ikitimur B, Karadag B, Cakmak HA, Ilerigelen B, Sonmez H. Comparison of exercise treadmill test, flow mediated dilatation, and inflammation in individuals with low risk of adverse cardiovascular events. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0902.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The relationship between endothelial dysfunction, a risk factor for coronary artery disease, and the incidence of cardiovascular disease (CVD) in the general population is not well known.
Objectives
To determine the utility of an exercise treadmill test (ETT) combined with inflammatory markers to show endothelial dysfunction for individuals with a low risk of adverse cardiovascular (CV) events.
Methods
Biomarkers of inflammation (lipoprotein-related phospholipase A2 (Lp-PLA2) and high-sensitive C-reactive protein (hs-CRP)) and biomarkers of endothelial dysfunction (nitric oxide, oxidized low-density lipoprotein (Ox-LDL), and sialic acid) were assessed in 60 apparently healthy patients with a positive (+) or negative (−) ETT and across endothelial function assessed by flow mediated dilatation (FMD) and Lp-PLA2 tertiles.
Results
Lp-PLA2 levels were increased in ETT (−) compared with ETT (+) patients. Half of ETT (−) patients were found to have levels of Lp-PLA2 in the highest tertile. There was a significant inverse relationship between ETT and inflammatory biomarkers when adjusted for age, Lp-PLA2 (r = −0.28, P = 0.04), or hs-CRP (r = −0.35, P = 0.01). No differences were found for biomarkers of endothelial dysfunction. All variables were reassessed across FMD tertiles. Total lipids, Ox-LDL, triglyceride, and Lp-PLA2 were higher for the lowest FMD tertile.
Conclusion
The elevation of Lp-PLA2 in ETT (−) patients and the inverse relationship with inflammatory biomarkers, suggest that ETT cannot address endothelial dysfunction for individuals with apparently low risk of adverse CV events, and cannot be used for risk stratification of the general population.
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Affiliation(s)
- Muhammed Sait Toprak
- Department of Medical Biochemistry , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Zeynep Gungor Ozturk
- Department of Medical Biochemistry , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Ozlem Balci Ekmekci
- Department of Medical Biochemistry , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Hakan Ekmekci
- Department of Medical Biochemistry , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Baris Ikitimur
- Department of Cardiology , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Bilgehan Karadag
- Department of Cardiology , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Huseyin Altug Cakmak
- Department of Cardiology , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Baris Ilerigelen
- Department of Cardiology , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
| | - Huseyin Sonmez
- Department of Medical Biochemistry , Cerrahpasa Medical School , University of Istanbul , Istanbul 34452 , Turkey
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Miyamoto T, Kamada H, Tamaki A, Moritani T. Low-intensity electrical muscle stimulation induces significant increases in muscle strength and cardiorespiratory fitness. Eur J Sport Sci 2016; 16:1104-10. [DOI: 10.1080/17461391.2016.1151944] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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8
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Trimetazidine improves exercise tolerance in patients with ischemic heart disease. Herz 2015; 41:514-22. [DOI: 10.1007/s00059-015-4392-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 10/02/2015] [Accepted: 11/17/2015] [Indexed: 11/24/2022]
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Silva CGDSE, Araújo CGS. Sex-Specific Equations to Estimate Maximum Oxygen Uptake in Cycle Ergometry. Arq Bras Cardiol 2015; 105:381-9. [PMID: 26559985 PMCID: PMC4633002 DOI: 10.5935/abc.20150089] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/04/2015] [Accepted: 05/06/2015] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Aerobic fitness, assessed by measuring VO2max in maximum cardiopulmonary exercise testing (CPX) or by estimating VO2max through the use of equations in exercise testing, is a predictor of mortality. However, the error resulting from this estimate in a given individual can be high, affecting clinical decisions. OBJECTIVE To determine the error of estimate of VO2max in cycle ergometry in a population attending clinical exercise testing laboratories, and to propose sex-specific equations to minimize that error. METHODS This study assessed 1715 adults (18 to 91 years, 68% men) undertaking maximum CPX in a lower limbs cycle ergometer (LLCE) with ramp protocol. The percentage error (E%) between measured VO2max and that estimated from the modified ACSM equation (Lang et al. MSSE, 1992) was calculated. Then, estimation equations were developed: 1) for all the population tested (C-GENERAL); and 2) separately by sex (C-MEN and C-WOMEN). RESULTS Measured VO2max was higher in men than in WOMEN: -29.4 ± 10.5 and 24.2 ± 9.2 mL.(kg.min)-1 (p < 0.01). The equations for estimating VO2max [in mL.(kg.min)-1] were: C-GENERAL = [final workload (W)/body weight (kg)] x 10.483 + 7; C-MEN = [final workload (W)/body weight (kg)] x 10.791 + 7; and C-WOMEN = [final workload (W)/body weight (kg)] x 9.820 + 7. The E% for MEN was: -3.4 ± 13.4% (modified ACSM); 1.2 ± 13.2% (C-GENERAL); and -0.9 ± 13.4% (C-MEN) (p < 0.01). For WOMEN: -14.7 ± 17.4% (modified ACSM); -6.3 ± 16.5% (C-GENERAL); and -1.7 ± 16.2% (C-WOMEN) (p < 0.01). CONCLUSION The error of estimate of VO2max by use of sex-specific equations was reduced, but not eliminated, in exercise tests on LLCE.
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Affiliation(s)
- Christina G. de Souza e Silva
- Programa de Pós-Graduação em Cardiologia -
Universidade Federal do Rio de Janeiro; Instituto do Coração Edson Saad -
Universidade Federal do Rio de Janeiro; Clínica de Medicina do Exercício -
CLINIMEX, Rio de Janeiro, RJ - Brazil
| | - Claudio Gil S. Araújo
- Programa de Pós-Graduação em Cardiologia -
Universidade Federal do Rio de Janeiro; Instituto do Coração Edson Saad -
Universidade Federal do Rio de Janeiro; Clínica de Medicina do Exercício -
CLINIMEX, Rio de Janeiro, RJ - Brazil
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Myers J, Arena R, Cahalin LP, Labate V, Guazzi M. Cardiopulmonary Exercise Testing in Heart Failure. Curr Probl Cardiol 2015; 40:322-72. [DOI: 10.1016/j.cpcardiol.2015.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Crissey JM, Padilla J, Vieira-Potter VJ, Thorne PK, Koch LG, Britton SL, Thyfault JP, Laughlin MH. Divergent role of nitric oxide in insulin-stimulated aortic vasorelaxation between low- and high-intrinsic aerobic capacity rats. Physiol Rep 2015. [PMID: 26197933 PMCID: PMC4552535 DOI: 10.14814/phy2.12459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Low-intrinsic aerobic capacity is associated with increased risk for cardiovascular and metabolic diseases and is a strong predictor of early mortality. The effects of intrinsic aerobic capacity on the vascular response to insulin are largely unknown. We tested the hypothesis that rats selectively bred for a low capacity to run (LCR) exhibit vascular dysfunction and impaired vascular reactivity to insulin compared to high capacity running (HCR) rats. Mature female LCR (n = 21) and HCR (n = 17) rats were maintained under sedentary conditions, and in vitro thoracic aortic vascular function was assessed. LCR exhibited greater body mass (13%), body fat (35%), and subcutaneous, perigonadal, and retroperitoneal adipose tissue mass, than HCR. During an intraperitoneal glucose tolerance test, glucose area under the curve (AUC) was not different but insulin AUC was 2-fold greater in LCR than HCR. Acetylcholine and insulin-stimulated aortic vasorelaxation was significantly greater in LCR (65.2 ± 3.8%, and 32.7 ± 4.1%) than HCR (55.0 ± 3.3%, and 16.7 ± 2.8%). Inhibition of nitric oxide synthase (NOS) with L-NAME entirely abolished insulin-mediated vasorelaxation in the aorta of LCR, with no effect in HCR. LCR rats exhibited greater expression of Insulin Receptor protein, lower Endothelin Receptor-A protein, a down-regulation of transcripts for markers of immune cell infiltration (CD11C, CD4, and F4/80) and up-regulation of pro-atherogenic inflammatory genes (VCAM-1 and MCP-1) in the aorta wall. Contrary to our hypothesis, low-aerobic capacity was associated with enhanced aortic endothelial function and NO-mediated reactivity to insulin, despite increased adiposity and evidence of whole body insulin resistance.
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Affiliation(s)
| | - Jaume Padilla
- Nutrition and Exercise Physiology, University of Missouri, Columbia, Missouri Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri Child Health, University of Missouri, Columbia, Missouri
| | | | - Pamela K Thorne
- Biomedical Sciences, University of Missouri, Columbia, Missouri
| | - Lauren G Koch
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven L Britton
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - John P Thyfault
- Department of Molecular and Integrative Physiology, Kansas University Medical Center, Kansas, Kansas
| | - M Harold Laughlin
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri Biomedical Sciences, University of Missouri, Columbia, Missouri Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
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Abstract
Physical fitness is simply defined as the capacity to perform physical work. Energy is necessary to perform work and sustain life and is extracted aerobically and anaerobically. Evaluation of aerobic fitness is based on the assessment of maximal oxygen consumption (Vo2 max), either directly or indirectly. Direct assessment of Vo2 max is usually determined by a graded exercise test using open circuit spirometry. Indirect assessments of Vo2 max use standardized exercise protocols. Such protocols can also be used to estimate Vo2 max with the subject exercising at submaximal heart rate levels. These estimates are based on the linear relationship between exercise heart rate and O2 consumption. Walking and step tests that allow an estimate of fitness based on exercise and recovery heart rate responses are also available. Evaluation of anaerobic power consists of 30 to 120 seconds of high-intensity effort on a cycle ergometer, known as the Wingate test. Muscular strength is assessed by a maximum effort against the greatest resistance one can move through the full range of motion once, known as the 1-repetition maximum. Muscular endurance is assessed by tests requiring more than 12 repetitions, or the maximum number of push-ups or sit-ups one can execute without rest.
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Affiliation(s)
- Peter Kokkinos
- Cardiology Division, Veterans Affairs Medical Center; Georgetown University School of Medicine
- George Washington University School of Medicine and Health Sciences, Washington, DC
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13
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Goit RK, Paudel BH, Khadka R, Roy RK, Shrewastwa MK. Mild-to-moderate intensity exercise improves cardiac autonomic drive in type 2 diabetes. J Diabetes Investig 2014; 5:722-7. [PMID: 25422774 PMCID: PMC4234237 DOI: 10.1111/jdi.12238] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 02/12/2014] [Accepted: 03/09/2014] [Indexed: 01/29/2023] Open
Abstract
Aims/Introduction The aim of the present study was to determine the effect of moderate aerobic exercise on cardiac autonomic function in type 2 diabetic patients. Materials and Methods Heart rate variability of 20 patients with type 2 diabetes was assessed. Resting electrocardiogram for the heart rate variability analysis at spontaneous respiration was recorded for 5 min in the supine position before and after 6 months of supervised aerobic training given three times per week. Results In time domain measures, the square root of the mean of the sum of the squares of differences between adjacent R-R intervals (RMSSD; 29.7 [26–34.5] vs 46.4 [29.8–52.2] ms, P = 0.023) and the percentage of consecutive RR intervals that differ by more than 50 ms (pNN50; 10.7 [5.5–12.7] vs 26.1 [6.6–37.2]%, P = 0.025] were significantly increased after exercise. In frequency domain measures, low frequency (62.4 [59.1–79.2] vs 37 [31.3–43.3] nu, P = 0.003) and low frequency/high frequency (1.67 [1.44–3.8] vs 0.58 [0.46–0.59]%, P = 0.009) were significantly decreased, whereas high frequency (95 [67–149] vs 229 [98–427] ms2, P = 0.006) and high frequency (37.6 [20.8–40.9] vs 63 [56.7–68.7] normalized units, P = 0.003) were significantly increased after exercise. In a Poincaré plot, standard deviation perpendicular to the line of the Poincaré plot (SD1; 21.3 [18.5–24.8]–33.1 [21.5–37.2] ms, P = 0.027) was significantly increased after exercise. Conclusions These data suggest that three times per week moderate intensity aerobic exercise for 6 months improves cardiac rhythm regulation as measured by heart rate variability in type 2 diabetic patients.
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Affiliation(s)
| | - Bishnu Hari Paudel
- Department of Physiology, B P Koirala Institute of Health Sciences Dharan, Nepal
| | - Rita Khadka
- Department of Physiology, B P Koirala Institute of Health Sciences Dharan, Nepal
| | - Roshan Kumar Roy
- Department of Community Medicine, Nepalgunj Medical College Banke, Nepal
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De Lorenzo A, Meirelles V, Vilela F, Souza FCC. Use of the exercise treadmill test for the assessment of cardiac risk markers in adults infected with HIV. J Int Assoc Provid AIDS Care 2012; 12:110-6. [PMID: 23015380 DOI: 10.1177/1545109712460098] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite the association between HIV and coronary artery disease (CAD), there are no specific recommendations for the cardiovascular evaluation of the HIV-infected population. Besides being a tool for the evaluation of CAD, the exercise treadmill test (ETT) provides insights into functional capacity and autonomic function, which have been frequently affected in HIV infection, and thus may be useful in this setting. METHODS Forty-nine HIV-infected individuals without known CAD underwent ETT. Peak oxygen consumption during exercise (VO2 peak), functional capacity (in metabolic equivalents [METs]), exercise-induced ischemia, chronotropic incompetence (CI) and abnormal heart rate recovery (HRR) after exercise were studied. RESULTS VO2 peak was 31.4±4.8 mL/kg/min and functional capacity was 9.2±1.6 MET. CI was observed in 30.6%, and 10.2% had abnormal HRR. VO2 peak was lower in women and inversely correlated with age and body mass index. None of the patients displayed ischemic changes. CONCLUSION Although functional capacity was good, risk markers such as CI and abnormal HRR were not infrequent. This study identifies a subgroup of HIV-infected patients-the older, overweight, or obese-who may have higher risk and deserve cardiovascular screening with the ETT.
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Prognostic implications of stress-induced transient ischemic dilation of the left ventricle in patients with systolic dysfunction and fixed perfusion defects. Int J Cardiol 2010; 140:323-7. [DOI: 10.1016/j.ijcard.2008.11.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 11/16/2008] [Indexed: 11/22/2022]
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Stein R, Nguyen P, Abella J, Olson H, Myers J, Froelicher V. Prevalence and prognostic significance of exercise-induced right bundle branch block. Am J Cardiol 2010; 105:677-80. [PMID: 20185016 DOI: 10.1016/j.amjcard.2009.10.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 10/25/2009] [Accepted: 10/25/2009] [Indexed: 11/25/2022]
Abstract
Exercise-induced (EI) right bundle branch block (RBBB) is an infrequent electrocardiographic phenomenon, and controversy exists regarding its association with cardiovascular disease. We compared the prevalence and prognostic significance of RBBB, abnormal ST depression, and normal electrocardiographic findings in response to exercise testing in 9,623 consecutive veterans who underwent exercise testing from 1987 to 2007. EI RBBB, EI ST depression, and a normal exercise electrocardiographic response occurred in 0.24%, 15.2%, and 71.9% veterans, respectively. After appropriate exclusions, of the 8,047 patients analyzed, 6 patients in the EI RBBB subgroup died. Of these 6 deaths, 3 were cardiovascular deaths during the 9 years of follow-up. The annual death rate was 7.3% (1.4% cardiac deaths), 2.6% (1.2% cardiac deaths), and 1.8% (0.6% cardiac death) among those with EI RBBB, EI ST depression, and a normal ST response, respectively (p <0.0001). The patients with EI RBBB were significantly older, more overweight, and had a greater prevalence of coronary artery disease, heart failure, and hypertension compared to the 2 other subgroups. Patients with EI RBBB had an age-adjusted Cox proportional hazard ratio of 1.13 (p = 0.75, 95% confidence interval 0.51 to 2.5) for all-cause mortality and 1.57 (p = 0.43, 95% confidence interval 0.51 to 4.8) for cardiovascular mortality, respectively. In conclusion, EI RBBB is a rare occurrence during routine clinical exercise testing that appears to be benign.
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Association of socioeconomic status and exercise capacity in adults with coronary heart disease (from the Heart and Soul Study). Am J Cardiol 2008; 101:462-6. [PMID: 18312758 DOI: 10.1016/j.amjcard.2007.09.093] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Revised: 09/21/2007] [Accepted: 09/21/2007] [Indexed: 11/20/2022]
Abstract
Lower socioeconomic status (SES) was associated with reduced treadmill exercise capacity and predicted adverse cardiovascular outcomes. Why patients with low SES had reduced exercise capacity and whether this relation existed in patients with coronary heart disease (CHD) was not known. Using data from the Heart and Soul Study, the association of 4 indicators of SES (household income, education, housing status, and occupation) with treadmill exercise capacity was analyzed in 943 men and women with stable CHD. In multivariable linear regression models adjusted for demographic variables, co-morbidities, medication use, and health behaviors (smoking, alcohol use, body mass index, physical activity, and medication adherence), exercise capacity significantly decreased in a graded fashion from the highest to lowest categories of each SES variable (p <0.001 for all trends). Differences in exercise capacity between the lowest and highest SES categories were 2.4 METs for household income, 1.8 METs for education, 2.3 METs for housing, and 1.3 METs for occupation. In similarly adjusted logistic regression models comparing the lowest with the highest categories of SES, low SES was strongly associated with impaired exercise capacity (defined as <5 METs; odds ratios for income 5.5, 95% confidence interval [CI] 1.9 to 16.0; education 4.3, 95% CI 2.0 to 9.5; housing 4.5, 95% CI 2.1 to 9.6; and occupation 2.8, 95% CI 1.4 to 5.7, p <or=0.001 for all trends). In conclusion, 4 indicators of low SES were strongly associated with decreased exercise capacity in patients with CHD. Differences in traditional cardiac risk factors and health behaviors did not explain this association.
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Zoppini G, Cacciatori V, Gemma ML, Moghetti P, Targher G, Zamboni C, Thomaseth K, Bellavere F, Muggeo M. Effect of moderate aerobic exercise on sympatho-vagal balance in Type 2 diabetic patients. Diabet Med 2007; 24:370-6. [PMID: 17335467 DOI: 10.1111/j.1464-5491.2007.02076.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS The purpose of the study was to determine long-term cardiovascular autonomic adaptation to moderate endurance aerobic exercise in people with Type 2 diabetes in order to test the hypothesis of an enhanced vagal drive. METHODS We analysed the power spectral density of heart rate cyclic variations at rest, while lying, and while standing in 12 sedentary, non-smoking, Type 2 diabetic individuals. Testing was performed before and after a 6-month, supervised, progressive, aerobic training programme, twice weekly. Heart rate variability was assessed by autoregressive power spectral analysis (PSA); this method allows reliable quantification of low-frequency (LF) and high-frequency (HF) components, which are considered to be under mainly sympathetic and purely parasympathetic control, respectively. RESULTS In 10-min electrocardiogram recordings, mean RR intervals values lying and standing were similar before and after physical exercise. Likewise, total heart rate variability, expressed as total power spectral density (PSD), was not altered by exercise. In contrast, on standing, the HF component, expressed in normalized units, was significantly higher (20.1 +/- 4 vs. 30.4 +/- 5, P < 0.01), whereas the LF component was significantly lower (68.1 +/- 7 vs. 49.8 +/- 8, P < 0.01) after exercise; hence, on standing, the LF/HF ratio, reflecting the sympathetic vs. parasympathetic balance, was markedly lower (16.2 +/- 11 vs. 5.2 +/- 3.2, P = 0.003). No significant exercise-related changes in these PSA components were observed on lying. CONCLUSIONS A twice-weekly, 6-month, moderate, aerobic exercise programme, without a concomitant weight loss diet, is associated with significant improvements in cardiovascular autonomic function in overweight, non-smoking, Type 2 diabetic individuals.
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Affiliation(s)
- G Zoppini
- Division of Endocrinology and Metabolic Diseases, University of Verona, Verona and National Research Council, Institute of Bioengineery, Padua, Italy.
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Spies C, Otte C, Kanaya A, Pipkin SS, Schiller NB, Whooley MA. Association of metabolic syndrome with exercise capacity and heart rate recovery in patients with coronary heart disease in the heart and soul study. Am J Cardiol 2005; 95:1175-9. [PMID: 15877989 PMCID: PMC2776681 DOI: 10.1016/j.amjcard.2005.01.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2004] [Revised: 01/06/2005] [Accepted: 01/06/2005] [Indexed: 12/16/2022]
Abstract
It is not known whether the metabolic syndrome is associated with poor exercise capacity among patients who have established coronary heart disease. We evaluated the association of the metabolic syndrome with treadmill exercise capacity and heart rate recovery among patients who had coronary heart disease. We measured treadmill exercise capacity (METs) and heart rate recovery (beats per minute) in 943 subjects who had known coronary heart disease. Of these, 377 (40%) had the metabolic syndrome as defined by criteria of the National Cholesterol Education Program. Participants who had the metabolic syndrome were more likely to have poor exercise capacity (METs <5, 33% vs 18%, p <0.0001) and poor heart rate recovery (<or=16 beats/min, 34% vs 21%, p <0.0001) than those who did not have the metabolic syndrome. In ordinal logistic regression analyses, the metabolic syndrome was associated with decreased exercise capacity (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7 to 2.8, p <0.0001) and decreased heart rate recovery (OR 1.8, 95% CI 1.4 to 2.3, p <0.0001). These associations remained strong after adjusting for potential confounding variables (OR 1.6, 95% CI 1.2 to 2.1, p = 0.003 for decreased exercise capacity; OR 1.4, 95% CI 1.1 to 1.9, p = 0.02 for decreased heart rate recovery). The metabolic syndrome is independently associated with poor exercise capacity and poor heart rate recovery in patients who have established coronary heart disease. Decreased exercise capacity may contribute to the adverse outcomes associated with the metabolic syndrome.
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Affiliation(s)
- Christian Spies
- Section of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
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Myers J, Kaykha A, George S, Abella J, Zaheer N, Lear S, Yamazaki T, Froelicher V. Fitness versus physical activity patterns in predicting mortality in men. Am J Med 2004; 117:912-8. [PMID: 15629729 DOI: 10.1016/j.amjmed.2004.06.047] [Citation(s) in RCA: 318] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2003] [Accepted: 06/24/2004] [Indexed: 12/13/2022]
Abstract
PURPOSE To compare the contributions of fitness level and physical activity patterns to all-cause mortality. METHODS Of 6213 men referred for exercise testing between 1987 and 2000, 842 underwent an assessment of adulthood activity patterns. The predictive power of exercise capacity and activity patterns, along with clinical and exercise test data, were assessed for all-cause mortality during a mean (+/-SD) follow-up of 5.5 +/- 2 years. RESULTS Expressing the data by age-adjusted quartiles, exercise capacity was a stronger predictor of mortality than was activity pattern (hazard ratio [HR] = 0.56; 95% confidence interval [CI]: 0.38 to 0.83; P < 0.001). In a multivariate analysis that considered clinical characteristics, risk factors, exercise test data, and activity patterns, exercise capacity (HR per quartile = 0.62; CI: 0.47 to 0.82; P < 0.001) and energy expenditure from adulthood recreational activity (HR per quartile = 0.72; 95% CI: 0.58 to 0.89; P = 0.002) were the only significant predictors of mortality; these two variables were stronger predictors than established risk factors such as smoking, hypertension, obesity, and diabetes. Age-adjusted mortality decreased per quartile increase in exercise capacity (HR for very low capacity = 1.0; HR for low = 0.59; HR for moderate = 0.46; HR for high = 0.28; P < 0.001) and physical activity (HR for very low activity = 1.0; HR for low = 0.63; HR for moderate = 0.42; HR for high = 0.38; P < 0.001). A 1000-kcal/wk increase in activity was approximately similar to a 1 metabolic equivalent increase in fitness; both conferred a mortality benefit of 20%. CONCLUSION Exercise capacity determined from exercise testing and energy expenditure from weekly activity outperform other clinical and exercise test variables in predicting all-cause mortality.
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Affiliation(s)
- Jonathan Myers
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Stanford University School of Medicine, Palo Alto, California, USA.
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Pitsavos CH, Chrysohoou C, Panagiotakos DB, Kokkinos P, Skoumas J, Papaioannou I, Michaelides AP, Singh S, Stefanadis CI. Exercise capacity and heart rate recovery as predictors of coronary heart disease events, in patients with heterozygous Familial Hypercholesterolemia. Atherosclerosis 2004; 173:347-52. [PMID: 15064112 DOI: 10.1016/j.atherosclerosis.2003.12.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2003] [Revised: 11/20/2003] [Accepted: 12/18/2003] [Indexed: 11/15/2022]
Abstract
BACKGROUND Several clinical and observational studies have established that exercise capacity and activity status are strong predictors of cardiovascular and overall mortality. We aimed to evaluate the relationship between exercise tolerance test (ETT) indices and occurrence of coronary heart disease (CHD), in patients with heterozygous Familial Hypercholesterolemia (eFH). METHODS During 1987-1997, we enrolled 639 cardiovascular disease-free patients with heterozygous eFH; 58 (9%) patients were excluded since they had a positive ETT. A fatal or non-fatal CHD event was the end point. Cox proportional hazards models were applied to evaluate the association between the investigated outcome and ETT indices. RESULTS During the follow-up (1987-2002), 53 (18%) men and 34 (10%) women developed a CHD event (11 were fatal). The age-adjusted event rate was 87 events per 2915 person-years (3%). Statistical analysis revealed that exercise capacity (hazard ratio = 0.82, P < 0.001), heart rate recovery at 1 min (hazard ratio = 0.91, P < 0.05), and peak pulse pressure levels (hazard ratio = 1.03, P < 0.001), were predictors of CHD, after controlling for several potential confounders. CONCLUSION Decreased exercise capacity, a delayed decrease in heart rate during the first minute of graded exercise, and increased peak pulse pressure are strong predictors of coronary events in patients with eFH. Physical activity should be strongly recommended in these patients.
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Affiliation(s)
- Christos H Pitsavos
- First Cardiology Department, School of Medicine, University of Athens, Greece
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Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002; 346:793-801. [PMID: 11893790 DOI: 10.1056/nejmoa011858] [Citation(s) in RCA: 2558] [Impact Index Per Article: 116.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Exercise capacity is known to be an important prognostic factor in patients with cardiovascular disease, but it is uncertain whether it predicts mortality equally well among healthy persons. There is also uncertainty regarding the predictive power of exercise capacity relative to other clinical and exercise-test variables. METHODS We studied a total of 6213 consecutive men referred for treadmill exercise testing for clinical reasons during a mean (+/-SD) of 6.2+/-3.7 years of follow-up. Subjects were classified into two groups: 3679 had an abnormal exercise-test result or a history of cardiovascular disease, or both, and 2534 had a normal exercise-test result and no history of cardiovascular disease. Overall mortality was the end point. RESULTS There were a total of 1256 deaths during the follow-up period, resulting in an average annual mortality of 2.6 percent. Men who died were older than those who survived and had a lower maximal heart rate, lower maximal systolic and diastolic blood pressure, and lower exercise capacity. After adjustment for age, the peak exercise capacity measured in metabolic equivalents (MET) was the strongest predictor of the risk of death among both normal subjects and those with cardiovascular disease. Absolute peak exercise capacity was a stronger predictor of the risk of death than the percentage of the age-predicted value achieved, and there was no interaction between the use or nonuse of beta-blockade and the predictive power of exercise capacity. Each 1-MET increase in exercise capacity conferred a 12 percent improvement in survival. CONCLUSIONS Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for cardiovascular disease.
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Affiliation(s)
- Jonathan Myers
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif CA 94304, USA.
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Brewer DE. Diagnostic testing. Prim Care 2000; 27:785-802;viii. [PMID: 10918680 DOI: 10.1016/s0095-4543(05)70174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The results of cardiac tests must always be interpreted through the lens of pretest probabilities created by the history and the physical examination. Tests should be chosen with a clear diagnostic and prognostic purpose in mind. A clear understanding of the relationship between the history and physical examination and more technologic diagnostic testing improves the primary care physician's ability to evaluate potential cardiac disease in an efficient and cost-effective manner.
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Affiliation(s)
- D E Brewer
- Department of Family Medicine, University of Tennessee, Knoxville, Tennessee.
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Abstract
Historically, the protocol used for exercise testing has been based on tradition, convenience or both. In the 1990s, a considerable amount of research has focused on the effect of the exercise protocol on test performance, including exercise tolerance, diagnostic accuracy, gas exchange patterns and the accuracy with which oxygen uptake (VO2) is predicted from the work rate. Studies have suggested that protocols which contain large and/or unequal increments in work cause a disruption in the normal linear relation between VO2 and work rate, leading to an overprediction of metabolic equivalents. Other studies have demonstrated that such protocols can mask the salutary effects of an intervention, and some have suggested that the protocol design can influence the diagnostic performance of the test. Guidelines published by major organisations have therefore suggested that the protocol be individualised based on the patient being tested and the purpose of the test. The ramp approach to exercise testing has recently been advocated because it facilitates recommendations made in these guidelines. This article reviews these issues and discusses the evolution of ramp testing which has occurred in the 1990s.
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Affiliation(s)
- J Myers
- Cardiology Division, Palo Alto VA Health Care System, California 94304, USA.
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Antonio Castillo Moreno J. Respuesta. Rev Esp Cardiol (Engl Ed) 2000. [DOI: 10.1016/s0300-8932(00)75254-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Snader CE, Marwick TH, Pashkow FJ, Harvey SA, Thomas JD, Lauer MS. Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: report of 3,400 patients from a single center. J Am Coll Cardiol 1997; 30:641-8. [PMID: 9283520 DOI: 10.1016/s0735-1097(97)00217-9] [Citation(s) in RCA: 154] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We sought to determine the relative influence of estimated functional capacity and thallium-201 (Tl-201) single-photon emission computed tomographic (SPECT) findings on prediction of short-term all-cause and cardiac-related mortality. BACKGROUND Decreased functional capacity and abnormal Tl-201 SPECT findings are predictive of increased cardiovascular risk and mortality. However, the relative importance of these variables as predictors of all-cause mortality is not well established. METHODS Analyses were based on 3,400 consecutive adults undergoing symptom-limited exercise Tl-201 SPECT testing at the Cleveland Clinic Foundation between September 1990 and December 1993; none had previous invasive procedures, heart failure or valve disease. Estimated functional capacity, classified by age and gender, and thallium perfusion defects, expressed as a stress extent thallium score on a 12-segment scale, were analyzed to determine their relative prognostic importance during 2 years of follow-up. RESULTS Of 3,400 patients, 108 (3.2%) died during follow-up; 32 deaths were identified as cardiac related. On univariable analysis, estimated functional capacity was a strong predictor of death, with 62 (57%) deaths occurring in patients achieving < 6 metabolic equivalents (METs) (log-rank chi-square 86, p < 0.0001). On multivariable analysis, the strongest independent predictors of all-cause mortality were fair or poor functional capacity (adjusted relative risk [RR] 3.96, 95% confidence interval [CI] 2.36 to 6.64, chi-square 27, p < 0.0001) and age (adjusted RR for 10 years 2.25, 95% CI 1.80 to 2.80, chi-square 27, p < 0.0001). The presence of SPECT thallium perfusion defects was a less powerful predictor of death (for each two additional segments with defects, adjusted RR 1.21, 95% CI 1.03 to 1.43, chi-square 5, p = 0.02). Cardiac mortality was predicted by both fair or poor functional capacity (adjusted RR 4.37, 95% CI 1.59 to 12.00, chi-square 8, p = 0.004) and by stress extent thallium score (adjusted RR 1.62, 95% CI 1.25 to 2.11, chi-square 13, p = 0.0003). CONCLUSIONS In this clinically low risk group, estimated functional capacity was a strong and overwhelmingly important independent predictor of all-cause mortality among patients undergoing exercise Tl-201 SPECT testing. The extent of myocardial perfusion defects was of comparable importance for the prediction of cardiac mortality.
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Affiliation(s)
- C E Snader
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
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Marcus R, Lowe R, Froelicher VF, Do D. The exercise test as gatekeeper. Limiting access or appropriately directing resources? Chest 1995; 107:1442-6. [PMID: 7750345 DOI: 10.1378/chest.107.5.1442] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- R Marcus
- Cardiology Section, Palo Alto (Calif), Veterans Affairs Medical Center 94304, USA
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