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Girault A, Leprêtre PM, Trachsel LD, Besnier F, Boidin M, Lalongé J, Juneau M, Bherer L, Nigam A, Gayda M. Determinants of V̇+O2peak Changes After Aerobic Training in Coronary Heart Disease Patients. Int J Sports Med 2024; 45:532-542. [PMID: 38267005 DOI: 10.1055/a-2253-1807] [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: 01/26/2024]
Abstract
This study aimed to highlight the ventilatory and circulatory determinants of changes in ˙VO2peak after exercise-based cardiac rehabilitation (ECR) in patients with coronary heart disease (CHD). Eighty-two CHD patients performed, before and after a 3-month ECR, a cardiopulmonary exercise testing (CPET) on a bike with gas exchanges measurements (˙VO2peak, minute ventilation, i. e., ˙VE), and cardiac output (Q˙c). The arteriovenous difference in O2 (C(a-v¯)O2) and the alveolar capillary gradient in O2 (PAi-aO2) were calculated using Fick's laws. Oxygen uptake efficiency slope (OUES) was calculated. A 5.0% cut off was applied for differentiating non- (NR: ˙VO2<0.0%), low (LR: 0.0≤ ∆˙VO2<5.0%), moderate (MR: 5.0≤∆˙VO2 < 10.0%), and high responders (HR: ∆˙VO2≥10.0%) to ECR. A total of 44% of patients were HR (n=36), 20% MR (n=16), 23% LR (n=19), and 13% NR (n=11). For HR, the ˙VO2peak increase (p<0.01) was associated with increases in ˙VE (+12.8±13.0 L/min, p<0.01), (+1.0±0.9 L/min, p<0.01), and C(a-v¯)O2 (+2.3±2.5 mLO2/100 mL, p<0.01). MR patients were characterized by+6.7±19.7 L/min increase in ˙VE (p=0.04) and+0.7±1.0 L/min of Q˙c (p<0.01). ECR induced decreases in ˙VE (p=0.04) and C(a-v¯)O2 (p<0.01) and a Q˙c increase in LR and NR patients (p<0.01). Peripheral and ventilatory responses more than central adaptations could be responsible for the ˙VO2peak change with ECR in CHD patients.
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Affiliation(s)
- Axel Girault
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
- Unit Research Physiological Adaptations to Exercise and Physical Rehabilitation, Université de Picardie Jules Verne, Amiens, France
| | - Pierre-Marie Leprêtre
- Unit Research Physiological Adaptations to Exercise and Physical Rehabilitation, Université de Picardie Jules Verne, Amiens, France
- Unit of Cardiac Rehabilitation, Hospital Center of Corbie, Corbie, France
| | - Lukas-Daniel Trachsel
- University Clinic for Cardiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Florent Besnier
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Maxime Boidin
- Department of Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Julie Lalongé
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
| | - Martin Juneau
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Louis Bherer
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Anil Nigam
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Mathieu Gayda
- Preventive medicine and physical activity Center (ÉPIC), Montreal Heart Institute, Université de Montréal, Montréal, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
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Kirsch M, Vitiello D, Trachsel LD, Boidin M, Lalongé J, Juneau M, Bherer L, Nigam A, Gayda M. Cardiac hemodynamics phenotypes and individual responses to training in coronary heart disease patients. Scand J Med Sci Sports 2024; 34:e14633. [PMID: 38650385 DOI: 10.1111/sms.14633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/18/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND In patients with coronary heart disease (CHD), individualized exercise training (ET) programs are strongly recommended to optimize peak oxygen uptake (V ̇ $$ \dot{\mathrm{V}} $$ O2peak) improvement and prognosis. However, the cardiac hemodynamic factors responsible for a positive response to training remain unclear. The aim of this study was to compare cardiac hemodynamic changes after an ET program in responder (R) versus non-responder (NR) CHD patients. METHODS A total of 72 CHD patients completed a 3-month ET program and were assessed by cycle ergometer cardiopulmonary exercise test (CPET:V ̇ $$ \dot{\mathrm{V}} $$ O2peak assessment) with impedance cardiography (ICG) for hemodynamic measurements before and after training. Cardiac hemodynamics (e.g., CO, CI, SV, ESV, EDV, and SVR) were measured by ICG during CPET. The R and NR groups were classified using the median change inV ̇ $$ \dot{\mathrm{V}} $$ O2peak (>the median for R and ≤the median for NR). RESULTS In the R group,V ̇ $$ \dot{\mathrm{V}} $$ O2peak (+17%, p < 0.001), CO, CI, SV, and HR increased by 17%, 17%, 13%, and 5%, respectively (p < 0.05) after the training program. In the NR group,V ̇ $$ \dot{\mathrm{V}} $$ O2peak, CO, CI, and SV increased by 0.5%, 5%, 8%, and 6%, respectively (p < 0.01). The SVR decreased in both groups (-19% in R and -11% in NR, p < 0.001). CONCLUSION Among CHD patients, the R group showed a better improvement in peak cardiac output via an increase in peak stroke volume and heart rate and a reduced systemic vascular resistance than the NR group. Different cardiac phenotype adaptations and clinical individual responses were identified in CHD patients according to the aerobic fitness responder's status.
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Affiliation(s)
- Marine Kirsch
- Preventive Medicine and Physical Activity Center (ÉPIC) & Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
- Université Paris Cité, Institut des Sciences du Sport Santé de Paris (I3SP), URP 3625, Paris, France
| | - Damien Vitiello
- Université Paris Cité, Institut des Sciences du Sport Santé de Paris (I3SP), URP 3625, Paris, France
| | - Lukas-Daniel Trachsel
- University Clinic for Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maxime Boidin
- Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Julie Lalongé
- Preventive Medicine and Physical Activity Center (ÉPIC) & Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
| | - Martin Juneau
- Preventive Medicine and Physical Activity Center (ÉPIC) & Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Louis Bherer
- Preventive Medicine and Physical Activity Center (ÉPIC) & Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Anil Nigam
- Preventive Medicine and Physical Activity Center (ÉPIC) & Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Mathieu Gayda
- Preventive Medicine and Physical Activity Center (ÉPIC) & Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
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Hu Q, Li PX, Li YS, Ren Q, Zhang J, Liang YC, Zhang QY, Han YL. Daily exercise improves the long-term prognosis of patients with acute coronary syndrome. Front Public Health 2023; 11:1126413. [PMID: 37006550 PMCID: PMC10050345 DOI: 10.3389/fpubh.2023.1126413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/22/2023] [Indexed: 03/17/2023] Open
Abstract
ObjectiveTo demonstrate the effect of daily exercise on the incidence of major adverse cardiovascular events (MACE) for patients with acute coronary syndrome (ACS).MethodsA cohort of 9,636 patients with ACS were consecutively enrolled in our retrospective study between November 2015 and September 2017, which were used for model development. 6,745 patients were assigned as the derivation cohort and 2,891 patients were assigned as the validation cohort. The least absolute shrinkage and selection operator (LASSO) regression and COX regression were used to screen out significant variables for the construction of the nomogram. Multivariable COX regression analysis was employed for the development of a model represented by a nomogram. The nomogram was then evaluated for performance traits such as discrimination, calibration, and clinical efficacy.ResultsAmong 9,636 patients with ACS (mean [SD] age, 60.3 [10.4] years; 7,235 men [75.1%]), the 5-year incidence for MACE was 0.19 at a median follow-up of 1,747 (1,160–1,825) days. Derived from the LASSO regression and COX regression, the nomogram has included 15 factors in total including age, previous myocardial infarction (MI), previous percutaneous coronary intervention (PCI), systolic pressure, N-terminal Pro-B-type natriuretic peptide (NT-proBNP), high-density lipoprotein cholesterol (HDL), serum creatinine, left ventricular end-diastolic diameter (LVEDD), Killip class, the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, left anterior descending (LAD) stenosis (≥50%), circumflex (LCX) stenosis (≥50%), right coronary artery (RCA) stenosis (≥50%), exercise intensity, cumulative time. The 5-year area under the ROC curve (AUC) of derivation and validation cohorts were 0.659 (0.643–0.676) and 0.653 (0.629–0.677), respectively. The calibration plots showed the strong concordance performance of the nomogram model in both two cohorts. Moreover, decision curve analysis (DCA) also showed the usefulness of nomogram in clinical practice.ConclusionThe present work provided a prediction nomogram predicting MACE for patients with ACS after incorporating the already known factors and the daily exercise, which demonstrated the effectiveness of daily exercise on the improvement of prognosis for patients with ACS.
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Affiliation(s)
- Qiang Hu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Cardiology, Air Force Hospital of Western Theater Command, Chengdu, China
| | - Peng-Xiao Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Yu-Shan Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Qiang Ren
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jian Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yan-Chun Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Quan-Yu Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- *Correspondence: Quan-Yu Zhang
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Ya-Ling Han
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Eser P, Trachsel LD, Marcin T, Herzig D, Freiburghaus I, De Marchi S, Zimmermann AJ, Schmid JP, Wilhelm M. Short- and Long-Term Effects of High-Intensity Interval Training vs. Moderate-Intensity Continuous Training on Left Ventricular Remodeling in Patients Early After ST-Segment Elevation Myocardial Infarction-The HIIT-EARLY Randomized Controlled Trial. Front Cardiovasc Med 2022; 9:869501. [PMID: 35783836 PMCID: PMC9247394 DOI: 10.3389/fcvm.2022.869501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/20/2022] [Indexed: 11/29/2022] Open
Abstract
Aim Due to insufficient evidence on the safety and effectiveness of high-intensity interval training (HIIT) in patients early after ST-segment elevation myocardial infarction (STEMI), we aimed to compare short- and long-term effects of randomized HIIT or moderate-intensity continuous training (MICT) on markers of left ventricular (LV) remodeling in STEMI patients receiving optimal guideline-directed medical therapy (GDMT). Materials and Methods Patients after STEMI (<4 weeks) enrolled in a 12-week cardiac rehabilitation (CR) program were recruited for this randomized controlled trial (NCT02627586). During a 3-week run-in period with three weekly MICT sessions, GDMT was up-titrated. Then, the patients were randomized to HIIT or isocaloric MICT for 9 weeks. Echocardiography and cardiopulmonary exercise tests were performed after run-in (3 weeks), end of CR (12 weeks), and at 1-year follow-up. The primary outcome was LV end-diastolic volume index (LVEDVi) at the end of CR. Secondary outcomes were LV global longitudinal strain (GLS) and cardiopulmonary fitness. Results Seventy-three male patients were included, with the time between STEMI and start of CR and randomization being 12.5 ± 6.3 and 45.8 ± 10.8 days, respectively. Mixed models revealed no significant group × time interaction for LVEDVi at the end of CR (p = 0.557). However, there was a significantly smaller improvement in GLS at 1-year follow-up in the HIIT compared to the MICT group (p = 0.031 for group × time interaction). Cardiorespiratory fitness improved significantly from a median value of 26.5 (1st quartile 24.4; 3rd quartile 1.1) ml/kg/min at randomization in the HIIT and 27.7 (23.9; 31.6) ml/kg/min in the MICT group to 29.6 (25.3; 32.2) and 29.9 (26.1; 34.9) ml/kg/min at the end of CR and to 29.0 (26.6; 33.3) and 30.6 (26.0; 33.8) ml/kg/min at 1 year follow-up in HIIT and MICT patients, respectively, with no significant group × time interactions (p = 0.138 and 0.317). Conclusion In optimally treated patients early after STEMI, HIIT was not different from isocaloric MICT with regard to short-term effects on LVEDVi and cardiorespiratory fitness. The worsening in GLS at 1 year in the HIIT group deserves further investigation, as early HIIT may offset the beneficial effects of GDMT on LV remodeling in the long term.
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Affiliation(s)
- Prisca Eser
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas D. Trachsel
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thimo Marcin
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Research Department, Berner Reha Zentrum, Heiligenschwendi, Switzerland
| | - David Herzig
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- University Clinic for Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Irina Freiburghaus
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefano De Marchi
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas J. Zimmermann
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Matthias Wilhelm
- Department of Cardiology, Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Effect of High-Intensity Interval Training on Physical Health in Coronary Artery Disease Patients: A Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Dev Dis 2021; 8:jcdd8110158. [PMID: 34821711 PMCID: PMC8622669 DOI: 10.3390/jcdd8110158] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 01/02/2023] Open
Abstract
The effects of exercise-based cardiac rehabilitation (CR) on physical health in coronary artery disease (CAD) patients has long been established, while the optimal exercise mode remains to be determined. This meta-analysis compared the efficacy of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) in CAD patients. Databases were searched up to December 2020. Twenty-five studies with 1272 participants were analyzed. The results showed that both HIIT and MICT induced significant VO2peak improvement with a 4.52 mL/kg/min (p < 0.01) and 2.36 mL/kg/min (p < 0.01), respectively. Additionally, a larger improvement of VO2peak (1.92 mL/kg/min, p < 0.01) was observed in HIIT over MICT. HIIT with medium and long intervals, higher work/rest ratio induced larger VO2peak improvement than the compared subgroup. Interestingly, non-isocaloric exercise protocols induced larger VO2peak improvement compared with isocaloric protocols. In addition, both HIIT and MICT significantly increased anaerobic threshold and peak power with HIIT superior to MICT. No significant different changes were observed in blood pressure after HIIT or MICT intervention, however when HIIT was compared with MICT, MICT seems superior to HIIT in reducing systolic blood pressure (−3.61 mmHg, p < 0.01) and diastolic blood pressure (−2.37 mmHg, p < 0.01). Although, HIIT and MICT induced significant improvement of most other parameters, like HRrest, HRpeak, left ventricular ejection fraction (LVEF), quality of life (QoL), no significant differences were noted between groups. This meta-analysis suggested that HIIT is superior to MICT in increasing VO2peak, anaerobic threshold, peak power in CAD patients. Additionally, the efficacy of HIIT over MICT in improving VO2peaks was influenced by HIIT intervals, work/rest ratio and total caloric consumption. Both HIIT and MICT did not significantly influence resting BP, however, MICT seemed to be more effective in reducing BP than HIIT. HIIT and MICT equally significantly influenced HRrest, HRpeak, HRR1min, OUES, LVEF%, QoL.
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Trachsel LD, Boidin M, Henri C, Fortier A, Lalongé J, Juneau M, Nigam A, Gayda M. Women and men with coronary heart disease respond similarly to different aerobic exercise training modalities: a pooled analysis of prospective randomized trials. Appl Physiol Nutr Metab 2020; 46:417-425. [PMID: 33096006 DOI: 10.1139/apnm-2020-0650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We aimed to compare cardiopulmonary exercise test (CPET) parameters, cardiac adaptations, and proportion of responders after different aerobic training programs amongst women and men with coronary heart disease (CHD). Patients with CHD were evaluated with a CPET and echocardiography before and after 3 months of aerobic exercise training. Peak oxygen uptake exercise training response was assessed according to the median peak oxygen uptake change for post- versus pretraining in the whole cohort (stratification non/low responders (NLR) vs. high-responders) and normalized for lean body mass (LBM). Eighty-three CHD patients were included (19 women, 64 men; 27 patients with interval, 19 with continuous, and 37 with combination exercises). Peak oxygen uptake, peak workload normalized for LBM, pulmonary variables (i.e., ventilation and oxygen uptake efficiency slope), and O2 pulse were significantly lower in women versus men. These parameters improved similarly with training in both sexes (p < 0.05). There were no differences in the proportion of NLR among women and men with CHD (7/19 (37%) vs. 35/64 (55%), p = 0.1719). Left ventricular ejection fraction and mean peak early diastolic mitral annulus velocity improved similarly with training in both sexes (p < 0.05). Women and men with CHD have a similar exercise training response regarding key CPET and echocardiographic parameters. The proportion of responders is similar. ClinicalTrials.gov: NCT03414996, NCT02048696, NCT03443193. Novelty: Cardiopulmonary adaptations to exercise training are similar among CHD men and women. Proportion of peak oxygen uptake for non/low/high responders is similar in CHD men and women. Left ventricular systolic and diastolic function improved similarly after exercise training in CHD men and women.
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Affiliation(s)
- Lukas-Daniel Trachsel
- Cardiovascular Prevention and Rehabilitation (ÉPIC) Center, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1N6, Canada.,Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada.,University Clinic for Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, CH-3010 Switzerland
| | - Maxime Boidin
- Cardiovascular Prevention and Rehabilitation (ÉPIC) Center, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1N6, Canada.,Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1C8, Canada.,School of Kinesiology and Exercise Science, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Christine Henri
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada.,Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1C8, Canada
| | - Annik Fortier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada
| | - Julie Lalongé
- Cardiovascular Prevention and Rehabilitation (ÉPIC) Center, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1N6, Canada.,Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1C8, Canada
| | - Martin Juneau
- Cardiovascular Prevention and Rehabilitation (ÉPIC) Center, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1N6, Canada.,Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada.,Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1C8, Canada
| | - Anil Nigam
- Cardiovascular Prevention and Rehabilitation (ÉPIC) Center, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1N6, Canada.,Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada.,Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1C8, Canada
| | - Mathieu Gayda
- Cardiovascular Prevention and Rehabilitation (ÉPIC) Center, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1N6, Canada.,Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada.,Research Centre, Montreal Heart Institute, Université de Montréal, Montreal, QC H1T 1C8, Canada
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