Effects of exercise and cardiac rehabilitation on cardiovascular outcomes

Exercise Training and Cardiac Rehabilitation in COVID-19 Patients with Cardiovascular Complications: State of Art

Recent scientific literature has investigated the cardiovascular implications of COVID-19. The mechanisms of cardiovascular damage seem to involve the protein angiotensin-converting enzyme 2 (ACE2), to which severe acute respiratory syndrome (SARS) coronavirus-2 (CoV-2) binds to penetrate cells and other mechanisms, most of which are still under study. Cardiovascular sequelae of COVID-19 include heart failure, cardiomyopathy, acute coronary syndrome, arrhythmias, and venous thromboembolism. This article aims to collect scientific evidence by exploiting PubMed, Scopus, and Pedro databases to highlight the cardiovascular complications of COVID-19 and to define the physiotherapy treatment recommended for these patients. Exercise training (ET), an important part of cardiac rehabilitation, is a powerful tool in physiotherapy, capable of inducing significant changes in the cardiovascular system and functional in the recovery of endothelial dysfunction and for the containment of thromboembolic complications. In conclusion, due to the wide variety of possible exercise programs that can be obtained by combining intensity, duration, and speed in various ways, and by adjusting the program based on continuous patient monitoring, exercise training is well suited to the treatment of post-COVID patients with an impaired cardiovascular system of various degrees.

Cardiac physiology in post myocardial infarction patients: the effect of cardiac rehabilitation programs-a systematic review and update meta-analysis

Cardiac rehabilitation program (CRP) is a recognized non-pharmacological modality to decrease mortality after acute myocardial infarction (AMI) events. We aimed to evaluate the effect of CRP on the cardiac physiology in patients post myocardial infarction (MI). Online database search of PubMed, MEDLINE, EMBASE, SCOPUS, COCHRANE, and GOOGLE SCHOLAR were performed (1988-Mar 2016); key bibliographies were reviewed. Studies comparing post MI patients who were enrolled in a CRP to those who were not, were included. Standardized mean difference (SMD) with the corresponding 95% confidence intervals (CI) by random and fixed effects models of pooled data were calculated. Study quality was assessed using CONSORT criteria. Outcomes of interest measured included resting and maximum heart rate (HR), peak VO₂, ejection fraction (EF%), wall motion score index (WMSI), left ventricular end diastolic volume (LVEDV) in cardiac rehabilitation patients versus control. Search strategy yielded 147 studies, 23 studies fulfilled the selection criteria, 19 of which were RCTs. These included a total of 1,683 patients; 827 were enrolled in a CRP while 855 did not receive the intervention. Median age was 58 years. There was no significant difference between the two groups in terms of age, comorbidities, severity of CAD, baseline EF or HR. Meta-analysis of data included demonstrated that CRP patients had lower post-intervention resting HR than non-CRP patients (SMD: -0.59; 95% CI: -0.73 to -0.46, fixed effect model P<0.05). EF% was significantly improved after CRP compared to control (SMD: 0.21; 95% CI: 0.02 to 0.40, P=0.03). Peak VO₂ was significantly improved by CRP (SMD: 1.00; 95% CI: 0.56 to 1.45; P<0.0001). LVEDV was significantly less in CRP patients (SMD: -0.31; 95% CI: -0.59 to -0.02, fixed effect model P<0.05). WMSI was significantly less in CRP patients (SMD: -0.41; 95% CI: -0.78 to -0.05, P=0.024). CRP improves cardiac function in post MI patients. This may explain the reported improvement of functionality and mortality among those patients. Further randomized trials may help evaluate the long-term benefits of CRP.

EFEITOS DO TREINAMENTO AERÓBICO E DO FORTALECIMENTO EM PACIENTES COM INSUFICIÊNCIA CARDÍACA

RESUMO Introdução: A intolerância ao exercício e a dispneia são os principais sintomas da insuficiência cardíaca (IC). Objetivo: Avaliar os efeitos de um programa de exercícios aeróbicos e de fortalecimento sobre a aptidão cardiorrespiratória, o pico de torque dos flexores e extensores de joelho e a qualidade de vida de pacientes com IC. Métodos: Estudo prospectivo, com avaliação pré e pós-reabilitação cardiovascular (RCV) de sete pacientes, com idade de 61 ± 6 anos, classe funcional II e III e fração de ejeção do ventrículo esquerdo 45,4 ± 2,3%. O programa de RCV consistiu em 24 sessões de 60 minutos com treinamento aeróbico na intensidade do limiar de anaerobiose (LA) e fortalecimento dos membros inferiores usando caneleiras de 3 a 5 kg. No início e após RCV os pacientes realizaram prova de esforço, dinamometria isocinética do joelho dominante e responderam o questionário WHOQOL-bref. Resultados: Após RCV, o tempo de exercício para atingir o LA foi atrasado (p= 0,04) e houve aumento significativo no consumo de oxigênio (VO2) (p < 0,01), da frequência cardíaca (FC) (p= 0,04), pulso de oxigênio (VO2/FC) (p = 0,02) e ventilação (VE) (p = 0,01) na intensidade do LA. Houve aumento do pico de torque dos músculos extensores de joelho (p = 0,02) e melhora significativa do domínio psicológico (p = 0,04) do questionário de qualidade de vida. Conclusão: O programa de RCV foi seguro e resultou em melhora do desempenho de exercícios submáximos, da força dos músculos extensores de joelho e da qualidade de vida de pacientes com IC.

Effects of High-Intensity Interval Training on Aerobic Capacity in Cardiac Patients: A Systematic Review with Meta-Analysis

Purpose. The aim of this study was to compare the effects of high-intensity interval training (INTERVAL) and moderate-intensity continuous training (CONTINUOUS) on aerobic capacity in cardiac patients. Methods. A meta-analysis identified by searching the PubMed, Cochrane Library, EMBASE, and Web of Science databases from inception through December 2016 compared the effects of INTERVAL and CONTINUOUS among cardiac patients. Results. Twenty-one studies involving 736 participants with cardiac diseases were included. Compared with CONTINUOUS, INTERVAL was associated with greater improvement in peak VO₂ (mean difference 1.76 mL/kg/min, 95% confidence interval 1.06 to 2.46 mL/kg/min, p < 0.001) and VO₂ at AT (mean difference 0.90 mL/kg/min, 95% confidence interval 0.0 to 1.72 mL/kg/min, p = 0.03). No significant difference between the INTERVAL and CONTINUOUS groups was observed in terms of peak heart rate, peak minute ventilation, VE/VCO₂ slope and respiratory exchange ratio, body mass, systolic or diastolic blood pressure, triglyceride or low- or high-density lipoprotein cholesterol level, flow-mediated dilation, or left ventricular ejection fraction. Conclusions. This study showed that INTERVAL improves aerobic capacity more effectively than does CONTINUOUS in cardiac patients. Further studies with larger samples are needed to confirm our observations.

Capacidade funcional como preditor de qualidade de vida na insuficiência cardíaca

INTRODUÇÃO: A insuficiência cardíaca (IC) prejudica a qualidade de vida (QV), enquanto a reabilitação cardiopulmonar e metabólica (RCPM) de pacientes com a síndrome proporciona melhora da capacidade funcional (CF) e da qualidade de vida. OBJETIVOS: Determinar a relação dos domínios da QV com a CF de pacientes com IC, assim como propor pontos de corte dos domínios da QV por meio da CF. MATERIAIS E MÉTODOS: Avaliou-se 57 pacientes com IC, classe funcional II e III, sendo 37 ingressantes (GI) no programa de RCPM e 20 participantes (GP) com mais de três meses de programa. A QV foi avaliada pelo questionário de Minnesota por meio dos domínios físicos, emocionais e dimensões gerais. A CF foi determinada por meio do teste de caminhada de seis minutos (TC6'), tendo pontos de corte definidos conforme proposto na literatura. Utilizou-se teste t de Student, correlação de Pearson e análise da curva ROC para responder aos objetivos da pesquisa, considerando significância de 5%. RESULTADOS: Participantes da RCPM apresentaram melhores escores da QV quando comparados aos ingressantes. Correlações significativas foram observadas entre o domínio emocional e TC6' para ambos os grupos. Verificou-se pontos de corte significativos dos domínios da QV advindos da CF, com destaque ao domínio emocional (sensibilidade/especificidade) para ambos os grupos. CONCLUSÃO: Os portadores de IC com mais de três meses de RCPM apresentaram melhor QV e capacidade funcional do que os iniciantes. O domínio emocional do questionário de Minnesota se mostrou um bom preditor de ponto de corte da capacidade funcional.

Self-efficacy: a useful construct to promote physical activity in people with stable chronic heart failure

AIM

To explore the conceptual underpinnings of self-efficacy to address the barriers to participating in physical activity and propose a model of intervention.

BACKGROUND

The benefits of physical activity in reducing cardiovascular risk have led to evidence-based recommendations for patients with heart disease, including those with chronic heart failure. However, adherence to best practice recommendations is often suboptimal, particularly in those individuals who experience high symptom burden and feel less confident to undertake physical activity. Self-efficacy is the degree of confidence an individual has in his/her ability to perform behaviour under several specific circumstances. Four factors influence an individual's level of self-efficacy: (1) past performance, (2) vicarious experience, (3) verbal persuasion and (4) physiological arousal.

DESIGN

Discursive.

METHODS

Using the method of a discursive paper, this article seeks to explore the conceptual underpinnings of self-efficacy to address the barriers to participating in physical activity and proposes a model of intervention, the Home-Heart-Walk, to promote physical activity and monitor functional status.

CONCLUSIONS

Implementing effective interventions to promote physical activities require appreciation of factors impacting on behaviour change. Addressing concepts relating to self-efficacy in physical activity interventions may promote participation and adherence in the longer term.

RELEVANCE TO CLINICAL PRACTICE

The increasing burden of chronic disease and the emphasis on self-management strategies underscore the importance of promoting adherence to recommendations, such as physical activity.

The effect of an educational intervention on coronary artery bypass graft surgery patients' participation rate in cardiac rehabilitation programs: a controlled health care trial

BACKGROUND

Cardiac rehabilitation has a beneficial effect on the prognosis and quality of life of cardiac patients, and has been found to be cost-effective. This report describes a comprehensive and low cost educational intervention designed to increase the attendance at cardiac rehabilitation programs of patients who have undergone coronary artery bypass graft surgery.

METHODS/DESIGN

A controlled prospective intervention trial. The control arm comprised 520 patients who underwent coronary artery bypass graft surgery between January 2004 and May 2005 in five medical centers across Israel. This group received no additional treatment beyond usual care. The intervention arm comprised 504 patients recruited from the same cardiothoracic departments between June 2005 and November 2006. This group received oral and written explanations about the advantages of participating in cardiac rehabilitation programs and a telephone call two weeks after hospital discharge intended to further encourage their enrollment. The medical staff attended a one-hour seminar on cardiac rehabilitation. In addition, it was recommended that referral to cardiac rehabilitation be added to the letter of discharge from the hospital. Both study groups were interviewed before surgery and one-year post surgery. A one-year post-operative interview assessed factors affecting patient attendance at cardiac rehabilitation programs, as well as the structure and content of the cardiac rehabilitation programs attended. Anthropometric parameters were measured at pre- and post-operative interviews;- and medical information was obtained from patient medical records. The effect of cardiac rehabilitation on one- and three-year mortality was assessed.

DISCUSSION

We report a low cost yet comprehensive intervention designed to increase cardiac rehabilitation participation by raising both patient and medical staff awareness to the potential benefits of cardiac rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00356863.

Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors

Lymphedema, a common and feared negative effect of breast cancer treatment, is generally described by arm swelling and dysfunction. Risk averse clinical recommendations guided survivors to avoid the use of the affected arm. This may lead to deconditioning and, ironically, the very outcome women seek to avoid. Recently published studies run counter to these guidelines.

Failure to improve cardiopulmonary fitness in cardiac rehabilitation

PURPOSE

A primary goal of cardiac rehabilitation (CR) exercise is to increase cardiopulmonary fitness. The aim of this study was to identify characteristics of CR participants who fail to improve peak oxygen uptake (peakV(O(2))).

METHODS

The study cohort included 385 consecutive patients with directly measured peakV(O(2)) prior to and upon completion of CR. Patients were classified as a "nonimprover" if exit peakV(O(2)) was less than or equal to entry peakV(O(2)).

RESULTS

Eighty-one (21%) patients failed to improve peakV(O(2)). Baseline characteristics predicting nonimprovement included the following: lower handgrip strength, lower peak exercise respiratory exchange ratio, a nonsurgical diagnosis, female status, and more medical comorbidities. The number of sessions attended and exercise duration were similar between groups. Nonimprovers, however, exercised at lower exercise intensity despite a similar rating of perceived exertion. By multivariate analysis, independent positive correlates of percentage change in peakV(O(2)) included exercise training intensity and baseline handgrip strength. Negative correlates included baseline peakV(O(2)), comorbidity score, self-reported physical function, and a diagnosis of diabetes (cumulative total r = 0.51, adjusted R = 0.26, P < .0001).

CONCLUSIONS

Twenty-one percent of CR participants failed to improve peakV(O(2)) primarily due to exercise training performed at lower relative intensity despite a similar rating of perceived exertion. For patients with baseline characteristics associated with nonimprovement, alternative training protocols should be considered.

Are the processes recommended by the NHMRC for improving Cardiac Rehabilitation (CR) for Aboriginal and Torres Strait Islander people being implemented?: an assessment of CR Services across Western Australia

BACKGROUND

Cardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services were interviewed.

RESULTS

The majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA.

CONCLUSIONS

This study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed.

Exercise training initiated after the onset of diabetes preserves myocardial function: effects on expression of beta-adrenoceptors

The present study was undertaken to assess cardiac function and characterize beta-adrenoceptor subtypes in hearts of diabetic rats that underwent exercise training (ExT) after the onset of diabetes. Type 1 diabetes was induced in male Sprague-Dawley rats using streptozotocin. Four weeks after induction, rats were randomly divided into two groups. One group was exercised trained for 3 wk while the other group remained sedentary. At the end of the protocol, cardiac parameters were assessed using M-mode echocardiography. A Millar catheter was also used to assess left ventricular hemodynamics with and without isoproterenol stimulation. beta-Adrenoceptors were assessed using Western blots and [(3)H]dihydroalprenolol binding. After 7 wk of diabetes, heart rate decreased by 21%, fractional shortening by 20%, ejection fraction by 9%, and basal and isoproterenol-induced dP/dt by 35%. beta(1)- and beta(2)-adrenoceptor proteins were reduced by 60% and 40%, respectively, while beta(3)-adrenoceptor protein increased by 125%. Ventricular homogenates from diabetic rats bound 52% less [(3)H]dihydroalprenolol, consistent with reductions in beta(1)- and beta(2)-adrenoceptors. Three weeks of ExT initiated 4 wk after the onset of diabetes minimized cardiac function loss. ExT also blunted loss of beta(1)-adrenoceptor expression. Interestingly, ExT did not prevent diabetes-induced reduction in beta(2)-adrenoceptor or the increase of beta(3)-adrenoceptor expression. ExT also increased [(3)H]dihydroalprenolol binding, consistent with increased beta(1)-adrenoceptor expression. These findings demonstrate for the first time that ExT initiated after the onset of diabetes blunts primarily beta(1)-adrenoceptor expression loss, providing mechanistic insights for exercise-induced improvements in cardiac function.

Clinical evidence for a health benefit from cardiac rehabilitation: an update

The recent decision by the Centers for Medicare and Medicaid Services to expand the indications for cardiac rehabilitation (CR) provides an opportunity to review the clinical evidence of the efficacy of exercise in the CR setting for patients who have experienced an acute myocardial infarction, coronary artery bypass graft surgery, stable angina, percutaneous coronary intervention, chronic heart failure, cardiac transplant, or cardiac valve repair/replacement. Evidence shows that physician-directed, exercise-based CR positively affects the basic pathophysiology of coronary artery disease, the extent of disability and level of quality of life, and the ability to potentially impact events of both morbidity and mortality. The role of CR, including regular exercise, lifestyle modification, and appropriate medical therapy, is effective in younger and older men and women with cardiac diagnoses. The efficacy of this important therapeutic modality warrants its more widespread application.

Exercise-based cardiac rehabilitation improves heart rate recovery in elderly patients after acute myocardial infarction

BACKGROUND

Heart rate recovery (HRR), defined as the fall in HR during the first minute after exercise, is a marker of vagal tone, which is a powerful predictor of mortality in patients with coronary artery disease and in older patients. Whether exercise training (ET) modifies HRR in elderly patients recovering from acute myocardial infarction (AMI) is still unknown. Therefore, this study aims at evaluating the effect of ET on HRR in elderly AMI patients.

METHODS

This was a prospective observational study including 268 older patients after AMI (217 men, 51 women), subdivided in two groups: Group A (n = 104), enrolled in an ET program; Group B (n = 164), discharged with generic instructions to continue physical activity. At baseline and at 3-month follow-up, all Group A and 54/164 Group B patients underwent a cardiopulmonary exercise stress test, whereas 110/164 Group B patients underwent an exercise stress test.

RESULTS

After completion of the ET program, in Group A we observed an improvement in oxygen consumption at peak exercise (VO2peak; from 14.7 +/- 1.3 to 17.6 +/- 1.9 mL/kg/min, p < .001), in the rate of increase of ventilation per unit of increase of carbon dioxide production (VE/VCO2slope; from 34.2 +/- 3.8 to 30.4 +/- 3.0, p < .001), and in HRR (from 13.5 +/- 3.7 to 18.7 +/- 3.5 beats/min, p < .001). The changes in VO2peak and in VE/VCO2slope after ET were correlated with the improvement of HRR (r = -0.865, p < .01; r = -0.594, p < .01, respectively). No changes in these parameters were observed in Group B patients.

CONCLUSIONS

In older AMI patients, ET results in HRR improvement, which was correlated to the improvement in cardiopulmonary parameters. These findings may shed additional light on the possible mechanisms of the beneficial prognostic effects of ET in this patient population.

Improved quality of life with cardiac rehabilitation for post-myocardial infarction patients in Korea

BACKGROUND

Health-related quality of life (HRQOL) has been used as a primary health outcome in cardiac rehabilitation programs (CRP).

AIMS

This study aimed to evaluate the effects of an 8-week CRP on HRQOL and exercise capacity in myocardial infarction (MI) patients in Korea.

METHODS

After matching on gender, age, and left ventricular ejection fraction, 60 subjects with a first acute MI were allocated to either a CRP group (n=31) or a Control group (n=29). The 8-week CRP included hospital-based, supervised exercise training (three times per week, average intensity of 65% VO(2peak)) and individual education sessions. The Control group was instructed on a home-based exercise regimen without contact during the 8 weeks. At baseline and 8 weeks, HRQOL was assessed by the Quality of Life Index (QLI)-cardiac version III; exercise capacity by a treadmill test.

RESULTS

After adjusting for education level, the overall QLI, health/functioning and psycho/spiritual scores showed greater increases in the CRP group than the Control group (p=.014, p=.016, and p=.036, respectively). We observed significant improvements in VO(2peak) (p<.0001), anaerobic threshold (p<.0001), and maximal exercise duration (p<.0001) in the CRP group, compared to the Control group.

CONCLUSIONS

These findings suggest that the Korean CRP can lead to significant improvements in HRQOL outcomes and exercise capacity.

Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review

BACKGROUND

Despite the documented efficacy of cardiac rehabilitation (CR), a minority of patients with diagnosed coronary artery disease are referred. Although referral is a necessary step in the promotion of CR uptake, little is known about its determinants.

PURPOSE

The objective of this paper was to systematically review the available literature on factors predicting referral of patients to CR to appraise both their relative impact and consistency across studies.

METHODS

Studies were identified by searching MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials. Search terms were "myocardial infarction," "acute myocardial infarction," "coronary artery disease," combined with "rehabilitation," "cardiac rehabilitation," "secondary prevention," "exercise training," "referral," and/or "consultation." Forty-five studies were identified and independently assessed by 2 reviewers using predetermined eligibility criteria.

RESULTS

Ten published observational studies (1999-2004) including 30,333 coronary artery disease patients were selected. Determinants of referral to CR were grouped as sociodemographic, health status, and health care system factors. Major predictors were English speaking (RR 9.56, 95% CI 2.18-41.93), prior myocardial infarction (RR 2.73, 95% CI 1.69-4.42), being admitted to hospitals providing CR (RR 5.35, 95% CI 4.04-7.10), and having insurance coverage (RR 2.94, 95% CI 1.13-7.66).

CONCLUSION

This review highlights disparities in referral to CR and reveals a treatment gap in the secondary prevention of cardiovascular disease. Precise estimates of the impact of all factors on referral are not possible, but some hierarchies and potential priorities for action are evident.

Exercise might favor reverse cholesterol transport and lipoprotein clearance: potential mechanism for its anti-atherosclerotic effects

Livers of C57 BL/6 mice exercised for 2 weeks showed a dramatic increase in scavenger receptor B1 (SR-B1), CD36 and low density lipoprotein (LDL) receptor and a decrease in acetyl LDL receptor gene expression. These effects on lipoprotein receptors are reminiscent of the effects mediated by peroxisome proliferator-activated receptor (PPARgamma) ligands.