Physical activity and exercise performance predict long-term prognosis in middle-aged women surviving acute coronary syndrome

Sex and Medium-term Outcomes of ST-Segment Elevation Myocardial Infarction in Kerala, India: A Propensity Score–Matched Analysis

Background

Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results.

Methods

A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)–capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score–matched groups were compared.

Results

We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups.

Conclusions

Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives.

Peak Systolic Blood Pressure During the Exercise Test: Reference Values by Sex and Age and Association With Mortality

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Short-Term Cigarette Smoking in Rats Impairs Physical Capacity and Induces Cardiac Remodeling

Despite the strong evidence on the cardiac and renal damages after chronic exposure to cigarette smoke, there is a paucity of data on its short-term effects. The study evaluated the short-term effects of cigarette smoking on left ventricular (LV) remodeling, in vitro myocardial and renal function. Female Wistar rats were randomized to control (C) and cigarette smoking rats for eight weeks. Physical capacity was assessed using an adapted model of exhaustive swim; left ventricle (LV) morphology and function were also evaluated. Renal function was assessed by creatinine clearance and urine protein. The in vitro myocardial performance was analyzed in isolated papillary muscles. Rats exhibited reduced physical capacity after short-term cigarette smoking. Although there was no change on LV function, reduced chamber diameter was found in the smoking group associated with an increased LV wall thickness. There was augmented cardiac mass compared to C that was confirmed by increased cardiomyocyte nucleus volume, but in vitro myocardial performance and renal function were unchanged. A short-term cigarette smoking induces cardiac remodeling without abnormalities in function. The smoking group still preserved renal function and in vitro myocardial performance. However, the reduced physical capacity may suggest an impairment of the cardiac reserve.

Relationship between Physical Inactivity and Long-term Outcome in Patients Aged≥80 Years with Acute Coronary Syndrome

Physical inactivity is very common in octogenarians. However, association between physical inactivity and mortality in octogenarians with acute coronary syndrome (ACS) remains unclear. In this study, we aimed to investigate association between physical inactivity and allcause mortality in octogenarian patients with ACS. In this study, we included a total of 353 hospitalized patients, aged >80 years, with ACS during the period of 5-year follow-up. The association between physical inactivity and all-cause mortality was analyzed by multivariable Cox aggression. Of the enrolled patients, 132 (37.4%) were defined as physically inactive, and 221 (62.6%) as physically active. Patients with physical inactivity tended to have lower survival rate (21.2% vs. 56.5%, P<0.001) and higher mortality rate (78.8% vs. 43.5%, PcO.OOl), and had a worse long-term outcome than those with physical activity (chi-square=27.52, and log rank PcO.OOl). The physical inactivity was still an independent predictor for long-term allcause mortality independent of confounders including age, prior heart failure, stroke, ejection fraction, beta-blocker, clopidogrel and percutaneous coronary intervention (HR: 2.35, 95% CI: 1.26-4.37, P=0.007). Our study demonstrates that physical inactivity is independently related to increased all-cause mortality in octogenarians with ACS.

Dietary and exercise change following acute cardiac syndrome onset: A latent class growth modelling analysis

The present study aim determine sub-group trajectories of change on measures of diet and exercise following acute coronary syndrome. 150 participants were assessed in hospital, 1 month and 6 months subsequently on measures including physical activity, diet, illness beliefs, coping and mood. Change trajectories were measured using latent class growth modelling. Multinomial logistic regression was used to predict class membership. These analyses revealed changes in exercise were confined to a sub-group of participants already reporting relatively high exercise levels; those eating less healthily evidenced modest dietary improvements. Coping, gender, depression and perceived control predicted group membership to a modest degree.

Low exercise blood pressure and risk of cardiovascular events and all-cause mortality: systematic review and meta-analysis

OBJECTIVE

The independent prognostic significance of abnormally low systolic blood pressure (SBP) during exercise stress testing (LowExBP) across different clinical and exercise conditions is unknown. We sought by systematic review and meta-analysis to determine the association between cardiovascular/all-cause outcomes and LowExBP across different patient clinical presentations, exercise modes, exercise intensities and categories of LowExBP.

METHODS

Seven online databases were searched for longitudinal studies reporting the association of LowExBP with risk of fatal and non-fatal cardiovascular events and/or all-cause mortality. LowExBP was defined as either: SBP drop below baseline; failure to increase >10 mmHg from baseline or; lowest SBP quantile among reporting studies.

RESULTS

After review of 13,257 studies, 19 that adjusted for resting SBP were included in the meta-analysis, with a total of 45,895 participants (average follow-up, 4.4 ± 3.0 years). For the whole population, LowExBP was associated with increased risk for fatal and non-fatal cardiovascular events and all-cause mortality (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.59-2.53, p < 0.001). In continuous analyses, a 10 mmHg decrease in exercise SBP was associated with higher risk (n = 9 HR: 1.13, 95% CI: 1.06-1.20, p < 0.001). LowExBP was associated with increased risk regardless of clinical presentation (coronary artery disease, heart failure, hypertrophic cardiomyopathy or peripheral artery disease), exercise mode (treadmill or bike), exercise intensity (moderate or maximal), or LowExBP category (all p < 0.05). However, bias toward positive results was apparent (Eggers test p < 0.001 and p = 0.009).

CONCLUSION

Our data show that irrespective of clinical or exercise conditions, LowExBP independently predicts fatal and non-fatal cardiovascular events and all-cause mortality.

The association between self-reported exercise intensity and acute coronary syndrome in emergency department chest pain patients

BACKGROUND

Regular exercise is thought to be protective against coronary artery disease. As a result, some physicians believe that the likelihood of acute coronary syndrome (ACS) in patients with acute chest pain is reduced in those who exercise regularly. We studied the association between self-reported frequency of exercising and the likelihood of ACS in patients presenting to the Emergency Department (ED) with chest pain.

METHODS

A multi-center prospective, descriptive, cohort study design was used in ED patients to determine whether the risk of ACS was reduced in patients who self-reported regular exercise.

RESULTS

There were 1093 patients enrolled. Median (interquartile range) age was 57 (48-67) years; 506 (45.7%) were female. ACS was diagnosed in 248 (22.7%) patients. Patients who did not exercise at least monthly were more likely to be diagnosed with ACS than those who did (129/466 [27.7%] vs. 119/627 [19.0%]; odds ratio 1.63, 95% CI 1.23-2.17). After adjusting for age, gender, body mass index, smoking, and prior history, limited exercise was still associated with ACS (adjusted odds ratio 1.52, 95% CI 1.10-2.10). There was no apparent association between frequency and intensity of exercise and risk of ACS.

CONCLUSION

Although self-reported frequency of exercise was significantly associated with a decrease in ACS in ED patients with chest pain, it should not be used to exclude ACS in symptomatic ED patients.

Post-myocardial infarction depression: increased hospital admissions and reduced adoption of secondary prevention measures--a longitudinal study

OBJECTIVE

Depression is prevalent in the aftermath of myocardial infarction (MI), and has been linked with mortality however few studies have investigated hospital admissions in MI survivors. Using a prospective cohort design, we examined the long-term relationship between depressive symptoms, post-MI hospital admissions and secondary prevention measures, in order to assess the burden of post-MI depression on patients and the healthcare system.

METHODS

A cohort of 632 patients aged ≤65 years, admitted for first-ever MI to 1 of the 8 hospitals in central Israel, was followed up for 10-13 years. Depressive symptoms were assessed at initial hospitalization using the Beck Depression Inventory. Rehospitalization and adoption of secondary prevention measures were recorded throughout follow-up.

RESULTS

Depressive symptoms were significantly associated with days of hospitalization during follow-up (RR, 1.37, CI, 1.26-1.49), an association which remained significant after risk adjustment (RR, 1.14, CI, 1.04-1.26). The association appeared stronger for cardiac-related admissions than for other, non-cardiac admissions. Depressed patients were less likely to stop smoking (OR, 0.75, CI, 0.60-0.94), be physically active (OR, 0.80, CI, 0.69-0.94) and participate in cardiac rehabilitation (OR, 0.74, CI, 0.59-0.92).

CONCLUSION

Post-MI depressive symptoms were shown to be associated with increased hospital admissions, particularly cardiac admissions, and with reduced adoption of secondary prevention behaviors. These findings have implications for patients' prognosis and quality of life and for healthcare costs. Depressive symptoms, even at the sub-clinical level, should be monitored in post-MI patients in order to identify those at greater risk of rehospitalization.

Sense of coherence predicts post-myocardial infarction trajectory of leisure time physical activity: a prospective cohort study

Background

Physical activity confers a survival advantage after myocardial infarction (MI), yet the majority of post-MI patients are not regularly active. Since sense of coherence (SOC) has been associated with health outcomes and some health behaviours, we investigated whether it plays a role in post-MI physical activity.

We examined the predictive role of SOC in the long-term trajectory of leisure time physical activity (LTPA) after MI using a prospective cohort design.

Methods

A cohort of 643 patients aged ≤ 65 years admitted to hospital in central Israel with incident MI between February 1992 and February 1993 were followed up for 13 years. Socioeconomic, clinical and psychological factors, including SOC, were assessed at baseline, and LTPA was self-reported on 5 separate occasions during follow-up. The predictive role of SOC in long-term trajectory of LTPA was assessed using generalized estimating equations.

Results

SOC was consistently associated with engagement in LTPA throughout follow-up. Patients in the lowest SOC tertile had almost twice the odds (odds ratio,1.99; 95% confidence interval,1.52-2.60) of decreasing their engagement in LTPA as those in the highest tertile. A strong association remained after controlling for disease severity, depression, sociodemographic and clinical factors.

Conclusion

Our evidence suggests that SOC predicts LTPA trajectory post-MI. Assessment of SOC can help identify high-risk MI survivors, who may require additional help in following secondary prevention recommendations which can dramatically improve prognosis.

Physical fitness and 6.5-year mortality in an 85-year-old community-dwelling population

Although poor physical fitness is known to be associated with increased mortality in adult and elderly populations, this association is not conclusive in very elderly. The purpose of the present study was to evaluate the association for a very old community-dwelling population. The participants (90 males, 117 females) were 85-year-old individuals residing in Fukuoka, Japan. Baseline examinations including muscle strength of the handgrip and leg extension, one-leg standing, leg stepping rate, and walking were performed in 2003 and these subjects were followed for 6.5 years. During the follow-up period, 81 individuals (49 males and 32 females) died. Handgrip strength and leg extension strength at age 85 were stronger in surviving men than in non-survivors. Total mortality adjusted for both gender and serum level of total cholesterol fell 5-6% with a 1-kg increase in the handgrip strength of a single hand or both hands. Total mortality also decreased 2% with a 1 kg increase in the leg extension strength of both legs. With adjustment for gender and total cholesterol, mortality fell by 57% in participants of the walking test and fell by 45% in participants of the stepping-rate test compared to mortality in nonparticipants. No association was found between mortality and participation in the handgrip strength test, leg extension strength test, or one-leg standing time test. In conclusion, not only poor muscle strength in handgrip or leg extension, but also nonparticipation in walking test or leg-stepping test were independent predictors of total mortality in a very elderly population.

Long-term trajectory of leisure time physical activity and survival after first myocardial infarction: a population-based cohort study

The benefits of leisure time physical activity (LTPA) in cardiovascular prevention are well established. While cardiac rehabilitation programmes have been demonstrated as improving myocardial infarction (MI) prognosis, the strength of the association between LTPA and post-MI survival has yet to be quantified. We evaluated long-term survival after MI of inactive, irregularly active, and regularly active patients and examined trajectories of LTPA and their relationship to mortality risk. Consecutive patients aged ≤65 years (n = 1,521), discharged from 8 hospitals in central Israel after first MI in 1992-1993, were followed through 2005. Extensive clinical and sociodemographic data, including self-reported LTPA habits, were obtained at baseline and at 4 subsequent interviews. Pre-MI inactive patients (54%) had lower socioeconomic status, higher prevalence of risk factors and comorbidities and more severe MI. The point prevalence rate of regular LTPA at all follow-up interviews was approximately 40% and 18% were regularly active throughout the entire follow-up. Over a median follow-up of 13.2 years, 427 deaths occurred. After multivariable adjustment, no association was observed between pre-MI LTPA and death. However, with LTPA categories modelled as time-dependent variables, providing an estimation of cumulative assessment and accounting for changes in LTPA post-MI, a strong inverse graded association was revealed (multivariable-adjusted hazard ratios, 0.56 [95% CI: 0.42-0.74] for regular and 0.71 [95% CI: 0.54-0.95] for irregular activity vs. none). Similar estimates were obtained among pre-MI sedentary patients. In summary, after MI, regularly active patients had about half the risk of dying compared with inactive patients, irrespective of pre-MI habits.

Physical fitness cannot be used to predict the likelihood of acute coronary syndromes in ED patients with chest pain

OBJECTIVE

The objective of the study was to explore the association between physical fitness and the likelihood of acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) with chest pain (CP). We hypothesized that the likelihood of ACS would be lower in physically fit patients and higher in patients with exercise-induced CP.

METHODS

The study involved a prospective, descriptive cohort in an academic suburban ED. Subjects were ED patients with CP admitted for suspected ACS. Demographic and clinical data were collected by trained research assistants using standardized forms. Patients were surveyed on level of fitness and whether they had ever experienced anginal type symptoms during exercise. Acute coronary syndrome was considered present if the patient had electrocardiographic evidence of infarction or ischemia; elevated troponin I levels; greater than 70% stenosis of culprit coronary artery; or a positive nuclear, echocardiographic, or treadmill stress test result. Patients readmitted within 30 days for reinfarction, cardiogenic shock, or arrhythmias were also considered to have ACS. The association between physical fitness and ACS was determined using χ(2) tests and odds ratios (ORs).

RESULTS

One hundred patients were enrolled. Mean age was 55.8 (±15.3) years; 36% were female; 85% were white. Thirteen (13%) patients had positive troponins, 22 of 36 catheterized patients had greater than 70% coronary artery stenosis, and 6 (6%) had abnormal stress test results. There were no deaths or reinfarctions within 30 days. The rate of ACS was similar in patients who were physically fit and those who were not (24% vs 37%; OR, 0.5 [95% confidence interval, 0.2-1.3]) and in patients who had experienced exercise-induced CP and those who had not (32% vs 29%; OR, 1.2 [95% confidence interval, 0.4-3.2]). Neither the frequency nor the intensity of exercise was associated with ACS.

CONCLUSIONS

Physically fit patients with CP were as likely to have ACS as those not physically fit. A history of exercise-induced CP was not associated with an increased likelihood of ACS.

Physical activity and mortality in men and women with coronary heart disease: a prospective population-based cohort study in Norway (the HUNT study)

BACKGROUND

Patients with established coronary heart disease (CHD) are encouraged to be physically active to prevent disease progression and to prolong life. The amount and intensity of exercise required for risk reduction in patients with CHD is not yet fully resolved.

DESIGN

Population-based prospective cohort study with 18 years of follow-up.

METHODS

A linkage between a Norwegian population-based study (Nord-Trøndelag health study) and the Cause of Death Registry at Statistics Norway. Exercise amount and intensity were measured at baseline (1984-1986) in 2137 men and 1367 women with CHD.

RESULTS

During 18 years of follow-up, 1741 (81.6%) men and 1100 (80.5%) women died. Compared with the reference category (no activity), one weekly exercise session was associated with a lower all-cause mortality, both in men (relative risk 0.80, 95% confidence interval 0.68-0.94) and women (relative risk 0.68, 95% confidence interval 0.55-0.83). This inverse association became stronger with increasing frequency (P< or =0.001 for men and women). Those who reported moderate or high-intensity exercise had a somewhat lower risk of death than those who exercised with low intensity.

CONCLUSION

Exercise training reduced all-cause and cardiovascular mortality in men and women with CHD. This study adds significantly to the sparse literature regarding prospective data on physical activity, exercise intensity and mortality in CHD patients.

Effects of intermittent hypoxia training on exercise performance, hemodynamics, and ventilation in healthy senior men

The efficacy and safety of intermittent hypoxia training (IHT) were investigated in healthy, 60- to 74-yr-old men. Fourteen men (Gr 1) who routinely exercised daily for 20 to 30 min were compared with 21 (Gr 2) who avoided exercise. Their submaximal work-load power values before the IHT training were 94 +/- 3.7 and 66 +/- 3.1, respectively. Before and after 10 days of IHT, the ventilatory response to sustained hypoxia (SH; 12% O(2) for 10 min), work capacity (bicycle ergometer), and forearm cutaneous perfusion (laser Doppler) were determined. During SH, no negative electrocardiogram (ECG) changes were observed in either group, and the ventilatory response to SH was unaltered by IHT. In Gr 1, IHT (normobaric rebreathing for 5 min, final Sa(O(2)) = 85% to 86%, followed by 5 min normoxia, 4/day) produced no changes in hemodynamic indixes and work capacity. In Gr 2, IHT decreased blood pressure (BP) by 7.9 +/- 3.1 mmHg (p < 0.05) and increased submaximal work by 11.3% (p < 0.05) and anaerobic threshold by 12.7% (p < 0.05). The increase in HR and BP caused by a 55 W-work load was reduced by 5% and 6.5%, respectively (p < 0.05). Cutaneous perfusion increased by 0.06 +/- 0.04 mL/min/100 g in Gr 1 and by 0.11 +/- 0.04 mL/min/100 g in Gr 2 (p < 0.05). Hyperemia recovery time increased significantly by 15.3 +/- 4.6 sec in Gr 1 and by 25.2 +/- 11.2 sec in Gr 2. Thus, healthy senior men well tolerate IHT as performed in this investigation. In untrained, healthy senior men, IHT had greater positive effects on hemodynamics, microvascular endothelial function, and work capacity.