Molecular effects of exercise training in patients with cardiovascular disease: focus on skeletal muscle, endothelium, and myocardium

Relevance of Cardiovascular Exercise in Cancer and Cancer Therapy-Related Cardiac Dysfunction

PURPOSE OF THE REVIEW

Cancer therapy-related cardiac dysfunction (CTRCD) has been identified as a threat to overall and cancer-related survival. Although aerobic exercise training (AET) has been shown to improve cardiorespiratory fitness (CRF), the relationship between specific exercise regimens and cancer survival, heart failure development, and reduction of CTRCD is unclear. In this review, we discuss the impact of AET on molecular pathways and the current literature of sports in the field of cardio-oncology.

RECENT FINDINGS

Cardio-oncological exercise trials have focused on variations of AET intensity by using moderate continuous and high intensity interval training, which are applicable, safe, and effective approaches to improve CRF. AET increases CRF, reduces cardiovascular morbidity and heart failure hospitalization and should thus be implemented as an adjunct to standard cancer therapy, although its long-term effect on CTRCD remains unknown. Despite modulating diverse molecular pathways, it remains unknown which exercise regimen, including variations of AET duration and frequency, is most suited to facilitate peripheral and central adaptations to exercise and improve survival in cancer patients.

Step count and multiple health outcomes: An umbrella review

OBJECTIVE

This study aimed to quantify the association between step count and multiple health outcomes in a healthy population.

METHODS

PubMed, Embase, Web of Science, and The Cochrane Library were systematically searched for systematic reviews and meta-analyses from inception to April 1, 2022. Literature screening, data extraction, and data analysis were performed in this umbrella review. The intervention factor was daily step counts measured based on devices. Multiple health outcomes included metabolic diseases, cardiovascular diseases, all-cause mortality, and other outcomes in the healthy population.

RESULTS

Twenty studies with 94 outcomes were identified in this umbrella review. The increase in daily step count contributed to a range of human health outcomes. Furthermore, the special population, different age groups, countries, and cohorts should be carefully considered. Negative correlation between step counts and the following outcomes: metabolic outcomes, cardiovascular diseases, all-cause mortality, postural balance, cognitive function, and mental health. However, there was no association between participation in the outdoor walking group and the improvement of systolic blood pressure and diastolic blood pressure. Analysis of the dose-response association between increasing daily step count and the risk of cardiovascular disease events and all-cause mortality showed a substantially linear relationship.

CONCLUSION

A wide range of health outcomes can benefit from the right number of steps.

Is It Possible to Train the Endothelium?-A Narrative Literature Review

This review provides an overview of current knowledge regarding the adaptive effects of physical training on the endothelium. The endothelium plays a crucial role in maintaining the health of vessel walls and regulating vascular tone, structure, and homeostasis. Regular exercise, known for its promotion of cardiovascular health, can enhance endothelial function through various mechanisms. The specific health benefits derived from exercise are contingent upon the type and intensity of physical training. The review examines current clinical evidence supporting exercise's protective effects on the vascular endothelium and identifies potential therapeutic targets for endothelial dysfunction. There is an urgent need to develop preventive strategies and gain a deeper understanding of the distinct impacts of exercise on the endothelium.

Inhibition of SPARC signal by aerobic exercise to ameliorate atherosclerosis

BACKGROUND AND AIMS

Inflammation and atherosclerosis (AS) are closely associated to Secreted Protein Acidic and Rich in Cysteine (SPARC) and its related factors. This study attempted to define the role and the potential mechanism of SPARC and its related factors in ameliorating hyperlipidemia and AS by aerobic exercise intervention.

METHODS

The AS rat model was established with a high-fat diet plus vitamin D3 intraperitoneal injection. Treadmill exercises training (5 days/week at 14 m/min for 60 min/day) for 6 weeks was carried out for AS rat intervention method. Western blotting and qRT-PCR were used to analyze the mRNA and protein expression of SPARC and its related factors, respectively. H&E staining was applied to evaluate the morphological changes and inflammation damage. Von Kossa staining was used to measure the degree of vascular calcification. Fluorescence immunohistochemistry staining was used to detect the expression and distribution of SPARC signal molecules.

RESULTS

SPARC was highly expressed and co-localization with the smooth muscle marker α-SMC in the AS rat. And its downstream factors, NF-κB, Caspase-1, IL-1β and IL-18 were upregulated (P < 0.05 or P < 0.01), FNDC5 expression was downregulated in AS rat model. However, slight declined body weight, delayed AS progression, decreased hyperlipidemia and favorable morphology of skeletal muscle and blood vessels have been detected in AS rat with aerobic exercise intervention. Moreover, the expression of SPARC and its downstream factors were decreased (P < 0.05 or P < 0.01), while elevated the expression of FNDC5 (P < 0.01) was observed after aerobic exercise intervention.

CONCLUSIONS

This study suggested that aerobic exercise ameliorated hyperlipidemia and AS by effectively inhibiting SPARC signal, and vascular smooth muscle cells may contribute greatly to the protection of AS.

Physical Activity and Cause-Specific Cardiovascular Mortality Among People With and Without Cardiovascular Disease: A Cohort Study of 0.6 Million US Adults

OBJECTIVE

To assess the association of physical activity (PA) with cause-specific cardiovascular disease (CVD) mortality among people with preexisting CVD and to analyze the relationship of PA with CVD-related mortality in people without CVD as well as the association of PA with nonspecific CVD mortality in both populations.

PARTICIPANTS AND METHODS

Of the total participants in the 1997 through 2018 US National Health Interview Survey waves, 87,959 adults with CVD and 527,185 without CVD were included. Leisure-time PA was self-reported; based on frequency and duration, minutes per week in PA were calculated and subsequently classified into: (1) none: 0 min/wk, (2) insufficient: 1 to 149.9 min/wk, (3) recommended: 150 to 300 min/wk, and (4) additional: more than 300 min/wk. Mortality data were obtained through link to records from the National Death Index. Statistical analyses were performed with Cox regression adjusted for potential confounders.

RESULTS

During a mean follow-up of 8.5 years, 12,893 participants with CVD, 9943 with coronary heart disease (CHD), and 843 with stroke died of CVD mortality, diseases of heart mortality, and cerebrovascular mortality, respectively. In fully adjusted models, compared with no PA, insufficient, recommended, and additional PA were associated with 25.9%, 37.1%, and 42.0% lower risk of diseases of heart mortality among people with prior CHD, respectively. Among people with stroke, recommended and additional PA was related to 30.7% and 59.3% lower risk of cerebrovascular mortality, respectively. The protective effect of PA on cause-specific CVD mortality was greater in people with CVD than in those without prior CVD. Moreover, PA was more markedly inversely associated with cause-specific CVD mortality than with nonspecific CVD mortality in people with CVD.

CONCLUSION

Physical activity was strongly associated with lower risk of CVD-, CHD-, and stroke-related mortality among people with a history of these specific diseases. Health care professionals should emphasize the importance of a physically active lifestyle in patients with CVD.

Exercise, cancer, and the cardiovascular system: clinical effects and mechanistic insights

Cardiovascular diseases and cancer are the leading causes of death in the Western world and share common risk factors. Reduced cardiorespiratory fitness (CRF) is a major determinant of cardiovascular morbidity and cancer survival. In this review we discuss cancer- induced disturbances of parenchymal, cellular, and mitochondrial function, which limit CRF and may be antagonized and attenuated through exercise training. We show the impact of CRF on cancer survival and its attenuating effects on cardiotoxicity of cancer-related treatment. Tailored exercise programs are not yet available for each tumor entity as several trials were performed in heterogeneous populations without adequate cardiopulmonary exercise testing (CPET) prior to exercise prescription and with a wide variation of exercise modalities. There is emerging evidence that exercise may be a crucial pillar in cancer treatment and a tool to mitigate cardiotoxic treatment effects. We discuss modalities of aerobic exercise and resistance training and their potential to improve CRF in cancer patients and provide an example of a periodization model for exercise training in cancer.

Assessing the effect of regular swimming exercise on the micro- and macrovascular physiology of older adults (ACELA II study)

Introduction: Cardiovascular disease (CVD) remains the main cause of death in the Western world. Our recent findings demonstrate potential CVD risk reduction in older adults who undertake regular swimming exercise. Nevertheless, it remains unknown whether an exercise intervention based on swimming is feasible and effective prior to a wider implementation of a CVD risk prevention strategy. Methods: This was a pragmatic, two-group, randomised controlled trial. A total of 40 older adults were randomly split into two groups (n = 20 per group). The swimming exercise group consisted of participants who engaged in swimming exercise (2-3 days/week, for 8 weeks). The control group did not perform any exercise. Flow-mediated dilation (%FMD) was the primary outcome. Secondary outcomes included raw cutaneous vascular conductance. Feasibility outcomes (e.g., recruitment, adherence, and attrition rates) were also assessed. Results: Statistically significant macrovascular (%FMD; swimming group: 9.8% ± 4.2%, p <0.001; control group: 4.6% ± 2.5%) and microvascular function (raw cutaneous vascular conductance; swimming group: 4.1 ± 0.9, p <0.01; control group: 3.2 ± 1.1) improvements were observed in the swimming group compared to the control group. Compliance to twice and thrice weekly in an 8-week swimming exercise was 92.6% and 88.4%, respectively, with no dropouts. Conclusion: Our 8-week, community-based, pragmatic swimming exercise intervention is a feasible and effective exercise programme that could be implemented in older adults for the prevention of age-related CVD. These findings suggest that swimming exercise could significantly reduce CVD risk in older adults, and a large research clinical trial is warranted to establish these findings.

Endothelial dysfunction as a factor leading to arterial hypertension

Hypertension remains the main cause of cardiovascular complications leading to increased mortality. The discoveries of recent years underline the important role of endothelial dysfunction (ED) in initiating the development of arterial hypertension. The endothelium lines the interior of the entire vascular system in the body and acts as a physical barrier between blood and tissues. Substances and mediators produced by the endothelium exhibit antithrombotic and anti-inflammatory properties. Oxidative stress and inflammation are conditions that damage the endothelium and shift endothelial function from vasoprotective to vasoconstrictive, prothrombotic, and pro-apoptotic functions. A dysfunctional endothelium contributes to the development of hypertension and further cardiovascular complications. Reduced nitric oxide (NO) bioavailability plays an essential role in the pathophysiology of ED-associated hypertension. New technologies provide tools to identify pathological changes in the structure and function of the endothelium. Endothelial dysfunction (ED) contributes to the development of arterial hypertension and should be considered in therapeutic strategies for children with hypertension.

Exercise during Hemodialysis in Patients with Chronic Kidney Failure

BACKGROUND: Patients with kidney failure undergoing hemodialysis experience physical deconditioning and multimorbidity. Exercise interventions may mitigate this outcome, but their clinical role is unclear. METHODS: This multicenter, cluster randomized controlled trial evaluated combined endurance and resistance exercise training during hemodialysis versus usual care in chronic kidney failure. It assessed physical functioning, quality of life, hospitalizations, and overall survival. The primary outcome was the change in the 60-second sit-to-stand test (STS60) between baseline and 12 months. RESULTS: A total of 1211 patients underwent randomization, 917 (65.9±14.4 years; 38.9% female) of whom were included in the full analysis (exercise intervention, n=446; usual care, n=471). At 12 months, the STS60 repetitions improved from 16.2±7.6 to 19.2±9.1 in the exercise group but declined from 16.2±7.1 to 14.7±7.9 in the usual care group (group difference, 3.85 repetitions; 95% confidence interval [CI], 2.22 to 5.48; P<0.0001). The timed up-and-go test (−1.1 seconds; 95% CI, −1.9 to −0.3) and the 6-minute walk test (37.5 m; 95% CI, 14.7 to 60.4) also differed in the exercise group versus usual care group. The physical summary score and vitality subscale of the quality of life questionnaire (i.e., the 36-item Short Form Health Survey) differed in the exercise group versus usual care group, but the other subscales did not change. Adverse events during dialysis sessions were similar in both groups. Median days spent in the hospital annually were 2 in the exercise group and 5 in the usual care group. Mortality and dialysis-specific adverse events were not affected. CONCLUSIONS: Twelve months of intradialytic exercise in patients with kidney failure significantly improved the STS60 compared with usual care. (Funded by the Innovation Fund, Federal Joint Committee; ClinicalTrials.gov number, NCT03885102.)

Impact of Geroscience on Therapeutic Strategies for Older Adults With Cardiovascular Disease: JACC Scientific Statement

Geroscience posits that cardiovascular disease (CVD) and other chronic diseases result from progressive erosion of the effectiveness of homeostatic mechanisms that oppose age-related accumulation of molecular damage. This hypothetical common root to chronic diseases explains why patients with CVD are often affected by multimorbidity and frailty and why older age negatively affects CVD prognosis and treatment response. Gerotherapeutics enhance resilience mechanisms that counter age-related molecular damage to prevent chronic diseases, frailty, and disability, thereby extending healthspan. Here, we describe the main resilience mechanisms of mammalian aging, with a focus on how they can affect CVD pathophysiology. We next present novel gerotherapeutic approaches, some of which are already used in management of CVD, and explore their potential to transform care and management of CVD. The geroscience paradigm is gaining traction broadly in medical specialties, with potential to mitigate premature aging, reduce health care disparities, and improve population healthspan.

m6A methyltransferase WTAP regulates myocardial ischemia reperfusion injury through YTHDF1/FOXO3a signaling

N6-methyladenosine (m6A) is emerging as an essential regulator in the progression of myocardial ischemia reperfusion (I/R) injury. However, the in-depth functions and mechanisms for m6A are still unclear. This work aimed to explore the potential functions and mechanisms for myocardial I/R injury. In this study, m6A methyltransferase WTAP and m6A modification level elevated in the hypoxia/reoxygenation (H/R) induced rat cardiomyocytes (H9C2) and I/R injury rat model. Bio-functional cellular experiments demonstrated that knockdown of WTAP remarkably released the proliferation and reduced the apoptosis and inflammatory cytokines induced by H/R. Moreover, exercise training alleviated WTAP level in exercise-trained rats. Mechanistically, methylated RNA immunoprecipitation sequencing (MeRIP-Seq) revealed that a remarkable m6A modification site was found in the 3'-UTR of FOXO3a mRNA. Moreover, WTAP triggered the installation of m6A modification on FOXO3a mRNA through m6A reader YTHDF1, thereby enhancing the stability of FOXO3a mRNA. Collectively, WTAP/YTHDF1/m6A/FOXO3a axis regulates the myocardial I/R injury progression, which provides new insights for the treatment of myocardial injury.

Effects of shear stress on vascular endothelial functions in atherosclerosis and potential therapeutic approaches

Different blood flow patterns in the arteries can alter the adaptive phenotype of vascular endothelial cells (ECs), thereby affecting the functions of ECs and are directly associated with the occurrence of lesions in the early stages of atherosclerosis (AS). Atherosclerotic plaques are commonly found at curved or bifurcated arteries, where the blood flow pattern is dominated by oscillating shear stress (OSS). OSS can induce ECs to transform into pro-inflammatory phenotypes, increase cellular inflammation, oxidative stress response, mitochondrial dysfunction, metabolic abnormalities and endothelial permeability, thereby promoting the progression of AS. On the other hand, the straight artery has a stable laminar shear stress (LSS), which promotes the transformation of ECs into an anti-inflammatory phenotype, improves endothelial cell function, thereby inhibits atherosclerotic progression. ECs have the ability to actively sense, integrate, and convert mechanical stimuli by shear stress into biochemical signals that further induces intracellular changes (such as the opening and closing of ion channels, activation and transcription of signaling pathways). Here we not only outline the relationship between functions of vascular ECs and different forms of fluid shear stress in AS, but also aim to provide new solutions for potential atherosclerotic therapies targeting intracellular mechanical transductions.

Sex differences in estimates of cardiac autonomic function using heart rate variability: effects of dietary capsaicin

PURPOSE

Heart rate variability (HRV) estimates the autonomic nervous system (ANS) influence on the heart and appears sex-specific. Sensory afferents exhibit sex-specificity; although, it is unknown if Capsaicin, an agonist for transient receptor potential vanilloid channel-1 (TRPV₁), alters cardiac ANS activity in a sex-dependent manner, which could be important given the predictive nature of HRV on risk of developing hypertension. Thus, we explored if there was sex-specificity in the effect of capsaicin on estimated cardiac ANS activity.

METHODS

HRV was measured in 38 young males (M: n = 25) and females (F: n = 13), in a blinded-crossover design, after acute ingestion of placebo or capsaicin. Resting HR, RR-interval, root-mean-square of successive differences (RMSSD), natural log-transformed RMSSD (LnRMSSD), standard deviation of n-n intervals (SDNN), number of pairs of successive n-n intervals differing by > 50 ms (NN50), and percent NN50 (PNN50) were obtained using standard techniques.

RESULTS

Significant sex differences were observed in mean HR (M: 59 ± 9.3 vs. F: 65 ± 12 beats/min, p = 0.036, η² = 0.098), minimum HR (M: 47 ± 8.3 vs. F: 56 ± 12 beats/min, p = 0.014, η² = 0.124), and NN50 (M: 177 ± 143 vs. F: 29 ± 17, p < 0.001, η² = 0.249). There was a significant interaction of sex*treatment (p = 0.02, η² = 0.027) for RMSSD, where males increased (78 ± 55 vs. 91 ± 64 ms), and females decreased (105 ± 83 vs. 76 ± 43 ms), placebo vs. capsaicin.

CONCLUSION

This controlled study recapitulates sex differences in HR and HRV, but revealed a sexual dimorphism in the parasympathetic response to capsaicin, perhaps due to differing TRPV₁-afferent sensitivity, highlighting a potential mechanism for differential regulation of hemodynamics, and CVD risk, and should be considered in future studies.

The effect of exercise training and physiotherapy on left and right heart function in heart failure with preserved ejection fraction: a systematic literature review

The impact of exercise training and physiotherapy on heart function and pulmonary circulation parameters in heart failure with preserved ejection fraction (HFpEF) patients is uncertain. Hence, we performed a systematic review of published trials studying physical training in HFpEF population, with a focus on exercise and physiotherapy effect on left ventricular (LV), right ventricular (RV) morphological, functional, and pulmonary circulation parameters. We searched Cochrane Library and MEDLINE/PubMed for trials that evaluated the effect of exercise training and/or physiotherapy in adult HFpEF patients (defined as LVEF ≥ 45%), including publications until March 2021. Our systematic review identified eighteen articles (n = 418 trained subjects, 4 to 52 weeks of training) and covered heterogeneous trials with various populations, designs, methodologies, and interventions. Five of twelve trials revealed a significant reduction of mitral E/e' ratio after the training (- 1.2 to - 4.9). Seven studies examined left atrial volume index; three of them showed its decrease (- 3.7 to - 8 ml/m²). Findings were inconsistent regarding improvement of cardiac output, E/A ratio, and E wave DecT and uncertain for RV function and pulmonary hypertension parameters. For now, no reliable evidence about rehabilitation effect on HFpEF cardiac mechanisms is available. There are some hypotheses generating findings on potential positive effects to parameters of LV filling pressure (E/e'), left atrium size, cardiac output, and RV function. This encourages a broader and more complex assessment of parameters reflecting cardiac function in future HFpEF exercise training studies.

Endothelial Reprogramming in Sports Traumatology: Role of the Widespread Neuro-Immuno-Endocrine-Endothelial System

This paper deals with the role of the widespread neuro-immuno-endocrine-endothelial system in sport traumatology. The aim of this work is to see if sport or regular physical activity is able to reprogram the endothelium, to advance the new concept of neuro-immuno-endocrine-endothelial diffused system, and to introduce in the practice of sport medicine a new test in the fields of “Athlete functional evaluation” and “Sports fitness”. The first object of this paper is to see whether sport or regular physical activity can change the functional structure of the endothelium. The second goal is to frame under a general view the knowledge and individual lines of research on endothelium, to highlight what we believe is, in the organization of homeostasis, the location of this ‘organ’, namely in the neuro-immune-endocrine system spread.

Non-Invasive Pulsatile Shear Stress Modifies Endothelial Activation; A Narrative Review

The monolayer of cells that line both the heart and the entire vasculature is the endothelial cell (EC). These cells respond to external and internal signals, producing a wide array of primary or secondary messengers involved in coagulation, vascular tone, inflammation, and cell-to-cell signaling. Endothelial cell activation is the process by which EC changes from a quiescent cell phenotype, which maintains cellular integrity, antithrombotic, and anti-inflammatory properties, to a phenotype that is prothrombotic, pro-inflammatory, and permeable, in addition to repair and leukocyte trafficking at the site of injury or infection. Pathological activation of EC leads to increased vascular permeability, thrombosis, and an uncontrolled inflammatory response that leads to endothelial dysfunction. This pathological activation can be observed during ischemia reperfusion injury (IRI) and sepsis. Shear stress (SS) and pulsatile shear stress (PSS) are produced by mechanical frictional forces of blood flow and contraction of the heart, respectively, and are well-known mechanical signals that affect EC function, morphology, and gene expression. PSS promotes EC homeostasis and cardiovascular health. The archetype of inducing PSS is exercise (i.e., jogging, which introduces pulsations to the body as a function of the foot striking the pavement), or mechanical devices which induce external pulsations to the body (Enhanced External Pulsation (EECP), Whole-body vibration (WBV), and Whole-body periodic acceleration (WBPA aka pGz)). The purpose of this narrative review is to focus on the aforementioned noninvasive methods to increase PSS, review how each of these modify specific diseases that have been shown to induce endothelial activation and microcirculatory dysfunction (Ischemia reperfusion injury-myocardial infarction and cardiac arrest and resuscitation), sepsis, and lipopolysaccharide-induced sepsis syndrome (LPS)), and review current evidence and insight into how each may modify endothelial activation and how these may be beneficial in the acute and chronic setting of endothelial activation and microvascular dysfunction.

The Challenge of Long COVID-19 Management: From Disease Molecular Hallmarks to the Proposal of Exercise as Therapy

Long coronavirus disease 19 (COVID-19) is the designation given to a novel syndrome that develops within a few months after infection by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and that is presenting with increasing incidence because of the numerous cases of infection. Long COVID-19 is characterized by a sequela of clinical symptoms that concern different organs and tissues, from nervous, respiratory, gastrointestinal, and renal systems to skeletal muscle and cardiovascular apparatus. The main common molecular cause for all long COVID-19 facets appears to be related to immune dysregulations, the persistence of inflammatory status, epigenetic modifications, and alterations of neurotrophin release. The prevention and management of long COVID-19 are still inappropriate because many aspects need further clarification. Exercise is known to exert a deep action on molecular dysfunctions elicited by long COVID-19 depending on training intensity, duration, and continuity. Evidence suggests that it could improve the quality of life of long COVID-19 patients. This review explores the main clinical features and the known molecular mechanisms underlying long COVID-19 in the perspective of considering exercise as a co-medication in long COVID-19 management.

Resistance Training in Patients With Coronary Artery Disease, Heart Failure, and Valvular Heart Disease: A REVIEW WITH SPECIAL EMPHASIS ON OLD AGE, FRAILTY, AND PHYSICAL LIMITATIONS

PURPOSE

Current guidelines recommend individually adapted resistance training (RT) as a part of the exercise regime in patients with cardiovascular diseases. The aim of this review was to provide insights into current knowledge and understanding of how useful, feasible, safe, and effective RT is in patients with coronary artery disease (CAD), heart failure (HF), and valvular heart disease (VHD), with particular emphasis on the role of RT in elderly and/or frail patients.

REVIEW METHODS

A review based on an intensive literature search: systematic reviews and meta-analyses published in 2010 or later; recent studies not integrated into meta-analyses or systematic reviews; additional manual searches.

SUMMARY

The results highlight the evaluation of effects and safety of RT in patients with CAD and HF with reduced ejection fraction (HFrEF) in numerous meta-analyses. In contrast, few studies have focused on RT in patients with HF with preserved ejection fraction (HFpEF) or VHD. Furthermore, few studies have addressed the feasibility and impact of RT in elderly cardiac patients, and data on the efficacy and safety of RT in frail elderly patients are limited. The review results underscore the high prevalence of age-related sarcopenia, disease-related skeletal muscle deconditioning, physical limitations, and frailty in older patients with cardiovascular diseases (CVD). They underline the need for individually tailored exercise concepts, including RT, aimed at improving functional status, mobility, physical performance and muscle strength in older patients. Furthermore, the importance of the use of assessment tools to diagnose frailty, mobility/functional capacity, and physical performance in the elderly admitted to cardiac rehabilitation is emphasized.

Exercise Training Effects on Circulating Endothelial and Progenitor Cells in Heart Failure

Heart failure (HF) is a major public health issue worldwide with increased prevalence and a high number of hospitalizations. Patients with chronic HF and either reduced ejection fraction (HFrEF) or mildly reduced ejection fraction (HFmrEF) present vascular endothelial dysfunction and significantly decreased circulating levels of endothelial progenitor cells (EPCs). EPCs are bone marrow-derived cells involved in endothelium regeneration, homeostasis, and neovascularization. One of the unsolved issues in the field of EPCs is the lack of an established method of identification. The most widely approved method is the use of monoclonal antibodies and fluorescence-activated cell sorting (FACS) analysis via flow cytometry. The most frequently used markers are CD34, VEGFR-2, CD45, CD31, CD144, and CD146. Exercise training has demonstrated beneficial effects on EPCs by increasing their number in peripheral circulation and improving their functional capacities in patients with HFrEF or HFmrEF. There are two potential mechanisms of EPCs mobilization: shear stress and the hypoxic/ischemic stimulus. The combination of both leads to the release of EPCs in circulation promoting their repairment properties on the vascular endothelium barrier. EPCs are important therapeutic targets and one of the most promising fields in heart failure and, therefore, individualized exercise training programs should be developed in rehabilitation centers.

Sustainability of physical work capacity two years post outpatient cardiac rehabilitation

OBJECTIVE

To determine if supervised training, after the completion of cardiac rehabilitation program, performed for a further two years would help maintain beneficial effects achieved during prolonged outpatient cardiac rehabilitation.

DESIGN

Longitudinal parallel-grouped intervention study.

SUBJECTS

Patients with coronary artery disease (n  =  41, age 59.5 ± 9.3 years), who finished cardiac rehabilitation phase III in our outpatient cardiac rehabilitation facility.

INTERVENTION

Two years of supervised exercise training consisting of endurance (either high intensity interval training or pyramid training) and resistance training sessions once a week.

MAIN MEASUREMENT

Peak physical work capacity was assessed via an ergometry testing at the beginning and at the end of the study.

RESULTS

Comparisons between end-of-cardiac rehabilitation and two years post cardiac rehabilitation revealed maintenance of peak physical work capacity after two years (begin vs end: 170  ±  59 W vs 167  ±  60 W; -0.5  ±  12.8%; p = 0.521). This was independent of exercise training protocols (percent change begin vs end: pyramid: 1.5 ±  11.8%; interval: -1.6  ±  13.4%; p = 0.459).

CONCLUSION

Improvement of physical exercise capacity gained during outpatient cardiac rehabilitation can be maintained for up to two years by once-weekly supervised exercise training. Long-term, group-based exercise programs offered at the end of cardiac rehabilitation might be an effective tool to help patients maintain their physical work capacity.

Effects of aquatic high-intensity interval training and moderate-intensity continuous training on central hemodynamic parameters, endothelial function and aerobic fitness in inactive adults

Objective

The effects of land-based high-intensity interval training (HIIT) on the cardiovascular system have already been demonstrated. However, the water environment is different from that on land. Therefore, we investigated the effects of 6-week aquatic HIIT and moderate-intensity continuous training (MICT) on central hemodynamic parameters, endothelial function, and aerobic fitness in inactive adults.

Methods

Thirty-one inactive adults were randomly assigned to HIIT or MICT group. HIIT group performed twelve 30-s swimming exercise bouts with the intensity of 95% HR_max and 15-18/20 RPE with a 60-s rest period between each bout. MICT group performed a 30-min uninterrupted swimming exercise with the intensity of 70%-75% HR_max and 12-14/20 RPE. Training frequency for both groups was three times a week. The pulse wave analysis and flow-mediated dilation (FMD) were measured by non-invasive equipments.

Results

The aerobic fitness significantly increased after HIIT, but no change was seen after MICT. Augmentation pressure (AP) and augmentation index normalized at 75 bpm (AIx@HR75) significantly decreased after HIIT but not MICT, whereas MICT rather than HIIT improved subendocardial viability ratio (SEVR), central and peripheral blood pressure, and resting HR. Only HIIT significantly increased brachial endothelial function.

Conclusion

A six-week aquatic HIIT and MICT had no differences in hemodynamic parameters, endothelial function, and aerobic fitness, however 6 weeks of aquatic HIIT reduced arterial stiffness, increased endothelial function and aerobic fitness, while 6 weeks of aquatic MICT reduced arterial blood pressure and resting HR and increased the coronary blood flow reserve.

The Role of Exercise-Induced Molecular Processes and Vitamin D in Improving Cardiorespiratory Fitness and Cardiac Rehabilitation in Patients With Heart Failure

Heart failure (HF) still affects millions of people worldwide despite great advances in therapeutic approaches in the cardiovascular field. Remarkably, unlike pathological hypertrophy, exercise leads to beneficial cardiac hypertrophy characterized by normal or enhanced contractile function. Exercise-based cardiac rehabilitation improves cardiorespiratory fitness and, as a consequence, ameliorates the quality of life of patients with HF. Particularly, multiple studies demonstrated the improvement in left ventricular ejection fraction (LVEF) among patients with HF due to the various processes in the myocardium triggered by exercise. Exercise stimulates IGF-1/PI3K/Akt pathway activation involved in muscle growth in both the myocardium and skeletal muscle by regulating protein synthesis and catabolism. Also, physical activity stimulates the activation of the mitogen-activated protein kinase (MAPK) pathway which regulates cellular proliferation, differentiation and apoptosis. In addition, emerging data pointed out the anti-inflammatory effects of exercises as well. Therefore, it is of utmost importance for clinicians to accurately evaluate the patient’s condition by performing a cardiopulmonary exercise test and/or a 6-min walking test. Portable devices with the possibility to measure exercise capacity proved to be very useful in this setting as well. The aim of this review is to gather together the molecular processes triggered by the exercise and available therapies in HF settings that could ameliorate heart performance, with a special focus on strategies such as exercise-based cardiac rehabilitation.

Stress and Physical Inactivity: Two Explosive Ingredients for the Heart in COVID-19 Pandemic Times

BACKGROUND

Coronavirus disease 2019 (Covid-19) pandemic is a global health crisis that has culminated in thousands of deaths. In order to reduce the spread of the Sars-CoV-2 virus, governments of several countries have adopted social isolation as a strategy. However, social isolation has culminated in deleterious effects on the population's health, including increased physical inactivity, stress and, consequently, adverse changes in body composition, cardiorespiratory capacity, muscle strength, physical functionality, and vascular events, which are increasingly pointed out as the main determinants of cardiovascular health. Staying physically active during lockdown is a challenge, especially for the population with a higher risk of mortality from COVID-19, who are still encouraged to maintain social distance until there is a vaccine available. Strategies to avoid physical inactivity and reduce stress levels can promote cardiovascular protection and must be considered during COVID-19 time.

OBJECTIVE

The aim of this paper is to discuss the risks of physical inactivity and stress for the cardiovascular system during the COVID-19 pandemic and propose strategies to protect cardiovascular health.

CONCLUSION

A home-based training protocol could be an interesting and effective strategy for the population who need to remain physically active and safe at home.

Response of endothelial function and oxidative stress after supervised aerobic exercise training in formerly preeclamptic women

We sought to investigate effects of aerobic exercise in women with preeclampsia history. 42 women were enrolled. After 16 weeks, we found improvement in endothelial function index and oxidative stress biomarkers in the exercise group. Moreover, the change of endothelial function index was significantly associated with the change of total antioxidant capacity in the exercise group. Our findings showed aerobic exercise improved exercise capacity, endothelial function and oxidative stress in formerly preeclamptic women, and favorable modification of oxidative stress might be a vital pathway of endothelial function's melioration in those women, which deserves further exploration.

Plasma-Derived microRNAs Are Influenced by Acute and Chronic Exercise in Patients With Heart Failure With Reduced Ejection Fraction

Background: Exercise training improves VO₂peak in heart failure with reduced ejection fraction (HFrEF), but the effect is highly variable as it is dependent on peripheral adaptations. We evaluated changes in plasma-derived miRNAs by acute and chronic exercise to investigate whether these can mechanistically be involved in the variability of exercise-induced adaptations.

Methods: Twenty-five male HFrEF patients (left ventricular ejection fraction < 40%, New York Heart Association class ≥ II) participated in a 15-week combined strength and aerobic training program. The effect of training on plasma miRNA levels was compared to 21 male age-matched sedentary HFrEF controls. Additionally, the effect of a single acute exercise bout on plasma miRNA levels was assessed. Levels of 5 miRNAs involved in pathways relevant for exercise adaptation (miR-23a, miR-140, miR-146a, miR-191, and miR-210) were quantified using RT-qPCR and correlated with cardiopulmonary exercise test (CPET), echocardiographic, vascular function, and muscle strength variables.

Results: Expression levels of miR-146a decreased with training compared to controls. Acute exercise resulted in a decrease in miR-191 before, but not after training. Baseline miR-23a predicted change in VO₂peak independent of age and left ventricular ejection fraction (LVEF). Baseline miR-140 was independently correlated with change in load at the respiratory compensation point and change in body mass index, and baseline miR-146a with change in left ventricular mass index.

Conclusion: Plasma-derived miRNAs may reflect the underlying mechanisms of exercise-induced adaptation. In HFrEF patients, baseline miR-23a predicted VO₂peak response to training. Several miRNAs were influenced by acute or repeated exercise. These findings warrant exploration in larger patient populations and further mechanistic in vitro studies on their molecular involvement.

miR-181c level predicts response to exercise training in patients with heart failure and preserved ejection fraction: an analysis of the OptimEx-Clin trial

AIMS

In patients with heart failure with preserved ejection fraction (HFpEF), exercise training improves the quality of life and aerobic capacity (peakV·O2). Up to 55% of HF patients, however, show no increase in peakV·O2 despite adequate training. We hypothesized that circulating microRNAs (miRNAs) can distinguish exercise low responders (LR) from exercise high responders (HR) among HFpEF patients.

METHODS AND RESULTS

We selected HFpEF patients from the Optimizing Exercise Training in Prevention and Treatment of Diastolic HF (OptimEx) study which attended ≥70% of training sessions during 3 months (n = 51). Patients were defined as HR with a change in peakV·O2 above median (6.4%), and LR as below median (n = 30 and n = 21, respectively). Clinical, ergospirometric, and echocardiographic characteristics were similar between LR and HR. We performed an miRNA array (n = 377 miRNAs) in 14 age- and sex-matched patients. A total of 10 miRNAs were upregulated in LR, of which 4 correlated with peakV·O2. Validation in the remaining 37 patients indicated that high miR-181c predicted reduced peakV·O2 response (multiple linear regression, β = -2.60, P = 0.011), and LR status (multiple logistic regression, odds ratio = 0.48, P = 0.010), independent of age, sex, body mass index, and resting heart rate. Furthermore, miR-181c decreased in LR after exercise training (P-group = 0.030, P-time = 0.048, P-interaction = 0.037). An in silico pathway analysis identified several downstream targets involved in exercise adaptation.

CONCLUSIONS

Circulating miR-181c is a marker of the response to exercise training in HFpEF patients. High miR-181c levels can aid in identifying LR prior to training, providing the possibility for individualized management.

Global impact of physical inactivity and implications for public health nursing

Physicalinactivity has been a public health problem worldwide for more than a decade. Of those who are physically active, a substantial percentage engage solely in low or very low physical activity (PA) levels. In the last 3 decades, the prevalence of PA in the United States has decreased with approximately 80% of adults not meeting the recommended guidelines for aerobic and muscle strengthening PA. The PA levels of youth have dramatically decreased with 85% of adolescents reporting no PA. Regular PA participation can aid in preventing chronic diseases. A strong inverse dose-response relationship exists between PA and the incidence of cardiovascular disease, all-cause and cardiovascular mortality. Moreover, low cardiorespiratory fitness levels are a risk factor for cardiovascular diseases: the leading cause of death and disability globally. Conversely, high amounts of moderate-to-vigorous intensity PA at levels 3-5 times recommended in guidelines reduce risk for all cause mortality. Socio-ecological determinants of PA are essential considerations for promoting across the life course. In health care and community settings, public health nurses have opportunities to promote PA through a socio-ecological approach across the life course of individuals and diverse populations.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

The molecular signature of high-intensity interval training in the human body

High-intensity training is becoming increasingly popular outside of elite sport for health prevention and rehabilitation. This expanded application of high-intensity training in different populations requires a deeper understanding of its molecular signature in the human body. Therefore, in this integrative review, cellular and systemic molecular responses to high-intensity training are described for skeletal muscle, cardiovascular system, and the immune system as major effectors and targets of health and performance. Different kinds of stimuli and resulting homeostatic perturbations (i. e., metabolic, mechanical, neuronal, and hormonal) are reflected, taking into account their role in the local and systemic deflection of molecular sensors and mediators, and their role in tissue and organ adaptations. In skeletal muscle, a high metabolic perturbation induced by high-intensity training is the major stimulus for skeletal muscle adaptation. In the cardio-vascular system, high-intensity training induces haemodynamic stress and deflection of the Ca ²⁺ handling as major stimuli for functional and structural adaptation of the heart and vessels. For the immune system haemodynamic stress, hormones, exosomes, and O ₂ availability are proposed stimuli that mediate their effects by alteration of different signalling processes leading to local and systemic (anti)inflammatory responses. Overall, high-intensity training shows specific molecular signatures that demonstrate its high potential to improve health and physical performance.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Unveiling the role of exercise training in targeting the inflammatory paradigm of heart failure with preserved ejection fraction: a narrative review

Heart failure with preserved ejection fraction (HFpEF) is currently lacking an effective pharmacological treatment with impact on major outcomes such as hospitalization and mortality. Exercise training (EXT) is recognized as an important nonpharmacological tool, capable of improving exercise capacity and quality of life, and has even been associated with a reduction in hospitalization and cardiovascular mortality risk. However, this positive impact largely lacks a physiological explanation. The aim of this narrative review was to provide an overview of the available data supporting the hypothesis that the beneficial role of EXT in HFpEF might be due to its effects on targeting the inflammatory paradigm described for this disease. A comprehensive literature search was conducted using the PubMed-NCBI database. We reviewed the effects of EXT throughout each step of the pathophysiological pathway leading to HFpEF and found clinical and/or preclinical evidence supporting the reduction of systemic inflammation, endothelial dysfunction, microvascular rarefaction, and myocardial stiffness. We also highlighted some gaps in the knowledge or topics that deserve further clarification in future studies. In conclusion, despite the scarcity of clinical studies in this population, there is compelling evidence suggesting that EXT modulates crucial aspects of the inflammatory pathway described for HFpEF and future investigation on cellular and molecular mechanisms are encouraged.

Nuclear factor E2-related factor 2 (NRF2) deficiency accelerates fast fibre type transition in soleus muscle during space flight

Microgravity induces skeletal muscle atrophy, particularly in the soleus muscle, which is predominantly composed of slow-twitch myofibre (type I) and is sensitive to disuse. Muscle atrophy is commonly known to be associated with increased production of reactive oxygen species. However, the role of NRF2, a master regulator of antioxidative response, in skeletal muscle plasticity during microgravity-induced atrophy, is not known. To investigate the role of NRF2 in skeletal muscle within a microgravity environment, wild-type and Nrf2-knockout (KO) mice were housed in the International Space Station for 31 days. Gene expression and histological analyses demonstrated that, under microgravity conditions, the transition of type I (oxidative) muscle fibres to type IIa (glycolytic) was accelerated in Nrf2-KO mice without affecting skeletal muscle mass. Therefore, our results suggest that NRF2 affects myofibre type transition during space flight.

Exercise Improves Endothelial Function via the lncRNA MALAT1/miR-320a Axis in Obese Children and Adolescents

Background

Endothelial dysfunction commonly occurs in obese children and adolescents, leading to an increased risk of cardiovascular diseases. Exercise has significant protective effects against endothelial dysfunction through regulating some noncoding RNAs. This study aimed to investigate the relationship of long noncoding RNA MALAT1 and microRNA-320a (miR-320a) with the exercise-induced improvement of endothelial dysfunction in obese children and adolescents.

Methods

Sixty obese children and adolescents were included in this study, including 40 cases that received 12-week exercise training and 20 cases that received only diet control. The anthropometric and blood indices before and after exercise were recorded and compared, and the endothelial dysfunction was evaluated by examining the levels of markers, including VCAM-1, ICAM-1, and E-selectin, using an ELISA assay. The expression levels of noncoding RNAs were assessed using real-time quantitative PCR, and their correlation with patients' recorded indices and endothelial dysfunction markers was analyzed.

Results

The 12-week exercise training significantly decreased the levels of VCAM-1, ICAM-1, and E-selectin and could inhibit MALAT1 but promote miR-320a expression in obese children and adolescents. The expression of MALAT1 and miR-320a was correlated with the changes in the anthropometric and blood indices of obese children and adolescents, and their correlations with endothelial dysfunction markers were obtained.

Conclusion

All the data revealed that exercise has significantly protective effects against endothelial dysfunction and can regulate the expression of the MALAT1/miR-320a axis. MALAT1 and miR-320a were correlated with endothelial dysfunction markers, indicating that the MALAT1/miR-320a axis may be related with the alleviating effects of exercise on endothelial function in obese children and adolescents.

LncRNA MALAT1/miR-320a axis is associated with exercise-induced improvement of endothelial dysfunction in obese children

BACKGROUND

Endothelial dysfunction commonly occurs in obese children, leading to increased risk of cardiovascular diseases. Exercise has protective effects against endothelial dysfunction through regulating some noncoding RNAs. This study aimed to investigate the relationship of long noncoding RNA MALAT1 and microRNA-320a (miR-320a) with the exercise-induced improvement of endothelial dysfunction in obese children.

METHODS

Sixty obese children were included in this study, and 40 cases received a 12-week exercise training. The morphological and blood indices before and after exercise were recorded and compared, and the endothelial dysfunction was evaluated by examining the levels of VCAM-1, ICAM-1, E-selectin, IL-6 and TNF-α using ELISA kits. The expression of noncoding RNAs was assessed using Real-Time quantitative PCR. Endothelial cells were used to explore the effects of MALAT1 and miR-320a on endothelial function.

RESULTS

The 12-well exercise training decreased the levels of VCAM-1, ICAM-1 and E-selectin, and inhibited MALAT1 but promoted miR-320a expression in obese children. The expression of MALAT1 and miR-320a was correlated with the changes of morphological and blood indices in obese children, and their correlations with endothelial dysfunction markers were obtained. Additionally, MALAT1 overexpression or miR-320a reduction led to inhibited proliferation and increased inflammation in HUVECs.

CONCLUSION

All the data revealed that exercise has significantly protective effects against endothelial dysfunction, and can regulate the expression of the MALAT1/miR-320a axis. MALAT1 and miR-320a were correlated with endothelial dysfunction, indicating that the MALAT1/miR-320a axis may be related with the alleviating effects of exercise on endothelial function in obese children.

Clinical indicators and aetiological factors of sedentary lifestyle in patients with arterial hypertension

AIMS

The aim of this study is to verify the clinical validity of clinical indicators and aetiological factors of sedentary lifestyle in individuals with arterial hypertension.

BACKGROUND

Diagnostic validation is performed to expand nursing taxonomies and to revise or confirm the described concepts. New elements listed in the literature and those identified by the NANDA International definition for sedentary lifestyle need to be evaluated.

DESIGN

This is a cross-sectional and diagnostic validation study. The STROBE guidelines were used in this study.

METHODS

Two hundred and fifty subjects aged over 18 years were evaluated. The diagnostic status of the participants was obtained by latent class analysis. Logistic regression was used to identify aetiological factors with the manifestation of sedentary lifestyle, considering a significance level of 5%.

RESULTS

A total of 57.8% of the study participants met the diagnostic criteria for sedentary lifestyle. The clinical indicators with high sensitivity were as follows: "Average daily physical activity is less than recommended for gender and age"; "Does not perform physical activity during leisure time"; "Preference for activity low in physical activity" and "Overweight." The significantly related factors associated with the diagnosis of sedentary lifestyle were as follows: "Insufficient knowledge on physical activity," "Lack of time," "Negative self-perception of health," "Lack of security," "Lack of appropriate place," "Lack of motivation," "Activity intolerance," "Lack of sports ability," "Having a partner," "Using public transportation," "Perception of physical disability," "Pain," "Having a job/studying," "Laziness," "Impaired mobility," "Living in an urban area," "Education in a public institution," "Female gender," "Lack of confidence to practice physical exercise," "Education level," "Age" and "Lack of social support for the practice of physical exercise."

CONCLUSION

Four out of eight clinical indicators had a good adjustment by the latent class analysis. Of the 27 aetiological factors, 22 were significantly associated with sedentary lifestyle.

RELEVANCE TO PRACTICE

The correct identification of sedentary lifestyle and its elements supports care planning, especially for health promotion and disease prevention.

Exercise-induced changes in miRNA expression in coronary artery disease

OBJECTIVES

Micro ribonucleic acids (miRNAs) are small non-coding RNA molecules that control gene expression by translational inhibition. Exercise has been shown to affect several miRNAs' expression in healthy subjects, but this has not yet been studied in patients with coronary artery disease (CAD). Since exercise training confers beneficial long-term effects and may also trigger acute coronary events, it is of utmost interest to be able to identify those who are risk for untoward effects. Therefore, we set out to assess miRNA expression in response to maximal ergospirometry in patients with CAD.

METHODS

Total RNA was extracted from blood drawn immediately before and 5 min after maximal cycle-ergospirometry (10 male and 10 female CAD patients). A qRT-PCR was performed for 187 target miRNAs associated with endothelial function/dysfunction, cardiovascular disease, myocardial infarction, and sudden cardiac death.

RESULTS

In response to a maximal ergospirometry, 33 miRNAs significantly changed their expression levels. Of these miRNAs 16 were significantly differently expressed between gender. Using multi-variance analysis, nine miRNAs (let-7e-5p; miR-1; miR-19b-1-5p; miR-103a-3p; miR-148b-3p; miR-181b-5p; miR-188-5p; miR-423-5p; miR-874-3p) showed significantly different responses to maximal ergospirometry between genders.

CONCLUSIONS

We report for the first time that in patients with CAD, miRNA expression is amenable to maximal ergospirometry and that the extent of changes differs between genders. Affected by exercise and gender were miRNAs that are associated, among others, with pathways for glucose metabolism, oxidative stress, and angiogenesis. Future studies should assess whether disease-specific miRNA expression in response to maximal exercise might serve as a marker for patient outcome.

The Molecular Mechanisms of Cardiotoxicity Induced by HER2, VEGF, and Tyrosine Kinase Inhibitors: an Updated Review

AIM

In recent decades, there has been a revolutionary decrease in cancer-related mortality and an increase in survival due to the introduction of novel targeted drugs. Nevertheless, drugs targeting human epidermal growth factor receptor 2 (HER-2), angiogenesis, and other tyrosine kinases also come with unexpected cardiac side effects, including heart failure, hypertension, arterial thrombosis, and arrhythmias, and have mechanisms that are unlike those of classic chemotherapeutic agents. In addition, it is challenging to address some problems, as the existing guidelines need to be more specific, and further large-scale clinical trials and experimental studies are required to confirm the benefit of administering cardioprotective agents to patients treated with targeted therapies. Therefore, an improved understanding of cardiotoxicity becomes increasingly important to minimize the pernicious effects and maximize the beneficial effects of targeted agents.

METHODS

"Cardiotoxicity", "targeted drugs", "HER2", "trastuzumab", "angiogenesis inhibitor", "VEGF inhibitor" and "tyrosine kinase inhibitors" are used as keywords for article searches.

RESULTS

In this article, we report several targeted therapies that induce cardiotoxicity and update knowledge of the clinical evidence, molecular mechanisms, and management measures.

Endothelial Dysfunction, Inflammation and Coronary Artery Disease: Potential Biomarkers and Promising Therapeutical Approaches

Coronary artery disease (CAD) and its complications are the leading cause of death worldwide. Inflammatory activation and dysfunction of the endothelium are key events in the development and pathophysiology of atherosclerosis and are associated with an elevated risk of cardiovascular events. There is great interest to further understand the pathophysiologic mechanisms underlying endothelial dysfunction and atherosclerosis progression, and to identify novel biomarkers and therapeutic strategies to prevent endothelial dysfunction, atherosclerosis and to reduce the risk of developing CAD and its complications. The use of liquid biopsies and new molecular biology techniques have allowed the identification of a growing list of molecular and cellular markers of endothelial dysfunction, which have provided insight on the molecular basis of atherosclerosis and are potential biomarkers and therapeutic targets for the prevention and or treatment of atherosclerosis and CAD. This review describes recent information on normal vascular endothelium function, as well as traditional and novel potential biomarkers of endothelial dysfunction and inflammation, and pharmacological and non-pharmacological therapeutic strategies aimed to protect the endothelium or reverse endothelial damage, as a preventive treatment for CAD and related complications.

Systemic Inflammation, Vascular Function, and Endothelial Progenitor Cells after an Exercise Training Intervention in COPD

BACKGROUND

Exercise training is a cornerstone of the treatment of chronic obstructive pulmonary disease (COPD) in all disease stages. Data about the training effects with supplemental oxygen in nonhypoxemic patients remains inconclusive. In this study we set out to investigate the training and oxygen effects on inflammatory markers, vascular function, and endothelial progenitor cells in this population of increased cardiovascular risk.

METHODS

In this prospective, randomized, double-blind, crossover study, 29 patients with nonhypoxemic COPD performed combined endurance and strength training 3 times a week while breathing medical air or supplemental oxygen for the first 6-week period, and were then reallocated to the opposite gas for the following 6 weeks. Exercise capacity, inflammatory biomarkers, endothelial function (peripheral arterial tone analysis), and endothelial progenitor cells were assessed. Data were also analyzed for a subgroup with endothelial dysfunction (reactive hyperemia index <1.67).

RESULTS

Following 12 weeks of exercise training, patients demonstrated a significant improvement of peak work rate and an associated decrease of blood fibrinogen and leptin. Eosinophils were found significantly reduced after exercise training in patients with endothelial dysfunction. In this subgroup, peripheral arterial tone analysis revealed a significant improvement of reactive hyperemia index. Generally, late endothelial progenitor cells were found significantly reduced after the exercise training intervention. Supplemental oxygen during training positively influenced the effect on exercise capacity without impact on inflammation and endothelial function.

CONCLUSIONS

This is the first randomized controlled trial in patients with COPD to show beneficial effects of exercise training not only on exercise capacity, but also on systemic/eosinophilic inflammation and endothelial dysfunction.

The Endothelium as a Therapeutic Target in Diabetes: A Narrative Review and Perspective

Diabetes has reached worldwide epidemic proportions, and threatens to be a significant economic burden to both patients and healthcare systems, and an important driver of cardiovascular mortality and morbidity. Improvement in lifestyle interventions (which includes increase in physical activity via exercise) can reduce diabetes and cardiovascular disease mortality and morbidity. Encouraging a population to increase physical activity and exercise is not a simple feat particularly in individuals with co-morbidities (obesity, heart disease, stroke, peripheral vascular disease, and those with cognitive and physical limitations). Translation of the physiological benefits of exercise within that vulnerable population would be an important step for improving physical activity goals and a stopgap measure to exercise. In large part many of the beneficial effects of exercise are due to the introduction of pulsatile shear stress (PSS) to the vascular endothelium. PSS is a well-known stimulus for endothelial homeostasis, and induction of a myriad of pathways which include vasoreactivity, paracrine/endocrine function, fibrinolysis, inflammation, barrier function, and vessel growth and formation. The endothelial cell mediates the balance between vasoconstriction and relaxation via the major vasodilator endothelial derived nitric oxide (eNO). eNO is critical for vasorelaxation, increasing blood flow, and an important signaling molecule that downregulates the inflammatory cascade. A salient feature of diabetes, is endothelial dysfunction which is characterized by a reduction of the bioavailability of vasodilators, particularly nitric oxide (NO). Cellular derangements in diabetes are also related to dysregulation in Ca²⁺ handling with increased intracellular Ca²⁺overload, and oxidative stress. PSS increases eNO bioavailability, reduces inflammatory phenotype, decreases intracellular Ca²⁺ overload, and increases antioxidant capacity. This narrative review and perspective will outline four methods to non-invasively increase PSS; Exercise (the prototype for increasing PSS), Enhanced External Counterpulsation (EECP), Whole Body Vibration (WBV), Passive Simulated Jogging and its predicate device Whole Body Periodic Acceleration, and will discuss current knowledge on their use in diabetes.

Targeting the Endothelium to Achieve Cardioprotection

Despite considerable improvements in the treatment of myocardial infarction, it is still a highly prevalent disease worldwide. Novel therapeutic strategies to limit infarct size are required to protect myocardial function and thus, avoid heart failure progression. Cardioprotection is a research topic with significant achievements in the context of basic science. However, translation of the beneficial effects of protective approaches from bench to bedside has proven difficult. Therefore, there is still an unmet need to study new avenues leading to protecting the myocardium against infarction. In line with this, the endothelium is an essential component of the cardiovascular system with multiple therapeutic targets with cardioprotective potential. Endothelial cells are the most abundant non-myocyte cell type in the heart and are key players in cardiovascular physiology and pathophysiology. These cells can regulate vascular tone, angiogenesis, hemostasis, and inflammation. Accordingly, endothelial dysfunction plays a fundamental role in cardiovascular diseases, which may ultimately lead to myocardial infarction. The endothelium is of paramount importance to protect the myocardium from ischemia/reperfusion injury via conditioning strategies or cardioprotective drugs. This review will provide updated information on the most promising therapeutic agents and protective approaches targeting endothelial cells in the context of myocardial infarction.

Exercise and Circulating Microparticles in Healthy Subjects

This study aimed to explore the relationship between exercise and circulating microparticles (CMPs). PubMed, Web of Science, Embase, and the Cochrane Library databases were searched until August 13, 2020, using the terms "exercise" and "cell-derived microparticles." The Cochrane tool of risk of bias and the Methodological Index for Non-Randomized Studies were used to grade the studies. Twenty-six studies that met criteria were included in this review, including one before-after self-control study, 2 cohort studies, 4 randomized control trials, 5 case-control studies, and 14 descriptive studies. The studies were divided into a single bout and long-term exercise. The types of MPs contained endothelium-derived microparticles (EMPs), leukocyte-derived microparticles (LMPs), platelet-derived microparticles (PMPs), and erythrocyte-derived microparticles (ErMPs). This first systematic review found that the levels of CMPs continued to increase after a single bout of exercise in untrained subjects and were lower in trained subjects. PMPs expressed a transient increase after a single bout of exercise, and the proportion and duration of PMPs increment reduced in long-term exercise. Most studies showed a decline in LMPs in trained subjects after a single bout and long-term exercise, and variable changes were found in EMPs and ErMPs after exercise. A single bout of exercise drives the vessels exposed to high shear stress that promotes the formation of CMPs. However, the decline in CMPs in trained subjects may be attributed to the fact that they have a better ability to adapt to changes in hemodynamics and cellular function during exercise.

Effect of Exercise on Cardiovascular Function Following Spinal Cord Injury: A REVIEW

Spinal cord injury (SCI) is associated with a reduced level of physical activity, deterioration of patient body composition, metabolic profile, quality of life, and psychological functioning. As a result, risk of cardiovascular disease (CVD) increases and CVD-related death occurs at an earlier age than in individuals without SCI. Regular participation in exercise has been shown to exert beneficial effects also in patients with SCI. In this review, we analyze and discuss the effects of regular exercise training in SCI on cardiovascular function, autonomic function of the cardiovascular system, arterial stiffness, metabolism, inflammation, and gene expression.

Dojuksan ameliorates tubulointerstitial fibrosis through irisin-mediated muscle-kidney crosstalk

BACKGROUND

Sarcopenia progresses in chronic kidney disease (CKD) and is positively correlated with mortality in end-stage kidney disease patients. Circulating irisin, an exercise-induced myokine, gradually decreases during CKD stage progression. Irisin inhibits the progression of kidney fibrosis, which is the final common outcome of CKD. Our preliminary study with C2C12 cells showed that Dojuksan, a herbal decoction, increases the expression of PGC1α (a regulator of irisin) and FNDC5 (a precursor of irisin).

HYPOTHESIS

Dojuksan may increase circulating irisin and prevent the progression of kidney fibrosis.

STUDY DESIGN AND METHODS

Unilateral ureteral obstruction (UUO) was performed on seven-week-old male C57BL/6 mice to induce kidney tubulointerstitial fibrosis. Dojuksan (50, 100, or 200 mg/kg/day) or losartan (1.5 mg/kg/day), a standard clinical treatment for CKD, was administered orally one day prior to surgery and continued for seven days thereafter. To determine the role of irisin released from muscles, TGFβ-stimulated murine proximal tubular epithelial cells (mProx24 cells) were treated with conditioned media (CM) from Dojuksan-treated C2C12 muscle cells transfected with FNDC5 siRNA.

RESULTS

UUO mice exhibited muscle wasting along with progressive kidney injury. Similar to losartan, Dojuksan ameliorated kidney inflammation and fibrosis in UUO mice. Dojuksan, but not losartan, increased plasma irisin concentration in UUO mice. Dojuksan significantly increased basal FNDC5 expression and inhibited TNFα-induced and indoxyl sulfate-induced FNDC5 down-regulation in C2C12 cells. The TGFβ-induced collagen I (COL1) up-regulation in mProx24 cells was effectively inhibited by CM from C2C12 cells after Dojuksan treatment. Moreover, irisin inhibited TGFβ-induced COL1 in mProx24 cells, which was not affected by CM from C2C12 cells transfected with FNDC5 siRNA.

CONCLUSION

Dojuksan ameliorates kidney fibrosis through irisin-mediated muscle-kidney crosstalk, suggesting that Dojuksan may be used as an alternative therapeutic agent against CKD.