Exercise Prescription and Proscription for Patients With Coronary Artery Disease

Possible Mechanisms for Adverse Cardiac Events Caused by Exercise-Induced Hypertension in Long-Distance Middle-Aged Runners: A Review

Sudden cardiac death (SCD) is rare among athletes. However, hypertrophic cardiomyopathy is the leading cause of SCD among those <35 years of age. Meanwhile, coronary artery disease (CAD) is the primary SCD cause among those ≥35 years of age. CAD-induced plaque ruptures are believed to be a significant cause of cardiovascular diseases in middle-aged individuals who participate in extreme long-distance running activities such as marathons. A total of 1970 articles related to EIH were identified using search terms. Out of these, 1946 studies were excluded for reasons such as arterial hypertension, exercise-induced pulmonary hypertension, the absence of exercise stress testing (EST), and a lack of relevance to EIH. The study analyzed 24 studies related to both long-distance runners with exercise-induced hypertension (EIH) and the general public. Among these, 11 studies were quasi-experimentally designed studies used in randomized controlled trials (RCTs) on long-distance runners with EIH. Additionally, 12 studies utilized cohort designs, and one study with a quasi-experimental design was conducted among the general population. Recent studies suggest that an imbalance between oxygen demand and supply due to ventricular hypertrophy may be the actual cause of cardiovascular disease, regardless of CAD. Exercising excessively over an extended period can reduce endothelial function and increase arterial stiffness, which in turn increases afterload and leads to an excessive increase in blood pressure during exercise. Exercise-induced hypertension (EIH), which increases the morbidity rate of resting hypertension and is a risk factor for cardio-cerebro-vascular diseases, is more prevalent in middle-aged long-distance runners than in runners from other age groups, and it increases the prevalence of critical arrhythmias, such as atrial fibrillation or ventricular arrhythmias. EIH is associated with angiotensin II activity, and angiotensin II receptor blockers show promising effects in middle-aged runners. Further, guidelines for preventing excessive participation in races and restricting exercise intensity and frequency would be useful. This review identifies EIH as a potential risk factor for cardiovascular diseases and describes how EIH induces SCD.

Peak Exercise Capacity and Angina Threshold Improvement after Cardiac Rehabilitation in a Patient with Stable Angina and Low Hemoglobin

Cardiac rehabilitation (CR) is recommended for all patients with stable angina (SA) as an effective treatment. Hemoglobin (Hgb) levels predict exercise performance and may affect symptom threshold in SA patients. A multidisciplinary CR intervention was individually tailored for a 72-year-old patient with a diagnosis of SA, low Hgb (<10 g/dL), and typical chest pain at light-to-moderate exercise (<5 metabolic equivalent task), who was stratified as at high risk for cardiac events during exercise. Two symptom-limited exercise tests were performed before and after 36 sessions of supervised exercise training producing near-optimal accumulated total volume load and chronic training load. In this case report, we show that an individually tailored CR intervention in a patient with SA and low Hgb is feasible, effective, and safe at reducing the burden of symptoms while increasing peak exercise capacity, health-related quality of life, and physical activity engagement.

Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism

Long-term exercise intolerance and functional limitations are common after an episode of acute pulmonary embolism (PE), despite 3 to 6 months of anticoagulation. These persistent symptoms are reported in more than half of the patients with acute PE and are referred as "post-PE syndrome." Although these functional limitations can occur from persistent pulmonary vascular occlusion or pulmonary vascular remodeling, significant deconditioning can be a major contributing factor. Herein, the authors review the role of exercise testing to elucidate the mechanisms of exercise limitations to guide next steps in management and exercise training for musculoskeletal deconditioning.

Management of the master endurance athlete with stable coronary artery disease

Master endurance athletes are individuals > 35 years of age who either train for or participate in competitions. Considering the potential burden of coronary artery disease in this population, clinicians should be aware of the inherent dangers of exercise. A tailored approach with shared decision-making, balancing risks and benefits of exercise, is recommended to ensure safe exercise in these individuals.

The Role of Physical Activity and Exercise in Preventive Cardiology

The cardiovascular epidemiologist, Jeremy Morris, called physical activity "the best bargain in public health," but few clinicians use exercise and physical activity in their practice. Clinicians should routinely inquire about physical activity and recommend that patients achieve the minimal levels recommended by the 2018 Physical Activity Guidelines for Americans. Clinician should avoid unnecessary testing that discourages patients from an active lifestyle. Patients after myocardial infarction, cardiac surgery, or the diagnosis of heart failure or claudication should be referred to an exercise-based cardiac rehab program. Physical activity and exercise training may be a clinical bargain, but as all medicines must be used to be effective.

The Effectiveness of Adapted Personalized Motor Activity (AMPA) to Improve Health in Individuals with Mental Disorders and Physical Comorbidities: A Randomized Controlled Trial

Mental disorders are highly prevalent worldwide and have a high impact on daily functioning. Exercise therapy was found to improve health of individuals with physical and mental disorders. This study aims to investigate the effectiveness of an Adapted Personalized Motor Activity (AMPA) in improving health in individuals with physical and mental disorders. Forty-three patients affected by both mental and chronic nontransmissible conditions were randomly assigned to intervention group (AMPA intervention) and control group (no intervention). Perceived physical and mental health were assessed using the Short Form 12 (SF-12) questionaries. Moreover, subjects underwent an accurate medical screening process, complete clinical evaluation, body composition evaluation, and cardiopulmonary assessment. Repeated Measurement Analysis of the Variance (RM-ANOVA) was used to compare any changes in health and physiological parameters in-between groups. AMPA group showed a statistically significant improvement in both perceived mental and physical health. Moreover, Body Mass Index (BMI), glycolipid profile, aerobic functional capacity and cardiopulmonary parameters improved significantly among individuals from the intervention group compared with the individuals from the control group. AMPA may be considered a possible intervention to improve health in individuals suffering from multiple physical and mental disorders. Future studies should examine the effectiveness in larger and heterogeneous sample of chronically ill patients and the long-term effect of AMPA.

Exercise-mediated adaptations in vascular function and structure: Beneficial effects in coronary artery disease

Exercise exerts direct effects on the vasculature via the impact of hemodynamic forces on the endothelium, thereby leading to functional and structural adaptations that lower cardiovascular risk. The patterns of blood flow and endothelial shear stress during exercise lead to atheroprotective hemodynamic stimuli on the endothelium and contribute to adaptations in vascular function and structure. The structural adaptations observed in arterial lumen dimensions after prolonged exercise supplant the need for acute functional vasodilatation in case of an increase in endothelial shear stress due to repeated exercise bouts. In contrast, wall thickness is affected by rather systemic factors, such as transmural pressure modulated during exercise by generalized changes in blood pressure. Several mechanisms have been proposed to explain the exercise-induced benefits in patients with coronary artery disease (CAD). They include decreased progression of coronary plaques in CAD, recruitment of collaterals, enhanced blood rheological properties, improvement of vascular smooth muscle cell and endothelial function, and coronary blood flow. This review describes how exercise via alterations in hemodynamic factors influences vascular function and structure which contributes to cardiovascular risk reduction, and highlights which mechanisms are involved in the positive effects of exercise on CAD.

Cardiovascular Risk Assessment in the Older Athlete

CONTEXT

Limited data are available to guide cardiovascular screening in adult or masters athletes (≥35 years old). This review provides recommendations and the rationale for the cardiovascular risk assessment of older athletes.

EVIDENCE ACQUISITION

Review of available clinical guidelines, original investigations, and additional searches across PubMed for articles relevant to cardiovascular screening, risk assessment, and prevention in adult athletes (1990-2020).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Atherosclerotic coronary artery disease (CAD) is the leading cause of exercise-induced acute coronary syndromes, myocardial infarction, and sudden cardiac death in older athletes. Approximately 50% of adult patients who experience acute coronary syndromes and sudden cardiac arrest do not have prodromal symptoms of myocardial ischemia. The risk of atherosclerotic cardiovascular disease (ASCVD) can be estimated by using existing risk calculators. ASCVD 10-year risk is stratified into 3 categories: low-risk (≤10%), intermediate-risk (between 10% and 20%), and high-risk (≥20%). Coronary artery calcium (CAC) scoring with noncontrast computed tomography provides a noninvasive measure of subclinical CAD. Evidence supports a significant association between elevated CAC and the risk of future cardiovascular events, independent of traditional risk factors or symptoms. Statin therapy is recommended for primary prevention if 10-year ASCVD risk is ≥10% (intermediate- or high-risk patients) or if the Agatston score is >100 or >75th percentile for age and sex. Routine stress testing in asymptomatic, low-risk patients is not recommended.

CONCLUSION

We propose a comprehensive risk assessment for older athletes that combines conventional and novel risk factors for ASCVD, a 12-lead resting electrocardiogram, and a CAC score. Available risk calculators provide a 10-year estimate of ASCVD risk allowing for risk stratification and targeted management strategies. CAC scoring can refine risk estimates to improve the selection of patients for initiation or avoidance of pharmacological therapy.

Physical Activity, Exercise Prescription for Health and Home-Based Rehabilitation

The aim of this overview was to recommend individual training plans using exercise prescriptions for adults and older adults during home-based rehabilitation. Over the last decade, many regular physical activity studies with large prospective cohorts have been conducted. Taken together, more than a million subjects have been included in these exercise studies. The risk of morbidity and mortality has been reduced by 30% to 40% as a result of exercise. These risk reductions hold true for many diseases, as well as for prevention and rehabilitation. Physical activity has also been in the treatment of many diseases, such as cardiopulmonary, metabolic or neurologic/psychiatric diseases, all with positive results. Based on these results, the prescription of exercise was developed and is now known as the exercise prescription for health in many European countries. Details have been published by the European Federation of Sports Medicine Associations (EFSMA). The exercise prescription is strongly recommended for inpatients, discharged patients and outpatients who have recovered from severe diseases. Rehabilitation improves general health, physical fitness, quality of life and may increase longevity of life.

The Impact of the Weight Status on Cardiovascular Parameters Related to Physical Effort in Young Athletes

Excess weight leads to an impaired cardiovascular response to physical exertion even at a young age. Sports training during youth promotes cardiovascular adaptations. The aim of the study is to verify the impact of weight status on cardiovascular parameters related to physical effort in young people who engage in competitive sports. A retrospective study was conducted on 8307 young athletes (5578 males and 2729 females) aged 6–18 years (mean age 13.9 ± 2.2 years). The data concerning graded exercise tests of young athletes in normal weight and overweight were compared. Approximately, 13.4% of the sample had excess weight. Young overweight athletes show a higher resting heart rate as well as systolic and diastolic pressure than young normal weight athletes. Excess weight condition leads to a reduction in the duration of the graded exercise test, reaching higher blood pressure values at the end of the test compared to those with normal weight. After four min from the end of the test, heart rate and systolic/diastolic blood pressure remained higher in the young overweight athletes. Excess weight affects cardiovascular parameters both at rest and in response to physical exertion during youth; however, competitive sport seems to be able to keep these parameters within the normal range even in young overweight athletes.

Lack of Cited Evidence Underpinning Recommendations for Objective Assessment of Cardiovascular Function to Inform Exercise Prescription: A Systematic Review

BACKGROUND

The effectiveness of exercise in managing cardiovascular (CV) health and function is well established. Less clear is the process for optimising the safety and efficacy of an intervention, particularly how objective assessments might inform this process.

OBJECTIVE

The aim of this review was to investigate the cited evidence underpinning recommendations for assessing CV function to inform the safe and effective prescription of exercise in populations with established CV disease, as published in documents to guide practice authored by prominent organisations in cardiology and sports medicine.

METHODS

A systematic review of position statements and guiding documents on exercise prescription for CV health was conducted. Included documents were published between 1997 and 2016.

RESULTS

Following removal of duplicates, 3158 documents were considered, with full-text screening required for 334. Twenty-seven documents were included which provided 106 individual recommendations for specific objective assessments. Of the total number of recommendations, 60% had no accompanying citation and 28% of recommendations provided citations that did not directly support the statement made. Additionally, 52% of included documents did not state the methods of document development. That is, it was not clear if there was a literature review and/or expert consensus that was used to form recommendations included within.

CONCLUSION

Almost no cited evidence underpinning the extracted recommendations from the included guiding documents, nor any acknowledgement of this deficiency was established. There were limited explanations found for the methods involved in developing such guiding documents.

The Cardiovascular Stress Response as Early Life Marker of Cardiovascular Health: Applications in Population-Based Pediatric Studies-A Narrative Review

Stress inducement by physical exercise requires major cardiovascular adaptations in both adults and children to maintain an adequate perfusion of the body. As physical exercise causes a stress situation for the cardiovascular system, cardiovascular exercise stress tests are widely used in clinical practice to reveal subtle cardiovascular pathology in adult and childhood populations with cardiac and cardiovascular diseases. Recently, evidence from small studies suggests that the cardiovascular stress response can also be used within research settings to provide novel insights on subtle differences in cardiovascular health in non-diseased adults and children, as even among healthy populations an abnormal response to physical exercise is associated with an increased risk of cardiovascular diseases. This narrative review is specifically focused on the possibilities of using the cardiovascular stress response to exercise combined with advanced imaging techniques in pediatric population-based studies focused on the early origins of cardiovascular diseases. We discuss the physiology of the cardiovascular stress response to exercise, the type of physical exercise used to induce the cardiovascular stress response in combination with advanced imaging techniques, the obtained measurements with advanced imaging techniques during the cardiovascular exercise stress test and their associations with cardiovascular health outcomes. Finally, we discuss the potential for cardiovascular exercise stress tests to use in pediatric population-based studies focused on the early origins of cardiovascular diseases.

Detection and Management of Heart Disease in Athletes

Primary care clinicians fulfill critical roles of screening for, diagnosing, and managing cardiovascular disease. In young athletes, primary structural and electrical diseases are the focus. Coronary artery disease is the chief concern in older athletes. Sudden cardiac arrest may be the initial presentation of disease and is more common in young athletes than historically appreciated. The traditional preparticipation evaluation, or sports physical, is limited in its ability to accurately raise suspicion of underlying disease. The 12-lead electrocardiogram is a more accurate screening tool. Contemporary risk stratification and treatment protocols may allow for safe return to sport on a case-by-case basis.

Comparison of manual and automated auscultatory blood pressure during graded exercise among people with type 2 diabetes

Manual measurement of blood pressure (BP) during exercise testing is the recommended standard. Automated measurement of BP is an alternative method used during clinical exercise testing, but there is little data comparing manual and automated BP in this setting. The aim of this study was to determine the concordance between manual and automated BP during a standard clinical treadmill exercise test. 416 participants (66 ± 5 years; 54% male) completed a Bruce treadmill exercise test at baseline or follow-up within a clinical trial of participants with type 2 diabetes mellitus. Manual and automated BP were measured simultaneously at each exercise test stage. Manual BP was measured by a technician blinded to automated BP values (Tango+, Suntech). Concordance between manual and automated BP was assessed using mean differences and intraclass correlations (ICC). Concordance between manual and automated BP across all exercise stages was excellent for systolic BP (overall mean difference: 3 ± 11 mm Hg, P = .598; ICC = 0.964 [95% CI 0.942-0.977] and pulse pressure (overall mean difference: 2 ± 14 mm Hg, P = .595; ICC = 0.934 [95% CI 0.899-0.956]). Concordance between manual and automated diastolic BP across all exercise stages was moderate-to-good (overall mean difference: 1 ± 9 mm Hg, P = .905; ICC = 0.784 [95% CI 0.672-0.858]). Automated BP using the Tango + device is concordant with manual BP during early stages of a standard clinical exercise test. Thus, this automated method may be a suitable alternative to manual measurement of BP during clinical exercise testing.

Early Phase II Comprehensive Cardiac Rehabilitation after Acute Myocardial Infarction

Background

Cardiac rehabilitation is beneficial for patients after ST-segment elevation myocardial infarction (STEMI). However, most institutes perform outpatient training phase (phase II) of post-MI cardiac rehabilitation after 2-4 weeks. To evaluate the possibility of performing cardiac rehabilitation with an earlier schedule after STEMI.

Methods

We conducted a series of early phase II cardiac rehabilitation starting from 5-7 days after STEMI, including the training group (n = 28) and the control group (n = 42).

Results

The results showed an improved mental component summary of the SF-36 questionnaire after 6 months in the training group. No adverse event was noticed during this early phase II training.

Conclusions

Cardiac rehabilitation after STEMI might be started earlier than previously thought for clinical use or further research.

Age-Related Improvements in Peak Cardiorespiratory Fitness among Coronary Heart Disease Patients Following Cardiac Rehabilitation

While cardiorespiratory fitness (VO₂peak) can be improved with exercise and training, it is unclear whether older age is associated with an attenuated VO₂peak improvement among patients with coronary artery disease (CAD) who complete a cardiac rehabilitation (CR) program. A retrospective review of patient demographics and VO₂peak data from January 2012 to December 2017 was performed. CAD patients were included if they had successfully completed the supervised 6-month CR program (>75% of exercise prescription) and two VO₂peak assessments (respiratory exchange ratio (RER) >1.0). Among all patients, there was an improvement in VO₂peak from 21.1 ± 6.3 mL/kg/min to 26.5 ± 7.9 mL/kg/min (+26% ΔVO₂peak). Patients in the younger age category (age category 1: 30⁻39 years old) tended to have a greater percent of relative VO₂peak improvement when compared to all other age categories (e.g., adults 50 years of age and older). In the regression analysis, VO₂peak improvement was associated with younger age (β = -0.286, p < 0.0001), after adjustment for the baseline VO₂peak (β = -0.456, p < 0.0001), final prescribed exercise speed at CR program completion (β = 0.254, p < 0.0001), body mass index (β = -0.172, p < 0.0001), and male sex (β = 0.153, p < 0.0001). Nonetheless, the study findings indicate that older adults who complete CR may be able to obtain clinically relevant improvements in VO₂peak of greater than 20%, and therefore, should be referred for CR.

Factors associated with objectively measured exercise participation after hospitalization for acute coronary syndrome

BACKGROUND

Guidelines recommend exercise for secondary prevention of acute coronary syndrome (ACS), however adherence to guidelines is low. A paucity of data examining factors associated with objectively-measured exercise post-discharge in ACS survivors exists. The purpose of this study was to identify factors associated with exercise during the 5 weeks after ACS discharge.

METHODS

A sample of 151 ACS patients treated at a university hospital were enrolled into an observational cohort study and wore an accelerometer for 35 days post-discharge. Days on which participants accumulated ≥30 min of moderate-to-vigorous physical activity in bouts ≥10 min were considered exercise days. Participants were categorized as non-exercisers (0 exercise days) or exercisers (≥1 exercise day). A multi-variable logistic regression model was used to examine the association between exercise and socio-demographics, depression, SF-12 physical and mental health scores, disease severity, length of hospitalization, and percutaneous coronary intervention.

RESULTS

39.7% of participants were non-exercisers. Factors associated with non-exercise were age (OR: 1.11; 95% CI: 1.06-1.17, p < 0.001), female sex (OR: 2.76; 95% CI: 1.10-6.95, p = 0.031), and lower SF-12 physical health score (OR: 0.94; 95% CI: 0.90-0.98, p = 0.005).

CONCLUSION

In ACS patients in whom exercise participation was objectively measured for 5 weeks post-discharge, demographic and poor physical health factors were associated with non-exercise. These findings identify populations (e.g. older adults, women) at especially high risk for being physically inactive in whom more intense intervention may be warranted.

Evaluation of cardiac rehabilitation on functional capacity in depressed and nondepressed patients after angioplasty

Background:

About 50% of the annual deaths in the developed countries are as a result of coronary artery disease. Several studies have shown the role of cardiac rehabilitation (CR) in improving cardiovascular indices including functional capacity, reducing depression, and mortality rates in cardiovascular patients. One of the psychological problems observed in cardiovascular patients is depression. Depression is one of the most important barriers to the treatment of heart attack, because it leads to denial of the disease and reduces the patient's motivation to continue treatment.

Objectives:

There are controversy information about the relationship between the effects of CR on these cases after angioplasty. The aim of this study was to evaluate the effect of CR on functional capacity in depressed and nondepressed patients after angioplasty in patients referred to Imam Khomeini, Ahvaz.

Methods:

This descriptive epidemiological study was performed on 54 patients referred for angioplasty. Functional capacity and depression score before and after participation in the 2-month CR program were evaluated in two groups of depressed and nondepressed patients. Data were analyzed by SPSS software, and the significance level was considered as P < 0.05.

Results:

The results of this study showed that in both the groups, the functional capacity after CR was significantly increased compared with the previous period (P < 0.001). Also in depressed patients, there was a significant decrease in depression scores (P < 0.001).

Conclusion:

Our findings showed improvement of functional capacity index following angioplasty, suggesting that patients participating in CR can be recommended by therapists. In addition, the results of this study showed that the participation in the CR program greatly affects the improvement of functional capacity and reduction in depression in patients undergoing angioplasty.

Compensatory Increase in Heart Rate Is Responsible for Exercise Tolerance among Male Patients with Permanent Atrial Fibrillation

Atrial fibrillation (AF) is an exacerbating factor for exercise tolerance due to the loss of atrial kick. However, many patients with permanent AF, which lasts for at least a year without interruption, and preserved left ventricular ejection fraction (LVEF ≥ 50%) are asymptomatic and have good exercise tolerance. In such cases, the possible mechanism that compensates for the decrease in cardiac output accompanying the loss of atrial kick is a sufficient increase in heart rate (HR) during exercise. We investigated the relationship between exercise tolerance and peak HR during exercise using cardiopulmonary exercise testing in 242 male patients with preserved LVEF, 214 with sinus rhythm (SR) and 28 with permanent AF. Peak HR was significantly higher in the AF group than the SR group (148.9 ± 41.9 vs. 132.0 ± 22.0 beats/min, p = 0.001). However, oxygen uptake at peak exercise did not differ between the AF and SR groups (19.4 ± 5.7 vs. 21.6 ± 6.0 mL/kg/min, p = 0.17). In multiple regression analysis, peak HR (β, 0.091; p < 0.001) and the interaction term constructed by peak HR and presence of permanent AF (β, 0.05; p = 0.04) were selected as determinants for peak VO₂; however, presence of permanent AF was not selected (β, -0.38; p = 0.31). Therefore, the impact of peak HR on exercise tolerance differed between the AF and SR groups, suggesting that a sufficient increase in HR during exercise is an important factor to preserve exercise tolerance among patients with AF.

THE RATE OF CARDIAC RHYTHM RECOVERY POST EXERTION IN PHYSICAL REHABILITATION OF CARDIOLOGICAL PATIENTS

Taken the rising mortality and morbidity of the population due to cardiovascular diseases (CVD), rehabilitation of cardiovascular patients remains actual. Regular exercises are the leading components of cardiorehabilitation, that is evidently beneficial. Taken this, the question raises on the adequacy and efficacy of training regimens. Utilization of the parameter representing the velocity of heart rate decline by every minute of recovery phase after the exertion, is quite informative. The borderline set for heart rate, with increasing cardiovascular risk if below. Dynamics of such parameter during the programs of physical rehabilitation might be a marker of the events efficacy. Recently, there is a deficiency of information on the normal parameters of heart rate recovery rate in CVD patients. Hence a question raises, on the unification of approaches in evaluation of recovery period and data collection on the influence of long term exercises on CVD prognosis.

Voluntary exercise training restores anticontractile effect of NO in coronary arteries of adult rats with antenatal/early postnatal hypothyroidism

INTRODUCTION

Our recent study showed that NO-mediated anticontractile effect of endothelium is absent in coronary arteries of adult rats, which suffered from antenatal/early postnatal hypothyroidism. This study tested the hypothesis that exercise training would improve such detrimental consequences of early thyroid deficiency.

DESIGN AND METHODS

Wistar dams received propylthiouracil (PTU, 7 ppm) in drinking water during gestation and two weeks postpartum; control dams received tap water. Six-week-old male offspring of control (CON) and PTU dams was divided into sedentary (CON-Sed, n = 12; PTU-Sed, n = 10) and trained (CON-Tr, n = 12; PTU-Tr, n = 10) groups; the latter had 24-h access to running wheels. Eight weeks later coronary arteries were studied by wire myography. Anticontractile effect of NO was assessed by the effects of NOS inhibitor L-NNA on the basal tone and contractile response to U46619. Oxidative phosphorylation complexes and eNOS were estimated by Western blotting.

RESULTS

T₃/T₄ and TSH levels (ELISA) were normalized in the progeny of PTU-treated dams at the age of 6 weeks and were not affected by training. Total running distance did not differ between CON-Tr and PTU-Tr. The contents of oxidative phosphorylation complexes were increased post-training in triceps brachii muscle from CON-Tr and PTU-Tr and in heart from PTU-Tr. Coronary arteries of PTU-Sed compared to CON-Sed demonstrated higher basal tone and contractile response to U46619, which were not further increased by L-NNA. The effects of L-NNA on the basal tone and contractile response to U46619 did not differ in CON-Tr and PTU-Tr groups, but were elevated in PTU-Tr compared to PTU-Sed group. PTU-Tr rats in comparison to PTU-Sed group had higher eNOS content in heart. Responses of coronary arteries to DEA/NO did not differ among all experimental groups.

CONCLUSIONS

Long-lasting coronary endothelial dysfunction resulted from transient thyroid deficiency during the antenatal/early postnatal period can be corrected by voluntary exercise training.

Exercise And Heart Failure: Advancing Knowledge And Improving Care

Exercise limitation is the hallmark of heart failure, and an increasing degree of intolerance is associated with poor prognosis. Objective evaluation of functional class (e.g., cardiopulmonary exercise testing) is essential for adequate prognostication in patients with advanced heart failure and for implementing an appropriate exercise training program. A graded exercise program has been shown to be beneficial in patients with heart failure and has become an essential component of comprehensive cardiac rehabilitation in these patients. An exercise program tailored to the patient's preferences, possibilities, and physiologic reserve has the greatest chance of being successful. Despite being safe, effective, and a guideline-recommended treatment to improve quality of life, exercise training remains grossly underutilized. Patient, physician, insurance and practice barriers need to be addressed to improve this quality gap.

Physical Activity in Patients Treated With Peritoneal Dialysis: A Protocol for a Systematic Review

Background:

Patients with chronic diseases are known to benefit from exercise. Despite a lack of compelling evidence, patients with end-stage kidney disease treated with peritoneal dialysis are often discouraged from participating in exercise programs that include resistance training due to concerns about the development of hernias and leaks. The actual effects of physical activity with or without structured exercise programs for these patients remain unclear. The purpose of this study is to more completely define the risks and benefits of physical activity in the end-stage kidney disease population treated with peritoneal dialysis.

Methods/design:

We will conduct a systematic review examining the effects of physical activity on end-stage kidney disease patients treated with peritoneal dialysis. For the purposes of this review, exercise will be considered a purposive subcategory of physical activity. The primary objective is to determine if physical activity in this patient population is associated with improvements in mental health, physical functioning, fatigue and quality of life and if there is an increase in adverse outcomes. With the help of a skilled librarian, we will search MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials for randomized trials and observational studies. We will include adult end-stage kidney disease patients treated with peritoneal dialysis that have participated in an exercise training program or had their level of physical activity assessed directly or by self-report. The study must include an assessment of the association between physical activity and one of our primary or secondary outcomes measures. We will report study quality using the Cochrane Risk of Bias Assessment Tool for randomized controlled trials and the Newcastle–Ottawa Scale for observational studies. Quality across studies will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The results of this review may help to inform guideline development for exercise recommendations specific to this patient population.

Systematic review registration:

PROSPERO:CRD42016041695.

An Atelocollagen Coating for Efficient Local Gene Silencing by Using Small Interfering RNA

In the last decades, many efforts have been made to counteract adverse effects after stenting atherosclerotic coronary arteries. A breakthrough in better vascular wall regeneration was noted in the new era of drug-eluting stents. A novel personalized approach is the development of gene-eluting stents promising an alteration in gene expression involved in regeneration. We investigated a coating system consisting of the polymer atelocollagen (ATCOL) and a specific small interfering RNA (siRNA) for intercellular adhesion molecule-1 (ICAM-1) found on the surface of defective endothelial cells (ECs). We demonstrated very high cell viability, in which EA.hy926 grew on 0.008% or 0.032% ATCOL layers. Additionally, hemocompatibility assays proved the biocompatibility of this coating. The highest transfection efficiency with EA.hy926 was achieved with 5 μg siRNA immobilized in ATCOL after 2 days. The release of fluorescent-labeled siRNA was about 9 days. Long-term knockdown of ICAM-1 was analyzed by flow cytometry, revealing that the coating with 0.008% ATCOL and 5 μg siICAM-1 provoked gene silencing up to 8 days. 5′-RNA ligase-mediated rapid amplification of cDNA ends PCR (RLM-RACE-PCR) demonstrated the specificity of our established ATCOL gene-silencing coating, meaning that our coating is well suited for further investigations in in vivo studies. Herein, we would like to demonstrate that our ATCOL is well-suited for better artery wall regeneration after stent implantation.

Physical activity on prescription schemes (PARS): do programme characteristics influence effectiveness? Results of a systematic review and meta-analyses

BACKGROUND

Physical activity on prescription schemes (PARS) are health promotion programmes that have been implemented in various countries. The aim of this study was to outline the differences in the design of PARS in different countries. This study also explored the differences in the adherence rate to PARS and the self-reported level of physical activity between PARS users in different countries.

METHOD

A systematic literature review and meta-analyses were conducted. We searched PubMed and EBASCO in July 2015 and updated our search in September 2015. Studies that reported adherence to the programme and self-reported level of physical activity, published in the English language in a peer-reviewed journal since 2000, were included. The difference in the pooled adherence rate after finishing the PARS programme and the adherence rate before or during the PARS programme was 17% (95% CI 9% to 24%). The difference in the pooled physical activity was 0.93 unit score (95 CI -3.57 to 1.71). For the adherence rate, a meta-regression was conducted.

RESULTS

In total, 37 studies conducted in 11 different countries met the inclusion criteria. Among them, 31 reported the adherence rate, while the level of physical activity was reported in 17 studies. Results from meta-analyses show that PARS had an effect on the adherence rate of physical activity, while the results from the meta-regressions show that programme characteristics such as type of chronic disease and the follow-up period influenced the adherence rate.

CONCLUSIONS

The effects of PARS on adherence and self-reported physical activity were influenced by programme characteristics and also by the design of the study. Future studies on the effectiveness of PARS should use a prospective longitudinal design and combine quantitative and qualitative data. Furthermore, future evaluation studies should distinguish between evaluating the adherence rate and the self-reported physical activity among participants with different chronic diseases.

Effect of Structured Physical Activity on Respiratory Outcomes in Sedentary Elderly Adults with Mobility Limitations

OBJECTIVES

To evaluate the effect of structured physical activity on respiratory outcomes in community-dwelling elderly adults with mobility limitations.

DESIGN

Multicenter, randomized trial of physical activity vs health education, with respiratory variables prespecified as tertiary outcomes over an intervention period of 24-42 months. Physical activity included walking (goal of 150 min/week) and strength, flexibility, and balance training. Health education included workshops on topics relevant to older adults and upper extremity stretching exercises.

SETTING

Lifestyle Interventions and Independence in Elders (LIFE) Study.

PARTICIPANTS

Community-dwelling persons aged 70-89 with Short Physical Performance Battery scores less than 10 (N = 1,635).

MEASUREMENTS

Dyspnea severity (defined as moderate to severe according to a Borg index >2 immediately after a 400-m walk), forced expiratory volume in 1 second (FEV1) (<lower limit of normal (LLN) defined low breathing capacity), and maximal inspiratory pressure (MIP) (<LLN defined respiratory muscle weakness) were assessed at baseline and 6, 18, and 30 months. Hospitalization for exacerbation of obstructive airways disease (EOAD) and pneumonia was also ascertained over the 42-month follow-up period.

RESULTS

The randomized groups were similar in baseline demographics, including mean age (79) and sex (67% female). The effect of physical activity on dyspnea severity, FEV1, and MIP was no different from that of health education but was associated with higher likelihood of respiratory hospitalization, significantly for EOAD (hazard ratio (HR) = 2.34, 95% confidence interval (CI) = 1.19-4.61, P = .01) and marginally for pneumonia (HR = 1.54, 95% CI = 0.98-2.42, P = .06).

CONCLUSION

In older persons with mobility limitations, physical activity was associated with higher likelihood of respiratory hospitalization than health education, but differences in dyspnea severity, FEV1, and MIP did not accompany this effect-indicating that higher hospital use could be attributable to greater participant contact.

Behavioural intervention to increase physical activity in adults with coronary heart disease in Jordan

BACKGROUND

Patients with coronary heart disease often do not follow prescribed physical activity recommendations. The aim of this study was to assess the efficacy of a behavioural intervention to increase physical activity in patients with coronary heart disease not attending structured cardiac rehabilitation programmes.

METHODS

Parallel randomised controlled trial comparing 6-month multi-component behavioural change intervention (n = 71) with usual care (n = 85) was conducted in two hospitals in Jordan, Middle East. Intervention included one face-to-face individualised consultation, 6 telephone support calls (for goal-setting, feedback and self-monitoring) and 18 reminder text messages. Patients were randomly allocated to the two groups by opening opaque sealed sequence envelopes. The patients and the researcher who provided the intervention and assessed the outcomes were not blinded. Outcomes were assessed at baseline and 6 months. Primary outcome was physical activity level, secondary outcomes were blood pressure, body mass index, exercise self-efficacy for exercise and health-related quality of life.

RESULTS

Intervention and control groups were comparable at baseline. Moderate physical activity significantly increased in the intervention group compared with control group (mean change (SD) of frequency: 0.23 (0.87) days/week versus -.06 (0.40); duration: 15.53 (90.15) minutes/week versus -3.67 (22.60) minutes/week; intensity: 31.05 (105.98) Metabolic equivalents (METs) versus 14.68 (90.40) METs). Effect size was 0.03 for moderate PA frequency, 0.02 for moderate PA duration and 0.01 for moderate PA intensity. Walking significantly increased in the intervention group compared with control group (mean change (SD) of frequency: 3.15 (2.75) days/week versus 0.37 (1.83) days/week; duration: 150.90 (124.47) minutes/week versus 24.05 (195.93) minutes/week; intensity: 495.12 (413.74) METs versus14.62 (265.06) METs). Effect size was 0.36 for walking frequency, 0.05 for walking duration, 0.32 for walking intensity and 0.29 for total PA intensity. Intervention participants had significantly lower blood pressure, lower body mass index, greater exercise self-efficacy and better health-related quality of life at 6 months compared with controls.

CONCLUSIONS

Multi-component behavioural intervention increases physical activity, and improves body composition, physiological and psychological outcomes in CHD patients not attending structured rehabilitation programmes.

TRIAL REGISTRATION

Current Controlled Trials retrospectively registered in 21-03-2012. ISRCTN48570595 .

Occult coronary artery disease in middle-aged sportsmen with a low cardiovascular risk score: The Measuring Athlete's Risk of Cardiovascular Events (MARC) study

BACKGROUND

Most exercise-related cardiac arrests in men aged ≥45 years are due to coronary artery disease (CAD). The current sports medical evaluation (SME) of middle-aged sportsmen includes medical history, physical examination and resting and exercise electrocardiography (ECG). We investigated the added value of low-dose cardiac computed tomography (CCT) - both non-contrast CT for coronary artery calcium scoring (CACS) and contrast-enhanced coronary CT angiography (CCTA) - in order to detect occult CAD in asymptomatic recreational sportsmen aged ≥45 years without known cardiovascular disease.

METHODS

Following a normal SME (with resting and bicycle exercise ECG), 318 asymptomatic sportsmen underwent CCT and 300 (94%) had a low European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE) risk. Occult CAD was defined as a CACS ≥100 Agatston units (AU) or obstructive (≥50%) luminal stenosis on CCTA. The number needed to screen (NNS) in order to prevent one cardiovascular event within 5 years with statin treatment was estimated.

RESULTS

Fifty-two (16.4%, 95% confidence interval (CI): 12.7-20.8%) of 318 participants had a CACS ≥100 AU. The CCTA identified an additional eight participants with luminal narrowing ≥50% (and a CACS <100 AU). Taken together, CCT identified CAD in 60 (18.9%, 95% CI: 14.9-23.5%) of 318 participants. The 5-year estimated NNS was 183 (95% CI: 144-236) for CACS and 159 (95% CI: 128-201) for CACS combined with CCTA.

CONCLUSIONS

Coronary CT detects occult CAD in almost one in five asymptomatic sportsmen aged ≥45 years after a normal SME that included resting and bicycle exercise ECG. CACS reveals most of the relevant CAD with limited additional value of contrast-enhanced CCTA. The NNS in order to prevent one cardiovascular event compares favourably to that of other screening tests.

Efecto de un programa de entrenamiento físico sobre condición física saludable en hipertensos

Resumo Objetivo: Determinar el efecto de un programa de entrenamiento físico sobre la condición física saludable en sujetos con hipertensión arterial controlada. Método: Se desarrolló un ensayo clínico en 78 personas diagnosticadas con hipertensión arterial controlada que voluntariamente aceptaron participar en la investigación y que reunieron los criterios de inclusión, de entre ellos fue seleccionado el grupo de estudio: 39 sujetos con hipertensión arterial controlada a quienes se les aplicó el programa de entrenamiento físico; y el grupo control: 39 sujetos con hipertensión arterial controlada a quienes se les aplicó un programa educativo combinado con el ejercicio no dirigido que practicaban habitualmente (tejo, rana, ajedrez). Al inicio del estudio se diligenció una encuesta para la caracterización sociodemográfica y clínica de los participantes, esta última diligenciada al final del estudio. Se utilizó el estadístico t Student para muestras independientes; también se hizo t de student pareada antes-después o en su defecto la prueba no paramétrica U de Mann-Whitney. Resultados: El 84,6 por ciento fueron mujeres; 64,1 por ciento cuentan con nivel escolar de primaria. Las diferencias de medias mostraron significancia estadística p<0,05 en colesterol HDL (lipoproteina de alta densidad), LDL (lipoproteina de baja densidad), triglicéridos, fuerza de miembros inferiores y fuerza abdominal. Conclusion: Los resultados reportados permiten concluir que las variables medidas HDL, LDL y triglicéridos muestran diferencias estadísticamente significativas entre los grupos experimentales y de control en los dos momentos del estudio, pero no entre los tiempos. Lo mismo ocurre en las variables de fuerza de las extremidades inferiores y abdominales, lo que sugiere un efecto positivo del programa implementado.

Physical activity in the prevention of coronary heart disease: implications for the clinician

Cardiovascular disease (CVD) continues to be a leading cause of death worldwide. Because regular physical activity (PA) independently decreases the risk of coronary heart disease (CHD) while also having a positive, dose-related impact on other cardiovascular (CV) risk factors, it has increasingly become a focus of CHD prevention. Current guidelines recommend 30 min of moderate-intensity PA 5 days a week, but exercise regimens remain underused. PA adherence can be fostered with a multilevel approach that involves active individual participation, physician counselling and health coaching, community involvement, and policy change, with incorporation of cardiac rehabilitation for patients requiring secondary prevention. Viewing exercise quantity as a vital sign, prescribing PA like a medication, and using technology, such as smartphone applications, encourage a global shift in focus from CVD treatment to prevention. Community-wide, home-based and internet-based prevention initiatives may also offer a developing pool of resources that can be tapped into to promote education and PA compliance. This review summarises the underlying rationale, current guidelines for and recommendations to cultivate a comprehensive focus in the endorsement of PA in the primary and secondary prevention of CHD.

Predicting aerobic fitness improvements after participation in a hybrid supervised and home-based exercise program in people with type 2 diabetes

OBJECTIVE

Structured, gym-based exercise training has been shown to be effective at improving aerobic fitness and glycemic control in persons with type 2 diabetes. However, community-based diabetes programs more commonly incorporate less structured programming, promoting exercise at home. The objectives of this study were to evaluate a community-based, hybrid exercise program encouraging home-based exercise for improving aerobic fitness, and to examine the components of exercise prescription that contribute to this fitness change.

METHODS

A retrospective analysis of 583 persons with type 2 diabetes who had participated in the Toronto Rehabilitation Institute's diabetes exercise program was performed. All subjects completed 6 months of structured aerobic and resistance exercise supervised once per week on-site, with 4 more unsupervised sessions per week completed at home. Cardiopulmonary fitness testing and anthropometric measures were performed at baseline and at program completion. A multivariate regression analysis examined the outcome of aerobic fitness (peak oxygen consumption), controlling for age, sex, body mass index, weight change, initial fitness at entry into the program and walking exercise performed (distance, duration and pace).

RESULTS

Peak oxygen consumption improved significantly from 19.1±0.2 at baseline to 21.9±0.3 mL·kg(-1)·min(-1) at 6 months (p<0.001). Weight and body mass index also improved significantly (p<0.001). The regression model was able to predict 76.9% of the variance in aerobic fitness, with distance walked contributing the most to improved exercise capacity.

CONCLUSIONS

A 6-month hybrid exercise program delivered in a community rehabilitation program setting successfully improved aerobic fitness in people living with type 2 diabetes.

Identifying Coronary Artery Disease in Asymptomatic Middle-Aged Sportsmen: The Additional Value of Pulse Wave Velocity

Background

Cardiovascular screening may benefit middle-aged sportsmen, as coronary artery disease (CAD) is the main cause of exercise-related sudden cardiac death. Arterial stiffness, as measured by pulse wave velocity (PWV), may help identify sportsmen with subclinical CAD. We examined the additional value of PWV measurements to traditional CAD risk factors for identifying CAD.

Methods

From the Measuring Athlete’s Risk of Cardiovascular events (MARC) cohort of asymptomatic, middle-aged sportsmen who underwent low-dose Cardiac CT (CCT) after routine sports medical examination (SME), 193 consecutive sportsmen (aged 55±6.6 years) were included with additional PWV measurements before CCT. Sensitivity, specificity and predictive values of PWV values (>8.3 and >7.5m/s) assessed by Arteriograph were used to identify CAD (coronary artery calcium scoring ≥100 Agatston Units or coronary CT angiography luminal stenosis ≥50%) and to assess the additional diagnostic value of PWV to established cardiovascular risk factors.

Results

Forty-seven sportsmen (24%) had CAD on CCT. They were older (58.9 vs. 53.8 years, p<0.001), had more hypertension (17 vs. 4%, p=0.003), higher cholesterol levels (5.7 vs. 5.4mmol/l) p=0.048), and more often were (ever) smokers (55 vs. 34%, p=0.008). Mean PWV was higher in those with CAD (8.9 vs. 8.0 m/s, p=0.017). For PWV >8.3m/s respectively >7.5m/s sensitivity to detect CAD on CT was 43% and 74%, specificity 69% and 45%, positive predictive value 31% and 30%, and negative predictive value 79% and 84%. Adding PWV to traditional risk factor models did not change the area under the curve (from 0.78 (95% CI = 0.709-0.848)) to AUC 0.78 (95% CI 0.710-0.848, p = 0.99)) for prediction of CAD on CCT.

Conclusions

Limited additional value was found for PWV on top of established risk factors to identify CAD. PWV might still have a role to identify CAD in middle-aged sportsmen if risk factors such as cholesterol are unknown.

Rationale and design of the Measuring Athlete's Risk of Cardiovascular events (MARC) study : The role of coronary CT in the cardiovascular evaluation of middle-aged sportsmen

Background

More than 90 % of exercise-related cardiac arrests occur in men, predominantly those aged 45 years and older with coronary artery disease (CAD) as the main cause. The current sports medical evaluation (SME) of middle-aged recreational athletes consists of a medical history, physical examination, and resting and exercise electrocardiography. Coronary CT (CCT) provides a minimally invasive low radiation dose opportunity to image the coronary arteries. We present the study protocol of the Measuring Athlete’s Risk of Cardiovascular events (MARC) study. MARC aims to assess the additional value of CCT to a routine SME in asymptomatic sportsmen ≥45 years without known CAD.

Design

MARC is a prospective study of 300 asymptomatic sportsmen ≥45 years who will undergo CCT if the SME does not reveal any cardiac abnormalities. The prevalence and determinants of CAD (coronary artery calcium score ≥100 Agatston Units (AU) or ≥50 % luminal stenosis) will be reported. The number needed to screen to prevent the occurrence of one cardiovascular event in the next 5 years, conditional to adequate treatment, will be estimated.

Discussion

We aim to determine the prevalence and severity of CAD and the additional value of CCT in asymptomatic middle-aged (≥45 years) sportsmen whose routine SME revealed no cardiac abnormalities.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-014-0630-0) contains supplementary material, which is available to authorized users.

Comparison of cardiopulmonary exercise testing variables in COPD patients with and without coronary artery disease

BACKGROUND

Coronary artery disease (CAD) is a common concomitant condition and an important cause of morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). Since COPD and CAD can both independently cause reduced exercise capacity, it is reasonable to hypothesize that the combination of these diseases may compound the abnormalities observed during cardiopulmonary exercise testing (CPET). However, little is known about the impact of CAD on the CPET response in COPD patients. The aim of this study is to compare exercise capacity and gas exchange variables in COPD patients with and without CAD.

METHODS

Fifty-four COPD subjects without CAD (COPDnoCAD) were matched to 54 COPD subjects diagnosed with CAD (COPD/CAD) according to age, gender, body mass index and severity of COPD. All subjects underwent resting pulmonary function and symptom-limited CPET.

RESULTS

Comparing COPDnoCAD patients with COPD/CAD patients revealed that exercise capacity, as measured by % peak oxygen consumption (42 ± 16% vs 53 ± 19%, p = 0.002) and % peak wattage (23 ± 13% vs 32 ± 16%, p = 0.001), was significantly lower in COPD/CAD. Ventilatory response, as measured by VE/VCO2 nadir (36 ± 9 vs 32 ± 5, p = 0.001), was significantly higher in COPD/CAD, with % peak VO2 and VE/VCO2 nadir correlating to % FEV1 and inversely correlating with %DLCO.

CONCLUSION

COPD patients with CAD have significantly impaired CPET responses with lower exercise capacity and impaired gas exchange compared to COPD patients without CAD. These findings may affect the clinical interpretation of CPET data in COPD patients who have concomitant CAD.

The effects of exercise on cardiovascular outcomes before, during, and after treatment for breast cancer

Asymptomatic cardiotoxicity following breast cancer treatment is a significant issue for many patients, as these patients typically face an increased risk of cardiovascular disease (CVD). Exercise has well established benefits to improve and maintain cardiovascular function across patients with and without CVD. However, there is a dearth of information on the effects of exercise on cardiovascular outcomes in breast cancer patients. While pre-clinical studies support the use of exercise in mitigating cardiotoxicity, only one human study has specifically investigated cardiac function following an exercise intervention during chemotherapy treatment. No significant differences were observed between groups, which highlights the unidentified role of exercise in altering the risk of cardiotoxicity in breast cancer patients. Issues such as establishing the optimal timing, type, and intensity of an exercise program before, during, or after oncologic treatment for breast cancer are unclear. CVD risk and incidence increase in breast cancer survivors post therapy, and CVD is the number one killer of women in the United States. Thus, there is an increasing need to define the efficacy of exercise as a non-pharmacologic intervention in this growing population.

Recent advancements in tissue engineering for stem cell-based cardiac therapies

Advances in cardiac tissue engineering have recently focused on utilizing stem cells to regenerate infarcted and scarred myocardium. Due to their proliferative nature and tremendous potential for differentiation, stem cells are presently being investigated for clinical applications. Unfortunately, limiting factors such as massive cell death and poor retention have hampered clinical outcomes. Consequently, the development of an efficient delivery system for stem cells to the target site is essential. The use of innovative tissue engineering techniques has opened up new horizons within the field of cellular cardiomyoplasty. This paper will present a comprehensive overview of the recent advancements in stem cell technology destined for myocardial tissue repair. In addition, the multidisciplinary approach to tissue engineering presented here will provide the reader with insight into the clinical realization of cellular cardiomyoplasty.