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Hansen D, Kraenkel N, Kemps H, Wilhelm M, Abreu A, Pfeiffer AFH, Jordão A, Cornelissen V, Völler H. Management of patients with type 2 diabetes in cardiovascular rehabilitation. Eur J Prev Cardiol 2019; 26:133-144. [DOI: 10.1177/2047487319882820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The clinical benefits of rehabilitation in cardiovascular disease are well established. Among cardiovascular disease patients, however, patients with type 2 diabetes mellitus require a distinct approach. Specific challenges to clinicians and healthcare professionals in patients with type 2 diabetes include the prevalence of peripheral and autonomic neuropathy, retinopathy, nephropathy, but also the intake of glucose-lowering medication. In addition, the psychosocial wellbeing, driving ability and/or occupational status can be affected by type 2 diabetes. As a result, the target parameters of cardiovascular rehabilitation and the characteristics of the cardiovascular rehabilitation programme in patients with type 2 diabetes often require significant reconsideration and a multidisciplinary approach. This review explains how to deal with diabetes-associated comorbidities in the intake screening of patients with type 2 diabetes entering a cardiovascular rehabilitation programme. Furthermore, we discuss diabetes-specific target parameters and characteristics of cardiovascular rehabilitation programmes for patients with type 2 diabetes in a multidisciplinary context, including the implementation of guideline-directed medical therapy.
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Affiliation(s)
- Dominique Hansen
- REVAL – Rehabilitation Research Center, Hasselt University, Belgium
- Jessa Hospital, Heart Center Hasselt, Belgium
- BIOMED – Biomedical Research Center, Hasselt University, Belgium
| | - Nicolle Kraenkel
- Department of Endocrinology, Diabetes and Nutrition, Charité – Universitätsmedizin Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Hareld Kemps
- Department of Cardiology, Maxima Medical Centre, the Netherlands
| | | | - Ana Abreu
- Serviço de Cardiologia, Hospital Universitário de Santa Maria/Centro Hospitalar Universitário Lisboa Norte (CHULN), Portugal
| | - Andreas FH Pfeiffer
- Department of Endocrinology, Diabetes and Nutrition, Charité – Universitätsmedizin Berlin, Germany
- DZD (German Centre for Diabetes Research), partner site Berlin/Nuthetal, Germany
| | - Alda Jordão
- Department of Internal Medicine, Hospital Pulido Valente, Portugal
| | | | - Heinz Völler
- Center of Rehabilitation Research, University of Potsdam, Germany
- Klinik am See, Rehabilitation Center for Internal Medicine, Germany
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Hwang CL, Lim J, Yoo JK, Kim HK, Hwang MH, Handberg EM, Petersen JW, Holmer BJ, Leey Casella JA, Cusi K, Christou DD. Effect of all-extremity high-intensity interval training vs. moderate-intensity continuous training on aerobic fitness in middle-aged and older adults with type 2 diabetes: A randomized controlled trial. Exp Gerontol 2018; 116:46-53. [PMID: 30576716 DOI: 10.1016/j.exger.2018.12.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 01/16/2023]
Abstract
Aging and diabetes are associated with decreased aerobic fitness, an independent predictor of mortality. Aerobic exercise is prescribed to improve aerobic fitness; however, middle-aged/older diabetic patients often suffer from mobility limitations which restrict walking. Non-weight-bearing/low-impact exercise is recommended but the optimal exercise prescription is uncertain. The goal of this randomized controlled trial was twofold: 1) to test if high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT), implemented on a non-weight-bearing all-extremity ergometer, are feasible, well-tolerated and safe in middle-aged/older adults with type 2 diabetes; and 2) to test whether all-extremity HIIT is more effective in improving aerobic fitness than MICT. A total of 58 sedentary individuals with type 2 diabetes (46 to 78 years; 63 ± 1) were randomized to all-extremity HIIT (n = 23), MICT (n = 19) or non-exercise control (CONT; n = 16). All-extremity HIIT and MICT, performed 4×/week for 8 weeks under supervision, resulted in no adverse events requiring hospitalization or medical treatment. Aerobic fitness (VO2peak) improved by 10% in HIIT and 8% in MICT and maximal exercise tolerance increased by 1.8 and 1.3 min, respectively (P ≤ 0.002 vs. baseline; P ≥ 0.9 for HIIT vs. MICT). In conclusion, all-extremity HIIT and MICT are feasible, well-tolerated and safe and result in similar improvements in aerobic fitness in middle-aged/older individuals with type 2 diabetes. These findings have important implications for exercise prescription for diabetic patients; they indicate that all-extremity exercise is a feasible alternative to weight-bearing exercise and those who are unable or unwilling to engage in HIIT may receive similar benefits from MICT.
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Affiliation(s)
- Chueh-Lung Hwang
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America
| | - Jisok Lim
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America
| | - Jeung-Ki Yoo
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America
| | - Han-Kyul Kim
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America
| | - Moon-Hyon Hwang
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America; Division of Health and Exercise Science, Incheon National University, Incheon, Republic of Korea
| | - Eileen M Handberg
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - John W Petersen
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Brady J Holmer
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America
| | - Julio A Leey Casella
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL, United States of America
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL, United States of America
| | - Demetra D Christou
- Department of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States of America.
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Abstract
Background Evidence suggests that low levels of Vitamin D may adversely affect the cardiovascular (CV) system. Several studies have been done regarding the relation and possible causative role of Vitamin D in CV disorders and its well-known risk factors; however, there are limited studies in this part of the world. The aims were as follows: (1) To study the relation between serum Vitamin D level between nonhypertensive and hypertensive patients. (2) To study the relation of serum Vitamin D levels in patients with isolated systolic hypertension (ISH), isolated diastolic hypertension, systolo-diastolic hypertension, and their comparison vis-à-vis nonhypertensives. Materials and Methods A cross-sectional study was conducted with 154 patients attending medicine outpatient department of a tertiary care hospital of North Bengal from June 2012 to May 2013. The Vitamin D was measured by direct ELISA method. Blood pressure (BP) measurements were done. Statistical analysis was done by using SPSS 16.0 for Windows. Results The Vitamin D level in the hypertensive group was 22.36 ± 12.64; ISH Group was 22.04 ± 14.26; the isolated diastolic hypertension (IDH) Group was 18.82 ± 0.00; and the systolo-diastolic hypertensives (SDH) Group was 22.67 ± 12.51. Then, the mean value of Vitamin D in nonhypertensive Group (27.47 ± 13.43) was significantly (P < 0.05) higher than IDH, SDH, and the hypertensive as a whole groups. The relation with ISH Group also reached near significance (P = 0.074). There was a negative correlation with BP and serum Vitamin D. This remained statistically significant (P = 0.044) for systolic BP (SBP) and near significant (P = 0.075) for mean arterial pressure. In population having serum Vitamin D <30 ng/ml (deficient or insufficient), the negative correlation relationship between SBP and serum Vitamin D remains statistically significant (P = 0.010). Conclusion Among the hypertensives, SDH shows significantly lower levels of serum Vitamin D. The patients with ISH show a trend, though not statistically significant, toward a lower level of Vitamin D compared to the nonhypertensive population.
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Affiliation(s)
- Arnab Kar
- Department of General Medicine, Malda Medical College, Malda, West Bengal, India
| | - Sumana Datta
- ART Centre, Malda Medical College, Malda, West Bengal, India
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Qiu S, Cai X, Sun Z, Zügel M, Steinacker JM, Schumann U. Aerobic Interval Training and Cardiometabolic Health in Patients with Type 2 Diabetes: A Meta-Analysis. Front Physiol 2017; 8:957. [PMID: 29218018 PMCID: PMC5703832 DOI: 10.3389/fphys.2017.00957] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/10/2017] [Indexed: 12/28/2022] Open
Abstract
Vigorous to maximal aerobic interval training (INT) has received remarkable interest in improving cardiometabolic outcomes for type 2 diabetes patients recently, yet with inconsistent findings. This meta-analysis was aimed to quantify its effectiveness in type 2 diabetes. Randomized controlled trials (RCTs) were identified by searches of 3 databases to October 2017, which evaluated the effects of INT with a minimal training duration of 8 weeks vs. moderate-intensity continuous training (MICT) or non-exercise training (NET) among type 2 diabetes patients on outcomes including cardiorespiratory fitness, glycemic control, body composition, blood pressure, and lipid profiles. Weighted mean differences with 95% confidence intervals (CIs) were calculated with the random-effects model. Nine datasets from 7 RCTs with 189 patients were included. Compared with MICT, INT improved maximal oxygen consumption (VO2max) by 2.60 ml/kg/min (95% CI: 1.32 to 3.88 ml/kg/min, P <0.001) and decreased hemoglobin A1c (HbA1c) by 0.26% (95% CI: −0.46% to −0.07%, P = 0.008). These outcomes for INT were also significant vs. energy expenditure-matched MICT, with VO2max increased by 2.18 ml/kg/min (P = 0.04) and HbA1c decreased by 0.28% (P = 0.01). Yet their magnitudes of changes were larger compared with NET, with VO2max increased by 6.38 ml/kg/min (P <0.001) and HbA1c reduced by 0.83% (P = 0.004). Systolic blood pressure could be lowered by INT compared with energy expenditure-matched MICT or NET (both P <0.05), but other cardiometabolic markers and body composition were not significantly altered in general. In conclusion, despite a limited number of studies, INT improves cardiometabolic health especially for VO2max and HbA1c among patients with type 2 diabetes, and might be considered an alternative to MICT. Yet the optimal training protocols still require to be established.
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Affiliation(s)
- Shanhu Qiu
- Department of Endocrinology, Institute of Diabetes, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xue Cai
- Department of Endocrinology, Institute of Diabetes, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Zilin Sun
- Department of Endocrinology, Institute of Diabetes, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Martina Zügel
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
| | - Jürgen M Steinacker
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
| | - Uwe Schumann
- Division of Sports and Rehabilitation Medicine, Ulm University Medical Center, Ulm, Germany
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Bertoluci MC, Moreira RO, Faludi A, Izar MC, Schaan BD, Valerio CM, Bertolami MC, Chacra AP, Malachias MVB, Vencio S, Saraiva JFK, Betti R, Turatti L, Fonseca FAH, Bianco HT, Sulzbach M, Bertolami A, Salles JEN, Hohl A, Trujilho F, Lima EG, Miname MH, Zanella MT, Lamounier R, Sá JR, Amodeo C, Pires AC, Santos RD. Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM). Diabetol Metab Syndr 2017; 9:53. [PMID: 28725272 PMCID: PMC5512820 DOI: 10.1186/s13098-017-0251-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/30/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes. MAIN BODY The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy. CONCLUSIONS Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.
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Affiliation(s)
- Marcello Casaccia Bertoluci
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, Porto Alegre, RS 90035-003 Brazil
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-903 Brazil
| | - Rodrigo Oliveira Moreira
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
- Faculdade de Medicina de Valença (FMV), Rua Sebastião Dantas Moreira, 40, Valença, RJ 27600-000 Brazil
- Faculdade de Medicina da Universidade Presidente Antônio Carlos (FAME/UNIPAC), Av. Juiz de Fora, 1100, Juiz De Fora, MG 36048-000 Brazil
| | - André Faludi
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Maria Cristina Izar
- Universidade Federal de São Paulo (UNIFESP), Rua Loefgren, 1350, São Paulo, SP 04040-001 Brazil
| | | | - Cynthia Melissa Valerio
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ 20211-340 Brazil
| | - Marcelo Chiara Bertolami
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Ana Paula Chacra
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Sérgio Vencio
- Universidade Federal de Goiás (UFG), 1ª Avenida, s/n, Setor Leste Universitário, Goiânia, GO 74605-020 Brazil
| | - José Francisco Kerr Saraiva
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Av. John Boyd Dunlop, s/n, Campinas, SP 13059-900 Brazil
| | - Roberto Betti
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | - Luiz Turatti
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Henrique Tria Bianco
- Universidade Federal de São Paulo (UNIFESP), Rua Loefgren, 1350, São Paulo, SP 04040-001 Brazil
| | - Marta Sulzbach
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Adriana Bertolami
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - João Eduardo Nunes Salles
- Faculdade de Ciências, Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr, 112, São Paulo, SP 01221-020 Brazil
| | - Alexandre Hohl
- Universidade Federal de Santa Catarina (UFSC), Rua Profa. Maria Flora Pausewang, s/n, Florianópolis, SC 88040-970 Brazil
| | - Fábio Trujilho
- Clínica de Endocrinologia e Metabologia, Av. Tancredo Neves, 1632/708, Salvador, BA 41820-020 Brazil
| | - Eduardo Gomes Lima
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | - Marcio Hiroshi Miname
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
| | | | - Rodrigo Lamounier
- Centro de Diabetes de Belo Horizonte, Rua Niquel, 31, Belo Horizonte, MG 30220-280 Brazil
| | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia, Av. Dante Pazzanese, 500, São Paulo, SP 04012-180 Brazil
| | - Antonio Carlos Pires
- Faculdade de Medicina de São José do Rio Preto, Av. Brg. Faria Lima, 5416, São José do Rio Preto, SP 15090-000 Brazil
| | - Raul D. Santos
- Universidade de São Paulo (USP), Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP 05403-000 Brazil
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Chillarón JJ, Roux JAFL, Benaiges D, Pedro-Botet J. Subclinical cardiovascular disease in type 2 diabetes mellitus: To screen or not to screen. World J Clin Cases 2014; 2:415-421. [PMID: 25232543 PMCID: PMC4163762 DOI: 10.12998/wjcc.v2.i9.415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/30/2014] [Accepted: 07/14/2014] [Indexed: 02/05/2023] Open
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) has risen in recent decades, and cardiovascular disease remains the leading cause of death in this population. Several clinical trials have demonstrated the benefit of tight control of risk factors on the incidence and mortality of cardiovascular disease. However, in clinical practice, few patients achieve the therapeutic goals. The current diagnostic procedures for subclinical cardiovascular disease in T2DM patients have not been shown to improve prognosis or mortality, probably because they do not categorize cardiovascular risk. Thus, clinical practice guidelines do not systematically recommend screening for subclinical atherosclerosis in these patients, although it is known that patients with extra-coronary atherosclerosis, microangiopathy and poorly-controlled cardiovascular risk factors are at high risk for cardiovascular disease. Improvements in the reliability of diagnostic tests, with fewer side effects and better cost efficiency, may better help to stratify cardiovascular risk in this group of patients, and further evaluation on this topic should be considered.
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Lavie CJ, Johannsen N, Swift D, Sénéchal M, Earnest C, Church T, Hutber A, Sallis R, Blair SN. Exercise is Medicine - The Importance of Physical Activity, Exercise Training, Cardiorespiratory Fitness and Obesity in the Prevention and Treatment of Type 2 Diabetes. EUROPEAN ENDOCRINOLOGY 2014; 10:18-22. [PMID: 29872459 PMCID: PMC5983092 DOI: 10.17925/ee.2014.10.01.18] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/26/2013] [Indexed: 01/22/2023]
Abstract
Type 2 diabetes has reached epidemic proportions worldwide and is associated with increased risk of cardiovascular diseases and premature mortality. Diet and physical activity (PA)-based lifestyle interventions have been shown to prevent progression to type 2 diabetes in patients at high risk. Regular PA substantially reduces the risk of type 2 diabetes and a high level of PA is associated with a substantial reduction in type 2 diabetes risk. In addition, there is strong evidence suggesting a steep inverse relationship between both PA and cardiorespiratory fitness (CRF) and mortality in patients with type 2 diabetes. Of particular concern is the dramatic, steep increase in mortality among patients with low CRF. An important point is that obese individuals who are at least moderately fit have a lower mortality risk than those who are normal weight but unfit. A large body of evidence demonstrates that exercise improves glycaemic control in type 2 diabetes; the greatest improvements are achieved with combined aerobic and resistance training. A primary goal of public health strategies is to promote PA and move patients out of the least fit, highrisk cohort by increasing PA among the least active. Any plan to deal with the global epidemic of type 2 diabetes must give major attention to low PA and how this can be reversed in the general population.
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Affiliation(s)
- Carl J Lavie
- Professor of Medicine, Medical Director, Cardiac Rehabilitation and Prevention Director, Stress Testing Laboratory, Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, and Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, US
| | - Neil Johannsen
- Assistant Professor, School of Kinesiology, Louisiana State University and Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, US
| | - Damon Swift
- Postdoctoral Researcher, Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana, US
| | - Martin Sénéchal
- Postdoctoral Researcher, Manitoba Institute of Child Health, Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Conrad Earnest
- Professor, Department for Health, University of Bath, UK and Pennington Biomedical Research Center, Baton Rouge, Louisiana, US
| | - Timothy Church
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, US
| | - Adrian Hutber
- Vice President, Exercise is Medicine, American College of Sports Medicine, Indianapolis, Indiana, US
| | - Robert Sallis
- Department of Family Medicine, Fontana Medical Center, Kaiser Permanente, Southern California, California, US
| | - Steven N Blair
- Professor, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, US
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Johannsen NM, Swift DL, Lavie CJ, Earnest CP, Blair SN, Church TS. Categorical analysis of the impact of aerobic and resistance exercise training, alone and in combination, on cardiorespiratory fitness levels in patients with type 2 diabetes: results from the HART-D study. Diabetes Care 2013; 36:3305-12. [PMID: 23877979 PMCID: PMC3781553 DOI: 10.2337/dc12-2194] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Low cardiorespiratory fitness (CRF) is an independent risk factor for cardiovascular disease (CVD), especially in individuals with type 2 diabetes. Age-predicted, sex-stratified, and maximal MET cut points have been developed to determine the risk of CVD events and mortality in low CRF categories. We examined the proportion of Health Benefits of Aerobic and Resistance Training in Individuals With Type 2 Diabetes (HART-D) participants above these cut points before and after 9 months of aerobic training (AT), resistance training (RT), or a combination of both (ATRT). RESEARCH DESIGN AND METHODS Participants from the HART-D study (n=196) who were randomly assigned to exercise training (AT, RT, or ATRT) or to a nonexercise control group between April 2007 and August 2009 were used in this ancillary study. Cut points were previously established for age-predicted METs (>100% and >85%, mean and increased CVD risk, respectively), age- and sex-stratified METs (Aerobic Center Longitudinal Study), and clinically discernible METs (men>8.0, women>6.5). RESULTS Baseline prevalence of participants above these cut points was similar for all intervention groups (P>0.50) and ranged from 11.9% (>100% age predicted) to 55.1% (>85% age predicted). Baseline prevalence and age-, sex-, and race/ethnic group-adjusted percentage of participants above each cut point increased significantly after AT and ATRT (P<0.05 for all). CONCLUSIONS Structured exercise training, especially the AT component, was associated with a greater number of participants moving above established cut points indicative of low CRF. These results have public health and clinical implications for the growing number of patients with type 2 diabetes at high risk for CVD.
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Sandercock GRH, Cardoso F, Almodhy M, Pepera G. Cardiorespiratory fitness changes in patients receiving comprehensive outpatient cardiac rehabilitation in the UK: a multicentre study. Heart 2012. [DOI: 10.1136/heartjnl-2012-303055] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Di Franco A, Lanza GA, Di Monaco A, Sestito A, Lamendola P, Nerla R, Tarzia P, Virdis D, Vollono C, Valeriani M, Crea F. Coronary microvascular function and cortical pain processing in patients with silent positive exercise testing and normal coronary arteries. Am J Cardiol 2012; 109:1705-10. [PMID: 22459303 DOI: 10.1016/j.amjcard.2012.02.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/05/2012] [Accepted: 02/05/2012] [Indexed: 11/19/2022]
Abstract
ST-segment depression during exercise stress testing in asymptomatic subjects showing normal coronary arteries is considered a "false-positive" result. Coronary microvascular dysfunction, however, might be a possible cause of ST-segment depression in these cases. We assessed the coronary blood flow response to adenosine and to cold pressor test in the left anterior descending artery, using transthoracic Doppler echocardiography in 14 asymptomatic subjects with exercise-induced ST-segment depression and normal coronary arteries (group 1), 14 patients with microvascular angina (group 2), and 14 healthy subjects (group 3). Flow-mediated dilation was assessed in the brachial artery. Central pain processing was assessed using cortical laser evoked potentials during chest and right hand stimulation with 3 sequences of painful stimuli. The coronary blood flow response to adenosine was 1.8 ± 0.4, 1.9 ± 0.5, and 3.1 ± 0.9 in groups 1, 2, and 3, respectively (p <0.001). The corresponding coronary blood flow responses to the cold pressor test were 1.74 ± 0.4, 1.53 ± 0.3, and 2.3 ± 0.6 (p <0.001). The flow-mediated dilation was 5.5 ± 2.3%, 4.6 ± 2.4%, and 9.8 ± 1.2% in the 3 groups, respectively (p <0.001). The laser evoked potential N2/P2 wave amplitude decreased throughout the 3 sequences of stimulation in groups 1 and 3 but not in group 2 (chest, -19 ± 22%, +11 ± 42% and -36 ± 12%, p <0.001; right hand, -22 ± 25%, +12 ± 43% and -30 ± 20%, p = 0.009; in groups 1, 2, and 3). In conclusion, exercise stress test-induced ST-segment depression in asymptomatic subjects with normal coronary arteries cannot be considered as a simple false-positive result, because it can be related to coronary microvascular dysfunction. The different symptomatic state compared to patients with microvascular angina can, at least in part, be explained by differences in cortical processing of neural pain stimuli.
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Affiliation(s)
- Antonino Di Franco
- Institute of Cardiology, Università Cattolica del Sacro Cuore, Rome, Italy
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Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation 2012; 125:e2-e220. [PMID: 22179539 PMCID: PMC4440543 DOI: 10.1161/cir.0b013e31823ac046] [Citation(s) in RCA: 3169] [Impact Index Per Article: 264.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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12
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Sandercock G, Hurtado V, Cardoso F. Changes in cardiorespiratory fitness in cardiac rehabilitation patients: a meta-analysis. Int J Cardiol 2011; 167:894-902. [PMID: 22206636 DOI: 10.1016/j.ijcard.2011.11.068] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 11/26/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Improving patients' cardiorespiratory fitness is an important therapeutic outcome in cardiac rehabilitation. The ability of cardiac rehabilitation to reduce mortality and morbidity has been evidenced through several meta-analyses. Whether cardiac rehabilitation can increase cardiorespiratory fitness and which factors may influence such gains are less well quantified. METHODS We performed detailed literature searches of electronic databases and manually searched papers concerning changes in cardiorespiratory fitness in cardiac rehabilitation patients. We performed random-effects meta-analysis of mean improvements in cardiorespiratory fitness and subgroup analyses to determine potential sources of heterogeneity. RESULTS Data from 31 studies produced 48 groups (n=3827) with a mean improvement of 1.55 (95% CI 1.21-1.89) METs, (p<0.001); equivalent to standardised effect size of ES=0.97 (95% CI 0.80-1.13). As this value was highly heterogeneous (Q=852, p<0.001) we performed subgroup analyses on the effect size data. Gains in fitness were highest in patients receiving >36 exercise sessions in studies where fitness was assessed using the Naughton Protocol. Patient characteristics associated with the highest fitness gains were age (being young) and sex (being male training in a male-only exercise group). Changes in fitness were unrelated to programme type (comprehensive or exercise-only), duration or study design. There was no association with patient's baseline fitness levels. CONCLUSION This is the first meta-analysis of changes in cardiovascular fitness in cardiac rehabilitation patients and shows clinically significant improvements in a large sample of patients from a variety of rehabilitation programmes. This analysis helps describe the characteristics of cardiac rehabilitation programmes which can increase patients' cardiorespiratory fitness.
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Affiliation(s)
- Gavin Sandercock
- Centre for Sports and Exercise Science, Department of Biological Sciences, University of Essex, Colchester CO43SQ, UK.
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Anderson HS, Kluding PM, Gajewski BJ, Donnelly JE, Burns JM. Reliability of peak treadmill exercise tests in mild Alzheimer disease. Int J Neurosci 2011; 121:450-6. [PMID: 21574893 PMCID: PMC3143203 DOI: 10.3109/00207454.2011.574762] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The purpose of this study was to determine the reliability of treadmill peak exercise testing in people with very mild-to-mild Alzheimer disease (AD). METHODS Sixteen subjects with very mild-to-mild AD performed graded peak treadmill exercise tests twice within a 14-day period. Heart rate, oxygen consumption, and respiratory exchange ratio (RER) were continuously monitored. Peak values were analyzed for absolute level of agreement. RESULTS Fourteen participants (87.5%) completed testing. Reliability was excellent with total peak oxygen consumption (VO2peak) (ml/kg/min) highly correlated across the two tests (r = 0.94, p < .001) with an intraclass correlation coefficient (ICC[3,1]) of 0.92 (95% confidence interval (CI) = 0.78, 0.97). The standard error of measurement (SEM) for VO2peak was 1.29 (95% CI = 0.88, 1.89). CONCLUSIONS These results indicate that peak exercise testing on a treadmill is reliable in the early stages of AD.
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Affiliation(s)
- Heather S Anderson
- Department of Neurology, University of Kansas School of Medicine, Kansas City, Kansas 66160, USA.
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14
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The ECG vertigo in diabetes and cardiac autonomic neuropathy. EXPERIMENTAL DIABETES RESEARCH 2011; 2011:687624. [PMID: 21747831 PMCID: PMC3124253 DOI: 10.1155/2011/687624] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 03/02/2011] [Indexed: 01/20/2023]
Abstract
The importance of diabetes in the epidemiology of cardiovascular diseases cannot be overemphasized. About one third of acute myocardial infarction patients have diabetes, and its prevalence is steadily increasing. The decrease in cardiac mortality in people with diabetes is lagging behind that of the general population. Cardiovascular disease is a broad term which includes any condition causing pathological changes in blood vessels, cardiac muscle or valves, and cardiac rhythm. The ECG offers a quick, noninvasive clinical and research screen for the early detection of cardiovascular disease in diabetes. In this paper, the clinical and research value of the ECG is readdressed in diabetes and in the presence of cardiac autonomic neuropathy.
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15
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Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, Carnethon MR, Dai S, de Simone G, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Greenlund KJ, Hailpern SM, Heit JA, Ho PM, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, McDermott MM, Meigs JB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Rosamond WD, Sorlie PD, Stafford RS, Turan TN, Turner MB, Wong ND, Wylie-Rosett J. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation 2011; 123:e18-e209. [PMID: 21160056 PMCID: PMC4418670 DOI: 10.1161/cir.0b013e3182009701] [Citation(s) in RCA: 3675] [Impact Index Per Article: 282.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.
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Ho JS, FitzGerald SJ, Barlow CE, Cannaday JJ, Kohl HW, Haskell WL, Cooper KH. Risk of mortality increases with increasing number of abnormal non-ST parameters recorded during exercise testing. ACTA ACUST UNITED AC 2010; 17:462-8. [DOI: 10.1097/hjr.0b013e328336a10d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | | | | | - Harold W. Kohl
- University of Texas Health Science Center and University of Texas, Austin, Texas
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17
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Patel NB, Balady GJ. Diagnostic and prognostic testing to evaluate coronary artery disease in patients with diabetes mellitus. Rev Endocr Metab Disord 2010; 11:11-20. [PMID: 20225090 DOI: 10.1007/s11154-010-9129-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Coronary artery disease (CAD) continues to be the most common cause of morbidity and mortality in patients with diabetes mellitus (DM). In recent years, the strategies for treatment of CAD in DM have undergone much evolution. Currently, all patients with DM, regardless of symptoms or diagnosed CAD, are treated aggressively for CAD risk factor reduction. In this clinical climate, the ability to specifically identify patients with disease that will benefit from more aggressive and invasive therapies remains a challenge. In this article we review the current literature on diagnostic and prognostic utility of conventional non-invasive modalities for assessment of CAD in patients with DM, as well as on novel and emerging methods for CAD risk stratification.
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Affiliation(s)
- Neal B Patel
- Section of Cardiology, Department of Medicine, Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA
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18
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Lyerly GW, Sui X, Church TS, Lavie CJ, Hand GA, Blair SN. Maximal exercise electrocardiographic responses and coronary heart disease mortality among men with metabolic syndrome. Mayo Clin Proc 2010; 85:239-46. [PMID: 20160139 PMCID: PMC2843111 DOI: 10.4065/mcp.2009.0509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the association between abnormal exercise electrocardiographic (E-ECG) test results and mortality (all-cause and that resulting from coronary heart disease [CHD] or cardiovascular disease [CVD]) in a large population of asymptomatic men with metabolic syndrome (MetS). PATIENTS AND METHODS A total of 9191 men (mean age, 46.9 years) met the criteria of having MetS. All completed a maximal E-ECG treadmill test (May 14, 1979, through April 9, 2001) and were without a previous CVD event or diabetes at baseline. Main outcomes were all-cause mortality, mortality due to CHD, and mortality due to CVD. Cox regression analysis was used to quantify the mortality risk according to E-ECG responses. RESULTS During a follow-up of 14 years, 633 deaths (242 CVD and 150 CHD) were identified. Mortality rates and hazard ratios (HRs) across E-ECG responses were the following: for all-cause mortality: HR, 1.36; 95% confidence interval (CI), 1.09-1.70 for equivocal responses and HR, 1.41; 95% CI, 1.12-1.77 for abnormal responses (P(trend)<.001); for mortality due to CVD: HR, 1.29; 95% CI, 0.88-1.88 for equivocal responses and HR, 2.04; 95% CI, 1.46-2.84 for abnormal responses (P(trend)<.001); and for mortality due to CHD: HR, 1.62; 95% CI, 1.02-2.56 for equivocal responses and HR, 2.45; 95% CI, 1.62-3.69 for abnormal responses (P(trend)<.001). A positive gradient for CHD, CVD, and all-cause mortality rates across E-ECG categories within 3, 4, or 5 MetS components was observed (P<.001 for all). CONCLUSION Among men with MetS, an abnormal E-ECG response was associated with higher risk of all-cause, CVD, and CHD mortality. These findings underscore the importance of E-ECG tests to identify men with MetS who are at risk of dying.
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Affiliation(s)
- G William Lyerly
- Department of Kinesiology, School of Health, Kinesiology, and Sport Studies, Coastal Carolina University, PO Box 261954, Conway, SC 29528, USA.
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Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J. Heart Disease and Stroke Statistics—2010 Update. Circulation 2010; 121:e46-e215. [PMID: 20019324 DOI: 10.1161/circulationaha.109.192667] [Citation(s) in RCA: 2603] [Impact Index Per Article: 185.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Affiliation(s)
- Shlomo Stern
- The Hebrew University of Jerusalem, Jerusalem, Israel.
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Affiliation(s)
- Ho-Joong Youn
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Weltman NY, Saliba SA, Barrett EJ, Weltman A. The Use of Exercise in the Management of Type 1 and Type 2 Diabetes. Clin Sports Med 2009; 28:423-39. [DOI: 10.1016/j.csm.2009.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Hoeks S, Flu WJ, van Kuijk JP, Bax J, Poldermans D. Cardiovascular risk assessment of the diabetic patient undergoing major noncardiac surgery. Best Pract Res Clin Endocrinol Metab 2009; 23:361-73. [PMID: 19520309 DOI: 10.1016/j.beem.2009.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Noncardiac surgery is associated with an increased risk for cardiovascular morbidity and mortality. It is important to stratify the risk of these patients for perioperative cardiac events. Diabetes, a presently rapidly expanding disease, is a major risk factor for cardiovascular morbidity and mortality. Importantly, silent ischemia is more common in diabetic patients than in the general population. When preoperative risk assessment identifies an increased risk, further cardiac testing is warranted. The most commonly used stress tests for detecting cardiac ischemia is treadmill or bicycle ergometry. However, patients undergoing noncardiac surgery frequently have limited exercise capacity due to co-morbidities. Pharmacologic testing, such as dobutamine stress echocardiography and dipyridamole myocardial perfusion scintigraphy can be performed in patients with limited exercise capacity. Non-invasive stress testing should be considered, especially in diabetic patients, to detect asymptomatic coronary artery disease. Furthermore, when an increased cardiac risk is assessed, two strategies could be used to reduce the incidence of perioperative cardiac events: 1) prophylactic coronary revascularization from which the value is still controversial, and 2) pharmacological treatment (with beta-blockers, statins and aspirin), associated with improved post-operative outcome.
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Affiliation(s)
- Sanne Hoeks
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RV. Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease. Mayo Clin Proc 2009; 84:373-83. [PMID: 19339657 PMCID: PMC2665984 DOI: 10.1016/s0025-6196(11)60548-x] [Citation(s) in RCA: 216] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Substantial data have established a sedentary lifestyle as a major modifiable risk factor for coronary heart disease (CHD). Increased levels of physical activity, exercise training, and overall cardiorespiratory fitness have provided protection in the primary and secondary prevention of CHD. This review surveys data from observational studies supporting the benefits of physical activity, exercise training, and overall cardiorespiratory fitness in primary prevention. Clearly, cardiac rehabilitation/secondary prevention (CRSP) programs have been greatly underused by patients with CHD. We review the benefits of CRSP programs on CHD risk factors, psychological factors, and overall CHD morbidity and mortality. These data support the routine referral of patients with CHD to CRSP programs. Patients should be vigorously encouraged to attend these programs.
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Affiliation(s)
- Carl J Lavie
- Cardiac Rehabilitation and Exercise Laboratories, Ochsner Medical Center, New Orleans, LA 70121-2483, USA.
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Freeman J, Ashley EA, Froelicher V. Should the exercise ECG be used to screen for sudden cardiac death? Eur Heart J 2009; 30:528-9. [DOI: 10.1093/eurheartj/ehp029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, Ford E, Furie K, Go A, Greenlund K, Haase N, Hailpern S, Ho M, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott M, Meigs J, Mozaffarian D, Nichol G, O'Donnell C, Roger V, Rosamond W, Sacco R, Sorlie P, Stafford R, Steinberger J, Thom T, Wasserthiel-Smoller S, Wong N, Wylie-Rosett J, Hong Y. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 119:e21-181. [PMID: 19075105 DOI: 10.1161/circulationaha.108.191261] [Citation(s) in RCA: 1356] [Impact Index Per Article: 84.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Lavie CJ, Milani RV, O'Keefe JH. The russert impact: a golden opportunity to promote primary coronary prevention. Ochsner J 2008; 8:108-113. [PMID: 21603461 PMCID: PMC3096330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
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