Effectiveness of Rehabilitation Interventions in Individuals With Emerging Virtual Respiratory Tract Infectious Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Assessing rehabilitation effectiveness for persistent symptoms post-infection with emerging viral respiratory diseases.

DATA SOURCES

Systematic review of seven databases (MEDLINE, EMBASE, Cochrane Library, PEDro, MedRxiv, CNKI, Wanfang) until 30 December 2023.

REVIEW METHODS

Evaluated 101 studies (9593 participants) on respiratory function, exercise capacity, and quality of life. Methodological quality was assessed using the Cochrane Collaboration's Risk of Bias tool for randomized controlled trials (RCTs), the Newcastle-Ottawa Scale (NOS) for observational studies and non-RCTs, and the NIH Quality Assessment Tools for before-after studies.

RESULTS

The most common rehabilitation program combined breathing exercises with aerobic exercise or strength training. Rehabilitation interventions significantly enhanced respiratory function, as evidenced by improvements on the Borg Scale (MD, -1.85; 95% CI, -3.00 to -0.70, low certainty), the mMRC Dyspnea Scale (MD, -0.45; 95% CI, -0.72 to -0.18, low certainty), and the Multidimensional Dyspnoea-12 Scale (MD, -4.64; 95% CI, -6.54 to -2.74, moderate certainty). Exercise capacity also improved, demonstrated by results from the Six-Minute Walk Test (MD, 38.18; 95% CI, 25.33-51.03, moderate certainty) and the Sit-to-Stand Test (MD, 3.04; 95% CI, 1.07-5.01, low certainty).

CONCLUSION

Rehabilitation interventions are promising for survivors of viral respiratory diseases, yet gaps in research remain. Future investigations should focus on personalizing rehabilitation efforts, utilizing remote technology-assisted programs, improving research quality, and identifying specific subgroups for customized rehabilitation strategies to achieve the best outcomes for survivors.

(Non)-Exertional Variables of Cardiopulmonary Exercise Testing in Heart Failure with and Without Cardiac Amyloidosis

PURPOSE OF REVIEW

Cardiac amyloidosis (CA) constitutes an important etiology of heart failure with preserved ejection fraction (HFpEF) or heart failure with mildly reduced ejection fraction (HFmrEF). Since patients with CA show early exhaustion, we aimed to investigate whether non-exertional variables of cardiopulmonary exercise testing (CPET) provide additional information in comparison to traditional peak oxygen consumption (VO2peak).

RECENT FINDINGS

We retrospectively investigated CPET variables of patients with HFpEF and HFmrEF with (n = 21) and without (n = 21, HF) CA at comparable age and ejection fraction. Exertional and non-exertional CPET variables as well as laboratory and echocardiographic markers were analyzed. The primary outcome was the difference in CPET variables between groups. The secondary outcome was rehospitalization in patients with CA during a follow-up of 24 months. Correlations between CPET, NTproBNP, and echocardiographic variables were calculated to detect patterns of discrimination between the groups. HF patients with CA were inferior to controls in most exertional and non-exertional CPET variables. Patients with CA were hospitalized more often (p = 0.002), and rehospitalization was associated with VE/VCO2 (p = 0.019), peak oxygen pulse (p = 0.042), the oxygen equivalent at the first ventilatory threshold (p = 0.003), circulatory (p = 0.024), and ventilatory power (p < .001), but not VO2peak (p = 0.127). Higher performance was correlated with lower E/e' and NTproBNP as well as higher resting heart rate and stroke volume in CA. Patients with CA displayed worse non-exertional CPET performance compared to non-CA HF patients, which was associated with rehospitalization. Differences between correlations of resting echocardiography and CPET variables between groups emphasize different properties of exercise physiology despite comparable ejection fraction.

Persisting exercise ventilatory inefficiency in subjects recovering from COVID-19. Longitudinal data analysis 34 months post-discharge

BACKGROUND

SARS-CoV-2 infection has raised concerns about long-term health repercussions. Exercise ventilatory inefficiency (EVin) has emerged as a notable long-term sequela, potentially impacting respiratory and cardiovascular health. This study aims to assess the long-term presence of EVin after 34 months and its association with cardiorespiratory health in post-COVID patients.

METHODS

In a longitudinal study on 32 selected post-COVID subjects, we performed two cardiopulmonary exercise tests (CPETs) at 6 months (T0) and 34 months (T1) after hospital discharge. The study sought to explore the long-term persistence of EVin and its correlation with respiratory and cardiovascular responses during exercise. Measurements included also V̇O2peak, end-tidal pressure of CO2 (PETCO2) levels, oxygen uptake efficiency slope (OUES) and other cardiorespiratory parameters, with statistical significance set at p < 0.05. The presence of EVin at both T0 and T1 defines a persisting EVin (pEVin).

RESULTS

Out of the cohort, five subjects (16%) have pEVin at 34 months. Subjects with pEVin, compared to those with ventilatory efficiency (Evef) have lower values of PETCO2 throughout exercise, showing hyperventilation. Evef subjects demonstrated selective improvements in DLCO and oxygen pulse, suggesting a recovery in cardiorespiratory function over time. In contrast, those with pEvin did not exhibit these improvements. Notably, significant correlations were found between hyperventilation (measured by PETCO2), oxygen pulse and OUES, indicating the potential prognostic value of OUES and Evin in post-COVID follow-ups.

CONCLUSIONS

The study highlights the clinical importance of long-term follow-up for post-COVID patients, as a significant group exhibit persistent EVin, which correlates with altered and potentially unfavorable cardiovascular responses to exercise. These findings advocate for the continued investigation into the long-term health impacts of COVID-19, especially regarding persistent ventilatory inefficiencies and their implications on patient health outcomes.

The evolving role of cardiopulmonary exercise testing in ischemic heart disease - state of the art review

PURPOSE OF REVIEW

Cardiopulmonary exercise testing (CPET) is the gold standard for directly assessing cardiorespiratory fitness (CRF) and has a relatively new and evolving role in evaluating atherosclerotic heart disease, particularly in detecting cardiac dysfunction caused by ischemic heart disease. The purpose of this review is to assess the current literature on the link between cardiovascular (CV) risk factors, cardiac dysfunction and CRF assessed by CPET.

RECENT FINDINGS

We summarize the basics of exercise physiology and the key determinants of CRF. Prognostically, several studies have been published relating directly measured CRF by CPET and outcomes allowing for more precise risk assessment. Diagnostically, this review describes in detail what is considered healthy and abnormal cardiac function assessed by CPET. New studies demonstrate that cardiac dysfunction on CPET is a common finding in asymptomatic individuals and is associated with CV risk factors and lower CRF. This review covers how key CPET parameters change as individuals transition from the asymptomatic to the symptomatic stage with progressively decreasing CRF. Finally, a supplement with case studies with long-term longitudinal data demonstrating how CPET can be used in daily clinical decision making is presented.

SUMMARY

In summary, CPET is a powerful tool to provide individualized CV risk assessment, monitor the effectiveness of therapeutic interventions, and provide meaningful feedback to help patients guide their path to improve CRF when routinely used in the outpatient setting.

Physical exercise as a treatment for persisting symptoms post-COVID infection: review of ongoing studies and prospective randomized controlled training study

BACKGROUND AND PURPOSE

No evidence-based treatment is available for patients with persisting symptoms post-COVID-19 infection. We hypothesized that physical exercise may represent a safe and effective treatment option for post-COVID.

METHODS

We performed a systematic search of the literature that revealed a lack of randomized training studies in patients post-COVID. Based on these findings, a prospective randomized controlled study with open-label and blinded endpoint evaluation was designed. 272 patients with symptoms of fatigue persisting over 6 weeks post-COVID infection were screened. Patients with pathological cardiovascular findings were excluded. 57 patients consented and were randomized to 4 weeks of supervised personalized strength and endurance training or usual care. The follow-up period was 3 and 6 months.

RESULTS

There were no adverse events related to the training. Spiroergometry of the training group showed a significantly higher increase in VO2peak (10.0 ± 12.7% vs. 0.1 ± 8.9%, p < 0.01, respectively) and oxygen pulse (9.8 ± 10.8% vs. 0.0 ± 13.9%, p < 0.05, respectively). Parameters of the Multidimensional Fatigue Inventory-20, McGill Quality of Life Questionnaire, and Post-COVID-19 Functional Status were improved after 4 weeks in both groups. In the follow-up period, the total physical activity per week was significantly greater in the exercise group than in controls (1280 ± 1192 min vs. 644 ± 554 min, p < 0.05, respectively). The improvements in fatigue and quality of life were not statistically different between the training and usual care groups.

CONCLUSION

Exercise is safe and improves maximal exercise capacity in post-COVID patients. Fatigue and quality of life improve over time in individuals that are willing to participate in a training study irrespective of their allocation.

REGISTRATION

German Clinical Trials Register: DRKS00026686. Date of registration: 27.09.2021.

The cardiorespiratory optimal point as a discriminator of lesion severity in adults with congenital heart disease

BACKGROUND

Peak oxygen consumption (VO2peak), which depends on maximal exertion and is reduced in adults with congenital heart disease (ACHD), is associated with lesion severity. The lowest ventilatory equivalent for oxygen (the minimum value of VE/VO2) reflects the cardiorespiratory optimal point (COP) as best possible respiration-circulatory interaction and may discriminate between lesion types without the need for maximal exertion. However, data on COP in ACHD is scarce.

METHODS

We retrospectively analyzed stable ACHD with moderate (N.=13) and severe lesions (N.=17) reporting to our outpatient clinic undergoing cardiopulmonary exercise testing. The primary outcome of the study was the difference of COP between moderate and severe lesions. Secondary outcomes were between group differences of the submaximal variable exercise oxygen uptake efficiency slope (OUES) and peak O2 pulse (O2pulsemax) as a surrogate for peripheral oxygen extraction and stroke volume increase during exercise.

RESULTS

The group of severe lesions displayed higher COP (29.5±7.0 vs. 25.2±6.2, P=0.028) as well as lower O2pulsemax (13.3±8.4 vs. 14.9±3.4 mL/beat/kg 102, P=0.038). VO2peak (17.4±6.5 vs. 20.8±8.5 mL/kg/min, P=0.286) and OUES (1.5±0.7 vs. 1.8±0.9, P=0.613) showed a trend towards lower values in severe lesions. COP was a better between group discriminator than O2pulsemax (area under the curve 73.8% vs. 72.4%).

CONCLUSIONS

As a submaximal variable, COP discriminated between moderate and severe lesions and may prove beneficial in a highly vulnerable population that is often unable to undergo exertional testing.

Cardiopulmonary Profiling of Athletes with Post-Exertional Malaise after COVID-19 Infection-A Single-Center Experience

(1) Background: Cardiopulmonary exercise testing (CPET) has been suggested by the European Society of Cardiology (ESC) for assessing the exercise limitations of apparently healthy individuals, but data on elite athletes regarding this test are scarce. (2) Methods: We analyzed CPET in elite (n = 43, 21.9 ± 3.7 years) and recreational (n = 40, 34.7 ± 13.0 years) athletes with persistent subjective exercise intolerance and post-exertional malaise (PEM) after COVID-19 infection. The primary outcome was the point prevalence of the adequate cardiopulmonary response (ACPR), defined by the presence of all of the following ESC criteria for apparently healthy individuals: (1) >100% of predicted peak oxygen consumption (predVO2peak), (2) VE/VCO2 < 30, (3) no exercise oscillatory ventilation (EOV), and (4) heart rate recovery of ≥12 beats/minute 1 min after exercise termination (HRR1). Results: ACPR occurred more frequently in elite athletes than in recreational athletes (70.0% vs. 39.5%; p = 0.005), mainly driven by the lower VE/VCO2 (<30: 97.7% vs. 65%, p < 0.001). Elite (11.6%) and recreational athletes (22.5%) showing a plateau of O2 pulse did not display ACPR. Conclusions: ACPR was not observed in all recreational and elite athletes with PEM. In particular, perturbed VE/VCO2 and the plateauing of O2 pulse are suitable for quantifying exercise limitations and may identify a high-risk population with long-COVID-19 syndrome who require their training intensities to be adapted.

Increased Dead Space Ventilation as a Contributing Factor to Persistent Exercise Limitation in Patients with a Left Ventricular Assist Device

(1) Background: The exercise capacity of patients with a left ventricular assist device (LVAD) remains limited despite mechanical support. Higher dead space ventilation (VD/VT) may be a surrogate for right ventricular to pulmonary artery uncoupling (RV-PA) during cardiopulmonary exercise testing (CPET) to explain persistent exercise limitations. (2) Methods: We investigated 197 patients with heart failure and reduced ejection fraction with (n = 89) and without (HFrEF, n = 108) LVAD. As a primary outcome NTproBNP, CPET, and echocardiographic variables were analyzed for their potential to discriminate between HFrEF and LVAD. As a secondary outcome CPET variables were evaluated for a composite of hospitalization due to worsening heart failure and overall mortality over 22 months. (3) Results: NTproBNP (OR 0.6315, 0.5037-0.7647) and RV function (OR 0.45, 0.34-0.56) discriminated between LVAD and HFrEF. The rise of endtidal CO2 (OR 4.25, 1.31-15.81) and VD/VT (OR 1.23, 1.10-1.40) were higher in LVAD patients. Group (OR 2.01, 1.07-3.85), VE/VCO2 (OR 1.04, 1.00-1.08), and ventilatory power (OR 0.74, 0.55-0.98) were best associated with rehospitalization and mortality. (4) Conclusions: LVAD patients displayed higher VD/VT compared to HFrEF. Higher VD/VT as a surrogate for RV-PA uncoupling could be another marker of persistent exercise limitations in LVAD patients.

Feasibility of Aerobic Exercise Training to Mitigate Cardiotoxicity of Breast Cancer Therapy: A Systematic Review and Meta-Analysis

BACKGROUND

Current anticancer treatments for breast cancer (BC) may cause cardiotoxicity. This study aimed to investigate the effectiveness of aerobic exercise in mitigating cardiotoxicity caused by BC therapy.

MATERIALS AND METHODS

PubMed, Embase, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database were searched until February 7, 2023. Clinical trials investigating the effectiveness of exercise training, including aerobic exercise, in BC patients receiving treatments that could cause cardiotoxicity were eligible. Outcome measures included cardiorespiratory fitness (CRF) (peak oxygen consumption, VO₂peak), left ventricular ejection fraction, and peak oxygen pulse. Intergroup differences were determined by standard mean differences (SMD) and 95% confidence intervals (CIs). Trial sequential analysis (TSA) was utilized to ensure whether the current evidence was conclusive.

RESULTS

Sixteen trials involving 876 participants were included. Aerobic exercise significantly improved CRF measured by VO₂peak in mL/kg/min (SMD 1.79, 95% CI 0.99-2.59) when compared to usual care. This result was confirmed through TSA. Subgroup analyses revealed that aerobic exercise given during BC therapy significantly improved VO₂peak (SMD 1.84, 95% CI 0.74-2.94). Exercise prescriptions at a frequency of up to 3 times per week, an intensity of moderate to vigorous, and a >30-minute session length also improved VO₂peak.

CONCLUSION

Aerobic exercise is effective in improving CRF when compared to usual care. Exercise performed up to 3 times per week, at a moderate-to-vigorous intensity, and having a session length >30 minutes is considered effective. Future high-quality research is needed to determine the effectiveness of exercise intervention in preventing cardiotoxicity caused by BC therapy.

Heart failure classification based on resting ejection fraction does not display a unique exercise response pattern

BACKGROUND

Heart failure with preserved (HFpEF), mildly reduced (HFmrEF) and reduced (HFrEF) ejection fraction (EF) remains a controversial categorization. Whether these three categories reflect a distinct pattern of exercise limitation in cardiopulmonary exercise testing (CPET) needs to be investigated. We aimed to analyze whether CPET variables differ between all heart failure categories (HF).

METHODS

We analyzed CPET variables of stable HFpEF (n = 123), HFmrEF (n = 31), and HFrEF (n = 153; 74 patients with and 79 patients without left ventricular assist device, LVAD) patients. The association between HF and peak oxygen consumption (VO_2peak) was used as a primary outcome, while the association between HF, oxygen uptake efficiency slope (OUES), and increase of O₂ pulse (ΔO₂ pulse) were analyzed as secondary outcomes.

RESULTS

VO_2peak displayed a consistent decline across all HF categories (19.8 ml ± 6.2/kg/min vs. 17.5 ± 7.9 ml/kg/min vs. 13.7 ± 4.0 ml/kg/min, p < 0.001). OUES only showed differences between HFpEF and HFrEF (1.8 ± 0.6 vs. 1.4 ± 0.5, p < 0.001) as well as HFmrEF and HFrEF (1.9 ± 0.9 vs. 1.4 ± 0.5, p = 0.004). ΔO₂ pulse differed between HFpEF and HFrEF (7.7 ± 3.5 ml/beat/kg*100 vs. 5.5 ± 3.0 ml/beat/kg*100, p < 0.001) as well as HFpEF and HFmrEF (7.7 ± 3.5 ml/beat/kg*100 vs. 6.3 ± 4.1 ml/beat/kg*100, p = 0.049). Outcome variables did not differ between HFrEF with and without LVAD support (VO_2peak: p = 0.364, OUES: p = 0.129, ΔO₂ pulse: p = 0.564).

CONCLUSIONS

HF did not display a distinct CPET profile. Thus, EF-based categorization does not entirely reflect exercise limitations. CPET variables could contribute to better characterize HF phenotypes.

Indoxyl sulfate mediates low handgrip strength and is predictive of high hospitalization rates in patients with end-stage renal disease

Background and aims

Sarcopenia has a higher occurrence rate in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) than in the general population. Low handgrip strength-and not sarcopenia per se-is associated with clinical outcomes in patients with CKD, including cardiovascular mortality and hospitalization. The factors contributing to low handgrip strength are still unknown. Accordingly, this study aimed to determine whether uremic toxins influence low handgrip strength in patients with CKD.

Materials and methods

This cohort study lasted from August 2018 to January 2020. The participants were divided into three groups: the control group [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min], an advanced CKD group (eGFR = 15-60 ml/min), and an ESRD group (under maintenance renal replacement therapy). All participants underwent handgrip strength measurement, dual-energy X-ray absorptiometry, and blood sampling for myokines (irisin, myostatin, and interleukin 6) and indoxyl sulfate. Sarcopenia was defined according to the Asian Working Group for Sarcopenia consensus as low appendicular skeletal muscle index (appendicular skeletal muscle/height2 of < 7.0 kg/m2 in men and < 5.4 kg/m2 in women) and low handgrip strength (< 28 kg in men and < 18 kg in women).

Results

Among the study participants (control: n = 16; CKD: n = 17; and ESRD: n = 42), the ESRD group had the highest prevalence of low handgrip strength (41.6 vs. 25% and 5.85% in the control and CKD groups, respectively; p < 0.05). The sarcopenia rate was similar among the groups (12.5, 17.6, and 19.5% for the control, CKD, and ESRD groups, respectively; p = 0.864). Low handgrip strength was associated with high hospitalization rates within the total study population during the 600-day follow-up period (p = 0.02). The predictions for cardiovascular mortality and hospitalization were similar among patients with and without sarcopenia (p = 0.190 and p = 0.094). The serum concentrations of indoxyl sulfate were higher in the ESRD group (227.29 ± 92.65 μM vs. 41.97 ± 43.96 μM and 6.54 ± 3.45 μM for the CKD and control groups, respectively; p < 0.05). Myokine concentrations were similar among groups. Indoxyl sulfate was associated with low handgrip strength in univariate and multivariate logistic regression models [univariate odds ratio (OR): 3.485, 95% confidence interval (CI): 1.372-8.852, p = 0.001; multivariate OR: 8.525, 95% CI: 1.807-40.207, p = 0.007].

Conclusion

Handgrip strength was lower in the patients with ESRD, and low handgrip strength was predictive of hospitalization in the total study population. Indoxyl sulfate contributed to low handgrip strength and counteracted the benefits of myokines in patients with CKD.

Betablockers reduce oxygen pulse increase and performance in heart failure patients with preserved ejection fraction

BACKGROUND

Beta blockers (BB) reduce chronotropic response and exercise capacity in heart failure with preserved ejection fraction (HFpEF). To analyze the influence of BB on exercise performance and O 2 pulse increase as a surrogate for stroke volume in HFpEF.

METHODS

We retrospectively analyzed the influence of BB intake (yes: n = 48/no: n = 51) on peak oxygen uptake (VO 2peak), oxygen uptake efficiency slope (OUES), and increase of O 2 pulse in HFpEF patients undergoing cardiopulmonary exercise testing (CPET). Associations of outcome variables and risk category of the algorithm of the Heart Failure Association of the European Society of Cardiology (HFA-PEFF score) were calculated.

RESULTS

Patients on BB showed lower VO 2peak (p = .003) and OUES (p = .002), with a dominant effect in the high-risk (p = .020; 0.002), but not in the low risk-group (p = .434; p = .499). In the intermediate group BB showed a trend towards lower VO 2peak (p = .078) and lower values for OUES (p = .020). Patients on BB also demonstrated a lower increase of O 2 pulse during exercise (p = .002), without differences between HFA-PEFF risk groups (low: p = .322, intermediate: p = .269, high: p = .313).

CONCLUSIONS

BB reduce exercise capacity and O 2 pulse increase in HFpEF patients. Direct quantification of O 2 pulse increase may help to improve the discrimination of HFpEF patients.

Influence of extracellular volume fraction on peak exercise oxygen pulse following thoracic radiotherapy

Background

Radiation-induced myocardial fibrosis increases heart failure (HF) risk and is associated with a restrictive cardiomyopathy phenotype. The myocardial extracellular volume fraction (ECVF) using contrast-enhanced cardiac magnetic resonance (CMR) quantifies the extent of fibrosis which, in severe cases, results in a noncompliant left ventricle (LV) with an inability to augment exercise stroke volume (SV). The peak exercise oxygen pulse (O₂Pulse), a noninvasive surrogate for exercise SV, may provide mechanistic insight into cardiac reserve. The relationship between LV ECVF and O₂Pulse following thoracic radiotherapy has not been explored.

Methods

Patients who underwent thoracic radiotherapy for chest malignancies with significant incidental heart dose (≥5 Gray (Gy), ≥10% heart) without a pre-cancer treatment history of HF underwent cardiopulmonary exercise testing to determine O₂Pulse, contrast-enhanced CMR, and N-terminal pro-brain natriuretic peptide (NTproBNP) measurement. Multivariable-analyses were performed to identify factors associated with O₂Pulse normalized for age/gender/anthropometrics.

Results

Thirty patients (median [IQR] age 63 [57–67] years, 18 [60%] female, 2.0 [0.6–3.8] years post-radiotherapy) were included. The peak VO₂ was 1376 [1057–1552] mL·min^− 1, peak HR = 150 [122–164] bpm, resulting in an O₂Pulse of 9.2 [7.5–10.7] mL/beat or 82 (66–96) % of predicted. The ECVF, LV ejection fraction, heart volume receiving ≥10 Gy, and NTproBNP were independently associated with %O₂Pulse (P < .001).

Conclusions

In patients with prior radiotherapy heart exposure, %-predicted O₂Pulse is inversely associated markers of diffuse fibrosis (ECVF), ventricular wall stress (NTproBNP), radiotherapy heart dose, and positively related to LV function. Increased LV ECVF may reflect a potential etiology of impaired LV SV reserve in patients receiving thoracic radiotherapy for chest malignancies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40959-021-00127-6.

Exercise feature and predictor of prognosis in patients with pulmonary artery stenosis-associated pulmonary hypertension

AIMS

The prognosis is poor for patients with pulmonary artery stenosis-associated pulmonary hypertension (PAS-PH). Identifying predictors of prognosis in PAS-PH is crucial to preventing premature death, which has rarely been investigated. We aimed to explore the cardiopulmonary exercise testing (CPET) parameters to predict the prognosis of these patients.

METHODS

We prospectively included all patients with PAS-PH who underwent CPET between September 2014 and June 2021 in Fuwai Hospital (ClinicalTrials.gov ID: NCT02061787). The primary outcome was clinical worsening, including death, rehospitalization for heart failure, or deterioration of PH.

RESULTS

Seventy-two patients were included in this study. A median of 2-year follow-up revealed that 18 (25%) patients experienced clinical worsening. The 1-year, 3-year, and 5-year event-free survival rates were 92.5%, 81.7%, and 62.7%, respectively. Patients with clinical worsening demonstrated significantly worse baseline haemodynamics and poorer exercise capacity than their counterparts. Multivariable Cox regression identified that peak O₂ pulse could independently predict clinical worsening [hazard ratio: 0.344, 95% confidence interval (CI) 0.188-0.631, P < 0.001], outperforming other parameters. Peak O₂ pulse correlated with PH severity. Incorporating peak O₂ pulse into the simplified 2015 European Society of Cardiology/European Respiratory Society risk stratification improved the accuracy for predicting clinical worsening (pre vs. post area under the curve: 0.727 vs. 0.846, P < 0.001; net reclassification index: 0.852, 95% CI 0.372-1.332, P < 0.001; integrated discrimination index 0.133, 95% CI 0.031-0.235, P = 0.011).

CONCLUSIONS

The prognosis is poor for PAS-PH, and exercise intolerance and ventilation inefficiency are commonly observed. Peak O₂ pulse independently predicted the prognosis of these patients. A low peak O₂ pulse identified patients at high risk of clinical deterioration and served for risk stratification of PAS-PH.

Sub Maximal Ergospirometry Parameters in Untrained Non-Frail Octogenarian Subjects

Background and Objectives: The prevalence of chronic diseases increases with age, and in octogenarian elderly, a cardiorespiratory test with gas analysis is more effective in determining the risk of mortality than applying the conventional risk factors. Materials and Methods: 25 untrained non-frail octogenarian subjects (four men) performed a submaximal test with gas analysis, which was stopped after the second ventilatory threshold (VT2) was reached. The variables analyzed were oxygen consumption at the first threshold (VO2 VT1); ventilatory class (VE/VCO2); oxygen uptake efficiency slope (OUES); cardiorespiratory optimal point (COP); oxygen pulse difference between VT2 and VT1 (diff. VO2/HR VT2-VT1). Results: the variables were classified categorically based on cut-off points present in the literature, where the variable with the highest percentage of altered cases was dif. VO2/HR VT2-VT1 at 48%; followed by VO2 VT1 at 40%, OUES at 36%, COP at 32%, and VE/VCO2 at 24%. Chi-square analysis between the measured parameters defined that normal and altered variables were related to each other, except for the variable VE/VCO2 and OUES. Conclusions: it was found that the main altered variable was the oxygen pulse and the least altered variable was VCO2/VCO2; there was only a statistically significant difference in a pair of OUES vs. VE/VCO2 variables.

Smartphone-Assisted High-Intensity Interval Training in Inflammatory Rheumatic Disease Patients: Randomized Controlled Trial

BACKGROUND

Patients with inflammatory rheumatic diseases (IRDs) experience disease-related barriers to physical training. Compared with the general population, IRD patients are reported to have reduced maximal oxygen uptake (VO2max) and physical activity levels. Supervised high-intensity interval training (HIIT) is documented to counteract the reduced VO2max and poor cardiovascular health associated with IRDs. However, supervised HIIT is resource demanding.

OBJECTIVE

This study sought to investigate if self-administered 4×4-min HIIT guided by a smartphone app (Myworkout GO) could yield similar HIIT-induced effects as standard 4×4-min HIIT performed under the guidance and supervision of health care professionals. The effects studied were on VO2max and health-related quality of life (HRQoL).

METHODS

Forty patients (33 female patients, mean age 48 years, SD 12 years; 7 male patients, mean age 52 years, SD 11 years) diagnosed with rheumatoid arthritis, spondyloarthritis, or systemic lupus erythematosus were randomized to a supervised group (SG) or an app group (AG). Both groups were instructed to perform 4×4-min intervals with a rate of perceived exertion of 16 to 17, corresponding to 85% to 95% of the maximal heart rate, twice a week for 10 weeks. Treadmill VO2max and HRQoL measured using RAND-36 were assessed before and after the exercise period.

RESULTS

VO2max increased (P<.001) in both groups after 10 weeks of HIIT, with improvements of 3.6 (SD 1.3) mL/kg/min in the SG and 3.7 (SD 1.5) mL/kg/min in the AG. This was accompanied by increases in oxygen pulse in both groups (P<.001), with no between-group differences apparent for either measure. Improvements in the HRQoL dimensions of bodily pain, vitality, and social functioning were observed for both groups (P<.001 to P=.04). Again, no between-group differences were detected.

CONCLUSIONS

High-intensity 4×4-min interval training increased VO2max and HRQoL, contributing to patients' reduced cardiovascular disease risk, improved health and performance, and enhanced quality of life. Similar improvements were observed following HIIT when IRD patients were guided using perceived exertion by health care professionals or the training was self-administered and guided by the app Myworkout GO. Utilization of the app may help reduce the cost of HIIT as a treatment strategy in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04649528; https://clinicaltrials.gov/ct2/show/NCT04649528.

Peak oxygen pulse and mortality risk in healthy women and men: The Ball State Adult Fitness Longitudinal Lifestyle Study (BALL ST)

Peak oxygen pulse (O₂ pulse_peak) may have predictive utility for health outcomes yet, presently, has only been examined in men and only using a single baseline measure.

PURPOSE

The primary aim of this investigation was to evaluate the relationship between O₂ pulse_peak and all-cause mortality in apparently healthy women and men. A secondary aim was to explore the relationship between longitudinal changes to O₂ pulse_peak and mortality.

METHODS

The sample included 3877 participants (43% women) for the primary aim and 759 participants (32% women) who performed two cardiopulmonary exercise tests ≥1 year apart for the secondary aim. Cox proportional hazard models were performed to determine the relationship between O₂ pulse_peak and mortality. Prognostic peak oxygen consumption (VO_2peak) and O₂ pulse_peak models were compared using the concordance index and Akaike information criterion (AIC).

RESULTS

In the assessment from baseline, there were 730 deaths over a 24.7 ± 11.8 year follow-up period. For men, a single measure of O₂ pulse_peak was inversely associated with risk for mortality (P < 0.05). However, the concordance index and AIC indicated lower discrimination compared to VO_2peak models and O₂ pulse_peak did not provide complementary benefit to VO_2peak models. For women, O₂ pulse_peak was not associated with mortality risk. In the longitudinal analysis, there were 168 deaths over a follow-up of 20.1 ± 11.4 years. Changes to O₂ pulse_peak were not significantly related to mortality in either sex.

CONCLUSIONS

Within an apparently healthy cohort, a single assessment of O₂ pulse_peak is related to all-cause mortality in men but not women. Further, longitudinal changes to O₂ pulse_peak are not predictive of mortality in either sex. These findings suggest O₂ pulse_peak may have limited prognostic utility in healthy individuals, particularly within healthy women.

Prognostic value of aerobic capacity and exercise oxygen pulse in postaortic dissection patients

BACKGROUND

Although recommendations encourage daily moderate activities in post aortic dissection, very little data exists regarding cardiopulmonary exercise testing (CPET) to personalize those patient's physical rehabilitation and assess their cardiovascular prognosis.

DESIGN

We aimed at testing the prognostic insight of CPET regarding aortic and cardiovascular events by exploring a prospective cohort of patients followed-up after acute aortic dissection.

METHODS

Patients referred to our department after an acute (type A or B) aortic dissection were prospectively included in a cohort between September 2012 and October 2017. CPET was performed once optimal blood pressure control was obtained. Clinical follow-up was done after CPET for new aortic event and major cardio-vascular events (MCE) not directly related to the aorta.

RESULTS

Among the 165 patients who underwent CPET, no adverse event was observed during exercise testing. Peak oxygen pulse was 1.46(1.22-1.84) mlO2/beat, that is, 97 (83-113) % of its predicted value, suggesting cardiac exercise limitation in a population under beta blockers (92% of the population). During a follow-up of 39(20-51) months from CPET, 42 aortic event recurrences and 22 MCE not related to aorta occurred. Low peak oxygen pulse (<85% of predicted value) was independently predictive of aortic event recurrence, while low peak oxygen uptake (<70% of predicted value) was an independent predictor of MCE occurrence.

CONCLUSION

CPET is safe in postaortic dissection patients should be used to not only to personalize exercise rehabilitation, but also to identify those patients with the highest risk for new aortic events and MCE not directly related to aorta.

Peak oxygen uptake and incident coronary heart disease in a healthy population: the HUNT Fitness Study

AIMS

The majority of previous research on the association between cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) is based on indirect assessment of CRF in clinically referred predominantly male populations. Therefore, our aim was to examine the associations between VO2peak measured by the gold-standard method of cardiopulmonary exercise testing and fatal and non-fatal coronary heart disease (CHD) in a healthy and fit population.

METHODS AND RESULTS

Data on VO2peak from 4527 adults (51% women) with no previous history of cardiovascular or lung disease, cancer, and hypertension or use of antihypertensive medications participating in a large population-based health-study (The HUNT3 Study), were linked to hospital registries and the cause of death registry. Average VO2peak was 36.0 mL/kg/min and 44.4 mL/kg/min among women and men, and 83.5% had low 10-year risk of CVD at baseline. Average follow-up was 8.8 years, and 147 participants reached the primary endpoint. Multi-adjusted Cox-regression showed 15% lower risk for the primary endpoint per one-MET (metabolic equivalent task) higher VO2peak [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77-0.93], with similar results across sex. The highest quartile of VO2peak had 48% lower risk of event compared with the lowest quartile (multi-adjusted HR 0.52, 95% CI 0.33-0.82). Oxygen pulse and ventilatory equivalents of oxygen and carbon dioxide also showed significant predictive value for the primary endpoint.

CONCLUSION

VO2peak was strongly and inversely associated with CHD across the whole fitness continuum in a low-risk population sample. Increasing VO2peak may have substantial benefits in reducing the burden of CHD.

Handgrip strength is inversely associated with fatal cardiovascular and all-cause mortality events

Purpose: We aimed to assess the associations of handgrip strength (HS) with cardiovascular and all-cause mortality and whether adding data on HS to cardiovascular disease (CVD) risk factors is associated with improvement in CVD mortality prediction.Design: Handgrip strength was assessed in a population-based sample of 861 participants aged 61-74 years at baseline. Relative HS was obtained by dividing the absolute value by body weight.Results: During a median (interquartile range) follow-up of 17.3 (12.6-18.4) years, 116 fatal coronary heart diseases (CHDs), 195 fatal CVDs and 412 all-cause mortality events occurred. On adjustment for several risk factors, the hazard ratios (95% confidence intervals (CIs)) for fatal CHD, fatal CVD and all-cause mortality were 0.59 (0.37-0.95), 0.59 (0.41-0.86) and 0.66 (0.51-0.84), respectively, comparing extreme tertiles of relative HS. Adding relative HS to a CVD mortality risk prediction model containing established risk factors did not improve discrimination or reclassification using Harrell's C-index (C-index change: 0.0034; p = .65), integrated-discrimination-improvement (0.0059; p = .20) and net-reclassification-improvement (-1.31%; p = .74); however, there was a significant difference in -2 log likelihood (p < .001).Conclusions: Relative HS is inversely associated with CHD, CVD and all-cause mortality events. Adding relative HS to conventional risk factors improves CVD risk assessment using sensitive measures of discrimination.KEY MESSAGESHandgrip strength (HS) assessment is simple, inexpensive and it takes only a few minutes to measure in clinical practice; however, its prognostic role for fatal cardiovascular outcomes on top of traditional risk factors in apparently healthy populations is uncertain.In a population-based prospective cohort study, good HS adjusted for body weight was associated with lower risk of fatal cardiovascular outcomes and the associations remained consistent across several clinically relevant subgroups.Handgrip strength may be a useful prognostic tool for fatal CHD and CVD events, in the general population.

Monitoring functional capacity in heart failure

This document reflects the key points of a consensus meeting of the Heart Failure Association of European Society of Cardiology (ESC) held to provide an overview the role of physiological monitoring in the complex multimorbid heart failure (HF) patient. This article reviews assessments of the functional ability of patients with HF. The gold standard measurement of cardiovascular functional capacity is peak oxygen consumption obtained from a cardiopulmonary exercise test. The 6-min walk test provides an indirect measure of cardiovascular functional capacity. Muscular functional capacity is assessed using either a 1−repetition maximum test of the upper and lower body or other methods, such as handgrip measurement. The short physical performance battery may provide a helpful, indirect indication of muscular functional capacity.

Screening young athletes for diseases at risk of sudden cardiac death: role of stress testing for ventricular arrhythmias

Aims

The athletic preparticipation evaluation (PPE) protocol proposed by the European Society of Cardiology includes history, physical examination and resting electrocardiogram (ECG). The aim of this study was to assess the results of adding constant-load ECG stress testing (EST) to the protocol for the evaluation of ventricular arrhythmias (VA) inducibility.

Methods

We evaluated a consecutive cohort of young athletes with history, physical examination, resting ECG and EST. Athletes with VA induced by EST underwent 24-hour 12-lead Holter monitoring and echocardiography. Cardiac magnetic resonance (CMR) was reserved for those with frequent, repetitive or exercise-worsened VA, and for athletes with echocardiographic abnormalities.

Results

Of 10,985 athletes (median age 15 years, 66% males), 451 (4.1%) had an abnormal history, physical examination or resting ECG and 31 (0.28%) were diagnosed with a cardiac disease and were at risk of sudden cardiac death. Among the remaining 10,534 athletes, VA at EST occurred in 524 (5.0%) and a previously missed at-risk condition was identified in 23 (0.22%); the most common (N = 10) was an echocardiographically silent non-ischaemic left-ventricular fibrosis evidenced by CMR. The addition of EST increased the diagnostic yield of PPE by 75% (from 0.28% to 0.49%) and decreased the positive predictive value by 20% (from 6.9% to 5.5%). During a 32 ± 21 months follow-up, no cardiac arrests occurred among either eligible athletes or non-eligible athletes with cardiovascular disease.

Conclusions

The addition of exercise testing for the evaluation of VA inducibility to history, physical examination and ECG resulted in an increase of the diagnostic yield of PPE at the expense of an increase in false-positive findings.

Comparison of non-exercise cardiorespiratory fitness prediction equations in apparently healthy adults

AIMS

A recent scientific statement suggests clinicians should routinely assess cardiorespiratory fitness using at least non-exercise prediction equations. However, no study has comprehensively compared the many non-exercise cardiorespiratory fitness prediction equations to directly-measured cardiorespiratory fitness using data from a single cohort. Our purpose was to compare the accuracy of non-exercise prediction equations to directly-measured cardiorespiratory fitness and evaluate their ability to classify an individual's cardiorespiratory fitness.

METHODS

The sample included 2529 tests from apparently healthy adults (42% female, aged 45.4 ± 13.1 years (mean±standard deviation). Estimated cardiorespiratory fitness from 28 distinct non-exercise prediction equations was compared with directly-measured cardiorespiratory fitness, determined from a cardiopulmonary exercise test. Analysis included the Benjamini-Hochberg procedure to compare estimated cardiorespiratory fitness with directly-measured cardiorespiratory fitness, Pearson product moment correlations, standard error of estimate values, and the percentage of participants correctly placed into three fitness categories.

RESULTS

All of the estimated cardiorespiratory fitness values from the equations were correlated to directly measured cardiorespiratory fitness (p < 0.001) although the R2 values ranged from 0.25-0.70 and the estimated cardiorespiratory fitness values from 27 out of 28 equations were statistically different compared with directly-measured cardiorespiratory fitness. The range of standard error of estimate values was 4.1-6.2 ml·kg-1·min-1. On average, only 52% of participants were correctly classified into the three fitness categories when using estimated cardiorespiratory fitness.

CONCLUSION

Differences exist between non-exercise prediction equations, which influences the accuracy of estimated cardiorespiratory fitness. The present analysis can assist researchers and clinicians with choosing a non-exercise prediction equation appropriate for epidemiological or population research. However, the error and misclassification associated with estimated cardiorespiratory fitness suggests future research is needed on the clinical utility of estimated cardiorespiratory fitness.

Leisure time and occupational physical activity, resting heart rate and mortality in the Arctic region of Norway: The Finnmark Study

Aims

This study examined the association of leisure time physical activity, occupational physical activity, and resting heart rate with all-cause and cardiovascular disease mortality in Sami and non-Sami populations.

Study design

This was a longitudinal, observational population-based study.

Methods

The Finnmark 3 study cohort was examined in 1987–1988 and followed for all-cause and cardiovascular disease mortality for 26 years. The cohort included 17,697 men and women with a mean age of 47.2 years at baseline. Leisure time physical activity and occupational physical activity were assessed with a validated questionnaire at baseline, whereas cause of death was obtained from the Norwegian Cause of Death Registry.

Results

A total of 1983 women and 3147 men died during follow-up. Leisure time physical activity was linearly and inversely associated with all-cause mortality, but not coronary heart disease mortality. Compared to inactive subjects, all-cause mortality was significantly reduced by 16% in the active leisure time physical activity group (hazard ratio 0.84; 95% confidence interval 0.76–0.92). Both for all-cause and cardiovascular disease mortality, we observed a U-shaped relationship with occupational physical activity, as participants in the walking and lifting group had significantly lower mortality than both the mostly sedentary and the heavy manual labour group ( p < 0.05). An increase in resting heart rate by one beat per minute was associated with a 1.1% increase in all-cause mortality (hazard ratio 1.011; 95% confidence interval 1.009–1.013). The associations were similar in Sami and non-Sami subjects.

Conclusion

In this population-based study, leisure time physical activity was inversely associated with all-cause mortality, whereas resting heart rate was positively associated with all-cause and cardiovascular disease mortality. There was a U-shaped association between occupational physical activity and cardiovascular disease and all-cause mortality.

The role of cardiorespiratory fitness on the risk of sudden cardiac death at the population level: A systematic review and meta-analysis of the available evidence

Cardiorespiratory fitness (CRF) has been widely studied as a powerful and independent predictor of all-cause and disease-specific mortality. Sudden cardiac death (SCD) is recognized as a significant cause of mortality among the general population, including the general population without previous symptoms of any coronary heart disease (CHD). Consequently, SCD is an important public health problem, which constitutes a clinical challenge. Thus, prevention of SCD by detecting early risk factors could be a useful tool, contributing to the American Heart Association's goal of decreasing the incidence of SCD at the population level. The identification of these risk factors for CVD would facilitate the large-scale screening of those participants at higher risk of SCD. This systematic review collects information about the role of CRF on the risk of SCD at the available evidence, and analyzes the long-term influence of CRF as a risk factor and independent predictor of SCD.

Cardiovascular prevention and at-risk behaviours in a large population of amateur rugby players

BACKGROUND AND AIM

We aimed to investigate cardiovascular risk factors and health behaviours prospectively in a large population of French amateur rugby players.

METHODS

An anonymous questionnaire was displayed to rugby players aged over 12 years enrolled in the 2014-2015 French amateur rugby championship from the Burgundy region (n = 5140). Questions addressed awareness on: (a) cardiovascular prevention; (b) tobacco, alcohol and highly caffeinated beverages consumption; and (c) adherence to prevention guidelines (ECG checks, training in basic life support, avoidance of sports practice during fever/infectious episodes).

RESULTS

Among the 640 participants who completed the questionnaires, most were male (90%) and were aged under 35 years (80%). Almost half had basic life support training (42%), but only a minority attended an ECG check-up before licensing (37%), and only a few were aware of the cardiovascular prevention information campaign (17%), similarly across the age groups. Surprisingly, playing rugby with fever was commonly reported (44%) and was even more frequent in young women (55%). A high number of respondents were current smokers (35%), of whom most reported consumption less than 2 hours before/after a rugby session. Alcohol drinkers were frequent (69%), of whom most (79%) drank alcohol less than 2 hours before/after a match. Highly caffeinated beverages consumption (34%) was high, particularly in younger players (39%). Half highly caffeinated beverages consumption was in the setting of a rugby session, even greater in women and mainly motivated by performance enhancement (34%).

CONCLUSION

Our findings from a representative regional cohort may help to identify targets for cardiovascular prevention through the development of educational programmes aiming to improve the knowledge and behaviour of amateur rugby players.

Isocapnic buffering period: From physiology to clinics

Background

During cardiopulmonary exercise test, the isocapnic buffering period ranges between anaerobic threshold (AT) and respiratory compensation point (RCP). We investigated whether oxygen uptake (VO2) increase during the isocapnic buffering period (ΔVO2AT-RCP) is related to heart failure severity and prognosis.

Methods

We retrospectively analysed reduced ejection fraction heart failure patients who attained RCP at cardiopulmonary exercise test. The study endpoint was the composite of cardiovascular mortality and urgent heart transplantation/left ventricular assist device implantation. Hazard ratio was assessed to identify the increase of risk associated with ΔVO2AT-RCP (below and above the median of ΔVO2AT-RCP).

Results

AT and RCP were both identified in 782 (39.2%) out of 1995 reduced ejection fraction heart failure cases. Left ventricular ejection fraction and peak VO2 were 33 ± 9% and 16.5 ± 4.5 mL/kg per min (61 ± 16% of predicted value), suggesting moderate heart failure. At five years, endpoint did not vary between patients below and above the median ΔVO2AT-RCP (3.85 mL/min per kg (25–75th interquartile range = 2.69–5.46)). ΔVO2AT-RCP correlated with several parameters associated to heart failure prognosis, such as peak VO2, VE/VCO2 slope, brain natriuretic peptide and left ventricular ejection fraction. The ΔVO2AT-RCP value was associated with prognosis at univariate but not at multivariable analysis, where only VE/VCO2 slope endured.

Conclusion

ΔVO2AT-RCP correlates with several parameters linked to heart failure severity. Isocapnic buffering period stratifies heart failure patients, but not more than other prognostic indices.