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Squires RW. Cardiac transplant and exercise cardiac rehabilitation. Heart Fail Rev 2023; 28:1267-1275. [PMID: 37014453 DOI: 10.1007/s10741-023-10305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
Cardiac transplantation is the final therapeutic option for patients with end-stage heart failure. Most patients experience a favorable functional ability post-transplant. However, episodes of acute rejection, and multiple comorbidities such as hypertension, diabetes mellitus, chronic kidney disease and cardiac allograft vasculopathy are common. The number of transplants has increased steadily over the past two decades with 3,817 operations performed in the United States in 2021. Patients have abnormal exercise physiologic responses related to surgical cardiac denervation, diastolic dysfunction, and the legacy of reduced skeletal muscle oxidative capacity and impaired peripheral and coronary vasodilatory reserve resulting from pre-transplant chronic heart failure. Cardiorespiratory fitness is below normal for most patients with a mean peak VO2 of approximately 60% of predicted for healthy persons. Cardiac transplant recipients are therefore excellent candidates for Exercise-Based Cardiac Rehabilitation (CR). CR is safe and is a recommendation of professional societies both before (pre-rehabilitation) and after transplantation. CR improves peak VO2, autonomic function, quality of life, and skeletal muscle strength. Exercise training reduces the severity of cardiac allograft vasculopathy, stroke risk, percutaneous coronary intervention, hospitalization for either acute rejection or heart failure, and death. However, there are deficits in our knowledge regarding CR for women and children. In addition, the use of telehealth options for the provision of CR for cardiac transplant patients requires additional investigation.
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Affiliation(s)
- Ray W Squires
- Professor of MedicineDivision of Preventive CardiologyDepartment of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Little KA, Smith JR, Medina-Inojosa JR, Chacin Suarez AS, Taylor JL, Hammer SM, Fischer KM, Bonikowske AR, Squires RW, Thomas RJ, Olson TP. Predictors of Changes in Peak Oxygen Uptake After Outpatient Cardiac Rehabilitation: Importance of Cardiac Rehabilitation Attendance. Mayo Clin Proc Innov Qual Outcomes 2022; 6:428-435. [PMID: 36097546 PMCID: PMC9463170 DOI: 10.1016/j.mayocpiqo.2022.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022] Open
Abstract
Objective To determine whether the number of cardiac rehabilitation (CR) sessions attended and selected clinical characteristics were predictive of patients who exhibited improvement in peak oxygen uptake (VO2peak) after CR. Patients and Methods Using the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients aged 18 years or older from Olmsted County, Minnesota, who underwent cardiopulmonary exercise testing before and after CR from 1999 to 2017. Regression models were created to assess the clinical predictors of VO2peak improvement (>0% baseline) after CR. Results The analysis included 671 patients, of which 524 (78%) patients exhibited VO2peak improvement after CR. The significant univariate predictors of VO2peak improvement included younger age (odds ratio [OR], 0.98; 95% CI, 0.96-0.99), lower pre-CR VO2peak (OR, 0.96; 95% CI, 0.94-0.99), and no history of peripheral artery disease (OR, 0.50; 95% CI, 0.31-0.81) (all, P<.005). The significant independent predictors of VO2peak improvement from the multivariable analysis included the number of CR sessions (OR, 1.04; 95% CI, 1.02-1.05), younger age (OR, 0.96; 95% CI, 0.94-0.98), lower pre-CR VO2peak (OR, 0.92; 95% CI, 0.89-0.95), and no history of peripheral artery disease (OR, 0.47; 95% CI, 0.28-0.78) (all, P<.005). Conclusion These findings highlight the importance of patient participation in CR sessions and individual clinical characteristics in influencing VO2peak improvement after CR in patients with cardiovascular disease.
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Affiliation(s)
- Kasara A Little
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Jenna L Taylor
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Shane M Hammer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Karen M Fischer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Ray W Squires
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Randal J Thomas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Takao N, Iwasaka J, Kurose S, Miyauchi T, Tamanoi A, Tsuyuguchi R, Fujii A, Tsutsumi H, Kimura Y. Evaluation of oxygen uptake adjusted by skeletal muscle mass in cardiovascular disease patients with type 2 diabetes. J Phys Ther Sci 2021; 33:94-99. [PMID: 33642681 PMCID: PMC7897529 DOI: 10.1589/jpts.33.94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023] Open
Abstract
[Purpose] We aimed to evaluate oxygen uptake adjusted by total skeletal muscle mass in
patients with cardiovascular disease with or without type 2 diabetes mellitus.
[Participants and Methods] The participants included 54 males ≥50 years of age without
heart failure who underwent cardiopulmonary exercise testing during cardiac
rehabilitation. We divided the participants into two groups: patients with type 2 diabetes
mellitus (DM group) and patients without type 2 diabetes mellitus (NDM group). [Results]
We found no significant differences in age, weight, fat mass, or skeletal muscle mass
between the groups. There were also no differences in cardiac function, body composition,
and heart rate response. The DM group showed significantly lower peak oxygen uptake values
adjusted by skeletal muscle mass, despite the absence of significant differences in
skeletal muscle mass. A significant positive correlation was found between peak oxygen
uptake and age, weight, and skeletal muscle mass. Stepwise regression analysis revealed
that age, skeletal muscle mass, and medical history of diabetes were independent
predictors of absolute peak oxygen uptake. [Conclusion] Peak oxygen uptake adjusted by
skeletal muscle mass in patients with cardiovascular disease and type 2 diabetes mellitus
is lower than that in those without type 2 diabetes mellitus.
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Affiliation(s)
- Nana Takao
- Department of Health Science, Graduate School of Medicine, Kansai Medical University: 2-5-1 Shinmachi, Hirakata 573-1010, Japan.,Health Science Center, Kansai Medical University Hospital, Japan
| | - Junji Iwasaka
- Department of Medicine II, Kansai Medical University, Japan
| | - Satoshi Kurose
- Department of Health Science, Kansai Medical University, Japan
| | - Takumi Miyauchi
- Department of Health Science, Graduate School of Medicine, Kansai Medical University: 2-5-1 Shinmachi, Hirakata 573-1010, Japan.,Health Science Center, Kansai Medical University Hospital, Japan
| | - Astuko Tamanoi
- Health Science Center, Kansai Medical University Hospital, Japan
| | - Ryota Tsuyuguchi
- Department of Health Science, Graduate School of Medicine, Kansai Medical University: 2-5-1 Shinmachi, Hirakata 573-1010, Japan
| | - Aya Fujii
- Department of Health Science, Graduate School of Medicine, Kansai Medical University: 2-5-1 Shinmachi, Hirakata 573-1010, Japan.,Health Science Center, Kansai Medical University Hospital, Japan
| | - Hiromi Tsutsumi
- Department of Health Science, Kansai Medical University, Japan
| | - Yutaka Kimura
- Health Science Center, Kansai Medical University Hospital, Japan.,Department of Health Science, Kansai Medical University, Japan
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Increased aortic augmentation index is associated with reduced exercise capacity after heart transplantation. J Hypertens 2020; 38:1777-1785. [PMID: 32649621 DOI: 10.1097/hjh.0000000000002455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Exercise capacity is often reduced after heart transplantation. We aimed to investigate the association between aortic stiffness and exercise capacity after heart transplantation. METHODS We retrospectively analyzed the data of patients who underwent a cardiopulmonary exercise test and central hemodynamic measurements over 1 year following heart transplantation, from Janary 2011 to June 2018. RESULTS A total of 54 patients (mean age, 49 years; 72% men) were analyzed. The median peak oxygen uptake level was 21.1 ml/kg per min at a median time of 13 months after heart transplantation. In univariate linear regression, recipient age, pulmonary arterial pressure, pulmonary capillary wedge pressure, hemoglobin level, estimated glomerular filtration rate, aortic augmentation index, and pulse wave velocity were significant predictors for peak oxygen uptake level. After adjustment for other confounding variables, heart rate-corrected aortic augmentation index was a significant predictor for peak oxygen uptake (β = -0.141, 95% confidence interval, -0.263 to -0.058, P = 0.003). CONCLUSION In the present study, increased aortic augmentation index was associated with reduced exercise capacity after heart transplantation. Therefore, this simple measurement of aortic stiffness should be periodically used for the evaluation of exercise capacity after heart transplantation.
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Uithoven KE, Smith JR, Medina-Inojosa JR, Squires RW, Olson TP. The Role of Cardiac Rehabilitation in Reducing Major Adverse Cardiac Events in Heart Transplant Patients. J Card Fail 2020; 26:645-651. [PMID: 31981697 DOI: 10.1016/j.cardfail.2020.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 09/21/2019] [Accepted: 01/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Methods for reducing major adverse cardiac events (MACE) in patients after heart transplantation (HTx) are critical for long-term quality outcomes. METHODS AND RESULTS Patients with cardiopulmonary exercise testing prior to HTx and at least 1 session of cardiac rehabilitation (CR) after HTx were included. Exercise sessions were evaluated as ≥ 23 or < 23 sessions based on recursive partitioning. We included 140 patients who had undergone HTx (women: n = 41 (29%), age: 52 ± 12 years, body mass index: 27 ± 5 kg/m2). Mean follow-up was 4.1 ± 2.7 years, and 44 patients (31%) had a MACE: stroke (n = 1), percutaneous intervention (n = 5), heart failure (n = 6), myocardial infarction (n = 1), rejection (n = 16), or death (n = 15). CR was a significant predictor of MACE, with ≥ 23 sessions associated with a ∼ 60% reduction in MACE risk (hazard ratio [HR]: 0.42, 95% CI: 0.19-0.94, P = 0.035). This remained after adjusting for age, sex and history of diabetes (HR: 0.41, 95% CI: 0.18-0.94, P = 0.035) as well as body mass index and pre-HTx peak oxygen consumption (HR: 0.40, 95% CI: 0.18-0.92, P = 0.031). CONCLUSIONS After adjustment for covariates of age, sex, diabetes, body mass index, and pre-HTx peak oxygen consumption, CR attendance of ≥ 23 exercise sessions was predictive of lower MACE risk following HTx. In post-HTx patients, CR was associated with MACE prevention and should be viewed as a critical tool in post-HTx treatment strategies.
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Affiliation(s)
- Katelyn E Uithoven
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Joshua R Smith
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jose R Medina-Inojosa
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Ray W Squires
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Thomas P Olson
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Smith JR, Layrisse V, Medina-Inojosa JR, Berg JD, Ommen SR, Olson TP. Predictors of exercise capacity following septal myectomy in patients with hypertrophic cardiomyopathy. Eur J Prev Cardiol 2020; 27:1066-1073. [PMID: 31967491 DOI: 10.1177/2047487319898106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIMS Patients with hypertrophic obstructive cardiomyopathy (HOCM) have impaired exercise capacity. The gold standard therapy for patients with HOCM is septal myectomy surgery; however, changes in maximum oxygen uptake (VO2peak) following myectomy are variable, with VO2peak decreasing in some patients. Therefore, we evaluated changes in VO2peak following surgical myectomy to determine clinical predictors of those exhibiting decreased VO2peak post-myectomy. METHODS HOCM patients (N = 295) who performed symptom limited cardiopulmonary exercise testing prior to and following surgical myectomy were included for analysis. The VO2peak non-responder group (n = 128) was defined as <0% change in VO2peak from pre- to post-myectomy. Step-wise regression models using demographics, clinical, and physiologic characteristics were created to determine predictors of hypertrophic cardiomyopathy patients in the VO2peak non-responder group. RESULTS Independent predictors of the VO2peak non-responder group included higher pre-myectomy VO2peak (% predicted), older age, women, history of dyslipidemia, lack of cardiac rehabilitation enrollment, and lower body mass index (all p < 0.03). Forty-three (14.6%) patients reached the primary end-point of all-cause mortality during a median follow up of 11.25 years (interquartile range 6.94 to 16.40). After adjustment for age, sex, beta-blocker use, coronary artery disease history, and body mass index, the VO2peak non-responder group had greater risk of death compared with the VO2peak responder group (adjusted hazard ratio: 1.77, 95% confidence interval: 1.06-3.34, p = 0.01). CONCLUSION This large hypertrophic cardiomyopathy cohort demonstrated that demographic (i.e. female sex), lack of cardiac rehabilitation enrollment, and cardiovascular risk factors (i.e. history of dyslipidemia) are predictive of those patients that did not exhibit increases in VO2peak following septal myectomy surgery.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Veronica Layrisse
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA.,San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | | | - Jessica D Berg
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
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