Predicting impaired cardiopulmonary exercise capacity in patients with atrial fibrillation using a simple echocardiographic marker

BACKGROUND

Exercise intolerance is a common symptom associated with atrial fibrillation (AF). However, echocardiographic markers that can predict impaired exercise capacity are lacking.

OBJECTIVE

This study aimed to investigate the association between echocardiographic parameters and exercise capacity assessed by cardiopulmonary exercise testing in patients with AF.

METHODS

This single-center prospective study enrolled patients with AF who underwent echocardiography and cardiopulmonary exercise testing to evaluate exercise capacity at a tertiary center for AF management from 2020 to 2022. Patients with valvular heart disease, reduced left ventricular ejection fraction, or documented cardiomyopathy were excluded.

RESULTS

Of the 188 patients, 134 (71.2%) exhibited impaired exercise capacity (peak oxygen consumption ≤85%), including 4 (2.1%) having poor exercise capacity (peak oxygen consumption <50%). Echocardiographic findings revealed that these patients had an enlarged left atrial end-systolic diameter (LA); smaller left ventricular end-diastolic diameter (LVEDD); and increased relative wall thickness, tricuspid regurgitation velocity, and LA/LVEDD and E/e' ratios. In addition, they exhibited lower peak systolic velocity of the mitral annulus and LA reservoir strain. In the multivariate regression model, LA/LVEDD remained the only significant echocardiographic parameter after adjustment for age, sex, and body mass index (P = .020). This significance persisted even after incorporation of heart rate reserve, N-terminal pro-B-type natriuretic peptide level, and beta-blocker use into the model.

CONCLUSION

In patients with AF, LA/LVEDD is strongly associated with exercise capacity. Further follow-up and validation are necessary to clarify its clinical implications in patient care.

A non-invasive nomogram for predicting heart failure with preserved ejection fraction in taiwanese outpatients with unexplained dyspnea and fatigue

BACKGROUND

While Reddy proposed the H2FPEF diagnostic algorithm to aid in diagnosing heart failure with preserved ejection fraction (HFpEF), certain parameters like age and obesity are not suitable for Asian population, especially given the increasing incidence of HFpEF in younger individuals. Therefore, this study aimed to develop an easy-to-use nomogram with non-invasive indices that can be used in outpatient clinics in Taiwan to quickly estimate the probability of HFpEF and help decide whether further invasive cardiopulmonary exercise test (CPET) is needed.

METHODS

Outpatients with unexplained dyspnea and fatigue were recruited divided into HFpEF (n = 64) and non-HFpEF (n = 34) groups based on invasive CPET and echocardiography. Multivariate logistic regression analyses identified independent noninvasive variables for developing an HFpEF nomogram. The nomogram's performance was assessed and validated using the concordance index (C-index), area under the curve (AUC), calibration curves, and decision curve analysis.

RESULTS

Multivariate logistic regression analyses identified five independent noninvasive variables for developing an HFpEF nomogram, including dyslipidemia (OR = 5.264, p = 0.010), diabetes (OR = 3.929, p = 0.050), left atrial area (OR = 1.130, p = 0.046), hemoglobin <13 g/dL (OR = 5.372, p = 0.010), and NT-proBNP ≥245 pg/mL (OR = 5.108, p = 0.027). The nomogram showed good discriminatory ability (C-index = 0.842) and calibration performance (p = 0.873) and high net benefit (0.1-0.95). Notably, the HFpEF nomogram showed better diagnostic accuracy than the H2FPEF score model in predicting Taiwanese HFpEF patients (AUC: 0.873 vs. 0.608, p = 0.0006).

CONCLUSION

The noninvasive HFpEF nomogram provides a preliminary estimation of the probability of HFpEF in Taiwanese outpatients with unexplained dyspnea and fatigue, which may help the decision-making on further invasive CPET.

Long COVID and rehabilitation

Coronavirus disease 2019 (COVID-19) has caused tremendous morbidity and mortality worldwide. The large number of post-COVID survivors has drawn attention to the management of post-COVID condition, known as long COVID. This review examines current knowledge of long COVID, regarding its epidemiology, mechanism, and clinical presentations in both adults and children. We also review the rehabilitation principles, modules, and effects, and share Taiwan's efforts to provide a top-down, nationwide care framework for long COVID patients. Dyspnea, chronic cough, and fatigue are the most commonly reported symptoms in the first 6 months after infection, but cognitive impairment and psychological symptoms may persist beyond this time. Several possible mechanisms behind these symptoms were proposed, but remained unconfirmed. These symptoms negatively impact individuals' function, activities, participation and quality of life. Rehabilitation is a key element of management to achieve functional improvement. Early management should start with comprehensive evaluation and identification of red flags. Exercise-based therapy, an essential part of management of long COVID, can be conducted with different modules, including telerehabilitation. Post-exertional symptom exacerbation and orthostatic hypotension should be carefully monitored during exercise. Randomized control trials with a large sample size are needed to determine the optimal timing, dosage, and modules.

Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment

BACKGROUND

Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women's greatest barriers according to enrollment status.

METHODS

In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated.

RESULTS

Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women's barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5).

CONCLUSIONS

CR barriers-men's and women's-vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women's barriers in particular.

Association of Osteoarthritis With Increased Risk of Parkinson's Disease: A Population-Based, Longitudinal Follow-Up Study

OBJECTIVE

To investigate whether patients with osteoarthritis (OA) are at a higher risk of developing Parkinson's disease (PD).

METHODS

This retrospective cohort study was conducted using Taiwan's Longitudinal Health Insurance Database 2005. We enrolled 33,360 patients who were 50-64 years old and had OA in 2002-2005 to form the OA group. The comparison group consisted of 33,360 age- and sex-matched, randomly sampled subjects without OA. Then, their PD-free survival curves were generated using the Kaplan-Meier method. Multivariable Cox proportional hazards regression analysis was employed to estimate the effect of having OA on patients' subsequent risk of PD.

RESULTS

Of the 2 groups, the OA group had a significantly higher risk of developing PD (adjusted hazard ratio [HR_adj ] 1.41 [95% confidence interval (95% CI) 1.16-1.70], P = 0.0003). The PD-free survival rate of the OA group was also significantly lower than that of the comparison group (P = 0.0004). The subgroup analysis showed that patients with knee or hip OA appeared to have a higher magnitude of PD risk (HR_adj 1.55 [95% CI 1.14-2.11]) than patients with non-knee and non-hip OA (HR_adj 1.42 [95% CI 1.06-1.89]) or with uncategorized OA (HR_adj 1.32 [95% CI 1.05-1.64]).

CONCLUSION

Our findings suggest that OA is linked to an increased risk of developing PD.

Functional mobility effects of progressive early mobilization protocol on people with moderate-to-severe traumatic brain injury: A pre-post intervention study

BACKGROUND: Brain plasticity evoked by environmental enrichment through early mobilization may improve sensorimotor functions of patients with moderate-to-severe traumatic brain injury (TBI). Increasing evidence also suggests that early mobilization increases verticalization, which is beneficial to TBI patients in critical care. However, there are limited data on early mobilization interventions provided to patients with moderate-to-severe TBI. OBJECTIVE: We investigated the possible enhancing effects of revised progressive early mobilization on functional mobility and the rate of out-of-bed mobility attained by patients with moderate-to-severe TBI. METHODS: This is a quantitative study with a retrospective and prospective pre–post intervention design. We implemented a revised progressive early mobilization protocol for patients with moderate-to-severe TBI admitted to the trauma intensive care unit (ICU) within the previous seven days. The outcome parameters were the rate of patients attaining early mobilization (sitting on the edge of the bed) and the Perme ICU Mobility Score at discharge from the ICU. The outcome parameters in the intervention cohort were compared with those from a historical control cohort who received standard medical care a year previously. Differences in the Perme ICU Mobility Score between the two cohorts were assessed using univariate analysis of covariance. RESULTS: Forty-two patients were included in the progressive early mobilization program and were compared with 44 patients who underwent standard medical care. In the intervention cohort, 100% and 57.2% of the patients completed early rehabilitation and early mobilization, respectively, compared to 0% in the control cohort. The intervention cohort at ICU discharge showed significantly improved the Perme ICU Mobility Scores. CONCLUSIONS: The implementation of the revised progressive early mobilization program for patients with moderate-to-severe TBI resulted in significantly improved mobility at ICU discharge; however, the length of overall stay in the ICU may be not affected.

Vitamin B6 down-regulates the expression of human GPIIb gene

Glycoprotein IIb (GPIIb) is the alpha-subunit of the platelet membrane receptor GPIIb/IIIa, which plays a major role in platelet aggregation. Vitamin B6 has been reported to be an antiaggregative agent, although its mechanism is not well known. To understand the molecular mechanism of vitamin B6 on antiaggregation, we analyzed the effects of various forms of vitamin B6 on the expression of human GPIIb promoter using chloramphenicol acetyl transferase (CAT) as the reporter gene. The GPIIb promoter region was amplified by polymerase chain reaction (PCR), cloned into pBLCAT3 to drive the CAT reporter gene and transfected into human erythroleukemia (HEL) cells. Transient expression of the GPIIb promoter was determined after transfected cells were treated with 1 microM pyridoxine (PN), pyridoxal (PL), pyridoxal-5-phosphate (PLP), or 4-deoxypyridoxine (4-dex) for 48 h. Our results show that the GPIIb promoter activity was down-regulated to 54, 35 and 63% in the presence of PN, PL and PLP, respectively, as compared to an untreated control whose promoter activity was 100%. However, no adverse effect on GPIIb promoter was detected by 4-dex, which is an antagonist of vitamin B6. The down-regulation effect of vitamin B6 on GPIIb promoter activity may lead to a reduction of GPIIb protein expression and thus be detrimental to platelet aggregation.