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Ekström M, Sundh J, Andersson A, Angerås O, Blomberg A, Börjesson M, Caidahl K, Emilsson ÖI, Engvall J, Frykholm E, Grote L, Hedman K, Jernberg T, Lindberg E, Malinovschi A, Nyberg A, Rullman E, Sandberg J, Sköld M, Stenfors N, Sundström J, Tanash H, Zaigham S, Carlhäll CJ. Exertional breathlessness related to medical conditions in middle-aged people: the population-based SCAPIS study of more than 25,000 men and women. Respir Res 2024; 25:127. [PMID: 38493081 PMCID: PMC10944596 DOI: 10.1186/s12931-024-02766-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Breathlessness is common in the population and can be related to a range of medical conditions. We aimed to evaluate the burden of breathlessness related to different medical conditions in a middle-aged population. METHODS Cross-sectional analysis of the population-based Swedish CArdioPulmonary bioImage Study of adults aged 50-64 years. Breathlessness (modified Medical Research Council [mMRC] ≥ 2) was evaluated in relation to self-reported symptoms, stress, depression; physician-diagnosed conditions; measured body mass index (BMI), spirometry, venous haemoglobin concentration, coronary artery calcification and stenosis [computer tomography (CT) angiography], and pulmonary emphysema (high-resolution CT). For each condition, the prevalence and breathlessness population attributable fraction (PAF) were calculated, overall and by sex, smoking history, and presence/absence of self-reported cardiorespiratory disease. RESULTS We included 25,948 people aged 57.5 ± [SD] 4.4; 51% women; 37% former and 12% current smokers; 43% overweight (BMI 25.0-29.9), 21% obese (BMI ≥ 30); 25% with respiratory disease, 14% depression, 9% cardiac disease, and 3% anemia. Breathlessness was present in 3.7%. Medical conditions most strongly related to the breathlessness prevalence were (PAF 95%CI): overweight and obesity (59.6-66.0%), stress (31.6-76.8%), respiratory disease (20.1-37.1%), depression (17.1-26.6%), cardiac disease (6.3-12.7%), anemia (0.8-3.3%), and peripheral arterial disease (0.3-0.8%). Stress was the main factor in women and current smokers. CONCLUSION Breathlessness mainly relates to overweight/obesity and stress and to a lesser extent to comorbidities like respiratory, depressive, and cardiac disorders among middle-aged people in a high-income setting-supporting the importance of lifestyle interventions to reduce the burden of breathlessness in the population.
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Affiliation(s)
- Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, 221 84, Lund, Sweden.
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Andersson
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
- COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Blomberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mats Börjesson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg, Sweden
- Center for Lifestyle Intervention, Department MGAÖ, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kenneth Caidahl
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, and Sahlgrenska Academy, Gothenburg, Sweden
| | - Össur Ingi Emilsson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Jan Engvall
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Erik Frykholm
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Ludger Grote
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Sleep Disorders Centre, Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - André Nyberg
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Eric Rullman
- Department of Laboratory Medicine, Section of Clinical Physiology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jacob Sandberg
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, 221 84, Lund, Sweden
| | - Magnus Sköld
- Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Nikolai Stenfors
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hanan Tanash
- Department of Respiratory Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Suneela Zaigham
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Carl-Johan Carlhäll
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
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Kristenson K, Hedman K. Percent predicted peak oxygen uptake is superior to weight-indexed peak oxygen uptake in risk stratification before lung cancer lobectomy. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00187-9. [PMID: 38452887 DOI: 10.1016/j.jtcvs.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To improve preoperative risk stratification in lung cancer lobectomy by identifying and comparing optimal thresholds for peak oxygen uptake (VO2peak) presented as weight-indexed and percent of predicted values, respectively. METHODS This was a longitudinal cohort study including national registry data on patients scheduled for cancer lobectomy that used available data from preoperative cardiopulmonary exercise testing. The measured VO2peak was indexed by body mass (mL/kg/min) and also compared with 2 established reference equations (Wasserman-Hansen and Study of Health in Pomerania, respectively). By receiver operating characteristic analysis, a lower 90% specificity and an upper 90% sensitivity threshold were determined for each measure, in relation to the outcome of any major complication or death. For each measure and based on these thresholds, patients were categorized as low risk, intermediate risk, or high risk. The frequency of complications was compared between groups using χ2. RESULTS The frequency of complications differed significantly between the proposed low-, intermediate-, and high-risk groups when using % predicted Study of Health in Pomerania (5%, 21%, 35%, P = .007) or % predicted Wasserman-Hansen (5%, 25%, 35%, P = .002) but not when using the weight-indexed VO2peak groups (7%, 23%, 15%, P = .08). Nonsignificant differences were found using the threshold <15 mL/kg/min (P = .34). CONCLUSIONS This study showed that weight-indexed VO2peak was of less use as a marker of risk at the lower range of exercise capacity, whereas % predicted VO2peak was associated with a continuously increasing risk of major complications, also at the lower end of exercise capacity. As identifying subjects at high risk of complications is important, % predicted VO2peak is therefore preferable.
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Affiliation(s)
- Karolina Kristenson
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Herraiz-Adillo Á, Ahlqvist VH, Higueras-Fresnillo S, Hedman K, Hagström E, Fortuin-de Smidt M, Daka B, Lenander C, Berglind D, Östgren CJ, Rådholm K, Ortega FB, Henriksson P. Physical fitness in male adolescents and atherosclerosis in middle age: a population-based cohort study. Br J Sports Med 2024; 58:bjsports-2023-107663. [PMID: 38355280 DOI: 10.1136/bjsports-2023-107663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To examine the associations between physical fitness in male adolescents and coronary and carotid atherosclerosis in middle age. METHODS This population-based cohort study linked physical fitness data from the Swedish Military Conscription Register during adolescence to atherosclerosis data from the Swedish CArdioPulmonary bioImage Study in middle age. Cardiorespiratory fitness was assessed using a maximal cycle-ergometer test, and knee extension muscular strength was evaluated through an isometric dynamometer. Coronary atherosclerosis was evaluated via Coronary Computed Tomography Angiography (CCTA) stenosis and Coronary Artery Calcium (CAC) scores, while carotid plaques were evaluated by ultrasound. The associations were analysed using multinomial logistic regression, adjusted (marginal) prevalences and restricted cubic splines. RESULTS The analysis included 8986 male adolescents (mean age 18.3 years) with a mean follow-up of 38.2 years. Physical fitness showed a reversed J-shaped association with CCTA stenosis and CAC, but no consistent association was observed for carotid plaques. After adjustments, compared with adolescents in the lowest tertile of cardiorespiratory fitness and muscular strength, those in the highest tertile had 22% (OR 0.78; 95% CI 0.61 to 0.99) and 26% (OR 0.74; 95% CI 0.58 to 0.93) lower ORs for severe (≥50%) coronary stenosis, respectively. The highest physical fitness group (high cardiorespiratory fitness and muscular strength) had 33% (OR 0.67; 95% CI 0.52 to 0.87) lower OR for severe coronary stenosis compared with those with the lowest physical fitness. CONCLUSION This study supports that a combination of high cardiorespiratory fitness and high muscular strength in adolescence is associated with lower coronary atherosclerosis, particularly severe coronary stenosis, almost 40 years later.
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Affiliation(s)
- Ángel Herraiz-Adillo
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Viktor H Ahlqvist
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Sara Higueras-Fresnillo
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Physical Education, Sport and Human Motricity, Universidad Autónoma de Madrid, Madrid, Spain
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | | | - Bledar Daka
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | - Cecilia Lenander
- Department of Clinical Sciences in Malmö, Centre for Primary Health Care Research, Lund University, Lund, Sweden
| | - Daniel Berglind
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Carl Johan Östgren
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Centre of Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Karin Rådholm
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Francisco B Ortega
- Department of Physical Education and Sports, Faculty of Sport Sciences, Sport and Health University Research Institute (iMUDS) and CIBEROBN Physiopathology of Obesity and Nutrition, University of Granada, Granada, Spain
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Pontus Henriksson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Kristenson K, Hylander J, Boros M, Hedman K. VE/VCO 2 slope threshold optimization for preoperative evaluation in lung cancer surgery: identifying true high- and low-risk groups. J Thorac Dis 2024; 16:123-132. [PMID: 38410536 PMCID: PMC10894426 DOI: 10.21037/jtd-23-1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/03/2023] [Indexed: 02/28/2024]
Abstract
Background Cardiopulmonary exercise testing (CPET) enables measurement of the slope of the increase in minute ventilation in relation to carbon dioxide elimination during exercise (the VE/VCO2 slope). Several studies have shown that the VE/VCO2 slope is a strong marker for postoperative complications and mortality. However, current thresholds for adverse outcomes are generated from historical data in heart failure patients. Methods This was a retrospective analysis of 158 patients with lung cancer who underwent lobectomy or pneumonectomy during 2008-2020. The main outcome was major pulmonary complications (MPC) or death ≤30 days of cancer surgery. Patients were first categorized using two different single threshold approaches; the traditional threshold of 35 and the highest Youden value from the receiver operating curve (ROC) analysis. Secondly, patients were categorized into three risk groups using two thresholds. These two thresholds were determined in an ROC analysis, where the VE/VCO2 slope values generating either a 90% sensitivity (lower threshold) or a 90% specificity (upper threshold) for the main outcome were chosen. The frequency of complications was compared using Chi2. The overall model quality was evaluated by an area under the curve (AUC) analysis. Positive predictive values (PPVs) and negative predictive values (NPVs) are presented. Results The two thresholds, <30 (90% sensitivity) and >41 (90% specificity), created three risk groups: low risk (VE/VCO2 slope <30, n=44, 28%); intermediate risk (VE/VCO2 slope 30-41, n=95, 60%) and high risk (VE/VCO2 slope >41, n=19, 12%). The frequency of complications differed between groups: 5%, 16% and 47% (P<0.001). Using two thresholds compared to one threshold increased the overall model quality (reaching AUC 0.70, 95% confidence interval: 0.59-0.81), and identified a high sensitivity threshold (VE/VCO2 slope <30) which generated a NPV of 95% but importantly, also a high specificity threshold (VE/VCO2 slope >41) with a PPV of 47%. Conclusions Risk stratification based on three risk groups from the preoperative VE/VCO2 slope increased the model quality, was more discriminative and generated better PPV and NPV compared to traditional risk stratification into two risk groups.
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Affiliation(s)
- Karolina Kristenson
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Johan Hylander
- Department of Anesthesiology and Intensive Care in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Miklos Boros
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Carlén A, Lindow T, Cauwenberghs N, Elmberg V, Brudin L, Ekström M, Hedman K. Exercise Systolic Blood Pressure Response During Cycle Ergometry is Associated with Future Hypertension in Normotensive Individuals. Eur J Prev Cardiol 2024:zwae012. [PMID: 38204381 DOI: 10.1093/eurjpc/zwae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024]
Abstract
AIMS We aimed to investigate the association between the exercise systolic blood pressure (SBP) response and future hypertension (HTN) in normotensive individuals referred for cycle ergometry, with special regard to reference exercise SBP values, and exercise capacity. METHODS In this longitudinal cohort study, data from 14,428 exercise tests were cross-linked with Swedish national registries on diagnoses and medications. We excluded individuals with a baseline diagnosis of cardiovascular disease or HTN. The peak exercise SBP (SBPpeak) was recorded and compared to the upper limit of normal (ULN) derived from SBPpeak reference equations incorporating age, sex, resting SBP and exercise capacity. To evaluate the impact of exercise capacity, three SBP to work rate slopes (SBP/W-slopes), were calculated, relative to either supine or seated SBP at rest or to the first exercise SBP. Adjusted hazard ratios (HRadjusted [95% Confidence interval, CI]) for incident HTN during follow-up, in relation to SBP response metrics, were calculated. RESULTS We included 3,895 normotensive individuals (49±14 years, 45% females) with maximal cycle ergometer tests. During follow-up (median 7.5 years) 22% developed HTN. Higher SBPpeak and SBPpeak>ULN were associated with incident HTN (HRadjusted 1.19 [1.14-1.23] per 10 mmHg, and 1.95 [1.54-2.47], respectively). All three SBP/W-slopes were positively associated to incident HTN, particularly the SBP/W-slope calculated as supine-to-peak SBP (HRadjusted 1.25 [1.19-1.31] per 1 mmHg/10W). CONCLUSION Both SBPpeak>ULN based on reference values and high SBP/W-slopes were associated with incident HTN in normotensive individuals and should be considered in the evaluation of the cycle ergometry SBP response.
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Affiliation(s)
- Anna Carlén
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Clinical Sciences, Clinical Physiology, Lund University, Department of Research and Development, Region Kronoberg, Sweden
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Viktor Elmberg
- Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Kristenson K, Gerring E, Björnsson B, Sandström P, Hedman K. Peak oxygen uptake in combination with ventilatory efficiency improve risk stratification in major abdominal surgery. Physiol Rep 2024; 12:e15904. [PMID: 38163673 PMCID: PMC10758333 DOI: 10.14814/phy2.15904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024] Open
Abstract
This pilot study aimed to evaluate if peak VO2 and ventilatory efficiency in combination would improve preoperative risk stratification beyond only relying on peak VO2 . This was a single-center retrospective cohort study including all patients who underwent cardiopulmonary exercise testing (CPET) as part of preoperative risk evaluation before major upper abdominal surgery during years 2008-2021. The primary outcome was any major cardiopulmonary complication during hospitalization. Forty-nine patients had a preoperative CPET before decision to pursue to surgery (cancer in esophagus [n = 18], stomach [6], pancreas [16], or liver [9]). Twenty-five were selected for operation. Patients who suffered any major cardiopulmonary complication had lower ventilatory efficiency (i.e., higher VE/VCO2 slope, 37.3 vs. 29.7, p = 0.031) compared to those without complications. In patients with a low aerobic capacity (i.e., peak VO2 < 20 mL/kg/min) and a VE/VCO2 slope ≥ 39, 80% developed a major cardiopulmonary complication. In this pilot study of patients with preoperative CPET before major upper abdominal surgery, patients who experienced a major cardiopulmonary complication had significantly lower ventilatory efficiency compared to those who did not. A low aerobic capacity in combination with low ventilatory efficiency was associated with a very high risk (80%) of having a major cardiopulmonary complication.
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Affiliation(s)
- Karolina Kristenson
- Department of Thoracic and Vascular Surgery in Östergötland, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Edvard Gerring
- Department of Clinical Physiology, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Bergthor Björnsson
- Department of Surgery, Department of Biomedicine and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Per Sandström
- Department of Surgery, Department of Biomedicine and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
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Fedorowski A, Olsén MF, Nikesjö F, Janson C, Bruchfeld J, Lerm M, Hedman K. Cardiorespiratory dysautonomia in post-COVID-19 condition: Manifestations, mechanisms and management. J Intern Med 2023; 294:548-562. [PMID: 37183186 DOI: 10.1111/joim.13652] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A significant proportion of COVID-19 patients experience debilitating symptoms for months after the acute infection. According to recent estimates, approximately 1 out of 10 COVID-19 convalescents reports persistent health issues more than 3 months after initial recovery. This 'post-COVID-19 condition' may include a large variety of symptoms from almost all domains and organs, and for some patients it may mean prolonged sick-leave, homestay and strongly limited activities of daily life. In this narrative review, we focus on the symptoms and signs of post-COVID-19 condition in adults - particularly those associated with cardiovascular and respiratory systems, such as postural orthostatic tachycardia syndrome or airway disorders - and explore the evidence for chronic autonomic dysfunction as a potential underlying mechanism. The most plausible hypotheses regarding cellular and molecular mechanisms behind the wide spectrum of observed symptoms - such as lingering viruses, persistent inflammation, impairment in oxygen sensing systems and circulating antibodies directed to blood pressure regulatory components - are discussed. In addition, an overview of currently available pharmacological and non-pharmacological treatment options is presented.
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Affiliation(s)
- Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Karolinska University Hospital, Solna, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Monika Fagevik Olsén
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frida Nikesjö
- Department of Respiratory Medicine in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Judith Bruchfeld
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Infectious Diseases, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
| | - Maria Lerm
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Linköping, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Cauwenberghs N, Sente J, Sabovčik F, Ntalianis E, Hedman K, Claes J, Goetschalckx K, Cornelissen V, Kuznetsova T. Cardiorespiratory fitness components in relation to clinical characteristics, disease state and medication intake: A patient registry study. Clin Physiol Funct Imaging 2023; 43:441-452. [PMID: 37317062 DOI: 10.1111/cpf.12842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/24/2023] [Accepted: 06/12/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Interpretation of cardiopulmonary exercise testing (CPET) results requires thorough understanding of test confounders such as anthropometrics, comorbidities and medication. Here, we comprehensively assessed the clinical determinants of cardiorespiratory fitness and its components in a heterogeneous patient sample. METHODS We retrospectively collected medical and CPET data from 2320 patients (48.2% females) referred for cycle ergometry at the University Hospital Leuven, Belgium. We assessed clinical determinants of peak CPET indexes of cardiorespiratory fitness (CRF) and its hemodynamic and ventilatory components using stepwise regression and quantified multivariable-adjusted differences in indexes between cases and references. RESULTS Lower peak load and peak O2 uptake were related to: higher age, female sex, lower body height and weight, and higher heart rate; to the intake of beta blockers, analgesics, thyroid hormone replacement and benzodiazepines; and to diabetes mellitus, chronic kidney disease, non-ST elevation myocardial infarction and atrial fibrillation (p < 0.05 for all). Lower peak load also correlated with obstructive pulmonary diseases. Stepwise regression revealed associations of hemodynamic and ventilatory indexes (including heart rate, O2 pulse, systolic blood pressure and ventilation at peak exercise and ventilatory efficiency) with age, sex, body composition and aforementioned diseases and medications. Multivariable-adjusted differences in CPET metrics between cases and controls confirmed the associations observed. CONCLUSION We described known and novel associations of CRF components with demographics, anthropometrics, cardiometabolic and pulmonary diseases and medication intake in a large patient sample. The clinical implications of long-term noncardiovascular drug intake for CPET results require further investigation.
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Affiliation(s)
- Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Josephine Sente
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - František Sabovčik
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Evangelos Ntalianis
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jomme Claes
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - Kaatje Goetschalckx
- Research Unit Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Véronique Cornelissen
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Patti A, Blumberg Y, Hedman K, Neunhäuserer D, Haddad F, Wheeler M, Ashley E, Moneghetti KJ, Myers J, Christle JW. Respiratory gas kinetics in patients with congestive heart failure during recovery from peak exercise. Clinics (Sao Paulo) 2023; 78:100225. [PMID: 37356413 DOI: 10.1016/j.clinsp.2023.100225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 03/20/2023] [Accepted: 04/12/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Cardiopulmonary Exercise Testing (CPX) is essential for the assessment of exercise capacity for patients with Chronic Heart Failure (CHF). Respiratory gas and hemodynamic parameters such as Ventilatory Efficiency (VE/VCO2 slope), peak oxygen uptake (peak VO2), and heart rate recovery are established diagnostic and prognostic markers for clinical populations. Previous studies have suggested the clinical value of metrics related to respiratory gas collected during recovery from peak exercise, particularly recovery time to 50% (T1/2) of peak VO2. The current study explores these metrics in detail during recovery from peak exercise in CHF. METHODS Patients with CHF who were referred for CPX and healthy individuals without formal diagnoses were assessed for inclusion. All subjects performed CPX on cycle ergometers to volitional exhaustion and were monitored for at least five minutes of recovery. CPX data were analyzed for overshoot of respiratory exchange ratio (RER=VCO2/VO2), ventilatory equivalent for oxygen (VE/VO2), end-tidal partial pressure of oxygen (PETO2), and T1/2 of peak VO2 and VCO2. RESULTS Thirty-two patients with CHF and 30 controls were included. Peak VO2 differed significantly between patients and controls (13.5 ± 3.8 vs. 32.5 ± 9.8 mL/Kg*min-1, p < 0.001). Mean Left Ventricular Ejection Fraction (LVEF) was 35.9 ± 9.8% for patients with CHF compared to 61.1 ± 8.2% in the control group. The T1/2 of VO2, VCO2 and VE was significantly higher in patients (111.3 ± 51.0, 132.0 ± 38.8 and 155.6 ± 45.5s) than in controls (58.08 ± 13.2, 74.3 ± 21.1, 96.7 ± 36.8s; p < 0.001) while the overshoot of PETO2, VE/VO2 and RER was significantly lower in patients (7.2 ± 3.3, 41.9 ± 29.1 and 25.0 ± 13.6%) than in controls (10.1 ± 4.6, 62.1 ± 17.7 and 38.7 ± 15.1%; all p < 0.01). Most of the recovery metrics were significantly correlated with peak VO2 in CHF patients, but not with LVEF. CONCLUSIONS Patients with CHF have a significantly blunted recovery from peak exercise. This is reflected in delays of VO2, VCO2, VE, PETO2, RER and VE/VO2, reflecting a greater energy required to return to baseline. Abnormal respiratory gas kinetics in CHF was negatively correlated with peak VO2 but not baseline LVEF.
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Affiliation(s)
- Alessandro Patti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Division of Sports and Exercise Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Yair Blumberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Daniel Neunhäuserer
- Division of Sports and Exercise Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Francois Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA; Baker Department of Cardiometabolic Health, University of Melbourne, Australia; National Centre for Sports Cardiology, St Vincent's Hospital, Melbourne, Australia
| | - Jonathan Myers
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA; Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Department of Medicine, Stanford, California, USA; Stanford Sports Cardiology, Stanford University, Stanford, California, USA.
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10
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Eklund Gustafsson C, Ekström M, Ugander M, Brudin L, Carlén A, Hedman K, Lindow T. Prognostic value of peak work rate indexed by left ventricular diameter. Sci Rep 2023; 13:8806. [PMID: 37258692 DOI: 10.1038/s41598-023-35976-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 05/26/2023] [Indexed: 06/02/2023] Open
Abstract
Left ventricular diameter (LVEDD) increases with systematic endurance training but also in various cardiac diseases. High exercise capacity associates with favorable outcomes. We hypothesized that peak work rate (Wpeak) indexed to LVEDD would carry prognostic information and aimed to evaluate the association between Wpeak/LVEDDrest and cardiovascular mortality. Wpeak/LVEDDrest (W/mm) was calculated in patients with an echocardiographic examination within 3 months of a maximal cycle ergometer exercise test. Low Wpeak/LVEDDrest was defined as a value below the sex- and age-specific 5th percentile among lower-risk subjects. The association with cardiovascular mortality was evaluated using Cox regression. In total, 3083 patients were included (8.0 [5.4-11.1] years of follow-up, 249 (8%) cardiovascular deaths). Wpeak/LVEDDrest (W/mm) was associated with cardiovascular mortality (adjusted hazard ratio (HR) 0.28 [0.22-0.36]), similar to Wpeak in % of predicted, with identical prognostic strength when adjusted for age and sex (C-statistics 0.87 for both). A combination of low Wpeak/LVEDDrest and low Wpeak was associated with a particularly poor prognosis (adjusted HR 6.4 [4.0-10.3]). Wpeak/LVEDDrest was associated with cardiovascular mortality but did not provide incremental prognostic value to Wpeak alone. The combination of a low Wpeak/LVEDDrest and low Wpeak was associated with a particularly poor prognosis.
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Affiliation(s)
- Charlotte Eklund Gustafsson
- Department of Clinical Physiology, Research and Development, Växjö Central Hospital, Region Kronoberg, Växjö, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden
| | - Martin Ugander
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, Australia
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Carlén
- Department of Clinical Physiology in Linköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Thomas Lindow
- Department of Clinical Physiology, Research and Development, Växjö Central Hospital, Region Kronoberg, Växjö, Sweden.
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
- Clinical Physiology, Clinical Sciences, Lund University, 221 00, Lund, Sweden.
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11
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Ohlsson L, Moreira ADL, Bäck S, Lantz J, Carlhäll CJ, Persson A, Hedman K, Chew MS, Dahlström N, Ebbers T. Enhancing students' understanding of cardiac physiology by using 4D visualization. Clin Anat 2023; 36:542-549. [PMID: 36695446 DOI: 10.1002/ca.24009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
Difficulties in achieving knowledge about physiology and anatomy of the beating heart highlight the challenges with more traditional pedagogical methods. Recent research regarding anatomy education has mainly focused on digital three-dimensional models. However, these pedagogical improvements may not be entirely applicable to cardiac anatomy and physiology due to the multidimensional complexity with moving anatomy and complex blood flow. The aim of this study was therefore to evaluate whether high quality time-resolved anatomical images combined with realistic blood flow simulations improve the understanding of cardiac structures and function. Three time-resolved datasets were acquired using time-resolved computed tomography and blood flow was computed using Computational Fluid Dynamics. The anatomical and blood flow information was combined and interactively visualized using volume rendering on an advanced stereo projection system. The setup was tested in interactive lectures for medical students. Ninety-seven students participated. Summative assessment of examinations showed significantly improved mean score (18.1 ± 4.5 vs 20.3 ± 4.9, p = 0.002). This improvement was driven by knowledge regarding myocardial hypertrophy and pressure-velocity differences over a stenotic valve. Additionally, a supplementary formative assessment showed significantly more agreeing answers than disagreeing answers (p < 0.001) when the participants subjectively evaluated the contribution of the visualizations to their education and knowledge. In conclusion, the use of simultaneous visualization of time-resolved anatomy data and simulated blood flow improved medical students' results, with a particular effect on understanding of cardiac physiology and these simulations may be useful educational tools for teaching complex anatomical and physiological concepts.
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Affiliation(s)
- Linus Ohlsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - André Da Luz Moreira
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Sophia Bäck
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Jonas Lantz
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Carl-Johan Carlhäll
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anders Persson
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Radiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Michelle S Chew
- Department of Anesthesiology and Intensive Care, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nils Dahlström
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Radiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tino Ebbers
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
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12
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Elmberg V, Schiöler L, Lindow T, Hedman K, Malinovschi A, Lewthwaite H, Jensen D, Brudin L, Ekström M. Reference equations for breathlessness during incremental cycle exercise testing. ERJ Open Res 2023; 9:00566-2022. [PMID: 37057086 PMCID: PMC10086693 DOI: 10.1183/23120541.00566-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/16/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundExertional breathlessness is commonly assessed using incremental exercise testing (IET), but reference equations for breathlessness responses are lacking. We aimed to develop reference equations for breathlessness intensity during IET.MethodsRetrospective, consecutive cohort study of adults undergoing IET in Sweden. Exclusion criteria included cardiac or respiratory disease, death or any of the aforementioned diagnoses within 1 year of the IET, morbid obesity, abnormally low exercise capacity, submaximal exertion, or an abnormal exercise test. Probabilities for breathlessness intensity ratings (Borg CR10) during IET in relation to power output (%predWmax), age, sex, height, and body mass were analysed using marginal ordinal logistic regression. Reference equations for males and females were derived to predict the upper limit of normal (ULN), and the probability of different Borg CR10 intensity ratings.Results2581 participants (43% female) aged 18–90 years were included. Mean breathlessness intensity was similar between sexes at peak exertion (6.7±1.5versus6.4±1.5 Borg CR10 units) and throughout exercise in relation to %predWmax. Final reference equations included age, height and %predWmaxfor males, whereas height was not included for females. The models showed a close fit to observed breathlessness intensity ratings across %predWmaxvalues. Models using absolute W did not show superior fit. Scripts are provided for calculating the probability for different breathlessness intensity ratings, and the ULN by %predWmaxthroughout IET.ConclusionWe present the first reference equations for interpreting breathlessness intensity during incremental cycle exercise testing in males and females aged 18–90 years.
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13
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Gomes B, Hedman K, Kuznetsova T, Cauwenberghs N, Hsu D, Kobayashi Y, Ingelsson E, Oxborough D, George K, Salerno M, Ashley E, Haddad F. Defining left ventricular remodeling using lean body mass allometry: a UK Biobank study. Eur J Appl Physiol 2023; 123:989-1001. [PMID: 36617359 DOI: 10.1007/s00421-022-05125-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE The geometric patterns of ventricular remodeling are determined using indexed left ventricular mass (LVM), end-diastolic volume (LVEDV) and concentricity, most often measured using the mass-to-volume ratio (MVR). The aims of this study were to validate lean body mass (LBM)-based allometric coefficients for scaling and to determine an index of concentricity that is independent of both volume and LBM. METHODS Participants from the UK Biobank who underwent both CMR and dual-energy X-ray absorptiometry (DXA) during 2014-2015 were considered (n = 5064). We excluded participants aged ≥ 70 years or those with cardiometabolic risk factors. We determined allometric coefficients for scaling using linear regression of the logarithmically transformed ventricular remodeling parameters. We further defined a multiplicative allometric relationship for LV concentricity (LVC) adjusting for both LVEDV and LBM. RESULTS A total of 1638 individuals (1057 female) were included. In subjects with lower body fat percentage (< 25% in males, < 35% in females, n = 644), the LBM allometric coefficients for scaling LVM and LVEDV were 0.85 ± 0.06 and 0.85 ± 0.03 respectively (R2 = 0.61 and 0.57, P < 0.001), with no evidence of sex-allometry interaction. While the MVR was independent of LBM, it demonstrated a negative association with LVEDV in (females: r = - 0.44, P < 0.001; males: - 0.38, P < 0.001). In contrast, LVC was independent of both LVEDV and LBM [LVC = LVM/(LVEDV0.40 × LBM0.50)] leading to increased overlap between LV hypertrophy and higher concentricity. CONCLUSIONS We validated allometric coefficients for LBM-based scaling for CMR indexed parameters relevant for classifying geometric patterns of ventricular remodeling.
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Affiliation(s)
- Bruna Gomes
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA.
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Cardiology, Pneumology and Angiology, Heidelberg University Hospital, Heidelberg, Germany.
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94304, USA.
| | - Kristofer Hedman
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Department of Clinical Physiology in Linköping, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - David Hsu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Erik Ingelsson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
| | - David Oxborough
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, L3 9UT, UK
| | - Keith George
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, L3 9UT, UK
| | - Michael Salerno
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Euan Ashley
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, 94304, USA.
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford University School of Medicine, Falk Building 870 Quarry Rd, Stanford, CA, 94304, USA.
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14
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Hult L, Kylhammar D, Engvall J, Ostgren CJ, Nystrom F, Blomstrand P, Hedman K. Post systolic shortening by speckle tracking echocardiography as a predictor for cardiovascular events in patients with type 2 diabetes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Post systolic shortening (PSS), measured by speckle tracking echocardiography has emerged as a novel method to evaluate left ventricular function and has been linked to adverse outcomes.
Purpose
Our aim was to assess if the presence of pathological PSS had prognostic value in the prediction of major cardiovascular events in a cohort of patients with type-II diabetes (T2D).
Method
Three-hundred-and-sixty-four patients with T2D in the CARDIPP study (Cardiovascular Risk factors in Patients with Diabetes – a Prospective study in Primary care) underwent echocardiography between 2005 and 2009. All patients were evaluated with strain analysis by speckle tracking. PSS was defined as any myocardial contraction occurring after aortic valve closure (Figure 1). Pathological PSS was defined as a post systolic index (PSI) >5% where PSI was calculated as: (peak global longitudinal strain – peak systolic longitudinal strain) / (peak global longitudinal strain) x 100. The composite endpoint of any major cardiovascular event (MACE) was defined as the diagnosis of or death in heart failure, myocardial infarction, or stroke. Cox proportional hazard ratios (HR) with 95% confidence intervals were calculated and were adjusted for sex, age, body mass index, hypertension, smoking, previous cardiovascular events and HbA1c.
Results
Mean follow-up time was 11.2±2.3 years. Patients with pathological PSS had an increased unadjusted risk of MACE, (HR 3.73, 95% CI 2.06–6.76), which persisted after adjustment (HR 2.20, 95% CI 1.11–4.37) as compared to subjects without pathological PSS. When adding PSS to a risk prediction model including Global Longitudinal Strain (GLS), the adjusted HR (95% CI) for MACE was 2.94 (1.33–6.52) for subjects with reduced GLS (lower limit of normal −16%) and PSI >5%, compared to those with normal GLS and PSI ≤5%. Adverse events were more common in subjects with the combination of pathological PSS and GLS (Figure 2).
Conclusions
Our results suggest that PSS may provide important additional prognostic information in patients with T2D.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): This work was funded by grant support from FORSS, the Research Council of Southeastern Sweden and from FUTURUM, the Research Council of Jönköping.
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Affiliation(s)
- L Hult
- Linkoping University Hospital, Department of Health, Medicine and Caring Sciences, and Department of Clinical Physiology , Linkoping , Sweden
| | - D Kylhammar
- Linkoping University Hospital, Department of Health, Medicine and Caring Sciences, and Department of Clinical Physiology , Linkoping , Sweden
| | - J Engvall
- Linkoping University Hospital, Department of Health, Medicine and Caring Sciences, and Department of Clinical Physiology , Linkoping , Sweden
| | - C J Ostgren
- Linkoping University, Department of Health, Medicine and Caring Sciences , Linkoping , Sweden
| | - F Nystrom
- Linkoping University, Department of Health, Medicine and Caring Sciences , Linkoping , Sweden
| | - P Blomstrand
- Jonkoping University, Department of Natural Science and Biomedicine, School of Health and Welfare , Jonkoping , Sweden
| | - K Hedman
- Linkoping University Hospital, Department of Health, Medicine and Caring Sciences, and Department of Clinical Physiology , Linkoping , Sweden
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15
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Kristenson K, Hylander J, Boros M, Fyrenius A, Hedman K. Ventilatory efficiency in combination with peak oxygen uptake improves risk stratification in patients undergoing lobectomy. JTCVS Open 2022; 11:317-326. [PMID: 36172418 PMCID: PMC9510865 DOI: 10.1016/j.xjon.2022.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022]
Abstract
Objective We aimed to evaluate whether or not using the slope of the increase in minute ventilation in relation to carbon dioxide (VE/VCo2-slope), with a cutoff value of 35, could improve risk stratification for major pulmonary complications or death following lobectomy in lung cancer patients at moderate risk (Vo2peak = 10-20 mL/kg/min). Methods Single center, retrospective analysis of 146 patients with lung cancer who underwent lobectomy and preoperative cardiopulmonary exercise testing in 2008-2020. The main outcome was any major pulmonary complication or death within 30 days of surgery. Patients were categorized based on their preoperative cardiopulmonary exercise testing as: low-risk group, peak oxygen uptake >20 mL/kg/min; low-moderate risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope <35; and moderate-high risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope ≥35. The frequency of complications between groups was compared using χ2 test. Logistic regression was used to calculate the odds ratio with 95% CI for the main outcome based on the cardiopulmonary exercise testing group. Results Overall, 25 patients (17%) experienced a major pulmonary complication or died (2 deaths). The frequency of complications differed between the cardiopulmonary exercise testing groups: 29%, 13%, and 8% in the moderate-high, low-moderate, and low-risk group, respectively (P = .023). Using the low-risk group as reference, the adjusted odds ratio for the low-moderate risk group was 3.44 (95% CI, 0.66-17.90), whereas the odds ratio for the moderate-high risk group was 8.87 (95% CI, 1.86-42.39). Conclusions Using the VE/VCo2-slope with a cutoff value of 35 improved risk stratification for major pulmonary complications following lobectomy in lung cancer patients with moderate risk based on a peak oxygen uptake of 10 to 20 mL/kg/min. This suggests that the VE/VCo2-slope can be used for preoperative risk evaluation in lung cancer lobectomy.
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Hedman K, Lindow T, Elmberg V, Brudin L, Ekström M. Authors' reply to 'Reference values for systolic blood pressure at upright bicycle exercise tests' by Alfred Hager. Eur J Prev Cardiol 2022; 29:e298-e299. [PMID: 32349524 DOI: 10.1177/2047487320923055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Sweden
| | - Viktor Elmberg
- Department of Clinical Physiology, Blekinge Hospital, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences Lund, Lund University, Sweden
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Schultz MG, Currie KD, Hedman K, Climie RE, Maiorana A, Coombes JS, Sharman JE. The Identification and Management of High Blood Pressure Using Exercise Blood Pressure: Current Evidence and Practical Guidance. Int J Environ Res Public Health 2022; 19:ijerph19052819. [PMID: 35270514 PMCID: PMC8910717 DOI: 10.3390/ijerph19052819] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/16/2022] [Accepted: 02/24/2022] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is a leading risk factor for cardiovascular disease (CVD). The identification of high BP is conventionally based on in-clinic (resting) BP measures, performed within primary health care settings. However, many cases of high BP go unrecognised or remain inadequately controlled. Thus, there is a need for complementary settings and methods for BP assessment to identify and control high BP more effectively. Exaggerated exercise BP is associated with increased CVD risk and may be a medium to improve identification and control of high BP because it is suggestive of high BP gone undetected on the basis of standard in-clinic BP measures at rest. This paper provides the evidence to support a pathway to aid identification and control of high BP in clinical exercise settings via the measurement of exercise BP. It is recommended that exercise professionals conducting exercise testing should measure BP at a fixed submaximal exercise workload at moderate intensity (e.g., ~70% age-predicted heart rate maximum, stage 1-2 of a standard Bruce treadmill protocol). If exercise systolic BP is raised (≥170 mmHg), uncontrolled high BP should be assumed and should trigger correspondence with a primary care physician to encourage follow-up care to ascertain true BP control (i.e., home, or ambulatory BP) alongside a hypertension-guided exercise and lifestyle intervention to lower CVD risk related to high BP.
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Affiliation(s)
- Martin G. Schultz
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (R.E.C.); (J.E.S.)
- Correspondence: ; Tel.: +61-(0)-3-6226-4264; Fax: +61-(0)-3-6226-7704
| | - Katharine D. Currie
- Department of Kinesiology, Michigan State University, East Lansing, MI 48824, USA;
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, 58183 Linköping, Sweden;
| | - Rachel E. Climie
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (R.E.C.); (J.E.S.)
| | - Andrew Maiorana
- Faculty of Health Sciences, School of Physiotherapy and Exercise Science, Curtin University and Allied Health Department, Fiona Stanley Hospital, Perth, WA 6102, Australia;
| | - Jeff S. Coombes
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, QLD 4072, Australia;
| | - James E. Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (R.E.C.); (J.E.S.)
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von Gruenewaldt A, Nylander E, Hedman K. Classification and occurrence of an abnormal breathing pattern during cardiopulmonary exercise testing in subjects with persistent symptoms following COVID-19 disease. Physiol Rep 2022; 10:e15197. [PMID: 35179831 PMCID: PMC8855681 DOI: 10.14814/phy2.15197] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/05/2022] [Accepted: 01/30/2022] [Indexed: 05/13/2023] Open
Abstract
Reduced exercise capacity and several limiting symptoms during exercise have been reported following severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. From clinical observations, we hypothesized that an abnormal breathing pattern (BrP) during exercise may be common in these patients and related to reduced exercise capacity. We aimed to (a) evaluate a method to classify the BrP as normal/abnormal or borderline in terms of inter-rater agreement; (b) determine the occurrence of an abnormal BrP in patients with post-COVID; and (c) compare characteristics of post-COVID patients with normal and abnormal BrP. In a retrospective, cross-sectional study of patients referred for CPET due to post-COVID April 2020-April 2021, we selected subjects without a history of intensive care and with available medical records. Three raters independently categorized patients' BrP as normal, abnormal, or borderline, using four traditional CPET plots (respiratory exchange ratio, tidal volume over ventilation, ventilatory equivalent for oxygen, and ventilation over time). Out of 20 patients (11 male), 10 were categorized as having a normal, 7 an abnormal, and three a borderline BrP. Inter-rater agreement was good (Fleiss' kappa: 0.66 [0.66-0.67]). Subjects with an abnormal BrP had lower peak ventilation, lower exercise capacity, similar ventilatory efficiency and a similar level of dyspnea at peak exercise, as did subjects with a normal BrP. Patients' BrP was possible to classify with good agreement between observers. A third of patients had an abnormal BrP, associated with lower exercise capacity, which could possibly explain exercise related symptoms in some patients with post-COVID syndrome.
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Affiliation(s)
- Anna von Gruenewaldt
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Eva Nylander
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
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19
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Hedman K, Lindow T, Cauwenberghs N, Carlén A, Elmberg V, Brudin L, Ekström M. Peak exercise SBP and future risk of cardiovascular disease and mortality. J Hypertens 2022; 40:300-309. [PMID: 34475344 PMCID: PMC8728754 DOI: 10.1097/hjh.0000000000003008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 12/02/2022]
Abstract
OBJECTIVES This study aimed to evaluate the risk of all-cause mortality and incident cardiovascular disease associated with peak systolic blood pressure (PeakSBP) at clinical exercise testing. METHODS Data from 10 096 clinical exercise tests (54% men, age 18-85 years) was cross-linked with outcome data from national registries. PeakSBP was compared with recently published reference percentiles as well as expressed as percentage predicted PeakSBP using reference equations.Natural cubic spline modelling and Cox regression were used to analyse data stratified by sex and baseline cardiovascular risk profile. RESULTS Median [IQR] follow-up times were 7.9 [5.7] years (all-cause mortality) and 5.6 [5.9] years (incident cardiovascular disease), respectively. The adjusted risk of all-cause mortality [hazard ratio, 95% confidence interval (95% CI)] for individuals with PeakSBP below the 10th percentile was 2.00 (1.59-2.52) in men and 2.60 (1.97-3.44) in women, compared with individuals within the 10th--90th percentile. The corresponding risk for incident cardiovascular disease was 1.55 (1.28-1.89, men) and 1.34 (1.05-1.71, women). For males in the upper 90th percentile, compared with individuals within the 10th--90th percentile, the adjusted risks of all-cause death and incident cardiovascular disease were 0.35 (0.22-0.54) and 0.72 (0.57-0.92), respectively, while not statistically significant in women. Spline modelling revealed a continuous increase in risk with PeakSBP values less than 100% of predicted in both sexes, with no increase in risk more than 100% of predicted. CONCLUSION Low, but not high, PeakSBP was associated with an increased risk of mortality and future cardiovascular disease. Using reference standards for PeakSBP could facilitate clinical risk stratification across patients of varying sex, age and exercise capacity.
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Affiliation(s)
- Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping
| | - Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Clinical Sciences, Clinical Physiology, Lund University, Department of Research and Development, Region Kronoberg, Sweden
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Anna Carlén
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping
| | - Viktor Elmberg
- Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden
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20
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Nishi T, Kobayashi Y, Christle JW, Cauwenberghs N, Boralkar K, Moneghetti K, Amsallem M, Hedman K, Contrepois K, Myers J, Mahaffey KW, Schnittger I, Kuznetsova T, Palaniappan L, Haddad F. Incremental value of diastolic stress test in identifying subclinical heart failure in patients with diabetes mellitus. Eur Heart J Cardiovasc Imaging 2021; 21:876-884. [PMID: 32386203 DOI: 10.1093/ehjci/jeaa070] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS Resting echocardiography is a valuable method for detecting subclinical heart failure (HF) in patients with diabetes mellitus (DM). However, few studies have assessed the incremental value of diastolic stress for detecting subclinical HF in this population. METHODS AND RESULTS Asymptomatic patients with Type 2 DM were prospectively enrolled. Subclinical HF was assessed using systolic dysfunction (left ventricular longitudinal strain <16% at rest and <19% after exercise in absolute value), abnormal cardiac morphology, or diastolic dysfunction (E/e' > 10). Metabolic equivalents (METs) were calculated using treadmill speed and grade, and functional capacity was assessed by percent-predicted METs (ppMETs). Among 161 patients studied (mean age of 59 ± 11 years and 57% male sex), subclinical HF was observed in 68% at rest and in 79% with exercise. Among characteristics, diastolic stress had the highest yield in improving detection of HF with 57% of abnormal cases after exercise and 45% at rest. Patients with revealed diastolic dysfunction during stress had significantly lower exercise capacity than patients with normal diastolic stress (7.3 ± 2.1 vs. 8.8 ± 2.5, P < 0.001 for peak METs and 91 ± 30% vs. 105 ± 30%, P = 0.04 for ppMETs). On multivariable modelling found that age (beta = -0.33), male sex (beta = 0.21), body mass index (beta = -0.49), and exercise E/e' >10 (beta = -0.17) were independently associated with peak METs (combined R2 = 0.46). A network correlation map revealed the connectivity of peak METs and diastolic properties as central features in patients with DM. CONCLUSION Diastolic stress test improves the detection of subclinical HF in patients with diabetes mellitus.
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Affiliation(s)
- Tomoko Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Sports Cardiology, Stanford University, Stanford, CA, USA
| | - Nicholas Cauwenberghs
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Kapucijnenvoer 35 blok d - box 7001 3000 Leuven, Belgium
| | - Kalyani Boralkar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
| | - Kegan Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA.,Stanford Sports Cardiology, Stanford University, Stanford, CA, USA
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
| | - Kristofer Hedman
- Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA.,Department of Clinical Physiology, Linköping University, SE-581 83 Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Kévin Contrepois
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan Myers
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare System and Stanford University, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, 300 Pasteur Dr, Stanford, CA 94305, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, University of Leuven, Kapucijnenvoer 35 blok d - box 7001 3000 Leuven, Belgium
| | - Latha Palaniappan
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, 300 Pasteur Dr H2170, Stanford, CA 94305, USA
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21
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Hedman K, Kaminsky LA, Sabbahi A, Arena R, Myers J. Low but not high exercise systolic blood pressure is associated with long-term all-cause mortality. BMJ Open Sport Exerc Med 2021; 7:e001106. [PMID: 34178375 PMCID: PMC8190063 DOI: 10.1136/bmjsem-2021-001106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives The risks associated with achieving a high peak systolic blood pressure (SBP) during clinical exercise testing remain controversial, although this issue has not been evaluated in relation to predicted SBP standards. This cohort study aimed to evaluate the long-term risk of all-cause mortality in males in relation to reference values of peak SBP and the increase in SBP during exercise from the Fitness Registry and the Importance of Exercise: A National Database (FRIEND). Methods We followed 7164 males (mean age: 58.2±10.6 years) over 95 998 person-years of follow-up (mean 13.4±5.4 years), who performed a maximal treadmill exercise test at baseline. SBP was measured at rest and at peak exercise. Risk of all-cause mortality over 20 years (Cox regression) was determined in relation to reference percentiles of peak SBP and increase in SBP with exercise: <10th (low), 10th-90th, >90th (high) percentiles. Results A high peak or a large increase in SBP with exercise was not associated with all-cause mortality. Subjects with a low peak SBP had a 20% higher unadjusted risk for all-cause death compared with those with a normal value (1.20 (1.11-1.31)), and a statistically non-significant 7% higher risk after adjustment for all baseline risk factors (1.07 (0.97-1.18)). The corresponding unadjusted and adjusted risks associated with a low increase in SBP were 1.24 (1.15-1.35) and 1.11 (1.02-1.21), respectively. Conclusions A low-but not high-peak SBP is associated with increased unadjusted risk of all-cause mortality. The FRIEND percentiles of exercise SBP can aid clinicians in individualising risk assessment.
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Affiliation(s)
- Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Leonard A Kaminsky
- Fisher Institute of Health and Well-Being, Ball State University, Muncie, Indiana, USA
| | - Ahmad Sabbahi
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA.,School of Physical Therapy, South College, Knoxville, Tennessee, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonathan Myers
- Cardiology Division, VA Palo Alto Health Care System, Stanford University, Palo Alto, California, USA
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22
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HENN L, Ni Z, Liang X, Guedes M, Zhao J, Wittbrodt E, Khan F, Sloand J, Garcia-Sanchez J, Hedman K, James G, Pecoits-Filho R, Pisoni R, Robinson B, Zuo L. POS-526 UNDERSTANDING THE PATIENT EXPERIENCE AND CLINICAL COURSE DURING THE INCIDENT DIALYSIS PERIOD: DESIGN AND IMPLEMENTATION OF A DOPPS CHINA STUDY. Kidney Int Rep 2021. [DOI: 10.1016/j.ekir.2021.03.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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23
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JAMES G, Søndergaard H, Hedman K, Karlsson N, Wittbrodt E, Sabir I, Kim J, Allgren R, Stjernlöf G, Någård M, Chung H, Morris J, Wheeler D. POS-264 PATIENT PALATABILITY AND PREFERENCE STUDY OF 3 POTASSIUM BINDERS IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND HYPERKALAEMIA: RATIONALE AND DESIGN OF THE APPETIZE STUDY. Kidney Int Rep 2021. [DOI: 10.1016/j.ekir.2021.03.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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24
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JAMES G, Carrero J, Kumar S, Fishbane S, Wittbrodt E, Kanda E, Hedman K, Kashihara N, Kosiborod M, Lainscak M, Lam C, Pollock C, Stenvinkel P, Wheeler D, Pecoits-Filho R. POS-328 THE BURDEN OF HYPERKALEMIA IN PATIENTS WITH CHRONIC KIDNEY DISEASE: A REPORT FROM THE DISCOVER CKD RETROSPECTIVE COHORT. Kidney Int Rep 2021. [DOI: 10.1016/j.ekir.2021.03.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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25
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JAMES G, Carrero J, Kumar S, Fishbane S, Wittbrodt E, Kanda E, Hedman K, Kashihara N, Kosiborod M, Lainscak M, Lam C, Pollock C, Stenvinkel P, Wheeler D, Pecoits-Filho R. POS-329 TREATMENT PATTERNS IN CHRONIC KIDNEY DISEASE PATIENTS WITH HYPERKALEMIA: A REPORT FROM THE DISCOVER CKD RETROSPECTIVE COHORT. Kidney Int Rep 2021. [DOI: 10.1016/j.ekir.2021.03.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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26
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Lindow T, Ekström M, Brudin L, Carlén A, Elmberg V, Hedman K. Typical angina during exercise stress testing improves the prediction of future acute coronary syndrome. Clin Physiol Funct Imaging 2021; 41:281-291. [PMID: 33583090 DOI: 10.1111/cpf.12695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/08/2021] [Accepted: 02/08/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The prognostic value of angina during exercise stress testing is controversial, possibly due to previous studies not differentiating typical from non-typical angina. We aimed to assess the prognostic value of typical angina alone, or in combination with ST depression, during exercise stress testing for predicting cardiovascular events. METHODS We conducted a prospective observational cohort study including all patients who performed a clinical exercise stress test at the department of Clinical Physiology, Kalmar County Hospital between 2005 and 2012. The association between typical angina/ST depression and incident acute coronary syndrome (ACS) and cardiovascular mortality were analysed using Cox regression for long-term and 1-year follow-up. RESULTS Out of 11605 patients (median follow-up 6.7 years), 623 (5.4%) developed ACS and 319 (2.7%) died from cardiovascular causes. Compared to patients with no angina and no ST depression, typical angina and ST depression were associated with increased risk of future ACS; hazard ratio (HR) 3.5 ([95%CI] 2.6-4.7). This association was even stronger for ACS within one year (typical angina with and without concomitant ST depression; HR 20.8 (13.9-31.3) and 9.7 (6.1-15.4), respectively). Concordance statistics for ST depression in predicting ACS during long-term follow-up was 0.58 (0.56-0.60) and 0.69 (0.65-0.73) for ACS within one year, and 0.64 (0.62-0.66) and 0.77 (0.73-0.81), respectively, when typical angina was added to the model. CONCLUSIONS Typical angina during exercise stress testing is predictive of future ACS, especially in combination with ST depression, and during the first year after the test.
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Affiliation(s)
- Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Clinical Sciences, Clinical Physiology, Department of Research and Development, Lund University, Region Kronoberg, Sweden
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
| | - Anna Carlén
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Viktor Elmberg
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden.,Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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27
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Miller RJH, Hedman K, Amsallem M, Tulu Z, Kent W, Fatehi-Hassanabad A, Clarke B, Heidenreich P, Hiesinger W, Khush KK, Teuteberg J, Haddad F. Donor and Recipient Size Matching in Heart Transplantation With Predicted Heart and Lean Body Mass. Semin Thorac Cardiovasc Surg 2021; 34:158-167. [PMID: 33444763 DOI: 10.1053/j.semtcvs.2021.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Abstract
Donor and recipient size matching during heart transplant can be assessed using weight or predicted heart mass (PHM) ratios. We developed sex-specific allomteric equations for PHM and predicted lean body mass (PLBM) using the United Kingdom Biobank (UKB) and evaluated their predictive value in the United Network of Organ Sharing database. Donor and recipient size matching was based on weight, PHM and PLBM ratios. PHM was calculated using the Multiethnic Study of Atherosclerosis and UKB equations. PLBM was calculated using the UKB and National Health and Nutrition Examination Survey equations. Relative prognostic utility was compared using multivariable Cox analysis, adjusted for predictors of 1-year survival in the Scientific Registry of Transplant Recipients model. Of 53,648 adult patients in the United Network of Organ Sharing database between 1996 and 2016, 6528 (12.2%) died within the first year. In multivariable analysis, undersized matches by any metric were associated with increased 1-year mortality (all P < 0.01). Oversized matches were at increased risk using PHM or PLBM (all P < 0.01), but not weight ratio. There were significant differences in classification of size matching by weight or PHM in sex-mismatched donor-recipient pairs. A significant interaction was observed between pulmonary hypertension and donor undersizing (hazard ratio 1.15, P = 0.026) suggesting increased risk of undersizing in pulmonary hypertension. Donor and recipient size matching with simplified PHM and PLBM offered an advantage over total body weight and may be more important for sex-mismatched donor-recipient pairs. Donor undersizing is associated with worse outcomes in patients with pulmonary hypertension.
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Affiliation(s)
- Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
| | - Kristofer Hedman
- Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Myriam Amsallem
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Zeynep Tulu
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - William Kent
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Ali Fatehi-Hassanabad
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Brian Clarke
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Paul Heidenreich
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - William Hiesinger
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Kiran K Khush
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Jeffrey Teuteberg
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Francois Haddad
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
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Hedman K, Astrom-Aneq M, Nylander E, Bouma K, Mandic M, Rullman E. Effects Of Very Low Volume, High-intensity Interval Training On Left Ventricular Volume And Systolic Function. Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000675116.21676.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Molloy OE, Malara A, Hassan J, Lynch M, Clowry J, Hedman K, De Gascun CF, Kirby B. The prevalence of Human polyomavirus 2 (HPyV2) antibody positivity in psoriasis patients. J Clin Virol 2020; 127:104368. [DOI: 10.1016/j.jcv.2020.104368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 11/24/2022]
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30
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Amsallem M, Tedford RJ, Denault A, Sweatt AJ, Guihaire J, Hedman K, Peighambari S, Kim JB, Li X, Miller RJH, Mercier O, Fadel E, Zamanian R, Haddad F. Quantifying the Influence of Wedge Pressure, Age, and Heart Rate on the Systolic Thresholds for Detection of Pulmonary Hypertension. J Am Heart Assoc 2020; 9:e016265. [PMID: 32419583 PMCID: PMC7428994 DOI: 10.1161/jaha.119.016265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The strong linear relation between mean (MPAP) and systolic (SPAP) pulmonary arterial pressure (eg, SPAP=1.62×MPAP) has been mainly reported in precapillary pulmonary hypertension. This study sought to quantify the influence of pulmonary arterial wedge pressure (PAWP), heart rate, and age on the MPAP-SPAP relation. Methods and Results An allometric equation relating invasive MPAP and SPAP was developed in 1135 patients with pulmonary arterial hypertension, advanced lung disease, chronic thromboembolic pulmonary hypertension, or left heart failure. The equation was validated in 60 885 patients from the United Network for Organ Sharing (UNOS) database referred for heart and/or lung transplant. The MPAP/SPAP longitudinal stability was assessed in pulmonary arterial hypertension with repeated right heart catheterization. The equation obtained was SPAP=1.39×MPAP×PAWP-0.07×(60/heart rate)0.12×age0.08 (P<0.001). It was validated in the UNOS cohort (R2=0.93, P<0.001), regardless of the type of organ(s) patients were listed for (mean bias [-1.96 SD; 1.96 SD] was 0.94 [-8.00; 9.88] for heart, 1.34 [-7.81; 10.49] for lung and 0.25 [-16.74; 17.24] mm Hg for heart-lung recipients). Thresholds of SPAP for MPAP=25 and 20 mm Hg were lower in patients with higher PAWP (37.2 and 29.8 mm Hg) than in those with pulmonary arterial hypertension (40.1 and 32.0 mm Hg). In 186 patients with pulmonary arterial hypertension, the predicted MPAP/SPAP was stable over time (0.63±0.03 at baseline and follow-up catheterization, P=0.43). Conclusions This study quantifies the impact of PAWP, and to a lesser extent heart rate and age, on the MPAP-SPAP relation, supporting lower SPAP thresholds for pulmonary hypertension diagnosis in patients with higher PAWP for echocardiography-based epidemiological studies.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Stanford Cardiovascular Institute Stanford University School of Medicine Stanford CA
| | - Ryan J Tedford
- Division of Cardiology Department of Medicine Medical University of South Carolina Charleston SC
| | - Andre Denault
- Department of Anesthesiology and Division of Critical Care Montreal Heart Institute Université de Montréal Quebec Canada
| | - Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine Stanford University School of Medicine Stanford CA.,Vera Moulton Wall Center for Pulmonary Disease at Stanford University Stanford CA
| | - Julien Guihaire
- Research and Innovation Unit INSERM U999 DHU TORINO Paris Sud University Marie Lannelongue Hospital Le Plessis Robinson France
| | - Kristofer Hedman
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Department of Medical and Health Sciences Linköping University Linköping Sweden
| | - Shadi Peighambari
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Juyong Brian Kim
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Stanford Cardiovascular Institute Stanford University School of Medicine Stanford CA
| | - Xiao Li
- Department of Genetics Stanford University School of Medicine Stanford CA
| | - Robert J H Miller
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA
| | - Olaf Mercier
- Research and Innovation Unit INSERM U999 DHU TORINO Paris Sud University Marie Lannelongue Hospital Le Plessis Robinson France
| | - Elie Fadel
- Research and Innovation Unit INSERM U999 DHU TORINO Paris Sud University Marie Lannelongue Hospital Le Plessis Robinson France
| | - Roham Zamanian
- Division of Pulmonary and Critical Care Medicine Stanford University School of Medicine Stanford CA.,Vera Moulton Wall Center for Pulmonary Disease at Stanford University Stanford CA
| | - Francois Haddad
- Division of Cardiovascular Medicine Stanford University School of Medicine Stanford CA.,Stanford Cardiovascular Institute Stanford University School of Medicine Stanford CA
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Miller R, Hedman K, Vrotec B, Ingelsson E, Heidenreich P, Hiesinger W, Oyer P, Teuteberg J, Haddad F. Novel Methods for Donor and Recipient Size Matching in Heart Transplantation. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Hedman K, Patti A, Moneghetti KJ, Hsu D, Christle JW, Ashley E, Hadley D, Haddad F, Froelicher V. Impact of the distance from the chest wall to the heart on surface ECG voltage in athletes. BMJ Open Sport Exerc Med 2020; 6:e000696. [PMID: 32201618 PMCID: PMC7061894 DOI: 10.1136/bmjsem-2019-000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2020] [Indexed: 11/12/2022] Open
Abstract
Objective Available ECG criteria for detection of left ventricular (LV) hypertrophy have been reported to have limited diagnostic capability. Our goal was to describe how the distance between the chest wall and the left ventricle determined by echocardiography affected the relationship between ECG voltage and LV mass (LVM) in athletes. Methods We retrospectively evaluated digitised ECG data from college athletes undergoing routine echocardiography as part of their preparticipation evaluation. Along with LV mass and volume, we determined the chest wall–LV distance in the parasternal short-axis and long-axis views from two-dimensional transthoracic echocardiographic images and explored the relation with ECG QRS voltages in all leads, as well as summed voltages as included in six major ECG-LVH criteria. Results 239 athletes (43 women) were included (age 19±1 years). In men, greater LV–chest wall distance was associated with higher R-wave amplitudes in leads aVL and I (R=0.20 and R=0.25, both p<0.01), while in women greater distance was associated with higher R-amplitudes in V5 and V6 (R=0.42 and R=0.34, both p<0.01). In women, the chest wall–LV distance was the only variable independently (and positively) associated with R V5 voltage, while LVM, height and weight contributed to the relationship in men. Conclusions The chest wall–LV distance was weakly associated with ECG voltage in athletes. Inconsistent associations in men and women imply different intrathoracic factors affecting impedance and conductance between sexes. This may help explain the poor relationship between QRS voltage and LVM in athletes.
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Affiliation(s)
- Kristofer Hedman
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköpings universitet, Linköping, Sweden
| | - Alessandro Patti
- Stanford Sports Cardiology, Stanford University, Stanford, California, USA.,Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
| | - Kegan J Moneghetti
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - David Hsu
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Euan Ashley
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | | | - Francois Haddad
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
| | - Victor Froelicher
- Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA.,Stanford Sports Cardiology, Stanford University, Stanford, California, USA
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Hedman K, Lindow T, Elmberg V, Brudin L, Ekström M. Age- and gender-specific upper limits and reference equations for workload-indexed systolic blood pressure response during bicycle ergometry. Eur J Prev Cardiol 2020; 28:1360-1369. [PMID: 34647584 DOI: 10.1177/2047487320909667] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/08/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Guidelines recommend considering workload in interpretation of the systolic blood pressure (SBP) response to exercise, but reference values are lacking. DESIGN This was a retrospective, consecutive cohort study. METHODS From 12,976 subjects aged 18-85 years who performed a bicycle ergometer exercise test at one centre in Sweden during the years 2005-2016, we excluded those with prevalent cardiovascular disease, comorbidities, cardiac risk factors or medications. We extracted SBP, heart rate and workload (watt) from ≥ 3 time points from each test. The SBP/watt-slope and the SBP/watt-ratio at peak exercise were calculated. Age- and sex-specific mean values, standard deviations and 90th and 95th percentiles were determined. Reference equations for workload-indexed and peak SBP were derived using multiple linear regression analysis, including sex, age, workload, SBP at rest and anthropometric variables as predictors. RESULTS A final sample of 3839 healthy subjects (n = 1620 female) were included. While females had lower mean peak SBP than males (188 ± 24 vs 202 ± 22 mmHg, p < 0.001), workload-indexed SBP measures were markedly higher in females; SBP/watt-slope: 0.52 ± 0.21 versus 0.41 ± 0.15 mmHg/watt (p < 0.001); peak SBP/watt-ratio: 1.35 ± 0.34 versus 0.90 ± 0.21 mmHg/watt (p < 0.001). Age, sex, exercise capacity, resting SBP and height were significant predictors of the workload-indexed SBP parameters and were included in the reference equations. CONCLUSIONS These novel reference values can aid clinicians and exercise physiologists in interpreting the SBP response to exercise and may provide a basis for future research on the prognostic impact of exercise SBP. In females, a markedly higher SBP in relation to workload could imply a greater peripheral vascular resistance during exercise than in males.
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Affiliation(s)
- Kristofer Hedman
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Thomas Lindow
- Department of Clinical Physiology, Department of Research and Development, Växjö Central Hospital, Region Kronoberg, Växjö, Sweden.,Clinical Physiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Viktor Elmberg
- Clinical Physiology, Clinical Sciences, Lund University, Lund, Sweden.,Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Kalmar County Hospital, Kalmar, Sweden
| | - Magnus Ekström
- Respiratory Medicine and Allergology, Clinical Sciences, Lund University, Lund, Sweden
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34
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Hedman K, Moneghetti KJ, Hsu D, Christle JW, Patti A, Ashley E, Hadley D, Haddad F, Froelicher V. Limitations of Electrocardiography for Detecting Left Ventricular Hypertrophy or Concentric Remodeling in Athletes. Am J Med 2020; 133:123-132.e8. [PMID: 31738876 DOI: 10.1016/j.amjmed.2019.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electrocardiography (ECG) is used to screen for left ventricular hypertrophy (LVH), but common ECG-LVH criteria have been found less effective in athletes. The purpose of this study was to comprehensively evaluate the value of ECG for identifying athletes with LVH or a concentric cardiac phenotype. METHODS A retrospective analysis of 196 male Division I college athletes routinely screened with ECG and echocardiography within the Stanford Athletic Cardiovascular Screening Program was performed. Left-ventricular mass and volume were determined using echocardiography. LVH was defined as left ventricular mass (LVM) >102 g/m²; a concentric cardiac phenotype as LVM-to-volume (M/V) ≥1.05 g/mL. Twelve-lead electrocardiograms including high-resolution time intervals and QRS voltages were obtained. Thirty-seven previously published ECG-LVH criteria were applied, of which the majority have never been evaluated in athletes. C-statistics, including area under the receiver operating curve (AUC) and likelihood ratios were calculated. RESULTS ECG lead voltages were poorly associated with LVM (r = 0.18-0.30) and M/V (r = 0.15-0.25). The proportion of athletes with ECG-LVH was 0%-74% across criteria, with sensitivity and specificity ranging between 0% and 91% and 27% and 99.5%, respectively. The average AUC of the criteria in identifying the 11 athletes with LVH was 0.57 (95% confidence interval [CI] 0.56-0.59), and the average AUC for identifying the 8 athletes with a concentric phenotype was 0.59 (95% CI 0.56-0.62). CONCLUSION The diagnostic capacity of all ECG-LVH criteria were inadequate and, therefore, not clinically useful in screening for LVH or a concentric phenotype in athletes. This is probably due to the weak association between LVM and ECG voltage.
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Affiliation(s)
- Kristofer Hedman
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, Calif; Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - David Hsu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - Jeffrey W Christle
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - Alessandro Patti
- Stanford Sports Cardiology, Stanford University, Stanford, Calif; Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Italy
| | - Euan Ashley
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | | | - Francois Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
| | - Victor Froelicher
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, Calif; Stanford Sports Cardiology, Stanford University, Stanford, Calif
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35
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Moneghetti KJ, Singh T, Hedman K, Christle JW, Kooreman Z, Kobayashi Y, Bouajila S, Amsallem M, Wheeler M, Gerche AL, Ashley E, Haddad F. Echocardiographic Assessment of Left Ventricular Remodeling in American Style Footballers. Int J Sports Med 2019; 41:27-35. [PMID: 31791086 DOI: 10.1055/a-1014-2994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Several athletic programs incorporate echocardiography during pre-participation screening of American Style Football (ASF) players with great variability in reported echocardiographic values. Pre-participation screening was performed in National Collegiate Athletic Association Division I ASF players from 2008 to 2016 at the Division of Sports Cardiology. The echocardiographic protocol focused on left ventricular (LV) mass, mass-to-volume ratio, sphericity, ejection fraction, and longitudinal Lagrangian strain. LV mass was calculated using the area-length method in end-diastole and end-systole. A total of two hundred and thirty players were included (18±1 years, 57% were Caucasian, body mass index 29±4 kg/m2) after four players (2%) were excluded for pathological findings. Although there was no difference in indexed LV mass by race (Caucasian 78±11 vs. African American 81±10 g/m2, p=0.089) or sphericity (Caucasian 1.81±0.13 vs. African American 1.78±0.14, p=0.130), the mass-to-volume ratio was higher in African Americans (0.91±0.09 vs. 0.83±0.08, p<0.001). No race-specific differences were noted in LV longitudinal Lagrangian strain. Player position appeared to have a limited role in defining LV remodeling. In conclusion, significant echocardiographic differences were observed in mass-to-volume ratio between African American and Caucasian players. These demographics should be considered as part of pre-participation screening.
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Affiliation(s)
- Kegan James Moneghetti
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States.,Sports Cardiology, Stanford University, Stanford, United States
| | - Tamanna Singh
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Kristofer Hedman
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | | | - Zoe Kooreman
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Yukari Kobayashi
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Sara Bouajila
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Myriam Amsallem
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
| | - Matthew Wheeler
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States.,Sports Cardiology, Stanford University, Stanford, United States
| | - Andre La Gerche
- Baker IDI Heart and Diabetes Institute, Sports Cardiology Laboratory, Melbourne, Australia
| | - Euan Ashley
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States.,Sports Cardiology, Stanford University, Stanford, United States
| | - Francois Haddad
- School of Medicine, Cardiovascular Division, Stanford University, Stanford, United States
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36
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Cauwenberghs N, Hedman K, Kobayashi Y, Vanassche T, Haddad F, Kuznetsova T. The 2013 ACC/AHA risk score and subclinical cardiac remodeling and dysfunction: Complementary in cardiovascular disease prediction. Int J Cardiol 2019; 297:67-74. [DOI: 10.1016/j.ijcard.2019.09.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/16/2019] [Accepted: 09/20/2019] [Indexed: 01/02/2023]
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37
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Cauwenberghs N, Hedman K, Kobayashi Y, Haddad F, Kuznetsova T. P2488The 2013 ACC/AHA pooled cohort equations and insulin resistance status for detection of early-stage heart failure in the community. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Detection of heart failure (HF) in its subclinical phase would allow timely initiation of preventive measures that counter its pathophysiology. Here, we assessed the usefulness of traditional cardiovascular (CV) risk assessment and insulin resistance status to detect early-stage HF.
Methods
In 984 participants (mean age, 57.0 years, 52.3% women), we derived echocardiographic indexes of left ventricular (LV) structure and function and calculated the 10-year risk for a first atherosclerotic CV disease (ASCVD) using the 2013 ACC/AHA risk score. We assessed the discriminatory value of this risk score to detect LV maladaptation and the improvements in reclassification by insulin resistance status (HOMA-IR).
Results
The probability for LV maladaptation rose progressively with the 10-year ASCVD risk increasing. Participants at high 10-year ASCVD risk (>7.5%) had indeed significantly higher odds for LV concentric remodeling (odds ratio, 4.84), LV hypertrophy (OR, 5.93), abnormal LV longitudinal strain (OR, 2.04) and LV diastolic dysfunction (OR, 25.3) as compared to those at low ASCVD risk (<2.5%; P≤0.0003). Adding markers of insulin resistance to the ACC/AHA risk score moderately improved the integrated discrimination and net reclassification of all LV maladaptive phenotypes (P≤0.022) except LV diastolic dysfunction (P≥0.059). LV remodeling and abnormal LS was particularly more likely in insulin-resistant participants with a 10-year ASCVD risk between 5% and 15% than in their insulin-sensitive counterparts.
Prediction of early-stage HF profiles 2013 ACC/AHA risk score Addition of insulin resistance status to the 2013 ACC/AHA risk score AUC (95% CI) Integrated Discrimination Improvement Net Reclassification Improvement Absolute IDI (%) P value NRI (95% CI) P value LV concentric remodeling 0.70 (0.66 to 0.74) 0.0083 (11.3%) 0.022 0.23 (0.067 to 0.39) 0.0058 LV hypertrophy 0.70 (0.66 to 0.74) 0.017 (20.7%) 0.0033 0.27 (0.11 to 0.43) 0.0011 Abnormal LV LS 0.56 (0.53 to 0.62) 0.022 (202.0%) <0.0001 0.33 (0.18 to 0.49) <0.0001 LV diastolic dysfunction 0.82 (0.78 to 0.86) 0.0007 (0.45%) 0.84 0.093 (−0.11 to 0.30) 0.38 ≥2 LV abnormalities 0.76 (0.72 to 0.80) 0.0087 (7.3%) 0.071 0.22 (0.042 to 0.40) 0.016 The integrated discrimination improvement (IDI) and net reclassification improvement (NRI) reflect the improvements in classification by adding insulin resistance (by HOMA-IR) to the 2013 ACC/AHA risk score. HOMA-IR, Homeostatic Model for Assessment of Insulin Resistance; LS, longitudinal strain; LV, left ventricular.
Risk enhancers of LV maladaptation
Conclusions
The 2013 ACC/AHA risk score adequately captured the risk for echocardiographic phenotypes of early-stage HF. As risk enhancer, insulin resistance might improve risk stratification of subclinical HF in subjects at intermediate risk.
Acknowledgement/Funding
The European Union, European Research Council and the Flanders Scientific Research Fund supported this study.
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Affiliation(s)
- N Cauwenberghs
- University of Leuven, Hypertension and Cardiovascular Epidemiology, Leuven, Belgium
| | - K Hedman
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - Y Kobayashi
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - F Haddad
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - T Kuznetsova
- University of Leuven, Hypertension and Cardiovascular Epidemiology, Leuven, Belgium
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38
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Nicolau JC, Brieger D, Goodman S, Cohen MG, Simon T, Westermann D, Granger CB, Grieve R, Chen JY, Hedman K, Mellstrom C, Brandrup-Wognsen G, Owen R, Pocock S. P5471Baseline characteristics, healthcare resource use and clinical outcomes of stable post-myocardial infarction patients with diabetes: insights from the global prospective TIGRIS study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
There is a growing prevalence of diabetes worldwide in patients in the general population, including those with prior myocardial infarction (MI).
Purpose
To describe the characteristics, health status, resource utilization and clinical adverse events of stable post-MI patients with diabetes.
Methods
The long-Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease (TIGRIS) prospective observational study (NCT01866904) obtained data from 8985 stable patients 1–3 years post-MI from 369 centres in 25 countries, who provided diabetes status (no, yes, insulin-treated) and follow-up. Diabetes status, other patient characteristics, medications, medical history and healthcare resource utilization were recorded at enrolment. Health status was assessed at enrolment, 1 and 2 years by EQ-5D-3L and converted to an EQ-5D score. Deaths, cardiovascular (CV) events, bleeding events and related hospitalizations were recorded during 2 years of follow-up.
Results
Diabetes mellitus (DM) was prevalent at enrolment in 2966 (33%) patients of whom 872 (29%) were insulin-treated. Compared to patients without DM, those with DM had a higher mean body mass index (28.2 vs 26.6kg/m2) and heart rate (71 vs 67bpm), were more likely to have had ≥2 prior MIs (12% vs 10%), chronic kidney disease (10% vs 6%), peripheral artery disease (10% vs 5%), heart failure (15% vs 10%), anaemia (4% vs 2%), angina (12% vs 9%), stroke (6% vs 4%) and chronic obstructive pulmonary disease (9% vs 7%). Patients with DM reported more problems for each domain of the EQ-5D (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), which resulted in a lower mean EQ-5D utility score at enrolment (0.83±0.22 for no-diabetes vs 0.86±0.19 for diabetes). Moreover, they also had higher CV hospitalization rates in the 6 months prior to enrolment (6.4% vs 5%). All these measures were more marked in insulin-dependent diabetics. The incidences of all-cause death, CV death and the composite of CV death, MI and stroke were all significantly higher in patients with DM, especially those on insulin (see Figure). For CV death, MI and stroke the 2-year risk ratios, compared to patients without DM, were 2.64 (P<0.001) and 1.48 (P<0.001) respectively for those with insulin-treated DM and non-insulin treated.
Figure 1
Conclusions
Within a global population of stable post-MI patients, those with DM (especially those on insulin) have poorer health status and EQ-5D utility score, higher hospitalization rates and worse clinical outcomes compared with those without DM. Thus, in cardiac clinics worldwide, patients with DM require particularly close attention.
Acknowledgement/Funding
The study was funded by AstraZeneca
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Affiliation(s)
| | - D Brieger
- Concord Hospital and University of Sydney, Sydney, Australia
| | - S Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - M G Cohen
- University of Miami Miller School of Medicine, Miami, United States of America
| | - T Simon
- Assistance Publique-Hopitaux de Paris (APHP), Department of Clinical Pharmacology and Clinical Research Platform of East of Paris, Paris, France
| | - D Westermann
- University Heart Center Eppendorf, Department of General and Interventional Cardiology, Hamburg, Germany
| | - C B Granger
- Duke University Medical Center, Duke Clinical Research Institute, Durham, United States of America
| | - R Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - J Y Chen
- Guangdong General Hospital, Provincial Key Laboratory of Coronary Disease, Guangzhou, China
| | - K Hedman
- AstraZeneca Gothenburg, Mölndal, Sweden
| | | | | | - R Owen
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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39
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Hedman K, Moneghetti KJ, Hsu D, Christle JW, Haddad F, Froelicher VF. P4419The association between ECG voltage and left-ventricular mass, sex, body size and the distance between the heart and chest wall in college athletes. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The ECG is widely used in pre-participation evaluation (PPE) of athletes (ATH). While it is assumed that greater than normal QRS voltages reflect physiologically increased left ventricular mass (LVM), this has not been adequately demonstrated in ATH.
Purpose
To examine the relation between QRS voltage on surface ECG and LVM and explore if the distance from the chest wall to mid-LV (CWLVdis) affects QRS voltage in ATH.
Methods
We examined digitized ECG data and echocardiograms in college ATH, obtained as part of routine PPE in years 2010–16. ECG parameters included R and S-wave voltage components of the Sokolow-Lyon (S-L) and Cornell criteria for LV hypertrophy (i.e. SV1 + RV5-V6 and RaVL + SV3, respectively). Transthoracic 2D echocardiography was used to determine LVM (area-length method) and the CWLVdis (detailed in Fig1A). S-L positive (SV1 + RV5-V6 >35 mV or RaVL >11 mV) ATH were compared to S-L negative by t-test, and univariate correlation and multivariable regression analysis was used to explore independent effects of body characteristics, sex, LVM and CWLVdis on QRS voltage.
Results
Included were 227 ATH (age 18.6±0.7 yr; 85% male; 60%/33% Caucasian/Afro-american). Of these, 66% played American football, 18% volleyball and 16% basketball.
Overall, mean LVM was 174±37 g (range 96–284 g), and BSA-indexed LVM was 78±12 g/m2 (range 49–108 g/m2). Mean CWLVdis was 8.5±1.1 cm (range 5.6–11.3 cm) and was greater in males (p<0.001, Fig1B).
Forty-six ATH (24%, all male) were S-L positive and no ATH were positive according to Cornell criteria. S-L positive ATH had lower BMI (25.3±3.5 vs 26.9±4.9, p=0.012), greater absolute LVM (189.1±31.3 vs. 170.1±37.4 g, p=0.002) and greater BSA-indexed LVM (85.3±10.3 vs. 76.6±11.7 g/m2, p<0.001) than S-L negative ATH. The CWLVdis was similar between S-L positive and negative ATH (8.4±1.2 vs. 8.6±1.1, respectively, p=0.213).
CWLVdis was more strongly correlated to body mass (r=0.73, p<0.001, Fig. 1C) than to height (r=0.34, p<0.001). LVM correlated weakly to ECG voltage as combined in the S-L or Cornell criteria (Fig. 1C). CWLVdis was weakly correlated with R in aVL, V5 and V6 (r=0.21, 0.16 and 0.16, all p<0.02).
In multivariate analysis, male sex (β=0.31), LVM (β=0.45) and body mass index (β=-0.37) were independently associated with the S-L summed voltage (R2 0.26, p<0.001). For Cornell summed voltage, only sex was an independent predictor (β=0.48, R2 0.22, p<001).
Figure 1
Conclusion
The R and S wave ECG amplitudes used in the two most common ECG criteria for LV hypertrophy were weakly related in the highest to lowest order to sex, LVM, body size and the distance from the LV to the chest wall in our college ATH.
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Affiliation(s)
- K Hedman
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - K J Moneghetti
- School of Medicine, Division of Sports Cardiology, Stanford, United States of America
| | - D Hsu
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - J W Christle
- School of Medicine, Division of Sports Cardiology, Stanford, United States of America
| | - F Haddad
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - V F Froelicher
- School of Medicine, Division of Sports Cardiology, Stanford, United States of America
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40
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Hedman K, Cauwenberghs N, Christle JW, Tun AM, Kuznetsova T, Haddad F, Myers J. 6075Workload adjusted blood pressure response rather than peak systolic blood pressure is associated with increased all-cause mortality in males; results from 7097 treadmill exercise tests. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Systolic blood pressure (SBP) is routinely measured during exercise testing (ET) and is in part determined by cardiac output and peripheral vascular resistance. A frequently used threshold for defining hypertensive response to exercise is ≥210 mmHg but this does not account for the fact that SBP is related to workload, via cardiac output.
Purpose
To examine the prognostic implications of considering external workload (METs) adjusted SBP response to exercise.
Methods
We reviewed all symptom-limited treadmill ET in males between 1987 and 2007 at a single centre (inclusion/exclusion criteria detailed in figure 1A). SBP was measured standing at rest and at peak exercise. Workload adjusted BP response with exercise (SBP/MET slope) was calculated as ΔSBP/ΔMET. METs were calculated from peak speed and grade according to the standard American College of Sports Medicine (ACSM) formula. Age-predicted peak METs was calculated as: 18 - 0.15 × age. Ten-year Cox proportional hazard ratios (HR) with 95% confidence intervals were calculated and adjusted as outlined in figure 1B.
Results
7097 subjects were included, of which 1559 (22%) died within 10 years. Survivors were younger (57.2±10.6 y vs. 64.5±10.3 y, p<0.001) and reached higher % of age-predicted METs (97±33% vs. 82±33%, p<0.001). Survivors had higher peak SBP (181±26 vs. 176±27 mmHg, p<0.001) as well as greater ΔSBP (49±22 vs. 42±22 mmHg, p<0.001), while they had lower SBP/MET slope (7.0±4.4 vs. 8.9±6.5 mmHg/MET, p<0.001). A peak SBP ≥210 mmHg was associated with better survival; 10-yr adjusted HR: 0.76 (0.64–0.88, p<0.001). In contrast, a higher SBP/MET slope was associated with increased mortality (table 1).
Table 1. Ten year adjusted hazard ratios Variable HR (95% CI) P Variable HR (95% CI) P Variable HR (95% CI) P Peak SBP, Q1: 100–159 mmHg REF REF Delta SBP, Q1: 1–29 mmHg REF REF SBP/MET slope, Q1: 0.2–4.2 REF REF Peak SBP, Q2: 160–179 mmHg 0.81 (0.71–0.94) 0.006 Delta SBP, Q2: 30–46 mmHg 0.80 (0.70–0.91) 0.001 SBP/MET slope, Q2: 4.3–6.2 0.95 (0.81–1.12) 0.562 Peak SBP, Q3: 180–199 mmHg 0.68 (0.58–0.78) <0.001 Delta SBP, Q3: 47–61 mmHg 0.76 (0.66–0.88) <0.001 SBP/MET slope, Q3: 6.2–9.1 1.18 (1.01–1.37) 0.032 Peak SBP, Q4: ≥200 mmHg 0.60 (0.51–0.69) <0.001 Delta SBP, Q4: ≥62 mmHg 0.59 (0.50–0.69) <0.001 SBP/MET slope, Q4: ≥9.1 1.40 (1.22– 1.62) <0.001 HR, hazard ratio (adjusted according to figure 1B); SBP, systolic blood pressure; MET, metabolic equivalent of task; Q1–Q4, quartiles (Q1 as reference).
Figure 1
Conclusion
Workload adjusted blood pressure response to exercise in contrast to peak BP response was associated with increased mortality in male patients referred for ET. Of note, reaching a BP of at least 210 mmHg (suggested to define a hypertensive response to exercise) was associated with a 24% reduction in all-cause mortality.
Acknowledgement/Funding
K Hedman was supported by post-doc. grants from the Fulbright Commission, the Swedish Society of Medicine, County Council of Östergötland, Sweden
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Affiliation(s)
- K Hedman
- Stanford University, Cardiovascular Institute, Palo Alto, United States of America
| | - N Cauwenberghs
- KU Leuven, Research Unit Hypertension and Cardiovascular Epidemiology, Leuven, Belgium
| | - J W Christle
- School of Medicine, Division of Sports Cardiology, Stanford, United States of America
| | - A M Tun
- Veterans Affairs Palo Alto Health Care System, Division of Cardiology, Palo Alto, United States of America
| | - T Kuznetsova
- KU Leuven, Research Unit Hypertension and Cardiovascular Epidemiology, Leuven, Belgium
| | - F Haddad
- School of Medicine, Cardiovascular Institute, Stanford, United States of America
| | - J Myers
- Veterans Affairs Palo Alto Health Care System, Division of Cardiology, Palo Alto, United States of America
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Hedman K, Cauwenberghs N, Christle JW, Kuznetsova T, Haddad F, Myers J. Workload-indexed blood pressure response is superior to peak systolic blood pressure in predicting all-cause mortality. Eur J Prev Cardiol 2019; 27:978-987. [PMID: 31564136 DOI: 10.1177/2047487319877268] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS The association between peak systolic blood pressure (SBP) during exercise testing and outcome remains controversial, possibly due to the confounding effect of external workload (metabolic equivalents of task (METs)) on peak SBP as well as on survival. Indexing the increase in SBP to the increase in workload (SBP/MET-slope) could provide a more clinically relevant measure of the SBP response to exercise. We aimed to characterize the SBP/MET-slope in a large cohort referred for clinical exercise testing and to determine its relation to all-cause mortality. METHODS AND RESULTS Survival status for male Veterans who underwent a maximal treadmill exercise test between the years 1987 and 2007 were retrieved in 2018. We defined a subgroup of non-smoking 10-year survivors with fewer risk factors as a lower-risk reference group. Survival analyses for all-cause mortality were performed using Kaplan-Meier curves and Cox proportional hazard ratios (HRs (95% confidence interval)) adjusted for baseline age, test year, cardiovascular risk factors, medications and comorbidities. A total of 7542 subjects were followed over 18.4 (interquartile range 16.3) years. In lower-risk subjects (n = 709), the median (95th percentile) of the SBP/MET-slope was 4.9 (10.0) mmHg/MET. Lower peak SBP (<210 mmHg) and higher SBP/MET-slope (>10 mmHg/MET) were both associated with 20% higher mortality (adjusted HRs 1.20 (1.08-1.32) and 1.20 (1.10-1.31), respectively). In subjects with high fitness, a SBP/MET-slope > 6.2 mmHg/MET was associated with a 27% higher risk of mortality (adjusted HR 1.27 (1.12-1.45)). CONCLUSION In contrast to peak SBP, having a higher SBP/MET-slope was associated with increased risk of mortality. This simple, novel metric can be considered in clinical exercise testing reports.
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Affiliation(s)
- Kristofer Hedman
- Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA.,Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Nicholas Cauwenberghs
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA.,Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Jeffrey W Christle
- Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Francois Haddad
- Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Jonathan Myers
- Stanford Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Hedman K, Moneghetti KJ, Christle JW, Bagherzadeh SP, Amsallem M, Ashley E, Froelicher V, Haddad F. Blood pressure in athletic preparticipation evaluation and the implication for cardiac remodelling. Heart 2019; 105:1223-1230. [PMID: 31142598 DOI: 10.1136/heartjnl-2019-314815] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore blood pressure (BP) in athletes at preparticipation evaluation (PPE) in the context of recently updated US and European hypertension guidelines, and to determine the relationship between BP and left ventricular (LV) remodelling. METHODS In this retrospective study, athletes aged 13-35 years who underwent PPE facilitated by the Stanford Sports Cardiology programme were considered. Resting BP was measured in both arms; repeated once if ≥140/90 mm Hg. Athletes with abnormal ECGs or known hypertension were excluded. BP was categorised per US/European hypertension guidelines. In a separate cohort of athletes undergoing routine PPE echocardiography, we explored the relationship between BP and LV remodelling (LV mass, mass/volume ratio, sphericity index) and LV function. RESULTS In cohort 1 (n=2733, 65.5% male), 34.3% of athletes exceeded US hypertension thresholds. Male sex (B=3.17, p<0.001), body mass index (BMI) (B=0.80, p<0.001) and height (B=0.25, p<0.001) were the strongest independent correlates of systolic BP. In the second cohort (n=304, ages 17-26), systolic BP was an independent correlate of LV mass/volume ratio (B=0.002, p=0.001). LV longitudinal strain was similar across BP categories, while higher BP was associated with slower early diastolic relaxation. CONCLUSION In a large contemporary cohort of athletes, one-third presented with BP levels above the current US guidelines' thresholds for hypertension, highlighting that lowering the BP thresholds at PPE warrants careful consideration as well as efforts to standardise measurements. Higher systolic BP was associated with male sex, BMI and height and with LV remodelling and diastolic function, suggesting elevated BP in athletes during PPE may signify a clinically relevant condition.
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Affiliation(s)
- Kristofer Hedman
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| | - Kegan J Moneghetti
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Jeffrey W Christle
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Shadi P Bagherzadeh
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| | - Myriam Amsallem
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
| | - Euan Ashley
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Victor Froelicher
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Stanford University, Stanford Sports Cardiology, Stanford, California, USA
| | - Francois Haddad
- Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA.,Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA
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Abstract
The early vascular adaptation to indoor cycling, a popular activity at many fitness centres, is incompletely evaluated. Forty two healthy women (21-45 years) underwent measurements of arterial wall properties and geometry as well as a maximal bicycle exercise test before and after a 3 months period during which 21 of the women joined indoor cycling classes at a gym 2-3 times per week, while 21 women served as time controls. Peak work load increased by in average 16% (p<0.001) and ascending aortic diameter by 4% (p<0.01) in the exercise group, while unchanged in control group. The exercise intervention had no significant influence on the local intima-media thickness, blood pressure or the pulse pressure wave configuration while the carotid artery distensibility (p<0.05) was higher after the intervention. There was a positive correlation between change in (Δ) peak work load and Δ-diameter of tubular ascending aorta (r=0.42, p<0.01) in the exercise group. In conclusion, after only 3 months of bicycle exercise training, signs of central arterial remodelling were seen in premenopausal women, which was associated to improvement in exercise capacity.
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Affiliation(s)
- Niclas Bjarnegård
- Department of Medical and Health Sciences, Division of Cardiovascular Medicine, Linköping, Sweden.,Department of Clinical Physiology, Ryhov County Hospital, Jönköping, Sweden
| | - Kristofer Hedman
- Department of Medical and Health Sciences, Department of Clinical Physiology, Linköping, Sweden
| | - Toste Länne
- Department of Medical and Health Sciences, Division of Cardiovascular Medicine, Linköping, Sweden
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Hedman K, Moneghetti K, Christle JW, Bagherzadeh SP, Haddad F, Ashley EA, Froelicher V. COMPARISON OF UNITED STATES AND EUROPEAN CRITERIA FOR HYPERTENSION IN A LARGE COHORT OF COMPETITIVE ATHLETES EXAMINED AS PART OF PRE-PARTICIPATION EVALUATION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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Nilsson H, Nylander E, Borg S, Tamás É, Hedman K. Cardiopulmonary exercise testing for evaluation of a randomized exercise training intervention following aortic valve replacement. Clin Physiol Funct Imaging 2018; 39:103-110. [PMID: 30298625 PMCID: PMC6635758 DOI: 10.1111/cpf.12545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/12/2018] [Indexed: 12/18/2022]
Abstract
Aortic valve surgery is the definitive treatment for aortic stenosis (AS). No specific recommendation is available on how exercise training should be conducted and evaluated after aortic valve replacement (AVR). This study aimed to examine the effect of aerobic exercise training on exercise capacity following AVR. In addition to our primary outcome variable, peak oxygen uptake (peakVO2 ), the effect on submaximal cardiopulmonary variables including oxygen uptake kinetics (tau), oxygen uptake efficiency slope (OUES) and ventilatory efficiency (VE/VCO2 slope) was evaluated. Following AVR due to AS, 12 patients were randomized to either a group receiving 12 weeks of supervised aerobic exercise training (EX) or a control group (CON). Exercise capacity was assessed by a maximal cardiopulmonary exercise test (CPET). There was a significant increase in peak load (+28%, P = 0·031) and in peakVO2 (+23%, P = 0·031) in EX, corresponding to an increase in achieved percentage of predicted peakVO2 from 88 to 104% (P = 0·031). For submaximal variables, there were only non-statistically significant trends in improvement between CPETs in EX. In CON, there were no significant differences in any maximal or submaximal variable between CPETs. We conclude that 12 weeks of supervised aerobic exercise training induces significant adaptations in cardiopulmonary function following AVR, especially in regard to maximal variables including peakVO2 . In addition, we provide novel data on the effect on several submaximal variables following exercise training in this group of patients.
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Affiliation(s)
- Henric Nilsson
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Eva Nylander
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sabina Borg
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Éva Tamás
- Department of Cardiothoracic and Vascular Surgery and Department of Cardiovascular Medicine, Linköping University, Linköping, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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46
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Brieger D, Pocock SJ, Goodman SG, Westermann D, Blankenberg S, Nicolau JC, Chen JY, Granger CB, Grieve R, Yasuda S, Simon T, Cohen MG, Hedman K, Gregson J, Rennie K. 5261Linear ongoing risk of major cardiovascular events in a global prospective registry of high-risk patients with stable coronary disease: insights from the TIGRIS study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.5261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- D Brieger
- Concord Hospital, Anzac Research Institute, Sydney, Australia
| | - S J Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S G Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - D Westermann
- University Heart Center Hamburg, Hamburg, Germany
| | | | - J C Nicolau
- Instituto do Coracao FMUSP, Sao Paulo, Brazil
| | - J Y Chen
- Guangdong General Hospital Guangdong Cardiovascular Institute, Provincial Key Laboratory of Coronary Disease, Guangzhou, China People's Republic of
| | - C B Granger
- Duke Clinical Research Institute, Durham, United States of America
| | - R Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Yasuda
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | - T Simon
- University Pierre & Marie Curie Paris VI, Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - M G Cohen
- University of Miami Leonard M. Miller School of Medicine, Miami, United States of America
| | | | - J Gregson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - K Rennie
- Oxon Epidemiology UK, London, United Kingdom
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Hedman K, Sunnerud S, Carlén A, Janzon M, Nylander E. From guidelines to the sidelines: implementation of cardiovascular preparticipation evaluation in sports clubs is lagging. Br J Sports Med 2018; 53:3-4. [PMID: 29921655 DOI: 10.1136/bjsports-2018-099297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Kristofer Hedman
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sofia Sunnerud
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna Carlén
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Eva Nylander
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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48
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Bjarnegård N, Länne T, Cinthio M, Ekstrand J, Hedman K, Nylander E, Henriksson J. Vascular characteristics in young women-Effect of extensive endurance training or a sedentary lifestyle. Acta Physiol (Oxf) 2018; 223:e13041. [PMID: 29359513 DOI: 10.1111/apha.13041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 12/13/2022]
Abstract
AIM To explore whether high-level endurance training in early age has an influence on the arterial wall properties in young women. METHODS Forty-seven athletes (ATH) and 52 controls (CTR), all 17-25 years of age, were further divided into runners (RUN), whole-body endurance athletes (WBA), sedentary controls (SC) and normally active controls (AC). Two-dimensional ultrasound scanning of the carotid arteries was conducted to determine local common carotid artery (CCA) geometry and wall distensibility. Pulse waves were recorded with a tonometer to determine regional pulse wave velocity (PWV) and pulse pressure waveform. RESULTS Carotid-radial PWV was lower in WBA than in RUN (P < .05), indicating higher arterial distensibility along the arm. Mean arterial pressure was lower in ATH than in CTR and in RUN than in WBA (P < .05). Synthesized aortic augmentation index (AI@75) was lower among ATH than among CTR (-12.8 ± 1.6 vs -2.6 ± 1.2%, P < .001) and in WBA than in RUN (-16.4 ± 2.5 vs -10.7 ± 2.0%, P < .05), suggesting a diminished return of reflection waves to the aorta during systole. Carotid-femoral PWV and intima-media thickness (IMT), lumen diameter and radial distensibility of the CCA were similar in ATH and CTR. CONCLUSION Elastic artery distensibility and carotid artery IMT are not different in young women with extensive endurance training over several years and in those with sedentary lifestyle. On the other hand, our data suggest that long-term endurance training is associated with potentially favourable peripheral artery adaptation, especially in sports where upper body work is added. This adaptation, if persisting later in life, could contribute to lower cardiovascular risk.
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Affiliation(s)
- N. Bjarnegård
- Division of Cardiovascular Medicine; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
- Department of Clinical Physiology; Region Jönköping County; Jönköping Sweden
| | - T. Länne
- Division of Cardiovascular Medicine; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
- Department of Thoracic and Vascular Surgery; Region Östergötland; Linköping Sweden
| | - M. Cinthio
- Department of Biomedical Engineering; Faculty of Engineering; Lund University; Lund Sweden
| | - J. Ekstrand
- Division of Community Medicine; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - K. Hedman
- Department of Clinical Physiology and Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - E. Nylander
- Department of Clinical Physiology and Department of Medical and Health Sciences; Linköping University; Linköping Sweden
| | - J. Henriksson
- Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm Sweden
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49
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Saraste M, Atula S, Hedman K, Hurme S, Jalkanen A, Sneck M, Surcel HM, Maghzi AH, Airas L. Humoral response to John Cunningham virus during pregnancy in multiple sclerosis. Mult Scler Relat Disord 2018; 21:11-18. [PMID: 29454151 DOI: 10.1016/j.msard.2018.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/18/2018] [Accepted: 02/05/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pregnancy induces an immunosuppressive state in the mother to ensure immunological acceptance of the foetus. Impairment of cell-mediated immune responses may render the mother susceptible to intracellular pathogens. It is not presently known whether pregnancy alters the immunosurveillance for John Cunningham virus (JCV), an opportunistic pathogen associated with natalizumab treatment for multiple sclerosis (MS). OBJECTIVE To evaluate whether the humoral immune response to JCV is altered during pregnancy among MS patients and healthy controls to get insight to potential pregnancy-induced alterations related to immune response to JCV during pregnancy. METHODS Serum anti-JCV-antibody-indices (JCV-Ab-index) were determined by a two-step second-generation enzyme-linked immunosorbent assay in 49 MS patients during and after pregnancy and in 49 healthy controls during pregnancy. For comparison, total IgG levels and antibodies against Epstein-Barr, cytomegalo and measles viruses were similarly measured. RESULTS The JCV-Ab-indices of MS patients were not altered during the pregnancy (1st vs. 3rd trimester, 0.62 vs. 0.77, p = 0.99). Contrary to this, in the healthy controls JCV-Ab-indices (p = 0.005), antibody levels to the other viruses, and total IgG levels (p < 0.0001) decreased significantly during pregnancy. CONCLUSIONS JCV-Ab levels remain unaltered during MS pregnancy, while the total IgG concentration is reduced/diluted due to increasing plasma volumes during the course of pregnancy. This may imply a biologically significant alteration in the immune response to JCV during MS pregnancy.
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Affiliation(s)
- M Saraste
- Department of Neurology, University of Turku, Turku, Finland.
| | - S Atula
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - K Hedman
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - S Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - A Jalkanen
- Division of Clinical Neurosciences, University of Turku and Turku University Hospital, Turku, Finland
| | - M Sneck
- HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - H-M Surcel
- National Institute for Health and Welfare, Oulu, Finland
| | - A H Maghzi
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - L Airas
- Division of Clinical Neurosciences, University of Turku and Turku University Hospital, Turku, Finland
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50
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Sunnerud S, Nylander E, Janzon M, Carlén A, Hedman K. [Not Available]. Lakartidningen 2018; 115:EWLM. [PMID: 29381184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Low adherence to recommended pre-participation cardiac evaluation of Swedish athletes Pre-participation cardiac evaluation of athletes is recommended by international organizations like the European Society of Cardiology and the American Heart Association, as well as by the Swedish Sports Confederation. The purpose of the evaluation is to prevent sudden cardiac death in athletes by early identification of individuals at risk. To our knowledge, no previous study has been made regarding the implementation of pre-participation cardiac evaluation of athletes in Sweden. We performed an electronical survey addressing sports clubs in one out of 21 districts in which the Swedish Sports Confederation is geographically divided. Only four out of 22 responding clubs with elite athletes preformed cardiac evaluation. Lack of knowledge about the recommendations as well as how to perform the evaluation were mentioned as reasons not to evaluate the athletes. Our results indicate the need for more information about pre-participation cardiac evaluation of athletes in Sweden.
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Affiliation(s)
- Sofia Sunnerud
- Universitetssjukhuset i Linkoping - Linkoping, Sweden - Linköping, Sweden
| | - Eva Nylander
- Universitetssjukhuset i Linkoping - Linkoping, Sweden Universitetssjukhuset i Linkoping - Linkoping, Sweden
| | - Magnus Janzon
- Universitetssjukhuset i Linkoping - Linkoping, Sweden Universitetssjukhuset i Linkoping - Linkoping, Sweden
| | - Anna Carlén
- Universitetssjukhuset i Linkoping - Linkoping, Sweden Universitetssjukhuset i Linkoping - Linkoping, Sweden
| | - Kristofer Hedman
- Universitetssjukhuset i Linkoping - Linkoping, Sweden Universitetssjukhuset i Linkoping - Linkoping, Sweden
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