Sarcopenia in end-stage liver disease and after liver transplantation

Sarcopenia occurs in 30-70% of patients with end-stage liver disease and is associated with inferior pre- and post-liver transplant outcomes such as prolonged intubation times, long intensive care and hospitalization times, heightened risk of post-transplant infection, reduced health-related quality of life, and increased rates of mortality. The pathogenesis of sarcopenia is multifactorial and involves biochemical disturbances such as hyperammonemia, low serum concentrations of branched-chain amino acids (BCAAs) and low serum levels of testosterone, as well as chronic inflammation, inadequate nutritional status, and physical inactivity. Prompt recognition and accurate assessment of sarcopenia are critical and require imaging, dynamometry, and physical performance testing for the assessment of its subcomponents: muscle mass, muscle strength, and muscle function, respectively. Liver transplantation mostly fails to reverse sarcopenia in sarcopenic patients. In fact, some patients develop de novo sarcopenia after undergoing liver transplantation. The recommended treatment of sarcopenia is multimodal and includes a combination of exercise therapy and complementary nutritional interventions. Additionally, new pharmacological agents (e.g. myostatin inhibitors, testosterone supplements, and ammonia-lowering therapy) are under investigation in preclinical studies. Here, we present a narrative review of the definition, assessment, and management of sarcopenia in patients with end-stage liver disease prior to and after liver transplantation.

Personalized remotely guided preventive exercise therapy for a healthy heart: protocol and design of the PRIORITY study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation – Flanders (FWO)

Introduction

Approximately half of the heart failure population has heart failure with preserved ejection fraction (HFpEF), a chronic disease starting with cardiovascular risk factors such as hypertension, diabetes and obesity (stage A) which can further emerge in a structural heart disease without (stage B) or with (stage C) signs or symptoms. Structured exercise therapy is recommended as a Class IA intervention in national and international guidelines and, as such, should be offered to all patients. Yet, in current practice, exercise therapy is often only offered within a secondary prevention program. At present, there exists no comprehensive preventive care program that includes structured exercise for patients in the early stages of heart failure, when cardiovascular risk factors are present, but cardiac remodeling and dysfunction might still be reversible or even preventable.

Purpose

PRIORITY aims to investigate the use of remotely guided exercise therapy as a preventive clinical and cost-effective treatment in the HFpEF continuum. This includes both prevention of progression of asymptomatic diastolic dysfunction towards symptomatic HFpEF (= primary prevention) and delaying progression of symptomatic HFpEF (= secondary prevention).

Methods

A randomized controlled multicenter trial will be conducted in 450 patients (men and women, aged 35-80 years) with heart failure (n = 180 stage A, 180 stage B, 90 stage C). Participants are being recruited from 3 different hospitals and the general population during a 16-month period which started in September 2021. Patients will be randomized (1:1) to usual care or to the PRIORITY exercise intervention (i.e. a combination of supervised with remotely guided home-based training sessions). Training prescription is based on the EXPERT tool and includes person-tailored endurance and dynamic strength training. During one year, participants will receive 18 supervised exercise sessions supplemented with a structured progressive home-based exercise program. Outcomes will be assessed at baseline, 4 months, one and two-years. Primary outcome is the proportion of patients with a clinically relevant improvement in peak oxygen uptake at one-year. Secondary outcomes include vascular health, muscle metabolism, change in electrocardiographic parameters and physical fitness parameters (muscle strength, body composition). Further, big data of physical activity collected during the trial will be used to develop models using machine-learning algorithms which can predict physical activity uptake and changes in fitness to facilitate the creation of more personalized interventions and better tailored exercise prescription.

Conclusion

We anticipate that the PRIORITY study will contribute to better prevention of heart failure thanks to an early easily accessible person-tailored exercise intervention.

Prevention of heart failure in type 2 diabetes by exercise intervention: protocol and design of the PROTECTION study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): research Foundation - Flanders (FWO)

Introduction

Cardiac dysfunction is highly prevalent in patients with type 2 diabetes mellitus (T2DM), leading to increased risk of cardiac morbidity and premature death. Previous research underscored the high prevalence of a disturbed global longitudinal strain (GLS), a marker to predict this cardiac dysfunction, in both symptomatic and asymptomatic T2DM patients. Exercise-based therapy is recommended in the management of patients with type 2 diabetes. However, it remains unclear i) which type of exercise therapy to have the biggest effect on GLS and ii) which factors modify the effect of exercise therapy on GLS.

Purpose

The PROTECTION study will i) investigate the impact of exercise volume and intensity on GLS to optimize exercise prescription in T2DM and will ii) assess which patient-specific factors influence the change in GLS and physical fitness as a result of exercise intervention in T2DM.

Methods and analyses

The PROTECTION study is composed of two work packages (WP). In WP 1, 100 T2DM adults (50% male, aged 30-75 years) will be randomized to a usual care group or one of the three supervised exercise intervention groups (see Table 1) for a duration of 26 weeks. Outcome measures will be performed at baseline, 13, 26 and 52 weeks of follow-up. The primary outcomes are GLS and cardiac dimensions. Secondary outcomes include health-related physical fitness, blood biomarkers and physical activity behavior. Data will be analyzed by two-way ANOVA repeated measures. A two-tailed P-value <0.05 will be considered statistically significant.

Parallel with the randomized controlled trial, a longitudinal intervention study (WP2) involving 107 adults (50% male, aged 30-75 years) with T2DM will be conducted. All participants will engage in a supervised intervention for 26 weeks, including a high volume of moderate intense physical activity (see Table 1). The main objective of this work package is to define determinants of change in GLS during an exercise intervention. Moreover, the interaction between diet-exercise, habitual physical activity-exercise and phenotype-exercise on change in GLS will be studied in great detail. Patient-specific data will be analyzed by multivariate regression analysis. A two-tailed P-value <0.05 will be considered statistically significant.

Conclusion

It is anticipated that the PROTECTION study will contribute to a better understanding on i) which exercise characteristics are preferred to maximally improve GLS in T2DM and on ii) the determinants of the responsiveness of GLS and physical fitness to exercise in T2DM.

Cardiac autonomic associations on exercise and ambulatory capacity in individuals with lower-extremity artery disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): This work was in part supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP #2019/19596-7), and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq #303399/2018-0).

OnBehalf

Exercise and Chronic Disease Research Laboratory - Bauru, Brazil; Research Group for Cardiovascular Rehabilitation - Leuven, Belgium.

INTRODUCTION

Lower-extremity artery disease (LEAD) characterized by progressive atherosclerotic build-up in leg arteries is becoming increasingly prevalent, affecting more than 200 million people worldwide. In line with other atherosclerotic disorders, LEAD is often associated with autonomic dysfunction as evidenced by a reduced heart rate variability (HRV). To date, little is known on the impact of cardiac autonomic function on exercise and ambulatory capacity.

PURPOSE

We aimed to investigate whether autonomic function is associated with ambulatory capacity and exercise capacity in patients with LEAD.

METHODS

Thirty-four patients (age≥17 years) diagnosed with LEAD (ankle brachial index: ABI ≤ 0.9 and/or 20% decrease after a maximal treadmill test) suffering from intermittent claudication (Rutherford I-III) were recruited in the PROSECO-IC trial. Patients were grouped based on beta-blocker medication (β-blocker and non β-blocker). Intervals between R waves (i-RR) obtained by heart rate (HR) signal were acquired beat-to-beat via a digital telemetry system (Polar®️ H10) during 15 min of supine rest and were used for 5-minute HRV analysis. Time domain indexes (mean i-RR, SNDD, pNN50%), and frequency domains (high frequency band (HF), low frequency (LF, very LF (VLF)) and the ratio (LF/HF). HRV was analyzed in absolute (abs), normalized (nu) and log units (log). Ambulatory capacity was assessed by means of a submaximal treadmill test, graded maximal treadmill test using Gardner protocol (GTM) and 6 minutes walking test (6MWT); exercise capacity was assessed by means of a graded maximal cardiopulmonary exercise test (HR, blood pressure (BP) and peak oxygen uptake (VO2peak)) at resting, 2 minutes, and peak of exercise.

RESULTS

Pearson test showed that sympathetic modulation indexes were moderate associated with pain free distance in GTM (LF/HF: r = 0.52, p = 0.04), and pain free time in 6MWT (LFlog: r=-0.62, p = 0.01; VLF: r=-0.52, p = 0.04), respectively, in patients without β-blocker. Similar HR associations with HRV (time and frequency domain) were observed during submaximal treadmill test and cardiopulmonary exercise test (p ≤ 0.05). Test-t demonstrated a significantly increased response intra-groups in HR and BP during both tests (p ≤ 0.05). Average BP were positive associated with the earlier stages of the cardiopulmonary test (resting to 2 min) with LFlog (r = 0.70, p= <0.001) in β-blocker while non-β-blocker were associated from 2 min to peak with LFabs (r = 0.67, p= <0.001) and LF/HF (r = 0.52, p = 0.03). 

CONCLUSION

Sympathetic modulation was correlated with a longer pain free walking capacity in non-β-blockers. Yet, individuals treated by -β-blockers showed an earlier sympathetic modulation through exercise pressor response during the first stages of cardiopulmonary exercise compared to non-β-blockers with LEAD.

The use of Near-Infrared Spectroscopy to evaluate the effect of exercise on peripheral muscle oxygenation in patients with lower-extremity artery disease: a systematic review

Funding Acknowledgements

Type of funding sources: None.

Background

Near-Infrared Spectroscopy (NIRS) has been suggested as a new diagnostic tool in patients with lower-extremity artery disease (LEAD). The aim of this systematic review was i) to summarize the impact of exercise therapy on lower-limb muscle oxygenation, evaluated by means of NIRS, in patients with LEAD and ii) to give an overview on NIRS instruments and methodology.

Methods

A systematic search was conducted in MEDLINE and Embase, from the earliest date available until 16th of March 2020, to identify peer-reviewed studies involving the use of NIRS in the evaluation of exercise training on muscle oxygenation in patients with LEAD. Primary outcomes were NIRS-derived variables. Effect sizes were calculated as standardized mean differences. Assessment of methodological quality was done using a combined checklist from the Cochrane bias and the quality assessment tool for before-after studies without control group.

Results

Eleven original trials were included involving 16 exercise groups and 4 control groups. Tissue saturation index (TSI) at rest remained unchanged following the exercise interventions. Yet, exercise training increased time-to-minimum TSI during exercise (range effect sizes: +0.172 to +0.927). In addition, exercise training led to a faster recovery to half and full TSI rest values in most intervention groups (range effect sizes: -0.046 to -0.558 and -0.269 to -0.665 respectively). Finally, NIRS data reproducibility and analytic methods were underreported in the included studies. To illustrate, only four studies reported appropriate measures to ensure repeated reproducible probe positioning. The use of raw or filtered data for analysis was reported in none of the included articles.

Conclusion

The available NIRS data suggest that exercise training improves deoxygenation and reoxygenation patterns in patients with LEAD. Whereas NIRS is a promising tool in the evaluation of LEAD, the low number of RCT’s as well as large heterogeneity in NIRS assessment methods, outcome measures and instrumentation, warrants more research to better understand the role of muscle oxygenation associated with exercise-induced improvements in walking capacity. In particular the role of NIRS to study underlying mechanisms and determinants related to exercise progression in LEAD patients is appealing.

Abstract Figure. NIRS during treadmill test

Prediction of the Adherence to a Home-Based Cardiac Rehabilitation Program

The incidence and prevalence of cardiovascular diseases (CVD) is increasing which is partly due to an increase in unhealthy lifestyles, including lack of physical activity. Therefore, following a cardiovascular event, patients are encouraged to participate in a supervised exercise-based cardiac rehabilitation (CR) program. However, uptake rates of these programs are low and compliance to adequate volumes of physical activity after the completion of such programs are even lower. An approach that has been proposed towards the increase of patient adherence to exercise, is the incorporation of technology-enabled solutions which are applied at patient's homes. However, different factors may affect patient engagement with such alternative solutions. In this work, we use diverse types of data, including baseline characteristics of the patient (i.e. physiological, behavioral, demographical data) as well as usage data of a tele-rehabilitation solution during a 4-week familiarization period, in order to predict the compliance of patients with CVD to a technology-supported physical activity intervention after completion of a supervised exercise program. Patients were clustered based on their use of a technology intervention during a previously conducted study. Following a feature selection approach, a support vector machine was trained to classify patients as adherent or non-adherent to the intervention. The performance of the classifier was assessed by means of the receiving operator curve (ROC). Bio-psycho-social baseline variables predicted adherence with a ROC of 0.86, but adding usage data of the platform during a 4-week familiarization period increased the ROC up to 0.94. Furthermore, the high sensitivity values (83.8% and 95.5% respectively) support the strength of the models to identify those patients with CVD that will be adherent to a technology-enabled, home-based CR program.

Acute resveratrol supplementation in coronary artery disease: towards patient stratification

Objective: Resveratrol (RV) is a polyphenol with antioxidant, anti-inflammatory and cardio-protective properties. Our objective was to investigate whether acute supplementation with high doses of RV would improve flow-mediated dilation (FMD) and oxygen consumption (VO₂) kinetics in older coronary artery disease (CAD) patients. Design: We employed a placebo-controlled, single-blind, crossover design in which ten participants (aged 66.6 ± 7.8 years) received either RV or placebo (330 mg, 3× day^-1) during three consecutive days plus additional 330 mg in the morning of the fourth day with a seven-day wash-out period in-between. On the fourth day, FMD of the brachial artery and VO₂ on-kinetics were determined. Results: RV improved FMD in patients who had undergone coronary artery bypass grafting (CABG; -1.4 vs. 5.0%; p = .004), but not in those who had undergone percutaneous coronary intervention (PCI; 4.2 vs. -0.2%; NS). Conclusion: Acute high dose supplementation with RV improved FMD in patients after CABG surgery but impaired FMD in patients who underwent PCI. The revascularization method-related differential effects of RV may be due to its direct effects on endothelial-dependent dilator responses. Our findings have important implications for personalized treatment and stratification of older CAD patients.

Importance of characteristics and modalities of physical activity and exercise in defining the benefits to cardiovascular health within the general population: recommendations from the EACPR (Part I)

Over the last decades, more and more evidence is accumulated that physical activity (PA) and exercise interventions are essential components in primary and secondary prevention for cardiovascular disease. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit in achieving cardiovascular health. The present paper, as the first of a series of three, will make specific recommendations on the importance of these characteristics for cardiovascular health in the population at large. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and the individual member of the public. Based on previous and the current literature, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and exercise.