Cardiac rehabilitation for participants with implantable cardiac devices: A systematic review and meta-analysis

Aim

The aim is to discuss efficacy and safety of exercise-based cardiac rehabilitation (CR) programmes in participants with implantable cardiac devices compared with usual care.

Methods

MEDLINE, EMBASE and Cochrane databases were searched from inspection till July 15, 2022. Randomized controlled trials were included if they enrolled adult participants with implantable cardiac devices and tested exercise-based CR interventions in comparison with any control. Risk of bias was assessed, and endpoints data were pooled using random-effects model.

Results

Sixteen randomized trials enrolling 2053 participants were included. Study interventions differed between studies in terms of programme components, setting, exercise intensity, and follow-up. All studies included physical exercise component. In both implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) groups, exercise training in CR programmes improved peak oxygen uptake (VO2) [(mean difference (MD) 2.08 ml/kg/min; 95 % CI: 1.44-2.728, p < 0.0001; I2 = 99 %) and (MD 2.24 ml/kg/min; 95 % CI: 1.43-3.04, p < 0.0001; I2 = 96 %), respectively] and 6-min walk test in ICD group (MD 41.51 m; 95 % CI: 15.19-67.82 m, p = 0.002; I2 = 95 %) compared with usual care. In CRT group, there was no statistically significant improvement in left ventricular ejection fraction change between comparison groups. The results were consistent in subgroup analysis according to high or low-to-moderate exercise intensity for change in peak VO2 and ejection fraction in CRT group. There was no difference in number of ICD shocks between the comparators.

Conclusion

Exercise-based CR programmes appear to be safe when enrolling participants with implantable cardiac devices and leading to favourable functional outcomes.

Pulmonary Rehabilitation Outcomes of Post-Acute COVID-19 Patients during Different Waves of the Pandemic

(1) Background: Between the beginning of the coronavirus pandemic and summer 2022, we distinguished four pandemic waves, with different characteristics of the affected patients. This study investigated the impact of patient characteristics on the outcome of inpatient pulmonary rehabilitation (PR). (2) Methods: Using a prospective approach, the characteristics of post-acute COVID-19 patients of the different waves who participated in inpatient PR were compared based on their assessments and results collected as part of PR (Cumulative Illness Rating Scale (CIRS), six-minute walk test (6-MWT), Pulmonary Function Testing (PFT), and Functional Independent Measurement (FIM). (3) Results: A total of 483 patients were included in the analysis (Wave 1 n = 51, Wave 2 n = 202, Wave 3 n = 84, Wave 4 n = 146). Compared to Wave 3 + 4, patients of Wave 1 + 2 were older (69 vs. 63 years; p < 0.001), had a significantly lower CIRS (13.0 vs. 14.7 points; p = 0.004), had significant better PFT (FVC: 73 vs. 68%pred; p = 0.009; DLCO_SB: 58 ± 18 vs. 50 ± 17%pred; p = 0.001), and showed significantly more comorbidities (2.0 vs. 1.6 n/pers.; p = 0.009). Wave 3 + 4 showed significantly greater improvements according to the 6-MWT (147 vs. 188 m; p < 0.001) and the FIM (5.6 vs. 21.1 points; p < 0.001). (4) Conclusions: Patients of the COVID-19 infection waves differed significantly according to their anthropometric data, incidence of comorbidities, and impact of the infection. All cohorts achieved clinically relevant and significant functional improvements during PR, with significant higher improvements in Wave 3 + 4.

Study of Exercise Capacity and Quality of Life after SARS-CoV-2 Infection among the Elderly

COVID-19 significantly impacted the population by affecting physical health; social distancing and isolation influenced psychological health. This may have negative consequences, especially for older people. There is a lack of studies about the association between COVID-19 and exercise capacity among the elderly and improving quality of life after SARS-CoV-2 infection. This study aims to identify the potential sequelae of the COVID-19 disease regarding physical function and quality of life among people over 65 years old. This study recruited a total of 30 participants. A 6-minute walking test, somatic and functional measurements (including weight, height, HR, blood pressure and SpO₂%) and the World Health Organisation Quality of Life-BREF Questionnaire were used to assess aerobic capacity and quality of life. Experiencing COVID-19 can negatively impact exercise capacity. The results suggest that men may have worse sequelae than women after experiencing COVID-19. The lower values of SpO₂ in the COVID-19 group during the 6-MWT indicate a reduction in the gas diffusion capacity, which can be attributed to potential lung damage following having contracted the disease. Lockdown periods seem to have had a significant impact on the physical health, relationships and environment of the elderly people included in this study. We can conclude that physical effort may potentially impact exercise capacity and quality of life among post-COVID-19 elderly in a positive way, but further studies are needed to confirm its benefits.

Effect of Threshold Inspiratory Muscle Training on Functional Fitness and Respiratory Muscle Strength Compared to Incentive Spirometry in Children and Adolescents With Obesity: A Randomized Controlled Trial

BACKGROUND

To determine the effect of threshold inspiratory muscle training (IMT) on functional fitness and respiratory muscle strength (RMS) compared to incentive spirometry (IS) in children/adolescents with obesity.

METHODS

A total of 60 obese children/adolescents aged 8-15 years were randomized into the threshold IMT group (n = 20), the IS group (n = 20), or the control group (n = 20). The IMT group performed 30 inspiratory breaths with the intensity set at 40% of baseline maximal inspiratory pressure (MIP) twice daily for 8 weeks; the IS group performed 30 breaths with sustained maximum inspiration twice daily for 8 weeks; and, the control group was assigned no training device for 8 weeks. Six-min walk test (6-MWT), RMS, and spirometry were compared between baseline and 8 weeks.

RESULTS

Six-MWT distance (528.5 ± 36.2 vs. 561.5 ± 35.2 m, p = 0.002) and MIP (121.2 ± 26.8 vs. 135.3 ± 32.1%Predicted, p = 0.03) were significantly improved after 8 weeks of IMT training. There was no significant difference in any evaluated pulmonary function parameters between baseline and 8 weeks in the IS or control groups; however, 6-MWT distance demonstrated a trend toward significant improvement in the IS group (526.9 ± 59.1 vs.549.0 ± 50.6 m, p = 0.10). No significant difference among groups was found for any variable relative to change from baseline to post-training.

CONCLUSION

Eight weeks of threshold IMT training significantly improved both inspiratory muscle strength (MIP) and functional fitness (6-MWT) in children/adolescents with obesity. Eight weeks of IS training yielded a trend toward significantly improved functional fitness.

Effectiveness of Pulmonary Rehabilitation in Severe and Critically Ill COVID-19 Patients: A Controlled Study

Background: Severe and critically ill COVID-19 patients frequently need pulmonary rehabilitation (PR) after hospitalization. However, little is known about the effectiveness of PR in COVID-19 patients. Methods: We compared the performances in the six-min walk test (6MWT), chronic respiratory questionnaire (CRQ), and Functional Independence Measure (FIM) from inpatient PR between 51 COVID-19 patients and 51 other patients with common pneumonia. We used multivariate linear regression controlled for baseline values at entrance, age, sex, and cumulative illness rating scale. The odds ratios (ORs) of non-improvement/improvement in 6MWT (>30-m) and CRQ (>10-point) at discharge were compared between the two groups (Fisher’s exact test). Results: The two groups had similar improvements in 6MWT and CRQ, but the COVID-19 group achieved a 4-point higher FIM (p-value = 0.004). The OR of non-improvement/improvement in 6MWT was 0.30 (p-value = 0.13) between COVID-19 and controls; however, the odds of non-improvement in CRQ tended to be 3.02 times higher (p-value = 0.075) in COVID-19 patients. Severe and critical COVID-19 patients had similar rehabilitation outcomes. Conclusions: Inpatient PR can effectively improve physical functions and life quality in COVID-19 patients, irrespective of disease severity. Whether the relatively low gains in CRQ is an indicator of chronic disease development in COVID-19 patients needs further studies.

Plasma HMGB1 levels and physical performance in ICU survivors

PURPOSE

Physical impairment after critical illness is recognized as a part of the post-intensive care syndrome (PICS). About one third of intensive care unit (ICU) survivors suffer from long-term physical disability, yet the underlying pathophysiological mechanisms remain poorly understood. The pro-inflammatory alarmin, high mobility group box 1 (HMGB1), promotes muscle dysfunction in experimental models, and HMGB1 stays elevated in some patients after ICU discharge. Accordingly, we investigated the relationship between HMGB1 plasma levels and physical performance in ICU survivors.

METHODS

Prospective cohort study of 100 ICU survivors from the general ICU at the Karolinska University Hospital, Sweden. Patients returned for follow up at 3 (58 patients) and 6 months (51 patients) after ICU discharge. Blood samples were collected, and a 6-minute walk test (6-MWT), a handgrip-strength test (HST), and a timed-stands test (TST) were performed.

RESULTS

Compared to reference values of the different physical tests, 16% of patients underperformed at all tests at 3 months and 12% at 6 months. All test results, except hand-grip strength left, improved significantly over the follow-up period (P < .05). There was no significant association between plasma HMGB1 levels at 3 and 6 months and scores on the three tests (6-MWT, TST, and HST) (P = .50-0.69).

CONCLUSION

In this follow-up study of ICU survivors, we found no significant association between plasma HMGB1 levels and physical performance. Additional follow-up studies of HMGB1 plasma levels and muscle function in ICU survivors are still warranted.

EDITORIAL COMMENT

HMGB-1, a marker of cell damage and activation, is known to increase in ICU patients. In study participants at 3- to 6-month post-ICU stay, HMGB-1 levels were still elevated, although no association to the primary outcome, physical performance, was found. Mechanisms for failure to recover physical performance post-ICU remain unclear, and investigations into cause of post-intensive care syndrome need to continue.

TRIAL REGISTRATIONS

ClinicalTrials.gov identifier NCT02914756.

Effects of a Comprehensive Pulmonary Rehabilitation in Severe Post-COVID-19 Patients

BACKGROUND

Severe COVID-19 infection often leads to impairments requiring pulmonary rehabilitation (PR) following the acute phase. Little is known about the efficacy of PR in these patients. We therefore compared post-COVID-19 patients (PG) referred to PR patients with other lung diseases (LG).

METHODS

99 PG were admitted to PR. In a prospective design, the results of PG were collected and compared to the results of LG of 2019 (n = 419) according to Functional Independence Measurement (FIM), Cumulative Illness Rating Scale (CIRS), 6-min walk test (6-MWT), duration of PR, and Feeling Thermometer (FT).

RESULTS

According to age, sex, and CIRS, both groups showed no significant differences. The improvements in the 6-MWT in the pre to post comparison were on average 180 (±101) meters for PG and 102 (±89) meters for LG (p < 0.001). FT showed a significant enhancement for PG of 21 (±14) points and for LG of 17 (±16) points (p < 0.039), while FIM significantly increased by 11 (±10) points in PG and 7 (±8) points in LG (p < 0.001).

CONCLUSIONS

Comprehensive PR in PG is very effective according to the results in FIM, 6-MWT and FT. Therefore, we recommend PR following severe post-COVID-19 infections.

Obesity Indices for Predicting Functional Fitness in Children and Adolescents With Obesity

Objectives: We aimed to determine the obesity indices that affect 6-min walk test (6-MWT) distance in children and adolescents with obesity and to compare the 6-MWT distance of obese subjects with that of normal-weight subjects. Methods: Obese children and adolescents aged 8-15 years and normal-weight age- and gender-matched controls were enrolled. All participants performed the 6-MWT; respiratory muscle strength (RMS), including maximal inspiratory pressure and maximal expiratory pressure; and spirometry. Data between groups were compared. In the obesity group, correlation between obesity indices and pulmonary function testing (6-MWT, RMS, and spirometry) was analyzed. Results: The study included 37 obese and 31 normal-weight participants. The following parameters were all significantly lower in the obesity group than in the normal-weight group: 6-MWT distance (472.1 ± 66.2 vs. 513.7 ± 72.9 m; p = 0.02), forced expiratory volume in one second/forced vital capacity (FEV₁/FVC) (85.3 ± 6.7 vs. 90.8 ± 4.5%; p < 0.001), forced expiratory flow rate within 25-75% of vital capacity (FEF_25-75%) (89.8 ± 23.1 vs. 100.4 ± 17.3 %predicted; p = 0.04), and peak expiratory flow (PEF) (81.2 ± 15 vs. 92.5 ± 19.6 %predicted; p = 0.01). The obesity indices that significantly correlated with 6-MWT distance in obese children and adolescents were waist circumference-to-height ratio (WC/Ht) (r = -0.51; p = 0.001), waist circumference (r = -0.39; p = 0.002), body mass index (BMI) (r = -0.36; p = 0.03), and chest circumference (r = -0.35; p = 0.04). WC/Ht was the only independent predictor of 6-MWT distance by multiple linear regression. Conclusions: Children and adolescents with obesity had a significantly shorter 6-MWT distance compared with normal-weight subjects. WC/Ht was the only independent predictor of 6-MWT distance in the obesity group.

Shorter corridors can be used for the six-minute walk test in subjects with chronic lung diseases

BACKGROUND

The main limitation of the six-minute walk test (6-MWT) is that not all pulmonary function testing facilities have an indoor flat, 30-m-long corridor. Therefore, this study aimed 1) to evaluate the correlation and agreement of the distances walked in 30-m- vs. 15-m-long corridors by subjects with chronic lung diseases (CLD group) and 2) to compare the levels of oxygen saturation (nSpO₂), blood pressure (BP), heart rate recovery at minute one post-exercise (HRR1), and Borg scale scores for dyspnea and fatigue between the two distances walked.

METHODS

A prospective, cross-sectional study was conducted at the National Institute of Respiratory Diseases in Mexico City. Subjects with chronic lung diseases and healthy adults were invited to participate. The distance of the 6-MWT was randomly assigned based on whether the first test was in the 15-m or 30-m corridor.

RESULTS

Ninety individuals were included; the correlation in meters walked between the two corridors was r = 0.96 in CLD; the 95% limits of agreement for the 6-MWT ranged from -73 to +37 m. Most subjects walked further in the 30-m corridor (82%); however, the percent predicted values for the CLD group were 3.5% lower for the 15-m corridor than the 30-m corridor. Only 10.5% of the subjects with CLD would have been falsely classified as having a normal 6-MWT (false negative). No significant differences in the nSpO2, Borg scale, BP or HRR1 were found between the two 6-MWT corridor lengths.

CONCLUSION

The 6-MWT can be performed using a 15-m corridor in subjects with CLD, and the results for the distance walked, HRR1, nSpO₂, and Borg scale scores are similar to between the 15-m and 30-m corridors.

Evaluation of short-term use of nocturnal nasal continuous positive airway pressure for a clinical profile and exercise capacity in adult patients with obstructive sleep apnea-hypopnea syndrome

BACKGROUND AND AIM

The obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common chronic respiratory disease, characterized by repetitive complete or partial collapse of the upper airway during sleep. The clinical spectrum extends between stoppage of breathing, snoring, daytime somnolence, and fatigue, to serious cardiovascular disease, stroke, metabolic syndrome, increased morbidity, and mortality. We aim to evaluate the short-term use of nasal continuous positive airway pressure (nCPAP) therapy for the clinical profile and exercise capacity of patients with OSAHS.

PATIENT SELECTION

Twenty patients diagnosed with moderate-to-severe OSAHS were enrolled in the study (study group - 15; clinically and PSG-matched control group - 5).

MATERIALS AND METHODS

Each patient was clinically evaluated for sleep-related symptoms, and also assessed with spirometry, the six-minute walk test (6MWT), and a symptom-limited incremental cardiopulmonary exercise test (CPET). The study group patients were administered nCPAP therapy for eight hours each night for four weeks, while the control group patients were just observed. They were re-assessed after four weeks and the data were statistically analyzed between the two groups.

RESULTS

The study group patients showed a significant (P- < 0.05) improvement in the OSAHS symptoms-the Epworth sleepiness score, six-minute walk distance; duration of exercise, power output, peak oxygen uptake, anaerobic threshold, diastolic blood pressure, dyspnea, and fatigue-in comparison with the control group patients. The improvement in exercise capacity following nCPAP therapy was attributed to the relief of disabling the OSAHS symptoms and improved cardiovascular, ventilator, and musculoskeletal functions.

CONCLUSION

All OSAHS patients must be treated with nCPAP.