Author Archives: Paul Older

Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign

A Scientific Statement From the American Heart Association

Robert Ross, PhD, FAHA,
Steven N. Blair, PED, FAHA,
Ross Arena, PhD, PT, FAHA   et al.

Mounting evidence has firmly established that low levels
of cardiorespiratory fitness (CRF) are associated with a high risk of
cardiovascular disease, all-cause mortality, and mortality rates attributable
to various cancers. A growing body of epidemiological and clinical evidence
demonstrates not only that CRF is a potentially stronger predictor of
mortality than established risk factors such as smoking, hypertension,
high cholesterol, and type 2 diabetes mellitus, but that the addition of
CRF to traditional risk factors significantly improves the reclassification
of risk for adverse outcomes. The purpose of this statement is to review
current knowledge related to the association between CRF and health
outcomes, increase awareness of the added value of CRF to improve
risk prediction, and suggest future directions in research. Although the
statement is not intended to be a comprehensive review, critical references
that address important advances in the field are highlighted. The underlying
premise of this statement is that the addition of CRF for risk classification
presents health professionals with unique opportunities to improve patient
management and to encourage lifestyle-based strategies designed to
reduce cardiovascular risk. These opportunities must be realized to
optimize the prevention and treatment of cardiovascular disease and hence
meet the American Heart Association’s 2020 goals.

Abnormal heart-rate response during cardiopulmonary exercise testing identifies cardiac dysfunction in symptomatic patients with non-obstructive coronary artery disease

Sundeep Chaudhry , Naresh Kumar, Hushyar Behbahani , Akshay Bagai , Binoy K. Singh , NickMenasco , Gregory D. Lewis , Laurence Sperling , Jonathan Myers

International Journal of Cardiology 228 (2017) 114–121

Background: Symptomatic non-obstructive coronary artery disease is a growing clinical dilemma for whic hcontemporary testing is proving to be of limited clinical utility. New methods are needed to identify cardiac dysfunction.
Methods and results: This is a prospective observational cohort study conducted from December 2013 to August 2015 in two outpatient cardiology clinics (symptomatic cohort) and 24 outpatient practices throughout the US (healthy cohort) with centralized methodology and monitoring to compare heart-rate responses during cardiopulmonary exercise testing (CPET). Participants were 208 consecutive patients (median age, 61; range, 32–86 years) with exercise intolerance and without prior heart or lung disease in whom coronary anatomy was defined and 116 healthy subjects (median age, 45; range, 26–66 years). Compared to stress ECG, the novel change in heartrate as a function of work-rate parameter (ΔHR-WR Slope) demonstrated significantly higher sensitivity to detect under-treated atherosclerosis with similar specificity. In men, area under the ROC curve increased from 60% to 94% for non-obstructive CAD and from 64% to 80% for obstructive CAD. In women,  AUC increased from 64% to 85% for non-obstructive CAD and from 66% to 90% for obstructive CAD. ΔHR-WR Slope correctly reclassified abnormal studies in the non-obstructive CADgroup from 22% to 81%; in the obstructive CAD group from18% to 84% and in the revascularization group from 35% to 78%.
Conclusion: Abnormal heart-rate response during CPET is more effective than stress ECG for identifying undertreated atherosclerosis and may be of utility to identify cardiac dysfunction in symptomatic patients with normal routine cardiac testing.

Primary graft dysfunction: Long-term physical function outcomes among lung transplant recipients

Armstrong, Hilary F.; Lederer, David J.;
Bacchetta, Matthew; Bartels, Matthew N..

Heart & Lung: the Journal of Acute and Critical Care, November-December 2016, Vol. 45 Issue: Number 6 p544-549, 6p;

Abstract: Adults with primary graft dysfunction (PGD)
after lung transplantation are at increased risk for pulmonary and
functional impairment. No prior studies have described the long-term
(within 1.5 years of transplant) cardiopulmonary exercise testing
(CPET) results in adults with grade 3 PGD. The objective of this study
was to compare the functional outcomes of lung transplant patients with
and without grade 3 PGD via CPET and six-minute talk tests (6MWD).;

Acute effects of exercise on the inflammatory state in patients with idiopathic pulmonary arterial hypertension

Harbaum, Lars; Renk,
Emilia; Yousef, Sara; Glatzel, Antonia; Lüneburg, Nicole; Hennigs, Jan;
Oqueka, Tim; Baumann, Hans; Atanackovic, Djordje; Grünig, Ekkehard;
Böger, Rainer; Bokemeyer, Carsten; Klose, Hans.

BMC Pulmonary Medicine, December 2016, Vol. 16 Issue: Number 1 p1-11, 11p;

Abstract: Exercise training positively influences exercise tolerance and functional
capacity of patients with idiopathic pulmonary arterial hypertension
(IPAH). However, the underlying mechanisms are unclear. We hypothesized
that exercise modulates the activated inflammatory state found in IPAH
patients.                   Single cardiopulmonary exercise testing was
performed in 16 IPAH patients and 10 healthy subjects. Phenotypic
characterization of peripheral blood mononuclear cells and circulating
cytokines were assessed before, directly after and 1 h after exercise.
Before exercise testing, IPAH patients showed elevated
Th2 lymphocytes, regulatory T lymphocytes, IL-6, and TNF-alpha, whilst
Th1/Th17 lymphocytes and IL-4 were reduced. In IPAH patients but not in
healthy subject, exercise caused an immediate relative decrease of Th17
lymphocytes and a sustained reduction of IL-1-beta and IL-6. The higher
the decrease of IL-6 the higher was the peak oxygen consumption of IPAH
patients.                   Exercise seems to be safe from an immune
and inflammatory point of view in IPAH patients. Our results
demonstrate that exercise does not aggravate the inflammatory state and
seems to elicit an immune-modulating effect in IPAH patients.

The XIX (if you count Spain!) European Practicum held in Milan, Italy
October 26th – 29th 2016

The Practicum was very well attended and run in its entirety at Centro Cardiologico Monzino. This is a Hospital devoted entirely to patients with heart disease whether that be medical or surgical.
Milan is a large very old city with a host of exciting antiquities including the magnificent Cathedral and Castle. Professor Agostoni also found some very exciting and different restaurants.
The programme was the traditional European Practicum format with three days of lectures, tutorials and practical laboratory sessions. Several major players in the cardiopulmonary industry were represented; these included Carefusion, Cortex, Cosmed, Schiller and Geratherm.
The physiology lectures were given by Professor Susan Ward and despite having taken an interest in physiology over many years, I learn new information at every Practicum. It was very good to see that the lectures kept pace with current issues such as neoadjuvant therapy and the MECKI score.
An innovation this year was the introduction of three prizes to the best research papers presented to the Research session on the Saturday morning. The Board had decided to award each of the best three presenters a prize of US$1,500. The winners were, in no particular order, Stefania Paolillo, Felix Gerhardt and Roberto Badagliacca. It is hoped that these awards will be awarded each year.
It is gratifying to see registrants from so many countries and I noted the presence of registrants from mainland China.


Not a good photo. Many of our registrants were in the shade!!

Effects of high-intensity interval training on central haemodynamics and skeletal muscle oxygenation during exercise in patients with chronic heart failure

Spee, Ruud F; Niemeijer, Victor M; Wijn,
Pieter F; Doevendans, Pieter A; Kemps, Hareld M.

European Journal of Preventive Cardiology, December 2016, Vol. 23 Issue: Number 18
p1943-1952, 10p

Abstract: Background
High-intensity interval training
(HIT) improves exercise capacity in patients with chronic heart failure
(CHF). Moreover, HIT was associated with improved resting cardiac
function. However, the extent to which these improvements actually
contribute to training-induced changes in exercise capacity remains to
be elucidated. Therefore, we evaluated the effects of HIT on exercising
central haemodynamics and skeletal muscle oxygenation.Methods
Twenty-six CHF patients were randomised to a 12-week 4 × 4 minute HIT
program at 85–95% of peak VO2or usual care. Patients performed maximal
and submaximal cardiopulmonary exercise testing with simultaneous
assessment of cardiac output and skeletal muscle oxygenation by near
infrared spectroscopy, using the amplitude of the tissue saturation
index (TSIamp).

Results  Peak workload increased by 11% after HIT
(pbetween group = 0.01) with a non-significant increase in peak
VO2(+7%, pbetween group = 0.19). Cardiac reserve increased by 37% after
HIT (p within group = 0.03, pbetween group = 0.08); this increase was
not related to improvements in peak workload. Oxygen uptake recovery
kinetics after submaximal exercise were accelerated by 20% (pbetween
group = 0.02); this improvement was related to a decrease in TSIamp
(r= 0.71, p= 0.03), but not to changes in cardiac output

Conclusion  HIT induced improvements in maximal exercise
capacity and exercising haemodynamics at peak exercise. Improvements in
recovery after submaximal exercise were associated with attenuated
skeletal muscle deoxygenation during submaximal exercise, but not with
changes in cardiac output kinetics, suggesting that the effect of HIT
on submaximal exercise capacity is mediated by improved microvascular
oxygen delivery-to-utilisation matching.; (AN 40419387)