Category Archives: Publications

Short-term and Long-term Feasibility, Safety, and Efficacy of High-Intensity Interval Training in Cardiac Rehabilitation: The FITR Heart Study Randomized Clinical Trial.

Taylor JL;Holland DJ;Keating SE;Leveritt MD;Gomersall SR;Rowlands AV;Bailey TG;Coombes JS;

JAMA cardiology [JAMA Cardiol] 2020 Sep 02. Date of Electronic Publication: 2020 Sep 02.

Importance: High-intensity interval training (HIIT) is recognized as a potent stimulus for improving cardiorespiratory fitness (volume of oxygen consumption [VO2] peak) in patients with coronary artery disease (CAD). However, the feasibility, safety, and long-term effects of HIIT in this population are unclear.
Objective: To compare HIIT with moderate-intensity continuous training (MICT) for feasibility, safety, adherence, and efficacy of improving VO2 peak in patients with CAD.
Design, Setting, and Participants: In this single-center randomized clinical trial, participants underwent 4 weeks of supervised training in a private hospital cardiac rehabilitation program, with subsequent home-based training and follow-up over 12 months. A total of 96 participants with angiographically proven CAD aged 18 to 80 years were enrolled, and 93 participants were medically cleared for participation following a cardiopulmonary exercise test. Data were collected from May 2016 to December 2018, and data were analyzed from December 2018 to August 2019.
Interventions: A 4 × 4-minute HIIT program or a 40-minute MICT program (usual care). Patients completed 3 sessions per week (2 supervised and 1 home-based session) for 4 weeks and 3 home-based sessions per week thereafter for 48 weeks.
Main Outcomes and Measures: The primary outcome was change in VO2 peak during the cardiopulmonary exercise test from baseline to 4 weeks. Further testing occurred at 3, 6, and 12 months. Secondary outcomes were feasibility, safety, adherence, cardiovascular risk factors, and quality of life.
Results: Of 93 randomized participants, 78 (84%) were male, the mean (SD) age was 65 (8) years, and 46 were randomized to HIIT and 47 to MICT. A total of 86 participants completed testing at 4 weeks for the primary outcome, including 43 in the HIIT group and 43 in the MICT group; 69 completed testing at 12 months for VO2 peak, including 32 in the HIIT group and 37 in the MICT group. After 4 weeks, HIIT improved VO2 peak by 10% compared with 4% in the MICT group (mean [SD] oxygen uptake: HIIT, 2.9 [3.4] mL/kg/min; MICT, 1.2 [3.4] mL/kg/min; P = .02). After 12 months, there were similar improvements from baseline between groups, with a 10% improvement in the HIIT group and a 7% improvement in the MICT group (mean [SD] oxygen uptake: HIIT, 2.9 [4.5] mL/kg/min; MICT, 1.8 [4.3] mL/kg/min; P = .30). Both groups had high feasibility scores and low rates of withdrawal due to serious adverse events (3 participants in the HIIT group and 1 participant in the MICT group). One event occurred following exercise (hypotension) in the HIIT group. Over 12 months, both home-based HIIT and MICT had low rates of adherence (HIIT, 18 of 34 [53%]; MICT, 15 of 37 [41%]; P = .35) compared with the supervised stage (HIIT, 39 of 44 [91%]; MICT, 39 of 43 [91%]; P > .99).
Conclusions and Relevance: In this randomized clinical trial, a 4-week HIIT program improved VO2 peak compared with MICT in patients with CAD attending cardiac rehabilitation. However, improvements in VO2 peak at 12 months were similar for both groups. HIIT was feasible and safe, with similar adherence to MICT over 12-month follow-up. These findings support inclusion of HIIT in cardiac rehabilitation programs as an adjunct or alternative modality to moderate-intensity exercise.

Predictive value of cardiopulmonary fitness parameters in the prognosis of patients with acute coronary syndrome after percutaneous coronary intervention.

Niu S, Wang F, Yang S, Jin Z, Han X, Zou S, Guo D), Guo C;

J Int Med Res. 2020 Aug;48(8)

OBJECTIVES: We aimed to determine the predictive value of cardiopulmonary exercise testing (CPX) in the prognosis of patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). METHODS: We conducted a retrospective study including patients who underwent CPX within 1 year of PCI between September 2012 and October 2017. Patients were followed-up until the occurrence of a major adverse cardiac event (MACE) or administrative censoring (September 2019). A Cox regression model was used to identify significant predictors of a MACE. Model performance was evaluated in terms of discrimination (C-statistic) and calibration (calibration-in-the-large).
RESULTS: In total, 184 patients were included and followed-up for a median 51 months (interquartile range: 36-67 months) and 32 events occurred. Multivariable analysis revealed that body mass index and Gensini score were significant predictors of a MACE. Four CPX-related variables were found to be predictive of a MACE: premature CPX termination, peak oxygen uptake, heart rate reserve, and ventilatory equivalent for carbon dioxide slope. The final prediction model had a C-statistic of 0.92 and calibration-in-the-large 0.58%.
CONCLUSION: CPX-related parameters may have high predictive value for poor outcomes in patients with ACS who undergo PCI, indicating a need for appropriate treatment and timely management.

Effects of Lumacaftor/Ivacaftor on physical activity and exercise tolerance in three adults with cystic fibrosis.

Savi D; Schiavetto S; Simmonds NJ; Righelli D; Palange P.

Journal of Cystic Fibrosis. 18(3):420-424, 2019 05.

The combination of the corrector lumacaftor with the potentiator ivacaftor
has been approved for treatment of cystic fibrosis (CF) patients
homozygous for the Phe508del CFTR mutation. There are no reports detailing
the effect of lumacaftor-ivacaftor on physical activity (PA) and exercise
tolerance. We performed incremental cardiopulmonary exercise testing
(CPET) and we assessed PA pre- and post 2years initiation of
lumacaftor-ivacaftor in three CF adults. PA of mild intensity improved by
+13% in patient 1, + 84% in patients 2 and+89% in patient 3. Oxygen uptake
increased both at anaerobic threshold and at peak exercise (patient 1+33%,
patient 2+42% and patient 3+20%). Daily physical activities and exercise
tolerance improved after two years of lumacaftor-ivacaftor therapy.

Pulmonary Hypertension in Advanced Heart Failure: Assessment and Management of the Failing RV and LV. [Review]

Rao SD; Menachem JN; Birati EY; Mazurek JA.

Current Heart Failure Reports. 16(5):119-129, 2019 10.

PURPOSE OF REVIEW: In patients with heart failure with reduced ejection
fraction, the presence of pulmonary hypertension (PH-LHD) has a
significant impact on their prognosis. The purpose of this review is to
explain the methods of diagnosing PH-LHD and then discuss the available
therapeutic options.
RECENT FINDINGS: We begin by examining the methods of assessment of
PH-LHD-echocardiography, cardiopulmonary exercise testing, and right heart
catheterization-with a particular focus on the importance of accurate
measurement to ensure the proper determination of PH-LHD. We then focus
primarily on management of PH-LHD, with an examination of trials of
therapeutic options, use of mechanical circulatory support, and
transplantation. This review highlights the complexities in diagnosis and
management of PH-LHD. We outline a number of useful ways to maximize the
yield of diagnostic testing, as well as give suggestions on the use of
medical therapies, the role of both temporary mechanical support and left
ventricular assist device, and finally the ways to best bridge these
patients to transplantation.

Ventilatory Efficacy After Transcatheter Aortic Valve Replacement Predicts Mortality and Heart Failure Events in Elderly Patients.

Murata M; Adachi H; Nakade T; Miyaishi Y; Kan H; Okonogi S; Kuribara J;
Yamashita E; Kawaguchi R; Ezure M.

Circulation Journal. 83(10):2034-2043, 2019 09 25.
VI 1

BACKGROUND: We aimed to clarify the predictors of death or heart failure
(HF) in elderly patients who undergo transcatheter aortic valve
replacement (TAVR). Methods and Results: We prospectively enrolled 83
patients (age, 83+/-5 years) who underwent transthoracic echocardiography
(TTE) and cardiopulmonary exercise testing (CPET) with impedance
cardiography post-TAVR. We investigated the association of TTE and CPET
parameters with death and the combined outcome of death and HF
hospitalization. Over a follow-up of 19+/-9 months, peak oxygen uptake
(VO2) was not associated with death or the combined outcome. The minimum
ratio of minute ventilation (VE) to carbon dioxide production (VCO2) and
the VE vs. VCO2slope were higher in patients with the combined outcome.
After adjusting for age, sex, Society of Thoracic Surgeons score and peak
VO2, ventilatory efficacy parameters remained independent predictors of
the combined outcome (minimum VE/VO2: hazard ratio, 1.108; 95% confidence
interval, 1.010-1.215; P=0.031; VE vs. VCO2slope: hazard ratio, 1.035; 95%
confidence interval, 1.001-1.071; P=0.044), and had a greater area under
the receiver-operating characteristic curve. The VE vs. VCO2slope >=34.6
was associated with higher rates of the combined outcome, as well as lower
cardiac output at peak work rate during CPET.
CONCLUSIONS: In elderly patients, lower ventilatory efficacy post-TAVR is
a predictor of death and HF hospitalization, reflecting lower cardiac
output at peak exercise.

Muscle Cramping in the Marathon: Dehydration and Electrolyte Depletion vs. Muscle Damage.

Martínez-Navarro I; Montoya-Vieco A;Collado E;Hernando B; Panizo N; Hernando C;

Journal of strength and conditioning research [J Strength Cond Res] 2020 Aug 12. Date of Electronic Publication: 2020 Aug 12.

Our aim was to compare dehydration variables, serum electrolytes, and muscle damage serum markers between runners who suffered exercise-associated muscle cramps (EAMC) and runners who did not suffer EAMC in a road marathon. We were also interested in analyzing race pacing and training background. Nighty-eight marathoners took part in the study. Subjects were subjected to a cardiopulmonary exercise test. Before and after the race, blood and urine samples were collected and body mass (BM) was measured. Immediately after the race EAMC were diagnosed. Eighty-eight runners finished the marathon, and 20 of them developed EAMC (24%) during or immediately after the race. Body mass change, post-race urine specific gravity, and serum sodium and potassium concentrations were not different between crampers and noncrampers. Conversely, runners who suffered EAMC exhibited significantly greater post-race creatine kinase (464.17 ± 220.47 vs. 383.04 ± 253.41 UI/L, p = 0.034) and lactate dehydrogenase (LDH) (362.27 ± 72.10 vs. 307.87 ± 52.42 UI/L, p = 0.002). Twenty-four hours post-race also values of both biomarkers were higher among crampers (CK: 2,438.59 ± 2,625.24 vs. 1,166.66 ± 910.71 UI/L, p = 0.014; LDH: 277.05 ± 89.74 vs. 227.07 ± 37.15 UI/L, p = 0.021). The difference in the percentage of runners who included strength conditioning in their race training approached statistical significance (EAMC: 25%, non-EAMC: 47.6%; p = 0.074). Eventually, relative speed between crampers and noncrampers only differed from the 25th km onward (p < 0.05). Therefore, runners who suffered EAMC did not exhibit a greater degree of dehydration and electrolyte depletion after the marathon but displayed significantly higher concentrations of muscle damage biomarkers.

Reduced exertion high-intensity interval training (REHIT) in an adult with Cystic Fibrosis: A mixed-methods case study.

Aspinall SP; Hill DM; Mackintosh KA; McNarry MA;

Respiratory medicine case reports [Respir Med Case Rep] 2020 Jul 23; Vol. 31, pp. 101173. Date of Electronic Publication: 2020 Jul 23 (Print Publication: 2020).

Although aerobic capacity has been identified as an important predictor of mortality in Cystic Fibrosis (CF) individuals, many remain insufficiently active. As a ‘ lack of time ‘ is a commonly cited barrier to exercise, reduced-exertion high-intensity interval training (REHIT) may provide a truly time-effective method to increase aerobic capacity. Six-weeks of REHIT in a CF individual was assessed by a cardiopulmonary exercise test (CPET) and individual perceptions described using a self-report narrative. Peak oxygen uptake ( V˙O 2 peak) increased by 6% whilst pulmonary function remained unchanged. Qualitative data indicated social support and low-time commitment positively influenced adherence with fatigue and lack of enjoyment noted as a significant barriers. REHIT was demonstrated as a viable, manageable option for a CF individual with moderate-severe pulmonary limitation. Further research is needed to determine the efficacy of REHIT in a large representative sample to ascertain whether it represents an alternative treatment strategy.

Cardiopulmonary Function and Aerobic Exercise in Parkinson’s: A Systematic Review of the Literature.

Aburub A; Ledger SJ; Sim J; Hunter SM;

Movement disorders clinical practice [Mov Disord Clin Pract] 2020 Jul 25; Vol. 7 (6), pp. 599-606. Date of Electronic Publication: 2020 Jul 25 (Print Publication: 2020).

Background: Cardiorespiratory impairments are considered the main cause of mortality in the late stages of Parkinson’s. Aerobic exercise has been shown to improve pulmonary function in asthmatic patients and in healthy people. However, effects of aerobic exercise on cardiopulmonary function in people with Parkinson’s have not been investigated. Therefore, this study aimed to review the effects of aerobic exercise on cardiopulmonary function in people with Parkinson’s.
Methods: A systematic search was conducted using MEDLINE, AMED, CINHAL Plus, and relevant associated keywords, from January 1970 to January 2020. Inclusion criteria for the studies were: aerobic exercise as part of the intervention, pulmonary function test, and/or cardiopulmonary exercise test as outcome measures.
Results: In total, 329 citations were identified from the search, of which nine were included in this review. In general, aerobic exercise was found to have positive effects on cardiac function for people with Parkinson’s, but there is a lack of studies on the effects of aerobic exercise on pulmonary function.
Conclusion: People with early stages of Parkinson’s may experience positive effects of aerobic exercise on cardiac fitness. Further research is needed in this area, particularly into the effects of aerobic exercise on pulmonary function in early stages of the disease.

Ventilatory efficiency during ramp exercise in relation to age and sex in a healthy Japanese population.

Ashikaga K; Itoh H; Maeda T et al;

Journal of cardiology [J Cardiol] 2020 Aug 04. Date of Electronic Publication: 2020 Aug 04.

Background: The current understanding of ventilator efficiency variables during ramp exercise testing in the normal Japanese population is insufficient, and the responses of tidal volume (VT) and minute ventilation (V̇E) to the ramp exercise test in the normal Japanese population are not known.
Methods: A total of 529 healthy Japanese subjects aged 20-78 years underwent cardiopulmonary exercise testing using a cycle ergometer with ramp protocols. VT and V̇E at rest, at anaerobic threshold, and at peak exercise were determined. The slope of V̇E versus carbon dioxide (V̇CO 2 ) (V̇E vs. V̇CO 2 slope), minimum V̇E/V̇CO 2 , and oxygen uptake efficiency slope (OUES) were determined.
Results: For males and females in their 20 s, peak VT (VTpeak) was 2192 ± 376 and 1509 ± 260 mL (p < 0.001), peak V̇E (V̇Epeak) was 80.6 ± 18.7 and 57.7 ± 13.9 L/min (sex differences p < 0.001), the V̇E vs. V̇CO 2 slope was 24.4 ± 3.2 and 25.7 ± 3.2 (p = 0.035), the minimum V̇E/V̇CO 2 was 24.2 ± 2.3 and 27.0 ± 2.8 (p < 0.001), and the OUES was 2452 ± 519 and 1991 ± 315 (p < 0.001), respectively. VTpeak and V̇Epeak decreased with age and increased with weight and height. The V̇E vs. V̇CO 2 slope and minimum V̇E/V̇CO 2 increased with age, while conversely, the OUES decreased with age.
Conclusions: We have established the normal range of VT and V̇E responses, the V̇E vs. V̇CO 2 slope, the minimum V̇E/V̇CO 2 , and the OUES for a healthy Japanese population. Some of these parameters were influenced by weight, height, sex, and age. These results provide useful reference values for interpreting the results of cardiopulmonary exercise testing in cardiac patients.

The Influence of Atrial Strain on Functional Capacity in Patients with the Fontan Circulation.

Rato J; Mendes SC; Sousa A; Lemos M; Martins DS; Anjos R;

Pediatric cardiology [Pediatr Cardiol] 2020 Aug 08. Date of Electronic Publication: 2020 Aug 08.

Speckle-tracking echocardiography has been used to assess atrial function. This analysis is feasible in univentricular hearts. The aim of this study was to characterize the relationship between atrial strain and functional capacity in the Fontan circulation. Apical four-chamber echocardiographic loops of 39 Fontan patients were reviewed. The dominant atrium was assessed for active (ε act ), conduit (ε con ), and reservoir (ε res ) strain and ε actres ratio. Cardiopulmonary exercise test was performed on the same day and oxygen uptake (VO 2 ) at ventilatory threshold (VT) and peak VO 2 were chosen as the dependent variables. Statistical analysis was performed using SPSS ® version 23. Unpaired t test was used for binomial and continuous variable correlation; single and multivariable linear regression were used for continuous variable correlation. Statistical significance was defined as p value < 0.05. VO 2 at VT as a percentage of predicted VO 2 was 36.8% (SD 10.7). Peak VO 2 was 64.7% (SD 18.9) of the predicted value. In univariate analysis, both were associated with age, atrioventricular regurgitation, ejection fraction, ε res , ε con , and ε actres . In multivariate regression, higher VO 2 at VT and peak VO 2 were associated with younger age (p = 0.003 and p = 0.001, respectively) and higher ε con (p = 0.026 and p = 0.020). Evaluation of heart function is difficult in the Fontan circulation, hindered by complex ventricular morphology and lack of normative data. VO 2 provides a good surrogate. Atrial strain parameters are compromised in these patients and associated with VO 2 . Therefore, whenever possible, atrial strain should be measured as it may provide a new method of risk stratification.