Category Archives: Abstracts

High-intensity interval training is effective and superior to moderate continuous training in patients with heart failure with preserved ejection fraction: A randomized clinical trial.

Donelli da Silveira A; Beust de Lima J; Dos Santos Macedo D; Zanini M; Nery R; Antero Laukkanen J; Stein R;

European Journal Of Preventive Cardiology [Eur J Prev Cardiol] 2020 Jan 21, pp. 2047487319901206. Date of Electronic Publication: 2020 Jan 21.

Background: Heart failure with preserved ejection fraction (HFpEF) is a prevalent syndrome, with exercise intolerance being one of its hallmarks, contributing to worse quality of life and mortality. High-intensity interval training is an emerging training option, but its efficacy in HFpEF patients is still unknown.
Design: Single-blinded randomized clinical trial.
Methods: Single-blinded randomized clinical trial with exercise training 3 days per week for 12 weeks. HFpEF patients were randomly assigned to high-intensity interval training or moderate continuous training. At baseline and after 12 week follow-up, patients underwent clinical assessment, echocardiography and cardiopulmonary exercise testing (CPET).
Results: Mean age was 60 ± 9 years and 63% were women. Both groups (N = 19) showed improved peak oxygen consumption (VO2), but high-intensity interval training patients (n = 10) had a significantly higher increase, of 22%, compared with 11% in the moderate continuous training (n = 9) individuals (3.5 (3.1 to 4.0) vs. 1.9 (1.2 to 2.5) mL·kg-1·min-1, p < 0.001). Ventilatory efficiency and other CPET measures, as well as quality of life score, increased equally in the two groups. Left ventricular diastolic function also improved with training, reflected by a significant reduction in E/e’ ratio by echocardiography (-2.6 (-4.3 to -1.0) vs. -2.2 (-3.6 to -0.9) for high-intensity interval training and moderate continuous training, respectively; p < 0.01). There were no exercise-related adverse events.
Conclusions: This randomized clinical trial provided evidence that high-intensity interval training is a potential exercise modality for HFpEF patients, being more effective than moderate continuous training in improving peak VO2. However, the two strategies were equally effective in improving ventilatory efficiency and other CPET parameters, quality of life score and diastolic function after 3 months of training.

Cardiorespiratory Fitness Normalized to Fat-Free Mass and Mortality Risk.

Imboden MT; Kaminsky LA; Peterman JE; Hutzler HL; Whaley MH; Fleenor BS; Harber MP;

Medicine And Science In Sports And Exercise [Med Sci Sports Exerc] 2020 Jan 24. Date of Electronic Publication: 2020 Jan 24.

Purpose: Cardiorespiratory fitness (CRF) is known to be directly related to fat-free mass (FFM), therefore it has been suggested that normalizing CRF to FFM (VO2peakFFM) may be the most accurate expression of CRF as related to exercise performance and cardiorespiratory function. However, the influence of VO2peakFFM (ml·kgFFMmin) on predicting mortality has been largely unexplored. This study aimed to primarily assess the relationship between VO2peakFFM and all-cause and disease-specific mortality risk in apparently healthy adults. Further, this study sought to compare the predictive ability of VO2peakFFM to VO2peak normalized to total body weight (VO2peakTBW) for mortality outcomes.
Methods: Participants included 2,905 adults (1,555 men, 1,350 women) who completed a cardiopulmonary exercise test (CPX) between 1970-2016 to determine CRF. Body composition was assessed using the skinfold method to estimate FFM. CRF was expressed as VO2peakTBW and VO2peakFFM. Participants were followed for 19.0 ± 11.7 years after their CPX for mortality outcomes. Cox-proportional hazard models were performed to determine the relationship of VO2peakFFM with mortality outcomes. Parameter estimates were assessed to compare the predictive ability of CRF expressed as VO2peakTBW and VO2peakFFM.
Results: Overall, VO2peakFFM was inversely related to all-cause, CVD, and cancer mortality, with a 16.2, 8.4, and 8.0% lower risk per 1 ml·kgFFM·min improvement, respectively (p<0.01). Further, assessment of the parameter estimates showed VO2peakFFM to be a significantly stronger predictor of all-cause mortality than VO2peakTBW (parameter estimates: -0.49 vs. -0.16).
Conclusion: Body composition is an important factor when considering the relationship between CRF and mortality risk. Clinicians should consider normalizing CRF to FFM when feasible, as it will strengthen the predictive power of the measure.

Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test.

Pugliese NR; Mazzola M; Fabiani I; Gargani L; De Biase N; Pedrinelli R; Natali A; Dini FL;

European Journal Of Heart Failure [Eur J Heart Fail] 2020 Jan 16. Date of Electronic Publication: 2020 Jan 16.

Aim: We combined cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE) to identify early haemodynamic and metabolic alterations in patients with hypertension (HT) with and without heart failure with preserved ejection fraction (HFpEF).
Methods and Results: Fifty stable HFpEF-HT outpatients (mean age 68 ± 14 years) on optimal medical therapy, 63 well-controlled HT subjects (mean age 63 ± 11 years) and 32 age and sex-matched healthy controls (mean age 59 ± 15 years) underwent a symptom-limited graded ramp bicycle CPET-ESE. The acquisition protocol included left ventricular cardiac output, global longitudinal strain, E/e’, peak oxygen consumption (VO2 ), non-invasive arterial-venous oxygen content difference (AVO2 diff) and lung ultrasound B-lines. There was a decline in peak VO2 from controls (24.4 ± 3 mL/min/kg) to HFpEF-HT (15.2 ± 2 mL/min/kg), passing through HT (18.7 ± 2 mL/min/kg; P < 0.0001). HFpEF-HT displayed a lower peak cardiac output (9.8 ± 0.9 L/min) compared to HT (12.6 ± 1.0 L/min; P = 0.02) and controls (13.3 ± 1.0 L/min; P = 0.01). Peak AVO2 diff was reduced in HFpEF-HT and HT (13.3 ± 2 and 13.5 ± 2 mL/dL vs. controls: 16.9 ± 2 mL/dL; P < 0.0001). A different left ventricular contractility was observed among groups, expressed as low-load global longitudinal strain (-16.8 ± 5% in HFpEF-HT, -18.2 ± 3% in HT, and 20.9 ± 3% in controls; P < 0.0001), and distribution of E/e’ and B-lines [HFpEF-HT: 13.7 ± 3 and 16, interquartile range (IQR) 10-22; HT: 9.5 ± 2 and 8, IQR 4-10; controls: 6.2 ± 2 and 0, IQR 0-2; P < 0.0001].
Conclusions: Reduced peak VO2 values in HT with and without HFpEF may be the result of decreased AVO2 diff. CPET-ESE can also identify mild signs of left ventricular systo-diastolic dysfunction and pulmonary congestion, promoting advances in personalized therapy.

Resting respiratory lung volumes are “healthier” than exercise respiratory volumes in different types of palliated or corrected congenital heart disease.

Fabi M; Balducci A; Cazzato S; Aceti A; Gallucci M; Di Palmo E; Gargiulo G; Donti A; Lanari M;

Pediatric Pulmonology [Pediatr Pulmonol] 2020 Jan 17. Date of Electronic Publication: 2020 Jan 17.

Aims: Cardiac surgery has improved life expectancy of patients with congenital heart diseases (CHDs). Exercise capacity is an important determinant of survival in patients with CHDs. There is a lack of studies focusing on the role of resting respiratory performance in reducing exercise tolerance in these patients.
Objectives: To determine the prevalence and severity of respiratory functional impairment in different types of corrected/palliated CHDs, and its impact on an exercise test.
Materials and Methods: Retrospective single-center study involving 168 corrected/palliated patients with CHD and 52 controls. Patients CHD were divided into subgroups according to the presence of native pulmonary blood flow or total cavopulmonary connection (TCPC). All subjects performed complete pulmonary function tests and gas diffusion; patients with CHD also performed cardiopulmonary exercise test (CPX).
Results: Mean values of lung volumes were within the normal range in all CHD groups. Comparing to controls, patients with the reduced pulmonary flow and with TCPC had the highest reduction in lung volumes. CPX was reduced in all groups, most severely in TCPC, and it was correlated to decreased dynamic volumes in all CHD groups except in TCPC. Younger age at intervention and number of surgical operations negatively affected lung volumes.
Conclusions: Respiratory function is within the normal range in our patients with different CHDs at rest but altered in all CHDs during exercise when cardiorespiratory balance is likely to be inadequate. Comparing the different groups, patients with reduced pulmonary flow and TCPC are the most impaired.

Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial

Francesco CarliGuillaume Bousquet-DionRashami AwasthiNoha ElsherbiniSender LibermanMarylise BoutrosBarry SteinPatrick CharleboisGabriela GhitulescuNancy MorinThomas Jagoe , Celena Scheede-BergdahlEnrico Maria Minnella , Julio F Fiore Jr

JAMA Surg 2020 Jan 22  [On line ahead of print]

Importance: Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes.
Objective: To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation.
Design, setting, and participants: This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019.
Interventions: Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway.
Main outcomes and measures: The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures.
Results: Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups.
Conclusions and relevance: In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively.

Multidimensional aspects of dyspnea in obese patients referred for cardiopulmonary exercise testing.

Balmain BN; Weinstein K; Bernhardt V; Marines-Price R; Tomlinson AR; Babb TG;

Respiratory Physiology & Neurobiology [Respir Physiol Neurobiol] 2019 Dec 30; Vol. 274, pp. 103365. Date of Electronic Publication: 2019 Dec 30.

We investigated the contributions of obesity on multidimensional aspects of dyspnea on exertion (DOE) in patients referred for clinical cardiopulmonary exercise testing (CPET). Ratings of perceived breathlessness (RPB, Borg scale 0-10) were collected in obese (BMI ≥ 30; n = 47) and nonobese (BMI ≤ 25; n = 27) patients during two (one lower: ∼30 W; and one higher: ∼50 W) 4-6 min constant load cycling bouts. Multidimensional dyspnea profiles (MDP) were collected in the final 26 obese and 14 nonobese patients of the sample. RPB was greater (p = 0.05) in obese (3.3 ± 2.2 vs 2.4 ± 1.4) at lower work rates, but similar at higher work rates (4.9 ± 2.2 vs 4.4 ± 1.8). MDP sensory score including unpleasantness was 4.3 ± 2.2 in obese vs 2.5 ± 1.9 in nonobese (p < 0.001). The affective score was 1.9 ± 2.2 vs 0.7 ± 0.7, respectively (p < 0.01). Breathing sensations including ‘air hunger’, ‘effort’, and ‘breathing at lot’ were greater (p < 0.05) in obese, making these patients more frustrated/angry (p < 0.05). Obesity should be considered as a potential independent influencing factor that provokes DOE and unpleasantness when assessing breathlessness during CPET.

 

The role of cardiopulmonary exercise testing and training in patients with pulmonary hypertension: making the case for this assessment and intervention to be considered a standard of care.

Sabbahi A; Severin R; Ozemek C; Phillips SA; Arena R;

Expert Review Of Respiratory Medicine [Expert Rev Respir Med] 2020 Jan 03, pp. 1-11. Date of Electronic Publication: 2020 Jan 03.

Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

Cardiopulmonary Exercise Testing Provides Additional Prognostic Information in Cystic Fibrosis.

Hebestreit H; Hulzebos EHJ; Schneiderman JE; Karila C; Boas SR; Kriemler
S; Dwyer T; Sahlberg M; Urquhart DS; Lands LC; Ratjen F; Takken T;Varanistkaya L; Rucker V; Hebestreit A;
Usemann J; Radtke T; PrognosticValue of CPET in CF Study Group.

American Journal of Respiratory & Critical Care Medicine. 199(8):987-995,
2019 04 15.

RATIONALE: The prognostic value of cardiopulmonary exercise testing (CPET)
for survival in cystic fibrosis (CF) in the context of current clinical
management, when controlling for other known prognostic factors, is
unclear.

OBJECTIVES: To determine the prognostic value of CPET-derived measures
beyond peak oxygen uptake ( V. o2peak) following rigorous adjustment for
other predictors.

METHODS: Data from 10 CF centers in Australia, Europe, and North America
were collected retrospectively. A total of 510 patients completed a cycle
CPET between January 2000 and December 2007, of which 433 fulfilled the
criteria for a maximal effort. Time to death/lung transplantation was
analyzed using Cox proportional hazards regression. In addition,
phenotyping using hierarchical Ward clustering was performed to
characterize high-risk subgroups.

MEASUREMENTS AND MAIN RESULTS: Cox regression showed, even after
adjustment for sex, FEV1% predicted, body mass index (z-score), age at
CPET, Pseudomonas aeruginosa status, and CF-related diabetes as covariates
in the model, that V. o2peak in % predicted (hazard ratio [HR], 0.964; 95%
confidence interval [CI], 0.944-0.986), peak work rate (% predicted; HR,
0.969; 95% CI, 0.951-0.988), ventilatory equivalent for oxygen (HR, 1.085;
95% CI, 1.041-1.132), and carbon dioxide (HR, 1.060; 95% CI, 1.007-1.115)
(all P < 0.05) were significant predictors of death or lung
transplantation at 10-year follow-up. Phenotyping revealed that
CPET-derived measures were important for clustering. We identified a
high-risk cluster characterized by poor lung function, nutritional status,
and exercise capacity.

CONCLUSIONS: CPET provides additional prognostic information to
established predictors of death/lung transplantation in CF. High-risk
patients may especially benefit from regular monitoring of exercise
capacity and exercise counseling.

Moderate-intensity continuous exercise is superior to high-intensity interval training in the proportion of VO2peak responders after ACS.

Trachsel LD; Nigam A; Fortier A; Lalongé J; Juneau M; Gayda M;

Revista Espanola De Cardiologia (English Ed.) [Rev Esp Cardiol (Engl Ed)] 2019 Dec 11. Date of Electronic Publication: 2019 Dec 11.

Introduction and Objectives: We compared the effects of 12 weeks of low-volume high-intensity interval training (LV-HIIT) vs moderate-intensity continuous exercise training (MICET) on cardiopulmonary exercise test parameters and the proportion of non/low responders (NLR) to exercise training in post-acute coronary syndrome (ACS) patients.
Methods: Patients with a recent ACS were randomized to LV-HIIT, MICET, or a usual care group. LV-HIIT consisted of 2 to 3 sets of 6 to 10minutes with repeated bouts of 15 to 30seconds at 100% of peak workload alternating with 15 to 30seconds of passive recovery. Cardiopulmonary exercise test parameters were assessed, and key exercise variables were calculated. Training response was assessed according to the median VO2peak change post vs pretraining in the whole cohort (stratification NLR vs high response).
Results: Fifty patients were included in the analysis (LV-HIIT, n=23; MICET, n=18; usual care, n=9) and 74% were male. The proportion of NLR was higher in the LV-HIIT group than in the MICET group (LV-HIIT 61%, MICET 21%, and usual care 80%; P=.0040). VO2peak-dependent variables (VO2peak, percent-predicted VO2peak) improved in both training groups (P=.002 and P <.0001 for time with LV-HIIT and MICET, respectively), but the improvement was more pronounced with MICET (P=.004 and P=.001 for interaction, respectively). The ΔVO2/Δworkload slope improved only with MICET (P=.021).
Conclusions: In patients with a recent ACS, several prognostic VO2peak-dependent variables were improved after LV-HIIT, but the improvement was more pronounced or only found after MICET. Low-volume HIIT resulted in a higher proportion of NLR than isocaloric MICET. Clinical trialsregistered at ClinicalTrials.gov (Identifiers: NCT03414996 and NCT02048696).