Dear all

CPOC RCoA Bulletin September 2019

The attachment is the CPOC RCoA Bulletin.

It is of importance to many specialities, not just anaesthetists.

My regards

Paul

Ackland GL; Abbott TEF; Minto G; Owen T; Prabhu P; May SM; Reynolds JA; Cuthbertson BH; Wijesundera D; Pearse RM;

Plos One [PLoS One] 2019 Aug 21; Vol. 14 (8), pp. e0221277. Date of Electronic Publication: 20190821 (Print Publication: 2019).

Background: Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery.
Methods: In two prospective, blinded, observational cohort studies, we established the definition of impaired vagal function in terms of the HRR threshold that is associated with perioperative myocardial injury (HRR ≤ 12 beats min-1 (bpm), 60 seconds after cessation of cardiopulmonary exercise testing. The primary outcome of this secondary analysis was all-cause morbidity three and five days after surgery, defined using the Post-Operative Morbidity Survey. Secondary outcomes of this analysis were type of morbidity and time to become morbidity-free. Logistic regression and Cox regression tested for the association between HRR and morbidity. Results are presented as odds/hazard ratios [OR or HR; (95% confidence intervals).
Results: 882/1941 (45.4%) patients had HRR≤12bpm. All-cause morbidity within 5 days of surgery was more common in 585/822 (71.2%) patients with HRR≤12bpm, compared to 718/1119 (64.2%) patients with HRR>12bpm (OR:1.38 (1.14-1.67); p = 0.001). HRR≤12bpm was associated with more frequent episodes of pulmonary (OR:1.31 (1.05-1.62);p = 0.02)), infective (OR:1.38 (1.10-1.72); p = 0.006), renal (OR:1.91 (1.30-2.79); p = 0.02)), cardiovascular (OR:1.39 (1.15-1.69); p<0.001)), neurological (OR:1.73 (1.11-2.70); p = 0.02)) and pain morbidity (OR:1.38 (1.14-1.68); p = 0.001) within 5 days of surgery.
Conclusions: Multi-organ dysfunction is more common in surgical patients with cardiac vagal dysfunction, defined as HRR ≤ 12 bpm after preoperative cardiopulmonary exercise testing.

Hornsby WE; Departments of Internal Medicine, Division of Cardiovascular Medicine (Drs Hornsby, Saberi, Brook, Willer, Eagle, and Rubenfire and Ms Fink) and Cardiac Surgery (Drs Wu, Patel, and Yang), University of Michigan, Michigan Medicine, Ann Arbor; Creighton University School of Medicine, Omaha, Nebraska (Ms Norton); Department of Kinesiology, University of Windsor, Windsor, Ontario, Canada (Dr McGowan); Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York (Dr Jones); Departments of Computational Medicine and Bioinformatics and Human Genetics, University of Michigan, Ann Arbor (Dr Willer); and Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana (Dr Lavie).

Journal Of Cardiopulmonary Rehabilitation And Prevention [J Cardiopulm Rehabil Prev] 2019 Aug 29. Date of Electronic Publication: 2019 Aug 29.

Purpose: There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, Vo2peak), and blood pressure.
Methods: Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection.
Results: Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured Vo2peak was <36% predicted normative values (19.2 mL·kgmin vs 29.3 mL·kg·min, P < .0001); the most marked impairment in Vo2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups.
Conclusions: We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. Vo2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.

May SM; Reyes A; Martir G; Reynolds J; Paredes LG; Karmali S; Stephens RCM; Brealey D; Ackland GL;

British Journal Of Anaesthesia [Br J Anaesth] 2019 Sep 03. Date of Electronic Publication: 2019 Sep 03.

Background: Myocardial injury is more frequent after noncardiac surgery in patients with preoperative cardiac vagal dysfunction, as quantified by delayed heart rate (HR) recovery after cessation of cardiopulmonary exercise testing. We hypothesised that serial and dynamic measures of cardiac vagal activity are also associated with myocardial injury after noncardiac surgery.
Methods: Serial autonomic measurements were made before and after surgery in patients undergoing elective noncardiac surgery. Cardiac vagal activity was quantified by HR variability and HR recovery after orthostatic challenge (supine to sitting). Revised cardiac risk index (RCRI) was calculated for each patient. The primary outcome was myocardial injury (high-sensitivity troponin ≥15 ng L-1) within 48 h of surgery, masked to investigators. The exposure of interest was cardiac vagal activity (high-frequency power spectral analysis [HFLn]) and HR recovery 90 s from peak HR after the orthostatic challenge.
Results: Myocardial injury occurred in 48/189 (25%) patients, in whom 41/48 (85%) RCRI was <2. In patients with myocardial injury, vagal activity (HFLn) declined from 5.15 (95% confidence interval [CI]: 4.58-5.72) before surgery to 4.33 (95% CI: 3.76-4.90; P<0.001) 24 h after surgery. In patients who remained free of myocardial injury, HFLn did not change (4.95 [95% CI: 4.64-5.26] before surgery vs 4.76 [95% CI: 4.44-5.08] after surgery). Before and after surgery, the orthostatic HR recovery was slower in patients with myocardial injury (5 beats min-1 [95% CI: 3-7]), compared with HR recovery in patients who remained free of myocardial injury (10 beats min-1 [95% CI: 7-12]; P=0.02).
Conclusions: Serial HR measures indicating loss of cardiac vagal activity are associated with perioperative myocardial injury in lower-risk patients undergoing noncardiac surgery.

Tadic M; Cuspidi C; Suzic-Lazic J; Andric A; Sala C; Santoro C; Iracek O; Celic V;

Journal Of Clinical Hypertension (Greenwich, Conn.) [J Clin Hypertens (Greenwich)] 2019 Aug 26. Date of Electronic Publication: 2019 Aug 26.

We sought to assess functional capacity in recently diagnosed untreated hypertensive patients with different 24-hour blood pressure (BP) patterns (dipping, non-dipping, extreme dipping, and reverse dipping). This cross-sectional study involved 164 untreated hypertensive patients who underwent 24-hour ambulatory BP monitoring and cardiopulmonary exercise testing. Our findings showed that 24-hour and daytime BP values did not differ between four groups. Nighttime BP significantly and gradually increased from extreme dippers to reverse dippers. There was no significant difference in BPs at baseline and at the peak of exercise among four observed groups. Peak oxygen consumption (peak VO2) was significantly lower in reverse dippers than in dippers and extreme dippers. Heart rate recovery was significantly lower among reverse dippers than in dippers and extreme dippers. Ventilation/carbon dioxide slope (VE/VCO2) was significantly higher in reverse dippers and non-dippers in comparison with dippers and extreme dippers. Non-dipping BP pattern (non-dippers and reverse dippers together) was independently and negatively associated lower heart rate recovery in the first minute and peak VO2. Reverse dipping BP pattern was independently associated not only with heart rate recovery in the first minute and peak VO2, but also with VE/VCO2. In conclusion, untreated hypertensive patients with reverse dipping BP patterns showed significantly worse functional capacity than those with dipping and extreme dipping BP patterns. Circadian BP rhythm is related with functional capacity and should be taken into account in the risk assessment of hypertensive patients.

O’Neill LM; Guinan E; Doyle SL; Bennett AE; Murphy C; Elliott JA;
O’Sullivan J; Reynolds JV; Hussey J.

Annals of Surgery. 268(5):747-755, 2018 11.

OBJECTIVE: The Rehabilitation Strategies in Esophagogastric cancer
(RESTORE) randomized controlled trial evaluated the efficacy of a 12-week
multidisciplinary program to increase the cardiorespiratory fitness and
health-related quality of life (HRQOL) of esophagogastric cancer
survivors.

BACKGROUND: Patients following treatment for esophagogastric cancer are
at risk of physical deconditioning, nutritional compromise, and
sarcopenia. Accordingly, compelling rationale exists to target these
impairments in recovery.

METHODS: Disease-free patients treated for esophagogastric cancer were
randomized to either usual care or the 12-week RESTORE program (exercise
training, dietary counseling, and multidisciplinary education). The
primary outcome was cardiopulmonary exercise testing (VO2peak). Secondary
outcomes included body composition (bioimpedance analysis), and HRQOL
(EORTC-QLQ-C30). Outcomes were assessed at baseline (T0), postintervention
(T1), and at 3-month follow-up (T2).

RESULTS: Twenty-two participants were randomized to the control group
[mean (standard deviation) age 64.14 (10.46) yr, body mass index 25.67
(4.83) kg/m, time postsurgery 33.68 (19.56) mo], and 21 to the
intervention group [age 67.19(7.49) yr, body mass index 25.69(4.02) kg/m,
time postsurgery 23.52(15.23) mo]. Mean adherence to prescribed exercise
sessions were 94(12)% (supervised) and 78(27)% (unsupervised). Correcting
for baseline VO2peak, the intervention arm had significantly higher
VO2peak at both T1, 22.20 (4.35) versus 21.41 (4.49) mL . min . kg, P <
0.001, and T2, 21.75 (4.27) versus 20.74 (4.65) mL . min . kg, P = 0.001,
compared with the control group. Correcting for baseline values, no
changes in body composition or HRQOL were observed.

CONCLUSIONS: The RESTORE program significantly improved cardiorespiratory
fitness of disease-free patients after esophagogastric cancer surgery,
without compromise to body composition. This randomized controlled trial
provides proof of principle for rehabilitation programs in esophagogastric
cancer.

Borghi-Silva A; Di Thommazo-Luporini L; Carvalho LP.

Polish Archives Of Internal Medicine. 129(4):219-221, 2019 Apr 30.
VI 1

No abstract available

Takken T; Mylius CF; Paap D; Broeders W; Hulzebos HJ; Van Brussel M;
Bongers BC.

Expert Review of Cardiovascular Therapy. 17(6):413-426, 2019 Jun.
VI 1

Introduction: Reference values for cardiopulmonary exercise testing (CPET)
parameters provide the comparative basis for answering important questions
concerning the normalcy of exercise responses in patients, and
significantly impacts the clinical decision-making process.
Areas covered:
The aim of this study was to provide an updated systematic review of the
literature on reference values for CPET parameters in healthy subjects
across the life span. A systematic search in MEDLINE, Embase, and PEDro
databases were performed for articles describing reference values for CPET
published between March 2014 and February 2019.
Expert opinion:
Compared to the review published in 2014, more data have been published in the last
five years compared to the 35 years before. However, there is still a lot
of progress to be made. Quality can be further improved by performing a
power analysis, a good quality assurance of equipment and methodologies,
and by validating the developed reference equation in an independent
(sub)sample. Methodological quality of future studies can be further
improved by measuring and reporting the level of physical activity, by
reporting values for different racial groups within a cohort as well as by
the exclusion of smokers in the sample studied. Normal reference ranges
should be well defined in consensus statements.

VAN DE Sande DAJP; Schoots T; Hoogsteen J; Doevendans PA; Kemps HMC;

Medicine And Science In Sports And Exercise [Med Sci Sports Exerc] 2019 Jan; Vol. 51 (1), pp. 12-18.

Purpose: The clinical relevance of abnormal exercise testing (ET) results (at least 0.1 mV ST segment depression measured during exercise or recovery in three consecutive beats) in athletes without obstructive coronary artery disease (CAD) is not well understood. It is unknown whether this phenomenon reflects a physiological adaptation to sport or a truly ischemic response and a concomitant attenuated stroke volume (SV) response. The aim of this study was to investigate if athletes with abnormal ET results without obstructive CAD showed signs of an attenuated SV response using cardiopulmonary ET parameters.
Methods: A total of 78 male master athletes with abnormal ET results without obstructive CAD underwent cardiopulmonary ET. ΔO2 pulse/Δwork rate (WR), ΔV˙O2/ΔWR, and Δheart rate (HR)/ΔWR were assessed and compared with data from 78 male master athletes with normal ET results, matched for age, sports characteristics, and exercise capacity.
Results: The ΔO2 pulse/ΔWR ratio beyond anaerobic threshold in athletes with abnormal ET results was lower than that in athletes with normal ET results (0.73 ± 0.41 vs 1.12 ± 0.54, respectively, P < 0.001). The ΔV˙O2/ΔWR ratio was also lower in athletes with abnormal ET results (0.9 ± 0.2 vs 1.0 ± 0.3, respectively, P = 0.041). Furthermore, these athletes showed a greater increase in HR in the last 2 min of exercise (ΔHR/ΔWR ratio: 1.19 ± 0.5 vs 0.80 ± 0.6, P < 0.001).
Conclusion: Athletes with abnormal ET results without obstructive CAD showed an attenuated O2 pulse slope, decreased ΔV˙O2/ΔWR ratio, and increased ΔHR/ΔWR ratio beyond anaerobic threshold when compared with athletes with a normal ET result. These results support the hypothesis that at least a part of the athletes with an abnormal ET in absence of obstructive CAD have an attenuated SV response at high-intensity exercise.