Exercise Tolerance Parameters Research Articles

Comprehensive analysis of the efficacy of personalized rehabilitation programs in patients with breast cancer

To perform the comprehensive analysis of the efficacy of personalized rehabilitation programs in patients with BC. The combined comparative multi-centre randomised trial of rehabilitation program efficacy in patients with breast cancer was done. The study included 219 patients aged from 30 to 45 years (median 39.4 year), who were divided into 2 groups. The rehabilitation by programs, that included current personalized rehabilitative techniques (RT) with proved efficiency, based on scientometrical analysis of evidential research was performed in the first group patients. In the second group aftercare was done according to the standard programs. The comprehensive evaluation of treatment efficacy was conducted in several stages: 1) performance analysis of rehabilitative programs; 2) verification of the effectiveness' determinant of rehabilitation; 3) factor analysis to assess the mechanisms of therapeutic effects in experimental groups; 4) comparative analysis of alternative strategies for selecting rehabilitation programs. The use of rehabilitative programs, based on recommended RT, changes the rehabilitation structure, significantly increasing its efficacy by 17%. Furthermore, the percentage of high-efficiency usage of this type programs increases by 17% compared with standard programs. The main determinants, affecting the efficacy of rehabilitation programs, based on selected RT, are anamnestic data, parameters of exercise tolerance and physical activity and ultrasound parameters of upper limb blood flow. The therapeutic effects of personalized rehabilitation programs are realized by correction of clinical rates, increasing exercise tolerance and physical activity, as well as psychophysiological parameters. The use of the evaluation system of anamnestic, clinical, functional and psychophysiological features of patient (the effectiveness' determinant) in realization of personalized rehabilitation programs for women with BC, allows to predict and manage the efficacy of RT applying.

364 Pulmonary hypertension: survival and prognostic factors by subgroups

Abstract Aims The definition of pulmonary hypertension (PH) requires the documentation of mean pulmonary arterial pressure (PAPm) ≥20 mmHg at rest, assessed by right cardiac catheterization. This condition can characterize multiple clinical conditions with different pathophysiological and haemodynamic aspects. Specifically, in pulmonary arterial hypertension (IAP) (Group 1), the increase in PAP is due to an intrinsic pathology of the pulmonary microcirculation; Group 2 includes the forms of IP associated with a pathology of the left heart; Group 3 includes all pathologies of the pulmonary parenchyma and/or hypoxic conditions that lead to a secondary impairment of the small circulation; Group 4 identifies patients with chronic thromboembolic pulmonary heart (CPCTE); finally, Group 5 includes rare clinical conditions in which IP is linked to direct involvement or ab extrinsic compression of the pulmonary vessels. Methods and results To examine the number of deaths and the differences between the various subgroups, we analyzed the follow-up of approximately 76 patients (64.30 ± 13.20 years, 37% male) enrolled in the Pulmonary Hypertension Clinic of the San Giovanni AOU Dio and Ruggi d’Aragona of Salerno from 2014 to 2020 excluding patients with IP under definition and those ‘screened’ who did not show pulmonary hypertension at rest. At each visit, the patients were subjected to anamnestic data collection, physical examination, measurement of blood pressure, heart rate, arterial saturation, transthoracic cardiac echo color Doppler at rest, attribution of the functional class NYHA, evaluation of functional capacity by performing the test of the 6-min walk test (6MWT) and possible programming of right cardiac catheterization. From the data analysis it was found that 26 patients (34.21%, 55.81 ± 13.90 years, 27% males) were affected by IP group 1; 15 patients (19.48%, 74.12 ± 6.26 years, 20% male) were affected by IP group 2; 14 patients (18.18%, 63.34 ± 11.52 years, 71% male) were affected by IP group 3; 12 patients (15.58%, 67.22 ± 11.53 years, 33% male) were affected by IP group 4; 2 patients (2.60%, 71.57 ± 12.48 years, 0% male) were affected by IP group 5; 7 patients (9.09%, 70.07 ± 8.27 years, 57% male) were affected by group 2–3 mixed IP. Analysing the number of deaths, of the 76 patients, 17 deaths were recorded in total (22.37%). All patients in group 1 had been treated with specific therapy and survival was 88% at 3 years. Of the three deaths (12%) in this group, one patient had idiopathic PAH non-responder to pulmonary vasoreactivity test, one patient belonged to the IAP subgroup associated with congenital heart shunt but with concomitant lung disease, and the third patient belonged to the IAP subgroup associated with connective tissue disease (specifically Takayasu’s arteritis). From the analysis of the idiopathic IAP subgroup it emerged that the patients were all women, with an average age of 50.81 ± 3.98 years, and that the deceased patient was distinguished at the first visit from the other patients for: a history of arterial hypertension, dysthyroidism, and obesity; worst NYHA class (III vs. II), elevated heart rate (102 vs. 70.00 ± 7.07 b.p.m.) and blood pressure (SBP: 150.00 vs. 127.50 ± 10.61; DBP 90.00 vs. 75.00 ± 7.07 mmHg) at rest at the clinic visit. Transthoracic echocardiography revealed elevated PAPs values (100.00 vs. 42.50 ± 20.51 mmHg), low TAPSE values (20.00 vs. 26.50 ± 3.54 mm), reduced pulmonary acceleration time (ACT 60 ms), enlargement of the right atrium (area 22 cm2), worst exercise tolerance parameters (6MWT 300 m and 86% final SO2 vs. 427.50 ± 74.25 m and 96.50 ± 0.71% final SO2). Conclusions The percentage of deaths in the different groups appears very heterogeneous, especially if we consider the six deaths (42.86%) in group 3 and three deaths (42.86%) in patients with mixed IP groups 2 and 3. In these two groups, age and advanced NYHA class were the most representative prognostic factors. On the other hand, analysing patients belonging to the idiopathic IAP subgroup, a worse prognosis is entrusted to the negativity of the vasoreactivity test, to the presence of cardiovascular comorbidities (arterial hypertension and dysthyroidism in our case), to worse echocardiographic values (PAPs, TAPSE, ACT, atrial area right) and reduced functional capacity at the 6MWT. However, early treatment and innovative drugs together with a careful strategy have been allowed.

The Use of Samsung Health and ECG M-Trace Base II Applications for the Assessment of Exercise Tolerance in the Secondary Prevention in Patients after Ischemic Stroke.

Background and objectives: The aim of the study was to use the mobile application Samsung Health for the assessment of parameters of exercise tolerance and the ECG (electrocardiogram) M-Trace Base II for the assessment of cardiological parameters. Materials and Methods: The measurements were conducted during rest and after performing SMWT (Six Minute Walk Test) and SCT (Stair Climb Test) in 26 patients after ischemic stroke (IS) and 26 healthy individuals. Results: In the SMWT, the post-stroke group (SG) walked a shorter distance (p < 0.001), achieving lower mean gait velocity (p < 0.001) and lower maximum gait velocity (p = 0.002). In the SCT, SG achieved a lower mean gait velocity (p < 0.001) and lower maximum gait velocity (p < 0.001) when compared to the control group (CG). In SG, myocardial ischemia in ECG was noted in four patients after SMWT and in three patients following SCT. Both in SG and in CG the increase in SBP (systolic blood pressure) value measured after SMWT and SCT compared to at rest (p < 0.001) was observed. In SG, in the compared ratios rest to SMWT and SCT as well as SMWT to SCT, there was an increase in HR (heart rate) (p < 0.001). Conclusions: ECG M-Trace Base II and Samsung Health are mobile applications that can assess cardiological parameters and exercise tolerance parameters in patients after IS, so they can be used to plan the intensity of exercise in rehabilitation programs.

Soluble urokinase-type plasminogen activator receptor represents exercise tolerance and predicts adverse cardiac events in patients with heart failure.

Soluble urokinase-type plasminogen activator receptor (suPAR) is a membrane-binding protein that is released into the blood stream by immune activation. Recent reports suggest that circulating suPAR levels are associated with adverse cardiovascular outcomes. Exercise tolerance is an independent predictor of prognosis in patients with heart failure (HF); however, the relationship between serum suPAR level and exercise tolerance is unclear. We prospectively enrolled 94 patients who were hospitalized for worsening of HF. All patients underwent a symptom-limited cardiopulmonary exercise test to evaluate exercise tolerance. The median value of serum suPAR was 4848pg/ml. During follow up, 44 patients (47%) were admitted for all-cause mortality and re-hospitalization for HF. Median serum suPAR was significantly higher in the patients with cardiac events than in the patients with non-event group. Patients were divided into two groups according to circulating suPAR levels. Kaplan-Meier analysis demonstrated that adverse cardiac events were significantly higher in the high suPAR group (log-rank p = 0.023). Multivariate analysis revealed that suPAR was independently correlated with the parameters of exercise tolerance such as anaerobic threshold (p = 0.007) and peak oxygen uptake (p = 0.005). suPAR levels predicted adverse cardiac events and independently correlated with the parameters of exercise tolerance. suPAR could be a useful surrogate biomarker of exercise tolerance in patients with HF.

Respiratory Muscle Strength and Exercise Performance in Cystic Fibrosis-A Cross Sectional Study.

Introduction: Decreased respiratory muscle strength in patients with cystic fibrosis (CF) may cause progressive exercise intolerance during cardiopulmonary exercise testing (CPET), and may contribute to the development of chronic respiratory insufficiency. The aim of this study is to evaluate exercise tolerance during CPET of children and adults with clinically stable CF who exhibit different respiratory muscle strength.Methods: Sixty-nine clinically stable CF subjects aged 8–33 years underwent spirometry, body plethysmography, CPET, and respiratory muscle strength measurement. Respiratory muscle strength was measured using maximal inspiratory pressures (Pimax) and maximal expiratory pressures (Pemax). Participants were stratified into three groups according to Pimax values:below normal (≤80% predicted), normal (81–100% predicted), and above normal (>100% predicted). A similar stratification of participants was made according to Pemax values. The oxygen consumption on peak load (VO2peak) was expressed relative to BM (VO2peak/kg), relative to BM raised by the exponent of 0.67 (VO2peak/kg0.67) and as log-linear adjustment of VO2peak (VO2peak/kg−alo).Results: Participants with low Pemax values had a lower mean maximum load per kilogram/predicted (Wmax; p = 0.001) VO2peak/kg (p = 0.006), VO2peak/kg0.67 (p = 0.038) and VO2peak/kg−alo (p = 0.001). There were no significant differences in exercise tolerance parameters with regard to Pimax values. Stepwise multiple linear regressions confirmed that Pemax (B = 24.88, β = 0.48, p < 0.001) was the most powerful predictor of Wmax. There were no statistically significant differences in age, lung function parameters, exacerbation score, or respiratory muscle strength according to gender.Conclusions: In subjects with clinically stable CF, expiratory muscle strength is associated with a decrease in exercise performance during CPET and can predict exercise intolerance. Increase in expiratory muscle strength by patient specific rehabilitation protocols would result in improvement of exercise tolerance.

ASSESSMENT OF ANTIISCHEMIC AND ANTIANGINAL EFFECTS OF NICORANDIL BY TREADMILL TEST, UNDER THE FRAMEWORK OF KVAZAR STUDY

Aim. Under the framework of KVAZAR study, to assess antianginal and antiischemic effects of nicorandil therapy with exercise test on treadmill in chronic coronary heart disease patients (CCHD) with stable angina. Material and methods . Randomized, double blind, placebo-control study, conducted in 2 parallel groups, multicenter. Totally, 120 patients included, all were taking metoprolol tartrat 50 mg b.i.d. After randomization, main group was added nicorandil 10 mg b.i.d., in 2 weeks the dosage was increased to 20 mg b.i.d., control took placebo. Duration of the study 6 weeks. For the evaluation of efficacy of nicorandil therapy 10-20 mg b.i.d., exercise test was used, done at randomization visit (V0) and in 6 weeks (V6). Results. Intake of nicorandil, in 6 weeks was followed by a significant increase of the time before the onset of angina (p&lt;0,0001), time to ST depression appearance for 1 mm (p&lt;0,005) and time for angina attack of moderate severity development (p&lt;0,005). In placebo group, only the angina onset tolerance parameter improved (p&lt;0,01), but duration of exercise test and time for ST depression 1 mm did not change significantly. In the subgroup of patients having ischemic ECG changes during exercise test, it was showed significant increase of these changes in nicorandil vs placebo (p&lt;0,05); which confirms the anti-ischemic action of nicorandil during the day in double dosing regimen. Conclusion . Nicorandil did statistically significantly improve the parameters of exercise tolerance in CCHD patients with stable angina. The results of the study make it to conclude on the additional and clinically significant impact of the drug 10-20 mg b.i.d. as an effective antianginal medication of second-line therapy for treatment of patients with CCHD with stable angina.

Multiple BiV Stimulation Combinations by using Two RV Leads Improve Potential for Response to CRT: Results of the TriV HF ICD Study

Aims: Cardiac resynchronization therapy (CRT) nonresponder rates continue to be approximately 30%. To demonstrate the potential benefit of multiple pacing site combination options, the effect of three CRT pacing configurations with differing right ventricular (RV) lead placements were evaluated. Methods: This single center, randomized, feasibility trial evaluated three CRT pacing configurations with two RV lead positions-RV-apex (“BiV Apex”), RV-septum close to His Bundle (“BiV His”) and RV-apex+RV-septum close to His Bundle (“TriV”)-with a left ventricular (LV) lead. Changes in intraoperative LV dP/dtmax were evaluated and acute response was defined as an increase of ≥10% versus intrinsic rhythm. Chronic measures included the Packer Heart Failure Composite Response score, 6 minute hall walk (6MHW); echocardiographic, electrocardiographic and exercise tolerance parameters, B-type natriuretic peptide (BNP) and Quality of Life. Results: Acute hemodynamic testing was completed in 34/39 patients and resulted in significant increases in LV dP/dtmax in each CRT configuration. Choosing the best of the tested BiV configurations 85% of all patients showed at least one configuration with significant dP/dtmax rise. During follow up, Packer scores improved for the majority (73%) of patients, which was consistent with improvements in QRS width, 6MHW, BNP, ejection fraction, mitral regurgitation, NYHA class, quality of life, CPX workload and peak VO2, but overall there were no significant differences in either acute or chronic response rates between the three configurations. Conclusions: Concomitant multisite pacing at the RV apex and septum nearby His bundle is feasible and effective and may provide an additional option for CRT nonresponders.

Effects of Endurance Exercise Training and Crataegus Extract WS® 1442 in Patients with Heart Failure with Preserved Ejection Fraction – A Randomized Controlled Trial

Impaired exercise capacity is the core symptom of heart failure with preserved ejection fraction (HFpEF). We assessed effects of exercise training and Crataegus extract WS 1442 in HFpEF and aimed to identify mechanisms of action in an exploratory trial (German Clinical Trials Register DRKS00000259). 140 sedentary HFpEF NYHA II patients on standard treatment received eight weeks of aerobic endurance training and half were randomized to WS 1442 900 mg/day. Symptoms, 2 km walking time (T2km), parameters of exercise tolerance, cardiac and vascular function, muscular efficiency and skeletal muscular haemoglobin oxygen saturation (SO2) measured during a treadmill protocol were captured at baseline and after eight weeks. Adverse events were recorded during the trial. Mechanisms of action were explored by correlation and path analyses of changes. Symptoms and exercise capacity improved with training, but correlations between improvements were low and path models were rejected. SO2 increased, decreased or undulated with increasing exercise intensity in individual patients and was not altered by training. WS 1442 improved T2km (-12.7% vs. -8.4%, p = 0.019), tended to improve symptoms and to pronounce SO2-decrease with increasing exercise, an indicator of oxygen utilisation. Endurance training and WS 1442 were safe and well tolerated in combination with standard drug treatment.

Interactive videogame as rehabilitation tool of patients with chronic respiratory diseases: Preliminary results of a feasibility study

To evaluate the effectiveness of an interactive videogame (IV) system in addition to a supervised pulmonary rehabilitation programme (PRP) in patients with chronic respiratory diseases. Randomised Controlled Trial comparing standard PRP (20 patients, control group: CG), and PRP+sessions of interactive videogame-aided exercises (20 patients, experimental group: EG). Lung and respiratory muscle function, arterial blood gases, exercise capacity, dyspnoea, health status and health-related quality of life (HRQL) and emotional response were measured before and after PRP. A questionnaire on acceptability of the PRP was administered. Exercise capacity, dyspnoea and HRQL significantly improved in both groups after the PRP, whereas the EG showed a greater improvement in six-minute walk test and transitional dyspnoea index than the CG. No difference in psychological status or acceptability of PRP was observed between the two groups. The addition of IV training was more effective for improving some parameters of exercise tolerance and dyspnoea, although did not result in better psychological status nor it was better accepted than the standard PRP in patients with chronic respiratory diseases.

Cardiopulmonary exercise performance after total cavopulmonary connection with or without prior superior cavopulmonary connection.

To compare cardiopulmonary exercise capacity of patients undergoing primary total cavopulmonary connection (TCPC) with those undergoing TCPC after a prior bidirectional Glenn (BDG). Out of 42 patients in this study, 24 had undergone primary TCPC while 18 had undergone staged TCPC. The peak oxygen consumption (O(2) peak), O(2) pulse, chronotropic index, and other exercise parameters were studied. There were no significant differences in O(2) peak (940 ± 538 vs. 1010 ± 417 mL/min, p=0.42) and O(2) pulse (5.76 ± 3.52 vs. 6.85 ± 2.95) of patients undergoing staged TCPC versus primary TCPC, respectively; however, chronotropic index (0.43 ± 0.23 vs. 0.30 ± 017, p=0.047) was significantly different. Exercise tolerance was the same in fenestrated versus nonfenestrated TCPC groups and age at TCPC less than or more than 7 years. However, O(2) peak and O(2) pulse of patients with extracardiac TCPC was better than patients with lateral tunnel TCPC (p values 0.05, 0.04 and respectively). Some parameters of exercise tolerance of patients with antegrade pulmonary blood flow (APBF) interrupted at the time of BDG were better than those with APBF open. There were no differences in the exercise parameters of patients undergoing a staged versus a primary TCPC, fenestrated versus nonfenestrated TCPC, and age at surgery less than or more than 7 years. Exercise parameters were better in the extracardiac conduit group versus lateral tunnel TCPC groups. Patients who had a TCPC after prior interruption of APBF had better exercise parameters.

Exercise tolerance in breast cancer patients during radiotherapy after aerobic training

Aim of the studyIn spite of the introduction of dose constraints based on patient individual assessment techniques for radiation therapy (RT), some side effects from the heart and lungs are observed. Regular physical exercises improve efficiency, which was confirmed in clinical trials. The aim of this study was to evaluate endurance exercise tolerance and the impact of aerobic training (AT) on selected clinical parameters in breast cancer patients during RT.Material and methodsThis study involved 46 women with breast cancer who were irradiated using conformal technique (3DCRT) to a total dose of 50 Gray during a 5-week course of RT. In this period 25 patients (group A) simultaneously performed AT, and the rest of the patients, without rehabilitation (group B), undertook irregular physical activity on their own. The exercise tolerance was assessed through the 6-minute walk test (6MWT) using: oxygen saturation (SO2), heart rate (HR), blood pressure (BP), 6-minute walk distance (6MWD) and dyspnea scale.ResultsAfter AT in group A, a statistically significant (p < 0.05) decrease was observed in average diastolic BP before 6MWT and in HR parameters before and after 6MWT (p > 0.05), and 6MWD was increased (p < 0.05). In group B, after RT, an increase (p < 0.05) in HR was observed after the test as well as dyspnea. Oxygen saturation in both groups was not significantly changed.ConclusionsThe results of our study showed that regular AT after just 6 weeks caused an improvement in exercise tolerance parameters with a substantial decline in dyspnea in breast cancer patients receiving RT.

Journal of Rare Cardiovascular Diseases: Moving towards maturity, and implementing the Krakow RCD Classification as a milestone

Dear Readers – our Friends and Colleagues, The present, third, issues of your quarterly Journal of Rare Cardiovascular Diseases is an important landmark in the life of the Journal; the life that presents a process from inception to full maturity, with an increase in overall impact. The content of the issue brings to you a happy (we believe) combination of continuity and novelty. I am convinced that you will judge the issues that we bring to your attention today as relevant to your patients with rare cardiovascular disease (RCD), fulfilling one of the principal aims of the Journal. We start with a review of cardiac manifestations in Churg Strauss syndrome, a rare but important form of necrotizing small‑vessel vasculitis. The review is by the internationally‑recognized experts in the fileld, Professors Wojciech Szczeklik and Tomasz Miszalski‑Jamka, who have designed and carried out significant original research in this field and today have a large experience in cardiac imaging and managing patients with the disease. The original contribution that follows is a collaborative work from two Krakow centers that investigated the effect of cardiac involvement in systemic sclerosis and systemic lupus erythematosus on clinical and spiroergometric parameters of exercise tolerance. Those patients require a truly multi‑specialty management that will no doubt benefit from the new knowledge generated by the investigators reporting their work in this issue of Journal. Traditionally, you will also find a mixture of case reports from different corners of the world that, beautifully illustrated, present the diagnostic and management path in RCD patients that are likely to cross your professional path one day. Dr Aleksander Trabka‑Zawidzki and colleagues present the impact of accidentally discovered non‑compaction cardiomyopathy in a patient with the initial diagnosis of acute coronary syndrome. Dr Stephen J. Pettit and colleagues from the Scottish Advanced Heart failure Service discuss the challenges of mechanical support of circulation in a young man with acute fulminant myocarditis, where a timely an appropriate diagnosis leads to a pharmaco‑mechanical battle with the diseases, having done ‘it all’ (by what is achievable today) live saving may not necessarily come as a prize to the management and consultation team. This exemplifies how much is yet to be researched and developed in this area. Dr Grzegorz Kopec and colleagues share some nerve‑wracking challenges they experienced in a pregnant woman with Eisenmenger syndrome (with a happy end of home discharge of both for the child and the mother). Finally, Dr Kaznica‑Wiatr and colleagues discuss the issues of pulmonary arterial hypertension after the correction of cardiac shunts, while Dr Hanna Dziedzic‑Oleksy and her friends from the department and surgical colleagues discuss their management of a young patient with severe spine deformity and Marfan syndrome. Again, these reports reflect the basic feature of RCD field: multi‑specialty collaboration that enables some clinical successes that, until recently, remained unimaginable. The final article in this issue is a report by Dr Jakub Stepniewski on our launching a new EU‑supported project in rare cardiovascular diseases, entitled Development of the European Network in Orphan Cardiovascular Diseases. We are extremely happy to share with you the joy of our successful application and plans (some – quickly implemented) to formally extend the European collaboration RCD network. Please continue your support to your Journal. We look forward to your submissions in the form of original articles, reviews or RCD case reports that will not only highlight your work and experience to your colleagues in the field and will make it formally quotable. We also hope that you will join us this year at the ESC Congress Rare Cardiovascular Diseases Symposium in August/September 2013 in Amsterdam. Last but – by no means – least, please note the mixtures of letters and numbers that complete the “RCD code” closing the titles of Journal publications for the first time in the present issue. The RCD classification, aimed to introduce some systematic clarity and facilitate grouping of experts, is – as you can witness – being implemented!

Efficacy Comparison of Trimetazidine with Therapeutic Alternatives in Stable Angina Pectoris: A Network Meta-Analysis

Aims: To compare the antianginal efficacy of trimetazidine with that of other agents with no influence on heart rate. Methods and Results: Medline and Embase databases were searched for blinded, randomized, controlled trials assessing the effects of non-heart-rate-lowering antianginal treatments on exercise tolerance and/or clinical criteria in stable angina patients. All relevant trimetazidine trials including the VASCO trial, the results of which are published herein, were included. A Bayesian network meta-analysis on the summary data was performed. Comparator antianginal agents were considered as a group and in agent/class subgroups. Trials involving β-blockers, non-dihydropyridine calcium channel blockers, and ivabradine were excluded. 218 trials totaling 19,028 patients were included in at least 1 network analysis. Effects of trimetazidine were statistically significant compared with placebo for exercise tolerance and clinical criteria. Transposition of results into seconds for clinical interpretation of exercise tolerance parameters showed a mean improvement of +46 s (95% credibility interval: 28; 66) for total exercise duration, +55 s (35; 77) for 1-mm ST segment depression (T1), and +54 s (24; 84) for time to onset of angina, in favor of trimetazidine. Differences between trimetazidine and active comparators were not significant when exercise tolerance and clinical criteria were analyzed, with +7 s (–12; 28) for total exercise duration, –1 s (–23; 22) for T1, +8 s (–22; 40) for time to onset of angina, and –0.28 (–1.17; 0.64) attacks per week for trimetazidine compared with antianginal agents as a group. Conclusions: Trimetazidine efficacy was comparable to that of other non-heart-rate-lowering antianginal treatments in patients with stable angina pectoris.

Subgroup Analysis of a Randomized Controlled Trial Evaluating the Safety and Efficacy of Cardiac Contractility Modulation in Advanced Heart Failure

BackgroundCardiac contractility modulation (CCM) signals are nonexcitatory electrical signals delivered during the absolute refractory period intended to improve contraction. We previously tested the safety and efficacy of CCM in 428 NYHA functional class III/IV heart failure patients with EF ≤35% and narrow QRS randomized to optimal medical treatment (OMT) plus CCM (n = 215) versus OMT alone (n = 213) and found no significant effect on ventilatory anaerobic threshold (VAT), the study’s primary end point. In the present analysis, we sought to identify if there was a subgroup of patients who showed a response to CCM. Methods and ResultsThe protocol specified that multiregression analysis would be used to determine if baseline EF, NYHA functional class, pVO2, or etiology of heart failure influenced the impact of CCM on AT. Etiology and baseline pVO2 did not affect efficacy. However, baseline NYHA functional class III and EF ≥25% were significant predictors of increased efficacy. In this subgroup (comprising 97 OMT and 109 CCM patients, ∼48% of the entire population) VAT increased by 0.10 ± 2.36 in CCM versus −0.54 ± 1.83 mL kg−1 min−1 in OMT (P = .03) and pVO2 increased by 0.34 ± 3.11 in CCM versus −0.97 ± 2.31 (P = .001) at 24 weeks compared with baseline; 44% of CCM versus 23% of OMT subjects showed improvement of ≥1 class in NYHA functional class (P = .002), and 59% of CCM versus 42% of OMT subjects showed a ≥10-point reduction in Minnesota Living with Heart Failure Questionnaire (P = .01). All of these findings were similar to those seen at 50 weeks. ConclusionsThe results of this retrospective hypothesis-generating analysis indicate that CCM significantly improves objective parameters of exercise tolerance in a subgroup of patients characterized by normal QRS duration, NYHA functional class III symptoms, and EF >25%.

The Effect of EDTA Chelation Therapy in Symptomatic Coronary Heart Disease: An Observational Study

Ethylene Diamine Tetra Acetic Acid (EDTA) chelation therapy has been considered a definitive alternative therapy for by-pass surgery in atherosclerotic cardiovascular disease for more than four decades. It is a relatively inexpensive method believed to restore blood flow in atherosclerotic vessels. However, the benefits of chelation therapy yet remain controversial in the treatment of ischemic heart disease. We observed the effect of EDTA chelation therapy on exercise tolerance in 13 volunteering patients receiving conventional treatment for established symptomatic coronary heart disease. Each patient received 30 weekly infusions of EDTA followed by monthly 12 boosters according to the ACAM protocol (American College for Advancement in Medicine). This was in addition to the conventional therapies they received from their respective physician in hospital. Stress ECG, echocardiography and coronary angiogram findings were obtained at the beginning of treatment. The distance that a patient could walk on level ground at moderate speed and the number of steps he/she can climb up on a staircase until he/she begins to feel either chest pain or breathlessness were the two clinical parameters of exercise tolerance recorded to grade angina. Liver and renal functions were tested at 1st, 5th, 10th, 15th and 30th infusions. Of the 13 patients, 11 showed improvement in angina grading whilst 2 experienced no effect. One patient improved from angina grade IV to I, 6 from grade III to I, 1 from grade III to II and 3 from grade II to I. A statistically significant reduction in the mean score (p = 0.002) was noticed at 6th month of treatment when compared to that of the first month. A significant 1.7 fold increase (p = 0.009) in the mean SGPT level was observed at the 30th infusion when compared to the pre-treatment values. The SGOT level showed no significant change (p = 0.664). None of the patients showed clinical features of hepato-cellular damage. The mean serum creatinine level showed a trend for reduction (p = 0.083) with treatment. The recognized side effects of intravenous EDTA chelation therapy such as liver damage, renal damage, hypersensitivity, symptomatic hypocalcaemia, and thrombophlebitis were not encountered. Thus, EDTA chelation therapy as prescribed by the ACAM protocol seems safe and effective in improving exercise tolerance in ischemic heart disease when administered concurrently with conventional therapy.

Differences in Treadmill Exercise Tolerance Parameters Between Patients With Partial and Advanced Interatrial Depolarization Abnormality

Advanced interatrial block (aIAB) is considerably much less common than partial interatrial block (pIAB), occuring in <2% of the elderly hospitalized population. Less is, therefore, known of the true clinical burden of aIAB, particularly in relation to graded exercise. Therefore, 12 patients with aIAB and 30 patients with pIAB who performed a baseline exercise tolerance test and had a repeat test performed > or = 2 years later were included in the study. Exercise tolerance, echocardiographic findings, and major adverse cardiovascular events were compared. Left atrial size progressed at a significantly faster rate in those with aIAB. In addition, Duke Prognostic Treadmill scores were significantly lower on follow-up in those patients with aIAB. Overall, patients with aIAB had significantly greater left atrial size (48.3 +/- 9 vs 42.8 +/- 4 mm, p < 0.01) and significantly lower Duke Prognostic Treadmill scores than those with pIAB (-0.2 +/- 5 vs 4.1 +/- 4, p < 0.05). There were, however, no significant differences in the occurence of major adverse cardiovascular events. In conclusion, left atrial size progressed at a significantly faster rate but Duke Prognostic Treadmill scores were significantly lower in those with aIAB compared with patients with pIAB after > or = 2 years of follow-up. Further study is required to determine whether patients with aIAB require follow-up echocardiography and/or exercise tolerance tests for optimal risk stratification.

Left atrial volume provides independent and incremental information compared with exercise tolerance parameters in patients with heart failure and left ventricular systolic dysfunction

Objective:Left atrial volume (LAV) is a powerful predictor of outcome in patients with chronic heart failure (CHF) independently of symptomatic status, age and left ventricular (LV) function. It is unknown...

Elevated peak exercise systolic blood pressure is not associated with reduced exercise capacity in subjects with Type 2 diabetes

Subjects with Type 2 diabetes without cardiovascular disease have a reduced exercise capacity compared with nondiabetic subjects. However, the mechanisms responsible for this phenomenon are unknown. The purpose of this study was to evaluate the impact of exercise systolic blood pressure (SBP) response on diverse exercise tolerance parameters in Type 2 diabetic subjects. Twenty-eight sedentary men with Type 2 diabetes were recruited for this study. Subjects were treated with oral hypoglycemic agents and/or diet. Evaluation of glycemic control and peak exercise capacity were performed for each subject. The subjects were divided into two groups according to the median value of peak SBP (210 mmHg) measured in each subject. We observed a 13, 13, and 16% reduction in the relative peak oxygen uptake (V(O2 peak)), absolute V(O2 peak), and peak work rate in the low- compared with the high-peak SBP group [26.95 (SD 5.35) vs. 30.96 (SD 3.61) ml.kg(-1).min(-1), 2.5 (SD 0.4) vs. 2.8 (SD 0.6) l/min, and 169 (SD 34) vs. 202 (SD 32) W; all P < 0.05]. After adjusting for age, relative V(O2 peak) was still significantly different (P < 0.05). There were similar peak respiratory exchange ratio (RER) [1.20 (SD 0.08) vs. 1.16 (SD 0.07); P = 0.24] and peak heart rate [160 (SD 20) vs. 169 (SD 15) beats/min; P = 0.18] between the low- compared with the high-SBP group. No difference in glycemic control was observed between the two groups. The results reported in this study suggest that in subjects with Type 2 diabetes without cardiovascular disease, an elevated exercise SBP is not associated with reduced exercise capacity and its modulation is probably not related to glycemic control.

Impact of an Elevated Maximal Systolic Blood Pressure on Exercise Tolerance in Patients With Type 2 Diabetes

Patients with type 2 diabetes present exercise intolerance compared to non diabetic subjects, even without cardiovascular complications. However, the mechanisms responsible for this phenomenon are unknown. PURPOSE: To evaluate the impact of the systolic blood pressure (SBP) on different exercise tolerance parameters in type 2 diabetic patients without cardiovascular complications. METHODS: A total of 28 sedentary men with type 2 diabetes have been recruited to participate in this study. All patients were treated with oral hypoglycaemic agents and/or diet. Evaluation of the glycaemic control (fasting blood glucose and glycated hemoglobin) and the maximal exercise tolerance on an ergocycle were performed for each subject. The subjects were then separated into two groups paired for weight, height and body mass index (BMI) according the median maximal SBP (210 mmHg). RESULTS: Per study design, there was a difference between the maximal SBP between groups (193±16 vs 235±19 mmHg; p<0.001). A reduced increment in SBP (maximal SBP - resting SBP) during exercise was observed in the low SBP group compared to the high SBP group (63±21 vs 98±17 mmHg; p<0.001). We observed a 13%, 13% and 16% reduction in the relative and absolute maximal oxygen uptake (VO2max) and in the maximal work rate in the low compared to the high SBP group [26.95±5.35vs30.96±3.61 ml · kg−1 min−1; 2.5±0.4 vs 2.8±0.6 L · min−1 and 169±34 vs 202±32 watts (all p<0.05)]. An elevated rate-pressure product (SBP × heart rate) was also observed in the high SBP group (39676±5219 vs 30822±4406 mmHg · batt; p<0.001). No difference in the glycaemic control was observed between the 2 groups. Significant relations were present between the absolute VO2 max (r=0.405), maximal exercise time (r=0.414), maximal work rate (r=0.454) and the maximal SBP (all p<0.05). CONCLUSIONS: These results suggest that, in type 2 diabetic patients without cardiovascular complications, an increased afterload does not influence negatively maximal exercise tolerance. Furthermore, the different SBP changes during exercise may not be related to glycaemic control.

969 Left atrial volume predicts outcome in patients with dilated cardiomyopathy independently of exercise tolerance parameters

969 Left atrial volume predicts outcome in patients with dilated cardiomyopathy independently of exercise tolerance parameters