Predicting impaired cardiopulmonary exercise capacity in patients with atrial fibrillation using a simple echocardiographic marker.

BACKGROUND: Exercise intolerance is a common symptom associated with atrial fibrillation (AF). However, echocardiographic markers that can predict impaired exercise capacity are lacking. OBJECTIVE: This study aimed to investigate the association between echocardiographic parameters and exercise capacity assessed by cardiopulmonary exercise testing in patients with AF. METHODS: This single-center prospective study enrolled patients with AF who underwent echocardiography and cardiopulmonary exercise testing to evaluate exercise capacity at a tertiary center for AF management from 2020 to 2022. Patients with valvular heart disease, reduced left ventricular ejection fraction, or documented cardiomyopathy were excluded. RESULTS: Of the 188 patients, 134 (71.2%) exhibited impaired exercise capacity (peak oxygen consumption ≤85%), including 4 (2.1%) having poor exercise capacity (peak oxygen consumption <50%). Echocardiographic findings revealed that these patients had an enlarged left atrial end-systolic diameter (LA); smaller left ventricular end-diastolic diameter (LVEDD); and increased relative wall thickness, tricuspid regurgitation velocity, and LA/LVEDD and E/e' ratios. In addition, they exhibited lower peak systolic velocity of the mitral annulus and LA reservoir strain. In the multivariate regression model, LA/LVEDD remained the only significant echocardiographic parameter after adjustment for age, sex, and body mass index (P = .020). This significance persisted even after incorporation of heart rate reserve, N-terminal pro-B-type natriuretic peptide level, and beta-blocker use into the model. CONCLUSION: In patients with AF, LA/LVEDD is strongly associated with exercise capacity. Further follow-up and validation are necessary to clarify its clinical implications in patient care.

Post-exercise left atrial conduit strain predicted hemodynamic change in heart failure with preserved ejection fraction.

OBJECTIVES: Left ventricle function directly impacts left atrial (LA) conduit function, and LA conduit strain is associated with exercise intolerance in patients with heart failure with preserved ejection fraction (HFpEF). Pulmonary capillary wedge pressure (PCWP) before and during exercise is the current gold standard for diagnosing HFpEF. Post-exercise ΔPCWP can lead to worse long-term outcomes. This study examined the correlation between LA strain and post-exercise ΔPCWP in patients with HFpEF. METHODS: We enrolled 100 subjects, including 74 with HFpEF and 26 with non-cardiac dyspnea, from November 2017 to December 2020. Subjects underwent echocardiography, invasive cardiac catheterization, and expired gas analysis at rest and during exercise. Arterial blood pressure, right atrial pressure, pulmonary artery pressure, and PCWP were recorded during cardiac catheterization. Cardiac output, stroke volume, pulmonary vascular resistance, pulmonary artery compliance, systemic vascular resistance, and LV stroke work were calculated using standard formulas. RESULTS: Exercise LA conduit strain significantly correlated with both post-exercise ΔPCWP (r = - 0.707, p < 0.001) and exercise PCWP (r = - 0.659; p < 0.001). Exercise LA conduit strain differentiated patients who did and did not meet the 2016 European Society of Cardiology HFpEF criteria with an area under the curve of 0.69 (95% confidence interval, 0.548-0.831) using a cutoff value of 14.25, with a sensitivity of 0.64 and a specificity of 0.68. CONCLUSIONS: Exercise LA conduit strain significantly correlates with post-exercise ΔPCWP and has a comparable power to identify patients with HFpEF. Additional studies are warranted to confirm the ability of LA conduit strain to predict long-term outcomes among patients with HFpEF. CLINICAL RELEVANCE STATEMENT: Exercise left atrial conduit strain was highly associated with the difference of post-exercise pulmonary capillary wedge pressure and may indicate increased mortality risk in patients with heart failure with preserved ejection fraction, and also has comparable diagnostic ability. KEY POINTS: • Left atrial conduit strain is associated with exercise intolerance in patients with heart failure with preserved ejection fraction. • Left atrial conduit strain during exercise can identify patients with heart failure with preserved ejection fraction. • Exercise left atrial conduit strain significantly correlates with the difference of pulmonary capillary wedge pressure during and before exercise which might predict the long-term outcomes of heart failure with preserved ejection fraction patients.

Right Ventricular-Vascular Uncoupling Predicts Pulmonary Hypertension in Clinically Diagnosed Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Pulmonary hypertension (PH) is highly prevalent in patients with heart failure with preserved ejection fraction (HFpEF), and it is a strong predictor of adverse outcomes. We aimed to determine possible echocardiographic parameters to predict the presence of PH in patients with HFpEF. METHODS AND RESULTS: A total of 113 patients with HFpEF were prospectively enrolled from November 2017 to July 2022. The patients underwent invasive cardiac catheterization and simultaneous echocardiography at rest and during exercise. The parameters indicating right ventricle-pulmonary artery uncoupling, including tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) and tricuspid annular systolic velocity (TAS')/PASP were calculated. Receiver operating characteristic curve analysis was used to determine the optimal cut-off points of TAPSE/PASP and TAS'/PASP to differentiate patients with HFpEF with PH from those without PH. Sixty-eight patients with HFpEF with PH and 45 without PH were included. Those with PH had lower TAPSE/PASP and TAS'/PASP at rest and during exercise compared with those without PH. Both resting/stress TAPSE/PASP and TAS'/PASP were correlated with rest/exercise pulmonary capillary wedge pressure and mean pulmonary artery pressure. In multivariable regression analysis, TAPSE/PASP remained a significant predictor of exercise pulmonary capillary wedge pressure and mean pulmonary artery pressure. In receiver operating characteristic curve analysis, the optimal cut-off points of TAPSE/PASP and TAS'/PASP to differentiate patients with HFpEF with PH from those without PH were ≤0.62 and ≤0.47, respectively. CONCLUSIONS: Right ventricle-pulmonary artery uncoupling is closely correlated with abnormal rest/exercise hemodynamics (pulmonary capillary wedge pressure and mean pulmonary artery pressure) in patients with HFpEF. TAPSE/PASP and TAS'/PASP can be useful parameters to detect PH in patients with HFpEF.

2023 TAMIS/TSOC/TACVPR Consensus Statement for Patients with Acute Myocardial Infarction Rehabilitation.

Cardiac rehabilitation is a comprehensive intervention recommended in international and Taiwanese guidelines for patients with acute myocardial infarction. Evidence supports that cardiac rehabilitation improves the health-related quality of life, enhances exercise capacity, reduces readmission rates, and promotes survival in patients with cardiovascular disease. The cardiac rehabilitation team is comprehensive and multidisciplinary. The inpatient, outpatient, and maintenance phases are included in cardiac rehabilitation. All patients admitted with acute myocardial infarction should be referred to the rehabilitation department as soon as clinically feasible. Pre-exercise evaluation, including exercise testing, helps physicians identify the risks of cardiac rehabilitation and organize appropriate exercise prescriptions. Therefore, the Taiwan Myocardial Infarction Society (TAMIS), Taiwan Society of Cardiology (TSOC), and Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation (TACVPR) address this consensus statement to assist healthcare practitioners in performing cardiac rehabilitation in patients with acute myocardial infarction.

Muscle Microcirculatory Responses to Incremental Exercises Are Correlated with Peak Oxygen Uptake in Individuals With and Without Type 2 Diabetes Mellitus.

Background: The role of impaired oxygen extraction on peak oxygen uptake (V̇O2peak) has been extensively studied using noninvasive and indirect methods in both diabetic patients and healthy participants. Methods: A total of 22 participants with type 2 diabetes mellitus [T2DM; median (range) age: 60 (47-70) years] and 22 controls [58 (52-69) years] with no history of diabetes were recruited (reference no. 201812135RINB). Subjects performed an exhaustive incremental exercise and were evaluated using a gas analyzer and near-infrared spectroscopy (NIRS) to determine V̇O2peak and changes in muscle oxygenation (SmO2) in the vastus lateralis, respectively. Measurements were taken at rest, warm-up, a period during exercise when SmO2 reached a minimum saturation plateau, and recovery. The microcirculatory responses of the vastus lateralis muscle during incremental exercise in patients with T2DM were compared with those in control individuals, and the correlation between changes in SmO2 and V̇O2peak was estimated. Results: The diabetic group demonstrated lower V̇O2peak, peak workload, peak heart rate, peak minute ventilation (all P < 0.05), and lower SmO2 during the rest, warm-up, and recovery phases (all P < 0.05) compared with the control group. A correlation was observed between the change in SmO2 between the warm-up and plateau value and the V̇O2peak (r = 0.608, P = 0.006). Conclusions: The results obtained in this study using NIRS support the feasibility of directly measuring changes in muscle SmO2 magnitudes to estimate the contributions of peripheral active muscle to systemic O2 uptake (V̇O2) during incremental exercise.

Effects of Slowness, Frailty, Insufficient Intake, and Delirium in Patients Following Cardiac Surgery: A Cohort Study.

BACKGROUND: Slow gait, frailty, insufficient postoperative caloric intake, and delirium, although seemingly distinct, can appear simultaneously in patients who underwent cardiac surgery. OBJECTIVES: The aim of this study was to evaluate how these 4 factors overlap and how they individually and cumulatively affect cardiac surgery outcomes. METHODS: The effects of slowness (gait speed <0.83 m/s), frailty (≥3/5 Fried criteria), insufficient postoperative intake (<800 kcal/d), and delirium (defined by the Confusion Assessment Method) on hospital length of stay (LOS) and 3-month mortality were analyzed in 308 adult patients. RESULTS: Slowness, frailty, insufficient intake, and delirium affected 27.5%, 29.5%, 31.5%, and 13.3% of participants, respectively; only 42.2% (130/308) were free from these risks. Risk overlap was prevalent, as 26.3% (n = 81) had 2 or more risk factors. The most obvious overlap was in delirium (80% of delirious participants had other risks), suggesting that delirium cannot be managed in isolation. Individually, whereas slowness was associated only with longer LOS, frailty, insufficient intake, and delirium all led to longer LOS and higher mortality. When equally weighting each risk factor to analyze their cumulative effects, LOS increased by 4.4 days (95% confidence interval, 3.0-5.7) and 3-month mortality increased by 2.6-fold (95% confidence interval, 1.4-4.6), with each risk factor added, independent of participants' educational level, body mass index, and risk for cardiac surgery (EuroSCORE II ≥6). CONCLUSIONS: Because a clinical overlap of slowness, frailty, insufficient postoperative intake, and delirium was evident in patients who underwent cardiac surgery, and risk of death and longer hospital stay increased with each factor added, care should be revised to consider these overlapping factors to maximize patient outcomes.

Exercise Capacity and Quality of Life in Pulmonary Arterial Hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a progressive pulmonary vascular disease with a high mortality rate that can be divided into different groups according to etiology and prognosis. Few studies have investigated differences in the exercise capacity and quality of life (QOL) among the different groups of PAH patients. Therefore, we aimed to (1) compare the hemodynamic exercise responses between patients with idiopathic pulmonary arterial hypertension (IPAH) and PAH associated with other diseases (APAH), and (2) determine the factors associated with exercise capacity in patients with PAH. METHODS: Six patients diagnosed with IPAH and eight with APAH [congenital heart disease (CHD)-dominant PAH] were included in this study. The main outcome measures included body composition, exercise capacity, hemodynamic measurements, physical activity levels, fatigue severity, and QOL. RESULTS: The CHD-dominant PAH group had a significantly lower predicted peak oxygen consumption (VO2pred %), pressure of end-tidal carbon dioxide at the peak and at anaerobic threshold (PETCO2peak and PETCO2@AT), and significantly elevated ventilatory equivalent (VE/VCO2slope and VE/VCO2@AT) compared with the IPAH group. Multiple regression analysis indicated that PETCO2@AT was significantly associated with either VO2peak (ß = 0.805, adjusted R2 = 0.619, p = 0.001) or 6-minute walk distance (ß = 0.816, adjusted R2 = 0.638, p < 0.001). CONCLUSIONS: Patients with CHD-dominant PAH had poor exercise capacity and exercise responses compared to those with IPAH. Evaluating exercise capacity and the patient response to exercise using cardiopulmonary exercise testing is increasingly important in view of the etiology of PAH.

Surviving and Thriving 1 Year After Cardiac Surgery: Frailty and Delirium Matter.

BACKGROUND: We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD). METHODS: Consecutive cardiac surgery patients (n = 298) at a university hospital were assessed for preoperative frailty using Fried's phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year after surgery. RESULTS: Preoperative frailty presented in 85 of participants (28.5%) and POD in 38 (12.8%). Frail participants were at increased risk for POD (odds ratio = 4.9; P < .001). Overall, 1-year mortality was 4.0% (n = 12) and functional change was 0.4 ± 11.0 Barthel points. Controlling for age, cardiac risk, and baseline ADL, frailty-only and comparison participants had comparable 1-year functional outcomes. The POD-only group had greater mortality (adjusted hazard ratio = 23.9; P = .01), whereas the combined frailty-POD group had the greatest ADL decline (ß = -23.7; P = .01) and the highest mortality (adjusted hazard ratio = 30.2; P = .006) compared with the comparison group. CONCLUSIONS: Preoperative frailty alone did not negatively affect cardiac surgery patients' functional outcomes up to 1 year, but coexisting frailty and POD led to substantial loss of independence on 3 to 4 ADLs and a 30.2-fold higher likelihood of dying 1 year after surgery. Because frailty led to a 4.9-fold increase in POD risk, frailty may serve as a presurgical screen to identify patients who would likely benefit from delirium prevention and functional recovery programs to maximize 1-year postsurgical outcomes.

Rehabilitation programs for patients with COronaVIrus Disease 2019: consensus statements of Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation.

The COronaVIrus Disease 2019 (COVID-19), which developed into a pandemic in 2020, has become a major healthcare challenge for governments and healthcare workers worldwide. Despite several medical treatment protocols having been established, a comprehensive rehabilitation program that can promote functional recovery is still frequently ignored. An online consensus meeting of an expert panel comprising members of the Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation was held to provide recommendations for rehabilitation protocols in each of the five COVID-19 stages, namely (1) outpatients with mild disease and no risk factors, (2) outpatients with mild disease and epidemiological risk factors, (3) hospitalized patients with moderate to severe disease, (4) ventilator-supported patients with clear cognitive function, and (5) ventilator-supported patients with impaired cognitive function. Apart from medications and life support care, a proper rehabilitation protocol that facilitates recovery from COVID-19 needs to be established and emphasized in clinical practice.

Promoting Patient Utilization of Outpatient Cardiac Rehabilitation: a joint International Council and Canadian Association of Cardiovascular prevention and rehabilitation position statement

Cardiac rehabilitation (CR) is a recommendation in international clinical practice guidelines given its benefits; however, use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrollment and adherence into implementable recommendations. The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patients' utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A Web call was convened to achieve consensus and confirm strength of the recommendations (based on Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review and public comment. The 3 drafted recommendations were that to increase enrollment, health care providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence, part of CR could be delivered remotely (weak). Ratings (mean ± SD) for the 3 recommendations were 5.95 ± 0.69, 5.33 ± 1.12, and 5.64 ± 1.08, respectively. Interventions can significantly increase utilization of CR and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization and to ensure that CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement.

BACKGROUND: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its' benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations. METHODS: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment. RESULTS: The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95 ±â€¯0.69 (mean ±â€¯standard deviation), 5.33 ±â€¯1.12 and 5.64 ±â€¯1.08, respectively. CONCLUSIONS: Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

Inhaled Prostacyclin on Exercise Echocardiographic Cardiac Function in Preserved Ejection Fraction Heart Failure.

PURPOSE: Treatments that improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF) have shown no benefits for those with heart failure with preserved ejection fraction (HFpEF). Our study aimed to investigate the effect of inhaled iloprost on myocardial performance during exercise in HFpEF. METHODS: The study participants were enrolled from the ILO-HOPE trial (NCT03620526), a prospective randomized, double-blind, placebo-controlled study that was designed to investigate the effects of iloprost on cardiovascular hemodynamics during exercise in patients with HFpEF. Subjects were randomized 1:1 to inhalation of iloprost or placebo for 5 min. Two-dimensional transthoracic echocardiography with high temporal resolution was implemented to measure left ventricular (LV) longitudinal strain, LV diastolic function, and RV function both at rest and during supine exercise at 20-W workload. RESULTS: LV global longitudinal strain (GLS) in response to exercise increased more in the iloprost group (LV GLS, -24.96 ± 1.20 vs -20.75 ± 3.00, P < 0.001). Iloprost also resulted in greater increment of LV GLS during exercise (ΔLV GLS, +6.02 ± 1.39 vs +3.44 ± 0.80, P < 0.001). Moreover, iloprost use was associated with enhancement of LV diastolic function, RV systolic function, and relief of pulmonary hypertension during exercise. CONCLUSIONS: In patients with HFpEF, inhaled iloprost favorably improved myocardial performance during exercise by increasing LV GLS reserve, decreasing LV diastolic filling load, and reducing stress-induced pulmonary hypertension and thereby improving RV systolic function. Larger studies are needed to validate the result and long-term benefits of iloprost in patients with HFpEF.

The effectiveness of cardiac rehabilitation in non-ischemic dilated cardiomyopathy patients: A pilot study.

BACKGROUND/PURPOSE: We aimed to investigate the efficacy of cardiac rehabilitation (CR) through parameters of cardiopulmonary exercise testing (CPET) and echocardiography in non-ischemic dilated cardiomyopathy (DCM) patients. METHODS: We retrospectively identified non-ischemic DCM patients through medical records (between October 2011 and October 2018) in rehabilitation outpatient-clinics. Patients were divided into rehabilitation and control groups. Patients in the rehabilitation group eligible for inclusion had CR for 3-6 months. Control group patients were without rehabilitation. We recorded CPET and echocardiography parameters at the baseline and follow-up time-points. For safety evaluation, we investigated all adverse effects during training sessions. We utilized Mann-Whitney U test for between- and Wilcoxon signed-rank test for within-group comparisons. RESULTS: Twenty-five patients (14 in rehabilitation and 11 in control group) were included. In the rehabilitation group, significantly increased peak V˙O2/kg, peak V˙O2%, peak workload and peak O2 pulse were observed after completing CR, and echocardiographic parameters including left ventricular ejection fraction and end-systolic volume. Rehabilitation group patients demonstrated better improvement (change from the baseline) in peak V˙O2/kg, peak V˙O2% and peak workload vs. control. No adverse effects during rehabilitation trainings were observed. CONCLUSION: For non-ischemic DCM, rehabilitation led to superior cardiopulmonary outcomes vs. no rehabilitation, without adverse effects.

Promoting Patient Utilization of Outpatient Cardiac Rehabilitation: A JOINT INTERNATIONAL COUNCIL AND CANADIAN ASSOCIATION OF CARDIOVASCULAR PREVENTION AND REHABILITATION POSITION STATEMENT.

PURPOSE: Cardiac rehabilitation (CR) is a recommendation in international clinical practice guidelines given its benefits; however, use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrollment and adherence into implementable recommendations. METHODS: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patients' utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A Web call was convened to achieve consensus and confirm strength of the recommendations (based on Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review and public comment. RESULTS: The 3 drafted recommendations were that to increase enrollment, health care providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence, part of CR could be delivered remotely (weak). Ratings (mean ± SD) for the 3 recommendations were 5.95 ± 0.69, 5.33 ± 1.12, and 5.64 ± 1.08, respectively. CONCLUSIONS: Interventions can significantly increase utilization of CR and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization and to ensure that CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

Stress Echocardiography-Derived E/e' Predicts Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: The correlation between echocardiographic parameters and hemodynamics data in patients with heart failure with preserved ejection fraction (HFpEF) is unclear. It is important to find a non-invasive echocardiographic parameter for predicting exercise pulmonary capillary wedge pressure (PCWP). AIM: This study sought to determine the correlation between echocardiographic parameters and hemodynamics data at rest and during exercise in HFpEF patients. METHODS AND RESULTS: This study was a cross-sectional cohort exploratory analysis of baseline data from the ILO-HOPE trial. A total of 34 HFpEF patients were enrolled. The average age was 70 ± 12 years, and most (74%) were women. The patients underwent invasive cardiac catheterization and expired gas analysis at rest and during exercise. Echocardiography including tissue Doppler imaging was performed, and global longitudinal strain and other novel diastolic function indexes were analyzed at rest and during exercise. At rest, no significant correlation was noted between resting PCWP and echocardiographic parameters. However, a significant correlation was observed between post-exercise PCWP and stress E/e' (septal, lateral, and mean) ratio (p = 0.003, 0.031, 0.012). Moreover, post-exercise ΔPCWP showed a good correlation with stress E/e' (septal, lateral, and mean; all p ≤ 0.001) and global longitudinal strain (GLS) during exercise (p = 0.03). After multivariate regression analysis with adjustment for possible confounding factors including age and sex, there was still a significant correlation between post-exercise ΔPCWP and E/e' (r = 0.62, p < 0.001 for E/e'mean). CONCLUSION: Only stress echocardiography derived tissue Doppler E/e' ratio is closely correlated with abnormal exercise hemodynamics (PCWP and post-exercise ΔPCWP) in HFpEF. This echocardiographic marker is substantially more sensitive than other novel echocardiographic parameters during exercise, and may have significant diagnostic utility for ambulatory HFpEF patients with dyspnea. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov, identifier NCT03620526.

Nature of Cardiac Rehabilitation Around the Globe.

BACKGROUND: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. METHODS: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. FINDINGS: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ±â€¯2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ±â€¯1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). INTERPRETATION: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes.

Cardiac Rehabilitation Availability and Density around the Globe.

BACKGROUND: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. METHODS: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. FINDINGS: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35-1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04-1.06), and significantly lower with private (OR = .92, 95%CI = .91-.93) or public (OR = .83, 95%CI = .82-84) funding compared to hybrid sources.Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150-390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. INTERPRETATION: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.

Effects of sarcopenia on functional improvement over the first year after cardiac surgery: a cohort study.

BACKGROUND: Sarcopenia is linked with poor postoperative outcomes. AIMS: To evaluate the effects of sarcopenia on first-year functional changes after cardiac surgery. METHODS: In this prospective cohort study, functional changes (physical activity levels in metabolic equivalent hours/week, 6-minute walking distance in metres, and grip strength in kg) from preoperative baseline to 1, 3, 6 and 12 months postoperatively were compared in adult patients with and without sarcopenia undergoing cardiac surgery at a tertiary medical centre. Presurgical sarcopenia was defined as low muscle mass plus either low strength or poor physical performance (i.e. reduced gait speed). Secondary outcomes (length of hospital stay and 1-year mortality) were compared between sarcopenia and non-sarcopenia groups. RESULTS: Sarcopenia presented in 27.7% ( n=67) of 242 participants. Participants with sarcopenia were significantly older, predominantly women, and had lower body mass index and higher cardiac surgery risk (measured by the EuroSCORE II) than those without sarcopenia. For both groups, physical activity levels, walking distance and grip strength steadily improved over the year following cardiac surgery. Independent of EuroSCORE II, changes in physical activity levels, walking distance and grip strength did not differ significantly between the sarcopenia and non-sarcopenia groups 1, 3, 6 and 12 months after surgery. Nevertheless, the sarcopenia group had a significantly longer length of hospital stay than the non-sarcopenia group (19.4 vs. 15.3 days; ß=2.9, P=0.02) but 1-year mortality (3.4 vs. 3.9% for non-sarcopenia group) was comparable. CONCLUSIONS: Despite a longer length of hospital stay for the sarcopenia group, sarcopenia was not a restriction for cardiac surgery given their comparable functional improvement and mortality 1 year following surgery.

Relation between serum myokines and phase II cardiac rehabilitation.

Patients with coronary heart disease or acute myocardial infarction after cardiac catheterization with stenting referred for phase II cardiac rehabilitation (CR) were grouped according to their preference. Cardio-pulmonary exercise testing (CPET) was used to determine oxygen uptake ((Equation is included in full-text article.)) at peak exercise and anaerobic threshold (AT). The control patients received counseling only while the experiment group received 36 sessions of CR in 3 to 6 months. Exercise physiology parameters and serum myokines (myostatin, insulin-like growth factor-1 (IGF-1), and interleukin-6 (IL-6) were measured pre- and postrehabilitation.There were 29 patients in the experiment group and 10 in the control group, with no significant differences in baseline parameters. The experiment group had prominent progress in aerobic capacity and body composition after CR, but their serum myokine concentrations did not change significantly. Serum myostatin is positively correlated to peak (Equation is included in full-text article.)pre- and post-training, and pretraining AT (Equation is included in full-text article.), after adjusting for age, sex, and body composition. Serum IGF-1 is positively correlated with grip strength before training.Serum myostatin level is positively correlated to aerobic capacity, and IGF-1 level is positively correlated to grip strength in cardiac patients receiving CR.