Sedentary Time and Cumulative Risk of Preserved and Reduced Ejection Fraction Heart Failure: From the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: This study examined the relationship between self-reported sedentary time (ST) and the cumulative risk of heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) in a diverse cohort of U.S. adults 45-84 years of age. METHODS AND RESULTS: Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we identified 6,814 subjects, all free of baseline cardiovascular disease. Cox regression was used to calculate the hazard ratios (HR) associated with risk of HFpEF and HFrEF. Weekly ST was dichotomized based on the 75th percentile (1890 min/wk). During ∼11.2 years of follow-up there were 178 first incident HF diagnoses: 74 HFpEF and 69 HFrEF. Baseline ST >1890 min/wk was significantly associated with an increased risk of HFpEF (HR 1.87, 95% confidence interval [CI] 1.13-3.09, P = .01), but not of HFrEF. The relationship with HFpEF remained significant in fully adjusted models including physical activity and waist circumference (HR 2.16, 95% CI 1.23-3.78, P < .01). In addition, every 60-minute increase in weekly ST was associated with a 3% increased risk of HFpEF (HR 1.03, 95% CI 1.01-1.05, P < .01). CONCLUSIONS: Sedentary time >1890 min/wk (∼4.5 h/d) is a significant predictor of HFpEF, independently from physical activity and adiposity.

Healthy Living Medicine in the Workplace: More Work to Do.

Non-communicable diseases (NCDs) are five of the top ten causes of death for Americans: cardiovascular disease (CVD), cancer, lower respiratory disease, stroke and diabetes mellitus. Risk factors for these NCDs and for CVD are tobacco use, poor diet quality, physical inactivity, increase body mass index, increased blood pressure, increased blood cholesterol, and glucose intolerance. Depression, depressive symptoms and anxiety also contribute to CVD risk. There is also evidence work stress itself contributes to CVD risk. By 2024 there is expected to be approximately 164 million workers in the US labor force and the share of older workers will likewise increase. Currently, about 25 million of those are over the age of 55, the age at which many diseases of lifestyle become clinically apparent. Furthermore, Americans spend as much as half of their waking hours at work. This makes the worksite an important target for the delivery of healthy living medicine.

Cardiopulmonary exercise testing in patients with pulmonary hypertension: clinical recommendations based on a review of the evidence.

Pulmonary hypertension (PH) remains an ominous diagnosis despite advances in pharmacological and surgical therapy. Early and effective diagnosis is important for clinicians making treatment determinations and patients wishing to understand the prognostic implications of their illness. Cardiopulmonary exercise testing (CPX) has the power to reveal the underlying pathophysiological consequences of the disease process. Research, especially over the last 10-15 years, has demonstrated the utility of this tool. Several CPX variables have been shown to be consistently altered in patients with PH and more so as severity of disease increases. However, to further enhance clinical application, additional research is needed to better define optimal CPX measures and associated cutoff values. This paper gives class-based recommendations with associated levels of evidence for the use of CPX in the PH patient population.

Development and Implementation of Worksite Health and Wellness Programs: A Focus on Non-Communicable Disease.

The development and implementation of worksite health and wellness programs (WHWPs) in the United States (US) hold promise as a means to improve population health and reverse current trends in non-communicable disease incidence and prevalence. However, WHWPs face organizational, economic, systematic, legal, and logistical challenges which have combined to impact program availability and expansion. Even so, there is a burgeoning body of evidence indicating WHWPs can significantly improve the health profile of participating employees in a cost effective manner. This foundation of scientific knowledge justifies further research inquiry to elucidate optimal WHWP models. It is clear that the development, implementation and operation of WHWPs require a strong commitment from organizational leadership, a pervasive culture of health and availability of necessary resources and infrastructure. Since organizations vary significantly, there is a need to have flexibility in creating a customized, effective health and wellness program. Furthermore, several key legal issues must be addressed to facilitate employer and employee needs and responsibilities; the US Affordable Care Act will play a major role moving forward. The purposes of this review are to: 1) examine currently available health and wellness program models and considerations for the future; 2) highlight key legal issues associated with WHWP development and implementation; and 3) identify challenges and solutions for the development and implementation of as well as adherence to WHWPs.

Much potential but many unanswered questions for high-intensity intermittent exercise training for patients with heart failure.

There is a robust trove of scientific studies that support the positive physical and mental health benefits associated with aerobic exercise for healthy individuals. These recommendations suggest that more vigorous exercise can be performed on fewer days for the same benefit. High-intensity intermittent exercise (HIIE) training has begun to show promise. HIIE seems safe and improves physiology, quality of life, and functional capacity. This review defines HIIE, discusses its physiologic benefit for patients with heart failure, outlines the studies that have been conducted to date, and places it in the context of the current clinical environment of exercise training for these patients.

The Affordable Care Act: new opportunities for cardiac rehabilitation in the workplace?

Many people affected by cardiovascular disease (CVD) are working age. Employers bear a large percentage of the costs associated with CVD. Employers pay 80 times more in diagnosis and treatment than in prevention, although there is evidence that 50% to 70% of all diseases are associated with preventable health risks. As a result, the worksite is an appealing location to deliver health care.Cardiac rehabilitation has developed a track record of delivering improved outcomes for patients with CVD. Partnerships between cardiac rehabilitation providers and worksite health programs have the potential to improve referral and participation rates of employees with CVD. The current era of health reform in the United States that has been stimulated by the Affordable Care Act provides an ideal opportunity to reconsider worksite health programs as an essential partner in the health care team.

Current trends in reducing cardiovascular risk factors in the United States: focus on worksite health and wellness.

Health care in the United States (US) is changing with a broad provision of health care services to every American due to the Affordable Care Act (ACA) slated to begin in January of 2014. An important aspect of the ACA is that US companies may begin to offer health insurance incentives to employees for participating in health and wellness initiatives. Moreover, since US employers directly absorb many of the financial costs associated with the high degree of cardiovascular (CV) risk factors present in their personnel, employers may be financially vested in improving employee health. However, employers must also consider the costs of developing and maintaining programs to improve employee health and their return on investment (ROI). This review will identify key risk factors to address in a worksite health and wellness program and to examine the performance of such programs in improving CV risk factors and their ROI.

A meta-analysis of the prognostic significance of cardiopulmonary exercise testing in patients with heart failure.

The objective of the study is to assess the role of cardiopulmonary exercise testing (CPX) variables, including peak oxygen consumption (VO(2)), which is the most recognized CPX variable, the minute ventilation/carbon dioxide production (VE/VCO(2)) slope, the oxygen uptake efficiency slope (OUES), and exercise oscillatory ventilation (EOV) in a current meta-analysis investigating the prognostic value of a broader list of CPX-derived variables for major adverse cardiovascular events in patients with HF. A search for relevant CPX articles was performed using standard meta-analysis methods. Of the initial 890 articles found, 30 met our inclusion criteria and were included in the final analysis. The total subject populations included were as follows: peak VO(2) (7,319), VE/VCO(2) slope (5,044), EOV (1,617), and OUES (584). Peak VO(2), the VE/VCO(2) slope and EOV were all highly significant prognostic markers (diagnostic odds ratios ≥ 4.10). The OUES also demonstrated promise as a prognostic marker (diagnostic odds ratio = 8.08) but only in a limited number of studies (n = 2). No other independent variables (including age, ejection fraction, and beta-blockade) had a significant effect on the meta-analysis results for peak VO(2) and the VE/VCO(2) slope. CPX is an important component in the prognostic assessment of patients with HF. The results of this meta-analysis strongly confirm this and support a multivariate approach to the application of CPX in this patient population.

The influence of referral source on characteristics of patients undergoing cardiac stress testing: emergency department versus outpatient office.

OBJECTIVES: Chest pain is a common reason for accessing an emergency department (ED) and a frequent cause of outpatient physician visits. Whether patients referred for cardiac stress testing from these referral sources differ in clinically significant ways is unknown, and is thus the purpose of this investigation. METHODS: This study prospectively assessed 301 patients presenting to Virginia Commonwealth University Medical Center with symptoms suggestive of myocardial ischemia. All subjects underwent nuclear stress testing as a part of their assessment. RESULTS: Patients referred from the ED were more likely to be African American and outpatients were more likely to be Caucasian. Outpatients were older than those referred from the ED. Patients referred from the ED were less likely to have a diagnosis of hypertension, dyslipidemia, or diabetes, but were more likely to smoke. The exercise response was similar, with a few exceptions. There were no differences in the frequency of equivocal or positive nuclear stress test results based on referral source. CONCLUSIONS: The results of the present study indicate that several characteristics of patients undergoing outpatient nuclear stress testing differ according to referral source. Future research should be directed toward developing effective strategies to reduce ED utilization and increasing outpatient management.

Overestimation of aerobic capacity with the bruce treadmill protocol in patients being assessed for suspected myocardial ischemia.

INTRODUCTION: Peak oxygen uptake (VO2) is prognostic for morbidity and mortality. Estimating aerobic capacity during traditional exercise stress testing is common as it has been shown that total treadmill time on the Bruce protocol predicts peak VO2. However, the potential to overestimate peak VO2 exists and may have clinical implications regarding the interpretation of exercise test data. METHODS: Subjects (N = 303) with symptoms suggestive of myocardial ischemia underwent a myocardial perfusion study and an exercise test with simultaneous ventilatory expired gas analysis. Estimated peak VO2 from the Bruce treadmill protocol was compared with measured peak VO2. The Duke Treadmill Score (DTS) was calculated with treadmill time (DTS(time)) and also with measured VO2 (DTS(measured)),expressed as metabolic equivalents (METs), and converted to time. RESULTS: Peak measured METs was significantly lower than peak estimated METs in the entire cohort (6.5 ± 1.9 vs 8.8 ± 2.8, P < .001) as well as in female (5.7 ± 1.4 and 7.8 ± 2.1, P < .001) and male (7.3 ± 2.0 and 9.7 ± 3.1, P < .001) subgroups. Calculation of the DTS with measured METs resulted in a significantly lower score compared with its calculation with treadmill time (2.7 ± 3.5 vs 5.8 ± 4.6, P < .001). Receiver operating characteristic curve analysis revealed that DTS(measured) produce a statistically significant model for diagnosing a perfusion defect in both men and women (P < .05), whereas DTS(time) was diagnostic only in men (P < .05). DISCUSSION: This study demonstrates that estimates of aerobic capacity are significantly higher than measured values and this difference may result in a significant underestimation of morbidity/mortality risk.

Cardiopulmonary exercise testing is equally prognostic in young, middle-aged and older individuals diagnosed with heart failure.

BACKGROUND: Previous research has demonstrated the prognostic value of cardiopulmonary exercise testing (CPX) in elderly patients with heart failure (HF). Investigations that have comprehensively examined the value of CPX across different age groups are lacking. The purpose of the present investigation was to evaluate the prognostic value of CPX in young, middle-aged and older patients with HF. METHODS: A total of 1605 subjects (age: 59.2 ± 13.7 years, 78% male) underwent CPX and were subsequently tracked for major cardiac events. Ventilatory efficiency (VE/VCO(2) slope) and peak oxygen consumption (VO(2)), both absolute and percent-predicted, were determined. The prognostic value of these CPX variables was assessed in ≤ 45, 46-65 and ≥ 66 year subgroups. RESULTS: The three year event rates for major cardiac events in the ≤ 45, 46-65 and ≥ 66 year subgroups were 8.8%, 6.0% and 5.7%, respectively. The VE/VCO(2) slope (Hazard ratio ≥ 1.07, p<0.001), peak VO(2) (Hazard ratio ≤ 0.87, p<0.001) and percent-predicted peak VO(2) (Hazard ratio 0 ≤ 0.98, p<0.001) were all significant prognostic markers in each age subgroup. While the VE/VCO(2) slope carried the greatest prognostic strength, peak VO(2) and percent-predicted peak VO(2) were retained in multivariate analyses (Residual Chi-Square ≥ 5.2, p<0.05). With respect to peak VO(2), the actual value was the more robust prognostic marker in the ≤ 45 and ≥ 66 year subgroups while the percent-predicted expression provided better predictive resolution in subjects who were 46-65 years old. CONCLUSIONS: These results indicate that, irrespective of a patient's age at presentation, CPX provides valuable prognostic information in the HF population.

Quantifying exertion level during exercise stress testing using percentage of age-predicted maximal heart rate, rate pressure product, and perceived exertion.

OBJECTIVE: To determine if the attainment of at least 85% of age-predicted maximal heart rate (APMHR), using the equation 220 - age, and/or at least 25,000 as the product of maximal heart rate and systolic blood pressure (rate pressure product, RPP) is an accurate indicator of exertion level during exercise stress testing. PATIENTS AND METHODS: From May 1, 2009, to February 15, 2010, 238 patients (mean ± SD age, 49.3±11.9 years; 50% male) with symptoms suggestive of myocardial ischemia underwent an exercise stress test with the addition of ventilatory expired gas analysis and a myocardial perfusion study. Ventilatory expired gas analysis determined the peak respiratory exchange ratio (RER), which is considered a valid and reliable variable for quantifying a patient's exertion during exercise. RESULTS: Of the patients, 207 (87%) attained a peak RER of 1.00 or more, and 123 (52%) attained a peak RER of 1.10 or more. An APMHR of 85% or more and peak RPP of 25,000 or more were both ineffective in identifying patients who put forth a maximal exercise effort (ie, peak RER, ≥1.10). Perceived exertion was a significant indicator (P=.04) of patient exertion, with a threshold of 15 (6-20 scale) being an optimal cut point. The percentage of equivocal myocardial perfusion study results was significantly higher in patients who demonstrated a submaximal exercise effort by peak RER (P≤.007). CONCLUSION: Aerobic exercise testing is an integral component in the assessment of patients with suspected myocardial ischemia. Our findings indicate that the currently used percentage of APMHR and peak RPP thresholds are ineffective in quantifying a patient's level of exertion during exercise stress testing.

Cardiopulmonary exercise testing characteristics in heart failure patients with and without concomitant chronic obstructive pulmonary disease.

BACKGROUND: The assessment of aerobic exercise capacity is an important component in the clinical management of patients with heart failure (HF). Although a significant percentage of patients diagnosed with HF also present with chronic obstructive pulmonary disease (COPD) comorbidity, the combined impact of these chronic conditions on the aerobic exercise response is unknown and is therefore the purpose of the present investigation. METHODS: Sixty-nine subjects with HF and COPD were matched to 69 subjects solely diagnosed with HF according to age, sex, and HF etiology. All subjects underwent resting pulmonary function and diffusion capacity testing, echocardiography with tissue Doppler imaging, and cardiopulmonary exercise testing (CPX). RESULTS: Subjects with COPD comorbidity had significantly lower pulmonary function testing and diffusion capacity values versus HF alone (P < .05). In addition, subjects with both HF and COPD had significantly higher pulmonary artery systolic pressures (51.9 ± 9.0 vs 37.0 ± 7.8 mm Hg, P < .001) as assessed by pulsed Doppler echocardiography. Cardiopulmonary exercise testing revealed a significantly poorer response in subjects with HF and COPD by all variables that were analyzed, including peak oxygen consumption (12.1 ± 4.3 vs 16.3 ± 4.3 mL kg⁻¹ min⁻¹, P < .001), minute ventilation/carbon dioxide production slope (42.7 ± 7.4 vs 33.3 ± 6.6, P < .001) and heart rate recovery at 1 minute (12.1 ± 2.5 vs 14.2 ± 2.9 beats, P < .001). CONCLUSIONS: Patients with HF and the comorbidity of COPD have significantly impaired CPX responses. This novel finding may impact the clinical interpretation of CPX data in patients with HF who also present with this chronic pulmonary condition.

Usefulness of decrease in oxygen uptake efficiency slope to identify myocardial perfusion defects in men undergoing myocardial ischemic evaluation.

Cardiopulmonary exercise testing (CPX) might aid in the diagnosis of coronary artery disease. However, a heterogeneous clinical population without previous workup bias has not been studied nor has a more extensive list of CPX variables. A total of 303 subjects (age 49.9 ± 11.6 years, 157 men) with symptoms suggestive of coronary artery disease underwent CPX and a single photon emission computed tomographic myocardial perfusion study (MPS). Ventilatory efficiency was calculated using the oxygen uptake efficiency slope (OUES). The change in the OUES was calculated by subtracting the OUES response during the first 50% of CPX from the OUES obtained during the last 25% of CPX. A negative change in the OUES (< 0) from the first 50% to the last 25% of CPX was predictive of positive MPS findings only in the male subjects. The diagnostic significance of the change in OUES in men was found for any level (including equivocal studies) of positive MPS findings (area under the curve 0.67, 95% confidence interval 0.59 to 0.76, p < 0.0001) and was even stronger in those with a more definitive (excluding equivocal studies) perfusion defect (area under the curve 0.76, 95% confidence interval 0.67 to 0.85; relative risk 5.4, 95% confidence interval 2.1 to 13.8, p < 0.0001). In conclusion, this is the first time that a change in ventilatory efficiency, assessed using the OUES, has been shown to be predictive of positive MPS findings However, the OUES change only provided diagnostic information for men, a finding that warrants additional analysis.

Defining the optimal prognostic window for cardiopulmonary exercise testing in patients with heart failure.

BACKGROUND: Ventilatory efficiency (VE/VCO(2) slope) and peak oxygen consumption (VO) provide robust prognostic information in patients with heart failure undergoing cardiopulmonary exercise testing (CPX). The purpose of this study is to assess the change in prognostic characteristics of CPX at different time intervals. METHODS AND RESULTS: Seven hundred ninety-one subjects (74% male, mean age: 60.7+/-12.9 years, ejection fraction: 34.6+/-15.0%, ischemic etiology: 51%) underwent CPX and were tracked for major cardiac events over a 4-year period. All event-free subjects were tracked for at least 3 years. Mean VE/VCO(2) slope and peak VO(2) were 35.0+/-10.0 and 16.0+/-6.4 mL O(2) . kg(-1) . min(-1), respectively. There were a total of 263 major cardiac events (199 deaths, 45 transplants, and 19 left ventricular assist device implantations). Both continuous and dichotomous expressions of the VE/VCO(2) slope and peak VO(2) were prognostically significant up to 18 months post-CPX. Continuous and dichotomous expressions of the VE/VCO(2) slope remained prognostically significant up to 36 months post-CPX, whereas peak VO(2) was not predictive during the third and fourth year of follow-up. In a multivariate analysis, the VE/VCO(2) slope was consistently the superior prognostic marker, whereas peak VO(2) added predictive value and was retained in the regression up to 18 months post-CPX. CONCLUSIONS: These results indicate that commonly assessed CPX variables retain prognostic value for at least 2 years. The VE/VCO(2) slope is the superior predictor of adverse events throughout follow-up, although peak VO(2) provides additive prognostic information during the first 2 years of follow-up.

Heart rate recovery and tissue Doppler echocardiography in heart failure.

BACKGROUND: Previous research has demonstrated the prognostic value of echocardiography with tissue Doppler imaging (TDI) in the heart failure (HF) population. Heart rate recovery (HRR) has also recently shown promise as a prognostic marker. HYPOTHESIS: We hypothesize echocardiography with TDI and HRR will be significantly correlated and both will provide prognostic information. METHODS: A total of 243 subjects underwent echocardiography with TDI and maximal exercise testing to determine: (1) the ratio between mitral early (E) to mitral annular (E') and E to mitral late (A) velocity; (2) left ventricular ejection fraction (LVEF); (3) left ventricular (LV) mass; (4) LV end-systolic volume (LVESV); and (5) HRR at 1 minute postexercise (HRR(1)). RESULTS: HRR(1) was significantly correlated with LVEF (r = 0.14, P = .03), LV mass (r = - 0.30, P <.001), E/A (r = - 0.22, P = .001), and E/E' (r = - 0.49, P <.001). Multivariate Cox regression analysis revealed HRR(1) was the strongest predictor of cardiac mortality (chi(2): 55.5, P <.001); LV mass (residual chi(2): 13.1, P <.001), E/E' (residual chi(2): 11.2, P = .001), and LVESV (residual chi(2): 5.9, P = .015) all added significant prognostic value and were retained in the regression while LVEF was removed (residual chi(2): 0.008, P = .93). CONCLUSIONS: To our knowledge, this is the first investigation demonstrating an association between HRR and variables obtained from echocardiography with TDI in subjects with HF. The combination of both assessment techniques provides improved prognostic discrimination.

Prognostic characteristics of heart rate recovery according to sex in patients with heart failure.

We hypothesized that heart rate recovery (HRR) will provide superior prognostic resolution in female compared to male heart failure (HF) patients. A total of 745 patients with HF underwent exercise testing to determine HRR. While receiver operating characteristic curve analysis revealed HRR prognostic classification schemes were significant for both males (area: 0.72, 95% CI: 0.67-0.78, p<0.001) and females (area: 0.82, 95% CI: 0.75-0.89, p<0.001), it was stronger in the latter group. The prognostic strength of HRR may be superior in female HF patients. This discrepancy may be driven by the ability of HRR to better reflect autonomic function in females.

Neuromuscular electrical stimulation and inspiratory muscle training as potential adjunctive rehabilitation options for patients with heart failure.

Aerobic and resistance exercise training programs produce an abundance of physiologic and clinical benefits in patients with heart failure (HF). Improved maximal aerobic capacity, submaximal aerobic endurance, muscle force production, perceived quality of life, and skeletal muscle characteristics are among the more established outcomes resulting from these rehabilitation techniques. Moreover, both aerobic and resistance exercise training appear to portend a low risk to patients with HF when appropriate exercise prescription methods are followed. While the aforementioned training techniques will undoubtedly continue to be at the center of a well-formulated rehabilitation program, other adjunctive interventions, which are presently underutilized in clinical practice, may prove beneficial in patients with HF. Specifically, both neuromuscular electrical stimulation (NMES) and inspiratory muscle training (IMT) appear to significantly improve several physiologic, exercise, symptomatologic, and quality-of-life parameters. NMES targets skeletal muscle abnormalities, whereas IMT primarily targets the weakened respiratory musculature, both often encountered in patients with HF. A PubMed search using relevant key words identified 19 original investigations examining the impact of NMES (13 studies) and IMT (6 studies) training programs in patients with HF. The resultant review (1) provides a summary of the original research outcomes of both NMES and IMT in patients with HF; (2) addresses current research gaps, providing a direction for future investigations; and (3) provides clinical scenarios where NMES and IMT may prove to be beneficial during the rehabilitation of patients with HF.