Exercise Training in Pulmonary Hypertension: AN UPDATED SYSTEMATIC REVIEW WITH META-ANALYSIS.

PURPOSE: Given that previous reviews on exercise training in pulmonary hypertension (PH) were largely based on a small number of randomized controlled trials (RCT), their conclusions are subject to bias. This review sought to identify the impact of exercise training on functional capacity and health-related quality of life (HRQoL) in PH using advanced statistical approaches such as meta-analysis by stratification according to study design. REVIEW METHODS: Five databases were searched from January 2015 to April 2020 to update a previous review. Included articles had data extracted, risk of bias (ROB) assessed, and quality rating performed. Data were analyzed using meta-analysis with a random-effects model for 6-min walk test (6MWT) distance and HRQoL. Heterogeneity was explored using stratified meta-analysis, within patient correlation and meta-regression. RESULTS: A total of 28 studies (11 RCT, 12 pre-/post-studies, 2 two-group non-RCT, and three case series) consisting of 1264 patients were included. Meta-analysis of six RCT demonstrated an improved 6MWT distance by 49.5 m (95% CI, 27.2-71.8: I2 = 73%; 254 participants; low-moderate ROB) with a low correlation coefficient of 0.34, while the 12 pre-/post-non-RCT showed an improvement of 68.69 m (95% CI, 50.50-86.69: I2 = 36%; 784 participants; high ROB) along with improvements in V˙ o2peak (weighted mean difference [WMD] = 3.03 mL/kg/min, 95% CI, 2.17-3.90: I2 = 0%, P = .82), and HRQoL (WMD = 2.74: 95% CI, -0.82 to 6.30). Metaregression showed that the benefit of exercise on 6MWT distance did not significantly vary across the trial study characteristics. CONCLUSION: This updated review identified an additional body of evidence supporting the efficacy of exercise training on 6MWT distance and HRQoL in stable PH patients. These benefits appeared to be consistent across models of delivery.

Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle-income setting: A randomized controlled trial protocol.

Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower-resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart-health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle-income country. Following a pilot study, a single-center, single-blinded, 2 parallel-arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre-intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6-month intervention comprises an app, website, SMS texts with generic heart-health management advice, and bi-weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent-to-treat. If results of this novel trial of women-focused eCR in a middle-income country demonstrate clinically-significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.

Review of Trials on Exercise-Based Rehabilitation Interventions Following Acute Decompensated Heart Failure: OBSERVATIONS FROM THE WHO INTERNATIONAL CLINICAL TRIALS REGISTRY PLATFORM.

PURPOSE: Cardiac rehabilitation is an important intervention for patients with heart failure. However, its clinical application in acute decompensated heart failure (ADHF) remains underutilized with limited research available. An assessment of current research in this area will help guide future investigations. The aim of this review is to summarize the current research focusing on rehabilitation interventions following recovery from ADHF. REVIEW METHODS: A systematic search was carried out on all trials registered in the clinical trial registry database of the World Health Organization-International Clinical Trial Registry Platform (WHO-ICTRP). Studies focusing on ADHF and utilizing any exercise and rehabilitation-based intervention were included. RESULTS: A majority of 11 trial protocols, including 3827 participants with low ejection fraction (<40%), were identified from the WHO-ICTRP database. Majority of the protocols (64%) focused on exercise-based interventions with approximately one-quarter (29%) focusing on neuromuscular electrical stimulation and one on noninvasive ventilation during exercise. Irrespective of the mode of exercise, all protocols employed low-moderate intensity training with outcomes focusing on physical function and quality of life. CONCLUSION: Studies on rehabilitative interventions for ADHF are still in their early stages. More research is needed using innovative methodologies and testing for feasibility and fidelity.

Feasibility of an exercise-based cardiac rehabilitation algorithm in patients following percutaneous coronary intervention for acute coronary syndrome.

Cardiac rehabilitation (CR) is underutilised across the world and India. The use of simple algorithms is one way to facilitate CR, however, these algorithms need to be feasible to use across low resource settings. The objectives were to assess the feasibility of a CR algorithm following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). A single group, pre-post study on 50 participants undergoing PCI for ACS found significant improvement in various feasibility metrics at discharge and 30-days, with no major adverse events. The proposed CR algorithm was safe and feasible for low and moderate risk patients with ACS undergoing PCI.

Effects of home-based exercise training on functional outcomes and quality of life in patients with pulmonary hypertension: A randomized clinical trial.

OBJECTIVES: The objective of this study was to assess the effects of home-based exercise training (HBET) on function and quality of life (QoL) in patients with pulmonary hypertension (PH). METHODS: A prospective, nonblinded, randomized clinical trial was carried out on 84 medically stable patients with PH belonging to any functional class or etiology and of either sex. Patients were randomized to either standard care or HBET. Both groups also received education using the Pulmonary Hypertension Manual (PulHMan). Outcomes included functional capacity from 6-min walk distance (6MWD), QoL using the Medical Outcomes Survey Short Form - 36, functional class (FC), and right heart indices (right ventricular systolic pressure [RVSP] and tricuspid annular plane systolic excursion [TAPSE]) and were assessed at entry and after 12 weeks. RESULTS: HBET improved 6MWD by 48.5 m and 13 m in the experimental and control groups, respectively (p < 0.001). QoL showed statistical improvements after HBET between the groups for the physical and mental components and for the various subdomains (except body pain). Furthermore, FC improved by one grade with HBET (p < 0.001). CONCLUSION: HBET program improved functional capacity, QoL, and FC in patients with PH.

A study of right ventricular function in pre- and post-valvular surgeries.

AIMS: The aim of this study is to compare tricuspid annular plane systolic excursion (TAPSE) in pre- and postoperative valvular heart surgery patients using M-mode imaging, to determine changes in tissue Doppler parameters among patients undergoing valvular heart surgery, and to analyze tissue deformation parameters of right ventricle (RV) and RV strain in pre- and postoperative patients. MATERIALS AND METHODS: This was an observational, cross-sectional, single-center study that included 24 patients who underwent echocardiographic assessment prior to surgery, after surgery, and at 1-month follow-up. Assessment of left and right ventricles by M-mode echocardiography, evaluation of RV by 2D Doppler echocardiography, tissue Doppler imaging, and strain imaging were performed. RESULTS: The TAPSE was significantly reduced immediately after surgery (14.8 ± 0.37 vs. 10.9 ± 0.26 mm), which was then improved on follow-up assessment (17.8 ± 34 mm) (p = 0.001). Tricuspid valve diastolic velocity was increased after surgery and then gradually declined at 1-month follow-up (p = 0.003). Presurgery RV free wall strain was found to be reduced, which was then improved during post-procedure analysis as well as on follow-up (p = 0.001). CONCLUSIONS: After cardiac valvular surgery, RV myocardial deformation showed a gradual improvement after 1 month, although there was an immediate decline in RV function postsurgery. The pattern of RV contraction, as showed by RV strain, varied postsurgery, which was remarkably increased in postoperative patients at the time of follow-up. Tissue deformation imaging being an emerging technique helps in the assessment of minute, subtle changes that occur in the RV myocardial function in cardiac patients undergoing valve surgery.

Changes in derived measures from six-minute walk distance following home-based exercise training in congestive heart failure: A preliminary report.

The response of derived parameters from six-minute walk distance (6MWD), like 6MW work (6MWW), to exercise training and its correlation with quality of life (QoL) in congestive heart failure (CHF) is not known. A secondary analysis from a randomized controlled trial on 30 patients (23 males; mean age 57.7±10.4 years; mean ejection fraction 31±10%) with CHF in NYHA class I-IV who completed an eight-week home-based exercise training program found a significant improvement in 6MWW (p<0.05), with similar correlations between 6MWD and 6MWW with QoL. 6MWW does not appear to provide additional benefit to 6MWD in cardiac rehabilitation for CHF.

Exercise intolerance in pulmonary hypertension: mechanism, evaluation and clinical implications.

INTRODUCTION: Exercise intolerance in pulmonary hypertension (PH) is a major factor affecting activities of daily living and quality of life. Evaluation strategies (i.e., non-invasive and invasive tests) are integral to providing a comprehensive assessment of clinical and functional status. Despite a growing body of literature on the clinical consequences of PH, there are limited studies discussing the contribution of various physiological systems to exercise intolerance in this patient population. AREAS COVERED: This review, through a search of various databases, describes the physiological basis for exercise intolerance across the various PH etiologies, highlights the various exercise evaluation methods and discusses the rationale for exercise training amongst those diagnosed with PH. Expert commentary: With the growing importance of evaluating exercise capacity in PH (class 1, Level C recommendation), understanding why exercise performance is altered in PH is crucial. Thus, the further study is required for better quality evidence in this area.

Effects of Exercise Training on Exercise Capacity in Pulmonary Arterial Hypertension: A Systematic Review of Clinical Trials.

BACKGROUND: Pulmonary arterial hypertension (PAH) causes profound functional limitations and poor quality of life. Yet, there is only a limited literature available on the role of exercise training. This paper systematically reviews the effects of exercise training on exercise capacity in PAH. METHODS: A systematic search of databases (PubMed, CINAHL, CENTRAL, Web of Science and PEDRo) was undertaken for English language articles published between 1(st) January 1980 and 31(st) March 2015. Quality rating for all articles was done using the Downs and Black scoring system. RESULTS: Fifteen articles of good (n=4), moderate (n=6) and poor (n=5) quality were included in the review. Exercise interventions included aerobic, resistance, inspiratory muscle training or a combination, for 6-18 weeks. Improvements were seen in exercise capacity (six minute walk distance (6MWD) and peak VO2) by 17-96m and 1.1-2.1ml/Kg/min, functional class by one class and quality of life, with minimal adverse events. CONCLUSIONS: There is evidence to recommend the use of exercise training as an adjunct to medical treatment in PAH. More clinical trials and research are required to assess the effects of different types of exercise programs in patients with PAH, while focussing on strong exercise endpoints to quantify the improvements seen with exercise training.

A review of ongoing trials in exercise based rehabilitation for pulmonary arterial hypertension.

Exercise based rehabilitation for patients with pulmonary arterial hypertension (PAH) is a new treatment option for these patients to improve their functional capacity and quality of life. Despite the benefits seen in cardiopulmonary rehabilitation in various other conditions, it has been underutilized for the patients with PAH. A review of currently registered ongoing trials on exercise training for patients with PAH from the World Health Organization International Clinical Trial Registry Platform was done using the key words "rehabilitation", "exercise training", "pulmonary artery hypertension" and "pulmonary hypertension" for a period of 10 years (2002-2012). The search revealed 57 registered trials in various trial registries from which seven met the inclusion criteria. The current studies are being carried out in Germany (n=4), Brazil (n=1), Australia (n=1) and India (n=1). This indicates a shift in focus from the only medical management to the rehabilitation and long term care for patients with PAH.

Evaluating exercise capacity in patients with pulmonary arterial hypertension.

Cardiopulmonary exercise testing (CPET), performed in a clinical laboratory setting, has long been used to evaluate persons with suspected or confirmed cardiopulmonary disease. This form of testing is now recognized as the gold standard for evaluating a person's aerobic exercise performance. In addition, simplified submaximal approaches to assessing functional capacity are readily available; perhaps the most recognized being the 6-min walk test. With the growing interest in CPET for evaluating patients with pulmonary artery hypertension (PAH), gaining a better understanding of the significance of the various outcomes used and how they are relevant to evaluating patients with PAH is a an important endeavor. This review highlights the utility of CPET; the various outcomes that can be derived from this assessment and the various functional tests commonly used as well as related tests that may have a role in clinical assessment of patients with PAH.

Predictors of warfarin-induced bleeding in a South Indian cardiology unit.

OBJECTIVES: Warfarin-induced bleedingresults in increased morbidity and mortality and higher cost of healthcare. The objective of the study is to identify the predictors of warfarin-induced bleeding in the Cardiology Unit of a teaching hospital. MATERIALS AND METHODS: A cross-sectional study was carried out for a period of six months in a tertiary care teaching hospital. A total of 235 patients were enrolled in the study, to identify the predictors of warfarin-induced bleeding. Only prescriptions with warfarin were selected for the study. The chi square test was used to find the association between demography and risk factors. RESULTS: Out of 235 patients, 61 (25.95%) had developed warfarin-induced bleeding and the majority were in the age group of 41 - 61 years (60.65%), and it was also found to be higher in women (62.29%). The length of stay was > 14 days (65.57%) and the number of drugs prescribed was in the range of 6 - 12 (52.45%). Aspirin (40.98%), Heparin (36.06%), Clopidogrel (22.95%), and Streptokinase (14.75%) were the most common drugs involved, and other comorbid conditions like diabetes (37.70%), hypertension (32.78%), smoking (57.37%), and alcohol (32.78%) were found to be major predictors of warfarin-induced bleeding in this study. The severity of warfarin-induced most of the bleeding reactions were moderate (44.26%) and the most common site of bleeding was gastrointestinal system (34.42%). CONCLUSION: Predictors of warfarin-induced bleeding were found to be female gender, length of stay, number of medications, drugs like aspirin, heparin, and clopidogrel, and other comorbidities like smoking, alcohol, and hypertension.

Potential drug interactions in patients admitted to cardiology wards of a south Indian teaching hospital.

BACKGROUND: The potential drug-drug interaction (pDDI) increases as the number of concomitant medications increases. Patients with cardiovascular disorders are at higher risk for drug- drug interactions because of the types and number of drugs they receive. While drug interactions are reported to be common, there is no published report of the prevalence of such interactions among Indian cardiac patients. The aim of the present study was to identify the pattern of pDDI and document any observed interaction. It was also planned to evaluate the demography of patients and correlate it with the drug-drug interactions. METHOD: A prospective observational study from Oct 2007 to Apr 2008 was carried out in 'cardiology department' of a hospital in South India. Those patients who were taking at least two drugs and had a hospital stay of at least 48 hours were included in the study. The medications of the patients were analyzed for possible interactions. Factors associated with pDDI were studied. The actual interactions that were observed during the hospital stay in the study subjects were documented. RESULTS: A total of 812 patients were included in the study. 388 pDDIs were identified among 249 patients. The incidence of pDDI was 30.67%. The most common potential interactions were between aspirin & heparin (29.38%), and clopidogrel & heparin (7.21%). Drug classes most commonly involved were antiplatelets, anticoagulants and diuretics. Majority of interactions were of moderate severity, delayed onset, and pharmacodynamic in nature. Total 68 actual interactions were observed in the observed cases. CONCLUSION: The present study identified pDDIs and also documented interactions in cardiovascular patients. Factors which had correlation with adverse drug interactions were identified. This study highlights the need for screening prescriptions of cardiovascular patients for pDDIs and proactive monitoring of patients who have identified risk factors; this helps in detection and prevention of possible adverse drug interactions.

Effects of Combined Early In-Patient Cardiac Rehabilitation and Structured Home-based Program on Function among Patients with Congestive Heart Failure: A Randomized Controlled Trial.

AIMS: To determine the effects of combined in-patient rehabilitation with a home-based program on function and quality of life. SETTING AND DESIGN: Tertiary care, university teaching hospital, randomized controlled trial. PATIENTS AND METHODS: Thirty admitted patients with congestive heart failure with New York Heart Association class II -IV. A five step individualised phase-1 cardiac rehabilitation program followed by a structured home based rehabilitation for eight weeks was given to the experimental group while the control group only received physician directed advice. Six minute walk distance was assessed at discharge and follow-up, while quality of life (SF36) was assessed at admission, discharge, and follow-up. STATISTICAL ANALYSIS USED: Independent t-test, paired t-test and repeated measures ANOVA with Bonferroni post-hoc analysis. RESULTS: At admission patients in both the groups were comparable. After the phase-1 cardiac rehabilitation, there was a change in the six minute walk distance between control and experimental group (310 m vs. 357 m, respectively; P = 0.001). Following the eight week home-based program, there was a greater increase in six minute walk distance in the experimental group when compared to the control group (514 m vs. 429 m; P < 0.001). Quality of life as measured by the SF-36 at the end of 8-weeks showed a statistically significant difference (P < 0.05) in the experimental group for both the mental and physical components. CONCLUSION: Early in-patient rehabilitation followed by an eight week home based exercise program improves function and quality of life in patients with congestive heart failure.

Holt-oram syndrome with hemizygous continuation of inferior vena cava.

A rare and previously unreported combination of Holt-Oram syndrome, atrial septal defect, patent ductus arteriosus, isolated left atrial isomerism and inferior vena caval interruption with hemizygous continuation to the left superior vena cava is described.

Usefulness of transthoracic echocardiography for identification of left atrial thrombus before balloon mitral valvuloplasty.

The objectives of this study were (1) to identify clinical and transthoracic echocardiographic features of patients with mitral stenosis who have thrombus recognized on transesophageal echocardiography, and (2) to define a clinical and echocardiographic model to predict the presence of left atrial thrombus in these patients.