Reduction in Arterial Stiffness Index (SI) in Response to Combination Antioxidant Therapy.

Antioxidants reduce arterial stiffness, but the effects previously reported are weak. A systematic review of the antioxidants vitamin E, vitamin C, vitamin A, and beta-carotenes (the most commonly studied antioxidants) on pulse wave velocity (PWV) found an effect size of only -0.20 (approximately -16 m/s or -2.5%). Studies in rats of the potent pro-oxidant substance acetaldehyde have shown that combinations of sulfur-containing antioxidants, including thiamine and l-cysteine, with ascorbic acid potently protect against oxidative-stress-mediated mortality. The effects of these combinations of oxidants on PWV have not been studied. The present study evaluated the effects of 2 weeks of therapy with a combination of sulfur-containing antioxidants (cysteine, thiamine, and pyridoxine) in combination with ascorbic acid on stiffness index (SI), a measure of arterial stiffness that is strongly correlated with PWV, using a Pulse Trace recorder in a diverse group of 78 volunteers. SI fell by -1.7 m/s relative to placebo (95% confidence intervals -0.6 to -2.7 m/s), a reduction of -19% (95% confidence intervals -9% to -31%). The Glass effect size was 1.4, indicating a very strong treatment effect which was substantially greater than the effect size found in previous studies of antioxidants. PWV reduction was correlated significantly with increasing age. Further studies of similar antioxidant combinations are required to determine whether they are of value in the treatment or prevention of cardiovascular disease.

Effect of personal activity intelligence (PAI) monitoring in the maintenance phase of cardiac rehabilitation: a mixed methods evaluation.

BACKGROUND: Personal activity intelligence (PAI) is a single physical activity metric based upon heart rate responses to physical activity. Maintaining 100 PAI/week is associated with a 25% risk reduction in cardiovascular disease mortality and 50 PAI/week provides 60% of the benefits. The effect of utilising this metric within a cardiac population has not been previously investigated. The aim of this study was to determine the effect of PAI monitoring on the amount and/or intensity of physical activity for people in the maintenance phase of cardiac rehabilitation and to explore participants' perceptions of this approach. METHODS: A concurrent mixed methods approach was undertaken. Participants in the maintenance phase of cardiac rehabilitation monitored PAI for six weeks via a wearable physical activity monitoring device (WPAM). In the first three weeks participants were blinded to their PAI score. A quality-of-life questionnaire (EQ-5D-5L) was completed, and semi-structured interviews conducted to investigate attitudes to PAI monitoring. Daily PAI data was collected throughout the 6-week period. RESULTS: Twenty participants completed the trial. PAI earned/day was increased after participants could view their data (mean difference: 2.1 PAI/day (95% CI 0.3, 4.0), p = 0.027). The median change in percentage of days participants achieved a Total PAI score of 25 (p = 0.023) and 50 (p = 0.015) were also increased. The mean change in total scores for the EQ-5D-5L and EQVAS were improved after 6 weeks (0.6 ± 1.05; 95% CI (0.11-1.09); p = 0.019); (5.8/100; 95% CI (2.4-9.2); p = 0.002 respectively). Thematic framework analysis identified three global themes (perceptions on the WPAM, PAI and factors affecting exercise). Most participants stated motivation to exercise increased after they could view their PAI data. Many of the participants believed they would continue to use PAI long-term. Others were undecided; the latter primarily due to technical issues and/or preferring devices with greater functionality and attractiveness. All participants would recommend PAI. CONCLUSION: This exploratory study showed monitoring PAI via a WPAM increased the amount and/or intensity of physical activity within the cardiac population. Participants found PAI interesting, beneficial, and motivating. If technical issues, aesthetics, and functionality of the WPAM were improved, participants may continue to use the approach long-term. PAI may be a viable strategy to assist people with cardiac disease maintain physical activity adherence.

Immune checkpoint inhibitor-induced takotsubo syndrome and diabetic ketoacidosis: rare reactions.

Immune checkpoint inhibitors (ICIs) are increasingly used to treat certain malignancies due to their higher efficacy compared with conventional chemotherapy. As familiarity with these agents increases, it is becoming apparent that a significant number of patients treated with ICIs experience adverse events. With time, more immune-related adverse events (IRAEs) are being recognised. It is important to be vigilant for IRAEs and recognise that a patient may have multiple IRAEs affecting multiple organ systems. Common cardiovascular adverse events associated with ICIs include myocarditis, arrhythmias and pericarditis. This case report identifies a patient presenting with takotsubo syndrome followed by ketoacidosis (associated with sodium-glucose transport protein 2 (SGLT2) inhibitor) in the setting of combination ipilimumab and nivolumab therapy for metastatic melanoma.

Folic acid supplementation improves vascular endothelial function, yet not skin blood flow during exercise in the heat, in patients with heart failure.

Heart failure (HF) patients are susceptible to heat strain during exercise, secondary to blunted skin blood flow (SkBF) responses, which may be explained by impaired nitric oxide (NO)-dependent vasodilation. Folic acid improves vascular endothelial function and SkBF through NO-dependent mechanisms in healthy older individuals and patients with cardiovascular disease. We examined the effect of folic acid supplementation (5 mg/day for 6 wk) on vascular function [brachial artery flow-mediated dilation (FMD)] and SkBF responses [cutaneous vascular conductance (CVC)] during 60 min of exercise at a fixed metabolic heat production (300 WHprod) in a 30°C environment in 10 patients with HF (New York Heart Association Class I-II) and 10 healthy controls (CON). Serum folic acid concentration increased in HF [preintervention (pre): 1.4 ± 0.2; postintervention (post): 8.9 ± 6.7 ng/ml, P = 0.01] and CON (pre: 1.3 ± 0.6; post: 5.2 ± 4.9 ng/ml, P = 0.03). FMD improved by 2.1 ± 1.3% in HF ( P < 0.01), but no change was observed in CON postintervention ( P = 0.20). During exercise, the external workload performed on the cycle ergometer to attain the fixed level of heat production for exercise was similar between groups (HF: 60 ± 13; CON: 65 ± 20 external workload, P = 0.52). Increases in CVC during exercise were similar in HF (pre: 0.89 ± 0.43; post: 0.83 ± 0.45 au/mmHg, P = 0.80) and CON (pre: 2.01 ± 0.79; post: 2.03 ± 0.72 au/mmHg, P = 0.73), although the values were consistently lower in HF for both pre- and postintervention measurement intervals ( P < 0.05). These findings demonstrate that folic acid improves vascular endothelial function in patients with HF but does not enhance SkBF during exercise at a fixed metabolic heat production in a warm environment.

Australian cardiac rehabilitation exercise parameter characteristics and perceptions of high-intensity interval training: a cross-sectional survey.

PURPOSE: This study explored current demographics, characteristics, costs, evaluation methods, and outcome measures used in Australian cardiac rehabilitation (CR) programs. It also determined the actual usage and perceptions of high-intensity interval training (HIIT). METHODS: A cross-sectional observational web-based survey was distributed to 328 Australian CR programs nationally. RESULTS: A total of 261 programs completed the survey (79.6% response rate). Most Australian CR programs were located in a hospital setting (76%), offered exercise sessions once a week (52%) for 6-8 weeks (49%) at moderate intensity (54%) for 46-60 min (62%), and serviced 101-500 clients per annum (38%). HIIT was reported in only 1% of programs, and 27% of respondents believed that it was safe while 42% of respondents were unsure. Lack of staff (25%), monitoring resources (20%), and staff knowledge (18%) were the most commonly reported barriers to the implementation of HIIT. Overall, Australian CR coordinators are unsure of the cost of exercise sessions. CONCLUSION: There is variability in CR delivery across Australia. Only half of programs reassess outcome measures postintervention, and cost of exercise sessions is unknown. Although HIIT is recommended in international CR guidelines, it is essentially not being used in Australia and clinicians are unsure as to the safety of HIIT. Lack of resources and staff knowledge were perceived as the biggest barriers to HIIT implementation, and there are inconsistent perceptions of prescreening and monitoring requirements. This study highlights the need to educate health professionals about the benefits and safety of HIIT to improve its usage and patient outcomes.

High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: a systematic review and meta-analysis.

BACKGROUND: Aerobic capacity has been shown to be inversely proportionate to cardiovascular mortality and morbidity and there is growing evidence that high-intensity interval training (HIIT) appears to be more effective than moderate-intensity continuous training (MICT) in improving cardiorespiratory fitness within the cardiac population. Previously published systematic reviews in cardiovascular disease have neither investigated the effect that the number of weeks of intervention has on cardiorespiratory fitness changes, nor have adverse events been collated. OBJECTIVE: We aimed to undertake a systematic review and meta-analysis of randomized controlled trials (RCTs) within the cardiac population that investigated cardiorespiratory fitness changes resulting from HIIT versus MICT and to collate adverse events. METHODS: A critical narrative synthesis and meta-analysis was conducted after systematically searching relevant databases up to July 2017. We searched for RCTs that compared cardiorespiratory fitness changes resulting from HIIT versus MICT interventions within the cardiac population. RESULTS: Seventeen studies, involving 953 participants (465 for HIIT and 488 for MICT) were included in the analysis. HIIT was significantly superior to MICT in improving cardiorespiratory fitness overall (SMD 0.34 mL/kg/min; 95% confidence interval [CI; 0.2-0.48]; p<0.00001; I2=28%). There were no deaths or cardiac events requiring hospitalization reported in any study during training. Overall, there were more adverse events reported as a result of the MICT (n=14) intervention than the HIIT intervention (n=9). However, some adverse events (n=5) were not classified by intervention group. CONCLUSION: HIIT is superior to MICT in improving cardiorespiratory fitness in participants of cardiac rehabilitation (CR). Improvements in cardiorespiratory fitness are significant for CR programs of >6-week duration. Programs of 7-12 weeks' duration resulted in the largest improvements in cardiorespiratory fitness for patients with coronary artery disease. HIIT appears to be as safe as MICT for CR participants.

Transcatheter Aortic Valve Implantation in Intermediate Surgical Risk Patients With Severe Aortic Stenosis: A Systematic Review and Meta-Analysis.

BACKGROUND: Recent data from randomised and observational studies have reported non-inferior outcomes for transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement (SAVR) in intermediate-risk patients. We performed a systematic review to evaluate the mortality of TAVI compared to SAVR in intermediate-risk patients. METHODS: A comprehensive search of four major databases (Embase, Ovid MEDLINE, PubMed, and Google Scholar) was performed from their inception to 29 April 2016. We included original research studies reporting data on TAVI and SAVR in intermediate-risk patients. We compared the outcomes of TAVI to SAVR. RESULTS: A total of 2,375 and 2,377 intermediate-risk patients underwent TAVI and SAVR respectively. The 30-day all-cause (p=0.07), 30-day cardiac (p=0.53), and 12-month all-cause mortality (p=0.34) was similar between the two groups. However, TAVI through transfemoral access had a significantly lower mortality than SAVR (OR 0.58, p=0.006). The incidence of ≥moderate aortic incompetence (p<0.00001) and pacemaker implantation (p<0.0001) was higher in the TAVI group. CONCLUSIONS: In the intermediate-risk patients, the 30-day and 12-month mortality are similar between TAVI and SAVR. Increased operator experience and improved device technology have led to a significant reduction in mortality in intermediate-risk patients undergoing TAVI.

Thermoeffector Responses at a Fixed Rate of Heat Production in Heart Failure Patients.

PURPOSE: Heart failure (HF) patients seem to exhibit altered thermoregulatory responses during exercise in the heat. However, the extent to which these responses are altered due to physiological impairments independently of biophysical factors associated with differences in metabolic heat production (Hprod), evaporative heat balance requirements (Ereq), and/or body size is presently unclear. Therefore, we examined thermoregulatory responses in 10 HF patients and 10 age-matched controls (CON) similar in body size during exercise at a fixed rate of Hprod and therefore Ereq in a 30°C environment. METHODS: Rectal temperature, local sweat rate, and cutaneous vascular conductance were measured throughout 60 min of cycle ergometry. Whole-body sweat rate was estimated from pre-post nude body weight corrected for fluid intake. RESULTS: Despite exercising at the same rate of Hprod (HF, 338 ± 43 W; CON, 323 ± 31 W; P = 0.25), the rise in rectal temperature was greater (P < 0.01) in HF (0.81°C ± 0.16°C) than in CON (0.49°C ± 0.27°C). In keeping with a similar Ereq (HF, 285 ± 40 W; CON, 274 ± 28 W; P = 0.35), no differences in whole-body sweat rate (HF, 0.45 ± 0.11 L·h; CON, 0.41 ± 0.07 L·h; P = 0.38) or local sweat rate (HF, 0.96 ± 0.17 mg·cm·min; CON, 0.79 ± 0.15 mg·cm·min; P = 0.50) were observed between groups. However, the rise in cutaneous vascular conductance was lower in HF than in CON (HF, 0.83 ± 0.42 au·mm Hg; CON, 2.10 ± 0.79 au·mm Hg; P < 0.01). In addition, the cumulative body heat storage estimated from partitional calorimetry was similar between groups (HF, 154 ± 106 kJ; CON, 196 ± 174 kJ; P = 0.44). CONCLUSIONS: Collectively, these findings demonstrate that HF patients exhibit a blunted skin blood flow response, but no differences in sweating. Given that HF patients had similar body heat storage to that of CON at the same Hprod, their greater rise in core temperature can be attributed to a less uniform internal distribution of heat between the body core and periphery.

Efficacy and Complications of Transcatheter Aortic Valve Implantation With and Without Balloon Aortic Valvuloplasty.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an effective treatment for severe aortic stenosis in high-risk patients. Several complications related to the TAVI procedure, including aortic regurgitation (AR), cerebrovascular accident (CVA) and the requirement for permanent pacemaker (PPM), are thought to be secondary to balloon aortic valvuloplasty (BAV) before TAVI. The aim of the present review was to evaluate any beneficial role of the direct TAVI approach over BAVTAVI. METHODS: A comprehensive search of major databases was performed. Only studies comparing TAVI with and without BAV were included. A total of nine full length articles was included in the analysis. RESULTS: Among 2,650 patients, 1,043 underwent 'direct TAVI' without pre-BAV, while 1,607 underwent TAVI following BAV. Overall, there was no difference between the 30-day all-cause mortality (OR 0.96, 95% CI 0.63-1.47, p = 0.86), CVA (OR 0.81, 95% CI 0.34-1.92, p = 0.63) and PPM implantation (OR 0.84, 95% CI 0.66- 1.05, p = 0.12) between the two approaches. The rate of moderate to severe AR was significantly lower with direct TAVI implantation (OR 0.44, 95% CI 0.20-0.96, p = 0.04). In the case of self-expandable valves, direct TAVI was associated with a lower device success (OR 5.15, 95% CI 1.33-19.9, p = 0.02). CONCLUSIONS: No difference was identified in mortality between direct TAVI and BAV-TAVI. However, direct TAVI is associated with a lower incidence of AR, a finding that would only be confirmed by conducting further randomized studies.

Heart Failure and Thermoregulatory Control: Can Patients With Heart Failure Handle the Heat?

Upon heat exposure, the thermoregulatory system evokes reflex increases in sweating and skin blood flow responses to facilitate heat dissipation and maintain heat balance to prevent the continuing rise in core temperature. These heat dissipating responses are mediated primarily by autonomic and cardiovascular adjustments; which, if attenuated, may compromise thermoregulatory control. In patients with heart failure (HF), the neurohumoral and cardiovascular dysfunction that underpins this condition may potentially impair thermoregulatory responses and, consequently, place these patients at a greater risk of heat-related illness. The aim of this review is to describe thermoregulatory mechanisms and the factors that may increase the risk of heat-related illness in patients with HF. An understanding of the mechanisms responsible for impaired thermoregulatory control in HF patients is of particular importance, given the current and projected increase in frequency and intensity of heat waves, as well as the promotion of regular exercise as a therapeutic modality. Furthermore, novel therapeutic strategies that may improve thermoregulatory control in HF, and the clinical relevance of this work in this population will be discussed.

Altered thermoregulatory responses in heart failure patients exercising in the heat.

Heart failure (HF) patients appear to exhibit impaired thermoregulatory capacity during passive heating, as evidenced by diminished vascular conductance. Although some preliminary studies have described the thermoregulatory response to passive heating in HF, responses during exercise in the heat remain to be described. Therefore, the aim of this study was to compare thermoregulatory responses in HF and controls (CON) during exercise in the heat. Ten HF (NYHA classes I-II) and eight CON were included. Core temperature (Tc), skin temperature (Tsk), and cutaneous vascular conductance (CVC) were assessed at rest and during 1 h of exercise at 60% of maximal oxygen uptake. Metabolic heat production (Hprod) and the evaporative requirements for heat balance (Ereq) were also calculated. Whole-body sweat rate was determined from pre-post nude body mass corrected for fluid intake. While Hprod (HF: 3.9 ± 0.9; CON: 6.4 ± 1.5 W/kg) and Ereq (HF: 3.3 ± 0.9; CON: 5.6 ± 1.4 W/kg) were lower (P < 0.01) for HF compared to CON, both groups demonstrated a similar rise in Tc (HF: 0.9 ± 0.4; CON: 1.0 ± 0.3°C). Despite this similar rise in Tc, Tsk (HF: 1.6 ± 0.7; CON: 2.7 ± 1.2°C), and the elevation in CVC (HF: 1.4 ± 1.0; CON: 3.0 ± 1.2 au/mmHg) was lower (P < 0.05) in HF compared to CON Additionally, whole-body sweat rate (HF: 0.36 ± 0.15; CON: 0.81 ± 0.39 L/h) was lower (P = 0.02) in HF compared to CON Patients with HF appear to be limited in their ability to manage a thermal load and distribute heat content to the body surface (i.e., skin), secondary to impaired circulation to the periphery.

Cardiac damage associated with stress hyperglycaemia and acute coronary syndrome changes according to level of presenting blood glucose.

OBJECTIVE: To determine the prevalence of stress hyperglycaemia in people presenting with acute coronary syndrome (ACS), and the relationships between admission glucose and cardiac damage, cardiovascular mortality and morbidity. METHODS: In a prospective observational study people presenting with ACS at the Gold Coast Hospital had their admission glucose (AG) level tested to determine stress hyperglycaemia. A range of measurements supplemented this data including troponin levels, category of ACS and major adverse coronary events (MACEs) were obtained through hospital records and patient follow-up post-discharge. RESULTS: One hundred eighty-eight participants were recruited. The prevalence of stress hyperglycaemia in ACS was 44% with 31% having a previous diagnosis of type 2 diabetes and 7.7% had undiagnosed diabetes. The stress hyperglycaemic group had a significantly higher median troponin levels compared to participants with normal blood glucose levels on admission (p<0.05) however the highest presenting glucose group (>15 mmol/L) had troponin levels similar to people presenting with normal blood glucose levels and ACS (p>0.05). CONCLUSIONS: Cardiac necrosis as measured by troponin levels is significantly increased in people with ACS and stress hyperglycaemia. This study found that one in four participants presenting with ACS and an admission glucose of >7.0 had no previous diagnosis for diabetes. PRACTICE IMPLICATION: Consistently ordering HbA1C testing on patients with high AG can enable earlier diagnosis and treatment of diabetes.

Effect of probiotics on blood pressure: a systematic review and meta-analysis of randomized, controlled trials.

Previous human clinical trials have shown that probiotic consumption may improve blood pressure (BP) control. The aim of the present systematic review was to clarify the effects of probiotics on BP using a meta-analysis of randomized, controlled trials. PubMed, Scopus, Cochrane Library (Central), Physiotherapy Evidence Database, and Clinicaltrial.gov databases were searched until January 2014 to identify eligible articles. Meta-analysis using a random-effects model was chosen to analyze the impact of combined trials. Nine trials were included. Probiotic consumption significantly changed systolic BP by -3.56 mm Hg (95% confidence interval, -6.46 to -0.66) and diastolic BP by -2.38 mm Hg (95% confidence interval, -2.38 to -0.93) compared with control groups. A greater reduction was found with multiple as compared with single species of probiotics, for both systolic and diastolic BP. Subgroup analysis of trials with baseline BP ≥130/85 mm Hg compared with <130/85 mm Hg found a more significant improvement in diastolic BP. Duration of intervention <8 weeks did not result in a significant reduction in systolic or diastolic BP. Furthermore, subgroup analysis of trials with daily dose of probiotics <10(11) colony-forming units did not result in a significant meta-analysis effect. The present meta-analysis suggests that consuming probiotics may improve BP by a modest degree, with a potentially greater effect when baseline BP is elevated, multiple species of probiotics are consumed, the duration of intervention is ≥8 weeks, or daily consumption dose is ≥10(11) colony-forming units.

Lipoprotein (A) in clinical practice.

Lipoprotein (a) is a strong and independent risk factor for atherosclerosis severity and a predictor of the risk of ischaemic heart disease and stroke. Many questions are still unanswered in relation to the clinical relevance of the scientific observations on Lp(a) and its application in the realms of cardiovascular prevention. Lp(a), a lipoprotein subtype, is linked to the Apo(a) gene located on chromosome 6q26-27 independently associated with increased risk of coronary artery disease (CAD). For this review, data sources from Cochrane, Pubmed, MEDLINE from 1960 till 2012 were analysed systematically. At least one-off measurement of plasma Lp(a) was found to be indicated in those with premature coronary disease when no real causative factor was identified. Management seemed promising with PCSK9 I, apheresis, CETPI, dietary choices and ACEi. There was clear evidence that Lp(a) is a definite risk marker for atherosclerotic cardiovascular disease (CVD).

Effects of community-based meditative Tai Chi programme on improving quality of life, physical and mental health in chronic heart-failure participants.

BACKGROUND: There is increasing evidence that coronary heart disease is linked with a number of psychosocial risk factors and biophysiological risk factors such as metabolic syndrome. This study aimed to compare Tai Chi programme heart-failure participants between the pre-intervention phase and six month after intervention time in health-related quality of life (HRQoL), including physical health, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. In addition, the difference between pre-intervention and post-intervention time in psychological distress and resilience, body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were compared. METHODS: A prospective intervention study was conducted in 2012 to evaluate the effectiveness of a community-based meditation Tai Chi intervention programme to improve heart-failure patients' health. Measures included the Short-Form 12 Health Survey (SF-12), General Health Questionnaire (GHQ30), resilience scale, BMI, blood pressure and waist circumference. Univariate analysis of variance was used to compare the difference between pre- and post-intervention in Tai Chi participants. RESULTS: Outcomes differed in significance and magnitude across four HRQoL measures, psychological distress and resilience between the pre- and post-intervention time in heart-failure patients who participated in the Tai Chi exercise. The participants in the post-intervention time also reduced BMI, SBP, and waist circumference. CONCLUSIONS: Regular and more than six months Tai Chi exercises had a beneficial effect to HRQoL, reducing psychological distress, promoting resilience, and reducing the BMI and blood pressure level in heart-failure patients.

A case of mobile aortic arch thrombus with systemic embolisation--a management dilemma.

We report the case of splenic infarct secondary to embolisation from a polypoid 17 mm×10 mm thoracic aorta thrombi in a 60 year-old female. The management and prognostic value of thoracic aorta thrombi are poorly defined in literature. This patient was successfully treated with oral anticoagulation as opposed to surgical intervention. Repeat transoesophageal echocardiography and computed tomography have demonstrated marked reduction in thrombi size with no further embolic event.