Safety and feasibility of a functional electrical stimulation cycling-based muscular dysfunction diagnostic method in mechanically ventilated patients.

BACKGROUND: A nonvolitional diagnostic method based on FES-Cycling technology has recently been demonstrated for mechanically ventilated patients. This method presents good sensitivity and specificity for detecting muscle dysfunction and survival prognosis, even in unconscious patients. As the clinical relevance of this method has already been reported, we aimed to evaluate its safety and feasibility. METHODS: An observational prospective study was carried out with 20 critically ill, mechanically ventilated patients. The FES-cycling equipment was set in a specific diagnostic mode. For safety determination, hemodynamic parameters and peripheral oxygen saturation were measured before and immediately after the diagnostic protocol, as well as venous oxygen saturation and blood lactate. The creatine phosphokinase level (CPK) was measured before and 24, 48, and 72 h after the test. The time taken to carry out the entire diagnostic protocol and the number of patients with visible muscle contraction (capacity of perceptive muscular recruitment) were recorded to assess feasibility. RESULTS: Heart rate [91 ± 23 vs. 94 ± 23 bpm (p = 0.0837)], systolic [122 ± 19 vs. 124 ± 19 mm Hg (p = 0.4261)] and diastolic blood pressure [68 ± 13 vs. 70 ± 15 mm Hg (p = 0.3462)], and peripheral [98 (96-99) vs. 98 (95-99) % (p = 0.6353)] and venous oxygen saturation [71 ± 14 vs. 69 ± 14% (p = 0.1317)] did not change after the diagnostic protocol. Moreover, blood lactate [1.48 ± 0.65 vs. 1.53 ± 0.71 mmol/L (p = 0.2320)] did not change. CPK did not change up to 72 h after the test [99 (59-422) vs. 125 (66-674) (p = 0.2799) vs. 161 (66-352) (p > 0.999) vs. 100 (33-409) (p = 0.5901)]. The time taken to perform the diagnostic assessment was 11.3 ± 1.1 min. In addition, 75% of the patients presented very visible muscle contractions, and 25% of them presented barely visible muscle contractions. CONCLUSIONS: The FES cycling-based muscular dysfunction diagnostic method is safe and feasible. Hemodynamic parameters, peripheral oxygen saturation, venous oxygen saturation, and blood lactate did not change after the diagnostic protocol. The muscle damage marker (CPK) did not increase up to 72 h after the diagnostic protocol.

Effects of Resistance Training on Cardiovascular Function in Patients With Peripheral Artery Disease: A Randomized Controlled Trial.

Gomes, APF, Correia, MA, Soares, AHG, Cucato, GG, Lima, AHRA, Cavalcante, BR, Sobral-Filho, DC, and Ritti-Dias, RM. Effects of resistance training on cardiovascular function in patients with peripheral artery disease: A randomized controlled trial. J Strength Cond Res 32(4): 1072-1080, 2018-The aim of this study was to analyze the effects of resistance training on cardiovascular function of patients with peripheral artery disease (PAD). In total, 30 patients with PAD were invited to participate in this randomized controlled trial, randomly allocated to a control (n = 15, 66 ± 2 years; stretching and relaxation exercises) or resistance training group (n = 15, 60 ± 3 years; 3 sets of 10 repetitions of 8 whole-body exercises, with a 2-minute interval between sets). Resting and 24-hour blood pressure (BP), cardiac output, systemic vascular resistance, and autonomic variables were obtained before and after 12 weeks of intervention. A blinded investigator performed all analyses. After 12 weeks of intervention there was maintenance of resting systolic, diastolic, and mean BP (p > 0.18), cardiac output (p = 0.46), and systemic vascular resistance (p = 0.55) in both groups. There was a time effect reduction in heart rate (p = 0.02), accompanied by changes in cardiac autonomic modulation (p = 0.03). There were no changes in 24-hour systolic, diastolic, and mean BP, heart rate, or rate pressure product (p > 0.05). The BP variability decreased in systolic (asleep, p = 0.003), diastolic (24 hours and awake, p = 0.001), and mean (24 hours and asleep, p < 0.02) only in the resistance training (RT) group. Twelve weeks of RT did not change resting and 24-hour BP, or their hemodynamic and autonomic determinants in patients with PAD; however, there were decreases in BP variability, indicating that it could be considered as an alternative to reducing cardiovascular risk in patients with PAD.

2022 HRS expert consensus statement on evaluation and management of arrhythmic risk in neuromuscular disorders.

This international multidisciplinary document is intended to guide electrophysiologists, cardiologists, other clinicians, and health care professionals in caring for patients with arrhythmic complications of neuromuscular disorders (NMDs). The document presents an overview of arrhythmias in NMDs followed by detailed sections on specific disorders: Duchenne muscular dystrophy, Becker muscular dystrophy, and limb-girdle muscular dystrophy type 2; myotonic dystrophy type 1 and type 2; Emery-Dreifuss muscular dystrophy and limb-girdle muscular dystrophy type 1B; facioscapulohumeral muscular dystrophy; and mitochondrial myopathies, including Friedreich ataxia and Kearns-Sayre syndrome, with an emphasis on managing arrhythmic cardiac manifestations. End-of-life management of arrhythmias in patients with NMDs is also covered. The document sections were drafted by the writing committee members according to their area of expertise. The recommendations represent the consensus opinion of the expert writing group, graded by class of recommendation and level of evidence utilizing defined criteria. The recommendations were made available for public comment; the document underwent review by the Heart Rhythm Society Scientific and Clinical Documents Committee and external review and endorsement by the partner and collaborating societies. Changes were incorporated based on these reviews. By using a breadth of accumulated available evidence, the document is designed to provide practical and actionable clinical information and recommendations for the diagnosis and management of arrhythmias and thus improve the care of patients with NMDs.

Effectiveness of chlorthalidone/amiloride versus losartan in patients with stage I hypertension and diabetes mellitus: results from the PREVER-treatment randomized controlled trial.

AIMS: To compare the blood pressure (BP)-lowering efficacy of a chlorthalidone/amiloride combination pill with losartan, during initial management of JNC 7 Stage I hypertension in patients with type 2 diabetes mellitus. METHODS: In an a priori subgroup analysis of a randomized, double-blind, controlled trial, volunteers aged 30-70 years, with stage I hypertension and diabetes mellitus, were randomized to 12.5/2.5 mg of chlorthalidone/amiloride (N = 47) or 50 mg of losartan (N = 50), and followed for 18 months in 21 clinical centers. If BP remained uncontrolled after three months, study medication dose was doubled, and if uncontrolled after six months, amlodipine (5 and 10 mg) and propranolol (40 and 80 mg BID) were added as open label drugs in a progressive fashion. RESULTS: Systolic BP decreased to a greater extent in participants allocated to diuretics compared to losartan (P < 0.001). After 18 months of follow-up, systolic BP was 128.4 ± 10.3 mmHg in the diuretic group versus 133.5 ± 8.0 in the losartan group (P < 0.01). In the diuretic group, 36 out of 43 participants (83.7%) had a JNC 7 normal BP, compared to 31/47 (66%) in the losartan group (P = 0.089). Serum cholesterol was higher in the diuretic arm at the end of the trial. Other biochemical parameters and reports of adverse events did not differ by treatment. CONCLUSIONS: Treatment of hypertension based on a combination of chlorthalidone and amiloride is more effective for BP lowering compared to losartan in patients with diabetes mellitus and hypertension. TRIAL REGISTRATION: Clinical trials registration number: NCT00971165.

Familial Hypertrophic Cardiomyopathy: Late Potentials and Other Prognostic Markers.

Familial hypertrophic cardiomyopathy is an autosomal dominant genetic disease considered the most common cause of sudden cardiac death in individuals under 35 years old, especially the athletes. This study aimed to investigate the association between the presence of late potentials and a family history of sudden death, syncope, and complex ventricular arrhythmias on patients with hypertrophic cardiomyopathy. A case series study was carried out from March 2001 to December 2002, including 22 patients with hypertrophic cardiomyopathy according to transthoracic echocardiogram criteria. Patients on a cardiac pacemaker, right bundle branch block, cardiac transplant, and under no possibilities to realize the exams were excluded. The results showed that asymmetric septal hypertrophy was the most common type (73%), 63% had a positive familial history of hypertrophic cardiomyopathy, 55% sudden cardiac death, and 23% syncope. Also, complex ventricular arrhythmias were detected in 14% and late potentials in 23% of patients. According to this study, the presence of late potentials was not associated with familial sudden death, syncope, and complex ventricular arrhythmias.

Does whole body vibration training improve heart rate variability in kidney transplants patients? A randomized clinical trial.

BACKGROUND: Whole-body vibration (WBV) is an exercise modality that can promote improvements in heart rate variability (HRV) with lower patient overload, and consequently reduce cardiovascular risk in renal transplant patients. The aim of this study was to evaluate the effects of a 12-week WBV training program of two weekly sessions on HRV. METHODS: A double-blind, randomized controlled clinical trial with 12 kidney transplant recipients of both genders who underwent WBV training (35 Hz) twice a week for 12 weeks on alternate days (WBV Group) and training with sub-therapeutic WBV (8 Hz) (Sham Group). Variables were evaluated in time and frequency domains of HRV through the 24-h Holter monitor, heart rate (HR), blood pressure (BP) and maximum oxygen consumption (VO2max) through an exercise stress test. RESULTS: The delta between Sham and WBV groups showed an increase in the low frequency (Δ = 959.05 Hz; p = 0.01) and in the high frequency (Δ = 204.42 Hz; p = 0.04) of the HRV compared to Sham group. No changes in the ergometric variables were observed for any of the groups. CONCLUSION: The present study evidenced an increase in the low and high frequency of HRV in individuals who participated in the Sham WBV group. There was no improvement in the autonomic balance in the groups, in the other HRV parameters, or the exercise test after the WBV training period.

Autonomic modulation in patients with congenital generalized lipodystrophy (Berardinelli-Seip syndrome).

AIMS: This study was designed to assess cardiac autonomic regulation in congenital generalized lipodystrophy (CGL) patients using 24 h heart rate variability (HRV). METHODS AND RESULTS: A cross-sectional study was carried out to evaluate 18 patients with CGL and 19 healthy controls matched by sex and age. We measured blood pressure, plasma concentrations of glucose, triglycerides, cholesterol, high-density lipoprotein-cholesterol, insulin resistance by the homeostatic model assessment (HOMA-R), left ventricular mass (LVM) (by two-dimensional echocardiography), and 24 h HRV (by the time domain indices MeanRR, SDNN, and rMSSD). Compared with controls, CGL patients had higher blood pressure (systolic, 131.1 vs. 106.3 mmHg, P < 0.05; diastolic, 85.0 vs. 68.2 mmHg, P < 0.05) and 10 patients met criteria for arterial hypertension and concentric left ventricular hypertrophy (LVM index > or =115 g/m(2)and relative left ventricular wall thickness > or =0.42). Patients with CGL had higher levels of glucose, triglycerides, cholesterol, and HOMA-R and 12 met criteria for type 2 diabetes mellitus. Compared with controls, CGL patients had lower MeanRR (639.8 vs. 780.5 ms, P < 0.001), SDNN (79.2 vs. 168.5 ms, P < 0.001), and rMSSD (15.8 vs. 59.6 ms, P < 0.001). In CGL patients, the reduction in HRV was independent of the metabolic and haemodynamic disturbances. CONCLUSION: Congenital generalized lipodystrophy patients have abnormal autonomic modulation, reflected by increased heart rate and pronounced reduction in HRV, independent of the metabolic and haemodynamic disturbances observed in this disorder.

Schistosomiasis-associated pulmonary arterial hypertension: survival in endemic area in Brazil.

BACKGROUND: The survival of schistosomiasis-associated pulmonary arterial hypertension (Sch-PAH) patients in endemic areas is unknown, but can be estimated using predictive equations. METHODS: We retrospectively analyzed all consecutive patients diagnosed with Sch-PAH referred to the Pronto SocorroCardiologico de Pernambuco between 2004 and 2010 using specific therapy and measured laboratory, diagnostic imaging, and baseline hemodynamic parameters. Observed and predicted survivals according to the National Institutes of Health (NIH) and Pulmonary Hypertension Connection (PHC) registry equations were compared by the Kaplan-Meier method, log-rank test and Cox proportional hazards model. RESULTS: Sixty-eight patients (47 [69.1%] women) observed for a mean of 3.1 years (range, 7-72 months), median survival was 74 months, and 42 (61.7%) survived. The sex and age distributions were similar for functional class I/II and III/IV patients. Hemodynamic abnormalities were severe: mean right atrial pressure, 12.6 ± 6.2 mmHg; mean pulmonary artery pressure, 60.3 ± 13.69 mmHg; pulmonary vascular resistance, 14.62 ± 7.04 Wood units; and cardiac index, 2.3 ± 0.8 L/min/m2. The usual idiopathic PAH predictors were not prognostic in Sch-PAH patients. The 1-, 3- and 5-year survival rates were 92.1%, 75.2%, and 50.8%, respectively, and those estimatedby the NIH and PHC registry equations were 68%, 45% and 32% (p = 0.001), and 93%, 79% and 68% (p = 0.340), respectively. CONCLUSIONS: Sch-PAH patients in endemic areas have severe hemodynamic profiles and reduced long-term survivaldespite treatment. The PHC registry equation may be a useful tool to estimate survival in Sch-PAH.

Carbohydrate antigen 125: a promising tool for risk stratification in heart diseases.

All patients with heart diseases should undergo risk stratification to predict those who are at high risk for short- and long-term adverse outcomes. Carbohydrate antigen 125 (CA125) is a glycoprotein produced by mesothelium that has clinical role in ovarian cancer monitoring. However, as it is not specific for ovarian cells, CA125 could also be used in heart diseases to monitor congestion and inflammation. Pericarditis, atrial fibrillation, heart failure and coronary artery disease are some scenarios in which this biomarker was studied.CA125 identifies patients at high risk of rehospitalizations and death, in addition to being associated with hemodynamic data (ejection fraction and right atrial pressure). Hence, CA125 is a tool for risk stratification in heart diseases.

Effectiveness of low-dose diuretics for blood pressure reduction to optimal values in prehypertension: a randomized clinical trial.

BACKGROUND: To determine the effectiveness of low-dose diuretic therapy to achieve an optimal level of blood pressure (BP) in adults with prehypertension. METHODS: The PREVER-prevention trial was a randomized, parallel, double-blinded, placebo-controlled trial, with 18 months of follow-up, conducted at 21 academic medical centers in Brazil. Of 1772 individuals evaluated for eligibility, 730 volunteers with prehypertension who were aged 30-70 years, and who did not reach optimal blood pressure after 3 months of lifestyle intervention, were randomized to a fixed association of chlorthalidone 12.5 mg and amiloride 2.5 mg or placebo once a day. The main outcomes were the percentage of participants who achieved an optimal level of BP. RESULTS: A total of 372 participants were randomly allocated to diuretics and 358 to placebo. After 18 months of treatment, optimal BP was noted in 25.6% of the diuretic group and 19.3% in the placebo group (P < 0.05). The mean net reduction in SBP and DBP for the diuretic group compared with placebo was 2.8 mmHg (95% CI 1.1 to 4.5) and 1.1 mmHg (95% CI -0.09 to 2.4), respectively. Most participants in the active treatment group (74.5%) and in the placebo group (80.7%) continued to have BP in the prehypertension range or progressed to hypertension. CONCLUSION: Low-dose diuretic therapy increased the probability of individuals with prehypertension to achieve optimal BP but most of those treated continued to have a BP in the prehypertension range or progressed to having overt hypertension.

Effectiveness of Chlorthalidone Plus Amiloride for the Prevention of Hypertension: The PREVER-Prevention Randomized Clinical Trial.

BACKGROUND: Prehypertension is associated with higher cardiovascular risk, target organ damage, and incidence of hypertension. The Prevention of Hypertension in Patients with PreHypertension (PREVER-Prevention) trial aimed to evaluate the efficacy and safety of a low-dose diuretic for the prevention of hypertension and end-organ damage. METHODS AND RESULTS: This randomized, parallel, double-blind, placebo-controlled trial was conducted in 21 Brazilian academic medical centers. Participants with prehypertension who were aged 30 to 70 years and who did not reach optimal blood pressure after 3 months of lifestyle intervention were randomized to a chlorthalidone/amiloride combination pill or placebo and were evaluated every 3 months during 18 months of treatment. The primary outcome was incidence of hypertension. Development or worsening of microalbuminuria, new-onset diabetes mellitus, and reduction of left ventricular mass were secondary outcomes. Participant characteristics were evenly distributed by trial arms. The incidence of hypertension was significantly lower in 372 study participants allocated to diuretics compared with 358 allocated to placebo (hazard ratio 0.56, 95% CI 0.38-0.82), resulting in a cumulative incidence of 11.7% in the diuretic arm versus 19.5% in the placebo arm (P=0.004). Adverse events; levels of blood glucose, glycosylated hemoglobin, creatinine, and microalbuminuria; and incidence of diabetes mellitus were no different between the 2 arms. Left ventricular mass assessed through Sokolow-Lyon voltage and voltage-duration product decreased to a greater extent in participants allocated to diuretic therapy compared with placebo (P=0.02). CONCLUSIONS: A combination of low-dose chlorthalidone and amiloride effectively reduces the risk of incident hypertension and beneficially affects left ventricular mass in patients with prehypertension. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov, www.ensaiosclinicos.gov. Unique identifiers: NCT00970931, RBR-74rr6s.

Individual blood pressure responses to walking and resistance exercise in peripheral artery disease patients: Are the mean values describing what is happening?

OBJECTIVE: The aim of this study was to analyze the average and individual blood pressure responses to walking and resistance exercise in patients with peripheral artery disease. METHODS: Thirteen patients underwent three experimental sessions: walking exercise, resistance exercise, and control. Ambulatory blood pressure, heart rate, and rate pressure product were obtained before and until 24 hours after sessions. RESULTS: The mean cardiovascular values during 24 hours, awake, and sleep periods were similar (P > 0.05) after the three experimental sessions. The analysis of individual data revealed that during 24 hours, eight of 13 patients reduced systolic or diastolic blood pressure in ≥4.0 mm Hg in at least one of the exercise session; furthermore, most of these patients presented greater responses after resistance exercise. The clinical characteristics of patients seem to influence the blood pressure responses after exercises. Individual data showed that part of patients presented clinically significant decreases in blood pressure, showing that these patients have acute cardiovascular benefits after performing an acute bout of exercise. CONCLUSIONS: Although, in average, a bout of walking or resistance exercise did not decrease ambulatory blood pressure in peripheral artery disease patients, the individual data revealed that most patients presented clinically relevant blood pressure reductions, especially after resistance exercise.

A new proposal to guide velocity and inclination in the ramp protocol for the treadmill ergometer.

OBJECTIVE: To suggest criteria to guide protocol prescription in ramp treadmill testing, according to sex and age, based on velocity, inclination, and max VO2 reached by the population studied. METHODS: Prospective study describing heart rate (HR), time, velocity, inclination, and VO2 estimated at maximum effort of 1840 individuals from 4 to 79 years old, who performed a treadmill test (TT) according to the ramp protocol. A paired Student t test was used to assess the difference between predicted and reached max VO2, calculated according to the formulas of the "American College of Sports Medicine". RESULTS: Submaximal HR was surpassed in 90.1% of the examinations, with a mean time of 10.0 2.0 minute. Initial and peak inclination velocity of the exercise and max VO2 were inversely proportional to age and were greater in male patients. Predicted Max VO2 was significantly lower than that reached in all patients, except for female children and adolescents (age < 20 years old). CONCLUSION: Use of velocity, inclination, and maximum VO2 actually reached, as a criterion in prescribing the ramp protocol may help in the performance of exercise in treadmill testing. The ramp protocol was well accepted in all age groups and sexes with exercise time within the programmed 8 to 12 minutes.

Recommendations of the Brazilian Society of Cardiac Arrhythmias for holter monitoring services.

BACKGROUND: There are innumerous indicators to assure the quality of a service. However, medical competence and the proper performance of a procedure determine its final quality. The Brazilian Society of Cardiac Arrhythmias recommends minimum parameters necessary to guarantee the excellence of ambulatory electrocardiographic monitoring services. OBJECTIVE: To recommend minimum medical competences and the information required to issue a Holter monitoring report. METHODS: This study was grounded in the concept of evidence-based medicine and, when evidence was not available, the opinion of a writing committee was used to formulate the recommendation. That committee consisted of professionals with experience on the difficulties of the method and management in providing services in that area. RESULTS: The professional responsible for the Holter monitoring analysis should know cardiovascular pathologies and have consistent formation on electrocardiography, including cardiac arrhythmias and their differential diagnoses. The report should be written in a clear and objective way. The minimum parameters that comprise a Holter report should include statistics of the exam, as well as quantification and analysis of the rhythm disorders observed during monitoring. CONCLUSION: Ambulatory electrocardiographic monitoring should be performed by professionals knowledgeable about electrocardiographic analysis, whose report should comprise the minimum parameters mentioned in this document.

Low-intensity resistance exercise does not affect cardiac autonomic modulation in patients with peripheral artery disease.

OBJECTIVE: To analyze the effect of a single bout of resistance exercise on cardiac autonomic modulation in patients with peripheral artery disease. METHODS: Fifteen patients with peripheral artery disease (age: 58.3±4.0 years) underwent the following sessions in a random order: resistance exercise (three sets of 10 repetitions of the six resistance exercises with a workload of 5-7 in the OMNI-RES scale) and control (similar to the resistance session; however, the resistance exercises were performed with no load). The frequency domain (low frequency, high frequency and sympathovagal balance) and symbolic analysis (0V, 1V and 2V patterns) of heart rate variability were obtained before and until one hour after the interventions. RESULTS: After the resistance exercise and control sessions, similar increases were observed in the consecutive heartbeat intervals (control: 720.8±28.6 vs. 790.9±34.4 ms; resistance exercise: 712.9±30.1 vs. 756.8±37.9 ms; p<0.05) and in the pattern of the symbolic analysis with no variation (0V) (control: 25.1±3.5 vs. 33.4±4.1%; resistance exercise: 26.1±3.2 vs. 29.7±3.5%; p<0.05) until 50 min after both interventions. The pattern of two variations (2V) decreased similarly (control: 11.2±2.1 vs. 8.3±2.1%; resistance exercise: 9.5±1.7 vs. 7.8±1.7%; p<0.05). In contrast, the pattern of one variation (1V), the low and high frequency bands and sympathovagal balance did not change after the interventions (p>0.05). CONCLUSION: A single bout of resistance exercise did not alter cardiac autonomic modulation in patients with peripheral artery disease.

Pulmonary artery pressure, gender, menopause, and pregnancy in schistosomiasis-associated pulmonary hypertension.

BACKGROUND: Schistosomiasis-associated pulmonary arterial hypertension (SPAH) is a major concern worldwide. However, the role of gender-specific contributing factors in SPAH is unknown. OBJECTIVE: We investigated how systolic pulmonary artery pressure (SPAP) values and the presence of severe SPAP relate to gender, menopausal status, and pregnancy history in SPAH patients. METHODS: Seventy-nine patients diagnosed with SPAH from 2000 to 2009 were assessed and 66 were enrolled in the study. Information about age, menopausal status, pregnancy, echocardiography-derived SPAP, and invasive mean pulmonary artery pressure (mPAP) was collected from medical records. The relation between values of SPAP and mPAP and their agreement for severe disease were assessed. Regression models assessed the association of gender, menopausal status, and pregnancy history with SPAP values and the presence of severe SPAP. RESULTS: Moderate correlation and good agreement for severe disease were found between mPAP and SPAP. Mean SPAP values were similar for men and women. A trend toward higher values of SPAP was found for non-menopausal women compared to men. Higher SPAP values were found for menopausal compared to non-menopausal women; the values were non-significant after adjustment for age. Pregnancy history had no association with SPAP. Menopause and positive pregnancy had no association with severe SPAP. CONCLUSION: In SPAH patients, neither gender, nor menopausal status, nor pregnancy history showed independent correlation with SPAP values assessed by echocardiography.