The evolving role of cardiopulmonary exercise testing in ischemic heart disease - state of the art review.

PURPOSE OF REVIEW: Cardiopulmonary exercise testing (CPET) is the gold standard for directly assessing cardiorespiratory fitness (CRF) and has a relatively new and evolving role in evaluating atherosclerotic heart disease, particularly in detecting cardiac dysfunction caused by ischemic heart disease. The purpose of this review is to assess the current literature on the link between cardiovascular (CV) risk factors, cardiac dysfunction and CRF assessed by CPET. RECENT FINDINGS: We summarize the basics of exercise physiology and the key determinants of CRF. Prognostically, several studies have been published relating directly measured CRF by CPET and outcomes allowing for more precise risk assessment. Diagnostically, this review describes in detail what is considered healthy and abnormal cardiac function assessed by CPET. New studies demonstrate that cardiac dysfunction on CPET is a common finding in asymptomatic individuals and is associated with CV risk factors and lower CRF. This review covers how key CPET parameters change as individuals transition from the asymptomatic to the symptomatic stage with progressively decreasing CRF. Finally, a supplement with case studies with long-term longitudinal data demonstrating how CPET can be used in daily clinical decision making is presented. SUMMARY: In summary, CPET is a powerful tool to provide individualized CV risk assessment, monitor the effectiveness of therapeutic interventions, and provide meaningful feedback to help patients guide their path to improve CRF when routinely used in the outpatient setting.

Interleukin-1 Inhibition for the Prevention and Treatment of Heart Failure.

ABSTRACT: Heart failure (HF) is a complex syndrome that remains a leading cause of morbidity and mortality worldwide. Abundant evidence suggests inflammation plays a key role in the development and perpetuation of HF, but there are currently no anti-inflammatory treatments approved for use in HF. Interleukin-1 (IL-1), the prototypical pro-inflammatory cytokine, has been implicated in adverse cardiac remodeling and left ventricular dysfunction. Multiple early phase clinical trials using IL-1 blockade in patients at risk for or diagnosed with HF have suggested favorable safety and efficacy in reducing inflammatory biomarkers, as well as positive signals in surrogate and clinical endpoints. Additional large scale clinical trials are urgently needed to confirm the safety and efficacy of this therapeutic approach specifically in HF. In this narrative review, we discuss current evidence regarding IL-1 blockade in the prevention and treatment of HF.

The Role of Cardiopulmonary Exercise Testing in Hypertrophic Cardiomyopathy.

This review emphasizes the importance of cardiopulmonary exercise testing (CPET) in patients diagnosed with hypertrophic cardiomyopathy (HCM). In contrast to standard exercise testing and stress echoes, which are limited due to the ECG changes and wall motion abnormalities that characterize this condition, CPET allows for the assessment of the complex pathophysiology and severity of the disease, its mechanisms of functional limitation, and its risk stratification. It is useful tool to evaluate the risk for sudden cardiac death and select patients for cardiac resynchronization therapy (CRT), cardiac transplantation, or mechanical circulatory support, especially when symptomatology and functional status are uncertain. It may help in differentiating HCM from other forms of cardiac hypertrophy, such as athletes' heart. Finally, it is used to guide and monitor therapy as well as for exercise prescription. It may be considered every 2 years in clinically stable patients or every year in patients with worsening symptoms. Although performed only in specialized centers, CPET combined with echocardiography (i.e., CPET imaging) and invasive CPET are more informative and provide a better assessment of cardiac functional status, left ventricular outflow tract obstruction, and diastolic dysfunction during exercise in patients with HCM.

Rationale and design of interleukin-1 blockade in recently decompensated heart failure (REDHART2): a randomized, double blind, placebo controlled, single center, phase 2 study.

BACKGROUND: Heart failure (HF) is a global leading cause of mortality despite implementation of guideline directed therapy which warrants a need for novel treatment strategies. Proof-of-concept clinical trials of anakinra, a recombinant human Interleukin-1 (IL-1) receptor antagonist, have shown promising results in patients with HF. METHOD: We designed a single center, randomized, placebo controlled, double-blind phase II randomized clinical trial. One hundred and two adult patients hospitalized within 2 weeks of discharge due to acute decompensated HF with reduced ejection fraction (HFrEF) and systemic inflammation (high sensitivity of C-reactive protein > 2 mg/L) will be randomized in 2:1 ratio to receive anakinra or placebo for 24 weeks. The primary objective is to determine the effect of anakinra on peak oxygen consumption (VO2) measured at cardiopulmonary exercise testing (CPX) after 24 weeks of treatment, with placebo-corrected changes in peak VO2 at CPX after 24 weeks (or longest available follow up). Secondary exploratory endpoints will assess the effects of anakinra on additional CPX parameters, structural and functional echocardiographic data, noninvasive hemodynamic, quality of life questionnaires, biomarkers, and HF outcomes. DISCUSSION: The current trial will assess the effects of IL-1 blockade with anakinra for 24 weeks on cardiorespiratory fitness in patients with recent hospitalization due to acute decompensated HFrEF. TRIAL REGISTRATION: The trial was registered prospectively with ClinicalTrials.gov on Jan 8, 2019, identifier NCT03797001.

Physiological behavior during stress anticipation across different chronic stress exposure adaptive models.

Anticipation of stress induces physiological, behavioral and cognitive adjustments that are required for an appropriate response to the upcoming situation. Additional research examining the response of cardiopulmonary parameters and stress hormones during anticipation of stress in different chronic stress adaptive models is needed. As an addition to our previous research, a total of 57 subjects (16 elite male wrestlers, 21 water polo player and 20 sedentary subjects matched for age) were analyzed. Cardiopulmonary exercise testing (CPET) on a treadmill was used as the laboratory stress model; peak oxygen consumption (VO2) was obtained during CPET. Plasma levels of adrenocorticotropic hormone (ACTH), cortisol, alpha-melanocyte stimulating hormone (alpha-MSH) and N-terminal-pro-B type natriuretic peptide (NT-pro-BNP) were measured by radioimmunometric, radioimmunoassay and immunoassay sandwich technique, respectively, together with cardiopulmonary measurements, 10 minutes pre-CPET and at the initiation of CPET. The response of diastolic blood pressure and heart rate was different between groups during stress anticipation (p = 0.019, 0.049, respectively), while systolic blood pressure, peak VO2 and carbon-dioxide production responses were similar. ACTH and cortisol increased during the experimental condition, NT-pro-BNP decreased and alpha-MSH remained unchanged. All groups had similar hormonal responses during stress anticipation with the exception of the ACTH/cortisol ratio. In all three groups, ΔNT-pro-BNP during stress anticipation was the best independent predictor of peak VO2 (B = 36.01, r = 0.37, p = 0.001). In conclusion, the type of chronic stress exposure influences the hemodynamic response during anticipation of physical stress and the path of hormonal stress axis activation. Stress hormones released during stress anticipation may hold predictive value for overall cardiopulmonary performance during the stress condition.

LAY SUMMARYThe study revealed differences in hormonal and hemodynamic responses during anticipation of stress between athletes and sedentary participants. Stress hormones released during stress anticipation may hold predictive value for overall cardiopulmonary performance during the stress condition.

Promotion and maintenance of physically active lifestyle in older outpatients 2 years after acute coronary syndrome.

AIMS: To examine long-term changes in lifestyle and exercise capacity of older patients hospitalized for acute coronary syndrome (ACS) involved in an innovative centre- and home-based exercise-based secondary prevention program. METHODS: A sample of 118 patients with ACS (age 76 [72-80] years) was analysed. Long-term changes in self-reported weekly leisure-time physical activity (wLTPA), walking speed (WS), and estimated cardiorespiratory fitness (eCRF, VO2peak, mL/kg/min) were the outcome variables. The program consisted of seven individual on-site sessions including motivational interviewing to reach exercise goals. Exercise prescription was based on the results of a standardized moderate and perceptually regulated treadmill walk to estimate VO2peak. wLTPA, WS, and eCRF were assessed at 1 (baseline), 2, 3, 4, 6, 12, and 24 months after discharge. RESULTS: 87, 76, and 70 patients completed follow-up at 6, 12, and 24 months, respectively. wLTPA significantly increased during the follow-up period (median METs/H/week 2.5, 11.2, 12.0, and 13.4 at baseline, 6, 12, and 24 months, respectively; P < 0.0001). At baseline, 18% of the sample met the current international guidelines for physical activity, while 75%, 70%, and 76% of them met the recommended values at 6-, 12-, and 24-month follow-up sessions, respectively. These results were associated with increasing median WS (2.9 ± 1.0, 4.3 ± 1.2, 4.5 ± 1.1, 4.5 ± 1.2 km/h, respectively, P < 0.0001), and VO2peak (16.5, 21.4, 21.1, 21.3 mL/kg/min, respectively, P < 0.0001). CONCLUSIONS: This early, individualized exercise intervention improved long-term adherence to a physically active lifestyle, walking capacity, and eCRF in older patients after ACS. Larger studies are needed to confirm short- and long-term clinical benefits of this intervention.

Whole-body electrical stimulation as a strategy to improve functional capacity and preserver lean mass after bariatric surgery: a randomized triple-blind controlled trial.

BACKGROUND/OBJECTIVES: Bariatric surgery (BS) is a successful, long-lasting treatment option for obese. The early postoperative (PO) period is followed by dietary restriction and physical inactivity, leading to declines in muscle mass and functional capacity. Whole-body electromyostimulation (WB-EMS) may be a feasible and potential early rehabilitation strategy post BS. The aim was to evaluate the effects of WB-EMS with exercise training (Fe) on functional capacity, body composition, blood biomarkers, muscle strength, and endurance post BS. SUBJECTS/METHODS: This is a randomized, triple-blind, sham-controlled trial. Thirty-five volunteers underwent a Roux-en-Y gastric bypass and were randomized into a WB-EMS (WB-EMSG) or control group (ShamG). Preoperative evaluations consisted of maximal and submaximal exercise testing, body composition, blood biomarkers, quadriceps strength, and endurance. After discharge, functional capacity and body composition were obtained. Exercise training protocols in both groups consisted of 14 dynamic exercises, 5 days per week, completing 30 sessions. The WB-EMSG also underwent an electrical stimulation protocol (Endurance: 85 Hz, 350 ms, 6 s of strain, 4 f of rest; Strength: 30 Hz, 350 ms, 4 s of strain, 10 seconds of rest, with bipolar electrical pulse). After intervention, subjects were reevaluated. RESULTS: The protocol started on average 6.7 ± 3.7 days after discharge. Both groups presented with a decline in functional capacity after BS (p < 0.05) and a reduction in all body composition measurements (p < 0.05). The exercise training program led to significant improvements in functional capacity (ShamG - PO: 453.8 ± 66.1 m, Post: 519.2 ± 62.8 m; WB-EMSG- PO: 435.9 ± 74.5, Post: 562.5 ± 66.4 m, p < 0.05), however, only the WB-EMSG demonstrated significant changes of distance walked (interaction time vs group effect, p < 0.05). In addition, adiponectin significantly increased only in the WB-EMSG (p < 0.05). The WB-EMSG was also able to preserve muscle strength, endurance, and fatigue index, while the ShamG demonstrated significant decline (p < 0.05). CONCLUSION: WB-EMS + Fe can be an attractive and feasible method following BS to enhance functional capacity and prevent deterioration of muscle function in the early PO. CLINICAL TRIAL REGISTRATION: ReBEC, RBR-99qw5h, on 20 February 2015.

Nonpharmacological Management of Resistant Hypertension.

PURPOSE OF REVIEW: In the United States (US), 46% of adults have hypertension (systolic blood pressure ≥ 130 mmHg, diastolic blood pressure ≥ 80 mmHg). Approximately, 16% of patients with hypertension have apparent treatment-resistant hypertension (aTRH) and the incidence of true resistant hypertension (RHT) is thought to be much lower (~ 2%). These patients with RHT are at a higher risk for adverse events and worse clinical outcomes. RECENT FINDINGS: Although lifestyle interventions have proven to be effective as the first line of defense in treating hypertension, their role in the management of patients with RHT is not well established. Despite fewer in number, available studies examining lifestyle interventions in patients with RHT do indeed show promising results. In this review, we aim to discuss the role of common lifestyle interventions such as physical activity, exercise, weight loss, and dietary modifications on blood pressure control in patients with RHT.

The COVID-19 pandemic and physical activity during intermittent fasting, is it safe? A call for action.

Intermittent fasting (IF) has recently gained popularity, and has been used for centuries in many religious practices. The Ramadan fasting is a mandatory form of IF practiced by millions of healthy adult Muslims globally for a whole lunar month every year. In Islam, the "Sunna" also encourages Muslims to practice IF all along the year (e.g.; two days a week). The 2019-Coronavirus disease (COVID-19) pandemic in the context of Ramadan has raised the question whether fasting is safe practice during the COVID-19 pandemic health crisis, and what would be the healthy lifestyle behaviors while fasting that would minimize the risk of infection. As COVID-19 lacks a specific therapy, IF and physical activity could help promote human immunity and be part of holistic preventive strategy against COVID-19. In this commentary, the authors focus on this dilemma and provide recommendations to the fasting communities for safely practicing physical activity in time of COVID-19 pandemic.

The effects of canagliflozin compared to sitagliptin on cardiorespiratory fitness in type 2 diabetes mellitus and heart failure with reduced ejection fraction: The CANA-HF study.

BACKGROUND: Canagliflozin reduces hospitalizations for heart failure (HF) in type 2 diabetes mellitus (T2DM). Its effect on cardiorespiratory fitness and cardiac function in patients with established HF with reduced ejection fraction (HFrEF) is unknown. METHODS: We conducted a double-blind randomized controlled trial of canagliflozin 100 mg or sitagliptin 100 mg daily for 12 weeks in 88 patients, and measured peak oxygen consumption (VO2 ) and minute ventilation/carbon dioxide production (VE/VCO2 ) slope (co-primary endpoints for repeated measure ANOVA time_x_group interaction), lean peak VO2 , ventilatory anaerobic threshold (VAT), cardiac function and quality of life (ie, Minnesota Living with Heart Failure Questionnaire [MLHFQ]), at baseline and 12-week follow-up. RESULTS: The study was terminated early due to the new guidelines recommending canagliflozin over sitagliptin in HF: 17 patients were assigned to canagliflozin and 19 to sitagliptin, total of 36 patients. There were no significant changes in peak VO2 and VE/VCO2 slope between the two groups (P = .083 and P = .98, respectively). Canagliflozin improved lean peak VO2 (+2.4 mL kgLM-1 min-1 , P = .036), VAT (+1.5 mL kg-1 min-1 , P = .012) and VO2 matched for respiratory exchange ratio (+2.4 mL Kg-1 min-1 , P = .002) compared to sitagliptin. Canagliflozin also reduced MLHFQ score (-12.1, P = .018). CONCLUSIONS: In this small and short-term study of patients with T2DM and HFrEF, interrupted early after only 36 patients, canagliflozin did not improve the primary endpoints of peak VO2 or VE/VCO2 slope compared to sitagliptin, while showing favourable trends observed on several additional surrogate endpoints such as lean peak VO2 , VAT and quality of life.

Complexity analysis of heart rate variability in chronic obstructive pulmonary disease: relationship with severity and symptoms.

PURPOSE: Chronic obstructive pulmonary disease (COPD) negatively impacts autonomic control of the heart rate, as assessed by time and frequency domains of heart rate variability (HRV) analysis. However, it is unknown whether symbolic dynamic analysis may identify cardiac autonomic impairment, and whether such nonlinear indices may be associated with disease severity, prognostic markers, perceived dyspnea and functional capacity in patients with COPD. The current study assessed cardiac autonomic modulation by symbolic analysis of HRV in patients with COPD compared with healthy controls. METHODS: We recruited 54 COPD patients and 20 healthy controls. The interval between two successive R-wave peaks was calculated in the resting supine position. HRV was analyzed using symbolic markers and Shannon entropy (SE). The six-minute walk test (6MWT) was applied in a 30-m corridor. RESULTS: We found a lower 6MWT distance in patients with COPD compared with healthy controls (p < 0.05). We found increased SE and decreased percentage of no variation patterns (0V%) in COPD patients compared with the control group (p = 0.001). Significant correlations were found between the percentage of one variation pattern (1V%) and the Medical Research Council dyspnea scale (r = 0.38, p = 0.01), BODE index (r = 0.38, p = 0.01), forced expiratory volume in the first second (FEV1) [L] (r = -0.44, p = 0.003) and FEV1 [%] (r = -0.35, p = 0.02). It was found that SE was inversely associated with 0V% (r = -0.87, p < 0.0001). CONCLUSION: COPD patients present with depressed sympathetic modulation of HR and higher SE compared with healthy controls. This increased irregularity was inversely associated with 0V%. These results suggested that COPD patients seem to have a cardiac control shifted towards a parasympathetic predominance compared with controls. Symbolic dynamic and complexity index of HRV are related to disease severity, symptoms and functional impairment in these patients.

The Impact of Obesity in Heart Failure.

Obesity has reached worldwide epidemic proportions, adversely impacting health on a global scale. Overweight and obesity adversely impact cardiac structure and function, affecting systolic and diastolic ventricular function. Studies and meta-analyses have documented an obesity paradox in large heart failure cohorts, where overweight and obese individuals with established heart failure have a better short- and medium-term prognosis compared with lean patients; this relationship is strongly impacted by level of cardiorespiratory fitness. There are implications for therapies aimed at increasing lean and muscle mass, and weight loss, for the prevention and treatment of compared with in patients with concomitant obesity.

Accuracy of Physical Function Questions to Predict Moderate-Vigorous Physical Activity as Measured by Hip Accelerometry.

BACKGROUND: Functional capacity assessment is a core component of current perioperative cardiovascular evaluation and management guidelines for noncardiac surgery. The authors investigated the ability of standardized physical function questions to predict whether participants engaged in moderate physical activity as measured by hip accelerometers. METHODS: Participant responses to physical functioning questions and whether they engaged in moderate physical activity were extracted from the National Health and Nutrition Examination Survey (2003 to 2004 and 2005 to 2006). Physical activity intensity was measured using hip accelerometers. Adult participants with at least one Revised Cardiac Risk Index condition were included in the analysis. Standardized physical function questions were evaluated using a classification and regression tree analysis. Training and test datasets were randomly generated to create and test the analysis. RESULTS: Five hundred and twenty-two participants were asked the physical functioning questions and 378 of 522 (72.4%) had a bout of moderate-vigorous activity. Classification and regression tree analysis identified a "no difficulty" response to walking up 10 stairs and the ability to walk two to three blocks as the most sensitive questions to predict the presence of a 2-min bout of moderate activity. Participants with positive responses to both questions had a positive likelihood ratio of 3.7 and a posttest probability greater than 90% of a 2-min bout of moderate-vigorous activity. The sensitivity and specificity of positive responses to physical functioning questions in the pruned tree were 0.97 (95% CI, 0.94 to 0.98) and 0.16 (95% CI, 0.10 to 0.23) for training data, and 0.88 (95% CI, 0.75 to 0.96) and 0.10 (95% CI, 0.00 to 0.45) for the test data. Participants with at least one 2-min bout of moderate activity had a greater percentage of overall daily active time (35.4 ± 0.5 vs. 26.7 ± 1.2; P = 0.001) than those without. CONCLUSIONS: Standardized physical function questions are highly sensitive but poorly specific to identify patients who achieve moderate physical activity. Additional strategies to evaluate functional capacity should be considered.

2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations.

In the past several decades, cardiopulmonary exercise testing (CPX) has seen an exponential increase in its evidence base. The growing volume of evidence in support of CPX has precipitated the release of numerous scientific statements by societies and associations. In 2012, the European Association for Cardiovascular Prevention & Rehabilitation and the American Heart Association developed a joint document with the primary intent of redefining CPX analysis and reporting in a way that would streamline test interpretation and increase clinical application. Specifically, the 2012 joint scientific statement on CPX conceptualized an easy-to-use, clinically meaningful analysis based on evidence-vetted variables in color-coded algorithms; single-page algorithms were successfully developed for each proposed test indication. Because of an abundance of new CPX research in recent years and a reassessment of the current algorithms in light of the body of evidence, a focused update to the 2012 scientific statement is now warranted. The purposes of this update are to confirm algorithms included in the initial scientific statement not requiring revision, to propose revisions to algorithms included in the initial scientific statement, to propose new algorithms based on emerging scientific evidence, to further clarify the application of oxygen consumption at ventilatory threshold, to describe CPX variables with an emerging scientific evidence base, to describe the synergistic value of combining CPX with other assessments, to discuss personnel considerations for CPX laboratories, and to provide recommendations for future CPX research.

Physiological responses in different intensities of resistance exercise - Critical load and the effects of aging process.

Aim was to identify critical load (CL) in young and elderly apparently healthy male cohorts. To contrast the metabolic, cardiovascular and perceptual responses on CL according to age. We evaluated 12 young (23 ± 3 years) and 10 elderly (70 ± 2 years) apparently healthy active males, who underwent: (1) 1 repetition maximum (1RM) test on a 45° Leg Press; (2) on different days, three high-intensity resistance exercise constant load tests (60%, 75% and 90% 1RM) until fatigue (Tlim). Absolute values of both the CL asymptote and curvature constant (kg) were significantly lower in elderly subjects (P < 0.05). In contrast, elderly subjects demonstrated a significantly higher number of repetitions at CL when compared with young subjects (P < 0.05). As expected, oxygen uptake (VO2) and heart rate (HR) during maximal aerobic exercise testing were significantly reduced in older subjects. However, percent-predicted aerobic capacity were higher in older subjects (P < 0.05). In addition, blood lactate ([La-]) corrected to Tlim and rating of perceived exertion values were greater in younger subjects at all intensities (P < 0.05). These findings, despite reduced force production in older subjects, endurance-related parameters are well preserved according to age-adjusted percent-predicted values in apparently healthy males.

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.

The Role of Gas Exchange Variables in Cardiopulmonary Exercise Testing for Risk Stratification and Management of Heart Failure with Reduced Ejection Fraction.

Heart failure with reduced ejection fraction (HFrEF) is common in the developed world and results in significant morbidity and mortality. Accurate risk assessment methods and prognostic variables are therefore needed to guide clinical decision making for medical therapy and surgical interventions with the ultimate goal of decreasing risk and improving health outcomes. The purpose of this review is to examine the role of cardiopulmonary exercise testing (CPET) and its most commonly used ventilatory gas exchange variables for the purpose of risk stratification and management of HFrEF. We evaluated five widely studied gas exchange variables from CPET in HFrEF patients based on nine previously used systematic criteria for biomarkers. This paper provides clinicians with a comprehensive and critical overview, class recommendations and evidence levels. Although some CPET variables met more criteria than others, evidence supporting the clinical assessment of variables beyond peak V̇O2 is well-established. A multi-variable approach also including the V̇E-V̇CO2 slope and EOV is therefore recommended.

A practical clinical approach to utilize cardiopulmonary exercise testing in the evaluation and management of coronary artery disease: a primer for cardiologists.

PURPOSE OF REVIEW: There is growing clinical interest for the use of cardiopulmonary exercise testing (CPET) to evaluate patients with or suspected coronary artery disease (CAD). With mounting evidence, this concise review with relevant teaching cases helps to illustrate how to integrate CPET data into real world patient care. RECENT FINDINGS: CPET provides a novel and purely physiological basis to identify cardiac dysfunction in symptomatic patients with both obstructive-CAD and nonobstructive-CAD (NO-CAD). In many cases, abnormal cardiac response on CPET may be the only objective evidence of potentially undertreated ischemic heart disease. When symptomatic patients have NO-CAD on coronary angiogram, they are still at increased risk for cardiovascular events. This problem appears to be more common in women than men and may warrant more aggressive risk factor modification. As the main intervention is lifestyle (diet, smoking cessation, exercise) and medical therapy (statins, angiotensin-converting enzyme inhibitors, beta-blockers), serial CPET testing enables close surveillance of cardiovascular function and is responsive to clinical status. SUMMARY: CPET can enhance outpatient evaluation and management of CAD. Diagnostically, it can help to identify physiologically significant obstructive-CAD and NO-CAD in patients with normal routine cardiac testing. CPET may be of particular value in symptomatic women with NO-CAD. Prognostically, precise quantification of improvements in exercise capacity may help to improve long-term lifestyle and medication adherence for this chronic condition.

The role of diet for prevention and management of hypertension.

PURPOSE OF REVIEW: Regular consumption of a diet high in sodium, energy dense foods, fat content, refined carbohydrates, added sugar and low in fruits and vegetables contributes to an increased risk of developing hypertension (HTN) and cardiovascular disease. This review aims to provide a synopsis of evidence-based dietary approaches that have been effective in lowering blood pressure (BP) in pre-HTN and individuals with HTN. RECENT FINDINGS: Recent dietary recommendations have emphasized overall dietary patterns and its relation between food and BP. The Dietary Approaches to Stop Hypertension (DASH) diet and modifications to the DASH diet, coupled with reductions in sodium intake, show dose-dependent decreases in BP. Implementation of digital lifestyle interventions based on the DASH diet have been effective and show potential for clinical application. SUMMARY: Adopting a diet rich in plant-based foods, whole grains, low-fat dairy products, and sodium intake within normal limits can be effective in the prevention and management of HTN. These diets have been found to be more effective in older adults and hypertensive persons, particularly in studies that provided meals or frequent dietary counseling.

Effect of Interleukin-1 Blockade on Left Ventricular Systolic Performance and Work: A Post Hoc Pooled Analysis of 2 Clinical Trials.

BACKGROUND: Interleukin-1 (IL-1) blockade seems to improve anaerobic exercise in patients with systolic heart failure through improved left ventricular (LV) systolic performance. However, it is unclear whether IL-1 blockade affects LV systolic performance. METHODS: We pooled data from 2 clinical trials of patients with systolic heart failure who were randomized to IL-1 blockade or placebo. We estimated changes in LV systolic performance (LV ejection fraction [LVEF] and end-systolic elastance [LVEes]) and pressure-volume area (PVA), a surrogate of oxygen consumption, after 14 days of treatment. RESULTS: LVEF increased from 30% (24%-38%) to 36% (29%-43%) between baseline and day 14 only in anakinra-treated patients (P = 0.03 for within-group change and P = 0.02 for between-group change compared with placebo). LVEes increased from 1.0 mm Hg/mL (0.7-1.5) to 1.3 mm Hg/mL (0.8-1.6) in anakinra-treated patients between baseline and day 14 but not in placebo-treated patients (P = 0.03 for within-group change and P = 0.08 for between-group change). A change in PVA between baseline and 14 days was not detected in either anakinra or placebo patients. CONCLUSIONS: In this post hoc analysis, LVEes and LVEF increased significantly in patients treated with an IL-1 blocker but not in placebo-treated patients. An effect of IL-1 blockade on calculated PVA was not detected.