Multi-Ethnic Study of Atherosclerosis Early Heart Failure Study: Rationale, Design, and Baseline Characteristics.

BACKGROUND: Current prevalence estimates of heart failure (HF) are primarily based on self-report or HF hospitalizations. There is an unmet need to define the prevalence and pathogenesis of early symptomatic HF, which may be undiagnosed and precedes HF hospitalization. METHODS: The MESA (Multi-Ethnic Study of Atherosclerosis) Early HF study was conducted during MESA exam 6 to determine the prevalence of early HF and investigate the transition from risk factors to early HF in a diverse population-based cohort of older adults. Between 2016 and 2018, 3285 MESA participants from 6 field centers underwent comprehensive speckle-tracking echocardiography with passive leg raise maneuver, Kansas City Cardiomyopathy Questionnaire, 6-minute walk test, arterial stiffness assessment, and proteomics (including NT-proBNP [N-terminal pro-B-type natriuretic peptide]). RESULTS: Median age was 73 (25th-75th percentile 67-81) years, 53.2% were female, 25.6% were Black, 12.8% were Chinese, and 40.0% were White. The prevalence of HF risk factors was high: hypertension, 61.9%; former or current smoking, 53.7%; obesity 34.8%; diabetes; 24.7%; and chronic kidney disease; 22%. Overt cardiovascular disease, which ranged from 2.1% (HF) to 13.6% (atrial fibrillation), was less common. Of the 3285 participants, 96% underwent proteomics, 94% Kansas City Cardiomyopathy Questionnaire, 93% speckle-tracking echocardiography with passive leg raise, 82% arterial stiffness exam, and 77% 6-minute walk test. Feasibility of resting speckle-tracking echocardiography (87%-99% across cardiac chambers) and passive leg raise Doppler/speckle-tracking echocardiography (>84%) measurements was high. A total of 120 unique echocardiographic indices were measured. CONCLUSIONS: The MESA Early HF study is a key resource for cardiovascular researchers who are interested in improving the epidemiological and phenotypic characterization of early HF. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005487.

Physical Activity During Breast Cancer Therapy Associates With Preserved Exercise Capacity and Cardiac Function (WF97415).

Background: Cancer treatment increases cardiovascular disease risk, but physical activity (PA) may prevent cardiovascular disease. Objectives: This study examined whether greater PA was associated with better submaximal exercise capacity and cardiac function during cancer therapy. Methods: Participants included 223 women with stage I to III breast cancer (BC) before and 3 months after undergoing treatment and 126 control participants. Leisure-time PA (LTPA) was reported using the Godin-Shephard LTPA questionnaire. Cardiac function was assessed by cardiac magnetic resonance. Submaximal exercise capacity was determined by 6-minute walk distance. Results: BC participants reported similar baseline LTPA scores (24.7; 95% CI: 21.7-28.0) as control participants (29.4; 95% CI: 25.0-34.2). The BC group declined to 16.9 (95% CI: 14.4-19.6) at 3 months relative to 30.8 (95% CI: 26.2-35.8) in control participants. Among BC participants, more LTPA was related to better exercise capacity (ß ± SE: 7.1 ± 1.6; 95% CI: 4.0-10.1) and left ventricular (LV) circumferential strain (-0.16 ± 0.07; 95% CI: -0.29 to -0.02). Increased LTPA over the 3 months was associated with decreased likelihood of treatment-induced cardiac dysfunction according to LV circumferential strain classifications (OR: 0.98; 95% CI: 0.97-0.998). BC participants reporting insufficient LTPA according to PA guidelines exhibited deteriorations in exercise capacity (adjusted mean difference ± SE: -29 ± 10 m; P = 0.029), LV end-systolic volume (5.8 ± 1.3 mL; P < 0.001), LV ejection fraction (-3.2% ± 0.8%; P = 0.002), and LV circumferential strain (2.5% ± 0.5%; P < 0.001), but BC participants meeting LTPA guidelines did not exhibit these adverse changes. Conclusions: PA declined during BC therapy; however, PA participation was associated with attenuated declines in exercise capacity and cardiac function that are often observed in this population. (Understanding and Predicting Breast Cancer Events After Treatment [WF97415 UPBEAT]; NCT02791581).

Evaluation of a blood-based geroscience biomarker index in a randomized trial of caloric restriction and exercise in older adults with heart failure with preserved ejection fraction.

Intermediate endpoints are needed to evaluate the effect of interventions targeting the biology of aging in clinical trials. A working group identified five blood-based biomarkers that may serve such a purpose as an integrated index. We evaluated the responsiveness of the panel to caloric restriction or aerobic exercise in the context of a randomized clinical trial conducted in patients with heart failure with preserved ejection fraction (HFpEF) with obese phenotype who were predominantly female. Obese HFpEF is highly prevalent in women, and is a geriatric syndrome whose disease pathology is driven by non-cardiac factors and shared drivers of aging. We measured serum Interleukin-6, TNF-α-receptor-I, growth differentiating factor-15, cystatin C, and N-terminal pro-b-type natriuretic peptide at baseline and after 20 weeks in older participants with stable obese HFpEF participating in a randomized, controlled, 2 × 2 factorial trial of caloric restriction and/or aerobic exercise. We calculated a composite biomarker index, summing baseline quintile scores for each biomarker, and analyzed the effect of the interventions on the index and individual biomarkers and their associations with changes in physical performance. This post hoc analysis included 88 randomized participants (71 women [81%]). The mean ± SD age was 66.6 ± 5.3 years, and body mass index (BMI) was 39.3 ± 6.3 kg/m2. Using mixed models, mean values of the biomarker index improved over 20 weeks with caloric restriction (- 0.82 [Formula: see text] 0.58 points, p = 0.05), but not with exercise (- 0.28 [Formula: see text] 0.59 points, p = [Formula: see text]), with no evidence of an interaction effect of CR [Formula: see text] EX [Formula: see text] time (p = 0.80) with adjustment for age, gender, and BMI. At baseline, the biomarker index was inversely correlated with 6-min walk distance, scores on the short physical performance battery, treadmill test peak workload and exercise time to exhaustion (all [Formula: see text] s = between - 0.21 and - 0.24). A reduction in the biomarker index was also associated with increased 4-m usual walk speed ([Formula: see text] s = - 0.31). Among older patients with chronic obese HFpEF, caloric restriction improved a biomarker index designed to reflect biological aging. Moreover, the index was associated with physical performance and exercise tolerance.

The importance of healthy lifestyle behaviors in the prevention of cardiovascular disease.

Cardiovascular disease (CVD) is the leading cause of death globally. Advancements in the treatment of CVD have reduced mortality rates, yet the global burden of CVD remains high. Considering that CVD is still largely a preventable disease, prioritizing preventative measures through healthy lifestyle (HL) behaviors is necessary to lessen the burden of CVD. HL behaviors, such as regular exercise, healthy eating habits, adequate sleep, and smoking cessation, can influence a number of traditional CVD risk factors as well as a less commonly measured risk factor, cardiorespiratory fitness (CRF). It is important to note that cardiac rehabilitation programs, which traditionally have focused on secondary prevention, also emphasize the importance of making comprehensive HL behavior changes. This review discusses preventative measures to reduce the burden of CVD through an increased uptake and assessment of HL behaviors. An overview of the importance of CRF as a risk factor is discussed along with how to improve CRF and other risk factors through HL behavior interventions. The role of the clinician for promoting HL behaviors to prevent CVD is also reviewed.

Impact of cardiac surgery-associated acute kidney injury on activities of daily living at discharge in elderly cardiac surgery patients.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a critical complication associated with mortality and morbidity. This study aimed to clarify the impact of CSA-AKI on activities of daily living (ADL) at discharge in elderly cardiac surgery patients. We included 122 cardiac patients who underwent coronary artery bypass surgery, valve surgery, or combined surgery by mid-line incision followed by postoperative cardiac rehabilitation (CR) from March 2015 to May 2020. CSA-AKI was based on KDIGO criteria. The index of ADL was the Functional Independence Measure (FIM). We compared background factors, clinical parameters, activity level before hospitalization, CR progress, and FIM in patients with or without CSA-AKI. Multiple regression analysis was performed with FIM at discharge as the dependent variable and items with p < 0.01 in bivariate correlation as independent variables. Ultimately, 122 patients were divided into the non-CSA-AKI group (n = 84) and CSA-AKI group (n = 38). CR progression in the CSA-AKI group was significantly slower and FIM was lower than that in the non-CSA-AKI group. Moreover, even after adjustment for confounding factors, CSA-AKI (ß = -0.18), start day of walking (ß = -0.34), postoperative atrial fibrillation (ß = -0.15), and activity level before hospitalization (ß = -0.37) were predictive factors of ADL decline at discharge (adjusted R2 = 0.52). CSA-AKI of elderly cardiac surgery patients was a predictive factor of ADL decline at discharge.

Trends in Physical Activity Among US Adults With Heart Failure, 2007-2016.

PURPOSE: Lack of physical activity (PA) is an important risk for heart failure (HF). The objective of this study was to examine PA trends in HF and non-HF participants from a nationally representative sample of US adults from 2007 to 2016. METHODS: Work-related/recreational activities (min/wk) were calculated on the basis of the reported frequency, intensity, and duration, respectively. Multivariable analyses were performed using National Health and Nutrition Examination Survey data. RESULTS: Among 28 824 participants, younger (aged 18-64 yr) HF participants reported less PA time than non-HF groups, especially vigorous PA. Differences were found to be smaller in older (≥ 65 yr) participants. Overall, the percentage of younger participants who met PA guidelines was significantly lower in the HF individuals in work-related PA and total PA from 2007 to 2016 than in the non-HF participants (OR = 0.55: 95% CI, 0.39-0.59 for total PA, 0.45, 0.28-0.75 for vigorous work-related PA, and 0.68, 0.47-0.97 for moderate work-related PA, respectively). In older participants, only when considering total PA, the prevalence of meeting PA guidelines was significantly different between HF and non-HF groups (0.78, 0.62-0.98). CONCLUSIONS: Self-reported PA, especially vigorous activities, is much lower in older HF participants. However, the disparity in meeting PA guidelines between those with HF and without HF is remarkable in younger individuals. Future research should focus on better understanding the psychological and physical barriers to engaging in PA among HF patients.

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 yr and Its Role in Promoting Preventive Cardiology: Part 2.

Aggressive risk factor modification, including smoking cessation, blood pressure management, and more intensive efforts to control hyperlipidemia, as well as stress management training, are associated with improved cardiovascular outcomes and impressive mortality reductions. This commentary addresses these topics, with specific reference to lifestyle modification and complementary cardioprotective medications.

Increased skeletal intermuscular fat is associated with reduced exercise capacity in cancer survivors: a cross-sectional study.

BACKGROUND: Cancer survivors experience on average a 20% reduction in peak exercise capacity (VO2 peak) post-cancer treatment. Intermuscular fat (IMF) is a strong predictor of reduced exercise capacity in heart failure (HF) patients; however it is unknown whether increased IMF is related to reduced VO2 peak in cancer survivors. METHODS AND RESULTS: Twenty eight individuals: 14 cancer survivors > 12-months post-cancer treatment and 14 individuals without cancer were matched on age, gender, and body mass index (BMI). Participants underwent magnetic resonance imaging (MRI) assessments of IMF within the paraspinal muscles, VO2 peak and exercise-associated measures of left ventricular ejection fraction (LVEF). Blinded analyses were performed. Associations between the ratio of IMF to skeletal muscle (SM) were estimated using Pearson's partial correlation coefficients. Individuals with cancer and non-cancer comparators were of similar age (54 ± 17 versus 54 ± 15 years; p = 1.0), gender (5 men and 9 women, both groups), and BMI (27 ± 4 versus 26 ± 4; p = 0.57). Peak VO2 was 22% lower in cancer survivors versus non-cancer comparators (26.9 vs 34.3 ml/kg/min; p = 0.005), and was correlated with IMF:SM in both cancer survivors and non-cancer individuals after accounting for exercise-associated LVEF, resting LVEF, BMI, other body fat depots, and cardiovascular disease (CVD) co-morbidities (p < 0.001 to 0.08 for all adjusted correlations). CONCLUSION: Among cancer survivors that previously received anthracyclines, increased intermuscular fat is associated with reduced VO2 peak even after accounting for exercise-associated cardiac function. This suggests IMF is important in the development of exercise intolerance, an outcome experienced by a large number of cancer survivors.

Left Ventricular Mass Change After Anthracycline Chemotherapy.

BACKGROUND: Myocardial atrophy and left ventricular (LV) mass reductions are associated with fatigue and exercise intolerance. The relationships between the receipt of anthracycline-based chemotherapy (Anth-bC) and changes in LV mass and heart failure (HF) symptomatology are unknown, as is their relationship to LV ejection fraction (LVEF), a widely used measurement performed in surveillance strategies designed to avert symptomatic HF associated with cancer treatment. METHODS AND RESULTS: We performed blinded, serial assessments of body weight, LVEF and mass, LV-arterial coupling, aortic stiffness, and Minnesota Living with Heart Failure Questionnaire measures before and 6 months after initiating Anth-bC (n=61) and non-Anth-bC (n=15), and in 24 cancer-free controls using paired t and χ2 tests and multivariable linear models. Participants averaged 51±12 years, and 70% were women. Cancer diagnoses included breast cancer (53%), hematologic malignancy (42%), and soft tissue sarcoma (5%). We observed a 5% decline in both LVEF (P<0.0001) and LV mass (P=0.03) in the setting of increased aortic stiffness and disrupted ventricular-arterial coupling in those receiving Anth-bC but not other groups (P=0.11-0.92). A worsening of the Minnesota Living with Heart Failure Questionnaire score in Anth-bC recipients was associated with myocardial mass declines (r=-0.27; P<0.01) but not with LVEF declines (r=0.11; P=0.45). Moreover, this finding was independent of LVEF changes and body weight. CONCLUSIONS: Early after Anth-bC, LV mass reductions associate with worsening HF symptomatology independent of LVEF. These data suggest an alternative mechanism whereby anthracyclines may contribute to HF symptomatology and raise the possibility that surveillance strategies during Anth-bC should also assess LV mass.

Preoperative exercise therapy for gastrointestinal cancer patients: a systematic review.

BACKGROUND: Gastrointestinal cancer patients are susceptible to significant postoperative morbidity. The aim of this systematic review was to examine the effects of preoperative exercise therapy (PET) on patients undergoing surgery for GI malignancies. METHODS: In accordance with PRISMA statement, all prospective clinical trials of PET for patients diagnosed with GI cancer were identified by searching MEDLINE, Embase, Cochrane Library, ProQuest, PROSPERO, and DARE (March 8, 2017). The characteristics and outcomes of each study were extracted and reviewed. Risk of bias was evaluated using the Cochrane risk of bias tool by two independent reviewers. RESULTS: Nine studies (534 total patients) were included in the systematic review. All interventions involved aerobic training but varied in terms of frequency, duration, and intensity. PET was effective in reducing heart rate, as well as increasing oxygen consumption and peak power output. The postoperative course was also improved, as PET was associated with more rapid recovery to baseline functional capacity after surgery. CONCLUSIONS: PET for surgical patients with gastrointestinal malignancies may improve physical fitness and aid in postoperative recovery.

Aqua walking as an alternative exercise modality during cardiac rehabilitation for coronary artery disease in older patients with lower extremity osteoarthritis.

BACKGROUND: The purpose of this study was to examine the effects of aqua walking (AW) on coronary artery disease (CAD) and cardiorespiratory fitness in older adults with osteoarthritis in the lower extremity and compare it with that of traditional over-ground walking. METHODS: Sixty consecutive eligible patients who had undergone percutaneous coronary intervention for CAD with limited ambulation due to lower extremity osteoarthritis were recruited. They were randomly assigned to the AW program group, treadmill/track walking (TW) program group, or non-exercise control group (CON). Assessments were performed before and after 24 weeks of medically supervised exercise training. RESULTS: Significant differences were observed in the change in %body fat (TW: -2.7%, AW: -2.8%, CON: -0.4%), total cholesterol level (TW: -23.6 mg/dL, AW: -27.2 mg/dL, CON: 15.8 mg/dL), resting heart rate (TW: -6.3 bpm, AW: -6.9 bpm, CON: 1.3 bpm), and cardiorespiratory fitness expressed as VO2 peak (TW: 2.3 mL/kg·min-1, AW: 2.0 mL/kg·min-1, CON: -2.5 mL/kg·min-1) over 24 weeks among the groups. However, no significant differences in the change in these measures were found between the TW and AW groups. CONCLUSION: AW appears to be a feasible alternative exercise modality to over-ground walking for cardiac rehabilitation and can be recommended for older adults with CAD and osteoarthritis.

Effect of Spironolactone on Exercise Tolerance and Arterial Function in Older Adults with Heart Failure with Preserved Ejection Fraction.

OBJECTIVES: To evaluate the effects of an aldosterone antagonist on exercise intolerance in older adults with heart failure and preserved ejection fraction (HFpEF). DESIGN: Randomized, placebo-controlled, double-blind trial. SETTING: Academic medical center, Winston-Salem, North Carolina. PARTICIPANTS: Older adults (N = 80, aged 71 ± 1; 80% female) with stable compensated HFpEF and controlled blood pressure (BP). MEASUREMENTS: Participants were randomized into a 9-month treatment of spironolactone 25 mg/d vs placebo. Assessments were peak exercise oxygen consumption (VO2 ), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), cardiac magnetic resonance imaging, Doppler echocardiography, and vascular ultrasound. RESULTS: Seventy-one participants completed the trial: 37 in the spironolactone group and 34 in the placebo group. Adherence according to pill count was excellent (spironolactone 95%, placebo 97%). Mean spironolactone dose was 24.3 ± 2.9 mg/d and was well tolerated. Spironolactone significantly reduced systolic and diastolic BP at rest and peak exercise. At 9-month follow-up, baseline-adjusted peak VO2, the primary outcome, was 13.5 ± 0.3 mL/kg per minute in the spironolactone group versus 13.9 ± 0.3 mL/kg per minute in the placebo group (adjusted mean difference -0.4 mL/kg per minute; 95% confidence interval = -1.1-0.4 mL/kg per minute; P = .38). The 95% confidence intervals of spironolactone's effect on peak VO2 (-8.2% to 3.2%) excluded a clinically significant beneficial effect. There were also no significant differences in 6-minute walk distance, arterial stiffness, left ventricular (LV) mass, LV mass/end-diastolic volume, or MLHFQ score. CONCLUSION: In older adults with stable compensated HFpEF, 9 months of spironolactone 25 mg/d was well tolerated and reduced BP but did not improve exercise capacity, quality of life, LV mass, or arterial stiffness.

Association between Modified Shuttle Walk Test and cardiorespiratory fitness in overweight/obese adults with primary hypertension: EXERDIET-HTA study.

The aims of the study were to evaluate the relationship between Modified Shuttle Walk Test (MSWT) with peak oxygen uptake (V˙O2peak) in overweight/obese people with primary hypertension (HTN) and to develop an equation for the MSWT to predict V˙O2peak. Participants (N = 256, 53.9 ± 8.1 years old) with HTN and overweight/obesity performed a cardiorespiratory exercise test to peak exertion on an upright bicycle ergometer using an incremental ramp protocol and the 15-level MSWT. The formula of Singh et al was used as a template to predict V˙O2peak, and a new equation was generated from the measured V˙O2peak-MSWT relationship in this investigation. The correlation between measured and predicted V˙O2peak for Singh et al equation was moderate (r = 0.60, P < .001) with a standard error of the estimate (SEE) of 4.92 mL·kg-1 minute-1, SEE% = 21%. The correlation between MSWT and measured V˙O2peak as well as for the new equation was strong (r = 0.72, P < .001) with a SEE of 4.35 mL·kg-1 minute-1, SEE% = 19%. These results indicate that MSWT does not accurately predict functional capacity in overweight/obese people with HTN and questions the validity of using this test to evaluate exercise intolerance. A more accurate determination from a new equation in the current study incorporating more variables from MSWT to estimate V˙O2peak has been performed but still results in substantial error.

Differences in daily in-hospital physical activity and geriatric nutritional risk index in older cardiac inpatients: preliminary results.

BACKGROUND: Little is known about the differences in the geriatric nutritional risk index (GNRI) status in older patients and their relationship to accelerometer-derived measures of physical activity (PA) levels. We determined both differences in daily measured PA based on the GNRI and related cut-off values for PA in elderly cardiac inpatients. METHODS: We divided 235 consecutive elderly cardiac inpatients (mean age 73.6 years, men 70.6%) into four groups by age and GNRI: older-high group, 65-74 years with high GNRI (≥92 points) (n = 111); older-low group, low GNRI (<92 points) (n = 30); very old-high group, ≥75 years with high GNRI (n = 55); and very old-low group with low GNRI (n = 39). Average step count and physical activity energy expenditure (PAEE in kcal) per day for 2 days of these inpatients were assessed by accelerometer and compared between the four groups to determine cut-off values of PA. RESULTS: Step counts and PAEE were significantly lower in the low-GNRI versus high-GNRI groups in the older (2,742.1 vs. 4,198.1 steps, 55.4 vs. 101.3 kcal, P < 0.001), and very old (2,469.6 vs. 3,423.7 steps, 54.5 vs. 79.1 kcal, P < 0.001) cardiac inpatients. Respective cut-off values for step counts and PAEE were 3,017.6 steps/day and 69.4 kcal (P < 0.01) in the older and 2,579.4 steps/day and 58.8 kcal in the very old cardiac inpatients (P < 0.01). CONCLUSION: Poor nutritional status, as indicated by a low GNRI, may be a useful predictor of step counts and PAEE. The cut-off values determined in this study might be target values to be attained by older cardiac inpatients.

Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure.

This review discusses the scientific and clinical evidence for cardiac rehabilitation in patients who have undergone percutaneous revascularization, heart transplant, and heart valve surgery, and in patients with chronic heart failure. Across these diagnoses, regardless of age, there is considerable benefit of cardiac rehabilitation and supervised exercise training for increasing functional capacity, favorably modifying disease-related risk factors, decreasing symptoms, detecting signs and symptoms of disease before they become serious complications, and improving quality of life. The available evidence for this component of cardiovascular disease management, albeit not perfect, still warrants its more widespread application.