Recommendations for objective cardiovascular assessment to inform clinical exercise prescription: An Exercise Physiologist and Physiotherapist expert consensus.

OBJECTIVES: Exercise is beneficial in managing cardiovascular health. Objective assessments of cardiovascular function assist in identifying the presence or absence of exertional symptoms, and functional and physiological thresholds necessary to inform safe and effective exercise programmes. This study aimed to generate expert consensus on assessments of cardiovascular function to support clinical decision-making for professionals providing clinical exercise services. DESIGN: Three-round e-Delphi. METHODS: Expert Exercise Physiologists and Physiotherapists were recruited to participate in an e-Delphi. Experts were asked to list all objective cardiovascular assessments deemed necessary to inform safe and effective exercise prescription. In subsequent e-Delphi rounds, experts rated the importance of each item, provided a rationale to support their assertions, and reconsidered others' ratings and rationale to shift or reaffirm their position. These results were then translated into a clinical guidance document by the authors in consultation with a Cardiologist and an experienced Exercise Physiologist with expertise in cardiovascular assessment. RESULTS: Thirty-one experts participated in the e-Delphi and fourteen participants completed all three rounds. Forty objective assessments were initially suggested. Six items reached consensus by the end of Round 2 (resting and exercise heart rate, resting, exercise, and recovery blood pressure, and peak exercise-induced rating of perceived exertion). One additional item reached consensus in Round 3 (exercise oxygen saturation). CONCLUSIONS: In the absence of research evidence, the collective experience and insights of an expert panel can inform an evidence gap. Further research is required to determine the feasibility of implementing these seven assessments in practice where CV assessment is indicated.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement.

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Characterising running economy and change of direction economy between soccer players of different playing positions, levels and sex.

Traditional movement economy (ME) measures the energetic cost of in-line running. However, it is debatable whether such a measure is representative of movement efficiency for team sport athletes who are required to run and change direction repeatedly. This study evaluated ME during both in-line running and runs with directional changes and provided a preliminary exploration as to whether these abilities discriminate soccer players according to playing position, level, and sex. Forty-three soccer players were assessed for ME as extrapolated from oxygen uptake during in-line running (RE) and running with changes of directions (using 20 and 10 m shuttle runs [SRE20 and SRE10]) at 8.4 km/h mean speed. ME worsened with change of direction frequency (p < 0.001). Coefficient of determination was high between RE and SRE20 (r2 = 0.601) but dropped below 0.5 for RE and SRE10 (r2 = 0.280) as change of direction frequency increased. No significant differences were observed between different player positions, however, centre midfielders reported the best ME across any position and running mode, with the largest differences observed in centre backs over SRE10 (41.9 ± 2.7 ml/kg/min [centre midfielders] vs 45 ± 1.8 ml/kg/min [centre backs]; ES = 1.19). No significant differences were observed for ME over any running condition for male players of different playing levels. Female players exhibited better ME than male players with significant differences observed for SRE10 (41.5 ± 2.6 ml/kg/min [females] vs 44 ± 2.6 ml/kg/min [males]; p = 0.013; ES = 0.94). RE does not adequately account for efficiency during activities that involve changes of direction. SRE10 is a stronger discriminator of ME between soccer players of different position and sex.

Modulators of Change-of-Direction Economy After Repeated Sprints in Elite Soccer Players.

PURPOSE: To investigate the acute effect of repeated-sprint activity (RSA) on change-of-direction economy (assessed using shuttle running economy [SRE]) in soccer players and explore neuromuscular and cardiorespiratory characteristics that may modulate this effect. METHODS: Eleven young elite male soccer players (18.5 [1.4] y old) were tested on 2 different days during a 2-week period in their preseason. On day 1, lower-body stiffness, power and force were assessed via countermovement jumps, followed by an incremental treadmill test to exhaustion to measure maximal aerobic capacity. On day 2, 2 SRE tests were performed before and after a repeated-sprint protocol with heart rate, minute ventilation, and blood lactate measured. RESULTS: Pooled group analysis indicated no significant changes for SRE following RSA due to variability in individual responses, with a potentiation or impairment effect of up to 4.5% evident across soccer players. The SRE responses to RSA were significantly and largely correlated to players' lower-body stiffness (r = .670; P = .024), and moderately (but not significantly) correlated to players' force production (r = -.455; P = .237) and blood lactate after RSA (r = .327; P = .326). CONCLUSIONS: In summary, SRE response to RSA in elite male soccer players appears to be highly individual. Higher lower-body stiffness appears as a relevant physical contributor to preserve or improve SRE following RSA.

High-intensity Interval Training Shock Microcycle Improves Running Performance but not Economy in Female Soccer Players.

This study aimed to evaluate the effect of high-intensity interval training shock microcycles (HIITSM) on endurance, running economy and change of direction economy in female soccer players. Nineteen sub-elite female soccer players were randomised to two groups: HIITSM (10 HIIT sessions over 13 days) or HIITTRAD (4 HIIT sessions over 13 days) interventions. Endurance performance was evaluated through the 30-15 intermittent fitness test (30-15IFT); running economy over a 5-min treadmill run; and change of direction economy over two conditions: (1) 5-min 20m shuttle run, and (2) 5-min 10m shuttle run. HIITSM significantly improved 30-15IFT scores compared to baseline (+4.4%, p=0.009; d=0.96) and 30-15IFT scores relative to HIITTRAD (p=0.002; d=2.01). There was no significant interaction (group×time) for running economy and change of direction economy. Pre- to post- intervention there was a significant main time effect for blood lactate over 20m and 10m shuttle runs (p<0.001 and p=0.037, respectively), with large (d=0.93) and moderate (d=0.53) changes observed for the HIITSM over the two distances, respectively. HIITSM may be more effective than HIITTRAD to improve 30-15IFT over shorter training periods but may not affect running economy and change of direction economy.

Reliability of Change-of-Direction Economy in Soccer Players.

PURPOSE: To evaluate the reliability of new change-of-direction-economy tests (assessing energetic efficiency when performing continuous shuttle runs) compared with common running-economy tests in soccer players Methods: Sixteen subelite, male soccer players were recruited to perform a testing battery involving running economy (RE), 10-m shuttle-running economy (SRE10), and 20-m shuttle-running economy (SRE20) at 8.4 km·h-1 mean speed on 2 different days within 48 hours. SRE10 and SRE20 consisted of continuous shuttle runs interspersed with 180° directional changes. During the RE, SRE20, and SRE10 tests, respiratory exchange ratio and oxygen uptake were collected and used to calculate the movement-economy values over any running condition as oxygen cost and energetic cost. The secondary variables (carbon dioxide production, heart rate, minute ventilation, and blood lactate) were also monitored during all tests. RESULTS: Depending on expression (oxygen cost or energetic cost), reliability was established for RE (CV: 5.5%-5.8%; ICC = .77-.88), SRE10 (CV: 3.5%-3.8%; ICC = .78-.96), and SRE20 (CV: 3.5%-3.8%; ICC = .66-.94). All secondary physiological variables reported good reliability (CV < 10%), except for blood lactate (CV < 35.8). The RE, SRE10, and SRE20 tests show good reliability in soccer players, whereas blood lactate has the highest variability among physiological variables during the economy tests. CONCLUSION: The assessment of change-of-direction economy through performing 20- and 10-m shuttle runs is reliable and can be applied to evaluate soccer players' energetic movement efficiency under more soccer-specific running conditions.

Lack of Cited Evidence Underpinning Recommendations for Objective Assessment of Cardiovascular Function to Inform Exercise Prescription: A Systematic Review.

BACKGROUND: The effectiveness of exercise in managing cardiovascular (CV) health and function is well established. Less clear is the process for optimising the safety and efficacy of an intervention, particularly how objective assessments might inform this process. OBJECTIVE: The aim of this review was to investigate the cited evidence underpinning recommendations for assessing CV function to inform the safe and effective prescription of exercise in populations with established CV disease, as published in documents to guide practice authored by prominent organisations in cardiology and sports medicine. METHODS: A systematic review of position statements and guiding documents on exercise prescription for CV health was conducted. Included documents were published between 1997 and 2016. RESULTS: Following removal of duplicates, 3158 documents were considered, with full-text screening required for 334. Twenty-seven documents were included which provided 106 individual recommendations for specific objective assessments. Of the total number of recommendations, 60% had no accompanying citation and 28% of recommendations provided citations that did not directly support the statement made. Additionally, 52% of included documents did not state the methods of document development. That is, it was not clear if there was a literature review and/or expert consensus that was used to form recommendations included within. CONCLUSION: Almost no cited evidence underpinning the extracted recommendations from the included guiding documents, nor any acknowledgement of this deficiency was established. There were limited explanations found for the methods involved in developing such guiding documents.

TEXT messages to improve MEDication adherence and Secondary prevention (TEXTMEDS) after acute coronary syndrome: a randomised clinical trial protocol.

BACKGROUND: Identifying simple, low-cost and scalable means of supporting lifestyle change and medication adherence for patients following a cardiovascular (CV) event is important. OBJECTIVE: The TEXTMEDS (TEXT messages to improve MEDication adherence and Secondary prevention) study aims to investigate whether a cardiac education and support programme sent via mobile phone text message improves medication adherence and risk factor levels in patients following an acute coronary syndrome (ACS). STUDY DESIGN: A single-blind, multicentre, randomised clinical trial of 1400 patients after an ACS with 12 months follow-up. The intervention group will receive multiple weekly text messages that provide information, motivation, support to adhere to medications, quit smoking (if relevant) and recommendations for healthy diet and exercise. The primary endpoint is the percentage of patients who are adherent to cardioprotective medications and the key secondary outcomes are mean systolic blood pressure (BP) and low-density lipoprotein cholesterol. Secondary outcomes will also include total cholesterol, mean diastolic BP, the percentage of participants who are adherent to each cardioprotective medication class, the percentage of participants who achieve target levels of CV risk factors, major vascular events, hospital readmissions and all-cause mortality. The study will be augmented by formal economic and process evaluations to assess acceptability, utility and cost-effectiveness. SUMMARY: The study will provide multicentre randomised trial evidence of the effects of a text message-based programme on cardioprotective medication adherence and levels of CV risk factors. ETHICS AND DISSEMINATION: Primary ethics approval was received from Western Sydney Local Health District Human Research Ethics Committee (HREC2012/12/4.1 (3648) AU RED HREC/13/WMEAD/15). Results will be disseminated via peer-reviewed publications and presentations at international conferences. TRIAL REGISTRATION NUMBER: ACTRN12613000793718; Pre-results.

The development of a new cardiac rehabilitation needs assessment tool (CRNAT) for individualised secondary prevention.

BACKGROUND: Cardiac rehabilitation and secondary prevention are evidence-based strategies to reduce the risk of recurrent cardiac events but are underutilised. New approaches are required to improve uptake. METHODS: A new cardiac rehabilitation needs assessment tool (CRNAT), for use by cardiology ward nurses, was developed and refined in collaboration with stakeholders through action research. The tool documented patients' risk factors, initiated a discussion about secondary prevention and linked patients to post-discharge follow-up. The initial version of the tool was developed through consultation with cardiac rehabilitation specialist staff (n=3), reviewed by ward nurses (n=4) and general practitioners (GP) (n=8), and piloted in patients (n=8). Review was undertaken at six months post implementation through patient (n=66) and GP (n=10) surveys, with additional patient feedback through focus groups (n=8 patients) and phone interviews (n=14). At 12 months, ward nurses (n=21) were surveyed. RESULTS: The CRNAT was well regarded by patients and GPs and stakeholder feedback resulted in only minor changes to the tool's content. Feedback from ward nurses led to important changes to the process of administering the tool to streamline its use in an inpatient setting. CONCLUSIONS: Feedback from end users is important when developing a new clinical tool to ensure it meets their requirements.

Comorbidities and medication burden in patients with chronic obstructive pulmonary disease attending pulmonary rehabilitation.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by concomitant systemic manifestations and comorbidities such as cardiovascular disease. Little data exist on the prevalence of comorbidities and medication burden in people with COPD attending pulmonary rehabilitation (PR) programs in Australia. This study aimed to determine the prevalence of comorbidities and describe the type and number of medications reported in a sample of patients with COPD referred to PR. METHODS: A retrospective audit was conducted on patients referred to PR over a 1-year period. Data were collected on patient demographics, disease severity, comorbidities, and medications by review of patient notes, physician referral, and self-reported medication use. RESULTS: Data were available on 70 patients (forced expiratory volume in 1 second = 37.5 [26.0] % predicted). Ninety-six percent of patients had at least 1 comorbidity, and 29% had 5 or more. The most common comorbidities were associated with cardiovascular disease (64% of patients). Almost half of the sample was overweight or obese (49%). Prescription medication use was high, with 57% using between 4 and 7 medications, and 29% using 8 or more. CONCLUSIONS: Patients with COPD attending PR in Australia have high rates of comorbidity. The number of medications prescribed for these individuals is similar to that seen in other chronic disease states such as chronic heart failure. Pulmonary rehabilitation presents opportunities for clinicians to educate patients on self-management strategies for multiple comorbidities, review medication usage, and discuss strategies aimed at optimizing adherence with medication regimes.

Identifying culturally appropriate strategies for coronary heart disease secondary prevention in a regional Aboriginal Medical Service.

Aboriginal Australians experience high rates of coronary heart disease (CHD) at an early age, highlighting the importance of effective secondary prevention. This study employed a two-stage process to evaluate CHD management in a regional Aboriginal Medical Service. Stage 1 involved an audit of 94 medical records of clients with documented CHD using the Audit and Best Practice in Chronic Disease approach to health service quality improvement. Results from the audit informed themes for focus group discussions with Aboriginal Medical Service clients (n=6) and staff (n=6) to ascertain barriers and facilitators to CHD management. The audit identified that chronic disease management was the focus of appointments more frequently than in national data (P<0.05), with brief interventions for lifestyle modification occurring at similar or greater frequency. However, referrals to follow-up support services for secondary prevention were lower (P<0.05). Focus groups identified psychosocial factors, systemic shortcomings, suboptimal medication use and variable awareness of CHD signs and symptoms as barriers to CHD management, whereas family support and culturally appropriate education promoted health care. To optimise CHD secondary prevention for Aboriginal people, health services require adequate resources to achieve best-practice systems of follow up. Routinely engaging clients is required to ensure services meet diverse community needs.

Build it and they will come: outcomes from a successful cardiac rehabilitation program at an Aboriginal Medical Service.

OBJECTIVE: Cardiovascular disease (CVD) is the leading disease burden in Aboriginal Australians, but culturally appropriate cardiac rehabilitation programs are lacking. We evaluated the uptake and effects on lifestyle, and cardiovascular risk factors, of cardiac rehabilitation at an Aboriginal Medical Service (AMS). METHODS: The program involved weekly exercise and education sessions (through 'yarning') for Aboriginal people with or at risk of CVD. Participants' perceptions of the program and the impact on risk factors were evaluated following 8 weeks of attendance. RESULTS: In twenty-eight participants (20 females) who completed 8 weeks of sessions, body mass index (34.0 ± 5.1 v. 33.3 ± 5.2 kgm⁻²; P<0.05), waist girth (113 ± 14 v. 109 ± 13 cm; P<0.01) and blood pressure (135/78 ± 20/12 v. 120/72 ± 16/5 mmHg; P<0.05) decreased and 6- min walk distance increased (296 ± 115 v. 345 ± 135m; P<0.01). 'Yarning' helped identify and address a range of chronic health issues including medication compliance, risk factor review and chest pain management. CONCLUSIONS: AMS-based cardiac rehabilitation was well attended, and improved cardiovascular risk factors and health management. An AMS is an ideal location for managing cardiovascular health and provides a setting conducive to addressing a broad range of chronic conditions.

Achieving coordinated secondary prevention of coronary heart disease for all in need (SPAN).

Effective disease management after an acute coronary event is essential, but infrequently implemented, due to challenges around the research evidence and its translation. Policy-makers, health professionals and researchers are confronted by the need for increased services, to improve access and equity, but often with finite and reducing resources. There is a clear need to develop innovative ways of delivering ongoing preventative care to the vast and increasing population with coronary disease. However, translation into clinical practice is becoming increasingly difficult while the volume of trial and review evidence of disparate models of delivery expands. Indeed, the prevention literature has evolved into a complex web of differing models offered to diverse patient populations in an array of settings. We describe a united organisation of care that aims to facilitate coordinated secondary prevention for all in need (SPAN). SPAN is inherently flexible yet provides a minimum level of health service standardisation. It can be delivered across any area health service regardless of a patient's age, gender, ethnicity, geographical location, or socioeconomic status. Importantly, the setting, communication technologies and components of each patient's care are governed and woven into continuing care provided by the family physician in concert with a cardiac care facilitator.