Patient blood management in elective bypass cardiac surgery: A 2-step single-centre interventional trial to analyse the impact of an educational programme and erythropoiesis stimulation on red blood cell transfusion.

Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. Perioperative patient blood management (PBM) is widely recommended in current practice guidelines. The aim of this protocol is to analyse the effect of a global perioperative PBM programme on the red blood cell (RBC) transfusion ratio, morbidities and rehabilitation score in elective cardiac surgery.This study is a prospective, single-centre trial with a 2-step protocol, A and B, as follows: A: non-drug intervention: the caregiver is given a blood management educational programme; B: drug intervention: systematic correction of perioperative iron, vitamin deficiencies, and anaemia. This study was designed to enrol 900 patients (500 in group A and 400 in group B) in a rolling period starting at anaesthesia consultation and ending 3 months after surgery. The primary objective was a 20% reduction in RBC transfusion after implementation of PBM programmes (protocol A + B) when compared to our previous transfusion ratio in the first half of 2018 (30.4% vs 38%). The secondary objectives were to evaluate the impact for each step of the study on the RBC transfusion rate, morbidity and the quality of postoperative rehabilitation.The strength of this study is its evaluation of the effect of a global PBM programme on RBC transfusion in cardiac surgery through a 2-step protocol. We aim to assess for the first time the impact of non-drug and drug interventions on RBC transfusion, comorbidities and delayed rehabilitation parameters. TRIALS REGISTRATIONS: ClinicalTrials.gov, NCT04040023: registered 29 July 2019.

Observations on changes in ventricular repolarization following four weeks of exercise training in chronic heart failure patients.

OBJECTIVE: The aim of this study was to investigate the effects of exercise training on ventricular repolarization dynamicity and heart rate variability in chronic heart failure patients. DESIGN: A total of 22 chronic heart failure patients with reduced ejection fraction in sinus rhythm were included in the study. The patients were in NYHA classes II-III with an ejection fraction of 29.7 ± 7.7%. Before and after 4 weeks of aerobic exercise training, all patients performed a cardiopulmonary exercise test, a standard twelve-lead electrocardiogram and a 24 h Holter recording from which heart rate variability and ventricular repolarization dynamicity were assessed. RESULTS: We observed a significant decrease of QTpeak (p < .001) and QTend (p < .001) at RR intervals ranging from 600 to 1000 ms on 24 h QT/RR regressions after 4 weeks of exercise training. Our analyses revealed that short-term exercise training induced significant changes in the frequency and time domain HRV parameters on an overall time-period of 24 h. CONCLUSION: Four weeks of exercise training induced significant changes in ventricular repolarization dynamicity in chronic heart failure patients. In addition, short-term exercise training was enough to improve patients' heart rate variability.

Short-term effects of a 3-week interval training program on heart rate variability in chronic heart failure. A randomised controlled trial.

BACKGROUND: Exaggerated sympathetic nervous system activity associated with low heart rate variability (HRV) is considered to trigger cardiac arrhythmias and sudden death. Regular exercise training is efficient to improve autonomic balance. OBJECTIVE: We aimed to verify the superiority of high-intensity interval training (HIIT) to enhance HRV, cardiorespiratory fitness and cardiac function as compared with moderate intensity continuous training (MICT) in a short, intense cardiac rehabilitation program. METHODS: This was a prospective, monocentric, evaluator-blinded, randomised (1:1) study with a parallel two-group design. Overall, 31 individuals with voluntary chronic heart failure (CHF) (left ventricular ejection fraction [LVEF]<45%) were allocated to MICT (n=15) or HIIT (n=16) for a short rehabilitation program (mean [SD] 27 [4] days). Participants underwent 24-hr electrocardiography, echocardiography and a cardiopulmonary exercise test at entry and at the end of the study. RESULTS: High-frequency power in normalized units (HFnu%) measured as HRV increased with HIIT (from 21.2% to 26.4%, P<0.001) but remained unchanged with MICT (from 23.1% to 21.9%, P=0.444, with a significant intergroup difference, P=0.003). Resting heart rate (24-hr Holter electrocardiography) decreased significantly for both groups (from 68.2 to 64.6 bpm and 66.0 to 63.5 bpm for MICT and HIIT, respectively, with no intergroup difference, P=0.578). The 2 groups did not differ in premature ventricular contractions. Improvement in peak oxygen uptake was greater with HIIT than MICT (+21% vs. +5%, P=0.009). LVEF improved with only HIIT (from 36.2% to 39.5%, P=0.034). CONCLUSIONS: In this short rehabilitation program, HIIT was significantly superior to the classical MICT program for enhancing parasympathetic tone and peak oxygen uptake. CLINICALTRIALS. GOV IDENTIFIER: NCT03603743.

Practitioners' Views on IPV and Its Solutions: An Integrative Literature Review.

There are ongoing debates in the scientific community and in practice settings about how intimate partner violence (IPV) should be defined and understood and about how various interventions must be carried out. If these debates are to bear fruit, however, we must first gain a comprehensive understanding of each stakeholder's viewpoints on IPV and its solutions. This article seeks to contribute to this goal by summarizing empirical studies investigating how practitioners who work with IPV perpetrators understand the problem and its solutions. Based on an integrative review of the literature, it focuses on how practitioners define IPV and its causes, how they perceive the perpetrators and victims, and on the solutions they put forward in order to work against this social problem. The limitations of our current knowledge are outlined as well as the implications of this review for IPV debates.

Preventive fraction of physical fitness on risk factors in cardiac patients: Retrospective epidemiological study.

AIM: To quantify the preventive fraction of physical fitness on the risk factors in patients with cardiovascular diseases (CVDs). METHODS: A total of 249 subjects (205 men and 44 women) suffering from CVD were categorized into four groups, according to their percentage of physical fitness. We calculated the odds ratio to obtain the preventive fraction in order to evaluate the impact of the physical fitness level on the risk factors (i.e., abdominal obesity, depression, diabetes, dyslipidemia, hypertension, obesity, overweight and smoking). RESULTS: It is observed that a normal physical fitness level is sufficient to induce a preventive action on abdominal obesity (38%), diabetes (12%), hypertension (33%), obesity (12%) and overweight (11%). Also, the preventive fraction increases with the level of physical fitness, in particular for hypertension (36%) and overweight (16%). A high physical fitness level does not necessarily induce a preventive action in most risk factors, excluding depression. CONCLUSION: This is the first study which demonstrates that reaching a normal physical fitness level is enough to induce a protection for some risk factors, despite having a CVD.

Improved Walking Claudication Distance with Transcutaneous Electrical Nerve Stimulation: An Old Treatment with a New Indication in Patients with Peripheral Artery Disease.

OBJECTIVE: The aim of this study was to determine whether 45 mins of transcutaneous electrical nerve stimulation before exercise could delay pain onset and increase walking distance in peripheral artery disease patients. DESIGN: After a baseline assessment of the walking velocity that led to pain after 300 m, 15 peripheral artery disease patients underwent four exercise sessions in a random order. The patients had a 45-min transcutaneous electrical nerve stimulation session with different experimental conditions: 80 Hz, 10 Hz, sham (presence of electrodes without stimulation), or control with no electrodes, immediately followed by five walking bouts on a treadmill until pain occurred. The patients were allowed to rest for 10 mins between each bout and had no feedback concerning the walking distance achieved. RESULTS: Total walking distance was significantly different between T10, T80, sham, and control (P < 0.0003). No difference was observed between T10 and T80, but T10 was different from sham and control. Sham, T10, and T80 were all different from control (P < 0.001). There was no difference between each condition for heart rate and blood pressure. CONCLUSIONS: Transcutaneous electrical nerve stimulation immediately before walking can delay pain onset and increase walking distance in patients with class II peripheral artery disease, with transcutaneous electrical nerve stimulation of 10 Hz being the most effective.

Whole-body strength training using a Huber Motion Lab in coronary heart disease patients: safety, tolerance, fuel selection, and energy expenditure aspects and optimization.

OBJECTIVE: The aim of this study was to investigate safety, tolerance, relative exercise intensity, and muscle substrate oxidation during sessions performed on a Huber Motion Lab in coronary heart disease patients. DESIGN: After an assessment of Vo2 peak, 20 coronary heart disease patients participated in two different exercises performed in random order at 40% and 70% (W40 and W70) of the maximal isometric voluntary contraction. RESULTS: No significant arrhythmia or abnormal blood pressure responses occurred during either session, and no muscle soreness was reported within 48 hrs posttest. The authors found a difference between W40 and W70 sessions for mean (standard deviation) ventilation (25.1% [8%] and 32.1% [9%] of maximal ventilation, respectively; P = 0.04) and a small difference for mean (standard deviation) heart rate (73 [7] and 79 [8] beats/min, respectively; P < 0.01). When compared with the W40, the W70 was associated with higher active energy expenditure (2.4 [0.6] and 3.1 [0.9] Kcal/min, respectively; P < 0.0001) and a similar mean (standard deviation) oxygen uptake (5.5 [1] and 6.6 [1] ml/min per kilogram, respectively; P = 0.07). The qualitative percentages of carbohydrates and lipids oxidized were 71% and 29%, respectively, at W40 and 91% and 9%, respectively, at W70. CONCLUSIONS: Both protocols, which consisted of repeating 6-sec phases of contractions with 10 secs of passive recovery on the Huber Motion Lab, seemed to be well tolerated, safe, and feasible in this group of coronary heart disease patients.

[Cardiac rehabilitation: physiologic basis, beneficial effects and contraindications]. / La réadaptation cardiaque: bases physiologiques, effets bénéfiques, contre-indications.

Cardiac rehabilitation can reduce morbidity and mortality cost-effectively among patients with many types of cardiovascular disease yet is widely underutilized. Rehabilitation is helpful not only for patients who have had myocardial infarction but also for those with stable angina or congestive heart failure and those who have undergone myocardial revascularization, transplantation, or valve surgery. The beneficial effects of rehabilitation include a reduction in mortality from cardiovascular disease, improved exercise tolerance, and fewer cardiac symptoms. This method includes improved risk factor management, more successful smoking cessation, better psychosocial well-being, and an increased likelihood of return to work. Rehabilitation requires a multidisciplinary team focusing on therapeutic education, individually tailored exercise, and optimization of functional status and mental health. Current research trends in this area include the evaluation of new secondary prevention modalities and alternatives such as home-based rehabilitation.

High-intensity interval exercise improves vagal tone and decreases arrhythmias in chronic heart failure.

PURPOSE: Autonomic dysfunction including sympathetic activation and vagal withdrawal has been reported in patients with chronic heart failure (CHF). We tested the hypotheses that high-intensity interval exercise (HIIE) in CHF patients would enhance vagal modulation and thus decrease arrhythmic events. METHODS: Eighteen CHF patients underwent a baseline assessment (CON) and were then randomized to a single session of HIIE and to an isocaloric moderate-intensity continuous exercise (MICE). We evaluated the HR, HR variability parameters, and arrhythmic events by 24-h Holter ECG recordings after HIIE, MICE, and CON sessions. RESULTS: We found that HR was significantly decreased after HIIE (68 ± 3 bpm, P < 0.01) when compared with CON and MICE values (71.1 ± 2 and 69 ± 3 bpm, respectively). HIIE led to a significant increase in normalized high-frequency power (35.95% ± 2.83% vs 31.56% ± 1.93% and 24.61% ± 2.62% for CON and MICE, respectively, P < 0.01). Both exercise conditions were associated with an increase in very low frequency power comparative to CON. After HIIE, premature ventricular contractions were significantly decreased (531 ± 338 vs 1007 ± 693 and 1671 ± 1604 for CON and MICE, respectively, P < 0.01). An association was found between the changes in premature ventricular contraction and the changes in low-frequency/high-frequency ratio (r = 0.66, P < 0.01) in patients exposed to HIIE. CONCLUSION: We demonstrate that a single session of HIIE improves autonomic profile of CHF patients, leading to significant reductions of HR and arrhythmic events in a 24-h posttraining period. Cardioprotective effects of HIIE in CHF patients need to be confirmed in a larger study population and on a long-term basis.

Telephone support oriented by accelerometric measurements enhances adherence to physical activity recommendations in noncompliant patients after a cardiac rehabilitation program.

OBJECTIVE: To assess the efficacy of a strategy, based on telephone support oriented by accelerometer measurements, on the adherence to physical activity (PA) recommendations in cardiac patients not achieving PA recommendations. DESIGN: Prospective and randomized study. SETTING: A cardiac rehabilitation program (CRP) at a clinic. PARTICIPANTS: Stable, noncompliant cardiac (coronary artery disease, heart failure, post-cardiovascular surgery) patients (weekly moderate-intensity PA <150 min) were randomly assigned to an intervention group (n=19) or a control group (n=10). INTERVENTIONS: The intervention group wore an accelerometer for 8 weeks. Every 15 days, feedback and support were provided by telephone. The control group wore the accelerometer during the 8th week of the intervention only. MAIN OUTCOME MEASURES: Active energy expenditure (EE) (in kilocalories) and the time spent doing light, moderate, or intense PA (minutes per week). RESULTS: In the intervention group, the time spent at moderate-intensity PA increased from 95.6±80.7 to 137.2±87.5 min/wk between the 1st and 8th week (P=.002), with 36.8% of the sample achieving the target amount of moderate-intensity PA. During the 8th week, the EE averaged 543.7±144.1 kcal and 266.7±107.4 kcal in the intervention group and control group, respectively (P=.004). CONCLUSIONS: Telephone support based on accelerometer recordings appeared to be an effective strategy to improve adherence to PA in noncompliant patients. This intervention could be implemented after a CRP as an inexpensive, modern, and easy-to-use strategy.

Validity of a questionnaire to assess the physical activity level in coronary artery disease patients.

The aim of the study is to compare, in coronary artery disease patients, physical activity (PA) assessed with the Dijon Physical Activity Questionnaire (DPAQ) and the true PA objectively measured using an accelerometer. Seventy patients wore an accelerometer (MyWellness Key actimeter) throughout 1 week after a cardiac rehabilitation program that included therapeutic education about regular PA. Patients completed the DPAQ at the end of the week. The mean weekly active energy expenditure was 619.9 ± 374.6 kcal, and the mean DPAQ score was 21.3 ± 3.1/30 points. There were low but significant correlations between total active energy expenditure and the DPAQ score (ρ=0.4, P=0.009). There were no correlations between peak power output and total DPAQ score. The DPAQ significantly correlates with objective measures given by the MyWellness Key actimeter. The choice between these tools relies on the clinician's appreciation, taking into account patients' characteristics and goals as well as the cost of the method and availability of the tool.

Effects of short-term exercise and exercise training on cognitive function among patients with cardiac disease.

PURPOSE: A number of studies have investigated the effect of physical activity on cognitive performance in healthy subjects although no consensus in results has been established. In patients with cardiac disease that has been associated with cognitive impairment, research regarding improvement in cognition function assumes a clinical interest. We assessed the effect of both acute exercise and aerobic training on cognitive function in patients with coronary artery disease and heart failure who participated in cardiac rehabilitation (CR). METHODS: Twenty-four men (mean age = 51.6 +/- 6.5 years) completed 2 experimental sessions, before (S1) and after exercise training (S2). During each session, participants underwent cognitive evaluations at rest and during exercise on a cycloergometer at 30% of maximal power. Two types of evaluations were used, an exclusively cognitive test (COG, such as arithmetic test, memory test) and a tracking task (TRAC) including motor precision. RESULTS: At S1, no significant difference appeared between rest and acute exercise for COG score (31.5 +/- 9.5 vs 32.2 +/- 10.5; ns). In contrast, acute exercise significantly improved TRAC performance (149 +/- 54 vs 140 +/- 44; P < .05). At S2, COG score improved with exercise (35.5 +/- 10.6 vs 40 +/- 10.8; P < or = .001) but TRAC score remained unchanged (138 +/- 50 vs 134 +/- 42; ns). Concerning the impact of exercise (Delta%), a significant difference was observed for COG (0.03 [-0.03 to 0.11] vs 0.14 [-0.01 to 0.24]; P < .05), before and after training, respectively, but not for TRAC. CONCLUSIONS: Limited data are available concerning the effect of acute exercise and exercise training on cognitive function in patients with cardiac disease. This study provides evidence for the importance of CR in improving cognitive function.

[Influence of depression on the prognosis of cardiovascular diseases]. / Syndromes dépressifs et pronostic des maladies cardiovasculaires.

Coronary artery disease, heart failure and depression are all highly prevalent after 60 years of age. They significantly affect quality of life and represent a major economic burden for society. Some epidemiological and observational studies suggest that depression is an independent risk factor for the onset and progression of ischemic heart disease and heart failure. Patients with depression are more likely to develop ischemic heart disease, and they are more likely to die or to have a recurrence after myocardial infarction. Heart failure is frequently associated with depression, and this combination carries an increased risk of complications and mortality. Several factors seem to link depression with cardiovascular events and poor outcome, including poor adherence to treatment, sympathetic stimulation, endothelial dysfunction, low heart rate variability, and abnormal platelet function. There is strong evidence that depressive symptoms are a negative prognostic factor in patients with heart failure and coronary heart disease. Treatment of depression improves quality of life, but its impact on the outcome of heart diseases is controversial. Selective serotonin reuptake inhibitors seem preferable to tricyclic antidepressant for depressive patients with cardiac diseases, because of their good tolerability and lack of cardiovascular effects.

QT dynamicity: a prognostic factor for sudden cardiac death in chronic heart failure.

INTRODUCTION: The aim of this study was to determine whether impaired adaptation of the QT interval to changes in heart rate predicts sudden death in patients with chronic heart failure (CHF). METHODS: We prospectively included 175 CHF patients in sinus rhythm. QT dynamicity was evaluated by analyzing 24-h Holter recordings. The linear regression slope of QT interval measured to the apex and to the end of T wave plotted against RR intervals was calculated using a dedicated Holter algorithm. RESULTS: Mean follow-up was 29.9+/-17.9 months. There were 48 deaths, of which 21 were sudden. The actuarial 3-year mortality rates were 38.4% for overall mortality and 14.1% for sudden death. Of all the parameters, an increased QTe/RR slope (>0.28) was the strongest independent predictor of sudden death (relative risk 3.47, 95% confidence interval 1.43-8.40, p=0.006). CONCLUSION: Increased 24-h QTe dynamicity is independently predictive of sudden death among patients with heart failure. This simple parameter may help to stratify risk and select patients who may benefit from antiarrhythmic prophylaxis.