The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada.

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.

En dépit des avancées importantes de la recherche médicale et des efforts en santé publique, il reste des lacunes dans les connaissances sur la santé cardiaque des femmes sur les plans de l'épidémiologie, du tableau clinique, de la prise en charge, des résultats, de l'éducation, de la recherche et des publications. Du point de vue historique, la cardiopathie a d'abord été perçue comme une maladie qui touchait les hommes et les individus de sexe masculin. De ce fait, la compréhension des risques particuliers et des symptômes qu'éprouvent les femmes est limitée. Ces lacunes dans les connaissances posent particulièrement problème puisqu'à l'échelle mondiale la cardiopathie est la cause principale de décès chez les femmes. Jusqu'à récemment, la recherche en cardiologie, notamment la recherche préclinique et clinique, ne portait pas sur le sexe et le genre. Le recrutement souvent limité aux participants masculins et aux individus dont l'identité de genre correspond au sexe masculin et l'absence d'analyses de données en fonction du sexe ou du genre ont eu pour conséquence un manque de données sur la façon dont les traitements et les interventions nuisent aux patientes féminines et aux individus dont l'identité de genre correspond au sexe féminin, et ce, de façon différente. Cette absence de données a mené à un traitement sous-optimal et à des limites de notre compréhension des mécanismes sous-jacents de la cardiopathie chez les femmes, et est directement reliée à nos connaissances limitées, et à nos lacunes en formation professionnelle et en éducation du public. Le fait que les femmes ne connaissent souvent pas leurs facteurs de risque de maladies du cœur ou les symptômes qu'elles peuvent éprouver entraîne des retards de diagnostic et de traitements. De plus, le fait que les prestataires de soins de santé ne reçoivent pas la formation adéquate pour poser le diagnostic et traiter la cardiopathie chez les femmes les mène à poser un mauvais diagnostic ou à ne pas traiter suffisamment. Pour pallier ces lacunes de connaissances, il faut une approche à plusieurs volets, qui porte notamment sur l'éducation et les changements dans les politiques, et qui repose sur la recherche fondée sur des données probantes. Dans ce chapitre, nous passons en revue l'état actuel de la recherche existante sur les maladies cardiovasculaires au Canada, plus particulièrement chez les femmes.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Women's Knowledge of Future Cardiovascular Risk Associated With Complications of Pregnancy: A Systematic Review.

Background: Several common pregnancy conditions significantly increase a woman's risk of future cardiovascular diseases (CVD). Patient education and interventions aimed at awareness and self-management of cardiovascular risk factors may help modify future cardiovascular risk. The aim of this systematic review was to examine education interventions for cardiovascular risk after pregnancy, clinical measures/scales, and knowledge outcomes in published qualitative and quantitative studies. Methods: Five databases were searched (from inception to June 2023). Studies including interventions and validated and nonvalidated measures of awareness/knowledge of future cardiovascular risk among women after complications of pregnancy were considered. Quality was rated using the Mixed Methods Appraisal Tool. Results were analyzed using the Synthesis Without Meta-analysis reporting guideline. Characteristics of interventions were reported using the Template for Intervention Description and Replication. Fifteen studies were included; 3 were randomized controlled trials. Results: In total, 1623 women had a recent or past diagnosis of hypertensive disorders of pregnancy, gestational diabetes mellitus, and/or premature birth. Of the 7 studies that used online surveys or questionnaires, 2 reported assessing psychometric properties of tools. Four studies used diverse educational interventions (pamphlets, information sheets, in-person group sessions, and an online platform with health coaching). Overall, women had a low level of knowledge about their future CVD risk. Interventions were effective in increasing this knowledge. Conclusions: In conclusion, women have a low level of knowledge of risk of CVD after pregnancy complications. To increase this level of knowledge and self-management, this population has a strong need for psychometrically validated tailored education interventions.

Contexte: Plusieurs problèmes médicaux liés à la grossesse augmentent significativement le risque d'une maladie cardiovasculaire (MCV) ultérieure chez les femmes. L'éducation des patients et les interventions axées sur la sensibilisation aux facteurs de risques cardiovasculaire et sur l'autoprise en charge pourraient aider à limiter le risque de MCV. La présente analyse des études qualitatives et quantitatives publiées visait à examiner les interventions éducatives au sujet des risques cardiovasculaires après la grossesse, les mesures et échelles cliniques qui y sont associées, et les résultats de ces interventions sur le plan des connaissances. Méthodologie: Des recherches ont été réalisées dans cinq bases de données (de leur date de création jusqu'à juin 2023). Les études considérées incluaient des interventions et des mesures validées ou non de la sensibilisation des femmes au sujet des risques de MCV après des complications liées à la grossesse ou de leurs connaissances à ce sujet. La qualité des études a été évaluée avec l'Outil d'évaluation de la qualité méthodologique des études incluses dans une revue mixte, et les résultats ont été évalués à l'aide de la méthodologie Synthesis Without Meta-analysis. Les caractéristiques des interventions ont été relevées selon le modèle Template for Intervention Description and Replication. Quinze études ont été retenues, dont 3 essais contrôlés randomisés. Résultats: Au total, 1623 femmes avaient reçu récemment ou auparavant un diagnostic de trouble hypertensif lié à la grossesse, de diabète gestationnel et/ou de travail prématuré. Parmi les 7 études ayant eu recours à des questionnaires ou des sondages en ligne, 2 mentionnaient l'évaluation des propriétés psychométriques des outils. Dans 4 études, plusieurs interventions éducatives ont été utilisées (dépliants, feuillets informatifs, séances de groupe en personne et plateforme en ligne offrant un accompagnement en matière de santé). De manière générale, le niveau de connaissance des femmes au sujet de leur risque de MCV était faible, mais les interventions se sont révélées efficaces pour améliorer ces connaissances. Conclusions: En conclusion, les femmes ne connaissent pas bien les risques de MCV associés aux complications survenues au cours de la grossesse. Pour améliorer le niveau des connaissances et l'autoprise en charge, des interventions conçues pour cette population et validées sur le plan psychométrique sont indispensables.

Inpatient vs. Outpatient: A Systematic Review of Information Needs throughout the Heart Failure Patient Journey.

The objective of this systematic review was to identify and describe information needs for individuals with heart failure (HF) throughout their patient journey. Six databases were searched (APA PsycINFO, CINAHL Ultimate, Embase, Emcare Nursing, Medline ALL, and Web of Science Core Collection) from inception to February 2023. Search strategies were developed utilizing the PICO framework. Potential studies of any methodological design were considered for inclusion through a snowball hand search. Data from the included articles were extracted by a reviewer, and the extraction accuracy was independently cross-checked by another author. Quality appraisal was assessed using the Mixed-Methods Appraisal Tool. A narrative synthesis was used to analyze all the outcomes according to the Synthesis Without Meta-analysis reporting guidelines. Twenty-five studies (15 quantitative and 10 qualitative) were included. Socioeconomic, cultural, and demographic factors influencing information needs were considered. The top three information needs for outpatients included general HF information, signs and symptoms and disease management strategies. For inpatients, medications, risk factors, and general HF were reported as the top needs. These divergent needs emphasize the importance of tailored education at different stages. Additionally, the review identified gaps in global representation, with limited studies from Africa and South America, underscoring the need for inclusive research. The findings caution against overgeneralization due to varied reporting methods. Practical implications call for culturally sensitive interventions to address nuanced HF patients' needs, while future research must prioritize standardized reporting, consider diverse patient journey timepoints, and minimize biases for enhanced reliability and applicability.

A Systematic Review of Clinical Practice Guidelines and Consensus Statements for Cardiac Rehabilitation Delivery: Consensus, Divergence, and Important Knowledge Gaps.

BACKGROUND: After 2020, clinical practice recommendations have been released to inform cardiac rehabilitation (CR) programs of best practices for post-COVID programming. The objective of this systematic review was to identify and summarize recommendations from clinical practice guidelines (CPGs) and consensus statements for CR delivery postpandemic. METHODS: Five databases (March 2020 through April 2023), grey literature and Web sites of CR international associations were searched. Inclusion criteria were local, national, and international association-endorsed CPGs, and/or position, expert, and scientific statements related to CR delivery (program models, program elements, and core components). Two researchers independently screened the citations for inclusion. The Appraisal of Guidelines for Research and Evaluation (AGREE) II was used for quality assessment. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guidelines. RESULTS: Overall, 4890 records were identified; 4 CPGs, 9 position/scientific statements, and 6 expert/Delphi consensus papers were included. All guidelines/statements included information related to program delivery models, with 95% endorsing the use of virtual, hybrid, home-based, and telerehabilitation, especially during the pandemic. Outside of the context of COVID-19, program components including referral, CR indications, CR contraindications, timing, and structure were included in the 4 CPGs and 2 of 15 statements. Recommendations related to CR core components were primarily focused on exercise, with no changes since before the pandemic except for COVID-19 considerations for safety. One guideline was specific to women, and 1 scientific statement to heart failure with preserved ejection fraction. CONCLUSIONS: Although 19 documents were identified, CR delivery in low resource settings and for culturally and linguistically diverse populations require attention. Additionally, few recommendations on nutrition, psychosocial counselling, and patient education were reported.

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study.

BACKGROUND: The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models. OBJECTIVE: The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic. METHODS: Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis. RESULTS: Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation. CONCLUSIONS: Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

Sustained Effects of Different Exercise Modalities on Physical and Mental Health in Patients With Coronary Artery Disease: A Randomized Clinical Trial.

BACKGROUND: Twelve-week high-intensity interval training (HIIT), moderate-to-vigorousintensity continuous training (MICT), and Nordic walking (NW) have been shown to improve functional capacity, quality of life (QoL), and depression symptoms in patients with coronary artery disease. However, their prolonged effects or whether the improvements can be sustained remains unknown. In this study we compared the effects of 12 weeks of HIIT, MICT, and NW on functional capacity, QoL, and depression symptoms at week 26. METHODS: Patients with coronary artery disease were randomized to a 12-week HIIT, MICT, or NW program followed by a 14-week observation phase. At baseline, and at weeks 12 and 26, functional capacity was measured with a 6-minute walk test (6MWT); QoL was assessed using the HeartQoL and Short Form-36; and depression severity using the Beck Depression Inventory-II. Prolonged (between baseline and week 26) and sustained (between weeks 12 and 26) effects were assessed using linear mixed models with repeated measures. RESULTS: Of 130 participants randomized, 86 (HIIT: n = 29; MICT: n = 27; NW: n = 30) completed week 26 assessments. There were significant improvements in 6MWT distance, QoL, and depression symptoms from baseline to week 26 (P < 0.05); NW increased 6MWT distance (+94.2 ± 65.4 m) more than HIIT (+59.9 ± 52.6 m; interaction effect P = 0.025) or MICT (+55.6 ± 48.5 m; interaction effect P = 0.010). Between weeks 12 and 26, 6MWT distance and physical QoL increased significantly (P < 0.05). CONCLUSIONS: Twelve weeks of HIIT, MICT, and NW have positive prolonged effects on functional capacity, QoL, and depression symptoms. However, NW conferred additional benefits in increasing functional capacity. The effects of the 12-week exercise programs were sustained at week 26.

A Social-Ecological Perspective of the Perceived Barriers and Facilitators to Virtual Education in Cardiac Rehabilitation: A MIXED-METHODS APPROACH.

PURPOSE: This study explored the perceived barriers and facilitators to participation in patients who did and did not attend virtual cardiac rehabilitation (CR) education sessions. METHODS: A mixed-methods approach was used. Virtual patient education was delivered during the coronavirus-19 pandemic. Phase 1 included a cross-sectional online survey completed by individuals who did and did not participate in these sessions. For phase 2, six virtual focus group sessions were conducted using the social-ecological framework to guide thematic analysis and interpretation of findings. RESULTS: Overall, 106 online surveys were completed; 60 (57%) attended Cardiac College Learn Online (CCLO) sessions only, one (1%) Women with Heart Online (WwHO) only, 21 (20%) attended both, and 24 (22%) did not attend virtual sessions. Half of the participants who attended virtual sessions viewed between one and four sessions. Most participants were from Canada (95%) and included the Toronto Rehabilitation Institute/Toronto Western Hospital centers (76%). Focus group findings revealed six overarching themes: Intrapersonal (mixed emotions/feelings; personal learning preferences); Interpersonal (desire for warmth of human contact and interaction); Institutional (the importance of external endorsement of sessions); and Environmental (technology; perceived facilitators and barriers). CONCLUSION: These findings highlight the unprecedented situation that patients and CR programs are facing during the pandemic. Virtual patient education may be more accessible, convenient, and responsive to the complex needs of these CR participants.

The effects of high-intensity interval training, Nordic walking and moderate-to-vigorous intensity continuous training on functional capacity, depression and quality of life in patients with coronary artery disease enrolled in cardiac rehabilitation: A randomized controlled trial (CRX study).

BACKGROUND: Coronary artery disease (CAD) patients undergoing revascularization procedures often experience ongoing, diminished functional capacity, high rates of depression and markedly low quality of life (QoL). In CAD patients, studies have demonstrated that high-intensity interval training (HIIT) is superior to traditional moderate-to-vigorous intensity continuous training (MICT) for improving functional capacity, whereas no differences between Nordic walking (NW) and MICT have been observed. Mental health is equally as important as physical health, yet few studies have examined the impact of HIIT and NW on depression and QoL. The purpose of this randomized controlled trial (RCT) was to compare the effects of 12 weeks of HIIT, NW and MICT on functional capacity in CAD patients. The effects on depression severity, brain-derived neurotrophic factor (BDNF) and QoL were also examined. METHODS: CAD patients who underwent coronary revascularization procedures were randomly assigned to: (1) HIIT (4 × 4-min of high-intensity work periods at 85%-95% peak heart rate [HR]), (2) NW (resting HR [RHR] + 20-40 bpm), or (3) MICT (RHR + 20-40 bpm) twice weekly for 12 weeks. Functional capacity (six-min walk test [6MWT]), depression (Beck Depression Inventory-II [BDI-II]), BDNF (from a blood sample), and general (Short-Form 36 [SF-36]) and disease-specific (HeartQoL) QoL were measured at baseline and follow-up. Linear mixed-effects models for repeated measures were used to test the effects of time, group and time × group interactions. RESULTS: N = 135 CAD patients (aged 61 ± 7 years; male: 85%) participated. A significant time × group interaction (p = 0.042) showed greater increases in 6MWT distance (m) for NW (77.2 ± 60.9) than HIIT (51.4 ± 47.8) and MICT (48.3 ± 47.3). BDI-II significantly improved (HIIT: -1.4 ± 3.7, NW: -1.6 ± 4.0, MICT: -2.3 ± 6.0 points, main effect of time: p < 0.001) whereas BDNF concentrations did not change (HIIT: -2.5 ± 9.6, NW: -0.4 ± 7.7, MICT: -1.2 ± 6.4 ng/mL, main effect of time: p > 0.05). Significant improvements in SF-36 and HeartQoL values were observed (main effects of time: p < 0.05). HIIT, NW and MICT participants attended 17.7 ± 7.5, 18.3 ± 8.0 and 16.1 ± 7.3 of the 24 exercise sessions, respectively (p = 0.387). CONCLUSIONS: All exercise programmes (HIIT, NW, MICT) were well attended, safe and beneficial in improving physical and mental health for CAD patients. NW was, however, statistically and clinically superior in increasing functional capacity, a predictor of future cardiovascular events.

Submaximal Exercise Testing in Cardiovascular Rehabilitation Settings (BEST Study).

BACKGROUND: This study compared changes in measured versus predicted peak aerobic power (V̇O2 peak) following cardiovascular rehabilitation (CR). Peak cardiopulmonary exercise testing (CPET) results were compared to four V̇O2 peak estimation methods: the submaximal modified Bruce treadmill, Astrand-Ryhming cycle ergometer, and Chester step tests, and the Duke Activity Status Index (DASI). METHODS: Adults with cardiovascular disease (CVD) who completed a 12-week CR program were assessed at baseline and 12 weeks follow-up. CPET, the DASI and three subsequent submaximal exercise tests were performed in a random order. RESULTS: Of the 50 adults (age: 57 ± 11 years) who participated, 46 completed the 12-week CR program and exercise tests. At baseline 69, 68, and 38% of the treadmill, step and cycle tests were successfully completed, respectively. At follow-up 67, 80, and 46% of the treadmill, step and cycle tests were successfully completed, respectively. No severe adverse events occurred. Significant improvements in V̇O2 peak were observed with CPET (3.6 ± 5.5 mL.kg-1.min-1, p < 0.001) and the DASI (2.3 ± 4.2 mL.kg-1.min-1, p < 0.001). Bland-Altman plots of the change in V̇O2 peak between CPET and the four V̇O2 peak estimation methods revealed the following: a proportional bias and heteroscedastic 95% limits of agreement (95% LoA) for the treadmill test, and for the cycle and step tests and DASI, mean bias' and 95% LoA of 1.0 mL.kg-1.min-1 (21.3, -19.3), 1.4 mL.kg-1.min-1 (15.0, -12.3) and 1.0 mL.kg-1.min-1 (13.8, -11.8), respectively. CONCLUSION: Given the greater number of successful tests, no serious adverse events and acceptable mean bias, the step test appears to be a valid and safe method for assessing group-level mean changes in V̇O2 peak among patients in CR. The DASI also appears to be a valid and practical questionnaire. Wide limits of agreement, however, limit their use to predict individual-level changes.

Results of the Sedentary Intervention Trial in Cardiac Rehabilitation (SIT-CR Study): A pilot randomized controlled trial.

BACKGROUND: Sedentary time (ST) is negatively associated with cardiometabolic health and fitness. Traditional cardiac rehabilitation (CR) programming may not significantly reduce ST. The objectives of the study were to assess the feasibility and practicality of activPAL devices for measuring ST in CR, and whether prompting cues to interrupt sedentary behaviour can decrease ST and improve clinical outcomes. METHODS: An 8-week, two-arm pilot randomized controlled trial allocated coronary artery disease patients to either a control (usual care CR) or intervention (CR + sedentary prompts from an activPAL3-VT) group. Primary outcomes included: recruitment; acceptability; completion; and, adherence rates. Secondary outcomes included changes in: ST; physical activity (PA); cardiometabolic health; psychosocial health; and, fitness. RESULTS: Forty participants (16 females; 19 intervention; 62 ±â€¯10 years) were randomized. Outcome data were available for 95% of participants. All but one participant completed the full intervention. Most (73%) intervention participants felt the prompts had somewhat changed their sedentary behaviour. At baseline, participants spent 47% of their day sedentary. No significant group differences in changes for any of the ST, PA or fitness outcomes were observed. The mean group difference for post-intervention ST (controlling for baseline) was 30.3 min/day (95% CI: -51.7, 112.2) in favour of the intervention. The intervention group reported significantly better physical health and had a lower ratio of total cholesterol-to-high density lipoprotein when compared to controls. CONCLUSIONS: It is feasible to use activPAL devices to measure ST in a CR setting. Further studies are needed to assess the effectiveness of multi-component sedentary behaviour interventions.

Impact of Workplace Physical Activity Interventions on Physical Activity and Cardiometabolic Health Among Working-Age Women: A Systematic Review and Meta-Analysis.

BACKGROUND: Cardiovascular disease is the leading cause of death among women in high-income Organization for Economic Co-operation and Development countries. Physical activity is protective for cardiovascular disease. The realities of modern life require working-age women to address work-related, family, and social demands. Few working-age women meet current moderate-to-vigorous-intensity physical activity (MVPA) recommendations. Given that working-age women spend a substantial proportion of their waking hours at work, places of employment may be an opportune and a controlled setting to implement programs, improving MVPA levels and enhancing cardiometabolic health. METHODS AND RESULTS: Eight electronic databases were searched to identify all prospective cohort and experimental studies reporting an MVPA outcome of workplace interventions for working-age women (mean age, 18-65 years) in high-income Organization for Economic Co-operation and Development countries. Risk of bias was assessed using the Cochrane risk of bias tool; quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. A qualitative synthesis was performed for all studies, and meta-analyses were conducted where possible. Twenty-four studies met the inclusion criteria; 20 studies were included in the meta-analyses. Workplace interventions significantly increased minutes per week of metabolic equivalents (4 studies; standardized mean differences, 2.07; 95% confidence interval [CI], 1.44 to 2.69), but not minutes per week of MVPA (13 studies; standardized mean differences, 0.38; 95% CI, -0.15 to 0.92) or metabolic equivalents per week (3 studies; standardized mean differences, 0.11; 95% CI, -0.48 to 0.71). Workplace interventions also significantly decreased body mass (7 studies; mean differences, -0.83 kg; 95% CI, -1.64 to -0.02), body mass index (6 studies; mean differences, -0.35 kg/m2; 95% CI, -0.62 to -0.07), low-density lipoprotein (4 studies; mean differences, -0.11 mmol/L; 95% CI, -0.17 to -0.04), and blood glucose (2 studies; mean differences, -0.18 mmol/L; 95% CI, -0.29 to -0.07). These workplace interventions targeting MVPA levels and known beneficial cardiometabolic health sequelae were of lower quality evidence. CONCLUSIONS: Workplace interventions variably improve MVPA levels and related cardiometabolic health sequelae of working-age women in high-income Organization for Economic Co-operation and Development countries. Our findings underscore the need for ongoing research in this area but also increased dissemination of the existing programs and knowledge.

Associations between measures of vascular structure and function and systemic circulating blood markers in humans.

Examination of relationships between systemic markers and functional measures of arterial structure and function may assist in determining alternative indices of vascular regulation and designing and evaluating interventions to improve arterial structure and function. Twenty young healthy individuals, 20 older healthy men, and 26 individuals with coronary artery disease (CAD), comprising a spectrum of vascular health, participated. Systemic markers of vascular structure and function included: pro-collagen type I C-peptide (PIP) - marker of collagen synthesis, C-telopeptide of type I collagen (CTX) - marker of collagen degradation, endothelin-1 (ET-1) - vasoconstrictor, and interleukin-6 (IL-6) - inflammatory marker. Functional measures of arterial structure and function included carotid artery distensibility and brachial artery flow-mediated dilation (FMD). Moderate positive relationships were observed between carotid distensibility and CTX and PIP (r = 0.57, P < 0.0001 and r = 0.47, P < 0.0001). A negative correlation exists between ET-1 and FMD (r = -0.44, P = 0.0004); however, no relationship was observed between IL-6 and FMD (P = 0.25). Over a broad range of vascular health, relationships were observed between markers of type I collagen turnover and arterial stiffness and between a marker of vasoconstriction and endothelial function. These results indicate that regulatory links, between the indices examined, exist. Therefore, monitoring systemic markers rather than functional vascular measures, may provide sufficient information about vascular health and should be considered in the design and evaluation of vascular interventions.

Associations of non-invasive measures of arterial structure and function, and traditional indicators of cardiovascular risk in adults with cerebral palsy.

BACKGROUND: Persons with cerebral palsy (CP) have mobility limitations and may be at increased risk for cardiovascular disease (CVD). AIMS: To determine the feasibility of assessing novel CVD risk indicators and to identify predictors of CVD risk in a clinic-based group of adults with CP. METHODS: In an observational study, we examined 42 adults with CP (mean age 33.5 ± 12.3 yr). Traditional (resting blood pressure, smoking status and lipids) and novel CVD risk indicators (endothelial function, arterial stiffness, and carotid wall thickness) were assessed. RESULTS: Measures of endothelial function and central arterial stiffness were conducted in 100% and 83% of participants, respectively. Age was the strongest independent predictor of vascular health (cIMT, Age, R square = 0.576, p = 0.001). CONCLUSION: Non-invasive measures of arterial structure and function are feasible to assess and may assist in the prediction of CVD risk in adults with CP.

The influence of cardiac autonomic activity on the QT-variability index in able-bodied and incomplete spinal cord injured individuals.

OBJECTIVES: To investigate, via autonomic blockade, if the QT-variability index (QTVI) is a measure of cardiac autonomic regulation in able-bodied (AB) and incomplete spinal cord injured (SCI) individuals. METHODS: Four SCI (41.6±13.4years; C4-C7, AIS B-D, 13.4±13.4years post injury) and 4 AB (33.0±7.8years) individuals were tested. QTVI was determined from electrocardiographic readings obtained during supine rest and cardiovascular (CV) stress, with and without autonomic blockade. CV stress was induced by 40° head-up tilt, the hand submerged in 10°C water and the jaw clenched. Autonomic blockade was achieved with metoprolol (ß-blockade) and atropine (cholinergic blockade). RESULTS: There was no group×condition interaction for QTVI, although there was a significant main effect for condition. After collapsing across groups, QTVI increased with CV stress (p=0.01) and decreased with subsequent ß-blockade (p=0.04), suggesting that during CV stress, QTVI is reflective of cardiac sympathetic activity. During supine rest, ß-blockade did not change QTVI (p=0.24), however, cholinergic blockade increased QTVI (p<0.001), suggesting that during rest, QTVI is inversely related to cardiac parasympathetic regulation. CONCLUSION: During times of CV stress, QTVI reflects cardiac sympathetic activity, while during resting conditions, QTVI is inversely related to cardiac parasympathetic activity. These relationships persist after autonomically incomplete SCI.

Citrulline does not enhance blood flow, microvascular circulation, or myofibrillar protein synthesis in elderly men at rest or following exercise.

Aging is associated with anabolic resistance, a reduced sensitivity of myofibrillar protein synthesis (MPS) to postprandial hyperaminoacidemia, particularly with low protein doses. Impairments in postprandial skeletal muscle blood flow and/or microvascular perfusion with hyperaminoacidemia and hyperinsulinemia may contribute to anabolic resistance. We examined whether providing citrulline, a precursor for arginine and nitric oxide synthesis, would increase arterial blood flow, skeletal muscle microvascular perfusion, MPS, and signaling through mTORC1. Twenty-one elderly males (65-80 yr) completed acute unilateral resistance exercise prior to being assigned to ingest a high dose (45 g) of whey protein (WHEY) or a low dose (15 g) of whey protein with 10 g of citrulline (WHEY + CIT) or with 10 g of nonessential amino acids (WHEY + NEAA). A primed, continuous infusion of L-[ring-(13)C6] phenylalanine with serial muscle biopsies was used to measure MPS and protein phosphorylation, whereas ultrasound was used to measure microvascular circulation under basal and postprandial conditions in both a rested (FED) and exercised (EX-FED) leg. Argininemia was greater in WHEY + CIT vs. WHEY and WHEY + NEAA from 30 to 300 min postexercise (P < 0.001), but there were no treatment differences in blood flow or microvascular perfusion (all P > 0.05). Phosphorylation of p70S6K-Thr(389) was greater in WHEY vs. WHEY + NEAA (P = 0.02). Postprandial MPS was greater in WHEY vs. WHEY + CIT and WHEY + NEAA under both FED (WHEY: ~128%; WHEY + CIT: ~56%; WHEY + NEAA: ~38%) and EX-FED (WHEY: ~251%; WHEY + CIT: ~124%; WHEY + NEAA: ~108%) conditions (P = 0.003). Citrulline coingestion with a low quantity of protein was ineffective in augmenting the anabolic properties of protein compared with nonessential amino acids.

Endothelial function increases after a 16-week diet and exercise intervention in overweight and obese young women.

Weight loss improves endothelial function in overweight individuals. The effects of weight loss through combined aerobic and resistance training and caloric restriction on in vivo vascular measures and blood markers associated with the regulation of endothelial function have not been comprehensively examined. Therefore, we investigated brachial artery endothelial function and potential regulatory blood markers in twenty overweight women (30.3 ± 2.0 years) who participated in 16 weeks of aerobic (5 d/wk) and resistance training (2 d/wk) (combined: ≥ 250 kcal/d) and caloric restriction (-500 kcal/d versus requirement). Resting brachial artery flow mediated dilation (FMD) and circulating endothelin-1 (ET-1) and interleukin-6 (IL-6) were assessed at baseline and following the intervention. Relative and absolute FMD increased (before: 4.0 ± 0.5% versus after: 6.9 ± 0.6%, P < 0.05, and before: 0.14 ± 0.02 mm versus after: 0.23 ± 0.02 mm, P < 0.05, resp.), while body mass decreased (before: 86.9 ± 2.4 kg versus after: 81.1 ± 2.4 kg, P < 0.05) following the intervention. There were no changes in either blood marker (IL-6: before: 1.5 ± 0.2 pg/mL versus after: 1.5 ± 0.1 pg/mL, P > 0.05, and ET-1: before: 0.55 ± 0.05 pg/mL versus after: 0.59 ± 0.09 pg/mL, P > 0.05). 16 weeks of combined aerobic/resistance training and diet-induced weight loss improved endothelial function in overweight and obese young women, but this increase was not associated with changes in blood markers of vasoconstriction or inflammation.