Cardiorespiratory fitness and morbidity and mortality in patients with non-small cell lung cancer: a prospective study with propensity score weighting.

INTRODUCTION: This study aimed to investigate the association between cardiorespiratory fitness (CRF) and perioperative morbidity and long-term mortality in operable patients with early-stage non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: This prospective study included consecutive patients with early-stage NSCLC who underwent presurgical cardiopulmonary exercise testing between November 2014 and December 2019 (registration number: ChiCTR2100048120). Logistic and Cox proportional hazards regression were applied to evaluate the correlation between CRF and perioperative complications and long-term mortality, respectively. Propensity score overlap weighting was used to adjust for the covariates. We performed sensitivity analyses to determine the stability of our results. RESULTS: A total of 895 patients were followed for a median of 40 months [interquartile range 25]. The median age of the patients was 59 years [range 26-83], and 62.5% were male. During the study period, 156 perioperative complications and 146 deaths were observed. Low CRF was associated with a higher risk of death (62.9 versus 33.6 per 1000 person-years; weighted incidence rate difference, 29.34 [95% CI, 0.32 to 58.36] per 1000 person-years) and perioperative morbidity (241.6 versus 141.9 per 1000 surgeries; weighted incidence rate difference, 99.72 [95% CI, 34.75 to 164.70] per 1000 surgeries). A CRF of ≤ 20 ml/kg/min was significantly associated with a high risk of long-term mortality (weighted hazard ratio, 1.98 [95% CI, 1.31 to 2.98], p < 0.001) and perioperative morbidity (weighted odds ratio, 1.93 [1.28 to 2.90], p = 0.002) compared to higher CRF. CONCLUSION: The study found that low CRF is significantly associated with increased perioperative morbidity and long-term mortality in operable patients with early-stage NSCLC.

Low cardiorespiratory fitness is significantly associated with increased perioperative morbidity and long-term mortality in operable patients with early-stage non-small cell lung cancer.Future research is recommended to investigate the potential prognostic role of integrating cardiorespiratory fitness into the currently used prognosis algorithm for patients with non-small cell lung cancer.

Exercise Test Predicts Both Noncardiovascular and Cardiovascular Death in a Primary Prevention Population.

OBJECTIVE: To identify specific causes of death and determine the prevalence of noncardiovascular (non-CV) deaths in an exercise test referral population while testing whether exercise test parameters predict non-CV as well as CV deaths. PATIENTS AND METHODS: Non-imaging exercise tests on patients 30 to 79 years of age from September 1993 to December 2010 were reviewed. Patients with baseline CV diseases and non-Minnesota residents were excluded. Mortality through January 2016 was obtained through Mayo Clinic Records and the Minnesota Death Index. Exercise test abnormalities included low functional aerobic capacity (ie, less than 80%), heart rate recovery (ie, less than 13 beats/min), low chronotropic index (ie, less than 0.8), and abnormal exercise electrocardiogram (ECG) of greater than or equal to 1.0 mm ST depression or elevation. We also combined these four abnormalities into a composite exercise test score (EX_SCORE). Statistical analyses consisted of Cox regression adjusted for age, sex, diabetes, hypertension, obesity, current and past smoking, and heart rate-lowering drug. RESULTS: The study identified 13,382 patients (females: n=4736, 35.4%, 50.5±10.5 years of age). During 12.7±5.0 years of follow-up, there were 849 deaths (6.3%); of these 162 (19.1%) were from CV; 687 (80.9%) were non-CV. Hazard ratios for non-CV death were significant for low functional aerobic capacity (HR, 1.42; 95% CI, 1.19 to 1.69; P<.0001), abnormal heart rate recovery (HR, 1.36; 95% CI, 1.15 to 1.61; P<.0033), and low chronotropic index (HR, 1.49; 95% CI, 1.26 to 1.77; P<.0001), whereas abnormal exercise ECG was not significant. All exercise test abnormalities including EX_SCORE were more strongly associated with CV death versus non-CV death except abnormal exercise ECG. CONCLUSION: Non-CV deaths predominated in this primary prevention cohort. Exercise test abnormalities not only predicted CV death but also non-CV death.

Prognostic role of minute ventilation/carbon dioxide production slope for perioperative morbidity and long-term survival in resectable patients with nonsmall-cell lung cancer: a prospective study using propensity score overlap weighting.

BACKGROUND: The role of minute ventilation/carbon dioxide production ( / CO 2 ) slope, a ventilation efficiency marker, in predicting short-term and long-term health outcomes for patients with nonsmall-cell lung cancer (NSCLC) undergoing lung resection has not been well investigated. MATERIAL AND METHODS: This prospective cohort study consecutively enrolled NSCLC patients who underwent a presurgical cardiopulmonary exercise test from November 2014 to December 2019. The association of / CO 2 slope with relapse-free survival (RFS), overall survival (OS), and perioperative mortality was evaluated using the Cox proportional hazards and logistic models. Covariates were adjusted using propensity score overlap weighting. The optimal cut-off point of the E/ CO 2 slope was estimated using the receiver operating characteristics curve. Internal validation was completed through bootstrap resampling. RESULTS: A cohort of 895 patients [median age (interquartile range), 59 (13) years; 62.5% male] was followed for a median of 40 (range, 1-85) months. Throughout the study, there were 247 relapses or deaths and 156 perioperative complications. The incidence rates per 1000 person-years for relapses or deaths were 108.8 and 79.6 among patients with high and low E/ CO 2 slopes, respectively [weighted incidence rate difference per 1000 person-years, 29.21 (95% CI, 7.30-51.12)]. A E/ CO 2 slope of greater than or equal to 31 was associated with shorter RFS [hazard ratio for relapse or death, 1.38 (95% CI, 1.02-1.88), P =0.04] and poorer OS [hazard ratio for death, 1.69 (1.15-2.48), P =0.02] compared to a lower / CO 2 slope. A high E/ CO 2 slope increased the risk of perioperative morbidity compared with a low E/ CO 2 slope [odds ratio, 2.32 (1.54-3.49), P <0.001]. CONCLUSIONS: In patients with operable NSCLC, a high E/ CO 2 slope was significantly associated with elevated risks of poorer RFS, OS, and perioperative morbidity.

Cardiopulmonary testing in long COVID-19 versus non-COVID-19 patients with undifferentiated Dyspnea on exertion.

BACKGROUND: Dyspnea and fatigue are characteristics of long SARS-CoV-2 (COVID)-19. Cardiopulmonary exercise testing (CPET) can be used to better evaluate such patients. RESEARCH QUESTION: How significantly and by what mechanisms is exercise capacity impaired in patients with long COVID who are coming to a specialized clinic for evaluation? STUDY DESIGN AND METHODS: We performed a cohort study using the Mayo Clinic exercise testing database. Subjects included consecutive long COVID patients without prior history of heart or lung disease sent from the Post-COVID Care Clinic for CPET. They were compared to a historical group of non-COVID patients with undifferentiated dyspnea also without known cardiac or pulmonary disease. Statistical comparisons were performed by t-test or Pearson's chi2 test controlling for age, sex, and beta blocker use where appropriate. RESULTS: We found 77 patients with long COVID and 766 control patients. Long COVID patients were younger (47 ± 15 vs 50 ± 10 years, P < .01) and more likely female (70% vs 58%, P < .01). The most prominent difference on CPETs was lower percent predicted peak V̇O2 (73 ± 18 vs 85 ± 23%, p < .0001). Autonomic abnormalities (resting tachycardia, CNS changes, low systolic blood pressure) were seen during CPET more commonly in long COVID patients (34 vs 23%, P < .04), while mild pulmonary abnormalities (mild desaturation, limited breathing reserve, elevated V̇E/V̇CO2) during CPET were similar (19% in both groups) with only 1 long COVID patient showing severe impairment. INTERPRETATION: We identified severe exercise limitation among long COVID patients. Young women may be at higher risk for these complications. Though mild pulmonary and autonomic impairment were common in long COVID patients, marked limitations were uncommon. We hope our observations help to untangle the physiologic abnormalities responsible for the symptomatology of long COVID.

Advances, Challenges, and Progress in Cardiac Rehabilitation in Chronic CVD Management.

PURPOSE OF REVIEW: To review the benefits, challenges, and advances in cardiac rehabilitation (CR) in the management of cardiovascular disease (CVD). RECENT FINDINGS: Novel strategies of delivering CR are being studied that use remote technologies to link patients with CR professionals. These strategies used alone or in tandem with center-based, face-to-face strategies appear to have shorter-term effectiveness, but additional work is needed to assess the longer-term impact. Cardiac rehabilitation improves patient outcomes, but only a minority of eligible individuals participate. Solutions exist to help bridge the barriers to CR participation, including systematic solutions, such as automatic CR referral of eligible patients. Efforts are underway to improve participation, improve the effectiveness of CR therapies, and enhance the reach of CR into new patient groups. Future work in the field is focused on opportunities to advance the science, practice, and policies that will shape and improve the delivery and impact of CR services.

Cardiac transplant and exercise cardiac rehabilitation.

Cardiac transplantation is the final therapeutic option for patients with end-stage heart failure. Most patients experience a favorable functional ability post-transplant. However, episodes of acute rejection, and multiple comorbidities such as hypertension, diabetes mellitus, chronic kidney disease and cardiac allograft vasculopathy are common. The number of transplants has increased steadily over the past two decades with 3,817 operations performed in the United States in 2021. Patients have abnormal exercise physiologic responses related to surgical cardiac denervation, diastolic dysfunction, and the legacy of reduced skeletal muscle oxidative capacity and impaired peripheral and coronary vasodilatory reserve resulting from pre-transplant chronic heart failure. Cardiorespiratory fitness is below normal for most patients with a mean peak VO2 of approximately 60% of predicted for healthy persons. Cardiac transplant recipients are therefore excellent candidates for Exercise-Based Cardiac Rehabilitation (CR). CR is safe and is a recommendation of professional societies both before (pre-rehabilitation) and after transplantation. CR improves peak VO2, autonomic function, quality of life, and skeletal muscle strength. Exercise training reduces the severity of cardiac allograft vasculopathy, stroke risk, percutaneous coronary intervention, hospitalization for either acute rejection or heart failure, and death. However, there are deficits in our knowledge regarding CR for women and children. In addition, the use of telehealth options for the provision of CR for cardiac transplant patients requires additional investigation.

Cardiac Complications of COVID-19 Infection and the Role of Physical Activity.

Since December 2019, the newly emerging coronavirus has become a global pandemic with >250 million people infected and >5 million deaths worldwide. Infection with coronavirus disease-2019 (COVID-19) causes a severe immune response and hypercoagulable state leading to tissue injury, organ damage, and thrombotic events. It is well known that COVID-19 infection predominately affects the lungs; however, the cardiovascular complications of the disease have been a major cause of morbidity and mortality. In addition, patients with cardiovascular disease are vulnerable to contract a severe form of the illness and increased mortality. A significant number of patients who survived the disease may experience post-COVID-19 syndrome with a variety of symptoms and physical limitations. Here, we review the cardiac complications of COVID-19 infection and the results of cardiopulmonary exercise testing and guidelines for exercise training after infection.

The Association Between a Second Course of Cardiac Rehabilitation and Cardiovascular Outcomes Following Repeat Percutaneous Coronary Intervention Events.

PURPOSE: Survivors of coronary artery disease (CAD) events are at risk for repeat events. Although evidence supports cardiac rehabilitation (CR) after an initial CAD event, it is unclear whether a repeat course of CR (CR × 2) is beneficial after a recurrent CAD event. The purpose of this study was to determine the association of CR × 2 with clinical outcomes in persons undergoing repeat percutaneous coronary intervention (PCI). METHODS: We assessed the prevalence of CR × 2 and its impact on cardiovascular outcomes in individuals who experienced a repeat PCI at the Mayo Clinic hospitals between January 1, 1998, and December 31, 2013. Landmark analyses were used to calculate unadjusted and propensity score adjusted mortality rates and cardiovascular (CV) events rates for patients who underwent CR × 2 compared with those who did not. RESULTS: Among 240 individuals who had a repeat PCI and who had participated in CR after their first PCI, 97 (40%) participated in CR × 2. Outcomes were assessed for a mean follow-up time of 7.8 yr (IQR 7.1-9.0 yr). Propensity score-based inverse probability weighting analysis revealed that CR × 2 was associated with significantly lower target lesion revascularization (HR = 0.47: 95% CI, 0.26-0.86; P = .014), lower combined end point of CV death, myocardial infarction, and target lesion revascularization (HR = 0.57: 95% CI, 0.36-0.89; P = .014), and lower CV hospitalization (HR = 0.60; 95% CI, 0.43-0.84; P = .003). CONCLUSION: A second course of CR following repeat PCI is associated with a lower risk of adverse clinical outcomes. These findings support current policies that allow for repeat courses of CR following recurrent CV events.

Reference Standards for Peak Rating of Perceived Exertion during Cardiopulmonary Exercise Testing: Data from FRIEND.

INTRODUCTION: Peak rating of perceived exertion (RPE) is measured during clinical cardiopulmonary exercise testing (CPX) and is commonly used as a subjective indicator of maximal effort. However, no study to date has reported reference standards or the distribution of peak RPE across a large cohort of apparently healthy individuals. PURPOSE: This study aimed to determine reference standards for peak RPE when using the 6-20 Borg scale for both treadmill and cycle tests. METHODS: The analysis included 9551 tests (8821 treadmill, 730 cycle ergometer) from 13 laboratories within the Fitness Registry and Importance of Exercise National Database (FRIEND). Using data from tests conducted January 1, 1980, to January 1, 2021, percentiles of peak RPE for men and women were determined for each decade from 20 to 89 yr of age for treadmill and cycle exercise modes. Two-way ANOVA was used to compare differences in peak RPE values between sexes and across age groups. RESULTS: There were statistically significant differences in RPE between age groups whether the test was performed on a treadmill or cycle ergometer ( P < 0.05). However, the mean and median RPE for each sex, age group, and test mode were between 18 and 19. In addition, 83% of participants met the traditional RPE criteria of ≥18 for indicating sufficient maximal effort. CONCLUSIONS: This report provides the first normative reference standards for peak RPE in both male and female individuals performing CPX on a treadmill or cycle ergometer. Furthermore, these reference standards highlight the general consistency of peak RPE responses during CPX.

A Nonexercise Prediction of Peak Oxygen Uptake for Patients With Cardiovascular Disease: DATA FROM THE FITNESS REGISTRY AND THE IMPORTANCE OF EXERCISE INTERNATIONAL DATABASE (FRIEND).

PURPOSE: Nonexercise predictions of peak oxygen uptake (V˙ o2peak ) are used clinically, yet current equations were developed from cohorts of apparently healthy individuals and may not be applicable to individuals with cardiovascular disease (CVD). Our purpose was to develop a CVD-specific nonexercise prediction equation for V˙ o2peak . METHODS: Participants were from the Fitness Registry and Importance of Exercise International Database (FRIEND) with a diagnosis of coronary artery bypass surgery (CABG), myocardial infarction (MI), percutaneous coronary intervention (PCI), or heart failure (HF) who met maximal effort criteria during a cardiopulmonary exercise test (n = 15 997; 83% male; age 63.1 ± 10.4 yr). The cohort was split into development (n = 12 798) and validation groups (n = 3199). The prediction equation was developed using regression analysis and compared with a previous equation developed on a healthy cohort. RESULTS: Age, sex, height, weight, exercise mode, and CVD diagnosis were all significant predictors of V˙ o2peak . The regression equation was:V˙ o2peak (mL · kg -1 · min -1 ) = 16.18 - (0.22 × age [yr]) + (3.63 × sex [male = 1; female = 0]) + (0.14 × height [cm]) - (0.12 × weight [kg]) + (3.62 × mode [treadmill = 1; cycle = 0]) - (2.70 × CABG [yes = 1, no = 0]) - (0.31 × MI [yes = 1, no = 0]) + (0.37 × PCI [yes = 1, no = 0]) - (4.47 × HF [yes = 1, no = 0]). Adjusted R 2 = 0.43; SEE = 4.75 mL · kg -1 · min -1 .Compared with measured V˙ o2peak in the validation group, percent predicted V˙ o2peak was 141% for the healthy cohort equation and 100% for the CVD-specific equation. CONCLUSIONS: The new equation for individuals with CVD had lower error between measured and predicted V˙ o2peak than the healthy cohort equation, suggesting population-specific equations are needed for predicting V˙ o2peak ; however, errors associated with nonexercise prediction equations suggest V˙ o2peak should be directly measured whenever feasible.

Predictors of Changes in Peak Oxygen Uptake After Outpatient Cardiac Rehabilitation: Importance of Cardiac Rehabilitation Attendance.

Objective: To determine whether the number of cardiac rehabilitation (CR) sessions attended and selected clinical characteristics were predictive of patients who exhibited improvement in peak oxygen uptake (VO2peak) after CR. Patients and Methods: Using the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients aged 18 years or older from Olmsted County, Minnesota, who underwent cardiopulmonary exercise testing before and after CR from 1999 to 2017. Regression models were created to assess the clinical predictors of VO2peak improvement (>0% baseline) after CR. Results: The analysis included 671 patients, of which 524 (78%) patients exhibited VO2peak improvement after CR. The significant univariate predictors of VO2peak improvement included younger age (odds ratio [OR], 0.98; 95% CI, 0.96-0.99), lower pre-CR VO2peak (OR, 0.96; 95% CI, 0.94-0.99), and no history of peripheral artery disease (OR, 0.50; 95% CI, 0.31-0.81) (all, P<.005). The significant independent predictors of VO2peak improvement from the multivariable analysis included the number of CR sessions (OR, 1.04; 95% CI, 1.02-1.05), younger age (OR, 0.96; 95% CI, 0.94-0.98), lower pre-CR VO2peak (OR, 0.92; 95% CI, 0.89-0.95), and no history of peripheral artery disease (OR, 0.47; 95% CI, 0.28-0.78) (all, P<.005). Conclusion: These findings highlight the importance of patient participation in CR sessions and individual clinical characteristics in influencing VO2peak improvement after CR in patients with cardiovascular disease.

Age-Related Differences for Cardiorespiratory Fitness Improvement in Patients Undergoing Cardiac Rehabilitation.

Objective: We investigated age-related differences for peak oxygen uptake (peak VO2) improvement with exercise training during cardiac rehabilitation (CR). Patients and Methods: This was a retrospective cohort study of the Mayo Clinic Rochester CR program including adult patients who attended CR (≥1 session) for any eligible indication between 1999 and 2017 and who had a cardiopulmonary exercise test pre and post CR with VO2 data (peak respiratory exchange ratio ≥1.0). Younger (20-49 yrs), midlife (50-64 yrs), and older adults (≥65 yrs) were compared using ANOVA for delta and percent change in peak VO2; and percentage of peak VO2 responders (>0% change). Results: 708 patients (age: 60.8 ± 12.1 years; 24% female) met inclusion criteria. Delta and percent change in peak VO2 was lower for older adults (1.6 ± 3.2 mL.kg.min-1; 12 ± 27%) compared with younger (3.7 ± 4.0 mL.kg.min-1, p < 0.001; 23 ± 28%, p = 0.002) and midlife adults (2.8 ± 3.8 mL.kg.min-1, p < 0.001; 17 ± 28%, p = 0.04). For midlife, delta change, but not percent change in peak VO2 was significantly lower (p = 0.02) compared with younger. Percentage of responders was only different between older and younger (72 vs. 86%; p = 0.008). Sensitivity analyses in non-surgical patients showed similar differences for delta change, and differences in percent change remained significant between older and younger adults (10 ± 20% vs. 16 ± 18%; p = 0.04). Conclusions: In CR patients, older adults had lower improvement in cardiorespiratory fitness than younger and midlife adults. While excluding surgical patients reduced age-related differences, older adults still had lower cardiorespiratory fitness improvement during CR. These findings may have implications for individualizing CR programming in aging populations to reduce future cardiovascular risk.

Updated Reference Standards for Cardiorespiratory Fitness Measured with Cardiopulmonary Exercise Testing: Data from the Fitness Registry and the Importance of Exercise National Database (FRIEND).

OBJECTIVE: To provide updated reference standards for cardiorespiratory fitness (CRF) for the United States derived from cardiopulmonary exercise (CPX) testing when using a treadmill or cycle ergometer. PATIENTS AND METHODS: Thirty-four laboratories in the United States contributed data to the Fitness Registry and the Importance of Exercise National Database. Analysis included 22,379 tests (16,278 treadmill and 6101 cycle ergometer) conducted between January 1, 1968, through March 31, 2021, from apparently healthy adults (aged 20 to 89 years). Percentiles of peak oxygen consumption for men and women were determined for each decade from 20 through 89 years of age for treadmill and cycle exercise modes, as well as when defining maximal effort as respiratory exchange ratio (RER) greater than or equal to 1.0 or RER greater than or equal to 1.1. RESULTS: For both men and women, the 50th percentile scores for each exercise mode decreased with age and were higher in men across all age groups and higher for treadmill compared with cycle CPX. The average rate of decline per decade over a 6-decade period was 13.5%, 4.0 mLO2·kg-1·min-1 for treadmill CPX and 16.4%, 4.3 mLO2·kg-1·min-1 for cycle CPX. Observationally, the mean peak oxygen consumption was similar whether using an RER criterion of greater than or equal to 1.0 or greater than or equal to 1.1 across the different test modes, ages, and for both sexes. The updated reference standards for treadmill CPX were 1.5 - 4.6 mLO2·kg-1·min-1 lower compared with the previous 2015 standards whereas the updated cycling standards were generally comparable to the original 2017 standards. CONCLUSION: These updated cardiorespiratory fitness reference standards improve the representativeness of the US population compared with the original standards.

Cardiac rehabilitation for heart transplant patients: Considerations for exercise training.

Heart transplantation (HT) is the treatment of choice for eligible patients with end-stage chronic heart failure (HF). One-year survival world-wide is >85%. Many patients experience a reasonable functional ability post-HT, but episodes of acute rejection, as well as multiple co-morbidities such as hypertension, diabetes, chronic kidney disease and cardiac allograft vasculopathy are common. Immunosuppression with prednisone frequently results in increased body fat and skeletal muscle atrophy. Exercise capacity is below normal for most patients with a mean peak oxygen uptake (VO2) of approximately 60% of expected. HT recipients have abnormal exercise physiology findings related to surgical cardiac denervation, diastolic dysfunction, and the legacy of reduced skeletal muscle oxidative capacity and impaired vasodilatory ability resulting from pre-HT chronic HF. The heart rate response to exercise is blunted. Cardiac reinnervation resulting in partial normalization of the heart rate response to exercise occurs in approximately 40% of HT recipients months to years after HT. Supervised exercise training in cardiac rehabilitation (CR) programs is safe and is recommended by professional societies both before (pre-habilitation) and after HT. Exercise training does not require alteration in immunosuppressants. Exercise training in adults after HT improves peak VO2 and skeletal muscle strength. It has also been demonstrated to reduce the severity of cardiac allograft vasculopathy. In addition, CR exercise training is associated with reduced stroke risk, percutaneous coronary intervention, hospitalization for either acute rejection or HF, and death. There are only limited data for exercise training in the pediatric population.

Enrollment and Adherence to Early Outpatient and Maintenance Cardiac Rehabilitation Programs.

Early outpatient (ECR) and maintenance cardiac rehabilitation (MCR) programs are essential, evidence-based services that have received unequivocal endorsement by national and international professional organizations. However, the latest data characterizing ECR enrollment and adherence fell well short of what would be expected for a therapy that has accumulated decades of empirical evidence touting the associated physiologic, physical, psychosocial, and financial benefits. Although national participation levels have remained stagnant, a series of recent publications showcase effective strategies that could bolster both ECR enrollment and adherence levels at the institutional level. Unlike ECR, fewer reports on enrollment and adherence rates exist for MCR, partly due to the lack of standardization of this service. In this review, we aim to highlight current data on enrollment and adherence to ECR and MCR and discuss evidence-based programmatic strategies to support utilization of both services.

Multicomponent Cardiac Rehabilitation and Cardiovascular Outcomes in Patients With Stable Angina: A Systematic Review and Meta-analysis.

OBJECTIVE: To carry out a systematic review of the effect of cardiac rehabilitation (CR) and its components on cardiovascular outcomes in patients with stable angina. METHODS: We searched the databases including Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL from their inception up to November 1, 2017. The search was not restricted to time or publication status but was limited to the English language. Two independent investigators screened the identified studies and extracted the data in duplicate. We reviewed the included studies and, where possible, pooled their results and conducted meta-analyses. Risk of bias was assessed using Cochrane Collaboration tools. RESULTS: The search identified 7508 studies. Ten randomized trials including 4005 participants with the mean (SD) age of 59.6 (5.7) years were considered eligible for inclusion in our analyses. The results of meta-analyses of exercise-based CR for patients with stable angina revealed that CR improved exercise capacity (the difference between baseline and follow-up was 0.76 watt [0.49 to 1.02] higher in the CR group vs the non-CR group) and decreased angina frequency (standard mean difference, -0.27 [CI, -0.43 to 0.11]). No significant differences were noted in other outcomes, including quality of life. Mortality could not be adequately assessed because it was analyzed in only 1 exercise-based CR study. CONCLUSION: Our systematic review, involving a relatively small number of studies with low to moderate risk of bias and with considerable heterogeneity, found a significant decrease in angina frequency and increase in exercise capacity in patients with stable angina who participated in an exercise-based CR program. Studies involving the impact of components of CR are limited and generally report beneficial outcomes. Additional studies are needed to clarify the possible role of CR in the management of patients with stable angina.

Cardio-Oncology Rehabilitation (CORE) Exercise Prescription and Programming: A PRACTICAL GUIDE.

BACKGROUND: Patients with cancer almost universally report diminished health-related quality of life. Many patients experience persistent fatigue and most have below-average exercise capacities. Despite the publication of exercise guidelines for cancer survivors that encourage physical activity, few patients exercise on a regular basis. Cardiovascular disease is a major cause of death in early-stage malignancies. Exercise training has been demonstrated to decrease cardiovascular events in patients with cancer. In addition, regular exercise improves exercise capacity, reduces fatigue, and improves quality of life in cancer survivors. CLINICAL CONSIDERATIONS: A 2019 American Heart Association scientific statement, endorsed by the American Cancer Society, provided a framework and rationale for partnering with existing multidimensional, interdisciplinary outpatient cardiac rehabilitation programs to provide supervised exercise training and risk factor control services for patients with cancer and cancer survivors: cardio-oncology rehabilitation. In addition, the American College of Sports Medicine has published recommendations for cancer exercise training. SUMMARY: This article provides practical suggestions for incorporating patients with cancer into cardiac rehabilitation and for patient-specific exercise prescription. Illustrative patient case examples are provided.

Type 2 Myocardial Infarction: CURRENT CONCEPTS AND OUR EXPERIENCE WITH CARDIAC REHABILITATION.

BACKGROUND: Type 2 myocardial infarction (T2MI) is commonly encountered in clinical practice, yet little is known about this challenging condition. Outpatient cardiac rehabilitation (CR) is an integral component in the care of patients with MI. However, specific recommendations for CR, information on the feasibility of participation, and outcome measures for patients with T2MI are lacking. CLINICAL CONSIDERATIONS: The frequency of T2MI is markedly variable and depends on the studied population, disease definition, adjudication process, cardiac troponin assays, and cutoff values used to make the diagnosis of T2MI. Clinically, it is difficult to distinguish T2MI from type 1 MI or myocardial injury. Type 2 myocardial infarction occurs due to myocardial oxygen supply-demand mismatch without acute atherothrombotic plaque disruption and is associated with adverse short- and long-term prognoses. Currently, there are substantial gaps in knowledge regarding T2MI and there are no clear guidelines for the optimal management of these patients. SUMMARY: In this article, we present important current concepts surrounding T2MI including the definition, pathophysiology, epidemiology, diagnosis, prognosis, and management. We also discuss referral patterns to CR and participation rates and provide our experience with a case series of 17 patients. Very few patients with T2MI are referred to and participate in CR. Our small case series indicated that patients with T2MI respond favorably to CR and that exercise training following standard guidelines appears safe and is well tolerated.