Usefulness of the cardiopulmonary exercise test up to the anaerobic threshold for pati-ents aged ≥ 80 years with cardiovascular disease on cardiac rehabilitation.

OBJECTIVE: A cardiopulmonary exercise test provides information regarding appropriate exercise intensity, but there have been few reports on its use in patients over 80 years of age. DESIGN: Retrospective observational study. PATIENTS: A total of 511 cardiovascular disease patients who performed a cardiopulmonary exercise test from February 2011 to January 2020 were investigated. METHODS: Patients were stratified according to age: < 70 years, 70-79 years, and ≥ 80 years, and the results of the cardiopulmonary exercise test up to anaerobic threshold were compared. RESULTS: Patients in the < 70 age bracket showed higher oxygen consumption, carbon dioxide output, and ventilatory volume and lower ventilation equivalents per oxygen consumption and carbon dioxide output in all time periods. However, there were no significant differences in these parameters or the work rate (70-79 years of age: 41.4 ± 11.7 watts, vs ≥ 80 years: 42.2 ± 10.9 watts, p = 0.95) or oxygen consumption per body weight at anaerobic threshold (12.2 ± 0.2 ml/min/kg, vs 12.1 ± 0.4 ml/min/kg, p = 0.97) between the 70-79 year age bracket and the ≥ 80 year age bracket. CONCLUSION: Even for cardiovascular disease patients age ≥ 80 years, a cardiopulmonary exercise test up to anaerobic threshold can supply useful information for guiding cardiac rehabilitation.

Effect of Left Ventricular Diastolic Dysfunction on the Cardiopulmonary Exercise Test in Patients With Cardiovascular Disease.

Left ventricular diastolic dysfunction exists in patients with heart failure with reduced ejection fraction and causes activity restriction and a poor prognosis, but there have been few reports about exercise tolerance in patients with diastolic dysfunction, regardless of left ventricular ejection fraction (LVEF). In this study, 294 cardiovascular disease patients who performed a cardiopulmonary exercise test (CPX) with an adequate examination by echocardiography at Fukuoka University Hospital from 2011 to 2020 were investigated. Patients were divided into groups with grade I and grade II or III diastolic dysfunction according to diagnostic criteria, regardless of LVEF, by echocardiography. After adjusting for age, gender, body mass index, smoking, and LVEF by propensity score matching, we compared the results of CPX between the grade I and grade II/III groups. There were no significant differences in hemodynamic parameters, or in the respiratory exchange ratio, oxygen uptake per body weight, oxygen uptake per heart rate, or parameters of ventilatory volume. Ventilatory equivalents per oxygen uptake and per carbon dioxide output were significantly worse in the grade II/III group from the rest to peak periods during CPX. In conclusion, left ventricular diastolic dysfunction worsens ventilatory efficacy during CPX. This effect potentially contributes to a poor prognosis in left ventricular diastolic dysfunction.

Influence of Discontinuation of Cardiac Rehabilitation in Elderly Outpatients Due to the COVID-19 Pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic has restricted people's activities and necessitated the discontinuation of cardiac rehabilitation (CR) programs for outpatients. In our hospital, CR for outpatients had to be discontinued for 3 months. We investigated the influence of this discontinuation of CR on physical activity, body composition, and dietary intake in cardiovascular outpatients. Method: Seventy-eight outpatients who restarted CR were investigated. We measured body composition, balance test, stage of locomotive syndrome, and food frequency questionnaire (FFQ) results at restart and 3 months later. We also investigated the results of examination that were obtained before discontinuation. Results: With regard to baseline characteristics, the percentage of male was 62.7% (n = 49), and average age and body mass index were 74.1 ± 8.5 years and 24.9 ± 7.0 kg/m2, respectively. Stage of locomotive syndrome and the results of FFQ did not change significantly. The one-leg standing time with eyes open test significantly worsened at restart (p < 0.001) and significantly improved 3 months later (p = 0.007). With regard to body composition, all limb muscle masses were decreased at restart and decreased even further 3 months later. Conclusions: Discontinuation of CR influenced standing balance and limb muscle mass. While the restart of CR may improve a patient's balance, more time is required for additional daily physical activities. The recent pandemic-related interruption of CR should inspire the development of alternatives that could ensure the continuity of CR in a future crisis.

Depression and Anxiety Are Associated with Physical Performance in Patients Undergoing Cardiac Rehabilitation: A Retrospective Observational Study.

BACKGROUND: Cardiac rehabilitation (CR) combined with stress management training has been shown to be associated with fewer clinical events than CR alone. However, there have been no reports on the associations of CR with the psychological condition and detailed physical activities evaluated on the same day. METHOD: One hundred outpatients who participated in a CR program were graded on the hospital anxiety and depression scale (HADS). We divided them into a high HADS group (n = 32) and a normal HADS group (n = 68) and investigated by whole patients, ischemic heart disease (IHD) patients, and heart failure patients. RESULTS: Overall, the patient age was 70.5 ± 9.6 years, the percentage of males was 73.0%, and the body mass index was 23.4 (21.7-26.0) kg/m2. In the high HADS group, overall functional mobility was poor and the distance in a two-minute walking test was short. Especially in IHD patients, the high HADS group showed high fat mass in body composition and low exercise tolerance and ventilator equivalents in cardiopulmonary exercise test. CONCLUSIONS: Depression and anxiety involved poor physical performance in CR outpatients and particularly involved low exercise tolerance in IHD patients. To evaluate accurate physical performance, it is necessary to investigate psychological condition.

Difference in Prognosis between Continuation and Discontinuation of A 5-Month Cardiac Rehabilitation Program in Outpatients with Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Cardiac rehabilitation (CR) is a requisite component of care for patients with heart failure (HF). We aimed to evaluate the clinical outcomes in outpatients with HF with preserved ejection fraction (HFpEF) compared to those in patients with non-HFpEF who did and did not continue a 5-month CR program. METHODS: 173 outpatients with HF who participated in a 5-month CR program were registered. We divided them into two groups: HFpEF (n = 84, EF 63 ± 7%) and non-HFpEF (n = 89, EF 31 ± 11%). We further divided the patients into those who continued the CR program (continued group) and those who did not (discontinued group) in the HFpEF and non-HFpEF groups. The clinical outcomes at 5 months were compared among the groups. RESULTS: There were no significant differences in patient characteristics at baseline between the continued and discontinued groups in the HFpEF and non-HFpEF groups except for % diabetes mellitus in the non-HFpEF group. The rates of all-cause death and hospital admissions in the continued group in both the HFpEF and non-HFpEF groups were significantly lower than those in the discontinued group. The all-cause death and hospital admissions in each group were independently associated with the continuation of the CR program. CONCLUSIONS: The continuation of a 5-month CR program was associated with the prevention of all-cause death and hospital admissions in both the HFpEF and non-HFpEF groups.

Presence and severity of coronary artery disease in patients who achieved intensive blood pressure reduction at the time of coronary computed tomography angiography.

Blood pressure (BP)-lowering treatment should be aimed at achieving intensive BP control. Coronary computed tomography angiography (CCTA) has become more widely available and enables the accurate noninvasive assessment of coronary artery stenosis for screening. The presence and severity of coronary artery disease (CAD) in patients who achieved intensive BP control at the time of CCTA were compared to those in patients without hypertension (HTN). Nine hundred eighty-five consecutive subjects who were clinically suspected of having CAD or who had at least one cardiac risk factor underwent CCTA. The patients were divided into four groups: patients without HTN (non-HTN group), hypertensive patients who underwent intensive BP lowering (intensive group, <130/80 mmHg), patients who underwent standard BP lowering (standard group, 130-139/80-89 mmHg) and patients with uncontrolled BP (uncontrolled group, >140/90 mmHg). Interestingly, %CAD in the Intensive group was significantly higher than that in patients without HTN. The Intensive group was older and had a higher body mass index, more significantly stenosed coronary vessels, lower levels of high-density lipoprotein cholesterol in the blood, and higher rates of dyslipidemia, diabetes, and anti-dyslipidemia and anti-diabetic medication use than the non-HTN group. The presence of CAD in the Intensive group was independently associated with age, male and smoking, whereas the presence of CAD in the non-HTN group was associated with age, male and family history. Finally, predictors of the number of VDs in the non-HTN and intensive BP-lowering groups were age, male, DL, and intensive BP lowering. In conclusion, these results suggest that hypertensive patients need more rigorous management of other coronary risk factors, despite receiving intensive BP-lowering treatment.

A Coronary Artery Calcium Score of Zero in Patients Who Have Undergone Coronary Computed Tomography Angiography Is Associated With Freedom From Major Adverse Cardiovascular Events.

BACKGROUND: The coronary artery calcification score (CACS) is a good marker of future cardiovascular risk. We determined the association between the CACS and the prognosis in patients who have undergone coronary computed tomography angiography (CCTA). METHODS: We performed a prospective cohort study and enrolled 502 consecutive patients who underwent CCTA for screening of coronary artery disease (CAD) at Fukuoka University Hospital (FU-CCTA Registry) and either were clinically suspected of having CAD or had at least one cardiovascular risk factor with a follow-up of up to 5 years. The patients were divided into CACS = 0 and CACS > 0 groups. Using CCTA, ≥ 50% coronary stenosis was diagnosed as CAD, and the number of significantly stenosed coronary vessels (VD), Gensini score and CACS were quantified. The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, ischemic stroke, acute myocardial infarction and coronary revascularization). RESULTS: %CAD, the number of VD and the Gensini score in the CACS = 0 group were significantly lower than those in the CACS > 0 group. %MACE in the CACS = 0 group was also significantly lower than that in the CACS > 0 group. Kaplan-Meier curves indicated that the CACS = 0 group showed significantly greater freedom from MACE than the CACS > 0 group (P = 0.008). Finally, only CACS = 0 was independently associated with MACE (odd ratio: 0.41, 95% confidence interval: 0.17 - 0.97, P = 0.041). CONCLUSIONS: A CACS of 0 in patients who underwent CCTA was associated with a good prognosis.

Associations between the psoas major muscle index and the presence and severity of coronary artery disease.

The associations between the presence and severity of coronary artery disease (CAD) and measurements of the psoas major muscle (PMM) as assessed by multidetector row coronary computed tomography angiography (MDCT) are not known.We enrolled 793 patients who were clinically suspected to have CAD or had at least one cardiac risk factor and had undergone MDCT. The number of significantly stenosed coronary vessels (VD) and measurements of the PMM index (PMMI) were determined using MDCT.PMMI in the CAD group was significantly lower than that in the non-CAD group in males, but not females. In addition, the levels of PMMI tended to increase as the number of VD decreased in males. When male patients were divided into 2 groups according to median value of age, that is, relatively younger (53.4 ±â€Š9.2 years) and older (72.6 ±â€Š5.7 years) groups, the presence of CAD was independently associated with PMMI in the younger group by a multiple logistic regression analysis. The cut-off level of PMMI that gave the greatest sensitivity and specificity for the diagnosis of CAD in younger males was 8.3 cm/m (sensitivity 0.441, specificity 0.752).In conclusion, PMMI may be an imaging marker for evaluating the presence and/or severity of CAD in males, and particularly in the non-elderly.

Regression and Stabilization of Coronary Vulnerable Plaque by Evolocumab as Assessed by Multidetector Row Computed Tomography.

A 65-year-old man was followed for his coronary conditions using 320-multi detector row computed tomography (MDCT) for 30 months. He had soft plaque in the right coronary artery (RCA) [mean density of plaque was 22 hounsfield units (HU)]. His initial serum low-density lipoprotein cholesterol (LDL-C) was 72 mg/dL. After 30 months, his serum LDL-C was 26 mg/dL under 5.0 mg/day rosuvastatin and evolocumab 140 mg/2 weeks. MDCT showed a regression of the plaque in the RCA and the plaque density was 114 HU (intermediate plaque). In conclusion, intensive lipid-lowering therapy with evolocumab induced the regression and stabilization of coronary vulnerable plaque.

A Woman With Hypertriglyceridemia Who Acquired Antibody Against GPIHBP1.

We report a case of a woman with primary hypertriglyceridemia caused by acquired glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GPIHBP1) autoantibody. This case highlights the necessity of detecting GPIHBP1 autoantibody in patients with acquired hypertriglyceridemia. (Level of Difficulty: Intermediate.).

Successful case of direct puncture of a prosthetic bypass graft in endovascular treatment for long superficial artery chronic total occlusion: a case report.

BACKGROUND: The access site for endovascular therapy (EVT) is often limited because of multi-vascular diseases. Prior lower limb bypass can potentially limit the availability of common femoral artery access when EVT is required. CASE SUMMARY: An 88-year-old woman who presented with non-healing ulceration in the dorsalis pedis of the left foot despite treatment for several months was admitted to our hospital. She had undergone axillo-bilateral femoral bypass surgery for right critical limb ischaemia 3 years previously. Ultrasound and contrast computed tomography demonstrated bypass graft occlusion, left superficial femoral artery (SFA)-popliteal artery long chronic total occlusion from the origin with severe calcification and severe stenosis in the bilateral common femoral artery close to the anastomotic site. EVT for the left SFA occlusion was necessary to save the left foot, but access sites for EVT were limited. We decided to puncture an occluded axillo-femoral prosthetic bypass graft. It is difficult to cross the wire with only an antegrade approach. Therefore, it was necessary to use a bi-directional approach with dorsalis pedis artery puncture and the Rendez-vous technique. Finally, angiogram demonstrated improved blood flow to the wound site, and haemostasis at the puncture site could be achieved by manual compression. The ulceration healed within a month. DISCUSSION: Direct puncture of a prosthetic bypass graft and additional techniques resulted in complete revascularization. Thus, direct puncture of a bypass graft could be a useful EVT strategy for patients with complex and extremely long chronic total occlusion.

Efficacy and safety of a combination antihypertensive drug (olmesartan plus azelnidipine): "Issues with hypertension studies in real-world practice".

Background: This study investigated whether a combination drug containing an angiotensin II receptor blocker (ARB) and a calcium channel blocker (CCB) could provide effective antihypertensive therapy.Methods: A multicenter, prospective, open-label study was conducted at the clinics of Clinical Research Network. The subjects had uncontrolled blood pressure (BP) despite ARB or CCB monotherapy. The effect on both office and home BP was examined after patients switched to a combination drug (REZ: containing 20 mg of olmesartan [OL] and 16 mg of azelnidipine [AZ]).Results: A total of 78 patients were enrolled. After switching to REZ, a significant and sustained reduction of office BP was observed. The proportion of patients who achieved the target for both office and home BP was an increase from 0% to 55%. Switching from amlodipine to REZ resulted in a significant and sustained decrease of office and home BP. There was also a significant decrease of home pulse rate (PR), but office PR was unchanged. To determine the accuracy of the BP and PR values reported by patients, the frequency of each number as the first digit was determined. The frequency of "0" was extremely high for both office and home BP values, and the same was noted for home PR values.Conclusion: The results of this study suggested that switching from a single drug to combination therapy with REZ could achieve a stronger antihypertensive effect. However, concern was raised regarding the methods of BP and PR measurement and recording in this clinical trial involving general practitioners.