Depressive symptoms, right ventricular function, and muscular strength are associated with peak oxygen uptake in patients with implantable left ventricular assist devices.

BACKGROUND: Left ventricular assist device (LVAD) implantation is among the most effective treatment options for patients with severe heart failure. Although previous studies have examined the factors related to peak oxygen uptake (peak VO2 ), they were limited by the few patients involved and their focus on medical and physical functions. Therefore, this study comprehensively examined the factors associated with peak VO2 , which is an important prognostic factor in patients with implantable LVADs. METHODS: Eighty-nine patients who underwent initial LVAD implantation and were eligible for cardiopulmonary exercise testing (CPX) between May 2014 and September 2021 were included. The patients' mean age was 48 ± 12 years, and 70% were males. Based on previous studies, the cut-off was set at 12 and 14 mL/kg/min for patients taking ß-blocker and those not taking ß-blockers, respectively. Furthermore, factors associated with peak VO2 were examined using multivariate logistic regression analysis. RESULTS: The mean time from surgery to CPX administration was 73 ± 40 days. The high group had a higher cardiac index, right ventricular stroke work index (RVSWI), and isometric knee extensor muscular strength and lower Patient Health Questionnaire-9 (PHQ-9) and B-type natriuretic peptide values than the low group. Multivariate logistic regression analysis showed that RVSWI and KEMS were positively correlated, whereas PHQ-9 was negatively associated with peak VO2 . CONCLUSION: Right ventricular function, depressive symptoms, and lower limb muscular strength were associated with exercise capacity in patients with implantable LVADs.

Disease management using home-based cardiac rehabilitation for patients with heart failure.

Home-based cardiac rehabilitation (HBCR) is expected to address the low participation rate in cardiac rehabilitation; however, it is not covered by insurance in Japan, and the optimal method for monitoring a patient's condition during exercise has not been determined. Patients hospitalized for heart failure often deteriorate soon after discharge and require appropriate disease monitoring. In this report, we describe cases in which real-time monitoring of exercise intensity, electrocardiography, and video chat during HBCR was useful in the management of heart failure. Furthermore, the use of HBCR enabled frequent disease monitoring, even during the coronavirus disease 2019 pandemic, and timely medicine adjustment. Learning objective: Clinicians cannot perform radiography, blood tests, or physical examinations at home during home-based cardiac rehabilitation (HBCR). Therefore, it is particularly important to reconsider the appropriate monitoring indicators for HBCR and apply them to disease management. Our cases suggest that real-time monitoring of the following three indicators is useful for disease management using HBCR: (1) exercise intensity, (2) electrocardiography, and (3) shortness of breath.

Depressive symptoms interfere with the improvement in exercise capacity by cardiac rehabilitation after left ventricular assist device implantation.

BACKGROUND: Although depressive symptoms are associated with an increased risk of readmission after left ventricular assist device (LVAD) implantation, it is unclear whether they affect the efficacy of exercise-based cardiac rehabilitation (EBCR). This study aimed to investigate the effect of depressive symptoms on EBCR efficacy. METHODS: We analyzed 48 patients who participated in EBCR after LVAD implantation (mean age 45 ± 12 years; 60% male). Patients were classified into two groups using the Zung Self-Rating Depression Scale (SDS): depressive group (SDS ≥40, n = 27) and non-depressive group (SDS <40, n = 21). We examined changes in peak oxygen uptake (VO2 ), knee extensor muscular strength (KEMS), and quality of life (QOL) during EBCR using analysis of covariance. RESULTS: Although baseline characteristics were similar between the two groups, the non-depressive group was less likely to receive diuretics (22% vs. 52%, p = 0.030). Peak VO2 , KEMS, and QOL significantly increased over time in both groups (all p < 0.05). The depressive group had a significantly lower change in peak VO2 than the non-depressive group (2.7 vs. 1.6 ml/kg/min; mean difference: -1.1 ml/kg/min, 95% confidence interval [CI]: -0.045 to -2.17; p = 0.041, d = 0.59). There was no between-group difference regarding the change in KEMS or QOL. Adjusting for the baseline value, a significant difference between groups was observed only in peak VO2 (p = 0.045). CONCLUSIONS: Although EBCR significantly improved exercise capacity after LVAD implantation, depressive symptoms interfered with this improvement. Further studies are needed to determine whether psychological interventions for depression, in addition to EBCR, would improve the response to EBCR after LVAD implantation.

Sex-related Differences in Exercise Capacity Trends and Determinants after Cardiac Rehabilitation in Patients with Acute Myocardial Infarction.

OBJECTIVE: This study aimed to investigate whether longitudinal changes in exercise capacity in patients with acute myocardial infarction (AMI) differ by sex and clarified what contributed to these differences. METHODS: We retrospectively examined the differences in each variable between men and women in 156 patients with AMI (mean age: 65 ± 12 years; 82.0% male) who participated in a 3-month cardiac rehabilitation (CR) program and could be followed-up for exercise capacity 12-months after AMI onset. Sex-related differences in the change in peak oxygen uptake (peak VO2) at baseline, 3-months, and 12-months after AMI were analyzed. RESULTS: Male patients with AMI were younger and had higher body mass index and employment rate than women. The attendance of the CR program was higher in women (men vs. women; 10 [3-15] vs. 14 [11-24] sessions, p = 0.0002). Women showed a significant lower %change in peak VO2 after 12 months (men vs. women; 7.8% [-0.49% to 14.6%] vs. 1.3% [-5.7% to 7.5%], p = 0.013). In multiple linear regression analysis, age (ß = -0.76, 95% confidence interval [CI] = -1.0 to -0.50, p <0.0001) and female sex (ß = -6.3, 95% CI = -9.1 to -3.5, p <0.0001) were negative independent predictors of change in peak VO2 over 12 months, while CR attendance (ß = 0.21, 95% CI = 0.0032-0.42, p = 0.047) and recommended exercise habit after the CR program (ß = 2.1, 95% CI = 0.095-4.1, p = 0.040) were positive independent predictors of change in peak VO2 over 12 months. CONCLUSION: In female patients, exercise capacity improved during the CR program but decreased to AMI onset levels after 12 months.

Cardiac rehabilitation program improves exercise capacity in heart transplantation recipients regardless of marginal donor factors.

Cardiac rehabilitation (CR) is recommended to improve exercise capacity after heart transplantation (HTx); however, the effects of marginal donor factors are unclear. Forty-one recipients participated in a 3-month CR program early after HTx (mean age 39 ± 14 years; 88% male). Patients were divided into marginal (≥ 2 marginal donor factors; n = 24) and control groups (< 2 marginal donor factors; n = 17). We examined donor and recipient factors related to change in peak oxygen uptake (peak VO2) during the CR program using multiple linear regression analysis. Baseline characteristics were similar between groups, although the mean age was higher in the marginal group (43 ± 13 vs. 34 ± 14 years, p = 0.043). Peak VO2 and knee extensor muscular strength (KEMS) improved significantly in both groups (p < 0.05), but there were no observed inter-group differences. Multiple analysis revealed change in KEMS (ß = 0.52, 95% CI = 0.023-1.01) as an independent predictor of change in peak VO2 after adjustment for recipients' age, sex, and CR attendance frequency (adjusted R2 = 0.25, p = 0.0084), whereas marginal donor factors were not a predictor (p = 0.76). The CR program improved exercise capacity in HTx recipients regardless of marginal donor factors, suggesting that recipients of marginal donor hearts should be referred to CR programs.

Effects of exercise training on physical activity in heart failure patients treated with cardiac resynchronization therapy devices or implantable cardioverter defibrillators.

OBJECTIVE: This study elucidated the effects of exercise training on physical activity, 6-min walk distance, and all-cause hospitalization rates in patients with chronic heart failure, and evaluated factors contributing to changes in physical activity. DESIGN: Prospective cohort observational study. PATIENTS AND METHODS: Patients (n =62) who completed an exercise training programme after implantable cardioverter-defibrillator or cardiac resynchronization therapy treatment between May 2017 and May 2018 were included. Patients exercised for 20-50 min 3-5 times weekly for 3 months and were assigned to the active (≥ 10 min/day) or non-active (< 10 min/day) group based on changes in walking times between baseline and 3 months, as assessed by the International Physical Activity Questionnaire. RESULTS: The 6-min walk distance improved in both groups with exercise training. Physical activity level did not increase in some patients, despite improvements in exercise tolerance. Depression improved significantly in the active group, but no correlation was found with physical activity. Factors contributing to physical activity changes were not identified. The all-cause hospitalization rate was lower in the active group during follow-up (mean 10.5 months). CONCLUSION: Exercise training effectively increased 6-min walk distance regardless of physical activity. Non-active patients experienced increased all-cause hospitalizations. Increasing physical activity improves patient outcomes.

Effect of Exercise Training in Heart Failure Patients Without Echocardiographic Response to Cardiac Resynchronization Therapy.

Background: Cardiac resynchronization therapy (CRT) is an effective treatment of heart failure (HF) with ventricular dyssynchrony, but not all patients respond to a similar extent. We investigated the efficacy and safety of exercise training (ET) in patients without response to CRT. Methods and Results: Thirty-four patients who participated in a 3-month ET program and underwent cardiopulmonary exercise testing at baseline and after the program were divided into 17 responders and 17 non-responders based on echocardiographic response criteria: either an increase in ejection fraction (EF) ≥10% or a reduction in left ventricular (LV) end-systolic volume ≥10%. Baseline characteristics including peak oxygen uptake (V̇O2) and isometric knee extensor muscle strength (IKEMS) were similar in both groups, but non-responders had lower EF and larger LV. During the ET program, neither group had exercise-related adverse event including life-threatening ventricular arrhythmia. Peak V̇O2 and IKEMS were significantly improved in both groups and there was no significant difference in change in peak V̇O2 or IKEMS between responders and non-responders. On multiple regression analysis, change in IKEMS was an independent predictor of change in peak V̇O2, whereas the response to CRT was not. Conclusions: In HF patients undergoing CRT implantation, ET safely improved exercise capacity regardless of response to CRT, suggesting that even advanced HF patients without response to CRT can possibly benefit from ET.

Predictors of improvements in exercise capacity during cardiac rehabilitation in the recovery phase after coronary artery bypass graft surgery versus acute myocardial infarction.

This study aimed to elucidate the predictors of improvements in exercise capacity during cardiac rehabilitation (CR) in the recovery phase after coronary artery bypass graft surgery (CABG) versus acute myocardial infarction (AMI). We studied 152 patients (91 after AMI and 61 after CABG) who participated in a 3-month CR program. All patients underwent a cardiopulmonary exercise test, blood tests, maximal quadriceps isometric strength (QIS) measurement, and bioelectrical impedance body composition measurement at the beginning and end of the 3-month CR program. At baseline, the percentage of predicted peak oxygen uptake (%pred-PVO2), maximal QIS, and hemoglobin (Hb) were significantly lower, while C-reactive protein (CRP) was significantly higher, in the CABG than the AMI group. After the 3-month CR, %change in PVO2 (%ΔPVO2) was significantly greater in the CABG than the AMI group (18 ± 15% vs 11 ± 12%, P < 0.01). At univariate analysis, baseline plasma brain natriuretic peptide (BNP), %change in maximal QIS after CR (%Δ maximal QIS), and change in plasma hemoglobin (ΔHb) significantly correlated with %ΔPVO2 in the CABG group, whereas only baseline %pred-PVO2 did so in the AMI group. Multiple regression analysis revealed that the same factors were independent and significant predictors of %ΔPVO2 in the CABG and AMI groups. The predictors of improvements in exercise capacity after CR differed between patients after CABG or AMI. Specifically, in CABG patients both enhancing QIS and correcting anemia may contribute to greater improvements in exercise capacity after CR, while a more effective CR program should be designed for CABG patients with high baseline BNP.

Cholinesterase levels predict exercise capacity in cardiac recipients early after transplantation.

PURPOSE: Although cardiac rehabilitation is recommended for patients early after heart transplantation (HTx), adequate exercise effect cannot always be obtained, partly because in patients with chronic heart failure, exercise capacity is reduced due to malnutrition while waiting for HTx. This study aimed to investigate the relationships between exercise capacity and clinical variables, including nutritional indicators, early after HTx. PATIENTS AND METHODS: Forty-three HTx recipients were studied. The mean age at HTx was 38 ± 14 years, and 86% were male. We assessed the relationships between peak oxygen uptake (VO2 ) and clinical variables, including plasma B-type natriuretic peptide (BNP), isometric knee extensor muscle strength (KEMS), and nutritional indicators within 1 week of their respective discharges. RESULTS: Peak VO2 correlated positively with isometric KEMS (r = .63, P < .0001) and negatively with BNP level (r = -.37, P = .015). Of the nutritional indicators, only cholinesterase levels had a significant relationship with peak VO2 (r = .34, P = .028), whereas the Geriatric Nutritional Risk Index and the Controlling Nutritional Status scores did not. In multiple linear regression analysis, cholinesterase levels and isometric KEMS were independent predictors of peak VO2 . CONCLUSION: Cholinesterase levels predicted exercise capacity early after HTx.

Effect of exercise intervention on endothelial function and incidence of cardiovascular disease in patients with type 2 diabetes.

AIM: The effects of exercise intervention and to assess its long-term efficacy in preventing subsequent cardiovascular events in patients with type 2 diabetes were little known on randomized controlled trial. METHODS: Thirty-eight type 2 diabetic patients (21 men and 17 women) were assigned to either the exercise group (n=21) or the control group without exercise training (n=17) by simple randomization. The exercise training group was scheduled for aerobic and resistance exercise programs for 3 months. After the 3-month, we investigated endothelial function, insulin resistance, adipocytokines and inflammatory markers. The endothelial function was evaluated by examining a flow-mediated endothelium-dependent vasodilatation (FMD). Furthermore, we followed the incidence of cardiovascular events for 24 months. RESULTS: After 3-month, HbA1C was decreased significantly in both groups. FMD was increased from 7.3+/-4.7% to 10.9+/-6.2% only in the exercise group (p<0.05). Long-term follow-up data showed that the control group developed cardiovascular events more frequently than did the exercise group (p<0.05). CONCLUSIONS: Exercise improves endothelial dysfunction independently of glycemic control and insulin sensitivity in patients with type 2 diabetes. The beneficial effects of 3-month exercise to reduce cardiovascular events persist for 24 months.