Controversies Surrounding Exercise in Genetic Cardiomyopathies.

Exercise and sports are an integral part of daily life for millions of Americans, with 16% of the US population older than age 15 years engaged in sports or exercise activities (Bureau of Labor statistics). The physical and psychological benefits of exercise are well-recognized. However, high-profile cases of athletes dying suddenly on the field, often due to undiagnosed genetic cardiomyopathies, raise questions about the risks and benefits of exercise for those with cardiomyopathy.

Effectiveness and safety of a home-based cardiac rehabilitation programme of mixed surveillance in patients with ischemic heart disease at moderate cardiovascular risk: A randomised, controlled clinical trial.

BACKGROUND: Previous studies have documented the feasibility of home-based cardiac rehabilitation programmes in low-risk patients with ischemic heart disease, but a similar solution needs to be found for patients at moderate cardiovascular risk. The objective of this study was to analyse the effectiveness and safety of a home-based cardiac rehabilitation programme of mixed surveillance in patients with ischemic cardiopathology at moderate cardiovascular risk. METHODS: A randomised, controlled clinical trial was designed wherein 28 patients with stable coronary artery disease at moderate cardiovascular risk, who met the selection criteria for this study, participated. Of these, 14 were assigned to the group undergoing traditional cardiac rehabilitation in hospital (control group) and 14 were assigned to the home-based mixed surveillance programme (experimental group). The patients in the experimental group went to the cardiac rehabilitation unit once a week and exercised at home, which was monitored with a remote electrocardiographic monitoring device (NUUBO®). The in-home exercises comprised of walking at 70% of heart rate reserve during the first month, and 80% during the second month, for 1 h per day at a frequency of 5 to 7 days per week. A two-way repeated measures analysis of variance (ANOVA) was performed to evaluate the effects of time (before and after intervention) and time-group interaction regarding exercise capacity, risk profile, cardiovascular complications, and quality of life. RESULTS: No significant differences were observed between the traditional cardiac rehabilitation group and the home-based with mixed surveillance group for exercise time and METS achieved during the exertion test, and the recovery rate in the first minute (which increased in both groups after the intervention). The only difference between the two groups was for quality of life scores (10.93 [IC95%: 17.251, 3.334, p = 0.007] vs -4.314 [IC95%: -11.414, 2.787; p = 0.206]). No serious heart-related complications were recorded during the cardiac rehabilitation programme. CONCLUSIONS: The home-based cardiac rehabilitation programme with mixed surveillance appears to be as effective and safe as the traditional model in patients with ischemic heart disease who are at moderate cardiovascular risk. However, the cardiac rehabilitation programmes carried out in hospital seems to have better results in improving the quality of life. TRIAL REGISTRATION: Retrospectively registered NCT02796404 (May 23, 2016).

Exercise Prescription for the Athlete with Cardiomyopathy.

Inherited cardiomyopathies have highly variable expression in terms of symptoms, functional limitations, and disease severity. Associated risk of sudden cardiac death is also variable. International guidelines currently recommend restriction of all athletes with cardiomyopathy from participation in competitive sports. While the guidelines are necessarily conservative because predictive risk factors for exercise-triggered SCD have not been clearly identified, the risk is clearly not uniform across all athletes and all sports. The advent of implantable cardioverter defibrillators, automated external defibrillators, and successful implementation of emergency action plans may safely mitigate risk of sudden cardiac death during physical activity. An individualized approach to risk stratification of athletes that recognizes patient autonomy may allow many individuals with cardiomyopathies to safely train and compete.

In-hospital cardiac arrest: can we change something?

Cardiac arrest is classified as 'in-hospital' if it occurs in a hospitalised patient who had a pulse at the time of admission. A probability of patient's survival until hospital discharge is very low. The reasons for this are old age, multiple co-morbidity of patients, late recognition of cardiac arrest, poor knowledge about basic life support algorithm, insufficient equipment, absence of qualified resuscitation teams (RTs) and poor organization.The aim of this study was to demonstrate characteristics of in-hospital cardiac arrests and resuscitation measures in University Hospital Osijek. We analysed retrospectively all resuscitation procedures data where anaesthesiology RTs provided cardiopulmonary resuscitation (CPR) during 5-year period.We analysed 309 in-hospital resuscitation attempts with complete documentation. Victims of cardiac arrest were principally elderly patients, neurological (30.4 %), surgical (25.24 %) and neurosurgical patients (15.2 %) with many associated severe diseases. In 85.6 % of the cases, resuscitation was initiated by ward personnel and RTs arrived within 5 min in 67 % of the cases. However, in 14.6 % of the cases resuscitation measures had not been started before RT arrival. We found statistical correlation between lower initial survival rates and length of hospital stay (p = 0.001), presence of cerebral ischemia (p = 0.026) or cardiomyopathy (p = 0.004) and duration of CPR (p = 0.041). Initial survival was very low (14.6 %), and full recovery was accomplished in only eight patients out of 309 (2.59 %).Identification of terminal chronic patients in which the CPR is not reasonable, a better organisation and ward personnel education can contribute to better overall success.

Rehabilitación cardíaca en la cardiotoxicidad. A propósito de un caso / Cardiac rehabilitation in cardiotoxicity. A case report

La toxicidad cardiovascular es una de las complicaciones más devastadoras del tratamiento del cáncer de mama. La mayoría de los fármacos antineoplásicos tienen toxicidad cardíaca. El objetivo del estudio es revisar, mediante un caso clínico, los efectos de la rehabilitación cardíaca en pacientes tratados con trastuzumab. La paciente inició un cuadro de disnea a mínimos esfuerzos. Con el diagnóstico de insuficiencia cardiaca secundaria a trastuzumab (FEVI, 35%), fue remitida a rehabilitación. Tras el programa de rehabilitación cardíaca durante 2 meses, se revaloró a la paciente: la capacidad funcional se había incrementado de forma significativa con normalización de FEV1. Los programas de rehabilitación cardíaca antes y durante la quimioterapia se podrían convertir en un posible tratamiento con efecto cardioprotector(AU)

Cardiovascular toxicity is one of the most devastating complications of breast cancer treatment. Most of the anticancer medicines have cardiac toxicity. The purpose of our study has been to review the effects of cardiac rehabilitation in trastuzumab-treated patients based on a case report. After the patient was diagnosed with trastuzumab-induced cardiac failure (LVEF 35%), she initiated cardiac rehabilitation. After 2 months of our rehabilitation program her functional capacity increased significantly, with normalization of her LVEF. Cardiac rehabilitation programs during and after chemotherapy may become a possible treatment with cardioprotective effect(AU)

Health-related quality of life in Brazilian outpatients with Chagas and non-Chagas cardiomyopathy.

PURPOSE: To examine differences in demographic, clinical, and health-related characteristics of quality of life in heart failure patients with Chagas and non-Chagas cardiomyopathy in Brazil. METHODS: This observational study was carried out with 43 Brazilian out-patients with Chagas and 59 non-Chagas cardiomyopathy. RESULTS: No differences were evident between the 2 groups regarding age, sex, mean left-ventricular ejection fraction, and duration of follow-up. Compared with the non-Chagas group, patients with Chagas cardiomyopathy had a higher percentage of participants using artificial pacemakers (P < .001), more symptoms of heart failure as measured by New York Heart Association classes III and IV (P = .02), higher intakes of aspirin and warfarin, a higher use of artificial pacemakers because of bradycardia, and lower health-related quality of life in the Physical Functioning (P = .01) and Role Physical (P = .002) domains of the Medical Outcomes Study Short Form 36-Item Health Status Survey. CONCLUSION: Our study population was limited to one region endemic for Chagas disease in Brazil, and therefore findings need to be confirmed and should not be generalized to other populations without further research.

Trimetazidine potentiates the effects of exercise training in patients with ischemic cardiomyopathy referred for cardiac rehabilitation.

BACKGROUND: Patients referred for cardiac rehabilitation may take advantage from combining trimetazidine (TMZ) with exercise training (ET), as both treatments produce similar effects in the cardiovascular system. It is, however, unknown whether the combination of TMZ with ET may determine greater improvements in functional capacity and endothelial function than ET alone. DESIGN: A randomized longitudinal controlled study. METHODS: We studied 116 patients (97 men and 19 women, mean age 58+/-9 years) with ischemic heart disease and left ventricular dysfunction who were referred for cardiac rehabilitation. Coronary risk factors were present in 82 patients (diabetes in 28 patients). Patients were randomized into three matched groups. A group (TMZ+training, TT, n=30) received TMZ at doses of 20 mg three times daily orally for 8 weeks in addition to standard medications and underwent a supervised program of ET at 60% of oxygen uptake at peak, three times a week for 8 weeks. A group (exercise, E, n=30) completed the ET program without receiving TMZ. A control group (C, n=26) was neither exercised nor received TMZ. A fourth group (TMZ, n=30) receiving TMZ 20 mg three times daily for 8 weeks was also studied. On study entry and at 8 weeks all patients underwent echocardiography, cardiopulmonary exercise testing, and vasomotor reactivity of the brachial artery. RESULTS: Oxygen uptake at peak was significantly increased in the TT (25%), TMZ (15.1%), and E group (15.3%) (P<0.001 TT vs. C; P<0.05 vs. TMZ and E). Left ventricular ejection fraction was also improved in TT (18.4%), TMZ (15.7%), and E (12.9%) (P<0.001 TT vs. C; P<0.05 vs. TMZ and E), as a result of reduction in end-systolic volume. The endothelium-dependent dilation was similarly improved (P<0.001 TMZ vs. C; P<0.05 vs. TMZ and E). The most significant improvements were observed in the subgroup TT with multiple risk factors. CONCLUSION: The addition of TMZ to ET determined greater improvements in functional capacity, left ventricular ejection fraction, and endothelium-dependent dilation than TMZ or ET given alone. No differences between improvements after TMZ and E as compared with controls were observed.

Exercise training improves cardiac performance in diabetes: in vivo demonstration with quantitative cine-MRI analyses.

Diabetic cardiomyopathy is a distinct myocardial complication of the catabolic state of untreated insulin-dependent diabetes mellitus in the streptozotocin-induced diabetic rat. Exercise training has long been utilized as an effective adjunct to pharmacotherapy in the management of the diabetic heart. However, the in vivo functional benefit(s) of the training programs on cardiac cycle events in diabetes are poorly understood. In this study, we used three groups of Sprague-Dawley rats (sedentary control, sedentary diabetic, and exercised diabetic) to assess the effects of endurance training on the left ventricular (LV) cardiac cycle events in diabetes. At the end of 9 wk of exercise training, noninvasive cardiac functional evaluation was performed by using high-resolution magnetic resonance imaging (9.4 T). An ECG-gated cine imaging protocol was used to capture the LV cardiac cycle events through 10 equally incremented phases. The cardiac cycle phase volumetric profiles showed favorable functional changes in exercised diabetic group, including a prevention of decreased end-diastolic volume and attenuation of increased end-systolic volume that accompanies sedentary diabetes. The defects in LV systolic flow velocity, acceleration, and jerk associated with sedentary diabetes were restored toward control levels in the trained diabetic animals. This magnetic resonance imaging study confirms the prevailing evidence from earlier in vitro and in vivo invasive procedures that exercise training benefits cardiac function in this model of diabetic cardiomyopathy despite the extreme catabolic state of the animals.

Rehabilitación cardíaca en pacientes portadores de cardiomiopatía dilatada isquémica. INCOR-EsSALUD 2004-2005 / Rehabilitation cardiac in carrying patients of cardiomiopatia expanded isquemica. INCOR-EsSALUD 2004-2005

El presente estudio prospectivo se realizó en el Area de Prevención y Rehabilitación Cardiaca del Instituto Nacional del Corazón (INCOR). Se evaluaron 50 pactes, con Diagnóstico de Cardiomiopatia Dilatada Isquémica. Todos con Fracción de Eyección Menor de 40 por ciento por Ecocardiografía, Cateterismo cardiaco y/o Perfusión Miocárdica. Estos pacientes no tenían más opción de revascularización por decisión en Reunión Clínica pero con tratamiento óptimo para falla cardiaca. La edad Promedio fue de: 62.1 con un Rango 54-81, 84 por ciento correspondieron al sexo masculino y 16 por ciento al sexo femenino, clínicamente estables en los 3 meses anteriores a su Reclutamiento. Los criterios de exclusión fueron: Angina Inestable, Infarto agudo de Miocardio, Enfermedad Cardiaca Valvular significativa, Enfermedad Pulmonar Crónica significativa, Insuficiencia Renal Crónica Terminal y limitación ortopédica o neurológica. Todos los pacientes fueron evaluados clínicamente previo al ingreso al programa, se les realizo un test ergométrico tipo Naughton. El mismo procedimiento se realizo al culminar el Programa. Los pacientes elegidos Clase funcional (CF) II-III siguieron el siguiente protocolo de Rehabilitación Cardiaca: Seguimiento: Durante 12 meses, con asistencia de 3 sesiones por semana, se trabajó con un pico VO2 de 70 por ciento, y con control de frecuencia cardiaca o por escala de Borg para la percepción del esfuerzo...

Role of exercise in rehabilitation of cancer survivors.

Approximately 70% of all children diagnosed with malignancy become long-term survivors. Anthracycline cardiotoxicity may complicate physical performance and invite a "spectrum of disuse." There is a paucity of information derived from longitudinal, prospective, randomized clinical trials of exercise in cancer survivors, and there are no guidelines concerning the risk of recreational (non-competetive) exercise in adolescent and young adult patients with anthracycline cardiomyopathy. This review will discuss screening procedures that should be performed when assigning exercise regimens to cancer survivors with or without evidence of left ventricular dysfunction. Current recommendations for exercise testing and exercise prescription are also provided.

Cardiac rehabilitation in patients with implantable defibrillators. Feasibility and complications.

OBJECTIVE: We examined patients with implantable cardioverter defibrillators (ICD) in order to demonstrate their safe participation in a standard rehabilitation program. DESIGN: Prospective cohort study of a consecutive series of patients after ICD implantation. Setting Inpatient rehabilitation center. PATIENTS AND METHODS: A total of 118 patients (73.7% male, mean age 60+/-11 years) took part for 23 +/- 4 days in a standard inpatient rehabilitation program including physical activity, psychological care, heart function seminars, and resuscitation exercises with family members. The following noninvasive tests were performed: symptomlimited exercise testing, two-dimensional echocardiography, Holter monitoring, telemetric ICD interrogation, optional fluoroscopy or X-ray examination of the thorax, and (in some patients) defibrillation threshold testing. RESULTS: Out of 118 patients 101 patients (85.6%) participated in regular ergometer training during which the initial workload of 23 +/- 11 Watts could be increased to 45 +/- 18 Watts. An individual conditioning program was assigned to 15% (n = 17) patients, thereby enabling the inclusion of all patients in the rehabilitation process. Under these conditions 12 patients (10%) experienced ICD malfunctions requiring therapy. As a consequence of all cardiac function tests, ICD reprogramming was necessary in 26 patients (22.1%). CONCLUSION: Following ICD implantation, patients may participate in a standard rehabilitation program without serious complications and with a significant increase in physical capacity. However, ICD malfunction occurs in approximately 10% of patients. Additional tests performed by skilled medical staff and appropriate technical equipment allows the ICD program to be optimized.

Enhancing recall of information from a patient education booklet: a trial using cardiomyopathy patients.

A quasi-experimental trial was conducted to compare the effect on information recall of: (a) the use of adjunct questions (AQ) in printed materials; and (b) a procedure (the 5Rs) for integrating printed patient education materials into face-to-face teaching. A total of 51 patients with severe left ventricular failure (cardiomyopathy) was assigned to one of three groups (n=17). Each group worked with a purpose-prepared booklet, the first in association with the 5Rs procedure; the second group with a version of the booklet containing adjunct questions; and the third with a text only version of the booklet. Recall of information from the booklet was measured using a checklist scored on the basis of responses secured in a standardised interview. Improved recall was associated with both the adjunct questions and the 5Rs procedure, with the latter achieving a substantially superior outcome. The practical implications of these findings are presented and directions for further research indicated.

[Classification of myocardial dystrophies in aviation medical certification]. / Klassifikatsiia miokardiodistrofii v praktike vrachebno-letnoi ékspertizy.

Myocardial dystrophy is one of the most common noncoronary lesions of the myocardium in pilots. However, the abundance of proposed classifications of myocardial dystrophies poses certain problems to medical experts. The authors attempt to consider the existing classifications from the standpoint of aviation medical certification and advocate the most acceptable, to their thinking, systematics by N.P. Paleev and L.I.Levitina (1991). Examples of establishing diagnoses of myocardial dystrophy are included. The best suited program for the aviation medical certification board to work out the final statement regarding the occupational fitness of pilots with myocardial dystrophy is proposed.

Extended cardiac support with a portable left ventricular assist system in the home.

Since 1986, the HeartMate left ventricular assist system (LVAS) has been widely used as a bridge to transplantation. Recently, a multicenter study was undertaken to evaluate the safety of allowing patients supported by the vented electric (VE) LVAS to await transplantation at home. Eligible patients progressed from 1 day to 3 day passes, then were discharged from the hospital. Twenty-nine patients at four centers were evaluated for incidence of adverse events and change in quality of life. Mean time of support was 193.7 +/- 138 days (range, 35-504 days). Patients spent a total of 2,922 days at home: 344 1 day passes and 150 3 day passes were issued; 21 patients were discharged from the hospital. There were 15 readmissions to the hospital: 9 for medical reasons and 6 for device related problems. Patients were able to resolve numerous technical problems at home. No deaths occurred outside of the hospital. Two patients returned to full-time employment, and all patients resumed an active lifestyle. Although adverse events occurred, the results of this study appear to demonstrate that patients may safely await transplantation at home while supported by a HeartMate VE-LVAS.

Use of a left ventricular assist device in an outpatient setting.

The vented electric Heartmate LVAD (VE-LVAD) (Thermo Cardiosystems, Inc., Woburn, MA) is a reliable, fully portable system that allows selected patients with end-stage cardiomyopathy to undergo outpatient treatment while waiting for heart transplantation. This implantable, pusher-plate LVAD is actuated by an electric motor located within the pump housing. The patient wears external batteries and a system controller, which power and control the LVAD motor through a percutaneous lead. Since May 1991, four men have been supported with the VE-LVAD. They ranged in age from 33 to 50 years (mean, 44.3 years); two had idiopathic cardiomyopathy, and two had ischemic cardiomyopathy. Of the four patients, three underwent support of 196, 219, and 504 days; support in the fourth patient is ongoing at more than 90 days. All four patients were fully rehabilitated to New York Heart Association Class I status. Because they were well and fully mobile, the protocol was amended to allow these patients to leave the hospital in a four phase program that begins with 16 hr day passes and leads to hospital discharge. When patients leave the hospital, they are accompanied by trained family members or friends. The patients who have participated in the program have performed routine activities, attended social events, and spent the night at home. The VE-LVAD system seems safe and appropriate for the outpatient setting in selected patients. Patients have been able to manage the system without assistance from medical or engineering personnel. This initial positive experience with outpatient LVAD treatment demonstrates the potential for providing long-term cardiac support with this type of implantable technology.