Effectiveness of Fixed-Dose Combination Therapy (Polypill) Versus Exercise to Improve the Blood-Lipid Profile: A Network Meta-analysis

Exercise type and settings, quality of life, and mental health in coronary artery disease: a network meta-analysis

BACKGROUND AND AIMS

Individuals with coronary artery disease have poorer mental health, health-related quality of life (HR-QoL), and cognition compared with (age-matched) controls. Exercise training may attenuate these effects. The aim is to systematically review and meta-analyse the effects of different exercise types and settings on brain structure/function, cognition, HR-QoL, mental health (e.g. depression, anxiety), and sleep in patients with coronary artery disease.

METHODS

A systematic search was conducted and a network meta-analysis compared (i) exercise types, high-intensity interval training (HIIT), HIIT + resistance (HIIT + R), moderate-intensity training (MIT), MIT + R and stretching-toning-balance training, and (ii) exercise settings, in-person and home-based.

RESULTS

A total of 42 randomized controlled trials with a parallel group design were identified, of which 36 were included in the meta-analysis. Few studies included cognition (n = 2), sleep (n = 2), and none brain structure/function (n = 0). Most studies examined HR-QoL (n = 30), depression (n = 15), and anxiety (n = 9), in which outcomes were meta-analysed. HIIT + R, HIIT, and MIT were associated with improved HR-QoL vs. no exercise (i.e. usual care) [standardized mean difference, SMD: 1.53 (95% confidence interval 0.83; 2.24), 0.44 (0.15; 0.73), and 0.44 (0.20; 0.67), respectively]. In-person exercise was associated with larger and significant improvements [HR-QoL SMD: 0.51 (0.28; 0.74), depressive SMD: -0.55 (-1.03; -0.07), and anxiety symptoms SMD: -1.16 (-2.05; -0.26)] compared with no exercise, whereas home-based programmes were not significantly associated with improvements in these outcomes. Findings were robust in secondary (i.e. intervention duration and volume) and sensitivity analyses excluding high risk of bias studies.

CONCLUSIONS

Exercise training, especially in-person sessions, was associated with improved HR-QoL, depression and anxiety, independently of exercise type. However, this study raises concern about the effectiveness of home-based programmes in improving these outcomes.Study protocol was registered in PROSPERO (ID: CRD42023402569).

An empirical study on 209 networks of treatments revealed intransitivity to be common and multiple statistical tests suboptimal to assess transitivity

BACKGROUND

Transitivity assumption is the cornerstone of network meta-analysis (NMA). Investigating the plausibility of transitivity can unveil the credibility of NMA results. The commonness of transitivity was examined based on study dissimilarities regarding several study-level aggregate clinical and methodological characteristics reported in the systematic reviews. The present study also demonstrated the disadvantages of using multiple statistical tests to assess transitivity and compared the conclusions drawn from multiple statistical tests with those from the approach of study dissimilarities for transitivity assessment.

METHODS

An empirical study was conducted using 209 published systematic reviews with NMA to create a database of study-level aggregate clinical and methodological characteristics found in the tracenma R package. For each systematic review, the network of the primary outcome was considered to create a dataset with extracted study-level aggregate clinical and methodological characteristics reported in the systematic review that may act as effect modifiers. Transitivity was evaluated by calculating study dissimilarities based on the extracted characteristics to provide a measure of overall dissimilarity within and between the observed treatment comparisons. Empirically driven thresholds of low dissimilarity were employed to determine the proportion of datasets with evidence of likely intransitivity. One-way ANOVA and chi-squared test were employed for each characteristic to investigate comparison dissimilarity at a significance level of 5%.

RESULTS

Study dissimilarities covered a wide range of possible values across the datasets. A 'likely concerning' extent of study dissimilarities, both intra-comparison and inter-comparison, dominated the analysed datasets. Using a higher dissimilarity threshold, a 'likely concerning' extent of study dissimilarities persisted for objective outcomes but decreased substantially for subjective outcomes. A likely intransitivity prevailed in all datasets; however, using a higher dissimilarity threshold resulted in few networks with transitivity for semi-objective and subjective outcomes. Statistical tests were feasible in 127 (61%) datasets, yielding conflicting conclusions with the approach of study dissimilarities in many datasets.

CONCLUSIONS

Study dissimilarity, manifested from variations in the effect modifiers' distribution across the studies, should be expected and properly quantified. Measuring the overall study dissimilarity between observed comparisons and comparing it with a proper threshold can aid in determining whether concerns of likely intransitivity are warranted.

Effects of exercise, metformin and their combination on glucose metabolism in individuals with abnormal glycaemic control: a systematic review and network meta-analysis

OBJECTIVE

To compare the efficacy of exercise, metformin and their combination on glucose metabolism in individuals with abnormal glycaemic control.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Embase, Web of Science, PubMed/MEDLINE and SPORTDiscus.

ELIGIBILITY CRITERIA

Randomised controlled trials involving exercise, metformin or their combined treatments in individuals with prediabetes or type 2 diabetes mellitus (T2DM) were included. Outcomes included haemoglobin A1c (HbA1c), 2-hour glucose during oral glucose tolerance test, fasting glucose, fasting insulin and homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

407 articles with 410 randomised controlled trials (n=33 802) were included. In prediabetes, the exercise showed greater efficacy than metformin on HbA1c levels (mean difference -0.16%, 95% CI (-0.23 to -0.09) vs -0.10%, 95% CI (-0.21 to 0.02)), 2-hour glucose (-0.68 mmol/L, 95% CI (-0.97 to -0.39) vs 0.01 mmol/L, 95% CI (-0.38 to 0.41)) and HOMA-IR (-0.54, 95% CI (-0.71 to -0.36) vs -0.23, 95% CI (-0.55 to 0.10)), while the efficacy on fasting glucose was comparable (-0.26 mmol/L, 95% CI (-0.32 to -0.19) vs -0.33 mmol/L, 95% CI (-0.45 to -0.21)). In T2DM, metformin was more efficacious than exercise on HbA1c (-0.88%, 95% CI (-1.07 to -0.69) vs -0.48%, 95% CI (-0.58 to -0.38)), 2-hour glucose (-2.55 mmol/L, 95% CI (-3.24 to -1.86) vs -0.97 mmol/L, 95% CI (-1.52 to -0.42)) and fasting glucose (-1.52 mmol/L, 95% CI (-1.73 to -1.31) vs -0.85 mmol/L, 95% CI (-0.96 to -0.74)); exercise+metformin also showed greater efficacy in improving HbA1c (-1.23%, 95% CI (-2.41 to -0.05)) and fasting glucose (-2.02 mmol/L, 95% CI (-3.31 to -0.74)) than each treatment alone. However, the efficacies were modified by exercise modality and metformin dosage.

CONCLUSION

Exercise, metformin and their combination are efficacious in improving glucose metabolism in both prediabetes and T2DM. The efficacy of exercise appears to be superior to metformin in prediabetes, but metformin appears to be superior to exercise in patients with T2DM.

PROSPERO REGISTRATION NUMBER

CRD42023400622.

Appropriate exercise prescription in primary and secondary prevention of cardiovascular disease: why this skill remains to be improved among clinicians and healthcare professionals. A call for action from the EXPERT Network†

In Europe alone, on a yearly basis, millions of people need an appropriate exercise prescription to prevent the occurrence or progression of cardiovascular disease (CVD). A general exercise recommendation can be provided to these individuals (at least 150 min of moderate-intensity endurance exercise, spread over 3-5 days/week, complemented by dynamic moderate-intensity resistance exercise 2 days/week). However, recent evidence shows that this one size does not fit all and that individual adjustments should be made according to the patient's underlying disease(s), risk profile, and individual needs, to maximize the clinical benefits of exercise. In this paper, we (i) argue that this general exercise prescription simply provided to all patients with CVD, or elevated risk for CVD, is insufficient for optimal CVD prevention, and (ii) show that clinicians and healthcare professionals perform heterogeneously when asked to adjust exercise characteristics (e.g. intensity, volume, and type) according to the patient's condition, thereby leading to suboptimal CVD risk factor control. Since exercise training is a class 1A intervention in the primary and secondary prevention of CVD, the awareness of the need to improve exercise prescription has to be raised among clinicians and healthcare professionals if optimized prevention of CVD is ambitioned.

Low Energy Availability and Increased Risk of Relative Energy Deficiency in Sport (RED-S) During a 3767-km Thru-Hike on the Pacific Crest Trail: A Case Study

Long-distance "thru-hiking" has extraordinary physical demands and has become increasingly popular. This report describes a man (55 y) who thru-hiked the Pacific Crest Trail in 2021 and was at risk of developing the relative energy deficiency in sport (RED-S) syndrome. Hiking distance was 3767 km over 128 d. Eighty-eight days (69%) were full days of hiking, covering 38±8 km/d (mean±SD) in 7.9±1.6 h/d. Exercise energy expenditure above rest (heart rate vs indirect calorimetry regression method) was 2834±1518 kcal/d, total energy expenditure was 5702±1323 kcal/d, and energy intake was 4141 kcal/d. Body mass decreased by 9%, and fat mass (dual-energy X-ray absorptiometry) decreased by 46%. Energy availability (energy intake minus exercise energy expenditure) was 19.3 kcal/d/kg fat-free mass, indicating low energy availability (defined as <30 kcal/d/kg). Dual-energy X-ray absorptiometry-measured spine bone mineral density (BMD) decreased by 8.6%, with little to no decrease in total hip (-1.0%) and femoral neck (-1.5%) BMD. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides increased by 24, 39, and 57%, respectively. Within 8 mo after the hike, BMD and serum lipids nearly or fully returned to baseline. No changes in high-density lipoprotein cholesterol, glycemia, or blood pressure were observed. According to guidelines, these observations are consistent with a moderate risk of RED-S, and a medical evaluation and treatment plan are advisable in order to avoid clinical manifestations (eg, stress fractures, anemia, psychological disturbances). To minimize RED-S risk, it may be prudent for thru-hikers to optimize energy availability by moderating daily hiking distances and/or increasing food intake.

[Update on lipid lowering therapy in peripheral artery disease]

Despite clear guideline recommendations, only about every second PAD patient is prescribed statins, women less often than men. There is an international consensus that every PAD patient should be treated with statins, as these not only lower lipids but also stabilize plaque, resulting in a prognostic benefit. Limb-related endpoints (MALE) can be reduced by 24% compared to placebo by lowering lipids. The combination of low-dose, high-potency statin with ezetimibe can be equivalent to high-dose statin monotherapy and, with better tolerability, promote therapy adherence. Statin intolerance is observed more frequently in certain risk groups but is very rare overall. Effective alternatives are bempedoic acid and PCSK9 inhibitors. About 20% of the population have severely elevated Lp(a) levels that require risk factor management beyond lipid management. A high Lp(a) concentration is associated with PAD progression as an independent risk factor for all atherosclerosis manifestations. Every adult should have an Lp(a) assessment once in their lifetime.

Comparative efficacy of various hypoxic training paradigms on maximal oxygen consumption: A systematic review and network meta-analysis

Background

Enhancement in maximal oxygen consumption (VO2max) induced by hypoxic training is important for both athletes and non-athletes. However, the lack of comparison of multiple paradigms and the exploration of related modulating factors leads to the inability to recommend the optimal regimen in different situations. This study aimed to investigate the efficacy of seven common hypoxic training paradigms on VO2max and associated moderators.

Methods

Electronic (i.e., five databases) and manual searches were performed, and 42 studies involving 1246 healthy adults were included. Pairwise meta-analyses were conducted to compare different hypoxic training paradigms and hypoxic training and control conditions. The Bayesian network meta-analysis model was applied to calculate the standardised mean differences (SMDs) of pre-post VO2max alteration among hypoxic training paradigms in overall, athlete, and non-athlete populations, while meta-regression analyses were employed to explore the relationships between covariates and SMDs.

Results

All seven hypoxic training paradigms were effective to varying degrees, with SMDs ranging from 1.45 to 7.10. Intermittent hypoxia interval training (IHIT) had the highest probability of being the most efficient hypoxic training paradigm in the overall population and athlete subgroup (42%, 44%), whereas intermittent hypoxic training (IHT) was the most promising hypoxic training paradigm among non-athletes (66%). Meta-regression analysis revealed that saturation hours (coefficient, 0.004; P = 0.038; 95% CI [0.0002, 0.0085]) accounted for variations of VO2max improvement induced by IHT.

Conclusion

Efficient hypoxic training paradigms for VO2max gains differed between athletes and non-athletes, with IHIT ranking best for athletes and IHT for non-athletes. The practicability of saturation hours is confirmed with respect to dose-response issues in the future hypoxic training and associated scientific research.

Registration

This study was registered in the PROSPERO international prospective register of systematic reviews (CRD42022333548).

Lifestyle and Health-Related Quality of Life Relationships Concerning Metabolic Disease Phenotypes on the Nutrimdea Online Cohort

Obesity, diabetes and cardiovascular events are non-communicable diseases (NCDs) directly related to lifestyle and life quality. Rises on NCDs rates are leading to increases in early deaths concerning metabolic morbidities. Health-related quality of life (HRQoL) has been described as a subjective perception about the influence of health and personal features on human well-being. This study aimed to characterize phenotypic and lifestyle roles on the occurrence of metabolic diseases and determine the potential mutual interactions and with HRQoL. Data from an online adult population (NUTRiMDEA study, n = 17,332) were used to estimate an adapted Obesogenic Score (ObS), while logistic regression analyses were fitted in order to examine relevant factors related to the prevalence of different metabolic diseases including HRQoL. Sex and age showed significant differences depending on lifestyle and metabolic health (p < 0.05). Adherence to the Mediterranean diet and physical activity showed a mutual interaction concerning ObS (p < 0.001), as well with metabolic health (p = 0.044). Furthermore, metabolic diseases showed own features related to sociodemographic and lifestyle characteristics in this population. Metabolic syndrome components may be differently influenced by diverse lifestyle or socioeconomic factors which in turn affect the perceived HRQoL. These outcomes should be taken into account individually for a precision medicine and public health purposes.