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Lee J, Zarezadehmehrizi A, LaVoy EC, Markofski MM, Park Y. Exercise Training Improves Brachial Artery Endothelial Function, but Does Not Alter Inflammatory Biomarkers in Patients with Peripheral Artery Disease: a Systematic Review and Meta-analysis. J Cardiovasc Transl Res 2023:10.1007/s12265-023-10451-0. [PMID: 37870688 DOI: 10.1007/s12265-023-10451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/06/2023] [Indexed: 10/24/2023]
Abstract
The study aimed to systematically review the effects of exercise training (EX) on brachial artery flow-mediated dilation (FMD) and inflammatory biomarkers in patients with peripheral artery disease (PAD). Five electronic databases were searched: (i) patients with PAD aged ≥ 18; (ii) structured EX ≥ 2 weeks; (iii) measured brachial artery FMD; and (iv) measured blood inflammatory biomarkers. Eighteen studies met the inclusion criteria. EX increased FMD but had no effect on C-reactive protein, interleukin-6, and tumor necrosis factor-α. Subgroups with moderate intensity had a greater increase in FMD than subgroups with vigorous intensity. There was no difference in effect on FMD and three inflammatory biomarkers between subgroups training for ≤ 12 weeks and > 12 weeks of EX, < 50 min and ≥ 50 min of session duration, and < 150 min and ≥ 150 min of weekly volume, respectively. These results suggest that EX-induced improvement in vascular function can be independent of the improvement of systemic inflammation.
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Affiliation(s)
- Junghoon Lee
- Laboratory of Integrated Physiology, Department of Health and Human Performance, University of Houston, 3875 Holman St, Houston, TX, 77204-6015, USA
| | - Aliasghar Zarezadehmehrizi
- Laboratory of Integrated Physiology, Department of Health and Human Performance, University of Houston, 3875 Holman St, Houston, TX, 77204-6015, USA
| | - Emily C LaVoy
- Laboratory of Integrated Physiology, Department of Health and Human Performance, University of Houston, 3875 Holman St, Houston, TX, 77204-6015, USA
| | - Melissa M Markofski
- Laboratory of Integrated Physiology, Department of Health and Human Performance, University of Houston, 3875 Holman St, Houston, TX, 77204-6015, USA
| | - Yoonjung Park
- Laboratory of Integrated Physiology, Department of Health and Human Performance, University of Houston, 3875 Holman St, Houston, TX, 77204-6015, USA.
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Tan R, Baranauskas MN, Karl ST, Ortiz de Zevallos J, Shei RJ, Paris HL, Wiggins CC, Bailey SJ. Effects of dietary nitrate supplementation on peak power output: Influence of supplementation strategy and population. Nitric Oxide 2023; 138-139:105-119. [PMID: 37438201 DOI: 10.1016/j.niox.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Increasing evidence indicates that dietary nitrate supplementation has the potential to increase muscular power output during skeletal muscle contractions. However, there is still a paucity of data characterizing the impact of different nitrate dosing regimens on nitric oxide bioavailability and its potential ergogenic effects across various population groups. This review discusses the potential influence of different dietary nitrate supplementation strategies on nitric oxide bioavailability and muscular peak power output in healthy adults, athletes, older adults and some clinical populations. Effect sizes were calculated for peak power output and absolute and/or relative nitrate doses were considered where applicable. There was no relationship between the effect sizes of peak power output change following nitrate supplementation and when nitrate dosage when considered in absolute or relative terms. Areas for further research are also recommended including a focus on nitrate dosing regimens that optimize nitric oxide bioavailability for enhancing peak power at times of increased muscular work in a variety of healthy and disease populations.
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Affiliation(s)
- Rachel Tan
- Department of Sports Medicine, Pepperdine University, Malibu, CA, 90263, USA.
| | - Marissa N Baranauskas
- Department of Human Physiology & Nutrition, University of Colorado, Colorado Springs, CO, 80918, USA
| | - Sean T Karl
- Department of Sports Medicine, Pepperdine University, Malibu, CA, 90263, USA
| | | | - Ren-Jay Shei
- Indiana University Alumni Association, Indiana University, Bloomington, IN, 47408, USA
| | - Hunter L Paris
- Department of Sports Medicine, Pepperdine University, Malibu, CA, 90263, USA
| | - Chad C Wiggins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen J Bailey
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
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Heider D, Rezvani F, Matschinger H, Dirmaier J, Härter M, Herbarth L, Steinisch P, Böbinger H, Schuhmann F, Krack G, Korth T, Thomsen L, Chase DP, Schreiber R, Alscher MD, Finger B, König HH. The effect of telephone health coaching and remote exercise monitoring for peripheral artery disease (TeGeCoach) on health care cost and utilization: results of a randomized controlled trial. Eur J Health Econ 2023:10.1007/s10198-023-01616-4. [PMID: 37428355 DOI: 10.1007/s10198-023-01616-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) is the third most prevalent atherosclerotic cardiovascular disease. In 2016, costs per patient associated with PAD exceeded even the health-economic burden of coronary heart disease. Although affecting over 200 million people worldwide, a clear consensus on the most beneficial components to be included in home-based exercise programs for patients with peripheral artery disease is lacking. The aim of the study was to examine the health care use and costs caused by the 12-month patient-centered 'Telephone Health Coaching and Remote Exercise Monitoring for Peripheral Artery Disease' (TeGeCoach) program in a randomized controlled trial. METHODS This is a two-arm, parallel-group, open-label, pragmatic, randomized, controlled clinical trial (TeGeCoach) at three German statutory health insurance funds with follow-up assessments after 12 and 24-months. Study outcomes were medication use (daily defined doses), days in hospital, sick pay days and health care costs, from the health insurers' perspective. Claims data from the participating health insurers were used for analyses. The main analytic approach was an intention-to-treat (ITT) analysis. Other approaches (modified ITT, per protocol, and as treated) were executed additionally as sensitivity analysis. Random-effects regression models were calculated to determine difference-in-difference (DD) estimators for the first- and the second year of follow-up. Additionally, existing differences at baseline between both groups were treated with entropy balancing to check for the stability of the calculated estimators. RESULTS One thousand six hundred eighty-five patients (Intervention group (IG) = 806; Control group (CG) = 879) were finally included in ITT analyses. The analyses showed non-significant effects of the intervention on savings (first year: - 352€; second year: - 215€). Sensitivity analyses confirmed primary results and showed even larger savings. CONCLUSION Based on health insurance claims data, a significant reduction due to the home-based TeGeCoach program could not be found for health care use and costs in patients with PAD. Nevertheless, in all sensitivity analysis a tendency became apparent for a non-significant cost reducing effect. TRIAL REGISTRATION NCT03496948 (www. CLINICALTRIALS gov), initial release on 23 March 2018.
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Affiliation(s)
- Dirk Heider
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Farhad Rezvani
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Herbert Matschinger
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Herbarth
- KKH Kaufmännische Krankenkasse Statutory Health Insurance, Hannover, Germany
| | - Patrick Steinisch
- KKH Kaufmännische Krankenkasse Statutory Health Insurance, Hannover, Germany
| | - Hannes Böbinger
- TK Techniker Krankenkasse Statutory Health Insurance, Hamburg, Germany
| | | | - Gundula Krack
- mhplus Krankenkasse Statutory Health Insurance, Ludwigsburg, Germany
| | | | | | | | | | - Mark-Dominik Alscher
- Robert Bosch Gesellschaft Für Medizinische Forschung mbH, Bosch-Institute of Clinical Pharmacology, Dr. Margarete Fischer, Stuttgart, Germany
| | - Benjamin Finger
- Robert Bosch Gesellschaft Für Medizinische Forschung mbH, Bosch-Institute of Clinical Pharmacology, Dr. Margarete Fischer, Stuttgart, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Tan R, Baranauskas MN, Karl ST, Ortiz de Zevallos J, Shei RJ, Paris HL, Wiggins CC, Bailey SJ. Effects of dietary nitrate supplementation on muscular power output: Influence of supplementation strategy and population. Nitric Oxide 2023:S1089-8603(23)00047-2. [PMID: 37244391 DOI: 10.1016/j.niox.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
Increasing evidence indicates that dietary nitrate supplementation has the potential to increase muscular power output during skeletal muscle contractions. However, there is still a paucity of data characterizing the impact of different nitrate dosing regimens on nitric oxide bioavailability its potential ergogenic effects across various population groups. This narrative review discusses the potential influence of different dietary nitrate supplementation strategies on nitric oxide bioavailability and muscular power output in healthy adults, athletes, older adults and some clinical populations. Areas for further research are also recommended including a focus individualized nitrate dosing regimens to optimize nitric oxide bioavailability and to promote muscular power enhancements in different populations.
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Affiliation(s)
- Rachel Tan
- Department of Sports Medicine, Pepperdine University, Malibu, CA, 90263, USA.
| | - Marissa N Baranauskas
- Department of Human Physiology & Nutrition, University of Colorado, Colorado Springs, CO, 80918, USA
| | - Sean T Karl
- Department of Sports Medicine, Pepperdine University, Malibu, CA, 90263, USA
| | | | - Ren-Jay Shei
- Indiana University Alumni Association, Indiana University, Bloomington, IN, 47408, USA
| | - Hunter L Paris
- Department of Sports Medicine, Pepperdine University, Malibu, CA, 90263, USA
| | - Chad C Wiggins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephen J Bailey
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
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Enea I, Martelli E. Focus on the Prevention of Acute Limb Ischemia: Centrality of the General Practitioner from the Point of View of the Internist. J Clin Med 2023; 12:jcm12113652. [PMID: 37297848 DOI: 10.3390/jcm12113652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
The thrombotic mechanism, being common to peripheral arterial disease (PAD), acute myocardial infarction (AMI), and stroke, is responsible for the highest number of deaths in the western world. However, while much has been done for the prevention, early diagnosis, therapy of AMI and stroke, the same cannot be said for PAD, which is a negative prognostic indicator for cardiovascular death. Acute limb ischemia (ALI) and chronic limb ischemia (CLI) are the most severe manifestations of PAD. They both are defined by the presence of PAD, rest pain, gangrene, or ulceration and we consider ALI if symptoms last less than 2 weeks and CLI if they last more than 2 weeks. The most frequent causes are certainly atherosclerotic and embolic mechanisms and, to a lesser extent, traumatic or surgical mechanisms. From a pathophysiological point of view, atherosclerotic, thromboembolic, inflammatory mechanisms are implicated. ALI is a medical emergency that puts both limb and the patient's life at risk. In patients over age 80 undergoing surgery, mortality remains high reaching approximately 40% as well as amputation approximately 11%. The purpose of this paper is to summarize the scientific evidence on the possibilities of primary and secondary prevention of ALI and to raise awareness among doctors involved in the management of ALI, in particular by describing the central role of the general practitioner.
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Affiliation(s)
- Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, 81100 Caserta, Italy
| | - Eugenio Martelli
- Division of Vascular Surgery, Department of Cardiovascular Science, S. Anna and S. Sebastiano Hospital, Campania, 81100 Caserta, Italy
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Science, 00131 Rome, Italy
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Kosmac K, Ismaeel A, Kim-Shapiro DB, McDermott MM. Praliciguat and Soluble Guanylate Cyclase Stimulators for Peripheral Artery Disease. Circ Res 2023; 132:49-51. [PMID: 36603062 DOI: 10.1161/circresaha.122.322298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Kate Kosmac
- University of Kentucky Center for Muscle Biology, Lexington (K.K., A.I.)
| | - Ahmed Ismaeel
- University of Kentucky Center for Muscle Biology, Lexington (K.K., A.I.)
| | | | - Mary M McDermott
- Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine (M.M.M.)
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Pearson SJ, Sindall P, Caldow E, Taberner P. The effect of resistance training on functional capacity in middle-aged to elderly individuals with peripheral artery disease: a meta-analysis. INT ANGIOL 2022; 41:525-532. [PMID: 36194384 DOI: 10.23736/s0392-9590.22.04922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is an ischemic disease of the lower limbs, caused by atherosclerotic plaques, leading to impairments in functional capacity and reduced quality of life. This meta-analysis aimed to assess the effect of 12-week and 24-week resistance training (RT) interventions on 6-minute walking distance (6WMD) and initial claudication distance (ICD) measured during a 6-minute walk test (6MWT). EVIDENCE ACQUISITION A meta-analysis was conducted in accordance with PRISMA guidelines, with an electronic search conducted using the online database of PUBMED. Methodological quality of all included studies was completed using a modified version of the Newcastle Ottawa Scale (NOS). The effect sizes (ES) of 6MWD and ICD were calculated, with the 12-week and 24-week interventions analyzed separately. EVIDENCE SYNTHESIS An initial literature search yielded 1973 results that were consequently reduced to 7 studies to be included in the final meta-analysis. The pooled effect size for 6MWD for 12-week and 24-week interventions was ES=0.189 [95% CI: -0.074 to 0.451] P=0.159 and ES=0.298 [95% CI: -0.036 to 0.631] P=0.080 respectively. For ICD, ES=0.498 [95% CI: 0.000 to 0.995] P=0.050 and ES: 1.106 [95% CI: 0.120 to 0.428] P=0.001 respectively. CONCLUSIONS Short-term RT interventions have a positive effect on functional capacity in middle-aged to elderly individuals with PAD. There was a greater effect on ICD compared to 6MWD, with 24-week interventions showing larger effects for both measures. Improvements in functional capacity in such populations confers significant potential for positive health outcomes.
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Affiliation(s)
- Stephen J Pearson
- Department of Health and Social Care, University of Salford, Salford, UK -
| | - Paul Sindall
- Department of Health and Social Care, University of Salford, Salford, UK
| | - Edward Caldow
- Department of Health and Social Care, University of Salford, Salford, UK
| | - Patrick Taberner
- Department of Health and Social Care, University of Salford, Salford, UK
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Leslie R, May S, Scordis C, Isgar V, Poulton P, Garnham A. Outcomes following supervised exercise and home-based exercise for patients with intermittent claudication. J Vasc Nurs 2022; 40:157-161. [PMID: 36435597 DOI: 10.1016/j.jvn.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Intermittent claudication (IC) is the most common symptom of peripheral arterial disease (PAD) which presents as a consequence of muscle ischaemia resulting from the atherosclerotic obstruction to arterial flow. High-quality evidence (Lane et al., 2017) shows that exercise programmes provide important benefits compared with usual care in improving pain-free and maximum walking distance in people with IC, but do not improve ankle-brachial pressure index (ABPI). METHODS Retrospective data were analysed to examine walking and ABPI outcomes for participants who completed a 12-week course of supervised or home-based exercise. All participants had a history of IC. RESULTS 46 participants (mean age 69±11 years; 76% male; 29% current smokers) referred for exercise were assessed, completed a 12-week course of exercise (home-based or supervised) and subsequently attended for re-assessment. Claudication onset distance (COD) increased by 363% (mean improvement 344.7 ± 265.1m; p < .001) and peak walking distance (PWD) by 324.4% in the supervised exercise group; COD increased by 30.6% (mean improvement 32.8 ± 57.2 m; p = 0.026) and PWD by 31.5% in the home-based exercise group. Resting ABPI for the total cohort significantly improved from 0.82 ± 0.25 at A1 to 0.88 ± 0.25 at A2 (p = 0.027). DISCUSSION A 12-week course of supervised exercise results in significantly greater walking distance outcomes (COD and PWD) than unmonitored home-based exercise. In contrast with previous findings (Lane et al. 2017), this retrospective study demonstrated a significant improvement in resting ABPI with both supervised exercise as well as home-based exercise. CONCLUSION A 12-week programme of exercise favourably influenced walking and ABPI outcomes for patients with IC. Both home-based exercise and supervised individualised exercise increased walking distances, but the magnitude of the improvement in walking outcomes was greater in individuals who attended supervised exercise therapy.
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Affiliation(s)
- R Leslie
- Chief Allied Health Professional, Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton WV10 0QP, United Kingdom.
| | - S May
- Exercise Physiologist Cardiac Rehabilitation, Royal Wolverhampton NHS Trust, United Kingdom
| | - C Scordis
- Specialist Exercise Physiologist Cardiac Rehabilitation, Royal Wolverhampton NHS Trust, United Kingdom
| | - V Isgar
- Clinical Nurse Specialist Vascular, Royal Wolverhampton NHS Trust, United Kingdom
| | - P Poulton
- Clinical Nurse Specialist Vascular, Royal Wolverhampton NHS Trust, United Kingdom
| | - A Garnham
- Vascular Surgeon, Royal Wolverhampton NHS Trust, United Kingdom
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Ibeggazene S, Pymer S, Birkett ST, Caldow E, Harwood AE. A systematic review of exercise intervention reporting quality and dose in studies of intermittent claudication. Vascular 2022; 31:477-488. [PMID: 35130092 DOI: 10.1177/17085381211070700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Exercise therapy is an important treatment option for people with intermittent claudication (IC). Appropriate reporting of exercise interventions in populations with IC within randomised controlled trials (RCTs) is important to ensure that research can be translated into clinical practice. Therefore, the purpose of our review is to evaluate the reporting of exercise interventions in RCTs of exercise therapy in patients with IC. METHODS A systematic search was performed to identify relevant trials in patients with IC published until May 2020. Studies including only participants with critical limb ischaemia or asymptomatic peripheral artery disease were excluded. Each trial was scored using the recently developed 'Consensus on Exercise Reporting Template' (CERT) which has a maximum obtainable score of 19. RESULTS Of 1489 unique records identified from the search, 73 trials were included, reporting 107 exercise interventions. Overall, the average CERT score was 10/19. The exercise equipment used, the use of supervision and a description of whether the exercise prescription was tailored or generic were the most frequently reported intervention components. The motivational strategies used, intervention adherence and intervention fidelity were the most underreported CERT components. There was no trend indicating that CERT scores were higher in more recent publications. CONCLUSIONS We have identified that important details about exercise interventions are frequently missing from the published literature. These missing data hinder replication of research findings and limit the translation of evidence into clinical practice.
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Affiliation(s)
- Saïd Ibeggazene
- College of Health, Wellbeing and Life Sciences, 7314Sheffield Hallam University, Sheffield, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, 12195Hull York Medical School, Hull, UK
| | - Stefan T Birkett
- School of Sport and Health Sciences, 6723University of Central Lancashire, Preston, UK
| | - Edward Caldow
- School of Health and Society, 7046University of Salford, Salford, UK
| | - Amy E Harwood
- Centre for Sports, Exercise and Life Sciences, 120958Coventry University, Coventry, UK
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Abstract
Approximately 6% of adults worldwide have atherosclerosis and thrombosis of the lower limb arteries (peripheral artery disease (PAD)) and the prevalence is rising. PAD causes leg pain, impaired health-related quality of life, immobility, tissue loss and a high risk of major adverse events, including myocardial infarction, stroke, revascularization, amputation and death. In this Review, I describe the pathophysiology, presentation, outcome, preclinical research and medical management of PAD. Established treatments for PAD include antithrombotic drugs, such as aspirin and clopidogrel, and medications to treat dyslipidaemia, hypertension and diabetes mellitus. Randomized controlled trials have demonstrated that these treatments reduce the risk of major adverse events. The drug cilostazol, exercise therapy and revascularization are the current treatment options for the limb symptoms of PAD, but each has limitations. Novel therapies to promote collateral and new capillary growth and treat PAD-related myopathy are under investigation. Methods to improve the implementation of evidence-based medical management, novel drug therapies and rehabilitation programmes for PAD-related pain, functional impairment and ischaemic foot disease are important areas for future research.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia. .,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia. .,The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
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Chehuen M, Andrade-Lima A, Silva Junior N, Miyasato R, Souza RWAD, Leicht A, Brum PC, Oliveira EM, Wolosker N, Forjaz CLDM. Physiological Responses to Maximal and Submaximal Walking in Patients with Symptomatic Peripheral Artery Disease. Arq Bras Cardiol 2021; 117:309-316. [PMID: 34495225 PMCID: PMC8395785 DOI: 10.36660/abc.20200156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/12/2020] [Indexed: 11/18/2022] Open
Abstract
Fundamento: Embora a caminhada máxima e submáxima sejam recomendadas para pacientes com doença arterial periférica (DAP), a realização desses exercícios pode induzir diferentes respostas fisiológicas. Objetivos: Comparar os efeitos agudos de caminhada máxima e submáxima na função cardiovascular, a regulação e os processos fisiopatológicos associados pós-exercício em pacientes com DAP sintomática. Métodos: Trinta pacientes do sexo masculino foram submetidos a 2 sessões: caminhada máxima (protocolo de Gardner) e caminhada submáxima (15 períodos de 2 minutos de caminhada separados por 2 minutos de repouso ereto). Em cada sessão, foram medidos a pressão arterial (PA), a frequência cardíaca (FC), a modulação autonômica cardíaca (variabilidade da FC), os fluxos sanguíneos (FS) do antebraço e da panturrilha, a capacidade vasodilatadora (hiperemia reativa), o óxido nítrico (ON), o estresse oxidativo (a peroxidação lipídica) e a inflamação (quatro marcadores), pré e pós-caminhada. ANOVAs foram empregadas e p < 0,05 foi considerado significativo. Resultados: A PA sistólica e a PA média diminuíram após a sessão submáxima, mas aumentaram após a sessão máxima (interações, p < 0,001 para ambas). A PA diastólica não foi alterada após a sessão submáxima (p > 0,05), mas aumentou após a caminhada máxima (interação, p < 0,001). A FC, o equilíbrio simpatovagal e os FS aumentaram de forma semelhante após as duas sessões (momento, p < 0,001, p = 0,04 e p < 0,001, respectivamente), enquanto a capacidade vasodilatadora, o ON e o estresse oxidativo permaneceram inalterados (p > 0,05). As moléculas de adesão vascular e intercelular aumentaram de forma semelhante após as sessões de caminhada máxima e submáxima (momento, p = 0,001). Conclusões: Nos pacientes com a DAP sintomática, a caminhada submáxima, mas não a máxima, reduziu a PA pós-exercício, enquanto a caminhada máxima manteve a sobrecarga cardíaca elevada durante o período de recuperação. Por outro lado, as sessões de caminhada máxima e submáxima aumentaram a FC, o equilíbrio simpatovagal cardíaco e a inflamação pós-exercício de forma semelhante, enquanto não alteraram a biodisponibilidade de ON e o estresse oxidativo pós-exercício.
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Affiliation(s)
- Marcel Chehuen
- Universidade de São Paulo - Escola de Educação Física e Esportes, São Paulo, SP - Brasil
| | | | - Natan Silva Junior
- Universidade de São Paulo - Escola de Educação Física e Esportes, São Paulo, SP - Brasil
| | - Roberto Miyasato
- Universidade de São Paulo - Escola de Educação Física e Esportes, São Paulo, SP - Brasil
| | | | - Anthony Leicht
- James Cook University, Townsville, Queensland - Austrália
| | - Patricia Chakur Brum
- Universidade de São Paulo - Escola de Educação Física e Esportes, São Paulo, SP - Brasil
| | - Edilamar M Oliveira
- Universidade de São Paulo - Escola de Educação Física e Esportes, São Paulo, SP - Brasil
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McDermott MM, Dayanidhi S, Kosmac K, Saini S, Slysz J, Leeuwenburgh C, Hartnell L, Sufit R, Ferrucci L. Walking Exercise Therapy Effects on Lower Extremity Skeletal Muscle in Peripheral Artery Disease. Circ Res 2021; 128:1851-1867. [PMID: 34110902 DOI: 10.1161/circresaha.121.318242] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Walking exercise is the most effective noninvasive therapy that improves walking ability in peripheral artery disease (PAD). Biologic mechanisms by which exercise improves walking in PAD are unclear. This review summarizes evidence regarding effects of walking exercise on lower extremity skeletal muscle in PAD. In older people without PAD, aerobic exercise improves mitochondrial activity, muscle mass, capillary density, and insulin sensitivity in skeletal muscle. However, walking exercise increases lower extremity ischemia in people with PAD, and therefore, mechanisms by which this exercise improves walking may differ between people with and without PAD. Compared with people without PAD, gastrocnemius muscle in people with PAD has greater mitochondrial impairment, increased reactive oxygen species, and increased fibrosis. In multiple small trials, walking exercise therapy did not consistently improve mitochondrial activity in people with PAD. In one 12-week randomized trial of people with PAD randomized to supervised exercise or control, supervised treadmill exercise increased treadmill walking time from 9.3 to 15.1 minutes, but simultaneously increased the proportion of angular muscle fibers, consistent with muscle denervation (from 7.6% to 15.6%), while angular myofibers did not change in the control group (from 9.1% to 9.1%). These findings suggest an adaptive response to exercise in PAD that includes denervation and reinnervation, an adaptive process observed in skeletal muscle of people without PAD during aging. Small studies have not shown significant effects of exercise on increased capillary density in lower extremity skeletal muscle of participants with PAD, and there are no data showing that exercise improves microcirculatory delivery of oxygen and nutrients in patients with PAD. However, the effects of supervised exercise on increased plasma nitrite abundance after a treadmill walking test in people with PAD may be associated with improved lower extremity skeletal muscle perfusion and may contribute to improved walking performance in response to exercise in people with PAD. Randomized trials with serial, comprehensive measures of muscle biology, and physiology are needed to clarify mechanisms by which walking exercise interventions improve mobility in PAD.
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Affiliation(s)
- Mary M McDermott
- Department of Medicine and Preventive Medicine (M.M.M., J.S.), Northwestern University Feinberg School of Medicine
| | - Sudarshan Dayanidhi
- Shirley Ryan Ability Laboratory (S.D.), Northwestern University Feinberg School of Medicine
| | - Kate Kosmac
- Center for Muscle Biology, University of Kentucky (K.K.)
| | - Sunil Saini
- Jawaharlal Nehru University, School of Biotechnology, New Delhi, India (S.S.)
| | - Joshua Slysz
- Department of Medicine and Preventive Medicine (M.M.M., J.S.), Northwestern University Feinberg School of Medicine
| | | | - Lisa Hartnell
- Division of Intramural Research, National Institute on Aging (L.H., L.F.)
| | - Robert Sufit
- Department of Neurology (R.S.), Northwestern University Feinberg School of Medicine
| | - Luigi Ferrucci
- Division of Intramural Research, National Institute on Aging (L.H., L.F.)
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Pymer SA, Ibeggazene S, Palmer J, Tew GA, Ingle L, Smith GE, Chetter IC, Harwood AE. An Updated Systematic Review and Meta-Analysis of Home-based Exercise Programmes for Individuals with Intermittent Claudication. J Vasc Surg 2021:S0741-5214(21)00835-1. [PMID: 34087396 DOI: 10.1016/j.jvs.2021.03.063] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Supervised exercise programmes (SEP) are effective for improving walking distance in patients with intermittent claudication (IC) but provision and uptake rates are sub-optimal. Access to such programmes has also been halted by the Coronavirus pandemic. The aim of this review is to provide a comprehensive overview of the evidence for home-based exercise programmes (HEP). DATA SOURCES Medline, EMBASE, CINAHL, PEDro and Cochrane CENTRAL were searched for terms relating to HEP and IC. REVIEW METHODS This review was conducted in according with the published protocol and PRISMA guidance. Randomised and non-randomised trials that compared a HEP to SEP, basic exercise advice or no exercise controls for IC were included. A narrative synthesis was provided for all studies and meta-analyses conducted using data from randomised trials. The primary outcome was maximal walking distance. Sub-group analyses were performed to consider the effect of monitoring. Risk of bias was assessed using the Cochrane tool and quality of evidence via GRADE. RESULTS 23 studies with 1907 participants were included. Considering the narrative review, HEPs were inferior to SEPs which was reflected in the meta-analysis (MD 139m, 95% CI 45 to 232m, p = .004, very-low-quality evidence). Monitoring was an important component, as HEPs adopting this were equivalent to SEPs (MD: 8m, 95% CI -81 to 97, p = .86; moderate-quality evidence). For HEPs versus basic exercise advice, narrative review suggested HEPs can be superior, though not always significantly so. For HEPs versus no exercise controls, narrative review and meta-analysis suggested HEPs were potentially superior (MD: 136m, -2-273m p = .05, very-low-quality evidence). Monitoring was also a key element in these comparisons.Other elements such as appropriate frequency (≥3x a week), intensity (to moderate-maximum pain), duration (20 progressing to 60 minutes) and type (walking) of exercise were important, as was education, self-regulation, goal setting, feedback and action planning. CONCLUSION When SEPs are unavailable, HEPs are recommended. However, to elicit maximum benefit they should be structured, incorporating all elements of our evidence-based recommendations. PROSPERO REGISTRATION NUMBER CRD42018091248.
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Facioli TDP, Buranello MC, Regueiro EMG, Basso-Vanelli RP, Durand MDT. Effect of Physical Training on Nitric Oxide Levels in Patients with Arterial Hypertension: An Integrative Review. International Journal of Cardiovascular Sciences 2021. [DOI: 10.36660/ijcs.20200244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Birkett ST, Harwood AE, Caldow E, Ibeggazene S, Ingle L, Pymer S. A systematic review of exercise testing in patients with intermittent claudication: A focus on test standardisation and reporting quality in randomised controlled trials of exercise interventions. PLoS One 2021; 16:e0249277. [PMID: 33939704 PMCID: PMC8092776 DOI: 10.1371/journal.pone.0249277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
A systematic review was conducted to identify the range of terminology used in studies to describe maximum walking distance and the exercise testing protocols, and testing modalities used to measure it in patients with intermittent claudication. A secondary aim was to assess the implementation and reporting of the exercise testing protocols. CINAHL, Medline, EMBASE and Cochrane CENTRAL databases were searched. Randomised controlled trials whereby patients with intermittent claudication were randomised to an exercise intervention were included. The terminology used to describe maximal walking distance was recorded, as was the modality and protocol used to measure it. The implementation and reporting quality was also assessed using pre-specified criteria. Sixty-four trials were included in this review. Maximal walking distance was reported using fourteen different terminologies. Twenty-two different treadmill protocols and three different corridor tests were employed to assess maximal walking distance. No single trial satisfied all the implementation and reporting criteria for an exercise testing protocol. Evidence shows that between-study interpretation is difficult given the heterogenous nature of the exercise testing protocols, test endpoints and terminology used to describe maximal walking distance. This is further compounded by poor test reporting and implementation across studies. Comprehensive guidelines need to be provided to enable a standardised approach to exercise testing in patients with intermittent claudication.
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Affiliation(s)
- Stefan T. Birkett
- School of Sport and Health Sciences, University of Central Lancashire, Preston, United Kingdom
| | - Amy E. Harwood
- Centre for Sports, Exercise and Life Sciences, Coventry University, Coventry, United Kingdom
| | - Edward Caldow
- School of Health and Society, University of Salford, Salford, United Kingdom
| | - Saïd Ibeggazene
- College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, United Kingdom
| | - Lee Ingle
- Department of Sport, Health and Exercise Science, University of Hull, Hull, United Kingdom
| | - Sean Pymer
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, United Kingdom
- * E-mail:
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Andrade-Lima A, Silva Junior N, Chehuen M, Miyasato R, Souza RWA, Leicht AS, Brum PC, de Oliveira EM, Wolosker N, Forjaz CLM. Walking Training Improves Systemic and Local Pathophysiological Processes in Intermittent Claudication. Eur J Vasc Endovasc Surg 2021; 61:954-963. [PMID: 33875324 DOI: 10.1016/j.ejvs.2021.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/25/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study examined the impact of submaximal walking training (WT) on local and systemic nitric oxide (NO) bioavailability, inflammation, and oxidative stress in patients with intermittent claudication (IC). METHODS The study employed a randomised, controlled, parallel group design and was performed in a single centre. Thirty-two men with IC were randomly allocated to two groups: WT (n = 16, two sessions/week, 15 cycles of two minutes walking at an intensity corresponding to the heart rate obtained at the pain threshold interspersed by two minutes of upright rest) and control (CO, n = 16, two sessions/week, 30 minutes of stretching). NO bioavailability (blood NO and muscle nitric oxide synthase [eNOS]), redox homeostasis (catalase [CAT], superoxide dismutase [SOD], lipid peroxidation [LPO] measured in blood and muscle), and inflammation (interleukin-6 [IL-6], C-reactive protein [CRP], tumour necrosis factor α [TNF-α], intercellular adhesion molecules [ICAM], vascular adhesion molecules [VCAM] measured in blood and muscle) were assessed at baseline and after 12 weeks. RESULTS WT statistically significantly increased blood NO, muscle eNOS, blood SOD and CAT, and muscle SOD and abolished the increase in circulating and muscle LPO observed in the CO group. WT decreased blood CRP, ICAM, and VCAM and muscle IL-6 and CRP and eliminated the increase in blood TNF-α and muscle TNF-α, ICAM and VCAM observed in the CO group. CONCLUSION WT at an intensity of pain threshold improved NO bioavailability and decreased systemic and local oxidative stress and inflammation in patients with IC. The proposed WT protocol provides physiological adaptations that may contribute to cardiovascular health in these patients.
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Affiliation(s)
- Aluisio Andrade-Lima
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil.
| | - Natan Silva Junior
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Marcel Chehuen
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Roberto Miyasato
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Rodrigo W A Souza
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Anthony S Leicht
- Sport & Exercise Science, James Cook University, Townsville, Australia
| | - Patricia C Brum
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | | | | | - Claudia L M Forjaz
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
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Kurowska K, Antosik K, Kobylińska M, Decyk A. Beetroot Juice - Legal Doping for Athletes? Central European Journal of Sport Sciences and Medicine 2021; 35:57-70. [DOI: 10.18276/cej.2021.3-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Coca-Martinez M, Kinio A, Hales L, Carli F, Gill HL. Combined Exercise and Nutrition Optimization for Peripheral Arterial Disease: A Systematic Review. Ann Vasc Surg 2020; 71:496-506. [PMID: 33160056 DOI: 10.1016/j.avsg.2020.09.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/10/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with peripheral arterial disease (PAD) who suffer from claudication have a low exercise capacity, poor quality of life, and often severe disability. Exercise and healthy nutrition have been shown to be important factors to prevent disease progression. This systematic review aims to assess the evidence supporting the use of combined nutrition and structured exercise in patients with intermittent claudication. METHODS Publications that included a combination of structured exercise (SE) and a nutritional intervention and that reported quality of life, exercise capacity, pain-free walking distance, limb blood flow hemodynamics, need for revascularization surgery, or surgical outcomes were systematically searched. Publications were screened, selected, and reviewed by 2 independent reviewers. RESULTS Four publications were found reporting the effects of combined SE and nutrition programs. Pooled statistical analysis across trials was not performed because of the heterogeneity of study designs and type of interventions. Only 2 randomized controlled trials were found, reporting conflicting results with regard to the effects of combined SE and nutrition on exercise capacity. Only one trial reported quality of life measures. Blood flow was increased in the intervention involving inorganic nitrate in addition to SE. CONCLUSIONS There are conflicting results and lack of quality data proving the benefit of nutrition and SE programs on patient-centered outcomes and limb blood flow. There are no data on the effects of combined nutrition and exercise on the need for revascularization surgery or postrevascularization outcomes. More randomized controlled trials are needed to assess the effects of multimodal interventions on patient-centered outcomes and clinical outcomes of PAD.
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Affiliation(s)
- Miquel Coca-Martinez
- Division of Vascular Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada; Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Anna Kinio
- Division of Vascular Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lindsay Hales
- Montreal General Hospital Medical Library, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Heather L Gill
- Division of Vascular Surgery, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
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Kapil V, Khambata RS, Jones DA, Rathod K, Primus C, Massimo G, Fukuto JM, Ahluwalia A. The Noncanonical Pathway for In Vivo Nitric Oxide Generation: The Nitrate-Nitrite-Nitric Oxide Pathway. Pharmacol Rev 2020; 72:692-766. [DOI: 10.1124/pr.120.019240] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Rodrigues E, Silva I. Supervised exercise therapy in intermittent claudication: a systematic review of clinical impact and limitations. INT ANGIOL 2020; 39:60-75. [DOI: 10.23736/s0392-9590.19.04159-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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21
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Kashi DS, Shabir A, Da Boit M, Bailey SJ, Higgins MF. The Efficacy of Administering Fruit-Derived Polyphenols to Improve Health Biomarkers, Exercise Performance and Related Physiological Responses. Nutrients 2019; 11:nu11102389. [PMID: 31591287 PMCID: PMC6836214 DOI: 10.3390/nu11102389] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 09/20/2019] [Accepted: 09/25/2019] [Indexed: 12/16/2022] Open
Abstract
Polyphenols are secondary metabolites involved in a myriad of critical processes in plants. Over recent decades, special attention has been paid to the anti-oxidative role of fruit-derived polyphenols in the human diet, with evidence supporting the contribution of polyphenols in the prevention of numerous non-communicable disease outcomes. However, due to the low concentration in biological fluids in vivo, the antioxidant properties of polyphenols seem to be related to an enhanced endogenous antioxidant capacity induced via signaling through the nuclear respiratory factor 2 pathway. Polyphenols also seem to possess anti-inflammatory and antioxidant properties and have been shown to enhance vascular function via nitric oxide mediated mechanisms. Consequently, there is rationale to support fruit-derived polyphenol supplementation to enhance exercise performance, possibly via improved muscle perfusion. Fruit-derived polyphenol supplementation in exercise studies have included a variety of fruits, e.g., New Zealand blackcurrant, pomegranate, and cherry, in the form of extracts (multicomponent or purified), juices and infusions to varying degrees of benefit. For example, research has yet to link the health-related benefits of black elderberry (Sambucus nigra L.) ingestion to exercise performance in spite of the purported health benefits associated with black elderberry provision in vitro and in vivo models, which has been attributed to their high antioxidant capacity and polyphenol content. This review summarizes the existing evidence supporting a beneficial effect of fruit-derived polyphenols on various biological processes and outlines the potential for black elderberry ingestion to improve nitric oxide production, exercise performance, and the associated physiological responses before-, during- and post-exercise.
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Affiliation(s)
- Daniel S Kashi
- School of Human Sciences, Derby University, Kedleston Road, Derby DE22 1GB, UK.
| | - Akbar Shabir
- School of Human Sciences, Derby University, Kedleston Road, Derby DE22 1GB, UK.
| | - Mariasole Da Boit
- School of Allied Health Sciences, De Montfort University, The Gateway, Leicester LE1 9BH, UK.
| | - Stephen J Bailey
- School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough LE11 3TU, UK.
| | - Matthew F Higgins
- School of Human Sciences, Derby University, Kedleston Road, Derby DE22 1GB, UK.
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22
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Abstract
RATIONALE A primary goal of therapy for patients with peripheral artery disease (PAD) and intermittent claudication is increased ambulatory function. Supervised exercise rehabilitation was recently shown to confer superior walking benefits to pharmacological or surgical interventions. Increases in plasma inorganic nitrite, via oral nitrate, have been shown to increase exercise performance in both human and animal models, especially in hypoxic conditions. OBJECTIVE To determine whether a 36-session exercise rehabilitation program while consuming oral inorganic nitrate (4.2 mmol concentrated beetroot juice) would produce superior benefits over exercise plus placebo in pain-free walking and markers of increased skeletal muscle perfusion in patients with PAD and intermittent claudication. METHODS AND RESULTS This was a randomized, double-blind, per-protocol study design. After the 12-week protocol, claudication onset time on a maximal treadmill test increased by 59.2±57.3 s for the exercise plus placebo group (n=13) and by 180.3±46.6 s for the exercise plus beetroot juice group (n=11; P≤0.05). This produced a between treatment medium to large standardized effect size (Cohen d) of 0.62 (95% CI, -0.23 to +1.44). The data for 6-minute walk distance showed a similar pattern with increases of 24.6±12.1 and 53.3±19.6 m ( P≤0.05) in the exercise plus placebo and exercise plus beetroot juice groups, respectively. Measures of gastrocnemius perfusion, including ankle-brachial index, peak reactive hyperemic blood flow, and tissue deoxygenation characteristics, during exercise (assessed my near-infrared spectroscopy) all changed significantly for the exercise plus beetroot juice group with moderate-to-large effect sizes over exercise plus placebo changes. CONCLUSIONS Although it is premature to speculate on overall clinical utility of a nitrate-based therapy for PAD, this early pilot study evidence is encouraging. Specifically, our data suggests that increasing plasma nitrite before exercise may allow PAD subjects to train with less pain, at higher workloads for longer durations at each training session, thereby maximizing the beneficial peripheral vascular and skeletal muscle adaptations. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT01684930 and NCT01785524.
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Affiliation(s)
- Mary Woessner
- From the Institute of Health and Sport, Victoria University, Melbourne, Australia (M.W.)
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC (M.W., M.D.V., W.E.K., J.D.A.)
| | - Mitch D VanBruggen
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC (M.W., M.D.V., W.E.K., J.D.A.)
| | - Carl F Pieper
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (C.F.P., R.S.)
| | - Richard Sloane
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (C.F.P., R.S.)
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC (M.W., M.D.V., W.E.K., J.D.A.)
| | - Andrew J Gow
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ (A.J.G.)
| | - Jason D Allen
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC (M.W., M.D.V., W.E.K., J.D.A.)
- Department of Kinesiology, University of Virginia, Charlottesville (J.D.A.)
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Park SY, Kwak YS, Pekas EJ. Impacts of aquatic walking on arterial stiffness, exercise tolerance, and physical function in patients with peripheral artery disease: a randomized clinical trial. J Appl Physiol (1985) 2019; 127:940-949. [PMID: 31369328 DOI: 10.1152/japplphysiol.00209.2019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Peripheral artery disease (PAD) is an atherosclerotic disease that is associated with attenuated vascular function, cardiorespiratory capacity, physical function, and muscular strength. It is essential to combat these negative effects on health by incorporating lifestyle interventions to slow disease progression, such as exercise. We sought to examine the effects of aquatic walking exercise on cardiovascular function, cardiorespiratory capacity [maximal volume of oxygen consumption (V̇o2max)], exercise tolerance [6-min walking distance (6MWD)], physical function, muscular strength, and body composition in patients with PAD. Patients with PAD (n = 72) were recruited and randomly assigned to a 12-wk aquatic walking training group (AQ, n = 35) or a control group (CON, n = 37). The AQ group performed walking and leg exercises in waist-to-chest-deep water. Leg arterial stiffness [femoral-to-ankle pulse wave velocity (legPWV)], heart rate (HR), blood pressure (BP), ankle-to-brachial index (ABI), V̇o2max, 6MWD, physical function, muscular strength, body composition, resting metabolic rate (RMR), and flexibility were measured before and after 12 wk. There were significant group × time interactions (P < 0.05) after 12 wk for legPWV and HR, which significantly decreased (P < 0.05) in AQ, and V̇o2max, 6MWD, physical function, and muscular strength, which significantly increased (P < 0.05) in AQ, compared with no changes in CON. There were no significant differences (P > 0.05) for BP, ABI, RMR, or flexibility after 12 wk. Interestingly, there was relatively high adherence (84%) to the aquatic walking exercise program in this population. These results suggest that aquatic walking exercise is an effective therapy to reduce arterial stiffness and resting HR and improve cardiorespiratory capacity, exercise tolerance, physical function, and muscular strength in patients with PAD.NEW & NOTEWORTHY The results of this study reveal for the first time that aquatic walking exercise can decrease arterial stiffness and improve exercise tolerance, cardiorespiratory capacity, and muscular strength in patients with peripheral artery disease (PAD). Aquatic walking exercise training demonstrates relatively high exercise adherence in this population. Aquatic walking exercise training may be a useful therapeutic intervention for improving physical function in patients with PAD.
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Affiliation(s)
- Song-Young Park
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska.,Department of Physical Education, Dong-Eui University, Busan, South Korea
| | - Yi-Sub Kwak
- Department of Physical Education, Dong-Eui University, Busan, South Korea
| | - Elizabeth J Pekas
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska
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McCarthy O, Moser O, Eckstein ML, Bain SC, Pitt J, Bracken R. Supplementary Nitric Oxide Donors and Exercise as Potential Means to Improve Vascular Health in People with Type 1 Diabetes: Yes to NO? Nutrients 2019; 11:E1571. [PMID: 31336832 DOI: 10.3390/nu11071571] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 06/26/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022] Open
Abstract
Type 1 diabetes (T1D) is associated with a greater occurrence of cardiovascular pathologies. Vascular dysfunction has been shown at the level of the endothelial layers and failure to maintain a continuous pool of circulating nitric oxide (NO) has been implicated in the progression of poor vascular health. Biochemically, NO can be produced via two distinct yet inter-related pathways that involve an upregulation in the enzymatic activity of nitric oxide synthase (NOS). These pathways can be split into an endogenous oxygen-dependent pathway i.e., the catabolism of the amino acid L-arginine to L-citrulline concurrently yielding NO in the process, and an exogenous oxygen-independent one i.e., the conversion of exogenous inorganic nitrate to nitrite and subsequently NO in a stepwise fashion. Although a body of research has explored the vascular responses to exercise and/or compounds known to stimulate NOS and subsequently NO production, there is little research applying these findings to individuals with T1D, for whom preventative strategies that alleviate or at least temper vascular pathologies are critical foci for long-term risk mitigation. This review addresses the proposed mechanisms responsible for vascular dysfunction, before exploring the potential mechanisms by which exercise, and two supplementary NO donors may provide vascular benefits in T1D.
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Liddle L, Burleigh MC, Monaghan C, Muggeridge DJ, Sculthorpe N, Pedlar CR, Butcher J, Henriquez FL, Easton C. Variability in nitrate-reducing oral bacteria and nitric oxide metabolites in biological fluids following dietary nitrate administration: An assessment of the critical difference. Nitric Oxide 2019; 83:1-10. [DOI: 10.1016/j.niox.2018.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/02/2018] [Accepted: 12/04/2018] [Indexed: 02/08/2023]
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Treat-Jacobson D, McDermott MM, Bronas UG, Campia U, Collins TC, Criqui MH, Gardner AW, Hiatt WR, Regensteiner JG, Rich K. Optimal Exercise Programs for Patients With Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e10-e33. [DOI: 10.1161/cir.0000000000000623] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Affiliation(s)
- Jay H Traverse
- From the Cardiovascular Division, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, University of Minnesota School of Medicine
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Stoner L, Hanson ED, Gram M, Allen JD, Malin SK. Research Toolbox for Peripheral Arterial Disease - Minimally Invasive Assessment of the Vasculature and Skeletal Muscle. Circ J 2018; 82:2462-2469. [PMID: 30058605 DOI: 10.1253/circj.cj-18-0283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In 2010, more than 200 million people were afflicted with peripheral arterial disease (PAD). Because it is atherosclerotic in etiology, it is not surprising that PAD is a leading cause of cardiovascular morbidity. Cardiovascular disease (CVD) risk can be decreased if ambulatory physical function is improved. However, physical function is limited by a mismatch between oxygen supply and demand in the legs, which results in exertional pain, leg weakness, and balance problems. Therefore, a key factor for improving physical function, and decreasing CVD outcomes, is ensuring oxygen supply meets the oxygen demand. The purpose of this review is to highlight and evaluate practical and minimally invasive tools for assessing PAD etiology, with a specific focus on tools suited to studies focusing on improving physical function and CVD outcomes. Specifically, the macrovascular, microvascular, and skeletal muscle pathology of PAD is briefly outlined. Subsequently, the tools for assessing each of these components is discussed, including, where available, the evidence to contextualize these tools to PAD pathology as well as physical function and CVD outcomes. The goal of this review is to guide researchers to the appropriate tools with respect to their methodological design.
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Affiliation(s)
- Lee Stoner
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Erik D Hanson
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Martin Gram
- School of Sport and Exercise, Massey University
| | - Jason D Allen
- Department of Kinesiology, University of Virginia.,Division of Cardiovascular Medicine, University of Virginia
| | - Steven K Malin
- Department of Kinesiology, University of Virginia.,Division of Endocrinology & Metabolism, University of Virginia.,Robert M. Berne Cardiovascular Research Center, University of Virginia
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Hart CR, Layec G, Trinity JD, Le Fur Y, Gifford JR, Clifton HL, Richardson RS. Oxygen availability and skeletal muscle oxidative capacity in patients with peripheral artery disease: implications from in vivo and in vitro assessments. Am J Physiol Heart Circ Physiol 2018; 315:H897-H909. [PMID: 29932772 DOI: 10.1152/ajpheart.00641.2017] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Evidence suggests that the peak skeletal muscle mitochondrial ATP synthesis rate ( Vmax) in patients with peripheral artery disease (PAD) may be attenuated due to disease-related impairments in O2 supply. However, in vitro assessments suggest intrinsic deficits in mitochondrial respiration despite ample O2 availability. To address this conundrum, Doppler ultrasound, near-infrared spectroscopy, phosphorus magnetic resonance spectroscopy, and high-resolution respirometry were combined to assess convective O2 delivery, tissue oxygenation, Vmax, and skeletal muscle mitochondrial capacity (complex I + II, state 3 respiration), respectively, in the gastrocnemius muscle of 10 patients with early stage PAD and 11 physical activity-matched healthy control (HC) subjects. All participants were studied in free-flow control conditions (FF) and with reactive hyperemia (RH) induced by a period of brief ischemia during the last 30 s of submaximal plantar flexion exercise. Patients with PAD repeated the FF and RH trials under hyperoxic conditions (FF + 100% O2 and RH + 100% O2). Compared with HC subjects, patients with PAD exhibited attenuated O2 delivery at the same absolute work rate and attenuated tissue reoxygenation and Vmax after relative intensity-matched exercise. Compared with the FF condition, only RH + 100% O2 significantly increased convective O2 delivery (~44%), tissue reoxygenation (~54%), and Vmax (~60%) in patients with PAD ( P < 0.05), such that Vmax was now not different from HC subjects. Furthermore, there was no evidence of an intrinsic mitochondrial deficit in PAD, as assessed in vitro with adequate O2. Thus, in combination, this comprehensive in vivo and in vitro investigation implicates O2 supply as the predominant factor limiting mitochondrial oxidative capacity in early stage PAD. NEW & NOTEWORTHY Currently, there is little accord as to the role of O2 availability and mitochondrial function in the skeletal muscle dysfunction associated with peripheral artery disease. This is the first study to comprehensively use both in vivo and in vitro approaches to document that the skeletal muscle dysfunction associated with early stage peripheral artery disease is predominantly a consequence of limited O2 supply and not the impact of an intrinsic mitochondrial defect in this pathology.
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Affiliation(s)
- Corey R Hart
- Geriatric Research, Education, and Clinical Center, George E. Whalen Veterans Affairs Medical Center , Salt Lake City, Utah.,Department of Exercise and Sport Science, University of Utah , Salt Lake City, Utah
| | - Gwenael Layec
- Geriatric Research, Education, and Clinical Center, George E. Whalen Veterans Affairs Medical Center , Salt Lake City, Utah.,Department of Medicine, Division of Geriatrics, University of Utah , Salt Lake City, Utah.,Department of Nutrition and Integrative Physiology, University of Utah , Salt Lake City, Utah
| | - Joel D Trinity
- Geriatric Research, Education, and Clinical Center, George E. Whalen Veterans Affairs Medical Center , Salt Lake City, Utah.,Department of Medicine, Division of Geriatrics, University of Utah , Salt Lake City, Utah.,Department of Nutrition and Integrative Physiology, University of Utah , Salt Lake City, Utah
| | - Yann Le Fur
- Centre de Résonance Magnétique Biologique et Médicale Unité Mixte de Recherché 7339, Aix-Marseille Université, Centre National de la Recherche Scientifique, Marseille , France
| | - Jayson R Gifford
- Geriatric Research, Education, and Clinical Center, George E. Whalen Veterans Affairs Medical Center , Salt Lake City, Utah
| | - Heather L Clifton
- Geriatric Research, Education, and Clinical Center, George E. Whalen Veterans Affairs Medical Center , Salt Lake City, Utah.,Department of Medicine, Division of Geriatrics, University of Utah , Salt Lake City, Utah
| | - Russell S Richardson
- Geriatric Research, Education, and Clinical Center, George E. Whalen Veterans Affairs Medical Center , Salt Lake City, Utah.,Department of Medicine, Division of Geriatrics, University of Utah , Salt Lake City, Utah.,Department of Nutrition and Integrative Physiology, University of Utah , Salt Lake City, Utah
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Hageman D, Fokkenrood HJP, Gommans LNM, van den Houten MML, Teijink JAW. Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication. Cochrane Database Syst Rev 2018; 4:CD005263. [PMID: 29627967 PMCID: PMC6513337 DOI: 10.1002/14651858.cd005263.pub4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although supervised exercise therapy (SET) provides significant symptomatic benefit for patients with intermittent claudication (IC), it remains an underutilized tool. Widespread implementation of SET is restricted by lack of facilities and funding. Structured home-based exercise therapy (HBET) with an observation component (e.g., exercise logbooks, pedometers) and just walking advice (WA) are alternatives to SET. This is the second update of a review first published in 2006. OBJECTIVES The primary objective was to provide an accurate overview of studies evaluating effects of SET programs, HBET programs, and WA on maximal treadmill walking distance or time (MWD/T) for patients with IC. Secondary objectives were to evaluate effects of SET, HBET, and WA on pain-free treadmill walking distance or time (PFWD/T), quality of life, and self-reported functional impairment. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (December 16, 2016) and the Cochrane Central Register of Controlled Trials (2016, Issue 11). We searched the reference lists of relevant studies identified through searches for other potential trials. We applied no restriction on language of publication. SELECTION CRITERIA We included parallel-group randomized controlled trials comparing SET programs with HBET programs and WA in participants with IC. We excluded studies in which control groups did not receive exercise or walking advice (maintained normal physical activity). We also excluded studies comparing exercise with percutaneous transluminal angioplasty, bypass surgery, or drug therapy. DATA COLLECTION AND ANALYSIS Three review authors (DH, HF, and LG) independently selected trials, extracted data, and assessed trials for risk of bias. Two other review authors (MvdH and JT) confirmed the suitability and methodological quality of trials. For all continuous outcomes, we extracted the number of participants, mean outcome, and standard deviation for each treatment group through the follow-up period, if available. We extracted Medical Outcomes Study Short Form 36 outcomes to assess quality of life, and Walking Impairment Questionnaire outcomes to assess self-reported functional impairment. As investigators used different scales to present results of walking distance and time, we standardized reported data to effect sizes to enable calculation of an overall standardized mean difference (SMD). We obtained summary estimates for all outcome measures using a random-effects model. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS For this update, we included seven additional studies, making a total of 21 included studies, which involved a total of 1400 participants: 635 received SET, 320 received HBET, and 445 received WA. In general, SET and HBET programs consisted of three exercise sessions per week. Follow-up ranged from six weeks to two years. Most trials used a treadmill walking test to investigate effects of exercise therapy on walking capacity. However, two trials assessed only quality of life, functional impairment, and/or walking behavior (i.e., daily steps measured by pedometer). The overall methodological quality of included trials was moderate to good. However, some trials were small with respect to numbers of participants, ranging from 20 to 304.SET groups showed clear improvement in MWD/T compared with HBET and WA groups, with overall SMDs at three months of 0.37 (95% confidence interval [CI] 0.12 to 0.62; P = 0.004; moderate-quality evidence) and 0.80 (95% CI 0.53 to 1.07; P < 0.00001; high-quality evidence), respectively. This translates to differences in increased MWD of approximately 120 and 210 meters in favor of SET groups. Data show improvements for up to six and 12 months, respectively. The HBET group did not show improvement in MWD/T compared with the WA group (SMD 0.30, 95% CI -0.45 to 1.05; P = 0.43; moderate-quality evidence).Compared with HBET, SET was more beneficial for PFWD/T but had no effect on quality of life parameters nor on self-reported functional impairment. Compared with WA, SET was more beneficial for PFWD/T and self-reported functional impairment, as well as for some quality of life parameters (e.g., physical functioning, pain, and physical component summary after 12 months), and HBET had no effect.Data show no obvious effects on mortality rates. Thirteen of the 1400 participants died, but no deaths were related to exercise therapy. Overall, adherence to SET was approximately 80%, which was similar to that reported with HBET. Only limited adherence data were available for WA groups. AUTHORS' CONCLUSIONS Evidence of moderate and high quality shows that SET provides an important benefit for treadmill-measured walking distance (MWD and PFWD) compared with HBET and WA, respectively. Although its clinical relevance has not been definitively demonstrated, this benefit translates to increased MWD of 120 and 210 meters after three months in SET groups. These increased walking distances are likely to have a positive impact on the lives of patients with IC. Data provide no clear evidence of a difference between HBET and WA. Trials show no clear differences in quality of life parameters nor in self-reported functional impairment between SET and HBET. However, evidence is of low and very low quality, respectively. Investigators detected some improvements in quality of life favoring SET over WA, but analyses were limited by small numbers of studies and participants. Future studies should focus on disease-specific quality of life and other functional outcomes, such as walking behavior and physical activity, as well as on long-term follow-up.
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Affiliation(s)
- David Hageman
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
| | | | - Lindy NM Gommans
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
| | - Marijn ML van den Houten
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
| | - Joep AW Teijink
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
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Falconer D, Papageorgiou N, Salem K, Lim WY, Katsargyris A, Avgerinos E, Tousoulis D. Nitric oxide donors for peripheral artery disease. Curr Opin Pharmacol 2018; 39:77-85. [DOI: 10.1016/j.coph.2018.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 02/18/2018] [Accepted: 02/22/2018] [Indexed: 01/02/2023]
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Abstract
Physical activity is critically important for Type 2 diabetes management, yet adherence levels are poor. This might be partly due to disproportionate exercise intolerance. Submaximal exercise tolerance is highly sensitive to muscle oxygenation; impairments in exercising muscle oxygen delivery may contribute to exercise intolerance in Type 2 diabetes since there is considerable evidence for the existence of both cardiac and peripheral vascular dysfunction. While uncompromised cardiac output during submaximal exercise is consistently observed in Type 2 diabetes, it remains to be determined whether an elevated cardiac sympathetic afferent reflex could sympathetically restrain exercising muscle blood flow. Furthermore, while deficits in endothelial function are common in Type 2 diabetes and are often cited as impairing exercising muscle oxygen delivery, no direct evidence in exercise exists, and there are several other vasoregulatory mechanisms whose dysfunction could contribute. Finally, while there are findings of impaired oxygen delivery, conflicting evidence also exists. A definitive conclusion that Type 2 diabetes compromises exercising muscle oxygen delivery remains premature. We review these potentially dysfunctional mechanisms in terms of how they could impair oxygen delivery in exercise, evaluate the current literature on whether an oxygen delivery deficit is actually manifest, and correspondingly identify key directions for future research.
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Affiliation(s)
- Veronica J Poitras
- School of Kinesiology and Health Studies, Queen's University , Kingston, Ontario , Canada.,Department of Physiology, Queen's University , Kingston, Ontario , Canada.,Children's Hospital of Eastern Ontario, Research Institute , Ottawa, Ontario , Canada
| | - Robert W Hudson
- Department of Medicine, Division of Endocrinology, Queen's University , Kingston, Ontario , Canada
| | - Michael E Tschakovsky
- School of Kinesiology and Health Studies, Queen's University , Kingston, Ontario , Canada
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Woessner MN, McIlvenna LC, Ortiz de Zevallos J, Neil CJ, Allen JD. Dietary nitrate supplementation in cardiovascular health: an ergogenic aid or exercise therapeutic? Am J Physiol Heart Circ Physiol 2018; 314:H195-H212. [DOI: 10.1152/ajpheart.00414.2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oral consumption of inorganic nitrate, which is abundant in green leafy vegetables and roots, has been shown to increase circulating plasma nitrite concentration, which can be converted to nitric oxide in low oxygen conditions. The associated beneficial physiological effects include a reduction in blood pressure, modification of platelet aggregation, and increases in limb blood flow. There have been numerous studies of nitrate supplementation in healthy recreational and competitive athletes; however, the ergogenic benefits are currently unclear due to a variety of factors including small sample sizes, different dosing regimens, variable nitrate conversion rates, the heterogeneity of participants’ initial fitness levels, and the types of exercise tests used. In clinical populations, the study results seem more promising, particularly in patients with cardiovascular diseases who typically present with disruptions in the ability to transport oxygen from the atmosphere to working tissues and reduced exercise tolerance. Many of these disease-related, physiological maladaptations, including endothelial dysfunction, increased reactive oxygen species, reduced tissue perfusion, and muscle mitochondrial dysfunction, have been previously identified as potential targets for nitric oxide restorative effects. This review is the first of its kind to outline the current evidence for inorganic nitrate supplementation as a therapeutic intervention to restore exercise tolerance and improve quality of life in patients with cardiovascular diseases. We summarize the factors that appear to limit or maximize its effectiveness and present a case for why it may be more effective in patients with cardiovascular disease than as ergogenic aid in healthy populations.
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Affiliation(s)
- Mary N. Woessner
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
| | - Luke C. McIlvenna
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
| | - Joaquin Ortiz de Zevallos
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia
| | - Christopher J. Neil
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
| | - Jason D. Allen
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia
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Lima AHRA, Chehuen M, Cucato GG, Soares AHG, Askew CD, Barbosa JPAS, Gomes CC Jr, Wolosker N, Forjaz CLM, Ritti-Dias RM. Relationship between walking capacity and ambulatory blood pressure in patients with intermittent claudication. Blood Press Monit 2017; 22:115-21. [PMID: 28195842 DOI: 10.1097/MBP.0000000000000243] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Patients with intermittent claudication (IC) often have high blood pressure (BP), which increases their cardiovascular risk. However, whether walking capacity is associated with BP levels in patients with IC remains unknown. Therefore, this study was designed to investigate whether the total walking distance is associated with ambulatory BP in patients with IC. PARTICIPANTS AND METHODS This was a cross-sectional study of 75 patients with IC (58 men; 17 women). A maximal treadmill test (Gardner protocol) was performed to assess total walking distance in these patients. Furthermore, ambulatory BP, heart rate, rate-pressure product, and BP load were obtained over a 24-h period. One-way analysis of variance and multiple linear regression were carried out. RESULTS Walking capacity was correlated negatively with the following: (i) asleep systolic BP, diastolic BP, mean BP and heart rate; (ii) 24-h, awake and asleep RPP; and (iii) awake and asleep systolic BP load (all P<0.05). These associations occurred irrespective of confounders such as age, sex, BMI, smoking status, and number of antihypertensive medications. CONCLUSION A better walking capacity is associated with lower ambulatory BP parameters in patients with IC.
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed-effect model unless we identified significant heterogeneity, in which case we used a random-effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow-up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty-seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre-existing limitations to their exercise capacity.Meta-analysis from nine studies with 391 participants showed overall improvement in pain-free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high-quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high-quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years.Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate-quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate-quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low-quality evidence).Researchers measured quality of life using Short Form (SF)-36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta-analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate-quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate-quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF-36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains - 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' - did not show improvement at six months.Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants.Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes - over 300 participants for most outcomes - using reproducible methods. AUTHORS' CONCLUSIONS High-quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.
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Affiliation(s)
- Risha Lane
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Amy Harwood
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Lorna Watson
- NHS FifeCameron House, Cameron BridgeWindygatesLevenUKKY8 5RG
| | - Gillian C Leng
- National Institute for Health and Care Excellence10 Spring GardensLondonUKSW1A 2BU
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Early KS, Stewart A, Johannsen N, Lavie CJ, Thomas JR, Welsch M. The Effects of Exercise Training on Brachial Artery Flow-Mediated Dilation: A Meta-analysis. J Cardiopulm Rehabil Prev 2017; 37:77-89. [PMID: 28033167 DOI: 10.1097/HCR.0000000000000206] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Flow-mediated dilation, a barometer of cardiovascular (CV) health, is reported to increase with exercise training (ET); however, the potential moderating factors of ET are not clear to date. The purpose of this study was to determine the effect of ET assessed by brachial artery flow-mediated dilation (BAFMD). METHODS Authors searched PubMed between January 1999 and December 2013, bibliographies, and reviews to identify studies examining ET and BAFMD. Two independent reviewers extracted quality, descriptive, exercise, and outcome data of eligible studies. Data were presented as weighted effect sizes (ESs) and 95% confidence limits. RESULTS Analysis included 66 studies reporting BAFMD data (1865 ET and 635 control subjects). Overall, ET had significant improvements in BAFMD compared with controls (P < .0001). Exercise training at higher ET intensities resulted in a greater increase in BAFMD (9.29; 95% CI, 5.09-13.47) than lower ET intensities (3.63; 95% CI, -0.56 to 7.83) or control (-0.42; 95% CI, -2.06 to 1.21). Subjects whose ET duration was ≥150 min/wk (11.33; 95% CI, 7.15-15.51) had a significant improvement in BAFMD compared with those with <150 min/wk (4.79; 95% CI, 3.08-6.51) or control (-0.30; 95% CI, -1.99 to 1.39). Age (P = .11) and baseline artery diameter (P = .31) did not modify the BAFMD response to ET. CONCLUSION Exercise training contributes to a significant increase in BAFMD. These results provide indirect evidence that ET alters a well-known factor associated with the primary and secondary prevention of CV diseases. Exercise training interventions, including greater intensity and duration, may optimize the increase in BAFMD.
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Woessner MN, VanBruggen MD, Pieper CF, O'Reilly EK, Kraus WE, Allen JD. Combined Dietary Nitrate and Exercise Intervention in Peripheral Artery Disease: Protocol Rationale and Design. JMIR Res Protoc 2017; 6:e139. [PMID: 28974486 PMCID: PMC5645641 DOI: 10.2196/resprot.7596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 12/12/2022] Open
Abstract
Background Peripheral artery disease (PAD) is caused by atherosclerotic occlusions in the legs. It affects approximately 8-12 million people in the United States alone, one-third of whom suffer from intermittent claudication (IC), defined as ischemic leg pain that occurs with walking and improves with rest. Patients with IC suffer a markedly impaired quality of life and a high perception of disability. Improving pain-free walking time is a primary goal of rehabilitation in this population. Objective The nitric oxide (NO)-PAD trial is designed to compare the effects that 12 weeks of supervised exercise training, in combination with a high inorganic nitrate-content (beetroot [BR] juice) beverage or placebo (PL) beverage, has on clinical outcomes of exercise and functional capacity in two groups of PAD+IC patients: exercise training plus beetroot (EX+BR) and exercise training plus placebo (EX+PL). The primary aims of this randomized controlled, double-blind pilot study are to determine group differences following 12 weeks of EX+BR versus EX+PL in the changes for (1) exercise capacity: pain-free walking time (claudication onset time, COT), peak walk time (PWT), and maximal exercise capacity (peak oxygen uptake, VO2peak) during a maximal-graded cardiopulmonary exercise test (max CPX) and (2) functional capacity: 6-minute walk (6MW) distance. The secondary aims will provide mechanistic insights into the exercise outcome measures and will include (1) gastrocnemius muscle oxygenation during exercise via near-infrared spectroscopy (NIRS); (2) gastrocnemius muscle angiogenesis: capillaries per unit area and per muscle fiber, and relative fraction of type I, IIa, IIb, and IId/x fibers; and (3) vascular health/function via brachial artery flow-mediated dilation, lower-limb blood flow via plethysmography, and pulse wave velocity and reflection. Methods A total of 30 subjects between 40 and 80 years of age with PAD who are limited by IC will undergo exercise training 3 days per week for 12 weeks (ie, 36 sessions). They will be randomized to either the EX+BR or EX+PL group where participants will consume a beverage high in inorganic nitrate (4.2 mmol) or a low-nitrate placebo, respectively, 3 hours prior to each training session. Results Data collection from this study has been completed and is in the process of analysis and write-up. While the study is too underpowered—EX+BR, n=11; EX+PL, n=13—to determine between-group differences in the primary outcomes of COT, PWT, and 6MW, preliminary observations are promising with Cohen d effect sizes of medium to large. Conclusions Exercise training is currently the most effective therapy to increase functional capacity in PAD+IC. If the addition of inorganic nitrate to an exercise regimen elicits greater benefits, it may redefine the current standard of care for PAD+IC. Trial Registration ClinicalTrials.gov NCT01684930; https://clinicaltrials.gov/ct2/show/NCT01684930 (Archived by WebCite at http://www.webcitation.org/6raXFyEcP)
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Affiliation(s)
- Mary N Woessner
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia.,Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Mitch D VanBruggen
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Carl F Pieper
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
| | - Erin K O'Reilly
- Office of Regulatory Affairs and Quality, Duke University Medical Center, Durham, NC, United States
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Jason D Allen
- Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia.,Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
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Sfyri P, Matsakas A. Crossroads between peripheral atherosclerosis, western-type diet and skeletal muscle pathophysiology: emphasis on apolipoprotein E deficiency and peripheral arterial disease. J Biomed Sci 2017; 24:42. [PMID: 28688452 PMCID: PMC5502081 DOI: 10.1186/s12929-017-0346-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/07/2017] [Indexed: 12/16/2022] Open
Abstract
Atherosclerosis is a chronic inflammatory process that, in the presence of hyperlipidaemia, promotes the formation of atheromatous plaques in large vessels of the cardiovascular system. It also affects peripheral arteries with major implications for a number of other non-vascular tissues such as the skeletal muscle, the liver and the kidney. The aim of this review is to critically discuss and assimilate current knowledge on the impact of peripheral atherosclerosis and its implications on skeletal muscle homeostasis. Accumulating data suggests that manifestations of peripheral atherosclerosis in skeletal muscle originates in a combination of increased i)-oxidative stress, ii)-inflammation, iii)-mitochondrial deficits, iv)-altered myofibre morphology and fibrosis, v)-chronic ischemia followed by impaired oxygen supply, vi)-reduced capillary density, vii)- proteolysis and viii)-apoptosis. These structural, biochemical and pathophysiological alterations impact on skeletal muscle metabolic and physiologic homeostasis and its capacity to generate force, which further affects the individual's quality of life. Particular emphasis is given on two major areas representing basic and applied science respectively: a)-the abundant evidence from a well-recognised atherogenic model; the Apolipoprotein E deficient mouse and the role of a western-type diet and b)-on skeletal myopathy and oxidative stress-induced myofibre damage from human studies on peripheral arterial disease. A significant source of reactive oxygen species production and oxidative stress in cardiovascular disease is the family of NADPH oxidases that contribute to several pathologies. Finally, strategies targeting NADPH oxidases in skeletal muscle in an attempt to attenuate cellular oxidative stress are highlighted, providing a better understanding of the crossroads between peripheral atherosclerosis and skeletal muscle pathophysiology.
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Affiliation(s)
- Peggy Sfyri
- Molecular Physiology Laboratory, Centre for Atherothrombotic & Metabolic Disease, Hull York Medical School, University of Hull, Cottingham Road, Hull, HU6 7RX, United Kingdom
| | - Antonios Matsakas
- Molecular Physiology Laboratory, Centre for Atherothrombotic & Metabolic Disease, Hull York Medical School, University of Hull, Cottingham Road, Hull, HU6 7RX, United Kingdom.
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Yuan S, Kevil CG. Nitric Oxide and Hydrogen Sulfide Regulation of Ischemic Vascular Remodeling. Microcirculation 2016; 23:134-45. [PMID: 26381654 DOI: 10.1111/micc.12248] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 09/13/2015] [Indexed: 12/22/2022]
Abstract
Blockage or restriction of blood flow through conduit arteries results in tissue ischemia downstream of the disturbed area. Local tissues can adapt to this challenge by stimulating vascular remodeling through angiogenesis and arteriogenesis thereby restoring blood perfusion and removal of wastes. Multiple molecular mechanisms of vascular remodeling during ischemia have been identified and extensively studied. However, therapeutic benefits from these findings and insights are limited due to the complexity of various signaling networks and a lack of understanding central metabolic regulators governing these responses. The gasotransmitters NO and H2 S have emerged as master regulators that influence multiple molecular targets necessary for ischemic vascular remodeling. In this review, we discuss how NO and H2 S are individually regulated under ischemia, what their roles are in angiogenesis and arteriogenesis, and how their interaction controls ischemic vascular remodeling.
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Affiliation(s)
- Shuai Yuan
- Departments of Pathology, Molecular and Cellular Physiology, and Cell Biology and Anatomy, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Christopher G Kevil
- Departments of Pathology, Molecular and Cellular Physiology, and Cell Biology and Anatomy, LSU Health Shreveport, Shreveport, Louisiana, USA
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Ahluwalia A, Gladwin M, Coleman GD, Hord N, Howard G, Kim-Shapiro DB, Lajous M, Larsen FJ, Lefer DJ, McClure LA, Nolan BT, Pluta R, Schechter A, Wang CY, Ward MH, Harman JL. Dietary Nitrate and the Epidemiology of Cardiovascular Disease: Report From a National Heart, Lung, and Blood Institute Workshop. J Am Heart Assoc 2016; 5:e003402. [PMID: 27385425 PMCID: PMC5015377 DOI: 10.1161/jaha.116.003402] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Amrita Ahluwalia
- The William Harvey Research Institute, Barts & The London Medical School, Queen Mary University of London, UK
| | - Mark Gladwin
- Vascular Medicine Institute, Pittsburgh University, Pittsburgh, PA
| | | | | | | | | | - Martin Lajous
- Nacional de Salud Pública de Mexico, Mexico, Albania
| | | | - David J Lefer
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Leslie A McClure
- Dornsife School of Public Health at Drexel University, Philadelphia, PA
| | | | - Ryszard Pluta
- National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Alan Schechter
- National Institute for Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Chia-Yih Wang
- National Center for Health Statistics, CDC, Hyattsville, MD
| | | | - Jane L Harman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
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Dörenkamp S, Mesters EPE, Nijhuis-van der Sanden MWG, Teijink JAW, de Bie RA, Hoogeboom TJ. How Well Do Randomized Controlled Trials Reflect Standard Care: A Comparison between Scientific Research Data and Standard Care Data in Patients with Intermittent Claudication undergoing Supervised Exercise Therapy. PLoS One 2016; 11:e0157921. [PMID: 27336741 PMCID: PMC4919097 DOI: 10.1371/journal.pone.0157921] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 06/07/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of the present study was to assess the degree and impact of patient selection of patients with intermittent claudication undergoing supervised exercise therapy in Randomized Controlled Trials (RCTs) by describing commonly used exclusion criteria, and by comparing baseline characteristics and treatment response measured as improvement in maximum walking distance of patients included in RCTs and patients treated in standard care. METHODS We compared data from RCTs with unselected standard care data. First, we systematically reviewed RCTs that investigated the effect of supervised exercise therapy in patients with intermittent claudication. For each of the RCTs, we extracted and categorized the eligibility criteria and their justifications. To assess whether people in RCTs (n = 1,440) differed from patients treated in daily practice (n = 3,513), in terms of demographics, comorbidity and walking capacity, we assessed between group-differences using t-tests. To assess differences in treatment response, we compared walking distances at three and six months between groups using t-tests. Differences of ≥15% were set as a marker for a clinically relevant difference. RESULTS All 20 included RCTs excluded large segments of patients with intermittent claudication. One-third of the RCTs eligibility criteria were justified. Despite, the numerous eligibility criteria, we found that baseline characteristics were largely comparable. A statistically significant and (borderline) clinically relevant difference in treatment response after three and six months between trial participants and standard care patients was found. Improvements in maximum walking distance after three and six months were significantly and clinically less in trial participants. CONCLUSIONS The finding that baseline characteristics of patients included in RCTs and patients treated in standard care were comparable, may indicate that RCT eligibility criteria are used implicitly by professionals when referring patients to standard physiotherapy care. The larger treatment response reported in standard physiotherapy care compared to clinical trials, might suggest that scientific studies underestimate the benefits of supervised exercise therapy in patients with intermittent claudication.
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Affiliation(s)
- S. Dörenkamp
- Department of Epidemiology, Functioning and Rehabilitation Programme, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - E. P. E. Mesters
- Department of Epidemiology, Functioning and Rehabilitation Programme, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - M. W. G. Nijhuis-van der Sanden
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare and Department of Rehabilitation, Nijmegen, The Netherlands
| | - J. A. W. Teijink
- Department of Epidemiology, Functioning and Rehabilitation Programme, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - R. A. de Bie
- Department of Epidemiology, Functioning and Rehabilitation Programme, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - T. J. Hoogeboom
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare and Department of Rehabilitation, Nijmegen, The Netherlands
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Lyu X, Li S, Peng S, Cai H, Liu G, Ran X. Intensive walking exercise for lower extremity peripheral arterial disease: A systematic review and meta-analysis. J Diabetes 2016; 8:363-77. [PMID: 25940390 DOI: 10.1111/1753-0407.12304] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 03/25/2015] [Accepted: 04/26/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Supervised treadmill exercise is the recommended therapy for peripheral arterial disease (PAD) patients with intermittent claudication (IC). However, most PAD patients do not exhibit typical symptoms of IC. The aim of the present study was to explore the efficacy and safety of intensive walking exercise in PAD patients with and without IC. METHODS The PubMed, Embase and Cochrane Library databases were systematically searched. Randomized controlled trials comparing the effects of intensive walking exercise with usual care in patients with PAD were included for systematic review and meta-analysis. RESULTS Eighteen trials with 1200 patients were eligible for the present analysis. Compared with usual care, intensive walking exercise significantly improved the maximal walking distance (MWD), pain-free walking distance, and the 6-min walking distance in patients with PAD (P < 0.00001 for all). Subgroup analyses indicated that a lesser improvement in MWD was observed in the subgroup with more diabetes patients, and that the subgroup with better baseline walking ability exhibited greater improvement in walking performance. In addition, similar improvements in walking performance were observed for exercise programs of different durations and modalities. No significant difference was found in adverse events between the intensive walking and usual care groups (relative risk 0.84; 95% confidence interval 0.51, 1.39; P = 0.50). CONCLUSIONS Regardless of exercise length and modality, regularly intensive walking exercise improves walking ability in PAD patients more than usual care. The presence of diabetes may attenuate the improvements in walking performance in patients with PAD following exercise.
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Affiliation(s)
- Xiafei Lyu
- Diabetic Foot Center, Chengdu, China
- Department of Endocrinology and Metabolism, West China Hospital, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Chengdu, China
| | - Shifeng Peng
- Clinical Medicine of Eight-year Program, West China School of Medicine, Sichuan University, Chengdu, China
| | - Huimin Cai
- Clinical Medicine of Eight-year Program, West China School of Medicine, Sichuan University, Chengdu, China
| | - Guanjian Liu
- Chinese Cochrane Center, West China Hospital, Chengdu, China
| | - Xingwu Ran
- Diabetic Foot Center, Chengdu, China
- Department of Endocrinology and Metabolism, West China Hospital, Chengdu, China
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Rodríguez-Núñez I, Romero F, Saavedra MJ. [Exercise-induced shear stress: Physiological basis and clinical impact]. Arch Cardiol Mex 2016; 86:244-54. [PMID: 27118039 DOI: 10.1016/j.acmx.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 02/10/2016] [Accepted: 03/17/2016] [Indexed: 11/30/2022] Open
Abstract
The physiological regulation of vascular function is essential for cardiovascular health and depends on adequate control of molecular mechanisms triggered by endothelial cells in response to mechanical and chemical stimuli induced by blood flow. Endothelial dysfunction is one of the major risk factors for cardiovascular disease, where an imbalance between synthesis of vasodilator and vasoconstrictor molecules is one of its main mechanisms. In this context, the shear stress is one of the most important mechanical stimuli to improve vascular function, due to endothelial mechanotransduction, triggered by stimulation of various endothelial mechanosensors, induce signaling pathways culminating in increased bioavailability of vasodilators molecules such as nitric oxide, that finally trigger the angiogenic mechanisms. These mechanisms allow providing the physiological basis for the effects of exercise on vascular health. In this review it is discussed the molecular mechanisms involved in the vascular response induced by shear stress and its impact in reversing vascular injury associated with the most prevalent cardiovascular disease in our population.
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Affiliation(s)
- Iván Rodríguez-Núñez
- Laboratorio de Biología del Ejercicio, Escuela de Kinesiología, Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile; Carrera de Kinesiología, Facultad de Salud, Universidad Santo Tomás, Concepción, Chile; Programa de Doctorado en Ciencias Médicas, Facultad de Medicina, Universidad de la Frontera. Laboratorio de Neurociencia y Biología de péptidos CEBIOR-CEGIN BIOREN, Depto. Ciencias Preclínicas, Facultad Medicina, UFRO, Temuco, Chile; Programa de Magíster en Kinesiología Cardiorrespiratoria, Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile.
| | - Fernando Romero
- Programa de Doctorado en Ciencias Médicas, Facultad de Medicina, Universidad de la Frontera. Laboratorio de Neurociencia y Biología de péptidos CEBIOR-CEGIN BIOREN, Depto. Ciencias Preclínicas, Facultad Medicina, UFRO, Temuco, Chile
| | - María Javiera Saavedra
- Programa de Magíster en Kinesiología Cardiorrespiratoria, Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile
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Walker MA, Hoier B, Walker PJ, Schulze K, Bangsbo J, Hellsten Y, Askew CD. Vasoactive enzymes and blood flow responses to passive and active exercise in peripheral arterial disease. Atherosclerosis 2015; 246:98-105. [PMID: 26771386 DOI: 10.1016/j.atherosclerosis.2015.12.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/02/2015] [Accepted: 12/21/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is characterised by impaired leg blood flow, which contributes to claudication and reduced exercise capacity. This study investigated to what extent vasoactive enzymes might contribute to altered blood flow in PAD (Fontaine stage II). METHODS We compared femoral artery blood flow during reactive hyperaemia, leg-extension exercise and passive leg movement, and determined the level of vasoactive enzymes in skeletal muscle samples from the vastus lateralis in PAD (n = 10, 68.5 ± 6.5 years) and healthy controls (CON, n = 9, 62.1 ± 12.3 years). Leg blood flow was measured with Doppler ultrasound and muscle protein levels of phosphorylated endothelial nitric oxide synthase, NADPH oxidase, cyclooxygenase 1 and 2, thromboxane synthase, and prostacyclin synthase were determined. RESULTS Leg blood flow during the initial 90 s of passive leg movement (242 ± 33 vs 441 ± 75 ml min(-1), P = 0.03) and during reactive hyperaemia (423 ± 100 vs 1255 ± 175 ml min(-1), P = 0.002) was lower in PAD than CON, whereas no significant difference was observed for leg blood flow during exercise (1490 ± 250 vs 1887 ± 349 ml min(-1), P = 0.37). PAD had higher NADPH oxidase than CON (1.04 ± 0.19 vs 0.50 ± 0.06 AU, P = 0.02), with no differences for other enzymes. Leg blood flow during exercise was correlated with prostacyclin synthase (P = 0.001). CONCLUSION Elevated NADPH oxidase indicates that oxidative stress may be a primary cause of low nitric oxide availability and impaired blood flow in PAD.
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Affiliation(s)
- Meegan A Walker
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia.
| | - Birgitte Hoier
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark.
| | - Philip J Walker
- School of Medicine, Royal Brisbane and Women's Hospital, University of Queensland, Herston, Queensland, Australia
| | - Karl Schulze
- Sunshine Vascular Surgery and Imaging, Buderim, Queensland, Australia
| | - Jens Bangsbo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark.
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark.
| | - Christopher D Askew
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia.
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Aherne T, McHugh S, Kheirelseid EA, Lee MJ, McCaffrey N, Moneley D, Leahy AL, Naughton P. Comparing Supervised Exercise Therapy to Invasive Measures in the Management of Symptomatic Peripheral Arterial Disease. Surg Res Pract 2015; 2015:960402. [PMID: 26601122 DOI: 10.1155/2015/960402] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 10/05/2015] [Accepted: 10/11/2015] [Indexed: 11/17/2022] Open
Abstract
Peripheral arterial disease (PAD) is associated with considerable morbidity and mortality. Consensus rightly demands the incorporation of supervised exercise training (SET) into PAD treatment protocols. However, the exact role of SET particularly its relationship with intervention requires further clarification. While supervised exercise is undoubtedly an excellent tool in the conservative management of mild PAD its use in more advanced disease as an adjunct to open or endovascular intervention is not clearly defined. Indeed its use in isolation in this cohort is incompletely reported. The aim of this review is to clarify the exact role of SET in the management of symptomatic PAD and in particular to assess its role in comparison with or as an adjunct to invasive intervention. A systematic literature search revealed a total 11 randomised studies inclusive of 969 patients. All studies compared SET and intervention with monotherapy. Study results suggest that exercise is a complication-free treatment. Furthermore, it appears to offer significant improvements in patients walk distances with a combination of both SET and intervention offering a superior walking outcome to monotherapy in those requiring invasive measures.
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Ferguson SK, Glean AA, Holdsworth CT, Wright JL, Fees AJ, Colburn TD, Stabler T, Allen JD, Jones AM, Musch TI, Poole DC. Skeletal Muscle Vascular Control During Exercise: Impact of Nitrite Infusion During Nitric Oxide Synthase Inhibition in Healthy Rats. J Cardiovasc Pharmacol Ther 2015; 21:201-8. [PMID: 26272082 DOI: 10.1177/1074248415599061] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/17/2015] [Indexed: 12/26/2022]
Abstract
The nitric oxide synthase (NOS)-independent pathway of nitric oxide (NO) production in which nitrite (NO2 (-)) is reduced to NO may have therapeutic applications for those with cardiovascular diseases in which the NOS pathway is downregulated. We tested the hypothesis that NO2 (-) infusion would reduce mean arterial pressure (MAP) and increase skeletal muscle blood flow (BF) and vascular conductance (VC) during exercise in the face of NOS blockade via L-NAME. Following infusion of L-NAME (10 mg kg(-1), L-NAME), male Sprague-Dawley rats (3-6 months, n = 8) exercised without N(G)-nitro-L arginine methyl ester (L-NAME) and after infusion of sodium NO2 (-) (7 mg kg(-1); L-NAME + NO2 (-)). MAP and hindlimb skeletal muscle BF (radiolabeled microsphere infusions) were measured during submaximal treadmill running (20 m min(-1), 5% grade). Across group comparisons were made with a published control data set (n = 11). Relative to L-NAME, NO2 (-) infusion significantly reduced MAP (P < 0.03). The lower MAP in L-NAME+NO2 (-) was not different from healthy control animals (control: 137 ± 3 L-NAME: 157 ± 7, L-NAME + NO2 (-): 136 ± 5 mm Hg). Also, NO2 (-) infusion significantly increased VC when compared to L-NAME (P < 0.03), ultimately negating any significant differences from control animals (control: 0.78 ± 0.05, L-NAME: 0.57 ± 0.03, L-NAME + NO2 (-); 0.69 ± 0.04 mL min(-1) 100 g(-1) mm Hg(-1)) with no apparent fiber-type preferential effect. Overall, hindlimb BF was decreased significantly by L-NAME; however, in L-NAME + NO2 (-), BF improved to a level not significantly different from healthy controls (control: 108 ± 8, L-NAME: 88 ± 3, L-NAME + NO2 (-): 94 ± 6 mL min(-1) 100 g(-1), P = 0.38 L-NAME vs L-NAME + NO2 (-)). Individuals with diseases that impair NOS activity, and thus vascular function, may benefit from a NO2 (-)-based therapy in which NO bioavailability is elevated in an NOS-independent manner.
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Affiliation(s)
- Scott K Ferguson
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Angela A Glean
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Clark T Holdsworth
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Jennifer L Wright
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Alex J Fees
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - Trenton D Colburn
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Thomas Stabler
- Institute of Sport Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
| | - Jason D Allen
- Institute of Sport Exercise and Active Living, Victoria University, Melbourne, Victoria, Australia
| | - Andrew M Jones
- Sport and Health Sciences, University of Exeter, St Luke's Campus, Exeter, United Kingdom
| | - Timothy I Musch
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - David C Poole
- Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA Department of Kinesiology, Kansas State University, Manhattan, KS, USA
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Hageman D, Gommans LN, Fokkenrood HJ, Koelemay MJ, Teijink JA. Commentary on "Supervised versus unsupervised exercise for intermittent claudication: A sytematic review and meta-analysis". Am Heart J 2015; 170:e1-3. [PMID: 26299241 DOI: 10.1016/j.ahj.2015.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Vemulapalli S, Dolor RJ, Hasselblad V, Schmit K, Banks A, Heidenfelder B, Patel MR, Jones WS. Supervised vs unsupervised exercise for intermittent claudication: A systematic review and meta-analysis. Am Heart J 2015; 169:924-937.e3. [PMID: 26027632 DOI: 10.1016/j.ahj.2015.03.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 03/21/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Supervised exercise (SE) is widely accepted as an effective therapy for intermittent claudication (IC), but its use is limited by cost. Unsupervised exercise (UE) represents a less costly alternative. We assessed the comparative effectiveness of SE vs UE in patients with IC. METHODS AND RESULTS We searched PubMed, EMBASE, and the Cochrane Database of Systematic Reviews and identified 27 unique studies (24 randomized controlled trials, 4 observational studies) that evaluated the comparative effectiveness of SE vs UE in 2074 patients with IC. Compared with UE, SE was associated with a moderate improvement in maximal walking distance at 6 months (effect size 0.77, 95% CI 0.36-1.17, P < .001) and 12 months (effect size 0.56, 95% CI 0.34-0.77, P < .001). Supervised exercise also improved claudication distance to a moderate extent compared with UE at 6 months (effect size 0.63, 95% CI 0.40-0.85, P < .001) and 12 months (effect size 0.41, 95% CI 0.18-0.65, P = .001). There was no difference in the Short Form-36 quality of life at 6 months (effect size -0.05, 95% CI -0.50 to 0.41, P = .84) or walking impairment questionnaire distance (effect size 0.24, 95% CI -0.03 to 0.50, P = .08) or speed (effect size 0.26, 95% CI -0.06 to 0.59, P = .11). CONCLUSIONS In claudication patients, SE is more effective than UE at improving maximal walking and claudication distances, yet there is no difference in general quality of life or patient-reported community-based walking. Further studies are needed to investigate the relationship between functional gain and disease-specific quality of life.
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Mays RJ, Hiatt WR, Casserly IP, Rogers RK, Main DS, Kohrt WM, Ho PM, Regensteiner JG. Community-based walking exercise for peripheral artery disease: An exploratory pilot study. Vasc Med 2015; 20:339-47. [PMID: 25755148 DOI: 10.1177/1358863x15572725] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supervised walking exercise is an effective treatment to improve walking ability of patients with peripheral artery disease (PAD), but few exercise programs in community settings have been effective. The aim of this study was to determine the efficacy of a community-based walking exercise program with training, monitoring and coaching (TMC) components to improve exercise performance and patient-reported outcomes in PAD patients. This was a randomized, controlled trial including PAD patients (n=25) who previously received peripheral endovascular therapy or presented with stable claudication. Patients randomized to the intervention group received a comprehensive community-based walking exercise program with elements of TMC over 14 weeks. Patients in the control group did not receive treatment beyond standard advice to walk. The primary outcome in the intent-to-treat (ITT) analyses was peak walking time (PWT) on a graded treadmill. Secondary outcomes included claudication onset time (COT) and patient-reported outcomes assessed via the Walking Impairment Questionnaire (WIQ). Intervention group patients (n=10) did not significantly improve PWT when compared with the control group patients (n=10) (mean ± standard error: +2.1 ± 0.7 versus 0.0 ± 0.7 min, p=0.052). Changes in COT and WIQ scores were greater for intervention patients compared with control patients (COT: +1.6 ± 0.8 versus -0.6 ± 0.7 min, p=0.045; WIQ: +18.3 ± 4.2 versus -4.6 ± 4.2%, p=0.001). This pilot using a walking program with TMC and an ITT analysis did not improve the primary outcome in PAD patients. Other walking performance and patient self-reported outcomes were improved following exercise in community settings. Further study is needed to determine whether this intervention improves outcomes in a trial employing a larger sample size.
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Affiliation(s)
- Ryan J Mays
- School of Physical Therapy and Rehabilitation Science, College of Health Professions and Biomedical Sciences, University of Montana, Missoula, MT, USA The International Heart Institute of Montana Foundation, Saint Patrick Hospital, Providence Medical Group, Missoula, MT, USA Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA Center for Women's Health Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - William R Hiatt
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA CPC Clinical Research, Aurora, CO, USA
| | | | - R Kevin Rogers
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA CPC Clinical Research, Aurora, CO, USA
| | - Deborah S Main
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
| | - Wendy M Kohrt
- Center for Women's Health Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - P Michael Ho
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Judith G Regensteiner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA Center for Women's Health Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Li S, Li Q, Lyu X, Tian H, Ran X. Alternative Statistical Analysis Shows Exercise Training-Induced Improvements in Peak VO2 are Clinically Significant. Sports Med 2015; 45:763-5. [DOI: 10.1007/s40279-015-0317-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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