Cardiorespiratory Fitness and Incidence of Major Adverse Cardiovascular Events in US Veterans: A Cohort Study

Effects of Non-Face-to-Face Chronic Care Management on Service Utilization and Outcomes Among US Medicare Beneficiaries with Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) results in heavy economic and disease burdens in Louisiana. The Centers for Medicare and Medicaid Services has reimbursed non-face-to-face chronic care management (NFFCCM) for patients with two or more chronic conditions since 2015.

OBJECTIVE

To assess the impacts of NFFCCM on healthcare utilization and health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included Medicare fee-for-service beneficiaries with T2DM and at least one additional chronic disease between 2014 and 2018.

EXPOSURES

At least one record of NFFCCM Current Procedural Terminology codes.

MAIN MEASURES

The health outcomes in the study included major adverse cardiovascular events (MACE), all-cause mortality, and heart failure. The monthly service utilization and continuity of care index for primary care were also included. The propensity score method was used to balance the baseline differences between the two groups. Weighted multivariate regression models were developed using propensity score weights to assess the impacts of NFFCCM on outcomes.

KEY RESULTS

During the 5 years of study period, 8415 patients among the 118,643 Medicare beneficiaries received at least one NFFCCM. Patients receiving any NFFCCM had reduced healthcare utilization compared with patients not receiving NFFCCM, including 0.012 (95% CI - 0.014 to - 0.011; p < 0.001) fewer monthly hospital admissions, 0.017 (95% CI - 0.019 to - 0.016; p < 0.001) fewer monthly ED visits, and 0.399 (95% CI 0.375 to 0.423; p < 0.001) more monthly outpatient encounters. Patients receiving NFFCCM services had lower MACE event rates of 7.4% (95% CI 7.1 to 7.8%; p < 0.001), all-cause mortality rate of 7.8% (95% CI 7.4 to 8.1%; p < 0.001), and heart failure rate of 0.3% (95% CI 0.2 to 0.5%; p < 0.001), respectively.

CONCLUSIONS AND RELEVANCE

These findings suggest that reimbursement for NFFCCM was associated with the shifting high-cost utilization to lower-cost primary health care settings among patients with diabetes in Louisiana.

Estimating cardiorespiratory fitness in older adults using the international physical activity questionnaire

Introduction

Non-exercise estimates of cardiorespiratory fitness hold great utility for epidemiological research and clinical practice. Older adults may yield the greatest benefit from fitness estimates due to limited capacity to undergo strenuous maximal exercise testing, however, few of the previously developed non-exercise equations are suitable for use in older adults. Thus, the current study developed a non-exercise equation for estimating cardiorespiratory fitness in older adults derived from the widely used International Physical Activity Questionnaire (IPAQ).

Methods

This study was a secondary analysis of baseline data from a randomized controlled trial. Participants were community-dwelling, cognitively unimpaired older adults aged 60-80 years (n = 92). They completed the IPAQ and underwent maximal exercise testing on a cycle ergometer. Stepwise linear regression was used to determine the equation in a randomly selected, sex-balanced, derivation subset of participants (n = 60), and subsequently validated using a second subset of participants (n = 32).

Results

The final equation included age, sex, body mass index and leisure time activity from the IPAQ and explained 61% and 55% of the variance in the derivation and validation groups, respectively (standard error of estimates = 3.9, 4.0). Seventy-seven and 81% of the sample fell within ±1SD (5.96 and 6.28 ml·kg-1·min-1) of measured VO2peak for the derivation and validation subgroups. The current equation showed better performance compared to equations from Wier et al. (2006), Jackson et al. (1990), and Schembre & Riebe (2011), although it is acknowledged previous equations were developed for different populations.

Conclusions

Using non-exercise, easily accessible measures can yield acceptable estimates of cardiorespiratory fitness in older adults, which should be further validated in other samples and examined in relation to public health outcomes.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

Exercise for patients with chronic kidney disease: from cells to systems to function

Chronic kidney disease (CKD) is among the leading causes of death and disability, affecting an estimated 800 million adults globally. The underlying pathophysiology of CKD is complex creating challenges to its management. Primary risk factors for the development and progression of CKD include diabetes mellitus, hypertension, age, obesity, diet, inflammation, and physical inactivity. The high prevalence of diabetes and hypertension in patients with CKD increases the risk for secondary consequences such as cardiovascular disease and peripheral neuropathy. Moreover, the increased prevalence of obesity and chronic levels of systemic inflammation in CKD have downstream effects on critical cellular functions regulating homeostasis. The combination of these factors results in the deterioration of health and functional capacity in those living with CKD. Exercise offers protective benefits for the maintenance of health and function with age, even in the presence of CKD. Despite accumulating data supporting the implementation of exercise for the promotion of health and function in patients with CKD, a thorough description of the responses and adaptations to exercise at the cellular, system, and whole body levels is currently lacking. Therefore, the purpose of this review is to provide an up-to-date comprehensive review of the effects of exercise training on vascular endothelial progenitor cells at the cellular level; cardiovascular, musculoskeletal, and neural factors at the system level; and physical function, frailty, and fatigability at the whole body level in patients with CKD.

2023 update: The importance of cardiorespiratory fitness in the United States

The American Heart Association issued a Policy Statement in 2013 that characterized the importance of cardiorespiratory fitness (CRF) as an essential marker of health outcomes and specifically the need for increased assessment of CRF. This statement summarized the evidence demonstrating that CRF is "one of the most important correlates of overall health status and a potent predictor of an individual's future risk of cardiovascular disease." Subsequently, this Policy Statement led to the development of a National Registry for CRF (Fitness Registry and the Importance of Exercise: A National Data Base [FRIEND]) which established normative reference values for CRF for adults in the United States (US). This review provides an overview of the progress made in the past decade to further our understanding of the importance of CRF, specifically related to prevention and for clinical populations. Additionally, this review overviews the evolvement and additional uses of FRIEND and summarizes a hierarchy of assessment methods for CRF. In summary, continued efforts are needed to expand the representation of data from across the US, and to include data from pediatric populations, to further develop the CRF Reference Standards for the US as well as further develop Global CRF Reference Standards.

Physical Activity and Cardiorespiratory Fitness as Modulators of Health Outcomes: A Compelling Research-Based Case Presented to the Medical Community

The beneficial health effects and prognostic significance of regular moderate-to-vigorous physical activity (PA), increased cardiorespiratory fitness (CRF), or both are often underappreciated by the medical community and the patients they serve. Individuals with low CRF have higher annual health care costs, higher rates of surgical complications, and are two to three times more likely to die prematurely than their fitter counterparts when matched for risk factor profile or coronary calcium score. Increased levels of habitual PA before hospitalization for acute coronary syndromes are also associated with better short-term cardiovascular outcomes. Accordingly, this review examines these relations and the potential underlying mechanisms of benefit (eg, exercise preconditioning), with specific reference to the incidence of cardiovascular, cancer, and coronavirus diseases, and the prescriptive implications and exercise thresholds for optimizing health outcomes. To assess the evidence supporting or refuting the benefits of PA and CRF, we performed a literature search (PubMed) and critically reviewed the evidence to date. In aggregate, these data are presented in the context of clarifying the impact that regular PA and/or increased CRF have on preventing and treating chronic and infectious diseases, with reference to evidence-based exercise thresholds that the medical community can embrace and promote.

Analysis of Cardiorespiratory Fitness in Early Adulthood and Midlife With All-Cause Mortality and Fatal or Nonfatal Cardiovascular Disease

IMPORTANCE

Optimizing cardiovascular fitness is a prevention strategy against premature death and cardiovascular disease (CVD) events. Since this evidence has largely been established in older populations, the importance of cardiorespiratory fitness during earlier periods of adulthood remains unclear.

OBJECTIVE

To examine the association of early-adulthood cardiorespiratory fitness and percentage of early-adulthood cardiorespiratory fitness retained during midlife with subsequent risk of all-cause mortality and CVD-related morbidity and mortality overall as well as by sex and race.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study analyzed data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, an ongoing prospective cohort study conducted at field center clinics in Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. Participants in the CARDIA study were aged 18 to 30 years when they completed the baseline graded exercise test protocol in 1985 to 1986 and have since undergone follow-up examinations biannually and every 2 to 5 years. Data were collected through August 31, 2020, and were analyzed in October 2022.

EXPOSURES

Cardiorespiratory fitness was estimated from a symptom-limited, maximal graded exercise test protocol conducted at baseline and at year 7 and year 20 follow-up examinations.

MAIN OUTCOMES AND MEASURES

All-cause mortality and combined fatal and nonfatal CVD events were obtained since year 20 of follow-up examinations through August 31, 2020. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) for each primary exposure with each outcome.

RESULTS

A total of 4808 participants (mean [SD] age at baseline, 24.8 [3.7] years; 2670 females [56%]; 2438 Black individuals [51%]) were included in the sample. During 68 751 person-years of follow-up, there were 302 deaths (6.3%) and 274 CVD events (5.7%) since year 20. Every 1-minute increment in cardiorespiratory fitness at baseline was associated with a lower risk of all-cause mortality in females (HR, 0.73; 95% CI, 0.64-0.82) and males (HR, 0.87; 95% CI, 0.80-0.96). Every 5% increment in cardiorespiratory fitness retained through year 20 was associated with a lower risk of all-cause mortality (HR, 0.89; 95% CI, 0.79-0.99), but no evidence of effect modification by race or sex was found. Every 1-minute increment in cardiorespiratory fitness at baseline was associated with a lower risk of fatal or nonfatal CVD (HR, 0.89; 95% CI, 0.82-0.96), and the estimated HR per 5% increment in cardiorespiratory fitness retained throughout midlife was 0.89 (95% CI, 0.78-1.00), with no evidence for interaction by race or sex.

CONCLUSIONS AND RELEVANCE

This cohort study found that higher early-adulthood cardiorespiratory fitness and greater retention of early-adulthood cardiorespiratory fitness throughout midlife were associated with a lower risk of premature death and CVD events. Additional research is needed to clarify the association of cardiorespiratory fitness timing across the life course with risk of clinical outcomes.

Sex-specific associations of cardiorespiratory fitness and galectin-3 in the general population

AIMS

Low cardiorespiratory fitness (CRF) is associated with greater mortality and morbidity. Galectin-3 (Gal-3) is a prognostic biomarker for fibrosis and heart failure. Gal-3 is also associated with a greater risk for cardiovascular mortality. Whether CRF is related with Gal-3 is unclear. The objective of this study was to assess the sex-specific associations of CRF and Gal-3 levels in the general population.

METHODS

Gal-3 concentrations were determined using a sandwich enzyme immunoassay in the population-based Study of Health in Pomerania (SHIP-TREND-0). Sex-stratified linear regression models adjusted for age, current smoking status, and renal function were used. Individuals with left ventricular ejection fraction (LVEF) <40%, previous myocardial infarction, atrial fibrillation, chronic lung disease, severe renal disease (estimated glomerular filtration rate <30 mL/min/mm2 ), a history of cancer, and extreme values for Gal-3 (<1st percentile; >99th percentile) were excluded.

RESULTS

A total of n = 1515 participants with a median age of 49 (IQR: 39-60 years, 48% males) were included. In men, a 1 L/min greater VO2 peak was significantly related to 0.50 ng/mL (95% CI -0.8068 to -0.1938, P < 0.01) less Gal-3. In males, a 1 mL/min/kg higher VO2 peak adjusted for body weight was associated with -0.0286 ng/mL (95% CI -0.0052 to -0.0005, P = 0.02) less Gal-3. When VO2 peak was adjusted for lean mass 1 mL/kg/min more was correlated with a -0.0022 ng/mL (95% CI -0.0043 to -0.0007, P = 0.04) less Gal-3. In women, VO2 peak (β -0.2046 95% CI -0.6541 to 0.2449, P = 0.37) and VO2 peak adjusted for lean mass (β -0.0019 95% CI -0.0421 to -0.0050, P = 0.12) were not related with Gal-3, whereas a 1 mL/min/kg higher VO2 peak adjusted for body weight was significantly associated with a -0.0064 ng/mL lower Gal-3 (95% CI -0.0092 to -0.0035, P < 0.01). There were no differences between pre-menopausal and post-menopausal women.

CONCLUSIONS

VO2 peak was associated with Gal-3 only in men, but VO2 peak adjusted for body weight in women and men. Our results suggest that the adverse consequences of low CRF may be mediated by Gal-3. Further research is needed to understand the sex-specific association between CRF and Gal-3 and whether they are clinically relevant.

The impact of greenspace or nature-based interventions on cardiovascular health or cancer-related outcomes: A systematic review of experimental studies

SIGNIFICANCE

Globally, cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality. While having different etiologies, CVD and cancer are linked by multiple shared risk factors, the presence of which exacerbate adverse outcomes for individuals with either disease. For both pathologies, factors such as poverty, lack of physical activity (PA), poor dietary intake, and climate change increase risk of adverse outcomes. Prior research has shown that greenspaces and other nature-based interventions (NBIs) contribute to improved health outcomes and climate change resilience.

OBJECTIVE

To summarize evidence on the impact of greenspaces or NBIs on cardiovascular health and/or cancer-related outcomes and identify knowledge gaps to inform future research.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and Peer Review of Electronic Search Strategies (PRESS) guidelines, we searched five databases: Web of Science, Scopus, Medline, PsycINFO and GreenFile. Two blinded reviewers used Rayyan AI and a predefined criteria for article inclusion and exclusion. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). This review is registered with PROSPERO, ID # CRD42021231619.

RESULTS & DISCUSSION

Of 2565 articles retrieved, 31 articles met the inclusion criteria, and overall had a low risk of bias. 26 articles studied cardiovascular related outcomes and 5 studied cancer-related outcomes. Interventions were coded into 4 categories: forest bathing, green exercise, gardening, and nature viewing. Outcomes included blood pressure (BP), cancer-related quality of life (QoL) and (more infrequently) biomarkers of CVD risk. Descriptions of findings are presented as well as visual presentations of trends across the findings using RAW graphs. Overall studies included have a low risk of bias; and alluvial chart trends indicated that NBIs may have beneficial effects on CVD and cancer-related outcomes.

CONCLUSIONS & IMPLICATIONS

(1) Clinical implication: Healthcare providers should consider the promotion of nature-based programs to improve health outcomes. (2) Policy implication: There is a need for investment in equitable greenspaces to improve health outcomes and build climate resilient neighborhoods. (3) Research or academic implication: Research partnerships with community-based organizations for a comprehensive study of benefits associated with NBIs should be encouraged to reduce health disparities and ensure intergenerational health equity. There is a need for investigation of the mechanisms by which NBIs impact CVD and exploration of the role of CVD biological markers of inflammation among cancer survivors.

Benefits of the First Pritikin Outpatient Intensive Cardiac Rehabilitation Program

PURPOSE

Intensive cardiac rehabilitation (ICR) is a comprehensive, medically supervised exercise treatment program covered by Medicare for patients with approved cardiac diagnoses. The aim of this study was to determine the benefits of the first Pritikin outpatient ICR program.

METHODS

This retrospective analysis included patients referred to ICR or traditional cardiac rehabilitation (CR) during the first 7 yr (2013-2019) at the first facility to implement Pritikin ICR. Intensive cardiac rehabilitation is composed of 36 education sessions on nutrition, exercise, and a healthy mindset, in addition to 36 monitored exercise sessions that comprise traditional CR. Assessments included anthropometrics (weight, body mass index, and waist circumference), dietary patterns, physical function (6-min walk test, [6MWT] Short Physical Performance Battery [SPPB: balance, 4-m walk, chair rise], handgrip strength), and health-related quality of life (Dartmouth COOP, 36-item Short Form Survey). Baseline and follow-up measures were compared within and between groups.

RESULTS

A total of 1963 patients enrolled (1507 ICR, 456 CR, 66.1 ± 11.4 yr, 68% male, 82% overweight or obese); 1141 completed the program (58%). The ICR patients completed 22 exercise and 18 education sessions in 9.6 wk; CR patients completed 19 exercise sessions in 10.3 wk. ICR resulted in improvements ( P &lt; .001 pre vs post) in all anthropometric measures, dietary patterns, 6MWT distance, all SPPB components, grip strength, and health-related quality of life. The improvements in anthropometrics and dietary patterns were greater in ICR than in CR.

CONCLUSIONS

The Pritikin outpatient ICR program promoted improvements in several cardiovascular health indices. Critical next steps are to assess long-term health outcomes after ICR, including cardiac events and mortality.

Associations of the serum n-6 PUFA with exercise cardiac power in men

Low intake or tissue concentrations of the n-6 PUFA, especially to the major n-6 PUFA linoleic acid (LA), and low exercise cardiac power (ECP) are both associated with CVD risk. However, associations of the n-6 PUFA with ECP are unknown. The aim of the present study was to explore cross-sectional associations of the serum total n-6 PUFA, LA, arachidonic acid (AA), γ-linolenic acid (GLA) and dihomo-γ-linolenic acid (DGLA) concentrations with ECP and its components. In total, 1685 men aged 42-60 years from the Kuopio Ischaemic Heart Disease Risk Factor Study and free of CVD were included. ANCOVA was used to examine the mean values of ECP (maximal oxygen uptake (VO2max)/maximal systolic blood pressure (SBP)) and its components in quartiles of the serum total and individual n-6 PUFA concentrations. After multivariable adjustments, higher serum total n-6 PUFA concentration was associated with higher ECP and VO2max (for ECP, the extreme-quartile difference was 0·77 ml/mmHg (95 % CI 0·38, 1·16, Pfor trend across quartiles < 0·001) and for VO2max 157 ml/min (95 % CI 85, 230, Pfor trend < 0·001), but not with maximal SBP. Similar associations were observed with serum LA concentration. Higher serum AA concentration was associated with higher ECP but not with VO2max or maximal SBP. The minor serum n-6 PUFA GLA and DGLA were associated with higher maximal SBP during exercise test and DGLA also with higher VO2max but neither with ECP. In conclusion, especially LA concentration was associated with higher ECP. This may provide one mechanism for the cardioprotective properties of, especially, LA.

Prognostic Interplay Between Coronary Artery Calcium Scoring and Cardiorespiratory FItness: The CAC-FIT Study

OBJECTIVE

To assess the incremental prognostic role of coronary artery calcium score (CACS) and exercise capacity (EC), two independent prognostic tests in the assessment of patients with coronary artery disease.

METHODS

The cohort consisted of patients who had clinically indicated exercise stress testing and CACS assessment from January 1, 2015, to September 30, 2021, with a median of 27 days between each other. Exercise capacity was defined by peak metabolic equivalents of task (METs) achieved during exercise stress test. The CACS was determined by the Agatston method. Patients were observed from the latest test date to incident major adverse cardiac events (inclusive of all-cause death, nonfatal myocardial infarction, late revascularization, and admission for heart failure).

RESULTS

There were a` total of 1932 patients in the study population (mean age, 56±12 years; 42% female, 48% hypertension, 21% diabetes, 48% dyslipidemia). Peak METs below 6 was achieved in 8% of patients, and the median (interquartile range) CACS was 9 (0-203). In multivariable Cox regression models, both CACS (1 unit increase in log CACS: hazard ratio, 1.19; 95% CI, 1.06 to 1.34; P=.003;) and EC (1 unit increase in peak METs: hazard ratio, 0.89; 95% CI, 0.81 to 0.97; P=.01) were independently associated with outcomes. Using CACS+EC added incremental prognostic value over clinical and fitness models (C index increase from 0.68 to 0.75; P=.015). Incident event rates increased across categories of CACS and EC.

CONCLUSION

Our analysis found that CACS and EC have complementary risk-stratifying roles in coronary artery disease.

State of Knowledge on Molecular Adaptations to Exercise in Humans: Historical Perspectives and Future Directions

For centuries, regular exercise has been acknowledged as a potent stimulus to promote, maintain, and restore healthy functioning of nearly every physiological system of the human body. With advancing understanding of the complexity of human physiology, continually evolving methodological possibilities, and an increasingly dire public health situation, the study of exercise as a preventative or therapeutic treatment has never been more interdisciplinary, or more impactful. During the early stages of the NIH Common Fund Molecular Transducers of Physical Activity Consortium (MoTrPAC) Initiative, the field is well-positioned to build substantially upon the existing understanding of the mechanisms underlying benefits associated with exercise. Thus, we present a comprehensive body of the knowledge detailing the current literature basis surrounding the molecular adaptations to exercise in humans to provide a view of the state of the field at this critical juncture, as well as a resource for scientists bringing external expertise to the field of exercise physiology. In reviewing current literature related to molecular and cellular processes underlying exercise-induced benefits and adaptations, we also draw attention to existing knowledge gaps warranting continued research effort. © 2021 American Physiological Society. Compr Physiol 12:3193-3279, 2022.

Short- and long-term effects of different exercise programs on the gait performance of older adults with subjective cognitive decline: A randomized controlled trial

BACKGROUND

Older adults, especially those with cognitive decline, often have poor gait performance, which results in poor clinical outcomes due to falls or decreased daily physical activity. The effects of various exercises on gait performance have been studied, whereas the short-term and long-term effects of different exercise modalities remain unknown.

OBJECTIVE

To compare the short- and long-term effects of aerobic training (AT), resistance training (RT), and combined training (CT) on the gait performance of community-dwelling older adults with subjective cognitive decline (SCD).

DESIGN

A four-arm, randomized controlled trial.

SETTING AND SUBJECTS

388 community-dwelling older adults with SCD (mean age, 72.3 years).

METHODS

Participants attended an exercise or education class twice a week for 26 weeks. 10 gait performance parameters were examined at baseline, post-intervention (Week 26), and after 26 weeks of follow-up (Week 52) using an electronic walkway system.

RESULTS

The mean adherence of exercise sessions was 82.5 to 85.9%. All exercise intervention induced an improvement in gait speed, stride time, cadence, stride length, and double-support time at Week 26 (p < .05), without significant intergroup differences among exercise interventions. However, only RT showed a significant effect on some spatiotemporal gait parameters at Week 52. The analyses for the gait variability parameters showed mild effects of all exercise interventions.

CONCLUSION

All of the exercise programs examined had a positive short-term effect on spatiotemporal gait parameters of older adults with SCD, despite no effect on gait variability parameters. RT are most recommended when long-lasting effects are the primary aim.

The Association of Sleep Apnea and Cardiorespiratory Fitness With Long-Term Major Cardiovascular Events

OBJECTIVE

To determine the risk of long-term major adverse cardiovascular events (MACE) when sleep-disordered breathing (SDB) and decreased cardiorespiratory fitness (CRF) co-occur.

METHODS

We included consecutive patients who underwent symptom-limited cardiopulmonary exercise tests between January 1, 2005, and January 1, 2010, followed by first-time diagnostic polysomnography within 6 months. Patients were stratified based on the presence of moderate-to-severe SDB (apnea/hypopnea index ≥15 per hour) and decreased CRF defined as <70% predicted peak oxygen consumption (VO₂). Long-term MACE was a composite outcome of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), stroke or transient ischemic attack (TIA), and death, assessed until May 21, 2018. Cox-proportional hazard models were adjusted for factors known to influence CRF and MACE.

RESULTS

Of 498 included patients (60±13 years, 28.1% female), 175 (35%) had MACE (MI=17, PCI=14, CABG=13, stroke=20, TIA=12, deaths=99) at a median follow-up of 8.7 years (interquartile range=6.5 to 10.3 years). After adjusting for age, sex, beta blockers, systemic hypertension, diabetes mellitus, coronary artery disease, cardiac arrhythmia, chronic obstructive pulmonary disease, smoking, and use of positive airway pressure (PAP), decreased CRF alone (hazard ratio [HR]=1.91, 95% confidence interval [CI], 1.15 to 3.18; P=.01), but not SDB alone (HR=1.26, 95% CI, 0.75 to 2.13, P=.39) was associated with increased risk of MACE. Those with SDB and decreased CRF had greater risk of MACE compared with patients with decreased CRF alone (HR=1.85; 95% CI, 1.21 to 2.84; P<.005) after accounting for these confounders. The risk of MACE was attenuated in those with reduced CRF alone after additionally adjusting for adequate adherence to PAP (HR=1.59; 95% CI, 0.77 to 3.31; P=.21).

CONCLUSION

The incidence of MACE, especially mortality, was high in this sample. Moderate-to-severe SDB with concurrent decreased CRF was associated with higher risk of MACE than decreased CRF alone. These results highlight the importance of possibly including CRF in the risk assessment of patients with SDB and, conversely, that of screening for SDB in patients with low peak VO₂.

Sex Differences in Cardiometabolic Health Indicators after HIIT in Patients with Coronary Artery Disease

PURPOSE

Cardiorespiratory fitness (CRF) is an independent predictor of mortality, and females typically achieve smaller improvements in CRF than males after exercise-based cardiac rehabilitation. High-intensity interval training (HIIT) has been shown to produce superior improvements in CRF than traditional cardiac rehabilitation, but the sex differences are unknown. The purpose of this systematic review and meta-analysis was to evaluate sex differences for changes in CRF and cardiometabolic health indicators after HIIT in adults with coronary artery disease (CAD).

METHODS AND RESULTS

A systemic search of five electronic databases for studies examining the effect of HIIT on measured CRF and cardiometabolic health indicators in adults with CAD was performed. Data (published and unpublished) from 14 studies were included in the meta-analyses with approximately eightfold greater male than female participation (n = 836 vs n = 103). Males with CAD achieved a near-significant absolute improvement in CRF (mean difference [MD] = 1.07, 95% confidence interval [CI] = -0.08 to 2.23 mL·kg-1⋅min-1, P = 0.07) after HIIT when compared with control; there were insufficient data to conduct such an analysis in females. Significantly smaller improvements in CRF were experienced by females than males (MD = -1.10, 95% CI = -2.08 to -0.12 mL·kg-1⋅min-1, P = 0.03); there was no sex difference for the relative (percentage) change in CRF after HIIT. Females achieved significantly smaller reductions in body mass index (MD = -0.25, 95% CI = -0.03 to -0.47 kg·m-2, P = 0.02) and fasting blood glucose (MD = -0.38, 95% CI = -0.05 to -0.72, P = 0.03); no sex differences were observed for other cardiometabolic health indicators.

CONCLUSION

There are no sex differences for relative improvements in CRF after HIIT; however, females are greatly underrepresented in trials. Future studies should increase female participation and perform sex-based analyses to determine sex-specific outcomes following HIIT.

Major adverse cardiovascular events after implantation of absorb bioresorbable scaffold: One-year clinical outcomes

Background/Aim: Bioresorbable vascular scaffold (BVS) represents a novel generation of intracoronary devices designed to be fully resorbed after healing of the stented lesion, delivering antiproliferative drug to suppress restenosis, providing adequate diameter of the coronary vessel and preserving the vascular endothelial function. It was supposed that BVS will reduce neointimal proliferation and that their late bioresorption will reduce the negative effects of traditional drug-eluting stents, including the late stent thrombosis, local vessel wall inflammation, loss of coronary vasoreactivity and the need for the long-term dual antiplatelet therapy. The purpose of this research was to investigate efficacy and safety of Absorb everolimus-eluting BVS implantation and the prevalence of major adverse cardiovascular events (MACE) at the mid-term follow-up. Methods: The study encompassed 42 patients selected for BVS implantation and fulfilling inclusion criteria - 37 male and 5 female - admitted to the Dedinje Cardiovascular Institute, Belgrade, Serbia over the one-year period (from January 2015 to January 2016) for percutaneous coronary intervention (PCI). Coronary vessel patency before and after stenting was assessed by the Thrombolysis in Myocardial Infarction flow (TIMI) grades. After the index PCI procedure with BVS all patients were clinically followed by regular (prescheduled or event-driven) visits during the next 12-month period. Results: In the intention-to-treat analysis, all Absorb BVS procedures were successful, without the need for conversion to other treatment modalities. The complete reperfusion (TIMI flow grade 3) after the intervention was established in 97.6 % of patients and 100 % of them achieved the TIMI flow grade ≥ 2. The presence of angina pectoris was reduced significantly by the BVS procedure: stable angina 57.1 % to 11.9 %, (p < 0.001) and unstable angina 31 % to 0 %, respectively (p < 0.001). After the one-year follow-up, the MACE rate was 11.9 %. Myocardial infarction occurred in 4.8 % and the need for PCI reintervention in 2.4 % of cases (not influenced by the gender or the age of patients). There were 4 cases of death (all patients were older and had lower values of left ventricular ejection fraction). Conclusion: The results of the current research demonstrated a high interventional success rate of the Absorb BVS implantation, followed by the early improvement of the anginal status. However, that was not translated into the favourable mid-term clinical outcomes, opening debate about the current status of Absorb BVS and the need for future refinements of stent design and implantation techniques.

Physical Activity, Exercise Prescription for Health and Home-Based Rehabilitation

The aim of this overview was to recommend individual training plans using exercise prescriptions for adults and older adults during home-based rehabilitation. Over the last decade, many regular physical activity studies with large prospective cohorts have been conducted. Taken together, more than a million subjects have been included in these exercise studies. The risk of morbidity and mortality has been reduced by 30% to 40% as a result of exercise. These risk reductions hold true for many diseases, as well as for prevention and rehabilitation. Physical activity has also been in the treatment of many diseases, such as cardiopulmonary, metabolic or neurologic/psychiatric diseases, all with positive results. Based on these results, the prescription of exercise was developed and is now known as the exercise prescription for health in many European countries. Details have been published by the European Federation of Sports Medicine Associations (EFSMA). The exercise prescription is strongly recommended for inpatients, discharged patients and outpatients who have recovered from severe diseases. Rehabilitation improves general health, physical fitness, quality of life and may increase longevity of life.

Cardiorespiratory Fitness as a Correlate of Cardiovascular, Anthropometric, and Physical Risk Factors: Using the Ruffier Test as a Template

Background

Assessment of cardiorespiratory fitness (CRF) is a standard procedure in routine clinical practices. Early identification of risk factors through screening is vital in the fight against chronic diseases. Evaluation of CRF can impose cost implications in the clinical setting; thus, a simple and easy-to-use test is to be advocated. The Ruffier test is a simple test that can assess CRF, and it is necessary to find whether the test reflects the effects of compounding factors in CRF.

Objective

This study aims to determine the association between CRF (estimated VO2max) with cardiovascular, anthropometric, and physical risk factors using the Ruffier test.

Methods

A cross-sectional study with a sample of 52 male participants was conducted. Before the Ruffier test, each participant's body weight, height, waist circumference, skinfold thickness, thigh length, lower-limb length, thigh circumference, physical activity, blood pressure, smoking, diabetes, and pulmonary functions were recorded, and these factors correlated with CRF.

Results

There was a significant inverse relationship found between the estimated VO2max and age, height, body weight, body mass index, waist circumference, a sum of skinfold, fat percentage, thigh length, lower-limb length, thigh circumference, smoking, blood pressure, heart rates, and diabetes (p < 0.05). A significant positive correlation was found between the estimated VO2max with physical activity and respiratory functions (p < 0.05). In the multivariable model, body weight and resting heart rate were significantly inversely associated with the estimated VO2max(p < 0.05).

Conclusion

Using the Ruffier test, various risk factors of CRF are correlated with the estimated VO2max. This test reflects the effects of different compounding factors on CRF; therefore, it can be used in routine clinical practices to identify the risk factors early.

Peak oxygen uptake and incident coronary heart disease in a healthy population: the HUNT Fitness Study

AIMS

The majority of previous research on the association between cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) is based on indirect assessment of CRF in clinically referred predominantly male populations. Therefore, our aim was to examine the associations between VO2peak measured by the gold-standard method of cardiopulmonary exercise testing and fatal and non-fatal coronary heart disease (CHD) in a healthy and fit population.

METHODS AND RESULTS

Data on VO2peak from 4527 adults (51% women) with no previous history of cardiovascular or lung disease, cancer, and hypertension or use of antihypertensive medications participating in a large population-based health-study (The HUNT3 Study), were linked to hospital registries and the cause of death registry. Average VO2peak was 36.0 mL/kg/min and 44.4 mL/kg/min among women and men, and 83.5% had low 10-year risk of CVD at baseline. Average follow-up was 8.8 years, and 147 participants reached the primary endpoint. Multi-adjusted Cox-regression showed 15% lower risk for the primary endpoint per one-MET (metabolic equivalent task) higher VO2peak [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77-0.93], with similar results across sex. The highest quartile of VO2peak had 48% lower risk of event compared with the lowest quartile (multi-adjusted HR 0.52, 95% CI 0.33-0.82). Oxygen pulse and ventilatory equivalents of oxygen and carbon dioxide also showed significant predictive value for the primary endpoint.

CONCLUSION

VO2peak was strongly and inversely associated with CHD across the whole fitness continuum in a low-risk population sample. Increasing VO2peak may have substantial benefits in reducing the burden of CHD.

Cardiorespiratory Fitness and the Risk of First Acute Myocardial Infarction: The HUNT Study

Background

The majority of studies evaluating cardiorespiratory fitness (CRF) as a cardiovascular risk factor use cardiovascular mortality and not cardiovascular disease events as the primary end point, and generally do not include women. The aim of this study was to investigate the association of estimated CRF (eCRF) with the risk of first acute myocardial infarction (AMI).

Methods and Results

We included 26 163 participants (51.5% women) from the HUNT study (Nord‐Trøndelag Health Study), with a mean age of 55.7 years, without cardiovascular disease at baseline. Baseline eCRF was grouped into tertiles. AMI was derived from hospital records and deaths from the Norwegian Cause of Death Registry. We used Fine and Gray regression modeling to estimate subdistribution hazards ratio (SHR) of AMI, accounting for competing risk of death. During a mean (range) follow‐up of 13 (0.02–15.40) years (347 462 person‐years), 1566 AMI events were recorded. In fully adjusted models men in the 2 highest eCRF had 4% (SHR: 0.96, 95% CI: 0.83–1.11) and 10% (SHR: 0.90, 95% CI: 0.77–1.05) lower SHR of AMI, respectively, when compared with men in the lowest tertile. The corresponding numbers in women were 12% (SHR: 0.88, 95% CI: 0.72–1.08) and 25% (SHR: 0.75, 95% CI: 0.60–0.95).

Conclusions

eCRF was inversely associated with risk of AMI event among women but not in men. Our data suggest that high eCRF may have substantial benefit in reducing the risk of AMI. Therefore, our data suggest that an increased focus on eCRF as a cardiovascular disease risk marker in middle‐aged and older adults is warranted.

The Effects of Aerobic Exercise on N-terminal Pro-B-type Natriuretic Peptide and Cardiopulmonary Function in Patients With Heart Failure: A Meta-Analysis of Randomised Clinical Trials

BACKGROUND

Aerobic exercise (AEx) improves outcomes in heart failure (HF). N-terminal pro B-type natriuretic peptide (NT-pro-BNP) is a prognosticator in HF. There are few data on the association of AEx, NT-pro-BNP, and cardiopulmonary function; hence, robust evidence is needed. The aim of this study was to measure the effects of AEx on NT-pro-BNP levels and cardiopulmonary function in HF.

METHOD

Databases (Pubmed, EMBASE, Medline, Cochrane Central Registry, and Scopus) were systematically searched for randomised controlled trials (RCTs) that assessed the association of AEx with NT-pro-BNP and cardiopulmonary function (VE/VCO₂ slope, peak VO₂, maximal workload, and left ventricular ejection fraction [LVEF]) in HF. RevMan 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014) was used to produce forest plots, and the random-effect model was applied with the effects measure of weighted mean differences (WMD) and 95% confidence interval (CI).

RESULTS

Thirteen (13) RCTs recruited 1,503 patients and 1,494 controls. Aerobic exercise was significant in lowering NT-pro-BNP (pg/mL) compared with control group (WMD=-741.69, 95% CI -993.10 to -490.27 [p<0.00001; I²=63%]). VE/VCO₂ slope was also significantly reduced (WMD=-3.57, 95% CI -6.48 to -0.67 [p=0.02; I²=97%]). Peak VO₂ (mL/kg/min) significantly improved (WMD=3.68, 95% CI 2.39-4.96 [p<0.00001; I²=96%]). Maximal workload (watt) significantly increased following AEx (WMD=22.80, 95% CI 18.44-27.17 [p<0.00001; I²=78%]). Furthermore, there was a significant enhancement of LVEF (%) in the AEx group (WMD=2.42, 95% CI 0.64-4.19 [p=0.008; I²=71%]).

CONCLUSIONS

Aerobic exercise improves the NT-pro-BNP, ventilatory efficiency, aerobic capacity, maximal workload, and the left ventricular function in patients with HF.

Short physical performance battery discriminates clinical outcomes in hospitalized patients aged 75 years and over

AIM

Low physical function is associated with poor outcomes in hospitalized patients; however, little is known about vulnerable populations such as those aged ≥ 75 years. We examined whether the Short Physical Performance Battery (SPPB) was associated with clinical outcomes in hospitalized patients aged ≥ 75 years.

METHODS

In total, 147 patients aged ≥ 75 years (mean age, 86.5 ± 4.7 years; 89 males) completed the SPPB and Mini-Mental State Examination (MMSE) before hospital discharge. Patients were divided into three groups by SPPB score: 0 (unable to perform SPPB), 1-6 (low performance), and 7-12 (high performance). The first occurrence of all-cause unplanned readmission or all-cause mortality within 1 year after discharge was set as the endpoint.

RESULTS

The median SPPB score of the study population was 2; 41 % were unable to perform SPPB, 33 % had low performance, and 26 % had high performance. High SPPB was associated with younger age, higher body weight, and higher MMSE score. During the follow-up period, 35 (23.8 %) patients were readmitted to hospital and 19 (12.9 %) died. Even after adjusting for covariates, SPPB score was a significant and independent predictor of poor outcomes (hazard ratio for 1 point increase in SPPB, 0.88; P = .002). The subgroup analysis showed SPPB was inversely associated with the occurrence of poor outcomes in patients with cognitive impairment.

CONCLUSIONS

SPPB is inversely associated with risks for readmission and mortality in hospitalized patients aged ≥ 75 years, especially those with cognitive impairment. The present results indicate the SPPB is useful for accurate prognosis in hospital settings.

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.

Impact of cardiorespiratory fitness on survival in men with low socioeconomic status

AIMS

Although both low socioeconomic status (SES) and poor cardiorespiratory fitness (CRF) are associated with increased chronic disease and heightened mortality, it remains unclear whether moderate-to-high levels of CRF are associated with survival benefits in low SES populations. This study evaluated the hypothesis that SES and CRF predict all-cause mortality and cardiovascular disease mortality and that moderate-to-high levels of CRF may attenuate the association between low SES and increased mortality.

METHODS

This study included 2368 men, who were followed in the Kuopio Ischaemic Heart Disease Study cohort. CRF was directly measured by peak oxygen uptake during progressive exercise testing. SES was characterized using self-reported questionnaires.

RESULTS

During a 25-year median follow-up, 1116 all-cause mortality and 512 cardiovascular disease mortality events occurred. After adjusting for potential confounders, men with low SES were at increased risks for all-cause mortality (hazard ratio 1.49, 95% confidence interval: 1.30-1.71) and cardiovascular disease mortality (hazard ratio1.38, 1.13-1.69). Higher levels of CRF were associated with lower risks of all-cause mortality (hazard ratio 0.54, 0.45-0.64) and cardiovascular disease mortality (hazard ratio 0.53, 0.40-0.69). In joint associations of SES and CRF with mortality, low SES-unfit had significantly higher risks of all-cause mortality (hazard ratio 2.15, 1.78-2.59) and cardiovascular disease mortality (hazard ratio 1.95, 1.48-2.57), but low SES-fit was not associated with a heightened risk of cardiovascular disease mortality (hazard ratio 1.09, 0.80-1.48) as compared with their high SES-fit counterparts.

CONCLUSION

Both SES and CRF were independently associated with subsequent mortality; however, moderate-to-high levels of CRF were not associated with an excess risk of cardiovascular disease mortality in men with low SES.

Development of Global Reference Standards for Directly Measured Cardiorespiratory Fitness: A Report From the Fitness Registry and Importance of Exercise National Database (FRIEND)

OBJECTIVE

To begin the process of developing global reference standards for adults from directly measured cardiorespiratory fitness (CRF).

METHODS

Percentiles of maximal oxygen consumption (VO₂max) for men and women were determined for each decade from 20 through 79 years of age using International data from the Fitness Registry and Importance of Exercise: A National Database (FRIEND-I) along with previously published data from seven studies. FRIEND-I data from January 1, 2014, through January 1, 2019, included 11,678 maximal treadmill tests from three countries, whereas the previously published reports included 32,329 maximal treadmill tests from six countries.

RESULTS

FRIEND-I data revealed significant differences between sex and age groups for VO₂max (P<0.01). For the 20- to 29-years of age group, the 50^th percentile VO₂max in men and women were 49.5 mLO₂⋅kg^-1⋅min^-1 and 40.6 mLO₂⋅kg^-1⋅min^-1, respectively. VO₂max declined an average of 9% per decade with the 50^th percentile for the 70- to 79-years of age group having a VO₂max of 30.8 mLO₂⋅kg^-1⋅min^-1 in men and 25.0 mLO₂⋅kg^-1⋅min^-1 in women. These results were similar in magnitude and direction to the previously published literature. Within both the FRIEND-I and previously published data there were CRF differences between countries.

CONCLUSION

This report begins to establish global reference standards for CRF. Continued development of FRIEND-I will increase global representation providing an improved ability to identify and stratify CRF risk categories.

High-Intensity Walking Time Is a Key Determinant to Increase Physical Fitness and Improve Health Outcomes After Interval Walking Training in Middle-Aged and Older People

OBJECTIVE

To examine the effects of interval walking training (IWT) on the estimated peak aerobic capacity (eV˙O_2peak) and lifestyle-related disease (LSD) score while focusing on exercise intensity and volume in middle-aged and older people.

PARTICIPANTS AND METHODS

Men and women (N=679; mean age, 65±7 SD years) completed 5-month IWT. Participants were instructed to repeat 5 or more sets of fast and slow walking for 3 minutes each at 70% or more and 40% eV˙O_2peak for walking, respectively, per day for 4 or more d/wk. This study was conducted from April 1, 2005, through February 29, 2008.

RESULTS

Interval walking training increased eV˙O_2peak by 14% and decreased LSD score by 17% on average (P<.001). During 5-month IWT, fast and slow walking times were 88±65 SD and 100±86 min/wk, respectively, but varied among participants. We divided participants into approximately 10 bins for 6 minutes each of fast and slow walking times per week up to 60 min/wk, and above this time, approximately 8 bins for 30 or 60 minutes each of fast and slow walking up to the maximal time. We found that both eV˙O_2peak and LSD score improved as fast walking time per week increased up to 50 min/wk (R²=0.94; P<.001 for eV˙O_2peak; R²=0.51; P=.03 for LSDS) but plateaued above this time. In contrast, improvement in neither eV˙O_2peak nor LSDS was positively correlated with slow or total walking time per week. Multiple regression analyses confirmed that fast walking time per week was the major determinant of improvements in eV˙O_2peak (P<.001) and LSD score (P=.001).

CONCLUSION

High-intensity walking time during IWT is a key factor to increase eV˙O_2peak and decrease LSD score in middle-aged and older people.

Associations between sleep and episodic memory updating

Prior research shows that contextual reminders can reactivate hippocampal links to previously consolidated memories, rendering them susceptible to being updated with new information which then is reconsolidated. Studies implicate sleep in the reconsolidation of reactivated memories, but it is unknown what role sleep plays in updating of a previously consolidated trace with new information. We tracked participants' sleep during an episodic reconsolidation paradigm, first with actigraphy (Experiment 1) then with polysomnography (Experiment 2). Our paradigm involved two learning sessions and a retrieval session, each separated by 48 hr. We reminded participants of the first learning experience immediately prior to the second, which led them to update the earlier memory with elements of the later experience. In Experiment 1, less sleep after Session 1 and more sleep after Session 2 are associated with increased updating. In Experiment 2, N2 sleep spindles (SSs) after the reminder and new learning are associated with more updating, but primarily when spindle activity after Session 1 is low. Thus, total sleep time and N2 SSs contribute to sleep-dependent updating of episodic memory. This outcome is consistent with other work connecting SS activity to the integration of novel information into existing knowledge structures, extended here with the study of how variations in sleep over successive nights contribute to this process. We discuss some possible roles of spindles in the decontextualization of hippocampal memory over time. Although much work addresses the role of sleep in the consolidation of new memories, this work uniquely addresses the contribution of sleep to the updating of a previously consolidated trace with new information.

Sex-Specific Associations of Brain-Derived Neurotrophic Factor and Cardiorespiratory Fitness in the General Population

The brain-derived neurotrophic factor (BDNF) was initially considered to be neuron-specific. Meanwhile, this neurotrophin is peripherally also secreted by skeletal muscle cells and increases due to exercise. Whether BDNF is related to cardiorespiratory fitness (CRF) is currently unclear. We analyzed the association of serum BDNF levels with CRF in the general population (Study of Health in Pomerania (SHIP-TREND) from Northeast Germany; n = 1607, 51% female; median age 48 years). Sex-stratified linear regression models adjusted for age, height, smoking, body fat, lean mass, physical activity, and depression analyzed the association between BDNF and maximal oxygen consumption (VO₂peak), maximal oxygen consumption normalized for body weight (VO₂peak/kg), and oxygen consumption at the anaerobic threshold (VO₂@AT). In women, 1 mL/min higher VO₂peak, VO₂peak/kg, and VO₂@AT were associated with a 2.43 pg/mL (95% confidence interval [CI]: 1.16 to 3.69 pg/mL; p = 0.0002), 150.66 pg/mL (95% CI: 63.42 to 237.90 pg/mL; p = 0.0007), and 2.68 pg/mL (95% CI: 0.5 to 4.8 pg/mL; p = 0.01) higher BDNF serum concentration, respectively. No significant associations were found in men. Further research is needed to understand the sex-specific association between CRF and BDNF.

Cardiorespiratory Fitness and Health Care Costs in Diabetes: The Veterans Exercise Testing Study

BACKGROUND

This study aimed to determine the association between cardiorespiratory fitness and healthcare expenditures among individuals with and without diabetes.

METHODS

Health care costs were quantified among 3924 consecutive men (mean age 58 ± 11 years) referred for a maximal exercise test, and compared according to presence (n = 2457) and absence (n = 1467) of diabetes and fitness. Fitness was classified into 4 categories based on age-stratified quartiles of peak metabolic equivalents: least-fit (5.1 ± 1.5 metabolic equivalents; n = 1044), moderately-fit (7.6 ± 1.5 metabolic equivalents; n = 938), fit (9.4 ± 1.5 metabolic equivalents; n = 988), and highly-fit (12.4 ± 2.2 metabolic equivalents; n = 954). Annual costs per subject were quantified over an 8-year period.

RESULTS

Age, BMI, and presence of cardiovascular disease (CVD) were similar between subjects with and without diabetes. After adjusting for age and presence of CVD, annual costs per person were higher among diabetics vs. non-diabetics. Individuals with and without diabetes in the highly-fit category had annual costs (US dollars x 10³) (mean ± standard deviation) that were on average $32,178 and $30,816 lower, respectively, than individuals in the least-fit category. For each 1-metabolic equivalent higher fitness, annual cost savings per person were $5,193 and $3,603 for individuals with and without diabetes, respectively.

CONCLUSIONS

Higher fitness is associated with lower health care costs. Cost savings associated with higher fitness are particularly evident among individuals with diabetes. The economic burden of diabetes may be reduced through interventions that target improvements in fitness.

[Optical coherence tomography angiography as a future diagnostic tool in sports medicine?]

BACKGROUND

High-intensity interval training (HIIT) proved to be efficient for increasing health-related fitness in general and in patients with life style-induced chronic diseases. This study aimed to evaluate if (I) individual physical fitness and (II) a HIIT intervention affects optical coherence tomography angiography (OCTA) measurements at the ocular fundus of healthy young adults.

METHODS

A total of 65 healthy participants performed a standardized incremental running test to determine their physical fitness. This was defined as speed at the individual anaerobic threshold and maximum running speed followed by a 4-week HIIT with two exercise sessions/week. The OCTA measurements of the foveal avascular zone (FAZ) and flow densities in various segments of the macula and optic nerve head were performed at rest before and after HIIT.

RESULTS

An inverse correlation between individual fitness and FAZ area was detected. No further correlations between individual physical fitness and other OCTA parameters were found. In response to HIIT the mean FAZ area in the deep retinal plexus and macular flow density of the superficial layer decreased by 14.00 ± 13.02% and 1.26 ± 3.20%, respectively. The flow density of the nerve head layer in the peripapillary area showed an increase of 1.94 ± 2.39%. All other parameters showed no differences between measurements before and after HIIT.

CONCLUSION

Differences were found in the OCTA measurements of the FAZ depending on the individual physical fitness. Performing HIIT can induce significant changes in certain OCTA parameters. Therefore, OCTA imaging appears to be a promising imaging modality in the field of sports medicine.

Cardiorespiratory fitness and cardiovascular disease - The past, present, and future

The importance of cardiorespiratory fitness (CRF) is now well established and it is increasingly being recognized as an essential variable which should be assessed in health screenings. The key findings that have established the clinical significance of CRF are reviewed in this report, along with an overview of the current relevance of exercise as a form of medicine that can provide a number of positive health outcomes, including increasing CRF. Current assessment options for assessing CRF are also reviewed, including the direct measurement via cardiopulmonary exercise testing which now can be interpreted with age and sex-specific reference values. Future directions for the use of CRF and related measures are presented.

Change in Cardiorespiratory Fitness and Risk of Stroke and Death: Long-Term Follow-Up of Healthy Middle-Aged Men

Background and Purpose- Low cardiorespiratory fitness is associated with increased risk of cardiovascular disease. The present study aims to assess whether change of fitness over time has any impact on long-term risk of stroke and death. Methods- We recruited healthy men aged 40 to 59 years in 1972 to 1975, and followed them until 2007. Physical fitness was assessed with a bicycle ECG test at baseline and again at 7 years, by dividing the total exercise work by body weight. Participants were categorized as remained fit, became unfit, remained unfit, or became fit, depending on whether fitness remained or crossed the median values from baseline to the 7-year visit. Outcome data were collected up to 35 years, from study visits, hospital records, and the National Cause of Death Registry. Risks of stroke and death were estimated by Cox regression analyses and expressed as hazard ratios (HRs) with 95% CIs. Results- Of 2014 participants, 1403 were assessed both at baseline and again at 7 years, and were followed for a mean of 23.6 years. Compared with the became unfit group, risk of stroke was 0.85 (0.54-1.36) for the remained unfit, 0.43 (0.28-0.67) for the remained fit, and 0.34 (0.17-0.67) for the became fit group. For all-cause death, risks were 0.99 (0.76-1.29), 0.57 (0.45-0.74), and 0.65 (0.46-0.90), respectively. Among those with high fitness at baseline, the became unfit group had a significantly higher risk of stroke (HR, 2.35; CI, 1.49-3.63) and death (HR, 1.74; CI, 1.35-2.23) than those who remained fit. Among those who had low fitness at baseline, the became fit group had a significantly lower risk of stroke (HR, 0.40; CI, 0.21-0.72) and death (HR, 0.66; CI, 0.50-0.85) than participants in the remained unfit group. Conclusions- Cardiorespiratory fitness at baseline and change in fitness was associated with large changes in long-term risk of stroke and death. These findings support the encouragement of regular exercise as a stroke prevention strategy.

An Update on the Role of Cardiorespiratory Fitness, Structured Exercise and Lifestyle Physical Activity in Preventing Cardiovascular Disease and Health Risk

The cardiovascular disease (CVD) pandemic has placed considerable strain on healthcare systems, quality of life, and physical function, while remaining the leading cause of death globally. Decades of scientific investigations have fortified the protective effects of cardiorespiratory fitness (CRF), exercise training, and physical activity (PA) against the development of CVD. This review will summarize recent efforts that have made significant strides in; 1) the application of novel analytic techniques to increase the predictive utility of CRF; 2) understanding the protective effects of long-term compliance to PA recommendations through large cohort studies with multiple points of assessment; 3) and understanding the potential harms associated with extreme volumes of PA.

The Duke treadmill score with bicycle ergometer: Exercise capacity is the most important predictor of cardiovascular mortality

Background

The Duke treadmill score, a widely used treadmill testing tool, is a weighted index combining exercise time or capacity, maximum ST-segment deviation and exercise-induced angina. No previous studies have investigated whether the Duke treadmill score and its individual components based on bicycle exercise testing predict cardiovascular death.

Design

Two populations with a standard bicycle testing were used: 3936 patients referred for exercise testing (2371 men, age 56 ± 13 years) from the Finnish Cardiovascular Study (FINCAVAS) and a population-based sample of 2683 men (age 53 ± 5.1 years) from the Kuopio Ischaemic Heart Disease study (KIHD).

Methods

Cox regression was applied for risk prediction with cardiovascular mortality as the primary endpoint.

Results

In FINCAVAS, during a median 6.3-year (interquartile range (IQR) 4.5–8.2) follow-up period, 180 patients (4.6%) experienced cardiovascular mortality. In KIHD, 562 patients (21.0%) died from cardiovascular causes during the median follow-up of 24.1 (IQR 18.0–26.2) years. The Duke treadmill score was associated with cardiovascular mortality in both populations (FINCAVAS, adjusted hazard ratio (HR) 3.15 for highest vs. lowest Duke treadmill score tertile, 95% confidence interval (CI) 1.83–5.42, P < 0.001; KIHD, adjusted HR 1.71, 95% CI 1.34–2.18, P < 0.001). However, after progressive adjustment for the Duke treadmill score components, the score was not associated with cardiovascular mortality in either study population, as exercise capacity in metabolic equivalents of task was the dominant harbinger of poor prognosis.

Conclusions

The Duke treadmill score is associated with cardiovascular mortality among patients who have undergone bicycle exercise testing, but metabolic equivalents of task, a component of the Duke treadmill score, proved to be a superior predictor.

Personal Activity Intelligence and Mortality in Patients with Cardiovascular Disease: The HUNT Study

OBJECTIVE

To test whether Personal Activity Intelligence (PAI), a personalized metric of physical activity (PA) tracking, is associated with all-cause and cardiovascular disease (CVD) mortality in patients with self-reported CVD and to determine whether these associations change depending on whether contemporary PA recommendations are met.

PATIENTS AND METHODS

A total of 3133 patients with CVD (mean [SD] age, 67.6 [10.3] years; 64% men) were followed from the date of participation in the Nord-Trøndelag Health Study (between January 1, 1984, and February 28, 1986) until the date of death or the end of follow-up (December 31, 2015). The participants' weekly PAI score was calculated and divided into 4 groups (PAI scores of 0, ≤50, 51-99, and ≥100). We used Cox proportional hazards regression models to estimate hazard ratios for CVD and all-cause mortality rates.

RESULTS

After mean follow-up of 12.5 years (39,157 person-years), there were 2936 deaths (94%), including 1936 CVD deaths. Participants with weekly PAI scores of 100 or greater had 36% (95% CI, 21%-48%) and 24% (95% CI, 10%-35%) lower risk of mortality from CVD and all causes, respectively, compared with the inactive group. Participants had similar risk reductions associated with their weekly PAI scores regardless of following contemporary PA recommendations or not.

CONCLUSION

Obtaining a weekly PAI score of at least 100 was associated with lower mortality risk from CVD and all causes in individuals with CVD regardless of whether the current PA recommendations were met.

Exercise Testing in Sports Medicine

BACKGROUND

Bicycle and treadmill exercise tests are used in sports medicine and occupational medicine to detect latent disease, to monitor treatment, and to measure patients' physical performance ability and reserve. In this review, we describe the indications, contraindications, and manner of performance of these tests, along with the variables tested, criteria for evaluation, (sub)maximal stress, and the factors that affect these tests, including age, sex, and medications.

METHODS

This review is based on pertinent articles retrieved by a selective literature search and on the ergometry guidelines of four medical specialty societies.

RESULTS

The proper performance of ergometric stress tests calls for preparation and monitoring by qualified staff as well as standardized testing conditions. Ergometric studies are indispensable as a clinical diagnostic method for the early recognition of disease, for follow-up over time, and for individual counseling. The patient's maximal achievable performance is a predictor of morbidity and mortality. Among the variables that can be measured in the submaximal performance range, the respiratory rate, heart rate, and lactate performance curves are more accurate prognostic predictors than the so-called threshold values (physical working capacity, anaerobic-aerobic threshold). Ergometric stress tests can be used to detect (among other conditions) latent hypertension, pulmonary diseases (e.g., exertional asthma), pabnormal ECG changes, and cardiovascular disorders (e.g., ischemia, arrhythmia, congestive heart failure). The ergometric findings are influenced by the choice of stress-inducing protocol. They provide important information for the planning and monitoring of exercise training and for the treatment of persons suffering from diverse physical conditions, as well as for leisure-time athletes. They are less suit- able for use in the design of training programs for high-performance athletes.

CONCLUSION

Ergometric stress tests provide important data in clinical and preventive medicine. The findings are often difficult to interpret because of the wide range of normal findings, the use of different stress-inducing protocols, and the lack of gen- erally accepted reference values. The establishment of a nationwide fitness and health registry for ergometric data would be very helpful for the individualized inter- pretation of test findings and for the monitoring of exercise training and therapy.

A new generalized cycle ergometry equation for predicting maximal oxygen uptake: The Fitness Registry and the Importance of Exercise National Database (FRIEND)

Background

To develop a clinically applicable equation derived from direct assessment of maximal oxygen uptake (VO2max) to predict VO2max assessed indirectly during cycle ergometry.

Design

VO2max was assessed by open-circuit spirometry during a graded maximal exercise test using cycle ergometry. Multivariable linear regression analysis was applied to identify the most relevant variables and construct the best prediction model for VO2max using a random sample of 70% from each of the following age categories: <40, 40–50, 50–70 and >70 years; the remaining 30% was used for validation. Work rate (Watts*6.12/kg of body weight) and gender were considered in the final regression model as predictors of measured VO2max and the resulting equation was compared to the traditional American College of Sports Medicine (ACSM) equation.

Methods

Participants were part of the Fitness Registry and the Importance of Exercise National Database (FRIEND), a multi-institutional initiative with the primary objective of establishing normative VO2max values across the adult lifespan. The final cohort consisted of 5100 (3378 men; mean age 35.9 ± 12.1 years and 1722 women; mean age 47.5 ± 14.0 years).

Results

The following equation was generated: VO2max in ml O2·kg–1·min–1 = 1.74* (Watts*6.12/kg of body weight) + 3.5. The derived FRIEND-ergometry equation predicted VO2max with an overall relative bias of 0.51% ± 0.11 compared to a 15.46% ± 0.13 associated with the traditional ACSM equations ( P < 0.001). This predictive value was independent of gender, race, cardiac risk factors and cardiac, antihypertensive, metabolic and/or lipid-lowering medication.

Conclusion

The FRIEND-ergometry equation is considerably more precise than the traditional ACSM equation with an overall error over 30 times lower than that associated with the ACSM equation.

Cardiorespiratory Fitness and Health Outcomes: A Call to Standardize Fitness Categories

An inverse association between physical activity or fitness status and health outcomes has been reported by several cohort studies. When fitness categories are established in quartiles or quintiles based on the peak exercise capacity achieved, the association is graded. Although significant health benefits of increased cardiorespiratory fitness (CRF) have been uniformly reported, the degree of protection has varied substantially between studies. This variability is likely due to varying methods used to define CRF categories, and not considering age, despite its strong effect on CRF. To ameliorate these methodological discrepancies, we propose standardized guidelines by which age-specific CRF categories should be defined.

Cardiorespiratory Fitness, Coronary Artery Calcium, and Cardiovascular Disease Events in a Cohort of Generally Healthy Middle-Age Men: Results From the Cooper Center Longitudinal Study

BACKGROUND

A robust literature demonstrates that coronary artery calcification (CAC) and cardiorespiratory fitness (CRF) are independent predictors of cardiovascular disease (CVD) events. Much less is known about the joint associations of CRF and CAC with CVD risk. In the setting of high CAC, high versus low CRF has been associated with decreased CVD events. The goal of this study was to assess the effect of continuous levels of CRF on CVD risk in the setting of increasing CAC burden.

METHODS

We studied 8425 men without clinical CVD who underwent preventive medicine examinations that included an objective measurement of CRF and CAC between 1998 and 2007. There were 383 CVD events during an average follow-up of 8.4 years. Parametric proportional hazards regression models based on a Gompertz mortality rule were used to estimate total CVD incidence rates at 70 years of age as well as hazard ratios for the included covariates.

RESULTS

CVD events increased with increasing CAC and decreased with increasing CRF. Adjusting for CAC level (scores of 0, 1-99, 100-399, and ≥400), for each additional MET of fitness, there was an 11% lower risk for CVD events (hazard ratio, 0.89; 95% confidence interval, 0.84-0.94). When CAC and CRF were considered together, there was a strong association between continuous CRF and CVD incidence rates in all CAC groups.

CONCLUSIONS

In a large cohort of generally healthy men, there is an attenuation of CVD risk at all CAC levels with higher CRF.

Association Between Cardiorespiratory Fitness and Health Care Costs: The Veterans Exercise Testing Study

OBJECTIVE

To determine the association between cardiorespiratory fitness (CRF) and annual health care costs in Veterans.

PATIENTS AND METHODS

The sample included 9942 subjects (mean age, 59±11 years) undergoing a maximal exercise test for clinical reasons between January 2005 and December 2012. Cardiorespiratory fitness, expressed as a percentage of age-predicted peak metabolic equivalents (METs) achieved, was categorized in quartiles. Total and annualized health care costs, derived from the Veterans Administration Allocated Resource Center, were compared using multiple regression, controlling for demographic and clinical characteristics.

RESULTS

A gradient for reduced health care costs was observed as CRF increased, with subjects in the least-fit quartile having approximately $14,662 (P<.001) higher overall costs per patient per year compared with those in the fittest quartile, after controlling for potential confounding variables. Each 1-MET higher increment in fitness was associated with a $1592 annual reduction in health care costs (5.6% lower cost per MET), and each higher quartile of fitness was associated with a $4163 annual cost reduction per patient. The effect of CRF was more pronounced among subjects without cardiovascular disease (CVD), suggesting that the results were not driven by the possibility that less-fit individuals had greater CVD. Cost savings attributable to higher fitness were greatest in overweight and obese subjects, with lower savings observed among those individuals with a body mass index less than 25 kg/m². In a model including historical, clinical, and exercise test responses, heart failure was the strongest predictor of health care costs, followed by CRF (P<.01).

CONCLUSION

Low CRF is associated with higher health care costs. Efforts to improve CRF may not only improve health but also result in lower health care costs.

Perioperative management of the obese surgical patient

INTRODUCTION

The escalation in the prevalence of obesity throughout the world has led to an upsurge in the number of obese surgical patients to whom perioperative care needs to be delivered.

SOURCES OF DATA

After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered.

AREAS OF AGREEMENT

There were no controversies regarding preoperative management and the intraoperative care of the obese surgical patient.

AREAS OF CONTROVERSY

Is there a healthy obese state that gives rise to the obesity paradox regarding postoperative complications?

GROWING POINTS

This review considers how to prepare for and manage the obese surgical patient through the entire spectrum, from preoperative assessment to possible postoperative intensive care.

AREAS TIMELY FOR DEVELOPING RESEARCH

What results in an obese patient developing 'unhealthy' obesity?

New Generalized Equation for Predicting Maximal Oxygen Uptake (from the Fitness Registry and the Importance of Exercise National Database)

Impaired cardiorespiratory fitness (CRF) is closely linked to chronic illness and associated with adverse events. The American College of Sports Medicine (ACSM) regression equations (ACSM equations) developed to estimate oxygen uptake have known limitations leading to well-documented overestimation of CRF, especially at higher work rates. Thus, there is a need to explore alternative equations to more accurately predict CRF. We assessed maximal oxygen uptake (VO₂ max) obtained directly by open-circuit spirometry in 7,983 apparently healthy subjects who participated in the Fitness Registry and the Importance of Exercise National Database (FRIEND). We randomly sampled 70% of the participants from each of the following age categories: <40, 40 to 50, 50 to 70, and ≥70 and used the remaining 30% for validation. Multivariable linear regression analysis was applied to identify the most relevant variables and construct the best prediction model for VO₂ max. Treadmill speed and treadmill speed × grade were considered in the final model as predictors of measured VO₂ max and the following equation was generated: VO₂ max in ml O₂/kg/min = speed (m/min) × (0.17 + fractional grade × 0.79) + 3.5. The FRIEND equation predicted VO₂ max with an overall error >4 times lower than the error associated with the traditional ACSM equations (5.1 ± 18.3% vs 21.4 ± 24.9%, respectively). Overestimation associated with the ACSM equation was accentuated when different protocols were considered separately. In conclusion, The FRIEND equation predicts VO₂ max more precisely than the traditional ACSM equations with an overall error >4 times lower than that associated with the ACSM equations.