Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia: a cohort study

The Role of Exercise in Statin-Associated Muscle Symptoms Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To provide a synthesis of randomized controlled trials (RCTs) investigating statin-associated muscle symptoms (SAMS) in adults who underwent exercise training intervention.

Patients and Methods

We systematically searched 5 electronic databases for placebo-controlled RCTs through January 31, 2023. We included short-term and long-term exercise interventions that compared the efficacy and safety of exercise+statin vs exercise+placebo in healthy adults and reported SAMS preintervention and postintervention. Publication bias and methodological study quality assessments were performed.

Results

Five of 454 potentially qualifying RCTs met the inclusion criteria, all short-term exercise RCTs. Participants were predominantly physically inactive young to middle-aged (M=37.2 y) men (57%), 252 (49%) who were on statin therapy, and 271 (53%) on placebo. Of the 3 RCTs providing qualitative SAMS results, 19 (9%) out of 220 participants reported SAMS on exercise+statin and 10 (4%) out of 234 reported SAMS on exercise+placebo. There was no difference between exercise+statin vs exercise+placebo for maximal oxygen consumption (d=-0.18; 95% CI, -0.37 to 0.00; P=.06) or creatine kinase after short-term exercise (d=0.59; 95% CI, -0.06 to 1.25; P=.08). Participants in the exercise+statin group reduced low-density lipoprotein cholesterol vs exercise+placebo (d=-1.84; 95% CI, -2.28 to -1.39; P<.001). Most of the RCTs exhibited low levels of risk of bias (k=4, 80%) and achieved moderate methodological study quality (75.0%±5.2%).

Conclusion

Self-reported SAMs tended to be 5% greater after short-term exercise in statin users compared with placebo, although this difference did not achieve statistical significance. There remains an important need for placebo-controlled RCTs investigating the prevalence of statin-induced SAMS during exercise training.

Exercise and lipids

Evidence from the existing literature suggests that exercise has positive effects for prevention and treatment of cardiovascular diseases by reducing risk factors such as elevated blood lipids. Based on clinical and observational clinical trials, it is well established that increased physical activity and regular exercise has a favourable impact on blood lipids and lipoprotein profiles. Exercise training significantly decreases blood triglycerides concentration and increases high density lipoprotein cholesterol levels. Though the Indian data depicting the effect of exercise on lipids is scarce, exercise directly improves "atherogenic dyslipidaemia" which is frequently present among Indians i.e. HDL-C is increased, TG is reduced and LDL-C particle size is improved. While drug therapy is key to the treatment of dyslipidaemia, lifestyle alterations such as exercise should continue to be actively promoted and encouraged by clinicians. Exercise is a low cost, non pharmacological therapeutic lifestyle change that is of value to lipid metabolism and cardiovascular fitness.

High-dose atorvastatin therapy progressively decreases skeletal muscle mitochondrial respiratory capacity in humans

BACKGROUNDWhile the benefits of statin therapy on atherosclerotic cardiovascular disease are clear, patients often experience mild to moderate skeletal myopathic symptoms, the mechanism for which is unknown. This study investigated the potential effect of high-dose atorvastatin therapy on skeletal muscle mitochondrial function and whole-body aerobic capacity in humans.METHODSEight overweight (BMI, 31.9 ± 2.0) but otherwise healthy sedentary adults (4 females, 4 males) were studied before (day 0) and 14, 28, and 56 days after initiating atorvastatin (80 mg/d) therapy.RESULTSMaximal ADP-stimulated respiration, measured in permeabilized fiber bundles from muscle biopsies taken at each time point, declined gradually over the course of atorvastatin treatment, resulting in > 30% loss of skeletal muscle mitochondrial oxidative phosphorylation capacity by day 56. Indices of in vivo muscle oxidative capacity (via near-infrared spectroscopy) decreased by 23% to 45%. In whole muscle homogenates from day 0 biopsies, atorvastatin inhibited complex III activity at midmicromolar concentrations, whereas complex IV activity was inhibited at low nanomolar concentrations.CONCLUSIONThese findings demonstrate that high-dose atorvastatin treatment elicits a striking progressive decline in skeletal muscle mitochondrial respiratory capacity, highlighting the need for longer-term dose-response studies in different patient populations to thoroughly define the effect of statin therapy on skeletal muscle health.FUNDINGNIH R01 AR071263.

Progression to Insulin Therapy in Patients With Type 2 Diabetes According to Cardiorespiratory Fitness, Body Mass Index, and Statin Therapy

OBJECTIVE

To evaluate the association between statin therapy, cardiorespiratory fitness (CRF), body mass index (BMI), and progression to insulin therapy in type 2 diabetes mellitus (T2DM).

METHODS

Participants were patients with T2DM (mean age, 62.7±8.4 years; men, 178,992; women, 8360) not treated with insulin, with no evidence of uncontrolled cardiovascular disease, who completed an exercise treadmill test between October 1, 1999, and September 3, 2020. Of these, 158,578 were treated with statins and 28,774 were not. We established 5 age-specific CRF categories according to peak metabolic equivalents of task achieved during an exercise treadmill test.

RESULTS

During a median follow-up period of 9.0 years, 51,182 patients progressed to insulin therapy with an average annual incidence rate of 28.4 events/1000 person-years. The adjusted progression rate was 27% higher in statin-treated patients (hazard ratio [HR], 1.27; 95% CI, 1.24 to 1.31), related directly to BMI and inversely related to CRF. A progressively higher rate was noted in statin-treated vs non-statin-treated patients within all BMI categories, ranging from 23% for normal weight to 90% for those with BMI of 35 kg/m2 and higher. The statin-CRF interaction revealed 43% higher rate in the least-fit statin-treated patients (HR, 1.43; 95% CI, 1.35 to 1.51) and a progressive decline with increased CRF to 30% lower risk in highly fit statin-treated patients (HR, 0.70; 95% CI, 0.66 to 0.75).

CONCLUSION

In patients with T2DM, the statin-related progression to insulin therapy was associated with relatively low CRF and high BMI levels. The progression rate was mitigated by increased CRF regardless of BMI. Clinicians should foster regular exercise for patients with T2DM to enhance CRF and to lessen the rate of progression to insulin therapy.

Pharmacological modulation of vascular ageing: A review from VascAgeNet

Vascular ageing, characterized by structural and functional changes in blood vessels of which arterial stiffness and endothelial dysfunction are key components, is associated with increased risk of cardiovascular and other age-related diseases. As the global population continues to age, understanding the underlying mechanisms and developing effective therapeutic interventions to mitigate vascular ageing becomes crucial for improving cardiovascular health outcomes. Therefore, this review provides an overview of the current knowledge on pharmacological modulation of vascular ageing, highlighting key strategies and promising therapeutic targets. Several molecular pathways have been identified as central players in vascular ageing, including oxidative stress and inflammation, the renin-angiotensin-aldosterone system, cellular senescence, macroautophagy, extracellular matrix remodelling, calcification, and gasotransmitter-related signalling. Pharmacological and dietary interventions targeting these pathways have shown potential in ameliorating age-related vascular changes. Nevertheless, the development and application of drugs targeting vascular ageing is complicated by various inherent challenges and limitations, such as certain preclinical methodological considerations, interactions with exercise training and sex/gender-related differences, which should be taken into account. Overall, pharmacological modulation of endothelial dysfunction and arterial stiffness as hallmarks of vascular ageing, holds great promise for improving cardiovascular health in the ageing population. Nonetheless, further research is needed to fully elucidate the underlying mechanisms and optimize the efficacy and safety of these interventions for clinical translation.

Assessing the efficacy of duration and intensity prescription for physical activity in mitigating cardiometabolic risk after spinal cord injury

PURPOSE OF REVIEW

Spinal cord injury (SCI) heightens susceptibility to cardiometabolic risk (CMR), predisposing individuals to cardiovascular disease. This monograph aims to assess the optimal duration and intensity of physical activity (PA) for managing CMR factors, particularly obesity, after SCI and provide modality-specific PA durations for optimal energy expenditure.

RECENT FINDINGS

PA guidelines recommend at least 150 min/week of moderate-intensity activity. However, non-SCI literature supports the effectiveness of engaging in vigorous-intensity PA (≥6 METs) and dedicating 250-300 min/week (≈2000 kcal/week) to reduce CMR factors. Engaging in this volume of PA has shown a dose-response relationship, wherein increased activity results in decreased obesity and other CMR factors in persons without SCI.

SUMMARY

To optimize cardiometabolic health, individuals with SCI require a longer duration and higher intensity of PA to achieve energy expenditures comparable to individuals without SCI. Therefore, individuals with SCI who can engage in or approach vigorous-intensity PA should prioritize doing so for at least 150 min/wk. At the same time, those unable to reach such intensities should engage in at least 250-300 min/week of PA at a challenging yet comfortable intensity, aiming to achieve an optimal intensity level based on their abilities. Given the potential to decrease CMR after SCI, increasing PA duration and intensity merits careful consideration in future SCI PA directives.

Prevalence, pattern, and correlates of dyslipidemia in Bangladeshi individuals

BACKGROUND

The burden of dyslipidemia in Bangladesh remains inadequately characterized.

OBJECTIVES

To determine and describe the prevalence and pattern of dyslipidemia and its associated risk factors among an adult Bangladeshi population.

DESIGN

Population-based, cross-sectional study. Participants were adults living in all eight administrative divisions of Bangladesh. The total sample size was 7084 (53.1 % women, 46.9% urban residents). Primary outcome measures were triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and the use of lipid lowering medication. In addition, control of LDL-C and control of non high-density lipoprotein cholesterol (non-HDL-C) were investigated.

RESULTS

The overall dyslipidemia prevalence was 76.7%, with 35.7% showing a high TG level, 18.5% showing a high LDL-C level, 63.8% showing a low HDL-C level, and 7.2% of the participants showing all three lipid abnormalities. Sylhet division had the highest prevalence (83.8%) of overall dyslipidemia, while Rangpur had the lowest prevalence (69.3%). The control of LDL-C (<50 mg/dL) and non-HDL-C (<80 mg/dL) among adults with a previous history of atherosclerotic cardiovascular diseases (ASCVD) were 5.1% and 6.9% respectively. The regression models showed that male sex and age 45-59 years were significant predictors of overall dyslipidemia. Both smokers and smokeless tobacco users were significant factors for overall dyslipidemia and high TG. A high waist-hip ratio was associated with overall dyslipidemia and all other subtypes of dyslipidemia.

CONCLUSION

The high prevalence of dyslipidemia in Bangladesh necessitates lifestyle interventions to prevent and control this cardiovascular risk factor.

Prescribing statin therapy in physically (in)active individuals vs prescribing physical activity in statin-treated patients: A four-scenario practical approach

Statins are among the most commonly prescribed medications worldwide. Statin-associated muscle symptoms (SAMS) represent a frequent statin-related adverse effect associated with statin discontinuation and increased cardiovascular disease (CVD) events. Emerging evidence indicate that the majority of SAMS might not be actually caused by statins, and the nocebo/drucebo effect (i.e. adverse effects caused by negative expectations) might also explain SAMS. Physical activity (PA) is a cornerstone in the management of CVD risk. However, evidence of increased creatine-kinase levels in statin-treated athletes exposed to a marathon has been generalized, at least to some extent, to the general population and other types of PA. This generalization is likely inappropriate and might induce fear around PA in statin users. In addition, the guidelines for lipid management focus on aerobic PA while the potential of reducing sedentary behavior and undertaking resistance training have been overlooked. The aim of this report is to provide a novel proposal for the concurrent prescription of statin therapy and PA addressing the most common and clinically relevant scenarios by simultaneously considering the different stages of statin therapy and the history of PA. These scenarios include i) statin therapy initiation in physically inactive patients, ii) PA/exercise initiation in statin-treated patients, iii) statin therapy initiation in physically active patients, and iv) statin therapy in athletes and very active individuals performing SAMS-risky activities.

Effect of overall lifestyle on the all-cause mortality and cardiovascular disease death in dyslipidemia patients with or without lipid-lowering therapy: a cohort study

BACKGROUND

Lifestyle adjustment has been reported as one of the interventions for dyslipidemia. This study aimed to explore the effect of overall lifestyle on the risk of all-cause mortality and cardiovascular disease (CVD) death in dyslipidemia patients with or without lipid-lowering therapy.

METHODS

This was a retrospective cohort study, and data were extracted from the National Health and Nutrition Examination Survey (NHANES). Overall lifestyle was assessed based on Mediterranean diet score, physical activity, smoking status, sleep duration, and body mass index (BMI). Multivariate Cox regression model was used to explore the effect of overall lifestyle score on the risk of all-cause mortality and CVD death. Results were shown as hazard ratio (HR), with 95% confidence interval (CI).

RESULTS

A total of 11,549 dyslipidemia patients were finally included in this study. The results showed that optimal overall lifestyle was associated with the decreased risk of all-cause mortality (HR = 0.47, 95%CI: 0.34-0.64) and CVD death (HR = 0.45, 95%CI: 0.22-0.94) in patients without lipid-lowering therapy. The similar results were found in patients with lipid-lowering therapy (all-cause mortality: HR = 0.45, 95%CI: 0.33-0.62; CVD death: HR = 0.38, 95%CI: 0.23-0.63).

CONCLUSIONS

A favorable overall lifestyle may have great benefits to improve the prognosis of dyslipidemia, highlighting the importance of overall lifestyle adjustment for dyslipidemia patients.

Use of Wearable Devices for Peak Oxygen Consumption Measurement in Clinical Cardiology: Case Report and Literature Review

BACKGROUND

Oxygen consumption is an important index to evaluate in cardiac patients, particularly those with heart failure, and is measured in the setting of advanced cardiopulmonary exercise testing. However, technological advances now allow for the estimation of this parameter in many consumer and medical-grade wearable devices, making it available for the medical provider at the initial evaluation of patients. We report a case of an apparently healthy male aged 40 years who presented for evaluation due to an Apple Watch (Apple Inc) notification of low cardiac fitness. This alert triggered a thorough workup, revealing a diagnosis of familial nonischemic cardiomyopathy with severely reduced left ventricular systolic function. While the use of wearable devices for the measurement of oxygen consumption and related parameters is promising, further studies are needed for validation.

OBJECTIVE

The aim of this report is to investigate the potential utility of wearable devices as a screening and risk stratification tool for cardiac fitness for the general population and those with increased cardiovascular risk, particularly through the measurement of peak oxygen consumption (VO2). We discuss the possible advantages of measuring oxygen consumption using wearables and propose its integration into routine patient evaluation and follow-up processes. With the current evidence and limitations, we encourage researchers and clinicians to explore bringing wearable devices into clinical practice.

METHODS

The case was identified at Sheba Medical Center, and the patient's cardiac fitness was monitored through an Apple Watch Series 6. The patient underwent a comprehensive cardiac workup following his presentation. Subsequently, we searched the literature for articles relating to the clinical utility of peak VO2 monitoring and available wearable devices.

RESULTS

The Apple Watch data provided by the patient demonstrated reduced peak VO2, a surrogate index for cardiac fitness, which improved after treatment initiation. A cardiological workup confirmed familial nonischemic cardiomyopathy with severely reduced left ventricular systolic function. A review of the literature revealed the potential clinical benefit of peak VO2 monitoring in both cardiac and noncardiac scenarios. Additionally, several devices on the market were identified that could allow for accurate oxygen consumption measurement; however, future studies and approval by the Food and Drug Administration (FDA) are still necessary.

CONCLUSIONS

This case report highlights the potential utility of peak VO2 measurements by wearable devices for early identification and screening of cardiac fitness for the general population and those at increased risk of cardiovascular disease. The integration of wearable devices into routine patient evaluation may allow for earlier presentation in the diagnostic workflow. Cardiac fitness can be serially measured using the wearable device, allowing for close monitoring of functional capacity parameters. Devices need to be used with caution, and further studies are warranted.

The effect of a multi-component behavior change technique intervention on medication adherence among individuals on primary prevention statin therapy: a dose-finding protocol

BACKGROUND

In the USA, the primary cause of death and morbidity continues to be cardiovascular disease (CVD). Numerous trials have shown that statin medication reduces the likelihood of CVD events; it is a cornerstone of CVD prevention. However, studies have also indicated that up to 60% of the estimated 26.8 million Americans prescribed primary prevention statin treatment are nonadherent during the first year. Multi-component behavioral change technique (BCT) therapies have shown moderate promise in improving medication adherence as well as other positive health behaviors (such as physical activity). However, no research has looked at the duration of multi-component BCT intervention needed to result in a clinically significant improvement in statin adherence behaviors. This study aims to determine the necessary dose of a multi-component BCT intervention (defined as duration in weeks) to promote adherence to statin medication among those on primary prevention statin treatment by utilizing the modified time-to-event continuous reassessment method (TiTE-CRM).

METHODS AND DESIGN

The study will utilize the modified TiTE-CRM in 42 participants, recruited in 14 cohorts of 3 participants each. The goal of this analysis is to identify the minimum effective dose (MED) of a multi-behavior change technique (BCT) intervention required to increase adherence to statins by 20% between baseline and follow-up periods. Using the TiTE-CRM method, the dose of the behavior intervention in weeks will be assigned to each cohort based on the performance of the prior cohort. At the end of the study, the intervention dose that has been found to be associated with a 20% increase in statin adherence among 80% of participants assigned to that dose will be identified as the MED.

DISCUSSION

If successful, the current trial will provide additional guidance to researchers and clinicians seeking to increase statin medication adherence using a BCT intervention by identifying the dose (i.e., the duration) of an intervention required to meaningfully increase adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05273736. Registered on March 10, 2022. https://www.

CLINICALTRIALS

gov/ct2/show/NCT05273736.

Comparing physical activity prescription with verbal advice for general practice patients with cardiovascular risk factors: results from the PEPPER randomised controlled trial

BACKGROUND

Regular physical activity improves health and quality of life for people with cardiovascular risk factors. However, few studies have demonstrated the applicability of strategies in health care to promote physical activity.

OBJECTIVE

To evaluate if a written physical activity prescription combined with pedometer increases physical activity over one year compared with verbal advice in patients with cardiovascular disease risk in primary care.

METHODS

The randomised-controlled, interventional, 12-month PEPPER study recruited patients aged 35 to 74 years, having quarterly followed-ups for hypertension, dyslipidaemia, or diabetes, and judged insufficiently active. Seventeen practices randomised patients into either the experimental group, who received a written, personalised prescription for daily step numbers, pedometer and logbook, or control group, who received verbal advice to do at least 15 min of rapid walking or equivalent daily. The primary outcome was the change in total weekly energy expenditure measured using an accelerometer at 3 months. The secondary outcomes were changes in step count, physical activity levels, quality of life, perceived obstacles to physical activity, and biomedical indicators at 3 and 12 months.

RESULTS

One hundred and twenty-one participants were randomised. Although, weekly energy expenditure did not differ between the prescription and verbal instruction group, the estimated time spent doing moderate-intensity activity was significantly higher in the prescription group than the verbal group by an average of four minutes/week (p = 0.018)(95% CI [0.7 - 7.4]) reaching 48 min after 12 months (95% CI: 8 - 89). Similarly, this was associated with a clinically, higher average step number of 5256 steps/week increase over a year (95% CI: 660 - 9852). Among the most sedentary subgroup, walking less than 5000 steps/day at baseline, an 8868 steps/week (95% CI [2988 - 14700]) increase was observed in the prescription group.

CONCLUSION

Prescribing physical activity did not significantly modify total weekly energy expenditure, but slightly increased moderate-intensity activity duration and step counts, particularly among the most sedentary participants. Prescribing personalised physical activity goals encourages sedentary patients to engage in physical activity.

TRIAL REGISTRATION

The PEPPER trial is registered in the US National Institutes of Health Clinical Trials Registry under number NCT02317003 (15/12/2014).

Nonexercise machine learning models for maximal oxygen uptake prediction in national population surveys

OBJECTIVE

Nonexercise algorithms are cost-effective methods to estimate cardiorespiratory fitness (CRF), but the existing models have limitations in generalizability and predictive power. This study aims to improve the nonexercise algorithms using machine learning (ML) methods and data from US national population surveys.

MATERIALS AND METHODS

We used the 1999-2004 data from the National Health and Nutrition Examination Survey (NHANES). Maximal oxygen uptake (VO2 max), measured through a submaximal exercise test, served as the gold standard measure for CRF in this study. We applied multiple ML algorithms to build 2 models: a parsimonious model using commonly available interview and examination data, and an extended model additionally incorporating variables from Dual-Energy X-ray Absorptiometry (DEXA) and standard laboratory tests in clinical practice. Key predictors were identified using Shapley additive explanation (SHAP).

RESULTS

Among the 5668 NHANES participants in the study population, 49.9% were women and the mean (SD) age was 32.5 years (10.0). The light gradient boosting machine (LightGBM) had the best performance across multiple types of supervised ML algorithms. Compared with the best existing nonexercise algorithms that could be applied to the NHANES, the parsimonious LightGBM model (RMSE: 8.51 ml/kg/min [95% CI: 7.73-9.33]) and the extended LightGBM model (RMSE: 8.26 ml/kg/min [95% CI: 7.44-9.09]) significantly reduced the error by 15% and 12% (P < .001 for both), respectively.

DISCUSSION

The integration of ML and national data source presents a novel approach for estimating cardiovascular fitness. This method provides valuable insights for cardiovascular disease risk classification and clinical decision-making, ultimately leading to improved health outcomes.

CONCLUSION

Our nonexercise models provide improved accuracy in estimating VO2 max within NHANES data as compared to existing nonexercise algorithms.

Changes in Cardiorespiratory Fitness and Survival in Patients With or Without Cardiovascular Disease

BACKGROUND

The association between cardiorespiratory fitness (CRF) and mortality risk is based mostly on 1 CRF assessment. The impact of CRF change on mortality risk is not well-defined.

OBJECTIVES

This study sought to evaluate changes in CRF and all-cause mortality.

METHODS

We assessed 93,060 participants aged 30-95 years (mean 61.3 ± 9.8 years). All completed 2 symptom-limited exercise treadmill tests, 1 or more years apart (mean 5.8 ± 3.7 years) with no evidence of overt cardiovascular disease. Participants were assigned to age-specific fitness quartiles based on peak METS achieved on the baseline exercise treadmill test. Additionally, each CRF quartile was stratified based on CRF changes (increase, decrease, no change) observed on the final exercise treadmill test. Multivariable Cox models were used to estimate HRs and 95% CIs for all-cause mortality.

RESULTS

During a median follow-up of 6.3 years (IQR: 3.7-9.9 years), 18,302 participants died with an average yearly mortality rate of 27.6 events per 1,000 person-years. In general, changes in CRF ≥1.0 MET were associated with inverse and proportionate changes in mortality risk regardless of baseline CRF status. For example, a decline in CRF of >2.0 METS was associated with a 74% increase in risk (HR: 1.74; 95% CI: 1.59-1.91) for low-fit individuals with CVD, and 69% increase (HR: 1.69; 95% CI: 1.45-1.96) for those without CVD.

CONCLUSIONS

Changes in CRF reflected inverse and proportional changes in mortality risk for those with and without CVD. The impact of relatively small CRF changes on mortality risk has considerable clinical and public health significance.

Statins and diabetes: What are the connections?

Randomized trials suggest moderate-intensity statins increase type 2 diabetes risk by around 11% with a potential further 12% moving to high-intensity statins, such that high intensity may increase risk by 20% or more relative to placebo. These data translate into one extra diabetes case per 100-200 statin recipients over 5 years, with ∼10-fold greater benefits on major vascular outcomes. The underlying mechanisms for diabetes harm are not clear but could include modest weight gain (noted in randomized trials), or, speculatively, beta cell harm. Concordant genetic studies link HMG CoA Reductase inhibition to diabetes risk and weight gain. Patients should be warned about a slight diabetes risk when prescribed statin and told that modest lifestyle improvements can i) nullify diabetes risk, and ii) improve cardiovascular risks beyond statins. Doctors should also measure glycemia status post statin commencement, most commonly with HbA1c, and tailor lifestyle advice and care dependent on the results.

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.

Epidemiological, mechanistic, and practical bases for assessment of cardiorespiratory fitness and muscle status in adults in healthcare settings

Given their importance in predicting clinical outcomes, cardiorespiratory fitness (CRF) and muscle status can be considered new vital signs. However, they are not routinely evaluated in healthcare settings. Here, we present a comprehensive review of the epidemiological, mechanistic, and practical bases of the evaluation of CRF and muscle status in adults in primary healthcare settings. We highlight the importance of CRF and muscle status as predictors of morbidity and mortality, focusing on their association with cardiovascular and metabolic outcomes. Notably, adults in the best quartile of CRF and muscle status have as low as one-fourth the risk of developing some of the most common chronic metabolic and cardiovascular diseases than those in the poorest quartile. The physiological mechanisms that underlie these epidemiological associations are addressed. These mechanisms include the fact that both CRF and muscle status reflect an integrative response to the body function. Indeed, muscle plays an active role in the development of many diseases by regulating the body's metabolic rate and releasing myokines, which modulate metabolic and cardiovascular functions. We also go over the most relevant techniques for assessing peak oxygen uptake as a surrogate of CRF and muscle strength, mass, and quality as surrogates of muscle status in adults. Finally, a clinical case of a middle-aged adult is discussed to integrate and summarize the practical aspects of the information presented throughout. Their clinical importance, the ease with which we can assess CRF and muscle status using affordable techniques, and the availability of reference values, justify their routine evaluation in adults across primary healthcare settings.

Association Between Plasma Ceramides and One-Year Mortality in Patients with Acute Coronary Syndrome: Insight from the PEACP Study

Background

The plasma lipidome profile is likely to improve risk stratification in patients with acute coronary syndrome (ACS) and predict cardiovascular events for secondary disease prevention. Ceramides are involved in the initiation or acceleration of several key pathophysiological processes in atherosclerosis. This study evaluated whether plasma ceramide levels at admission was associated with one-year mortality in patients with ACS.

Methods

In total, 826 patients with ACS from a prospective multicenter study for early evaluation of acute chest pain were enrolled. High-performance liquid chromatography with tandem mass spectrometry (LC/MS) was used to measure the plasma levels of eleven ceramides (C16-C26). The primary outcome was all-cause mortality, and the secondary outcome was cardiac mortality during the one-year follow-up. The relationship between the ceramide levels and mortality was evaluated by Cox regression analysis. The receiver operating characteristic (ROC) curve was established to evaluate discrimination of ceramides.

Results

Eighty-eight (10.7%) patients died after a 12-month follow-up. Five ceramides (C16:0, C18:0, C20:0, C24:1 and C24:2) and their ratios to Cer(d18:1/24:0) were independently associated with the risk of all-cause death and cardiac death. Combining the Global Registry of Acute Coronary Events (GRACE) score with ceramides and their ratios to Cer(d18:1/24:0) had areas under ROC curves ranging from 0.778-0.804 (P<0.001) for all-cause mortality, which was greater than that of the GRACE score alone.

Conclusion

Measurements of long-chain ceramides and very-long-chain ceramides may help in identifying a high risk of mortality beyond traditional assessment tools in patients with ACS.

Trial Registration

clinicaltrials.gov, identifier: NCT04122573.

Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations

The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.

Health characteristics, knowledge, and attitude towards basic life support among marathon runners in Thailand: a population-based survey

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is not common but associated with a low survival rate. There is no evidence investigating the effects of previous Basic Life Support (BLS) training among long-distance runners. The goal of this study is to demonstrate the health characteristics, knowledge, and attitudes towards BLS among marathon runners.

METHODS

An online cross-sectional survey was asked to all 2019 Chiang Mai University marathon participants as a part of the running registration. Details of health characteristic, running history, and BLS training details were requested. The primary outcomes were knowledge and attitude towards BLS among marathon runners.

RESULTS

Of all 10,507 questionnaires sent, the response rate was 92.9%. One-nineth of participants were 50 years of age or above. The mean age was 36.8±9.9 years. Most were male (56.1%) and Thai (99.4%). Only a quarter (2454 out of 9761 runners) of study population had previous BLS training. Family history of sudden cardiac death or cardiac death with unknown causes was more in participants with previous BLS training than those without (1.1% vs. 0.6%, P=0.01). Previous BLS training group answered the national emergency call number correctly more than those without (90.4% vs. 73.0%, P<0.001) and previous BLS training group were more likely to initiate CPR than those without (median self-confidence 8 vs. 5, respectively, P<0.001).

CONCLUSIONS

Only a quarter of running participants have participated in BLS training before entering a marathon running. Having previous BLS training is associated with higher self-confidence to attempt CPR. Organized planning including trained medical staff, adequate equipment, and qualified bystanders is recommended.

Effects of statins on fat oxidation improvements after aerobic exercise training

BACKGROUND

Statin blunts cardiorespiratory fitness improvements after exercise training and may affect fat oxidation adaptations to training.

METHODS

One hundred and six metabolic syndrome individuals either chronically medicated with statins (i.e., STATIN group; n = 46) or statin naïve (i.e., CONTROL group; n = 60) completed a 16-week supervised high-intensity interval training (HIIT) program. Maximal rates of oxygen consumption (V̇O2MAX), fat oxidation (FOMAX), and the shape of the workload-fat oxidation curve were assessed before and 48 h after training in an overnight fasted state.

RESULTS

Starting from a similar value at baseline, both groups increased V̇O2MAX after training, but the increase was larger in the CONTROL than in the STATIN group (19.4% vs. 12.6%; P = 0.013). Before training, FOMAX in the STATIN group was lower (0.19 ± 0.08 vs. 0.23 ± 0.07 g·min-1; P = 0.023) and took place at a lower workload (33 ± 21 vs. 37 ± 19 W; P = 0.015) than in CONTROL. After training, FOMAX improved similarly in both groups (0.06 ± 0.08; 95% CI, 0.03 to 0.08 g·min-1 and 0.05 ± 0.09; 95% CI, 0.03 to 0.07 g·min-1, for STATIN and CONTROL respectively; P < 0.001). Still, after training, FOMAX occurred at a 28% lower workload in the STATIN group (38 ± 26 vs. 53 ± 32 W, P = 0.048).V̇O2 -workload slope decreased after training in both groups (both P < 0.001) along with reductions in the respiratory exchange ratio - workload slope. Fat oxidation increased at all workloads after training regardless of the use of statins.

CONCLUSION

Long-term statin treatment is associated with blunted exercise fat oxidation before exercise training. However, statin use does not blunt the improvements in exercise fat oxidation (FOMAX) derived from intense aerobic exercise training. This finding should encourage statin users to exercise-train to benefit from increased fat oxidation once their fitness level improves.

The associations between exercise and lipid biomarkers

Cardiovascular diseases (CVD) remain the leading cause of death globally, and further efforts are being undertaken to understand and modify CVD risk factors, such as dyslipidemia (DLD), hypertension, and diabetes. The sedentary lifestyle of most individuals today contributes to the prevalence of these conditions. Uncontrolled dyslipidemia serves as a fertile ground for atherosclerotic plaque formation, while lipoproteins (Lp) act as cofactors for inflammatory processes that cause plaque destabilization leading to subsequent CVD events. As such, many health experts and institutions continue to emphasize the importance of cardiorespiratory fitness (CRF) and muscular strength (MusS) with the intent to reduce atherogenic lipoproteins and proprotein convertase subtilisin kexin type 9 (PCSK-9) expression. Concordantly, the two modes of exercise training (ET), such as aerobic ET (aET) and resistance ET (rET) have both demonstrated to improve CRF and MusS, respectively. Although both modes of ET were shown to independently reduce mortality, participation in both forms resulted in a more pronounced improvement in cholesterol levels and CVD-related mortality. Though reduction of adiposity is not a pre-requisite to achieve better control of DLD through increased CRF and MusS, the beneficial effects of physical activity on the inflammatory processes linked to atherosclerosis are almost always associated with a simultaneous decrease in overall adiposity. It is therefore essential to promote both aET and rET, including weight loss in order to attenuate the risks stemming from atherosclerosis and its proinflammatory components.

Understanding heterogeneity of responses to, and optimizing clinical efficacy of, exercise training in older adults: NIH NIA Workshop summary

Exercise is a cornerstone of preventive medicine and a promising strategy to intervene on the biology of aging. Variation in the response to exercise is a widely accepted concept that dates back to the 1980s with classic genetic studies identifying sequence variations as modifiers of the VO₂max response to training. Since that time, the literature of exercise response variance has been populated with retrospective analyses of existing datasets that are limited by a lack of statistical power from technical error of the measurements and small sample sizes, as well as diffuse outcomes, very few of which have included older adults. Prospective studies that are appropriately designed to interrogate exercise response variation in key outcomes identified a priori and inclusive of individuals over the age of 70 are long overdue. Understanding the underlying intrinsic (e.g., genetics and epigenetics) and extrinsic (e.g., medication use, diet, chronic disease) factors that determine robust versus poor responses to various exercise factors will be used to improve exercise prescription to target the pillars of aging and optimize the clinical efficacy of exercise training in older adults. This review summarizes the proceedings of the NIA-sponsored workshop entitled, "Understanding Heterogeneity of Responses to, and Optimizing Clinical Efficacy of, Exercise Training in Older Adults" and highlights the importance and current state of exercise response variation research, particularly in older adults, prevailing challenges, and future directions.

Exercise for Primary and Secondary Prevention of Cardiovascular Disease: JACC Focus Seminar 1/4

Regular exercise that meets or exceeds the current physical activity guidelines is associated with a reduced risk of cardiovascular disease (CVD) and mortality. Therefore, exercise training plays an important role in primary and secondary prevention of CVD. In this part 1 of a 4-part focus seminar series, we highlight the mechanisms and physiological adaptations responsible for the cardioprotective effects of exercise. This includes an increase in cardiorespiratory fitness secondary to cardiac, vascular, and skeletal muscle adaptations and an improvement in traditional and nontraditional CVD risk factors by exercise training. This extends to the role of exercise and its prescription in patients with CVDs (eg, coronary artery disease, chronic heart failure, peripheral artery disease, or atrial fibrillation) with special focus on the optimal mode, dosage, duration, and intensity of exercise to reduce CVD risk and improve clinical outcomes in these patients.

Cardiorespiratory Fitness and the Risk of All-Cause, Cardiovascular and Cancer Mortality in Men with Hypercholesterolemia

Background: Whether higher cardiorespiratory fitness (CRF) confers protection against cardiovascular disease (CVD) in individuals with manifest hypercholesterolemia is poorly understood. Methods: Participants were 8920 men aged 20−82 years with hypercholesterolemia but no history of CVD and/or cancer and who received a preventive examination at the Cooper Clinic in Dallas, TX, USA, during 1974−2001. CRF was quantified as maximal treadmill test duration and was grouped for analysis as low, moderate, or high based on the traditional Aerobics Center Longitudinal Study cutpoints. Using Cox regression analyses, we computed hazard ratios and 95% confidence intervals for risk of mortality based on CRF. Results: During an average of 17 years of follow-up, 329 CVD and 290 cancer deaths occurred. After control for baseline age, examination year, body mass index, total cholesterol, smoking, alcohol intake, physical activity, hypertension, diabetes, and parental history of CVD, hazard ratios (95% confidence interval) for CVD deaths across moderate and high categories of CRF (with low fit as referent) were: 0.66 (0.50−0.87) and 0.55 (0.39−0.79), respectively. There was an inverse association between CRF and CVD death among normal-weight (trend p < 0.0001), younger (<60 y, trend p = 0.01), and inactive men (trend p = 0.002). However, no significant association was found between CRF and cancer mortality. Conclusions: Among men with hypercholesterolemia, higher CRF was associated with a lower risk of dying from CVD independent of other clinical risk factors. Our findings underscored the importance of promoting CRF in the primary prevention of CVD in patients with hypercholesterolemia.

Cardiorespiratory Fitness and Mortality Risk Across the Spectra of Age, Race, and Sex

BACKGROUND

Cardiorespiratory fitness (CRF) is inversely associated with all-cause mortality. However, the association of CRF and mortality risk for different races, women, and elderly individuals has not been fully assessed.

OBJECTIVES

The aim of this study was to evaluate the association of CRF and mortality risk across the spectra of age, race, and sex.

METHODS

A total of 750,302 U.S. veterans aged 30 to 95 years (mean age 61.3 ± 9.8 years) were studied, including septuagenarians (n = 110,637), octogenarians (n = 26,989), African Americans (n = 142,798), Hispanics (n = 35,197), Native Americans (n = 16,050), and women (n = 45,232). Age- and sex-specific CRF categories (quintiles and 98th percentile) were established objectively on the basis of peak METs achieved during a standardized exercise treadmill test. Multivariable Cox models were used to estimate HRs and 95% CIs for mortality across the CRF categories.

RESULTS

During follow-up (median 10.2 years, 7,803,861 person-years of observation), 174,807 subjects died, averaging 22.4 events per 1,000 person-years. The adjusted association of CRF and mortality risk was inverse and graded across the age spectrum, sex, and race. The lowest mortality risk was observed at approximately 14.0 METs for men (HR: 0.24; 95% CI: 0.23-0.25) and women (HR: 0.23; 95% CI: 0.17-0.29), with no evidence of an increase in risk with extremely high CRF. The risk for least fit individuals (20th percentile) was 4-fold higher (HR: 4.09; 95% CI: 3.90-4.20) compared with extremely fit individuals.

CONCLUSIONS

The association of CRF and mortality risk across the age spectrum (including septuagenarians and octogenarians), men, women, and all races was inverse, independent, and graded. No increased risk was observed with extreme fitness. Being unfit carried a greater risk than any of the cardiac risk factors examined.

Hypercholesterolemia Diagnosis, Treatment Patterns, and 12-Month Target Achievement in Clinical Practice in Germany in Patients with Familial Hypercholesterolemia

Background: Familial hypercholesterolemia (FH) is a highly prevalent disorder and a risk factor for early coronary artery disease. The objective of this registry was to document the clinical characteristics of patients with definite FH in Germany and to document lipid profiles, lipid-lowering therapy, and lipid target achievement during longitudinal follow-up. Methods: HYDRA-FH was a national, prospective, multicenter, non-interventional registry conducted in 35 centers in Germany. Consecutive adult patients with definite FH were included (n = 241). Results: In the cross-sectional analysis (n = 233), lipid-lowering therapy involved statins (82.0%), ezetimibe (31.8%), and PCSK9 antibodies (18.5%); 11.2% of patients were receiving no lipid-lowering drugs. Median lipid levels were: low-density lipoprotein cholesterol (LDL-C) 134 mg/dL (3.5 mmol/L), high-density lipoprotein cholesterol (HDL-C) 48 mg/dL (1.2 mmol/L), triglycerides 160 mg/dL (1.9 mmol/L), total cholesterol 211 mg/dL (5.5 mmol/L). Values were above the normal threshold (150 mg/dL) for LDL-C in 72.9%, total cholesterol in 29.7%, and triglycerides in 45.0% of patients. After the 12-month follow-up (n = 145), only 17.2% had LDL-C < 70 mg/dL, and 20.7% had either LDL-C < 70 mg/dL or a reduction of ≥50% versus baseline. Conclusion: This study provides insight into the clinical characteristics and current treatment status of patients with FH in Germany. Many patients with FH do not achieve recommended lipid levels.

Joint effects of self-reported sleep and modifiable physical activity on risk of dyslipidaemia in women aged 45-55 years: a cross-sectional study

OBJECTIVES

Modifiable physical activity (PA) plays an important role in dyslipidaemia risk in middle-aged women with sleep problems, especially perimenopausal women. We aimed to explore the joint effects of sleep and PA on the risk of dyslipidaemia in women aged 45-55 years, and the extent to which PA moderated the effect of sleep on the risk of dyslipidaemia.

DESIGN

A cross-sectional study.

SETTING

This study was based on the survey of Chronic Disease and Nutrition Monitoring in Adults in Inner Mongolia in 2015.

PARTICIPANTS

721 women aged 45-55 years were included.

OUTCOME MEASUREMENT

PA was measured by the Global Physical Activity Questionnaire. Sleep was measured by questionnaire formulated by the Chinese Center for Disease Control and Prevention. Multivariate logistic regression analyses were performed to determine the joint effects of sleep and PA on dyslipidaemia risk. OR and 95% CI were reported.

RESULTS

Among all participants, 60.6% had sleep problems, 29.0% had low PA and 41.1% had dyslipidaemia. Women with sleep problems had higher dyslipidaemia risk than women without sleep problems, irrespective of low, moderate or high PA, with OR (95% CI) of 4.24 (2.40 to 7.49), 3.14 (1.80 to 5.49) and 2.04 (1.20 to 3.48), respectively. PA could not completely attenuate the negative association between sleep and dyslipidaemia risk. With PA increased from low to high, the OR of dyslipidaemia decreased by 2.20. Women with sleep problems and low PA had higher risks of high total cholesterol, high triglyceride, low high-density lipoprotein cholesterol and high low-density lipoprotein cholesterol than women without sleep problems and high PA, with OR (95% CI) of 2.51 (1.18 to 5.35), 2.42 (1.23 to 4.74), 2.88 (1.44 to 5.74) and 2.52 (1.12 to 5.70), respectively.

CONCLUSIONS

Among women aged 45-55 years, the joint effects of self-reported sleep and PA on dyslipidaemia risk were more marked for sleep than for PA. Modifiable PA is a widely accessible and effective intervention to reduce the dyslipidaemia risk in women with sleep problems, particularly among perimenopausal women.

Moderate Intensity Exercise Training Improves Skeletal Muscle Performance in Symptomatic and Asymptomatic Statin Users

BACKGROUND

The combination of statin therapy and physical activity reduces cardiovascular disease risk in patients with hyperlipidemia more than either treatment alone. However, mitochondrial dysfunction associated with statin treatment could attenuate training adaptations.

OBJECTIVES

This study determined whether moderate intensity exercise training improved muscle and exercise performance, muscle mitochondrial function, and fiber capillarization in symptomatic and asymptomatic statin users.

METHODS

Symptomatic (n = 16; age 64 ± 4 years) and asymptomatic statin users (n = 16; age 64 ± 4 years) and nonstatin using control subjects (n = 20; age 63 ± 5 years) completed a 12-week endurance and resistance exercise training program. Maximal exercise performance (peak oxygen consumption), muscle performance and muscle symptoms were determined before and after training. Muscle biopsies were collected to assess citrate synthase activity, adenosine triphosphate (ATP) production capacity, muscle fiber type distribution, fiber size, and capillarization.

RESULTS

Type I muscle fibers were less prevalent in symptomatic statin users than control subjects at baseline (P = 0.06). Exercise training improved muscle strength (P < 0.001), resistance to fatigue (P = 0.01), and muscle fiber capillarization (P < 0.01), with no differences between groups. Exercise training improved citrate synthase activity in the total group (P < 0.01), with asymptomatic statin users showing less improvement than control subjects (P = 0.02). Peak oxygen consumption, ATP production capacity, fiber size, and muscle symptoms remained unchanged in all groups following training. Quality-of-life scores improved only in symptomatic statin users following exercise training (P < 0.01).

CONCLUSIONS

A moderate intensity endurance and resistance exercise training program improves muscle performance, capillarization, and mitochondrial content in both asymptomatic and symptomatic statin users without exacerbating muscle complaints. Exercise training may even increase quality of life in symptomatic statin users. (The Effects of Cholesterol-Lowering Medication on Exercise Performance [STATEX]; NL5972/NTR6346).

Impact of cardiorespiratory fitness on outcomes in cardiac rehabilitation

Cardiovascular rehabilitation (CR) significantly improves outcomes in patients with cardiovascular diseases (CVD), especially coronary heart disease and heart failure (HF). Although CR is often considered as an exercise training (ET) program for patients following CVD events, CR is more than just ET as it involves education, dietary and psychological counseling, as well as a multi-factorial risk factor modification. However, a major component of ET involves efforts to measure and improve levels of cardiorespiratory fitness (CRF). In this state-of-the-art review, we analyze the data, including from our John Ochsner Heart and Vascular Institute, evaluating CRF and its impact on psychological improvements and major outcomes with CR, especially long-term survival.

The Effects of Exercise on Lipid Biomarkers

The World Health Organization has declared obesity to be a global epidemic that increases cardiovascular disease (CVD) mortality risk factors, such as hypertension, diabetes, dyslipidemia, and atherosclerosis. The increasing ratio of time spent in sedentary activities to that spent performing physically demanding tasks increases the trends to obesity and susceptibility to these risk factors. Dyslipidemia is the foundation of atherosclerotic buildup and lipoproteins serve as cofactors to the inflammatory processes that destabilize plaques. Increasing cardiorespiratory fitness and muscular strength helps attenuate concentrations of low-density lipoproteins (LDLs), such as LDL cholesterol, and increase levels of high-density lipoprotein cholesterol, as well as reduce proprotein convertase subtilisin kexin type 9 expression. Effects of physical activity on the inflammatory pathways of atherosclerosis, specifically C-reactive protein, are more closely related to reducing the levels of adiposity in tandem with increasing fitness, than with exercise training alone. The purpose of this review is to describe the physiology of dyslipidemia and relate it to CVD and exercise therapies.

Rationale for the use of metformin and exercise to counteract statin-associated side effects

INTRODUCTION

Statins are the most widely prescribed drugs for lowering low-density lipoprotein cholesterol (LDL-C) and reducing cardiovascular morbidity and mortality. They are usually well-tolerated, but have two main safety concerns: statin-associated muscle symptoms (SAMS) and new-onset type 2 diabetes (NOD).

METHODS

A PubMed search was carried out using the following key words were used: statins, statin-associated muscle symptoms, statin myalgia, statin-associated diabetes, metformin and statins, exercise and statins.

RESULTS

Mitochondrial damage and muscle atrophy are likely the central mechanisms producing SAMS, whereas decreased glucose transport, fatty acid oxidation and insulin secretion are likely involved in the development of NOD. Metformin and exercise training share many pathways that could potentially contrast SAMS and NOD. Clinical evidence also supports the combination of statins with metformin and exercise.

CONCLUSION

This combination appears attractive both from a clinical and an economical viewpoint, since all three therapies are highly cost-effective and their combination could result in diabetes and cardiovascular disease prevention.

Physical Activity, Cardiorespiratory Fitness, and Population-Attributable Risk

OBJECTIVE

To determine population-attributable risk (PAR) and exposure impact number (EIN) for mortality associated with impaired cardiorespiratory fitness (CRF), physical inactivity, and other risk markers among veteran subjects.

METHODS

The sample included 5890 male subjects (mean age 58±15) who underwent a maximal exercise test for clinical reasons between January 1, 1992, and December 31, 2014. All-cause mortality was the end point. Cox multivariable hazard models were performed to determine clinical, demographic, and exercise-test determinants of mortality. Population-attributable risks and EIN for the lowest quartile of CRF and for inactive behavior were analyzed, accounting for competing events.

RESULTS

There were 2728 deaths during a mean ± standard deviation follow-up period of 9.9±5.8 years. Having low CRF (<5.0 metabolic equivalents [METs]) was associated with an approximate 3-fold higher risk of mortality and a PAR of 12.9%. Each higher MET achieved on the treadmill was associated with a 15% reduction in mortality (hazard ratio [HR]=0.85; 95% confidence interval [CI], 0.83 to 0.88; P<.001). Nearly half the sample was inactive, and these subjects had a 23% higher mortality risk and a PAR of 8.8%. The least fit quartile (<5.0 METs) had relative risks of ≈6.0 compared with the most-fit group (HR=5.99; 95% CI, 4.9 to 7.3). The least-active tertile had ≈2-fold higher risks of mortality vs the most active subjects (HR=1.9; 95% CI, 0.91 to 4.1). The lowest EIN was observed for low fitness (3.8; 95% CI, 3.4 to 4.3, P<.001), followed by diabetes, smoking, hypertension, and physical inactivity (all P<.001 except for diabetes, P=.008).

CONCLUSION

Both higher CRF and physical activity provide protection against all-cause mortality in subjects referred for exercise testing for clinical reasons. Encouraging physical activity with the aim of increasing CRF would have a significant impact on reducing mortality.

Exercise blood pressure, cardiorespiratory fitness and mortality risk

OBJECTIVE

To assess the cardiorespiratory fitness (CRF) impact on the association between exercise blood pressure (BP) and mortality risk.

PATIENTS AND METHODS

We assessed CRF in 15,004 US Veterans (mean age 57.5 ± 11.2 years) who completed a standardized treadmill test between January 1, 1988 and July 28, 2017 and had no evidence of ischemia. They were classified as Unfit or Fit according to the age-specific metabolic equivalents (METs) achieved <50% (6.2 ± 1.6 METs; n = 8440) or ≥ 50% (10.5 ± 2.4 METs; n = 6264). To account for the impact of resting systolic BP (SBP) on outcomes, we calculated the difference (Peak SBP-Resting SBP) and termed it SBP-Reserve. We noted a significant increase in mortality associated with SBP-Reserve ≤52 mmHg and stratified the cohort accordingly (SBP-Reserve ≤52 mmHg and > 52 mmHg). We applied multivariable Cox models to estimate hazard ratios (HR) and 95% confidence interval (CIs) for outcomes.

RESULTS

Mortality risk was significantly elevated only in Unfit individuals with SBP-Reserve ≤52 mmHg compared to those with SBP-Reserve >52 mmHg (HR = 1.35; CI: 1.24-1.46; P < 0.001). We then assessed the CRF and SBP-Reserve interaction on mortality risk with Fit individuals with SBP-Reserve >52 mmHg serving as the referent. Mortality risk was 92% higher (HR = 1.92%; 95% CI: 1.77-2.09; P < 0.001) in Unfit individuals with SBP-Reserve ≤52 mmHg and 47% higher (HR = 1.47; 95% CI: 1.33-1.62; P < 0.001) in those with SBP-Reserve >52 mmHg.

CONCLUSION

Low CRF was associated with increased mortality risk regardless of peak exercise SBP. The risk was substantially higher in individuals unable to augment their exercise SBP >52 mmHg beyond resting levels.

The impact of moving more, physical activity, and cardiorespiratory fitness: Why we should strive to measure and improve fitness

A large and growing body of epidemiologic research spanning roughly 7 decades has demonstrated that individuals who are more physically active have a lower incidence of cardiovascular disease (CVD) and all-cause mortality compared to those who are comparatively sedentary. Despite these well-established benefits of physical activity (PA), most adults and children do not get an adequate amount of PA. This is true not just in the United States but has been increasingly recognized throughout advanced countries. The theme of this Progress in Cardiovascular Diseases Symposium is "moving more", recognizing that any amount of increased physical movement, including occupational, recreational, household tasks, etc., has significant health benefits. Being physically active is associated with better health outcomes independent of cardiorespiratory fitness (CRF), a concept that would have been considered heretical a few decades ago. We now recognize that simply moving from a sedentary to a moderately active group or modest increases in CRF (e.g. moving from the least fit quintile of CRF to the next least fit quintile) has the most noticeable health benefits. In this review, the concept of "moving more" and its implications for CRF are discussed as they relate to the prevention and treatment of CVD.

Pharmacological Management of Cardiac Disease in Patients with Type 2 Diabetes: Insights into Clinical Practice

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) has emerged as a growing pandemic. Cardiovascular disease (CVD) constitutes another major health problem, with coronary heart disease being the leading cause of cardiovascular death. Patients with T2DM require a multilevel therapeutic approach, both for primary and secondary prevention of CVD.

OBJECTIVE

To present and summarize the most recent, highest level evidence retrieved from literature, relevant to the pharmaceutical management of CVD in T2DM.

METHODS

We conducted a comprehensive search of the literature on MEDLINE from its inception till today, primarily for relevant systematic reviews, meta-analyses and randomized controlled trials.

RESULTS

There is a trend towards more intensified therapeutic interventions in T2DM, concerning glycemic, lipid and blood pressure control. New drugs, such as sodium-glucose co-transporter 2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and proprotein convertase subtilisin/ kexin type 9 (PCSK9) inhibitors might evolve as key players in the management of diabetes and its complications within the next years. Classic drugs, such as those targeting the renin-angiotensinaldosterone system, statins and aspirin remain first-line treatment options, both for primary and secondary prevention of CVD. Lifestyle interventions should always be integrated into a complete therapeutic strategy in diabetic patients. Novel drugs, such as finerenone and LCZ696 have provided significant results in cardiovascular outcome studies; however, their role in T2DM has to be further elucidated.

CONCLUSION

Pharmaceutical approach of CVD in T2DM is multilevel and complex. Drug classes featuring pleiotropic effects may boost our armamentarium in the fight against CVD.

Effects of Exercise Training and Statin Use in People Living with Human Immunodeficiency Virus with Dyslipidemia

PURPOSE

To evaluate the effects of the combination of exercise training (ET) and statins in people living with human immunodeficiency virus.

METHODS

This was a randomized, double-blind, placebo-controlled clinical trial. Eighty-three people living with human immunodeficiency virus were assigned to either placebo (PL), statins (STA), PL + ET (PLET) or STA + ET (STAET) groups. Volunteers assigned to STA and STAET groups were administered 10 mg of rosuvastatin, whereas the PL and PLET groups were administered a placebo. The PLET and STAET groups performed ET three times a week. Before and after the 12-wk follow-up, the volunteers underwent to anthropometric assessment and blood collection to evaluate lipid profile, cardiovascular markers, inflammatory profile; a Doppler ultrasound examination, muscle strength (MS) and cardiorespiratory fitness (CF) tests were performed.

RESULTS

There was a decrease in total cholesterol, triglycerides, low-density lipoprotein, C-reactive protein, fibrinogen, interleukin (IL)-1β and right carotid intima-media thickness in the STA, PLET, and STAET groups compared with PL group (P < 0.001). Furthermore, there was a decrease in total cholesterol, triglycerides, low-density lipoprotein, IL-1β, IL-6, and IL-8 levels and in left and right carotid intima-media thickness and an increase in HDL-c levels in the STAET groups compared with the STA (P ≤ 0.001) and PLET groups (P ≤ 0.001). There was an increase in IL-10 levels, peak-systolic velocity, end-diastolic velocity, wall shear rate in the PLET and STAET groups compared with the PL (P ≤ 0.001) and STA groups (P ≤ 0.001). The PLET and STAET groups reduced body fat mass, body fat percentage and increased lean body mass, MS and CF compared with PL (P ≤ 0.001) and STA (P ≤ 0.001) groups.

CONCLUSIONS

The combination of ET and statins is useful to enhance lipid and inflammatory profiles, reduce cardiovascular disease markers, and improve Doppler ultrasound findings, MS and CF in people living with HIV.

Cardiovascular Risk and Statin Therapy Considerations in Women

Despite major progress in the prevention and treatment of cardiovascular diseases, women remain an underdiagnosed and insufficiently treated group, with higher hospitalization and death rates compared to men. Obesity, more frequently encountered in women, raises the risk of metabolic syndrome and cardiovascular diseases as women age. There are some differences based on sex regarding the screening, diagnosis, and treatment of dyslipidemia, as it has been observed that women are less frequently prescribed statins and, when they are, they receive lower doses, even after myocardial infarction or coronary revascularization. Real-life data show that, compared to men, women are at higher risk of non-adherence to statin treatment and are more predisposed to discontinue treatment because of side effects. Statin metabolism has some particularities in women, due to a lower glomerular filtration rate, higher body fat percentage, and overall faster statin metabolism. In women of fertile age, before initiating statin treatment, contraception methods should be discussed because statins may have teratogenic effects. Older women have a higher likelihood of polypharmacy, with greater potential for drug interactions when prescribing a statin.

Exercise: The ultimate treatment to all ailments?

Extensive clinical research has provided robust evidence that exercise is a cost‐effective measure to substantially alleviate the burden of a large number of diseases, many of which belong to the cardiovascular (CV) spectrum. In terms of cardiac benefit, the positive effects of exercise are attributed to improvements in standard risk factors for atherosclerosis, as well as to its positive impact on several pathophysiological mechanisms for CV diseases. For secondary prevention, exercise, optimally in the context of a cardiac rehabilitation program, has been shown to improve functional capacity and survival. Clinicians should encourage physical activity and provide exercise recommendations for all patients, taking into consideration any underlying pathology. In the present review, the benefits of exercise for the prevention and treatment of major CV risk factors and heart conditions are analyzed.

Balancing cardiovascular benefit and diabetogenic harm of therapy with statins: Real-world evidence from Italy

AIM

To provide information on the balance between the cardiovascular (CV) benefit and the diabetogenic harm of statin therapy in the current clinical practice.

METHODS

All the 115,939 residents (older than 50 years) in the Italian Lombardy Region newly treated with statins between 2003 and 2005, were followed from the first statin prescription until 2012 to identify those experiencing a macrovascular complication and those with at least one sign suggestive of new onset diabetes. The proportion of days of follow-up covered by statin prescriptions measured adherence with statins. Hazard ratio, and relative 95% confidence interval (CI), for the two considered outcomes associated with statin adherence, were separately estimated (proportional hazard models). Number needed to treat (NNT) and number needed to harm (NNH), i.e., number of individuals who must be treated with statins in order to prevent a macrovascular complication, or to generate a new onset diabetes, respectively, were calculated to evaluate the balance between CV benefit and diabetogenic harm of statin therapy.

RESULTS

Compared to those at very low adherence with statins, patients at high adherence showed a significant reduction of macrovascular risk (28%, 95% CI: 23%-33%) and a greater risk of developing diabetic condition (67%, 50%-86%). In the whole cohort, the NNT was 26, whereas the NNH 65. NNT was lower than NNH also in all considered strata of age, gender, clinical profile.

CONCLUSIONS

This large cohort investigation provides real-world evidence that the balance between CV benefit and diabetogenic harm of statin therapy is largely favourable to treatment benefits.

Statin therapy in athletes and patients performing regular intense exercise - Position paper from the International Lipid Expert Panel (ILEP)

Acute and chronic physical exercises may enhance the development of statin-related myopathy. In this context, the recent (2019) guidelines of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) for the management of dyslipidemias recommend that, although individuals with dyslipidemia should be advised to engage in regular moderate physical exercise (for at least 30 min daily), physicians should be alerted with regard to myopathy and creatine kinase (CK) elevation in statin-treated sport athletes. However it is worth emphasizing that abovementioned guidelines, previous and recent ESC/EAS consensus papers on adverse effects of statin therapy as well as other previous attempts on this issue, including the ones from the International Lipid Expert Panel (ILEP), give only general recommendations on how to manage patients requiring statin therapy on regular exercises. Therefore, these guidelines in the form of the Position Paper are the first such an attempt to summary existing, often scarce knowledge, and to present this important issue in the form of step-by-step practical recommendations. It is critically important as we might observe more and more individuals on regular exercises/athletes requiring statin therapy due to their cardiovascular risk.

Exercise Training Adaptations in Metabolic Syndrome Individuals on Chronic Statin Treatment

BACKGROUND

Statins reduce atherogenic dyslipidemia and cardiovascular disease (CVD) risk in metabolic syndrome (MetS) individuals. Exercise training could also contribute to reduce CVD by improving cardiorespiratory fitness and fat oxidation. However, statin use could interfere with training adaptations.

METHODS

A total of 106 MetS individuals were divided into statin users (statin group, n = 46) and statin-naïve (control group, n = 60). Groups were matched by age, weight, and MetS components. Subjects completed 16 weeks of high intensity interval training (HIIT). Before and after HIIT, muscle biopsies were collected to assess mitochondrial content (citrate synthase [CS] activity) and the activity of the rate limiting β-oxidation enzyme (3-hydroxyacyl-CoA-dehydrogenase [HAD]). Fasting plasma glucose, insulin, TG, HDL-c, and LDL-c concentrations were measured. Exercise maximal fat oxidation (FOMAX) and oxygen uptake (VO2PEAK) were determined.

RESULTS

Training improved MetS similarly in both groups (MetS z-score -0.26 ± 0.38 vs. -0.22 ± 0.31; P < 0.001 for time and P = 0.60 for time x group). Before training, the statin group had reduced muscle HAD activity and whole body FOMAX compared to the control group. However, 16 weeks of HIIT increased HAD and FOMAX in both groups (P < 0.03, time-effect). The statin group did not prevent the increases in CS with HIIT observed in the control group (38% vs 64%, respectively; P < 0.001, time-effect). Conversely, with training VO2PEAK improved less in the statin than in the control group (12% vs. 19%, respectively; P = 0.013, time × group effect).

CONCLUSION

Chronic statin use in MetS does not interfere with exercise training improvements in MetS components, FOMAX, or mitochondrial muscle enzymes (ie, CS and HAD). However, the statin group attenuated the improvements in VO2PEAK with training.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier no. NCT03019796, January 13, 2017.