1
|
Keteyian SJ, Grimshaw C, Ehrman JK, Kerrigan DJ, Abdul-Nour K, Lanfear DE, Brawner CA. The iATTEND Trial: A Trial Comparing Hybrid Versus Standard Cardiac Rehabilitation. Am J Cardiol 2024; 221:94-101. [PMID: 38670326 DOI: 10.1016/j.amjcard.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/22/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
The improving ATTENDance (iATTEND) to cardiac rehabilitation (CR) trial tested the hypotheses that hybrid CR (HYCR) (combination of virtual and in-facility CR sessions) would result in greater attendance compared with traditional, facility-based only CR (FBCR) and yield equivalent improvements in exercise capacity and health status. Patients were randomized to HYCR (n = 142) or FBCR (n = 140), stratified by gender and race. Attendance was assessed as number of CR sessions completed within 6 months (primary end point) and the percentage of patients completing 36 CR sessions. Other end points (tested for equivalency) included exercise capacity and self-reported health status. HYCR patients completed 1 to 12 sessions in-facility, with the balance completed virtually using synchronized, 2-way audiovisual technology. Neither total number of CR sessions completed within 6 months (29 ± 12 vs 28 ± 12 visits, adjusted p = 0.94) nor percentage of patients completing 36 sessions (59 ± 4% vs 51 ± 4%, adjusted p = 0.32) were significantly different between HYCR and FBCR, respectively. The between-group changes for exercise capacity (peak oxygen uptake, 6-minute walk distance) and health status were equivalent. Regarding safety, no sessions required physician involvement, there was 1 major adverse event after a virtual session, and no falls required medical attention. In conclusion, although we rejected our primary hypothesis that attendance would be greater with HYCR versus FBCR, we showed that FBCR and HYCR resulted in similar patient attendance patterns and equivalent improvements in exercise capacity and health status. HYCR which incorporates virtually supervised exercise should be considered an acceptable alternative to FBCR. NCT Identifier: 03646760; The Improving ATTENDance to Cardiac Rehabilitation Trial - Full-Text View - ClinicalTrials. gov; https://classic.clinicaltrials.gov/ct2/show/NCT03646760.
Collapse
Affiliation(s)
- Steven J Keteyian
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan.
| | - Crystal Grimshaw
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan
| | - Dennis J Kerrigan
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan
| | - Khaled Abdul-Nour
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan
| | - David E Lanfear
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health Detroit, Michigan
| |
Collapse
|
2
|
Elshawi R, Sakr S, Al-Mallah MH, Keteyian SJ, Brawner CA, Ehrman JK. FIT calculator: a multi-risk prediction framework for medical outcomes using cardiorespiratory fitness data. Sci Rep 2024; 14:8745. [PMID: 38627439 PMCID: PMC11021455 DOI: 10.1038/s41598-024-59401-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
Accurately predicting patients' risk for specific medical outcomes is paramount for effective healthcare management and personalized medicine. While a substantial body of literature addresses the prediction of diverse medical conditions, existing models predominantly focus on singular outcomes, limiting their scope to one disease at a time. However, clinical reality often entails patients concurrently facing multiple health risks across various medical domains. In response to this gap, our study proposes a novel multi-risk framework adept at simultaneous risk prediction for multiple clinical outcomes, including diabetes, mortality, and hypertension. Leveraging a concise set of features extracted from patients' cardiorespiratory fitness data, our framework minimizes computational complexity while maximizing predictive accuracy. Moreover, we integrate a state-of-the-art instance-based interpretability technique into our framework, providing users with comprehensive explanations for each prediction. These explanations afford medical practitioners invaluable insights into the primary health factors influencing individual predictions, fostering greater trust and utility in the underlying prediction models. Our approach thus stands to significantly enhance healthcare decision-making processes, facilitating more targeted interventions and improving patient outcomes in clinical practice. Our prediction framework utilizes an automated machine learning framework, Auto-Weka, to optimize machine learning models and hyper-parameter configurations for the simultaneous prediction of three medical outcomes: diabetes, mortality, and hypertension. Additionally, we employ a local interpretability technique to elucidate predictions generated by our framework. These explanations manifest visually, highlighting key attributes contributing to each instance's prediction for enhanced interpretability. Using automated machine learning techniques, the models simultaneously predict hypertension, mortality, and diabetes risks, utilizing only nine patient features. They achieved an average AUC of 0.90 ± 0.001 on the hypertension dataset, 0.90 ± 0.002 on the mortality dataset, and 0.89 ± 0.001 on the diabetes dataset through tenfold cross-validation. Additionally, the models demonstrated strong performance with an average AUC of 0.89 ± 0.001 on the hypertension dataset, 0.90 ± 0.001 on the mortality dataset, and 0.89 ± 0.001 on the diabetes dataset using bootstrap evaluation with 1000 resamples.
Collapse
Affiliation(s)
- Radwa Elshawi
- Institute of Computer Science, University of Tartu, Tartu, Estonia.
| | - Sherif Sakr
- Institute of Computer Science, University of Tartu, Tartu, Estonia
| | | | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, 6525 Second Ave., Detroit, MI, 48202, USA
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, 6525 Second Ave., Detroit, MI, 48202, USA
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, 6525 Second Ave., Detroit, MI, 48202, USA
| |
Collapse
|
3
|
Brawner CA, Lazar MH. Cardiopulmonary exercise testing criteria for advanced therapies in patients with heart failure. Heart Fail Rev 2023; 28:1297-1306. [PMID: 37644366 DOI: 10.1007/s10741-023-10337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Many cardiology associations endorse the role of the cardiopulmonary exercise test (CPET) to define the severity of impairment of functional capacity in individuals with heart failure with reduced ejection fraction (HFrEF) and when evaluating the need for advanced therapies for these patients. The focus of the CPET within the cardiology community has been on peak volume of oxygen uptake (VO2). However, several CPET variables are associated with outcomes in individuals with and without chronic disease and can inform clinical decisions in individuals with HFrEF. In this manuscript, we will review the normal cardiopulmonary response to a graded exercise test and review current guideline recommendations relative to CPET in patients with HFrEF.
Collapse
Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, 6525 Second Ave., Detroit, MI, 48202, USA.
| | - Michael H Lazar
- Division of Pulmonary & Critical Care Medicine, Henry Ford Hospital, 2799 West Grand Blvd Suite K17, Detroit, MI, 48202, USA
| |
Collapse
|
4
|
Keteyian SJ, Steenson K, Grimshaw C, Mandel N, Koester-Qualters W, Berry R, Kerrigan DJ, Ehrman JK, Peterson EL, Brawner CA. Among Patients Taking Beta-Adrenergic Blockade Therapy, Use Measured (Not Predicted) Maximal Heart Rate to Calculate a Target Heart Rate for Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2023; 43:427-432. [PMID: 37311037 PMCID: PMC10615658 DOI: 10.1097/hcr.0000000000000806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Among patients in cardiac rehabilitation (CR) on beta-adrenergic blockade (βB) therapy, this study describes the frequency for which target heart rate (THR) values computed using a predicted maximal heart rate (HR max ), correspond to a THR computed using a measured HR max in the guideline-based heart rate reserve (HR reserve ) method. METHODS Before CR, patients completed a cardiopulmonary exercise test to measure HR max , with the data used to determine THR via the HR reserve method. Additionally, predicted HR max was computed for all patients using the 220 - age equation and two disease-specific equations, with the predicted values used to calculate THR via the straight percent and HR reserve methods. The THR was also computed using resting heart rate (HR) +20 and +30 bpm. RESULTS Mean predicted HR max using the 220 - age equation (161 ± 11 bpm) and the disease-specific equations (123 ± 9 bpm) differed ( P < .001) from measured HR max (133 ± 21 bpm). Also, THR computed using predicted HR max resulted in values that were infrequently within the guideline-based HR reserve range calculated using measured HR max . Specifically, 0 to ≤61% of patients would have had an exercise training HR that fell within the guideline-based range of 50-80% of measured HR reserve . Use of standing resting HR +20 or +30 bpm would have resulted in 100% and 48%, respectively, of patients exercising below 50% of HR reserve . CONCLUSIONS A THR computed using either predicted HR max or resting HR +20 or +30 bpm seldom results in a prescribed exercise intensity that is consistent with guideline recommendations for patients in CR.
Collapse
Affiliation(s)
| | | | - Crystal Grimshaw
- Division of Cardiovascular Medicine, Henry Ford Health, Detroit, MI
| | - Noah Mandel
- Division of Cardiovascular Medicine, Henry Ford Health, Detroit, MI
| | | | - Robert Berry
- Division of Cardiovascular Medicine, Henry Ford Health, Detroit, MI
| | | | | | | | | |
Collapse
|
5
|
Ehrman JK, Keteyian SJ, Johansen MC, Blaha MJ, Al-Mallah MH, Brawner CA. Improved cardiorespiratory fitness is associated with lower incident ischemic stroke risk: Henry Ford FIT project. J Stroke Cerebrovasc Dis 2023; 32:107240. [PMID: 37393688 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Change in cardiorespiratory fitness (CRF) modulates vascular disease risk; however, it's unclear if this adds further prognostic information, particularly for ischemic stroke. The objective of this analysis is to describe the association between the change in CRF over time and subsequent incident ischemic stroke. METHODS This is a retrospective, longitudinal, observational cohort study of 9,646 patients (age=55±11 years; 41% women; 25% black) who completed 2 clinically indicated exercise tests (> 12 months apart) and were free of any stroke at the time of test 2. CRF was expressed as metabolic-equivalents-of-task (METs). Incident ischemic stroke was identified using ICD codes. The adjusted hazard ratio (aHR) was determined for risk of ischemic stroke associated with change in CRF. RESULTS Mean time between tests was 3.7 years (IQR, 2.2, 6.0). During a median of 5.0 years (IQR, 2.7, 7.6 y) of follow-up, there were 873 (9.1%) ischemic stroke events. Each 1 MET increase between tests was associated with a 9% lower ischemic stroke risk (aHR 0.91 [0.88-0.94]; n = 9.646). There was an interaction effect by baseline CRF category, but not for sex or race. A sensitivity analysis which removed those who experienced an incident diagnosis known to be associated with an increased risk of ischemic vascular disease, validated our primary findings (aHR 0.91 [0.88, 0.95]; n= 6,943). CONCLUSIONS Improvement in CRF over time is independently and inversely associated with a lower risk of ischemic stroke. Encouragement of regular exercise focused on improving CRF may reduce ischemic stroke risk.
Collapse
Affiliation(s)
- Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA.
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Michelle C Johansen
- Cerebrovascular Division, Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Lutherville, MD, USA
| | | | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| |
Collapse
|
6
|
Kerrigan DJ, Reddy M, Walker EM, Cook B, McCord J, Loutfi R, Saval MA, Baxter J, Brawner CA, Keteyian SJ. Cardiac Rehabilitation Improves Fitness in Patients With Subclinical Markers of Cardiotoxicity While Receiving Chemotherapy: A RANDOMIZED CONTROLLED STUDY. J Cardiopulm Rehabil Prev 2023; 43:129-134. [PMID: 35940850 DOI: 10.1097/hcr.0000000000000719] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Heart failure (HF) due to cardiotoxicity is a leading non-cancer-related cause of morbidity and mortality in cancer survivors. Cardiac rehabilitation (CR) improves cardiorespiratory fitness (CRF) and reduces morbidity and mortality in patients with HF, but little is known about its effects on cardiotoxicity in the cancer population. The objective of this study was to determine whether participation in CR improves CRF in patients undergoing treatment with either doxorubicin or trastuzumab who exhibit markers of subclinical cardiotoxicity. METHODS Female patients with cancer (n = 28: breast, n = 1: leiomyosarcoma) and evidence of subclinical cardiotoxicity (ie, >10% relative decrease in global longitudinal strain or a cardiac troponin of >40 ng·L -1 ) were randomized to 10 wk of CR or usual care. Exercise consisted of 3 d/wk of interval training at 60-90% of heart rate reserve. RESULTS Cardiorespiratory fitness, as measured by peak oxygen uptake (V˙ o2peak ), improved in the CR group (16.9 + 5.0 to 18.5 + 6.0 mL∙kg -1 ∙min -1 ) while it decreased in the usual care group (17.9 + 3.9 to 16.9 + 4.0 mL∙kg -1 ∙min -1 ) ( P = .009). No changes were observed between groups with respect to high-sensitivity troponin or global longitudinal strain. CONCLUSION This study suggests that the use of CR may be a viable option to attenuate the reduction in CRF that occurs in patients undergoing cardiotoxic chemotherapy. The long-term effects of exercise on chemotherapy-induced HF warrant further investigation.
Collapse
Affiliation(s)
- Dennis J Kerrigan
- Division of Cardiovascular Medicine (Drs Kerrigan, Reddy, McCord, Brawner, and Keteyian, Mr Saval, and Ms Baxter) and Department of Pathology (Dr Cook), Henry Ford Hospital, Detroit, Michigan; and Departments of Radiation Oncology (Dr Walker) and Medical Oncology (Dr Loutfi), Henry Ford Cancer Institute at Henry Ford Health System, Detroit, Michigan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Overstreet B, Ward-Ritacco C, Neric F, Brawner CA, Thompson B, Hargens T, Thompson W. Technical Requirements for Clinical Exercise Physiologists as Qualified Health Professionals. ACSM's Health and Fitness Journal 2023. [DOI: 10.1249/fit.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
|
8
|
Shea MG, Headley S, Mullin EM, Brawner CA, Schilling P, Pack QR. Comparison of Ratings of Perceived Exertion and Target Heart Rate-Based Exercise Prescription in Cardiac Rehabilitation: A RANDOMIZED CONTROLLED PILOT STUDY. J Cardiopulm Rehabil Prev 2022; 42:352-358. [PMID: 35383680 PMCID: PMC10037230 DOI: 10.1097/hcr.0000000000000682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Although ratings of perceived exertion (RPE) are widely used to guide exercise intensity in cardiac rehabilitation (CR), it is unclear whether target heart rate ranges (THRRs) can be implemented in CR programs that predominantly use RPE and what impact this has on changes in exercise capacity. METHODS We conducted a three-group pilot randomized control trial (#NCT03925493) comparing RPE of 3-4 on the 10-point modified Borg scale, 60-80% of heart rate reserve (HRR) with heart rate (HR) monitored by telemetry, or 60-80% of HRR with a personal HR monitor (HRM) for high-fidelity adherence to THRR. Primary outcomes were protocol fidelity and feasibility. Secondary outcomes included exercise HR, RPE, and changes in functional exercise capacity. RESULTS Of 48 participants randomized, four patients dropped out, 20 stopped prematurely (COVID-19 pandemic), and 24 completed the protocol. Adherence to THRR was high regardless of HRM, and patients attended a median (IQR) of 33 (23, 36) sessions with no difference between groups. After randomization, HR increased by 1 ± 6, 6 ± 5, and 10 ± 9 bpm ( P = .02); RPE (average score 3.0 ± 0.05) was unchanged, and functional exercise capacity increased by 1.0 ± 1.0, 1.9 ± 1.5, 2.0 ± 1.3 workload METs (effect size between groups, ηp2 = 0.11, P = .20) for the RPE, THRR, and THRR + HRM groups, respectively. CONCLUSIONS We successfully implemented THRR in an all-RPE CR program without needing an HRM. Patients randomized to THRR had higher exercise HR but similar RPE ratings. The THRR may be preferable to RPE in CR populations for cardiorespiratory fitness gains, but this needs confirmation in an adequately powered trial.
Collapse
Affiliation(s)
- Meredith G Shea
- Division of Cardiovascular Medicine
- Springfield College Department of Exercise Science and Athletic Training, Springfield MA
- Mayo Clinic Arizona, Scottsdale AZ
| | - Samuel Headley
- Institute for Healthcare Delivery and Population Science
- Springfield College Department of Exercise Science and Athletic Training, Springfield MA
| | - Elizabeth M. Mullin
- Springfield College Department of Exercise Science and Athletic Training, Springfield MA
| | | | | | - Quinn R. Pack
- Division of Cardiovascular Medicine
- Institute for Healthcare Delivery and Population Science
- Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
| |
Collapse
|
9
|
Pack QR, Shea M, Brawner CA, Headley S, Hutchinson J, Madera H, Keteyian SJ. Exercise Prescription Methods and Attitudes in Cardiac Rehabilitation: A NATIONAL SURVEY. J Cardiopulm Rehabil Prev 2022; 42:359-365. [PMID: 35185145 PMCID: PMC9385888 DOI: 10.1097/hcr.0000000000000680] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE High-quality exercise training improves outcomes in cardiac rehabilitation (CR), but little is known about how most programs prescribe exercise. Thus, the aim was to describe how current CR programs prescribe exercise. METHODS We conducted a 33-item anonymous survey of CR program directors registered with the American Association of Cardiovascular and Pulmonary Rehabilitation. We assessed the time, mode, and intensity of exercise prescribed, as well as attitudes about maximal exercise testing and exercise prescription. Results were summarized using descriptive statistics. Open-ended responses were coded and quantitated thematically. RESULTS Of 1470 program directors, 246 (16.7%) completed the survey. In a typical session of CR, a median of 5, 35, 10, and 5 min was spent on warm-up, aerobic exercise, resistance training, and cooldown, respectively. The primary aerobic modality was the treadmill (55%) or seated dual-action step machine (40%). Maximal exercise testing and high-intensity interval training (HIIT) were infrequently reported (17 and 8% of patients, respectively). The most common method to prescribe exercise intensity was ratings of perceived exertion followed by resting heart rate +20-30 bpm, although 55 unique formulas for establishing a target heart rate or range (THRR) were reported. Moreover, variation in exercise prescription between staff members in the same program was reported in 40% of programs. Program directors reported both strongly favorable and unfavorable opinions toward maximal exercise testing, HIIT, and use of THRR. CONCLUSIONS Cardiac rehabilitation program directors reported generally consistent exercise time and modes, but widely divergent methods and opinions toward prescribing exercise intensity. Our results suggest a need to better study and standardize exercise intensity in CR.
Collapse
Affiliation(s)
- Quinn R. Pack
- Division of Cardiovascular Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA
- Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
| | - Meredith Shea
- Division of Cardiovascular Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
- Springfield College Department of Exercise Science and Athletic Training Springfield MA
- Mayo Clinic Arizona, Scottsdale AZ
| | | | - Samuel Headley
- Springfield College Department of Exercise Science and Athletic Training Springfield MA
| | - Jasmin Hutchinson
- Springfield College Department of Exercise Science and Athletic Training Springfield MA
| | - Hayden Madera
- Center for Cardiac Fitness, The Miriam Hospital, Providence, RI
| | | |
Collapse
|
10
|
Brawner CA, Pack Q, Berry R, Kerrigan DJ, Ehrman JK, Keteyian SJ. Relation of a Maximal Exercise Test to Change in Exercise Tolerance During Cardiac Rehabilitation. Am J Cardiol 2022; 175:139-144. [PMID: 35570164 DOI: 10.1016/j.amjcard.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to test the hypothesis that an individualized exercise training target heart rate (HR) based on a maximal graded exercise test (GXT) is associated with greater improvements in exercise tolerance during cardiac rehabilitation (CR) compared with no GXT. In this retrospective study, we identified patients who completed 9 to 36 visits of CR between 2001 and 2016, with a length of stay ≤18 weeks and a visit frequency of 1 to 3 days per week. Patients were grouped based on whether their exercise was guided by a target HR determined from a GXT. To assess the relation between GXT and change in exercise training metabolic equivalents of task (METs), we used generalized linear models adjusted for age, gender, race, referral reason, CR visits, CR frequency, METs at start, CR location, and year of participation. Out of 4,455 patients (37% female, 48% White, median age = 62 years), 53% were prescribed a target HR based on a GXT. Compared with no GXT, a GXT was associated with a significantly greater increase in covariate-adjusted METs during CR and percentage change from start (+0.44 METs [95% confidence interval [CI] 0.38 to 0.51] and +17% [95% CI 14% to 19%], respectively). In a sensitivity analysis limited to patients with 24 to 36 visits at ≥2 days per week (n = 1,319), a GXT was associated with a significantly greater increase in covariate-adjusted exercise training METs (+0.51 [95% CI 0.36 to 0.66]; +19% [95% CI 13% to 24%]). In conclusion, to maximize the potential increase in exercise capacity during CR, patients should undergo a GXT to determine an individualized exercise training target HR.
Collapse
Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan.
| | - Quinn Pack
- Division of Cardiovascular Medicine, Baystate Medical, Springfield, Massachusetts
| | - Robert Berry
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Dennis J Kerrigan
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
11
|
Keteyian SJ, Jackson SL, Chang A, Brawner CA, Wall HK, Forman DE, Sukul D, Ritchey MD, Sperling LS. Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE. J Cardiopulm Rehabil Prev 2022; 42:235-245. [PMID: 35135961 PMCID: PMC10865223 DOI: 10.1097/hcr.0000000000000675] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence. METHODS We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type. RESULTS In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States. CONCLUSIONS The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.
Collapse
Affiliation(s)
- Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | | | - Anping Chang
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Clinton A. Brawner
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | | | - Daniel E. Forman
- Divisions of Geriatrics and Cardiology, University of Pittsburgh and the VA Pittsburgh GRECC, Pittsburgh, PA
| | - Devraj Sukul
- Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, MI
| | | | - Laurence S. Sperling
- Centers for Disease Control and Prevention, Atlanta, GA
- Emory University School of Medicine, Center for Heart Disease Prevention, Atlanta, GA
| |
Collapse
|
12
|
Chu DJ, Ahmed AM, Qureshi WT, Brawner CA, Keteyian SJ, Nasir K, Blumenthal RS, Blaha MJ, Ehrman JK, Cainzos-Achirica M, Patel KV, Al Rifai M, Al-Mallah MH. Prognostic Value of Cardiorespiratory Fitness in Patients with Chronic Kidney Disease: The FIT (Henry Ford Exercise Testing) Project. Am J Med 2022; 135:67-75.e1. [PMID: 34509447 DOI: 10.1016/j.amjmed.2021.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/01/2021] [Accepted: 07/31/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE We conducted this study to investigate the association of cardiorespiratory fitness and all-cause mortality among patients with chronic kidney disease. METHODS We studied a retrospective cohort of patients from the Henry Ford Health System who underwent clinically indicated exercise stress testing with baseline cardiorespiratory fitness and estimated glomerular filtration rate measurement. Cardiorespiratory fitness was expressed as metabolic equivalents of task, and kidney function was categorized into stages according to estimated glomerular filtration rate. Multivariable-adjusted Cox proportional hazard models were used to examine the association between metabolic equivalents of task and all-cause mortality among patients with chronic kidney disease stages 3-5. Discrimination of mortality was assessed using receiver operating characteristic curves, while reclassification was evaluated using net reclassification index (NRI). RESULTS Among 50,121 participants, the mean age was 55 ± 12.6 years; 47.5% were women, 64.5% were white, and 6877 (13.7%) participants had chronic kidney disease stage 3-5. Over a median follow-up of 6.7 years, 6308 participants died (12.6%). Each 1-unit higher metabolic equivalents of task was associated with a significant 15% reduction in all-cause mortality (hazard ratio 0.85; 95% confidence interval [CI], 0.84-0.87). Metabolic equivalents of task improved discriminatory ability of mortality prediction when added to traditional risk factors and estimated glomerular filtration rate (area under the curve 0.7996; 95% CI, 0.789-0.810 vs 0.759; 95% CI, 0.748-0.770, respectively; P < .001). The addition of metabolic equivalents of task to traditional risk factors resulted in significant reclassification (6% for events, 5% for non-events: NRI = 0.13, P < .001). CONCLUSIONS Cardiorespiratory fitness improves mortality risk prediction among patients with chronic kidney disease. Cardiorespiratory fitness provides incremental prognostic information when added to traditional risk factors and may help guide treatment options among patients with renal dysfunction.
Collapse
Affiliation(s)
- Daniel J Chu
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Amjad M Ahmed
- King Abdulaziz Cardiac Center, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Waqas T Qureshi
- Department of Cardiology, University of Massachusetts, Worcester
| | | | | | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md; Department of Cardiology, Houston Methodist Hospital, Houston, Texas
| | | | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md
| | | | | | - Kershaw V Patel
- Department of Cardiology, Houston Methodist Hospital, Houston, Texas
| | - Mahmoud Al Rifai
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mouaz H Al-Mallah
- Department of Cardiology, Houston Methodist Hospital, Houston, Texas.
| |
Collapse
|
13
|
Overstreet B, Kirkman D, Qualters WK, Kerrigan D, Haykowsky MJ, Tweet MS, Christle JW, Brawner CA, Ehrman JK, Keteyian SJ. Rethinking Rehabilitation: A REVIEW OF PATIENT POPULATIONS WHO CAN BENEFIT FROM CARDIAC REHABILITATION. J Cardiopulm Rehabil Prev 2021; 41:389-399. [PMID: 34727558 DOI: 10.1097/hcr.0000000000000654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although cardiac rehabilitation (CR) is safe and highly effective for individuals with various cardiovascular health conditions, to date there are only seven diagnoses or procedures identified by the Centers for Medicare & Medicaid Services that qualify for referral. When considering the growing number of individuals with cardiovascular disease (CVD), or other health conditions that increase the risk for CVD, it is important to determine the extent for which CR could benefit these populations. Furthermore, there are some patients who may currently be eligible for CR (spontaneous coronary artery dissection, left ventricular assistant device) but make up a relatively small proportion of the populations that are regularly attending and participating. Thus, these patient populations and special considerations for exercise might be less familiar to professionals who are supervising their programs. The purpose of this review is to summarize the current literature surrounding exercise testing and programming among four specific patient populations that either do not currently qualify for (chronic and end-stage renal disease, breast cancer survivor) or who are eligible but less commonly seen in CR (sudden coronary artery dissection, left ventricular assist device). While current evidence suggests that individuals with these health conditions can safely participate in and may benefit from supervised exercise programming, there is an immediate need for high-quality, multisite clinical trials to develop more specific exercise recommendations and support the inclusion of these populations in future CR programs.
Collapse
Affiliation(s)
- Brittany Overstreet
- Kinesiology and Applied Physiology Department, University of Delaware, Newark (Dr Overstreet); Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond (Dr Kirkman); Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan (Ms Qualters and Drs Kerrigan, Brawner, Ehrman, and Keteyian); Faculty of Nursing, University of Alberta, Edmonton, Canada (Dr Haykowsky); Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota (Dr Tweet); and Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California (Dr Christle)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Whelton SP, McAuley PA, Dardari Z, Orimoloye OA, Michos ED, Brawner CA, Ehrman JK, Keteyian SJ, Blaha MJ, Al-Mallah MH. Fitness and Mortality Among Persons 70 Years and Older Across the Spectrum of Cardiovascular Disease Risk Factor Burden: The FIT Project. Mayo Clin Proc 2021; 96:2376-2385. [PMID: 34366139 DOI: 10.1016/j.mayocp.2020.12.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/16/2020] [Accepted: 12/22/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To determine whether fitness could improve mortality risk stratification among older adults compared with cardiovascular disease (CVD) risk factors. METHODS We examined 6509 patients 70 years of age and older without CVD from the Henry Ford ExercIse Testing Project (FIT Project) cohort. Patients performed a physician-referred treadmill stress test between 1991 and 2009. Traditional categorical CVD risk factors (hypertension, hyperlipidemia, diabetes, and smoking) were summed from 0 to 3 or more. Fitness was grouped as low, moderate, and high (<6, 6 to 9.9, and ≥10 metabolic equivalents of task). All-cause mortality was ascertained through US Social Security Death Master files. We calculated age-adjusted mortality rates, multivariable adjusted Cox proportional hazards, and Kaplan-Meier survival models. RESULTS Patients had a mean age of 75±4 years, and 3385 (52%) were women; during a mean follow-up of 9.4 years, there were 2526 deaths. A higher fitness level (P<.001), not lower CVD risk factor burden (P=.31), was associated with longer survival. The age-adjusted mortality rate per 1000 person-years was 56.7 for patients with low fitness and 0 risk factors compared with 24.9 for high fitness and 3 or more risk factors. Among patients with 3 or more risk factors, the adjusted mortality hazard was 0.68 (95% CI, 0.61 to 0.76) for moderate and 0.51 (95% CI, 0.44 to 0.60) for high fitness compared with the least fit. CONCLUSION Among persons aged 70 years and older, there was no significant difference in survival of patients with 0 vs 3 or more risk factors, but a higher fitness level identified older persons with good long-term survival regardless of CVD risk factor burden.
Collapse
Affiliation(s)
- Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Paul A McAuley
- Department of Health, Physical Education, and Sport Studies, Winston-Salem State University, Winston-Salem, NC
| | - Zeina Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Olusola A Orimoloye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Erin D Michos
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | | |
Collapse
|
15
|
Thompson PD, Baggish AL, Blaha MJ, Brawner CA, Eickhoff-Shemek JM, Hunt TN, Kraus WE. Increasing the Availability of Automated External Defibrillators at Sporting Events: A Call to Action from the American College of Sports Medicine. Curr Sports Med Rep 2021; 20:418-419. [PMID: 34357888 DOI: 10.1249/jsr.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Given that most sudden cardiac arrests (SCAs) occur outside of a medical facility, often in association with exercise and sporting events, and given that early cardiopulmonary resuscitation (CPR) plus defibrillation is the strongest predictor of survival from SCA, this Call to Action from the American College of Sports Medicine recommends increasing the availability and effectiveness of early CPR plus defibrillation so that the time from collapse-to-first automated external defibrillator shock is less than 3 min.
Collapse
Affiliation(s)
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Tamerah N Hunt
- Department of Health Sciences and Kinesiology, Georgia Southern University, Statesboro, GA
| | | |
Collapse
|
16
|
Kerrigan DJ, Brawner CA, Ehrman JK, Keteyian S. Cardiorespiratory Fitness Attenuates the Impact of Risk Factors Associated With COVID-19 Hospitalization. Mayo Clin Proc 2021; 96:822-823. [PMID: 33673935 PMCID: PMC7817471 DOI: 10.1016/j.mayocp.2021.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | - Steven Keteyian
- Preventive Cardiology Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
17
|
Reiter-Brennan C, Dzaye O, Al-Mallah MH, Dardari Z, Brawner CA, Lamerato LE, Keteyian SJ, Ehrman JK, Blaha MJ, Visvanathan K, Marshall CH. Fitness and prostate cancer screening, incidence, and mortality: Results from the Henry Ford Exercise Testing (FIT) Project. Cancer 2021; 127:1864-1870. [PMID: 33561293 DOI: 10.1002/cncr.33426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The relation between cardiorespiratory fitness (CRF) and prostate cancer is not well established. The objective of this study was to determine whether CRF is associated with prostate cancer screening, incidence, or mortality. METHODS The Henry Ford Exercise Testing Project is a retrospective cohort study of men aged 40 to 70 years without cancer who underwent physician-referred exercise stress testing from 1995 to 2009. CRF was quantified in metabolic equivalents of task (METs) (<6 [reference], 6-9, 10-11, and ≥12 METs), estimated from the peak workload achieved during a symptom-limited, maximal exercise stress test. Prostate-specific antigen (PSA) testing, incident prostate cancer, and all-cause mortality were analyzed with multivariable adjusted Poisson regression and Cox proportional hazard models. RESULTS In total, 22,827 men were included, of whom 739 developed prostate cancer, with a median follow-up of 7.5 years. Men who had high fitness (≥12 METs) had an 28% higher risk of PSA screening (95% CI, 1.2-1.3) compared with those who had low fitness (<6 METs. After adjusting for PSA screening, fitness was associated with higher prostate cancer incidence (men aged <55 years, P = .02; men aged >55 years, P ≤ .01), but not with advanced prostate cancer. Among the men who were diagnosed with prostate cancer, high fitness was associated with a 60% lower risk of all-cause mortality (95% CI, 0.2-0.9). CONCLUSIONS Although men with high fitness are more likely to undergo PSA screening, this does not fully account for the increased incidence of prostate cancer seen among these individuals. However, men with high fitness have a lower risk of death after a prostate cancer diagnosis, suggesting that the cancers identified may be low-risk with little impact on long-term outcomes.
Collapse
Affiliation(s)
- Cara Reiter-Brennan
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Radiology and Neuroradiology, Charite, Berlin, Germany
| | - Omar Dzaye
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Radiology and Neuroradiology, Charite, Berlin, Germany.,Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan
| | | | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kala Visvanathan
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Catherine H Marshall
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
18
|
Brawner CA, Ehrman JK, Bole S, Kerrigan DJ, Parikh SS, Lewis BK, Gindi RM, Keteyian C, Abdul-Nour K, Keteyian SJ. Inverse Relationship of Maximal Exercise Capacity to Hospitalization Secondary to Coronavirus Disease 2019. Mayo Clin Proc 2021; 96:32-39. [PMID: 33413833 PMCID: PMC7547590 DOI: 10.1016/j.mayocp.2020.10.003] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To investigate the relationship between maximal exercise capacity measured before severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalization due to coronavirus disease 2019 (COVID-19). METHODS We identified patients (≥18 years) who completed a clinically indicated exercise stress test between January 1, 2016, and February 29, 2020, and had a test for SARS-CoV-2 (ie, real-time reverse transcriptase polymerase chain reaction test) between February 29, 2020, and May 30, 2020. Maximal exercise capacity was quantified in metabolic equivalents of task (METs). Logistic regression was used to evaluate the likelihood that hospitalization secondary to COVID-19 is related to peak METs, with adjustment for 13 covariates previously identified as associated with higher risk for severe illness from COVID-19. RESULTS We identified 246 patients (age, 59±12 years; 42% male; 75% black race) who had an exercise test and tested positive for SARS-CoV-2. Among these, 89 (36%) were hospitalized. Peak METs were significantly lower (P<.001) among patients who were hospitalized (6.7±2.8) compared with those not hospitalized (8.0±2.4). Peak METs were inversely associated with the likelihood of hospitalization in unadjusted (odds ratio, 0.83; 95% CI, 0.74-0.92) and adjusted models (odds ratio, 0.87; 95% CI, 0.76-0.99). CONCLUSION Maximal exercise capacity is independently and inversely associated with the likelihood of hospitalization due to COVID-19. These data further support the important relationship between cardiorespiratory fitness and health outcomes. Future studies are needed to determine whether improving maximal exercise capacity is associated with lower risk of complications due to viral infections, such as COVID-19.
Collapse
Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI.
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Shane Bole
- Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Dennis J Kerrigan
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Sachin S Parikh
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Barry K Lewis
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Ryan M Gindi
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Khaled Abdul-Nour
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
19
|
Keteyian SJ, Grimshaw C, Brawner CA, Kerrigan DJ, Reasons L, Berry R, Peterson EL, Ehrman JK. A Comparison of Exercise Intensity in Hybrid Versus Standard Phase Two Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2021; 41:19-22. [PMID: 33351540 PMCID: PMC7768817 DOI: 10.1097/hcr.0000000000000569] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare exercise training intensity during standard cardiac rehabilitation (S-CR) versus hybrid-CR (combined clinic- and remote home-/community-based). METHODS The iATTEND (improving ATTENDance to cardiac rehabilitation) trial is currently enrolling subjects and randomizing patients to S-CR versus hybrid-CR. This substudy involves the first 47 subjects who completed ≥18 CR sessions. Patients in S-CR completed all visits in a typical phase II clinic-based setting and patients in hybrid-CR completed up to 17 of their sessions remotely using telehealth (TH). Exercise training intensity in both CR settings is based on heart rate (HR) data from each CR session, expressed as percent HR reserve. RESULTS Among patients in both study groups, there were no serious adverse events or falls that required hospitalization during or within 3 hr after completing a CR session. Expressed as a percentage of HR reserve, the overall mean exercise training intensities during both the S-CR sessions and the TH-CR sessions from hybrid-CR were not significantly different at 63 ± 12% and 65 ± 10%, respectively (P = .29). CONCLUSION This study showed that hybrid-CR delivered using remote TH results in exercise training intensities that are not significantly different from S-CR.
Collapse
Affiliation(s)
- Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | - Crystal Grimshaw
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | - Clinton A. Brawner
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | - Dennis J. Kerrigan
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | - Lisa Reasons
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | - Robert Berry
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | - Edward L. Peterson
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Jonathon K. Ehrman
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| |
Collapse
|
20
|
Reiter-Brennan C, Dzaye O, Al-Mallah MH, Dardari Z, Brawner CA, Lamerato LE, Keteyian SJ, Ehrman JK, Visvanathan K, Blaha MJ, Marshall CH. Abstract 4348: Cardiorespiratory fitness levels in men who develop prostate cancer and its association with all-cause mortality. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-4348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Cardiorespiratory fitness (CRF) is associated with a reduction in both cancer- and cardiovascular-specific mortality. In men however, little is known about the impact of pre-diagnostic CRF on mortality after prostate cancer. We hypothesized that among men with prostate cancer, low levels of CRF, measured prior to diagnosis, are associated with a higher risk of all-cause mortality.
Methods: From the Henry Ford FIT Project, a cohort of 37,730 men who underwent clinically-indicated exercise stress test from 1991 through 2009, we identified 1,440 men who developed prostate cancer after stress test. CRF was measured in peak metabolic equivalents of task (METs) and categorized as less than 6, 6 to 9, 10 to 11, and at least 12 (reference). Multivariable Cox proportional hazard models were developed to evaluate the association between CRF, measured prior to prostate cancer diagnosis, and all-cause mortality. Models were adjusted for age at prostate cancer diagnosis (baseline), race, BMI, current aspirin and statin use, smoking history, hypertension, diabetes, prior cardiovascular disease (myocardial infarction and heart failure), time from stress test to prostate cancer diagnosis, and cancer stage (local, regional, distant) at diagnosis.
Results: Mean age at time of stress test was 61 +/- 9 yr (57% white, 39% black), with 7 (+/-4) yrs of follow up after prostate cancer diagnosis. 81% of men were diagnosed with localized prostate cancer; 15% with regional disease, and 2% with distant metastatic disease. Mean time from stress test to diagnosis was 6 +/- 5 yrs. Mean METs achieved was 9 (+/- 3). Patients with low fitness (METs less than 6) before diagnosis had 2.6 times the risk of all-cause mortality (95% CI 1.6-4.2) compared to those with high fitness (METS at least 12). Those with CRF of 6-9 METs had 1.9 times the risk (95% CI 1.2-3.0). The risk of mortality was not different between the two highest fitness groups (P= 0.71; P for trend across all fitness groups less than 0.01). Results were similar when stratified by race.
Conclusion: Low CRF prior to the diagnosis of prostate cancer in men is associated with a higher risk of all-cause mortality. This study highlights the prognostic importance of fitness even before a cancer diagnosis.
Citation Format: Cara Reiter-Brennan, Omar Dzaye, Mouaz H. Al-Mallah, Zeina Dardari, Clinton A. Brawner, Lois E. Lamerato, Steven J. Keteyian, Jonathan K. Ehrman, Kala Visvanathan, Michael J. Blaha, Catherine Handy Marshall. Cardiorespiratory fitness levels in men who develop prostate cancer and its association with all-cause mortality [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4348.
Collapse
|
21
|
Reiter-Brennan C, Dzaye O, Al-Mallah MH, Dardari Z, Brawner CA, Lamerato LE, Keteyian SJ, Ehrman JK, Visvanathan K, Blaha MJ, Marshall CH. Abstract 5773: Cardiorespiratory fitness and PSA screening patterns in the Henry Ford FIT Project. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-5773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: High levels of cardiorespiratory fitness (CRF) have been associated with a decreased risk of many cancers, but the association with prostate cancer (PCa) is less clear. A possible explanation for the lack of consistency is that prostate specific antigen (PSA) screening and in turn prostate cancer detection is more frequent in men with higher fitness although the relationship between fitness and PSA screening is not established.
Methods: The Henry Ford (HF) FIT Project is a retrospective cohort study of 69,894 consecutive patients who underwent physician-referred exercise stress testing from 1991 through 2009. Cancer diagnosis was identified through linkage to the HF tumor registry. We included men aged 40-70 yr who had CRF testing beginning in 1995 (when PSA screening became widespread), without prevalent cancer, followed at least 3 yrs and up to 10 years, who never develop prostate cancer (n=12,442). CRF was measured in metabolic equivalents of task (METs) and categorized as less than 6 (ref), 6-9, 10-11, and at least 12. PSA values were abstracted from the HF electronic medical record between 1995 and 2010. Individuals with at least 3 screening PSA tests were categorized as high screeners. Logistic regression was used to evaluate the relationship between CRF and high PSA screeners, adjusted for age at stress test and race.
Results: Participants had a mean age of 54 ± 8 yrs (67% white; 25% black) and mean follow-up was 7±2 yrs. Compared to individuals with low fitness (less than 6 METs, reference), those with higher fitness (6-9, 10-11, at least 12 METs) had higher odds of being a high PSA screener (Table). When stratified by race, the OR for black patients were not statistically different than white patients (Table). Results were similar among those with comorbidities (myocardial infarction, heart failure, or diabetes) at baseline.
Odds ratio of being a high screener (at least 3 PSA tests) in individuals followed 3-10 yearsMETs categoryAll (n=12,442Whites (n=8,356Blacks (n=3,049)Patients w/comorbidities (n=3,924)<6RefRefRefRef6-91.6(1.3-1.8)1.6(1.3-2.0)1.4(1.1-1.9)1.6(1.3-2.0)10-111.9(1.6-2.2)1.9(1.6-2.4)1.7(1.3-2.2)2.0(1.7-2.4)>=122.4 (2.1-2.9)2.5(2.0-3.1)2.1(1.6-2.8)3.2(2.5-4.0)
Conclusion: High CRF is associated with more frequent PSA screening. This points towards a healthy screening bias and should be accounted for in studies looking at fitness and incident prostate cancer.
Citation Format: Cara Reiter-Brennan, Omar Dzaye, Mouaz H. Al-Mallah, Zeina Dardari, Clinton A. Brawner, Lois E. Lamerato, Steven J. Keteyian, Jonathan K. Ehrman, Kala Visvanathan, Michael J. Blaha, Catherine Handy Marshall. Cardiorespiratory fitness and PSA screening patterns in the Henry Ford FIT Project [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5773.
Collapse
|
22
|
Al Rifai M, Blaha MJ, Ahmed A, Almasoudi F, Johansen MC, Qureshi W, Sakr S, Virani SS, Brawner CA, Ehrman JK, Keteyian SJ, Al-Mallah MH. Cardiorespiratory Fitness and Incident Stroke Types: The FIT (Henry Ford ExercIse Testing) Project. Mayo Clin Proc 2020; 95:1379-1389. [PMID: 32622446 DOI: 10.1016/j.mayocp.2019.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To study the association between cardiorespiratory fitness (CRF) and incident stroke types. PATIENTS AND METHODS We studied a retrospective cohort of patients referred for treadmill stress testing in the Henry Ford Health System (Henry Ford ExercIse Testing Project) without history of stroke. CRF was expressed by metabolic equivalents of task (METs). Using appropriate International Classification of Diseases, Ninth Revision codes, incident stroke was ascertained through linkage with administrative claims files and classified as ischemic, hemorrhagic, and subarachnoid hemorrhage (SAH). Multivariable-adjusted Cox proportional hazards models examined the association between CRF and incident stroke. RESULTS Among 67,550 patients, mean ± SD age was 54±13 years, 46% (n=31,089) were women, and 64% (n=43,274) were white. After a median follow-up of 5.4 (interquartile range 2.7-8.5) years, a total of 7512 incident strokes occurred (6320 ischemic, 2481 hemorrhagic, and 275 SAH). Overall, there was a graded lower incidence of stroke with higher MET categories. Patients with METs of 12 or more had lower risk of overall stroke [0.42 (95% CI, 0.36-0.49)], ischemic stroke [0.69 (95% CI, 0.58-0.82)], and hemorrhagic stroke [0.71 (95% CI, 0.52-0.95)]. CONCLUSION In a large ethnically diverse cohort of patients referred for treadmill stress testing, CRF is inversely associated with risk for ischemic and hemorrhagic stroke.
Collapse
Affiliation(s)
- Mahmoud Al Rifai
- Section of Cardiology, Baylor College of Medicine, Houston, TX; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | - Amjad Ahmed
- King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia
| | | | | | - Waqas Qureshi
- Division of Cardiology, University of Massachusetts Medical School, Worcester, MA
| | - Sherif Sakr
- King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia
| | - Salim S Virani
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Mouaz H Al-Mallah
- Department of Cardiac Imaging, Houston Methodist DeBakey Heart & Vascular Center, TX.
| |
Collapse
|
23
|
Chu DJ, Al Rifai M, Virani SS, Brawner CA, Nasir K, Al-Mallah MH. The relationship between cardiorespiratory fitness, cardiovascular risk factors and atherosclerosis. Atherosclerosis 2020; 304:44-52. [DOI: 10.1016/j.atherosclerosis.2020.04.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023]
|
24
|
Marshall CH, McAuley PA, Tsai HL, Dardari Z, Al-Mallah MH, Brawner CA, Lamerato LE, Keteyian S, Ehrman J, Blaha MJ. The association of fitness and body mass index (BMI) on all-cause mortality in cancer survivors: The Henry Ford Exercise Testing Project (The FIT Project). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7060 Background: The obesity paradox –i.e. inverse associations between body mass index (BMI) and mortality – has been reported in patients with cancer, heart failure, and diabetes. However, the influence of cardiorespiratory fitness (CRF) on this relationship is not well established. This study assesses the association of BMI and CRF with all-cause mortality among cancer patients. Methods: The Henry Ford (HF) FIT Project is a retrospective cohort study of 69,885 consecutive patients who underwent physician-referred exercise stress testing from 1991 through 2009. Cancer diagnosis was identified through linkage to the HF tumor registry. We included patients 40-70 years old, with BMI recorded, at time of exercise test, with a history of cancer > 6 months prior. BMI was categorized as normal (18.5-24.9kg/m2), overweight (25-29.9kg/m2), or obese ( > = 30kg/m2). All-cause mortality was obtained from the National Death Index. Because of a significant interaction between BMI and cancer type, patients with breast or prostate cancer were excluded. Multivariable adjusted Cox proportional hazard models were used to evaluate the association of CRF andBMI with all-cause mortality; adjusted for age at exercise test, sex, diabetes, smoking, cancer stage, and time from cancer diagnosis to exercise test. Results: Included were 676 patients with a mean age of 58 years (SD 7.5), 51% female, 70% White, 25% Black, with a median of 4.8 years from diagnosis to exercise test and median follow up time of 10.3 years. Among patients achieving < 10 METs, those who are overweight and obese had a lower risk of mortality HR 0.47 (95% CI 0.25,0.86) and HR 0.44 (95% CI 0.26, 0.74, respectively), compared to those with normal BMI. Among patients with METs > = 10, those who were overweight had the lowest risk of all-cause mortality (HR 0.23, 95% CI 0.09-0.62) compared to normal weight, while no statistically significant different risk of mortality was observed when comparing those who are obese to normal weight (HR 0.37, 95% CI 0.13-1.06). In an analysis combining BMI and fitness groups (four categories), those with BMI > = 25 and METs > = 10 had the lowest risk of all-cause mortality (Table). Conclusions: In non-breast/non-prostate cancer patients, increased BMI is associated with improved overall survival in those with METs < 10, while a U-shaped relationship between BMI and all-cause mortality exists among those with METs > = 10. [Table: see text]
Collapse
Affiliation(s)
| | | | | | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | | | | | | | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
25
|
Bryson T, Debbs JC, She R, Gui H, Luzum JA, Zeld N, Brawner CA, Keteyian SJ, Ehrman JK, Williams LK, Lanfear DE. A SINGLE NUCLEOTIDE POLYMORPHISM WITHIN THE RXRA GENE PREDICTS A FAVORABLE RESPONSE TO EXERCISE IN HEART FAILURE. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31639-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
26
|
Whelton SP, McAuley PA, Dardari Z, Orimoloye OA, Brawner CA, Ehrman JK, Keteyian SJ, Al-Mallah M, Blaha MJ. Association of BMI, Fitness, and Mortality in Patients With Diabetes: Evaluating the Obesity Paradox in the Henry Ford Exercise Testing Project (FIT Project) Cohort. Diabetes Care 2020; 43:677-682. [PMID: 31949085 DOI: 10.2337/dc19-1673] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/21/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the effect of fitness on the association between BMI and mortality among patients with diabetes. RESEARCH DESIGN AND METHODS We identified 8,528 patients with diabetes (self-report, medication use, or electronic medical record diagnosis) from the Henry Ford Exercise Testing Project (FIT Project). Patients with a BMI <18.5 kg/m2 or cancer were excluded. Fitness was measured as the METs achieved during a physician-referred treadmill stress test and categorized as low (<6), moderate (6-9.9), or high (≥10). Adjusted hazard ratios for mortality were calculated using standard BMI (kilograms per meter squared) cutoffs of normal (18.5-24.9), overweight (25-29.9), and obese (≥30). Adjusted splines centered at 22.5 kg/m2 were used to examine BMI as a continuous variable. RESULTS Patients had a mean age of 58 ± 11 years (49% women) with 1,319 deaths over a mean follow-up of 10.0 ± 4.1 years. Overall, obese patients had a 30% lower mortality hazard (P < 0.001) compared with normal-weight patients. In adjusted spline modeling, higher BMI as a continuous variable was predominantly associated with a lower mortality risk in the lowest fitness group and among patients with moderate fitness and BMI ≥30 kg/m2. Compared with the lowest fitness group, patients with higher fitness had an ∼50% (6-9.9 METs) and 70% (≥10 METs) lower mortality hazard regardless of BMI (P < 0.001). CONCLUSIONS Among patients with diabetes, the obesity paradox was less pronounced for patients with the highest fitness level, and these patients also had the lowest risk of mortality.
Collapse
Affiliation(s)
- Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Paul A McAuley
- Department of Health, Physical Education and Sport Studies, Winston-Salem State University, Winston-Salem, NC
| | - Zeina Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Olusola A Orimoloye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Mouaz Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
27
|
Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan.
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
28
|
Ritchey MD, Maresh S, McNeely J, Shaffer T, Jackson SL, Keteyian SJ, Brawner CA, Whooley MA, Chang T, Stolp H, Schieb L, Wright J. Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative. Circ Cardiovasc Qual Outcomes 2020; 13:e005902. [PMID: 31931615 DOI: 10.1161/circoutcomes.119.005902] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. METHODS AND RESULTS We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. CONCLUSIONS Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.
Collapse
Affiliation(s)
- Matthew D Ritchey
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.D.R., S.L.J., T.C., H.S., L.S.)
| | - Sha Maresh
- Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore, MD (S.M., J.M., T.S.)
| | - Jessica McNeely
- Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore, MD (S.M., J.M., T.S.)
| | - Thomas Shaffer
- Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore, MD (S.M., J.M., T.S.)
| | - Sandra L Jackson
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.D.R., S.L.J., T.C., H.S., L.S.)
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan (S.J.K., C.A.B.)
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan (S.J.K., C.A.B.)
| | - Mary A Whooley
- School of Medicine, University of California, San Francisco (M.W.)
| | - Tiffany Chang
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.D.R., S.L.J., T.C., H.S., L.S.).,IHRC, Inc. (T.C., H.S.)
| | - Haley Stolp
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.D.R., S.L.J., T.C., H.S., L.S.).,IHRC, Inc. (T.C., H.S.)
| | - Linda Schieb
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (M.D.R., S.L.J., T.C., H.S., L.S.)
| | - Janet Wright
- Office of the Surgeon General, US Department of Health and Human Services, Washington, DC (J.W.)
| |
Collapse
|
29
|
Rifai MA, Qureshi WT, Dardari Z, Keteyian SJ, Brawner CA, Ehrman JK, Ahmed A, Sakr S, Virani SS, Blaha MJ, Al-Mallah MH. The Interplay of the Global Atherosclerotic Cardiovascular Disease Risk Scoring and Cardiorespiratory Fitness for the Prediction of All-Cause Mortality and Myocardial Infarction: The Henry Ford ExercIse Testing Project (The FIT Project). Am J Cardiol 2019; 124:511-517. [PMID: 31221461 DOI: 10.1016/j.amjcard.2019.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/04/2019] [Accepted: 05/16/2019] [Indexed: 11/15/2022]
Abstract
Cardiorespiratory fitness (CRF) is inversely associated with atherosclerotic cardiovascular disease (ASCVD) risk. It is unclear whether the prognostic value of CRF differs by baseline estimated ASCVD risk. We studied a retrospective cohort of patients without known heart failure or myocardial infarction (MI) who underwent treadmill stress testing. CRF was measured by metabolic equivalents of task (METs) and ASCVD risk was calculated using the Pooled Cohorts Equations. Multivariable-adjusted Cox regressions analyses examined the association between METs and incident all-cause mortality and MI outcomes stratified by baseline ASCVD risk. The C-index evaluated risk discrimination while net reclassification improvement evaluated reclassification with CRF added to the ASCVD risk score. Our study population consisted of 57,999 patients of mean age 53 (13) years, 49% women, 64% white, 29% black. Over a median follow-up 11 years (interquartile range 8 to 14 years) there were 6,670 (11%) deaths, while there were 1,757 (3.0%) MIs over a median follow-up of 6 years (interquartile range 3 to 8 years). Among patients with ASCVD risk ≥20%, those with METs ≥12 had a 77% lower risk of all-cause mortality (Hazard ratio 0.23 95% confidence interval = 0.20, 0.27) and 67% lower risk of MI (Hazard ratio 0.33 95% confidence interval = 0.24, 0.46) compared to METs <6. Similar results were obtained for those with ASCVD risk <5%. Addition of METs to ASCVD risk score improved the C-statistic from 0.778 to 0.798 for all-cause mortality and 0.726 to 0.733 for MI (both p <0.001). Addition of METs to ASCVD risk score significantly reclassified risk of all-cause mortality (p <0.001) but not MI (p = 0.052). In conclusion, CRF is inversely associated with risk of all-cause mortality and MI at all levels of ASCVD risk, and provides incremental risk discrimination and reclassification beyond the ASCVD risk score.
Collapse
Affiliation(s)
- Mahmoud Al Rifai
- Department of Internal Medicine, The University of Kansas School of Medicine, Wichita, Kansas; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Waqas T Qureshi
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan; Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Zeina Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Amjad Ahmed
- Data Systems Group, Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Sherif Sakr
- Data Systems Group, Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Salim S Virani
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Mouaz H Al-Mallah
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan; Houston Methodist Hospital, Houston, Texas.
| |
Collapse
|
30
|
Cremer PC, Wu Y, Ahmed HM, Pierson LM, Brennan DM, Al-Mallah MH, Brawner CA, Ehrman JK, Keteyian SJ, Blumenthal RS, Blaha MJ, Cho L. Use of Sex-Specific Clinical and Exercise Risk Scores to Identify Patients at Increased Risk for All-Cause Mortality. JAMA Cardiol 2019; 2:15-22. [PMID: 27784057 DOI: 10.1001/jamacardio.2016.3720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Risk assessment tools for exercise treadmill testing may have limited external validity. Cardiovascular mortality has decreased in recent decades, and women have been underrepresented in prior cohorts. Objectives To determine whether exercise and clinical variables are associated with differential mortality outcomes in men and women and to assess whether sex-specific risk scores better estimate all-cause mortality. Design, Setting, and Participants This retrospective cohort study included 59 877 patients seen at the Cleveland Clinic Foundation (CCF cohort) from January 1, 2000, through December 31, 2010, and 49 278 patients seen at the Henry Ford Hospital (FIT cohort) from January 1, 1991, through December 31, 2009. All patients were 18 years or older and underwent exercise treadmill testing. Data were analyzed from January 1, 2000, to October 27, 2011, in the CCF cohort and from January 1, 1991, to April 1, 2013, in the FIT cohort. Main Outcomes and Measurements The CCF cohort was divided randomly into derivation and validation samples, and separate risk scores were developed for men and women. Net reclassification, C statistics, and integrated discrimination improvement were used to compare the sex-specific risk scores with other tools that have all-cause mortality as the outcome. Discrimination and calibration were also evaluated with these sex-specific risk scores in the FIT cohort. Results The CCF cohort included 59 877 patients (59.4% men; 40.5% women) with a median (interquartile range [IQR]) age of 54 (45-63) years and 2521 deaths (4.2%) during a median follow-up of 7 (IQR, 4.1-9.6) years. The FIT cohort included 49 278 patients (52.5% men; 47.4% women) with a median (IQR) age of 54 (46-64) years and 6643 deaths (13.5%) during a median (IQR) follow-up of 10.2 (7-13.4) years. C statistics for the sex-specific risk scores in the CCF validation sample were higher (0.79 in women and 0.81 in men) than C statistics using other tools in women (0.70 for Duke Treadmill Score; 0.74 for Lauer nomogram) and men (0.72 for Duke Treadmill Score; 0.75 for Lauer nomogram). Net reclassification and integrated discrimination improvement were superior with the sex-specific risk scores, mostly owing to correct reclassification of events. The sex-specific risk scores in the FIT cohort demonstrated similar discrimination (C statistic, 0.78 for women and 0.79 for men), and calibration was reasonable. Conclusions and Relevance Sex-specific risk scores better estimate mortality in patients undergoing exercise treadmill testing. In particular, these sex-specific risk scores help to identify patients at the highest residual risk in the present era.
Collapse
Affiliation(s)
- Paul C Cremer
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Cleveland, Ohio
| | - Haitham M Ahmed
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, Maryland
| | - Lee M Pierson
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Mouaz H Al-Mallah
- King Abdulaziz Cardiac Center, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard, Health Affairs, Riyadh, Saudia Arabia6Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, Maryland
| | - Leslie Cho
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
31
|
Marshall CH, Al-Mallah MH, Dardari Z, Brawner CA, Lamerato LE, Keteyian SJ, Ehrman JK, Visvanathan K, Blaha MJ. Cardiorespiratory fitness and incident lung and colorectal cancer in men and women: Results from the Henry Ford Exercise Testing (FIT) cohort. Cancer 2019; 125:2594-2601. [PMID: 31056756 PMCID: PMC6778750 DOI: 10.1002/cncr.32085] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/05/2019] [Accepted: 02/11/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND To the authors' knowledge, the relationship between cardiorespiratory fitness (CRF) and lung and colorectal cancer outcomes is not well established. METHODS A retrospective cohort study was performed of 49,143 consecutive patients who underwent clinician-referred exercise stress testing from 1991 through 2009. The patients ranged in age from 40 to 70 years, were without cancer, and were treated within the Henry Ford Health System in Detroit, Michigan. CRF, measured in metabolic equivalents of task (METs), was categorized as <6 (reference), 6 to 9, 10 to 11, and ≥12. Incident cancer was obtained through linkage to the cancer registry and all-cause mortality from the National Death Index. RESULTS Participants had a mean age of 54 ± 8 years. Approximately 46% were female, 64% were white, 29% were black, and 1% were Hispanic. The median follow-up was 7.7 years. Cox proportional hazard models, adjusted for age, race, sex, body mass index, smoking history, and diabetes, found that those in the highest fitness category (METs ≥12) had a 77% decreased risk of lung cancer (hazard ratio [HR], 0.23; 95% CI, 0.14-0.36) and a 61% decreased risk of incident colorectal cancer (HR, 0.39; 95% CI, 0.23-0.66; with additional adjustment for aspirin and statin use). Among those diagnosed with lung and colorectal cancer, those with high fitness had a decreased risk of subsequent death of 44% and 89%, respectively (HR, 0.56 [95% CI, 0.32-1.00] and HR, 0.11 [95% CI, 0.03-0.37], respectively). CONCLUSIONS In what to the authors' knowledge is the largest study performed to date, higher CRF was associated with a lower risk of incident lung and colorectal cancer in men and women and a lower risk of all-cause mortality among those diagnosed with lung or colorectal cancer.
Collapse
Affiliation(s)
- Catherine Handy Marshall
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland.,Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mouaz H Al-Mallah
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan.,King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Lois E Lamerato
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Kala Visvanathan
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, Maryland
| |
Collapse
|
32
|
Whelton SP, Dardari Z, Handy Marshall C, Ahmed H, Brawner CA, Ehrman JK, Keteyian SJ, Mallah MA, Blaha MJ. Relation of Isolated Low High-Density Lipoprotein Cholesterol to Mortality and Cardiorespiratory Fitness (from the Henry Ford Exercise Testing Project [FIT Project]). Am J Cardiol 2019; 123:1429-1434. [PMID: 30827489 DOI: 10.1016/j.amjcard.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 12/19/2022]
Abstract
Isolated low high-density lipoprotein cholesterol (HDL-C) is associated with lower fitness and increased mortality. Whether the association between isolated low HDL-C and mortality differs by fitness is uncertain. Patients in the Henry Ford ExercIse Testing Project (FIT Project) completed a physician-referred treadmill stress test and those prescribed lipid-lowering medications or with known cardiovascular disease were excluded. Isolated low HDL-C was defined as HDL-C <40 mg/dl for men and <50 mg/dl for women with low-density lipoprotein cholesterol (LDL-C) and triglycerides <100 mg/dl (n = 688). An optimal lipid panel was defined as HDL-C ≥40 mg/dl for men and ≥50 mg/dl for women with LDL-C and triglycerides <100 mg/dl (n = 2,923). Mortality was ascertained through Social Security Death Index linkage. Patients with isolated low HDL-C had a mean age of 48.9 ± 12.9 years and 62.9% were women. Over a mean follow-up of 10.3 ± 5 years, 12.8% of patients with isolated low HDL-C and 8.7% with optimal lipids died. Compared to individuals with optimal lipids, those with isolated low HDL-C who achieved <6 METs had a lower survival (p = 0.02), whereas there was no mortality difference for those who achieved 6 to 10 METs (p = 0.13) or ≥10 METs (p = 0.66). In adjusted Cox models, the mortality hazard for those with isolated low HDL-C compared with optimal lipids was 1.73 (95% confidence interval [CI] 1.18 to 2.54), 1.90 (95% CI 1.19 to 3.04), and 0.97 (95% CI 0.53 to 1.78) for the METS categories of <6, 6 to 10, and ≥10. In conclusion, individuals with isolated low HDL-C fitness significantly improved risk stratification and only those with lower fitness had an increased totality mortality risk.
Collapse
|
33
|
Rariden BS, Boltz AJ, Brawner CA, Pinkstaff SO, Richardson MR, Johnson TM, Churilla JR. Sedentary Time and Cumulative Risk of Preserved and Reduced Ejection Fraction Heart Failure: From the Multi-Ethnic Study of Atherosclerosis. J Card Fail 2019; 25:418-424. [PMID: 30930104 DOI: 10.1016/j.cardfail.2019.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 03/08/2019] [Accepted: 03/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study examined the relationship between self-reported sedentary time (ST) and the cumulative risk of heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) in a diverse cohort of U.S. adults 45-84 years of age. METHODS AND RESULTS Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we identified 6,814 subjects, all free of baseline cardiovascular disease. Cox regression was used to calculate the hazard ratios (HR) associated with risk of HFpEF and HFrEF. Weekly ST was dichotomized based on the 75th percentile (1890 min/wk). During ∼11.2 years of follow-up there were 178 first incident HF diagnoses: 74 HFpEF and 69 HFrEF. Baseline ST >1890 min/wk was significantly associated with an increased risk of HFpEF (HR 1.87, 95% confidence interval [CI] 1.13-3.09, P = .01), but not of HFrEF. The relationship with HFpEF remained significant in fully adjusted models including physical activity and waist circumference (HR 2.16, 95% CI 1.23-3.78, P < .01). In addition, every 60-minute increase in weekly ST was associated with a 3% increased risk of HFpEF (HR 1.03, 95% CI 1.01-1.05, P < .01). CONCLUSIONS Sedentary time >1890 min/wk (∼4.5 h/d) is a significant predictor of HFpEF, independently from physical activity and adiposity.
Collapse
|
34
|
Orimoloye OA, Kambhampati S, Hicks AJ, Al Rifai M, Silverman MG, Whelton S, Qureshi W, Ehrman JK, Keteyian SJ, Brawner CA, Dardari Z, Al-Mallah MH, Blaha MJ. Higher cardiorespiratory fitness predicts long-term survival in patients with heart failure and preserved ejection fraction: the Henry Ford Exercise Testing (FIT) Project. Arch Med Sci 2019; 15:350-358. [PMID: 30899287 PMCID: PMC6425214 DOI: 10.5114/aoms.2019.83290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/11/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Higher cardiorespiratory fitness (CRF) is associated with improved exercise capacity and quality of life in heart failure with preserved ejection fraction (HFpEF), but there are no large studies evaluating the association of HFpEF, CRF, and long-term survival. We therefore aimed to determine the association between CRF and all-cause mortality, in patients with HFpEF. MATERIAL AND METHODS In the Henry Ford Exercise Testing (FIT) Project, 167 patients had baseline HFpEF, defined as a clinical diagnosis of heart failure with ejection fraction ≥ 50% on echocardiogram. The CRF was estimated from the peak workload (in METs) from a clinician-referred treadmill stress test and categorized as poor (1-4 METs), intermediate (5-6 METs), and moderate-high (≥ 7 METs). Additional analyses assessing the effect of HFpEF and CRF on mortality were also conducted, matching HFpEF patients to non-HFpEF patients using propensity scores. RESULTS Mean age was 64 ±13 years, with 55% women, and 46% Black. Over a median follow-up of 9.7 (5.2-18.9) years, there were 103 deaths. In fully adjusted models, moderate-high CRF was associated with 63% lower mortality risk (HR = 0.37, 95% CI: 0.18-0.73) compared to the poor-CRF group. In the propensity-matched cohort, HFpEF was associated with a HR of 2.3 (95% CI: 1.7-3.2) for mortality compared to non-HFpEF patients, which was attenuated to 1.8 (95% CI: 1.3-2.5) after adjusting for CRF. CONCLUSIONS Moderate-high CRF in patients with HFpEF is associated with improved survival, and differences in CRF partly explain the intrinsic risk of HFpEF. Randomized trials of interventions aimed at improving CRF in HFpEF are needed.
Collapse
Affiliation(s)
- Olusola A. Orimoloye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Swetha Kambhampati
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Albert J. Hicks
- Department of Medicine/Cardiology Division, Baylor Scott & White Health, Temple, USA
| | - Mahmoud Al Rifai
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Seamus Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Waqas Qureshi
- Division of Cardiovascular Medicine, Wake Forest University of Medicine, Winston Salem, NC, USA
| | - Jonathan K. Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Clinton A. Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Mouaz H. Al-Mallah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| |
Collapse
|
35
|
Brawner CA, Ehrman JK, Myers J, Chase P, Vainshelboim B, Farha S, Saval MA, McGuire R, Pozehl B, Keteyian SJ. Exercise Oscillatory Ventilation: Interreviewer Agreement and a Novel Determination. Med Sci Sports Exerc 2018; 50:369-374. [PMID: 28902683 DOI: 10.1249/mss.0000000000001423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Determination of exercise oscillatory ventilation (EOV) is subjective, and the interreviewer agreement has not been reported. The purposes of this study were, among patients with heart failure (HF), as follows: 1) to determine the interreviewer agreement for EOV and 2) to describe a novel, objective, and quantifiable measure of EOV. METHODS This was a secondary analysis of the HEART Camp: Promoting Adherence to Exercise in Patients with Heart Failure study. EOV was determined through a blinded review by six individuals on the basis of their interpretation of the EOV literature. Interreviewer agreement was assessed using Fleiss kappa (κ). Final determination of EOV was based on agreement by four of the six reviewers. A new measure (ventilation dispersion index; VDI) was calculated for each test, and its ability to predict EOV was assessed with the receiver operator characteristics curve. RESULTS Among 243 patients with HF (age, 60 ± 12 yr; 45% women), the interreviewer agreement for EOV was fair (κ = 0.303) with 10-s discrete data averages and significantly better, but only moderate (κ = 0.429) with 30-s rolling data averages. Prevalence rates of positive and indeterminate EOVs were 18% and 30% with the 10-s discrete averages and 14% and 13% with the 30-s rolling averages, respectively. VDI was strongly associated with EOV, with areas under the receiver operator characteristics curve of 0.852 to 0.890. CONCLUSIONS Interreviewer agreement for EOV in patients with HF is fair to moderate, which can negatively affect risk stratification. VDI has strong predictive validity with EOV; as such, it might be a useful measure of prognosis in patients with HF.
Collapse
Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan Myers
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Paul Chase
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Shadi Farha
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Matthew A Saval
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Rita McGuire
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Bunny Pozehl
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
36
|
Al Rifai M, Blaha MJ, Rahman F, Ehrman JK, Brawner CA, Keteyian SJ, Al-Mallah MH, McEvoy JW. Inverse association of pulse pressure augmentation during exercise with heart failure and death. Heart 2018; 105:639-644. [PMID: 30361271 DOI: 10.1136/heartjnl-2018-313736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/13/2018] [Accepted: 09/26/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Resting pulse pressure (PP) is a risk factor for heart failure (HF); however, whether PP augmentation during exercise, a parameter easily obtained from routine treadmill stress testing, is associated with incident HF is unknown. Thus, we aimed to study the relationship between a novel parameter, the pulse pressure stress index (P2SI), and adverse outcomes among adults undergoing clinical exercise stress testing in the Henry Ford Exercise Testing Project. METHODS The P2SI was calculated as PP at peak exercise divided by resting PP and was analysed continuously and categorically using quartiles. Cox models examined the association between P2SI and adjusted HR (aHR) of incident HF, myocardial infarction (MI) or death. Receiver operating curve (ROC) analyses tested the optimal prognostic cut-point for P2SI. RESULTS Among 55 524 participants without prior MI or HF, mean (SD) age was 53 (13) years, 51% were men and 29% black. A total of 2516 HF, 1606 MI and 6224 mortality outcomes occurred. Quartile 3 P2SI (2.0-2.4) was chosen as the reference category based on ROC analyses. There was a graded inverse association of low P2SI with excess HF (aHR of 1.3 (95% CI 1.1 to 1.5) for quartile 2 and 1.5 (95% CI 1.2 to 1.8) for quartile 1, p for trend<0.001) and mortality (aHR of 1.1 (95% CI 1.01 to 1.2) for quartile 2 and 1.3 (95% CI 1.2 to 1.5) for quartile 1, p for trend<0.001). There was no association between P2SI and MI after adjustment. P2SI added significant prognostic information to more established stress testing parameters such as peak systolic blood pressure, per cent maximal predicted heart rate achieved and metabolic equivalents of task achieved. CONCLUSIONS Poor augmentation of PP with exercise, specifically a P2SI below 2, is a novel and readily quantifiable exercise-based risk feature for HF and death.
Collapse
Affiliation(s)
- Mahmoud Al Rifai
- Department of Medicine, University of Kansas School of Medicine, Wichita, Kansas, USA.,The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Faisal Rahman
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | - Mouaz H Al-Mallah
- Henry Ford Hospital, Detroit, Michigan, USA.,Cardiovascular Imaging and PET, Houston Methodist DeBakey Heart & Vascular Center, Houston Texas, Texas, USA
| | - John William McEvoy
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Cardiology, National Institute for Preventive Cardiology and National University of Ireland, Galway Campus, Galway, Ireland
| |
Collapse
|
37
|
Keteyian SJ, Kerrigan DJ, Lewis B, Ehrman JK, Brawner CA. Exercise training workloads in cardiac rehabilitation are associated with clinical outcomes in patients with heart failure. Am Heart J 2018; 204:76-82. [PMID: 30081276 DOI: 10.1016/j.ahj.2018.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 05/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with coronary heart disease, the exercise workload (i.e., metabolic equivalents of task, METs) at which patients exercise train upon entry and completion of cardiac rehabilitation (CR) are independently related to prognosis. Unknown is the association between exercise training workloads in CR and clinical outcomes in patients with heart failure (HF). METHODS Patients with HF who participated in an early outpatient CR program were used in this retrospective analysis. Exercise workloads upon entry and completion of CR were converted to METs. The primary outcome was all-cause mortality and the secondary outcome was HF hospitalization. Cox regression analysis was used to assess the adjusted risk between MET levels in CR and clinical outcomes. RESULTS Among 707 patients, the median exercise training workload at the start and end of CR was 2.5 METs (IQR 2.1 to 3.1 METs) and 3.2 METS (IQR 2.7 to 4.1 METs), respectively, for men and 2.2 METs (IQR 1.9 to 2.6 METs) and 2.9 METS (IQR 2.3 to 3.4 METs), respectively, for women. There were 242 deaths and 266 HF hospitalizations. METs achieved at the end of CR had the strongest independent association with all-cause mortality (adjusted HR, 95% CI: 0.58, 0.48-0.70) and HF hospitalization (adjusted HR, 95% CI: 0.62, 0.52-0.74). Each 1 MET higher work load at the end of CR was associated with a 42% and 38% lower adjusted risk for all-cause mortality and HF hospitalization, respectively. CONCLUSIONS In a diverse cohort of patients with chronic HF our data suggests that an easily accessible measure of exercise capacity (i.e., METs) that is collected during CR is independently associated with the adjusted risk for both all-cause mortality and HF-specific hospitalization. Training at MET levels <3.5 METs identifies patients that might benefit from closer clinical surveillance and reinforced adherence to medical and lifestyle preventive strategies.
Collapse
Affiliation(s)
- Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI.
| | - Dennis J Kerrigan
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Barry Lewis
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
38
|
McAuley PA, Keteyian SJ, Brawner CA, Dardari ZA, Al Rifai M, Ehrman JK, Al-Mallah MH, Whelton SP, Blaha MJ. Exercise Capacity and the Obesity Paradox in Heart Failure: The FIT (Henry Ford Exercise Testing) Project. Mayo Clin Proc 2018; 93:701-708. [PMID: 29731178 DOI: 10.1016/j.mayocp.2018.01.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/18/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess the influence of exercise capacity and body mass index (BMI) on 10-year mortality in patients with heart failure (HF) and to synthesize these results with those of previous studies. PATIENTS AND METHODS This large biracial sample included 774 men and women (mean age, 60±13 years; 372 [48%] black) with a baseline diagnosis of HF from the Henry Ford Exercise Testing (FIT) Project. All patients completed a symptom-limited maximal treadmill stress test from January 1, 1991, through May 31, 2009. Patients were grouped by World Health Organization BMI categories for Kaplan-Meier survival analyses and stratified by exercise capacity (<4 and ≥4 metabolic equivalents [METs] of task). Associations of BMI and exercise capacity with all-cause mortality were assessed using multivariable-adjusted Cox proportional hazards models. RESULTS During a mean follow-up of 10.1±4.6 years, 380 patients (49%) died. Kaplan-Meier survival plots revealed a significant positive association between BMI category and survival for exercise capacity less than 4 METs (log-rank, P=.05), but not greater than or equal to 4 METs (P=.76). In the multivariable-adjusted models, exercise capacity (per 1 MET) was inversely associated, but BMI was not associated, with all-cause mortality (hazard ratio, 0.89; 95% CI, 0.85-0.94; P<.001 and hazard ratio, 0.99; 95% CI, 0.97-1.01; P=.16, respectively). CONCLUSION Maximal exercise capacity modified the relationship between BMI and long-term survival in patients with HF, upholding the presence of an exercise capacity-obesity paradox dichotomy as observed over the short-term in previous studies.
Collapse
Affiliation(s)
- Paul A McAuley
- Department of Health, Physical Education and Sport Studies, Winston Salem State University, Winston Salem, NC.
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Zeina A Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mahmoud Al Rifai
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Mouaz H Al-Mallah
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD; King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Seamus P Whelton
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
39
|
Handy C, Al-Mallah MH, Dardari Z, Brawner CA, Lamerato LE, Keteyian S, Ehrman JK, Visvanathan K, Blaha MJ. Cardiorespiratory fitness and incident lung and colon cancer: FIT-Cancer Cohort. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.1502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Catherine Handy
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
| | - Mouaz H Al-Mallah
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, MI
| | | | - Steven Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Kala Visvanathan
- Johns Hopkins Kimmel Cancer Center and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
40
|
Rariden BS, Richardson MR, Johnson TM, Brawner CA, Pinkstaff SO, Churilla JR. Sedentary Time and Cumulative Risk of Preserved and Reduced Ejection Fraction Heart Failure. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000538366.58233.ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
41
|
Ahmed AM, Qureshi WT, Sakr S, Blaha MJ, Brawner CA, Ehrman JK, Keteyian SJ, Al-Mallah MH. Prognostic value of exercise capacity among patients with treated depression: The Henry Ford Exercise Testing (FIT) Project. Clin Cardiol 2018; 41:532-538. [PMID: 29665017 DOI: 10.1002/clc.22923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/28/2018] [Accepted: 02/04/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Exercise capacity is associated with survival in the general population. Whether this applies to patients with treated depression is not clear. HYPOTHESIS High exercise capacity remains associated with lower risk of all-cause mortality (ACM) and nonfatal myocardial infraction (MI) among patients with treated depression. METHODS We included 5128 patients on antidepressant medications who completed a clinically indicated exercise stress test between 1991 and 2009. Patients were followed for a median duration of 9.4 years for ACM and 4.5 years for MI. Exercise capacity was estimated in metabolic equivalents of tasks (METs). Cox proportional hazards regression models were used. RESULTS Patients with treated depression who achieved ≥12 METs (vs those achieving <6 METs) were younger (age 46 ± 9 vs 61 ± 12 years), more often male (60% vs 23%), less often black (10% vs 27%), and less likely to be hypertensive (51% vs 86%), have DM (9% vs 38%), or be obese (11% vs 36%) or dyslipidemic (45% vs 54%). In the fully adjusted Cox proportional hazard regression model, exercise capacity was associated with a lower ACM (HR per 1-MET increase in exercise capacity: 0.82, 95% CI: 0.79-0.85, P < 0.001) and nonfatal MI (HR: 0.92, 95% CI: 0.87-0.97, P = 0.004). CONCLUSIONS Exercise capacity had an inverse association with both ACM and nonfatal MI in patients with treated depression, independent of cardiovascular risk factors. These results highlight the potential impact of assessing exercise capacity to identify risk, as well as promoting an active lifestyle among treated depression patients.
Collapse
Affiliation(s)
- Amjad M Ahmed
- King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Waqas T Qureshi
- Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Sherif Sakr
- Department of Public Health, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Clinton A Brawner
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
| | - Jonathan K Ehrman
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Steven J Keteyian
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
| | - Mouaz H Al-Mallah
- King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of medicine, King Saud bin Abdulaziz for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
42
|
Ehrman JK, Brawner CA, Shafiq A, Lanfear DE, Saval M, Keteyian SJ. Cardiopulmonary Exercise Measures of Men and Women with HFrEF Differ in Their Relationship to Prognosis: The Henry Ford Hospital Cardiopulmonary Exercise Testing (FIT-CPX) Project. J Card Fail 2018; 24:227-233. [PMID: 29496519 DOI: 10.1016/j.cardfail.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 02/12/2018] [Accepted: 02/15/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND This study evaluated if different prognostic characteristics exist for peak oxygen consumption (VO2), percent predicted peak VO2 (ppVO2), and the slope of the change in minute ventilation to volume of carbon dioxide produced (VE-VCO2) slope between men and women with heart failure and reduced ejection fraction (HFrEF). METHODS Analysis of the Henry Ford Hospital Cardiopulmonary Exercise Testing database (n = 1085; 33% women, 55% black) of individuals with HFrEF who completed a physician-referred cardiopulmonary exercise testing (CPX) between 1997 and 2010. Primary outcome was a composite of all-cause death, left ventricular assist device placement, and orthotopic heart transplant . Logistic and Cox regressions were performed and Kaplan-Meier survival curves were developed to describe relationships of the CPX variables and the composite outcome within and between men and women. RESULTS All patients were followed-up for a minimum of 5 years, during which there were 643 combined events (62%; 499 deaths, 64 left ventricular assist device implants, 80 orthotopic heart transplant). Each CPX variable was significantly related to event-free survival among both men and women. Log-rank assessment of Kaplan-Meier curves noted survival differences for peak VO2 and VE-VCO2 slope (p ≤ .002), but not ppVO2 (P = .32), between men and women. CONCLUSIONS Prognostic values for peak VO2 and the VE-VCO2 slope might be considered separately for men and women, whereas the ppVO2 value corresponding to 1- and 3-year survival rates may not be different between the sexes.
Collapse
Affiliation(s)
| | | | - Ali Shafiq
- Aurora Health Care, Milwaukee, Wisconsin
| | | | | | | |
Collapse
|
43
|
Sakr S, Elshawi R, Ahmed AM, Qureshi WT, Brawner CA, Keteyian SJ, Blaha MJ, Al-Mallah MH. Comparison of machine learning techniques to predict all-cause mortality using fitness data: the Henry ford exercIse testing (FIT) project. BMC Med Inform Decis Mak 2017; 17:174. [PMID: 29258510 PMCID: PMC5735871 DOI: 10.1186/s12911-017-0566-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/22/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prior studies have demonstrated that cardiorespiratory fitness (CRF) is a strong marker of cardiovascular health. Machine learning (ML) can enhance the prediction of outcomes through classification techniques that classify the data into predetermined categories. The aim of this study is to present an evaluation and comparison of how machine learning techniques can be applied on medical records of cardiorespiratory fitness and how the various techniques differ in terms of capabilities of predicting medical outcomes (e.g. mortality). METHODS We use data of 34,212 patients free of known coronary artery disease or heart failure who underwent clinician-referred exercise treadmill stress testing at Henry Ford Health Systems Between 1991 and 2009 and had a complete 10-year follow-up. Seven machine learning classification techniques were evaluated: Decision Tree (DT), Support Vector Machine (SVM), Artificial Neural Networks (ANN), Naïve Bayesian Classifier (BC), Bayesian Network (BN), K-Nearest Neighbor (KNN) and Random Forest (RF). In order to handle the imbalanced dataset used, the Synthetic Minority Over-Sampling Technique (SMOTE) is used. RESULTS Two set of experiments have been conducted with and without the SMOTE sampling technique. On average over different evaluation metrics, SVM Classifier has shown the lowest performance while other models like BN, BC and DT performed better. The RF classifier has shown the best performance (AUC = 0.97) among all models trained using the SMOTE sampling. CONCLUSIONS The results show that various ML techniques can significantly vary in terms of its performance for the different evaluation metrics. It is also not necessarily that the more complex the ML model, the more prediction accuracy can be achieved. The prediction performance of all models trained with SMOTE is much better than the performance of models trained without SMOTE. The study shows the potential of machine learning methods for predicting all-cause mortality using cardiorespiratory fitness data.
Collapse
Affiliation(s)
- Sherif Sakr
- King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, King Abdulaziz Medical City for National Guard - Health affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Department Mail Code: 1413, P.O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Radwa Elshawi
- Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Amjad M Ahmed
- King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, King Abdulaziz Medical City for National Guard - Health affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Department Mail Code: 1413, P.O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | - Waqas T Qureshi
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Steven J Keteyian
- King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, King Abdulaziz Medical City for National Guard - Health affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Department Mail Code: 1413, P.O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia
| | | | - Mouaz H Al-Mallah
- King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, King Abdulaziz Medical City for National Guard - Health affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Department Mail Code: 1413, P.O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia. .,Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA.
| |
Collapse
|
44
|
Al-Mallah MH, Elshawi R, Ahmed AM, Qureshi WT, Brawner CA, Blaha MJ, Ahmed HM, Ehrman JK, Keteyian SJ, Sakr S. Using Machine Learning to Define the Association between Cardiorespiratory Fitness and All-Cause Mortality (from the Henry Ford Exercise Testing Project). Am J Cardiol 2017; 120:2078-2084. [PMID: 28951020 DOI: 10.1016/j.amjcard.2017.08.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/02/2017] [Accepted: 08/08/2017] [Indexed: 10/19/2022]
Abstract
Previous studies have demonstrated that cardiorespiratory fitness is a strong marker of cardiovascular health. Machine learning (ML) can enhance the prediction of outcomes through classification techniques that classify the data into predetermined categories. The aim of the analysis is to compare the prediction of 10 years of all-cause mortality (ACM) using statistical logistic regression (LR) and ML approaches in a cohort of patients who underwent exercise stress testing. We included 34,212 patients (55% males, mean age 54 ± 13 years) free of coronary artery disease or heart failure who underwent exercise treadmill stress testing between 1991 and 2009 and had complete 10-year follow-up. The primary outcome of this analysis was ACM at 10 years. The probability of 10-years ACM was calculated using statistical LR and ML, and the accuracy of these methods was calculated and compared. A total of 3,921 patients died at 10 years. Using statistical LR, the sensitivity to predict ACM was 44.9% (95% confidence interval [CI] 43.3% to 46.5%), whereas the specificity was 93.4% (95% CI 93.1% to 93.7%). The sensitivity of ML to predict ACM was 87.4% (95% CI 86.3% to 88.4%), whereas the specificity was 97.2% (95% CI 97.0% to 97.4%). The ML approach was associated with improved model discrimination (area under the curve for ML [0.923 (95% CI 0.917 to 0.928)]) compared with statistical LR (0.836 [95% CI 0.829 to 0.846], p<0.0001). In conclusion, our analysis demonstrates that ML provides better accuracy and discrimination of the prediction of ACM among patients undergoing stress testing.
Collapse
|
45
|
Shaya GE, Juraschek SP, Feldman DI, Brawner CA, Ehrman JK, Keteyian SJ, Al-Mallah MH, Blaha MJ. Relation of Exercise Capacity to Risk of Development of Diabetes in Patients on Statin Therapy (the Henry Ford Exercise Testing Project). Am J Cardiol 2017; 120:769-773. [PMID: 28716336 DOI: 10.1016/j.amjcard.2017.05.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/10/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
Abstract
High exercise capacity (EC) has been associated with a lower risk of incident diabetes, whereas statin therapy has been associated with a higher risk. We sought to investigate whether the association between EC and diabetes risk is modified by statin therapy. This retrospective cohort study included 47,337 patients without diabetes or coronary artery disease at baseline (age 53 ± 13 years, 48% women, 66% white) who underwent clinical treadmill stress testing within the Henry Ford Health System from January 1, 1991, to May 31, 2009. The patients were stratified by baseline statin use and estimated peak METs achieved during exercise testing. Hazard ratios for incident diabetes were calculated using Cox proportional hazards models adjusted for demographic characteristics, co-morbidities, pertinent medications, and stress test indication. We observed 6,921 new diabetes cases (14.6%) over a median follow-up period of 5.1 years (interquartile interval of 2.6 to 8.2 years). Compared with the statin group, the no-statin group achieved higher mean METs (8.9 ± 2.7 vs 9.6 ± 3.0, respectively; p <0.001). After adjustment for covariates, a higher EC was associated with a lower risk of incident diabetes, irrespective of statin use (p-interaction = 0.15). Each 1-MET increment was associated with an 8%, 8%, and 6% relative risk reduction in the total cohort, the no-statin, and the statin groups, respectively (95% confidence interval, 0.91 to 0.93, 0.91 to 0.93, and 0.91 to 0.96, respectively; p <0.001 for all). We conclude that a higher EC is associated with a lower risk of incident diabetes regardless of statin use.
Collapse
|
46
|
Same RV, Al Rifai M, Feldman DI, Billups KL, Brawner CA, Dardari ZA, Ehrman JK, Keteyian SJ, Al-Mallah MH, Blaha MJ. Prognostic value of exercise capacity among men undergoing pharmacologic treatment for erectile dysfunction: The FIT Project. Clin Cardiol 2017; 40:1049-1054. [PMID: 28805967 DOI: 10.1002/clc.22768] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/04/2017] [Accepted: 07/11/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Vascular erectile dysfunction (ED) has been identified as a potentially useful risk factor for predicting future cardiovascular events, particularly in younger men. Because these men typically score more favorably on traditional cardiovascular disease risk assessment tools, there exists a gap in knowledge for how to most appropriately identify those men who would benefit from more aggressive treatments. To date, no studies have examined the impact of fitness on cardiovascular outcomes in men with ED. This study sought to examine the prognostic impact of maximal exercise capacity on cardiovascular-related outcomes in men ages 40 to 60 years being treated for ED. HYPOTHESIS We hypothesized that there would be an independent association between higher baseline fitness level and lower cardiovascular events. METHODS We analyzed 1152 men with pharmacy claims file-confirmed active pharmacologic treatment for ED from the Henry Ford Exercise Testing (FIT) Project (1991-2009). All patients were free of coronary heart disease and heart failure, and underwent clinician-referred exercise stress testing, with fitness measured in metabolic equivalents of task (METs). Multivariable Cox proportional hazard models adjusted for traditional cardiovascular risk factors were used to study the association between fitness and all-cause mortality, major adverse cardiovascular events (MACE) (defined as myocardial infarction or revascularization), and incident type 2 diabetes mellitus. RESULTS The mean age of the population was 53 years, with 39% African Americans. In multivariable analysis, each 1 MET of fitness was associated with a 16% lower risk of death (hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.76-0.94, P = 0.002), and a nonsignificant reduction in MACE (HR: 0.89, 95% CI: 0.79-1.003, P = 0.048), and incident diabetes (HR: 0.92, 95% CI: 0.85-1.01, P = 0.129). CONCLUSIONS Higher baseline fitness is associated with improved cardiovascular prognosis in a population of middle-aged men treated for ED.
Collapse
Affiliation(s)
- Robert V Same
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, Maryland
| | - Mahmoud Al Rifai
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, Maryland.,Department of Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - David I Feldman
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, Maryland.,University of Miami Miller School of Medicine, Miami, Florida
| | - Kevin L Billups
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, Maryland.,Johns Hopkins Brady Urologic Institute, Johns Hopkins Medicine, Baltimore, Maryland
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, Maryland
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Mouaz H Al-Mallah
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan.,King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, Maryland
| |
Collapse
|
47
|
Brawner CA, Keteyian SJ. Do We Need Another Walking Test? ∗. JACC: Heart Failure 2017; 5:421-422. [DOI: 10.1016/j.jchf.2017.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/02/2017] [Indexed: 11/28/2022]
|
48
|
Kupsky DF, Ahmed AM, Sakr S, Qureshi WT, Brawner CA, Blaha MJ, Ehrman JK, Keteyian SJ, Al-Mallah MH. Cardiorespiratory fitness and incident heart failure: The Henry Ford ExercIse Testing (FIT) Project. Am Heart J 2017; 185:35-42. [PMID: 28267473 DOI: 10.1016/j.ahj.2016.12.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/01/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior studies have demonstrated cardiorespiratory fitness (CRF) to be a strong marker of cardiovascular health. However, there are limited data investigating the association between CRF and risk of progression to heart failure (HF). The purpose of this study was to determine the relationship between CRF and incident HF. METHODS We included 66,329 patients (53.8% men, mean age 55 years) free of HF who underwent exercise treadmill stress testing at Henry Ford Health Systems between 1991 and 2009. Incident HF was determined using International Classification of Diseases, Ninth Revision codes from electronic medical records or administrative claim files. Cox proportional hazards models were performed to determine the association between CRF and incident HF. RESULTS A total of 4,652 patients developed HF after a median follow-up duration of 6.8 (±3) years. Patients with incident HF were older (63 vs 54 years, P<.001) and had higher prevalence of known coronary artery disease (42.3% vs 11%, P<.001). Peak metabolic equivalents (METs) of task were 6.3 (±2.9) and 9.1 (±3) in the HF and non-HF groups, respectively. After adjustment for potential confounders, patients able to achieve ≥12 METs had an 81% lower risk of incident HF compared with those achieving <6 METs (hazard ratio 0.19 [95% CI 0.14-0.29], P for trend < .001). Each 1 MET achieved was associated with a 16% lower risk (hazard ratio 0.84 [95% CI 0.82-0.86], P<.001) of incident HF. CONCLUSIONS Our analysis demonstrates that higher level of fitness is associated with a lower incidence of HF independent of HF risk factors.
Collapse
Affiliation(s)
- Daniel F Kupsky
- Heart and Vascular Institute, Henry Ford Hospital System, Detroit, MI
| | - Amjad M Ahmed
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Sherif Sakr
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | | | - Clinton A Brawner
- Heart and Vascular Institute, Henry Ford Hospital System, Detroit, MI
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD
| | - Jonathan K Ehrman
- Heart and Vascular Institute, Henry Ford Hospital System, Detroit, MI
| | - Steven J Keteyian
- Heart and Vascular Institute, Henry Ford Hospital System, Detroit, MI
| | - Mouaz H Al-Mallah
- Heart and Vascular Institute, Henry Ford Hospital System, Detroit, MI; King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Kingdom of Saudi Arabia.
| |
Collapse
|
49
|
Al Rifai M, Patel J, Hung RK, Nasir K, Keteyian SJ, Brawner CA, Ehrman JK, Sakr S, Blumenthal RS, Blaha MJ, Al-Mallah MH. Higher Fitness Is Strongly Protective in Patients with Family History of Heart Disease: The FIT Project. Am J Med 2017; 130:367-371. [PMID: 27751899 DOI: 10.1016/j.amjmed.2016.09.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 09/20/2016] [Accepted: 09/20/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cardiorespiratory fitness protects against mortality; however, little is known about the benefits of improved fitness in individuals with a family history of coronary heart disease. We studied the association between cardiorespiratory fitness and risk of incident coronary heart disease and all-cause mortality, hypothesizing an inverse relationship similar to individuals without a family history of coronary heart disease. METHODS We included 57,999 patients (aged 53 ± 13 years; 49% were female; 29% were black) from the Henry Ford Exercise Testing (FIT) Project. Cardiorespiratory fitness was expressed in metabolic equivalents of task based on exercise stress testing. Family history was determined as self-reported coronary heart disease in a first-degree relative at any age. We used Cox proportional hazards models adjusted for demographics and cardiovascular disease risk factors to examine the association between cardiorespiratory fitness and risk of incident coronary heart disease and mortality over a median (interquartile range) follow-up of 5.5 (5.6) and 10.4 (6.8) years, respectively. RESULTS Overall, 51% reported a positive family history. Each 1-unit metabolic equivalent increase was associated with lower incident coronary heart disease and mortality risk regardless of family history status. The hazard ratio and 95% confidence interval for a negative family history and a positive family history were 0.87 (0.84-0.89) and 0.87 (0.85-0.89) for incident coronary heart disease and 0.83 (0.82-0.84) and 0.83 (0.82-0.85) for mortality, respectively. There was no significant interaction between family history and categoric cardiorespiratory fitness, sex, or age (P >.05 for all). CONCLUSIONS Higher cardiorespiratory fitness is strongly protective in all patients regardless of family history status, supporting recommendations for regular exercise in those with a family history.
Collapse
Affiliation(s)
- Mahmoud Al Rifai
- The University of Kansas, School of Medicine, Wichita; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md
| | - Jaideep Patel
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md; Department of General of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond.
| | - Rupert K Hung
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md; Center for Prevention and Wellness, Baptist Health South Florida, Miami, Fla
| | | | | | | | - Sherif Sakr
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Md
| | - Mouaz H Al-Mallah
- Henry Ford Hospital, Detroit, Mich; King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; King Abdulaziz Cardiac Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| |
Collapse
|
50
|
Brawner CA, Al-Mallah MH, Ehrman JK, Qureshi WT, Blaha MJ, Keteyian SJ. Change in Maximal Exercise Capacity Is Associated With Survival in Men and Women. Mayo Clin Proc 2017; 92:383-390. [PMID: 28185659 DOI: 10.1016/j.mayocp.2016.12.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/22/2016] [Accepted: 12/15/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To describe the relationship between change in maximal exercise capacity (MEC) over time and risk of all-cause mortality separately in men and women. PATIENTS AND METHODS Consecutive patients (n=10,854; mean ± SD age, 54±11 years; 43% women; 30% nonwhite) who completed 2 physician-referred exercise tests between January 2, 1991, and May 28, 2009, were identified from the Henry Ford Exercise Testing (FIT) Project. The MEC was quantified in metabolic equivalents of task (METs) calculated from peak workload on a treadmill and adjusted to the equivalent for a 50-year-old man. Multivariable Cox proportional hazards regression was performed to assess risk of all-cause mortality associated with change in MEC based on (1) change from age-/sex-adjusted low fitness (<8 METs) to intermediate or high fitness and (2) an absolute change in METs. RESULTS Relative to patients with low fitness at both tests, increasing from low to intermediate or high fitness was associated with lower risk of all-cause mortality (adjusted hazard ratio [aHR] = 0.63 [95% CI, 0.45-0.87] in men and 0.56 [95% CI, 0.34-0.91] in women). Each 1-MET increase in age-/sex-adjusted MEC between baseline and follow-up was associated with an aHR of 0.87 (95% CI, 0.84-0.91) in men and 0.84 (95% CI, 0.79-0.89) in women, with no significant interaction by sex (P=.995). Similar aHRs were observed in a subgroup with intermediate fitness at baseline. CONCLUSION In men and women referred for an exercise stress test, change in MEC over time is inversely related to risk of all-cause mortality.
Collapse
Affiliation(s)
- Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI.
| | - Mouaz H Al-Mallah
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI; King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul-Aziz Cardiac Center, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Waqas T Qureshi
- Department of Cardiology, Wake Forest University, Winston-Salem, NC
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Medicine, Baltimore, MD
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| |
Collapse
|