bluuebunny/crossref_metadata_2025 huggingface dataset:
Chronotropic incompetence - still on time to make a difference?
Authors: Martins A , Garcia A B , Abrantes A , Cravo J , Alves Da Silva P , Gregorio C , Raposo M , Sousa P , Bento B , Santos L , Rodrigues M C , Cunha N , Aguiar-Ricardo I , Pinto F J , Abreu A
Published: June 2024

Introduction

Chronotropic incompetence (CI) is prevalent among individuals with cardiovascular disease. This phenomenon is frequently noted in cardio-pulmonary exercise testing (CPET) in patients participating in cardiac rehabilitation (CR) programs and often attributed to a combination of factors, notably the administration of beta-blockers (BB).

Recent evidence casted doubt over long term beta-blocker use on ischemic pts with preserved ejection fraction and some large scale trials as BETAMI and DANBLOCK are undergoing to clarify BB role in this specific population.

Aim

This study aimed to evaluate alterations in the chronotropic response observed in consecutive patients undergoing CPET and to explore the impacts of BB on this physiological parameter.

Methods

We conducted a single centre, prospective study of consecutive patients who were submitted to CPET. CI was defined as chronotropic index (max HR-resting HR/predicted HR-resting HR)<0,8 and chronotropic deficit ((predicted HR-max HR)/predicted HR)<0,2.

Results

446 patients were analysed (80,5% males; mean age of 6011; 83,4% ischemic patients) In our population, 95,8% had CI assessed during the CPET. 79% (n= 347) were under BB therapy, from which 68.3% (n=222) without heart failure with reduced ejection fraction. Most[ir1] pts used either low (bisoprolol 2,5mg or equivalent) or intermediate (bisoprolol 5mg or equivalent) BB dose (30% and 28,7% respectively). During a mean follow-up of 2,5±1,8 years, most pts (60,7%) maintained drug dosage, 8,7% increased and only 4,9% stopped.

The use of BB was associated with CI (p=0.002), chronotropic index < 80% (p<0.001) and with chronotropic deficit >20% (p=0.019). This was independent of the dosage of BB used. All of these pts were associated with a poorer exercise capacity as assessed by CPET and measured by VO2/kg, a known strong prognostic surrogate in this pts. There was however no significant difference regarding VO2/kg between pts with low or high BB dosage (mean 17.3 vs 17.8 mL/kg, p=0.513).

Conclusion

As mentioned, recent meta-analysis questioned the benefit for long term beta-blocker use on ischemic pts with preserved ejection fraction; indeed, most patients with preserved ejection were under beta-blocker therapy. In this subpopulation the rate of CI was similarly high and positively associated with BB use and lower values of oxygen consumption.

CI is highly prevalent in our population and it is directly related to BB use. Its broad use in pts with coronary artery disease and preserved LVEF is being questioned and those who display CI may be ideal candidates to halt this therapeutic.
Optimizing cardiac rehabilitation adherence: unveiling the potential of remote cardiac telerehabilitation
Authors: Gregorio C , Abrantes A , Cravo J , Simoes De Oliveira C , Garcia A B , Martins A M , Azaredo Raposo M , Sousa P , Fiuza S , Caldeira E , Cordeiro Ferreira M , Cunha N , Aguiar-Ricardo I , Pinto F J , Abreu A
Published: June 2024

Introduction

Participation in Cardiac Rehabilitation (CR) has shown to enhance both morbidity and mortality outcomes in patients (pts) with cardiovascular disease (CV). The socio-demographic (SD) analysis is a crucial part of pt evaluation process to optimize CR adherence.

Purpose

Analyze the influence of SD status on CR adherence and CV risk factors control.

Methods

A single-center prospective cohort study was conducted, involving consecutive pts enrolled in a phase 2 CR program, from 2015 to 2023. SD variables were defined as education level (raging from completion of middle-school to doctorate), marital and employment status. Clinical, laboratory and cardiopulmonary exercise testing (CPET) data, program participation and progression to phase 3 program (CR center, local gym, home gym or no exercise during follow-up) were examined.

Results

A total of 446 pts were included (80% male; mean age 60.5±11.5 years). Overall pts completed on average 14 CR sessions, which corresponds to 92% of scheduled sessions. Among the SD variables, 71% of pts were married, 58% completed their education up to high-school, 42% held at least a Bachelor’s degree and 52.1% were employed. Regarding clinical data, 72.1% of pts had arterial hypertension, 72.2% had dyslipidemia, 26.6% were diabetic and 62.9% were active or past smokers. Regarding exercise program methodologies, 59.5% of pts were enrolled in a CR center and 24.5% of pts were not involved in any physical program. Subgroup analyses revealed that married pts were more likely to complete phase 2 (p=0.031) with a tendency to proceed to a phase 3 program in a CR Center (p=0.056). Similarly, the subgroup of pts with an education up to high-school had a higher % of adherence to phase 2 sessions (p=0.014) and a propensity to CR Center adhesion (p=0.06) and CR Center/Local gym at FUP (p=0.028). Retired/unemployed pts were more likely to complete phase 2 compared to employed pts (p=0.06). Finally, CV risk factor control and improvement in CPET parameters were independent of SD status.

Conclusion

Our study demonstrated a high adherence rate to phase 2 CR program, especially in patients with lower levels of education, likely associated with a less demanding work schedule and in married patients. This work highlights the importance of developing strategies, particularly cardiac telerehabilitation, for certain patient subgroups to optimize adherence.
Unlocking physical potential: the crucial role of cardiac rehabilitation in enhancing physical capacity
Authors: Inacio Cazeiro D , Mendes Cravo J , Vilela M , Ferreira D , Abrantes A , Azaredo Raposo M , Gregorio C , Afonso G , Araujo G , Miguel Correia S , Costa J , Cunha N , Aguiar-Ricardo I , J Pinto F , Abreu A
Published: June 2024

Introduction

Cardiac rehabilitation (CR) is a structured program that combines exercise and education to help patients (pts) recover from cardiac conditions, in order to improve their cardiovascular health and enhance overall well-being and quality of life.

Purpose

To compare cardiopulmonary exercise test (CPET) parameters and 6 minute walking test (6MWT) performance before and after CR program completion.

Methods

Single center prospective study of consecutive pts that completed a center-based CR program from 2015 to April 2023. The CR program included evaluation by a cardiologist physician, nutritionist and psychologist, 2 weekly supervised exercise sessions, and educational sessions. CPET and 6MWT were performed at baseline and after program conclusion. Student T and Pearson correlation tests were used for statistical analysis.

Results

We included 446 pts, 81% males, mean age 60±11 years. Ischemic cardiomyopathy was the main reason for CR referral, followed by dilated and valvular cardiomyopathy in 84%, 6% and 6% of pts, respectively. Most pts had hypertension, 72% had dyslipidemia, 60% of pts were current or former smokers and 20% were diabetic. Most pts were overweight (median BMI 27 kg/m2), mean ejection fraction was 49% and median NTproBNP was 478 pg/mL. Overall, pts completed on average 14 CR sessions, which corresponds to 92% of scheduled sessions. After CR program, pts experienced a significant improvement on CPET parameters with an increase in VO2 peak (17±5 vs 19±5 ml/kg/min, p<0.001), percentage of predicted VO2 peak (66±17 vs 68±17ml/kg/min, p<0.001), O2 pulse (mean 11.7±3 vs 13±5, p<0.001), maximum workload (12±3 vs 135±41 W, p<0.001), duration of CPET (8.5±2 vs 9±3, p<0.001) and total distance on 6MWT (443±105 vs 558±113m, p<0.001), as well as a decrease in optimal cardiorespiratory point (OCP) (27±6 vs 26±6, p=<0.001), reflecting physical capacity improvement. This improvement was consistent when performing subgroup analysis for gender, people older than 70 years, obese pts (defined as BMI>30kg/m2), ischemic and non-ischemic cardiomyopathy. We found a positive correlation between program adherence and improvement in VO2 peak, VO2 pulse and OCP (rs 16%, p=0.045; rs 16% p=0.042 and rs 26% p=0.001, respectively).

Conclusion

In our population, CR program significantly improved CPET and 6MWT performance and enhanced physical fitness and well-being, especially in patients with higher program adherence rates.
Is there a role for cardiopulmonary exercise testing in genotype positive phenotype negative individuals?
Authors: Abela M , Scicluna J , Karlsson F , Gauci M , Felice T , Scerri C
Published: June 2024

Introduction

Genetic testing in cardiomyopathy is now recommended by most scientific societies. It is useful for phenotypical characterisation, risk stratification and genetic segregation. Current guidelines recommend a comprehensive evaluation on all genotype positive (G+) phenotype negative (P-) that should also include advanced cardiac imaging. The role of exercise testing in those with pre-clinical disease has never been explored.

Objective

The main objective of this study was to evaluate cardiopulmonary exercise testing (CPET) data in G+ P- individuals. Only those with a cardiomyopathy gene would be included.

Methodology

G+ P- who were referred for CPET testing were included. CPET was performed on an ergometer using a ramp protocol. Cardiac limitation was defined as having ≥2 abnormal CPET variables: low VO2 MAX, low O2/Pulse, high VE/VCO2, low VO2/WR, low PETCO2 at peak exercise, low HR recovery, inappropriate blood pressure response, new ECG changes and ventricular arrhythmias.

Results

16 subjects fulfilled the inclusion criteria (62.5% female, mean age 44.8±16.9 years). A fourth engaged in >4 hours of physical activity weekly. Most had a family history of cardiomyopathy (DCM 68.8%, AC 12.5%, Fabry 6.3%, HCM 6.3%). A third (31.3%) had a family history of sudden cardiac death. Patients were G+ for ACTC1 (29.4%), TTN (29.4%), MYBPC3 (11.8%), DSG2 (11.8%), GLA/NEXN/MYH7 (each 5.9%).

Minority (31.3%) had symptoms. Resting ECG was abnormal in 37.5% of cases. Echocardiography was normal in all patients. Most (68.8%) underwent a cardiac MRI, none had features suggestive of cardiomyopathy. The remaining scans were pending at the time of submission or turned down by participants.

All successfully completed a maximal exercise test. Most subjects fulfilled criteria for cardiac limitation during exercise (87.6%), most (68.8%) having 3 or more abnormal CPET variables (Table 1). Aerobic exercise capacity was reduced in half of participants. O2/Pulse was reduced in 37.5%, VE/VCO2 was increased in 31.3%, VO2/WR was reduced in 62.5% and PETCO2 at peak exercise was low in 56.3%. A fourth experienced new repolarisation changes. A third (31.3%) experienced ventricular arrhythmias during exercise.

Conclusion

Evidence of a cardiac limitation during CPET in G+ P- subjects is a frequent finding, potentially contributing to more elaborate phenotyping. Its predictive role in P- (at baseline) individuals should be explored in larger cohorts.
Association between exercise capacity and bone mineral contents measured by bioelectrical impedance analysis in patients with coronary artery disease
Authors: Kanazawa M , Honjo H , Konno T , Takahashi H , Takahashi S , Kaagaya Y , Saito H , Sato K , Kondo M , Miura M , Kawatsu S , Endo H , Oda K , Nakamura A
Published: June 2024

Background

Associations between osteoporosis and heart failure or cardiovascular disease have been already reported, however, there are few reports about the association between exercise capacity and bone mineral content (BMC) measured by bioelectrical impedance analysis (BIA) in patients with coronary artery disease (CAD).

Purpose

In the present study, we aimed to elucidate association between BMC and exercise capacity in CAD patients.

Methods

We performed cardiopulmonary exercise testing and BIA in total 181 patients (age 63.1±10.7 years old) who admitted to our hospital by CAD. They were treated with medical treatment (n=5), percutaneous coronary intervention (n=134) or coronary artery bypass grafting (n=42). The patients implanted cardiac devices such as pacemaker or implantable cardioverter-defibrillator were excluded. We analyzed the association between BMC measured by BIA and parameters of exercise capacity, laboratory date of blood hemoglobin concentration (Hb), estimated glomerular filtration rate (eGFR), and the parameters of echocardiography (left ventricular ejection fraction, left ventricular dimension, left atrium dimension, E/A).

Results

BMC showed significant correlation between peak oxygen uptake (peak VO2/W：r=0.312, p＜0.001), peak oxygen pulse (peak VO2/HR：r=0.582, p＜0.001). The parameters of echocardiography showed no significant correlation between BMC. In the laboratory data, Hb showed a significant correlation between BMC (r=0.399, p<0.001), whereas eGFR did not.

Conclusions

The present study demonstrated that BMC showed significant correlations between exercise capacity such as peak VO2/W, peak VO2/HR, and Hb in CAD patients. Both exercise capacity and BMC are strong indicator of prognosis. We also have to take care of bone metabolism in treatment of CAD patients.
Does lifetime sports participation increase the risk of having a pacemaker installed due to bradycardia?
Authors: Bondarev S , Achkasov E , Zorzi A , Safaryan A , Graziano F
Published: June 2024

Introduction

Traditionally, sinus bradycardia and AV block in athletes have been associated with vagus nerve activity. It is known that exercise can cause a decrease in the density of key ionic currents involved in the generation and conduction of impulses in the heart. This remodeling can persist over long periods of time, exacerbating age-related intrinsic dysfunction. The purpose of our study was to examine the characteristics of former professional athletes with a pacemaker due to idiopathic SA and AV node dysfunction, compared with a sedentary control group.

Methods

18 former professional athletes (9 men, 9 women, mean age 69±13 years), group 1. Of these, 9 were involved in endurance sports (endurance subgroup), 9 were engaged in strength disciplines, strength subgroup. The control group consisted of 343 patients, of which 20 people had idiopathic dysfunction of the sinus and/or AV node (10 men, 10 women, 75.2±10.4 years, group 2). 323 patients (182 men, 141 women, 75.0±11.4 years) had various cardiac pathologies and made up the 3rd group. Clinical data, anamnesis, Holter monitoring, and echocardiography were analyzed.

Results

The age of diagnosis of SA or AV block and pacemaker (PM) implantation was significantly higher in the strength subgroup of group 1 compared to the endurance subgroup (72.4±9.5 and 64.0±7.5 years, p<0.01; 68 .5±13.0 and 65.0±11.7 years, p<0.05). The prevalence of AV block was higher in the endurance subgroup (78%) compared to the strength subgroup (48%), p < 0.05. At the time of implantation, the average age in the strength subgroup and group 2 did not differ (73.0±10.3 and 75.2±8.3 years, p>0.05), but was significantly lower (65.0±11.7 years, p<0.01) in the endurance subgroup. The age of PM installation in group 3 was lower than in groups 1 and 2 (72.4±7.4 and 75.2±8.3 years, p<0.05; 72.4 and 68.5±13.0 years, p<0.01, respectively). Other clinical characteristics did not differ between individuals in groups 1 and 2. The role of sports activities is evidenced by the correlations obtained for group 1 between the age of onset of first complaints (46.7±16.3 years), diagnosis (65.0±9.3 years), age of PM installation (68.5±13.0 years) and duration of sports in years (12.3±6.2 years), r=0.3, r=0.5, r=0.5 at p<0.05, respectively. A correlation coefficient was obtained between the age of stopping sports (25.2±7.5 years) and installation of PM (68.5±13.0 years) r=0.3 at p<0.05.

Conclusions

former professional endurance athletes with idiopathic SN dysfunction/AV block manifested the disease earlier in the life course compared to former power/mixed athletes and non-athletes. The nature and duration of sports play an important role in the formation of SA and AV conduction disorders. This suggests that bradycardia/AV block caused by intense and prolonged endurance sports may not always be a benign and adaptive phenomena.
Asynchronous segmental early relaxation phenomenon in endurance athletes with exercise
Authors: Allwood R , Janssens K , Mitchell A , Spencer L , Claessen G , La Gerche A
Published: June 2024

Background/Introduction

Asynchronous segmental early relaxation phenomenon (ASERP) is the sudden localised outward motion of a portion of the left ventricular wall occurring in the early phase of isovolumic relaxation period. It has been seen in patients with normal or diseased hearts and observed at rest and with exercise echocardiography. However, its prevalence and mechanisms are not well described in the athletic population.

Purpose

The aim of this study is to determine the prevalence of ASERP and its clinical features in elite endurance athletes compared to healthy non-athletes with exercise. To investigate its associations with left ventricular mechanics and cardiopulmonary exercise testing-derived aerobic capacity.

Methods

This is a retrospective observational cohort study of 21 endurance athletes (34 ± 10 years of age, 81% male) and 11 non-athletes (31 ± 10 years of age, 82% male), free from known cardiovascular disease. Participants were assessed with a 12-lead electrocardiogram (ECG), resting transthoracic echocardiogram, cardiopulmonary exercise test (CPET), and exercise stress echocardiogram (ESE) at a research institute. Athletes had participated in endurance exercise for an average of 19.4 ± 7.3 years. The majority were cyclists (38%), who trained 13.1 ± 6 hours per week of moderate to high-intensity exercise.

Results

ASERP was observed in 47.6% of athletes and 45.5% of non-athletes with exercise, with 70% of athletes having more than 1 segment involved. Only 26 of 384 analysed segments were positive for ASERP, occurring in 7.5% of segments in athletes and 5.3% in non-athletes. The apical septum and lateral septum were most commonly involved in 58% and 19%, respectively. Athletes and non-athletes with ASERP had a higher prevalence of early repolarisation on resting ECG (73 vs. 24%, p=0.012), higher mean rate pressure product (p=0.038) and greater change in mean peak systolic blood pressure (p=0.020) on CPET. An exaggerated blood pressure response more commonly occurred in athletes with ASERP. On echocardiography, lower mean strain rate in early diastole (SRe) 4Ch (p=0.036) and mean SRe in the apical septum (p=0.034) occurred at rest, and after exercise a higher mean SRe 4Ch (p=0.044) occurred in those with ASERP. ASERP did not significantly impact VO2max (p= 0.991).

Conclusion(s)

ASER is a relatively common phenomenon occurring in exercise stress echocardiography in endurance athletes and non-athletes. ASERP predominantly occurred in the apical septal and lateral segments, with a slightly higher prevalence seen in endurance athletes, often occurring in multiple segments. ASERP may be sensitive to acute changes in left ventricular loading conditions, occurring in those with a high hemodynamic response, and greater changes in systolic blood pressure and SRe with exercise. Future work incorporating load-independent assessment of myocardial work may be useful. Figure 1Two athletes with ASERP.  Figure 2ASERP with enhanced strain.
The impact of drug use in athletes on resting LV systolic function and contractile reserve
Authors: Marwaha S , Bulleros P , Fanton Z , Maclachlan H , Bhatia R , Finocchiaro G , Prasad S , Gati S , Papadakis M , Sharma S
Published: June 2024

Background

Consumption of recreational or performance enhancing agents can have long term adverse effects on the cardiovascular system, however, the effect of these agents on left ventricle size and the contractile reserve is unclear.

Method

145 male athletes with dilated left ventricle (LV) completed a confidential questionnaire enquiring about recreational and performance enhancing drug use and subsequently underwent a stress echocardiogram and cardiovascular magnetic resonance (CMR) imaging. Basal and peak left ventricular ejection function (LVEF) during stress echocardiography were used to determine. contractile reserve volumetric analysis on CMR imaging was used to determine LV size.

Results

44(30%) of athletes had acknowledged using recreational or performance enhancing drugs 12(8%) had used a form of anabolic drugs and 32 (22%) had used forms of non-anabolic drugs (such as cocaine, ecstasy and cannabis). Drug use was more commonly seen in gym/body building, 41.7% followed by 30.4% in runners, 28.5% in dual athletes, 28% in cyclists, 27.2% in rowers/skiers.

There were no significant differences in the mean indexed LV diastolic volumes between none-drug users, anabolic drug users and non-anabolic drug users(113.3ml/m2, 11.1ml/m2 and and 118ml/m2 respectively). Athletes who had taken anabolic steroids had a lower baseline LVEF compared to non-drug users with an of 52.5% and 56.59% and 56.5% respectively; p= 0.04.

Contractile reserve was significantly higher in anabolic users with an increase in mean LVEF from baseline to peak exercise of 22.7% compared with 16.1% in non-drug users and 14.4% in non-anabolic drug users (p value 0.034).

Conclusion

Recreational and performance drug use is relatively common amongst athletes. Anabolic drug use was associated with a baseline low LVEF but with high contractile reserve mimicking the situation of the true grey zone athlete (dilated LV with borderline LV function). We suspect initial increase in myocardial reserve reflects the Starling phenomenon of augmented stroke volume due to increased LV load, however, the long-term consequences of this phenomenon require further study.
Performance of the 'International Criteria' for interpretation of athletes' ECGs in a Dutch cohort
Authors: Bultman L , Snoek J A , Jongman J K
Published: June 2024

Background/introduction

The prevalence of false-positive ECGs in cardiovascular pre-participation screening has historically been high. These false positives screening outcomes lead to additional health care costs. The most recent criteria for interpretation of athletes’ resting ECGs are the ‘International Criteria’ published in 2017. These criteria aim to reduce the amount of false positive ECGs, while preserving sensitivity. To assess the performance of these criteria in daily practice, evaluation across diverse cohorts is imperative.

Purpose

Our study aimed to assess the performance of the International Criteria within our Dutch cohort. The primary objective was to evaluate the impact of the International Criteria on the number of abnormal ECG’s, compared to the previous criteria (ESC 2010, Seattle, and Refined).

Methods

In this prospective observational cohort study all preparticipation screenings in a Dutch hospital between April 2016 and March 2023 were recorded in a database. Retrospectively, all ECGs were systematically re-evaluated. Statistical analysis was performed using McNemar's test for paired binary data.

Results

A total of 1862 ECGs were included. This cohort included both elite and amateur athletes aged 12-35 years. Application of the International Criteria classified 36 ECGs (1.9%) as abnormal, whereas use of the ESC 2010, Seattle, and Refined criteria resulted in 888 (47.6%), 70 (3.7%), and 73 (3.9%) abnormal ECGs, respectively. Applying the International Criteria significantly reduced the number of abnormal ECGs compared to the previous criteria (all p<0.001). This reduction was mostly due to optimalisation of the definitions used in the borderline category. The sensitivity for known pathology within our cohort was 100% when using the International Criteria.

Notably, the newer definition for pathologic Q waves, as described in the Refined and International Criteria, did not decrease the prevalence of abnormal Q waves in our cohort. Abnormal Q waves were the most frequent observed abnormality, accounting for 70% of observed abnormalities in our female population. Another finding was the presence of an extreme axis in 18 athletes (0.97%). However, this is not considered an abnormal finding in the International Criteria.

Conclusions

Use of the International Criteria shows a significant and clinically relevant reduction of the number abnormal ECGs within this Dutch cohort, without an apparent reduction in sensitivity. One of the aspects with considerable potential for optimalization for future criteria appears to be the definition used for abnormal Q waves. Another potential improvement could be defining criteria for interpretation of ECGs with an extreme axis. Amount of abnormal ECGs and sensitivity.  Prevalence of abnormalities using IC.
Interpretation of athlete's ECG in a pediatric population using the International Criteria
Authors: Graziano F , Manfrin L , Genta E O , Balla D , Vago H , Zorzi A , Corrado D , Brusamolin L , Giada F
Published: June 2024

Background

In Italy, the starting age for pre-participation screening (PPS) is defined by the single sports federations and sometimes includes individuals under the age of 12. Current International Criteria for ECG interpretation in athletes are recommended for subjects between 12 and 35 years of age.

Purpose

To define the prevalence of ECG alterations (normal, borderline, abnormal) in the ≤12 years population compared to older athletes, and to define which of these are training-related. To assess the applicability of the 2017 International Criteria to a population ≤12 year-old.

Methods

Athletes of both sexes, aged 7-18 years, undergoing PPS in the period 2019-2022, regardless of the sport discipline, were retrospectively enrolled. The screening protocol for competitive athletes is defined by Italian law. The ECG was interpreted according to the recommendations of the 2017 International Criteria.

Results

The final population was composed by 2140 athletes (mean age 12.5 ±2.61 years, 60% ≤12 years). No statistically significant differences were found in the percentage of normal (98% vs 97%, p=0.4), borderline (1.8% vs 1.5%, p=0.5) and abnormal (0.5% vs 1.2%, p=0.06) alterations in the group ≤12 years compared to >12 years. The most frequently observed ECG abnormalities were incomplete right bundle branch block (iRBBB, 22.8%), early repolarisation (14.8%) and left ventricular hypertrophy (13.8%). When comparing the two age groups, a statistically significant difference was found in the prevalence of sinus bradycardia (SB, 0.6% vs 8.2%, p<0.001), 1st degree atrio-ventricular block (AVB, 0.2% vs 1.6% p<0.001) and T-wave inversion in V1-V3 (7.3% vs 2.3%, p<0.001) (Figure 1). Furthermore, in the younger age group, there was no correlation between the prevalence of these ECG changes and the level of training.

Conclusions

SB and 1st degree AVB are extremely rare in athletes ≤12 year-old and do not appear to be training-related, and therefore should be considered as abnormal findings in this population. Furthermore, in both groups, complete RBBB, 2nd degree Mobitz 1 AVB and the presence of one premature ventricular beat on ECG should also be classified as abnormal. The results highlight the limitations of using International Criteria for the interpretation of the athlete's ECG in young people under 18 years, and particularly under 12. Figure 1
The role of depression in ischemic heart disease- An analysis of NHANES database 2017-2018
Authors: Truong N N K , Hayashi M , Vu V H
Published: June 2024

Background

Recent studies have shown frequent co-occurrence of depression and ischemic heart disease (IHD). However, the association between depression and IHD has not been elucidated. I conducted the study on National Health and Nutrition Examination Survey (NHANES) database 2017-2018 to investigate the potential correlation between the severity of depression, as assessed by the Patient Health Questionnaire-9 (PHQ-9), and IHD, while also accounting for possible confounders and mediators that may impact this relationship.

Methods

This is a cross-sectional study analyzing NHANES surveillance data for the period 2017 to 2018. NHANES is a cross-sectional survey that is conducted in a two-year cycle. Since 1999, continuous NHANES surveys have been done. We skipped over the older NHANES cycles from 1999-2000 to 2005-2006 due to the difference in how physical activity is measured. NHANES 2017-2018 is the most completed cycle because the following cycles were conducted during the COVID-19 pandemic. The study enrolled individuals aged 20 years or above, who were required to fill out questionnaires assessing their cardiac health and the severity of their depressive symptoms. Depression was classified into three categories based on the PHQ-9 score: none or minor (scored 0-4), moderate (scored 5-14), and severe (scored greater than 15). Multivariable logistic regression model was used to explore the relationship between depression severity and IHD. In addition, we also investigate the interaction of gender and depression severity in this model.

Results

A total of 1,557 participants were included in the study. Amongst those, 90.36% of study population reported no history of cardiovascular diseases. Male and female proportion was comparable, with female accounted for 56%. Depression severity measured by PHQ-9 scale was associated with IHD, with OR= 0.87, 95% CI 0.48- 1.53 for moderate depression and OR= 2.18, 95% CI 0.48- 5.03 for severe depression (p= 0.096). Female was significantly associated with a lower odds of IHD (OR= 0.46, 95%CI 0.26-0.79, p= 0.006). Interestingly, female with moderate depressive symptoms had higher odds of IHD compared to male. Meanwhile, individuals with severe depression were found to be at higher risk for IHD, independent of their gender.

Conclusion

In this cross-sectional study, the results imply that depression may be a risk factor for IHD in addition to other well-known traditional risk factors. Consequently, it is recommended that individuals at elevated risk for IHD, particularly women, undergo screening for depression.
Comparing protocol-led lipid management with daily practice in post-myocardial infarction patients
Authors: Van Trier T J , Omar Khader A , Liem A H , Groenemeijer B E , Schut A , Tijssen J G P , Martens F M A C , Alings M A
Published: June 2024

Introduction

The PENELOPE study demonstrated the effectiveness of a 3-step, guideline-based lipid management strategy in achieving low-density lipoprotein-cholesterol (LDL-C) goals in very high-risk atherosclerotic cardiovascular disease (ASCVD) patients. However, this was an uncontrolled observation. The PENELOPE-CTRL study therefore retrospectively compared these findings with real-world lipid management practices in the Netherlands.

Methods

Between 2019 and 2020, the PENELOPE study enrolled 663 patients <70 years with acute coronary syndrome with a history of diabetes mellitus or ASCVD, to investigate a 3-step lipid lowering treatment (LLT) intensification (statins, +ezetimibe, +PCSK9 inhibitors) to achieve LDL-c ≤1.8 mmol/L. For the comparative analysis, the real-life PENELOPE-CTRL (N=827) comprised a comparable cohort of retrospectively included patients with similar inclusion criteria. The primary outcome was the proportion of patients reaching an LDL-C target of ≤1.8 mmol/L within six months and at one-year follow-up.

Results

Baseline lipid management was similar in both cohorts, with 33% in PENELOPE vs. 32% in PENELOPE-CTRL on target. The stepwise protocol outperformed real-life practice, with 86% (95% CI 83%-88%) vs. 55% (95% CI 51%-58%) reaching an LDL-c ≤1.8mmol/L within the study period (p<0.001). After one year, this effect was attenuated but remained statistically significant in favour of the intervention (LDL on target 64% (95% CI 60%-68%) vs. 55% (95% CI 50%-60%), p=0.008).(Figure 1).

Conclusion

Using a stepwise lipid protocol significantly improves the proportion of patients reaching LDL-C target in very high-risk post-acute coronary syndrome patients compared to real-life controls. These effects were attenuated after one year follow-up, suggesting the need for long-term follow-up to lower lipid-driven residual risk. Protocol-led vs. daily LDL-C management.
Cholesterol paradox in atrial fibrillation: is it solved in lipid-lowering drugs users?
Authors: Bartos B , Cyganski P , Rynkiewicz A , Morze J
Published: June 2024

Background

In recent years, a growing number of prospective observational studies have consistently observed a paradoxical inverse association between atherogenic lipid fractions, particularly low-density lipoprotein cholesterol (LDL-C) and incident atrial fibrillation (AF), suggesting a protective role of hypercholesterolemia. However, elevated lipid levels at baseline study examinations increase likelihood of lipid-lowering therapy (LLT) initiation during follow-up, introducing substantial time-varying confounding. Consequently, patients under LLT may represent a more homogeneous clinical group for further exploration of the "cholesterol paradox" in AF.

Purpose

We aimed to investigate the association of baseline serum and genetically-predicted LDL-C levels with risk of AF development in patients receiving LLT.

Methods

We conducted a prospective cohort study of 90,114 UK Biobank participants aged 40–69 years, who did not have history of AF at baseline and who reported use of any kind of LLT during a nurse-led interview. Baseline LDL-C was measured in non-fasted serum samples using a direct assay. For genetically-predicted LDL-C, we used a previously published polygenic risk score (PRS). We used Cox proportional hazards regression to estimate AF risk associated with serum and genetically-predicted LDL-C levels. We considered two covariate adjustment sets: Model 1 - including age, sex and body mass index; and Model 2 further including ethnicity, deprivation index, smoking status, alcohol intake, systolic and diastolic blood pressure, glycated hemoglobin, anti-hypertensive and anti-diabetic medication use, prevalent coronary heart disease and valvular heart disease. Potential non-linearity was explored using restricted cubic splines.

Results

During a median of 13.1 years (1,199,436 person-years) of follow-up, 11,164 participants developed incident AF. The median baseline serum LDL-C was 2.9 mmol/L [interquartile range: 2.4-3.4 mmol/L]. In Model 1, a 1 mmol/L increase in LDL-C level was associated with lower risk of AF (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.73-0.77). Following further covariate adjustment (Model 2), the inverse association between LDL-C and risk of AF was attenuated (HR: 0.98, 95%CI: 0.96-1.01). There was no evidence for nonlinearity (Figure 1) of these associations (P-nonlinearity=0.74 and 0.63). PRS for LDL-C was neither associated with AF in Model 1 (HR per 1 standard deviation increase: 0.96, 95%CI: 0.92-1.00) nor Model 2 (HR: 0.97, 95%CI: 0.93-1.02).

Conclusions

In a cohort of patients receiving LLT, an inverse link between LDL-C and AF disappeared after adjustment for other clinical factors. Additionally, the absence of genetic evidence supporting a protective role of lipids further suggests that the "cholesterol paradox" in AF may be attributed to residual confounding rather than a causal relationship.
Direct oral anticoagulants compared to warfarin in morbidly obese patients on anticoagulation: a systematic review and meta-analysis
Authors: Sagris M , Ktenopoulos N K , Pamporis K P , Theofilis P T , Toutouzas K T , Tsioufis K T , Tousoulis D T
Published: June 2024

Introduction

Current guidelines and consensus statements advise against the use of direct oral anticoagulants (DOACs) for morbidly obese patients with body mass index (BMI) > 40 kg/m2, indicating warfarin as the first-line treatment.

Methods

We systematically searched databases from their inception to October 3, 2023, to review and examine the effectiveness and safety of DOACs compared to warfarin in patients with BMI > 40 kg/m2 and atrial fibrillation (AF) or venous thromboembolism (VTE). The outcomes of all-cause mortality, major and minor bleeding, stroke/systematic embolism (SE), and VTE their composite endpoint were analyzed using a random-effect model.

Results

This meta-analysis comprised 21 studies and 116,670 morbidly obese patients with AF or VTE on oral anticoagulation therapy -50,116 on DOACs (43%) vs. (57%) 66,554 on Warfarin-. The DOAC use was significantly associated with lower all-cause mortality and major bleeding risk compared to the warfarin group. Although the risk of composite endpoint, stroke/SE, and VTE were lower in the DOAC group, no statistically significant difference was observed, indicating no superiority of Warfarin compared to DOAC use. The risk of minor bleeding events, hemorrhagic stroke, and ischemic stroke were lower in the DOAC compared to the warfarin group. The same trend favoring DOACs over Warfarin in all assessed endpoints was observed in the subgroup analysis based on anticoagulation indication (AF or VTE).

Conclusion

Our findings are of paramount importance indicating, firstly, the non-superiority of Warfarin compared to DOAC use, and secondly, a significantly better profile of DOACs in terms of safety and effectiveness in morbidly obese patients with BMI > 40 kg/m2 in all the assessed endpoints.
Comparison of changes on left atrial function obtained after two regimes of combined exercise in patients with coronary heart disease
Authors: Caminiti G , Marazzi G , D'antoni V , Morsella V , Catena M , Vadala S , Di Biasio D , Silvestrini M , Volterrani M
Published: June 2024

Introduction

Left atrial function is impaired in patients with coronary heart disease (CHD) and reflects a rising left ventricular diastolic pressure. The effects of exercise training on atrial function are poorly understood.

Aim

investigating the effects of two regimes of combined exercise training (CT) program on left atrial function in patients with CHD.

Methods

The study included 45 stable patients, who were randomly assigned to three groups: fifteen pts were assigned to a supervised CT with low frequency (two session/week) (CTLF); fifteen to supervised CT with high frequency (three session/week) (CTHF); a third group was asked to follow contemporary exercise preventive guidelines at home (control). The CT lasted 12-weeks. Before and after training, all patients performed a symptoms-limited exercise test and an echocardiography. The training included aerobic continuous at moderate intensity, and resistance exercise performed at 60% of 1 repetition maximum.

Results

At 12-weeks, exercise duration at ergometric test presented a significant greater increase in the CTLF and CTHF groups compared to control (p 0.002). Peak atrial longitudinal strain (PALS) and conduit phase presented a significant increase in the CTHF and were unchanged in CTLF and control (p 0.008). Peak atrial contraction strain (PACS) presented a greater increase in CTHF than control. Left ventricular global longitudinal strain, increased significantly in both CTHF and CTLF compared to control (p 0.004). No side effects were observed.

Conclusions

A regimen of CT at high frequency was more effective than low frequency in improving atrial function in CHD patients.
The impact of cardiac rehabilitation on muscle strength: a crucial element of functional capacity
Authors: Garcia A , Oliveira C , Martins A , Abrantes A , Alves Da Silva P , Roxo D , Ramalhinho M , Poupino J , Alves M , Cunha N , Aguiar Ricardo I , Pinto F , Abreu A
Published: June 2024

Introduction

Cardiac rehabilitation (CR) is defined as a multidisciplinary program encompassing exercise training, modification of cardiovascular risk factors, and psychosocial assessment. Physician-prescribed exercise is a crucial and safe component that can significantly enhance the quality of life and functional capacity.

Purpose

The purpose of this study is to assess whether improvements in muscular strength have an impact on functional capacity.

Methods

A prospective analysis of patients enrolled in a cardiac rehabilitation phase two program was conducted. Standardized forms were utilized to collect patient data, including baseline characteristics, muscle strength evaluation (upper and lower limb strength and Time Up and Go test), the six-minute walking test (6MWT), and cardiopulmonary exercise test. Descriptive and inferential statistics were performed.

Results

We enrolled 446 patients participating in the phase two CR program (81% male; mean age at the program's beginning was 61+/-11 years). The mean number of exercise sessions performed was 14+/-6. Among them, 85% had ischemic heart disease, 6% had valvular heart disease, and 3% had dilated cardiomyopathy. During the initial assessment, 73% of patients were in NYHA functional class II, 19% in NYHA I, and 8% in NYHA III. Forty-three percent of patients had a reduced left ventricular ejection fraction (LVEF <50%). Throughout the CR program, there was an improvement in lower limb (mean value increased from 15 Kg to 20 Kg, p=0.001), upper limb strength (mean value increased from 19 to 23 Kg, p=0.001), and in the time taken for the Up and Go test (a decrease in mean time from 14 s to 9 s, p=0.001). Patients demonstrating improvement in at least one of these parameters also showed, at the end of the programme, enhanced 6MWT mean time (from 454 to 569 meters), peak VO2 (from 15 to 17 mL/Kg/min), and the duration of cardiopulmonary stress testing (from 7:50 to 8:39) (p=0.001). In patients with reduced LVEF, there was a tendency toward enhanced 6MWT time in those who showed improvement in all the three upper and lower limb strength and in the Time Up and Go test compared with those who do not improve in all these tests (620 to 553 meters), which did not reach significance.

Conclusion

Strength exercise is a vital component of CR programs and can significantly contribute to improvements in functional capacity. Therefore, its practice should be emphasized to enhance overall program effectiveness. Particularly in patients with reduced ejection fraction, a global strength improvement can have a positive impact on daily life functional capacity.
Outcome of early intervention in sudden cardiac arrest during exercise: case series
Authors: Baiazid D , Alhashimi H , Alassaf O , Musa A
Published: June 2024

Introduction

Exercise is frequently promoted in the realm of health and wellness as a cornerstone of vitality and longevity especially in young healthy individuals. However, for individuals with undiscovered coronary artery disease (CAD), an unexpected threat can emerge from sudden cardiac arrest (SCA).

Purpose

We are evaluating young patients presenting with cardiac arrest during strenuous exercise and found to have significant CAD.

Methodology

In this cross-sectional study all patients who were admitted as a case of post-exercise cardiac arrest between the years 2020 to 2023 and found to have CAD were evaluated. Their demographics, past medical history, laboratory workup findings, quality of CPR, coronary angiography (CAG) findings and outcomes were evaluated. Descriptive analyses were used to report results.

Results

7 cases fulfilled the inclusion criteria all of which were male with a mean age of 41 years old (range: 28-51). All patients had immediate high-quality cardiopulmonary resuscitation (CPR) starting at the time of collapse, the average CPR time till ROSC was 32.4 minutes (range: 10-47). Three patients (43%) were not known to have any comorbidities; 14% had diabetes mellitus, 29% had dyslipidemia, and 29% had previous ischemic heart disease. Furthermore, analysis of the laboratory workup of the three patients not known to have any comorbidities did not reveal any undiscovered comorbidity. Post-ROSC ECGs showed 3 anterior (43%), 3 inferior (43%) and 1 posterior (14%) territory changes and urgent CAG showed the Left Anterior Descending artery to be the culprit artery in four of the patients, Right Coronary artery in two and the Left Circumflex in the other two. 57% of patients were discharged alive, 29% of which had a neurological deficit, while 43% were deceased.

Discussion: Although cardiac arrest is not a common presentation of CAD, exercise can induce coronary stenosis and an adrenaline surge that can cause ventricular arrhythmias and/or cardiac arrest. While most patients in our study experienced positive outcomes, it's important to note that not all shared this favorable result. This variation emphasizes the importance of early intervention managing exercise-related cardiac events. Moreover, our study illustrates the importance of immediate high-quality CPR for better outcomes.

Conclusion

Strenuous exercise may precipitate cardiac arrest in individuals with undiscovered coronary artery disease; however, early life-saving interventions including high-quality CPR and percutaneous coronary intervention (PCI) have the potential to improve the overall prognosis.
Predictors of moderate-to-vigorous intensity physical activity prior to enrollment in cardiac rehabilitation
Authors: Kambic T , Hadzic V , Lainscak M
Published: June 2024

Background

Patients with cardiovascular diseases, especially coronary artery disease (CAD) frequently have high levels of sedentary behaviour and low levels of moderate-to-vigorous physical activity (MVPA). While some determinants of sedentary behaviour have been established in patients completing out-patient cardiac rehabilitation (CR), the factors influencing MVPA levels remain largely unknown in CAD patients prior to enrolment to CR.

Purpose

This study aimed to investigate the associations between baseline clinical characteristics, body composition, (sub)maximal physical performance, blood biomarkers and MVPA levels in patients with CAD prior to enrolment to CR.

Methods

Sixty-four patients with CAD were recruited in the routine, out-patient CR and 61 completed the study (72% men): mean (SD) age = 61 (8), height = 172 (8) cm, weight = 85 (15) kg, left ventricular ejection fraction = 53 (9) %. In two measurement days, maximal aerobic capacity (ramp test), glucose and blood lipids (total cholesterol, triglycerides, HDL, LDL), body composition using bioimpedance (body weight, waist-to-hip circumference, fat and lean mass), (sub)maximal physical performance of upper and lower limbs (hand grip test, arm curl test, maximal leg press strength, 10 sit-to-stand test, six min walk test) and physical activity (eight wear days of triaxial accelerometer on right hip) were measured. The predictors of MVPA levels were determined using stepwise multivariate linear regression models.

Results

Patients were predominantly sedentary (daily time = 493 [93] min, daily % = 61 [9] %), with low levels of MVPA (daily time = 66 [28] min, daily % = 8 [4] %). Only maximal aerobic capacity (r = 0.487; p < 0.001), body fat percentage (r = -0.460; p < 0.001), maximal leg press strength (r = 0.256; p = 0.049), arm curl test (r = 0.370; p = 0.003), 10 sit-to-stands (r = -0.415; p = 0.001) and six min walk test distance (r = 0.317; p = 0.013) were correlated with MVPA. After stepwise regression, only maximal aerobic capacity and logarithm (log.) of body fat percentage predicted MVPA and explained 53% of variability in MVPA levels (F = 11,153; p < 0.001). Higher levels of baseline maximal aerobic capacity (beta = + 0.324; p = 0.019) and lower log. body fat mass percentage (beta = - 0.278; p = 0.043) significantly predicted higher levels of MVPA (regression equation: MVPA = 115.57 min + 1.86*maximal aerobic capacity – 58.53* log. body fat mass percentage).

Conclusions

Prior to enrolment in out-patient CR, only maximal endurance and body composition predict baseline levels of MVPA in patients with CAD.