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Although lifestyle interventions are first-line treatment for individuals living with prediabetes and type 2 diabetes (T2D), they are rarely implemented effectively in routine clinical care.We present a retrospective analysis of a 12-month, single-centre, structured multidomain lifestyle intervention clinic offered to patients living with prediabetes and type 2 diabetes. The intervention consisted of expert-guided educational and nutritional counselling combined with a personalized physical exercise prescription with the main goal of improving metabolic health and reaching remission. Anthropometric parameters, glucose, basal insulin, glycated hemoglobin (A1C) and lipid levels were measured at baseline and at 3, 6 and 12 months after the lifestyle intervention initiation. Remission of prediabetes and T2D were defined as a return of A1C at 6 months to6.5% (or5.7% for prediabetes) and persisting for at least 3 months in the absence of glucose-lowering pharmacotherapy.After a multidomain, expert-guided lifestyle intervention, 117 individuals living with prediabetes and T2D had significantly improved metabolic profiles: Mean weight change at 12 months was -4.9 kg (95% confidence interval [CI], -4.0 to -5.7; p0.001), and mean change in A1C at 12 months was -0.6% (95% CI, -0.4 to -0.7; p0.001). A substantial proportion of individuals reached the criteria for remission (20% among participants with prediabetes and 12% among those with T2D).The results of this study suggest that prioritizing lifestyle changes in a multifaceted, progressive, 12-month intervention in this population improves anthropometric and insulin resistance measures and has the potential to normalize metabolic values, even to the point of reaching the criteria of remission.

As global temperatures continue to rise, extreme heat events are becoming more frequent and intense. Extreme heat affects cardiovascular health as it is associated with a greater risk of adverse cardiovascular events, especially for adults with preexisting cardiovascular diseases. Nonetheless, the pathophysiology underlying the association between extreme heat and cardiovascular risk remains understudied. Furthermore, specific recommendations to mitigate the effects of extreme heat on cardiovascular health remain limited to guide clinical practice within the context of a warming climate. The overall objective of this review article is to raise awareness that extreme heat poses a risk for cardiovascular health. Specifically, the review discusses why cardiovascular healthcare professionals should care about extreme heat, how extreme heat affects cardiovascular health, and recommendations to minimise the cardiovascular consequences of extreme heat. Future research directions are also provided to further our understating of the cardiovascular health consequences of extreme heat. A better awareness and understanding of the cardiovascular consequences of extreme heat will help cardiovascular health professionals assess the risk and optimise the care of their patients exposed to an increasingly warm climate.

Finnish sauna bathing habits are associated with a decreased risk of cardiovascular mortality. The physiologic adaptations mediating this association remain to be fully elucidated. This study tested the hypothesis that Finnish sauna bathing acutely improves peripheral flow-mediated dilation (FMD) in middle-aged and older adults with stable coronary artery disease (CAD).Twenty-two adults (20 male, 2 female; 67 ± 10 years) with stable CAD underwent 2 periods of 10 minutes in a Finnish sauna (81.3 ± 2.7°C, 23 ± 3% humidity) separated by 10 minutes of thermoneutral rest. Before and 51 ± 8 minutes after sauna bathing, brachial artery FMD and postocclusive reactive hyperemia (PORH) were evaluated by means of Doppler ultrasound.Sauna bathing increased core temperature (mean +0.66°C [95% CI 0.54-0.77], P0.01) and heart rate (+27 beats/min [24-29], P0.01), and decreased systolic (-19 mm Hg [-31 to -6]; P0.01) and diastolic (-6 mm Hg [-11 to -1], P0.01) blood pressures. Brachial artery FMD was greater after sauna bathing (+1.21% [0.16-2.26], P = 0.04), whereas PORH was unchanged (peak: +0.51 mL/min/mm Hg [-0.13 to 1.15], P = 0.11; area under the curve: +0.21 mL/mm Hg [-0.12 to 0.54]; P = 0.19).A typical Finnish sauna bathing session acutely improves peripheral FMD in middle-aged and older adults with stable CAD.

Introduction and objectives We compared the effects of 12 weeks of low-volume high-intensity interval training (LV-HIIT) vs moderate-intensity continuous exercise training (MICET) on cardiopulmonary exercise test parameters and the proportion of non/low responders (NLR) to exercise training in post-acute coronary syndrome (ACS) patients. Methods Patients with a recent ACS were randomized to LV-HIIT, MICET, or a usual care group. LV-HIIT consisted of 2 to 3 sets of 6 to 10 minutes with repeated bouts of 15 to 30 seconds at 100% of peak workload alternating with 15 to 30 seconds of passive recovery. Cardiopulmonary exercise test parameters were assessed, and key exercise variables were calculated. Training response was assessed according to the median VO2peak change post vs pretraining in the whole cohort (stratification NLR vs high response). Results Fifty patients were included in the analysis (LV-HIIT, n = 23; MICET, n = 18; usual care, n = 9) and 74% were male. The proportion of NLR was higher in the LV-HIIT group than in the MICET group (LV-HIIT 61%, MICET 21%, and usual care 80%; P = .0040). VO2peak-dependent variables (VO2peak, percent-predicted VO2peak) improved in both training groups (P = .002 and P Conclusions In patients with a recent ACS, several prognostic VO2peak-dependent variables were improved after LV-HIIT, but the improvement was more pronounced or only found after MICET. Low-volume HIIT resulted in a higher proportion of NLR than isocaloric MICET. Clinical trialsregistered at ClinicalTrials.gov (Identifiers: NCT03414996 and NCT02048696)

Resumen Introduccion y objetivos Se comparo los efectos de 12 semanas de ejercicio intervalico de alta intensidad y de bajo volumen (EIAI-BV) frente a un ejercicio continuo de intensidad moderada (ECIM), sobre los parametros de la prueba de esfuerzo cardiopulmonar y la proporcion de no respondedores o con baja respuesta (NBR) al ejercicio fisico en pacientes que sufrieron un sindrome coronario agudo (SCA). Metodos Se aleatorizo a pacientes con un SCA reciente a EIAI-BV, ECIM y a cuidados habituales. EIAI-BV consto de 2 a 3 sesiones de 6-10 minutos con periodos de repeticion de 15 a 30 s al 100% de la carga de trabajo alternados con 15-30 segundos de recuperacion pasiva. Los parametros de la prueba de ejercicio cardiopulmonar se evaluaron y se calcularon las variables claves. La respuesta al ejercicio se evaluo con la mediana de VO2 pico de cambio (post- frente a preejercicio) en toda la cohorte estratificada en NBR al ejercicio frente a alta respuesta. Resultados Se incluyo a 50 pacientes en el analisis (EIAI-BV, n = 23; ECIM, n = 18; cuidados habituales, n = 9), el 74% eran varones. La proporcion de NBR fue mayor en el EIAI-BV en comparacion con el grupo ECIM y el grupo de cuidados habituales (el 61 frente al 21 y el 80%, respectivamente; p = 0,0040). Las variables dependientes del VO2 (VO2 pico y porcentaje VO2 pico predicho) mejoraron en ambos grupos de entrenamiento (p = 0,002 y p Conclusiones En pacientes con un SCA reciente, varias variables pronosticas dependientes del VO2 pico mejoraron despues de EIAI-BV, pero la mejora fue mas pronunciada o bien mejoro unicamente despues de ECIM. El EIAI-BV resulto en una mayor proporcion de NBR en comparacion con el ECIM isocalorico. Ensayos registrados en ClinicalTrials.gov (Identificadores: NCT03414996 and NCT02048696)

BACKGROUND Type 2 diabetes (T2D) and pre-diabetes are mostly lifestyle diseases associated with high rates of morbidity, mortality, and health care expenditures. Different intensive lifestyle interventions have shown to be useful for effective control and even reverse these conditions. However, these strategies are rarely implemented as first-line choices. Objectives The Montreal Heart Institute Cardiovascular Prevention Center (EPIC) started a comprehensive lifestyle clinic for patients with T2D in 2019. We sought to study the impacts of a 12-month non-pharmacological intervention on body weight, insulin sensitivity and remission of T2D. METHODS AND RESULTS Between January and December 2019, 105 diabetic patients (HbA1c ≥ 6.5%) were recruited. Anthropometric measures and fasting blood analysis were measured at 0-3-6 and 12 months. All patients received regular nutritional counselling (therapeutic moderate carbohydrate restriction Mediterranean diet) and personalized physical exercise prescription (≥30 minutes of moderate aerobic training, 5 times a week, and strength training). Glucose-lowering therapies, if taken, were not modified unless necessary. Partial and complete remission of diabetes were defined by HbA1c 3.5Kg at 3 months (OR 4.1, 95%CI: 1.5 to 11.1, p=0.005) were significantly more likely to attain partial remission. CONCLUSION Prioritizing lifestyle changes were shown to improve anthropometric and insulin resistance measures even to the point of normalizing some metabolic values among subjects with T2D. These changes were mostly achieved after 3 months and were maintained throughout the intervention.

Background Individuals with coronary heart disease (CHD) exhibit cognitive deficits and cerebrovascular dysfunctions, and are at higher risk of developing dementia. Cognitive function in individuals with CHD has never been studied during acute aerobic exercise. Given the increasing popularity of training at high peak power output (PPO), its impact on cerebrovascular and cognitive functions in individuals with CHD should be further studied. Method Thirty-eight individuals with CHD and 16 healthy controls completed two exercise bouts at 30% and 70% of their individualized PPO on an ergocycle while performing a cognitive task including non-executive and executive conditions. Variations of oxy- deoxy-hemoglobin, and total hemoglobin concentrations were measured on left prefrontal cortex at both PPO using near-infrared spectroscopy. Results Cognitive task performances were equivalent between groups at all intensity levels. Individuals with CHD exhibited larger variation of deoxyhemoglobin in the executive condition and larger variation in total hemoglobin concentration in all task conditions compared to healthy controls at 70% of PPO. Conclusion Exercising at high intensity seems to have a larger impact on cerebral blood volume in CHD patients compared to healthy age-matched controls. Higher exercise intensity has negative impacts on cerebral blood volume variations during a cognitive task in CHD patients and could potentially lead to other neurocognitive dysfunctions. Other studies are needed to determine if a cognitive task administered during an exercise test could help identify individuals with CHD at higher risk of developing cognitive decline.

Objective To develop and validate a self-report questionnaire to measure barriers to regular physical activity (PA) in patients with stable coronary artery disease (CAD). Methods Phase 1: 17 patients completed a semi-structured interview. After grouping and reformulating the reported barriers, their pertinence was reevaluated by the patients. Then, a decision algorithm was used to select items. A principal component analysis was performed to determine content validity. Phase 2: 49 patients completed the questionnaire resulting from phase 1 twice, 7 days apart, and questionnaires to evaluate depression, anxiety, and the level of physical activity. Construct validity was evaluated by analysis of Spearman's correlation coefficient between the total score for the questionnaire and a convergent dimension (anxiety), as well as a divergent dimension (Dijon physical activity score). Internal consistency was evaluated by Cronbach's alpha coefficient. Test-retest reliability was evaluated by the intraclass coefficient (ICC). Results Eleven items were selected after phase 1. The questionnaire presented good face validity and the content validity seemed satisfactory after analysis of the literature by the experts. Construct validity was moderate. Internal consistency was very good (Cronbach's α>0.81). Reproducibility was excellent with an ICC at 0.95. Feasibility was good with less than 3 minutes to complete the questionnaire. Conclusion This questionnaire presents good psychometric properties. A further prospective study should evaluate sensitivity to change and help determine a threshold value indicating the need for a specific behavioral strategy to alleviate barriers to physical activity in these patients.

Purpose The purpose of this study was to establish the relationship between various expressions of relative exercise intensity percentage of maximal oxygen uptake (%VO 2max ), percentage of maximal heart rate (%HR max ), %VO 2 reserve (%VO 2 R), and %HR reserve (%HRR)) in order to obtain the more appropriate method for exercise intensity prescription when using an immersible ergocycle (IE) and to propose a prediction equation to estimate oxygen consumption (VO 2 ) based on IE pedaling rate (rpm) for an individualized exercise training prescription. Methods Thirty-three healthy participants performed incremental exercise tests on IE and dryland ergocycle (DE) at equal external power output (P ext ). Exercise on IE began at 40 rpm and was increased by 10 rpm until exhaustion. Exercise on DE began with an initial load of 25 W and increased by 25 W/min until exhaustion. VO 2 was measured with a portable gas analyzer (COSMED K4b 2 ) during both incremental tests. On IE and DE, %VO 2 R, %HR max , and %HRR at equal P ext did not differ ( p > 0.05). Results The %HRR vs. %VO 2 R regression for both IE and DE did not differ from the identity line %VO 2 R IE = 0.99 × HRR IE (%) + 0.01 ( r 2 = 0.91, SEE = 11%); %VO 2 R DE = 0.94 × HRR DE (%) + 0.01 ( r 2 = 0.94, SEE = 8%). Similar mean values for %HR max , %VO 2 R, and %HRR at equal P ext were observed on IE and DE. Predicted VO 2 obtained according to rpm on IE is represented by: VO 2 (L/min) = 0.000542 × rpm 2 − 0.026 × rpm + 0.739 ( r = 0.91, SEE = 0.319 L/min). Conclusion The %HRR–%VO 2 R relationship appears to be the most accurate for exercise training prescription on IE. This study offers new tools to better prescribe, control, and individualize exercise intensity on IE.

In this review, we discuss the most recent forms of exercise training available to patients with cardiac disease and their comparison or their combination (or both) during short- and long-term (phase II and III) cardiac rehabilitation programs. Exercise training modalities to be discussed include inspiratory muscle training (IMT), resistance training (RT), continuous aerobic exercise training (CAET), and high-intensity interval training (HIIT). Particular emphasis is placed on HIIT compared or combined (or both) with other forms such as CAET or RT. For example, IMT combined with CAET was shown to be superior to CAET alone for improving functional capacity, ventilatory function, and quality of life in patients with chronic heart failure. Similarly, RT combined with CAET was shown to optimize benefits with respect to functional capacity, muscle function, and quality of life. Furthermore, in recent years, HIIT has emerged as an alternative or complementary (or both) exercise modality to CAET, providing equivalent if not superior benefits to conventional continuous aerobic training with respect to aerobic fitness, cardiovascular function, quality of life, efficiency, safety, tolerance, and exercise adherence in both short- and long-term training studies. Finally, short-interval HIIT was shown to be useful in the initiation and improvement phases of cardiac rehabilitation, whereas moderate- or longer-interval (or both) HIIT protocols appear to be more appropriate for the improvement and maintenance phases because of their high physiological stimulus. We now propose progressive models of exercise training (phases II-III) for patients with cardiac disease, including a more appropriate application of HIIT based on the scientific literature in the context of a multimodal cardiac rehabilitation program.

The aims of this work were (1) to compare cerebral oxygenation-perfusion (COP), central hemodynamics, and peak oxygen uptake (V˙o2peak) in heart transplant recipients (HTRs) vs age-matched healthy controls (AMHCs) during exercise and recovery and (2) to study the relationships between COP, central hemodynamics, and V˙o2peak in HTRs and AMHCs.Twenty-six HTRs (3 women) and 27 AMHCs (5 women) were recruited. Maximal cardiopulmonary function (gas exchange analysis), cardiac hemodynamics (impedance cardiography), and left frontal COP (near-infrared spectroscopy) were measured continuously during and after a maximal ergocycle (Ergoline 800S, Bitz, Germany) test.Compared with AMHCs, HTRs had lower V˙o2peak, maximal cardiac index (CImax), and maximal ventilatory variables (P0.05). COP was lower during exercise (oxyhemoglobin [ΔO2Hb], 50% and 75% of V˙O2peak, total hemoglobin [ΔtHb], 100% of V˙O2peak; P0.05), and recovery in HTRs (ΔO2Hb, minutes 2-5; ΔtHb, minutes 1-5; P0.05) compared with AMHCs. End-tidal pressure of CO2 was lower during exercise compared with that in AMHCs (P0.0001). In HTRs, CImax was positively correlated with exercise cerebral hemodynamics (R = 0.54-0.60; P0.01).In HTRs, COP was reduced during exercise and recovery compared with that in AMHCs, potentially because of a combination of blunted cerebral vasodilation by CO2, cerebrovascular dysfunction, reduced cardiac function, and medication. The impaired V˙O2peak observed in HTRs was mainly caused by reduced maximal ventilation and CI. In HTRs, COP is impaired and is correlated with cardiac function, potentially impacting cognitive function. Therefore, we need to study which interventions (eg, exercise training) are most effective for improving or normalizing (or both) COP during and after exercise in HTRs.

BackgroundNo previous studies have investigated a high-intensity interval training program (HIIT) with an immersed ergocycle and Mediterranean diet counseling (Med) in obese patients. We aimed to compare the effects of an intensive lifestyle intervention, Med and HIIT with a water-immersed versus dryland ergocycle, on cardiometabolic and exercise parameters in obese patients.MethodsWe retrospectively identified 95 obese patients at their entry into a 9-month Med and HIIT program: 21 were trained on a water-immersed ergocycle and 74 on a standard dryland ergocycle. Body composition, cardiometabolic and exercise parameters were measured before and after the program.ResultsFor obese patients performing water- and dryland-exercise (mean age 58±9 years versus 55±7 years), BMI was higher for the water- than dryland-exercise group (39.4±8.3kg/m2 versus 34.7±5.1kg/m2, P

Circulating levels of angiopoietin-like 2 (ANGPTL2), a proinflammatory and proatherogenic protein, are elevated in patients with coronary artery disease (CAD). We hypothesized that high-intensity intermittent exercise (HIIE), known to be beneficial in patients with CAD, would reduce circulating ANGPTL2 levels.Plasma levels of ANGPTL2 were measured before and 20 minutes, 24 hours, and 72 hours after an acute exercise session in a crossover study comparing HIIE to moderate-intensity continuous exercise (MICE) in 14 patients with CAD and 20 age-matched and 20 young healthy controls.Pre-exercise ANGPTL2 levels were 3-fold higher in patients with CAD than in age-matched controls (P0.05) and correlated negatively with Vo2max/lean body mass (P0.0001). In healthy controls, ANGPTL2 levels were low and not affected by HIIE or MICE. In patients with CAD, ANGPTL2 levels decreased significantly by 41% after 20 minutes of HIIE, a reduction that was maintained after 24 and 72 hours (P0.05). In contrast, although ANGPTL2 levels decreased by 47% after 20 minutes of MICE, they increased by 104% after 24 hours and returned to baseline values after 72 hours (P0.05). A negative correlation was observed between this increase in ANGPTL2 levels and the mean rate-pressure product (heart rate × systolic blood pressure; index of myocardial O2 consumption) measured during MICE, suggesting that subclinical ischemia might promote ANGPTL2 expression.In patients with CAD, circulating ANGPTL2 levels are acutely reduced after HIIE and transiently increased after MICE. A sustained reduction in circulating ANGPTL2 levels could contribute to the chronic beneficial cardiometabolic effects of HIIE in patients with CAD.

This overview provides a guideline for the management of stable ischemic heart disease. It represents the work of a primary and secondary panel of participants from across Canada who achieved consensus on behalf of the Canadian Cardiovascular Society. The suggestions and recommendations are intended to be of relevance to primary care and specialist physicians with an emphasis on rational deployment of diagnostic tests, expedited implementation of long- and short-term medical therapy, timely consideration of revascularization, and practical follow-up measures.

High-intensity interval exercise (HIIE) is gaining in popularity in fitness centres, even among coronary heart disease (CHD) patients. However, whether HIIE can have deleterious acute effects on the vasculature in CHD has not been studied. We hypothesized that when compared with moderate-intensity continuous exercise (MICE), a single bout of HIIE could lead to vascular damage and increasing numbers of circulating endothelial and platelet microparticles (EMPs, PMPs) in stable, physically fit CHD patients.Nineteen male CHD patients (aged 62 ± 11 years) underwent, in random order, a single session of HIIE corresponding to 15-second intervals at 100% of peak power output and 15-second passive recovery intervals, and an isocaloric MICE session. EMPs (CD31+ and/or CD62E+ and CD42b-); PMPs (CD42b+); nitrates and nitrites; prostacycline; and troponin T, cardiac form (cTnT), were measured 10 minutes before exercise and 20 minutes, 24 hours, and 72 hours after both exercise sessions.EMPs, PMPs, nitrates and nitrites, prostacycline, and cTnT remained unchanged after both HIIE and MICE exercise sessions. Initial EMP concentration correlated inversely with EMP concentration 20 minutes post exercise, irrespective of exercise modality (r = 0.78, P0.0001).A single HIIE session with very short exercise and passive recovery periods appears safe and does not induce changes to markers of endothelial function. Future studies are required to determine the safety of a long-term HIIE training program.

Background The purpose of this study was to compare cardiopulmonary responses, exercise adherence, tolerance, and safety of optimized high-intensity interval exercise (HIIE) compared with moderate-intensity continuous exercise (MICE) in patients with heart failure and reduced ejection fraction (HFREF). Methods Twenty patients with HFREF (aged 61 ± 9.9 years) were randomly assigned to HIIE corresponding to 2 × 8 minutes of 30-second intervals at 100% of peak power output and 30-second passive recovery intervals and to a 22-minute MICE corresponding to 60% of peak power output. Gas exchange, electrocardiogram, and blood pressure were measured continuously. Cardiac troponin T (cTnT), C-reactive protein (CRP), and brain natriuretic peptide (BNP) were measured before, 20 minutes after, and 24 hours after HIIE and MICE. Results Cardiopulmonary responses did not differ between MICE and HIIE. Higher exercise adherence and efficiency were observed on HIIE with a similar perceived exertion and time spent above 90% of peak oxygen consumption compared with MICE. Neither HIIE nor MICE caused any significant arrhythmias or increased CRP, BNP, or cTnT. Conclusions Compared with MICE, HIIE demonstrated a higher exercise adherence and was well tolerated in patients with HFREF, while still providing a high-level physiological stimulus and leaving indices of inflammation (CRP), myocardial dysfunction (BNP), and myocardial necrosis (cTnT) unaffected.

Aging is a natural and complex physiological process influenced by many factors, some of which are modifiable. As the number of older individuals continues to increase, it is important to develop interventions that can be easily implemented and contribute to "successful aging". In addition to a healthy diet and psychosocial well-being, the benefits of regular exercise on mortality, and the prevention and control of chronic disease affecting both life expectancy and quality of life are well established. We summarize the benefits of regular exercise on longevity, present the current knowledge regarding potential mechanisms, and outline the main recommendations. Exercise can partially reverse the effects of the aging process on physiological functions and preserve functional reserve in the elderly. Numerous studies have shown that maintaining a minimum quantity and quality of exercise decreases the risk of death, prevents the development of certain cancers, lowers the risk of osteoporosis and increases longevity. Training programs should include exercises aimed at improving cardiorespiratory fitness and muscle function, as well as flexibility and balance. Though the benefits of physical activity appear to be directly linked to the notion of training volume and intensity, further research is required in the elderly, in order to develop more precise recommendations, bearing in mind that the main aim is to foster long-term adherence to physical activity in this growing population.

The long-term prognostic value of heart rate recovery (HRR) has been incompletely documented in patients with coronary artery disease (CAD). We sought to confirm the prognostic value of HRR in a large cohort with stable CAD.From the Coronary Artery Surgery Study registry, a database of 24,958 patients with CAD who underwent cardiac catheterization between 1974 and 1979, we identified 4097 patients with baseline exercise stress testing data. HRR was measured at 3 minutes post exercise during a passive recovery. Clinical outcomes were evaluated according to HRR in both threshold and continuous models.Median long-term follow-up was 14.7 years (interquartile range, 9.8-16.2). HRR46 beats per minute (Bpm) most appropriately differentiated nonsurvivors from survivors (area under receiver operating characteristic curve = 0.613) and was associated with an increased risk of all-cause death (adjusted hazard ratio = 1.15; P = 0.011). Increasing HRR was associated with a lower risk of all-cause (adjusted hazard ratio = 0.94 per 10 Bpm; 95% confidence interval, 0.91-0.97; P = 0.0005) and cardiovascular (CV) mortality (adjusted hazard ratio = 0.94 per 10 Bpm; 95% confidence interval, 0.90-0.98; P = 0.003).HRR at 3 minutes independently predicts long-term all-cause and CV mortality in patients with stable CAD. Measurement of HRR at 3 minutes during passive recovery can be used as a complementary tool to identify patients with a higher total and CV risk.

Background: There are little data on the optimization of high-intensity aerobic interval exercise (HIIE) protocols in patients with chronic heart failure (CHF). Therefore, we compared acute cardiopulmonary responses to 4 different HIIE protocols to identify the optimal one. Methods and Results: Twenty men with stable systolic CHF performed 4 different randomly ordered single HIIE sessions with measurement of gas exchange. For all protocols (A, B, C, and D) exercise intensity was set at 100% of peak power output (PPO). Interval duration was 30 seconds (A and B) or 90 seconds (C and D), and recovery was passive (A and C) or active (50% of PPO in B and D). Time spent above 85% of VO2peak and time above the ventilatory threshold were similar across all 4 HIIE protocols. Total exercise time was significantly longer in protocols with passive recovery intervals (A: 1,651 6 347 s; C: 1,574 6 382 s) compared with protocols with active recovery intervals (B: 986 6 542 s; D: 961 6 556 s). All protocols appeared to be safe, with exercise tolerance being superior during protocol A. Conclusion: Among the 4 HIIE protocols tested, protocol A with short intervals and passive recovery appeared to be superior. (J Cardiac Fail 2012;18:126e133)

Background: Decreased heart rate recovery (HRR) is a predictor of mortality in patients with coronary artery disease and preserved left ventricular function. We investigated the changes in HRR and assessed the impact of β-blockade therapy on these parameters in patients with symptomatic congestive heart failure (CHF). Methods and Results: HRR, defined as the difference from peak exercise heart rate (HR) to HR measured at 1, 2, and 3 minutes after maximal exercise test, was studied in 23 stable CHF patients and 12 healthy subjects. Patients with CHF performed a maximal exercise test using a Ramp protocol before and after 6 months of therapy with either metoprolol or carvedilol. Patients with CHF exhibited a significantly attenuated HRR compared with healthy subjects at 1 minute (17.8 ± 5.8 versus 26.8 ± 16.2 beats), 2 minutes (34.0 ± 10.6 versus 48.0 ± 11.2 bpm) and 3 minutes (41.0 ± 12.4 versus 60.0 ±12.4 bpm) after exercise (P

Objective: Depression in the hospital after myocardial infarction (MI) has been associated with a substantial increase in the long-term risk of cardiac mortality, but little is known about other outcomes. This study uses Quebec Medicare data to examine the relationship between post-MI depression and physician costs, including both out-patient care and hospital readmissions. Methods: The sample consists of 848 1-year survivors of an acute MI who had completed the Beck Depression Inventory (BDI) in hospital. Two hundred sixty subjects had BDI scores of ≥10 (30.7%), indicative of mild to moderate symptoms of depression. Quebec Medicare data during the index admission for an acute MI and during the year following discharge were compared for the patients with elevated BDI scores and those with normal scores. Results: Total costs, in Canadian dollars (out-patient physician charges plus physician costs during admissions plus estimates of associated direct costs), were about 41% higher (p = 0.004) for patients with elevated BDI scores. The difference was primarily related to out-patient and emergency room visits and readmission costs associated with longer stays in hospital wards, and was not accounted for by use of psychiatric services or readmissions for revascularization. Conclusion: Results suggest that, in addition to the survival risks associated with post-MI depression, there are increased health care costs linked to both readmissions and out-patient contacts among depressed patients who survive the first post-MI year. The extent to which the increased use of health care may have reduced depression and enhanced survival remains unclear.

Sauna bathing is a popular recreational activity that is generally considered to be safe. However, there have been case reports of adverse cardiac events. We sought to determine whether sauna use caused myocardial ischemia in patients with coronary artery disease.Sixteen patients with proven coronary artery disease were submitted to three conditions (rest, exercise, and sauna bathing) with continuous electrocardiographic (ECG) monitoring and regular blood pressure measurements. During each condition, patients were injected with Tc-99 sestamibi followed by nuclear scintigraphic imaging. Perfusion defect scores were calculated in 15 patients.Sauna bathing was well tolerated. There was a mean (+/- SD) increase in heart rate of 32% +/- 20% in the sauna (resting mean heart rate = 60 +/- 9 beats per minute vs sauna mean heart rate = 79 +/- 11 beats per minute, P0.001) and a 13% +/- 6% drop in systolic blood pressure (resting mean systolic blood pressure = 142 +/- 14 mm Hg vs sauna mean systolic blood pressure = 123 +/- 15 mm Hg, P0.001). There were no arrhythmias or ECG changes in the sauna. Compared with rest, there was significant ischemia during sauna bathing (average perfusion defect score at rest = -0.44 vs average sauna score = -0.93, P0.001). The perfusion defect score in the sauna was worse than the resting score in 14 of the 15 patients. Sauna-associated perfusion defect scores were highly correlated with exercise-induced scores (R2 = 0.65, P0.001).In patients with stable coronary artery disease, sauna use is clinically well tolerated but is associated with scintigraphically demonstrated myocardial ischemia.

Objectives. This study was defined as a pilot investigation of the usefulness and safety of intravenous diltiazem as adjunctive therapy to tissue plasminogen activator in acute myocardial infarction, followed by oral therapy for 4 weeks. Background. Experimental studies have documented that calcium antagonists protect the myocardial cell against the damage caused by coronary artery occlusion and reperfusion, yet no benefits have been conclusively demonstrated in acute myocardial infarction (AMI) in humans. Methods. In this pilot study, 59 patients with an AMI treated with tissue-type plasminogen activator (t-PA) were randomized, double blinded, to intravenous diltiazem or placebo for 48 h, followed by oral therapy for 4 weeks. The primary objective was to detect an effect on indices of regional left ventricular function and perfusion. Patients were also closely monitored for clinical events, coronary artery patency and indices of infarct size and of left ventricular function. Results. Creatine kinase elevation, Q wave score, global and regional left ventricular function and coronary artery patency at 48 h were not significantly different between the diltiazem and placebo groups. A greater improvement observed in regional perfusion and function with diltiazem was likely explained by initial larger defects. Diltiazem, compared to placebo, reduced the rate of death, reinfarction or recurrent ischemia at 35 days from 41% to 13% (p = 0.027) and prevented the need for an urgent intervention. The rate of death or myocardial infarction was reduced by 65% (p = 0.15). These benefits could not be explained by differences in baseline characteristics such as age, site and extent of infarction, time of inclusion or concomitant therapy. Heart rate and blood pressure were reduced throughout the study with active diltiazem treatment. Side effects of diltiazem were bradycardia and hypotension that required transient or permanent discontinuation of the study drug in 27% of patients, vs. 17% of patients with placebo. Conclusions. A protective effect for clinical events related to early postinfarction ischemia and reinfarction was suggested in this study, with diltiazem administered intravenously with t-PA followed by oral therapy for 1 month, with no effect on coronary artery patency and left ventricular function and perfusion.

Summary Background Increases in life stress have been linked to poor prognosis after myocardial infarction (MI). Previous research suggested that a programme of monthly screening for psychological distress, combined with supportive and educational home nursing interventions for distressed patients, may improve post-MI survival among men. Our study assessed this approach for both men and women. We aimed to find out whether the programme would reduce 1-year cardiac mortality for women and men. Methods We carried out a randomised, controlled trial of 1376 post-MI patients (903 men, 473 women) assigned to the intervention programme (n=692) or usual care (n=684) for 1 year. All patients completed a baseline interview that included assessment of depression and anxiety. Survivors were also interviewed at 1 year. Findings The programme had no overall survival impact. Preplanned analyses showed higher cardiac (9·4 vs 5·0%, p=0·064) and all-cause mortality (10·3 vs 5·4%, p=0·051) among women in the intervention group. There was no evidence of either benefit or harm among men (cardiac mortality 2·4 vs 2·5%, p=0·94; all-cause mortality 3·1 vs 3·1%, p=0·93). The programme's impact on depression and anxiety among survivors was small. Interpretation Our results do not warrant the routine implementation of programmes that involve psychological-distress screening and home nursing intervention for patients recovering from MI. The poorer overall outcome for women, and the possible harmful impact of the intervention on women, underline the need for further research and the inclusion of adequate numbers of women in future post-MI trials.

Objectives . This study was undertaken to determine the effect of a standardized meal on the ischemie threshold and exercise capacity in a series of 20 patients with stable angina, exerciseinduced ischemia and reversible exercise-induced perfusion defects. Background . It is generally accepted that exercise tolerance in patients with angina is reduced after a meal. However, studies that have addressed this phenomenon have yielded results that are contradictory and inconclusive. Methods . Two exercise tests using the Brace protocol with technetium-99m ( 99m Tc)-sestamibi were performed on consecutive days in a randomized order. One test was performed in the fasting state and the other 30 min after a 1,000-calorle meal. Results . In the postprandial state, exercise time to ischemia was reduced by 20% from 248 ± 93 s to 197 ±87 s (p = 0.0007), time to angina by 15% from 340 ± 82 s to 287 ± 94 s (p = 0.002) and exercise tolerance by 9% from 376 ± 65 s to 344 ± 86 s (p = 0.002). Rate-pressure products at these exercise test end points were not significantly different in the fasting and postprandial tests, and the quantitative 99m Tc-sestamibi ischemia score was unchanged. Conclusions . In patients with stable angina, a 1,000-calorie meal significantly reduced tine to ischemia, time to angina and exercise tolerance because of a more rapid increase in myocardial oxygen demand with exercise. The extent and severity of exerciseinduced ischemia were unchanged.

BACKGROUND: Accurate measurement of physical activity (PA) is necessary to monitor trends, assess relations with health and measure adherence to PA guidelines. While accelerometers provide accurate measures of PA they rely on validated cut-points to quantify time spent in light, moderate and vigorous intensities. Cut-points have largely been established using healthy populations; however, accelerometer output can differ based on cardiorespiratory fitness, suggesting that among individuals with compromised functioning such as those with coronary artery disease (CAD); these cut-points may lead to a misclassification of intensity. The objective of this study was to compare well-known and widely used cut-points (Sasaki) derived from healthy adults with those developed in a CAD population (Mark). METHODS: Two-hundred and thirty-one adults with CAD (mean SD: 63.7 9.2 years) wore an ActiGraph GT3X accelerometer for a minimum of 4 consecutive days and 10 hours/day. Daily time spent in moderate-to-vigorous PA (MVPA) was compared using two cut-point definitions: Mark (58.3 10.7 years, mean v

(CO) and cerebral oxygenation/perfusion (COP) in heart transplant recipients (HTR) and age-matched controls (AMC) during maximal exercise (ME), 2) to study the relationships between VO2 peak, CO, COP inHTR and AMC. 27 AMC and 26HTR were recruited. VO2 peak and cardiac hemodynamic (impedance cardiography) were measured during a ME. COP (O2Hb, tHb) was measured using near-infrared spectroscopy (NIRS). RESULTS: Compared to AMC, HTR had a lower VO2 peak (ml/min/kg of lean body mass), maximal (max) cardiac index (CImax), max ventilation, max tidal volume and max respiratory frequency vs. AMC (P

This study was undertaken to compare a low level and a symptom-limited test performed before hospital discharge after an uncomplicated myocardial infarction.Exercise testing after myocardial infarction provides useful prognostic information. Usually either a low level test is performed before hospital discharge or a symptom-limited test is performed at 3 weeks.The study group comprised 202 patients with an uncomplicated myocardial infarction; 58 patients had a non-Q wave infarction and 115 patients had received thrombolytic therapy. Both a low level and a symptom-limited exercise test were performed in 200 of the 202 study patients in randomized order on consecutive days, a mean of 7.4 +/- 2.3 days after infarction.The symptom-limited test required a considerably greater effort than the low level test: exercise duration was 554 +/- 209 versus 389 +/- 125 s (p less than 0.0001), and peak work load was 5.7 +/- 1.8 versus 4.2 +/- 1.1 METs (p less than 0.0001). The peak heart rate was higher during the symptom-limited test (121 +/- 20 vs. 108 +/- 14 beats/min, p less than 0.0001), as was the rate-pressure product. The number of patients who developed ST segment depression greater than or equal to 1 mm increased from 56 during the low level test to 89 during the symptom-limited test (p less than 0.0001). ST segment depression greater than or equal to 2 mm occurred in 22 patients during the low level test and in 41 patients during the symptom-limited test, an 86% increase (p less than 0.0001). The number of patients with either angina or ST depression greater than or equal to 1 mm increased from 66 to 105 (p less than 0.0001) with the symptom-limited test. Exercise test results were similar for patients with a Q wave or a non-Q wave infarction. Exercise duration was longer and exercise-induced ST depression less frequent in patients who had received thrombolytic therapy.A symptom-limited exercise test performed before hospital discharge after uncomplicated myocardial infarction provides a significantly greater cardiovascular stress than does a low level test and is associated with an ischemic response nearly twice as frequently. The prognostic significance of a positive response at higher work loads has not been defined.

Because of their unstable pathophysiology, it was hypothesized that patients with non-Q-wave acute myocardial infarctions (AMI) would be more vulnerable to the negative effects of psychological stress than patients with Q-wave AMI, and thus would be more likely to benefit from programs aimed at relieving stress. This hypothesis was tested through secondary analysis of data from a 1-year randomized clinical trial of psychological stress monitoring and intervention after AMI. After discharge, treatment group patients were telephoned each month and asked to respond to an index of psychological stress symptoms (General Health Questionnaire GHQ-20). Those with high stress symptoms (GHQ greater than or equal to 5) received home nursing visits. Control group patients received usual care. The sample consisted of 461 men, aged 31 to 86 years, who responded to the GHQ-20 before hospital discharge. Patients were followed for 5 years using record data. There were 321 Q-wave AMIs, 112 non-Q-wave AMIs and 28 indeterminate electrocardiograms. Life-table analyses showed that among patients with non-Q-wave AMIs receiving usual care, high stress in the hospital (GHQ greater than or equal to 5) was associated with a 1-year relative risk (RR) of cardiac mortality of 5.49 +/- 1.39 (p = 0.01). In comparison, control patients with Q-wave MIs had no stress-related increase in risk (RR = 0.41 +/- 2.08, p = 0.40). In the treatment group, the patients with non-Q-wave AMIs did not experience an increase in risk associated with high stress (RR = 1.80 +/- 1.79, p = 0.52).(ABSTRACT TRUNCATED AT 250 WORDS)

Silent myocardial ischemia is associated with adverse outcome in several subsets of coronary artery disease patients. This article presents results of a placebo-controlled, randomized, double-blind study of the effects of sustained-release diltiazem (180 mg twice daily) on ischemic episodes in 60 patients with documented coronary artery disease. The mean age of the study population was 60 years and 93% were male. The mean number of episodes of silent ischemia per patient was 5.6 (placebo) and 2.8 (diltiazem), a 50% reduction (p

BACKGROUND: high-intensity interval exercise has been extensively used with athletes and healthy subjects. There are a few evidences that it could improves physiology and functional capacity in heart failure patients, but still some answers about muscle metabolism need to be addressed. METHODS: substrate oxidation was compared during 4 different high intensity intermittent exercise (HIIE) protocols in patients with heart failure and reduced ejection fraction (HFREF). Eighteen males (56 17 years, LVEF: 28 7%) randomly performed 4 HIIE with measurement of gas exchange. Exercise intensity protocols were set at 100% of peak power output (PPO). Interval duration was 30 seconds (A and B) or 90 seconds (C and D), and recovery was passive (A and C) or active (50% of PPO in B and D). Energy expenditure was calculated using Weir equation and substrate oxidation (glucose: CHO, and lipid) was calculated by the Frayn equation (for quantitative measure) and from a table of non-protein respiratory quotient (qualitative measure) using gas exchange analysis. RESULTS: mean O2peak was 17.8 4.6 ml/min/kg (or 1.54 4.6 L/min) and peak power output was 109 31 Watts. At rest, fat oxidation averaged 0.13 0.04 g/min, representing 68 22 % of total substrate utilisation. CHO oxidation averaged 0.16 0.1 g/min representing 31 22% of total. During exercise, absolute CHO oxidation significantly decreased and absolute lipid oxidation significantly increased in each HIIE protocol (P

Objectives Recent data suggested that coronary heart disease (CHD) is associated with non-amnesic mild cognitive impairment. Our purpose was to assess cognitive performances at rest, VO2max, cardiac output (CO), and cerebral hemodynamic changes during maximal exercise in patients with stable CHD. Methods 22 stable fit CHD patients (70,9±9,3 years), 10 healthy age-matched (68,6±8,6 years), 10 middle aged controls and 10 young controls ( Results There was no intergroup difference in VO2max or maximal CO between cardiac and healthy age-matched individuals. Some cognitive tests, especially for executive functioning, were significantly better for the healthy matched group (Trail Making Test-B; Inhibition/Flexibility Stroop Task and Backward Digit Span, p differences were observed with lower amplitudes in HHb signalss for less fit subjects. In control groups, middle aged and young subjects had significant higher performances in VO2max, most of cognitive tests and higher amplitudes changes for NIRS indices while exercising. Conclusion Despite comparable maximal exercise tolerances and CO, CHD individuals presented reduced cognitive performances compared to healthy age-matched subjects. We evidenced an inter-individual variability among CHD patients for cerebral NIRS signals changes, especially with age and fitness. These results suggest that variations in HHb are much more related to exercise capacity than O2Hb in CHD patients.