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Background. The COVID-19 pandemic has induced many governments to promote national lockdowns. Despite a period of quarantine is the best option and recommendation to stop the rapid spread of infections, this may have collateral effects on other dimensions of the isolated patients’ physical and mental health. Physical activity is the major component of cardiac rehabilitation programs that have been abruptly discontinued. Aims. To counteract physical inactivity during the COVID-19 outbreak we propose an home cardiac rehabilitation program under telemonitoring guidance, the home-bAsed physiCal acTivity Intervention during cOvid-19 quaraNtine (ACTION) study, testing its feasibility. Methods and results. ACTION is an observational study in cardiac outpatients referred to an exercise-based cardiac rehabilita-tion program. A program consisting of aerobic recommendations combined with a selection of strength and balance exercises is recommended. Video tutorials providing details of the workouts will be sent to patients. Selected patients can be followed during the home-sessions via video connection using current smartphone applications. Conclusions. The ACTION study could provide applicable results for safe and effective exercise therapy in outpatients with car-diovascular disease, while preventing the COVID-19 outbreak from generating adverse health consequences due to acute cessa-tion of physical activity. Findings from the ACTION study can also be useful after the end of COVID-19 outbreak for patients who cannot participate in traditional center- or home-based cardiac rehabilitation programs.

Objectives The myotendinous junction (MTJ) represents a specialized anatomic region through which the contractile strength is transmitted from the muscle to the tendon. The integrity of this region is essential to permit force transmission and to optimize energy expenditure during walking, running, and globally for human movement. We evaluated the MTJ with shear wave elastography to assess its elasticity variation during a functional test. Methods Forty professional soccer players were enrolled in the study. Shear wave elastography was performed at the level of the medial gastrocnemius MTJ both in a resting position and during a standing calf rise position to assess functional contraction. Results All 40 participants were male, aged between 18 and 38 years (mean age, 25 years). The results of the elastographic study showed mean stiffness values ± SD of 4.19 ± 0.86 m/s for the right medial gastrocnemius and 4.20 ± 0.87 m/s for the left medial gastrocnemius with the muscle relaxed. During contraction, the stiffness values were 8.33 ± 0.5 m/s for the right medial gastrocnemius and 8.30 ± 0.48 m/s for the left medial gastrocnemius. Conclusions Our study showed an increase of stiffness at the level of the MTJ during muscle contraction. This result is in line with the physiologic stiffening of the MTJ to resist the high level of force applied during muscle contraction. Shear wave elastography could be a useful method to assess the characteristics of the MTJ under both physiologic and pathologic conditions.

Hypertension poorly responsive to medications is defined resistant hypertension. We have previously shown that 1-year of guided walking is followed by highly significant reduction of systolic blood pressure in hypertensive subjects. Aim of this study was to assess the effect of a 1-year of guided walking on the blood pressure of sedentary hypertensive subjects including patients with resistant hypertension. Two hundred and fifty-nine sedentary subjects with systolic pressure ≥130 mmHg were subdivided in a group without blood pressure medications and in a group taking three or more antihypertensive drugs, including diuretics. Blood pressure, body weight, body mass index, waist circumference, and walking speed were determined at enrollment and after 1-year of walking, supervised by exercise physiologists. At baseline, systolic pressure was significantly higher in the subjects under therapy (144.6 ± 12.2 vs. 140.2 ± 10.7). Two hundred and three subjects (124 without and 79 with therapy) completed the program. During the 1-year program each subject walked ~220 h. After 1-year a significant decrease (P

Background Lack of physical activity represents a risk factor for both cardiovascular and chronic venous diseases (CVD), nevertheless a specific exercise protocol for CVD patient is still missing. This investigation was aimed to assess the impact of a standardized exercise protocol in a thermal water environment on physical fitness and quality-of-life (QoL) in CVD patients. Methods Sixteen (16) CVD patients performed 5 standardized exercise sessions in a thermal water pool. Before starting the exercise protocol, the cohort filled International Physical Activity Questionnaire (IPAQ) to determine their physical activity level. At baseline and at the end of the exercise program, leg volume, QoL, musculoskeletal and cardiovascular physical fitness were assessed by means of water plethysmography, validated questionnaire and functional test, blood pressure and heart rate at rest were also reported. Results All the patients were categorized as physically inactive: average activity time 235.6 (155.2) MET-minutes per week. At the end of the study, a significant leg volume reduction was found (−16%; p Conclusions The proposed exercise protocol in thermal aquatic environment demonstrated to be an effective treatment modality improving both cardiovascular and musculoskeletal outcomes and QoL in sedentary CVD patients. Aquatic environment investigations require proper analysis of the various factors involved, in a standardized and reproducible way. The herein report can be a reference for further studies on different health related conditions.

BACKGROUND Progressive ageing of the population has highlighted the importance of the relationship between physical function and frailty in patients with chronic disease. The aim of this study was to assess the association between exercise capacity and grip strength (GS) in a cohort of older patients involved in an exercise-based secondary prevention program. METHODS 65 outpatients (aged 75±6 years) were included. Exercise capacity was assessed through the estimation of maximal oxygen consumption (VO2peak) and the measurement of walking speed (WS). GS was evaluated in the dominant arm using a hand-held dynamometer. RESULTS Patients with higher VO2peak and WS values exhibited significantly higher GS (p

Aims The prognostic implication of periprocedural myocardial infarction (MI) in older patients has been less investigated. The aim of this study is to assess the relationship between large periprocedural MI and long-term mortality in older patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) undergoing percutaneous coronary intervention (PCI). Methods This is a pooled analysis of older NSTEACS patients who were included in the FRASER and HULK studies. Periprocedural MI was defined in agreement with the Society for Cardiovascular Angiography and Interventions definition. The primary outcome was all-cause mortality. The secondary outcome was cardiovascular mortality. The predictors of periprocedural MI and the relationship with scales of physical performance, namely Short Physical Performance Battery and grip strength, were also investigated. Results The study included 586 patients. Overall, periprocedural MI occurred in 24 (4.1%) patients. After a median follow-up of 1023 (740-1446) days, the primary endpoint occurred in 94 (16%) patients. After multivariable analysis, periprocedural MI emerged as an independent predictor of all-cause mortality (hazard risk 4.30, 95% confidence interval 2.27-8.12). This finding was consistent for cardiovascular mortality (hazard risk 7.45, 95% confidence interval 3.56-15.67). SYNTAX score, multivessel PCI and total stent length were independent predictors of large periprocedural MI. At hospital discharge, patients suffering from periprocedural MI showed poor values of Short Physical Performance Battery and grip strength as compared with others. Conclusion In a cohort of older NSTEACS patients undergoing PCI, large periprocedural MI occurred in around 4% of patients and was associated with long-term occurrence of all-cause and cardiovascular mortality. Clinical trial registration ClinicalTrials.gov: NCT02324660 and NCT03021044.

Whether contrast-associated acute kidney injury (CA-AKI) is only a bystander or a risk factor for mortality in older patients undergoing percutaneous coronary intervention (PCI) is not well understood. Data from FRASER (NCT02386124) and HULK (NCT03021044) studies have been analysed. All patients enrolled underwent coronary angiography. The occurrence of CA-AKI was defined based on KDIGO criteria. The primary outcome of the study was to test the relation between CA-AKI and 3-month mortality. Overall, 870 older ACS adults were included in the analysis (mean age 78 ± 5 years, 28% females). CA-AKI occurred in 136 (16%) patients. At 3 months, 13 (9.6%) patients with CA-AKI died as compared with 13 (1.8%) without it (p &lt, 0.001). At multivariable analysis, CA-AKI emerged as independent predictor of 3-month mortality (HR 3.51, 95%CI 1.05–7.01). After 3 months, renal function returned to the baseline value in 78 (63%) with CA-AKI. Those without recovered renal function (n = 45, 37%) showed an increased risk of mortality as compared to recovered renal function and no CA-AKI subgroups (HR 2.01, 95%CI 1.55–2.59, p = 0.009 and HR 2.71, 95%CI 1.45–5.89, p &lt, 0.001, respectively). In conclusion, CA-AKI occurs in a not negligible portion of older MI patients undergoing invasive strategy and it is associated with short-term mortality.

BackgroundTo assess the association between walking speed (WS) and its improvement on hospitalization rates and costs in outpatients with cardiovascular disease.MethodsSix hundred forty-nine patients participating in an exercise-based secondary prevention program were studied. Patients were divided at baseline into two groups characterized by low and high WS based on the average WS maintained during a moderate 1-km treadmill-walking test. WS and other covariates were grouped into three domains (demographic factors, medical history and risk factors), and used to estimate a propensity score, in order to create homogeneous groups of patients. All-cause hospitalization was assessed 3 years after baseline as a function of WS. Hospitalization and related costs were also assessed during the fourth-to-sixth years after enrollment. To test whether the hospitalization costs were related to changes in WS after 36 months, a multistrata permutation test was performed by combining within strata partial tests.ResultsThe results support the hypothesis that hospitalization costs are significantly reduced in accordance with an improvement in WS. This effect is most evident among older patients, overweight or obese, smokers, and those without a history of coronary artery bypass surgery.ConclusionsThe present study supports growing evidence of an inverse association between WS, risk of hospitalization and consequent health-care costs. The joint use of propensity score and multistrata permutation approaches represent a flexible and robust testing method which avoids the possible effects of several confounding factors typical of these studies.

The strict lockdown strategy prompted by the Italian government, to hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) spreading, reduced opportunities to perform physical activity. This study quantified an abrupt and statistically significant reduction by 25% of physical activity in patients with implantable defibrillators, during the forced 40-d in-home confinement., Purpose: The coronavirus disease-2019 (COVID-19) pandemic has been spreading rapidly worldwide since late January 2020. The strict lockdown strategy prompted by the Italian government, to hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) spreading, has reduced the possibility of performing either outdoor or gym physical activity (PA). This study investigated and quantified the reduction of PA in patients with automatic implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden death. Methods: Daily PA of 24 patients was estimated by processing recorded data from ICD-embedded accelerometric sensors used by the rate-responsive pacing systems. Results: During the forced 40-d in-home confinement, a mean 25% reduction of PA was observed as compared with the 40-d confinement-free period (1.2 ± 0.3 vs 1.6 ± 0.5 hr/d, respectively, P = .0001). Conclusions: This objective quantification of the impact of the COVID-19 pandemic on PA determined by an ICD device showed an abrupt and statistically significant reduction of PA in primary prevention ICD patients, during the in-home confinement quarantine. To counteract the deleterious effects of physical inactivity during the COVID-19 outbreak, patients should be encouraged to perform indoor exercise-based personalized rehabilitative programs.

Background Normal standards for peak oxygen consumption (VO2peak) are controversial because they tend to be population and protocol specific. This study was undertaken to examine the association between percentage of age-predicted VO2peak and all-cause hospital readmission in cardiac outpatients who were referred to an exercise-based secondary prevention program. Methods Hospital readmission was assessed in 1283 male patients with coronary heart disease (CHD) three years after enrolment, and related to the age-predicted VO2peak derived from the Fitness Registry and the Importance of Exercise: A National Data Base equation (FRIEND%PRED). VO2peak was estimated using a moderate perceptually regulated 1-km treadmill-walking test. Readmission was also assessed during the fourth-to-sixth years as function of improvement in FRIEND%PRED in 845 patients who were re-evaluated 3 years after baseline. Results During the 3-years after baseline, readmission rate was lower across increasing tertiles of FRIEND%PRED. Compared to the lowest tertile, the adjusted hazard ratios (HRs) for the second and third tertile were 0.98 (95% CI 0.76–1.27, p = 0.90) and 0.71 (0.53–0.95, p = 0.002). The rate of readmission from the fourth-to-sixth years after baseline was lower across tertiles of improved FRIEND%PRED, with adjusted HRs 0.78 (0.60–1.03, p = 0.08) and 0.58 (0.42–0.75, p Conclusions Age-predicted VO2peak estimated by a moderate treadmill-walk predicts hospital readmission in outpatients with CHD undergoing secondary prevention.

BACKGROUND A moderate 1-km treadmill walk test (1k-TWT) has been demonstrated to be a valid tool for estimating peak oxygen uptake (VO2peak) in outpatients with cardiovascular disease (CVD). The results obtained by the 1k-TWT predict survival and hospitalization in men and women with CVD. We aimed to examine whether shorter versions of the full 1k-TWT equally assess VO2peak in outpatients with CVD. METHODS One hundred eighteen outpatients with CVD, aged 70±9 years, referred to an exercise-based secondary prevention program, performed a moderate and perceptually-regulated (11-13/20 on the Borg Scale) 1k-TWT. Age, height, weight, heart rate, time to walk 100-m, 200-m, 300-m, and 400-m, and the full 1000-m, were entered into equations to estimate VO2peak. RESULTS The minimal distance providing similar VO2peak results of the full 1k-TWT was 200-m: 23.0±5.3 mL/kg/min and 23.0±5.5 mL/kg/min, respectively. The concordance correlation coefficient between the two was 0.97 (95%CI 0.96 to 0.98, P

The study has compared the effects of a program of guided walking (GW) and of a program of suggested walking (SW) on the blood pressure and on the lifestyle of sedentary hypertensive subjects. Participants were sedentary and had a systolic pressure ≥ 140 mmHg. They were divided in a group of GW (n = 93) and of SW (n = 99). Blood pressure, weight, BMI, waist circumference and walking speed were assessed at enrollment and after 6 months. Sixteen months after the end of the project, the subjects were contacted to check if they were maintaining the walking activity. During the 6 months, the weekly walking time was 300 min in the GW group and 120 in the SW group. Seventy subjects of the GW group and 88 of the SW group completed the program. Significantly decrease in weight, BMI and waist circumference was observed in both groups. Systolic and diastolic pressure decreased by 7.5 and 1.9 mmHg in the GW group and by 4.1 and 2.1 mmHg in the WS. The decrease in systolic pressure was significantly higher in the subjects of GW group. Sixteen months after the end of the study, 54 subjects of the WG and 30 of the SG declared to maintain a walking habit. Both programs resulted in significant reductions of systolic and diastolic pressure. The reduction of systolic pressure was significantly higher in the subjects who followed the GW program. The GW program was also more effective than the SW program in modifying the lifestyle of the participants.

ObjectiveTo establish the benefits of an early, tailored and low-cost exercise intervention in older patients hospitalised for acute coronary syndrome (ACS).MethodsThe study was a multicentre, randomised assessment of an exercise intervention in patients with ACS ≥70 years with reduced physical performance (as defined by the short physical performance battery (SPPB), value 4–9). The exercise intervention included four supervised sessions (1, 2, 3, 4 months after discharge) and home-based exercises. The control group attended a health education programme only. The outcomes were the 6-month and 1-year effects on physical performance, daily activities, anxiety/depression and quality of life. Finally, 1-year occurrence of adverse events was recorded.ResultsOverall, 235 patients with ACS (median age 76 (73–81) years) were randomised 1 month after ACS. Exercise and control groups were well balanced. Exercise intervention improved 6-month and 1-year grip strength and gait speed. Exercise intervention was associated with a better quality of life (as measured by EuroQol-visual analogue scale at 6 months 80 (70–90) vs 70 (50–80) points, pConclusionsThe proposed early, tailored, low-cost exercise intervention improves mobility, daily activities, quality of life and outcomes in older patients with ACS. Larger studies are needed to confirm the clinical benefit.Trial registration numberNCT03021044.

Low levels of cardiorespiratory fitness are associated with a high risk of cardiovascular disease (CVD) and all-cause mortality in women. The aim of this study was to determine the validity of a 500-m moderate treadmill-walking test for estimating peak oxygen uptake (VO2peak) in older women with CVD. Fifty-three women with stable CVD (age 70.4 ± 8.2 years) underwent exercise testing during an outpatient cardiac rehabilitation/secondary prevention program. Each patient completed a maximal cardiopulmonary exercise test, and a moderate and self-paced (11–13/20 on the Borg scale) 500-m treadmill-walking test. Treadmill walk time, age, weight, height, and heart rate during the test were entered into prediction equations previously validated for VO2peak estimation in male patients. Measured and estimated VO2peak values were not different (20.8 ± 4.3 vs 21.3 ± 4.6 mL/kg/min, P = 0.12). The comparison between measured and estimated VO2peak values yielded a correlation of R = 0.92 (SEE = 1.3 mL/kg/min, P

Objectives To determine the prognostic ability of established percent-predicted equations of peak oxygen consumption (%PRED) estimated by a moderate submaximal walking test in a large cohort of outpatients with cardiovascular disease (CVD). Design Population-based prospective study. Methods A total of 1442 male patients aged 25–85 years at baseline, underwent a moderate perceptually-regulated (11–13 on the 6–20 Borg scale) treadmill walk (1k-TWT) for peak oxygen consumption estimation (VO 2 peak). %PRED was derived from ACSM, Ades et al, Morris et al, and the Wasserman/Hansen equations, and their prognostic performance was assessed. Overall mortality was the end point. Participants were divided into quartiles of %PRED, and mortality risk was estimated using a Cox regression model. Results During a median 8.2 year follow-up, 167 all-cause deaths occurred. The Wasserman/Hansen equation provided the highest prognostic value. Mortality rate was lower across increasing quartiles of %PRED. Compared to the first quartile, after adjustment for confounders, the mortality risk decreased for the second, third, and fourth quartiles, with HRs of 0.75 (95% CI 0.44–1.29, p = 0.29), 0.67 (95% CI 0.38–1.18, p = 0.17), and 0.37 (95% CI 0.10–0.78, p = 0.009), respectively (p for trend Conclusions The percent-predicted VO 2 peak determined by Wasserman/Hansen equations applied to the 1k-TWT is inversely and significantly related to survival in cardiac outpatients. The 1k-TWT is a simple and useful tool for stratifying mortality risk in patients participating in secondary prevention programs.

To analyze the change in risk factors for cardiovascular diseases in sedentary subjects following 1 year of guided walking and check the maintenance of the walking habit 16 months after the end of the project. A total of 650 sedentary subjects (442 women, 208 men) were admitted to the project. Body mass index (BMI), waist circumference, systolic and diastolic blood pressure, and walking speed were determined at enrollment and redetermined after 1 year in the subjects completing the project. Daily groups of guided walking were organized. In the 326 subjects completing the project, highly significant reduction in body weight, BMI, waist circumference, systolic and diastolic blood pressure and increase in walking speed were documented. Out of the 326 finishers, 266 answered a questionnaire on the minutes of walking they were doing each week, 16 months after the end of the project: 258 declared 170 ± 110 min while eight declared to be back to inactivity. Guided walking was followed by highly significant reduction in risk factors for cardiovascular diseases and improved walking speed. Seventy-seven percent of the finishers were maintaining the walking practice 16 months after the end of the project, indicating that guided walking programs can be effective in permanently modifying the lifestyle of sedentary subjects.

More than one-half of patients admitted for acute coronary syndrome (ACS) are age ≥70 years. Mobility limitations and sedentary behavior are common in older ACS patients and contribute to high risk of recurrence and mortality ([1][1]). Although older ACS patients may benefit the most from

Aims The aim of this study was to determine the ability to predict all-cause mortality using established per cent-predicted (%PRED) equations for peak oxygen consumption (VO2peak) estimated by a submaximal walk test in outpatients with cardiovascular disease. Methods Male patients (N = 1491) aged 62 ± 10 years at baseline underwent a moderate and perceptually regulated (11–13 on the 6–20 Borg scale) 1-km treadmill-walking test to estimate VO2peak. %PRED was derived from the Fitness Registry and the Importance of Exercise: A National Data Base (FRIEND) and the Wasserman/Hansen equations. Results There were 215 deaths during a median 9.4-year follow-up. The FRIEND prediction equation provided better prognostic information with receiver operating curve analysis showing significantly different areas under the curve (0.72 and 0.69 for the FRIEND and the Wasserman/Hansen equations respectively, p = 0.001). Overall mortality rate was higher across decreasing tertiles of %PRED using FRIEND, with 26%, 11% and 5% for the least fit, intermediate and high fit tertiles, respectively (p for trend Conclusion Low %PRED VO2peak in cardiac outpatients determined by the FRIEND equation was associated with a high mortality rate independent of traditional cardiovascular risk factors and clinical history. The FRIEND equation may provide a suitable normal standard when applied to clinically stable outpatients with cardiovascular disease.

To determine the relationship between walking speed (WS) maintained during a 1 km test and its improvement on hospitalisation in cardiac outpatients who were referred to an exercise-based secondary prevention programme.Hospitalisation was assessed in 1791 patients 3 years after enrolment and related to the WS achieved during a 1 km walk at moderate intensity on a treadmill. Hospitalisation was also assessed during the fourth-to-sixth years as function of improvement in WS in 1111 participants who were re-evaluated 3 years after baseline.Three-year hospitalisation rate across tertiles of baseline WS was 50% for the slow walkers (2.7±0.6 km/hour), 41% for the moderate (4.1±0.3 km/hour) and 25% for the fast walkers (5.2±0.5 km/hour) (p for trend0.0001), with adjusted HRs (95% CI) of 0.93 (0.74 to 1.17, p=0.53) for intermediate and 0.58 (0.43 to 0.78, p=0.0003) for fast. Every 1 km/hour increase in WS was associated with a 21% reduction in hospitalisation (p0.0001). Hospitalisation from the fourth-to-sixth years was lower across tertiles of improved WS, with 44% for the low (0.2±0.4 km/hour), 34% for the intermediate (0.8±0.2 km/hour) and 30% for the high tertile (1.6±0.4 km/hour) (p for trend0.0001). Adjusted HRs were 0.68 (p=0.002) for the intermediate and 0.58 (p0.0001) for the high tertile. Every 1 km/hour increase in WS was associated with a 35% reduction in hospitalisation (p0.0001).Improvement in WS is associated with a significant, dose-dependent lower rate of all-cause hospitalisation in cardiac outpatients. WS is a simple, easily applied and clinically useful tool for cardiac patients undergoing secondary prevention.

Background The walking speed maintained during a moderate 1-km treadmill walk (1k-TWT) has been demonstrated to be a valid tool for estimating peak oxygen uptake (VO2peak), and to be inversely related to long-term survival and hospitalization in outpatients with cardiovascular disease (CVD). We aimed to examine whether 500-meters and 1-k moderate treadmill-walking tests equally estimate VO2peak in male outpatients with CVD. Methods One hundred forty-two clinically stable male outpatients with CVD, aged 34-92 years, referred to an exercise-based secondary prevention program, performed a moderate and perceptually-regulated (11-13/20 on the Borg Scale) 1k-TWT. Age, height, weight, time to walk 500-meter and the entire 1000-meter, and the corresponding heart rates were entered into validated equations to estimate VO2peak. Results VO2peak estimated from the 500-meters test was not different from that estimated from the 1k test (25.2±5.1 vs. 25.1±5.2 mL/kg/min). The correlation coefficient between the two was 0.98. The slope and the intercept of the relationship between the 500-meter and 1k tests were not different from the line of identity. Bland-Altman analysis demonstrated that 96% of the data points were within two standard deviations (from -1.9 to 1.7 mL/kg/min). Conclusions The 500-meter treadmill-walking test is a reliable method for estimating VO2peak in stable male outpatients with CVD. A shorter version of the test, 500-meter, provides similar information as that from the original 1k test, but is more time efficient. These findings have practical implications in the context of transitioning patients from clinically based and supervised programs to fitness facilities or self-guided exercise programs.

Background Reduced physical performance and impaired mobility are common in elderly patients after acute coronary syndrome (ACS) and they represent independent risk factors for disability, morbidity, hospital readmission and mortality. Regular physical exercise represents a means for improving functional capacity. Nevertheless, its clinical benefit has been less investigated in elderly patients in the early phase after ACS. The HULK trial aims to investigate the clinical benefit of an early, tailored low-cost physical activity intervention in comparison to standard of care in elderly ACS patients with reduced physical performance. Design HULK is an investigator-initiated, prospective multicenter randomized controlled trial (NCT03021044). After successful management of the ACS acute phase and uneventful first 1 month, elderly (≥70 years) patients showing reduced physical performance are randomized (1:1 ratio) to either standard of care or physical activity intervention. Reduced physical performance is defined as a short physical performance battery (SPPB) score of 4–9. The early, tailored, low-cost physical intervention includes 4 sessions of physical activity with a supervisor and an home-based program of physical exercise. The chosen primary endpoint is the 6-month SPPB value. Secondary endpoints briefly include quality of life, on-treatment platelet reactivity, some laboratory data and clinical adverse events. To demonstrate an increase of at least one SPPB point in the experimental arm, a sample size of 226 patients is needed. Conclusions The HULK study will test the hypothesis that an early, tailored low-cost physical activity intervention improves physical performance, quality of life, frailty status and outcome in elderly ACS patients with reduced physical performance. Trial registration Clinicaltrials.gov, identifier NCT03021044, first posted January, 13th 2017. Electronic supplementary material The online version of this article (10.1186/s12872-018-0839-8) contains supplementary material, which is available to authorized users.

Background The aim of the study was to assess the effects of walking on the blood pressure in sedentary adults with differing degrees of systolic blood pressure (SBP). Methods A total of 529 subjects with SBP above 120 mmHg were enrolled. Blood pressure, body weight, body mass index, waist circumference and walking speed were determined at enrolment and after six months. Walking sessions were supervised by exercise physiologists. Results The weekly walking time of the subjects completing the project was uniform and reached 300 minutes by the second month. 56% of participants completed the 6 months intervention (182 women 59.6 ± 9.0 years, and 114 men, 65.4 ± 8.6 years) 27 had a baseline SBP >160 mm Hg, 35 between 150–159, 70 between 140–149, 89 between 130–139 and 75 between 120–129 mmHg. Following six months of supervised walking, SBP was significantly reduced in all subgroups (p 160 and the smallest reduction (−2.6 mmHg) occurring in subjects with baseline SBP of 120–129 mmHg. Diastolic blood pressure, body weight, body mass index and waist circumference were also significantly reduced following the walking intervention (p Discussion In a large group of sedentary adults with varying degrees of SBP, 6 months of supervised walking elicited a marked reduction in systolic blood pressure with the largest reductions in pressure occurring in individuals with higher baseline SBP.

Background Maximal cardiopulmonary exercise testing (CPX) is the gold-standard for cardiorespiratory fitness assessment in chronic heart failure (CHF) patients. However, high costs, required medical supervision, and safety concerns make maximal exercise testing impractical for evaluating mobility-impaired adults. Thus, several submaximal walking protocols have been developed and currently used to estimate peak oxygen consumption (VO2peak) in CHF patients. However, these tests have to be performed at close to maximum exercise intensity. The aim of this study was to examine the validity of a 500-m treadmill-walking test carried out at moderate intensity for estimating VO2peak in community-dwelling adult and elderly patients with CHF and reduced left ventricular ejection fraction (HFrEF). Methods Forty-three clinically stable men with HFrEF (age 67.7 ± 9.2 years, and left ventricular ejection fraction, LVEF 38% ± 6%) underwent exercise testing during an outpatient cardiac rehabilitation/secondary prevention program. Each patients completed a CPX, and a moderate and self-paced (11–13/20 on the Borg scale) 500-m treadmill-walking test. Age, weight, height, walk time, and heart rate during the 500-m test were entered into prediction equations previously validated for VO2peak estimation from a 1000-m walking test in patients with cardiovascular disease and preserved LVEF. Results Directly measured and estimated VO2peak values were not different (21.6 ± 4.9 vs 21.7 ± 4.6 mL/kg/min). The comparison between measured and estimated VO2peak values yielded a correlation of R = 0.97 (SEE = 0.7 mL/kg/min, P

The effectiveness of different programs of physical activity outside randomized studies is difficult to determine. We carried out an audit in two different units where either a supervised physical activity (PA) program or a self-selected PA program was in use in individuals with type 2 diabetes or obesity. The supervised PA cohort (n = 101) received progressive gym training (120 min, twice a week for 13 weeks) by a dedicated team, with nutritional counseling during resting periods. The self-selected PA cohort (n = 69) was enrolled in a 13-week cognitive-behavioral program (120 min/week, in groups of 12–15 individuals), chaired by an expert team. Body weight and physical fitness (6-min walk test) were measured at baseline and after 6 and 12 months. Outcome measures were attrition, weight loss ≥10 % initial body weight, 10 % increase in 6-min walk test; their association with a PA program was tested by logistic regression analysis. Attrition rate was lower in the supervised PA group (28 vs. 45 % than in the self-selected cohort, P = 0.023). After adjustment for confounders, the supervised PA program was associated with a lower risk of attrition at 1 year (odds ratio 0.45; 95 % confidence interval, 0.21–0.98) at logistic regression analysis. Body weight similarly decreased in both groups (more rapidly in the supervised PA cohort); also physical fitness improved in a similar way, and no differences in achieved targets of body weight (supervised, 31 %; self-selected, 18 %; P = 0.118) or fitness (supervised, 62 %; self-selected, 49 %; P = 0.312) were demonstrated. Different PA programs produce very similar health benefits, but an initially supervised program has lower attrition rates, which might translate into better outcomes in the long term.

INTRODUCTION The aim of this study was to determine whether the 1-km treadmill walking test, previously developed to predict peak oxygen uptake ((Equation is included in full-text article.)O2peak) in stable cardiac outpatients, could be reproduced outdoors. METHODS Fifty male cardiac outpatients performed the 1-km walking test on a treadmill and on a flat track within 1 week. (Equation is included in full-text article.)O2peak was estimated for both testing conditions considering age, height, weight, walking speed, and heart rate. RESULTS Average walking speed was slightly higher during outdoor conditions (5.73 ± 0.77 km/h vs 5.55 ± 0.84 km/h), whereas mean heart rates were similar for both testing conditions (102 ± 18 beats/min vs 103 ± 16 beats/min). (Equation is included in full-text article.)O2peak values for treadmill and outdoor tests were not significantly different (26.4 ± 4.1 mL/kg/min vs 26.8 ± 4.5 mL/kg/min) and were strongly correlated (r = 0.93, P < .0001). The slope and the intercept of the (Equation is included in full-text article.)O2peak values were not different from the line of identity. CONCLUSIONS This moderate and perceptually regulated 1-km walking test administered outdoors gives similar results compared with a similar test performed on a treadmill. Therefore, (Equation is included in full-text article.)O2peak can be reasonably estimated using both testing modalities. This suggests that the outdoor 1-km test can be applied for indirect estimations of cardiorespiratory fitness in an outpatient setting.

Background Tendinopathies are conditions characterized by activity-induced pain, local tenderness and swelling for which a gold standard treatment is not established yet. Hyaluronic Acid (HA) is a key-molecule in several cellular activities and it is normally present in the extra-cellular matrix of tendons and ligaments. Amongst its properties, HA injections may reduce pain and determine disease-modifying effects. This study is an investigator-initiated open-label trial conducted to investigate the efficacy and safety of HA (500-730 kDa) peritendinous injections on pain reduction in patients affected by lateral elbow, Achilles or patellar tendinopathy. Methods A total of 71 tendons (34 with Achilles tendinopathy, 26 with lateral elbow tendinopathy, 11 with patellar tendinopathy) of 62 patients with painful tendinopathy were treated with a cycle of ultrasound-guided peritendinous injections one injection per week for three consecutive weeks. Efficacy assessments included changes in pain intensity measured by Visual Analogue Scale (VAS) at follow-up evaluations were performed 7 (V2), 14 (V3) and 56 days aften first treatment. An Ultrasound (US) assessment was also performed to evaluate changes in tendon thickness and neovascularization. Adverse events were recorded for safety analysis throughout the study. All results were analyzed with descriptive statistics appropriate to the nature of the variables. Results Significant reduction in VAS (p

Purpose Maximal oxygen uptake ((Equation is included in full-text article.)O2) and ventilatory threshold (VT) are widely used to assess cardiorespiratory fitness in healthy people, as well as in patients with various clinical conditions. The aim of this study was to determine whether an attenuation of (Equation is included in full-text article.)O2 occurs above the VT in patients with stable coronary artery disease. Methods A total of 33 male patients participating in an outpatient cardiac rehabilitation/secondary prevention program underwent maximal incremental cycle ergometry at increasing pedaling cadences up to the limit of tolerance. Ventilatory gas-exchange variables were measured breath by breath while work rate was recorded continuously. Ventilatory threshold was determined by a dual linear regression model (V-slope analysis). Results Four patients were excluded from the analysis because they were unable to pedal at the increasing cadences required by the protocol. The remaining 29 patients successfully completed the test without complications or evidence of significant ST segment depression. The slope of the (Equation is included in full-text article.)O2/work rate relationship above the VT decreased significantly (-44.6% on average) in 23 of the 26 patients in which VT was able to be determined. (Equation is included in full-text article.)O2 at the start of (Equation is included in full-text article.)O2 attenuation ((Equation is included in full-text article.)O2att) and at VT were highly correlated and in strong agreement (1637 ± 451 mL/min vs 1650 ± 473 mL/min, r = 0.96, P Conclusions (Equation is included in full-text article.)O2att does occur and coincides with the VT in the majority of patients tested with stable coronary artery disease.

Cardiopulmonary exercise testing is widely used in clinical assessment and exercise prescription. However, significant differences in physiological responses can occur depending on testing protocol. The aim of this study was to evaluate the cardiopulmonary responses to different incremental cycle pedaling cadences in cardiac patients.Eleven men with coronary artery disease (CAD) and 12 men with chronic heart failure (CHF) performed 2 maximal cycle tests at constant cadence (60-70 rpm, at fixed cadence) and at progressive cadence. Peak values for oxygen uptake (V(O(2)peak)), workload (W(peak)), and heart rate (HR(peak)); ventilatory threshold (VT); and the oxygen uptake (VO2) per unit work rate (WR) increment (ΔV(O(2))/ΔWR) obtained using 2 protocols were determined.V(O(2)peak) and W(peak), respectively, were higher during increasing cadence (INCR) compared with fixed cadence (FIX) protocol both in patients with CAD (32.7 ± 5.4 vs 28.1 ± 7.0 mL · kg(-1) · min(-1), P = .01; 214 ± 42 vs 150 ± 28 W, P = .001) and in patients with CHF (20.3 ± 7.4 vs 17.2 ± 5.5 mL · kg(-1) · min(-1), P = .006; 133 ± 45 vs 104 ± 33 W, P = .005). No differences were seen in HR(peak). Both in patients with CAD and in patients with CHF, V(O(2)) (21.7 ± 5.5 vs 16.8 ± 5.3 and 12.3 ± 7.4 vs 9.3 ± 2.8 mL · kg(-1) · min(-1)) and HR (114 ± 14 vs 98 ± 13 and 92 ± 17 vs 80 ± 17 bpm) at VT were significantly higher in INCR than in FIX protocol. No differences were seen in workload at VT. ΔV(O(2))/ΔWR during INCR protocol were higher in patients with CAD (13.4 ± 1.8 vs 9.5 ± 2.6 mL · kg(-1) · W(-1), P = .006) and patients with CHF (13.6 ± 4.1 vs 8.7 ± 1.9 mL · kg(-1) · W(-1), P = .006).These findings indicate that in tests at fixed cadence, there occurs an earlier activation of the anaerobic mechanisms leading to a premature exhaustion before a cardiopulmonary endpoint has been achieved.

The purpose of this study was to develop a test for identifying the speed of onset of claudication, or pain threshold speed (PTS), in 16 patients affected by intermittent claudication. An echo-Doppler examination and the ankle-brachial index (ABI) determination were also performed. Test repeatability was evaluated in 10 patients retested within a few days. All 16 patients underwent the incremental walking test 3 times during a 6-month rehabilitation training program to verify the test's sensitivity in detecting the expected functional modifications. PTS was identified in all patients examined and the test-retest correlation coefficient (R) for PTS was 0.98. During the 6-month rehabilitation period, the ABI rose from 0.43 +/-0.16 to 0.72+/-0.15 for the worst limb and PTS also rose significantly from 3.9+/-1.4 km/h to 6.1+/-1.1 km/h. The average increments of ABI and PTS were significantly correlated. An incremental walking test for the identification of the walking speed at which claudication occurs has been developed. The PTS is a reproducible parameter that can be combined with other test results to establish the severity of the disease and to check any modifications that occur during rehabilitation.

Purpose The aim of this study is to assess the association between peak oxygen uptake (VO 2 peak), determined using a perceptually regulated 1-km walking test (1k-TWT), and all-cause mortality in cardiac patients. Methods 1255 male patients, aged 25–85years, completed a moderate 1k-TWT to estimate VO 2 peak. Subjects were followed for all-cause mortality for up to 10years. Cox proportional hazard models were employed to determine variables associated with mortality. Based on the estimated VO 2 peak, the sample was subdivided into quartiles and mortality risks were calculated. To assess the discriminatory accuracy of the estimated VO 2 peak for estimating survival, receiver-operating-characteristics curves were constructed. Results During a median 8.2year follow-up, a total of 141 deaths from any cause occurred, yielding an average annual mortality of 1.4%. The strongest predictor of all-cause mortality was the estimated VO 2 peak ( c- statistic 0.71, 95% confidence intervals: 0.69–0.74, P 2 peak quartile to the lowest quartile. Compared to the lowest quartile, the hazard ratios (95% confidence intervals) for the second, third, and fourth quartiles were 0.77 (0.35–1.33), 0.43 (0.20–0.91), and 0.16 (0.05–0.54) respectively ( P for trend 2 peak over the follow-up period relative to subjects in the least fit quartile who did not improve. Conclusion VO 2 peak estimated by a novel 1k-TWT predicts survival in subjects with stable cardiovascular disease.

Objectives The aims of the study were to organise a program of guided walking for sedentary subjects, to analyse the changes of some risk factors for cardiovascular diseases after one year of walking and to check the permanence of unsupervised walking practice months after the program was over. Methods 650 adults and elderly subjects, declaring only occasional physical activity, were enrolled. Weight, height, waist circumference, systolic and diastolic blood pressure and walking speed (measured on a 100 metres course, at an intensity of 12-14 on the Borg scale) were determined at enrolment. Subjects were invited to walk as frequently as possible alone or with one of the several walking groups organised for the project. Walking groups were active five days a week with walking sessions of approximately one hour. The variables measured at enrolment were re-determined after one year. Sixteen month after the end of the project the participants completing the program fill in a questionnaire on the weekly walking hours they were still doing. Results 326 subjects (212 women and 114 men) walked from three to seven days a week and completed the one-year project. After 12 months of walking, highly significant reductions of body weight, BMI, waist circumference, systolic and diastolic blood pressure and highly significant increase in walking speed were documented1(Table 1). Identical results were obtained for both women and men. Sixteen months after the end of the project 258 subjects declared 170 ± 110 minutes a week of independent walking (Figure 1), a time superimposable to the one indicated by the 2008 Physical Activity Guidelines for Americans. Conclusions One year of guided walking has been followed by highly significant reductions of some risk factors for cardiovascular diseases and by a highly significant improvement of the walking speed. Sixteen months after the end of the project, 77% of the participants were independently maintaining the walking practice, indicating that guided walking is effective in permanently modifying the lifestyle of sedentary subjects. Acknowledgments Supported by the Italian Ministry of Education and Scientific Research and the Ministry of Sport. References Murphy MH, Nevill AM, Murtagh EM, Holder RL. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med. 2007;44(5):377–85.

Background/Aim Cardiovascular diseases (CVD) are the leading cause of mortality in the world and 9produce immense global health and economic burdens9, mostly attributable to hospital costs.1 The determination of peak oxygen consumption (VO2peak) is used for assessing disease severity, predicting prognosis, and examining the effectiveness of training programs for individuals with CVD.2 Aim of the study was to determine the association between VO2peak estimated by a moderate 1-km treadmill walk (1km-TWT)3 and all-cause hospitalization in cardiac outpatients. Methods We studied 1308 men aged 25-85 years at baseline, referred to our Center for an exercise-based secondary prevention programme. Participants were instructed to select a walking pace at a perceived intensity of 11-13 on the 6-20 Borg Scale to be maintained during the 1-km-TWT. The equation for VO2peak estimation was applied considering age, BMI, heart rate, and time to complete the 1-km3. All-cause hospitalization was checked 3 years after enrollment. Results Patients were subdivided into tertiles of VO2peak. Estimated VO2peak resulted 19.62.4, 23.81.1, and 29.03.0 mL/kg/min for the first (n=436, LOW FIT), second (n=436, MODERATE FIT), and third (n=436, HIGH FIT) tertile, respectively. During the following 3 years, hospitalizations were 203 for LOW FIT group (47% of the sample), 151 for MODERATE FIT group (35% of the sample), and 109 for HIGH FIT group (25% of the sample) (Figure). Compared to the LOW FIT group, the fully-adjusted hazard ratios for hospitalization were 0.79 (95%CI 0.59 to 1.05, P=0.10) for the MODERATE FIT group, and 0.53 (95%CI 0.35 to 0.79, P=0.002) for the HIGH FIT group (P for trend ≥0.0001). Hospital stay was 3654, 1963, and 1090 days for LOW, MODERATE, and HIGH FIT groups, respectively. The mean healthcare costs for hospitalization during the 3-years tracking period were 36% and 64% lower in the HIGH FIT and MODERATE FIT groups versus LOW FIT group (1.74, 1.11, and 0.63 million euros respectively). Conclusions An inverse association was found between exercise capacity and all-cause hospitalization in stable outpatients with cardiovascular disease. The lower VO2peak was associated with higher rates of hospitalization, independently of traditional cardiovascular risk factors and disease severity. The higher the baseline VO2peak, the lower the hospitalization rate, the shorter the length of hospital stay, and the lower the corresponding healthcare costs. The 1km-TWT represents a simple tool for assessing cardiorespiratory fitness and for predicting prognosis in patients with CVD. References Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics-2015 Update. A Report From the American Heart Association. Circulation 2015;131:e29–e322. Arena R, Myers J, Williams A, et al. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation 2007;116(3):329–43. Chiaranda G, Myers J, Mazzoni G, et al. Peak oxygen uptake prediction from a moderate, perceptually regulated, 1-km treadmill walk in Male cardiac patients. J Cardiopulm Rehabil Prev 2012;32:262–9.

Objective To determine whether the walking speed maintained during a 1 km treadmill test at moderate intensity predicts survival in patients with cardiovascular disease. Design Population-based prospective study. Setting Outpatient secondary prevention programme in Ferrara, Italy. Participants 1255 male stable cardiac patients, aged 25–85 years at baseline. Main outcome measures Walking speed maintained during a 1 km treadmill test, measured at baseline and mortality over a median follow-up of 8.2 years. Results Among 1255 patients, 141 died, for an average annual mortality of 1.4%. Of the variables considered, the strongest predictor of all-cause mortality was walking speed (95% CI 0.45 to 0.75, p

Objective: To assess the effectiveness of domiciliary physical fitness programmes in obese individuals. Design: Nine-month randomized controlled trial. Setting: Home-based intervention with outpatient visits. Subjects: Morbidly obese subjects (body mass index (BMI) ≥30) aged 25—65 years suitable for physical activities at home. Intervention: At the end of a preliminary one-month in-hospital rehabilitation programme (baseline), 52 patients were randomly assigned either to a structured educational programme (intervention group) of daily incremental physical activity at home (walking and skeletal muscle resistance training, with booklets and written instructions) or to a programme of general advice (control group) regarding exercise and long-term fitness. Main measures: Both groups were evaluated at baseline and every three months for: (1) time, metabolic equivalents (METs), and heart rate reserve (HRR) during a standardized 2-km walking test (2kmWT); (2) anthropometric measures (body weight, BMI, abdominal and neck circumference); (3) the Polar Fitness Test index (PFTI), and (4) time to exhaustion while sustaining consecutive isoload extensions in the dominant leg (isoload LE). Time during 2kmWT was the study primary outcome. Results: Body weight, BMI and abdominal circumference improved significantly (P Conclusion: This structured domiciliary fitness programme is feasible and provides sustained anthropometric and physiological benefits in some morbidly obese individuals.

Increased frequency of the homozygous II ACE genotype in Italian Olympic endurance athletes

Influence of low-density lipoprotein (LDL) receptor-related protein and ABO blood group genotypes on factor XI levels

Recombinant human erythropoietin (EPO), commercially available since 1988, is thought to be used by athletes in aerobic sports for the purpose of increasing oxygen transport and aerobic power. In an attempt to identify EPO administration, we have studied the peripheral blood of 20 subjects practising sports at an amateur level. Automated cytometry was performed on the blood samples before and during 45 days of EPO treatment. The same hematological indices were determined for a control population that consisted of 240 elite athletes from various sports. As expected following EPO treatment, RBC, [Hb] and Hct increased significantly (increments of 8%, 6.3% and 11%, respectively). A significant increase in reticulocyte count was also observed. In addition, automated erythrocyte analysis showed a significant increase in cells with a volume > 120 fl and hemoglobin content (HC)