Search

Endothelial function is reduced across the menopausal stages related to increased oxidative stress associated with estrogen deficiency. In vitro studies demonstrate that coadministration of VITC with BH4 prevents endothelial nitric oxide synthase (eNOS) uncoupling and reductions in NO by peroxynitrite; however, this remains untested in humans. We demonstrate that the coadministration of BH4 + VITC does not restore endothelial function in perimenopausal and postmenopausal women to the level of premenopausal women, suggesting that other mechanisms contribute.

The objective of this study was to characterize the impact of multimorbidity and cardiorespiratory fitness (CRF) on mortality in patients completing cardiac rehabilitation (CR).This cohort study included data from patients with a history of cardiovascular disease (CVD) completing a 12-wk CR program between January 1996 and March 2016, with follow-up through March 2017. Patients were stratified by the presence of multimorbidity, which was defined as having a diagnosis of ≥2 noncommunicable diseases (NCDs). Cox regression analyses were used to evaluate the effects of multimorbidity and CRF on mortality in patients completing CR. Symptom-limited exercise tests were completed at baseline, immediately following CR (12 wk), with a subgroup completing another test at 1-yr follow-up. Peak metabolic equivalents (METs) were determined from treadmill speed and grade.Of the 8320 patients (61 ± 10 yr, 82% male) included in the analyses, 5713 (69%) patients only had CVD diagnosis, 2232 (27%) had CVD+1 NCD, and 375 (4%) had CVD+≥2 NCDs. Peak METs at baseline (7.8 ± 2.0, 6.9 ± 2.0, 6.1 ± 1.9 METs), change in peak METs immediately following CR (0.98 ± 0.98, 0.83 ± 0.95, 0.76 ± 0.95 METs), and change in peak METs 1 yr after CR (0.98 ± 1.27, 0.75 ± 1.17, 0.36 ± 1.24 METs) were different (P.001) among the subgroups. Peak METs at 12 wk and the presence of coexisting conditions were each predictors (P.001) of mortality. Improvements in CRF by ≥0.5 METS from baseline to 1-yr follow-up among patients with or without multimorbidity were associated with lower mortality rates.Increasing CRF by ≥0.5 METs improves survival regardless of multimorbidity status.

Countless individuals in the United States continue to experience effects related to the coronavirus disease 2019 (COVID-19) pandemic, such as job/business instability, the breaking down of school systems, isolation, and negative health consequences. There are, however, certain populations and communities that continue to be disproportionately affected, resulting in severe health outcomes, decreased quality of life, and alarmingly high death rates. These populations typically live in historically excluded communities and identify as persons of color. To advance health equity in these communities, healthy living (HL) strategies are paramount. In fact HL Medicine - getting sufficient physical activity, practicing good nutrition, maintaining a healthy body weight, and not smoking, can be a viable solution. Applying these concepts, particularly the promotion of physical activity, through community collaboration can advance the goals of social justice action.

Cardiorespiratory fitness (CRF) has been proposed as a vital sign for the past several years, supported by a wealth of evidence demonstrating its significance as a predictor of health trajectory, exercise/functional capacity, and the quality of life. According to the Fick equation, oxygen consumption (VO

PURPOSE To examine the feasibility of screening for chronic obstructive pulmonary disease (COPD) in an outpatient cardiac rehabilitation (CR) setting and to evaluate the detection rate of COPD using a targeted screening protocol. METHODS A total of 95 patients (62.5 ± 10.0 yr; men, n = 77), >40-yr old with a history of smoking were included in the study sample. Each participant answered the 5-item Canadian Lung Health Test (CLHT) questionnaire assessing symptoms such as coughing, phlegm, wheezing, shortness of breath, and frequent colds. Endorsing ≥1 item was indicative of potential COPD and warranted pulmonary function testing (PFT) and/or spirometry to diagnose or rule out COPD. RESULTS The CLHT questionnaire identified 44 patients at risk for COPD, with an average of 1.9 ± 1.2 items endorsed. Of the patients who underwent PFT, 6 new cases of mild COPD were diagnosed, resulting in a true positive rate with CLHT screening of 19% and a false-positive rate of 81%. CONCLUSIONS Implementing the CLHT to patients referred to CR correctly identified COPD in

The COVID-19 pandemic is causing devastating global morbidity and mortality. Worldwide measures are taken to prevent human to human transmission and improve general health. Public lifestyle and health are affected by social distancing and isolation. A strong host immune response to the novel coronavirus is a key factor, for protection against infection and avoiding reaching severe stages of the disease.Pathophysiology and the human immune response of similar coronaviruses have been previously described. The novel coronavirus has distinct clinical stages related to the immune response. Exercise improves host innate immunity and affords protection to viral infections. Exercise also mitigates the negative effects of isolation including stress, anxiety, and sedentarism, all of which further reduces immunity and increases non-communicable disease risk.Improving host immunity and mitigating the negative effects of isolation via physical activity is strongly justified. Exercise should be done in moderate intensities and volumes during the current pandemic, which is a nutritionally, psychologically, socially challenging environment in the presence of a virulent viral organism. Proactively creating innovative health promotion models with technology and government involvement with the best available evidence should be encouraged to reduce physical inactivity during the current COVID-19 pandemic and after.

PURPOSE To determine the effects of individually tailored interventions designed to increase physical activity (PA) in cardiac patients. METHODS A total of 99 (77 men and 22 women, 61.5 ± 10.7 yr) patients entering a phase III cardiac rehabilitation program completed a 12-wk PA intervention. Patients were randomized to usual care (UC, time-based recommendation), pedometer feedback (PF), newsletter-based motivational messaging (MM), or PF + MM. Both PF groups were given a goal of increasing steps/d by 10% of individual baseline value each week. If the goal for the week was not reached, the same goal was used for the next week. Physical activity was assessed for 7 d before beginning and after completing the program. The change in steps/d, moderate to vigorous intensity PA minutes, and sedentary time were compared among intervention groups. RESULTS Average change in steps/d was found to be significantly greater (P < .01) in the PF (2957 ± 3185) and the PF + MM (3150 ± 3007) compared with UC (264 ± 2065) and MM (718 ± 2415) groups. No group experienced changes in moderate to vigorous intensity PA time and only the PF intervention group decreased sedentary time (baseline 470.2 ± 77.1 to postintervention 447.8 ± 74.9 min/d, P = .01). CONCLUSION The findings from this study demonstrate that using PF was superior to the usual time-based PA recommendations and to newsletter-based MM in patients starting a phase III CR program. Cardiac rehabilitation programs are encouraged to implement PA feedback with individualized PA goals in order to support the increase in PA.

Regular exercise enhances endothelial function in older men, but not consistently in estrogen-deficient postmenopausal women. Estradiol treatment improves basal endothelial function and restores improvements in endothelial function (flow-mediated dilation, FMD) to aerobic exercise training in postmenopausal women; however, estradiol treatment is controversial. Resveratrol, an estrogen receptor ligand, enhances exercise training effects on cardiovascular function and nitric oxide (NO) release in animal models, but impairs exercise training effects in men. We conducted a randomized cross-over, double-blinded, placebo-controlled pilot study to determine whether acute (single dose) resveratrol (250-mg tablet) or estradiol (0.05 mg/day transdermal patch) treatment enhances FMD at rest and after a single bout of moderate-intensity aerobic exercise in healthy estrogen-deficient postmenopausal women ( n = 15, 58.1 ± 3.2 yr). FMD was measured before and after (30, 60, and 120 min) a 40-min bout of moderate-intensity treadmill exercise (60–75% peak heart rate) under the respective conditions (separated by 1-2 wk). FMD was higher ( P < 0.05) before exercise and at all post-exercise time points in the resveratrol and estradiol conditions compared to placebo. FMD was increased from baseline by 120 min postexercise in the estradiol condition ( P < 0.001), but not resveratrol or PL conditions. Consistent with our previous findings, estradiol also enhances endothelial function in response to acute endurance exercise. Although resveratrol improved basal FMD, there was no apparent enhancement of FMD to acute exercise and, therefore, may not act as an estradiol mimetic. NEW & NOTEWORTHY The benefits of endurance exercise training on endothelial function are diminished in estrogen-deficient postmenopausal women, but estradiol treatment appears to restore improvements in endothelial function in this group. We show that basal endothelial function is enhanced with both acute estradiol and resveratrol treatments in estrogen-deficient postmenopausal women, but endothelial function is only enhanced following acute endurance exercise with estradiol treatment.

BACKGROUND: Type 2 diabetes and cardiometabolic comorbidities manifesting as the metabolic syndrome (MetS) are highly prevalent in coronary heart disease (CHD) patients attending cardiac rehabilitation (CR). The study aimed to determine the prevalence of cardiometabolic derangements and MetS, and compare post-CR clinical responses in a large cohort of CHD patients with and without diabetes. METHODS: Analyses were conducted on 3953 CHD patients [age: 61.1 ± 10.5 years; 741 (18.7%) with diabetes] that completed a representative 12-week CR program. A propensity model was used to match patients with diabetes (n = 731) to those without diabetes (n = 731) on baseline and clinical characteristics. RESULTS: Diabetic patients experienced smaller improvements in metabolic parameters after completing CR, including abdominal obesity, and lipid profiles (all P ≤ .002), compared to non-diabetic patients. For both groups, there were similar improvement rates in peak metabolic equivalents ([METs]; P < .001); however, peak METs remained lower at 12-weeks in patients with diabetes than without diabetes. At baseline, the combined prevalence of insulin resistance (IR) and diabetes was 57.3%, whereas IR was present in 48.2% of non-diabetic patients, of which rates were reduced to 48.2% and 32.8% after CR, respectively. Accordingly, MetS prevalence decreased from 25.5% to 22.3% in diabetic versus 20.0% to 13.4% in non-diabetic patients (all P ≤ .004). CONCLUSIONS: Completing CR appears to provide comprehensive risk reduction in cardio-metabolic parameters associated with diabetes and MetS; however, CHD patients with diabetes may require additional and more aggressive attention towards all MetS criteria over the course of CR in order to prevent future cardiovascular events.

INTRODUCTION: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life. AREAS COVERED: In this review we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training. EXPERT OPINION: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

Cardiac rehabilitation (CR) programs are recommended standard-of-care by all major cardiovascular medicine professional organizations. Exercise training is the cornerstone for CR, with aerobic training being the primary form of training. The benefits of exercise training are multiple; however, improved cardiorespiratory fitness is of utmost importance. Moderate-intensity continuous training, supplemented with resistance training, has traditionally been the most common form of exercise training in CR. This review discusses the role of aerobic exercise training in CR and the importance of effective and personalized exercise prescription for optimized results. We also focus on the benefits and utility of high-intensity interval training across different clinical populations commonly seen in the CR setting.

Cardiovascular disease (CVD) is the leading cause of death globally. Advancements in the treatment of CVD have reduced mortality rates, yet the global burden of CVD remains high. Considering that CVD is still largely a preventable disease, prioritizing preventative measures through healthy lifestyle (HL) behaviors is necessary to lessen the burden of CVD. HL behaviors, such as regular exercise, healthy eating habits, adequate sleep, and smoking cessation, can influence a number of traditional CVD risk factors as well as a less commonly measured risk factor, cardiorespiratory fitness (CRF). It is important to note that cardiac rehabilitation programs, which traditionally have focused on secondary prevention, also emphasize the importance of making comprehensive HL behavior changes. This review discusses preventative measures to reduce the burden of CVD through an increased uptake and assessment of HL behaviors. An overview of the importance of CRF as a risk factor is discussed along with how to improve CRF and other risk factors through HL behavior interventions. The role of the clinician for promoting HL behaviors to prevent CVD is also reviewed.

Cardiovascular disease predominates as the leading health burden among middle-aged and older American adults, but progress in improving cardiovascular health remains slow. Comprehensive, evidenced-based behavioral counseling interventions in primary care are a recommended first-line approach for promoting healthy behaviors and preventing poor cardiovascular disease outcomes in adults with cardiovascular risk factors. Assisting patients to adopt and achieve their health promotion goals and arranging follow-up support are critical tenets of the 5A Model for behavior counseling in primary care. These 2 steps in behavior counseling are considered essential to effectively promote meaningful and lasting behavior change for primary cardiovascular disease prevention. However, adoption and implementation of behavioral counseling interventions in clinical settings can be challenging. The purpose of this scientific statement from the American Heart Association is to guide primary health care professional efforts to offer or refer patients for behavioral counseling, beyond what can be done during brief and infrequent office visits. This scientific statement presents evidence of effective behavioral intervention programs that are feasible for adoption in primary care settings for cardiovascular disease prevention and risk management in middle-aged and older adults. Furthermore, examples are provided of resources available to facilitate the widespread adoption and implementation of behavioral intervention programs in primary care or community-based settings and practical approaches to appropriately engage and refer patients to these programs. In addition, current national models that influence translation of evidence-based behavioral counseling in primary care and community settings are described. Finally, this scientific statement highlights opportunities to enhance the delivery of equitable and preventive care that prioritizes effective behavioral counseling of patients with varying levels of cardiovascular disease risk.

Early outpatient (ECR) and maintenance cardiac rehabilitation (MCR) programs are essential, evidence-based services that have received unequivocal endorsement by national and international professional organizations. However, the latest data characterizing ECR enrollment and adherence fell well short of what would be expected for a therapy that has accumulated decades of empirical evidence touting the associated physiologic, physical, psychosocial, and financial benefits. Although national participation levels have remained stagnant, a series of recent publications showcase effective strategies that could bolster both ECR enrollment and adherence levels at the institutional level. Unlike ECR, fewer reports on enrollment and adherence rates exist for MCR, partly due to the lack of standardization of this service. In this review, we aim to highlight current data on enrollment and adherence to ECR and MCR and discuss evidence-based programmatic strategies to support utilization of both services.

Purpose of Review: In the United States (US), 46% of adults have hypertension (systolic blood pressure ≥ 130 mmHg, diastolic blood pressure ≥ 80 mmHg). Approximately, 16% of patients with hypertension have apparent treatment-resistant hypertension (aTRH) and the incidence of true resistant hypertension (RHT) is thought to be much lower (~ 2%). These patients with RHT are at a higher risk for adverse events and worse clinical outcomes. Recent Findings: Although lifestyle interventions have proven to be effective as the first line of defense in treating hypertension, their role in the management of patients with RHT is not well established. Despite fewer in number, available studies examining lifestyle interventions in patients with RHT do indeed show promising results. Summary: In this review, we aim to discuss the role of common lifestyle interventions such as physical activity, exercise, weight loss, and dietary modifications on blood pressure control in patients with RHT.

Coronavirus disease 2019 (COVID-19) continues to have a devastating effect on a global scale. COVID-19 variants continue to arise and counteract vaccination efficacy. As such, preventative health measures, such as social distancing and stay at home mandates, will continue for the foreseeable future. Evidence on those at greatest risk for poor outcomes if infected with COVID-19 has rapidly come to light. It has become clear that those with unhealthy lifestyle characteristics, chronic disease risk factors and/or a confirmed diagnosis of one or more chronic conditions are at greatest risk for hospitalization, intensive care unit admission, mechanical ventilation, and death if infected with COVID-19. The cytokine storm is a phenomenon that has been posited as a pathophysiologic response to COVID-19 infection that leads to poor outcomes. The current graphical review illustrates the association between unhealthy lifestyle characteristics and increased vulnerability to the cytokine storm as well as the physiologic mechanisms healthy living behaviors elicit and decrease risk for the cytokine storm. Through this graphical review, we will demonstrate unhealthy lifestyle characteristics, chronic disease risk factors and diagnoses, and COVID-19 outcomes are intricately linked, creating a new global syndemic. It is also clear that a primary way to uncouple this syndemic is through increasing healthy living behaviors, as illustrated in this graphical review. Moving forward, healthy living medicine should be practiced with renewed vigor to improve human resiliency to health threats posed by both chronic disease and viral infections.

OBJECTIVE: To determine the association between cost-sharing and adherence to cardiac rehabilitation (CR). PATIENTS AND METHODS: We collected detailed cost-sharing information for patients enrolled in CR at Baystate Medical Center in Springfield, MA, including the presence/absence and amounts of copays and deductibles. We evaluated the association between cost-sharing and the total number of CR sessions attended, as well as the influence of household income on CR attendance. RESULTS: In 2015, 603 patients enrolled in CR had complete cost-sharing information. In total, 235 (39%) had some form of cost-sharing. Of these, 82% had copays [median copay $20 (IQR 10, 32)] and 50% had an unmet deductible [median $500 (IQR 250, 1800)]. The presence of any amount or form of cost-sharing was associated with 6 fewer sessions of CR [16 (IQR 4 to 36) vs. 10 (IQR 4 to 27), P < .001]. Patients hospitalized in November or December with deductibles that renewed in January attended 4.5 fewer sessions of CR [8.5 (3.25 to 12.5) vs. 13 (5.25 to 36) P = .049]. After adjustment for differences in baseline characteristics, every $10 increase in copay was associated with 1.5 (95% CI −2.3 to −0.7) fewer sessions of CR (P < .001). Household income did not moderate these relationships. CONCLUSION: Cost-sharing was associated with lower CR attendance and exhibited a dose-response relationship such that higher cost-sharing was associated with lower CR attendance. Given that CR is cost-effective and underutilized, insurance companies and other payers should re-evaluate their cost-sharing policies for CR.

INTRODUCTION: Left ventricular assist device (LVAD) implantation has become a well-established treatment option for patients with end stage heart failure (HF) who are refractory to medical therapy. While LVADs implantation does effectively improve hemodynamic performance many patients still possess peripheral pathological adaptations often present in end-stage HF. Therefore, increased attention has been placed on investigating the effects of exercise training for patients with LVADs to improve clinical outcomes. However, the available evidence on exercise training for patients with LVADs is limited. AREAS COVERED: The purpose of this narrative review is to summarize: 1) The evolution of LVAD technology and usage; 2) The physiological responses to exercise in patients with LVADs; 3) The available evidence regarding exercise training; 4) Potential strategies to implement exercise training programs for this patient population. EXPERT OPINION: The available evidence for exercise training to improve physical function and clinical outcomes for patients with LVADs is promising but limited. Future research is needed to further elucidate the ideal exercise training parameters, method of delivery for exercise training, and unique barriers and facilitators to exercise training for patients receiving LVAD implantation.

The epidemic of obesity contributes to the burden of type 2 diabetes mellitus (T2DM) in the United States and worldwide. Importantly, obesity is not only preventable but can be treated, particularly with lifestyle modifications to forestall T2DM in those with excess adiposity. The mechanisms linking obesity to T2DM are numerous and involve adipose tissue remodeling as a result of unhealthy behaviors, including unhealthy diet, reduced physical activity (PA) and exercise training (ET), and increased sedentary behaviors. Taken together, these factors markedly reduce cardiorespiratory fitness (CRF), one of the strongest predictors for cardiovascular outcomes and all-cause mortality in the general population, but also in those with T2DM. In this review we describe the mechanisms leading to adipose tissue remodeling resulting in obesity, as well as the mechanisms linking excess adiposity to insulin resistance and, in turn, T2DM. We then present the therapeutic strategies that can be implemented in obesity to prevent T2DM, with a brief discussion on weight loss, and greater emphasis on PA and ET. We finally present the evidence to support the beneficial effects of such strategies in patients with established T2DM and discuss the importance of achieving improvements in CRF in this population to potentially improve clinical outcomes.

Sedentary behavior and physical inactivity are among the leading modifiable risk factors worldwide for cardiovascular disease and all-cause mortality. The promotion of physical activity and exercise training (ET) leading to improved levels of cardiorespiratory fitness is needed in all age groups, race, and ethnicities and both sexes to prevent many chronic diseases, especially cardiovascular disease. In this state-of-the-art review, we discuss the negative impact of sedentary behavior and physical inactivity, as well as the beneficial effects of physical activity /ET and cardiorespiratory fitness for the prevention of chronic noncommunicable diseases, including cardiovascular disease. We review the prognostic utility of cardiorespiratory fitness compared with obesity and the metabolic syndrome, as well as the increase of physical activity /ET for patients with heart failure as a therapeutic strategy, and ET dosing. Greater efforts at preventing sedentary behavior and physical inactivity while promoting physical activity, ET, and cardiorespiratory fitness are needed throughout the healthcare system worldwide and particularly in the United States in which the burden of cardiometabolic diseases remains extremely high.

The importance of cardiorespiratory fitness (CRF) is now well established and it is increasingly being recognized as an essential variable which should be assessed in health screenings. The key findings that have established the clinical significance of CRF are reviewed in this report, along with an overview of the current relevance of exercise as a form of medicine that can provide a number of positive health outcomes, including increasing CRF. Current assessment options for assessing CRF are also reviewed, including the direct measurement via cardiopulmonary exercise testing which now can be interpreted with age and sex-specific reference values. Future directions for the use of CRF and related measures are presented.

Substantial evidence shows that physical inactivity (PI) and sedentary behavior (SB) increases the risk of many chronic diseases and shortens life expectancy. We describe evidence that certain domains of physical activity (PA) in the United States (US) population have declined substantially over 5 decades. The prevalence of PI is very high worldwide, which has contributed to 6%-10% of the burden of many chronic diseases and premature mortality. Reduction or elimination of PI would likely produce substantial increases in life expectancy of the world's population. Great efforts are needed to reduce PI and SB and increase levels of PA in the US and worldwide.

Physical inactivity is strongly associated with an unfavorable health profile, increasing an individual's risk for developing cardiovascular disease. Initiating a regular exercise routine contributes to improvements in cardiorespiratory fitness, body composition, resting blood pressure, blood glucose, and circulating lipoproteins. However, the extent to which positive changes occur come with significant inter-individual variability within intervention groups; non-responders and responders have been commonly identified across populations, highlighting that not all exercise regimens are universally effective in all individuals and should therefore not be treated as a "one-size fits all" prescription. Recent studies have therefore emphasized reporting the quantity of participants favorably and meaningfully "responding" to varying amounts and intensities of exercise, thereby presenting the opportunity to view exercise prescription in the context of precision medicine. This review will address the impact of varying amounts and intensities of physical activity and exercise, highlighting their impact on key health metrics.

Physical inactivity is one of the leading modifiable risk factors for global mortality, with an estimated 20% to 30% increased risk of death compared with those who are physically active. The “behavior” of physical activity (PA) is multifactorial, including social, environmental, psychological, and genetic factors. Abundant scientific evidence has demonstrated that physically active people of all age groups and ethnicities have higher levels of cardiorespiratory fitness, health, and wellness, and a lower risk for developing several chronic medical illnesses, including cardiovascular disease, compared with those who are physically inactive. Although more intense and longer durations of PA correlate directly with improved outcomes, even small amounts of PA provide protective health benefits. In this state-of-the-art review, the authors focus on “healthy PA” with the emphasis on the pathophysiological effects of physical inactivity and PA on the cardiovascular system, mechanistic/triggering factors, the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion regarding PA. Sustainable and comprehensive programs to increase PA among all individuals need to be developed and implemented at local, regional, national, and international levels to effect positive changes and improve global health, especially the reduction of cardiovascular disease.

Healthy living medicine (HLM) is an emerging concept that recognizes the importance of: (1) Moving more and sitting less; (2) Consuming a healthy diet at the appropriate caloric load; (3) Maintaining a healthy body weight; and (4) Not smoking. Suffice to say, HLM should be practiced by all health professionals, prescribing a personalized healthy living polypill to individuals under their care while titrating the dosage for optimal adherence and therapeutic efficacy. Traditionally, HLM, particularly when practiced in the context of physical activity and diet, is commonly viewed as an all-or-none and one-size-fits-all paradigm. As an example, there has been a dichotomous perception to physical activity messaging, where achieving anything less than 150 minutes of moderate-intensity physical activity per day is not beneficial. The same holds true for the all-or-none perception of 5 servings of fruits and vegetables per day; anything less is not beneficial. While these are certainly desirable targets, healthy living practices at levels below current guidelines portend significant health benefits. Precision medicine is defined as "an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person." Much of the focus in precision medicine has been directed toward genomics and only recently has the influence of environment and lifestyle been considered. This review will highlight the importance of HLM directed toward the prevention and treatment of chronic diseases in the context of precision medicine.

Cancer survivors are at increased risk for cardiovascular disease (CVD)-related morbidity and mortality. Exercise-based cardiac rehabilitation (CR) programs improve CVD risk factors, including cardiorespiratory fitness (CRF). The purpose of this study was to investigate: (1) the association between CR completion and survival, and (2) whether CRF improvements translate to increased survival among patients with comorbid cancer and CVD.Patients with CVD and pre-existing cancer (any type) were referred to a 12-week exercise-based CR program between 01/1996 and 03/2016. Peak metabolic equivalents (METs) were assessed by graded exercise test pre-CR and at 12-weeks. Kaplan-Meier survival and multivariate cox regressions were performed to evaluate impact of CR completion and clinically-meaningful CRF improvements [ΔMETs≥1] on survival, adjusting for relevant covariates.Among 442 patients with CVD and cancer referred to CR (67 ± 10 years; 22% women), 361 (82%) completed CR. 102 deaths were recorded during the 12-year observation period. Compared to patients who did not complete CR, patients with comorbid cancer who completed CR demonstrated a survival advantage (63% vs 80.1%, p .001). CRF improved among completers during the 12-week program (mean change = 0.87 ± 0.93 METs, p .001); 41% experienced a clinically-meaningful ΔMETs≥1. A survival advantage was not observed in completers who experienced a ΔMETs≥1 improvement (p = .254).Completing a 12-week exercise-based CR program improved CRF and increased survival in patients with CVD and comorbid cancer. The results highlight the survival benefits of completing a CR program among CVD patients who experience added barriers imposed by cancer treatment and survival.

Cardiorespiratory fitness (CRF) is now an established vital sign. CRF, along with muscle function and bone and joint health is related to functional independence and a higher quality of life. Wasserman and colleagues proposed a gear model illustrating the integrated role of the respiratory, cardiovascular, and skeletal muscle systems during aerobic exercise; in 2015, a revision to the original model was proposed. Our understanding of the effects and challenges associated with the coronavirus disease 2019 (COVID-19) are rapidly evolving. Initial evidence indicates higher levels of CRF, and muscle function protect individuals infected with COVID-19 from a complicated medical course. Moreover, for those individuals infected with COVID-19, there are initial signs of a reduction in CRF following the initial phase of recovery. We are also gaining an understanding of long COVID syndrome, where individuals who have recovered from the acute phase of viral infection present with lasting symptoms, which include but are not limited to reduced CRF, shortness of breath, and fatigue. Clearly, these individuals will require rehabilitation to restore and/or improve CRF, muscle function, bone and joint health, functional capacity (ie, the ability to perform activities of daily living), and quality of life. The importance of assessing the synergistic function of systems essential to performing activities that require physical exertion is a health care imperative. This graphical narrative provides an update to the gear model initially proposed by Wasserman and updated to a gear and circuit in 2015. External CRF, muscle function, and bone and joint health influencers and an approach to clinical assessment are also introduced.

Frailty is a highly prevalent multisystem syndrome in older adults with heart failure (HF) and is associated with poor clinical prognosis and increased complexity of care. While frailty is neither disease nor age specific, it is a clinical manifestation of aging-related processes that reflects a reduced physiological ability to tolerate and recover from stress associated with aging, disease, or therapy. Within this context, physical frailty, which is distinctly oriented to physical functional domains (e.g., muscle weakness, slowness, and low activity), has been recognized as a critical vital sign in older persons with HF. Identification and routine assessment of physical frailty, using objective physical performance measures, may guide the course of patient-centered treatment plans that maximize the likelihood of improving clinical outcomes in older HF patients. Exercise-based rehabilitation is a primary therapy to improve cardiovascular health in patients with HF; however, the limited evidence supporting the effectiveness of exercise tailored to older and frail HF patients underscores the current gaps in management of their care. Interdisciplinary exercise interventions designed with consideration of physical frailty as a therapeutic target may be an important strategy to counteract functional deficits characteristic of frailty and HF, and to improve patient-centered outcomes in this population. The purpose of this current review is to provide a better understanding of physical frailty and its relation to management of care in older patients with HF. Implications of movement-based interventions, including exercise and physical rehabilitation, to prevent or reverse physical frailty and improve clinical outcomes will further be discussed.

PURPOSE Cardiopulmonary exercise testing (CPX) is the gold standard approach for the assessment of cardiorespiratory fitness (CRF). The primary aim of the current study was to determine reference standards for the minute ventilation/carbon dioxide production (V˙E/V˙co2) slope in a cohort from the "Fitness Registry and the Importance of Exercise: A National Database" (FRIEND) Registry. METHODS The current analysis included 2512 tests from 10 CPX laboratories in the United States. Inclusion criteria included CPX data on apparently healthy men and women: (1) age ≥20 yr; and (2) with a symptom-limited exercise test performed on a treadmill. Ventilation and V˙co2 data, from the initiation of exercise to peak, were used to calculate the V˙E/V˙co2 slope via least-squares linear regression. Reference values were determined for men and women by decade of life. RESULTS On average, V˙E/V˙co2 slope values were lower in men and increased with age independent of sex. Fiftieth percentile values increased from 27.1 in the second decade to 33.9 in the eighth decade in men and from 28.5 in the second decade to 33.7 in the eighth decade in women. In the overall group, correlations with baseline characteristics and the V˙E/V˙co2 slope were statistically significant (P < .05) although generally weak, particularly for age and body mass index. CONCLUSION The results of the current study establish reference values for the V˙E/V˙co2 slope when treadmill testing is performed, and all exercise data are used for the slope calculation. These results may prove useful in enhancing the interpretation of CPX results when assessing CRF.

Coronary artery disease (CAD) is the major cause of death of cardiovascular disease. It is initiated by atherosclerosis, which narrows the coronary arteries and limits blood flow and oxygen to the heart. Multiple pathophysiological conditions within the arteries, such as arterial wall thickening, endothelial dysfunction, and arterial stiffening, are associated with the development of atherosclerosis.We introduce a new concept of 'intravascular multimorbidity,' the presence and integration of multiple pathophysiological conditions within the arteries. We also introduce some measurements of intravascular multimorbidity and discuss how these measurements can be utilized in cardiac rehabilitation (CR).We propose that the measures of intravascular multimorbidity in different arteries may provide information on disease severity and serve as unique prognostic 'barometers' to disease progression in patients with CAD. By measuring the underlying disease mechanisms within the arteries and understanding individual variability of disease progression/regression, these measures may also provide a unique prognostic window in CR. The window into intravascular multimorbidity can help guide clinical strategies, for example, assessing progress and appropriate titration of exercise. Intravascular multimorbidity may represent an important opportunity for more researchers and clinical professions to evaluate patients in CR.

Age-related declines in skeletal muscle mass (i.e., sarcopenia) contribute to physical disability in older women. Although a menopause-related increase in fat mass is well documented, whether menopause influences muscle mass and sarcopenia is unclear. We determined the extent to which skeletal muscle mass differs across the stages of the menopause transition in women and whether these differences are associated with estradiol or other sex hormones. This was a cross-sectional study of 144 healthy women (aged 30–70 yr) classified as premenopausal [n = 30, 38 ± 6 yr (means ± SD)], early (n = 31, 50 ± 3 yr) and late (n = 30, 50 ± 4 yr) perimenopausal, and early (n = 26, 55 ± 3 yr) and late (n = 27, 62 ± 4 yr) postmenopausal. Appendicular lean mass (ALM) adjusted by the square of height in meters (ALM index; ALMi) was assessed by dual-energy X-ray absorptiometry. ALMi was lower (P < 0.05) in late perimenopausal and postmenopausal compared with early perimenopausal, with no significant differences between other groups (premenopausal 6.6 ± 0.6, early perimenopausal 6.8 ± 0.8, late perimenopausal 6.1 ± 0.8, early postmenopausal 6.5 ± 1.1, and late postmenopausal 6.2 ± 0.9 kg/m(2)). The prevalence of sarcopenia (ALMi ≤ 5.67 kg/m(2)) was 7%, 3%, 30%, 27%, and 32% in premenopausal, early and late perimenopausal, and early and late postmenopausal groups, respectively. ALMi measured across menopause stages was inversely correlated to follicle-stimulating hormone (FSH; r = −0.28, P = 0.003) but not to estradiol (r = 0.088, P = 0.34). The menopause transition appears to be a vulnerable period for the loss of skeletal muscle mass that may begin during the late perimenopausal transition. Future studies are necessary to investigate the potential effect of FSH on skeletal muscle. NEW & NOTEWORTHY Our data suggest that the late perimenopausal stage may be a vulnerable period for the loss of skeletal muscle, potentially related to elevations in FSH.

Pharmacologic advancements in the treatment of human immunodeficiency virus (HIV) has extended the life expectancy of people living with HIV (PLWH). An unfortunate side effect of HIV treatment, however, is an increased prevalence of dyslipidemia, glycemic dysregulation and abnormal distribution of body fat (lipodystrophy). Consequently, the risk of developing cardiovascular disease (CVD) is significantly increased in PLWH and ultimately a major cause of mortality. Physical activity and exercise training are interventions that have effectively protected against the development of CVD and, in the presence of CVD, has help mitigate morbidity and mortality. Early concerns over potential immunosuppressive effects of exercise in PLWH have largely been dispelled and in some cases exercise has been shown to strengthen markers of immune function. Interventions with aerobic exercise, resistance exercise, and their combination, particularly at higher intensities, are showing promising health outcomes in PLWH. This review will summarize the key cardiovascular and metabolic effects of antiretroviral therapy; the effects of the types and intensities of exercise on cardiorespiratory fitness, cardiometabolic markers, and muscle strength; and provide recommendations on strategies to apply exercise interventions in clinical settings.

PURPOSE The study aimed to investigate the differences in oxygen uptake ((Equation is included in full-text article.)O2) and heart rate (HR) (at rest, submaximal exercise, peak exercise, and recovery) in patients with heart failure with preserved ejection fraction (HFpEF) with β-blockers (BB) or without BB treatment (NBB) and to analyze the relationship between HR reserve (HRresv) and peak (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2peak) in BB and NBB. METHODS A total of 174 HFpEF patients (>65 yr; BB, n = 59; NBB, n = 115) were assessed with a cardiopulmonary exercise test to peak exertion using an incremental protocol. After 5 min of supine rest, HR and (Equation is included in full-text article.)O2 (HRrest, (Equation is included in full-text article.)O2rest) at submaximal exercise (HRsubmax, (Equation is included in full-text article.)O2submax), at peak exercise (HRpeak, (Equation is included in full-text article.)O2peak), at 1 min of passive recovery (HRrec1), HRresv (HRpeak- HRrest), and HR recovery (HRrecov = HRpeak- HRrec1) were evaluated. RESULTS Analysis showed that HRrest (66.0 ± 12.2 vs 69.7 ± 10.6 bpm), HRsubmax (91.7 ± 16.2 vs 98.6 ± 15.2 bpm), and HRrec1 (102.9 ± 18.9 vs 109.4 ± 16.9 bpm) were significantly lower (P ≤ .05) in BB than in NBB, respectively. However, there were no significant differences (P > .05) between the BB and the NBB for HRpeak, HRresv, HRrecov, (Equation is included in full-text article.)O2rest, (Equation is included in full-text article.)O2submax, and (Equation is included in full-text article.)O2peak. A significant relationship was found between HRresv and (Equation is included in full-text article.)O2peak values in both groups (BB, r = 0.52; NBB, r = 0.49, P < .001). CONCLUSIONS The nonsignificant differences in HRpeak, HRresv, HRrecov, or (Equation is included in full-text article.)O2 values between BB and NBB HFpEF patients, along with significant correlation between HRresv and (Equation is included in full-text article.)O2peak, suggest that these measures may have equal utility in prognostic and functional assessment as well as clinical applications, including the prescription of exercise, in elderly HFpEF patients.

The cardiovascular disease (CVD) pandemic has placed considerable strain on healthcare systems, quality of life, and physical function, while remaining the leading cause of death globally. Decades of scientific investigations have fortified the protective effects of cardiorespiratory fitness (CRF), exercise training, and physical activity (PA) against the development of CVD. This review will summarize recent efforts that have made significant strides in; 1) the application of novel analytic techniques to increase the predictive utility of CRF; 2) understanding the protective effects of long-term compliance to PA recommendations through large cohort studies with multiple points of assessment; 3) and understanding the potential harms associated with extreme volumes of PA.

Physical inactivity is one of the leading modifiable risk factors for global mortality, with an estimated 20% to 30% increased risk of death compared with those who are physically active. T...

Purpose of reviewRegular consumption of a diet high in sodium, energy dense foods, fat content, refined carbohydrates, added sugar and low in fruits and vegetables contributes to an increased risk of developing hypertension (HTN) and cardiovascular disease. This review aims to provide a synopsis of evidence-based dietary approaches that have been effective in lowering blood pressure (BP) in pre-HTN and individuals with HTN.Recent findingsRecent dietary recommendations have emphasized overall dietary patterns and its relation between food and BP. The Dietary Approaches to Stop Hypertension (DASH) diet and modifications to the DASH diet, coupled with reductions in sodium intake, show dose-dependent decreases in BP. Implementation of digital lifestyle interventions based on the DASH diet have been effective and show potential for clinical application.SummaryAdopting a diet rich in plant-based foods, whole grains, low-fat dairy products, and sodium intake within normal limits can be effective in the prevention and management of HTN. These diets have been found to be more effective in older adults and hypertensive persons, particularly in studies that provided meals or frequent dietary counseling.

We aimed to determine and compare predictors of postcardiac rehabilitation (CR) cardiorespiratory fitness (CRF), improvements in a large cohort of subjects with varying baseline CRF levels completing CR for ischemic heart disease and to refine prediction models further by baseline CRF.The Alberta Provincial Project for Outcomes Assessment in Coronary Heart disease (APPROACH) and TotalCardiology (TotalCardiology, Inc, Calgary, Alberta, Canada) databases were used retrospectively to obtain information on 10,732 (1955 [18.2%] female; mean age 60.4, standard deviation [SD] 10.5 years) subjects who completed the 12-week comprehensive CR program between 1996 and 2016. Peak metabolic equivalents (METs) were determined at program start and completion and identified patients at baseline with low fitness (L-Fit) (5 METs), moderate fitness (M-Fit, 5-8 METs), or high fitness (H-Fit,8 METs). Multivariable linear regression models were developed to predict METs at completion of the program.Across all fitness groups, mean baseline METs was the strongest predictor of CRF at completion of CR. Other factors-including sex, age, current smoking status, obesity, and diabetes-were highly predictive of post-CR CRF (all P0.05). Compared with H-fit patients, coronary artery bypass graft and chronic obstructive pulmonary disease in L-Fit patients, and cerebrovascular disease in M-Fit patients had an additional negative effect on the overall model variance in post-CR CRF.Expected CRF at the end of CR is highly predictable, with several key patient factors being clear determinants of CRF. Although most identified patient factors are not modifiable, our analysis highlights populations that may require extra attention over the course of CR to attain maximal benefit.

Compared with traditional exercise tests, cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise integrative physiology involving the pulmonary, cardiovascular, muscular, and cellular oxidative systems. Due to the prognostic ability of key variables, CPET applications in cardiology have grown impressively to include all forms of exercise intolerance, with a predominant focus on heart failure with reduced or with preserved ejection fraction. As impaired cardiac output and peripheral oxygen diffusion are the main determinants of the abnormal functional response in cardiac patients, invasive CPET has gained new popularity, especially for diagnosing early heart failure with preserved ejection fraction and exercise-induced pulmonary hypertension. The most impactful advance has recently come from the introduction of CPET combined with echocardiography or CPET imaging, which provides basic information regarding cardiac and valve morphology and function. This review highlights modern CPET use as a single or combined test that allows the pathophysiological bases of exercise limitation to be translated, quite easily, into clinical practice.