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PURPOSE Medically supervised exercise programs (MSEPs) are equally recommended for men and women with cardiovascular disease (CVD). Aware of the lower CVD mortality in women, we hypothesized that among patients attending a MSEP, women would also have better survival. METHODS Data from men and women, who were enrolled in a MSEP between 1994 and 2018, were retrospectively analyzed. Sessions included aerobic, resistance, flexibility and balance exercises, and cardiopulmonary exercise test was performed. Date and underlying cause of death were obtained. Kaplan-Meier methods and Cox proportional hazards regression were used for survival analysis. RESULTS A total of 2236 participants (66% men, age range 33-85 yr) attended a median of 52 (18, 172) exercise sessions, and 23% died during 11 (6, 16) yr of follow-up. In both sexes, CVD was the leading cause of death (39%). Overall, women had a more favorable clinical profile and a longer survival compared to men (HR = 0.71: 95% CI, 0.58-0.85; P < .01). When considering those with coronary artery disease and similar clinical profile, although women had a lower percentage of sex- and age-predicted maximal oxygen uptake at baseline than men (58 vs 78%; P < .01), after adjusting for age, women still had a better long-term survival (HR = 0.68: 95% CI, 0.49-0.93; P = .02). CONCLUSION Survival after attendance to a long-term MSEP was better among women, despite lower baseline cardiorespiratory fitness. Future studies should address whether men and women would similarly benefit when participating in an MSEP.

Background Physical inactivity has been shown to be associated with all-cause mortality in both healthy and unhealthy middle-aged and older individuals. While regular exercise is equally recommended for men and women, it is virtually unknown if sex influences the long-term survival among participants of a medically-supervised exercise program (MSEP). Purpose To evaluate if cardiovascular and all-cause mortality differs between men and women who participates in a MSEP. Methods Retrospective data from an open cohort of individuals aged 36 to 85 years old (66% men) who participated in a private MSEP between March 1994 and December 2018 were analyzed. The participants were free to attend the exercise sessions anytime from 6 a.m. to 9:30 p.m. (Monday to Friday) or 7 a.m. to 4 p.m. (Saturday). In median, the participants completed 47 sessions (1 to 5992 sessions) and attended for 6 months. Exercise sessions last between 60–80 minutes on average and included aerobic, muscle power, flexibility and balance exercises for all participants. Depending on clinical condition, gross and fine motor coordination, inspiratory muscle and isometric handgrip training were also performed under direct supervision of a multiprofessional team. Before each exercise session, the participant was briefly assessed by the exercise physician amd the aerobic exercise part was individually prescribed based on pre-participation evaluation/previous session data. Kaplan-Meier survival curves were separately determined for men and women - cardiovascular and all-cause mortality - and statistically compared by log rank test. Results Men and women had identical mean ages of 62.5 years-old (p>0.99) and median follow-up was 11 years, ranging from 0.1 to 24.8 years. From a total of 2,238 participants wit different disorders (68% with coronary artery disease), 465 died (21%), with almost three times higher death rate for men (15.1%) as compared to women (5.7%) (p Conclusion Long-term cardiovascular and all-cause mortality were much higher in men than women that participated in a MSEP and these differences could not be explained by age. Future studies are needed to explain these findings and to analyze if men and women in MSEP would need similar dose of exercise for better survival benefit. Acknowledgement/Funding CNPq/FAPERJ/Health State Secretary

Background: Cardiorespiratory (aerobic) fitness is strongly and directly related to major health outcomes, including all-cause mortality. Maximum oxygen uptake (VO2max), directly measured by maximal cardiopulmonary exercise test (CPET), represents the subject’s aerobic fitness. However, as CPET is not always available, aerobic fitness estimation tools are necessary. Objectives: a) to propose the CLINIMEX Aerobic Fitness Questionnaire (C-AFQ); b) to validate C-AFQ against measured VO2max; and c) to analyze the influence of some potentially relevant variables on the error of estimate. Methods: We prospectively studied 1,000 healthy and unhealthy subjects (68.6% men) aged from 14 to 96 years that underwent a CPET. The two-step C-AFQ describes physical activities with corresponding values in metabolic equivalents (METs) - ranging from 0.9 to 21 METs. Results: Application of C-AFQ took less than two minutes. Linear regression analysis indicated a very strong association between estimated (C-AFQ) and measured (CPET) maximal METs - r2 = 0.83 (Sy.x = 1.63; p < .001) - with median difference of only 0.2 METs between both values and interquartile range (percentiles 25 and 75) of 2 METs. The difference between estimated and measured METs was not influenced by age, sex, body mass index, clinical condition, ß-blocker use or sitting-rising test scores. Conclusion: C-AFQ is a simple and valid tool for estimating aerobic fitness when CPET is unavailable and it is also useful in planning individual ramp protocols. However, individual error of estimate is quite high, so C-AFQ should not be considered a perfect substitute for CPET’s measured VO2max.

Background: Maximal oxygen consumption (VO2max) and ventilatory threshold (VT) obtained during a cardiopulmonary exercise test (CPX) are used in the evaluation of athletes. However, the identification of these variables may sometimes be unreliable, which limits their use. In contrast, the cardiorespiratory optimal point (COP) is a submaximal variable derived from CPX with objective measurement and prognostic significance. However, its behavior in athletes is unknown. Objective: To describe the behavior of COP in professional soccer players and its association with VO2max and VT. Methods: VO2max, VT and COP were obtained retrospectively from 198 soccer players undergoing maximal treadmill CPX using ramp protocol. COP was defined as the lowest value of the ventilation/oxygen consumption ratio in a given minute of the CPX. The soccer players were stratified according to their field position: goalkeeper, center-defender, left/right-back, midfielder and forwarder. Continuous variables were compared using unpaired Student t test or ANOVA, or Mann-Whitney test or Kruskal-Wallis test depending on their distribution, and categorical variables were compared using chi-square test. Pearson correlation was used to test the association between COP and other ventilatory variables. A level of 5% was used for statistical significance. Results: COP (mean ± SD) was 18.2 ± 2.1 and was achieved at a speed 4.3 ± 1.4 km.h-1 lower than that achieved at the VT. While VO2max (62.1 ± 6.2 mL.kg-1.min-1) tended to be lower in goalkeepers (p < 0.05), the COP did not vary according to field position (p = 0.41). No significant association was observed between COP and VO2max (r = 0.032, p = 0.65) or between COP and VT (r = -0.003, p = 0.96). Conclusion: COP can be easily determined during submaximal exercise performed with incremental speed in soccer players and does not vary according to the athlete’s field position. The absence of association with VO2max and VT indicates that COP provides distinct and complementary information to these variables. Future studies are needed to determine the practical implications of COP in assessing athletes. (Int J Cardiovasc Sci. 2018; [online].ahead print, PP.0-0)

Consideracoes preliminares Os animais livres sempre foram e serao seres fisicamente ativos, sendo o confinamento ou o sedentarismo condicoes antinaturais. O homem, tal como e conhecido hoje, foi capaz de partir de regioes centrais e, por seus proprios meios de locomocao (exercicio), espalhar-se por longinquas areas do planeta. Buscar alimento e agua e fugir de predadores, da infância ate a senilidade, sempre estiveram atrelados ao exercicio. De fato, o sedentarismo e muito recente na historia da humanidade. Antes de discutir [...]

Background: Physiological reflexes modulated primarily by the vagus nerve allow the heart to decelerate and accelerate rapidly after a deep inspiration followed by rapid movement of the limbs. This is the physiological and pharmacologically validated basis for the 4-s exercise test (4sET) used to assess the vagal modulation of cardiac chronotropism. Objective: To present reference data for 4sET in healthy adults. Methods: After applying strict clinical inclusion/exclusion criteria, 1,605 healthy adults (61% men) aged between 18 and 81 years subjected to 4sET were evaluated between 1994 and 2014. Using 4sET, the cardiac vagal index (CVI) was obtained by calculating the ratio between the duration of two RR intervals in the electrocardiogram: 1) after a 4-s rapid and deep breath and immediately before pedaling and 2) at the end of a rapid and resistance-free 4-s pedaling exercise. Results: CVI varied inversely with age (r = -0.33, p < 0.01), and the intercepts and slopes of the linear regressions between CVI and age were similar for men and women (p > 0.05). Considering the heteroscedasticity and the asymmetry of the distribution of the CVI values according to age, we chose to express the reference values in percentiles for eight age groups (years): 18–30, 31–40, 41–45, 46–50, 51–55, 56–60, 61–65, and 66+, obtaining progressively lower median CVI values ranging from 1.63 to 1.24. Conclusion: The availability of CVI percentiles for different age groups should promote the clinical use of 4sET, which is a simple and safe procedure for the evaluation of vagal modulation of cardiac chronotropism.

OBJETIVO: Determinar a sensibilidade, a especificidade, os valores preditivos positivo e negativo e a acurácia de diferentes critérios eletrocardiográficos para vagotonia. MÉTODOS: Foram avaliados 74 atletas olímpicos brasileiros (51 homens e 23 mulheres) com idade entre 16 e 42 anos (24 ± 5 anos), tendo sido realizados, entre outros exames, um ECG de repouso de 12 derivações e uma avaliação do tônus vagal cardíaco (TVC) pelo teste de exercício sem carga de quatro segundos (T4s), cujo índice B/C (indicativo da magnitude do TVC) foi utilizado como padrão-ouro. O T4s é um teste que se baseia no mecanismo da taquicardia inicial do exercício e foi anteriormente padronizado e validado como capaz de avaliar o TVC sem influência do componente simpático. Dados de 10 atletas foram excluídos devido à presença de critérios ecocardiográficos para hipertrofia ventricular esquerda, ainda que provavelmente fisiológica. Com o auxílio de curvas ROC (receiver operating characteristic), selecionou-se o ponto de corte com a melhor combinação entre sensibilidade (Sens) e especificidade (Esp) para cada variável do ECG, calculando-se os valores preditivos positivo (VPP) e negativo (VPN) e a acurácia (AC). Foram ainda correlacionados o índice B/C e as variáveis do ECG. RESULTADOS: Há fraca associação entre o índice B/C e as variáveis do ECG, à exceção da duração do intervalo R-R (r = 0,353; P = 0,004), que também apresentou curva ROC significativa (chi2= 0,863; P = 0,002), sendo que o critério intervalo R-R > ou = 990ms apresentou os seguintes resultados: Sens - 100%; Esp - 73%; VPP 20%; VPN 100%; AC 75%. As variáveis do ECG que apresentaram pontos de corte com acurácia > 80% foram: amplitude da onda T em V5 > ou = 8,0mm; amplitude da onda T em V6 > ou = 7,0mm; amplitude da onda Q em V5 > ou = 7,0mm; amplitude da onda R em V4 > ou = 50,0mm; presença de supradesnível de ponto J em duas ou mais derivações; presença de supradesnível de segmento S-T em cinco ou mais derivações e presença de transição precordial rápida. DISCUSSÃO E CONCLUSÃO: O desempenho dos critérios eletrocardiográficos em termos de VPP, VPN e AC foi muito limitado, com a exceção da duração do intervalo R-R. A combinação de outros critérios como amplitude da onda T em V5 e V6, amplitude da onda R em V4 e presença de supradesnível de ponto J e do segmento S-T em várias derivações pode auxiliar na predição de vagotonia. OBJECTIVE: To determine sensitivity (Sens), specificity (Spec), positive (PPV) and negative (NPV) predictive value, and accuracy of different electrocardiographic criteria for vagotonia. METHODS: Seventy-four Olympic athletes (51 male and 23 female; age = 24 ± 5 years) underwent an evaluation consisting of a 12-lead resting electrocardiogram (ECG), and an assessment of cardiac vagal tone (CVT) by the 4-second cycling exercise testing (4-sET), with the B/C index utilized as the gold standard. The 4-sET is a well-standardized and valid protocol for CVT assessment based on the mechanism of exercise-onset tachycardia regardless of the sympathetic component. Using ROC (receiver operating characteristic) curves, the authors selected the cut-point with the best sensitivity (Sens)/specificity (Spec) ratio for each ECG variable, and calculated the positive (PPV) and negative predictive values (NPV), and accuracy (AC). The authors also correlated B/C index with ECG variables. RESULTS: B/C index showed a poor association with ECG variables, with the exception of R-R interval (r = 0.353; P = 0.004), that also presented a significant ROC curve (chi2= 0.863; P = 0.002), whereas the R-R interval > or = 990 ms criterion showed the following results: Sens - 100%; Spec - 73%; VPP 20%; VPN 100%; AC 75%. The ECG variables that presented cut-points with accuracy > 80% were: T-wave amplitude in lead V5 > or = 8.0 mm; T-wave amplitude in lead V6 > or = 7.0 mm; Q-wave amplitude in V5 > or = 7.0 mm; R-wave amplitude in V4 > or = 50.0 mm; presence of J-point elevation in two or more leads; presence of S-T segment elevation in five or more leads, and presence of fast precordial transition. DISCUSSION AND CONCLUSION: The performance of ECG criteria considering PPV, NPV, and AC was generally very poor, with the exception of the R-R interval. The combination of other criteria such as T-wave amplitude in leads V5 and V6, R-wave amplitude in V4, and presence of J-point and S-T segment elevation in several leads should help predicting vagotonia.

Two autonomic tests which evaluate cardiac vagal activity, the respiratory sinus arrhythmia and the newer 4-second exercise test, have been compared. From electrocardiograph tracings, respiratory sinus arrhythmia was quantified by the ratio between the longest R-R interval during expiration and the shortest one during inspiration (E/I ratio), and the 4-second exercise test by the ratio between the last R-R interval before and the shortest one during exercise (B/C ratio). In 29 healthy subjects there was a correlation (R = 0.60, p less than 0.05) between the responses to the two tests. In a group of six healthy subjects the same tests were performed after autonomic blockade with intravenous atropine and/or propranolol. The heart rate rise during the 4-second exercise test was nearly abolished by atropine (mean +/- SD) (B/C: control = 1.53/0.33; after atropine = 1.04/0.03), whereas RSA was diminished to a lesser extent (E/I: control = 1.59/0.24; after atropine = 1.13/0.07). beta-adrenoceptor blockade did not affect the test ratios (after propranolol: B/C = 1.51/0.33 and E/I = 1.45/0.14). Successive tests during the following hour after atropine infusion showed a somewhat faster recovery of the respiratory sinus arrhythmia than the heart rate acceleration induced by the 4-second exercise test (p less than 0.05). We conclude that there may be some difference in the mechanisms which contribute to the heart rate changes in these two autonomic cardiovascular tests; these remain to be clarified. The 4-second exercise test may be an alternative to the respiratory sinus arrhythmia test in the non-invasive evaluation of cardiac parasympathetic activity.

OBJETIVO: Determinar a viabilidade da utilizacao de tracado convencional de eletrocardiografia (ECG) para avaliacao da atividade vagal cardiaca (AVC). METODOS: Foram analisados, retrospectivamente, 1.395 individuos (995 homens), na faixa de idade de 46 + 17,2 anos (media ± desvio padrao), com tracados de ECG convencional para medida do Delta RR, que representa a diferenca, em ms, entre o maior e o menor intervalo RR, e com resultados da avaliacao autonomica parassimpatica, o teste de exercicio de quatro segundos (T4s), que quantifica a AVC por meio do indice vagal cardiaco (IVC). Foram obtidas curvas ROC para determinar os valores de Delta RR com melhor relacao entre sensibilidade e especificidade para os pontos de corte de baixa e alta AVC, respectivamente, de 1,20 e 1,95. RESULTADOS: Os valores de delta RR correlacionaram-se significativamente com os de IVC (r = 0,40; p 120 ms como os melhores pontos de corte para baixa e alta AVC, com sensibilidade de 75% e 57%, especificidade de 62% e 79% e areas das curvas ROC de 0,76 e 0,74, respectivamente. CONCLUSAO: A medida visual do delta RR em um tracado de ECG parece ser valida para a avaliacao clinica preliminar e rapida da AVC, podendo ser util em consultorios, emergencias ou situacoes nas quais o uso de metodos mais sofisticados de avaliacao autonomica nao seja viavel, oportuno ou conveniente.