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Background The metabolic syndrome (MetS) is highly prevalent and associated with higher risk of diabetes and cardiovascular events. Exercise programs have been shown to improve components of MetS, but the optimal design of a structured exercise program for treatment of the MetS remains unclear. Purpose To assess the impact of different exercise programs on the MetS and its components. Methods MEDLINE via PubMed and Embase was searched. Randomized controlled trials of supervised exercise alone and in combination with nutrition programs compared with usual care in adults with the MetS were selected. Two authors independently reviewed articles to select eligible studies and performed data abstraction. Eight studies representing 1218 patients were included. The participants had a median age of 51, median BMI of 29 kg/m2, and were 55% male. Mean weight loss increased with program duration. For combination programs, the mean weight loss was -2.6 kg, -3.7 kg, and -6.5 kg for 3, 6, and 12 months, respectively. The components of the MetS most frequently statistically significantly improved were waist circumference (6/6 studies), blood pressure (4/6 studies), and high-density lipoprotein cholesterol (3/6 studies). Limitations Studies did not include long-term follow-up post program completion to evaluate persistence of benefit. It is unknown whether the same results would be found in an older, more obese population. Conclusion Supervised exercise programs yield significant resolution of components of the MetS, particularly in reducing waist circumference. Longer program duration and frequent interval sessions appear to have highest benefit and thus may help reduce cardiovascular risk and diabetes associated with the MetS.

Peripartum cardiomyopathy (PPCM) is a potentially catastrophic form of heart failure caused by left ventricular systolic dysfunction that develops during pregnancy or in the early postpartum period. After the initial diagnosis and treatment, many women desire another pregnancy; however, risks of a subsequent pregnancy need to be considered, as PPCM may lead to significant adverse outcomes for both mother and fetus. The goal of this review is to provide information about risk stratification prior to subsequent pregnancy, strategies to mitigate the risk of subsequent pregnancy, and long-term maternal outcomes. The degree of myocardial recovery is currently the most effective predictor of heart failure relapse and adverse outcomes during a subsequent pregnancy. Women with persistent left ventricular systolic dysfunction have worse maternal and fetal outcomes during subsequent pregnancy. Pharmacologic options for the acute management of heart failure during pregnancy are limited to diuretics, beta-blockers, hydralazine, isosorbide dinitrate, and digoxin. After delivery, however, most guideline-directed heart failure medications can be used safely, including in women who are breastfeeding. Because of the risks of subsequent pregnancy, options for contraception should be discussed with women with PPCM. Finally, women with PPCM should be under the care of a multidisciplinary cardio-obstetrics team for preconception counseling and management during a subsequent pregnancy. An essential component of caring for women with PPCM includes detailed counseling about the risks of a subsequent pregnancy.

Introduction: Pulmonary hypertension is common among patients with end-stage renal disease, although data regarding the impact of right ventricular (RV) failure on postoperative outcomes remain limited. We hypothesized that echocardiographic findings of RV dilation and dysfunction are associated with adverse clinical outcomes after renal transplant. Methods: A retrospective review of adult renal transplant recipients at a single institution from January 2008 to June 2010 was conducted. Patients with transthoracic echocardiograms (TTEs) within 1 year leading up to transplant were included. The primary end point was a composite of delayed graft function, graft failure, and all-cause mortality. Results: Eighty patients were included. Mean follow-up time was 9.4 ± 0.8 years. Eight patients (100%) with qualitative RV dysfunction met the primary end point, while 39/65 patients (60.0%) without RV dysfunction met the end point ( p = 0.026). Qualitative RV dilation was associated with a significantly shorter time to all-cause graft failure ( p = 0.03) and death ( p = 0.048). RV systolic pressure was not measurable in 45/80 patients (56%) and was not associated with outcomes in the remaining patients. Conclusion: RV dilation and dysfunction are associated with adverse outcomes after renal transplant. TTE assessment of RV size and function should be a standard part of the pre-kidney transplant cardiovascular risk assessment.

End-stage kidney disease (ESKD) and heart failure (HF) often coexist and must be managed simultaneously. Multidisciplinary collaboration between nephrology and cardiology is critical when treating patients with such complicated physiology. There is no "one-size-fits-all" approach to the evaluation of patients with new left ventricular systolic dysfunction, and diagnostic testing should be adapted to an individual's risk factors. Guideline-directed medical therapy (GDMT) for systolic heart failure should be employed in these patients. While limited randomized data exist, observational data and post hoc analyses suggest that GDMT, including renin angiotensin aldosterone system inhibitors, is associated with improved cardiovascular outcomes and can be safely initiated at low doses with close monitoring of kidney function in this population. Volume status is typically managed through ultrafiltration, so close communication between cardiology and nephrology is necessary to achieve a patient's optimal dry weight and mitigate intradialytic hypotension. Patient education and engagement regarding sodium and fluid restriction is crucial, and symptom burden should be reassessed following changes to the dialysis regimen.

Background Lifestyle interventions are first-line therapy for non-alcoholic fatty liver disease (NAFLD). Aims To examine the prevalence of NAFLD among participants of the University of Michigan Metabolic Fitness (MetFit) Programme and to assess the impact of this programme on weight, metabolic and liver-related parameters among patients with and without NAFLD. Methods Adults who completed the programme between 2008 and 2016 were included. Clinical and laboratory data were collected at enrolment, and at 12 and 24 weeks. NAFLD was defined based on liver biopsy, imaging or clinical diagnosis. Results The cohort (N = 403; 253 12-week, 150 24-week) consisted primarily of middle-aged (median 54 years) white (88%) men (63%) with severe obesity (median BMI 37.4). 47.6% met criteria for NAFLD. At baseline, NAFLD patients were younger (52 vs 55 years), had higher weights and more metabolic derangements (higher fasting insulin and triglyceride, lower high-density lipoprotein-cholesterol). At programme completion, 30% achieved weight reduction ≥5%, 62% resolution of hypertriglyceridaemia, 33% resolution of low HDL, 27% resolution of impaired fasting glucose and 43% normalisation of alanine aminotransferase. Endpoints were unaffected by NAFLD. Longer programme duration (OR 6.7, 95% CI 3.6-12.3) and white race (OR 3.83, 95% CI 1.04-1.76) were independent predictors of ≥5% weight loss. Conclusions Nearly half of the patients referred to a structured lifestyle programme for metabolic syndrome had NAFLD. Although baseline metabolic derangements were more pronounced among NAFLD patients, the programme was equally efficacious in achieving weight loss and resolving metabolic syndrome components. Programme duration was the most important predictor of response.

Megan S Joseph,1 Monica A Konerman,2 Min Zhang,1 Boxian Wei,1 Ellen Brinza,1 Patrick Walden,1 Elizabeth A Jackson,1 Melvyn Rubenfire1 1Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, MI, USA; 2Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI, USA Introduction: Metabolic syndrome is associated with an increased risk of cardiovascular disease and multiple other chronic health conditions. Studies have demonstrated the effectiveness of structured diet and exercise programs to improve the components of metabolic syndrome. The durability of these benefits after program completion is unclear. The aim of this study was to evaluate trends in cardiovascular risk factors 12 months post completion of a 12- or 24-week structured lifestyle intervention program. Methods: Individuals with metabolic syndrome were referred to the Metabolic Fitness program, a 12- or 24-week lifestyle intervention program consisting of weekly exercise and nutrition education sessions. Patients were assessed at baseline, 12 weeks, and 24 weeks for those in the 24-week program. Data collection included weight, body mass index, waist circumference, body composition percentage, sBP, dBP, fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Unstructured follow-up data were obtained by retrospective chart review for up to 12 months post program completion. Results: Two-hundred twenty-five patients were enrolled in the 12-week program and 121 in the 24-week program. At the conclusion of the 12-week program, patients showed significant improvement in sBP and dBP. At the conclusion of the 24-week program, patients showed significant improvement in body mass index, weight, sBP, dBP, fasting blood glucose, total cholesterol, and triglycerides. However, 12 months after program completion, while the majority of parameters were still improved compared with baseline, only change in low-density lipoprotein cholesterol remained significantly improved compared with the end of 12-week program, and sBP had increased back above baseline in both programs. Conclusion: Patients with metabolic syndrome participating in a structured lifestyle intervention program show significant improvement in their cardiovascular risk and metabolic profile at program completion. The durability of these improvements appears to wane over time, however, stressing the need for programs that can facilitate maintenance of long-term behavior change. Keywords: metabolic syndrome, lifestyle interventions, obesity