Browsing by Subject "Exercise Test"
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Item Open Access Blood Pressure Response during Cardiopulmonary Exercise Testing in Heart Failure.(Medicine and science in sports and exercise, 2018-07) Il'giovine, Zachary J; Solomon, Nicole; Devore, Adam D; Wojdyla, Daniel; Patel, Chetan B; Rogers, Joseph GIntroduction
The prognostic value of peak V˙O2 and V˙E/V˙CO2 slope measured during cardiopulmonary exercise (CPX) testing has been well established in patients with advanced heart failure, but blood pressure response to exercise is less well characterized.Methods
We retrospectively studied 151 outpatients who underwent CPX testing as part of an advanced heart failure evaluation. The outcome of interest was failure of medical management, defined by death, cardiac transplantation, or left ventricular assist device placement. Patients were stratified into tertiles by change in systolic blood pressure (SBP) (<13, 13-26, and ≥27 mm Hg) during exercise.Results
Patients in the lowest tertile had the lowest peak V˙O2 (10.2 vs 10.6 vs 13.6 mL·kg·min, P = <0.001), the highest V˙E/V˙CO2 slope (42.8 vs 42.1 vs 36.3, P = 0.030), the shortest mean exercise time (5.1 vs 6.0 vs 7.0 min, P = <0.001), and the highest probability of failure of medical management at 1.5 yr (0.69 vs 0.41 vs 0.34, P = 0.011). After multivariate adjustment, increased SBP <20 mm Hg during exercise was associated with a lower hazard of medical management failure (hazard ratio = 0.96, 95% confidence interval [CI] = 0.934-0.987), whereas SBP increases >20 mm Hg were associated with an increased hazard (hazard ratio = 1.046, 95% CI = 1.018-1.075).Conclusion
In conclusion, changes in SBP during CPX testing provide additional prognostic information above standard clinical variables. The peculiar increase in risk noted in those with a rise in SBP >20 mm Hg is less clear and needs to be investigated further.Item Open Access Cardiorespiratory fitness and cognitive function in midlife: neuroprotection or neuroselection?(Ann Neurol, 2015-04) Belsky, Daniel W; Caspi, Avshalom; Israel, Salomon; Blumenthal, James A; Poulton, Richie; Moffitt, Terrie EOBJECTIVE: A study was undertaken to determine whether better cognitive functioning at midlife among more physically fit individuals reflects neuroprotection, by which fitness protects against age-related cognitive decline, or neuroselection, by which children with higher cognitive functioning select more active lifestyles. METHODS: Children in the Dunedin Longitudinal Study (N = 1,037) completed the Wechsler Intelligence Scales and the Trail Making, Rey Delayed Recall, and Grooved Pegboard tasks as children and again at midlife (age = 38 years). Adult cardiorespiratory fitness was assessed using a submaximal exercise test to estimate maximum oxygen consumption adjusted for body weight in milliliters/minute/kilogram. We tested whether more fit individuals had better cognitive functioning than their less fit counterparts (which could be consistent with neuroprotection), and whether better childhood cognitive functioning predisposed to better adult cardiorespiratory fitness (neuroselection). Finally, we examined possible mechanisms of neuroselection. RESULTS: Participants with better cardiorespiratory fitness had higher cognitive test scores at midlife. However, fitness-associated advantages in cognitive functioning were already present in childhood. After accounting for childhood baseline performance on the same cognitive tests, there was no association between cardiorespiratory fitness and midlife cognitive functioning. Socioeconomic and health advantages in childhood and healthier lifestyles during young adulthood explained most of the association between childhood cognitive functioning and adult cardiorespiratory fitness. INTERPRETATION: We found no evidence for a neuroprotective effect of cardiorespiratory fitness as of midlife. Instead, children with better cognitive functioning are selecting healthier lives. Fitness interventions may enhance cognitive functioning. However, observational and experimental studies testing neuroprotective effects of physical fitness should consider confounding by neuroselection.Item Open Access Care of the Patient with Chest Pain in the Observation Unit.(Emergency medicine clinics of North America, 2017-08) Borawski, Joseph B; Graff, Louis G; Limkakeng, Alexander TCare of the patient presenting to an emergency department (ED) with chest pain remains a common yet challenging aspect of emergency medicine. Acute coronary syndrome presents in nonspecific fashion. The development and evolution of the ED-based observation unit has helped to safely assess and diagnose those most at risk for an adverse cardiac event. Furthermore, there are several provocative testing modalities to help assess for coronary artery disease. This article serves to describe and discuss the modern ED-based observation unit approach to patients with chest pain and/or angina equivalents presenting to an ED.Item Open Access Clinical Predictors of Adherence to Exercise Training Among Individuals With Heart Failure: THE HF-ACTION STUDY.(Journal of cardiopulmonary rehabilitation and prevention, 2023-05) Collins, Katherine A; Reeves, Gordon R; Miller, Nancy Houston; Whellan, David J; O'Connor, Christopher M; Marcus, Bess H; Kitzman, Dalane W; Kraus, William E; HF-ACTION InvestigatorsPurpose
Suboptimal adherence is a major limitation to achieving the benefits of exercise interventions, and our ability to predict and improve adherence is limited. The purpose of this analysis was to identify baseline clinical and demographic characteristics predicting exercise training adherence in the HF-ACTION study cohort.Methods
Adherence to exercise training, defined by the total duration of exercise performed (min/wk), was evaluated in 1159 participants randomized to the HF-ACTION exercise intervention. More than 50 clinical, demographic, and exercise testing variables were considered in developing a model of the min/wk end point for 1-3 mo (supervised training) and 10-12 mo (home-based training).Results
In the multivariable model for 1-3 mo, younger age, lower income, more severe mitral regurgitation, shorter 6-min walk test distance, lower exercise capacity, and Black or African American race were associated with poorer exercise intervention adherence. No variable accounted for >2% of the variance and the adjusted R2 for the final model was 0.14. Prediction of adherence was similarly limited for 10-12 mo.Conclusions
Clinical and demographic variables available at the initiation of exercise training provide very limited information for identifying patients with heart failure who are at risk for poor adherence to exercise interventions.Item Open Access Commentary: The heart of the matter: Close clinical follow-up and exercise capacity in Fontan circulation.(The Journal of thoracic and cardiovascular surgery, 2021-08) Well, Andrew; Beckerman, ZivItem Open Access Congenital heart disease and pulmonary hypertension.(Heart Fail Clin, 2012-07) Gupta, Vedant; Tonelli, Adriano R; Krasuski, Richard AMany patients with congenital heart disease and systemic-to-pulmonary shunts develop pulmonary arterial hypertension (PAH), particularly if the cardiac defect is left unrepaired. A persistent increase in pulmonary blood flow may lead to obstructive arteriopathy and increased pulmonary vascular resistance, a condition that can lead to reversal of shunt and cyanosis (Eisenmenger syndrome). Cardiac catheterization is crucial to confirm diagnosis and facilitate treatment. Bosentan is the only medication to date to be compared with placebo in a randomized controlled trial specifically targeting congenital heart disease-associated PAH. Lung transplantation with repair of the cardiac defect or combined heart-lung transplantation is reserved for recalcitrant cases.Item Open Access Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease.(Annals of internal medicine, 2016-07) Mark, Daniel B; Federspiel, Jerome J; Cowper, Patricia A; Anstrom, Kevin J; Hoffmann, Udo; Patel, Manesh R; Davidson-Ray, Linda; Daniels, Melanie R; Cooper, Lawton S; Knight, J David; Lee, Kerry L; Douglas, Pamela S; PROMISE InvestigatorsBackground
PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) found that initial use of at least 64-slice multidetector computed tomography angiography (CTA) versus functional diagnostic testing strategies did not improve clinical outcomes in stable symptomatic patients with suspected coronary artery disease (CAD) requiring noninvasive testing.Objective
To conduct an economic analysis for PROMISE (a major secondary aim of the study).Design
Prospective economic study from the U.S. perspective. Comparisons were made according to the intention-to-treat principle, and CIs were calculated using bootstrap methods. (ClinicalTrials.gov: NCT01174550).Setting
190 U.S. centers.Patients
9649 U.S. patients enrolled in PROMISE between July 2010 and September 2013. Median follow-up was 25 months.Measurements
Technical costs of the initial (outpatient) testing strategy were estimated from Premier Research Database data. Hospital-based costs were estimated using hospital bills and Medicare cost-charge ratios. Physician fees were taken from the Medicare Physician Fee Schedule. Costs were expressed in 2014 U.S. dollars, discounted at 3% annually, and estimated out to 3 years using inverse probability weighting methods.Results
The mean initial testing costs were $174 for exercise electrocardiography; $404 for CTA; $501 to $514 for pharmacologic and exercise stress echocardiography, respectively; and $946 to $1132 for exercise and pharmacologic stress nuclear testing, respectively. Mean costs at 90 days were $2494 for the CTA strategy versus $2240 for the functional strategy (mean difference, $254 [95% CI, -$634 to $906]). The difference was associated with more revascularizations and catheterizations (4.25 per 100 patients) with CTA use. After 90 days, the mean cost difference between the groups out to 3 years remained small.Limitation
Cost weights for test strategies were obtained from sources outside PROMISE.Conclusion
Computed tomography angiography and functional diagnostic testing strategies in patients with suspected CAD have similar costs through 3 years of follow-up.Primary funding source
National Heart, Lung, and Blood Institute.Item Open Access Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial.(Physical therapy, 2016-05) Allen, Kelli D; Bongiorni, Dennis; Bosworth, Hayden B; Coffman, Cynthia J; Datta, Santanu K; Edelman, David; Hall, Katherine S; Lindquist, Jennifer H; Oddone, Eugene Z; Hoenig, HelenBackground
Efficient approaches are needed for delivering nonpharmacological interventions for management of knee osteoarthritis (OA).Objective
This trial compared group-based versus individual physical therapy interventions for management of knee OA.Design and methods
Three hundred twenty patients with knee OA at the VA Medical Center in Durham, North Carolina, (mean age=60 years, 88% male, 58% nonwhite) were randomly assigned to receive either the group intervention (group physical therapy; six 1-hour sessions, typically 8 participants per group) or the individual intervention (individual physical therapy; two 1-hour sessions). Both programs included instruction in home exercise, joint protection techniques, and individual physical therapist evaluation. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range=0-96, higher scores indicate worse symptoms), measured at baseline, 12 weeks, and 24 weeks. The secondary outcome measure was the Short Physical Performance Battery (SPPB; range=0-12, higher scores indicate better performance), measured at baseline and 12 weeks. Linear mixed models assessed the difference in WOMAC scores between arms.Results
At 12 weeks, WOMAC scores were 2.7 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% confidence interval [CI]=-5.9, 0.5; P=.10), indicating no between-group difference. At 24 weeks, WOMAC scores were 1.3 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=-4.6, 2.0; P=.44), indicating no significant between-group difference. At 12 weeks, SPPB scores were 0.1 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=-0.5, 0.2; P=.53), indicating no difference between groups.Limitations
This study was conducted in one VA medical center. Outcome assessors were blinded, but participants and physical therapists were not blinded.Conclusions
Group physical therapy was not more effective than individual physical therapy for primary and secondary study outcomes. Either group physical therapy or individual physical therapy may be a reasonable delivery model for health care systems to consider.Item Open Access Magnitude of spinal muscle damage is not statistically associated with exercise-induced low back pain intensity.(Spine J, 2011-12) Bishop, Mark D; Horn, Maggie E; Lott, Donovan J; Arpan, Ishu; George, Steven ZBACKGROUND CONTEXT: Findings on imaging of noncontractile anatomic abnormalities and the intensity of low back pain have weak associations because of false-positive rates among asymptomatic individuals. This association might be stronger for contractile tissues. PURPOSE: The purpose of this study was to examine the relationship between location and reports of pain intensity in the low back and exercise-induced muscle damage to the lumbar paraspinal muscles. STUDY DESIGN: Nondiagnostic observational study in a laboratory setting. METHODS: Delayed onset muscle soreness was induced in the low back of healthy pain-free volunteers. Measures of pain intensity (100-mm visual analog scale [VAS]) and location (area on the pain diagram) were taken before and 48 hours after exercise. Muscle damage was quantified using mechanical pain thresholds, motor performance deficits, and transverse relaxation time (T2)-weighted magnetic resonance imaging (MRI). Changes pre- to postexercise in signal intensity on T2-weighted imaging within the erector spinae, pain intensity, pain area, mechanical pain threshold, and isometric torque were assessed using paired t tests. Bivariate correlations were conducted to assess associations among muscle damage, pain intensity, and pain drawing area. RESULTS: Twenty participants volunteered (11 women; average age, 22.3 years; average body mass index, 23.5) for study participation. Reports of pain intensity at 48 hours ranged from 0 to 59 mm on the VAS. Muscle damage was confirmed by reductions in mechanical threshold (p=.011) and motor performance (p<.001) and by changes in T2-weighted MRI (p=.007). This study was powered to find an association of at least r=0.5 to be statistically significant. Correlations of continuous variables revealed no significant correlations between pain intensity and measures of muscle damage (ranging between -0.075 and 0.151). There was a significant association between the remaining torque deficit at 48 hours and pain area. CONCLUSIONS: The results of this study indicate that there was no association between the magnitude of muscle damage in the lumbar erector spinae and reported pain intensity in the low back. In future studies, larger cohorts may report statistically significant associations, but our data suggest that there will be low magnitude potentially indicating limited clinical relevance.Item Open Access Outpatient versus observation/inpatient management of emergency department patients rapidly ruled-out for acute myocardial infarction: Findings from the HIGH-US study.(American heart journal, 2021-01) Nowak, Richard M; Jacobsen, Gordon; Limkakeng, Alexander; Peacock, William F; Christenson, Robert H; McCord, James; Apple, Fred S; Singer, Adam J; deFilippi, Christopher RBackground
The actual Emergency Department (ED) dispositions of patients enrolled in observational studies and meeting criteria for rapid acute myocardial infarction (AMI) rule-out are unknown. Additionally, their presenting clinical profiles, cardiac testing/treatments received, and outcomes have not been reported.Methods
Patients in the HIGH-US study (29 sites) that ruled-out for AMI using a high-sensitivity cardiac troponin I 0/1-hour algorithm were evaluated. Clinical characteristics of patients having ED discharge were compared to patients placed in observation or hospital admitted (OBS/ADM). Reports of any OBS/ADM cardiac stress test (CST), cardiac catheterization (Cath) and coronary revascularization were reviewed. One year AMI/death and major adverse cardiovascular event rates were determined.Results
Of the 1,020 ruled-out AMI patients 584 (57.3%) had ED discharge. The remaining 436 (42.7%) were placed in OBS/ADM. Patients with risk factors for AMI, including personal or family history of coronary artery disease, hypertension, previous stroke or abnormal ECG were more often placed in OBS/ADM. 175 (40.1%) had a CST. Of these 32 (18.3%) were abnormal and 143 (81.7%) normal. Cath was done in 11 (34.3%) of those with abnormal and 13 (9.1%) with normal CST. Of those without an initial CST 85 (32.6%) had Cath. Overall, revascularizations were performed in 26 (6.0%) patients. One-year AMI/death rates were low/similar (P = .553) for the groups studied.Conclusions
Rapidly ruled-out for AMI ED patients having a higher clinician perceived risk for new or worsening coronary artery disease and placed in OBS/ADM underwent many diagnostic tests, were infrequently revascularized and had excellent outcomes. Alternate efficient strategies for these patients are needed.Item Open Access Pilot study of myocardial ischemia-induced metabolomic changes in emergency department patients undergoing stress testing.(PloS one, 2019-01) Limkakeng, Alexander T; Henao, Ricardo; Voora, Deepak; O'Connell, Thomas; Griffin, Michelle; Tsalik, Ephraim L; Shah, Svati; Woods, Christopher W; Ginsburg, Geoffrey SBACKGROUND:The heart is a metabolically active organ, and plasma acylcarnitines are associated with long-term risk for myocardial infarction. We hypothesized that myocardial ischemia from cardiac stress testing will produce dynamic changes in acylcarnitine and amino acid levels compared to levels seen in matched control patients with normal stress tests. METHODS:We analyzed targeted metabolomic profiles in a pilot study of 20 case patients with inducible ischemia on stress testing from an existing prospectively collected repository of 357 consecutive patients presenting with symptoms of Acute Coronary Syndrome (ACS) in an Emergency Department (ED) observation unit between November 2012 and September 2014. We selected 20 controls matched on age, sex, and body-mass index (BMI). A peripheral blood sample was drawn <1 hour before stress testing and 2 hours after stress testing on each patient. We assayed 60 select acylcarnitines and amino acids by tandem mass spectrometry (MS/MS) using a Quattro Micro instrument (Waters Corporation, Milford, MA). Metabolite values were log transformed for skew. We then performed bivariable analysis for stress test outcome and both individual timepoint metabolite concentrations and stress-delta metabolite ratios (T2/T0). False discovery rates (FDR) were calculated for 60 metabolites while controlling for age, sex, and BMI. We built multivariable regularized linear models to predict stress test outcome from metabolomics data at times 0, 2 hours, and log ratio between these two. We used leave-one-out cross-validation to estimate the performance characteristics of the model. RESULTS:Nine of our 20 case subjects were male. Cases' average age was 55.8, with an average BMI 29.5. Bivariable analysis identified 5 metabolites associated with positive stress tests (FDR < 0.2): alanine, C14:1-OH, C16:1, C18:2, C20:4. The multivariable regularized linear models built on T0 and T2 had Area Under the ROC Curve (AUC-ROC) between 0.5 and 0.55, however, the log(T2/T0) model yielded 0.625 AUC, with 65% sensitivity and 60% specificity. The top metabolites selected by the model were: Ala, Arg, C12-OH/C10-DC, C14:1-OH, C16:1, C18:2, C18:1, C20:4 and C18:1-DC. CONCLUSIONS:Stress-delta metabolite analysis of patients undergoing stress testing is feasible. Future studies with a larger sample size are warranted.Item Open Access Provoked exercise desaturation in patent foramen ovale and impact of percutaneous closure.(JACC Cardiovasc Interv, 2012-04) Devendra, Ganesh P; Rane, Ajinkya A; Krasuski, Richard AOBJECTIVES: This study was designed to assess the prevalence of provoked exercise desaturation (PED) in patients with patent foramen ovale (PFO) referred for cardiovascular evaluation and to evaluate the impact of PFO closure. BACKGROUND: Platypnea orthodeoxia syndrome is a rare, mechanistically obscure consequence of PFO that results in oxygen desaturation during postural changes. In our clinical experience, however, it is far less common than desaturation during exercise. METHODS: This was a single-center prospective study of 50 patients with newly diagnosed PFO. Each patient underwent standardized assessment for arterial oxygen saturation with pulse oximetry during postural changes and stair climbing exercise. Provoked exercise desaturation was defined as a desaturation of at least 8% from baseline to <90%. All patients who underwent closure were reevaluated 3 months after the procedure. Those with baseline PED were similarly reassessed for desaturation at follow-up. RESULTS: Mean age of the cohort was 46 ± 17 years, 74% were female, 30% had migraines, and 48% had experienced a cerebrovascular event. Seventeen patients (34%) demonstrated PED. Provoked exercise desaturation patients seemed demographically similar to non-PED patients. Ten PED patients underwent PFO closure (2 surgical, and 8 percutaneous). Drop in oxygen saturation was improved by an average of 10.1 ± 4.2% after closure (p < 0.001), and New York Heart Association functional class improved by a median of 1.5 classes (interquartile range: 0.75 to 2.00, p = 0.008). CONCLUSIONS: One-third of patients referred for assessment of PFO experience oxygen desaturation during stair exercise. Closure of PFO seems to ameliorate this phenomenon and improve functional status.Item Open Access Swimming-Induced Pulmonary Edema: Pathophysiology and Risk Reduction With Sildenafil.(Circulation, 2016-03-08) Moon, RE; Peacher, DF; Potter, JF; Wester, TE; Cherry, AD; Natoli, M; Otteni, CE; Kernagis, DN; White, WD; Freiberger, JBACKGROUND: Swimming-induced pulmonary edema (SIPE) occurs during swimming or scuba diving, often in young individuals with no predisposing conditions, and its pathophysiology is poorly understood. This study tested the hypothesis that pulmonary artery and pulmonary artery wedge pressures are higher in SIPE-susceptible individuals during submerged exercise than in the general population and are reduced by sildenafil. METHODS AND RESULTS: Ten study subjects with a history of SIPE (mean age, 41.6 years) and 20 control subjects (mean age, 36.2 years) were instrumented with radial artery and pulmonary artery catheters and performed moderate cycle ergometer exercise for 6 to 7 minutes while submersed in 20°C water. SIPE-susceptible subjects repeated the exercise 150 minutes after oral administration of 50 mg sildenafil. Work rate and mean arterial pressure during exercise were similar in controls and SIPE-susceptible subjects. Average o2 and cardiac output in controls and SIPE-susceptible subjects were: o2 2.42 L·min(-1) versus 1.95 L·min(-1), P=0.2; and cardiac output 17.9 L·min(-1) versus 13.8 L·min(-1), P=0.01. Accounting for differences in cardiac output between groups, mean pulmonary artery pressure at cardiac output=13.8 L·min(-1) was 22.5 mm Hg in controls versus 34.0 mm Hg in SIPE-susceptible subjects (P=0.004), and the corresponding pulmonary artery wedge pressure was 11.0 mm Hg versus 18.8 mm Hg (P=0.028). After sildenafil, there were no statistically significant differences in mean pulmonary artery pressure or pulmonary artery wedge pressure between SIPE-susceptible subjects and controls. CONCLUSIONS: These observations confirm that SIPE is a form of hemodynamic pulmonary edema. The reduction in pulmonary vascular pressures after sildenafil with no adverse effect on exercise hemodynamics suggests that it may be useful in SIPE prevention. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00815646.