Anderson Donelli da Silveira

Inspiratory Muscle Strength as a Determinant of Functional Capacity Early After Coronary Artery Bypass Graft Surgery

UNLABELLED Stein R, Maia CP, Silveira AD, Chiappa GR, Myers J, Ribeiro JP. Inspiratory muscle strength as a determinant of functional capacity early after coronary artery bypass graft surgery. OBJECTIVE To evaluate the effects of a 6-day postoperative in-hospital cardiopulmonary rehabilitation program on inspiratory muscle strength and its potential association with improved functional capacity after coronary artery bypass graft (CABG) surgery. DESIGN Prospective, randomized controlled trial. SETTING Tertiary public hospital in Brazil. PARTICIPANTS Men (N=20) after CABG were randomized to cardiopulmonary rehabilitation (n=10; age, 64+/-8y) or to usual care (n=10; age, 63+/-7y). INTERVENTIONS Ten subjects underwent a 6-day postoperative in-hospital program, which included the use of expiratory positive airway pressure mask and bronchial hygiene techniques, coupled with progressive distance walking and calisthenics as well as cardiopulmonary training. Ten controls were followed by their own physicians and received routine nursing assistance but were not exposed to any specific respiratory or motor physical intervention. MAIN OUTCOME MEASURES Maximal inspiratory and expiratory pressure were measured by a pressure transducer, and the highest pressure obtained in 6 measurements was used for analysis (before surgery, and 7 and 30d after surgery). The six-minute walk test (6MWT) was performed 7 days after surgery, and maximal cardiopulmonary exercise testing was performed 30 days after CABG. RESULTS After randomization, clinical and functional characteristics were similar in the 2 groups. Rehabilitation resulted in maintenance of maximal inspiratory pressure (PImax) measured at 7 and 30 days postoperatively, respectively (from 68+/-19% at baseline to 58+/-22% and to 61+/-22% predicted), while it was significantly reduced in the control group. 6MWT distance was longer 7 days after CABG in rehabilitation subjects (416+/-78m) than controls (323+/-67m). Peak oxygen uptake (Vo(2)peak) at day 30 was also higher (28%) in the rehabilitation group and was correlated with PImax (r=.90). CONCLUSIONS A 6-day rehabilitation program attenuated the postoperative reduction in respiratory muscle strength and also improved the recovery of functional capacity after CABG. The correlation between PImax and Vo(2)peak during the late postoperative period suggests that inspiratory muscle strength is an important determinant of functional capacity after CABG.

Association of anemia with clinical outcomes in stable coronary artery disease.

BackgroundAlthough anemia is pathophysiologically associated with myocardial ischemia, there are scarce data on its clinical impact in patients with stable coronary artery disease on contemporary treatment. This study aims to describe the prevalence of anemia, and its association with symptoms and outcomes in this population. MethodsWe conducted a prospective cohort study in stable documented coronary artery disease patients. Anemia criteria was hemoglobin (Hb) <12 g/dl in women and <13 g/dl in men. Hemoglobin levels were divided in quartiles (Q) adjusted for sex. Major events included acute coronary syndromes, stroke and cardiovascular deaths. Secondary outcomes were presence of angina and chronic use of nitrates. Cox regression models were used to evaluate the independent effect of anemia on clinical outcomes. ResultsAmong 310 patients, 71 (23%) met criteria for anemia. After a mean follow-up of 44±23 months, hemoglobin levels had a marked association with occurrence of major events (27% in Q1, 7% in Q2, 8% in Q3 and 12% in Q4; P<0.01). In multivariate analysis, anemia was independently associated with an increased risk of death [hazard ratio (HR) 6.5, 95% confidence interval (1.7–24.2)], major events [HR 3.3 (1.7–6.5)] and revascularization procedures [HR 2.3 (1.3–4.1)]. Persistent of angina symptoms (32 vs. 18%, P=0.01) and chronic use of nitrates (35 vs. 21%, P=0.02) were also more frequent among patients with anemia at baseline. ConclusionsIn patients with stable ischemic heart disease, presence of anemia, even mild, is associated with a worse prognosis. Strategies aiming at identifying reversible causes of anemia or new treatments should be evaluated in prospective clinical trials.

Increased atherothrombotic markers and endothelial dysfunction in steroid users

Background: The use of androgenic anabolic steroids (AAS) may be associated with changes in atherothrombotic markers and endothelial function. The purpose of this study was to compare atherothrombotic markers and endothelial function of AAS users and non-users. Design: Cross-sectional study. Methods: Ten athletes who were users of AAS (confirmed by urine analysis) and 12 non-user athletes were evaluated. Body weight, blood pressure, exercise load (hours/week), complete blood count (CBC), platelets, fibrinogen, lipids, high-sensitivity C-reactive protein (hs-CRP), follicle-stimulating hormone, testosterone and estradiol were measured. Endothelium-dependent and independent functions were assessed by brachial artery ultrasound. Results: AAS users had higher body mass and blood pressure (p < 0.05). Platelet count was higher whereas HDL-cholesterol was lower in AAS users compared with non-users (p < 0.05). Levels of hs-CRP were higher in AAS users (p < 0.001). Follicle-stimulating hormone was suppressed in all users and not suppressed in non-users (p < 0.001). Compared with non-users, flow-mediated dilation was significantly reduced in AAS users (p = 0.03), whereas endothelium-independent function was similar in both groups. Additionally, flow-mediated dilation was positively associated with levels of HDL- cholesterol (r = 0.49, p = 0.03). Conclusions: AAS users present important changes in blood lipids as well as in inflammatory markers, which are compatible with increased cardiovascular risk. Furthermore, this profile is accompanied by a reduction in the endothelial function.

Tai Chi Chuan for Cardiac Rehabilitation in Patients with Coronary Arterial Disease

Background Several studies have shown that Tai Chi Chuan can improve cardiac function in patients with heart disease. Objective To conduct a systematic review of the literature to assess the effects of Tai Chi Chuan on cardiac rehabilitation for patients with coronary artery disease. Methods We performed a search for studies published in English, Portuguese and Spanish in the following databases: MEDLINE, EMBASE, LILACS and Cochrane Register of Controlled Trials. Data were extracted in a standardized manner by three independent investigators, who were responsible for assessing the methodological quality of the manuscripts. Results The initial search found 201 studies that, after review of titles and abstracts, resulted in a selection of 12 manuscripts. They were fully analyzed and of these, nine were excluded. As a final result, three randomized controlled trials remained. The studies analyzed in this systematic review included patients with a confirmed diagnosis of coronary artery disease, all were clinically stable and able to exercise. The three experiments had a control group that practiced structured exercise training or received counseling for exercise. Follow-up ranged from 2 to 12 months. Conclusion Preliminary evidence suggests that Tai Chi Chuan can be an unconventional form of cardiac rehabilitation, being an adjunctive therapy in the treatment of patients with stable coronary artery disease. However, the methodological quality of the included articles and the small sample sizes clearly indicate that new randomized controlled trials are needed in this regard.

Tai Chi Chuan improves functional capacity after myocardial infarction: A randomized clinical trial

BACKGROUND Patients with a recent myocardial infarction (MI) present a reduction in functional capacity expressed as a decrease in peak oxygen consumption (Vo2 peak). The impact of a Tai Chi Chuan (TCC) cardiac rehabilitation program for patients recovering from recent MI has yet to be assessed. Our goal is to evaluate functional capacity after a TCC-based cardiac rehabilitation program in patients with recent MI. METHODS A single-blind randomized clinical trial was conducted. The researchers who performed the tests were blinded to group allocation. Between the 14th and 21st days after hospital discharge, all patients performed a cardiopulmonary exercise testing and a laboratory blood workup. Mean age was similar (56±9 years in the TCC group and 60±9 years in the control group). Patients allocated to the intervention group performed 3 weekly sessions of TCC Beijin style for 12 weeks (n=31). The control group participated in 3 weekly sessions of full-body stretching exercises (n=30). RESULTS After the 12-week study period, participants in the TCC group experienced a significant 14% increase in Vo2 peak from baseline (21.6 ± 5.2 to 24.6 ± 5.2 mL/kg per minute), whereas control participants had a nonsignificant 5% decline in Vo2 peak (20.4 ± 5.1 to 19.4 ± 4.4 mL/kg per minute). There was a significant difference between the 2 groups (P<.0001). CONCLUSIONS Tai Chi Chuan practice was associated with an increase in Vo2 peak in patients with a recent MI and may constitute an effective form of cardiac rehabilitation in this patient population.

Impact of treatment with glibenclamide or vildagliptin on glucose variability after aerobic exercise in type 2 diabetes: A randomized controlled trial

AIMS To evaluate the glucose variability, oxidative stress, metabolic and cardiovascular responses after an aerobic exercise session in diabetic patients on treatment with metformin plus vildagliptin or glibenclamide. METHODS Parallel clinical trial including patients with type 2 diabetes treated with metformin plus vildagliptin or glibenclamide for 12 weeks. Glucose variability, oxidative stress, metabolic (plasma glucose, insulin and glucagon-like-peptide-1) and cardiovascular responses were evaluated at rest, during and after a 30 min aerobic exercise session (70% of the peak heart rate). RESULTS Thirteen patients were included, seven in vildagliptin group (METV) and six in glibenclamide group (METG), baseline glycated hemoglobin (HbA1c) 8.8 ± 0.3%. Treatment reduced HbA1c (1.2% and 1.5% for METV and METG, respectively). The aerobic exercise session did not change glucose variability in both groups. A decrease in glucose during exercise recovery was found, with area under the curve lower in the METG vs. METV (p = 0.04). After the intervention, systolic blood pressure (SBP) decreased in both groups. Patients treated with vildagliptin showed lower SBP variability compared to those treated with glibenclamide. CONCLUSIONS Besides improvement in glucose control and reduction of SBP obtained by both treatments, lower blood pressure variability was observed in patients receiving vildagliptin. Glucose variability remained unaffected by both interventions and the exercise session.

Vasodilation and Reduction of Systolic Blood Pressure after One Session of High-Intensity Interval Training in Patients With Heart Failure with Preserved Ejection Fraction

Background Heart failure with preserved ejection fraction (HFpEF) is a multifactorial syndrome characterized by a limited exercising capacity. High-intensity interval training (HIIT) is an emerging strategy for exercise rehabilitation in different settings. In patients with HFpEF, HIIT subacute effects on endothelial function and blood pressure are still unknown. Objective To evaluate the subacute effect of one HIIT session on endothelial function and blood pressure in patients with HFpEF. Methods Sixteen patients with HFpEF underwent a 36-minute session of HIIT on a treadmill, alternating four minutes of high-intensity intervals with three minutes of active recovery. Brachial artery diameter, flow-mediated dilation, and blood pressure were assessed immediately before and 30 minutes after the HIIT session. In all analyses, p <0.05 was considered statistically significant. Results There was an increase in brachial artery diameter (pre-exercise: 3.96 ± 0.57 mm; post-exercise: 4.33 ± 0.69 mm; p < 0.01) and a decrease in systolic blood pressure (pre-exercise: 138 ± 21 mmHg; post-exercise: 125 ± 20 mmHg; p < 0.01). Flow-mediated dilation (pre-exercise: 5.91 ± 5.20%; post-exercise: 3.55 ± 6.59%; p = 0.162) and diastolic blood pressure (pre-exercise: 81 ± 11 mmHg; post-exercise: 77 ± 8 mmHg; p = 1.000) did not change significantly. There were no adverse events throughout the experiment. Conclusions One single HIIT session promoted an increase in brachial artery diameter and reduction in systolic blood pressure, but it did not change flow-mediated dilation and diastolic blood pressure.

Metodologias ativas de ensino-aprendizagem no processo de ensino em saúde no Brasil : uma revisão narrativa

Nas ultimas decadas, a formacao dos profissionais de saude tornou-se um ponto importante a ser discutido. O novo profissional desejado pelas ultimas reformas curriculares dos cursos da area da saude tem perfil humanista, critico e reflexivo, para atuar em todos os niveis de atencao a saude. Apesar disso, a educacao dos profissionais de saude ainda e, na maioria das vezes, baseada em um modelo fragmentado do saber, desconsiderando as necessidades de atuacao na pratica. Neste contexto, surgem as metodologias ativas de ensino-aprendizagem (MAEA), que propoem desafios a serem superados pelos estudantes, possibilitando-lhes ocupar o lugar de sujeitos na construcao do conhecimento. O objetivo deste estudo foi revisar artigos disponiveis em periodicos cientificos que exemplificassem o uso de MAEA no processo de ensino nos cursos de graduacao da area da saude, com enfase na realidade brasileira. A busca foi realizada atraves das bases de dados PubMed, SciELO e BVS, nas quais foram selecionados artigos cientificos de relatos de experiencia em portugues. Os resultados relatados nos artigos foram positivos em relacao ao uso das MAEA no processo de ensino em saude durante a graduacao. Palavras-chave: Aprendizagem ativa; educacao em saude; ensino

Genetic Evaluation, Familial Screening and Exercise

Genetic Evaluation, Familial Screening and Exercise Ricardo Stein,1,2,3,4 Juan Pablo Trujillo,5,6 Anderson Donelli da Silveira,1,4 Arsonval Lamounier Júnior,5,6 Lorenzo Monserrat Iglesias5,6 Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul1; Grupo de Pesquisa em Cardiologia do Exercício do Hospital de Clínicas de Porto Alegre (CardioEx);2 Serviço de Fisiatria e Reabilitação do Hospital de Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul;3 Vitta Centro de Bem Estar Físico,4 Porto Alegre, RS Brasil; Health in Code,5 La Coruña Spain; Grupo de Investigación Cardiovascular de La Universidad de La Coruña,6 La Coruña Spain *Ricardo Stein and Juan Pablo Trujillo contributed equally and are the first authors

No signs of ventilatory inefficiency in patients with heart failure with preserved ejection fraction and very low oxygen consumption: how is this possible?

We have read with interest the article by Palau et al., ‘‘Effects of inspiratory muscle training in patients with heart failure with preserved ejection fraction,’’ recently published in this journal. According to their results, in heart failure patients with preserved ejection fraction (HFpEF) associated with very low exercise capacity and normal maximal inspiratory pressure (MIP), inspiratory muscle training (IMT) improved aerobic capacity, ventilatory efficiency (VE/VCO2 slope) and quality of life. It is well established that IMT improves exercise capacity as well as other markers of disease severity in patients with systolic dysfunction and inspiratory muscle weakness (IMW). Is our belief that patients with IMW are the group that would benefit most when exposed to IMT. Based on this assumption, even in the HFpEF scenario, we wonder why the authors chose a subgroup of individuals with preserved inspiratory muscle strength instead of those with IMW. More importantly, the values found in the cardiopulmonary exercise testing (CPET) preand post-IMT are quite unusual in the HFpEF setting, since VE/ VCO2 slope is usually abnormal in these individuals, being even more a marker of worse prognosis than a low VO2 peak. 4 As exercise cardiologists who often perform CPET in this subset of patients, we wonder why the authors did not discuss this unexpected finding. It must be pointed out that there is a basic error on Table 2. We notice a discrepancy between the values in metabolic equivalents (METs) and the relative VO2 peak (expressed in ml kg min ). Assuming the first is equal to the second divided by 3.5, all METs values should be corrected. Anyhow, the authors deserve our respect since they were testing feasible interventions in subjects presenting a condition where most of the therapies fail to improve prognosis and exercise capacity.