Artur Haddad Herdy

Pre-and Postoperative Cardiopulmonary Rehabilitation in Hospitalized Patients Undergoing Coronary Artery Bypass Surgery : A Randomized Controlled Trial

Herdy AH, Marcchi PLB, Vila A, Tavares C, Collaço J, Niebauer J, Ribeiro JP: Pre- and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery: a randomized controlled trial. Am J Phys Med Rehabil 2008;87:714–719. Objective:Patients who have to wait in the hospital for coronary artery bypass surgery (CABG) are exposed to the potential risks of immobilization. This clinical trial was conducted to evaluate the effects of an in-hospital cardiopulmonary rehabilitation program performed before and after CABG on postoperative outcomes. Design:Fifty-six patients who had to wait for CABG in-hospital were randomly assigned to a cardiopulmonary rehabilitation (Rehab; n = 29) or to usual care (Control; n = 27). In the Rehab group, intervention lasted for at least 5 days preoperatively until discharge. The program consisted of phase I cardiac rehabilitation associated with respiratory physical therapy. Outcomes were blindly evaluated. Results:By hospital discharge, Rehab patients presented a shorter time to endotracheal extubation (1054 ± 376 vs. 1340 ± 666 min, P = 0.05), a reduction in the incidence of pleural effusion (relative risk [RR] = 0.2; 95% confidence interval [CI]: 0.5–0.8), atelectasis (RR = 0.15; 95% CI: 0.03–0.8), pneumonia (0 vs. 7 cases, [P = 0.004]), and atrial fibrillation or flutter (RR = 0.2; 95% CI: 0.05–0.8). Length of in-hospital stay after surgery was also reduced in the Rehab group (5.9 ± 1.1 vs. 10.3 ± 4.6 days [P < 0.001]). Conclusion:Pre- and postoperative cardiopulmonary rehabilitation in patients who await CABG in the hospital is superior to standard care and leads to a reduced rate of postoperative complications and shorter hospital stay.

Reference values for cardiopulmonary exercise testing for sedentary and active men and women

FUNDAMENTO: Os valores de referencia de teste cardiopulmonar (TCP) disponiveis no Brasil foram derivados de cicloergometro, em populacao sedentaria e relativamente pequena. OBJETIVO: Fornecer valores de referencia para o TCP em brasileiros de ambos os sexos, sedentarios e ativos. METODOS: ENtre 2006 e 2008, 3.992 TCP de individuos saudaveis foram selecionados de nosso laboratorio. Atletas, fumantes, portadores de qualquer patologia conhecida, usuarios de medicacao continua e obesos foram excluidos. VO2 pico foi considerado VO2 max. Analisamos tambem VO2 de limiar anaerobico, ventilacao maxima e pulso de oxigenio de acordo com sexo, faixa etaria, sedentarios e ativos. As faixas etarias foram assim divididas: G1 (15-24 anos), G2 (25-34), G3 (35-44), G4 (45-54), G5 (55-64) e G6 (65-74). RESULTADOS: De acordo com as faixas etarias, os valores medios de VO2 em ml/kg/min com os respectivos desvios-padrao foram: Homem ativo: G1-50,6 ± 7,3; G2-47,4 ± 7,4; G3-45,4 ± 6,8; G4-40,5 ± 6,5; G5-35,3 ± 6,2; G6-30,0 ± 6,1. Mulher ativa: G1-38,9 ± 5,7; G2-38,1 ± 6,6; G3-34,9 ± 5,9; G4-31,1 ± 5,4; G5-28,6 ± 6,1; G6-25,1 ± 4,4. Homem sedentario: G1-47,4 ± 7,9; G2-41,9 ± 7,2; G3-39,0 ± 6,8; G4-35,6 ± 7,7; G5-30,0 ± 6,3; G6-23,1 ± 6,3. Mulher sedentaria: G1-35,6 ± 5,7; G2-34,0 ± 4,8; G3-30,0 ± 5,4; G4-27,2 ± 5,0; G5-23,9 ± 4,2; G6-21,2 ± 3,4. CONCLUSAO: ESte artigo fornece valores de referencia de VO2 max, entre outros parâmetros, no Teste Cardiopulmonar realizados na esteira ergometrica em individuos de ambos os sexos, ativos e sedentarios.BACKGROUND The reference values for cardiopulmonary exercise testing (CPET) available in Brazil were derived from a cycle ergometer in a sedentary and relatively small population. OBJECTIVE Provide reference values for CPET in Brazilians of both sexes, either sedentary or active. METHODS From 2006 to 2008, 3,992 CEPT of healthy individuals were selected from our laboratory. Athletes, smokers, patients with any known pathology, users of continuous medication and obese patients were excluded. Peak VO(2) was considered max VO(2). We also analyzed the anaerobic threshold VO(2), maximum ventilation and oxygen pulse according to sex, age, sedentary and active patients. Age groups were divided as follows: G1 (15-24), G2 (25-34), G3 (35-44), G4 (45-54), G5 (55-64) and G6 (65-74). RESULTS According to age groups, the mean values of VO(2) in ml/kg/min with their standard deviations were: Active man: G1-50.6 ± 7.3, G2-47, 4 ± 7.4, G3-45, 4 ± 6.8, G4-40.5 ± 6.5; G5-35.3 ± 6.2; G6-30.0 ± 6.1. Active woman: G1-38.9 ± 5.7; G2-38.1 ± 6.6; G3-34.9 ± 5.9; G4-31.1 ± 5.4; G5-28.6 ± 6.1; G6-25.1 ± 4.4. Sedentary man: G1-47.4 ± 7.9; G2-41.9 ± 7.2; G3-39.0 ± 6.8; G4-35.6 ± 7.7; G5-30.0 ± 6.3; G6-23.1 ± 6.3. Sedentary woman: G1-35.6 ± 5.7; G2-34.0 ± 4.8; G3-30.0 ± 5.4; G4-27.2 ± 5.0; G5-23.9 ± 4.2; G6-21.2 ± 3.4. CONCLUSION This article provides reference values of max VO(2), among other parameters, in the Cardiopulmonary Exercise Testing performed on the treadmill in individuals of both sexes, either active and sedentary.

Valores de referência para o teste cardiopulmonar para homens e mulheres sedentários e ativos

FUNDAMENTO: Os valores de referencia de teste cardiopulmonar (TCP) disponiveis no Brasil foram derivados de cicloergometro, em populacao sedentaria e relativamente pequena. OBJETIVO: Fornecer valores de referencia para o TCP em brasileiros de ambos os sexos, sedentarios e ativos. METODOS: ENtre 2006 e 2008, 3.992 TCP de individuos saudaveis foram selecionados de nosso laboratorio. Atletas, fumantes, portadores de qualquer patologia conhecida, usuarios de medicacao continua e obesos foram excluidos. VO2 pico foi considerado VO2 max. Analisamos tambem VO2 de limiar anaerobico, ventilacao maxima e pulso de oxigenio de acordo com sexo, faixa etaria, sedentarios e ativos. As faixas etarias foram assim divididas: G1 (15-24 anos), G2 (25-34), G3 (35-44), G4 (45-54), G5 (55-64) e G6 (65-74). RESULTADOS: De acordo com as faixas etarias, os valores medios de VO2 em ml/kg/min com os respectivos desvios-padrao foram: Homem ativo: G1-50,6 ± 7,3; G2-47,4 ± 7,4; G3-45,4 ± 6,8; G4-40,5 ± 6,5; G5-35,3 ± 6,2; G6-30,0 ± 6,1. Mulher ativa: G1-38,9 ± 5,7; G2-38,1 ± 6,6; G3-34,9 ± 5,9; G4-31,1 ± 5,4; G5-28,6 ± 6,1; G6-25,1 ± 4,4. Homem sedentario: G1-47,4 ± 7,9; G2-41,9 ± 7,2; G3-39,0 ± 6,8; G4-35,6 ± 7,7; G5-30,0 ± 6,3; G6-23,1 ± 6,3. Mulher sedentaria: G1-35,6 ± 5,7; G2-34,0 ± 4,8; G3-30,0 ± 5,4; G4-27,2 ± 5,0; G5-23,9 ± 4,2; G6-21,2 ± 3,4. CONCLUSAO: ESte artigo fornece valores de referencia de VO2 max, entre outros parâmetros, no Teste Cardiopulmonar realizados na esteira ergometrica em individuos de ambos os sexos, ativos e sedentarios.BACKGROUND The reference values for cardiopulmonary exercise testing (CPET) available in Brazil were derived from a cycle ergometer in a sedentary and relatively small population. OBJECTIVE Provide reference values for CPET in Brazilians of both sexes, either sedentary or active. METHODS From 2006 to 2008, 3,992 CEPT of healthy individuals were selected from our laboratory. Athletes, smokers, patients with any known pathology, users of continuous medication and obese patients were excluded. Peak VO(2) was considered max VO(2). We also analyzed the anaerobic threshold VO(2), maximum ventilation and oxygen pulse according to sex, age, sedentary and active patients. Age groups were divided as follows: G1 (15-24), G2 (25-34), G3 (35-44), G4 (45-54), G5 (55-64) and G6 (65-74). RESULTS According to age groups, the mean values of VO(2) in ml/kg/min with their standard deviations were: Active man: G1-50.6 ± 7.3, G2-47, 4 ± 7.4, G3-45, 4 ± 6.8, G4-40.5 ± 6.5; G5-35.3 ± 6.2; G6-30.0 ± 6.1. Active woman: G1-38.9 ± 5.7; G2-38.1 ± 6.6; G3-34.9 ± 5.9; G4-31.1 ± 5.4; G5-28.6 ± 6.1; G6-25.1 ± 4.4. Sedentary man: G1-47.4 ± 7.9; G2-41.9 ± 7.2; G3-39.0 ± 6.8; G4-35.6 ± 7.7; G5-30.0 ± 6.3; G6-23.1 ± 6.3. Sedentary woman: G1-35.6 ± 5.7; G2-34.0 ± 4.8; G3-30.0 ± 5.4; G4-27.2 ± 5.0; G5-23.9 ± 4.2; G6-21.2 ± 3.4. CONCLUSION This article provides reference values of max VO(2), among other parameters, in the Cardiopulmonary Exercise Testing performed on the treadmill in individuals of both sexes, either active and sedentary.

Brazilian Cardiorespiratory Fitness Classification Based on Maximum Oxygen Consumption

Background Cardiopulmonary exercise test (CPET) is the most complete tool available to assess functional aerobic capacity (FAC). Maximum oxygen consumption (VO2 max), an important biomarker, reflects the real FAC. Objective To develop a cardiorespiratory fitness (CRF) classification based on VO2 max in a Brazilian sample of healthy and physically active individuals of both sexes. Methods We selected 2837 CEPT from 2837 individuals aged 15 to 74 years, distributed as follows: G1 (15 to 24); G2 (25 to 34); G3 (35 to 44); G4 (45 to 54); G5 (55 to 64) and G6 (65 to 74). Good CRF was the mean VO2 max obtained for each group, generating the following subclassification: Very Low (VL): VO2 < 50% of the mean; Low (L): 50% - 80%; Fair (F): 80% - 95%; Good (G): 95% -105%; Excellent (E) > 105%. Results Men VL < 50% L 50-80% F 80-95% G 95-105% E > 105% G1 < 25.30 25.30-40.48 40.49-48.07 48.08-53.13 > 53.13 G2 < 23.70 23.70-37.92 37.93-45.03 45.04-49.77 > 49.77 G3 < 22.70 22.70-36.32 36.33-43.13 43.14-47.67 > 47.67 G4 < 20.25 20.25-32.40 32.41-38.47 38.48-42.52 > 42.52 G5 < 17.54 17.65-28.24 28.25-33.53 33.54-37.06 > 37.06 G6 < 15 15.00-24.00 24.01-28.50 28.51-31.50 > 31.50 Women G1 < 19.45 19.45-31.12 31.13-36.95 36.96-40.84 > 40.85 G2 < 19.05 19.05-30.48 30.49-36.19 36.20-40.00 > 40.01 G3 < 17.45 17.45-27.92 27.93-33.15 33.16-34.08 > 34.09 G4 < 15.55 15.55-24.88 24.89-29.54 29.55-32.65 > 32.66 G5 < 14.30 14.30-22.88 22.89-27.17 27.18-30.03 > 30.04 G6 < 12.55 12.55-20.08 20.09-23.84 23.85-26.35 > 26.36 Conclusions This chart stratifies VO2 max measured on a treadmill in a robust Brazilian sample and can be used as an alternative for the real functional evaluation of physically and healthy individuals stratified by age and sex.

Cardiac abnormalities in the acquired immunodeficiency syndrome. A prospective study with a clinical-pathological correlation in twenty-one adult patients

OBJECTIVE To evaluate the cardiac abnormalities and their evolution during the course of the acquired immunodeficiency syndrome, as well as to correlate clinical and pathological data. METHODS Twenty-one patients, admitted to the hospital with the diagnosis of acquired immunodeficiency syndrome, were prospectively studied and followed until their death. Age ranged from 19 to 42 years (17 males). ECG and echocardiogram were also obtained every six months. After death, macro- and microscopic examinations were also performed. RESULTS The most frequent causes of referral to the hospital were: diarrhea or repeated pneumonias, tuberculosis, toxoplasmosis or Kaposi sarcoma. The most frequent findings were acute or chronic pericarditis (42%) and dilated cardiomyopathy (19%). Four patients died of cardiac problems: infective endocarditis, pericarditis with pericardial effusion, bacterial myocarditis and infection by Toxoplasma gondii. CONCLUSION Severe cardiac abnormalities were the cause of death in some patients. In the majority of the patients, a good correlation existed between clinical and anatomical-pathological data. Cardiac evaluation was important to detect early manifestations and treat them accordingly, even in asymptomatic patients.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation

Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

HIGH INTENSITY AEROBIC EXERCISE TRAINING INDUCES SIMILAR OR EVEN SUPERIOR BLOOD PRESSURE REDUCING EFFECTS IN CONTROLLED HYPERTENSIVE PATIENTS

Aerobic exercise training is currently used in the nonpharmacologic management of hypertension, however there is controversy on the optimal training intensity that should be recommended. Objective: To compare the effects two exercise training intensities on 24 hour blood pressure monitoring in

High Intensity Exercises in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) comprises several pathologies that present with variable degrees of dyspnea, high filling pressures, structural or diastolic alterations and great limitation to exercise.1 HFpEF can represent up to 50% of cases of hospital admissions due to decompensated heart failure (HF).2 Hypertension and obesity are conditions frequently associated with HFpEF and the adequate management of these two pathologies are essential for the treatment of this syndrome. One of the main characteristics of patients with HFpEF is the intolerance to exercise at different degrees and through diverse mechanisms.3 Exercises are among the main therapeutic strategies for the treatment of heart failure with reduced ejection fraction (HFrEF) and HFpEF, being important agents in decreasing the morbidity and mortality of these patients.4-6 Among the benefits of aerobic training in patients with HFpEF, we can highlight the improvement in endothelial function and arterial stiffness, contributing to the improvement of cardiovascular dynamics and symptoms.7 The physical training programs offered to patients with HF in cardiac rehabilitation services involve primarily aerobic exercises supplemented by resistant exercises, stretching and, in some cases, respiratory exercises.1 Aerobic exercises can be continuous, of moderate intensity or intercalating high and low-intensity efforts. High-intensity interval training (HIIT) is currently one of the most effective methods for improving cardiorespiratory and metabolic function. HIIT involves repeated activities, from short to long ones, of high-intensity exercises combined with periods of active or passive recovery.8 Kiviniemi et al. have recently reported that HIIT is superior to traditional continuous aerobic training in improving cardiac autonomic function and suggested that the effect verified on post-HIIT autonomic function was related to improved baroreflex modulation and vagal control.9 There are several potential adaptations that explain the positive changes induced by HIIT on the autonomic cardiac function. One of the potential mechanisms related to HIIT-induced improvement in cardiac vagal tone may be angiotensin II, which inhibits cardiac vagal activity. Sedentary or physically inactive individuals have higher plasma renin activity when compared to those who are physically active. Exercise causes angiotensin II suppression, which can, to some extent, mediate the improvement in cardiac vagal tone.10 Studies have also suggested that HIIT induces increased baroreflex sensitivity and reduces arterial stiffness.11 Comments about the current study In this interesting study, designed for the assessment of the acute effects of a single session of high-intensity interval training, Lima et al.12 studied post-training changes in blood pressure (BP) and endothelial function in 16 patients with HFpEF. As main results, it was possible to demonstrate a significant increase in the brachial artery diameter with a corresponding reduction in systolic BP. These findings indicate the potential benefit of this type of training for patients with HFpEF, with an improvement in blood pressure levels and, possibly, a beneficial effect on ventricular function. Although the authors did not find any significant changes in the flow-mediated dilation index, questions have been raised about the real importance and interpretation of this measurement.13 The BP reduction after the exercise sessions tends to last for hours, acting as powerful adjuvants to the vasodilation effects of antihypertensive drugs, which are commonly used in HFpEF. BP control is among the main goals for symptom improvement in HFpEF, and exercises are crucial to attain this goal and improve diastolic function.14

Cardiopulmonary Exercise Test: Fundamentals, Applicability and Interpretation

Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

Intense aerobic training promotes reduction of blood pressure in hypertensive

INTRODUCAO: O treinamento fisico promove importantes respostas adaptativas no organismo que diminuem a morbidade e a mortalidade em hipertensos. Entretanto, sao poucos os estudos que avaliaram a resposta pressorica do treinamento aerobio de diferentes intensidades em hipertensos. Objetivo: Analisar os efeitos do treinamento fisico aerobio intenso com relacao ao treinamento fisico moderado sobre a pressao arterial ambulatorial em hipertensos. METODOS: Participaram do estudo 32 hipertensos (48 ± 9 anos) randomizados como: grupo de treinamento aerobio de intensidade moderada (IM), intensidade de 60-65% da frequencia cardiaca de reserva, 40 minutos, tres sessoes por semana (n=12); exercicio aerobio de alta intensidade (AI), intensidade de 80% a 85% da frequencia cardiaca de reserva (n=12), com a duracao ajustada para atingir o mesmo gasto energetico que a IM e um grupo controle (GC) sem exercicios (n=10). Nos tres grupos foram avaliadas variaveis da monitorizacao ambulatorial da pressao arterial de 24 horas (MAPA) antes e apos as oito semanas de intervencao. RESULTADOS: Apos a intervencao a pressao arterial sistolica (PAS) da vigilia reduziu 10,1 mmHg (p=0,024) em AI e 9,7 mmHg (p=0,035) em IM e a pressao arterial diastolica (PAD) da vigilia reduziu 12,3 mmHg (p=0,002) em AI e 8,4 mmHg (p<0,001) em IM. A PAS do sono reduziu 9,5 mmHg (p=0,004) apenas em AI e 9,8 mmHg (p=0,005) em IM. A PAD do sono reduziu 8,2 mmHg (p=0,006) em AI e 4,8 mmHg (p<0,007) em IM. As cargas pressoricas sistolicas e diastolicas da vigilia e do sono reduziram-se significativamente apenas em AI. CONCLUSAO: Treinamento fisico aerobio moderado e intenso com duracao equalizada pelo gasto calorico tem efeito hipotensor semelhante em hipertensos. A carga pressorica reduziu apenas na AI, sendo assim intensidade-dependente.