Charlotte B. Ingul

Segmental and global longitudinal strain and strain rate based on echocardiography of 1266 healthy individuals: the HUNT study in Norway

AIMS To study the distribution of longitudinal systolic strain and strain rate (SR) as indicators of myocardial deformation according to age and sex in a healthy population. METHODS AND RESULTS Longitudinal strain and SR were determined in 1266 healthy individuals from three standard apical views, using a combination of speckle tracking (ST) and tissue Doppler imaging (TDI) to track regions of interest (ROIs). To test applicability of the reference values, we used a subset of the population to compare four methods of assessing myocardial deformation: (1) a combination of TDI and ST; (2) TDI with fixed ROIs; (3) TDI with tracking of ROIs; and (4) ST. Mean (SD) overall global longitudinal strain and SR were -17.4% (2.3) and -1.05 s(-1) (0.13) in women, and -15.9% (2.3) and -1.01 s(-1) (0.13) in men. Deformation indices decreased with increasing age. The combined and ST methods showed identical SR, but values were significantly lower than those obtained by TDI. Strain was overestimated by the ST method (18.4%) compared with the combined method (17.4%). CONCLUSION The reference values for global and segmental longitudinal strain and SR obtained from this population study are applicable for use in a wide clinical setting.

Aerobic interval training reduces blood pressure and improves myocardial function in hypertensive patients

Aims: Exercise is recommended as prevention, management, and control of all stages of hypertension. There are still controversies about the optimal training dose, frequency, and intensity. We aimed to study the effect of aerobic interval training on blood pressure and myocardial function in hypertensive patients. Methods and results: A total of 88 patients (52.0 ± 7.8 years, 39 women) with essential hypertension were randomized to aerobic interval training (AIT) (>90% of maximal heart rate, correlates to 85–90% of VO2max), isocaloric moderate intensity continuous training (MIT) (∼70% of maximal heart rate, 60% of VO2max), or a control group. Exercise was performed on a treadmill, three times per week for 12 weeks. Ambulatory 24-hour blood pressure (ABP) was the primary endpoint. Secondary endpoints included maximal oxygen uptake (VO2max), mean heart rate/24 hour, flow mediated dilatation (FMD), total peripheral resistance (TPR), and myocardial systolic and diastolic function by echocardiography. Systolic ABP was reduced by 12 mmHg (p < 0.001) in AIT and 4.5 mmHg (p = 0.05) in MIT. Diastolic ABP was reduced by 8 mmHg (p < 0.001) in AIT and 3.5 mmHg (p = 0.02) in MIT. VO2max improved by 15% (p < 0.001) in AIT and 5% (p < 0.01) in MIT. Systolic myocardial function improved in both exercise groups, diastolic function in the AIT group only. TPR reduction and increased FMD were only observed in the AIT group. Conclusions: This study indicates that the blood pressure reducing effect of exercise in essential hypertension is intensity dependent. Aerobic interval training is an effective method to lower blood pressure and improve other cardiovascular risk factors.

Incremental Value of Strain Rate Imaging to Wall Motion Analysis for Prediction of Outcome in Patients Undergoing Dobutamine Stress Echocardiography

Background— Wall motion score at dobutamine stress echocardiography is an independent predictor of mortality. We sought to determine whether quantification of DSE by strain rate imaging was incremental to wall motion score for predicting outcome. Methods and Results— In 646 patients undergoing dobutamine stress echocardiography for the evaluation of known or suspected coronary disease, customized software was used to automatically measure peak systolic strain rate (SRs) and end-systolic strain (Ses) in 18 segments. Results were expressed as the number of abnormal segments and the mean SRs and Ses per patient. All-cause mortality was identified over 7 years of follow-up (mean, 5.2±1.5 years). Contributions of clinical, wall motion, and SRs and Ses data to outcome were analyzed with Cox models, which also were used to define cut points for SRs and Ses. Ischemia (new or worsening wall motion abnormalities) was detected in 45%, and 39% had a previous myocardial infarction. In patients with no ischemia, annualized mortality without and with previous myocardial infarction were 2% and 3% compared with 5% in patients with ischemia. Peak wall motion score index, mean SRs, segmental Ses, and segmental SRs were all predictors of mortality, but only segmental SRs (hazard ratio, 3.6; 95% CI, 1.7 to 7.2) was independently predictive. In sequential Cox models, the model based on clinical data (overall &khgr;2, 12.7) was improved by peak wall motion score index (18.4, P=0.002) and further increased by either segmental SRs (31.8, P<0.001) or mean SRs (25.7, P=0.009). Conclusions— Segmental analysis by SRs, derived from automated strain rate imaging analysis of dobutamine stress echocardiography response, offers prognostic information that is independent and incremental to standard wall motion score index.

Impaired cardiac function among obese adolescents: effect of aerobic interval training.

OBJECTIVES To measure cardiac function before and after 3 months of aerobic interval training in obese adolescents and to compare the findings with those in lean counterparts. DESIGN Exercise intervention study. Cardiac function was assessed by echocardiography and maximal oxygen uptake by ergospirometry. SETTING The obese adolescents were referred from general practice to the St Olav University Hospital, Trondheim, Norway, and the control group was recruited from 2 schools. PARTICIPANTS Ten obese adolescents (mean [SD] age, 14.8 [1.2] years; mean [SD] body mass index {BMI; calculated as weight in kilograms divided by height in meters squared}, 33.5 [4.3]) and 10 lean counterparts (mean [SD] age, 14.9 [1.3] years; mean [SD] BMI, 20.4 [3.0]) participated. Intervention Aerobic interval training (4 x 4 minutes at 90% of maximal heart rate, 40 minutes of training in total) was performed twice per week for 13 weeks among the obese adolescents, whereas the lean counterparts only performed the tests. MAIN OUTCOME MEASURES Left ventricular end-diastolic volume, stroke volume, and maximal oxygen uptake. RESULTS Maximal oxygen uptake was 41.4% lower among the obese adolescents compared with the lean counterparts, but the maximal oxygen uptake increased by 8.6% (P = .008) after intervention. Obese adolescents initially had 7.8% and 14.5% lower left ventricular end-diastolic and stroke volumes, 21.3% reduced global strain rate and 16.3% global strain, reduced mitral annulus excursion and systolic/diastolic tissue velocity, longer isovolumic relaxation time, and longer deceleration time compared with the lean counterparts. No group difference was observed after the intervention. Aerobic interval training increased the ejection fraction but was lower compared with the lean counterparts. Aerobic interval training reduced fat content by 2.0% (P = .005) among the obese adolescents. CONCLUSIONS Aerobic interval training almost restored an impaired systolic and diastolic cardiac function among obese adolescents when compared with lean counterparts. These results may have implications for future treatment programs for obese adolescents.

Aerobic interval training compensates age related decline in cardiac function

Objectives. To study the effect of aerobic interval training (AIT) on myocardial function in sedentary seniors compared to master athletes (MA) and young controls. Design. Sixteen seniors (72± 1 years, 10 men) performed AIT (4 × 4 minutes) at ∼90% of maximal heart rate three times per week for 12 weeks. Results were compared with 11 male MA (74± 2 years) and 10 young males (23±2 years). Results. Seniors had an impaired diastolic function compared to the young at rest. AIT improved resting diastolic parameters, increased E/A ratio (44%, p <0.01), early diastolic tissue Doppler velocity (e′) (11%, p <0.05) and e′ during exercise (11%, p <0.01), shortened isovolumic relaxation rate (IVRT) (13%, p <0.01). Left ventricle (LV) systolic function (S′) was unaffected at rest, whereas S′ during stress echo increased by 29% (p <0.01). Right ventricle (RV) S′ and RV fractional area change (RFAC) increased (9%, p <0.01, 12%, p =0.01, respectively), but not RV e′. MA had the highest end-diastolic volume, stroke volume, diastolic reserve and RV S′. Conclusion. AIT partly reversed the impaired age related diastolic function in healthy seniors at rest, improved LV diastolic and systolic function during exercise as well as RV S′ at rest.

High intensity knee extensor training restores skeletal muscle function in copd patients

Improving reduced skeletal muscle function is important for optimising exercise tolerance and quality of life in chronic obstructive pulmonary disease (COPD) patients. By applying high-intensity training to a small muscle group, we hypothesised a normalisation of muscle function. Seven patients with COPD performed 6 weeks (3 days·week−1) of high-intensity interval aerobic knee extensor exercise training. Five age-matched healthy individuals served as a reference group. Muscle oxygen uptake and mitochondrial respiration of the vastus lateralis muscle were measured before and after the 6-week training programme. Initial peak work and maximal mitochondrial respiration were reduced in COPD patients and improved significantly after the training programme. Peak power and maximal mitochondrial respiration in vastus lateralis muscle increased to the level of the control subjects and were mainly mediated via improved complex I respiration. Furthermore, when normalised to citrate synthase activity, no difference in maximal respiration was found either after the intervention or compared to controls, suggesting normal functioning mitochondrial complexes. The present study shows that high-intensity training of a restricted muscle group is highly effective in restoring skeletal muscle function in COPD patients.

Exercise Training in Pregnancy for obese women (ETIP): study protocol for a randomised controlled trial

BackgroundBoth maternal pre-pregnancy obesity and excessive gestational weight gain are increasing in prevalence and associated with a number of adverse pregnancy outcomes for both mother and child. Observational studies regarding physical activity in pregnancy have found reduced weight gain in active mothers, as well as reduced risk of adverse pregnancy outcomes. There is however a lack of high quality, randomized controlled trials on the effects of regular exercise training in pregnancy, especially those with a pre-pregnancy body mass index (BMI) at or above 30 kg/m2.MethodsWe are conducting a randomised, controlled trial in Norway with two parallel arms; one intervention group and one control group. We will enroll 150 previously sedentary, pregnant women with a pre-pregnancy BMI at or above 30 kg/m2. The intervention group will meet for organized exercise training three times per week, starting in gestation week 14 (range 12-16). The control group will get standard antenatal care. The main outcome measure will be weight gain from baseline to delivery. Among the secondary outcome measures are changes in exercise capacity, endothelial function, physical activity level, body composition, serum markers of cardiovascular risk, incontinence, lumbopelvic pain and cardiac function from baseline to gestation week 37 (range 36-38). Offspring outcome measures include anthropometric variables at birth, Apgar score, as well as serum markers of inflammation and metabolism in cord blood.DiscussionThe results of this trial will provide knowledge about effects of regular exercise training in previously sedentary, obese pregnant women. If the program proves effective in reducing gestational weight gain and adverse pregnancy outcomes, such programs should be considered as part of routine pregnancy care for obese women.Trial RegistrationClinicalTrials.gov: NCT01243554

Strain and strain rate parametric imaging. A new method for post processing to 3-/4-dimensional images from three standard apical planes. Preliminary data on feasibility, artefact and regional dyssynergy visualisation

BackgroundWe describe a method for 3-/4D reconstruction of tissue Doppler data from three standard apical planes, post processing to derived data of strain rate / strain and parametric colour imaging of the data. The data can be displayed as M-mode arrays from all six walls, Bulls eye projection and a 3D surface figure that can be scrolled and rotated. Numerical data and waveforms can be re-extracted.MethodsFeasibility was tested by Strain Rate Imaging in 6 normal subjects and 6 patients with acute myocardial infarction. Reverberation artefacts and dyssynergy was identified by colour images. End systolic strain, peak systolic and mid systolic strain rate were measured.ResultsInfarcts were visualised in all patients by colour imaging of mid systolic strain rate, end systolic strain and post systolic shortening by strain rate. Reverberation artefacts were visible in 3 of 6 normals, and 2 of 6 patients, and were identified both on bulls eye and M-mode display, but influenced quantitative measurement. Peak systolic strain rate was in controls minimum -1.11, maximum -0.89 and in patients minimum -1.66, maximum 0.02 (p = 0.04). Mid systolic strain rate and end systolic strain did not separate the groups significantly.Conclusion3-/4D reconstruction and colour display is feasible, allowing quick visual identification of infarcts and artefacts, as well as extension of area of post systolic shortening. Strain rate is better suited to colour parametric display than strain.

Exercise and Vascular Function in Child Obesity: A Meta-Analysis

CONTEXT: Conduit artery flow-mediated dilation (FMD) is a noninvasive index of preclinical atherosclerosis in humans. Exercise interventions can improve FMD in both healthy and clinical populations. OBJECTIVE: This systematic review and meta-analysis aimed to summarize the effect of exercise training on FMD in overweight and obese children and adolescents as well as investigate the role of cardiorespiratory fitness (peak oxygen consumption [Vo2peak]) on effects observed. DATA SOURCES: PubMed, Medline, Embase, and Cinahl databases were searched from the earliest available date to February 2015. STUDY SELECTION: Studies of children and/or adolescents who were overweight or obese were included. DATA EXTRACTION: Standardized data extraction forms were used for patient and intervention characteristics, control/comparator groups, and key outcomes. Procedural quality of the studies was assessed using a modified version of the Physiotherapy Evidence Base Database scale. RESULTS: A meta-analysis involving 219 participants compared the mean difference of pre- versus postintervention vascular function (FMD) and Vo2peak between an exercise training intervention and a control condition. There was a significantly greater improvement in FMD (mean difference 1.54%, P < .05) and Vo2peak (mean difference 3.64 mL/kg/min, P < .05) after exercise training compared with controls. LIMITATIONS: Given the diversity of exercise prescriptions, participant characteristics, and FMD measurement protocols, varying FMD effect size was noted between trials. CONCLUSIONS: Exercise training improves vascular function in overweight and obese children, as indicated by enhanced FMD. Further research is required to establish the optimum exercise program for maintenance of healthy vascular function in this at-risk pediatric population.

Association of myocardial deformation with mortality independent of myocardial ischemia and left ventricular hypertrophy.

OBJECTIVES The aim of this study was to investigate the relative contributions of left ventricular hypertrophy (LVH) and myocardial ischemia to the association between abnormal myocardial deformation during dobutamine stress echocardiography (DSE) and mortality. BACKGROUND Both left ventricular hypertrophy (LVH) and myocardial ischemia are known to convey a significant adverse prognostic impact. In addition, myocardial deformation is an independent predictor of outcome in patients undergoing DSE. The mechanism of this association, however, is undefined. METHODS We studied 223 consecutive individuals with normal resting LV function undergoing DSE. The LV mass was indexed to height (g/m(2.7)) (LVMI), and LVH was designated as LVMI >or=51 g/m(2.7). Myocardial ischemia was defined on the basis of new, inducible wall motion abnormalities. Customized software was used to measure global strain rate (SRs), which was averaged in 18 myocardial segments at peak stress. Individuals were followed for all-cause mortality over a mean of 5.4 +/- 1.4 years. RESULTS Left ventricular hypertrophy was identified in 83 individuals (37%), and 63 (28%) had ischemia documented at DSE. In a Cox proportional hazards model, the strongest predictor of all-cause mortality for the total population was SRs (hazard ratio: 2.16, 95% confidence interval: 1.63 to 2.87, p < 0.01). Both LVH (p < 0.01) and ischemia (p < 0.05) had a significant adverse prognostic impact. Individuals with both LVH and ischemia had the worst outcome (p = 0.02) in comparison with the rest of the population. Among LV geometric patterns, concentric LVH had the worst outcome (p < 0.01). However, SRs was the strongest predictor of mortality in both LVH and ischemia. In a model reflecting clinical practice, SRs provided a significant increment in model power over baseline and variables identified at DSE. CONCLUSIONS The SRs is a powerful, independent predictor of all-cause mortality in individuals undergoing DSE and provides incremental information over baseline clinical and echocardiographic variables. Whereas SRs is influenced by both LVH and myocardial ischemia, both independently and additively, its predictive power for mortality is independent of both.