Djalma Rabelo Ricardo

Ability to sit and rise from the floor as a predictor of all-cause mortality

Background: While cardiorespiratory fitness is strongly related to survival, there are limited data regarding musculoskeletal fitness indicators. Our aim was to evaluate the association between the ability to sit and rise from the floor and all-cause mortality. Design: Retrospective cohort. Methods: 2002 adults aged 51–80 years (68% men) performed a sitting-rising test (SRT) to and from the floor, which was scored from 0 to 5, with one point being subtracted from 5 for each support used (hand/knee). Final SRT score, varying from 0 to 10, was obtained by adding sitting and rising scores and stratified in four categories for analysis: 0–3; 3.5–5.5, 6–7.5, and 8–10. Results: Median follow up was 6.3 years and there were 159 deaths (7.9%). Lower SRT scores were associated with higher mortality (p < 0.001). A continuous trend for longer survival was reflected by multivariate-adjusted (age, sex, body mass index) hazard ratios of 5.44 (95% CI 3.1–9.5), 3.44 (95% CI 2.0–5.9), and 1.84 (95% CI 1.1–3.0) (p < 0.001) from lower to higher SRT scores. Each unit increase in SRT score conferred a 21% improvement in survival. Conclusions: Musculoskeletal fitness, as assessed by SRT, was a significant predictor of mortality in 51–80-year-old subjects. Application of a simple and safe assessment tool such as SRT, which is influenced by muscular strength and flexibility, in general health examinations could add relevant information regarding functional capabilities and outcomes in non-hospitalized adults.

Reabilitação cardíaca com ênfase no exercício: uma revisão sistemática

RESUMO O objetivo desta revisao sistematica foi determinar o efeito da reabilitacao cardiaca com enfase no exercicio (RCEE) sobre a mortalidade, fatores de risco modificaveis e qualidade de vida relacionada a saude em pacientes com doenca arterial coronariana. Foram analisados apenas ensaios clinicos controlados e randomizados (ECCR) com follow-up igual ou superior a seis meses, publicados entre 1990 e 2004. Utilizaram-se os criterios propostos pelo Clinical Practice Guideline: cardiac rehabilitation para julgar os estudos selecionados. Fizeram parte desta revisao 21 ECCR envolvendo 2.220 pacientes entre 49 e 63 anos (86% homens). A maioria dos ECCR apresentaram resultados favoraveis a RCEE para mortalidade total e cardiaca quando comparada com os cuidados usuais (controle). Esse fato tambem foi observado para os eventos de reinfarto e revascularizacao do miocardio. Os resultados da RCEE sobre os fatores de risco modificaveis e a qualidade de vida nao foram conclusivos quando comparados com a intervencao controle, apesar de alguns estudos apresentarem diferencas estatisticas a favor da RCEE. Esta revisao confirma os beneficios da RCEE na abordagem terapeutica de coronariopatas, reduzindo suas taxas de mortalidade cardiaca e por todas as causas, alem de contribuir para a diminuicao da ocorrencia de outros eventos coronarianos, tais como a revascularizacao miocardica e a taxa de reinfarto. Em relacao aos fatores de risco modificaveis e a qualidade de vida, houve uma tendencia favoravel a utilizacao da RCEE. Em adendo, parece que o exercicio fisico regular per se constitui o principal responsavel pelos resultados favoraveis da intervencao em relacao aos desfechos estudados.

Validação do Teste de Exercício de 4 Segundos em Posição Ortostática

OBJECTIVE: To test the operational viability of and validate the 4-second exercise test (4sET) protocol in the orthostatic position (ORTHO). METHODS: The ORTHO protocol, an alternative to the conventional protocol (CYCLO), was used. The ORTHO protocol consists of performing sudden exercise in the orthostatic position - accelerated stationary walking (alternate upward flexion of the thighs) - from the fourth to the eighth second of a 12-second maximum inspiratory apnea, instead of rapid cycling without load. The adimensional cardiac vagal index (CVI) was calculated using the ratio between the longest RR interval (RRB) - the one immediately before, or the first during exercise - and the shortest RR interval during exercise - usually the last (RRC) - measured on electrocardiographic tracings at a 10-ms resolution. Forty-seven individuals (40±17 years, 169±9 cm, 72±14 kg) of both sexes, healthy or unhealthy, randomly underwent 3 consecutive repetitions of the 2 protocols, the first being performed only to acquaint patients with the procedure. RESULTS: Although differences in the CVI were found in both protocols (1.48±0.04 vs 1.42±0.04; P<0.001), no physiological relevance was observed. In 5 (11%) cases, a clinically significant difference between the ORTHO and CYCLO protocols was observed for CVI. The results of RRB, RRC, and CVI in the 2 protocols were strongly correlated, being 0.84, 0.85, and 0.93, respectively (P<0.001). CONCLUSION: The 4sET performed in the orthostatic position proved to be a valid option for assessing the vagal cardiac tonus in laboratories lacking a cycloergometer, without jeopardizing clinical interpretation. In addition to simplicity and applicability, the procedure also provides low operational costs.

Body Mass Index: A Scientific Evidence-Based Inquiry

OBJECTIVE To objectively and critically assess body mass index and to propose alternatives for relating body weight and height that are evidence-based and that eliminate or reduce the limitations of the body mass index. METHODS To analyze the relations involving weight and height, we used 2 databases as follows: 1) children and adolescents from Brazil, the United States, and Switzerland; and 2) 538 university students. We performed mathematical simulations with height data ranging from 115 to 190 cm and weight data ranging from 25 to 105 kg. We selected 3 methods to analyze the relation of weight and height as follows: body mass index - weight (kg)/height (m2); reciprocal of the ponderal index - height (cm)/weight 1/3 (kg); and ectomorphy. Using the normal range from 20 to 25 kg/m2 for the body mass index in the reference height of 170 cm, we identified the corresponding ranges of 41 to 44 cm/kg 1/3 for the reciprocal of the ponderal index, and of 1.45 to 3.60 for ectomorphy. RESULTS The mathematical simulations showed a strong association among the 3 methods with an absolute concordance to a height of 170 cm, but with a tendency towards discrepancy in the normal ranges, which had already been observed for the heights of 165 and 175 cm. This made the direct convertibility between the indices unfeasible. The reciprocal of the ponderal index and ectomorphy with their cut points comprised a larger age range in children and adolescents and a wider and more central range in the university students, both for the reported (current) and desired weights. CONCLUSION The reciprocal of the ponderal index and ectomorphy are stronger and are more mathematically logical than body mass index; in addition, they may be applied with the same cut points for normal from the age of 5 years on.

Intra and interdays reliability of the 4-second exercise test

The 4-second exercise test (T4s) is pharmacologically validated to assess cardiac vagal tone, and consists in pedaling, as fast as possible, a cycle-ergometer unloaded, from the 4th to the 8th second of a 12-second maximum inspiratory apnea. An dimensionless cardiac vagal index (CVI) is calculated from the ratio of the duration of the cardiac cycles (RR intervals at the electrocardiogram) from immediately before the exercise and the shorter of the exercise. Our objective was to determine T4s intra and interdays reliability, and the actual need for two trials, as described on the original protocol. In study 1, the interday reliability of the results was assessed prospectively from 15 asymptomatic subjects (28 ± 6 years) submitted to T4s for five consecutive days, being two trials carried out at each day. To determine CVI intraday reliability, in one of the five days, randomly selected, nine T4s consecutive trials were made. In study 2, the CVI intraday reliability was calculated from 1699 subjects (47 ± 17 years) in two trials. CVI presented high intraday and interday reliability (ri = 0.92; 95%CI = 0.84 to 0.97 and ri = 0.77; 95%CI = 0.49 to 0.92, respectively) for study 1 and for study 2 (ri = 0.89; 95%CI = 0.88 to 0.90). In spite of high reliability, there were some minor differences between the means (mean ± SEM = 1.32 ± 0.01 vs 1.37 ± 0.01; p < 0.001), and in only 15% of the cases this difference was higher than 0.20, thus not representing major clinical meaning. It was also observed that in 65% of the cases, the second trial was considered the best and, with only one trial, clinical misinterpretation could occur in 27% of the data. In summary, this study evidenced high CVI reliability assessed by T4s, and confirmed the need for two consecutive trials, as prescribed in its protocol.

Comparação entre métodos de avaliação da modulação vagal cardíaca

BACKGROUND: Several methods have been used to assess cardiac vagal modulation, but there are gaps regarding the association and accuracy of these methods. OBJECTIVE: To investigate the association between three valid, reproducible and commonly methods used to assess cardiac vagal modulation and compare their accuracies. METHODS: Thirty healthy men (23 ± 4 years) and 15 men with coronary artery disease (61 ± 10 years) were evaluated in counterbalanced design by Heart Rate Variability (HRV; variables: the time domain = pNN50, SDNN and RMSSD, the frequency domain HF = ms2 and HF n.u.), Respiratory Sinus Arrhythmia (RSA) and 4-second Exercise Test (T4s). Thirty healthy men (23 ± 4 years) and 15 men with coronary artery disease (61 ± 10 years) were evaluated in counterbalanced order by Heart Rate Variability (HRV; variables: the time domain = pNN50, SDNN and RMSSD, the frequency domain HF = ms2 and HF n.u.), Respiratory Sinus Arrhythmia (RSA) and 4-second Exercise Test (T4s). RESULTS: Healthy subjects had higher vagal modulation by the three methods (p <0.05). There was a correlation in the healthy group (p <0.05) between the results of HRV (SDNN and pNN50 and RSA, but there was no correlation between the T4s and the other two methods. In the group with coronary artery disease, there was a correlation between the results of HRV (pNN50, SDNN, RMSSD, HF ms2 and HF n.u.) and RSA. In addition, there was a correlation between the RSA and T4s. Finally, the T4s and RSA methods presented more accurate effect size and better accuracy (p <0.05), when compared to the HRV. CONCLUSION: HRV and RSA generated partially redundant results in healthy subjects and in patients with coronary artery disease, while the T4s generated results that were complementary to HRV and RSA in healthy subjects. In addition, RSA and T4s methods were more accurate when discriminating cardiac vagal modulation between healthy subjects and patients with coronary artery disease, when compared to HRV.

Teste de sentar-levantar: influência do excesso de peso corporal em adultos

As acoes de sentar e levantar do solo integram o repertorio motor de criancas e adultos e demandam forca e potencia muscular, flexibilidade de membros inferiores, equilibrio e coordenacao motora e sao provavelmente influenciadas pelas dimensoes corporais. Araujo (1999) propos um procedimento simples, denominado de teste de sentar-levantar (TSL), para avaliar a destreza nessas acoes. Neste estudo verificou-se a influencia do excesso de peso corporal sobre o desempenho no TSL. Todos os 461 (288 homens/173 mulheres) adultos submetidos a avaliacao na Clinimex, entre setembro de 1998 e junho de 2000, que realizaram o TSL foram retrospectivamente analisados. No TSL, os resultados variam de 0 a 5, separadamente para o sentar e para o levantar, perdendo-se um ponto para cada apoio utilizado (ex.: mao ou joelho) e meio ponto quando ha desequilibrio perceptivel. A relacao peso/altura foi avaliada por tres metodos distintos: indice de massa corporal (IMC)-peso (kg)/altura2 (m) -, reciproco do indice ponderal (RIP) -altura (cm)/peso1/3 (kg) e ectomorfia. Existe uma relacao inversa entre o desempenho no TSL e o excesso de peso em relacao a altura nos tres metodos nos dois sexos (p 25kg/m2 ou ectomorfia < 1,45 ou RIP < 41cm/kg1/3 apresentaram mais dificuldades para sentar e levantar do que aquelas que se situam no outro lado das escalas (p < 0,05), o que nao foi tao claramente observado nos homens. Isso pode ser devido as diferencas nos componentes de endomorfia e de mesomorfia nos dois sexos, permitindo que nos homens o peso proporcionalmente maior em relacao a altura seja devido a uma maior massa muscular, enquanto nas mulheres isso ocorre, na maioria das vezes, devido ao aumento da quantidade de gordura corporal. Conclui-se que o excesso de peso corporal dificulta as acoes de sentar e levantar em adultos, especialmente nas mulheres, o que se deve provavelmente a diferencas de composicao corporal que nao sao evidenciadas pelos metodos de analise da relacao peso/altura. Em adendo, obteve-se uma validacao indireta dos pontos de corte de normalidade propostos para o RIP e para a ectomorfia em relacao ao IMC, ja que os resultados do TSL foram similares.Sitting and rising from the floor belong to child and adult motor repertoire, demanding muscle strength and power, lower limb flexibility, and motor coordination, and are probably influenced by body dimensions. Araujo (1999) suggested a simple procedure, denominated Sitting-Rising Test (SRT), to evaluate the ability in these actions. In this study, the authors verified the influence of excess body weight on SRT performance. All 461 adults (288 male /173 female) submitted to medical examination between September 1998 and June 2000 and that performed SRT were retrospectively analyzed. In SRT, scores range from 0 to 5, separately for sitting and rising. One point is subtracted for each support used in the action (e.g. hand or knee) and half point is lost for any perceived unbalance. The weight/height ratio was evaluated by three different methods: body mass index (BMI) weight (kg)/height2 (m) -, reciprocal of ponderal index (RPI) -height (cm)/weight1/3 (kg), and ectomorphy. There was an inverse relationship between SRT performance and excess of body weight as related to height in all methods for both sexes (p160; 25 kg/m2 or ectomorphy < 1,45 or RPI < 41 cm/kg1/3 had worse performances in the SRT as compared with others that were located in the other side of measurement scales (p < 0.05), which was not so clearly observed in male subjects. This may be due to endomorphy and mesomorphy component differences in the two sexes, since excess body weight in men is sometimes caused primarily by muscle mass, while in the female subjects it typically occurs due to excessive fat mass. The authors conclude that excess body weight impairs sitting and rising actions in adults, especially in women, and this is probably due to different patterns of body composition that are not identified by the three methods of weight/height ratio studied. In addition, the authors were able to indirectly validate the RPI and ectomorphy normality cut-off points in relation to BMI, since they presented similar SRT results.

Fidedignidade intra e interdias do teste de exercício de quatro segundos

The 4-second exercise test (T4s) is pharmacologically validated to assess cardiac vagal tone, and consists in pedaling, as fast as possible, a cycle-ergometer unloaded, from the 4th to the 8th second of a 12-second maximum inspiratory apnea. An dimensionless cardiac vagal index (CVI) is calculated from the ratio of the duration of the cardiac cycles (RR intervals at the electrocardiogram) from immediately before the exercise and the shorter of the exercise. Our objective was to determine T4s intra and interdays reliability, and the actual need for two trials, as described on the original protocol. In study 1, the interday reliability of the results was assessed prospectively from 15 asymptomatic subjects (28 ± 6 years) submitted to T4s for five consecutive days, being two trials carried out at each day. To determine CVI intraday reliability, in one of the five days, randomly selected, nine T4s consecutive trials were made. In study 2, the CVI intraday reliability was calculated from 1699 subjects (47 ± 17 years) in two trials. CVI presented high intraday and interday reliability (ri = 0.92; 95%CI = 0.84 to 0.97 and ri = 0.77; 95%CI = 0.49 to 0.92, respectively) for study 1 and for study 2 (ri = 0.89; 95%CI = 0.88 to 0.90). In spite of high reliability, there were some minor differences between the means (mean ± SEM = 1.32 ± 0.01 vs 1.37 ± 0.01; p < 0.001), and in only 15% of the cases this difference was higher than 0.20, thus not representing major clinical meaning. It was also observed that in 65% of the cases, the second trial was considered the best and, with only one trial, clinical misinterpretation could occur in 27% of the data. In summary, this study evidenced high CVI reliability assessed by T4s, and confirmed the need for two consecutive trials, as prescribed in its protocol.

Cardiorespiratory optimal point: a submaximal variable of the cardiopulmonary exercise testing

Background: At the maximal Cardiopulmonary Exercise Testing (CPET), several ventilatory variables are analyzed, including the ventilatory equivalent for oxygen (VE/VO2). The minimum VE/VO2 value reflects the best integration between the respiratory and cardiovascular systems and may be called “Cardiorespiratory Optimal Point (COP)”. Objective: To determine the behavior of the COP according to gender and age in healthy adults and verify its association with other CPET variables. Methods: Of 2,237 individuals, 624 were selected (62% men and 48 ± 12 years), non-athletes, healthy, who were submitted to maximal CPET. COP or minimum VE/VO2 was obtained from the analysis of ventilation and oxygen consumption in every minute of CPET. We investigated the association between age and COP for both genders, as well as associations with: VO 2 max, VO 2 at anaerobic threshold (VO 2 AT), oxygen uptake efficiency slope (OUES) and with maximum VE. We also compared the intensity of exertion (MET) at the COP, AT and VO 2 max. Results: COP increases with age, being 23.2 ± 4.48 and 25.0 ± 5.14, respectively, in men and women = (p < 0.001). There are moderate and inverse associations with VO 2 max (r = -0.47; p < 0.001), with VO 2 AT (r = -0.42; p < 0.001) and with OUES (r = -0.34; p < 0.001). COP occurred, on average, at 44% do VO 2 max and before AT (67% of VO 2 max) (p < 0.001). Conclusion: COP, a submaximal variable, increases with age and is slightly higher in women. Being modestly associated with other ventilation measures, there seems to be an independent contribution to the interpretation of the cardiorespiratory response to CPET. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Heart rate variability across the menstrual cycle in young women taking oral contraceptives

Previous studies have shown that resting heart rate variability (HRV) is modified by different phases of the menstrual cycle in nonusers of oral contraceptive pills (OCP); however, the effect of OCP on autonomic control of the heart remains unclear. The purpose of this study was to investigate HRV during the low hormone (LH-not taking OCP) and during the high hormone (HH-active OCP use) phases of the menstrual cycle in young women. Seventeen healthy women (19-31 years) taking OCP for at least 6 consecutive months were enrolled in this study. Plasma estradiol and progesterone were verified at each visit. HRV was assessed by using one-lead electrocardiography in time and frequency domains, in which participants rested in the supine position for a 20-min period with a breathing rate of 15 cycles/min. In addition, resting heart rate, and systolic and diastolic blood pressure were obtained. Both plasma estradiol (LH: 19.8 ± 4.2 pg/mL vs. HH: 12.4 ± 1.5 pg/mL; p > .05) and progesterone (LH: 0.247 ± 0.58 ng/mL vs. HH: 0.371 ± 0.08 ng/mL; p > .05) (mean ± SE) levels were similar in both phases. No significant difference was obtained for any component of HRV, heart rate, or blood pressure between the LH and HH phases (p > .05). These results provide preliminary evidence that use of OCP does not affect HRV during the menstrual cycle in healthy women.