Frédéric Costes

Relation between heart rate variability and training load in middle-distance runners

PURPOSE Monitoring physical performance is of major importance in competitive sports. Indices commonly used, like resting heart rate, VO2max, and hormones, cannot be easily used because of difficulties in routine use, of variations too small to be reliable, or of technical challenges in acquiring the data. METHODS We chose to assess autonomic nervous system activity using heart rate variability in seven middle-distance runners, aged 24.6 +/- 4.8 yr, during their usual training cycle composed of 3 wk of heavy training periods, followed by a relative resting week. The electrocardiogram was recorded overnight twice a week and temporal and frequency indices of heart rate variability, using Fourier and Wavelet transforms, were calculated. Daily training loads and fatigue sensations were estimated with a questionnaire. Similar recordings were performed in a sedentary control group. RESULTS The results demonstrated a significant and progressive decrease in parasympathetic indices of up to -41% (P < 0.05) during the 3 wk of heavy training, followed by a significant increase during the relative resting week of up to +46% (P < 0.05). The indices of sympathetic activity followed the opposite trend, first up to +31% and then -24% (P < 0.05), respectively. The percentage increasing mean nocturnal heart rate variation remained below 12% (P < 0.05). There was no significant variation in the control group. CONCLUSION This study confirmed that heavy training shifted the cardiac autonomic balance toward a predominance of the sympathetic over the parasympathetic drive. When recorded during the night, heart rate variability appeared to be a better tool than resting heart rate to evaluate cumulated physical fatigue, as it magnified the induced changes in autonomic nervous system activity. These results could be of interest for optimizing individual training profiles.

Screening of Obstructive Sleep Apnea Syndrome by Heart Rate Variability Analysis

BACKGROUND Enhanced nocturnal heart rate variability (HRV) has been evoked in sleep-related breathing disorders. However, its capacity to detect obstructive sleep apnea syndrome (OSAS) has not been systematically determined. Thus, we evaluated the discriminant power of HRV parameters in a first group of patients (G1) and validated their discriminant capacity in a second group (G2). METHODS AND RESULTS In G1, 39 of 91 patients (42.8%) were identified as diseased by polysomnography, as were 24 of 52 patients (46%) in G2. Time-domain HRV variables (SD of NN intervals [SDNN], mean of the standard deviations of all NN intervals for all consecutive 5-minute segments of the recording [SDNN index], square root of the mean of the sum of the squares of differences between adjacent normal RR intervals [r-MSSD], and SD of the averages of NN intervals in all 5-minute segments of the recording [SDANN]) were calculated for daytime and nighttime periods, as well as the differences between daytime and nighttime values (Delta[D/N]). Correlations between HRV variables and OSAS status were analyzed in G1 by use of receiver-operating characteristic (ROC) curves and logistic regression analysis. By ROC curve analysis, 7 variables were significantly associated with OSAS. After adjustment for other variables through multiple logistic regression analysis, Delta[D/N]SDNN index and Delta[D/N] r-MSSD remained significant independent predictors of OSAS, with ORs of 8.22 (95% CI, 3.16 to 21.4) and 2.86 (95% CI, 1.21 to 6.75), respectively. The classification and regression tree methodology demonstrated a sensitivity reaching 89.7% (95% CI, 73.7 to 97.7) with Delta[D/N] SDNN index and a specificity of 98.1% (95% CI, 86.4 to 100) with Delta[D/N] SDNN using appropriate thresholds. These thresholds, applied to G2, yielded a sensitivity of 83% using Delta[D/N] SDNN index and a specificity of 96.5% using Delta[D/N] SDNN. CONCLUSIONS Time-domain HRV analysis may represent an accurate and inexpensive screening tool in clinically suspected OSAS patients and may help focus resources on those at the highest risk.

Relationship Among the Severity of Sleep Apnea Syndrome, Cardiac Arrhythmias, and Autonomic Imbalance

ROCHE, F., et al.: Relationship Among the Severity of Sleep Apnea Syndrome, Cardiac Arrhythmias, and Autonomic Imbalance. The relationship between obstructive sleep apnea syndrome (OSAS), cardiac arrhythmias, and conduction disturbances in adults remains controversial. Early studies showed a higher prevalence than more recent and designed epidemiological studies. To clarify the actual prevalence of cardiac arrhythmias and conduction disturbances in patients referred for assessment of OSAS, a prospective cohort study was conducted: 147 consecutive patients (103 men; mean age of 54.5 ± 10.7 years) underwent time‐synchronized polysomnography and ECG Holter monitoring. OSAS was diagnosed in 66 (44.9%) of them based on an apnea hypopnea index (AHI) ≥10. Prevalence of heart failure, of prior myocardial infarction, of hypertension, and of ventricular arrhythmias were similar in patients with or without OSAS. Nocturnal paroxysmal asystole was significantly more prevalent in OSAS patients (10.6 vs 1.2%; P < 0.02) and the number of episodes of bradycardia and pauses increased with the severity of the syndrome. Almost all bradycardic events occurred in patients with severe OSAS (AHI > 30), prolonged periods of arterial oxyhemoglobin desaturation, and low diurnal awake PaO2. Moreover, using heart rate variability analysis, nocturnal sinusal dysfunction contrasted with a blunted diurnal parasympathetic modulation of the sinus node. Frequent nocturnal nonsustained supraventricular tachycardias were predominantly found in patients with severe sleep related breathing disorders; however, an increased risk of ventricular arrhythmias was not found. Under continuous positive airway pressure treatment, the 1‐year follow‐up of OSAS patients with nocturnal pauses did not reveal any arrhythmic event justifying a specific intervention. (PACE 2003; 26:669–677)

Predicting sleep apnoea syndrome from heart period: a time-frequency wavelet analysis

Heart rate fluctuations are a typical finding during obstructive sleep apnoea, characterised by bradycardia during the apnoeic phase and tachycardia at the restoration of ventilation. In this study, a time-frequency domain analysis of the nocturnal heart rate variability (HRV) was evaluated as the single diagnostic marker for obstructive sleep apnoea syndrome (OSAS). The predictive accuracy of time-frequency HRV variables (wavelet (Wv) decomposition parameters from level 2 (Wv2) to level 256 (Wv256)) obtained from nocturnal electrocardiogram Holter monitoring were analysed in 147 consecutive patients aged 53.8±11.2 yrs referred for possible OSAS. OSAS was diagnosed in 66 patients (44.9%) according to an apnoea/hypopnoea index ≥10. Using receiver-operating characteristic curves analysis, the most powerful predictor variable was Wv32 (W 0.758, p<0.0001), followed by Wv16 (W 0.729, p<0.0001) and Wv64 (W 0.700, p<0.0001). Classification and Regression Trees methodology generated a decision tree for OSAS prediction including all levels of Wv coefficients, from Wv2 to Wv256 with a sensitivity reaching 92.4% and a specificity of 90.1% (percentage of agreement 91.2%) with this nonparametric analysis. Time-frequency parameters calculated using wavelet transform and extracted from the nocturnal heart period analysis appeared as powerful tools for obstructive sleep apnoea syndrome diagnosis.

Frequent and prolonged asymptomatic episodes of paroxysmal atrial fibrillation revealed by automatic long-term event recorders in patients with a negative 24-hour holter

ROCHE, F., et al.: Frequent and Prolonged Asymptomatic Episodes of Paroxysmal Atrial Fibrillation Revealed by Automatic Long‐Term Event Recorders in Patients with a Negative 24‐Hour Holter. The presence, frequency, and duration of episodes of paroxysmal atrial fibrillation (PAF) is difficult to establish. This is caused by the limited duration of standard Holter recordings and to the unsatisfactory yield of patient‐triggered event recorders, because of asymptomatic events and of an inconsistent use of the patient dependent triggering function. A prospective cohort of 65 consecutive patients with recurrent palpitations and a negative 24‐hour ECG Holter was investigated by means of a cardiac event recorder bearing continuous automatic arrhythmia analysis and storage. Over a mean duration of 77 ± 36 hours, episodes of PAF were diagnosed in 20 (31%) patients, who had a total of 37 episodes; mean duration of PAF episodes was 7 hours 50 minutes ± 8/hours 45 minutes (minimum 45 minutes, maximum 28 hours). Eleven (55%) of these 20 patients were asymptomatic and would have remained undiagnosed without the automatic mode of the event recorder. Asymptomatic PAF episodes were longer than symptomatic ones (10 hours 30 minutes ± 6 hours 30 minutes vs 4 hours 50 minutes ± 4 hours, P < 0.05). In addition, episodes of sustained paroxysmal supraventricular tachycardia (PSVT) were diagnosed in 39 (57%) patients, of whom 34 (87%) were symptomatic. In this prospective cohort, a second standard 24‐hour monitoring would have missed 44% of the patients with PAF or PSVT and a classical patient‐triggered event recorder 13%. In patients still complaining of palpitations after one negative 24‐hour Holter, numerous, prolonged, and often asymptomatic episodes of PAF can be revealed by long‐term automatic event recorders. These devices should help clarify the clinical consequences of such episodes.

Downregulation of Akt/mammalian target of rapamycin pathway in skeletal muscle is associated with increased REDD1 expression in response to chronic hypoxia

Although it is well established that chronic hypoxia leads to an inexorable loss of skeletal muscle mass in healthy subjects, the underlying molecular mechanisms involved in this process are currently unknown. Skeletal muscle atrophy is also an important systemic consequence of chronic obstructive pulmonary disease (COPD), but the role of hypoxemia in this regulation is still debated. Our general aim was to determine the molecular mechanisms involved in the regulation of skeletal muscle mass after exposure to chronic hypoxia and to test the biological relevance of our findings into the clinical context of COPD. Expression of positive and negative regulators of skeletal muscle mass were explored 1) in the soleus muscle of rats exposed to severe hypoxia (6,300 m) for 3 wk and 2) in vastus lateralis muscle of nonhypoxemic and hypoxemic COPD patients. In rodents, we observed a marked inhibition of the mammalian target of rapamycin (mTOR) pathway together with a strong increase in regulated in development and DNA damage response 1 (REDD1) expression and in its association with 14-3-3, a mechanism known to downregulate the mTOR pathway. Importantly, REDD1 overexpression in vivo was sufficient to cause skeletal muscle fiber atrophy in normoxia. Finally, the comparative analysis of skeletal muscle in hypoxemic vs. nonhypoxemic COPD patients confirms that hypoxia causes an inhibition of the mTOR signaling pathway. We thus identify REDD1 as a negative regulator of skeletal muscle mass during chronic hypoxia. Translation of this fundamental knowledge into the clinical investigation of COPD shows the interest to develop therapeutic strategies aimed at inhibiting REDD1.

Multimodal nutritional rehabilitation improves clinical outcomes of malnourished patients with chronic respiratory failure: a randomised controlled trial

Background In chronic respiratory failure (CRF), body composition strongly predicts survival. Methods A prospective randomised controlled trial was undertaken in malnourished patients with CRF to evaluate the effects of 3 months of home rehabilitation on body functioning and composition. 122 patients with CRF on long-term oxygen therapy and/or non-invasive ventilation (mean (SD) age 66 (10) years, 91 men) were included from eight respiratory units; 62 were assigned to home health education (controls) and 60 to multimodal nutritional rehabilitation combining health education, oral nutritional supplements, exercise and oral testosterone for 90 days. The primary endpoint was exercise tolerance assessed by the 6-min walking test (6MWT). Secondary endpoints were body composition, quality of life after 3 months and 15-month survival. Results Mean (SD) baseline arterial oxygen tension was 7.7 (1.2) kPa, forced expiratory volume in 1 s 31 (13)% predicted, body mass index (BMI) 21.5 (3.9) kg/m2 and fat-free mass index (FFMI) 15.5 (2.4) kg/m2. The intervention had no significant effect on 6MWT. Improvements (treatment effect) were seen in BMI (+0.56 kg/m2, 95% CI 0.18 to 0.95, p=0.004), FFMI (+0.60 kg/m2, 95% CI 0.15 to 1.05, p=0.01), haemoglobin (+9.1 g/l, 95% CI 2.5 to 15.7, p=0.008), peak workload (+7.2 W, 95% CI 3.7 to 10.6, p<0.001), quadriceps isometric force (+28.3 N, 95% CI 7.2 to 49.3, p=0.009), endurance time (+5.9 min, 95% CI 3.1 to 8.8, p<0.001) and, in women, Chronic Respiratory Questionnaire (+16.5 units, 95% CI 5.3 to 27.7, p=0.006). In a multivariate Cox analysis, only rehabilitation in a per-protocol analysis predicted survival (HR 0.27, 95% CI 0.07 to 0.95, p=0.042). Conclusions Multimodal nutritional rehabilitation aimed at improving body composition increased exercise tolerance, quality of life in women and survival in compliant patients, supporting its incorporation in the treatment of malnourished patients with CRF. Clinical Trial number NCT00230984.

Interval training in elderly men increases both heart rate variability and baroreflex activity.

AimsAutonomic nervous system activity decreases continuously with age and appears to be a powerful predictor of disease and death. Attempts are thus made to reactivate autonomic drive with the intent of improving health.MethodsWe assessed maximal oxygen consumption (VO2max), auto- nomic nervous system activity by heart rate variability (HRV) analysis and spontaneous cardiac baroreflex activity (SBR) in eleven elderly men (73.5±4.2 years) before and after a 14-week program of intensive cycloergometer interval training. The standard HRV indices were calculated using time domain (mean RR, PNN50, RMSSD, SDNN, SDANN and SDNNIDX), and Fourier transform (total power, ULF,VLF, LF, LFnu, HF, HFnu and LF/HF) analyses of 24-hour, daytime and nighttime Holter recordings. The SBR was calculated from 15-minute recordings of spontaneous blood pressure and RR interval variations using the sequence (slope, slSBR) and cross-spectral (αSBRHF and αSBRLF) methods.ResultsAfter the training period,VO2max increased by 18.6 % (26.8±4.4 to 31.8±5.2 ml · kg–1 · min–1, p<0.01). The nocturnal parasympathetic indices of HRV increased (PNN50: 3.05±2.21 to 5.00±2.87%, RMSSD: 29.1±7.6 to 38.8±10.9 ms, HF: 117±54 to 194±116 ms2/Hz, all p<0.05) as did the SBR indices (slSBR: 7.0±1.8 to 9.8±2.1 ms·mmHg–1, p<0.01; αSBRHF: 6.9±2.2 to 10.5±3.7 ms ·mmHg–1, p<0.05; αSBRLF: 5.3±2.3 to 6.9±3.1 ms ·mmHg–1, p=0.22).ConclusionIntensive endurance training in elderly men enhanced parasympathetic parameters of HRV and, interestingly, of SBR. Physiological mechanisms and long-term clinical effects on health status should be further investigated.

Noninvasive ventilation during exercise training improves exercise tolerance in patients with chronic obstructive pulmonary disease.

PURPOSE In patients with chronic obstructive pulmonary disease, pulmonary rehabilitation has been demonstrated to increase exercise capacity and reduce dyspnea. In the most disabled patients, the intensity of exercise during the training sessions is limited by ventilatory pump capacity. This study therefore evaluated the beneficial effect of noninvasive ventilation (NIV) support during the rehabilitation sessions on exercise tolerance. METHODS This study included 14 patients with stabilized chronic obstructive pulmonary disease, ages 63 +/- 7 years, with a forced expiratory volume in 1 second (FEV(1)) 31.5% +/- 9.2% of predicted value. All 14 patients participated in an outpatient pulmonary rehabilitation program. Seven of the patients trained with NIV during the exercise sessions (NIV group), whereas the remaining seven patients breathed spontaneously (control group). Exercise tolerance was evaluated during an incremental exercise test and during constant work rate exercise at 75% of peak oxygen consumption (VO(2)) before and after the training program. RESULTS The application of noninvasive ventilation increased exercise tolerance, reduced dyspnea, and prevented exercise-induced oxygen desaturation both before and after training. The pressure support was well tolerated by all the patients during the course of the training program. In the NIV group, training induced a greater improvement in peak VO(2) (18% vs 2%; P <.05) and a reduced ventilatory requirement for maximal exercise, as compared with the control group. The constant work rate exercise duration increased similarly in both groups (116% vs 81%, nonsignificant difference), and posttraining blood lactate was decreased at isotime (P <.05 in both groups), but not at the end of the exercise. CONCLUSION In this pilot study, exercise training with noninvasive ventilation support was well tolerated and yielded further improvement in the increased exercise tolerance brought about by pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. This improved exercise tolerance is partly explained by a better ventilatory adaptation during exercise.

Influence of training on NIRS muscle oxygen saturation during submaximal exercise

PURPOSE Endurance training improves the oxygen delivery and muscle metabolism. Muscle oxygen saturation measured by near infrared spectroscopy (IR-SO(2)), which is primarily influenced by the local delivery/demand balance, should thus be modified by training. We examined this effect by determining the influence of change in blood lactate and muscle capillary density with training on IR-SO(2) in seven healthy young subjects. METHODS Two submaximal exercise tests at 50% (Ex1) and 80% pretraining VO(2max) (Ex2) were performed before and after a 4-wk endurance-training program. RESULTS VO(2max) increased only slightly (+8%, NS) with training but the training effect was confirmed by the increased capillary density (+31%, P < 0.01) and citrate synthase activity (50%, P < 0.01), determined from muscle biopsy samples. Before training, blood lactate increased during the first 5 min of Ex1 and then remained constant (3.8 +/- 0.5 mmol x L(-1), P < 0.01), whereas it increased continuously during Ex2 (8.9 +/- 1.8 mmol x L(-1), P < 0.001). After training, lactate decreased significantly and remained constant during the two bouts of exercise (2.0 +/- 0.4 and 3.7 +/- 1.2 at the end of Ex1 and Ex2, respectively, both P < 0.001). During Ex1, IR-SO(2) dropped initially at the onset of exercise and recovered progressively without reaching the resting level. Training did not change this pattern of IR-SO(2). During Ex2, IR-SO(2) decreased progressively during the 15 min of exercise (P < 0.05); IR-SO2 kept constant after the initial drop after training. We found a significant relationship (r = 0.42, P = 0.03) between blood lactate and IR-SO(2) at the end of both bouts of exercise; this relationship was closer before training. By contrast, IR-SO(2) or IR-BV was not related to the capillary density. CONCLUSION The training-induced adaptation in blood lactate influences IR-SO(2) during mild- to hard-intensity exercise. Thus, NIRS could be used as a noninvasive monitoring of training-induced adaptations.