Günter Schlierf

Physical training in patients with stable chronic heart failure: Effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles

OBJECTIVES The present study was designed to evaluate the effect of an ambulatory training program on ultrastructural morphology and the oxidative capacity of skeletal muscle and its relation to central and peripheral hemodynamic variables in patients with chronic heart failure. BACKGROUND Clinical evidence supports the hypothesis that exercise intolerance in patients with chronic heart failure is not only a consequence of low cardiac output, but is also a result of alterations in oxidative metabolism of skeletal muscle. METHODS Twenty-two patients were prospectively randomized either to a training group (mean [+/-SD] ejection fraction 26 +/- 9%, n = 12) participating in an ambulatory training program or to a physically inactive control group (ejection fraction 27 +/- 10%, n = 10). At baseline and after 6 months, patients underwent symptom-limited bicycle exercise testing, and central and peripheral hemodynamic variables were measured. Percutaneous needle biopsy samples of the vastus lateralis muscle were obtained at baseline and after 6 months. The ultrastructure of skeletal muscle was analyzed by ultrastructural morphometry. RESULTS After 6 months, patients in the training group achieved an increase in oxygen uptake at the ventilatory threshold of 23% (from 0.86 +/- 0.2 to 1.07 +/- 0.2 liters/min, p < 0.01 vs. control group) and at peak exercise of 31% (from 1.49 +/- 0.4 to 1.95 +/- 0.4 liters/min, p < 0.01 vs. control group). There was no significant change in oxygen uptake at the ventilatory threshold and at peak exercise in the control group. The total volume density of mitochondria and volume density of cytochrome c oxidase-positive mitochondria increased significantly by 19% (from 4.7 +/- 1.5 to 5.6 +/- 1.5 vol%, p < 0.05 vs. control group) and by 41% (from 2.2 +/- 1.0 to 3.1 +/- 1.0 vol%, p < 0.05 vs. control group) after 6 months of regular physical exercise. Cardiac output at rest and at submaximal exercise remained unchanged but increased during maximal symptom-limited exercise from 11.9 +/- 4.0 to 14.1 +/- 3.3 liters/min in the training group (p < 0.05 vs. baseline; p = NS vs. control group). Peak leg oxygen consumption increased significantly by 45% (from 510 +/- 172 to 740 +/- 254 ml/min, p < 0.01 vs. control group). Changes in cytochrome c oxidase-positive mitochondria were significantly related to changes in oxygen uptake at the ventilatory threshold (r = 0.82, p < 0.0001) and at peak exercise (r = 0.87, p < 0.0001). CONCLUSIONS Regular physical training increases maximal exercise tolerance and delays anaerobic metabolism during submaximal exercise in patients with stable chronic heart failure. Improved functional capacity is closely linked to an exercise-induced increase in the oxidative capacity of skeletal muscle.

Various intensities of leisure time physical activity in patients with coronary artery disease: Effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions☆

Abstract Objectives . This study was designed to define the effect of different levels of leisure time physical activity on cardiorespiratory fitness and progression of coronary atherosclerotic lesions in unselected patients with coronary artery disease. Background . It has been shown in various studies that regression of coronary atherosclerotic lesions can be achieved by means of lipid-lowering drugs, reduction of fat consumption and physical exercise. Methods . Patients were prospectively randomized either to an intervention group (n = 29) participating in regular physical exercise or to a control group (n = 33) receiving usual care. Energy expenditure in leisure time physical activity was estimated from standardized questionnaires and from participation in group exercise sessions. After 12 months of particiption, repeat coronary angiography was performed; coronary lesions were measured by digital image processing. Results . After 1 year, patients in the intervention group achieved an increase in oxygen uptake at a ventilatory threshold of 7% (p Conclusions . Measurable improvement in cardiorespiratory fitness requires ~1,400 kcal/week of leisure time physical activity; higher work loads are necessary to halt progression of coronary atherosclerotic lesions (1,533 ± 122 kcal/week), whereas regression of coronary lesions is observed only in patients expending an average of 2,200 kcal/week in leisure time physical activity, amounting to ~5 to 6 h/week of regular physical exercise.

Exercise Training for Rehabilitation and Secondary Prevention of Falls in Geriatric Patients with a History of Injurious Falls

OBJECTIVE: To determine the safety and efficacy of an exercise protocol designed to improve strength, mobility, and balance and to reduce subsequent falls in geriatric patients with a history of injurious falls.

Malnutrition in Geriatric Patients: Diagnostic and Prognostic Significance of Nutritional Parameters

Nutritional status was assessed in 300 geriatric patients aged 75 years or more using clinical, anthropometric, biochemical and immunologic methods. Relations between different assessment methods and their prognostic significance with regard to 18-month mortality were examined. For biochemical variables 10% (prealbumin, vitamin B6) to 37% (vitamins A and C) were below conventional limits. In 44% of the patients lymphocytes were diminished. 44% were anergic. Judgement of nutritional status by clinical impression resulted in 22% being deemed undernourished. Clinical diagnosis of undernutrition was associated with low anthropometric measurements (p less than 0.05 for all parameters) and a high prevalence of low biochemical values (p less than 0.05 for albumin, prealbumin, transferrin, vitamin A, vitamin B1). The mean values of all anthropometric variables, plasma proteins, vitamins A and C were significantly lower in patients who died within the following 18 months compared to survivors. The greatest prognostic significance was related to the clinical diagnosis of malnutrition. We conclude that clinical assessment is useful for the evaluation of nutritional status in geriatric patients and the best of numerous nutritional parameters to estimate risk of long-term mortality.

Silent myocardial ischemia as a potential link between lack of premonitoring symptoms and increased risk of cardiac arrest during physical stress

The risk of cardiac arrest is increased during strenuous physical exercise in patients with stable coronary artery disease (CAD). Because premonitoring symptoms are rarely observed, silent myocardial ischemia may represent the pathophysiological basis for the induction of malignant ventricular arrhythmias. Holter monitoring was, therefore, performed in 40 consecutive patients entering a randomized intervention trial on progression of CAD. In 20 of 21 participants (95%) in the intervention program greater than or equal to 1 episode of silent myocardial ischemia was observed during the initial training session. The mean duration of silent myocardial ischemia per patient was 25 +/- 13 min/hr of training session. During normal daily activity only 5 patients (24%) experienced greater than or equal to 1 episode of silent myocardial ischemia (p less than 0.001) yielding a mean duration of 0.6 +/- 1.3 minutes of silent myocardial ischemia/hr of ordinary activity per patient (p less than 0.001 vs training session). During a control period of 24 hours without exercise training the incidence (33%) and mean duration of silent myocardial ischemia (0.8 +/- 2.1 min/hr/patient) were similar to those during normal daily activity on the day of the training session. During the training session the occurrence of frequent or repetitive ventricular arrhythmias was related to 10 silent myocardial ischemia episodes detected in 5 patients. During normal daily activity in 1 patient only was the onset of malignant ventricular arrhythmias associated with silent myocardial ischemia (p less than 0.05). Conditions and results of the Holter studies in the control group patients were comparable to those of the patients in the intervention group on the day without physical exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of drug compliance by continuous electronic monitoring: a pilot study in elderly patients discharged from hospital.

A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring.

Blood pressure and adipose tissue linoleic acid.

SummaryIn a natural, “free-living population” of 650 men, surveyed with the purpose of health assessment within an epidemiological design, a strongly significant negative correlation between the relative linoleic acid composition of adipose tissue and blood pressures was found (P<0.001). This correlation remained significant when age and weight were statistically controlled for. Thus, dietary, lipid-lowering linoleic acid seems to effect blood pressures as well in a favorable way.

Five Years of Physical Exercise and Low Fat Diet: Effects on Progression of Coronary Artery Disease

PURPOSE This study was designed to assess the long-term effects of low-fat diet and intensive physical exercise. METHODS Long-term efficacy of exercise and diet was assessed in 18 nonselected, fully employed patients with symptomatic coronary artery disease. Results were compared to 18 patients on usual care. RESULTS In the intervention group at 1 year, serum lipoproteins were brought to ideal levels, exercise-induced myocardial ischemia was significantly reduced, and progression in coronary atherosclerosis was retarded. After more than 5 years, patients in the intervention group showed a significant reduction in lipoprotein levels (total cholesterol, 248 [179-299] vs 214 [173-272] mg/dL, P < .01; low density lipoprotein, 146 [83-216], vs 152 [121-197] mg/dL, P < .005 vs control; triglycerides; 151 [80-303] mg/dl, vs 98 [46-182] mg/dL; P < .005) and body mass index (26 +/- 2.9 vs 25.4 +/- 3.3 kg/m2; P < .05). Exercise induced myocardial ischemia, measured by 201thallium scintigraphy, decreased by 29% (41 degrees +/- 36 degrees vs 29 degrees +/- 29 degrees, P = NS) and coronary atherosclerosis, assessed by angiography and digital image processing, progressed at a slower pace in light of a 21% increase in physical work capacity (169 +/- 40 vs 205 +/- 50, P < .01) and a 28% increase in maximal rate pressure product (25 +/- 6 vs 32 +/- 4, P < .004). In contrast, patients in the control group showed only poorly controlled coronary risk factors (total cholesterol, 243 [179-306] vs 26 [178-304] mg/dL, P = NS; low density lipoprotein, 151 [79-229] vs 196 [107-238] mg/dL, P < .0005 vs intervention; body mass index 25.7 +/- 2.5 vs 27.5 +/- 3.5 kg/m2, P < .01), whereas their physical work capacity tended to deteriorate (165 +/- 45 vs 142 +/- 62 Watts, P = not significant). CONCLUSIONS These data demonstrate that current usual care is insufficient in controlling risk factors of coronary artery disease. However, intensive physical exercise and low-fat diet remain an effective form of treatment after more than 5 years.

Myocardial ischemia during physical exercise in patients with stable coronary artery disease: predictability and prevention.

AIMS We assessed whether exercise-induced myocardial ischemia during intensive group exercise sessions can be predicted in patients with coronary artery disease and stable angina pectoris. METHODS AND RESULTS Twenty-three patients underwent cardiac catheterization, 201-thallium scintigraphy, and exercise testing prior to participation in group training sessions. Heart rates and myocardial ischemia were documented by Holter monitoring. The individual training heart rate was calculated as a percentage of the maximal heart rate achieved during symptom-limited exercise testing. Myocardial ischemia occurred significantly more often during group exercise sessions (15 of 23 patients) than during treadmill testing (4 of 23 patients, P<0.001). Maximal heart rate (145+/-23 vs. 134+/-21 beats/min, P<0.004) and maximal plasma lactate concentrations (6.0+/-2.9 vs. 4.3+/-2.0 mmol/l, P<0.05) were significantly higher than during symptom-limited exercise testing. Ischemic episodes occurred significantly more often during jogging than during competitive ball games or interval training. Myocardial ischemia occurred in patients who exceeded their individual target training heart rates (43 of 44 episodes; P<0.001). Duration of ischemic episodes did not correlate with any marker obtained at the beginning of the study. CONCLUSION These data demonstrate that routine diagnostic procedures do not sufficiently identify patients at risk for exercise-induced myocardial ischemia. Ischemic events are only effectively prevented by choosing adequate types of exercise and, above all, by the strict adherence to individual target heart rates.

Influence of diet on high-density lipoproteins

Evidence of a relation between diet and high-density lipoprotein (HDL) levels in humans comes from numerous cross-sectional and experimental studies. Evaluation of data from cross-sectional nutrition and health surveys sometimes yields different results for men and women but usually demonstrates positive correlations of HDL cholesterol levels with total energy intake, alcohol consumption, dietary cholesterol and total and animal fat, and negative correlations of HDL with dietary carbohydrates (simple sugars) and, in some instances, plant fats. Short-term dietary manipulation produced confirmatory evidence of a causal relation between diet and HDL with regard to several of these factors; however, there are few long-term data. The underlying mechanisms as well as the relation of HDL manipulation to cardiovascular health are still to be defined, particularly because the functions and fates of the HDL molecule may vary according to its composition and turnover, which are not reflected by the HDL cholesterol concentration. Furthermore, some relations between diet and HDL may only be the result of other metabolic consequences of dietary change, for instance, triglyceride metabolism and other lipoproteins. Although there is consistent evidence that a high HDL cholesterol level is indicative of a low risk of coronary heart disease in industrialized populations, evidence is inconclusive that manipulation of HDL leads to an alteration of risk.