J. Goodman

The Acute Risks of Exercise in Apparently Healthy Adults and Relevance for Prevention of Cardiovascular Events.

BACKGROUNDnIncreased physical activity (PA) is associated with improved quality of life and reductions in cardiovascular (CV) morbidity and all-cause mortality in the general population in a dose-response manner. However, PA acutely increases the risk of adverse CV event or sudden cardiac death (SCD) above levels expected at rest. We review the likelihood of adverse CV events related to exercise in apparently healthy adults and strategies for prevention, and contextualize our understanding of the long-term risk reduction conferred from PA.nnnMETHODSnA systematic review of the literature was performed using electronic databases; additional hand-picked relevant articles from reference lists and additional sources were included after the search.nnnRESULTSnThe incidence of adverse CV events in adults is extremely low during and immediately after PA of varying types and intensities and is significantly lower in those with long-standing PA experience. The risk of SCD and nonfatal events during and immediately after PA remains extremely low (well below 0.01 per 10,000 participant hours); increasing age and PA intensity are associated with greater risk. In most cases of exercise-related SCD, occult CV disease is present and SCD is typically the first clinical event.nnnCONCLUSIONSnExercise acutely increases the risk of adverse CV events, with greater risk associated with vigorous intensity. The risks of an adverse CV event during and immediately after exercise are outweighed by the health benefits of vigorous exercise performed regularly. A key challenge remains the identification of occult structural heart disease and inheritable conditions that increase the chances of lethal arrhythmias during exercise.

Synchronized personalized music audio-playlists to improve adherence to physical activity among patients participating in a structured exercise program: a proof-of-principle feasibility study

BackgroundPreference-based tempo-pace synchronized music has been shown to reduce perceived physical activity exertion and improve exercise performance. The extent to which such strategies can improve adherence to physical activity remains unknown. The objective of the study is to explore the feasibility and efficacy of tempo-pace synchronized preference-based music audio-playlists on adherence to physical activity among cardiovascular disease patients participating in a cardiac rehabilitation.MethodsThirty-four cardiac rehabilitation patients were randomly allocated to one of two strategies: (1) no music usual-care control and (2) tempo-pace synchronized audio-devices with personalized music playlistsu2009+u2009usual-care. All songs uploaded onto audio-playlist devices took into account patient personal music genre and artist preferences. However, actual song selection was restricted to music whose tempos approximated patients’ prescribed exercise walking/running pace (steps per minute) to achieve tempo-pace synchrony. Patients allocated to audio-music playlists underwent further randomization in which half of the patients received songs that were sonically enhanced with rhythmic auditory stimulation (RAS) to accentuate tempo-pace synchrony, whereas the other half did not. RAS was achieved through blinded rhythmic sonic-enhancements undertaken manually to songs within individuals’ music playlists. The primary outcome consisted of the weekly volume of physical activity undertaken over 3 months as determined by tri-axial accelerometers. Statistical methods employed an intention to treat and repeated-measures design.ResultsPatients randomized to personalized audio-playlists with tempo-pace synchrony achieved higher weekly volumes of physical activity than did their non-music usual-care comparators (475.6xa0min vs. 370.2xa0min, Pu2009<u20090.001). Improvements in weekly physical activity volumes among audio-playlist recipients were driven by those randomized to the RAS group which attained weekly exercise volumes that were nearly twofold greater than either of the two other groups (average weekly minutes of physical activity of 631.3xa0min vs. 320xa0min vs. 370.2xa0min, personalized audio-playlists with RAS vs. personalized audio-playlists without RAS vs. non-music usual-care controls, respectively, Pu2009<u20090.001). Patients randomized to music with RAS utilized their audio-playlist devices more frequently than did non-RAS music counterparts (Pu2009<u20090.001).ConclusionsThe use of tempo-pace synchronized preference-based audio-playlists was feasibly implemented into a structured exercise program and efficacious in improving adherence to physical activity beyond the evidence-based non-music usual standard of care. Larger clinical trials are required to validate these findings.Trial registrationClinicalTrials.gov ID (NCT01752595)

Left atrial phasic function interacts to support left ventricular filling during exercise in healthy athletes

We studied the contribution of phasic left atrial (LA) function to left ventricular (LV) filling during exercise. We hypothesized that reduced LV filling time at moderate-intensity exercise limits LA passive emptying and increases LA active emptying. Twenty endurance-trained males (55 ± 6 yr) were studied at rest and during light- (∼100 beats/min) and moderate-intensity (∼130 beats/min) exercise. Two-dimensional and Doppler echocardiography were used to assess phasic volumes and diastolic function. LV end-diastolic volume increased from rest to light exercise (54 ± 6 to 58 ± 5 ml/m(2), P < 0.01) and from light to moderate exercise (58 ± 5 to 62 ± 6 ml/m(2), P < 0.01). LA maximal volume increased from rest to light exercise (26 ± 4 to 30 ± 5 ml/m(2), P < 0.01) related to atrioventricular plane displacement (r = 0.55, P < 0.005), without further change at moderate exercise. LA passive emptying increased at light exercise (9 ± 2 to 13 ± 3 ml/m(2), P < 0.01) and then returned to baseline at moderate exercise, whereas LA active emptying increased appreciably only at moderate exercise (6 ± 2 to 14 ± 3 ml/m(2), P < 0.01). Thus, the total atrial emptying volume did not increase beyond light exercise, and the increase in LV filling at moderate exercise could be attributed primarily to an increase in the conduit flow volume (19 ± 3 to 25 ± 5 ml/m(2), P < 0.01). LA filling increases during exercise in relation to augmented LV longitudinal contraction. Conduit flow increases progressively with exercise in athletes, although this is driven by LV properties rather than intrinsic LA function. The pump function of the LA augments only at moderate exercise due to a reduced diastolic filling time and the Frank-Starling mechanism.

The relationship of pulmonary vascular resistance and compliance to pulmonary artery wedge pressure during submaximal exercise in healthy older adults.

A consistent inverse hyperbolic relationship has been observed between pulmonary vascular resistance and compliance, although changes in pulmonary artery wedge pressure (PAWP) may modify this relationship. This relationship predicts that pulmonary artery systolic, diastolic and mean pressure maintain a consistent relationship relative to the PAWP. We show that, in healthy exercising human adults, both pulmonary vascular resistance and compliance decrease in relation to exercise‐associated increases in PAWP. Pulmonary artery systolic, diastolic and mean pressures maintain a consistent relationship with one another, increasing linearly with increasing PAWP. Increases in PAWP in the setting of exercise are directly related to a decrease in pulmonary vascular compliance, despite small decreases in pulmonary vascular resistance, thereby increasing the pulsatile afterload to the right ventricle.

Development of the Health Incentive Program Questionnaire (HIP-Q) in a cardiac rehabilitation population.

The purpose of this study was to develop a questionnaire to facilitate the design of acceptable financial health incentive programs. A multiphase psychometric questionnaire development method was used. Theoretical and literature reviews and three focus groups generated a pool of content areas and items. New items were developed to ensure adequate content coverage. Field testing was conducted with a convenience sample of cardiac rehabilitation (CR) patients (nu2009=u200959) to establish face and construct validity (pu2009=u20090.021) and reliability (intraclass coefficientsu2009=u20090.42–0.87). The final questionnaire is comprised of 23 items. This questionnaire builds on previous attempts to explore acceptability by sampling a wider range of instrumental and affective attitudes and by measuring the effect of program features on the likelihood of incentive program participation. Future research is now needed to examine whether tailoring incentives to preferences assessed by the questionnaire improves uptake and effectiveness.

The Feasibility of Financial Incentives to Increase Exercise Among Canadian Cardiac Rehabilitation Patients.

PURPOSE: To examine the feasibility of conducting a randomized controlled trial investigating the effectiveness of financial incentives for exercise self-monitoring in cardiac rehabilitation (CR). METHODS: A 12-week, 2 parallel-arm, single-blind feasibility study design was employed. A volunteer sample of CR program graduates was randomly assigned to an exercise self-monitoring intervention only (control; n = 14; mean age ± SD, 62.7 ± 14.6 years), or an exercise self-monitoring plus incentives approach (incentive; n = 13; mean age ± SD, 63.6 ± 11.8 years). Control group participants received a “home-based” exercise self-monitoring program following CR program completion (exercise diaries could be submitted online or by mail). Incentive group participants received the “home-based” program, plus voucher-based incentives for exercise diary submissions (

Discordant Orthostatic Reflex Renin–Angiotensin and Sympathoneural Responses in Premenopausal Exercising-Hypoestrogenic Women

2 per day). A range of feasibility outcomes is presented, including recruitment and retention rates, and intervention acceptability. Data for the proposed primary outcome of a definitive trial, aerobic fitness, are also reported. RESULTS: Seventy-four CR graduates were potentially eligible to participate, 27 were enrolled (36.5% recruitment rate; twice the expected rate), and 5 were lost to followup (80% retention). Intervention acceptability was high with three-quarters of participants indicating that they would likely sign up for an incentive program at baseline. While group differences in exercise self-monitoring (the incentive “target”) were not observed, modest but nonsignificant changes in aerobic fitness were noted with fitness increasing by 0.23 mL·kg−1·min−1 among incentive participants and decreasing by 0.68 mL·kg−1·min−1 among controls. CONCLUSION: This preliminary study demonstrates the feasibility of studying incentives in a CR context, and the potential for incentives to be readily accepted in the broader context of the Canadian health care system.

The Role of Doppler Echocardiography in Predicting Left Atrial Pressure During Rest and Exercise

Our prior observations in normotensive postmenopausal women stimulated the hypotheses that compared with eumenorrheic women, active hypoestrogenic premenopausal women with functional hypothalamic amenorrhea would demonstrate attenuated reflex renin–angiotensin–aldosterone system responses to an orthostatic challenge, whereas to defend blood pressure reflex increases in muscle, sympathetic nerve activity would be augmented. To test these hypotheses, we assessed, in recreationally active women, 12 with amenorrhea (ExFHA; aged 25±1 years; body mass index 20.7±0.7 kg/m2; mean±SEM) and 17 with eumenorrhea (ExOv; 24±1 years; 20.9±0.5 kg/m2), blood pressure, heart rate, plasma renin, angiotensin II, aldosterone, and muscle sympathetic nerve activity at supine rest and during graded lower body negative pressure (−10, −20, and −40 mmu2009Hg). At baseline, heart rate and systolic blood pressure were lower (P<0.05) in ExFHA (47±2 beats/min and 94±2 mmu2009Hg) compared with ExOv (56±2 beats/min and 105±2 mmu2009Hg), but muscle sympathetic nerve activity and renin–angiotensin–aldosterone system constituents were similar (P>0.05). In response to graded lower body negative pressure, heart rate increased (P<0.05) and systolic blood pressure decreased (P<0.05) in both groups, but these remained consistently lower in ExFHA (P<0.05). Lower body negative pressure elicited increases (P<0.05) in renin, angiotensin II, and aldosterone in ExOv, but not in ExFHA (P>0.05). Muscle sympathetic nerve activity burst incidence increased reflexively in both groups, but more so in ExFHA (P<0.05). Otherwise, healthy hypoestrogenic ExFHA women demonstrate low blood pressure and disruption of the normal circulatory response to an orthostatic challenge: plasma renin, angiotensin II, and aldosterone fail to increase and blood pressure is defended by an augmented sympathetic vasoconstrictor response.

“WHY WARM UP?”: EXERCISE ONSET AND THE EARLY PEAK IN PULMONARY ARTERY WEDGE PRESSURE IN HEALTHY OLDER ADULTS

BACKGROUND: Current ASE guidelines require both impaired early diastolic mitral annular tissue Doppler (TD) parameters (septal e’ 20cm/s), any non-native mitral valves, any mitral stenosis, severe mitral annular calcification, greater than moderate mitral regurgitation and inadequate image quality. We then assessed whether or not those individuals met the tissue Doppler and LA volume criteria set out in the guidelines. A further subgroup analysis separated the results into those with normal EF (>50%) or depressed EF ( 50%). RESULTS: 615 individuals met both the inclusion and exclusion criteria. Of these, 561 or 91% fulfilled the tissue Doppler criteria (septal e’ < 8 cm/s and lateral e’ < 10 cm/s) while only 241 or 39% fulfilled the LA volume (LAV) criteria ( 34 ml/m). CONCLUSION: The majority of patients with impaired relaxation defined as E/A <0.6 do not meet the LA volume criteria for diastolic dysfunction. Conversely, the tissue Doppler parameters were met in most. In patients with an E/A<0.6 and abnormal tissue Doppler parameters the value of measuring LA volumes is debatable.