Kelly Allsup

Expression of the Irisin Precursor FNDC5 in Skeletal Muscle Correlates With Aerobic Exercise Performance in Patients With Heart Failure

Background—Exercise-induced increase in peroxisome proliferator-activated receptor-&ggr; coactivator-1&agr; (PGC-1&agr;) expression has been shown to increase the expression of the fibronectin type III domain containing 5 (FNDC5) gene and thereby its product, irisin, in mice. Given that exercise intolerance is a hallmark characteristic of heart failure (HF), and because PGC-1&agr; and irisin promote exercise benefits in animals, we hypothesized that expression of these genes relates to aerobic performance in patients with HF. Methods and Results—Systolic HF (left ventricular ejection fraction ⩽40%) patients underwent cardiopulmonary exercise testing to evaluate aerobic performance. High versus low aerobic performance was assessed using oxygen consumption (peak VO2 [>14 versus ⩽14 mL O2·kg−1·min−1]) and ventilatory efficiency (VE/VCO2 slope [<34 versus ≥34]). Muscle biopsies of the vastus lateralis and real-time polymerase chain reaction were used to quantify muscle gene expression. Twenty-four patients were studied. FNDC5 (5.7±3.5 versus 3.1±1.2, P<0.05) and PGC-1&agr; (9.9±5.9 versus 4.5±1.9, P<0.01) gene expressions were greater in the high-peak VO2 group; correlation between FNDC5 and PGC-1&agr; was significant (r=0.56, P<0.05) only in the high-peak VO2 group. Similarly, FNDC5 and PGC-1&agr; gene expression was greater in the high-performance group based on lower VE/VCO2 slopes (5.8±3.6 versus 3.3±1.4, P<0.05 and 9.7±6 versus 5.3±3.4, P<0.05); FNDC5 also correlated with PGC-1&agr; (r=0.55, P<0.05) only in the low VE/VCO2 slope group. Conclusions—This is the first study to show that FNDC5 expression relates to functional capacity in a human HF population. Lower FNDC5 expression may underlie reduced aerobic performance in HF patients.

Utility and efficacy of a smartphone application to enhance the learning and behavior goals of traditional cardiac rehabilitation: a feasibility study.

PURPOSE:Most eligible patients do not participate in traditional clinic-based cardiac rehabilitation (CR) despite well-established benefits. Novel approaches to overcome logistic obstacles and increase efficiencies of learning, behavior modification, and exercise surveillance may increase CR participation. In an observational study, the feasibility and utility of a mobile smartphone application for CR, Heart Coach (HC), were assessed as part of standard care. Ultimately, innovative CR models incorporating HC may facilitate better CR usage and value. METHODS:Twenty-six patients enrolled in CR installed HC. Over the next 30 days, they were prompted by HC to complete a daily “task list” that included medications, walking, education (text and videos), and surveys. Cardiac rehabilitation providers monitored each patients progress through a HC-based Web dashboard and also sent them personalized feedback and support. Completion of the tasks and feedback (qualitative and quantitative) from patients and clinicians were tracked. RESULTS:Patients engaged with HC 90% of days during the study period, with uniformly favorable impact on compliance and adherence. Eighty-three percent of patients reported a positive/very positive HC experience. Providers reported that HC enhanced their provision of therapy by improving communication, clinical insight, patient participation, and program efficiency. CONCLUSIONS:Integrating a mobile care delivery platform into CR was feasible, safe, and agreeable to patients and clinicians. It enhanced patient perceptions of CR care and physician perceptions of the CR caregiving process. Mobile-enabled technologies hold promise to extend the quality and reach of CR, and to better achieve contemporary accountable care goals.

Physical Activity Is Positively Associated with Episodic Memory in Aging

Aging is associated with performance reductions in executive function and episodic memory, although there is substantial individual variability in cognition among older adults. One factor that may be positively associated with cognition in aging is physical activity. To date, few studies have objectively assessed physical activity in young and older adults, and examined whether physical activity is differentially associated with cognition in aging. Young (n=29, age 18-31 years) and older adults (n=31, ages 55-82 years) completed standardized neuropsychological testing to assess executive function and episodic memory capacities. An experimental face-name relational memory task was administered to augment assessment of episodic memory. Physical activity (total step count and step rate) was objectively assessed using an accelerometer, and hierarchical regressions were used to evaluate relationships between cognition and physical activity. Older adults performed more poorly on tasks of executive function and episodic memory. Physical activity was positively associated with a composite measure of visual episodic memory and face-name memory accuracy in older adults. Physical activity associations with cognition were independent of sedentary behavior, which was negatively correlated with memory performance. Physical activity was not associated with cognitive performance in younger adults. Physical activity is positively associated with episodic memory performance in aging. The relationship appears to be strongest for face-name relational memory and visual episodic memory, likely attributable to the fact that these tasks make strong demands on the hippocampus. The results suggest that physical activity relates to cognition in older, but not younger adults.

Potential Neurobiological Benefits of Exercise in Chronic Pain and Posttraumatic Stress Disorder: Pilot Study

This pilot study assessed the effects of cardiopulmonary exercise testing and cardiorespiratory fitness on plasma neuropeptide Y (NPY), allopregnanolone and pregnanolone (ALLO), cortisol, and dehydroepiandrosterone (DHEA), and their association with pain sensitivity. Medication-free trauma-exposed participants were either healthy (n = 7) or experiencing comorbid chronic pain/posttraumatic stress disorder (PTSD) (n = 5). Peak oxygen consumption (VO2) during exercise testing was used to characterize cardiorespiratory fitness. Peak VO2 correlated with baseline and peak NPY levels (r = 0.66, p < 0.05 and r = 0.69, p < 0.05, respectively), as well as exercise-induced changes in ALLO (r = 0.89, p < 0.001) and peak ALLO levels (r = 0.71, p < 0.01). NPY levels at the peak of exercise correlated with pain threshold 30 min after exercise (r = 0.65, p < 0.05), while exercise-induced increases in ALLO correlated with pain tolerance 30 min after exercise (r = 0.64, p < 0.05). In contrast, exercise-induced changes in cortisol and DHEA levels were inversely correlated with pain tolerance after exercise (r = -0.69, p < 0.05 and r = -0.58, p < 0.05, respectively). These data suggest that cardiorespiratory fitness is associated with higher plasma NPY levels and increased ALLO responses to exercise, which in turn relate to pain sensitivity. Future work will examine whether progressive exercise training increases cardiorespiratory fitness in association with increases in NPY and ALLO and reductions in pain sensitivity in chronic pain patients with PTSD.

Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease

Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease Referral to exercise-based cardiac rehabilitation (CR) is 1 of 9 performance measures for secondary prevention after hospitalization for myocardial infarction (MI), p e r c u t a n e o u s c o r o n a r y intervention (PCI), and/or coronary artery bypass graft (CABG).1,2 Although CR programs significantly reduce morbidity and mortality in patients with ischemic heart disease (IHD),3 they are vastly underused among US Medicare beneficiaries.4 The use of CR programs in the Veterans Health Administration (VA) has not been described. Therefore, we sought to determine (1) the proportion of eligible veterans with IHD who participate in CR, (2) whether the presence of an on-site CR program is associated with greater participation, and (3) the characteristics of the CR participants.

Factors Associated With Utilization of Cardiac Rehabilitation Among Patients With Ischemic Heart Disease in the Veterans Health Administration: A QUALITATIVE STUDY.

BACKGROUND: Cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease but are vastly underutilized in the United States, including the Veterans Health Administration (VA) Healthcare System. Numerous barriers affecting utilization have been identified in other health care systems, but the specific factors affecting Veterans are unknown. We sought to identify barriers and facilitators associated with utilization of CR in VA facilities. METHODS: We performed a qualitative study of 56 VA patients, providers, and CR program managers at 30 VA facilities across the United States. We conducted semistructured interviews with key informants to explore their attitudes and knowledge toward CR. Interviews were conducted until thematic saturation occurred. Analyses using grounded theory to identify key themes were conducted using the qualitative data analysis package ATLAS.ti. RESULTS: We identified 6 themes as barriers and 5 as facilitators. The most common barriers to participation in CR were patient transportation issues (68%), lack of patient willingness to participate (41%), and no access to a nearby VA hospital with a CR program (30%). The most common facilitators were involvement of a dedicated provider or “clinical champion” (50%), provider knowledge of or experience with CR (48%), and patient desire for additional medical support (32%). CONCLUSIONS: Our findings suggest that addressing access issues and educating and activating providers on CR may increase utilization of CR programs. Targeting these specific factors may improve utilization of CR programs.

Dynamic assessment of ventilatory efficiency during recovery from peak exercise to enhance cardiopulmonary exercise testing

Background: While cardiopulmonary exercise testing (CPX) assessment is generally regarded as an optimal means to assess functional capacity in heart failure (HF) patients, strength parameters are omitted. CPX indices collected in recovery may provide additional insight regarding function, including strength. Design and methods: We performed a cross-sectional controlled study. Systolic HF patients (aged ≥50 years) and age-matched controls were assessed using CPX and strength evaluations. Standard CPX indices were assessed during exercise (peak oxygen consumption [VO2], first ventilatory threshold [1stVT], and ventilatory efficiency [VE/VCO2 slope]) as well as indices at 1-minute recovery (1 min VO2, 1 min VE/VCO2, and 1 min heart rate recovery [HRR]) and differences between peak and 1-minute recovery (ΔVO2 and ΔVE/VCO2). Lower extremity strength was evaluated using the 1-repetition maximum (1RM) and power. Results: Seventy adults (31 HF; 39 controls), mean age 66.2 ± 9.7 years were evaluated. Peak VO2 (15.4 ± 4.2 versus 23.4 ± 6.6 mlO2·kg−1·min−1, p < 0.0001) and 1stVT (10.9 ± 2.1 versus 14.4 ± 4.0mlO2·kg−1·min−1, p < 0.0001) were diminished in HF versus controls and VE/VCO2 slope was increased (42.3 ± 12.2 versus 35.4 ± 8.3, p < 0.01). HF patients had reduced 1minVO2 (13.1 ± 2.9 versus 16.3 ± 3.7 mlO2·kg−1·min−1, p < 0.0001), 1 min HRR (6.7 ± 11.4 versus 12.4 ± 7.6 beats, p < 0.02), and ΔVO2 (2.43 ± 2.3 versus 7.3 ± 5.0 mlO2·kg−1·min−1, p < 0.0001) as well as increased 1 min VE/VCO2 (37 ± 7.5 versus 31.5 ± 4.4, p < 0.001) and ΔVE/VCO2 (1.17 ± 3.0 versus −0.5 ± 1.3, p < 0.0001). Strength parameters were relatively lower in HF. While CPX exercise parameters correlated with strength, stronger correlations were observed between CPX recovery parameters and strength. Conclusions: CPX recovery indices corroborate disease-specific aerobic differences and distinguish differences in strength. Recovery ventilatory efficiency enhances CPX’s value as a comprehensive physical function tool.

A Qualitative Study of Participation in Cardiac Rehabilitation Programs in an Integrated Health Care System

INTRODUCTION Despite strong incentives to use cardiac rehabilitation (CR), patient participation is low in the Veterans Health Administration (VHA). This is paradoxical given that VHA is an integrated health care system that offers a range of CR programs which should logically reduce barriers to access to CR participation. The purpose of this study was to better understand the contextual factors that influence patient participation in CR and how patients consider factors together when making decisions about CR participation. MATERIALS AND METHODS Using a qualitative study design we examined patient and provider perceptions of CR across six VHA medical centers with high- and low-enrollment rates between December 2014 and October 2015. We conducted semistructured interviews with CR eligible patients who had both enrolled and not enrolled in CR (n = 16), cardiology providers who could refer patients to CR and CR staff who provided CR services (n = 15). Data were analyzed using grounded thematic techniques. RESULTS We identified program and patient-specific factors related to CR participation. The four program factors were: program responsiveness to patient needs, CR schedule, specialized CR program equipment, and the CR program social environment. Program factors were primarily discussed by individuals associated with sites that had high CR enrollment rates. The patient-specific factor that promoted participation was patient perceptions of CR benefits. Disincentives to participation included competing conditions or obligations, logistical/cost challenges, convenience, and fear of exercise. CR participation entailed a complex process in which patients balanced factors that reinforced patient perceptions that CR was beneficial against factors that acted as disincentives to participation. CONCLUSIONS CR participation was influenced by both program and patient factors. Patients weighed factors that fostered perceptions that CR was beneficial against factors that served as disincentives to CR participation when considering CR participation. High-enrollment sites may be better at countering disincentives to participate and/or improve patient perceptions of CR. Actionable ways to improve CR participation include encouraging providers to strongly and frequently endorse CR, educating patients about the importance and benefits of CR, emphasizing how exercises are individualized, supervised and monitored, educating patients about how CR is safe and effective, how CR offers peer support, and structuring CR programs to be responsive to patient needs in terms of duration, frequency, schedule, and location.

Self-Efficacy for Adoption and Maintenance of Exercise Among Fibromyalgia Patients: A Pilot Study:

Objective. While multimodal treatment approaches for fibromyalgia (FM), incorporating exercise, have been found most effective, information about factors associated with exercise adoption and maintenance is lacking. Design, Setting, and Methods. Women veterans with FM (N = 19) completed an anonymous Internet survey measuring FM impact (FI), adoption of exercise behavior, and self-efficacy for exercise. Using classifications of behavior specified by the transtheoretical model, the self-efficacy of participants classified in the action or maintenance (AM) stages was compared with those in earlier stages (precontemplation through preparation) of exercise readiness. Multivariate analysis of variance analyses examined differences in FI domains by stage of change. Analysis of covariance examined whether exercise self-efficacy differed by stage of change while controlling for FI. Results. Higher levels of self-efficacy were detected among participants in the AM stages. Participants in the AM stages also reported higher levels of FI symptoms. After controlling for FI, self-efficacy did not differ significantly between the 2 groups; however the effect size was large (η2 = .11). Conclusions. Findings of this pilot study suggest a role for self-efficacy in exercise adoption and maintenance, even in the setting of higher FM symptoms. Replication of this study with a larger sample size is warranted.

Notice of Retraction and Replacement. Schopfer DW, et al. Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease. JAMA Intern Med. 2014;174(10):1687-1689

Notice of Retraction and Replacement. Schopfer DW, et al. Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease. JAMA Intern Med. 2014;174(10):1687-1689 To the Editor We write to report a series of pervasive errors in our Research Letter, “Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease,” published in the October 2014 issue of JAMA Internal Medicine.1 The errors, once corrected, result in changes to a number of findings. Thus, we have requested that the original article be retracted and replaced. In the original article,1 we reported the proportion of eligible veterans in the Veterans Health Administration (VA) with ischemic heart disease who participated in cardiac rehabilitation (CR) after hospitalization for myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass graft; whether the presence of an on-site CR program was associated with greater participation; and the characteristics of the CR participants. The primary problem with the originally reported study was incorrect cohort identification (ie, we missed many patients who were eligible for cardiac rehabilitation). We did not query all relevant codes used to identify the cohort of patients with ischemic heart disease. For example, some International Classification of Diseases, Ninth Revision (ICD9), procedure codes were not included in the initial query. Therefore, the cohort originally used had fewer participants than the current cohort when we repeated our query. However, all subsequent coding regarding the analysis of the cohort was unchanged. The errors in the original article, once corrected, result in a substantial increase in the numbers of eligible patients included in the study, from 47 051 to 88 826. Despite the almost doubling of eligible patients in the corrected analysis, there was only a small change in the proportion of patients participating in CR (from 8.5% to 10.3%), and the overall proportion of patients participating in CR remains low. However, after correcting for the coding cohort identification errors, there are several changes in the findings reported in the corrected version compared with the originally published version. In the original article,1 we reported no statistically significant difference in CR participation by race, but the corrected version shows a difference: “10.4% of whites (7126 of 68 259) and 9.8% of nonwhites (1610 of 16 397) received any CR (P = .02).” Also, in the original article,1 we reported that participation rates increased from 7.5% to 9.4% (P < .01) from 2007 to 2011, but the corrected version indicates that participation rates “remained stable between 8.5% and 8.7% for all years.” In addition, there are a number of changes in the results of the multivariate model that assessed participant factors associated with participation in CR, with associations changing statistical significance for participants with income greater than