Koji Hiraki

Handgrip strength as a predictor of prognosis in Japanese patients with congestive heart failure.

Background Whether upper-extremity and lower-extremity muscle strength can predict a prognosis of congestive heart failure (CHF) patients is unclear. This study evaluated the impact of muscle strength on long-term mortality in patients with CHF. Design Prospective observational study of male Japanese CHF patients. Methods Clinical characteristics (age, body mass index, left ventricular ejection fraction, heart failure etiology, and medications) were obtained from hospital records of 148 male outpatients with stable CHF. Brain natriuretic peptide was determined as an index of disease severity. Peak oxygen uptake ( V . O 2 ), handgrip, and knee extensor muscle strength were also determined. Results After 1331.9 ± 700.3 days of follow-up, 13 cardiovascular-related deaths occurred, and the patients were divided into two groups: survival (n = 135) and nonsurvival (n = 13). No significant differences were found between the groups in clinical characteristics, brain natriuretic peptide levels, and knee extensor muscle strength. Peak ( V . O 2 ) (P = 0.011) and handgrip strength (P = 0.008) were significantly lower in the nonsurvival versus survival group. Left ventricular ejection fraction, peak ( V . O 2 ), and handgrip strength were found by univariate Cox proportional hazards analysis to be significant prognostic indexes of survival. Multivariate analysis, however, revealed handgrip strength to be an independent predictor of prognosis. A handgrip strength cutoff value of 32.2 kgf was determined by the analysis of receiver-operating characteristics and was assessed. Kaplan-Meier survival curves after log-rank test showed significant prognostic difference between the two groups (P = 0.008). Conclusion Handgrip strength may be useful for forecasting prognosis in patients with CHF. Eur J Cardiovasc Prev Rehabil 16:21-27

Muscle strength in relation to disease severity in patients with congestive heart failure.

Izawa KP, Watanabe S, Yokoyama H, Hiraki K, Morio Y, Oka K, Osada N, Omiya K: Muscle strength in relation to disease severity in patients with congestive heart failure. Am J Phys Med Rehabil 2007;86:893–900. Objective:Indices of exercise capacity such as peak oxygen uptake (&OV0312;O2peak) and muscle strength are important in association with reduced mortality. The present study compared differences in &OV0312;O2peak and muscle strength indices (grip strength and knee extensor and flexor muscle strength) with disease severity and investigated the relation of these variables in congestive heart failure (CHF) patients. Design:The study comprised 102 patients with stable CHF (93 men, age 61.4 ± 10.2 yrs) with left ventricular ejection fraction (LVEF) <40% by echocardiography. We used New York Heart Association (NYHA) functional class to index disease severity. &OV0312;O2peak, grip strength, knee extensor, and flexor muscle strength were determined. Patients were divided into three groups by NYHA class: class I (n = 39), class II (n = 49), and class III (n = 14). Results:Age, sex, and LVEF did not differ according to NYHA class. &OV0312;O2peak and all muscle strength indices decreased with increases in NYHA class (P < 0.05). &OV0312;O2peak correlated positively with all muscle strengths (P < 0.05). Stepwise linear regression analysis revealed that grip and knee extensor strength were important in predicting &OV0312;O2peak. Conclusions:Exercise capacity and disease severity in CHF patients may be influenced not only by lower-limb but also upper-limb muscle strength.

GENDER-RELATED DIFFERENCES IN CLINICAL CHARACTERISTICS AND PHYSIOLOGICAL AND PSYCHOSOCIAL OUTCOMES OF JAPANESE PATIENTS AT ENTRY INTO PHASE II CARDIAC REHABILITATION

OBJECTIVE To examine gender differences in clinical characteristics and physiological and psychosocial outcomes at entry into phase II cardiac rehabilitation. DESIGN Cross-sectional study. SUBJECTS The study comprised 442 consecutive patients with cardiac diseases assessed at entry into a phase II cardiac rehabilitation programme. METHODS Clinical characteristics of the patients, such as age, education, marital status, employment and body mass index, were obtained from hospital records. Oxygen uptake, handgrip and knee extensor muscle strength were measured to assess physiological outcomes. Self-efficacy for physical activity, hospital anxiety depression scale and health-related quality of life assessed by Short Form-36 were evaluated to assess psychosocial outcomes. RESULTS The number of married women and their levels of education, employment and body mass index were significantly lower, and their ages higher, than those of the men. Measures of physiological outcome in women were significantly lower than those in men. Measures of self-efficacy for physical activity and Short Form-36 physical and emotional subscale scores were lower and anxiety levels higher in women than in men. CONCLUSION Cardiac rehabilitation programmes exclusively for women focusing on physiological outcomes, group counselling, and training to enhance physical and emotional domains may encourage increased participation by women in cardiac rehabilitation.

Age-related differences in physiologic and psychosocial outcomes after cardiac rehabilitation.

Izawa KP, Watanabe S, Oka K, Hiraki K, Morio Y, Kasahara Y, Osada N, Omiya K, Iijima S: Age-related differences in physiologic and psychosocial outcomes after cardiac rehabilitation. Objective:To examine differences in physiologic and psychosocial outcomes between age groups after an exercise-based supervised-recovery phase II cardiac rehabilitation outpatient program. Design:This is a longitudinal observational study. The study assessed 442 consecutive cardiac patients. Patients were divided into the middle-aged group (<65 yrs, n = 242) and older-age group (≥65 yrs, n = 200). Peak oxygen uptake, handgrip and knee extensor muscle strength, upper- and lower-body self-efficacy for physical activity, and physical component summary and mental component summary scores as assessed by SF-36 were measured at 1 and 3 mos after the onset of acute myocardial infarction or cardiac surgery and were compared. Results:All physiologic and psychosocial outcomes increased significantly between months 1 and 3 in both groups. However, increases were greater in the middle-aged vs. older-aged group in peak oxygen uptake (+13.1% vs. +8.7%, P < 0.01), knee extensor muscle strength (+17.6% vs. +13.3%, P = 0.01), lower-body self-efficacy for physical activity (+17.3% vs. +12.7%, P = 0.02), and physical component summary score (+5.4% vs. +2.7%, P = 0.02). Conclusions:Age-related differences in various physiologic and psychosocial measures indicated greater improvement from an exercise-based supervised recovery-phase II cardiac rehabilitation outpatient program in middle-aged vs. older-aged patients. Older adults may derive equal mental or emotional benefit from such a cardiac rehabilitation program but do not experience as much improvement in physiologic outcomes as middle-aged adults.

Determination of the Effectiveness of Accelerometer Use in the Promotion of Physical Activity in Cardiac Patients: A Randomized Controlled Trial

OBJECTIVE To investigate the effect of the self-monitoring of physical activity by hospitalized cardiac patients attending phase I cardiac rehabilitation (CR). DESIGN Randomized controlled trial. SETTING University hospital CR program. PARTICIPANTS CR patients (N=126) with a mean age of 59.1 years. INTERVENTIONS Patients were randomly assigned to the self-monitoring group (group A, n=63) or the control group (group B, n=63). Along with CR, group A patients performed self-monitoring of their physical activity at the beginning of a phase I CR program (acute in-hospital phase for inpatients) and ending just before they began a phase II CR program (postdischarge recovery phase for outpatients). MAIN OUTCOME MEASURES Physical activity (averages of daily number of steps taken and daily energy expenditure for 1wk) as measured by accelerometer was assessed in both groups at baseline (t1) and before the beginning of phase II CR (t2). RESULTS Although there were no significant differences in physical activity values between groups A and B at t1, values of group A at t2 were significantly higher than those of group B (8609.6 vs 5512.9 steps, P<.001; 242.6 vs 155.9kcal, P<.001). CONCLUSIONS Self-monitoring of patient physical activity from phase I CR might effectively increase the physical activity level in preparation for entering a phase II CR program. Results of the present study could contribute to the development of new strategies for the promotion of physical activity in cardiac patients.

Usefulness of Step Counts to Predict Mortality in Japanese Patients With Heart Failure

The purpose of this study was to determine both an association between mortality and physical activity (PA) objectively measured by accelerometer and cutoff values for PA in Japanese outpatients with heart failure (HF). This prospective observational study comprised 170 HF outpatients (mean age, 65.2 years; 77% men). Peak oxygen uptake (VO2) and the relation between ventilation and carbon dioxide production (VE/VCO2 slope) as indices of exercise capacity were measured during cardiopulmonary exercise testing with a cycle ergometer. PA was assessed by accelerometer-measured average step count (steps) per day for 1 week. Study endpoint was cardiovascular-related death. Over an average follow-up of 1,377.1 (median, 1,335) days, 31 cardiovascular-related deaths occurred. Patients were then divided into survivor (n = 139) and nonsurvivor (n = 31) groups. Brain natriuretic peptide level was significantly different between groups. Peak VO2 and steps were also significantly lower and VE/VCO2 slope higher in the nonsurvivors versus survivors. Univariate Cox proportional hazards analysis showed brain natriuretic peptide, peak VO2, VE/VCO2 slope, and steps to be significant prognostic indicators of survival. Multivariate analysis showed PA of ≤4,889.4 steps/day to be a strong and independent predictor of prognosis (hazard ratio: 2.28, 95% confidence interval: 1.31-6.30; p = 0.008). Kaplan-Meier curves after log-rank test showed significant prognostic difference between PA of ≤4,889.4 and >4,889.4 steps/day in the 2 groups (log-rank: 12.19; p = 0.0005). In conclusion, step count as objectively measured by accelerometer may be a prognostic indicator of mortality in Japanese outpatients with HF.

Relation between physical activity and exercise capacity of ≥5 metabolic equivalents in middle- and older-aged patients with chronic heart failure

Purpose: Patients with exercise capacity of <5 metabolic equivalents (METs) are considered to have a high risk of death. The aim of this study was to determine age-related differences in physical activity associated with an exercise capacity of ≥5 METs in chronic heart failure (CHF) outpatients. Methods: We enrolled 157 stable CHF patients (79.6% men, age 60.3 ± 11.5 years). Patients were divided into two age-based groups (middle-aged, <65 years, n = 97) and (older-aged, ≥65 years, n = 60). Peak oxygen uptake (peak V˙ O2) was assessed by cardiopulmonary exercise testing. We further divided patients into groups according to exercise capacity: ≥5 METs and <5 METs. Physical activity was assessed by measuring the average number of steps/day for 1 week with an electronic pedometer. Results: Receiver-operating characteristic curves were used to select cutoff values for steps associated with an exercise capacity of ≥5 METs in the middle- and older-aged patients. Cutoff values of 6045 steps in the middle-aged and 6070 steps in the older-aged patients were determined. Conclusions: Both middle- and older-aged CHF patients with exercise capacity of ≥5 METs completed approximately 6000 steps/day. This could become a target amount for minimal physical activity that could contribute to increased exercise capacity in CHF patients. Implications for Rehabilitation Middle-aged and older-aged chronic heart failure (CHF) patients with a measured exercise capacity of ≥5 METs completed approximately 6000 steps/day as measured by electronic pedometer. This amount of steps could become a target amount for minimal physical activity that could contribute to increased exercise capacity in CHF patients.

Physical activity in relation to exercise capacity in chronic heart failure patients

Kazuhiro P. Izawa ⁎, Satoshi Watanabe , Koichiro Oka , Koji Hiraki , Yuji Morio , Yusuke Kasahara , Naoya Takeichi , Takae Tsukamoto , Naohiko Osada , Kazuto Omiya a,d a Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kanagawa 216-8511, Japan b Faculty of Sport Sciences, Waseda University, Saitama 359-1192, Japan c Department of Nursing, St. Marianna University School of Medicine Hospital, Kanagawa 216-8511, Japan d Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa 216-8511, Japan

Upper and Lower Extremity Muscle Strength Levels Associated With an Exercise Capacity of 5 Metabolic Equivalents in Male Patients With Heart Failure.

PURPOSE: Exercise capacity of fewer than 5 metabolic equivalents (METs) has been associated with high risk of death and poor physical functioning in male patients with heart failure (HF). Therefore, we aimed to determine upper and lower extremity muscle strength levels required to attain an exercise capacity of 5 or more METs in male outpatients with HF. METHODS: We enrolled 148 male HF patients (age 60.1 ± 1.0 years). Peak oxygen uptake (peak o2) was assessed by cardiopulmonary exercise testing (CPX). After CPX, we further divided the patients into groups according to exercise capacity: 5 or more METs (group A, n = 85) and fewer than 5 METs (group B, n = 63). Handgrip strength and knee extensor and flexor muscle strengths were assessed as indices of upper and lower extremity muscle strength, respectively. Receiver operating characteristic curves were used to select cutoff values for upper and lower extremity muscle strength resulting in an exercise capacity of 5 or more METs in these patients. RESULTS: Exercise capacity of 5 or more METs in male HF patients was equivalent to approximately 35.2 kgf of handgrip strength and 1.70 Nm/kg of knee extensor and 0.90 Nm/kg of knee flexor muscle strengths. CONCLUSIONS: These upper and lower extremity muscle strength values may be useful target goals for improvement of exercise capacity, risk management, and activities of daily living in male HF patients.

Association between mental health and physical activity in patients with chronic heart failure

Abstract Purpose: Poor mental health (MH) is common in chronic heart failure (CHF) patients. No studies have reported a relation between MH status and objectively measured physical activity (PA) in CHF patients. The study aim was to determine self-reported MH-related differences associated with PA and target values of PA for improved MH in CHF outpatients. Methods: We divided 243 CHF outpatients (mean age 57.1 years) into two groups according to MH assessed by Short Form-36 score: high-MH (≥68 points) group (n = 148) and poor-MH (<68 points) group (n = 95). Average step count (steps) and energy expenditure on PA (EE) (kcal) per day for 1 week of PA were assessed by an accelerometer and compared between groups. PA resulting in high MH was determined by the receiver-operating characteristic (ROC) analysis. Results: PA correlated positively with MH in all patients (steps: r = 0.46, p < 0.001; EE: r = 0.43, p < 0.001). After adjusting for patient characteristics, steps and EE were significantly lower in the poor-MH versus high-MH group (5020.1 ± 280.7 versus 7174.1 ± 221.5 steps, p < 0.001; 133.9 ± 10.8 versus 215.9 ± 8.4 kcal, p < 0.001). Cut-off values of 5590.8 steps and 141.1 kcal were determined as PA target values associated with improved MH. Conclusions: Poor MH status may reduce PA. Attaining PA target values may improve MH status of CHF outpatients. Implications for Rehabilitation Poor mental health may negatively affect physical exercise in CHF outpatients. In particular step counts and energy expenditure are lower in those with poor mental health. It may be that focused exercise training may impact positively both on mental health and physical well being.