Lola Coke

Clinician's guide to cardiopulmonary exercise testing in adults: A scientific statement from the American heart association

Exercise testing remains a remarkably durable and versatile tool that provides valuable diagnostic and prognostic information regarding patients with cardiovascular and pulmonary disease. Exercise testing has been available for more than a half century and, like many other cardiovascular procedures, has evolved in its technology and scope. When combined with exercise testing, adjunctive imaging modalities offer greater diagnostic accuracy, additional information regarding cardiac structure and function, and additional prognostic information. Similarly, the addition of ventilatory gas exchange measurements during exercise testing provides a wide array of unique and clinically useful incremental information that heretofore has been poorly understood and underutilized by the practicing clinician. The reasons for this are many and include the requirement for additional equipment (cardiopulmonary exercise testing [CPX] systems), personnel who are proficient in the administration and interpretation of these tests, limited or absence of training of cardiovascular specialists and limited training by pulmonary specialists in this technique, and the lack of understanding of the value of CPX by practicing clinicians. Modern CPX systems allow for the analysis of gas exchange at rest, during exercise, and during recovery and yield breath-by-breath measures of oxygen uptake (Vo2), carbon dioxide output (Vco2), and ventilation (Ve). These advanced computerized systems provide both simple and complex analyses of these data that are easy to retrieve and store, which makes CPX available for widespread use. These data can be readily integrated with standard variables measured during exercise testing, including heart rate, blood pressure, work rate, electrocardiography findings, and symptoms, to provide a comprehensive assessment of exercise tolerance and exercise responses. CPX can even be performed with adjunctive imaging modalities for additional diagnostic assessment. Hence, CPX offers the clinician the ability to obtain a wealth of information beyond standard exercise electrocardiography testing that when appropriately applied and interpreted …

Exercise Standards for Testing and Training A Scientific Statement From the American Heart Association

The 2001 version of the exercise standards statement1 has served effectively to reflect the basic fundamentals of ECG–monitored exercise testing and training of both healthy subjects and patients with cardiovascular disease (CVD) and other disease states. These exercise standards are intended for use by physicians, nurses, exercise physiologists and specialists, technologists, and other healthcare professionals involved in exercise testing and training of these populations. Because of an abundance of new research in recent years, a revision of these exercise standards is appropriate. The revision deals with basic fundamentals of testing and training, with no attempt to duplicate or replace current clinical practice guidelines issued by the American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and other professional societies. It is acknowledged that the published evidence for some recommendations made herein is limited, but the depth of knowledge and experience of the writing group is believed to provide justification for certain …

Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings A Science Advisory From the American Heart Association

Cardiovascular disease (CVD) continues to be the leading cause of morbidity and mortality in the United States and worldwide.1 In fact, the prevalence of CVD is on the rise as a function of increased longevity and the mounting effects of cardiac risk factors that typically accumulate over a lifetime. Outpatient cardiac rehabilitation (CR) programs offer a cost-effective, multidisciplinary, comprehensive approach to address these risk factors and to restore individuals to their optimal physiological, psychosocial, nutritional, and functional status.2–6 Thus, the benefits of CR extend well beyond the cardiovascular system, positively affecting an individuals overall health status. These benefits may be particularly important to certain CVD cohorts such as elderly patients who are more likely to present with greater functional limitations and frailty. Additionally, outpatient CR has been shown to dramatically reduce morbidity and mortality by nearly 25% compared with usual care.7,8 Despite the clear benefits of formal, supervised outpatient CR and exercise training programs, as well as strides in automatic referrals,9 current statistics continue to demonstrate that referral and participation rates of eligible patients remain alarmingly low,10–13 with participation particularly poor in rural areas and in eligible patients who have lower socioeconomic status, limited education, advanced age, and/or female sex.14,15 In addition, Gurewich et al16 reported several factors that are likely responsible for the poor referral rates to outpatient CR, which included “the degree of automation and assertiveness in securing referrals, the level of integration of CR within the hospital setting and physician community, the relationship to other CR facilities, and capacity constraints.” Given the continually poor referral and participation rate in outpatient CR despite increased efforts to reverse this trend, additional actions are required. This scientific advisory calls on the inpatient and home healthcare …

Recruiting and retaining young, sedentary, hypertension-prone African American women in a physical activity intervention study.

African American women have a high prevalence of hypertension and low level of physical activity compared with their counterparts. A sedentary lifestyle contributes to the development of hypertension, as well as other cardiovascular diseases, especially among African American women. Healthy People 2010 initiatives underscore the priority of reducing minority health disparities. To reduce health disparities, there has been recent emphasis on recruiting and retaining minority populations in clinical research studies. However, little information is available to guide researchers in the evaluation of impediments in successful recruitment and retention of young African American women. A first step is for researchers to report information concerning the efficacy of recruiting/retaining methods in order to facilitate minority participation in clinical trials and, ultimately, reduce health disparities. This report summarizes existing recruitment and retention methods from the literature, and describes how effective these strategies were in recruiting and retaining young, mildly hypertensive African American women to a physical activity intervention study. Multiple strategies, resources, and time were necessary to recruit and retain these women for the study. Among women enrolled, newspaper advertisements and flyers were the most effective recruiting strategies implemented (46% and 21%, respectively). Study retention was high (96%), which may have resulted from flexible scheduling, frequent contact, and a caring environment. Recruiting and retaining efforts need to be tailored to meet the needs of the target population.

Blood pressure responses to lifestyle physical activity among young, hypertension-prone African-American women.

Background: Physical inactivity and obesity increase the risk for hypertension, and both are more prevalent in African-American than Caucasian women. Regular physical activity serves as an important intervention for reducing cardiovascular risk, yet the ideal physical activity profile to meet the needs of young, sedentary African-American women remains unclear. We performed a randomized, parallel, single-blind study to examine the effect of lifestyle physical activity (LPA) on blood pressure indices in sedentary African-American women aged 18 to 45 years with prehypertension or untreated stage 1 hypertension. Methods: The primary intervention was an 8-week individualized, home-based program in which women randomized to Exercise (n = 14) were instructed to engage in lifestyle-compatible physical activity (eg, walking, stair climbing) for 10 minutes, 3 times a day, 5 days a week, at a prescribed heart rate corresponding to an intensity of 50% to 60% heart rate reserve. Women in the No Exercise group (n = 10) continued with their usual daily activities. Mean changes in cuff, ambulatory, and pressure load indices were compared using paired t tests, and physical activity adherence was expressed as percentages. Results: Women in the Exercise group had a significant reduction in systolic blood pressure (−6.4 mm Hg, P = .036), a decrease in diastolic blood pressure status to the prehypertensive level (90.8 vs 87.4 mm Hg), and greater reductions in nighttime pressure load compared with the No Exercise group. Adherence to LPA was exceedingly high by all measures (65%-98%) and correlated with change in systolic blood pressure (r = −0.620, P = .024). Conclusion: The accumulation of LPA reduced cuff, ambulatory, and pressure load. The accumulation of LPA appears well tolerated and feasible in this sample of young African-American women, demonstrated by the overall high adherence rates. Given the excess burden of pressure-related clinical sequelae among African Americans and the strong correlation between pressure load and target organ damage, LPA may represent a practical and effective strategy in this population.

Reducing the risks of diabetes complications through diabetes self-management education and support.

People with diabetes are at risk of developing complications that contribute to substantial morbidity and mortality. In 2011, the American Association of Diabetes Educators convened an invitational Reducing Risks Symposium, during which an interdisciplinary panel of 11 thought leaders examined current knowledge about the reduction and prevention of diabetes-related risks and translated evidence into diabetes care and self-management education. Symposium participants reviewed findings from the literature and engaged in a moderated roundtable discussion. This report summarizes the discussion and presents recommendations to incorporate into practice to improve outcomes. The objective of the symposium was to develop practical advice for diabetes educators and other members of the diabetes care team regarding the reduction of diabetes-related risks. Optimal diabetes management requires patients to actively participate in their care, which occurs most effectively with a multidisciplinary team. Diabetes education is an integral part of this team approach because it not only helps the patient understand diabetes, its progression, and possible complications, but also provides guidance and encouragement to the patient to engage in proactive risk-reduction decisions for optimal health. A variety of tools are available to help the diabetes educator develop an individualized, patient-centered plan for risk reduction. More research is needed regarding intervention efficacy, best practices to improve adherence, and quantification of benefits from ongoing diabetes support in risk reduction. Diabetes educators are urged to stay abreast of evolving models of care and to build relationships with health care providers both within and beyond the diabetes care team.

Improving cardiovascular health of underserved populations in the community with Life's Simple 7

Purpose:The purpose of this nurse practitioner (NP) led initiative was to improve the cardiovascular health of two underserved populations in the community using the American Heart Association (AHA) Lifes Simple 7 and My Life Check (MLC) tools. Data sources:Two inner city community sites were targeted: (a) a senior center servicing African American (AA) older adults, and (b) a residential facility servicing homeless women. Preprogram health data (blood pressure, cholesterol, blood glucose levels, body mass index, and health behaviors) were collected to calculate MLC scores. Postprogram health data were obtained on participants with the lowest MLC scores who completed the program. Conclusions:Eight older adults completed the program with a 37.1% increase in average MLC score (6.2 vs. 8.5). Ten women completed the program with a 9.3% decrease in average MLC score (4.3 vs. 3.9). Favorable benefits were observed in the AA older adults. In contrast, similar benefits were not observed in the women, which may be because of a constellation of social, environmental, biological, and mental health factors. Implications for practice:NPs are prepared to target community‐based settings to address the health of underserved populations. Engaging key stakeholders in the planning and implementation is essential for success.

Upper-body progressive resistance training improves strength and household physical activity performance in women attending cardiac rehabilitation.

PURPOSE The purpose of this study was to examine the impact of moderate-intensity, progressive, upper-body resistance training (RT) on muscle strength and perceived performance of household physical activities (HPA) among women in cardiac rehabilitation. METHODS The 10-week, pretest-posttest, experiment randomized women to either usual care (UC) aerobic exercise or RT. Muscle strength for 5 upper-body RT exercises (chest press, shoulder press, biceps curl, lateral row, and triceps extension) was measured using the 1-Repetition Maximum Assessment. The RT group progressively increased weight lifted using 40%, 50%, and 60% of obtained 1-Repetition Maximum Assessment at 3-week intervals. Perceived performance of HPA was measured with the Kimble Household Activities Scale. RESULTS The RT group (n = 16, mean age 64 ± 11) significantly increased muscle strength in all 5 exercises in comparison with the UC group (n = 14, mean age 65 ± 10) (chest press, 18% vs 11%; shoulder press, 24% vs 14%; biceps curl, 21% vs 12%; lateral row, 32% vs 9%; and triceps extension, 28% vs 20%, respectively). By study end, Household Activities Scale scores significantly increased (F = 13.878, P = .001) in the RT group (8.75 ± 3.19 vs 11.25 ± 2.14), whereas scores in the UC group decreased (8.60 ± 3.11 vs 6.86 ± 4.13). CONCLUSION Progressive upper-body RT in women shows promise as an effective tool to increase muscle strength and improve the ability to perform HPA after a cardiac event. Beginning RT early after a cardiac event in a monitored cardiac rehabilitation environment can maximize the strengthening benefit.

Perceptions of Insulin Treatment Among African Americans With Uncontrolled Type 2 Diabetes

Purpose: Little is known regarding perception of insulin treatment among midlife and older African American (AA) adults with type 2 diabetes, or how perception affects self-management behaviors. Using the Roy adaptation model, this qualitative descriptive study explored the perception of insulin treatment in midlife and older AAs living with uncontrolled type 2 diabetes. Method: Three 1-hour focus groups were conducted with a total of 13 participants. Thematic analysis of transcribed audio recordings used the constant comparative method. Results: Themes identified include (a) insulin as instigator of negative emotions, (b) adapting to a lifestyle with insulin, and (c) becoming an insulin user: a new identity. Conclusion: Adapting to insulin is a psychosocial process that commonly results in negative emotions, identity conflict, and new roles. Implications for practice: Further research is needed to understand how AA adults perceive insulin treatment, understand the role of perception in self-management behaviors, and determine whether interventions to change perceptions may be effective in improving adaptation to diabetes.

Impact of Individual and Neighborhood Factors on Cardiovascular Risk in White Hispanic and Non-Hispanic Women and Men

Cardiovascular disease (CVD) is the leading cause of mortality for adults in the US, regardless of ethnicity. A cross-sectional correlational design was used to describe and compare CVD risk and cardiac mortality in White Hispanic and non-Hispanic women and men. Data from 3,317 individuals (1,523 women and 1,794 men) hospitalized for non-cardiac causes during 2012-2013, and data from the 2010 United States Census were included. The sex-specific 10-year Framingham General Cardiovascular Risk Score (FRS-10) was used to estimate long-term risk for major cardiac events. Approximately three-quarters of the sample was White Hispanic. FRS-10 scores were generally low, but a high prevalence of risk factors not included in the standard FRS-10 scoring formula was seen. White Hispanic women had significantly lower estimated CVD risk scores compared to White Hispanic and non-Hispanic men despite higher non-FRS-10 risks. Neighborhood median household income had a significant negative relationship and Hispanic neighborhood concentration had a significant positive relationship with cardiac mortality. Hispanic concentration was the only predictor of estimated CVD risk in a multilevel model. CVD risk assessment tools that are calibrated for ethnic groups and socioeconomic status may be more appropriate for Hispanic individuals than the FRS-10. Neighborhood-level factors should be included in clinical cardiac assessment in addition to individual characteristics and behavioral risks. Researchers should continue to seek additional risk factors that may contribute to or protect against CVD in order to close the gap between estimated CVD risk and actual cardiac mortality for Hispanics in the US.