Roselien Buys

Endurance exercise beneficially affects ambulatory blood pressure: a systematic review and meta-analysis

Exercise is widely recommended as one of the key preventive lifestyle changes to reduce the risk of hypertension and to manage high blood pressure (BP), but individual studies investigating the effect of exercise on ambulatory BP have remained inconclusive. Therefore, the primary purpose of this systematic review and meta-analysis was to determine the effect of aerobic endurance training on daytime and night-time BP in healthy adults. A systematic literature search was conducted using PubMed and Cochrane Controlled Clinical trial registry from their inception to May 2012. Randomized controlled trials of at least 4 weeks investigating the effects of aerobic endurance training on ambulatory BP in healthy adults were included. Inverse weighted random effects models were used for analyses, with data reported as weighted means and 95% confidence limits. We included 15 randomized controlled trials, involving 17 study groups and 633 participants (394 exercise participants and 239 control participants). Overall, endurance training induced a significant reduction in daytime SBP [−3.2 mmHg, 95% confidence interval (CI), −5.0 to−1.3] and daytime DBP (−2.7 mmHg, 95% CI, −3.9 to −1.5). No effect was observed on night-time BP. The findings from this meta-analysis suggest that aerobic endurance exercise significantly decreases daytime, but not night-time, ambulatory BP.

TYPE 2 DIABETES IN PATIENTS WITH MAJOR DEPRESSIVE DISORDER: A META‐ANALYSIS OF PREVALENCE ESTIMATES AND PREDICTORS

Patients with depression may be at increased risk of type 2 diabetes mellitus (T2DM), which is a risk factor for cardiovascular diseases and premature mortality. We aimed to clarify the prevalence and predictors of T2DM in patients with major depressive disorder (MDD) and where possible compare the prevalence of T2DM in those with MDD versus general population controls.

Measures of exercise capacity in adults with congenital heart disease

BACKGROUND Exercise capacity in grown-ups with congenital heart disease (GUCH) is mostly reported by peak oxygen consumption (peak VO(2)). Our aim was to evaluate the maximal character of exercise tests, and to investigate submaximal measures of exercise capacity. METHODS Adults with Coarctation of the Aorta (COA, n=155), Tetralogy of Fallot (TOF, n=98), dextro-Transposition of the Great Arteries (dTGA, n=68) and Univentricular Heart (UVH, n=10), and 122 healthy adults performed cardiopulmonary exercise testing until exhaustion. Gas exchange was measured breath by breath. The maximal performance of the test was evaluated by respiratory exchange ratio (RER), ventilatory equivalent for oxygen and Borg scale. Oxygen uptake efficiency slope (OUES), VE/VCO(2) slope and VO(2)/WR slope were calculated and ventilatory anaerobic threshold (VAT) was defined. Correlations of these measures with peak VO(2) were calculated. RESULTS GUCH showed significantly lower peak VO(2) than controls (p<0.001), declining from 80% in COA, 74% in TOF, 64% in dTGA, to 55% in UVH. Compared to suggested criteria, mean peak RER and median Borg scale indicated a maximal effort in GUCH, however these results were significantly lower than controls (p<0.05). OUES, VO(2)/WR slope and VAT were significantly lower in patients compared to controls. OUES (r=0.853) and VAT (r=0.840) correlated best with peak VO(2); VO(2)/WR slope (r=0.551) and VE/VCO(2) slope (r=-0.421) correlated to a lesser degree (p<0.001). CONCLUSION The investigated GUCH show reduced exercise tolerance compared to controls, related to the underlying heart defect. Different expressions of exercise tolerance clearly reveal the same differences in exercise capacity across groups of GUCH.

Prevalence and predictors of type 2 diabetes mellitus in people with bipolar disorder: a systematic review and meta-analysis.

OBJECTIVE This systematic review and meta-analysis assessed the prevalence and predictors of type 2 diabetes mellitus (T2DM) in people with bipolar disorder. We also compared the prevalence of T2DM in people with bipolar disorder versus age- and gender-matched healthy controls. DATA SOURCES PubMed, EMBASE, PsycARTICLES, and CINAHL were searched from inception till October 23, 2014 using the medical subject headings terms bipolar disorder AND diabetes OR glucose. There was no language restriction. Observational studies including retrospective, cross-sectional, and prospective designs were eligible if they included participants with bipolar disorder diagnosed according to recognized diagnostic criteria (DSM or ICD). STUDY SELECTION Nineteen studies were included (n = 18,060; 54.8% male). DATA EXTRACTION Two independent authors extracted data in accordance with the meta-analysis of observational studies in epidemiology guidelines and PRISMA statement. A random effects meta-analysis was utilized. RESULTS The overall prevalence of T2DM was 9.4% (95% CI, 6.5%-12.7%). Compared with age- and gender-matched controls (n = 783,049; 48.7% male), people with bipolar disorder (n = 6,595; 48.6% male) had double the risk of T2DM (relative risk = 1.98; 95% CI, 1.6-2.4, P < .001). No significant moderators were found. In an exploratory regression analysis, the variance in T2DM prevalence in the background population was associated with the variance in T2DM prevalence in people with bipolar disorder (5 studies, n = 4,983) (r(2) = 0.85, t = 4.09, P = .03). CONCLUSIONS T2DM is significantly more common in people with bipolar disorder than in healthy controls of similar age and sex. The current meta-analysis furthermore indicates that changes in food, built, and social environments are needed in order to curb the diabetes epidemic in this high-risk population.

Peak oxygen uptake, ventilatory efficiency and QRS-duration predict event free survival in patients late after surgical repair of tetralogy of Fallot.

OBJECTIVE Patients with repaired tetralogy of Fallot (ToF) have an increased long-term risk of cardiovascular morbidity and mortality. Risk stratification in this population is difficult. Initial evidence suggests that cardiopulmonary exercise testing (CPET) may be helpful to risk-stratify patients with repaired ToF. METHODS AND RESULTS We studied 875 patients after surgical repair for ToF (358 females, age 25.5 ± 11.7 year, range 7-75 years) who underwent CPET between 1999 and 2009. During a mean follow-up of 4.1 ± 2.6 years after CPET, 30 patients (3.4%) died or had sustained ventricular tachycardia (VT). 225 patients (25.7%) had other cardiac related events (emergency admission, surgery, or catheter interventions). On multivariable Cox regression-analysis, %predicted peak oxygen uptake (V˙O2 %) (p=0.001), resting QRS duration (p=0.030) and age (p<0.001) emerged as independent predictors of mortality or sustained VT. Patients with a peak V˙O2 ≤ 65% of predicted and a resting QRS duration ≥ 170 ms had a 11.4-fold risk of death or sustained VT. Ventilatory efficiency expressed as V˙E/V˙CO2 slope (p<0.001), peak V˙O2 % (p=.001), QRS duration (p=.001) and age (p=0.046) independently predicted event free survival. V˙E/V˙CO2 slope ≥ 31.0, peak V˙O2 % ≤ 65% and QRS duration ≥ 170 ms were the cut-off points with best sensitivity and specificity to detect an unfavorable outcome. CONCLUSIONS CPET is an important predictive tool that may assist in the risk stratification of patients with ToF. Subjects with a poor exercise capacity in addition to a prolonged QRS duration have a substantially increased risk for death or sustained ventricular tachycardia, as well as for cardiac-related hospitalizations.

Regional right ventricular deformation in patients with open and closed atrial septal defect.

AIMS This study aimed at (i) evaluating regional right ventricular (RV) deformation in patients with an atrial septal defect (ASD)-type secundum using strain and strain rate imaging and (ii) investigating the relation of regional deformation with functional capacity using cardiopulmonary exercise testing (CPET) in order to identify subclinical changes in RV function. METHODS AND RESULTS Forty-five patients with ASD-type secundum (18 open, 27 closed) and 20 age-matched controls were included. All underwent standard echocardiography and colour-Doppler myocardial velocity imaging. Longitudinal deformation was measured in the RV free wall divided in two segments. ASD patients underwent symptom-limited CPET. When compared with controls, apical strain was higher (-38.2 ± 9.9 vs. -29.9 ± 6.6%; P= 0.004) and lower (-25.2 ± 6.1 vs. -29.9 ± 6.6%; P= 0.006) in patients with an open and a closed ASD, respectively. Apical strain was higher (-38.2 ± 9.9 vs. -27.9 ± 6.6%; P= 0.001) and lower (-25.2 ± 6.1 vs. -28.7 ± 7.4%; P= 0.022) than basal strain in patients with an open and a closed ASD, respectively. In patients with an open ASD, apical strain correlated with shunt-ratio (R = -0.78; P< 0.0001), RV end-diastolic area (R = -0.68; P= 0.002), and RV stroke volume (R = -0.67; P= 0.002). Peak oxygen consumption (peak vO₂) was below average in patients with an open (79 ± 19% predicted; P< 0.0001) and a closed ASD (89 ± 18% predicted; P= 0.002). After ASD repair, apical strain correlated with peak vO₂ (R = -0.49; P= 0.01) and with ventilatory efficiency (R = 0.62; P= 0.001). CONCLUSION Volume overload of the right ventricle in patients with ASD-type secundum causes a regional deformation pattern with higher apical strain, related to parameters of volume load severity. After ASD repair, lower apical strain values correlated with functional capacity. Measurement of apical strain seems sensitive for detecting mild RV dysfunction.

Usefulness of cardiopulmonary exercise testing to predict the development of arterial hypertension in adult patients with repaired isolated coarctation of the aorta

BACKGROUND Patients who underwent surgery for aortic coarctation (COA) have an increased risk of arterial hypertension. We aimed at evaluating (1) differences between hypertensive and non-hypertensive patients and (2) the value of cardiopulmonary exercise testing (CPET) to predict the development or progression of hypertension. METHODS Between 1999 and 2010, CPET was performed in 223 COA-patients of whom 122 had resting blood pressures of <140/90 mmHg without medication, and 101 were considered hypertensive. Comparative statistics were performed. Cox regression analysis was used to assess the relation between demographic, clinical and exercise variables and the development/progression of hypertension. RESULTS At baseline, hypertensive patients were older (p=0.007), were more often male (p=0.004) and had repair at later age (p=0.008) when compared to normotensive patients. After 3.6 ± 1.2 years, 29/120 (25%) normotensive patients developed hypertension. In normotensives, VE/VCO2-slope (p=0.0016) and peak systolic blood pressure (SBP; p=0.049) were significantly related to the development of hypertension during follow-up. Cut-off points related to higher risk for hypertension, based on best sensitivity and specificity, were defined as VE/VCO2-slope ≥ 27 and peak SBP ≥ 220 mmHg. In the hypertensive group, antihypertensive medication was started/extended in 48/101 (48%) patients. Only age was associated with the need to start/extend antihypertensive therapy in this group (p=0.042). CONCLUSIONS Higher VE/VCO2-slope and higher peak SBP are risk factors for the development of hypertension in adults with COA. Cardiopulmonary exercise testing may guide clinical decision making regarding close blood pressure control and preventive lifestyle recommendations.

A genetic predisposition score for muscular endophenotypes predicts the increase in aerobic power after training: the CAREGENE study

BackgroundIt is widely accepted that genetic variability might explain a large part of the observed heterogeneity in aerobic capacity and its response to training. Significant associations between polymorphisms of different genes with muscular strength, anaerobic phenotypes and body composition have been reported. Muscular endophenotypes are positively correlated with aerobic capacity, therefore, we tested the association of polymorphisms in twelve muscular related genes on aerobic capacity and its response to endurance training.Methods935 Coronary artery disease patients (CAD) who performed an incremental exercise test until exhaustion at baseline and after three months of training were included. Polymorphisms of the genes were detected using the invader assay. Genotype-phenotype association analyses were performed using ANCOVA. Different models for a genetic predisposition score (GPS) were constructed based on literature and own data and were related to baseline and response VO2 scores.ResultsCarriers of the minor allele in the R23K polymorphism of the glucocorticoid receptor gene (GR) and the ciliary neurotrophic factor gene (CNTF) had a significantly higher increase in peakVO2 after training (p < 0.05). Carriers of the minor allele (C34T) in the adenosine monophosphate deaminase (AMPD1) gene had a significantly lower relative increase (p < 0.05) in peakVO2. GPS of data driven models were significantly associated with the increase in peakVO2 after training.ConclusionsIn CAD patients, suggestive associations were found in the GR, CNTF and the AMPD1 gene with an improved change in aerobic capacity after three months of training. Additionally data driven models with a genetic predisposition score (GPS) showed a significant predictive value for the increase in peakVO2.

The oxygen uptake efficiency slope in 1411 Caucasian healthy men and women aged 20–60 years: reference values

Background The oxygen uptake efficiency slope (OUES) has been proposed as an independent, reproducible and objective measure of cardiorespiratory function that does not require maximal exercise testing. Existing reference values have been published for healthy paediatric populations and healthy elderly. However, reference ranges and equations for healthy adults of working age are insufficiently documented. The aim of the present study was to establish prediction equations and to describe reference values for healthy men and women aged 20–60 years. Design Cross-sectional study. Methods One thousand four hundred and eleven (877 men) healthy individuals (mean age 38.6 years; range 20–60) completed a maximal graded cycle exercise test until volitional exhaustion. Subsequently, oxygen uptake was plotted against the logarithm of total ventilation and the OUES was calculated by means of linear regression analysis. Results Multivariate regression analyses revealed age, sex and body surface area as statistically significant determinants of the OUES. Following this, sex-specific prediction equations for the OUES were established and cross-validated. Finally, the distribution of the OUES with age was described and reference values were established for men and women separately. Conclusions This study established a comprehensive set of reference values and reference equations for the OUES for a healthy population of men and women aged between 20 and 60 years.

Prognostic value of the oxygen uptake efficiency slope and other exercise variables in patients with coronary artery disease.

Background Peak exercise capacity is an independent predictor for mortality in patients with coronary artery disease. However, sometimes cardiopulmonary exercise tests are stopped prematurely. Therefore, submaximal exercise measures such as the oxygen uptake efficiency slope have been introduced. The aim of this study was to assess the prognostic value of the oxygen uptake efficiency slope and other exercise parameters, in patients with coronary artery disease. Methods Between 2000 and 2011, 1409 patients with coronary artery disease (age 60.7 ± 9.9 years; 1205 males) underwent cardiopulmonary exercise tests. A maximal effort was not reached in 161 (11.5%) patients. The oxygen uptake efficiency slope was calculated and information on mortality was obtained. Cox proportional hazards regression analyses were used to assess the relation of oxygen uptake efficiency slope and other gas exchange variables with all-cause and cardiovascular mortality. Receiver operating characteristic curve analyses was performed to define optimal cut-off values. Results During an average follow-up of 7.45 ± 3.20 years (range 0.16–13.95 years), 158 patients died, among which 68 patients for cardiovascular reasons. The oxygen uptake efficiency slope was related to all-cause (hazard ratio: 0.568, p < 0.001) and cardiovascular (hazard ratio: 0.461, p < 0.001) mortality. When significant covariates were entered in the analysis, oxygen uptake efficiency slope remained related to mortality (p < 0.05). When other submaximal exercise parameters were added to the model, oxygen uptake efficiency slope and minute ventilation/carbon dioxide production slope also remained significantly related to mortality. Conclusion The oxygen uptake efficiency slope is an independent predictor for all-cause and cardiovascular mortality in patients with coronary artery disease, irrespective of a truly maximal effort during cardiopulmonary exercise tests. Furthermore, the oxygen uptake efficiency slope provides prognostic information, complementary to the minute ventilation/carbon dioxide production slope and peak exercise capacity.