Sandra Apelt

Benefits of whole body vibration training in patients hospitalised for COPD exacerbations - a randomized clinical trial

BackgroundPatients with stable COPD show improvements in exercise capacity and muscular function after the application of whole body vibration. We aimed to evaluate whether this modality added to conventional physiotherapy in exacerbated hospitalised COPD patients would be safe and would improve exercise capacity and quality of life.Methods49 hospitalised exacerbated COPD patients were randomized (1:1) to undergo physiotherapy alone or physiotherapy with the addition of whole body vibration. The primary endpoint was the between-group difference of the 6-minute walking test (day of discharge – day of admission). Secondary assessments included chair rising test, quality of life, and serum marker analysis.ResultsWhole body vibration did not cause procedure-related adverse events. Compared to physiotherapy alone, it led to significantly stronger improvements in 6-minute walking test (95.55 ± 76.29 m vs. 6.13 ± 81.65 m; p = 0.007) and St. Georges Respiratory Questionnaire (-6.43 ± 14.25 vs. 5.59 ± 19.15, p = 0.049). Whole body vibration increased the expression of the transcription factor peroxisome proliferator receptor gamma coactivator-1-α and serum levels of irisin, while it decreased serum interleukin-8.ConclusionWhole body vibration during hospitalised exacerbations did not cause procedure-related adverse events and induced clinically significant benefits regarding exercise capacity and health-related quality of life that were associated with increased serum levels of irisin, a marker of muscle activity.Trial registrationGerman Clinical Trials Register DRKS00005979. Registered 17 March 2014.

Sleep-disordered breathing in patients with implantable cardioverter-defibrillator

AIMS To assess the prognostic significance of screening for sleep-disordered breathing in patients with implantable cardioverter-defibrillator (ICD) with regard to appropriate ICD therapy and total mortality. METHODS AND RESULTS Overnight sleep studies were performed in 204 ICD recipients not known to have sleep apnoea and with no history of daytime sleepiness. Sleep-disordered breathing was diagnosed in the presence of an apnoea-hypopnea index of five or more events per hour. Seventy patients (34%) had no sleep apnoea, 105 patients (51%) had central sleep apnoea, and 29 patients (14%) had obstructive sleep apnoea. During 38 ± 26 months follow-up, 80 patients (39%) received appropriate ICD therapy for ventricular tachycardia (VT) or ventricular fibrillation (VF), and 54 patients (26%) died. On multivariate Cox regression analysis, age, left ventricular (LV) end-diastolic diameter, secondary prevention ICD indication, use of diuretics, and absence of aldosterone antagonist therapy but not sleep apnoea were associated with appropriate ICD therapy for VT or VF. In addition, multivariate Cox analysis identified age and LV ejection fraction but not sleep apnoea as predictors of total mortality. CONCLUSION Undiagnosed sleep-disordered breathing is common in ICD recipients. The presence and severity of previously unknown sleep apnoea in ICD recipients, however, does not appear to be an independent predictor of appropriate ICD therapy or morality during follow-up.

Tagesschläfrigkeit bei obstruktiver Schlafapnoe (OSA) – pathogenetische Faktoren

Excessive daytime sleepiness (EDS) is one of the most frequent symptoms in patients with obstructive sleep apnoea (OSA). EDS can lead to substantial impairments in quality of life and is a major cause of fatal accidents. However, not all patients with OSA develop EDS. The aim of this paper is to review the current literature to identify factors having an impact on sleepiness in patients with OSA. Interestingly, a substantial heterogeneity of the results was found. Summarising these results, causes of EDS in patients with OSA are multifactorial. Severity of obesity and breathing disorders (apnoea/hypopnoea index) seem to be the most important predictors. Continuous positive airway pressure therapy significantly reduces sleepiness in patients with OSA.

Exercise training leads to physiological left ventricular hypertrophy in COPD

Patients with chronic obstructive pulmonary disease (COPD) are affected by dyspnoea, limited exercise capacity and reduced quality of life [1,2]. COPD is associated with increased pulmonary vascular resistance, which leads to increased load of the right heart and decreased filling pressure and stroke volume of the left ventricle (LV). Cardiac involvement is usually considered as occurrence of cor pulmonale. Dedicated changes of the LV are less known. Since pulmonary rehabilitation was shown to provide beneficial effects, current COPD guidelines recommend exercise training in patients ranging from mild to severe disease (www.goldcopd.org) [3,4]. It is expected that the rate of hospitalizations and the perceived intensity of breathlessness is reduced. Pulmonary rehabilitation was shown to improve peripheral metabolism and breathing pattern, e.g. by reduced hyperinflation and increased respiratorymuscle endurance. It should be taken into account, that typical symptoms primarily attributed to COPD can also result, at least in part, from concomitant heart failure. Since exercise training is known to improve symptomsof heart failure, it is hypothesized thatmoderate exercise training exhibits beneficial effects on LV morphology and function in COPD. A total of 10 patients with stable COPD (Table 1) in accordance to the GOLD criteria based on spirometry [1] were enrolled into this prospective study. Spirometry was performed in standardized manner including the forced expiratory volume in the first second (FEV1), vital capacity (VC), the Tiffeneau ratio and carbon monoxide diffusion capacity (DLCO). Capillary blood gas analysis was performed under resting conditions. Medical treatment consisted of inhalation therapy and oral medication of hypertension. An intensive physical exercise training was initiated and follow up examinations were performed after 6 months of continued training. Spirometry, echocardiographyand concentration of Btype natriuretic peptide (BNP) was assessed at time of enrolment and at follow up [5]. The study was approved by the local institutional ethics committee and written informed consent was obtained from all study participants. Echocardiography was used to measure LV enddiastolic and endsystolic cavity diameters, interventricular septum and posterior wall thickness. LV enddiastolic volume (LVEDV), endsystolic volume (LVESV), strokevolume (LVSV), ejection fraction (LVEF) and LVmasswas obtained based on the Penn-cube convention [6–8]. LV enddiastolic and endsystolic wall stress was calculated using a thick-walled spheremodel and the wall stress index as described [9]. Although we have previously shown that an echocardiography based approach overestimates LV mass and underestimates LVwall stress when comparedwith cardiacmagnetic resonance imaging [8], the present study is valid since similar methods were used at time of enrolment and follow up. An individualized structured training program includingwarming up, strength and endurance components twice a week was initiated and continued over 6 months. Within the first 3 months, training for the improvement of maximal strength and endurance was done. In the second half, it was aimed to maintain the achieved physical status. Strength training consisted of consecutive exercises of the upper and lower limbs (rowing, pulling down forces, rope pulling, knee bends). Subsequently, 12 min of cycle ergometer endurance training was performed. Every 3 weeks, the maximal individual force development was measured and exercise intensity was increased from 35% at the beginning up to 80% within the first 3 months. In parallel, endurance intensity was continuously increased from 60% to 125% of the maximal

The missing link between heart failure and sleep disordered breathing: increased left ventricular wall stress.

I study, we observed that the infusion of the combination cell product did not elicit, both in control and treated patients, any significant change in LVEF (Table 2A). Likewise in both group of patients, SSS and SRS values after three months of follow up did not significantly differ to those at baseline. In turn, in the group of treated but not in control patients we noticed a statistically significant decrease (p: 0.03) in SDS values, at 3 months of follow up (Table 2B). These findings are suggestive of a noteworthy decrease in myocardial ischemic burden triggered by the infusion of the combination cell product. The above assumption correlates with an improvement in quality of life measurements and a decreased nitroglycerin consumption (data not shown). The observed change in myocardial ischemic burden following intracoronary infusion of the cell product, gives strength to the contention that the infusion of a combination of ECs andMSC promotes the development of mature and stable new blood vessels. The previous assumption is also in agreement with the observation that after an acute MI, while the number of circulating EC precursors is within acceptable limits the level of circulating MSC is extremely low [6]. Whether the results here reported prove to be momentous, the concurrent infusion of a source of EC and MSC gains strength as a novel therapeutic modality to treat MI.

Benefits of High-Intensity Exercise Training to Patients with Chronic Obstructive Pulmonary Disease: A Controlled Study

Background: Various exercise training programs are used for patients with chronic obstructive pulmonary disease (COPD) of different severity. Objectives: To investigate the impact of individualized high-intensity training on exercise capacity with COPD. Methods: A total of 49 patients agreed to participate. Of these, 31 were assigned to the training group and 18 served as controls. The training group exercised twice a week for 90 min with consecutively increasing loads. At the time of enrollment (T0), as well as after 3 (T1) and 6 (T2) months, a 6-min walk test (6-MWT) was performed and data on health-related quality of life, femoral muscle thickness, and various serum markers were obtained. Results: The training group improved in their 6-MWT results (T0 = 407 ± 152 m vs. T1 = 459 ± 127 m, p = 0.002, vs. T2 = 483.2 ± 130.1 m, p = 0.004), in their cross-sectional area of the musculus rectus femoris (T0 = 6.2 ± 1.2 cm2 vs. T1 = 6.9 ± 1.2 cm2, p = 0.003, vs. 7.5 ± 1.6 cm2, p = 0.002), and in their St. Georges Respiratory Questionnaire (SGRQ) score (T0 = 43.3 ± 18.0 vs. T1 = 36.0 ± 18.4, p = 0.001, vs. T2 = 34.7 ± 18. 0, p = 0.004). Serum levels of myostatin, irisin, resistin, and α-Klotho did not change significantly within the training period. Of note, the exercise group showed an inverse relationship between serum levels of resistin and those of α-Klotho after 6 months (r = -0.608, p = 0.021). Conclusions: COPD patients undergoing an individualized, structured, high-intensity training program improved their exercise capacity, gained muscle mass, and improved their quality of life.

Severe central sleep apnea is associated with atrial fibrillation in patients with left ventricular systolic dysfunction.

The results of previous studies investigating the association between atrial fibrillation (AF) and central sleep apnea (CSA) in patients with left ventricular (LV) systolic dysfunction are contradictory.

Messung von Schlafdauer und Schlafqualität

ZusammenfassungDie Erholungsfunktion des Schlafes ist für die Schlafmedizin von wesentlichem Interesse. Zur Erfassung dieser Funktion werden verschiedene Faktoren herangezogen, unter denen der Schlafdauer und Schlafqualität eine besondere Bedeutung zukommt. Beide Begriffe stehen im Zentrum des Schlaferlebens, das letztlich die Zufriedenheit des Individuums mit der im Schlaf verbrachten Zeit ausdrückt. Die Schlafmedizin und Schlafforschung haben in den letzten Jahrzehnten Methoden entwickelt, die sowohl eine Erfassung der subjektiven als auch objektiven Dimension ermöglichen. Im subjektiven Bereich ist dies vor allem die schlafmedizinisch fokussierte Anamnese. Unterstützend werden standardisierte und validierte Fragebögen eingesetzt. Objektive Methoden sind zum Beispiel die Abschätzung der Schlaf- und Wachzeiten durch die Aktigraphie und Polygraphie. Die Polysomnographie ist unverändert der Goldstandard insbesondere bei multimorbiden Patienten. Eine wesentliche Tendenz der letzten Jahre ist es, die Messungen für den Betroffenen so störungsfrei wie möglich zu halten und von der stationären Überwachung zur Untersuchung im häuslichen Umfeld zu gelangen.AbstractRestorative functions of sleep are of special interest for sleep medicine. For the assessment of these restorative functions, various parameters are taken into account, among which sleep duration and sleep quality play the most important roles. Both terms are essential for sleep perception, expressing the subjective satisfaction of the individual with the time spent asleep. In recent decades, sleep medicine and sleep research have developed methods for the assessment of both objective and subjective dimensions of sleep. Among subjective methods, taking of the medical history focusing on the patient’s sleep is important. Standardized and validated questionnaires play a supportive role. Objective methods are, for example, estimation of the sleep–wake cycle by means of actigraphy and polygraphy. Especially in multimorbid patients, polysomnography is still the gold standard method for diagnostics. An important approach during recent years is shifting from bothering overnight examinations into less disturbing procedures for patients that include performing ambulatory, outpatient examinations in the patients’ home rather than inpatient surveillance within sleep centers.

Measuring sleep duration and sleep quality

ZusammenfassungDie Erholungsfunktion des Schlafes ist für die Schlafmedizin von wesentlichem Interesse. Zur Erfassung dieser Funktion werden verschiedene Faktoren herangezogen, unter denen der Schlafdauer und Schlafqualität eine besondere Bedeutung zukommt. Beide Begriffe stehen im Zentrum des Schlaferlebens, das letztlich die Zufriedenheit des Individuums mit der im Schlaf verbrachten Zeit ausdrückt. Die Schlafmedizin und Schlafforschung haben in den letzten Jahrzehnten Methoden entwickelt, die sowohl eine Erfassung der subjektiven als auch objektiven Dimension ermöglichen. Im subjektiven Bereich ist dies vor allem die schlafmedizinisch fokussierte Anamnese. Unterstützend werden standardisierte und validierte Fragebögen eingesetzt. Objektive Methoden sind zum Beispiel die Abschätzung der Schlaf- und Wachzeiten durch die Aktigraphie und Polygraphie. Die Polysomnographie ist unverändert der Goldstandard insbesondere bei multimorbiden Patienten. Eine wesentliche Tendenz der letzten Jahre ist es, die Messungen für den Betroffenen so störungsfrei wie möglich zu halten und von der stationären Überwachung zur Untersuchung im häuslichen Umfeld zu gelangen.AbstractRestorative functions of sleep are of special interest for sleep medicine. For the assessment of these restorative functions, various parameters are taken into account, among which sleep duration and sleep quality play the most important roles. Both terms are essential for sleep perception, expressing the subjective satisfaction of the individual with the time spent asleep. In recent decades, sleep medicine and sleep research have developed methods for the assessment of both objective and subjective dimensions of sleep. Among subjective methods, taking of the medical history focusing on the patient’s sleep is important. Standardized and validated questionnaires play a supportive role. Objective methods are, for example, estimation of the sleep–wake cycle by means of actigraphy and polygraphy. Especially in multimorbid patients, polysomnography is still the gold standard method for diagnostics. An important approach during recent years is shifting from bothering overnight examinations into less disturbing procedures for patients that include performing ambulatory, outpatient examinations in the patients’ home rather than inpatient surveillance within sleep centers.

Sleep disordered breathing and nonsustained ventricular tachycardia in patients with chronic heart failure

SummaryBACKGROUND: Patients with chronic heart failure (CHF) have a high incidence of sleep disordered breathing (SDB). It is assumed that patients with the combination of CHF and SDB have more ventricular couplets and nonsustained ventricular tachycardia (NSVT) than patients without SDB. METHODS: In 63 patients, 49 men and 14 women with chronic heart failure (EF < 45%), all-night polysomnography and long-term-ECG were performed. Mean age was 59 ± 15 years, mean BMI 27 ± 5 kg/m2. 56% had an ischemic, 44% a nonischemic heart disease. 51% had heart insufficiency classification NYHA III. RESULTS: 42 of the 63 patients (67%) had sleep disordered breathing (SDB) with an AHI ≥5/h. In 24 patients (38%) SDB was central, in 18 (29%) obstructive. More patients with SDB than patients without SDB had NSVT (50% vs. 19%). Nocturnal frequency of NSVT in patients with SDB was about twice as high as the rate observed during daytime (0.48/h vs. 0.21/h). In patients without SDB there was no relevant difference between day and night (0.23/h vs. 0.21/h). AHI correlated with NSVT (r = 0.329, p < 0.01). Day/night comparison of couplets was 2.3/h vs. 1.9/h in SDB patients and 2.0/h vs. 1.6/h in patients without SDB. CONCLUSIONS: Patients with chronic heart failure have a high prevalence of SDB. The combination of CHF and SDB predisposes for nocturnal malignant ventricular arrhythmias.ZusammenfassungEINLEITUNG: Bei Patienten mit chronischer Herzinsuffizienz ist eine erhöhte Inzidenz schlafbezogener Atmungsstörungen (SBAS) bekannt. In dieser Studie wurde untersucht, ob Patienten mit der Kombination aus chronischer Herzinsuffizienz und SBAS nachts häufiger ventrikuläre Tachyarrhythmien (Couplets, nichtanhaltende ventrikuläre Tachykardien) aufweisen als Patienten mit chronischer Herzinsuffizienz ohne SBAS. METHODE: Bei 63 Patienten, 49 Männer und 14 Frauen, mit chronischer Herzinsuffizienz (Ejektionsfraktion <45 %) wurden eine Polysomnographie sowie eine Langzeit-EKG-Registrierung durchgeführt. Das Alter der Patienten betrug im Mittel 59 ± 15 Jahre, der BMI 27 ± 5 kg/m2. Bei 56 % der Patienten lag eine ischämische, bei 44 % eine nichtischämische Herzerkrankung vor. 51 % der Patienten hatten eine Herzinsuffizienz der NYHA-Klasse III. ERGEBNISSE: Bei 42 der 63 Patienten konnte eine SBAS (AHI ≥ 5/h) nachgewiesen werden (67 %). 24 hatten eine primär zentrale (38 %), 18 eine obstruktive Atmungsstörung (29 %). Nicht-anhaltende ventrikuläre Tachykardien waren bei mehr Patienten mit SBAS als bei Patienten ohne SBAS nachweisbar (50 % vs. 19 %). Die Frequenz von NVT war bei den Patienten mit SBAS im Zeitsegment Nacht mit 0,48/h vs. 0,21/h verdoppelt, bei den Patienten ohne SBAS war kein relevanter Tag/Nacht Unterschied (0,23/h vs. 0,21/h) festzustellen. Der AHI korrelierte signifikant mit der Anzahl an NVT (r = 0,329, p < 0,01). Beim Vergleich der Couplets Tag vs. Nacht betrug die Häufigkeit bei den Patienten mit SBAS tagsüber 2,3/h, nachts 1,9/h, bei den Patienten ohne SBAS 2,0/h vs. 1,6/h. DISKUSSION: Schlafbezogene Atmungsstörungen sind bei Patienten mit chronischer Herzinsuffizienz häufig zu finden. Sie prädisponieren zum Auftreten von nächtlichen höhergradigen ventrikulären Herzrhythmusstörungen.BACKGROUND Patients with chronic heart failure (CHF) have a high incidence of sleep disordered breathing (SDB). It is assumed that patients with the combination of CHF and SDB have more ventricular couplets and nonsustained ventricular tachycardia (NSVT) than patients without SDB. METHODS In 63 patients, 49 men and 14 women with chronic heart failure (EF < 45%), all-night polysomnography and long-term-ECG were performed. Mean age was 59 ± 15 years, mean BMI 27 ± 5 kg/m(2). 56% had an ischemic, 44% a nonischemic heart disease. 51% had heart insufficiency classification NYHA III. RESULTS 42 of the 63 patients (67%) had sleep disordered breathing (SDB) with an AHI ≥5/h. In 24 patients (38%) SDB was central, in 18 (29%) obstructive. More patients with SDB than patients without SDB had NSVT (50% vs. 19%). Nocturnal frequency of NSVT in patients with SDB was about twice as high as the rate observed during daytime (0.48/h vs. 0.21/h). In patients without SDB there was no relevant difference between day and night (0.23/h vs. 0.21/h). AHI correlated with NSVT (r = 0.329, p < 0.01). Day/night comparison of couplets was 2.3/h vs. 1.9/h in SDB patients and 2.0/h vs. 1.6/h in patients without SDB. CONCLUSIONS Patients with chronic heart failure have a high prevalence of SDB. The combination of CHF and SDB predisposes for nocturnal malignant ventricular arrhythmias.