Victor Ribeiro Neves

Effects of progressive exercise during phase I cardiac rehabilitation on the heart rate variability of patients with acute myocardial infarction

Purpose. Heart rate variability (HRV) decreases after an acute myocardial infarction (AMI) due to changes in cardiac autonomic balance. The purpose of the present study, therefore, was to evaluate the effects of a progressive exercise protocol used in phase I cardiac rehabilitation on the HRV of patients with post-AMI. Material and methods. Thirty-seven patients who had been admitted to hospital with their first non-complicated AMI were studied. The treated group (TG, n = 21, age = 52 ± 12 years) performed a 5-day programme of progressive exercise during phase I cardiac rehabilitation, while the control group (CG, n = 16, age = 54 ± 11 years) performed only respiratory exercises. Instantaneous heart rate (HR) and RR interval were acquired by a HR monitor (Polar®S810i). HRV was analysed by frequency domain methods. Power spectral density was expressed as normalised units (nu) at low (LF) and high (HF) frequencies, and as LF/HF. Results. After 5 days of progressive exercise, the TG showed an increase in HFnu (35.9 ± 19.5 to 65.19 ± 25.4) and a decrease in LFnu and LF/HF (58.9 ± 21.4 to 32.5 ± 24.1; 3.12 ± 4.0 to 1.0 ± 1.5, respectively) in the resting position (p < 0.05). No changes were observed in the CG. Conclusions. A progressive physiotherapeutic exercise programme carried out during phase I cardiac rehabilitation, as supplement to clinical treatment increased vagal and decreased sympathetic cardiac modulation in patients with post-AMI.

Relationship between inspiratory muscle capacity and peak exercise tolerance in patients post-myocardial infarction

OBJECTIVE The study objective was to evaluate inspiratory muscle endurance in patients post-myocardial infarction without respiratory muscle weakness and its correlation with peak exercise capacity. METHODS Ten patients who recently had a myocardial infarction (recent infarction group [RIG]), 9 patients who less recently had a myocardial infarction (less recent infarction group [LIG]), and 12 healthy subjects (control group [CG]) underwent a cardiopulmonary exercise test and respiratory endurance protocol. Analysis of variance with post hoc Dunn comparisons was used to contrast performances on all tests, and Pearsons correlation was used to determine associations between variables. RESULTS The RIG presented lower maximal incremental pressure and oxygen consumption than the CG (P < .01). There was a positive correlation between peak oxygen uptake and both maximal inspiratory pressure (.68, P < .001) and maximal incremental pressure (.65, P < .001) in the RIG. CONCLUSION The RIG showed lower maximal incremental pressure, which is related to peak exercise capacity. This novel relationship in functional capacity can indicate the need to improve muscle endurance in these patients even in the absence of inspiratory muscle weakness.

Respiratory muscle endurance is limited by lower ventilatory efficiency in post-myocardial infarction patients

Background Reduced respiratory muscle endurance (RME) contributes to increased dyspnea upon exertion in patients with cardiovascular disease. Objective The objective was to characterize ventilatory and metabolic responses during RME tests in post-myocardial infarction patients without respiratory muscle weakness. Method Twenty-nine subjects were allocated into three groups: recent myocardial infarction group (RG, n=9), less-recent myocardial infarction group (LRG, n=10), and control group (CG, n=10). They underwent two RME tests (incremental and constant pressure) with ventilatory and metabolic analyses. One-way ANOVA and repeated measures one-way ANOVA, both with Tukey post-hoc, were used between groups and within subjects, respectively. Results Patients from the RG and LRG presented lower metabolic equivalent and ventilatory efficiency than the CG on the second (50± 06, 50± 5 vs. 42± 4) and third part (50± 11, 51± 10 vs. 43± 3) of the constant pressure RME test and lower metabolic equivalent during the incremental pressure RME test. Additionally, at the peak of the incremental RME test, RG patients had lower oxygen uptake than the CG. Conclusions Post-myocardial infarction patients present lower ventilatory efficiency during respiratory muscle endurance tests, which appears to explain their inferior performance in these tests even in the presence of lower pressure overload and lower metabolic equivalent.

Heart rate dynamics after exercise in cardiac patients with and without type 2 diabetes

Purpose: The incidence of cardiovascular events is higher in coronary artery disease patients with type 2 diabetes (CAD + T2D) than in CAD patients without T2D. There is increasing evidence that the recovery phase after exercise is a vulnerable phase for various cardiovascular events. We hypothesized that autonomic regulation differs in CAD patients with and without T2D during post-exercise condition. Methods: A symptom-limited maximal exercise test on a bicycle ergometer was performed for 68 CAD + T2D patients (age 61 ± 5 years, 78% males, ejection fraction (EF) 67 ± 8, 100% on β-blockade), and 64 CAD patients (age 62 ± 5 years, 80% males, EF 64 ± 8, 100% on β-blockade). Heart rate (HR) recovery after exercise was calculated as the slope of HR during the first 60 s after cessation of exercise (HRRslope). R–R intervals were measured before (5 min) and after exercise from 3 to 8 min, both in a supine position. R–R intervals were analyzed using time and frequency methods and a detrended fluctuation method (α1). Results: BMI was 30 ± 4 vs. 27 ± 3 kg m2 (p < 0.001); maximal exercise capacity, 6.5 ± 1.7 vs. 7.7 ± 1.9 METs (p < 0.001); maximal HR, 128 ± 19 vs. 132 ± 18 bpm (p = ns); and HRRslope, −0.53 ± 0.17 vs. −0.62 ± 0.15 beats/s (p = 0.004), for CAD patients with and without T2D, respectively. There was no differences between the groups in HRRslope after adjustment for METs, BMI, and medication (ANCOVA, p = 0.228 for T2D and, e.g., p = 0.030 for METs). CAD + T2D patients had a higher HR at rest than non-diabetic patients (57 ± 10 vs. 54 ± 6 bpm, p = 0.030), but no other differences were observed in HR dynamics at rest or in post-exercise condition. Conclusion: HR recovery is delayed in CAD + T2D patients, suggesting impairment of vagal activity and/or augmented sympathetic activity after exercise. Blunted HR recovery after exercise in diabetic patients compared with non-diabetic patients is more closely related to low exercise capacity and obesity than to T2D itself.

Segurança da intervenção fisioterápica precoce após o infarto agudo do miocárdio

INTRODUCTION: Physical therapy during phase I of cardiac rehabilitation (CPT) can be started 12 to 24 hours after acute myocardial infarction (AMI), however, it is common to extend the bed rest due to fear of patient’s instability. OBJECTIVES: To assess the hemodynamic and autonomic responses to post-AMI patients when subjected to first day of phase I protocol of CPT, as well as their safety. MATERIALS AND METHODS: We studied 51 patients with first uncomplicated AMI, 55 ± 11 years, 76% men. The patients were subjected to first day protocol phase I CPT, on average, 24 hours after AMI. The Instantaneous heart rate (HR) and RR interval were acquired by HR monitor (Polar™S810i) and blood pressure (BP) checked by auscultation. HR variability was analyzed in the time (RMSSD and RMSM-Ri in ms) and frequency domains. Power spectral density was expressed in absolute (ms2/Hz) and normalized (nu) units for the bands of low (LF) and high frequencies (HF) and as LF/HF ratio. RESULTS: The RMSSD, HF and HFnu have reduced performance of the exercises in relation to rest and post-exercise (p < 0.05), LFnu and LF/HF ratio increased (p < 0.05). HR and systolic BP showed an increase during the execution of the exercises in relation to rest (p < 0.05). There were no any signs and/or symptoms of exercise intolerance. CONCLUSION: The exercise was effective, because it caused changes hemodynamic and autonomic modulation in these patients, without causing any medical complications.

Diferenças regionais e custos dos procedimentos de fisioterapia no Sistema Único de Saúde do Brasil, 1995 a 2008

OBJETIVO: Descrever os atendimentos ambulatoriais fisioterapicos prestados pelo Sistema Unico de Saude (SUS) no Brasil quanto a sua distribuicao geografica, custos, tipos de procedimento e tipos de prestador. METODOS: Foram utilizados dados do Departamento de Informatica do SUS (DATASUS), referentes ao periodo de 1995 a 2008, que incluiam a quantidade e o valor dos procedimentos aprovados para pagamento pelas Secretarias de Saude e a quantidade e o valor dos procedimentos apresentados para pagamento. Os coeficientes de atendimento (CoA) foram calculados dividindo-se o numero de atendimentos no ano em uma regiao pela populacao estimada no mesmo ano e regiao. RESULTADOS: O CoA no Brasil em 2008 foi de 0,19 e as regioes Norte e Centro-Oeste apresentaram os menores coeficientes (0,13 e 0,10, respectivamente). Entre 1995 e 2007 houve um crescimento no coeficiente nacional de atendimentos de 33,7%, sendo que a regiao Norte apresentou o maior aumento, de 143,8%, a Centro-Oeste, de 62,1%, e a Nordeste, de 56,1%. O atendimento nas alteracoes motoras foi o procedimento mais realizado (61,8%) e os valores de pagamento aprovados foram menores que os apresentados pelos gestores dos servicos em 2008 (10,4%). Estabelecimentos privados com fins lucrativos prestaram 44,5% dos atendimentos fisioterapicos pagos pelo SUS em 2008. Os estabelecimentos municipais responderam por 26,6% dos atendimentos e os federais por apenas 0,9%. Entre 1995 e 2007, a quantidade de atendimentos oferecidos pelos estabelecimentos municipais cresceu 278,7%. CONCLUSOES: Observou-se que a oferta de atendimento fisioterapico ambulatorial pelo SUS ainda e pequena e geograficamente desigual, embora regioes menos desenvolvidas apresentem um maior crescimento no CoA. O SUS remunera inadequadamente os servicos prestados em fisioterapia e ainda o faz, em grande parte, por meio de convenios com estabelecimentos privados.