Wilby Williamson

Clinical cardiovascular risk during young adulthood in offspring of hypertensive pregnancies: insights from a 20-year prospective follow-up birth cohort

Objectives Offspring of hypertensive pregnancies have increased cardiovascular risk factors during childhood. We hypothesised that offspring of hypertensive pregnancies would demonstrate increased clinical levels of hypertension by young adult life, which would be proportional to the severity of the pregnancy complication. Design Prospective birth cohort study Setting Tertiary obstetric hospital. Participants 2868 young adult offspring of women enrolled during pregnancy into the Western Australia Pregnancy Cohort (Raine) Study. Main outcome measures Cardiovascular risk, including incidence of hypertension and metabolic disease, in those born to hypertensive compared to normotensive pregnancies. Results Young adult offspring of hypertensive pregnancies were 2.5 times (95% CI 1.32 to 4.56, p=0.004) more likely to have global lifetime risk (QRISK) scores above the 75th centile. Thirty per cent of 20 year olds with hypertensive blood pressures were born following a hypertensive pregnancy. Pre-eclampsia or hypertension resulting in preterm birth associated with a threefold (95% CI 1.3 to 7.0, p=0.01) greater risk of being hypertensive by age 20 years, with no differences in body mass index. Whereas pregnancy-induced hypertension associated with a smaller 3±1 mm Hg blood pressure rise (p=0.001) and a twofold (95% CI 1.5 to 2.8, p=0.001) greater risk of being obese or overweight. Risk factor associations were consistent throughout early life and independent of other birth-factors. Conclusions Incidence of offspring hypertension was significantly increased in those whose mothers had a more complicated pregnancy history, including preterm birth and pre-eclampsia.

Behavioural physical activity interventions in participants with lower-limb osteoarthritis: a systematic review with meta-analysis

Objective To assess effectiveness of osteoarthritis interventions to promote long-term physical activity behaviour change. Design A systematic review and meta-analysis. Protocol registration PROSPERO CRD4201300444 5 (http://www.crd.york.ac.uk/prospero/). Study selection Randomised controlled trials (RCTs) comparing physical activity interventions with placebo, no/or minimal intervention in community-dwelling adults with symptomatic knee or hip osteoarthritis. Primary outcomes were change in physical activity or cardiopulmonary fitness after a minimum follow-up of 6 months. Data extraction Outcomes were measures of physical activity (self-reported and objectively measured) and cardiovascular fitness. Standard mean differences between postintervention values were used to describe the effect sizes. Results 27 984 titles were screened and 180 papers reviewed in full. Eleven RCTs satisfied inclusion criteria, total study population of 2741 participants, mean age 62.2. The commonest reasons for study exclusion were follow-up less than 6 months and no physical activity measures. The majority of included interventions implement an arthritis self-management programme targeting coping skills and self-efficacy. Seven studies used self-report measures, the pooled effect of these studies was small with significant heterogeneity between studies (SMD 0.22 with 95% CI −0.11 to 0.56, z=1.30 (p=0.19) I2 statistic of 85%). Subgroup analysis of 6–12 month outcome reduced heterogeneity and increased intervention effect compared to control (SMD 0.53, 95% CI 0.41 to 0.65, z=8.84 (p<0.00001) I2 of 66%). Conclusions Arthritis self-management programmes achieve a small but significant improvement in physical activity in the short term. Effectiveness of intervention declines with extended follow-up beyond 12 months with no significant benefit compared to control. The small number of studies (11 RCTs) limited ability to define effective delivery methods. Investigation of behavioural lifestyle interventions for lower limb osteoarthritis populations would benefit from consensus on methodology and outcome reporting. This includes use of validated physical activity reporting tools and planning for long-term follow-up.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension? A Systematic Review and Meta-Analysis.

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18–40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of −4.40 mm Hg (95% confidence interval, −5.78 to −3.01) and in diastolic blood pressure of −4.17 mm Hg (95% confidence interval, −5.42 to −2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure −1.02 mm Hg (95% confidence interval, −2.34 to 0.29), and in diastolic blood pressure −0.91 mm Hg (95% confidence interval, −1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

Influencing health-related behaviour with wearable cameras: strategies & ethical considerations

BACKGROUND: The growing global burden of noncommunicable diseases makes it important to monitor and influence a range of health-related behaviours such as diet and physical activity Wearable cameras appear to record and reveal many of these behaviours in more accessible ways. However, having determined opportunities for improvement, most health-related interventions fail to result in lasting changes. AIM: To assess the use of wearable cameras as part of a behaviour change strategy and consider ethical implications of their use. METHODS: We examine relevant principles from behavioural science theory and consider the way images enhance or change the processes which underpin behaviour change. We propose ways for researchers to instigate the use of and engagement with these images to lead to more effective and long-lasting behaviour change interventions. We also consider the ethical implications of using digital life-logging technologies in these ways. We discuss the potential harms and benefits of such approaches for both the wearer and those they meet. DISCUSSION: Future behaviour change strategies based on self-monitoring could consider the use of wearable cameras. It is important that such work considers the ethical implications of this research and adheres to accepted guidelines and principles.

Physiological Stress Elicits Impaired Left Ventricular Function in Preterm-Born Adults.

Background Experimental and clinical studies show that prematurity leads to altered left ventricular (LV) structure and function with preserved resting LV ejection fraction (EF). Large-scale epidemiological data now links prematurity to increased early heart failure risk. Objectives The authors performed echocardiographic imaging at prescribed exercise intensities to determine whether preterm-born adults have impaired LV functional response to physical exercise. Methods We recruited 101 normotensive young adults born preterm (n = 47; mean gestational age 32.8 ± 3.2 weeks) and term (n = 54) for detailed cardiovascular phenotyping. Full clinical resting and exercise stress echocardiograms were performed, with apical 4-chamber views collected while exercising at 40%, 60%, and 80% of peak exercise capacity, determined by maximal cardiopulmonary exercise testing. Results Preterm-born individuals had greater LV mass (p = 0.015) with lower peak systolic longitudinal strain (p = 0.038) and similar EF to term-born control subjects at rest (p = 0.62). However, by 60% exercise intensity, EF was 6.7% lower in preterm subjects (71.9 ± 8.7% vs 78.6 ± 5.4%; p = 0.004) and further declined to 7.3% below the term-born group at 80% exercise intensity (69.8 ± 6.4% vs 77.1 ± 6.3%; p = 0.004). Submaximal cardiac output reserve was 56% lower in preterm-born subjects versus term-born control subjects at 40% of peak exercise capacity (729 ± 1,162 ml/min/m2 vs. 1,669 ± 937 ml/min/m2; p = 0.021). LV length and resting peak systolic longitudinal strain predicted EF increase from rest to 60% exercise intensity in the preterm group (r = 0.68, p = 0.009 and r = 0.56, p = 0.031, respectively). Conclusions Preterm-born young adults had impaired LV response to physiological stress when subjected to physical exercise, which suggested a reduced myocardial functional reserve that might help explain their increased risk of early heart failure. (Young Adult Cardiovascular Health sTudy [YACHT]; NCT02103231)

Time to rethink physical activity advice and blood pressure: A role for occupation-based interventions?

Cardiovascular death is the leading cause of mortality in women. Low physical fitness and sedentary behaviour are recognized as major risk factors and increased physical activity is therefore promoted as a strategy to reduce cardiovascular risk. Recommendations advise at least 150 minutes of moderate to vigorous activity per week and, when possible, reduced sitting time, with cardiovascular benefits gained from as little as 15 minutes of exercise per day. The same recommendations apply to patients with a history of cardiovascular disease, such as myocardial infarction or chronic heart failure, and systematic review evidence supports the use of aerobic exercise and resistance training in other chronic disease management settings, including blood pressure control. A major challenge for the health care community is the delivery of affordable interventions, which maintain increased physical activity behaviour in the long term, to sustain the health benefits. Environmental and lifestyle modifications across a range of domains – including transport, leisure, home and education – provide an important opportunity to increase activity within a population. Workplacebased physical activity interventions in particular have been identified as a way to provide effective risk reduction and, reassuringly, the reported incidence of serious adverse events in randomized control trials and within disease populations undergoing cardiac rehabilitation programmes is low. However, despite this volume of evidence that physical activity is good, it is possible that cardiovascular risk is increased in some people during certain types of exercise. Physical activity increases blood pressure, with heavy resistance exercise being associated with the most extreme transient changes in systolic levels. This type of static exercise reduces venous return and increases the cardiac afterload as well as strain. The presence of disease may further exacerbate these increases in blood pressure as people at risk of hypertension are known to have an exaggerated blood pressure response to exercise. People who exhibit this response are at increased risk of stroke and cardiovascular death. Similar transient physiological stresses to those observed in resistance exercise programmes may occur in occupational settings where people lift or manoeuvre heavy loads. Allesoe et al. have reported a prospective cohort study that explores the association between questionnaire-reported workplace physical activity and incident ischaemic heart disease retrieved from a national register of hospital discharges. They found that, in an occupational setting, self-reported high physical activity levels in women with hypertension were associated with a three-fold greater risk of future ischaemic heart disease than that seen in normotensive women who reported moderate physical activity at work. This is a novel finding in a population of over 12,000 women monitored prospectively for nearly 15 years. Previous occupation-based studies have tended to focus on male employees and therefore the authors should be commended for addressing this relevant question in a female population. There are distinct features of cardiovascular disease specific to women, such as the development of early hypertension related to pregnancy, as well as unique patterns of aortic and cardiac remodelling that may be relevant to their blood pressure response and warrant tailored primary prevention advice. The type of occupation may need to be part of this advice, but, equally, occupation may be important because it offers a setting and

Association of Cardiovascular Risk Factors With MRI Indices of Cerebrovascular Structure and Function and White Matter Hyperintensities in Young Adults.

Importance Risk of stroke and brain atrophy in later life relate to levels of cardiovascular risk in early adulthood. However, it is unknown whether cerebrovascular changes are present in young adults. Objective To examine relationships between modifiable cardiovascular risk factors and cerebrovascular structure, function, and white matter integrity in young adults. Design, Setting, and Participants A cross-sectional observational study of 125 young adults (aged 18-40 years) without clinical evidence of cerebrovascular disease. Data collection was completed between August 2014 and May 2016 at the University of Oxford, United Kingdom. Final data collection was completed on May 31, 2016. Exposures The number of modifiable cardiovascular risk factors at recommended levels, based on the following criteria: body mass index (BMI) <25; highest tertile of cardiovascular fitness and/or physical activity; alcohol consumption <8 drinks/week; nonsmoker for >6 months; blood pressure on awake ambulatory monitoring <130/80 mm Hg; a nonhypertensive diastolic response to exercise (peak diastolic blood pressure <90 mm Hg); total cholesterol <200 mg/dL; and fasting glucose <100mg/dL. Each risk factor at the recommended level was assigned a value of 1, and participants were categorized from 0-8, according to the number of risk factors at recommended levels, with higher numbers indicating healthier risk categories. Main Outcomes and Measures Cerebral vessel density, caliber and tortuosity, brain white matter hyperintensity lesion count. In a subgroup (n = 52), brain blood arrival time and cerebral blood flow assessed by brain magnetic resonance imaging (MRI). Results A total of 125 participants, mean (SD) age 25 (5) years, 49% women, with a mean (SD) score of 6.0 (1.4) modifiable cardiovascular risk factors at recommended levels, completed the cardiovascular risk assessment and brain MRI protocol. Cardiovascular risk factors were correlated with cerebrovascular morphology and white matter hyperintensity count in multivariable models. For each additional modifiable risk factor categorized as healthy, vessel density was greater by 0.3 vessels/cm3 (95% CI, 0.1-0.5; P = .003), vessel caliber was greater by 8 &mgr;m (95% CI, 3-13; P = .01), and white matter hyperintensity lesions were fewer by 1.6 lesions (95% CI, −3.0 to −0.5; P = .006). Among the 52 participants with available data, cerebral blood flow varied with vessel density and was 2.5 mL/100 g/min higher for each healthier category of a modifiable risk factor (95% CI, 0.16-4.89; P = .03). Conclusions and Relevance In this preliminary study involving young adults without clinical evidence of cerebrovascular disease, a greater number of modifiable cardiovascular risk factors at recommended levels was associated with higher cerebral vessel density and caliber, higher cerebral blood flow, and fewer white matter hyperintensities. Further research is needed to verify these findings and determine their clinical importance.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18–40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of −4.40 mm Hg (95% confidence interval, −5.78 to −3.01) and in diastolic blood pressure of −4.17 mm Hg (95% confidence interval, −5.42 to −2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure −1.02 mm Hg (95% confidence interval, −2.34 to 0.29), and in diastolic blood pressure −0.91 mm Hg (95% confidence interval, −1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension? A Systematic Review and Meta-AnalysisNovelty and Significance

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18–40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of −4.40 mm Hg (95% confidence interval, −5.78 to −3.01) and in diastolic blood pressure of −4.17 mm Hg (95% confidence interval, −5.42 to −2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure −1.02 mm Hg (95% confidence interval, −2.34 to 0.29), and in diastolic blood pressure −0.91 mm Hg (95% confidence interval, −1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

COMBINED EXERCISE ECHOCARDIOGRAPHY AND CARDIOPULMONARY EXERCISE TESTING DURING PREGNANCY - A LONGITUDINAL CARDIOVASCULAR ASSESSMENT IN THE SECOND TRIMESTER

Objectives Cardiopulmonary exercise testing (CPET) is a well-established investigation used to stratify operative and anaesthetic risk as well as being predictive of cardiovascular morbidity and mortality. Pregnancy is a biological stress test and we hypothesised that CPET could risk stratify women with cardio-respiratory or metabolic disease during pregnancy. However, normal values in normal pregnancy are required before the predictive value of this test can be assessed in women with cardio-respiratory disease. This pilot study was designed to test the feasibility and tolerability of performing combined CPET and exercise echocardiography during pregnancy. Methods We prospectively recruited 10 women with a singleton pregnancy; all were healthy with no known medical conditions. Each participant attended at mean 14+1 (±2 days) (visit 1) and 24+5 (±3 days) (visit 2) weeks of gestation. At each visit participants had a resting echocardiogram, fetal ultrasound scan and baseline blood sample collected. A stepwise incrementing CPET was then performed with a maternal echocardiogram at maximal exertion. A blood sample was collected at maximal exertion. Results The participants had a mean age at visit 1 of 35 years (±4), 6 were nulliparous, BMI was 24.3 (±3.3). Combined CPET and exercise echo was successfully completed in all participants. There was no significant difference between visits for resting mean arterial pressure: 86.7 mmHg (±9.6) at visit 1 and 86.5 mmHg (±8.1) at visit 2 (p = 0.95), but resting left ventricular (LV) end diastolic volume increased from 77.3 ml (±15.1) in visit 1 to 83.8 ml (±17.2) in visit 2 (p = 0.008). Systolic function did not significantly change between visits, ejection fraction: 63.8% (±5.9) compared to 61.4% (±4.6) at visit 2 (p = 0.36). Diastolic function was not significantly altered. During the CPET test the peak workload achieved was similar at both visits: 165 Watts (±35.7) in visit 1 and 170 Watts (±36.9) in visit 2 (p = 0.51) as was VO2 max ml/Kg/min: 28.5 (±6.3) compared to 26.6 (±2.9) (p = 0.34). Respiratory exchange ratio (RER) increased significantly between visits: 1.05 (±0.05) compared to 1.11 (±0.05) at visit 2 (p = 0.01). Lactates collected increased from 1.1 mmol/L (range 0.9–1.7) before maximal exercise to 6.4 mmol/L (range 4.5–8.8) after in visit 1 (p < 0.001) and from 1.1 mmol/L (range 0.5–2.8) to 6.0 mmol/L (range 2.2–7.7) in visit 2 (p < 0.001). All participants delivered healthy live neonates at term gestation, however 1 participant developed pregnancy induced hypertension and 2 developed preeclampsia. Conclusions We successfully demonstrated combined exercise echo and CPET studies is well tolerated in pregnant women at 14 and 24 weeks gestation. We also demonstrated this combined test as a successful technique for capturing a wealth of metabolic and cardiac structural and functional data. Cardiac volumes increased between visits. RER increased which might suggest test familiarity.