Made available in DSpace on 2016-06-02T20:19:12Z (GMT). No. of bitstreams: 1 2579.pdf: 1151605 bytes, checksum: bbdba1904bf51bc08fc113ee84d13c12 (MD5) Previous issue date: 2009-06-10 / Financiadora de Estudos e Projetos / Cardiovascular responses to different isometric contractions were evaluated in 12 patients (63 ± 11,6 years, mean ± dp) with coronary artery disease and/or risk factors, participants in the cardiac rehabilitation phase III. Heart rate variation (&#916;HR) was evaluated during maximum (CVM, five and ten seconds in duration) and submaximal (CVSM, 30 and 60% of CVM-5, until muscle exhaustion) voluntary contraction, using a handgrip dynamometer. Additionally, the RMSSD (representative index of vagal modulation) was calculated at rest (precontraction), at the last 30 seconds of CVSM and recovery (post-contraction). &#916;HR showed higher values in CVM CVM-10 vs-5 (17 ± 5,5 vs 12 ± 4,2 bpm, p <0.05) and the CVSM-60 vs CVSM -30 (19 ± 5,8 vs 15 ± 5,1 bpm, p <0.05). However, results for CVM-10 showed similar &#916;HR compared to results for CVSM (p> 0.05). RMSSD at rest decreased (p <0.05) during CVSM-30 (30% = 28 ± 17 vs 13 ± 8 ms) and CVSM-60 (60% = 26 ± 18 vs 10 ± 4 ms), but returned to baseline values as the contraction was interrupted. In in patients with coronary artery disease and/or risk factors, low intensity isometric contraction, maintained over long periods of time, presents the same effect on the responses of HR, compared to a briefly high intensity or maximal isometric effort. / As respostas da frequência cardíaca frente à diferentes percentuais de contração isométrica foram avaliadas em 12 pacientes (63 ± 11,6 anos; média±dp) com doença da artéria coronária e/ou fatores de risco para a mesma e participantes de um programa de reabilitação cardíaca fase III. A variação da frequência cardíaca (&#916;FC) foi avaliada durante a contração voluntária máxima (CVM; cinco e dez segundos de duração) e submáximas (CVSM; 30 e 60% da CVM-5, até exaustão muscular) de preensão palmar, utilizando-se um dinamômetro (hand grip). Adicionalmente, o RMSSD dos iR-R em ms (índice representativo da modulação vagal no nó sino atrial) foi calculado em repouso (pré-contração), nos últimos 30 segundos da CVSM e na recuperação (pós-contração). A &#916;FC apresentou maiores valores em CVM-10 vs CVM-5(17 ± 5,5 vs 12 ± 4,2 bpm, p<0,05) e no CVSM-60 vs CVSM -30 (19 ± 5,8 vs 15 ± 5,1 bpm, p<0,05). No entanto, os resultados para CVM-10 mostrou &#916;FC similar quando comparado aos resultados obtidos para CVSM (p>0,05). RMSSD de repouso reduziu (p<0,05) durante a CVSM-30 (30% = 28 ± 17 vs 13 ± 8 ms) e CVSM-60 (60% = 26 ± 18 vs 10 ± 4 ms), mas retornou aos valores basais quando a contração foi interrompida. Em pacientes com doença da artéria coronária e/ou fatores de risco para a mesma, a contração isométrica de baixa intensidade mantida por longos períodos de tempo, apresenta os mesmos efeitos sobre as respostas da FC, quando comparada à atividade isométrica de alta intensidade ou ao esforço isométrico máximo.

Submitted by Izabel Franco (izabel-franco@ufscar.br) on 2016-09-27T19:15:08Z No. of bitstreams: 1 TeseFCRC.pdf: 2532238 bytes, checksum: 322c81814ed25c363ba5e4aae4040c14 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-10-10T14:14:43Z (GMT) No. of bitstreams: 1 TeseFCRC.pdf: 2532238 bytes, checksum: 322c81814ed25c363ba5e4aae4040c14 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-10-10T14:14:54Z (GMT) No. of bitstreams: 1 TeseFCRC.pdf: 2532238 bytes, checksum: 322c81814ed25c363ba5e4aae4040c14 (MD5) / Made available in DSpace on 2016-10-10T14:15:05Z (GMT). No. of bitstreams: 1 TeseFCRC.pdf: 2532238 bytes, checksum: 322c81814ed25c363ba5e4aae4040c14 (MD5) Previous issue date: 2015-06-29 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / The thesis consisted of three studies described below. The study I, entitled "Hemodynamic and metabolic response during aerobic and resistance dynamic exercise in different intensities: A cross-sectional study on implications of intensity on safety and symptoms in patients with coronary disease". Where the objective of this study was to evaluate the clinical and physiological responses during resistance exercise in loads of 30 and 60% of 1-RM on the leg press 45° and compare the responses with maximum aerobic exercise. The evaluation included aerobic test on cycle ergometer and resistance test in leg press 45°. Ventilation, hemodynamic and clinical measurements were performed. The results showed that 60% of resistance exercise and the dynamic test increased variables response studied in compared the load of 30% in resistance exercise. We conclude that high repetition of resistance exercise results in physiological changes at an intensity comparable to maximal aerobic exercise. Further, the study II, entitled "Resistance training improves heart rate variability and muscular performance: A randomized controlled trial in patients with coronary artery disease study" The objective was to investigate the effects of a high repetition program/low load resistance training (RT) (HR/LL-RT) in heart rate variability (HRV) in muscular strength and endurance in patients with CAD. Test were carried out in 1-RM test in leg press 45°, HRV was captured in the supine position before and after eight weeks of RT. The HR/LL-RT program consisted of an exercise using leg press 45°; (three sets, twenty repetitions, twice a week for eight weeks). The results showed that after eight weeks RT there was a significant increase in the values of the RMSSD, ApEn SD1 indices and only the TG (p<0.05). There was a significant decrease in Mean HR after RT for TG (p<0.05). Additionally, there was significant improvement in muscular strength and endurance only for the TG (p<0.05). We conclude that eight weeks of HR/LL-RT is a sufficient stimulus to change heart function, muscle strength and endurance in patients with CAD. Finally, the study III, entitled: ''What the impact of resistance training on hemodynamic, autonomic and metabolic variables in coronary artery disease patients? The randomized controlled trial of eight weeks''. Where the objective was to evaluate the hemodynamic, metabolic, and the HRV effects during maximum intensity tolerated in constant loads protocols during dynamic and resistance exercise before and after eight weeks of resistance training program of low intensity and high reps (RTLHr) in patients with CAD. The results showed increase in maximum and submaximal load (p<0.01) and attenuation of the hemodynamic performance in the higher load (p<0.01) and reduced lactate concentration compared for TG. During the cycle ergometer exercise, there was attenuation of hemodynamic performance and increased minute ventilation (p<0.01). Finally, the TRBAr produced greater parasympathetic contribution (RMSSD and SD1), after RT. We conclude that eight weeks of RTLHr may attenuate the hemodynamic stress, metabolic and autonomic during resistance exercise with cardiovascular and autonomic beneficial effects also in the dynamic exercise. / A tese constou de três estudos descritos a seguir. O estudo I, intitulado: “Respostas hemodinâmicas e metabólicas durante o exercício dinâmico aeróbio e resistido em diferentes intensidades: Um estudo transversal com implicações da intensidade na segurança e sintomas nos pacientes com doença coronariana”, cujo o objetivo foi avaliar as respostas clínicas e fisiológicas durante o exercício resistido nas cargas de 30 e 60% de 1-RM no leg press 45° e comparar as respostas durante o exercício aeróbio máximo. A avaliação incluiu teste aeróbio no cicloergômetro e teste resistido no leg press 45°. Foram realizadas medidas ventilatórias, hemodinâmicas e clínicas. Os resultados apresentaram que na carga de 60% do exercício resistido e no teste dinâmico aumentaram a resposta nas variáveis estudadas quando comparados a carga de 30% no exercício resistido. Concluímos que altas repetições de exercício resistido resulta em modificações fisiológicas a uma intensidade comparável ao exercício aeróbio máximo. Na sequência, o estudo II, intitulado: “Treinamento resistido melhora a variabilidade da frequência cardíaca e o desempenho muscular: um estudo randomizado e controlado em pacientes com doença arterial coronariana.” O objetivo foi investigar os efeitos de um programa de alta repetição/baixa carga de treinamento resistido (TR) (AR/BC-TR) na variabilidade da frequência cardíaca (VFC), na força e resistência muscular em pacientes com doença arterial coronariana (DAC). Foram realizados teste de 1-RM, teste descontínuo no leg press 45°; a VFC foi captada na posição supina antes e após oito semanas de TR. O programa AR/BC-TR consistiu de um exercício utilizando leg press 45°; (três séries de vinte repetições, duas vezes por semana durante oito semanas). Os resultados mostraram que, após oito semanas de TR, houve aumento significativo dos valores dos índices RMSSD, SD1 e ApEn apenas para o GT (p<0,05). Houve uma diminuição significativa na média de FC após TR para GT (p<0,05). Adicionalmente, houve melhora significativa na força e resistência muscular apenas para o GT (p<0,05). Concluímos que oito semanas de AR/BC-TR foram um estímulo suficiente para alterar a função cardíaca, bem como a força e resistência muscular em pacientes com DAC. Finalmente, o estudo III, intitulado: ''Qual o impacto do treinamento resistido nas variáveis, hemodinâmicas, autonômicas e metabólicas em pacientes com doença arterial coronariana? Um estudo randomizado e controlado de 8 semanas'', cujo objetivo foi verificar os efeitos hemodinâmicos, metabólicos e da VFC durante a intensidade máxima tolerada em protocolos de cargas constantes de resistência e dinâmico antes e após oito semanas de programa de treinamento resistido de baixa intensidade e altas repetições (TRBAr) em pacientes com DAC. Os resultados mostraram aumento da carga máxima e submáxima (p<0,01) e atenuação da performance hemodinâmica na maior carga atingida (p<0,01) e redução da concentração de lactato para o GT. Durante o exercício em cicloergômetro, houve atenuação da performance hemodinâmica e aumento da ventilação minuto (p<0,01). Finalmente, o TRBAr produziu maior contribuição parassimpática (RMSSD e SD1), após o TR. Concluímos que oito semanas de TRBAr pode atenuar o estresse hemodinâmico, metabólico e autonômico durante o exercício resistido, com efeitos benéficos cardiovasculares e autonômicos também no exercício dinâmico.

Made available in DSpace on 2016-12-08T15:59:04Z (GMT). No. of bitstreams: 1 Tese de doutorado Lourenco Sampaio de Mara.pdf: 1379341 bytes, checksum: baa0c8e2efbdb57ed99a15951be025d1 (MD5) Previous issue date: 2013-03-04 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Fundamentação: A insuficiência cardíaca (IC) cursa com disfunções em diversos sistemas, repercussões na qualidade de vida (QV) e função sexual. A hipotestosteronemia é relevante na IC e fator contribuinte para o desbalanço catabolismo/anabolismo que integra a síndrome. Há pouco conhecimento a respeito dos efeitos do exercício de alta intensidade e terapia de suplementação de testosterona (TST) neste contexto. Hipótese: Exercício físico de alta intensidade e TST têm efeito sinérgico para um tratamento mais eficiente em pacientes com IC e baixos níveis de testosterona, inseridos em programa de reabilitação cardíaca (RC). Objetivo: Investigar os efeitos do exercício de alta intensidade e TST em pacientes com IC e baixos níveis de testosterona sérica participantes de programa de RC. Método: Dezenove pacientes portadores de IC (idade média de 58 anos; ± 10; fração de ejeção de 34 ±8%) foram randomizados para o grupo exercício alta intensidade (EAI) ou controle, (n=9) e grupo exercício de alta intensidade com suplementação de testosterona (EAIS) ou intervenção, (n=10). Pacientes exercitaram-se por 12 semanas e o grupo intervenção recebeu testosterona na primeira e sexta semanas. Antes e após o período de estudo foram obtidas medidas do teste cardiopulmonar, teste caminhada dos seis minutos (T6 ), ecocardiograma, função endotelial, erétil, perfil hormonal e da QV. Resultados: Houve aumento respectivamente intragrupos, do consumo máximo de oxigênio (12% e 15%; EAI e EAIS; p<0,05 e p<0,01), da distância percorrida no T6 (15% e 29%; EAI e EAIS; p<0,05 e p<0,01), da curva de eficiência de captação de oxigênio (22% e 14,2%; EAI e EAIS; p<0,05 em ambos os grupos), da velocidade máxima da onda E´ junto ao anel mitral septal (36%; EAI; p<0,05), da velocidade máxima da onda E´ junto ao anel mitral lateral (35%; EAI; p<0,05), do percentual de dilatação mediada pelo fluxo na artéria braquial (56% e 92%, EAI e EAIS, sem significância), dos escores da função erétil (150% e 59%, EAI e EAIS; p<0,01 e p<0,05), da testosterona total (78%, EAIS,p<0,01), da testosterona livre (89%; EAIS; p<0,01), da testosterona biodisponível (89%. EAIS; p<0,01), do hematócrito (8%, EAIS; p<0,01), do antígeno prostático específico (33%; EAIS; p<0,01). Houve diminuição da curva do equivalente ventilatório de dióxido de carbono (5%; EAIS; p<0,05), da relação da velocidade máxima da onda E com a velocidade máxima da onda E´ junto ao anel mitral septal (29%; EAI; P<0,05), do hormônio luteinizante (96%; EAIS; p<0,01), do hormônio folículo estimulante (84%; EAIS; p<0,01), do fator de necrose tumoral-&#945; (42% e 47%, EAI e EAIS; p<0,05 em ambos os grupos), do escore global do Minnesota Living with Heart Failure Questionnaire (54% e 54%;EAI e EAIS; p<0,01 e p<0,05), do domínio físico (52% e 54%; EAI e EAIS; p<0,01 e p<0,05), do domínio emocional (60%; EAIS; p<0,05), do domínio das questões remanescentes (58%; EAI; p<0,01). Entre grupos houve aumento a favor do EAIS nos níveis de testosterona total, testosterona livre e testosterona biodisponível (54%, p<0,05; 48%, p<0,05 e 48%, p<0,05 respectivamente), e diminuição a favor do EAIS nos níveis do hormônio folículo estimulante e luteinizante (83%, p<0,01 e 97%, p<0,01 respectivamente). Conclusões: Pacientes com IC e baixos níveis de testosterona submetidos a programa de exercícios de alta intensidade e TST apresentam melhora da capacidade funcional, dos índices de eficiência ventilatória, da função cardíaca, da QV e função erétil, contudo o estudo não corroborou a hipótese que a TST tem efeito sinérgico associado ao exercício físico de alta intensidade no tratamento destes pacientes.

Background: Cardiac Rehabilitation (CR) has been shown to be effective in reducing mortality and morbidity in Coronary Heart Disease (CHD). There is a limited amount of research that evaluates the impact of menu-based CR, in patients with Acute Coronary Syndrome with Low Troponin levels (ACSLT). Aim: This thesis contains a feasibility study and an exploratory study. The feasibility study aimed to examine the feasibility of a Randomised Controlled Trial (RCT) which would test the impact of a menu-based CR programme, on individuals diagnosed with ACSLT, against standard care. This feasibility study included staff views. The exploratory study aimed to explore the impact that ACSLT and CR can have on this client group. Method: The feasibility study was a repeated measures case-control trial of menu-based CR based on the theoretical framework of the Common Sense Model of Self-Regulation (CSM), using a range of health assessments. The areas assessed included misconceptions, symptoms, anxiety, depression and Health Related Quality of Life (HRQoL). In addition, focus groups were held with both ward and specialist CR staff to seek their views on the feasibility of a RCT of menu-based CR for ACSLT. The exploratory study consisted of description and analysis of the data that had been collected from the participants over the two year period as above. In addition it included qualitative data that had been collected during interviews with the participants. Findings: Participants (n=33) were recruited from cardiology wards following an admission with ACSLT. They were assessed at baseline (T1), nine months (T3) and 24 months (T4). Twenty-five participants completed the studies. The feasibility study was successful in its aim of testing the CR intervention and protocols for a further RCT. The intervention was acceptable to the participants and to the specialist staff, although the ward staff did not see the need for a RCT. The measures used, with the exception of the self-reporting measures, were suitable and provided a wide range of data that could be utilised in a RCT. However the changes to diagnostic categories meant that a RCT would no longer be feasible. The exploratory study found that both groups were similar on a range of baseline demographic and clinical factors. There was a tendency to benefit within the exploratory study which favoured the intervention. An additional finding from the exploratory study was the degree of uncertainty experienced by the participants, within the context of a changing political and clinical landscape. Discussion and conclusions: The studies presented in this thesis add to our knowledge by highlighting some of the difficulties in designing a RCT of menu-based CR in a specific subgroup of CHD and by presenting outcome data for a small group of participants that have not previously been studied within the literature. This data suggests that there was a tendency to benefit for the intervention that requires further study. Implications for practice: Patients with ACSLT are now being included in CR programmes due to the changes within the diagnostic criteria. Clinicians have little understanding of the impact of CR on this group of patients, or what type of interventions would work best. Large RCT’s will however be problematic and this thesis has highlighted that further work is required to explore how CR can best improve the well-being of individuals with ACSLT.

A Reabilitação Cardíaca (RC) composta de exercícios puramente dinâmicos (EPD) tem sido fortemente recomendada para pacientes com doença arterial coronariana (DAC). Contudo, os exercícios resistidos devem ser incluídos como parte de um programa formal, uma vez que contribuem para promover ganhos nas atividades de vida diária e assim na qualidade de vida (QV). Estudos recentes têm mostrado que a magnitude das respostas metabólicas e autonômicas cardíacas durante o exercício resistido dinâmico (ERD) também está associada com a determinação do limiar de anaerobiose (LA), o qual é um importante parâmetro para determinar a intensidade no EPD. Diante disso, não há informações sobre essas respostas metabólicas e autonômicas no ERD, para pacientes com DAC. Adicionalmente, pouco é sabido acerca da avaliação da funcionalidade/incapacidade percebidos por estes pacientes já incluídos em programas formais de RC, podendo ampliar informações para a tomada de decisões neste processo. Portanto, este estudo propõe ampliar o corpo do conhecimento acerca de duas vertentes, sendo uma mais fisiológica e outra abordagem mais ampliada, contendo aspectos bio-psico-sociais, Objetivamos 1) Determinar o LA pela variabilidade da frequência cardíaca (VFC) durante um protocolo de ERD, numa população diagnosticada com DAC, participante de um programa de RC composto somente de EPD; e 2) Aplicar a CIF (Classificação Internacional de Funcionalidade, Incapacidade e Saúde), tendo como base a vinculação da mesma com a QV auto-percebida, com o propósito de investigar se o programa formal de RC pode produzir impacto nos desfechos multidemensionais de funcionalidade e incapacidade. Vinte pacientes (idade: 63±7 anos) com DAC (FEVE: 60±10%), apresentando boa capacidade funcional e bom prognóstico, realizaram um protocolo de ERD incremental no leg-press. O protocolo iniciava em 10% de l-RM (repetição maxima), com subsequêntes aumentos de 10% até a exaustão física. A variabilidade da frequência cardíaca (VFC), através dos indices lineares (rMSSD e RMSM) e não-lineares (SD1, SD2, SD1/SD2), bem como o lactato sanguíneo, foram determinados no repouso e durante o ERD. Funcionalidade e incapacidade do grupo foram avaliadas através da aplicação do Processo de Vinculação entre o SF-36 com a CIF. ANOVA para medidas repetidas, análise de Bland-Altman, coeficientes de correlação de Pearson e estatística descritiva foram empregados. Admitiu-se nível de significância de 95%. Foram encontradas significativas alterações na VFC e lactato sanguíneo a partir de 30% de 1-RM (p<0.05). Análise de Bland-Altman revelou boa concordância entre limiar de lactato (LL) e limiar de rMSSD (LrMSSD), e de SD1 (LSD1). As cargas relativas obtidas (a partir de 1-RM) no LL, LrMSSD e LSD1 não diferiram (29%±5; 28%±5; 29%±5, respectivamente). A vinculação entre o SF-36 e a CIF permitiu detalhar uma relação de \"Funções corporais\" e principalmente as \"Atividades e Participações\" acometidas pela doença, bem como o grau de problemas/prejuízo destas, mesmo após o programa de RC. Concluímos que o uso da VFC durante o ERD poderia ser um método não-invasivo viável na prática clínica para determinar o LA em pacientes com DAC, auxiliando na definição de parâmetros de intensidade de exercício seguros e apropriados. Além disso, a funcionalidade e incapacidade de pacientes coronariopatas, percebidos sob o seu próprio ponto de vista, poderiam ser avaliadas utilizando-se o SF-36 sob o escopo da CIF, adicionando informações complementares ao processo da RC. / Cardiac Rehabilitation (CR) composed of dynamics purely exercises (DPE) has been strongly recommended for patients with coronary artery disease (CAD). However, resistance training should be included as part of a formal program, since they contribute to promote gains in daily activities and thus the quality of life (QoL). Recent studies have shown that the magnitude of the cardiac, metabolic, and autonomic responses during dynamic resistance exercise (DRE) is associated with the determination of the anaerobic threshold (AT), which is an important parameter to determine the intensity during DPE. Therefore, there is no information about these metabolic and autonomic responses in resistance exercise for patients with CAD. In addition, little is known about the assessment of functioning/disability perceived by these patients already included in formal CR programs, which may extend information for decision-making in this processo Therefore, this study proposes to extend the body in the knowledge of two approaches, with a more physiological and other broader approach, containing bio-psycho-social aspects. We aimed to 1) Determine the A T by heart rate variability (HRV) during an DRE protocol in a population diagnosed with CAD who participated in a CR program with DPE only; and 2) Apply the ICF (International Classification of Functioning, Disability and Health), based on the binding of the same with self-perceived QoL (SF-36), in order to investigate whether the formal RC program may have an impact on multidemensionais outcomes of functionality and disability. Twenty men (age: 63±7 years old) with CAD (LVEF: 60±10%), with good functional capacity and good prognosis, underwent a DRE incremental protocol on leg press until maximal exertion. The protocol began at 10% of 1-RM (repetition maximum), with subsequent increases of 10% until maximal exhaustion. Heart rate variability (HRV) indices from Poincaré plots (SD1, SD2, SD1/ISD2) and time domain (rMSSD and RMSM), as well as blood lactate were determined at rest and during PRE. Functioning and disability were assessed by the linking process between the SF-36 and the ICF. ANOVA for repeated measures, Bland-Altman analysis, Pearson correlation coefficients, and descriptive statistics were used for statistical analysis. The significance level accepted was 95%. Significant alterations in HRV and blood lactate were observed from 30% of 1 RM (p<0.05). Bland- Altman analysis demonstrated a consistent agreement between blood lactate threshold (LT) and rMSSD threshold (rMSSDT) and LT with SD1 threshold (SD1T). Relative values of 1-RM in all LT, rMSSDT and SD1T did not differ (29% ± 5 vs 28% ± 5 vs 29% ± 5, respectively). Finally, the assessment of functioning and disability using the SF-36 and ICF, allowed to list in more detail the \"Body functions\" and especially the \"Activities and Participation\" affected by the disease, as well as the degree of problems/impairments of these aspects, even after the RC program. In conclusion, HRV during DRE could be a feasible noninvasive method in clinical settings to determine AT in CAD patients for planning safe and appropriaje exercise intensities during CR. Moreover, the functioning and disability of coronary patients, perceived under their own point of view, could be assessed using the SF-36 under the scope ofthe lCF, adding supplementary information to the CR process.

Background: Even though specific agents for the treatment of patients with pulmonary hypertension (PH) are available, in PH patients, physical capacity and quality of life (QoL) are often restricted and survival is reduced. Objectives: This study prospectively investigated the long-term effects of respiratory and exercise training in patients with severe chronic PH regarding safety, time to clinical worsening and survival. Methods: Fifty-eight consecutive patients with severe PH on stable disease-targeted medication received exercise and respiratory training in hospital for 3 weeks and continued at home. They were prospectively followed for 24 ± 12 months. Primary endpoints were time to clinical worsening and survival. Adverse events and changes in the 6-min walking test, QoL, WHO functional class and gas exchange were secondary endpoints and were evaluated at baseline and at weeks 3 and 15. Results: All patients tolerated the exercise training well without severe adverse events. In week 15, 6-min walking test results were significantly improved compared to baseline (by 84 ± 49 m, p < 0.001), as well as QoL scores, WHO functional class (from 2.9 ± 0.5 to 2.6 ± 0.6, p < 0.01), peak oxygen consumption (from 12.5 ± 3.0 to 14.6 ± 3.9 ml/min/kg, p < 0.001), heart rate at rest (from 75 ± 12 to 61 ± 18 beats/min, p < 0.001) and maximal workload (from 65 ± 21 to 80 ± 25 W, p < 0.001). Survival at 1 and 2 years was 100 and 95%, respectively. Fifteen events occurred during the follow-up. Conclusion: This study indicates that exercise and respiratory training as add-on to medical treatment may improve exercise capacity and QoL, and that they have a good long-term safety in the described setting. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Mild cognitive deficits that negatively impact self-management education-related outcomes may be present in a proportion of cardiac rehabilitation patients and the degree of impairment may vary by the type of coronary revascularization procedure. The purpose of this study was to compare cognitive function, as measured by the Montreal Cognitive Assessment (MoCA), between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) patients, and to determine independent variables of MoCA score. In a cross-sectional study, 78 cardiac rehabilitation patients (CABG n = 38, PCI n = 40) completed the MoCA. Demographics were collected and disease burden was calculated using the age-adjusted Charlson Comorbidity Index (ACCI). Mild cognitive deficits (MoCA ≤26) were present in 55.3% CABG and 30.0% PCI patients. An independent Student’s t test showed that MoCA scores were significantly lower among CABG patients (mean = 24.5, SD = 3.3) compared to PCI patients (M = 26.7, SD = 2.7), t (76) = 3.15, p < 0.01. Descriptive analyses of cognitive domain scores indicated that deficits in short-term memory and language were present among CABG patients. Using a backward regression, coronary revascularization procedure (CABG vs. PCI) (p = 0.006) and disease burden (ACCI) (p = 0.015) remained significant, while heart failure diagnosis became non-significant and was removed from the model (F (2, 75) = 8.382, p < 0.001). The final model explained 16.1% of the total variance in MoCA score (adjusted R2 = 0.161). Results indicate that cognitive deficits were present in cardiac rehabilitation participants and associated with the type of coronary revascularization procedure, suggesting the need for formal cognitive screening and adaptation of education interventions in cardiac rehabilitation. A future prospective cohort study is required to establish temporality, and to measure education-related outcomes, such as health-related quality of life (HRQOL) and self-management. / Thesis / Master of Science (MSc) / Cardiac rehabilitation (CR) is a multifaceted program consisting of exercise and education that is essential to the care of post-coronary revascularization patients. While exercise has shown to improve health outcomes, education has demonstrated inconsistent effects. Since education has imposed cognitive demands, this discrepancy in outcomes may, in part, be due to cognitive deficits present in a proportion of program attendees: the degree of impairment may vary by type of coronary revascularization procedure prior to CR. This study compared cognitive function between two groups of coronary revascularization patients, post-coronary bypass surgery and post-coronary angioplasty, and determined independent variables for cognitive function. Results showed that coronary bypass surgery patients had significantly lower cognitive function than coronary angioplasty patients at program intake. Coronary bypass surgery and accumulated disease burden were weakly associated with decreased cognitive function. Cognitive screening and adapted education for patients with cognitive deficits should be considered to improve CR outcomes.

Contexte : Le diabète de type 2 (DT2) et le prédiabète sont considérablement liés au mode de vie, et sont un fardeau considérable pour les patients et les systèmes de santé. Bien que les interventions sur les habitudes de vie soient reconnues comme le traitement initial pour le prédiabète et le DT2, leur mise en œuvre efficace est rarement observée dans les soins cliniques de routine. Le fait d'atteindre une rémission de ces conditions à l'aide de telles interventions est encore plus rare. Méthodes : Nous présentons une analyse rétrospective de données issues d’une clinique d’intervention structurée et multidomaine sur le mode de vie, d’une durée de 12 mois, offerte à des patients atteints de prédiabète et de DT2. L’intervention consistait en des conseils éducatifs et nutritionnels guidés par des experts, combinés à une prescription personnalisée d’exercices physiques, dans le but principal d’améliorer la santé métabolique (perte de poids, diminution de l’hémoglobine glyquée, HbA1c), ainsi que d’atteindre la rémission du diabète, définie comme un retour de l'HbA1c à 6 mois à < 6,5 % (ou < 5,7 % pour le prédiabète) et persistant pendant au moins 3 mois en l'absence d’agents anti-diabétiques oraux. Résultats : À la suite d'une intervention sur les habitudes de vie de 117 participants avec prediabète ou diabète (âge moyen de 67,8 ± 9,5 ans, 63 % d'hommes, poids initial moyen de 92,7 ± 20,2 kilogrammes, HbA1c initiale moyenne de 6,9 % ± 0,8) une amélioration statistiquement significative de leur profil métabolique a été notée. La perte moyenne de poids à 12 mois était de - 4,9 kilogrammes (95% CI : - 4,0 à - 5,7, p<0,001), et la réduction moyenne de l'HbA1c à 12 mois était de - 0,6 % (95% CI : - 0,4 à - 0,7, p<0,001). Pour les participants atteints de DT2, 50 % d’entre eux ont atteint un taux d'HbA1c < 6,5 % après 6 mois d'intervention. De plus, 20 % des participants atteints de prédiabète et 12 % des participants atteints de DT2 ont atteint les critères de rémission. Conclusions : Cette première expérience de notre institution démontre comment une clinique d'intervention multidomaine sur le mode de vie peut être utile pour améliorer la santé métabolique et normaliser les valeurs glycémiques d’individus avec prédiabète ou DT2, même au point, pour certains, d'atteindre les critères de rémission. Suite à ces observations, nous proposons une étude prospective interventionnelle intitulée DIABEPIC1, qui examinera la faisabilité et l'efficacité d'un programme de réadaptation cardiaque amélioré combinant l'entraînement physique avec une intervention de réduction des aliments ultra-transformés, un régime méditerranéen et le jeûne intermittent, afin d’inverser le prédiabète jusqu'à la normalisation de la glycémie. L'impact de cette étude sur la mise en place de programmes de réadaptation cardiaque pour les patients atteints de prédiabète pourrait être important. En effet, si elle s'avère réalisable, elle pourrait améliorer la fonction cardiovasculaire après un événement coronarien aigu, améliorer la santé métabolique et en inverser un facteur de risque important et causal. (Identifiant de l’étude: NCT05459987). / Background: Type 2 diabetes (T2D) and prediabetes are predominantly related to lifestyle, representing a substantial burden to patients and the healthcare system. Effective implementation of lifestyle interventions as a first-line treatment for prediabetes and T2D is rarely seen in routine clinical care. Achieving remission of these conditions with such interventions is even more uncommon. Methods: We present a retrospective analysis of a 12-month single-center structured multidomain lifestyle intervention clinic offered to patients living with prediabetes and T2D. The intervention consisted of expert-guided educational and nutritional counseling combined with personalized physical training aiming at improving metabolic health and reaching remission. Remission of prediabetes and T2D were defined as a return of HbA1c at 6 months to < 6.5% (or < 5.7% for prediabetes) persisting for at least 3 months in the absence of glucose-lowering pharmacotherapy. Results: Following the multidomain expert-guided lifestyle intervention, 117 participants participants with prediabetes or T2D (mean age of 67.8 ± 9.5 years, 63% male, mean initial weight of 92.7± 20.2 Kilograms, mean initial HbA1c of 6.9% ± 0.8), significantly improved their metabolic profiles: mean weight loss at 12 months was – 4.9 kilograms (95% CI: - 4.0 to – 5.7, p<0.001), and mean reduction in HbA1c at 12 months was of – 0.6 % (95% CI: - 0.4 to - 0.7, p<0.001). 20% of participants with prediabetes and 12% of participants with type 2 diabetes achieved the remission criteria. In addition, 50% of all participants with T2D achieved HbA1c <6.5% after 6 months of intervention, demonstrating that tailored counseling and regular monitoring can improve the success of lifestyle treatments. Conclusions: After this initial experience from our institution showing how a multidomain lifestyle intervention clinic can be useful to improve metabolic health and normalize glycemic values in patients with prediabetes or T2D, even to the point of reaching criteria of remission, we propose a prospective interventional study entitled DIABEPIC1, which will examine the feasibility and effectiveness of an enhanced cardiac rehabilitation program combining exercise training with an ultra-processed food reduction intervention, a Mediterranean diet, and time-restricted dietary counseling to reverse prediabetes to normal glucose concentrations. The impact of this study on the delivery of cardiac rehabilitation programs for patients with prediabetes is significant. If proven feasible, it could improve cardiovascular function after an acute coronary event, enhance metabolic health and reverse a key causal cardiovascular risk factor. (Identifier of the study: NCT05459987)

Bakgrund: Under de senaste 30 åren har dödligheten i hjärt-kärlsjukdomarna minskat och fler och fler personer lever med sjukdomen. Träningsbaserad hjärtrehabilitering (THR) är en effektiv sekundär-preventiv åtgärd som förblir en underutnyttjad behandlingsform på grund av bristfälligt deltagande. Syfte: Syftet med förbättringsarbetet var att förbättra deltagande i THR. Syftet med studien av förbätt-ringsarbetet var att genom den teoretiska modellen COM-B undersöka hur patienter uppfattar vad som underlättar eller hindrar deras deltagande i THR. Metod: Med hjälp av Nolans förbättringsmodell testades två förändringar inom ramen för THR, näm-ligen ”Min träningsplan” och ”Träning ute”. Studie av förbättringsarbetet var en kvalitativ studie som baserades på COM-B modellen. Data från sju semistrukturerade intervjuer transkriberades och analy-serades med hjälp av deduktiv innehållsanalys. Resultat: Resultat av förbättringsarbetet visade förbättrat deltagande i THR. I genomsnitt påbörjade 62 % av patienterna THR och de deltog i genomsnitt två tillfällen mer än före förbättringsarbetet. Stu-dien av förbättringsarbetet visade på att dynamiskt tankesätt, aktiv livsstil, stöttning, ansvarstagande, målbilder, positiva känslor kring träning och upplägg verkade vara förknippade med det som underlät-tade deltagande i THR. Det som hindrade deltagande i THR var samsjuklighet och trötthet, svårighet att få ihop sitt livspussel samt oro och rädsla kring fysisk aktivitet. Slutsats: Oberoende vilka förändringsidéer som hade testats framstod det att patienternas egna för-mågor och motivation utvecklades genom större fokus på beteendeförändring som framtagande av ”Min träningsplan” och ”Träning ute” gav upphov till. Det sociala sammanhanget, trygghet kring fysisk akti-vitet, framtidshopp, välbefinnande och längtan till livet innan sjukdomen var faktorer som gjorde att deltagande i THR ersatte andra konkurrerande beteenden. / Background: During the last 30 years, mortality from cardiovascular diseases has decreased and more and more people are living with the disease. Exercise-based cardiac rehabilitation (ExCR) is an effective secondary prevention measure that remains an underutilized form of treatment due to poor participation. Purpose: The purpose of the improvement work was to increase participation in ExCR and the study of the improvement work aimed to use the COM-B theoretical model to investigate how patients apprehended hindering and promoting factors regarding participation in ExCR. Method: Using Nolan's improvement model, two changes to the framework for ExCR were tested, namely "My training plan" and "Training outside". The study of the improvement work was a qualitative study based on COM-B model. Data from seven semi-structured interviews were transcribed and ana-lysed using deductive content analysis. Results: Results showed improved participation in ExCR, 62% of patients started ExCR and they attended an average of two more sessions than before the improvement work. Study showed a growth mind-set, active lifestyle, support, taking responsibility, goal images, positive feelings about training and setup were promoting factors for participation in ExCR. Barriers were co-morbidity, fatigue, difficulty putting together the life's puzzle and worry and fear about physical activity. Conclusion: Regardless of which change ideas had been tested, it was clear that the patients' own abil-ities and motivation were developed through a greater focus on behavioural change, which the development of "My training plan" and "Exercise outside" gave rise to. The social context, feeling safe, hope for the future, well-being and longing for life before the illness were associated with capability to manage competing behaviours in order to participate in ExCR.

Adherence to guideline-recommended secondary cardiovascular prevention therapy (statins and cardiac rehabilitation) has been demonstrated to reduce the risk of all-cause mortality (Statins RRR 0.25, 95% CI 0.19-0.30; Cardiac Rehabilitation RRR 0.26, 95% CI 0.14-0.36) and secondary events.1,2 Yet, ≥50% of patients discontinue statin use within 12-month after an initial prescription and completion of cardiac rehabilitation is ≤20% in Ontario.3,4 Low statin adherence and cardiac rehab completion limits patients from realizing the full benefits of therapy. A meta-analysis of randomized controlled trials of adherence to statins for secondary prevention reported that nonadherence to statins was greater in non-white ethnicities compared to white ethnicities (OR 1.28, 95% CI 1.04-1.59) with geographical variation in outcomes.5 In respect to cardiac rehabilitation, the literature suggests that non-white ethnicities are less likely to complete cardiac rehabilitation compared to white participants.6,7 However, a gap remains in our knowledge of cardiac rehabilitation completion among immigrants due to lack of outcome reporting across clinical trials. The literature suggests that immigrants have improved health profiles relative to Canadian-born patients. Specifically, immigrants with ≤10 years of Canadian residency have greater medication adherence than immigrants with >10 of Canadian residency when compared to Canadian-born participants.6-9 This thesis was a planned sub-study of the Interventions Supporting Long-Term Adherence and Decreasing Cardiovascular Events (ISLAND) randomized control trial. The ISLAND study was a pragmatic, randomized controlled trial investigating the effect of educational reminders on adherence to guideline-recommended therapy post-myocardial infarction. Study participants were allocated in a 1:1:1 ratio to one of three groups: i) usual care, ii) educational reminders sent via post, or iii) combination post and interactive voice response educational reminders. Investigators were blinded to the allocation sequence, participant allocation, and outcome assessment. Medication adherence and completion of cardiac rehabilitation were assessed 12-months from baseline. This sub-study of ISLAND focused on participants who completed a 12-month outcome assessment with a recorded response to the following question, “Were you born a Canadian citizen?”. Immigrants experienced greater odds of statin adherence at 7-days (OR 1.36, 95% CI 1.00-1.85) and 30 days (OR 1.36, 95% CI 0.96-1.94) at one-year post-myocardial infarction, after adjusting for age, diabetes, sex, and smoking status. We found no evidence that immigration status was associated with cardiac rehabilitation completion (OR 0.91, 95% CI 0.72-1.14) after adjusting for age, diabetes, sex, smoking status, average neighborhood income quintile, education, and marital status. The odds of statin adherence at 7-days (OR 1.33, 95% CI 0.89-2.18) and 30-days (OR 1.39, 95% CI 0.89-2.18) was greater in visual minorities than white patients, however the difference was not statistically significant. We found no evidence of an association between ethnicity and cardiac rehabilitation completion (OR 0.98, 95% CI 0.75-1.29). Our analysis could not fully evaluate the healthy immigrant effect due to an insufficient sample size of immigrants with <10 years of Canadian residency exposure (n=29). In conclusion, we report a statistically significant 36% increase in the odds of 7-day and 30-day statin adherence in immigrants compared to Canadian-born patients. We also report that the odds of cardiac rehabilitation decreased by 9% in immigrants compared to Canadian-born patients at 12-months post-myocardial infarction but this was not statistically significant. Our findings offer support for the “healthy immigrant effect” continuing in immigrants with >10 years of Canadian residency exposure. We were unable to evaluate outcomes in immigrants with <10 years Canadian residency exposure due to a lack of sample size (n=29). / Thesis / Master of Science (MSc) / The primary purpose of this research project was to assess whether immigrants, individuals who reside in Canada but were born outside of the country, who have experienced a previous heart attack were adhere to heart health therapies better than Canadian-born patients. The heart health therapies of interest to our investigation are two guideline-recommended heart attack prevention therapies, statins and cardiac rehabilitation. The study design of our research project was a cohort sub-study of the ISLAND randomized control trial which investigated adherence to heart health therapies in patients residing in Ontario, Canada. Our major finding was that immigrants who lived in Canada for >10 years were more adherent to statin therapy for a previous heart attack compared to Canadian-born participants. Our findings support the hypothesis that immigrants tend to demonstrate behaviours associated with improved outcomes compared to their Canadian-born counterparts.