Introdução: O teste de caminhada de seis minutos (TC6M) é um teste muito utilizado para avaliar as condições de saúde de idosos e saudáveis, bem como pacientes com doenças pulmonares e cardiovasculares. Porém, poucos são os relatos na literatura científica habitual sobre a utilização do teste de caminhada de seis minutos para avaliar a morbidade e mortalidade de pacientes após infarto agudo do miocárdio (IAM). Objetivo: O objetivo deste estudo foi verificar se o TC6M tem valor preditivo para morbidade e/ou mortalidade cardiovascular após IAM. Queremos verificar o ponto de corte da distância no TC6M para síndrome coronariana aguda, insuficiência cardíaca, re-hospitalização ou óbito por causa cardiovascular. Método: Trata-se de um estudo observacional, no qual se utilizou análise de prontuários, contato telefônico, correio e SIM (Sistema de Informação de Mortalidade da Secretaria de Saúde) de pacientes com diagnóstico de IAM não complicado que realizaram o TC6M antes da alta hospitalar. Desfechos observados: síndrome coronariana aguda, insuficiência cardíaca, acidente vascular cerebral, re-hospitalização e óbito por causa cardiovascular. A coleta de dados se deu no Instituto Dante Pazzanese de Cardiologia, por meio de análise de prontuário e foram incluídos no estudo, os pacientes com diagnóstico de IAM não complicado que realizaram o teste de caminhada de seis minutos antes da alta hospitalar. Para análise estatística foram utilizados: correlação de Pearson ou Spearman, teste t de Student ou Mann-Whitney e ANOVA ou teste de Kruskall Wallis para analisar os efeitos das características físicas e clínicas dos pacientes analisados na distância percorrida no TC6M. Estas características e a distância percorrida foram avaliadas nos desfechos, ao longo de tempo, observando a curva de viii sobrevivência de Kaplan-Meier ou a sobrevivência em média de Cox, a significância dos efeitos foi testada por teste de log-rank ou pelo modelo de riscos proporcionais de Cox, respectivamente. Também foi ajustado um modelo de sobrevivência de Cox final para avaliar o efeito de todas as co-variáveis juntamente presentes no desfecho. Na análise múltipla foi utilizado o método de seleção de variáveis forward para selecionar as variáveis mais associadas à sobrevida. O tamanho dos efeitos, quando significativos, foi medido pela odds ratio (OR). Resultados: Foram incluídos 234 pacientes, 173(73,9 por cento ) do sexo masculino, 57,18 (10,35) anos, 103(44 por cento ) IAM anterior, 182 (77,8 por cento ) Killip I, 190 (81,2 por cento ) com terapia de reperfusão e fração de ejeção do ventrículo esquerdo de 49,99 (10,14) por cento . Foram observados 89 (38,03 por cento ) pacientes com pelo menos um desfecho adverso, sendo 18 (8,1 por cento ) óbitos por causa cardiovascular num período de seguimento médio de 1.355,47 (777,53) dias. A distância do TC6M não se associou à ocorrência dos desfechos adversos, porém à ocorrência de óbito, resultando dois modelos: a) metragem do primeiro quartil (370,5 m) (OR = 2,737; p = 0,046), índice de percepção de esforço (IPE) de Borg (OR = 1,380; p = 0,020) e saturação periférica de oxigênio (SpO2) < 90 por cento (OR = 2,326; p = 0,103); b) metragem do teste de log rank (232 m) (p = 0,036; OR = 3,459), índice de Borg (OR = 1,351; p = 0,044) e SpO2 < 90 por cento (OR = 2,936; p = 0,030). A metragem e a SpO2 também se associaram à pior sobrevida ao longo do tempo: modelo 1) IPE Borg (OR = 1,334; p = 0,041, SpO2 < 90 por cento (OR = 2,675; p = 0,067) e a distância de 370,5m (OR = 2,882; p = 0,042) e modelo 2: SpO2 < 90 por cento (OR = 4,193; p=0,004) e distância de 232m (OR = 5,014; p=0,005). Numa análise do comportamento da FC, SpO2 e PS e PD ao longo do tempo no TC6M entre os grupos óbito e não óbito foram observadas diferenças significantes apenas da FC (p < 0,0001) e SpO2 (p < 0,0001). Conclusão: Na amostra estudada, a distância e a SpO2 < 90 por cento no TC6M se associaram ao óbito e à pior sobrevida em pacientes após IAM não complicado. / Background: The six-minute walk test (6MWT) is a test used to assess the prognosis of patients with heart failure, chronic obstructive pulmonary disease and health status of the elderly. However, there are few reports in the scientific literature about the use of this test as a tool to assess the prognosis after acute myocardial infarction (AMI) patients. The aim of this study is to assess the prognostic value of the 6MWT in AMI patients. We also intend to point out whether there is a minimum distance in the 6MWT that defines a group of patients with worse prognosis, i.e, in the occurrence of death, re-infarction, or heart failure re-hospitalization from cardiovascular causes. Methods: This is an observational study for which we used analysis of medical records, telephone contact, mail and SIM (Mortality Information System of the Department of Health) of uncomplicated AMI patients who underwent 6MWT before hospital discharge. Observed outcomes: acute coronary syndrome, heart failure, stroke,re-hospitalization and cardiovascular death. Data collection has taken place at the Institute Dante Pazzanese of Cardiology, with analysis of medical records and has be included patients with uncomplicated AMI who underwent 6MWT before discharge. Statistical analysis: we used Pearson or Spearman correlation, Student\'s t test or Mann-Whitney test and ANOVA or Kruskal Wallis test to analyze the effects of physical and clinical characteristics in 6MWT distance. Such characteristics and the 6MWT distance were evaluated in outcomes over time, observing the Kaplan-Meier survival curve or the average survival by Cox, the significance of the effects was tested by log-rank test or the Cox proportional hazards model, respectively. It was also set a Cox survival x model to assess the effects of all covariates together present in the outcomes. We used selection of forward variables for multivariate analysis to select the variables most associated with survival. The size of the effects was measured by odds ratio (OR). Results: We included 234 patients, 173(73,9 per cent ) males, 57.18 (10.35) years old, 103(44 per cent ) anterior AMI, 182 (77.8 per cent ) Killip I, 190 (81.2 per cent ) with reperfusion therapy and left ventricular ejection fraction = 49.99 (10.14) per cent . We observed 89 (84.03 per cent ) patients with cardiovascular outcomes and 18 (8.1 per cent ) deaths for 1,355.47 (777.53) days of follow up. There was no association between the 6MWT distance and the combined endpoints. We observed association with 6MWT distance and death, resulting two models: a) distance of first quartile (370.5 m) (OR = 2.737, p = 0.046), Borg scale of perceived exertion (SPE) (OR = 1.380, p = 0.020) and oxygen saturation (SpO2) <90 per cent (OR = 2.326, p = 0,103); b) distance of the log rank test (232 m) (OR = 3.459, p = 0.036), Borg SPE (OR = 1.351, p = 0.044) and SpO2 <90 per cent (OR = 2.936, p = 0.030). The distance and the SpO2 were also associated with poor survival over time: model 1) Borg SPE (OR = 1.334, p = 0.041, SpO2 <90 per cent (OR = 2.675, p = 0.067) and 6MWT distance = 370.5 m (OR = 2.882, p = 0.042) and model 2: SpO2 <90 per cent (OR = 4.193, p = 0.004) and 6MWT distance = 232m (OR = 5.014, p = 0.005). In comparison with death group and survival group, there was a significant difference in HR (p <0.0001) and SpO2 (p <0.0001) overtime. Conclusion: The distance and SpO2 < 90 per cent in 6MWT were associated with death and worse survival conditions in patients after uncomplicated AMI.

Objetivo: Estudar o efeito da monitorização contínua da oximetria de pulso (SpO2) durante o teste de caminhada de 6 minutos (TC6m), na detecção da hipoxemia induzida pelo exercício, em pacientes com sintomas respiratórios. Métodos: Os pacientes realizaram testes de função pulmonar e TC6m. A saturação e a freqüência cardíaca foram determinadas por um oxímetro de pulso e os dados transferidos simultaneamente para um computador através de telemetria. Comparamos a menor saturação atingida durante o teste com os valores da SpO2 obtidos imediatamente após o TC6m. Também foram comparadas as diferenças clínico funcionais dos pacientes agrupados de acordo com a presença de dessaturação (SpO2 repouso – SpO2 no exercício 4%) e SpO2 88%. Resultados: Foram estudados 452 pacientes (236 homens, 61 ± 13 anos). A capacidade vital forçada (CVF), o volume expiratório forçado no primeiro segundo (VEF1), a relação VEF1/CVF e a capacidade de difusão pulmonar (DCO) foram respectivamente 65,8 ± 18,6% do previsto, 52,6 ± 23,7% do previsto, 62,8 ± 18,8% e 51,7 ± 20,9% do previsto. A média da SpO2 mínima registrada com auxílio de telemetria durante o TC6m foi de 89,9 ± 6,5% e da SpO2 no final do teste foi de 91,1 ± 6,5% (p<0,001). Em 241 pacientes (53,3%) ocorreu dessaturação no TC6m. Foram observados dois padrões diferenciados de dessaturação durante o exercício: um grupo de pacientes dessaturou no início do TC6m e recuperou a SpO2 antes do final do mesmo (57 pacientes, 23,7% dos pacientes que dessaturaram) e o outro grupo apresentou queda da SpO2 persistente até o final do exercício. A SpO2 basal e os valores de função pulmonar foram significativamente mais altos no grupo de pacientes com o primeiro padrão de dessaturação. A SpO2 foi 88% em 148 pacientes; em 26 destes (17,6%) níveis de SpO2 88% foram detectados somente durante o TC6m. Conclusão: Nosso estudo demonstra que a mensuração contínua da SpO2 durante o TC6m é melhor que a mensuração da SpO2 imediatamente após o teste para detectar dessaturação induzida por exercício. / Objective: To study the effect of continuous measurement of pulse oximetry (SpO2) during six-minute walk test (6MWT) on detection of exercise induced hypoxemia in patients with respiratory complaints. Methods: Patients performed lung function tests and 6MWT. SpO2 and pulse rate were obtained by a pulse oximeter and continuously transferred to a computer using telemetry. The lowest saturation reached during the test was compared with the SpO2 measured immediately after the 6MWT. We also compared functional and clinical differences of patients grouped according to desaturation (rest SpO2 - exercise SpO2 4%) and SpO2 88%. Results: We studied 452 patients (236 men, 61 ± 13 years old). Mean forced vital capacity (FCV), forced expiratory volume in 1 s (FEV1), FEV1/FCV and pulmonary diffusion capacity (DLCO) were 65.8 ± 18.6% of predicted, 52.6 ± 23.7% of predicted, 62.8 ± 18.8% and 51.7 ± 20.9% of predicted, respectively. Mean of lowest SpO2 registered using telemetry during 6MWT was 89.9% ± 6.5% and at the end of test 91.1% ± 6.5% (p<0.001). Desaturation was observed in 241 patients (53.3%). There were two different patterns of desaturation: SpO2 decrease at the beginning of the 6MWT with recovery before the test end (57 patients, 23.7% of the patients with desaturation) and SpO2 decrease maintained at the end of exercise. Rest SpO2 and lung function values were significantly higher in patients with the first desaturation pattern. SpO2 88% was observed in 148 patients; in 26 of these cases (17.6%) SpO2 88% levels were only detected during the 6MWT. Conclusion: Continuous SpO2 measuring is better than SpO2 measurement performed immediately after 6MWT in detecting exercise induced desaturation.

Objetivos: Avaliar o desempenho no teste de caminhada de seis minutos (TC6M) em pacientes adultos com bronquiectasias não fibrocísticas, estabelecendo associações entre TC6M e qualidade de vida relacionada à saúde (QVRS). Secundariamente, determinar relações entre TC6M, achados clínicos e função pulmonar a fim de identificar preditores de tolerância ao exercíco. Métodos: Estudo transversal envolvendo pacientes com bronquiectasias não fibrocística, idade ≥ 18 anos, com pelo menos um sintoma respiratório por 2 ou mais anos e volume expiratório forçado no primeiro segundo (VEF1) ≤ 70% do previsto. Realizou-se avaliação clínica, função pulmonar, TC6M e QVRS pelo questionário Short-Form 36. Resultados: Foram incluídos 70 pacientes (48 mulheres; idade média 54,5±17,7 anos; VEF1 médio 44,9±14,5%). Desempenho alterado no TC6M foi observado em 23 pacientes (Grupo 1) e desempenho normal em 47 pacientes (Grupo 2). Em comparação aos pacientes do Grupo 2, os pacientes do Grupo 1 apresentaram menor idade (p<0,001), menor idade de diagnóstico das bronquiectasias (p=0,006), menor proporção de ex fumantes (p=0,048), menor índice de massa corporal (IMC) (p=0,003), pior VEF1 % previsto (p=0,041) e pior pressão expiratória máxima % previsto (p=0,021). Não houve diferença significante entre grupos nos escores de QVRS (p>0,05). No modelo de regressão logística, idade menor (p=0,002) e IMC menor (p=0,034) se associaram significantemente com desempenho precário no TC6M. Conclusão: Elevada proporção de pacientes com bronquiectasias não fibrocísticas apresenta desempenho precário no TC6M. O desempenho ao exercício não se relacionou com a QVRS. Idade e IMC se associaram com performance ao exercício. / Objective: To determine the performance in 6-minute walk test (6MWT) in adult patients with non-cystic fibrosis bronchiectasis, establishing the relationship between 6-MWT and health-related quality of life (HRQL). Secondarily, to determine the relationship between 6MWT, clinical findings and lung function in order to identify predictors for exercise tolerance. Methods: Cross-sectional study involving patients with non-cystic fibrosis bronchiectasis aged ≥ 18 years, with at least one respiratory symptom for 2 years or more, and with predicted forced expiratory volume in first second (FEV1) ≤ 70%. Patients were submitted to clinical evaluation, pulmonary function tests, 6MWT and HRQL using the Short-Form 36 Questionnaire. Results: Seventy patients were included (48 females; mean age, 54.5±17.7 years; mean FEV1, 44.9 ±14.5%). We observed poor performance in 6MWT in 23 patients (Group 1) and normal performance in 47 patients (Group 2). In comparison with Group 2 patients, Group 1 patients presented lower age (p<0.001), lower age at diagnosis of bronchiectasis (p=0.006), lower proportion of ex-smokers (p=0.048), lower body mass index (BMI) (p=0.003), worse FEV1 % predicted (p=0.041), and worse maximum expiratory pressure % predicted (p=0.021). There was no significant difference between groups on scores for HRQL (p>0.05). In a logistic regression model, lower age (p=0.002) and lower BMI (p=0.034) were significantly associated with poor performance in 6MWT. Conclusion: There is a high rate of poor performance in 6MWT in patients with non-cystic fibrosis bronchiectasis. The exercise performance was not related to HRQL. Age and BMI were associated with the exercise performance.

Context: Increased physical activity participation and fitness are cardioprotective. The EUROACTION trial demonstrated that a preventive cardiology programme significantly increased self-reported physical activity participation (Wood et al., 2008). Objective: The EUROACTION Physical Activity and Fitness (EPAF) Study aimed to objectively evaluate the effectiveness of the EUROACTION physical activity and exercise intervention at increasing physical activity participation and fitness in people with coronary artery disease (COR) and those at high risk of developing cardiovascular disease (HRI) compared to standard care. Study design: A nested study within a paired cluster randomised controlled trial in eight European countries. Methodology: 12 pairs of centres (12 hospitals and 12 general practices) were randomised to receive the EUROACTION programme (INT) or be monitored for usual care (UC). In the INT hospitals, COR patients participated in a 16-week supervised exercise programme and a home-based activity intervention, delivered by a physiotherapist. In INT general practice nurses were trained to deliver personalised physical activity advice to HRI. Outcome measures: Objective physical activity participation was measured by mean number of steps per day (Yamax Digiwalker SW200 pedometer). Fitness was determined by the Incremental Shuttle Walk Test (ISWT) [hospital centres] and Chester Step Test (CST) [general practice centres]). Results: The mean number of steps in COR patients at 1–year was significantly higher in INT (+2310 steps, 95% CI +1226 to +3394 steps; P=0.003). The difference in cardiorespiratory fitness (ISWT) exceeded the minimal clinically important difference but was not statistically significant (+54 metres [95% CI - 102.8 to +211.0 metres]; P=0.42). In general practice centres, whilst no significant differences were found at 1 year in mean steps per day (+982 steps, 95% CI -569 to +2533 steps) and cardiorespiratory fitness (CST) at 1-year (+0.93 minutes, 95% CI -0.62 to +2.48 minutes), there was a difference in the change over time in fitness in favour of the INT (+0.94 mins [95% CI +0.23 to +1.66 mins]; P=0.02). Marked heterogeneity impacted on statistical power. All differences observed represented clinically important differences. Conclusion: The EPAF-Study has demonstrated that the EUROACTION programme was effective at increasing physical activity participation but objective measures indicate to a lesser degree than the self-reported physical activity outcomes previously published. Clinically important differences in objectively measured physical activity participation and cardiorespiratory fitness suggest further research, which is sufficiently powered, is warranted.

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Introdução: A tolerância ao exercício e os níveis de atividade física tendem a ser reduzidos em pacientes com fibrose cística (FC). Estudos trazem que o nível de atividade física pode estar associado com melhor estado nutricional e com um maiordeclínio da função pulmonar. Com a evolução da doença,o declínio da função pulmonar associado a distúrbios metabólicos e desnutrição, provocam alterações na mecânica respiratória, distúrbios musculoesqueléticos e deformidades torácicas, trazendo prejuízos na qualidade de vida destes indivíduos. Objetivo: Verificar a associação entre gravidade funcional pulmonar, nível de atividade física e variáveis de avaliação postural em adultos com FC. Secundariamente, verificar a correlação entre os parâmetros de atividade física observados pelo acelerômetro e pelo questionário internacional de atividade física (IPAQ) e, verificar a correlação entre os parâmetros de atividade física observados pelos dois instrumentos com a distância percorrida no teste de caminhada de seis minutos (DTC6M) e os parâmetros de avaliação postural.Métodos: Estudo de caráter transversal, aprovado pelo Comitê de Ética em Pesquisa do Hospital de Clínicas de Porto Alegre. Para a verificação de parâmetros de função pulmonar foi utilizado o exame de espirometria, para a verificação do nível de atividade física foi utilizado o questionário IPAQ e um acelerômetro, para avaliação postural foi utilizada a fotogrametria com auxílio do Software de avaliação postural (SAPO) e, para comparações complementares foi utilizado o teste de caminhada de seis minutos (TC6M). Resultados: Participaram do estudo 28 indivíduos adultos com FC, idade média de 25,1 anos e VEF1 (%) com média de 47,1. O VEF1 se associou com os parâmetros obtidos pelo acelerômetro, avaliação postural e TC6M, porém, não houve associação com os dados obtidos pelo IPAQ. Conclusão: Este estudo demonstrou que o declínio da função pulmonar dos pacientes adultos com FC está associado com maior cifose torácica, menor tempo em atividade física moderada e vigorosa e menor distância percorrida no TC6M. O acelerômetro demonstrou-se ser o melhor instrumento para avaliação da atividade física neste público. / Introduction: Exercise tolerance and levels of physical activity tend to be reduced in patients with cystic fibrosis (CF). Studies suggest that the level of physical activity may be associated with better nutritional status and with larger decline in lung function. With the evolution of the disease, the decline of lung function associated with metabolic disorders and malnutrition, causes alterations in respiratory mechanics, musculoskeletal disorders and thoracic deformities, bringing injury to the individual’s quality of life.Objective: To verify the association between pulmonary functional severity, physical activity level and postural evaluation variables in adults with CF. Secondly, to verify the correlation between the physical activity parameters observed by the accelerometer and the international physical activity questionnaire (IPAQ) and to verify the correlation between the parameters of physical activity observed by the two instruments with the six-minute walking distance (6MWD) and the parameters of postural evaluation. Methods:Cross-sectional study, approved by the Research Ethics Committee of the Hospital de Clínicas, Porto Alegre.The spirometry test was used to verify pulmonary function parameters. The IPAQ questionnaire and an accelerometer were used to assess the level of physical activity, for postural evaluation the photogrammetry was used with the aid of the Postural Evaluation Software (SAPO) and, for further comparisons, the six-minute walk test (6MWT) was used. Results: 28 adult subjects with CF, mean age of 25.1 years and FEV1 (%) with a mean of 47.1 participated in the study. FEV1 was associated with the parameters obtained by the accelerometer, postural evaluation and 6MWT, but there was no association with the data obtained by IPAQ. Conclusion: This study demonstrated that the decline in lung function in adult patients with CF is associated with higher thoracic kyphosis, shorter time in moderate and vigorous physical activity, and shorter distance walked on 6MWT. The accelerometer has been shown to be the best instrument for assessing physical activity in this public.

The objective of this thesis is to evaluate the use of Doppler echocardiography markers ofglobal dyssynchrony [total isovolumic time (t-IVT)] in the following 6 studies: 1) Its prognostic role in predicting cardiac events in patients undergoing CABG surgery,compared with conventional global systolic and diastolic measurements. 2) Its additional value in predicting six minute walk test (6-MWT) in patients with leftventricular (LV) ejection fraction (EF) &lt;45%. 3) Its prognostic value in comparison with other clinical, biochemical and echocardiographicvariables in patients with chronic systolic heart failure (HF). 4) The relationship between 6-MWT and cardiac function measurements in a consecutivegroup of patients, irrespective of EF and to identify predictors of exercise capacity. 5) To investigate the effect of age on LV t-IVT and Tei index compared with conventionalsystolic and diastolic parameters. 6) To assess potential additional value of markers of global LV dyssynchrony in predictingcardiac resynchronization therapy (CRT) response in HF patients. Study I Methods: This study included 74 patients before routine CABG who were followed up for18±12 months. Results: At follow-up, 29 patients were hospitalized for a cardiac event or died. LV-ESD wasgreater (P=0.003), fractional shortening (FS) lower (p&lt;0.001), E:A ratio and Tei index higher(all P&lt;0.001), and t-IVT longer (P&lt;0.001) in patients with events. Low FS [0.66 (0.50–0.87),P&lt;0.001], high E:A ratio [l4.13 (1.17–14.60), P=0.028], large LV-ESD [0.19 (0.05–0.84),P=0.029], and long t-IVT [1.37 (1.02–1.84), P=0.035] predicted events and deaths. Conclusion: Despite satisfactory surgical revascularization, long t-IVT and systolicdysfunction suggest persistent ventricular dyssynchrony that contributes to post-CABGcardiac events. Study II Methods: We studied 77 patients (60±12 year, and 33.3% females) with stable HF using 6-MWT.iii Results: E’ wave (r=0.61, p&lt;0.001), E/e’ ratio (r=-0.49, p&lt;0.001), t-IVT (r=-0.44, p&lt;0.001),Tei index (r=-0.43, p&lt;0.001) and NYHA class (r=-0.53, p&lt;0.001) had the highest correlationwith the 6-MWT distance. In multivariate analysis, only E/e’ ratio [0.800 (0.665-0.961),p=0.017], and t-IVT [0.769 (0.619-0.955), p=0.018] independently predicted poor 6-MWTperformance (&lt;300m). Conclusions: In HF, the higher the filling pressures and the more dyssynchronous the LV, thepoorer is the patient’s exercise capacity. Study III Methods: We studied 107 systolic HF patients; age 68±12 year, 25% females and measuredplasma NT-pro-BNP. Results: Over a follow-up period of 3718 months, t-IVT ≥12.3 sec/min, mean E/Em ratio≥10, log NT-pro-BNP levels ≥2.47 pg/ml and LV EF ≤32.5% predicted clinical events. Theaddition of t-IVT and NT-pro-BNP to conventional clinical and echocardiographic variablessignificantly improved the χ2 for the prediction of outcome from 33.1 to 38.0, (p&lt;0.001). Conclusions: Prolonged t-IVT adds to the prognostic stratification of patients with systolicHF. Study IV Methods: We studied 147 HF patients (61±11 year, 50.3% male) with 6-MWT.Results: The 6-MWT correlated with t-IVT (r=-0.49, p&lt;0.001) and Tei index (r=-0.43,p&lt;0.001) but not with any of the other clinical or echocardiographic parameters. Group Ipatients (&lt;300m) had lower Hb (p=0.02), lower EF (p=0.003), larger left atrium (p=0.02),thicker septum (p=0.02), lower A wave (p=0.01) and lateral wall a’ (p=0.047), longerisovolumic relaxation time (r=0.003) and longer t-IVT (p= 0.03), compared with Group II(&gt;300m). Only t-IVT ratio [1.257 (1.071-1.476), p=0.005], LV EF [0.947 (0.903-0.993),p=0.02], and E/A ratio [0.553 (0.315-0.972), p=0.04] independently predicted poor 6-MWTperformance. Conclusion: In HF, the limited 6-MWT is related mostly to severity of global LVdyssynchrony, more than EF or raised filling pressures. Study V Methods: We studied 47 healthy individuals (age 62±12 year, 24 female), arbitrarilyclassified into: M (middle age), S (seniors), and E (elderly). Results: Age strongly correlated with t-IVT (r=0.8, p&lt;0.001) and with Tei index (r=0.7,p&lt;0.001), E/A ratio (r=-0.6, p&lt;0.001), but not with global or segmental systolic function measurements or QRS duration. The normal upper limit of the t-IVT (95% CI) for the three groups was 8.3 s/min, 10.5 s/min and 14.5 s/min, respectively, being shorter in the S compared with the E group (p=0.001). T-IVT correlated with A wave (r=0.66, p&lt;0.001), E/Aratio (r=-0.56, p&lt;0.001), septal e’ (r=-0.49, p=0.001) and septal a’ (r=0.4, p=0.006), but notwith QRS. Conclusions: In normals, age is associated with exaggerated LV global dyssynchrony anddiastolic function disturbances, but systolic function remains unaffected. Study VI Methods: We studied 103 HF patients (67±12 year, 82.5% male) recruited for CRTtreatment. Results: Prolonged t-IVT [0.878 (0.802-0.962), p=0.005], long QRS duration [0.978 (0.960-0.996), p=0.02] and high tricuspid regurgitation pressure drop (TRPD) [1.047 (1.001-1.096),p=0.046] independently predicted response to CRT. A t-IVT ≥11.6 s/min was 67% sensitiveand 62% specific (AUC 0.69, p=0.001) in predicting CRT response. Respective values for aQRS ≥ 151ms were 66% and 62% (AUC 0.65, p=0.01). Combining the two variables had asensitivity of 67% but higher specificity of 88% in predicting CRT response. In atrialfibrillation (AF) patients, only prolonged t-IVT ≥11 s/min [0.690 (0.509-0.937), p=0.03]independently predicted CRT response with a sensitivity of 69% and specificity of 79% (AUC0.78, p=0.015). Conclusion: Combining prolonged t-IVT and broad QRS had higher specificity in predictingresponse to CRT, with the former the sole predictor of response in AF patients.

Falls in people aged over 65 years account for the largest proportion of all injury-related deaths and hospitalisations within Australia. Falls contributed to 1,000 deaths and 50,000 hospitalisations in older people during 1998 (Commonwealth Department of Health and Aged Care 2001). It has been predicted that by 2016, 16% of the Australian population will be aged over 65 years (Australian Bureau of Statistics 1999) placing considerable pressure on the health care system. Furthermore, prospective studies have shown that 30-50% of people aged 65 years and over, will experience a fall (Tinetti et al. 1988b; Campbell et al. 1989; Lord et al. 1994b; Hill 1999; Brauer et al. 2000; Stalenhoef et al. 2002) and this figure increases exponentially with age (Lord et al. 1994b). Many physiological falls risk factors have been established including reduced leg strength, poor balance, impaired vision, slowed reaction time and proprioception deficits. However, little research has been conducted to determine whether performance on aerobic fitness tasks is also a physiological falls risk factor. Aerobic fitness has previously been related to an individual's ability to perform activities of daily living, which in turn has been linked to falls. It was therefore proposed that aerobic fitness might also be a risk factor for falls among community dwelling older people. This research aimed to provide clinical evidence to inform public health practice. This thesis comprised of four objectives: the first to find suitable measures of aerobic fitness for older people; the second investigated relationships between existing clinical tests and future falls; the third explored relationships between aerobic fitness tests and future falls; the final objective was to examine the independent relationships between falls and clinical and physiological characteristics. The participants were recruited through a random sample from the local electoral roll, with an average age of 73 ±6 years. Of the 87 participants who completed the prospective component of the study, 37% were male and 63% were female. Sixty-three participants (65%) reported no previous falls, 19 (20%) reported a single fall, and 16 (15%) reported two or more falls in the previous 12 months. The first objective required participants recruited from the community to take part in submaximal and maximal fitness tests in order to find suitable measures of aerobic fitness. A further objective was to determine whether older people were able to fulfil the 'standard' criteria for completion of a maximum oxygen consumption test. The measures used in this research included: maximum oxygen consumption, peak oxygen consumption, ventilatory threshold, oxygen uptake kinetics, oxygen deficit, efficiencies, oxygen consumption at zero, 30 and 50 watts, predicted max and Six-Minute Walk Test distance. Only weak relationships were observed between submaximal aerobic measures and peak oxygen consumption. Furthermore, only 54% of participants were able to fulfil the criteria to complete a test of maximum oxygen consumption, indicating it was not a suitable measure for use among a sample of community dwelling older people. Therefore submaximal aerobic variables were used in the following chapters. The second objective investigated the relationship between clinical measures and falls among older people and was carried out to enable comparisons between the population in this study and those described in the literature. This research found that the Timed Up and Go (TUG) test was the most sensitive of all clinical tests (including the Berg Balance Scale, Function Reach, Performance Oriented Mobility Assessment and Physiological Profile Assessment) for the assessment of future falls. The TUG requires participants to stand up, walk 3m, turn, walk back, and sit down. Time taken to complete the test is the recorded value. For this study, a cut-off value of 7-seconds was established, above which individuals were at increased risk of falls. Previous research suggested cut-off times of over 10s were appropriate for older people. However, this is the first study to assess falls prospectively and definitively find that the TUG can discriminate between future fallers and non-fallers. This research also investigated the differences in falls risk factors for functionally different subsamples, as defined by their ability to undertake and complete the cycle test. The participants who could complete the test had significantly better balance ability and strength than those unable to undertake or complete the cycle test. However, this inability to undertake or complete the cycle test was not itself a predictor of future falls. These two groups also differed in the relationships between clinical test results and falls risk. Participants in the no-cycle group had very similar results to that of the entire cohort. Even after adjustment for age, the TUG, foot and hand reaction times and knee flexion strength were all performed better by non-fallers than fallers. However, none of these differed between fallers and non-fallers for participants in the cycle group. This group had better balance ability and strength than the no-cycle group. These results indicated that the cycle group differed from the no-cycle group and the entire sample, further indicating that factors other than the physiological variables measured in this research influence falls risk in strong participants with good balance ability. Similar results were reported when aerobic tests and falls were investigated in the third objective. In the whole sample, the fallers walked significantly less distance than non-fallers for the 6-MWT. Similar results were found for participants in the no-cycle group but not the cycle group. All participants were able to complete the Six-Minute Walk Test (6-MWT) although only 74% were able to undertake and complete the cycle test. The fourth objective was to consider all measures from the previous chapters as potential predictors of falls. The variables most predictive of future falls were the TUG and having experienced one or more falls in the previous 12 months. As a result they could be used as screening tools for the identification of high-risk fallers who require referral for further assessment. This could be completed by a General Practitioner or Practice Nurse, which would ensure that screening is being undertaken in the wider population. If the patient is at high risk they should be referred for falls risk factor assessment to determine an optimal tailored intervention to reduce future falls. Low risk patients should be referred for preventive evidence-based activities. These steps can potentially improve quality of life for individuals, and if effective in preventing future falls, will result in reduced costs to the individual and the Australian public. The results of this work demonstrate that the best screening tests are simple tasks like the TUG and asking an individual if they have experienced a fall in the last 12 months. This research also found that strong, mobile older people who could undertake and complete a submaximal cycle ergometer test, still experienced falls in the following 12 months, although the causes of this are currently unknown. This research showed that physiological falls risk factors are less relevant as these highly functional older people do not have physiological deficits. However, this research found that the 6-MWT showed promise as a predictor of falls in a group who could not complete a submaximal cycle ergometer test, who had lower strength, balance and functional fitness scores than a group who could complete this cycle test. The results showed that physiological falls risk factors are still very important for older people with lower physical abilities, and this is where aerobic fitness may still be related to falls. While the association between aerobic fitness and falls remains unclear, these are novel and provocative findings highlighting the need for future falls risk investigations to consider aerobic fitness as a contributing factor.

Introdução: A tolerância ao exercício e os níveis de atividade física tendem a ser reduzidos em pacientes com fibrose cística (FC). Estudos trazem que o nível de atividade física pode estar associado com melhor estado nutricional e com um maiordeclínio da função pulmonar. Com a evolução da doença,o declínio da função pulmonar associado a distúrbios metabólicos e desnutrição, provocam alterações na mecânica respiratória, distúrbios musculoesqueléticos e deformidades torácicas, trazendo prejuízos na qualidade de vida destes indivíduos. Objetivo: Verificar a associação entre gravidade funcional pulmonar, nível de atividade física e variáveis de avaliação postural em adultos com FC. Secundariamente, verificar a correlação entre os parâmetros de atividade física observados pelo acelerômetro e pelo questionário internacional de atividade física (IPAQ) e, verificar a correlação entre os parâmetros de atividade física observados pelos dois instrumentos com a distância percorrida no teste de caminhada de seis minutos (DTC6M) e os parâmetros de avaliação postural.Métodos: Estudo de caráter transversal, aprovado pelo Comitê de Ética em Pesquisa do Hospital de Clínicas de Porto Alegre. Para a verificação de parâmetros de função pulmonar foi utilizado o exame de espirometria, para a verificação do nível de atividade física foi utilizado o questionário IPAQ e um acelerômetro, para avaliação postural foi utilizada a fotogrametria com auxílio do Software de avaliação postural (SAPO) e, para comparações complementares foi utilizado o teste de caminhada de seis minutos (TC6M). Resultados: Participaram do estudo 28 indivíduos adultos com FC, idade média de 25,1 anos e VEF1 (%) com média de 47,1. O VEF1 se associou com os parâmetros obtidos pelo acelerômetro, avaliação postural e TC6M, porém, não houve associação com os dados obtidos pelo IPAQ. Conclusão: Este estudo demonstrou que o declínio da função pulmonar dos pacientes adultos com FC está associado com maior cifose torácica, menor tempo em atividade física moderada e vigorosa e menor distância percorrida no TC6M. O acelerômetro demonstrou-se ser o melhor instrumento para avaliação da atividade física neste público. / Introduction: Exercise tolerance and levels of physical activity tend to be reduced in patients with cystic fibrosis (CF). Studies suggest that the level of physical activity may be associated with better nutritional status and with larger decline in lung function. With the evolution of the disease, the decline of lung function associated with metabolic disorders and malnutrition, causes alterations in respiratory mechanics, musculoskeletal disorders and thoracic deformities, bringing injury to the individual’s quality of life.Objective: To verify the association between pulmonary functional severity, physical activity level and postural evaluation variables in adults with CF. Secondly, to verify the correlation between the physical activity parameters observed by the accelerometer and the international physical activity questionnaire (IPAQ) and to verify the correlation between the parameters of physical activity observed by the two instruments with the six-minute walking distance (6MWD) and the parameters of postural evaluation. Methods:Cross-sectional study, approved by the Research Ethics Committee of the Hospital de Clínicas, Porto Alegre.The spirometry test was used to verify pulmonary function parameters. The IPAQ questionnaire and an accelerometer were used to assess the level of physical activity, for postural evaluation the photogrammetry was used with the aid of the Postural Evaluation Software (SAPO) and, for further comparisons, the six-minute walk test (6MWT) was used. Results: 28 adult subjects with CF, mean age of 25.1 years and FEV1 (%) with a mean of 47.1 participated in the study. FEV1 was associated with the parameters obtained by the accelerometer, postural evaluation and 6MWT, but there was no association with the data obtained by IPAQ. Conclusion: This study demonstrated that the decline in lung function in adult patients with CF is associated with higher thoracic kyphosis, shorter time in moderate and vigorous physical activity, and shorter distance walked on 6MWT. The accelerometer has been shown to be the best instrument for assessing physical activity in this public.