Faculty Bibliography

OBJECTIVES/OBJECTIVE:This study investigated the effect of a very long-term exercise training program is not known in chronic heart failure (CHF) patients. BACKGROUND:We previously showed that long-term moderate exercise training (ET) improves functional capacity and quality of life in New York Heart Association class II and III CHF patients. METHODS:We studied 123 patients with CHF whose condition was stable over the previous 3 months. After randomization, a trained group (T group, n = 63) underwent a supervised ET at 60% of peak oxygen consumption (Vo(2)), 2 times weekly for 10 years, whereas a nontrained group (NT group, n = 60) did not exercise formally. The ET program was supervised and performed mostly at a coronary club with periodic control sessions twice yearly at the hospital's gym. RESULTS:In the T group, peak Vo(2) was more than 60% of age- and gender-predicted maximum Vo(2) each year during the 10-year study (p < 0.05 vs. the NT group). In NT patients, peak Vo(2) decreased progressively with an average of 52 ± 8% of maximum Vo(2) predicted. Ventilation relative to carbon dioxide output (VE/Vco(2)) slope was significantly lower (35 ± 9) in T patients versus NT patients (42 ± 11, p < 0.01). Quality-of-life score was significantly better in the T group versus the NT group (43 ± 12 vs. 58 ± 14, p < 0.05). During the 10-year study, T patients had a significant lower rate of hospital readmission (hazard ratio: 0.64, p < 0.001) and cardiac mortality (hazard ratio: 0.68, p < 0.001) than controls. Multivariate analysis selected peak Vo(2) and resting heart rate as independent predictors of events. CONCLUSIONS:Moderate supervised ET performed twice weekly for 10 years maintains functional capacity of more than 60% of maximum Vo(2) and confers a sustained improvement in quality of life compared with NT patients. These sustained improvements are associated with reduction in major cardiovascular events, including hospitalizations for CHF and cardiac mortality.

BACKGROUND:The objective of this study was to determine the effects of a moderate exercise training program on functional capacity, quality of life, and hospital readmission rate in chronic heart failure patients with implantable cardioverter defibrillators and cardiac resynchronization therapy. METHODS AND RESULTS/RESULTS:We studied 52 men (mean age 55+/-10 years, ejection fraction 31+/-7%) in chronic heart failure II (n=29) and III (n=23) NYHA functional class with ischemic cardiomyopathy who received implantable cardioverter defibrillators with or without cardiac resynchronization therapy. Patients were randomized into two groups. Group T (n=30 patients, 15 implantable cardioverter defibrillator, 15 implantable cardioverter defibrillator+cardiac resynchronization therapy) underwent a supervised exercise training program at 60% of peak VO2 three times a week for 8 weeks. Group C (n=22 patients, 12 implantable cardioverter defibrillator, 10 implantable cardioverter defibrillator+cardiac resynchronization therapy) avoided physical training. At 8 weeks, only trained patients had improvements in peak VO2 (P<0.01 versus C), endothelium-dependent dilatation of the brachial artery (P<0.001 versus C) and quality of life (P<0.001 versus C). Among trained patients, those with cardiac resynchronization therapy had greater improvements in peak VO2 and quality of life. During the follow-up (24+/-6 months), eight controls had sustained ventricular tachycardia requiring hospital readmission, while no trained patients had adverse events (log rank 8.56; P<0.001). The improvement in peak VO2 was correlated with the improvement in endothelium-dependent dilatation (r=0.65). CONCLUSION/CONCLUSIONS:Moderate exercise training is safe and has beneficial effects after implantable cardioverter defibrillator implantation, especially when cardiac resynchronization therapy is present. These effects are associated with improvement in quality of life and outcome.

OBJECTIVES/OBJECTIVE:The high sensitivity of electron beam tomography (EBT) in the detection of coronary artery calcium (CAC) and obstructive coronary artery disease prompted us to investigate the association between CAC detection and future cardiac events in patients with acute chest pain syndromes requiring hospitalization. BACKGROUND:Three studies have documented that EBT is a rapid and efficient screening tool for patients admitted to the emergency department (ED) with chest pain, but there is a paucity of long-term follow-up data on these chest pain patients. METHODS:We conducted a prospective observational study of 192 patients admitted to the ED of a large tertiary care hospital for chest pain syndromes. Upon admission, patients underwent EBT scanning in addition to the usual care for chest pain syndromes. During the 17-month enrollment period, 221 patients were scanned (54% men with a mean age of 53 +/- 9 years). Average follow-up was 50 +/- 10 months using chart review. RESULTS:Fifty-eight patients had coronary events confirmed by a blinded medical record review. The presence of CAC (a total calcium score >0) and increasing score quartiles were strongly related to the occurrence of hard cardiac events including myocardial infarction and death (p < 0.001) and all cardiovascular events (p < 0.001). Stratification by age- and gender-matching further increased the prognostic ability of EBT (for scores above vs. below the age- and gender-matched CAC scores; odds ratio: 13.1, 95% confidence intervals: 5.62, 35.9). CONCLUSIONS:These data support previous reports demonstrating that the presence of CAC in a symptomatic cohort is a strong predictor of future cardiac events. This study supports the use of EBT in a symptomatic cohort with prompt discharge of those patients with negative scans. Furthermore, the absence of CAC is associated with a very low risk of future cardiac risk events in this population over the subsequent seven years (annual event rate <1%).

OBJECTIVES/OBJECTIVE:The goal of this study was to determine the effects of exercise training (ET) on functional capacity and quality of life (QOL) in patients who received percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting (CS), the effects on the restenosis rate and the outcome. BACKGROUND:It is unknown whether ET induces beneficial effects after coronary angioplasty. METHODS:We studied 118 consecutive patients with coronary artery disease (mean age 57+/-10 years) who underwent PTCA or CS on one (69%) or two (31%) native epicardial coronary arteries. Patients were randomized into two matched groups. Group T (n = 59) was exercised three times a week for six months at 60% of peak VO2. Group C (n = 59) was the control group. RESULTS:Only trained patients had significant improvements in peak VO2 (26%, p < 0.001) and quality of life (26.8%, p = 0.001 vs. C). The angiographic restenosis rate was unaffected by ET (T: 29%; C: 33%, P = NS) and was not significantly different after PTCA or CS. However, residual diameter stenosis was lower in trained patients (-29.7%, p = 0.045). In patients with angiographic restenosis, thallium uptake improved only in group T (19%; p < 0.001). During the follow-up (33+/-7 months) trained patients had a significantly lower event rate than controls (11.9 vs. 32.2%, RR: 0.71, 95% confidence interval [CI]: 0.60 to 0.91, p = 0.008) and a lower rate of hospital readmission (18.6 vs. 46%, RR: 0.69, 95% CI: 0.55 to 0.93, p < 0.001). CONCLUSIONS:Moderate ET improves functional capacity and QOL after PTCA or CS. During the follow-up, trained patients had fewer events and a lower hospital readmission rate than controls, despite an unchanged restenosis rate.

BACKGROUND:It is still a matter of debate whether exercise training (ET) is a beneficial treatment in chronic heart failure (CHF). METHODS AND RESULTS/RESULTS:To determine whether long-term moderate ET improves functional capacity and quality of life in patients with CHF and whether these effects translate into a favorable outcome, 110 patients with stable CHF were initially recruited, and 99 (59+/-14 years of age; 88 men and 11 women) were randomized into 2 groups. One group (group T, n=50) underwent ET at 60% of peak &f1;O2, initially 3 times a week for 8 weeks, then twice a week for 1 year. Another group (group NT, n=49) did not exercise. At baseline and at months 2 and 14, all patients underwent a cardiopulmonary exercise test, while 74 patients (37 in group T and 37 in group NT) with ischemic heart disease underwent myocardial scintigraphy. Quality of life was assessed by questionnaire. Ninety-four patients completed the protocol (48 in group T and 46 in group NT). Changes were observed only in patients in group T. Both peak &f1;O2 and thallium activity score improved at 2 months (18% and 24%, respectively; P<0. 001 for both) and did not change further after 1 year. Quality of life also improved and paralleled peak VO2. Exercise training was associated both with lower mortality (n=9 versus n=20 for those with training versus those without; relative risk (RR)=0.37; 95% CI, 0.17 to 0.84; P=0.01) and hospital readmission for heart failure (5 versus 14; RR=0.29; 95% CI, 0.11 to 0.88; P=0.02). Independent predictors of events were ventilatory threshold at baseline (beta-coefficient=0.378) and posttraining thallium activity score (beta-coefficient -0.165). CONCLUSIONS:Long-term moderate ET determines a sustained improvement in functional capacity and quality of life in patients with CHF. This benefit seems to translate into a favorable outcome.