2019;32(4) – ABC CARDIOL

IJCS

Família ABC | IJCS

Viewpoint

Invasive Coronary Physiological Assessment in Symptomatic Middle-Aged Endurance Athletes

Omar M. Issa et al. J. Sawalla Guseh Ignacio Inglessis Aaron L. Baggish

Abstract

Despite the health benefits of routine exercise, coronary artery disease (CAD) is common among older competitive athletes and is an important cause of sudden cardiac death. Athletes with suspected or confirmed CAD routinely undergo conventional coronary angiography involving the performance of invasive coronary physiological assessment using the fractional flow reserve (FFR) or the instantaneous-wave free ratio (iFR). Data defining the role of invasive coronary physiological assessment, while robust in general clinical populations, are untested among older competitive athletes with CAD. The paper discusses the challenges and uncertainties surrounding the use of the FFR and iFR in this unique population with an emphasis on the need for future work to better define this approach.

Ler artigo completo

Review Article

Effects of Exercise Training on Cardiovascular and Autonomic Parameters in Stroke Survivors: A Systematic Review

Bruno Bavaresco Gambassi et al. Fabiano de Jesus Furtado Almeida Ana Eugênia Araújo Furtado Almeida João Alberto Ribeiro … Tânia Maria Gaspar Novais Paulo Adriano Schwingel Ciro Oliveira Queiroz Clarcson Plácido Conceição dos Santos Bruno Rodrigues

Abstract

Negative changes in cardiovascular and autonomic variables in stroke survivors have encouraged the global scientific community to focus on investigating therapeutic strategies to mitigate stroke damage. The objective of the present study was to describe the effects of exercise training on cardiovascular and autonomic variables in stroke survivors. We used the PICO (population, intervention, control/comparison, and outcome variables) model for the search of articles in PubMed and Physiotherapy Evidence Databases from 2009 to December 2018. The following data were also recorded: type of study, author, year of publication, participants (time after stroke, sample size, and age) and benefits of exercise training. A total of 544 articles were initially selected, of which nine peer-reviewed articles met the search criteria. These nine studies enrolled 611 participants (middle-aged or elderly), and pointed to positive effects of training on maximal oxygen uptake, peak aerobic capacity, 6-minute walk test and resting heart rate. However, more well-controlled studies are needed to confirm the benefits of exercise training on cardiovascular and autonomic variables in this population.

Ler artigo completo

Original Article

The Physical Activity Level, Body Composition and Diabetes Mellitus Influence the Association Between Depression and Hypertension in Community-Dwelling Elders

Carlos Geovane S. Araújo et al. Ivna Vidal Freire Ícaro José Santos Ribeiro Yanne Franca Montino … Cézar Augusto Casotti Rafael Pereira

Abstract

Background:

Depression and hypertension are highly prevalent among elderly people. Although the relationship between these conditions is well recognized, however, the factors that may influence such association are not clearly understood.

Objective:

To analyze the association between depression and hypertension in community-dwelling elders.

Methods:

Two-hundred and thirty-one community-dwelling elders provided information regarding the following variables: sex, age, ethnicity, smoking habit, physical activity level (PA), body mass index (BMI) and diabetes mellitus (DM). These variables can potentially influence depression and hypertension, as well as its relationship. Screening for depression was made using the Geriatric Depression Scale (GDS). The presence of hypertension was defined based on self-reported data and/or the use of antihypertensive drugs. The logistic regression technique was applied, using hypertension as the dependent variable and depressive state as a predictive variable. Logistic regression was applied with and without adjustment for the potential intervening variables.

Results:

The prevalence of depressive state and hypertension in the studied population was 14% and 59%, respectively. The association between depression and hypertension without adjustments was not significant (odds ratio [OR] = 2.28, 95% confidence interval [95%CI] = 0.98 – 5.32; p = 0.06). However, after adjusting for PA, BMI and DM, the strength of association between depression and hypertension significantly increased (OR = 3.08, 95%CI = 1.12 – 8.46; p = 0.03).

Conclusion:

The association between depression and hypertension in the elderly is directly influenced by PA, BMI and DM. This finding may guide strategies to increase the adherence to a healthier lifestyle.

Ler artigo completo

Original Article

CLINIMEX Aerobic Fitness Questionnaire: Proposal and Validation

Claudio Gil S. Araújo et al. Claudia Lucia Castro João Felipe Franca Christina Grüne de Souza e Silva

Abstract

Background:

Cardiorespiratory (aerobic) fitness is strongly and directly related to major health outcomes, including all-cause mortality. Maximum oxygen uptake (VO₂max), directly measured by maximal cardiopulmonary exercise test (CPET), represents the subject’s aerobic fitness. However, as CPET is not always available, aerobic fitness estimation tools are necessary.

Objectives:

a) to propose the CLINIMEX Aerobic Fitness Questionnaire (C-AFQ); b) to validate C-AFQ against measured VO₂max; and c) to analyze the influence of some potentially relevant variables on the error of estimate.

Methods:

We prospectively studied 1,000 healthy and unhealthy subjects (68.6% men) aged from 14 to 96 years that underwent a CPET. The two-step C-AFQ describes physical activities with corresponding values in metabolic equivalents (METs) – ranging from 0.9 to 21 METs.

Results:

Application of C-AFQ took less than two minutes. Linear regression analysis indicated a very strong association between estimated (C-AFQ) and measured (CPET) maximal METs – r2 = 0.83 (Sy.x = 1.63; p < .001) – with median difference of only 0.2 METs between both values and interquartile range (percentiles 25 and 75) of 2 METs. The difference between estimated and measured METs was not influenced by age, sex, body mass index, clinical condition, ß-blocker use or sitting-rising test scores.

Conclusion:

C-AFQ is a simple and valid tool for estimating aerobic fitness when CPET is unavailable and it is also useful in planning individual ramp protocols. However, individual error of estimate is quite high, so C-AFQ should not be considered a perfect substitute for CPET’s measured VO₂max.

Ler artigo completo

Original Article

Classification System for Cardiorespiratory Fitness Based on a Sample of the Brazilian Population

Antonio Eduardo Monteiro de Almeida et al. Igor Rafael Miranda Ferreira Santander Maria Izabel Macedo Campos Jorge René Garcia Arévalo … João Agnaldo do Nascimento Luiz Eduardo Fonteles Ritt Karlyse Claudino Belli Jorge Pinto Ribeiro Ricardo Stein

Abstract

Background:

Peak oxygen consumption (VO_2peak) is an important prognostic marker and its classification helps the cardiologist in the therapeutic decision-making process. The most commonly used cardiorespiratory fitness (CRF) classification has not been validated for the Brazilian population.

Objective:

To elaborate a CRF classification using a Brazilian sample and to compare it with the American Heart Association (AHA), Cooper and UNIFESP classifications.

Methods:

A total of 6,568 healthy subjects were analyzed through cardiopulmonary exercise testing (CPET). They were distributed by sex and the following age groups (years): 7-12, 13-19, 20-79 (per decades) and > 80 years. After measurement of the VO_2peak, participants were distributed into quintiles of CRF in very poor, poor, moderate, high and very high (AEMA Table). The CRF classifications by AEMA, AHA, Cooper, and UNIFESP were compared using the Wilcoxon, Kappa and concordance percentages.

Results:

VO_2peak presented an inverse and moderate correlation with age considering both sexes (R = -0.488, p < 0.001). All paired comparisons between CRF classification systems showed differences (p < 0.001) and disagreement percentage – AEMA versus AHA (k = 0.291, 56.7%), AEMA versus Cooper (k = 0.220, 62.4%) and AEMA versus UNIFESP (k = 0.201, 63.9 %).

Conclusion:

The AEMA table showed important discrepancies in the classification of CRF when compared to other tables widely used in our setting. Because it was obtained from a large sample of the Brazilian population, the AEMA table should be preferred over other classification systems in our population.

Ler artigo completo

Original Article

Cardiopulmonary Exercise Testing in Patients with Implantable Cardioverter-Defibrillator: A Retrospective Study

Carolina Mizzaci et al. Thiago Fagundes Felipe Malafaia Sandro Felicioni … Susimeire Buglia Carlos Alberto Hossri Almir Ferraz Rica Buchler Romeu Meneghelo Luiz Mastrocolla

Abstract

Background:

Cardiopulmonary exercise testing is widely used in the evaluation of patients with left ventricular dysfunction, and some of these patients have an implantable cardioverter-defibrillator (ICD). However, this test presents specific challenges because of the susceptibility to ventricular arrhythmias during maximal levels of exercise.

Objective:

To evaluate the safety of cardiopulmonary exercise testing in patients with ICD.

Methods:

The study included patients with ICD who underwent cardiopulmonary exercise testing between 2007 and 2015. The tests were completed once the electronic devices were programmed. The maximum allowed heart rate reached during exercise was 10 beats below the first therapy zone programmed.

Results:

The study included 69 patients with mean age 53.7 ± 10.8 years, including 68% men. Exercise time was 8.7±2.3 minutes, with peak oxygen consumption of 13.3 ± 4.3 ml.kg^-1.min^-1. Peak heart rate was 62.9 ± 13.4% of the maximum rate predicted, with all patients taking specific medication. Ventricular arrhythmia was observed in 29% of the patients, and paired ventricular extrasystoles, ventricular bigeminism or non-sustained ventricular tachycardia were observed in only 14.5% of the patients. There was no sustained ventricular arrhythmia resulting in ICD therapy or other complications, such as inappropriate therapies. The frequency of severe events was 0%, 95% CI (0 – 5.2%).

Conclusion:

In the sample of patients evaluated, the cardiopulmonary exercise testing was shown to be safe during its performance in a hospital setting, following the safety standards.

Ler artigo completo

Original Article

Physical Activity and Incidence of Atrial Fibrillation – Systematic Review and Meta-Analysis

Daniel Carlos Garlipp et al. Raphael Boesche Guimaraes Simone Louise Savaris Clovis Froemming Junior … Oscar Dutra Tiago Luiz Luz Leiria

Abstract

Background:

The relationship between exercise and atrial fibrillation (AF) is controversial.

Objectives:

To analyze the effects of physical activity on the incidence of atrial fibrillation using systematic review and meta-analysis.

Methods:

Systematic review and meta-analysis of studies that relate physical exercise and atrial fibrillation. The following databases were searched: PubMed, BVS Saúde and Cochrane. The following descriptors were used: “atrial fibrillation”, “exercise”, “physical activity” and “exercise therapy”. All prospective, retrospective, cross-sectional and cohort studies were investigated. All statistical analyzes were provided using Review Manager 5.3 to provide the mean difference (MD) and relative risk (RR) ratio with 95% confidence intervals (95% CI). The statistical method of heterogeneity index was used to assess heterogeneity. Level of significance was 5%.

Results:

Combined analysis of 11 studies totaling 276,323 participants aged between 12 and 90 years did not suggest a significant increase in AF in individuals submitted to physical exercise (RR = 0.914, 95% CI = 0.833-1.003, heterogeneity: p < 0.001).

Conclusions:

Physical exercise, lato sensu, without stratification by intensity, sex or age does not seem to be associated with an increase of atrial fibrillation.

Ler artigo completo

Review Article

Sudden Cardiac Death in Sports: Why Its Prevalence is So Different by Gender?

Cléa Simone Sabino de Souza Colombo et al. Nabil Ghorayeb Thiago Ghorayeb Garcia Ricardo Contesini Francisco

Abstract

Sports competition can be a trigger to fatal arrhythmias in predisposed individuals, leading to sudden cardiac death. Athletes have 2.8 fold more risk of sudden cardiac death than non-athletes. However, female athletes seem to have some cardiac protection, dying suddenly much less than men during sports. Although the mechanisms for this protection have not been well established until now, hormonal, genetic and molecular factors may play a role in it. The so-called “fair sex” might harbour the key for sudden cardiac death prevention.

Ler artigo completo

Editorial

Physical Activity, Exercise and Sport: A Five-Star Path for a Better Cardiovascular Health

Claudio Gil Soares de Araújo et al. Claudio Tinoco Mesquita

Why we must exercise? Although this question has many answers, many other questions arise from it. Which are the benefits of exercising? How much exercise is good for health? Is high-intensity exercise better than moderate-intensity exercise? Are there risks in exercising? What to do if someone does not like to exercise? Do cardiologists know the literature on exercise and heart? These are sounding questions that should be covered to understand the real need of exercising.

[…]

Ler artigo completo

Original Article

Comparative Analysis of Direct and Indirect Methods for the Determination of Maximal Oxygen Uptake in Sedentary Young Adults

Alfredo Moreira da Rocha Neto et al. Artur Haddad Herdy Pablo de Souza

Abstract

Background:

Maximal oxygen uptake is a powerful prognostic indicator and a reliable measure of physical conditioning. It can be measured directly by cardiopulmonary exercise testing (CPET) or indirectly by formulas derived from conventional protocols.

Objective:

We compared the VO₂ max obtained by formula using exercise testing with Bruce protocol (BP) with the VO₂ max obtained by CPET on the treadmill.

Methods:

We selected 41 healthy, non-obese, physically inactive young volunteers, aged between 21 and 50 years, residents of Florianópolis, Brazil.

Results:

Twenty-one women (52%) with mean age of 35.62 ± 8.83 years, and 20 males, with mean age of 32.5 ± 7.18 years participated in the study. Statistically significant differences were found for VO₂ max between the two methods (BP – 42.31 ± 5.21 ml/kg.min vs. CPET – 30.46 ± 5.50 ml/kg.min., p < 0.0001). The Bruce formula overestimated the result by 34.1% (BP – 45.95 ± 3.94 ml/kg.min vs. CPX – 34.27 ± 4.20 ml/kg.min, p < 0.0001) for men, and by 44.8% (BP – 38.84 ± 3.72 ml/kg.min vs. CPX – 26.83 ± 3.90, p < 0.0001) for women. A moderate correlation was observed between the methods (r = 0.65). When classifying the results according to the table of aerobic capacity of the American Heart Association, the agreement was null (kappa = 0.0034; Pearson chi2 = 0.001).

Conclusion:

VO₂ estimated by BP is not capable of demonstrating the true aerobic capacity in these individuals, while CPET is an important tool for early detection of diminished functional capacity in sedentary young men and women.

Ler artigo completo

Review Article

Physical Exercise in the Management of Erectile Dysfunction in Patients with Heart Failure

Ana Gonzáles et al. Tales de Carvalho Leonardo Andreato Sabrina Sties Anelise Sonza

Abstract

Erectile dysfunction (ED) is a highly prevalent problem that affects the quality of life, prognosis and survival of patients with heart failure (HF). In the management of ED, physical exercise is a therapeutic strategy that reduces disease-related symptoms and optimizes drug use. However, the repercussions of physical exercise on ED in individuals with HF still need to be elucidated. In this sense, the objective of this study was to evaluate the effects of physical exercise on erectile function (EF) in HF patients. This was a systematic review conducted according to PRISMA guidelines. Patients with HF, male and ejection fraction ≤ 45% were submitted to physical exercise of different modalities. The search for scientific articles was conducted in the electronic databases (PubMed, LILACS, Cochrane-Library, Science Direct) from the inception until October 2018, according to the MeSH dictionary descriptors, which were suitable for all databases. Results: Three studies were analyzed, includinng 99 male subjects, age ranging from 53 years (± 7.48) to 58 years (± 12). Seventy subjects were submitted to a physical exercise program and 29 were in the control group. In all studies, physical exercise showed positive results in the management of ED regardless of erectile dysfunction (ED) classification status and intensity of exercise used. It was concluded that physical exercise of different intensities was considered an effective therapeutic intervention to improve EF in individuals with HF and ED.

Ler artigo completo

Review Article

Update on Sports Participation for Athletes with Implantable Cardioverter Defibrillators

Abstract

Prior statements have recommended restriction from competitive sports participation for all athletes with ICDs. Recent data, however, suggests that many athletes can participate in sports without adverse events. In the ICD Sports Registry, 440 athletes, aged 8-60 years, 77 of which were high-level interscholastic athletes, who had continued to practice sports, were prospectively followed for 4 years, with no deaths or failures to defibrillate during practice, and no injuries related to arrhythmia or shock during sports. Shocks did occur, for ventricular and supraventricular arrhythmias. While more athletes received shocks during physical activity than at rest, there were no differences between competition or practice, versus other physical activity. Programming with higher rate cut-offs and longer durations was associated with fewer inappropriate shocks, with no increase in syncope. Based on this study, current recommendations now state that returning to competition may be considered for an athlete with an ICD. In considering this decision, the underlying disease and type of sport should be discussed, and shared decision-making between doctor, patient, and often family, is critical.

Ler artigo completo

Viewpoint

Exercise, Sports & Cardiovascular Health: Relevant Questions and Answers

Claudio Gil Araujo et al. Barry Franklin Jari Laukkanen Jonathan Myers … Josef Niebauer Jurgen Scharhag Philip J. Millar

Introduction

Currently, it is quite common for a clinical cardiologist to be questioned about exercise and sports, topics that are rarely discussed during formal medical education. In this regard, there is a clear need to access high-quality data and evidence-based information to give patients and family members the best advice.

Aiming to present the state-of-the art scientific information on the topic, we have invited several experts from different countries, all of them “knowledge-producers” in exercise and sports cardiology, to contribute with their expertise by answering specific and relevant questions in the matter. The answers were limited to about 250 words and they were asked to preferentially refer to their own publications.

[…]

Ler artigo completo

Review Article

Measuring Heart Rate During Exercise: From Artery Palpation to Monitors and Apps

Marcos Almeida et al. Altamiro Bottino Plínio Ramos Claudio Gil Araujo

Abstract

The use of technology has increased tremendously, by means of more reliable, smaller, more accessible and specially more user-friendly devices, which provide a wider range of features, and promote significant benefits for the population and health professionals. It is in this context that monitors and apps for heart rate (HR) measurement have emerged. HR is a clinical vital sign of diagnostic and prognostic importance. In response to body movement, HR tends to increase, in a direct relationship with the intensity of exercise. HR was primarily measured by the count of arterial pulse, and recently, HR can be precisely measured by monitors, bracelets and smartphone apps capable to perform real-time measurements and storage of data. This paper aimed to make a brief and updated review on the theme, providing a broader view of advantages and limitations of these resources for HR measurement in exercise. HR monitors and apps use basically two types of technology, optical sensor (photoplethysmography) and electrical signal from the heart. In general, these devices have shown good accuracy in measuring HR and HR variability at rest, but there are differences between brands and models considering the type, mode and intensity of exercise. HR measurements by monitors and smartphone apps are simple, accessible and may help cardiologists in the monitoring of the intensity of aerobic exercise, focusing on health promotion and on primary and secondary prevention of cardiovascular diseases.

Ler artigo completo

Original Article

Speed and Grade Increment During Cardiopulmonary Treadmill Testing: Impact on Exercise Prescription

Karlyse C. Belli et al. Paula F. Da Silva Leandro T. Franzoni Jonathan Myers … Ricardo Stein Jorge P. Ribeiro

Abstract

Background:

Maximal oxygen uptake (VO₂max) and both first (VT₁) and second (VT₂) thresholds have been used as reference points for exercise prescription in different populations.

Objective:

We aimed to test the hypothesis that exercise prescription, based on VTs determined by treadmill cardiopulmonary exercise testing (CPET), is influenced by the rate of increase in treadmill workload.

Methods:

Nine healthy individuals underwent two CPETs, followed by two sessions of submaximal exercise, both in randomized order. For the “speed” protocol, there was an increment of 0.1 to 0.3 km.h^-1 every 15s. The “grade” incremental protocol increased 1% every 30s and 0.1 km.h^-1 every 45s. This was followed by submaximal exercise sessions lasting 40min at an intensity corresponding to heart rate (HR) between the VT₁ and VT₂.

Results:

The “speed” protocol resulted in higher VT₁ (p = 0.01) and VT₂ (p = 0.02) when compared to the “grade” incremental protocol, but there was no effect on VO₂max. The target HR for the submaximal exercise sessions was higher in the “speed” protocol compared to the “grade” incremental protocol (p < 0.01) and remained stable during the two steady-state exercise sessions. Blood lactate remained stable during the submaximal exercise sessions, with higher values observed during the “speed” protocol than those “grade” incremental protocol (p < 0.01).

Conclusions:

Compared to a grade-based protocol, a speed-based protocol resulted in higher VT₁ and VT₂, which significantly affected cardiorespiratory and metabolic responses to prescribed exercise intensity in healthy young adults.

Ler artigo completo

Brief Communication

Jorge Pinto Ribeiro: a True Icon of Exercise Physiology and Cardiology

The initiative to make an edition dedicated to a certain area of knowledge in a scientific journal is always a major challenge full of hard work. Original articles, reviews and / or special cases in the field are expected and the best experts in the subject are those that the editor hopes to be able to count. This edition of the International Journal of Cardiology Science, headed by Dr. Claúdio Gil Soares de Araújo, is focused on physical exercise and its pages contain different articles on the matter. Probably, I was invited to contribute because I work and publish in the sports and exercise cardiology field, besides the fact that I am the Associate-Editor for exercise and rehabilitation of the Arquivos Brasileiros de Cardiologia. By the way, when the invitation letter arrived, I immediately accepted it, but wondered what my ideal contribution might be. Thus, over five days I glimpsed different possibilities, until one early morning, while running an insight came: Jorge Pinto Ribeiro!!! Nothing is fairer to remember than a professor and scientist with more than 150 publications, at least half of them in the exercise physiology/cardiology area. So, with the support of the International Journal of Cardiology Science Editors I was able to go through a few lines with a sense of affection and sadness, as long as many years have passed since this cardiology “giant” passed way. It is amazing to mention that, despite the hiatus of more than 6 years since his death, he continues to publish: at least three articles with his name can be found at Pubmed in the year 2018… and two^, in this Edition!!! Well, but who was the Jorge Pinto Ribeiro I met? The differential started with the name. At least for me an affirmative name. A name that always sounded strong, announcing that behind these 17 letters, Jorge Pinto Ribeiro, came a winner. No, actually, he was a champion. A champion at home, at work, at leisure, a blessed champion with unified qualities in a rare individual, a true winner. A man who was always offering the hand to help others on their achievements. Yes, he was the owner of this name, a person who at the height of his 57 years, in the distant year of 2012, left us. Indeed, after a Herculean fight against a rare disease, the flame of his intense and successful life was extinguished. Actually, his early departure left an enormous emptiness and deep longing in relatives, friends, colleagues, students and patients. However, we who know him well always remember his energy, his production, his life as a husband, father, brother, doctor, teacher… as a friend!!! Is evident, he was a man who lived the life. In short, as a brilliant cardiologist and one of the most talented scientists in exercise physiology/cardiology ever, Jorge Pinto Ribeiro certainly is reading the International Journal of Cardiology Science pages delighted and smiling.

Ricardo “Pinto Ribeiro” Stein

[…]

Ler artigo completo

Case Report

Sudden Cardiac Arrest in Athletes: Do not Miss Suspicious Details

Marta Luísa Braga et al. Paula Dias Mariana Vasconcelos Rui Almeida … Paulo Araújo Maria Maciel

Introduction

Sudden cardiac death (SCD) related to sports activities is an unexpected and rare event, usually occurring in young and apparently healthy athletes. The main cause of SCD in young athletes (< 35 years old) is ventricular arrhythmia (VA) associated with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy – ARVC, channelopathies). Some of these conditions can be suspected by routine pre-participation clinical evaluation, while others remain undetectable even after careful screening.^– This paper presents the case of a professional athlete with undiagnosed ARVC, whose first manifestation was malignant VA and biventricular dysfunction.

[…]

Ler artigo completo