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Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACCÂ State-of-the-Art Review.
Ijaz, N, Buta, B, Xue, QL, Mohess, DT, Bushan, A, Tran, H, Batchelor, W, deFilippi, CR, Walston, JD, Bandeen-Roche, K, et al
Journal of the American College of Cardiology. 2022;(5):482-503
Abstract
With the aging of the world's population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.
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Current Insights into Exercise-based Cardiac Rehabilitation in Patients with Coronary Heart Disease and Chronic Heart Failure.
Nichols, S, McGregor, G, Breckon, J, Ingle, L
International journal of sports medicine. 2021;(1):19-26
Abstract
Cardiac rehabilitation is a package of lifestyle secondary prevention strategies designed for patients with coronary heart disease and chronic heart failure. A community-based cardiac rehabilitation programme provides patients with a structured exercise training intervention alongside educational support and psychological counselling. This review provides an update regarding the clinical benefits of community-based cardiac rehabilitation from a psycho-physiological perspective, and also focuses on the latest epidemiological evidence regarding potential survival benefits. Behaviour change is key to long-term adoption of a healthy and active lifestyle following a cardiac event. In order for lifestyle interventions such as structured exercise interventions to be adopted by patients, practitioners need to ensure that behaviour change programmes are mapped against patient's priorities and values, and adapted to their level of readiness and intention to engage with the target behaviour. We review the evidence regarding behaviour change strategies for cardiac patients and provide practitioners with the latest guidance. The 'dose' of exercise training delivered to patients attending exercise-based cardiac rehabilitation is an important consideration because an improvement in peak oxygen uptake requires an adequate physiological stimulus to invoke positive physiological adaptation. We conclude by critically reviewing the latest evidence regarding exercise dose for cardiac patients including the role of traditional and more contemporary training interventions including high intensity interval training.
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Endocrine Challenges in Patients with Continuous-Flow Left Ventricular Assist Devices.
Martucci, G, Pappalardo, F, Subramanian, H, Ingoglia, G, Conoscenti, E, Arcadipane, A
Nutrients. 2021;(3)
Abstract
Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.
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Pathophysiology of Exercise Intolerance and Its Treatment With Exercise-Based Cardiac Rehabilitation in Heart Failure With Preserved Ejection Fraction.
Tucker, WJ, Angadi, SS, Haykowsky, MJ, Nelson, MD, Sarma, S, Tomczak, CR
Journal of cardiopulmonary rehabilitation and prevention. 2020;(1):9-16
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Abstract
Heart failure with preserved ejection fraction (HFpEF) is the fastest growing form of heart failure in the United States. The cardinal feature of HFpEF is reduced exercise tolerance (peak oxygen uptake, (Equation is included in full-text article.)O2peak) secondary to impaired cardiac, vascular, and skeletal muscle function. There are currently no evidence-based drug therapies to improve clinical outcomes in patients with HFpEF. In contrast, exercise training is a proven effective intervention for improving (Equation is included in full-text article.)O2peak, aerobic endurance, and quality of life in HFpEF patients. This brief review discusses the pathophysiology of exercise intolerance and the role of exercise training to improve (Equation is included in full-text article.)O2peak in clinically stable HFpEF patients. It also discusses the mechanisms responsible for the exercise training-mediated improvements in (Equation is included in full-text article.)O2peak in HFpEF. Finally, it provides evidence-based exercise prescription guidelines for cardiac rehabilitation specialists to assist them with safely implementing exercise-based cardiac rehabilitation programs for HFpEF patients.
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eHealth to improve patient outcome in rehabilitating myocardial infarction patients.
Verburg, A, Selder, JL, Schalij, MJ, Schuuring, MJ, Treskes, RW
Expert review of cardiovascular therapy. 2019;(3):185-192
Abstract
Cardiac rehabilitation is aimed at risk factor modification and improving quality of life. eHealth has a couple of potential benefits to improve this aim. The primary purpose of this review is to summarize available literature for eHealth strategies that have been investigated in randomized controlled trials in post-myocardial infarction (MI) patients. The second purpose of this review is to investigate the clinical effectiveness in post-MI patients. Areas covered: The literature was searched using PubMed. Randomized controlled trials (RCTs) describing interventions in patients that had experienced an ST-elevation myocardial infarction or non-ST acute coronary syndrome were eligible for inclusion. Fifteen full-texts were included and their results are described in this review. These RCTs described interventions that used remote coaching or remote monitoring in post-MI patients. Most interventions resulted in an improved cardiovascular risk profile. Remote coaching had a positive effect on activity and dietary intake. Expert opinion: eHealth might be clinically beneficial in post-MI patients, particularly for risk estimation. Moreover, eHealth as a tool for remote coaching on activity is a good addition to traditional cardiac rehabilitation programs. Further research needs to corroborate these findings.
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Peripheral Arterial Disease: Supervised Exercise Therapy Through Cardiac Rehabilitation.
Thomas, SG, Marzolini, S, Lin, E, Nguyen, CH, Oh, P
Clinics in geriatric medicine. 2019;(4):527-537
Abstract
Peripheral arterial disease (PAD) is frequently underdiagnosed and undertreated. This review identifies specific subgroups within older adults more likely to develop PAD, and describes methods to diagnose PAD and provide evidence in support of systematic referral to cardiac rehabilitation programs to enhance successful comprehensive management. Clear evidence and guidelines support the routine use of supervised exercise therapy to improve function, reduce risk of cardiovascular morbidity and mortality, and enhance the success of endovascular interventions.
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Prehabilitation: The Right Medicine for Older Frail Adults Anticipating Transcatheter Aortic Valve Replacement, Coronary Artery Bypass Graft, and Other Cardiovascular Care.
Boreskie, KF, Hay, JL, Kehler, DS, Johnston, NM, Rose, AV, Oldfield, CJ, Kumar, K, Toleva, O, Arora, RC, Duhamel, TA
Clinics in geriatric medicine. 2019;(4):571-585
Abstract
The wait before elective cardiac intervention or surgery presents an opportunity to prevent further physiologic decline preoperatively in older patients. Implementation of prehabilitation programs decreases length of hospital stay postoperatively, decreases time spent in the intensive care unit, decreases postoperative complications, and improves self-reported quality of life postsurgery. Prehabilitation programs should adopt multimodal approaches including nutrition, exercise, and worry reduction to improve patient resilience in the preoperative period. High-quality research in larger cohorts is needed, and interventions focusing on underrepresented frailer populations and women. Creative ways to improve accessibility, adherence, and benefits received from prehabilitation should be explored.
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Concordant Evidence-Based Interventions in Cardiac and Pulmonary Rehabilitation Guidelines.
Smith, SMS, Chaudhary, K, Blackstock, F
Journal of cardiopulmonary rehabilitation and prevention. 2019;(1):9-18
Abstract
Chronic conditions such as chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) contribute to a significant burden to patients and many experience a reduction in physical functioning, psychological health, and quality of life. The sentinel symptom for COPD and CVD is breathlessness. Rehabilitation programs have been proven to reduce disease symptoms and increase levels of physical and psychological wellness. Pulmonary and cardiac rehabilitation programs have been recommended in international and national guidelines for managing COPD and CVD. Given that these programs seek to reduce breathlessness and improve the physical and psychological functioning of people with COPD and CVD, this review examines the concordant evidence-based interventions in rehabilitation guidelines. The findings of this review indicate that there was concordance in the program design, location of programs, types of health professionals involved in program delivery, assessments of patient at commencement and completion of program, and the delivery of educational topics with minor deviations that were related to disease-specific topics. Apart from disease-specific recommendations, the main divergence from rehabilitation guidelines was found to be dietary screening, inspiratory muscle training, and psychological assessments in evidence-based recommendations for cardiac and pulmonary programs.
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Implications of Cardio-Respiratory Fitness on the Performance of Exercise Tests.
Jelinek, M, Hossack, K
Heart, lung & circulation. 2019;(4):e64-e66
Abstract
In 2016, the American Heart Association (AHA) produced a position paper on cardiorespiratory fitness (CRF) which defined CRF as the most important cardiac risk factor in the assessment of prognosis in a wide variety of clinical states [1]. The aim of the paper was to improve patient management and to encourage life-style based strategies designed to improve cardiovascular risk. The authors showed that: In this Brief Communication, we expand on how CRF can be assessed and reported in exercise testing.
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Tailoring Assessments and Prescription in Cardiac Rehabilitation for Older Adults: The Relevance of Geriatric Domains.
Fiatarone Singh, MA
Clinics in geriatric medicine. 2019;(4):423-443
Abstract
Older adults have distinctive health challenges that are relevant to the prevention and treatment of cardiovascular diseases and are potentially modifiable by cardiac rehabilitation. Cardiac rehabilitation in older adults provides opportunity to assess sarcopenia, obesity, osteoporosis, frailty, falls risk, arthritis, cognition, special senses, self-efficacy, depression, social support, polypharmacy, and nutritional adequacy. Therefore, broadening standard assessments to include these domains can help detect modifiable vulnerabilities and inform therapeutic priorities.