Endothelial progenitor cells mobilization and inflammation after cardiac rehabilitation on patients undergoing percutaneous coronary intervention after acute coronary sindrome
F Cesari1, R Marcucci1, F Sofi1, C Burgisser2, S Luly2, R Abbate1, GF Gensini1, F Fattirolli2
1Department of Medical and Surgical Critical Care, thrombosis Centre, University of Florence, Florence, Italy, 2Cardiac Rehabilitation Center, Unit of Gerontology and Geriatrics, University of Florence, Florence, Italy
Topic: Cardiovascular rehabilitation
Background: Endothelial progenitor cells (EPCs) are bone marrow-derived progenitor cells which support vascular endothelium, so playing a crucial role in the beginning and progression of atherosclerosis. It has been previously demonstrated that a potent trigger for EPCs mobilization is regular physical exercise. However, few data regarding the possible effect of cardiac rehabilitation (CR) program after primary percutaneous coronary intervention (PCI) on EPCs are available. We performed this study in order to assess the variations of EPCs in relation to inflammatory markers in patients who performed a four weeks CR after PCI.
Methods: 55 patients [45 M/10 F; mean age 58 (41–74) years] were admitted in an four weeks execise-based CR program after acute coronary syndrome and PCI. the numbers of EPCs and the sera levels of NT-ProBNP and high sensitivity C-reactive protein (CRP) were determined at the beginning (T1) and at the end (T2) of the CR program. All patients were under HMG-CoA reductase inhibitor therapy and performed a cardiopulmonary exercise test at T1 and at T2. Peripheral blood EPCs were measured by using flow cytometry and were defined as CD34+KDR+, CD133+KDR+ and CD34+CD133+KDR+. CRP and NT-ProBNP were measured by using a nephelometric and an immunometric method, respectively.
Results: With regards to EPCs, we observed a significantly increase at T2 with respect to T1 [CD34+KDR+: 7 (0–27) vs. 13 (0–37) cells/106 events p=0.010; CD133+KDR+: 7(0–27 vs. 10 (0–33)) cells/106 events p=0.018; CD34+CD133+KDR+: 7 (0–27) vs. 10 (0–33) cells/106 events p=0.014]. As expected, a significantly increase at T2 was observed for cardiopulmonary parameters (VO2 max and Watt) whereas hsCRP and NT-ProBNP levels significantly decreased at T2 with respect to T1 values.
By diving our patients populations in relation to the increase of EPCs, patients with an increase of EPCs were significantly younger with respect to the others [56 (42–74) vs. 61 (41–74) p>0.05], showed significantly lower baseline levels of CRP [2.5 (0.4–9.0) vs. 6.3 (0.3–9.1) mg/L p>0.05] and a better exercise tolerance with higher basal VO2max [21.0 (10.0–30.7) vs. 17.9 (10.0–28.0) ml/Kg/min]. Moreover, among cardiovascular risk factors the presence of smoking habit and obesity negatively influenced the increase of EPCs.
Conclusion: A four weeks exercise-based CR program after ACS and PCI, is able to determine an increase of EPCs number with a contemporary decrease of CRP and NT-ProBNP. However a different behaviour for EPCs can be detected among patients with regard to age, obesity, smoking habit, CRP levels and exercise tolerance.
P317
Electrical stimulation of skeletal muscles in aged patients with myocardial infarction
A N AlexeySumin1, AV Bezdenezhnykh1, OM Baidina2, TA Popova2, OP Hayredinova2
1RAMS Scientific-Research Institute for Complex Studying of Cardiovascular Diseases, Kemerovo, Russian Federation, 2Scientific-Clinical Center of the Miners Health Protection, Leninsk-Kuznetsky, Russian Federation
Topic: Cardiovascular rehabilitation
Purpose: Programs of cardiological rehabilitation are insufficiently used at aged patients after myocardial infarction (MI). the new individualised programs of trainings are capable to expand indications for physical trainings at these patients. the aim of study was to evaluate the effectiveness of an electrical stimulation of skeletal muscles (EMS) in improvement of the clinical and functional status of aged MI patients.
Methods: 57 patients older than 70 yrs with myocardial infarction (MI) are randomized into 2 groups: EMS (n=32, age 76,2±0,6 years) and control (n=25, age 74,4±0,7 years). In the EMS group was carried out of the EMS course, 2-hour sessions per day, during 10 days. Trunk muscles, thigh and calf muscles were stimulated. In the control group performed the usual course of inpatient rehabilitation. Before discharge patients were underwent static-dynamic test (SDT) and static tests (STAT) for the lower extremities flexors (LEF) and extensors (LEE). Power of respiratory muscles (PRM), six-minute walking test (6MWT) and bicycle ergometric test (VEM) were carried out. We evaluated the patients psychological state with FAM test (feeling activity mood).
Results: (see table) In the EMS-group were higher tolerance to physical load compared with controls. the muscle strength and static endurance in the EMS group was greater, compared with controls. By FAM test patients from EMS group indicators were better on a scale “Feeling” and “Mood”.
Conclusion: the EMC seems to have a beneficial effect on state of skeletal muscles, exercise tolerance and psychological status in aged patients with MI.
Results of EMS course in aged MI patient
Variables
EMS
Control
P value
VEM (W)
34.5±24.3
20.6±18.2
0.058
6MWT (m)
213.4±100.8
136.4±80.3
0.01
SDT LEF (kg)
8.5±1.9
5.0±1.8
0.21
SDT LEE (kg)
25.8±3.5
13.2±3.2
0.001
STAT LEF (kg∗sec)
767.0± 155.6
389.7±; 176.0
0.048
STAT LEE (kg∗sec)
63.5±23.2
17.9±8.5
0.07
RPM (mmHg)
59.7±28.0
33.6±29.5
0.006
Scale Feeling
4.4±0.2
3.3±0.4
0.04
Scale Mood
5.4±0.2
4.1 ±0.4
0.007
P318
Safety and tolerance of high altitude exposure (3454 m) in non-acclimatized patients with chronic heart failure
D Nobel, J Novak, P Palau, A Trepp, H Saner, J-P Schmid
Swiss Cardiovascular Center at the Bern University Hospital, Bern, Switzerland
Topic: Cardiovascular rehabilitation
Purpose: Patients with stable chronic heart failure are most of the time discouraged to expose themselves to high altitude. Nevertheless some of them wish to spend time in touristic destinations at altitudes higher than 2500 m. Little is known about safety and tolerance of such an altitude exposure in these patients.
Methods: We studied 29 patients (25 men, mean age 59.3±9.6 years) with chronic stable heart failure NYHA class II and a peak VO2 >50% predicted (ejection fraction 28.8±5.3%, peak VO2 18.5±3.5 ml/min/kg per min) after a rapid ascent by cable car from low land (540 m) to 3454 m, Jungfraujoch, Switzerland. All patients performed a symptom limited cardiopulmonary exercise test, echocardiography and Holter-ECG both at low land and high altitude.
Results: All patients completed the trial and both rapid ascent and a 5h stay including a maximal exercise stress test at 3454 m were well tolerated. None of the subjects had to return prematurely to low land and no exercise induced cardiac ischemia, severe dyspnea or symptomatic hypotension occurred. Two patients felt dizzy after a standard meal. At altitude, peak VO2 was 22.2% lower (14.4±3.6 vs. 18.5±3.5 ml/kg/min, p>0.001) and mean heart rate significantly higher (83.3±13.4 vs. 74.3± 12.3 bpm, p>0.001) compared to low land. there was no statistically significant difference of premature ventricular contractions (92±150/h at 540 m vs. 111±196/h at 3454 m, p=0.284) measured both over a time period of 8 h. One patient developed a sustained, but self limited ventricular tachycardia during maximal exercise at the Jungfraujoch. At high altitude, right ventricle to right atrium gradient increased from 25.3±9.6 to 30.3±9.3 mmHg (p=0.043, tricuspid regurgitation signal detected in 10 patients). TAPSE (18.3±4.7 vs. 18±4.9 mm, p=0.669) and tricuspid anulus TDI (12.3±2.5 vs. 11.5±2.9, p=0.41) showed no significant changes.
Conclusion: Patients with stable chronic heart failure in NYHA functional class II and an exercise capacity with a peak VO2 >50% of the predicted value tolerate an altitude exposure of 3454m well.
P319
Combined aerobic/resistance/inspiratory muscle training in patients with chronic heart failure. the ideal exercise program for CHF?
I D Laoutaris, A Manginas, S Adamopoulos, MS Kallistratos, DV Cokkinos, A Dritsas
Onassis Cardiac Surgery Center, Athens, Greece
Topic: Cardiovascular rehabilitation
Purpose: Aerobic training (AT) improves functional capacity in CHF patients. Resistance training (RT) may offer an additive benefit while high-intensity inspiratory muscle training (IMT) improves dyspnea and exercise capacity. A combined Aerobic/Resistance/Inspiratory (ARIS) training program may offermaximal benefits in CHF.
Methods: Fifteen patients, age 51±7 yrs and LVEF 28±8% were assigned in 3 groups of 5, exercising 3/week for 12 weeks: (i) ARIS group: 30 min AT using a bike at 70–80% of maximal heart rate (HR)/15 min RT of the quadriceps at 50% of 1 repetition maximum combined with upper body exercises using light weights/20 min high intensity IMT at 60% of sustained maximal inspiratory pressure (SPimax), (ii) AT group: bike exercise for 45 min at 70–80% of maximal HR and (iii) a no training (NT) group. Patients underwent cardiopulmonary exercise testing, quadriceps strength measurement using a dynamometer, inspiratory muscle strength (Pimax), endurance (SPimax) and inspiratory capacity (IC) by an electronic manometer connected to computer software and quality of life (QOL) using the Minnesota questionnaire. Results: ARIS group improved peakVO2 (26.2±2.4 vs. 22.2±3.2 ml/kg/min, p>0.05), anaerobic threshold (21.5±4.2 vs.17.9±3.4 ml/kg/min p>0.05), quadriceps strength (0.54±0.1 vs. 0.35±0.1 Nwm/kg, p>0.05), Pimax (114±22 vs.74±17 cmH2O, p>0.05), SPimax (592±179 vs. 351±112 cmH2O/s/103, p>0.05), IC (3.3±0.6 vs. 1.9±0.7 L, p>0.05) and QOL (30±5 vs. 36±5, p>0.05). AT group tended to improve peakVO2 (23.1±4.6 vs. 20.6±4 ml/kg/min, p=ns) while NT group did not improve.
Conclusion: Combined Aerobic/Resistance/Inspiratory training improved lower limb muscle strength, inspiratory indices, exercise tolerance and quality of life and may offer maximal exercise benefits in patients with CHF.
ARIS training program
P320
Effects of exercise training on high mobility group box-1 levels after acute myocardial infarction
F Giallauria1, PL Cirillo1, M D'agostino1, G Petrillo1, A Vitelli1, M Pacileo2, M Chiariello1, C Vigorito1
1University of Naples Federico II, Dpt of Clinical Medicine, Cardiovascular & Immunological Science, Naples, Italy, 2Division of Cardiology – Intensive Care Unit, “F. Lastaria” Hospital, Lucera (FG), Italy
Topic: Cardiovascular rehabilitation
Purpose: High mobility group box-1 (HMGB1) is a novel predictor of adverse postinfarction clinical outcomes, playing a crucial role in the appropriate post-infarction healing process. this was a single-center randomized study aimed at revealing the post-infarction HMGB1 expression pattern, its relationship with cardiac remodeling and exercise training.
Methods: 75 post-infarction patients were subdivided into two groups (T = training group; C = control group). Group T patients (n=37) were enrolled in a 6-month exercise-based Cardiac Rehabilitation (CR) program, while Group C patients (n=38) were discharged with generic instructions for maintaining physical activity and a correct lifestyle.
Results: At 6-month, HMGB1 levels were significantly reduced in the total population (26.1±23.5 vs. 16.2±12.9; p=0.0006). After adjusting for age, baseline VO2peak, baseline VE/VCO2slope, baseline HRR, baseline LVEDV, and the inclusion in the training group (coded as 1=training; 0=non training), linear regression analysis showed that the inclusion in the training group (b=–10.54, p=0.043) was associated with marked reduction of HMGB1 levels. At 6-month, HMGB1 levels were significantly lower in trained patients compared to controls (11.7±7.0 vs. 20.5±15.6, p=0.0027, respectively). In trained patients, decreased HMGB1 levels were significantly associated with the improvement in VO2peak (b=–4.169, p=0.004) and HRR (b=–2.563, p=0.002), and with reduced left ventricular end-diastolic volume (b=1.458, p=0.002).
Conclusions: the present study showed that in post-infarction patients undergoing exercise training, a decrease in HMGB1 levels was associated with the improvement of cardiopulmonary and autonomic function, and with favorable LV remodeling. Further studies are strongly encouraged in order to clarify whether the exercise-induced decrease of HMGB1 levels could have long-term prognostic implications after MI.
P321
Reproducibility of the six minute walk test in patients with chronic heart failure or chronic pulmonary disease
AE Karlsdottir1, M Gudjonsdottir2, A Kristjansdottir1, M Asgeirsdottir1, M Jonasson1, SB Sigurdsson2
1Reykjalundur Rehabilitation Center, Mosfellsbaer, Iceland, 2University of Iceland, Department of Physiology, Reykjavik, Iceland
Topic: Cardiovascular rehabilitation
Purpose: To evaluate the reproducibility of the 6 minute walk test (6MWT) in patients having chronic heart failure (CHF) or chronic pulmonary disease (COPD).
Methods: Twenty three patients with CHF (21M/2F); NYHA II-III and Ejection Fraction = 35% and 24 COPD (10M/14F) patients with FEV1 < 50% of predicted value were studied. the mean age of the CHF patients was 55.5 ± 9,8 years (mean ± SD) and of the COPD patients 64.1 ± 9,0 years. the CHF patients underwent four 6MWT pre and post a comprehensive inpatient cardiac rehabilitation. Same number of tests were performed on the COPD patients pre and post a comprehensive inpatient pulmonary rehabilitation. All tests were performed within a one week period pre and post rehabilitation. the average length of the program was 5.8 weeks ±1.1 (mean ± SD) and was based on a combination of endurance and resistance training.
Results: See table
Conclusion: For both patient groups a minimum of four tests are needed to exclude a learning effect when carried out pre and post six weeks of rehabilitation. there is a continuing trend towards better and better performance but it does not reach stability.
Mean distance walked (M) on each 6MWT
Pre Rehabilitation:
Test 1
Test 2
Test 3
Test 4
CHF patients
484±106.5
505.8±114.5°
511.9±124.9¢
523.3±117.4 £,¥,β,α
COPD patients
444.4±103.1
475.8±105.2°
478.8±103.7¢
492±106.4 £,¥,β,Δ
Post Rehabilitation:
CHF patients
542.1±109.9
549.0±111.4
556.1 ±113.5¢
562.4±113.1 £,¥,β
COPD patients
515.5 ± 95.6
531.5±99.2°
541.8±97.4¢,¤
547.3±95.8 £,¥,β
Pre and post rehabilitation:°:p>0.05 test 2vs test1 ¢:p>0.05 test3 vs test1 £:p>0.05 test4 vs test1 ¥:p>0.05 test 4 vs test 2 ¤:p>0.05 test 3 vs test 2 β: p>0.05 test 4 vs test 2 αα:p=0.07 test 4 vs test 3 Δ: p>0.05 test 4 vs test 3.
P322
High altitude exposure is a strong stimulus of exertional oscillatory ventilation in stable chronic heart failure
M Zurek, D Nobel, J Novak, P Palau, A Trepp, H Saner, J-P Schmid
Swiss Cardiovascular Center at the Bern University Hospital, Bern, Switzerland
Topic: Cardiovascular rehabilitation
Introduction: Exertional oscillatory ventilation (EOV) is an ominous respiratory pattern observed in chronic heart failure (CHF) patients and linked with a poor prognosis. the aetiology of EOV is debated and attributed either to impaired cardiac output response or disturbed ventilatory regulation, including augmented chemoreceptor sensitivity. In this study we aimed to analyze the effect of hypoxia on EOV in CHF patients exposed to high altitude.
Methods: Twenty nine CHF patients (25 men, mean age 59.3±9.6 years, LVEF 28.8±5.3%, peak VO2 18.5±3.5 ml/min/kg) underwent symptom limited cardiopulmonary exercise testing on an upright bicycle ergometer at low land (540m) and after a rapid ascent to high altitude (3454 m). EOV was defined as cyclic fluctuation of ventilation of >60% of exercise with amplitude swings that were >20% of mean ventilation. To characterise the ventilatory oscillation the amplitude and periodicity was measured during the first three regular oscillations at the beginning of incremental exercise.
Results: Peak VO2 at 3454m was 22.2% lower (14.4±3.6 vs. 18.5±3.5 ml/kg/min, p>0.001) and peak VCO2 output was significantly decreased (1398±451 vs. 1811±549 ml/min, p>0.001) in comparison to low land. High altitude exposure was characterized by a significantly higher ventilation (40.0±8.6 L/min vs. 37.4±7.8 L/min, p=0.021) and breathing frequency (27.4±6.0 vs. 25.3±6.1 breaths/min, p=0.009), measured at 60% of exercise duration. Accordingly, VE/VCO2 slope (39.9±6.5 vs. 30.7±3.9, p< 0.001) and VE/VCO2 ratio at 60% of exercise duration as a marker of abnormally high dead space fraction of tidal volume (41.4±5.6 vs. 32.3±4.8 p>0.001) were significantly increased.
At low land 7/29 patients presented EOV. High altitude exposure increased the mean amplitude of oscillations (7.6±2.4 L/min vs. 13.2±8.1L/min, p=0.018), the duration (4.7±1.5 cycles vs. 8.1±3.6 cycles, p=0.017) and decreased cycle length (44.1±10.1 sec vs. 29.0±6,7 sec, p=0.018). In 8 patients, EOV developed at high altitude.
Conclusions: Hypoxia induced changes in ventilation during exercise in CHF pts at high altitude are a strong stimulus of EOV. the principle mechanism involved seems to be a significant higher respiratory drive with increased dead space ventilation and an augmented hypoxic chemosensitivity. these observations favor the disturbed ventilatory control as a cause of EOV in CHF pts.
P323
Randomized controlled trial on the effect of a long-term secondary prevention program over 3 years in a high-risk low-education cohort
M Redaelli1, W Mayer-Berger2, D Simic1, M Kohlmeyer2, B Schwitalla2
1University of Witten/Herdecke, Witten, Germany, 2Clinic Roderbirken, Leichlingen, Germany
Topic: Cardiovascular rehabilitation
Purpose: Secondary prevention is an important component in cardiovascular therapy. In Germany, most patients are admitted to a short-term inpatient rehabilitation program after a cardiovascular event. Evaluations have shown poor results in the long run. Purpose of our study was (1) to test over 3 years if the high-risk profile and (2) health related quality of life (HRQL) can be bettered.
Method: 600 patients with coronary heart disease were included (t1). the intervention consisted of three weeks inpatient rehabilitation and telephone reminders over a period of 36 months. Per protocol we could evaluate n=221 in the usual care group (CG) and n=173 in the intervention group (IG) at t6 after 3 years. To evaluate the individual risk level, we used the PROCAM, respectively the FRAMINGHAM score knowing that this tool is established in primary prevention. Intima Media thickness (IMT) was measured at the common carotid artery on both sides following international standards.
Results: the average age was 49,67 years in the CG and 49,98 years in the IG at the beginning of the study. 77% had lower than 9 years of school education. No significant difference existed between the groups in clinical parameters and EUROQOL respectively HADS at the beginning. After 3 years (t6) the patients of IG showed a improved risk profile. the PROCAM score raised by 2,68 (from 3,09% to 5,77% for IG) and by 3,96 (from 3,55% to 7,51% for CG) from t1 to t6 (p>0,05), respectively FRAMINGHAM by 3,68 (from 5,38% to 9,06% for IG) and 4,95 (from 6,21% to 11,16% for CG) from t1 to t6 (p>0,05). the average IMT changed by increasing 0,03 mm in CG and no change in IG on the right side from t1 to t6, respectively by increasing 0,01 mm in CG and reduction by 0,03 mm in the CG on the left side (p>0,05). the IG shows significant better results at EUROQOL and HAD.
Conclusion: In this study with high-risk low-education patients the cardiovascular risk could be reduced. this low-cost long-term secondary prevention program with inpatient rehabilitation and telephone reminding for a 3 year period seems to be successful.
