Publications by authors named "Barry A Franklin"

233 Publications

Impact of Social Disparities on Cardiovascular Disease and COVID-19 Outcomes: BARRIERS TO CARE AND PREVENTIVE INTERVENTIONS.

J Cardiopulm Rehabil Prev 2022 03;42(2):84-89

Internal Medicine (Dr Franklin), Oakland University William Beaumont School of Medicine, Rochester, Michigan (Messrs Khemraj, Solano, and Patel); and Preventive Cardiology and Cardiac Rehabilitation, Beaumont Health, Royal Oak, Michigan (Dr Franklin).

The COVID-19 pandemic has exposed significant disparities within certain population subsets that manifest through greater disease burden and worse outcomes. In this commentary, we propose specific preventive interventions to address these disparities within the United States.
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http://dx.doi.org/10.1097/HCR.0000000000000691DOI Listing
March 2022

High level physical activity in cardiac rehabilitation: Implications for exercise training and leisure-time pursuits.

Prog Cardiovasc Dis 2022 Jan-Feb;70:22-32. Epub 2021 Dec 29.

Integrative Physiology and Athletic Training, University of Montana, Missoula, Montana, United States of America; International Heart Institute - St Patrick's Hospital, Providence Medical Center, Missoula, Montana, United States of America.

Importance: Regular moderate-to-vigorous physical activity and increased levels of cardiorespiratory fitness (CRF) are widely promoted as cardioprotective measures in secondary prevention interventions.

Observations: A low level of CRF increases the risk of cardiovascular disease (CVD) to a greater extent than merely being physically inactive. An exercise capacity <5 metabolic equivalents (METs), generally corresponding to the bottom 20% of the fitness continuum, indicates a higher mortality group. Accordingly, a key objective in early cardiac rehabilitation (CR) is to increase the intensity of training to >3 METs, to empower patients to vacate this "high risk" group. Moreover, a "good" exercise capacity, expressed as peak METs, identifies individuals with a favorable long-term prognosis, regardless of the underlying extent of coronary disease. On the other hand, vigorous-to-high intensity physical activity, particularly when unaccustomed, and some competitive sports are associated with a greater incidence of acute cardiovascular events. Marathon and triathlon training/competition also have limited applicability and value in CR, are associated with acute cardiac events each year, and do not necessarily provide immunity to the development of or the progression of CVD. Furthermore, extreme endurance exercise regimens are associated with an increased incidence of atrial fibrillation and accelerated coronary artery calcification.

Conclusions And Relevance: High-intensity training offers a time-saving alternative to moderate intensity continuous training, as well as other potential advantages. Additional long-term studies assessing safety, adherence, and morbidity and mortality are required before high-intensity CR training can be more widely recommended, especially in previously sedentary patients with known or suspected CVD exercising in non-medically supervised settings.
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http://dx.doi.org/10.1016/j.pcad.2021.12.005DOI Listing
April 2022

Compounders of the COVID crisis: the "perfect storm".

Authors:
Barry A Franklin

Proc (Bayl Univ Med Cent) 2022 23;35(1):133-136. Epub 2021 Aug 23.

Preventive Cardiology and Cardiac Rehabilitation, Beaumont Health, and Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.

Cultural and societal factors have placed some demographic, racial, and ethnic groups at increased risk of contracting and dying from coronavirus disease (COVID-19). This commentary addresses these population disparities and other potential modulators that negatively impact associated health outcomes in the US population, with specific reference to the need for greater self-responsibility.
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http://dx.doi.org/10.1080/08998280.2021.1961568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8682850PMC
August 2021

Association Between Personal Activity Intelligence and Mortality: Population-Based China Kadoorie Biobank Study.

Mayo Clin Proc 2022 04 3;97(4):668-681. Epub 2021 Dec 3.

Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA; School of Human Movement & Nutrition Sciences, University of Queensland, Australia.

Objective: To prospectively investigate the association between personal activity intelligence (PAI) - a novel metabolic metric which translates heart rate during physical activity into a simple weekly score - and mortality in relatively healthy participants in China whose levels and patterns of physical activity in addition to other lifestyle factors are different from those in high-income countries.

Patients And Methods: From the population-based China Kadoorie Biobank study, 443,792 healthy adults were recruited between June 2004 and July 2008. Participant's weekly PAI score was estimated and divided into four groups (PAI scores of 0, ≤50, 51-99, or ≥100). Using Cox proportional hazard analyses, we calculated adjusted hazard ratios (AHRs) for cardiovascular disease (CVD) and all-cause mortality related to PAI scores.

Results: During a median follow-up of 8.2 (interquartile range, 7.3 to 9.1) years, there were 21,901 deaths, including 9466 CVD deaths. Compared with the inactive group (0 PAI score), a baseline weekly PAI score greater than or equal to 100 was associated with a lower risk of CVD mortality, an AHR of 0.87 (95% CI, 0.81 to 0.94) in men, and an AHR of 0.84 (95% CI, 0.78 to 0.92) in women, after adjusting for multiple confounders. Participants with a weekly PAI score greater than or equal to 100 also had a lower risk of all-cause mortality (AHR, 0.93; 95% CI, 0.89 to 0.97 in men, and AHR, 0.93; 95%, 0.88 to 0.98 in women). Moreover, this subgroup gained 2.7 (95% CI, 2.4 to 3.0) years of life, compared with the inactive cohort.

Conclusion: Among relatively healthy Chinese adults, the PAI metric was inversely associated with CVD and all-cause mortality, highlighting the generalizability of the score in different races, ethnicities, and socioeconomic strata.
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http://dx.doi.org/10.1016/j.mayocp.2021.10.022DOI Listing
April 2022

Maximizing the cardioprotective benefits of exercise with age-, sex-, and fitness-adjusted target intensities for training.

Eur J Prev Cardiol 2022 02;29(1):e1-e3

Cardiology Division, VA Palo Alto Health Care System, Stanford University, Palo Alto, CA 94304, USA.

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http://dx.doi.org/10.1093/eurjpc/zwaa094DOI Listing
February 2022

Chronic Stress, Exercise and Cardiovascular Disease: Placing the Benefits and Risks of Physical Activity into Perspective.

Int J Environ Res Public Health 2021 09 21;18(18). Epub 2021 Sep 21.

Cardiovascular Medicine, Department of Cardiology, Beaumont Health, Royal Oak, MI 48073, USA.

Chronic stress, which has been exacerbated worldwide by the lingering COVID pandemic, has been strongly linked to cardiovascular disease (CVD). In addition, autonomic dysregulation via sustained sympathetic activity has been shown to increase the risk of arrhythmias, platelet aggregation, acute coronary syndromes and heart failure. Fortunately, effective coping strategies have been shown to attenuate the magnitude of hyperarousal associated with the stress response, including moderate-to-vigorous lifestyle activity and/or structured exercise. A good-to-excellent level of cardiorespiratory fitness also appears to be highly cardioprotective. These beneficial effects have been substantiated by numerous studies that have evaluated the levels of stress reactivity and stress recovery in physically active individuals versus matched sedentary controls, as well as before and after exercise interventions. On the other hand, unaccustomed strenuous exercise in habitually sedentary persons with underlying CVD is associated with a disproportionate incidence of acute cardiac events. Moreover, extreme exercise regimens appear to increase coronary calcification and the likelihood of developing atrial fibrillation. This review summarizes these relations and more, with specific reference to placing the benefits and risks of physical activity into perspective.
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http://dx.doi.org/10.3390/ijerph18189922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8471640PMC
September 2021

Effects of Supervised Exercise-Based Telerehabilitation on Walk Test Performance and Quality of Life in Patients in India With Chronic Disease: Combatting Covid-19.

Int J Telerehabil 2021 22;13(1):e6349. Epub 2021 Jun 22.

Department of Rehabilitation and Sports Medicine, Sir H.N. Reliance Foundation Hospital and Research Center, Mumbai, India.

Background: The world is currently undergoing a pandemic, caused by the SARS-CoV-2 virus (COVID-19). According to the World Health Organization, patients with chronic illnesses appear to be at the highest risk for COVID-19 associated sequelae. Inability to participate in outpatient-based rehabilitation programs and being home-bound can increase the risk for and potential worsening of chronic health conditions. This study evaluated the short-term effects of telerehabilitation on patients' walk test performance and health related quality of life (HRQoL).

Methods: 47 patients (23 cardiovascular, 15 pulmonary, 9 oncology) participated in the telerehabilitation program. At baseline and following a 1-month intervention, patients had their 6-minute walk test distance (6MWTD) and HRQoL assessed. Average daily step counts were measured by the PACER App.

Conclusions: Our results indicate that a short-term, supervised virtual telerehabilitation program had significant positive effects on 6MWTD and HRQoL in cardiac, pulmonary and oncology patients during COVID-19.
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http://dx.doi.org/10.5195/ijt.2021.6349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327636PMC
June 2021

Beyond cardioversion, ablation and pharmacotherapies: Risk factors, lifestyle change and behavioral counseling strategies in the prevention and treatment of atrial fibrillation.

Prog Cardiovasc Dis 2021 May-Jun;66:2-9. Epub 2021 May 21.

Department of Cardiovascular Medicine, Oakland University William Beaumont School of Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, United States of America.

Importance: It has been suggested that atrial fibrillation (AF) is the new cardiovascular disease epidemic of the 21st century. Clinical cardiology has largely focused on AF treatment and associated stroke prevention rather than preventing AF itself. To reduce the global consequences and associated costs of AF, it is critical to now embrace prevention as a priority. Proactively addressing the risk factors for AF and the underlying unhealthy lifestyle habits that contribute to them, using research-based counseling approaches, represents a complementary and adjunctive alternative in combatting this disease burden.

Observations: Encouraging and sustaining patient involvement to reduce AF incidence and improve outcomes begins with screening to identify risk factors, unhealthy lifestyle habits, and characteristics associated with failed attempts at favorably modifying these causalities. Modulators of and common barriers to achieving risk reduction and lifestyle change include self-efficacy, social support, age, sex, marital and socioeconomic status, education, employment, and psychosocial factors such as depression, isolation, anxiety and chronic life stress. Focused behavioral counseling approaches, including assessing the patient's readiness to change, motivational interviewing and using the 5 A's (assess, advise, agree, assist, arrange), along with employing initial downscaled goals to overcome inertia, are proven methodologies to overcome these common barriers to favorably modifying risk factors and unhealthy lifestyle habits.

Conclusions And Relevance: To complement and enhance the current armamentarium for the medical management of cardiac arrhythmias, there is an urgent need to proactively address the causative factors triggering new-onset, recurrent and persistent AF. Beyond the counseling skills of highly trained professionals (eg, psychiatrists, psychologists), this narrative review highlights the need for and potential impact on lifestyle modification that non-behavioral scientists, including internal medicine, cardiology, and allied health professionals, can have on the patients they serve.
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http://dx.doi.org/10.1016/j.pcad.2021.05.002DOI Listing
August 2021

Impact of cardiorespiratory fitness on survival in men with low socioeconomic status.

Eur J Prev Cardiol 2021 05 3;28(4):450-455. Epub 2020 Feb 3.

Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Finland.

Aims: Although both low socioeconomic status (SES) and poor cardiorespiratory fitness (CRF) are associated with increased chronic disease and heightened mortality, it remains unclear whether moderate-to-high levels of CRF are associated with survival benefits in low SES populations. This study evaluated the hypothesis that SES and CRF predict all-cause mortality and cardiovascular disease mortality and that moderate-to-high levels of CRF may attenuate the association between low SES and increased mortality.

Methods: This study included 2368 men, who were followed in the Kuopio Ischaemic Heart Disease Study cohort. CRF was directly measured by peak oxygen uptake during progressive exercise testing. SES was characterized using self-reported questionnaires.

Results: During a 25-year median follow-up, 1116 all-cause mortality and 512 cardiovascular disease mortality events occurred. After adjusting for potential confounders, men with low SES were at increased risks for all-cause mortality (hazard ratio 1.49, 95% confidence interval: 1.30-1.71) and cardiovascular disease mortality (hazard ratio1.38, 1.13-1.69). Higher levels of CRF were associated with lower risks of all-cause mortality (hazard ratio 0.54, 0.45-0.64) and cardiovascular disease mortality (hazard ratio 0.53, 0.40-0.69). In joint associations of SES and CRF with mortality, low SES-unfit had significantly higher risks of all-cause mortality (hazard ratio 2.15, 1.78-2.59) and cardiovascular disease mortality (hazard ratio 1.95, 1.48-2.57), but low SES-fit was not associated with a heightened risk of cardiovascular disease mortality (hazard ratio 1.09, 0.80-1.48) as compared with their high SES-fit counterparts.

Conclusion: Both SES and CRF were independently associated with subsequent mortality; however, moderate-to-high levels of CRF were not associated with an excess risk of cardiovascular disease mortality in men with low SES.
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http://dx.doi.org/10.1177/2047487319901057DOI Listing
May 2021

Omega-3 Fatty Acid Supplementation in the Primary and Secondary Prevention of Cardiovascular Events: NEW INSIGHTS.

J Cardiopulm Rehabil Prev 2021 05;41(3):137-140

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan (Drs O'Connell, Trivax, and Franklin); and Oakland University William Beaumont School of Medicine, Rochester, Michigan (Drs Trivax and Franklin).

Omega-3 fatty acid (O-3FA) supplementation has garnered interest since cardioprotective properties of dietary fish consumption were observed. In the general population, O-3FA supplementation has not improved cardiovascular outcomes. However, icosapent ethyl, a high-dose, purified form of eicosapentaenoic acid, has demonstrated additive cardioprotection to statins in high-risk patients with elevated triglycerides.
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http://dx.doi.org/10.1097/HCR.0000000000000608DOI Listing
May 2021

Exercise Preconditioning as a Cardioprotective Phenotype.

Am J Cardiol 2021 06 3;148:8-15. Epub 2021 Mar 3.

William Beaumont Hospital, Royal Oak, Michigan; Oakland University William Beaumont School of Medicine, Rochester, Michigan.

Cardiovascular disease (CVD) is potentiated by risk factors including physical inactivity and remains a leading cause of morbidity and mortality. Although regular physical activity does not reverse atherosclerotic coronary disease, precursory exercise improves clinical outcomes in those experiencing life-threatening CVD events. Exercise preconditioning describes the cardioprotective phenotype whereby even a few exercise bouts confer short-term multifaceted protection against acute myocardial infarction. First described decades ago in animal investigations, cardioprotective mechanisms responsible for exercise preconditioning have been identified through reductionist preclinical studies, including the upregulation of endogenous antioxidant enzymes, improved calcium handling, and enhanced bioenergetic regulation during a supply-demand mismatch. Until recently, translation of this research was only inferred from clinically-directed animal models of exercise involving ischemia-reperfusion injury, and reinforced by the gene products of exercise preconditioning that are common to mammalian species. However, recent clinical investigations confirm that exercise preconditions the human heart. This discovery means that simply the initiation of a remedial exercise regimen in those with abnormal CVD risk factor profiles will provide immediate cardioprotective benefits and improved clinical outcomes following acute cardiac events. In conclusion, the prophylactic biochemical adaptations to aerobic exercise are complemented by the long-term adaptive benefits of vascular and architectural remodeling in those who adopt a physically active lifestyle.
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http://dx.doi.org/10.1016/j.amjcard.2021.02.030DOI Listing
June 2021

Cardiorespiratory Fitness, Inflammation, and the Incident Risk of Pneumonia.

J Cardiopulm Rehabil Prev 2021 05;41(3):199-201

Department of Sport Science, University of Seoul, Seoul, South Korea (Dr Jae); Department of Exercise Science, Syracuse University, Syracuse, New York (Dr Heffernan); Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland (Drs Kurl and Laukkanen); National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, and Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, England (Dr Kunutsor); Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota (Drs Kim and Johnson); Preventive Cardiology and Cardiac Rehabilitation, Beaumont Health, Royal Oak, Michigan (Dr Franklin); and Institute of Clinical Medicine, Department of Medicine, University of Eastern Finland, Kuopio, and Central Finland Health Care District Hospital District, Department of Medicine, Jyväskylä, Finland District, Jyväskylä, Finland (Dr Laukkanen).

Introduction: Both inflammation and cardiorespiratory fitness (CRF) are associated with the risk of respiratory infections. To clarify the hypothesis that CRF attenuates the incident risk of pneumonia due to inflammation, we conducted a prospective study examining the independent and joint associations of inflammation and CRF on the risk of pneumonia in a population sample of 2041 middle-aged men.

Methods: Cardiorespiratory fitness was directly measured as peak oxygen uptake (V˙o2peak) during progressive exercise testing to volitional fatigue, and categorized into tertiles. Inflammation was defined by high-sensitivity C-reactive protein (hsCRP). Pneumonia cases were identified by internal medicine physicians using the International Classification of Diseases codes in clinical practice.

Results: During a median follow-up of 27 yr, 432 pneumonia cases were recorded. High hsCRP and CRF were associated with a higher risk (HR = 1.38; 95% CI, 1.02-1.88) and a lower risk of pneumonia (HR = 0.55; CI, 0.39-0.76) after adjusting for potential confounders, respectively. Compared with normal hsCRP-Fit, moderate to high hsCRP-Unfit had an increased risk of pneumonia (HR = 1.63; CI, 1.21-2.20), but moderate to high hsCRP-Fit was not associated with an increased risk of pneumonia (HR = 1.25; CI, 0.93-1.68).

Conclusions: High CRF attenuates the increased risk of pneumonia due to inflammation. These findings have potential implications for the prevention of respiratory infection characterized by systemic inflammation, such as coronavirus disease-2019 (COVID-19).
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http://dx.doi.org/10.1097/HCR.0000000000000581DOI Listing
May 2021

Cardiorespiratory Fitness Attenuates the Increased Risk of Sudden Cardiac Death Associated With Low Socioeconomic Status.

Am J Cardiol 2021 04 24;145:164-165. Epub 2021 Jan 24.

Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Institute of Clinical Medicine, Department of Medicine, University of Eastern Finland, Kuopio, Finland; Central Finland Health Care District Hospital District, Department of Medicine, Jyväskylä, Finland District, Jyväskylä, Finland.

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http://dx.doi.org/10.1016/j.amjcard.2021.01.012DOI Listing
April 2021

Usefulness of Coronary Computed Tomographic Angiography to Evaluate Coronary Artery Disease in Radiotherapy-Treated Breast Cancer Survivors.

Am J Cardiol 2021 03 4;143:14-20. Epub 2021 Jan 4.

Beaumont Hospital, Division of Cardiology, Royal Oak, Michigan.

Breast cancer is the most commonly diagnosed cancer in women and radiotherapy is a widely used treatment approach. However, there is an increased risk of coronary artery disease and cardiac death in women treated with radiotherapy. The present study was undertaken to clarify the relation between radiotherapy and coronary disease in women with previous breast irradiation using coronary computed tomographic angiography (CCTA). We conducted a retrospective analysis of women with a history of right or left-sided breast cancer (RBC; LBC) treated with radiotherapy who subsequently underwent CCTA. RBC patients who had reduced radiation doses to the myocardium served as controls. Patients (n = 6,593) with a history of nonmetastatic breast cancer treated with radiotherapy were screened for completion of CCTA; 49 LBC and 45 RBC women were identified. Age and risk factor matched patients with LBC had higher rates of coronary disease compared with RBC patients; left anterior descending (LAD) coronary artery (76% vs 31% [p < 0.001]), left circumflex (33% vs. 6.7% [p = 0.004]), and right coronary artery (37% vs 13% [p = 0.018]). Mean LAD radiation dose and mean heart dose strongly correlated with coronary disease, with a 21% higher incidence of disease in the LAD per Gy for mean LAD dose and a 95% higher incidence of disease in the LAD per Gy for mean heart dose. In conclusion, LBC patients treated with radiotherapy have a significantly higher incidence of coronary disease when compared with a matched group of patients treated for RBC. Radiation doses correlated with the incidence of coronary disease.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.038DOI Listing
March 2021

Chronotropic Response to Exercise Testing and the Risk of Stroke.

Am J Cardiol 2021 03 19;143:46-50. Epub 2020 Dec 19.

Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Institute of Clinical Medicine, Department of Medicine, University of Eastern Finland, Kuopio, Finland; Central Finland Health Care District Hospital District, Department of Medicine, Jyväskylä, Finland District, Jyväskylä, Finland.

Although the chronotropic response to exercise testing, defined as an inadequate heart rate response to incremental exercise to volitional fatigue, is associated with adverse cardiovascular outcomes, it remains unclear whether this response is related to the future risk of cerebrovascular events. We tested the hypothesis that the chronotropic response to exercise is associated with an increased risk of stroke in a general population. This prospective study was based on a population sample of 2,036 men aged 42 to 60 years in the Kuopio Ischemic Heart Disease cohort study. Chronotropic response to exercise was defined as the percentage of chronotropic index ([maximum heart rate - resting heart rate] / [220 - age - resting heart rate] × 100). Incident strokes were obtained from the Finnish national hospital discharge registry. During a median 27-year follow-up, 343 incident stroke (289 ischemic and 66 hemorrhagic) events occurred. Twelve events were diagnosed as both ischemic and hemorrhagic stroke. Comparing the bottom versus top quintile of chronotropic reserve, there was an increased risk of stroke (hazard ratio [HR] 1.73, 95% confidence Interval [CI]: 1.09 to 2.75) and ischemic stroke (HR 1.72, 95% CI, 1.04 to 2.85), but not hemorrhagic stroke (HR 2.23, 95% CI, 0.77 to 6.46) in analyses that adjusted for potential risk factors. These results suggest that an impaired chronotropic response to exercise is independently associated with a higher risk of total and ischemic stroke events in middle-aged men. The role of chronotropic incompetence during exercise testing as a potential prognostic indicator for stroke risk needs further investigation.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.042DOI Listing
March 2021

Running away from cardiovascular disease at the right speed: The impact of aerobic physical activity and cardiorespiratory fitness on cardiovascular disease risk and associated subclinical phenotypes.

Prog Cardiovasc Dis 2020 Nov - Dec;63(6):762-774. Epub 2020 Nov 13.

Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Higher levels of physical activity (PA) and cardiorespiratory fitness (CRF) are associated with lower risk of incident cardiovascular disease (CVD). However, the relationship of aerobic PA and CRF with risk of atherosclerotic CVD outcomes and heart failure (HF) seem to be distinct. Furthermore, recent studies have raised concerns of potential toxicity associated with extreme levels of aerobic exercise, with higher levels of coronary artery calcium and incident atrial fibrillation noted among individuals with very high PA levels. In contrast, the relationship between PA levels and measures of left ventricular structure and function and risk of HF is more linear. Thus, personalizing exercise levels to optimal doses may be key to achieving beneficial outcomes and preventing adverse CVD events among high risk individuals. In this report, we provide a comprehensive review of the literature on the associations of aerobic PA and CRF levels with risk of adverse CVD outcomes and the preceding subclinical cardiac phenotypes to better characterize the optimal exercise dose needed to favorably modify CVD risk.
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http://dx.doi.org/10.1016/j.pcad.2020.11.004DOI Listing
February 2021

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 yr and Its Role in Promoting Preventive Cardiology: Part 2.

J Cardiopulm Rehabil Prev 2020 07;40(4):209-214

Beaumont Health, Preventive Cardiology and Cardiac Rehabilitation, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan (Dr Franklin); Departments of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina (Dr Brubaker); Clinical Exercise Physiology Program, Ball State University, Muncie, Indiana (Dr Harber); Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana (Dr Lavie); VA Palo Alto Health Care System, Cardiology, Stanford University, Palo Alto, California (Dr Myers); and Fisher Institute of Health and Well-Being, Ball State University, Muncie, Indiana (Dr Kaminsky).

Aggressive risk factor modification, including smoking cessation, blood pressure management, and more intensive efforts to control hyperlipidemia, as well as stress management training, are associated with improved cardiovascular outcomes and impressive mortality reductions. This commentary addresses these topics, with specific reference to lifestyle modification and complementary cardioprotective medications.
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http://dx.doi.org/10.1097/HCR.0000000000000523DOI Listing
July 2020

Effects of single bout resistance exercise on glucose levels, insulin action, and cardiovascular risk in type 2 diabetes: A narrative review.

J Diabetes Complications 2020 08 3;34(8):107610. Epub 2020 May 3.

Division of Cardiology, School of Medicine, Department of Medicine, John Hopkins University, Baltimore, MD, USA. Electronic address:

Aims: Previous studies have reported beneficial effects of chronic resistance exercise in the prevention and treatment of type 2 diabetes. To clarify potential modulators of acute responses to resistance exercise, we reviewed the literature to determine the effects of a single bout of resistance exercise on cardiometabolic risk factors in type 2 diabetes.

Methods: Pubmed and Embase were searched for studies investigating the effects of single bouts of resistance exercise on glucose and insulin levels, and cardiovascular disease risk in people with diabetes. Fourteen reports were identified and reviewed to formulate evidence-based resistance exercise prescription recommendations.

Results: Glucose and insulin levels appear to decrease with resistance exercise with effects lasting up to 24 and 18 h, respectively. Bouts of resistance exercise may outperform aerobic exercise in reducing ambulatory blood pressure, with effects lasting up to 24 h. Moreover, resistance exercise after rather than before a meal may be more effective in reducing glucose, insulin, and triacylglycerol levels. However, reducing injectable insulin dosage prior to resistance exercise may blunt its favorable effects on glucose levels.

Conclusions: This review suggests that a single bout of resistance exercise may be effective for acutely improving cardiometabolic markers in people with diabetes.
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http://dx.doi.org/10.1016/j.jdiacomp.2020.107610DOI Listing
August 2020

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in Promoting Lifestyle Medicine for Prevention of Cardiovascular Diseases: PART 1.

J Cardiopulm Rehabil Prev 2020 05;40(3):131-137

Beaumont Health, Preventive Cardiology and Cardiac Rehabilitation, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan (Dr Franklin); Departments of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina (Dr Brubaker); Clinical Exercise Physiology Program, Ball State University, Muncie, Indiana (Dr Harber); Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana (Dr Lavie); VA Palo Alto Health Care System, Cardiology, Stanford University, Palo Alto, California (Dr Myers); and Fisher Institute of Health and Well-Being, Ball State University, Muncie, Indiana (Dr Kaminsky).

Risk to individuals for cardiovascular events are invariably tied to their exposure to major coronary risk factors. This risk can be substantially mitigated by lifestyle behaviors. This first part of this Commentary focuses on the important role both adopting healthful dietary patterns and regularly obtaining adequate physical activity have as preventative therapies for cardiovascular diseases.
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http://dx.doi.org/10.1097/HCR.0000000000000514DOI Listing
May 2020

Importance of Lifestyle Modification on Cardiovascular Risk Reduction: COUNSELING STRATEGIES TO MAXIMIZE PATIENT OUTCOMES.

J Cardiopulm Rehabil Prev 2020 05;40(3):138-143

Beaumont Health System, Department of Cardiovascular Medicine (Preventive Cardiology and Cardiac Rehabilitation), Royal Oak, Michigan, and Oakland University William Beaumont School of Medicine, Rochester, Michigan (Dr Franklin); VA Palo Alto Health Care System, Cardiology, Stanford University, Palo Alto, California (Dr Myers); and Veterans Affairs Medical Center, Rutgers University, Newark, New Jersey, and Department of Kinesiology and Health, Georgetown University School of Medicine, Washington, District of Columbia (Dr Kokkinos).

This commentary builds on the unhealthy lifestyle habits, population health, risk factors as harbingers of cardiovascular disease, current provider counseling practices, assessing patient readiness to change, and research-based interventions to facilitate behavior change (eg, the 5A's, motivational interviewing, and overcoming inertia with downscaled goals).
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http://dx.doi.org/10.1097/HCR.0000000000000496DOI Listing
May 2020

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association.

Circulation 2020 03 26;141(13):e705-e736. Epub 2020 Feb 26.

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.
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http://dx.doi.org/10.1161/CIR.0000000000000749DOI Listing
March 2020

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in the Evolution of Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2020 01;40(1):2-8

University of Vermont College of Medicine, Burlington (Dr Ades); Preventive Cardiology, Boston Medical Center, and Boston University School of Medicine, Massachusetts (Dr Balady); The LifeCare Company, and Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California (Ms Berra); Oakland University William Beaumont School of Medicine, Rochester, Michigan (Dr Franklin); Cardiovascular Medicine and Orthopedics/Sports Medicine, Stanford University School of Medicine, California (Dr Froelicher); Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia (Dr Hamm); Clinical Exercise Physiology, Ball State University, Muncie, Indiana (Dr Kaminsky); and Cardiology, Creighton University School of Medicine, Omaha, Nebraska (Dr Williams).

The maturing of a clinical discipline necessitates the ability to document scientific advancements and state-of-the-art reviews with a focus on clinical practice. Such was the case for the field of cardiac rehabilitation in 1981. Whereas a growing body of literature was demonstrating benefits of exercise in cardiac patients with regard to clinical, psychologic, and quality-of-life outcomes,, there were still concerns about the safety of exercise and whether it could be widely adapted in clinical care. Since this was a time period when searches of online databases such as PubMed had not yet been established (began in 1996), there was a great value of concentrating much of the cardiac rehabilitation literature in a single journal.This commentary describes the conceptualization and implementation of the Journal of Cardiopulmonary Rehabilitation and Prevention from 1981 to the present and its acceptance as the official journal of the American Association of Cardiovascular and Pulmonary Rehabilitation and later the Canadian Association of Cardiac Rehabilitation. The commentary also highlights the journal's inclusion in Index Medicus in 1995, its receipt of an impact factor from International Scientific Indexing in 2007, and its publication of many important scientific statements, often in collaboration with major scientific organizations such as the American Heart Association and the American College of Cardiology.
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http://dx.doi.org/10.1097/HCR.0000000000000494DOI Listing
January 2020

Relation of maximal systolic blood pressure during exercise testing to the risk of sudden cardiac death in men with and without cardiovascular disease.

Eur J Prev Cardiol 2020 12 11;27(19):2220-2222. Epub 2019 Oct 11.

Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Finland.

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http://dx.doi.org/10.1177/2047487319880031DOI Listing
December 2020

Mediating effects of exercise capacity on the association between physical activity and health-related quality of life among adolescents with complex congenital heart disease.

Am J Hum Biol 2019 11 18;31(6):e23297. Epub 2019 Jul 18.

Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, Michigan.

Objectives: There is little evidence on interrelationships between physical activity, sedentary behaviors, and health-related quality of life (HRQOL) among adolescents with congenital heart disease (CHD). We hypothesized that exercise capacity would have a mediating effect on the associations of either physical activity or sedentary behavior with HRQOL.

Methods: Adolescents with complex CHD (n = 111) were consecutively recruited from an outpatient clinic in a general hospital in South Korea. Physical activity and sedentary behavior were assessed using the global physical activity questionnaire. Exercise capacity was directly measured by peak oxygen uptake using a symptom-limited maximal treadmill exercise test. HRQOL was evaluated by both adolescents and their parents using the Pediatric Quality of Life Inventory questionnaire.

Results: The self-reported and parent proxy-reported HRQOL were positively associated with physical activity (ß = 0.16, P = .003; ß = 0.12, P = .049) and exercise capacity (ß = 0.63, P < .001; ß = 0.66, P < .001), but not with sedentary behavior in adjusted regression models. When both variables were entered in the same regression models, only exercise capacity remained significantly associated with the self-reported (ß = 0.50, P = .008) and parent proxy-reported HRQOL (ß = 0.62, P = .003). Exercise capacity acted as a full mediator variable on the relationship between physical activity and HRQOL (P < .05 for both).

Conclusions: The present findings suggest that exercise capacity mediates the association between physical activity and HRQOL, highlighting the importance of improving exercise capacity to potentially enhance HRQOL in adolescents with complex CHD.
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http://dx.doi.org/10.1002/ajhb.23297DOI Listing
November 2019

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology.

J Am Coll Cardiol 2019 07 13;74(1):133-153. Epub 2019 May 13.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.
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http://dx.doi.org/10.1016/j.jacc.2019.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341112PMC
July 2019

Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY.

J Cardiopulm Rehabil Prev 2019 07;39(4):208-225

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.
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http://dx.doi.org/10.1097/HCR.0000000000000447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530797PMC
July 2019

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology.

Circulation 2019 07 13;140(1):e69-e89. Epub 2019 May 13.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.
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http://dx.doi.org/10.1161/CIR.0000000000000663DOI Listing
July 2019

Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association.

Circulation 2019 05;139(21):e997-e1012

Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.
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http://dx.doi.org/10.1161/CIR.0000000000000679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603804PMC
May 2019

Preparticipation Screening Prior to Physical Activity in Community Lifestyle Interventions.

Transl J Am Coll Sports Med 2018 Nov;3(22):176-180

Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

Behavioral lifestyle interventions in the community setting are effective in reducing the risk and burden of chronic diseases. The promotion and implementation of physical activity plays a key role in these community-based lifestyle programs. New guidelines on preparticipation screening for cardiovascular disease prior to physical activity have been released which include substantive modifications. These updated recommendations represent a substantial paradigm shift toward a more liberal approach that results in fewer individuals needing to seek medical clearance before starting a physical activity program. This shift has significant implications for those promoting physical activity within the community setting. The objectives of this commentary are to review the updated recommendations within the context of community-based lifestyle intervention programs such as those currently being offered throughout the United States for the primary purpose of diabetes prevention and to discuss the implications for those providers developing and implementing such programs.
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http://dx.doi.org/10.1249/TJX.0000000000000073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411298PMC
November 2018
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