Publications by authors named "Gordon McGregor"

34 Publications

Is It Really Home-Based? A Commentary on the Necessity for Accurate Definitions across Exercise and Physical Activity Programmes.

Int J Environ Res Public Health 2021 09 1;18(17). Epub 2021 Sep 1.

Institute of Health and Wellbeing, Coventry University, Coventry CV1 2DS, UK.

: There is wide discrepancy in how published research defines and reports home-based exercise programmes. Studies consisting of fundamentally different designs have been labelled as home-based, making searching for relevant literature challenging and time consuming. This issue has been further highlighted by an increased demand for these programmes following the COVID-19 pandemic and associated government-imposed lockdowns. : To examine what specifically constitutes home-based exercise by: (1) developing definitions for a range of terms used when reporting exercise and physical activity programmes and (2) providing examples to contextualise these definitions for use when reporting exercise and physical activity programmes. : A literature search was undertaken to identify previous attempts to define home-based exercise programmes. A working document, including initial definitions and examples were developed, which were then discussed between six experts for further refinement. : We generated definitions for universal key terms within three domains (and subdomains) of programme design: location (home-based, community/centre-based, or clinical setting), prescription (structured or unstructured) and delivery (supervised, facilitated, or unsupervised). Examples for possible combinations of design terms were produced. : Definitions will provide consistency when using reporting tools and the intention is to discuss the issues presented as part of a Delphi study. This is of paramount importance due to the predicted increase in emerging research regarding home-based exercise.
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http://dx.doi.org/10.3390/ijerph18179244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8431042PMC
September 2021

A systematic review of rehabilitation in chronic heart failure: evaluating the reporting of exercise interventions.

ESC Heart Fail 2021 Jul 7. Epub 2021 Jul 7.

Centre for Sport, Exercise and Life Sciences, Faculty of Health and Life Sciences, Science and Health Building, Whitefriars Street, Coventry University, Coventry, CV1 2DS, UK.

A large body of research supports the use of exercise to improve symptoms, quality of life, and physical function in patients with chronic heart failure. Previous reviews have focused on reporting outcomes of exercise interventions such as cardiorespiratory fitness. However, none have critically examined exercise prescription. The aim of this review was to evaluate the reporting and application of exercise principles in randomised control trials of exercise training in patients with chronic heart failure. A systematic review of exercise intervention RCTs in patients with CHF, using the Consensus on Exercise Reporting Template (CERT), was undertaken. The Ovid Medline/PubMed, Embase, Scopus/Web of Science, and Cochrane Library and Health Technology Assessment Databases were searched from 2000 to June 2020. Prospective RCTs in which patients with CHF were randomized to a structured exercise programme were included. No limits were placed on the type or duration of exercise structured exercise programme or type of CHF (i.e. preserved or reduced ejection fraction). We included 143 studies, comprising of 181 different exercise interventions. The mean CERT score was 10 out of 19, with no study achieving a score of 19. Primarily, details were missing regarding motivational strategies, home-based exercise components, and adherence/fidelity to the intervention. Exercise intensity was the most common principle of exercise prescription missing from intervention reporting. There was no improvement in the reporting of exercise interventions with time (R  = 0.003). Most RCTs of exercise training in CHF are reported with insufficient detail to allow for replication, limiting the translation of evidence to clinical practice. We encourage authors to provide adequate details when reporting future interventions. Where journal word counts are restrictive, we recommend using supplementary material or publishing trial protocols prior to beginning the study.
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http://dx.doi.org/10.1002/ehf2.13498DOI Listing
July 2021

Changes in Physical Activity and Sedentary Behaviour Due to Enforced COVID-19-Related Lockdown and Movement Restrictions: A Protocol for a Systematic Review and Meta-Analysis.

Int J Environ Res Public Health 2021 May 14;18(10). Epub 2021 May 14.

Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK.

Prolonged lockdown/restriction measures due to the COVID-19 pandemic have reportedly impacted opportunities to be physically active for a large proportion of the population in affected countries globally. The exact changes to physical activity and sedentary behaviours due to these measures have not been fully studied. Accordingly, the objective of this PROSPERO-registered systematic review is to evaluate the available evidence on physical activity and sedentary behaviours in the general population during COVID-19-related lockdown/restriction measures, compared to prior to restrictions being in place. Defined searches to identify eligible studies published in English, from November 2019 up to the date of submission, will be conducted using the following databases: CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus, PSYCinfo, Coronavirus Research Database, Public Health Database, Publicly Available Content Database, SCOPUS, and Google Scholar. The applied inclusion criteria were selected to identify observational studies with no restrictions placed on participants, with outcomes regarding physical activity and/or sedentary behaviour during lockdown/restriction measures, and with comparisons for these outcomes to a time when no such measures were in place. Where appropriate, results from included studies will be pooled and effect estimates will be presented in random effects meta-analyses. To the best of our knowledge, this will be the first systematic review to evaluate one complete year of published data on the impact of COVID-19-related lockdown/restriction measures on physical activity and sedentary behaviour. Thus, this systematic review and meta-analysis will constitute the most up-to-date synthesis of published evidence on any such documented changes, and so will comprehensively inform clinical practitioners, public health agencies, researchers, policymakers and the general public regarding the effects of lockdown/restriction measures on both physical activity and sedentary behaviour.
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http://dx.doi.org/10.3390/ijerph18105251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8155982PMC
May 2021

Effect of Exercise Interventions on Health-Related Quality of Life After Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis.

Stroke 2021 Jul 27;52(7):2445-2455. Epub 2021 May 27.

Department of Neuroscience, Sheffield Institute for Translational Neuroscience (D.T., S.S.B., B.M., J.R., A.M.), University of Sheffield, United Kingdom.

Exercise interventions have been shown to help physical fitness, walking, and balance after stroke, but data are lacking on whether such interventions lead to improvements in health-related quality of life (HRQoL). In this systematic review and meta-analysis, 30 randomized controlled trials (n=1836 patients) were found from PubMed, OVID MEDLINE, Web of Science, CINAHL, SCOPUS, The Cochrane Library, and TRIP databases when searched from 1966 to February 2020 that examine the effects of exercise interventions on HRQoL after stroke or transient ischemic attack. Exercise interventions resulted in small to moderate beneficial effects on HRQoL at intervention end (standardized mean difference, -0.23 [95% CI, -0.40 to -0.07]) that appeared to diminish at longer-term follow-up (standardized mean difference, -0.11 [95% CI, -0.26 to 0.04]). Exercise was associated with moderate improvements in physical health (standardized mean difference, -0.33 [95% CI, -0.61 to -0.04]) and mental health (standardized mean difference, -0.29 [95% CI, -0.49 to -0.09]) domains of HRQoL while effects on social or cognitive composites showed little difference. Interventions that were initiated within 6 months, lasted at least 12 weeks in duration, involved at least 150 minutes per week, and included resistance training appeared most effective. Exercise can lead to moderate beneficial effects on HRQoL and should be considered an integral part of stroke rehabilitation.
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http://dx.doi.org/10.1161/STROKEAHA.120.032979DOI Listing
July 2021

Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN' (REGAIN): a structured summary of a study protocol for a randomised controlled trial.

Trials 2021 Jan 6;22(1). Epub 2021 Jan 6.

Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.

Objectives: The primary objective is to determine which of two interventions: 1) an eight week, online, home-based, supervised, group rehabilitation programme (REGAIN); or 2) a single online session of advice (best-practice usual care); is the most clinically and cost-effective treatment for people with ongoing COVID-19 sequelae more than three months after hospital discharge.

Trial Design: Multi-centre, 2-arm (1:1 ratio) parallel group, randomised controlled trial with embedded process evaluation and health economic evaluation.

Participants: Adults with ongoing COVID-19 sequelae more than three months after hospital discharge Inclusion criteria: 1) Adults ≥18 years; 2) ≥ 3 months after any hospital discharge related to COVID-19 infection, regardless of need for critical care or ventilatory support; 3) substantial (as defined by the participant) COVID-19 related physical and/or mental health problems; 4) access to, and able/supported to use email and internet audio/video; 4) able to provide informed consent; 5) able to understand spoken and written English, Bengali, Gujarati, Urdu, Punjabi or Mandarin, themselves or supported by family/friends.

Exclusion Criteria: 1) exercise contraindicated; 2) severe mental health problems preventing engagement; 3) previous randomisation in the present study; 4) already engaged in, or planning to engage in an alternative NHS rehabilitation programme in the next 12 weeks; 5) a member of the same household previously randomised in the present study.

Intervention And Comparator: Intervention 1: The Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN (REGAIN) programme: an eight week, online, home-based, supervised, group rehabilitation programme. Intervention 2: A thirty-minute, on-line, one-to-one consultation with a REGAIN practitioner (best-practice usual care).

Main Outcomes: The primary outcome is health-related quality of life (HRQoL) - PROMIS® 29+2 Profile v2.1 (PROPr) - measured at three months post-randomisation. Secondary outcomes include dyspnoea, cognitive function, health utility, physical activity participation, post-traumatic stress disorder (PTSD) symptom severity, depressive and anxiety symptoms, work status, health and social care resource use, death - measured at three, six and 12 months post-randomisation.

Randomisation: Participants will be randomised to best practice usual care or the REGAIN programme on a 1:1.03 basis using a computer-generated randomisation sequence, performed by minimisation and stratified by age, level of hospital care, and case level mental health symptomatology. Once consent and baseline questionnaires have been completed by the participant online at home, randomisation will be performed automatically by a bespoke web-based system.

Blinding (masking): To ensure allocation concealment from both participant and REGAIN practitioner at baseline, randomisation will be performed only after the baseline questionnaires have been completed online at home by the participant. After randomisation has been performed, participants and REGAIN practitioners cannot be blind to group allocation. Follow-up outcome assessments will be completed by participants online at home.

Numbers To Be Randomised (sample Size): A total of 535 participants will be randomised: 263 to the best-practice usual care arm, and 272 participants to the REGAIN programme arm.

Trial Status: Current protocol: Version 3.0 (27th October 2020) Recruitment will begin in December 2020 and is anticipated to complete by September 2021.

Trial Registration: ISRCTN:11466448 , 23rd November 2020 FULL PROTOCOL: The full protocol Version 3.0 (27th October 2020) is attached as an additional file, accessible from the Trials website (Additional file 1). In the interests of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.
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http://dx.doi.org/10.1186/s13063-020-04978-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785779PMC
January 2021

Insights into heart failure hospitalizations, management, and services during and beyond COVID-19.

ESC Heart Fail 2021 02 24;8(1):175-182. Epub 2020 Nov 24.

Cardiovascular Research Division, Translational and Biosciences Research Institutes, Newcastle University, Newcastle upon Tyne, UK.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2. The clinical presentation of this virus mainly manifests in the respiratory system but may also lead to severe complications in the cardiovascular system. The global burden of COVID-19 has led to an unprecedented need to gain further insight into patient outcomes, management, and clinical practice. This review aims to provide an overview of the current literature on heart failure (HF) hospitalizations, management, and care pathways for supporting patients during and beyond this pandemic. A literature review of five areas of interest was conducted and included: (i) HF hospitalization; (ii) recognizing the needs and supporting HF patients during COVID-19; (iii) supporting rehabilitation services; (iv) transitioning to a telehealth framework; and (v) the need for evidence. Patients with new-onset or existing HF are particularly vulnerable, but a significant reduction in HF hospital admissions has been reported. During these periods of uncertainty, the current care pathways for acute and elective cardiac patients have had to change with the relocation of HF services to protect the vulnerable and reduce transmission of COVID-19. Optimizing community HF services has the potential to reduce the pressures on secondary care during the recovery from this pandemic. Telemedicine and virtual health care are emerging technologies and overcome the risk of in-person exposure. Successful remote delivery of cardiac rehabilitation services has been reported during the pandemic. Delivery of a robust telehealth framework for HF patients will improve communication between clinician and patient. The reduction in HF admissions is a concern for the future and may result in unintended mortality. New-onset and current HF patients must understand their diagnosis and future prognosis and seek help and support using the appropriate platform when needed. Realigning HF services and the use of telemedicine and virtual health care has great potential but needs to be carefully understood to ensure engagement and approval in this population to overcome barriers and challenges.
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http://dx.doi.org/10.1002/ehf2.13061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753441PMC
February 2021

Protocol for a randomised controlled feasibility trial of exercise rehabilitation for people with postural tachycardia syndrome: the PULSE study.

Pilot Feasibility Stud 2020 19;6:157. Epub 2020 Oct 19.

Department of Cardiology, Hamad Medical Corporation, Doha, Qatar.

Background: Postural orthostatic tachycardia syndrome (POTS) is an autonomic nervous system disorder causing an abnormal cardiovascular response to upright posture. It affects around 0.2% of the population, most commonly women aged 13 to 50 years. POTS can be debilitating; prolonged episodes of pre-syncope and fatigue can severely affect activities of daily living and health-related quality of life (HRQoL). Medical treatment is limited and not supported by randomised controlled trial (RCT) evidence. Lifestyle interventions are first-line treatment, including increased fluid and salt intake, compression tights and isometric counter-pressure manoeuvres to prevent fainting. Observational studies and small RCTs suggest exercise training may improve symptoms and HRQoL in POTS, but evidence quality is low.

Methods: Sixty-two people (aged 18-40 years) with a confirmed diagnosis of POTS will be invited to enrol on a feasibility RCT with embedded qualitative study. The primary outcome will be feasibility; process-related measures will include the number of people eligible, recruited, randomised and withdrawn, along with indicators of exercise programme adherence and acceptability. Secondary physiological, clinical and health-related outcomes including sub-maximal recumbent bike exercise test, active stand test and HRQoL will be measured at 4 and 7 months post-randomisation by researchers blinded to treatment allocation. The PostUraL tachycardia Syndrome Exercise (PULSE) intervention consists of (1) individual assessment; (2) 12-week, once to twice-weekly, supervised out-patient exercise training; (3) behavioural and motivational support; and (4) guided lifestyle physical activity. The control intervention will be best-practice usual care with a single 30-min, one-to-one practitioner appointment, and general advice on safe and effective physical activity. For the embedded qualitative study, participants ( = 10 intervention, = 10 control) will be interviewed at baseline and 4 months post-randomisation to assess acceptability and the feasibility of progressing to a definitive trial.

Discussion: There is very little high-quality research investigating exercise rehabilitation for people with POTS. The PULSE study will be the first randomised trial to assess the feasibility of conducting a definitive multicentre RCT testing supervised exercise rehabilitation with behavioural and motivational support, compared to best-practice usual care, for people with POTS.

Trial Registration: ISRCTN45323485 registered on 7 April 2020.
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http://dx.doi.org/10.1186/s40814-020-00702-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7569199PMC
October 2020

Cardiovascular Functional Changes in Chronic Kidney Disease: Integrative Physiology, Pathophysiology and Applications of Cardiopulmonary Exercise Testing.

Front Physiol 2020 15;11:572355. Epub 2020 Sep 15.

Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, United States.

The development of cardiovascular disease during renal impairment involves striking multi-tiered, multi-dimensional complex alterations encompassing the entire oxygen transport system. Complex interactions between target organ systems involving alterations of the heart, vascular, musculoskeletal and respiratory systems occur in Chronic Kidney Disease (CKD) and collectively contribute to impairment of cardiovascular function. These systemic changes have challenged our diagnostic and therapeutic efforts, particularly given that imaging cardiac structure at rest, rather than ascertainment under the stress of exercise, may not accurately reflect the risk of premature death in CKD. The multi-systemic nature of cardiovascular disease in CKD patients provides strong rationale for an integrated approach to the assessment of cardiovascular alterations in this population. State-of-the-art cardiopulmonary exercise testing (CPET) is a powerful, dynamic technology that enables the global assessment of cardiovascular functional alterations and reflects the integrative exercise response and complex machinery that form the oxygen transport system. CPET provides a wealth of data from a single assessment with mechanistic, physiological and prognostic utility. It is an underutilized technology in the care of patients with kidney disease with the potential to help advance the field of cardio-nephrology. This article reviews the integrative physiology and pathophysiology of cardio-renal impairment, critical new insights derived from CPET technology, and contemporary evidence for potential applications of CPET technology in patients with kidney disease.
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http://dx.doi.org/10.3389/fphys.2020.572355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522507PMC
September 2020

Current Insights into Exercise-based Cardiac Rehabilitation in Patients with Coronary Heart Disease and Chronic Heart Failure.

Int J Sports Med 2021 Jan 10;42(1):19-26. Epub 2020 Jul 10.

Department of Sport, Health & Exercise Science, University of Hull, Hull, United Kingdom of Great Britain and Northern Ireland.

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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http://dx.doi.org/10.1055/a-1198-5573DOI Listing
January 2021

High INtensity Interval Training In pATiEnts with intermittent claudication (INITIATE): protocol for a multicentre, proof-of-concept, prospective interventional study.

BMJ Open 2020 07 6;10(7):e038825. Epub 2020 Jul 6.

Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK.

Introduction: The first-line recommended treatment for patients with intermittent claudication (IC) is a supervised exercise programme (SEP), which includes a minimum of 2-hours of exercise per week over a 12-week period. However, provision, uptake and adherence rates for these SEP programmes are poor, with time constraints cited as a common participant barrier. High-intensity interval training (HIIT) is more time-efficient and therefore has the potential to overcome this barrier. However, evidence is lacking for the role of HIIT in those with IC. This proof-of-concept study aims to consider the safety, feasibility, tolerability and acceptability of a HIIT programme for patients with IC.

Methods And Analysis: This multicentre, single-group, prospective, interventional feasibility study will recruit 40 patients with IC, who will complete 6 weeks of HIIT, 3 times a week. HIIT will involve a supervised programme of 10×1 min high-intensity cycling intervals at 85%-90% peak power output (PPO), interspaced with 10×1 min low intensity intervals at 20%-25% PPO. PPO will be determined from a baseline cardiopulmonary exercise test (CPET) and it is intended that patients will achieve ≥85% of maximum heart rate from CPET, by the end of the second HIIT interval. Primary outcome measures are safety (occurrence of adverse events directly related to the study), programme feasibility (including participant eligibility, recruitment and completion rates) and HIIT tolerability (ability to achieve and maintain the required intensity). Secondary outcomes include patient acceptability, walking distance, CPET cardiorespiratory fitness measures and quality of life outcomes.

Ethics And Dissemination: Ethical approval was obtained via a local National Health Service research ethics committee (Bradford Leeds - 18/YH/0112) and recruitment began in August 2019 and will be completed in October 2020. Results will be published in peer-reviewed journals and presented at international conferences and are expected to inform a future pilot randomised controlled trial of HIIT versus usual-care SEPs.

Trial Registration Number: NCT04042311; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2020-038825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342853PMC
July 2020

Does contemporary exercise-based cardiac rehabilitation improve quality of life for people with coronary artery disease? A systematic review and meta-analysis.

BMJ Open 2020 06 7;10(6):e036089. Epub 2020 Jun 7.

University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK.

Objectives: To determine the effect of contemporary exercise-based cardiac rehabilitation on generic and disease-specific health related quality of life for people with coronary artery disease.

Design: Systematic review and meta-analysis.

Study Eligibility Criteria: Randomised controlled trials testing exercise-based cardiac rehabilitation versus no exercise control that recruited after 31 December 1999. On 30 July 2019, we searched the Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid) and CINAHL (EBSCO) databases.

Study Appraisal And Synthesis: Studies were screened for inclusion by two independent reviewers. Risk of bias was assessed using the Cochrane risk of bias tool. Data were reported as pooled means (95% CI for between-group difference.

Results: We identified 24 studies (n=4890). We performed meta-analyses for 15 short-term and 9 medium-term outcomes (36-Item Short Form Survey Instrument (SF-36), EuroQol-5D (EQ-5D) and MacNew, a cardiac-specific outcome). Six short-term and five medium-term SF-36 domains statistically favoured exercise-based cardiac rehabilitation. Only for two short-term SF-36 outcomes, 'physical function' (mean difference 12.0, 95% CI 4.4 to 19.6) and 'role physical' (mean difference 16.9, 95% CI 2.4 to 31.3), did the benefit appear to be clinically important. Meta-analyses of the short-term SF-36 physical and mental component scores, EQ-5D and MacNew and the medium-term SF-36 physical component score, did not show statistically significant benefits. Only two studies had a low risk of bias (n=463 participants).

Conclusions And Implications Of Key Findings: There is some evidence of a short-term benefit of contemporary exercise-based cardiac rehabilitation on quality of life for people with coronary artery disease. However, the contemporary data presented in this review are insufficient to support its routine use.
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http://dx.doi.org/10.1136/bmjopen-2019-036089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282413PMC
June 2020

Supervised pulmonary hypertension exercise rehabilitation (SPHERe): study protocol for a multi-centre randomised controlled trial.

BMC Pulm Med 2020 May 19;20(1):143. Epub 2020 May 19.

Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.

Background: Supervised cardio-pulmonary rehabilitation may be safe and beneficial for people with pulmonary hypertension (PH) in groups 1 (pulmonary arterial hypertension) and 4 (chronic thromboembolic disease), particularly as a hospital in-patient. It has not been tested in the most common PH groups; 2 (left heart disease), 3 (lung disease), or 5 (other disorders). Further it has not been evaluated in the UK National Health Service (NHS) out-patient setting, or with long-term follow-up. The aim of this randomised controlled trial (RCT) is to test the clinical and cost-effectiveness of a supervised exercise rehabilitation intervention with psychosocial support compared to best practice usual care for people with PH in the community/outpatient setting.

Methods: This multi-centre, pragmatic, two-arm RCT with embedded process evaluation aims to recruit 352 clinically stable adults with PH (groups 1-5) and WHO functional class II-IV. Participants will be randomised to either the Supervised Pulmonary Hypertension Exercise Rehabilitation (SPHERe) intervention or control. The SPHERe intervention consists of 1) individual assessment and familiarisation sessions; 2) 8-week, twice-weekly, supervised out-patient exercise training; 3) psychosocial/motivational support and education; 4) guided home exercise plan. The control intervention consists of best practice usual care with a single one-to-one practitioner appointment, and general advice on physical activity. Outcomes will be measured at baseline, 4 months (post-intervention) and 12 months by researchers blinded to treatment allocation. The primary outcome is the incremental shuttle walk test at 4 months. Secondary outcomes include health-related quality of life (HRQoL), time to clinical worsening and health and social care use. A purposive sample of participants (n = 20 intervention and n = 20 control) and practitioners (n = 20) will be interviewed to explore experiences of the trial, outcomes and interventions.

Discussion: The SPHERe study is the first multi-centre clinical RCT to assess the clinical and cost effectiveness of a supervised exercise rehabilitation intervention compared to usual care, delivered in the UK NHS, for people in all PH groups. Results will inform clinicians and commissioners as to whether or not supervised exercise rehabilitation is effective and should be routinely provided for people with PH.

Trial Registration: ISRCTN no. 10608766, prospectively registered on 18th March 2019.
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http://dx.doi.org/10.1186/s12890-020-01182-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236437PMC
May 2020

Cardiovascular Functional Reserve Before and After Kidney Transplant.

JAMA Cardiol 2020 04;5(4):420-429

Cambridge Clinical Trials Unit and School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom.

Importance: Restitution of kidney function by transplant confers a survival benefit in patients with end-stage renal disease. Investigations of mechanisms involved in improved cardiovascular survival have relied heavily on static measures from echocardiography or cardiac magnetic resonance imaging and have provided conflicting results to date.

Objectives: To evaluate cardiovascular functional reserve in patients with end-stage renal disease before and after kidney transplant and to assess functional and morphologic alterations of structural-functional dynamics in this population.

Design, Setting, And Participants: This prospective, nonrandomized, single-center, 3-arm, controlled cohort study, the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) study, included patients with stage 5 chronic kidney disease (CKD) who underwent kidney transplant (KTR group), patients with stage 5 CKD who were wait-listed and had not undergone transplant (NTWC group), and patients with hypertension only (HTC group) seen at a single center from April 1, 2010, to January 1, 2013. Patients were followed up longitudinally for up to 1 year after kidney transplant. Clinical data collection was completed February 2014. Data analysis was performed from June 1, 2014, to March 5, 2015. Further analysis on baseline and prospective data was performed from June 1, 2017, to July 31, 2019.

Main Outcomes And Measures: Cardiovascular functional reserve was objectively quantified using state-of-the-art cardiopulmonary exercise testing in parallel with transthoracic echocardiography.

Results: Of the 253 study participants (mean [SD] age, 48.5 [12.7] years; 141 [55.7%] male), 81 were in the KTR group, 85 in the NTWC group, and 87 in the HTC group. At baseline, mean (SD) maximum oxygen consumption (V̇O2max) was significantly lower in the CKD groups (KTR, 20.7 [5.8] mL · min-1 · kg-1; NTWC, 18.9 [4.7] mL · min-1 · kg-1) compared with the HTC group (24.9 [7.1] mL · min-1 · kg-1) (P < .001). Mean (SD) cardiac left ventricular mass index was higher in patients with CKD (KTR group, 104.9 [36.1] g/m2; NTWC group, 113.8 [37.7] g/m2) compared with the HTC group (87.8 [16.9] g/m2), (P < .001). Mean (SD) left ventricular ejection fraction was significantly lower in the patients with CKD (KTR group, 60.1% [8.6%]; NTWC group, 61.4% [8.9%]) compared with the HTC group (66.1% [5.9%]) (P < .001). Kidney transplant was associated with a significant improvement in V̇O2max in the KTR group at 12 months (22.5 [6.3] mL · min-1 · kg-1; P < .001), but the value did not reach the V̇O2max in the HTC group (26.0 [7.1] mL · min-1 · kg-1) at 12 months. V̇O2max decreased in the NTWC group at 12 months compared with baseline (17.7 [4.1] mL · min-1 · kg-1, P < .001). Compared with the KTR group (63.2% [6.8%], P = .02) or the NTWC group (59.3% [7.6%], P = .003) at baseline, transplant was significantly associated with improved left ventricular ejection fraction at 12 months but not with left ventricular mass index.

Conclusions And Relevance: The findings suggest that kidney transplant is associated with improved cardiovascular functional reserve after 1 year. In addition, cardiopulmonary exercise testing was sensitive enough to detect a decline in cardiovascular functional reserve in wait-listed patients with CKD. Improved V̇O2max may in part be independent from structural alterations of the heart and depend more on ultrastructural changes after reversal of uremia.
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http://dx.doi.org/10.1001/jamacardio.2019.5738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042833PMC
April 2020

Cardiac stunning during haemodialysis: the therapeutic effect of intra-dialytic exercise.

Clin Kidney J 2021 May 17;14(5):1335-1344. Epub 2019 Dec 17.

Faculty of Health and Life Sciences, Centre for Sport, Exercise and Life Sciences, Coventry University, Coventry, UK.

Background: Cardiovascular risk is elevated in end-stage renal disease. Left ventricular (LV) dysfunction is linked to repetitive transient ischaemia occurring during haemodialysis (HD). Cardiomyocyte ischaemia results in 'cardiac stunning', evidenced by regional wall motion abnormalities (RWMAs). Ischaemic RWMA have been documented during HD resulting in maladaptive cardiac remodelling and increased risk of heart failure. Intra-dialytic exercise is well tolerated and can improve quality of life and functional capacity. It may also attenuate HD-induced cardiac stunning.

Methods: This exploratory study aimed to assess the effect of intra-dialytic cycle ergometry on cardiac stunning. Twenty exercise-naïve participants on maintenance HD (mean ± SD, 59 ± 11 years) underwent resting echocardiography and maximal cardiopulmonary exercise testing. Subsequently, cardiac stunning was assessed with myocardial strain-derived RWMAs at four time points during (i) standard HD and (ii) HD with 30 min of sub-maximal intra-dialytic cycle ergometry at a workload equivalent to 90% oxygen uptake at the anaerobic threshold (VOAT). Central haemodynamics and cardiac troponin I were also assessed.

Results: Compared with HD alone, HD with intra-dialytic exercise significantly reduced RWMAs after 2.5 h of HD (total 110 ± 4, mean 7 ± 4 segments versus total 77 ± 3, mean 5 ± 3, respectively; P = 0.008). Global cardiac function, intra-dialytic haemodynamics and LV volumetric parameters were not significantly altered with exercise.

Conclusions: Intra-dialytic exercise reduced cardiac stunning. Thirty minutes of sub-maximal exercise at 90% VOAT was sufficient to elicit acute cardio-protection. These data potentially demonstrate a novel therapeutic effect of intra-dialytic exercise.
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http://dx.doi.org/10.1093/ckj/sfz159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087145PMC
May 2021

Heart failure with preserved ejection fraction (HFpEF) pathophysiology study (IDENTIFY-HF): does increased arterial stiffness associate with HFpEF, in addition to ageing and vascular effects of comorbidities? Rationale and design.

BMJ Open 2019 11 19;9(11):e027984. Epub 2019 Nov 19.

University of Warwick, Warwick Medical School, Coventry, UK

Aims: There has been a paradigm shift proposing that comorbidities are a major contributor towards the heart failure with preserved ejection fraction (HFpEF) syndrome. Furthermore, HFpEF patients have abnormal macrovascular and microvascular function, which may significantly contribute towards altered ventricular-vascular coupling in these patients. The IDENTIFY-HF study will investigate whether gradually increased arterial stiffness (in addition to ageing) as a result of increasing common comorbidities, such as hypertension and diabetes, is associated with HFpEF.

Methods And Analysis: In our observational study, arterial compliance and microvascular function will be assessed in five groups (Groups A to E) of age, sex and body mass index matched subjects (age ≥70 years in all groups):Group A; normal healthy volunteers without major comorbidities such as hypertension and diabetes mellitus (control). Group B; patients with hypertension without diabetes mellitus or heart failure (HF). Group C; patients with hypertension and diabetes mellitus without HF. Group D; patients with HFpEF. Group E; patients with heart failure and reduced ejection fraction (parallel group). Vascular function and arterial compliance will be assessed using pulse wave velocity, as the primary outcome measure. Further outcome measures include cutaneous laser Doppler flowmetry as a measure of endothelial function, transthoracic echocardiography and exercise tolerance measures. Biomarkers include NT-proBNP, high-sensitivity troponin T, as well as serum galectin-3 as a marker of fibrosis.

Ethics And Dissemination: The study was approved by the regional research ethics committee (REC), West Midland and Black Country 17/WM/0039, UK, and permission to conduct the study in the hospital was also obtained from the RDI, UHCW NHS Trust. The results will be published in peer-reviewed journals and presented in local, national and international medical society meetings.

Trial Registration Number: NCT03186833.
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http://dx.doi.org/10.1136/bmjopen-2018-027984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886989PMC
November 2019

The effect of protein and essential amino acid supplementation on muscle strength and performance in patients with chronic heart failure: a systematic review.

Eur J Nutr 2020 Aug 28;59(5):1785-1801. Epub 2019 Oct 28.

Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle-Upon-Tyne, UK.

Purpose: Critically low skeletal muscle mass and strength, observed in 20% of people with chronic heart failure (CHF), reduces functional capacity, quality of life (QoL) and survival. Protein and essential amino acid (EAA) supplementation could be a viable treatment strategy to prevent declines in muscle strength and performance, and subsequently improve QoL and survival. This systematic review (PROSPERO: CRD42018103649) aimed to assess the effect of dietary protein and/or EAA supplementation on muscle strength and performance in people with CHF.

Methods: Searches of PubMed, MEDLINE and Embase identified studies that reported changes in strength or muscle performance following protein and/or EAA supplementation in patients with CHF. Following PRISMA guidelines and using predefined inclusion/exclusion criteria relating to participants, intervention, control, outcome and study design, two reviewers independently screened titles, abstracts and full manuscripts for eligibility. Risk of bias was assessed using Cochrane Risk of Bias Tool (RCTs) or Mixed Methods Appraisal Tool (cohort studies). Data were extracted for analysis using predefined criteria.

Results: Five randomised controlled trials (RCT) and one cohort study met our inclusion criteria. All RCTs had a high risk of bias. The methodological quality of the cohort study was moderate. Heterogeneity of extracted data prevented meta-analyses, qualitative synthesis was therefore performed. Data from 167 patients with CHF suggest that protein and/or EAA supplementation does not improve strength, but may increase six-minute walk test distance, muscle mass and QoL.

Conclusions: The limited quality of the studies makes firm conclusions difficult, however protein and/or EAA supplementation may improve important outcome measures related to sarcopenia. High-quality randomised controlled studies are needed.
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http://dx.doi.org/10.1007/s00394-019-02108-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351803PMC
August 2020

Optimising fitness for major vascular surgery.

BMJ 2019 Sep 2;366:l5002. Epub 2019 Sep 2.

Warwick Medical School, Coventry University and Exeter University, UK.

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http://dx.doi.org/10.1136/bmj.l5002DOI Listing
September 2019

Exercise rehabilitation programmes for pulmonary hypertension: a systematic review of intervention components and reporting quality.

BMJ Open Sport Exerc Med 2018 16;4(1):e000400. Epub 2018 Oct 16.

Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.

Objectives: To identify the components, and assess the reporting quality, of exercise training interventions for people living with pulmonary hypertension.

Design: Systematic review with analysis of intervention reporting quality using the Consensus on Exercise Reporting Template (CERT).

Data Sources: Eligible studies in the Cochrane Systematic Review of exercise-based rehabilitation for pulmonary hypertension, updated with a new search of relevant databases from 1 August 2016 to 15 January 2018.

Eligibility Criteria: Peer-reviewed journal articles of randomised and non-randomised controlled trials, and non-controlled prospective observational studies, investigating dynamic exercise training interventions in adult humans with diagnosed pulmonary hypertension, reporting on at least one physiological and/or psychosocial outcome.

Results: Interventions typically involved cycle ergometry and walking. They were delivered as 3-week inpatient, or outpatient and/or home-based programmes, lasting for 4-15 weeks. Components relating specifically to exercise prescription were described satisfactorily and in more detail than motivational/behavioural change strategies, adherence and fidelity. Mean CERT score was 13.1 (range 8-17) out of a possible maximum score of 19. No studies fully reported every aspect of an exercise intervention to the standard recommended by CERT.

Summary/conclusion: Considerable variability was evident in the components and reporting quality of interventions for exercise rehabilitation studies in pulmonary hypertension. Interventional studies using exercise training should pay greater attention to describing motivational/behavioural change strategies, adherence and fidelity. Detailed description of these parameters is essential for the safe and effective replication of exercise rehabilitation interventions for pulmonary hypertension in clinical practice.

Trial Registration Number: CRD42018085558.
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http://dx.doi.org/10.1136/bmjsem-2018-000400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196941PMC
October 2018

Feasibility and effects of intra-dialytic low-frequency electrical muscle stimulation and cycle training: A pilot randomized controlled trial.

PLoS One 2018 11;13(7):e0200354. Epub 2018 Jul 11.

Department of Nephrology, University Hospital, Coventry, United Kingdom.

Background And Objectives: Exercise capacity is reduced in chronic kidney failure (CKF). Intra-dialytic cycling is beneficial, but comorbidity and fatigue can prevent this type of training. Low-frequency electrical muscle stimulation (LF-EMS) of the quadriceps and hamstrings elicits a cardiovascular training stimulus and may be a suitable alternative. The main objectives of this trial were to assess the feasibility and efficacy of intra-dialytic LF-EMS vs. cycling.

Design, Setting, Participants, And Measurements: Assessor blind, parallel group, randomized controlled pilot study with sixty-four stable patients on maintenance hemodialysis. Participants were randomized to 10 weeks of 1) intra-dialytic cycling, 2) intra-dialytic LF-EMS, or 3) non-exercise control. Exercise was performed for up to one hour three times per week. Cycling workload was set at 40-60% oxygen uptake (VO2) reserve, and LF-EMS at maximum tolerable intensity. The control group did not complete any intra-dialytic exercise. Feasibility of intra-dialytic LF-EMS and cycling was the primary outcome, assessed by monitoring recruitment, retention and tolerability. At baseline and 10 weeks, secondary outcomes including cardio-respiratory reserve, muscle strength, and cardio-arterial structure and function were assessed.

Results: Fifty-one (of 64 randomized) participants completed the study (LF-EMS = 17 [77%], cycling = 16 [80%], control = 18 [82%]). Intra-dialytic LF-EMS and cycling were feasible and well tolerated (9% and 5% intolerance respectively, P = 0.9). At 10-weeks, cardio-respiratory reserve (VO2 peak) (Difference vs. control: LF-EMS +2.0 [95% CI, 0.3 to 3.7] ml.kg-1.min-1, P = 0.02, and cycling +3.0 [95% CI, 1.2 to 4.7] ml.kg-1.min-1, P = 0.001) and leg strength (Difference vs. control: LF-EMS, +94 [95% CI, 35.6 to 152.3] N, P = 0.002 and cycling, +65.1 [95% CI, 6.4 to 123.8] N, P = 0.002) were improved. Arterial structure and function were unaffected.

Conclusions: Ten weeks of intra-dialytic LF-EMS or cycling improved cardio-respiratory reserve and muscular strength. For patients who are unable or unwilling to cycle during dialysis, LF-EMS is a feasible alternative.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200354PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040736PMC
January 2019

Low frequency electrical muscle stimulation and endothelial function in advanced heart failure patients.

ESC Heart Fail 2018 08 3;5(4):727-731. Epub 2018 Jul 3.

Liverpool John Moores University, Liverpool, UK.

Aim: Obtain initial estimates of the change in brachial artery endothelial function and maximal oxygen uptake (VO ) with 8 weeks of low-frequency electrical muscle stimulation (LF-EMS) or sham in patients with advanced chronic heart failure.

Methods And Results: Using a double blind, randomized design, 35 patients with chronic heart failure (New York Heart Association class III-IV) were assigned to 8 weeks (5 × 60 min per week) of either LF-EMS (4 Hz, continuous) or sham (skin level stimulation only) of the quadriceps and hamstrings muscles. Four of the five sessions were at home and one under supervision. Ultrasound images of resting brachial artery diameter and post 5 min occlusion to determine flow-mediated dilation (FMD), a marker of vascular function and peak oxygen uptake (VO ) during cardiopulmonary exercise test, were measured before and after LF-EMS (n = 20) and sham (n = 15) interventions. FMD improved by 2.56% (95% confidence interval: 0.69 to 3.80) with LF-EMS compared with sham (P = 0.07). There were no notable changes in VO .

Conclusions: Improvements in FMD with LF-EMS may have a clinically meaningful effect as higher FMD is associated with better prognosis. This is a preliminary finding, and a larger trial is warranted.
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http://dx.doi.org/10.1002/ehf2.12293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6073028PMC
August 2018

Hemodynamic Instability during Dialysis: The Potential Role of Intradialytic Exercise.

Biomed Res Int 2018 27;2018:8276912. Epub 2018 Feb 27.

Faculty of Health and Life Sciences, Coventry University, Coventry, UK.

Acute haemodynamic instability is a natural consequence of disordered cardiovascular physiology during haemodialysis (HD). Prevalence of intradialytic hypotension (IDH) can be as high as 20-30%, contributing to subclinical, transient myocardial ischemia. In the long term, this results in progressive, maladaptive cardiac remodeling and impairment of left ventricular function. This is thought to be a major contributor to increased cardiovascular mortality in end stage renal disease (ESRD). Medical strategies to acutely attenuate haemodynamic instability during HD are suboptimal. Whilst a programme of intradialytic exercise training appears to facilitate numerous chronic adaptations, little is known of the acute physiological response to this type of exercise. In particular, the potential for intradialytic exercise to acutely stabilise cardiovascular hemodynamics, thus preventing IDH and myocardial ischemia, has not been explored. This narrative review aims to summarise the characteristics and causes of acute haemodynamic instability during HD, with an overview of current medical therapies to treat IDH. Moreover, we discuss the acute physiological response to intradialytic exercise with a view to determining the potential for this nonmedical intervention to stabilise cardiovascular haemodynamics during HD, improve coronary perfusion, and reduce cardiovascular morbidity and mortality in ESRD.
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http://dx.doi.org/10.1155/2018/8276912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848102PMC
September 2018

Early initiation of post-sternotomy cardiac rehabilitation exercise training (SCAR): study protocol for a randomised controlled trial and economic evaluation.

BMJ Open 2018 03 23;8(3):e019748. Epub 2018 Mar 23.

Department of Cardiac Rehabilitation, Centre for Exercise and Health, University Hospital, Coventry, UK.

Introduction: Current guidelines recommend abstinence from supervised cardiac rehabilitation (CR) exercise training for 6 weeks post-sternotomy. This practice is not based on empirical evidence, thus imposing potentially unnecessary activity restrictions. Delayed participation in CR exercise training promotes muscle atrophy, reduces cardiovascular fitness and prolongs recovery. Limited data suggest no detrimental effect of beginning CR exercise training as early as 2 weeks post-surgery, but randomised controlled trials are yet to confirm this. The purpose of this trial is to compare CR exercise training commenced early (2 weeks post-surgery) with current usual care (6 weeks post-surgery) with a view to informing future CR guidelines for patients recovering from sternotomy.

Methods And Analysis: In this assessor-blind randomised controlled trial, 140 cardiac surgery patients, recovering from sternotomy, will be assigned to 8 weeks of twice-weekly supervised CR exercise training commencing at either 2 weeks (early CR) or 6 weeks (usual care CR) post-surgery. Usual care exercise training will adhere to current UK recommendations. Participants in the early CR group will undertake a highly individualised 2-3 week programme of functional mobility, strength and cardiovascular exercise before progressing to a usual care CR programme. Outcomes will be assessed at baseline (inpatient), pre-CR (2 or 6 weeks post-surgery), post-CR (10 or 14 weeks post-surgery) and 12 months. The primary outcome will be change in 6 min walk distance. Secondary outcomes will include measures of functional fitness, quality of life and cost-effectiveness.

Ethics And Dissemination: Recruitment commenced on July 2017 and will complete by December 2019. Results will be disseminated via national governing bodies, scientific meetings and peer-reviewed journals.

Trial Registration Number: NCT03223558; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-019748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875596PMC
March 2018

Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence.

BMJ Open 2018 03 14;8(3):e019656. Epub 2018 Mar 14.

Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.

Objectives: To determine the contemporary effectiveness of exercise-based cardiac rehabilitation (CR) in terms of all-cause mortality, cardiovascular mortality and hospital admissions.

Data Sources: Studies included in or meeting the entry criteria for the 2016 Cochrane review of exercise-based CR in patients with coronary artery disease.

Study Eligibility Criteria: Randomised controlled trials (RCTs) of exercise-based CR versus a no-exercise control whose participants were recruited after the year 2000.

Study Appraisal And Synthesis Methods: Two separate reviewers independently screened the characteristics of studies. One reviewer quality appraised any new studies and assessed their risk of bias using the Cochrane Collaboration's recommended risk of bias tool. Data were reported as the risk difference (95% CI).

Results: We included 22 studies with 4834 participants (mean age 59.5 years, 78.4% male). We found no differences in outcomes between exercise-based CR and a no-exercise control at their longest follow-up period for: all-cause mortality (19 studies; n=4194; risk difference 0.00, 95% CI -0.02 to 0.01, P=0.38) or cardiovascular mortality (9 studies; n=1182; risk difference -0.01, 95% CI -0.02 to 0.01, P=0.25). We found a small reduction in hospital admissions of borderline statistical significance (11 studies; n=1768; risk difference -0.05, 95% CI -0.10 to -0.00, P=0.05).

Conclusions And Implications Of Key Findings: Our analysis indicates conclusively that the current approach to exercise-based CR has no effect on all-cause mortality or cardiovascular mortality, when compared with a no-exercise control. There may be a small reduction in hospital admissions following exercise-based CR that is unlikely to be clinically important.

Prospero Registration Number: CRD42017073616.
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http://dx.doi.org/10.1136/bmjopen-2017-019656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857699PMC
March 2018

Layer-specific systolic and diastolic strain in hypertensive patients with and without mild diastolic dysfunction.

Echo Res Pract 2018 Mar 5;5(1):41-49. Epub 2018 Feb 5.

Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, UK.

This study sought to examine layer-specific longitudinal and circumferential systolic and diastolic strain, strain rate (SR) and diastolic time intervals in hypertensive patients with and without diastolic dysfunction. Fifty-eight treated hypertensive patients were assigned to normal diastolic function (NDF,  = 39) or mild diastolic dysfunction (DD,  = 19) group. Layer-specific systolic and diastolic longitudinal and circumferential strains and SR were assessed. Results showed no between-group difference in left ventricular mass index (DD: 92.1 ± 18.1 vs NDF: 88.4 ± 16.3;  = 0.44). Patients with DD had a proportional reduction in longitudinal strain across the myocardium (endocardial for DD -13 ± 4%; vs NDF -17 ± 3,  < 0.01; epicardial for DD -10 ± 3% vs NDF -13 ± 3%,  < 0.01; global for DD: -12 ± 3% vs NDF: -15 ± 3,  = 0.01), and longitudinal mechanical diastolic impairments as evidenced by reduced longitudinal strain rate of early diastole (DD 0.7 ± 0.2 L/s vs NDF 1.0 ± 0.3 L/s,  < 0.01) and absence of a transmural gradient in the duration of diastolic strain (DD endocardial: 547 ± 105 ms vs epicardial: 542 ± 113 ms,  = 0.24; NDF endocardial: 566 ± 86 ms vs epicardial: 553 ± 77 ms,  = 0.03). Patients with DD also demonstrate a longer duration of early circumferential diastolic strain (231 ± 71 ms vs 189 ± 58 ms,  = 0.02). In conclusion, hypertensive patients with mild DD demonstrate a proportional reduction in longitudinal strain across the myocardium, as well as longitudinal mechanical diastolic impairment, and prolonging duration of circumferential mechanical relaxation.
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http://dx.doi.org/10.1530/ERP-17-0072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827572PMC
March 2018

Effect of exercise training on left ventricular mechanics after acute myocardial infarction-an exploratory study.

Ann Phys Rehabil Med 2018 May 31;61(3):119-124. Epub 2018 Jan 31.

Cardiff Metropolitan University, Cardiff, UK.

Background: Cardiac rehabilitation (CR) exercise training is beneficial after myocardial infarction (MI). Whilst the peripheral adaptations to training are well defined, little is known regarding the effect on left ventricular (LV) remodelling, particularly LV function. Efficient LV ejection and filling is achieved through deformation and rotation of the myocardium in systole and diastole - LV mechanics. The response of LV mechanics to CR exercise training in MI patients is unknown.

Methods: In this observational exploratory study, 36 (of 40 enrolled) male, MI patients completed either 10-weeks of twice-weekly gym based cardiovascular exercise at 60-80% VO (n=18), or a non-exercise control period (n=18). Cardiopulmonary exercise testing and speckle tracking echocardiography were performed at baseline and 10 weeks.

Results: Compared to the non-exercise group, VO improved with CR exercise training (Difference: +4.28 [95% CI: 1.34 to 7.23] ml.kg.min, P=0.01). Neither conventional LV structural or functional indices, nor LV global longitudinal strain, significantly changed in either group. In contrast, LV twist and twist velocity decreased in the exercise group and increased in the non-exercise group (Difference: -3.95° [95% CI: -7.92 to 0.03°], P=0.05 and -19.2°.s [95% CI: -35.9 to -2.7°.s], P=0.02, respectively).

Conclusion: In MI patients who completed CR exercise training, LV twist and twist velocity decreased, whereas these parameters increased in patients who did not exercise. These preliminary data may indicate reverse LV functional remodelling and improved functional reserve. The assessment of LV twist may serve as an indicator of the therapeutic benefit of CR exercise training and should be investigated in larger trials.
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http://dx.doi.org/10.1016/j.rehab.2018.01.003DOI Listing
May 2018

Randomised feasibility trial into the effects of low-frequency electrical muscle stimulation in advanced heart failure patients.

BMJ Open 2017 Aug 11;7(8):e016148. Epub 2017 Aug 11.

Department of Cardiac Rehabilitation, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK.

Objectives: Low-frequency electrical muscle stimulation (LF-EMS) may have the potential to reduce breathlessness and increase exercise capacity in the chronic heart failure population who struggle to adhere to conventional exercise. The study's aim was to establish if a randomised controlled trial of LF-EMS was feasible.

Design And Setting: Double blind (participants, outcome assessors), randomised study in a secondary care outpatient cardiac rehabilitation programme.

Participants: Patients with severe heart failure (New York Heart Association class III-IV) having left ventricular ejection fraction <40% documented by echocardiography were eligible.

Interventions: Participants were randomised (remotely by computer) to 8 weeks (5×60 mins per week) of either LF-EMS intervention (4 Hz, continuous, n=30) or sham placebo (skin level stimulation only, n=30) of the quadriceps and hamstrings muscles. Participants used the LF-EMS straps at home and were supervised weekly OUTCOME MEASURES: Recruitment, adherence and tolerability to the intervention were measured during the trial as well as physiological outcomes (primary outcome: 6 min walk, secondary outcomes: quadriceps strength, quality of life and physical activity).

Results: Sixty of 171 eligible participants (35.08%) were recruited to the trial. 12 (20%) of the 60 patients (4 LF-EMS and 8 sham) withdrew. Forty-one patients (68.3%), adhered to the protocol for at least 70% of the sessions. The physiological measures indicated no significant differences between groups in 6 min walk distance(p=0.13) and quality of life (p=0.55) although both outcomes improved more with LF-EMS.

Conclusion: Patients with severe heart failure can be recruited to and tolerate LF-EMS studies. A larger randomised controlled trial (RCT) in the advanced heart failure population is technically feasible, although adherence to follow-up would be challenging. The preliminary improvements in exercise capacity and quality of life were minimal and this should be considered if planning a larger trial.

Trial Registration Number: ISRCTN16749049.
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http://dx.doi.org/10.1136/bmjopen-2017-016148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629639PMC
August 2017

High-intensity interval training versus moderate-intensity steady-state training in UK cardiac rehabilitation programmes (HIIT or MISS UK): study protocol for a multicentre randomised controlled trial and economic evaluation.

BMJ Open 2016 11 16;6(11):e012843. Epub 2016 Nov 16.

Cardiff Centre for Exercise & Health, Cardiff Metropolitan University, Cardiff, UK.

Introduction: Current international guidelines for cardiac rehabilitation (CR) advocate moderate-intensity exercise training (MISS, moderate-intensity steady state). This recommendation predates significant advances in medical therapy for coronary heart disease (CHD) and may not be the most appropriate strategy for the 'modern' patient with CHD. High-intensity interval training (HIIT) appears to be a safe and effective alternative, resulting in greater improvements in peak oxygen uptake (VO). To date, HIIT trials have predominantly been proof-of-concept studies in the laboratory setting and conducted outside the UK. The purpose of this multicentre randomised controlled trial is to compare the effects of HIIT and MISS training in patients with CHD attending UK CR programmes.

Methods And Analysis: This pragmatic study will randomly allocate 510 patients with CHD to 8 weeks of twice weekly HIIT or MISS training at 3 centres in the UK. HIIT will consist of 10 high-intensity (85-90% peak power output (PPO)) and 10 low-intensity (20-25% PPO) intervals, each lasting 1 min. MISS training will follow usual care recommendations, adhering to currently accepted UK guidelines (ie, >20 min continuous exercise at 40-70% heart rate reserve). Outcome measures will be assessed at baseline, 8 weeks and 12 months. The primary outcome for the trial will be change in VO as determined by maximal cardiopulmonary exercise testing. Secondary measures will assess physiological, psychosocial and economic outcomes.

Ethics And Dissemination: The study protocol V.1.0, dated 1 February 2016, was approved by the NHS Health Research Authority, East Midlands-Leicester South Research Ethics Committee (16/EM/0079). Recruitment will start in August 2016 and will be completed in June 2018. Results will be published in peer-reviewed journals, presented at national and international scientific meetings and are expected to inform future national guidelines for exercise training in UK CR.

Trial Registration Number: NCT02784873; pre-results.
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http://dx.doi.org/10.1136/bmjopen-2016-012843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129054PMC
November 2016

Reverse left ventricular remodeling: effect of cardiac rehabilitation exercise training in myocardial infarction patients with preserved ejection fraction.

Eur J Phys Rehabil Med 2016 Jun 4;52(3):370-8. Epub 2015 Nov 4.

Cardiff Metropolitan University, Cardiff, England -

Background: In the increasingly prevalent population of postmyocardial infarction (MI) patients with preserved left ventricular (LV) ejection fraction (>45%), the effect of cardiac rehabilitation (CR) exercise training on LV structure and function is unknown.

Aim: To examine the reverse LV remodeling effect of CR exercise training in post-MI patients with preserved LV ejection fraction (>45%).

Design: Prospective, longitudinal, controlled trial.

Setting: Outpatient CR programme.

Population: Fifty six asymptomatic, post-MI patients without residual myocardial ischemia and LV ejection fraction >45%.

Methods: Within 3-6 weeks of MI, and 10 weeks later, echocardiography and cardiopulmonary exercise testing were performed. An exercise training group (N.=36) completed twice weekly gym based cardiovascular exercise (60-80% VO2 peak) and a resistance training programme, whilst a non-exercise group (N.=20) did not.

Results: In comparison to the non-exercise group, in which there was no change, 10 weeks of CR exercise training resulted in increased VO2peak and reduced LV end diastolic and systolic volumes (all P<0.05 vs. non-exercise group).

Conclusions: In post-MI patients with preserved LV ejection fraction (>45%), CR exercise training is effective in improving functional capacity and reducing LV volumes.

Clinical Rehabilitation Impact: In this previously unstudied population, the measurement of reverse LV volumetric remodeling may prove useful as an indicator of CR exercise programme efficacy. To maximize the potential clinical benefit from reverse LV remodeling, this patient group, should be actively encouraged to engage in CR exercise training.
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June 2016

Exaggerated blood pressure response to dynamic exercise despite chronic refractory hypotension: results of a human case study.

BMC Nephrol 2015 Jun 9;16:81. Epub 2015 Jun 9.

Departments of Renal Medicine and Transplantation, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.

Background: Chronic refractory hypotension is a rare but significant mortality risk in renal failure patients. Such aberrant physiology usually deems patient unfit for renal transplant surgery. Exercise stimulates the mechano-chemoreceptors in the skeletal muscle thereby modulating the sympathetic effects on blood pressure regulation. The haemodynamic response to dynamic exercise in such patients has not been previously investigated. We present a case with severe chronic hypotension who underwent exercise testing before and after renal transplantation, with marked differences in blood pressure response to exercise.

Case Presentation: A 40-year old haemodialysis-dependent patient with a 2 year history of refractory hypotension (≤80/50 mmHg) was referred for living donor renal transplantation at our tertiary centre. Each dialysis session was often less than 2 h and 30 min due to symptomatic hypotension. As part of the cardiovascular assessment, she underwent haemodynamic evaluation with cardiopulmonary exercise testing. Blood pressure normalized during unloaded pedalling but was exaggerated at maximal workload whereby it rose from 82/50 mmHg to a peak of 201/120 mmHg. Transthoracic echocardiography, tonometric measure of central vascular compliance and myocardial perfusion scan were normal. She subsequently underwent an antibody-incompatible renal transplantation and was vasopressor reliant for 14 days during the post-operative period. Eight weeks following transplant, resting blood pressure was normal and a physiological exercise-haemodynamic response was observed during a repeat cardiopulmonary exercise testing.

Conclusion: This case highlights the potential therapeutic role of unloaded leg cycling exercise during dialysis session to correct chronic hypotension, allowing patients to have greater tolerance to fluid shift. It also adds to existing evidence that sympathetic dysfunction is reversible with renal transplant. Furthermore chronic hypotension with preserved exercise-haemodynamic response and cardiovascular reserve should not preclude these patients from renal transplant surgery.
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http://dx.doi.org/10.1186/s12882-015-0076-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460705PMC
June 2015
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