Publications by authors named "Patrick D Savage"

62 Publications

Optimizing Training Response for Women in Cardiac Rehabilitation: A Randomized Clinical Trial.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Division of Cardiology, Department of Medicine, University of Vermont, Burlington.

Importance: Despite lower baseline fitness levels, women in cardiac rehabilitation (CR) do not typically improve peak aerobic exercise capacity (defined as peak oxygen uptake [peak Vo2]) compared with men in CR.

Objective: To evaluate the effect of high-intensity interval training (HIIT) and intensive lower extremity resistance training (RT) compared with standard moderate intensity continuous training (MCT) on peak Vo2 among women in CR.

Design, Setting, And Participants: This randomized clinical trial conducted from July 2017 to February 2020 included women from a community-based cardiac rehabilitation program affiliated with a university hospital in Vermont. A total of 56 women (mean [SD] age, 65 [11] years; range 43-98 years) participating in CR enrolled in the study.

Interventions: MCT (70% to 85% of peak heart rate [HR]) with moderate intensive RT or HIIT (90% to 95% of peak HR) along with higher-intensity lower extremity RT 3 times per week over 12 weeks.

Main Outcomes And Measures: The primary outcome was the between-group difference in change in peak Vo2 (L/min) from baseline to 12 weeks.

Results: Peak Vo2 increased to a greater degree in the HIIT group (+23%) than in the control group (+7%) (mean [SD] increase, 0.3 [0.2] L/min vs 0.1 [0.2] L/min; P = .03). Similarly, the change in leg strength was greater in the HIIT-RT group compared with the control group (mean [SD] increase, 15.3 [0.3] kg vs 6.4 [1.1] kg; P = .004).

Conclusions And Relevance: An exercise protocol combining HIIT and intensive lower extremity RT enhanced exercise training response for women in CR compared with standard CR exercise training. Women randomized to HIIT experienced significantly greater improvements in both peak Vo2 and leg strength during CR.

Trial Registration: ClinicalTrials.gov Identifier: NCT03438968.
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http://dx.doi.org/10.1001/jamacardio.2021.4822DOI Listing
November 2021

Reference Standards for Cardiorespiratory Fitness by Cardiovascular Disease Category and Testing Modality: Data From FRIEND.

J Am Heart Assoc 2021 Nov 8;10(22):e022336. Epub 2021 Nov 8.

Fisher Institute of Health and Well-BeingCollege of HealthBall State University Muncie IN.

Background The importance of cardiorespiratory fitness for stratifying risk and guiding clinical decisions in patients with cardiovascular disease is well-established. To optimize the clinical value of cardiorespiratory fitness, normative reference standards are essential. The purpose of this report is to extend previous cardiorespiratory fitness normative standards by providing updated cardiorespiratory fitness reference standards according to cardiovascular disease category and testing modality. Methods and Results The analysis included 15 045 tests (8079 treadmill, 6966 cycle) from FRIEND (Fitness Registry and the Importance of Exercise National Database). Using data from tests conducted January 1, 1974, through March 1, 2021, percentiles of directly measured peak oxygen consumption (VO) were determined for each decade from 30 through 89 years of age for men and women with a diagnosis of coronary artery bypass surgery, myocardial infarction, percutaneous coronary intervention, or heart failure. There were significant differences between sex and age groups for VO (<0.001). The mean VO was 23% higher for men compared with women and VO decreased by a mean of 7% per decade for both sexes. Among each decade, the mean VO from treadmill tests was 21% higher than the VO from cycle tests. Differences in VO were observed among the age groups in both sexes according to cardiovascular disease category. Conclusions This report provides normative reference standards by cardiovascular disease category for both men and women performing cardiopulmonary exercise testing on a treadmill or cycle ergometer. These updated and enhanced reference standards can assist with patient risk stratification and guide clinical care.
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http://dx.doi.org/10.1161/JAHA.121.022336DOI Listing
November 2021

Financial Analysis of Cardiac Rehabilitation and the Impact of COVID-19.

J Cardiopulm Rehabil Prev 2021 09;41(5):308-314

Vermont Center on Behavior and Health, University of Vermont, and Department of Psychiatry, Larner College of Medicine, University of Vermont, Burlington (Drs Melbostad, Gaalema, and Ades and Ms Mahoney); University of Vermont Medical Center, Burlington (Mr Savage and Dr Ades); and The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Dr Shepard).

Purpose: Provision of phase 2 cardiac rehabilitation (CR) has been directly impacted by coronavirus disease-19 (COVID-19). Economic analyses to date have not identified the financial implications of pandemic-related changes to CR. The aim of this study was to compare the costs and reimbursements of CR between two periods: (1) pre-COVID-19 and (2) during the COVID-19 pandemic.

Methods: Health care costs of providing CR were calculated using a microcosting approach. Unit costs of CR were based on staff time, consumables, and overhead costs. Reimbursement rates were derived from commercial and public health insurance. The mean cost and reimbursement/participant were calculated. Staff and participant COVID-19 infections were also examined.

Results: The mean number of CR participants enrolled/mo declined during the pandemic (-10%; 33.8 ± 2.0 vs 30.5 ± 3.2, P = .39), the mean cost/participant increased marginally (+13%; $2897 ± $131 vs $3265 ± $149, P = .09), and the mean reimbursement/participant decreased slightly (-4%; $2959 ± $224 vs $2844 ± $181, P = .70). However, these differences did not reach statistical significance. The pre-COVID mean operating surplus/participant ($62 ± $140) eroded into a deficit of -$421 ± $170/participant during the pandemic. No known COVID-19 infections occurred among the 183 participants and 14 on-site staff members during the pandemic period.

Conclusions: COVID-19-related safety protocols required CR programs to modify service delivery. Results demonstrate that it was possible to safely maintain this critically important service; however, CR program costs exceeded revenues. The challenge going forward is to optimize CR service delivery to increase participation and achieve financial solvency.
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http://dx.doi.org/10.1097/HCR.0000000000000643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436146PMC
September 2021

The Treatment of Obesity in Cardiac Rehabilitation: A REVIEW AND PRACTICAL RECOMMENDATIONS.

J Cardiopulm Rehabil Prev 2021 09;41(5):295-301

Division of Cardiology, Department of Medicine, The University of Vermont, Larner College of Medicine, Burlington.

Background: Cardiac rehabilitation (CR) programs have evolved from exercise-only programs designed to improve cardiorespiratory fitness to secondary prevention programs with a broader mandate to alter lifestyle-related behaviors that control cardiac risk factors and, thereby, reduce overall cardiovascular risk. As the obesity epidemic has evolved in the late 20th and early 21st centuries, the prevalence of type 2 diabetes mellitus and the metabolic syndrome have soared and blunted the otherwise expected downturn in deaths from coronary heart disease related to better control of risk factors. In that the causes of obesity are behavioral in origin, the most effective treatment strategy requires a comprehensive, behavioral-based approach.

Purpose: In this review, we outline optimal lifestyle approaches that can be delivered in the CR setting to assist cardiac patients with their long-term goals of reducing weight and improving cardiac risk factors while concurrently improving cardiorespiratory fitness. We also performed a survey of CR program throughout the United States and found that only 8% currently deliver a behavioral weight programs.

Conclusions: Cardiac rehabilitation programs need to take on an important challenge of secondary prevention, which is to develop behavioral weight loss programs to assist cardiac patients to lose weight and, thereby, improve multiple risk factors and long-term prognosis.
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http://dx.doi.org/10.1097/HCR.0000000000000637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522194PMC
September 2021

Assessment of the Early Disabling Effects of Coronary Artery Bypass Graft Surgery Using Direct Measures of Physical Function.

J Cardiopulm Rehabil Prev 2021 Mar 26. Epub 2021 Mar 26.

Division of Cardiology, Department of Medicine (Mr Rengo, Mr Savage, and Drs Ades and Toth) and Division of Cardiothoracic Surgery, Department of Surgery (Drs Hirashima and Leavitt), College of Medicine, The University of Vermont, Burlington.

Purpose: Coronary artery bypass graft (CABG) surgery is an important treatment option in patients with coronary artery disease. Despite its beneficial effects, CABG surgery and its subsequent hospitalization may reduce physical functional capacity in patients, contributing to physical disability. Our objective was to assess the early disabling effects of CABG surgery and its subsequent hospitalization using direct measurements of physical function.

Methods: Patients (n = 44) were assessed pre-surgery and at hospital discharge for physical function using the Short Physical Performance Battery (SPPB) and self-reported physical and mental health by questionnaire.

Results: The total SPPB score (P < .001) and all of its components (P < .01-.001) decreased markedly following CABG surgery and hospitalization, with greater reductions in total SPPB score (P < .05) and gait speed (P < .01) in patients with higher body mass index. While CABG surgery and hospitalization reduced patient-reported physical function, changes in these indices largely did not correlate with changes in SPPB outcomes.

Conclusion: Our results show the early disabling effects of CABG surgery and hospitalization on directly measured physical function, and that patients with higher body mass index had greater reductions. In addition, our results underscore the need to perform direct measurements of physical function to describe reductions in physiological functional capacity. These findings suggest the need for inpatient rehabilitation or early mobility programs to address this decline in physical function.

Abstract For Toc: This is the first study to evaluate the early disabling effects of coronary artery bypass graft surgery and hospitalization using direct measures of physical function. Although self-reported physical function also decreased, these changes largely did not correlate with direct measures of physical function.
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http://dx.doi.org/10.1097/HCR.0000000000000587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8464611PMC
March 2021

Improvement in Physical Function After Coronary Artery Bypass Graft Surgery Using a Novel Rehabilitation Intervention: A RANDOMIZED CONTROLLED TRIAL.

J Cardiopulm Rehabil Prev 2021 Nov;41(6):413-418

Division of Cardiology, Department of Medicine (Messrs Rengo and Savage Drs Ades and Toth) and Division of Cardiothoracic Surgery, Department of Surgery (Drs Hirashima and Leavitt), College of Medicine, The University of Vermont, Burlington.

Purpose: Cardiorespiratory and skeletal muscle deconditioning occurs following coronary artery bypass graft surgery and hospitalization. Outpatient, phase 2 cardiac rehabilitation (CR) is designed to remediate this deconditioning but typically does not begin until several weeks following hospital discharge. Although an exercise program between discharge and the start of CR could improve functional recovery, implementation of exercise at this time is complicated by postoperative physical limitations and restrictions. Our objective was to assess the utility of neuromuscular electrical stimulation (NMES) as an adjunct to current rehabilitative care following postsurgical discharge and prior to entry into CR on indices of physical function in patients undergoing coronary artery bypass graft surgery.

Methods: Patients were randomized to 4 wk of bilateral, NMES (5 d/wk) to their quadriceps muscles or no intervention (control). Physical function testing was performed at hospital discharge and 4 wk post-discharge using the Short Physical Performance Battery and the 6-min walk tests. Data from 37 patients (19 control/18 NMES) who completed the trial were analyzed. The trial was registered at ClinicalTrials.gov (NCT03892460).

Results: Physical function measures improved from discharge to 4 wk post-surgery across our entire cohort (P < .001). Patients randomized to NMES, however, showed greater improvements in 6-min walk test distance and power output compared with controls (P < .01).

Conclusion: Our results provide evidence supporting the utility of NMES to accelerate recovery of physical function after coronary artery bypass graft surgery.
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http://dx.doi.org/10.1097/HCR.0000000000000576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310525PMC
November 2021

Predictors of Cardiac Rehabilitation Participation: OPPORTUNITIES TO INCREASE ENROLLMENT.

J Cardiopulm Rehabil Prev 2021 09;41(5):322-327

Division of Cardiology, Department of Medicine (Drs Khadanga and Ades and Mr Savage), Vermont Center on Behavior and Health (Drs Khadanga, Gaalema, and Ades and Mr Savage), and Departments of Psychiatry and Psychology (Dr Gaalema), University of Vermont, Burlington.

Purpose: Participation in cardiac rehabilitation (CR) is low despite proven benefits. The aim of this study was to assess medical, psychosocial, and behavioral predictors of participation in a phase 2 CR.

Methods: This was a prospective observational study. Participants hospitalized for an acute cardiac event and eligible for CR completed in-hospital assessments, and the primary outcome was CR participation over a 4-mo follow-up. Measures included age, sex, educational attainment, smoking status, medical diagnosis, ejection fraction, and electronic referral to CR. Data included General Anxiety Disorder, Patient Health Questionnaire, Medical Outcomes Study Short Form-36, Behavioral Rating Inventory of Executive Function, and Duke Social Support Index. Logistic regression and Classification and Regression Tree analysis were performed.

Results: Of 378 hospitalized patients approached, 294 (31% females) enrolled in the study and 175 participated in CR. The presence of electronic referral, surgical diagnosis, non/former smoker, and strength of physician recommendation (all Ps < .02) were independent predictors for CR participation. No differences were seen in participation by measures of anxiety, depression, or executive function. Males with a profile of electronic referral to CR, high school or higher education, ejection fraction >50%, and strong physician recommendation were the most likely cohort to participate in CR (89%). Patients not referred to CR were the least likely to attend (20%).

Conclusions: Lack of CR referral, lower educational attainment, nonsurgical diagnosis, current smoking, and reduced ejection fraction can predict patients at a highest risk of CR nonparticipation. Specific interventions such as electronic referral and a strong in-person recommendation from a medical provider may enhance CR participation rates.
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http://dx.doi.org/10.1097/HCR.0000000000000573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310538PMC
September 2021

Response to Exercise Training During Cardiac Rehabilitation Differs by Sex.

J Cardiopulm Rehabil Prev 2020 09;40(5):319-324

Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington (Messrs Rengo and Savage and Drs Khadanga and Ades); and University of Vermont College of Medicine, Burlington (Drs Khadanga and Ades).

Purpose: Directly measured peak aerobic capacity or oxygen uptake is a powerful predictor of prognosis in individuals with cardiovascular disease. Women enter phase 2 cardiac rehabilitation (CR) with lower and their response to training, compared with men, is equivocal. We analyzed at entry and exit in patients participating in CR and improvements by diagnosis to assess training response. We also identified sex differences that may influence change in .

Methods: The cohort included consecutive patients enrolled in CR between January 1996 and December 2015 who performed entry exercise tolerance tests. Data collected included demographics, index diagnosis, , and exercise training response.

Results: The cohort consisted of 3925 patients (24% female). There was a significant interaction between baseline and diagnosis (P < .001), with percutaneous coronary intervention and myocardial infarction greater than other diagnoses. Surgical patients demonstrated greater improvement in than nonsurgical diagnoses (n = 1789; P < .001). Women had lower than men for all diagnoses (P < .02) and demonstrated less improvement (13 vs 17%, P < .001). Percent improvement using estimated metabolic equivalents of task (METs) were similar for women and men (33 vs 31%, P = NS). Despite overall increases in , 18% of patients (24% women, 16% men) failed to demonstrate any improvement (exit ≤ entry ).

Conclusions: While there were no differences in training effect estimated by METs, directly measured showed a significantly lower training response for women despite adjusting for covariates. In addition, 18% of patients did not see any improvement in . Alternatives to traditional CR exercise programming need to be considered.
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http://dx.doi.org/10.1097/HCR.0000000000000536DOI Listing
September 2020

Effects of Behavioral Weight Loss and Weight Loss Goal Setting in Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2020 11;40(6):383-387

Divisions of Endocrinology, University of Vermont Medical Center, and Larner College of Medicine, University of Vermont, Burlington (Dr Barrett); and Divisions of Cardiology, University of Vermont Medical Center, and Larner College of Medicine, University of Vermont, Burlington (Mr Savage and Dr Ades).

Purpose: Obesity is prevalent among participants in cardiac rehabilitation (CR). Establishing a weight loss goal is an important strategy for promoting weight loss. We evaluate the association between a pre-program weight loss goal and change in weight during CR.

Methods: Body weight was measured at CR entry and at exit from CR. Overweight/obese participants were categorized as having: (1) established a weight loss goal and attended behavioral weight loss sessions (G + BWL); (2) set a weight loss goal but did not attend BWL (G); (3) and neither set a weight loss goal nor attended BWL (NoG).

Results: The cohort consisted of 317 overweight/obese participants; 52 of whom set a weight loss goal and attended BWL, 227 patients set a goal but did not attend BWL, and 38 did neither. The G + BWL group lost more weight than the G group (-6.8 + 4.3 vs -1.1 + 3.5) (P < .0001). Both groups that established a weight loss goal lost more weight than the NoG group.

Conclusions: For overweight/obese individuals in CR, participating in BWL classes and setting a weight loss goal leads to more weight loss than G alone. Setting a weight loss goal alone leads to greater weight loss than not setting a weight loss goal.
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http://dx.doi.org/10.1097/HCR.0000000000000510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647951PMC
November 2020

Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery.

JAMA Cardiol 2019 12;4(12):1250-1259

Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: National guidelines recommend cardiac rehabilitation (CR) after cardiac valve surgery, and CR is covered by Medicare for this indication. However, few data exist regarding current CR enrollment after valve surgery.

Objective: To characterize CR enrollment after cardiac valve surgery and its association with outcomes, including hospitalizations and mortality.

Design, Setting, And Participants: This cohort study of patients undergoing valve surgery was conducted in calendar year 2014, with follow-up through 2015. The study included all fee-for-service Medicare beneficiaries undergoing open cardiac valve surgery in 2014. Patients identified by inpatient diagnosis codes for open aortic, mitral, tricuspid, and pulmonary valve surgery were included. Data analysis occurred from January 2018 to March 2019.

Exposures: Logistic regression was used to evaluate sociodemographic and clinical factors associated with CR enrollment.

Main Outcomes And Measures: We used Andersen-Gill models to evaluate the association of CR enrollment with 1-year hospitalization risk and Cox regression models to evaluate the association of CR enrollment with 1-year mortality risk.

Results: A total of 41 369 Medicare beneficiaries (median [interquartile range] age, 73 [68-79] years; 16 935 [40.9%] female) underwent open valve surgery in the United States in 2014. Fewer than half of patients (17 855 [43.2%]) who had valve surgery enrolled in CR programs. Several racial/ethnic groups had lower odds of enrolling in CR programs after valve surgery compared with white patients, including Asian patients (odds ratio [OR], 0.36 [95% CI, 0.28-0.47]), black patients (OR, 0.60 [95% CI, 0.54-0.67]), and Hispanic patients (OR, 0.36 [95% CI, 0.28-0.46]). Patients undergoing concomitant coronary artery bypass grafting had higher odds of CR enrollment (OR, 1.26 [95% CI, 1.20-1.31]) than those without the concomitant coronary artery bypass graft procedure, as did patients in the Midwest census region (OR, 2.40 [95% CI, 2.28-2.54]) compared with those in the South (reference). Cardiac rehabilitation enrollment was associated with fewer hospitalizations within 1 year of discharge (hazard ratio, 0.66 [95% CI, 0.63-0.69] after multivariable adjustment). Enrollment was also associated with a 4.2% absolute decrease in 1-year mortality risk (hazard ratio, 0.39 [95% CI, 0.35-0.44] after multivariable adjustment).

Conclusions And Relevance: Fewer than half of Medicare beneficiaries undergoing cardiac valve surgery enroll in CR programs, and there are marked racial/ethnic disparities among those that do. Cardiac rehabilitation is associated with decreased 1-year cumulative hospitalization and mortality risk after valve surgery. These results invite further study on barriers to CR enrollment in this population.
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http://dx.doi.org/10.1001/jamacardio.2019.4032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813589PMC
December 2019

Resistance Training for Older Adults in Cardiac Rehabilitation.

Clin Geriatr Med 2019 11 3;35(4):459-468. Epub 2019 Jul 3.

Department of Medicine, Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, 62 Tilley Drive, South Burlington, VT 05403, USA.

Cardiac rehabilitation plays a key role in the care of older patients after a coronary event. Hospitalizations are prevented and quality of life, exercise capacity, and physical function are improved. Almost 50% of cardiac rehabilitation participants are older adults (>65 years), many of whom are frail or deconditioned. Resistance training, as a component of cardiac rehabilitation, improves muscle strength, endurance, and physical function. The purpose of this review is to describe the effects of resistance training in cardiac rehabilitation for older adults with a particular focus on physical function.
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http://dx.doi.org/10.1016/j.cger.2019.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237336PMC
November 2019

What and Where in the World Is Cardiac Rehabilitation?

Authors:
Patrick D Savage

EClinicalMedicine 2019 Aug 2;13:2-3. Epub 2019 Jul 2.

University of Vermont, Burlington, United States.

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http://dx.doi.org/10.1016/j.eclinm.2019.06.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733994PMC
August 2019

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial.

JACC Heart Fail 2019 07 8;7(7):537-546. Epub 2019 May 8.

Division of Cardiology, University of Vermont Medical Center, Burlington, Vermont.

Objectives: This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).

Background: Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events.

Methods: A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year.

Results: Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079).

Conclusions: Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).
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http://dx.doi.org/10.1016/j.jchf.2018.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599560PMC
July 2019

Clinical and Demographic Trends in Cardiac Rehabilitation: 1996-2015.

J Cardiopulm Rehabil Prev 2019 07;39(4):266-273

University of Vermont College of Medicine, Burlington (Drs Gaalema, Naud, Priest, and Ades); and University of Vermont Medical Center, Burlington (Messrs Savage and Rengo and Drs Leadholm and Ades).

Purpose: Clinical interventions in programs such as cardiac rehabilitation (CR) are guided by clinical characteristics of participating patients. This study describes changes in CR participant characteristics over 20 yr.

Methods: To examine changes in patient characteristics over time, we analyzed data from 1996 to 2015 (n = 5396) garnered from a systematically and prospectively gathered database. Linear, logistic, multinomial logistic or negative binomial regression was used, as appropriate. Effects of sex and index diagnosis were considered both as interactions and as additive effects.

Results: Analyses revealed that mean age increased (from 60.7 to 64.2 yr), enrollment of women increased (from 26.8% to 29.6%), and index diagnosis has shifted; coronary artery bypass surgery decreased (from 37.2% to 21.6%), whereas heart valve repair/replacement increased (from 0% to 10.6%). Risk factors also shifted with increases in body mass index (28.7 vs 29.6 kg/m), obesity (from 33.2% to 39.6%), hypertension (from 51% to 62.5%), type 2 diabetes mellitus (from 17.3% to 21.7%), and those reporting current smoking (from 6.6% to 8.4%). Directly measured peak aerobic capacity remained relatively stable throughout. The proportion of patients on statin therapy increased from 63.6% to 98.9%, coinciding with significant improvements in lipid levels.

Conclusions: Compared with 1996, participants entering CR in 2015 were older, more overweight, and had a higher prevalence of coronary risk factors. Lipid values improved substantially concurrent with increased statin use. While the percentage of female participants increased, they continue to be underrepresented. Patients with heart valve repair/replacement now constitute 10.6% of the patients enrolled. Clinical programs need to recognize changing characteristics of attendees to best tailor interventions.
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http://dx.doi.org/10.1097/HCR.0000000000000390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594875PMC
July 2019

Progression of Exercise Training in Early Outpatient Cardiac Rehabilitation: AN OFFICIAL STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION.

J Cardiopulm Rehabil Prev 2018 05;38(3):139-146

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (Dr Squires); Fisher Institute of Health and Well-Being, Clinical Exercise Physiology Laboratory, Ball State University, Muncie, Indiana (Dr Kaminsky); Department of Exercise and Sport Science, University of Wisconsin-LaCrosse, LaCrosse, Wisconsin (Dr Porcari); Guerrieri Heart & Vascular Institute, Peninsula Regional Medical Center, Salisbury, Maryland (Ms Ruff); Cardiac Rehabilitation, University of Vermont Medical Center, Burlington, Vermont (Mr Savage); and Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska (Dr Williams).

Aerobic and resistance exercise training is a cornerstone of early outpatient cardiac rehabilitation (CR) and provides impressive benefits for patients. The components of the exercise prescription for patients with cardiovascular diseases are provided in guideline documents from several professional organizations and include frequency (how many sessions per week); intensity (how hard to exercise); time (duration of the exercise training session); type (modalities of exercise training); volume (the total amount or dose of exercise); and progression (the rate of increasing the dose of exercise). The least discussed, least appreciated, and most challenging component of the exercise prescription for CR health care professionals is the rate of progression of the dose of exercise. One reason for this observation is the heterogeneity of patients who participate in CR. All components of the exercise prescription should be developed specifically for each individual patient. This statement provides an overview of the principles of exercise prescription for patients in CR with special emphasis on the rate of progression. General recommendations for progression are given and patient case examples are provided to illustrate the principles of progression in exercise training.
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http://dx.doi.org/10.1097/HCR.0000000000000337DOI Listing
May 2018

Cardiac Rehabilitation Participation Rates and Outcomes for Patients With Heart Failure.

J Cardiopulm Rehabil Prev 2018 01;38(1):38-42

Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington (Messrs Rengo and Savage and Dr Ades); and University of Vermont College of Medicine, Burlington (Drs Barrett and Ades).

Purpose: Exercise training has been shown to reduce combined cardiovascular mortality and hospitalizations in patients with chronic heart failure (CHF) with reduced ejection fraction (HFrEF). Whereas there are extensive data on exercise training for individuals with HFrEF in a research setting, the experience of delivering cardiac rehabilitation (CR) services in the clinical setting has not been well described. With little knowledge regarding the number of qualifying patients with HFrEF in the United States, we described our 18-month experience recruiting hospitalized inpatients and stable outpatients into phase 2 CR.

Methods: Patients hospitalized with CHF HFrEF were tracked for enrollment in CR. Exercise training response was described for patients identified as inpatients and for stable HFrEF outpatients referred from cardiology clinic or heart failure clinic.

Results: The cohort included 83 patients hospitalized with CHF and 36 outpatients. Only 17% (14/83) of eligible HFrEF inpatients enrolled in CR following CHF hospitalization compared with 97% (35/36) outpatient referrals. Improvements in aerobic capacity for the total cohort were observed whether expressed as estimated metabolic equivalents (n = 19, 4.6 ± 1.6 to 6.2 ± 2.4, P < .0001) or (Equation is included in full-text article.)O2peak (n = 14, 14.4 ± 3.5 to 16.4 ± 4.6 mL/kg/min, P = .02) for those who completed CR.

Conclusion: Significant barriers to recruiting and enrolling patients with HFrEF were observed and only 17% of inpatients attended CR. Systematic in-hospital referral with close followup in the outpatient setting has the potential to capture more eligible patients. The participation of referred stable outpatients with HFrEF was much higher. Regardless of the referral source, patients with HFrEF completing CR can expect improvements in aerobic capacity, muscle strength, and depressive symptoms.
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http://dx.doi.org/10.1097/HCR.0000000000000252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741463PMC
January 2018

Obesity in coronary heart disease: An unaddressed behavioral risk factor.

Prev Med 2017 Nov 13;104:117-119. Epub 2017 Apr 13.

University of Vermont College of Medicine, Division of Cardiology, Burlington, VT 05405, United States.

Obesity is an independent risk factor for the development and progression of coronary heart disease (CHD). Over 80% of patients with CHD are overweight or obese. While obesity is often considered a relatively "minor" CHD risk factor, weight loss is a broadly effective risk-factor intervention. Weight loss can profoundly influence a number of "major" risk factors including: hypertension, dyslipidemia and insulin resistance/type 2 diabetes mellitus. Despite its prominence as a risk factor most cardiac rehabilitation (CR) programs do not have a specific, targeted intervention to assist patients with weight loss. Consequently, the weight loss that occurs during CR is quite small and unlikely to appreciably alter risk factors. Relying on CR associated exercise as a sole intervention is an ineffective strategy to promote weight loss. There is evidence, however, that behavioral weight loss (BWL) interventions can be effectively employed in the CR setting. In contrast to programs that do not offer a targeted intervention, studies show that participants in CR-related BWL programs lose significantly more weight. The additional weight loss from the BWL intervention is associated with greater improvements in insulin sensitivity and other components of the metabolic syndrome such as hypertension and lipid abnormalities. As a means of maximizing CHD risk factor reduction CR programs need to incorporate BWL programs as a standard programming for overweight/obese patients.
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http://dx.doi.org/10.1016/j.ypmed.2017.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640469PMC
November 2017

Directly Measured Physical Function in Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2017 May;37(3):175-181

Division of Cardiology, Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, Burlington (Messrs Rengo and Savage, Ms Shaw, and Dr Ades); and University of Vermont College of Medicine, Burlington (Dr Ades).

Purpose: The Short Physical Performance Battery (SPPB) is a strong predictor for risk of physical disability in older adults. Roughly half of individuals participating in phase II cardiac rehabilitation (CR) are 65 years or older, many presenting with low aerobic capacities and may be at increased risk for physical disability.

Methods: The cohort consisted of 196 consecutive patients (136 men), aged 65 years or older, entering CR who were prospectively evaluated by the SPPB. Data were also obtained for age, self-reported physical function (Medical Outcomes Study Short Form-36 questionnaire), and peak aerobic capacity. Measures were repeated upon completion of CR for those individuals who completed the program.

Results: The average age of patients was 74 ± 0.5 years. At baseline, total SPPB score was 9.7 ± 0.2 (out of 12). Followup data were obtained on 133 (68%) patients, with a mean improvement of 0.8 ± 0.1 (P < .0001), which was not clinically significant (≥1 point). Focusing on patients with a low baseline SPPB score, 72 subjects scored ≤9 (7.1 ± 0.2), with 45 completing exit measures. Improvements were found in gait speed (0.5 ± 0.1, P < .0001), chair-stand (1.0 ± 0.1, P < .0001), and total SPPB (1.6 ± 0.3, P < .0001) in this more disabled group. Measures of (Equation is included in full-text article.)O2peak were significantly reduced in the low SPPB group (13.5 ± 0.4 vs 17.5 ± 0.4 mL/kg/min, P < .0001). Measured (Equation is included in full-text article.)O2peak (R = 26%, P < .0001) and self-reported physical function score (R = 5%, P = .02) were the only multivariate predictors of baseline SPPB.

Conclusion: For patients who enter CR with low SPPB scores (37%), significant improvements in physical function were noted, largely explained by improved walking speed and leg strength (chair-stand).
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http://dx.doi.org/10.1097/HCR.0000000000000231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407931PMC
May 2017

Moderate-intensity resistance exercise alters skeletal muscle molecular and cellular structure and function in inactive older adults with knee osteoarthritis.

J Appl Physiol (1985) 2017 Apr 12;122(4):775-787. Epub 2017 Jan 12.

Department of Medicine, University of Vermont, Burlington, Vermont.

High-intensity resistance exercise (REX) training increases physical capacity, in part, by improving muscle cell size and function. Moderate-intensity REX, which is more feasible for many older adults with disease and/or disability, also increases physical function, but the mechanisms underlying such improvements are not understood. Therefore, we measured skeletal muscle structure and function from the molecular to the tissue level in response to 14 wk of moderate-intensity REX in physically inactive older adults with knee osteoarthritis ( = 17; 70 ± 1 yr). Although REX training increased quadriceps muscle cross-sectional area (CSA), average single-fiber CSA was unchanged because of reciprocal changes in myosin heavy chain (MHC) I and IIA fibers. Intermyofibrillar mitochondrial content increased with training because of increases in mitochondrial size in men, but not women, with no changes in subsarcolemmal mitochondria in either sex. REX increased whole muscle contractile performance similarly in men and women. In contrast, adaptations in single-muscle fiber force production per CSA (i.e., tension) and contractile velocity varied between men and women in a fiber type-dependent manner, with adaptations being explained at the molecular level by differential changes in myosin-actin cross-bridge kinetics and mechanics and single-fiber MHC protein expression. Our results are notable compared with studies of high-intensity REX because they show that the effects of moderate-intensity REX in older adults on muscle fiber size/structure and myofilament function are absent or modest. Moreover, our data highlight unique sex-specific adaptations due to differential cellular and subcellular structural and functional changes. Moderate-intensity resistance training causes sex-specific adaptations in skeletal muscle structure and function at the cellular and molecular levels in inactive older adult men and women with knee osteoarthritis. However, these responses were minimal compared with high-intensity resistance training. Thus adjuncts to moderate-intensity training need to be developed to correct underlying cellular and molecular structural and functional deficits that are at the root of impaired physical function in this mobility-limited population.
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http://dx.doi.org/10.1152/japplphysiol.00830.2016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407204PMC
April 2017

Patient Characteristics Predictive of Cardiac Rehabilitation Adherence.

J Cardiopulm Rehabil Prev 2017 Mar;37(2):103-110

Vermont Center on Behavior and Health, Burlington (Drs Gaalema, Higgins, and Ades, Mr Cutler, and Ms Elliott); Departments of Psychiatry (Drs Gaalema and Higgins, Mr Cutler, and Ms Elliott), Psychology (Drs Gaalema and Higgins), and Medical Biostatistics (Mr Savage and Rengo and Dr Ades), University of Vermont, Burlington; and Department of Medicine, University of Vermont Medical Center, Burlington (Dr Priest).

Purpose: Cardiac rehabilitation (CR) is a program of structured exercise and interventions for coronary risk factor reduction that reduces morbidity and mortality rates following a major cardiac event. Although a dose-response relationship between the number of CR sessions completed and health outcomes has been demonstrated, adherence with CR is not high. In this study, we examined associations between the number of sessions completed within CR and patient demographics, clinical characteristics, smoking status, and socioeconomic status (SES).

Methods: Multiple logistic regression and classification and regression tree (CART) modeling were used to examine associations between participant characteristics measured at CR intake and the number of sessions completed in a prospectively collected CR clinical database (n = 1658).

Results: Current smoking, lower SES, nonsurgical diagnosis, exercise-limiting comorbidities, and lower age independently predicted fewer sessions completed. The CART analysis illustrates how combinations of these characteristics (ie, risk profiles) predict the number of sessions completed. Those with the highest-risk profile for nonadherence (<65 years old, current smoker, lower SES) completed on average 9 sessions while those with the lowest-risk profile (>72 years old, not current smoker, higher SES, surgical diagnosis) completed 27 sessions on average.

Conclusions: Younger individuals, as well as those who report smoking or economic challenges or have a nonsurgical diagnosis, may require additional support to maintain CR session attendance.
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http://dx.doi.org/10.1097/HCR.0000000000000225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5322217PMC
March 2017

Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients.

Prev Med 2016 11 15;92:47-50. Epub 2016 Feb 15.

Vermont Center on Behavior and Health, University of Vermont, United States; Department of Medicine, Division of Cardiology, University of Vermont Medical Center, United States.

Purpose: Cardiac rehabilitation (CR) improves medical outcomes after myocardial infarction or coronary revascularization. Lower socioeconomic status (SES) patients are less likely to participate in and complete CR. The aim of this study was to test whether financial incentives may increase participation and adherence to CR among lower-SES patients.

Methods: Patients eligible to participate in CR with Medicaid insurance coverage were approached for inclusion. Patients were placed on an escalating incentive schedule of financial incentives contingent upon CR attendance. CR participation was compared to a usual care group of 101 Medicaid patients eligible for CR in the 18months prior to the study. Attendance (participating in ≥one CR sessions) and adherence (sessions completed out of 36) were compared between groups. The study was conducted in Vermont, USA, 2013-2015.

Results: Of 13 patients approached to be in the study and receive incentives, 10 (77%) agreed to participate. All 10 patients completed at least one session of CR, significantly greater than the 25/101 (25%) in the control condition (p<0.001). Of patients in both groups who attended at least one session of CR, adherence was higher in the intervention group (average of 31.1 sessions completed vs. 13.6 in the control group, p<0.001). CR completion rates were also higher during the intervention with 8 of 10 (80%) intervention patients completing all 36 sessions compared to only 2 of 25 (8%) control patients (p<0.001).

Conclusions: Financial incentives may be an efficacious strategy for increasing CR participation and adherence among Medicaid patients.
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http://dx.doi.org/10.1016/j.ypmed.2015.11.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4985497PMC
November 2016

Assessing Physical Activity as a Core Component in Cardiac Rehabilitation: A POSITION STATEMENT OF THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION.

J Cardiopulm Rehabil Prev 2016 Jul-Aug;36(4):217-29

Fisher Institute of Health and Well-Being, Ball State University, Muncie, Indiana (Dr Kaminsky); Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina (Dr Brubaker); University of Milano, San Paolo Hospital, Milan, Italy (Dr Guazzi); Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana (Dr Lavie); Clinical Exercise Physiology Program, Ball State University, Muncie, Indiana (Dr Montoye); School of Nursing, Auburn University, Auburn, Alabama (Dr Sanderson); Divisions of Cardiology, University of Vermont Medical Center, Burlington (Mr Savage).

Physical inactivity is a well-established major risk factor for cardiovascular disease. As such, physical activity counseling is 1 of the 10 core components of cardiac rehabilitation/secondary prevention programs recommended by the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). In addition, the ability to perform a physical activity assessment and report outcomes is 1 of the 10 core competencies of cardiac rehabilitation/secondary prevention professionals published by the AACVPR. Unfortunately, standardized procedures for physical activity assessment of cardiac rehabilitation patients have not been developed and published. Thus, the objective of this AACVPR statement is to provide an overview of physical activity assessment concepts and procedures and to provide a recommended approach for performing a standardized assessment of physical activity in all comprehensive cardiac rehabilitation programs following the core components recommendations.
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http://dx.doi.org/10.1097/HCR.0000000000000191DOI Listing
December 2017

Fitness during Breast Cancer Treatment and Recovery in an Athlete: A Case Study.

Med Sci Sports Exerc 2016 10;48(10):1893-7

1Hematology and Oncology, University of Vermont Medical Center, Burlington, VT; and 2Department of Clinical Cancer Prevention and Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: This is a case study of an aerobically trained, multisport, female athlete (age = 39) diagnosed with stage IIIc human epidermal growth factor receptor 2 positive breast cancer. The focus of the study is on measures of cardiorespiratory fitness (V˙O2peak) through the course of cancer therapy.

Methods: A symptom-limited cardiopulmonary exercise tolerance test was performed to determine V˙O2peak. The tests were performed at five different time points: 1) at diagnosis of breast cancer and before initiating chemotherapy, 2) after completion of chemotherapy (5 months postdiagnosis), 3) 2.5 months after bilateral mastectomy surgery (9 months postdiagnosis), 4) immediately after radiation therapy (11 months postdiagnosis), and 5) recovery (32 months postdiagnosis).

Results: At diagnosis and before initiating chemotherapy, V˙O2peak was 50.1 mL O2·min·kg. The most precipitous decline in fitness, approximately 14%, was observed from initial diagnosis through the completion of chemotherapy. The subject regained 9% of her fitness after chemotherapy, despite an intervening mastectomy surgery. Radiation therapy was associated with an approximately 4% decline in fitness from her postmastectomy surgery value. Ultimately, 32 months after diagnosis and 22 months after the completion of radiation therapy, the subject was able to regain pretreatment fitness levels.

Conclusion: The results of the case study describe the effects of undergoing extensive breast cancer therapy on measures of V˙O2peak for a highly aerobically trained, multisport athlete. In this case, exercise training reversed the decrement in measured V˙O2peak that occurred during cancer therapy.
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http://dx.doi.org/10.1249/MSS.0000000000000987DOI Listing
October 2016

Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation.

J Cardiopulm Rehabil Prev 2016 Sep-Oct;36(5):331-8

Department of Medicine, Division of Cardiology, University of Vermont Medical Center, Burlington.

Purpose: The goal of this study was to determine the prevalence of insulin resistance (IR) and type 2 diabetes mellitus (T2DM) in contemporary cardiac rehabilitation (CR) and to compare clinical responses in CR between these subsets of patients with coronary heart disease (CHD).

Methods: The study cohort included 818 patients enrolled in CR and separated into 3 groups: (1) individuals with normal hemoglobin A1c (HbA1c) (NoIR: HbA1c < 5.7%); (2) individuals with IR (IR: HbA1c ≥ 5.7 to <6.5%); (3) and individuals with T2DM (HbA1c ≥ 6.5%).

Results: The combined prevalence of IR (44%) and T2DM (23%) was 67%, which paralleled the prevalence of metabolic syndrome (MetSyn), present in 65% of patients. Women had a higher prevalence of IR and MetSyn than men (73% vs 64%, 72% vs. 63%, respectively) and a greater percentage with an elevated waist circumference (71% vs 60%) (all P < .05). All 3 groups experienced decreases in body weight (NoIR = -2.3 ± 4.0, IR = -1.7 ± 4.0, T2DM = -1.0 ± 4.2 kg) and increases in maximal metabolic equivalents (METs) at exercise testing (NoIR = +2.2 ± 2.5 vs IR = +2.1 ± 2.8 vs T2DM = +1.3 ± 2.3) (all P < .05). Individuals with NoIR achieved greater improvements in weight, body mass index, and METs than patients with T2DM (all P < .05). Selected individuals who participated in a 4-session behavioral weight-loss program lost more than twice the weight as nonparticipants.

Conclusions: The combined prevalence of IR and T2DM in patients with CHD enrolled in CR was remarkably high (67%). To reverse the deleterious consequences of IR and T2DM, targeted interventions involving exercise and weight loss need to be a central focus of CR programming.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5048191PMC
http://dx.doi.org/10.1097/HCR.0000000000000187DOI Listing
December 2017

Skeletal muscle ultrastructure and function in statin-tolerant individuals.

Muscle Nerve 2016 Feb 9;53(2):242-51. Epub 2015 Dec 9.

Department of Medicine, University of Vermont, College of Medicine, Burlington, Vermont, USA.

Introduction: Statins have well-known benefits on cardiovascular mortality, though up to 15% of patients experience side effects. With guidelines from the American Heart Association, American College of Cardiology, and American Diabetes Association expected to double the number of statin users, the overall incidence of myalgia and myopathy will increase.

Methods: We evaluated skeletal muscle structure and contractile function at the molecular, cellular, and whole tissue levels in 12 statin tolerant and 12 control subjects.

Results: Myosin isoform expression, fiber type distributions, single fiber maximal Ca(2+) -activated tension, and whole muscle contractile force were similar between groups. No differences were observed in myosin-actin cross-bridge kinetics in myosin heavy chain I or IIA fibers.

Conclusions: We found no evidence for statin-induced changes in muscle morphology at the molecular, cellular, or whole tissue levels. Collectively, our data show that chronic statin therapy in healthy asymptomatic individuals does not promote deleterious myofilament structural or functional adaptations.
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http://dx.doi.org/10.1002/mus.24722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673037PMC
February 2016

Chronic disuse and skeletal muscle structure in older adults: sex-specific differences and relationships to contractile function.

Am J Physiol Cell Physiol 2015 Jun 25;308(11):C932-43. Epub 2015 Mar 25.

Department of Medicine, College of Medicine, University of Vermont, Burlington, Vermont; Department of Molecular Physiology and Biophysics, College of Medicine, University of Vermont, Burlington, Vermont; and

In older adults, we examined the effect of chronic muscle disuse on skeletal muscle structure at the tissue, cellular, organellar, and molecular levels and its relationship to muscle function. Volunteers with advanced-stage knee osteoarthritis (OA, n = 16) were recruited to reflect the effects of chronic lower extremity muscle disuse and compared with recreationally active controls (n = 15) without knee OA but similar in age, sex, and health status. In the OA group, quadriceps muscle and single-fiber cross-sectional area were reduced, with the largest reduction in myosin heavy chain IIA fibers. Myosin heavy chain IIAX fibers were more prevalent in the OA group, and their atrophy was sex-specific: men showed a reduction in cross-sectional area, and women showed no differences. Myofibrillar ultrastructure, myonuclear content, and mitochondrial content and morphology generally did not differ between groups, with the exception of sex-specific adaptations in subsarcolemmal (SS) mitochondria, which were driven by lower values in OA women. SS mitochondrial content was also differently related to cellular and molecular functional parameters by sex: greater SS mitochondrial content was associated with improved contractility in women but reduced function in men. Collectively, these results demonstrate sex-specific structural phenotypes at the cellular and organellar levels with chronic disuse in older adults, with novel associations between energetic and contractile systems.
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http://dx.doi.org/10.1152/ajpcell.00014.2015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451348PMC
June 2015

Remission of recently diagnosed type 2 diabetes mellitus with weight loss and exercise.

J Cardiopulm Rehabil Prev 2015 May-Jun;35(3):193-7

Divisions of Cardiology (Dr Ades and Mr Savage), Endocrinology (Dr Marney), and Nutrition and Food Sciences (Dr Harvey and Ms Evans), University of Vermont Medical Center, Burlington, Vermont.

Purpose: To determine the rate of remission of recently diagnosed (<1 year) type 2 diabetes mellitus (T2DM) in overweight/obese individuals, with a 6-month program of weight loss and exercise.

Methods: Subjects (N = 12) were overweight/obese (body mass index = 35.8 ± 4.3 kg/m), sedentary, and unfit ((Equation is included in full-text article.)O2peak = 20.7 ± 4.7 mL·kg·min) and recently (<1 year) diagnosed with T2DM. They were willing to participate in a lifestyle program of behavioral weight loss counseling and supervised exercise located at a cardiac rehabilitation program prior to consideration of diabetes medications. Glycated hemoglobin (HbA1c) level before and after the study intervention was the primary study outcome, along with secondary metabolic, fitness, and body composition variables.

Results: Subjects had a baseline HbA1c of 6.5% to 8.0% (mean 6.8 ± 0.2). Subjects lost 9.7 ± 0.2 kg body weight (9%) and improved peak aerobic capacity by 18%. Two subjects withdrew for medical reasons unrelated to the lifestyle program. Eight of 10 completers (80%) went into partial T2DM remission, with the mean HbA1c decreasing from 6.8 ± 0.2% to 6.2 ± 0.3% (P < .001).

Conclusions: For individuals with recently diagnosed T2DM willing to undertake a formal lifestyle program, 80% of study completers and 67% of our total population achieved at least a partial T2DM remission at 6 months. Further study of this intervention at the time of diagnosis of T2DM with randomized controls and longer-term followup is warranted.
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http://dx.doi.org/10.1097/HCR.0000000000000106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4409919PMC
January 2016

Cardiac Rehabilitation After Heart Valve Surgery: COMPARISON WITH CORONARY ARTERY BYPASS GRAFT PATIENTS.

J Cardiopulm Rehabil Prev 2015 Jul-Aug;35(4):231-7

Cardiac Rehabilitation and Prevention, Division of Cardiology, University of Vermont Medical Center, Burlington, Vermont.

Purpose: Coronary artery bypass graft (CABG) surgery patients participating in cardiac rehabilitation (CR) experience improvements in aerobic fitness, but there has been little study of outcomes for heart valve (HV) surgical patients. The primary aims of this study were to evaluate baseline peak aerobic capacity for HV patients participating in CR and to compare outcomes between HV and CABG patients.

Methods: Five hundred seventy-six consecutive patients who underwent HV surgery (n = 125), HV plus CABG surgery (n = 57), or CABG surgery (n = 394), all with classic sternotomy and enrolled in CR, were prospectively studied. Changes in outcomes were assessed for individuals who completed CR (n = 313).

Results: HV patients were significantly older and had a greater percentage of females than the CABG-only group. Combining HV and HV + CABG groups, valvular disorders included 134 mitral, 39 aortic, and 8 combined abnormalities (mitral and aortic). For the entire cohort, the mean number of CR exercise sessions attended was 23.6 ± 11.7. Peak oxygen uptake ((Equation is included in full-text article.)) increased 19.5% from 17.4 ± 4.4 to 20.8 ± 5.5 mLO2·kg(-1)·min(-1) (P < .0001). Improvement in peak (Equation is included in full-text article.)with CR exercise training was similar between the 3 groups of patients. Within the group of patients who had HV surgery, percentage change in peak (Equation is included in full-text article.)was not significantly different between the 3 types of valvular abnormalities (ie, mitral [19.2%], aortic [24.4%], and mitral + aortic [21.9%]).

Conclusions: HV surgery patients achieve similar improvement in aerobic fitness from participating in CR exercise training as individuals who had CABG. The observed improvements in aerobic fitness are similar, regardless of the type of valve abnormality or whether CABG was performed concurrently.
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http://dx.doi.org/10.1097/HCR.0000000000000104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483139PMC
March 2016

Exercise-based oncology rehabilitation: leveraging the cardiac rehabilitation model.

J Cardiopulm Rehabil Prev 2015 Mar-Apr;35(2):130-9

Department of Internal Medicine, Vermont Center on Behavior and Health, (Drs Dittus, Lakoski, and Ades), Department of Rehabilitation and Movement Science (Mr Kokinda), Department of Internal Medicine and Molecular Physiology and Biophysics (Dr Toth), and Department of Internal Medicine (Dr O'Brien), University of Vermont, Burlington; and Fletcher Allen Health Care (Mr Savage, Ms Stevens, and Ms Woods).

Purpose: The value of exercise and rehabilitative interventions for cancer survivors is increasingly clear, and oncology rehabilitation programs could provide these important interventions. However, a pathway to create oncology rehabilitation has not been delineated. Community-based cardiac rehabilitation (CR) programs staffed by health care professionals with experience in providing rehabilitation and secondary prevention services to individuals with coronary heart disease are widely available and provide a potential model and location for oncology rehabilitation programs. Our purpose was to outline the rehabilitative needs of cancer survivors and demonstrate how oncology rehabilitation can be created using a CR model.

Methods: We identify the impairments associated with cancer and its therapy that respond to rehabilitative interventions. Components of the CR model that would benefit cancer survivors are described. An example of an oncology rehabilitation program using a CR model is presented.

Results: Cancer survivors have impairments associated with cancer and its therapy that improve with rehabilitation. Our experience demonstrates that effective rehabilitation services can be provided utilizing an existing CR infrastructure. Few adjustments to current CR models would be needed to provide oncology rehabilitation. Preliminary evidence suggests that cancer survivors participating in an oncology rehabilitation program experience improvements in psychological and physiologic parameters.

Conclusions: Utilizing the CR model of rehabilitative services and disease management provides a much needed mechanism to bring oncology rehabilitation to larger numbers of cancer survivors.
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http://dx.doi.org/10.1097/HCR.0000000000000091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342296PMC
November 2015

Muscle disuse alters skeletal muscle contractile function at the molecular and cellular levels in older adult humans in a sex-specific manner.

J Physiol 2014 Oct 18;592(20):4555-73. Epub 2014 Jul 18.

Department of Medicine, College of Medicine, University of Vermont, Burlington, VT, USA Department of Molecular Physiology and Biophysics, College of Medicine, University of Vermont, Burlington, VT, USA

Physical inactivity that accompanies ageing and disease may hasten disability by reducing skeletal muscle contractility. To characterize skeletal muscle functional adaptations to muscle disuse, we compared contractile performance at the molecular, cellular and whole‐muscle levels in healthy active older men and women (n = 15) and inactive older men and women with advanced‐stage, symptomatic knee osteoarthritis (OA) (n = 16). OA patients showed reduced (P < 0.01) knee extensor function. At the cellular level, single muscle fibre force production was reduced in OA patients in myosin heavy chain (MHC) I and IIA fibres (both P < 0.05) and differences in IIA fibres persisted after adjustments for fibre cross‐sectional area (P < 0.05). Although no group differences in contractile velocity or power output were found for any fibre type, sex was found to modify the effect of OA, with a reduction in MHC IIA power output and a trend towards reduced shortening velocity in women, but increases in both variables in men (P < 0.05 and P = 0.07, respectively). At the molecular level, these adaptations in MHC IIA fibre function were explained by sex‐specific differences (P ≤ 0.05) in myosin–actin cross‐bridge kinetics. Additionally, cross‐bridge kinetics were slowed in MHC I fibres in OA patients (P < 0.01), attributable entirely to reductions in women with knee OA (P < 0.05), a phenotype that could be reproduced in vitro by chemical modification of protein thiol residues. Our results identify molecular and cellular functional adaptations in skeletal muscle that may contribute to reduced physical function with knee OA‐associated muscle disuse, with sex‐specific differences that may explain a greater disposition towards disability in women.
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http://dx.doi.org/10.1113/jphysiol.2014.279034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287744PMC
October 2014
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