A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: A secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study

Background Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. Methods In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg −1 min −1 and peak oxygen consumption (VO 2 peak) >16 ml kg −1 min −1, cut-points that represent a reduced risk of postoperative complications. Results Five questions were identified to have dominance in predicting AT>11 ml kg −1 min −1 and VO 2 peak>16 ml.kg −1min −1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg −1.min −1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO 2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO 2 peak>16 ml.kg −1.min −1 and VO 2 peak<16 ml.kg −1.min −1. Conclusions The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management

The effects of acute dynamic exercise on haemostasis in first class Scottish football referees

Purpose Physical fitness may confer protection from thrombosis; however, exercise-induced platelet activation may be involved in the triggering of acute vascular events. This study aimed to assess haemostatic responses to acute exercise in trained and sedentary middle-aged subjects. Methods 21 first class Scottish football referees and 15 sedentary controls performed a treadmill exercise test. Blood sampling was performed before, immediately after and 30 minutes post-exercise. Samples were analysed for platelet count, prothrombin time, activated partial thromboplastin time (APTT) and serum fibrinogen. Platelet activation was assessed using flow cytometry with CD62 (P-selectin) and antifibrinogen antibodies at rest and in response to ADP and epinephrine. Results Total platelet count (x 10(-9)/l) increased immediately post-exercise (228.2 (40.5), 278.6 (48.9) p = 0.001) remaining elevated at 30 minutes in both groups. APTT (s) was reduced immediately post-exercise (32.15 (3.1), 29.7 (3.94) p = 0.001) with a further reduction seen at 30 minutes (32.15 (3.1), 28.4 (3.31) p = 0.001). In the referees, percentage CD62 expression increased immediately post-exercise (0.688 (0.52), 1.42 (1.3) p = 0.008). Percentage antifibrinogen expression increased post-exercise (5.19 (4.31), 13.01 (14.24) p = 0.017), with a further increase at 30 minutes (5.19 (4.31), 20.47 (26.8) p = 0.02). Conclusion This study suggests that in an older athletic population, physical fitness does not protect against the prothrombotic effects of exercise. Our data would suggest that during a football match when referees achieve approximately 80% of peak VO2 (23) they may be at risk of significant platelet activation. Prophylactic platelet inhibition should be considered in this group after appropriate screening and risk stratificatio

Exercise consultation improves short-term adherence to exercise during phase iv cardiac rehabilitation: a randomized controlled trial

This randomized-controlled trial demonstrates that an exercise consultation, based on the transtheoretic model of exercise behavior change, significantly improves short-term adherence to exercise

Management strategies in unstable coronary artery disease: current problems and future perspectives.

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A randomised controlled trial of deferred stenting versus immediate stenting to prevent no-reflow in acute ST-elevation myocardial infarction

Background: In primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI), no-reflow after stenting may cause heart failure acutely and in the longer term. Currently there are no evidence-based treatments for no-reflow. We hypothesised that after initial reperfusion, deferral of stent implantation, might reduce no-reflow and its sequelae compared to usual care with immediate stenting. Methods: A prospective single centre randomised controlled trial in consecutive STEMI patients. Patients with risk factors for no-reflow were eligible if TIMI 3 flow had been established by initial aspiration thrombectomy and/or balloon angioplasty. Randomisation was to deferred stenting (DS, 4–16 h later) or usual care with immediate stenting (IS). The primary end-point was the incidence of no-reflow (TIMI 0/1 flow). MRI was performed two days post-MI and all patients had prospective follow-up. Results: Of 451 consecutive STEMI patients treated in our centre (11 March–21 November 2012), 101 patients were randomised (n=52 DS, n=49 IS). Compared with usual care, no-reflow was less frequent in the DS group: 0.0% vs. 10% (p=0.005), as were intra-procedural thrombotic events (IPTEs), 14% vs. 41% (p=0.003), and microvascular obstruction was revealed by MRI, 44% vs. 59% (p=0.36). Conclusion: For the first time we have found that a strategy of deferred stenting in selected patients reduced no reflow and IPTEs in primary PCI. Our intervention is pragmatic and potentially widely applicable. Our results support the rationale for a multicentre trial to assess the safety and cost-effectiveness of deferred stenting in primary PCI