The Clinical Utility of Cardiopulmonary Exercise Testing in Patients With Suspected Myocardial Ischemia

Heart disease is a major cause of morbidity and mortality in the United States with coronary artery disease (CAD) representing more than half of all cardiovascular events. Stable patients presenting with symptoms suggestive of CAD are likely to undergo either an exercise ECG and/or imaging study as a first line diagnostic assessment. A cardiopulmonary exercise test (CPX) is an ECG stress test plus ventilatory gas analysis. Recently CPX has been used to detect exercise-induced myocardial ischemia suggestive of underlying CAD. Currently there are a number of diagnostic tests available for the identification of CAD with the most widely used being exercise ECG, myocardial perfusion imaging (MPI) and cardiac catheterization. Exercise ECG, although inexpensive, has a number of well-recognized limitations, including low sensitivity resulting in false positive results. MPI and catheterization are more accurate but also more invasive and expensive. It appears that CPX may improve the diagnostic accuracy of exercise ECG in a cost effective manner

Development and implementation of worksite health and wellness programs: a focus on non-communicable disease

The development and implementation of worksite health and wellness programs (WHWPs) in the United States (US) hold promise as a means to improve population health and reverse current trends in non-communicable disease incidence and prevalence. However, WHWPs face organizational, economic, systematic, legal, and logistical challenges which have combined to impact program availability and expansion. Even so, there is a burgeoning body of evidence indicating WHWPs can significantly improve the health profile of participating employees in a cost effective manner. This foundation of scientific knowledge justifies further research inquiry to elucidate optimal WHWP models. It is clear that the development, implementation and operation of WHWPs require a strong commitment from organizational leadership, a pervasive culture of health and availability of necessary resources and infrastructure. Since organizations vary significantly, there is a need to have flexibility in creating a customized, effective health and wellness program. Furthermore, several key legal issues must be addressed to facilitate employer and employee needs and responsibilities; the US Affordable Care Act will play a major role moving forward. The purposes of this review are to: 1) examine currently available health and wellness program models and considerations for the future; 2) highlight key legal issues associated with WHWP development and implementation; and 3) identify challenges and solutions for the development and implementation of as well as adherence to WHWPs

Healthy Living Medicine in the Workplace: More Work to Do

Non-communicable diseases (NCDs) are five of the top ten causes of death for Americans: cardiovascular disease (CVD), cancer, lower respiratory disease, stroke and diabetes mellitus. Risk factors for these NCDs and for CVD are tobacco use, poor diet quality, physical inactivity, increase body mass index, increased blood pressure, increased blood cholesterol, and glucose intolerance. Depression, depressive symptoms and anxiety also contribute to CVD risk. There is also evidence work stress itself contributes to CVD risk. By 2024 there is expected to be approximately 164 million workers in the US labor force and the share of older workers will likewise increase. Currently, about 25 million of those are over the age of 55, the age at which many diseases of lifestyle become clinically apparent. Furthermore, Americans spend as much as half of their waking hours at work. This makes the worksite an important target for the delivery of healthy living medicine

Cardiopulmonary exercise testing in patients with pulmonary hypertension: Clinical recommendations based on a review of the evidence

Pulmonary hypertension (PH) remains an ominous diagnosis despite advances in pharmacological and surgical therapy. Early and effective diagnosis is important for clinicians making treatment determinations and patients wishing to understand the prognostic implications of their illness. Cardiopulmonary exercise testing (CPX) has the power to reveal the underlying pathophysiological consequences of the disease process. Research, especially over the last 10-15 years, has demonstrated the utility of this tool. Several CPX variables have been shown to be consistently altered in patients with PH and more so as severity of disease increases. However, to further enhance clinical application, additional research is needed to better define optimal CPX measures and associated cutoff values. This paper gives class-based recommendations with associated levels of evidence for the use of CPX in the PH patient population

Current trends in reducing cardiovascular risk factors in the United States: Focus on worksite health and wellness

Health care in the United States (US) is changing with a broad provision of health care services to every American due to the Affordable Care Act (ACA) slated to begin in January of 2014. An important aspect of the ACA is that US companies may begin to offer health insurance incentives to employees for participating in health and wellness initiatives. Moreover, since US employers directly absorb many of the financial costs associated with the high degree of cardiovascular (CV) risk factors present in their personnel, employers may be financially vested in improving employee health. However, employers must also consider the costs of developing and maintaining programs to improve employee health and their return on investment (ROI). This review will identify key risk factors to address in a worksite health and wellness program and to examine the performance of such programs in improving CV risk factors and their ROI. © 2014 Elsevier Inc

The affordable care act: New opportunities for cardiac rehabilitation in the workplace?

Many people affected by cardiovascular disease (CVD) are working age. Employers bear a large percentage of the costs associated with CVD. Employers pay 80 times more in diagnosis and treatment than in prevention, although there is evidence that 50% to 70% of all diseases are associated with preventable health risks. As a result, the worksite is an appealing location to deliver health care.Cardiac rehabilitation has developed a track record of delivering improved outcomes for patients with CVD. Partnerships between cardiac rehabilitation providers and worksite health programs have the potential to improve referral and participation rates of employees with CVD. The current era of health reform in the United States that has been stimulated by the Affordable Care Act provides an ideal opportunity to reconsider worksite health programs as an essential partner in the health care team. Copyright © 2014 by American College of Occupational and Environmental Medicine

Sedentary Time and Cumulative Risk of Preserved and Reduced Ejection Fraction Heart Failure: From the Multi-Ethnic Study of Atherosclerosis

Background: This study examined the relationship between self-reported sedentary time (ST) and the cumulative risk of heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) in a diverse cohort of U.S. adults 45–84 years of age. Methods and Results: Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we identified 6,814 subjects, all free of baseline cardiovascular disease. Cox regression was used to calculate the hazard ratios (HR) associated with risk of HFpEF and HFrEF. Weekly ST was dichotomized based on the 75th percentile (1890 min/wk). During ∼11.2 years of follow-up there were 178 first incident HF diagnoses: 74 HFpEF and 69 HFrEF. Baseline ST \u3e1890 min/wk was significantly associated with an increased risk of HFpEF (HR 1.87, 95% confidence interval [CI] 1.13–3.09, P = .01), but not of HFrEF. The relationship with HFpEF remained significant in fully adjusted models including physical activity and waist circumference (HR 2.16, 95% CI 1.23–3.78, P \u3c .01). In addition, every 60-minute increase in weekly ST was associated with a 3% increased risk of HFpEF (HR 1.03, 95% CI 1.01–1.05, P \u3c .01). Conclusions: Sedentary time \u3e1890 min/wk (∼4.5 h/d) is a significant predictor of HFpEF, independently from physical activity and adiposity