Exercise training in heart failure with preserved and reduced ejection fraction: A systematic review and meta-analysis

Background: While exercise training (ET) is an established tool in heart failure (HF), no research to date has analysed the efficacy of ET in both preserved (HFpEF) and reduced (HFrEF) ejection fraction phenotypes across the same clinically important parameters. Methods: A comprehensive systematic search was performed to identify trials published between 1990 and May 2021. Controlled trials of adults reporting pre and post ET peak VO2, six-minute walk distance (6MWD), Minnesota living with heart failure (MLHFQ), Kansas City Cardiomyopathy Questionnaire (KCCQ) and left ventricular ejection fraction (LVEF) were considered. Parameters of cardiac diastolic function, brain natriuretic peptides (BNP)/ N-terminal prohormone of BNP (NTproBNP) and follow-up hospitalisation and mortality data were also analysed. Results: 93 studies (11 HFpEF and 82 HFrEF) were included in the final analysis, with a pooled sample size of 11,081 participants. HFpEF analysis demonstrated significant improvements in peak VO2 (Weighted Mean Difference:2.333 ml·min-1·kg-1, Pfixed<0.001), 6MWD (WMD:35.396 m, Pfixed<0.001), MLHFQ (WMD:-10.932, Prandom<0.001), KCCQ (WMD:3.709, Pfixed=0.037) and E/e’ (WMD: -1.709, [95% CI] = -2.91--0.51, Prandom=0.005). HFrEF analysis demonstrated significant improvements in peak VO2 (WMD:3.050 ml·min-1·kg-1, Prandom<0.001), 6MWD (WMD:37.299 m, Prandom<0.001), MLHFQ (WMD:-10.932, Prandom<0.001), LVEF (WMD:2.677 %, Prandom=0.002) and BNP/NTproBNP (SMD:-1.349, Prandom<0.001). Outcome analysis was only performed in HFrEF, which found no significant changes in hospitalisation, all-cause mortality or composite end-points. Conclusion: ET significantly improves exercise capacity and quality of life in both HFpEF and HFrEF patients. In HFpEF patients, ET significantly improved an important index of diastolic function, with significant improvements in LVEF and NTproBNP/BNP seen in HFrEF patients only. Such benefits did not translate into significantly reduced hospitalisation or mortality after short-term follow up

Board of directors in the New England electronics industry

Thesis (M.A.)--Boston Universit

Artificial intelligence calculated global longitudinal strain and left ventricular ejection fraction predicts cardiac events and all-cause mortality in patients with chest pain

Background: Assessment of left ventricular ejection fraction (LVEF) and myocardial deformation with global longitudinal strain (GLS) has shown promise in predicting adverse cardiovascular events. The aim of this study was to evaluate whether artificial intelligence (AI) calculated LVEF and GLS is associated with major adverse cardiac events (MACE) and all-cause mortality in patients presenting with chest pain. Methods: We studied 296 patients presenting with chest pain, who underwent transthoracic echocardiography (TTE). Clinical data, downstream clinical investigations and patient outcomes were collected. Resting TTE images underwent AI contouring for automated calculation of LVEF and GLS with Ultromics EchoGo Core 2.0. Regression analysis was performed to identify clinical and AI calculated parameters associated with MACE and all-cause mortality. Results: During a median follow-up period of 7.8 years (IQR 6.4, 8.8), MACE occurred in 34 (11.5%) patients and all-cause mortality in 60 (20%) patients. AI calculated LVEF (Odds Ratio [OR] 0.96; 95% CI 0.93-0.99 and 0.96; 95% CI 0.93-0.99) and GLS (1.11; 95% CI 1.01-1.21 and 1.08; 95% CI 1.00-1.16) were independently associated with MACE and all-cause mortality, respectively. According to Cox proportional hazards, a LVEF -15% was associated with a 2.5 times MACE and 2.3 times all-cause mortality hazard rate compared to those with a GLS ≤-15. Conclusion: AI calculated resting LVEF and GLS is independently associated with MACE and all-cause mortality in high CVD risk patients. These results may have significant clinical implications through improved risk stratification of patients with chest pain, accelerated workflow of labour-intensive technical measures, and reduced healthcare costs

Body mass index mortality paradox in chronic kidney disease patients with suspected cardiac chest pain

Background: Chronic kidney disease (CKD) is a silent clinical condition associated with adverse comorbidity and high cardiovascular disease (CVD) risk. An inverse relationship with body mass index (BMI) and mortality has been demonstrated in hemodialysis patients. However, it is unclear if this risk‐factor paradox is evident in non‐dialysis CKD patients. The aims of this study were to explore the relationship between, nutritional status, markers of inflammation, autonomic and cardiac function with BMI. Longitudinal follow‐up explored the relationship between BMI and allcause mortality. Methods: 211‐consecutive CKD patients referred for dobutamine stress echocardiography to detect or exclude myocardial ischemia were recruited. BMI, albumin, C‐reactive protein (CRP) and haemoglobin (Hb) were recorded as markers of nutritional and inflammatory status. Left ventricular ejection fraction (LVEF) and heart rate variability (HRV) as an indicator of cardiac function was recorded. All subjects were followed prospectively until November 2014 and study end‐point was all‐cause mortality. Results: BMI was inversely associated with CKD status. After covariate adjustment, this association remained. During a mean follow‐up period of 3.3±0.9 years there were 35 deaths (17%). BMI was inversely associated with all‐cause mortality (HR 0.81, 95% CI 0.71‐0.9). Other important independent predictors of mortality were heart rate variability (HR 0.98, 95% CI 0.97‐0.99), myocardial ischemia (HR 1.37, 95% CI 1.17‐1.81), and albumin (HR 0.86, 95% CI 0.81‐ 0.92). Conclusions: The presence of a BMI paradox exists in non‐dialysis CKD patients. This risk‐factor paradox was an independent predictor of all‐cause mortality and may have significant clinical implications relevant to screening, assessment and treatment and requires further study

Validity and reliability of RPE as a measure of intensity during isometric wall squat exercise

Background and Aims: Isometric exercise (IE), including wall squat training, has been shown to be effective at reducing resting blood pressure (BP). Rating of perceived exertion (RPE) is also widely used as an accessible additional measure of IE intensity. Despite this, no RPE scales have been specifically designed for use with IE and it is not clear whether RPE is sensitive enough to distinguish between different lower limb IE workloads. Therefore, the aims of this study were to assess the validity and reliability of RPE as a measure of IE intensity (workload) and physiological exertion (Heart rate and BP), and to examine whether RPE is able to discern differences in wall squat workload (knee angle) at a resolution of 10-degrees, as was previous shown for heart rate (HR) and BP. Methods: Twenty-nine male participants completed 8 separate isometric wall squat testing sessions, separated by a minimum of 5-hours. Each session consisted of a single 2-minute isometric wall squat test, at one of five randomised workloads (knee joint angles). Three of the knee angles were repeated, a second time, to allow measurements of reliability. Throughout the exercise protocol, HR and BP were recorded continuously; values for each 30-second time-point were calculated as the mean of the proceeding 5-seconds, peak values for the 2-minute bout were taken as the mean results for the final 5- seconds of the bout. Additionally, mean results for the full 2-minute period were calculated. RPE was collected every 30 seconds. Concurrent validity was assessed by correlating RPE results with the criterion measures: Knee joint angle, HR and BP. Differences in RPE were assessed across consecutive workloads and time-points. Results: There were significant increases in RPE at each consecutive wall squat workload (p < 0.001) and between each consecutive 30-second time point (p < 0.001). Additionally, the RPE results produced a significant inverse relationship with knee angle (r = -0.79; p < 0.001) and significant positive relationships with HR (r = 0.53, p < 0.001) and BP (systolic: r = 0.77; diastolic: r = 0.62; mean arterial pressure: r = 0.70, p < 0.001). Conclusion: RPE provides a valid and reliable measure of isometric wall squat intensity, physiological exertion, and can discern between knee angles with a resolution of 10°. Relevance for patients: Patients and practitioners implementing isometric exercise training for arterial blood pressure reduction can use RPE to accurately monitor the intensity of the exercise and the physiological responses

Validity and reliability of the ‘Isometric Exercise Scale’ (IES) for measuring ratings of perceived exertion during continuous isometric exercise

Purpose: Isometric exercise (IE) interventions have been shown to be effective at reducing resting arterial blood pressure (BP). IE intensity is generally determined using force, electromyography (EMG), heart rate (HR), or knee joint angle. However, ratings of perceived exertion (RPE) may provide a more accessible means of determining exercise intensity. Therefore, the aim of this study was to assess the validity of a specific Isometric Exercise Scale (IES) during a continuous incremental isometric wall squat test. Methods: Twenty-nine male participants completed 4 incremental IE tests. Each test consisted of 5 isometric wall squat intensities, determined by knee joint angles from 135° to 95°, each held for up to 2 minutes. The tests were continuous until volitional fatigue or completion of the 5 work stages. Throughout the exercise protocol, RPE (IES and Borg’s CR-10), HR and blood pressure were recorded. Results: The IES produced a strong positive linear relationship with the CR-10 (r = 0.967) . Additionally, strong positive relationships between the IES and wall squat duration (r = 0.849), HR (r = 0.819) and BP (r = 0.841) were seen. Intra-class correlation coefficients and coefficients of variations for the IES ranged from r = 0.81 to 0.91 and 4.5% to 54% respectively, with greater reliability seen at the higher workloads. Conclusions: The IES is a valid and reliable measure of RPE, exercise intensity, and it accurately represents the changes in physiological measures of exertion during IE; as such, the IES can be used as a useful additional measure of exercise intensity during IET interventions

A study in the financial valuation of a topping oil refinery

Oil refineries underpin modern day economics, finance and engineering – without their refined products the world would stand still, as vehicles would not have petrol, planes grounded without kerosene and homes not heated, without heating oil. In this thesis I study the refinery as a financial asset; it is not too dissimilar to a chemical plant, in this respect. There are a number of reasons for this research; over recent years there have been legal disputes based on a refiner's value, investors and entrepreneurs are interested in purchasing refineries, and finally the research in this arena is sparse. In this thesis I utilise knowledge and techniques within finance, optimisation, stochastic mathematics and commodities to build programs that obtain a financial value for an oil refinery. In chapter one I introduce the background of crude oil and the significance of the refinery in the oil value chain. In chapter two I construct a traditional discounted cash flow valuation often applied within practical finance. In chapter three I program an extensive piecewise non linear optimisation solution on the entire state space, leveraging off a simulation of the refined products using a set of single factor Schwartz (1997) stochastic equations often applied to commodities. In chapter four I program an optimisation using an approximation on crack spread option data with the aim of lowering the duration of solution found in chapter three; this is achieved by utilising a two-factor Hull & White sub-trinomial tree based numerical scheme; see Hull & White (1994) articles I & II for a thorough description. I obtain realistic and accurate numbers for a topping oil refinery using financial market contracts and other real data for the Vadinar refinery based in Gujurat India

Strongman training – Needs analysis and integration into strength and conditioning programming: part 2.

The article aims to evaluate the integration of strongman based exercises within the practice of strength and conditioning. It should give the reader a clear understanding of the specific physiological and biomechanical traits of each of the exercises discussed in the previous article. This information will then be used to discuss its amalgamation within traditional based exercises within the planning of a periodised programme for strength and conditioning practitioners

Strongman training – a rationale for its inclusion in strength & conditioning: part 1

This article, the first in a two-part series, aims to introduce the concepts of strongman-type training relative to some of the exercises adopted. It should give the reader a detailed background into the evolution of strongman training with a strong rationale for its inclusion within the practice of strength and conditioning