Stress Testing for Diastolic Dysfunction: An Old Approach to a New Question

BACKGROUND: Currently, conventional cycle echocardiography is the recommended method for diagnosing diastolic dysfunction in patients with unexplained dyspnea upon exertion. However, this method has several underlying limitations including movement and respiratory artifact. These limitations are often exaggerated in patients who are obese and suffer from exertional dyspnea, and therefore limit its application in clinical diagnosis. Our group recently demonstrated that isometric handgrip echocardiography is a powerful sub-clinical diastolic discriminator that avoids the limitations of conventional cycle echocardiography and that can be easily implemented in the clinic. PURPOSE: However, to date it remains unclear how these two methodologies compare, and thus was the focus of the present investigation. We hypothesized that isometric handgrip echocardiography would be a more robust method for unmasking exercise induced diastolic dysfunction compared to conventional cycle echocardiography, due to its markedly different hemodynamic load. METHODS: To test this hypothesis, we recruited 24 individuals from the community (9 male, 15 female, age range: 18 - 80), who all performed 3 minutes of isometric handgrip echocardiography followed by 3 minutes of dynamic cycle exercise (20 W). At rest and during the final minute of each exercise protocol heart rate (HR), mean arterial pressure (MAP) and Doppler derived E/e’ were recorded. Consistent with our previous work, and that of others, individuals who had a change in E/e’ from rest to exercise of \u3e1.5 (ΔE/e’ \u3e 1.5) were defined as responders, while non-responders were defined as ΔE/e’ \u3c 1.5. RESULTS: Both isometric handgrip and low-intensity cycle exercise resulted in a similar rise in HR (ΔHR: 22 ± 13 vs. 25 ± 7, handgrip vs. cycle exercise, P \u3e 0.05), while isometric handgrip resulted in a larger increase in MAP (ΔMAP: 28 ± 14 vs. 16 ± 12, handgrip vs. cycle exercise, P = 0.0003). Remarkably, the increased afterload stress experienced by the myocardium during isometric handgrip exercise was more robust at unmasking sub-clinical diastolic dysfunction in asymptomatic elderly individuals compared to conventional cycle exercise (handgrip: n = 14 vs. n = 10; and cycle: n = 10 vs. n = 14, responders vs. non-responders). CONCLUSION: Taken together, these data highlight the usefulness of isometric handgrip echocardiography at isolating myocardial diastolic relaxation abnormalities in community dwelling individuals, beyond that of dynamic cycle exercise. Future work should focus on confirming the sensitivity of this method in individuals at risk for or with diagnosed heart failure

Can We Calculate Mean Arterial Pressure in Humans?

Mean arterial pressure (MAP) is either measured with an oscillometric cuff and then systolic (SBP) and diastolic (DBP) blood pressures are estimated from an unknown algorithm; or SBP and DBP are measured via auscultation and MAP calculated using measures of systolic pressure (SBP), diastolic pressure (DBP), and a form-factor (FF; equation: [(SBP-DBP)*FF]+DBP). The typical FF used is 0.33 though others (0.4) have been proposed. Recent work indicates that estimation of aortic MAP via a FF leads to inaccurate values and should therefore be interpreted with caution, whether this is the case for local MAP is unknown. While the implications for hypertension (HTN) diagnosis are minimal, the calculation of local MAP is essential to the study of blood pressure regulation and exercise hemodynamics in patient populations (e.g. heart failure). PURPOSE: To compare the calculation of local MAP using catheter waveforms and a FF, against MAP derived from the pressure-time integral (PTI; i.e. average pressure across the cardiac cycle) measured via radial arterial catheterization. METHODS: We analyzed radial arterial catheter waveforms from 39 patients (Age: 71±7 years; BMI: 38.4±6.7; Female: 66%; HTN prevalence: 97%) with heart failure with preserved ejection fraction (HFpEF) at rest and during cycling exercise at 20 Watts. We compared the PTI (from the catheter waveform) with the calculation of MAP from the peak and nadir of the same waveforms (5-beat averages) using the 0.33 and 0.4 FF’s in the FF equation. RESULTS: Compared to the PTI (91±13 mmHg), resting MAP was not significantly different when calculated using the 0.33 FF (91±11 mmHg, P\u3e0.999) but was higher when using the 0.4 FF (96±12 mmHg, PCONCLUSION:While the 0.33 FF provides an accurate assessment of MAP on average during rest and exercise in the radial artery in patients with HFpEF, the limits of agreement are large reflecting a lack of precision in measurement at an individual level. Indirect calculations of MAP via a FF may lead to inaccurate conclusions regarding the mechanisms of blood pressure regulation both at rest and during exercise testing in this population

Cardiac mechanisms for low aerobic power in anthracycline treated, older, long-term breast cancer survivors

Breast cancer survivors have reduced peak aerobic capacity (VO2peak) which may be related to latent or lingering chemotherapy induced cardiac damage. Nine, older (67 ± 3 years), long-term survivors (9.8 years) of anthracycline based chemotherapy and age- and sex-matched healthy controls were recruited and tested to determine whether: i) VO2peak remains reduced in long-term survivorship; and ii) reductions in VO2peak are due to cardiac dysfunction. VO2peak was significantly reduced in breast cancer survivors relative to healthy controls (15.9 ± 2.0 vs 19.9 ± 3.1 ml/kg/min, p = 0.006), however the heart rate and stroke volume responses to exercise were normal (heart rate reserve; 88 ± 9 vs 85 ± 10 bpm, p = 0.62: stroke volume reserve; 13 ± 6 vs 13 ± 9 ml,p = 0.94). These findings indicate low-normal ventricular size in long-term breast cancer survivors, but normal reserve function

Synchronizing Cardiac Cycle Phase with Foot Strike to Optimize Cardiac Performance in Patients with Chronic Systolic Heart Failure and Cardiac Resynchronization Therapy (CRT)

Despite advances in medical and Cardiac Resynchronization Therapy (CRT), patients with chronic systolic heart failure (HF) have persistent symptoms including dyspnea on exertion and exercise intolerance. Novel strategies to improve exercise performance in these patients, such as optimizing cardio-locomotor coupling, could be particularly beneficial to improve functional capacity. For example, runners display a lower heart rate and higher oxygen pulse, suggestive of a higher stroke volume (SV), when foot strike occurs in diastole. Whether patients with HF undergoing CRT can similarly increase SV is unknown. PURPOSE: To compare the effects of diastolic versus systolic foot strike timing on exercise hemodynamics in patients with HF and CRT. METHODS: Ten patients (Age: 58 ± 17 years, 40% Female) with HF and previously implanted CRT pacemakers completed repeated 5-minute bouts of walking on a treadmill at a fixed but individualized speed (range: 1.5-3mph). Participants were randomized to walking to an auditory tone to synchronize their foot strike to either the systolic (ECG R-wave; 0 or 100%±15% or R-R interval) or diastolic phase (45±15% of the R-R interval) of their cardiac cycle. Participants were included if ≥50% of their steps were valid (i.e. in time). Patients wore a chest strap with an attached ECG sensor and accelerometer (CounterpaceR). Foot strike timing and associated valid step counts were assessed via CounterpaceR or post-hoc analysis of foot strike waveforms. Cardiopulmonary parameters were measured breath by breath via indirect calorimetry and cardiac output was measured via acetylene rebreathing, with SV calculated as the quotient of cardiac output and heart rate. RESULTS: There was no difference in oxygen uptake between conditions (1.02 ± 0.44 vs. 1.04 ± 0.44 L/min, P=0.298). When compared to systolic walking, stepping in diastole was associated with higher SV (Diastolic: 80 ± 28 vs. Systolic: 74 ± 26 ml, P=0.003) and cardiac output (8.3 ± 3.5 vs. 7.9 ± 3.4 L/min, P=0.004); heart rate (paced) was not different between conditions (101 ± 15 vs. 103 ± 14 bpm, P=0.300). Mean arterial pressure was significantly lower during diastolic walking (85 ± 12 vs. 98 ± 20 mmHg, P=0.007). CONCLUSION: In patients with HF and previous CRT, synchronizing foot strike with diastole during walking increased SV and cardiac output and reduced arterial pressure. Our findings indicate that in such paced hearts, diastolic stepping increases oxygen delivery and decreases afterload, which may facilitate increased exercise capacity. Therefore, if added to pacemakers, this cardio-locomotor coupling technology may maximize CRT efficiency and increase exercise participation and quality of life in patients with HF

Left ventricular morphology and function in adolescents: Relations to fitness and fatness.

BACKGROUND: Obesity in childhood predisposes individuals to cardiovascular disease and increased risk of premature all-cause mortality. The aim of this study was to determine differences in LV morphology and function in obese and normal-weight adolescents. Furthermore, relationships between LV outcomes, cardiorespiratory fitness (CRF) and adiposity were explored. METHODS: LV morphology was assessed using magnetic resonance imaging (MRI) in 20 adolescents (11 normal-weight [BMI equivalent to 18kg/m(2)-25kg/m(2)] and 9 obese [BMI equivalent to ≥30kg/m(2)]); 13.3±1.1years, 45% female, Tanner puberty stage 3 [2-4]) using magnetic resonance imaging (MRI). Global longitudinal strain (GLS), strain rate (SR) and traditional echocardiographic indices were used to assess LV function. CRF (peak oxygen consumption), percent body fat (dual-energy x-ray absorptiometry), abdominal adipose tissue (MRI), and blood biochemistry markers were also evaluated. RESULTS: Adolescents with obesity showed significantly poorer LV function compared to normal-weight adolescents (P0.05). Moderate to strong associations between myocardial contractility and relaxation, adiposity, arterial blood pressure and cardiorespiratory fitness were noted (r=0.49-0.71, P<0.05). CONCLUSION: Obesity in adolescence is associated with altered LV systolic and diastolic function. The notable relationship between LV function, CRF and adiposity highlights the potential utility of multidisciplinary lifestyle interventions to treat diminished LV function in this population. CLINICAL TRIAL REGISTRATION: NCT01991106

A Multi-Center Comparison of VO2peak Trainability Between Interval Training and Moderate Intensity Continuous Training

There is heterogeneity in the observed VO2peak response to similar exercise training, and different exercise approaches produce variable degrees of exercise response (trainability). The aim of this study was to combine data from different laboratories to compare VO2peak trainability between various volumes of interval training and Moderate Intensity Continuous Training (MICT). For interval training, volumes were classified by the duration of total interval time. High-volume High Intensity Interval Training (HIIT) included studies that had participants complete more than 15 min of high intensity efforts per session. Low-volume HIIT/Sprint Interval Training (SIT) included studies using less than 15 min of high intensity efforts per session. In total, 677 participants across 18 aerobic exercise training interventions from eight different universities in five countries were included in the analysis. Participants had completed 3 weeks or more of either high-volume HIIT (n = 299), low-volume HIIT/SIT (n = 116), or MICT (n = 262) and were predominately men (n = 495) with a mix of healthy, elderly and clinical populations. Each training intervention improved mean VO2peak at the group level (P \u3c 0.001). After adjusting for covariates, high-volume HIIT had a significantly greater (P \u3c 0.05) absolute VO2peak increase (0.29 L/min) compared to MICT (0.20 L/min) and low-volume HIIT/SIT (0.18 L/min). Adjusted relative VO2peak increase was also significantly greater (P \u3c 0.01) in high-volume HIIT (3.3 ml/kg/min) than MICT (2.4 ml/kg/min) and insignificantly greater (P = 0.09) than low-volume HIIT/SIT (2.5 mL/kg/min). Based on a high threshold for a likely response (technical error of measurement plus the minimal clinically important difference), high-volume HIIT had significantly more (P \u3c 0.01) likely responders (31%) compared to low-volume HIIT/SIT (16%) and MICT (21%). Covariates such as age, sex, the individual study, population group, sessions per week, study duration and the average between pre and post VO2peak explained only 17.3% of the variance in VO2peak trainability. In conclusion, high-volume HIIT had more likely responders to improvements in VO2peak compared to low-volume HIIT/SIT and MICT

Heart failure with preserved ejection fraction: learning from failure

Detailed formal protocol with illustrations and extensive bibliography.UT Southwestern--Internal Medicin

Influence of the mode of deformation on recrystallisation behaviour of titanium through experiments, mean field theory and phase field model

The influence of the mode of deformation on recrystallisation behaviour of Ti was studied by experiments and modelling. Ti samples were deformed through torsion and rolling to the same equivalent strain of 0.5. The deformed samples were annealed at different temperatures for different time durations and the recrystallisation kinetics were compared. Recrystallisation is found to be faster in the rolled samples compared to the torsion deformed samples. This is attributed to the differences in stored energy and number of nuclei per unit area in the two modes of deformation. Considering decay in stored energy during recrystallisation, the grain boundary mobility was estimated through a mean field model. The activation energy for recrystallisation obtained from experiments matched with the activation energy for grain boundary migration obtained from mobility calculation. A multi-phase field model (with mobility estimated from the mean field model as a constitutive input) was used to simulate the kinetics, microstructure and texture evolution. The recrystallisation kinetics and grain size distributions obtained from experiments matched reasonably well with the phase field simulations. The recrystallisation texture predicted through phase field simulations compares well with experiments though few additional texture components are present in simulations. This is attributed to the anisotropy in grain boundary mobility, which is not accounted for in the present study