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Therapeutic impact of exercise on psychiatric diseases: guidelines for exercise testing and prescription.

Aerobic exercise seems to be effective in improving general mood and symptoms of depression and anxiety in healthy individuals and psychiatric patients. This effect is not limited to aerobic forms of exercise. There are almost no contraindications for psychiatric patients to participate in exercise programmes, provided they are free from cardiovascular and acute infectious diseases. However, very little is known about the effects of exercise in psychiatric disease other than those in depression and anxiety disorders. A few reports indicate the need for controlled investigations in psychotic and personality disorders. Unfortunately, no general concept for a therapeutic application of physical activity has been developed so far. Reliance on submaximal measures is highly recommended for fitness assessment. Monitoring of exercise intensity during training sessions is most easily done by measuring the heart rate using portable devices (whereas controlling the exact workload may be preferable for scientific purposes). Appropriate pre- and post-training testing is emphasised to enable adequate determinations of fitness gains and to eventually allow positive feedback to be given to patients in clinical settings.

Adult↗

Heart rate response during exercise testing and ambulatory ECG monitoring in patients with syndrome X.

The response of the heart rate during exercise testing and 24-hour ambulatory electrocardiographic (ECG) monitoring performed with patients not receiving antianginal treatment was assessed in 26 patients (9 men and 17 women; mean age 51 +/- 8 years) with syndrome X (angina pectoris with normal coronary arteries), in 27 patients with coronary artery disease (10 men and 17 women; mean age 55 +/- 9 years), and in 21 healthy subjects (8 men and 13 women; mean age 47 +/- 11 years). In patients with syndrome X the slope of the regression line of heart rate versus time (heart rate/time slope) during exercise testing was similar to that of patients with coronary artery disease (3.3 +/- 0.8 versus 3.1 +/- 1.2 beats/min), but significantly lower than that in healthy subjects (4.2 +/- 1.1 beats/min; p less than 0.003). In patients with syndrome X the intercept of the heart rate/time slope was significantly higher than that in coronary artery disease patients and healthy subjects (102 +/- 15, 86 +/- 18, and 90 +/- 16 beats/min, respectively; p less than 0.015). Resting preexercise heart rate was also significantly higher in syndrome X, compared with coronary artery disease patients and healthy subjects (91 +/- 16, 79 +/- 16, and 80 +/- 14 beats/min, respectively). During ambulatory ECG monitoring, mean diurnal heart rate (from 6 AM to 6 PM) was higher in patients with syndrome X (83 +/- 8 beats/min) than in patients with coronary artery disease (75 +/- 8 beats/min) and healthy subjects (74 +/- 11 beats/min) (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Angina Pectoris↗

Platelet count and platelet function in patients with angina pectoris (before and after a cycloergometric exercise test).

Platelet count and platelet function (circulating platelet aggregates, retention by glass beads and aggregation) were studied under basal conditions and after a cycloergometric exercise test in 10 subjects with stable angina pectoris and 10 normal subjects. There were no baseline differences between patients and controls in any of the tests of platelet function, nor did the values change after the exercise test. There was, however, a significant increase in the number of circulating platelets after the test in angina patients. Possible reasons for this phenomenon are discussed, with emphasis on the role of catecholamine hypersecretion induced by the physical exercise.

Adult↗

[Evaluation of the cardiac performance in patients with coronary artery disease by the pulmonary blood volume change in exercise test].

Evaluation of the cardiac performance was studied by the change of the pulmonary blood volume (PBV) during the exercise testing in 17 normal subjects (group N), 18 patients with angina pectoris (group A) and 25 with both old myocardial infarction and angina pectoris (group M). The exercise testing was performed by bicycle ergometer in supine position. Blood pressure, heart rate, cardiac output measured by dye dilution method, left ventricular ejection fraction (EF) by multi-gate method, pulmonary artery pressure by Swan-Ganz catheter and PBV was measured during exercise. PBV was estimated by the radioactivity of the systemically administered Tc-99m labeled RBC in the lung field. ROI was adjusted over the right upper and lower lung field. And also the effect of the nitroglycerin was examined. In the result, (1) EF at the peak exercise increased in group N but decreased in group A and M, (2) Increased pulmonary artery diastolic pressure at the peak exercise (PAd at exercise) was remarkably higher in group A and M than group N. (3) PBV was unchanged in group N, however, increased 9.6% in group A and 10.9% in group M. (4) Increased rate of PBV revealed good correlation with delta EF (r = -0.68, p less than 0.01) and PAd at exercise (r = 0.83, p less than 0.01), and was considered as the pulmonary congestion due to left ventricular dysfunction. (5) After the sublingual administration of nitroglycerin, the increased PAd and PBV at the peak exercise was suppressed. Particularly, it was remarkable in group A. Then it was concluded that the noninvasive measurement of PBV during exercise could suggest the extent of the pulmonary congestion and was very useful for evaluation of the cardiac performance in coronary artery disease.

Adult↗

Serum potassium exercise test in the diagnosis of familial periodic paralysis.

We studied the serum potassium rise during a 30-min 100 W exercise test in 5 controls, 3 familial periodic paralysis (FPP) patients and their 2 symptom-less brothers. The controls showed a steep and high exercise response (the 10-min rise was 0.59 +/- 0.13 mmol/l and the maximal rise was 0.71 +/- 0.11 mmol/l). The FPP patients showed a slow and flat exercise response (the 10-min rise was 0.08 +/- 0.11 mmol/l and the maximal rise was 0.17 +/- 0.12 mmol/l, P less than 0.001 for both values). The 2 symptom-less brothers showed a similar divergence. The values of 0.05 mmol/l (10-min) and 0.25 mmol/l (maximal) of one brother suggest the diagnosis of FPP, whereas the values of 0.55 (10-min) and 0.65 mmol/l (maximal) of the other brother suggest the exclusion of the disease. We regard the serum potassium exercise test to be worthy of further study as a diagnostic test of FPP.

Adult↗

The predictive value of the time course of ST segment depression during exercise testing in patients referred for coronary angiograms.

We studied the time course of ST segment depression during and after exercise testing in 462 subjects who also had coronary angiograms. Sixty-three percent of patients with late onset-early offset ST depression, previously reported to be likely to have false positive tests, had significant coronary artery disease, and 32% had three-vessel disease. Those with early onset and late offset ST depression and those with resting ST depression that was accentuated with exercise had a high prevalence of significant coronary artery disease and three-vessel disease. We found that observation of the time course of ST depression during and after exercise adds significantly to the information gained during exercise testing.

Aged↗

Water intake and fluid shifts in horses: effects of hydration status during two exercise tests.

In the present study, the main objective was to study factors affecting postexercise voluntary water intake in horses. Four Standardbred horses (mean +/- s.e. bwt 500 +/- 8 kg) were used to study water intake and effects of altering hydration status before an incremental exercise test (INCR) and a 40 min constant velocity exercise test (CONST) on a treadmill. Exercise was performed during normohydration (N), after dehydration for 24 h (DEH) and after hyperhydration with 12 l water 30 min before exercise (HH). DEH resulted in a bodyweight loss of 3% and there were signs of some fluid uptake prior to exercise in both HH trials. By the end of the INCR, the calculated change in plasma volume (PVcalc) was -13 +/- 1, -21 +/- 1 and -11 +/- 3% in the N, DEH and HH trials, respectively. During the highest exercise velocities a hypotonic shift of fluid was seen in all INCR trials. There was a greater accumulation of plasma lactate (pLA) in HH-than in N-INCR, probably caused by the extra weight to be carried. CONST induced a similar fluid loss (3%) in all trials, but the decrease in PVcalc at the end of exercise was significantly smaller in HH (-7 +/- 2%) than in N (-14 +/- 1%) and DEH (-19 +/- 2%). In DEH-INCR and DEH-CONST, plasma sodium concentration (pNa) was higher than in N until drinking water was offered 1 h postexercise. In the presence of both an increased pNa and a decrease in PVcalc when dehydrated, the horses drank immediately when offered water postexercise. In N-CONST, there was a significant decrease in calculated PVcalc (-10 +/- 2%) but no increase in pNa when water was given and in this trial the horses rehydrated less rapidly. Plasma aldosterone concentration (PAC) had increased to the same magnitude in all trials after about 10 min, irrespective of type of exercise or hydration status. It was concluded that when both an osmotic and hypovolemic thirst stimulus was present, the horses rehydrated more rapidly postexercise.

Animals↗

Development of an exercise testing protocol for patients with a lower limb amputation: results of a pilot study.

Due to a decrease in physical activity, lower limb amputees experience a decline in physical fitness. This causes problems in walking with a prosthesis because energy expenditure in walking with a prosthesis is much higher than in walking with two sound legs. Exercise training may therefore increase the functional walking ability of these patients. To generate a safe and effective aerobic training program, exercise testing of amputees is recommended. The objectives of this study were to develop a maximal exercise testing protocol for lower limb amputees and to compare two different testing methods: combined arm-leg ergometry and arm ergometry. The protocols were tested in five amputee patients. Combined ergometry elicited a higher oxygen uptake and heart rate than arm ergometry. Electrocardiography during combined ergometry was easier to read. Combined ergometry was judged most comfortable by the amputees. The exercise testing protocol was useful in lower limb amputees to determine their maximal aerobic capacity and their main exercise limitation. Future exercise training programs may be based on this testing protocol. Combined arm-leg ergometry is appropriate for unilateral amputees without significant claudication of the remaining leg. Continuous arm ergometry is suitable for unilateral amputees with significant claudication of the remaining limb or bilateral amputees.

Adolescent↗

Self-paced walking as a method for exercise testing in elderly and young men.

1. An exercise test has been developed which is suitable for elderly or frail subjects. It is based on free walking at three different speeds on a level indoor course of 256m. The subject sets his own pace in accord with simple instructions. 2. Twenty-four elderly men and ten young men took part in the study. 3. The time and number of paces taken to cover two sections of 100m within the course were used to establish that the subjects walked steadily. Walking speed, pace frequency and stride length were then calculated. 4. Heart rate was obtained with body-borne tape recorders and related to the walking speed. The heart rate at a standard walking speed could then be obtained by interpolation. This is an assessment of the cardiovascular response to exercise (physical condition). The variation on repeating the test was +/-5 per cent and there was no significant difference between the two age groups. 5. The assessment was found to correlate moderately well with a conventional assessment of physical condition based on oxygen uptake from tests on a bicycle ergometer. 6. The test could also be used as a performance index since walking speed was characteristic for the subject. The younger group walked significantly faster than the older group. As a performance index the test is therefor sensitive to age differences.

Adult↗

The prognostic significance of clinical history, exercise testing and ambulatory electrocardiography in patients with uncomplicated myocardial infarction.

The prognostic value of early clinical history, exercise testing and ambulatory electrocardiography was assessed in 263 men (mean age 50 years) recovering from an uncomplicated myocardial infarction (MI). During a mean follow-up period of 31 months, 11 patients died of cardiac causes, 22 developed a non fatal recurrent MI, 16 unstable angina (UA) and 16 underwent coronary artery bypass surgery. The appearance at the exercise stress test of an ischemic S-T segment depression of 0.2 mV or greater (P less than 0.001) as well as the achievement of a work load of 360 Kg-m/m' or less (P less than 0.01) and of a rate-pressure product of 200 Units or less (P less than 0.01), were found to be predictive of the future development of UA, but neither of cardiac death nor of non fatal recurrent MI. The ischemic response was also seen to be predictive of cardiac death (P less than 0.05). S-T segment depression of 0.1 mV or greater, angina and ventricular ectopic activity during the stress test and clinical history were not of predictive value. Complex ventricular ectopic activity (multiform extrasystoles, couplets and ventricular tachycardia) recorded during 24 hour ambulatory electrocardiogram was seen to be predictive of death and non fatal MI. Whereas some parameters such as the ejection fraction and the extension of coronary artery disease are generally accepted as good predictors for cardiac events, others, such as those derived from exercise testing, history and ambulatory electrocardiography may change their predictive value from one survey to another. These discrepancies are due to differences in patient characteristics, in methodology and in medical management.(ABSTRACT TRUNCATED AT 250 WORDS)

Angina, Unstable↗

Ventricular arrhythmias during exercise testing, jogging, and sedentary life: a comparative study of healthy physically active men, healthy sedentary men, and men with previous myocardial infarction.

The occurrence of ventricular arrhythmias during exercise testing, jogging, and sedentary life with and without preceding exercise was studied with the aid of ambulatory electrocardiographic monitoring in healthy physically active men, healthy sedentary men, and men with previous myocardial infarction (15 men in each group). Ventricular premature beats of the same grade were found during exercise testing and jogging in ten of the 15 healthy physically active men, in ten of the 15 healthy sedentary men, and in eight of the 15 men with previous myocardial infarction. When unifocal ventricular premature beats were omitted, the corresponding figures were 14/15, 11/15, and 15/15, respectively. Healthy physically active men had less ventricular arrhythmias in all of the tested situations. The greatest number and also the highest grades of ventricular arrhythmias during the exercises were found in healthy sedentary men, whereas the men with previous myocardial infarction had ventricular arrhythmias more during sedentary life.

Adult↗

Plasma thromboxane B2, 6-keto PGF1 alpha and cyclic nucleotides levels as related to treadmill exercise test in patients with ischemic heart disease.

Plasma prostanoids and levels of cyclic nucleotides were studied in forty-nine outpatients with precordial pains and subjected to the treadmill exercise test. Blood samples were drawn before, immediately after and 30 minutes after exercise, from antecubital veins. Plasma TXB2, 6-keto PGF1 alpha, cyclic AMP and cyclic GMP levels were measured by radioimmunoassay. The results of exercise tests were evaluated according to the treadmill exercise score (TES) of Hollenberg et al. Patients were divided into two groups; those with TES (-) with ischemic findings in exercise and those with TES (+) with normal exercise response. There were no differences in TXB2 levels between the two groups before exercise. Immediately after exercise statistically significant differences in TXB2 levels were present between the two groups. There were increased levels in the TES (-) group and decreased levels in the TES (+) group (p less than 0.01). Although the 6-keto PGF1 alpha levels were the same between the two groups before exercise, 6-keto PGF1 alpha levels in the TES (+) group increased significantly immediately after exercise. Similar changes were noted in the case of cyclic nucleotides, and the differences increased immediately after exercise. We conclude that high responses of cyclic nucleotides and PGI2 are required to counteract increases in levels of TXA2 and diminution of these responses may be an important phenomenon involved in the physiological status of ischemic heart disease.

6-Ketoprostaglandin F1 alpha↗

[Prediction of severity of coronary artery disease by treadmill exercise testing].

Coronary angiography was performed in 250 patients with a significant ischemic ST segment change detected by symptom-limited maximum treadmill exercise testing, and relationship between anatomical severity of coronary artery disease and parameters in exercise testing was studied. The age of the patients ranged from 34 to 76 years (188 men, 62 women). One-vessel disease (1VD) was presented in 82 patients, two-vessel disease (2VD) in 42, three-vessel disease or left main coronary disease (3VD) in 26, and no significant stenosis was presented in 100 subjects (Normal). Functional aerobic impairement (FAI) was evaluated in each group as a parameter of exercise capacity, myocardial aerobic impairment (MAI) and heart rate impairment (HRI) were also evaluated as a parameter of maximum myocardial oxygen requirements and maximum heart rate, respectively. Using these parameters, discriminant analysis was performed to compare the group with significant coronary artery disease and the Normal group. Also, to compare the group with multi-vessel disease and the group with less than 2VD. Also, the 3VD group and the group with less than 3VD. FAI, MAI and HRI were significantly different (p less than 0.0001) in each group. The discriminant formula to separate the group of significant coronary artery disease from the Normal group was Z = -1.049 + 0.02 [FAI] +0.08 [MAI] +0.03 [HRI]. According to this formula, sensitivity was 92.5% and specificity was 71.5%. The discriminant formula to separate the group with multi-vessel disease from the group with less than 2VD was Z = -4.731 + 0.07 [FAI] +0.106 [MAI] +0.02 [HRI]. According to this formula, sensitivity was 96.3% and specificity was 78.8%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Relationship of C-reactive protein to presence and severity of coronary atherosclerosis in patients with stable angina pectoris or a pathological exercise test.

BACKGROUND: C-reactive protein (CRP) level is a sensitive marker of inflammation and a probable predictor of cardiovascular risk. The aim of this study was to assess the relationship between the presence and the extent of coronary atherosclerosis and CRP level in patients referred for coronary angiography for stable angina pectoris or a pathological exercise test. PATIENTS AND METHODS: A group of 200 patients were prospectively analyzed for the relationship between the presence and extent of coronary atherosclerosis and high-sensitivity CRP. Patients with stable angina pectoris or a pathological exercise test were included. RESULTS: For the whole group the CRP geometric mean was 2.92 mg/l and the median 3.0 mg/l. There was no difference between groups of patients with different extents of coronary lesions (P = 0.320, one-way analysis of variance). In patients without significant coronary disease the CRP geometric mean was 3.1 (2.28-4.21) mg/l with a variation coefficient of 118.4%; in patients with coronary artery disease the geometric mean was 2.83 (2.34-3.43) mg/l with a variation coefficient of 104.0%. The difference in CRP between both groups was not significant (P = 0.601). There was also no significant difference in CRP levels between groups of patients with and without a history of myocardial infarction (2.65 (2.08-3.36) mg/l and 3.18 (2.54-3.98) mg/l, P = 0.266) respectively. There was no correlation between the classification of angina pectoris and the logarithm of CRP level (P = 0.331). This relationship was not confirmed even in the group of patients with significant coronary artery disease (P = 0.693). CONCLUSIONS: CRP level is not related to the extent or the presence of coronary atherosclerosis assessed by coronary angiography, history of myocardial infarction or class of stable angina pectoris in patients referred for coronary angiography for stable angina pectoris or a pathological exercise test.

Aged↗

Cardiopulmonary exercise testing in interstitial lung disease.

Interstitial lung disease (ILD) can determine severe lung function impairment both at rest and during exercise. Usually, resting measurements of lung and cardiac function give enough information on the degree of the disease. Thus, exercise testing should be reserved only for particular situations such as presence at the same time of cardiac and respiratory involvement, symptomatic patients with normal spirometry, and to check the response to therapy. A better understanding of the pathophysiology and cardiorespiratory consequences of ILD can give an important contribution in improving methods of exercise testing to assess disability. In this perspective, we analyze the factors limiting exercise performance: the progressive hypoxemia that appears or is worsened by exertion; the ventilatory abnormalities that lead to a rapid shallow breathing pattern with a VE that reach the MVV; and the cardiovascular limitation with low maximum heart rate, low cardiac output and high PVR and PAP.

Exercise Test↗

Exercise test in variant form of angina pectoris. Comparison of the results with spontaneous attacks.

Exercise tests were performed in 14 patients with untreated variant angina with frequent spontaneous attacks and in 15 patients after treatment abolished the attacks. (1) Anginal attacks associated with ST elevation were induced by exercise in 79% of untreated patients. By contrast, ST elevation was not observed in treated patients and ST depression was induced in 53% of the cases. (2) Exercise-induced ST elevation in untreated patients was shown in the same leads as the spontaneous attacks. (3) Exercise-induced ST elevation appeared initially during the recovery phase after exercise in 36% of untreated patients. Exercise-induced ST depression appeared during or immediately after exercise. (4) The reproducibility of exercise-induced ST elevation was low with repeated tests at different stages, but exercise-induced ST depression was consistently observed. (5) The exercise-induced ST depression and lack of ST changes in treated patients were highly suggestive of the presence and absence of organic coronary artery disease, respectively. However, the exercise-induced ST elevation in untreated patients did not differentiate between the presence or absence of organic stenosis of the coronary arteries. The results of exercise tests vary with the stage of variant angina. It is suggested that a coronary arterial spasm is a trigger mechanism for exercise-induced angina in cases of variant angina with frequent spontaneous attacks.

Adult↗

Feasibility of mobile cardiopulmonary exercise testing.

QUESTIONS UNDER STUDY: Evaluation of cardiopulmonary capacity and work ability is often done by cardiopulmonary exercise testing under laboratory conditions. Mobile CPET devices allow measurements under specific real-life conditions, i.e.: at the patient's workplace. We investigated the feasibility and validity of mobile CPET in healthy controls. METHOD: We compared oxygen uptake measured by mobile CPET (MCPET) with that by standard CPET (LCPET), and we compared oxygen uptake with markers of self-reported physical exhaustion. Twenty-two healthy subjects (15 male, 21-49 years) underwent LCPET and 6 outdoors 12-min running tests (MCPETs) at different intensities. Physical exhaustion and the time they could continue exercising (T(EX)) was reported for each level. Standard descriptive statistics were applied. RESULTS: Of 132 MCPETs, performed in 22 subjects, 128 (97%) were of suitable quality. The facemask was well tolerated and nobody felt uncomfortable at any time. On average VO2 [peak] was 21% (SD 9%) higher with MCPET compared to LCPET (median 3.60, range [2.22, 5.14] versus median 2.63, range [1.67, 4.16] L*min(-1)), but showed a strong correlation (r2 = 0.90). MCPET-VO2 at steady state correlated with subjectively rated physical exhaustion, and with TEX. CONCLUSIONS: Out-of-laboratory MCPET was feasible, correlated with parameters of standard CPET, and correlated with markers of physical exhaustion. After validation in patients, MCPET could be used for a rational evaluation of cardiopulmonary capacity and work ability in selected patients.

Adult↗

Comparison of endothelial vasodilator function, inflammatory markers, and N-terminal pro-brain natriuretic peptide in patients with or without chronotropic incompetence to exercise test.

OBJECTIVE: To investigate the role of endothelial function, inflammatory markers, and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with impaired chronotropic response during exercise test. METHODS: 86 subjects were enrolled. Treadmill exercise test was conducted according to the modified Bruce protocols. Brachial ultrasound was used to measure endothelium dependent flow mediated vasodilatation (FMD). Chronotropic incompetence was defined as either failure to achieve 85% of the age predicted maximum heart rate or a low chronotropic index (< 0.8). RESULTS: Of the 86 patients, 20 (23%) exhibited chronotropic incompetence. The patients were divided into three groups according to chronotropic index: group 1, < 0.8 (n = 20); group 2, 0.8-1.0 (n = 26); and group 3, > 1.0 (n = 40). Patients with impaired chronotropic response had significantly lower FMD than those with higher chronotropic response (mean (SD) 2.8 (1.9)% v 5.0 (2.8)% v 5.3 (2.5)%, p = 0.002, for groups 1, 2, and 3, respectively). Serum concentrations of high-sensitivity C reactive protein (hsCRP), monocyte chemoattractant protein-1 (MCP-1), and NT-proBNP were significantly higher in group 1 than in groups 2 and 3 (hsCRP: 19 (12) v 9 (6) v 9 (6) mg/l, p < 0.05; MCP-1: 140 (51) v 133 (60) v 108 (46) pg/ml, p = 0.046; NT-proBNP: 4760 (1980) v 3710 (850) v 3910 (1060) mg/l, p = 0.019, respectively). In addition, chronotropic index was significantly related to FMD (r = 0.380, p = 0.001) and inversely related to hsCRP (r = -0.267, p = 0.013). By multivariate analysis, impaired chronotropic response was significantly related to endothelial dysfunction (p = 0.012). CONCLUSION: Patients with impaired chronotropic response to graded exercise had endothelial dysfunction, enhanced systemic inflammation, and higher NT-proBNP concentrations. These findings may partly explain the mechanism of chronotropic incompetence as a predictor of cardiovascular risk and increased mortality.

Adult↗