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Sepsis is associated with marked alterations in hemodynamic responses, autonomic dysfunction and impaired vascular function. However, to our knowledge, analysis of noninvasive markers to identify greater risk of death has not yet been investigated. Thus, our aim was to explore the prognostic utility of cardiac output (CO), stroke volume (SV), indices of vagal modulation (RMSSD and SD1), total heart rate variability (HRV) indices and FMD of brachial artery (%FMD), all measured noninvasively, in the first 24 hours of the diagnosis of sepsis. 60 patients were recruited at ICU between 2015 and 2017 and followed by 28 days. CO, SV, RR intervals were measurement. Doppler ultrasound was used to assess brachial artery FMD and the hyperemic response were obtained (%FMD). Patients were divided by survivors (SG) and nonsurvivors groups (NSG). A total of 60 patients were analysed (SG = 21 and NSG = 39). Survivors were younger (41±15 years vs. 55±11 years) and used less vasoactive drugs. As expected, APACHE and SOFA scores were lower in NSG compared to SG. In addition, higher SD1, triangular index, % FMD, velocity baseline and hyperemia flow velocity as well as lower HR values were observed in the SG, compared to NSG (P<0.05). Interestingly, RMSSD and SD1 indices were independent predictors of %FMD, ΔFMD and FMDpeak. RMSSD threshold of 10.8ms and %FMD threshold of -1 were optimal at discriminatomg survivors and nonsurvivors. Noninvasive measurements of autonomic and endotelial function may be important markers of sepsis mortality, which can be easily obtained in the early stages of sepsis at the bedside.

BackgroundCardiorespiratory fitness (CRF) is an important prognostic marker in chronic obstructive pulmonary disease (COPD). Obstructive sleep apnea (OSA) also negatively affects exercise tolerance. However, the impact of their association on CRF has not been evaluated. We hypothesized that patients with overlap syndrome would demonstrate a greater impairment in CRF, particularly those with severe COPD.MethodsIndividuals with COPD were recruited. First, subjects underwent clinical and spirometry evaluation. Next, home-based sleep evaluation was performed. Subjects with an apnea-hypopnea index (AHI) < 15 episodes/h were allocated to the COPD group and those with an AHI ≥ 15 episodes/h to the overlap group. On the second visit, subjects underwent a cardiopulmonary exercise test. Subsequently, they were divided into four groups according to the severity of COPD and coexistence of OSA: COPDI/II; overlap I/II; COPDIII/IV; and overlap III/IV.Results: Of the 268 subjects screened, 31 were included. The overlap group exhibited higher values for peak carbon dioxide (COPD: 830 [678–1157]; overlap: 1127 [938–1305] mm Hg; p < 0.05), minute ventilation (COPD: 31 [27–45]; overlap: 48 [37–55] L; p < 0.05), and peak systolic blood pressure (COPD: 180 [169–191]; overlap: 220 [203–227] mm Hg; p <; 0.001) and peak diastolic blood pressure COPD: 100 [93–103]; overlap: 110 [96–106] mm Hg; p < 0.001). COPD severity associated with OSA produced a negative impact on exercise time (COPDIII/IV: 487 ± 102; overlap III/IV: 421 ± 94 s), peak oxygen uptake (COPDIII/IV: 12 ± 2; overlap III/IV: 9 ± 1 ml.Kg.min−1 ; p < 0.05) and circulatory power (COPDIII/IV: 2306 ± 439; overlap III/IV: 2162 ±  340 ml/kg/min.mmHg; p < 0.05).ConclusionOverlap syndrome causes greater hemodynamic and ventilatory demand at the peak of dynamic exercise. In addition, OSA overlap in individuals with more severe COPD impairs CRF.

Background Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs). Methods Thirty-nine patients will be assessed at baseline (T0–18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed. Discussion In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU. Trial registration Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf . Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/

The endothelium plays an important role in maintaining vascular homeostasis and regulating blood vessel function. Endothelial function is considered an independent predictor for risk of future cardiovascular events in cardiovascular and non-cardiovascular patients, as well as a predictor for postoperative complications in cardiovascular surgery patients. Brachial artery flow-mediated dilation by high-resolution ultrasound is widely used to evaluate endothelium-dependent vasodilation, which is mainly mediated by nitric oxide release. Physical exercise exerts beneficial effects on endothelial function and can be used in both primary and secondary prevention of cardiac and peripheral artery diseases, even in the postoperative period of cardiovascular surgery.

Our aim was to identify optimal cardiopulmonary exercise testing (CPET) threshold values that distinguish disease severity progression in patients with co-existing systolic heart failure (HF) and chronic obstructive pulmonary disease (COPD), and to evaluate the impact of the cut-off determined on the prognosis of hospitalizations. We evaluated 40 patients (30 men and 10 woman) with HF and COPD through pulmonary function testing, doppler echocardiography and maximal incremental CPET on a cycle ergometer. Several significant CPET threshold values were identified in detecting a forced expiratory volume in 1 second (FEV 1 ) < 1.6 L: 1) oxygen uptake efficiency slope (OUES) < 1.3; and 2) circulatory power (CP) < 2383 mmHg.mlO 2 .kg −1 . CPET significant threshold values in identifying a left ventricular ejection fraction (LVEF) < 39% were: 1) OUES: < 1.3; 2) CP < 2116 mmHg.mlO 2 .kg −1 .min −1 and minute ventilation/carbon dioxide production ( V̇ E / V̇ CO 2 ) slope>38. The 15 (38%) patients hospitalized during follow-up (8 ± 2 months). In the hospitalizations analysis, LVEF < 39% and FEV 1 < 1.6, OUES < 1.3, CP < 2116 mmHg.mlO 2 .kg −1 .min −1 and V̇ E / V̇ CO 2  > 38 were a strong risk predictor for hospitalization (P ≤ 0.050). The CPET response effectively identified worsening disease severity in patients with a HF-COPD phenotype. LVEF, FEV 1, CP, OUES, and the V̇ E / V̇ CO 2 slope may be particularly useful in the clinical assessment and strong risk predictor for hospitalization.

Sepsis is a serious organ dysfunction leading to endothelial damage in critical patients. Physiologically, there is an augment of vascular diameter in response to increased vascular blood flow and shear stress stimulus. However, the pattern of vascular response in face of passive mobilization (PM), an early mobilization physical strategy, has not yet been explored in patients with sepsis. To explore patterns of vascular response to PM and associations with clinical and cardiovascular profile in patients with sepsis. Cross-sectional, single-arm study. Thirty-two patients diagnosed with sepsis were enrolled. Vascular response was assessed by flow-mediated dilation (FMD) using brachial artery ultrasound, before and after PM. The PM (to assess the response pattern) and SR (shear rate) were also calculated. PM protocol consisted of knees, hips, wrists, elbows, shoulders, dorsiflexion/plantar flexion movements 3 × 10 repetitions each (15 min). Arterial stiffness was assessed by Sphygmocor®, by analyzing the morphology and pulse wave velocity. Cardiac autonomic modulation (CAM) was assessed by analyzing heart rate variability indexes (mean HR, RMSSD, LF, HF, ApEn, SampEn, DFA). Different vascular responses were observed after PM: (1) increased vascular diameter (responders) (n = 13, %FMD = 11.89 ± 5.64) and (2) reduced vascular diameter (non-responders) (n = 19, %FMD= −7.42 ± 6.44). Responders presented a higher non-linear DFA2 index (p = 0.02). There was a positive association between FMD and DFA (r = 0.529; p = 0.03); FMD and SampEn (r = 0.633; p < 0.01). A negative association was identified between FMD and LF (Hz) (r= −0.680; p < 0.01) and IL-6 (r= −0.469; p = 0.037) and SR and CRP (r= −0.427; p = 0.03).

An amendment to this paper has been published and can be accessed via a link at the top of the paper.An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The impact of COVID‐19 on cardiorespiratory fitness (CRF) is negative, increasing the likelihood of exertional symptoms such as fatigue and shortness of breath, and adversely affecting vascular function, impairing cardiovascular health. This study investigated endothelial function and its relationship with CRF in patients who have recovered COVID‐19. Patients were evaluated 1 month after infection, including clinical assessment, pulmonary function, endothelial function (measured by flow‐mediated dilation), and cardiopulmonary exercise testing. COVID‐19 survivors exhibited reduced exercise capacity, with poor values of peak V̇O2peak and FMD (%) according to disease severity. However, endothelial function was worse in COVID‐19 patients, regardless of severity, compared to the control group. Significant associations were observed between poorer FMD (%) and peak V̇O2, workload, circulatory power, and V̇O2peak/WR. Endothelial function was significantly associated with CRF in COVID‐19 patients according to disease severity. Strategies to improve CRF and reduce the negative impacts of endothelial function damage should be further investigated.

The study was conducted to determine the impact of chronic obstructive pulmonary disease (COPD) in association with obstructive sleep apnea syndrome (OSAS) on cardiac autonomic control and functional capacity. The study was a cross-sectional prospective controlled clinical study. Heart rate variability indices of 24 COPD (n = 12) and COPD+OSAS (n = 12) patients were evaluated and compared by electrocardiographic recordings acquired during rest, active postural maneuver (APM), respiratory sinus arrhythmia maneuver (RSA-m), and the 6-minute walk test (6MWT). The COPD group presented higher parasympathetic modulation during APM when compared to the COPD+OSAS group ( = 0.02). The COPD+OSAS group presented higher sympathetic modulation during RSA-m when compared to the COPD group ( = 0.00). The performance during 6MWT was similarly impaired in both groups, despite the greater severity of the COPD group. Subjects with COPD+OSAS present marked sympathetic modulation, and the presence of OSAS in COPD subjects has a negative impact on functional capacity regardless of the severity of lung disease.

To evaluate heart rate variability during an inspiratory muscle endurance protocol at three different load levels [30%, 60% and 80% of maximal inspiratory pressure], in patients who had previously undergone coronary artery bypass grafting. Nineteen late postoperative myocardial revascularization patients participating in a cardiovascular rehabilitation program were studied. Maximal inspiratory pressure maneuvers were performed. An inspiratory muscle endurance protocol at 30%, 60% and 80% of maximal inspiratory pressure was applied for four minutes each, in random order. Heart rate and RR intervals were recorded and heart rate variability was analyzed by time (RMSSD-the mean of the standard deviations for all R-R intervals, and RMSM-root-mean square differences of successive R-R intervals) and frequency domains indices (high and low frequency) in normalized units. ANOVA for repeated measurements was used to compare heart rate variability indices and Student t-test was used to compare the maximal inspiratory pressure and maximal expiratory pressure values. Heart rate increased during performance of maximal respiratory pressures maneuvers, and the maximal inspiratory pressure and maximal expiratory pressure mean values were significantly lower than predicted values (P <0.05). RMSSD increased significantly at 80% in relation to rest and 30% of maximal inspiratory pressure and RMSM decreased at 30% and 60% of maximal inspiratory pressure in relation to rest (P <0.05). Additionally, there was significant and progressive decrease in low frequency and increase in high frequency at 30%, 60% and 80% of maximal inspiratory pressure in relation to the resting condition. These results suggest that respiratory muscle training at high intensities can promote greater parasympathetic activity and it may confer important benefits during a rehabilitation program in post-coronary artery bypass grafting.