Exercise training and endothelial function in patients with type 2 diabetes: a meta-analysis

Background: The prevalence of patients with concomitant cardiovascular disease and diabetes mellitus (DM) is increasing rapidly. We aimed to compare the effectiveness of current cardiac rehabilitation (CR) programs across seven European countries between elderly cardiac patients with and without DM. Methods: 1633 acute and chronic coronary artery disease (CAD) patients and patients after valve intervention with an age 65 or above who participated in comprehensive CR (3 weeks to 3 months, depending on centre) were included. Peak oxygen uptake (VO 2 peak), body mass index, resting systolic blood pressure, low-density lipoproteincholesterol (LDL-C), and glycated haemoglobin (HbA1c) were assessed before start of CR, at termination of CR (variable time point), and 12 months after start of CR, with no intervention after CR. Baseline values and changes from baseline to 12-month follow-up were compared between patients with and without DM using mixed models, and mortality and hospitalisation rates using logistic regression. Results: 430 (26.3%) patients had DM. Patients with DM had more body fat, lower educational level, more comorbidities, cardiovascular risk factors, and more advanced CAD. Both groups increased their VO 2 peak over the study period but with a significantly lower improvement from baseline to follow-up in patients with DM. In the DM group, change in HbA1c was associated with weight change but not with change in absolute VO 2 peak. 12-month cardiac mortality was higher in patients with DM. Conclusions: While immediate improvements in VO 2 peak after CR in elderly patients with and without DM were similar, 12-month maintenance of this improvement was inferior in patients with DM, possibly related to disease progression. Glycemic control was less favourable in diabetic patients needing insulin in the short-and long-term. Since glycemic control was only related to weight loss but not to increase in exercise capacity, this highlights the importance of weight loss in obese DM patients during CR.

Section: Blood Pressurementioning

confidence: 89%

Clinical outcomes after cardiac rehabilitation in elderly patients with and without diabetes mellitus: The EU-CaRE multicenter cohort study

Eser

Marcin

Prescott

et al. 2020

“…In fact, long-term (12 months), resistance + aerobic exercise training has been demonstrated to suppress cytokine production through reduced inflammatory cell infiltration of adipose tissue and improved adipocyte function [117]. Also, the autonomic tone was proved to ameliorate after 12 weeks of personalised physical training (both aerobic and resistance exercise) [102], as well as endothelial function [118], intima-media thickness, and arterial stiffness [119]. Notably, also several echocardiographic parameters can be improved with exercise training [120].…”

Section: Effect Of Exercise Trainingmentioning

confidence: 99%

“…In addition, diabetes-related endothelial dysfunction might also explain the reduced increase in cardiorespiratory fitness after exercise training. Whilst the improvement in endothelial function is associated with the increased cardiorespiratory fitness in both T2DM subjects and the general population [134], the increase appears smaller in the first ones [118,134]. Another explanation for the reduced sensitivity of VO 2peak to physical exercise in T2DM could be related to an interference of glucose lowering drugs with mitochondria.…”

Section: Effect Of Exercise Trainingmentioning

confidence: 99%

Type 2 diabetes and reduced exercise tolerance: a review of the literature through an integrated physiology approach

Nesti

Pugliese

Sciuto

et al. 2020

The association between type 2 diabetes mellitus (T2DM) and heart failure (HF) is well established. Early in the course of the diabetic disease, some degree of impaired exercise capacity (a powerful marker of health status with prognostic value) can be frequently highlighted in otherwise asymptomatic T2DM subjects. However, the literature is quite heterogeneous, and the underlying pathophysiologic mechanisms are far from clear. Imaging-cardiopulmonary exercise testing (CPET) is a non-invasive, provocative test providing a multi-variable assessment of pulmonary, cardiovascular, muscular, and cellular oxidative systems during exercise, capable of offering unique integrated pathophysiological information. With this review we aimed at defying the cardiorespiratory alterations revealed through imaging-CPET that appear specific of T2DM subjects without overt cardiovascular or pulmonary disease. In synthesis, there is compelling evidence indicating a reduction of peak workload, peak oxygen assumption, oxygen pulse, as well as ventilatory efficiency. On the contrary, evidence remains inconclusive about reduced peripheral oxygen extraction, impaired heart rate adjustment, and lower anaerobic threshold, compared to non-diabetic subjects. Based on the multiparametric evaluation provided by imaging-CPET, a dissection and a hierarchy of the underlying mechanisms can be obtained. Here we propose four possible integrated pathophysiological mechanisms, namely myocardiogenic, myogenic, vasculogenic and neurogenic. While each hypothesis alone can potentially explain the majority of the CPET alterations observed, seemingly different combinations exist in any given subject. Finally, a discussion on the effects-and on the physiological mechanisms-of physical activity and exercise training on oxygen uptake in T2DM subjects is also offered. The understanding of the early alterations in the cardiopulmonary response that are specific of T2DM would allow the early identification of those at a higher risk of developing HF and possibly help to understand the pathophysiological link between T2DM and HF.

“…Data are mean ± SD or n (%). 'Ischemic cause' indicates coronary artery disease or myocardial infarction A, peak velocity of mitral inflow during atrial systole; ACE, angiotensin converting enzyme; ARB, angiotensin II receptor blocker; BMI, body mass index; BNP, B-type natriuretic peptide; DPP4, dipeptidyl peptidase 4; E, peak velocity of mitral inflow during early diastole; e' , average of septal and lateral mitral annular early diastolic peak velocities; eGFR, estimated glomerular filtration rate; HbA1c, glycohemoglobin A1c; NA, not applicable; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; MRAs, mineralocorticoid receptor antagonists; NYHA, New York Heart Association a n = 169, 38 Data are mean ± SD or n (%). Abbreviations are as defined in peak VO 2 and the AT VO 2 were lowered in the diabetics in the LVEF 40-49% group, but not in the LVEF ≥ 50% group, after adjustment for age-squared, gender, anemia, renal function, LVEF, and log BNP (Additional file 1: Table S2).…”

Section: Table 1 Baseline Characteristics Of the Total Chf Populationmentioning

confidence: 99%

“…Accordingly, promotion of increased physical activity and exercise training is essential for CHF patients with T2DM to improve cardiorespiratory fitness and reduce cardiovascular or all-cause mortality. Indeed, various types of exercise training including moderate-intensity continuous training and high-intensity interval training are reported to improve cardiac function, vascular function, lipid profiles, and low-grade inflammation as well as exercise capacity in obese subjects or patients with T2DM [35][36][37][38] and in patients with CHF [39]. A large clinical trial has shown that sustained improvement of exercise capacity by intensive lifestyle intervention aiming at increased physical activity and weight loss reduces risk of incident HF in obese subjects with T2DM [40].…”

Section: Table 4 Multivariable Analysis For Peak Vo 2 In the Chf Patimentioning

confidence: 99%

Type 2 diabetes is an independent predictor of lowered peak aerobic capacity in heart failure patients with non-reduced or reduced left ventricular ejection fraction

Abe

Yokota

Fukushima

et al. 2020

Background Although type 2 diabetes mellitus (T2DM) is one of the most frequent comorbidities in patients with chronic heart failure (CHF), the effects of T2DM on the exercise capacity of CHF patients are fully unknown. Here, we tested the hypothesis that the coexistence of T2DM lowers CHF patients’ peak aerobic capacity. Methods We retrospectively analyzed the cases of 275 Japanese CHF patients with non-reduced ejection fraction (left ventricular ejection fraction [LVEF] ≥ 40%) or reduced EF (LVEF < 40%) who underwent cardiopulmonary exercise testing. We divided them into diabetic and nondiabetic groups in each CHF cohort. Results The mean peak oxygen uptake (VO2) value was 16.87 mL/kg/min in the non-reduced LVEF cohort and 15.52 mL/kg/min in the reduced LVEF cohort. The peak VO2 was lower in the diabetics versus the nondiabetics in the non-reduced LVEF cohort with the mean difference (95% confidence interval [95% CI]) of − 0.93 (− 1.82 to − 0.04) mL/kg/min and in the reduced LVEF cohort with the mean difference of − 1.05 (− 1.96 to − 0.15) mL/kg/min, after adjustment for age-squared, gender, anemia, renal function, LVEF, and log B-type natriuretic peptide (BNP). The adjusted VO2 at anaerobic threshold (AT), a submaximal aerobic capacity, was also decreased in the diabetic patients with both non-reduced and reduced LVEFs. Intriguingly, the diabetic patients had a lower adjusted peak O2 pulse than the nondiabetic patients in the reduced LVEF cohort, but not in the non-reduced LVEF cohort. A multivariate analysis showed that the presence of T2DM was an independent predictor of lowered peak VO2 in CHF patients with non-reduced LVEF and those with reduced LVEF. Conclusions T2DM was associated with lowered peak VO2 in CHF patients with non-reduced or reduced LVEF. The presence of T2DM has a negative impact on CHF patients’ exercise capacity, and the degree of impact is partly dependent on their LV systolic function.