Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting. In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.

BACKGROUND: Inspiratory muscle training (IMT) has been widely applied to different populations, including the general population of older adults. In addition to increasing inspiratory muscle strength, other benefits of IMT in the health of this population have been reported. The primary aim of this study was to review the effects of IMT on the general parameters of health (eg, respiratory, functional, physical, and other variables) in older adults (≥ 60 y), and the secondary aim was to analyze the main IMT protocol used in the studies. METHODS: We searched the MEDLINE, PEDro, SciELO, and LILACS databases to identify relevant randomized controlled clinical trials, and we assessed their methodological quality according to the PEDro scale. The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines were used to guide the development of the protocol for this systematic review. RESULTS: The search yielded 7 studies involving 248 participants from 917 titles. The main outcomes investigated in response to IMT were related to the respiratory, functional, and physical variables. The results indicate that IMT promotes an increase of inspiratory muscle strength and diaphragmatic thickness in older adults. There was heterogeneity in the protocols described for this population with respect to the total training time (4–8 weeks), intensity (30–80% of the maximum inspiratory pressure), and weekly frequency (5 or 7 sessions). CONCLUSIONS: The reviewed studies revealed a positive trend for the effectiveness of IMT in improving inspiratory muscle performance in elderly subjects. More randomized studies are needed to evaluate other outcomes (eg, functional capacity, exercise capacity, cardiac autonomic control, quality of life, and others) to provide robust evidence that this training modality can promote improvements in health parameters in this population. In addition, the usual IMT prescription in this population is based on sets and repetitions, of mild to moderate intensity, performed on most days of the week, for ≥ 4 weeks.

Analyzes of cardiac autonomic responses at the initial transient of exercise have been used for the investigation of the cardiovascular health. We evaluated the influence of aerobic fitness on HR and HRV responses at the onset of exercise. 25 male subjects (22.3±2.4 years) were divided into 2 groups: ‘low aerobic fitness’ (36.2±2.6ml.kg⁻¹.min⁻¹; n=10) and ‘high aerobic fitness’ (46.4±5.0ml.kg⁻¹.min⁻¹; n=15). The experimental session consisted of assessing the beat-to-beat HR at rest and during submaximal exercise. The autonomic responses at the onset of exercise were calculated by fitting the HR and HRV (rMSSD-index) curves during the initial 300s of exercise into a first-order exponential equation. The time constant of HR and of the rMSSD index (τ_onHR and τ_onrMSSD) were calculated for analysis. We observed lower values of τ_onrMSSD in the high aerobic fitness group compared to the low aerobic fitness group (26.8±5s vs. 38.0±18s, respectively; p=0.02). The τ_onHR (42.0±15 vs. 49.3±26s, p=0.38) for the groups showed no difference. Aerobic fitness partially influenced the autonomic responses during exercise, since individuals with higher fitness showed faster decreases in beat-to-beat HRV at the onset of exercise.

Trevizani, GA, Seixas, MB, Benchimol-Barbosa, PR, Vianna, JM, da Silva, LP, and Nadal, J. Effect of resistance training on blood pressure and autonomic responses in treated hypertensives.J Strength Cond Res32(5): 1462–1470, 2018—This study evaluated the effect of resistance training (RT) on heart rate variability (HRV) and on blood pressure (BP) responses to acute and short-term exposure in treated hypertensive (HT) subjects. Twenty-one men participated in the study, 8 HT under drug treatment regimen and achieving adequate BP control before inclusion and 13 normotensive (NT). The RT protocol consisted of 12 sessions with eight exercises (leg extension, leg press, leg curl, bench press, seated row, triceps push-down, seated calf flexion, and seated arm curl) performed for two sets of 15–20 repetitions with 50% of one repetition maximum with 2-minute rest intervals in between sets, 3×/week. Heartbeat measurements were taken before and after RT, and BP was measured at the beginning and at the end of each session after 10-minute rest. The repeated measures analysis of variance (effect: group vs. training) evaluated BP and HRV responses. Effect size (ES) calculation measured the magnitude of the RT effect on these variables. There was a statistically significant reduction in postexercise systolic BP in both groups (p= 0.040), without significant change in resting BP along RT (p= 0.159). Regarding HRV, it was observed a reduced sympathetic-vagal balance (training interaction vs. group:p= 0.058, ES = −0.83) in HT subjects. Resistance training promotes a significant acute reduction of BP in the HT and NT groups and provides a slight benefit of cardiac autonomic balance in the HT.