The Effects of a 10-wk Outpatient Pulmonary Rehabilitation Program on Exercise Performance, Muscle Strength, Soluble Biomarkers, and Quality of Life in Patients With Pulmonary Hypertension Purpose: Pulmonary arterial hypertension (PAH) is characterized by right ventricular failure, leading to exertional dyspnea, skeletal muscle weakness, and poor quality of life (QOL). Apart from treatment with PAH-specific drugs, guidelines recommend pulmonary rehabilitation (PR). Clinical PR programs have shown improvement in functional capacity and QOL. However, little is known about the effectiveness of an outpatient PR program. The aim of our study was to assess effectiveness of a multidisciplinary outpatient PR program. Methods: Patients with PAH or chronic thromboembolic pulmonary hypertension (CTEPH), who were in a stable condition on optimized drug therapy, followed a 10-wk outpatient program in a rehabilitation center. The PR program was designed to improve exercise capacity and health status by means of low load cycling, walking, and muscle training twice a week combined with psychological counseling. QOL was measured by the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) questionnaire. Results: Twenty-one patients (13 women) with PAH (n = 16) or CTEPH (n = 5) completed the study. All patients were in New York Heart Association (NYHA) functional class III, and their mean age was 45 ± 16 yr. After PR, the mean cycling endurance time increased by 4.4 min (P < .001), 6-min walk distance by 12.2 m (P < .05), and maximum inspiratory pressure by 5.8 cm H2O (P = .01). Skeletal muscle function increased significantly. The CAMPHOR questionnaire demonstrated significant decrease in symptoms and improvement in QOL. Soluble biomarkers did not show any change before and after PR. Conclusions: Outpatient PR could be an effective instrument to improve exercise capacity and health status in patients with PAH or CTEPH. Correspondence: Karin Boomars, MD, PhD, Department of Pulmonary Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands (k.boomars@erasmusmc.nl). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults Purpose: Outpatient cardiac rehabilitation (CR) participation after myocardial infarction (MI) reduces all-cause mortality; however, less is known about effects of CR on post-MI hospitalization. The study objective was to investigate effects of CR on hospitalization following acute MI among older adults. Methods: Medicare beneficiaries aged 65 to 88 yr hospitalized in 2008 with acute MI, who survived at least 60 d post-discharge, had a revascularization procedure during index hospitalization, and did not have an MI in previous year were eligible for this study. CR initiation was assessed in the 60 d post-discharge. Competing risk survival analysis was used to estimate the proportion of discharged beneficiaries hospitalized between the end of 60-d exposure window and December 31, 2009, treating death as a competing event. Results: The mean ± SD age of 32 851 Medicare beneficiaries meeting study criteria was 75 ± 6.0 yr, approximately half were male (52%), and the majority were white (88%). In this study, 21% of beneficiaries initiated CR within the exposure window. At 1 yr post-discharge, CR initiators had a lower risk of recurrent MI (4.2% [95% CI, 3.5-5.1]), cardiovascular (15.7% [95% CI, 14.3-17.2]), and all-cause (30.4% [95% CI, 28.8-32.1]) hospitalization than noninitiators (5.2% [95% CI, 5.0-5.5]; 18.0% [95% CI, 17.6-18.4]; and 33.2% [95% CI, 32.5-33.8], respectively). There was no difference in fracture risk (negative control outcome). Conclusions: This study provides evidence that CR can reduce the 1-yr risk of cardiovascular and all-cause hospital admissions in Medicare aged MI survivors. Correspondence: Montika Bush, PhD, Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, 170 Manning Dr, CB# 7594, Chapel Hill, NC 27599 (mbush8@unc.edu). Dr Stürmer receives investigator-initiated research funding and support as Principal Investigator (R01 AG056479) from the National Institute on Aging and as coinvestigator (R01 HL118255, R01 MD011680) from the National Institutes of Health (NIH). He also receives salary support as Director of Comparative Effectiveness Research (CER), NC TraCS Institute, UNC Clinical and Translational Science Award (UL1TR002489), the Center for Pharmacoepidemiology (current members: GlaxoSmithKline, UCB BioSciences, Merck, Takeda), from pharmaceutical companies (GSK, Amgen, AstraZeneca, Novo Nordisk), and from a generous contribution from Dr Nancy A. Dreyer to the Department of Epidemiology, University of North Carolina at Chapel Hill. Dr Stürmer does not accept personal compensation of any kind from any pharmaceutical company. He owns stock in Novartis, Roche, BASF, AstraZeneca, and Novo Nordisk. Dr Brookhart has received investigator-initiated research funding and support as Principal Investigator (NIH, R21 HD080214, R01 AG023178, R01 AG056479); as co-Investigator from the Agency for Healthcare Research, Patient Centered Outcomes Research Institute, AstraZeneca, and Amgen; honoraria paid via UNC for scientific advisory from Merck, GSK, Pfizer, and World Health Information Consultants; and consulting fees from RxAnte. The author others declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Characterization of Dyspnea in Veteran Lung Cancer Survivors Following Curative-Intent Therapy Purpose: Dyspnea is highly prevalent in lung cancer survivors following curative-intent therapy. We aimed to identify clinical predictors or determinants of dyspnea and characterize its relationship with functional exercise capacity (EC). Methods: In an analysis of data from a cross-sectional study of lung cancer survivors at the VA San Diego Healthcare System who completed curative-intent therapy for stage I-IIIA disease ≥1 mo previously, we tested a thorough list of comorbidities, lung function, and lung cancer characteristics. We assessed dyspnea using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Lung Cancer Module 13 (LC13) and functional EC using the 6-minute walk. We replicated results with the University of California San Diego Shortness of Breath Questionnaire. Results: In 75 participants at a median of 12 mo since treatment completion, the mean ± SD LC13-Dyspnea score was 35.3 ± 26.2; 60% had abnormally high dyspnea. In multivariable linear regression analyses, significant clinical predictors or determinants of dyspnea were (β [95% CI]) psychiatric illness (−20.8 [−32.4 to −9.09]), heart failure with reduced ejection fraction (−15.5 [−28.0 to −2.97]), and forced expiratory volume in the first second of expiration (−0.28 [−0.49 to −0.06]). Dyspnea was an independent predictor of functional EC (−1.54 [−2.43 to −0.64]). These results were similar with the University of California San Diego Shortness of Breath Questionnaire. Conclusion: We identified clinical predictors or determinants of dyspnea that have pathophysiological bases. Dyspnea was independently associated with functional EC. These results have implications in efforts to reduce dyspnea and improve exercise behavior and functional EC in lung cancer survivors following curative-intent therapy. Correspondence: Duc Ha, MD, MAS; Institute for Health Research, Kaiser Permanente Colorado, 2550 S Parker Rd Ste 200, Aurora, CO 80014 (duc.m.ha@kp.org). This work was supported directly by the American Cancer Society (PF-17-020-01-CPPB) and the National Institutes of Health (1T32HL134632-01 from the NHLBI) and indirectly by the National Cancer Institute (L30CA208950). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cardiopulmonary Exercise Testing Following Open Repair for a Proximal Thoracic Aortic Aneurysm or Dissection Purpose: There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, Vo2peak), and blood pressure. Methods: Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection. Results: Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured Vo2peak was <36% predicted normative values (19.2 mL·kg−1.min−1 vs 29.3 mL·kg−1·min−1, P < .0001); the most marked impairment in Vo2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups. Conclusions: We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. Vo2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness. Correspondence: Bo Yang, MD, PhD, Department of Cardiac Surgery, University of Michigan, Michigan Medicine, 1500 East Medical Center Dr, 5155 Frankel Cardiovascular Center, Ann Arbor, MI, 48109 (boya@med.umich.edu). External financial support: Bo Yang is supported by the National Institutes of Health (K08HL130614 and R01HL141891) and The Phil Jenkins and Darlene & Stephen J. Szatmari Funds. Cristen J. Willer is supported by the National Institutes of Health (R01-HL127564, R35-HL135824, and R01-HL142023). Himanshu J. Patel is supported by The Joe D. Morris Collegiate Professorship, the David Hamilton Fund, and the Phil Jenkins Breakthrough Fund in Cardiac Surgery. Kim A. Eagle is consultant for NHLBI and has a research grant from Gore. Lee W. Jones is supported by the National Cancer Institute, AKTIV Against Cancer, and the Kavli Trust. Sara Saberi is the site principal investigator for 2 clinical trials funded by Myokardia and receives financial support from Myokardia. Internal financial support: Whitney E. Hornsby, Bo Yang, Cristen J. Willer, and Sara Saberi are supported by the University of Michigan, Michigan Medicine, Frankel Cardiovascular Center, Aikens Fund for Aortic Research. Himanshu J. Patel is a consultant for WL gore Edwards and Medtronic. All other authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Aerobic Exercise Effects on Quality of Life and Psychological Distress After an Implantable Cardioverter Defibrillator Purpose: The purpose of this study was to evaluate quality of life (QOL), psychological function, and self-efficacy outcomes in the Anti-Arrhythmic Effects of Exercise After an ICD Trial. Methods: In the Anti-Arrhythmic Effects of Exercise After an ICD Trial, 160 patients (124 men and 36 women) who had an implantable cardioverter defibrillator for primary (43%) or secondary (57%) prevention were randomized to exercise (EX, n = 84) or usual care (UC, n = 76). The EX consisted of 8 wk of home walking 1 hr/d 5 d/wk, followed by 16 wk of maintenance home walking for 150 min/wk. Adherence was determined from exercise logs, ambulatory HR recordings, and phone calls. Assessments were conducted at baseline, 8, and 24 wk for QOL: Patient Concerns Assessment and Short Form-36; anxiety: State Trait Anxiety Inventory; depression: Physician Health Questionnaire-Depression; and self-efficacy: Self-Efficacy for Walking Scale. Results: Participants averaged 55 ± 12 yr of age with ejection fraction = 40.6 ± 15.7%. The EX significantly decreased depression severity (EX: 1.33 ± 0.64; UC: 1.51 ± 0.86, P = .05) and improved self-efficacy (EX: 7.65 ± 1.97; UC: 6.85 ± 2.40, P = .05) at 8 wk. There were no significant effects at 24 wk. Adherent exercisers had significant improvements in QOL, psychological, and self-efficacy outcomes at 8 and 24 wk compared with those who were nonadherent. There were no implantable cardioverter defibrillator shocks associated with exercise. Conclusions: The EX conferred significant effects on depression and self-efficacy at 8 wk, without effects on QOL. Adherent exercisers experienced significant improvements in outcomes over those who were nonadherent or received UC. Correspondence: Cynthia M. Dougherty, ARNP, PhD, University of Washington, School of Nursing, Box 357266, 1959 NE Pacific St, HSB T615A, Seattle, WA 98195 (cindyd@uw.edu). The authors declare no conflicts of interest. Clinical Trial Registration Information: ClinicalTrials.gov number: NCT 00522340, https://trialbulletin.com/lib/entry/ct-00522340 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Rehabilitation Improves Cardiac Volumes and Functional Capacity in Patients With Endomyocardial Fibrosis: A RANDOMIZED CONTROLLED TRIAL Purpose: Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy associated with low functional capacity and high mortality rates. Exercise training has been proved to be a nonpharmacological treatment of cardiovascular diseases. Therefore, the purpose of this study was to determine the effects of exercise rehabilitation in EMF patients. Methods: Twenty-two EMF patients, functional classes II and III (New York Heart Association [NYHA]), were randomized to the control (C-EMF) or exercise rehabilitation (Rehab-EMF) group. Patients in the Rehab-EMF group underwent 4 mo of exercise rehabilitation, whereas patients in the C-EMF group were instructed to maintain their usual daily routine. Peak oxygen uptake (Vo2), cardiac function, and quality of life were evaluated. All assessments were performed at baseline and after 4 mo. Results: After 4 mo of rehabilitation, peak Vo2 increased in the Rehab-EMF group (17.4 ± 3.0 to 19.7 ± 4.4 mL/kg/min, P < .001), whereas the C-EMF group showed no difference (15.3 ± 3.0 to 15.0 ± 2.0 mL/kg/min, P = .87). Also, post-intervention, peak Vo2 in the Rehab-EMF group was greater than that in the C-EMF group (P < .001). Furthermore, the Rehab-EMF group, when compared to the C-EMF group, showed an increase in left ventricular end-diastolic volume (102.1 ± 64.6 to 136.2 ± 75.8 mL vs 114.4 ± 55.0 to 100.4 ± 49.9 mL, P < .001, respectively) and decrease in left atrial diastolic volume (69.0 ± 33.0 to 34.9 ± 15.0 mL vs 44.6 ± 21.0 to 45.6 ± 23.0 mL, P < .001, respectively). Quality-of-life scores also improved in the Rehab-EMF group, whereas the C-EMF group showed no change (45 ± 23 to 27 ± 15 vs 47 ± 15 to 45 ± 17, P < .001, respectively). Conclusion: Exercise rehabilitation is a nonpharmacological intervention that improves functional capacity, cardiac volumes, and quality of life in EMF patients after endocardial resection surgery. In addition, exercise rehabilitation should be prescribed to EMF patients to improve their clinical condition. Correspondence: Ana Luiza Carrari Sayegh, PhD, Clinical Unit of Cardiomyopathy, Heart Institute, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44 Cerqueira Cesar, Sao Paulo, SP 05403-000, Brazil (ana_luizas@hotmail.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effect of Cardiac Rehabilitation on Sexual Satisfaction Among Patients After Coronary Artery Bypass Graft Surgery Purpose: After coronary artery bypass graft (CABG) surgery, many patients experience diminished sexual function and satisfaction. The present study aimed to investigate the effect of outpatient cardiac rehabilitation (OCR) on the level of sexual satisfaction among post-CABG patients. Methods: A clinical trial was performed at the Al-Zahra Hospital, Shiraz, Iran, from July 2017 to January 2018. Based on the inclusion criteria, 104 post-CABG patients were recruited into the study. The participants were randomly assigned to the intervention (OCR) group (n = 52) or the usual care group (n = 52). The intervention group received 20 sessions of OCR, whereas the usual care group received the routine hospital care and education. Data were collected using the Index of Sexual Satisfaction and a demographic data sheet. The data were analyzed using the SPSS software, v23.0 (IBM) and the independent sample t test, paired-samples t test, and χ2 test. Results: There was no statistically significant difference in the mean pre-intervention score for sexual satisfaction between the groups. However, a statistically significant difference in the mean post-intervention score for sexual satisfaction was observed between the groups (P < .001). The difference in the mean pre- and post-intervention scores for sexual satisfaction in the intervention group was statistically significant (P < .001), whereas there was no significant difference in the usual care group. Conclusion: Post-CABG patients who completed the OCR program experienced an increased level of sexual satisfaction. It is, therefore, recommended to include an OCR program as part of the patient treatment and aftercare following CABG surgery. Correspondence: Mahnaz Rakhshan, PhD, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz 71936-13119, Iran (mzrakhshan@ymail.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Randomized Study Examining the Effects of Mild-to-Moderate Group Exercises on Cardiovascular, Physical, and Psychological Well-Being in Patients With Heart Failure Purpose: To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms. Methods: Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU. Results: Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to −345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to −127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, −35 to −374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P < .01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P < .01). Treatment as usual group decreased insignificantly 1 point (95% CI, −1 to 3, P = .27). Conclusions: Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU. Correspondence: Laura S. Redwine, PhD, College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, MDC22, Tampa, FL 33612 (lredwine@health.usf.edu). This research was supported by R01HL096784. The protocol for the parent study can be found at clinicaltrial.gov. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Clinical Trial number: NCT01625819. ORCID#: 0000-0001-7633-2034. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: COMPARISON BETWEEN MEN AND WOMEN Purpose: To compare functional and cardiovascular variables of men and women with peripheral artery disease (PAD). Methods: This observational, cross-sectional study included 67 women and 144 men (age 66 ± 9 and 67 ± 10 yr, respectively) with PAD. Patients were submitted to a clinical evaluation, 6-min walk test (6MWT) and cardiovascular evaluation, including blood pressure, arterial stiffness variables, and heart rate variability. Results: Women had lower claudication onset distance (P = .033) and 6MWT distance (P < .001), and similar percentage of the predicted 6MWT distance (P > .05). Women had higher pulse pressure (P = .002), augmentation index (P < .001), augmentation index corrected by 75 bpm (P < .001), and brachial and central systolic blood pressure (P = .041 and P = .029). Diastolic blood pressure, pulse wave velocity, and heart rate variability were similar between sexes (P > .05). Conclusion: Although predicted 6MWT performance was similar between sexes, women had higher blood pressure and wave reflection variables compared with men. Interventions to reduce blood pressure and wave reflection should be emphasized in women with PAD. Correspondence: Raphael M. Ritti-Dias, PhD, Universidade Nove de Julho, São Paulo, SP, Brazil (raphaelritti@gmail.com) The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Wearable Cardioverter Defibrillator–Guided 6-Min Walk Test Performed at Home Is Accurate and Reliable: RESULTS OF THE TRENDS STUDY Purpose: The 6-min walk test (6MWT) is broadly used to evaluate the functional ability of patients with heart failure (HF). The purpose of this study was to evaluate the accuracy and reliability of the wearable cardioverter defibrillator (WCD)–guided 6MWT performed at home by patients with HF versus in-clinic testing. Methods: Patients (n = 197) with HF and a low ejection fraction prescribed a WCD were randomized to 2 groups. Group 1 completed an in-clinic clinician-guided 6MWT while wearing the WCD; results were recorded by the clinician. Group 2 completed a WCD-guided 6MWT, also performed in the clinic; results were recorded by the WCD accelerometer. Both groups performed weekly unsupervised WCD-guided 6MWTs at home, with results recorded by the WCD. Results: The initial in-clinic 6MWT showed no significant group difference in distance walked (group 1 = 306 m; group 2 = 297 m). For patients in group 2 who completed at least one 6MWT at home, there was a 15-step decrease between the in-clinic WCD-guided 6MWT and the first at-home 6MWT, 558 and 543 median steps (P = .001), respectively. Among patients with at least 8 weekly home WCD-guided 6MWTs (n = 70), there was no significant difference in the number of steps walked during the 6MWT from week to week. Conclusions: Results of the in-clinic 6MWT are similar between clinician-guided and WCD-guided patients across objective distances. Distances walked with a WCD-guided walk test were consistent whether conducted in the clinic or at home and were reliable over time. Correspondence: Ashley E. Burch, PhD, Department of Psychology, East Carolina University, 104 Rawl Bldg, Greenville, NC 27858 (burchas15@ecu.edu). Ashley E. Burch, PhD: research grants: Medtronic, ZOLL Medical. All funds are directed to East Carolina University. Andreas J. Rieth, MD: research grants: Pfizer, directed to Kerckhoff-Klinik Forschungs GmbH; Biotest, directed to Kerckhoff Herzforschungsinstitut; speaker fees and/or honoraria: St Jude Medical, Actelion, Novartis, and Orion Pharma. Nicole R. Bianco, PhD, Employee, ZOLL Medical. Samuel F. Sears, PhD: honoraria/consulting fees: Medtronic, Boston Scientific, St Jude Medical, ZOLL Medical; research grants: Medtronic, ZOLL Medical. All funds are directed to East Carolina University. The rest of the authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.