Aortic Aneurysm: DIAGNOSIS, MANAGEMENT, EXERCISE TESTING, AND TRAINING.
Journal
Journal of cardiopulmonary rehabilitation and prevention
ISSN: 1932-751X
Titre abrégé: J Cardiopulm Rehabil Prev
Pays: United States
ID NLM: 101291247
Informations de publication
Date de publication:
07 2020
07 2020
Historique:
entrez:
1
7
2020
pubmed:
1
7
2020
medline:
4
8
2021
Statut:
ppublish
Résumé
Some patients who participate in cardiac rehabilitation have aortic abnormalities, including abdominal and thoracic aneurysm (AAA and TAA, respectively). There is scant guidance on implementing exercise training in these individuals. This article reviews the epidemiology, diagnostic process, medical issues, and the available exercise training literature, and provides recommendations for performing regular exercise. Patients with aortic abnormalities are at risk for enlargement, aneurysm development, dissection, and rupture. During exercise, individuals with large aneurysms may be at greater risk of an adverse event. The available literature suggests little increased risk of complications when training at low and moderate intensities in those with an AAA, and exercise may be protective for aneurysm expansion. There is little exercise data for TAA, but the available literature suggests training at lower intensities and avoidance of excessive increases of blood pressure. When exercise testing and training are performed, the intensity should be controlled to avoid complications. It is prudent to keep systolic blood pressure <180 mm Hg in most patients and <160 mm Hg in those at greater risk of dissection or rupture (eg, women and larger sized aneurysm) during aerobic training. During resistance training, patients should avoid sudden excessive blood pressure increases (ie, avoid the Valsalva maneuver), and keep intensity below 40-50% of the 1-repetition maximum. Existing data suggest these patients may improve functional capacity and reduce the rate of aneurysm expansion. Most patients with AAA can safely perform exercise training when conservative guidelines are followed. Additional research is needed to fully determine whether exercise is protective against aneurysm expansion, and the effects of exercise in those who have had surgical repair. More research is necessary to provide specific recommendations for those with a TAA.
Sections du résumé
BACKGROUND
Some patients who participate in cardiac rehabilitation have aortic abnormalities, including abdominal and thoracic aneurysm (AAA and TAA, respectively). There is scant guidance on implementing exercise training in these individuals. This article reviews the epidemiology, diagnostic process, medical issues, and the available exercise training literature, and provides recommendations for performing regular exercise.
CLINICAL CONSIDERATIONS
Patients with aortic abnormalities are at risk for enlargement, aneurysm development, dissection, and rupture. During exercise, individuals with large aneurysms may be at greater risk of an adverse event. The available literature suggests little increased risk of complications when training at low and moderate intensities in those with an AAA, and exercise may be protective for aneurysm expansion. There is little exercise data for TAA, but the available literature suggests training at lower intensities and avoidance of excessive increases of blood pressure.
EXERCISE TESTING AND TRAINING
When exercise testing and training are performed, the intensity should be controlled to avoid complications. It is prudent to keep systolic blood pressure <180 mm Hg in most patients and <160 mm Hg in those at greater risk of dissection or rupture (eg, women and larger sized aneurysm) during aerobic training. During resistance training, patients should avoid sudden excessive blood pressure increases (ie, avoid the Valsalva maneuver), and keep intensity below 40-50% of the 1-repetition maximum. Existing data suggest these patients may improve functional capacity and reduce the rate of aneurysm expansion.
SUMMARY
Most patients with AAA can safely perform exercise training when conservative guidelines are followed. Additional research is needed to fully determine whether exercise is protective against aneurysm expansion, and the effects of exercise in those who have had surgical repair. More research is necessary to provide specific recommendations for those with a TAA.
Identifiants
pubmed: 32604251
doi: 10.1097/HCR.0000000000000521
pii: 01273116-202007000-00003
doi:
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
215-223Subventions
Organisme : RRD VA
ID : IK6 RX002477
Pays : United States
Références
Braverman AC, Harris KM, Kovacs RJ, Maron BJ, on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on CV Disease in the Young, Council on CV and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Task Force 7: Aortic Diseases, Including Marfan Syndrome: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e303–e309.
Delsart P, Maldonado-Kauffmann P, Bic M, et al. Post aortic dissection: gap between activity recommendation and real life patients aerobic capacities. Int J Cardiol. 2016;219:271–276.
Mathur A, Mohan V, Ameta D, Bhardwaj G, Haranahalli P. Aortic aneurysm. J Translational Int Med. 2016;4(1):35–41.
Lederle FA, Johnson GR, Wilson SE, et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med. 1997;126(6):441–449.
Karthikesalingam A, Holt PJ, Vidal-Diez A, et al. Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA. Lancet. 2014;383(9921):963–969.
Yin K, Locham SS, Schermerhorn ML, Malas MB. Trends of 30-day mortality and morbidities in endovascular repair of intact abdominal aortic aneurysm during the last decade. J Vasc Surg. 2019;69(1):64–73.
Lo RC, Bensley RP, Hamdan AD, Wyers M, Adams JE, Schermerhorn ML, on behalf of the Vascular Study Group of New England. Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England. J Vasc Surg. 2013;57(5):1261–1268.
Ramanath VS, Oh JK, Sundt TM, Eagle KA. Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc. 2009;84(5):465–481.
Kuzmik GA, Sang AX, Elefteriades JA. Natural history of thoracic aortic aneurysms. J Vasc Surg. 2012;56(2):565–671.
Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. 2005;111:816–828.
Davies RR, Kaple RK, Mandapati D, et al. Natural history of ascending aortic aneurysms in the setting of an unreplaced bicuspid aortic valve. Ann Thorac Surg. 2007;83(4):1338–1344.
Mori M, Bin Mahmood SU, Yousef S, et al. Prevalence of incidentally identified thoracic aortic dilations: insights for screening criteria. Can J Cardiol. 2019;35(7):892–898.
Lilja F, Wanhainen A, Mani K. Changes in abdominal aortic aneurysm epidemiology. J Cardiovasc Surg (Torino). 2017;58(6):848–853.
Kanagasaby R, Gajraj H, Poinon L, Scott RA. Co-morbidity in patient with abdominal aortic aneurysm. J Med Screen. 1996;3(4):208–210.
Szilagyi DE. Clinical diagnosis of intact and ruptured abdominal aortic aneurysms. In: Bergan JJ, Yao JST, eds. Aneurysms: Diagnosis and Treatment. New York, NY: Grune & Stratton;1982:205–212.
Kiev J, Eckhardt A, Karstein MD. Reliability and accuracy of physical examination in detection of abdominal aortic aneurysms. Vasc Surg. 1997;31:143–146.
Sterpetti AV, Feldhaus RJ, Schultz RD, Blair EA. Identification of abdominal aortic aneurysm patients with different clinical features and clinical outcomes. Am J Surg. 1988;156(6):466–472
Chervu A, Clagett GP, Valentine RJ, Myers SI, Rossi PJ. Role of physical examination in detection of abdominal aortic aneurysms. Surg. 1995;117(4):454–457.
Zangirolami AC, Oliveira FV, Tepedino MS. Ortner's syndrome: secondary laryngeal paralysis caused by a great thoracic aorta aneurysm. Int Arch Otorhinolaryngol. 2015;19(2):180–182.
Goldstein SA, Evangelista A, Abbara S, et al. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of CV Imaging: endorsed by the Society of CV Computed Tomography and Society for cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2015;28(2):119–182.
Lin FY, Devereux RB, Roman MJ, et al. Assessment of the thoracic aorta by multidetector computed tomography: age- and sex-specific reference values in adults without evident cardiovascular disease. J Cardiovasc Comput Tomogr. 2008;2(5):298–308.
Baird PA, Sadovnick AD, Yee IM, Cole CW, Cole L. Sibling risks of abdominal aortic aneurysm. Lancet. 1995;346(8975):601–604.
Danyi P, Elefteriades JA, Jovin IS. Medical therapy of thoracic aortic aneurysms are we there yet? Circulation. 2011;124(13):1469–1476.
Hiratzka LF, Bakris GL, Beckman JA, et al. ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary. Circulation. 2010;121:1544–1579.
Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2–77.e2.
Wanhainen A, Verzini F, Van Herzeele I, et al. Editor's Choice-European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019;57(1):8–93.
Donas KP, Torsello G. Complications and reinterventions after EVAR: are they decreasing in incidence? J Cardiovasc Surg (Torino). 2011;52(2):189–192.
Williamson WK, Nicoloff AD, Taylor LM Jr, Moneta GL, Landry GJ, Porter JM. Functional outcome after open repair of abdominal aortic aneurysm. J Vasc Surg. 2001;33(5):913–920.
Casey K, Hernandez-Boussard T, Mell MW, Lee JT. Differences in readmissions after open repair versus endovascular aneurysm repair. J Vasc Surg. 2013;57(1):89–95.
Vaitkevicius PV, Fleg JL, Engel JH, et al. Effects of age and aerobic capacity on arterial stiffness in healthy adults. Circulation. 1993;88(4, pt 1):1456–1462.
Hundley WG, Kitzman DW, Morgan TM, et al. Cardiac cycle-dependent changes in aortic area and distensibility are reduced in older patients with isolated diastolic heart failure and correlate with exercise intolerance. J Am Coll Cardiol. 2001;38(3):796–802.
Myers J, Powell A, Smith K, Fonda H, Dalman RL; Stanford AAA SCCOR Investigators. Cardiopulmonary exercise testing in small abdominal aortic aneurysm: profile, safety, and mortality estimates. Eur J Cardiovasc Rehabil Prev. 2011:18(3);459–466.
Young EL, Karthikesalingam A, Huddart S, et al. A systematic review of the role of cardiopulmonary exercise testing in vascular surgery. Eur J Vasc Endovasc Surg. 2012;44(1):64–71.
Martin D, O'Doherty A, Imray C. The prognostic value of cardiopulmonary exercise testing in vascular surgery patients. Eur J Vasc Endovasc Surg. 2012;44(4):457.
Rose GA, Davies RG, Appadurai IR, et al. Cardiorespiratory fitness is impaired and predicts mid-term postoperative survival in patients with abdominal aortic aneurysm disease. Exp Physiol. 2018;103(11):1505–1512.
Grant SW, Hickey GL, Wisely NA, et al. Cardiopulmonary exercise testing and survival after elective abdominal aortic aneurysm repair†. Br J Anaesth. 2015;114(3):430–436.
Hornsby WF, Norton EL, Fink S, et al. Cardiopulmonary exercise testing following open repair for a proximal thoracic aortic aneurysm or dissection. J Cardiopulm Rehabil Prev. 2020;40(2):108–115.
Fuglsang S, Heiberg J, Hjortdal VE, Laustsen S. Exercise-based cardiac rehabilitation in surgically treated type-A aortic dissection patients. Scand Cardiovasc J. 2017;51(2):99–105.
Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873–934.
Pouwels S, Willigendael EM, van Sambeek MR, Nienhuijs SW, Cuypers PW, Teijink JA. Beneficial effects of pre-operative exercise therapy in patients with an abdominal aortic aneurysm: a systematic review. Eur J Vasc Endovasc Surg. 2015:49(1);66–76.
Myers J, McElrath M, Jaffe A, et al. A randomized trial of exercise training in abdominal aortic aneurysm disease: the AAA STOP Trial. Med Sci Sports Exerc. 2014;46:2–9.
Myers J, Dalman R, Hill B. Exercise, vascular health, and abdominal aortic aneurysm disease. J Clin Exercise Physiol. 2012;1:1–8.
Nakayama A, Morita H, Nagayama M, et al. Cardiac Rehabilitation protects against the expansion of abdominal aortic aneurysm. J Am Heart Assoc. 2018;7(5):pii:e007959. doi: 10.1161/JAHA.117.007959.
Kothmann E, Batterham AM, Owen SJ, et al. Effect of short-term exercise training on aerobic fitness in patients with abdominal aortic aneurysms: a pilot study. Br J Anaesthesia. 2009;103(4):505–510.
Barakat HM, Shahin Y, Barnes R, et al. Supervised exercise program improves aerobic fitness in patients awaiting abdominal aortic aneurysm repair. Ann Vasc Surg. 2014;28(1):74–79.
Tew GA, Moss J, Crank H, Mitchell PA, Nawaz S. Endurance exercise training in patients with small abdominal aortic aneurysm: A randomized controlled pilot study. Arch Phys Med Rehabil. 2012:93(12);2148–2153.
Dalman RL, Tedesco MM, Myers J, Taylor CA. AAA disease: mechanism, stratification, and treatment. Ann N Y Acad Sci. 2006;1085:92–109.
Taylor CA, Hughes TJ, Zarins CK. Effects of exercise on hemodynamic conditions in the abdominal aorta. J Vasc Surg. 1999;29(6):1077–1089.
Les AS, Shadden SC, Figueroa CA, et al. Quantification of hemodynamics in abdominal aortic aneurysms during rest and exercise using magnetic resonance imaging and computational fluid dynamics. Ann Biomed Eng. 2010;38(4):1288–1313.
Brown LC, Thompson SG, Greenhalgh RM, Powell JT; UK Small Aneurysm Trial Participants. Fit patients with small abdominal aortic aneurysms (AAAs) do not benefit from early intervention. J Vasc Surg. 2008;48(6):1375–1381.
Lindblad B, Börner G, Göttsater A. Factors associated with development of large abdominal aortic aneurysms in middle aged men. Eur J Vasc Endovasc Surg. 2005;30(4):346–352.
Törnwall ME, Virtamo J, Haukka JK, Albanes D, Huttunen JK. Lifestyle factors and risk for abdominal aortic aneurysm in a cohort of Finnish male smokers. Epidemiology. 2001;12(1):94–100.
Singh K, Bønaa KH, Jacobsen BK, Bjørk L, Solberg S. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study: The Tromsø Study. Am J Epidemiol. 2001;154(3):236–244.
EVAR trial participants. Endovascular aneurysm repair and outcome in patients until for open repair of abdominal aortic aneurysm (EVAR trail 2): randomized controlled trial. Lancet. 2005;365:2187–2192.
Brown LC, Greenhalgh RM, Howell S, Powell JT, Thompson SG. Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials. Br J Surg. 2007;94(6):709–716.
Myers J, Fonda H. The impact of fitness on surgical outcomes: the case for prehabilitation. Curr Sports Med Rep. 2016;15(4):282–289.
Corone S, Iliou MC, Pierre B, et al. French registry of cases of type I acute aortic dissection admitted to a cardiac rehabilitation center after surgery. Eur J Cardiovasc Prev Rehabil. 2009;16(1):91–95.
Thijssen CGE, Bons LR, Gökalp AL, et al. Exercise and sports participation in patients with thoracic aortic disease: a review. Expert Rev Cardiovasc Ther. 2019;17(4):251–266.
Malek LA. Cardiac rehabilitation in patients with thoracic aortic disease: review of the literature and design of a program. Heart Mind. 2018;2:65–69.
Benninghoven D, Hamann D, von Kodolitsch Y, et al. Inpatient rehabilitation for adult patients with Marfan syndrome: an observational pilot study. Orphanet J Rare Dis. 2017;12(1):127.
Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55(14):e27–e129.
Chaikof EL, Brewster DC, Dalman RL, et al.; Society for Vascular Surgery. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(4 suppl):S2–S49.
Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH. Eligibility and Disqualification Recommendations for Competitive Athletes with CV Abnormalities: Task Force 1: Classification of Sports: Dynamic, Static, and Impact. A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation. 2015:132;e262–e266.
Boodhwani M, Andelfinger G, Leipsic J, et al. Canadian CV society position statement on the management of thoracic aortic disease. Can J Cardiol. 2014;30(6):577–589.
Fonda H, Myers J. Aneurysms. In: Durstine JL, Moore GE, Painter PL, eds. ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities. 4th ed. Champaign, IL: Human Kinetics; 2016:169–174.
Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med. 2001;345(12):892–902.
Altobelli E, Rapacchietta L, Profeta VF, Fagnano R. Risk factors for abdominal aortic aneurysm in population-based studies: a systematic review and meta-analysis. Int J Environ Res Public Health. 2018;15(12):pii:E2805.