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AbstractArterial stiffness is one of the major risk factors and markers of cardiovasculardisease (CVD). An increase in the arterial stiffness is influenced by variousfactors such as age, lifestyle, genetics and the presence of other cardiovascularrisks such as obesity and diabetes. Arterial stiffness is a consistent thread inthis thesis. This thesis investigates the effects of exercise-based managementprogrammes for CVD and risk factors with a focus on carotid-radial applanationtonometry which is a specific non-invasive technique for measuring arterialstiffness. Erectile dysfunction is a marker of CVD and is associated withendothelial dysfunction that leads to arterial stiffness. The effects of centrebased,supervised and exercise-based cardiac rehabilitation (CR) programmeswere studied on the changes in arterial stiffness, erectile dysfunction and qualityof life of patients with CVD. Despite the effectiveness of CR programmes, thereis poor attendance at these programmes and unsupervised home-based, IT(information technology)-supported programmes could improve patientparticipation and cost effectiveness. Moreover, earlier identification of risks andappropriate management can reduce the incidence of CVD. There are no suchprogrammes for early stages of CVD in practice, especially in developingcountries such as India. A 12-week, IT-supported home-based exerciseprogramme in India, for patients with metabolic syndrome was developed andstudied. In general, arterial stiffness was improved in both centre-based andhome-based exercise programmes. There were acute increases in arterialstiffness following exercise in healthy Caucasians and South Asians as well aspeople with metabolic syndrome. Carotid-radial pulse wave analysis could be asimple and reliable prognostic tool in exercise based rehabilitation programmes.ii
ACKNOWLEDGEMENTSWithout the support, patience and guidance of the following people, it would notbe possible to complete this thesis. I owe my deepest gratitude to all of them.I must thank first, Prof. David Brodie, Emeritus Professor in CardiovascularHealth, Bucks New University and my first supervisor, for the opportunity to doPhD. He offered a tireless guidance, encouragement, tolerance, meticulousfeedback and support throughout the research work that continued even afterhis retirement. He has been an inspiration for all the time with his wisdom,knowledge and commitment and that continuously motivated me. I am indeptedto him.I thank Dr. Keiran Henderson, my second supervisor, for his continuous, tirelesssupport and feedback on the written work.I thank the staff in cardiac rehabilitation teams who supported to carry out theresearch work successfully.I thank Prof. Narasimman, HoD of Physiotherapy, Fr. Muller Medical Collegeand Hospitals, Mangalore, India for the research collaborations with Bucks NewUniversity and for the enormous help in the successful completions of researchwork in India. I would like to thank Prabu Raja, Benjamin Varghese, NatashaPerira, Samantha Carneiro, and Gretel Goveas for their help in carrying out theresearch work in India.I thank the staff at the research centre for Society & Health and my colleagues,Lin Guo and Dionne Mathew for their support and help.I thank my parents and brother for their continuous encouragement andsupport.Finally and most importantly, I thank my wife Ila, for her love, enduredtolerance, encouragement, support and sacrifices throughout the period of thisthesis, and I dedicate this thesis to her.iii
Page 1: CHANGES IN ARTERIAL STIFFNESS AND O
Page 5 and 6: TABLE OF CONTENTSCHAPTER 1. INTRODU
Page 7 and 8: 3.1. Introduction .................
Page 9 and 10: 4.6. References ...................
Page 11 and 12: 6.2. Cardiac Rehabilitation (CR) ..
Page 13 and 14: 7.4.1. Pulse wave reflections .....
Page 15 and 16: 8.4.2. Management of insulin resist
Page 17 and 18: 10.1.1. Objectives ................
Page 19 and 20: 11.2.4. IT support ................
Page 21 and 22: LIST OF FIGURESFigure 1.1 The struc
Page 23 and 24: LIST OF TABLESTable 2.1 Commerciall
Page 25 and 26: Table 9.6 Chi-squared independence
Page 27 and 28: SBPSystolic blood pressureSEVRSuben
Page 29 and 30: differed from oxygen consumption un
Page 31: 12345678910111213141516171819202122
Page 34 and 35: To establish the changes in arteria
Page 36 and 37: Arterial stiffness as a marker of c
Page 38 and 39: Chapter Seven investigates the effe
Page 40 and 41: Henry, R. M., Kostense, P. J., Spij
Page 42 and 43: Triposkiadis, F., Kallikazaros, I.,
Page 44 and 45: 2.1. Arterial mechanics2.1.1. Struc
Page 46 and 47: Figure 2.3 Diagrammatic representat
Page 48 and 49: Figure 2.5 Schematic representation
Page 50 and 51: Metalloproteinases (MMP), collectiv
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2.2.3. Genetic relationsArterial st
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(Schimmler 1965; Avolio et al. 1983
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increasing age (Heffernan et al. 20
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2011). In more recent medicine, San
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appearance, it was also a simple mo
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adding a screw, the device was capa
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development of new hydraulic and el
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Budapest, Hungary). A list of commo
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Figure 2.16 The Complior- A piezo-e
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Khoshdel et al (2006) carried out a
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Figure 2.18 Structure of an arteria
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Figure 2.20 A sequence of pulse wav
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induces the release of nitric oxide
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2.5. ConclusionsVarious molecular,
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left ventricular load in a northern
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of primary coronary events in hyper
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Frank, O. (1926). "Die Theorie der
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Hope, S. A., Meredith, I. T., and C
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Kullo, I. J., and Malik, A. R. (200
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McNulty, M., Mahmud, A., and Feely,
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Nemes, A., Takacs, R., Gavaller, H.
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levels in essential hypertension."
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Sengstock, D. M., Vaitkevicius, P.
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glycation end products." The Journa
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Yan, S. D., Schmidt, A. M., Anderso
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3.1. IntroductionCentral aortic pre
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for arterial stiffness twice conseq
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‘suprasternal notch’ using a ta
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Table 3.1 Paired t-test results for
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Table 3.2 Intra class correlations
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data are centred and scaled using a
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hour-to-hour and week-to-week repro
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3.6. ReferencesAvest, E., Holewijn,
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Siebenhofer, A., Kemp, C., Sutton,
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4.1. Introduction4.1.1. Arterial st
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4.1.3. HypothesesH1- There will be
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continuous breath-by-breath measure
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exercise capacity variables and art
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Table 4.2 Difference in exercise va
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Table 4.4 Difference in exercise va
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Table 4.6 Difference in baseline ar
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Table 4.8 Changes in arterial stiff
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Figure 4.1 VO 2 peak vs. Augmentati
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4.4. DiscussionPulse wave analysis
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pressure and a decrease in SEVR aft
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participants would improve the powe
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4.6. ReferencesACSM. (2000). ACSM's
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M. (2009). "The accuracy of central
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Vaitkevicius, P. V., Fleg, J. L., E
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5.1. Introduction5.1.1. Obesity pre
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5.1.3. HypothesisIn young healthy I
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Site 4 Supra-iliac - A diagonal fol
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independent t test was used to find
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5.3.2. RelationshipsThe relationshi
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The participants who had higher phy
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compared with their body mass index
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Pulse wave velocity had significant
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quality of the results using this l
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de Jongh, R. T., Ijzerman, R. G., S
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Maffeis, C., Talamini, G., and Tato
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Wang, J., Thornton, J. C., Russell,
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6.1. Erectile dysfunctionErectile d
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enlargement of the penis and compre
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and listed the prevalence of ED. Th
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the patient had experienced an MI.
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6.1.5.2. Drug induced EDA medical t
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C-reactive protein (CRP) is a marke
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High risk:Unstable or refractory an
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elaxation and the inflow of arteria
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1998). A structured care for chroni
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These step changes include myocardi
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Negotiation of a written individual
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and primary health care teams take
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life improved in all the age groups
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Successful risk factor modification
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and consequent dissatisfaction is m
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(Turner et al. 2002). More research
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Blumentals, W. A., Gomez-Caminero,
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Jackson, G. (2006). "The second Pri
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Marchionni, N., Fattirolli, F., Fum
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Taylor, H. A., Jr. (1999). "Sexual
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7.1. Introduction7.1.1. Pathology o
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7.2.2. SubjectsThe study involved 1
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decreasing the number of undiagnose
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7.3. ResultsIn total, all the male
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PercentageModerate6%Complete18%Seve
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7.3.2. Medication for ED in CR7.3.2
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7.5 Correlations between erectitile
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CR. However, the recommendations fo
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2003; Enko et al. 2008). Peripheral
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7.4.2.1. International index of ere
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average cavernosal artery being 0.5
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according to their level of risks.
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7.6. ReferencesBarrett-Connor, E. (
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Mahmud, A., Hennessy, M., and Feely
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Wave Velocity as Index of Arterial
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8.1. Introduction8.1.1. Development
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The International Diabetes Federati
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8.1.2. Controversies among definiti
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Nutrition Survey, shows that 73.9%
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density lipoproteins (HDL), and vic
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8.2.7. Lifestyle8.2.7.1. DietDietar
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8.2.7.4. EducationEducation levels
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(NHANES III) found that 4% of USA a
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8.4. Management of metabolic syndro
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doses of statin are recommended to
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8.4.5.2. DietA lack of awareness of
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programmes, using recently develope
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Alberti, K. G., Zimmet, P., and Sha
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Bhatheja, R., and Bhatt, D. L. (200
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de Oliveira, E. P., de Souza, M. L.
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Fan, J. G., Zhu, J., Li, X. J., Che
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Grundy, S. M., Cleeman, J. I., Dani
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cause and cardiovascular mortality
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the incidence of metabolic syndrome
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Adult Treatment Panel III definitio
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Orchard, T. J., Becker, D. J., Bate
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Regitz-Zagrosek, V., Lehmkuhl, E.,
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Tillin, T., Forouhi, N., Johnston,
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CHAPTER 9. PREVALENCE OF HYPERTENSI
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the American Heart Association (Gru
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were used to screen the population.
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9.2.4. Quality controlThe result fr
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Table 9.1 Demographic and lifestyle
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Table 9.2 Chi-squared ‘goodness o
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Figure 9.2 Percentage of individual
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The univariate correlations between
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Table 9.7 Chi-squared significance
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physical activities were comparativ
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carbohydrate meal consumption is re
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countries such as Thailand (12%-18%
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and abdominal obesity with multiple
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Samal, D., Greisenegger, S., Auff,
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10.1. IntroductionMetabolic syndrom
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and sub-endocardial viability ratio
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able to pace themselves with the sp
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10.3.2. Total group changesThe chan
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Table 10.2 Changes in pulse wave an
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However, there were no significant
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Table 10.4 Comparison of arterial s
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10.3.5. RelationshipsIn general, th
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Table 10.7 Correlations between phy
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decrease after 20 weeks aerobic tra
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a Chinese population also had a sim
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10.4.4. LimitationsA larger number
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muscle contraction at comparable wo
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Oliver, J. J., and Webb, D. J. (200
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CHAPTER 11. EFFECTS OF AN IT-SUPPOR
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and diet are the major recommendati
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people’s lives. Use of text messa
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test. Participants were asked not t
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the internet using multi-messaging
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Table 11.1 Changes in arterial stif
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Table 11.2 Changes in health relate
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Table 11.3 Changes in blood glucose
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group-2 improved from 732 ±230.6m
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developed metabolic syndrome and le
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home-based exercise programme in pa
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significant improvement compared wi
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11.6. ReferencesAmerican Thoracic S
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systematic review and meta-analysis
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Maximisation study (BRUM): a random
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Oliver, J. J., and Webb, D. J. (200
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Thomas, R. J. (2007). "Cardiac reha
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CHAPTER 3: REPRODUCIBILITY OF ARTER
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CHAPTER 7: CHANGES IN ERECTILE DYSF
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CHAPTER 11: EFFECTS OF AN IT SUPPOR
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withdrawn and excluded from the the
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the prevalence is increasing global
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APPENDIX I. Bland- Altman plots sho
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Figure A.1.3 Bland - Altman limits
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Figure A.1.5. Bland - Altman limits
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Page 398 and 399:
Page 400 and 401:
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Fig. A.2.2 VO 2 Peak vs. pulse wave
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Fig. A.2.4 VO 2 Peak vs. augmentati
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Fig. A.2.6 VO 2 Peak vs. augmentati
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Fig. A.2.8 VO 2 Peak vs. aortic aug
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Fig. A.2.10 VO 2 Peak vs. aortic pu
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Fig. A.2.12 VO 2 Peak vs. aortic sy
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Fig. A.2.14 VO2 Peak vs. aortic Dai
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Fig. A.2.16 VO2 Peak vs. mean press
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Fig. A.2.18 VO2 Peak vs. ejection d
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Fig. A.2.20 VO2 Peak vs. subendocar
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Fig. A.2.22 VO2 Peak vs. heart rate
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EGIR 8.9%Ko et al (2006)China, Hong
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Lee et al (2007)Son le et al (2005)
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Gentles et al (2007) New Zealand 35
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Dekker et al (2005) Netherlands 50-
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Goodpaster et al (2005)USA, Pittsbu
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