Pain threshold is achieved at intensity above anaerobic threshold in patients with intermittent claudication

PURPOSE: Walking training is considered as the first treatment option for patients with peripheral arterial disease and intermittent claudication (IC). Walking exercise has been prescribed for these patients by relative intensity of peak oxygen uptake (VO(2)peak), ranging from 40% to 70% VO(2)peak, or pain threshold (PT). However, the relationship between these methods and anaerobic threshold (AT), which is considered one of the best metabolic markers for establishing training intensity, has not been analyzed. Thus, the aim of this study was to compare, in IC patients, the physiological responses at exercise intensities usually prescribed for training (% VO(2) peak or % PT) with the ones observed at AT. METHODS: Thirty-three IC patients performed maximal graded cardiopulmonary treadmill test to assess exercise tolerance. During the test, heart rate (HR), VO(2), and systolic blood pressure were measured and responses were analyzed at the following: 40% of VO(2)peak; 70% of VO(2)peak; AT; and PT. RESULTS: Heart rate and VO(2) at 40% and 70% of VO(2)peak were lower than those at AT (HR: -13 +/- 9% and -3 +/- 8%, P < .01, respectively; VO(2): -52 +/- 12% and -13 +/- 15%, P < .01, respectively). Conversely, HR and VO(2) at PT were slightly higher than those at AT (HR: +3 +/- 8%, P < .01; VO(2): + 6 +/- 15%, P = .04). None of the patients achieved the respiratory compensation point. CONCLUSION: Prescribing exercise for IC patients between 40% and 70% of VO(2)peak will induce a lower stimulus than that at AT, whereas prescribing exercise at PT will result in a stimulus above AT. Thus, prescribing exercise training for IC patients on the basis of PT will probably produce a greater metabolic stimulus, promoting better cardiovascular benefits.

Hematological parameters and anaerobic threshold in Brazilian soccer players throughout a training program

We assessed the responses of hematological parameters and their relationship to the anaerobic threshold of Brazilian soccer players during a training program. Twelve athletes were evaluated at the beginning (week 0, T1), in the middle (week 6, T2), and at the end (week 12, T3) of the soccer training program. On the first day at 7:30 AM, before collecting the blood sample at rest for the determination of the hematological parameters, the athletes were conducted to the anthropometric evaluation. On the second day at 8:30 AM, the athletes had their anaerobic threshold measured. Analysis of variance with Newman-Keuls`post hoc was used for statistical comparisons between the parameters measured during the soccer training program. Correlations between the parameters analyzed were determined using the Pearson`s correlation coefficient. Erythrocytes concentration, hemoglobin, and hematocrit were significantly increased from T1 to T2. The specific soccer training program led to a rise in erythrocytes, hemoglobin, and hematocrit from T1 to T2. We assumed that these results occurred due to the plasma volume reduction and may be explained by the soccer training program characteristics. Furthermore, we did not observe any correlation between the anaerobic threshold and the hematological parameters.

Effect of low-dose combined oral contraceptive on aerobic capacity and anaerobic threshold level in active and sedentary young women

Background: The purpose of this study was to evaluate the effect of long-term use of oral contraceptives (DC) containing 0.20 mg of ethinylestradiol (EE) combined with 0.15 mg of gestodene (GEST) on the peak aerobic capacity and at the anaerobic threshold (AT) level in active and sedentary young women. Study Design: Eighty-eight women (23 +/- 2.1 years old) were divided into four groups active-OC (G1), active-NOC (G2), sedentary-OC (G3) and sedentary-NOC (G4) and were submitted to a continuous ergospirometric incremental test on a cycloergometer with 20 to 25 W min(-1) increments. Data were analyzed by two-way ANOVA with Tukey post hoc test. Level of significance was set at 5%. Results: The OC use effect for the variables relative and absolute oxygen uptake VO(2) mL kg(-1) min(-1); VO(2), L min(-1), respectively), carbon dioxide output (VCO(2), L min(-1)), ventilation (VE, L min(-1)), heart rate (HR, bpm), respiratory exchange ratio (RER) and power output (W) data, as well as the interaction between OC use and exercise effect on the peak of test and at the AT level did not differ significantly between the active groups (G1 and G2) and the sedentary groups (G3 and G4). As to the exercise effect, for all variables studied, it was noted that the active groups presented higher values for the variables VO(2), VCO(2), VE and power output (p<.05) than the sedentary groups. The RER and HR were similar (p>.05) at the peak and at the AT level between G1 vs. G3 and G2 vs. G4. Conclusions: Long-term use of OC containing EE 0.20 mg plus GEST 0.15 mg does not affect aerobic capacity at the peak and at the AT level of exercise tests. (C) 2010 Elsevier Inc. All rights reserved.

Responsiveness to exercise training in juvenile dermatomyositis: a twin case study

Background: Patients with juvenile dermatomyositis (JDM) often present strong exercise intolerance and muscle weakness. However, the role of exercise training in this disease has not been investigated. Purpose: this longitudinal case study reports on the effects of exercise training on a 7-year-old patient with JDM and on her unaffected monozygotic twin sister, who served as a control. Methods: Both the patient who was diagnosed with JDM as well as her healthy twin underwent a 16-week exercise training program comprising aerobic and strengthening exercises. We assessed one repetition-maximum (1-RM) leg-press and bench-press strength, balance, mobility and muscle function, blood markers of inflammation and muscle enzymes, aerobic conditioning, and disease activity scores. As a result, the healthy child had an overall greater absolute strength, muscle function and aerobic conditioning compared to her JDM twin pair at baseline and after the trial. However, the twins presented comparable relative improvements in 1-RM bench press, 1-RM leg press, VO(2peak), and time-to-exhaustion. The healthy child had greater relative increments in low-back strength and handgrip, whereas the child with JDM presented a higher relative increase in ventilatory anaerobic threshold parameters and functional tests. Quality of life, inflammation, muscle damage and disease activity scores remained unchanged. Results and Conclusion: this was the first report to describe the training response of a patient with non-active JDM following an exercise training regimen. The child with JDM exhibited improved strength, muscle function and aerobic conditioning without presenting an exacerbation of the disease.

Ventilation behavior in trained and untrained men during incremental test: evidence of one metabolic transition point

This study aimed to describe and compare the ventilation behavior during an incremental test utilizing three mathematical models and to compare the feature of ventilation curve fitted by the best mathematical model between aerobically trained (TR) and untrained ( UT) men. Thirty five subjects underwent a treadmill test with 1 km.h(-1) increases every minute until exhaustion. Ventilation averages of 20 seconds were plotted against time and fitted by: bi-segmental regression model (2SRM); three-segmental regression model (3SRM); and growth exponential model (GEM). Residual sum of squares (RSS) and mean square error (MSE) were calculated for each model. The correlations between peak VO2 (VO2PEAK), peak speed (Speed(PEAK)), ventilatory threshold identified by the best model (VT2SRM) and the first derivative calculated for workloads below (moderate intensity) and above (heavy intensity) VT2SRM were calculated. The RSS and MSE for GEM were significantly higher (p < 0.01) than for 2SRM and 3SRM in pooled data and in UT, but no significant difference was observed among the mathematical models in TR. In the pooled data, the first derivative of moderate intensities showed significant negative correlations with VT2SRM (r = -0.58; p < 0.01) and Speed(PEAK) (r = -0.46; p < 0.05) while the first derivative of heavy intensities showed significant negative correlation with VT2SRM (r = -0.43; p < 0.05). In UT group the first derivative of moderate intensities showed significant negative correlations with VT2SRM (r = -0.65; p < 0.05) and Speed(PEAK) (r = -0.61; p < 0.05), while the first derivative of heavy intensities showed significant negative correlation with VT2SRM (r= -0.73; p < 0.01), Speed(PEAK) (r = -0.73; p < 0.01) and VO2PEAK (r = -0.61; p < 0.05) in TR group. The ventilation behavior during incremental treadmill test tends to show only one threshold. UT subjects showed a slower ventilation increase during moderate intensities while TR subjects showed a slower ventilation increase during heavy intensities.

The Borg Scale as an Important Tool of Self-Monitoring and Self-Regulation of Exercise Prescription in Heart Failure Patients During Hydrotherapy - A Randomized Blinded Controlled Trial

Background: The Borg Scale may be a useful tool for heart failure patients to self-monitor and self-regulate exercise on land or in water (hydrotherapy) by maintaining the heart rate (HR) between the anaerobic threshold and respiratory compensation point. Methods and Results: Patients performed a cardiopulmonary exercise test to determine their anaerobic threshold/respiratory compensation points. The percentage of the mean HR during the exercise session in relation to the anaerobic threshold HR (%EHR-AT), in relation to the respiratory compensation point (%EHR-RCP), in relation to the peak HR by the exercise test (%EHR-Peak) and in relation to the maximum predicted HR (%EHR-Predicted) was calculated. Next, patients were randomized into the land or water exercise group. One blinded investigator instructed the patients in each group to exercise at a level between ""relatively easy and slightly tiring"". The mean HR throughout the 30-min exercise session was recorded. The %EHR-AT and %EHR-Predicted did not differ between the land and water exercisegroups, but they differed in the %EHR-RCP (95 +/- 7 to 86 +/- 7. P<0.001) and in the %EHR-Peak (85 +/- 8 to 78 +/- 9, P=0.007). Conclusions: Exercise guided by the Borg scale maintains the patient's HR between the anaerobic threshold and respiratory compensation point (ie, in the exercise training zone). (Circ J 2009; 73: 1871-1876)

Exercise intensity optimization for men with high cardiorespiratory fitness

Exercise intensity is a key parameter for exercise prescription but the optimal range for individuals with high cardiorespiratory fitness is unknown. The aims of this study were (1) to determine optimal heart rate ranges for men with high cardiorespiratory fitness based on percentages of maximal oxygen consumption (%VO(2max)) and reserve oxygen consumption (%VO(2reserve)) corresponding to the ventilatory threshold and respiratory compensation point, and ( 2) to verify the effect of advancing age on the exercise intensities. Maximal cardiorespiratory testing was performed on 210 trained men. Linear regression equations were calculated using paired data points between percentage of maximal heart rate (%HR(max)) and %VO(2max) and between percentage of heart rate reserve (%HRR) and %VO(2reserve) attained at each minute during the test. Values of %VO(2max) and %VO(2reserve) at the ventilatory threshold and respiratory compensation point were used to calculate the corresponding values of %HRmax and %HRR, respectively. The ranges of exercise intensity in relation to the ventilatory threshold and respiratory compensation point were achieved at 78-93% of HR(max) and 70-93% of HRR, respectively. Although absolute heart rate decreased with advancing age, there were no age-related differences in %HR(max) and %HRR at the ventilatory thresholds. Thus, in men with high cardiorespiratory fitness, the ranges of exercise intensity based on %HR(max) and %HRR regarding ventilatory threshold were 78-93% and 70-93% respectively, and were not influenced by advancing age.

Role of beta-alanine supplementation on muscle carnosine and exercise performance

ARTIOLI, G. G., B. GUALANO, A. SMITH, J. STOUT, and A. H. LANCHA, JR. Role of beta-Alanine Supplementation on Muscle Carnosine and Exercise Performance. Med. Sci. Sports Exerc., Vol. 42, No. 6, pp. 1162-1173, 2010. In this narrative review, we present and discuss the current knowledge available on carnosine and beta-alanine metabolism as well as the effects of beta-alanine supplementation on exercise performance. Intramuscular acidosis has been attributed to be one of the main causes of fatigue during intense exercise. Carnosine has been shown to play a significant role in muscle pH regulation. Carnosine is synthesized in skeletal muscle from the amino acids L-histidine and beta-alanine. The rate-limiting factor of carnosine synthesis is beta-alanine availability. Supplementation with beta-alanine has been shown to increase muscle carnosine content and therefore total muscle buffer capacity, with the potential to elicit improvements in physical performance during high-intensity exercise. Studies on beta-alanine supplementation and exercise performance have demonstrated improvements in performance during multiple bouts of high-intensity exercise and in single bouts of exercise lasting more than 60 s. Similarly, beta-alanine supplementation has been shown to delay the onset of neuromuscular fatigue. Although beta-alanine does not improve maximal strength or (V) over dotO(2max), some aspects of endurance performance, such as anaerobic threshold and time to exhaustion, can be enhanced. Symptoms of paresthesia may be observed if a single dose higher than 800 mg is ingested. The symptoms, however, are transient and related to the increase in plasma concentration. They can be prevented by using controlled release capsules and smaller dosing strategies. No important side effect was related to the use of this amino acid so far. In conclusion, beta-alanine supplementation seems to be a safe nutritional strategy capable of improving high-intensity anaerobic performance.

Weight loss associated with exercise training restores ventilatory efficiency in obese children

The purpose of this study was to test the hypothesis that in obese children: 1) Ventilatory efficiency (VentE) is decreased during graded exercise; and 2) Weight loss through diet alone (D) improves VentE, and 3) diet associated with exercise training (DET) leads to greater improvement in VentE than by D. Thirty-eight obese children (10 +/- 0.2 years; BMI > 95(th) percentile) were randomly divided into two Study groups: D (n=17; BMI = 30 +/- 1 kg/m(2)) and DET (n = 21; 28 +/- 1 kg/m(2)). Ten lean children were included in a control group (10 +/- 0.3 years; 17 +/- 0.5 kg/m(2)). All children performed maximal treadmill testing with respiratory gas analysis (breath-by-breath) to determine the ventilatory anaerobic threshold (VAT) and peak oxygen consumption (VO(2) peak). VentE was determined by the VE/VCO(2) method at VAT. Obese children showed lower VO(2) peak and lower VentE than controls (p < 0.05). After interventions, all obese children reduced body weight (p < 0.05). D group did not improve in terms of VO(2) peak or VentE (p > 0.05). In contrast, the DET group showed increased VO(2) peak (p = 0.01) and improved VentE(Delta VE/VCO(2) = -6.1 +/- 0.9; p = 0.01). VentE is decreased in obese children, where weight loss by means of DET, but not D alone, improves VentE and cardiorespiratory fitness during graded exercise.

Ventilation behavior during upper-body incremental exercise

Pires, FO, Hammond, J, Lima-Silva, AE, Bertuzzi, RCM, and Kiss, MAPDM. Ventilation behavior during upper-body incremental exercise. J Strength Cond Res 25(1): 225-230, 2011-This study tested the ventilation (V(E)) behavior during upper-body incremental exercise by mathematical models that calculate 1 or 2 thresholds and compared the thresholds identified by mathematical models with V-slope, ventilatory equivalent for oxygen uptake (V(E)/(V) over dotO(2)), and ventilatory equivalent for carbon dioxide uptake (V(E)/(V) over dotCO(2)). Fourteen rock climbers underwent an upper-body incremental test on a cycle ergometer with increases of approximately 20 W.min(-1) until exhaustion at a cranking frequency of approximately 90 rpm. The V(E) data were smoothed to 10-second averages for V(E) time plotting. The bisegmental and the 3-segmental linear regression models were calculated from 1 or 2 intercepts that best shared the V(E) curve in 2 or 3 linear segments. The ventilatory threshold(s) was determined mathematically by the intercept(s) obtained by bisegmental and 3-segmental models, by V-slope model, or visually by V(E)/(V) over dotO(2) and V(E)/(V) over dotCO(2). There was no difference between bisegmental (mean square error [MSE] = 35.3 +/- 32.7 l.min(-1)) and 3-segmental (MSE = 44.9 +/- 47.8 l.min(-1)) models in fitted data. There was no difference between ventilatory threshold identified by the bisegmental (28.2 +/- 6.8 ml.kg(-1).min(-1)) and second ventilatory threshold identified by the 3-segmental (30.0 +/- 5.1 ml.kg(-1).min(-1)), V(E)/(V) over dotO(2) (28.8 +/- 5.5 ml.kg(-1).min(-1)), or V-slope (28.5 +/- 5.6 ml.kg(-1).min(-1)). However, the first ventilatory threshold identified by 3-segmental (23.1 +/- 4.9 ml.kg(-1).min(-1)) or by VE/(V) over dotO(2) (24.9 +/- 4.4 ml.kg(-1).min(-1)) was different from these 4. The V(E) behavior during upper-body exercise tends to show only 1 ventilatory threshold. These findings have practical implications because this point is frequently used for aerobic training prescription in healthy subjects, athletes, and in elderly or diseased populations. The ventilatory threshold identified by V(E) curve should be used for aerobic training prescription in healthy subjects and athletes.

Energy systems contributions in 2,000 m race simulation: a comparison among rowing ergometers and water

This study investigated the energy system contributions of rowers in three different conditions: rowing on an ergometer without and with the slide and rowing in the water. For this purpose, eight rowers were submitted to 2,000 m race simulations in each of the situations defined above. The fractions of the aerobic (W(AER)), anaerobic alactic (W(PCR)) and anaerobic lactic (W([La-])) systems were calculated based on the oxygen uptake, the fast component of excess post-exercise oxygen uptake and changes in net blood lactate, respectively. In the water, the metabolic work was significantly higher [(851 (82) kJ] than during both ergometer [674 (60) kJ] and ergometer with slide [663 (65) kJ] (P <= 0.05). The time in the water [515 (11) s] was higher (P < 0.001) than in the ergometers with [398 (10) s] and without the slide [402 (15) s], resulting in no difference when relative energy expenditure was considered: in the water [99 (9) kJ min(-1)], ergometer without the slide [99.6 (9) kJ min(-1)] and ergometer with the slide [100.2 (9.6) kJ min(-1)]. The respective contributions of the WAER, WPCR and W[La-] systems were water = 87 (2), 7 (2) and 6 (2)%, ergometer = 84 (2), 7 (2) and 9 (2)%, and ergometer with the slide = 84 (2), 7 (2) and 9 (1)%. (V) over dotO(2), HR and lactate were not different among conditions. These results seem to indicate that the ergometer braking system simulates conditions of a bigger and faster boat and not a single scull. Probably, a 2,500 m test should be used to properly simulate in the water single-scull race.

Exercise training improves muscle vasodilatation in individuals with T786C polymorphism of endothelial nitric oxide synthase gene

Negrão M.V, Alves CR, Alves G.B, Pereira A.C, Dias R.G, Laterza M.C, Mota G.F, Oliveira E.M, Bassaneze V, Krieger J.E, Negrão C.E, Rondon M.U.P. Exercise training improves muscle vasodilatation in individuals with T786C polymorphism of endothelial nitric oxide synthase gene. Physiol Genomics 42A: 71-77, 2010. First published July 6, 2010; doi:10.1152/physiolgenomics.00145.2009.-Allele T at promoter region of the eNOS gene has been associated with an increase in coronary disease mortality, suggesting that this allele increases susceptibility for endothelial dysfunction. In contrast, exercise training improves endothelial function. Thus, we hypothesized that: 1) Muscle vasodilatation during exercise is attenuated in individuals homozygous for allele T, and 2) Exercise training improves muscle vasodilatation in response to exercise for TT genotype individuals. From 133 preselected healthy individuals genotyped for the T786C polymorphism, 72 participated in the study: TT (n = 37; age 27 +/- 1 yr) and CT + CC (n = 35; age 26 +/- 1 yr). Forearm blood flow (venous occlusion plethysmography) and blood pressure (oscillometric automatic cuff) were evaluated at rest and during 30% handgrip exercise. Exercise training consisted of three sessions per week for 18 wk, with intensity between anaerobic threshold and respiratory compensation point. Resting forearm vascular conductance (FVC, P = 0.17) and mean blood pressure (P = 0.70) were similar between groups. However, FVC responses during handgrip exercise were significantly lower in TT individuals compared with CT + CC individuals (0.39 +/- 0.12 vs. 1.08 +/- 0.27 units, P = 0.01). Exercise training significantly increased peak VO(2) in both groups, but resting FVC remained unchanged. This intervention significantly increased FVC response to handgrip exercise in TT individuals (P = 0.03), but not in CT + CC individuals (P = 0.49), leading to an equivalent FVC response between TT and CT + CC individuals (1.05 +/- 0.18 vs. 1.59 +/- 0.27 units, P = 0.27). In conclusion, exercise training improves muscle vasodilatation in response to exercise in TT genotype individuals, demonstrating that genetic variants influence the effects of interventions such as exercise training.

EFFECTS OF 14-WEEK SWIMMING TRAINING PROGRAM ON THE PSYCHOLOGICAL, HORMONAL, AND PHYSIOLOGICAL PARAMETERS OF ELITE WOMEN ATHLETES

Santhiago, V, da Silva, ASR, Papoti, M, and Gobatto, CA. Effects of 14-week swimming training program on the psychological, hormonal, and physiological parameters of elite women athletes. J Strength Cond Res 25(3): 825-832, 2011-The purpose of the study was to investigate the influence of a 14-week swimming training program on psychological, hormonal, and performance parameters of elite women swimmers. Ten Olympic and international-level elite women swimmers were evaluated 4 times along the experiment (i.e., in T1, T2, T3, and T4). On the first day at 8: 00 AM, before the blood collecting at rest for the determination of hormonal parameters, the athletes had their psychological parameters assessed by the profile of mood-state questionnaire. At 3: 00 AM, the swimmers had their anaerobic threshold assessed. On the second day at 3: 00 AM, the athletes had their alactic anaerobic performance measured. Vigor score and testosterone levels were lower (p <= 0.05) in T4 compared with T3. In addition, the rate between the peak blood lactate concentration and the median velocity obtained in the alactic anaerobic performance test increased in T4 compared with T3 (p < 0.05). For practical applications, the swimming coaches should not use a tapering with the present characteristics to avoid unexpected results.

RESPONSES OF HEMATOLOGICAL PARAMETERS AND AEROBIC PERFORMANCE OF ELITE MEN AND WOMEN SWIMMERS DURING A 14-WEEK TRAINING PROGRAM

Santhiago, V, da Silva, ASR, Papoti, M, and Gobatto, CA. Responses of hematological parameters and aerobic performance of elite men and women swimmers during a 14-week training program. J Strength Cond Res 23(4): 1097-1105, 2009-The main purpose of the present investigation was to verify the responses of hematological parameters in men and women competitive swimmers during a 14-week training program. Twenty-three Olympic and international athletes were evaluated 4 times during the experiment: at the beginning of the endurance training phase (T1), at the end of the endurance training phase (T2), at the end of the quality phases (T3), and at the end of the taper period (T4). On the first day at 8:00 AM, each swimmer had a blood sample taken for the determination of hematological parameters. At 3:00 PM, the athletes had their aerobic performance measured by anaerobic threshold. On the second day at 8: 00 AM, the swimmers had their aerobic performance measured by critical velocity. Hematocrit and mean corpuscular volume diminished (p <= 0.05) from T1 to T2 (men: 5.8 and 7.2%; women: 11.6 and 6.8%), and increased (p <= 0.05) from T2 to T3 (men: 7.2 and 6.0%; women: 7.4 and 5.2%). These results were related to the plasma volume changes of the athletes. However, these alterations do not seem to affect the swimmers` aerobic performance. For practical applications, time-trial performance is better than aerobic performance (i.e., anaerobic threshold and critical velocity) for monitoring training adaptations.

Effects of Exercise Training on Myocardial Blood Flow Reserve in Patients With Heart Failure and Left Ventricular Systolic Dysfunction

Exercise training has been shown to be effective in improving exercise capacity and quality of life in patients with heart failure and left ventricular (LV) systolic dysfunction. Real-time myocardial contrast echocardiography (RTMCE) is a new technique that allows quantitative analysis of myocardial blood flow (MBF). The aim of this study was to determine the effects of exercise training on MBF in patients with LV dysfunction. We studied 23 patients with LV dysfunction who underwent RTMCE and cardiopulmonary exercise testing at baseline and 4 months after medical treatment (control group, n = 10) or medical treatment plus exercise training (trained group, n = 13). Replenishment velocity (0) and MBF reserves were derived from quantitative RTMCE. The 4-month exercise training consisted of 3 60-minute exercise sessions/week at an intensity corresponding to anaerobic threshold, 10% below the respiratory compensation point. Aerobic exercise training did not change LV diameters, volumes, or ejection fraction. At baseline, no difference was observed in MBF reserve between the control and trained groups (1.89, 1.67 to 1.98, vs 1.81, 1.28 to 2.38, p = 0.38). Four-month exercise training resulted in a significant increase in beta reserve from 1.72 (1.45 to 1.48) to 2.20 (1.69 to 2.77, p <0.001) and an MBF reserve from 1.81 (1.28 to 2.38) to 3.05 (2.07 to 3.93, p <0.001). In the control group, 13 reserve decreased from 1.51 (1.10 to 1.85) to 1.46 (1.14 to 2.33, p = 0.03) and MBF reserve from 1.89 (1.67 to 1.98) to 1.55 (1.11 to 2.27, p <0.001). Peak oxygen consumption increased by 13.8% after 4 months of exercise training and decreased by 1.9% in the control group. In conclusion, exercise training resulted in significant improvement of MBF reserve in patients with heart failure and LV dysfunction. (C) 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;105:243-248)