Dear Laurent,

since 2008 I am working in a Cardiac Rehabilitation Unit linked to the University Hospital of Padua, Italy. Our Unit is located in the Alps (Cortina d'Ampezzo), at an altitude of 1315 m a.s.l.. Such an altitude is generally considered as "low altitude".

We usually receive patients with a combination of risk factors: middle age and elderly persons, with coronary heart disease or recent major clinical events (myocardial infarction, cardiac surgery), that are exposed to exercise-based rehabilitation during a two weeks (average) period. Among more than 2000 patients submitted to residential cardiac rehabilitation in the past few years, no major side-effects have been registered during the daily sessions of structured exercises. It must be said that exercise intensity was based on careful evaluation of patient's status and "monitored" with Borg scale. In patients with recent episodes of heart failure, a preliminari cardiopulmonary exercise test was performed, and exercise intensity was maintained at or around anaerobic threshold.

In this way, we believe that exercise-based cardiac rehabilitation is feasible and safe in this kind of patients also in a mountain resort.

No significant modifications have been observed also of blood pressure, heart rate or other clinical parameters with the rapid ascent from the University Hospital at Padua (12 m a.s.l.) to the level of 1315 m a.s.l. of the Rehabilitation Centre.[i] These results are somehow similar to what is knownin literature for patients with metabolic syndrome, that travelled from Innsbruck (576 m a.s.l) to Obertauern (1700 m a.s.l.), resided there during 3 weeks and went also hiking, taking care that physical effort did not exceed 55-65% of individual maximal heart rate, without major adverse effects.[ii] Furthermore, in literature can be found a paper reporting that patients with stable heart failure have been accompanied to an altitude of 3454 m a.s.l., where they were able to perform moderately vigorous effort, without serious events, demonstrating only a reduced performance that was approximately 22% less than their performance at lower altitudes.[iii]

Thus, we believe that it is possible to perform exercise-based rehabilitation at least at low mountain altitudes, provided that physical effort is maintained approximately below or around individual anaerobic threshold.

Hoping to having been somehow useful, I present my best regards.

Merry Christmas and Happy New Year.

Leonida Compostella, MD

[i] Carraro Umberto. [Effects of ascension to mountain in heart disease patients in subacute phase: an observational study]. Thesis for Graduation in Medicine, University of Padua, AA 2009-2010

[ii] Mair J, Hammerer-Lercher A, Mittermayr M et al. 3-week hiking holidays at moderate altitude do not impair cardiac function in individuals with metabolic syndrome. Int J Cardiol 2008; 123(2):186-188

[iii] Schmid JP, Nobel D, Brugger N et al. Short-term high altitude exposure at 3454 m is well tolerated in patients with stable heart failure. Eur J Heart Fail 2015; 17(2):182-186

Dear Laurent,

I have no evidence but an opinion to contribute.

I think that 2 factors might be more important than altitude, but are usually correlated: Clean air and a wavy landscape. Think of Cortina D’Ampezzo: You won’t find many even streets there; even if you are not a climber, you have to walk up and down. And very few would challenge the rule that the air is better there than in lower Lombardy.

Thinking of Milano, Paris, Berlin, or London: These towns might lack both ... and walking up and down might be largely reduced to staircases of the underground, provided that people do not prefer moving stairs.

Mexico City (“DF”) has quite a high altitude, but neither clean air not a wavy landscape.

Many places at coasts (Portugal, Spain, Western England, Italy) have both: Clean air from the ocean and a wavy landscape.

Although it is rather intuition: Most would rate the air in Franche-Comte better than the average air in Paris or Lyon. Science often starts with intuition and later confirms (or not) such hypotheses by data.

Thank you, Hans-Joachim Kremer, for your appreciation of air and landscape in Cortina. I will pass your message to the Local Tourism Authority!

Dear Leonida and Hans Joachim,

I thank you for your answers and I agree that as in Cortina, quality of air in Franche Comté is good! My question was related to the interest of exersising in hypoxia as an original way to improve the effectiveness of training program. Training in altitude is well known in athletes but some authors suggest that it could be an effective way to increase the efficiency of training program even with patients. As high intensity interval training for example. Such training could be done in climatic chambers in low altitude and with bad air quality...

From the physiological point of view lots remain to be done to disentangle the effects of altitude from those of exercise. I was wondering if scientific evidences or pragmatic approaches exist on the clinical side with cardiovascular patients.

Thanks again for your answer and Best wishes for the coming year.

Laurent

In India, where I practice, we do not have such options.

The society being so well knit, refuse to move apart for the sake of treatment.

Any exercise advised will be in the locality only. If they are asked to go to different places for better exercise, they would rather not do the exercise even when it is good, rather than moving out even temporarily.

I think we are not considering the effect of altitude, hence.

We have compared pulse oximetry values at sea level and 1500 m.a.s.l in acute care patient populations.  We found that at this altitude the median SpO2 reading was -2% between the patient populations.  Older patients will also tend to have lower baseline SpO2.  So, it is possible that some of your elderly patients may become marginally hypoxic  (90% SpO2) at higher altitude prior to exercise training.  I am not aware of any adverse events in our data.

Thank you M Welch. Hzve you published these data?

No, we have not published this data.  Our most recent publication is Multiparameter vital signs database to assist in alarm optimization for general care units, J Clin Monit Comput. October 2015.  It is available on open source.  This article describes our cloud based physiologic data collection method.

M Welch

Thank you for the reference