Drug prescriptions and referral to cardiac rehabilitation after acute coronary events: comparison between men and women in the French PREVENIR Survey

Cardiac Rehabilitation Programs: Content, Effectiveness, Limitations, and Gaps in Knowledge

Cardiac rehabilitation (CR) constitutes a valuable therapeutic approach for patients with a broad spectrum of cardiovascular diseases facilitating the development and maintenance of a desirable level of physical, social, and psychological functioning following the onset of cardiovascular disease. Nowadays, cardiac rehabilitation programs emphasize the use of a multidisciplinary approach. The current review aims at presenting the state-of-the-art knowledge on the indications of patients entering cardiac rehabilitation programs, including their core components, duration, and effectiveness. Following a careful review of the international literature, we conclude that there are significant differences between the most commonly cited international CR guidelines as well as additional limitations and gaps in knowledge. Despite the benefits associated with CR and despite their widespread acceptance, CR referrals and program attendance remains low, while many questions have not been so far addressed through scientific research. Overall, the findings of our study suggest a critical need for the development of robust and evidence-based standardized CR interventions to increase their use and effectiveness throughout the world.

Design, methodology and baseline characteristics of the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD)

A significant number of women with signs and symptoms of ischemia with no obstructive coronary artery disease (INOCA) have coronary vascular dysfunction detected by invasive coronary reactivity testing (CRT). However, the noninvasive assessment of coronary vascular dysfunction has been limited.

METHODS

The Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) was a prospective study of women with suspected INOCA aimed to investigate whether (1) cardiac magnetic resonance imaging (CMRI) abnormalities in left ventricular morphology and function and myocardial perfusion predict CRT measured coronary microvascular dysfunction, (2) these persistent CMRI abnormalities at 1-year follow-up predict persistent symptoms of ischemia, and (3) these CMRI abnormalities predict cardiovascular outcomes. By design, a sample size of 375 women undergoing clinically indicated invasive coronary angiography for suspected INOCA was projected to complete baseline CMRI, a priori subgroup of 200 clinically indicated CRTs, and a priori subgroup of 200 repeat 1-year follow-up CMRIs.

RESULTS

A total of 437 women enrolled between 2008 and 2015, 374 completed baseline CMRI, 279 completed CRT, and 214 completed 1-year follow-up CMRI. Mean age was 55± 11 years, 93% had 20%-50% coronary stenosis, and 7% had <20% stenosis by angiography.

CONCLUSIONS

The WISE-CVD study investigates the utility of noninvasive CMRI to predict coronary vascular dysfunction in comparison to invasive CRT, and the prognostic value of CMRI abnormalities for persistent symptoms of ischemia and cardiovascular outcomes in women with INOCA. WISE-CVD will provide new understanding of a noninvasive imaging modality for future clinical trials.

[Cardiac rehabilitation in women]

Coronary artery disease (CAD) occurs later in life in women when compared to men (10 years later). The FAST-MI study has shown that the profile of women with CAD has changed in the past 15 years, they are younger, more obese, and usually smokers. Whatever the age at which CAD occurs in women, the prognosis tends to be worse than in men, despite a higher frequency of acute coronary syndrome (ACS) with angiographically normal coronary arteries in women. In women without significant lesion at coronary angiography, the WISE study has shown abnormalities of the coronary vasomotricy. Despite its beneficial effect on morbidity and mortality, cardiac rehabilitation is underused particularly in women. Indeed, several factors do not encourage a woman to follow a cardiac rehabilitation program, even after an ACS. These factors may be cultural, domestic, familial, orthopedic, or even the fear of exercising. Therefore, physicians have to be particularly convincing in women, in order to have them participating in rehabilitation programs. Physical capacity is lower in women when compared to men. However, the weaker the physical capacity, the better the benefit of cardiac rehabilitation. Physical endurance training continuously or in interval, associated to muscle strengthening can improve the physical capacity in women. Vascular risk factors correction is also an important step for the management of women with CAD. Therapeutic education and several available workshops help women to better understand their disease and to improve their self-management when they return home. Anxiety, depression, and sexual dysfunction frequently deteriorate the quality of life of our patients. Therefore, psychological management is also essential in our departments.

Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (TEACH) Study

BACKGROUND

Little is known about physical activity levels in patients with coronary artery disease (CAD) who are not engaged in cardiac rehabilitation. We explored the trajectory of physical activity after hospitalization for CAD, and examined the effects of demographic, medical, and activity-related factors on the trajectory.

DESIGN

A prospective cohort study.

METHODS

A total of 782 patients were recruited during CAD-related hospitalization. Leisure-time activity energy expenditure (AEE) was measured 2, 6 and 12 months later. Sex, age, education, reason for hospitalization, congestive heart failure (CHF), diabetes, and physical activity before hospitalization were assessed at recruitment. Participation in cardiac rehabilitation was measured at follow-up.

RESULTS

AEE was 1948+/-1450, 1676+/-1290, and 1637+/-1486 kcal/week at 2, 6 and 12 months, respectively. There was a negative effect of time from 2 months post-hospitalization on physical activity (P<0.001). Interactions were found between age and time (P=0.012) and education and time (P=0.001). Main effects were noted for sex (men more active than women; P<0.001), CHF (those without CHF more active; P<0.01), diabetes (those without diabetes more active; P<0.05), and previous level of physical activity (those active before hospitalization more active after; P<0.001). Coronary artery bypass graft patients were more active than percutaneous coronary intervention (PCI) patients (P=0.033).

CONCLUSIONS

Physical activity levels declined from 2 months after hospitalization. Specific subgroups (e.g. less educated, younger) were at greater risk of decline and other subgroups (e.g. women, and PCI, CHF, and diabetic patients) demonstrated lower physical activity. These groups need tailored interventions.

Impact of exercise-based cardiac rehabilitation on long-term clinical outcomes in patients with left main coronary artery stenosis

BACKGROUND

Cardiac rehabilitation may reduce cardiovascular mortality and morbidity rates in patients with coronary artery disease. The specific relationship between cardiac rehabilitation participation and left main coronary artery stenosis is unknown.

DESIGN

Prospective registry analysis.

METHODS

Data from a registry of 3120 patients with left main coronary artery stenosis, collected between 1995 and 2010, were analyzed. A total of 596 patients (19.6%) had participated in a cardiac rehabilitation program.

RESULTS

The crude seven-year mortality, cardiovascular mortality, target-vessel revascularization and myocardial infarction rates were significantly lower in the cardiac rehabilitation than in the non-rehabilitation group, and the incidence of stroke tended to be lower in the cardiac rehabilitation group. Multivariate analysis showed that cardiac rehabilitation was associated with significantly lower risks of mortality (hazard ratio (HR), 0.70; 95% confidence interval (CI), 0.49-1.00; p = 0.05) and cardiovascular mortality (HR, 0.69; 95% CI, 0.48-0.97; p = 0.03). However, the adjusted HR of myocardial infarction, target-vessel revascularization and stroke did not differ significantly. Propensity score-matched analysis of 507 pairs showed that cardiac rehabilitation was associated with significant decreases in mortality (HR, 0.62; 95% CI, 0.43-0.89; p = 0.009) and cardiovascular mortality (HR, 0.54; 95% CI, 0.36-0.80; p = 0.002) but had no beneficial effects on myocardial infarction, target-vessel revascularization or stroke.

CONCLUSIONS

Exercise-based cardiac rehabilitation participation was associated with significant decreases in mortality. Our findings show that cardiac rehabilitation programs should be implemented in standard management for patients with left main coronary artery stenosis.

High age predicts low referral of hyperthyroid patients to specialized hospital departments: evidence for referral bias

BACKGROUND

Hospital-based studies may be hampered by referral bias. We investigated how the phenomenon may influence studies of hyperthyroid patients.

METHODS

By means of a computer-based linkage to the laboratory database and subsequent detailed evaluation of subjects with abnormal test results, we prospectively identified all 1148 patients diagnosed with overt hyperthyroidism in a four-year period in and around Aalborg City, Denmark. Each patient was classified according to nosological type of hyperthyroidism. We studied the referral pattern of patients to local hospital units, and analyzed how referral depended on subtype of disease, sex, age, and degree of biochemical hyperthyroidism.

RESULTS

In a 4-year period, 1032 hyperthyroid patients were diagnosed at primary care offices, and 435 of these (42.2%) were referred to specialized units, 92 patients had hyperthyroidism diagnosed in other hospital departments (referral: 43, 46.7%), and 24 patients had hyperthyroidism diagnosed at the specialized unit after referral for other diseases. Patients suffering from Graves' disease (GD; n=474, median age=65.8 years) were referred more often (odds ratio=1.7 [95% confidence interval 1.3-2.2]) than those diagnosed with multinodular toxic goiter (MNTG; n=525, median age=74.6 years). Higher age was associated with less referral of patients suffering from MNTG (referred vs. nonreferred patients, 64.0 vs. 77.4 years, p<0.001) and GD (43.9 vs. 56.4 years, p<0.001), whereas GD patients referred to a hospital had more severe biochemical hyperthyroidism (serum total triiodothyronine, 4.86 vs. 3.79 nmol/L; serum total thyroxine, 204 vs. 180 nmol/L; both p<0.001). Findings were confirmed in multivariate models reporting age as a significant predictor for referral in both GD and MNTG patients (both p<0.001). Among referred hyperthyroid patients (all combined), those aged up to 40 years (referral rate, 66.8%) were represented 11.6 (6.6-20.6) times more often than those aged 80 years and above (referral rate, 14.8%).

CONCLUSIONS

Hyperthyroid patients referred to a specialized hospital unit were younger (GD+MNTG) and had more severe biochemical hyperthyroidism (GD) compared to nonreferred patients. Thus, referral bias may influence hospital-based studies of hyperthyroid patients, and may hamper external generalization of such studies. Whether the referral bias of hyperthyroid patients in Denmark can be generalized to other countries or cultures remains unknown.

Reproducibility, validity and responsiveness of the 200-metre fast walk test in patients undergoing cardiac rehabilitation

Objective:

To investigate the reliability, validity and responsiveness of the 200-metre fast walk test in patients with coronary artery disease engaged in a cardiac rehabilitation programme.

Design:

Descriptive study.

Setting:

Tertiary care hospital.

Subjects:

Thirty stable patients with coronary artery disease (51.9 ± 8.7 years), referred to the cardiac rehabilitation department after an acute coronary syndrome.

Intervention:

Not applicable.

Main measures:

Six-minute walk test distance, time to perform the 200-m fast walk test, peak power output of the graded maximal exercise test, before and after the programme; SF-36 quality of life questionnaire at baseline. Walk tests were performed twice at baseline to assess reliability.

Results:

The 200-m fast walk test was highly reliable (ICC = 0.97). It was significantly correlated with the graded maximal exercise test peak power and the 6-minute walk test at baseline ( r = −0.417; P < 0.05; and r = −0.566; P < 0.01, respectively) and after the training programme ( r = −0.460, P < 0.05; and r = −0.926; P < 0.01, respectively). At baseline, there was a strong correlation between the 200-m fast walk test time and the physical component score of the SF-36 ( r = −0.77; P < 0.01), but not between the 200-m fast walk test time and the SF-36 mental component score. Mean 200-m fast walk test time was significantly different between the patients performing ≤90 W ( n = 11) or ≥100 W ( n = 19) at the baseline graded maximal exercise test (121.7 ± 13.6 vs. 115.5 ± 10.1 seconds; P < 0.05). The responsiveness was strong with a standardized response mean at 1.11.

Conclusion:

The 200-m fast walk test is a reliable, valid and responsive high-intensity walk test in patients with coronary artery disease after an acute coronary syndrome. It can thus give additional information to that given by the 6-minute walk test and the graded maximal exercise test.

Outpatient cardiac rehabilitation attendance in England: variability by region and clinical characteristics

PURPOSE

Cardiac rehabilitation is an effective but underprovided treatment for patients recovering from acute cardiac events. The geographical spread of provision has not been investigated recently in any country. This study aimed to investigate the level of participation in cardiac rehabilitation programs of patients following myocardial infarction or revascularization (eligible patients) and the geographical equity of attendance.

METHODS

Questionnaire data were collected from all cardiac rehabilitation centers in England for the year 2003/2004. The number of patients attending rehabilitation was compared with eligible patients across the 9 Government Office Regions of England as indicated by Hospital Episode Statistics.

RESULTS

Nationally, 29% of eligible patients attended rehabilitation, while within various regions, the proportion of eligible patients participating in rehabilitation ranged between 14% (95% CI, 13.2-14.3) and 37% (95% CI, 36.6-37.6). Participation also differed significantly by primary cardiac event: myocardial infarction, 25%; percutaneous coronary intervention, 24%; and coronary artery bypass surgery, 66% (P < .001).

CONCLUSION

The participation rate of eligible patients in cardiac rehabilitation was low in all regions. There were large differences between regions with widely varying incidence of attendance in different parts of the country.

Adverse baseline physiological and psychosocial profiles of women enrolled in a cardiac rehabilitation clinical trial

PURPOSE

Coronary heart disease (CHD) remains the leading cause of death in women. Despite positive outcomes associated with cardiac rehabilitation (CR), investigations of women are sparse. This article presents the baseline physiological and psychosocial profiles of 182 women in the Women's-Only Cardiac Rehabilitation study.

METHOD

Women were randomized to a women's-only motivational interviewing or traditional CR group. Physiological measures included lipid profiles, body mass index, functional capacity, and anthropomorphic measures. Psychosocial measures included optimism, hope, social support, anxiety, depression, quality of life, and health perceptions. The median age was used to split the sample to examine data on 92 younger (< or = 64 years) and 90 older (>64 years) women.

RESULTS

With a mean age of 63 years, 66.5% were white, 47% were retired, and 54% were married. Most women were physically inactive (83%), hypertensive (76%), and overweight (56%). Most women (71.4%) met the criteria for metabolic syndrome. Younger women demonstrated significantly worse psychosocial profiles than older women. More of the younger women (64%) had depressive symptoms than older women (37%). Younger women demonstrated a mean Center for Epidemiological Studies Depression Scale score of 20.8 +/- 12.4, whereas older women had a substantially lower mean score of 14.9 +/- 9.5 (P < .001). Younger participants also reported significantly more anxiety than older participants (38.8 +/- 13.4 vs 32.8 +/- 10.6, P < .001).

CONCLUSION

Younger women enrolled in a CR clinical trial had adverse baseline risk factor profiles placing them at high risk for disease progression.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

Cardiac rehabilitation in England: a detailed national survey

AIMS

The purpose of this study is to conduct a detailed analysis of cardiac rehabilitation programmes in England to compare actual provision with the recommendations of the National Service Framework and Scottish Intercollegiate Guideline Network guidelines.

METHODS

Questionnaires and interviews were conducted with key staff from one centre in each Strategic Health Authority in England to establish staffing levels, patient throughput, programme details, data collection and funding.

RESULTS

There were major discrepancies between programmes and the national recommendations. Perceptions of the service were often at variance within key staff in the trust. Staffing levels, lack of facilities and space were identified as a weakness in many of the programmes. Inadequate exercise sessions, poor record keeping and a failure to tailor the sessions to the patients needs were common. Mean funding was pound288 per patient rehabilitated.

CONCLUSIONS

For those 30% of eligible patients who enter cardiac rehabilitation in England, the service suffers from inadequate staffing, facilities and space, associated with gross underfunding. If the recommended 85% of eligible patients were included the situation would be much worse. The Department of Health recommendations for cardiac rehabilitation have not been translated into action, with most hospitals giving it low priority compared with other cardiology services. A treatment with demonstrable benefits should at least meet the standards recommended by national guidelines.

Consistency of lipid-altering effects of ezetimibe/simvastatin across gender, race, age, baseline low density lipoprotein cholesterol levels, and coronary heart disease status: results of a pooled retrospective analysis

BACKGROUND

The combination tablet containing ezetimibe and simvastatin (EZE/SIMVA), inhibits both the intestinal absorption and endogenous production of cholesterol, providing significantly greater low-density lipoprotein cholesterol (LDL-C) lowering than EZE or SIMVA alone. The purpose of this pooled analysis was to evaluate the consistency of efficacy (i.e., between-treatment difference) of EZE/SIMVA versus SIMVA within several selected subgroups of patients with primary hypercholesterolemia.

METHODS

For the present analysis, data were pooled from three similarly designed, 12-week, randomized, double-blind, placebo-controlled factorial studies consisting of 3083 patients with primary hypercholesterolemia (n = 311 in placebo group; n = 302 in EZE group; n = 1234 in pooled SIMVA group; n = 1236 in pooled EZE/SIMVA group). In these clinical studies, primary hypercholesterolemia was defined as an LDL-C value between 145 and 250 mg/dL inclusive and a triglyceride (TG) level of less than 350 mg/dL. The results for the pooled SIMVA and pooled EZE/SIMVA groups were used for the present analyses. The pooled analyses focused on the consistency of the between-treatment differences (i.e., incremental effect) for EZE/SIMVA (pooled across doses) versus SIMVA (pooled across doses) on various lipid and non-lipid parameters within different patient subgroups defined according to gender, race (Caucasian, Non-Caucasian), baseline age (< 65, > or = 65 years), baseline LDL-C (< 160, > or = 160 mg/dL), and coronary heart disease (CHD) history. Tolerability was also examined for pooled EZE/SIMVA and pooled SIMVA within these selected subgroups. In a modified intention-to-treat analysis, an ANOVA model was used for testing the consistency of pooled treatment effects on lipid and non-lipid parameters within each selected subgroup.

RESULTS

For the entire cohort, baseline lipid profiles were similar for the patients in the pooled EZE/SIMVA group compared with those in the pooled SIMVA group. Treatment with EZE/SIMVA led to significant (p < 0.001) incremental improvements in LDL-C, non-high density lipoprotein cholesterol (non-HDL-C), apolipoprotein B, TG and high sensitivity C-reactive protein compared to SIMVA, across the entire cohort. These changes were consistent within each of the selected subgroups. Moreover, more patients attained LDL-C goal levels < 100 mg/dL with EZE/SIMVA than with SIMVA in the entire cohort and this was consistent across all subgroups, except baseline LDL-C. In this pooled retrospective analysis, treatment with EZE/SIMVA was generally well tolerated across subgroups, with a safety profile similar to SIMVA monotherapy. Although this pooled analysis was performed on a large cohort of patients with primary hypercholesterolemia, the results of this analysis were specific for this select patient population and generalizations to other populations should be applied with caution.

CONCLUSION

The enhanced lipid-altering effects of EZE/SIMVA versus those of SIMVA observed in the entire cohort were consistent within all subgroups examined. EZE/SIMVA represents an effective and well-tolerated therapeutic option for the treatment of a wide range of patient subgroups with primary hypercholesterolemia.

A Behavior Change Intervention for Women in Cardiac Rehabilitation

There is undeniable evidence for physical and psychosocial benefits of cardiac rehabilitation programs for individuals suffering from coronary heart disease. Yet, fewer women than men are referred to, begin, or complete cardiac rehabilitation programs. The numerous logistical, economic, and motivational barriers to healthy behavior change place women at risk for subsequent CHD events. To close this gender gap and improve outcomes, novel, efficacious, and individualized rehabilitative approaches for women with coronary heart disease are needed. The purpose of this article is to describe a theory-driven behavioral intervention designed exclusively for women with coronary heart disease. The 12-week intervention is being tested in a randomized controlled trial involving women referred to a cardiac rehabilitation program. The tenets of the Transtheoretical Model of behavior change and motivational interviewing guided the development and implementation of the stage-matched, individualized intervention to promote healthy behavior change for women with coronary heart disease. The ongoing trial will examine the efficacy of the intervention on physiological and psychosocial outcomes.

Prevention of medication errors

Medication error is the most frequent source of medical error that is associated with adverse events, and, in many cases, is preventable. Medication errors can occur at any step in the medication process. Medication error prevention and reduction begins with a systematic approach to their detection. An important approach to mitigating errors involves the reduction of variation in task performance using tested techniques and technologies from other industries. The most important component of error prevention and reduction is the proactive promotion of a safety culture by organizational leadership, with sustained education and support for users.