Rising time from bed in acute phase after hospitalization predicts frailty at hospital discharge in patients with acute heart failure

Association between natriuretic peptides and C-reactive protein with frailty in heart failure: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and frailty are accompanied by a bidirectional relationship, sharing common risk factors including elevated levels of natriuretic peptides and inflammation. The aim of this study was to compare biomarkers associated with poor clinical outcomes, that is, plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and frailty vs. patients with HF without frailty.

METHODS

From inception until July 2023, PubMed, Scopus, Web of Science, and Cochrane Library a systematic literature search was conducted. To evaluate whether frailty is linked with greater levels of BNP, NT-proBNP, and CRP, a meta-analysis using a random-effects model was used to calculate the pooled effects (CRD42023446607).

RESULTS

Fifty-three studies were included in this systematic review and meta-analysis. Patients with HF and frailty displayed significantly higher levels of BNP (k = 11; SMD: 0.53, 95%CI 0.30-0.76, I2 = 86%, P < 0.01), NT-proBNP (k = 23; SMD: 0.33, 95%CI 0.25-0.40, I2 = 72%, P < 0.01), and CRP (k = 8; SMD: 0.30, 95%CI 0.12-0.48, I2 = 62%, P < 0.01) vs. patients with HF without frailty. Using meta-regression, body mass index (BMI) and age were deemed potential moderators of these findings.

CONCLUSIONS

Frailty in HF is linked to increased concentrations of BNP, NT-proBNP, and CRP, which have been epidemiologically associated with adverse outcomes. The increased risk of NYHA III/IV classification further emphasizes the clinical impact of frailty in this population.

Association of admission frailty and frailty changes during cardiac rehabilitation with 5-year outcomes

AIMS

Examine the association between (1) admission frailty and (2) frailty changes during cardiac rehabilitation (CR) with 5-year outcomes (i.e. time to mortality, first hospitalization, first emergency department (ED) visit, and number of hospitalizations, hospital days, and ED visits).

METHODS AND RESULTS

Data from patients admitted to a 12-week CR programme in Halifax, Nova Scotia, from May 2005 to April 2015 (n = 3371) were analysed. A 25-item frailty index (FI) estimated frailty levels at CR admission and completion. FI improvements were determined by calculating the difference between admission and discharge FI. CR data were linked to administrative health data to examine 5-year outcomes [due to all causes and cardiovascular diseases (CVDs)]. Cox regression, Fine-Gray models, and negative binomial hurdle models were used to determine the association between FI and outcomes. On average, patients were 61.9 (SD: 10.7) years old and 74% were male. Mean admission FI scores were 0.34 (SD: 0.13), which improved by 0.07 (SD: 0.09) by CR completion. Admission FI was associated with time to mortality [HRs/IRRs per 0.01 FI increase: all causes = 1.02(95% CI 1.01,1.04); CVD = 1.03(1.02,1.05)], hospitalization [all causes = 1.02(1.01,1.02); CVD = 1.02(1.01,1.02)], ED visit [all causes = 1.01(1.00,1.01)], and the number of hospitalizations [all causes = 1.02(95% CI 1.01,1.03); CVD = 1.02(1.00,1.04)], hospital days [all causes = 1.01(1.01,1.03)], and ED visits [all causes = 1.02(1.02,1.03)]. FI improvements during CR had a protective effect regarding time to all-cause hospitalization [0.99(0.98,0.99)] but were not associated with other outcomes.

CONCLUSION

Frailty status at CR admission was related to long-term adverse outcomes. Frailty improvements during CR were associated with delayed all-cause hospitalization, in which a larger effect was associated with a greater chance of improved outcome.

Early rehabilitation after acute myocardial infarction: A nationwide inpatient database study

BACKGROUND

The effects and safety of early rehabilitation in intensive care units (ICU) remain unclear for patients after acute myocardial infarction (AMI).

METHODS

Using Japanese Diagnosis Procedure Combination inpatient data between July 2010 and March 2018, we identified 31,603 adult patients with AMI who underwent percutaneous coronary intervention on the day of admission and who were admitted to the ICU for more than three consecutive days. Patients who started a rehabilitation program within three days of ICU admission were included in the early rehabilitation group, while others were included in the usual care group. The primary outcome was activities of daily living (ADL) at discharge, as measured using the Barthel Index score. We conducted inverse probability of treatment weighting analyses.

RESULTS

The data of 31,603 patients were examined, 5,147 of whom were assigned to the early rehabilitation group. In the weighted cohort, the Barthel Index score at discharge was not significantly different between the two groups. The early rehabilitation group had a significantly shorter hospital stay, shorter ICU stay, and lower total hospitalization costs.

CONCLUSIONS

No correlations were observed between early rehabilitation and ADL at discharge. However, the present results suggest that early rehabilitation is safe and associated with lower hospital costs and shorter hospital stays after AMI.

The C-reactive protein to prealbumin ratio on admission and its relationship with outcome in patients hospitalized for acute heart failure

BACKGROUND

Inflammation and malnutrition are common problems in patients who are hospitalized for acute heart failure (AHF). C-reactive protein (CRP) is an acute-phase reactant and nonspecific marker for evaluating systemic inflammation. There has been growing interest in prealbumin for nutritional assessment. Additionally, prealbumin is a negative acute-phase protein because its synthesis is suppressed in the inflammatory setting in which cytokines stimulate hepatic production of acute-phase proteins (e.g. CRP). Therefore, the CRP to prealbumin ratio (CP ratio) may be a comprehensive marker of inflammation and malnutrition. We evaluated the relationship of the CP ratio with mortality in patients with AHF.

METHODS

We analyzed 257 hospitalized patients with AHF who had CRP and prealbumin levels examined on admission.

RESULTS

The median CP ratio on admission was 0.57, with an interquartile range of 0.11 to 1.94. In receiver operating characteristic curve analysis, the area under the curve was 0.729 and the optimal cut-off point of the CP ratio for all-cause death was >1.60 (sensitivity: 67.5%; specificity: 77.6%; p = 0.003). Kaplan-Meier survival curves showed that patients with a high CP ratio (>1.60) had a significantly greater risk of all-cause, cardiac, and non-cardiac death (log-rank test, all p<0.001) than patients with a low CP ratio (≤1.60). Multivariable analysis adjusted for imbalanced baseline variables showed that a high CP ratio was independently associated with higher all-cause mortality (adjusted hazard ratio 3.88; 95% confidence interval 1.91-7.86; p<0.001).

CONCLUSIONS

The ratio of two hepatic proteins, CRP and prealbumin, may be useful in risk stratification of patients with AHF.

Clinical usefulness of oxygen uptake during usual gait in patients with cardiovascular disease

BACKGROUND

Although oxygen uptake (VO₂) during exercise stress is a surrogate marker for prognosis in patients with cardiovascular disease (CVD), the stress test is sometimes difficult to perform owing to patient conditions, such as ageing or comorbidities. We investigated the relationships between VO₂ during usual gait with physical function and prognosis in patients with CVD.

METHODS

This single-centre observational study enrolled consecutive patients who were hospitalized for CVD treatment. Isometric quadriceps strength (QS) and 6-min walk distance (6MWD) as physical functions, and VO₂ during usual gait speed were measured at hospital discharge. We assessed the changes in VO₂ per body weight between at rest and during gait divided by gait speed (VO₂/kg/gait) and analysed the relationships of VO₂/kg/gait with physical functions and composite incidences of all-cause death or unplanned readmission after discharge.

RESULTS

In 367 patients (age, 65 ± 13 years; females, 34%), 112 clinical events occurred. VO₂/kg/gait showed significant negative correlations to QS (β = -0.114, p = 0.024) and 6MWD (β = -0.163, p < 0.001) after adjusting for confounding factors. High VO₂/kg/gait was significantly associated with a high rate of clinical events (hazard ratio for 1 standard deviation of VO₂/kg/gait, 1.36; 95% confidence interval, 1.11-1.66). This association was also observed in subgroups of older age and frailty.

CONCLUSIONS

High VO₂ during usual gait was a relevant factor for low physical function and poor prognosis in patients with CVD and even in older age and frailty, meaning that VO₂ during usual gait might be a novel and useful marker in clinical practice.

Association between physical activity and changes in renal function in patients after acute myocardial infarction: A dual-center prospective study

BACKGROUND

Acute myocardial infarction (AMI) causes a decline in renal function. This study aimed to elucidate the longitudinal association between physical activity levels and changes in renal function up to 6 months after the onset of AMI.

METHODS

In this dual-center prospective observational study, 73 AMI patients (67 men; average age, 65.0±11.7 years) were enrolled from 2017 to 2019. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 and 6 months post-discharge. The renal function was evaluated based on cystatin C-based estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 6 months post-discharge. Generalized estimating equation (GEE) models were used to test the longitudinal association between physical activity levels and within-patient changes in eGFRcys. Both GEE models with a follow-up period of 3 and 6 months were constructed to assess the effects of the passage of time.

RESULTS

Patients were stratified into the low (n=36; 2903±1187 steps/day) and high groups (n=37; 7988±3192 steps/day) based on the median number of steps. Both GEE models at the 3- (p=0.027) and 6-month follow-up (p=0.034) showed a significant positive association between the physical activity levels and within-patient changes in eGFRcys. The changes in eGFRcys at 6 months were -0.3 mL/min/1.73 m² and +4.4 mL/min/1.73 m² among the low and high group participants, respectively.

CONCLUSIONS

There was a significant positive association between physical activity and renal function changes after the onset of AMI, which persisted when the follow-up period was extended from 3 to 6 months. Our findings support the importance of interventions that enable maintaining high physical activity levels as a strategy for preserving renal function in AMI patients.

Feasibility of home-based cardiac rehabilitation using an integrated telerehabilitation platform in elderly patients with heart failure: A pilot study

BACKGROUND

Cardiac rehabilitation (CR) is a widely recommended evidence-based intervention for patients with cardiovascular disease. However, the participation rate in CR has been reported to be low globally, mainly due to barriers in access to the CR center. We evaluated the feasibility and safety of a new remote real-time monitoring system for supervising home-based CR among elderly patients with heart failure (HF).

METHODS

Hospitalized patients or outpatients followed for HF were enrolled. Patients received 12-week home-based CR under remote supervision using an integrated platform for telerehabilitation. Feasibility was evaluated by the participation and completion rates of the home-based CR sessions. Safety was assessed by adverse events during the sessions. All patients underwent baseline and 12-week assessment of exercise tolerance and lower extremity muscle strength.

RESULTS

All 10 patients (mean age 76 ± 7 years; 60% male) who participated in the study completed the program without withdrawal during the study period. Median participation rate in the exercise sessions was 94.4% (interquartile range: 88.9-97.9%). While fatigue, common cold, and palpitation were observed, no serious cardiovascular events were reported. Six-minute walk distance significantly improved from 383 ± 94 m to 432 ± 83 m (p=0.003).

CONCLUSIONS

Home-based CR under real-time supervision was feasible and safe among elderly HF patients. Our study suggests that home-based CR using an integrated telerehabilitation platform may be a potential option for patients who are unable to participate in center-based CR due to geographic or social accessibility and physical barrier issues.

Disabilities of the arms, pinch strength, and mild cognitive impairment in patients with coronary artery disease

BACKGROUND

We aimed to examine the relationship between the difficulty of activity using the arms and mild cognitive impairment (MCI), the relationship between the difficulty of activity using the arms and manual function, and cognitive function in patients with coronary artery disease (CAD).

METHODS

We conducted a cross-sectional study of 263 non-dementia patients who met the study criteria from 2328 CAD patients. MCI was estimated with the Japanese version of the Montreal Cognitive Assessment (MoCA-J). The difficulty of activity using the arms was evaluated using the Disability of the Arm, Shoulder, Disability of the Arm, Shoulder and Hand and Hand (DASH) questionnaire. Manual function was evaluated by pinch strength and handgrip strength.

RESULTS

Age (odds ratio, 1.10), three-fingered pinch strength (odds ratio, 0.69), and DASH score (odds ratio, 1.03) were independently associated with MCI in the multivariable logistic regression analysis. Hemoglobin (β=-0.15), handgrip strength (β=-0.37), and MoCA-J score (β=-0.15) were independently associated with DASH score (Model 1: p<0.001, adjusted R²=0.33); hemoglobin (β=-0.17), eGFR (β=-0.14), three-fingered pinch strength (β=-0.25), and MoCA-J score (β=-0.14) were independently associated with DASH score in the multivariate regression analysis (Model 2: p<0.001, adjusted R²=0.31).

CONCLUSIONS

The difficulty of activity using the arms was independently associated with manual and cognitive function and MCI in CAD patients.