Cardiac rehabilitation and its effects on cognition in patients with coronary artery disease and heart failure

Considerations Regarding Management of Heart Failure in Older Adults

Understanding noncardiovascular comorbidities and geriatric syndromes in elderly patients with heart failure (HF) is important as the average age of the population increases. Healthcare professionals need to consider these complex dynamics when managing older adults with HF, especially those older than 80. A number of small studies have described associations between HF and major geriatric domains. With information on patients' cognitive, functional decline, and ability to adhere to therapy, physicians can plan for individualized treatment goals and recommendations for these patients.

Adaptation and validation of the cardiovascular version of the Return-to-Work Obstacles and Self-Efficacy Scale (ROSES-CVD) to the Italian context

PURPOSE

Effective cardiac rehabilitation interventions must provide adequate support to overcome psychosocial return-to-work (RTW) barriers. No validated instrument is available for this aim for cardiovascular patients. The Return-to-work Obstacles and Self-Efficacy Scale (ROSES) measures RTW obstacles workers perceive and the self-efficacy for overcoming them through 46 items and ten dimensions. This study aimed to adapt and validate ROSES for cardiovascular disease (CVD) in the Italian context.

METHODS

This prospective study involved 183 CVD working patients at baseline and 121 six months later. ROSES-CVD internal consistency, construct, and predictive validity was evaluated with Cronbach's α, Confirmatory factor analyses (CFA), and ANCOVAs.

RESULTS

CFAs adequately replicated the original ROSES model (CFI = .92-.96; TLI = .91-.94; RMSEA = .042-.057; SRMR = .046-.071) with α close or higher than .70 for all dimensions. Four ROSES-CVD dimensions significantly predicted the number of days to RTW controlling for age, gender, educational level, and surgery type. Workers who perceived salient RTW obstacles and low self-efficacy in any of these dimensions in mean returned to work from 38 to 53 days later.

CONCLUSIONS

The study supported the validity and reliability of ROSES-CVD. This tool can be used in rehabilitation to detect CVD patients at risk of a longer RTW process and define appropriate cardiac rehabilitation intervention.IMPLICATIONS FOR REHABILITATIONVocational rehabilitation interventions should provide tailor-made support to overcome RTW barriers based on individual risk assessmentThe Italian translation of ROSES-CVD is a valid and reliable tool to measure psychosocial barriers to RTW among CVD working patientsThe use of ROSES-CVD would allow detection of CVD patients at risk of longer RTW processAdministering ROSES-CVD can help focus traditional vocational intervention on individually relevant obstacles to RTW.

Prehabilitation before elective coronary artery bypass grafting surgery: a scoping review

OBJECTIVE

The objective of this scoping review was to identify and map existing preoperative interventions, referred to as prehabilitation, in adult patients at home awaiting elective coronary artery bypass grafting surgery. This review also sought to report feasibility and patient experiences to shape clinical practice and underpin a future systematic review.

INTRODUCTION

As patients age, comorbidities become more common. Strategies to improve postoperative outcomes and to accelerate recovery are required in patients undergoing coronary artery bypass grafting. Prehabilitation refers to a proactive process of increasing functional capacity before surgery to improve the patient's ability to withstand upcoming physiologic stress and, thus, avoid postoperative complications.

INCLUSION CRITERIA

Studies that included adult patients awaiting coronary artery bypass grafting surgery at home and that described interventions optimizing preoperative physical and psychological health in any setting were included.

METHODS

The JBI methodology for conducting scoping reviews was used to identify relevant studies in MEDLINE, CINAHL, Cochrane Library, Embase, Scopus, SweMed+, PsycINFO, and PEDro. Gray literature was identified searching Google Scholar, ProQuest Dissertations and Theses, MedNar, OpenGrey, NICE Evidence search, and SIGN. Studies in Danish, English, German, Norwegian, and Swedish were considered for inclusion, with no geographical or cultural limitations, or date restrictions. Two independent reviewers screened titles and abstracts, and studies meeting the inclusion criteria were imported into Covidence. Sixty-seven studies from November 1987 to September 2022 were included. The data extraction tool used for the included papers was developed in accordance with the review questions and tested for adequacy and comprehensiveness with the first 5 studies by the same 2 independent reviewers. The tool was then edited to best reflect the review questions. Extracted findings are described and supported by figures and tables.

RESULTS

Sixty-seven studies were eligible for inclusion, representing 28,553 participants. Analyses of extracted data identified various preoperative interventions for optimizing postoperative and psychological outcomes for adult patients awaiting elective coronary artery bypass grafting surgery. Based on similarities, interventions were grouped into 5 categories. Eighteen studies reported on multimodal interventions, 17 reported on psychological interventions, 14 on physical training interventions, 13 on education interventions, and 5 on oral health interventions.

CONCLUSION

This scoping review provides a comprehensive summary of strategies that can be applied when developing a prehabilitation program for patients awaiting elective coronary artery bypass surgery. Although prehabilitation has been tested extensively and appears to be feasible, available evidence is mostly based on small studies. For patients undergoing elective coronary artery bypass grafting to derive benefit from prehabilitation, methodologically robust clinical trials and knowledge synthesis are required to identify optimal strategies for patient selection, intervention design, adherence, and intervention duration. Future research should also consider the cost-effectiveness of prehabilitation interventions before surgery. Finally, there is a need for more qualitative studies examining whether individual interventions are meaningful and appropriate to patients, which is an important factor if interventions are to be effective.

The Utility of High Intensity Interval Training to Improve Cognitive Aging in Heart Disease Patients

Adults with cardiovascular disease and heart failure are at higher risk of cognitive decline. Cerebral hypoperfusion appears to be a significant contributor, which can result from vascular dysfunction and impairment of cerebral blood flow regulation. In contrast, higher cardiorespiratory fitness shows protection against brain atrophy, reductions in cerebral blood flow, and cognitive decline. Given that high intensity interval training (HIIT) has been shown to be a potent stimulus for improving cardiorespiratory fitness and peripheral vascular function, its utility for improving cognitive aging is an important area of research. This article will review the physiology related to cerebral blood flow regulation and cognitive decline in adults with cardiovascular disease and heart failure, and how HIIT may provide a more optimal stimulus for improving cognitive aging in this population.

Prehabilitation of Cardiac Surgical Patients, Part 1: Anemia, Diabetes Mellitus, Obesity, Sleep Apnea, and Cardiac Rehabilitation

The concept of "prehabilitation" consists of screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgery, but may have profound impacts on outcomes particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of prehabilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision making. In this two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized by our center for cardiac presurgical care. This first installment will focus on the management of anemia, obesity, sleep apnea, diabetes, and cardiac rehabilitation prior to surgery. The second will focus on frailty, malnutrition, respiratory disease, alcohol and smoking cessation, and depression.

Differences in cognitive function, cardiorespiratory fitness and BDNF concentration in physically active CHD patients vs healthy controls

BACKGROUND

Coronary heart disease (CHD) is frequently associated with cognitive impairment (CI), whereas physical exercise may improve cognition. To date, the cognitive profile of physically active CHD patients remains poorly understood. Physical activity and cognition has been associated with neurotrophic biomarkers that are positively modulated by a higher cardiorespiratory fitness (V̇ O₂peak) and/or active lifestyle. This study aimed to compare the cognitive functions, V̇ O₂peak and trophic biomarkers in physically active CHD patients vs healthy controls.

METHODS

Thirty-nine CHD patients and 20 controls performed a cardiopulmonary exercise test, a neuropsychological assessment (short-term and working memory, processing speed, executive functions, and long-term verbal memory), and a blood draw to measure brain-derived neurotrophic factor (BDNF), insulin-like growth factor-1 (IGF1), and cathepsin B (CTSB) plasma concentrations. Physical activity was also measured with an accelerometer for 1 week.

RESULTS

Compared to controls, CHD patients had lower V̇ O₂peak (22.2 vs 29.3 mL/min/kg, p<0.001), but similar moderate to vigorous physical activity levels (27.5 vs 34.4 min/day, p=0.114). CHD patients had poorer performances for executive functions (0.198 vs -0.370, p=0.004) and processing speed (0.150 vs -0.293, p=0.025), as well as lower BDNF concentrations (166.4 vs 300.2 ng/ml, p=0.027), but similar IGF-1 and CTSB concentrations (p>0.05) when compared to controls. BDNF was an independent predictor of processing speed in CHD, and IGF-1 and BDNF were independent predictors of verbal memory in healthy controls.

CONCLUSION

Despite similar physical activity levels, fit CHD patients had lower V̇ O₂peak values, cognitive performances (executive functions and processing speed) and BDNF concentrations when compared to controls.

Association of dementia with in-hospital outcomes in primary heart failure and acute myocardial infarction hospitalizations

BACKGROUND

Dementia and cardiovascular diseases contribute to a significant disability and healthcare utilization in the elderly.

OBJECTIVE

The in-hospital treatment patterns and outcomes of heart failure (HF) and acute myocardial infarction (AMI) are not well-studied in this population.

METHODS

We used the National Inpatient Sample database to identify AMI and HF hospitalizations in adults ≥65 years between 2016 and 2018.

RESULTS

A total of 2,466,369 HF hospitalizations (277,900 with dementia [11.3%]) and 1,094,155 AMI hospitalizations (100,365 with dementia [9.2%]) were identified. Patients with dementia were older (mean age 83.8 vs 78.6 years for HF, and 83.0 vs 75.8 years for AMI) with female predominance (59.0% for HF and 56.0% for AMI) than those without dementia. In adjusted analysis, patients with dementia had higher in-hospital mortality (HF 4.7% vs 3.1%, aOR 1.33 [1.27-1.39] and AMI 9.9% vs 5.9%, aOR 1.23 [1.17-1.30]), p < 0.001) and lower mechanical circulatory support utilization. Patients with AMI and dementia were less likely to receive revascularization (including percutaneous coronary intervention, coronary artery bypass grafting, and thrombolysis), vasopressors, and invasive mechanical ventilation. They had a longer mean length of stay (LOS) (5.5 vs 5.3 days for HF and 5.1 vs 4.8 days for AMI, p < 0.001 for both), a lower inflation-adjusted cost of care for AMI ($15,486 vs $23,215, p < 0.001), and higher rates of transfer to rehabilitation facilities.

CONCLUSION

Patients with dementia admitted for HF or AMI had higher in-hospital mortality, a longer LOS, and were less likely to receive aggressive revascularization interventions after AMI.

Cardiac rehabilitation for older adults: current evidence and future potential

INTRODUCTION

Growth of the older adult demographic has resulted in an increased number of older patients with cardiovascular disease (CVD) in combination with comorbid diseases and geriatric syndromes. Cardiac rehabilitation (CR) is utilized to promote recovery and improve outcomes, but remains underutilized, particularly by older adults. CR provides an opportunity to address the distinctive needs of older adults, with focus on CVD as well as geriatric domains that often dominate management and outcomes.

AREAS COVERED

Utility of CR for CVD in older adults as well as pertinent geriatric syndromes (e.g. multimorbidity, frailty, polypharmacy, cognitive decline, psychosocial stress, and diminished function) that affect CVD management.

EXPERT OPINION

Mounting data substantiate the importance of CR as part of recovery for older adults with CVD. The application of CR as a standard therapy is especially important as the combination of CVD and geriatric syndromes catalyzes functional decline and can trigger progressive clinical deterioration and dependency. While benefits of CR for older adults with CVD are already evident, further reengineering of CR is necessary to better address the needs of older candidates who may be frail, especially as remote and hybrid formats of CR are becoming more widespread.

Investigation of the Effects of Home-Based Exercise and Cognitive Training on Cognitive and Physical Functions in Cardiac Patients: The COVEPICARDIO Study Protocol of a Randomized Clinical Trial

Introduction: During the COVID-19 pandemic, confinement measures are likely to produce collateral damage to health (stress, confusion, anxiety), especially in frail individuals and those living with cardiovascular disease (CVD). In cardiac patients in particular, these measures dramatically increase the level of physical inactivity and sedentary lifestyle, which can decrease cardiorespiratory capacity and increase the risk of acute events, rehospitalization, and depressive syndromes. Maintaining a minimum level of physical activity and cognitive stimulation during the COVID-19 crisis is essential for cardiac patients. This study is designed to document the effects of 6 months of home-based physical exercise alone or combined with cognitive training on cognitive and physical functions in patients with CVD over 50 years old.

Methods and Analysis: 122 patients (>50 years old) with stable CVD and no contraindication to perform physical exercise training will be recruited and randomly assigned to one of the 2 following arms: (1) Home-based physical exercise alone, (2) Home-based physical exercise combined with cognitive training. The intervention lasts 6 months, with remote assessments performed prior to, mid and post-training. A follow-up 6 months after the end of the intervention (12 month) is also proposed. The primary outcome is cognition, including general functioning (Montreal Cognitive Assessment (MoCA) score), as well as performances on measures of executive functions, processing speed, and episodic memory. The secondary outcome is physical performance, including balance, gait and mobility, leg muscle strength and estimated cardiorespiratory fitness. Tertiary outcomes include mood, anxiety, and health-related quality of life as assessed by self-reported online questionnaires.

Discussion: With the COVID-19 crisis, there is a critical need for remote exercise and cognitive training, and to further investigate this topic, in particular for cardiac patients. The present context can be viewed as an opportunity to perform a major shift from center-based programs to home-based physical exercise. This is especially important to reach out to older adults living in remote areas, where access to such interventions is limited.

ClinicalTrials.gov: [https://clinicaltrials.gov/ct2/show/NCT04661189], NCT04661189.

Cardiac rehabilitation for coronary artery disease: latest updates

PURPOSE OF REVIEW

To summarize recent innovations in cardiac rehabilitation and provide a view towards the future of cardiac rehabilitation as it adjusts to the pressures of a global pandemic.

RECENT FINDINGS

Although cardiac rehabilitation has been shown to result in a mortality benefit, research continues to enumerate the benefits of cardiac rehabilitation to patient function and quality of life in a growing range of cardiovascular diseases. In addition, new methodologies and new models of cardiac rehabilitation have emerged with the goal of increasing patient referral and participation.

SUMMARY

Cardiac rehabilitation continues to evolve and adapt to serve a growing and diversifying number of patients with cardiovascular disease with the goal of both decreasing mortality and improving patient function.

Cognitive impairment and psychological state in acute coronary syndrome patients: A prospective descriptive study at cardiac rehabilitation entry, completion and follow-up

BACKGROUND

Cognitive impairment may limit the uptake of secondary prevention in acute coronary syndrome patients, but is poorly understood, including in cardiac rehabilitation participants.

AIM

The aim of this study was to explore cognitive impairment in relation to psychological state in acute coronary syndrome patients over the course of cardiac rehabilitation and follow-up.

METHODS

Acute coronary syndrome patients without diagnosed dementia were assessed on verbal learning, processing speed, executive function and visual attention, at cardiac rehabilitation entry, completion and follow-up and scores adjusted using normative data. The hospital anxiety and depression scale measured psychological state.

RESULTS

Participants (n = 40) had an average age of 66.2 (±8.22) years and were 70% men. Mild cognitive impairment occurred at cardiac rehabilitation entry in single 62.5% and multiple 22.5% domains but was significantly less prevalent by cardiac rehabilitation completion (52.5% and 15.0%) and follow-up (32.5% and 7.0%). Domains most often impaired were verbal learning (52.5%) and processing speed (25.6%), again decreasing significantly with time (verbal learning cardiac rehabilitation completion 42.5%, follow-up 22.5%; processing speed cardiac rehabilitation completion 15.0%, follow-up 15.0%). A small group of patients had persistent multiple domain cognitive impairment. At cardiac rehabilitation entry patients with cognitive impairment in processing speed, a single domain or multiple domains had more depression, and patients with cognitive impairment in executive function had more depression and anxiety.

CONCLUSIONS

At cardiac rehabilitation entry, mild cognitive impairment is very common in post-acute coronary syndrome patients and worse in patients who have depression or anxiety symptoms. Cognitive impairment decreases significantly by cardiac rehabilitation follow-up. A small proportion of patients has persistent, multiple domain cognitive impairment flagging potential long-term changes and the need for further investigations and cognitive rehabilitation.

Prehabilitation before elective coronary artery bypass grafting surgery: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify and map existing preoperative interventions, referred to as prehabilitation, in adult patients at home awaiting coronary bypass grafting (CABG) surgery. This scoping review also seeks to examine the feasibility and patient experiences in order to inform clinical practice and underpin a future systematic review.

INTRODUCTION

As patients age, comorbidities become more common. Strategies to improve postoperative outcomes and to accelerate recovery are required in patients undergoing CABG. Prehabilitation refers to a proactive process of increasing functional capacity before surgery to improve the patient's capacity to withstand upcoming physiologic stress and thus avoid postoperative complications.

INCLUSION CRITERIA

This scoping review will consider any studies including adult patients at home awaiting CABG surgery. Studies will provide information on any prehabilitation intervention to optimize preoperative physical and psychological health status. Studies conducted in any setting will be included.

METHODS

The methodology will follow the JBI recommendations for scoping reviews. Any published or unpublished source of information will be considered. Studies published in English, German, Danish, Swedish, and Norwegian will be included, with no geographical or cultural limitations. Retrieved papers will be screened by two independent reviewers, and a standardized tool will be used to extract data from each included source. The results will be presented as a map of the data extracted in a tabular form together with a narrative summary to provide a description of the existing evidence.

Cardiac Rehabilitation During Quarantine in COVID-19 Pandemic: Challenges for Center-Based Programs

Because of the coronavirus disease 2019 (COVID-19) epidemic, many cardiac rehabilitation (CR) services and programs are stopped. Because CR is a class I level A recommendation with clinical benefits that are now well documented, the cessation of CR programs can lead to dramatic consequences in terms of public health. We propose here a viewpoint of significant interest about the sudden need to develop remote home-based CR programs both in clinical research and in clinical care routine. This last decade, the literature on remote home-based CR programs has been increasing, but to date only clinical research experiences have been implemented. Benefits are numerous and the relevance of this approach has obviously increased with the actual health emergency. The COVID-19 crisis, the important prevalence of smartphones, and high-speed Internet during confinement should be viewed as an opportunity to promote a major shift in CR programs with the use of telemedicine to advance the health of a larger number of individuals with cardiac disease.

Effects of cardiac rehabilitation on cognitive impairments in patients with cardiovascular diseases: a systematic review

BACKGROUND

One of the most common problems associated with cardiovascular diseases (CVDs) is cognitive impairments (CIs) leading to reduced quality of life and treatment adherence in patients. The aim of this systematic review was to examine the effects of cardiac rehabilitation (CR) on cognitive function in CVD patients.

MATERIAL AND METHOD

PubMed, Scopus, Web of Science and Ovid MEDLINE databases were searched for identification the relevant studies without language restriction. We included the studies published from root to August 2019, evaluating the effects of CR on at least one type of cognitive functions through valid neuropsychological tests. Finally, nine studies with different study designs were entered in this systematic review. The full texts of these studies were critically appraised with various quality assessment tools.

RESULT

Patients were evaluated by different cognitive domains including global cognition, attention, executive function, memory and language prior to and following CR program among included studies. Most of the included studies reported significant cognitive improvement of the attention/executive function and memory domains. Two studies showed statistically significant improvement in global cognition using Modified Mini-Mental State (3MS) and Montreal Cognitive Assessment (MoCA) tools. Similar effects were not found in language domain.

CONCLUSION

It seems that cognitive impairments in CVD patients can be improved with CR program. Because this review is limited by low number of included studies, and there were various study designs without control groups, the results should be generalized cautiously. Further studies are recommended.

Effect of metformin on all-cause and cardiovascular mortality in patients with coronary artery diseases: a systematic review and an updated meta-analysis

BACKGROUND

Metformin is the most widely prescribed drug to lower glucose and has a definitive effect on the cardiovascular system. The goal of this systematic review and meta-analysis is to assess the effects of metformin on mortality and cardiac function among patients with coronary artery disease (CAD).

METHODS

Relevant studies reported before October 2018 was retrieved from databases including PubMed, EMBASE, Cochrane Library and Web of Science. Hazard ratio (HR) was calculated to evaluate the all-cause mortality, cardiovascular mortality and incidence of cardiovascular events (CV events), to figure out the level of left ventricular ejection fraction (LVEF), creatine kinase MB (CK-MB), type B natriuretic peptide (BNP) and to compare the average level of low density lipoprotein (LDL).

RESULTS

In this meta-analysis were included 40 studies comprising 1,066,408 patients. The cardiovascular mortality, all-cause mortality and incidence of CV events were lowered to adjusted HR (aHR) = 0.81, aHR = 0.67 and aHR = 0. 83 respectively after the patients with CAD were given metformin. Subgroup analysis showed that metformin reduced all-cause mortality in myocardial infarction (MI) (aHR = 0.79) and heart failure (HF) patients (aHR = 0.84), the incidence of CV events in HF (aHR = 0.83) and type II diabetes mellitus (T2DM) patients (aHR = 0.83), but had no significant effect on MI (aHR = 0.87) and non-T2DM patients (aHR = 0.92). Metformin is superior to sulphonylurea (aHR = 0.81) in effects on lowering the incidence of CV events and in effects on patients who don't use medication. The CK-MB level in the metformin group was lower than that in the control group standard mean difference (SMD) = - 0.11). There was no significant evidence that metformin altered LVEF (MD = 2.91), BNP (MD = - 0.02) and LDL (MD = - 0.08).

CONCLUSION

Metformin reduces cardiovascular mortality, all-cause mortality and CV events in CAD patients. For MI patients and CAD patients without T2DM, metformin has no significant effect of reducing the incidence of CV events. Metformin has a better effect of reducing the incidence of CV events than sulfonylureas.