Entering Cardiac Rehabilitation With Peripheral Artery Disease: A RETROSPECTIVE COMPARISON TO CORONARY ARTERY DISEASE

Pre-participation Withdrawal and Noncompletion of Cardiac Rehabilitation in Peripheral Artery Disease: MATCHED COMPARISONS TO CORONARY ARTERY DISEASE

PURPOSE

Despite the mortality benefit of cardiac rehabilitation (CR) participation, as well as its cost-effectiveness for people with peripheral artery disease (PAD), there are limited data on adherence and completion of CR in those with and without concomitant coronary artery disease (CAD). The objective of this study was to compare CR pre-participation withdrawal and noncompletion between patients with PAD and concomitant PAD and CAD (PAD/CAD) versus matched and unmatched patients with CAD (uCAD).

METHODS

Consecutively referred patients between 2006-2017 with PAD (n = 271) and PAD/CAD (n = 610) were matched to CAD by age, sex, diabetes, smoking status, and referral year. The uCAD (n = 14 487) group was included for comparison. Reasons for withdrawal were ascertained by interview.

RESULTS

There were no significant differences in pre-participation withdrawal between PAD and matched CAD (46 vs 43%, P = .49), nor in noncompletion (22 vs 18%, P = .28). Results were similar for PAD/CAD and matched CAD (withdrawal: 36 vs 34%, P = .37) and (noncompletion: 25 vs 23%, P = .46). A smaller proportion of patients with uCAD withdrew (28%) than patients with PAD ( P < .001) and PAD/CAD ( P < .001), with no difference in noncompletion ( P > .40, both). There were no differences between PAD and PAD/CAD and their matched counterparts for medical and nonmedical reasons for withdrawal and noncompletion ( P ≥ .25, all).

CONCLUSION

Pre-participation withdrawal rates were similar between patients with PAD, PAD/CAD, and their matched cohorts but greater than patients with uCAD. Once patients started CR, there were similar completion rates among all groups. Reports that patients with PAD are less likely to start CR may be related to their complex medical profile rather than PAD alone. Strategies to improve participation among patients with PAD should focus on the immediate post-referral period.

Rehabilitation contributes to lower readmission rates for individuals with peripheral arterial disease: A retrospective observational study

BACKGROUND

Non-pharmacological interventions, such as rehabilitation, are crucial for the treatment of people with peripheral arterial disease (PAD). Although several studies have shown rehabilitation is effective in improving the functional prognosis of PAD, there is currently insufficient evidence regarding its effect on readmission rates.

OBJECTIVES

To examine the impact of rehabilitation on readmission rates for people with PAD.

METHODS

A retrospective analysis of the JMDC hospital database was performed on data from two groups of people aged ≥20 years who were hospitalized between 2014 and 2020 with PAD, as based on a previous diagnosis. Participants were divided according to whether they did, or did not, receive any form of rehabilitation as part of their treatment in hospital. The primary outcome was readmission rates at 30, 60, 90, and 180 days after initial admission. A one-to-one propensity score matching was used to compare readmission rates between rehabilitation and non-rehabilitation groups.

RESULTS

We included 13,453 people with PAD, of whom 2701 pairs (5402 subjects) were selected after being matched in the rehabilitation and non-rehabilitation groups. The rehabilitation group participants had significantly lower mortality and readmission rates at 30, 60, 90, and 180 days. The odds ratios (95% confidence interval) for both groups were 0.79 (0.69-0.91; 30 days), 0.81 (0.71-0.91; 60 days), 0.78 (0.69-0.88; 90 days), and 0.79 (0.71-0.88; 180 days).

CONCLUSIONS

This large, nationwide study found that rehabilitation treatment during hospitalization was associated with lower readmission rates and mortality for people following hospitalization with PAD and supports its inclusion as a standard PAD treatment.

Diabetes Is Negatively Associated With Meeting Physical Activity Time-Intensity Guidelines in Patients With Claudication

PURPOSES

We determined the percentage of patients with peripheral artery disease (PAD) and claudication who meet the 2018 physical activity (PA) time-intensity guidelines, and we identified the clinical characteristics associated with the status of meeting the guidelines.

METHODS

Five hundred seventy-two patients were assessed on their daily ambulatory activity for 1 wk with a step activity monitor, and were evaluated on whether or not they achieved 150 min/wk of moderate-intensity PA.

RESULTS

Thirty-one percent (n = 175) of the patients with PAD met the PA time-intensity guidelines and 69% (n = 397) did not. In a final multivariable logistic regression model identifying the independent predictors of meeting the PA time-intensity guidelines from clinical characteristics, diabetes was the only significant variable entered (OR = 0.310: 95% CI, 0.175-0.538; P < .001) and was associated with a 69% lower chance of meeting the guidelines. Patients with diabetes spent less daily time in moderate-intensity ambulatory PA than patients without diabetes (15 ± 13 vs 23 ± 20 min/d; P < .001).

CONCLUSIONS

Thirty-one percent of patients with PAD and claudication met the PA time-intensity guidelines. Furthermore, patients with diabetes were least likely to meet the PA time-intensity guidelines, as they had a 69% lower chance than patients without diabetes. The clinical significance is that PAD patients who have diabetes are particularly susceptible to being physically sedentary, and are therefore prime patients who should be encouraged to increase their daily PA.

Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era

Cardiac rehabilitation (CR) is an integral part of the management of various cardiovascular disease such as coronary artery disease (CAD), peripheral artery disease (PAD), or chronic heart failure (CHF), with proven morbidity and mortality benefits. This article aims to review and summarize the scientific literature related to cardiac rehabilitation programs for patients with PAD and how they were adapted during the COVID-19 pandemic. The implementation of CR programs has been problematic since the COVID-19 pandemic due to social distancing and work-related restrictions. One of the main challenges for physicians and health systems alike has been the management of PAD patients. COVID-19 predisposes to coagulation disorders that can lead to severe thrombotic events. Home-based walking exercises are more accessible and easier to accept than supervised exercise programs. Cycling or other forms of exercise are more entertaining or challenging alternatives to exercise therapy. Besides treadmill exercises, upper- and lower-extremity ergometry also has great functional benefits, especially regarding walking endurance. Supervised exercise therapy has a positive impact on both functional capacity and also on the quality of life of such patients. The most effective manner to acquire this seems to be by combining revascularization therapy and supervised exercise. Rehabilitation programs proved to be a mandatory part of the integrative approach in these cases, increasing quality of life, and decreasing stress levels, depression, and anxiety.

Factors Associated With Change in Cardiovascular Fitness for Patients With Peripheral and Coronary Artery Disease in Cardiac Rehabilitation

PURPOSE

Cardiac rehabilitation (CR) yields improvements in cardiorespiratory fitness (peak oxygen uptake [V˙o2peak]). Predictors of change in V˙o2peak have been reported among patients with coronary artery disease (CAD) but have not been compared with peripheral artery disease (PAD). This study determined predictors of improved V˙o2peak among patients with PAD, CAD, and concomitant PAD and CAD (PAD/CAD) following a 6-mo home-based outpatient CR program (1supervised and 4 home weekly sessions).

METHODS

This study was a retrospective (2006-2017) multiple linear regression analysis of CR patients with PAD (n = 63), CAD (n = 63), and PAD/CAD (n = 164). Peripheral artery disease and CAD were matched for age, sex, smoking status, diabetes, and year in program.

RESULTS

Mean age of all patients was 68.9±10.1 yr, 72% were male, and mean improvement in V˙o2peak was 2.1 ± 3.3 mL/kg/min (14.5% improvement) following CR. In CAD, younger age (β = .30, P = .015), male sex (β = -.29, P = .019), and more recent year of entry (β = .26, P = .035) were predictors of improved V˙o2peak. In PAD, only male sex (β = -.36, P = .004) and in PAD/CAD, not having diabetes (β = -.24, P = .002), not smoking (β = -.25, P = .001), and shorter elapsed time from referring diagnosis to entry (β = -.19, P = .016) were predictors.

CONCLUSIONS

While younger age and male sex were predictors of improved V˙o2peak in CAD, age did not influence PAD, and neither age nor sex influenced PAD/CAD. Peripheral artery disease-related limitations may override some demographic factors, and strategies for improving V˙o2peak should be explored. Managing smoking and comorbid diagnoses including diabetes and a timely entry to CR may yield greater improvements in V˙o2peak among individuals with PAD.

Including Patients With Stroke in Cardiac Rehabilitation: BARRIERS AND FACILITATORS

More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.