Cardiac rehabilitation and mortality reduction after myocardial infarction: the emperor's new clothes? Evidence in favour of cardiac rehabilitation

[Prognostic effects of cardiac rehabilitation in patients with acute coronary syndrome]

AIM

Reduction of major adverse cardiovascular events (MACE) at 5 years in patients with acute coronary syndrome (ACS) and percutaneous coronary intervention who completed a cardiac rehabilitation program.

METHODS

We included 230 consecutive men with a diagnosis of ACS and percutaneous coronary intervention in the first half of 2015 according to the inclusion criteria. Two cohorts of 115 patients each were compared, one of them (rehabilitated group) with patients who completed the cardiac rehabilitation program and the other (control group) who received conventional outpatient care. Base-line characteristics and MACE at 5-years follow-up were compared and analyzed. MACE included re-infarction, heart failure, cerebrovascular accident and all-cause mortality.

RESULTS

At 5 years of follow-up, a statistically significant reduction in MACE (27.19% vs 7.83%; OR 0.23 [IC 0.10-0.50]; P=.0001), all-cause mortality (OR 0.12 [IC 0.01-0.94]; P=0.01), re-infarction rate (OR 0.29 [IC 0.11-0.77]; P=.007) and cerebrovascular accident (P=.014) was found in the rehabilitated group (RG). MACE-free survival was significantly longer in the RG, regardless of risk (HR 0.25 [IC 0.12-0.53]; P=.000).

CONCLUSION

In our sample, cardiac rehabilitation programs showed a prognostic benefit in patients with ACS and percutaneous coronary intervention, with a statistically significant reduction in MACE, re-infarction rate and CVA at five-year follow-up.

Impact of Exercise-Based Cardiac Rehabilitation on the Mid-Term Outcomes of Patients After Acute Myocardial Infarction Treated With Current Acute-Phase Management and Optimal Medical Therapy

BACKGROUND

Early reported beneficial effects of cardiac rehabilitation (CR) have recently been disputed. The present study aimed to investigate the clinical impact of CR on the mid-term outcomes of patients following ST-segment elevation myocardial infarction (STEMI) treated with currently available management.

METHODS

This study reviewed 145 consecutive patients who underwent primary coronary intervention and were discharged without any disability after STEMI during 2013-2015.

RESULTS

Among the patients, 66 (45.5%) completed an outpatient CR program (CR group) and 79 were their non-CR counterparts or patients who dropped out of the program (N-D group). There were no between-group differences in patient demographics and clinical profiles, including door-to-balloon times and prescriptions. A total of 27 patients developed major adverse cardiac and cerebrovascular events (MACCE) during follow-up. The MACCE-free survival rates were 88% and 76% in the CR and N-D groups, respectively (log-rank, p=0.04). Cox proportional analysis demonstrated that inclusion in the N-D group was a significant predictor of MACCEs (HR, 2.36; 95% CI, 1.07-5.74; p=0.03). In the CR group, peak oxygen consumption and ventilatory efficiency determined by cardiopulmonary exercise testing significantly improved after the program (p<0.01).

CONCLUSIONS

The impact of CR on the mid-term prognosis of patients with STEMI, even in the current myocardial infarction management era, was beneficial.

Cardiac rehabilitation in patients with acute coronary syndrome with primary percutaneous coronary intervention is associated with improved 10-year survival

Aims

We aimed to assess the effects of a multidisciplinary cardiac rehabilitation (CR) program on survival after treatment with primary percutaneous coronary intervention (pPCI) for acute coronary syndrome (ACS).

Methods and results

Using propensity matching analysis, a total of 1159 patients undergoing CR were 1:1 matched with ACS patients who did not undergo CR and survived at least 60 days. The Kaplan-Meier analyses and multivariate Cox regression analysis were applied to study differences in survival. During follow-up, a total of 335 (14.5%) patients had died. Cumulative mortality rates at 5 and 10 years were 6.4% and 14.7% after CR and 10.4% and 23.5% in the no CR group (P < 0.001). Cardiac rehabilitation patients had 39% lower mortality than non-CR controls [10-year mortality 14.7% vs. 23.5%; adjusted hazard ratio (HR) 0.61; 95% confidence interval (CI) 0.46-0.81]. A total of 915 (78.9%) patients completed CR and had 46% lower mortality than those who did not complete CR (10-year mortality 13.6% vs. 18.9%; adjusted HR 0.54; 95% CI 0.42-0.70).

Conclusion

Patients who underwent pPCI for ACS, with a CR program had lower mortality than their non-CR counterparts. Mortality was particularly low in patients who completed the program. In conclusion, CR is still beneficial in terms of survival.

Perspectives of cardiac rehabilitation staff on strategies used to assess, monitor and review - a descriptive qualitative study

BACKGROUND

The mechanisms contributing to the success of cardiac rehabilitation (CR) are poorly understood and may include assessment, monitoring and review activities enabled by continuity of care and this is investigated in this study.

OBJECTIVES

To identify active assessment components of CR.

METHODS

A qualitative study using focus groups and individual interviews. CR staff (n = 39) were recruited via professional association email and network contacts and organised into major themes.

RESULTS

CR staff assessment strategies and timely actions undertaken provided a sophisticated post-discharge safety net for patients. Continuity of care enabled detection of adverse health indicators, of which medication issues were prominent. Interventions were timely and personalised and therefore likely to impact outcomes, but seldom documented or reported and thus invisible to audit.

CONCLUSION

CR staff assessment and intervention activities provide an unrecognised safety net of activities enabled by continuity of care, potentially contributing to the effectiveness of CR.

Nurse mentor perceptions in the delivery of a home-based cardiac rehabilitation program to support patients living in rural areas: An interpretive study

Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with heart disease. Mentoring of patients by nurses trained in CR has been proposed as an innovative model of cardiac care. Little is known however, about the experience of mentors facilitating such programs and adapting to this new role. The aim of this qualitative study was to explore nurse mentor perceptions of their role in the delivery of a home-based CR program for rural patients unable to attend a hospital or outpatient CR program. Seven nurses mentored patients by telephone providing patients with education, psychosocial support and lifestyle advice during their recovery. An open-ended survey was administered to mentors by email and findings revealed mentors perceived their role to be integral to the success of the program. Nurses were satisfied with the development of their new role as patient mentors. They believed their collaborative skills, knowledge and experience in coronary care, timely support and guidance of patients during their recovery and use of innovative audiovisual resources improved the health outcomes of patients not able to attend traditional programs. Cardiac nurses in this study perceived that they were able to successfully transition from their normal work practices in hospital to mentoring patients in their homes.

Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation

Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.