Does cardiac rehabilitation favour the young over the old?

A Comparison Between Cardiac Telerehabilitation Program and Outpatient Hospital-Based Cardiac Rehabilitation Program for Patients Undergoing Coronary Artery Bypass Graft (CABG) Surgery: A Review

Coronary artery disease (CAD) is a prevalent and possibly fatal cardiovascular ailment, and it is treated surgically by coronary artery bypass grafting (CABG). The coronary arteries, which supply the heart with oxygen and nutrients, are the most commonly affected. Even though CABG is a frequently employed procedure to restore cardiac blood flow, prolonged rehabilitation is necessary for long-term success. For patients with heart disease, cardiac rehabilitation (CR) involves a comprehensive therapeutic approach. It consists of risk mitigation, regular exercise, health education, and efficient stress management. Information and communication technology is used in telerehabilitation (TR), a rehabilitation service that offers a flexible choice that improves self-management. This study examined novel approaches and effective intervention elements while comparing cardiac TR with center-based programs in terms of risk factor management, patient commitment, and satisfaction.

Implementation of an Appointment-Based Cardiac Rehabilitation Approach: A Single-Center Experience

Background There has been a focus on alternative cardiac rehabilitation (CR) delivery models aimed at improving CR adherence and completion. We examined pre- and post-CR health outcomes, reasons for discharge, and predictors of completion using a patient-driven appointment-based CR approach that uses center-scheduled class start times. Methods and Results Data were used from an urban single-center CR program at Yale New Haven Health (2012-2017) that enrolled 2135 patients. We evaluated pre- and post-CR outcomes (12 weeks) using paired t tests and used a multivariable logistic regression model to examine predictors of CR completion (≥36 sessions) for the overall cardiovascular disease population. The mean age of participants was 65±12 years, 27.9% were women, and 5.1% were Black patients, and patients completed a median of 30 of 36 sessions. Patients achieved significant improvements in health outcomes, including across age and sex subgroups. The primary reason for discharge was completion of all 36 sessions of CR (46.4%). The final logistic regression model contained 12 predictors: age, sex, Black race, marital status, employment, number of physician-reported risk factors, dietary fat intake >30%, obesity, lack of exercise, benign prostatic hyperplasia, and self-reported stress and physical activity. Conclusions We demonstrated that patients participating in an appointment-based CR program achieved significant improvements in health outcomes and across sex/age subgroups. In addition, older individuals were more likely to complete CR. An appointment-based approach could be a viable alternative CR method to aid in optimizing the dose-response benefit of CR for patients with cardiovascular disease.

Obese patients' characteristics and weight loss outcomes in cardiac rehabilitation: An observational study of registry data

AIM

Cardiac rehabilitation (CR) guidelines advocate weight loss for obese patients but mean weight loss is small. We sought to determine the extent to which obese patients' characteristics prior to CR predict weight loss.

METHODS

An observational, pre- and post CR study of routine practice using the UK National Audit of Cardiac Rehabilitation dataset was undertaken. Backward, stepwise, multiple linear regression analysis was used to identify characteristics prior to CR that predicted weight change in obese patients.

RESULTS

In 29,601 obese patients undertaking CR, mean weight loss was 0.9 kg (SD 4.3; p < 0.001) in men (74% of sample) and 0.5 kg (SD 3.9; p < 0.001) in women. Smoking cessation since the cardiac event independently predicted less weight loss by 1.2 kg (95% CI; 0.9, 1.5 kg; p < 0.001). Diabetes, cardiac surgery, living in a deprived area, being female, low fitness levels and pain independently predicted less weight loss during CR. Higher initial weight, greater age and being employed predicted increased weight loss.

CONCLUSION

This is the first study to identify how the characteristics of obese patients independently predict different amounts of weight loss during CR in free-living individuals. It is also the largest, registry-based study to investigate predictors of weight loss in obese patients in CR. Knowledge of the extent to which obese patients' characteristics predict more or less weight loss can aid: the generation of guidelines; agreement of realistic goals with patients; and tailoring of weight management support.

Cardiac rehabilitation in older patients: Indication or limitation?

OBJECTIVE

To assess the clinical impact of a cardiac rehabilitation program in an older population.

METHODS

This is a retrospective analysis of 731 coronary patients who attended phase 2 of a cardiac rehabilitation program between January 2009 and December 2016. We compared the response to the program of older (≥65 years) and younger (<65 years) patients, analyzing changes in metabolic profile (including body mass index, waist circumference and lipid profile), exercise capacity, cardiac autonomic regulation parameters (such as chronotropic index and resting heart rate), and health-related quality of life scores.

RESULTS

Older patients represented 15.9% of our cohort. They showed significant reductions in waist circumference (male patients: 98.0±7.9 cm vs. 95.9±7.9 cm, p<0.001; female patients: 90.5±11.4 cm vs. 87.2±11.7 cm, p<0.001), LDL cholesterol (102.5 [86.3-128.0] mg/dl vs. 65.0 [55.0-86.0] mg/dl, p<0.001) and triglycerides (115.0 [87.8-148.5] mg/dl vs. 97.0 [81.8-130.0] mg/dl, p<0.001). Post-training data also showed a noticeable improvement in older patients' exercise capacity (7.6±1.8 METs vs. 9.3±1.8 METs, p<0.001), along with a higher chronotropic index and lower resting heart rate. Additionally, health-related quality of life indices improved in older subjects. However, our overall analysis found no significant differences between the groups in changes of the studied parameters.

CONCLUSION

Older coronary patients benefit from cardiac rehabilitation interventions, similarly to their younger counterparts. Greater involvement of elderly patients in cardiac rehabilitation is needed to fully realize the therapeutic and secondary preventive potential of such programs.

Cardiovascular rehabilitation in patients aged 70-year-old or older: benefits on functional capacity, physical activity and metabolic profile in younger vs. older patients

Background

The benefits of exercise-based cardiac rehabilitation (EBCR) programs in post-acute myocardial infarction (AMI) patients have been demonstrated. Our aim was to assess the impact of EBCR in ≥ 70-years-old vs. younger post-AMI patients.

Methods

We retrospectively evaluated patients who underwent a supervised EBCR protocol, twice a week during 6-12 weeks. We evaluated changes in several outcomes based on pre- and post-CRP assessments.

Results

Of a total of 1607 patients, 333 (21%) were ≥ 70-years-old. After the EBCR, an overall improvement on functional capacity, daily physical activity, lipid profile, body mass index, glycated hemoglobin (HbA1c), N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-reactive protein was observed in both younger and older patients (P < 0.05). Older patients showed a smaller benefit on the increment of daily physical activity and lipid profile improvement, but a larger reduction in NT-pro-BNP. In the multivariate analysis, only improvements on daily physical activity and HbA1c were dependent on age.

Conclusion

As their younger counterparts, older patients, significantly improved functional capacity, metabolic parameters and level of daily physical activity after EBCR.

Influence of sociodemographic characteristics on the preferred format of health education delivery in individuals with type 2 diabetes mellitus and or cardiovascular disease: a questionnaire study

AIM

To examine the influence of sociodemographic factors of interest on preference for a particular health education format among people with type 2 diabetes and/or cardiovascular disease.

METHODS

A questionnaire was used to collect information on the influence of six sociodemographic factors of interest on the preference for health education formats in people with type 2 diabetes and/or cardiovascular disease. Chi-squared tests were used to examine the distribution of preferences between groups. The characteristics of the population preferring the online format were then examined in more detail using logistic regression.

RESULTS

Responses were received from 1559 participants. Overall the preferred health education format was one-to-one learning from a doctor or nurse (67%). Age, gender, diagnosis and educational level all affected the preferences expressed. The characteristics showing most consistent and significant influence were age and educational level. Overall, 29% ranked the online format highly (scores 1 or 2). This group were more likely to be aged < 65 years (P < 0.001) and to have a higher level of educational attainment (upper secondary education or higher; P < 0.001).

CONCLUSIONS

Significant differences between sociodemographic groups exist in preferences for health education formats among people with type 2 diabetes and/or cardiovascular disease. Preferences should be considered when designing educational interventions to ensure they are accessible to the target group and to avoid increases in health inequality.

Differential Impact of a Cardiac Rehabilitation Program on Functional Parameters in Elderly versus Non-Elderly Myocardial Infarction Survivors

BACKGROUND

Exercise-based cardiac rehabilitation (EBCR) plays a pivotal role in the management of acute myocardial infarction (AMI). Studies have shown that older individuals have a worse prognosis after an AMI, attesting to the importance of risk reduction strategies. We aimed at assessing the impact of age (patients dichotomized as ≥65 years old or <65 years old) on the functional benefits of an EBCR program among AMI survivors.

DESIGN

Observational, retrospective cohort study.

PARTICIPANTS

All patients admitted due to an AMI who completed a phase II EBCR program after discharge, between November 2012 and April 2017.

INTERVENTION

EBCR program.

MEASUREMENTS

Functional parameters were assessed by a symptom-limited cardiopulmonary exercise test.

RESULTS

A total of 379 patients were included (30% aged ≥65 years). After the EBCR program, peak oxygen uptake (pVO2) and exercise duration increased significantly. Patients aged ≥65 years presented with more comorbidities and a lower functional capacity. Those aged ≥65 years presented significantly smaller improvements in pVO2 (0.79 ± 2.61 vs. 1.60 ± 3.11 mL/kg/min, p = 0.016) and exercise duration [75 (59-120) vs. 120 s (60-180), p = 0.002]. This was maintained after adjusting for several potential confounders.

CONCLUSION

Older patients have a worse functional capacity than their younger counterparts. Still, a contemporary EBCR program was associated with significant functional improvements among those aged ≥65 years. The smaller improvements even after adjustments for potential confounders suggest that physiological differences may contribute to this finding. These results highlight the relevance of EBCR among this higher-risk subgroup.

Cardiac rehabilitation in elderly athletes. Analysis of eldery participation in Wizz Air Cluj-Napoca Marathon

Cardiac rehabilitation remains an indispensable tool of the cardiologist’s arsenal for improving cardiovascular health in his patients. The range of applications of cardiac rehabilitation has increased over time. In recent years outstanding athletic performances of elderly people have been reported. In this article we present the benefits of cardiac rehabilitation for elderly population and for elderly athletes. We also make an analysis of the elderly participation in WizzAir Cluj-Napoca Marathon: number of finishers, best running time, evolution of running time over years, male-to-female ratio participation and results. Key words: cardiac rehabilitation, elderly, marathon, semimarathon, Wizz Air,

Predictors of cardiorespiratory fitness improvement in phase II cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) improves cardiorespiratory fitness (CRF) and has been shown to reduce cardiovascular events and death. However, data about predictors of fitness improvement during CR are limited and conflicting. The objective of this study was to determine predictors of improvement in metabolic equivalents of task (METs) based on formal exercise testing throughout phase II CR.

METHODS

We retrospectively reviewed 20 671 patients enrolled in phase II CR at our center from 2006 to 2016. Patients who completed 36 sessions and had entry and exit exercise stress tests were included for study. The short form-36 (SF-36) questionnaire was used to assess quality-of-life. Univariate and multivariate regression analyses were performed to determine independent predictors of METs improvement.

RESULTS

Of the full cohort, 827 patients completed 36 sessions and had entry/exit stress test data. The majority of patients (N = 647, 78.2%) had improvement in METs (mean Δ 2.0 ± 1.2 METs), including patients ≥65 and < 65 years old (77% vs 79%, P = 0.46 for difference). METs improvement was negatively associated with body mass index, diabetes, left ventricular dysfunction, and poor baseline fitness; and positively associated with SF-36 score (P < 0.05 for all). After multivariable adjustment, improvement was no longer affected by age, ejection fraction, or baseline fitness. Patients with poor fitness (≤5 METS) and adequate fitness (> 5 METS) both had improvement, with no statistical difference between the groups (P = 0.36).

CONCLUSIONS

In a large cohort of phase II CR patients, improvement in CRF was seen in the majority of patients across all ages, genders, and levels of baseline fitness.

In the modern era of percutaneous coronary intervention: Is cardiac rehabilitation engagement purely a patient or a service level decision?

Aims

Despite the proven benefits of cardiac rehabilitation (CR), utilization rates remain below recommendation in the percutaneous coronary intervention cohort in most European countries. Although extensive research has been carried out on CR uptake, no previous study has investigated the factors that lead patients to attend the initial CR baseline assessment (CR engagement). This paper attempts to provide new insights into CR engagement in the growing percutaneous coronary intervention population.

Methods and results

In total, we analysed data on 59,807 patients who underwent percutaneous coronary intervention during 2013 to 2016 (mean age 65 years; 25% female). Twenty factors were hypothesized to have a direct impact on CR engagement and they were grouped into four main categories; namely socio-demographic factors, cardiac risk factors, medical status and service-level factors. A binary logistic regression model was constructed to examine the association between CR engagement and tested factors. All but one of the proposed factors had a statistically significant impact on CR engagement. Results showed that CR engagement decreases by 1.2% per year of age (odds ratio 0.98) and is approximately 7% lower (odds ratio 0.93) in female patients, while patients are 4.4 times more likely to engage if they receive a confirmed joining date (odds ratio 4.4). The final model achieved 86.6% sensitivity and 49.0% specificity with an area under the receiver operating characteristic curve of 0.755.

Conclusion

The present results highlight the important factors of the likelihood of CR engagement. This implies that future strategies should focus on factors that are associated with CR engagement.