Effect of early short-term cardiac rehabilitation after acute ST-elevation and non-ST-elevation myocardial infarction on 1-year mortality

Adherence to drug therapy in patients with heart failure associated with reduced ejection fractions (HFrEF) during cardiac rehabilitation and after 3 and 6 months

INTRODUCTION

Heart failure represents a major challenge for healthcare systems worldwide. Rehabilitation is recommended as an important pillar of therapy for these patients, especially for those with reduced left ventricular ejection fraction (HFrEF: heart failure with reduced ejection fraction).

METHODS

The data collected in this multi-center project provide information on the rates of patients with HFrEF who were treated in five German rehabilitation facilities and whether the patients adhered to drug therapy at 3-/6-month follow-up. The project was supported by an unrestricted grant from Novartis-Pharma-GmbH.

RESULTS

The mean age of the 234 patients included was 63.4 ± 10.6 years and 78% were male. The mean LVEF was 31 ± 8% at admission and 36 ± 10% at discharge. Only 20.6% of the patients were assigned to rehabilitation with the main indication HF. The most frequent main indication was acute coronary syndrome (46.6%). A high proportion of patients was already on the recommended drug therapy upon admission (94% beta blockers, 100% angiotensin-effective drugs, 70% mineralocorticoid receptor antagonists, etc.). This was optimized, in particular by a higher proportion of patients treated with sodium-glucose cotransporter-2 inhibitors (35% admission vs. 45% discharge) and sacubitril/valsartan (49% admission vs. 64% discharge), which was further optimized during the 6-month follow-up (e.g., 50% SGLT2 inhibitors, 67% sacubitril/valsartan).

DISCUSSION

These data illustrate the effect of rehabilitation in terms of optimizing drug therapy, which stabilized over the course of 6 months. Furthermore, only a few patients with the main diagnosis HFrEF are referred for cardiac rehabilitation, although it is an essential part of guideline-based therapy.

Causal Model Building in the Context of Cardiac Rehabilitation: A Systematic Review

Randomization is an effective design option to prevent bias from confounding in the evaluation of the causal effect of interventions on outcomes. However, in some cases, randomization is not possible, making subsequent adjustment for confounders essential to obtain valid results. Several methods exist to adjust for confounding, with multivariable modeling being among the most widely used. The main challenge is to determine which variables should be included in the causal model and to specify appropriate functional relations for continuous variables in the model. While the statistical literature gives a variety of recommendations on how to build multivariable regression models in practice, this guidance is often unknown to applied researchers. We set out to investigate the current practice of explanatory regression modeling to control confounding in the field of cardiac rehabilitation, for which mainly non-randomized observational studies are available. In particular, we conducted a systematic methods review to identify and compare statistical methodology with respect to statistical model building in the context of the existing recent systematic review CROS-II, which evaluated the prognostic effect of cardiac rehabilitation. CROS-II identified 28 observational studies, which were published between 2004 and 2018. Our methods review revealed that 24 (86%) of the included studies used methods to adjust for confounding. Of these, 11 (46%) mentioned how the variables were selected and two studies (8%) considered functional forms for continuous variables. The use of background knowledge for variable selection was barely reported and data-driven variable selection methods were applied frequently. We conclude that in the majority of studies, the methods used to develop models to investigate the effect of cardiac rehabilitation on outcomes do not meet common criteria for appropriate statistical model building and that reporting often lacks precision.

Trainingstherapie hilft Patienten bereits früh nach Rekompensation einer akuten Herzin-suffizienz

Senioren, die wegen einer akuten Herzinsuffizienz ins Krankenhaus kommen, sind häufig körperlich eingeschränkt, mitunter gebrechlich und depressiv. Manche Betroffene erholen sich davon nicht mehr, verlieren die Unabhängigkeit und haben ein hohes Rehospitalisierungsrisiko. Die REHAB-HF-Studie belegt den Nutzen einer frühen, individuell angepassten Mobilisierung.

[Impact of COVID-19 on cardiac rehabilitation during the first year of the pandemic: A comparison of the performance numbers in Germany from 2019 and 2020]

INTRODUCTION

In Germany, the COVID-19 pandemic led to substantial changes in outpatient and acute clinical cardiac care and rehabilitation. To estimate the influence of the COVID-19 pandemic on cardiac rehabilitation in 2020, institutional performance was compared to the pre-pandemic year 2019.

METHODS

The performance numbers from rehabilitation institutions were compared. These data were provided in 2019 and 2020 as part of an online survey that the German Society for the Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) performs annually.

RESULTS

Complete data for 2019 and 2020 were available from 60 institutions. The overall number of patients treated was reduced by 14.3%, with substantial differences between institutions. Women were more affected (-16.4%) than men (-13.4%) and retirees (-14.5%) significantly more than people still in the workforce (-7.5%). In 25 institutions (42.4%) there was a COVID-19 outbreak resulting in a partial or complete shutdown in 15.7%. In total, 34.5% of the institutions treated patients with COVID-19 infection, 30.5% after such an infection. A large majority of these institutions (72.1%) had to bear the costs for testing suspected cases of SARS-CoV-2-infection alone.

CONCLUSION

The economic and logistic burden of the COVID-19 pandemic has posed a threat to cardiac rehabilitation in Germany.

Prediction parameters of left ventricular diastolic dysfunction improvement in patients after acute coronary syndrome

OBJECTIVES

The aim of this study was to examine the effects of comprehensive cardiac rehabilitation (CCR) in patients after acute coronary syndrome (ACS) resolved by percutaneous coronary intervention (PCI) on left ventricular diastolic dysfunction (LVDD) and to extract the parameters that have the greatest influence on LVDD improvement.

METHODS

The study included 85 subjects who were divided into intervention (N = 56) and control (N = 29) groups depending on CCR attendance. Initially and after 12 weeks, patients of both groups were subjected to echocardiography to assess LVDD, as well as CPET to assess improvement in functional capacity.

RESULTS

The study showed that 23 patients (27.1%) of both groups demonstrated the improvement of LVDD degree. The improvement of the LVDD degree in the intervention group was significant, whereas in the control group, it did not change (a one-degree improvement in 22 (39.3%) patients of the intervention group (p < 0.001) and only 1 (3.4%) (p > 0.05) in the control group). Multivariate binary logistic regression showed that key parameters in LVDD improvement were participation in the CCR, E/A ratio and haemoglobin value. We created a model, for prediction of LVDF improvement, with a cut-off value of 33 (area = 0.9, p < 0.0005), a sensitivity of 87.0% and a specificity of 85.5%.

CONCLUSIONS

CCR can be used as an effective non-pharmacological measure to improve LVDD and functional capacity in patients after ACS. The statistical model may have practical application in prediction of clinical benefit in such a group of patients.

Efficacy of Lipid-Lowering Therapy during Cardiac Rehabilitation in Patients with Diabetes Mellitus and Coronary Heart Disease

Background: Cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) increases adherence to a healthy lifestyle and to secondary preventive medication. A notable example of such medication is lipid-lowering therapy (LLT). LLT during CR improves quality of life and prognosis, and thus is particularly relevant for patients with diabetes mellitus, which is a major risk factor for CHD. Design: A prospective, multicenter registry study with patients from six rehabilitation centers in Germany. Methods: During CR, 1100 patients with a minimum age of 18 years and CHD documented by coronary angiography were included in a LLT registry. Results: In 369 patients (33.9%), diabetes mellitus was diagnosed. Diabetic patients were older (65.5 ± 9.0 vs. 62.2 ± 10.9 years, p < 0.001) than nondiabetic patients and were more likely to be obese (BMI: 30.2 ± 5.2 kg/m² vs. 27.8 ± 4.2 kg/m², p < 0.001). Analysis indicated that diabetic patients were more likely to show LDL cholesterol levels below 55 mg/dL than patients without diabetes at the start of CR (Odds Ratio (OR) 1.9; 95% CI 1.3 to 2.9) until 3 months of follow-up (OR 1.9; 95% CI 1.2 to 2.9). During 12 months of follow-up, overall and LDL cholesterol levels decreased within the first 3 months and remained at the lower level thereafter (p < 0.001), irrespective of prevalent diabetes. At the end of the follow-up period, LDL cholesterol did not differ significantly between patients with or without diabetes mellitus (p = 0.413). Conclusion: Within 3 months after CR, total and LDL cholesterol were significantly reduced, irrespective of prevalent diabetes mellitus. In addition, CHD patients with diabetes responded faster to LTT than nondiabetic patients, suggesting that diabetic patients benefit more from LLT treatment during CR.

Do Cardiac Rehabilitation Affect Clinical Prognoses Such as Recurrence, Readmission, Revascularization, and Mortality After AMI?: Systematic Review and Meta-Analysis

Objective

We conducted a systematic review and meta-analysis to analyze the effects of cardiac rehabilitation (CR) on post-discharge prognoses of patients with acute myocardial infarction (AMI).

Methods

A literature search was conducted through four international medical and two Korean databases. Primary outcomes for the effectiveness of CR included all-cause mortality, cardiovascular mortality, recurrence, revascularization, major adverse cardiovascular event, major adverse cardiocerebrovascular event, and readmission. We summarized and analyzed results of studies about CR for AMI, including not only randomized controlled trials (RCTs) but also non-RCTs. We calculated the effect size separately by the study type.

Results

Fourteen articles were finally selected. Of these, two articles were RCTs, while 12 were non-RCTs. In RCTs, the overall mortality rate was lower in the group that participated in CR than that in the conventional care group by 28% (relative risk=0.72; 95% confidence interval, 0.34–1.57). Among non-RCTs, CR participation significantly decreased the overall risk of mortality. Moreover, the rates of recurrence and major adverse cardiovascular events were lower in the group that participated in CR compared to those in the non-CR group.

Conclusion

The meta-analysis shows that CR reduces the risk of re-hospitalization and all-cause mortality after AMI, compared to no participation in CR. This outcome was seen in RCTs as well as in non-RCTs. More studies are necessary for concrete conclusions about the beneficial effects of CR after AMI in various settings.

Long-term Cardiac Maintenance Programming: A SINGLE-SITE ANALYSIS OF MORE THAN 200 PARTICIPANTS

PURPOSE

Greater than 65% of all cardiac mortality is related to coronary artery disease (CAD). Cardiac rehabilitation (CR) aims to reduce cardiovascular risk and number of hospital readmissions. Cardiac maintenance programs (CMPs) are designed to sustain or improve health after completing early CR. Although CMPs are supported by most national health guidelines, few long-term studies on these diverse programs have been performed.

METHODS

This was a retrospective repeated-measures analysis with case-controlled subanalysis. Within-subject differences for CMP participants were examined between enrollment and last clinical visit. Assessments included medical history, anthropometry, blood analysis, and cardiopulmonary exercise testing. A subset of 20 CMP participants were compared with 20 patients with CAD who chose not to participate in CMP, matched for age, sex, and follow-up duration.

RESULTS

A total of 207 patients (60 ± 9 yr, 16% female) were included for the primary analyses. Average follow-up was 6.3 ± 4.8 yr (range 4-20 yr). CMP participants reduced peak workload (1.76 ± 0.56 to 1.60 ± 0.58 W/kg; P < .001) and aerobic capacity (26.1 ± 6.2 to 24.6 ± 7.1 mL/kg/min; P = .003). High-density lipoprotein-cholesterol increased significantly (48 ± 12 to 51 ± 14 mg/dL; P < .001), whereas all other metabolic risk factors remained unaffected. Matched controls had higher functional capacity (2.35 ± 0.81 vs 1.56 ± 0.52 W/kg; P < .001) and lower body mass index (25.3 ± 3.6 vs 28.6 ± 3.9 kg/m2) at baseline, but no significant differences with respect to long-term efficacy were observed.

CONCLUSIONS

Long-term participation in CMP did not result in maintaining functional capacity or cardiovascular risk profile in patients with CAD. However, compared with matched nonparticipants, CMP participants (are more deconditioned at baseline) but do not seem to deteriorate as quickly.

In-hospital cardiac rehabilitation and clinical outcomes in patients with acute myocardial infarction after percutaneous coronary intervention: a retrospective cohort study

OBJECTIVES

To verify the associations between participation in an in-hospital cardiac rehabilitation (CR) programme and clinical outcomes among patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI).

DESIGN

A retrospective cohort study using the Japanese administrative claims database.

SETTING

Japanese acute-care hospitals.

PARTICIPANTS

Patients aged ≥18 years who underwent PCI due to AMI and survived to discharge.

PRIMARY AND SECONDARY OUTCOME MEASURE

The primary outcomes were revascularisation, all-cause readmission and cardiac readmission (median follow-up period: 324 days, 236 days and 263 days, respectively). The secondary outcomes were all-cause mortality and cardiac mortality (median follow-up period: both were 460 days).

RESULT

The data of 13 697 patients were extracted from the database, and 65.4% of them participated in an in-hospital CR. The risks of revascularisation, all-cause readmission and cardiac readmission among CR participants were compared with those of non-participants using two statistical techniques: matched-pair analysis based on propensity score and a 30-day landmark analysis. The results of those analysis were consistent and showed that the CR participants had lower risk of revascularisation (adjusted HR: 0.74; 95% CI: 0.65 to 0.84), all-cause readmission (HR: 0.81; 95% CI: 0.74 to 0.88) and cardiac readmission (HR: 0.77; 95% CI: 0.70 to 0.85). However, all-cause mortality and cardiac mortality were not associated with participation in the CR.

CONCLUSIONS

It was suggested that in-hospital CR participation may reduce the risk of revascularisation, all-cause readmission and cardiac readmission among patients with AMI after PCI. In-hospital CR may expand the potential benefits of CR in addition to outpatient CR.

Cardiac rehabilitation and 5-year mortality after acute myocardial infarction. Report from 11 tertiary hospitals in Korea (ETHIK Study)

BACKGROUND

The participation rate for cardiac rehabilitation (CR) remains low in some Europe and Asia including Korea.

AIM

To investigate effects of CR on prognosis improvements in terms of recurrence, readmission, revascularization, and mortality rates in patients with acute myocardial infarction (AMI) in Korea.

DESIGN

A retrospective cohort study.

SETTING

Eleven Tertiary Hospitals In Korea (ETHIK Study).

POPULATION

Data from a total of 7299 patients between January 2012 and December 2015 were collected, of which data from 7136 patients were linked to insurance claims data. In the final analysis, 6743 patients were included.

METHODS

Patients who participated in the CR program while receiving outpatient treatment were classified into CR group. Those who did not participate in CR programs were classified into the non-CR group.

RESULTS

Kaplan-Meier survival analyses showed five-year survival rate of 96.9% in the CR group and 93.3% in the non-CR group. The hazard ratio (HR) for total 5-year mortality in the CR group was approximately 0.41 (95% CI: 0.27-0.63) times that of the non-CR group, indicating a reduction in the risk of mortality by approximately 59% in propensity score weighted cohort of 1878 patients. The HR for major adverse cardiac events (MACE) with respect to 5-year mortality, MI recurrence, revascularization, and readmission due to cardiovascular disease in CR group was 0.96 times that of non-CR group (95% CI: 0.83-1.12), without significant difference between the two groups.

CONCLUSIONS

In this study, 5-year mortality decreased by 59% in patients with AMI who had participated in CR compared to those who did not.

CLINICAL REHABILITATION IMPACT

This finding should be very helpful in emphasizing the need for CR in a country like Korea where CR has not yet been actively implemented.

Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II)

Background

Despite numerous studies and meta-analyses the prognostic effect of cardiac rehabilitation is still under debate. This update of the Cardiac Rehabilitation Outcome Study (CROS II) provides a contemporary and practice focused approach including only cardiac rehabilitation interventions based on published standards and core components to evaluate cardiac rehabilitation delivery and effectiveness in improving patient prognosis.

Design

A systematic review and meta-analysis.

Methods

Randomised controlled trials and retrospective and prospective controlled cohort studies evaluating patients after acute coronary syndrome, coronary artery bypass grafting or mixed populations with coronary artery disease published until September 2018 were included.

Results

Based on CROS inclusion criteria out of 7096 abstracts six additional studies including 8671 patients were identified (two randomised controlled trials, two retrospective controlled cohort studies, two prospective controlled cohort studies). In total, 31 studies including 228,337 patients were available for this meta-analysis (three randomised controlled trials, nine prospective controlled cohort studies, 19 retrospective controlled cohort studies; 50,653 patients after acute coronary syndrome 14,583, after coronary artery bypass grafting 163,101, mixed coronary artery disease populations; follow-up periods ranging from 9 months to 14 years). Heterogeneity in design, cardiac rehabilitation delivery, biometrical assessment and potential confounders was considerable. Controlled cohort studies showed a significantly reduced total mortality (primary endpoint) after cardiac rehabilitation participation in patients after acute coronary syndrome (prospective controlled cohort studies: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; retrospective controlled cohort studies HR 0.64, 95% CI 0.53–0.76; prospective controlled cohort studies odds ratio 0.20, 95% CI 0.08–0.48), but the single randomised controlled trial fulfilling the CROS inclusion criteria showed neutral results. Cardiac rehabilitation participation was also associated with reduced total mortality in patients after coronary artery bypass grafting (retrospective controlled cohort studies HR 0.62, 95% CI 0.54–0.70, one single randomised controlled trial without fatal events), and in mixed coronary artery disease populations (retrospective controlled cohort studies HR 0.52, 95% CI 0.36–0.77; two out of 10 controlled cohort studies with neutral results).

Conclusion

CROS II confirms the effectiveness of cardiac rehabilitation participation after acute coronary syndrome and after coronary artery bypass grafting in actual clinical practice by reducing total mortality under the conditions of current evidence-based coronary artery disease treatment. The data of CROS II, however, underscore the urgent need to define internationally accepted minimal standards for cardiac rehabilitation delivery as well as for scientific evaluation.

Resilience is strongly associated with health-related quality of life but does not buffer work-related stress in employed persons 1 year after acute myocardial infarction

PURPOSE

Resilience may facilitate the adaptation after experiencing a severe disease such as acute myocardial infarction (AMI) and attenuate the negative effects of stress on health-related quality of life (HRQOL). However, it is unclear so far whether resilience moderates a negative association between work-related stress and HRQOL in employed patients after AMI.

METHODS

Patients with confirmed AMI and regular paid employment admitted to a hospital in the study region of the MONICA/KORA Myocardial Infarction Registry, Germany (04/2014-06/2017) were included and completed questionnaires during their hospital stay and 6 and 12 months after discharge. The Resilience Questionnaire (RS-11) and the Effort-Reward Imbalance (ERI) Questionnaire were used to assess trait resilience and ERI, respectively. HRQOL was measured by the Short Form 36 Health Survey (SF-36) mental and physical component summary scales. Generalized estimating equations (GEE) adjusted for relevant potential confounding variables (demographic, social, stress-related, and clinical) were used to determine the association between resilience and HRQOL in the study course.

RESULTS

From the 346 patients enrolled in the study, 270 patients (78.0%) had completed all surveys. High baseline trait resilience was significantly and independently associated with high physical HRQOL (ß = 0.15, p < 0.0001) and high mental HRQOL (ß = 0.37, p < 0.0001) 1 year post AMI. No significant interaction effects between trait resilience and ERI were found in the physical HRQOL GEE model (ß = 0.05, p = 0.7241) and in the mental HRQOL model (ß = 0.05, p = 0.3478).

CONCLUSIONS

The results demonstrated that trait resilience is independently and strongly related with post-AMI HRQOL but does not moderate the association between ERI and HRQOL.

The effectiveness of modern cardiac rehabilitation: A systematic review of recent observational studies in non-attenders versus attenders

BACKGROUND

The beneficial effects of cardiac rehabilitation (CR) have been challenged in recent years and there is now a need to investigate whether current CR programmes, delivered in the context of modern cardiology, still benefit patients.

METHODS

A systematic review of non-randomised controlled studies was conducted. Electronic searches of Medline, Embase, CINAHL, science citation index (web of science), CIRRIE and Open Grey were undertaken. Non-randomised studies investigating the effects of CR were included when recruitment occurred from the year 2000 onwards in accordance with significant CR guidance changes from the late 1990's. Adult patients diagnosed with acute myocardial infarction (AMI) were included. Non-English articles were considered. Two reviewers independently screened articles according to pre-defined selection criteria as reported in the PROSPERO database (CRD42015024021).

RESULTS

Out of 2,656 articles, 8 studies involving 9,836 AMI patients were included. Studies were conducted in 6 countries. CR was found to reduce the risk of all-cause and cardiac-related mortality and improve Health-Related Quality of Life (HRQOL) significantly in at least one domain. The benefits of CR in terms of recurrent MI were inconsistent and no significant effects were found regarding re-vascularisation or re-hospitalisation following AMI.

CONCLUSION

Recent observational evidence draws different conclusions to the most current reviews of trial data with respect to total mortality and re-hospitalisation, questioning the representativeness of historic data in the modern cardiological era. Future work should seek to clarify which patient and service level factors determine the likelihood of achieving improved all-cause and cardiac mortality and reduced hospital re-admissions.

The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy: A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS)

Background

The prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event.

Design

Structured review and meta-analysis.

Methods

Randomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later.

Results

Out of n = 18,534 abstracts, 25 studies were identified for final evaluation (RCT: n = 1; pCCS: n = 7; rCCS: n = 17), including n = 219,702 patients (after ACS: n = 46,338; after CABG: n = 14,583; mixed populations: n = 158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20–0.69; rCCS: HR 0.64, 95% CI 0.49–0.84; odds ratio 0.20, 95% CI 0.08–0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54–0.70) and in mixed CAD populations.

Conclusions

CR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.

Rehabilitation in Patients With Coronary Heart Disease: Participation and Its Effect on Prognosis

BACKGROUND

In Germany, rehabilitation is considered to be indicated after an acute hospital stay for the treatment of a severe cardiac condition. In comparative studies, at least 51% of German hospital patients with coronary heart disease (CHD) who were entitled to rehabilitative measures actually took part n rehabilitation.

METHODS

We examined data on 1910 patients with CHD who took part in two prospective cohort studies at the University Hospital of Halle (Saale) in the years 2007-2011. We contacted these patients again with a questionnaire to determine which ones had undergone rehabilitation. For patients who died before we could contact them, the attempt was made to obtain the dates and causes of death from the local authorities. The primary endpoint of was overall mortality.

RESULTS

The median duration of follow-up was 136 ± 71 weeks. 727 patients (38.1%) had applied for rehabilitation during their acute hospitalization, but only 552 patients (28.9%) actually underwent it. Patients who did not undergo rehabilitation were older than those who did (68.6 ± 10.3 vs. 64.9 ± 10.5 years) and suffered more commonly from diabetes (41.3% vs. 33.7%; p = 0.002), arterial hypertension (89.2% vs. 85.3%; p = 0.017), and peripheral arterial occlusive disease (15.3% vs. 9.8%; p = 0.002). There were more smokers in the rehabilitation group. Kaplan-Meier analysis and multivariate Cox regression analysis both showed that the patients who underwent rehabilitation had lower mortality (hazard ratio 0.067, 95% confidence interval 0.025-0.180, p < 0.001).

CONCLUSION

Rehabilitation for cardiac patients was associated with lower mortality. Fewer patients underwent rehabilitation in this study than in other, comparable studies. Those who did not were older and had a greater burden of accompanying disease.

Management of patients with ST-segment elevation or non-ST-segment elevation acute coronary syndromes in cardiac rehabilitation centers

BACKGROUND

Current data on the management of patients in cardiac rehabilitation (CR) after an acute hospital stay due to ST-segment elevation or non-ST segment elevation acute coronary syndromes (STE-ACS or NSTE-ACS) are limited. We aimed to describe patient characteristics, risk factor management, and lipid target achievement of patients in CR in Germany and compare the 2 groups.

HYPOTHESIS

With respect to the risk factor pattern and treatment effects during a CR stay, there are important differences between STE-ACS and NSTE-ACS patients.

METHODS

Comparison of 7950 patients by STE-ACS or NSTE-ACS status in the Transparency Registry to Objectify Guideline-Oriented Risk Factor Management registry (2010) who underwent an inpatient CR period of about 3 weeks.

RESULTS

STE-ACS patients compared to NSTE-ACS patients were significantly younger (60.5 vs 64.4 years, P < 0.0001), and had diabetes mellitus, hypertension, or any risk factor (exception: smoking) less often. At discharge, in STE-ACS compared to NSTE-ACS patients, the low-density lipoprotein cholesterol (LDL-C) <100 mg/dL goal was achieved by 75.3% and 76.2%, respectively (LDL-C <70 mg/dL by 27.7% and 27.4%), the high-density lipoprotein cholesterol goal of >50 mg/dL in women and >40 mg/dL in men was achieved by 49.3% and 49.0%, respectively, and the triglycerides goal of <150 mg/dl was achieved by 72.3% and 74.3%, respectively (all comparisons not significant). Mean systolic and diastolic blood pressure were 121/74 and 123/74 mm Hg, respectively (P < 0.0001 systolic, diastolic not significant). The maximum exercise capacity was 110 and 102 W, respectively (P < 0.0001), and the maximum walking distance was 581 and 451 meters, respectively (P value not significant).

CONCLUSIONS

Patients with STE-ACS and NSTE-ACS differed moderately in their baseline characteristics. Both groups benefited from the participation in CR, as their lipid profile, blood pressure, and physical fitness improved.

Cardiac rehabilitation and outcome in stable outpatients with recent myocardial infarction

OBJECTIVE

To compare the mortality rate and the rate of subsequent ischemic events (myocardial infarction [MI], ischemic stroke, or limb amputation) in patients with recent MI according to the use of cardiac rehabilitation or no rehabilitation.

DESIGN

Longitudinal observational study.

SETTING

Ongoing registry of outpatients.

PARTICIPANTS

Patients (N=1043) with recent acute MI were recruited; of these, 521 (50%) participated in cardiac rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subsequent ischemic events and mortality rates were registered.

RESULTS

Over a mean follow-up of 18 months, 50 patients (4.8%) died and 49 (4.7%) developed 52 subsequent ischemic events (MI: n=43, ischemic stroke: n=6, limb amputation: n=3). Both the mortality rate (.16 vs 5.57 deaths per 100 patient-years; rate ratio=.03; 95% confidence interval [CI], 0.0-0.1]) and the rate of subsequent ischemic events (1.65 vs 4.54 events per 100 patient-years; rate ratio=0.4; 95% CI, 0.2-0.7) were significantly lower in cardiac rehabilitation participants than in nonparticipants. Multivariate analysis confirmed that patients in cardiac rehabilitation had a significantly lower risk of death (hazard ratio=.08; 95% CI, .01-.63; P=.016) and a nonsignificant lower risk of subsequent ischemic events (hazard ratio=.65; 95% CI, .30-1.42).

CONCLUSIONS

The use of cardiac rehabilitation in patients with recent MI was independently associated with a significant decrease in the mortality rate and a nonsignificant decrease in the rate of subsequent ischemic events.

Short-term comprehensive cardiac rehabilitation after AMI is associated with reduced 1-year mortality: results from the OMEGA study

BACKGROUND

The prognostic effect of early, comprehensive short-term cardiac rehabilitation on top of current, guideline-adjusted treatment of acute myocardial infarction has not sufficiently been evaluated.

DESIGN

Prospective cohort study.

METHODS

Within the OMEGA study population, the clinical course of 3560 patients still alive 3 months after acute myocardial infarction were evaluated by comparing patients who had attended to cardiac rehabilitation (70.6%) with those who did not. Total mortality and major adverse cerebrovascular and cardiovascular events, as well as non-fatal events, were evaluated within the time period of 4-12 months after hospital admission for acute myocardial infarction. The effect of cardiac rehabilitation on clinical events was estimated by using the propensity score method to adjust for confounding parameters in multivariate analysis.

RESULTS

Patients participating in cardiac rehabilitation were younger, more often had acute revascularization, less often experienced non-ST-elevation myocardial infarction, and less often had a history of diabetes or cardiovascular events. Total mortality (OR 0.46, 95% CI 0.27-0.77) and major adverse cerebrovascular and cardiovascular events (OR 0.53, 95% CI 0.38-0.75) were significantly lower in the rehabilitation group. Subgroup analysis including major clinical characteristics also revealed significantly reduced rates of total death and major adverse cerebrovascular and cardiovascular events in the rehabilitation group.

CONCLUSIONS

Attendance to early, comprehensive short-term cardiac rehabilitation programmes on top of current guideline-adjusted treatment of acute myocardial infarction is associated with a significantly improved 1-year prognosis.

[Cardiac rehabilitation in Germany: a successful model with promising prospects]

Over the past 20 years the German Pension Insurance has rehabilitated nearly 800,000 patients with coronary heart disease. In particular, phase-II rehabilitation has been established as an integral part of cardiac patient care. However, the decreasing number of participants in phase-III must be seen critically. Today's cardiac rehabilitation is characterised by evidence-based treatment modules and a sophisticated quality assurance system that ensures quality orientation in all aspects, from access to rehabilitation through to aftercare. Future developments such as vocationally-oriented medical rehabilitation and the use of new technologies will further improve cardiac rehabilitation. Positive patient feedback and scientific evidence of the effectiveness of cardiac rehabilitation are further incentives to maintain this forward-looking approach.

[Telemedicine during cardiac rehabilitation after acute myocardial infarction]

After acute myocardial infarction, cardiac rehabilitation should be an essential part of any therapy aimed at long-term success. Telemedical studies have mostly investigated ECG-monitored exercise training at home and internet-based counseling for lifestyle modification in selected patients. This approach cannot replace the holistic and multidisciplinary approach of cardiac rehabilitation. Telemedicine should be further evaluated, however, as it offers significant opportunities to facilitate access to rehabilitation for those patients who would otherwise not be able to attend for geographical, logistic or psychosocial reasons.

Cardiac rehabilitation attendance and outcomes in coronary artery disease patients

BACKGROUND

Cardiac rehabilitation (CR) is an efficacious yet underused treatment for patients with coronary artery disease. The objective of this study was to determine the association between CR completion and mortality and resource use.

METHODS AND RESULTS

We conducted a prospective cohort study of 5886 subjects (20.8% female; mean age, 60.6 years) who had undergone angiography and were referred for CR in Calgary, AB, Canada, between 1996 and 2009. Outcomes of interest included freedom from emergency room visits, hospitalization, and survival in CR completers versus noncompleters, adjusted for clinical covariates, treatment strategy, and coronary anatomy. Hazard ratios for events for CR completers versus noncompleters were also constructed. A propensity model was used to match completers to noncompleters on baseline characteristics, and each outcome was compared between propensity-matched groups. Of the subjects referred for CR, 2900 (49.3%) completed the program, and an additional 554 subjects started but did not complete CR. CR completion was associated with a lower risk of death, with an adjusted hazard ratio of 0.59 (95% confidence interval, 0.49-0.70). CR completion was also associated with a decreased risk of all-cause hospitalization (adjusted hazard ratio, 0.77; 95% confidence interval, 0.71-0.84) and cardiac hospitalization (adjusted hazard ratio, 0.68; 95% confidence interval, 0.55-0.83) but not with emergency room visits. Propensity-matched analysis demonstrated a persistent association between CR completion and reduced mortality.

CONCLUSIONS

Among those coronary artery disease patients referred, CR completion is associated with improved survival and decreased hospitalization. There is a need to explore reasons for nonattendance and to test interventions to improve attendance after referral.

Is cardiac rehabilitation still relevant in the new millennium?

Cardiac rehabilitation is an evidence-based intervention which has evolved over time and incorporates physical, psycho-social and educational components with the aim of improving the patients' functioning following a cardiac event. The evidence base for cardiac rehabilitation following acute myocardial infarction has been growing over the past half a century. Individual randomized control trials were small and, therefore, mortality outcomes usually failed to reach significance; however, meta-analyses have proven consistently that participation in cardiac rehabilitation following a myocardial infarction is associated with a significant improvement in mortality. In the era of revascularization and improved drug therapies, observational studies still provide evidence that independent of other treatments, cardiac rehabilitation is a life-saving measure. Although early studies often only studied young males, more contemporary data include patients from all sectors of society and have found that groups such as women, the elderly and those with heart failure appear to have greater mortality benefits compared with the traditional young male cohort. Uptake remains a problem and one challenge for the future is ensuring improved uptake on to good-quality rehabilitation programmes and demonstrating these positive effects.

[Outpatient rehabilitation after myocardial infarction or for heart failure]

Reducing cardiac mortality and improving quality of life are the main objectives of cardiac rehabilitation. In recent years, outpatient rehabilitation within easy patient reach has achieved the same status as inpatient rehabilitation. Outpatient rehabilitation permits close involvement of the patient's family and social environment, thus easing reintegration into everyday life. However, the health care system is not yet utilizing outpatient rehabilitation to its full potential. This contribution illustrates the principles of rehabilitation following myocardial infarction or for heart failure in an outpatient setting, as well as its potential and future development.

Current state of cardiac rehabilitation in Germany: patient characteristics, risk factor management and control status, by education level

Background

After the acute hospital stay, most cardiac patients in Germany are transferred for a 3–4-week period of inpatient cardiac rehabilitation. We aim to describe patient characteristics and risk factor management of cardiac rehabilitation patients with a focus on drug treatment and control status, differentiated by education level (low level, elementary school; intermediate level, secondary modern school; high level, grammar school/university).

Methods

Data covering a time period between 2003 and 2008 from 68,191 hospitalized patients in cardiac rehabilitation from a large-scale registry (Transparency Registry to Objectify Guideline- Oriented Risk Factor Management) were analyzed descriptively. Further, a multivariate model was applied to assess factors associated with good control of risk factors.

Results

In the total cohort, patients with a manifestation of coronary artery disease (mean age 63.7 years, males 71.7%) were referred to cardiac rehabilitation after having received percutaneous coronary intervention (51.6%) or coronary bypass surgery (39.5%). Statin therapy increased from 76.3% at entry to 88.9% at discharge, and low density lipoprotein cholesterol < 100 mg/dL rates increased from 31.1% to 69.6%. Mean fasting blood glucose decreased from 108 mg/dL to 104 mg/dL, and mean exercise capacity increased from 78 W to 95 W. Age and gender did not differ by education. In contrast with patients having high education, those with low education had more diabetes, hypertension, and peripheral arterial disease, had lower exercise capacity, and received less treatment with statins and guideline-orientated therapy in general. In the multivariate model, good control was significantly more likely in men (odds ratio 1.38; 95% confidence interval 1.30–1.46), less likely in patients of higher age (0.99; 0.99–0.99), with diabetes (0.90; 0.85–0.95), or peripheral arterial disease (0.88; 0.82–0.95). Compared with a low level education, a mid level education was associated with poor control (0.94; 0.89–0.99), while high education did not have a significant effect (1.08; 0.99–1.17).

Conclusion

Patients with different levels of education treated in cardiac rehabilitation did not differ relevantly in terms of demographics, but did differ in some clinical aspects. With respect to the ultimate goal of cardiac rehabilitation, ie, optimal control of risk factors, education level does not play an important role.

Clinical practice of defibrillator implantation after myocardial infarction: impact of implant time: results from the PreSCD II registry

Aims

Current guidelines recommend implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden cardiac death in patients with the reduced left ventricular function (LVEF ≤30%) not earlier than 40 days after myocardial infarction (MI). The aim of the prospective Prevention of Sudden Cardiac Death II (PreSCD II) registry was to investigate the clinical practice of ICD therapy in post-MI patients and to assess the impact on survival.

Methods and results

10 612 consecutive patients (61 ± 12 years, 76% male) were enrolled 4 weeks or later after MI in 19 cardiac rehabilitation centres in Germany from December 2002 to May 2005. All patients with left ventricular ejection fraction (LVEF) ≤40% (n = 952) together with a randomly selected group of patients with preserved left ventricular function (n = 1106) were followed for 36 months. Cox proportional hazard models were used to correlate ICD implantation and survival with baseline characteristics. Of all patients studied, 75.9% were enrolled within 4–8 weeks, 10.7% more than 1 year after MI. Pre-specified Group 1 with an LVEF ≤30% consisted of 269 patients (2.5%), Group 2 with LVEF 31–40% of 727 patients (6.9%), and Group 3 with LVEF >40% of 1148 randomly selected patients from the cohort of 9616 patients with preserved LV function. After 36 months, only 142 patients (6.9%) had received an ICD; 82 (31.7%) of Group 1, 49 (7%) of Group 2, and 11 (1%) in Group 3. The ICD was implanted in 47% of all patients within 1 year after their index MI. Implantable cardioverter-defibrillator patients were predominantly characterized by low ejection fraction, but also by several other independent risk factors. Patients who received an ICD had an adjusted 44% lower mortality (hazard ratio 0.56, 95% confidence intervals 0.32–1.01; P = 0.053) than comparable patients without ICD therapy. All cause mortality of ICD recipients was significantly lower if the ICD was implanted later than 11 months after acute MI (P < 0.001).

Conclusions

The PreSCD II registry demonstrated that the number of patients who develop a low LVEF (≤30%) after acute MI is small. However, only few patients with guideline-based ICD indication received ICD therapy. All cause mortality was significantly reduced only if the ICD was implanted late (>11 months) after MI.