Impact of completeness of revascularization by coronary intervention on exercise capacity early after acute ST-elevation myocardial infarction

Effects of cardiac rehabilitation on inflammatory biomarkers in unstable ischemic heart disease patients following percutaneous coronary intervention: a randomized controlled study

INTRODUCTION

Several blood inflammatory markers, such as high-sensitivity C-reactive protein (hs-CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), are linked to increased risk for cardiovascular diseases. This study aimed to evaluate these inflammatory markers after cardiac rehabilitation (CR) in patients with unstable ischemic heart disease (UIHD) who underwent successful percutaneous coronary intervention (PCI).

METHODS

A cohort of 115 patients with successful PCI due to UIHD enrolled in the study from January 2018 to March 2021. We used a permuted block stratified randomization technique (2 : 1 ratio). Seventy-seven patients were randomized to the CR group and 38 patients to the control group. The CR group underwent a 12-week pre-specified CR regimen. Blood samples were taken at baseline and follow-up at 12 weeks for both groups.

RESULT

Among the 115 patients, 33 patients were female. The mean age was (53 ± 5.55 years) in the control and (53 ± 6.09 years) in the CR group. The two groups were comparable regarding their baseline characteristics and the values of the inflammatory markers. By contrast, at 12 weeks, the inflammatory marker values were significantly lower in the CR group compared to the control group; hs-CRP: 0.11 [0.08-0.14] vs. 0.21 [0.19-0.21], P -value <0.001; NLR: 2.17 [1.42-2.43] vs. 2.26 [2.07-2.6], P -value: 0.016; PLR: 91.2821 [63.3333-103.2000] vs. 92.600 [84.6154-110.0000], P -value: 0.027.

CONCLUSION

CR after PCI in UIHD patients may attenuate some inflammatory markers, which might benefit cardiovascular health. Further studies are required to evaluate these findings with longer follow-up and the powered to measure major cardiovascular event rates.

Determinants of Exercise Capacity Following ST-Elevation Myocardial Infarction (STEMI)

BACKGROUND

Abnormal left ventricular systolic and diastolic function and reduced exercise capacity are associated with worse prognosis following ST-elevation myocardial infarction (STEMI). However, evidence is lacking on the determinants of exercise capacity following STEMI. We sought to determine the impact of systolic and diastolic dysfunction on exercise capacity and outcomes following first-ever STEMI.

METHODS

In a retrospective analysis of 139 consecutive STEMI patients who had a transthoracic echocardiogram following STEMI and completed exercise treadmill testing, the primary outcome was to identify clinical and echocardiographic determinants of exercise capacity, and the secondary outcome was to identify determinants of major adverse cardiac events (MACEs).

RESULTS

Mean number of metabolic equivalents (METs > 8) was used as a cut-off. Age, female sex, anterior infarction, abnormal diastolic function, minimum left atrial indexed volume (LAVI_min) ≥ 18 mL/m², average e', and E/e' were associated with METs ≤ 8, but not left ventricular ejection fraction (LVEF). On multivariate analysis, LAVI_min (OR 4.3, 95%CI 1.3-14.2; p = 0.017), anterior infarction (OR 2.6, 95%CI 1.2-5.9; p = 0.022), and abnormal diastolic function (OR 3.73, 95%CI 1.7-8.4; p = 0.001) were independent predictors of METs ≤ 8. On Kaplan-Meier analysis, METs ≤ 8 (p = 0.01) and abnormal diastolic function (p = 0.04) were associated with MACEs (median follow-up 2.3 years). METs ≤ 8 was an independent predictor of MACEs (HR 3.4, 95%CI 1.2-9.8; p = 0.02).

CONCLUSIONS

Following first-ever STEMI, increased LAVI_min, anterior infarction, and abnormal diastolic function were independent predictors of reduced exercise capacity. Furthermore, reduced exercise capacity was an independent predictor of MACEs. These results highlight important prognostic and therapeutic implications related to abnormal diastolic function in STEMI patients that are distinct from those with LV systolic impairment.

Cardiac Rehabilitation of Patients with Acute ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention in a Han Population in Northern China: A Prospective Cohort Study

Background

Cardiac rehabilitation (CR) has been associated with improved cardiac function in cardiovascular diseases. Our aim was to explore the factors associated with cardiac function and CR.

Methods

This prospective cohort study had 473 STEMI patients admitted for primary percutaneous coronary intervention (PCI) who were divided into a CR group (group A, n = 104) and a non-CR group (group B, n = 369) based on whether they could complete CR. Patients’ clinical features, such as age, hyperlipidemia, family history of premature coronary heart disease (FHPCHD), smoking history, body mass index (BMI, kg/m²), number of diseased vessels, arrhythmia during PCI, N-terminal pro–B-type natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF) and major adverse cardiac events (MACEs) at 6 months after PCI were compared. Then, the clinical characteristics of patients were further analyzed according to those with MACEs (n = 78) and those without MACEs (n = 395).

Results

After CR of 6 months, NT-proBNP levels (p = 0.027), 6-MWD (meter, P = 0.000), LVEF (P = 0.000) were significantly improved in group A compared to group B, but not for SMWA (P = 0.875). Multivariate analysis indicated that even though patients in group A (OR 3.06, 95% CI 1.132–8.274, p = 0.03) have a higher incidence of hyperlipidemia, their MACEs (OR 0.191, 95% CI 0.038–0.961, p = 0.05) at 6 months were significantly lower than in group B, mainly because the average patient low age (<65 years, OR 0.917, 95% CI 0.859–0.979, p = 0.01) and significant improvement of 6-MWD (OR 7.999, 95% CI 4.342–14.737, P = 0.00) and the LVEF at 6 months (OR 1.112, 95% CI 1.072–1.154, p = 0.00). Further analysis based on the MACES outcomes showed that there were 6 factors associated with the occurrence of MACEs, they were age >65 years (OR 1.032, 95% CI 1.009–1.009, p = 0.007), smoking history (OR 0.485, 95% CI 0.238–0.989, p = 0.046), education level (OR 2.646, 95% CI 1.370–5.108, p = 0.004), 6-MWD (OR 1.688, 95% CI 1.104–2.811, p = 0.044), LVEF (OR 0.958, 95% CI 0.926–0.991, p = 0.013) and CR (OR 6.271, 95% CI 2.236–17.590, p = 0.000).

Conclusion

CR, including exercise rehabilitation, is a beneficial option to reduce MACEs in STEMI patients treated with primary PCI.

Efficacy of CPET Combined with Systematic Education of Cardiac Rehabilitation After PCI: A Real-World Evaluation in ACS Patients

Introduction

There are scarce real-world data on the long-term efficacy and safety of cardiopulmonary exercise testing (CPET) combined with the systematic education of cardiac rehabilitation (CR) approach for patients post-coronary stenting, which is, therefore, the subject of this study.

Methods

Data collected between 1 April 2015 and 20 May 2017 from 11,345 patients in the rehabilitation center database at our hospital were retrospectively analyzed. Five hundred thirty-six patients with incomplete information, or unable to cooperate with telephone follow-up, were excluded; 4001 patients received the combined CR approach; and 6808 patients received only routine post-procedure education (controls). Of these, 2805 CR participants (CR group) were matched 1:1 to controls (control group) using propensity scores. The main outcome was quality of life in Seattle Angina Questionnaire (SAQ) scores. SAQ was measured in hospital and at follow-up; meanwhile, volume/type of habitual exercise, major adverse cardiovascular event (MACE), and its components of target vessel revascularization, myocardial infarction, and cardiac death were recorded and analyzed.

Results

At median 583 (range 184–963) day follow-up, compared with controls, the CR group showed fewer patients not engaging in physical exercise (22 vs. 956, p < 0.05); more cumulative exercise time (h/week) (8.22 ± 6.17 h vs. 3.00 ± 1.65 h, p < 0.05); higher SAQ scores (physical limitation, 69.59 ± 10.96 vs. 57.49 ± 7.19; anginal stability, 80.50 ± 18.21 vs. 58.82 ± 11.95; anginal frequency, 78.58 ± 11.07 vs. 67.14 ± 22.41; treatment satisfaction, 82.33 ± 13.21 vs. 56.84 ± 21.61; quality of life, 68.69 ± 18.33 vs. 60.26 ± 17.13, all p < 0.01), but a similar MACE rate (log-rank p = 0.621).

Conclusion

Compared with only routine post-procedure education, CR combining at least one-time CPET with a systematic cardiac education program before discharge improved engagement in physical activity and quality of life for patients after percutaneous coronary intervention (PCI) without increasing clinical adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01871-y.

Cardiopulmonary exercise test in myocardial ischemia detection

Exercise electrocardiography has low sensitivity for detection of myocardial ischemia. However, when combined with cardiopulmonary exercise testing (CPEX), the sensitivity and specificity of ischemia detection improves significantly. CPEX offers unique advantages over imaging techniques in tricky situations such as balanced ischemia. Early abnormal oxygen uptake would point toward profound coronary stenosis that could be missed in perfusion imaging. CPEX could be an invaluable tool in asymptomatic left bundle branch block pattern, without exposing patients to the risks of computerized tomography or invasive coronary angiography. Normal oxygen uptake curves would rule out significant coronary stenosis as the cause of left bundle branch block pattern. Elseways, abnormal oxygen uptake in patients with normal coronary arteries could indicate microvascular angina. Furthermore, exercise capacity is an excellent predictor of cardiovascular risk in those with and without heart disease. Using two clinical cases we introduce the concept of gas-exchange and hemodynamic changes encountered in ischemic heart disease.

A practical clinical approach to utilize cardiopulmonary exercise testing in the evaluation and management of coronary artery disease: a primer for cardiologists

PURPOSE OF REVIEW

There is growing clinical interest for the use of cardiopulmonary exercise testing (CPET) to evaluate patients with or suspected coronary artery disease (CAD). With mounting evidence, this concise review with relevant teaching cases helps to illustrate how to integrate CPET data into real world patient care.

RECENT FINDINGS

CPET provides a novel and purely physiological basis to identify cardiac dysfunction in symptomatic patients with both obstructive-CAD and nonobstructive-CAD (NO-CAD). In many cases, abnormal cardiac response on CPET may be the only objective evidence of potentially undertreated ischemic heart disease. When symptomatic patients have NO-CAD on coronary angiogram, they are still at increased risk for cardiovascular events. This problem appears to be more common in women than men and may warrant more aggressive risk factor modification. As the main intervention is lifestyle (diet, smoking cessation, exercise) and medical therapy (statins, angiotensin-converting enzyme inhibitors, beta-blockers), serial CPET testing enables close surveillance of cardiovascular function and is responsive to clinical status.

SUMMARY

CPET can enhance outpatient evaluation and management of CAD. Diagnostically, it can help to identify physiologically significant obstructive-CAD and NO-CAD in patients with normal routine cardiac testing. CPET may be of particular value in symptomatic women with NO-CAD. Prognostically, precise quantification of improvements in exercise capacity may help to improve long-term lifestyle and medication adherence for this chronic condition.