Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

Protocol for a multicentre, prospective observational cohort study in Japan: association among hospital-acquired disability, regular exercise and long-term care dependency in older patients after cardiac surgery

INTRODUCTION

Cardiac surgery for older patients, postoperative functional decline and the need for long-term care have received increasing attention as essential outcomes in recent years. Therefore, prevention of functional decline and long-term care dependency after cardiac surgery are important; however, our current understanding of postoperative functional trajectory and effects of postoperative regular exercise on long-term functional decline and long-term care dependency is limited. Therefore, we will conduct a multicentre, prospective cohort study to (1) examine the effect of hospital-acquired disability on long-term functional decline and long-term care dependency and (2) investigate the favourable effect of postoperative regular exercise on long-term functional decline and long-term care dependency in older patients after cardiac surgery.

METHODS AND ANALYSIS

We designed a prospective, multicentre cohort study to enrol older patients aged≥65 years undergoing elective coronary artery bypass graft or valve surgery. We will conduct medical record reviews to collect data on patient demographics, comorbidities, operative details, progression of in-hospital postoperative cardiac rehabilitation and functional trajectory from a few days before cardiac surgery to the day before hospital discharge. They will be followed up for 2 years to obtain information on their health status including functional status, regular exercise and clinical events by mail. Primary endpoints of this study are long-term functional decline and long-term care dependency after cardiac surgery. Secondary endpoints are readmission due to cardiac events or all-cause mortality.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Department of Physical Therapy, Faculty of Health Science, Juntendo University, and of each collaborating hospital. We obtained written informed consent from all study participants after the description of the study procedures. Publication of the study results is anticipated in 2025.

Association between physical activity and changes in renal function in patients after acute myocardial infarction: A dual-center prospective study

BACKGROUND

Acute myocardial infarction (AMI) causes a decline in renal function. This study aimed to elucidate the longitudinal association between physical activity levels and changes in renal function up to 6 months after the onset of AMI.

METHODS

In this dual-center prospective observational study, 73 AMI patients (67 men; average age, 65.0±11.7 years) were enrolled from 2017 to 2019. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 and 6 months post-discharge. The renal function was evaluated based on cystatin C-based estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 6 months post-discharge. Generalized estimating equation (GEE) models were used to test the longitudinal association between physical activity levels and within-patient changes in eGFRcys. Both GEE models with a follow-up period of 3 and 6 months were constructed to assess the effects of the passage of time.

RESULTS

Patients were stratified into the low (n=36; 2903±1187 steps/day) and high groups (n=37; 7988±3192 steps/day) based on the median number of steps. Both GEE models at the 3- (p=0.027) and 6-month follow-up (p=0.034) showed a significant positive association between the physical activity levels and within-patient changes in eGFRcys. The changes in eGFRcys at 6 months were -0.3 mL/min/1.73 m² and +4.4 mL/min/1.73 m² among the low and high group participants, respectively.

CONCLUSIONS

There was a significant positive association between physical activity and renal function changes after the onset of AMI, which persisted when the follow-up period was extended from 3 to 6 months. Our findings support the importance of interventions that enable maintaining high physical activity levels as a strategy for preserving renal function in AMI patients.

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

Current Status and Effect of Outpatient Cardiac Rehabilitation After Percutaneous Coronary Intervention in Japan

Background: Although cardiac rehabilitation (CR) has been reported to be associated with better clinical outcomes in patients with cardiovascular diseases, there are few nationwide studies about CR participation by patients with coronary artery disease in Japan.

Methods and Results: We performed a nationwide retrospective cohort study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan between April 2014 and March 2018. Patients were divided into 2 groups (acute coronary syndrome [ACS] and stable coronary artery disease [sCAD]), and the rates of participation in in- and outpatient CR after percutaneous coronary intervention (PCI) were investigated. Propensity score-matched analysis was performed and the association between outpatient CR participation and all-cause mortality 3 months after PCI was examined. Overall, 616,664 patients (ACS, n=202,853; sCAD, n=413,811) were analyzed. The participation rates of CR increased annually. The participation rate was higher for inpatient than outpatient CR in both the ACS (52% vs. 9%, respectively) and sCAD (15% vs. 3%, respectively) groups. Prognosis was better for patients with than without outpatient CR in both the ACS (hazard ratio [HR] 0.52; 95% confidence interval [CI] 0.47–0.59) and sCAD (HR 0.72; 95% CI 0.65–0.80) groups.

Conclusions: Outpatient CR was associated with a better prognosis in patients with ACS or sCAD. The participation rates of outpatient CR following PCI were extremely low in Japan.

Cardiology Department Practices in the First Wave of the Coronavirus Disease Pandemic - A Nationwide Survey in Japan by the Japanese Circulation Society

Background: From the early phase of the Coronavirus disease-2019 (COVID-19) pandemic, cardiologists have paid attention not only to COVID-19-associated cardiovascular sequelae, but also to treatment strategies for rescheduling non-urgent procedures. The chief objective of this study was to explore confirmed COVID-19 cardiology case experiences and departmental policies, and their regional heterogeneity in Japan. Methods and Results: We performed a retrospective analysis of a nationwide survey performed by the Japanese Circulation Society on April 13, 2020. The questionnaire included cardiology department experience with confirmed COVID-19 cases and restriction policies, and was sent to 1,360 certified cardiology training hospitals. Descriptive analysis and spatial autocorrelation analysis of each response were performed to reveal the heterogeneity of departmental policies. The response rate was 56.8% (773 replies). Only 16% of all responding hospitals experienced a COVID-19 cardiology case. High-risk procedures were restricted in more than one-fifth of hospitals, including transesophageal echocardiography (34.9%) and scheduled catheterization (39.5%). The presence of a cardiologist in the COVID-19 team, the number of board-certified cardiologists, any medical resource shortage and a state of emergency were positively correlated with any type of restriction. Conclusions: We found both low clinical case experiences with COVID-19 and restrictions of cardiovascular procedures during the first COVID-19 wave in Japan. Restrictions arising as a result of COVID-19 were affected by hospital- and country-level variables, such as a state of emergency.

Cardiology Department Policy in Japan After Coronavirus Disease-2019 (COVID-19) - Descriptive Summary of 2nd Nationwide Survey by the Japanese Circulation Society

Background: Cardiovascular department restriction policies on procedures resulting from the COVID-19 pandemic have not been fully evaluated. Methods and Results: We performed a retrospective analysis of a nationwide survey performed by the Japanese Circulation Society in August 2020. The total response rate was 48.9% (651/1,331). The rate of restriction of cardiovascular procedures peaked in April. Exacerbations of heart failure due to hospital restrictions were noted in 43.8% of departments. Conclusions: Many departments restricted their cardiological procedures, and this rate changed according to the pandemic situation. The exacerbation of cardiovascular disease resulting from pandemic restrictions should not be ignored.

Association between physical activity and change in renal function in patients after acute myocardial infarction

BACKGROUND

Combined renal dysfunction worsens the subsequent prognosis in patients after acute myocardial infarction (AMI). Therefore, establishing a therapeutic modality to maintain or improve renal function in AMI patients is necessary. This study aimed to elucidate the association between physical activity level and change in renal function in such patients.

DESIGN

Prospective and observational study.

METHODS

We enrolled 41 patients (35 men; average age, 67.5 ± 12.6 years) after AMI onset. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 months after discharge. Renal function was evaluated based on cystatin C based-estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 3 months post-discharge. Generalized estimating equations (GEE) was used to test the association between physical activity level and within-patient changes in eGFRcys.

RESULTS

Patients were stratified into low (n = 21; number of steps, 2335 ± 1219 steps/day) and high groups (n = 20; number of steps, 7102 ± 2365 steps/day). eGFRcys significantly increased from baseline to after 3 months in the high group (76.5 ± 13.8 to 83.2 ± 16.0 mL/min/1.73 m2, q = 0.004), whereas no significant change was observed in the low group (65.1 ± 15.9 to 62.2 ± 20.2 mL/min/1.73 m2, q = 0.125). Result of GEE adjusted for potential confounding variables showed a significant positive association between physical activity level and within-patient changes in eGFRcys (p = 0.003). Changes in eGFRcys was -2.9 mL/min/1.73 m2 among low group versus +6.7 mL/min/1.73 m2 among high group.

CONCLUSIONS

Physical activity level was positively associated with changes in renal function, demonstrating that high physical activity may suppress renal function decline in patients after AMI.

Clinical outcomes after acute myocardial infarction according to a novel stratification system linked to a rehabilitation program

BACKGROUND

A risk classification of acute myocardial infarction (AMI) linked to a rehabilitation program has not been established.

METHODS

We allocated 292 patients with AMI into the low- (L) (n=108), intermediate- (I) (n=72), and high- (H) (n=112) risk groups according to our original risk classification. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death, non-fatal AMI, stent thrombosis, and ischemia-driven target vessel revascularization. The mean follow-up period was 252 days.

RESULTS

The length of coronary care unit (CCU) stay and hospital stay was shortest in the L-risk group (CCU stay, 1.0±1.0 days; hospital stay, 5.6±3.2 days), followed by the I-risk group (CCU stay, 2.3±1.8 days; hospital stay, 8.1±2.7 days), and longest in the H-risk group (CCU stay, 5.1±5.0 days; hospital stay, 14.6±12.6 days) (p<0.001). MACE were most frequently observed in the H-risk group (26.8%), followed by the I-risk group (5.6%), and least in the L-risk group (1.9%) (p<0.001).

CONCLUSIONS

The lengths of hospital stay and CCU stay were significantly shortest in the L-risk group, followed by the I-risk group, and longest in the H-risk group. MACE were most frequently observed in the H-risk group, followed by the I-risk group, and least in the L-risk group. These results support the validity of our new classification system.

A Review of Cardiac Rehabilitation Delivery Around the World

Herein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases. Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.