Virtual cardiac rehabilitation during the COVID-19 pandemic: a tertiary site experience

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): University of British Columbia Clinician Investigator Program

Background

The COVID-19 pandemic resulted in the abrupt suspension of centre-based cardiac rehabilitation (CR). Multidisciplinary virtual CR (VCR) with the use of digital, telephone, and video communication was implemented for continued care access. Exercise therapy was delivered through synchronous video-supervised sessions, pre-recorded sessions, and self-directed physical activity.

Purpose

To describe patient characteristics, completion rates, and safety outcomes in a real-world VCR population.

Methods

Prospective observational study of a tertiary academic CR program. VCR was implemented at pandemic onset (March 2020). Patients who were enrolled in, and either completed or dropped out, during the study period were included. Completers were defined as completing 6 months of virtual enrolment and an exit assessment. Risk was defined by the AACPVR 2020 risk categorization. Adverse cardiovascular events were defined as a patient-initiated event requiring medical assessment and stratified as exercise or non-exercise related. Continuous variables are presented as means and SD or medians and IQR. Student’s t-test was used for between group comparisons. Categorical variables are presented as n (%) and compared using the χ2 test or Fischer’s exact test. A p-value <0.05 was considered significant.

Results

Between March 13th, 2020, and August 31st, 2021, 222 [mean age 61.8 years (SD, 12.6) 77% male], were enrolled and discharged from the VCR program (Table 1). There were 160 completers and 62 non-completers (completion rate 72%). Among the non-completers 26 attended the MD intake assessment only. The remaining 36 completed a median of 85 days (IQR 25-197). This cohort included 21 (9%) high-risk and 35 (16%) moderate risk patients. Those at moderate risk were more likely to be non-completers and those at low risk were more likely to be completers (Table 1). Two exercise and 17 non-exercise adverse events were observed (median clinical surveillance 217 days [IQR 205-240]) (Table 2). Exercise related adverse events included neurally mediated syncope during a synchronous video exercise session in a low risk patient. This was responded to as per centre developed virtual safety protocols. A second syncope related to heart block occurred in a moderate risk patient during independent physical activity and required permanent pacemaker insertion. Both patients completed the program. Three non-exercise adverse cardiac events resulted in cessation of participation included one death and two heart failure hospitalizations (Table 2). One stroke and 13 emergency department visits for cardiac symptoms occurred in completers.

Conclusion

Real world VCR is feasible, including in those at moderate to high risk. Modest completion rates and a low exercise related adverse event rate were observed. Synchronous video exercise sessions with video monitoring and safety protocols may improve response to adverse exercise related events.

Molecular and physiological effects of nesiritide

BACKGROUND

Nesiritide (Natrecor, Janssen-Ortho Inc, Canada), or recombinant human B-type natriurtic peptide (BNP), is a molecule identical in structure to endogenous BNP-32. This peptide is secreted from cardiac myocytes in response to volume and pressure overload. While high levels of circulating BNP are measured by commercially available assays during acute decompensated heart failure (ADHF), the detection of alternate, potentially more active, but undermeasured forms of BNP needs to be considered.

AIM

The present review summarizes the molecular and physiological effects of nesiritide in the setting of hospitalized patients with ADHF. In particular, an overview of the molecular structure and circulating isoforms of BNP is given, followed by a discussion of the vasodilatory, renal, antagonistic neurohormonal, pulmonary, anti-inflammatory and cardiac remodelling effects of recombinant human BNP.

SUMMARY

Nesiritide has beneficial effects in the treatment of ADHF that go beyond the traditional goals of reducing pulmonary capillary wedge pressure, preload and afterload, and relieving symptoms of dyspnea. Therefore, the unique pharmacological profile of this medication provides an additional treatment option for Canadian patients with ADHF.

Safety and Efficacy of Rosuvastatin Therapy for the Prevention of Hyperlipidemia in Adult Cardiac Transplant Recipients

BACKGROUND

Hyperlipidemia after orthotopic heart transplantation (OHT) is associated with immunosuppression. Many OHT patients have increased lipid levels above published guidelines despite treatment with high doses of statins. Treatment with rosuvastatin (ROS) in OHT patients has not yet been evaluated. Therefore, we assessed its efficacy and safety in an OHT population.

METHODS

Twenty-one OHT recipients, median age 66 years, whose lipid levels were sub-optimal on the highest tolerated doses of statins, received ROS in addition to standard immunosuppression. Total cholesterol (TC), low-density lipoprotein (LDL-C) and high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), liver transaminases (AST) and creatinine kinase (CK) were measured before and during treatment with ROS.

RESULTS

After 6 weeks on an average ROS dose of 10 mg/day, a TC:HDL-C ratio of <4 was reached in 76% of patients, and 70% of patients reached an LDL-C level of <2.5 mmol/liter (100 mg/dl). TC decreased to <5.2 mmol/liter (200 mg/dl) in 80% of patients and TG decreased to <2 mmol/liter (175 mg/dl) in 61% of patients. Except for the HDL-C increase, all changes were statistically significant. The decrease in the median TC:HDL-C ratio between baseline and 6 weeks was also statistically significant (p = 0.001). There were no significant changes in CK or AST levels, and no clinical evidence of myositis. One patient developed myalgia and 2 were withdrawn from the study because of mild elevation of CK (<3-fold upper limit of normal [ULN]).

CONCLUSIONS

In the setting of tertiary referral centers, ROS appears to be safe and effective in lowering LDL-C in OHT recipients in whom treatment with other statins failed to achieve target LDL-C. No evidence of liver or muscle dysfunction was noted. Long-term studies are needed to ascertain the effect of ROS therapy on incidence of coronary artery disease (CAD) in this population.