Current Evidence and Future Directions of Omega-3 Supplementation and Cardiovascular Disease Risk

Omega-3 supplementation has a controversial role in the secondary prevention of cardiovascular diseases. Despite large clinical trials published over the years, the evidence of omega-3 in preventing cardiovascular diseases, especially coronary heart disease, is still inconclusive. However, recent clinical trials using higher dose of omega-3 or highly purified esters of omega-3 shows promising result, with reduction in cardiovascular death and incidence of cardiovascular disease. This review aims to summarize the possible mechanism of omega-3 in preventing cardiovascular disease and future directions of research regarding the benefit of omega-3 in cardiovascular disease.

The effect of resistance training on PCSK9 levels in patients undergoing cardiac rehabilitation after coronary artery bypass grafting: a randomized study

BACKGROUND

Resistance training is commonly recommended as part of secondary prevention for post-coronary artery bypass graft (CABG) patients in conjunction with aerobic exercise. Despite its potential benefits, there is currently a lack of studies investigating the impact of resistance training on proprotein convertase subtilisin kexin 9 (PCSK9).

AIM

To evaluate the effect of intensive resistance training on proprotein convertase subtilisin kexin 9 (PCSK9) levels among post-CABG patients undergoing cardiac rehabilitation (CR).

METHODS

In this prospective, open-label, randomized trial, 87 post-coronary artery bypass graft (CABG) patients were randomly assigned into two groups: moderate to high intensity resistance training and aerobic training (n = 44) or aerobic training alone (n = 43) for a total of 12 sessions. Changes in PCSK9 levels was determined as a primary endpoint, while secondary endpoints included changes in the six-minute walk test (6-MWT) results, aerobic capacity, WHO-5 well-being index, fasting blood glucose, and lipid profile. Both groups underwent intention-to-treat analysis.

RESULTS

Following completion of cardiac rehabilitation program, the intervention group demonstrated a significant decrease in mean PCSK9 levels when compared to the control group (β = -55 ng/ml, 95% CI -6.7 to -103.3, p = 0.026), as well as significant improvements in the 6-MWT result (β = 28.2 m, 95% CI 2.4-53.9, p = 0.033), aerobic capacity (β = 0.9 Mets, 95% CI 0.1-1.7, p = 0.021), and WHO-5 well-being index (β = 8.1, 95% CI 2.0-14.4, p = 0.011) in patients who received resistance and aerobic training. No statistically significant changes were observed in fasting blood glucose, cholesterol, LDL-C, HDL-C, and triglyceride levels.

CONCLUSION

Resistance training in CR significantly reduced PCSK-9 levels and increases patient's functional capacity and quality of life. (NCT02674659 04/02/2016).

Smartphone-Based Cardiac Rehabilitation Program Improves Functional Capacity in Coronary Heart Disease Patients: A Systematic Review and Meta-Analysis

Cardiac rehabilitation (CR) reduces mortality and morbidity in coronary heart disease (CHD); however, patients show a lack of adherence to CR. Alternatively, telehealth interventions have shown promising results for improving target outcomes in CR. This study aimed to review the effect of smartphone-based CR on the functional capacity of CHD patients. A literature search was performed using PubMed, MEDLINE, Embase, and Cochrane Library on 21 March, 2022 to find randomised controlled trials on smartphone usage in CR to improve functional capacity. Outcomes included maximal oxygen consumption (VO2 max), a 6-min walk test (6-MWT), quality of life, smoking cessation, and modifiable risk factors. Eleven trials recruiting CHD patients were reviewed. Wearable devices connected to smartphone- or chat-based applications were commonly used for CR delivery. Most trials managed to provide exercise prescriptions, education on medication adherence and controlling risk factors, and psychosocial counselling through the intervention. Functional capacity improved significantly following smartphone-based CR in CHD patients compared to control groups, as measured by VO2 max and 6-MWT; patients were more likely to quit smoking. Compared to traditional care, smartphones that delivered CR to CHD patients demonstrate superior outcomes regarding increasing functional capacity. There is no significant improvement on lipid profile, blood pressure, HbA1C, body mass index, and quality of life. It can be used either alone or as an adjunct. Ultimately, the patients' preferences and circumstances should be considered.

Anti-Inflammatory, Antioxidant, Metabolic and Gut Microbiota Modulation Activities of Probiotic in Cardiac Remodeling Condition: Evidence from Systematic Study and Meta-Analysis of Randomized Controlled Trials

Heart failure (HF) is a global pandemic with increasing prevalence and mortality rates annually. Its main cause is myocardial infarction (MI), followed by rapid cardiac remodeling. Several clinical studies have shown that probiotics can improve the quality of life and reduce cardiovascular risk factors. This systematic review and meta-analysis aimed to investigate the effectiveness of probiotics in preventing HF caused by a MI according to a prospectively registered protocol (PROSPERO: CRD42023388870). Four independent evaluators independently extracted the data using predefined extraction forms and evaluated the eligibility and accuracy of the studies. A total of six studies consisting of 366 participants were included in the systematic review. Probiotics are not significant in intervening left ventricular ejection fraction (LVEF) and high-sensitivity C-reactive protein (hs-CRP) when compared between the intervention group and the control group due to inadequate studies supporting its efficacy. Among sarcopenia indexes, hand grip strength (HGS) showed robust correlations with the Wnt biomarkers (p < 0.05), improved short physical performance battery (SPPB) scores were also strongly correlated with Dickkopf-related protein (Dkk)-3, followed by Dkk-1, and sterol regulatory element-binding protein 1 (SREBP-1) (p < 0.05). The probiotic group showed improvement in total cholesterol (p = 0.01) and uric acid (p = 0.014) compared to the baseline. Finally, probiotic supplements may be an anti-inflammatory, antioxidant, metabolic, and intestinal microbiota modulator in cardiac remodeling conditions. Probiotics have great potential to attenuate cardiac remodeling in HF or post-MI patients while also enhancing the Wnt signaling pathway which can improve sarcopenia under such conditions.

Gender Differences of Gly972Arg Polymorphism of the IRS-1 Gene Related to Cardiovascular Disease Risk Factors Among Indonesians

BACKGROUND

Cardiovascular disease is driven by traditional risk factors, sex, and genetic differences. The Asian population, specifically Indonesians, has been known at high risk of insulin resistance and endothelial dysfunction. A possible genetic risk factor related to cardiovascular diseases is Gly972Arg polymorphism of insulin receptor substrate 1 (IRS-1) gene, as this impairs endothelial function. To date, whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians is unknown. This study aimed to to define whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians.

METHODS

We studied adults living in two areas (rural and urban) in Indonesia. We collected demographic and clinical data from the study subjects. Gly972Arg polymorphism of the IRS-1 gene (rs1801278) was detected using TaqMan real-time polymerase chain reaction.

RESULTS

A total of 378 subjects were recruited. The wild-type allele (CC) was found in 86 (22.8%) subjects, heterozygous mutant allele (CT) in 245 (64.8%), and homozygous mutant allele in 47 (12.4%). The proportion of subjects with T alleles was significantly higher among women than men (54.6% vs. 45.4%, odds ratio: 1.89; p = 0.01). Subjects with T allele more often have hypertension (odds ratio: 1.69, p = 0.058).

CONCLUSION

There were a higher proportion of women than men carrying the T allele of Gly972Arg polymorphism among Indonesians. Individuals with the T allele appeared to show a greater prevalence of hypertension. These results may explain a possible mechanism of the high prevalence of metabolic syndrome in Indonesia, especially in women.

Cardiac rehabilitation results among patients who have undergone cardiac surgery after covid-19 infection

Funding Acknowledgements

Type of funding sources: None.

Background

Coronavirus disease 2019 (Covid-19) has become a global pandemic. Covid-19 increases morbidity in patients with underlying cardiovascular disease. The six-minute walk test (6MWT) is a simple test for assessing cardiopulmonary fitness and has been applied to assess post-surgical recovery in cardiac populations. Decreased heart rate recovery (HRR) over 1 or 2 minutes after exercise shows autonomic dysfunction and is associated with an increased risk of mortality. We conducted a cross sectional study to determine if Covid-19 affects cardiac rehabilitation parameters, such as 6MWT distance, HRR-1, and HRR-2 among patients who have undergone cardiac surgery.

Methods

This analysis included 155 adults who had elective cardiac surgery at the National Heart Center Harapan Kita (NHCHK) from January to June 2022. Each participant performed a 6MWT and treadmill evaluation in phase II cardiac rehabilitation (CR) program. To analyze the association of 6mwt distances and heart rate recovery among patients with covid-19 and without covid-19 who had undergone elective cardiac surgery using Mann Whitney and Chi-Square tests.

Results

Forty-Seven (30.3%) patients had a history of Covid-19. The mean 6MWT was 339.53 ± 59.90 m in the pre-CR program, increased to 415.37 ± 46.46 m in the post-CR program. The mean HRR1 was 15.16 ± 9.44, and HRR2 was 56.59± 35.47. There were no differences in 6MWT distance, HRR1, and HRR2 among patients with a history of Covid-19 and without a history of Covid-19 (P= 0.48, p=0.56, p=0.12).

Conclusion

The cardiac rehabilitation (CR) program improves the 6MWT distance. Covid-19 does not affect the ability of patients to do six-minute walk tests; neither HRR-1 nor HRR-2 among patients who have undergone cardiac surgery.

The impact of diabetes mellitus on improvement of resting rate pressure product in patients with refractory angina undergone external counter pulsation

Funding Acknowledgements

Type of funding sources: None.

Background

The management of coronary artery disease (CAD) has developed significantly in the last few decades. One of the therapeutic modalities that could be considered to patients with refractory angina caused by CAD is external counter pulsation (ECP). Rate pressure product (RPP) is a determinant of cardiac oxygen consumption and heart workload. It is a simple parameter that could be calculated easily by multiplying systolic blood pressure and heart rate. Increased resting RPP is associated with higher myocardial oxygen consumption and decreased cardiac efficiency. Studies that discuss factors that influence the decrease of resting RPP due to ECP procedure as a possible mechanism underlying the improvement of clinical symptoms in patients with refractory angina are still very limited.

Purpose

This study aimed to determine the impact of diabetes mellitus (DM) as one of most common risk factors for complex CAD and refractory angina on the decremental of resting RPP in refractory angina patients who have undergone standard 35 sessions of ECP.

Methods

This is a cohort retrospective study that collected data from registry of all patients who have completed 35 sessions of ECP procedures from 2018 until 2021. We compared the improvement of resting RPP after program completion and evaluated the effect of DM and blood glucose levels on the difference in resting RPP. Statistical test was performed by SPSS software for windows.

Results

A total of 16 patients were enrolled in this study with mean age of 65.4 years old. Subjects in this study were predominantly male (87.5%) and most of the subjects (68.8%) were diagnosed with CAD/3-vessels disease (3VD). The main risk factors found in the subjects were hypertension (75%) and DM (62.5%). All subjects underwent random blood sugar examination before starting ECP procedure with mean 122.7 mg/dL. Paired samples T-test analysis found that there was a decrease in resting RPP in subjects after undergoing ECP compared to before the procedure (7046.1 ± 1515.3 vs 8572.5 ± 1915.7; p-value &lt;0.001). Independent samples T-test showed that the presence of DM reduced the mean decrease of resting RPP in study subjects (1034.8 ± 1122.2 vs 2345.7 ± 1167.5; p-value 0.043). Pearson correlation analysis showed that there was no significant correlation between blood sugar levels and decrease in resting RPP after ECP completion in study subjects (correlation coefficient -0.049; p-value: 0.869).

Conclusion

Standard 35 ECP sessions could decrease resting RPP in refractory angina patients. The improvements may contribute to the clinical benefit of ECP. However, the presence of DM can reduce the effectiveness of ECP in improving resting RPP, regardless of the blood sugar levels. These findings were probably related to cardiovascular autonomic neuropathy that were commonly found among diabetics. Further research is needed to elucidate the exact underlying mechanisms of these outcomes.

A Novel Peptide Elabela is Associated with Hypertension-Related Subclinical Atherosclerosis

INTRODUCTION

Elabela is a newly identified peptide which, alongside apelin, acts as an endogenous ligand that activates the angiotensin receptor-like 1 receptor. Previous studies have shown the association of elabela with hypertension, but information about the role of elabela in hypertension-related subclinical atherosclerosis is scarce.

AIM

We aimed to determine the elabela levels in hypertensive patients and explore its association with subclinical atherosclerosis.

METHODS

A total of 104 subjects with hypertension were included in the study. Elabela levels were measured using an enzyme-linked immunosorbent assay, by first extracting the peptide following the manufacturer's instructions. Subclinical atherosclerosis was assessed by measuring the carotid intima-media thickness (IMT) using ultrasound.

RESULTS

Compared to stage 1, elabela levels decreased in stage 2 hypertension (0.23 [0.13, 0.45] ng/ml vs. 0.14 [0.09, 0.23] ng/ml; P = 0.000), and in the group with increased carotid IMT compared to normal IMT (0.24 [0.13, 0.38] ng/ml vs. 0.15 [0.10, 0.23] ng/ml; P = 0.005). Additionally, a linear correlation analysis showed that elabela had a significant negative correlation with systolic blood pressure (r = - 0.340, P = 0.000) and carotid IMT (r = - 0.213; P = 0.030). In multivariate analysis, lower elabela levels were associated with a higher cardiovascular risk group in this study (OR 5.0, 95% CI 1.8-13.5, P < 0.001).

CONCLUSIONS

This study demonstrated for the first time that circulating elabela declined in a higher stage of hypertension and hypertensive patients with increased carotid IMT, implicating that elabela may be involved in the pathogenesis of hypertension-associated subclinical atherosclerosis.

Endothelin-1 negatively correlates with functional capacity in patients with breast cancer receiving first line anthracycline-based chemotherapy

Funding Acknowledgements

Type of funding sources: None.

Background

Endothelial dysfunction caused by anthracycline is one of the key mechanism of chemotherapy induced cardiomyopathy that ultimately resulted in heart remodeling and exercise limitations. An endothelial molecular factor Endothelin-1 (ET-1) is known to be extremely important in vasoconstriction and angiogenesis. Interestingly, ET-1 concentration is also altered in vascular injury following anthracycline administration suggesting a distinct association. Nonetheless, the correlation between ET-1 and functional capacity in chemotherapy induced cardiomyopathy remained largely unknown.

Purpose

To elucidate correlation between ET-1 serum concentration with left ventricular (LV) function and functional capacity using echocardiography and 6 minute walk test (6MWT) following anthracycline-based chemotherapy in patient with breast cancer.

Methods

This is a prospective study that involves 19 female participants diagnosed with breast cancer (stage IIA-IV) receiving first line chemotherapy with 4-8 cycles of anthracycline-based regiments. Baseline pre-chemotherapy characteristics, ET-1 serum concentration, echocardiography and 6MWT, followed by post-chemotherapy evaluation were measured. Additionally, 6MWT were also performed at 6 months and 12 months after completion of chemotherapy.

Results

ET-1 serum significantly increased post-chemotherapy (1.521±0.57 vs 1.817±0.52 pg/mL, p=0.0169) in comparison with baseline. 6MWT distance was decreased after initial pre-chemotherapy measurement (372.5±84.23), 366.8±51.96 and 358.5±51.97 post-chemotherapy and 6 months after chemotherapy completion respectively. Moreover, post-chemotherapy LV ejection fraction (LVEF) was significantly lower in high ET-1 group (≥ 1.817 pg/mL) as compared to patients with low ET-1 (70.39±3.75 vs 65.80±2.49, p=0.0465) regardless comparable baseline LVEF. In addition, Pearson’s correlation test displayed a tendency of negative correlation between post chemotherapy ET-1 with 6MWT distance post-chemotherapy and 6 months after chemotherapy completion (r = -0.264, p=0.2745, 95% CI = -0.64-0.22 and r = -0.172, p=0.4803, 95% CI = -0.58-0.3).

Conclusion

Collectively, these findings strongly suggest that ET-1 may serve as a novel biomarker to predict compromised functional capacity in cancer patients underwent chemotherapy, arguably requires further investigations.

Asian Pacific Society of Cardiology Consensus Recommendations for Pre-participation Screening in Young Competitive Athletes

Sports-related sudden cardiac death is a rare but devastating consequence of sports participation. Certain pathologies underlying sports-related sudden cardiac death could have been picked up pre-participation and the affected athletes advised on appropriate preventive measures and/or suitability for training or competition. However, mass screening efforts - especially in healthy young populations - are fraught with challenges, most notably the need to balance scarce medical resources and sustainability of such screening programmes, in healthcare systems that are already stretched. Given the rising trend of young sports participants across the Asia-Pacific region, the working group of the Asian Pacific Society of Cardiology (APSC) developed a sports classification system that incorporates dynamic and static components of various sports, with deliberate integration of sports events unique to the Asia-Pacific region. The APSC expert panel reviewed and appraised using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed, which were then put to an online vote. Consensus was reached when 80% of votes for a recommendation were agree or neutral. The resulting statements described here provide guidance on the need for cardiovascular pre-participation screening for young competitive athletes based on the intensity of sports they engage in.

C23. CARDIAC REHABILITATION AFTER CONGENITAL HEART DISEASE SURGERY

Background

The survival rates of children with congenital heart disease (CHD) have dramatically increased due to the contribution of advance in medical and surgical care. Nonetheless, patients often have decreased exercise capacity and health-related issues that affect their quality of life. Cardiac rehabilitation programs in patients after CHD surgery have shown improvement in peak-VO2 and cardio respiratory fitness . Paradoxically, only a minority of CHD patients receives formal cardiac rehabilitation and are often encouraged towards a sedentary lifestyle as a result of overprotection and uncertainty as to which physical activities and with what intensity should be recommended. We therefore present case report about cardiac rehabilitation after CHD surgery based on current evidence to show the importance and benefit in CHD patient

Case Illustration

A 17 years old female patient came to Rehab clinic after Valve replacement and ASD surgical closure for severe mitral and tricuspid regurgitation, ASD secundum and Cor triatiatum. Her last stay in hospital was prolonged due to several complications. Her appearance was frail and she even was not able to walk. After a thorough examination and 6 minutes walk test, she went phase II rehabilitation. After Cardiac rehabilitation, she got better and her cardio respiratory fitness was improved. Based on her result in 6 minutes walk test and calculation, She was capable to do daily activity life on her own and ready to continue phase III rehabilitation.

Discussion

Patient who have underwent cardiac rehabilitation after congenital heart disease surgery have been presented. Systematic Examination should be performed prior cardiac rehabilitation in order to give an individualized exercise prescription.

C23. CARDIAC REHABILITATION AFTER CONGENITAL HEART DISEASE SURGERY

Background

The survival rates of children with congenital heart disease (CHD) have dramatically increased due to the contribution of advance in medical and surgical care. Nonetheless, patients often have decreased exercise capacity and health-related issues that affect their quality of life. Cardiac rehabilitation programs in patients after CHD surgery have shown improvement in peak-VO2 and cardio respiratory fitness . Paradoxically, only a minority of CHD patients receives formal cardiac rehabilitation and are often encouraged towards a sedentary lifestyle as a result of overprotection and uncertainty as to which physical activities and with what intensity should be recommended. We therefore present case report about cardiac rehabilitation after CHD surgery based on current evidence to show the importance and benefit in CHD patient

Case Illustration

A 17 years old female patient came to Rehab clinic after Valve replacement and ASD surgical closure for severe mitral and tricuspid regurgitation, ASD secundum and Cor triatiatum. Her last stay in hospital was prolonged due to several complications. Her appearance was frail and she even was not able to walk. After a thorough examination and 6 minutes walk test, she went phase II rehabilitation. After Cardiac rehabilitation, she got better and her cardio respiratory fitness was improved. Based on her result in 6 minutes walk test and calculation, She was capable to do daily activity life on her own and ready to continue phase III rehabilitation.

Discussion

Patient who have underwent cardiac rehabilitation after congenital heart disease surgery have been presented. Systematic Examination should be performed prior cardiac rehabilitation in order to give an individualized exercise prescription.

External Counterpulsation Improves Angiogenesis by Preserving Vascular Endothelial Growth Factor-A and Vascular Endothelial Growth Factor Receptor-2 but Not Regulating MicroRNA-92a Expression in Patients With Refractory Angina

Objective: External counterpulsation (ECP) provides long-term benefits of improved anginal frequency and exercise tolerance in patients with refractory angina (RA). This is postulated as a result of improved angiogenesis and endothelial function through an increase in shear stress. Angiogenesis is mainly represented by vascular endothelial growth factor-A (VEGF-A) and its receptor, vascular endothelial growth factor receptor-2 (VEGFR-2). The microRNA-92a (miR-92a) is a flow-sensitive miRNA that regulates atherosclerosis and angiogenesis in response to shear stress. Thus, ECP beneficial effect might be achieved through interaction between VEGF-A, VEGFR-2, and miR-92a. This study aims to evaluate the ECP effect on VEGF-A, VEGFR-2, and miR-92a in patients with RA in a sham-controlled manner. Methods: This was a randomized sham-controlled trial, enrolling 50 patients with RA who have coronary artery disease (CAD). Participants were randomized (1:1 ratio) to 35 sessions of either ECP (n = 25) or sham (n = 25), each session lasting for 1 h. Plasma levels of VEGF-A and VEGFR-2 were assayed by the ELISA technique. The quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was performed to measure miR-92a circulating levels in plasma. Result: External counterpulsation significantly preserved VEGF-A and VEGFR-2 level compared to sham [ΔVEGF-A: 1 (-139 to 160) vs.-136 (-237 to 67) pg/ml, p = 0.026; ΔVEGFR-2: -171(-844 to +1,166) vs. -517(-1,549 to +1,407) pg/ml, p = 0.021, respectively]. Circulating miR-92a increased significantly in ECP [5.1 (4.2-6.4) to 5.9 (4.8-6.4), p < 0.001] and sham [5.2 (4.1-9.4) to 5.6 (4.8-6.3), p = 0.008] post-intervention. The fold changes tended to be higher in ECP group, although was not statistically different from sham [fold changes ECP = 4.6 (0.3-36.5) vs. sham 2.8 (0-15), p = 0.33)]. Conclusion: External counterpulsation improved angiogenesis by preserving VEGF-A and VEGFR-2 levels. Both ECP and sham increased miR-92a significantly, yet the changes were not different between the two groups. (Study registered on www.clinicaltrials.gov, no: NCT03991871, August 8, 2019, and received a grant from the National Health Research and Development of Ministry of Health of Indonesia, No: HK.02.02/I/27/2020).

Randomised controlled trial into the role of ramipril in fibrosis reduction in rheumatic heart disease: the RamiRHeD trial protocol

INTRODUCTION

Rheumatic heart disease (RHD) is a major burden in developing countries and accounts for 80% of all people living with the disease, where it causes most cardiovascular morbidity and mortality in children and young adults. Chronic inflammation and fibrosis of heart valve tissue due to chronic inflammation in RHD will cause calcification and thickening of the impacted heart valves, especially the mitral valve. This fibrogenesis is enhanced by the production of angiotensin II by increased transforming growth factor β expression and later by the binding of interleukin-33, which is known to have antihypertrophic and antifibrotic effects, to soluble sST2. sST2 binding to this non-natural ligand worsens fibrosis. Therefore, we hypothesise that ACE inhibitors (ACEIs) would improve rheumatic mitral valve stenosis.

METHODS AND ANALYSIS

This is a single-centre, double-blind, placebo-controlled, randomised clinical trial with a pre-post test design. Patients with rheumatic mitral stenosis and valve dysfunction will be planned for cardiac valve replacement operation and will be given ramipril 5 mg or placebo for a minimum of 12 weeks before the surgery. The expression of ST2 in the mitral valve is considered to be representative of cardiac fibrosis. Mitral valve tissue will be stained by immunohistochemistry to ST2. Plasma ST2 will be measured by ELISA. This study is conducted in the Department of Cardiology and Vascular Medicine, Universitas Indonesia, National Cardiac Center Harapan Kita Hospital, Jakarta, Indonesia, starting on 27 June 2019.

ETHICS AND DISSEMINATION

The performance and dissemination of this study were approved by the ethics committee of National Cardiovascular Center Harapan Kita with ethical code LB.02.01/VII/286/KEP.009/2018.

TRIAL REGISTRATION NUMBER

NCT03991910.

Determinants and Prediction Equations of Six-Minute Walk Test Distance Immediately After Cardiac Surgery

Background: To date, there is no reference for a 6-min walk test distance (6-MWD) immediately after cardiac surgery. Therefore, this study aimed to identify the determinants and to generate equations for prediction reference for 6-MWD in patients immediately after cardiac surgery.

Methods: This is a cross-sectional study of the 6-min walk test (6-MWT) prior to participation in the cardiac rehabilitation (CR) program of patients after coronary artery bypass surgery (CABG) or valve surgery. The 6-MWT were carried out in a gymnasium prior to the CR program immediately after the cardiac surgery. Available demographic and clinical data of patients were analyzed to identify the clinical determinants of 6-MWD.

Results: This study obtained and analyzed the data of 1,509 patients after CABG and 632 patients after valve surgery. The 6-MWD of all patients was 321.5 ± 73.2 m (60–577). The distance was longer in the valve surgery group than that of patients in the CABG group (327.75 ± 70.5 vs. 313.59 ± 75.8 m, p < 0.001). The determinants which significantly influence the 6-MWD in the CABG group were age, gender, diabetes, atrial fibrillation, and body height, whereas in the valve surgery group these were age, gender, and atrial fibrillation. The multivariable regression models generated two formulas using the identified clinical determinants for patients after CABG: 6-MWD (meter) = 212.57 + 30.47 (if male gender) − 1.62 (age in year) + 1.09 (body height in cm) − 12.68 (if with diabetes) − 28.36 (if with atrial fibrillation), and for patients after valve surgery with the formula: 6-MWD (meter) = 371.05 + 37.98 (if male gender) − 1.36 (age in years) − 10.61 (if atrial with fibrillation).

Conclusion: This study identified several determinants for the 6-MWD and successively generated two reference equations for predicting 6-MWD in patients after CABG and valve surgery.

Case Report: Heparin-induced thrombocytopenia during COVID-19 outbreak: the importance of scoring system in differentiating with sepsis-induced coagulopathy

Background: COVID-19 disease is accompanied by derangement of coagulation with a risk of fatal thromboembolic formation. COVID-19 patients are among those indicative for heparin treatment. Increased heparin administration among COVID-19 patients increased heparin induced-thrombocytopenia's risk with/without thrombocytopenia. Case presentation: We present a 71-year-old male patient who came to the emergency room (ER) with a COVID-19 clinical manifestation followed by positive PCR nasopharyngeal swab result. He was assessed to have acute respiratory distress syndrome (ARDS), as shown by rapid progression of hypoxemic respiratory failure and bilateral pulmonary infiltrate. He was then treated with moxifloxacin, remdesivir, dexamethasone, unfractionated heparin (UFH) pump, and multivitamins. During admission, his respiratory symptoms got worse, so he transferred to the ICU for NIV support. On the ninth day of admission, he had gross hematuria followed by a rapid fall of platelet count. We used two different scoring systems (4Ts and HEP scoring system) to confirm the diagnosis of heparin-induced thrombocytopenia (HIT). Following the discontinuation of UFH injection, the thrombocyte continued to rise, and hematuria disappeared. Conclusion: Heparin-induced thrombocytopenia is associated with an increased risk of severe disease and mortality among COVID-19 patients. The differential diagnosis of HIT could be difficult as thrombocytopenia can also be caused by the progression of infection. We use two scoring systems (4Ts and HEP scoring) in order to help us managing the patient. These could improve the outcomes, thus avoiding morbidity and mortality.

Case Report: Heparin-induced thrombocytopenia during COVID-19 outbreak: the importance of scoring system in differentiating with sepsis-induced coagulopathy

Background: COVID-19 disease is accompanied by derangement of coagulation with a risk of fatal thromboembolic formation. COVID-19 patients are among those indicative for heparin treatment. Increased heparin administration among COVID-19 patients increased heparin induced-thrombocytopenia's risk with/without thrombocytopenia. Case presentation: We present a 71-year-old male patient who came to the emergency department (ED) with a COVID-19 clinical manifestation that PCR nasopharyngeal swab confirmed. He was assessed to have acute respiratory distress syndrome (ARDS), as shown by rapid progression of hypoxemic respiratory failure and bilateral pulmonary infiltrate. He was then treated with moxifloxacin, remdesivir, dexamethasone, heparin pump, and multivitamins. During admission, his respiratory symptoms got worse, so he transferred to the ICU for NIV support. On the ninth day of admission, he had gross hematuria followed by a rapid fall of platelet count. We used two different scoring systems (4Ts and HEP scoring system) to confirm the diagnosis of heparin-induced thrombocytopenia (HIT). Following the discontinuation of heparin injection, the thrombocyte continued to rise, and hematuria disappeared. Conclusion: Heparin-induced thrombocytopenia is associated with an increased risk of severe disease and mortality among COVID-19 patients. The differential diagnosis of HIT could be difficult among COVID-19 patients as thrombocytopenia can also be caused by infection progression. We use two scoring systems, 4Ts and HEP scoring, that can help us to manage the patient. With good management, we can avoid patient morbidity and mortality.

Exercise-based cardiac rehabilitation adaptation protocol during COVID-19 pandemic achieved similar results as compared to non-pandemic usual practice: a single-center retrospective study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Dr. Sardjito Hospital Funding

Background

During the COVID-19 pandemic, exercise-based cardiac rehabilitation (EBCR) faced challenges. Patients could not freely attend EBCR in hospital. In our hospital, cardiac rehabilitation (CR) service adapted to the pandemic condition by reducing to sessions per week. 

Purpose

This study aimed to investigate whether the adaptation protocol of EBCR during COVID-19 period influenced the CR result.

Methods

This was a retrospective cohort study. The subjects were patients underwent EBCR program in CR Service of our hospital. We retrieved the CR program registry and divided it into two periods, namely the non-pandemic period (January 2019 – February 2020) and the COVID-19 period (March 2020 – December 2020). During the non-pandemic period, subjects performed EBCR 3 times (@45 min) per week for 10-12 total sessions. During the COVID-19 period, the EBCR session was reduced 2 times (@45 min) per week for 10-12 total sessions. However, patients might modify the sessions provided space availability and acceptable reason. After total sessions were completed, the treadmill test evaluation was performed. We compared the duration and metabolic equivalent (METs) achieved in the treadmill test evaluation.

Results

There was nearly 50% reduction in patients who underwent EBCR during the COVID-19 pandemic (n = 48), compared to during the non-pandemic period (n = 96). Post septal defect closure (42.7% vs. 60.4%) and mitral valve surgery (35.4% vs. 29.2%) predominated subjects registered for EBCR during the non-pandemic and the COVID-19 period, whereas post CABG was the minority (4.2% vs. 4.2%). Among 144 registered subjects, majority completed EBCR sessions and underwent treadmill test evaluation (79 (82.3%) vs. 37 (77.1%) during the non-pandemic and the COVID-19 period). During the COVID-19 period, the most common sessions were 2 times per week (48.6%), followed by 5 times per week (32.4%), whereas during the non-pandemic period, 3 times per week was the most common (77.2%), followed by 5 times per week (19.0%) (p &lt; 0.001). Total sessions did not significantly differ between the non pandemic and the COVID-19 period. Total sessions also did not significantly differ among subjects undergoing 2 times per week, 3 times per week, and 5 times per week sessions. There was no difference in duration (7.1 ± 1.9 min vs. 6.6 ± 1.9 min, p = 0,136) and METs (7.5 ± 1.8 vs. 6.9 ± 1.9, p = 0.192) achieved on treadmill evaluation between subjects on two time periods. There was no significant difference in duration (6.9 ± 1.9 min, 7.0 ± 1.9 min and 6.8 ± 1.8 min)and METs (7.1 ± 1.9, 7.3 ± 1.7 and 7.4 ± 2.1) achieved on treadmill evaluation among subjects who underwent EBCR 2 times per week, 3 times per week and 5 times per week respectively.

Conclusion

The adaptation protocol of EBCR during the COVID-19 period by reducing sessions per week did not influence the duration and METs achieved on treadmill evaluation at the end of CR as compared to usual EBCR practice.

The Effects of Aerobic Exercise on N-terminal Pro-B-type Natriuretic Peptide and Cardiopulmonary Function in Patients With Heart Failure: A Meta-Analysis of Randomised Clinical Trials

BACKGROUND

Aerobic exercise (AEx) improves outcomes in heart failure (HF). N-terminal pro B-type natriuretic peptide (NT-pro-BNP) is a prognosticator in HF. There are few data on the association of AEx, NT-pro-BNP, and cardiopulmonary function; hence, robust evidence is needed. The aim of this study was to measure the effects of AEx on NT-pro-BNP levels and cardiopulmonary function in HF.

METHOD

Databases (Pubmed, EMBASE, Medline, Cochrane Central Registry, and Scopus) were systematically searched for randomised controlled trials (RCTs) that assessed the association of AEx with NT-pro-BNP and cardiopulmonary function (VE/VCO₂ slope, peak VO₂, maximal workload, and left ventricular ejection fraction [LVEF]) in HF. RevMan 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014) was used to produce forest plots, and the random-effect model was applied with the effects measure of weighted mean differences (WMD) and 95% confidence interval (CI).

RESULTS

Thirteen (13) RCTs recruited 1,503 patients and 1,494 controls. Aerobic exercise was significant in lowering NT-pro-BNP (pg/mL) compared with control group (WMD=-741.69, 95% CI -993.10 to -490.27 [p<0.00001; I²=63%]). VE/VCO₂ slope was also significantly reduced (WMD=-3.57, 95% CI -6.48 to -0.67 [p=0.02; I²=97%]). Peak VO₂ (mL/kg/min) significantly improved (WMD=3.68, 95% CI 2.39-4.96 [p<0.00001; I²=96%]). Maximal workload (watt) significantly increased following AEx (WMD=22.80, 95% CI 18.44-27.17 [p<0.00001; I²=78%]). Furthermore, there was a significant enhancement of LVEF (%) in the AEx group (WMD=2.42, 95% CI 0.64-4.19 [p=0.008; I²=71%]).

CONCLUSIONS

Aerobic exercise improves the NT-pro-BNP, ventilatory efficiency, aerobic capacity, maximal workload, and the left ventricular function in patients with HF.

Survival analysis of patients with rheumatic MS after PBMV compared with MVS in a low-to-middle-income country

Introduction

Rheumatic mitral stenosis continues to be prevalent in developing countries, notably in endemic areas. Over the last few decades, percutaneous balloon mitral valvuloplasty (PBMV) has been established as a lower-cost alternative treatment for mitral stenosis (MS) in low-to-middle-income countries. PBMV has also been suggested to be an effective and safe alternative treatment modality. This study aims to analyse the survival of rheumatic MS patients treated with PBMV compared with those treated with mitral valve surgery (MVS).

Methods

This study was a national, single-centre, longitudinal study using a survival analysis method in 329 consecutive patients suffering from rheumatic heart disease with severe MS who underwent PBMV compared with 142 consecutive patients with similar characteristics who underwent MVS between January 2011 and December 2016. Survival analysis and event-free duration were determined over a median follow-up of 24 months in the PBMV group and 27 months in the MVS group.

Results

The results showed that of the 329 consecutive patients in the PBMV group, 61 patients (18.5) had an event (6 patients died and 55 patients were hospitalised), and of the 142 consecutive patients in the MVS group, 19 patients (13.4%) had an event (5 patients died, and 14 patients were hospitalised). The hazard ratio was 0.631 (95% confidence interval, 0.376–1.058; P = 0.081). Longer short-term survival was found in the MVS group but was not statistically significant. Event-free survival was significantly longer in the MVS group (P = 0.002), by 5 months.

Conclusions

In this study, the efficacy and safety of PBMV was reconfirmed, as PBMV proved to be non-inferior to MVS in survival prognosis, but sustained event-free duration was significantly better in the MVS group than in the PBMV group.