Breathing patterns and ventilatory efficiency in elderly cardiac patients with and without left ventricular dysfunction before and after exercise-based cardiac rehabilitation: the EU-CaRE study

Introduction

Coronary artery disease (CAD) may progress to left ventricular dysfunction (LVD) and chronic heart failure. A reduced ventilatory efficiency in these patients is associated with worse outcome. However, breathing patterns at rest and during exercise and their change during exercise-based cardiac rehabilitation (exCR) have been poorly described in this population. We aimed to analyse respiratory and gas-exchange parameters in elderly patients with CAD included in a multicentre study on effectiveness of exCR across seven European countries (EU-CaRE).

Methods

Patients aged 65 years and older with acute (ACS) and chronic coronary syndromes (CCS) who participated in exCR were included. Cardiopulmonary exercise testing (CPET) was performed before (T0) and at termination of exCR (T1), and 12 months after start of exCR (T2). Ventilation (VE), breathing frequency (BF), and end-expiratory carbon dioxide pressure (PetCO2) were measured at rest, at first ventilatory threshold and peak exercise. Ventilatory efficiency, expressed as VE/VCO2 slope and the nadir of VE/VCO2 ratio were measured during the ramp test. Peak oxygen uptake was averaged over 30 s. Breathing parameters over time were compared between patients without and with left ventricular dysfunction (LVD, defined as LV ejection fraction <45%) by mixed linear models corrected for age, sex and body mass index.

Results

818 out of 1633 patients of the EU-CaRE study fulfilled inclusion criteria, 151 (18%) had LVD, of these, 86% were in New York Heart Association (NYHA) functional class I. Mean age was 72.5±5.4 years, 21.9% were women, and 79.8% had acute ACS. Compared to patients without LVD, in patients with LVD resting VE was increased 9%, VE/VCO2 slope 14%, and nadir VE/VCO2 ratio 9%, while PetCO2 was reduced at rest and peak exercise by 6%. From before to after exCR, resting ventilation and breathing frequency, as well as VE/VCO2 slope and nadir VE/VCO2 during exercise decreased significantly more in patients with LVD compared to patients without, while improvement in peak oxygen uptake was similar (Figure 1).

Conclusions

In contrast to their own perception based on NYHA class, patients with LVD had exaggerated breathing at rest and as response to exercise with consistently reduced PetCO2 and ventilatory efficiency. Abnormal breathing patterns may be an early and clinically relevant sign of LVD and linked to increased chemosensitivity and/or abnormal ergoreflex. Exercise-based CR may contribute to improvements of breathing patterns and ventilator efficiency in this population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation program and Swiss State Secretariat for Education, Research and Innovation for the Swiss consortium partner

P6218Greater burden of risk factors and need of cardiac rehabilitation in elderly patients with lower educational attainment

Background

A socioeconomic gap in cardiac rehabilitation (CR) has been described in younger populations but whether this is also true in the ageing population is unknown.

Purpose

To describe if poorer education is a predictor for exercise capacity, comorbidity, lifestyle- and risk factors and medical treatment at baseline in CR in an elderly population.

Methods

The observational EU-CaRE study is a European prospective study with eight participating CR centers in seven countries (Denmark, France, Germany, the Netherlands, Italy, Spain and Switzerland). Patients aged 65 or older with CHD or valve surgery participating in CR were consecutively included. Educational attainment was divided into basic, intermediate and high

Results

A total of 1626 patients were included. Educational attainment differed across centers (p<0.001). The groups differed little regarding index event, comorbidity and medical treatment. However, patients with only basic education had more diabetes, higher BMI, less physical activity, lower exercise capacity and higher scores for depression (PHQ 9) and anxiety (GAD). Differences were not affected by adjustment for age, gender and country.

Demographics and risk factor control N=1626 High (N=388) Intermediate (N=788) Basic (N=460) p-value* DEMOGRAPHICS Age (yrs), median (IQR) 72 (68, 76) 71 (68, 75) 74 (70, 78) <0.001 Men 330 (86.8%) 603 (79.3%) 291 (67.4%) <0.001 RISK FACTORS p-value** LDL >1.8 mmol/l*** 255 (66.1%) 518 (66.8%) 293 (63.7%) 0.060 Systolic BP >140 mmHg 85 (22.0%) 179 (23.1%) 100 (21.7%) 0.601 Smoker 26 (6.8%) 80 (10.3%) 46 (10.0%) 0.214 Moderate exercise <4days/week 179 (46.4%) 340 (43.9%) 271 (58.9%) 0.024 BMI >27 kg/m2 133 (35.5%) 389 (50.2%) 255 (55.4%) <0.001 VO2 peak <80% of predicted 220 (57.0%) 443 (57.2%) 252 (54.8%) 0.037 HbA1c >48mmol/mol*** 115 (29.8%) 264 (34.1%) 230 (50.0%) <0.001 Diet score, mean (SD) 6.50 (2.28) 5.93 (2.47) 7.32 (2.35) <0.001 GAD score, median (IQR) 2.0 (0.0,4.0) 2.0 (0.0,5.0) 3.5 (0.0,7.0) 0.051 PHQ-9 score, median (IQR) 4.0 (1.0,7.0) 4.0 (1.0,7.0) 6.0 (2.0,10.0) 0.020 Abbreviations: IQR, interquartile range; SD, standard deviation; ACS, acute coronary syndrome; CAD, coronary artery disease. *Adjusted for center. **Adjusted for center, age, gender. ***Only for ischemic heart disease patients.

Conclusions

The results emphasize the need of CR in this patient-group and that a targeted CR approach should be considered to achieve equal health opportunities also in the elderly.

Acknowledgement/Funding

Horizon2020

P1927A European randomised controlled trial for m-health guided cardiac rehabilitation in the elderly; results of the EU-CaRE RCT study

Introduction

Knowledge about effectiveness of cardiac rehabilitation (CR) in the elderly is limited. Participation rates in supervised CR are consistently lower in the elderly and innovative interventions are needed. The EU has granted a CR study project; a randomised controlled trial conducted in 5 European countries, investigating the effectiveness of mobile telemonitoring guided CR (mCR) in elderly cardiac patients who declined regular CR.

Methods

Patients ≥65 years with indication for CR who declined regular CR were eligible for inclusion. Patients were randomised between regular care (without CR) and a 6-month mCR programme: dedicated programmed smartphone, heartrate monitoring (target HR zones) and coaching. The primary endpoint is the difference in VO2peak between 6-months follow-up and baseline.

Results

Between 2015 and 2018 179 patients were included. Baseline characteristics between groups (table 1) did not differ significantly, except for hypertension. The difference in VO2peak was significantly better in the mCR group (table 1). After correction (mixed linear model) for baseline VO2 peak (fixed factor) and centre (random factor) this difference remained significant. Mean number of registered activity sessions was 4.79 (95% CI; 4.07–5.50) per patient per week.

Table 1. Baseline and primary outcome parameters Baseline Control Programme (n=90) mCR Programme (n=89) P-value Gender (m/f) 76/14 69/20 0.238 Age (mean±SD) 73.57±5.46 72.38±5.37 0.121 Diabetes 15 (16.7%) 23 (25.8%) 0.133 Hypertension 60 (66.7%) 73 (82.0%) 0.019* Hypercholesteremia 71 (78.3%) 74 (83.1%) 0.468 Normal LV-function 48/89 (53.9%) 53/89 (59.6%) 0.497 Index event (CABG/Valve/PCI/none) 0.735   Cardiac history prior to index event 48/89 (53.9%) 53/89 (59.6%) 0.702   Non cardiac comorbidity 40 (44.4%) 44 (49.4%) 0.503 Results   Baseline VO2peak (ml/kg/min) (95% CI) 19.83 (18.65–21.01) 18.78 (18.67–19.89) 0.191   Delta VO2peak at 6 months (ml/kg/min) (95% CI) 0.20 4 (−0.34–0.83) 1.62 (0.86–2.39) 0.005*   Corrected delta VO2peak at 6 months (ml/kg/min) 0.50 (−1.04–2.04) 1.65 (0.11–3.2) 0.015* *Significant.

Conclusions

The application of mCR in elderly patients who declined regular CR results in a better physical condition after 6 months. Compliance to mCR was excellent.

Acknowledgement/Funding

European Union's Horizon 2020 research and innovation programme under grant agreement number 634439, and funding from the Swiss Government.

P2509Less effect of cardiac rehabilitation for elderly cardiac patients with lower educational attainment

Background

Previous analyses from EU-CaRE study have shown that elderly cardiac patients with basic education have a greater burden of cardiovascular risk factors and a lower exercise capacity at baseline of cardiac rehabilitation (CR). We hypothesize that participation in CR will diminish this socioeconomic gap.

Purpose

To describe if educational level predicts the benefits of CR in an elderly population in Europe.

Methods

The observational EU-CaRE study is a prospective study with eight participating CR centers in seven countries (Denmark, France, Germany, the Netherlands, Italy, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery participating in CR were included. Data were obtained at baseline (T0) and at the end of CR (T1) and include risk factors for cardiovascular disease, clinical and psychological assessment, medical treatment and exercise capacity. Patients were divided into basic, intermediate and higher educational levels. We compared changes from T0-T1 by multiple regression models.

Results

A total of 1621 (99% of included) patients were eligible for follow-up analyses. At baseline patients with basic education had more diabetes, higher BMI, lower exercise capacity (VO2 peak) and higher scores for depression (GAD) and anxiety (PHQ-9). At T1 they had improved significantly less on these parameters. The results were not affected by adjustment for gender, age, country and baseline value of the variable. Use of evidence-based medication did not differ by level of education.

Difference between T0 and T1 Factor High Intermediate Basic p-value* N total 1621 N=386 N=775 N=460 BMI, mean (SD) −0.16 (0.71) −0.08 (0.82) −0.26 (0.95) 0.794 LDL (mmol/L), mean (SD) −0.07 (0.63) −0.11 (0.62) −0.04 (0.58) 0.978 HbA1c (mmol/mol), mean (SD) 0.23 (3.70) 0.52 (4.39) 0.04 (5.79) 0.021 GAD score, mean (SD) −0.92 (2.72) −0.76 (3.07) −0.13 (3.47) 0.003 PHQ-9 score, mean (SD) −1.45 (3.21) −1.16 (3.36) −0.93 (4.49) <0.001 Diet score, mean (SD) 0.57 (1.72) 0.63 (1.90) 0.23 (1.81) 0.003 VO2 peak (ml/kg/min), mean (SD) 2.47 (2.90) 1.95 (2.78) 1.75 (2.56) 0.016 *Adjusted for gender, age, country and baseline value.

Difference in VO2peak, GAD and PHQ score

Conclusions

In this large European study with high-quality data from 7 CR centers we found an increased gap disfavoring the lower educated elderly patients participating in CR. These results indicate that “one-size cardiac rehabilitation” does not fit all and indicate that a more personalized CR with attention to the different needs of some patient groups is appropriate.

Acknowledgement/Funding

Horizon2020