Effect of mobile guided cardiac rehabilitation on quality of life – the EU-CaRE randomised clinical trial

Background and purpose

Although participation in cardiac rehabilitation (CR) improves quality of life (QoL), participation in CR, especially among elderly, is limited.

We conducted this study to assess whether mobile home-based CR (mCR) increases QoL in elderly (≥65 years old) patients with coronary artery disease (CAD) or a valvular intervention who decline participation in conventional CR.

Methods

It is designed as a randomised multi-centre study with two parallel arms. Randomisation assigned patients either to mCR or a control group. mCR Consisted of six months of home-based CR with telemonitoring and coaching. Control-group patients did not receive any form of CR throughout the study period. Quality of life was measured with the SF-36v2 questionnaire at 0, 6 and 12 months.

Results

A total of 179 patients were included in this study (90 control, 89 mCR). A flowchart of the trial is presented in Figure 1. Patients were predominantly male (81.1%). Baseline characteristics can be found in Table 1.

Patients using mCR improved on physical QoL after 6 (p=0.026) and 12 (p=0.008) months. There was no difference on mental QoL for both groups (mCR 6 months p=0.563, 12 months p=0.945; control 6 months p=0.589, 12 months p=0.542). No difference existed in QoL between the mCR and control group (physical: 6 months p=0.070, 12 months p=0.150; mental: 6 months p=0.355, 12 months p=0.625).

Conclusion

Although there is no significant difference in QoL between the control and mCR group, mCR increases physical QoL after 6 and 12 months in elderly patients who decline participation in conventional CR. Therefore E-Health tools should be considered as an alternative for conventional CR when (elderly) patients decline to participate in conventional CR.

Figure 1. Flow chart of all eligible patients

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation programme

The impact of age and socioeconomic factors on response to exercise training in patients with ischemic heart disease, heart failure and after valve replacement

 

The impact of baseline characteristics on response to exercise training in patients with ischemic heart disease.

Background

Exercise training improves peak oxygen uptake, an important predictor of mortality in patients with coronary artery disease (CAD). Unfortunately, some patients do not response with an increase in peak oxygen uptake after exercise training. If it is possible to identify these patients it would be possible to tailor their exercise training.

Purpose

To investigate if baseline characteristics can predict response to exercise training in patients with heart disease.

Methods

A retrospective analysis of 1443 CAD patients (age 64±11 y (mean (±SD)), 74% male, participated and completed an eight-week supervised outpatient exercise intervention with two weekly training sessions of 1.5 hours with high intensity interval- (>80% of VO2peak) and resistance training. Patient characteristics were entered in the local database as the patients entered cardiac rehabilitation (CR). VO2peak was assessed before and after CR using a cardiopulmonary exercise test (CPET) with a maximal symptom limited bicycle ergometer test. Breathing gases were collected and analysed breath-by-breath. Each test aimed at physical exhaustion and a respiratory exchange ratio of more than 1.1 to ensure the validity of the CPET test. Patients were divided into responders defined as an improvement in aerobic capacity (change in VO2peak) after CR and non-responders if no improvement (change in VO2peak of 0.0ml/kg/min or less) post CR. We performed a multivariable logistic regression analysis using responders vs. non-responders as the endpoint. Explanatory variables were identified according to previous literature and comprised the following variables; age, sex, baseline VO2peak, tobacco use, diabetes, COPD, revascularization, working status, educational attainment, ethnicity and hypercholesteremia.

Results

1097 patients were responders and 346 (24%) non-responders to the exercise training despite no difference in attendance. Logistic regression analysis of responders vs. non-responders in relation to baseline characteristics are shown in the table.

Conclusion

In summarize, 24% of these heart patients were exercise non-responders. High baseline VO2peak, older age, having COPD, being on disability pension, low educational attainment and non-western ethnicity were predictors of training non-response. Identification of patients with a large likelihood of non-response is a beginning towards patient tailored exercise programmes.

Baseline characteristics in responders. CABG: coronary artery bypass graft; COPD: chronic obstructive pulmonary disease; PCI: percutaneous coronary intervention; SD: standard deviation; VO2peak: change in peak oxygen uptake. P-values of <0.05 are considered significant and shown in bold. 95% confidence intervals are shown in last column.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Helsefonden

Effect of weight loss, exercise and risk factor control in microvascular angina. A randomized controlled pilot trial

Background

Coronary microvascular dysfunction (CMD) is a common cause of angina in women and associated with adverse cardiovascular prognosis. Currently, no evidence-based treatment for CMD exists.

Purpose

To examine whether an intervention targeting cardiovascular risk factors is feasible and improves angina symptoms and microvascular function in women with CMD and no obstructive coronary artery disease.

Methods

We randomized 62 women aged 40–75, with body mass index >25 kg/m2, angina symptoms monthly or more and coronary flow velocity reserve (CFVR) <2.5 to a 24-week intervention comprising low energy diet, exercise training, and optimized medical treatment of hypertension, dyslipidemia and diabetes or to usual care. Patients were assessed before randomization and after 24 weeks. The primary outcomes were CFVR assessed by transthoracic Doppler stress-echocardiography and angina burden measured by the Seattle Angina Questionnaire (SAQ). Secondary endpoints were exercise capacity (VO2max), body composition and glycemic control, anxiety and depression symptoms measured by the Hospital Anxiety and Depression Scale (HADS).

Results

Fifty-six participants (90%) completed the study. Median age was 65 years. The intervention group obtained a mean weight loss of 10 kg, mainly (9 kg) from fat tissue (all p<0.0001), increased work load (p<0.01), decreased triglycerides, low density lipoprotein and low plasma cholesterol (all p<0.006). HbA1c in non-diabetes participants also decreased (p<0.05).

There was a clinically relevant improvement in all angina symptoms (9–21-point increase on all SAQ scales (all p<0.01)) as well as in depression score (p=0.008). There was no effect on CFVR or other secondary outcomes.

Conclusion

A major weight loss and intensified risk factor control resulted in significant improvement in angina burden but no improvement of coronary microvascular function among women with microvascular angina.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Unlimited research funding sources from the Capital region of Denmark and Bispebjerg-Frederiksberg Hospital internal funding sources.

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

P3107Effect of cardiac rehabilitation predicts event-free survival

Background

Participation in cardiac rehabilitation (CR) improves prognosis. Whether more effect of exercise training also affects prognosis is unknown.

Purpose

To investigate whether change in VO2peak after CR is a predictor of future cardiovascular disease and/or mortality

Methods

Retrospective analysis on 1237 cardiac patients completing a CR program in Copenhagen in 2011–2017 with a cardiopulmonary exercise test performed at baseline and end of CR. The association between change in VO2peak and future risk of morbidity and mortality through registry linkage was assessed by Cox regression analysis adjusting for age, sex, cardiac diagnosis, comorbidities and baseline VO2peak.

Results

1237 patients were included, mean was age 64 (±11) years and 75% were males. 30% of the patients did not improve in VO2peak. There were 166 events and 76 deaths during a median follow-up of 2.3 years. Both baseline VO2peak and change in VO2peak were significantly associated with risk after multivariable adjustment.

Change in VO2peak: MACE and mortality

Conclusion

Improvement in VO2peak during a CR program is a strong predictor of subsequent prognosis in cardiac patients.

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

P1557Sustainable effectiveness of cardiac rehabilitation in elderly patients in 7 European countries: main results from the EU-CARE study

Background

The EU-CaRE project aims to obtain the evidence base to improve, tailor and optimise cardiac rehabilitation (CR) programmes regarding sustainable effectiveness, cost-effectiveness and participation level in the elderly.

Purpose

To compare the effect of CR programmes in 7 European countries on the main outcome.

Methods

The observational EU-CaRE study is a prospective study with eight participating CR sites in seven countries (Denmark, France, Germany, Italy, the Netherlands, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery undergoing CR were included. Data were obtained at baseline (T0), at the end of CR (T1) and at 1 year (T2). VO2peak was assessed by cardiopulmonary exercise test. We compared changes in VO2peak across sites in multilevel regression models for repeated measures, adjusting for age, gender, baseline VO2peak, comorbidities, CVD risk factors and educational attainment. Results are reported separately for patients undergoing surgery (CABG/valve replacement) and other indications (MI/stable CAD/PCI).

Results

1633 patients were included, and VO2peak was available at all three timepoints for 1243 patients (76%), 492 undergoing surgery and 751 for other indications. Lag time from index event to first CPET and baseline VO2peak varied significantly across centres. Mean age was 72.9 (range 65–90), mean VO2peak at T0 was 16.49 (SD 4.94), at T1, 18.55 (5.33) and at T2 19.03 (5.43) ml/kg/min.

For patients not undergoing surgery mean improvement T0-T1 was 1.57 (2.98) and T0-T2 was 1.40 (3.17) ml/kg/min (both p<0.001). In the surgery patients as expected baseline VO2peak was lower but in contrast to non-surgery continued to improve after CR: T0-T1 improvement was 2.77 (2.76) and T0-T2 improvement was 4.29 (3.83) (both p<0.001). At one-year follow-up surgery and non-surgery patients had similar VO2peak (p=0.59). The greatest mean improvement in a site from baseline to one year was 2.04 (3.74) and the smallest 0.59 (2.54) ml/kg/min for non-surgery and, correspondingly 6.13 (4.83) and 1.29 (2.06) ml/kg/min for surgery patients (both multivariable adjusted p for differences between sites p<0.001).

In addition to age and gender, baseline and one-year VO2peak was lower in patients with diabetes, hypertension, smokers, patients with other co-morbidity, lower educational attainment and lower mental component score of the SF36. These factors had no systematic impact on the effect of CR.

VO2peak at baseline, after CR and 1 year

Conclusions

The study provides high-quality data on the effectiveness of current CR programmes in Western Europe. Overall, CR was effective in achieving significant improvements in exercise and maintaining these effects. There were significant differences in effect between sites indicating a potential for improvement by adapting CR programs.

Acknowledgement/Funding

Horizon 2020

P634Motivation for physical activity predicts effect of cardiac rehabilitation in an elderly cardiac population

Background

Motivation for physical activity is a psychological parameter that is sparsely described in secondary prevention, and it is plausible that motivation contributes to differential effect of CR.

Purpose

To investigate if motivation, measured using the behavioural regulation in exercise questionnaire (BREQ-2), predicts VO2peak in elderly cardiac patients before and after CR.

Methods

Prospective cohort study (Danish cohort from the EU-CaRE study) of elderly patients with ischemic or valvular disease enrolled in CR. Motivation for physical activity was measured using the BREQ-2 questionnaire at baseline, which measures five constructs of motivation and a summed score. VO2peak was measured before and after CR by a cardiopulmonary exercise test (CPET). The impact of motivation on VO2peak was examined using standardized multiple regression analyses.

Results

203 patients performed the baseline tests. 182 (90%) completed CR and had full data available. Dropout was not associated with motivation. VO2peak at baseline was 18 ml/kg/min (SD±5.1) and was associated with motivation score: for each SD increase in motivation VO2peak was 1.05 (0.43–1.69) ml/kg/min higher (p<0.01). Mean improvement was 2.3 (12%) ml/kg/min (SD±4.3). Higher motivation was positively associated with VO2peak (0.78 (0.33–1.24) pr. SD improvement (p=0.01) after adjusting for age, sex, depression, comorbidities and baseline VO2peak (Table). Subscales of the BREQ2 indicate that internal but not external motivation drives this positive association.

Predictors of change in VO2peak Age and sex adjusted Multiple adjusted model Motivation (RAI pr. SD) 0.57 (0.12 to 1.01)* 0.78 (0.33 to 1.24)** Baseline VO2peak (pr. SD) −0.56 (−1.16 to 0.21) −1.30 (−1.94 to −0.66)*** Age (pr. SD) −0.84 (−1.85 to 0.18) −1.00 (−2.01 to −0.01)* Sex (male) −0.18 (−1.21 to 0.85) 0.74 (−0.28 to 1.76) Previous smoker −0.23 (−1.22 to 0.77) −0.37 (−1.34 to 0.59) Current smoker −1.43 (−3.00 to 0.14) −1.89 (−3.36 to −0.40)* Diabetes (Yes) −1.37 (−2.50 to −0.24)* −1.62 (−2.78 to −0.48)** Kidney disease (Yes) −0.98 (−2.37 to 0.42) −1.45 (−2.84 to −0.06)* PHQ-9 (pr. SD) 0.22 (−0.24 to 0.69) 0.21 (−0.24 to 0.66)

Conclusion

In elderly cardiac patients, level of motivation is important to achieve benefits of CR. Future studies should address if motivation measured with BREQ-2 can be applied as a screening tool for elderly patients to provide more personalized intervention.

Contamination of arctic Fjord sediments by Pb-Zn mining at Maarmorilik in central West Greenland

This study focuses on heavy metal contamination of arctic sediments from a small Fjord system adjacent to the Pb-Zn "Black Angel" mine (West Greenland) to investigate the temporal and spatial development of contamination and to provide baseline levels before the mines re-opening in January 2009. For this purpose we collected multi-cores along a transect from Affarlikassaa Fjord, which received high amounts of tailings from 1973 to 1990, to the mouth of Qaumarujuk Fjord. Along with radiochemical dating by (210)Pb and (137)Cs, geochemical analyses of heavy metals (e.g. As, Cd, Hg, Pb, and Zn) were carried out. Maximum contents were found at 12 cm depth in Affarlikassaa. After 17 years the mine last closed, specific local hydrographic conditions continue to disperse heavy metal enriched material derived from the Affarlikassaa into Qaumarujuk. Total Hg profiles from multi-cores along the transect clearly illustrate this transport and spatial distribution pattern of the contaminated material.

Recombinant uracil phosphoribosyltransferase from the thermophile Bacillus caldolyticus: expression, purification, and partial characterization

The upp gene encoding the major uracil phosphoribosyltransferase (UPRT) of the thermophile Bacillus caldolyticus was cloned by complementation of an Escherichia coli upp mutation. The nucleotide sequence of the cloned DNA revealed an open reading frame of 630 bp encoding a polypeptide of 209 amino acids (M(r) 22,817) with 84% amino acid sequence identity to the deduced upp gene product of Bacillus subtilis. Primer extension analysis indicated that the transcriptional start site of the cloned gene was positioned 37 or 38 bp upstream of the coding region. When over-expressed in E. coli, the recombinant UPRT represented approximately 18% of the soluble cellular proteins. The enzyme was purified to homogeneity by two sequential precipitations with 50 mM Na-phosphate, pH 7.0. Gel filtration chromatography indicated that the native enzyme existed as a dimer at high protein concentrations but that it dissociated to a monomeric form on dilution. In dilute solutions the enzyme is highly unstable but can be stabilized by addition of bovine serum albumin. In concentrated solution (> 5 mg/ml) the enzyme is stable for months at 4 degrees C, even in the absence of bovine serum albumin. By comparing the UPRT activity of crude extracts of B. subtilis and B. caldolyticus it was found that the enzyme from B. caldolyticus was considerably more stable toward thermal inactivation than the homologous enzyme from B. subtilis.