Clinical determinants and barriers to cardiac rehabilitation enrolment of patients with heart failure with reduced ejection fraction

Introduction

Cardiac rehabilitation (CR) is a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF). Despite the robust evidence supporting its safety and benefits, there is an incomplete understanding of the reasons of the underutilization of CR programs in HFrEF. These reasons are complex and probably encompass healthcare system- and patient-level barriers.

Purpose

To study the clinical determinants and barriers to enrolment in a CR program for HFrEF patients.

Methods

We conducted a study of consecutive heart failure patients followed at a dedicated HFrEF cardiology clinic from January 2019 to April 2021. Patients were divided according to previous enrolment in CR program. Data were collected from electronic health records, and in case of missing data patients were asked by telephone about the reason for not participating in CR using a structured and validated questionnaire for this purpose.

Results

Of 228 patients with HFrEF, 60% had not been enrolled in a CR program; they were older (63 vs 58 years; p<0.01) and more likely to have comorbidities such as hypertension (56% vs 41%; p=0.03) or concomitant chronic obstructive pulmonary disease (20% vs 8%; p=0.01). Conversely, patients enrolled in CR programs were more likely to have a previous history of acute myocardial infarction (34% vs 20%; p=0.02). Regarding heart failure-related clinical features (NYHA functional class, LVEF, ICD/CRT), we did not find any significant differences between groups. The main reasons for not being enrolled in CR programs were: no medical referral (31%), concomitant medical problems (27%) such as musculoskeletal problems, patient refusal (11%) and geographical distance to the hospital (9%).

Conclusion

Despite the high proportion (40%) of HFrEF patients who underwent CR program compared to previous studies, the enrolment to CR can be further improved. The main barriers are related to health professionals (no referral), healthcare system (geographical distance to the hospital) and patients (concomitant noncardiac problems). Innovative strategies should target these factors to increase the delivery of CR program in HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Home-based cardiac rehabilitation can reduce anxiety and depression in heart failure patients

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). CIAFEL, UnIC and UMIB are supported by national funds through Fundação para a Ciência e Tecnologia, I.P. [(UIDB/00617/2020), (UIDB/00051/2020 and UIDP/00051/2020), and (UIDB/00215/2020 and UIDP/00215/2020), respectively]. CS received an individual grant from CAPES [BEX 0554/14-6].

Introduction

The current COVID-19 pandemic has led to significant changes in physical and mental health and has become a major challenge for cardiac rehabilitation (CR) programs. CR is an essential component in the treatment of heart failure (HF), as it improves cardiorespiratory fitness and quality of life, as well as reducing hospitalization rates. COVID-19 pandemic increased social isolation, and the CR centers were closed. Center-based CR requires the patient to travel to the hospital, which increases the risk of SARS-CoV-2 infection in this high-risk population. In this context, home-based CR can be an excellent strategy to reduce the physical and mental consequences of the social isolation imposed by the COVID-19 pandemic.

Objective

To test the effectiveness of a home-based CR program on cardiorespiratory fitness and anxiety and depression levels in individuals with HF during covid-19 pandemic.

Methods

Forty-two individuals with HF (age: 61.3±12.0; LVEF: 37.5±11.2) were included in this study. The exercise training program consisted in 12 weeks of combined exercise training (2x/week; 60min/day, 60-80% VO2peak), with 4 supervised exercise sessions in the hospital context and the remaining at home. Patients were monitored using a heart rate monitor and weekly phone calls. The following parameters were evaluated: cardiorespiratory fitness through the 6-minute walk test (6MWT) and anxiety and depression levels through the Hospital Anxiety and Depression Scale (HADS).

Results

After the home-based CR program, there was a significant increase in the 6MWT of 49 meters (95%IC: 38 to 60; p<0.001) and a significant decrease in anxiety levels of -1.12 points (95%CI: - 2.163 to -0.075 p=0.036). No significant changes were found in depression levels (p=0.954). Furthermore, the improvements in cardiorespiratory fitness were significantly associated with the reduction in the levels of anxiety (r= -0.281; p=0.028) and depression (r=: -0.278; p=0.030).

Conclusions

The home-based CR program was able to improve cardiorespiratory fitness and this improvement was associated with a decrease in anxiety and depression levels in individuals with HF. The results suggest that home-based CR can be an important strategy to minimize the physical and mental impact induced by social isolation imposed by COVID-19 pandemic in HF patients.

Impact of a home-based cardiac rehabilitation program in heart failure during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). CIAFEL, UnIC and UMIB are supported by national funds through Fundação para a Ciência e Tecnologia, I.P. [(UIDB/00617/2020), (UIDB/00051/2020 and UIDP/00051/2020), and (UIDB/00215/2020 and UIDP/00215/2020), respectively]. CS received an individual grant from CAPES [BEX 0554/14-6].

Introduction

Cardiac rehabilitation (CR) is an evidence-based recommended treatment of heart failure (HF) patients. During the COVID-19 pandemic, the shutdown of CR centers was necessary to limit the infection risk among high-risk patients. The integration of a home-based CR (HBCR) program in CR units can help to improve the delivery of care and improve cardiovascular outcomes of HF patients.

Purpose

To assess the effectiveness of an HBCR program in HF patients.

Methods

This is a sub­study of the EXercise InTervention in Heart Failure trial (EXIT-HF), which include forty-nine HF patients (preserved and reduced ejection fraction). The HBCR program consisted in 12-week combined exercise program (60%-80% of peak oxygen consumption (VO2 peak)), 2 training sessions per week, for a total of 24 sessions. Patients performed 4 supervised training sessions and the remaining sessions at home. All patients performed a cardiopulmonary exercise test (VO2 peak), the 6-minute-walking test (6MWT), collected blood analysis (plasma NT-proBNP), and answered the Minnesota Living with Heart Failure Questionnaire.

Results

Forty-two patients (86%) complete at least 80% of prescribed training sessions (age: 61.1±12; FEVE: 37.1±10.8). The HBCR program improve VO2 peak from 18.3 to 20.1ml/kg/min (+1.8 ml/kg/min; 95%IC:1.4 to 2.4; p<0.001) and the walked distance at the 6MWT from 462 to 512 meters (+49 meters; 95%IC: 38 to 60; p<0.001). In addition, overall quality of life was improved (-13 points; 95%IC:-7.8 to -18.5; p<0.001), as well physical (-6.3 points; 95%IC:-3.5 to -9; p<0.001) and emotional dimension of quality of life (-2.8points ; 95%IC: -0.9 to -4.7; p=0.06). No significant change was found in NT-proBNP levels (820±1220 vs 674±903; p=0.285).

Conclusions

Our results showed that HBCR is feasible and can improve functional capacity and quality of life in HF patients.

Impact of cardiac rehabilitation on inflammation in patients with ischaemic cardiomyopathy

Introduction

The benefits of cardiac rehabilitation (CR) in patients with ischaemic cardiomyopathy are well-known. However, inflammatory states have been associated to an increased risk of cardiovascular events.

Purpose

Evaluate the impact of CR in the serum levels of inflammatory biomarkers and identify potential predictors of that effect.

Methods

We retrospectively studied consecutive patients with ischaemic cardiomyopathy who completed a CR programme between 2011 and 2017. Patients underwent a supervised exercise training protocol, twice a week during a period of 8 to 12 weeks. Functional capacity was evaluated by metabolic equivalents assessed prior the beginning and 3 months after the programme with a symptom limited exercise treadmill test. Patients without levels of serum C-reactive protein at beginning and at the end of CR programme were excluded. Median variation of serum C-reactive protein was assessed and two groups were defined: one with levels above that and one with levels below.

Results

Of 250 patients (60.3±11.1 years, 84% male), 67% were admitted after an acute myocardial infarction. Left ventricular ejection fraction ≤40% before CR was present in 32% of individuals. Median levels of serum C-reactive protein before CR were 8.8 (3.1–21.7) mg/L and median variation after CRP was a decrease of 5.1 (0.9–17.7) mg/L (p&lt;0.001). Before CR, higher levels of serum C-reactive protein were seen in obese (15.7 [8–52.7] versus 8.8 [3.2–27.8], p=0.04) and those with higher NT-proBNP (p&lt;0.001). Patients with decrease of &gt;5.1mg/L of serum C-reactive protein had lower prevalence of hypertension (18% versus 30%, p=0.02), higher prevalence of obesity (16% versus 7%, p=0.03), lower levels of HDL cholesterol (38.3 [11.1] versus 43.2 [12.6], p&lt;0.001) and higher levels of NT-proBNP (1079 [610.3–1988] versus 488 [215–777], p&lt;0.001) at baseline. An increase of at least of 10% of functional capacity after CR was reached in 65% of patients, similar between groups. Patients with decrease of serum C-reactive protein &gt;5.1mg/L had also higher reduction of NT-proBNP after CR comparing to baseline (491.1 [142.7–948.5] versus 162.0 [30.9–295.2], p&lt;0.001).

Conclusions

Serum levels of inflammatory biomarkers decreased after CR in patients with ischaemic cardiomyopathy. Normotension, obesity, lower HDL and higher levels of natriuretic peptides are associated to a better response.

Funding Acknowledgement

Type of funding sources: None.

Syncope: call for the missed diagnosis

Funding Acknowledgements

Type of funding sources: None.

Background

Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas.

Purpose

To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope.

Methods

Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation.

Results

In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications.

Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department.

Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance).

Conclusions

Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Effect of exercise training on amyloid-like protein aggregates among patients with heart failure

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): MG and CS were supported by a PhD FCT grant (SFRH/BD/128893/2017) and by an individual grant from CAPES [BEX 0554/14-6], respectively. This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). iBiMED is a research unit supported by the Portuguese Foundation for Science and Technology (REF: UID/BIM/04501/2020) and FEDER/Compete2020 funds).

Introduction

Amyloid-like protein aggregates play a decisive role in the pathology of heart failure. Alterations in protein homeostasis, in particular, the clearance of toxic amyloid-like aggregates are emerging therapeutic targets in cardiovascular medicine. The clinical benefits of cardiac rehabilitation and exercise training are widely accepted in heart failure; however, little is known about the potential benefit of exercise training in amyloid-like protein aggregates.

Purpose

To assess the effects of a moderate-intensity exercise training program on amyloid-like protein aggregates levels among patients with heart failure with reduced ejection fraction.

Methods

Eighteen subjects participated in the study; eight patients (age: 66.6 ± 5.9 years; FEVE: 38.4 ± 8.9%) with heart failure with reduced ejection fraction participated in a 3-month exercise training program (2 x 60 min sessions per week of moderate-intensity aerobic and resistance exercise). Ten healthy subjects (age: 68. 4 ± 3.1 years) were recruited to an age-matched reference group.  Amyloid-like protein aggregates were assessed before and after 3 months of exercise training. Clinical data, medication, anthropometrics, and cardiorespiratory fitness were also assessed. Thioflavin T (ThT) dye fluorescence was used to quantify the plasma levels of amyloid-like aggregates and the Fourier transform infrared spectroscopy (FTIR) was applied to evaluate the conformation of cross-β-sheet structures characteristic of amyloid protein aggregates.

Results

Exercise program improved cardiorespiratory fitness by 14.0 ± 17.1% (17.4 ± 3.2 to 19.7 ± 2.9 ml/kg/min) and reduced NT-proBNP levels by 16.5% (34.2) (median concentration of 632 pg/mL (720.8) to 517.5 pg/mL (707.0)) in the heart failure patients. A slight decrease of amyloid-like aggregates levels was observed in post-exercise training samples (a reduction of 3.1%); interestingly, after the exercise training program, the heart failure patients showed levels of amyloid-like aggregates similar to the reference group (1132.0 ± 114.2 vs. 1094.8 ± 132.9 a.u.). Additionally, the PLS-R multivariate analysis of the amide I region of the FTIR spectra revealed enrichment of antiparallel β-sheets (1693 cm-1) assigned to amyloid-like oligomers in the samples of heart failure patients before, but not after, the exercise program. Of note, oligomeric species, as intermediates of amyloid assembly, can contribute to the increase of amyloid burden, but also, some have been reported to be highly reactive and toxic to cells, being key elements of amyloid pathogenesis.

Conclusions

 Our preliminary results indicate that 3 months of exercise training may have significant effects on amyloid-like oligomers, and start hindering the formation of the larger ThT-positive aggregates among patients with heart failure.

Abstract Figure.

P1346 Not all chest pains are scary: a case report of an important - but often forgotten - diagnosis

INTRODUCTION

Epipericardial fat necrosis (EFN) is an uncommon self-limiting benign condition that curses with chest pain. The first case was reported in 1957 and since than only few cases were reported. Recently, new imaging modalities have increased its diagnosis.

CASE REPORT

An otherwise healthy 42 years-old man presented with severe left-sided pleuritic chest pain, non-radiating, with 4 days duration, mildly relieved by an analgesic. No other symptoms nor history of infection. Physical examination, chest x-ray (CXR), ECG, routine laboratory testing, d-dimer and troponin measurements were unrevealing. Chest CT with contrast showed an increased density of anterior pericardial fat with nodular appearance consistent with EFN. The transthoracic echocardiogram was normal. For better characterization, a cardiac MRI was performed, and confirmed a small nodular lesion (10x17mm) with regular contours, externally to the pericardium, in relation to the apex of the right ventricle and the anterior thoracic wall (hypersignal on T1 and T2, loss of signal in fat saturation sequences, no contrast capture during the first pass nor late enhancement). The mass was delimited from the remaining pericardiac fat by a regular halo. Combined antiinflamatory therapy was started with favourable evolution. Cardiac surgery concluded that there was no need to perform a biopsy of the lesion unless there was recurrence of the symptoms. At 3 and 6-month follow-up, chest pain had resolved (no recurrence) - CT was performed for comparison and still showed a slight densification of the anterior mediastinum’s fat.

DISCUSSION

EFN is an often-overlooked etiology of chest pain in patients with a negative cardiopulmonary workup. The aetiology of EFN is still unknown but appears to be similar to other analogous conditions such as epiploic appendagitis and fat necrosis in the omentum or breast. It’s not expectable that patients with EFN have a higher risk of coronary heart disease. Onset is usually acute but can persist up to a year. Increased heart rate and diaphoresis may be found. ECG and lab tests are usually normal. CXR often shows a paracardiac opacity, occasionally with an associated pleural effusion. CT typically shows a fatty lesion anterior to the pericardium, in the epipericardial fat, with stranding of surrounding soft tissue. In most cases the adjacent pericardium is also thickened. CT enables prompt diagnosis in most cases, preventing further invasive procedures. No evidence-based treatment guidelines are available due to the rarity and benign behaviour of the disease. Treatment is usually conservative with analgesics and non-steroidal anti-inflammatory drugs. Follow-up imaging is recommended to confirm resolution and exclude neoplastic diseases such as liposarcoma. It is important to be familiar with its features since the clinical and radiologic characteristics suggest a presumptive diagnosis, thereby avoiding more aggressive techniques.

Abstract P1346 Figure. MRI - small nodular lesion

Aging and Proteins: What Does Proteostasis Have to Do with Age?

The world is aging and we must face the challenges that this brings. One of the reasons for the increasing aging of the world's population is the increase in life expectancy and, since we live longer, it is of paramount importance to live well and to prevent age-associated diseases. In this way, it is crucial to improve knowledge of the aging process and of the mechanisms that contribute to it. Ideally it would be of great interest to have a panel of biomarkers of healthy aging that would allow an estimate of the biological age of an individual. One of the changes that greatly contribute to aging is the loss of protein homeostasis, also called proteostasis. To ensure the proper function of cells and to maintain cellular proteostasis, organisms have developed systems to control protein synthesis, folding and degradation. Loss or dysfunction of proteostasis is at the root of many well-studied human neurological diseases, such as Alzheimer's disease and, more recently, it has been implicated in the aging process with some reports showing long-lived animals to have improved proteostasis. Growing evidence suggests a strong link between modifications in the quantity and/or activity of several players involved in proteostasis and longevity. In this review, we give an overview of the main characteristics of aging with focus on proteostasis. We present how changes in components of proteostasis, during aging, impact the lifespan of model organisms. We also briefly review the current state of aging biomarkers and discuss the potential of proteostasis network components as markers of healthy aging.

Harmonization: a methodology for advancing research in multiple sclerosis

Decreasing research funding is in conflict with the increasing need to conduct large studies to examine rare risk factors and interactions between risk factors. As a result, investigators are searching for strategies to stretch research funds and to design studies that will maximize investments already made. Multiple sclerosis (MS) is generally accepted as a multifactorial disease, and the assessment of interactions between risk factors and the desire to assess risk factors within particular sub-groups requires a large number of participants. Harmonization is a methodology that may help address this problem. Harmonization is a methodological approach that aims to systematize the process of combining individual data that are collected in several observational studies. Combining data will increase sample size, but the quality of the harmonized result is only as high as the quality of the individual studies and the comparability of the constructs measured. In this short report, we introduce the concept of harmonization and provide examples where harmonization may be advantageous in MS research.

HLA-DRB1 confers increased risk of pediatric-onset MS in children with acquired demyelination

BACKGROUND

Multiple sclerosis (MS) in the pediatric age group is being increasingly recognized. In adults, complex interactions between genetic and environmental factors contribute to risk and the major genetic component of MS susceptibility localizes to the major histocompatibility complex (human leukocyte antigen [HLA]). Whether HLA alleles predict MS in at-risk children presenting with acquired demyelinating syndromes (ADS) of the CNS is unknown.

METHODS

HLA-DRB1 alleles were typed using an allele-specific PCR amplification method on samples from 266 children presenting with ADS enrolled in the prospective Canadian Pediatric Demyelinating Disease Study and from 196 healthy controls.

RESULTS

Sixty-four of 266 children with ADS met established criteria for a diagnosis of MS during a mean follow-up of 3.2 ± 1.5 years. Children harboring DRB1*15 alleles were more likely to be diagnosed with MS (χ(2) = 12.2, p < 0.001; OR = 2.7), an observation strengthened by children of European ancestry (χ(2) = 10.5, p = 0.001; OR = 3.3). DRB1*15 allele frequencies in children with ADS of European ancestry subsequently diagnosed with MS were greater than in children with monophasic ADS (χ(2) = 10.7, p = 0.001) or healthy controls (χ(2) = 12.5, p < 0.001). The proportion of children with non-European ancestry diagnosed with MS was not influenced by DRB1*15 status.

CONCLUSION

DRB1*15 alleles confer increased susceptibility to pediatric-onset MS, supporting a fundamental similarity in genetic contribution to MS risk in both pediatric- and adult-onset disease. The specificity of the DRB1*15 risk allele for children with subsequent MS diagnosis, but not for all children with ADS, indicates that the risk conveyed by DRB1*15 relates to chronic CNS disease (MS), rather than acquired demyelination in general.