Tailor-made cardiac rehabilitation for patients with obesity: results of the OPTICARE-XL randomized controlled trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Organisation for Health Research and Development (ZonMW) and Capri Cardiac Rehabilitation

Background

More than a third of the patients referred to cardiac rehabilitation (CR) suffers from obesity, and this number is growing. However, in patients with obesity, standard CR is not effective in achieving the recommended physical activity levels and results achieved in weight loss and health related quality of life (HRQOL) are unsatisfactory.

Purpose

To describe the effectiveness of a new state of the art CR program designed for patients with obesity, OPTICARE XL, on weight, physical activity and HRQOL.

Methods

A total of 201 patients that were referred to CR after a diagnosis of coronary artery disease (CAD) or atrial fibrillation (AF) and a BMI≥30 were randomized to standard CR (n=99) or OPTICARE XL CR (n=102). Standard CR consists of a 6 till 12 week aerobic exercise program, supplemented with cardiovascular lifestyle education. OPTICARE XL CR is a one-year intervention including aerobic and strength exercise, behavioral coaching on diet and physical activity and an after-care program. Weight was measured with a calibrated weight scale, physical activity (steps/day) was measured with an Actigraph GT3X+, and HRQOL with the MacNew questionnaire. Data was analyzed by means of linear mixed-effect models.

Results

Included patients had a mean age of 59 years, were predominantly male (73%) and the majority was referred to CR after a CAD (66% CAD, 34% AF). Patients in the OPTICARE XL group showed on average greater weight loss three months after the start of CR (mean change -3.6 kg vs -1.8 kg, respectively, p=0.002). Six months post CR, changes in body weight were equal between groups (-2.5 kg in both groups, p=0.959). No significant between-group differences were seen in improvements in physical activity both three months after the start of CR (+880 steps/day for OPTICARE XL vs +481 steps/day for standard CR, p=0.169) and six months post CR (+331 steps/ day vs +283 steps/day, p=0.919). With regard to HRQOL score, also no significant between groups differences in improvements were seen both three months after the start of CR (+0.6 for OPTICARE XL vs +0.5 for standard CR, p=0.169) and six months post CR (+0.5 for both groups, p=0.907).

Conclusion

OPTICARE XL had added value on the short-term, but this did not sustain on the long-term. We suggest to re-evaluate the OPTICARE XL program to expand short-term effects.

P5428QRS narrowing more than 15 ms after CRT implantation is strongly associated with the long-term survival

Background

Cardiac resynchronization therapy (CRT) is used in selected heart failure patients with electrical cardiac dyssynchrony with a prolonged QRS duration and a left ventricle ejection fraction (LVEF) ≤35%. QRS duration post CRT implantation can probably predict responders and survivors. The aim of our study is to investigate the effect of QRS change on long-term survival post CRT implantation.

Methods

We performed a retrospective cohort study in patients receiving a CRT device in our tertiary referral center between January 2009 and January 2018. Clinical and electrocardiographic (ECG) data were collected at baseline, one week after CRT implantation, six months, and yearly during follow-up. The primary endpoint was death, left ventricle assisting device implantation, or heart transplantation. At the end, the cohort was dichotomized to the cut-off value of ≥15ms according current literature.

Results

The study population consisted of 219 patients of whom 145 (66%) patients were survivors and 74 (34%) non-survivors. Non-survivors were significantly older (63 vs. 68 years, p=0.001), male gender (67% vs. 82%, p=0.015), had more often diabetes mellitus (20% vs. 39%, p=0.002), chronic obstructive pulmonary disease (12% vs. 28%, p=0.003), an ischemic etiology of heart failure (42% vs. 61%, p=0.009) with previous myocardial infarction (29% vs 53%, p=0.001), previous revascularization (32% vs. 49%, p=0.019), atrial fibrillation (21% vs. 39%, p=0.004), worser NYHA class (p=0.008), and amiodarone use (10% vs. 22%, p=0.024). Blood urea nitrogen (BUN) (8.1 mmol/L vs. 10.4 mmol/L, p<0.001) and creatinine levels (96 μmol/L vs. 114 μmol/L, p=0.001) were also higher in the non-survivors group. Median QRS duration (168 ms IQR [154 to 182]) at baseline was comparable between survivors and non-survivors (170 ms vs. 166 ms, p=0.17). However, median QRS change one week after CRT implantation was significantly better in the survivors (−19 ms IQR [−30 to −2] vs. −6 ms IQR [−24 to +12], p=0.004). The QRS change at the last FU (median 5.1 years IQR [2.9 to 7.8] was consistently higher in the survivor group (−16 ms IQR [−29 to 0] vs. +1 ms IQR [−27 to +20], p=0.004). Dichotomized to ΔQRS narrowing of ≥15 ms after CRT implantation showed significantly better long-term survival (figure).

Kaplan-Meier curve

Conclusion

QRS narrowing cut-off of ≥15 ms post CRT implantation is strongly associated with the long term survival in chronic heart failure patients with reduced LVEF.

Smoking cessation in European patients with coronary heart disease. Results from the EUROASPIRE IV survey: A registry from the European Society of Cardiology

OBJECTIVE

We investigated smoking cessation rates in coronary heart disease (CHD) patients throughout Europe; current and as compared to earlier EUROASPIRE surveys, and we studied characteristics of successful quitters.

METHODS

Analyses were done on 7998 patients from the EUROASPIRE-IV survey admitted for myocardial infarction, unstable angina and coronary revascularisation. Self-reported smoking status was validated by measuring carbon monoxide in exhaled air.

RESULTS

Thirty-one percent of the patients reported being a smoker in the month preceding hospital admission for the recruiting event, varying from 15% in centres from Finland to 57% from centres in Cyprus. Smoking rates at the interview were also highly variable, ranging from 7% to 28%. The proportion of successful quitters was relatively low in centres with a low number of pre- event smokers. Overall, successful smoking cessation was associated with increasing age (OR 1.50; 95% CI 1.09-2.06) and higher levels of education (OR 1.38; 95% CI 1.08-1.75). Successful quitters more frequently reported that they had been advised (56% vs. 47%, p < .001) and to attend (81% vs. 75%, p < .01) a cardiac rehabilitation programme.

CONCLUSION

Our study shows wide variation in cessation rates in a large contemporary European survey of CHD patients. Therefore, smoking cessation rates in patients with a CHD event should be interpreted in the light of pre-event smoking prevalence, and caution is needed when comparing cessation rates across Europe. Furthermore, we found that successful quitters reported more actions to make healthy lifestyle changes, including participating in a cardiac rehabilitation programme, as compared with persistent smokers.

[Heart failure in men and women: important differences in the diagnostic workup and treatment]

OBJECTIVE

To determine gender differences in diagnostic workup and treatment of patients with heart failure.

DESIGN

Retrospective.

METHOD

The data of 8914 patients (of whom 4166 women; 47%) with confirmed heart failure, who participated in the Euro Heart Survey on Heart Failure (EHS-HF) were analysed.

RESULTS

On average, the women in the study were older than the men (75 versus 68 years) and less often suffered from a coronary heart disease (56 versus 66%). Women were more likely to have hypertension (59 versus 49%), diabetes mellitus (29 versus 26%), or valvular heart disease (42 versus 36%). Fewer women had an ultrasonographic evaluation of ventricular function (59 versus 74%) and, among those investigated, fewer had left ventricular systolic dysfunction (44 versus 72%). These observed results remained stable after adjustment for age and other possible confounding variables. Medication with a documented positive impact on survival, i.e. angiotensin converting enzyme (ACE) inhibitors, beta-blocking drugs and the diuretic spironolactone, was prescribed less often to women than men. Women, however, received symptomatic medication such as other diuretics and digoxin more often than men.

CONCLUSION

Men and women with heart failure differed with respect to a number of relevant clinical characteristics. Clinicians should take good note of this and take measures to prevent differences in patient care.

Management of patients with heart failure in clinical practice: differences between men and women

OBJECTIVES

This study evaluated gender differences in clinical characteristics, treatment and outcome among patients with heart failure, and to what extent these differences are due to age and differences in left ventricular (LV) function. Although gender differences are observed among heart failure patients, few studies have been adequately powered to investigate these differences.

METHODS

A total of 8914 (out of 10 701) patients (47% women) from the Euro Heart Survey on Heart Failure with confirmed diagnosis of heart failure were included in the analyses.

RESULTS

Women were older (74.7 vs 68.3 years, p<0.001), and less often had evidence of coronary artery disease (56% vs 66%, age-adjusted odds ratio (OR) 0.62; 95% CI 0.57 to 0.68). Women were more likely to have hypertension, diabetes, or valvular heart disease. Fewer women had an investigation of LV function (59% vs 74%, age-adjusted OR 0.67; 95% CI 0.61 to 0.74), and, among those investigated, fewer had moderate/severe left ventricular systolic dysfunction (44% vs 71%, age-adjusted OR 0.35; 95% CI 0.32 to 0.39). Drugs with a documented impact on survival, that is ACE-inhibitors and beta-blockers, were given less often to women, even in the adjusted analysis (OR 0.72; 95% CI 0.61 to 0.86 and OR 0.76; 95% CI 0.65 to 0.89, respectively). 12-week mortality was similar for men and women.

CONCLUSIONS

Fewer women had an assessment of LV function, but, when investigated, women had better ventricular function. Women were less often treated with evidence-based drugs, even after adjustment for age and important clinical characteristics. Clinicians need to be aware of deficiencies in the treatment of women with heart failure and measures should be taken to rectify them.

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization

AIMS

The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD).

METHODS AND RESULTS

Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%).

CONCLUSION

The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.

Differences between patients with a preserved and a depressed left ventricular function: a report from the EuroHeart Failure Survey

AIMS

Due to a lack of clinical trials, scientific evidence regarding the management of patients with chronic heart failure and preserved left ventricular function (PLVF) is scarce. The EuroHeart Failure Survey provided information on the characteristics, treatment and outcomes of patients with PLVF as compared to patients with a left ventricular systolic dysfunction (LVSD).

METHODS AND RESULTS

We performed a secondary analysis using data from the EuroHeart Failure Survey, only including patients with a measurement of LV function (n = 6806). We selected two groups: patients with LVSD (54%) and patients with a PLVF (46%). Patients with a PLVF were, on average, 4 years older and more often women (55% vs. 29%, respectively, p < 0.001) as compared to LVSD patients, and were more likely to have hypertension (59% vs. 50%, p < 0.001) and atrial fibrillation (25% vs. 23%, p = 0.01). PLVF patients received less cardiovascular medication compared to PLVF patients, with the exception of calcium antagonists. Multivariate analysis revealed that LVSD was an independent predictor for mortality, while no differences in treatment effect on mortality between the two groups was observed. A sensitivity analysis, using different thresholds to separate patients with and without LVSD revealed comparable findings.

CONCLUSIONS

In the EuroHeart Failure Survey, a high percentage of heart failure patients had PLVF. Although major clinical differences were seen between the groups, morbidity and mortality was high in both groups.