Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis

BACKGROUND

Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter.

PURPOSE

To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively.

RESULTS

Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups.

CONCLUSION

At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.

Meniscal repair at the time of primary ACLR does not negatively influence short term knee stability, graft rupture rates, or patient-reported outcome measures: the STABILITY experience

PURPOSE

To assess how meniscal repair and excision impact short term patient-reported outcome measures (PROMs), knee stability, and early graft rupture rates following primary hamstring anterior cruciate ligament reconstruction (ACLR) with or without lateral extra-articular tenodesis (LET) in a group of young active patients where meniscal repair is commonly advocated.

METHODS

Six hundred and eighteen patients under 25 years of age at high-risk of graft failure following ACLR were recruited to the Stability 1 study. Multivariable regression models were developed to identify statistically and clinically significant surgical and demographic predictors of Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Subjective Knee Form (IKDC), ACL Quality of Life Questionnaire (ACL-QOL) and Marx Activity Rating Scale (MARS) scores. Chi-Square tests of independence were used to explore the association between meniscal status (torn, not torn), meniscal treatment (excision or repair), graft rupture, and rotatory knee laxity.

RESULTS

Medial meniscus repair was associated with worse outcomes on the KOOS (β = -1.32, 95% CI: -1.57 to -1.10, p = 0.003), IKDC (β = -1.66, 95% CI: -1.53 to -1.02, p = 0.031) and ACL-QOL (β = -1.25, 95% CI: -1.61 to 1.02, p = n.s.). However, these associations indicated small, clinically insignificant changes based on reported measures of clinical relevance. Other important predictors of post-operative PROMs included age, sex, and baseline scores. Medial meniscus excision and lateral meniscus treatment (repair or excision) did not have an important influence on PROMs. There was no significant association between meniscal treatment and graft rupture or rotatory knee laxity.

CONCLUSION

While repairing the medial meniscus may result in a small reduction in PROM scores at two-year follow-up, these differences are not likely to be important to patients or clinicians. Any surgical morbidity associated with meniscal repair appears negligible in terms of PROMs. Meniscal repair does not affect rotatory laxity or graft failure rates in the short term. Therefore, meniscal repair should likely be maintained as the standard of care for concomitant meniscal tears with ACLR.

LEVEL OF EVIDENCE

III.

Aortic valve calcium score: does it correlate with mean transaortic gradient?

Introduction

Aortic valvular calcium score (AVCS) is useful in patients with aortic stenosis for whom echocardiography was not conclusive in grading its severity. Transcatheter aortic valve implantation (TAVI) is an established procedure of treatment in symptomatic severe AS. The burden of aortic valve calcification has been associated with some TAVI related complications (as perivalvular leaks), but at the same time it is well accepted that some degree of calcification is needed to ensure stable anchoring of the prosthesis to the aortic annulus.

Purpose

To assess if there is a correlation between aortic valve calcium score and mean transvalvular gradient 6 months after TAVI – is a higher AVCS correlated with lower mean transaortic gradient after TAVI?

Methods

We performed a single-center, retrospective cohort study including patients who underwent TAVI with a preoperative standardized contrast enhanced MSCT with AVCS available. Clinical and echocardiographic data were collected previously to TAVI (pre-TAVI) and at 6 months follow up (6M-FUP).

Results

A total of 187 patients were included, with 54% female and a mean age of 79.4±9.0 years old. Most patients had tricuspid aortic valve (95.7%); 5 patients had aortic bicuspidy and 3 had aortic valve bioprothesis. Concerning the valve type, 73.3% had new generation prosthesis and the main valve used was the CoreValve Evolut Pro (33.7%). Also, 38,5% needed balloon pre-dilation before TAVI. The mean pre-TAVI aortic transvalvular maximum and mean gradients were 76.5±23.2 mmHg and 48.3±15.5 mmHg, respectively; mean aortic valve area was 0.75±0.16 cm2. The mean AVCS was 2851±1524 AU (Agaston Units); 81.2% of women had AVCS&gt;1300 AU and 74.4% men had AVCS &gt;2000 AU. Comparing transvalvular aortic gradients previously and 6M-FUP after TAVI, there was an average differential of maximum gradient of 61±22 mmHg and of mean gradient of 40±15 mmHg. A negative and weak correlation was found between the AVCS and the maximum gradient (pearson coefficient of −0.181, p=0.02) and between mean gradient at 6M-FUP (pearson coefficient of −0.191, p=0.014).

Discussion and conclusion

AVCS is a significant predictor for death, stroke and perivalvular leaks after TAVI. On the other hand, high AVCS is associated with better seating in the native annulus during deployment. Nevertheless, high AVCS did not strongly correlated with mean transaortic gradient 6 months after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Reduced 3D-left atrium ejection fraction predicts development of atrial fibrillation in patients with hypertrophic cardiomyopathy

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM), occurring in approximately 25% of patients, related to left atrial (LA) dilatation and remodeling. HCM patients who develop AF have increased risk of HCM-related death, functional impairment, and stroke. Accurate risk stratification for AF in this population is crucial as contemporary treatments are highly successful.

Purpose

To assess if new echocardiographic parameters can predict the development of AF in HCM patients.

Methods

HCM patients who underwent comprehensive echocardiographic examination during 2011 were followed and checked for “de novo” AF until November 2021. We searched for associations between AF development and novel echocardiographic parameters such as LA Volume index, Left Atrioventricular Coupling Index (LACI, as LAVI/a'), 3D LA volumes and 3D LA ejection fraction (3D-LAEF).

Results

A total of 43 patients were included, with 62.8% male and mean age 56,1±6,2 years old. 55.8% had the septal asymmetric HCM type and mean LV mass was 326±127g. Mean LA diameter and biplane 2D volume was 46±7 mm and 78±37 mL, respectively. 11.6% of patients already had AF. During a median follow-up of 9.4 years, the incidence of “de novo” AF was 31,6%. Within the total 17 patients with AF, 35,2% took warfarin and the remaining direct oral anti-coagulation. No stroke was documented. There were 3 deaths (mortality rate of 7,0%), none from cardiac causes.

No association was found between AF development and LAVI, LACI or 3D LA volumes. We only found a statistically significant difference regarding 3D-LAEF, which was lower in patients who developed AF compared with those without AF (26±12% VS 39±19%, p=0.04).

Binary logistic regression analysis found that reduced 3D-LAEF predicts the development of AF (p=0.019, odds ratio [OR] 2.6, 95% confidence interval [CI] 1.0 to 1.1). The area under a receiver operating characteristic curve using 3D-LAEF as a predictive marker for AF development in HCM patients was 0.743 (p=0.004). When the cut-off value of 3D-LAEF was set at 34,5%, the sensitivity and specificity for AF diagnosis were 66% and 86%, respectively.

Conclusion

In our study, 3D LAEF predicted the development of AF in HCM patients – this may be a useful tool to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Patient delay in acute myocardial infarction: a long journey still ahead

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs &lt;7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.

20 year-follow up of mitral stenosis patients after percutaneous valve commissurotomy: moderate disease of other valves as predictor for re-intervention

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve (MV) surgery in the treatment of patients with clinically significant mitral stenosis (MS). About 40% of patients treated with PMC will require at least one reintervention (either PMC or MVS) along time.

Purpose

To evaluate the long-term results of PMC in patients with rheumatic MS.

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during early and long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, MV re-intervention or cardiovascular hospitalization.

Results

A total of 124 patients were enrolled: 108 (87%) were female, with a mean age at the time of PMC of 46±11 years.

At baseline, 34% patients were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function and 83% presented pulmonary hypertension. Regarding associated valve disease, 46 patients had mild tricuspid regurgitation (TR), 19 mild aortic regurgitation (AR), 14 moderate IT and 5 moderated AR.

Most of the procedures were successful (91%) and without complications (94%), with median improvement in MV area of 0.9 cm2 (IQR 0.5) and median reductions in mean transmitral gradient (MTG) of 6 mmHg (IQR 6) and in pulmonary artery systolic pressure (PASP) of 8 mmHg (IQR 10) early after PMC.

During the mean follow-up of 20±6 years, 52 (42%) of patients had MV re-intervention (86% surgery and 14% re-PMC), 37 (30%) were hospitalized and 30 (24%) died. Concerning time-to-event analysis, approximately 80% of patients kept MACE-free after 10 years; after 30 years, more than 20% continued MACE-uneventful, approximately 50% were alive and about 45% were free from re-intervention.

Considering patients submitted to surgical re-intervention, 9 underwent MV valvuloplasty and the others MV replacement with mechanical (32) or biological prothesis (11). At the same procedure, 23 patients were submitted to tricuspid annuloplasty, 9 to other valve replacement and one to coronary artery bypass graft.

Using Cox regression, we found that the presence of moderate disease of other valves at PMC time was associated with a 2.3-fold greater rate of re-intervention compared to patients with none or mid disease of other valves (HRcrude 2.3; 95% IC 1.221–4.331, p=0.017). After adjusting for the success of the PMC and for mitral regurgitation after PMC, the observed effect remained significant (HRadjusted = 2.7; 95% CI 1.417–5.233, p=0.003).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. Still, about 40% required re-intervention, with moderate disease of other valves as its independent predictor.

Funding Acknowledgement

Type of funding sources: None.

Cardiac Optimal Point: Identifying high risk patients for an optimal approach

Funding Acknowledgements

Type of funding sources: None.

Introduction

In recent years it has been proposed the concept of cardiorespiratory optimal point (COP) to best characterize populations who underwent cardiac rehabilitation programmes (CRP). The COP is defined as the minimum ratio between ventilation and oxygen consumption (VE/VO2) obtained during the cardiopulmonary exercise test (CPET) and it has been suggested that COP values &gt; 30 conveyed worse prognosis.

Purpose

To validate OP as a predictor of events and its correlation with exercise activity and quality of life on the long term.

Methods

Single center observational study of patients enrolled on CRP - from February 2018 to May 2019 – who did CPET as part of routine evaluation. COP was defined as the lowest point of VE/VO2 ratio. Clinical and laboratorial characteristics were obtained at admission and discharge of CRP. Exercise practice was accessed using IPAQ questionnaire and quality of life was assessed based on a validated inquire - Kansas City Cardiomyopathy Questionnaire (KCCQ-23) – both by phone interview.

Results

A total of 78 patients (mean age 63.2 ±11.6, 84.6% male) were evaluated and followed for a mean follow-up of 2,68±0,53 years. Main aetiology was ischemic heart disease (86%), followed by dilated cardiomyopathy (5,1%) and valvular heart disease (2,6%).

A COP value above 30 correlated with a worse global score in KCC-23 (r =0.283, p = 0.47), and in particular domains such as frequency and severity of symptoms (p = 0.046, r 0.335 and p=0.16, r= 0.4, respectively), quality of life (p=0.039, r= 0.293) and social limitation (p = 0.001, r=0.5). COP also correlated with VO2 peak in basal CPET (p&lt;0.001, r= 0.450) and on follow-up CPET (p= 0.39, r= 0.303).

COP failed to predict events or levels of exercise activity on the long term, as evaluated by the IPAQ score. However, COP&gt;30 did seem to correlate with a higher mortality rate on the follow-up although such trend was not statistically significant (possibly due to short follow-up time and sample size).

Conclusion

COP values &gt; 30 identify patients with worse prognosis, predicting worse quality of life and higher mortality. Although it did not seem to be a good predictor of exercise adherence after CRP.

Shorter cardiac rehabilitation programs: taking time is taking effectiveness?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Due to the covid-19 outbreak, cardiac rehabilitation programs (CRP) underwent most needed adaptions to stay operative. To face all the requests and guarantee sanitary measures, we reduced the duration of the program from about 12 weeks to about 8 weeks, so we could have smaller groups but still respond to all patients who had been referred. However, it is still unclear whether less hours of contact and exercise sessions can achieve the same results as traditional CRP.

Objective

To analyse the effectiveness of shorter duration CRP on risk factor control and exercise tolerance after concluding the program.

Methods

Observational single center study including two groups of patients who underwent CRP: one group who had been in 12 weeks-CRP before the pandemic sprout and another group enrolled in an 8-week program after April 2021. Albeit differences in their duration, both CRP had the same structure: observation by cardiologist, physiatrist, specialist nurse, exercise (aerobic and strength exercises) and educational sessions, as well as nutrition and psychologist consultation.

Results

A total of 114 pts were analysed (mean age 62,4±11,6 years, 85.1% men, 86% with ischemic heart disease). Main comorbidities were hypertension (68,4%), dyslipidaemia (70%) and diabetes (30,7%). 78 pts completed a longer programme with 12 weeks duration while 36 underwent a shorter CRP with 8 weeks. There were no statistically significant differences between both groups regarding population demographics, aetiology, LVEF and co-morbidities.

After CRP, there was significant improvement in risk factor control (mainly lipidic profile and weight) and echocardiographic parameters in both groups. We noted an important reduction in LDL levels (85±42.6mg/dL before CRP and 67.68±28.45mg/dL after), approaching the guideline recommended levels (<55mg/dL): 29.8% before vs 42.6% after (p=0.079), with no difference between the two groups (p=0,65). Significant improvement of LVEF was also observed (53% to 57%, p <0.001) without difference between the two groups (p=0.112).

Exercise tolerance improved similarly in both groups, assessed by the time of exercise stress test: we registered a global increase of 65 ± 1.38s after CRP, with no difference between the two groups (p = 0.157).

Conclusion

Shorter duration CRP showed similar results concerning risk factor control, echocardiographic LVEF and exercise tolerance improvement, suggesting that they can be an effective alternative when needed.

Very acute benefits on physical performance in elderly patients who undergone TAVI

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) emerged as a safe and efficient procedure in patients with high or prohibitive surgical risk or in older patients. The prevalence of severe aortic stenosis is growing up, given de aging of population. These patients are much often frailty and experience low levels of physical activity and functional capacity as a result of their aortic valve disease and comorbidities. When untreated severe aortic stenosis has a poor prognosis so it is of utmost importance to restore the normal hemodynamic condition and consequently to improve functional capacity.

Aim

To assess the acute benefits (in 1 moth) of TAVI on functional capacity and physical performance.

Methods

Single center prospective study of patients submitted to TAVi between April 2021 and September 2021. Patients were evaluated at baseline (before TAVI) and one month after the procedure. To assess physical activity and functional capacity it was used the International Physical Activity Questionnaire (IPAQ) and the short physical performance battery (SPPB) which is a group of measures that combines the results of the gait speed (two timed trials of a 4-m walk – fastest recorded), chair stand (time to raise for a chair 5 times) and balance tests (ability to stand for 10 seconds with feet in 3 different positions). Additionally, patients were submitted to handgrip strength test. Paired sample t-test and Wilcoxon test were used to statistical analysis.

Results

We included 20 patients, with a mean age of 85±5,86 years, 40% (8) male. 19 patients undergone TAVI due severe native aortic stenosis and 1 due to bioprosthetic aortic valve dysfunction. The vascular access site was transfemoral in 19 patients and transapical in 1 patient.

No patient had vigorous physical activity either before or after TAVI, but the daily sitting time was lower after the procedure (mean time: 634 versus 570 minutes), however not statistically significant. Regarding the results of SPPB patients experience improvements in balance (p=0,035) and chair stand (time to raise for a chair 5 times: 19,04 versus 17,05 seconds), p=0,01.

Patients tended to be faster in 4m velocity test, however with no statistical difference (8,49 versus 6,6 seconds). No statistical differences were also observed in handgrip strength test.

Conclusion

In an elderly population, TAVI appears to have an early and beneficial effect (in 1 moth) on some domains oh physical activity and functional capacity.

Usefulness of the 6-minute walk test vs cardiopulmonary exercise test for exercise prescription in coronary artery disease patients going into a phase III cardiac rehabilitation program

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Determining the intensity of exercise is a very important component to obtain the dose-benefits associated with exercise, while maitaining the safaty of the patient with coronary artery disease (CAD) in a cardiovascular rehabilitation (CR) programme. The cardiopulmonary exercise test (CPET) is the gols standard for exercise prescription according to the intend intensisty of aerobic workout. However, its availability is not a reality in many CR centres. The 6-minute walk test (6MWT) is a valid and widely used method because it is low-cost and simple to apply. Nevertheless, it is still unknown the corresponding intensity reached on a 6MWT compared to the one reached on a CPET in already physically active patients with CAD starting a CR phase III programme.

Purpose

To use the peak heart rate (HR) of the 6MWT as a method to prescribe the intensity of aerobic exercise in CAD patients starting a phase III CR programme and to compare it with the ventilatory threshold (VT) of the CPET.

Methods

In this retrospective study, a cohort of patients with CAD enrolled in a phase III CR programme. At the beginning of the programme, all patients performed a 6MWT and a CPET in the same week with at least 48-hour difference. The HR on the 6MWT was recorded continuously using a HR polar (H10 Polar) and on CPET using a twelve-lead ECG. Other parameters were assessed such as objective physical activity (accelerometer) and body composition.

Results

Eighty patients (87.5% males, 60.8 ± 9.4 years old) with CAD were included in this study. Patients were, on average, physically active (361 ± 182 minutes/week of moderate to vigorous physical activity) and overweight (body mass index: 27.7 ± 3.5 kg/m2). The VO2 peak reached on the CPET was 20.3 ± 5.4 ml/kg/min and the percentage of predicted maximum HR was 78.3 ± 11.4 %. The first and second VT corresponded to 75.6 ± 7.8% and 91.2 ± 4.5% of the peak HR obtained with CPET, respectively. The 6MWT HR peak was 113 ± 16 bpm (90.0 ± 13.0 HR peak CPET) and did not differ from the HR of the second VT with a mean value of 115 ± 16 bpm (91.2 ± 4.5% HR peak CPET), p&gt;0.05. Although, the 6MWT HR peak was significantly higher than the HR oh the first VT (95 ± 14 bpm, p&lt;0.001). In a subgroup analysis, the patients who, during the 6MWT, reached more the 90% of the HR peak CPET (n=35, 44% oof the sample) were the ones with lower functional capacity (VO2 peak: 18.4 ± 5.4 ml/kg/min vs 21.7 ± 5.0 ml/kg/min, p=0.006) and higher age (64.4 ± 8.7 years old vs 60.8 ± 9.4 years old, p=0.002).

Conclusion(s)

In the absence of a CPET, the use of a 6MWT HR peak in physically active patients with CAD starting a phase III CR programme has shown to be an efficient method to prescribe moderate to vigorous exercise intensity, corresponding to the second VT. Higher intensities on the 6MWT might be reached in active elderly patients with reduced functional capacity.

Nutrition guidelines compliance in cardiovascular disease patients attending a long-term exercise-based cardiac rehabilitation program during COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Introduction

Dietary habits influence cardiovascular disease (CVD) risk, mainly through risk factors such as lipids, blood pressure, body weight and diabetes. Therefore, a healthy diet is recommended as a cornerstone of CVD prevention in all individuals and in reducing risk of recurrent disease, yet few studies have examined diet quality in cardiac-rehabilitation patients on a long-term basis.

Purpose

To evaluate the compliance with dietary guidelines in patients who attend a long-term cardiac rehabilitation program (phase III) during COVID-19 era.

Methods

The study was developed between October 2020 and October 2021 in a phase III centre-based cardiac rehabilitation program. To evaluate dietary intake a 24hour recall questionnaire was used. Diet composition was analysed using ESHA’s Food Processor® software. Cunningham equation was used to evaluate resting energy expenditure and physical activity expenditure measured by accelerometery was added to calculate daily energetic requirements. The nutrients and cut-offs considered for the analysis were saturated fat (&lt;10%), sodium (&lt;2g), potassium (≥3.5g), fibre (≥30g), and alcohol (&lt;100g/week), considering the 2021 ESC Guidelines on CVD Prevention in Clinical Practice or the World Health Organization guidelines for a healthy diet. To evaluate weight and height a digital scale SECA 799 and a stadiometer SECA 220 were used, respectively.

Results

A total of 57 patients (78.9% men) with a mean age of 63.8±8.5 were evaluated. Mean body mass index (BMI) was 28.4±3.8kg/m2, being most patients overweight or obese (61.7%). A higher caloric consumption, compared to the individual energy requirements, was found in 26.3% of patients. No statistical differences were found between mean saturated fat intake (10.1±3.6%) and the recommended intake (p=0.85). Mean sodium consumption was 3.42±1.46 grams and mean potassium intake was 3.0±1.0 grams. Sodium intake was significantly higher (p&lt;0.001), and potassium intake significantly lower (p&lt;0.001) than the recommendation. Fibre intake was also significantly lower than the recommendation (median intake was 21.1±12.2 grams, p&lt;0.001). Among patients who drank alcoholic beverages (n=28), the median alcohol intake per day was 17.4±26.3 grams which was significantly higher than the limit recommended (p=0.043).

Conclusion

Our findings showed that these patients deviated from the recommendations in some key nutrients. The intake of sodium and alcohol was higher than the recommendations, and the intake of potassium and fibre were lower than the recommendations. Moreover, most patients were overweight or obese. This study highlights the need for individual nutritional counselling sessions as a reinforcement of a standard educational program, to effectively promote an adequate diet, which may reduce the risk of recurrent disease. Further research about nutritional intervention in patients undergoing on a long-term basis cardiac rehabilitation is warranted.

Cardiorespiratory fitness assessment on active patients who kept attending their phase III exercise-based cardiac rehabilitation during the COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorespiratory fitness (CRF) is a powerful predictor of all-cause mortality among individuals with coronary artery disease (CAD). A structured community-based phase III cardiac rehabilitation (CR) is very important in lifelong maintenance of phase II CRF and health gains. During the COVID-19 pandemic, CR programs had to adapt, mainly using new technologies and remote follow-up. The CRF impact in patients (Ps) who kept going their phase III program, during this troubled era is still unknown.

Purpose

Assess the variation in CRF and prognostic parameters in Ps with CAD who maintain high adherence levels in their phase III CR before and during the COVID-19 pandemic.

Methods

A cohort of Ps enrolled in a community-based phase 3 CR program, with active participation at the end of 2019, was included in this retrospective study. The inclusion criteria for this study were high levels of attendance (>80%) to the CR program before and during COVID-19 and high levels of physical activity with more than 150 mins of moderate to vigorous physical activity (MVPA). All Ps were evaluated with transthoracic echocardiography (TTE) and a cardiorespiratory exercise test (CPET) in a cycloergometer in 2019 and between october and november of 2021. All Ps had used accelerometers to measure their physical activity levels and dual-energy absorptiometry (DEXA) scan to evaluate their body composition. Between 2020 and 2021, Ps had online (in lockdown periods) and face to face exercise training sessions, 3xtimes per week, 60 mins each exercise session.

A t-test paired two sample for means was used to compare CPET variables before the beginning of the first COVID lockdown (end of 2019) and after the removal of the majority of restrictions (end of 2021).

Results

A total of 30 Ps with high levels of adherence were included (99.6% male, 65 ± 9 years old). In this cohort, the majority had history of an ACS before the referral to the CR program (73.3%) and 55.6 ± 10.4% of left ventricular ejection fraction.

There was no significant difference in body mass index (27.9 ± 3.2 kg/m2 vs 28.1 ± 3.6 kg/m2, p=0.493 but there was a significant increase in the percentage of body fat mass (30.1 ± 5.7% vs 31.0 ± 6.6%, p= 0.042). There was a maintenance on MVPA levels (352 ± 137 minutes/week vs 313 ± 194 minutes/week, p = 0.106) during this period.

When comparing the 2 CPET results, Ps achieved higher exercise loads in the 2021 test (175 ± 51W vs 185 ± 52W, p=0.005), higher VO2 peak (25.3 ± 6.9 ml/kg/min vs 21.5 ± 6.3 ml/kg/min, p =0.001) and higher percentage of predicted VO2max (78.8 ± 16.8% vs 95.27 ± 20.8%, p = 0.001).

Conclusion

In spite of all the difficulties in maintaining a phase III CR program during the COVID-19 pandemic, we observed that in physically active CAD Ps, with the aid of new technologies and remote follow-up (during the lockdown periods) and face to face exercise sessions, it is still possible to have functional gains and improvements in CRF.

TAVI, multidimensional early benefits in elderly patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic stenosis is the most common valvular heart disease in Europe and in symptomatic patients, when untreated presents a high rate of morbidity and mortality. Its prevalence is estimated to grow even more, given the aging of the population. Transcatheter aortic valve implantation (TAVI) emerged as a safe and efficient procedure in patients with high or prohibitive surgical risk or in older patients, who are much often frailty, with impaired cognitive function and have poor quality of life.

Aim

To assess the acute benefits (in 1 moth) of TAVI on cognitive function, anxiety and depression and independence in activities of daily living.

Methods

Single center prospective study of patients submitted to TAVi between April 2021 and September 2021. Patients were evaluated at baseline (before TAVI) and one month after the procedure. To assess cognitive function, anxiety and depression and independence in activities of daily living we used the Mini Mental State Examination (MMSE), Hospital Anxiety and Depression Scale (HADS); Katz Index of Independence in Activities of Daily Living; and Lawton-Brody Instrumental Activities of Daily Living Scale, respectively. Paired sample t-test and Wilcoxon test were used to statistical analysis.

Results

We included 20 patients, with a mean age of 85±5,86 years, 40% (8) male. 19 patients undergone TAVI due severe native aortic stenosis and 1 due to bioprosthetic aortic valve dysfunction. The vascular access site was transfemoral in 19 patients and transapical in 1 patient. The median MMSE results were higher 1 month after TAVI (21,3 versus 23,5, p=0,012), essentially due to a better results in the temporal orientation and evocation domains (p=0,011 and p=0,022, respectively). Patients experienced lower levels of anxiety and depression after TAVI, mean score 5,4 versus 3,9 (p=NS) and 7 versus 4,25 (p=0,002) respectively for anxiety and depression, as assessed by HADS scale. No statistical difference was observed on the results of basal and post TAVI evaluation of Katz and Lawton-Brody scales.

Conclusion

In an elderly population, TAVI appears to have an early and beneficial effect on cognitive function and depression, but no benefits were observed on independence in activities of daily living.

Optimizing treatment for non muscle-invasive bladder cancer with an app

OBJECTIVES

To evaluate overall and recurrence-progression rate-adjusted concordance of treatment prescription in non-muscle-invasive bladder cancer (NMIBC) of an app based on the best available scientific evidence and the urologist's opinion.

METHODS

Development of an app (APPv) specifically designed for the treatment and follow-up of NMIBC and validation of the proposed APPv treatment endpoint by means of a prospective double-blind observational concordance study of related samples in 100 patients with initial or successive histological diagnosis of NMIBC.

RESULTS

The treatment prescribed by the urologist agrees with that proposed by the APPv in 64% of cases (kappa index 0.55, P < 0.0001). Regarding low risk, the agreement is 77% (kappa 0.55, P = 0.002), 63% (kappa 0.52, P < 0.0001) for intermediate risk, 17% (kappa 0.143, P = 0.014) in high risk and 66% (kappa 0.71, P = 0.01) for very high risk. Of patients receiving adjuvant intravesical treatment according to APPv, 89.1% remain free of recurrence vs. 61.1% of those with disagreement (P = 0.0004), with a RR 0.46 (95%CI: 0.25-0.86) vs. RR 2.4 (95%CI: 1.5-3.8, P = 0.001). In the APPv-urologist agreement group, 100% of patients are free of progression and 88.9% in the disagreement group (P = 0.004) with a RR 1 vs. RR 1.125 (95%CI: 1-1.26, P = 0.004).

CONCLUSIONS

APPv can improve adherence to treatment recommendations according to clinical practice guidelines and health outcomes at NMIBC.

Test-Retest Reliability and Sensitivity to Change of Ultrasound-Based Methods of Measuring Synovial Inflammation in Knee Osteoarthritis

OBJECTIVES

To assess test-retest reliability of musculoskeletal ultrasound (US) measures of inflammation in patients with knee osteoarthritis (OA) and to assess the sensitivity to change of US measures of inflammation in patients with knee OA.

METHODS

To mimic a common clinical scenario, 36 patients (n = 70 knees) with symptomatic knee OA who were in stable condition underwent 2 assessments within 14 days by different operators and different US machines, graded by a single rater. Test-retest reliability was measured using Cohen's kappa coefficient, intraclass correlation coefficient (ICC), and absolute agreement parameters. A total of 51 patients (n = 72 knees) were tested immediately before and 21-28 days after intraarticular glucocorticoid injection to investigate sensitivity to change and longitudinal construct validity. Paired t-tests and standardized response mean (SRM) were used to assess sensitivity to change. Multivariate linear regression was used to investigate longitudinal construct validity of US with Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scores, while adjusting for covariates.

RESULTS

US measures of inflammation demonstrated moderate (κ = 0.41, 0.60) to substantial (κ = 0.61, 0.80) agreement. Quantitative measures of synovitis and effusion demonstrated good test-retest reliability (ICC_2,1 0.71, 0.92). US measures of synovitis and effusion demonstrated low-to-moderate sensitivity to change (SRM -0.29, -0.50). The associations between changes in US measures and KOOS pain scores over time were low, and 95% confidence intervals included zero.

CONCLUSION

In a clinical setting, US measures of inflammatory features of knee OA have substantial reliability and low-to-moderate sensitivity to change, whereas measures of structural OA features are less reliable. Longitudinal construct validity of US measures of synovitis and effusion to KOOS pain scores is not strongly supported.

Impact of severe mitral annular calcification on mitral regurgitation after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who are at intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequent in patients with aortic stenosis, and its presence is associated with increased cardiovascular morbidity and mortality. Not infrequently, it is associated with significant morphologic and functional abnormalities of the mitral valve apparatus.

Purpose

 The aim of this work is to evaluate the relationship between severe MAC and the presence and development of significant mitral regurgitation after TAVI.

Methods

 We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019. Clinical, echocardiographic and procedure-related data were collected until a follow-up of 6 months. Statistical analysis was conducted on IBM SPSS® Statistics software. Descriptive statistics were calculated for all variables. Sample T-test, Chi-square and Wilcoxon sign test were used. A p-value &lt; 0.05 was considered significant. The presence and severity of MAC was defined according to echocardiographic data. Severe MAC was defined by the presence of calcification of more than half of the mitral annular circumference.

Results

 A total of 343 patients were enrolled in the study. The mean age of the population was 80 ± 8 years, 45% were male. Mean functional area was 0.75 ± 0.18 cm2, mean transvalvular pressure gradient was 48 ± 15 mmHg and the mean left ventricular ejection fraction (LVEF) was 54 ± 14%.  MAC was detected in 231 (67%) patients. In 44 (19%) of these patients, MAC was graded as severe. Patients with severe MAC tended to have higher prevalence of moderate (27.3 vs 20.4%, p = 0.30) as well as severe (4.5 vs 1.8%, p = 0.24) mitral regurgitation at baseline. After TAVI, the prevalence of moderate mitral regurgitation at 6 months was similar between both groups (22.5 vs 20.4%, p = 0.76). Although not reaching statistical significance, patients with severe MAC had higher prevalence of severe mitral regurgitation at 6 months post-procedure (12.2 VS 5.0%, p = 0.07) as well as higher incidence of worsening of mitral regurgitation (34.2 vs 23.7%, p = 0.16). The proportion of patients that had improvement (13.2 vs 15.0%, p = 0.76) or no change (52.6 vs 61.3%, p = 0.31) in the degree of mitral regurgitation was similar in both groups. 

Conclusion

 The presence of severe MAC at baseline echocardiography in patients undergoing TAVI may be associated with worsening of mitral regurgitation after the procedure. These patients tend to have higher prevalence of severe mitral regurgitation post-TAVI. Further studies are needed in order to further elucidate this association.

Can aortic calcium score predict new conduction disturbances in pos-transcatheter aortic valve implantation?

Funding Acknowledgements

Type of funding sources: None.

Background

Transcatheter aortic valve implantation (TAVI) may be the first line treatment for severe aortic stenosis according to overall patient characteristics. Semi-quantitative Agatston score (AS), which quantifies aortic calcium by cardiac computed tomography (CCT), has knowledgeable practical and clinical implications, and is performed in TAVI diagnostic workup. Since conduction disturbances continue to be the most frequent complication, further refinements are required to predict high-risk patients.

Purpose

To access if aortic AS relates with new conduction disturbances and permanent pacemaker (PPM) implantation in patients undergoing TAVI.

Methods

We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019; patients with previous permanent pacemaker (PPM) or had no aortic AS were excluded. Clinical and electrocardiogram (ECG) data were collected at admission and after the procedure. All categorical variables are reported as numbers and percentages. Continuous variables were analyzed using the two-tailed unpaired Student’s t-test and are reported as mean values and the standard deviation. Statistical analysis was performed using the IBM SPSS.

Results

172 patients with a mean age 79 ± 9.1 years old were included (see table 1 for baseline characteristics). AS was on average 3008 ± 2262 (see table 2 for remaining diagnostic workup and procedure characteristics).

Comparing AS with new conduction disturbances, no statistically significant difference was found for new complete left branch block (LBBB) (no vs new LBBB, AS: 3179 ± 2555 vs 2637 ± 1388, p= 0,15) and with new complete atrioventricular block (AVB) (no vs new AVB, AS: 2834 ± 1520 vs 4485 ± 5285, p = 0.2). Considering PPM implantation after TAVI, there was a tendency for higher AS and PPM implantation (no vs PPM implantation, AS: 2756 ± 1451 vs 4242 ± 4310, p = 0.07).

In patients who had pre-ballooning, there was no difference relating to AS; however, in patients who had no pre-ballooning there was a trend to higher AS and PPM implantation (no vs PPM implantation, AS: 2417 ± 1301 vs 4616 ± 4969, p = 0.06). No statistically significant difference was found when comparing earlier (Portico, CoreValve Evolut R) vs newer valves (CoreValve Evolut Pro; Edward Sapiens 3; Accurate Neo).

Conclusion

Aortic calcium measured by Agatston score did not show a correlation with new LBBB or new AVB after TAVI. Nevertheless, it seems to be a trend for higher AS and PPM implantation; this was more noticeable when pre-ballooning was not performed. Further studies are needed in order to further elucidate this association. Abstract Figure. Patients baseline characteristics  Abstract Figure. TAVI diagnostic workup and procedure

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined.

PURPOSE/HYPOTHESIS

The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level.

RESULTS

Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture.

CONCLUSION

The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Synovial tissue perivascular edema is associated with altered gait patterns in patients with knee osteoarthritis

OBJECTIVE

To explore mechanisms of mechanoinflammation, we investigated the association between the presence of knee synovial perivascular edema and gait biomechanics that serve as surrogate measures of knee load in patients with knee osteoarthritis (OA).

DESIGN

Patients with symptomatic, radiographic knee OA and neutral to varus alignment undergoing total knee arthroplasty or high tibial osteotomy participated in this cross-sectional analysis. All participants underwent 3D gait analysis prior to surgery. Synovial biopsies were obtained during surgery for histopathological assessment. The association between the presence of synovial perivascular edema (predictor) and the external knee moment (outcome) in each orthogonal plane was analyzed using multivariate linear regression and polynomial mixed effects regression models, while adjusting for age, sex, BMI, and gait speed.

RESULTS

Ninety-two patients with complete gait and histopathological data were included. When fitted over 100% of stance, regression models indicated substantial differences between patients with and without synovial perivascular edema for knee moments in frontal, sagittal and transverse planes. The knee adduction moment was higher in patients with edema from 16 to 74% of stance, with the largest difference at 33% of stance (β = 6.87 Nm [95%CI 3.02, 10.72]); whereas the knee flexion-extension moment differed from 15 to 92% of stance, with the largest difference in extension at 60% of stance (β = -10.80 Nm [95%CI -16.20, -5.40]).

CONCLUSIONS

In patients with knee OA, the presence of synovial perivascular edema identified by histopathology is associated with aberrant patterns of knee loading throughout stance, supporting the link between biomechanics and synovial inflammation.

Training responsiveness of cardiorespiratory fitness and arterial stiffness following moderate-intensity continuous training and high-intensity interval training in adults with intellectual and developmental disabilities

BACKGROUND

Cardiorespiratory fitness (CRF) prompts antiatherogenic adaptations in vascular function and structure. However, there is an extraordinary interindividual variability in response to a standard dose of exercise, wherein a substantial number of adults with intellectual and developmental disabilities (IDD) do not improve CRF. We (1) evaluated the effects of 12-month of moderate-intensity continuous training (MICT) on CRF and arterial stiffness and (2) tested whether an additional 3-month of high-intensity interval training (HIIT) would add to improvements in CRF responsiveness and arterial stiffness.

METHODS

Fifteen adults with mild-to-moderate IDD (male adults = 9, 30.1 ± 7.5 years old) met 3 days per week for 30 min MICT for 12 months, after which the incidence of CRF responsiveness was calculated (≥5.0% change in absolute peak VO₂ ). Thereafter, responders and non-responders started HIIT for 3 months with identical daily training load/frequency. Peak VO₂ , local and regional indices of arterial stiffness were assessed prior to and after each period.

RESULTS

Sixty per cent of the participants were non-responders following MICT, but the incidence dropped to 20% following HIIT (P = 0.03). Absolute peak VO₂ values reached significant difference from pre-intervention (+0.38 ± 0.08 L min^-1 , P = 0.001) only when HIIT was added. Lower limb pulse wave velocity (PWV) decreased following MICT (-0.8 ± 1.1 m s^-1 , P = 0.049), whereas central PWV only decreased following HIIT (-0.8 ± 0.9 m s^-1 , P = 0.013).

CONCLUSIONS

Cardiorespiratory fitness responsiveness and reductions in PWV to a 12-month MICT period in adults with IDD improved following a period of HIIT programme inducing higher metabolic stress.

Identification of the novel HLA-B allele, HLA-B*44:532 by next-generation sequencing

The novel HLA-B*44:532 allele differs from HLA-B*44:02:01:01 by one nucleotide substitution in Exon 3. This article is protected by copyright. All rights reserved.

Catheter ablation supported by extracorporeal membrane oxygenation -last resort treatment of arrhythmic storm?

Introduction

Arrhythmic storm (AS) is associated with high mortality, even with best medical care and hemodynamic support. If medical therapeutic failure, electrophysiological mapping and ablation are potential lifesaving therapies. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and can be used as a salvage intervention in patients with cardiogenic shock. Considering the seriousness of AS and the technical complexity involved, catheter ablation supported by VA-ECMO is infrequently performed. We sought to assess the safety and effectiveness of emergent catheter ablation procedures performed in patients on VA-ECMO at our hospital.

Methods

Retrospective study of all ventricular tachycardia (VT) catheter ablation procedures performed with VA-ECMO support at a tertiary centre between 2016 and 2020. Follow-up data was obtained from review of electronical records.

Results

Five patients underwent 6 emergent VT ablation procedures due to AS. The median age was 62 years (range, 52) and 4 patients were men. Three patients had VT at admission, while 2 were admitted with an acute coronary syndrome and developed VT during the hospitalization. Four patients had ischemic heart disease, though only 1 had previous history of VT; the remaining patient presented no structural heart disease. Median left ventricle ejection fraction was 11% (range 30).

All patients had incomplete response to amiodarone, lidocaine or overdrive pacing, before being proposed to catheter ablation. Four patients were on ECMO support before ablation, while 1 was cannulated during the procedure due to hemodynamic instability. Ablation was performed using a retrograde approach in 3 patients, and combined retrograde and transeptal access in 2; one patient had epicardial ablation after unsuccessful endovascular approach. Three patients had left ventricle substrate ablation and the remaining 2 of the right ventricle. No major complications were seen directly related to the procedures.

The median length of stay in intensive care unit was 22 days (range 41 days). Weaning of VA-ECMO was accomplished in all patients. Two patient died during the same hospitalization (one due to uncontrolled arrhythmic events). At a median 23 months (range 31) of follow-up of the surviving patients, two had recurrence of VT but no one had return of AS.

Conclusion

In our sample VT ablation on VA-ECMO support was a safe procedure, with no immediate complications. However, as reported in the literature, a high mortality rate was observed both in-hospital and during follow-up, mostly related to advanced structural heart disease. Also, considerable VT recurrence rates were seen, but with no re-hospitalization. Our experience shows that catheter ablation is a life-saving procedure in otherwise uncontrollable AS and allowed absolute success in weaning VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Synovitis is associated with constant pain in knee osteoarthritis: a cross-sectional study of OMERACT knee ultrasound scores

OBJECTIVE

To examine the association between ultrasound (US)-detected knee inflammation and intermittent and constant pain experiences in patients with knee osteoarthritis (OA).

METHODS

Participants with radiographically early- (KL ≤ 2) and late-stage (KL ≥ 3) disease and frequent symptoms underwent musculoskeletal US measures of inflammation using the OMERACT knee US scoring system. Pain experiences were captured using the Intermittent and Constant OA Pain (ICOAP) tool. We assessed the association between US-synovitis and ICOAP pain experiences using a series of linear, logistic, or multinomial logistic regression models (as appropriate for each variable), while adjusting for age, sex, body mass index (BMI), and radiographic stage. Secondary analyses were performed similarly by radiographic stage.

RESULTS

Pain and synovitis measures from 248 patients (453 knees) were included. Worse synovitis was associated with higher ICOAP constant pain scores (β 8.05 [95%CI 0.67, 15.43]), but not intermittent pain scores. Moderate-to-severe synovitis was associated with a 4.73-fold increased relative risk [95%CI 1.06, 8.80] of a constant pain pattern. In secondary analyses, moderate-to-severe synovitis in early radiographic OA was associated with 2.70-higher odds [95%CI 1.04, 7.02] of any constant pain, 3.28-higher odds [95%CI 1.43, 7.52] of any intermittent pain, and with higher intermittent (β 10.47 [95%CI 1.03, 19.91]) and constant (β 12.62 [95%CI 3.02, 22.23]) pain scores. No associations identified for synovitis in those with late radiographic OA.

CONCLUSION

In patients with knee OA, moderate-to-severe synovitis is most strongly associated with constant pain. Inflammation may play context-specific roles across pain experiences, especially in earlier radiographic stages of knee OA.

Body composition, lipid profile and mediterranean diet adherence in cardiovascular disease patients attending a long-term exercise-based cardiac rehabilitation program during COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Cardiovascular disease (CVD) is recognized as a major public health issue and remains the leading cause of mortality worldwide. There is a clear association between adiposity, blood lipid profile, and adherence to the Mediterranean diet (MD) with the risk of CVD. However, the assessment of body composition parameters, dietary patterns and nutritional intervention in CVD patients undergoing a cardiovascular rehabilitation (CR) program remains insufficient. 

Purpose

 to characterize body composition, lipid profile and MD adherence in patients with CVD who were attending an exercise-based CR program during COVID-19 era. 

Methods

 The study was developed between October 2020 and January 2021 in a phase III centre-based CR program. Body composition was assessed by dual energy x-ray absorptiometry Hologic Explorer-W. Adherence to the MD was assessed by the 14-item MD questionnaire. Fasting blood sample was taken for measurement of lipid profile. 

Results

 A sample of 41 patients (mean age 64.4 ± 7.9 years, 87.8% male) was evaluated. The most prevalent CVD were coronary artery disease (89.5%) and heart failure (21.1%). The main CVD risk factors at admission in the CR program were dyslipidaemia (71.1%), hypertension (68.4%), physical inactivity (26.3%) and diabetes mellitus (21.0%). In our sample the mean body mass index was 28 ± 3.8 kg/m2, being most patients overweight (75.6%), and having a substantially increased risk of metabolic complications (85.3%) accordingly to waist-hip ratio. Body composition assessment showed that 14.6% of the patients had a body fat mass index above 90th percentile. Although only 9.8% of the patients had reduced fat free mass, 17.1% showed appendicular lean mass below the reference value. In addition, less than one third of the patients (31.7%) revealed a high adherence to the MD pattern. A sub-analysis on blood lipids (n = 26) showed that most patients had levels of LDL cholesterol (76.9%) and non-HDL cholesterol (65.4%) above the therapeutic target and 15.4% had triglycerides higher than 150 mg/dl. 

Conclusion

 Body composition, lipid profile and dietary patterns, play a major role in CVD secondary prevention. Our findings showed that a substantial number of CVD patients, in COVID-19 era, did not have optimal body composition, were above lipid profile targets, and had a low/medium adherence to the MD. Thus, this study highlights the relevance of nutrition on cardiometabolic status and demonstrates the crucial role of nutritional intervention as an integrated part of a long-term phase III CR program. Moreover, further research about nutritional intervention in patients undergoing CR is warranted.

COVID-19 era in long-term cardiac rehabilitation programs: how did physical activity and sedentary time change compared to previous years?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiovascular rehabilitation (CR) was one of the many areas negatively affected by the COVID-19 pandemic. A high number of cardiovascular disease (CVD) patients had their centre-based program suspended. Physical activity (PA) recommendations for CVD patients are well established and its benefits largely documented. However, few studies have objectively measured the PA of these patients throughout the years and specifically during the COVID-19 pandemic. 

Purpose

To objectively measure PA and sedentary time (ST) during COVID-19 pandemic in comparison with the previous 2 years in CVD patients who were attending a phase III centre-based CR program. 

Methods

Before COVID-19, eighty-seven CVD patients (mean age 62.9 ± 9.1, 82.8% male) were attending a face-to-face long-term CR program. Of the 87 patients, 78.2% have been on the program for at least 1 year. Every year, PA and ST were objectively assessed by accelerometery. After the CR centre-based program suspension due to COVID-19, efforts were done to create a CR home-based digital model to maintain the continuum of care and avoid losing the previous acquired benefits. After 7 months of suspension, the face-to-face CR centre was reopened and 57.5% (n = 50) patients returned. We completed the assessment of PA and ST of 37 patients (mean age 64.8 ± 8.1, 89.2% male) and compared it as follows: M1) two assessments before COVID-19; M2) last assessment before COVID-19; M3) 7 months after CR program suspension (last trimester of 2020). Patients wore an ActiGraph accelerometer for 7 consecutive days to assess daily and weekly minutes of light PA, moderate-to-vigorous PA and ST. We used repeated-measures ANOVA and Wilcoxon signed rank as a non-parametric alternative.

Results

Intention-to-treat analysis showed that in M3 patients decreased their average daily time spent in moderate-to-vigorous PA when compared with M2 (M3: 37.90 ± 3.30 min/day vs M2: 45.01 ± 3.14 min/day, p = 0.035), no changes were found between M1 and M2. Average daily time spent in light PA improved significantly from M1 to M2 (M1: 154.81 ± 7.20 min/day vs M2: 169.17 ± 6.44 min/day, p = 0.042) but did not change from M2 to M3. Despite this, in M3, 81.08% of the patients still met the recommendations for moderate-to-vigorous PA (M1: 89.19% and M2: 91.89%). No changes were found in ST.

Conclusion

Despite a significant decrease on the amount of moderate-to-vigorous PA during the COVID-19 era, most CVD patients, first in the centre-based CR program and after in the home-based CR program, were able to meet PA recommendations throughout the last years. These findings suggest that CVD patients who attend supervised long-term CR programs might be aware of the importance of reaching PA guidelines. Reducing ST by replacing it by PA of any intensity could be an important and reachable target for long-term CR programs.

Home-based cardiac rehabilitation during COVID-19 pandemic: effectiveness of an educational intervention

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patient education is considered a core component of cardiac rehabilitation (CR) and nowadays, particularly during the COVID-19 pandemic, online education programs are critical. However, the best strategy for implementing these digital programs to increase patients’ adherence and learning is not fully established.

Purpose

To assess the uptake and effectiveness of an educational intervention transmitted through video sessions integrated into a home-based CR program (CR-HB).

Methods

Prospective cohort study including patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB program during COVID-19 pandemic. The CR-HB  program consisted of a multidisciplinary online program with educational videos for pts and family members / caregivers, that aimed to educate on necessary behavioural and lifestyle changes. Weekly, a 15-minute video was uploaded and lectured by the correspondent health professional from the CR team. The educational sessions covered the following topics: COVID-19 and cardiovascular (CV) disease, coronary artery disease, hypertension, dyslipidemia, smoking cessation, diabetes, medical therapy and adherence, healthy diet, exercise and physical activity, sedentary behaviour and sexual dysfunction and CV disease.

At the end of the program we applied a 10 questions questionnaire to evaluate the knowledge of pts about the topics of educational sessions. All the pts answered the questionnaire and results were compared between the pts who attended the educational sessions and the ones who didn’t.

Results

 

116 pts with CV disease were included in the CR-HB program (62.6 ± 8.9 years, 95 males). Almost 90% (n = 103) of the participants had coronary artery disease and the mean LVEF was 52 ± 11%. Obesity was the most common risk factor (75%) followed by hypertension (60%), family history of CV disease (42%), dyslipidemia (38%), diabetes (18%), and smoking (13%).

The pts participated, on average, in 1.45 ± 2.6 education sessions (rate participation of 13.2%). About half of the pts (49%) attended, at least, one session and these pts attended, on average, 3 sessions (2.96 ± 3.0). The questionnaire results were better in pts who attended at least 1 educational session than in those who did not attend any (7.4 ± 1.9 vs 7,1 ± 1.7), however this difference was not statistically significant.

Regarding education status, 33 pts (45.2%) had a bachelor degree and this group of pts had a significant higher result in questionnaire (7.8 ± 1.9 vs 6.7 ± 1.8; p = 0.015) and tended to participate more often in education sessions (2.13 vs 1.6, p = 0.06).

Conclusions

Our study showed a low rate of participation in sessions, highlighting the importance of developing strategies to increase motivation and adherence to online educational programs. Also, more literate patients had significantly greater health knowledge and adherence to educational sessions, suggesting that this population could benefit more from this type of programs.

Cardiovascular risk factor control: is it possible with a home-based cardiac rehabilitation program?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiovascular risk factors (CVRF) control, needing different strategies, through patient education, lifestyle changes and therapeutic optimization is a central core of cardiac rehabilitation. However, further studies are needed to demonstrate effectiveness of home-based Cardiac Rehabilitation (CR-HB) programs in controlling CVRF.  

Purpose

To evaluate the effectiveness of a CR-HB program in controlling cardiovascular risk factors.

Methods

Prospective cohort study including patients who were previously participating in a centre-based CR program and accepted to participate in a CR-HB program due to forced closure of the centre-based CR program for COVID-19 pandemic. The CR-HB consisted of a multidisciplinary digital CR program, including patient regular assessment, exercise, educational, and psychological and relaxation sessions. A structured online educational program for patients and family members/caregivers was provided including educational videos, and powerpoints and webinars. A real time Webinar regarding "nutritional myths and facts" was organized with the duration of 90 minutes as a substitution of the regular face-to-face regular workshop provided at our centre-based CR program. Also, self-control of blood pressure and heart rate and of glycemia in diabetics were promoted, as well as smoking cessation.

To assess the impact of the CR-HB on risk factors control, all the patients were submitted to a clinical and analytical evaluation before and after the end of this at distance program. 

Results

116 cardiovascular disease patients (62.6 ± 8.9 years, 95 males) who were attending a face-to-face CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease. Regarding risk factors, obesity was the most prevalent risk factor (74.7 %) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 

Regarding the blood pressure control, 80% of the patients stated that almost daily they measured blood pressure at home; baseline systolic pressure decreased from 117 ± 13 to 113 ±12mmHg, p = 0.007, while there was no significant change in diastolic pressure.  

The majority (76%) of diabetic patients said they controlled blood glucose; HbA1c decreased from 6.1 ± 1.1 to 5.9 ± 0.9mg/dL (p = 0.047).

Considering the lipid profile, LDL decreased (from 75 ± 30 to 65 ± 26mg/dL, p = 0.012). The Nt-proBNP also decreased (818 ± 1332 vs 414pg/ml ± 591, p = 0.042). There were no other statistically significant differences concerning risk factors modification. 

Conclusions

Our study showed that a Home-based Cardiac Rehabilitation program can improve or maintain cardiovascular risk factors control, which has important prognostic implications and is frequently a difficult task to achieve.

Digital home-based multidisciplinary cardiac rehabilitation: the way to counteract physical inactivity during the COVID-19 pandemic?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Centre-based cardiac rehabilitation (CR) programs have been forced to close due to the need for physical and social distancing imposed by COVID-19 pandemic. A major problem emerges concerning the potential harmful effects resulting from the suspension of the centre-based CR programs, leading to physical inactivity and unhealthy lifestyle routines. Therefore, the development of alternative delivery models to maintain access to CR programs and to avoid physical inactivity should be organized and tested.

Purpose

To assess the physical activity (PA) levels in a group of patients with known cardiovascular disease (CVD), after completing 3-months of a home-based multidisciplinary digital CR program, organized as an alternative method to the centre-based CR suspended program.

Methods

One hundred and sixteen patients with CVD (62.6 ± 8.9 years, 95 males) who were previously attending a face-to-face CR program were included and the following parameters were assessed at baseline and 3 months: self-reported PA and sedentary behaviour, adherence to the online CR program, cardiovascular and non-cardiovascular symptoms, feelings towards the pandemic, dietary habits, risk factor control, safety and adverse events. The intervention consisted in a multidisciplinary digital CR program, including online exercise training sessions, online educational sessions, psychological online group sessions, risk factor control, nutritional and psychological consults and patient regular assessment by cardiologist and nurse.

Results

Ninety-eight CVD patients successfully completed all the online assessments (15.5% drop-out). It was observed a significant increase from moderate-to-vigorous PA (230 ± 198 mins/week to 393 ± 378 mins/week, p < 0.001) and a decrease of the sedentary time at 3-months (6.47 ± 3.26 hours/day to 5.17 ± 3.18 hours/day, p < 0.001). Seventy percent of the patients met the PA recommendations and 41% reached more than 300 minutes per week of moderate to vigorous PA at 3 months. Almost half of the participants (46.9%) did at least more than one online exercise training session per week and attended at least one of the online educational sessions. There were no major adverse events reported and only one minor non-cardiovascular event occurred.

Conclusion

Patients with CVD, who suspended centre-based CR due to COVID-19 pandemic and started a home-based multidisciplinary digital CR program, had a significant improvement in moderate to vigorous PA after 3 months. Therefore, home-based CR programs showed to be a good option for selected clinically stable patients, who are eligible for CR and cannot attend a centre-based CR program due to COVID-19 pandemic or eventually other reasons.

Left ventricular remodeling: is there a real impact of cardiac rehabilitation?

Funding Acknowledgements

Type of funding sources: None.

Introduction

A number of randomized controlled trials have examined the effect of exercise training on left ventricle (LV) remodeling in individuals with cardiovascular disease. However, the results of these trials have been inconclusive. 

Purpose

Evaluation of the impact of a cardiac rehabilitation program (CRP) on left ventricle remodelling evaluated by echocardiogram. 

Methods

Observational single centre study including consecutive patients, undergoing structured CRP since June 2016 until February 2020. Phase II CRP included 3 months of exercise training, aerobic and strength exercise, individually prescribed, 3 times a week, 60 minutes sessions. All patients were submitted to a clinical evaluation, echocardiogram, and cardiopulmonary exercise test before and after the CRP.

Results

205 patients (62.6 ± 11 years, 83.4% men, 82.3% ischemic disease) were included in a phase II CRP. Most patients had ischemic disease (82.3%) and 23.5% of patients had left ventricular ejection fraction (LVEF) &lt;40%. Of the cardiovascular risk factors, hypertension was the most prevalent (76%), followed by dyslipidaemia (67.4%), active smoking (45.9%) and diabetes (26.9%). 

After the CRP, there was a significant improvement of LVEF (from 48.3 ± 13 to 52 ± 11.6 %, p = 0.001) and a significant reduction of LV volumes (LV end-diastolic volume, LVEDV , decreased from 140 ± 81 to 121 ± 57, p = 0.002; LV end-systolic volume , LVESV , reduced from 80 ± 75 to 64 ± 48, p = 0.004). Considering only the patients with LVEF &lt; 40% (n = 38), the improvement was even greater: LVEF increased from 30 ± 8 to 39 ± 13 (p = 0.002); LVEDV reduced from 206 ± 107 to 159 ± 81 (p = 0.001) and LVESV reduced from 142 ± 99 to 101 ± 66 (p = 0.002). 63.6%(n = 14) of these patients improved at least 10% of LVEF and only 1 of them had a cardiac resynchronization therapy device. 

Conclusions

A phase II CR program was associated with significant improvements in left ventricular reverse remodelling irrespective of baseline EF classification. Those with reduced baseline EF derived an even greater improvement, highlighting the great importance of CR in this subgroup of patients.

Home-based Cardiac Rehabilitation - the real barriers of programs at distance

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite the established benefits of cardiac rehabilitation (CR), it remains significantly underutilized. Home-based CR (CR-HB) programs should offer the same core CR components as Centre-based programs (CR-CB) but several aspects need to be adapted, communication and supervision must be improved. Although CR-HB has been successfully deployed and is a valuable alternative to CR-CB, there is less structured experience with these non-uniform programs and further studies are needed to understand which patients (pts) are indicated to this type of program.

Purpose

To investigate pt-perceived facilitators and barriers to home-based rehabilitation exercise.

Methods

Prospective cohort study which included pts who were participating in a CR-CB program and accepted to participate in a CR-HB program after CR-CB closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including pt risk evaluation and regular assessment, exercise, educational and psychological sessions. The online exercise training sessions consisted of recorded videos and real time online supervised exercise training group sessions. It was recommended to do each session 3 times per week, during 60 min. A pictorial exercise training guidebook was available to all participants including instructions regarding safety, clothing and warm-up, and a detailed illustrated description of each  exercise sessions. Also, for questions or difficulties regarding the exercises, an e-mail and telephone was provided. Once a month, real time CR exercise sessions was provided with a duration of 60min.

Results

116 cardiovascular disease pts (62.6 ± 8.9years, 95 males) who were attending a face-to-face CR program were included in a CR-HB program. The majority of the pts had coronary artery disease (89%) and 5% valvular disease. Regarding risk factors, obesity was the most common (75%) followed by hypertension (60%), family history (42%), dyslipidaemia (38%), diabetes (18%), and smoking (13%). Almost half (47%) of the participants did at least one online exercise training session per week: 58% did 2-3 times per week, 27% once per week and 15% more than 4 times per week. Participants who did less than one exercise session per week reported as cause: lack of motivation (38%), preference of a different mode of exercise training such as exercise in the exterior space (26%), technology barrier such as impossibility to stream online videos (11%), fear of performing exercise without supervision (4%), and limited space at home (4%).

Conclusions

Our study based on real-life results of a CR-HB program shows a sub-optimal rate of participation in exercise sessions due to different causes, but mainly for the lack of motivation to exercise alone or preference for walking in exterior space. The knowledge of the CR-HB program barriers will facilitate to find out strategies to increase the participation rate and to select the best candidates for this type of programs.

COVID-19 era in long-term cardiac rehabilitation programs: how was muscle strenght and lean mass affected in cardiovascular patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Exercise prescription is one of the main components of phase III Cardiac Rehabilitation (CR) programs due to its documented prognostic benefits. It has been well established that, when added to aerobic training, resistance training (RT) leads to greater improvements in peripheral muscle strength and muscle mass in patients with cardiovascular disease (CVD). With COVID-19, most centre-based CR programs had to be suspended and CR patients had to readjust their RT program to a home-based model where weight training was more difficult to perform. How COVID-19 Era impacted lean mass and muscle strength in trained CVD patients who were attending long-term CR programs has yet to be discussed.

Purpose

To assess upper and lower limb muscle strength and lean mass in CVD patients who had their centre-based CR program suspended due to COVID-19 and compare it with previous assessments.

Methods

87 CVD patients (mean age 62.9 ± 9.1, 82.8% male), before COVID-19, were attending a phase III centre-based CR program 3x/week and were evaluated annually. After 7 months of suspension, 57.5% (n = 50) patients returned to the face-to-face CR program. Despite all constraints caused by COVID-19, body composition and muscle strength of 35 participants (mean age 64.7 ± 7.9, 88.6% male) were assessed. We compared this assessment with previous years and established three assessment time points: M1) one year before COVID-19 (2018); M2) last assessment before COVID-19 (2019); M3) the assessment 7 months after CR program suspension (last trimester of 2020). Upper limbs strength was measured using a JAMAR dynamometer, 30 second chair stand test (number of repetitions – reps) was used to measure lower limbs strength and dual energy x-ray absorptiometry was used to measure upper and lower limbs lean mass. Repeated measures ANOVA were used.

Results

Intention to treat analysis showed that upper and lower limbs lean mass did not change from M1 to M2 but decreased significantly from M2 to M3 (arms lean mass in M2: 5.68 ± 1.00kg vs M3: 5.52 ± 1.06kg, p = 0.004; legs lean mass in M2: 17.40 ± 2.46kg vs M3: 16.77 ± 2.61kg, p = 0.040). Lower limb strength also decreased significantly from M2 to M3 (M2: 23.31 ± 5.76 reps vs M3: 21.11 ± 5.31 reps, p = 0.014) after remaining stable in the year prior to COVID-19. Upper limb strength improved significantly from M1 to M2 (M1: 39.00 ± 8.64kg vs M2: 40.53 ± 8.77kg, p = 0.034) but did not change significantly from M2 to M3 (M2 vs M3: 41.29 ± 9.13kg, p = 0.517).

Conclusion

After CR centre-based suspension due to COVID-19, we observed a decrease in upper and lower limbs lean mass and lower limb strength in previously trained CVD patients. These results should emphasize the need to promote all efforts to maintain physical activity and RT through alternative effective home-based CR programs when face-to-face models are not available or possible to be implemented.

Home-based Cardiac Rehabilitation: the patients claim for new strategies but do they adhere?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation (CR) programs are established interventions to improve cardiovascular health, despite asymmetries in referral. With covid 19 outbreak, cardiac rehabilitation home based (CR-HB) programs emerged as an alternative. However, its adherence and implementation may vary greatly with socio-demographic factors.

Purpose

To assess adherence to the various components of a CR-HB program. 

Methods

Prospective cohort study which included patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB after the centre-based CR program closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including: 1.patient clinical and exercise risk assessment; 2.psychological tele-appointments; 3. online exercise training sessions; 4.structured online educational program for patients and family members/caregivers;  5. follow-up questionnaires; 6. nutrition tele-appointments; 7. physician tele-appointments

Adherence to the program was assessed by

drop-out rate; number of exercise sessions in which each patient participated; number of educational sessions attended and a validated questionnaire on therapeutic adherence (composed of 7 questions with minimum punctuation of 7 and maximum of 40 points).

Results

116 cardiovascular disease (CVD) pts (62.6 ± 8.9 years, 95 males) who were attending a Centre-based CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease; 13.8% pts had heart failure; the mean LVEF was 52 ± 11%. Regarding risk factors, obesity was the most common risk factor (74.7 %) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 

Ninety-eight pts (85.5%) successfully completed the program. Almost half (46.9%) of the participants did at least one online exercise training session per week. Among the pts who did online exercise training sessions, 58% did 2-3 times per week, 27% once per week and 15% more than 4 times per week. 

The pts participated, on average, in 1.45 ± 2.6 education sessions (rate of participation of 13,2%) and therapeutic adherence was high (39,7 ± 19; min 35-40). 

Regarding educational status of the pts, 33 pts (45,2%) had a bachelor degree. These pts tended to participate more in exercise sessions (1,7 ± 1,7 vs 1,2 ± 1,4 sessions per week) and in education sessions (2.13 vs 1.6), although this difference was not statistically significant. The therapeutic adherence did not vary with patients’ level of education. 

Conclusion

Our results showed that a high percentage of patients completed the program and almost half were weekly physically active. However, in regard to educational sessions, the degree of participation was much lower. Educational status seemed to correlate with a higher degree of participation and, in the future, patient selection might offer better results in these kinds of programs.

Home-based Cardiac Rehabilitation in Covid Era: Is it a safe option?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Home-based Cardiac Rehabilitation (CR-HB) models have been shown to be effective, however, there is a large variation of protocols and minimal evidence of effectiveness in higher risk populations, in which exercise at distance might be concerning. In addition, lack of reimbursement models has discouraged the widespread adoption of CR-HB. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has emerged due to the decreased availability of on-site services.

Purpose

Evaluation of the safety of a CR-HB program during COVID-19 pandemic. 

Methods

Prospective cohort study which included patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB after the centre-based CR program closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including: 1.pts regular clinical and exercise risk assessment; 2.psychological tele-appointments and group sessions; 3. online exercise training sessions, which consisted of recorded videos and real time online exercise training sessions (each session recommended 3 times per week, during 60 minutes); 4.structured online educational program for pts and family members/caregivers, including educational videos and webinars; 5. follow-up fortnightly questionnaire to evaluate risk factors control and need for appointments or directing to hospital; 6. nutrition tele-appointments; 7. physician tele-appointments, scheduled according to follow-up questionnaire or at patients request (e-mail or telephone) to avoid unnecessary exposure and overload in the hospital. Minor and major adverse events such as hospitalizations due to cardiac event or other non CV reason, cardiac or noncardiac death, during or immediately after the exercise sessions, were collected.

Results

116 cardiovascular disease (CVD) pts (62.6 ± 8.9 years, 95 males) who were attending a Centre-based CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease; 13.8% pts had heart failure. The mean LVEF was 52 ± 11%; 31,1% of the population had at least moderate risk. Regarding risk factors, obesity was the most common risk factor (74.7%) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 

98 CVD pts (85.5%) successfully completed all the online assessments. Three male participants dropped out for hospitalization due to knee surgery, pacemaker implantation and in-stent restenosis without relation to exercise sessions. No major events were registered during the exercise training sessions and only one minor adverse event, sprained ankle, was reported during the training sessions.

Conclusions

This CR-HB program, originated by the need of social distancing during  COVID-19 pandemic, revealed to be a valuable and safe strategy to reach at distance most patients previously in a Centre-based CR program.

Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study

Background:

A spectrum of anterolateral rotatory laxity exists in anterior cruciate ligament (ACL)–injured knees. Understanding of the factors contributing to a high-grade pivot shift continues to be refined.

Purpose:

To investigate factors associated with a high-grade preoperative pivot shift and to evaluate the relationship between this condition and baseline patient-reported outcome measures (PROMs).

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A post hoc analysis was performed of 618 patients with ACL deficiency deemed high risk for reinjury. A binary logistic regression model was developed, with high-grade pivot shift as the dependent variable. Age, sex, Beighton score, chronicity of the ACL injury, posterior third medial or lateral meniscal injury, and tibial slope were selected as independent variables. The importance of knee hyperextension as a component of the Beighton score was assessed using receiver operator characteristic curves. Baseline PROMs were compared between patients with and without a high-grade pivot.

Results:

Six factors were associated with a high-grade pivot shift: Beighton score (each additional point; odds ratio [OR], 1.17; 95% CI, 1.06-1.30; P = .002), male sex (OR, 2.30; 95% CI, 1.28-4.13; P = .005), presence of a posterior third medial (OR, 2.55; 95% CI, 1.11-5.84; P = .03) or lateral (OR, 1.76; 95% CI, 1.01-3.08; P = .048) meniscal injury, tibial slope >9° (OR, 2.35; 95% CI, 1.09-5.07; P = .03), and chronicity >6 months (OR, 1.70; 95% CI, 1.00-2.88; P = .049). The presence of knee hyperextension improved the diagnostic utility of the Beighton score as a predictor of a high-grade pivot shift. Tibial slope <9° was associated with only a high-grade pivot in the presence of a posterior third medial meniscal injury. Patients with a high-grade pivot shift had higher baseline 4-Item Pain Intensity Measure scores than did those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14; P = .04); however, there was no difference between groups in baseline International Knee Documentation Committee, ACL Quality of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and Osteoarthritis Outcome Score subscale scores.

Conclusion:

Ligamentous laxity, male sex, posterior third medial or lateral meniscal injury, increased posterior tibial slope, and chronicity were associated with a high-grade pivot shift in this population deemed high risk for repeat ACL injury. The effect of tibial slope may be accentuated by the presence of meniscal injury, supporting the need for meniscal preservation. Baseline PROMs were similar between patients with and without a high-grade pivot shift.

A qualitative dominant mixed methods exploration of novel educational material for patients considering total knee arthroplasty

PURPOSE

To optimize non-operative management and decision making surrounding TKR we created educational whiteboard videos for patients with knee OA. The purpose of this study was to pilot our educational videos with end-users (patients) to determine patients' experiences and perspectives regarding the content and clarity of videos and to better understand their potential impact on patient's health behaviour. Materials and methods: This was a mixed methods evaluation, using a qualitative descriptive approach, of patients attending their first consultation with an arthroplasty surgeon for TKR. We conducted in-depth semi-structured interviews with patients. Three members of the research team coded data independently, implementing a thematic analysis. Results: Thirteen participants were included. Participants indicated that the videos enhanced their confidence and clarity surrounding their decision to undergo TKR. The videos also addressed several knowledge gaps in their understanding of OA management. Barriers to uptake of the education were identified including limited access to PTs and the challenge of weight loss. Conclusions: The current educational intervention was valued by patients with knee OA. Implementation of these videos may have important implications for patients, providers, and our health care system.IMPLICATIONS FOR REHABILITATIONPatients with knee OA referred by primary care physicians to arthroplasty surgeons have knowledge gaps that may influence their self-management and decision making surrounding their condition.Educational materials can address these gaps and support patients in their understanding and management of their condition, which may have important downstream implications.Barriers to accessing non-operative care including physiotherapy must be pre-emptively addressed to ensure that enhanced knowledge is met with improved access for patients.

Coronary artery fistulas: a single-center case series

Introduction

Coronary artery fistulas (CAFs) are rare anomalous connections between a coronary artery and a major vessel or cardiac chamber. Currently they are being increasingly encountered due to the more widespread use of various imaging modalities and coronary angiography. Although the vast majority of CAFs are incidentally diagnosed and have no clinical relevance, they can cause significant morbidity such as myocardial infarction, congestive heart failure and endocarditis.

Methods

A consecutive series of 55867 coronary arteriograms performed in our Cardiology Department from 2007 to 2019 was retrospectively investigated for the presence of coronary artery fistulas. Patients clinical, angiographic and therapeutic data up to november 2019 were analyzed. Data were obtained from medical records of hospital stay and subsequent consultations.

Results

We identified 50 patients who were diagnosed with one or more CAFs, with ages between 5 and 85 years (mean 59 years). 62% (n=31) were males.

The great majority of patients had a single fistula (n=34, 68%), 11 patients had two fistulas (22%), 1 patient had 3 fistulas (2%) and 4 patients had multiple fistulas (8%).

CAFs arose more frequently from the left anterior descending artery (n=27), followed by the right coronary (n=18), left circumflex (n=15), left main (n=5) and intermediate artery (n=2). The most frequent drainage site was the pulmonary artery (n=38).

The majority of CAFs were incidentally found (n=32; 64%) and thought to have no significance for the patients' clinical status. As for the rest of the patients, CAFs were diagnosed during evaluation of: a heart murmur (n=7); exertional chest pain with no associated significant atherosclerotic coronary artery disease (n=7); exertional dyspnea (n=2); positive exercise stress test (n=1); NSTEMI and cardiac arrest (n=1).

Regarding treatment, watchful waiting was the main approach (n=40; 80%). 3 patients had their CAFs closed during surgery for another heart condition (CABG/aortic valve replacement). In 1 patient, heart surgery was specifically conducted for fistula closure. 6 patients (12%) underwent fistula transcatheter closure.

Conclusion

CAFs are rare coronary anomalies and the majority has no clinical relevance, so watchful waiting is the commonest approach. When they are hemodynamically significant or symptoms/complications arise, surgical or transcatheter closure should be considered. This study describes the angiographic, clinical and therapeutic data of CAFs detected along the last 12 years in a single tertiary care center catheterization laboratory.

Funding Acknowledgement

Type of funding source: None

Associations Between Cadence and Knee Loading in Patients With Knee Osteoarthritis

OBJECTIVE

To test the hypothesis that higher walking cadence is associated with lower knee loading, while controlling for walking speed, in patients with medial compartment tibiofemoral osteoarthritis (OA).

METHODS

A total of 691 patients underwent quantitative gait analysis, including 3-dimensional knee moments and temporospatial parameters. Using multivariate linear regression, we tested the association of walking cadence with the knee adduction moment angular impulse (a surrogate measure of medial knee compartment load throughout the stance), while controlling for walking speed. We repeated the analysis while also adjusting for sex, age, body mass index, radiographic OA, knee pain, lateral trunk lean, foot progression angle, and mechanical axis angle, and while replacing the knee adduction moment angular impulse with other surrogate measures of knee loading.

RESULTS

While controlling for walking speed, we found that a lower cadence was associated with higher knee adduction moment angular impulse (standardized β = -0.396, P < 0.001), suggesting a 0.02% body weight × height × seconds (%BW × Ht × s) decrease in impulse for each step per minute increase in cadence (unstandardized β -0.020 %BW × Ht × s [95% confidence interval -0.027, -0.015]), and remained consistent after adjusting for covariates. A lower cadence was also associated with higher first (standardized β = -0.138, P = 0.010) and second peak knee adduction moment (standardized β = -0.132, P = 0.018), higher peak knee flexion moment (standardized β = -0.128, P = 0.049), and vertical ground reaction force (standardized β = -0.116, P = 0.035) in the adjusted analyses.

CONCLUSION

When controlling for walking speed, we found that a lower cadence is associated with higher knee loading per step in patients with medial tibiofemoral OA. Future research should investigate the potential beneficial biomechanical and clinical effects of increasing walking cadence in patients with knee OA.

AB1165 MEDICATION ADHERENCE DATA IN A RANDOMIZED TRIAL: LARGE CHALLENGES TO COME FROM RAW DATA TO A WORKABLE AND RELIABLE DATASET

Background:

Medication adherence in the GLORIA trial, among elderly patients with rheumatoid arthritis, is measured with caps that register openings of the medication bottle. At each study visit, one or two medication bottles with cap (kits) are dispensed, each containing 90 capsules. Multiple steps are needed to come to a workable dataset to describe adherence.

Objectives:

To describe the steps that are needed to come from raw data to a workable dataset to analyze adherence data that are recorded by electronic caps.

Methods:

The medication bottle contains a cap with the ability to register cap openings. The raw dataset from the caps consist of an excel file with one opening event per row, recorded as date and time. One cap yields approximately 90 rows. First, the kit numbers were matched to the corresponding patient numbers, that are recorded in another excel file. Instances where two kits were dispensed were recorded with two kit numbers in one cell and need to be copied to two cells with one kit number. Second, the VLOOKUP function was used to combine dates and kit numbers. One row now contains all openings from one kit. Then, the number of days between first opening and each next opening date was calculated. A range of 90 days was made to calculate how many times the bottle was opened on each day of the 90-days period. The results were color-coded to visualize instances of zero, one or ≥two openings on a day.

Results:

The colored calendar matrix (Figure 1) can now be used to categorize adherence patterns.

Conclusion:

A monitoring cap seems a simple instrument to measure adherence. However, multiple steps and a lot of time are needed to come to a workable dataset for the study of adherence patterns.

Acknowledgments:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‟Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

Linda Hartman: None declared, Elisa Alessandri: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

FRI0581 IN ELDERLY PATIENTS, CAPS THAT RECORD MEDICATION BOTTLE OPENINGS ARE UNRELIABLE AND THUS NOT THE GOLD STANDARD FOR ADHERENCE

Background:

Adherence is a serious problem in treatment of inflammatory diseases. To measure adherence, caps that record medication bottle openings may be superior to capsule counts (1). In the ongoing two-year GLORIA trial on the addition of low-dose (5 mg) prednisolone or placebo to standard of care in elderly patients (65+ years) with rheumatoid arthritis, adherence was measured in both ways during the whole trial.

Objectives:

To describe adherence patterns, and to compare adherence as assessed with adherence caps and with capsule counts in the GLORIA trial.

Methods:

The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. Overall adherence according to number of bottle openings was compared with adherence according to the capsule count. Good adherence was defined as 80%: i.e. for caps 80% of days one opening recorded, and for counts less than 20% of prescribed tablets returned at the subsequent visit. Each patient has a maximum of 8 periods of 90 days.

Results:

Trial inclusion has closed in 2018 at 452 patients; the current dataset contains adherence data of 385 patients. Mean number of recorded 90-day periods per patient was 4 (range 1-8). Based on capsule counts over all periods, 90% of the patients met the 80% threshold of adherence; based on cap data only 31% met this criterion.

The four adherence patterns are shown in a calendar matrix, with yellow for zero, green for one and blue for ≥two openings on a day (Figure 1). Bottles were supposed to be opened once a day.

Patients were categorized according to the opening pattern seen in at least 50% of assessed periods:

32% non-use(<20% of the days an opening);26% stable use(≥80% of the days 1 opening);40% irregular use(different adherence patterns, in or between periods);2% weekly use(1 opening per week).

Conclusion:

In our trial of elderly rheumatoid arthritis patients, patients appeared to be mostly adherent according to conventional capsule counts. Results from adherence caps were highly discrepant with the capsule counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so.

References:

[1] El Alili M, Vrijens B, Demonceau J, Evers SM, Hiligsmann M. A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence. Br J Clin Pharmacol 2016;82:268-79.

Acknowledgments:

The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.

Disclosure of Interests:

Linda Hartman: None declared, Sabrina Paolino: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

Nasal fractures: a dedicated clinic providing reduction under local anaesthesia improves time to manipulation

INTRODUCTION

Guidelines for nasal injury state that assessment should be at 7-10 days post-injury and manipulation within 14 days. We performed a plan, do, study, act improvement cycle to assess whether a dedicated nasal fracture service led to better outcomes.

MATERIALS AND METHODS

A retrospective study was carried out of all patients undergoing manipulation under anaesthesia for nasal trauma between February 2013 and December 2016 in a district general hospital. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented followed by a prospective study of all patients presenting to the clinic between February and November 2017. Main outcome measures included time from injury to otolaryngology assessment, time from injury to manipulation and incidence of secondary septorhinoplasty.

RESULTS

The retrospective series involved 525 patients including 381 males (72.6%) and 144 females (27.4%). Mean time from injury to assessment was 10 days. Mean time from injury to surgery was 14.5 days. Mean time from assessment to surgery was five days. The incidence of septorhinoplasty was 2.3%. The prospective series involved 119 patients including 78 males (65.5%) and 41 females (34.5%). Following implementation of a nasal fracture clinic, mean time from injury to assessment and manipulation was 6.1 days and 5.4% of patients underwent septorhinoplasty for secondary deformity.

DISCUSSION

Implementation of a nasal fracture clinic providing reduction under local anaesthesia reduced the time to assessment and manipulation. The incidence of septorhinoplasty is low following reduction under general or local anaesthesia. Assessment earlier than seven days is feasible and advice for referral can be changed accordingly.

Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial

BACKGROUND

Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure.

HYPOTHESIS

We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively.

RESULTS

A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; P < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; P < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 (P = .003) and KOOS (P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months (P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale (P = .11).

CONCLUSION

The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery.

REGISTRATION

NCT02018354 ( ClinicalTrials.gov identifier).

P1750 Association of high-sensitivity troponin elevation and LVEF decline in anthracycline-treated breast cancer patients

Introduction

Cancer therapies have been linked to a wide variety of side effects, with cardiotoxicity being the most significant one. Early detection of subclinical cardiac dysfunction in cancer patients (pts) is necessary in order to prevent unfavorable outcomes. High-sensitivity troponin I (hsTI) levels have been proposed as predictors of cancer therapy related cardiotoxicity and may guide cardioprotective therapy initiation.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer pts under chemotherapy in a single center cardio-oncology unit and to assess its relationship with hsTI levels.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to a value below 50%. Elevation of hsTI was defined as at least one measurement above the 99th percentile upper reference limit during follow-up (&gt;34 ng/L).

Pts had an organized follow-up in our cardio-oncology unit, consisting of a clinical, laboratorial (with dosing of cardiac biomarkers) and echocardiographic assessment at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases).

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 17 pts (20.5%) were considered at high risk of cardiac dysfunction due to hsTI elevation.

During follow-up, the percent increase in the hsTI level (from basal level) correlated with CTRCD (p = 0.02). On the other hand, the absolute maximum value of hsTI did not (p = 0.159).

In fact, pts who developed CTRCD had a significantly higher percent increase in the hsTI levels (142.9% +- 57.5%) vs those without CTRCD (14.29% +- 4.6%), p &lt; 0.001. On ROC curve analysis, percent increase in troponin was a good identifier of CTRCD (AUC of 0.986; 95% CI 0.95-1.00; p = 0.022) and the best cut-off value was a 79.8% increase in hsTI (sensitivity: 100%; specificity: 97.2%).

Conclusion

In our population, the percent increase in the hsTI levels correlated with CTRCD. Larger studies are needed to prove this parameter as a predictor of CTRCD.

Abstract P1750 Figure.

Magnetostriction in Amorphous Co66Fe34 Microcantilevers Fabricated with Hydrogenated Amorphous Silicon

To study the magnetostriction of Co66Fe34 thin films, amorphous silicon microcantilevers were prepared by surface micromachining, and the 136 nm-thick magnetostrictive film was deposited by electron beam physical vapor deposition and patterned on top of the microcantilever structure. The magnetostriction of the Co66Fe34 films was confirmed by measuring the deflection of the cantilevers under a varying magnetic field, reaching displacements up to 8 nm. The configuration was simulated using COMSOL software, yielding a similar deflection behavior as a function of the magnetic field, with a film with a magneto strictive coefficient of λ S ~ 55 p.p.m. The experimental configuration uses a laser and a position sensitive detector to measure the displacement, based on an optical lever configuration, and a piezoelectric stage to calibrate the system.

P656 Cardiac dysfunction in breast cancer patients treated with anthracyclines: a single-center experience

Introduction

Cardiac dysfunction is a well-documented side effect of cancer treatment, with significant morbidity and mortality. Cardio-oncology units play a vital role in the early identification and management of cancer therapy related cardiovascular side effects and provide a multidisciplinary care for cancer patients.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer patients (pts) under chemotherapy in a single center cardio-oncology unit, and to assess its predictors.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to below 50%. Pts with &gt;15% relative percentage reduction from baseline Global longitudinal strain (GLS) or with elevation of high-sensitivity Troponin I (hsTI) levels were considered to be at high risk for developing CTRCD and started cardioprotective treatment with an ACE inhibitor/ARB and a beta-blocker, as did pts with confirmed CRTCD. Also, in pts under antihypertensive drug therapy, switching drugs to cardioprotective ones was performed in the index consultation.

Follow-up was organized in our cardio-oncology consultation at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases). Interruption of chemotherapy was a joint decision of the oncology and cardiology teams.

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 28 pts (33.7%) were considered to be at high risk due to GLS reduction during follow-up and 17 pts (20.5%) were at high risk due to hsTI elevation.

From all the baseline characteristics, only basal BNP correlated with CTRCD (p = 0.033). Other characteristics such as age, presence of cardiovascular risk factors and the previously proposed Cardiotoxicity Risk Score (CRS) did not.

There was a high percentage of pts (51.8%; n = 43) under cardioprotective drugs. 37% of the pts initiated cardioprotective drugs following cardio-oncology consultation. Chemotherapy was discontinued in only 2 pts (2.4%).

Conclusion

CTRCD is difficult to predict by baseline clinical characteristics. Monitoring and management of CTRCD by a multidisciplinary cardio-oncology team resulted in a high rate of cardioprotective drugs use and low rate of permanent discontinuation of chemotherapy. Further studies are needed to further analyze the relationship between these two variables.