Cardiac rehabilitation: pedagogical education strategies have positive effect on long-term patient-reported outcomes

This study examined whether patients attending cardiac rehabilitation (CR) based on the pedagogical strategy learning and coping (LC) led to improved health-related quality of life (HRQL), reduced symptoms of anxiety and depression and improved self-management 6 and 12 months after the completion of CR compared with patients attending CR based on the pedagogical strategy 'Empowerment, Motivation and Medical Adherence' (EMMA). A pragmatic cluster-controlled trial of two pedagogical strategies, LC and EMMA, including 10 primary health care settings and 555 patients diagnosed with ischaemic heart disease and referred to CR between August 2018 and July 2019 was conducted. In total, 312 patients replied to the questionnaires collected at baseline, 12 weeks, 6 months and 12 months after completing CR. Linear regression analyses adjusted for potential confounder variables and cluster effects were performed. We found clinically relevant and statistically significant improvements in HRQL, anxiety, depression and self-management after completing CR. The improvements were sustained at 6 and 12 months after the completion of CR. We found no differences between the two evidence-based patient education strategies. In conclusion, this study supports the use of evidence-based patient education strategies, but there is no evidence to suggest that one pedagogical strategy is superior to the other.

Bias in self-reported height and weight in a cohort of young adults – perspectives for cardio-metabolic risk prevention programmes

Background

Precise assessment of obesity is essential in evaluating and applying preventive strategies to avoid adverse cardio-metabolic risk profiles later in life. Self-reported measures of height and weight is often used in cohort and cross-sectoral studies due to practical and financial reasons. However, bias due to self-reporting is well known with risk of overestimation of height and underestimation of weight. The latter is particular reported among women and persons with obesity. Little is known about the influence of educational factors in the self-reporting of height and weight. To gain insight into the extent to which different factors bias self-reporting, is important to assess the validity of self-reported body mass index (BMI) within groups of people with certain characteristics.

Purpose

The aim was to investigate the validity of self-reported height and weight versus objective measured height and weight. Additionally, the study aimed to examine if sex, measured BMI, and educational factors biased the self-reporting differenially.

Methods

The study included 264 participants, all aged 28 years who were a sub-sample from an ongoing cohort in Central Denmark Region. The participants attended a physical health examination, including measures of height and weight after having self-reported these not knowing they were to be objectively measured later. Data of their own and parental educational levels were drawn from registries. Paired t-tests were used to assess the descriptive differences between self-reported and measured values and linear regression was used to assess the independent effects of sex, education, and BMI on the differences. In model 1 adjustment for all other variables except for BMI was conducted and full adjustments were made in model 2.

Results

Overall, participants overestimated their height by 0.89 (0.67; 1.10) cm and underestimated their weight by 2.47 (1.78; 3.17) kg (Table 1). Female sex was found to independently bias underreporting of weight (β −1.51 (−2.86; −0.15)) and male sex overestimated height (β 0.83 (0.38; 1.27) (Table 2). Additionally, being overweight or obese also independently biased the underestimation of self-reported weight ((β 2.23 (0.64; 3.83) and β 5.22 (3.51; 6.94)) (Table 2). Additionally, participants with overweight were less likely to overestimate their height compared to those with normal weight. Without adjustments for BMI, low level of education also biased underestimation of weight significantly (Table 2).

Conclusion

Women and persons with obesity in particular underestimated weight. Participants with lower level of education also underestimated weight but this was explained by obesity. Men overestimated their height but participants with obesity were less likely to overestimate height compared to normal weighty. When screening for overweight and obesity to initiate interventions to prevent cardio-metabolic diseases, the lack of accuracy in self-reported values must be taken into account.

Funding Acknowledgement

Type of funding sources: None.

Physical activity during adolescence and early adulthood and adult cardiometabolic risk profile: a longitudinal study

Introduction

Physical activity (PA) is important in the prevention of cardiometabolic diseases. However, little is known of the effect of maintaining PA during adolescence and cardiometabolic risk in early adulthood.

Purpose

This 14-year longitudinal prospective cohort study investigated the association of maintaining PA since adolescence and subsequent cardiometabolic risk factors in early adulthood and to what extend adiposity affects this.

Methods

Data were drawn from an ongoing cohort and consisted of 262 participants with longitudinal information on PA and cardiometabolic risk factors in adulthood. The cardiometabolic risk factors were collected by blood samples, anthropometric measures, and blood pressure in a health examination at the age of 28 years (table 1). Subsequently, the risk factors were clustered in four domains (“Inflammation”, “Lipids”, “Glucose metabolism” and “Blood pressure”) and calculated into z-scores. Further, a composite z-score of all domains was calculated. PA was obtained by questionnaires at age 15, 18, 21 and 28. The participants were categorized into “inactive maintainers”, “fluctuaters” and “active maintainers” and linear regression was used to examine the association between PA groups and the cardiometabolic domains in a crude and two adjusted models 1 and 2.

Results

Increasing z-scores from “active maintainers” to “fluctuaters” to “inactive maintainers” were seen in all domains except in “blood pressure” when adjusted for sex, smoking, parental and own education, and parental cardiovascular medical history, and significantly different when comparing “active maintainers” to “inactive maintainers” (table 2, model 1). In the composite z-score outcome including all domains, a significantly adverse z-score was found for “inactive maintainers” z=0.63, p=0.001 when adjusted for the variables in model 1 (table 2). When also adjusted for body fat percentage (model 2), the z-score became insignificant z=0.19, p=0.198 (table 2).

Conclusion

Maintaining PA from adolescence to early adulthood is associated with a significant lower cardiometabolic risk profile compared to inactive maintainers. However, some of the adverse risk profile is explained by being overweight or obese. Given the increasing prevalence of CVD and diabetes these results highlight the importance of maintaining PA at all stages of life.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Karen Elise Jensen Foundation and The Steno Partner Collaboration between Goedstrup Hospital and Steno Diabetes Center Aarhus.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Short- and long-term effects of the patient education strategy-learning and coping-in cardiac rehabilitation: a randomized controlled trial (LC-REHAB)

The objectives were to assess the short- and long-term effect of the patient education strategy 'Learning and Coping' (LC) in cardiac rehabilitation (CR) on health-related quality of life, patient education impact, cardiac risk factors and lifestyle. In total, 825 patients hospitalized with ischaemic heart disease or heart failure were randomized to either LC-CR or standard CR at three Danish hospitals. Teaching approach in LC-CR was situational, inductive and reflective, with experienced patients as co-educators and supplemental interviews. Teaching approach in standard CR was structured and deductive. Outcomes were assessed immediately after CR, and after 3 months (short term), and after 3 years (long term). Between-arm differences in favour of LC-CR were SF-12 'role emotional' (3.7, 95% CI: 0.6-6.8) and MDI depression score (0.9, 0.1-1.8) immediately after CR, exercise capacity (4 W, 1-9) at 3 months and SF-12 'role physical' (4.6, 0.1-9.0) (long term). Between-arm differences in favour of controls were waist circumference (-1.7 cm, -2.3 to -1.0) immediately after CR and HeiQ domain 'Constructive attitudes and approaches' (0.11, 0.04-0.18), triglycerides (-0.12 mmol/l, -0.21 to -0.02), systolic blood pressure (-3.12 mmHg, -5.66 to -0.58) at 3 months. Adding LC strategies to CR provides inconsistent short-term results but improves 'role physical' long term.

Effects of the patient education strategy 'Learning and Coping' in cardiac rehabilitation on readmissions and mortality: a randomized controlled trial (LC-REHAB)

We assessed the effects of the patient education strategy 'Learning and Coping' (LC) in cardiac rehabilitation (CR) on mortality and readmissions by exploring results from the LC-REHAB trial. In all, 825 patients with ischaemic heart disease or heart failure were randomized to the intervention arm (LC-CR) or the control arm (standard CR) at three hospitals in Denmark. LC-CR was situational and inductive, with experienced patients as co-educators supplemented with two individual interviews. Group-based training and education hours were the same in both arms. Outcomes were time to death or readmission, length of stay and absolute number of deaths or readmissions. No between-arm differences were found in time to death, first readmission, or length of stay. Within 30 days after completion of CR, the absolute number of all-cause readmissions was 117 in the LC arm and 146 in the control arm, adjusted odds ratio 78 (95% CI: 0.61-1.01), P = 0.06. This trend diminished over time. Adding LC strategies to standard CR showed a short term but no significant long-term effect on mortality or readmissions. However, the study was not powered to detect differences in mortality and morbidity. Thus, a risk of overseeing a true effect was present.