InterVFast-effectiveness and acceptance of intermittent fasting in cardiac rehabilitation patients: study protocol of a randomized controlled trial

BACKGROUND

Research on intermittent fasting has shown that it can improve a variety of health outcomes, including blood sugar control, blood lipid levels and blood pressure. Only few studies document longer periods of fasting, especially in rehabilitation participants. Cardiac inpatient rehabilitation follows a multidisciplinary approach including change of health behaviour to reduce patients' risk of future cardiovascular events. To date, evidence suggests that intermittent fasting can be an effective way to improve health and well-being, but more research is needed to fully understand its long-term effects and factors that promote the implementation. Therefore, the aim of the ongoing InterVFast trial is to investigate the effectiveness of intermittent fasting amongst cardiac rehabilitation patients after 4-week inpatient rehabilitation as well as 3 and 12 months subsequently including patients' perspective.

METHODS

This single-centre randomized controlled trial evaluates the effectiveness of the InterVFast intervention in weight loss (primary outcome). We also examine patients' acceptance and the effect on relevant outcomes as blood glucose and triglyceride levels, cholesterol and high-sensitivity C-reactive protein. Weight, blood samples and clinical data are collected as part of the initial and final examination during inpatient rehabilitation. During inpatient rehabilitation, participants daily note fasting intervals and meals eaten as well as practicability in a fasting diary. In addition, interviews about perceived advantages and disadvantages and acceptance are carried out with the participants in the IG. A standardized follow-up examination (weight, blood samples) will be carried out by the family doctor after 3 and 12 months (t2 and t3).

DISCUSSION

Compared to other weight-loss intervention studies, our study addresses patients with coronary heart disease and includes patients' acceptance as well as long-term maintenance. It is hypothesized that participation in the InterVfast intervention will improve relevant health outcomes in a sample of cardiac rehabilitation patients and thus constitute a behavioural prevention strategy to reduce the risk of future cardiac events and improve overall health and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov DRKS00023983. Registered on February 17, 2022.

[The Role of Heart-Focused Anxiety in the Need for Psychological Support and Self-Assessment of Early Retirement - Indications from Cardiac Inpatient Rehabilitation]

OBJECTIVE

The psychosocial care of cardiac patients is becoming increasingly important. In inpatient cardiac rehabilitation, patients should be ideally screened for psychosocial risk factors and given psychological support. Heart-focused anxiety can significantly impair quality of life and subsequently influence prognosis of the course of the disease as well as social and occupational participation. Due to the difference between reported prevalence of heart-focused anxiety and the observed lower rate of patients expressing need for psychological support, the authors assumed that some patients do not express their need for psychological support. Therefore, aim of the study was to identify these patients through a simple screening instrument in order to offer them appropriate psychological support and consequently to maintain rehabilitation goals, including ability to work.

METHODS

We conducted a cross-sectional study at an inpatient cardiac rehabilitation center, Roderbirken, Leichlingen, Germany. Patients completed a standardised questionnaire, consisting of the Cardiac Anxiety Questionnaire, the Hospital Anxiety and Depression Scale and Scale I of the Screening Instrument Work and Occupation. Data were analyzed using descriptive statistics and logistic regression analysis. Ethical approval was obtained.

RESULTS

Finally, 507 patients were included in the analysis (82.6% men, mean age 54.4±7.1 years). Of these, 40.0% expressed need for psychological support. Prevalence of heart-focused anxiety was 15.7%; among them significantly more patients expressed need for psychological support (59.0 vs. 41.0%; p<0.05). Also patients with mental disorders expressed need for psychological support (57.6 vs. 0.7%; p<0.05). Subjective assessment of early retirement was associated with heart-focused anxiety and with depressive symptoms (both p<0.001) as well as education and employment status.

DISCUSSION

Based on the results of the self-assessment instruments as well as the socioeconomic and clinical patient characteristics, possible indicators of subjective occupational prognosis can be derived.

CONCLUSION

An screening through Hospital Anxiety and Depression Scale can facilitate target achievement of return to work in cardiac rehabilitation.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

[Are Intensified Secondary Prevention Programmes Effective Interventions to Reduce Disability-Related Early Retirement After Cardiac Rehabilitation?]

PURPOSE

We aimed to combine follow-up data from 3 randomized controlled studies to evaluate the effectiveness of intensified (telephone-based) secondary prevention programmes on disability-related early retirement.

METHODS

Each trial (SeKoNa, Sinko and OptiHyp) compared an intensified (telephone-based) secondary prevention concept as an intervention to an untreated control group (standard management). We extracted extensive baseline data on sociodemographic, clinical and diagnostic characteristics on an individual patient level from the original trial data sets. Follow-up analysis is based on routine data of the German Pension Insurance Rhineland (obtained in August 2019). The primary outcome parameters are mortality (all causes), recurrent cardiac events, and employment status three years after rehabilitation. Here we report results regarding disability-related early retirement. Outcome data were pooled with via meta-analysis for individual patient data (Individual Patient Data Meta-Analysis IPD-MA) using classical meta-analytical techniques (one-stage approach using mixed models and 2-stage approach with inverse variance estimation as fixed effects model).

RESULTS

A total of 1058 cardiac rehabilitation patients were included in the analyses. There were no differences between the pooled intervention group (n=499) and the pooled control group (n=559) regarding any baseline parameter at discharge after 3-week cardiac rehabilitation. There are no indications of statistical heterogeneity. In the total sample incident disability-related early retirement rate was 11.8% at 3-year follow-up. Participation in an intensified secondary prevention programme reduced the risk by about 60% compared to the control group (OR: 0.43; 95% CI: 0.36-0.51).

CONCLUSION

The need for effective rehabilitation programmes is rapidly growing due to the current demographic trend with an increase in ageing working populations. Secondary prevention programmes following 3-week inpatient rehabilitation are an effective tool to sustainably support the prevention of health-related premature reduction in earning capacity pensions and therefore should complement the existing rehabilitation offer. Based on our results we conclude that secondary prevention should be provided long enough (at least one year) and in personal contact.

Health-related quality of life after heart surgery - Identification of high-risk patients: A cohort study

BACKGROUND

This cohort study evaluated factors, which have been shown to be relevant for Health-Related Quality of Live (HRQL) after cardiac surgery and investigated the combinatory impact on HRQL. Additionally, the aim was to introduce a first attempt to developing a risk estimation model which could identify patients at risk for impaired HRQL.

METHODS

For this single-centre cohort study, 6099 cardiac surgical patients (60% isolated coronary bypass surgery) filled in the Nottingham Health Profile (NHP) for the evaluation of HRQL six months after surgery and provided information regarding their medical and socio-demographic status. For the NHP scores the deviation to the matched normative data of a healthy sample was calculated. A robust linear regression examined factors that influence HRQL. As a next step, based on the regression model, a risk estimation model was developed which is a first attempt to classify patients into risk categories.

RESULTS

Male gender, age below 60 or between 60 and 74 years, living alone, no occupation, bypass surgery, NYHA status II, III or IV and chest pain were identified as risk factors to determine impaired HRQL. The model explains 29.13% of the variance. Based on the risk estimation model 27.4% were classified as medium or high risk.

CONCLUSIONS

For the first time a multilevel method was applied to evaluate HRQL after heart surgery showing that socio-demographic variables are important co-factors to dyspnea and chest pain. We take a first attempt in developing a new approach that should encourage further research in this field to frame a screening tool that may help identifying patients at risk in the future.

Tele-Assist – Ergebnisse der Machbarkeitsstudie eines telemedizinischen Versorgungsangebotes für die kardiologische und orthopädische Rehabilitation in der Klinik Roderbirken und der Aggertalklinik

Sowohl in der Orthopädie wie in der Kardiologie ist die Sekundärprävention nach der Rehabilitation unzureichend. Durch die stetige Verbreitung von mobilen, internet-basierten, multimedialen Diensten wird immer deutlicher, dass für eine personenzentrierte und wirksame Nachsorge neue mediale Möglichkeiten effektiv genutzt werden können. Internetbasierte Anwendungen wie E-Mail, asynchrones E-Learning oder Chat gewinnen hierbei zunehmend an Bedeutung.

Dieser Beitrag stellt die Ergebnisse des Projektes Tele-Assist vor. Basierend auf nationalen und internationalen Leitlinien der Orthopädie und Kardiologie wurde in dem Projekt Tele-Assist auf Basis des MeineReha®-Systems ein digital integriertes und interaktives Therapieprogramm für die Rehabilitation entwickelt und auf seine Umsetzbarkeit in zwei Kliniken überprüft.Abschließend werden die Evaluationsergebnisse hinsichtlich Akzeptanz, Motivation und Patientensicherheit angeführt.

Recommendations for resistance exercise in cardiac rehabilitation. Recommendations of the German Federation for Cardiovascular Prevention and Rehabilitation

Aerobic endurance training has been an integral component of the international recommendations for cardiac rehabilitation for more than 30 years. Notwithstanding, only in recent years have recommendations for a dynamic resistance-training program been cautiously put forward. The perceived increased risk of cardiovascular complications related to blood pressure elevations are the primary concern with resistance training in cardiac patients; recent studies however have demonstrated that this need not be a contraindication in all cardiac patients. While blood pressure certainly may rise excessively during resistance training, the actual rise depends on a variety of controllable factors including magnitude of the isometric component, the load intensity, the amount of muscle mass involved as well as the number of repetitions and/or the load duration. Intra-arterial blood pressure measurements in cardiac patients have demonstrated that that during low-intensity resistance training [40-60% maximum voluntary contraction (MVC)] with 15-20 repetitions, only modest elevations in blood pressure are revealed, similar to those seen during moderate endurance training. When properly implemented by an experienced exercise therapist, in specific patient groups an individually tailored, medically supervised dynamic resistance training program carries no inherent higher risk for the patient than aerobic endurance training. As an adjunct to endurance training, in selected patients, resistance training can increase muscle strength and endurance, as well as positively influence cardiovascular risk factors, metabolism, cardiovascular function, psychosocial well-being and quality of life. According to present data, resistance training is however not recommended for all patient groups. The appropriate training method and correct performance are highly dependent on each patient's clinical status, cardiac stress tolerance and possible comorbidities. Most studies have used middle-aged men of average normal aerobic performance capacity and with good left-ventricular (LV) function. Data are lacking for high-risk groups, women and older patients. With the current knowledge it is reasonable to include resistance training without any restraints as part of cardiac rehabilitation programs for coronary artery disease (CAD) patients with good cardiac performance capacity (i.e., revascularised and with good myocardial function). As patients with myocardial ischaemia and/or poor left ventricular function may develop wall motion disturbances and/or severe ventricular arrhythmias during resistance exercise, the following criteria are suggested for resistance training: moderate-to-good LV function, good cardiac performance capacity [>5-6 metabolic equivalents of oxygen consumption (METS)=1.4 watt/kg body weight], no symptoms of angina pectoris or ST segment depression under continued maintenance of the medical therapy. Based on available data, this article presents recommendations for risk stratification in cardiac rehabilitation programs with respect to the implementation of dynamic resistance training. Additional recommendations for specific patient groups and detailed directions showing how to structure and implement such therapy programs are presented as well.

Long-term results of a three-week intensive cardiac out-patient rehabilitation program in motivated patients with low social status

The short-term benefits of cardiac rehabilitation (CR) are well established. In contrast, well-documented long-term results are rare. The objective of this longitudinal multi-centre observational study was to examine the effects of intensive out-patient CR in a larger patient cohort, especially for patients with low social status. We present the final results 24 months after CR.

METHODS

The study group of 327 patients (288 men, 39 women, aged 56.0+/-10.8 years, coronary artery disease in 295, other cardiac diseases in 32) participated in a 3- week CR programme followed by clinical re-evaluations 6 (III), 12 (IV) an 24 (V) months later.

RESULTS

The improvement in mean maximal performance of 100.5+/-31.4 to 123.1+/-36.2 W (p<0.01) achieved during CR was further improved to 128.7+/-40.9 W (p < 0,01) after 24 months. Of the patients, 61.2% reported regular physical activity during the 24 months of the study. The lipid management achieved by CR was maintained over 24 month. At I 65%, at II 84.4% and at V 82.4% of the patients with coronary artery disease (CAD) were undergoing lipid lowering therapy. BMI increased from 26.8+/-3.0 to 27.6+/-3.6 kg/m2 (p < 0.01) during follow-up. Of the patients, 23.2% were active smokers at V. Cardiovascular diagnosis remained unaltered in 74.3% of patients. The obtained results are interesting with respect to the social status of the patients since 68% were general laborers. The results confirm the long-term effectiveness of an intensive 3-week out-patient CR programme. Most of the benefits achieved by CR appear to be sustainable in this population for at least 2 years.

Einsatz von Kraftausdauertraining und Muskelaufbautraining in der kardiologischen Rehabilitation

While aerobic endurance training has been a substantial part of international recommendations for cardiac rehabilitation during the last 30 years, there is still a rather reserved attitude of the medical community to resistance exercise in this field. Careful recommendations for resistance exercise in cardiac patients was only published a few years ago. It has been taken for granted that strength exercise elicits a substantial increase in blood pressure and thus imposes, especially in cardiac patients, a risk of potentially fatal cardiovascular complications. Results of the latest studies show that the existing recommended overcaution is not justified. Strength exercise can indeed result in extreme increases of blood pressure, but this is not the case for all loads of this kind. The actual blood pressure response to strength exercise depends on the isometric component, the exercise intensity (load or resistance used), muscle mass activated, the number of repetitions in the set and/or the duration of the contraction as well as involvement of Valsalva maneuver. Intra arterially performed blood pressure measurements during resistance exercise in patients with heart disease showed that strength training carried out at low intensities (40-60% of MVC) and with high numbers of repetitions (15-20) only evokes a moderate increase of blood pressure comparable with blood pressure measures induced by moderate endurance training. If used properly and performed accurately, individually dosed, medically supervised and controlled through experienced sport therapists, a dynamic resistance exercise is-at least for a certain group of patients-not associated with higher risks than an aerobic endurance training and can in addition to endurance training improve muscle force and endurance, have a positive influence on cardiovascular function, metabolism, cardiovascular risk factors as well as psychosocial well-being and overall quality of life. However, with respect to currently available data, resistance exercise cannot be generally recommended for all groups of patients. The appropriate kind and execution of training is highly dependent on current clinical status, cardiac capacity as well as possible accompanying diseases of the patient. Most of the studies carried out up to date included small samples of middle-aged male patients with almost normal levels of aerobic endurance performance and good left ventricular function. Data is missing for risk groups, older patients and women. Therefore, an integration of dynamic resistance exercises in cardiac rehabilitation can only be recommended without hesitation for CHD patients with high physical capacity (good myocardial function, revascularized). Since patients with myocardial ischemia and/or low left ventricular functioning might develop wall motion disturbances and/or dangerous ventricular arrhythmia when performing resistance exercises, prevalence of the following conditions is recommend: moderate to high LV-function, high physical performance (>5-6 metabolic equivalents= >1.4 watts/kg body weight) in absence of angina pectoris symptoms or ST-depression, by maintained current medication. In the proposed recommendations, a classification of risks for resistance training in cardiac rehabilitation is being made based on current data and is complemented by specific recommendations for particular groups of patients and detailed guidelines for setup and completion of the therapy program.

[Effects of a phase II cardiac rehabilitation program performed on an outpatient basis]

BACKGROUND AND OBJECTIVE

In Germany, phase II cardiac rehabilitation has always been carried out on an inpatient basis. Meanwhile, the governmental health authorities are demanding more flexible solutions for cardiac rehabilitation. The objective of this study is to examine the effects of phase II cardiac rehabilitation performed on an outpatient basis (OCR) in a larger patient cohort. These are the first results of patients before and directly after the OCR performed at six different rehabilitation centers.

PATIENTS AND METHODS

The study group consisted of 479 men and 74 women, 56.1 +/- 11.5 years. Cardiovascular indications for the OCR were myocardial infarction in 219 cases, coronary artery disease (CAD) in 92, in 84 cases with invasive procedures, coronary artery bypass graft in 185, cardiac valve surgery in 26, and other cardiac diseases in 29. 70% of the patients were worker, 25% without professional training. Staying with the family (42%) and aversion to stationary programs (61%)were the main reasons for the choice of OCR. Without OCR,27.4% would have refused any rehabilitation program.

RESULTS

Maximal physical performance increased from 97.8 + - 31.4 to 120.4 +/- 37.3 W (p < 0.001). LDL cholesterol was reduced from 145.9 +/- 42.7 to 117.5 +/- 34.7 mg% (p < 0.001), triglycerides from 203.3 +/- 136.0 to 161.9 +/- 91.6 mg% (p < ).010), HDL cholesterol increased from 39.8 + 11.2 to 41.0 +/- 11.3 mg% (p = 0.003). The use of lipid-lowering therapy in CAD patients increased from 63.1% to 80.7%. A reduction in body mass index from 27.1 +/- 3.6 to 26.9 +/- 3.5 kg/m2 (p = 0.010) was demonstrated. The number of active smokers decreased from 53.8% to 25.6%.

CONCLUSION

The results obtained are interesting with respect to the patients' social status. With 70% general laborers, our cohort is in contrast to previously published OCR data. On the whole, these results demonstrate that rehabilitative measures can also be implemented on an outpatient basis, without a decrease in the quality of treatment. This also applies to patients who represent lower socioeconomic levels. The results should motivate to work harder and more sufficiently on the development of more flexible cardiac rehabilitation programs.