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Objective: To determine immediate performance measures for short-term, multicomponent cardiac rehabilitation (CR) in clinical routine in patients of working age, taking into
account cardiovascular risk factors, physical performance, social medicine, and subjective health parameters and to explore the underlying dimensionality.
Design: Prospective observational multicenter register study in 12 rehabilitation centers throughout Germany.
Setting: Comprehensive 3-week CR.
Background Transcatheter aortic-valve implantation (TAVI) is an established alternative therapy in patients with severe aortic stenosis and a high surgical risk. Despite a rapid growth in its use, very few data exist about the efficacy of cardiac rehabilitation (CR) in these patients. We assessed the hypothesis that patients after TAVI benefit from CR, compared to patients after surgical aortic-valve replacement (sAVR).
Methods From September 2009 to August 2011, 442 consecutive patients after TAVI (n=76) or sAVR (n=366) were referred to a 3-week CR. Data regarding patient characteristics as well as changes of functional (6-min walk test. 6-MWT), bicycle exercise test), and emotional status (Hospital Anxiety and Depression Scale) were retrospectively evaluated and compared between groups after propensity score adjustment.
Results Patients after TAVI were significantly older (p<0.001), more female (p<0.001), and had more often coronary artery disease (p=0.027), renal failure (p=0.012) and a pacemaker (p=0.032). During CR, distance in 6-MWT (both groups p0.001) and exercise capacity (sAVR p0.001, TAVI p0.05) significantly increased in both groups. Only patients after sAVR demonstrated a significant reduction in anxiety and depression (p0.001). After propensity scores adjustment, changes were not significantly different between sAVR and TAVI, with the exception of 6-MWT (p=0.004).
Conclusions Patients after TAVI benefit from cardiac rehabilitation despite their older age and comorbidities. CR is a helpful tool to maintain independency for daily life activities and participation in socio-cultural life.
Objective: We aimed to characterize patients after an acute cardiac event regarding their negative expectations around returning to work and the impact on work capacity upon discharge from cardiac rehabilitation (CR).
Methods: We analyzed routine data of 884 patients (52±7 years, 76% men) who attended 3 weeks of inpatient CR after an acute coronary syndrome (ACS) or cardiac surgery between October 2013 and March 2015. The primary outcome was their status determining their capacity to work (fit vs unfit) at discharge from CR. Further, sociodemographic data (eg, age, sex, and education level), diagnoses, functional data (eg, exercise stress test and 6-min walking test [6MWT]), the Hospital Anxiety and Depression Scale (HADS) and self-assessment of the occupational prognosis (negative expectations and/or unemployment, Würzburger screening) at admission to CR were considered.
Results: A negative occupational prognosis was detected in 384 patients (43%). Out of these, 368 (96%) expected not to return to work after CR and/or were unemployed before CR at 29% (n=113). Affected patients showed a reduced exercise capacity (bicycle stress test: 100 W vs 118 W, P<0.01; 6MWT: 380 m vs 421 m, P<0.01) and were more likely to receive a depression diagnosis (12% vs 3%, P<0.01), as well as higher levels on the HADS. At discharge from CR, 21% of this group (n=81) were fit for work (vs 35% of patients with a normal occupational prognosis (n=175, P<0.01)). Sick leave before the cardiac event (OR 0.4, 95% CI 0.2–0.6, P<0.01), negative occupational expectations (OR 0.4, 95% CI 0.3–0.7, P<0.01) and depression (OR 0.3, 95% CI 0.1–0.8, P=0.01) reduced the likelihood of achieving work capacity upon discharge. In contrast, higher exercise capacity was positively associated.
Conclusion: Patients with a negative occupational prognosis often revealed a reduced physical performance and suffered from a high psychosocial burden. In addition, patients’ occupational expectations were a predictor of work capacity at discharge from CR. Affected patients should be identified at admission to allow for targeted psychosocial care.
Background: Although the benefits for health of physical activity (PA) are well documented, the majority of the population is unable to implement present recommendations into daily routine. Mobile health (mHealth) apps could help increase the level of PA. However, this is contingent on the interest of potential users.
Objective: The aim of this study was the explorative, nuanced determination of the interest in mHealth apps with respect to PA among students and staff of a university.
Methods: We conducted a Web-based survey from June to July 2015 in which students and employees from the University of Potsdam were asked about their activity level, interest in mHealth fitness apps, chronic diseases, and sociodemographic parameters.
Results: A total of 1217 students (67.30%, 819/1217; female; 26.0 years [SD 4.9]) and 485 employees (67.5%, 327/485; female; 42.7 years [SD 11.7]) participated in the survey. The recommendation for PA (3 times per week) was not met by 70.1% (340/485) of employees and 52.67% (641/1217) of students. Within these groups, 53.2% (341/641 students) and 44.2% (150/340 employees)—independent of age, sex, body mass index (BMI), and level of education or professional qualification—indicated an interest in mHealth fitness apps.
Conclusions: Even in a younger, highly educated population, the majority of respondents reported an insufficient level of PA. About half of them indicated their interest in training support. This suggests that the use of personalized mobile fitness apps may become increasingly significant for a positive change of lifestyle.
Background
Outcome quality management requires the consecutive registration of defined variables. The aim was to identify relevant parameters in order to objectively assess the in-patient rehabilitation outcome.
Methods
From February 2009 to June 2010 1253 patients (70.9 ± 7.0 years, 78.1% men) at 12 rehabilitation clinics were enrolled. Items concerning sociodemographic data, the impairment group (surgery, conservative/interventional treatment), cardiovascular risk factors, structural and functional parameters and subjective health were tested in respect of their measurability, sensitivity to change and their propensity to be influenced by rehabilitation.
Results
The majority of patients (61.1%) were referred for rehabilitation after cardiac surgery, 38.9% after conservative or interventional treatment for an acute coronary syndrome. Functionally relevant comorbidities were seen in 49.2% (diabetes mellitus, stroke, peripheral artery disease, chronic obstructive lung disease). In three key areas 13 parameters were identified as being sensitive to change and subject to modification by rehabilitation: cardiovascular risk factors (blood pressure, low-density lipoprotein cholesterol, triglycerides), exercise capacity (resting heart rate, maximal exercise capacity, maximal walking distance, heart failure, angina pectoris) and subjective health (IRES-24 (indicators of rehabilitation status): pain, somatic health, psychological well-being and depression as well as anxiety on the Hospital Anxiety and Depression Scale).
Conclusion
The outcome of in-patient rehabilitation in elderly patients can be comprehensively assessed by the identification of appropriate key areas, that is, cardiovascular risk factors, exercise capacity and subjective health. This may well serve as a benchmark for internal and external quality management.
Background
Multi-component cardiac rehabilitation (CR) is performed to achieve an improved prognosis, superior health-related quality of life (HRQL) and occupational resumption through the management of cardiovascular risk factors, as well as improvement of physical performance and patients’ subjective health. Out of a multitude of variables gathered at CR admission and discharge, we aimed to identify predictors of returning to work (RTW) and HRQL 6 months after CR.
Design
Prospective observational multi-centre study, enrolment in CR between 05/2017 and 05/2018.
Method
Besides general data (e.g. age, sex, diagnoses), parameters of risk factor management (e.g. smoking, hypertension), physical performance (e.g. maximum exercise capacity, endurance training load, 6-min walking distance) and patient-reported outcome measures (e.g. depression, anxiety, HRQL, subjective well-being, somatic and mental health, pain, lifestyle change motivation, general self-efficacy, pension desire and self-assessment of the occupational prognosis using several questionnaires) were documented at CR admission and discharge. These variables (at both measurement times and as changes during CR) were analysed using multiple linear regression models regarding their predictive value for RTW status and HRQL (SF-12) six months after CR.
Results
Out of 1262 patients (54±7 years, 77% men), 864 patients (69%) returned to work. Predictors of failed RTW were primarily the desire to receive pension (OR = 0.33, 95% CI: 0.22–0.50) and negative self-assessed occupational prognosis (OR = 0.34, 95% CI: 0.24–0.48) at CR discharge, acute coronary syndrome (OR = 0.64, 95% CI: 0.47–0.88) and comorbid heart failure (OR = 0.51, 95% CI: 0.30–0.87). High educational level, stress at work and physical and mental HRQL were associated with successful RTW. HRQL was determined predominantly by patient-reported outcome measures (e.g. pension desire, self-assessed health prognosis, anxiety, physical/mental HRQL/health, stress, well-being and self-efficacy) rather than by clinical parameters or physical performance.
Conclusion
Patient-reported outcome measures predominantly influenced return to work and HRQL in patients with heart disease. Therefore, the multi-component CR approach focussing on psychosocial support is crucial for subjective health prognosis and occupational resumption.
Introduction: Adequate cognitive function in patients is a prerequisite for successful implementation of patient education and lifestyle coping in comprehensive cardiac rehabilitation (CR) programs. Although the association between cardiovascular diseases and cognitive impairments (CIs) is well known, the prevalence particularly of mild CI in CR and the characteristics of affected patients have been insufficiently investigated so far.
Methods: In this prospective observational study, 496 patients (54.5 ± 6.2 years, 79.8% men) with coronary artery disease following an acute coronary event (ACE) were analyzed. Patients were enrolled within 14 days of discharge from the hospital in a 3-week inpatient CR program. Patients were tested for CI using the Montreal Cognitive Assessment (MoCA) upon admission to and discharge from CR. Additionally, sociodemographic, clinical, and physiological variables were documented. The data were analyzed descriptively and in a multivariate stepwise backward elimination regression model with respect to CI.
Results: At admission to CR, the CI (MoCA score < 26) was determined in 182 patients (36.7%). Significant differences between CI and no CI groups were identified, and CI group was associated with high prevalence of smoking (65.9 vs 56.7%, P = 0.046), heavy (physically demanding) workloads (26.4 vs 17.8%, P < 0.001), sick leave longer than 1 month prior to CR (28.6 vs 18.5%, P = 0.026), reduced exercise capacity (102.5 vs 118.8 W, P = 0.006), and a shorter 6-min walking distance (401.7 vs 421.3 m, P = 0.021) compared to no CI group. The age- and education-adjusted model showed positive associations with CI only for sick leave more than 1 month prior to ACE (odds ratio [OR] 1.673, 95% confidence interval 1.07–2.79; P = 0.03) and heavy workloads (OR 2.18, 95% confidence interval 1.42–3.36; P < 0.01).
Conclusion: The prevalence of CI in CR was considerably high, affecting more than one-third of cardiac patients. Besides age and education level, CI was associated with heavy workloads and a longer sick leave before ACE.
Aim: We aimed to identify patient characteristics and comorbidities that correlate with the initial exercise capacity of
cardiac rehabilitation (CR) patients and to study the significance of patient characteristics, comorbidities and training
methods for training achievements and final fitness of CR patients.
Methods: We studied 557 consecutive patients (51.7 Æ 6.9 years; 87.9% men) admitted to a three-week in-patient CR.
Cardiopulmonary exercise testing (CPX) was performed at discharge. Exercise capacity (watts) at entry, gain in training
volume and final physical fitness (assessed by peak O 2 utilization (VO 2peak ) were analysed using analysis of covariance
(ANCOVA) models.
Results: Mean training intensity was 90.7 Æ 9.7% of maximum heart rate (81% continuous/19% interval training, 64%
additional strength training). A total of 12.2 Æ 2.6 bicycle exercise training sessions were performed. Increase of training
volume by an average of more than 100% was achieved (difference end/beginning of CR: 784 Æ 623 watts  min). In the
multivariate model the gain in training volume was significantly associated with smoking, age and exercise capacity at
entry of CR. The physical fitness level achieved at discharge from CR as assessed by VO 2peak was mainly dependent on
age, but also on various factors related to training, namely exercise capacity at entry, increase of training volume and
training method.
Conclusion: CR patients were trained in line with current guidelines with moderate-to-high intensity and reached a
considerable increase of their training volume. The physical fitness level achieved at discharge from CR depended on
various factors associated with training, which supports the recommendation that CR should be offered to all cardiac
patients.
BACKGROUND: Reduced left ventricular ejection fraction (LVEF) ≤30% is the most powerful prognostic indicator for sudden cardiac death (SCD) in patients after myocardial infarction (MI), but there are little data about long-term changes of LVEF after revascularization and the following implantation of a cardioverter defibrillator (ICD).
METHODS: We performed a retrospective analysis of 277 patients with reduced LVEF at least 1month after MI and complete revascularization. Patients (median time post-MI 23.4months; 74.3% after PCI, 25.7% after CABG were assigned either to group 1 (LVEF<30%) or group 2 (LVEF 30-40%). Biplane echocardiography was redone after a mean follow-up of 441±220days.
RESULTS: LVEF increased significantly in both two groups (group 1: 26.2±4.8% to 32.4±8.5%; p<0.001; group 2: 38.2±2.5% to 44.4±9.6%; p<0.001). However, statistical analysis of first and second LVEF measurement by means of a LOWESS regression and with an appropriate correction of the regression towards the mean effect revealed only a moderate increase of the mean LVEF from 35 to 37% (p<0.001) with a large interindividual variation.
CONCLUSIONS: The impact of early revascularization on LVEF appears to be low in the majority of post-MI heart failure patients. Owing to the high variability, a single measurement may not be reliable enough to justify a decision on ICD indication.
Background:
Endomyocardial biopsy is considered as the gold standard in patients with suspected myocarditis. We aimed to evaluate the impact of bioptic findings on prediction of successful return to work.
Methods:
In 1153 patients (48.9 ± 12.4 years, 66.2% male), who were hospitalized due to symptoms of left heart failure between 2005 and 2012, an endomyocardial biopsy was performed. Routine clinical and laboratory data, sociodemographic parameters, and noninvasive and invasive cardiac variables including endomyocardial biopsy were registered. Data were linked with return to work data from the German statutory pension insurance program and analyzed by Cox regression.
Results:
A total of 220 patients had a complete data set of hospital and insurance information. Three quarters of patients were virus-positive (54.2% parvovirus B19, other or mixed infection 16.7%). Mean invasive left ventricular ejection fraction was 47.1% ± 18.6% (left ventricular ejection fraction <45% in 46.3%). Return to work was achieved after a mean interval of 168.8 ± 347.7 days in 220 patients (after 6, 12, and 24 months in 61.3%, 72.2%, and 76.4%). In multivariate regression analysis, only age (per 10 years, hazard ratio, 1.27; 95% confidence interval, 1.10–1.46; p = 0.001) and left ventricular ejection fraction (per 5% increase, hazard ratio, 1.07; 95% confidence interval, 1.03–1.12; p = 0.002) were associated with increased, elevated work intensity (heavy vs light, congestive heart failure, 0.58; 95% confidence interval, 0.34–0.99; p < 0.049) with decreased probability of return to work. None of the endomyocardial biopsy–derived parameters was significantly associated with return to work in the total group as well as in the subgroup of patients with biopsy-proven myocarditis.
Conclusion:
Added to established predictors, bioptic data demonstrated no additional impact for return to work probability. Thus, socio-medical evaluation of patients with suspected myocarditis furthermore remains an individually oriented process based primarily on clinical and functional parameters.