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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
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.
Background
Aim of the study was to find predictors of allocating patients after transcatheter aortic valve implantation (TAVI) to geriatric (GR) or cardiac rehabilitation (CR) and describe this new patient group based on a differentiated characterization.
Methods
From 10/2013 to 07/2015, 344 patients with an elective TAVI were consecutively enrolled in this prospective multicentric cohort study. Before intervention, sociodemographic parameters, echocardiographic data, comorbidities, 6-min walk distance (6MWD), quality of life and frailty (score indexing activities of daily living [ADL], cognition, nutrition and mobility) were documented. Out of these, predictors for assignment to CR or GR after TAVI were identified using a multivariable regression model.
Results
After TAVI, 249 patients (80.7 ± 5.1 years, 59.0% female) underwent CR (n = 198) or GR (n = 51). GR patients were older, less physically active and more often had a level of care, peripheral artery disease as well as a lower left ventricular ejection fraction. The groups also varied in 6MWD. Furthermore, individual components of frailty revealed prognostic impact: higher values in instrumental ADL reduced the probability for referral to GR (OR:0.49, p < 0.001), while an impaired mobility was positively associated with referral to GR (OR:3.97, p = 0.046). Clinical parameters like stroke (OR:0.19 of GR, p = 0.038) and the EuroSCORE (OR:1.04 of GR, p = 0.026) were also predictive.
Conclusion
Advanced age patients after TAVI referred to CR or GR differ in several parameters and seem to be different patient groups with specific needs, e.g. regarding activities of daily living and mobility. Thus, our data prove the eligibility of both CR and GR settings.
Die berufliche Wiedereingliederung von Patienten nach akutem Herzinfarkt stellt sowohl aus gesellschaftlicher wie auch aus individueller Sicht einen entscheidenden Schritt zur vollständigen Rekonvaleszenz dar. Lediglich 10% der Patienten werden durch kardiale Probleme an der Reintegration behindert. Neben medizinischen und berufsbezogenen Faktoren determinieren insbesondere psychosoziale Parameter eine erfolgreiche Wiederaufnahme der Tätigkeit. Verschiedene Programme der Rentenversicherungsträger werden dabei unterstützend angeboten.
Exercise prescription in patients with different combinations of cardiovascular disease risk factors
(2018)
Whereas exercise training is key in the management of patients with cardiovascular disease (CVD) risk (obesity, diabetes, dyslipidaemia, hypertension), clinicians experience difficulties in how to optimally prescribe exercise in patients with different CVD risk factors. Therefore, a consensus statement for state-of-the-art exercise prescription in patients with combinations of CVD risk factors as integrated into a digital training and decision support system (the EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool) needed to be established. EXPERT working group members systematically reviewed the literature for meta-analyses, systematic reviews and/or clinical studies addressing exercise prescriptions in specific CVD risk factors and formulated exercise recommendations (exercise training intensity, frequency, volume and type, session and programme duration) and exercise safety precautions, for obesity, arterial hypertension, type 1 and 2 diabetes, and dyslipidaemia. The impact of physical fitness, CVD risk altering medications and adverse events during exercise testing was further taken into account to fine-tune this exercise prescription. An algorithm, supported by the interactive EXPERT tool, was developed by Hasselt University based on these data. Specific exercise recommendations were formulated with the aim to decrease adipose tissue mass, improve glycaemic control and blood lipid profile, and lower blood pressure. The impact of medications to improve CVD risk, adverse events during exercise testing and physical fitness was also taken into account. Simulations were made of how the EXPERT tool provides exercise prescriptions according to the variables provided. In this paper, state-of-the-art exercise prescription to patients with combinations of CVD risk factors is formulated, and it is shown how the EXPERT tool may assist clinicians. This contributes to an appropriately tailored exercise regimen for every CVD risk patient.
Hintergrund
Einem Großteil der Bevölkerung gelingt es trotz ausreichenden Wissens um die protektiven Effekte nicht, ausreichende körperliche Aktivität in den Alltag zu integrieren. Digitale Assistenzsysteme könnten hierbei unterstützend eingesetzt werden. Dies setzt jedoch das Interesse potentieller Nutzer voraus.
Methode
In einer Online-Befragung wurden im Juni/Juli 2015 Mitarbeiter und Studierende der Universität Potsdam zum individuellen Ausmaß der sportlichen Aktivität, dem Interesse an elektronischer Trainingsunterstützung und weiteren Parametern befragt.
Ergebnis 1217 Studierende und 485 Mitarbeiter (67,3 bzw. 67,5% Frauen, 26±4,9 bzw. 42,7±11,7 Jahre) nahmen an der Studie teil. Die empfohlene sportliche Aktivität (≥3 Tage bzw. 150 min/Woche) wurde von 70,1% der Mitarbeiter und 52,7% der Studierenden nicht erreicht. Innerhalb dieser Gruppen zeigten 53,2% (Studierende) bzw. 44,2% (Mitarbeiter), unabhängig von Alter, Geschlecht, BMI bzw. Bildungsniveau, Interesse an einer elektronischen Trainingsunterstützung.
Schlussfolgerung
Auch in jüngeren Bevölkerungsgruppen mit hohem Bildungsniveau ist die Mehrzahl der Personen unzureichend körperlich aktiv. Ein Interesse an Trainingsunterstützung besteht in etwa der Hälfte dieser sportlich inaktiven Gruppe. Dies legt den Schluss nahe, dass der personalisierte Einsatz mobiler Assistenzsysteme für die positive Beeinflussung des Lebensstils zunehmend an Bedeutung gewinnen könnte.
Objectives To examine the effectiveness of extensive social therapy intervention during inpatient multi-component cardiac rehabilitation (CR) on return to work and quality of life in patients with low probability of work resumption after an acute cardiac event. Methods Patients after acute cardiac event with negative subjective expectations about return to work or unemployment (n = 354) were included and randomized in clusters of 3-6 study participants. Clusters were randomized for social counseling and therapy led by a social worker, six sessions of 60 min each in 3 weeks, or control group (usual care: individual counseling meeting by request). The return to work (RTW) status and change in quality of life (QoL, short form 12: Physical and Mental Component Summary PCS and MCS) 12 months after discharge from inpatient CR were outcome measures. Results The regression model for RTW showed no impact of the intervention (OR 1.1, 95% CI 0.6-2.1, P = 0.79; n = 263). Predictors were unemployment prior to CR as well as higher anxiety values at discharge from CR. Likewise, QoL was not improved by social therapy (linear mixed model: Delta PCS 0.3, 95% CI - 1.9 to 2.5; P = 0.77; n = 177; Delta MCS 0.7, 95% CI - 1.9 to 3.3; P = 0.58; n = 215). Conclusions In comparison to usual care, an intensive program of social support for patients during inpatient cardiac rehabilitation after an acute cardiac event had no additional impact on either the rate of resuming work or quality of life.
Ziel der Studie Die vorliegende Untersuchung beinhaltete die explorative Erfassung potenzieller Indikatoren der Ergebnisqualität der kardiologischen Rehabilitation (CR) für Patienten unter 65 Jahren.
Methoden In einer 4-stufigen webbasierten Delphi-Befragung (04-07/2016) von in der CR tätigen Ärzten[2] , Psychologen und Sport-/Physiotherapeuten wurden Parameter der körperlichen Leistungsfähigkeit, der Sozialmedizin, der subjektiven Gesundheit und kardiovaskuläre Risikofaktoren hinsichtlich ihrer Eignung als Qualitätsindikator bewertet.
Ergebnisse Von 44 vorgegebenen wie auch von den Teilnehmern vorgeschlagenen Parametern wurden 21 Parameter (48%), die Hälfte davon psychosoziale Faktoren, als potenzielle Qualitätsindikatoren ausgewählt, wobei lediglich für das Rauchverhalten, den Blutdruck, das LDL-Cholesterin und die max. Belastbarkeit im Belastungs-EKG ein Konsens (Zustimmung>75% der Befragten) erzielt wurde.
Schlussfolgerung Die Wahl der Qualitätsindikatoren durch die Experten erfolgte mehrheitlich mit nur geringer Einigkeit. Eine klinische und wissenschaftliche Evaluierung der gewählten Parameter ist daher zwingend erforderlich.
Hintergrund In den letzten Jahrzehnten führte die leitliniengerechte Therapie des akuten Myokardinfarktes (MI) zu einer Mortalitätsreduktion in Deutschland, wobei zwischen einzelnen Bundesländern erhebliche Unterschiede beschrieben werden. Ziel war es daher, die aktuelle Versorgungssituation von Patienten mit MI in der Region Nordost-Deutschland (Berlin, Brandenburg [BRB] und Mecklenburg-Vorpommern [MV]) zu untersuchen und Prädiktoren der 1-Jahresmortalität unter Berücksichtigung der regionalen Zuordnung zu identifizieren.
Methode Auf Basis pseudonymisierter Abrechnungsdaten einer gesetzlichen Krankenversicherung wurden für das Jahr 2012 anhand des ICD 10-Codes I21 und I22 von 1 387 084 Versicherten insgesamt 6733 Patienten mit stationärer Aufnahme bei MI gefiltert. Neben der Krankenhaus- und 1-Jahresmortalität wurden potenzielle Prognoseprädiktoren unter Berücksichtigung von Komorbiditäten, periinfarziellen Prozeduren und sekundärpräventiver Pharmakotherapie erfasst und im Ländervergleich analysiert.
Ergebnisse Sowohl die Krankenhaus- als auch die 1-Jahresmortalitätsrate der einzelnen Länder (Berlin 13,6 resp. 27,5 %, BRB 13,9 resp. 27,9 %, MV 14,4 resp. 29,0 %) war vergleichbar zur Gesamtrate (13,9 % resp. 28,0 %) und im Ländervergleich weitgehend identisch. Die multiple Analyse der Einflussfaktoren auf die 1-Jahresmortalität identifizierte vor allem die Koronarangiografie (OR 0,42, 95 % KI 0,35 – 0,51, p < 0,001) und die Umsetzung der pharmakologischen Leitlinienempfehlungen (OR 0,14, 95 % KI 0,12 – 0,17, p < 0,001) als wesentliche Maßnahmen zur Risikoreduktion. Bei beiden Einflussfaktoren lagen univariat keine statistischen Unterschiede zwischen den drei Bundesländern vor.
Schlussfolgerung Die vorliegenden Daten lassen auf eine vergleichbare stationäre und poststationäre Versorgung und 1-Jahresprognose von Patienten mit akutem MI in den Bundesländern Berlin, Brandenburg und Mecklenburg-Vorpommern in der untersuchten Population schließen, wobei insbesondere der Durchführung einer Koronarangiografie und der adäquaten Umsetzung einer leitliniengerechten Pharmakotherapie prognostische Bedeutung zukommt.
Background: Melatonin exerts multiple biological effects with potential impact on human diseases. This is underscored by genetic studies that demonstrated associations between melatonin receptor type 2 gene (MTNR1B) polymorphisms and characteristics of type 2 diabetes. We set out to test the hypothesis whether genetic variants at MTNR1B are also relevant for other disease phenotypes within the cardiovascular continuum. We thus investigated single nucleotide polymorphisms (SNPs) of MTNR1B in relation to blood pressure (BP) and cardiac parameters in hypertensive patients.
Methods: Patients (n = 605, mean age 56.2 +/- 9.4 years, 82.3% male) with arterial hypertension and cardiac ejection fraction (EF) >= 40% were studied. Cardiac parameters were assessed by echocardiography.
Results: The cohort comprised subjects with coronary heart disease (73.1%) and myocardial infarction (48.1%) with a mean EF of 63.7 +/- 8.9%. Analysis of SNPs rs10830962, rs4753426, rs12804291, rs10830963, and rs3781638 revealed two haplotypes 1 and 2 with frequencies of 0.402 and 0.277, respectively. Carriers with haplotype 1 (CTCCC) showed compared to non-carriers a higher mean 24-hour systolic BP (difference BP: 2.4 mm Hg, 95% confidence interval (CI): 0.3 to 4.5 mm Hg, p = 0.023). Haplotype 2 (GCCGA) was significantly related to EF with an absolute increase of 1.8% (CI: 0.45 to 3.14%) in carriers versus non-carriers (p = 0.009).
Conclusion: Genetics of MTNR1B point to impact of the melatonin signalling pathway for BP and left ventricular function. This may support the importance of the melatonin system as a potential therapeutic target.