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- cardiac rehabilitation (5)
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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: 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: Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare.
Objective: The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare.
Methods: From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints.
Results: Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7; P=.95) and the control group (average difference 79.6 m; SD 48.7; P=.95) increased their distance in the 6-minute-walk-test. Improvements in other functional parameters, as well as in quality of life and pain, were achieved in both groups. The higher proportion of working patients in the intervention group (64.6%; P=.01) versus the control group (46.2%) is of note.
Conclusions: The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare.
Background: Telerehabilitation can contribute to the maintenance of successful rehabilitation regardless of location and time. The aim of this study was to investigate a specific three-month interactive telerehabilitation routine regarding its effectiveness in assisting patients with physical functionality and with returning to work compared to typical aftercare.
Objective: The aim of the study was to investigate a specific three-month interactive telerehabilitation with regard to effectiveness in functioning and return to work compared to usual aftercare.
Methods: From August 2016 to December 2017, 111 patients (mean 54.9 years old; SD 6.8; 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, their distance in the 6-minute walk test was assessed as the primary endpoint. Other functional parameters, including health related quality of life, pain, and time to return to work, were secondary endpoints.
Results: Patients in the intervention group performed telerehabilitation for an average of 55.0 minutes (SD 9.2) per week. Adherence was high, at over 75%, until the 7th week of the three-month intervention phase. Almost all the patients and therapists used the communication options. Both the intervention group (average difference 88.3 m; SD 57.7; P=.95) and the control group (average difference 79.6 m; SD 48.7; P=.95) increased their distance in the 6-minute-walk-test. Improvements in other functional parameters, as well as in quality of life and pain, were achieved in both groups. The higher proportion of working patients in the intervention group (64.6%; P=.01) versus the control group (46.2%) is of note.
Conclusions: The effect of the investigated telerehabilitation therapy in patients following knee or hip replacement was equivalent to the usual aftercare in terms of functional testing, quality of life, and pain. Since a significantly higher return-to-work rate could be achieved, this therapy might be a promising supplement to established aftercare.
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.
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.
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 The prognostic effect of multi-component cardiac rehabilitation (CR) in the modern era of statins and acute revascularisation remains controversial. Focusing on actual clinical practice, the aim was to evaluate the effect of CR on total mortality and other clinical endpoints after an acute coronary event.
Design Structured review and meta-analysis.
Methods Randomised controlled trials (RCTs), retrospective controlled cohort studies (rCCSs) and prospective controlled cohort studies (pCCSs) evaluating patients after acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) or mixed populations with coronary artery disease (CAD) were included, provided the index event was in 1995 or later.
Results Out of n=18,534 abstracts, 25 studies were identified for final evaluation (RCT: n=1; pCCS: n=7; rCCS: n=17), including n=219,702 patients (after ACS: n=46,338; after CABG: n=14,583; mixed populations: n=158,781; mean follow-up: 40 months). Heterogeneity in design, biometrical assessment of results and potential confounders was evident. CCSs evaluating ACS patients showed a significantly reduced mortality for CR participants (pCCS: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20-0.69; rCCS: HR 0.64, 95% CI 0.49-0.84; odds ratio 0.20, 95% CI 0.08-0.48), but the single RCT fulfilling Cardiac Rehabilitation Outcome Study (CROS) inclusion criteria showed neutral results. CR participation was also associated with reduced mortality after CABG (rCCS: HR 0.62, 95% CI 0.54-0.70) and in mixed CAD populations.
Conclusions CR participation after ACS and CABG is associated with reduced mortality even in the modern era of CAD treatment. However, the heterogeneity of study designs and CR programmes highlights the need for defining internationally accepted standards in CR delivery and scientific evaluation.
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 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.