The prognostic effect of cardiac rehabilitation in the era of acute revascularisation and statin therapy : A systematic review and meta-analysis of randomized and non-randomized studies - The Cardiac Rehabilitation Outcome Study (CROS)

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

The importance of return to work: How to achieve optimal reintegration in ACS patients

The vocational reintegration of patients after an acute coronary syndrome is a crucial step towards complete convalescence from the social as well as the individual point of view. Return to work rates are determined by medical parameters such as left ventricular function, residual ischaemia and heart rhythm stability, as well as by occupational requirement profile such as blue or white collar work, night shifts and the ability to commute (which is, in part, determined by physical fitness). Psychosocial factors including depression, self-perceived health situation and pre-existing cognitive impairment determine the reintegration rate to a significant extent. Patients at risk of poor vocational outcomes should be identified in the early period of rehabilitation to avoid a reintegration failure and to prevent socioprofessional exclusion with adverse psychological and financial consequences. A comprehensive healthcare pathway of acute coronary syndrome patients is initiated by cardiac rehabilitation, which includes specific algorithms and assessment tools for risk stratification and occupational restitution. As the first in its kind, this review addresses determinants and legal aspects of reintegration of patients experiencing an acute coronary syndrome, and offers practical advice on reintegration strategies particularly for vulnerable patients. It presents different approaches and scientific findings in the European countries and serves as a recommendation for action

importance of rehabilitation success determinants

Einleitung: Die kardiologische Rehabilitation (CR) wirkt auf unterschiedliche physiologische und psychologische Patientenparameter nach akutem kardiologischem Ereignis ein und soll so den Gesundheitsstatus des Patienten ganzheitlich verbessern. Vorliegende Arbeit hatte zum Ziel, das Rehabilitationsergebnis anhand eines komplexen Scores zu quantifizieren und darüber hinaus unabhängige Einflussgrößen (Patientenmerkmale) auf den Rehabilitationserfolg zu ermitteln. Methodik: Die Arbeit ist Teil der prospektiven Registerstudie EVA-Reha® Kardiologie, in die in der Pilotphase zwischen 02/2009 und 06/2010 1253 kardiologische Rehabilitanden (70,9 ± 7,0 Jahre, 78,1 % männl.) in 12 Kliniken konsekutiv eingeschlossen worden sind. Aus einer Vielzahl von soziodemographischen (z. B. Alter, Geschlecht) und klinischen Variablen (z. B. Indikation zur CR, diagnostische, Leistungs-, Labor-, subjektive Parameter) wurden rehabilitationsrelevante, änderungssensitive Qualitätsindikatoren identifiziert und in Schweregrade kategorisiert. Die Bewertungen des Wechsels von Schweregraden zum Ende der CR (Punktevergabe von -1 = verschlechtert bis +2 = sehr gebessert) wurden in einem Score zusammengeführt. Unabhängige Einflussgrößen dieses Scores wurden mit Hilfe eines gemischten Modells unter Berücksichtigung der Kliniken als zufälligem Effekt ermittelt. Ergebnisse: Zur Quantifizierung des Rehabilitationserfolges konnte ein multiples Ergebniskriterium (MEK) aus 13 Qualitätsindikatoren der Dimensionen ‚kardiovaskuläre Risikofaktoren‘, ‚körperliche Leistungsfähigkeit‘ und ‚subjektive Gesundheit‘ gebildet werden, bei dem patientenindividuell lediglich interventionsbedürftige Variablen Berücksichtigung fanden. Als effektstärkste unabhängige Einflussgrößen erwiesen sich das Rauchverhalten, die Durchführung eines Belastungs-EKGs bzw. eines Depressivitäts-Screenings sowie die Rehabilitationskliniken selbst. Schlussfolgerung: Anhand des MEK kann der individuelle Erfolg einer kardiologischen Rehabilitationsmaßnahme beurteilt werden. Dieser Score scheint zum einen als Benchmarkgröße für outcome-basierte Einrichtungsvergleiche, zum anderen als Zielgröße für weitere klinische bzw. wissenschaftliche Untersuchungen geeignet zu sein. So konnten schlüssige Einflussgrößen auf den Rehabilitationserfolg identifiziert werden, die künftig bei der Bewertung des Rehabilitationserfolges Beachtung finden und für die zielgerichtete Behandlungssteuerung älterer Patienten genutzt werden sollten.Background: During cardiac rehabilitation (CR), the overall patient health status after an acute cardiac event should be enhanced by the simultaneous improvement of several physiological and psychological patient outcomes. This investigation aimed to quantify the rehabilitation success using a multiple score. Additionally, independent predictors (patient characteristics) on the rehabilitation outcome should be determined. Methods: This thesis is a part of the prospective registry EVA-Reha® Cardiology. During the pilot period (02/2009 to 06/2010), 1,253 cardiac patients (70.9 ± 7.0 years, 78.1 % men) were consecutively enrolled in 12 CR centres. A multitude of sociodemographic (e. g. age, gender) and clinical (e. g. indication for CR, diagnostic, exercise, and laboratory parameters) variables were documented. Of these, CR- related and change-sensitive indicators were identified and divided into degrees of severity. Changes of severity degrees were rated at discharge from CR with points between -1 (worsened) and +2 (greatly improved), which were used to construct a score. Independent predictors of these score were analysed using a mixed model with a random intercept for the centre effect. Results: A multiple outcome criterion (MOC) was developed using 13 indicators in three domains (cardiovascular risk factors, exercise capacity, and subjective health). Only patient indicators requiring intervention were taken into consideration. Strongest independent predictors of MOC were smoking behaviour, performance of an exercise stress test or a depression screening test, and the CR centres themselves. Conclusion: The patient’s individual success of a CR- program can be evaluated using the MOC. This measure seems to be suitable for outcome based centre profiling and can be used for further clinical and scientific investigations. In the differentiated evaluation of rehabilitation success, the identified predictors should be taken into account. Additionally, they can be used to better tailor CR to the needs of older cardiac patients

Improvement of left ventricular ejection fraction in revascularized postmyocardial patients: indication for statistical fallacy

Abstract 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 1 month after MI and complete revascularization. Patients (median time post-MI 23.4 months; 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 ± 220 days. 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

The Pandora’s Box of Frailty Assessments: Which Is the Best for Clinical Purposes in TAVI Patients? A Critical Review

Frailty assessment is recommended before elective transcatheter aortic valve implantation (TAVI) to determine post-interventional prognosis. Several studies have investigated frailty in TAVI-patients using numerous assessments; however, it remains unclear which is the most appropriate tool for clinical practice. Therefore, we evaluate which frailty assessment is mainly used and meaningful for ≤30-day and ≥1-year prognosis in TAVI patients. Randomized controlled or observational studies (prospective/retrospective) investigating all-cause mortality in older (≥70 years) TAVI patients were identified (PubMed; May 2020). In total, 79 studies investigating frailty with 49 different assessments were included. As single markers of frailty, mostly gait speed (23 studies) and serum albumin (16 studies) were used. Higher risk of 1-year mortality was predicted by slower gait speed (highest Hazard Ratios (HR): 14.71; 95% confidence interval (CI) 6.50–33.30) and lower serum albumin level (highest HR: 3.12; 95% CI 1.80–5.42). Composite indices (five items; seven studies) were associated with 30-day (highest Odds Ratio (OR): 15.30; 95% CI 2.71–86.10) and 1-year mortality (highest OR: 2.75; 95% CI 1.55–4.87). In conclusion, single markers of frailty, in particular gait speed, were widely used to predict 1-year mortality. Composite indices were appropriate, as well as a comprehensive assessment of frailty

Impact of clinical and sociodemographic patient characteristics on the outcome of cardiac rehabilitation in older patients

Background Cardiac rehabilitation (CR) seeks to simultaneously improve several outcome parameters related to patient risk factors, exercise capacity and subjective health. A single score, the multiple outcome criterion (MOC), comprised of alterations in 13 outcome variables was used to measure the overall success of CR in an older population. As this success depends on the older patient's characteristics at the time of admission to CR, we attempted to determine the most important influences. Methods The impact of baseline characteristics on the success of CR, measured by MOC, was analysed using a mixed model for 1,220 older patients (70.9 +/- A 7.0 years, 78.3 % men) who enrolled in 12 CR clinics. A multitude of potentially influential baseline patient characteristics was considered including sociodemographic variables, comorbidity, duration of hospital stay, exercise capacity, cardiovascular risk factors, emotional status, and laboratory and echocardiographic data. Results Overall, CR was successful, as indicated by the mean value of the MOC (0.6 +/- A 0.45; min -1.0, max 2.0; positive values denoting improvement, negative ones deterioration). Examples of association with negative MOC values included smoking (MOC -0.15, p < 0.001), female gender (MOC -0.07, p = 0.049), and a longer hospital stay (MOC -0.03, p = 0.03). An example of association with positive MOC value was depression score (MOC 0.06, p = 0.003). Further associations included maximal exercise capacity, blood pressure, heart rate and the rehabilitation centre attended. Conclusion Our results emphasize the necessity to take into consideration baseline characteristics when evaluating the success of CR and setting treatment targets for older patients

Effect of cardiac rehabilitation on functional and emotional status in patients after transcatheter aortic-valve implantation

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

Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine : Update of the Cardiac Rehabilitation Outcome Study (CROS-II)

BACKGROUND: Despite numerous studies and meta-analyses the prognostic effect of cardiac rehabilitation is still under debate. This update of the Cardiac Rehabilitation Outcome Study (CROS II) provides a contemporary and practice focused approach including only cardiac rehabilitation interventions based on published standards and core components to evaluate cardiac rehabilitation delivery and effectiveness in improving patient prognosis. DESIGN: A systematic review and meta-analysis. METHODS: Randomised controlled trials and retrospective and prospective controlled cohort studies evaluating patients after acute coronary syndrome, coronary artery bypass grafting or mixed populations with coronary artery disease published until September 2018 were included. RESULTS: Based on CROS inclusion criteria out of 7096 abstracts six additional studies including 8671 patients were identified (two randomised controlled trials, two retrospective controlled cohort studies, two prospective controlled cohort studies). In total, 31 studies including 228,337 patients were available for this meta-analysis (three randomised controlled trials, nine prospective controlled cohort studies, 19 retrospective controlled cohort studies; 50,653 patients after acute coronary syndrome 14,583, after coronary artery bypass grafting 163,101, mixed coronary artery disease populations; follow-up periods ranging from 9 months to 14 years). Heterogeneity in design, cardiac rehabilitation delivery, biometrical assessment and potential confounders was considerable. Controlled cohort studies showed a significantly reduced total mortality (primary endpoint) after cardiac rehabilitation participation in patients after acute coronary syndrome (prospective controlled cohort studies: hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.20-0.69; retrospective controlled cohort studies HR 0.64, 95% CI 0.53-0.76; prospective controlled cohort studies odds ratio 0.20, 95% CI 0.08-0.48), but the single randomised controlled trial fulfilling the CROS inclusion criteria showed neutral results. Cardiac rehabilitation participation was also associated with reduced total mortality in patients after coronary artery bypass grafting (retrospective controlled cohort studies HR 0.62, 95% CI 0.54-0.70, one single randomised controlled trial without fatal events), and in mixed coronary artery disease populations (retrospective controlled cohort studies HR 0.52, 95% CI 0.36-0.77; two out of 10 controlled cohort studies with neutral results). CONCLUSION: CROS II confirms the effectiveness of cardiac rehabilitation participation after acute coronary syndrome and after coronary artery bypass grafting in actual clinical practice by reducing total mortality under the conditions of current evidence-based coronary artery disease treatment. The data of CROS II, however, underscore the urgent need to define internationally accepted minimal standards for cardiac rehabilitation delivery as well as for scientific evaluation