The effectiveness of modern cardiac rehabilitation : A systematic review of recent observational studies in non-attenders versus attenders

BACKGROUND: The beneficial effects of cardiac rehabilitation (CR) have been challenged in recent years and there is now a need to investigate whether current CR programmes, delivered in the context of modern cardiology, still benefit patients. METHODS: A systematic review of non-randomised controlled studies was conducted. Electronic searches of Medline, Embase, CINAHL, science citation index (web of science), CIRRIE and Open Grey were undertaken. Non-randomised studies investigating the effects of CR were included when recruitment occurred from the year 2000 onwards in accordance with significant CR guidance changes from the late 1990's. Adult patients diagnosed with acute myocardial infarction (AMI) were included. Non-English articles were considered. Two reviewers independently screened articles according to pre-defined selection criteria as reported in the PROSPERO database (CRD42015024021). RESULTS: Out of 2,656 articles, 8 studies involving 9,836 AMI patients were included. Studies were conducted in 6 countries. CR was found to reduce the risk of all-cause and cardiac-related mortality and improve Health-Related Quality of Life (HRQOL) significantly in at least one domain. The benefits of CR in terms of recurrent MI were inconsistent and no significant effects were found regarding re-vascularisation or re-hospitalisation following AMI. CONCLUSION: Recent observational evidence draws different conclusions to the most current reviews of trial data with respect to total mortality and re-hospitalisation, questioning the representativeness of historic data in the modern cardiological era. Future work should seek to clarify which patient and service level factors determine the likelihood of achieving improved all-cause and cardiac mortality and reduced hospital re-admissions

Exercise interventions for smoking cessation

Background Taking regular exercise, whether cardiovascular‐type exercise or resistance exercise, may help people to give up smoking, particularly by reducing cigarette withdrawal symptoms and cravings, and by helping to manage weight gain. Objectives To determine the effectiveness of exercise‐based interventions alone, or combined with a smoking cessation programme, for achieving long‐term smoking cessation, compared with a smoking cessation intervention alone or other non‐exercise intervention. Search methods We searched the Cochrane Tobacco Addiction Group Specialised Register for studies, using the term 'exercise' or 'physical activity' in the title, abstract or keywords. The date of the most recent search was May 2019. Selection criteria We included randomised controlled trials that compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme alone or another non‐exercise control group. Trials were required to recruit smokers wishing to quit or recent quitters, to assess abstinence as an outcome and have follow‐up of at least six months. Data collection and analysis We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention‐to‐treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison, as either smoking cessation or relapse prevention. We carried out meta‐analyses where appropriate, using Mantel‐Haenszel random‐effects models. Main results We identified 24 eligible trials with a total of 7279 adult participants randomised. Two studies focused on relapse prevention among smokers who had recently stopped smoking, and the remaining 22 studies were concerned with smoking cessation for smokers who wished to quit. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most of the trials employed supervised, group‐based cardiovascular‐type exercise supplemented by a home‐based exercise programme and combined with a multi‐session cognitive behavioural smoking cessation programme. The comparator in most cases was a multi‐session cognitive behavioural smoking cessation programme alone. Overall, we judged two studies to be at low risk of bias, 11 at high risk of bias, and 11 at unclear risk of bias. Among the 21 studies analysed, we found low‐certainty evidence, limited by potential publication bias and by imprecision, comparing the effect of exercise plus smoking cessation support with smoking cessation support alone on smoking cessation outcomes (RR 1.08, 95% CI 0.96 to 1.22; I2 = 0%; 6607 participants). We excluded one study from this analysis as smoking abstinence rates for the study groups were not reported. There was no evidence of subgroup differences according to the type of exercise promoted; the subgroups considered were: cardiovascular‐type exercise alone (17 studies), resistance training alone (one study), combined cardiovascular‐type and resistance exercise (one study) and type of exercise not specified (two studies). The results were not significantly altered when we excluded trials with high risk of bias, or those with special populations, or those where smoking cessation intervention support was not matched between the intervention and control arms. Among the two relapse prevention studies, we found very low‐certainty evidence, limited by risk of bias and imprecision, that adding exercise to relapse prevention did not improve long‐term abstinence compared with relapse prevention alone (RR 0.98, 95% CI 0.65 to 1.47; I2 = 0%; 453 participants). Authors' conclusions There is no evidence that adding exercise to smoking cessation support improves abstinence compared with support alone, but the evidence is insufficient to assess whether there is a modest benefit. Estimates of treatment effect were of low or very low certainty, because of concerns about bias in the trials, imprecision and publication bias. Consequently, future trials may change these conclusions.PLAIN LANGUAGE SUMMARY: Can exercise help people quit smoking? Background We reviewed the evidence about whether exercise helps people who want to quit smoking, or have recently stopped smoking, to stop smoking for at least six months. Taking regular exercise may help people give up smoking by helping with cigarette withdrawal and cravings, and by helping them to manage weight gain, which can be a concern among people trying to quit. Study characteristics We found 24 studies with a total of 7279 people. Two studies focused on helping those who had recently stopped smoking and the rest of the studies included current smokers who wished to quit. All the studies were conducted with adults. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most studies offered supervised and group‐based, aerobic‐type exercise. The evidence is up‐to‐date to May 2019. Key results When we combined the results of 21 studies (6607 participants) which compared exercise and smoking‐cessation programmes to smoking cessation programmes alone, there was no evidence that exercise increased quit rates at six months or longer. There was no evidence that the effect was different for different types of exercise. When we combined results from two studies (453 participants), there was no evidence that exercise helped people who had recently quit to stay quit. Quality of evidence We judged the quality of evidence for whether exercise programmes help people quit smoking as low certainty, suggesting that future research could change these results. The low certainty is because we cannot rule out chance as an explanation for the suggested slight benefit. It could be that exercise may not help at all, or it could be that supporting people to do exercise modestly increases quit rates. We do not know which of these is true. We also consider that a good number of the trials may be biased. We have concerns that small studies which found smaller effects were less likely to be published than small studies which found bigger effects, making the average result misleading. We judged the evidence from two studies examining whether exercise helps people to avoid relapse to smoking to be of very low certainty, again suggesting that more research is needed. This is due to imprecision of the estimated effects and a high risk of bias in the methods used by one of the studies

Nuevos aspectos morfológicos de los defectos septales atrioventriculares : implicaciones morfonegéticas

Reducción altaLos defectos septales atrioventriculares (dsav) son un grupo de cardiopatías congénitas en las que esta ausente el septum atrioventricular (sav) hay un único anillo valvular atrioventricular, válvulas situadas a un mismo nivel y alteradas morfológicamente, acortamiento de la porción de entrada ventricular izquierda (vi) junto con alargamiento de la de salida. Variaciones al grado de afectación dan lugar a casos leves con pequeño cortocircuitos arteriovenoso, hasta casos graves, con gran cortocircuito, en los que además pueden haber importantes anomalías asociadas. Esta patología ha sido objeto de múltiples controversias en relación a aspectos de nomenclatura, embriología y anatomía. La existencia de un caso de dsav sin foramen primun, considerado clásicamente elemento obligado en estas malformaciones a la par que los hallazgos de un trabajo de embriología descriptiva que mostró que el septum primum se unía los cojinetes sin que estos participaran en la tabicación atrial, fue nuestro punto de partida para encontrar especímenes adicionales sin foramen primum. Lo cual es importante para deslindar las tabicaciones atrial y atrioventricular como dos procesos independientes, ya que en estos corazones malformados hay un fallo en los cojinetes dorsal y ventral. Existe un patrón de corazón normal en base a una serie de medidas de grosores, tractos y perímetros, las cuales sirven para hacer cálculos de volúmenes ventriculares si se emplean formulas para tal fin. La realización de tales medidas en nuestro estudio sirvieron para cuantificar de manera mas objetiva los parámetros anatómicos de esta malformación y poder compararlos con los patrones de corazón normal para establecer sus diferencias y tratar de comprender mejor su fisiopatología. La morfología detallada de esta cardiopatía, correlacionada con el conocimiento de la embriología de la tabicación atrioventricular y de sus válvulas, nos proporciono una base par comprender algunos mecanismos embriopatológicos.Univ. de Granada, Departamento de Ciencias Morfológicas. Leída el 20-05-8

Mitral-aortic Intervalvular Fibrosa Aneurysm with Rupture into Left Atrium: An Uncommon Cause of Acute Dyspnea

Aneurysm of the mitral-aortic intervalvular fibrosa (MAIF) is an exceptionally rare but a potentially catastrophic complication, commonly following aortic valve endocarditis. We present a 24-year-old male presenting with acute onset dyspnea secondary to MAIF aneurysm rupturing into a left atrium causing large shunt which was diagnosed on echocardiography. The MAIF aneurysm in the absence of infective endocarditis rupturing into left atrium is extremely rare

Rehabilitación cardíaca postinfarto de miocardio en enfermos de bajo riesgo: resultados de un programa de coordinación entre cardiología y atención primaria

Introducción y objetivos. Evaluar la eficacia de un programa de rehabilitación cardíaca para pacientes con infartos de miocardio de bajo riesgo coordinados por la cardiología especializada y en colaboración con atención primaria. Pacientes y método. Un total de 153 pacientes con infarto de miocardio de bajo riesgo fueron remitidos de forma consecutiva al centro de atención primaria para proseguir con el control evolutivo. En 113 pacientes se aplicó un programa conjunto que incluía ejercicio físico, control de los factores de riesgo, programa antitabaco, charlas de educación sanitaria y valoración psicológica. Los 40 pacientes restantes en los que no se aplicó el programa formaron el grupo control. Resultados. No se observaron diferencias basales entre los 2 grupos. A los 3 y a los 12 meses mejoró el abandono de tabaco (4,6 frente al 15,6% a los 12 meses; p < 0,05) y el índice de masa corporal (26 ± 2 frente a 29 ± 2 a los 12 meses; p < 0,05). La dislipemia, la glucemia y la presión arterial estuvieron controladas por igual. El grupo activo mejoró la calidad de vida al año de seguimiento (78 ± 2 frente a 91 ± 2, p < 0,05), la capacidad de esfuerzo medida en equivalentes metabólicos (10,3 ± 2 frente a 8,4 ± 3; p < 0,01) y el retorno laboral (el 84,6 frente al 53,3%; p < 0,05). Conclusiones. En enfermos con antecedentes de infarto de miocardio de bajo riesgo que realizan un programa de rehabilitación cardíaca coordinado entre cardiología y atención primaria se observa una mejoría de la calidad de vida y de la tolerancia al esfuerzo, un mayor retorno laboral, un mayor abandono del hábito tabáquico y una disminución del índice de masa corporal al año de seguimiento. Estos resultados indican la necesidad de potenciar programas similares