Use and Outcomes Associated With Perioperative Amiodarone in Cardiac Surgery

Background: In randomized controlled trials, perioperative administration of amiodarone has been shown to reduce the incidence of postoperative atrial arrhythmias and length of stay (LOS) among patients undergoing coronary bypass surgery. However, little is known about the use or effectiveness of perioperative amiodarone in routine clinical practice. Methods and Results: We studied patients \u3e /=18 years old without a previous history of atrial or ventricular arrhythmias who underwent elective coronary bypass surgery between 2013 and 2014 within a network of 235 US hospitals. Perioperative amiodarone was defined as receipt of amiodarone either on the day of or the day preceding surgery. We used covariate-adjusted modeling and instrumental variable methods to examine the association between receipt of amiodarone and the development of atrial arrhythmias, in-hospital mortality, readmission, LOS, and cost. Of 12 758 patients, 2195 (17.2%) received perioperative amiodarone, 3330 (26.1%) developed atrial arrhythmias postoperatively, and the average LOS was 6.4 days (+/-2.6 days). Instrumental variable analysis showed that receipt of perioperative amiodarone was associated with lower risk of atrial arrhythmias (risk difference -11 percentage points, 95% CI -19 to -4 percentage points; P=0.002) and a shorter LOS (-0.7 day, 95% CI -1.39 to -0.01 days; P=0.048). There was no association between receipt of perioperative amiodarone and in-hospital mortality, cost, or readmission. Conclusions: Among patients undergoing coronary bypass surgery without previous arrhythmias, perioperative amiodarone is associated with a lower risk of atrial arrhythmias and shorter LOS. These findings are consistent with previous randomized trials and lend support to current guideline recommendations

Derivation and Validation of an Inâ Hospital Mortality Prediction Model Suitable for Profiling Hospital Performance in Heart Failure

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142499/1/jah32925_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142499/2/jah32925.pd

MI-PACE Home-Based Cardiac Telerehabilitation Program for Heart Attack Survivors: Usability Study

BACKGROUND: Cardiac rehabilitation programs, consisting of exercise training and disease management interventions, reduce morbidity and mortality after acute myocardial infarction. OBJECTIVE: In this pilot study, we aimed to developed and assess the feasibility of delivering a health watch-informed 12-week cardiac telerehabilitation program to acute myocardial infarction survivors who declined to participate in center-based cardiac rehabilitation. METHODS: We enrolled patients hospitalized after acute myocardial infarction at an academic medical center who were eligible for but declined to participate in center-based cardiac rehabilitation. Each participant underwent a baseline exercise stress test. Participants received a health watch, which monitored heart rate and physical activity, and a tablet computer with an app that displayed progress toward accomplishing weekly walking and exercise goals. Results were transmitted to a cardiac rehabilitation nurse via a secure connection. For 12 weeks, participants exercised at home and also participated in weekly phone counseling sessions with the nurse, who provided personalized cardiac rehabilitation solutions and standard cardiac rehabilitation education. We assessed usability of the system, adherence to weekly exercise and walking goals, counseling session attendance, and disease-specific quality of life. RESULTS: Of 18 participants (age: mean 59 years, SD 7) who completed the 12-week telerehabilitation program, 6 (33%) were women, and 6 (33%) had ST-elevation myocardial infarction. Participants wore the health watch for a median of 12.7 hours (IQR 11.1, 13.8) per day and completed a median of 86% of exercise goals. Participants, on average, walked 121 minutes per week (SD 175) and spent 189 minutes per week (SD 210) in their target exercise heart rate zone. Overall, participants found the system to be highly usable (System Usability Scale score: median 83, IQR 65, 100). CONCLUSIONS: This pilot study established the feasibility of delivering cardiac telerehabilitation at home to acute myocardial infarction survivors via a health watch-based program and telephone counseling sessions. Usability and adherence to health watch use, exercise recommendations, and counseling sessions were high. Further studies are warranted to compare patient outcomes and health care resource utilization between center-based rehabilitation and telerehabilitation

Exercise Testing and Exercise Rehabilitation for Patients With Atrial Fibrillation

INTRODUCTION AND PURPOSE: Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increasing prevalence with advancing age. It is associated with dyspnea, exercise intolerance, and increased risk for clinical events, especially stroke and heart failure. This article provides a concise review of exercise testing and rehabilitation in patients with persistent or permanent AF. CLINICAL CONSIDERATIONS: The first goal in the treatment of AF is to reduce symptoms (eg, palpitations) and a fast ventricular rate. The second goal is to reduce the risk of a stroke. Exercise testing and rehabilitation may be useful once these goals are achieved. However, there are no large, randomized exercise training trials involving patients with AF, and what data are available comes from single-site trials, secondary analyses, and observational studies. EXERCISE TESTING AND TRAINING: There are no specific indications for performing a graded exercise test in patients with AF; however, such testing may be used to screen for myocardial ischemia or evaluate chronotropic response during exertion. Among patients with AF, exercise capacity is 15% to 20% lower and peak heart rate is higher than in patients in sinus rhythm. Exercise rehabilitation improves exercise capacity, likely improves quality of life, and may improve symptoms associated with AF. Whole-body aerobic exercise is recommended. SUMMARY: Atrial fibrillation is a common cardiac condition and in these patients, exercise rehabilitation favorably improves exercise capacity. However, prospective randomized controlled trials are needed to better define the effects of exercise training on safety; quality of life; clinical outcomes; and central, autonomic, and peripheral adaptations

Association Between Patient Cost Sharing and Cardiac Rehabilitation Adherence

OBJECTIVE: To determine the association between cost sharing and adherence to cardiac rehabilitation (CR). PATIENTS AND METHODS: We collected detailed cost-sharing information for patients enrolled in CR at Baystate Medical Center in Springfield, Massachusetts, including the presence (or absence) and amounts of co-pays and deductibles. We evaluated the association between cost sharing and the total number of CR sessions attended as well as the influence of household income on CR attendance. RESULTS: In 2015, 603 patients enrolled in CR had complete cost-sharing information. In total, 235 (39%) had some form of cost sharing. Of these, 192 (82%) had co-pays (median co-pay, $20; interquartile range [IQR],$10-$32) and 79 (34$500; IQR, $250-$1800). The presence of any amount or form of cost sharing was associated with 6 fewer sessions of CR (16; IQR, 4-36 vs 10; IQR, 4-27; P CONCLUSION: Cost sharing was associated with lower CR attendance and exhibited a dose-response relationship such that higher cost sharing was associated with lower CR attendance. Given that CR is cost-effective and underutilized, insurance companies and other payers should reevaluate their cost-sharing policies for CR

Comparison of Ratings of Perceived Exertion and Target Heart Rate-Based Exercise Prescription in Cardiac Rehabilitation: A RANDOMIZED CONTROLLED PILOT STUDY

PURPOSE: Although ratings of perceived exertion (RPE) are widely used to guide exercise intensity in cardiac rehabilitation (CR), it is unclear whether target heart rate ranges (THRRs) can be implemented in CR programs that predominantly use RPE and what impact this has on changes in exercise capacity. METHODS: We conducted a three-group pilot randomized control trial (#NCT03925493) comparing RPE of 3-4 on the 10-point modified Borg scale, 60-80% of heart rate reserve (HRR) with heart rate (HR) monitored by telemetry, or 60-80% of HRR with a personal HR monitor (HRM) for high-fidelity adherence to THRR. Primary outcomes were protocol fidelity and feasibility. Secondary outcomes included exercise HR, RPE, and changes in functional exercise capacity. RESULTS: Of 48 participants randomized, four patients dropped out, 20 stopped prematurely (COVID-19 pandemic), and 24 completed the protocol. Adherence to THRR was high regardless of HRM, and patients attended a median (IQR) of 33 (23, 36) sessions with no difference between groups. After randomization, HR increased by 1 ± 6, 6 ± 5, and 10 ± 9 bpm (P = .02); RPE (average score 3.0 ± 0.05) was unchanged, and functional exercise capacity increased by 1.0 ± 1.0, 1.9 ± 1.5, 2.0 ± 1.3 workload METs (effect size between groups, ηp2 = 0.11, P = .20) for the RPE, THRR, and THRR + HRM groups, respectively. CONCLUSIONS: We successfully implemented THRR in an all-RPE CR program without needing an HRM. Patients randomized to THRR had higher exercise HR but similar RPE ratings. The THRR may be preferable to RPE in CR populations for cardiorespiratory fitness gains, but this needs confirmation in an adequately powered trial