Rehabilitation after pulmonary Embolism

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. Prospective observational multi-centre study, enrolment in CR between 05/2017 and 05/2018. 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. 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. 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. The study was registered at the German Clinical Trial Registry and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (DRKS00011418; http://www.drks.de/DRKS00011418, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00011418).

Current guidelines recommend individually adapted resistance training (RT) as a part of the exercise regime in patients with cardiovascular diseases. The aim of this review was to provide insights into current knowledge and understanding of how useful, feasible, safe, and effective RT is in patients with coronary artery disease (CAD), heart failure (HF), and valvular heart disease (VHD), with particular emphasis on the role of RT in elderly and/or frail patients. A review based on an intensive literature search: systematic reviews and meta-analyses published in 2010 or later; recent studies not integrated into meta-analyses or systematic reviews; additional manual searches. The results highlight the evaluation of effects and safety of RT in patients with CAD and HF with reduced ejection fraction (HFrEF) in numerous meta-analyses. In contrast, few studies have focused on RT in patients with HF with preserved ejection fraction (HFpEF) or VHD. Furthermore, few studies have addressed the feasibility and impact of RT in elderly cardiac patients, and data on the efficacy and safety of RT in frail elderly patients are limited. The review results underscore the high prevalence of age-related sarcopenia, disease-related skeletal muscle deconditioning, physical limitations, and frailty in older patients with cardiovascular diseases (CVD). They underline the need for individually tailored exercise concepts, including RT, aimed at improving functional status, mobility, physical performance and muscle strength in older patients. Furthermore, the importance of the use of assessment tools to diagnose frailty, mobility/functional capacity, and physical performance in the elderly admitted to cardiac rehabilitation is emphasized.

BackgroundMulti-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.DesignProspective observational multi-centre study, enrolment in CR between 05/2017 and 05/2018.MethodBesides 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.ResultsOut 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.ConclusionPatient-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.Trial registrationThe study was registered at the German Clinical Trial Registry and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (DRKS00011418; http://www.drks.de/DRKS00011418, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00011418).

Descriptive patterns of severe chronic pulmonary hypertension by chest radiography

Exercise-based cardiac rehabilitation improves physical performance and health-related quality of life (HRQoL). However, whether improvements in physical performance are associated with changes in HRQoL has not been adequately investigated in a nonischemic cardiac population. Patients who were ablated for atrial fibrillation, who underwent heart valve surgery or who were treated for infective endocarditis, and who participated in 1 of 3 randomized controlled rehabilitation trials were eligible for the current study. Change in physical performance and HRQoL were measured before and after a 12-wk exercise intervention. Physical performance was assessed using a cardiopulmonary exercise test, a 6-min walk test, and a sit-to-stand test. Health-related quality of life was assessed using the generic 36-Item Short Form Health Survey and the disease-specific HeartQoL questionnaire. Spearman correlation coefficient (ρ) and linear regressions quantified the association between changes in physical outcome measures and changes in HRQoL. A total of 344 patients were included (mean age: 60.8 ± 11.6 yr and 77% males). Associations between changes in physical outcome measures and HRQoL ranged from very weak to weak (ρ = -0.056 to 0.228). The observed associations were more dominant within physical dimensions of the HRQoL compared with mental or emotional dimensions. After adjusting for sex, age, and diagnosis, changes in physical performance explained no more than 20% of the variation in the HRQoL. The findings show that the positive improvement in HRQoL from exercise-based cardiac rehabilitation cannot simply be explained by an improvement in physical performance.

fatigue is a common, but still one of the least understood symptoms in multiple sclerosis (MS). We aimed to investigate whether fatigue was associated with demographic-, clinical-, health-related quality of life (HRQoL)- and physical performance variables, and whether change in fatigue after treatment was associated with changes in HRQoL and physical performance. sixty patients were included for inpatient physiotherapy. Fifty-six patients completed the study and were available for analysis. Fatigue (Fatigue Severity Scale; FSS), HRQoL (Multiple Sclerosis Impact Scale; MSIS-29) and physical performance (walking ability and balance) were assessed at screening, baseline, after treatment and at follow-up after 3 and 6 months. We analysed possible associations between fatigue and other variables at baseline by regression models, and between change in fatigue versus changes in both HRQoL and physical performance variables after physiotherapy by correlation analysis. fatigue at baseline was associated with HRQoL (explained 21.9% of variance), but not with the physical performance tests. Change in fatigue was correlated with change in HRQoL, but not with changes in physical performance. All measures were improved after treatment (P ≤ 0.001). While improvements in fatigue and HRQoL were lost at follow-up, improvements in physical performance tests were maintained for at least 6 months (P ≤ 0.05). fatigue was associated with HRQoL at baseline. Improvement in fatigue seemed to be related to other factors than improvement in physical performance. A broader strategy including both physical and psychological dimensions seems to be needed to improve fatigue over the long-term.

To review the literature on health-related quality of life (HRQoL) outcomes for exercise-based cardiac rehabilitation (EBCR) in contemporary acute coronary syndrome (ACS) patients. Electronic databases (CENTRAL, MEDLINE, Embase, and CINAHL) were searched from January 2000 to March 2019 for randomised controlled trials (RCTs) comparing EBCR to a no-exercise control in ACS patients recruited after year 2000, follow-up of at least 6months, and HRQoL as outcome. Potential papers were independently screened by two reviewers. Risks of bias were assessed using the Cochrane Tool. Data analyses were performed using RevMan v5.3, random effects model. Fourteen RCTs (1739 participants) were included, with eight studies suitable for meta-analyses. EBCR resulted in statistically significant and clinically important improvements in physical performance (mean difference [MD] 7.09, 95% CI 0.08, 14.11) and general health (MD 5.08, 95% CI 1.03, 9.13) (SF-36) at 6months, and in physical functioning (MD 9.82, 95% CI 1.46, 18.19) at 12months. Statistically significant and sustained improvements were also found in social and physical functioning. Meta-analysis of two studies using the MacNew Heart Disease HRQoL instrument did not show any significant benefits. Of the six studies unsuitable for meta-analyses, five reported significant changes in overall HRQoL, general physical activity levels and functional capacity, or quality-adjusted life-years (QALYs). In an era where adherence to clinical practice guidelines has improved survival, EBCR still achieves clinically meaningful improvements in physical performance, general health, and physical functioning in the short and long term in contemporary ACS patients.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of pulmonary embolism. As for most rare diseases, epidemiologic data are scarce, but recent registries suggest an incidence of at least 5 per million inhabitants per year. A history of massive or recurrent acute pulmonary embolism is observed in most patients with CTEPH, but the proportion of patients who develop CTEPH after acute pulmonary embolism is a matter of debate, further complicated by the possible misdiagnosis of CTEPH as acute pulmonary embolism. A complete resolution of thrombi is usually not achieved after acute pulmonary embolism, and the clinical relevance of a "postpulmonary embolism syndrome" with persistent perfusion defects and exercise intolerance is discussed. Risk factors most consistently associated with CTEPH are circulating anti-phospholipid antibodies or lupus anticoagulant, increased factor VIII, non-O blood groups, and chronic inflammatory diseases. There is no female predominance, and it is a disease of older age. Survival in the absence of specific surgical or medical treatment is poor and depends on the hemodynamic severity.

Monitoring for Pulmonary Hypertension Following Pulmonary Embolism: The INFORM Study

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Slovenian Research Agency Background Resistance training (RT) is an adjunct exercise therapy to aerobic training (AT) in cardiac rehabilitation, but it remains unknown whether the dose-dependent relationship between RT load (high load [HL] vs. low load [LL]) and improvement in anthropometry, body composition and physical performance exists in patients with coronary artery disease (CAD). Purpose The aim of our study was to investigate the effects of HL-RT and LL-RT on top of AT in comparison to AT on anthropometry, body composition and physical performance in patients with CAD. Methods A total of 79 patients with a stable CAD were randomised to HL-RT+AT (n = 21), LL-RT+AT (n = 19) or AT (n = 19) and performed 36 training sessions. Fifty-nine patients with mean (SD) age 61 (8) years and left ventricular ejection fraction 53 (9) % completed the study. AT progressed from 50 % to 80% of peak power output achieved at baseline cardiopulmonary exercise test, and RT progressed from 70% of one repetition maximum (1-RM) to 80% of 1-RM in HL-RT group, and from 35% of 1-RM to 40% of 1-RM in LL-RT group. We measured anthropometry (body mass, waist and hip circumference, and waist to hip circumference ratio), body composition (lean body mass and %, body fat mass and %, and phase angle) and physical performance evaluating upper muscle strength (arm curl and hand grip test) and lower muscle strength (five sit-to stand test, up-and-go test, heel raise test), mobility (gait speed test), flexibility (back scratch test, sit-and-reach test), balance (stork balance test) and submaximal endurance (6 min walk test distance) at baseline and post-training. Results Waist circumference and waist-to-hip circumference ratio decreased significantly following LL-RT (both p < 0.01), without post-training differences between training interventions in other anthropometry measures and body composition measures (all p > 0.079). HL-RT and LL-RT induced improvements in all physical performance measures, while AT alone did not improve gait speed, upper limb flexibility and performance of up-and-go test. HL-RT was associated with greater improvement in gait speed (+12 %, p =0.044), arm curl test (+13 %, p = 0.037) and time of Up-and-go test (+9 %, p <0.001) compared to AT group, while LL-RT improved more time of Up-and-Go test (+18 %, p < 0.001) and time of five sit-to-stands (+14 %, p = 0.016) compared to AT. There was no difference between HL-RT and LL-RT in post-training change of physical performance measures. Conclusions The addition of RT to AT is associated with greater improvements in submaximal muscle strength and mobility compared to AT and should be encouraged in future multimodal exercise-based cardiac rehabilitation.

IntroductionPoor physical performance is associated with an increased risk of post-discharge cardiovascular events in patients with heart failure. In this study, we investigated the association between physical frailty and improvements in physical performance through cardiac rehabilitation in hospitalized older patients with heart failure.MethodsThe study included 100 patients with heart failure (aged ≥65 years) hospitalized between January 2023 and August 2024, with a short physical performance battery (SPPB) score ranging from 1 to 11 points at the initiation of cardiac rehabilitation. Patients achieving an improvement of ≥1 SPPB points during hospitalization were classified as the improved group, while those with unchanged or declining scores comprised the non-improved group. We retrospectively examined the association between physical frailty and improvement in physical performance due to acute-phase cardiac rehabilitation during hospitalization.ResultsAmong the 100 patients, 62 and 38 were categorized into the improved and non-improved groups, respectively. Although no significant differences were observed regarding age, sex, or rehabilitation duration between the groups, the prevalence of physical frailty was significantly higher in the non-improved than in the improved group. Modified Poisson regression analysis, controlling for age, sex, and New York Heart Association functional class, showed that physical frailty was significantly associated with a reduced likelihood of improvement in physical performance.ConclusionPhysical frailty may inhibit improvement in physical performance among hospitalized older patients with heart failure. Therefore, enhancing acute-phase rehabilitation strategies for patients with frailty and strengthening the post-discharge follow-up system are essential.

A Multidisciplinary Pulmonary Embolism Response Team

Introduction Comprehensive cardiac rehabilitation (CR) programs based on the bio-psycho-social approach of the international classification of functioning and disease are carried out to achieve improved prognosis, superior health-related quality of life (HRQL) and social integration. We aimed to identify predictors of returning to work (RTW) and HRQL among cardiovascular risk factors and physical performance as well as patient-reported outcome measures (PROMs) modifiable during CR. Methods We designed a prospective observational multi-center study and enrolled 1,586 patients (2017/18) in 12 German rehabilitation centers regardless of their primary allocation diagnoses (e.g. acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), coronary artery disease (CAD), valvular disease). Besides general data (e.g. age, gender, diagnoses), parameters of risk factor management (e.g. smoking, lipid profile, hypertension, lifestyle change motivation), physical performance (e.g. maximum exercise capacity, endurance training load, 6-min walking distance), and PROMs (e.g. depression, heart-focused anxiety, HRQL, subjective well-being, somatic and mental health, pain, general self-efficacy, pension desire as well as self-assessment of occupational prognosis using several questionnaires) were documented at CR admission and discharge. 6 months after discharge, status of RTW and HRQL (SF-12) were captured by a follow-up (FU) survey and analyzed in multivariable regression models with multiple imputation of missing values. Results Out of the study participants, 1,262 patients (54±7 years, 77% men) responded to the follow-up survey and could be analyzed regarding the outcome parameters. Most of them were assigned to CR primarily due to AMI (40%) or CAD without myocardial infarction (18%), followed by heart valve diseases in 12% of patients and CABG (8%). 864 patients (69%) returned to work within the follow-up period. Pension desire, negative self-assessed occupational prognosis, heart-focussed anxiety, major life events, smoking and heart failure were negatively associated with RTW, while higher endurance training load, HRQL and work stress were positively associated (Figure 1). HRQL after 6 months was determined more by PROMs (e.g. pension desire, heart-focused anxiety, physical/mental HRQL in SF-12, physical/mental health in indicators of rehab-status questionnaire (IRES-24), stress, well-being in the World Health Organization well-being index and self-efficacy expectations) than by clinical parameters or physical performance. Conclusions Patient-reported outcome measures predominantly influenced RTW and HRQL in heart-disease patients, whereas patients' pension desire and heart-focussed anxiety had a dominant impact on all investigated endpoints. Therefore, the multi-component CR approach focussing on psychosocial support is crucial for subjective health prognosis and occupational resumption. Figure 1. Predictors of returning to work Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): German pension insurance

Among survivors of acute pulmonary embolism (PE), roughly half report persistent dyspnea, impaired functional status, and decreased quality of life. Post-pulmonary embolism syndrome (PPES) is a broad condition which has been increasingly recognized in recent years and may be due to post-pulmonary embolism functional impairment, chronic thromboembolic disease, or the most severe long-term complication of PE, chronic thromboembolic pulmonary hypertension. Despite guideline recommendations for appropriate follow-up for post-pulmonary embolism patients, PPES remains underrecognized and diagnostic testing underutilized. Patients with symptoms suggestive of PPES at follow-up should undergo a transthoracic echocardiogram to screen for the presence of pulmonary hypertension; additional testing, such as a ventilation/perfusion scan, right heart catheterization, and cardiopulmonary exercise testing may be indicated. The pathophysiology of post-pulmonary embolism syndrome is complex and heterogeneous. In chronic thromboembolic pulmonary hypertension, the pathophysiology reflects persistent pulmonary arterial thrombi and a progressive small vessel vasculopathy. In patients with chronic thromboembolic disease or chronic thromboembolic pulmonary hypertension, medical therapy, balloon pulmonary angioplasty, or pulmonary thromboendarterectomy should be considered, and in cases of chronic thromboembolic pulmonary hypertension, pulmonary thromboendarterectomy significantly improves mortality. In all causes of post-pulmonary embolism syndrome, rehabilitation is a safe treatment option that may improve quality of life.

Counterpoint: Should Systemic Lytic Therapy Be Used for Submassive Pulmonary Embolism? No