Ambulatory Cardiac Rehabilitation Research Articles

Calculation of Oxygen Uptake during Ambulatory Cardiac Rehabilitation.

Background: Cardiopulmonary exercise testing is not used routinely. The goal of this study was to determine whether accurate estimates of VO2 values can be made at the beginning and at the end of a rehabilitation program. Methods: A total of 91 cardiac rehabilitation patients were included. Each participant had to complete cardiopulmonary exercise testing at the beginning and at the end of a rehabilitation program. Measured VO2 values were compared with estimates based on three different equations. Results: Analyses of the means of the differences in the peak values showed very good agreement between the results obtained with the FRIEND equation or those obtained with a combination of rules of thumb and the results of the measurements. This agreement was confirmed with the ICCs and with the standard errors of the measurements. The ACSM equation performed worse. The same tendency was seen when considering the VO2 values at percentage-derived work rates. Conclusions: The FRIEND equation and the more easily applicable combination of rules of thumb are suitable for estimating the peak VO2 and the VO2 at a percentage-derived work rate in cardiac patients both at the beginning and at the end of a cardiac rehabilitation program.

Health outcomes of an ambulatory exercise-based cardiac rehabilitation program across patient risk categories

Abstract Background Exercise-based cardiac rehabilitation is recommended after an ST-segment elevation myocardial infarction (STEMI) to improve prognosis, quality of life and control of cardiovascular risk factors. Ambulatory training has been proposed as an alternative if in-hospital training is unavailable. Purpose To study the health outcomes of an ambulatory exercise-based Cardiac Rehabilitation Program (aCRP) in STEMI patients across different patient risk profiles. Methods A Phase 2 aCRP aimed to STEMI patients was implemented in our hospital in 2022. Conventional or cardiopulmonary exercise testing (C/CPET) was performed, patient risk was stratified as low risk or intermediate/high risk, and a 3-month, individualized aerobic and strength ambulatory training program was provided. C/CPET was repeated at the end of Phase 2 and peak oxygen consumption (peak VO2) was measured. Questionnaires were used to analyse quality of life (SF-36), depression (PHQ-2), anxiety (GAD-2), adherence to Mediterranean diet (PREDIMED) and weekly physical activity (IPAQ). Comparisons were performed between patients at low risk and patients at intermediate/high risk. A p<0.05 was considered statistically significant. Results The cohort comprised 41 patients who completed Phase 2 of aCRP (mean age 60.1±10.2 years, 82.9% male and 53.7% smokers) and were stratified as low risk (n=15, 36.6%) or intermediate/high risk (n=26, 63.4%). Reductions in systolic blood pressure (-7.9±15.7mmHg), LDL cholesterol (-59.5±35mg/dL), weight (-3±6.5kg) and body mass index (BMI, -1±2.2) were attained (all p<0.05). Smoking abstinence was accomplished in 90.9% of smokers and most patients achieved an LDL<55mg/dL target (75.6%). Quality of life improved (+8.4±23.7 points in SF-36, p=0.03) and anxiety symptoms diminished (-0.6±1.8 points in GAD2, p=0.04). A median 4.1±4.7ml/kg/min peak VO2 increase was achieved (+17.9% from baseline, p<0.001) and patients increased their reported weekly physical activity in 2681.1±3385.3 METS/week (+156.2% from baseline, p<0.001). No significant differences were noted between low risk and intermediate/high risk patients, except lower LDL<55mg/dL (65.4% vs. 93.3%, p=0.045) and higher weight loss and BMI reduction (-4.2±7.7 vs. -0.8±3kg, p=0.05 and -0.16±1.1 vs. -1.54±2.5, p=0.02, respectively) in intermediate/high risk patients. No readmissions for cardiovascular causes or complications of ambulatory training were registered. Conclusions In STEMI patients, a Phase 2 ambulatory Cardiac Rehabilitation Program can provide excellent control of cardiovascular risk factors, improve quality of life, and significantly increase functional capacity and reported weekly physical activity. Results are comparable in patients at low risk and intermediate/high risk of cardiac rehabilitation, which could support the inclusion of intermediate/high risk patients in ambulatory exercise-based cardiac rehabilitation programs if in-hospital supervised training is unavailable.Health outcomes of aCRP.

Residual difference in LDL cholesterol as an indicator of adherence to lifestyle changes during cardiac rehabilitation

Abstract Background Cardiac Rehabilitation can help achieve target LDL by optimization of pharmacological lipid-lowering therapy and lifestyle changes after ST-segment elevation myocardial infarction (STEMI). Purpose To study the characteristics of patients with suboptimal LDL reduction after STEMI in a Phase 2 ambulatory Cardiac Rehabilitation Program (aCRP) and describe the relative contribution of adherence to lifestyle changes to this instance. Methods We studied 41 STEMI patients who completed an exercise-based Phase 2 aCRP. Conventional or cardiopulmonary exercise testing (C/CPET) was performed before and after Phase 2 and peak oxygen consumption (peak VO2) was assessed. Several questionnaires were used to analyse quality of life (SF-36), adherence to Mediterranean diet (PREDIMED), weekly physical activity (IPAQ) and therapeutic adherence (Morisky-Green). Lipid-lowering therapy and LDL were registered before STEMI, at the start of Phase 2, and at the end of Phase 2. At the end of Phase 2, we analysed the difference between measured and theoretical LDL (LDL before STEMI minus expected LDL reduction by prescribed lipid-lowering therapy), which was defined as "residual difference in LDL" (RD-LDL). Comparisons were performed between patients with positive RD-LDL (lower than theoretically expected) and patients with negative RD-LDL (higher than theoretically expected). A p<0.05 was considered statistically significant. Results Mean age of the cohort was 60.1±10.2 years and most patients were male (82.9%). Most patients (n=33, 80.5%) underwent lipid-lowering therapy up-titration during Phase 2 aCRP, and an LDL<55mg/dL target was achieved in 31 (75.6%) patients. During Phase 2 aCRP, 25 (61%) patients depicted higher than expected LDL reduction (negative RD-LDL) and 16 (39%) patients showed lower than expected LDL reduction (positive RD-LDL). Patients with positive RD-LDL reported less weekly physical activity before Phase 2 aCRP (957±1130.34 vs. 2202.3±2749.7 METS/week, p=0.04) and were less likely to achieve LDL<55mg/dL (50% vs. 92%, p=0.002). No differences were found in adherence to Mediterranean diet or pharmacological treatment at the end of Phase 2. However, a significant higher improvement in quality of life (+18.4±29.2 vs. +2.1±17.2 points in SF-36, p=0.03) and in weekly physical activity (4436.4±4116.3 vs. 1557.7±2267.4 METS/week, p=0.02) was noted compared to patients with negative RD-LDL. Peak VO2 increased similarly in both groups at the end of Phase 2 (mean increase of 4.64±5.67 vs. 3.81±3.95 ml/kg/min, p=0.83). Conclusions Up-titration of lipid-lowering therapy is required in most patients throughout our Phase 2 aCRP to achieve target LDL. More than a third of patients showed lower than expected LDL reduction (positive residual difference in LDL), which cannot be attributed to worse adherence to Mediterranean diet, pharmacological treatment, or physical exercise recommendations.Residual difference in LDL cholesterol.

Achievement of Low-Density Lipoprotein Cholesterol Targets in Cardiac Rehabilitation: Impact of the 2019 ESC/EAS Dyslipidaemia Guidelines.

In 2019 the European Society of Cardiology (ESC) lowered the target values for low-density lipoprotein cholesterol (LDL-C) from <1.8 mmol/L to <1.4 mmol/L for secondary prevention of cardiovascular disease (CVD). The aim of this study was to determine the clinical impact of the 2019 ESC/EAS dyslipidaemia guidelines on lipid-lowering therapies and achievement rates of LDL-C targets in a contemporary cohort of CAD patients participating in an ambulatory cardiac rehabilitation (CR) program.We conducted a retrospective analysis of prospectively collected data from the Swiss Secondary Prevention Registry (SwissPR) in patients with Coronary Artery Disease (CAD), who completed the ambulatory cardiovascular rehabilitation program (CR) of the University Hospital Basel, Switzerland from January 2017 to April 2021. To evaluate the impact of the guideline publication, the cohort was split into a pre-Guideline 2019 group (A) and a post-Guideline 2019 group (B). In total 1320 patients were screened leaving 875 patients for analysis. At discharge, more patients in group B were on maximal statin doses (20% vs. 9%, p < 0.0001) and on combination therapy with ezetimibe (51% vs. 17%, p < 0.0001) than in group A, which resulted in 53% of patients reaching the LDL-C target of <1.4 mmol/L in group B. Regression analysis revealed that dyslipidaemia and positive smoking history represent independent predictors for intensified lipid-lowering medication, whereas absolving CR after publication of the 2019 guidelines was the only significant predictor for reduced LDL-C at CR discharge. We found a significant difference in prescription rates of lipid-lowering medication, especially combination therapies and statin doses, after publication of the 2019 ESC/EAS dyslipidaemia guidelines resulting in an achievement rate of >50% of the LDL-C target <1.4 mmol/L in CAD patients participating in ambulatory CR.

Second Nationwide Survey of Japanese Cardiac Rehabilitation Training Facilities During the Coronavirus Disease 2019 (COVID-19) Outbreak.

Background: We previously reported the results of a questionnaire survey of 37 cardiac rehabilitation (CR) training facilities conducted during April 2020, in Japan.Methods and Results: We conducted a second questionnaire survey in 38 CR training facilities to explore the preventive measures against Coronavirus Disease 2019 (COVID-19) after a nationwide state of emergency was declared and to investigate differences between the 2 surveys. No significant differences were observed, except for the requirement for patients to wear surgical masks during CR (P=0.01) in the second survey. Thirty-four facilities (89%) continued CR with innovations, 61% revised their instruction manuals (vs. 46% in the first survey), and, in 39%, patients requested resumption of ambulatory CR and training videos.Conclusions: In the second survey, 74% of facilities were unable to continue conventional group ambulatory CR; however, patients maintained their physical activity and exercise regimens and managed their illnesses with the aid of telephones and mobile devices.

Comparison of the 2010 and 2020 World Health Organization guidelines on physical activity in patients with percutaneous coronary interventions early after hospital discharge

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Swiss heart foundation Background Physical activity (PA) is inversely associated with mortality and adverse outcome in patients with cardiovascular disease, and can be objectively measured by accelerometry. In 2020, the World Health Organization (WHO) has updated their recommendations on PA for adults including those with chronic conditions, omitting the 10 min bout criterion.[1] The aim of this study was to determine the proportions of cardiac patients immediately after hospital discharge from percutaneous coronary interventions (PCI) who fulfil the old [2] and updated WHO PA criteria, and compare the results with established step-based cut-off values. Methods Patients after PCI for acute or chronic coronary syndrome with a maximal age of 80 and eligible for ambulatory cardiac rehabilitation were recruited for this observational single centre study. They were provided with a wrist-worn tri-axial accelerometer without display that recorded movement data starting from the day following hospital discharge for the subsequent 18 days. Acceleration data was analysed with the widely used free GGIR package. The proportions of patients fulfilling recommendations for moderate to vigorous PA (MVPA) were determined according to the 2010 and 2020 WHO guidelines as well as 7,500 [3] and 10,000 steps.[4] Results 159 patients (41%) participated in this study. Data from 135 patients (85%), who had at least 7 days of ≥12 h wear-time were included in the analyses. Their median age was 62 (1st quartile 56, 3rd quartile 68), 22 (16%) were women, and 15 and 120 patients had a CCS and ACS, respectively. Their median wear time was 18 (16, 18) days. 102 (75.6%) had at least 30 min of MVPA on an average day and hence fulfilled the 2020 WHO guidelines. When MVPA was determined using the 2010 WHO guidelines, which only counted MVPA of bouts of at least 10 min, only 23 patients (17.8%) achieved at least 30 min of MVPA on an average day (Figure 1). 67.4% of our patients achieved ≥7,500 steps/d and 71 patients (52.6%) performed ≥10,000 steps/d. Conclusion In cardiac patients early after PCI most of the MVPA was accumulated in bouts shorter than 10 min. Applying the 2010 and 2020 WHO PA criteria to objectively measured PA led to a fourfold discrepancy. The 7,500 step cut-off corresponded with the 2020 WHO recommendations. Since achievement of intensity- or step-based cut-offs is greatly dependent on device type, wearing location, data sampling and analysis, it is currently poorly defined and not suited for patient classification and counselling. The clinical implication of this observation will be assessed in a cardiovascular outcome analysis.

Modern methods of remote monitoring and rehabilitation of patients with cardiovascular diseases

Highlights. The review summarizes the latest achievements in the field of remote patient monitoring, highlights the main advantages and limitations of modern methods of remote monitoring and rehabilitation of patients with cardiovascular diseases.Abstract. Devices for remote health monitoring and rehabilitation that use modern telemedicine technologies are becoming more and more widespread in cardiovascular disease management. Modern technologies are affordable and reliable assistants for healthcare professionals, they assist in monitoring patients “at home”, early detection of adverse events, and timely notification of the need for medical help. The review summarizes the latest achievements in the field of remote patient monitoring for ambulatory management, diagnostics, dynamic monitoring, and cardiac rehabilitation of patients with cardiovascular diseases. The main advantages and limitations of remote patient monitoring technologies are presented, and methods for the implementation of these technologies are discussed.

Rehabilitation Using Mobile Health for Older Adults With Ischemic Heart Disease in the Home Setting (RESILIENT): Protocol for a Randomized Controlled Trial.

BackgroundParticipation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults’ uptake, and efficacy data are currently lacking.ObjectiveThis study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial.MethodsRESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement).ResultsAs of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024.ConclusionsThe RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting.Trial RegistrationClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130International Registered Report Identifier (IRRID)DERR1-10.2196/32163

Preliminary Study on Clinical Factors Affecting Medication Adherence in Patients with Cardiac Disease Undergoing Ambulatory Cardiac Rehabilitation

Preliminary Study on Clinical Factors Affecting Medication Adherence in Patients with Cardiac Disease Undergoing Ambulatory Cardiac Rehabilitation

Prevalence of iron deficiency in cardiac rehabilitation

Iron deficiency (ID) is highly prevalent in patients with cardiovascular diseases (CVD), especially in heart failure (HF). Less is known on ID prevalence in cardiac rehabilitation (CR). To precise prevalence of ID in patient undergoing cardiac rehabilitation, and its impact on functional capacity (FC) and quality of life (QoL). Patients starting ambulatory CR program in our center were checked for ID, defined as ferritin < 100 ng/mL or < 300 ng/mL with transferin saturation (TSAT) < 20%. Functionnal capacity (FC) was defined in Watts with stress test, and QoL assessed with physical score (PS) and emotional score (ES) of SF-36. Left ventricular ejection fraction (LVEF) was tertilized as reduced (rEF < 40%), middly-reduced (mr-EF 40-49%) and preserved (pEF > 50%). Among the 211 patients included, mean age was 58 ± 13 years, and 165 (78%) were male. Main reason of CR referral was coronary artery disease (CAD). At baseline, prevalence of ID was 39% in all population, and equaly prevalent in the three categories of LVEF: rEF (35%), mrEF (38%) and pEF (40%) ( P = 0.9). Patients referred after cardiac surgery and HF episode presented most frequently with ID compared to CAD patients, respectively 61%, 46% and 31%. ( P = 0.01) ( Fig. 1 A). Compared to non-ID (NID) patients, ID patients had lower FC: 103W ± 33 versus (vs.) 114W ± 38 ( P = 0.02) ( Fig. 1 B) , and there was a trend toward lower PS and ES in ID compared to NID patients: respectively 40 ± 29 vs. 47 ± 24 ( P = 0.08) and 45 ± 33 vs. 52 ± 28 ( P = 0.1). Benefice of CR was higher in ID patients according to FC improvement (+21 ± 23% vs. + 15 ± 22%, P = 0.06), and PS et ES improvement were similar to non-ID patients: respectively +22 ±46% vs. +28 ± 45% ( P = 0.5) and +33 ± 67% vs. 23 ± 42% ( P = 0.3). ID is highly prevalent in patient undergoing CR program, especially after heart surgery and in HF. In ID patients, improvement of FC and QoL are respectively higher and similar to NID patients.

Cardiac rehabilitation in COVID-19 pandemic period

BackgroundCOVID-19 pandemic constitutes a challenge in cardiovascular disease management. Little is known about COVID-19 prevalence and incidence in cardiac rehabilitation (CR) programs.AimTo evaluate the prevalence and incidence of COVID-19 in patients undergoing CR in ambulatory setting.MethodsFrom august to October 2020, all patients admitted in a single ambulatory CR program were screened for COVID-19 infection before and after CR, through naso-pharyngeal RT-PCR and serology assays before and after the CR. Number of patients was reduced from 9 to 4 in each group, 2 meters distancing respected, and all patients and staff had to wear surgical mask during sessions. Hand washing and material disinfection were systematic before and after each session for both patients and health professionals.ResultsAmong the 81 patients included, 63 (76%) were male, mean age was 57 ± 11 years (Table 1). None (0%) had positive RT-PCR before entering CR and only 2 (2.7%) were tested positive after CR. These two patients were asymptomatic. After serological analysis, 3 patients (3.8%) had anti-bodies against SARS-COV-2 before and after participating CR (Fig. 1). These 3 patients were negative on nasal swab before and after CR. No seroconversion was observed. In total (before and after CR), 5 patients (6.0%) were tested positive with COVID-19. Those 5 patients were younger (mean age 51 years old versus 58, P = 0.02), with better functional capacity before and after CR: respectively 7.1 METs (versus 5.2 METs, P = 0.01) and 8.3 METs (versus 6.3 METs, P = 0.03). In COVID+ patients, improvement of functional capacity was similar to COVID–patients: respectively 0.8 METs (P = 0.9) and 15 Watts (P = 0.9).ConclusionCR is not associated with risk of infection with SARS-COV-2, provided that basic sanitary measures are stricly applied. It is also associated with functional capacity improvement, even in patients who previously had COVID-19.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Development and Evaluation of Best Practice Alerts: Methods to Optimize Care Quality and Clinician Communication.

Cardiac rehabilitation in COVID-19 pandemic period

Abstract Background The current COVID-19 pandemic constitutes a challenge in cardiovascular disease (CVD) management. Little is known on how the virus impacts cardiac rehabilitation (CR) programs (CRP) safety and efficacy. Aim To evaluate the efficacy of basic sanitary procedures to limit the risk of virus spreading in patients undergoing cardiac rehabilitation in ambulatory setting. Methods From august to October 2020, all patients admitted in a single ambulatory CR program were screened for COVID-19 infection before and after CR. Negative naso-pharyngeal swab through RT-PCR was mandatory within seven days before starting the program, and advised after leaving the program. Serologic tests were also advised before and after the CRP. Number of patients were reduced from 9 to 4 in each group, 2 meters distancing respected, and all patients and staff had to wear surgical mask during sessions. Regular hand washing and hydro-alcoholic solutions use were mandatory for both patients and health professionnals. Material disinfection was systematic before and after each session. Results Among the 81 patients included, 63 (76%) were male, mean age was 57±11 years (see table). Sanitary protection measures were well applied and tolerated, especially use of surgical mask during exercice sessions. After RT-PCR on nasal swab, none (0%) were positive before entering CR and only 2 (2.7%) were tested positive after CR. These two patients were asymptomatic. The other patients in the same group as those having positive nasal test after CR were tested negative and were asymptomatic. According to serological analysis, the same 3 patients (3.8%) had anti-bodies against SARS-COV-2 before and after participating CR (see graph). These 3 patients were negative on nasal swab before and after CR. No seroconversion was observed. Mean delay between first and second RT-PCR on nasal swab and serological analysis were 30±15 and 32±15 days, respectively. In total (before and after CR), 5 patients (6.0%) were tested positive with SARS-COV-2. Those 5 patients were younger (mean age 51 years old versus 58, p=0.2), with better functional capacity before and after CR: respectively 7.1 METs (versus 5.2 METs, p=0.014) and 8.3 METs (versus 6.3 METs, p=0.03). In COVID+ patients, improvement of functional capacity was similar to COVID− patients: respectively 0.8 METs (p=0.9) and 15 Watts (p=0.9). Conclusion During COVID-19 pandemic, cardiac rehabilitation is not associated with risk of infection with SARS-CoV-2, provided that basic sanitary measures are stricly applied. It is also associated with functionnal capacity improvement, especially in patients who previously had COVID-19. Funding Acknowledgement Type of funding sources: None. Patients baseline characteristics in CRPatients COVID-19 status in CR

Objectively Measured Physical Activity in Patients with Coronary Artery Disease: A Cross-Validation Study.

Physical activity (PA) and sedentary behavior (SB) levels in healthy adults are predominately based on self-reporting measures, which generally overestimate PA but underestimate SB. Patients with coronary artery disease (CAD) eligible for cardiac rehabilitation (CR) follow an individualized program; thus, objective assessment of physical performance and regular daily activity is required. This study aimed to compare self-reported and objectively measured PA and SB in patients with CAD prior to out-patient CR. We included 91 patients with CAD and assessed their PA with an accelerometer for 8 days prior to CR, along with the short form of the international physical activity questionnaire. We found that most patients were sedentary (61%, ~8 h/day), and on average performed 63 min/day of moderate-to-vigorous-intensity physical activity (MVPA). Males performed less daily light-intensity physical activity (−5%, p = 0.011) and performed more MVPA (+2%, p = 0.002) compared to females. Maximal aerobic capacity was significantly associated with MVPA (Spearman rho = 0.483, p < 0.001) and MVPA > 10 min bouts (Spearman rho = 0.391, p < 0.001). Self-reported measures overestimated MVPA (total MVPA, +108 min/day, p < 0.001; MVPA > 10 min bouts, +152 min, p < 0.001) and underestimated SB (−174 min/day, p < 0.001) compared to objective measures. There was no significant correlation between methods in MVPA (Spearman rho = 0.147, p = 0.165)), MVPA > 10 min bouts (Spearman rho = −0.059, p = 576), and SB (Spearman rho = 0.139, p = 0.187). Quantitative analysis demonstrated the huge proportional bias for MVPA, MVPA > 10 min bouts, and SB. Our findings demonstrate that self-reported physical activity provides inaccurate estimates of MVPA and SB in patients with CAD entering the ambulatory CR. This strongly supports the more objective assessments of daily PA, preferably using an accelerometer.

Outpatient cardiac rehabilitation in coronary artery disease: impact on cardiovascular outcomes

Cardiac rehabilitation (CR) is a model of care proven to reduce recurrent cardiovascular events, new hospitalizations and mortality in patients with coronary artery disease. The aim of this study was to describe ambulatory CR in Gualdo-Tadino, ASL1 of Perugia (Italy), analyzing the outcomes of this population at 1 year and in the medium-long term. The clinical instrumental characteristics and the outcome of patients referred to CR after ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), angina, coronary artery bypass graft (CABG), ischemic heart disease have been analyzed. Follow-up interval: 2005-2018. Average follow-up 4.9 ± 4.4 years/patient. Comorbidity, new events, and mortality have been analyzed. From a population of 1552, 1384 were selected with a history of coronary artery disease: age 64.6 ± 9.8 years; 17% female (mean age 67.6 ± 8.8 years); 13.2% elderly >75 years; 57.2% were referred for CR after STEMI, 17.1% after non-STEMI, 19.9% after angina or ischemic heart disease. Patients with CABG were 79 (5.7%), but treatment by CABG was used in 287 patients (20.7%) referred for STEMI, non-STEMI or angina. CR lasted on average about 3 weeks, followed by scheduled periodic visits every 6 months and every 1-2 years thereafter. At the last check, 82.4% of patients were on antiplatelets, 71.1% on beta-blockers, 75.8% on angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, 90.5% on statins or cholesterol-lowering agents, with the following secondary prevention targets: LDL cholesterol 87.5 ± 31.9 mg/dl (target <70 mg/dl in 30.4% of patients) and 78.9 ± 28.7 mg/dl (target <70 mg/dl in 37.2% of patients) in the whole population and in those enrolled since 2010, respectively; heart rate was 63.4 ± 10.8 bpm, systolic and diastolic blood pressure 128.3 ± 15.6/73.6 ± 8.6 mmHg, triglyceridemia 135.6 ± 73.6 mg/dl. Events during the overall follow-up were 156 reinfarctions in 136 patients, 341 coronary angioplasty procedures in 258 patients, angina in 99 patients, CABG in 60 patients, re-CABG in 7 patients, heart failure in 21 patients, stroke in 44 patients. At 1-year follow-up, 10.3% of patients had a new hospitalization for cardiovascular events (1.6%) or coronary angioplasty (8.7%). Peripheral vascular disease, diabetes mellitus and chronic renal failure, analyzed in 627 patients in an average period of 6.5 years, increased by 11.0%, 5.3% and 4.8%, respectively. All-cause mortality over the entire period and at 1 year was 10.5% and 0.7%, respectively. Multivariate analysis shows that the probability of death increases in males, with age, left ventricular dysfunction, peripheral vascular disease, dyslipidemia and diabetes, while it decreases as the number of controls increases. The probability of reinfarction is higher in smoking patients, with renal insufficiency, vascular disease, neoplasms. The study highlights the efficacy of ambulatory CR programs and subsequent follow-up in the treatment of a population with coronary heart disease, risk factors and comorbidities. The increase of comorbidities, particularly peripheral vascular disease, diabetes mellitus and chronic renal failure - along with the non-reduction of smoking - have significantly affected the outcome, despite the effective control of the other coronary risk factors.

A comprehensive secondary prevention benchmark (2PBM) score identifying differences in secondary prevention care in patients after acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grands from AstraZeneca, Boehringer Ingelheim and Sanofi Background Reaching secondary prevention targets improves long-term prognosis in patients after acute coronary syndrome (ACS). Although prevention targets are defined by guidelines, their achievement rates are insufficiently documented. Suitable benchmarking tools are lacking. Purpose We aimed to determine the degree of secondary prevention care by creating a secondary prevention benchmark score (2PBM) and using it in patients undergoing ambulatory cardiac rehabilitation (CR) after an acute coronary syndrome. Methods In this observational cohort study, 472 consecutive ACS patients who completed the local ambulatory CR programme between 2017-2019 were included. Benchmarks for secondary prevention medication, clinical and lifestyle targets were predefined and combined in the complete 2PBM with maximum 10 points. The association of patient characteristics and achievement rates of individual components and the complete 2PBM were assessed using multivariable logistic regression analysis. Results Patients were on average 62 ± 11 years old and predominantly male (n = 406; 86%). Type of ACS was ST-elevation myocardial infarction (STEMI) in 241 patients (51%) and non-ST-elevation myocardial infarction in 216 patients (46%). Achievement rates for individual components of the 2PBM were 71% for medication, 35% for clinical and 61% for lifestyle benchmarks. Achievement of medication benchmark was associated with younger age [odds ratio (OR): 0.979, 95% confidence interval (CI) 0.959-0.996, p = 0.021] and history of STEMI [OR: 2.05, 95% CI 1.35-3.12, p = 0.001]. Achievement of clinical benchmark was associated with medication benchmark [OR: 1.66, 95% CI 1.03-2.71, p = 0.042]. The complete 2PBM was achieved by 74 patients (16%), while 362 patients (77%) reached ≥8 points. Achievement of complete 2PBM was independently associated with a history of STEMI [OR: 1.79, 95 CI 1.06-3.08 p = 0.032]. Conclusion Benchmarking with 2PBM identifies gaps and achievements in secondary prevention care. A history of STEMI was associated with the highest 2PBM score, suggesting best secondary prevention care in patients after STEMI. 2PBM may be used for internal quality control, comparison of cohorts and future correlation studies between CR targets and outcomes. Abstract Figure.

SF-36 is a fast and easy way of assessing quality of life and correlates with exercise capacity in patients undergoing cardiac rehabilitation

Cardiac rehabilitation (CR) is associated with improvement of quality of life (QOL) and exercice capacity (EC). Less is known on how EC interplays with QOL. To analyse the correlation between the 36-item Short Form Health Survey (SF-36) and EC. We used both dimensions (physical score, PS, and emotional score, ES) of the french validated version of the SF-36 to assess QOL before and after 8 weeks of CR in all patients admitted between January and Mars 2019, in a single ambulatory CR center. Clinical, biological and echocardiographic datas were retrospectively analysed as well as exercice capacity on stress test: performance in Watts and METs, 6 minutes walking test (6-MWT in meters) and aerobic capacity (VO2 in mL/min/kg). A total of 129 patients were included (see Table 1 ). Using a dedicated excel file, assessment of SF-36 was fast (less than 1 minute). According to t -test, both EC and QOL improved after CR: the mean EC, PS and ES respectively raised from 113 ± 32 to 134 ± 42 Watts ( P < 10 −41 ), 55 ± 21% to 68 ± 21% ( P < 10 −11 ) and 62 ± 23% to 72 ± 18% ( P < 10 −11 ). After Pearson correlation testing, PS and ES did correlate with each other ( r = 0.7, P < 10 −33 ). Physical score correlated with EC in Watts ( r = 0.34, P < 10 −7 , Fig. 1 ), METs ( r = 0.33, P < 10 −6 ), 6-MWT ( r = 0.33, P < 10 −3 ), VO2max ( r = 0.28, P = 0.006), effort duration in minutes ( r = 0.31, P < 10 −5 ) and also with male sex ( r = 0.14, P = 0.32), but not with age, LVEF, anaerobic threshold, hemoglobine and natriuretic peptides. Emotional score correlated with EC in Watts ( r = 0.20, P = 0.003), METs ( r = 0.20, p.004), VO2max ( r = 0.26, P = 0.01) and effort duration in minutes ( r = 0.22, P = 0.001). SF-36 is a fast, validated and easy way of assessing global QOL in patient undergoing ambulatory CR, and is positively correlated with exercise capacity and male sex, but not age and LVEF. Its use should be systematic to evaluate efficacy of a CR program on improving QOL.

Wearable Monitoring and Interpretable Machine Learning Can Objectively Track Progression in Patients during Cardiac Rehabilitation.

Cardiovascular diseases (CVD) are often characterized by their multifactorial complexity. This makes remote monitoring and ambulatory cardiac rehabilitation (CR) therapy challenging. Current wearable multimodal devices enable remote monitoring. Machine learning (ML) and artificial intelligence (AI) can help in tackling multifaceted datasets. However, for clinical acceptance, easy interpretability of the AI models is crucial. The goal of the present study was to investigate whether a multi-parameter sensor could be used during a standardized activity test to interpret functional capacity in the longitudinal follow-up of CR patients. A total of 129 patients were followed for 3 months during CR using 6-min walking tests (6MWT) equipped with a wearable ECG and accelerometer device. Functional capacity was assessed based on 6MWT distance (6MWD). Linear and nonlinear interpretable models were explored to predict 6MWD. The t-distributed stochastic neighboring embedding (t-SNE) technique was exploited to embed and visualize high dimensional data. The performance of support vector machine (SVM) models, combining different features and using different kernel types, to predict functional capacity was evaluated. The SVM model, using chronotropic response and effort as input features, showed a mean absolute error of 42.8 m (±36.8 m). The 3D-maps derived using the t-SNE technique visualized the relationship between sensor-derived biomarkers and functional capacity, which enables tracking of the evolution of patients throughout the CR program. The current study showed that wearable monitoring combined with interpretable ML can objectively track clinical progression in a CR population. These results pave the road towards ambulatory CR.

Personalized determination of target training heart rates for all ages, including patients with heart disease

BackgroundLack of physical exercise was recently accepted as a clinical diagnosis (ICD‐10‐CM Z72.3). The prescription of exercise requires a personalized training plan. Currently the Karvonen formula is used to calculate a target training heart rate (HR) by subtracting the age from 220. Because of individual differences in aerobic exercise capacities, resting parasympathetic tone, cardiac disease state, co‐morbidities, and medications (especially beta blocker), we suggest applying treadmill exercise tolerance testing to determine a personalized training HR zone, including patients with heart disease.Methods and study protocolIn 1999, the Austrian ambulatory cardiac rehabilitation was established and currently includes 12 centers. The cardiac rehabilitation program consists of three phases; phase I begins during the hospital stay, while phase II (6 weeks, 4 times/week) and phase III (up to 13 months, 2 times/week) are conducted in ambulatory cardiac rehabilitation centers under physician supervision. Additional home‐based training is recommended every day of the week. Male and female subjects participating in phase II and phase III rehabilitation underwent initial screening, and subjects with aortic stenosis, low systolic output (EF% &lt; 15), and dyspnea at rest (NYHA Class IV) were excluded. Bicycle ergometer exercise protocols used were 10W/10W/min (~90% of subjects) or 20W/20W/min (~10% of subjects) and HR was monitored continuously to generate a continuous HR curve to show a clear HR deflection point.ResultsWe retrospectively analyzed 9042 ECG treadmill test results (male = 7053, female = 1989) conducted at the Center for Ambulatory Rehabilitation Graz between 1‐1‐1999 and 10‐31‐2019. No significant difference in maximal training capacities was found between male and female subjects. Under physician supervision treadmill exercise tolerance testing was safe and well tolerated by maximally challenged male and female subjects of all ages, and no cardiac or cerebral events occurred during or after treadmill testing. The HR deflection point was assessed for each subject. The personalized training HR zone was compiled of 80–95% of the HR deflection point (not 220‐age), and training initiated during phase II and continued during phase III. Subjects were encouraged to achieve optimal training HR for 30 minutes daily and advised to perform muscle strengthening exercises twice per week.ConclusionOur study shows that optimal training heart rates can be determined by treadmill exercise testing, when patients are maximally challenged. Once “true” exhaustion is tested (which is often not achieved) a personalized target training HR zone can be calculated utilizing the individual HR deflection point. This approach will offer two advantages: 1) evaluation of underlying cardiovascular disease (cardiac ischemia), and 2) determination of an individualized and recommended target training heart rates for the “medical prescription of exercise”.

P3101Risk stratification model for exercise training complications in patients with heart disease (EXERISK study)

Abstract Background Exercise training is worldwide recommended to treat patients with heart disease, but sometimes, it can trigger adverse outcomes (ischemia, arrhythmias or sudden death). Several clinical tools are used to stratify patients, usually developed by expert consensus without any clinical validation during exercise sessions. Purpose The aim of this study was to develop up and validate a contemporary risk stratification calculator to identify patients at high risk of adverse outcomes during physical training. Methods A cohort of patients with heart disease that participated in a cardiac rehabilitation program were studied. A data base was constructed using several variables of interest derived from clinical records, patient evaluations, paraclinical reports along with stress testing. All patients participated in an ambulatory hospital-based cardiac rehabilitation program. Every patient exercised 5 times a week, 30 minutes continuously at a moderate-intensity, using a high-tech cyclergometer. Aerobic training was complemented with a three times a week, general gymnastics circuit. All sessions were highly supervised by trained personal, including a cardiologist. Major outcome variables were sudden death, coronary acute syndrome, syncope or stroke. Minor outcomes were any kind of arrhythmia and the presence of ischemia (angina or ST depression). Nominal, categorical or numerical variables were presented as appropriate. A bivariate analysis was performed. Those statistically significant variables (p&lt;0.05), were used in a logistic regression multivariable analysis with a step by step forward-Wald method. The obtained linear general model (G) was incorporated into a logistic equation and results were compared with traditional risk-stratification scales. Results A total of 639 patients were included, and no major adverse outcome occurred. Seventy six percent of patients presented arrhythmias and 5% showed ischemia. Seventeen stochastically significant variables were obtained from clinical records and paraclinical tests, and were included in two multivariable models, focusing on arrhythmia (EXERISK-A) or ischemia (EXERISK-I). After analysis, three variables remained associated with arrhythmia (maximal METs, left ventricle ejection fraction and frequent premature ventricular complexes) and three with ischemia (history of angina, METs and SYNTAX score). Once logistic equations were obtained, traditional risk-stratification scales were applied to the sample. Figure 1 shows ROC curve comparison of both models with traditional stratification scales. The area under the curve was 0.730 (EXERISK-A) and 0.856 (EXERISK-I) EXERISK Conclusion Exercise-induced arrhythmias are a very common finding in patients with heart disease, few patients showed ischemia and no mayor adverse cardiovascular outcomes were demonstrated. Both risk stratification models (EXERISK-A and EXERISK-I), can accurately predict arrhythmias or ischemia in a simple and rapid fashion.