Number Of Cardiac Rehabilitation Sessions Research Articles

Abstract 10546: Predictors of Changes in Peak Oxygen Consumption Following Outpatient Cardiac Rehabilitation: Importance of Cardiac Rehabilitation Adherence

Introduction: Cardiac rehabilitation (CR) is associated with improvements in exercise capacity (peak oxygen uptake (VO 2 peak)); however, 23% of CR patients do not improve VO 2 peak following CR. CR adherence (i.e. number of CR sessions attended) has been proposed to play an important role in VO 2 peak improvement following CR, but has not been investigated. Identifying clinical predictors of VO 2 peak improvement are critical as the degree of VO 2 peak improvement is associated with improved long-term outcomes in these patients. Purpose: To determine if clinical characteristics and number of CR sessions attended were predictive of patients who exhibited improvement in VO 2 peak following CR. Methods: Using the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients >18 years old from Olmsted County, Minnesota who underwent cardiopulmonary exercise testing prior to and following CR from 1999 to 2017. Regression models were created to assess clinical predictors of VO 2 peak improvement (>0% baseline) following CR. Results: The analysis included 804 patients (75% men) with a mean age of 60.7±12.4 years. Of the 804 patients, 609 (76%) patients exhibited VO 2 peak improvement following CR. Significant univariate predictors of VO 2 peak improvement included younger age (OR: 0.99, 95% CI: 0.97-1.00), lower pre-CR VO 2 peak (OR: 0.97, 95% CI: 0.94-0.99), history of peripheral artery disease (OR: 0.48, 95% CI: 0.32-0.73), and smoking (OR: 0.63, 95% CI: 0.45-0.90). Significant independent predictors of VO 2 peak improvement from a multivariate analysis included younger age (OR: 0.98, 95% CI: 0.96-1.00), number of CR sessions (OR: 1.02, 95% CI: 1.01-1.03), lower pre-CR VO 2 peak (OR: 0.94, 95% CI: 0.91-0.96), history of peripheral artery disease (OR: 0.42, 95% CI: 0.27-0.66), and smoking (OR: 0.56, 95% CI: 0.39-0.82). Conclusions: These findings demonstrate the importance of CR adherence and individual clinical characteristics in influencing VO 2 peak improvement following CR in patients with CVD. These findings may influence the clinical practice by providing specific clinical characteristics to account for when personalizing the CR treatment plan to maximize positive outcomes.

The impact of mitral regurgitation grade on exercise capacity following cardiac rehabilitation program after transcatheter aortic valve implantation

Abstract Introduction Severe aortic stenosis (AS) and mitral regurgitation (MR) often coexist. Transcatheter aortic valve implantation (TAVI) is becoming widely used for the treatment of patients (pts) with symptomatic severe AS. However, conflicting data reside concerning the impact of MR on outcomes after TAVI. Also, very few data exist regarding the benefits of a cardiac rehabilitation program (CRP) following TAVI in pts with MR. Purpose To evaluate the effect of a CRP in functional parameters after TAVI, particularly in pts with MR grade ≥ II. Methods Retrospective study which included all pts submitted to TAVI between 2014 and 2020 that completed a CRP following the procedure. Cardiopulmonary exercise tests (CPET) were performed after TAVI at baseline (pre-CRP) and post-CRP. We evaluated pre- and post-CRP peak oxygen consumption (pVO2), pVO2 at the anaerobic threshold (AT), respiratory exchange ratio (RER), VE/VCO2 and CPET duration. The exercise protocol included low/medium intensity exercises and consisted of sessions 3 times per week carried over 3 months. MR grading severity was assessed with transthoracic echocardiography performed after TAVI and was divided into 2 groups (grade < II vs grade ≥ II). Results Fifty-two pts were included, 59,6% were male, mean age of 78,6±8,6 years-old. Mean Society of Thoracic Surgery (STS) risk score was 4,9. Mean pre-TAVI aortic valve area was 0,68 cm2, with a mean gradient of 45,5 mmHg and a mean ejection fraction (EF) of 51%. The majority of pts implanted a self-expandable prosthesis (55,8%). Twenty-seven (51,9%) pts had MR grade ≥ II. Baseline characteristics were similar between pts with MR grade < II vs MR grade ≥ II, with the exception of the prevalence of coronary artery disease which was higher in MR grade ≥ II (p=0,036). Patients with MR grade < II had higher maximum and median aortic gradients before TAVI (p<0,05 for all). The mean number of cardiac rehabilitation sessions was 21±7, without differences between both groups. In pts with MR grade ≥ II, there was an improvement in CPET duration after CRP (HF protocol from 03:57 min to 05:02 min; p=0,017 and modified Bruce protocol from 06:03 min to 06:41 min; p=0,049) but without significant changes in pVO2 (14,7 mL/kg/min to 14,9 mL/kg/min; p=0,990), RER or VEVCO2/VO2 ratio. Patients with MR grade < II significantly improved pVO2 (13,8 mL/kg/min to 14,7 mL/kg/min; p=0,015), and CPET duration with HF protocol from 05:04 min to 06:23 min; p=0,006 after CRP. There was also an improvement in VEVCO2/VO2 ratio, although not statically significant. Conclusions Patients with MR grade < II after TAVI who underwent a CRP significantly improved pVO2 and CPET duration. Although pts with MR grade ≥ II did not improved pVO2 after a CRP, an improvement in CPET duration may translate into a clinical benefit in these pts. These results highlight the importance of further research and personalization among this potentially higher risk subset of pts. Funding Acknowledgement Type of funding sources: None.

Abstract 13631: Improving Cardiac Rehabilitation Attendance Through an Appointment-based Approach

Introduction: Cardiac rehabilitation (CR) is the pillar of secondary prevention for patients with cardiovascular disease (CVD). Despite its effectiveness, there remain systemic issues with adherence to in-clinic CR sessions, with the median number of CR sessions completed nationwide being 26 (out of a total of 36 sessions). We evaluated pre-post health outcomes for patients participating in a patient-driven appointment-based CR program, reasons for discharge, as well as predictors of total CR sessions attended. Methods: We utilized data from the Yale New-Haven Health (YNHH) CR program over a 6-year period (2012-2017). Data was collected on patient demographics, socio-economic status, and clinical characteristics. We evaluated CR outcomes with paired T-tests and conducted logistic regression analysis to determine predictors of CR adherence and completion. Results: A total of 2,135 patients were enrolled in CR from 2012 to 2017 (27.9% women, mean age 65±12 years). Patients completed a median of 30 sessions out of a total of 36. The primary reason for discharge was completion of all 36 sessions of CR (46.4%). The appointment-based CR program resulted in significant improvements in physical health outcomes (Table) , with matched-subject improvements of 1.42 METs increase, 0.32 kg/m 2 decrease in BMI and a 1.88% decrease in body fat percentage (P<0.001). Patients also demonstrated improvements in blood pressure control, lipid profiles and diabetes management. Logistic regression modeling found that patient-specific medical factors, such as self-reported levels of stress and physical activity were predictive of CR completion. Conclusion: We demonstrated that an appointment-based CR program led to an increase in the median number of CR sessions completed versus the nationwide average, and produced significant improvements in health outcomes. Appointment-based CR could aid in optimizing the dose-response benefit of CR for patients with CVD.

The Association Between Cardiac Rehabilitation Attendance and Hospital Readmission.

Purpose: Cardiac rehabilitation is associated with improved clinical outcomes, but the impact of individual cardiac rehabilitation sessions on readmission rates is less studied. Methods: A retrospective evaluation of the relationship between the number of cardiac rehabilitation sessions completed and all-cause and cardiac readmission rates at 1 year was conducted. The 1-year cardiac readmission counts were modeled via Poisson regression. Results: Of the 347 patients included in the primary analysis, 227 (65%) completed all assigned cardiac rehabilitation sessions. At 1 year, 135 patients (39%) had at least 1 cardiac readmission, and 155 patients (45%) had at least 1 all-cause readmission. The primary result was that every additional cardiac rehabilitation session completed was associated with a 1.75% lower incidence rate of 1-year cardiac readmission (P = .01) and a 2% lower incidence rate of all-cause hospital readmission (P = .001). Conclusion: Regardless of the number of cardiac rehabilitation sessions assigned, each additional session attended was associated with reduced cardiac readmission by 1.75% and all-cause readmission by 2%.

Abstract 18234: Patient Participation in Cardiac Rehabilitation and Long-term Cardiovascular Events: A Population-based study

Introduction: Cardiac rehabilitation (CR) is recommended for secondary prevention following a coronary artery disease (CAD) event. The association between CR attendance and long-term major cardiovascular events (MACE)in the community has not been previously reported . Hypothesis: We tested the hypothesis that higher CR participation would be related to a lower risk of MACE,in residents of Olmsted county, Minnesota. Methods: We performed a community-based retrospective longitudinal study on patients referred to CR for CAD events or procedures between the years 2002 and 2012. Follow-up was performed using a record linkage system from the Rochester Epidemiology Project. CR participation was assessed as the number of CR sessions attended, and was analyzed as a continuous variable, as quintiles and also as a binomial variable using 12 sessions as the cutoff. The composite outcome MACE was defined as having an acute coronary syndrome (myocardial infarction (MI) or unstable angina), revascularization (CABG or PCI), ventricular arrhythmias requiring hospitalization, stroke or death from any cause. Multivariate models were adjusted for age and gender and also for factors associated with MACE in the univariate analysis. Results: Our cohort included 2273 patients, 69% males, mean age (SEM) 64 (0.26) years. After a mean follow-up of 6 (0.07) years, 827 patients had an event: MI (73), unstable angina (113), CABG(53), PCI (260), ventricular arrhythmia (13), stroke (72) and death (243). Participation in 12 or more sessions (vs <12 sessions) had a lower rate of MACE (HR 0.81, 95% CI 0.70-0.93, p=0.003, see Figure1 . After adjusting for smoking, hypertension, diabetes and history of MI the association remained significant HR 0.85, 95% CI 0.74-0.98, p=0.03. Conclusions: A higher participation in CR was associated with a lower risk of MACE. These results provide additional evidence of important CR health advantages and expand on previous evidence of a dose-response benefit of CR.

Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction

Guidelines recommend cardiac rehabilitation after acute myocardial infarction, yet little is known about the impact of cardiac rehabilitation on medication adherence and clinical outcomes among contemporary older adults. The optimal number of cardiac rehabilitation sessions is not clear. We linked patients 65years or older enrolled in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from January 2007 to December 2010 to Medicare longitudinal claims data to obtain 1 year follow-up. A total of 11,862 patients participated in cardiac rehabilitation after acute myocardial infarction, attending a median number of 26 sessions. Patients attending ≥26 sessions were more likely to be male, had lesser prevalence of comorbid conditions and prior revascularization, and were more likely to present with ST-segment elevation myocardial infarction, compared with patients attending 1 to 25 sessions. Among patients with Medicare Part D prescription coverage, increasing number of cardiac rehabilitation sessions was associated with improvement in adherence to secondary prevention medications such as P2Y12 inhibitors and β-blockers. Each 5-session increase in participation was associated with lower mortality (adjusted hazard ratio [HR] 0.87, 95% CI 0.83-0.92) and lower overall risk of major adverse cardiac event (adjusted HR 0.69, 95% CI 0.65-0.73) and death/readmission (adjusted HR 0.79, 95% CI 0.76-0.83). In this older patient population, number of cardiac rehabilitation sessions attended was associated with improved medication adherence and lower downstream cardiovascular risk in a dose-response relationship. This provides support for the continued use of cardiac rehabilitation for older adults and encourages efforts to maximize attendance.

Effect of cardiac rehabilitation on muscle mass, muscle strength, and exercise tolerance in diabetic patients after coronary artery bypass grafting

BackgroundThe effects of cardiac rehabilitation (CR) on muscle mass, muscle strength, and exercise tolerance in patients with diabetes mellitus (DM) who received CR after coronary artery bypass grafting (CABG) have not been fully elucidated. MethodsWe enrolled 78 consecutive patients who completed a supervised CR for 6 months after CABG (DM group, n=37; non-DM group, n=41). We measured mid-upper arm muscle area (MAMA), handgrip power (HGP), muscle strength of the knee extensor (Ext) and flexor (Flex), and exercise tolerance at the beginning and end of CR. ResultsNo significant differences in confounding factors, including age, gender, ejection fraction, or number of CR sessions, were observed between the two groups. At the beginning of CR, the levels of Ext muscle strength and peak VO2 were significantly lower in the DM group than in the non-DM group. At the end of CR, significant improvement in the levels of muscle strength, HGP, and exercise tolerance was observed in both groups. However, the levels of Ext muscle strength, HGP, peak VO2, thigh circumference, and MAMA were significantly lower in the DM group than in the non-DM group. In addition, no significant improvement in thigh circumference and MAMA was observed in the DM group. At the end of CR, the levels of thigh circumference and MAMA correlated with Ext and Flex muscle strength as well as with HGP. Percent changes in the levels of Ext muscle strength were significantly correlated with those of MAMA and hemoglobin A1c. ConclusionsThese data suggest that improvement in muscle strength may be influenced by changes in muscle mass and high glucose levels in DM patients undergoing CR after CABG. A CR program, including muscle mass intervention and blood glucose control, may improve deterioration in exercise tolerance in DM patients after CABG.

Recent Advances in Preventive Cardiology and Lifestyle Medicine

Multifactorial risk factor modification and control, especially interventions designed to reduce total cholesterol, systolic blood pressure, smoking prevalence, overweight/obesity, diabetes mellitus, and physical inactivity, can have a profound and favorable impact on decreasing the incidence of initial and recurrent cardiovascular events. Between 1980 and 2000, mortality rates from coronary heart disease (CHD) fell by >40%. Using a previously validated statistical model (IMPACT), researchers attempted to determine how much of this decrease could be explained by the use of medical and surgical treatments as opposed to changes in risk factors among US adults aged 25 to 84 years. Approximately half of the decline in cardiovascular deaths was attributed to reductions in major risk factors (obesity and diabetes mellitus were notable exceptions), and approximately half was attributed to evidence-based medical therapies (eg, secondary prevention medications, rehabilitation, and initial treatments for acute myocardial infarction [AMI]).1 In contrast, emergent and elective revascularization accounted for only 7% of the overall decline in deaths from CHD. Recently, similar results were reported in a Canadian study that evaluated the decrease in CHD mortality between 1994 and 2005.2 Over the past decade, mortality rates from CHD and stroke in the United States decreased by >25% (Figure 1).3 Although there were also impressive reductions in the prevalence of uncontrolled high blood pressure, elevated blood cholesterol, and, to a lesser extent, cigarette smoking, there was only limited impact on other risk factors, including increases in the prevalence of obesity and diabetes mellitus, and a small reduction in those not engaged in moderate or vigorous physical activity.3 These indicators represent major challenges to achieving future goals for cardiovascular health promotion and disease reduction. Figure 1. Mortality rates from coronary heart disease and stroke, rate of uncontrolled blood pressure, and prevalence of high cholesterol from 2004 to 2008. Reproduced …

Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries

For patients with coronary heart disease, exercise-based cardiac rehabilitation improves survival rate and has beneficial effects on risk factors for coronary artery disease. The relationship between the number of sessions attended and long-term outcomes is unknown. In a national 5% sample of Medicare beneficiaries, we identified 30 161 elderly patients who attended at least 1 cardiac rehabilitation session between January 1, 2000, and December 31, 2005. We used a Cox proportional hazards model to estimate the relationship between the number of sessions attended and death and myocardial infarction (MI) at 4 years. The cumulative number of sessions was a time-dependent covariate. After adjustment for demographic characteristics, comorbid conditions, and subsequent hospitalization, patients who attended 36 sessions had a 14% lower risk of death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.77 to 0.97) and a 12% lower risk of MI (HR, 0.88; 95% CI, 0.83 to 0.93) than those who attended 24 sessions; a 22% lower risk of death (HR, 0.78; 95% CI, 0.71 to 0.87) and a 23% lower risk of MI (HR, 0.77; 95% CI, 0.69 to 0.87) than those who attended 12 sessions; and a 47% lower risk of death (HR, 0.53; 95% CI, 0.48 to 0.59) and a 31% lower risk of MI (HR, 0.69; 95% CI, 0.58 to 0.81) than those who attended 1 session. Among Medicare beneficiaries, a strong dose-response relationship existed between the number of cardiac rehabilitation sessions and long-term outcomes. Attending all 36 sessions reimbursed by Medicare was associated with lower risks of death and MI at 4 years compared with attending fewer sessions.

Rural residents' use of cardiac rehabilitation programs.

The goal of this study was to identify the factors that influence the use of cardiac rehabilitation services by rural residents. The Andersen-Newman framework, which consists of three determinants of health services utilization (predisposing, enabling, and need factors), was used to direct this research. The three data collection points were at time of discharge from the hospital, two weeks post discharge, and one week following the date that the cardiac rehabilitation program would have been completed. Packets for the three data collection points were unique and contained instruments to assess various factors influencing the use of health services. The sample (N = 254) were adults living in rural areas who had experienced a cardiac event and received treatment at one of four hospitals in two western states and who provided useable data on all three questionnaires. Findings indicated that 72 (28%) of the participants attended some portion of a rehabilitation program, and only 43 (17%) completed the full 36-week program. Four predisposing factors, one enabling factor, and two need factors were significant in explaining the number of cardiac rehabilitation sessions attended. Further research is needed to validate these factors and to identify others which may influence the use of cardiac rehabilitation by rural residents. Likewise, it is essential to examine alternate ways to meet the rehabilitative needs of rural cardiac clients.