Effects of different early cardiac rehabilitation exercise treatments on the prognosis of acute myocardial infarction patients receiving percutaneous coronary intervention.

OBJECTIVES: Exercise rehabilitation is the core of Cardiac Rehabilitation (CR) and will improve the prognosis of patients receiving Percutaneous Coronary Intervention (PCI surgery). The current study retrospectively analyzed the effects of different exercise-based CR strategies on the prognosis of AMI patients receiving PCI treatment. METHODS: Clinicopathological information from 127 patients was collected and divided into different groups based on the exercise-based CR received, including Continuous Resistance Exercise (COR), Continuous Aerobic Exercise (COA), Interval Resistance Exercise (IVR), Interval Aerobic Exercise (IVA), Inspiratory Muscle Exercises (ITM), and Control. The differences regarding cardio-pulmonary function, hemodynamics, and life quality were analyzed against different CR strategies. RESULTS: All the exercise-based CR strategies showed improving effects compared with patients in the Control group regarding cardio-pulmonary parameters, with IVR showing the strongest improving effects (IVR > ITM > COR > IVA > COA) (p < 0.05) at the first recoding point. However, the improving effects of exercise-based CR declined with time. Regarding the effects on hemodynamics parameters, the improving effects of exercise-based CR were only observed regarding LVEF, and the effects of IVR were also the strongest (IVR > COR > ITM > COA > IVA) (p < 0.05). Similar improving effects were also observed for 6MWT and life quality (IVR showing the strongest improving effects) (p < 0.05), which all declined three months after the surgery. CONCLUSIONS: The current study showed that exercise-based CRs had better improving effects than the normal nursing strategy on the prognosis of AMI patients receiving PCI surgery.

Associations Between Psychological Factors and Adherence to Health Behaviors After Percutaneous Coronary Intervention: The Role of Cardiac Rehabilitation.

BACKGROUND: Cardiac rehabilitation (CR) participation after percutaneous coronary intervention (PCI) for coronary heart disease lowers the disease burden and risk of recurrent cardiac events. Examining psychological factors may improve post-PCI health behavior adherence. PURPOSE: To determine whether psychological factors are associated with post-PCI health behavior adherence, and the role of CR participation. METHODS: Data from 1,682 patients (22.1% female, Mage = 64.0, SDage = 10.5 years) from the THORESCI cohort were included. Adjusted mixed models were used to examine associations between psychological factors and the 1-year course of health behaviors, using interactions to test for moderation by CR participation. RESULTS: Psychological factors were associated with the trajectories of adherence to medical advice, exercise, and diet. The strongest association found was between optimism and the trajectory of dietary adherence (B: = -0.09, p = .026). Patients with high optimism levels had a worse trajectory of dietary adherence compared to patients with low to middle optimism levels. Participation in CR buffered the associations of high anxiety, pessimism, and low to middle resilience, but strengthened the associations of high stress in the past year with the probability of smoking. CONCLUSIONS: Psychological factors are associated with post-PCI health behavior adherence, but the pattern of associations is complex. Patients with high levels of anxiety, pessimism, and low to middle resilience levels may disproportionately benefit from CR. Cardiac rehabilitation programs could consider this to improve post-PCI health behavior adherence. CLINICAL TRIALS REGISTRATION #: NCT02621216.

For patients with coronary heart disease who have undergone percutaneous coronary intervention (PCI), participating in cardiac rehabilitation (CR) reduces the disease burden and the risk of future cardiac events. However, adherence to the health behaviors targeted in CR could be improved. Using data from 1,682 patients included in the THORESCI study, we explored whether psychological factors could predict health behavior adherence and the role of participation in CR. Results revealed that psychological factors were linked to adherence to medical advice, exercise, and diet. Overall, patients with low to moderate optimism levels exhibited more favorable changes in healthy dietary habits than patients with high levels of optimism. Participation in CR made the link between high anxiety, pessimism, low to moderate resilience, and lower adherence to health behaviors less strong. Cardiac rehabilitation programs could use these results to enhance the health behavior adherence of patients who have undergone PCI.

Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE.

PURPOSE: This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence. METHODS: We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type. RESULTS: In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States. CONCLUSIONS: The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.

Optimizing Training Response for Women in Cardiac Rehabilitation: A Randomized Clinical Trial.

Importance: Despite lower baseline fitness levels, women in cardiac rehabilitation (CR) do not typically improve peak aerobic exercise capacity (defined as peak oxygen uptake [peak Vo2]) compared with men in CR. Objective: To evaluate the effect of high-intensity interval training (HIIT) and intensive lower extremity resistance training (RT) compared with standard moderate intensity continuous training (MCT) on peak Vo2 among women in CR. Design, Setting, and Participants: This randomized clinical trial conducted from July 2017 to February 2020 included women from a community-based cardiac rehabilitation program affiliated with a university hospital in Vermont. A total of 56 women (mean [SD] age, 65 [11] years; range 43-98 years) participating in CR enrolled in the study. Interventions: MCT (70% to 85% of peak heart rate [HR]) with moderate intensive RT or HIIT (90% to 95% of peak HR) along with higher-intensity lower extremity RT 3 times per week over 12 weeks. Main Outcomes and Measures: The primary outcome was the between-group difference in change in peak Vo2 (L/min) from baseline to 12 weeks. Results: Peak Vo2 increased to a greater degree in the HIIT group (+23%) than in the control group (+7%) (mean [SD] increase, 0.3 [0.2] L/min vs 0.1 [0.2] L/min; P = .03). Similarly, the change in leg strength was greater in the HIIT-RT group compared with the control group (mean [SD] increase, 15.3 [0.3] kg vs 6.4 [1.1] kg; P = .004). Conclusions and Relevance: An exercise protocol combining HIIT and intensive lower extremity RT enhanced exercise training response for women in CR compared with standard CR exercise training. Women randomized to HIIT experienced significantly greater improvements in both peak Vo2 and leg strength during CR. Trial Registration: ClinicalTrials.gov Identifier: NCT03438968.

Rates of revascularization and PCI:CABG ratio: a new indicator predicting in-hospital mortality in acute coronary syndromes.

OBJECTIVE: The principal trend in acute coronary syndrome (ACS) is increasing utilization of percutaneous coronary interventions (PCI) and declining coronary artery bypass graft surgery (CABG) utilization. This study was designed to evaluate whether higher PCI:CABG ratios lead to higher in-hospital PCI or CABG mortality. METHODS: The National Readmission Database for years 2016 was queried for all hospitalized ACS patients who underwent coronary revascularization during their admission. The study population was derived from 355 US hospitals and included 103 021 patients. Hospitals were grouped based on their PCI:CABG ratio into low, intermediate, and high ratio quartiles with a median [interquartile ranges (IQR)] PCI:CABG ratio of 2.9 (2.5-3.2), 5.0 (4.3-5.9) and 8.9 (7.8-10.3), respectively multivariable logistic regression with adjustment for age, demographics and comorbidities were used to identify CABG:PCI ratio related risk for in-hospital CABG and PCI mortality. RESULTS: Higher PCI:CABG ratios correlated with an increased CABG mortality. There was a median (IQR) mortality of 2.5% (1.6-4.3) in the low ratio quartile; 3.1% (1.9-5.3) in the intermediate quartiles; and 5.3% (3.2-9.1) in the high ratio quartile (P < 0.001). On multivariate analysis, the PCI:CABG ratio was associated with an increased risk for CABG mortality with an adjusted odds ratio of 1.38 (95% CI, 1.14-1.67, P < 0.001) and 2.17 (95% CI, 1.70-2.80, P < 0.001) for hospitals with intermediate and high PCI:CABG ratios, respectively. There was no significant association between PCI:CABG ratio and PCI mortality. CONCLUSIONS: The programmatic PCI:CABG ratio is a valid indicator of optimal case selection. The PCI:CABG ratio correlates with in-hospital mortality in ACS.

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial.

OBJECTIVES: This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR). BACKGROUND: Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events. METHODS: A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO2) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year. RESULTS: Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079). CONCLUSIONS: Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).

The Influence of Comprehensive Cardiac Rehabilitation on Heart Rate Variability Indices after CABG is More Effective than after PCI.

The aim of this study was to evaluate the influence of cardiac rehabilitation (CR) on heart rate variability (HRV) indices in men with coronary artery disease (CAD) treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). The study population consisted of 131 male patients with CAD prospectively and consecutively admitted to CR after PCI n = 72, or CABG n = 59. Participants performed cycle ergometer interval training for 45 min three times a week for 8 weeks. At baseline and after 8 weeks, all patients underwent the HRV assessment. HRV indices in CAGB survivals were significantly lower in comparison to PCI patients at baseline. Significant increases were seen for SDNN, rMSSD, and HF in the CABG group and only in HF component in PCI group after 8 weeks of CR. Eight weeks of CR seems to be more effective in CABG patients than patients after PCI.

Cardiac rehabilitation after percutaneous coronary intervention: Results from a nationwide survey.

AIM: The purpose of this study was to estimate the proportion of Norwegian coronary heart disease patients participating in cardiac rehabilitation programmes after percutaneous coronary intervention, and to determine predictors of cardiac rehabilitation participation. METHODS: Participants were patients enrolled in the Norwegian Coronary Stent Trial. We assessed cardiac rehabilitation participation in 9013 of these patients who had undergone their first percutaneous coronary intervention during 2008-2011. Of these, 7068 patients (82%) completed a self-administered questionnaire on cardiac rehabilitation participation within three years after their percutaneous coronary intervention. RESULTS: Twenty-eight per cent of the participants reported engaging in cardiac rehabilitation. Participation rate differed among the four regional health authorities in Norway, varying from 20%-31%. Patients undergoing percutaneous coronary intervention for an acute coronary syndrome were more likely to participate in cardiac rehabilitation than patients with stable angina (odds ratio 3.2; 95% confidence interval 2.74-3.76). A multivariate statistical model revealed that men had a 28% lower probability ( p<0.001) of participating in cardiac rehabilitation, and the odds of attending cardiac rehabilitation decreased with increasing age ( p<0.001). Contributors to higher odds of cardiac rehabilitation participation were educational level >12 years (odds ratio 1.50; 95% confidence interval 1.32-1.71) and body mass index>25 (odds ratio 1.19; 95% confidence interval 1.05-1.36). Prior coronary artery bypass graft was associated with lower odds of cardiac rehabilitation participation (odds ratio 0.47; 95% confidence interval 0.32-0.70) Conclusion: The estimated cardiac rehabilitation participation rate among patients undergoing first-time percutaneous coronary intervention is low in Norway. The typical participant is young, overweight, well-educated, and had an acute coronary event. These results varied by geographical region.

Perfil contemporâneo da intervenção coronária percutânea em octogenários / Contemporary profile of percutaneous coronary intervention in octogenarians

Introdução: Com o aumento da longevidade observado nas últimas décadas, as intervenções coronárias percutâneas (ICP) em octogenários são cada vez mais indicadas. Objetivo: Traçar o perfil clínico-epidemiológico-angiográfico e os principais detalhes associados à ICP dos pacientes octogenários. Métodos: Cento e cinquenta pacientes octogenários foram submetidos à ICP entre janeiro de 2015 a dezembro de 2016, no Instituto Dante Pazzanese de Cardiologia, correspondendo a 3,7% dos 3987 casos tratados e a 18% dos com idade >70 anos, e incluídos de forma sequencial e prospectiva. Não houve critérios de exclusão. Os resultados clínicos expostos foram restritos à fase hospitalar. Resultados: A maioria (63%) era do sexo masculino, com idade média de 86±3,9 anos (máximo de 102 anos). Do total de pacientes, 91,3% eram hipertensos, 37,4% diabéticos, a ICP prévia foi realizada em para 17,4%, enquanto 34,1% apresentaram infarto prévio. A cinecoronariografia identificou que 70,4% eram multiarteriais, dos quais 4% exibiam lesões não pro - tegidas do tronco da coronária esquerda. A maioria (55%) apresentava disfunção ventricular significativa. Stents farmacológicos (SF) foram utilizados em 97,2% dos casos. O sucesso angiográfico foi obtido em 97,5% e o sucesso clínico em 93,2%. A mortalidade e o infarto ocorreram abaixo de 4,3% dos casos. Conclusão: Nessa população, observaram-se que os pacientes octogenários constituíram a minoria dos idosos tratados; a doença multiarterial grave foi o achado predominante; os stents farmacológicos foram implantados quase em todos os casos e os sucessos angiográfico e clínico apresentaram-se elevado

With the increase in longevity observed in recent decades, percutaneous coronary interventions (PCI) in octogenarians are increasingly indicated. Objective: To outline the clinical, epidemiological and angiographic profile and main details associated with PCI in octogenarian patients. Methods: One hundred and fifty octogenarian patients underwent PCI between January 2015 and December 2016 at the Dante Pazzanese In - stitute of Cardiology, corresponding to 3.7% of the 3987 cases treated and 18% of those aged> 70 years, and included sequentially and prospectively. There were no exclusion criteria. The clinical results were restricted to the hospital phase. Results: The majority (63%) were males, with a mean age of 86±3.9 years (maximum 102 years). Of the total patients, 91.3% were hypertensive, 37.4% were diabetic, 17.4% had previously undergone PCI, while 34.1% had previous infarction. The coronary angiography indicated that 70.4% were multiarterial, of which 4% had unprotected lesions of the trunk of the left coronary artery. The majority (55%) had significant ventricular dysfunction. Pharmacological stents were used in 97.2% of the cases. Angiographic success was achieved in 97.5% and clinical success in 93.2%. Mortality and infarction occurred in less than 4.3% of the cases. Conclusion: In this population, it was observed that octogenarian patients constituted a minority of treated elderly; severe multivessel disease was the predominant finding; pharmacological stents were implanted in almost all cases, and angiographic and clin

Permanent work disability in patients ≤50 years old after percutaneous coronary intervention and coronary artery bypass grafting (the CRAGS study).

Background: The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization. Methods and Results: The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P < 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P = 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P < 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up. Conclusions: Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care.

Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery: Data From the Clinical Outcomes Assessment Program.

BACKGROUND: Despite guideline recommendations that patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass surgery, or valve surgery be referred to cardiac rehabilitation, cardiac rehabilitation is underused. The objective of this study was to examine hospital-level variation in cardiac rehabilitation referral after PCI, coronary artery bypass surgery, and valve surgery. METHODS AND RESULTS: We analyzed data from the Clinical Outcomes Assessment Program, a registry of all nonfederal hospitals performing PCI and cardiac surgery in Washington State. We included eligible PCI, coronary artery bypass surgery, and valve surgery patients from 2010 to 2015. We analyzed PCI and cardiac surgery separately by performing multivariable hierarchical logistic regression for the outcome of cardiac rehabilitation referral at discharge, clustered by hospital. Patient-level covariates included age, sex, race/ethnicity, comorbidities, and procedure indication/status. Cardiac rehabilitation referral was reported in 48% (34 047/71 556) of PCI patients and 91% (21 831/23 972) of cardiac surgery patients. The hospital performing the procedure was a stronger predictor of referral than any individual patient characteristic for PCI (hospital referral range 3%-97%; median odds ratio, 5.94; 95% confidence interval, 4.10-9.49) and cardiac surgery (range 54%-100%; median odds ratio, 7.09; 95% confidence interval, 3.79-17.80). Hospitals having an outpatient cardiac rehabilitation program explained only 10% of PCI variation and 0% of cardiac surgery variation. CONCLUSIONS: Cardiac rehabilitation referral at discharge was less prevalent after PCI than cardiac surgery. The strongest predictor of cardiac rehabilitation referral was the hospital performing the procedure. Efforts to improve cardiac rehabilitation referral should focus on increasing referral after PCI, especially in low referral hospitals.

'PERFSCORE' - a multidimensional score: a simple way to predict the success of cardiac rehabilitation.

BACKGROUND: We propose a simple and reliable score, performance score ('PERFSCORE'), that allows cardiologists to assess the achievement of therapeutic goals. METHODS: We identified six indicators of cardiac rehabilitation performance: heart rate (HR) less than 70 beats/min; blood pressure (BP) less than 140/90 mmHg; smoking cessation or non-smokers; left ventricular ejection fraction (LVEF) more than 40%; LDLc less than 100 mg/dl or more than 70 mg/dl if diabetic; and on treatment at least with three drugs among angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARBs), ß-blockers, statins, and ASA. These six indicators are considered to be the collective expression of a latent variable measuring performance. To assess the relative contribution of each indicator in the definition of cardiac rehabilitation performance, we fitted a structural equation model using the 'Stata 13' system. RESULTS: A total of 839 consecutive patients were analyzed; 49% had recent ST- elevation myocardial infarction/non-ST elevation myocardial infarction and 51% had undergone elective percutaneous coronary intervention/coronary artery bypass graft. At the end of cardiac rehabilitation, LVEF was 55 ±â€Š11%; HR, 69 ±â€Š13 beats/min; SBP, 135 ±â€Š20 mmHg; DBP, 79 ±â€Š10 mmHg; LDLc, 88 ±â€Š29 mg/dl; 56% had stopped smoking; 71% were on ß-blockers; 78% ACE inhibitors or ARBs; 87% were on statins, and 96% were on ASA. Weights for each indicator in the PERFSCORE were 0.57 for HR, 0.40 for BP, 0.87 for LVEF, 0.78 for smoking, 0.42 for LDLc, and 0.75 for drugs, multiplied by 1 if the target has been reached, otherwise by 0. Higher performance values correspond to better cardiac rehabilitation results. The point range was 0-36: less than 24, not satisfying cardiac rehabilitation; 24-29, satisfying cardiac rehabilitation; and more than 29, optimal cardiac rehabilitation. CONCLUSION: In conclusion, we propose an easy algorithm to calculate the success of cardiac rehabilitation.

Predictors of Suboptimal Gain in Exercise Capacity After Cardiac Rehabilitation.

Cardiac rehabilitation (CR) improves exercise capacity (EC), but not all CR participants achieve such improvements. Our primary aim was to develop a tool to identify those with suboptimal improvement in EC after CR. We retrospectively analyzed 541 patients enrolled in a phase-II CR program after a cardiac event or intervention from 2003 to 2014. EC was assessed with the 6-minute walk test. We developed a multivariate linear regression model and corresponding nomogram to predict EC after CR. The predictors included in the final model were age, gender, baseline EC, primary referral diagnosis, body mass index, systolic blood pressure at rest, triglycerides, low-density lipoprotein cholesterol, lipid-lowering medication use, and an interaction term of low-density lipoprotein cholesterol with lipid-lowering therapy. The prediction model was internally validated using bootstrap methods, and a nomogram was created for ease of use. In conclusion, this tool helps to identify those patients with suboptimal improvement in EC who could be targeted for individualized interventions to increase their performance.

Cardiac Rehabilitation: Improving Function and Reducing Risk.

Cardiac rehabilitation is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. The overall goals focus on improving daily function and reducing cardiovascular risk factors. Cardiac rehabilitation includes interventions aimed at lowering blood pressure and improving lipid and diabetes mellitus control, with tobacco cessation, behavioral counseling, and graded physical activity. The physical activity component typically involves 36 sessions over 12 weeks, during which patients participate in supervised exercise under cardiac monitoring. There are also intensive programs that include up to 72 sessions lasting up to 18 weeks, although these programs are not widely available. Additional components of cardiac rehabilitation include counseling on nutrition, screening for and managing depression, and assuring up-to-date immunizations. Cardiac rehabilitation is covered by Medicare and recommended for patients following myocardial infarction, bypass surgery, and stent placement, and for patients with heart failure, stable angina, and several other conditions. Despite proven benefits in mortality rates, depression, functional capacity, and medication adherence, rates of referral for cardiac rehabilitation are suboptimal. Groups less likely to be referred are older adults, women, patients who do not speak English, and persons living in areas where cardiac rehabilitation is not locally available. Additionally, primary care physicians refer patients less often than cardiologists and cardiothoracic surgeons.

Hospital revascularisation capability and quality of care after an acute coronary syndrome in Switzerland.

BACKGROUND: Patients with acute coronary syndrome (ACS) transferred to regional nonacademic hospitals after percutaneous coronary intervention (PCI) may receive fewer preventive interventions than patients who remain in university hospitals. We aimed at comparing hospitals with and without PCI facilities regarding guidelines-recommended secondary prevention interventions after an ACS. METHODS: We studied patients with ACS admitted to a university hospital with PCI facilities in Switzerland, and either transferred within 48 hours to regional nonacademic hospitals without PCI facilities or directly discharged from the university hospital. We measured prescription rates of evidence-based recommended therapies after ACS including reasons for nonprescription of aspirin, statins, ß-blockers, angiotensin converting-enzyme inhibitors (ACEI) / angiotensin II receptor blockers (ARB), along with cardiac rehabilitation attendance and delivery of a smoking cessation intervention. RESULTS: Overall, 720 patients with ACS were enrolled; 541 (75.1%) were discharged from the hospital with PCI facilities, 179 (24.9%) were transferred to hospitals without PCI facilities. Concomitant prescription of aspirin, ß-blockers, ACEI/ARB and statins at discharge was similar in hospitals with and without PCI facilities, reaching 83.9% and 85.5%, respectively (p = 0.62). Attendance at cardiac rehabilitation reached 55.5% for the hospital with PCI facilities and 65.7% for hospitals without PCI facilities (p = 0.02). In-hospital smoking cessation interventions were delivered to 70.8% patients exclusively at the hospital with PCI facilities. CONCLUSION: Quality of care for patients with ACS discharged from hospitals without PCI facilities was similar to that of patients directly discharged from the hospital with PCI facilities, except for in-hospital smoking cessation counselling and cardiac rehabilitation attendance.

Routine initial exercise stress testing for treatment stratification in comprehensive cardiac rehabilitation.

There is evidence of substantial benefit of cardiac rehabilitation (CR) for patients with low exercise capacity at admission. Nevertheless, some patients are not able to perform an initial exercise stress test (EST). We aimed to describe this group using data of 1094 consecutive patients after a cardiac event (71±7 years, 78% men) enrolled in nine centres for inpatient CR. We analysed sociodemographic and clinical variables (e.g. cardiovascular risk factors, comorbidities, complications at admission), amount of therapy (e.g. exercise training, nursing care) and the results of the initial and the final 6-min walking test (6MWT) with respect to the application of an EST. Fifteen per cent of patients did not undergo an EST (non-EST group). In multivariable analysis, the probability of obtaining an EST was higher for men [odds ratio (OR) 1.89, P=0.01], a 6MWT (per 10 m, OR 1.07, P<0.01) and lower for patients with diabetes mellitus (OR 0.48, P<0.01), NYHA-class III/IV (OR 0.27, P<0.01), osteoarthritis (OR 0.39, P<0.01) and a longer hospital stay (per 5 days, OR 0.87, P=0.02). The non-EST group received fewer therapy units of exercise training, but more units of nursing care and physiotherapy than the EST group. However, there were no significant differences between both groups in the increase of the 6MWT during CR (123 vs. 108 m, P=0.122). The present study confirms the feasibility of an EST at the start of CR as an indicator of disease severity. Nevertheless, patients without EST benefit from CR even if exercising less. Thus, there is a justified need for individualized, comprehensive and interdisciplinary CR.

Passive Leg Raising Correlates with Future Exercise Capacity after Coronary Revascularization.

Hemodynamic properties affected by the passive leg raise test (PLRT) reflect cardiac pumping efficiency. In the present study, we aimed to further explore whether PLRT predicts exercise intolerance/capacity following coronary revascularization. Following coronary bypass/percutaneous coronary intervention, 120 inpatients underwent a PLRT and a cardiopulmonary exercise test (CPET) 2-12 days during post-surgery hospitalization and 3-5 weeks after hospital discharge. The PLRT included head-up, leg raise, and supine rest postures. The end point of the first CPET during admission was the supra-ventilatory anaerobic threshold, whereas that during the second CPET in the outpatient stage was maximal performance. Bio-reactance-based non-invasive cardiac output monitoring was employed during PLRT to measure real-time stroke volume and cardiac output. A correlation matrix showed that stroke volume during leg raise (SVLR) during the first PLRT was positively correlated (R = 0.653) with the anaerobic threshold during the first CPET. When exercise intolerance was defined as an anaerobic threshold < 3 metabolic equivalents, SVLR / body weight had an area under curve value of 0.822, with sensitivity of 0.954, specificity of 0.593, and cut-off value of 1504·10-3mL/kg (positive predictive value 0.72; negative predictive value 0.92). Additionally, cardiac output during leg raise (COLR) during the first PLRT was related to peak oxygen consumption during the second CPET (R = 0.678). When poor aerobic fitness was defined as peak oxygen consumption < 5 metabolic equivalents, COLR / body weight had an area under curve value of 0.814, with sensitivity of 0.781, specificity of 0.773, and a cut-off value of 68.3 mL/min/kg (positive predictive value 0.83; negative predictive value 0.71). Therefore, we conclude that PLRT during hospitalization has a good screening and predictive power for exercise intolerance/capacity in inpatients and early outpatients following coronary revascularization, which has clinical significance.

Statin use following hospitalization among Medicare beneficiaries with a secondary discharge diagnosis of acute myocardial infarction.

BACKGROUND: Patients with coronary heart disease are recommended to use statins following hospital discharge. Acute myocardial infarction (AMI) is a common complication of hospitalization, but the use of statins following discharge among patients who were not initially hospitalized for AMI has not been assessed adequately. METHODS AND RESULTS: Using the Medicare 5% national random sample, we determined statin use among beneficiaries who were hospitalized and who had a secondary discharge diagnosis of AMI and among beneficiaries who had a primary discharge diagnosis of AMI, coronary artery bypass grafting, or percutaneous coronary intervention in 2007-2009. Statin use was defined by a pharmacy (Medicare Part D) claim within 90 days following discharge. Of 8175 Medicare beneficiaries who did not take statins prior to hospitalization, 31.2% with AMI as a secondary discharge diagnosis, 60.5% with AMI as the primary discharge diagnosis, 67.6% with coronary artery bypass grafting, and 63.9% with a percutaneous coronary intervention initiated statins. After multivariable adjustment, the risk ratio for statin initiation comparing beneficiaries with a secondary versus primary discharge diagnosis of AMI was 0.59 (95% CI 0.54 to 0.65). Among 5468 Medicare beneficiaries taking statins prior to hospitalization, statin use following discharge was lower for those with AMI as a secondary discharge diagnosis (71.8%) compared with their counterparts with AMI, coronary artery bypass grafting, and percutaneous coronary intervention (84.1%, 83.8%, and 87.3%, respectively) as the primary discharge diagnosis. CONCLUSION: Medicare beneficiaries with a secondary hospital discharge diagnosis of AMI were less likely to fill statins compared with those with other coronary heart disease events.