Ventilatory efficiency as a prognostic factor for postoperative complications in patients undergoing elective major surgery: a systematic review.

BACKGROUND: Major surgery is associated with high complication rates. Several risk scores exist to assess individual patient risk before surgery but have limited precision. Novel prognostic factors can be included as additional building blocks in existing prediction models. A candidate prognostic factor, measured by cardiopulmonary exercise testing, is ventilatory efficiency (VE/VCO2). The aim of this systematic review was to summarise evidence regarding VE/VCO2 as a prognostic factor for postoperative complications in patients undergoing major surgery. METHODS: A medical library specialist developed the search strategy. No database-provided limits, considering study types, languages, publication years, or any other formal criteria were applied to any of the sources. Two reviewers assessed eligibility of each record and rated risk of bias in included studies. RESULTS: From 10,082 screened records, 65 studies were identified as eligible. We extracted adjusted associations from 32 studies and unadjusted from 33 studies. Risk of bias was a concern in the domains 'study confounding' and 'statistical analysis'. VE/VCO2 was reported as a prognostic factor for short-term complications after thoracic and abdominal surgery. VE/VCO2 was also reported as a prognostic factor for mid- to long-term mortality. Data-driven covariable selection was applied in 31 studies. Eighteen studies excluded VE/VCO2 from the final multivariable regression owing to data-driven model-building approaches. CONCLUSIONS: This systematic review identifies VE/VCO2 as a predictor for short-term complications after thoracic and abdominal surgery. However, the available data do not allow conclusions about clinical decision-making. Future studies should select covariables for adjustment a priori based on external knowledge. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022369944).

Qualitative assessment of expectations on the content, form and way of delivery of a prehabilitation programme in patients with lung resection surgery - A Swiss tertiary centre experience.

Objective: To assess the interest in a prehabilitation programme of patients awaiting lung resection and to identify expectations from such a programme. Introduction: At present, in Switzerland, there are no multimodal clinical prehabilitation programmes for lung resection patients awaiting surgery. Methods: Semi-structured face-to-face interviews were conducted with patients who have had or were awaiting lung resection at a Swiss tertiary centre. Thematic analysis was performed to identify common prespecified themes. Results: Twenty-two patients (45.5% female, age 70.6 ± 16.6 years) were interviewed. Seventy-seven percent were interested in a prehabilitation programme. Sixty-two percent, 67% and 90% were interested in endurance, strength and respiratory training, respectively. Six patients (27%) were active smokers, of whom two (one-third) were interested in a smoking cessation programme. Seventy-six percent were interested in nutrition counselling and 90% in receiving education on risk factor management. Forty percent preferred centre-based training/counselling sessions, 20% preferred home-based training/counselling and 30% found both forms acceptable. Patients were willing to perform prehabilitation activities on 2.6 days/week for a total of 162 min/week. Participating in peer groups was desired by only 25%. Conclusions: Patients with lung resection were highly interested in participating in prehabilitation, albeit only for a mean time cost of 2.7 h per week. Offering a prehabilitation programme with a combination of in-hospital group sessions and home-based training seems feasible.

Supervised exercise training in patients with cancer during anthracycline-based chemotherapy to mitigate cardiotoxicity: a randomized-controlled-trial.

Background: Exercise training (ET) has been shown to mitigate cardiotoxicity of anthracycline-based chemotherapies (AC) in animal models. Data from randomized controlled trials in patients with cancer are sparse. Methods: Patients with breast cancer or lymphoma receiving AC were recruited from four cancer centres and randomly assigned to 3 months supervised ET. Primary outcome was change in left ventricular global longitudinal strain (GLS) from baseline (before AC) to post AC (AC-end) compared between the EXduringAC group, who participated in an exercise intervention during AC including the provision of an activity tracker, and the control group EXpostAC, who received an activity tracker only. Secondary outcome parameters were changes in high sensitivity Troponin T (hsTnT), NT-pro-brain natriuretic peptide (NT-proBNP), peak oxygen consumption (peak VO2) and objectively measured physical activity (PA) during this same time-period. All assessments were repeated at a 12-week follow-up from AC-end, when also the EXpostAC group had completed the ET, that started after AC. In exploratory analyses, robust linear models were performed to assess the association of PA with changes in echocardiographic parameters and biomarkers of LV function. Results: Fifty-seven patients (median age 47 years; 95% women) were randomized to EXduringAC (n = 28) and EXpostAC (n = 29) group. At AC-end, GLS deteriorated in both study groups (albeit insignificantly) with 7.4% and 1.0% in EXduringAC (n = 18) and EXpostAC (n = 18), respectively, and hsTnT and NT-proBNP significantly increased in both groups, without difference between groups for any parameter. Change in peak VO2 (-1.0 and -1.1 ml/kg/min) at AC-end was also similar between groups as was duration of moderate-to-vigorous PA (MVPA) with a median of 33 [26, 47] min/day and 32 [21, 59] min/day in the EXduringAC and EXpostAC group, respectively. In the robust linear model including the pooled patient population, MVPA was significantly associated with a more negative GLS and lesser increase in hsTnT at AC-end. Conclusion: In this small scale RCT, supervised ET during AC was not superior to wearing a PA tracker to mitigate cardiotoxicity. The dose-response relationship between PA and cardioprotective effects during AC found in our and previous data supports the notion that PA should be recommended to patients undergoing AC. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT03850171.

Breathing pattern and pulmonary gas exchange in elderly patients with and without left ventricular dysfunction-modification with exercise-based cardiac rehabilitation and prognostic value.

Background: Inefficient ventilation is an established prognostic marker in patients with heart failure. It is not known whether inefficient ventilation is also linked to poor prognosis in patients with left ventricular dysfunction (LVD) but without overt heart failure. Objectives: To investigate whether inefficient ventilation in elderly patients with LVD is more common than in patients without LVD, whether it improves with exercise-based cardiac rehabilitation (exCR), and whether it is associated with major adverse cardiovascular events (MACE). Methods: In this large multicentre observational longitudinal study, patients aged ≥65 years with acute or chronic coronary syndromes (ACS, CCS) without cardiac surgery who participated in a study on the effectiveness of exCR in seven European countries were included. Cardiopulmonary exercise testing (CPET) was performed before, at the termination of exCR, and at 12 months follow-up. Ventilation (VE), breathing frequency (BF), tidal volume (VT), and end-expiratory carbon dioxide pressure (PETCO2) were measured at rest, at the first ventilatory threshold, and at peak exercise. Ventilatory parameters were compared between patients with and without LVD (based on cardio-echography) and related to MACE at 12 month follow-up. Results: In 818 patients, age was 72.5 ± 5.4 years, 21.9% were women, 79.8% had ACS, and 151 (18%) had LVD. Compared to noLVD, in LVD resting VE was increased by 8%, resting BF by 6%, peak VE, peak VT, and peak PETCO2 reduced by 6%, 8%, and 5%, respectively, and VE/VCO2 slope increased by 11%. From before to after exCR, resting VE decreased and peak PETCO2 increased significantly more in patients with compared to without LVD. In LVD, higher resting BF, higher nadir VE/VCO2, and lower peak PETCO2 at baseline were associated with MACE. Conclusions: Similarly to patients with HF, in elderly patients with ischemic LVD, inefficient resting and exercise ventilation was associated with worse outcomes, and ExCR alleviated abnormal breathing patterns and gas exchange parameters.

Multimodal prehabilitation for major surgery in elderly patients to lower complications: protocol of a randomised, prospective, multicentre, multidisciplinary trial (PREHABIL Trial).

INTRODUCTION: The global volume of surgery is growing and the population ageing, and economic pressure is rising. Major surgery is associated with relevant morbidity and mortality. Postoperative reduction in physiological and functional capacity is especially marked in the elderly, multimorbid patient with low fitness level, sarcopenia and malnutrition. Interventions aiming to optimise the patient prior to surgery (prehabilitation) may reduce postoperative complications and consequently reduce health costs. METHODS AND ANALYSIS: This is a multicentre, multidisciplinary, prospective, 2-arm parallel-group, randomised, controlled trial with blinded outcome assessment. Primary outcome is the Comprehensive Complications Index at 30 days. Within 3 years, we aim to include 2×233 patients with a proven fitness deficit undergoing major surgery to be randomised using a computer-generated random numbers and a minimisation technique. The study intervention consists of a structured, multimodal, multidisciplinary prehabilitation programme over 2-4 weeks addressing deficits in physical fitness and nutrition, diabetes control, correction of anaemia and smoking cessation versus standard of care. ETHICS AND DISSEMINATION: The PREHABIL trial has been approved by the responsible ethics committee (Kantonale Ethikkomission Bern, project ID 2020-01690). All participants provide written informed consent prior to participation. Participant recruitment began in February 2022 (10 and 8 patients analysed at time of submission), with anticipated completion in 2025. Publication of the results in peer-reviewed scientific journals are expected in late 2025. TRIAL REGISTRATION NUMBER: NCT04461301.

Effect of a physical activity intervention on lower body bone health in childhood cancer survivors: A randomized controlled trial (SURfit).

It remains controversial whether physical activity promotes bone health in childhood cancer survivors (CCS). We aimed to assess the effect of a one-year general exercise intervention on lower body bone parameters of CCS. CCS ≥16 years at enrollment, <16 years at diagnosis and ≥5 years in remission were identified from the national Childhood Cancer Registry. Participants randomized to the intervention group were asked to perform an additional ≥2.5 hours of intense physical activity/week, controls continued exercise as usual. Bone health was assessed as a secondary trial endpoint at baseline and after 12-months. We measured tibia bone mineral density (BMD) and morphology by peripheral quantitative computed tomography and lumbar spine, hip and femoral neck BMD by dual-energy x-ray absorptiometry. We performed intention-to-treat, per protocol, and an explorative subgroup analyses looking at low BMD using multiple linear regressions. One hundred fifty-one survivors (44% females, 7.5 ± 4.9 years at diagnosis, 30.4 ± 8.6 years at baseline) were included. Intention-to-treat analysis revealed no differences in changes between the intervention and control group. Per protocol analyses showed evidence for an improvement in femoral neck and trabecular BMD between 1.5% and 1.8% more in participants being compliant with the exercise program. Trabecular BMD increased 2.8% more in survivors of the intervention group with BMD z-score ≤-1 compared to those starting at z-score >-1. A nonstandardized personalized exercise programs might not be specific enough to promote bone health in CCS, although those compliant and those most in need may benefit. Future trials should include bone stimulating exercise programs targeting risk groups with reduced bone health and motivational features to maximize compliance.

Objectively measured adherence to physical activity among patients with coronary artery disease: Comparison of the 2010 and 2020 World Health Organization guidelines and daily steps.

Background: Tailored recommendations for patients after percutaneous coronary interventions (PCI) need physical activity (PA) to be objectively measured and assessed for adherence to guidelines. The recent WHO guidelines removed the daily recommended bout duration, while the potential impact of this change on patients after PCI remains unclear. Aim: We evaluated prevalence estimates of adherence to PA recommendations among patients after PCI across the 2010 [≥30 min moderate- to vigorous-intensity PA (MVPA) at ≥ 10-min bout duration] and 2020 WHO guidelines (≥30 min of MVPA of any bout duration), as well as 7,500 and 10,000 steps. Methods: We conducted an observational longitudinal single-center study with patients after PCI for chronic or acute coronary syndrome (ACS); maximal age 80 years. Wrist-worn accelerometers recorded participants' PA data from the evening of hospital discharge over the next 18 days. Results: We analyzed data from 282 participants with sufficient minimum wear time (7 days of ≥12 h), including 45 (16%) women; and 249 (88%) with ACS. Median wear time was 18 (17, 18) days. Median participant age was 62 (55, 69) years. Fifty-two participants (18.4%) fulfilled 2010 WHO guidelines and 226 (80.1%) fulfilled the 2020 WHO guidelines. Further, 209 (74.1%) participants achieved ≥7,500 steps/day and 155 (55.0%) performed ≥10,000 steps/day. Conclusion: Among participants after PCI, most MVPA was accumulated in bouts <10 min, leading to a fourfold discrepancy between participants fulfilling the 2010 and 2020 WHO PA recommendations. The number of steps/day may be a valid proxy to recent WHO PA recommendations as it is not dependent on the bout-length definition. Clinical trial registration: [ClinicalTrials.gov], identifier [NCT04663373].

Prognostic impact of physical activity patterns after percutaneous coronary intervention. Protocol for a prospective longitudinal cohort. The PIPAP study.

Introduction: Current guidelines recommend wearable activity trackers to detect insufficient physical activity (PA) and help increase PA to prevent or ameliorate cardiovascular disease. However, there is a paucity of data regarding how objectively measured PA trajectories, patterns, and sedentary time, are associated with mortality and recurrent events after percutaneous coronary intervention (PCI) in patients with established coronary artery disease (CAD). Additionally, it remains unclear if early PA and sedentary time after PCI are associated with such outcomes. Therefore, in the present study (ClinicalTrials.gov Identifier: NCT04663373), we aim to establish the associations of objectively measured PA with major adverse cardiac events and mortality at one-year follow-up. Methods and analysis: In this single-centre observational study, patients with CAD will be prospectively recruited immediately after PCI. All the information from the clinical history, baseline characteristics, and outcomes during follow-up will be obtained from the CARDIOBASE registry. Accelerometer data will be collected for 18 days following hospital discharge and 14 days at one-year follow-up. PA trajectories will be identified by group-based trajectory modeling. Major adverse cardiac events and mortality will be prospectively monitored up to 1 year after PCI. All data will be collected using Research Electronic Data Capture.

Short- and Long-Term Effects of High-Intensity Interval Training vs. Moderate-Intensity Continuous Training on Left Ventricular Remodeling in Patients Early After ST-Segment Elevation Myocardial Infarction-The HIIT-EARLY Randomized Controlled Trial.

Aim: Due to insufficient evidence on the safety and effectiveness of high-intensity interval training (HIIT) in patients early after ST-segment elevation myocardial infarction (STEMI), we aimed to compare short- and long-term effects of randomized HIIT or moderate-intensity continuous training (MICT) on markers of left ventricular (LV) remodeling in STEMI patients receiving optimal guideline-directed medical therapy (GDMT). Materials and Methods: Patients after STEMI (<4 weeks) enrolled in a 12-week cardiac rehabilitation (CR) program were recruited for this randomized controlled trial (NCT02627586). During a 3-week run-in period with three weekly MICT sessions, GDMT was up-titrated. Then, the patients were randomized to HIIT or isocaloric MICT for 9 weeks. Echocardiography and cardiopulmonary exercise tests were performed after run-in (3 weeks), end of CR (12 weeks), and at 1-year follow-up. The primary outcome was LV end-diastolic volume index (LVEDVi) at the end of CR. Secondary outcomes were LV global longitudinal strain (GLS) and cardiopulmonary fitness. Results: Seventy-three male patients were included, with the time between STEMI and start of CR and randomization being 12.5 ± 6.3 and 45.8 ± 10.8 days, respectively. Mixed models revealed no significant group × time interaction for LVEDVi at the end of CR (p = 0.557). However, there was a significantly smaller improvement in GLS at 1-year follow-up in the HIIT compared to the MICT group (p = 0.031 for group × time interaction). Cardiorespiratory fitness improved significantly from a median value of 26.5 (1st quartile 24.4; 3rd quartile 1.1) ml/kg/min at randomization in the HIIT and 27.7 (23.9; 31.6) ml/kg/min in the MICT group to 29.6 (25.3; 32.2) and 29.9 (26.1; 34.9) ml/kg/min at the end of CR and to 29.0 (26.6; 33.3) and 30.6 (26.0; 33.8) ml/kg/min at 1 year follow-up in HIIT and MICT patients, respectively, with no significant group × time interactions (p = 0.138 and 0.317). Conclusion: In optimally treated patients early after STEMI, HIIT was not different from isocaloric MICT with regard to short-term effects on LVEDVi and cardiorespiratory fitness. The worsening in GLS at 1 year in the HIIT group deserves further investigation, as early HIIT may offset the beneficial effects of GDMT on LV remodeling in the long term.

Time-Dependent Effect of Anthracycline-Based Chemotherapy on Central Arterial Stiffness: A Systematic Review and Meta-Analysis.

Background and Aims: Anthracycline-based chemotherapy (ANTH-BC) has been proposed to increase arterial stiffness, however, the time-dependency of these effects remain unclear. This systematic review and meta-analysis aimed to investigate the time-dependent effect of ANTH-BC on markers of central aortic stiffness, namely aortic distensibility (AD) and pulse-wave-velocity (PWV) in cancer patients. Methods: An extensive literature search without language restrictions was performed to identify all studies presenting longitudinal data on the effect of ANTH-BC on either AD and/or central PWV in cancer patients of all ages. An inverse-variance weighted random-effect model was performed with differences from before to after chemotherapy, as well as for short vs. mid-term effects. Results: Of 2,130 articles identified, 9 observational studies with a total of 535 patients (mean age 52 ± 11; 73% women) were included, of which four studies measured AD and seven PWV. Short-term (2-4 months), there was a clinically meaningful increase in arterial stiffness, namely an increase in PWV of 2.05 m/s (95% CI 0.68-3.43) and a decrease in AD (albeit non-significant) of -1.49 mmHg-1 (-3.25 to 0.27) but a smaller effect was observed mid-term (6-12 months) for PWV of 0.88 m/s (-0.25 to 2.02) and AD of -0.37 mmHg-1 (-1.13 to 0.39). There was considerable heterogeneity among the studies. Conclusions: Results from this analysis suggest that in the short-term, ANTH-BC increases arterial stiffness, but that these changes may partly be reversible after therapy termination. Future studies need to elucidate the long-term consequences of ANTH-BC on arterial stiffness, by performing repeated follow-up measurements after ANTH-BC termination. Systematic Review Registration: [www.crd.york.ac.uk/prospero/], identifier [CRD42019141837].

Qualitative analysis of facilitators and barriers to centre- and home-based exercise training in breast cancer patients - a Swiss tertiary centre experience.

BACKGROUND: Exercise is an effective therapy for breast cancer patients to reduce fatigue and to improve health-related quality of life and physical function. Yet breast cancer patients often do not meet the recommended physical activity guidelines. To better understand why recommendations are not met and to improve long-term physical activity maintenance, this study aimed at identifying facilitators and barriers of breast cancer survivors to supervised, centre-based exercise within a cardio-oncological rehabilitation programme and to unsupervised, home-based exercise both during and after the completion of the programme, as well as strategies used to manage these barriers. METHODS: Breast cancer patients who had previously completed a structured centre-based exercise programme at a Swiss tertiary centre were recruited by mailed invitation letter. Semi-structured telephone interviews were conducted with consenting patients and subsequent thematic analysis was performed to identify common themes. RESULTS: Of the 37 eligible breast cancer patients, 19 patients (51%, mean age 48.9 ± 9.7 years) responded to our invitation. Baseline characteristics did not differ from the total eligible population. General facilitators for exercise were anticipated and experienced benefits on physical and mental health and enjoyment of exercise. Facilitators specific for supervised centre-based exercise were social support, accountability and the provision of structured exercise by the programme. Centre-based exercise barriers included physical, psychological and environmental barriers, whereby psychological barriers were reported predominantly in the context of home-based exercise. Strategies to manage these barriers were diverse and included the adaptation of training circumstances, behaviour change strategies and strategies to deal with side effects. CONCLUSIONS: This first study on facilitators of and barriers to exercise in breast cancer patients in Switzerland identified more barriers, particularly psychological barriers, for unsupervised home-based exercise than for supervised centre-based exercise. These findings support the importance of providing structured supervised exercise programmes for breast cancer patients and suggest that a special focus should be directed at the transition from supervised to self-organized exercise in order to enhance and maintain long-term exercise participation.

Young endurance training starting age in non-elite athletes is associated with higher proximal aortic distensibility.

OBJECTIVE: Decreased proximal aortic distensibility (AD) is known to significantly predict all-cause mortality and cardiovascular events among individuals without overt cardiovascular disease. This cross-sectional study investigated the association of endurance training (ET) parameters, namely, ET starting age, ET years and yearly ET volume with AD in non-elite endurance athletes. METHODS: Healthy, normotensive, male Caucasian participants of a 10-mile race were assessed with a 2D echocardiogram and comprehensive interview. Ascending aortic diameters were measured simultaneously with pulse pressure. Aortic strain, AD and aortic stiffness index were calculated. Predictors of AD were investigated among training parameters by linear regression models corrected for age, resting heart rate, stroke volume index and mean blood pressure. RESULTS: Ninety-two of 121 athletes (aged 42±8 years) had sufficient echocardiogram quality and were used for analysis. ET starting age (range 6-52 years) and years of ET (range 2-46 years) were highly collinear and used in two separate models for AD. Significant factors for AD were ET starting age, 10-mile race time and resting heart rate in model I, and age, years of ET, 10-mile race time and heart rate in model II (all p<0.01). CONCLUSIONS: In our cohort of healthy, non-elite, middle-aged runners, AD was significantly higher in athletes with younger ET starting age or more years of ET (in the model adjusted for confounders). In the model with years of ET, age had a negative contribution to AD, suggesting that with older age, the benefit of more years of ET on AD decreased. Future studies assessing the effect of exercise training on arterial properties should include training starting age.

Validation of open-source step-counting algorithms for wrist-worn tri-axial accelerometers in cardiovascular patients.

BACKGROUND: Accurate quantification of daily steps in a cardiovascular patient population is of high importance for primary and secondary prevention. While sensor derived step counts have been sufficiently validated for hip-worn devices and commercial wrist-worn devices, there is a lack of knowledge on validity of freely available step counting algorithms for raw acceleration data collected at the wrist. RESEARCH QUESTION: How accurate are step-counting algorithms for wrist worn tri-axial accelerometers in a cardiac rehabilitation training setting? METHODS: Two step counting algorithms (Windowed Peak Detection, Autocorrelation) for tri-axial accelerometers (Axivity AX-3), were tested. Steps were recorded by chest-mounted GoPro video cameras as gold standard. Cardiovascular patients without neurological impairments enrolled in an ambulatory rehabilitation program were recruited. Recordings were performed during one 45-90 min outdoor physical therapy session of which 5-min segments of six movement categories, namely Walking, Running, Nordic, Stairs, Arm Movement [AM] With [+] and Without [-] Walking [W] were identified and analyzed. Mean absolute difference and mean absolute percentage error [MAPE] with regard to true steps measured from video are reported to report accuracy. RESULTS: Training sessions of 22 patients were recorded and analyzed. Steps were overestimated during AM-W and underestimated during Walking, Running and Stairs. Windowed Peak Detection algorithm was more accurate during AM+W and AM-W and Autocorrelation performed better during Nordic. A MAPE of close or below 10% was achieved by both algorithms for the categories: Walking, Running, Stairs and Nordic. SIGNIFICANCE: Both algorithms provided accurate results for estimation of step counts in a controlled setting of a cardiovascular patient population. The quantification of daily number of steps recorded by wrist-worn accelerometers delivering raw data analyzed by freely available algorithms is a cost-effective option for research studies.

Effect of self-tailored high-intensity interval training versus moderate-intensity continuous exercise on cardiorespiratory fitness after myocardial infarction: A randomised controlled trial.

BACKGROUND: Whether high-intensity interval training (HIIT) is more efficient than moderate-intensity continuous exercise (MICE) to increase cardiorespiratory fitness in patients with acute coronary syndrome at moderate-to-high cardiovascular risk is controversial. The best approach to guide training intensity remains to be determined. OBJECTIVE: We aimed to assess intensities achieved with self-tailored HIIT and MICE according to perceived exertion and to compare the effect on cardiorespiratory fitness in patients early after ST-elevation myocardial infarction (STEMI). METHODS: We included 69 males starting cardiac rehabilitation within 4 weeks after STEMI. After a 3-week run-in phase with MICE, 35 patients were randomised to 9 weeks of HIIT (2×HIIT and 1×MICE per week) and 34 patients to MICE (3×MICE). Training workload for MICE was initially set at the patients' first ventilatory threshold (VT). HIIT consisted of 4×4-min intervals with a workload above the second VT in high intervals. Training intensity was adjusted weekly to maintain the perceived exertion (Borg score 13-14 for MICE, ≥15 for HIIT). Session duration was 38min in both groups. Peak oxygen consumption (VO2) was measured by cardiopulmonary exercise testing pre- and post-intervention. RESULTS: Both groups improved peak VO2 (ml/kg/min) (HIIT +1.9, P<0.001; MICE +3.2, P<0.001, Cohen's d -0.4), but changes in VO2 were not significantly different between groups (P=0.104). Exercise regimes did not differ between groups in terms of energy expenditure or training time, but perceived exertion was higher with HIIT. CONCLUSIONS: Self-tailored HIIT was feasible in patients early after STEMI. It was more strenuous but not superior nor more time-efficient than MICE in improving peak VO2. The trial was registered at ClinicalTrial.gov (NCT02627586).

Clinical outcomes and cardiac rehabilitation in underrepresented groups after percutaneous coronary intervention: an observational study.

AIMS: Underrepresentation of migrants, women, and older adults in cardiovascular disease (CVD) trials may contribute to disparate care and survival. Among patients who underwent percutaneous coronary intervention (PCI), we aimed to investigate the associations of (i) underrepresented groups with major adverse cardiac events (MACE), CVD mortality, and non-CVD mortality, (ii) underrepresented groups with cardiac rehabilitation (CR) uptake, and (iii) CR uptake with outcomes. METHODS AND RESULTS: We included 15 211 consecutive patients from the CARDIOBASE Bern PCI registry (2009-18). In multi-state models comparing transition probabilities of events, sex was not associated with increased risk of any event. For each year increase in age, the increased risk of non-CVD and CVD mortality was 8% [95% confidence interval (CI) 6-9%]. Being migrant was associated with a lower risk of non-CVD mortality [hazard ratio (HR) (95% CI) 0.49 (0.27-0.90)] but not with CVD mortality. In logistic regression analysis, CR uptake was lower among women [odds ratio (95% CI) = 0.72 (0.57-0.86)] and older adults [0.32 (0.27-0.38)], but not among migrants. In cox regression, CR was independently associated with lower all-cause [HR (95% CI) = 0.12 (0.03-0.37)] and CVD mortality [0.1 (0.02-0.7)], but not with MACE [1.08 (0.8-1.4)]. CONCLUSION: Among underrepresented groups undergoing PCI, age, but not migration status nor sex, contributed to disparities in mortality. Migrant status did not result in lower attendance of CR. Considering the protective associations of CR on CVD mortality independent of age, sex, and migration status, the lower uptake in women and older adults is noteworthy.

Changes and prognostic value of cardiopulmonary exercise testing parameters in elderly patients undergoing cardiac rehabilitation: The EU-CaRE observational study.

OBJECTIVE: We aimed 1) to test the applicability of the previously suggested prognostic value of CPET to elderly cardiac rehabilitation patients and 2) to explore the underlying mechanism of the greater improvement in exercise capacity (peak oxygen consumption, VO2) after CR in surgical compared to non-surgical cardiac patients. METHODS: Elderly patients (≥65 years) commencing CR after coronary artery bypass grafting, surgical valve replacement (surgery-group), percutaneous coronary intervention, percutaneous valve replacement or without revascularisation (non-surgery group) were included in the prospective multi-center EU-CaRE study. CPETs were performed at start of CR, end of CR and 1-year-follow-up. Logistic models and receiver operating characteristics were used to determine prognostic values of CPET parameters for major adverse cardiac events (MACE). Linear models were performed for change in peak VO2 (start to follow-up) and parameters accounting for the difference between surgery and non-surgery patients were sought. RESULTS: 1421 out of 1633 EU-CaRE patients performed a valid CPET at start of CR (age 73±5.4, 81% male). No CPET parameter further improved the receiver operation characteristics significantly beyond the model with only clinical parameters. The higher improvement in peak VO2 (25% vs. 7%) in the surgical group disappeared when adjusted for changes in peak tidal volume and haemoglobin. CONCLUSION: CPET did not improve the prediction of MACE in elderly CR patients. The higher improvement of exercise capacity in surgery patients was mainly driven by restoration of haemoglobin levels and improvement in respiratory function after sternotomy. TRIAL REGISTRATION: Netherlands Trial Register, Trial NL5166.

Predictors for one-year outcomes of cardiorespiratory fitness and cardiovascular risk factor control after cardiac rehabilitation in elderly patients: The EU-CaRE study.

INTRODUCTION: Studies on effectiveness of cardiac rehabilitation (CR) in elderly cardiovascular disease patients are rare, and it is unknown, which patients benefit most. We aimed to identify predictors for 1-year outcomes of cardiorespiratory fitness and CV risk factor (CVRF) control in patients after completing CR programs offered across seven European countries. METHODS: Cardiovascular disease patients with minimal age 65 years who participated in comprehensive CR were included in this observational study. Peak oxygen uptake (VO2), body mass index (BMI), resting systolic blood pressure (BPsys), and low-density lipoprotein-cholesterol (LDL-C) were assessed before CR (T0), at termination of CR (T1), and 12 months after start of CR (T2). Predictors for changes were identified by multivariate regression models. RESULTS: Data was available from 1241 out of 1633 EU-CaRE patients. The strongest predictor for improvement in peak VO2 was open chest surgery, with a nearly four-fold increase in surgery compared to non-surgery patients. In patients after surgery, age, female sex, physical inactivity and time from index event to T0 were negative predictors for improvement in peak VO2. In patients without surgery, previous acute coronary syndrome and higher exercise capacity at T0 were the only negative predictors. Neither number of attended training sessions nor duration of CR were significantly associated with change in peak VO2. Non-surgery patients were more likely to achieve risk factor targets (BPsys, LDL-C, BMI) than surgery patients. CONCLUSIONS: In a previously understudied population of elderly CR patients, time between index event and start of CR in surgery and disease severity in non-surgery patients were the most important predictors for long-term improvement of peak VO2. Non-surgery patients had better CVRF control.

Patient interest in mHealth as part of cardiac rehabilitation in Switzerland.

PURPOSE: Smartphone-based health interventions (mHealth) offer the potential to overcome barriers to accessibility of cardiac rehabilitation. We aimed (1) to examine patients’ interest in mHealth as part of the outpatient cardiac rehabilitation (phase II) and long-term aftercare (phase III) and (2) to identify the influence of sociodemographic and clinical patient characteristics on interest in mHealth. METHODS: A questionnaire was consecutively handed out to 2041 patients concluding outpatient cardiac rehabilitation between March 2013 and December 2018 at the University Hospital Bern. Multivariate logistic models were used to identify influencing factors (age, sex, smartphone ownership, year, compliance with cardiac rehabilitation, physical fitness, body mass index, diabetes mellitus, German speaking) for mHealth interest. RESULTS: The questionnaire was returned by 1025 patients (50.2% response rate). Seventy-one percent of the responding patients preferred the cardiac rehabilitation as offered with three weekly centre-based sessions, whereas 12% preferred and 17% considered replacing two out of the three centre-based sessions per week with mHealth. Forty-eight percent were interested in continuing exercise training using mHealth after completion of cardiac rehabilitation. Smartphone ownership was the most important indicator for patient interest in mHealth (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.53–4.23), whereas age (per year) was not independently associated with mHealth interest for phase II (OR 0.99, 95% CI 0.98–1.01) and only weakly associated with phase III (OR 0.98, 95% CI 0.96–0.99). CONCLUSION: In a Swiss urban region with easy access to cardiac rehabilitation, patients who participated in a centre-based cardiac rehabilitation programme between 2013 and 2018 showed little interest in mHealth during phase II. However, almost half of them expressed interest in continuing training with mHealth during phase III.

Offering, participation and adherence to cardiac rehabilitation programmes in the elderly: a European comparison based on the EU-CaRE multicentre observational study.

AIMS: Cardiac rehabilitation (CR) is strongly recommended but participation of elderly patients has not been well characterized. This study aims to analyse current rates and determinants of CR referral, participation, adherence, and compliance in a contemporary European cohort of elderly patients. METHODS AND RESULTS: The EU-CaRE observational study included data from consecutive patients aged ≥ 65 with acute coronary syndrome, revascularization, stable coronary artery disease, or heart valve replacement, recruited in eight European centres. Rates and factors determining offering, participation, and adherence to CR programmes and compliance with training sessions were studied across centres, under consideration of extensive-outpatient vs. intensive-inpatient programmes. Three thousand, four hundred, and seventy-one patients were included in the offering and participation analysis. Cardiac rehabilitation was offered to 80.8% of eligible patients, formal contraindications being the main reason for not offering CR. Mean participation was 68.0%, with perceived lack of usefulness and transport issues being principal barriers. Mean adherence to CR programmes of participants in the EU-CaRE study (n = 1663) was 90.3%, with hospitalization/physical impairment as principal causes of dropout. Mean compliance with training sessions was 86.1%. Older age was related to lower offering and participation, and comorbidity was associated with lower offering, participation, adherence, and compliance. Intensive-inpatient programmes displayed higher adherence (97.1% vs. 85.9%, P < 0.001) and compliance (full compliance: 66.0% vs. 38.8%, P < 0.001) than extensive-outpatient programmes. CONCLUSION: In this European cohort of elderly patients, older age and comorbidity tackled patients' referral and uptake of CR programmes. Intensive-inpatient CR programmes showed higher completion than extensive-outpatient CR programmes, suggesting this formula could suit some elderly patients.

Heart rate kinetics during standard cardiopulmonary exercise testing in heart transplant recipients: a longitudinal study.

AIMS: Heart transplantation (HTx) results in complete autonomic denervation of the donor heart, causing resting tachycardia and abnormal heart rate (HR) responses to exercise. We determined the time course of suggestive cardiac reinnervation post HTx and investigated its clinical significance. METHODS AND RESULTS: Heart rate kinetics during standard cardiopulmonary exercise testing at 2.5-5 years after HTx was assessed in 58 patients. According to their HR increase 30 s after exercise onset, HTx recipients were classified as denervated (slow responders: <5 beats per minute [b.p.m.]) or potentially reinnervated (fast responders: ≥5 b.p.m.). Additionally, in 30 patients, longitudinal changes of maximal oxygen consumption and HR kinetics were assessed during the first 15 post-operative years. At 2.5-5 years post HTx, 38% of our study population was potentially reinnervated. Fast responders were significantly younger (41 ± 15 years) than slow responders (53 ± 13 years, P = 0.003) but did not differ with regard to donor age, immunosuppressive regime, cardiovascular risk factors, endomyocardial biopsy, or vasculopathy parameters. While HR reserve (56 ± 20 vs. 39 ± 15 b.p.m., P = 0.002) and HR recovery after 60 s (15 ± 11 vs. 5 ± 6 b.p.m., P < 0.001) were greater in fast responders, resting HR, peak HR of predicted, and peak oxygen consumption of predicted were comparable. CONCLUSIONS: Signs of reinnervation occurred mainly in younger patients. Maximal oxygen consumption was independent of HR kinetics.