Exercise-Based Cardiac Rehabilitation and All-Cause Mortality Among Patients With Atrial Fibrillation.

Background There is limited evidence of long-term impact of exercise-based cardiac rehabilitation (CR) on clinical end points for patients with atrial fibrillation (AF). We therefore compared 18-month all-cause mortality, hospitalization, stroke, and heart failure in patients with AF and an electronic medical record of exercise-based CR to matched controls. Methods and Results This retrospective cohort study included patient data obtained on February 3, 2021 from a global federated health research network. Patients with AF undergoing exercise-based CR were propensity-score matched to patients with AF without exercise-based CR by age, sex, race, comorbidities, cardiovascular procedures, and cardiovascular medication. We ascertained 18-month incidence of all-cause mortality, hospitalization, stroke, and heart failure. Of 1 366 422 patients with AF, 11 947 patients had an electronic medical record of exercise-based CR within 6-months of incident AF who were propensity-score matched with 11 947 patients with AF without CR. Exercise-based CR was associated with 68% lower odds of all-cause mortality (odds ratio, 0.32; 95% CI, 0.29-0.35), 44% lower odds of rehospitalization (0.56; 95% CI, 0.53-0.59), and 16% lower odds of incident stroke (0.84; 95% CI, 0.72-0.99) compared with propensity-score matched controls. No significant associations were shown for incident heart failure (0.93; 95% CI, 0.84-1.04). The beneficial association of exercise-based CR on all-cause mortality was independent of sex, older age, comorbidities, and AF subtype. Conclusions Exercise-based CR among patients with incident AF was associated with lower odds of all-cause mortality, rehospitalization, and incident stroke at 18-month follow-up, supporting the provision of exercise-based CR for patients with AF.

Prediagnosis and postdiagnosis leisure time physical activity and survival following diagnosis with ovarian cancer.

Little is known about the influence of prediagnosis and postdiagnosis physical activity on ovarian cancer survival. We investigated this association in two large cohorts, the Nurses' Health Study (NHS) and NHSII. Analyses included 1461 women with confirmed invasive, epithelial ovarian cancer and data on physical activity. Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for ovarian cancer-specific mortality. Ovarian cancer-specific mortality was not associated with physical activity reported 1-8 years before diagnosis overall (≥7.5 vs <1.5 MET-hours/week, HR = 0.96), for high-grade serous/ poorly differentiated tumors, or non-serous/ low-grade serous tumors (P-heterogeneity = .45). An inverse association was observed for activity 1-4 years after diagnosis (≥7.5 vs <1.5 MET-hours/week, HR = 0.67, 95%CI: 0.48-0.94), with similar results by histotype (P-heterogeneity = .53). Women who decreased their activity from ≥7.5 MET-hours/week 1-8 years before diagnosis to <7.5 MET-hours/week 1-4 years after diagnosis, compared to those with <7.5 MET-hours/week across periods, had a 49% increased risk of death (HR = 1.49, 95%CI: 1.07-2.08). Physical activity after, but not before, ovarian cancer diagnosis was associated with better prognosis.

Efficacy of a long-term pulmonary rehabilitation maintenance program for COPD patients in a real-life setting: a 5-year cohort study.

BACKGROUND: Pulmonary rehabilitation (PR) improves exercise capacity, health-related quality of life (HRQoL) and dyspnea in chronic obstructive pulmonary disease (COPD) patients. Maintenance programs can sustain the benefits for 12 to 24 months. Yet, the long-term effects (> 12 months) of pragmatic maintenance programs in real-life settings remain unknown. This prospective cohort study assessed the yearly evolution in the outcomes [6-min walking distance (6MWD), HRQoL, dyspnea] of a supervised self-help PR maintenance program for COPD patients followed for 5 years. The aim was to assess the change in the outcomes and survival probability for 1 to 5 years after PR program discharge in COPD patients following a PR maintenance program supported by supervised self-help associations. METHODS: Data were prospectively collected from 144 COPD patients who followed a pragmatic multidisciplinary PR maintenance program for 1 to 5 years. They were assessed yearly for 6MWD, HRQol (VQ11) and dyspnea (MRC). The 5-year survival probability was compared to that of a control PR group without a maintenance program. A trajectory-based cluster analysis identified the determinants of long-term response. RESULTS: Maintenance program patients showed significant PR benefits at 4 years for 6MWD and VQ11 and 5 years for MRC. The 5-year survival probability was higher than for PR patients without PR maintenance. Two clusters of response to long-term PR were identified, with responders being the less severe COPD patients. CONCLUSIONS: This study provides evidence of the efficacy of a pragmatic PR maintenance program in a real-life setting for more than 3 years. In contrast to short-term PR, long-term PR maintenance appeared more beneficial in less severe COPD patients.

Effectiveness of continuous unsupervised exercise therapy after above-knee femoropopliteal bypass.

OBJECTIVE: Exercise therapy has acceptable outcomes for patients with intermittent claudication, although few reports exist regarding the results of continuous exercise therapy after surgical reconstruction for intermittent claudication. This study aimed to analyze the long-term outcomes of unsupervised exercise therapy for patients after above-knee femoropopliteal bypass. MATERIAL AND METHODS: We retrospectively analyzed 69 patients (69 limbs, 69 grafts) who underwent above-knee femoropopliteal bypass from April 2009 to March 2018 in our hospital. At six months after above-knee femoropopliteal bypass, we evaluated the maintenance of unsupervised exercise therapy. Patients who continued unsupervised exercise therapy or discontinued unsupervised exercise therapy were assessed via 1:1 propensity matching. Long-term outcomes such as patency, survival, and major adverse cardiovascular events were compared between the groups after matching. We also analyzed the maintaining rate of unsupervised exercise therapy in a study cohort. RESULTS: Twenty-nine (42%) patients continued unsupervised exercise therapy until six months after above-knee femoropopliteal bypass. The discontinued unsupervised exercise therapy had higher proportions of female sex (p = 0.015) and cerebrovascular disease (p = 0.025) than did the continued unsupervised exercise therapy. The mean follow-up period was 65 ± 36 months. After propensity matching, the rates of the following factors were significantly higher in the continued unsupervised exercise therapy than in the discontinued unsupervised exercise therapy: primary patency (97% vs. 61%, p = 0.0041), secondary patency (100% vs. 69%, p = 0.0021), and freedom from major adverse cardiovascular events (61% vs. 24%, p = 0.0071) at five years. Both groups had a similar survival rate. The maintaining rate of unsupervised exercise therapy in the study cohort was 44% at six months, 41% at one year, 36% at three years, 25% at five years, and 25% at seven years. CONCLUSION: The findings of this study suggested superior long-term outcomes, including graft patency and freedom from major adverse cardiovascular events, with unsupervised exercise therapy after open bypass than with the usual therapy. Unsupervised exercise therapy may be recommended for the patients after open bypass.

Physical activity after ischemic stroke and its association with adverse outcomes: A nationwide population-based cohort study.

BACKGROUND: Sufficient physical activity (PA) is highly recommended to improve the prognosis after stroke. However, there have been only a few studies evaluating the changes in PA level after stroke. AIMS: We aimed to identify the changes in PA level between before and after stroke, and to determine the association between PA and adverse outcomes. METHODS: This observational, retrospective cohort study was performed using  the Nationwide Health Insurance Service (NHIS) database in South Korea. Subjects between the ages of 20 to 80 years, who had a first-ever ischemic stroke from 2010 to 2013, were included. Subjects were divided into either the "sufficient" or "insufficient" subgroups, depending on the result of the self-reported PA questionnaire. Adverse outcomes, including all-cause mortality, stroke recurrence, and myocardial infarction (MI), were collected from a post-stroke health checkup to 2017. RESULTS: Of the 34,243 subjects with ischemic stroke, only 21.24% had sufficient PA level after stroke. Among those with insufficient PA level, only 17.34% improved their PA level after stroke. Subjects with sufficient PA level after stroke, regardless of their PA level prior to stroke, showed a lower risk of composite adverse outcomes (adjusted Hazard Ratio [HR], 95% CI: 0.85, 0.80-0.90). Subjects who went from insufficient to sufficient PA level (HR 0.87, 95% CI: 0.81-0.93) showed a significantly lower risk of composite adverse outcomes. CONCLUSIONS: Achieving a sufficient PA level after ischemic stroke appears to significantly reduce major adverse events. Further effort is needed to promote the PA level after ischemic stroke.

A systematic review of the impact of preoperative exercise for patients with abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA) surgery carries significant risk of morbidity and mortality. Preoperative exercise may improve the physical fitness capacity of patients with AAA as well as postoperative outcomes. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed on MEDLINE, Embase, and Cochrane Library for relevant studies. A methodologic assessment of included studies was conducted using the Physiotherapy Evidence Database (PEDro) scale. RESULTS: Seven studies (six randomized controlled trials and one retrospective cohort study) were included. The overall quality of studies was assessed to range from fair to good. Three studies included AAA patients without indication for surgery, whereas four other studies included AAA patients awaiting surgical repair. One study implemented an inspiratory muscle training program; five studies implemented a continuous moderate-intensity exercise regimen; one study implemented a high-intensity interval training program. Overall compliance with the exercise regimen was high (94% in those not waiting for surgery; 75.8% to 82.3% in those waiting for surgery). In patients not awaiting surgery, preoperative exercise may improve physical fitness parameters including ventilatory threshold (P = .016 at 12 weeks; P = .09 at 12 months) and anaerobic threshold (10% increase; P = .007) but not peak oxygen consumption (P = .183 at 12 weeks; P = .29 at 12 months). In patients awaiting surgery, one study demonstrated a statistically significant improvement in peak oxygen consumption (difference, 1.6 mL/kg/min; P = .004) and anaerobic threshold (difference, 1.9 mL/kg/min; P = .012) for patients who exercised. In terms of postoperative outcomes, exercise may reduce the risk of cardiac, renal, and respiratory complications, although only in those who undergo open surgery. Only patients who underwent endovascular repair had a shorter length of hospital stay when preoperative exercise was conducted. CONCLUSIONS: Despite the encouraging evidence of preoperative exercise for AAA patients, it remains premature to recommend it as a preoperative intervention. Given the heterogeneity of reported outcomes, future studies should consider conducting well-designed randomized controlled trials with standardized reporting outcomes and definitions.

Effect of pre-discharge cardiopulmonary fitness on outcomes in patients with ST-elevation myocardial infarction after percutaneous coronary intervention.

BACKGROUND: The purpose of this study was to analyze cardiopulmonary fitness in Phase I cardiac rehabilitation on the prognosis of patients with ST-Elevation Myocardial Infarction (STEMI) after percutaneous coronary intervention (PCI). METHODS: The study enrolled a total of 499 STEMI patients treated with PCI between January 2015 and December 2015. Patients were assigned to individualized exercise prescriptions (IEP) group and non-individualized exercise prescriptions (NIEP) group according to whether they accept or refuse individualized exercise prescriptions. We compared the incidence of major cardiovascular events between the two groups. IEP group were further divided into two subgroups based on prognosis status, namely good prognosis (GP) group and poor prognosis (PP) group. Key cardio-pulmonary exercise testing (CPX) variables that may affect the prognosis of patients were identified through comparison of the cardio-respiratory fitness (CRF). RESULTS: There is no significant difference in the incidence of cardio-genetic death, re-hospitalization, heart failure, stroke, or atrial fibrillation between the IEP and the NIEP group. But the incidence of total major adverse cardiac events (MACE) was significantly lower in the IEP group than in the NIEP group (P = 0.039). The oxygen consumption (VO2) at ventilation threshold (VT), minute CO2 ventilation (E-VCO2), margin of minute ventilation carbon dioxide production (△CO2), rest partial pressure of end-tidal carbon dioxide(R-PETCO2), exercise partial pressure of end-tidal carbon dioxide(E-PETCO2) and margin of partial pressure of end-tidal carbon dioxide(△PETCO2) were significantly higher in the GP subgroup than in the PP subgroup; and the slope for minute ventilation/carbon dioxide production (VE/VCO2) was significantly lower in GP subgroup than in PP subgroup (P = 0.010). The VO2 at VT, VE/VCO2 slope, E-VCO2, △CO2, R-PETCO2, E-PETCO2 and margin of partial pressure of end-tidal carbon dioxide CO2 (△PETCO2) were predictive of adverse events. The VO2 at VT was an independent risk factor for cardiovascular disease prognosis. CONCLUSIONS: Individualized exercise prescription of Phase I cardiac rehabilitation reduced the incidence of cardiovascular events in patients with STEMI after PCI. VO2 at VT is an independent risk factor for cardiovascular disease prognosis, and could be used as an important evaluating indicator for Phase I cardiac rehabilitation.

Targeting relatives: Impact of a cardiac rehabilitation programme including basic life support training on their skills and attitudes.

BACKGROUND: Training families of patients at risk for sudden cardiac death in basic life support (BLS) has been recommended, but remains challenging. This research aimed to determine the impact of embedding resuscitation training for patients in a cardiac rehabilitation programme on relatives' BLS skill retention at six months. DESIGN: Intervention community study. METHODS: Relatives of patients suffering acute coronary syndrome or revascularization enrolled on an exercise-based cardiac rehabilitation programme were included. BLS skills of relatives linked to patients in a resuscitation-retraining programme (G-CPR) were compared with those of relatives of patients in a standard programme (G-Stan) at baseline, following brief instruction and six months after. Differences in skill performance and deterioration and self-perceived preparation between groups over time were assessed. RESULTS: Seventy-nine relatives were included and complete data from 66 (G-Stan=33, G-CPR=33) was analysed. Baseline BLS skills were equally poor, improved irregularly following brief instruction and decayed afterwards. G-CPR displayed six-month better performance and lessened skill deterioration over time compared with G-Stan, including enhanced compliance with the BLS sequence ( p = 0.006 for group*time interaction) and global resuscitation quality ( p = 0.007 for group*time interaction). Self-perceived preparation was higher in G-CPR ( p = 0.002). CONCLUSIONS: Relatives of patients suffering acute coronary syndrome or revascularization enrolled on a cardiac rehabilitation programme showed poor BLS skills. A resuscitation-retraining cardiac rehabilitation programme resulted in relatives' higher BLS awareness, skill retention and confidence at six months compared with the standard programme. This may suggest a significant impact of this formula on the family setting and support the active role of patients to enhance health education in their environment.

Exercise-based cardiac rehabilitation for adults with heart failure.

BACKGROUND: Chronic heart failure (HF) is a growing global health challenge. People with HF experience substantial burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous (2014) Cochrane systematic review reported that exercise-based cardiac rehabilitation (CR) compared to no exercise control shows improvement in HRQoL and hospital admission among people with HF, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane Review include the following: (1) most trials were undertaken in patients with HF with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with preserved (≥ 45%) ejection fraction HF (HFpEF) were under-represented; and (2) most trials were undertaken in the hospital/centre-based setting. OBJECTIVES: To determine the effects of exercise-based cardiac rehabilitation on mortality, hospital admission, and health-related quality of life of people with heart failure. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and three other databases on 29 January 2018. We also checked the bibliographies of systematic reviews and two trial registers. SELECTION CRITERIA: We included randomised controlled trials that compared exercise-based CR interventions with six months' or longer follow-up versus a no exercise control that could include usual medical care. The study population comprised adults (> 18 years) with evidence of HF - either HFrEF or HFpEF. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all identified references and rejected those that were clearly ineligible for inclusion in the review. We obtained full papers of potentially relevant trials. Two review authors independently extracted data from the included trials, assessed their risk of bias, and performed GRADE analyses. MAIN RESULTS: We included 44 trials (5783 participants with HF) with a median of six months' follow-up. For this latest update, we identified 11 new trials (N = 1040), in addition to the previously identified 33 trials. Although the evidence base includes predominantly patients with HFrEF with New York Heart Association classes II and III receiving centre-based exercise-based CR programmes, a growing body of studies include patients with HFpEF and are undertaken in a home-based setting. All included studies included a no formal exercise training intervention comparator. However, a wide range of comparators were seen across studies that included active intervention (i.e. education, psychological intervention) or usual medical care alone. The overall risk of bias of included trials was low or unclear, and we downgraded results using the GRADE tool for all but one outcome.Cardiac rehabilitation may make little or no difference in all-cause mortality over the short term (≤ one year of follow-up) (27 trials, 28 comparisons (2596 participants): intervention 67/1302 (5.1%) vs control 75/1294 (5.8%); risk ratio (RR) 0.89, 95% confidence interval (CI) 0.66 to 1.21; low-quality GRADE evidence) but may improve all-cause mortality in the long term (> 12 months follow up) (6 trials/comparisons (2845 participants): intervention 244/1418 (17.2%) vs control 280/1427 (19.6%) events): RR 0.88, 95% CI 0.75 to 1.02; high-quality evidence). Researchers provided no data on deaths due to HF. CR probably reduces overall hospital admissions in the short term (up to one year of follow-up) (21 trials, 21 comparisons (2182 participants): (intervention 180/1093 (16.5%) vs control 258/1089 (23.7%); RR 0.70, 95% CI 0.60 to 0.83; moderate-quality evidence, number needed to treat: 14) and may reduce HF-specific hospitalisation (14 trials, 15 comparisons (1114 participants): (intervention 40/562 (7.1%) vs control 61/552 (11.1%) RR 0.59, 95% CI 0.42 to 0.84; low-quality evidence, number needed to treat: 25). After CR, a clinically important improvement in short-term disease-specific health-related quality of life may be evident (Minnesota Living With Heart Failure questionnaire - 17 trials, 18 comparisons (1995 participants): mean difference (MD) -7.11 points, 95% CI -10.49 to -3.73; low-quality evidence). Pooling across all studies, regardless of the HRQoL measure used, shows there may be clinically important improvement with exercise (26 trials, 29 comparisons (3833 participants); standardised mean difference (SMD) -0.60, 95% CI -0.82 to -0.39; I² = 87%; Chi² = 215.03; low-quality evidence). ExCR effects appeared to be consistent different models of ExCR delivery: centre vs. home-based, exercise dose, exercise only vs. comprehensive programmes, and aerobic training alone vs aerobic plus resistance programmes. AUTHORS' CONCLUSIONS: This updated Cochrane Review provides additional randomised evidence (11 trials) to support the conclusions of the previous version (2014) of this Cochane Review. Compared to no exercise control, CR appears to have no impact on mortality in the short term (< 12 months' follow-up). Low- to moderate-quality evidence shows that CR probably reduces the risk of all-cause hospital admissions and may reduce HF-specific hospital admissions in the short term (up to 12 months). CR may confer a clinically important improvement in health-related quality of life, although we remain uncertain about this because the evidence is of low quality. Future ExCR trials need to continue to consider the recruitment of traditionally less represented HF patient groups including older, female, and HFpEF patients, and alternative CR delivery settings including home- and using technology-based programmes.

Mortality and morbidity following exercise-based renal rehabilitation in patients with chronic kidney disease: the effect of programme completion and change in exercise capacity.

BACKGROUND: Twelve weeks of renal rehabilitation (RR) have been shown to improve exercise capacity in patients with chronic kidney disease (CKD); however, survival following RR has not been examined. METHODS: This study included a retrospective longitudinal analysis of clinical service outcomes. Programme completion and improvement in exercise capacity, characterised as change in incremental shuttle walk test (ISWT), were analysed with Kaplan-Meier survival analyses to predict risk of a combined event including death, cerebrovascular accident, myocardial infarction and hospitalisation for heart failure in a cohort of patients with CKD. Time to combined event was examined with Kaplan-Meier plots and log rank test between 'completers' (attended >50% planned sessions) and 'non-completers'. In completers, time to combined event was examined between 'improvers' (≥50 m increase ISWT) and 'non-improvers' (<50 m increase). Differences in time to combined event were investigated with Cox proportional hazards models (adjusted for baseline kidney function, body mass index, diabetes, age, gender, ethnicity, baseline ISWT and smoking status). RESULTS: In all, 757 patients (male 54%) (242 haemodialysis patients, 221 kidney transplant recipients, 43 peritoneal dialysis patients, 251 non-dialysis CKD patients) were referred for RR between 2005 and 2017. There were 193 events (136 deaths) during the follow-up period (median 34 months). A total of 43% of referrals were classified as 'completers', and time to event was significantly greater when compared with 'non-completers' (P = 0.009). Responding to RR was associated with improved event-free survival time (P = 0.02) with Kaplan-Meier analyses and log rank test. On multivariate analysis, completing RR contributed significantly to the minimal explanatory model relating clinical variables to the combined event (overall χ2 = 38.0, P < 0.001). 'Non-completers' of RR had a 1.6-fold [hazard ratio = 1.6; 95% confidence interval (CI) 1.00-2.58] greater risk of a combined event (P = 0.048). Change in ISWT of >50 m contributed significantly to the minimal explanatory model relating clinical variables to mortality and morbidity (overall χ2 = 54.0, P < 0.001). 'Improvers' had a 40% (hazard ratio = 0.6; 95% CI 0.36-0.98) independent lower risk of a combined event (P = 0.041). CONCLUSIONS: There is an association between completion of an RR programme, and also RR success, and a lower risk of a combined event in this observational study. RR interventions to improve exercise capacity in patients with CKD may reduce risk of morbidity and mortality, and a pragmatic randomised controlled intervention trial is warranted.

Effect of multidisciplinary cardiac rehabilitation on the response to cardiac resynchronization therapy.

BACKGROUND: Both cardiac resynchronization therapy (CRT) and Multidisciplinary Cardiac Rehabilitation (CR) beneficially influence symptomatic status, exercise capacity, quality of life, and heart failure readmission rates. However, the interaction between both therapies remain incompletely addressed. METHODS: Consecutive CRT patients implanted in a single tertiary care center were retrospectively analyzed. Patients were dived according to the participation in a structured CR-program following CRT-implant. The effect on functional status (New York Heart Association; NYHA-class), reverse remodeling (change in left ventricular ejection fraction; LVEF), and the combined endpoint of heart failure readmission and all-cause mortality was assessed after multivariate correction. RESULTS: A total of 655 patients were analyzed of whom 223(34%) did and 432(66%) did not participate in a structured multidisciplinary CR-program following implant. No adverse events relating to exercise training occurred during the CR-program. Patients who participated in the CR-program had a more pronounced improvement in NYHA-class at 6-months (P = 0.006), even after multivariate correction (ß = -0.144; 95% CI = [-0.270; -0.018]; P = 0.025). Maximal workload and VO2max on CPET at 6 months improved significantly even after adjustment (P < 0.001, respectively P = 0.017). At 6-months, CR associated with more improvement in LVEF (+11.9 ± 13 vs +14.5 ± 11; P = 0.008), however, this relationship was lost after multivariate correction (P = 0.136). During 36 ± 22 months follow-up, patients in the CR group had a higher event-free survival for the combined endpoint (P = 0.001), even after multivariate correction (adjusted HR = 0.547; CI = 0.366-0.818; P = 0.003). CONCLUSIONS: Following CRT-implant, the participation in a structured CR-program is safe and beneficially influences symptomatic response and clinical outcome. The beneficial effects of exercise training are potentially independent and additive to the beneficial reverse remodeling effect induced by CRT itself.

Cardiac Rehabilitation Protects Against the Expansion of Abdominal Aortic Aneurysm.

BACKGROUND: Virtually no reports on the effects of exercise in patients with a small abdominal aortic aneurysm (AAA) exist. METHODS AND RESULTS: We conducted a retrospective cohort study on 1515 patients with a small AAA before surgery at 2 high-volume hospitals in Tokyo, Japan, from April 2004 to September 2015. A carefully modified cardiac rehabilitation program without excessive blood pressure elevation during exercise was prescribed to 50 patients with an AAA. Using propensity score matching, mortality and clinical outcomes, including AAA expansion rate, were compared between 2 groups: rehabilitation group and nonrehabilitation group. The background characteristics of the rehabilitation group (n=49) and the nonrehabilitation group (n=163) were almost identical. The risk for AAA repair was much lower in the rehabilitation group after matching (before matching: hazard ratio, 0.43; 95% confidence interval, 0.25-0.72; P=0.001; and after matching: hazard ratio, 0.19; 95% confidence interval, 0.07-0.50; P<0.001). AAA expansion rate was slower in the rehabilitation group (before matching: rehabilitation versus nonrehabilitation group, 2.3±3.7 versus 3.8±3.4 mm/y [P=0.008]; after matching: rehabilitation versus nonrehabilitation group, 2.1±3.0 versus 4.5±4.0 mm/y [P<0.001]). Elevation of blood pressure during exercise was positively correlated with AAA expansion rate after the rehabilitation program (r=0.569, P<0.001). CONCLUSIONS: Cardiac rehabilitation protects against the expansion of small AAAs and mitigates the risk associated with AAA repair, possibly because of the decreased elevation of blood pressure during exercise. CLINICAL TRIAL REGISTRATION: URL: upload.umin.ac.jp. Unique identifier: UMIN000028237.

Slow Gait Speed and Cardiac Rehabilitation Participation in Older Adults After Acute Myocardial Infarction.

BACKGROUND: Lack of participation in cardiac rehabilitation (CR) and slow gait speed have both been associated with poor long-term outcomes in older adults after acute myocardial infarction (AMI). Whether the effect of CR participation on outcomes after AMI differs by gait speed is unknown. METHODS AND RESULTS: We examined the association between gait speed and CR participation at 1 month after discharge after AMI, and death and disability at 1 year, in 329 patients aged ≥65 years enrolled in the TRIUMPH (Translational Research Investigating Underlying Disparities in Recovery From Acute Myocardial Infarction: Patients' Health Status) registry. Among these patients, 177 (53.7%) had slow gait speed (<0.8 m/s) and 109 (33.1%) participated in CR. Patients with slow gait speed were less likely to participate in CR compared with patients with normal gait speed (27.1% versus 40.1%; P=0.012). In unadjusted analysis, CR participants with normal gait speed had the lowest rate of death or disability at 1 year (9.3%), compared with those with slow gait speed and no CR participation (43.2%). After adjustment for cardiovascular risk factors and cognitive impairment, both slow gait speed (odds ratio, 2.30; 95% confidence interval, 1.30-4.06) and non-CR participation (odds ratio, 2.34; 95 confidence interval, 1.22-4.48) were independently associated with death or disability at 1 year. The effect of CR on the primary outcome did not differ by gait speed (P=0.70). CONCLUSIONS: CR participation is associated with reduced risk for death or disability after AMI. The beneficial effect of CR participation does not differ by gait speed, suggesting that slow gait speed alone should not preclude referral to CR for older adults after AMI.

Home-based telerehabilitation in older patients with chronic obstructive pulmonary disease and heart failure: a randomised controlled trial.

Background: chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) frequently coexist in older people, reducing patients' quality of life (QoL) and increasing morbidity and mortality. Objective: we studied the feasibility and efficacy of an integrated telerehabilitation home-based programme (Telereab-HBP), 4 months long, in patients with combined COPD and CHF. The primary outcome was exercise tolerance evaluated at the 6-min walk test (6MWT). Secondary outcomes were time-to-event (hospitalisation and death), dyspnoea (MRC), physical activity profile (PASE), disability (Barthel) and QoL (MLHFQ and CAT). Study design: randomised, open, controlled, multicenter trial. Methods: the Telereab-HBP included remote monitoring of cardiorespiratory parameters, weekly phone-calls by the nurse, and exercise programme, monitored weekly by the physiotherapist. All outcomes were studied again after 2 months of a no-intervention period. Results: in total, 112 patients were randomised, 56 per group. Their mean (SD) age was 70 (9) years, and 92 (82.1%) were male. After 4 months, the IG were able to walk further than at baseline: mean (95% CI) Δ6MWT was 60 (22.2,97.8) m; the CG showed no significant improvement: -15 (-40.3,9.8) m; P = 0.0040 between groups. In IG, the media time to hospitalisation/death was 113.4 days compared with 104.7 in the CG (P = 0.0484, log-rank test). Other secondary outcomes: MRC (P = 0.0500), PASE (P = 0.0015), Barthel (P = 0.0006), MLHFQ (P = 0.0007) and CAT (P = 0.0000) were significantly improved in the IG compared with the CG at 4 months. IG maintained the benefits acquired at 6 months for outcomes. Conclusions: this 4-month Telereab-HBP was feasible and effective in older patients with combined COPD and CHF.

Nordic walking for individuals with cardiovascular disease: A systematic review and meta-analysis of randomized controlled trials.

Background Exercise is the cornerstone of rehabilitation programmes for individuals with cardiovascular disease (IwCVD). Although conventional cardiovascular rehabilitation (CCVR) programmes have significant advantages, non-conventional activities such as Nordic walking (NW) may offer additional health benefits. Our aim was to appraise research evidence on the effects of Nordic walking for individuals with cardiovascular disease. Design Systematic review and meta-analysis. Methods A literature search of clinical databases (PubMed, MEDLINE, Scopus, Web of Science, Cochrane) was conducted to identify any randomized controlled trials, including: (i) individuals with cardiovascular disease, (ii) analyses of the main outcomes arising from Nordic walking (NW) programmes. Data from the common outcomes were extracted and pooled in the meta-analysis. Standardized mean differences (SMDs) were calculated and pooled by random effects models. Results Fifteen randomized controlled trials were included and eight trials entered this meta-analysis. Studies focused on coronary artery disease, peripheral arterial disease, heart failure and stroke. In coronary artery disease, significant differences between NW+CCVR and CCVR were found in exercise capacity (SMD: 0.49; p = 0.03) and dynamic balance (SMD: 0.55; p = 0.01) favouring NW+CCVR. In peripheral artery disease, larger changes in exercise duration (SMD: 0.93; p < 0.0001) and oxygen uptake (SMD: 0.64; p = 0.002) were observed following NW compared with controls. In heart failure, no significant differences were found between NW and CCVR or usual care for peak VO2 and functional mobility. In post-stroke survivors, functional mobility was significantly higher following treadmill programmes with poles rather than without (SMD: 0.80; p = 0.03). Conclusions These data portray NW as a feasible and promising activity for individuals with cardiovascular disease. Further studies are necessary to verify whether NW may be incorporated within CCVR for individuals with cardiovascular disease.

Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry.

AIMS: Physical activity is protective against cardiovascular (CV) events, both in general population and in high-risk CV cohorts. However, the relationship between physical activity with major adverse outcomes in atrial fibrillation (AF) is not well-established. Our aim was to analyse this relationship in a 'real-world' AF population. Second, we investigated the influence of physical activity on arrhythmia progression. METHODS AND RESULTS: We studied all patients enrolled in the EURObservational Research Programme on AF (EORP-AF) Pilot Survey. Physical activity was defined as 'none', 'occasional', 'regular', and 'intense', based on patient self-reporting. Data on physical activity were available for 2442 patients: 38.9% reported none, 34.7% occasional, 21.7% regular, and 4.7% intense physical activity. Prevalence of the principal CV risk factors progressively decreased from none to intense physical activity. Lower rates of CV death, all-cause death, and composite outcomes were found in AF patients who reported regular and intense physical activity (P < 0.0001). Increasing physical activity was inversely associated with CV death/any thromboembolic event (TE)/bleeding in the whole cohort, irrespective of gender, paroxysmal AF, elderly age, or high stroke risk. Any level of physical activity intensity was significantly associated with lower risk of CV death/any TE/bleeding at 1-year follow-up. Physical activity was not significantly associated with arrhythmia progression. CONCLUSION: Atrial fibrillation patients taking regular exercise were associated with a lower risk of all-cause death, even when we considered various subgroups, including gender, elderly age, symptomatic status, and stroke risk class. Efforts to increase physical activity among AF patients may improve outcomes in these patients.

Effect of functional electrical stimulation on cardiovascular outcomes in patients with chronic heart failure.

Background/design Functional electrical stimulation of lower limb muscles is an alternative method of training in patients with chronic heart failure (CHF). Although it improves exercise capacity in CHF, we performed a randomised, placebo-controlled study to investigate its effects on long-term clinical outcomes. Methods We randomly assigned 120 patients, aged 71 ± 8 years, with stable CHF (New York Heart Association (NYHA) class II/III (63%/37%), mean left ventricular ejection fraction 28 ± 5%), to either a 6-week functional electrical stimulation training programme or placebo. Patients were followed for up to 19 months for death and/or hospitalisation due to CHF decompensation. Results At baseline, there were no significant differences in demographic parameters, CHF severity and medications between groups. During a median follow-up of 383 days, 14 patients died (11 cardiac, three non-cardiac deaths), while 40 patients were hospitalised for CHF decompensation. Mortality did not differ between groups (log rank test P = 0.680), while the heart failure-related hospitalisation rate was significantly lower in the functional electrical stimulation group (hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.21-0.78, P = 0.007). The latter difference remained significant after adjustment for prognostic factors: age, gender, baseline NYHA class and left ventricular ejection fraction (HR 0.22, 95% CI 0.10-0.46, P < 0.001). Compared to placebo, functional electrical stimulation training was associated with a lower occurrence of the composite endpoint (death or heart failure-related hospitalisation) after adjustment for the above-mentioned prognostic factors (HR 0.21, 95% CI 0.103-0.435, P < 0.001). However, that effect was mostly driven by the favourable change in hospitalisation rates. Conclusions In CHF patients, 6 weeks functional electrical stimulation training reduced the risk of heart failure-related hospitalisations, without affecting the mortality rate. The beneficial long-term effects of this alternative method of training require further investigation.