Performance of the "CCS Algorithm" in real world patients.

BACKGROUND: With the publication of the 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation, the Canadian Cardiovascular Society Atrial Fibrillation Guidelines Committee has introduced a new triage and management algorithm; the so-called "CCS Algorithm". The CCS Algorithm is based upon expert opinion of the best available evidence; however, the CCS Algorithm has not yet been validated. Accordingly, the purpose of this study is to evaluate the performance of the CCS Algorithm in a cohort of real world patients. METHODS: We compared the CCS Algorithm with the European Society of Cardiology (ESC) Algorithm in 172 hospital inpatients who are at risk of stroke due to non-valvular atrial fibrillation in whom anticoagulant therapy was being considered. RESULTS: The CCS Algorithm and the ESC Algorithm were concordant in 170/172 patients (99% of the time). There were two patients (1%) with vascular disease, but no other thromboembolic risk factors, which were classified as requiring oral anticoagulant therapy using the ESC Algorithm, but for whom ASA was recommended by the CCS Algorithm. CONCLUSIONS: The CCS Algorithm appears to be unnecessarily complicated in so far as it does not appear to provide any additional discriminatory value above and beyond the use of the ESC Algorithm, and its use could result in under treatment of patients, specifically female patients with vascular disease, whose real risk of stroke has been understated by the Guidelines.

Identifying patients at low risk for activity-related events: the RARE Score.

PURPOSE: To prospectively assess whether the Risk of Activity Related Events (RARE) Score accurately identifies patients who are at low risk of experiencing an adverse event while exercise training at cardiac rehabilitation. METHODS: Individuals screened for entry into cardiac rehabilitation were classified as high-risk (RARE Score ≥ 4) or low-risk (RARE Score < 4) using the RARE Score. Patients were followed until program completion or withdrawal, and adverse events were documented. RESULTS: Individuals (n = 656) were eligible for analysis (high risk: n = 260; low risk: n = 396). Eleven events (1 major, 10 minor) were recorded during the study, and the overall event rate was low (1 event per 1321 patient hours of exercise training). Individuals triaged as high-risk had significantly more events than the low-risk cohort (high risk: n = 8 vs low risk: n = 3; P = .024) and were 4 times more likely to experience an adverse event (OR: 4.2; 95% CI: 1.0-20.0). More than 99% of low-risk patients were event free (negative predictive value: 99.2%; 95% CI: 98.3-99.8), while participating in exercise at cardiac rehabilitation. CONCLUSION: The RARE Score accurately identifies patients who are at low risk of experiencing adverse events during exercise training at cardiac rehabilitation. The identification of low-risk patients allows for the possibility of reduced on-site supervision and monitoring, or the provision of alternative models of cardiac rehabilitation, including community- or home-based cardiac rehabilitation programs.

High and low contact frequency cardiac rehabilitation programmes elicit similar improvements in cardiorespiratory fitness and cardiovascular risk factors.

AIM: Cardiac rehabilitation (CR) is a proven intervention that substantially improves physical health and decreases death and disability following a cardiovascular event. Traditional CR typically involves 36 on-site exercise sessions spanning a 12-week period. To date, the optimal dose of CR has yet to be determined. This study compared a high contact frequency CR programme (HCF, 34 on-site sessions) with a low contact frequency CR programme (LCF, eight on-site sessions) of equal duration (4 months). METHODS: A total of 961 low-risk cardiac patients (RARE score <4) self-selected either a HCF (n = 469) or LCF (n = 492) CR programme. Cardiorespiratory fitness and cardiovascular risk factors were measured on admission and discharge. RESULTS: Similar proportions of patients completed HCF (n = 346) and LCF (n = 351) (p = 0.398). Patients who were less fit (<8 METs) were more likely to drop out of the LCF group, while younger patients (<60 years) were more likely to drop out of the HCF group. Both groups experienced similar reductions in weight (-2.3 vs. -2.4 kg; p = 0.779) and improvements in cardiorespiratory fitness (+1.5 vs. +1.4 METs; p = 0.418). CONCLUSIONS: Patients in the LCF programme achieved equivalent results to those in the HCF programme. Certain subgroups of patients, however, may benefit from participation in a HCF programme, including those patients who are predisposed to prematurely discontinuing the programme and those patients who would benefit from increased monitoring. The LCF model can be employed as an alternative option to widen access and participation for patients who are unable to attend HCF programmes due to distance or time limitations.

Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation.

Equicaloric bouts of interval (IE: 5 × 2:2 min at 85% and 40% maximal oxygen uptake) and steady state (SS: 21 min at 60% maximal oxygen uptake) exercise were performed by 13 older prehypertensive males on separate days, at equivalent times of day, to assess the influence of exercise mode on postexercise hypotension (PEH). Exercise conditions were compared with a control session. Cardiovascular measures were collected for 30 min prior to, and 60 min following exercise. PEH, as measured by mean postexercise systolic blood pressure (SBP) decrease (IE: -4 ± 6 mm Hg; SS: -3 ± 4 mm Hg; control: 4 ± 4 mm Hg), area under the SBP curve (IE: -240 ± 353 mm Hg·min; SS: -192 ± 244 mm Hg·min), and minimum SBP achieved (IE: -15 ± 7 mm Hg; SS: -13 ± 7 mm Hg), was equivalent after both conditions. Stroke volume was significantly reduced (IE: -14.6 ± 16.0 mL; SS: -10.1 ± 14.2 mL, control -1.7 ± 2.2 mL) and heart rate was significantly elevated (IE: 13 ± 8 beats·min⁻¹; SS: 7.9 ± 8 beats·min⁻¹; control: -2 ± 3 beats·min⁻¹) postexercise after both conditions. Cardiac output and total peripheral resistance were nonsignificantly decreased and increased postexercise, respectively. Baroreflex sensitivity (BRS) was reduced following IE (p < 0.05) and heart rate variability (HRV) parameters were reduced after both conditions, with IE eliciting larger and longer reductions in some indices. The results from the current study indicate that older prehypertensive adults experience similar PEH following equicaloric bouts of IE and SS exercise despite larger alterations in HRV and BRS elicited by IE.