Neuromuscular electrostimulation: a new therapeutic option to improve radio-cephalic arteriovenous fistula maturation in end-stage chronic kidney disease patients.

BACKGROUND: Radio-cephalic arteriovenous fistula (RCAVF) is the gold standard vascular access for end-stage chronic kidney disease patients. Exercises after arteriovenous fistula (AVF) creation improve maturation. No articles are published regarding neuromuscular electrostimulation (NMES) in AVF maturation. OBJECTIVES: To assess the usefulness of a NMES programme on RCAVF maturation process. METHODS: An 8-week single-centre prospective study. Two groups were established: control group (CG): underwent usual RCAVF forearm exercises and electrostimulation group (ESG): underwent RCAVF NMES programme. Handgrip (HG) measurement, preoperative Doppler ultrasonography (DUS) parameters, clinical and DUS maturation as well as surgical complications were assessed. RESULTS: Thirty-six patients (54% men). Mean age 67.9 ± 14.3 years; 12 ESG and 24 CG. Demographic data, comorbidities, medical treatment, HG and DUS measurement at baseline were similar. HG increased in both groups at the end of the study (CG 24.5 ± 9.5 vs. 26.1 ± 10.1 kg, p 0.048; ESG 25.8 ± 10.3 vs. 26.3 ± 11.6 kg, p 0.644). RCAVF forearm vein diameter (CG 3.1 ± 0.7 vs. 5.7 ± 1.1 mm; ESG 2.9 ± 0.8 vs. 6.1 ± 1.7 mm) and humeral artery blood flow rate (CG 110.5 ± 20.7 vs. 1053.4 ± 510.7 ml/min; ESG 118.2 ± 31.6 vs. 954.1 ± 542.2 ml/min) statistically increased for both groups. A significant increase in clinical maturation in ESG (62.5 vs. 91.7%, p 0.046) at 8 weeks was observed. Four patients in each group developed juxta-anastomotic stenosis and were surgically repaired. No adverse NMES effects were registered. CONCLUSIONS: NMES of forearm muscles is a safe and effective technique to improve RCAVF maturation and constitutes a novel alternative to forearm isometrics exercises. Nevertheless, further studies are required to confirm the potential effect of NMES in the vascular access maturation process.

Clinical Utility of a New Predicting Score for Radiocephalic Arteriovenous Fistula Survival.

BACKGROUND: Radiocephalic arteriovenous fistula (RC-AVF) is the recommended first choice for vascular access (VA). The CAVeA2T2 scoring system was recently published (ipsilateral central venous catheter access, age >73 years, vein <2.2 mm, lower limb angioplasty, and absent intraoperative thrill). The aim of the present study was to assess the clinical utility of the CAVeA2T2 scoring system for predicting RC-AVFs survival in our center and its subsequent application in VA management. MATERIAL AND METHODS: In this single-center retrospective study, all RC-AVFs performed from January 2010 to July 2014 were included. The CAVeA2T2 was applied. Primary, assisted primary, and secondary patency rates were measured. RESULTS: Sixty RC-AVFs were analyzed. Mean age was 64.3 ± 14.7 years. Mean CAVeA2T2 score was 1.23 ± 1.2. The median fistula secondary patency was 13.7 ± 1.6 months. Secondary patency was at 6 weeks and at 6, 12, and 24 months: 88.3%, 66.7%, 55%, and 31.7%, respectively. Increasing score (≥2) was associated with a decrease in primary (log-rank, χ2 = 16.7, dif = 1, P = 0.0001) and secondary patency rate survival (log-rank, χ2 = 5.4, dif = 1, P = 0.0001). In addition, stratification of the CAVeA2T2 score into 3 groups (scores 0-1, 2, and 3+) retained its significance for primary (log-rank, χ2 = 19.4, dif = 2, P = 0.0001) and secondary patency rate survival (log-rank, χ2 = 5.5, dif = 2, P = 0.046) at the end of the study. CONCLUSIONS: In the present study, the CAVeA2T2 scoring system has proved to be a useful, easy to apply tool that is highly predictive of RC-AVF survival. Based on our results, we should avoid perform RC-AVFs, in those patients with CAVeA2T2 score ≥2 and late nephrology referral. Prospective studies should be designed to establish the management of patients with a higher CAVeA2T2 score.

Supervised versus non-supervised exercise in patients with recent myocardial infarction: A propensity analysis.

BACKGROUND: The influence of supervised versus non-supervised exercise training on outcome in patients with a recent myocardial infarction (MI) is controversial. DESIGN: Longitudinal observational study. METHODS: FRENA is an ongoing registry of stable outpatients with symptomatic coronary, cerebrovascular or peripheral artery disease. We compared the rate of subsequent ischaemic events (MI, ischaemic stroke or lower limb amputation) and the mortality rate in patients with recent MI, according to the use of supervised versus non-supervised exercise training. The influence of physical activity on outcomes was estimated by using propensity score method in multivariate analysis. RESULTS: As of February 2014, 1124 outpatients with recent MI were recruited, of whom 593 (53%) participated in a supervised exercise training programme. Over a mean follow-up of 15 months, 25 patients (3.3%) developed 26 subsequent ischaemic events - 24 MI, one stroke, one lower-limb amputation - and 12 (1.6%) died. The mortality rate (0.15 vs. 2.89 deaths per 100 patient-years; rate ratio = 0.05; 95% confidence interval, 0.01-0.39) was significantly lower in supervised exercise than in non-supervised exercise patients. On propensity score analysis, the rate of the composite outcome was significantly lower in supervised exercise patients (1.80 vs. 6.51 events per 100 patient-years; rate ratio = 0.28; 95% confidence interval, 0.12-0.64). CONCLUSIONS: The use of supervised exercise training in patients with recent MI was associated with a significant decrease in the composite outcome of subsequent ischaemic events and death.

Cardiac rehabilitation and outcome in stable outpatients with recent myocardial infarction.

OBJECTIVE: To compare the mortality rate and the rate of subsequent ischemic events (myocardial infarction [MI], ischemic stroke, or limb amputation) in patients with recent MI according to the use of cardiac rehabilitation or no rehabilitation. DESIGN: Longitudinal observational study. SETTING: Ongoing registry of outpatients. PARTICIPANTS: Patients (N=1043) with recent acute MI were recruited; of these, 521 (50%) participated in cardiac rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subsequent ischemic events and mortality rates were registered. RESULTS: Over a mean follow-up of 18 months, 50 patients (4.8%) died and 49 (4.7%) developed 52 subsequent ischemic events (MI: n=43, ischemic stroke: n=6, limb amputation: n=3). Both the mortality rate (.16 vs 5.57 deaths per 100 patient-years; rate ratio=.03; 95% confidence interval [CI], 0.0-0.1]) and the rate of subsequent ischemic events (1.65 vs 4.54 events per 100 patient-years; rate ratio=0.4; 95% CI, 0.2-0.7) were significantly lower in cardiac rehabilitation participants than in nonparticipants. Multivariate analysis confirmed that patients in cardiac rehabilitation had a significantly lower risk of death (hazard ratio=.08; 95% CI, .01-.63; P=.016) and a nonsignificant lower risk of subsequent ischemic events (hazard ratio=.65; 95% CI, .30-1.42). CONCLUSIONS: The use of cardiac rehabilitation in patients with recent MI was independently associated with a significant decrease in the mortality rate and a nonsignificant decrease in the rate of subsequent ischemic events.

Predictors of outcome in stable outpatients with peripheral artery disease.

Patients with peripheral artery disease (PAD) are at increased risk for subsequent ischemic events. We used data from the FRENA Registry to find predictors of subsequent myocardial infarction (MI), ischemic stroke, and limb amputation in stable outpatients with PAD. As of January 2012, 1,270 patients with PAD were recruited, of whom 1,042 (82 %) had Fontaine stage II; 113 (8.9 %) stage III; and 115 (9.1 %) stage IV. Over a mean follow-up of 14 months, 35 patients developed MI, 25 had stroke, 39 underwent limb amputation, and 91 died. Among patients with Fontaine stage II, the incidence of MI (2.09 events per 100 patient-years; 95 % CI 1.43-2.97) or stroke (0.93; 95 % CI 0.52-1.56) was similar to that of limb amputation (3.22; 95 % CI 2.37-4.29). On multivariate analysis, patients with diabetes [hazard ratio (HR) 2.09; 95 % CI 1.05-4.18], prior coronary disease (HR 5.35; 95 % CI 2.24-12.8), or atrial fibrillation (HR 3.11; 95 % CI 1.52-6.37) were at increased risk for MI; female (HR 2.94; 95 % CI 1.32-6.67), those with prior stroke (HR 5.21; 95 % CI 1.22-22.2) or atrial fibrillation (HR 3.37; 95 % CI 1.45-7.85) at increased risk for stroke; and female (HR 2.38; 95 % CI 1.23-4.55), those with diabetes (HR 3.50; 95 % CI 1.58-7.73) or advanced stages of PAD were at increased risk for limb amputation. Prior coronary artery disease, diabetes and atrial fibrillation predicted subsequent MI; female gender, prior stroke and atrial fibrillation predicted stroke; and female gender, diabetes, and advanced stages of PAD predicted limb amputation.

Alcohol consumption and outcome in stable outpatients with peripheral artery disease.

BACKGROUND: The influence of alcohol consumption on outcome in patients with peripheral artery disease (PAD) has not been thoroughly studied. METHODS: Factores de Riesgo y ENfermedad Arterial (FRENA) is an ongoing, multicenter, observational registry of consecutive stable outpatients with arterial disease. We compared the mortality rate and the incidence of subsequent ischemic events in patients with PAD, according to their alcohol habits. RESULTS: As of August 2010, 1073 patients with PAD were recruited, of whom 863 (80%) had intermittent claudication (Fontaine stage II), 102 (9.5%) had rest pain (Fontaine stage III), and 108 (10%) had ischemic skin lesions (Fontaine stage IV). In all, 422 patients (39%) consumed alcohol during the study period. Over a mean follow-up of 13 months, 150 patients (14%) developed subsequent ischemic events (myocardial infarction 28, stroke 30, disabling claudication/critical limb ischemia 100), and 70 patients (6.5%) died. The incidence of subsequent events was the same in both subgroups: 11.8 events per 100 patient-years (rate ratio: 1.00; 95% confidence interval [CI], 0.72-1.41), but the mortality rate was significantly lower in alcohol consumers than in non-consumers: 2.78 vs 6.58 deaths per 100 patient-years (rate ratio: 0.42; 95% CI, 0.23-0.74; P = .002). This better outcome was consistently found in patients with Fontaine stages II and III or IV, and persisted after multivariate adjustment (relative risk: 0.49; 95% CI, 0.28-0.88). CONCLUSIONS: In patients with PAD, moderate alcohol consumption was associated with lower cardiovascular mortality and overall mortality than abstention. These patients should be informed that low to moderate alcohol consumption may not be harmful to their health.