Comparison of the improvement of flow-mediated dilatation in patients with acute coronary syndrome versus stable angina after six-month cardiac rehabilitation.

BACKGROUND: We investigated whether the improvement in endothelial function, measured using flow-mediated dilatation (FMD), an important predictor of cardiovascular outcomes, was comparable in acute coronary syndrome (ACS) versus stable angina patients after percutaneous coronary intervention (PCI) and a six-month cardiac rehabilitation (CR) programme. METHODS: We analysed the results from 119 patients who completed a six-month CR programme after successful PCI for stable angina (n = 50) and ACS (n = 69). RESULTS: After six months of CR, the results of FMD were significantly improved in both groups. There were no significant between-group differences in the FMD results at the six-month follow up. CONCLUSIONS: After successful PCI and a six-month CR programme, FMD values were equally improved in both stable angina and ACS patients.

Correlation between exercise, personal income level and health-related quality of life in patients with newly diagnosed stable angina.

BACKGROUND: Stable angina is one of the most common clinical types of coronary artery disease (CAD) and associated with poor health-related quality of life (HRQL). However, few studies have evaluated the risk factors associated with HRQL in patients with newly diagnosed stable angina. METHODS: A cross-sectional survey was conducted with 342 consecutive outpatients with newly diagnosed stable angina from October 2017 to January 2018 at the Second Affiliated Hospital of Army Medical University, Chongqing, China. Eight dimensions of HRQL were evaluated via the 36-item Short-Form Health Survey, including physical functioning, role limitation due to physical problems, bodily pain, general health, vitality, social functioning, role limitation due to emotional problems, and mental health. Physical and mental component summaries were calculated. Multiple stepwise regression was performed to determine the factors associated with HRQL. RESULTS: Patients who were older, were females, did not exercise, had lower educational levels, had lower monthly incomes, had smoking/drinking habits, and had diabetes, hypertension, or hyperlipemia showed lower physical HRQL scores, while those who were older with lower educational levels and lower monthly incomes showed lower mental HRQL scores. The results of the multiple stepwise regression analyses showed that physical and mental HRQL were positively correlated with exercise and monthly income and negatively associated with age. Patients with monthly income ≥5000 Yuan showed higher HRQL scores than those with monthly income < 5000 Yuan. Sleep quality and drinking were negatively associated with physical, but not mental HRQL. CONCLUSIONS: Our findings indicated that exercise and personal income level, both modifiable factors, were positively associated with physical and mental HRQL. These findings could have implications for clinical suggestions and strategies to improve HRQL in patients with stable angina.

Effects of Exercise Training With and Without Ranolazine on Peak Oxygen Consumption, Daily Physical Activity, and Quality of Life in Patients With Chronic Stable Angina Pectoris.

Ranolazine reduces angina frequency and increases exercise capacity. We hypothesized that exercise training with ranolazine would allow subjects to train at greater intensities, resulting in greater improvements in exercise capacity, physical activity, and health-related quality of life (HRQOL). In a pilot study, subjects with chronic stable angina pectoris were randomized to ranolazine (n = 13) or placebo (n = 16). After a 2-week drug titration period, subjects participated in a 12-week exercise program. Peak VO2, physical activity (via accelerometer), and HRQOL were assessed before and after training. After exercise training, peak VO2increased twice as much with ranolazine (2.1 ± 3.4 ml/kg/min) as with placebo (0.9 ± 1.5) (both p <0.05). After exercise training, both groups significantly improved HRQOL score (p <0.05); however, the improvement with ranolazine (19 ± 21) was almost 50% greater than with placebo (13 ± 18). There was a significant decrease in maximal heart rate after training with ranolazine but not with placebo (group difference, p = 0.04). Oxygen pulse (peak VO2/peak HR) increased in both groups after training; but, the increase was 4 times greater with ranolazine - resulting in a significant difference between groups (p = 0.044). In conclusion, patients with angina, the addition of ranolazine to an exercise program may improve aerobic fitness, physical activity, and HRQOL beyond the results of an exercise training program alone. Exercise training with ranolazine led to significantly greater increases in oxygen pulse, which is significantly correlated with stroke volume and is an independent predictor of mortality.

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

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

Exercise-based cardiac rehabilitation for adults with stable angina.

BACKGROUND: A previous Cochrane review has shown that exercise-based cardiac rehabilitation (CR) can benefit myocardial infarction and post-revascularisation patients. However, the impact on stable angina remains unclear and guidance is inconsistent. Whilst recommended in the guidelines of American College of Cardiology/American Heart Association and the European Society of Cardiology, in the UK the National Institute for Health and Care Excellence (NICE) states that there is "no evidence to suggest that CR is clinically or cost-effective for managing stable angina". OBJECTIVES: To assess the effects of exercise-based CR compared to usual care for adults with stable angina. SEARCH METHODS: We updated searches from the previous Cochrane review 'Exercise-based cardiac rehabilitation for patients with coronary heart disease' by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, DARE, CINAHL and Web of Science on 2 October 2017. We searched two trials registers, and performed reference checking and forward-citation searching of all primary studies and review articles, to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) with a follow-up period of at least six months, which compared structured exercise-based CR with usual care for people with stable angina. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias and extracted data according to the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors also independently assessed the quality of the evidence using GRADE principles and we presented this information in a 'Summary of findings' table. MAIN RESULTS: Seven studies (581 participants) met our inclusion criteria. Trials had an intervention length of 6 weeks to 12 months and follow-up length of 6 to 12 months. The comparison group in all trials was usual care (without any form of structured exercise training or advice) or a no-exercise comparator. The mean age of participants within the trials ranged from 50 to 66 years, the majority of participants being male (range: 74% to 100%). In terms of risk of bias, the majority of studies were unclear about their generation of the randomisation sequence and concealment processes. One study was at high risk of detection bias as it did not blind its participants or outcome assessors, and two studies had a high risk of attrition bias due to the numbers of participants lost to follow-up. Two trials were at high risk of outcome reporting bias. Given the high risk of bias, small number of trials and participants, and concerns about applicability, we downgraded our assessments of the quality of the evidence using the GRADE tool.Due to the very low-quality of the evidence base, we are uncertain about the effect of exercise-based CR on all-cause mortality (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.18 to 5.67; 195 participants; 3 studies; very low-quality evidence), acute myocardial infarction (RR 0.33, 95% CI 0.07 to 1.63; 254 participants; 3 studies; very low-quality evidence) and cardiovascular-related hospital admissions (RR 0.14, 95% CI 0.02 to 1.1; 101 participants; 1 study; very low-quality evidence). We found low-quality evidence that exercise-based CR may result in a small improvement in exercise capacity compared to control (standardised mean difference (SMD) 0.45, 95% CI 0.20 to 0.70; 267 participants; 5 studies, low-quality evidence). We were unable to draw conclusions about the impact of exercise-based CR on quality of life (angina frequency and emotional health-related quality-of-life score) and CR-related adverse events (e.g. skeletomuscular injury, cardiac arrhythmia), due to the very low quality of evidence. No data were reported on return to work. AUTHORS' CONCLUSIONS: Due to the small number of trials and their small size, potential risk of bias and concerns about imprecision and lack of applicability, we are uncertain of the effects of exercise-based CR compared to control on mortality, morbidity, cardiovascular hospital admissions, adverse events, return to work and health-related quality of life in people with stable angina. Low-quality evidence indicates that exercise-based CR may result in a small increase in exercise capacity compared to usual care. High-quality, well-reported randomised trials are needed to assess the benefits and harms of exercise-based CR for adults with stable angina. Such trials need to collect patient-relevant outcomes, including clinical events and health-related quality of life. They should also assess cost-effectiveness, and recruit participants that are reflective of the real-world population of people with angina.

Predictors of Suboptimal Gain in Exercise Capacity After Cardiac Rehabilitation.

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

Cardiac Rehabilitation: Improving Function and Reducing Risk.

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

Ivabradine in combination with beta-blocker reduces symptoms and improves quality of life in elderly patients with stable angina pectoris: age-related results from the ADDITIONS study.

BACKGROUND: Clinical trials have proven the anti-anginal and anti-ischemic efficacy of the pacemaker current inhibitor ivabradine in combination with beta-blockers in patients with stable angina pectoris (AP). This retrospective subgroup analysis of the ADDITIONS study evaluated the effectiveness and tolerability of ivabradine combined with beta-blockers, and its effects on angina symptoms and quality of life in elderly patients ≥ 75 years in everyday practice. METHODS: In the non-interventional, multicenter, prospective, open-label ADDITIONS study 2330 patients with stable AP of different age groups were treated with a flexible dose of ivabradine twice daily in addition to beta-blockers for 4 months. Heart rate (HR), number of angina attacks, nitrate consumption, tolerance, and quality of life (QoL) were evaluated. A subgroup analysis was performed, focusing on 479 patients (21%) ≥ 75 years. RESULTS: In these 479 patients ≥ 75 years ivabradine (mean dose 11.61 ± 3.18 mg per day) after 4 months of treatment reduced HR by 19.2 ± 11.6 bpm to 65.4 ± 8.3 bpm. The average number of angina attacks per week was decreased by 1.6 ± 1.8 to 0.4 ± 1.3 and the average consumption of short-acting nitrates per week was reduced by 2.2 ± 3.2 to 0.6 ± 1.8 units (both p < 0.0001). There was a marked shift in Canadian Cardiovascular Society (CCS) grade distribution with most patients (57%) now classified as CCS grade I, and 42% as CCS grades II and III. This was accompanied by an improvement in EQ-5D QoL index to 0.75 ± 0.22 (p < 0.0001). Tolerability of ivabradine treatment was rated by the physicians as "very good/good" for 72%/28% of elderly patients. CONCLUSIONS: In daily clinical practice, addition of ivabradine to beta-blockers was effective in reducing HR, angina attacks and nitrate consumption in elderly patients (≥ 75 years) with stable angina pectoris. In addition, a marked improvement of CCS symptom scores and QoL was demonstrated. Treatment was generally well tolerated.

Supervised exercise for acute coronary patients in primary care: a randomized clinical trial.

BACKGROUND: Functional capacity is a prognostic factor for coronary patients; accordingly, they are recommended to walk. OBJECTIVE: To assess whether an exercise program supervised in primary care increases their functional capacity more than unsupervised walking. METHODS: A randomized clinical trial was carried out at eight primary care centres of the Spanish Health Service and involving 97 incident cases of low-risk acute coronary patients, <80 years old, randomly assigned to either an unsupervised walking program (UW group; n = 51) or a 6-month cycle ergometer exercise program with gradually increasing frequency and workload intensity supervised by primary care nurses (SE group; n = 46). The two groups received the same common components of secondary prevention care. Changes in functional capacity were assessed in terms of peak oxygen consumption (VO2peak) during exercise testing measured at baseline and at 7 months by cardiologists blinded to group assignment. RESULTS: Overall, 76% of participants completed the study, 30 in the SE and 44 in the UW. Both groups increased baseline-adjusted VO2peak: 5.56ml/kg per minute in the SE (95% confidence interval [CI] 3.38-7.74) and 1.64ml/kg per minute in the UW (95% CI -0.15 to 3.45). The multivariate-adjusted difference between groups was 4.30ml/kg per minute (95% CI 1.82-6.79; P = 0.001) when analyzing completers and 2.83ml/kg per minute (95% CI 0.61-5.05; P = 0.01) in the intention-to-treat analysis, including all participants with baseline values carried forward for those lost to follow-up. CONCLUSIONS: A cycle ergometer exercise program supervised by primary care nurses increased the functional capacity of coronary patients more than unsupervised walking with a clinically relevant difference.

Cardiac rehabilitation uptake and its determinants in the Netherlands.

AIMS: Despite its documented efficacy, cardiac rehabilitation (CR) is still not well implemented in current clinical practice. The aims of the present study were to assess CR uptake rates in the Netherlands, and to identify factors that determine uptake. METHODS: The cohort consisted of persons insured with Achmea Zorg en Gezondheid. Based on insurance claims, we assessed CR uptake rates in 2007 among patients with an acute coronary syndrome (ACS), patients who underwent coronary artery bypass graft surgery, percutaneous coronary intervention (PCI), or valvular surgery, and patients with stable angina pectoris (AP) or chronic heart failure (CHF). In addition, we evaluated the relation between CR uptake and demographic, disease-related, and geographic factors for patients with an ACS and/or intervention. RESULTS: The CR uptake rate in the entire cohort (n = 35,752) was 11.7%. The uptake rate among patients with an ACS and/or intervention (n = 12,201) was 28.5%, as opposed to 3.0% among patients with CHF or stable AP (n = 23,551). The highest CR uptake rate was observed in patients who underwent cardiac surgery (58.7%). Factors associated with lower CR uptake were female gender, older age, elective PCI (as compared to acute PCI), unstable AP (as compared to myocardial infarction), larger distance to the nearest provider of CR, and comorbidity. CONCLUSION: A minority of Dutch patients eligible for CR received CR. Future implementation strategies should focus on females, elderly patients, patients with unstable AP and/or after elective PCI, patients with long travelling distances to the nearest CR provider, and patients with comorbidities.

Nitrates as an integral part of optimal medical therapy and cardiac rehabilitation for stable angina: review of current concepts and therapeutics.

The goals of optimal medical therapy in patients with stable angina pectoris are to reduce the risk of cardiovascular mortality and future cardiovascular events, improve exercise capacity, and enhance quality of life. Whereas myocardial revascularization is frequently employed in the management of patients with stable angina, a variety of pharmacologic interventions are recommended as part of optimal medical management. The use of short- and rapidly-acting nitrates (eg, sublingual nitroglycerin spray and tablets) is at the core of the therapeutic armamentarium and should be integrated into optimal medical therapy for stable angina along with exercise therapy. The potential clinical implications from these observations are that prophylactic sublingual nitrates, when combined with cardiac rehabilitation, may allow the patient with angina to exercise to a greater functional capacity than without sublingual nitrates.