Journal of Cardiopulmonary Rehabilitation and Prevention最新文献

Purpose: Centers for Medicare and Medicaid Services-reimbursed clinical supervised exercise therapy (SET) programs for the treatment of peripheral artery disease (PAD) are in their infancy. This study evaluated the clinical effectiveness of guideline-directed exercise prescription that reflects current recommendations in SET and the influence of exercise modality on outcomes.

Methods: A retrospective chart review of patients with PAD enrolled in a Midwest clinical SET program between October 1, 2017 and December 31, 2022 was conducted. Patient demographic and medical characteristics, SET participation (including exercise modality, number of sessions completed, and attrition), and outcomes (6-minute walk test distance and Vascular Quality of Life Questionnaire-6) were abstracted. Outcomes were evaluated overall and by exercise modality (ie, treadmill only, total body recumbent stepping, and multimodality aerobic exercise).

Results: Four hundred patients with PAD completed ≥1 SET session during this period and were included in the present study. The enrolled sample was 88% non-Hispanic White, 39% female, and had a mean age of 71.2 ± 9.6 years and a mean ankle brachial index of 0.67 ± 0.23. Participants attended 17.6 (50%) of 36 sessions. Attendance (P =.52) and attrition (P =.15) were not significantly different among modalities. All groups experienced significantly increased 6-minute walk test distance (53.5 ± 4.5 m; P <.01) and Vascular Quality of Life Questionnaire-6 (3.03 ± 0.31, P <.01); baseline-adjusted between-group differences were not significant (P =.77 and P =.80, respectively).

Conclusions: Clinically implemented SET programs that follow current guidelines for exercise prescription improve walking capacity and quality of life in persons with symptomatic PAD. This study represents the first steps in the generation of program benchmarks for clinical SET programs.

Introduction: The benefits of pulmonary rehabilitation (PR) for patients with chronic obstructive pulmonary disease (COPD) are well-established, but data on the relative efficacy of PR in patients with interstitial lung disease (ILD) and prolonged symptoms from coronavirus disease-2019 (Long COVID) remain limited. With the increasing prevalence of Long COVID, understanding the role of PR in this group is essential.

Methods: Records of patients enrolled in PR between September 1, 2020, to November 30, 2022, at an academic health system were analyzed. Patients were categorized into COPD, ILD, and Long COVID groups based on primary referral diagnosis. Outcome measures included 6-minute walk test distance, COPD Assessment Tool, Modified Medical Research Council Questionnaire, and psychosocial assessments. Mixed-linear modeling for repeated measures compared pre- and post-PR outcomes within and across groups by referral diagnosis while adjusting for baseline covariates.

Results: Of the 316 patients enrolled in PR, 192 completed PR. Demographics were similar across groups, though patients with Long COVID were younger, more likely to be Hispanic, and have higher body mass index than patients referred for COPD. Significant improvements were observed in functional capacity, dyspnea, quality of life, depression, anxiety, and stress in all 3 groups following PR without significant between-group differences in PR outcomes.

Discussion: This single-center analysis suggests that PR was associated with significantly improved physical and psychosocial well-being in patients with COPD, ILD, and Long COVID with comparable outcomes across all groups. Future randomized-controlled trials are needed to confirm the benefits of PR for patients with Long COVID.

Purpose: Exercise stress tests (EST) are used to evaluate functional capacity before cardiac rehabilitation (CR). The prognostic value of EST to understand health outcomes in the year following an EST after participating in CR is not well understood.

Methods: We reviewed charts of 488 patients (females, n = 64) who underwent an EST within 100 days of starting CR. The outcomes of revascularization, rehospitalization, mortality, and the combination of revascularization or mortality were compared between patients with positive EST (n = 38), negative EST (n = 123), and nondiagnostic EST (n = 327).

Results: The positive EST group displayed significantly higher risk for revascularization or mortality within 1 year post-EST (HR = 13.6: 95% CI, 1.6-119.4; P =.018) compared with the negative EST group. Having a prior coronary artery bypass graft surgery independently increased the hazard of rehospitalization at 1 year (HR = 5.1: 95% CI, 1.9-13.5; P =.001) and the composite endpoint at 1 year (HR = 5.7: 95% CI, 1.6-19.7; P =.006) post-EST. The risk for rehospitalization in females (HR = 2.3: 95% CI, 1.0-5.3; P =.050) was greater than for males at 1 year, warranting future investigation into sex-based differences of long-term health outcomes post cardiac event.

Conclusions: The utility of EST for patients referred to CR has been debated, but our results demonstrate that EST may provide valuable information for prognosis and decision-making in cardiac care pathways.

Purpose: Expiratory flow limitation (EFL) and dynamic hyperinflation (DH) may significantly impact exercise capacity in patients with heart disease. Although commonly linked to lung diseases, recent evidence highlights their role in cardiovascular disease (CVD), contributing to exercise intolerance. This systematic review examines studies from the past decade on pulmonary function during exercise, measured using inspiratory capacity (IC) maneuvers, in patients with CVD, emphasizing prevalence and clinical significance.

Review methods: A systematic literature search in PubMed, Scopus, and Cochrane (January 2014-February 2024) explored pulmonary function during exercise in patients with CVD. Two independent reviewers assessed studies using established Quality Assessment Tools.

Summary: Seven studies including 231 patients with CVD (mean age 31-66 yr, predominantly male) used cardiopulmonary exercise testing to evaluate exercise-induced DH or EFL with varying definitions. Study quality was mixed. Patients with myocardial infarction showed EFL at moderate exercise, while patients with stable coronary artery disease exhibited EFL only at high intensities. Up to 50% of patients with pulmonary arterial hypertension have DH during peak exercise (P < .05). In patients with heart failure, 25% experienced DH, while others maintained stable breathing. Patients who are post-Fontan displayed pulmonary inefficiencies without DH. Methodological variability precludes definitive conclusions on DH prevalence in patients with CVD. However, reduced IC during exercise, DH, and EFL occur in a substantial proportion of patients, indicating a lower EFL threshold and earlier ventilatory constraints. Further research into heart-lung integration during exercise is crucial for developing personalized treatments and improving clinical management in those patients.

Purpose: Literature on early mobilization and exercise training in patients recovering from acute heart failure (AHF) is promising. However, there lacks uniformity in the time of initiation, exercise prescription, safety criteria, and termination criteria. Thus, the aim was to develop a mobilization algorithm for patients recovering from AHF.

Methods: A modified web-based Delphi process was undertaken involving 15 panelists from across the globe. In Round 1, new variables, modifications to suggested variables, and agreement-disagreement within the panelists were obtained. In Round 2, agreement on a 5-point Likert scale was obtained. In Round 3, the algorithm was compiled, and excluded statements were discussed via web-based calls. The new variables were grouped into themes via an inductive process. The level of agreement and rating for each statement were analyzed using descriptive statistics, including frequency and percentages. We used Kappa statistics to examine the level of agreement between the panelists for each criterion. The consensus criterion was defined a priori as statements with a mean rating of ≥4 on the 5-point Likert scale by ≥70% of the panelists and Kendall's coefficient of concordance ( W ) of ≥0.3 between panelists.

Results: From Round 1, 54 new variables were obtained. More than two-thirds (118/170, 69%) of statements reached consensus and reported a fair level of agreement between panelists ( W ≥ 0.3). The final algorithm with all its criteria received a 100% (13/13) consensus.

Conclusion: Physician-referral criteria, physiotherapy assessment process, exercise prescription, safety criteria, and termination criteria were formulated for early mobilization and exercise training for patients recovering from AHF.

Purpose: Despite the 2022 American Heart Association/American College of Cardiology guidelines recommending cardiac rehabilitation (CR) after aortic dissection repair, both patient participation in CR and the associated clinical outcomes remain poorly understood.

Methods: Adults (≥18 years of age) discharged alive following thoracic aortic dissection surgery across the Mayo Clinic Enterprise (January 2012 to November 2022), with follow-up until May 2024, were included (IRB #24-001141). Data were presented using summary statistics and logistic regression modeling.

Results: A total of 186 patients were referred; 37% were female, and the median age was 64 (51, 73) years. Dissections were classified as type A (43%), type B (18%), or a combination, and 55% had residual dissection. Over half (53%) did not start CR, with older age (aOR = 0.97: 95% CI, 0.94 - 0.99; P = .003), family history of aortic dissections and/or aneurysms (aOR = 0.17: 95% CI, 0.04 - 0.54; P = .005), and tobacco use (aOR = 0.35: 95% CI, 0.13 - 0.91; P = .037) being associated with lower odds of enrollment. Of the 87 who enrolled, 34 did so at a Mayo Clinic facility. There were no complications, with no difference in adverse outcomes. Among those with evaluations at graduation from CR (n = 21), quality of life (Dartmouth index 16 [14, 19] vs 25 [22, 30]; P = .002) and 6-minute walk distance (488 [375, 531] vs 302 [235, 398] m; P = .001) improved.

Conclusions: Following thoracic aortic dissection repair, CR significantly improved quality of life and functional capacity without adverse events. Further work is needed to improve enrollment and establish data-driven safety margins for exercise.

Purpose: Lifestyle and social frailty factors are a new focus in the multidimensional concept of frailty, as recent reports have found strong associations with negative health outcomes. We searched for specific social and lifestyle frailty factors independently associated with 5-year survival and the risk of hospitalization in patients with severe chronic obstructive pulmonary disease (COPD).

Methods: We retrospectively analyzed questionnaire data from the National Emphysema Treatment Trial (NETT) and identified items related to the published definition of social frailty. Classification and Regression Tree, a machine learning method, was used to select variables most strongly associated with survival time or hospitalizations beyond 12 months of NETT study enrollment. Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models were used to determine relationships between social/lifestyle variables and hospitalization and survival.

Results: Four social and lifestyle frailty factors were significantly related to survival (impaired lifting, bathing and dressing, in-store shopping, and loneliness). Two social and lifestyle frailty factors were significantly related to risk of hospitalization (emotional distress and difficulty performing work or activities). A combination of 6 questions provided clinical phenotypes that were robustly and independently associated with mortality risk and hospitalization with hazard ratios that ranged from 2.4 to 11.2 and 2.2 to 3.5 for survival and hospitalization, respectively, after adjustment for age, sex, disease severity, and physical frailty.

Conclusion: Lifestyle and social frailty factors that could be easily identified in practice may represent a novel approach to a multidimensional frailty assessment to predict survival and hospitalization in patients with severe COPD.

Purpose: To examine 12-month maintenance of physical and psychosocial benefits achieved during the veterans affairs (VA) home-based cardiac rehabilitation (HBCR) program.

Methods: Using a retrospective, observational design, data were collected from 16 HBCR VA sites. Analyses included participants with data on enrollment, program completion, and 12-month follow-up. Changes over time were examined using repeated measures ANOVA. Logistic regression was used to examine the patient's primary referral diagnosis for enrollment and baseline AACVPR risk stratification category, to predict cardiac-related hospitalization and emergency department (ED) visits at 12 months.

Results: Of the 572 patients who completed the program, 208 patients (36%) had data at all three time points. Most participants were White males with a mean age of 69.5 ± 8.2 years. Approximately half of the included participants (n = 99) were classified as high risk at enrollment. Over 12 months, several significant improvements were found (P ≤.05), including exercise capacity, depression (Patient Health Questionnaire-9 scores and American Association of Cardiovascular and Pulmonary Rehabilitation criteria), self-reported cardiac self-efficacy (understanding of managing heart disease), eating habits (Rate Your Plate, Heart Assessment), weight, diastolic blood pressure, and high-density lipoprotein cholesterol levels. Fourteen percent (n = 30) of participants had one or more cardiac-related ED visits, and 14% (n = 29) of participants had one or more cardiac-related hospitalizations.

Conclusions: Home-based models have been proven to be a safe and effective alternative to on-site programs. Our findings demonstrate maintenance of health benefits at 12 months following a home-based model. Future analysis of the HBCR model is necessary to evaluate maintenance improvements in those participants who did not receive additional follow-up appointments.

Purpose: To investigate (1) the relationship between socioeconomic status of patients with acute coronary syndrome and participation in cardiac rehabilitation and (2) the relationship between patient participation stratified by socioeconomic status and their outcomes at 12 months.

Methods: Analyzed data were from the CONCORDANCE registry. Patients were stratified (quintiles) according to the National Index of Relative Socio-Economic Disadvantage. The odds of a major adverse cardiovascular event (MACE; defined as heart failure, myocardial infarction, stroke, or cardiac-cause death) and separately all-cause death between hospital discharge and 12 months were analyzed using multilevel logistic regression models, adjusting for clinical history and hospital clustering.

Results: Of 3787 patients referred to cardiac rehabilitation, followed up at 6 and 12 months, 1834 (48%) participated in cardiac rehabilitation. Participation rate was higher among patients in least socioeconomically disadvantaged quintiles (Q5 [least disadvantaged]: 61%, Q4: 53%, Q3: 42%, Q2: 47%, Q1 [most disadvantaged]: 42%). The odds of MACE were not different between participants and non-participants (6% vs 8%, OR = 0.87: 95% CI, 0.66-1.15). However, the odds of death were lower among participants than non-participants (0.4% vs 2%, OR = 0.35: 95% CI, 0.16-0.78). The association between participation and MACE and death did not differ by socioeconomic status ( Pinteraction = .6943 and Pinteraction = .6339, respectively).

Conclusions: Although patient socioeconomic status may influence their participation rates in cardiac rehabilitation, no significant differences were observed in the relationships between participation and MACE or mortality at 12 months across socioeconomic groups. Targeted strategies are needed to improve participation rates across all socioeconomic groups.