Journal of Cardiopulmonary Rehabilitation and Prevention最新文献

Purpose: Smoking cessation is challenging, and many patients entering cardiac rehabilitation (CR) continue to smoke. Those who smoke may experience less improvement during CR. This study examined improvements during CR based on smoking status.

Methods: Data were collected from patients enrolled between 2012-2021 at CR programs participating in a national registry. Patients were categorized by self-reported cigarette smoking status (current vs. former/never). Variables examined included patient characteristics (age, sex, race, educational attainment, insurance coverage, qualifying diagnosis, and body mass index), number of CR sessions attended, and baseline and change in psychological (depression/anxiety symptoms) and cardiorespiratory fitness (6-minute walk test distance [6MWT], max metabolic equivalent of task [MET]) measures. Baseline values were compared using Chi-square tests or unpaired t -tests as appropriate, and changes in outcome variables were examined using multivariable linear regression.

Results: Of the 447 921 patients, 34 656 (8%) reported current smoking at the time of entry. Current smoking was associated with younger age (58.8 vs. 66.9 years), lower socioeconomic status (Medicaid-enrolled, 11% vs. 3%), qualifying for CR due to myocardial infarction (42% vs. 26%), higher anxiety (50.0 vs. 45.3) and depression (6.5 vs. 4.6) scores, lower cardiorespiratory fitness at entry (max MET 3.4 vs. 3.6), and completing fewer CR sessions (17.7 vs. 23.3). Current smoking was independently associated with significantly less improvement in cardiorespiratory fitness (-17.6 meters in 6MWT distance and -0.26 in max MET) and worse depression scores at exit (0.53 higher).

Conclusions: Those who enter CR and are smoking are at high risk and may not benefit as much from CR as those who do not smoke. Continued effort must be placed on improving smoking cessation efforts within CR.

Purpose: To describe the design of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) national pulmonary rehabilitation (PR) registry and the demographic and clinical characteristics of enrolled participants.

Methods: We defined enrollment as attending at least 1 rehabilitation session. Participant characteristics are expressed as median (IQR) or number (%). We used participant zip codes to determine county of residence and created a heat map of participants per county in the continental US. In those aged 65 years and older, we compared participant characteristics with published data on Medicare beneficiaries.

Results: From 2013 to 2021, 70 085 individuals from 319 programs have enrolled. Median age is 70 years (63, 76), 52% are female, 78% are White, and 99% have health insurance. Comorbidities and a history of smoking are common. Chronic obstructive pulmonary disease, including emphysema and chronic bronchitis, is the primary admission diagnosis for 71% of enrollees. At least 1 participant resides in 42% of continental US counties, with more representation in counties from the upper Midwest and East Coast of the US. Demographic characteristics of those aged 65 years and older are similar to samples of Medicare beneficiaries.

Conclusions: The AACVPR PR registry provides a wealth of data to examine patient outcomes and quality of care in PR. Not surprisingly, non-White individuals, those with lower education levels, and those who are uninsured are underrepresented in the AACVPR PR registry, reflecting national trends.

Purpose: To describe the design of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) National Cardiac Rehabilitation (CR) registry and the demographic and clinical characteristics of enrolled participants.

Methods: We defined enrollment as attending at least 1 CR session. Participant characteristics are expressed as median (IQR) or number (%). We used participant zip codes to determine the county of residence and created a heat map of participants per county in the continental US. In those aged 65 years and older, we compared participant characteristics with published data on Medicare beneficiaries in CR.

Results: From 2012 to 2021, 489 507 individuals from 702 programs have enrolled. Median age is 67 years (59, 74), 70% are male, 77% are White, and 99% have health insurance. Cardiovascular risk factors, comorbidities, and use of secondary prevention medications are highly prevalent. A coronary artery disease-related diagnosis is the primary admission diagnosis for 78% of enrollees, while only 6% have a primary admission diagnosis of heart failure. At least 1 participant resides in 78% of continental US counties, with more representation in counties from the upper Midwest, East Coast, and southwestern US. Demographic characteristics of those aged 65 years and older are similar to the CR samples of Medicare beneficiaries.

Conclusions: The AACVPR CR registry provides a wealth of data to examine patient outcomes and quality of care in CR. Females, non-White individuals, those with heart failure, and those who are uninsured are underrepresented in the AACVPR CR registry, reflecting national trends.

Purpose: Patients with ischemia with no obstructive coronary arteries (INOCA) and myocardial infarction with no obstructive coronary arteries (MINOCA) may benefit from cardiac rehabilitation. Episodes of INOCA can be caused by different mechanisms including coronary microvascular dysfunction and coronary artery spasm, while episodes of MINOCA can be caused by plaque disruption (rupture or erosion), coronary artery spasm, or coronary embolism. Both conditions affect women more than men.

Review methods: The current review evaluates available evidence on exercise and cardiac rehabilitation in patients with INOCA and MINOCA.

Summary: Small studies have shown that exercise training can result in improvements in endothelial function, myocardial perfusion, exercise capacity, and overall wellbeing and quality of life in patients with INOCA. Structured cardiac rehabilitation programs have also been shown to improve symptoms of angina, physical functioning, and quality of life for patients with INOCA. Studies of cardiac rehabilitation among patients with MINOCA have found that only one third participate in cardiac rehabilitation, but among those who do, observational studies and a randomized controlled trial demonstrate a lower risk of major adverse cardiovascular events (such as all-cause mortality and nonfatal myocardial infarction) with cardiac rehabilitation. However, given that INOCA and MINOCA are conditions that predominantly affect women and may be caused by non-atherosclerotic mechanisms, tailoring of traditional cardiac rehabilitation programs (eg, education components) may be desirable to meet the specific needs of these patients. Future studies should explore the effectiveness of tailored cardiac rehabilitation programs with novel delivery methods to optimize programs for patients with INOCA and MINOCA.

Purpose: Evidence for optimal timing of pulmonary rehabilitation initiation, especially during stable chronic obstructive pulmonary disease (COPD) or following its acute exacerbation (AE), is conflicting.

Review methods: PubMed, EMBASE, and Cochrane CENTRAL were systematically searched before August 2022. The identified interventions were classified as single-component programs (endurance, resistance, and respiratory muscle training) and multi-component programs (combinations of these interventions). The revised risk-of-bias tool 2.0 was used to assess the risk of bias of the included studies. Network meta-analyses were performed separately for stable COPD and AECOPD using a random-effects model to calculate mean differences (MD). A total of 52 trials with 2,828 patients were included. For patients with stable COPD, multi-component programs combining endurance, resistance, and respiratory muscle training significantly improved the six-minute walk test (6MWT) distance (MD = 72.09: 95% CI, 48.16-96.02 meters) compared to usual care. In AECOPD, post-discharge initiation of rehabilitation with a combination of endurance and resistant training significantly reduced the readmission rate (OR = 0.44: 95% CI, 0.21-0.91); conversely, pre-discharge initiation with endurance training alone achieved the most significant improvements in both the readmission rate (OR = 0.09: 95% CI, 0.01-0.56) and 6MWT distance (MD = 167.69: 95% CI, 81.23-254.15 meters).

Summary: The integration of endurance, resistance, and respiratory muscle training improved exercise capacity in patients with stable COPD. Prioritizing endurance training prior to discharge demonstrated the most favorable outcomes in both readmission rates and exercise capacity for patients with AECOPD, although further validation is needed.

Purpose: Patients with heart failure with preserved ejection fraction (HFpEF) have significant impairments in patient-reported outcomes (PRO) including physical functioning and quality of life (QOL). We conducted a meta-analysis of randomized clinical trials of supervised exercise training (SET) to examine the efficacy of such training.

Methods: We included six single-blinded SET trials in patients with HFpEF, defined as a left ventricular EF ≥50%, published since 2010 in which participants were randomized to a facility-based exercise training program or usual care. We identified trials from a 2024 Cochrane review of exercise-based cardiac rehabilitation for adults with heart failure as well as other reviews and meta-analyses in PubMed. We used random effects meta-analysis to estimate the respective SET effects for five endpoints: the 36-Item Short Form Survey (SF-36) Physical Functioning Scale (PFS), the SF-36 Physical Component Summary, the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) total score, the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary Score, and the KCCQ QOL subscale.

Results: The treatment effect estimate favored SET for all five endpoints. However, the SET effect was only statistically significant for the SF-36 PFS ( P < .0001) and the MLWHFQ total score ( P = .01).

Conclusions: This meta-analysis demonstrated clear evidence that patient-reported physical functioning, an outcome that patients with HFpEF identify as a prominent disability, is significantly improved with SET. It also showed consistent improvements across several other multi-dimensional measures of QOL.

Purpose: Individuals with lower socioeconomic status (SES) are less likely to engage in cardiac rehabilitation (CR) following a major cardiac event. Identifying barriers to attending CR is crucial for facilitating recovery for this vulnerable population.

Methods: Data are from a randomized controlled trial on improving CR attendance for individuals with lower SES (N = 192; 35% female). Of these, 103 (40% female) were randomly assigned to a case management arm and included in the present analysis. Participants were recruited at or shortly after hospitalization for a CR-qualifying cardiac event and were asked about 1) their primary post-discharge concern (Concerns Assessment) and 2) eight potential barriers to CR attendance/secondary prevention (Barriers Assessment; medical, transportation, employment, financial, housing, psychosocial, childcare, legal). Concerns were sorted into these categories, and the frequency of each was calculated and ranked.

Results: Sixty-eight participants (66%) completed the Concerns Assessment, and 96 (93%) completed the Barriers Assessment. Health-related issues were the most common primary post-hospitalization concern (57%), followed by no concerns (16%). Financial (70%), employment (48%), and transportation (47%) issues were the three most cited barriers.

Conclusions: Participants most often rated their health as their primary concern at hospitalization, but non-medical needs were more often reported as barriers. The obstacles commonly identified in the present study are often not addressed during hospital admission. Hospitalization is a critical time for emergent treatment and is where support for on-going care should begin. Addressing these barriers before discharge is an important step toward improving secondary prevention.