The inability to perform a 6 minute walking test after cardio-thoracic surgery is a marker of clinical severity and poor outcome. Data from the ISYDE-2008 Italian survey

Functional limitation predicts mortality in heart failure with preserved ejection fraction

BACKGROUND

While the prognostic value of six-minute walking test (6MWT) in patients with heart failure (HF) and reduced ejection fraction has been firmly established, there are few or no data correlating the distance walked during 6MWT (6MWD) with mortality in patients with HF with preserved ejection fraction (HFpEF) METHODS: We studied 482 patients with HFpEF who had been admitted to inpatients cardiac rehabilitation. The primary outcome was 3-year all-cause mortality. The association between 6MWD and the primary outcome was assessed using multivariable models. Established risk markers were incorporated into the models.

RESULTS

174 patients died during the 3-year follow-up. Taking the highest tertile of 6MWD (≥360 m) as reference, the adjusted hazard ratio (HR) of the primary outcome was 2.23 (95 % CI 1.31-3.78; p = .003) for the patients in the intermediate tertile (241-359 m) and 4.94 (95 % CI 2.90-8.39; p < .001) for those in the lowest tertile (≤240 m). The annual mortality rate was 25.0 % in the lowest tertile, 10.9 % in the intermediate tertile, and 5.3 % in the highest tertile. When the distance walked was normalized for age, sex, and body mass index and expressed as percent-of-predicted walking distance, the adjusted HR was 1.30 (95 % CI 0.76-2.22; p = .331) for the patients in the intermediate tertile (58.2 % to 77.6 %) and 3.52 (95 % CI 2.12-5.85; p < .001) for those in the lowest tertile (≤58.1 %).

CONCLUSIONS

Our findings suggest that measuring functional capacity by evaluating the distance that a patient can walk over a period of 6 min provides important prognostic information in HFpEF.

Six-minute walk test distance at time of hospital discharge is strongly and independently associated with all-cause mortality following cardiac surgery

We investigated the impact of distance covered in the six-minute walk test (6mWT) before being discharged from the hospital after cardiac surgery on the risk of all-cause mortality. Our study included 1127 patients who underwent cardiac surgery and then took part in a standardised physiotherapist-supervised inpatient rehabilitation programme during 2007-2017. The percentage of the predicted 6mWT distance, and the lower limit of normal distance was calculated based on individual patients' age, sex, and body mass index. We used Cox regression with adjustment for confounders to determine multivariable-adjusted hazard ratios (HRs) for mortality. Over a median follow-up period of 6.4 (IQR: 3.5-9.2) years, 15% (n = 169) patients died. We observed a strong and independent inverse association between 6mWT distance and mortality, with every 10 m increase in distance associated to a 4% reduction in mortality (HR: 0.96, 95% CI 0.94-0.98, P < 0.001). Those in the top tertile for predicted 6mWT performance had a 49% reduced risk of mortality (HR: 0.51, 95% CI 0.33-0.79) compared to those in the bottom tertile. Patients who met or exceeded the minimum normal 6mWT distance had 36% lower mortality risk (HR: 0.64, 95% CI 0.45-0.92) compared to those who did not meet this benchmark. Subgroup analysis showed that combined CABG and valve surgery patients walked less in the 6mWT compared to those undergoing isolated CABG or valve surgeries, with a significant association between 6mWT and mortality observed in the isolated procedure groups only. In conclusion, the longer the distance covered in the 6mWT before leaving the hospital, the lower the risk of mortality.

Enhancing early functional independence following cardiac surgery: a quality improvement programme

Early mobility and activity programmes following cardiac surgery are vital for improved patient outcomes, as they accelerate the recovery of functional capacity and walking distance. We observed that only 5.3% of our patients achieved a Functional Independence Measurement (FIM) score of 80% or more by the third postoperative day (POD). Additionally, the average 6-minute walk distance achieved by the fourth POD was only 188 m. Therefore, a quality improvement (QI) project was implemented with the aim of attaining a FIM score of 80% by the third POD for more than 80% of patient underwent/undergoing cardiac surgery without complications.A model-for-improvement framework was used to drive continuous improvement. This project was implemented in February 2021. Baseline data were prospectively collected between November 2020 and January 2021 (preintervention). Outcomes were analysed using standard control chart rules to detect changes over time. Unpaired Student t-tests assessed significant differences in mean levels between two groups, (preintervention vs postintervention).χ2 tests were conducted between the two groups according to gender and patient satisfaction scores.The percentage of patients who achieved a FIM score of 80% or more by the third POD gradually increased to 91.4% 5 months following programme implementation and was sustained thereafter. The mean patient FIM score significantly improved to 81.20±3.77 (p<0.001) by the third POD. Similarly, the mean 6-minute walk distance increased to 267.90±36.10 m (p<0.001) by the fourth POD. The percentage of patients who displayed the level of confidence needed to carry out activities of daily living (ADL) and exercises independently at home increased to 89.4% (p<0.001) by the fifth POD. No adverse events associated with the mobility and activity programme were reported.This QI project demonstrated a substantial improvement in patient functional independence, walking distance and the level of confidence needed to independently carry out ADL and exercises following cardiac surgery.

Independent predictors and equation of six-minute walk test in post-cardiac surgery

BACKGROUND

The six-minute walk test (6MWT) has been used to evaluate postsurgical recovery in cardiac patients. No previous study has compared the 6MWT at follow-up with a baseline, or evaluated the long-term effects of cardiac surgery on post-discharge 6MWT OBJECTIVES: To identify the factors independently associated with 6MWD, and to develop an equation to predict 6MWT at the 4-6-week follow-up after post-cardiac surgery hospital discharge.

METHODS

Patient data of elective coronary artery bypass graft (CABG) or non-CABG surgery patients were retrospectively collected. The 6MWT was performed at hospital discharge and at the 4-6-week follow-up. Available demographic and clinical data of patients were analyzed to determine the independent factors of 6MWT. An equation to predict 6MWT were generated by forward stepwise multiple linear regression analysis.

RESULTS

The data of 275 patients (mean age: 62.20±14.57 years, 64.7% male) were analyzed. The mean 6MWT was 179.14±92.18 m at discharge, and increased to 335.20±115.51 m at the 4-6-week follow-up. The 6MWT at the 4-6-week follow-up was independently correlated with 6MWT at discharge, regular exercise, age, gender, and preoperative New York Heart Association (NYHA) classification.

CONCLUSION

The independent predictors: 6MWT at discharge, regular exercise, age, gender, and NYHA classification were used to generate an equation to predict 6MWT at 4-6 weeks after hospital discharge.

Six-minute walk test in cardiac rehabilitation

Six-minute walk test (6MWT) is a simple and safe tool for assessing exercise tolerance in  various  categories  of  patients.  Currently,  6MWT  is  used to assess the functional status of a patient and determine the strategy of increasing physical activity, primarily in patients with reduced exercise tolerance and contraindications for cardiopulmonary exercise  test. The basic requirements for the 6MWT are presented, taking into account the factors affecting its  informativeness  and  accuracy,  as  well  as the interpretation of results. The diagnostic and prognostic value of 6MWT in different categories of patients are discussed. The prospects for 6MWT use in cardiac rehabilitation for planning rehabilitation program, prescribing exercises,  determining  the  risk   of   complications,   and   evaluating the effectiveness  are  considered.  The  limitations  of  6MWT  and  ways to overcome it, as well as directions for further research are presented.

Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery: EXPERIENCE OF A CARDIOVASCULAR REHABILITATION PROGRAM

PURPOSE

This single-center retrospective analysis aimed to evaluate the prognostic relevance of 6-min walk test (6MWT) in patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery.

METHODS

One hundred one patients able to perform a 6MWT within the first week of admission (time after surgery: 16 ± 8 d) were included (age 68 ± 11 y; 55% female; median left ventricular ejection fraction 55% [interquartile range: 50-60]; 51% after aortic valve surgery). Study endpoints were cardiovascular death and the combined outcome of cardiovascular death/cardiac hospitalization. Univariate and multivariate analyses were performed to analyze predictive value of the 6MWT.

RESULTS

After a median follow-up of 27 mo, cardiovascular mortality was 9.9% while combined endpoint occurrence was 33%. Patients experiencing study endpoints had lower left ventricular ejection fraction, higher N-terminal prohormone of brain natriuretic peptide serum levels, and longer in-hospital stay (all P < .05). The 6MWT distance was a significant predictor of cardiovascular death (hazard ratio [HR] = 0.89, 95% CI: 0.81-0.97, P = .007) and cardiac hospitalizations (HR = 0.95, 95% CI: 0.90-0.99, P = .02). Even after adjusting for the relevant confounding variables of cardiovascular death and cardiac hospitalization, the adjusted HR = 0.88, 95% CI: 0.75-0.98, P = .028 and adjusted HR = 0.95, 95% CI: 0.90-0.99, P = .05, respectively.

CONCLUSIONS

In patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery, 6MWT proved to be an independent prognostic tool, potentially allowing identification of high-risk patients for whom a more intensive and tailored in-hospital cardiovascular rehabilitation program should be designed and implemented in order to avoid unfavorable cardiovascular events.

Factors Affecting Length of Stay in Adult Outpatient Physical Rehabilitation: A Scoping Review of the Literature

PURPOSE

To identify factors affecting length of stay (LOS) for adults participating in outpatient physical or occupational therapy programmes.

METHOD

A scoping review of the literature was conducted using the Ovid MEDLINE, EMBASE, CINAHL, AMED, and Cochrane Library databases.

RESULTS

A total of 19 articles were retained from the search, and 2 additional articles were retrieved from grey literature (i.e., non-published sources). Personal factors affecting LOS are age and sex, both of which had inconsistent effects on LOS, and communication, language, physical, and cognitive difficulties, for which higher levels of function were generally associated with shorter LOS. Institutional factors affecting LOS were location, interdisciplinary communication, number of disciplines involved, and type of rehabilitation setting. Finally, two clinician-related factors-fewer treatment goals and a selection of evidence-informed treatment techniques-were associated with shorter LOS.

CONCLUSIONS

Research on factors affecting adult outpatient rehabilitation LOS is limited and inconsistent. A preliminary list of LOS factors was produced, but this topic should be further explored with the collaboration of researchers and clinical institutions.

Prognostic value of physical function tests: hand grip strength and six-minute walking test in elderly hospitalized patients

To discern if physical function test are better mortality predictors than muscle mass in elderly hospitalized patients, we analyzed the prognostic value of muscle mass malnutrition and compared it with physical muscle function tests, including the six-minute walking test (6MWT) and hand grip strength. We included the ankle brachial index (ABI) to assess arterial disease, related to muscle atrophy due to hypoperfusion. We also analyzed the relationship of ABI with malnutrition, physical function tests and survival. We studied 310 hospitalized patients older than 60 years. To assess nutritional status, we determined BMI, triceps skinfold and mid-arm muscle area; we performed a subjective nutritional assessment; and evaluated the degree of inflammatory stress. We assessed physical function by hand grip strength and 6MWT. We evaluated arterial disease by ABI. Forty-one patients died during hospitalization; 269 were discharged and followed for a mean 808 days, reaching a mortality of 49%. Muscle malnutrition was frequent and was related to mortality, but the best predictors were physical function tests: inability to perform the 6MWT and low handgrip strength. Function tests were closely related to each other and correlated with nutritional data. Reduced ABI was related to impaired nutritional status, physical function tests and mortality.

Determinants of distance walked during the six-minute walk test in patients undergoing cardiac surgery at hospital discharge

Introduction

The aim of this study was to identify the determinants of distance walked in six-minute walk test (6MWD) in patients undergoing cardiac surgery at hospital discharge.

Methods

The assessment was performed preoperatively and at discharge. Data from patient records were collected and measurement of the Functional Independence Measure (FIM) and the Nottingham Health Profile (NHP) were performed. The six-minute walk test (6MWT) was performed at discharge. Patients undergoing elective cardiac surgery, coronary artery bypass grafting or valve replacement were eligible. Patients older than 75 years who presented arrhythmia during the protocol, with psychiatric disorders, muscular or neurological disorders were excluded from the study.

Results

Sixty patients (44.26% male, mean age 51.53 ± 13 years) were assessed. In multivariate analysis the following variables were selected: type of surgery (P = 0.001), duration of cardiopulmonary bypass (CPB) (P = 0.001), Functional Independence Measure - FIM (0.004) and body mass index - BMI (0.007) with r = 0.91 and r2 = 0.83 with P < 0.001. The equation derived from multivariate analysis: 6MWD = Surgery (89.42) + CPB (1.60) + MIF (2.79 ) - BMI (7.53) - 127.90.

Conclusion

In this study, the determinants of 6MWD in patients undergoing cardiac surgery were: the type of surgery, CPB time, functional capacity and body mass index.

Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: a nonrandomized controlled study

BACKGROUND

Exercise rehabilitation after cardiac surgery has beneficial effects, especially on a long-term basis. Rehabilitative programs with telemedicine plus appropriate technology might satisfy the needs of performing rehabilitation at home.

OBJECTIVE

The purpose of this study was to compare exercise capacity after home-based cardiac rehabilitation (HBCR) or in-hospital rehabilitation in patients at low to medium risk for early mortality (EuroSCORE 0-5) following cardiac surgery.

DESIGN

A quasi-experimental study was conducted.

METHODS

At hospital discharge, patients were given the option to decide whether to enroll in the HBCR program. Clinical examinations (electrocardiography, cardiac echo color Doppler, chest radiography, blood samples) of patients in the HBCR group were collected during 4 weeks of rehabilitation, and exercise capacity (assessed using the Six-Minute Walk Test [6MWT]) was assessed before and after rehabilitation. A group of patients admitted to the in-hospital rehabilitation program was used as a comparison group. Patients in the HBCR group were supervised at home by a medical doctor and telemonitored daily by a nurse and physical therapist by video conference. Periodic home visits by health staff also were performed.

RESULTS

One hundred patients were recruited into the HBCR group. An equal number of patients was selected for the comparison group. At the end of the 4-week study, the 2 groups showed improvement from their respective baseline values only in the 6MWT. No difference was found in time × group interaction.

LIMITATIONS

Because patients self-selected to enroll in the HBCR program and because they were enrolled from a single clinical center, the results of the study cannot be generalized.

CONCLUSIONS

In patients who self-selected HBCR, the program was found to be effective and comparable to the standard in-hospital rehabilitative approach, indicating that rehabilitation following cardiac surgery can be implemented effectively at home when coadministered with an integrated telemedicine service.