Validating the 6-minute walk test as an indicator of recovery in patients undergoing cardiac surgery: A prospective cohort study

The effect of a selenium-based anti-inflammatory strategy on postoperative functional recovery in high-risk cardiac surgery patients - A nested sub-study of the sustain CSX trial

AIM

The cardiac surgery-related ischemia-reperfusion-related oxidative stress triggers the release of cytotoxic reactive oxygen and nitrogen species, contributing to organ failure and ultimately influencing patients' short- and long-term outcomes. Selenium is an essential co-factor for various antioxidant enzymes, thereby contributing to the patients' endogenous antioxidant and anti-inflammatory defense mechanisms. Given these selenium's pleiotropic functions, we investigated the effect of a high-dose selenium-based anti-inflammatory perioperative strategy on functional recovery after cardiac surgery.

MATERIALS AND METHODS

This prospective study constituted a nested sub-study of the SUSTAIN CSX trial, a double-blinded, randomized, placebo-controlled multicenter trial to investigate the impact of high-dose selenium supplementation on high-risk cardiac surgery patients' postoperative recovery. Functional recovery was assessed by 6-min walk distance, Short Form-36 (SF-36) and Barthel Index questionnaires.

KEY FINDINGS

174 patients were included in this sub-study. The mean age (SD) was 67.3 (8.9) years, and 78.7 % of the patients were male. The mean (SD) predicted 30-day mortality by the European System for Cardiac Operative Risk Evaluation II score was 12.6 % (9.4 %). There was no difference at hospital discharge and after three months in the 6-min walk distance between the selenium and placebo groups (131 m [IQR: not performed - 269] vs. 160 m [IQR: not performed - 252], p = 0.80 and 400 m [IQR: 299-461] vs. 375 m [IQR: 65-441], p = 0.48). The SF-36 and Barthel Index assessments also revealed no clinically meaningful differences between the selenium and placebo groups.

SIGNIFICANCE

A perioperative anti-inflammatory strategy with high-dose selenium supplementation did not improve functional recovery in high-risk cardiac surgery patients.

Effect of Adding Early Bedside Cycling to Inpatient Cardiac Rehabilitation on Physical Function and Length of Stay After Heart Valve Surgery: A Randomized Controlled Trial

OBJECTIVE

To assess whether adding bedside cycling to inpatient cardiac rehabilitation (CR) early after heart valve surgery could lead to better physical function and shorter length of hospital stays.

DESIGN

This is a single-centered, randomized, controlled, parallel-group intervention study.

SETTINGS

This study was conducted at the National Heart Institute from December 2022 to June 2023.

PARTICIPANTS

Thirty-one patients following heart valve surgery completed this study after being randomized into 2 groups: an intervention group (n1=16) and an active control group (n2=15). Eligibility criteria were heart valve surgery with median sternotomy, clinical stability, and age from 20 to 40 years.

INTERVENTIONS

The intervention group received early bedside cycling for the lower limbs, using a mini bike, in addition to an inpatient CR program, and the control group received the inpatient CR program alone.

MAIN OUTCOME MEASURE

The primary outcome was the physical functional capacity assessed by the 6-minute walk distance (6MWD). The secondary outcomes were the Barthel Index (BI), the forced vital capacity (FVC), the length of intensive care unit (ICU) stay, the total length of hospital stay, and the physical component summary (PCS) of the 12-item Short Form (SF-12) Health Survey.

RESULTS

Compared with the control group, the intervention group showed significantly greater 6MWD (P<.001), BI score (P<.001), and FVC (P=.006) at hospital discharge, and shorter ICU stay (P=.002) and total hospital stay (P=.015). At 1-month follow-up, the intervention group showed a non-significantly higher PCS mean score than the control group (P=.057).

CONCLUSION

Adding early bedside cycling to a usual inpatient CR program after heart valve surgery could induce significantly greater short-term physical functional capacity as assessed by the 6MWD, better activities of daily living as evaluated by the BI, higher pulmonary function as measured by the FVC, and shorter lengths of ICU and total hospital stays than the usual inpatient CR program alone.

The prevalence and impact of sarcopenia in older cardiac patients undergoing inpatient cardiac rehabilitation - results from a prospective, observational cohort pre-study

BACKGROUND

The prevalence of sarcopenia and its impact in older patients undergoing inpatient cardiac rehabilitation (iCR) after cardiac procedure has been insufficiently studied. The main aim of this study was to evaluate the prevalence of sarcopenia and quantify the functional capacity of older sarcopenic and non-sarcopenic patients participating in iCR.

METHODS

Prospective, observational cohort study within the framework of the ongoing multicenter prehabilitation study "PRECOVERY". A sample of 122 patients ≥75 years undergoing iCR after cardiac procedure were recruited in four German iCR facilities and followed up 3 months later by telephone. At iCR (baseline), the Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) questionnaire was used to identify sarcopenic patients. In addition, Katz-Index, Clinical Frailty Scale (CFS), handgrip strength (HGS), Short Physical Performance Battery (SPPB) and 6-minute walk distance (6MWD) measured functional capacity and frailty at baseline. Outcomes were prevalence of sarcopenia and the correlation of sarcopenia to functional capacity and frailty at baseline as well as the SARC-F score at follow-up. The Wilcoxon test was applied for pre-post-test analysis. Correlation between sarcopenia and 6MWD, SPPB score and HGS was tested with the eta coefficient with one-way ANOVA.

RESULTS

Complete assessments were collected from 101 patients (79.9 ± 4.0 years; 63% male). At baseline, the mean SARC-F score was 2.7 ± 2.1; 35% with sarcopenia. Other baseline results were Katz-Index 5.7 ± 0.9, CFS 3.2 ± 1.4, HGS 24.9 ± 9.9 kg, SPPB score 7.5 ± 3.3 and 6MWD 288.8 ± 136.5 m. Compared to baseline, fewer patients were sarcopenic (23% versus 35%) at follow-up. In the subgroup of sarcopenic patients at baseline (n = 35), pre-post comparison resulted in a significant SARC-F improvement (p = 0.017). There was a significant correlation between sarcopenia measured by SARC-F and poor results in the assessments of functional capacity (p < 0.001; r > 0.546).

CONCLUSIONS

The prevalence of sarcopenia in older patients at iCR after cardiac procedure is high (35%) and remains high at follow-up (23%). Sarcopenia screening is important since the diagnosis of sarcopenia in these patients correlates significantly with poor functional capacity. The results indicate that these patients may benefit from prehabilitation aimed at improving perioperative outcomes, increasing functional capacity and mitigating adverse effects.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS; http://www.drks.de ; DRKS00032256). Retrospectively registered on 13 July 2023.

Elective Cardiac Procedure Patients Have Low Preoperative Cardiorespiratory Fitness

Preoperative cardiorespiratory fitness may influence the recovery after cardiac procedure. The aim of this study was to investigate the cardiorespiratory fitness of patients scheduled for elective cardiac procedures, using a six-minute walk test, and compare the results with a population-based sample of Finnish adults. Patients (n=234) awaiting percutaneous coronary intervention or coronary angiography, coronary artery bypass grafting, aortic valve replacement or mitral valve surgery performed the six-minute walk test. VO2max was calculated based on the walk test. The patients were compared to a population-based sample of 60-69-year-old Finnish adults from the FinFit2017 study. The mean six-minute walk test distances (meters) and VO2max (ml/kg/min) of the patient groups were: 452±73 and 24.3±6.9 (coronary artery bypass grafting), 499±84 and 27.6±7.2 (aortic valve replacement), 496±85 and 27.4±7.3 (mitral valve surgery), and 519±90 and 27.3±6.9 (percutaneous coronary intervention or coronary angiography). The population-based sample had significantly greater walk test distance (623±81) and VO2max (31.7±6.1) than the four patient groups (all p-values<0.001). All patient groups had lower cardiorespiratory fitness than the reference population of 60-69-year-old Finnish adults. Particularly the coronary artery bypass grafting group had a low cardiorespiratory fitness, and therefore might be prone to complications and challenging rehabilitation after the operation.

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.

Factors Affecting Recovery of 6-Minute Walk Distance After Coronary Artery Bypass Grafting

Background: This single-center retrospective analysis investigated the number of days required for postoperative 6-minute walk distance (6MWD) to recover to preoperative values after coronary artery bypass grafting (CABG) and the factors influencing this recovery. Methods and Results: The 6MWD was measured in 101 patients (median age 69 years; 18 women) before and every day after CABG. Univariate and multivariate analyses were performed to identify factors affecting 6MWD recovery to preoperative values after CABG. The median number of days required for recovery of 6MWD after CABG was 9 (interquartile range 7-11 days). Patients were divided into 2 groups based on the median number of days required for recovery of 6MWD; there were 60 patients in the early recovery group (<9 days) and 41 in the "non-early" recovery group (38 who recovered after the median 9 days, and 3 who did not recover during hospitalization). Using univariate logistic regression analysis, diabetes (P=0.01), stroke (P=0.26), left ventricular ejection fraction (P=0.27), and grip strength (P=0.13) were selected for multivariate analysis. Multivariate logistic regression analysis revealed that diabetes (odds ratio 2.955; 95% confidence interval 1.208-7.229; P=0.02) was the only independent predictor of 6MWD recovery. Conclusions: Diabetes was the single factor influencing the recovery of postoperative 6MWD in patients undergoing CABG.

A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance from baseline to pre-operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre-specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre-operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in-hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0-25.1)). Six-minute walk test was not significantly different between groups (mean difference (95%CI) -7.8 m (-30.6-15.0), p = 0.503) in the intention-to-treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six-minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time-points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH₂ O (4.6-16.6) cmH₂ O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre-operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six-minute walk test distance pre-operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.

Inspiratory Muscle and Functional Performance of Patients Entering Cardiac Rehabilitation after Cardiac Valve Replacement

Limited research has examined inspiratory muscle performance (IMP) and functional performance (FP) of patients after valve replacement surgery (VRS). The purpose of this study was to examine IMP as well as several measures of FP in patients post-VRS. The study results of 27 patients revealed that patients undergoing transcatheter VRS were significantly (p = 0.01) older than patients undergoing minimally invasive or median sternotomy VRS with the median sternotomy VRS group performing significantly (p < 0.05) better than the transcatheter VRS group in the 6-min walk test, 5x sit-to-stand test, and sustained maximal inspiratory pressure. The 6-min walk test and IMP measures in all groups were significantly (p < 0.001) lower than predicted values. Significant (p < 0.05) relationships were found between IMP and FP with greater IMP being associated with greater FP. Pre-operative and early post-operative rehabilitation may improve IMP and FP post-VRS.

Wearable Activity Trackers Objectively Measure Incidental Physical Activity in Older Adults Undergoing Aortic Valve Replacement

BACKGROUND

For older adults with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR), recovery of physical function is important, yet few studies objectively measure it in real-world environments. This exploratory study explored the acceptability and feasibility of using wearable trackers to measure incidental physical activity (PA) in AS patients before and after AVR.

METHODS

Fifteen adults with severe AS wore an activity tracker at baseline, and ten at one month follow-up. Functional capacity (six-minute walk test, 6MWT) and HRQoL (SF 12) were also assessed.

RESULTS

At baseline, AS participants (n = 15, 53.3% female, mean age 82.3 ± 7.0 years) wore the tracker for four consecutive days more than 85% of the total prescribed time, this improved at follow-up. Before AVR, participants demonstrated a wide range of incidental PA (step count median 3437 per day), and functional capacity (6MWT median 272 m). Post-AVR, participants with the lowest incidental PA, functional capacity, and HRQoL at baseline had the greatest improvements within each measure; however, improvements in one measure did not translate to improvements in another.

CONCLUSION

The majority of older AS participants wore the activity trackers for the required time period before and after AVR, and the data attained were useful for understanding AS patients' physical function.

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.

Effect of minimally invasive cardiac surgery compared with conventional surgery on post-operative physical activity and rehabilitation in patients with valvular heart disease

Background

Minimally invasive cardiac surgery (MICS) has steadily become more and more popular. MICS is less invasive and has a faster return to normality after surgery. Patients who had MICS continue to exercise more frequently than those who had the conventional median sternotomy surgery. It is generally established that physical activity lowers mortality and the risk of cardiac disease. The purpose of the study: is to evaluate and compare physical activity levels in MICS and conventional surgery.

Result

The level of preoperative physical activity did not significantly differ between the two groups. However, the MICS group significantly exceeded the conventional group in terms of postoperative progress, amount of physical activity, and 6-minute walking test. Also, Visual Analog Scale (VAS) score was significantly less.

Conclusion

Minimally invasive cardiac surgery has a higher margin of benefit, and speedy recovery to normality, which is accompanied by a lower VAS score and increased physical activity in comparison to conventional surgery.

Preoperative 6-minute walk test predicts prolonged hospitalization after transcatheter tricuspid valve replacement

The purpose of this study is to determine whether preoperative 6-minute walk test (6MWT) is associated with prolonged postoperative hospitalization in high risk patients with severe tricuspid regurgitation (TR) after transcatheter tricuspid valve replacement (TTVR). Forty-one patients with severe TR who underwent TTVR and discharged between September 2018 and April 2021 were enrolled in this study. Patients were divided into 2 groups according to whether the postoperative hospital stay was >10 days and patients' data were retrospectively collected. 6MWT was performed before operation. Twenty-one patients were in the control group (≤10 days) and 20 patients were in the prolonged postoperative stay (PPS) group (>10 days). 6MWT distance was significantly decreased in PPS group (192.70 ± 62.34 vs 274.57 ± 52.09 m, P < .05). PPS group had more patients with severe liver disease (50.00% vs 19.05%, P < .05), higher systolic pulmonary artery pressure (45.05 ± 9.28 vs 35.57 ± 8.91 mm Hg, P < .05) and longer procedure time (159.85 ± 56.61 vs 124.43 ± 31.67 min, P < .05). Multivariable logistic regression analysis found 6MWT <267 m was an independent risk factor with the odds ratio of 10.95 (1.66-72.39, P < .05) for prolonged postoperative hospitalization in patients who received TTVR. In the present study, we identified that preoperative decreased 6MWT distance was an independent risk factor for prolonged hospitalization in high risk TR patients after TTVR.

Subjective and objective assessments are associated for physical function but not cognitive function in community-dwelling stroke survivors

PURPOSE

To investigate the relation between subjectively and objectively assessed cognitive and physical functioning among community-dwelling stroke survivors, and to examine the association of stroke severity with subjectively and objectively assessed cognitive and physical impairments.

MATERIALS AND METHODS

Secondary data analysis was conducted with 127 community-dwelling stroke survivors. For cognitive functioning, objective measures included the NIH Toolbox Cognition Battery and the Executive Function Performance Test; subjective measures included the Quality of Life in Neurological Disorders Applied Cognition. Objective and subjective physical functioning was measured by the NIH Toolbox 2-Minute Walk Test and the Patient-Reported Outcomes Measurement Information System Physical Function, respectively.

RESULTS

A positive correlation was observed between subjective and objective physical functioning, whereas the correlation between subjective and objective cognitive functioning was nonsignificant. Stroke severity was associated with objective cognitive impairment and objective and subjective physical impairment, but not subjective cognitive impairment.

CONCLUSIONS

The lack of association between objective and subjective cognitive functioning challenges the conventional assumption that perceived functioning reflects actual performance. We recommend using both objective and subjective measures to accurately identify cognitive and physical impairment following stroke.Implications for RehabilitationSubjective cognitive functioning is not associated with objective cognitive functioning, suggesting that solely relying on stroke patients' reports is inadequate and may inaccurately estimate patients' actual deficits.Both objective and subjective measures should be used to accurately identify cognitive and physical impairment following stroke.Practitioners should be cognizant of stroke patients' behavioral signs associated with underlying cognitive problems that warrant further evaluation.

Clinically Meaningful Change in 6 Minute Walking Test and the Incremental Shuttle Walking Test following Coronary Artery Bypass Graft Surgery

The 6-min walk test (6MWT) and incremental shuttle walk test (ISWT) are widely used measures of exercise tolerance, which depict favorable performance characteristics in a variety of cardiac and pulmonary conditions. Both tests are valid and reliable method of assessing functional ability in cardiac rehabilitation population. Several studies have calculated the minimal clinically important difference (MCID) of these exercise tests in different populations. The current study aims to estimate MCID of 6MWT and ISWT in patients after Coronary artery bypass graft (CABG) surgery. In this descriptive observational study, nonprobability purposive sampling technique was used to assess 89 post CABG patients. The participants performed the 6MWT and ISWT along with vital monitoring on third, fifth and seventh post operative days. The data was with calculation of 6MWT and ISWT MCID through distribution and anchor-based methods. Results showed significant improvement (p < 0.001) in 6MWT as well as in ISWT after seven days of in-patient cardiac rehabilitation. The minimal detectable difference of 6MWT determined by the distribution-based method was 36.11 whereas MCID calculated by Anchor based method was 195 m. The minimal detectable difference of ISWT determined by the distribution-based method was 9.94 whereas MCID calculated by Anchor based method was 42.5 m. In conclusion our results will assist the future researchers and clinicians to interpret clinical trials as well as to observe the clinical course of post operative cardiac patients.

Construct validity and responsiveness of the Duke Activity Status Index (DASI) as a measure of recovery after colorectal surgery

BACKGROUND

Returning to preoperative levels of physical function is highly valued by patients recovering from surgery. The Duke Activity Status Index (DASI, a 12-item questionnaire) may be a simple yet robust tool to assess postoperative recovery of functional capacity. This study assessed construct validity and responsiveness of the DASI as a measure of recovery after colorectal surgery.

METHODS

Data from a trial on early mobilization after colorectal surgery were analyzed. Patients completed the DASI questionnaire preoperatively and at postoperative weeks (POW) 2 and 4. Construct validity was assessed by testing the primary a priori hypotheses that postoperative DASI scores (1) are higher in patients without vs with postoperative complications and (2) correlate with six-minute walk test distance (6MWD). Exploratory analyses assessed the association between DASI scores and (1) preoperative physical status [higher (ASA ≤ 2) vs lower (ASA > 2)], (2) stoma creation (no stoma vs stoma), (3) age [younger (≤ 75 years) vs older (> 75 years)], (4) time to readiness for discharge [shorter (≤ 4 days) vs longer (> 4 days)], and (5) surgical approach (laparoscopic vs open). Responsiveness was assessed by testing a priori hypotheses that DASI scores are higher (1) preoperatively vs at POW2 and (2) at POW4 vs POW2. Mean differences in DASI scores were obtained using linear regression. The association between DASI and 6MWD was assessed via Pearson correlation.

RESULTS

We analyzed data from 100 patients undergoing colorectal surgery (mean age 65; 57% male; 81% laparoscopic). Mean DASI scores were 47.9 ± 12.1 preoperatively, 22.4 ± 12.7 at POW2, and 33.2 ± 15.7 at POW4. The data supported our two primary construct validity hypotheses, as well as 3/5 exploratory hypotheses. Both responsiveness hypotheses were supported.

CONCLUSIONS

Our findings support that the DASI questionnaire can be a useful tool to assess postoperative recovery of functional capacity in research and clinical practice.

Delivery of Acute Rehabilitation to a Postcoronary Artery Bypass Graft COVID-19 Patient in a Pandemic Environment

During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.

Improvement in Physical Function After Coronary Artery Bypass Graft Surgery Using a Novel Rehabilitation Intervention: A RANDOMIZED CONTROLLED TRIAL

PURPOSE

Cardiorespiratory and skeletal muscle deconditioning occurs following coronary artery bypass graft surgery and hospitalization. Outpatient, phase 2 cardiac rehabilitation (CR) is designed to remediate this deconditioning but typically does not begin until several weeks following hospital discharge. Although an exercise program between discharge and the start of CR could improve functional recovery, implementation of exercise at this time is complicated by postoperative physical limitations and restrictions. Our objective was to assess the utility of neuromuscular electrical stimulation (NMES) as an adjunct to current rehabilitative care following postsurgical discharge and prior to entry into CR on indices of physical function in patients undergoing coronary artery bypass graft surgery.

METHODS

Patients were randomized to 4 wk of bilateral, NMES (5 d/wk) to their quadriceps muscles or no intervention (control). Physical function testing was performed at hospital discharge and 4 wk post-discharge using the Short Physical Performance Battery and the 6-min walk tests. Data from 37 patients (19 control/18 NMES) who completed the trial were analyzed. The trial was registered at ClinicalTrials.gov (NCT03892460).

RESULTS

Physical function measures improved from discharge to 4 wk post-surgery across our entire cohort (P < .001). Patients randomized to NMES, however, showed greater improvements in 6-min walk test distance and power output compared with controls (P < .01).

CONCLUSION

Our results provide evidence supporting the utility of NMES to accelerate recovery of physical function after coronary artery bypass graft surgery.

The 6-Minute Walk Test predicts long-term physical improvement among intensive care unit survivors: a prospective cohort study

Objetivo

Avaliar a capacidade do Teste de Caminhada de 6 Minutos para predizer a melhora do estado funcional físico em longo prazo de pacientes sobreviventes à unidade de terapia intensiva.

Métodos

Foram avaliados, de forma prospectiva, entre fevereiro de 2017 e agosto de 2018, em um ambulatório pós-unidade de terapia intensiva, 32 sobreviventes à unidade de terapia intensiva. Foram inscritos consecutivamente os pacientes com permanência na unidade de terapia intensiva acima de 72 horas (para admissões emergenciais) ou acima de 120 horas (para admissões eletivas) que compareceram ao ambulatório pós-unidade de terapia intensiva 4 meses após receberem alta da unidade de terapia intensiva. A associação entre a distância percorrida no Teste de Caminhada de 6 Minutos realizado na avaliação inicial e a evolução do estado funcional físico foi avaliada durante 8 meses, com utilização do Índice de Barthel.

Resultados

A distância média percorrida no Teste de Caminhada de 6 Minutos foi significantemente mais baixa nos sobreviventes à unidade de terapia intensiva do que na população geral (405m versus 557m; p < 0,001). A idade (β = -4,0; p < 0,001) e a fraqueza muscular (β = -99,7; p = 0,02) se associaram com a distância percorrida no Teste de Caminhada de 6 Minutos. A distância percorrida no Teste de Caminhada de 6 Minutos se associou com melhora do estado funcional físico no período de 8 meses de acompanhamento desses pacientes (razão de chance para cada 10m: 1,07; IC95% 1,01 - 1,16; p = 0,03). A área sob a curva Característica de Operação do Receptor para predição da melhora funcional física pelo Teste de Caminhada de 6 Minutos foi de 0,72 (IC95% 0,53 - 0,88).

Conclusão

O Teste de Caminhada de 6 Minutos, realizado 4 meses após a alta da unidade de terapia intensiva, predisse com precisão moderada a melhora do estado funcional físico de sobreviventes à unidade de terapia intensiva.

Analysis of exercise tolerance on the basis of six-minute walk test - 6MWT and Borg RPE scale in men with inguinal hernia before and after Lichtenstein repair

&lt;b&gt;Introduction:&lt;/b&gt; Assessment of exercise tolerance (ET) plays an important role in qualifications for treatment and rehabilitation. &lt;br&gt;&lt;b&gt;Aim: &lt;/b&gt;The aim of the study was to assess ET in patients before and after inguinal hernia operations with Lichtenstein method. &lt;br&gt;&lt;b&gt;Material and methods:&lt;/b&gt; The cohort study included men with inguinal hernia divided into the study group (SG) (n = 50) and control (CG) (n = 50) undergone the Lichtenstein surgery. Patients from the SG met the criterion of coexistence of cardiovascular and respiratory diseases. Day before and on the second day after surgery, patients performed 6MWT and subjectively rate the exertion according to Borg- RPE- Scale (before, immediately after and 10 minutes after the test). 6MWT distance, Borg scale ratings were analysed. On the second day after surgery 66% of patients from the SG and 58% from the CG did not complete the test. Patients from the SG before (500,07 ± 40,38 m) and on the second day after surgery (243,46 ± 18,18 m) achieved shorter distances compared to the CG (565,93 ± 20,41 m; 249,47 ± 26,66 m), p &lt; 0,001 i p = 0,481. A statistically significant negative correlation between 6MWT distance before surgery and age of the patients was confirmed. Patients who did not develop complications achieved significantly longer distances on admission (p = 0,003 for SG, p = 0,004 for CG). For 6MWT before surgery and 2 days after surgery, patients from the SG showed a significantly higher level of fatigue compared to the CG after the test (before: p = 0,001, after: p = 0,001). Patients form the SG often discontinued 6MWT and less tolerated effort compared to the CG. Hence, 6MWT is useful tool for ascertaining physical capacity and ET.

A COVID-19 Rehabilitation Prospective Surveillance Model for Use by Physiotherapists

The long-term sequelae of coronavirus disease 2019 (COVID-19) are only now beginning to be defined, but it is already known that the disease can have direct and indirect impacts mainly on the cardiorespiratory and neuromuscular systems and may affect mental health. A role for rehabilitation professionals from all disciplines in addressing COVID-19 sequelae is recognised, but it is essential that patient assessment be systematic if health complications are to be identified and treated and, if possible, prevented. The aim is to present a COVID-19 prospective surveillance model based on sensitive and easily used assessment tools, which is urgently required. Following the Oxford Centre for Evidence-Based Medicine Level of Evidence Tool, an expert team in cardiorespiratory, neuromuscular and mental health worked via telemeetings to establish a model that provides guidelines to rehabilitation professionals working with patients who require rehabilitation after suffering from COVID-19. A COVID-19 prospective surveillance model is proposed for use by rehabilitation professionals and includes both face-to-face and telematic monitoring components. This model should facilitate the early identification and management of long-term COVID-19 sequelae, thus responding to an arising need.

Reliability and repeatability of a smartphone-based 6-min walk test as a patient-centred outcome measure

Aims

The 6-min-walk test (6MWT) is a validated proxy for frailty and a predictor of clinical outcomes, yet is not widely used due to implementation challenges. This comparative effectiveness study assesses the reliability and repeatability of a home-based 6MWT compared to in-clinic 6MWTs in patients with cardiovascular disease.

Methods and results

One hundred and ten (110) patients scheduled for cardiac or vascular surgery were enrolled during a study period from June 2018 to December 2019 at the Palo Alto VA Hospital. Subjects were provided with an Apple iPhone 7 and Apple Watch Series 3 loaded with the VascTrac research study application and performed a supervised in-clinic 6MWT during enrolment, at 2 weeks, 1, 3, and 6 months post-operatively. Subjects also received notifications to perform at-home smartphone-based 6MWTs once a week for a duration of 6 months. Test-retest reliability of in-clinic measurements and at-home measurements was assessed with an industry standard Cronbach's alpha reliability test. Test-retest reliability for in-clinic ground truth 6MWT steps vs. in-clinic iPhone 6MWT steps was 0·99, showing high reliability between the two tested measurements. When comparing for in-clinic ground truth 6MWT steps vs. neighbouring at-home iPhone 6MWT steps, reliability was 0·74.

Conclusion

Running the test-reliability test on both measurements shows that an iPhone 6MWT test is reliable compared to an in-clinic ground truth measurement in patients with cardiovascular disease.

Testes funcionais validados em indivíduos hospitalizados e não hospitalizados: revisão sistemática

Objetivo: Realizar uma revisão sistemática sobre os testes funcionais validados em diferentes perfis de indivíduos hospitalizados e não hospitalizados e avaliar as evidências psicométricas para confiabilidade e validade. Métodos: Trata-se de uma revisão sistemática. Foram utilizadas as bases de dados EMBASE, MEDLINE, Lilacs e SciELO com as palavras-chave Functional Tests (Walk Test, Gait Speed Test, Chair Stand Test, Timed Up And Go, Step Test),Validation Studies as Topic e sinônimos. Foram incluídos estudos de validação de testes funcionais em indivíduos hospitalizados ou não hospitalizados que utilizaram os critérios de validade e/ou confiabilidade e relacionaram os testes a diferentes variáveis. Esses artigos poderiam ser observacionais longitudinais ou de corte transversal ou estudos de validação que utilizaram dados de ensaios clínicos. Foram excluídos os artigos que não apresentaram características importantes da amostra e a descrição do teste. Resultados: A pesquisa resultou em 36.150 artigos, e 89 foram incluídos. Os estudos foram organizados em tabelas com informações como autor, ano; critérios de validação; amostra; teste; variáveis associadas; resultados. A qualidade dos artigos foi avaliada por meio da Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Conclusão: Os testes funcionais são válidos e confiáveis para a avaliação de indivíduos hospitalizados e não hospitalizados, estando associados à força muscular, capacidade de caminhar, controle postural, atividades de vida diária, risco de quedas, hospitalização e mortalidade.

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.

Beyond the myocardium? SGLT2 inhibitors target peripheral components of reduced oxygen flux in the diabetic patient with heart failure with preserved ejection fraction

Recent cardiovascular outcome trials have highlighted the propensity of the antidiabetic agents, SGLT2 inhibitors (SGLT2is or -flozin drugs), to exert positive clinical outcomes in patients with cardiovascular disease at risk for major adverse cardiovascular events (MACEs). Of interest in cardiac diabetology is the physiological status of the patient with T2DM and heart failure with preserved ejection fraction (HFpEF), a well-examined association. Underlying this pathologic tandem are the effects that long-standing hyperglycemia has on the ability of the HFpEF heart to adequately deliver oxygen. It is believed that shortcomings in oxygen diffusion or utilization and the resulting hypoxia thereafter may play a role in underlying the clinical sequelae of patients with T2DM and HFpEF, with implications in the long-term decline of extra-cardiac tissue. Oxygen consumption is one of the most critical factors in indexing heart failure disease burden, warranting a probe into the role of SGLT2i on oxygen utility in HFpEF and T2DM. We investigated the role of oxygen flux in the patient with T2DM and HFpEF extending beyond the heart with focuses on cellular metabolism, perivascular fibrosis with endothelial dysfunction, hematologic changes, and renal effects with neurohormonal considerations in the patient with HFpEF and T2DM. Moreover, we give a commentary on potential therapeutic targets of these components with SGLT2i to gain insight into disease burden amelioration in patients with HFpEF and T2DM.

Improvements in exercise capacity of older adults during cardiac rehabilitation

AIMS

Cardiac rehabilitation plays a vital role in secondary prevention of cardiovascular patients. Female sex and higher age, however, are associated with non-referral to cardiac rehabilitation. Improving exercise capacity during cardiac rehabilitation is essential to reduce morbidity and mortality risks. The objective of this study was to closely examine the beneficial changes in exercise capacity of older patients of both sexes during cardiac rehabilitation and to identify the most important predictors of the change in exercise capacity.

METHOD

A sample of 13,612 patients (mean age = 69.10 ± 11.8 years, 63.7% men, 19% > 80 years) was analysed. Data were prospectively assessed from 2012-2018 in six Swiss in-patient cardiovascular rehabilitation clinics. Improvement in exercise capacity measured with the six-minute walking test represents the outcome variable. Univariate and multivariate analyses, as well as the random forest method were used to estimate variable importance.

RESULTS

Mean improvement in the six-minute walking test was 113.5 ± 90.5 m (men = 118.7 ± 110.0; women = 104.4 ± 93.0, Cohen's d = 0.16). The presence of heart failure, diabetes mellitus and psychiatric diagnoses was related to reduced but nonetheless clinically relevant six-minute walking test improvement. Random forest analysis suggests that baseline exercise capacity, age, time in rehabilitation and heart failure were the most important predictors for improvement in exercise capacity. Clinically relevant improvements in exercise capacity (>45 m) were also present into old age (85 years) and for both sexes.

CONCLUSION

As indicated by these results, efforts need to be increased to refer eligible patients to structured rehabilitation programmes, irrespective of patients' age and sex.

Characterizing Patient-Centered Postoperative Recovery After Adult Cardiac Surgery: A Systematic Review

Background

Improving postoperative recovery is important, with a national focus on postacute care, but the volume and quality of evidence in this area are not well characterized. We conducted a systematic review to characterize studies on postoperative recovery after adult cardiac surgery using patient‐reported outcome measures.

Methods and Results

From MEDLINE and Web of Science, studies were included if they prospectively assessed postoperative recovery on adult patients undergoing cardiac surgery using patient‐reported outcome measures. Six recovery domains were defined by prior literature: nociceptive symptoms, mental health, physical function, activities of daily living, sleep, and cognitive function. Of the 3432 studies, 105 articles met the inclusion criteria. The studies were small (median sample size, 119), and mostly conducted in single‐center settings (n=81; 77%). Study participants were predominantly men (71%) and white (88%). Coronary artery bypass graft was included in 93% (n=98). Studies commonly selected for elective cases (n=56; 53%) and patients with less comorbidity (n=67; 64%). Median follow‐up duration was 91 (interquartile range, 42–182) days. Studies most commonly assessed 1 domain (n=42; 40%). The studies also varied in the instruments used and differed in their reporting approach. Studies commonly excluded patients who died during the follow‐up period (n=48; 46%), and 45% (n=47) did not specify how those patients were analyzed.

Conclusions

Studies of postoperative patient‐reported outcome measures are low in volume, most often single site without external validation, varied in their approach to missing data, and narrow in the domains and diversity of patients. The evidence base for postoperative patient‐reported outcome measures needs to be strengthened.