Physical activity increases survival after heart valve surgery

Exploring barriers and facilitators of behavioural changes in dietary intake and physical activity: a qualitative study in older adults undergoing transcatheter aortic valve implantation

PURPOSE

The majority of older patients, scheduled for a cardiac procedure, do not adhere to international dietary intake and physical activity guidelines. The purpose of this study was to explore barriers and facilitators regarding dietary intake and physical activity behaviour change in older patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

We conducted a qualitative study using semi-structured interviews with patients undergoing TAVI. Interviews were analysed by two independent researchers using thematic analysis, the capability, opportunity and motivation behaviour model was used as a framework.

RESULTS

The study included 13 patients (82 ± 6 years old, 6 females) until data saturation was reached. Six themes were identified, which were all applicable to both dietary intake and physical activity. Three following themes were identified as barriers: (1) low physical capability, (2) healthy dietary intake and physical activity are not a priority at an older age and (3) ingrained habits and preferences. Three following themes were identified as facilitators: (1) knowledge that dietary intake and physical activity are important for maintaining health, (2) norms set by family, friends and caregivers and (3) support from the social environment.

CONCLUSION

Our study found that older patients had mixed feelings about changing their behaviour. The majority initially stated that dietary intake and physical activity were not a priority at older age. However, with knowledge that behaviour could improve health, patients also stated willingness to change, leading to a state of ambivalence. Healthcare professionals may consider motivational interviewing techniques to address this ambivalence.

Long-term effects of cardiac rehabilitation after heart valve surgery - results from the randomised CopenHeartVR trial

Aims. The CopenHeart_VR trial found positive effects of cardiac rehabilitation (CR) on physical capacity at 4 months. The long-term effects of CR following valve surgery remains unclear, especially regarding readmission and mortality. Using data from he CopenHeart_VR Trial we investigated long-term effects on physical capacity, mental and physical health and effect on mortality and readmission rates as prespecified in the original protocol. Methods. A total of 147 participants were included after heart valve surgery and randomly allocated 1:1 to 12-weeks exercise-based CR including a psycho-educational programme (intervention group) or control. Physical capacity was assessed as peak oxygen uptake (VO₂ peak) measured by cardiopulmonary exercise testing, mental and physical health by Short Form-36 questionnaire, Hospital Anxiety and Depression Scale, and HeartQol. Mortality and readmission were obtained from hospital records and registers. Groups were compared using mixed regression model analysis and log rank test. Results. No differences in VO₂ peak at 12 months or in self-assessed mental and physical health at 24 months (68% vs 75%, p = .120) was found. However, our data demonstrated reduction in readmissions in the intervention group at intermediate time points; after 3, 6 (43% vs 59%, p = .03), and 12 (53% vs 67%, p = .04) months, respectively, but no significant effect at 24 months. Conclusions. Exercise-based CR after heart valve surgery reduces combined readmissions and mortality up to 12 months despite lack of improvement in exercise capacity, physical and mental health long-term. Exercise-based CR can ensure short-term benefits in terms of physical capacity, and lower readmission within a year, but more research is needed to sustain these effects over a longer time period. These considerations should be included in the management of patients after heart valve surgery.

Effectiveness of additional resistance and balance training and telephone support program in exercise-based cardiac rehabilitation on quality of life and physical activity: Randomized control trial

OBJECTIVES

To evaluate 20 days and 3 months follow-up effectiveness of cardiac rehabilitation (CR) enhanced by resistance/balance training and telephone-support program compared to usual CR care in improving quality of life, clinical course and physical activity behavior.

DESIGN

Single-centre randomized controlled trial.

SETTING

Inpatient CR clinic.

SUBJECTS

116 (76.1 ± 6.7 years, 50% male) patients 14.5 ± 5.9 days after valve surgery/intervention were randomized to intervention group (IG, n = 60) or control group (CG, n = 56).

INTERVENTION

Additional resistance/balance training (3 days/week) during phase-II CR and telephone-support program during 3-month follow-up. CG patients were provided with usual CR care.

MAIN MEASURES

Short Form 36 Health Survey scales, European Quality of Life 5 Dimensions 3 Level Version QoL index, visual analog scale, clinical course, and physical activity behavior assessed with standardized questionnaires.

RESULTS

IG reported statistically significant higher mental component score (48.5 ± 6.91 vs. 40.3 ± 11.21 at the baseline, 50.8 ± 9.76 vs. 42.6 ± 9.82 after 20 days, 49.4 ± 8.45 vs. 40.5 ± 8.9 after 12 weeks follow up), general health (48.6 ± 3.17 vs. 45.0 ± 2.95 at the baseline, 53.6 ± 3.02 vs. 43.8 ± 2.55 after 20 days, 53.2 ± 3.11 vs. 44.2 ± 3.07 after 12 weeks) and role limitations due to emotional problems (48.5 ± 15.2 vs. 27.7 ± 11.5 at the baseline, 72.7 ± 12.6 vs. 30.5 ± 11.2 after 20 days, 66.6 ± 14.2 vs. 36.1 ± 11.2 after 12 weeks) in all three assessments (p < 0.05). CG patients had more documented hospital admissions (4 (8%) vs 10 (25%), p = 0.027), atrial fibrillation paroxysms (3 (6.0%) vs. 10 (35.0%), p = 0.011) and blood pressure swings (13 (26%) vs. 20 (50%), p = 0.019). IG patients chose more different physical activities (1.7 ± 0.7 vs. 1.25 ± 0.63, p = 0.002), spent more time being physical active every day (195.6 ± 78.6 vs. 157.29 ± 78.8, p = 0.002).

CONCLUSIONS

The addition of resistance/balance exercises and telephone-support program 12 weeks after to the CR could linked to higher physical activity levels and fewer clinical complications but did not lead to a significant improvement in quality of life.

Decreased activities of daily living at discharge predict mortality and readmission in elderly patients after cardiac and aortic surgery: A retrospective cohort study

Recently, activities of daily living (ADL) were identified as a prognostic factor among elderly patients with heart disease; however, a specific association between ADL and prognosis after cardiac and aortic surgery is not well established. We aimed to clarify the impact of ADL capacity at discharge on prognosis in elderly patients after cardiac and aortic surgery.This retrospective cohort study included 171 elderly patients who underwent open operation for cardiovascular disease in a single center (median age: 74 years; men: 70%). We used the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to the BI at discharge, indicating a high (BI ≥ 85) or low (BI < 85) ADL status. All-cause mortality and unplanned readmission events were observed after discharge.Thirteen all-cause mortality and 44 all-cause unplanned readmission events occurred during the median follow-up of 365 days. Using Kaplan-Meier analysis, a low ADL status was determined to be significantly associated with all-cause mortality and unplanned readmission. In the multivariable Cox proportional hazard models, a low ADL status was an independent predictor of all-cause mortality and unplanned readmission after adjusting for age, sex, length of hospital stay, and other variables (including preoperative status, surgical parameter, and postoperative course).A low ADL status at discharge predicted all-cause mortality and unplanned readmission in elderly patients after cardiac and aortic surgery. A comprehensive approach from the time of admission to postdischarge to improve ADL capacity in elderly patients undergoing cardiac and aortic surgery may improve patient outcomes.

The impact of additional resistance and balance training in exercise-based cardiac rehabilitation in older patients after valve surgery or intervention: randomized control trial

Background

To evaluate the short- and mid-term effect of a specially tailored resistance and balance training provided in addition to usual cardiac rehabilitation (CR) care program in older patients after valve surgery/intervention.

Methods

Single-center (inpatient CR clinic in Lithuania) randomized controlled trial. Two hundred fifty-two patients were assessed for eligibility on the first day of admittance to CR early after (14.5 ± 5.9 days) valve surgery/intervention between January 2018 and November 2019. Participants were coded centrally in accordance with randomization 1:1 using a computerized list. Control group (CG) patients were provided with usual care phase-II-CR inpatient multidisciplinary CR program, while intervention group (IG) patients received additional resistance and balance training (3 d/wk). Patients participated in a 3-month follow-up. Main outcome measures were functional capacity (6 min walk test (6MWT, meters), cardiopulmonary exercise testing), physical performance (Short Physical Performance Battery (SPPB, score) and 5-m walk test (5MWT, meters/second)), strength (one repetition maximum test for leg press), physical frailty (SPPB, 5MWT).

Results

One hundred sixteen patients (76.1 ± 6.7 years, 50% male) who fulfilled the study inclusion criteria were randomized to IG (n = 60) or CG (n = 56) and participated in CR (18.6 ± 2.7 days). As a result, 6MWT (IG 247 ± 94.1 vs. 348 ± 100.1, CG 232 ± 102.8 vs. 333 ± 120.7), SPPB (IG 8.31 ± 2.21 vs. 9.51 ± 2.24, CG 7.95 ± 2.01 vs. 9.08 ± 2.35), 5MWT (IG 0.847 ± 0.31 vs. 0.965 ± 0.3, CG 0.765 ± 0.24 vs 0.879 ± 0.29) all other outcome variables and physical frailty level improved significantly (p < 0.05) in both groups with no significant difference between groups. Improvements were sustained over the 3-month follow-up for 6MWT (IG 348 ± 113 vs. CG 332 ± 147.4), SPPB (IG 10.37 ± 1.59 vs CG 9.44 ± 2.34), 5MWT (IG 1.086 ± 0. 307 vs CG 1.123 ± 0.539) and other variables. Improvement in physical frailty level was significantly more pronounced in IG (p < 0.05) after the 3-month follow-up.

Conclusion

Exercise-based CR improves functional and exercise capacity, physical performance, and muscular strength, and reduces physical frailty levels in patients after valve surgery/intervention in the short and medium terms. SPPB score and 5MWT were useful for physical frailty assessment, screening and evaluation of outcomes in a CR setting. Additional benefit from the resistance and balance training could not be confirmed.

Trial registration

NCT04234087, retrospectively registered 21 January 2020.

[Evaluation of the Model project "Prescription for Exercise" in Baden-Württemberg: An Explorative Qualitative Survey]

OBJECTIVE

Exercise has a positive effect on health, which has already been proven in many studies. Doctors have an important role in helping patients to get more exercise. Against this background, the preventive model project "Exercise on Prescription" (RfB) was launched in Germany in 2009. This allows doctors to give their patients a prescription for exercise. In Baden-Württemberg, this offer was tested in 4 regions from 2015 to 2016. The aim of the present study was to evaluate the use of the RfB by doctors in Baden-Württemberg at the end of the trial phase by means of qualitative interviews of physicians participating in the program in 2017.

METHODS

The telephone interviews were conducted using a structured interview guide.

RESULTS

The qualitative survey showed a positive attitude of the physicians towards the RfB. The lack of local offers and the lack of direct cost reimbursement by the statutory health in-surances were cited as inhibiting factors for the issuance of the RfB. Further influencing factors were the self-motivation of the patients and the anticipated probability of implementation.

CONCLUSION

The present qualitative survey not only documented the obstacles to RfB being issued by doctors and the patients' implementation of the physical activity recommendations, but also beneficial factors with regard to the future use of the RfB outside the model project.

High prevalence of physical inactivity after heart valve surgery and its association with long-term mortality: A nationwide cohort study

AIMS

Physical activity (PA) and systematic efforts, such as cardiac rehabilitation, are recommended by several national guidelines for those who have received heart valve surgery. However, only a few studies have demonstrated real-world situations, such as changes in the PA level after heart valve surgery, and their effects on long-term outcomes. We designed this study to investigate the changes in PA after heart valve surgery and their associations with mortality using nationwide representative data.

METHODS

This study was performed using the Korean National Health Insurance Service database. We included patients who received heart valve surgery from 2009 to 2015 and underwent regular health checkups before and after surgery. Subjects were grouped according to their PA level before and after the surgery. Information on all-cause mortality was obtained until 31 December 2016, with a maximum follow-up period of 5 years.

RESULTS

Of the 6587 subjects, 3258 (49.5%) were physically inactive after surgery. Among patients who were physically active (n = 3070), 1196 (39.0%) became inactive after surgery. The postoperative 'inactive' group showed higher mortality than the 'active' group (hazard ratio (HR): 1.41, 95% confidence interval (CI): 1.08-1.83). The 'inactive/inactive' group showed the highest risk of mortality (HR: 1.69, 95% CI: 1.19-2.40) compared with the 'active/active' group.

CONCLUSIONS

Insufficient PA level after heart valve surgery is associated with higher risk of mortality. However, maintaining sufficient PA after heart valve surgery may be challenging for many patients. Therefore, systematic efforts, such as cardiac rehabilitation, should be considered in those who received heart valve surgery.

Physical Training and Cardiac Rehabilitation in Heart Failure Patients

Regardless of advances in medical and interventional treatment of cardiovascular disease (CVD), a limited number of patients attend a cardiac rehabilitation (CR) programme on a regular basis. Due to modern therapies more individuals will be surviving an acute cardiovascular event, but the expected burden of chronic heart failure will be increasing worldwide.However, both in high- and low-income countries, secondary prevention after an acute myocardial infarction or stroke has been implemented in less than a half of eligible patients.Combined interventions are still needed to reduce decompensations, hospitalizations and mortality in heart failure patients from any origin. In addition to medical treatments, regular exercise has been demonstrated to improve metabolic and hemodynamic conditions in both asymptomatic risk factor carriers and cardiac patients. Risk factor control and exercise should gather together for an effective management of patients.Exercise-based training is a core component of primary and secondary prevention. It should involve healthy carriers of cardiovascular risk factors, and patients with cardiomyopathy as well. The supposed attenuated effect of CR in the era of advanced revascularization and structural interventions is due to the heterogeneity of training models and physical training in the literature. Moreover, lifestyle modification, psycho-social challenges and patient's compliance are potential confounders.In this chapter the most recent evidences about training modalities and potential benefit of CR in heart failure patients are discussed.