Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Does changes of dipeptidyl peptidase-4 and IGF binding protein 1 during cardiac rehabilitation can predict recurrent anginal pain – correlation with nitric oxide response – 3 years follow up

Background

Dipeptidyl peptidase 4 (DPP4) is a proteolytic enzyme, and its expression and activity is increased in coronary artery disease (CAD). Insulin-like growth factor binding protein 1 (IGF BP1) can affect prognosis and mortality from cardiovascular diseases.

Purpose

To evaluate the effects of cardiac rehabilitation on DPP4 and circulating IGF BP1 levels, also on circulating blood marker of endothelial function, nitric oxide (NOx); to assess their relationship and prognostic significance on recurrent chest pain.

Methods

51 subjects; 31 pts with stable CAD (CAD group; 58.4±6.8 years) and 20 healthy controls (C group; 57.4±8.1 years) were studied. All patients underwent a supervised 3 weeks exercise training. At baseline and after 3 weeks in all pts values of DPP4, IGF BP1 and NOx were determined and exercise test was performed. Clinical long-term follow-up (3 years) was performed. All medical therapy were documented, and for this analysis, we focused on recurrent anginal chest pain.

Results

After follow-up period there were no cardiovascular (CV) hard end points (CV death, MI, stroke), however 18 pts (58%) had episodes of typical anginal chest pain while 13 pts (42%) were without anginal chest pain. Baseline value of DPP4 and IGF BP1 was significantly higher in CAD than in C group (P<0.01 and P<0.01), while NOx was lower (58.61±7.64 vs 77.28±29.86 μmol/L P=0.024). After 3 weeks of exercise training DPP4 decreased significantly in CAD group (from 762.32±185.76 to 604.88±206.18 μg/L, P<0.001), as well as IGF BP1 (P=0.018) and NOx inreased (P<0.01). Those changes resulted in no significant difference in DPP4, IGF BP1 and NOx after three weeks between CAD and C group. Exercise capacity (METs) at baseline was significantly lower in CAD than in C group (P<0.001), and it significantly increase in CAD group after exercise period (P<0.001).A positive correlation during exercise period was found between IGF BP1 decrease and NOx increase (r=0.790, P<0.001), between IGF BP1 decrease and DPP 4 decrease (r=0.880, P<0.001), between IGF BP1 decrease and METs increase (r=0.866, P<0.001), between DPP 4 decrease and NOx increase (r=0.975, P<0.001), between DPP 4 decrease and METs increase (r=0.718, P<0.001), and between METs increase and NOx increase (r=0.846, P<0.001). Univaried logistic regression analyses were performed and showed that NOx increase (OR 0.842, CI 0.562–0.944, p<0.01), DPP4 decrease (OR 0.718, CI 0.644–0.826, p=0.01), IGF BP1 decrease (OR 0.695, CI 0.475–0.822, p=0.002) and METS increase (OR 0.924, CI 0.788–0.988, p=0.015) significantly predict a 3 years period without anginal chest pain.

Conclusion

Residential cardiovascular rehabilitation, in patients with stable CAD, improved endothelial function. Patients with higher increase of NOx and METs, and greater reduction in DPP4 and IGF BP1 after 3 weeks of specialized cardiac rehabilitation, during 3 years follow up, were without anginal chest pain and without any CV event.

Funding Acknowledgement

Type of funding source: None

Is there a gender difference in endothelial response on exercise training in heart failure patients with preserved ejection fraction?

Purpose

To examine the reaction of endothelium, assess through changes of circulating blood markers of endothelial function: the stable end products of nitric oxide (NOx), S – nitrosothiols (RSNO – reservoir for bioavailable nitric oxide), dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) that promotes exercise training in female and male patients (pts) with heart failure with preserved ejection fraction (HFpEF).

Methods

A total of 78 pts with HFpEF were enrolled in the study: 43 male (M group) and 35 female (F group). In all pts, before and after a short-term supervised 3 weeks exercise training at residential center values of NOx, RSNO, ADMA and SDMA were determined and exercise test was performed.

Results

After 3 weeks of exercise training NOx increased significantly in both groups: in M group (from 34.4±7.5 to 42.3±9.5 μmol/l, P<0.001), and in F group (from 31.3±6.8 to 41.5±7.2 μmol/l, P<0.001), as well as RSNO: In M group RSNO increased from 3.6±1.7 to 4.6±1.9 μmol/l (P<0.05) and in F group from 3.1±1.5 to 4.2±2.2 μmol/l (P<0,05). Increase in NOX and RSNO after exercise training was higher in F than in M group: NOx 32,6% vs 22,9%; RSNO 35,1% vs 27%. Value of ADMA as well of SDMA decreased in both groups after 3 weeks: ADMA in M group from 0.315±0.09 to 0.278±0.12 μmol/l (by 11.7%; ns), and in F group from 0.342±0.08 to 0.297±0.13 μmol/l (by 13.1%; ns); SDMA in M group from 0.269±0.08 to 0.234±0.09 μmol/l (by 13%; ns), and in F group from 0.285±0.09 to 0.245±0.10 μmol/l (by 14%; ns). After 3 weeks, level and duration of exercise test were significantly higher in M (both P<0,001), as well as, in F group (both P<0.001), compared to baseline values.

Conclusions

There was no gender difference in the way of endothelial response on exercise training in pts with HFpEF. Exercise training induced favorable modification of endothelial function, expressed through significant increased of NOx, RSNO and decreased of ADMA, SDMA in male as well as in female pts. Those positive changes in endothelial function were associated with significant improvement in exercise capacity. Some higher percentage of NOx and RSNO increase in women suggests that they have more pronounced benefit of exercise training than men.

Funding Acknowledgement

Type of funding source: None

P638High intensity interval exercise training improves endothelial function in patients with heart failure with preserved ejection fraction

Background

Cardiac rehabilitation has traditionally invoved low-to moderate intensity continuous exercise training (MICT). There is growing evidence that high intensity interval exercise training (HIIT) shows similar or greater efficacy compared with MICT. However, the relationship between the training modality and its effects on endothelial function still remains to be elucidated.

Purpose

To evaluate the impact of high intensity interval exercise training versus low-to moderate intensity continuous exercise training on circulating blood markers of endothelial function: the stable end product of nitric oxide (NOx), S–nitrosothiols (RSNO–reservoir for bioavailable nitric oxide), dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) in patients (pts) with heart failure with preserved ejection fraction (HFpEF).

Methods

A total of 43 pts with HFpEF (mean age 57.5±6.8y) admitted at residential rehabilitation center were enrolled in the study. Patients were randomized to HIIT, (HIIT group, n=20) and MICT, (MICTgroup, n=23). At baseline and 3 weeks later, in all pts values of NOx, RSNO, ADMA and SDMA were determined and exercise test was performed.

Results

After 3 weeks NOx increased significantly in both groups: in HIITgroup (from 34.7±7.5 to 48.5±8.3 μmol/l, P<0.0001), in MICTgroup (from 35.0±9.5 to 42.5±10.0 μmol/l, P<0.05), and value of NOx after 3 weeks was higher in HIIT than in MICT group (P<0.05). Value of ADMA as well of SDMA decreased in both groups after 3 weeks, and this decrease was significant in HIIT group: ADMA in HIIT group (from 0.305±0.055 to 0.250±0.077 μmol/l, P<0.005) and in MICT group (from 0.325±0.069 to 0.280±0.140 μmol/l, ns); SDMA in HIIT group (from 0.285±0.050 to 0.240±0.060 μmol/l, P<0,005) and in MICT group (from 0.270±0.080 to 0.247±0.063 μmol/l, ns). Value of RSNO significantly increased in both groups, with higher increase in HIIT group: in HIIT group (from 3.0±1.5 to 5.1±1.7 μmol/l, P<0.001), in MICTgroup (from 3.2±1.7 to 4.5±2.3 μmol/l, P<0.05). Compared to the baseline, at the end of the study, exercise capacity (METs) was significantly higher in both groups (P<0.0001). Higher increase in METs in HIIT group during exercise training (by 39.8%), compared to increase in MICT group (by 27.2%), resulted in significantly higher exercise tolerance in HIIT than in MICT group at the end of the study (P<0.02). In both groups, adverse events during or after exercise training, were not occurred.

Conclusions

In pts with HFpEF high intensity interval exercise training as well as low-to moderate intensity continuous exercise training induced favorable modification of endothelial function, expressed through increase of NOx and RSNO, and decrease of ADMA and SDMA. More significant increase of NOx and RSNO, and significant decrease of ADMA and SDMA gives an advantage to HIIT over MICT exercise training in patients with HFpEF.