P366 EFFECTS OF EXERCISE REHABILITATION IN PATIENTS WITH LONG COVID–19

Moving from the first COVID–19 pandemic to the chronic phase of COVID–19, more than 50 long–term detrimental effects have been recognized in the so–called long COVID–19 syndrome. The exact mechanisms underlying the exercise capacity reduction and functional limitations are unknown, however, rehabilitation could play a pivotal role. The aim of this study was to evaluate whether a combination of aerobic and resistance training performed in the same session for 8 weeks could be well–tolerated and effective in long COVID–19 patients with reduced exercise capacity [(<85% of predicted peak aerobic capacity (VO2peak)] at 3–month from hospital discharge after COVID–19. The exercise training program included 3 exercise sessions per week. Each session included: a) aerobic exercise (starting at 30 min and increasing to 60 min) with 5 min warm–up and 5–min cool down; b) nine major muscle group resistance exercises (for the lower extremity: leg extension/flexion, abduction/adduction, and leg press; for the upper extremity: push–up/pull–down; for the core muscles: abdomen, back). The intensity of aerobic exercise was defined according to VO2peaktest results targeting the 80% level of lactate threshold in Watts. Resistance training load was determined for each muscle groups according to the results of the maximal dynamic strength testing (1RM; one repetition maximum) and was confirmed and updated after 4 weeks by defining new 1RM values. Resistance training prescription loading was defined as 40% of 1RM, 2 sets (3 sets for last two weeks) and 12 repetitions for each muscle group. The duration of a single training session was approximately 90 min. Out of 220 patients screened, 50 patients (aged 55.8±9.7 years, 15 women, body mass index 26.6±5.2 kg/m2) were enrolled. Mean exercise training sessions was 66.1±34.0; none of the patients dropped out from the study. VO2peak increased 15% and peak ventilation 9% (p < 0.001 for both). After the training program, mean percentage of VO2peak significantly increased (+14.2%, p < 0.001). Muscle strength increased markedly for all major muscle groups ranging from 16% to 33% increase (p < 0.010). An exercise rehabilitation with combined aerobic and resistance exercises for 8 weeks increases markedly both cardiorespiratory and musculoskeletal fitness in long COVID–19 patients. These results may highlight the importance of regular exercise rehabilitation aiming to promote daily activities, independent living, and better quality of life.

Post-traumatic stress disorder, depression and anxiety symptoms in COVID-19 outpatients with different levels of respiratory and ventilatory support in the acute phase undergoing three months follow up

BACKGROUND

The well-known COVID-19 pandemic totally transformed people's lives, paving the way to various psychopathological symptoms. In particular, patients may experience a short- and long-term decreasing in their wellbeing. In this vein, the aim of this paper is to assess the COVID-19 patients' psychopathological profile (Post Traumatic Stress Disorder, distress, anxiety and depression symptoms), detecting possible differences linked to the ventilatory treatments.

METHODS

Outpatients who recovered from COVID-19 were asked to provide socio-demographic and clinical information, and to complete a brief psychological screening evaluation (Impact of Event Scale-Revised - IES-R, Depression Anxiety Stress Scale - DASS-21).

RESULTS

Overall, after informed consent, 163 Italian patients took part in this research. Of them, 31,9% did not undergo any ventilatory therapy, 27,6% undertook oxygen therapy; 28,2% underwent noninvasive mechanical ventilation and 12.3% received invasive mechanical ventilation. Although no statistically significant differences were revealed among patients stratified by spontaneous breathing or ventilatory therapies, they reported statistically significant more depression (4.5+5.2 vs 3.5+3.2; p=.017) and anxiety (4.3+4.5 vs 2.4+2.6; p<.00001) symptoms than normative groups. Moreover, patients experiencing COVID-19 disease as a trauma, complained statistically significant higher levels of depression, anxiety and stress symptoms than who did not describe a clinically relevant traumatic experience (p<0.001).

CONCLUSIONS

Thus, this study suggests to healthcare professionals to consider COVID-19 experience as a potential real trauma for patients and underlines the necessity to define patients' psychopathological profile in order to propose tailored and effective preventive and supportive psychological interventions.

Cardiopulmonary exercise testing in COVID-19 patients at 3 months follow-up

Background

Long-term effects of Coronavirus Disease of 2019 (COVID-19) and their sustainability are of the utmost relevance. For the chronic phase, the main concerns are the development of pulmonary interstitial disease and/or lingering cardiovascular involvement. How to intercept, assess, and treat these patients with long-term consequences of COVID-19 remains uncertain.

Purpose

We aimed to determine: 1) functional capacity of COVID-19 survivors by cardiopulmonary exercise testing (CPET); 2) those characteristics associated with CPET performance; 3) safety and tolerability of CPET.

Methods

We prospectively enrolled consecutive patients with laboratory-confirmed COVID-19 discharged alive at a single hospital in northern Italy. At 3-month from hospital discharge, complete clinical evaluation, trans-thoracic echocardiography, cardiopulmonary exercise testing (CPET), pulmonary function test (PFT), and dominant leg extension (DLE) maximal strength evaluation were performed.

Results

From 225 patients discharged from March to November 2020 we excluded 12 incomplete/missing cases, and 13 unable to perform CPET leading to a final population of 200 patients. At PFT all median parameters were within normality range.

Median percent-predicted peak oxygen uptake (%pVO2) was 88% (78.3–103.1). Ninety-nine (49.5%) patients had %pVO2 below, whereas 101 (50.5%) above the 85% predicted value (indicating normality).

Sixteen (16.2%) patients had respiratory, 28 (28.9%) cardiac, 21 (21.2%) mixed-cardiopulmonary, and 34 (34.3%) non-cardiopulmonary limitation of exercise. One-hundred sixty (80.0%) patients complain at least one symptom, without relationship with peakVO2.

Multivariate linear regression analysis showed percent-predicted forced expiratory volume in one-second (β=5.29, p=0.023), percent-predicted diffusing capacity of lungs for carbon monoxide (β=6.31, p=0.001), and DLE maximal strength (β=14.09, p=0.008) independently associated with peakVO2.

At sensitivity analysis, the results of previous multivariate linear regression analysis were also similar among sub-groups of patients with no previous significant disease in anamnesis (cardiovascular disease except for arterial hypertension, respiratory disease, kidney disease, or cancer) and of those with a length of hospital stay ≤7 days.

None major event was reported during/after CPET, whereas only two cases (1.0%) had a mild symptomatic hypotension post exercise. None of the involved health professionals developed COVID-19.

Conclusions

CPET after COVID-19 is safe and about 1/3rd of COVID-19 survivors show functional capacity limitation mainly explained by muscular impairment, calling for future research to identify patients at higher risk of long-term effects that may benefit from careful surveillance and targeted rehabilitation.

Funding Acknowledgement

Type of funding sources: None.

Cardiopulmonary exercise testing in COVID-19 patients at 3 months follow-up

Background

Long-term effects of Coronavirus Disease of 2019 (COVID-19) are of utmost relevance.

We aimed to determine: 1) the functional capacity of COVID-19 survivors by cardiopulmonary exercise testing (CPET); 2) the characteristics associated with cardiopulmonary exercise testing (CPET) performance; 3) the safety and tolerability of CPET.

Methods

We prospectively enrolled consecutive patients with laboratory-confirmed COVID-19 from Azienda Sanitaria Locale 3, Genoa. Three months after hospital discharge a complete clinical evaluation, trans-thoracic echocardiography, CPET, pulmonary function tests, and dominant leg extension (DLE) maximal strength measurement were performed.

Results

From the 225 patients discharged alive from March to November 2020, we excluded 12 incomplete/missing cases and 13 unable to perform CPET, leading to a final cohort of 200. Median percent-predicted peak oxygen uptake (%pVO2) was 88% (78.3–103.1).

Ninety-nine (49.5%) patients had %pVO2 below, whereas 101 (50.5%) above the 85% predicted value.

Among the 99 patients with reduced %pVO2, 61 (61%) had a normal anaerobic threshold: of these, 9(14.8%) had respiratory, 21(34.4%) cardiac, and 31(50.8%) non-cardiopulmonary reasons for exercise limitation. Inerestingly, 80% of patients experienced at least one disabling symtpom, not related to %pVO2 or functional capacity.

Multivariate linear regression showed percent-predicted forced expiratory volume in one-second(β = 5.29,p = 0.023), percent-predicted diffusing capacity of lungs for carbon monoxide(β = 6.31,p = 0.001), and DLE maximal strength(β = 14.09,p = 0.008) to be independently associated with pVO2.

No adverse event was reported during or after CPET, and no involved health professional developed COVID-19.

Conclusions

At three months after discharge, about 1/3rd of COVID-19 survivors show functional limitations, mainly explained by muscular impairment, calling for future research to identify patients at higher risk of long-term effects that may benefit from careful surveillance and targeted rehabilitation.

[Italian cardiologists and tobacco smoking. A survey on the prevalence and knowledge of smoking and strategies for smoking cessation in a cohort of Italian cardiologists]

BACKGROUND

Tobacco use is the single most preventable cause of death. Its cessation is the most cost-effective strategy for reducing long-term cardiovascular morbidity and mortality. Although both healthcare professionals and the general population are aware of the detrimental effects of smoking on health, more than 25% of Italians are current smokers. Recent surveys showed that almost 50% of smoker patients relapse to smoke after having been discharged for acute coronary syndrome. Physicians who smoke may be a barrier for effective cessation interventions. Thus, it is important to assess cardiologists' attitude toward smoking habits and the implementation of smoking cessation programs.

METHODS

The survey "Italian cardiologists and smoking habits" has been held in 2013 during the 44° National Congress of the Italian Association of Hospital Cardiologists (ANMCO) to assess cardiologists' smoking status, their level of knowledge about smoking cessation interventions and their involvement in the management of smoking cessation. Out of more than 1200 cardiologists attending the ANMCO congress, 610 subjects (aged 51 ± 11 years) answered an anonymous 35-item questionnaire; they were asked to declare their smoking status (9.5% current smokers).

RESULTS

Among doctors who attended the survey, 58% correctly indicated smoking as an addiction and 45% regularly advised their patients to stop smoking. The majority of cardiologists (93%) reported a positive attitude toward smoking cessation strategies, 62% of them thought that cardiologists themselves should treat smoking dependence, though specific tools (70%) and education for the management of smoking cessation are lacking (66%). Two thirds of the entire sample of ANMCO cardiologists declared their willingness to participate in specialized educational programs.

CONCLUSIONS

More than a half of Italian cardiologists are aware that smoking is an addiction. Although they feel themselves yet inadequate toward this approach, they are favorable to implement their own knowledge and skills toward smoking cessation.

[Appropriateness of diagnostic tests in cardiovascular prevention: what can we skip?]

In recent years, a huge increase in the use of cardiac procedures, both invasive and non-invasive, was observed. Diagnostic tests, mainly non-invasive tests, are often prescribed inappropriately, in most cases replacing the clinical evaluation. The rate of inappropriate tests in cardiology is largely variable, depending on regional issues and different medical approach. When the test entails radiation exposure, the biological risk for both the patient and the environment must be taken into account. For this reason, the test that results in less biological risk should always be preferred as a first step.Moreover, it has not been clearly demonstrated that some diagnostic tests help to improve the outcome, that is to prevent cardiovascular events. As many as one sixth of the patients who undergo stress imaging are not taking proper medication, and very frequently no change in therapy is made after the test, regardless of the outcome. Since the appropriateness of diagnostic evaluation requests is mandatory, we focused on the diagnostic tests usually performed in primary and secondary prevention that carry no contribution to the clinical management of patients. This review addresses the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models.

Effect of smoking relapse on outcome after acute coronary syndromes

The aim of the present study was to evaluate the smoking relapse rate among smokers who had become abstinent during admission for acute coronary syndromes. The association between smoking relapse and mortality was also analyzed. A cohort of 1,294 consecutive active smokers who had interrupted smoking after admission for acute coronary syndromes (1,018 men and 276 women, mean age 59.7 ± 12.3 years) was followed up for 12 months after the index admission. All patients received a brief in-hospital smoking cessation intervention consisting of repeated counseling sessions. During follow-up, 813 patients (62.8%) resumed regular smoking (median interval to relapse 19 days, interquartile range 9 to 76). Increasing age (hazard ratio [HR] 1.034 per year, 95% confidence interval [CI] 1.028 to 1.039, p = 0.001) and female gender (HR 1.23, 95% CI 1.09 to 1.42, p = 0.03) were independent predictors of smoking relapse. Patients enrolled in a cardiac rehabilitation program (HR 0.74, 95% CI 0.51 to 0.91, p = 0.02) and those with diabetes (HR 0.79, 95% CI 0.68 to 0.94, p = 0.03) were more likely to remain abstinent. During follow-up, 97 patients died (1-year probability of death 0.075, 95% CI 0.061 to 0.090). Multivariate analysis with the Cox proportional hazard regression method, including smoking relapse as a time-dependent covariate, demonstrated that, after adjustment for patient demographics, the clinical history features and variables related to the index event, the resumption of smoking was an independent predictor of total mortality (HR 3.1, 95% CI 1.3 to 5.7, p = 0.004). In conclusion, smoking relapse after acute coronary syndromes is associated with increased mortality, and counseling interventions should be integrated into the postdischarge support to reduce the negative effects of smoking resumption.

[Pharmacotherapy of tobacco smoking from the point of view of the clinical cardiologist]

Medical programs supporting smoking cessation are a complex task to set up. Each smoker should be evaluated for his stage of motivation to change, his nicotine dependence degree and also for the presence of relevant existing comorbidities. Several non pharmacologic techniques and a number of drugs have been demonstrated clearly effective in the smoking cessation therapy field. The purpose of this review is to analyse the available drug therapies mainly considering their possible use in the clinical cardiology "real world" scenario. Specific attention has been paid to the cardiovascular safety of each drug therapy trying to anticipate possible questions and concerns emerging in the daily practice of the clinical cardiologist, who normally can't be considered a smoking cessation "natural born" specialist.

[Nicotine dependence therapy: medical counselling and other non pharmacological interventions]

Cigarette smoking and nicotine dependence represent a complex disease. In the treatment program design the combination of non pharmacological and pharmacological therapy, the concurrence of physicians and other health professionals has been demonstrated the most successful therapeutic approach. This article reviews the main evidence based non pharmacological interventions. Social support request, self-monitoring and smoking behaviour modification are cornerstones of the preparation to quit. Post cessation counselling is mainly focused on problem solving activities. The complementary use of exercise and relaxation training is also evaluated.

[Clinical evaluation of smokers]

The number of patients who continue to smoke after a major cardiac event is high. More and more often the patients ask the cardiologist to help them quitting smoking. In the last few years the rapid developments in the neuropharmacological field set up the bases for a more effective and evidence based treatment of nicotine dependence. Thus a number of reviews, guidelines and original articles has been published in internal medicine, cardiology and pneumology journals and their main purpose was to increase as much as possible the number of physicians able to set up a "specialistic" nicotine dependence treatment. The aim of this article is instead to review the stages of the smoker clinical evaluation in a "specialistic" environment and to translate them in practical tips ready to be used in the cardiological daily practice. Three issues are specifically reviewed: motivation to quit, degree of nicotine dependence and the role of mood disturbances.

Usefulness of transdermal clonidine in hypertensive patients undergoing minor surgical operations

Transdermal clonidine (TTSC) treatment was evaluated in 29 patients with mild to moderate hypertension scheduled for minor surgery. Two weeks before the scheduled operation, patients underwent 24-h ambulatory blood-pressure monitoring (ABPM) to evaluate the efficacy of previous oral antihypertensive treatment, which was then substituted with TTSC, 0.1 mg/day. After 1 week, the efficacy of TTSC was clinically assessed, and the dose increased to 0.2 mg/day if needed. ABPM was repeated 2 days before the scheduled operation and 2 days after surgery. The 24-h blood pressure (BP) and heart rate (HR) profiles were smoothed by Fourier analysis. Three patients withdrew for adverse events and one for inefficacy after dose adjustment, TTSC being effective in the remaining 25 patients. Two patients who completed treatment lacked postsurgical ABPM recording. In the 23 patients with all ABPM recordings, average 24-h BP and HR obtained preoperatively during TTSC treatment were slightly reduced compared with values recorded during previous oral therapy. BP changes after surgery were negligible, whereas HR showed a moderate increase. Minor adverse events occurred in four (14%) of 29 patients. Our results demonstrate that TTSC provides adequate BP control in patients with mild to moderate hypertension undergoing minor surgery.

Right ventricular dysplasia: radioisotopic angiography

To evaluate if regional wall motion (RWM) abnormalities detected at rest in patients with high presumption of right ventricular dysplasia (RVD) are confirmed by stress test and could be considered of diagnostic value in the clinical setting of the disease, 12 patients underwent first-pass radionuclide angiography (RA) at rest and during exercise. The mean global right ventricular ejection fraction (EF) was 29.83 +/- 7.91 at rest; during exercise, we found a non-significant increase (32.16 +/- 9.8, P greater than 0.05). Six segments with systo-diastolic dyskinesis, three segments with diastolic dyskinesis, and 10 segments with akinesis at rest confirmed the same degrees of dysfunction during exercise. Eight of the 15 hypokinetic segments at rest showed normal function during exercise; the remaining seven confirmed the same degree of dysfunction during exercise. We conclude that various degrees of RWM abnormalities are found in all patients with RVD; hypokinetic dysfunction has to be confirmed by exercise. RWM abnormalities are not specific for RVD, and clinical and electrophysiological data should be combined to obtain as much evidence as possible for diagnosis.