Predictors of long-term survival in patients undergoing residential cardiac rehabilitation (rCR) after transcatheter aortic valve replacement (TAVR): a multicenter retrospective study

Purpose

To evaluate exercise-based rCR derived outcome predictors in patients referred after TAVR.

Methods

Data of 232 patients (aged 82±6 years, 45%males) admitted to an average 3-week rCR program after TAVR (walking, up to 30 minutes of cycling or treadmill session twice daily, respiratory and calisthenic training) from January 2009 to December 2017 and home discharged, were retrospectively collected at 10 rCR Divisions of Istituti Clinici Scientifici Maugeri. Comorbidity (cumulative illness rated state-comorbidity index) (CIRS-CI) score, echocardiography on admission, disability (Barthel Index) (BI) score at discharge, six minutes walking test distance (6MWT) on discharge and maximal training session intensity (MTSI expressed in METs per minutes) were collected. All-cause mortality was assessed up to 3 years after rCR discharge.

Results

During a 3-year follow-up, there were 74 (32%) deaths. At univariate analysis, at discharge non survivors compared to survivors had significantly higher comorbidity rate (CIRS-ICC 5.2±2.3 vs 4.1±1.9, p=0.000) and disability level (BI 80.4±24 vs 88.8±17, p=0.000). Moreover, they had worse renal function (creatinine 1.6±0.9mg/dl vs 1.2±0.4, p=0.000), were more often on diuretic therapy (73% vs 53.2%, p=0.003) and on beta-blocker therapy (73% vs 57,6%, p=0.042) and had a markedly reduced functional capacity (6MWTD 221±100m vs 265±105m, p=0.001). At multivariate logistic stepwise analysis a lower comorbidity (CIRS-ICC), a more preserved renal function (creatinine level), a reduced use of diuretic therapy and 6MWT at discharge confirmed their power as independent predictors of survival at follow up (Table, Harrel's C = 0.707)

Conclusions

Patients attending rCR after TAVR are very old with significant comorbidity; overall mortality at 3-year follow-up after CR discharge is substantial. Our results suggest the need to implement ad-hoc long-term care strategies based on residual exercise capacity, comorbidity score and renal function for tailoring follow-up in patients discharged from rCR after TAVR.

Funding Acknowledgement

Type of funding sources: None. Table 1

Delphi consensus recommendations on how to provide cardiovascular rehabilitation in the COVID-19 era

This Delphi consensus by 28 experts from the European Association of Preventive Cardiology (EAPC) provides initial recommendations on how cardiovascular rehabilitation (CR) facilities should modulate their activities in view of the ongoing coronavirus disease 2019 (COVID-19) pandemic. A total number of 150 statements were selected and graded by Likert scale [from -5 (strongly disagree) to +5 (strongly agree)], starting from six open-ended questions on (i) referral criteria, (ii) optimal timing and setting, (iii) core components, (iv) structure-based metrics, (v) process-based metrics, and (vi) quality indicators. Consensus was reached on 58 (39%) statements, 48 'for' and 10 'against' respectively, mainly in the field of referral, core components, and structure of CR activities, in a comprehensive way suitable for managing cardiac COVID-19 patients. Panelists oriented consensus towards maintaining usual activities on traditional patient groups referred to CR, without significant downgrading of intervention in case of COVID-19 as a comorbidity. Moreover, it has been suggested to consider COVID-19 patients as a referral group to CR per se when the viral disease is complicated by acute cardiovascular (CV) events; in these patients, the potential development of COVID-related CV sequelae, as well as of pulmonary arterial hypertension, needs to be focused. This framework might be used to orient organization and operational of CR programmes during the COVID-19 crisis.

[HCF-ANMCO/AICPR/GIEC/ITAHFA/SICOA/SICP/SIMG/SIT Cardiological Societies Council Consensus document: Anticoagulant therapy in venous thromboembolism and atrial fibrillation of the patient with cancer. Current knowledge and new evidence]

Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, either symptomatic or incidental, is a common complication in the history of cancer disease. The risk of VTE is 4-7-fold higher in oncology patients, and it represents the second leading cause of death, after cancer itself. In cancer patients, compared with the general population, VTE therapy is associated with higher rates of recurrent thrombosis and/or major bleeding. The need for treatment of VTE in patients with cancer is a challenge for the clinician because of the multiplicity of types of cancer, the disease stage and the imbricated cancer treatment. Historically, in cancer patients, low molecular weight heparins have been preferred for treatment of VTE. More recently, in large randomized clinical trials, direct oral anticoagulants (DOACs) demonstrated to reduce the risk of VTE. However, in the "real life", uncertainties remain on the use of DOACs, especially for the bleeding risk in patients with gastrointestinal cancers and the potential drug-to-drug interactions with specific anticancer therapies.In cancer patients, atrial fibrillation can arise as a perioperative complication or for the side effect of some chemotherapy agents, as well as a consequence of some associated risk factors, including cancer itself. The current clinical scores for predicting thrombotic events (CHA2DS2-VASc) or for predicting bleeding (HAS-BLED), used to guide antithrombotic therapy in the general population, have not yet been validated in cancer patients. Encouraging data for DOAC prescription in patients with atrial fibrillation and cancer are emerging: recent post-hoc analysis showed safety and efficacy of DOACs for the prevention of embolic events compared to warfarin in cancer patients. Currently, anticoagulant therapy of cancer patients should be individualized with multidisciplinary follow-up and frequent reassessment. This consensus document represents an advanced state of the art on the subject and provides useful notes on clinical practice.

3039Vulnerability of carotid atherosclerosis: relationship with plaque location, plaque eccentricity and vessel remodeling patterns. Insight from the the MAGNETIC observational study

Conclusions

Carotid atherosclerotic plaque vulnerability seems to be independently associated with longitudinal location, plaque eccentricity and vessel positive remodeling.

Acknowledgement/Funding

Bayer AG, Leverkusen, Germany

[ANMCO/ANCE/ARCA/GICR-IACPR intersociety consensus document: long-term antiplatelet therapy in patients with coronary artery disease]

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS) and/or receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischemia, repeat hospitalization, and death. Over the last years, multiple randomized clinical trials have been published comparing duration of DAPT after PCI and in ACS patients investigating either a shorter or prolonged DAPT regimen.Although current European Society of Cardiology guidelines provide backup to individualize treatment, it seems difficult to identify the ideal patient profile who could safely reduce or prolong DAPT duration in daily clinical practice. The aim of this consensus document is to review the contemporary literature on optimal DAPT duration and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Metabolic syndrome in patients with intermittent claudication referred to vascular rehabilitation

AIM

The prevalence of the metabolic syndrome, a clustering of cardiovascular risk factors whose underlying pathophysiology is related to insulin resistance, was estimated in patients with intermittent claudication referred to a short-course intensive rehabilitation program focused on physical training. Improvements in walking distance at the end of the program were also compared among patients with and without the syndrome.

METHODS

The metabolic syndrome was documented among 34 (39%) out of 87 enrolled patients, without significant differences between those with and without the syndrome concerning sex (males 91% vs 92% respectively, P=0.816), age (64+/-8 vs 65+/-7 years, P=0.54), coronary heart disease (44% vs 32%, P=0.365), localization of peripheral arterial disease, and impairment of walking capacity as evaluated by constant treadmill test (initial claudication distance (ICD) 156+/-93 vs 176+/-126 m, P=0.428; absolute claudication distance (ACD) 429+/-324 vs 409+/-269 m, P=0.756).

RESULTS

At the end of the program, both ICD and ACD significantly improved without any of significant differences between the two groups (ICD +152% vs +174% respectively, P=0.518; ACD +112% vs +177%, P=0.053).

CONCLUSIONS

Metabolic syndrome is frequent among patients with intermittent claudication and is not associated with poor response to physical training. Our data highlight the need for considering vascular rehabilitation in these patients in order to both improve walking capacity and minimize cardiovascular morbidity and mortality.

Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication

AIM

The aim of this study was to provide cost-description and cost-effectiveness of a short-course intensive in-hospital rehabilitation program in patients with intermittent claudication.

METHODS

Costs per case treated were calculated according to a local standard protocol including diagnostic evaluation of peripheral arterial disease and other related cardiovascular conditions, physical training, and secondary prevention. Three additional less structured scenarios were also evaluated.

RESULTS

All 107 enrolled patients (males 91%, mean age 65+/-8 years) completed the program (4-week duration; twice a day walking exercise) and showed significant increases in walking performance, as evaluated by constant treadmill-test. At admission, the mean values of initial claudication distance (ICD) and absolute claudication distance (ACD) were 150+/-111 and 432+/-327 m, respectively. At the end of the program, 12 (11%) patients completed the treadmill test without pain, while 31 (29%) completed the test without stopping due to maximal pain. Among the remaining 64 (60%) patients, the ICD and ACD increased by 137% and 112%, respectively. The cost per case treated ranged from Euro 1733.2 (standard protocol) to Euro 918.9 (physical training only). By adding the cost of hospitalization and indirect costs, the same costs ranged from Euro 4626.2 to Euro 3811.9. The average cost to walk one additional meter without pain as a result of the rehabilitation program was Euro 57.5, while the cost to walk one additional meter before stopping was Euro 27. As showed by sensitivity analysis, the maintenance of the expected level of treatment success was crucial for program's cost-effectiveness.

CONCLUSION

From the societal viewpoint, short-course intensive rehabilitation may be cost-effective in patients with stable intermittent claudication and could be considered in decision models evaluating different therapeutic options.

Clinical validation of an anxiety and depression screening test for intensive in-hospital rehabilitation

Routine hospital psychological care must necessarily make use of a clinically reliable screening instrument for the identification of the patients to be referred for a clinical interview with a psychologist. This study compared two tests for the evaluation of anxiety and depression that are widely used in the hospital setting: the Hospital Anxiety and Depression Scale (HADS) and Form A-D, consisting of the State-Trait Anxiety Inventory (STAI-X1) for the evaluation of anxiety, and the Depression Questionnaire (DQ) for measuring depression. The aim of the study was to identify which of these instruments is the most suitable for screening a population admitted at in-hospital intensive rehabilitation using the clinical interview-based psychological evaluation as the gold standard. Both of the tests showed a concordance with the clinical opinion expressed by the psychologist, whose judgement was guided by the use of the validation study evaluation form. The analyses confirmed the good correlation of the two instruments in measuring anxiety and depression. The sensitivity of the STAI-X1 (52%) was less than that of HADS section A (72%), but its specificity (99%) was greater than that observed with the application of the HADS Anxiety subscale (84%). Analysis of the ROC curves showed that the STAI-X1 percentages of sensitivity and specificity tended to balance at higher level with a cut-off point equal to the 80th percentile. The results of the analysis of the DQ demonstrated equivalence with the results obtained using HADS section D, with a cut-off point of the 90th percentile. On the basis of these results, and given that both the STAI-X1 and the DQ have a broadly based Italian normative population, we feel that they can be recommended for psychological screening of patients in an in-hospital intensive rehabilitation.

[Stratification of arrhythmia risk in infarction: reflexions in the light of large trials]

The identification of patients at higher risk of life-threatening ventricular arrhythmias after myocardial infarction still represents a clinically relevant problem, particularly after results of recent studies which support the efficacy of implantable cardioverter defibrillator (ICD) in reducing total mortality in patients with a previous myocardial infarction and left ventricular dysfunction, with and without additional risk markers. However, owing to the high cost of ICD therapy, an effective arrhythmic risk stratification may be desirable. The low diagnostic accuracy reported by various studies using single risk stratifiers (either invasive and non invasive) suggested a combined use of multiple parameters in order to improve the predictive power of the risk stratification algorithms. This approach, that takes into account the multifactorial genesis of malignant ventricular arrhythmias, has been demonstrated to be able to identify subgroups of patients at very high arrhythmic risk. In particular, a two-level algorithm based upon the selection of candidates to electrophysiologic study among patients with abnormal non-invasive testing, showed itself as a particularly effective tool for identification of such patients. In this paper the Authors summarize most recent results on the risk stratification protocols and the use of ICDs and provide an operative algorithm that keeps into account either aggressive and moderate approaches to patients surviving a myocardial infarction.