First report of the International Council of Cardiovascular Prevention and Rehabilitation's Registry (ICRR)

OBJECTIVES

Cardiac rehabilitation - programs comprehensively delivering outpatient secondary prevention - is under-available and under-studied in the resource-poor settings where it is needed most. This report summarizes the governance, participating sites, patient characteristics and outcomes, as well as knowledge translation activities during first year of operation of ICCPR's registry, namely the International Cardiac Rehab Registry.

METHODS

A pilot study was undertaken with five centers, demonstrating feasibility, satisfaction with the on-boarding processes, as well as data quality.

RESULTS

Fourteen centers have been engaged from all regions but Europe; Data have been entered on >1000 patients (18.1% female; mean age = 57.6), of whom 62.4% completed their programs and 19.9% dropped out for work or clinical reasons. Post-program, completers had significantly better work status, functional capacity, medication adherence, physical activity levels, diet, as well as lower tobacco use than non-completers (all p < 0.05). A site Certification program was developed and piloted, with five centers now recognized for their quality, given they met over 70% of the 13 internationally agreed standards based on Registry data and a virtual site assessment.

CONCLUSION

Annual assessments have started. Quality improvement activities will soon be underway. We continue to invite new programs, supporting development in resource-poor settings to the benefit of patients served.

Controlled pilot test of a translated cardiac rehabilitation education curriculum in percutaneous coronary intervention patients in a middle-income country delivered using WeChat: acceptability, engagement, satisfaction and preliminary outcomes

In China, despite the rapid increase in percutaneous coronary interventions (PCIs), cardiac rehabilitation (CR) is just burgeoning, leaving a need for comprehensive evidence-based education curricula. This pilot study assessed the acceptability of Simplified Chinese CR education delivered via booklets and videos on WeChat asynchronously and the impact on improving knowledge, risk factors, health behaviors and quality of life. In this pre-post, controlled, observational study, interested PCI patients received the 12-week intervention or usual care and WeChat without education. Participants completed validated surveys, including the Coronary Artery Disease Education-Questionnaire and Self-Management Scale. Acceptability (14 Likert-type items), engagement (minutes per week) and satisfaction were assessed in intervention participants. Ninety-six patients consented to participate (n = 49 intervention), of which 66 (68.8%) completed the follow-up assessments. Twenty-seven (77.1%) retained intervention participants engaged with the materials, rating content as highly acceptable (all means ≥4/5) and satisfactory (2.19 ± 0.48/3); those engaging more with the intervention were significantly more satisfied (P = 0.03). While participants in both groups achieved some improvements, only intervention participants had significant increases in disease-related knowledge, reductions in body mass index and triglycerides, as well as improvements in diet (all P < 0.05). In this first study validating the recently translated CR patient education intervention, acceptability and benefits have been supported.

The first 142 amino acids of glutamate decarboxylase do not contribute to epitopes recognized by autoantibodies associated with Type 1 diabetes

AIMS

Glutamate decarboxylase (GAD) antibodies are the most widely used predictive marker for Type 1 diabetes, but many individuals currently found to be GAD antibody-positive are unlikely to develop diabetes. We have shown previously that radioimmunoassays using N-terminally truncated ³⁵ S-GAD₆₅ (96-585) offer better disease specificity with similar sensitivity to full-length ³⁵ S-GAD₆₅ (1-585). To determine whether assay performance could be improved further, we evaluated a more radically truncated ³⁵ S-GAD₆₅ (143-585) radiolabel.

METHODS

Samples from people with recent-onset Type 1 diabetes (n = 157) and their first-degree relatives (n = 745) from the Bart's-Oxford family study of childhood diabetes were measured for GAD antibodies using ³⁵ S-labelled GAD₆₅ (143-585). These were screened previously using a local radioimmunoassay with ³⁵ S-GAD₆₅ (1-585). A subset was also tested by enzyme-linked immunosorbent assay (ELISA), which performs well in international workshops, but requires 10 times more serum. Results were compared with GAD antibody measurements using ³⁵ S-GAD₆₅ (1-585) and ³⁵ S-GAD₆₅ (96-585).

RESULTS

Sensitivity of GAD antibody measurement was maintained using ³⁵ S-GAD₆₅ (143-585) compared with ³⁵ S-GAD₆₅ (1-585) and ³⁵ S-GAD₆₅ (96-585). Specificity for Type 1 diabetes was improved compared with ³⁵ S-GAD₆₅ (1-585), but was similar to ³⁵ S-GAD₆₅ (96-585). Relatives found to be GAD antibody-positive using these truncated labels were at increased risk of diabetes progression within 15 years, compared with those positive for GAD(1-585) antibody only, and at similar risk to those found GAD antibody-positive by ELISA.

CONCLUSIONS

The first 142 amino acids of GAD₆₅ do not contribute to epitopes recognized by Type 1 diabetes-associated GAD antibodies. Low-volume radioimmunoassays using N-terminally truncated ³⁵ S-GAD₆₅ are more specific than those using full-length GAD₆₅ and offer practical alternatives to the GAD antibody ELISA for identifying children at increased risk of Type 1 diabetes.

Cardiac rehabilitation wait times and relation to patient outcomes

BACKGROUND

Most cardiac rehabilitation (CR) associations have published guidelines recommending timely and early access.

AIM

To review the effects of early CR initiation on patient outcomes, and to describe the wait times associated with positive outcomes.

DESIGN

Studies were identified via a limited systematic search on key resource databases, including MEDLINE, EMBASE, and CINAHL. A focused Internet search was conducted with a concentrated grey literature search for evidence reports.

POPULATION

Studies which enrolled adult cardiac patients who were eligible to participate in a CR program, based on CR guidelines, were considered.

METHODS

Methodological filters limited retrieval for articles published between January 1, 2002-March 4, 2013. Two reviewers screened references which were identified by the search strategy by examining the titles and abstracts. If the abstract identified the appropriate patient group, and addressed CR wait times, the full article was obtained for inclusion consideration. Ten articles were included for review. Results were extracted from included studies, and results were synthesized narratively.

RESULTS

Early access was generally shown to be safe, and to have positive effects in terms of cardiac function and patient enrollment. Positive effects on functional capacity were shown with CR initiation within 3 months from an index event. Effects on quality of life were null in the long-term. Wait times ranged from 8.5-127.0 days. Seventeen days may be the optimal wait time to balance benefit with risk.

CONCLUSION

Timely access to cardiac rehab can achieve greater patient enrolment. Research on the effects of early access on heart healthy behaviors and mental health are needed. Evidence-based recommendations for wait times should be formulated by indication.

CLINICAL REHABILITATION IMPACT

Delays to intake should be minimized, and wait times shortened significantly, so that patients can reap the maximum benefits from CR participation.

Outcomes associated with cardiac rehabilitation participation in patients with musculoskeletal comorbidities

BACKGROUND

Individuals with coronary artery disease (CAD) and musculoskeletal comorbidities (MSKCs) have much to gain from physical activity, yet are less likely to be referred to cardiac rehabilitation (CR) than those without MSKCs. Whether patients with MSKCs achieve demonstrated benefits of CR participation such as improved quantity and quality-of-life remains unknown.

AIM

To compare all-cause mortality, major acute cardiovascular events (MACEs), quality-of-life and psychosocial well-being in patients with CAD and coexisting MSKCs by CR participation.

DESIGN

Prospective and observational study in which patients were administered a questionnaire in the hospital and 1 year later. The cohort was linked to provincial databases.

SETTING

Eleven hospitals in Ontario, Canada.

POPULATION

CAD patients (N.=1680).

METHODS

CAD inpatients were administered a questionnaire assessing sociodemographic and clinical characteristics. Clinical data were extracted from charts. CR participation, quality-of-life, depressive symptoms, functional status, and physical activity behavior were measured 1 year later by questionnaire. The cohort was linked to provincial administrative databases to ascertain mortality and MACEs for a median of 2.7 years post-index cardiac hospitalization. Associations of CR participation with outcomes were tested after adjustment for differences in participation propensity.

RESULTS

Of study participants, 50.7% (851/1680) had MSKCs and of those with MSKCs, 49.8% (424/851) participated in CR. Patients with MSKCs who participated in CR had greater physical quality-of-life (P<0.03) and lower mortality than those with MSKCs who did not attend CR, after adjusting for propensity for CR participation (1.4% vs. 4%; participant vs. non-participants, P=0.03) - non-participants' hazard ratio 3.91 [95%CI,1.23-12.36]). There were no differences for MACEs.

CONCLUSION

Among those with MSKCs, participation in CR is associated with survival benefit and better physical quality-of-life compared to non-participants.

CLINICAL REHABILITATION IMPACT

Our findings showing the high prevalence of MSKCs in those with CAD and the benefits of CR, add to the literature that will provide the basis for exploration of initiatives to improve care for those with CAD and MSKC, and to overcome barriers to improved outcomes and reduced death. These results will help to guide focused research to optimize complex outpatient care in this group, including increasing the utilization of CR.

Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis

BACKGROUND

The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity.

AIMS

To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity.

METHOD

An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses.

RESULTS

Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26-1.38, P<0.001) for all-cause mortality and 1.19 (95% CI 1.14-1.24, P<0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively.

CONCLUSIONS

The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z-score.

The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature

The incidence of postpartum depression (PPD) in Western societies is approximately 10-15% and its cause multi-faceted. Because mothers largely constitute infants' social environment and mediate their experience of the external world, it is imperative to investigate the effects of PPD on child growth and development. PsycInfo, Medline, Embase, CINAHL, ProQuest, and Health Star databases were searched with key terms for English language abstracts from 1990 onwards, and key contents were searched. There are small effects of PPD on cognitive development such as language and IQ, seen particularly among boys. Behavioral effects are variably supported, but may persist up to 5 years postpartum and beyond. However, chronic or recurrent maternal depression, rather than postpartum depression per se is likely related to later effects on the child. These adverse effects of PPD based on sex of infant are discussed.