Cardiovascular rehabilitation delivery and outcomes in Switzerland: data from a national database over the last decade

Background

Cardiac rehabilitation (CR) is a multidisciplinary, comprehensive, exercise-based intervention strongly recommended by current guidelines to improve symptoms and quality of life and to reduce cardiovascular adverse outcomes, mainly in patients with coronary artery disease and heart failure. CR activities have not been reported on a Swiss national base so far.

Purpose

To report CR outcome variables from a Swiss national base.

Methods

As part of the Swiss working group for cardiovascular prevention, rehabilitation, and sports cardiology (SCPRS) quality standards, all Swiss CR centres provide yearly a quality indicator report on an online questionnaire. Annual data from 2010 to 2019 were transferred as medians or means of all individual patients' data from each centre. We used the t-Student test to compare changes of outcome variables between entry and exit of the programme.

Results

A total of 133,060 CR patients were included (68,690 inpatients and 64,370 outpatients) with a progressive increase reaching its climax with 14'909 patients/year in 2018. Mean age ± standard deviation (SD) in outpatient and inpatient programmes was 60±1 and 68±1 years, and women percentage 21% and 32%, respectively. The most common CR indication was acute coronary syndrome (51%) in outpatient, whereas cardiovascular surgery of various types (60%) was the main indication in inpatient programmes. Mean improvement ± SD of functional capacity was 38% ±3.6 using the six-minute walk test in inpatient (p<0.001) and 21% ±2 using cycle-ergometer maximal exercise testing in outpatient programmes (p<0.001). Quality of life mainly assessed with the 12-item Short Form Survey (SF-12) in outpatient CR improved by 13% ±4.5. MacNew Heart questionnaire systematically performed in inpatient programmes showed significant improvement at emotional level by 12% ±0.4, at physical level by 30% ±0.9, and at social level by 18% ±0.6.

Conclusion

Even if still underutilised in certain groups of patients such as women or heart failure, CR has gained growing importance in Switzerland during the last decade. Functional capacity, as well as quality of life, was significantly improved. Individual CR patient data should be collected in the future to improve assessment of outcome parameters and benchmarking of centres.

Funding Acknowledgement

Type of funding sources: None.

[Psychosocial Aspects in Cardiac Rehabilitation: From Theory to Practice. A Position Paper From the Cardiac Rehabilitation Section of The European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology]

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with establishedCHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

[Suddenly occurring exercise intolerance]

In this case report, the differencial diagnosis of exercise intolerance associated with dyspnea and the diagnostic approach with cardio-pulmonary exercise testing with detection of an exercise induced second-degree atrio-ventricular block as a cause of chronotropic incompetence is described.

[Proposal for a shortened i.v. antibiotic treatment as cost-saving measure in the treatment of uncomplicated infections]

New oral antibiotics with high rates of absorption and good bioavailability make it possible to reduce costs by shortening the i.v. treatment period. During two 2-month periods we analyzed every patient of the Medical Department who received i.v. treatment. We tried to reduce i.v. treatment duration simply by discussion with the responsible physician, guided essentially by the clinical course. The number of patients with reduced i.v. treatment were compared with a control period. We found that by this means, an i.v. treatment period of 4-7 days could often be reduced to 1-3 days. The main target pathologies with corresponding cost savings appeared to be infections of the lower respiratory tract, with a cost-saving potential of 1.4 days (p < 0.0001) and urinary tract infections with a cost-saving potential of SFr. 179.-(US$ 138.-) per case.

Atmospheric reactions of polycyclic aromatic hydrocarbons: facile formation of mutagenic nitro derivatives

Directly active mutagens are formed on exposure of the promutagen benzo[a]pyrene to gaseous pollutants in smog. In simulated atmospheres containing 1 part per million nitrogen dioxide and traces of nitric acid, directly mutagenic nitro derivatives are readily formed from both benzo[a]pyrene and perylene, a non-mutagen in the Ames reversion assay. Possible formation of direct mutagens by such reactions on sample collection filters, in exhaust effluents, and in the atmosphere should be recognized.