Purpose: Cardiovascular disease can partially be prevented by not being overweight and by making prudent lifestyle choices with regard to diet, physical activity, and smoking. Hence, behaviour change programmes should simultaneously be targeted at multiple lifestyle factors. the purpose of the present study was to evaluate the medium-term effect of a tailored behaviour change programme on a composite lifestyle change score.
Methods: this was a randomised controlled trial with 314 participants allocated to a control and an intervention condition consisting of a tailored behaviour change programme (web-based and individual coaching). It was a homogenous study sample of highly educated adults with a Master s degree in Law. the dose of the coaching was chosen by the participants and registered throughout the trial. Outcome measures were weight, saturated fat intake, fruit- and vegetable intake, physical activity, smoking status and a composite lifestyle change score. T-tests, Mann Whitney U tests and a One-way analysis of variance were used to compare the study conditions and three intervention dose groups (no/low, medium, and high intervention dose). Statistical significance was set at a = .05.
Results: the participants in the intervention condition improved proportionally more for weight, saturated fat intake, fruit- and vegetable intake, physical activity, and the composite lifestyle score than participants the control condition. However, none of the differences reached statistical significance. Nevertheless, the composite lifestyle change score was significantly higher in the high intervention dose group compared to the group with no or a low intervention dose (P = .01).
Conclusions: the composite lifestyle change score was positively related to the intervention dose. Behaviour change programmes that target multiple lifestyle factors should be evaluated accordingly by using a composite lifestyle change score. the intervention effect, however, should be considered in the light of the actual intervention dose received.
P509
A novel telephone approach to secondary prevention increases access for acute coronary syndrome patients
L Neubeck, J Redfern
University of Sydney, Sydney, Australia
Topic: Cardiovascular rehabilitation
Background: Currently there is a large evidence-practice gap in secondary prevention of coronary heart disease (CHD) where only the minority of people with CHD access facility cardiac rehabilitation (CR). this study compares attendance rates at secondary prevention programmes before and after implementation of a complementary novel telephone based CHOICE intervention. Barriers and enablers to implementing the novel model of secondary prevention among acute coronary syndrome (ACS) survivors were determined.
Methods: We collected data for two six-month periods and summarised the total number of ACS admissions (identified using diagnostic related codes) at four tertiary hospitals and determined the number and proportion of those patients who attended a secondary prevention program. In the first period (May-Nov 2008) only facility CR was available and in the second period (May-Nov 2009) facility CR and an additional novel telephone-based CHOICE program were available. We then compared the proportion of ACS patients admitted in each period who participated in CR or CHOICE. A literature review, qualitative surveys focus groups and interviews were used to elicit barriers and enablers to introducing and implementing the CHOICE programme.
Results: In the May-Nov 2008, period 821 patients were admitted with an ACS and 293 (36%) attended facility CR. For the corresponding period in 2009, 693 patients were admitted with ACS, an estimated one third participated in CR and 121 (17.5%) participated in the additional CHOICE program. Overall, 17.5% patients attended CHOICE who would not otherwise have received formal secondary prevention and this difference was significant (CI 0.12 to 0.21, p<0.001). A substantial number declined to participate in the CHOICE program because it was a research study (79 (10%), CI 0.06 to 0.16, p <0.001). Analysis of the barriers and enablers suggest that actively engaging patients, having informed and knowledgeable staff and a social context of support for evidence based clinical practice were important determinants for successful implementation.
Conclusions: Offering a complementary telephone intervention in addition to CR significantly improved participation in a formal secondary prevention programme. Improving access to an effective secondary prevention program for patients who have CHD is likely to translate into reductions in coronary events and absolute risk.
P510
Efficacy of telemonitoring service in cardiac rehabilitation programs in public gyms
P Deligiannis, N Kouidis, A Farmakiotis, E Kouidi, A Deligiannis
Laboratory of Sports Medicine, Aristotle University of thessaloniki, thessaloniki, Greece
Topic: Cardiovascular rehabilitation
Background: Exercise-based cardiac rehabilitation programs (ECRP) has been shown to be effective in decreasing the risk of re-infarction and improving clinical outcomes and quality of life for coronary artery disease (CAD) patients. However, the risk of complications during exercise is almost twice that in healthy adults and the symptoms during exercise are often interpreted incorrectly. In recent years the use of home telemonitoring systems (TS) allows an early and accurate diagnosis with a consistent reduction in time to treatment and positive effects on the mortality rate of cardiac patients. However, its use in an outpatient ECRP has not so far been established.
Objectives: the aim of this study was to assess the effectiveness of TS in outpatient ECRP in public gyms.
Methods: One hundred and four CAD patients (aged 62.5±5.7 years) volunteering to participate in ECRP in public gyms were randomly divided into two equal groups: Group A 52 patients, who followed a standard unmonitored ECPR of 3 weekly sessions of 6 months duration and Group B: 52 patients, who were enrolled in ECPR of similar duration and were monitored by TS. Simultaneous voice and 12-lead electrocardiographic (ECG) transmissions were obtained from the trainers in public gyms via a telemedicine ECG equipment in real time by plain old or mobile telephony and evaluated by cardiologists in the medical center.
Results: During the 6-month ECPR a total of 163 cases were monitored: 53 were related to transmission of vital signs and symptoms, while 110 ECG were transmitted by exercise trainers. In all cases instruction were given from the referring cardiologist to the trainers. Successful transmissions were reported in 98.3% of the total cases. the average time, from the initial clinical findings to transmissions, reports and interventions, was 293±11sec. Only one patient of group B vs 15 of group A required medical emergencies. From these 15 cases of group A only two were hospitalized. TS was associated with a good compliance to ECRP (93% in group B vs 86% in A).
Conclusion: TS improves compliance and allows an early and accurate diagnosis of cardiac events during exercise training in cardiac patients. therefore, TS emerges as an accurate and useful tool in an outpatient cardiac rehabilitation program.
P511
Prognostic effect of cardiac rehabilitation after acute myocardial infarction - results of the OMEGA-study
B Rauch1, S Schneider2, R Schiele3, H Gohlke4, H Katus5, J Senges2
1ZAR Ludwigshafen Klinikum, Center for Ambulatory Rehabilitation, Cardiology, Angiology, Neurology, Ludwigshafen am Rhein, Germany, 2Heart Attack Research Center at the University of Heidelberg, Ludwigshafen am Rhein, Germany, 3Clinical Center of Ludwigshafen, Department of Cardiology, Ludwigshafen am Rhein, Germany, 4Heart Centre, Bad Krozingen, Germany, 5University Hospital Heidelberg, Internal Medicine III, Department of Cardiology, Angiology and Pneumology, Heidelberg, Germany
Topic: Cardiovascular rehabilitation OMEGA-study group
Purpose: To assess the effect of cardiac rehabilitation (REHA) on clinical events during follow-up after acute myocardial infarction.
Methods: OMEGA is a randomized, placebo-controlled, double blind, multicenter trial to test the effects of omega-3-acid-ethyl-esters-90 on the rate of sudden cardiac death, total mortality and non fatal clinical events in survivors of acute myocardial infarction with and without ST-elevation (AMI). According to the study protocol participation to REHA was asked by telephone 3 months after AMI. Total death and major cardiac and cardiovascular events (MACCE = death, non fatal myocardial infarction and non fatal stroke) then were prospectively assessed during the follow-up period of 4 12 months after AMI, including a total of 3.560 patients.
Results: within 3 months after AMI 70.6% of all patients had REHA. During the follow-up 4-12 months after AMI 70 patients died and 154 patients had MACCE. Whereas patients with impaired left ventricular function were equally distributed bet ween the groups with and without REHA, patients who participated REHA were younger, more often had acute revascularization during AMI, less often had diabetes or cardiovascular events in history (AMI, stroke, bypass-surgery or coronary interventions). After multivariable analysis the rates of death and MACCE during follow-up were significantly reduced in the REHA-group (death: OR 0.53; 95% CI 0.31 0.89; MACCE: OR 0.57; 95% CI 0.4 0.81). Subgroup analysis including age above or below 70 years, gender, diabetes mellitus, impaired left ventricular function and acute revascularization also consistently revealed a significantly reduced rate of death and MACCE during follow-up in the REHA-group. the effect of REHA did not significantly differ between patients suffering from ST-elevation and non-ST-elevation myocardial infarction.
Conclusions: the data suggest an important contribution of cardiac rehabilitation to improve prognosis after acute myocardial infarction.
P512
Completing an audit loop of cardiac rehabilitation across the english cardiac networks
M Shahid1, J Travis2, L Binder3, R Tipson4, E Flint3
1Dudley Group of Hospitals NHS Trust, Dudley, United Kingdom, 2University of Birmingham, Birmingham, United Kingdom, 3NHS Heart Improvement Programme, London, United Kingdom, 4Action Heart Cardiac Rehabilitation Services, Dudley, United Kingdom
Topic: Cardiovascular rehabilitation
Introduction: “Cardiac Rehabilitation (CR) is the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health.” 1 Despite the Myocardial Ischaemia National Audit Project documented (2007) expansion of CR staffing in some centres within the UK, provision of this essential aspect has been shown to remain patchy in the National Audit of Cardiac Rehabilitation (NACR) 2005–08 data and has not achieved NSF and NICE targets.
Aims: the aims of the audit were to:
1. Assess the progress and development of CR across the English networks.
2. Evaluate the impact of the National Campaign and Cardiac Networks on CR development.
3. Complete first audit loop and inform the CR National priority project team and a project Steering group of the results and outcome.
Methods: A twenty eight part questionnaire was developed and distributed by the NHS Heart Improvement Programme and Black Country Cardiovascular Network in August 2008. these were received from September 2008 to May 2009.
Results: there has been a 100% response rate, of which 89% showed an agreed work plan in progress during the last year. NSF standards and NICE post Myocardial Infarction (MI) guidelines, including CR, were met by 47% and 39% respectively. Only half (46%) have a lead cardiologist for each programme. Compared to the year 2007, commissioning links remained challenging and only 36% reported a robust commissioning link. thirty two percent are revisiting the CR pathway with introduction of Primary PCI compared to only 10% in 2007. Fifty three percent have reported help from the National Campaign in focusing their local commitment to CR services. Eighty nine percent are following defined (mostly BACR) standards of service provision, and 71% are auditing them to inform commissioning. More than half (61%) have limited or no provision of CR for heart failure patients and only two of the networks offer viable home-based option. Patient and public involvement (PPI) is present in 89%. the majority (75%) of networks have also been successful in improving CR across their region.
Conclusions: Commitment to NACR by networks is impressive Earlier PCI pathways are revisiting CR resources with increasing frequency Commissioning links are viewed as no more robust than previously Home-based options and services for heart failure patients are poorly developed CR networks are learning how to impact on CR services but they need to increase their influence on commissioning.
P513
Prevalence and risk factors for erectile dysfunction in patients entering cardiac rehabilitation
P Blanc1, L Mourot2, A Boussuges3, S Jhowry1, S Chopra1, S Maunier1
1centre de reeducation cardiovasculaire et respiratoire, Sainte Clotilde, Reunion, 2EA 3920 et IFR133, Universite de Franche Comte, Physiologie, Faculte de Medecine, Besaneon, France, 3EA 3280, Universite de la Mediterranee et IMNSSA Faculte de Medecine, Nord Marseille, France
Topic: Cardiovascular rehabilitation
Purpose: To determine the prevalence and risk factors for erectile dysfunction (ED) in cardiac rehabilitation (CR). Prospective study.
Methods: 578 consecutive patients (mean age 55.3+ –10.4, 24–82 years) were screened by the psychologist for ED upon CR admission. ED was measured via the IIEF-5 questionnaire. CR admissions were due to: coronary artery by-pass grafting (30%), coronary angioplasty/stent (38%), angor pectoris or myocardial infarction (8%), aortic/mitral valve replacement (9%), other (15%).
Results: the prevalence of ED was 72%. Severity distribution was as follows: 35% had mild ED [IIEF5: 17-21], 21% mild to moderate [IIEF5: 12-16], 7% moderate [IIEF5: 8-11] and 9% severe ED [IIEF5: 5-7]. Moreover, in 79% of cases, patients recall ED up to 29 +/– 34 month prior to cardiovascular event.
there was a significant positive correlation between age and severity of ED (p<0.001). Patients age group was defined as such: =39 years, 40 to 49, 50 to 59 and =60 years. the median IIEF-5 obtained for the above defined age group was respectively 20.8, 19, 17.4 and 15.8.
ED was significantly higher in patients with coronary heart disease, type2 diabetes and hypertension (all p <0.001). A low peak of VO2 <14 ml/kg/min (p<0.001), LVEF =35% (p<0.05) and ankle-brachial index < 0.9 (p<0.01) were significantly associated with mild to severe ED. Levels of cholesterol, smoking, body mass index, waist circumference was not associated with ED.
On the other hand, the risk of ED was significantly higher for patients using diuretic (p<0.05), and higher, but statistically insignificant, for patients using calcium channel inhibitor (p=0.06), angiotensin II antagonist (p=0.05), as compared to non users. Use of beta-blockers, angiotensin-converting enzyme inhibitors and statins showed no correlation with ED.
Finally, ED was significantly correlated with anxiety (p=0.002), depression (p<0.001) (HAD scale), and professional inactivity (p=0.002).
Conclusions: Erectile dysfunction is highly frequent in CR patients and should be screened, more particularly in patients with high risk cardiovascular. Diuretics increase ED. Finally, ED is correlated with depression/anxiety and psychosocial factors. Further investigations of the impact of a CR program on ED would be of utmost interest.
P514
the correlation between cognitive impairment and prognostic parameters in patients with congestive heart failure or after cardiac surgery
E Menditto, E Nervo, E Lombardo, C Taglieri, S Piccolo, P Vallauri, M De Blasi, M Feola
Cardiovascular Rehabilitation-Heart Failure Unit, Fossano, Italy
Topic: Cardiovascular rehabilitation
Cognitive impairment has been observed in patients with congestive heart failure (CHF) or after cardiac surgery. We analysed in-hospital patients with CHF or after cardiac surgery before discharge with neuropsychological tests attempting to correlate results with prognostic parameters.
Methods: All subjects underwent a complete neuropsychological examination consisting of the mini mental state examination (MMSE), anxiety and depression scale (HADS) and geriatric depression scale (GDS). the severity of CHF was evaluated with NYHA class, brain natriuretic peptide (BNP) plasma level (using the Biosite method) and transthoracic echocardiography for the evaluation of left ventricular ejection fraction (LVEF).
Results: Four hundred eighty-three patients admitted for cardiovascular rehabilitation (320 males; mean age 70 ys) entered this observational study. the mean NYHA class at admission was 2,46 ± 0,7, LVEF was 46,29 ± 14,1%, mean BNP at admission proved to be 467,9 ± 526,1 pg/ml and 6min WT was calculated 320,5 ± 91,7 m. Patients were admitted for cardiovascular rehabilitation after coronary artery bypass (30%), after valve replacement (27%), myocardial infarction (54,2%) or for CHF (55%). In 9,1% of subjects a pathological MMSE score (considered = 24) was determined. A positive correlation between MMSE and age (p = 0,0001; R = 0.066), BNP (p = 0,0001; R = 0.056), NYHA class (p = 0,0001; R= 0,056), and LVEF (p = 0,0001; R = 0,12) was observed. the GDS at admission seemed to be related to BNP (p = 0,0001; R = 0,32) and NYHA class (p = 0,0001; R = 0,013).
Conclusion: Cognitive impairment and mood depression in patients with CHF or after cardiac surgery are frequent. In our population MMSE correlate with the severity of haemodynamic dysfunction (plasma BNP) and symptoms (NYHA functional class).
P515
Lack of supervision after residential cardiac rehabilitation increases cardiovascular risk factors
R Berent1, SP Von Duvillard2, J Auer3, H Sinzinger4, P Schmid1
1Center for Cardiovascular Rehabilitation, Bad Schallerbach, Austria, 2College of Idaho, Departments of Biology and Physical Education, Caldwell, United States of America, 3Department of Cardiology, Braunau, Austria, AthOS, Institute for Diagnosis and Treatment of Atherosclerosis and Lipid Disorders, Vienna, Austria
Topic: Cardiovascular rehabilitation
Background: Cardiovascular rehabilitation (CR) is an important component of care for patients with cardiovascular disease (CVD) and has been well documented and promoted by various health organizations and position statements worldwide.
Purpose: the purpose of this study was to investigate whether patients readmitted to CR on average 16 months after their previous discharge, maintained the reduction in CVD risk factors, maintained or improved functional capacity, occurrence of adverse cardiovascular events, and possible modifications in prescribed medications.
Methods: Five hundred and seventy patients (60±10 years) underwent cycle ergometry and blood sampling at the beginning, the end of 21±2 days of the previous CR, and again at readmission to CR the CR consisted of cycling for 17±4min at frequency of six times a week and daily walking for 45min at 6070% of the maximal individual heart rate.
Results: Blood total cholesterol, low-density lipoprotein-cholesterol, triglycerides, and body mass index decreased significantly during CR. Resting blood pressure, maximal performance (watts), maximal oxygen uptake, and heart rate recovery improved significantly in 1min (P<0.001). At readmission, all traditional CVD risk factors increased significantly, although medication was unchanged and angiotensin converting enzyme inhibitors were partly replaced by angiotensin II receptor antagonists. Exercise performance remained unchanged.
Conclusion: At readmission, we observed an increase in CVD risk factors, although, physical fitness remained stable. thus, failure of lifestyle modification after CR indicates the cause for concern. Reinforcement of home setting sessions of CR patients or other strategies to enhance long-term compliance to lifestyle changes could reduce the observed attrition in CR benefits.
P516
EuroSCORE is predictive for postoperative nursing effort
V Goeber, H Saner, JP Schmid, T Carrel
Swiss Cardiovascular Center at the Bern University Hospital, Bern, Switzerland
Topic: Cardiovascular rehabilitation
Background: Number of multi-morbid patients (pts) in cardiac surgery is increasing. Resources in postoperative treatment and cardiac rehabilitation are becoming more and more important and needs to be calculated at an early stage. In an prospective cohort study we found the EuroSCORE predictive for both intensity of postoperative care and cardiac rehabilitation. the aim of this analysis was to assess the predictive value of the EuroSCORE for the postoperative daily nursing effort after cardiac surgery.
Methods: In this prospective cohort study data of all cardiac and thoracic aortic surgery pts over a period of 6 months were evaluated before, during and after cardiac and thoracic aortic surgery. EuroSCORE (additive and logistic) has been used to predict perioperative mortality, intensity of postoperative care and cardiac rehabilitation. We assessed prospectively the daily nursing effort of every patient using the PRN-system (Projet de Recherche en Nursing; each point is 1 minute in patient care by a registered nurse) subsequent to intensive care.
Results: Complete data from 475 pts (345 males, 130 females; mean age 65.1 years) have been collected. Mean cumulative postoperative PRN was 734 (minimum 83, maximum 19929), daily mean PRN 70 (min. 36, max. 175) and mean on first day on the ward 118 (min. 14, max. 199). Preoperative EuroSCORE was in the range of 0–16 (mean 5.5). We found a significant correlation of EuroSCORE and cumulative (p=0.015), daily PRN (p<0.01) and PRN on first day on the ward (p<0.01).
Conclusions: EuroSCORE predicts length of intensive care, postoperative nursing effort on the ward and the need of in patient cardiac rehabilitation. For this reason it is a very helpful tool to calculate postoperative resources already before cardiac surgery.
P517
the Italian survey on CArdiac Rehabilitati On and Secondary prevention after cardiac revascularization (ICAROS study). Preliminary results - patients characteristics
R Tramarin1, R Griffo2, S De Feo3, PL Temporelli4, F Fattirolli5, M Ambrosetti6, C Riccio7
1Fondazione Europea per la Ricerca Biomedica, Cernusco S/N, Italy, 2La Colletta Hospital, Arenzano, Italy, 3Dott. Pederzoli Clinic, Peschiera del garda, Italy, 4Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Rehabilitation of Veruno, Veruno, Italy, Careggi University Hospital, Florence, Italy 6Cunardo - Va, Le Terrazze Clinic, Italy Caserta, A.O. S. Anna e S. Sebastiano, Italy
Topic: Cardiovascular rehabilitation
Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology
Background: Cardiac Rehabilitation and Prevention (CRP) is recognized as the standard model for global treatment of pts with heart disease in post-acute phase and it represents the most care- and cost-effective model for the implementation of strategies of secondary prevention.
Purpose: To define the clinical characteristics of pts referred to CRP program after PTCA or CABG, the core components of CRP programs, and the 6-month and 1 year clinical outcome as well as pts adherence to pharmacological therapy and recommended life styles.
Methods: Prospective, longitudinal, multicentric survey, with web-based data collection carried out by the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology. the study population consisted of 1430 consecutive pts, discharged from 64 Italian CR centres from Nov 17th to Dec 15th 2009 at the end of CRP program after CABG (also associated to valve or ascending aorta surgery) or PTCA. Data on 6-months follow-up have already be collected; the 12-months follow-up is still ongoing.
Results: age was 66.0±10.3 yrs (20% women). Indications for CRP were: CABG in 67.8%, PTCA 32.2% (12.9% elective, 15.5% primary, 3,8% rescue). 66.1% of pts underwent in-hospital, 18.5% day-hospital and 15.4% ambulatory CRP program. 41.3% of pts had =1 complication during acute phase. 31,3% of pts had =1 comorbidity: prior AMI 32.9%, symptomatic atherosclerosis 17.8%, diabetes 29.4%, COPD 12.7%, renal failure 7.8%, gastrointestinal 10.1%, hepatic 3.3%, neurological 5%, orthopedic 10.3%, oncological disease 4.9%. CV risk factors were: 62.5% actual/past smokers, 72.6% hypertension, 67,4% hypercolesterolemia. 28.9% of pts had =1 complication during CRP: 7.1% atrial fibrillation, 0.3% PMK, 0.3% AMI, 0.3% stroke/TIA, 0.8% minor neurological damage, 2.2% heart failure, 2.2% acute renal failure 0.8% or liver, 1.3% thoracentesis, 0.3% mechanical ventilation, 1.0% surgical complication, 0.3% re-PTCA, 2.2% infection, 1.3% transfusion. During CRP 45.9% pts had a 6-min walk test at admission and 47,8% at discharge, 24,3% and 37,7% an exercise test, 5.3% and 6.9% a cardiopulmonary test; 4,9% electrical and 1,0% pharmacological cardioversion, 93.5% echo (LVEF >50% in 66.3%, <30% in 2.9%), 52.2 Holter ECG, 6.8 ABPM, 52.4% multidimensional evaluation, 36.2% multidisciplinary consulting, 96.9% exercise sessions (92.2% group, 30.3 individual). At 6-mts the drop-out rate was < 1%
Conclusion: surveys and registries are effective means of assessing the implementation of guidelines. the low rate of lost-to-follow-up offers a unique possibility to analyze the long term results of CRP programmes.
P518
the Italian survey on CArdiac Rehabilitati On and Secondary prevention after cardiac revascularization (ICAROS study). Preliminary results - pharmacological performance
S De Feo1, PL Temporelli2, R Tramarin3, F Fattirolli4, R Griffo5, M Ambrosetti6, C Riccio7
1Dott. Pederzoli Clinic, Peschiera del garda, Italy, 2Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Rehabilitation of Veruno, Veruno, Italy, Fondazione Europea per la Ricerca Biomedica, Cernusco S/N, Italy, 4Careggi University Hospital, Florence, Italy, 5La Colletta Hospital, Arenzano, Italy 6Cunardo - Va, Le Terrazze Clinic, Italy 7Caserta, A.O. S. Anna e S. Sebastiano, Italy
Topic: Cardiovascular rehabilitation
ICAROS investigators
Background: Cardiac Rehabilitation and Prevention (CRP) represents the most care- and cost-effective model for implementation of adequate strategies of secondary prevention.
Purpose: To define the effect of CRP programs in terms of achievement of pharmacological treatment according to guidelines.
Methods: study population consisted of pts enrolled in the ICAROS study, a prospective, longitudinal, multicentric survey, with web-based data collection carried out by the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology.1430 consecutive pts, discharged from 64 Italian CR centres from Nov 17th to Dec 15th 2009 at the end of CRP program after CABG or PTCA were included. Pharmacological therapies at admission and discharge to CRP were compared. Data at 6-months have been collected; the 12-months follow-up is ongoing.
Results: age was 66.0±10.3 yrs (20% women). Indications for CRP were: CABG in 67.8%, PTCA 32.2% (12,9% elective, 15,5% primary, 3,8% rescue). 66.1% of pts underwent in-hospital, 18.5% day-hospital and 15.4% ambulatory CRP program. 62,2% of pts received educational intervention: general information 98.8%, dietary 96,5%, smoking cessation 58.3%, pharmacological therapy 95.3%, 66% diabetes; 85.2% of pts received an individual psychological intervention. During CRP pharmacological therapy was overall incremented (in Table 1).
Conclusion: surveys and registries are effective means of assessing the implementation of guidelines.6-month and 1 year pts adherence to pharmacological therapy and recommended life styles, the achievement and maintenance of the targets will be collected.
Admission
Discharge
ACEi/ARBs (%)
59.2
75
β-blockers (%)
68.3
77
Statins (%)
68.6
84
n-3PUFA (%)
12.8
25,7
Oral anticoagulant (%)
18.2
14,5
Antiplatelet agents
91.5
ASA (%)
85,6
Clopidogrel (%)
30,8?
Other antiplatelet agents (%)
5,3
P519
Screening for obstructive sleep apnoea in a cardiac prevention and rehabilitation programme
P O'neill
Imperial College London, London, United Kingdom
Topic: Cardiovascular rehabilitation
Background: Obstructive sleep apnoea syndrome (OSAS) affects 2–4% of the population and is more likely in men, those who are obese or >65 years of age. Repetitive apnoeas may result in increased cardiovascular stress including a reduction in myocardial contractility, activation of the sympathetic nervous system and resistant hypertension. Preliminary data suggests that treating OSAS with continuous positive airway pressure (CPAP) may lower blood pressure and in patients with heart failure, improve cardiac function. Yet, OSAS remains significantly underdiagnosed. We hypothesised that patients with cardiovascular disease were more likely to have OSAS than the general population due to shared risk factors.
Aim: To determine the likelihood of undiagnosed OSAS in patients attending a Cardiovascular Disease Prevention and Rehabilitation Programme (CRPR).
Methods: Sequential patients attending CPRP at Charing Cross Hospital were sent the Epworth Sleepiness Scale and a pilot screening tool for witnessed apnoea prior to attendance at the programme. those scoring an ESS =10/24 or reporting witnessed apnoea were referred for a sleep study at Imperial College Healthcare Sleep Centre. Results were analysed for apnoea frequency (AHI) and oxygen desaturations (ODI) per hour. those who were positive for OSAS were offered treatment with continuous positive airway therapy (CPAP) or lifestyle modifications.
Results: 80/101 sequential attendees consented to participate (85% M, mean age 64.5 ± 10.1 years: 65.9 ± 8.5 M and 64.0 ± 10.1 F). 23 patients had either hypersomnolence (ESS>10/24), witnessed apnoea or both. To date, 11/23 patients have had a sleep study, 7/23 have declined a study and 5/23 are awaiting a study. Of the 11, all have been found to have evidence of OSAS with 5 in the severe range (AHI = 30 events per hour), 2 in the moderate range (AHI 15 29 events per hour), and 4 with mild pathology. After clinical review, 6 were thought to merit CPAP therapy.
Conclusion: Screening for OSA in a CPRP was feasible and resulted in detection of previously unrecognised OSAS.
P520
Seven day blood pressure monitoring in patients after myocardial infarction in secondary phase of cardiovascular rehabilitation
J Siegelova1, A Havelkova1, B Fiser1, P Vank1, J Dusek1, M Pohanka1, G Cornelissen2, F Halberg2
1Masaryk University, Faculty of Medicine, Brno, Czech Republic, 2University of Minnesota, Minnesota, United States of America
Topic: Cardiovascular rehabilitation
the aim of the present study was evaluation of blood pressure variability by 7-day ambulatory blood pressure (BP) monitoring in patients after myocardial infarction.
Forty patients 4 — 12 weeks after myocardial infarction (IM) in secondary phase of cardiovascular rehabilitation treated with beta-blockers, Ca-antagonists and ACE-inhibitors (age between 41 and 77 years, mean age 61 years) were compared with 44 healthy controls (C, age between 40 and 77 years, mean age 54 years). Data from 24 hours were fitted by sinusoidal curve (cycle length 24 hours, least square method) in each day of monitoring and mean values of MESOR (mean value of the sinusoidal curve) and amplitude of sinusoidal curve of 7-day monitoring were calculated. MESOR approximately corresponds to the 24-hour mean, double amplitude (DA) corresponds to the difference between day and night values.
A significant increase of systolic BP (SBP) MESOR with age was found in C (r=0.39, p<0.01), but not in IM (r=0.23). Diastolic BP (DBP) MESOR was not related to age in C (r=014) but a decrease of DBP with age in IM was observed (r=0.362, p<0.05). Mean value of SBP MESOR was higher in C than in IM (128±9 vs. 121±8 mmHg, p<0.01), as well as DBP MESOR (81±7 vs. 74±7 mmHg, p<0.01). DA SBP decreased with age in C (r=0.30, p<0.05) but not in IM (r=0.03). Similarly DA DBP decreased with age in C (r=0.41, p<0.01) and not in IM (r=0.08). Mean values of DA were lower in IM (DA SBP: 21±10 vs. 16±8 mmHg, p<0.01; DA DBP: 16±8 vs. 12±5 mmHg, p<0.01). Heart rate (HR) was not age related in both groups, difference in mean values of HR was not observed (C: 71 ±10, IM: 65±8bpm). DAHR was lower in IM (15±8 vs. 9±5 bpm).
the study demonstrates that the treatment of myocardial infarction patients (rehabilitation included) can normalize the risk of high blood pressure as well as the risk of high blood pressure variability.
P521
Changes in frequency of peripheral blood lymphocyte subpopulations in patients with myocardial infarction during a period of early medical rehabilitation
D Raljevic1, V Persic1, A Ruzic1, B Miletic1, D Travica Samsa1, M Rakic1, V Pehar1, G Laskarin2
1Clinical Hospital thalassotherapia Opatija, Opatija, Croatia, 2Department of Physiology and Immunology, Medical Faculty, University of Rijeka, Rijeka, Croatia
Topic: Cardiovascular rehabilitation
Purpose: the site of infarction and remote myocardial regions are characterized with inflammatory reaction and leukocyte infiltration. However, there is insufficient knowledge about the involvement of peripheral blood lymphocyte subpopulations in this inflammatory process. the purpose of the study was to investigate changes in the frequency of lymphocyte subpopulations in peripheral blood of patients with myocardial infarctation (MI) during the early medical rehabilitation period.
Methods: Twelve patients with ST elevation MI (STEMI) and diminished possibility for further progression of the coronary artery disease due to percutaneous coronary intervention and 12 patients with non-STEMI who were treated with standard drug therapy were enrolled in this pilot study. the group of twenty healthy volunteers was used as the control. Peripheral blood samples were taken from MI patients on day 7, 14, 21 and 28 after the acute coronary event and peripheral blood mononuclear cells (PBMC) were immediately isolated by gradient density centrifugation. the frequencies of lymphocyte subpopulation were analyzed by simultaneous assessment of surface markers using fluorochrome conjugated monoclonal antibodies directed toward CD3 and CD56 molecules. T cells were distinguished from the other lymphocyte subpopulations as cells labeled with anti-CD3 monoclonal antibody, but negative for CD56 staining (CD3+CD56- cells). the cells stained as CD3-CD56+ were determined as NK cells, whereas CD3+ and CD56+ cells were counted as NK/T cells.
Results: In patients with non-STEMI the frequency of T cells decreased on day 7 and 14 and in the patients with STEMI on day 14 and 21 after the acute myocardial ischemia in comparison with healthy persons. At the end of early rehabilitation period on day 28 the percentage of T cells is restored in both groups of patients. the frequency of NKT cells in peripheral blood of patients with non-STEMI increased on day 14 when compared with healthy volunteers and patients with STEMI. On day 21 and 28 the percentage of NKT cells did not differ from the control. the frequency of NK cells did not significantly change at time points investigated.
Conclusions: the fluctuation of peripheral blood T and NKT cells during early medical rehabilitation period suggests their participation in myocardial remodeling events. the investigation of their activation status would provide better insight in immune response and it would open possibilities for new approaches in early medical rehabilitation of patients with MI.
P522
Cardio-renal classification is predictor of exercise capacity and heart failure hospital readmission in patients after cardiac surgery
M Saitoh, N Morotomi, N Ishii, M Nagayama
Sakakibara Heart Institute, Fuchu, Japan
Topic: Cardiovascular rehabilitation
Backgrounds: the aim of study was to clarify the affect of cardio-renal classification on exercise capacity and heart failure (HF) hospital readmission in patients after cardiac surgery.
Methods: 1156 patients (825 males and 399 females, mean age 67±14 years; CABG 444, AVR 316, MVP 205, MVR 86, ICR 38, other 14) who underwent cardiac surgery between 2006 and 2007. Patients were categorized into 4 groups, depending on LVEF and estimated GFR (eGFR) (group?; LVEF?40% & eGFR? 60ml/min/1.73m2, group?; LVEF<40% & eGFR?60ml/min/ 1.73m2, group?; LVEF?40% & eGFR<60ml/min/1.73m2, group?; LVEF<40% & eGFR<60ml/min/1.73m2. the following data was analyzed, (1) exercise capacity, (2) HF hospital readmission within 6-month. HF hospital readmission was used by Kaplan-Meier survival analysis.
Results: Exercise capacity at baseline in group? and ? were significantly lower than that in the others, however that in all groups were significantly increased after outpatients cardiac rehabilitation (pDiscussion: the cardio-renal classification is a independent risk factor for low exercise capacity and high HF hospital readmission after cardiac surgery.
Cumulative percentage
P523
the gender differences after an acute coronary syndrome: female response to a program of secondary cardiovascular prevention and rehabilitation
M P Donataccio, G Menegatti, D Cassater, P Lipari, D Nicolis, P Pasoli, F Filippi, C Vassanelli For the Pricavv Group
University of Verona, Department of Cardiology, Verona, Italy
Topic: Cardiovascular rehabilitation
Purpose: Heart disease in women (F) is characterized by greater disability and early death after an acute coronary event compared with men (M). Aim of our study is to investigate how gender differences (GD) could affect a cardiac rehabilitation program (CRP).
Methods: From April 2008 to September 2009 we enrolled 246 consecutive patients (p) (mean age 60 ± 11,04 years), 15% F, 85% M. Discharge diagnosis were: Unstable Angina (22,6%, 55 p), NSTEMI (27%, 66 p) and STEMI (50,4%, 123 p). the 12-months CRP was based on nurse counselling, multispecialistic visits and controlled training. Serial blood samples were assessed at discharge, at 6 and 12 months.
Results: Traditional cardiovascular risk factors distribution was similar for both F and M. At discharge, mean left ventricular ejection fraction value was 55,7 ± 9,2% (from 25 to 78, M 55,8 ± 9 vs F 54,8 ± 10,4%, P=ns) and intima media thickness was 0,938 ±0,164 mm (from 0,6 to 1,37, M 0,93 ± 0,17 vs F 0,992 ± 0,14 mm, P=ns). During the 6 months after discharge F accessed more frequently to emergency department (25 vs 11,8%, p=ns) while new admissions for cardiologic causes were similar for both genders (F 25 vs M 11,7%). Analysis of drugs prescription didn t show any significant GD at discharge, at 6 and 12 months.
Conclusions: Almost in all clinical trial F are underrepresented as well in our group of outpatient CR. Literature review shows that womens experience of CR may be different to that of males. Future research need to be conducted to know if a CRP exclusively for F could be useful.
Gender differences: blood samples
Baseline
P
6 months
12 months
P
M
F
M
F
M
F
Total cholesterol (mg/dl)
167±36,3
185,4±35,2
<0,00S
157,8±32,9
167,5±38,6
ns
153,9±26,2
178,8±48,1
0,011
Ldl cholesterol(mg/dl)
100.4±32
115,9±35,7
0,009
89,6±27,6
93,5±34,3
ns
82,9±19,1
103,3±43,5
0,009
Hdl cholesterolmg/dl)
38,2±9,1
45,8±10,4
<0,000
42±9,6
52,2±9,2
<0,00
43,5±8,2
50,3±12,9
0,016
Tryglicerides(mg/dl)
139,9±73,7
117,6±47,7
ns
143,9±160,4
108,5±50,9
ns
126,6±79,2
125±65
ns
NT-proBNP(ng/L)
611,1±812,7
913,7±916,6
ns
169,6±280,9
258,2±407,7
ns
215,8±390,5
455,9±898,5
ns
ApoA(g/L)
1,11±0,16
1,3S±0,35
ns
1,27±0,19
1,49±0,18
<0,000
1,43±0,28
1,43±0,28
0,07
ApoB(g/L)
0,85 ⊥ 0,21
0,84 ⊥ 0,25
ns
0,81 ⊥ 0,21
0,77 ⊥ 0,27
ns
0,89 ⊥ 0,31
0,90 ⊥ 0,31
ns
Lp (a)(mg/L)
480,6 ⊥ 393,9
710,9 ⊥ 409,7
0,019
412 ⊥ 289
648,5 ⊥ 426
ns
381,4 ⊥ 312,5
475,3 ⊥ 348,9
ns
hsPGR(mg/L)
5,2 ⊥ 5,5
5,6 ⊥ 6,6
ns
3,3 ⊥ 4,3
7,2 ⊥ 16,7
0,03
2,1 ⊥ 2,2
4,9 ⊥ 6,8
0,01
P524
Undiagnosed and de novo diabetes mellitus in coronary patients included in a cardiac rehabilitation program
S Castrejon Castrejon, M Abeytua-Jimenez, T Martinez-Castellanos, J Cuesta-Cuesta, K Villelabeitia-Jaureguizar, E Vaquerizo-Garcia, PL Sanchez-Fernandez, F Fernandez-Aviles
University Hospital General Gregorio Maranon, Madrid, Spain
Topic: Cardiovascular rehabilitation
Background: Previous studies have shown that the prevalence of undiagnosed diabetes mellitus is 10–30% in coronary patients. However, very little is known about the total prevalence and incidence of new cases of this metabolic disorder among typical patients attending a rehabilitation program, with stable coronary disease and a high degree of cardiovascular risk factors at baseline.
Methods this study followed a cohort of 254 coronary patients included in an intensive program of cardiac rehabilitation and secondary prevention over a 3-years period. At each stage of the follow-up a thorough clinical, anthropometric and analytical evaluation of this patients was carried out in order to diagnose the development of new cases of diabetes mellitus and assess the presence of predictive factors of this outcome.
Results At baseline the prevalence of diabetes was 31.6%. 39 of these 74 patients (52.7%) were undiagnosed diabetics. Non-diabetic patients presented a high prevalence of well-established risk factors for diabetes: 38.8% presented glucose intolerance, 17% abnormally elevated plasma glucose in the fasting state (>100 mg/dl) and 10,6% fulfilled criteria for metabolic syndrome. Undiagnosed diabetics presented a higher body mass index [29.3 (SD 4.7) versus 27.6 (SD 3.6), p=0.017], a larger proportion of elevated abdominal perimeter in both sexes [74.1% versus 47.5%, p=0,011] and higher levels of plasmatic homocysteine [12 mg/L (SD 4 mg/L) versus 10.3 mg/L (SD 3.2 mg/L), p=0.041] than non-diabetics, but not differed in other characteristics. Undiagnosed patients were slightly younger (p=0.013) and their exercise tolerance (measured in METS and adjusted by age and sex) was better (p<0.005) than previously diagnosed patients. At the end of the study there had been 22 cases of new-onset (“de novo”) diabetes (13.8%), which constitute an incidence rate of 7.2 new diagnoses/100 patient-year. None of these patients had experimented weight loss or a significative increase of their physical capacity. Nevertheless, owing to the relatively low incidence of diabetes and the short follow-up time we were no able to detect any potent predictive factor of “de novo” diabetes mellitus.
Conclusions Undiagnosed diabetes mellitus and incidence of new cases are two very frequent situations among high risk coronary patients enrolled in cardiac rehabilitation programs. Unveiling the presence of this disease, together with putting under control its etiologic determinants (above all sedentarism, obesity, metabolic syndrome and prediabetic glucose disorders) can be undertakenin a specific rehabilitation program.
P525
Does a phase 1 cardiac rehabilitation program have an impact on patient’ life after an acute myocardial infartion?
M S Pereira, R Faria, J Silva, N Marques, A Tome, A Valente, S Brito, V Gomes
Hospital Faro, Faro, Portugal
Topic: Cardiovascular rehabilitation
Introduction: the Cardiac Rehabilitation Programs (CRP) - Phase I, which are applied in an early phase after an Acute Myocardial Infarction (AMI), are being implemented in cardiology departments, together with conventional therapies, in order to prevent the development of the disease, to improve functional capacity and quality of life after an infarction.
Purpose: To evaluate the impact of a Phase I CRP during an eight months follow-up (FU) period after an AMI.
Methods: the study had included a group of 190 patients (pts), consecutively admitted by AMI, between January and July 2008, and involved in a CRP during the hospital stay, based on education of the patient and family and low intensity exercise. the CRP database was used and from the 190 pts or relatives contacted by phone, we could get a positive response in 164 pts (86%). For those pts aged <69 years, the “International Physical Activity Questionnaire”- IPAQ short version, had been applied. the SPSS program was used for statistical analysis.
Results: In this 164 pts group the mean age was 66,7 ± 12,3 years, and 114 (70%) were male. Considering AMI classification, 102 (62%) had STEMI and 62 (38%) NSTEMI. the Follow-up (FU) lasted an average of 8,2 ± 1,2 months. the occurrence of MACE was: Death-3 (2%), Re-AMI-5 (3%), PTCA-1 (0,6%), CABG-2 (1,2%). According to NYHA functional class, pts were distributed as follows: I-130 (80%), II-29 (18%), III-3 (2%), IV- none. And considering CCS class, the distribution was as follows: I-150 (93%); II-10 (6%); III-2 (1%); IV-none. the percentage of smokers among AMI pts was 26% (43 pts). During FU only 9% (16 pts) were smokers, p<0,01. the referring rate of adhesion to therapy was 94% (153 pts). At the time of AMI, 78% (128 pts) had a sedentary lifestyle and during FU that rate was 49% (80 pts), p<0,01. According to IPAQ performed in 81 pts (49%), 54 pts (67%) reported a “low” activity level, 25 pts (31%) “moderated” and 2 pts (2 %) “high” levels. the number of pts being “very” or “extremely” satisfied with the CRP was 160 (98%).
Conclusions: 1- Most of the AMI pts included in the Phase I CRP were in NYHA/CCS class I or II, after 8 months of FU. 2 - the occurrence of MACE was low, namely the mortality rate of 2%. 3 - the compliance with the guidelines of the CRP and the rate of therapy adhesion were satisfactory and a significant reduction of sedentary behaviour and tobacco consumption were observed. 4- Almost all pts ranked high levels of satisfaction with the CRP.
P526
Promoting lifestyle changes in patients with cardiovascular disease and/or diabetes mellitus: the effects of 4 weeks multidimensional inpatient rehabilitation with follow up
J Fossum, R Jensen, MI Amundsen, A Dyresen, SH Wigers
the Rehabilitation Centre Jeloy Kurbad, Moss, Norway
Topic: Cardiovascular rehabilitation
the Jeloy Kurbad cardiovascular rehabilitation team
Purpose: To reveal psychological and physiological outcome from multidimensional in patient rehabilitation in patients with cardiovascular disease (CVD) and/or diabetes mellitus (DM).
Methods: this is an open prospective study on 232 consecutively admitted patients, from March 2005 to July 2008, with CVD and/or DM. they received 4 weeks in patient rehabilitation, and were followed up by blood lipid and HbA1c tests at their GPs after 3 months, and a new rehabilitation week after 6 months. they were 58% women, on average 57 years old and with a disease duration of 12 years. the rehabilitation, in groups of 7–12, comprised physical exercise at least twice a day (interval- and strength training, aerobics, games and sports in pool or gym, and outdoor walking), relaxation with CD, education (18 hours on pathology, risk factors, dietary habits, stress management, motivation and self management) and a diet rich in vegetables and fruits, with fish, but rarely meat. Outcome measures were: 1) Patient administered questionnaires on demographic data, physical activity level and 5-step rating scales on patient satisfaction, impairment, well being and motivation. 2) Work capacity (bicycle test). 3) BMI and waist circumference. 4) Blood lipids and HbA1c.
Results: After 4 weeks they reported high rehabilitation satisfaction and a significantly increased sense of security, overall well being, motivation for further life style adjustments, increased work capacity and HDL, as well as reduced BMI, waist circumference, Total-Cholesterol, LDL and triglycerides (TG). After 3 months, 77% had their blood levels checked, showing significantly reduced Total-Cholesterol, LDL and TG levels compared to baseline. 66% completed the 6 month follow up: 58% returned for another rehabilitation week, while 8% solely mailed us their questionnaires and test results. there were no significant baseline differences between completers and non-completers. At 6 months, patients reported significantly less impairment, as well asincreased sense of security, self efficacy, quality of life, global subjective improvement, physical activity level, work capacity and HDL, compared to baseline. More over, BMI, waist circumference, LDL and TG were still significantly reduced.
Conclusions: A 4-week comprehensive rehabilitation program, with 3 and 6 months follow up, may induce overall positive long-term effects in patients with CVD and/or DM. these findings indicate that comprehensive rehabilitation may promote positive lifestyle changes, both with respect to dietary habits and physical activity level.
