Anne-Marie Willems

Prevalence of potential cardiac resynchronization therapy candidates and actual use of cardiac resynchronization therapy in patients hospitalized for heart failure.

Cardiac resynchronization therapy (CRT) is increasingly used as an additional therapy for patients with chronic heart failure (CHF) in New York Heart Association (NYHA) class III or IV on optimal medical therapy who have a left ventricular ejection fraction (LVEF) ≤35% and an increased QRS duration (≥120 ms). A recent meta-analysis also indicates that patients with milder heart failure could potentially benefit from this therapy. Despite the evidence regarding the effects of CRT, recent surveys suggest that this therapy is probably underused, with a large variation between hospitals regarding implantation rates in patients hospitalized with CHF. Also, although implantation rates for implantable cardioverter defibrillator and CRT-D have increased significantly in Europe, there remain major (and unexplained) differences between countries. Finally, data on the prevalence of CRT candidates in hospitalized CHF patients are limited.

Impact of the Preoperative Risk and the Type of Surgery on Exercise Capacity and Training After Valvular Surgery

Information on exercise capacity and training in patients who underwent valvular surgery is scarce. The aim of this study is to evaluate postoperative exercise capacity and functional improvement after exercise training according to the preoperative risk and type of surgery. In this prospective study, 145 patients who underwent aortic valve surgery (AVS) or mitral valve surgery (MVS) and who were referred for cardiac rehabilitation were stratified according to the preoperative risk (European System for Cardiac Operative Risk Evaluation [EuroSCORE]) and type of surgery (sternotomy vs ministernotomy or port access). Exercise capacity was evaluated at the start and end of cardiac rehabilitation. Postoperative exercise capacity and the benefit from exercise training were compared between the groups. Patients with a higher preoperative risk had a worse postoperative exercise capacity, with a lower load, peak VO2, anaerobic threshold and 6-minute walking distance (all p<0.001), and a higher VE/VCO2 slope (p=0.01). In MVS, port access patients performed significantly better at baseline (all p<0.05), but in AVS, ministernotomy patients performed better than sternotomy patients with a concomitant coronary artery bypass graft (p<0.05). Training resulted in an improvement in exercise capacity in each risk group and each type of surgery (all p<0.05). This gain in exercise capacity was comparable for the EuroSCORE risk groups and for the types of surgery, for patients after AVS or MVS. In conclusion, exercise capacity after cardiac surgery is related to the preoperative risk and the type of surgery. Despite these differences in postoperative exercise capacity, a similar benefit from exercise training is obtained, regardless of their preoperative risk or type of surgery.

Comorbidities and Psychosocial Characteristics as Determinants of Dropout in Outpatient Cardiac Rehabilitation.

Background: Despite the clear benefits of cardiac rehabilitation (CR), a considerable number of patients drop out early. Objective: Therefore, we wanted to evaluate dropout in CR with a special focus on comorbidities and psychosocial background. Methods: Patients who attended CR after acute coronary syndrome, cardiac surgery, or heart failure (N = 489) were prospectively included. Dropout was defined as attending 50% of the training sessions or less (n = 96 [20%]). Demographic and clinical characteristics, exercise parameters, and psychosocial factors were analyzed according to dropout, and those with a trend toward a significant difference (P < .10) were entered in a multivariate logistic model. Results: The presence of a cerebrovascular accident (4.18 [1.39–12.52]) involved a higher risk of dropout, and a comparable trend was seen for the presence of chronic obstructive pulmonary disease (2.55 [0.99–6.54]). Attending the training program only twice per week also implicated a higher risk of an early withdrawal (3.76 [2.23–6.35]). In contrast, patients on &bgr;-blockers were less likely to withdraw prematurely (0.47 [0.22–0.98]). Singles were more likely to drop out (2.89 [1.56–5.35]), as well as those patients who were dependent on others to get to CR (2.01 [1.16–3.47]). Finally, the reporting of severe problems on the anxiety/depression subscale of the EuroQOL-5D questionnaire involved a higher odds for dropout (7.17 [1.46–35.29]). Conclusions: Neither demographic characteristics nor clinical status or exercise capacity could independently identify patients who were at risk of dropout. The presence of comorbidities and a vulnerable psychosocial background rather seem to play a key role in dropout.

The impact of drop-out in cardiac rehabilitation on outcome among coronary artery disease patients:

Background The effect of adherence to cardiac rehabilitation (CR) on outcome is not clear. Therefore, we aimed to assess the impact of drop-out for non-medical reasons of CR on event-free survival in coronary artery disease (CAD). Methods A total of 876 patients who attended CR after acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were included. Drop-out was defined as attending ≤50% of the training sessions. A combined endpoint of all-cause mortality and rehospitalization for a cardiovascular event was used to specify event-free survival. Differences in clinical characteristics were assessed and parameters with p < 0.10 were entered in a multiple Cox regression analysis. Results A total of 15% died or had a cardiovascular event during a median follow-up period of 33 months (interquartile range 24, 51). Overall, 17% dropped out before finishing half of the program. Patients who withdrew prematurely had a risk twice as high for a cardiovascular event or death (hazard ratio 1.92, 95% confidence interval 1.28–2.90) than those who attended more than half of the sessions. Both ACS (2.36, 1.47–3.58) and PCI (2.20, 1.22–3.96), as primary indicators for CR, were associated with an adverse outcome and also a prior history of chronic heart failure (CHF) remained negatively associated with event-free survival (3.67, 1.24–10.91). Finally, the presence of hyperlipidemia was independently related to a worse outcome (1.48, 1.02–2.16). Conclusions Drop-out for non-medical reasons was independently associated with a negative outcome in CAD. Therefore, underlying factors for drop-out should gain more attention in future research and should be taken into account when organizing CR.

Lifestyle behaviour and risk factor control in coronary patients: Belgian results from the cross-sectional EUROASPIRE surveys

Abstract Objective: The aim of this study was to assess lifestyle behaviour as well as risk factor management across Belgian coronary patients who participated in the cross-sectional European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) surveys. Methods: Analyses are based on a series of coronary patients by combining data from the Belgian participants in the EUROASPIRE III (328 patients; in 2006–2007) and EUROASPIRE IV (343 patients; in 2012–2013) surveys. Four hospitals located in the Ghent area participated in the surveys. Patients included in the analyses were ≥18 years old and had been hospitalised for a coronary event. Information on cardiovascular risk factors, lifestyle behaviour and medical treatment were obtained. Results: Overall, the proportion of smokers was 11% with 40% persistent smokers. Adequate physical activity levels were reported by 17%, 28% of patients were obese, 47% was central obese and known diabetes was prevalent in 21% of patients. Hypertension was observed in 46% of patients and 20% had a total cholesterol ≥5 mmol/L. About 80% had participated in a cardiac rehabilitation programme and the majority of patients were treated with blood pressure (92%) or lipid-lowering drugs (92%). Anxiety and depressive symptoms were reported by 30% and 24%, respectively. Differences between EUROASPIRE III and IV were limited. Conclusions: Compared to the overall EUROASPIRE results in Europe, Belgian CHD patients seem to do slightly better. However, tackling obesity, physical inactivity, hypertension and psychosocial distress remains an important challenge in the management of coronary patients.

Exercise training results in an improvement of chronotropic incompetence in patients with a preserved ejection fraction, independent of baseline nt-probnp

P384 Homocysteine concentration and risk of death in adult Polish population A Anna Waskiewicz, E Sygnowska, W Piotrowski, A Piwonska National Institute of Cardiology, Warsaw, Poland Topic: Other risk factors (Prevention & Epidemiology) Purpose: Although there is a considerable epidemiologic evidence for a relation between homocysteine (Hcy) level and cardiovascular disease (CVD), the role of Hcy as a causal risk factor remains controversial. The aim of the study was to determine associations between Hcy level and all-cause and cardiovascular mortality in general population of Poland. Methods: Within the frame of the National Multicentre Health Survey (WOBASZ), a representative sample of whole Polish population aged 20-74 was screened in years 2003-2005. Baseline determinations, among other classical risk factors, included Hcy level in 7165 responders, performed by an immunoenzymatic method using IMMULITE 1 analyser and DPC reagents. Survival rates were followed up until 2009 and average follow-up time was 5,4 years. The cohort was divided into 3 groups according to Hcy levels; <8,20 mmol/l in the lowest tetrile and> 10,51 mmol/l in the upper tetrile. Results: During the 38818,9 person-years of follow-up there were 270 deaths including 108 due to cardiovascular disease, 37 due to coronary heart disease and 21 due to stroke. Mortality rates were 13,81/1000 in the third and 2,67/1000 person/years in the first tetrile Hcy level and cardiovascular disease mortality rates were 6,03/1000 and 1,07/1000 person/years respectively. The relative risk of all-cause and cardiovascular disease mortality was significantly higher in the upper compared to the lowest Hcy tetrile in crude and multivariable proportional hazards models adjusted for sex, age, smoking status, hypertension, body mass index, total cholesterol, glucose and hs CRP. Hazards ratios (95% confidence intervals) were as follows: all-cause’mortality HR (95% CI): crude1⁄4 4,528 (2,947-6,154), multivariable-adjusted1⁄4 1,766 (1,1972,605), cardiovascular disease mortality crude1⁄4 4,322 (2,426-7,700), multivariableadjusted1⁄4 1,937 (1,051-3,569). Conclusions: In Polish population aged 20-74 years Hcy level >10,51 mmol/l were associated with increased all-cause and cardiovascular disease mortality.

Heart rate reserve is an important determinant of exercise capacity in heart failure with normal ejection fraction

P208 Heart rate reserve is an important determinant of exercise capacity in heart failure with normal ejection fraction S Sofie Pardaens, C Van Laethem, J Bartunek, N Van De Veire, M Vanderheyden, AM Willems, J De Sutter Ghent University, Ghent, Belgium, OLV Hospital Aalst, Cardiovascular Center, Aalst, Belgium, AZ Maria Middelares Hospital, Ghent, Belgium Topic: Heart Failure (Sports Cardiology) Background Diastolic dysfunction is a common form of heart failure, in particular in the elderly. Just like in patients with systolic heart failure (SHF), heart failure patients with a normal ejection fraction (HFNEF) have a reduced exercise performance which has prognostic implications. In contrast to SHF, determinants of exercise capacity in patients with a normal ejection fraction have not been studied yet. Purpose To investigate which variables are major determinants of exercise parameters such as peak oxygen uptake (pVO2), ventilation-carbon dioxide slope (VE/VCO2 slope) and the oxygen uptake efficiency slope (OUES). Methods Demographic and clinical data were registered in 71 patients diagnosed with HFNEF (age 64 12 years, left ventricular ejection fraction (LVEF) 63 9%, 70% men). All patients performed bicycle cardiopulmonary exercise testing until exhaustion. Results 15 variables were included in a multivariable linear regression analysis: gender, age, body mass index, heart rate reserve (HRR), LVEF, smoking status, the presence of: ischemia, chronic obstructive pulmonary disease, diabetes, arterial hypertension, atrial fibrillation, left bundle branch block or pacemaker and a prior history of ischemic events or CHF. HRR, a prior history of ischemic events, age, smoking status and gender predicted pVO2 (R HRR= 0.301, total R= 0.669, p<0.001). VE/VCO2 slope was only explained by the HRR (R HRR= 0.086, total R= 0.086, p=0.013). OUES was predicted by HRR, a prior history of ischemic events, gender and diabetes (R HRR= 0.280, total R= 0.593, p<0.001). Conclusion In patients with HFNEF, HRR is the most important clinical determinant of exercise capacity measured by spiroergometry. This suggests that HRR could be a major target of improvement of symptoms of exercise intolerance in these patients.