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Does Cardiac Rehabilitation After an Acute Cardiac Syndrome Lead to Changes in Physical Activity Habits? Systematic Review

Background Optimal physical activity levels have health benefits for patients with acute coronary syndrome (ACS) and are an important goal of cardiac rehabilitation (CR). Purpose The purpose of this study was to systematically review literature regarding short-term effects (<6 months after completion of CR) and long-term effects (≥6 months after completion) of standard CR on physical activity levels in patients with ACS. Data Sources PubMed, EMBASE, CINAHL, and PEDro were systematically searched for relevant randomized clinical trials (RCTs) published from 1990 until 2012. Study Selection Randomized clinical trials investigating CR for patients with ACS reporting physical activity level were reviewed. Data Extraction Two reviewers independently selected articles, extracted data, and assessed methodological quality. Results were summarized with a best evidence synthesis. Results were categorized as: (1) center-based/home-based CR versus no intervention, (2) comparison of different durations of CR, and (3) comparison of 2 types of CR. Data Synthesis A total of 26 RCTs were included. Compared with no intervention, there was, at most, conflicting evidence for center-based CR and moderate evidence for home-based CR for short-term effectiveness. Limited evidence and no evidence were found for long-term maintenance for center-based and home-based CR, respectively. When directly compared with center-based CR, moderate evidence showed that home-based CR has better long-term effects. There was no clear evidence that increasing training volume, extending duration of CR, or adding an extra intervention to CR is more effective. Limitations Because of the variety of CR interventions in the included RCTs and the variety of outcome measures in the included RCTs, pooling of data was not possible. Therefore, a best evidence synthesis was used. Conclusions It would appear that center-based CR is not sufficient to improve and maintain physical activity habits. Home-based programs might be more successful, but the literature on these programs is limited. More research on finding successful interventions to improve activity habits is needed.

Marital quality and loneliness as predictors for subjective health status in cardiac rehabilitation patients following percutaneous coronary intervention

Background Low marital quality is associated with adverse health outcomes and lower personal well-being. Loneliness increases the risk of cardiovascular disease and mortality and predicts poor quality of life. The aim of this study was to investigate the association between marital quality and loneliness and subjective health status in primary percutaneous coronary intervention (pPCI) patients who underwent cardiac rehabilitation (CR). Design/methods In a prospective cohort study, pPCI patients that followed CR were included between 2009–2011. A total of 223 patients responded to the Short Form 12 (SF-12) (subjective health status), Maudsley Marital Questionnaire (MMQ-6) (marital quality) and University of California, Los Angeles – Revised (UCLA-R) questionnaires at baseline (pre-CR) and at three months (post-CR) or at 12 months follow-up. Subjective health status is displayed by a physical component summary (PCS) score and a mental component summary (MCS) score. Generalized estimating equation (GEE) analyses were performed to test improvements in subjective health status. Results Changes over time in subjective health status scores were similar between patients with optimal marital quality vs patients with less optimal marital quality and non-lonely patients vs lonely patients. The MCS level at one-year follow-up of both patients with less optimal marital quality and lonely patients was lower compared with a healthy Dutch population (respectively; mean MCS score 47.3 (standard deviation (SD) 10.5); p = 0.013 and mean MCS score 46.1 (SD 11.2); p = 0.010). Conclusion Both patients with less optimal marital quality and lonely patients did not reach the MCS level of a healthy Dutch population. Therefore, extra care and support should be given to these patients in a CR programme.

Participation in Society in Patients With Coronary Artery Disease Before and After Cardiac Rehabilitation

OBJECTIVES To assess changes in participation in society (frequency, restrictions, satisfaction) during and after cardiac rehabilitation (CR) and to assess associations between participation and heath-related quality of life (HRQOL). DESIGN Prospective cohort study. SETTING Outpatient CR center. PARTICIPANTS Patients with coronary artery disease (N=121; mean age, 57y; 96 men [79%]). INTERVENTIONS Multidisciplinary CR. MAIN OUTCOME MEASURES Participation in society was assessed with the Utrecht Scale for Evaluation of Rehabilitation-Participation and HRQOL with the MacNew Heart Disease health-related quality of life questionnaire. All measurements were performed pre-CR, post-CR, and 1 year after the start of CR. RESULTS Frequency of participation did not change during and after CR. The proportion of patients experiencing restrictions in participation decreased from 69% pre-CR to 40% post-CR (P<.001) and 29% at 1 year (P<.001 vs post-CR). Pre-CR, 71% of patients were dissatisfied with their participation. This improved to 49% post-CR (P<.001) and 53% at 1 year (P<.001 vs pre-CR). Experienced restrictions explained 5% to 7% of the improvement in HRQOL during CR and satisfaction with participation explained 10% to 19%. CONCLUSIONS Participation in society improves in patients undergoing CR. Despite these improvements, the presence of coronary artery disease is associated with persistent restrictions and dissatisfaction with participation. Because experienced restrictions and dissatisfaction are related to changes in HRQOL it is important to address these aspects of participation during CR.

Effects of two behavioral cardiac rehabilitation interventions on physical activity: A randomized controlled trial

BACKGROUND Standard cardiac rehabilitation (CR) is insufficient to help patients achieve an active lifestyle. The effects of two advanced and extended behavioral CR interventions on physical activity (PA) and sedentary behavior (SB) were assessed. METHODS In total, 731 patients with ACS were randomized to 1) 3months of standard CR (CR-only); 2) 3months of standard CR with three pedometer-based, face-to-face PA group counseling sessions followed by 9months of aftercare with three general lifestyle, face-to-face group counseling sessions (CR+F); or 3) 3months of standard CR, followed by 9months of aftercare with five to six general lifestyle, telephonic counseling sessions (CR+T). An accelerometer recorded PA and SB at randomization, 3months, 12months, and 18months. RESULTS The CR+F group did not improve their moderate-to-vigorous intensity PA (MVPA) or SB time compared to CR-only (between-group difference=0.24% MVPA, P=0.349; and 0.39% SB, P=0.529). However, step count (between-group difference=513 steps/day, P=0.021) and time in prolonged MVPA (OR=2.14, P=0.054) improved at 3months as compared to CR-only. The improvement in prolonged MVPA was maintained at 18months (OR=1.91, P=0.033). The CR+T group did not improve PA or SB compared to CR-only. CONCLUSIONS Adding three pedometer-based, face-to-face group PA counseling sessions to standard CR increased daily step count and time in prolonged MVPA. The latter persisted at 18months. A telephonic after-care program did not improve PA or SB. Although after-care should be optimized to improve long-term adherence, face-to-face group counseling with objective PA feedback should be added to standard CR.

Randomised controlled trial of two advanced and extended cardiac rehabilitation programmes

Objective The OPTICARE (OPTImal CArdiac REhabilitation) randomised controlled trial compared two advanced and extended cardiac rehabilitation (CR) programmes to standard CR for patients with acute coronary syndrome (ACS). These programmes were designed to stimulate permanent adoption of a heart-healthy lifestyle. The primary outcome was the SCORE (Systematic COronary Risk Evaluation) 10-year cardiovascular mortality risk function at 18 months follow-up. Methods In total, 914 patients with ACS (age, 57 years; 81% men) were randomised to: (1) 3 months standard CR (CR-only); (2) standard CR including three additional face-to-face active lifestyle counselling sessions and extended with three group fitness training and general lifestyle counselling sessions in the first 9 months after standard CR (CR+F); or (3) standard CR extended for 9 months with five to six telephone general lifestyle counselling sessions (CR+T). Results In an intention-to-treat analysis, we found no difference in the SCORE risk function at 18 months between CR+F and CR-only (3.30% vs 3.47%; p=0.48), or CR+T and CR-only (3.02% vs 3.47%; p=0.39). In a per-protocol analysis, two of three modifiable SCORE parameters favoured CR+F over CR-only: current smoking (13.4% vs 21.3%; p<0.001) and total cholesterol (3.9 vs 4.3 mmol/L; p<0.001). The smoking rate was also lower in CR+T compared with the CR-only (12.9% vs 21.3%; p<0.05). Conclusions Extending CR with extra behavioural counselling (group sessions or individual telephone sessions) does not confer additional benefits with respect to SCORE parameters. Patients largely reach target levels for modifiable risk factors with few hospital readmissions already following standard CR. Trial registration number ClinicalTrials.gov NCT01395095; results.

FATIGUE DURING AND AFTER CARDIAC REHABILITATION

OBJECTIVE To estimate fatigue during and after a multidisciplinary cardiac rehabilitation programme and its association with aerobic capacity. DESIGN Longitudinal cohort study. PATIENTS A total of 121 patients with coronary artery disease (79% men), mean age 57 years. METHODS Fatigue was measured with the Fatigue Severity Scale (FSS) and aerobic capacity with the 6-min walk test (6MWT). FSS scores ≥ 4 were defined as fatigue and >5.1 as severe fatigue. Measurements were taken before (T0) and after rehabilitation (T1) and at 1-year follow-up (T2). RESULTS Fatigue decreased from 3.49 at baseline to 3.03 post-rehabilitation (p=0.002) and decreased further to 2.75 at follow-up (p<0.001 vs T0). At baseline, 17.7% of patients were classified as severely fatigued. After cardiac rehabilitation, the prevalence decreased to 10.6% (p<0.001) and to 8.1% at follow-up (p=0.011 vs T0). Although the prevalence of severely fatigued patients decreased, it was still high compared with healthy individuals (3.5%). Aerobic capacity was weakly associated with a reduction in fatigue (p=0.030). CONCLUSION Fatigue decreased during and after cardiac rehabilitation. However, the prevalence of severely fatigued patients remained high after cardiac rehabilitation. Fatigue should be identified at an early stage in order to provide additional programmes aiming to reduce severe fatigue.

Cardiac rehabilitation in patients with acute coronary syndrome with primary percutaneous coronary intervention is associated with improved 10-year survival

Aims We aimed to assess the effects of a multidisciplinary cardiac rehabilitation (CR) program on survival after treatment with primary percutaneous coronary intervention (pPCI) for acute coronary syndrome (ACS). Methods and results Using propensity matching analysis, a total of 1159 patients undergoing CR were 1:1 matched with ACS patients who did not undergo CR and survived at least 60 days. The Kaplan-Meier analyses and multivariate Cox regression analysis were applied to study differences in survival. During follow-up, a total of 335 (14.5%) patients had died. Cumulative mortality rates at 5 and 10 years were 6.4% and 14.7% after CR and 10.4% and 23.5% in the no CR group (P < 0.001). Cardiac rehabilitation patients had 39% lower mortality than non-CR controls [10-year mortality 14.7% vs. 23.5%; adjusted hazard ratio (HR) 0.61; 95% confidence interval (CI) 0.46-0.81]. A total of 915 (78.9%) patients completed CR and had 46% lower mortality than those who did not complete CR (10-year mortality 13.6% vs. 18.9%; adjusted HR 0.54; 95% CI 0.42-0.70). Conclusion Patients who underwent pPCI for ACS, with a CR program had lower mortality than their non-CR counterparts. Mortality was particularly low in patients who completed the program. In conclusion, CR is still beneficial in terms of survival.

Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients

BACKGROUND Cardiac rehabilitation (CR) is recommended as secondary prevention in primary percutaneous coronary intervention (pPCI) patients. This study was conducted to expand the knowledge about age-effects of CR in pPCI patients. The aim of this study was to compare changes in subjective health status (SHS) during and after CR between patients <60years and patients ≥60years, who underwent pPCI after myocardial infarction. METHODS Between 2009 and 2011, in total 282 pPCI patients who participated in CR were included. Patients completed the Short Form 12 (SF-12) questionnaire at baseline (pre-CR), 3months (post-CR) and 12months follow-up. Patients were divided into two age-groups, <60years versus ≥60years. To compare improvements in SHS between groups, Generalized Estimating Equations (GEE) analyses were performed. RESULTS The mean physical component summary (PCS) score improved over time in both groups and even reached mean levels of the normative Dutch population. The improvement on the PCS score was equal in both age groups. The mental component summary (MCS) score also improved in both groups. Patients <60years reported on average more improvement on the MCS score than patients ≥60years (Exp(B) 1.019; 95%CI 1.009-1.030; P<0.001). However, mean levels of the normative Dutch population were not reached by patients <60years. CONCLUSION Even though pPCI patients <60years reported more improvement on the MCS score, mean levels of the normative Dutch population were not reached. Therefore, a tailored CR program with more focus on their mental status, may be beneficial in younger patients.