Trina Hauer

Cardiac Rehabilitation Attendance and Outcomes in Coronary Artery Disease Patients

Background— Cardiac rehabilitation (CR) is an efficacious yet underused treatment for patients with coronary artery disease. The objective of this study was to determine the association between CR completion and mortality and resource use. Methods and Results— We conducted a prospective cohort study of 5886 subjects (20.8% female; mean age, 60.6 years) who had undergone angiography and were referred for CR in Calgary, AB, Canada, between 1996 and 2009. Outcomes of interest included freedom from emergency room visits, hospitalization, and survival in CR completers versus noncompleters, adjusted for clinical covariates, treatment strategy, and coronary anatomy. Hazard ratios for events for CR completers versus noncompleters were also constructed. A propensity model was used to match completers to noncompleters on baseline characteristics, and each outcome was compared between propensity-matched groups. Of the subjects referred for CR, 2900 (49.3%) completed the program, and an additional 554 subjects started but did not complete CR. CR completion was associated with a lower risk of death, with an adjusted hazard ratio of 0.59 (95% confidence interval, 0.49–0.70). CR completion was also associated with a decreased risk of all-cause hospitalization (adjusted hazard ratio, 0.77; 95% confidence interval, 0.71–0.84) and cardiac hospitalization (adjusted hazard ratio, 0.68; 95% confidence interval, 0.55–0.83) but not with emergency room visits. Propensity-matched analysis demonstrated a persistent association between CR completion and reduced mortality. Conclusions— Among those coronary artery disease patients referred, CR completion is associated with improved survival and decreased hospitalization. There is a need to explore reasons for nonattendance and to test interventions to improve attendance after referral.

Cardiovascular Fitness and Mortality After Contemporary Cardiac Rehabilitation

OBJECTIVE To assess the association between cardiorespiratory fitness (CRF) and outcomes in a cardiac rehabilitation (CR) cohort. PATIENTS AND METHODS We conducted a retrospective study of 5641 patients (4282 men [76%] and 1359 women [24%]; mean ± SD age, 60.0±10.3 years) with coronary artery disease who participated in CR between July 1, 1996, and February 28, 2009. Based on peak metabolic equivalents (METs), patients were classified as low fitness (LFit) (<5 METs), moderate fitness (5-8 METs), or high fitness (>8 METs). RESULTS Baseline fitness predicted long-term mortality: relative to the LFit group, patients with moderate fitness had an adjusted hazard ratio of 0.54 (95% CI, 0.42-0.69), and those with high fitness a hazard ratio of 0.32 (95% CI, 0.24-0.44). Improvement in CRF at 12 weeks was associated with decreased overall mortality, with a 13% point reduction with each MET increase (P<.001) and a 30% point reduction in those who started with LFit. At 1 year, each MET increase in CRF was associated with a 25% point reduction in overall mortality in the whole group (P<.001). CONCLUSION In this study of contemporary CR patients, higher baseline fitness predicted lower mortality. The novel finding was that improvement in fitness during a CR program and improvements that persisted at 1 year were also associated with decreased mortality, most strongly in patients who start with LFit.

Cardiac rehabilitation referral, attendance and mortality in women:

Background Cardiac rehabilitation (CR) reduces mortality in women and men with coronary artery disease (CAD). The objective of this study was to examine sex differences in long-term mortality, based on CR referral rates and attendance patterns in a large CAD population. Design This is a retrospective cohort study. Methods The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) and Cardiac Wellness Institute of Calgary (CWIC) databases were used to obtain information on all patients. Rates of referral to and attendance at CR were compared by sex. Logistic regression models were constructed to assess whether sex predicted CR referral or completion. The association between referral, completion, and survival was assessed by sex using Cox proportional hazard models. Results 25,958 subjects (6374—24.6%—were women) with at least one vessel CAD were included. Females experienced reduced rates of CR referral (31.1% vs 42.2%, p < 0.0001) and completion (50.1 vs 60.4%, p < 0.0001). Adjusting for demographic and clinical characteristics, relative to men, CR referral was significantly lower in women (adjusted odds ratio (OR) 0.74, 95% CI 0.69, 0.79) as was CR completion (adjusted OR 0.73, 95% CI 0.66, 0.81). Women completing CR experienced the greatest reduction in mortality (HR 0.36, 95% CI 0.28, 0.45) with a relative benefit greater than men (HR 0.51, 95% CI 0.46, 0.56). Conclusion This is the first large cohort study to demonstrate that referral to and attendance at CR is associated with a significant mortality reduction in women, comparatively better than that in men.

Optimizing Value from Cardiac Rehabilitation: A Cost-Utility Analysis Comparing Age, Sex and Clinical Subgroups

OBJECTIVE To assess the cost utility of a center-based outpatient cardiac rehabilitation program compared with no program within patient subgroups on the basis of age, sex, and clinical presentation (acute coronary syndrome [ACS] or non-ACS). METHODS We performed a cost-utility analysis from a health system payer perspective to compare cardiac rehabilitation with no cardiac rehabilitation for patients who had a cardiac catheterization. The Markov model was stratified by clinical presentation, age, and sex. Clinical, quality-of-life, and cost data were provided by the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology. RESULTS The incremental cost per quality-adjusted life-year (QALY) gained for cardiac rehabilitation varies by subgroup, from

The independent effect of traditional cardiac rehabilitation and the LEARN program on weight loss: a comparative analysis.

18,101 per QALY gained to

Patients with Diabetes in Cardiac Rehabilitation: Attendance and Exercise Capacity.

104,518 per QALY gained. There is uncertainty in the estimates due to uncertainty in the clinical effectiveness of cardiac rehabilitation. Overall, the probabilistic sensitivity analysis found that 75% of the time participation in cardiac rehabilitation is more expensive but more effective than not participating in cardiac rehabilitation. CONCLUSION The cost-effectiveness of cardiac rehabilitation varies depending on patient characteristics. The current analysis indicates that cardiac rehabilitation is most cost effective for those with an ACS and those who are at higher risk for subsequent cardiac events. The findings of the current study provide insight into who may benefit most from cardiac rehabilitation, with important implications for patient referral patterns.

An investigation of the benefits of stress management within a cardiac rehabilitation population

INTRODUCTION: Despite its numerous other benefits, cardiac rehabilitation (CR) has not consistently proven to be an effective, although much needed, intervention for weight loss in the cardiovascular disease (CVD) population. Comparatively, the LEARN (Lifestyle, Exercise, Attitudes, Relationships, Nutrition) program appears to be an effective intervention for weight loss. The purpose of the present investigation was to compare changes in body weight in a CVD cohort consecutively participating in traditional CR and the LEARN program. METHODS: Forty-four patients diagnosed with CVD (22 men/22 women) participated in a 12-week multidisciplinary CR program. All patients successfully completed the LEARN program following CR. Body mass index (BMI) and body weight were recorded immediately prior to and following both CR and LEARN. RESULTS: The peak metabolic equivalents were significantly higher following CR (7.3 ± 1.6 vs 8.5 ±1.6, P < .001), while body weight (203.5 ± 32.6 vs 201.8 ± 32.5 lbs, P > .10) and BMI (32.1 ±4.0 vs 31.8 ±3.9 kg/m2, P > .05) were unchanged. All subjects then successfully completed the LEARN program, participating in an average of 10 sessions. There was a significant reduction in body weight (203.3 ± 30.7 vs 190.1 ± 30.4 lbs, P < .001) and BMI (32.0 ± 3.9 vs 29.5 ±3.8 kg/m2, P < .001) following the LEARN program. DISCUSSION: Our results support the independent value of the LEARN program in eliciting weight loss for CR patients. Clinicians delivering CR services should consider integrating a focused weight loss program, such as LEARN, into their usual CR programs.

Obesity Negatively Impacts Aerobic Capacity Improvements Both Acutely and 1‐Year Following Cardiac Rehabilitation

PURPOSE Diabetes increases mortality after myocardial infarction, but participation in cardiac rehabilitation (CR) reduces this risk. Our objectives were to examine whether attendance at CR and changes in cardiorespiratory fitness differed according to diabetic status and sex. METHODS Retrospective cohort study of patients referred for CR in Calgary between 1996 and 2010. Cardiorespiratory fitness in metabolic equivalents (METs) was estimated by maximal exercise testing at baseline, at the end of the 12-wk CR program, and 1-yr after CR. RESULTS Among 7036 nondiabetic and 1546 diabetic patients who started, 84.9% of nondiabetic versus 79.5% of diabetic patients completed CR (P < 0.0001). The difference between diabetic and nondiabetic patients was greater in women (81.7% vs 72.1%, P < 0.0001) than that in men (86.0% vs 82.5%, P = 0.004). Patients without diabetes were more likely to return for the 1-yr assessment (53.7% vs 42.7%, P < 0.0001), and nondiabetic women were more likely than diabetic women to attend the 1-yr follow-up (44.3% vs 31.7%, P < 0.0001). Change in cardiorespiratory fitness from baseline to 12 wk was +1.0 METs in nondiabetic men, +0.9 METS in diabetic men, +0.9 METs in nondiabetic women, and +0.7 METs in diabetic women (within-group change; P = 0.0009). Changes in cardiorespiratory fitness at 1 yr compared with baseline were +0.9, +0.6, +0.9, and +0.5 METS, respectively (within-group change, P = 0.0001). CONCLUSIONS Patients with diabetes, especially females, were less likely than patients without diabetes to complete CR and attend follow-up. Among patients who attended 1-yr follow-up, changes in cardiorespiratory fitness were not as well maintained in diabetic patients as in nondiabetic patients. Identifying barriers and targeting CR adherence interventions to patients with diabetes may help improve outcomes.

Factors Associated With Cardiorespiratory Fitness at Completion of Cardiac Rehabilitation: Identification of Specific Patient Features Requiring Attention

PURPOSE: Research describing whether stress management can improve clinical outcomes for patients in cardiac rehabilitation (CR) has yielded equivocal findings. METHODS: The present investigation retrospectively examined the incremental impact of exercise and stress management (n = 188), relative to exercise only (n = 1389), on psychosocial and physical health outcomes following a 12-week CR program. RESULTS: Participation in stress management and exercise was associated with greater reductions in waist circumference and systolic blood pressure, relative to exercise alone, for patients with baseline clinical elevations on these measures. The stress management group had more depressive symptoms (as measured by the Hospital Anxiety and Depression Scale; t[1] = 3.81, P < .001) and lower physical quality of life (as measured by the 12-Item Short Form Health Survey Physical Component; t[1] = 3.00, P = .003) than the exercise-only group at baseline, but there were no differences between the groups at 12 weeks in terms of depressive symptoms (t[1] = 1.74, P = .082) or physical quality of life (t[1] = 1.56, P = .120). CONCLUSION: These findings suggest that stress management may offer additional benefits in selected patients over and above exercise in CR.

Exercise Therapy for Heart Failure Patients in Canada

Cardiac rehabilitation (CR) produces a host of health benefits related to modifiable cardiovascular risk factors. The purpose of the present investigation was to determine the influence of body weight, assessed through BMI, on acute and long‐term improvements in aerobic capacity following completion of CR. Three thousand nine hundred and ninety seven subjects with coronary artery disease (CAD) participated in a 12‐week multidisciplinary CR program. Subjects underwent an exercise test to determine peak estimated metabolic equivalents (eMETs) and BMI assessment at baseline, immediately following CR completion and at 1‐year follow‐up. Normal weight subjects at 1‐year follow‐up demonstrated the greatest improvement in aerobic fitness and best retention of those gains (gain in peak METs: 0.95 ± 1.1, P < 0.001). Although the improvement was significant (P < 0.001), subjects who were initially classified as obese had the lowest aerobic capacity and poorest retention in CR fitness gains at 1‐year follow‐up (gain in peak eMETs: 0.69 ± 1.2). Subjects initially classified as overweight by BMI had a peak eMET improvement that was also significantly better (P < 0.05) than obese subjects at 1‐year follow‐up (gain in peak eMETs: 0.82 ± 1.1). Significant fitness gains, one of the primary beneficial outcomes of CR, can be obtained by all subjects irrespective of BMI classification. However, obese patients have poorer baseline fitness and are more likely to “give back” fitness gains in the long term. Obese CAD patients may therefore benefit from additional interventions to enhance the positive adaptations facilitated by CR.