How to implement geriatric co-management in your hospital? Insights from the G-COACH feasibility study.

BACKGROUND: Geriatric co-management is advocated to manage frail patients in the hospital, but there is no guidance on how to implement such programmes in practice. This paper reports our experiences with implementing the 'Geriatric CO-mAnagement for Cardiology patients in the Hospital' (G-COACH) programme. We investigated if G-COACH was feasible to perform after the initial adoption, investigated how well the implementation strategy was able to achieve the implementation targets, determined how patients experienced receiving G-COACH, and determined how healthcare professionals experienced the implementation of G-COACH. METHODS: A feasibility study of the G-COACH programme was performed using a one-group experimental study design. G-COACH was previously implemented on two cardiac care units. Patients and healthcare professionals participating in the G-COACH programme were recruited for this evaluation. The feasibility of the programme was investigated by observing the reach, fidelity and dose using registrations in the electronic patient record and by interviewing patients. The success of the implementation reaching its targets was evaluated using a survey that was completed by 48 healthcare professionals. The experiences of 111 patients were recorded during structured survey interviews. The experiences of healthcare professionals with the implementation process was recorded during 6 semi-structured interviews and 4 focus groups discussions (n = 27). RESULTS: The programme reached 91% in a sample of 151 patients with a mean age of 84 years. There was a high fidelity for the major components of the programme: documentation of geriatric risks (98%), co-management by specialist geriatrics nurse (95%), early rehabilitation (80%), and early discharge planning (74%), except for co-management by the geriatrician (32%). Both patients and healthcare professionals rated G-COACH as acceptable (95 and 94%) and feasible (96 and 74%). The healthcare professionals experienced staffing, competing roles and tasks of the geriatrics nurse and leadership support as important determinants for implementation. CONCLUSIONS: The implementation strategy resulted in the successful initiation of the G-COACH programme. G-COACH was perceived as acceptable and feasible. Fidelity was influenced by context factors. Further investigation of the sustainability of the programme is needed. TRIAL REGISTRATION: ISRCTN22096382 (21/05/2020).

Exercise capacity, muscle strength and objectively measured physical activity in patients after heart transplantation.

Maximal exercise capacity of patients after heart transplantation (HTX) remains limited, affecting their quality of life. Evidence on the evolution of muscle strength and physical activity (PA) post-HTX is lacking, but a prerequisite to tailor cardiac rehabilitation programmes. Forty-five consecutive patients were evaluated every 3 months during the first year post-HTX. Functional exercise capacity (Six minutes walking distance test (6MWD)), peripheral (Quadriceps strength (QF)) and respiratory (Maximal inspiratory strength (MIP)) muscle strength were evaluated. PA (number of steps (PAsteps), active time (PAactive) and sedentary time (PAsed)) was objectively measured. 6MWD, QF, MIP, PAsteps and PAactive significantly improved over time (P < 0.001). No change in PAsed was noticed (P = 0.129). Despite improvements in 6MWD and QF, results remained substantially below those of age-and gender-matched healthy subjects. One year post-HTX, 30% of patients presented with peripheral muscle weakness. Baseline levels of 6MWD and QF were significantly higher in patients with pretransplant LVAD-implantation and this difference was maintained during follow-up. cardiac rehabilitation, combining aerobic exercise training and peripheral muscle strength training, is mandatory in patients post-HTX. Inspiratory muscle training should be implemented when respiratory muscle weakness is present. Programmes improving physical activity and reducing sedentary time post-HTX are essential.

Geriatric co-management for cardiology patients in the hospital: A quasi-experimental study.

BACKGROUND/OBJECTIVES: Older patients admitted to cardiac care units often suffer functional decline. We evaluated whether a nurse-led geriatric co-management program leads to better functional status at hospital discharge. DESIGN: A quasi-experimental before-and-after study was performed between September 2016 and December 2018, with the main endpoint at hospital discharge and follow-up at 6 months. SETTING: Two cardiac care units of the University Hospitals Leuven. PARTICIPANTS: One hundred and fifty-one intervention and 158 control patients aged 75 years or older admitted for acute cardiovascular disease or transcatheter aortic valve implantation. INTERVENTION: A nurse from the geriatrics department performed a comprehensive geriatric assessment within 24 h of admission. The cardiac care team and geriatrics nurse drafted an interdisciplinary care plan, focusing on early rehabilitation, discharge planning, promoting physical activity, and preventing geriatric syndromes. The geriatrics nurse provided daily follow-up and coached the cardiac team. A geriatrician co-managed patients with complications. MEASUREMENTS: The primary outcome was functional status measured using the Katz Index for independence in activities of daily living (ADL; one-point difference was considered clinically relevant). Secondary outcomes included the incidence of ADL decline and complications, length of stay, unplanned readmissions, survival, and quality of life. RESULTS: The mean age of patients was 85 years. Intervention patients had better functional status at hospital discharge (8.9, 95% CI = 8.7-9.3 versus 9.5, 95% CI = 9.2-9.9; p = 0.019) and experienced 18% less functional decline during hospitalization (25% vs. 43%, p = 0.006). The intervention group experienced significantly fewer cases of delirium and obstipation during hospitalization, and significantly fewer nosocomial infections. At 6-month follow-up, patients had significantly better functional status and quality of life. There were no differences regarding length of stay, readmissions, or survival. CONCLUSION: This first nurse-led geriatric co-management program for frail patients on cardiac care units was not effective in improving functional status, but significantly improved secondary outcomes.

Limiting factors of peak and submaximal exercise capacity in LVAD patients.

AIMS: Although patients supported with a Continuous-Flow Left Ventricular Assist Device (CF-LVAD) are hemodynamically stable, their exercise capacity is limited. Hence, the aim of this work was to investigate the underlying factors that lead to peak and submaximal exercise intolerance of CF-LVAD supported patients. METHODS: Seven months after CF-LVAD implantation, eighty three patients performed a maximal cardiopulmonary exercise test and a six minute walk test. Peak oxygen uptake and the distance walked were measured and expressed as a percentage of the predicted value (%VO2p and %6MWD, respectively). Preoperative conditions, echocardiography, laboratory results and pharmacological therapy data were collected and a correlation analysis against %VO2p and %6MWD was performed. RESULTS: CF-LVAD patients showed a relatively higher submaximal exercise capacity (%6MWD = 64±16%) compared to their peak exertion (%VO2p = 51±14%). The variables that correlated with %VO2p were CF-LVAD parameters, chronotropic response, opening of the aortic valve at rest, tricuspid insufficiency, NT-proBNP and the presence of a cardiac implantable electronic device. On the other hand, the variables that correlated with %6MWD were diabetes, creatinine, urea, ventilation efficiency and CF-LVAD pulsatility index. Additionally, both %6MWD and %VO2p were influenced by the CF-LVAD implantation timing, calculated from the occurrence of the cardiac disease. CONCLUSION: Overall, both %6MWD and %VO2p depend on the duration of heart failure prior to CF-LVAD implantation. %6MWD is primarily determined by parameters underlying the patient's general condition, while %VO2p mostly relies on the residual function and chronotropic response of the heart. Moreover, since %VO2p was relatively lower compared to %6MWD, we might infer that CF-LVAD can support submaximal exercise but is not sufficient during peak exertion. Hence concluding that the contribution of the ventricle is crucial in sustaining hemodynamics at peak exercise.

Effects of downhill walking in pulmonary rehabilitation for patients with COPD: a randomised controlled trial.

The development of contractile muscle fatigue (CMF) affects training responses in patients with chronic obstructive pulmonary disease (COPD). Downhill walking induces CMF with lower dyspnoea and fatigue than level walking. This study compared the effect of pulmonary rehabilitation (PR) comprising downhill walking training (DT) to PR comprising level walking (conventional training (CT)) in patients with COPD.In this randomised controlled trial, 35 patients (62±8 years; forced expiratory volume in 1 s (FEV1) 50±17% predicted) were randomised to DT or CT. Exercise tolerance (6-minute walk test distance (6MWD); primary outcome), muscle function, symptoms, quality-of-life and physical activity levels were assessed before and after PR. Absolute training changes and the proportion of patients exceeding the 30 m 6MWD minimally important difference (MID) were compared between groups. Quadriceps muscle biopsies were collected after PR in a subset of patients to examine physiological responses to long-term eccentric training.No between-group differences were observed in absolute 6MWD improvement (mean 6MWD change 77±46 m DT versus 56±47 m CT; p=0.45), however 94% of patients in DT exceeded the 6MWD MID compared to 65% in CT (p=0.03). Patients in DT tended to have larger improvements than CT in other outcomes. Muscle biopsy analyses did not differ between groups.PR incorporating downhill walking confers similar magnitudes of effects to PR with conventional walking across clinical outcomes in patients with COPD, however, offers a more reliable stimulus to maximise the achievement of clinically relevant gains in functional exercise tolerance in people with COPD.

Predicting hospitalisation-associated functional decline in older patients admitted to a cardiac care unit with cardiovascular disease: a prospective cohort study.

BACKGROUND: Up to one in three of older patients who are hospitalised develop functional decline, which is associated with sustained disability, institutionalisation and death. This study developed and validated a clinical prediction model that identifies patients who are at risk for functional decline during hospitalisation. The predictive value of the model was compared against three models that were developed for patients admitted to a general medical ward. METHODS: A prospective cohort study was performed on two cardiac care units between September 2016 and June 2017. Patients aged 75 years or older were recruited on admission if they were admitted for non-surgical treatment of an acute cardiovascular disease. Hospitalisation-associated functional decline was defined as any decrease on the Katz Index of Activities of Daily Living between hospital admission and discharge. Predictors were selected based on a review of the literature and a prediction score chart was developed based on a multivariate logistic regression model. RESULTS: A total of 189 patients were recruited and 33% developed functional decline during hospitalisation. A score chart was developed with five predictors that were measured on hospital admission: mobility impairment = 9 points, cognitive impairment = 7 points, loss of appetite = 6 points, depressive symptoms = 5 points, use of physical restraints or having an indwelling urinary catheter = 5 points. The score chart of the developed model demonstrated good calibration and discriminated adequately (C-index = 0.75, 95% CI (0.68-0.83) and better between patients with and without functional decline (chi2 = 12.8, p = 0.005) than the three previously developed models (range of C-index = 0.65-0.68). CONCLUSION: Functional decline is a prevalent complication and can be adequately predicted on hospital admission. A score chart can be used in clinical practice to identify patients who could benefit from preventive interventions. Independent external validation is needed.

Effectiveness of high intensity interval training supplemented with peripheral and inspiratory resistance training in chronic heart failure: a pilot study.

Background: Cardiac rehabilitation (CR) is an evidence-based therapy in chronic heart failure (CHF). There is still debate about the optimal training protocol in CHF. The use of high intensity interval training (HIIT) supplemented with peripheral (PRT) and inspiratory resistance training (IRT) might be more beneficial because of the higher impact on the peripheral and inspiratory muscles, with less symptoms of dyspnoea and lower amount of dropouts as a result. We compared our standard exercise-based CR programme, mainly consisting of moderate intensity interval training to a programme combining HIIT, PRT and IRT (resistance training supplemented HIIT (RHIIT) programme).Design: Randomised controlled pilot study.Methods: Twenty patients with CHF were randomised on a 1:1 basis to the standard or RHIIT programme. At baseline and after 3 months, peak exercise capacity (VO2peak), peripheral (QF) and inspiratory respiratory muscle strength (MIP), quality of life (QOL) and physical activity were measured.Results: The RHIIT programme resulted in a significantly larger improvement in QF (ΔQF RHIIT programme: 19.3 ± 11.8 vs standard programme: -6.89 ± 19.0 Nm (p < .01)) and MIP (ΔMIP RHIIT programme: -44.9 ± 29.9 vs standard programme: 0.56 ± 19.4 cmH2O (p < .01)). Both programmes equally improved in VO2peak (p = .91), whereas ventilatory efficiency and physical activity remained stable.Conclusion: HIIT supplemented with PRT and IRT might be applicable as standard protocol in CHF. Larger studies are warranted to confirm our findings. The RHIIT programme resulted in similar training effects in VO2peak in a shorter training period. This might be beneficial in a chronic patient population such as CHF, where adherence is difficult.

Health status deterioration in subjects with mild to moderate airflow obstruction, a six years observational study.

BACKGROUND: Patients with COPD need to cope with a disabling disease, which leads to health status impairment. AIM: To investigate the long term change of health status in subjects with mild to moderate airflow obstruction and to compare this to subjects without airflow obstruction, with and without a smoking history. Second, to investigate the factors potentially associated to rapid health status decline in our total cohort. METHODS: Two hundred and one subjects were included. Generic [Short form 36 health survey (SF36) and EuroQol - 5 dimensions (EQ-5D)] and disease specific [Clinical COPD questionnaire (CCQ) and COPD Assessment Test (CAT)] health status questionnaires were regularly repeated over a six years period. Other functional outcomes comprised measures of lung function, physical fitness, physical activity and emotional state. RESULTS: On average, health status decline did not differ between groups with the exception of the EQ-5D index, which deteriorated faster in subjects with airflow obstruction compared to the never smoking control group [- 0.018(0.008) versus 0.00006(0.003), p = 0.03]. Subjects presenting at least one exacerbation had faster rate of deterioration measured with CAT [0.91(0.21) versus - 0.26(0.25), p < 0.01]. Characteristics of the fast declining group were older age, worse lung function, physical fitness, physical activity and disease specific baseline health status. Subjects with airflow obstruction had a 2.5 (95% CI 1.36-4.71) higher risk of presenting fast overall health status decline. Fast overall decline was associated with the presence of acute exacerbation(s) (44% of the subjects with exacerbation(s) versus 17% of subjects without exacerbation, p = 0.03). Changes in fat free mass, functional exercise capacity and in symptoms of anxiety and depression correlated weakly to changes in health status measured with all questionnaires. CONCLUSION: Subjects with mild airflow obstruction present a significant deterioration of health status, which is generally not much faster compared to smoking and never smoking controls. Subjects with fast decline in overall health status are older and more likely to have airflow obstruction, acute respiratory exacerbation(s), reduced physical fitness, physical activity and impaired COPD specific health status at baseline. TRIAL REGISTRATION: NCT01314807 - retrospectively registered on March 2011.

Six years progression of exercise capacity in subjects with mild to moderate airflow obstruction, smoking and never smoking controls.

BACKGROUND: Exercise capacity is an important feature in patients with COPD. Its impairment drives disability and dependency for daily activities performance. This study evaluated the six years change in exercise capacity in subjects with airflow obstruction and compared this to subjects without airflow obstruction, with and without a smoking history. METHODS: Cardiopulmonary exercise tests (CPET) were repeatedly performed during a six years follow up period. Peak oxygen uptake (VO2peak), work rate (WRpeak), heart rate (HRpeak), minute ventilation (VEpeak), respiratory exchange ratio (RERpeak) and ventilatory reserve (VE/MVV) were collected as effort dependent outcomes. The slopes of oxygen uptake, ventilatory and mechanical efficiency (OUES, ΔVE/ΔVCO2 and ΔVO2/ΔWR) were collected as effort independent outcomes. RESULTS: One hundred and thirty-eight subjects were included. Thirty-eight presented airflow obstruction (63±6 years, 74% men, FEV1 90±15%pred), 44 had a smoking history but no airflow obstruction (61±5 years, 61% men, FEV1 105±15%pred) and 56 had never smoked (61±7 years, 57% men, FEV1 117±18%pred). At baseline, the airflow obstruction group had slightly worse exercise capacity in comparison to the never smoking control group, in absolute terms and expressed as percentage of the predicted value (VO2peak = 27±5 versus 32±8 ml/min/kg, p<0.01; 112±29 versus 130±33%pred, p = 0.04). Most exercise variables showed a statistically significant yearly deterioration, with exception of VE/MVV, ΔVE/ΔVCO2 and ΔVO2/ΔWR. The yearly decline in VO2peak and OUES was not faster in subjects with airflow obstruction than in smoking and never smoking controls (VO2peak -67 (9) versus -76 (9) ml/min, p = 0.44 and versus -58 (9), p = 0.47; OUES -32 (11) versus -68 (10), p = 0.03 and versus -68 (13), p = 0.03). CONCLUSIONS: With exception of VO2peak, effort dependent variables deteriorated faster in subjects with airflow obstruction compared to never smoking controls. The deterioration of effort independent variables, however, was not accelerated in the airflow obstruction group compared to controls.

Geriatric CO-mAnagement for Cardiology patients in the Hospital (G-COACH): study protocol of a prospective before-after effectiveness-implementation study.

INTRODUCTION: Although the majority of older patients admitted to a cardiology unit present with at least one geriatric syndrome, guidelines on managing heart disease often do not consider the complex needs of frail older patients. Geriatric co-management has demonstrated potential to improve functional status, and reduce complications and length of stay, but evidence on the effectiveness in cardiology patients is lacking. This study aims to determine if geriatric co-management is superior to usual care in preventing functional decline, complications, mortality, readmission rates, reducing length of stay and improving quality of life in older patients admitted for acute heart disease or for transcatheter aortic valve implantation, and to identify determinants of success for geriatric co-management in this population. METHODS AND ANALYSIS: This prospective quasi-experimental before-and-after study will be performed on two cardiology units of the University Hospitals Leuven in Belgium in patients aged ≥75 years. In the precohort (n=227), usual care will be documented. A multitude of implementation strategies will be applied to allow for successful implementation of the model. Patients in the after cohort (n=227) will undergo a comprehensive geriatric assessment within 24 hours of admission to stratify them into one of three groups based on their baseline risk for developing functional decline: low-risk patients receive proactive consultation, high-risk patients will be co-managed by the geriatric nurse to prevent complications and patients with acute geriatric problems will receive an additional medication review and co-management by the geriatrician. ETHICS AND DISSEMINATION: The study protocol was approved by the Medical Ethics Committee UZ Leuven/KU Leuven (S58296). Written voluntary (proxy-)informed consent will be obtained from all participants at the start of the study. Dissemination of results will be through articles in scientific and professional journals both in English and Dutch and by conference presentations. TRIAL REGISTRATION NUMBER: NCT02890927.

Hospitalization-associated disability in older adults with valvular heart disease: incidence, risk factors and its association with care processes.

BACKGROUND: The aim of this study was to determine the incidence and recovery of hospitalisation-associated disability (HAD), the associated risk factors, and the link with care processes in patients aged 70 years or older hospitalised with valvular heart disease (VHD). METHODS: Prospective cohort study performed on the cardiology and cardiac surgery units of University Hospitals Leuven, Belgium. HAD was defined as the loss of independence to complete one of the Activities of Daily Living (ADLs) between hospital admission and discharge. Recovery of HAD at 30 days post hospital discharge was achieved when patients recovered their baseline ADL status (2 weeks before hospital admission) (ClinicalTrials.gov: NCT02572999). RESULTS: Eighty patients were enrolled in the study, 77 completed the assessment at discharge and 62 responded at 30 days follow-up. Forty patients (51.9%) developed HAD; 18 of them (45.0%) recovered their baseline ADL status. The risk of HAD increased when patients were physically restrained (relative risk (RR) 1.73, 95% confidence interval (CI) 1.20-2.49), had indwelling catheters (RR 1.80, 95% CI 0.85-3.80) and received preventive pressure ulcer measures (RR 1.71, 95% CI 1.07-2.74). Patients with HAD had longer hospital stays (+3 days, p = .011) and longer use of indwelling catheters (+2 days, p = .024). CONCLUSION: Half of the older adults with VHD developed HAD. The results indicate a potential association between HAD and care processes, which could be used as quality measures and intervention targets. Validation in larger cohort studies is recommended.

Validity and reliability of strain gauge measurement of volitional quadriceps force in patients with COPD.

This study investigated the validity and reliability of fixed strain gauge measurements of isometric quadriceps force in patients with chronic obstructive pulmonary disease (COPD). A total cohort of 138 patients with COPD were assessed. To determine validity, maximal volitional quadriceps force was evaluated during isometric maximal voluntary contraction (MVC) manoeuvre via a fixed strain gauge dynamometer and compared to (a) potentiated non-volitional quadriceps force obtained via magnetic stimulation of the femoral nerve (twitch (Tw); n = 92) and (b) volitional computerized dynamometry (Biodex; n = 46) and analysed via correlation coefficients. Test-retest and absolute reliability were determined via calculations of intra-class correlation coefficients (ICCs), smallest real differences (SRDs) and standard errors of measurement (SEMs). For this, MVC recordings in each device were performed across two test sessions separated by a period of 7 days ( n = 46). Strain gauge measures of MVC demonstrated very large correlation with Tw and Biodex results ( r = 0.86 and 0.88, respectively, both p < 0.0001). ICC, SEM and SRD were numerically comparable between strain gauge and Biodex devices (ICC = 0.96 vs. 0.93; SEM = 8.50 vs. 10.54 N·m and SRD = 23.59 vs. 29.22 N·m, respectively). The results support that strain gauge measures of quadriceps force are valid and reliable in patients with COPD.

Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis.

Background: geriatric consultation teams have failed to impact clinical outcomes prompting geriatric co-management programmes to emerge as a promising strategy to manage frail patients on non-geriatric wards. Objective: to conduct a systematic review of the effectiveness of in-hospital geriatric co-management. Data sources: MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to 6 May 2016. Reference lists, trial registers and PubMed Central Citations were additionally searched. Study selection: randomised controlled trials and quasi-experimental studies of in-hospital patients included in a geriatric co-management study. Two investigators performed the selection process independently. Data extraction: standardised data extraction and assessment of risk of bias were performed independently by two investigators. Results: twelve studies and 3,590 patients were included from six randomised and six quasi-experimental studies. Geriatric co-management improved functional status and reduced the number of patients with complications in three of the four studies, but studies had a high risk of bias and outcomes were measured heterogeneously and could not be pooled. Co-management reduced the length of stay (pooled mean difference, -1.88 days [95% CI, -2.44 to -1.33]; 11 studies) and may reduce in-hospital mortality (pooled odds ratio, 0.72 [95% CI, 0.50-1.03]; 7 studies). Meta-analysis identified no effect on the number of patients discharged home (5 studies), post-discharge mortality (3 studies) and readmission rate (4 studies). Conclusions: there was low-quality evidence of a reduced length of stay and a reduced number of patients with complications, and very low-quality evidence of better functional status as a result of geriatric co-management.

The Minimal Important Difference in Physical Activity in Patients with COPD.

BACKGROUND: Changes in physical activity (PA) are difficult to interpret because no framework of minimal important difference (MID) exists. We aimed to determine the minimal important difference (MID) in physical activity (PA) in patients with Chronic Obstructive Pulmonary Disease and to clinically validate this MID by evaluating its impact on time to first COPD-related hospitalization. METHODS: PA was objectively measured for one week in 74 patients before and after three months of rehabilitation (rehabilitation sample). In addition the intraclass correlation coefficient was measured in 30 patients (test-retest sample), by measuring PA for two consecutive weeks. Daily number of steps was chosen as outcome measurement. Different distribution and anchor based methods were chosen to calculate the MID. Time to first hospitalization due to an exacerbation was compared between patients exceeding the MID and those who did not. RESULTS: Calculation of the MID resulted in 599 (Standard Error of Measurement), 1029 (empirical rule effect size), 1072 (Cohen's effect size) and 1131 (0.5SD) steps.day-1. An anchor based estimation could not be obtained because of the lack of a sufficiently related anchor. The time to the first hospital admission was significantly different between patients exceeding the MID and patients who did not, using the Standard Error of Measurement as cutoff. CONCLUSIONS: The MID after pulmonary rehabilitation lies between 600 and 1100 steps.day-1. The clinical importance of this change is supported by a reduced risk for hospital admission in those patients with more than 600 steps improvement.

Physical Activity Characteristics across GOLD Quadrants Depend on the Questionnaire Used.

BACKGROUND: The GOLD multidimensional classification of COPD severity combines the exacerbation risk with the symptom experience, for which 3 different questionnaires are permitted. This study investigated differences in physical activity (PA) in the different GOLD quadrants and patient's distribution in relation to the questionnaire used. METHODS: 136 COPD patients (58±21% FEV1 predicted, 34F/102M) completed COPD assessment test (CAT), clinical COPD questionnaire (CCQ) and modified Medical Research Council (mMRC) questionnaire. Exacerbation history, spirometry and 6MWD were collected. PA was objectively measured for 2 periods of 1 week, 6 months apart, in 5 European centres; to minimise seasonal and clinical variation the average of these two periods was used for analysis. RESULTS: GOLD quadrants C+D had reduced PA compared with A+B (3824 [2976] vs. 5508 [4671] steps.d-1, p<0.0001). The choice of questionnaire yielded different patient distributions (agreement mMRC-CAT κ = 0.57; CCQ-mMRC κ = 0.71; CCQ-CAT κ = 0.72) with different clinical characteristics. PA was notably lower in patients with an mMRC score ≥2 (3430 [2537] vs. 5443 [3776] steps.d-1, p <0.001) in both the low and high risk quadrants. CONCLUSIONS: Using different questionnaires changes the patient distribution and results in different clinical characteristics. Therefore, standardization of the questionnaire used for classification is critical to allow comparison of different studies using this as an entry criterion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT01388218.

Functional performance and quality of life in high-risk comorbid patients undergoing transcatheter aortic valve implantation for symptomatic aortic valve stenosis.

AIMS: We assessed the impact of transcatheter aortic valve implantation (TAVI) on functional performance and quality of life (QoL) in a high-risk patient population with multiple comorbidities. METHODS AND RESULTS: Between January 2009 and December 2014, 145 high-risk patients (EuroSCORE II 7.3% [4.9; 14.9]) with severe symptomatic aortic valve stenosis (AS) underwent TAVI in a single centre. We prospectively evaluated New York Heart Association (NYHA) functional class, 6-minute walking distance (6MWD), and QoL using the validated Dutch version of the EuroQol-5D (EQ-5D) descriptive assessment and a visual analogue scale (EQ-VAS) at baseline, 30 days, as well as 6, 12, and 24 months after TAVI. All patients were eligible for analysis. New York Heart Association functional class improved significantly at 30-day, 6-, 12-, and 24-month follow-up (P < 0.001 for all). The absolute 6MWD improved significantly at 30 days (+19.3 ± 8.2 m; P= 0.0499) and at 6 months (+23.3 ± 8.1 m; P = 0.0194). A favourable trend was maintained at 12 months (+17.1 ± 8.8 m; P = 0.1879), whereas at 24 months 6MWD was similar to baseline values. No significant change in the descriptive assessment of QoL (EQ5D) was observed, whereas the EQ-VAS showed a significant improvement in QoL up to 24 months (P < 0.0180 for all time-points). CONCLUSION: In high-risk comorbid patients with symptomatic AS, TAVI results in a significant but temporary improvement of functional performance when assessed with objective measures of 6MWD but not of EQ-5D. Moreover, TAVI has a significant and sustained impact on subjective well-being and exercise capacity assessed with the EQ-VAS and NYHA score.

The effects of a physical activity counseling program after an exacerbation in patients with Chronic Obstructive Pulmonary Disease: a randomized controlled pilot study.

BACKGROUND: In some patients with COPD, the disease is characterized by exacerbations. Severe exacerbations warrant a hospitalization, with prolonged detrimental effects on physical activity. Interventions after an exacerbation may improve physical activity, with longstanding health benefits. Physical activity counseling and real-time feedback were effective in stable COPD. No evidence is available on the use of this therapeutic modality in patients after a COPD exacerbation. METHODS: Thirty patients were randomly assigned to usual care or physical activity counseling, by telephone contacts at a frequency of 3 times a week and real-time feedback. Lung function, peripheral muscle strength, functional exercise capacity, symptom experience and COPD-related health status were assessed during hospital stay and 1 month later. RESULTS: Both groups significantly recovered in physical activity (PAsteps: control group: 1013 ± 1275 steps vs intervention group: 984 ± 1208 steps (p = 0.0005); PAwalk: control group: 13 ± 14 min vs intervention group: 13 ± 16 min (p = 0.0002)), functional exercise capacity (control group: 64 ± 59 m (p = 0.002) vs intervention group: 67 ± 84 m (p = 0.02)) and COPD-related health status (CAT: control group: -5 [-7 to 1] (p = 0.02) vs intervention group: -3 [-10 to 1] points (p = 0.03)). No differences between groups were observed. CONCLUSION: From our pilot study, we concluded that telephone based physical activity counseling with pedometer feedback after an exacerbation did not result in better improvements in physical activity and clinical outcomes compared to usual care. Because of the difficult recruitment and the negative intermediate analyses, this study was not continued. TRIAL REGISTRATION: Clinicaltrials.gov NCT02223962. Registered 4 September 2013.

Physiological responses during downhill walking: A new exercise modality for subjects with chronic obstructive pulmonary disease?

Skeletal muscle quadriceps low-frequency fatigue (LFF) during exercise promotes improvements in exercise capacity with exercise training. In healthy subjects, eccentric muscle work induced by downhill walking (DW) generates higher muscular stress, whilst metabolic cost is lower compared to level walking (LW). We investigated quadriceps LFF and metabolic cost of DW in patients with chronic obstructive pulmonary disease. Ten participants (67 ± 7 years, FEV1 51 ± 15% predicted) performed DW, DW carrying a load (DWL) of 10% body weight via vest and LW, in random order. Quadriceps potentiated twitch force (TWqpot) was assessed before and after each walk, and muscle damage was assessed before and 24 hours after each walk via serum creatine kinase (CK) levels. Ventilation (VE) and oxygen consumption (VO2) were measured via breath-by-breath analysis during each walk. DW and DWL resulted in a greater decrease in TWqpot (-30 ± 14 N in DW, p < 0.05; and -22 ± 16 N in DWL, p < 0.05) compared to LW (-3 ± 21 N, p > 0.05). CK levels only increased 24 hours following DW and DWL (p < 0.05). DW and DWL showed lower VE and VO2 than LW (p < 0.05). DW is associated with enhanced quadriceps LFF and lower cardiorespiratory costs than LW. The addition of a chest load to DW does not seem to enhance these effects.

Pulmonary rehabilitation: timing, location, and duration.

Pulmonary rehabilitation programs vary in terms of duration and location. Differences also exists in the patients who are judged eligible for rehabilitation. This article reviews the options clinicians have to organize programs in terms of who should be referred, when, where, and for how long. There are several risk factors for lack of uptake and non-adherence to programs. Logistical aspects are also an important barrier. In terms of election, patients with muscle dysfunction are likely the best candidates for exercise training. Patients with exercise-induced symptoms and those after exacerbations should also be referred.