EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

BACKGROUND: The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO2peak when compared with no CR. OBJECTIVE: To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR. METHODS: Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis. The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio. RESULTS: The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO2peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO2peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO2peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants. CONCLUSION: From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

[Returning to work after an acute coronary syndrome: When waiting is wasting]. / Retour au travail après un accident coronarien aigu.

BACKGROUND: Return to work (RTW) after acute coronary syndrome (ACS) is an important issue for the patient's future. AIMS: The study aim was to determine whether RTW practice complies with guidelines or is delayed by failure in patient management. We analysed the factors influencing RTW beyond the 90-day period recommended by guidelines. METHODS: We conducted a survey of 216 self-employed workers admitted to the hospital for ACS using self-report questionnaires and medical examination. Factors influencing RTW, occupational and cardiac features, and recall and source of medical information were investigated. RESULTS: Ninety-three of 216 patients did not return to work by 90 days, despite good cardiac performance in 30 cases (32 %). The mean sick leave duration was 93.3±103.7 days. Advice concerning return to work was completely missing for 44 % of patients. Cardiac performance was independent of sick leave duration, but was correlated with the likelihood of RTW (P<0.001). Patients assimilated about 70 % of the medical information they were provided, but only 53 % of work-related information. Recall of work-related information was better among patients admitted to a rehabilitation facility (65 %) compared to those who did not receive rehabilitation (P<0.05). CONCLUSION: Cardiologists should assess the patient's cardiac performance within 2 months after ACS. Patient management should also include cardiac rehabilitation or therapeutic education toward improving information recall.

Colchicine for postoperative pericardial effusion: a multicentre, double-blind, randomised controlled trial.

OBJECTIVES: Pericardial effusion is common after cardiac surgery. Growing evidence suggests that colchicine may be useful for acute pericarditis, but its efficacy in reducing pericardial effusion volume postoperatively has not been assessed. METHODS: This randomised, double-blind, placebo-controlled study conducted in 10 centres in France included 197 patients at high risk of tamponade (ie, with moderate to large-sized persistent effusion (echocardiography grades 2, 3 or 4 on a scale of 0-4)) at 7-30 days after cardiac surgery. Patients were randomly assigned to receive colchicine, 1 mg daily (n=98), or a matching placebo (n=99). The main end point was change in pericardial effusion grade after 14-day treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS: The placebo and the colchicine groups showed a similar mean baseline pericardial effusion grade (2.9±0.8 vs 3.0±0.8) and similar mean decrease from baseline after treatment (-1.1±1.3 vs -1.3±1.3 grades). The mean difference in grade decrease between groups was -0.19 (95% CI -0.55 to 0.16, p=0.23). In total, 13 cases of cardiac tamponade occurred during the 14-day treatment (7 and 6 in the placebo and colchicine groups, respectively; p=0.80). At 6-month follow-up, all patients were alive and had undergone a total of 22 (11%) drainages: 14 in the placebo group and 8 in the colchicine group (p=0.20). CONCLUSIONS: In patients with pericardial effusion after cardiac surgery, colchicine administration does not reduce the effusion volume or prevent late cardiac tamponade. CLINICAL TRIAL REG NO: NCT01266694.

[The best of cardiac rehabilitation in 2006]. / L'essentiel de l'année 2006 en réadaptation cardiaque et cardiologie du sport.

The meta-analysis showing the benefits of physical training revisited: Taylor examined only the cardiac rehabilitation trials of exercise intervention alone (versus usual care) and demonstrated that cardiac mortality is 28 % reduced and exercise appears to have an independent mortality benefit. An economic evaluation of cardiac rehabilitation: a systematic review of 15 economic evaluations. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. But further well-designed trials are required. Pronostic value of some variables determined by exercise testing entering cardiac rehabilitation and after physical training. A beneficial effect of physical training versus usual care on BNP and neurohormones in patients with chronic heart disease. Patients on beta blockers after myocardial infarction: determination of a more accurate training heart frequency derived from the classical Karvonen's formula. The combination of trimetazidine with exercise training provides greater improvements in functional capacity, left ventricular function and the endothelium-dependent relaxation of the brachial artery than exercise training alone in patients with ischaemic cardiomyopathy referred for cardiac rehabilitation. Guidelines for resistance exercise after cardiac event: a new paradigm less restrictive, safe and efficient to accelerate patients' return to daily activities. Recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease: the result of consensus among experts from the ESC study group of sports cardiology.

[Best of functional evaluation and cardiac rehabilitation in 2005]. / L'essentiel de l'anné 2005 en évaluation fonctionnelle et réadaptation des cardiaques.

The latest in cardiac rehabilitation has been impacted by: The East German PET publication which showed fewer ischaemic events and progression of the atheromatous disease in symptomatic and stable coronary patients who carry out regular physical exercise in comparison with patients who underwent angioplasty with stenting. Two meta-analyses updated the data showing the benefits of physical training: a 20% reduction in global mortality in coronary disease and 35% in cardiac failure. Two French studies reporting reassuring data for our daily practice: the serious complications of cardiac rehabilitation are exceptionally rare: the register for 2003 with data from 65 French centres, over 25,000 patients and 743,000 patient/exercise hours. Physical training two weeks after mitral valvuloplasty is not harmful for the valve repair and is beneficial in terms of exercise capacity for the patient. Epidemiological studies showing that women and elderly patients are, unfortunately, often excluded from programmes of cardiac rehabilitation.

Factors associated with increased serum levels of cardiac troponins T and I in chronic haemodialysis patients: Chronic Haemodialysis And New Cardiac Markers Evaluation (CHANCE) study.

BACKGROUND: Serum concentrations of the cardiac troponins (cTn) T and I, specific markers of myocardial injury, are frequently elevated in haemodialysis patients. The clinical relevance of this is unclear. The aim of this study was to investigate factors associated with increased serum levels of cTn in haemodialysis patients. METHODS: We included in this cross-sectional study 258 chronic haemodialysis patients (150 men, age 60+/-15 years) without acute coronary symptoms. Clinical data, echocardiographic hypertrophy, biochemical status, and haemodialysis regimen were evaluated for each patient. Pre-dialysis serum cTnT (Elecsys, Roche), cTnI (Stratus and RXL, Dade-Berhing), and CK-MB (Stratus, Dade-Berhing) concentrations were determined. Logistic regression was the principal method of analysis. RESULTS: Pre-dialysis levels of cTnT >0.1 ng/ml (n=48, 18.6% of patients) were associated with age (P<0.001), diabetes (P<0.005), history of ischaemic heart disease (P<0.05), and left ventricular hypertrophy (P<0.05). In multivariate analysis, age odds ratio ((OR) 1.04), diabetes (OR 4.9), and indexed left ventricular mass (OR 1.01) were found to be independently associated with cTnT concentration above the threshold. Only six patients had cTnI-Stratus levels >0.6 ng/ml. cTnI-RXL levels >0.3 ng/ml (n=13, 5.0%) were associated with age (P=0.05) and hypercholesterolaemia (P<0.05). Only age (OR 1.06) remained associated in multivariate analysis. CONCLUSION: Elevated baseline serum levels of cardiac troponins were associated with cardiovascular risk factors, history of ischaemic heart disease and left ventricular hypertrophy in asymptomatic chronic haemodialysis patients.

[Role of rehabilitation in the treatment of chronic heart insufficiency]. / Place de la réadaptation dans le traitement de l'insuffisance cardiaque chronique.

Rehabilitation is an important component of the modern comprehensive care plan for patients with chronic heart failure. Cardiac rehabilitation combines exercise training with therapeutical adaptations, behavioral modifications and psychosocial interventions. Based on these data, patients with controlled heart failure should be involved in cardiac rehabilitation programs. Training prescription needs a strict previous cardiac evaluation. Exercise training monitoring must be adjusted to the physical tolerance of each patient. Cardiac rehabilitation has been found to improve functional capacity, reduce symptoms, and finally reduce cardiac morbidity and mortality. These beneficial effects were associated with muscular, endothelial and ventilatory improvements. Reduced sympathetic tone may decrease arrhythmias and may limit the progression of left ventricular dysfunction.

[Therapeutic strategies in acute myocardial infarction: antiarrhythmic therapy]. / Stratégies thérapeutiques lors de la phase aiguë de l'infarctus du myocarde: les antiarythmiques.

Antiarrhythmic therapy is a special case in the therapeutic strategy of acute myocardial infarction. There are very few controlled therapeutic trials and its use is mainly based on clinical experience rather than on scientific evidence. The most common arrhythmias requiring treatment in acute myocardial infarction are atrial fibrillation, ventricular tachycardia and ventricular fibrillation. There is no evidence to support the use Class I antiarrhythmics. Lidocain may be used in some cases. Similarly, contradictory results have been reported with the use of magnesium salts and the general tendency is not to use this ion in acute myocardial infarction. The most commonly used antiarrhythmic agents are the betablockers and amiodarone. The general principles of treatment should be respected: all antiarrhythmic drugs have negative inotropic effects, apart from digitalis. All antiarrhythmics may have a proarrhythmic effect including digitalis, especially in this clinical context. Whenever possible, continuous intravenous infusions are to be preferred to bolus injections. In addition, and when possible, electrotherapy is preferable to antiarrhythmic drug therapy. Finally, a number of cardiac arrhythmias observed in acute myocardial infarction should be "respected" or treated by electrotherapy but never by antiarrhythmic drugs.

Cardiorespiratory consequences of sleep apnoea syndrome in patients with massive obesity.

Assessment of cardiorespiratory consequences of sleep apnoea syndrome (SAS) is difficult owing to confounding factors, especially obesity, that are strongly associated with SAS. This study was designed to assess the cardiorespiratory consequences of SAS by comparing the results of a comprehensive cardiorespiratory evaluation in apnoeic and nonapnoeic patients with massive obesity. In a retrospective chart-review study, we studied 60 patients with massive obesity defined by a body mass index (BMI) >40 kg.m(-2), presenting no chronic respiratory disease, who underwent an extensive assessment of cardiorespiratory consequences of obesity, including overnight polysomnography, lung function tests, arterial blood gas analysis, evaluation of vascular risk factors, myocardial scintigraphy with dipyridamole stress-test, isotopic ventriculography, Doppler echocardiography and Holter electrocardiogram recording. SAS defined by an apnoea + hypopnoea index (AHI) > or = 10 was diagnosed in 42% of patients (25 out of 60). Mean+/-SD AHI of SAS-positive (SAS+) patients was 38+/-24. Age, BMI, ventilatory function parameters, prevalence of smoking history and diabetes mellitus did not differ significantly in SAS+ versus SAS-negative (SAS-) groups. The following complications were observed more frequently in SAS+ than in SAS- patients: daytime hypoxaemia (35 vs 9%, p<0.02), pulmonary arterial hypertension (36 vs 7%, p<0.05) and increased interventricular septal thickness (50 vs 15%, p<0.03). No association was found between SAS on the one hand and systemic arterial hypertension, coronary artery disease, left ventricular dysfunction and nocturnal cardiac arrhythmias on the other. Nocturnal apnoeas in massive obesity may thus be associated with moderate daytime hypoxaemia, mild pulmonary arterial hypertension and moderate left ventricular hypertrophy, but not with severe cardiorespiratory complications.

Correlation between time-domain measures of heart rate variability and scatterplots in postinfarction patients.

Heart rate variability (HRV) is usually measured in time or frequency domains. Beat-to-beat variability, which cannot be assessed by frequency-domain analysis, and can only be assessed globally by time-domain analysis, provides information concerning the nonlinear behavior of heart rate. This beat-to-beat variability can be displayed on scatterplots, where each RR interval is plotted against the preceding RR interval. However, the relationship between scatterplots and other measures of HRV is unknown. We studied the correlations between time-domain measures and scatterplot length, width, and area in 50 postinfarction patients. Scatterplot length and width were measured after printing. Scatterplot area was calculated from length and width, assimilating the plot to an ellipse. Long-term variability indexes (SDNN and SDANN) were strongly correlated with scatterplot length (r > 0.9, P < 0.0001), and short-term variability parameters (pNN50 and variability index) with scatterplot width (r > 0.9; P < 0.0001). Scatterplots are, therefore, a simple way of providing information concerning long- and short-term HRV. Furthermore, measurement of scatterplot width at different given RR intervals could be an approach to the evaluation of short-term HRV for different heart rates. This could provide a simple way of assessing cardiac parasympathetic modulation at different heart rates.

[Return to work following myocardial infarction. Medical and socio-professional factors]. / Reprise du travail après infarctus du myocarde. Facteurs médicaux et socioprofessionnels.

The aim of this study was to assess the influence of medical and socioprofessional factors on return to work after myocardial infarction. The authors studied a continuous series of 174 patients with an average age of 51.3 years, all of whom were active before their illness. The average follow-up period was 33 months. One hundred and thirty of the patients (75%) returned to work. The only clinical factors predictive of not returning to work were older age short exercise time and fall in blood pressure on exercise. On the other hand, nearly all socioprofessional factors, social class, type of occupation, size of company, length of employment in their company, physical stresses related to their occupation, were related to return to work. The average time before returning to work was 5.5 +/- 1 month. Though certain immediate criteria of severity of infarction such as previous myocardial infarction or anterior wall infarction were related to a more delayed return to work. The cardiac status evaluated by complementary investigations (left ventricular ejection fraction, exercise testing and Holter monitoring) was not related to the time before return to work. Of the socioprofessional factors, only difficulties related to the patients' work (modification or change of job) were associated with a more delayed return to work. Forty-four patients (33.8%) returned to work after a change in working hours (28 patients), the tasks involved (20 patients) or position (7 patients). Only the lower socioprofessional classes, independent workers and extremes of age could benefit from these measures.

[Changes in heart rate variability after myocardial infarction. Value of Poincareé's diagram]. / Evolution de la variabilité de la fréquence cardiaque après infarctus du myocarde. Apport du diagramme de Poincaré.

The variability of the heart rate is reduced after myocardial infarction. It then progressively increases, to return to near normal values after several months. However, these changes in heart rate variability occur at the same time as slowing of the heart rate which makes interpretation difficult. Poincaré's diagram is constructed from a Holter recording plotting each RR interval against the preceding RR interval. The authors have developed a geometric approach to this diagram to evaluate parasympathetic tone for a given heart rate. By measuring the dispersion in height of the Poincaré's diagram, the authors evaluate the shor-term variability for a given RR interval. Two 24 hr Holter recordings were performed in 52 patients at one and two weeks after a myocardial infarction. The dispersion in the height of the Poincaré's diagrams was measured at the 10th, 25th, 50th, 75th and 90th percentiles of the total dispersion. The authors have shown an increase in the short-term variability of the shortest RR intervals (1th, 25th and 50th percentiles) which is not observed in the longer RR intervals (75th and 90th percentiles). In conclusion, theres is an increase in the heart rate variability at the shortest RR intervals. This suggests that the recovery of parasympathic tone after myocardial infarction occurs mainly at the fastest heart rates.

[Impact of controlling risk factors after myocardial infarction]. / Impact du contrôle des facteurs de risque après infarctus du myocarde.

The relative risks of each factors and the benefits of their reduction after myocardial infarction are comparable to those observed in primary prevention. However, because of an overexposure to the risk, the absolute gains are five times greater. The impact of diet is one of the most important: in addition to the limitation of polyunsaturated fats and global calory intake, especially in cases of central obesity, the increase in dietary alpha-linolenic acid and in omega-3, has been shown to reduce the risk of myocardial infarction and mortality by up to 70%. Supplements of vitamins A and E could be useful. After infarction, the risks of an ex-smoker decrease rapidly by half and become comparable to those of non-smokers in 2 to 3 years. Physical exercise reduces cardiovascular mortality by 20-25% and contributes to better control of risk factors. The management of some psycho-physiological factors (reaction to stress, hostility) also gives encouraging results). A 10% reduction in total cholesterol leads to a 20% or more decrease in coronary events and a 10% reduction in mortality with a marked dose-response effect inciting to the reduction of its level to under 2 g/l. The progression of atherosclerosis delayed; early lesions, with the greatest risk of rupture and thrombosis, are stabilised and may even regress. A low HDL-c concentration should lead to more energetic reduction of LDL-c and control of smoking, obesity and sedentarity. Its association with hypertriglyceridaemia, glucose intolerance, hypertension and central obesity defines the syndrome of insulin resistance which multiplies cardiovascular risk.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of obstructive cardiomyopathy by permanent apical ventricular stimulation]. / Le traitement de la cardiomyopathie obstructive par la stimulation ventriculaire apicale permanente.

The treatment of obstructive hypertrophic cardiomyopathy is classically based on beta blockers, cardiac calcium channel blockers or amiodarone to improve the symptoms and to decrease the intraventricular gradient. However, this treatment may prove to be insufficient or poorly tolerated. Two chamber cardiac pacing no constitutes an alternative to surgical treatment, as it improves the symptoms and decreases the left intraventricular gradient, by modifying the ventricular activation sequence. In order to be effective, ventricular pacing must be continuous, with a sufficiently short atrioventricular period to allow continuous ventricular preexcitation, while preserving atrial contraction. However, it has yet to be demonstrated that continuous ventricular pacing provides a survival benefit for these patients.

[Radiofrequency catheter ablation: theoretical and technical aspects]. / Ablation par courants de radiofréquence; aspects théoriques et techniques.

Radiofrequency currents produce circumscribed tissue necrosis by progressive and localised heating. Endocardial application via the percutaneous approach with a specific electrophysiological catheter enables destruction of the anatomical substrate of many cardiac arrhythmias. The technique is well tolerated due to the absence of barometric phenomena and general anaesthesia, and the possibility of modulating the energy delivered, which explains why it has supplanted fulguration in most indications. The technological evolution aims to increase the lesional power and decrease the number of complications. This implies the development of catheters capable of delivering greater currents without the risk of thrombus formation and of generators dependent on electrical or thermal parameters. The low incidence of complications reported by centres using the technique is based on an excellent understanding of the technique, the use of appropriate material, the surveillance of parameters which allow detection of unwanted effects and the respect of a strict operation protocol. In the absence of these precautions, the wide diffusion of this technique, favored by its low cost and relative simplicity, may be associated with an increase in the number of side effects which could be lethal. This cannot be accepted in a technique with such wide indications, including arrhythmias with a usually benign long-term prognosis.

[Interventional cardiology methods in the treatment of ventricular arrhythmia]. / Les méthodes interventionnelles cardiologiques dans le traitement des arythmies ventriculaires.

Sustained ventricular arrhythmias are the primary cause of sudden death in France. Treatment possibilities have increased in recent years with the development of interventional rhythmology techniques. Thus alongside the classical pharmacological approach, clinicians now have access to more aggressive treatment methods such as implantable pacing-defibrillation systems or endocavitary excision techniques. Implantable defibrillation systems are of proven efficacy in reducing ventricular arrhythmias but their action is merely palliative. Technological advances have simplified their implantation and increased their diagnostic and therapeutic abilities. Their high price is nevertheless one of the factors limiting their wider use in some countries. Endocavitary excision techniques, with a radical curative effects, are used only in cases of sustained monomorphous ventricular tachycardia in the absence of any associated cardiac surgery procedure. Coronary angioplasty is of rhythmological value when the etiopathogenesis of the arrhythmia is of proven ischemic origin. Rather than being competitors, these various methods are complementary, each having specific characteristics forming the basis of particular indications.

[Mechanisms of atrial fibrillation: recent advances]. / Mécanismes de la fibrillation auriculaire, acquisitions récentes.

Atrial fibrillation (AF) is due to the presence of multiple reentry pathways. Although this mechanism has been known for some time, new information has recently been acquired about the factors of atrial vulnerability and the conditions of myocardial alteration. There are two main factors of atrial vulnerability: intra-atrial conduction defects and abnormalities of the refractory periods. In addition, the concept of critical mass and the influence of the autonomic nervous system have to be taken into consideration. The abnormalities of the refractory periods liable to increase atrial vulnerability are their shortening, spatial dispersion and poor adaptation to the heart rate. All these changes may be demonstrated at cellular level. The product of the intra-atrial conduction velocity and the duration of the refractory period defines the wave length. The risk of developing reentry pathways increases as the wave length shortens. Moreover, the more the atrium fibrillates, the greater will be the decrease of the refractory periods, atrial fibrillation giving rise to atrial fibrillation. Histological lesions of the atrial tissue may be demonstrated, even in the absence of underlying cardiac disease. They mainly consist of fibrosis, fatty degeneration and myocytic hypertrophy. In the long-term, atrial fibrillation leads to a number of structural abnormalities of the atrial, and sometimes ventricular tissues, progressing to cardiomyopathy in some cases.

[Torsades de pointes]. / Les torsades de pointes.

Torsades de pointes are defined and characterised by specific, polymorphic but organised ventricular activation on the surface electrocardiogram. They constitute episodes of rapid tachycardia which are usually short lasting and terminate spontaneously. However, they may recur and persist, leading to syncope or sudden death. They occur typically in cases with abnormalities of ventricular repolarisation with prolongation of the QTU interval and variable deformations of the TU waves. The basal abnormalities may be modest or intermittent. A bigeminy with a long coupling interval and alternating long and short cycles often precede the burst of arrhythmia. Abnormalities of ventricular repolarisation and torsades de pointes may be the result of congenital syndromes (catecholamine-dependent torsades) or acquired factors (pause-dependent torsades) such as paroxysmal bradycardia, drugs which prolong the repolarisation and potassium and magnesium deficiencies. The electrophysiological mechanisms comprise reentry and after depolarisation induced activity genetic factors causing abnormalities of the G-proteins, potassium currents or adrenergic receptors may also play a role. Emergency treatment consists of intravenous magnesium salts, sometimes of betablockers or verapamil for maintenance therapy. The association of a potassium-sparing drug may be useful. Cardiac pacing may be necessary. Left sympathetic denervation or implantation of an automatic defibrillator are exceptional therapeutic options in refractory congenital torsades de pointes.