Evolution of Early Postoperative Cardiac Rehabilitation in Patients with Acute Type A Aortic Dissection.

INTRODUCTION: Surgically treated acute type A aortic dissection (ATAAD) patients are often restricted from physical exercise due to a lack of knowledge about safe blood pressure (BP) ranges. The aim of this study was to describe the evolution of early postoperative cardiac rehabilitation (CR) for patients with ATAAD. METHODS: This is a retrospective study of 73 patients with ATAAD who were referred to the CR department after surgery. An incremental symptom-limited exercise stress test (ExT) on a cyclo-ergometer was performed before and after CR, which included continuous training and segmental muscle strengthening (five sessions/week). Systolic and diastolic blood pressure (SBP and DBP) were monitored before and after all exercise sessions. RESULTS: The patients (78.1% male; 62.2 ± 12.7 years old; 54.8% hypertensive) started CR 26.2 ± 17.3 days after surgery. During 30.4 ±11.6 days, they underwent 14.5 ± 4.7 sessions of endurance cycling training, and 11.8 ± 4.3 sessions of segmental muscle strengthening. At the end of CR, the gain of workload during endurance training and functional capacity during ExT were 19.6 ± 10.2 watts and 1.2 ± 0.6 METs, respectively. The maximal BP reached during endurance training was 143 ± 14/88 ± 14 mmHg. The heart rate (HR) reserve improved from 20.2 ± 13.9 bpm to 33.2 ± 16.8 bpm while the resting HR decreased from 86.1 ± 17.4 bpm to 76.4 ± 13.3 bpm. CONCLUSION: Early post-operative exercise-based CR is feasible and safe in patients with surgically treated ATAAD. The CR effect is remarkable, but it requires a close BP monitoring and supervision by a cardiologist and physical therapist during training.

Responses to exercise training in patients with heart failure. Analysis by oxygen transport steps.

BACKGROUND: Exercise training (ET) increases exercise tolerance, improves quality of life and likely the prognosis in heart failure patients with reduced ejection fraction (HFrEF). However, some patients do not improve, whereas exercise training response is still poorly understood. Measurement of cardiac output during cardiopulmonary exercise test might allow ET response assessment according to the different steps of oxygen transport. METHODS: Fifty-three patients with HFrEF (24 with ischemic cardiomyopathy (ICM) and 29 with dilated cardiomyopathy (DCM) had an aerobic ET. Before and after ET program, peak oxygen consumption (VO2peak) and cardiac output using thoracic impedancemetry were measured. Oxygen convection (QO2peak) and diffusion (DO2) were calculated using Fick's principle and Fick's simplified law. Patients were considered as responders if the gain was superior to 10%. RESULTS: We found 55% VO2peak responders, 62% QO2peak responders and 56% DO2 responders. Four patients did not have any response. None baseline predictive factor for VO2peak response was found. QO2peak response was related to exercise stroke volume (r = 0.84), cardiac power (r = 0.83) and systemic vascular resistance (SVRpeak) (r = -0.42) responses. Cardiac power response was higher in patients with ICM than in those with DCM (p < 0.05). Predictors of QO2peak response were low baseline exercise stroke volume and ICM etiology. Predictors of DO2 response were higher baseline blood creatinine and prolonged training. CONCLUSION: The analysis of the response to training in patients with HFrEF according to the different steps of oxygen transport revealed different phenotypes on VO2peak responses, namely responses in either oxygen convection and/or diffusion.

[Secondary cardiovascular prevention strategies]. / Stratégies de prévention cardiovasculaire secondaire.

Secondary cardiovascular prevention strategies. Patients with a documented peripheral or coronary artery disease, subclinical atheroma, diabetes associated with target organ damage or a major risk factor or severe kidney failure have a risk of cardiovascular death above 10% in the next 10 years. They all should be helped to adopt a healthier life style and be prescribed a targeted polytherapy. Unless intolerant or contraindicated, an antiplatelet agent, a statin (whatever may be the initial LDL-cholesterol level) and a renin-angiotensin blocker should be prescribed for all patients. Especially important, a LDL-cholesterol target below 1.8 mM/l (70 mg/dl) or reduced by at least 50% of the initial level should be obtained. Significant other changes have recently occurred in the European guidelines, which are summarized in this article.

Stratégies de prévention cardiovasculaire secondaire. Les sujets ayant une maladie artérielle prouvée (quel que soit le territoire impliqué), une athérosclérose infraclinique, un diabète avec l'atteinte d'un organe cible ou au moins un facteur de risque associé ou une insuffisance rénale sévère ont un risque évolutif d'événements cardiovasculaires graves supérieur 10 % à 10 ans et relèvent d'une prévention dite secondaire. Celle-ci repose toujours à la fois sur une incitation à modifier le style de vie et sur une polythérapie médicamenteuse ciblée. Sauf contre-indication ou intolérance, un antiagrégant, une statine (quel que soit le niveau de départ du cholestérol lié aux lipoprotéines de basse densité [LDLcholestérol]) et un bloqueur du système rénine-angiotensine (inhibiteur de l'enzyme de conversion de l'angiotensine [IEC] en première intention, bloqueur des récepteurs de l'angiotensine II [ARA II] en cas d'intolérance) sont la prescription de base. L'objectif de baisse du LDLcholestérol est d'obtenir un taux inférieur à 0,7 g/L (1,8 mmol/L) ou une baisse de plus de 50 % du LDL-cholestérol initial. Des changements significatifs d'autres recommandations sont intervenus depuis 2016, qui sont décrits dans cet article.

[Helping patients to engage in health care]. / Repères conceptuels et pratiques pour faciliter l'engagement d'un patient dans ses soins.

Helping patients to engage in health care. Engaging in health care, be it preventive care, is a tough challenge for both patients and health care providers. Being threatened by the irruption of a chronic disease, or even by a hazard for his own health, every individual is seeking for a bearable daily living and tries to recover some autonomy and power upon his life. This long-standing process is actually a permanent endeavour to reconfigure beliefs and values, rebuild a new identity and learn how to cope with uncertainties. The role for all health care providers is to facilitate this complex process, using appropriate communication skills and pedagogic knowledge that we discuss in this article.

Repères conceptuels et pratiques pour faciliter l'engagement d'un patient dans ses soins. L'engagement d'un patient dans ses soins, fussent-ils des actions de prévention, est un enjeu et un défi pour tout patient comme pour tout soignant. Menacé par l'annonce d'une maladie chronique (ou même seulement d'un risque pour sa santé), un individu cherche à préserver une existence supportable, à retrouver une capacité à décider pour soi pour reprendre du pouvoir sur sa vie. Ce processus est un travail sur soi, qui passe à la fois par une reconfiguration des croyances et valeurs, une reconstruction de l'identité et des apprentissages nouveaux. Le rôle du soignant est de faciliter ce travail, par une communication et une pédagogie appropriées que nous détaillons dans cet article.

Cardiac rehabilitation in patients with pacemakers and implantable cardioverter defibrillators.

Large subsets of patients admitted in cardiac rehabilitation centers are having a pacemaker, cardiac resynchronization (CRT) or implantable cardiac defibrillator (ICD). Cardiac rehabilitation for patients, mostly with heart failure, with implanted electronic devices as pacemakers or ICD is a unique opportunity not only to optimize the medical treatment, to increase their exercise capacity and improves their clinical condition but also to supervise the correct functioning of the device. CRT reduces clinical symptoms and increases slightly the exercise capacity. But in these patients, the clinical improvements are likely to be explained by both the enhancement of cardiac function induced by the device and by the improved peripheral (muscular and vascular) and cardiac effects of exercise. The additional expected gain by exercise in this population is between 14 to 25%. In patients implanted with an ICD, exercise training is safe, without increasing shocks or anti-tachycardia pacing therapy. The comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves exercise capacity, quality of life, general and mental health. Nevertheless, further large scale studies was needed to evaluate the most appropriate management and demonstrate definitively the role of cardiac rehabilitation in this particular group of patients.

Erectile dysfunction and depressive mood in men with coronary heart disease.

BACKGROUND: Erectile dysfunction (ED) is a frequent comorbid condition in men with coronary heart disease (CHD). Depressive mood is associated with adverse outcomes in CHD patients. The aim of this study was to explore the relationships between ED and depressive mood in CHD male patients. METHODS: Eighty-five CHD male patients were given standardized questionnaires to assess ED, depressive mood, current anxiety, and Type-D personality (i.e. negative affectivity and social inhibition). RESULTS: A significant ED was found in 57.6% of the patients. Controlling for psychometric measures, CHD risk factors, and drugs, a significant ED was independently predicted by depressive mood, hypertension and, marginally, age. CONCLUSIONS: These results confirm the high prevalence of ED in CHD male patients. They suggest that ED in CHD male patients may be more strongly associated with depressive mood than with antihypertensive drugs. Because depressive mood is associated with adverse CHD outcomes and may require adequate treatment, clinicians should better search for depressive mood in CHD patients presenting with ED.

Role of previous treatment with sulfonylureas in diabetic patients with acute myocardial infarction: results from a nationwide French registry.

BACKGROUND: The cardiovascular effects of sulfonylureas (SU) in diabetic patients are controversial and it has been suggested that diabetic patients with acute myocardial infarction while on SU were at increased risk. OBJECTIVES: To assess the in-hospital outcome of patients with acute myocardial infarction according to the use of SU at the time of the acute episode. METHODS: Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction admitted within 48 h of symptom onset in November 2000. RESULTS: Among the 2320 patients included in the registry, 487 (21%) had diabetes, of whom 215 (44%) were on SU. Patients on SU were older and had a more frequent history of hyperlipidemia than those not receiving SU. Type and location of infarction were similar in the two groups, and there was no difference in Killip class on admission. In-hospital mortality was lower in patients on SU (10.2%) than in those without SU (16.9%) (p = 0.035). There was a trend toward less frequent ventricular fibrillation (2.3% vs 5.9%, p = 0.052). In two models of multivariate analyses, SU therapy was associated with decreased in-hospital mortality (model 1: relative risk: 0.44, p = 0.012; model 2: relative risk: 0.37, p = 0.020). CONCLUSIONS: In this nationwide registry reflecting real-world practice, the use of sulfonylureas in diabetic patients was not associated with increased in-hospital mortality.

Ischemic heart disease in type 2 diabetes.

Type 2 diabetes has reached epidemic proportions and an increasing proportion of patients with coronary artery disease (CAD) are diabetics. CAD in diabetics has specificities and, in particular, more extensive atherosclerosis; diabetic patients are also more frequently asymptomatic, with silent myocardial ischemia, which makes the diagnosis of CAD more difficult. In addition, diabetic patients with CAD have poorer outcomes than nondiabetics. The management of diabetic patients with CAD is based on intensive intervention on lifestyle and risk factors, together with the mandatory use of medications of proven benefit as regards secondary prevention in coronary patients: antiplatelet agents, statins, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Glycemic control is also essential; although the use of sulfonylureas has been controversial, there is now a vast amount of data suggesting a beneficial effect, in particular when agents more specific for the pancreatic adenosine triphosphate-dependent potassium (K(ATP)) channels are used. At the acute stage of myocardial infarction, the Diabetes mellitus, Insulin Glucose infusion in Acute Myocardial Infarction (DIGAMI) trial suggested a beneficial effect of insulin therapy prolonged for 3 months after hospital discharge; these data will have to be confirmed by larger intervention trials. Finally, the respective roles of coronary angioplasty and coronary surgery in diabetics are debated; a post hoc analysis of the Bypass Angioplasty Revascularization Investigation (BARI) trial data showed increased mortality in diabetics with multivessel CAD treated with angioplasty compared with surgery, but the results of the more recent trials using intracoronary stents appear more balanced; in this regard, the effects of drug-eluting stents, which dramatically decrease the incidence of re-stenosis, seem promising.