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.

Mehran contrast nephropathy risk score: Is it still useful 10 years later?

BACKGROUND: Nowadays, contrast-induced nephropathy (CIN) is the third cause of acquired acute renal impairment in hospital. CIN is related to increased in-hospital morbidity, mortality, costs of medical care, and long admissions. Because of this, we hypothesized it would be useful to determine the risk of CIN with scores such as the Mehran score. The aim of this study was to validate the Mehran score in a contemporary cohort of Spanish patients with acute coronary syndrome (ACS). METHODS: We assessed the calibration and discriminatory capacity of Mehran score to predict CIN in a cohort of 1520 patients with a definitive diagnosis of ACS and who underwent coronary angiography between March 2008 and June 2012. We excluded patients on chronic dialysis and those without data of contrast volume. The calibration of the model was assessed with the Hosmer-Lemeshow goodness-of-fit test and discriminatory capacity was assessed by C-statistic, which is equivalent to the area under the receiver-operating characteristic curve. RESULTS: From the total group, 118 patients (7.8%) developed CIN. They were older, with higher rates of diabetes (DM) and hypertension and worse renal function and anemia (p<0.001). The odds ratios for different score components in Mehran's population versus our study were similar except for DM, hypotension, and intra-aortic balloon pump (1.6%, 2.68%, 2.55% vs 0.9%, 1.89%, and 2.86%, respectively). Calibration and discriminatory capacity of Mehran score were excellent with a Hosmer-Lemeshow p=0.7, C-statistic value >0.8. CONCLUSIONS: Mehran risk score has been validated in our study as a good score for predicting CIN in patients with ACS who underwent coronary angiography. According to this, we support its use in patients hospitalized for ACS in order to identify the ones at risk, and to optimize CIN prophylactic therapy prior to and after catheterization.

Necrosis licuefactiva del anillo mitral / Liquefactive necrosis of the mitral ring

La necrosis licuefactiva del anillo valvular mitral se describe como una forma rara de calcificación perianular con un aspecto característico. Suele tratarse de un hallazgo ecográfico incidental que en la tomografía computarizada aparece típicamente como una masa semilunar hipodensa o hiperdensa con un margen de mayor densidad y situada en la zona posterior del anulus. El uso habitual de la TCMD hace que esta entidad se identifique cada vez con más frecuencia, y es importante familiarizarse con ella para evitar errores diagnósticos. Presentamos 3 casos de necrosis licuefactiva del anillo mitral, uno de ellos confirmado quirúrgicamente, y se discuten sus características de imagen y diagnóstico diferencial (AU)

Liquefactive necrosis of the mitral ring is a rare type of periannular calcification that has a characteristic appearance. It is usually discovered incidentally during echocardiography. On CT, it typically appears as a hypointense or hyperintense semilunar mass with margins of greater density that is situated in the area behind the annulus. The routine use of MDCT has led to increasing detection of this entity, and it is important for radiologists to be familiar with these findings to avoid diagnostic errors. We present three cases of liquefactive necrosis of the mitral ring, one of which was confirmed at surgery. We discuss the imaging characteristics and differential diagnosis of this entity (AU)

[Liquefactive necrosis of the mitral ring]. / Necrosis licuefactiva del anillo mitral.

Liquefactive necrosis of the mitral ring is a rare type of periannular calcification that has a characteristic appearance. It is usually discovered incidentally during echocardiography. On CT, it typically appears as a hypointense or hyperintense semilunar mass with margins of greater density that is situated in the area behind the annulus. The routine use of MDCT has led to increasing detection of this entity, and it is important for radiologists to be familiar with these findings to avoid diagnostic errors. We present three cases of liquefactive necrosis of the mitral ring, one of which was confirmed at surgery. We discuss the imaging characteristics and differential diagnosis of this entity.