Outcome associated with prescription of cardiac rehabilitation according to predicted risk after acute myocardial infarction: Insights from the FAST-MI registries.

BACKGROUND: Cardiac rehabilitation is strongly recommended in patients after acute myocardial infarction. AIMS: To assess cardiac rehabilitation prescription after acute myocardial infarction according to predicted risk, and its association with 1-year mortality, using the FAST-MI registries. METHODS: We used data from three 1-month French nationwide registries, conducted 5 years apart from 2005 to 2015, including 13130 patients with acute myocardial infarction admitted to coronary or intensive care units. Atherothrombotic risk stratification was performed using the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P). Patients were classified into three categories: Group 1 (low risk; no or one risk indicator; score of 0 or 1); Group 2 (intermediate risk; two risk indicators; score of 2); and Group 3 (high risk; at least three risk indicators; score of≥3). RESULTS: Among the 12291 patients, cardiac rehabilitation prescription was 43.6% (49.9% in Group 1; 43.0% in Group 2; 35.2% in Group 3). Using Cox multivariable analysis, cardiac rehabilitation prescription was associated with lower mortality at 1 year in the overall population (3.8% vs. 8.2%; hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.61-0.85; P<0.001). Cardiac rehabilitation was associated with improved 1-year mortality, with homogeneous relative risk reductions in low- and intermediate-risk categories (HR 0.70, 95% CI 0.51-0.94) compared with high-risk patients (HR 0.72, 95% CI 0.59-0.88). In absolute terms, however, mortality decrease associated with cardiac rehabilitation was positively correlated with risk level (Group 1, 0.9% vs. 2.4%; Group 2, 3.0% vs. 4.2%; Group 3, 10.5% vs. 17.3%). CONCLUSION: Cardiac rehabilitation prescription was inversely correlated with patient risk. A positive association between cardiac rehabilitation and 1-year survival after acute myocardial infarction was present whatever the risk level, but the greatest mortality reduction was observed in high-risk patients.

Impact of cardiac rehabilitation referral on one-year outcome after discharge of patients with acute myocardial infarction.

BACKGROUND: Cardiac rehabilitation after an acute myocardial infarction has a class I recommendation in the present guidelines. However, data about the impact on mortality in Switzerland are not available. Therefore, we analysed one-year outcome of acute myocardial infarction patients according to cardiac rehabilitation referral at discharge. DESIGN AND METHODS: Data were extracted from the Swiss AMIS Plus registry and included patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, who were asked to give their informed consent to a telephone follow-up one year after discharge. RESULTS: From 10,141 patients, 1956 refused to participate in follow-up and 302 were lost to follow-up. There were 4508 (57.2%) patients with cardiac rehabilitation referrals compared with 3375 (42.8%) without. Patients referred to cardiac rehabilitation were younger (62.4 years vs. 68.8 years), more often male (77% vs. 70%), presented more often with ST-elevation myocardial infarction (63.5% vs. 52.1%) and, apart from smoking (44.0% vs. 34.9%), they had fewer risk factors, such as dyslipidaemia (55.0% vs. 60.1%), hypertension (55.6% vs. 65.3%) and diabetes (16.7% vs. 21.5%). Patients referred to cardiac rehabilitation had a lower crude one-year all-cause mortality (1.7% vs. 5.8%; p < 0.001) and lower rates of re-infarction, rehospitalization for cardiovascular disease and intervention (all p < 0.005). In a multivariable logistic regression analysis, cardiac rehabilitation was an independent predictor for lower mortality rate (odds ratio 0.65; 95% confidence interval 0.48-0.89; p = 0.007). CONCLUSIONS: Although the detailed data of cardiac rehabilitation programmes and patient participation were not available for this study, our data from 7883 acute myocardial infarction patients showed a better one-year outcome for patients with cardiac rehabilitation referrals than for those without.

Improvement of low-density lipoprotein cholesterol target achievement rates through cardiac rehabilitation for patients after ST elevation myocardial infarction or non-ST elevation myocardial infarction in Germany: Results of the PATIENT CARE registry.

AIMS: The PATIENT CARE registry aimed to document clinical characteristics of patients during cardiac rehabilitation after myocardial infarction, including the current pharmacological treatment, risk factor modification and achievement of treatment targets for low-density lipoprotein cholesterol (LDL-C). METHODS: Multicentre, prospective non-interventional study at 20 cardiac rehabilitation in-patient centres across Germany. RESULTS: A total of 1408 patients post myocardial infarction were analysed. Patients' mean age was 62 ± 11 years and 27.0% were women. ST elevation myocardial infarction ( n = 657; 48.7%), and non-ST elevation myocardial infarction ( n = 617; 45.8%) were equally balanced causes for hospitalization, while previous coronary artery bypass grafting was reported in n = 134 patients (9.9%). On average, cardiac rehabilitation began 19 ± 10 days after the index event and lasted for 22 ± 4 days. At discharge, 96.7% of patients received statins, 13.0% another lipid-lowering medication in addition to a statin, 98.5% antithrombotic drugs and 22.3% antidiabetic medication. The rate of patients with LDL-C on target according to the European Society of Cardiology/European Atherosclerosis Society dyslipidaemia guidelines 2011 (<70 mg/dl (1.8 mmol/l) or at least 50% reduction of baseline value) was increased from 21.4% at admission to cardiac rehabilitation to 41.9% at discharge after cardiac rehabilitation. Most patients (95.2%) completed the cardiac rehabilitation and 88% returned to their former work at full time. CONCLUSION: During cardiac rehabilitation, the modifiable cardiovascular risk factors, in particular the LDL-C, were substantially improved in patients after myocardial infarction. The great majority were able to return to work. However, less than 50% reached the LDL-C guideline targets during short-term cardiac rehabilitation.

Social inequality and barriers to cardiac rehabilitation in the rehab-North register.

AIM: Barriers to participation in cardiac rehabilitation (CR) may occur at three levels of the referral process (lack of information, declining to participate, and referral to appropriate CR programme). The aim is to analyse the impact of socioeconomic status on barriers to CR and investigate whether such barriers influenced the choice of referral. METHODS: The Rehab-North Register, a cross-sectional study, enrolled 5455 patients hospitalised at Aalborg University Hospital with myocardial infarction (MI) during 2011-2014. Patients hospitalised with ST-elevated MI and complicated non-ST-elevated MI were to be sent to specialized CR, whereas patients with uncomplicated non-ST-elevated MI and unstable angina pectoris were to be sent to community-based CR. Detailed selected socioeconomic information was gathered from statistical registries in Statistics Denmark. Data was assessed using logistic regression. RESULTS: Patients being retired, low educated, and/or with an annual gross income <27.000 Euro/yr were significantly less informed about cardiac rehabilitation programmes. Patients being older than 70 years, retired, low educated and/or with an annual gross income <27.000 Euro were significantly less willing to participate in CR. Further, this patient population were to a higher extent referred to community-based CR. CONCLUSION: Patients with low socioeconomic status received less information about and were less willing to participate in cardiac rehabilitation. The same patient population was to a higher extent referred to community-based CR. Knowledge about barriers at different levels and the impact of social inequality may help in tailoring a better approach in the referral process to CR.

Excess mortality and guideline-indicated care following non-ST-elevation myocardial infarction.

BACKGROUND: Adherence to guideline-indicated care for the treatment of non-ST-elevation myocardial infarction (NSTEMI) is associated with improved outcomes. We investigated the extent and consequences of non-adherence to guideline-indicated care across a national health system. METHODS: A cohort study ( ClinicalTrials.gov identifier: NCT02436187) was conducted using data from the Myocardial Ischaemia National Audit Project ( n = 389,057 NSTEMI, n = 247 hospitals, England and Wales, 2003-2013). Accelerated failure time models were used to quantify the impact of non-adherence on survival according to dates of guideline publication. RESULTS: Over a period of 1,079,044 person-years (median 2.2 years of follow-up), 113,586 (29.2%) NSTEMI patients died. Of those eligible to receive care, 337,881 (86.9%) did not receive one or more guideline-indicated intervention; the most frequently missed were dietary advice ( n = 254,869, 68.1%), smoking cessation advice ( n = 245,357, 87.9%), P2Y12 inhibitors ( n = 192,906, 66.3%) and coronary angiography ( n = 161,853, 43.4%). Missed interventions with the strongest impact on reduced survival were coronary angiography (time ratio: 0.18, 95% confidence interval (CI): 0.17-0.18), cardiac rehabilitation (time ratio: 0.49, 95% CI: 0.48-0.50), smoking cessation advice (time ratio: 0.53, 95% CI: 0.51-0.57) and statins (time ratio: 0.56, 95% CI: 0.55-0.58). If all eligible patients in the study had received optimal care at the time of guideline publication, then 32,765 (28.9%) deaths (95% CI: 30,531-33,509) may have been prevented. CONCLUSION: The majority of patients hospitalised with NSTEMI missed at least one guideline-indicated intervention for which they were eligible. This was significantly associated with excess mortality. Greater attention to the provision of guideline-indicated care for the management of NSTEMI will reduce premature cardiovascular deaths.

[The usefulness of complete blood count in predicting cardiac rehabilitation failure in post-NSTEMI patients]. / Przydatnosc badania morfologicznego krwi w przewidywaniu niepowodzenia rehabilitacji kardiologicznej u chorych po NSTEMI.

ACS (acute coronary syndrome) NSTEMI is more prevalent than ACS STEMI. Within four years the mortality rate was twice higher in NSTEMI group than in the STEMI group. Studies have demonstrated that cardiac rehabilitation decreases the risk of all-cause mortality as well as the mortality related to cardiovascular events. AIM: The aim of the study was to evaluate with the use of an index of own design the prognostic value of the complete blood count (CBC) in predicting cardiac rehabilitation failure in post-NSTEMI patients. MATERIALS AND METHODS: The study comprised 116 post-NSTEMI patients, 81 men and 35 women, aged 64,12±11,29 years, admitted for cardiac rehabilitation to the Department of Internal Medicine and Cardiac Rehabilitation, MU in Lodz. On admission fasting blood cell count was performed, serum glucose and creatinine level was determined (GFR assessment). The following results were considered abnormal: glucose level ≥100 mg/dl, GFR<60 ml/min/1.73m2, RBC < 4x106 µl, WBC > 10x103/µl, PLT < 150x103/µl. Exercise test (cycloergometer) was performed twice in all patients - before and after the completion (4 weeks) of the II phase of the rehabilitation to assess its effects. RESULTS: Basing on logistic regression analysis and the results of individual odds ratio (OR) of the tested blood parameters, their prognostic impact on the risk of cardiac rehabilitation failure was determined. This risk was defined on the basis of patient's inability to tolerate any workload increment (0 Watt) between the initial and final result of the exercise test despite the applied cardiac rehabilitation program. The most statistically significant risk factors were selected as the result of logistic regression model building on the basis of which cardiac rehabilitation failure index was determined. Anemia and leucocytosis determined most significantly the failure of cardiac rehabilitation (respectively OR=2,77 and OR=2,36; p=0,01). They were used to construct a rehabilitation failure index with the values ranging from 0 to 2, where 0 - corresponds to absence of anemia and leucocytosis, 1 - corresponds to the occurrence of anemia or leucocytosis in post-NSTEMI patients and was associated with 2,65-fold increase of the risk of cardiac rehabilitation failure, 2 - corresponds to simultaneous occurrence of anemia and leucocytosis and was associated with 7,02-fold increase of the risk of cardiac rehabilitation failure. CONCLUSIONS: Complete blood count is useful in predicting cardiac rehabilitation failure. Anemia and leucocytosis are the most significant determinants of cardiac rehabilitation failure in post-NSTEMI patients. Cardiac rehabilitation failure index can be used for its individual programming. Then optimal rehabilitation effects can be obtained maintaining its safety in post-NSTEMI patients.