Identifying Factors for Low-Risk Participation in Alternative Cardiac Rehabilitation Models for Patients with Coronary Heart Disease Using MI'S SCOREPAD.

Introduction: Although a recent joint society scientific statement (the American Association of Cardiovascular Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology) suggests home-based cardiac rehab (CR) is appropriate for low- and moderate-risk patients, there are no paradigms to define such individuals with coronary heart disease. Methods: We reviewed a decade of data from all patients with coronary heart disease enrolled in a single CR center (University of Michigan) to identify the prevalence of low-risk factors, which may inform on consideration for participation in alternative models of CR. Low-risk factors included not having any of the following: metabolic syndrome, presence of implantable cardioverter defibrillator or permanent pacemaker, active smoking, prior stroke, congestive heart failure, obesity, advanced renal disease, poor exercise capacity, peripheral arterial disease, angina, or clinical depression (MI'S SCOREPAD). We report on the proportion of participants with these risk factors and the proportion with all of these low-risk factors. Results: The mean age of CR participants (n = 1984) was 63 years; 25% were women, and 82% were non-Hispanic White. The mean number of low-risk factors was 8.5, which was similar in the 2011-2012 and 2018-2019 cohorts (8.5 vs. 8.3, respectively, P = 0.08). Additionally, 9.3% of the 2011-2012 cohort and 7.6% of the 2018-2019 cohort had all 11 of the low-risk factors. Conclusion: In this observational study, we provide a first paradigm of identifying factors among coronary heart disease patients that may be considered low-risk and likely high-gain for participation in alternative models of CR. Further work is needed to track clinical outcomes in patients with these factors to determine thresholds for enrolling participants in alternative forms of CR.

Cardiorespiratory Fitness After Open Repair for Acute Type A Aortic Dissection - A Prospective Study.

Cardiorespiratory fitness (as measured by peak oxygen consumption [VO2peak]) is an independent predictor of cardiovascular disease and all-cause mortality. Limited data exist on VO2peak following repair for an acute type A aortic dissection (ATAAD) or proximal thoracic aortic aneurysm (pTAA). This study prospectively evaluated VO2peak, functional capacity, and health-related quality of life (HR-QOL) following open repair. Participants with a history of an ATAAD (n = 21) or pTAA (n = 43) performed cardiopulmonary exercise testing (CPX), 6-minute walk testing, and HR-QOL at 3 (early) and 15 (late) months following open repair. The median age at time of surgery was 55-years-old and 60-years-old in the ATAAD and pTAA groups, respectively. Body mass index significantly increased between early and late timepoints for both ATAAD (p = 0.0245, 56% obese) and pTAA groups (p = 0.0045, 54% obese). VO2peak modestly increased by 0.8 mLO2·kg-1·min-1 within the ATAAD group (p = 0.2312) while VO2peak significantly increased by 2.2 mLO2·kg-1·min-1 within the pTAA group (p = 0.0003). Anxiety significantly decreased in the ATAAD group whereas functional capacity and HR-QOL metrics (social roles and activities, physical function) significantly improved in the pTAA group (p values < 0.05). There were no serious adverse events during CPX. Cardiorespiratory fitness among the ATAAD group remained 36% below predicted normative values >1 year after repair. CPX should be considered post-operatively to evaluate exercise tolerance and blood pressure response to determine whether mild-to-moderate aerobic exercise should be recommended to reduce future risk of morbidity and mortality.

Increasing Cardiac Rehabilitation Participation Through a "Nearer to Home" Patient Referral Program.

PURPOSE: Time to travel to cardiac rehabilitation (CR) centers is a barrier to participation, and tertiary referral centers often care for patients living at a substantial distance. We sought to determine the impact of referring eligible patients to CR centers closer to home or workplace on overall participation rate. METHODS: An observational review was conducted in patients from a large cardiovascular program who were referred to CR (January 1, 2015, through December 31, 2016). Those declining participation due to distance from their home were identified and provided coordinated referral to a CR program they chose near their home or workplace. RESULTS: Of the 2912 patients referred to CR, 673 (23%) participated and 1900 declined due to distance. Contact was made in 2017 with 1237 of the 1900 of whom 1083 recalled a discussion of distance referral and completed the phone survey. Participants mean age was 64 yr, predominantly White (88%), male (65%), married (66%), and 70% had ≥ comorbidity. Out of the 1083 referred to a local CR program, 78% reported attending. Of those who attended CR, 55% (469/849) would not have attended had they not been referred to a program closer to their home or workplace. Overall participation increased from 23% to >50% of those referred from our institution. CONCLUSIONS: Coordinating CR referrals from the discharging facility to facilities closer to home or workplace is an effective means for increasing participation. The very low-cost effort has the potential to have a very meaningful impact on the long-term outcome of cardiovascular patients.

Small-Gauge Pars Plana Vitrectomy for Visually Significant Vitreous Floaters.

Purpose: This article evaluates our experience at a retina-only private practice with small-gauge pars plana vitrectomy (PPV) for visually significant vitreous floaters. We review the surgical outcomes, complication rates, and percentage of second-eye surgery for the same indication. Methods: A retrospective, interventional case series was conducted of consecutive patients undergoing PPV for significant vitreous floaters from September 2014 to December 2018 at a high-volume vitreoretinal surgery practice. Preoperative visual acuity (VA), complication rates, and visual outcome following surgery were evaluated. Results: A total of 104 eyes in 81 patients underwent PPV for visually significant floaters; 35 (43.2%) patients had PPV in both eyes. Mean preoperative VA was 0.16 ± 0.17 logMAR (∼20/29 Snellen equivalent) and improved to 0.12 ± 0.15 logMAR (∼20/26 Snellen; Wilcoxon test, P = .008) at the last follow-up after PPV. All patients had improvement in VA at the final postoperative visit, with a VA of 20/40 or better achieved in 93.3% of cases. The complication rate of vitreous hemorrhage postoperatively was 0.96%. There were no cases of postoperative retinal tears, breaks, or endophthalmitis. Conclusions: Small-gauge PPV in the carefully selected patient is an effective and safe procedure to eliminate symptoms. VA following PPV for vitreous floaters significantly improved. Nearly half of the patients studied (43.2%) underwent PPV in the other eye.

Reduced Fine Particulate Matter Air Pollution Exposures Using In-Home Portable Air Cleaners: PILOT RESULTS OF THE CARDIAC REHABILITATION AIR FILTER TRIAL (CRAFT).

PURPOSE: Fine particulate matter (PM2.5) air pollution is a leading risk factor for cardiovascular disease. Even low levels common to millions of Americans pose health risks. However, no study has tested protective measures such as in-home portable air cleaners (PACs) among at-risk cardiac patients. We conducted a pilot phase of the Cardiac Rehabilitation Air Filter Trial (CRAFT)-a randomized, double-blind, crossover study of outpatient cardiac rehabilitation patients at Michigan Medicine. METHODS: During a routine visit, patients were provided with 2 PACs to run continuously for 5 d in both the bedroom and the main living space. PACs were randomized as active (with HEPA filter) versus sham. On day 4, subjects wore a personal PM2.5 monitor for 24-hr without activity restrictions. After a 1-wk washout, patients crossed over to the opposite mode. RESULTS: Patients (n = 20; 4 women) were elderly (70.8 ± 9.6 yr) nonsmokers with cardiovascular disease living near the facility (10.7 ± 6.0 mi). Compared with sham, active in-home PAC use significantly lowered personal-level 24-hr PM2.5 exposures by 43.8% (-12.2 µg·m; 95% CI, -24.2 to -0.2). Sensitivity analyses corroborated the reductions in most patients. CONCLUSION: An inexpensive in-home PAC can effectively lower personal PM2.5 exposures in cardiac patients. These benefits occurred even in a region with overall good air quality and if maintained over the long-term could translate into major reductions in cardiovascular events.

Cardiopulmonary Exercise Testing Following Open Repair for a Proximal Thoracic Aortic Aneurysm or Dissection.

PURPOSE: There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, (Equation is included in full-text article.)O2peak), and blood pressure. METHODS: Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection. RESULTS: Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured (Equation is included in full-text article.)O2peak was <36% predicted normative values (19.2 mL·kgmin vs 29.3 mLkgmin, P < .0001); the most marked impairment in (Equation is included in full-text article.)O2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups. CONCLUSIONS: We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. (Equation is included in full-text article.)O2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.