RESUMO
The incremental shuttle walk test (ISWT) is a valid, reliable submaximal exercise test used in the assessment of patients prior to cardiac rehabilitation (CR). Simultaneous electrocardiogram (ECG) measurements would provide important information on the safety of the test, and adequacy of subsequent cardiac risk stratification. Risk stratification is recommended to assess patients' suitability for cardiac rehabilitation. For example, ST-segment depression >2 mm from baseline during testing would place a person in a high-risk category. However, such ECG measurements are rarely undertaken in clinical practice. The aim of the study was to investigate the incidence of ECG changes during an ISWT, and report on the possible impact of these findings on subsequent cardiac risk stratification. A retrospective case note review was undertaken for the year 2017. Baseline clinical characteristics from eligible patients were gathered including those with ischaemic heart disease, heart failure, transplant and valve replacement, along with ECG measurements during the ISWT. The impact of ECG findings on cardiac risk stratification was calculated, based on risk stratification developed by the American Association of Cardiovascular and Pulmonary Rehabilitation. The safety of the ISWT was measured by the absence of major ECG changes. Data were gathered for 295 patients. Minor ECG changes were identified during the ISWT in 189 patients (64.1%), with no major changes. The presence of silent myocardial ischaemia (ST-segment depression) had an impact on cardiac risk stratification in 27 patients. There was a statistically significant positive association between ST-segment depression with cardiac risk stratification (p<0.001). In conclusion, the ISWT is safe in terms of ECG changes. The impact of ECG findings on cardiac risk stratification is significant and worthy of further consideration.
RESUMO
OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is often undertaken in the oldest frailest cohort of patients undergoing cardiac interventions. We plan to investigate the potential benefit of cardiac rehabilitation (CR) in this vulnerable population. DESIGN: We undertook a pilot randomised trial of CR following TAVI to inform the feasibility and design of a future randomised clinical trial (RCT). PARTICIPANTS: We screened patients undergoing TAVI at a single institution between June 2016 and February 2017. INTERVENTIONS: Participants were randomised post-TAVI to standard of care (control group) or standard of care plus exercise-based CR (intervention group). OUTCOMES: We assessed recruitment and attrition rates, uptake of CR, and explored changes in 6-min walk test, Nottingham Activities of Daily Living, Fried and Edmonton Frailty scores and Hospital Anxiety and Depression Score, from baseline (30 days post TAVI) to 3 and 6 months post randomisation. We also undertook a parallel study to assess the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the post-TAVI population. RESULTS: Of 82 patients screened, 52 met the inclusion criteria and 27 were recruited (3 patients/month). In the intervention group, 10/13 (77%) completed the prescribed course of 6 sessions of CR (mean number of sessions attended 7.5, SD 4.25) over 6 weeks. At 6 months, all participants were retained for follow-up. There was apparent improvement in outcome scores at 3 and 6 months in control and CR groups. There were no recorded adverse events associated with the intervention of CR. The KCCQ was well accepted in 38 post-TAVI patients: mean summary score 72.6 (SD 22.6). CONCLUSIONS: We have demonstrated the feasibility of recruiting post-TAVI patients into a randomised trial of CR. We will use the findings of this pilot trial to design a fully powered multicentre RCT to inform the provision of CR and support guideline development to optimise health-related quality of life outcomes in this vulnerable population. Retrospectively registered 3rd October 2016 clinicaltrials.gov NCT02921880. TRIAL REGISTRATION: Clinicaltrials.Gov identifier NCT02921880.
RESUMO
OBJECTIVES: Refractory angina patients suffer debilitating chest pain despite optimal medical therapy and previous cardiovascular intervention. Cardiac rehabilitation is often not prescribed due to a lack of evidence regarding potential efficacy and patient suitability. A randomised controlled study was undertaken to explore the impact of cardiac rehabilitation on cardiovascular risk factors, physical ability, quality of life and psychological morbidity among refractory angina sufferers. METHODS: Forty-two refractory angina patients (65.1 ± 7.3 years) were randomly assigned to an 8-week Phase III cardiac rehabilitation program or symptom diary control. Physical assessment, Progressive Shuttle Walk test, Hospital Anxiety and Depression Scale, Health Anxiety Questionnaire, the York Angina Beliefs scale, ENRICHD Social Support Instrument and SF-36 were completed before and after intervention and at 8-week follow-up. RESULTS: Following cardiac rehabilitation, patients demonstrated improved physical ability compared with controls in Progressive Shuttle Walk level attainment (p = 0.005) and total distance covered (p = 0.015). Angina frequency and severity remained unchanged in both groups, with the control demonstrating worsening SF-36 pain scale (63.43 ± 22.28 vs. 55.46 ± 23.98, p = 0.025). Cardiac rehabilitation participants showed improved Health Anxiety Questionnaire reassurance (1.71 ± 1.72 vs. 1.14 ± 1.23, p = 0.026) and York Beliefs anginal threat perception (12.42 ± 4.58 vs. 14.35 ± 4.73, p = 0.05) after cardiac rehabilitation. Physical measures were broadly unaffected. CONCLUSIONS: Cardiac rehabilitation can be prescribed to improve physical ability without affecting angina frequency or severity among patients with refractory angina.
