Effects of a Renal Rehabilitation Exercise Program in Patients with CKD: A Randomized,Controlled Trial

Background and objectives

Patients with CKD have a high prevalence of cardiovascular disease associated with or exacerbated by inactivity. This randomized, controlled study investigated whether a renal rehabilitation exercise program for patients with stages 3 or 4 CKD would improve their physical function and quality of life.

Design, setting, participants, & measurements

In total, 119 adults with CKD stages 3 and 4 were randomized, and 107 of these patients proceeded to usual care or the renal rehabilitation exercise intervention consisting of usual care plus guided exercise two times per week for 12 weeks (24 sessions). Physical function was determined by three well established performance-based tests: 6-minute walk test, sit-to-stand test, and gait-speed test. Health-related quality of life was assessed by the RAND 36-Item Short Form Health Survey.

Results

At baseline, no differences in self-reported level of activity, 6-minute walk test, and sit-to-stand test scores were observed between the usual care (n=48) and renal rehabilitation exercise (n=59) groups, although baseline gait-speed test score was higher in the renal rehabilitation exercise group (P<0.001). At follow-up, the renal rehabilitation exercise group but not the usual care group showed significant improvements in the 6-minute walk test (+210.4±266.0 ft [19% improvement] versus −10±219.9 ft; P<0.001), the sit-to-stand test (+26.9±27% of age prediction [29% improvement] versus +0.7±12.1% of age prediction; P<0.001), and the RAND-36 physical measures of role functioning (P<0.01), physical functioning (P<0.01), energy/fatigue levels (P=0.01), and general health (P=0.03) and mental measure of pain scale (P=0.04). The renal rehabilitation exercise regimen was generally well tolerated.

Conclusions

A 12-week/24-session renal rehabilitation exercise program improved physical capacity and quality of life in patients with CKD stages 3 and 4. Longer follow-up is needed to determine if these findings will translate into decreased mortality rates.     

The effect of dietary modification on the training outcome and body composition in patients undergoing a cardiac rehabilitation programme

The benefit of the exercise element of cardiac rehabilitation is well recognized. This study examines the influence of dietary modification during an exercise programme on changes in functional capacity in rehabilitation patients. Thirty male post coronary artery bypass graft patients were recruited. Prior to commencing a ten-week aerobic exercise programme all patients underwent a symptom limited exercise stress test (EST), body composition analysis, a fasting lipid profile and dietary assessment. Patients were assigned to one of three dietary regimens for the duration of the exercise programmes. Diets were modified in terms of carbohydrate and fat content as follows: diet A was an athletic type diet (60–65% carbohydrate, 20–25% fat), diet B was a traditional lipid-lowering diet (50–55% carbohydrate, 30% fat) and diet C was a weight-reducing lipid-lowering diet (50–55% carbohydrate, 30% fat). All baseline measurements were repeated on completion of the exercise programme. EST results for subjects who followed diet A, the high carbohydrate diet showed a significant improvement in functional capacity and duration of exercise post-training (P<0.007 and P<0.005 respectively). These improvements were achieved at a significantly lower heart rate for equal work load compared to the other two groups (P<0.005). These combined improvements were not achieved by either of the other two groups. The results of this study suggest that dietary manipulation significantly influences the outcome of exercise training in cardiac rehabilitation. The optimum diet in this patient group was a high carbohydrate, low fat, and weight-maintenance diet.     

Increased morbidity and mortality of a concomitant colectomy during a pancreaticoduodenectomy: an NSQIP propensity-score matched analysis

BackgroundSelect patients with peri-ampullary cancers require concomitant colon resection (CR) during a pancreaticoduodenectomy (PD) for margin-negative resections. This study analysed the impact of concomitant CR on major morbidity (MM) and mortality.MethodsNational Surgical Quality Improvement Program (NSQIP) patients undergoing PD for peri-ampullary cancers were identified from 2005 to 2012. A 4 : 1 propensity-score matched analysis isolated the impact of CR upon PD. Risk factors for 30-day MM and mortality were analysed to determine post-operative sequelae of PD+CR.ResultsFrom 10 965 PD and 159 PD+CR patients, 624 and 156, respectively, were selected for 4 : 1 matched analysis. PD+CR resulted in a higher MM and mortality (50.0% and 9.0%) versus PD alone (28.8% and 2.9%, respectively, P< 0.001). Multivariate analysis identified risk factors for MM after PD: concomitant CR [odds ratio (OR)–3.19, P< 0.001], smoking (OR–1.92, P = 0.005), a lack of functional independence (OR–3.29, P = 0.018), cardiac disease (OR–2.39, P = 0.011), decreased albumin (per g/dl, OR–1.38, P = 0.033) and a longer operative time (versus median time, OR–1.56, P = 0.029). Independent predictors of mortality included concomitant CR (OR–3.16, P = 0.010), ventilator dependence (OR–13.87, P< 0.001) and septic shock (OR–6.02, P < 0.001).ConclusionsCR was an independent predictor of MM and mortality after a PD. Patients requiring PD+CR should be identified pre-operatively, maximally optimized and referred to experienced surgeons at expert centres.     

Long-term reduction of cardiac mortality after myocardial infarction: 10-year results of a comprehensive rehabilitation programme

The long-term outcome of different methods of post-MI care hasbeen studied in two non-selected groups of MI patients: an interventiongroup (n = 147), participating in a cardiac rehabilitation (CR)programme, was compared to a reference group receiving standardcare (n = 158). The CR programme included a post-MI clinic,physical training, information on smoking and diet, and psychologicalsupport. After 5 years there was no difference in mortality (29.3 vs31.6%), but the recurrence rate of non-fatal MI (17.3 vs 33.3%P <0.05) and of total cardiac events (39.5 vs 53.2%, P <0.05) was lower in the intervention gro up, and more patientswere still at work (51.8 vs 27.4% P < 0.01). After 10 years there was a reduction in total (42.2 vs 57.6%P < 0.001) and cardiac mortality (36.7 vs 48.1% P < 0.001).Fewer patients in the intervention group suffered from non-fatalreinfarction (28.6 vs 39.9%, P < 0.001). Among those patientswho had not yet reached the age of retirement more patientshad resumed employment (58.6 vs 22.0% P < 0.05). We conclude, that the secondary preventive effect of the programmehas contributed to the higher rate of survival.     

Effects of cardiac rehabilitation on physical function and exercise capacity in elderly cardiovascular patients with frailty

BackgroundThe effects of cardiac rehabilitation (CR) on long-term prognosis of cardiovascular disease (CVD) are well known. However, the effect of CR on frail CVD patients has not been fully addressed.MethodsThis study consisted of 89 CVD patients with their age ≥65 years old (68 males, 75 ± 6 years), who participated in the outpatient CR program for 3 months. All the patients underwent cardiopulmonary exercise testing and the physical frailty was assessed using the Japanese Version of the Cardiovascular Health Study Standard before and after CR. Based on the assessment of frailty before CR, the patients were divided into the following two groups: frailty group (n = 23) and non-frailty group (n = 66: robust in 10 and pre-frail in 56 patients).ResultsIn the frailty group, 20 patients (87%) improved from frail status after CR, and usual walking speed, maximal grip strength, and lower extremity strength were significantly improved (1.06±0.20 vs. 1.20±0.18 m/sec, p<0.001; 21.7 ± 5.5 vs. 23.6 ± 6.3 kg, p<0.01; 0.37±0.09 vs. 0.43±0.11 kgf/kg, p = 0.001, respectively), but peak VO₂ did not change after CR (15.9 ± 3.1 vs. 16.2 ± 3.8 ml/min/kg, NS). In the non-frailty group, all these parameters were significantly improved after CR (1.24±0.19 vs. 1.29±0.23 m/sec, p<0.05, 28.7 ± 7.0 vs. 30.2 ± 7.3 kg, p<0.001, 0.50±0.18 vs. 0.54±0.13 kgf/kg, p<0.05, 17.7 ± 4.7 vs 18.5 ± 4.2 ml/min/kg, p<0.01, respectively).ConclusionShort-term CR could obtain the improvement of the physical function, providing the prerequisite step for possibly following improvement of exercise capacity in elderly CVD patients with frailty. It may be inferred that longer duration of CR would be needed to obtain the improvement of exercise capacity in these patients, being the future consideration to be determined.     

New phenotype of familial dilated cardiomyopathy and conduction disorders

Background

The majority of patients with coronary heart disease (CHD) are overweight. However, little weight loss occurs with participation in a standard cardiac rehabilitation (CR) program.

Methods

Fifteen overweight patients (average body mass index of 31.0 kg/m²) with CHD completed a 4-month exercise training program in a CR program. The exercise program consisted primarily of walking long duration (60-90 minutes per session) 5 to 7 days per week at a relatively low intensity of 50% to 60% of peak VO₂. Measures of body composition by dual-energy x-ray absorptiometry, body fat distribution by computed tomography, plasma lipid-lipoprotein, glucose and insulin concentrations, and peak VO₂ were obtained before and after the exercise intervention. Patients maintained an isocaloric diet throughout the study.

Results

Patients had reductions in total body weight (−4.6 kg), fat mass (−3.6 kg), percent body fat (−2.9%), and waist circumference (−5.6 cm) (all P <.001) while maintaining fat-free mass. Subcutaneous adipose tissue was reduced by 12% (P <.001) and visceral adipose tissue was lowered by 14% (P <.001). There were favorable changes in the lipid-metabolic profile with reductions in triglyceride levels (−23.7%), total cholesterol/HDL-C ratio (−14.3%), and fasting insulin levels (−22.3%) (all P <.05). Peak VO₂ increased by 21.2% (P <.001).

Conclusions

The present pilot study results suggest that a high caloric training exercise training program in the CR setting may be effective in promoting weight loss and improving coronary risk factors in overweight coronary patients. Although additional research with randomized control patients is needed, this alternative to traditional CR may be considered to maximize weight loss as part of a secondary prevention program.     

Efficacy of once daily penbutolol in chronic stable angina. An objective comparison with long-acting propranolol

The effects of penbutolol (40 mg daily) and long-acting propranolol (160 mg daily) were assessed in 26 patients with chronic stable angina in a placebo-controlled randomised double-blind crossover study with 2-weekly treatment periods. In addition to conventional subjective assessment, serial multistage treadmill exercise was used to obtain objective data on drug efficacy and 24-hr ambulatory electrocardiography performed for diurnal heart rate analysis. The mean exercise time of 6.3 ± 0.5 (SEM) min on placebo increased to 7.3 ± 0.6 min on penbutolol (P < 0.01) and to 7.9 ± 0.5 min on propranolol (P < 0.001). The pre-exercise resting heart rate was 73 ± 2 beats/min on placebo and decreased to 63 ± 2 beats/min on penbutolol (P < 0.001) and 58 ± 2 beats/min on propranolol (P < 0.001). The maximum exercise heart rate was similarly reduced by both drugs and there was a corresponding reduction in peak exercise double product. The time-corrected maximum ST segment depression was reduced by both drugs and neither produced a delay in ST segment recovery. Both drugs effected significant reductions in ambulatory maximum hourly heart rates throughout 24 hr. The lowest observed heart rate on penbutolol was 40 beats/min and 34 beats/min on propranolol. Penbutolol is an effective antianginal agent with a profile of action similar to that of propranolol.     

Relationship of ventricular longitudinal function to contractile reserve in patients with mitral regurgitation

Background

Latent left ventricular (LV) dysfunction in patients with valvular or myocardial disease may be identified by loss of contractile reserve (CR) at exercise echocardiography. Contraction in the LV longitudinal axis may be more sensitive than radial contraction to minor disturbances of LV function. We sought to determine whether tissue Doppler measurement of longitudinal function could be used to identify CR.

Methods

Exercise echocardiography was performed in 86 patients (20 women, age 53 ± 18 years), 72 with asymptomatic or minimally symptomatic mitral regurgitation, and 14 normal controls. Pulsed-wave tissue Doppler imaging (DTI) was used to measure maximum annular systolic velocity at rest and stress. Inducible ischemia was excluded by analysis of wall motion by an experienced observer. CR was defined by ≥5% improvement of stress compared with rest ejection fraction (EF). Exercise capacity was assessed from expired gas analysis.

Results

CR was present in 34 patients with mitral regurgitation (47%); peak EF in patients with and without CR was 74% ± 11% versus 54% ± 15% (P < .0001). CR could not be predicted by resting EF, volumes or sphericity, and DTI measurement of base-apex function was the only resting echocardiographic parameter to distinguish between patients with and without CR (10 ± 2 vs 8 ± 2 cm/s, P < .03). This parameter showed greater differences after stress (14 ± 4 vs 11 ± 3 cm/s, P < .001). Patients with CR showed lower peak DTI than controls, as well as lower exercise capacity and EF response to exercise. In a multiple linear regression model, rest DTI (P = .03) was an independent correlate of contractile reserve. The other correlates were age (P < .0001), resting (P < .0001) and peak end-systolic volume (P = .01), and resting (P < .0001) and peak end-diastolic volume (P < .0001); the model r² was 0.93 (P < .001).

Conclusion

In the absence of regional LV dysfunction, measurement of longitudinal axis function by DTI may be a marker of CR.     

Hospital- and Patient-Level Analysis of Quality Indicators in Acute Coronary Syndrome Care: A Nationwide Database Study

BackgroundThis study aimed to clarify the variations in the quality of care provided to patients with acute coronary syndrome (ACS) and to investigate the association between quality of care and mortality at both hospital and patient levels with the use of a nationwide database.MethodsPatients with ACS who underwent percutaneous coronary intervention (PCI) from April 2014 to March 2018 were included from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Twelve quality indicators (QIs) available from administrative data and the association of the QIs with all-cause mortality were investigated.ResultsFrom the analysis of 216,436 patients from 1215 hospitals, adherence to PCI on admission day, aspirin use on arrival, P2Y12 inhibitor use, and left ventricular function assessment were high (median proportion > 90%), and adherence to outpatient cardiac rehabilitation was low (median proportion < 10%). At the hospital level, acute-phase composite QI score was associated with reduced risk-adjusted 30-day mortality (β = −0.92 [95% confidence interval −1.19 to −0.65]; P < 0.001). At the patient level, all acute-phase and subacute-phase QIs were inversely associated with 30-day and 2-year mortalities, respectively (all P < 0.001).ConclusionsSubstantial variations in ACS care were observed in the current nationwide database. High adherence to the QI sets was associated with significant survival gains at both hospital and patient levels. Multilevel approach in QI assessment may be effective for improvement of survival in this population.     

Effect of a cardiac rehabilitation program on exercise oscillatory ventilation in Japanese patients with heart failure

Although exercise oscillatory ventilation has emerged as a potent independent risk factor for adverse prognosis in heart failure, it is not well known whether cardiac rehabilitation can improve oscillatory ventilation. In this study, we investigated the magnitude of oscillations in ventilation before and after cardiac rehabilitation in chronic heart failure patients with exercise oscillatory ventilation. Cardiac rehabilitation (5-month program) was performed in 26 patients with chronic heart failure who showed an oscillatory ventilation pattern during cardiopulmonary exercise testing (CPX). After the 5-month rehabilitation program was completed, the patients again underwent CPX. To determine the magnitude of oscillations in ventilation, the amplitude and cycle length of the oscillations were calculated and compared with several other parameters, including biomarkers that have established prognostic value in heart failure. At baseline before cardiac rehabilitation, both oscillation amplitude (R = 0.625, P < 0.01) and cycle length (R = 0.469, P < 0.05) were positively correlated with the slope of minute ventilation vs. carbon dioxide production. Plasma BNP levels were positively correlated with amplitude (R = 0.615, P < 0.01) but not cycle length (R = 0.371). Cardiac rehabilitation decreased oscillation amplitude (P < 0.01) but failed to change cycle length. The change in amplitude was positively correlated with the change in BNP levels (R = 0.760, P < 0.01). Multiple regression analysis showed that only the change in amplitude was an independent predictor of the change in BNP levels (R = 0.717, P < 0.01). A 5-month cardiac rehabilitation program improves exercise oscillatory ventilation in chronic heart failure patients by reducing the oscillation amplitude. This effect is associated with a reduction of plasma BNP levels, potentially contributing to an improvement of heart failure.     

Prevalence and clinical outcomes of patients with apparent treatment‐resistant hypertension enrolled in Phase 2 cardiac rehabilitation

Phase 2 cardiac rehabilitation (CR) employs evidenced‐based interventions to modify the risk of cardiac morbidity in its participants. The prevalence of apparent treatment‐resistant hypertension (aTRH) among CR participants is unknown. A retrospective analysis of a longitudinal cohort of patients who completed CR between 2012 and 2017 was undertaken. The prevalence of hypertension was 62% (n = 311). 11% of participants with hypertension had aTRH (n = 35). Participants with aTRH exhibited lower exercise capacity (EC) before starting CR and after its completion compared to normotensive counterparts (P < .001). aTRH participants were more likely to experience a decrease in EC, even after participating in cardiac rehabilitation, compared to normotensive participants (P = .02). aTRH participants were more likely to be hospitalized or seen in the emergency department after cardiac rehabilitation completion compared to normotensive counterparts (OR: 2.85, P < .01). CR presents an opportunity to identify and appropriately care for patients with aTRH.     

Effect of cardiac rehabilitation on functional outcomes after coronary revascularization

Background Current guidelines recommending cardiac rehabilitation (CR) after coronary revascularization are largely based on early studies that evaluated only a subset of the population and failed to assess the impact of CR on a patient's perception of their functional status. The main objective of this study was to evaluate the impact of CR in a diverse contemporary population on patient functional outcomes. Methods We studied the effect of CR on 6-month SF-36 Physical Functioning (PF) in 700 patients (mean age 67 ± 11 years, 37% women) who underwent coronary bypass grafting or percutaneous intervention from August 1998 to July 2000. Results Overall CR participation was 24%. At baseline, CR participants had higher PF (mean 62.5 vs 52.5, P < .001). After adjusting for baseline clinical variables and PF score, CR was associated with significant improvement in 6-month PF (+5.0, 95% CI 1.0-9.0). This improvement was observed in all patient subgroups, but tended to be greater in magnitude in men versus women, patients aged <70 years versus ≥70 years, and patients with coronary bypass grafting versus patients with percutaneous intervention. CR participants also tended to be more likely to engage in regular exercise (63% vs 55%, P = .06) and modify their diet (82% vs 73%, P = .07). Rates of rehospitalization and repeat revascularization were similar among CR participants and nonparticipants. Conclusions CR after coronary revascularization is associated with improved functional outcomes and adoption of secondary preventive measures. Innovative strategies to facilitate CR enrollment and tailoring programs to better address the needs of all patient subgroups would extend these benefits to more eligible patients. (Am Heart J 2003;145:445-51.)     

Automated Referral to Cardiac Rehabilitation After Coronary Artery Bypass Grafting Is Associated With Modest Improvement in Program Completion

BackgroundCardiac rehabilitation (CR) is a guideline-indicated modality for reducing residual cardiovascular risk among patients undergoing coronary artery bypass grafting (CABG) surgery. However, many referred patients do not initiate or complete a CR program; even more patients are never even referred.MethodsAll post-CABG patients in Calgary, Alberta, Canada, from January 1, 1996, to March 31, 2016, were included. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation databases. Automated referral to CR at discharge after CABG was instituted on July 1, 2007. We used interrupted time series analysis to evaluate the impact of automated referral on CR referral and completion rates and studied the association of these CR process markers with mortality.ResultsA total of 8,118 patients underwent CABG surgery during the study period: 5,103 before automation and 3,015 after automation. Automation increased referral rates from 39.5% to 75.0% (P < 0.001). Automated referral was associated with a 7.2% increase in CR completion in the overall population (33.3% vs 26.1%; P < 0.001). In adjusted models, CR referral alone was not associated with reduced mortality (hazard ratio [HR] 0.84, 95% CI 0.64-1.11), but CR completion was (HR 0.43, 95% CI 0.31-0.61).ConclusionAutomated referral in post-CABG patients resulted in modest improvement in CR program completion. Therefore, even when CR referral is automated to include all eligible patients, additional strategies to support CR program enrollment and completion remain necessary to achieve the desired health benefits.     

Four-week multidisciplinary cardiac rehabilitation produces similar improvements in exercise capacity and quality of life to a 10-week program

BACKGROUND: Cardiac rehabilitation (CR) is widely accepted as beneficial for patients with myocardial infarction (MI) and coronary artery bypass graft (CABG). A need exists to evaluate how different formats of delivery can best meet CR service demands. METHODS AND RESULTS: Cardiac patients (n = 60) were randomly assigned to either a standard 10-week (30 sessions) or a 4-week (20 sessions) multifactorial rehabilitation program. Patients underwent exercise testing using the Bruce protocol before, immediately after, and then 6 months after CR. Patients also completed the SF-36 quality of life questionnaire and the Hospital Anxiety and Depression scale at each time point. Compared with pre-CR, exercise time and metabolic equivalents attained were significantly increased, and heart rate significantly decreased both immediately (P<.05) and 6 months after CR (P<.05) in both groups, with no between-group differences. Significant improvements (P<.05) in energy, pain, and general health were reported after CR, and in energy and emotional and social well-being at 6 months after CR. No differences were seen between the groups. CONCLUSIONS: Cardiac rehabilitation after MI and CABG significantly improved exercise capacity and general health and well-being. No significant differences were detected between groups undergoing a 10-week or 4-week course. These preliminary data suggest that shortened courses of CR may be beneficial to cardiac patients and such courses may also facilitate more widespread use of CR.     

Examination of clinical and psychosocial determinants of exercise capacity change in cardiac rehabilitation

Purpose

Most cardiac rehabilitation (CR) completers improve in multiple functional and psychosocial domains. However, not all demonstrate uniform improvement in functional indicators such as exercise capacity. This study examined baseline predictors and correlates of change in exercise capacity from CR intake to completion.

Redesigning care for chronic conditions: improving hospital‐based ambulatory care for people with osteoarthritis of the hip and knee

Background: Osteoarthritis of the hip and knee is a highly prevalent chronic condition in Australia that commonly affects older people who have other comorbidities. We report the pilot implementation of a new chronic disease management osteoarthritis service, which was multidisciplinary, evidence‐based, supported patient self‐management and care coordination. Methods: A musculoskeletal coordinator role was pivotal to service redesign and osteoarthritis pathway implementation. Impact evaluation included: service utilization, patient and general practitioner service experience, a ‘before and after’ audit of clinician adherence to recommendations, and 3‐ and 6‐month patient health outcomes (pain, physical function, patient and physician global health (Visual Analogue Scale), disability (Multi‐Attribute Prioritisation Tool), Partners in Health Scale and body mass index). Results: A total of 123 patients, median age of 66 years, were assessed. Documentation of osteoarthritis assessment and management improved for all parameters. At 3 months there were improvements in self‐reported pain (P < 0.001), global function (P < 0.001), physician and patient reported global health (P < 0.001), Partners in Health Score (P < 0.001) and Hip and Knee Multi‐Attribute Prioritisation Tool score (P < 0.014). Body mass index did not improve. Patients and general practitioners reported positive experiences, but there was variable uptake of recommendations by patients. The main factors influencing uptake of recommendations were access block to community services in the first 3 months and patient preferences for therapy. The cost implications for implementation were low. Conclusion: The osteoarthritis service model is feasible to implement, is well received by patients and staff, and provides a template for translation into other settings.     

Symptomatic myocardial infarction without chest pain: Prevalence and clinical course

Symptomatic myocardial infarction without chest pain was identified in 26 of 102 patients (25.5 percent) admitted to the hospital with acute myocardial infarction. As a group, these patients had a significantly lesser prevalence of a history of angina (P < 0.05) and cigarette smoking (P < 0.01). Their mean age was 69.1 years compared with 58.7 years for patients with chest pain (P < 0.001). The group had a significantly greater median delay between the onset of symptoms and (1) arrival at the hospital (P < 0.05), (2) examination by a physician in the emergency room (P < 0.05), (3) diagnosis of possible myocardial infarction (P < 0.001), and (4) transfer from the emergency room to the intensive care unit (P < 0.001). They had significantly higher admission values for mean heart rate, respiratory rate, temperature and white blood cell count and more frequent in-hospital complications of pneumonia (P < 0.001) and cardiogenic shock (P < 0.05). Mortality in the group was 50 percent compared with 18 percent in the group with chest pain (P < 0.05). Discriminant function analysis identified an at-risk population with 80 percent reliability.     

The role and outcome of cardiac rehabilitation program in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is associated with diminished cardiac function, and exercise tolerance.

Hypothesis

We sought to investigate the role of cardiac rehabilitation program (CR) in patients with AF.

Methods

The study included 2165 consecutive patients that participated in our CR program between the years 2009 to 2015. All were evaluated by a standard exercise stress test (EST) at baseline, and upon completion of at least 3 months of training. Participants were dichotomized according to baseline fitness and the degree of functional improvement. The combined primary end point was cardiac related hospitalization or all‐cause mortality.

Results

A total of 292 patients had history of AF, with a mean age of 68 ± 9 years old, 76% of which were males. The median predicted baseline fitness of AF patients was significantly lower compared to non‐AF patients (103% vs 122%, P < 0.001, respectively). Prominent improvement was achieved in the majority of the patients in both groups (64% among AF patients and 63% among those without AF). Median improvement in fitness between stress tests was significantly higher in patients with AF (124% vs 110%, P < 0.001, respectively). Among AF patients, high baseline fitness was associated with a lower event rates (HR 0.40; 95%CI 0.23‐0.70; P = 0.001). Moreover, prominent improvement during CR showed a protective effect (HR 0.83; 95% CI 0.69‐0.99; P = 0.04).

Conclusion

In patients with AF participating in CR program, low fitness levels at baseline EST are associated with increased risk of total mortality or cardiovascular hospitalization during long‐term follow‐up. Improvement on follow‐up EST diminishes the risk.     

Outcomes of Dysphagia Intervention in a Pulmonary Rehabilitation Program

People with chronic obstructive pulmonary disease (COPD) or chronic respiratory disease demonstrate an increased prevalence of oropharyngeal dysphagia as a consequence of impaired coordination between respiration and swallowing function. To date, the effect of patient education and intervention on the management of oropharyngeal dysphagia within pulmonary rehabilitation programs has not been reported or evaluated. Data were collected on participants who were enrolled in the Outpatient Pulmonary Rehabilitation Program and who received dysphagia intervention. Intervention consisted of some or all of the following: (1) a 1-hour dysphagia education program, (2) screening for oropharyngeal dysphagia, and (3) individual comprehensive oropharyngeal dysphagia assessment and management if a screening assessment was failed. A statistically significant improvement was found in participants’ knowledge of dysphagia and COPD (P < 0.001). Participants’ retention of this knowledge 4 days post education remained statistically significant (P < 0.001). Twenty-seven percent of participants who were screened had symptoms of oropharyngeal dysphagia. Fifty-five (53%) participants receiving further individual dysphagia assessment/management correctly completed pre/post swallowing-related quality-of-life surveys (SWAL-QOL). Statistically significant improvement was found in the following subscales: Burden of Dysphagia (P < 0.009), Physical Problems of Dysphagia (P < 0.012) and Managing Diet Options/Food Selection (P < 0.016). Dysphagia education, screening, and management in a pulmonary rehabilitation program improved participants’ swallowing-related quality of life and overall self-management of chronic respiratory disease and dysphagia.