The Role of Cardiac Rehabilitation in Reducing Major Adverse Cardiac Events in Heart Transplant Patients
Introduction
Cardiac rehabilitation (CR) is a recommended treatment strategy for multiple populations to elicit well-established improvements in functional capacity, quality of life and long-term outcomes.1, 2, 3, 4, 5, 6 Risk reduction has been shown in both all-cause and cardiovascular mortality with CR participation following percutaneous coronary intervention (PCI), myocardial infarction, coronary artery bypass graft surgery, and ventricular assist device implantation.1,7, 8, 9, 10 More recently, long-term major adverse cardiac events (MACE) have also been investigated in these populations as a method of identifying high-risk patients for early integration of preventive care.2,11 One such study of PCI patients found that CR participation was associated with a significant reduction in MACE incidence,2 advocating the clinical importance of CR.
CR participation for patients undergoing open-heart surgery and heart transplantation (HTx) has been shown to be a safe and beneficial component of postoperative care12, 13, 14, 15, 16 and, importantly, HTx is a reimbursable diagnosis for CR. In HTx patients, CR has been reported to further increase functional capacity and quality of life outcomes, surpassing improvements seen as the result of HTx alone while also reducing mortality risk.13,14,16 Along with this, specific adaptations to both cardiac and skeletal muscle have been shown in HTx patients (eg, oxidative capacity, improved vasculature, decreased myopathy), aiding in proper surgical recovery and postoperative risk-factor reduction.17,18 These patients undergoing HTx are in the most severe stages of heart failure, it is clinically important to understand preventive strategies to reduce MACE risk (as defined in the current study by stroke, PCI, heart failure (HF), myocardial infarction, acute rejection, and/or all-cause mortality) in this clinically complex population.19, 20, 21 To date, however, the association of CR in reducing the incidence of MACE in HTx patients is unknown.
Therefore, our study aimed to investigate the predictive role of post-HTx CR participation compared to other clinical and demographic variables in reducing MACE risk. Based on previous studies investigating MACE in other cardiac populations and the known physiologic benefits of CR participation, we hypothesized that CR involvement would be associated with a significantly lower number of MACE events in HTx patients.
Section snippets
Participants and Study Design
This retrospective, single-center analysis included consecutive adult patients who had undergone HTx and who participated in CR following HTx between the years of 2007 and 2016. Demographic and clinical characteristics were obtained from an institutional database and medical records. Inclusion criteria included at least 1 documented CR exercise session based on HTx referral and completion of pre-HTx cardiopulmonary exercise testing (CPET). Patients were excluded if they had 1) incomplete CPET
Patient Population and Clinical Characteristics
Demographic and clinical characteristics based on CR exercise sessions are presented in Table 1. The mean number of CR exercise sessions attended for each group are as follows: 13 ± 6 for the < 23 CR sessions group and 28 ± 5 for the ≥ 23 CR sessions group (P < 0.001). Time from HTx to the start of CR averaged 31 days, with an average of 32 days for those in the ≥ 23 CR sessions group and an average of 28 days for those in the < 23 CR sessions group (P = 0.407). Of the 140 HTx patients included
Discussion
This study aimed to investigate the predictive role of CR participation in reducing MACE risk in HTx patients. Attendance of ≥ 23 CR exercise sessions following HTx was found to be associated with significantly lower MACE risk. These results were established using the recursive partitioning model, which allows for concurrent investigation of distinct risk categories for a predictive binary outcome. Importantly, after adjustment for other cardiovascular risk factors, such as age, sex, history of
Disclosures
None declared.
This work was supported by the National Institutes of Health (HL-126638 to TPO) and the American Heart Association (18POST3990251 to JRS).
References (55)
- et al.
Cardiac rehabilitation and quality of life: a systematic review
Int J Nurs Stud
(2012) - et al.
Exercise-based rehabilitation improves skeletal muscle capacity, exercise tolerance, and quality of life in both women and men with chronic heart failure
J Card Fail
(1998) - et al.
Effects of exercise training on outcomes in women with heart failure: analysis of HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise TraiNing) by sex
JACC Heart Fail
(2014) - et al.
Cardiac rehabilitation after myocardial infarction in the community
J Am Coll Cardiol
(2004) - et al.
Association of Cardiac Rehabilitation With Decreased Hospitalizations and Mortality After Ventricular Assist Device Implantation
JACC Heart Fail
(2018) - et al.
Safety of early enrollment into outpatient cardiac rehabilitation after open heart surgery
Am J Cardiol
(2015) - et al.
Association between early cardiac rehabilitation and long-term survival in cardiac transplant recipients
Mayo Clin Proc
(2016) - et al.
The effect of early cardiac rehabilitation on health-related quality of life among heart transplant recipients and patients with coronary artery bypass graft surgery
Transplant Proc
(2011) - et al.
Relation of waist-hip ratio to long-term cardiovascular events in patients with coronary artery disease
Am J Cardiol
(2018) - et al.
The Registry of the International Society for Heart and Lung Transplantation: Twenty-eighth Adult Heart Transplant Report–2011
J Heart Lung Transplant
(2011)
Effect of body mass index on exercise capacity in patients with hypertrophic cardiomyopathy
Am J Cardiol
Technical considerations related to the minute ventilation/carbon dioxide output slope in patients with heart failure
Chest
Exercise therapy for cardiac transplant recipients
Prog Cardiovasc Dis
A recursive partitioning approach to investigating correlates of self-rated health: The CARDIA Study
SSM Popul Health
Cardiac rehabilitation and readmissions after heart transplantation
J Heart Lung Transplant
Structure of skeletal muscle in heart transplant recipients
J Am Coll Cardiol
Oxidative capacity of skeletal muscle in heart failure patients versus sedentary or active control subjects
J Am Coll Cardiol
Skeletal muscle response to short endurance training in heart transplant recipients
J Am Coll Cardiol
2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America
J Card Fail
The changing face of heart transplantation
J Am Coll Cardiol
Improved survival of patients with end-stage heart failure listed for heart transplantation: analysis of organ procurement and transplantation network/U.S. United Network of Organ Sharing data, 1990 to 2005
J Am Coll Cardiol
OPTN/SRTR 2013 Annual Data Report: heart
Am J Transplant
Organ allocation around the world: insights from the ISHLT International Registry for Heart and Lung Transplantation
J Heart Lung Transplant
The future of heart transplantation
Am J Transplant
Predictors of rehospitalization time during the first year after heart transplant
Heart Lung
Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community
Circulation
Cardiac rehabilitation reduces the rate of major adverse cardiac events after percutaneous coronary intervention
Eur J Cardiovasc Nurs
Cited by (21)
Cardiac rehabilitation for heart transplant patients: Considerations for exercise training
2022, Progress in Cardiovascular DiseasesCitation Excerpt :Participation in CR (55% participation rate, mean number of sessions: 26.7) was associated with a 29% lower one-year risk of re-hospitalization. Uithoven and associates evaluated the relationship between the number of CR sessions performed and major adverse cardiac events (MACE) in 140 HT recipients (41 women, age 52 ± 12 years).61 Patients were divided into two groups: ≤23 sessions (group 1) and ≥ 23 sessions (group 2).
Inspiratory muscle weakness in cardiovascular diseases: Implications for cardiac rehabilitation
2022, Progress in Cardiovascular DiseasesCitation Excerpt :Although survival rates at one-year post-surgery are approaching ~85%, recovery following HTxp remains complicated by factors such as primary graft dysfunction, allograft vasculopathy, and immunorejection of the new heart. It is becoming increasingly clear that prompt adoption of exercise-based CR is not only safe but may beneficially reverse the pathophysiological consequences of cardiac denervation and prevent immunosuppression-induced adverse effects following HTxp.39–41 However, it appears that several other patient-related ‘risk factors’ adversely affect the postoperative clinical course in HTxp recipients, including inspiratory muscle weakness.
Cardiac Rehabilitation: You Can't Have “Too Much of a Good Thing”
2020, Journal of Cardiac Failure
See page 650 for disclosure information.