The Role of Cardiac Rehabilitation in Reducing Major Adverse Cardiac Events in Heart Transplant Patients

https://doi.org/10.1016/j.cardfail.2020.01.011Get rights and content

Highlights

  • The present study found that attending ≥ 23 exercise sessions of cardiac rehabilitation (CR) was a significant predictor of avoidance of major adverse cardiac events, associated with a ∼ 60% reduction in risk of major adverse cardiac events.

  • This finding remained after adjustment for the covariates of age, sex, diabetes, body mass index, and pretransplant peak oxygen uptake.

  • These results support the finding that high rates of CR attendance and, ideally, CR program completion optimize results.

  • Following heart transplantation, CR participation should be viewed as a critical tool in the post-heart transplantation treatment strategy to maximize positive outcomes.

Abstract

Background

Methods for reducing major adverse cardiac events (MACE) in patients after heart transplantation (HTx) are critical for long-term quality outcomes.

Methods and Results

Patients with cardiopulmonary exercise testing prior to HTx and at least 1 session of cardiac rehabilitation (CR) after HTx were included. Exercise sessions were evaluated as ≥ 23 or < 23 sessions based on recursive partitioning. We included 140 patients who had undergone HTx (women: n = 41 (29%), age: 52 ± 12 years, body mass index: 27 ± 5 kg/m2). Mean follow-up was 4.1 ± 2.7 years, and 44 patients (31%) had a MACE: stroke (n = 1), percutaneous intervention (n = 5), heart failure (n = 6), myocardial infarction (n = 1), rejection (n = 16), or death (n = 15). CR was a significant predictor of MACE, with ≥ 23 sessions associated with a ∼ 60% reduction in MACE risk (hazard ratio [HR]: 0.42, 95% CI: 0.19–0.94, P = 0.035). This remained after adjusting for age, sex and history of diabetes (HR: 0.41, 95% CI: 0.18–0.94, P = 0.035) as well as body mass index and pre-HTx peak oxygen consumption (HR: 0.40, 95% CI: 0.18–0.92, P = 0.031).

Conclusions

After adjustment for covariates of age, sex, diabetes, body mass index, and pre-HTx peak oxygen consumption, CR attendance of ≥ 23 exercise sessions was predictive of lower MACE risk following HTx. In post-HTx patients, CR was associated with MACE prevention and should be viewed as a critical tool in post-HTx treatment strategies.

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).

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      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

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      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.

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