Thomas, Randal J.

Background: CHA2DS2-VASc score has been shown to predict occurrences of incident stroke in patients with history of atrial fibrillation (A-Fib)/ Flutter. However, data on whether if CHA2DS2-VASc score would predict incidence of stroke in patients without A-Fib/ Flutter is less clear. Methods: From 1993 through 2010, all patients undergoing a clinically indicated treadmill exercise test (TMET) at the Mayo Clinic, Rochester, MN were identified (N= 76,857). From this, Olmsted and neighboring counties residents were selected (N=14,095). From this, patients with age <18 years; prior history of valvular heart disease or A-Fib/ Flutter were excluded. Patient undergoing only Bruce or accelerated Naughton protocols on TMET were considered. Patients were stratified into 4 groups at baseline based on CHA2DS2-VASc score as determined at the time of TMET; group-0 score=0; group-I=1; group-2=2; group-3≥3. Patients were prospectively followed from the date of TMET until end of January 2016 for occurrence of incident stroke (ischemic and hemorrhagic). Stroke diagnosis was ascertained through retrospective chart review. Traumatic intracranial bleed was not considered. Proportional hazard regression modeling was done to assess relationship of CHA2DS2-VASc score with the stroke outcome while adjusting for METs achieved, sex, obesity, smoking status, and other relevant risk factors. Results: Final study population comprised of 12,624 patients with female comprising 37% of the cohort. Mean age in our study group was 52.2 ± 12.8 years. During an overall median follow-up of 14 (8 to 17) years, 1,255 (9.9%) patients developed incident stroke. While using CHA2DS2-VASc group-3 as referent, patients in CHA2DS2-VASc group-0 [0.18(0.14-0.23, p<.001)], group-1[0.33 (0.28-0.39, p<.001)], and group-2 [0.50 (0.43-0.58, p<.001)] were at significantly lower risk of developing stroke. Each increase of one point on the CHA2DS2-VASc scale was associated with a 51% [1.51(1.45-1.58, p<.001)] increase in incidence of stroke. Conclusion: CHA2DS2-VASc score predicts incidence of stroke in patients without history of A-Fib/ Flutter.

Introduction: Cardiac rehabilitation (CR) is recommended for secondary prevention following a coronary artery disease (CAD) event. The association between CR attendance and long-term major cardiovascular events (MACE)in the community has not been previously reported . Hypothesis: We tested the hypothesis that higher CR participation would be related to a lower risk of MACE,in residents of Olmsted county, Minnesota. Methods: We performed a community-based retrospective longitudinal study on patients referred to CR for CAD events or procedures between the years 2002 and 2012. Follow-up was performed using a record linkage system from the Rochester Epidemiology Project. CR participation was assessed as the number of CR sessions attended, and was analyzed as a continuous variable, as quintiles and also as a binomial variable using 12 sessions as the cutoff. The composite outcome MACE was defined as having an acute coronary syndrome (myocardial infarction (MI) or unstable angina), revascularization (CABG or PCI), ventricular arrhythmias requiring hospitalization, stroke or death from any cause. Multivariate models were adjusted for age and gender and also for factors associated with MACE in the univariate analysis. Results: Our cohort included 2273 patients, 69% males, mean age (SEM) 64 (0.26) years. After a mean follow-up of 6 (0.07) years, 827 patients had an event: MI (73), unstable angina (113), CABG(53), PCI (260), ventricular arrhythmia (13), stroke (72) and death (243). Participation in 12 or more sessions (vs <12 sessions) had a lower rate of MACE (HR 0.81, 95% CI 0.70-0.93, p=0.003, see Figure1 . After adjusting for smoking, hypertension, diabetes and history of MI the association remained significant HR 0.85, 95% CI 0.74-0.98, p=0.03. Conclusions: A higher participation in CR was associated with a lower risk of MACE. These results provide additional evidence of important CR health advantages and expand on previous evidence of a dose-response benefit of CR.

Background: Cardiac rehabilitation (CR) improves functional capacity after heart valve surgery (HVS), but no survival benefit has yet been described. We hypothesized that attendance at CR after HVS would be associated with improved long-term survival. Methods: In 2013, we surveyed all patients (or a close family member if the patient was deceased) who had isolated HVS between 2006 through 2010 at the Mayo Clinic to assess if they attended CR after their HVS. We assessed survey reliability among local patients by comparing self-reported vs. medical-record verified CR attendance with the kappa statistic. We then performed a propensity-adjusted landmark mortality analysis through October 2014 for the association between CR attendance and long-term all-cause mortality conditional upon surviving the first year after HVS. Results: Survey response rate was 40% (573/1420), with responders more likely to be older, have longer hospitalizations, more aortic valve disease, but have better survival than non-responders. Among local patients, there was “substantial” agreement between reported attendance and medical-record verified CR attendance (agreement at 84%, kappa = 0.62.) A total of 547 patients (age 70 yrs., 62% male, 59% aortic valve surgery) with valid survey responses were included in the propensity analysis, of whom 296 (54.1%) attended CR. There were 100 deaths during a median follow-up of 5.4 years. For all patients, the propensity-adjusted model suggested no impact of CR on mortality (HR 1.03, 95% CI, 0.66 to 1.62). When stratified by procedure type, results suggested a potentially favorable, but non-significant, effect among patients with mitral valve surgery (HR 0.49, 95% CI 0.15 to 1.56), but not among patients with aortic valve surgery (HR 1.00, 95% CI 0.61 to 1.64.) Conclusions: Important improvements in functional capacity from CR have been previously reported after HVS, but, contrary to our hypothesis, we found that CR does not provide long-term survival benefits after HVS. These findings need additional confirmation to better clarify any mortality impact that may exist for CR following HVS, particularly among patients undergoing mitral valve surgery.

Background There is wide variability in cardiac rehabilitation (CR) dose (ie, number of sessions) delivered, and no evidence‐based recommendations regarding what dose to prescribe. We aimed to test what CR dose impacts major adverse cardiovascular events (MACEs). Methods and Results This is an historical cohort study of all patients who had coronary artery disease and who initiated supervised CR between 2002 and 2012 from a single major CR center. CR dose was defined as number of visits including exercise and patient education. Follow‐up was performed using record linkage from the Rochester Epidemiology Project. MACEs included acute myocardial infarction, unstable angina, ventricular arrhythmias, stroke, revascularization, or all‐cause mortality. Dose was analyzed in several ways, including tertiles, categories, and as a continuous variable. Cox models were adjusted for factors associated with dose and MACE. The cohort consisted of 2345 patients, who attended a mean of 12.5±11.1 of 36 prescribed sessions. After a mean follow‐up of 6 years, 695 (29.65%) patients had a MACE, including 231 who died. CR dose was inversely associated with MACE (hazard ratio, 0.66 [95% CI]; 0.55–0.91) in those completing ≥20 sessions, when compared with those not exposed to formal exercise sessions (≤1 session; log‐rank P =0.007). We did not find evidence of nonlinearity ( P ≥0.050), suggesting no minimal threshold nor ceiling. Each additional session was associated with a lower rate of MACE (fully adjusted hazard ratio, 0.98 [95% CI, 0.97–0.99]). Greater session frequency was also associated with lower MACE risk (fully adjusted hazard ratio, 0.74 [95% CI, 0.58–0.94]). Conclusions CR reduces MACEs, but the benefit appears to be linear, with greater risk reduction with higher doses, and no upper threshold.

Objectives To observe the weight change in Chinese youth during a 4-month COVID-19 lockdown, and the association between weight change and mental health, physical activity and sedentary time changes, and dietary habits. Design A retrospective observational study. Settings Two universities located in Zhejiang and Hunan provinces, China. Participants This study enrolled 12 889 college students whose body weight was measured before the lockdown (1 December 2019–20 January 2020) at the two universities, and reported their weight measured at home or community after the end of the lockdown (1–23 May 2020) via an online follow-up questionnaire. Primary and secondary outcome measures The primary outcome was the weight change in Chinese youth during a 4-month lockdown resulting from the COVID-19 pandemic. The secondary outcomes were the relationships of weight change to COVID-19-related stress, depression, anxiety, physical activity and sedentary time changes, and dietary habits. Results Participants’ ages ranged from 17 to 27 years ( M =19, SD=1) with 80.2% identified as female. The average absolute and relative changes in body weight were 2.6 (95% CI 2.0 to 3.2)) kg and 4.2% (95% CI 4.0% to 4.3%) for men, and 2.1 (1.9 to 2.4) kg and 4.2% (95% CI 3.9% to 4.4%) for women. An increase in overweight and obese individuals according to Asian cut-off points as a demographic percentage by 4.5% and 2.7% and 4.8% and 3.4% in men and women, respectively ( P <0.001), was observed. Weight gain was significantly associated with increased sedentary time and an increase in COVID-19-related stress and depression score. Conclusion The present study’s results suggest that the risk of weight gain in Chinese youth during the lockdown increased and that strategies to decrease sedentary time and improve mental health may be warranted to mitigate weight gain during and after the COVID-19 pandemic.

Background: We conducted this study to assess the safety of symptom-limited cardiopulmonary exercise testing (CPX) in patients with varying severity of aortic stenosis (AS). We hypothesized that exercise testing would be safe, as defined by a rates for all-cause death of <0.01% and rate of nonfatal major cardiovascular (CV) events <0.1% within 24 hours of CPX. Secondary purpose of this study was to determine the frequency of complications during CPX. Methods: This cohort study was carried out with 308 consecutive patients with varying degree of AS (as determined by standard echocardiographic criteria) with no or equivocal symptoms who were referred for clinically indicated cardiopulmonary testing between 1994 and 2009. We did not include patients with pending or completed heart transplant, or ventricular assist device implantation. These patients underwent standard symptom limited CPX, and continuous monitoring of heart rate, blood pressure, and electrocardiogram was performed. Complications recorded included death, non-fatal major CV events (cardiac arrest, symptomatic and sustained ventricular or atrial tachycardia, and syncope), and minor events such as hypotension, non-sustained atrial and ventricular arrhythmias, positive exercise ECG and anginal pain. Results: The mean age of patients was 66 ± 14 years, and 252 (82%) were males. The number of patients with mild, moderate and severe AS were 44 (14%), 138 (49%), and 126 (41%) respectively. No death or major CV event occurred during or within 24 hours of CPX. Eleven patients developed supraventricular arrhythmias without compromising hemodynamic status, and one had asymptomatic non-sustained ventricular tachycardia. Detailed description of complications is presented in the Table 1 . Conclusion: Our results show that symptom-limited CPX is safe among AS patients with no or equivocal symptoms based on no deaths or major CV events in our cohort. Minor complications occurred in 110 patients (36%). Table 1 Mild AS (n=44) Moderate AS (n=138) Severe AS (n=126) Age 61.7 ± 15.3 66.5 ± 13.86 67.89 ± 12.74 Males 36 (81%) 128 (83%) 96 (85%) Test protocol O2 protocol 39 (86%) 123 (89%) 104 (82%) Other 5 15 22 Reason for termination Symptom-limited 41 (93%) 114 (82%) 96 (76%) Other 3 24 30 Chest pain None 41 (93%) 122 (88%) 117 (93%) Non-cardiac 0 2 0 Non-anginal 0 2 0 Anginal 2 14 9 Treadmill ECG interpretation Negative 27 (61%) 67 (49%) 45 (37%) Non-diagnostic 14 48 58 Positive 3 23 23 Ventricular arrhythmia None 42 (95%) 134 (97%) 122 (97%) 3-5 beats VT 2 3 4 NSVT 0 1 0 Supraventricular arrhythmia None 42 (95%) 135 (97%) 120 (95%) SVT ≤ 30 sec 2 3 4 SVT > 30 sec 0 0 1 Afib 0 0 1 BP response Normal 41 (93%) 117 (85%) 93 (74%) Hypotensive 3 21 33 AS = Aortic Stenosis, ECG = Electrocardiogram, VT = Ventricular tachycardia, NSVT = Non-sustained ventricular tachycardia, SVT = Supraventricular tachycardia, Afib = Atrial fibrillation, BP = Blood pressure

Background: Participation in cardiac rehabilitation (CR) has been shown to decrease mortality following acute myocardial infarction (MI), but its impact on rehospitalizations requires examination. Methods: We included patients who were hospitalized with first-ever MI in Olmsted County Minnesota from 1987-2010 and survived to hospital discharge. Participation in CR within the first 30 days following MI was determined using billing data and was analyzed as a time-dependent covariate. The association between CR participation and all-cause rehospitalization was analyzed using Andersen-Gill models to account for repeated events. As CR participation is a non-randomized intervention, we adjusted for propensity to participate after fitting a logistic regression model using 13 factors significantly associated with participation on univariate analysis. Patients were censored at the time of death or last follow-up. Results: Among 2991 patients (mean age 67 years, 59% male, 31% ST elevation MI), 1480 (49%) participated in CR following acute MI hospital discharge (first session occurred at a mean of 9 days post-discharge). Most patients (75%) were rehospitalized at least once during a mean follow-up of 7.6 years, and CR participation was associated with reduced risk of rehospitalization. The rehospitalization rates were 39% and 59% at one year for participants and non-participants, respectively. In unadjusted analysis, CR participation was associated with a markedly decreased risk of rehospitalization (HR 0.51, 95% CI 0.49-0.53, p<0.001). After adjusting for propensity to participate, the association between CR participation and all-cause rehospitalization persisted (HR 0.70, 95% CI 0.67-0.73, p<0.001). Conclusions: CR participation is associated with a markedly reduced risk of rehospitalization after incident MI. In addition to reducing mortality, improving CR participation rates may have a large impact post-MI healthcare resource use.

Introduction: Cardiac rehabilitation (CR) is an effective but highly underutilized therapy for heart disease. Efforts are underway to increase CR referral and enrollment, but little is known about the potential capacity for growth in CR utilization in the United States. To address this concern, we estimated the current national capacity of CR programs across the United States and assessed obstacles to potential growth. Methods: We surveyed all CR Program Directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November of 2012. Respondents reported current enrollment levels, current program capacity, program capacity given reasonable expansion, and obstacles to growth. Results: Of 812 Program Directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs compared to non-respondents (4.0 vs. 4.6 full time employees, p = 0.01), but were otherwise similar. Current enrollment levels demonstrated a median [IQ range] of 140 [75,232] patients per year and a current estimated capacity of 192 [100,300] patient per year. Respondents estimated that programs could expand services by 25% to 240 [141,380] patients annually, assuming a significant increase in patient demand and a feasible increase in resources. We estimate that if programs filled to their current capacity, national CR utilization rates would increase from 34.7% to 46.4% (95% CI, 43.9 to 48.9) of eligible US patients each year. Given feasible program expansion, utilization could increase to a maximum of 58.4% (95% CI, 55.2 to 61.6) of qualifying patients. Capacity projections based upon absolute patient numbers and national statistics revealed concordant results. The most commonly cited obstacles to increasing patient participation are shown in the figure. As seen, the majority (88%) are controllable system-related factors unrelated to patient behavior. Conclusions: Even with substantial expansion of all existing CR programs, there is currently insufficient capacity in current CR programs to meet national service needs. Solutions to this problem will likely include the creation of new CR programs, and new policies that improve reimbursement for CR and also embrace new models of CR delivery.

Background: Cardiac Rehabilitation (CR) is an effective but highly underutilized treatment for heart disease. Prior studies have demonstrated that the use of strategies such as systematic referral (as part of an order set that does not depend on physician initiative or memory, usually with an opt-out option), liaison facilitated referral (a specific staff member who discusses the program, encourages attendance, and facilitates referral), an early appointment (< 2 weeks), and telephone appointment reminder calls can all improved enrollment rates. However, it is unclear how frequently these strategies are utilized across the United States, how often CR programs monitor their participation rates, and how often quality improvement (QI) projects designed to improve participation rates are performed. Methods: We surveyed all CR program directors in the American Association of Cardiovascular and Pulmonary Rehabilitation’s (AACVPR) database. We assessed basic program features, use of systematic referral, liaison facilitated referral, early appointments, and telephone reminder calls and QI projects. We also assessed self-reported referral, enrollment, and completion rates. Results: Response rate was 36% (290/812). Non-response bias analysis showed reasonable survey representativeness. Over the past 5 years, 49% of programs measured hospital referral, 21% office/clinic referral, 71% program enrollment, and 74% program completion rates. Self-reported rates (interquartile range) were 68 [32 to 90]% for hospital referral, 35 [15 to 60]% for office/clinic referral, 70[46 to 80]% for program enrollment, and 75[62 to 82]% for program completion. Programs reported utilizing a hospital-based systematic referral, liaison facilitated referral, or inpatient CR program 64%, 68%, and 60% of the time, respectively. Early appointments (< 2 weeks) were utilized by 35% and consistent phone call appointment reminders were utilized by 50%. Over the past 5 years, the percent or programs performing QI projects were 62% for hospital referral, 42% for clinic referral, 60% for program enrollment, and 57% for program completion. Measurement of participation rates was highly correlated with performing QI projects (p < 0.0001.) Conclusions: Although programs are aware of participation rate gaps, the monitoring of participation rates is suboptimal, quality improvement initiatives are infrequent, and proven strategies for increasing patient participation are inconsistently utilized. Awareness in outpatient clinical settings is particularly low. These issues likely contribute to the national CR participation gap and may prove to be useful targets for national QI initiatives.

Background : Studies have shown an association between obesity and total mortality in patients with and without coronary artery disease. Less is known regarding the impact of obesity after cardiac arrest. Obese survivors of ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) may have worse outcomes than nonobese patients due to resuscitation challenges, long-term risks of cardiovascular disease, and other comorbidities. Methods : All patients who presented with a VF OHCA in Rochester Minnesota from November 1990-September 2006 were included. Patients were classified by weight (BMI <25, 25–30, >30). ICD shocks for VF/VT were determined by review of subsequent device interrogations. Results : 226 patients (age 63.7±13.5) were treated for VF OHCA with an average call-to-shock time of 6.3±1.8 minutes. 99 patients (44%) survived to hospital discharge with neurologic recovery. Data to calculate BMI were available in 213(95%). There was no difference between the relative distribution of body weight between the hospital survivors [<25(32%), 25–30(37%), >30(31%)] and nonsurvivors [<25(32%), 25–30(44%), >30(28%)], p=0.711. There was no difference in ICD implantation rates between weight groups (p=0.251). The patients were followed for an average of 5.8±4.4 years. The 5-year survival was 80±5%. 5-year survival was lower in underweight/normal patients [<25, 71% (63–79) compared to heavier patients (25–30:88% (82–94), p=0.001]. The survival difference persisted after adjustment for age (p=0.02). Malignancy was the most common cause of death in the underweight group. The 5-year survival free of ICD shocks was 61±7% with no weight-based difference in shocks. Conclusion : There was no apparent weight-based influence on resuscitation survival after VF OHCA. Patients who are under to normal weight had a lower long-term survival and represent a high-risk population primarily due to noncardiac diseases.