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Introduction: Arrhythmias commonly occur during clinical exercise stress testing (EST), however there are limited data on prognostic significance, particularly differences between individuals with minor versus significant arrhythmia burden. Hypothesis: We hypothesized that significant but not minor arrhythmia burden during EST would be predictive of future all-cause mortality. Methods: Adults who underwent clinically indicated EST at Mayo Clinic Rochester between September 1993 and April 2017 were included and followed-up until March 2021 using the National Death Index to ascertain survival status. Expert clinician coding pertaining to arrhythmia burden during EST were used to group individuals (see Table 1 ). Cox proportional hazard models adjusted for known predictors of exercise-induced arrhythmias, were used to test the association of arrhythmia burden with all-cause mortality. Results: A total of 30796 individuals were included (age: 55±14yrs; female: 36%; Table 1 ). Mean follow-up was 8.8±3.6yrs, with a total of 2516 deaths. Arrhythmia during EST was associated with all-cause mortality compared with no arrhythmia (HR: 1.72; 95% CI: 1.58-1.88; p<0.001), however significant arrhythmia showed greater association compared with minor arrhythmia (HR: 2.07; 95% CI: 1.81-2.38; p<0.001). Both minor and significant arrhythmia during EST were significant predictors of all-cause mortality compared with no arrhythmia ( Figure, Table 2 ), however, after model adjustments, only significant arrhythmia was associated with all-cause mortality (HR: 1.40; 95% CI: 1.21-1.63; p<0.001) ( Table 2 ). Conclusions: After multivariate adjustment, significant arrhythmia burden during EST showed a 40% increased future risk of all-cause mortality, Conversely, adjusting for age and sex attenuated the effect of minor arrhythmia burden during EST on incidence of death. These results highlight the clinical significance of arrhythmia burden during exercise testing.

Introduction: Cardiac rehabilitation (CR) is a comprehensive secondary cardiovascular disease (CVD) program which integrates structured lifestyle interventions to reduce morbidity and mortality. The Life’s Simple 7 (LS7) is an objective measure of cardiovascular health (CVH) which incorporates health-promoting behaviors and clinical factors however, it has not been rigorously evaluated in the CR setting. Methods: Retrospective cohort study of 937 patients who attended center-based CR at Mayo Clinic from Jan 2018 -Sept 2020. Patient characteristics and LS7 component metrics at baseline (pre-CR) and completion (post-CR) were collected: 3 clinical factors (blood pressure [BP], cholesterol, and hemoglobin A1c [HbA1c]), and 4 health behaviors (smoking, body mass index [BMI], physical activity [PA] and diet). LS7 score was computed as a composite of each LS7 component by assigning 2-points for ideal, 1-point for intermediate, or 0-points for poor CVH ranging from 0-14 points. LS7 score was further categorized as poor 0-6, intermediate 7-8 and ideal 9 -14. Results: Patients were 64±13 years old, 34% were female, and attended a mean of 11±12 CR sessions, Table 1. At baseline, the LS7 components with the highest proportion within the poor category were HbA1c (201/495, 41%) and BMI (465/936, 50%), Table 2. From pre to post-CR, there was a reduction in proportion of patients classified within the poor category for each LS7 component except HbA1c ( Figure 1 ), and the proportion of patients with LS7 scores in the ideal range increased from 6.4% to 19% (P<0.001). There was a statistically significant improvement in LS7 score from 5.5±1.8 to 6.7± 2.4 (+Δ1.6±2.4, P<.0001), Table 2 . Conclusions: Patients attending CR demonstrated an improvement in LS7 score and almost all LS7 components suggesting an overall positive impact of CR on CVH. Further research is needed to better understand the impact of the individual LS7 components on CV outcomes in diverse populations participating in CR.

Introduction: The COVID-19 pandemic imposed significant constraints to delivery of cardiac rehabilitation (CR) with many programs relying on delivery of home-based cardiac rehabilitation (HBCR). We sought to compare the effects of HBCR vs conventional center-based CR (CBCR) on clinical metrics, health-related quality of life, and modifiable risk factors in CR patients. Methods: Retrospective cohort study comparing 511 HBCR patients (March 2020-April 2021; COVID-19 pandemic) and 765 age and sex matched CBCR patients (Jan 2018-Jan2020; immediately pre-pandemic) from the Mayo Clinic Health System. We assessed changes in clinical outcomes before and after CR. HBCR included 12 sessions (one in-person assessment + weekly education and exercise monitoring phone/video calls). Conventional CBCR included 36 sessions (3 sessions per week for 12 weeks). Continuous data were described as mean±SD, and comparisons of change between groups were assessed with linear regression adjusting for baseline value, in complete cases. Results: HBCR and CBCR patients were 65±14 yrs old (68% male) and 65±14 yrs old (67% male) respectively. HBCR patients demonstrated greater improvement in exercise days/week whereas CBCR patients had greater improvement in exercise min/day. HBCR patients had greater improvement in blood glucose with a trend towards greater improvement in non-HDL cholesterol. Both groups demonstrated similar improvement on nutrition, depression, health-related quality of life surveys and total, LDL and HDL cholesterol, as well as HbA1c between the groups. Conclusions: Collecting clinical metrics during the COVID-19 pandemic proved challenging due to the initial closure of out-patient services. For patients in whom data was captured, HBCR appears to be similarly effective at improving several intermediate outcomes compared to CBCR. HBCR may be an effective alternative for improving clinical outcomes in patients who are unable to participate in CBCR.

Introduction: Many center-based cardiac rehabilitation programs were forced to close during the pandemic resulting in a programmatic shift to delivering cardiac rehabilitation remotely in the home-based setting. This study examined sex differences in the change of exercise frequency and exercise capacity in patients participating in home-based cardiac rehabilitation (HBCR) during the COVID-19 pandemic. Methods: Retrospective cohort study of 567 HBCR patients between March 2020 and May 2021. Patients who completed the Duke Activity Status Index questionnaire before and after HBCR were included. We calculated the number of reported exercise days/ week, exercise min/day, and VO 2 peak estimated. Patients were divided into two groups according to sex (Male/Female). Continuous data are described as mean±SD and baseline data compared with a two-sample t-test. The delta change from pre-post between groups also are compared with a two-sample t-test. Results: Of 567 HBCR patients, 118 patients completed both pre and post HBCR questionnaires (Male, n=82, 66±12 yo vs Female, n=36, 65±12 yo, p=0.80). There were no differences between groups for baseline exercise days/week or exercise min/day pre HBCR (4.0±2.8 vs 4.1±3.0 days, p=0.87; 22±20 vs 18±20 min, p=0.33); however, VO 2 peak at baseline HBCR was higher in males than females (22.3±8.1 vs 18.9±5.9 ml/kg/min, p<0.05). Both groups improved exercise days/week (4.0±2.8 to 5.7±1.5 vs 4.1±3.0 to 5.7±1.4 days, p<0.05 for both), exercise min/day (22±20 to 40±15 vs 18±20 to 37±21 min, p<0.05 for both), and VO 2 peak (22.3±8.1 to 27.8±8.0 vs 18.9±5.9 to 22.7±6.5, ml/kg/min, p<0.05 for both). In addition, there was no significant difference for the delta change of the three outcomes between groups (1.7±2.7 vs 1.6±2.5 days; 18±19 vs 19±18 min; 5.5±6.5 vs 3.8±4.5 ml/min/kg, p>0.05 for all). Conclusions: Female patients entering HBCR during the COVID-19 pandemic demonstrated lower exercise capacity compared to males; however, both female and male patients increased exercise frequency (days/week and min/day) and exercise capacity (estimated VO 2 peak) similarly after attending HBCR during the COVID-19 pandemic.

Introduction: The COVID-19 pandemic resulted in the closure of many center-based cardiac rehabilitation programs leading many institutions to rely on home-based cardiac rehabilitation (HBCR) to provide critical secondary cardiovascular disease prevention and rehabilitation. The impact of age on the change of exercise frequency and exercise capacity as a result of HBCR during the COVID-19 pandemic remains unknown. Methods: Retrospective cohort study of 567 HBCR patients between March 2020 and May 2021. Patients who completed the Duke Activity Status Index questionnaire at enrollment and completion of HBCR were included. We calculated the number of reported exercise days/week , exercise min/day, and VO 2 peak estimated. Patients were divided into two groups according to age (Younger<65 y.o; Older≥65 y.o). Continuous data are described as mean ±SD and baseline data compared with a two-sample t-test. The delta change from pre-post between groups also are compared with a two-sample t-test. Results: Of 567 HBCR patients, 118 patients completed both pre and post HBCR questionnaires (Younger, n=54, 56±8 years old vs Older, n=64, 74±7 y.o, p<0.05). Both groups improved exercise days/week (4.4±2.8 to 5.8±1.3 vs 3.8±2.9 to 5.6±1.6 days, p<0.05 for both), exercise min/day (21±20 to 41±17 vs 20±20 to 37±17 min, p<0.05 for both), and VO 2 peak (20.5±7.1 to 27.6±8.0 vs 21.9±8.1 to 25.1±7.7 ml/min/kg, p<0.05 for both). The delta change for exercise days/week and exercise min/day were not significantly different between groups (1.4±2.7 vs 1.9±2.7 days and 19±19 vs 17±18 min, p>0.05); however, the Younger patients significantly increased their VO 2 peak more than the older patients (7.1±6.1 vs 3.2±5.3 ml/min/kg, p<0.05). Conclusions: During the COVID-19 pandemic, exercise frequency (days/week and min/day) and exercise capacity (estimated VO2peak) increased in all patients participating in HBCR. With this, the increase in estimated exercise capacity was greater in younger patients compared with older patients. These findings suggest that additional work is needed to explore factors potentially limiting improvement and strategies to maximize improvement in exercise capacity in older patients participating in HBCR.

Introduction: Patients undergoing cardiac rehabilitation (CR) exhibit various degrees of illness severity and high prevalence of chronic conditions (CC). Cardiorespiratory fitness (CRF) is a key predictor of outcomes in patients with cardiovascular disease. Participation in CR is associated with increased CRF, reduced future cardiovascular events, and mortality. Peak oxygen uptake (VO 2 ) is the gold-standard method to evaluate CRF; however, the burden of multimorbidity and its impact on CRF improvement has not been extensively studied. Methods: We included 618 patients who were ≥ 18 years old and underwent cardiopulmonary exercise testing prior to and after CR at Mayo Clinic. Using the Rochester Epidemiology Project records- linkage system, we assessed the prevalence of 18 CC defined by the US Department of Health and Human Services. To evaluate changes in peak VO 2 in patients with multimorbidity (categorized as ≥6 CC), we created logistic regression models adjusting for age, sex, and baseline peak VO 2 . Results: Mean age was 61.5 ± 11.0 years and 75.5% were male. Most patients (81.2%) attended ≥18 CR sessions. Half (50.4%) of patients had at least 6 CC (median 6; range 0-13). Overall, peak VO 2 at baseline was 20.7 ± 6.3 mL/kg per min and the percent change in peak VO 2 following CR was 11.4% ± 21.6%, Figure 1A . Multimorbidity was associated with lower improvement in peak VO 2 following CR compared to patients with <6 CC (7.5% vs 11.4%, p=0.0001). Furthermore, across categories of CRF improvement (i.e., 1%, 5%, and 10% percent change in peak VO 2 ) lower multimorbidity was associated with a 1.5-2-fold increase in CRF when compared to those with higher multimorbidity (≥6 CC), Figure 1B . Conclusions: Patients entering CR have a high multimorbidity burden. Our results suggest that multimorbidity in CR patients attenuates improvement in peak VO 2 . Individualized interventions should focus on managing and reducing multimorbidity to minimize the negative impact on CRF improvement.

Introduction: Multimorbidity is associated with physical disability, increased health care utilization, reduced quality of life, and mortality. Whereas most literature has focused on the co-occurrence of somatic conditions, we aim to (i) establish the prevalence of combined somatic and mental health multimorbidity (SMM) in cardiac rehabilitation (CR) patients, and (ii) determine the most prevalent co-occurrence of cardio-metabolic conditions (CMC) with other somatic or mental health conditions in CR patients. Methods: Using the Rochester Epidemiology Project records-linkage system, we identified residents of Southern MN and Western WI who attended (≥1) CR sessions from 1995 to 2019. The prevalence of 18 chronic conditions defined by the US Department of Health and Human Services was electronically extracted. Heat maps were created to assess the pairwise prevalence of cardio-metabolic (CMC; n=6) with mental (n=5) and other somatic (n=7) chronic conditions (Table 1) . Results: We included 13,056 patients; 68.5% were male. Patients were 65.5±12.5 years old with 44.7% ≤65 years old. Median number of conditions was 7 (Range 0-18) with 52.6% of patients having ≥7 conditions. Hyperlipidemia (89.3%), hypertension (79.5%), and arrhythmias (72.4%) were the most prevalent CMC. The prevalence of combined SMM (≥2 conditions) was 44.9% and was higher in those <65 years ( p <.0001). Depression (26.8%) and anxiety (24.7%) were the most common mental conditions involved in SMM and frequently co-occurred with CMC. Among other prevalent somatic conditions, arthritis (51.7%), chronic obstructive pulmonary disease (33.5%), and cancer (29.3%) co-occurred with CMC (Figure 1). Conclusions: Half of patients in CR have ≥7 chronic conditions. Somatic and mental health multimorbidity (SMM) is highly prevalent and is more frequent in those younger than 65 years old. Our results highlight the critical need to better understand the clinical burden of SMM in patients undergoing CR.

Introduction: The presence of chronic somatic and mental health conditions is complex and challenging for patients and the health care system due to the health deficit accumulation, worsening outcomes, and increased health care utilization. While previous studies on multimorbidity have focused on somatic chronic conditions, we aim to assess the relation between somatic, mental, and combined somatic-mental multimorbidity (SMM) and impact on Major Adverse Cardiac Events (MACE) in patients enrolled in phase II outpatient cardiac rehabilitation (CR). Methods: Using the Rochester Epidemiology Project records-linkage system, we identified patients from Olmsted County, Minnesota who were 18 years old and attended (≥1) CR sessions at Mayo Clinic Rochester. The prevalence of 18 (somatic=13; mental=5) chronic conditions defined by the US Department of Health and Human Services was ascertained electronically. Results: We included 618 patients; 24.4% were female. Patients were 61.5±11.0 years old with 38.0% ≥65 years old. Overall median number of chronic conditions was 6 (Range 0-13) with 98.8% of patients having ≥2 conditions. The prevalence of combined SMM was 44.6%. Mean follow-up was 7.3± 4.5 years, 147 (23.7%) patients had MACE (number): acute coronary syndrome (46), percutaneous coronary intervention (33), heart failure (16), stroke (8), coronary artery bypass grafting (4), ventricular arrhythmias (4), or death (65). Risk of MACE in patients with SMM was significantly higher compared to patients with only somatic conditions (HR: 1.62, 95% CI: 1.14-2.30, p=0.01 ), Figure 1. The association remained significant after adjustment for age and sex ( p=0.006 ). Conclusions: Our results show that somatic-mental multimorbidity (SMM) in CR patients is highly prevalent and imposes a higher risk of MACE compared with patients who have only somatic conditions highlighting the importance of individualized assessment and care plans to reduce adverse events and mortality.

Introduction: Cardiac rehabilitation (CR) is associated with improvements in exercise capacity (peak oxygen uptake (VO 2 peak)); however, 23% of CR patients do not improve VO 2 peak following CR. CR adherence (i.e. number of CR sessions attended) has been proposed to play an important role in VO 2 peak improvement following CR, but has not been investigated. Identifying clinical predictors of VO 2 peak improvement are critical as the degree of VO 2 peak improvement is associated with improved long-term outcomes in these patients. Purpose: To determine if clinical characteristics and number of CR sessions attended were predictive of patients who exhibited improvement in VO 2 peak following CR. Methods: Using the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients >18 years old from Olmsted County, Minnesota who underwent cardiopulmonary exercise testing prior to and following CR from 1999 to 2017. Regression models were created to assess clinical predictors of VO 2 peak improvement (>0% baseline) following CR. Results: The analysis included 804 patients (75% men) with a mean age of 60.7±12.4 years. Of the 804 patients, 609 (76%) patients exhibited VO 2 peak improvement following CR. Significant univariate predictors of VO 2 peak improvement included younger age (OR: 0.99, 95% CI: 0.97-1.00), lower pre-CR VO 2 peak (OR: 0.97, 95% CI: 0.94-0.99), history of peripheral artery disease (OR: 0.48, 95% CI: 0.32-0.73), and smoking (OR: 0.63, 95% CI: 0.45-0.90). Significant independent predictors of VO 2 peak improvement from a multivariate analysis included younger age (OR: 0.98, 95% CI: 0.96-1.00), number of CR sessions (OR: 1.02, 95% CI: 1.01-1.03), lower pre-CR VO 2 peak (OR: 0.94, 95% CI: 0.91-0.96), history of peripheral artery disease (OR: 0.42, 95% CI: 0.27-0.66), and smoking (OR: 0.56, 95% CI: 0.39-0.82). Conclusions: These findings demonstrate the importance of CR adherence and individual clinical characteristics in influencing VO 2 peak improvement following CR in patients with CVD. These findings may influence the clinical practice by providing specific clinical characteristics to account for when personalizing the CR treatment plan to maximize positive outcomes.

Purpose The purpose of the present study was to investigate body mass index, multi-morbidity, and COVID-19 Risk Score as predictors of severe COVID-19 outcomes. Patients Patients from this study are from a well-characterized patient cohort collected at Mayo Clinic between January 1, 2020 and May 23, 2020; with confirmed COVID-19 diagnosis defined as a positive result on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays from nasopharyngeal swab specimens. Measures Demographic and clinical data were extracted from the electronic medical record. The data included: date of birth, gender, ethnicity, race, marital status, medications (active COVID-19 agents), weight and height (from which the Body Mass Index (BMI) was calculated, history of smoking, and comorbid conditions to calculate the Charlson Comorbidity Index (CCI) and the U.S Department of Health and Human Services (DHHS) multi-morbidity score. An additional COVID-19 Risk Score was also included. Outcomes included hospital admission, ICU admission, and death. Results Cox proportional hazards models were used to determine the impact on mortality or hospital admission. Age, sex, and race (white/Latino, white/non-Latino, other, did not disclose) were adjusted for in the model. Patients with higher COVID-19 Risk Scores had a significantly higher likelihood of being at least admitted to the hospital (HR = 1.80; 95% CI = 1.30, 2.50; P < .001), or experiencing death or inpatient admission (includes ICU admissions) (HR = 1.20; 95% CI = 1.02, 1.42; P = .028). Age was the only statistically significant demographic predictor, but obesity was not a significant predictor of any of the outcomes. Conclusion Age and COVID-19 Risk Scores were significant predictors of severe COVID-19 outcomes. Further work should examine the properties of the COVID-19 Risk Factors Scale.