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Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients
IJCA-24371; No of Pages 4 International Journal of Cardiology xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients Kimberley Pieters a,1, Elisabeth M.W.J. Utens b,1, Nienke ter Hoeve c,d,1, Myrna van Geffen c,d,1, Karolijn Dulfer b,1, Madoka Sunamura c,1, Ron T. van Domburg a,⁎,1 a
Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, The Netherlands Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC – Sophia Children's Hospital, Rotterdam, The Netherlands Capri Cardiac Rehabilitation Rotterdam, The Netherlands d Department of Rehabilitation Medicine, Erasmus Medical Center Rotterdam, The Netherlands b c
a r t i c l e
i n f o
Article history: Received 10 August 2016 Received in revised form 28 December 2016 Accepted 3 January 2017 Available online xxxx Keywords: Percutaneous coronary intervention Myocardial infarction Cardiac rehabilitation Subjective health status
a b s t r a c t Background: Cardiac rehabilitation (CR) is recommended as secondary prevention in primary percutaneous coronary intervention (pPCI) patients. This study was conducted to expand the knowledge about age-effects of CR in pPCI patients. The aim of this study was to compare changes in subjective health status (SHS) during and after CR between patients b 60 years and patients ≥60 years, who underwent pPCI after myocardial infarction. Methods: Between 2009 and 2011, in total 282 pPCI patients who participated in CR were included. Patients completed the Short Form 12 (SF-12) questionnaire at baseline (pre-CR), 3 months (post-CR) and 12 months followup. Patients were divided into two age-groups, b60 years versus ≥60 years. To compare improvements in SHS between groups, Generalized Estimating Equations (GEE) analyses were performed. Results: The mean physical component summary (PCS) score improved over time in both groups and even reached mean levels of the normative Dutch population. The improvement on the PCS score was equal in both age groups. The mental component summary (MCS) score also improved in both groups. Patients b 60 years reported on average more improvement on the MCS score than patients ≥60 years (Exp(B) 1.019; 95%CI 1.009–1.030; P b 0.001). However, mean levels of the normative Dutch population were not reached by patients b 60 years. Conclusion: Even though pPCI patients b60 years reported more improvement on the MCS score, mean levels of the normative Dutch population were not reached. Therefore, a tailored CR program with more focus on their mental status, may be beneficial in younger patients. © 2017 Elsevier B.V. All rights reserved.
1. Introduction Nowadays, primary percutaneous coronary intervention (pPCI) is the treatment of choice in patients who suffer from acute coronary syndrome. Cardiac rehabilitation (CR) is recommended for secondary prevention of cardiac problems in these patients [1], as meta-analyses and reviews demonstrated that CR reduces cardiovascular mortality [2–4], all-cause mortality [2,4,5], hospital admissions [2,3] and recurrent myocardial infarction [5]. Moreover, CR has a positive effect on total
⁎ Corresponding author at: Thoraxcenter, Erasmus Medical Center, Department of Cardiology, 's Gravendijkwal 230, Room Ba561, 3015 CE Rotterdam, The Netherlands, PO box 55, 3000 WB Rotterdam, The Netherlands. E-mail address: [email protected] (R.T. van Domburg). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
cholesterol levels [4], triglyceride levels [4], systolic blood pressure [4] and subjective health status (SHS) [2–6]. Although not confirmed by all studies, improvements in SHS possibly remain at follow-up [2]. Improving the subjective health status is an important objective, as a poor subjective health status is associated with a worse prognosis [7,8]. CR programs in older coronary artery disease patients have a positive influence on lipids [9], obesity indexes and exercise capacity [9, 10]. The improvement in exercise test results of older patients is comparable to younger patients [10,11]. Unfortunately, little research has been done into whether this pattern (comparable age-effects of CR) also applies to the SHS [11–14], and more specifically if it also applies to long term-results in pPCI patients. Knowledge about the age-effects of CR may help to improve CR by offering tailored programs. To bridge this gap in knowledge, the aim of this study was to investigate the change in SHS in pPCI patients participating in CR over a 12 months period and to compare SHS changes in the group of patients b60 years to changes in the group of patients ≥60 years.
http://dx.doi.org/10.1016/j.ijcard.2017.01.006 0167-5273/© 2017 Elsevier B.V. All rights reserved.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
2
K. Pieters et al. / International Journal of Cardiology xxx (2017) xxx–xxx
2. Methods 2.1. Patient sample Consecutive series of patients treated with pPCI between January 2009 and March 2011 and who participated in CR were prospectively included. The study was approved by the local research ethics committee (MEC-2009-080) and was conducted according to the Helsinki Declaration. All patients provided informed consent. The study design has been published elsewhere [15].
at both T1 and T2 were also excluded. The 282 remaining patients were used in the analysis (Fig. 1). No differences were found in age, gender, cardiac history and risk factors between responders and nonresponders at baseline. Whereas the group of non-responders at both T1 and T2 consisted of more smokers (57% vs. 43%; P = 0.041) and younger patients than the group of responders (56.0 vs. 59.1; P = 0.021). 3.2. Patient characteristics
2.2. Cardiac rehabilitation All patients participated in an outpatient CR program offered by Capri Cardiac Rehabilitation Rotterdam in accordance to the Dutch guidelines [16]. The program consisted of 1.5 h of supervised group exercise sessions given twice a week at a local sport accommodation. The sessions consisted of strength and aerobic exercises. Depending on the patients improvements, the CR program took for 4 to 13 weeks. In addition to the exercise sessions, there were group education sessions regarding medical background, cardiovascular risk factors, diet and emotions. Moreover, patients could attend counselling sessions for smoking cessation, healthy diet and stress management. If indicated, individual consults with a psychiatrist, psychologist, social worker or dietician were provided.
In the group of patients b 60 years were more men and smokers and there were more patients with a positive family history than in the group of patients ≥ 60 years. Moreover, less patients in the younger group had hypertension or a history of AMI. The group of patients b60 years also reported a lower PCS and MCS score at baseline than the group of older patients. Both age groups attended a similar amount of training sessions. More patients in the group b60 years visited a psychologist, psychiatrist and social worker than in the group ≥ 60 years (Table 1).
2.3. Data collection Patients received by postal mail questionnaires before the start of CR (T0), post-CR (T1) and at 12 months follow-up (T2). A postal reminder was sent out after 4 weeks of no response. Socio-demographic and clinical characteristics included age, gender, diabetes mellitus, smoking, hyperlipidemia, hypertension, body mass index, family history and medical history. This data was obtained from the medical charts. 2.4. Subjective health status Subjective health status was assessed with the Dutch version of the Short Form 12 (SF-12), an internationally widely used and validated questionnaire [17]. The SF-12 consists of a physical component summary (PCS) score and a mental component summary (MCS) score. The PCS includes physical functioning, role functioning physical, bodily pain and general health. The MCS includes social functioning, role functioning emotional, vitality and mental health. Both the PCS and MCS score range from 0 to 100. The mean score is 50 in a normative Dutch population [18]. A higher score is interpreted as a better subjective health status.
3.3. Subjective health status Fig. 2 shows changes in PCS and MCS scores in both age groups. At baseline, the mean PCS and MCS scores of both groups were lower, thus more unfavorable, compared to Dutch normative data. At T2, so after CR, both groups reached the mean levels of the normative PCS score (mean PCS score b 60 years 50.3 (SD ± 9.5); P = 0.744. ≥60 years 50.5 (SD ± 8.7); P = 0.512). However, at T2, the group of patients b60 years had a lower MCS score than the mean levels of the normative Dutch population (mean MCS score 47.6 (SD ± 10.8); P = 0.018). The group of patients ≥60 years did reach the mean levels of the normative Dutch population (mean MCS score ≥ 60 years 49.3 (SD ± 9.4); P = 0.460) (Fig. 2). Unadjusted, a greater improvement at one year follow-up was found in the group of patients b 60 years on the MCS score as well as on
2.5. Statistical analyses Patients were only included in analysis when they had at least completed questionnaires at baseline and a minimum of 1 follow-up moment. Categorical variables were summarized as percentages and differences between categorical variables were compared with the Chi-square test or Fisher's exact test when appropriate. Continuous variables were presented as means with standard deviation. The student's t-test was used to compare differences between continuous variables. In case of three or less missing answers on the SF-12 questionnaire, an imputation method was used [19]. A one sample t-test was used to compare the mean PCS and MCS scores at T2 to those of the Dutch normative population. Based on the mean age of the study sample (59.1 years), age was dichotomized into patients b60 years and ≥60 years. The student's t-test was used to compare the change in PCS and MCS scores in one year between both age groups. Changes over time in PCS and MCS between groups were compared with Generalized Estimating Equations (GEE) analyses with an autoregressive structure and with PCS and MCS as dependent outcome variables and time and group as categorical variables. A GEE model was chosen because it adjusts for the dependency of observations within one individual and it corrects for missing values [20]. An autoregressive structure was selected because measurement times were unequally spaced. The PCS and MCS scores were not normally distributed. Therefore, a log link function was used. For the dependent variable, outcomes were displayed as the exponent of the regression coefficients EXP(B), which indicates the ratio between the SHS change in the group of patients b60 years and the group of patients ≥60 years. Confounders were based on the literature and include; sex, PCS and MCS score at baseline, acute myocardial infarction (AMI), smoking, hypertension, diabetes mellitus, family history, completion of CR (≥18 training sessions) and individual sessions with a psychologist, psychiatrist and social worker. A 2-sided P value of b0.05 was considered significant. All analyses were performed using SPSS version 21.
3. Results 3.1. Study sample A total of 413 patients participated in a CR program following pPCI after MI. The mean time between pPCI and the start of the CR program was 42 days. Of these patients, 63 did not respond to the SF-12 questionnaire at baseline and were excluded. The 68 patients who did not respond
Fig. 1. Flowchart study sample. Abbreviations: CR, cardiac rehabilitation; SHS, subjective health status.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
K. Pieters et al. / International Journal of Cardiology xxx (2017) xxx–xxx Table 1 Characteristics of the study sample. CR (n = 282) Age category
b60 years (n = 145; 51.4%)
≥60 years (n = 137; 48.6%)
P-value
Mean age ± SD Mean BMI ± SD Male gender, n(%)
51.6 ± 6.1 27.7 ± 4.3 126 (86.9)
67.0 ± 5.4 27.0 ± 3.6 104 (75.9)
b0.001a 0.148 0.017a
History CVA, n(%) Cardiac event, n(%) - AMI - PCI - CABG
0 (0.0) 12 (8.3) 5 (3.4) 9 (6.2) 2 (1.4)
4 (2.9) 20 (14.6) 14 (10.2) 15 (10.9) 1 (0.7)
0.054 0.094 0.027a 0.159 1.000
Risk factors Smoking, n(%) Hypercholesterolemia, n(%) Hypertension, n(%) Diabetes mellitus, n(%) Family history, n(%)
83 (57.2) 51 (35.2) 45 (31.0) 15 (10.3) 93 (64.1)
40 (29.2) 59 (43.1) 61 (44.5) 20 (14.6) 67 (48.9)
b0.001a 0.173 0.019a 0.278 0.010a
Baseline SHS Mean PCS baseline ± SD Mean MCS baseline ± SD
44.3 ± 8.9 42.3 ± 11.5
47.3 ± 9.0 47.2 ± 10.2
0.006a b0.001a
Cardiac rehabilitation Training sessions ± SD Individual consultsb, n(%)
23.7 ± 9.2 21 (14.5)
21.9 ± 8.7 8 (5.8)
0.089 0.017a
Abbreviations: AMI, acute myocardial infarction; BMI, body mass index; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; CVA, cerebral vascular accident; MCS, mental component summary; PCI, percutaneous coronary intervention; PCS, physical component summary; SHS, subjective health status. a P-value b 0.05 was considered significant. b Individual consults with psychiatrists, psychologists and social workers.
the PCS score (Fig. 2). Because of baseline differences, changes on MCS and PCS scores were also compared using a multivariable GEE-analysis. The group of patients b60 years had less improvement on the PCS score over time than the group of patients ≥60 years (Exp(B) 0.961; 95%CI 0.935–0.988; P = 0.005). However, the group of younger patients differed on several baseline characteristics. After adjustment the difference was no
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longer significant (Exp(B) 1.007; 95%CI 0.987–1.027; P = 0.489). A greater improvement over time on the MCS score was found in the group of patient b 60 years than in the group of patients ≥60 years (Exp(B) 0.931; 95%CI 0.901–0.963; P b 0.001). This difference in improvement remained significant after correcting (Exp(B) 1.019; 95%CI 1.009–1.030; P b 0.001). 4. Discussion Although an improvement in MCS score over time in both age groups was found, younger patients benefited more, whereas the improvement in PCS score was equal between both groups. The MCS and PCS scores improved in both groups and, with exception of the MCS score in the group of younger patients, the MCS and PCS scores even reached the mean score of the normative Dutch population. This indicates a recovery of the SHS in patients participating in a CR program. Not reaching the mean MCS score of the normative Dutch population in the group of patients b 60 years might be due to the fact that the MCS score at baseline was lower in this group compared to the score in the older group of patients, thus a greater improvement was necessary to reach this score. It cannot be ruled out that the lower MCS score in the group of patients b60 years contributed to the occurrence of the cardiac event, as some previous studies found a relationship between the SHS and ischemic heart disease incidence [21–23]. However, a more recent study did not confirm the relationship between SHS domains on a validated questionnaire and ischemic heart disease [24]. Our findings are in line with Saeidi et al. [12]. They also found greater improvements in some mental components of the SHS after CR in a group of patients b 65 years compared to a group of patients ≥65 years, whereas the improvement on the physical component was equal between both groups [12]. It should be taken into account that the MCS and PCS scores only improved between the range of 1.20 and 6.00 points and, even though the change in MCS score was significantly different between both groups, it is a relatively small difference. The minimal clinically important difference in both the MCS and PCS score is in the range of 3 to 5 points [25]. Therefore, some of the improvements might not be clinically relevant.
Fig. 2. Changes in PCS and MCS scores. ⁎P-value b 0.05 was considered significant. P-values represent the difference in improvement between T0 and T2 between patients b60 years and patients ≥60 years. The dotted line represents the mean score of the normative Dutch population (50). Abbreviations: MCS, mental component summary; PCS, physical component summary.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
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K. Pieters et al. / International Journal of Cardiology xxx (2017) xxx–xxx
The question arises to what extend the SHS improvement is due to CR or whether similar results would have been achieved without CR. Two studies showed that older patients depend more on CR to improve their SHS [13,14]. In contrast to the group of younger patients, previous studies show that SHS in the group of older patients did not improve without CR [13,14]. As a result, older patients have a greater need for CR, since this group has less natural recovery. 4.1. Limitations The present study has several limitations. Our study design, without a control group, does not allow us to compare the improvement in SHS to the natural improvement. Therefore, it is not possible to determine which portion of the improvement in SHS is due to CR. Another limitation of this study is that selection bias may be present, given that the group of non-responders at both T1 and T2 consisted of more smokers and younger patients than the responders. In case of a difference in quality of life between the included and excluded patients, the results of the younger patients could have been influenced more than the results of the older patients. 5. Conclusions Even though, greater improvement on the MCS score was found in CR patients b 60 years, this group did not reach the mean MCS score of the normative Dutch population. This may display the need of a tailored CR program for younger patients, focusing slightly more on their mental status. Whereas, this study does not show the need for change in the current CR program for patients ≥60 years to improve SHS. Sources of funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest All authors declare no conflicts of interest and sources of support. References [1] J. Perk, G. De Backer, H. Gohlke, et al., European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the fifth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts), Int. J. Behav. Med. 19 (2012) 403–488. [2] B.S. Heran, J.M. Chen, S. Ebrahim, et al., Exercise-based cardiac rehabilitation for coronary heart disease, Cochrane Database Syst. Rev. (2011), CD001800. [3] L. Anderson, N. Oldridge, D.R. Thompson, et al., Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis, J. Am. Coll. Cardiol. 67 (2016) 1–12.
[4] R.S. Taylor, A. Brown, S. Ebrahim, et al., Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials, Am. J. Med. 116 (2004) 682–692. [5] A.M. Clark, L. Hartling, B. Vandermeer, F.A. McAlister, Meta-analysis: secondary prevention programs for patients with coronary artery disease, Ann. Intern. Med. 143 (2005) 659–672. [6] C.W. Shepherd, A.E. While, Cardiac rehabilitation and quality of life: a systematic review, Int. J. Nurs. Stud. 49 (2012) 755–771. [7] L. Schenkeveld, S.S. Pedersen, J.W. van Nierop, et al., Health-related quality of life and long-term mortality in patients treated with percutaneous coronary intervention, Am. Heart J. 159 (2010) 471–476. [8] P.M. Mommersteeg, J. Denollet, J.A. Spertus, S.S. Pedersen, Health status as a risk factor in cardiovascular disease: a systematic review of current evidence, Am. Heart J. 157 (2009) 208–218. [9] C.J. Lavie, R.V. Milani, Effects of cardiac rehabilitation programs on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in a large elderly cohort, Am. J. Cardiol. 76 (1995) 177–179. [10] M.A. Williams, C.M. Maresh, D.J. Esterbrooks, J.J. Harbrecht, M.H. Sketch, Early exercise training in patients older than age 65 years compared with that in younger patients after acute myocardial infarction or coronary artery bypass grafting, Am. J. Cardiol. 55 (1985) 263–266. [11] C.J. Lavie, R.V. Milani, Disparate effects of improving aerobic exercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients, J. Cardpulm. Rehabil. 20 (2000) 235–240. [12] M. Saeidi, S. Mostafavi, H. Heidari, S. Masoudi, Effects of a comprehensive cardiac rehabilitation program on quality of life in patients with coronary artery disease, ARYA Atheroscler. 9 (2013) 179–185. [13] E. Seki, Y. Watanabe, S. Sunayama, et al., Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo cardiac rehabilitation program (J-CARP), Circ. J. 67 (2003) 73–77. [14] N. Marchionni, F. Fattirolli, S. Fumagalli, et al., Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial, Circulation 107 (2003) 2201–2206. [15] J. Roijers, M. Sunamura, E.M. Utens, et al., Marital quality and loneliness as predictors for subjective health status in cardiac rehabilitation patients following percutaneous coronary intervention, Eur. J. Prev. Cardiol. 23 (2016) 1245–1254. [16] Revalidatiecommissie NVVC/Nederlandse Hartstichting, Dutch multidisciplinary guidelines cardiac rehabilitation[2016 July 2016]. Available from: http://www. nvvc.nl/hr 2011. [17] B. Gandek, J.E. Ware, N.K. Aaronson, et al., Cross-validation of item selection and scoring for the SF-12 health survey in nine countries: results from the IQOLA project. International quality of life assessment, J. Clin. Epidemiol. 51 (1998) 1171–1178. [18] F. Mols, A.J. Pelle, N. Kupper, Normative data of the SF-12 health survey with validation using postmyocardial infarction patients in the Dutch population, Qual. Life Res. 18 (2009) 403–414. [19] T.V. Perneger, B. Burnand, A simple imputation algorithm reduced missing data in SF-12 health surveys, J. Clin. Epidemiol. 58 (2005) 142–149. [20] J.W. Twisk, Longitudinal data analysis. A comparison between generalized estimating equations and random coefficient analysis, Eur. J. Epidemiol. 19 (2004). [21] S.S. Mikkelsen, E.L. Mortensen, T. Flensborg-Madsen, A prospective cohort study of quality of life and ischemic heart disease, Scand. J. Public Health 42 (2014) 60–66. [22] L. Moller, T.S. Kristensen, H. Hollnagel, Self rated health as a predictor of coronary heart disease in Copenhagen, Denmark, J. Epidemiol. Community Health 50 (1996) 423–428. [23] T. Benjak, G.V. Mavrinac, Subjective quality of life and cardiovascular risk factors in a Croatian adult population, Coll. Anthropol. 33 (Suppl. 1) (2009) 159–163. [24] Y. Dadjou, M. Kermani-Alghoraishi, M. Sadeghi, et al., The impact of health-related quality of life on the incidence of ischaemic heart disease and stroke; a cohort study in an Iranian population, Acta Cardiol. 71 (2016) 221–226. [25] G. Samsa, D. Edelman, M.L. Rothman, G.R. Williams, J. Lipscomb, D. Matchar, Determining clinically important differences in health status measures: a general approach with illustration to the health utilities index mark II, PharmacoEconomics 15 (1999) 141–155.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients Kimberley Pieters a,1, Elisabeth M.W.J. Utens b,1, Nienke ter Hoeve c,d,1, Myrna van Geffen c,d,1, Karolijn Dulfer b,1, Madoka Sunamura c,1, Ron T. van Domburg a,⁎,1 a
Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, The Netherlands Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC – Sophia Children's Hospital, Rotterdam, The Netherlands Capri Cardiac Rehabilitation Rotterdam, The Netherlands d Department of Rehabilitation Medicine, Erasmus Medical Center Rotterdam, The Netherlands b c
a r t i c l e
i n f o
Article history: Received 10 August 2016 Received in revised form 28 December 2016 Accepted 3 January 2017 Available online xxxx Keywords: Percutaneous coronary intervention Myocardial infarction Cardiac rehabilitation Subjective health status
a b s t r a c t Background: Cardiac rehabilitation (CR) is recommended as secondary prevention in primary percutaneous coronary intervention (pPCI) patients. This study was conducted to expand the knowledge about age-effects of CR in pPCI patients. The aim of this study was to compare changes in subjective health status (SHS) during and after CR between patients b 60 years and patients ≥60 years, who underwent pPCI after myocardial infarction. Methods: Between 2009 and 2011, in total 282 pPCI patients who participated in CR were included. Patients completed the Short Form 12 (SF-12) questionnaire at baseline (pre-CR), 3 months (post-CR) and 12 months followup. Patients were divided into two age-groups, b60 years versus ≥60 years. To compare improvements in SHS between groups, Generalized Estimating Equations (GEE) analyses were performed. Results: The mean physical component summary (PCS) score improved over time in both groups and even reached mean levels of the normative Dutch population. The improvement on the PCS score was equal in both age groups. The mental component summary (MCS) score also improved in both groups. Patients b 60 years reported on average more improvement on the MCS score than patients ≥60 years (Exp(B) 1.019; 95%CI 1.009–1.030; P b 0.001). However, mean levels of the normative Dutch population were not reached by patients b 60 years. Conclusion: Even though pPCI patients b60 years reported more improvement on the MCS score, mean levels of the normative Dutch population were not reached. Therefore, a tailored CR program with more focus on their mental status, may be beneficial in younger patients. © 2017 Elsevier B.V. All rights reserved.
1. Introduction Nowadays, primary percutaneous coronary intervention (pPCI) is the treatment of choice in patients who suffer from acute coronary syndrome. Cardiac rehabilitation (CR) is recommended for secondary prevention of cardiac problems in these patients [1], as meta-analyses and reviews demonstrated that CR reduces cardiovascular mortality [2–4], all-cause mortality [2,4,5], hospital admissions [2,3] and recurrent myocardial infarction [5]. Moreover, CR has a positive effect on total
⁎ Corresponding author at: Thoraxcenter, Erasmus Medical Center, Department of Cardiology, 's Gravendijkwal 230, Room Ba561, 3015 CE Rotterdam, The Netherlands, PO box 55, 3000 WB Rotterdam, The Netherlands. E-mail address: [email protected] (R.T. van Domburg). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
cholesterol levels [4], triglyceride levels [4], systolic blood pressure [4] and subjective health status (SHS) [2–6]. Although not confirmed by all studies, improvements in SHS possibly remain at follow-up [2]. Improving the subjective health status is an important objective, as a poor subjective health status is associated with a worse prognosis [7,8]. CR programs in older coronary artery disease patients have a positive influence on lipids [9], obesity indexes and exercise capacity [9, 10]. The improvement in exercise test results of older patients is comparable to younger patients [10,11]. Unfortunately, little research has been done into whether this pattern (comparable age-effects of CR) also applies to the SHS [11–14], and more specifically if it also applies to long term-results in pPCI patients. Knowledge about the age-effects of CR may help to improve CR by offering tailored programs. To bridge this gap in knowledge, the aim of this study was to investigate the change in SHS in pPCI patients participating in CR over a 12 months period and to compare SHS changes in the group of patients b60 years to changes in the group of patients ≥60 years.
http://dx.doi.org/10.1016/j.ijcard.2017.01.006 0167-5273/© 2017 Elsevier B.V. All rights reserved.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
2
K. Pieters et al. / International Journal of Cardiology xxx (2017) xxx–xxx
2. Methods 2.1. Patient sample Consecutive series of patients treated with pPCI between January 2009 and March 2011 and who participated in CR were prospectively included. The study was approved by the local research ethics committee (MEC-2009-080) and was conducted according to the Helsinki Declaration. All patients provided informed consent. The study design has been published elsewhere [15].
at both T1 and T2 were also excluded. The 282 remaining patients were used in the analysis (Fig. 1). No differences were found in age, gender, cardiac history and risk factors between responders and nonresponders at baseline. Whereas the group of non-responders at both T1 and T2 consisted of more smokers (57% vs. 43%; P = 0.041) and younger patients than the group of responders (56.0 vs. 59.1; P = 0.021). 3.2. Patient characteristics
2.2. Cardiac rehabilitation All patients participated in an outpatient CR program offered by Capri Cardiac Rehabilitation Rotterdam in accordance to the Dutch guidelines [16]. The program consisted of 1.5 h of supervised group exercise sessions given twice a week at a local sport accommodation. The sessions consisted of strength and aerobic exercises. Depending on the patients improvements, the CR program took for 4 to 13 weeks. In addition to the exercise sessions, there were group education sessions regarding medical background, cardiovascular risk factors, diet and emotions. Moreover, patients could attend counselling sessions for smoking cessation, healthy diet and stress management. If indicated, individual consults with a psychiatrist, psychologist, social worker or dietician were provided.
In the group of patients b 60 years were more men and smokers and there were more patients with a positive family history than in the group of patients ≥ 60 years. Moreover, less patients in the younger group had hypertension or a history of AMI. The group of patients b60 years also reported a lower PCS and MCS score at baseline than the group of older patients. Both age groups attended a similar amount of training sessions. More patients in the group b60 years visited a psychologist, psychiatrist and social worker than in the group ≥ 60 years (Table 1).
2.3. Data collection Patients received by postal mail questionnaires before the start of CR (T0), post-CR (T1) and at 12 months follow-up (T2). A postal reminder was sent out after 4 weeks of no response. Socio-demographic and clinical characteristics included age, gender, diabetes mellitus, smoking, hyperlipidemia, hypertension, body mass index, family history and medical history. This data was obtained from the medical charts. 2.4. Subjective health status Subjective health status was assessed with the Dutch version of the Short Form 12 (SF-12), an internationally widely used and validated questionnaire [17]. The SF-12 consists of a physical component summary (PCS) score and a mental component summary (MCS) score. The PCS includes physical functioning, role functioning physical, bodily pain and general health. The MCS includes social functioning, role functioning emotional, vitality and mental health. Both the PCS and MCS score range from 0 to 100. The mean score is 50 in a normative Dutch population [18]. A higher score is interpreted as a better subjective health status.
3.3. Subjective health status Fig. 2 shows changes in PCS and MCS scores in both age groups. At baseline, the mean PCS and MCS scores of both groups were lower, thus more unfavorable, compared to Dutch normative data. At T2, so after CR, both groups reached the mean levels of the normative PCS score (mean PCS score b 60 years 50.3 (SD ± 9.5); P = 0.744. ≥60 years 50.5 (SD ± 8.7); P = 0.512). However, at T2, the group of patients b60 years had a lower MCS score than the mean levels of the normative Dutch population (mean MCS score 47.6 (SD ± 10.8); P = 0.018). The group of patients ≥60 years did reach the mean levels of the normative Dutch population (mean MCS score ≥ 60 years 49.3 (SD ± 9.4); P = 0.460) (Fig. 2). Unadjusted, a greater improvement at one year follow-up was found in the group of patients b 60 years on the MCS score as well as on
2.5. Statistical analyses Patients were only included in analysis when they had at least completed questionnaires at baseline and a minimum of 1 follow-up moment. Categorical variables were summarized as percentages and differences between categorical variables were compared with the Chi-square test or Fisher's exact test when appropriate. Continuous variables were presented as means with standard deviation. The student's t-test was used to compare differences between continuous variables. In case of three or less missing answers on the SF-12 questionnaire, an imputation method was used [19]. A one sample t-test was used to compare the mean PCS and MCS scores at T2 to those of the Dutch normative population. Based on the mean age of the study sample (59.1 years), age was dichotomized into patients b60 years and ≥60 years. The student's t-test was used to compare the change in PCS and MCS scores in one year between both age groups. Changes over time in PCS and MCS between groups were compared with Generalized Estimating Equations (GEE) analyses with an autoregressive structure and with PCS and MCS as dependent outcome variables and time and group as categorical variables. A GEE model was chosen because it adjusts for the dependency of observations within one individual and it corrects for missing values [20]. An autoregressive structure was selected because measurement times were unequally spaced. The PCS and MCS scores were not normally distributed. Therefore, a log link function was used. For the dependent variable, outcomes were displayed as the exponent of the regression coefficients EXP(B), which indicates the ratio between the SHS change in the group of patients b60 years and the group of patients ≥60 years. Confounders were based on the literature and include; sex, PCS and MCS score at baseline, acute myocardial infarction (AMI), smoking, hypertension, diabetes mellitus, family history, completion of CR (≥18 training sessions) and individual sessions with a psychologist, psychiatrist and social worker. A 2-sided P value of b0.05 was considered significant. All analyses were performed using SPSS version 21.
3. Results 3.1. Study sample A total of 413 patients participated in a CR program following pPCI after MI. The mean time between pPCI and the start of the CR program was 42 days. Of these patients, 63 did not respond to the SF-12 questionnaire at baseline and were excluded. The 68 patients who did not respond
Fig. 1. Flowchart study sample. Abbreviations: CR, cardiac rehabilitation; SHS, subjective health status.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
K. Pieters et al. / International Journal of Cardiology xxx (2017) xxx–xxx Table 1 Characteristics of the study sample. CR (n = 282) Age category
b60 years (n = 145; 51.4%)
≥60 years (n = 137; 48.6%)
P-value
Mean age ± SD Mean BMI ± SD Male gender, n(%)
51.6 ± 6.1 27.7 ± 4.3 126 (86.9)
67.0 ± 5.4 27.0 ± 3.6 104 (75.9)
b0.001a 0.148 0.017a
History CVA, n(%) Cardiac event, n(%) - AMI - PCI - CABG
0 (0.0) 12 (8.3) 5 (3.4) 9 (6.2) 2 (1.4)
4 (2.9) 20 (14.6) 14 (10.2) 15 (10.9) 1 (0.7)
0.054 0.094 0.027a 0.159 1.000
Risk factors Smoking, n(%) Hypercholesterolemia, n(%) Hypertension, n(%) Diabetes mellitus, n(%) Family history, n(%)
83 (57.2) 51 (35.2) 45 (31.0) 15 (10.3) 93 (64.1)
40 (29.2) 59 (43.1) 61 (44.5) 20 (14.6) 67 (48.9)
b0.001a 0.173 0.019a 0.278 0.010a
Baseline SHS Mean PCS baseline ± SD Mean MCS baseline ± SD
44.3 ± 8.9 42.3 ± 11.5
47.3 ± 9.0 47.2 ± 10.2
0.006a b0.001a
Cardiac rehabilitation Training sessions ± SD Individual consultsb, n(%)
23.7 ± 9.2 21 (14.5)
21.9 ± 8.7 8 (5.8)
0.089 0.017a
Abbreviations: AMI, acute myocardial infarction; BMI, body mass index; CABG, coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; CVA, cerebral vascular accident; MCS, mental component summary; PCI, percutaneous coronary intervention; PCS, physical component summary; SHS, subjective health status. a P-value b 0.05 was considered significant. b Individual consults with psychiatrists, psychologists and social workers.
the PCS score (Fig. 2). Because of baseline differences, changes on MCS and PCS scores were also compared using a multivariable GEE-analysis. The group of patients b60 years had less improvement on the PCS score over time than the group of patients ≥60 years (Exp(B) 0.961; 95%CI 0.935–0.988; P = 0.005). However, the group of younger patients differed on several baseline characteristics. After adjustment the difference was no
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longer significant (Exp(B) 1.007; 95%CI 0.987–1.027; P = 0.489). A greater improvement over time on the MCS score was found in the group of patient b 60 years than in the group of patients ≥60 years (Exp(B) 0.931; 95%CI 0.901–0.963; P b 0.001). This difference in improvement remained significant after correcting (Exp(B) 1.019; 95%CI 1.009–1.030; P b 0.001). 4. Discussion Although an improvement in MCS score over time in both age groups was found, younger patients benefited more, whereas the improvement in PCS score was equal between both groups. The MCS and PCS scores improved in both groups and, with exception of the MCS score in the group of younger patients, the MCS and PCS scores even reached the mean score of the normative Dutch population. This indicates a recovery of the SHS in patients participating in a CR program. Not reaching the mean MCS score of the normative Dutch population in the group of patients b 60 years might be due to the fact that the MCS score at baseline was lower in this group compared to the score in the older group of patients, thus a greater improvement was necessary to reach this score. It cannot be ruled out that the lower MCS score in the group of patients b60 years contributed to the occurrence of the cardiac event, as some previous studies found a relationship between the SHS and ischemic heart disease incidence [21–23]. However, a more recent study did not confirm the relationship between SHS domains on a validated questionnaire and ischemic heart disease [24]. Our findings are in line with Saeidi et al. [12]. They also found greater improvements in some mental components of the SHS after CR in a group of patients b 65 years compared to a group of patients ≥65 years, whereas the improvement on the physical component was equal between both groups [12]. It should be taken into account that the MCS and PCS scores only improved between the range of 1.20 and 6.00 points and, even though the change in MCS score was significantly different between both groups, it is a relatively small difference. The minimal clinically important difference in both the MCS and PCS score is in the range of 3 to 5 points [25]. Therefore, some of the improvements might not be clinically relevant.
Fig. 2. Changes in PCS and MCS scores. ⁎P-value b 0.05 was considered significant. P-values represent the difference in improvement between T0 and T2 between patients b60 years and patients ≥60 years. The dotted line represents the mean score of the normative Dutch population (50). Abbreviations: MCS, mental component summary; PCS, physical component summary.
Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006
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K. Pieters et al. / International Journal of Cardiology xxx (2017) xxx–xxx
The question arises to what extend the SHS improvement is due to CR or whether similar results would have been achieved without CR. Two studies showed that older patients depend more on CR to improve their SHS [13,14]. In contrast to the group of younger patients, previous studies show that SHS in the group of older patients did not improve without CR [13,14]. As a result, older patients have a greater need for CR, since this group has less natural recovery. 4.1. Limitations The present study has several limitations. Our study design, without a control group, does not allow us to compare the improvement in SHS to the natural improvement. Therefore, it is not possible to determine which portion of the improvement in SHS is due to CR. Another limitation of this study is that selection bias may be present, given that the group of non-responders at both T1 and T2 consisted of more smokers and younger patients than the responders. In case of a difference in quality of life between the included and excluded patients, the results of the younger patients could have been influenced more than the results of the older patients. 5. Conclusions Even though, greater improvement on the MCS score was found in CR patients b 60 years, this group did not reach the mean MCS score of the normative Dutch population. This may display the need of a tailored CR program for younger patients, focusing slightly more on their mental status. Whereas, this study does not show the need for change in the current CR program for patients ≥60 years to improve SHS. Sources of funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest All authors declare no conflicts of interest and sources of support. References [1] J. Perk, G. De Backer, H. Gohlke, et al., European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the fifth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts), Int. J. Behav. Med. 19 (2012) 403–488. [2] B.S. Heran, J.M. Chen, S. Ebrahim, et al., Exercise-based cardiac rehabilitation for coronary heart disease, Cochrane Database Syst. Rev. (2011), CD001800. [3] L. Anderson, N. Oldridge, D.R. Thompson, et al., Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis, J. Am. Coll. Cardiol. 67 (2016) 1–12.
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Please cite this article as: K. Pieters, et al., Age does matter: Younger pPCI patients profit more from cardiac rehabilitation than older patients, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.01.006