Purpose:
Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF).
Methods:
We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression).
Results:
Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31).
Conclusions:
Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.
Background
Patients with renal insufficiency have poor short‐term outcomes after transcatheter aortic valve replacement (TAVR).
Methods
Retrospective chart review identified 575 consecutive patients not on hemodialysis who underwent TAVR between September 2014 and January 2017. Outcomes were defined by VARC‐2 criteria. Primary outcome of all‐cause mortality was evaluated at a median follow‐up of 811 days (interquartile range 125–1,151).
Results
Preprocedural glomerular filtration rate (GFR) was ≥60 ml/min in 51.7%, 30–60 ml/min in 42.1%, and < 30 ml/min in 6.3%. Use of transfemoral access (98.8%) and achieved device success (91.0%) did not differ among groups, but less contrast was used with lower GFR (23 ml [15–33], 24 ml [14–33], 13 ml [8–20]; p < .001). Peri‐procedural stroke (0.7%, 2.1%, 11.1%; p < .001) was higher with lower GFR. Core lab analysis of preprocedural computed tomography scans of patients who developed a peri‐procedural stroke identified potential anatomic substrate for stroke in three out of four patients with GFR 30–60 ml/min and all three with GFR <30 ml/min (severe atheroma was the most common subtype of anatomical substrate present). Compared to GFR ≥60 ml/min, all‐cause mortality was higher with GFR 30–60 ml/min (HR 1.61 [1.00–2.59]; aHR 1.61 [0.91–2.83]) and GFR <30 ml/min (HR 2.41 [1.06–5.48]; aHR 2.34 [0.90–6.09]) but not significant after multivariable adjustment. Follow‐up echocardiographic data, available in 63%, demonstrated no difference in structural heart valve deterioration over time among groups.
Conclusions
Patients with baseline renal insufficiency remain a challenging population with poor long‐term outcomes despite procedural optimization with a transfemoral‐first and an extremely low‐contrast approach.
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