Speaker
Elisabetta Tonet, MD
Cardiology Consultant
Cardiology Unit
Azienda Ospedaliero–Universitaria di Ferrara, Italy
Keywords
Cardiovascular; Myocardial Infarction; Rehabilitation
Key Points
- The standard of care in myocardial infarction (MI) management has evolved dramatically in the 20th century, shifting from absolute bed rest to early ambulation to the modern cardiac rehabilitation concept focused on physical activity. This typically includes inpatient mobilization, a 6 – 12 week outpatient program, and a maintenance phase.
- Traditional cardiac rehabilitation programs have several limitations, including standardized activities, early withdrawal, high costs, and low enrollment of older adults. The latter factor is increasingly significant, as the contemporary MI patient has also changed; 2/3 of MI patients are over 65 years old.
- Despite advancements in acute care, older patients presenting with MI are the highest risk population with the worst prognosis. Older adults also represent the least physically active group, often experiencing functional decline, frailty and disability after MI.
- The research team sought to assess a physical activity model with both remote and supervised, in-person, monthly sessions. In the HULK pilot study, this intervention was seen to improve short physical performance battery values 6 months after acute coronary syndrome.
- The Physical Activity Intervention in Elderly Patients with Myocardial Infarction (PIpELINe) trial evaluated whether an early, tailored, multi-domain rehabilitation intervention improved outcomes in older patients (65+ years old) admitted to the hospital for MI and with impaired physical performance.
- PIpELINe was an investigator-initiated, multicenter, prospective, superiority randomized trial conducted across 7 centers in Italy. The intervention included metabolic risk factors management; diet counseling; and exercise training. The primary outcome was cardiovascular (CV) death or CV-related, unplanned hospitalization.
- The research team found that the multi-domain cardiac rehabilitation program reduced CV death or CV-related, unplanned hospitalization in their target population by 8% compared to usual care.
Discussion Themes
One difficulty cited by similar projects is older adults’ reluctance to participate in clinical trials. In this case, the research team found that a monthly, sustained program that provided guidance following an MI was attractive to this population. The main barrier to enrollment was the pandemic.
The impact of the intervention on heart failure and unplanned hospitalization may be more pertinent to this population than CV death, as they pertain to functional decline and quality of life.
The monthly pace renders this intervention low-cost with high availability.
The multidimensionality of the trial makes it difficult to identify which factors drove the effectiveness of the intervention and to what extent. Dr. Tonet suspects that the physical activity component was the most impactful.