[Black Square] PHYSICAL FRAILTY AND PULMONARY REHABILITATION IN COPD: A PROSPECTIVE COHORT STUDY
Maddocks M, Kon SSC, Canavan JL, Jones SE, Nolan CM, Labey A, Polkey MI, Man WD-C
Thorax. 2016;71:988-995.
Background: Frailty is an important clinical syndrome that is consistently associated with adverse outcomes in older people. The relevance of frailty to chronic respiratory disease and its management is unknown.
Objectives: To determine the prevalence of frailty among patients with stable COPD and examine whether frailty affects completion and outcomes of pulmonary rehabilitation.
Methods 816 outpatients with COPD (mean (SD) age 70 (10) years, FEV1% predicted 48.9 (21.0)) were recruited between November 2011 and January 2015. Frailty was assessed using the Fried criteria (weight loss, exhaustion, low physical activity, slowness and weakness) before and after pulmonary rehabilitation. Predictors of programme non-completion were identified using multivariate logistic regression, and outcomes were compared using analysis of covariance, adjusting for age and sex.
Results: 209/816 patients (25.6%, 95% CI 22.7 to 28.7) were frail. Prevalence of frailty increased with age, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) score and age-adjusted comorbidity burden (all p <= 0.01). Patients who were frail had double the odds of programme non-completion (adjusted OR 2.20, 95% CI 1.39 to 3.46, p = 0.001), often due to exacerbation and/or hospital admission. However, rehabilitation outcomes favoured frail completers, with consistently better responses in MRC score, exercise performance, physical activity level and health status (all p < 0.001). After rehabilitation, 71/115 (61.3%) previously frail patients no longer met case criteria for frailty.
Conclusions: Frailty affects one in four patients with COPD referred for pulmonary rehabilitation and is an independent predictor of programme non-completion. However, patients who are frail respond favourably to rehabilitation and their frailty can be reversed in the short term.
Editor's Comment: All the ravages, from the scourges of aging, comorbid illnesses, the undesired consequences of treatment, and more, converge to produce a fragile state that is being increasingly seen to predict outcomes in patients with chronic obstructive pulmonary disease (COPD). This state, now termed frailty, may influence participation in health care interventions as well as the response to such intervention. What is unclear, and rather important, is whether this frail state is a fixed and inevitable consequence of the contributors above, or instead amenable to treatment, with an improvement in expected outcomes as a consequence.
The present study, the first of its kind, assessed 816 patients with COPD, and identified frailty, by the easily applied Fried criteria, in a quarter (209). It then followed patients through a pulmonary rehabilitation intervention. Frail subjects successfully completed pulmonary rehabilitation much less than the non-frail but, hearteningly, those that did finish had a greater benefit in most major measures including Medical Research Council score, exercise performance, physical activity level, and health status. Importantly, amongst the completers, 61.3% no longer met frailty criteria after rehabilitation.
Frailty is a potentially useful global index of performance and, hence, has broad predictive value. This alone is perhaps insufficient to recommend its routine use in clinical practice, especially pulmonary rehabilitation. Showing that it may be a reversible state counts as an important step forward as it enhances this easy assessment to one that can also be used longitudinally to measure the impact of interventions and produce a change in predicted outcomes. -SK
[Black Square] RELATIONSHIP BETWEEN PULMONARY REHABILITATION AND CARE DEPENDENCY IN COPD
Janssen DJA, Wilke S, Smid DE, Franssen FME, Augustin IM, Wouters EFM, Spruit MA
Thorax. 2016;71:1054-1056
Abstract: The aims of this study were to explore care dependency before and after pulmonary rehabilitation (PR) in patients with COPD (n = 331) and to compare the response to PR between care dependent and independent patients. At baseline, 85 (25.7%) patients had a Care Dependency Scale (CDS) score <=68 points and were considered as care dependent. CDS scores of these patients improved after PR (p < 0.001). After PR, CDS score of 38 (44.7%) patients with a baseline CDS score <=68 points increased to >68 points. Patients with a baseline CDS score <= 68 points or >68 points showed after PR a comparable improvement in COPD Assessment Test, Hospital Anxiety and Depression Scale and 6-min walk distance (all p < 0.05).
Editor's Comment: This is a brief report on a secondary analysis of approximately 60% of the participants in the chronic obstructive pulmonary disease (COPD), Health Status, and Comorbidities (Chance) study. The Chance study prospectively explored the impact of cardiovascular comorbidities on COPD Assessment Test (CAT) and its responsiveness to pulmonary rehabilitation (PR) in 518 patients with moderate-to-very-severe COPD. This secondary analysis examines the impact of PR on the Care Dependency Scale (CDS), based on 15 items regarding basic and instrumental activities of daily living, with possible scores ranging from 15 (worst) to 75 (best) and with scores <=68 indicating CDS. It is worth noting that CDS was not created for COPD and its performance properties are not fully established for this condition.
Like frailty, in another recent study also reviewed above, a quarter of patients fell into the poor CDS category, and it is tempting to suggest that these are similar assessments. Similarly, its prevalence increased with age, lower FEV1, and other markers of severity. Also like frailty, CDS appeared a modifiable state with 38 of the 85 patients (44.7%) with scores <=68 improving out of the CDS range following PR. However, unlike the frailty data, they did not show an enhanced benefit from the PR in the usual indices, with both the CDS and non-CDS groups showing similar improvements in COPD Assessment Test, Hospital Anxiety and Depression Scale, and 6-minute walk distances.
Frailty and care dependence likely represent similar areas of dysfunction although they are clearly not entirely congruent. Interventions such as PR appear to have the potential to improve these in some ways in certain patients, but the ability to recognize those that might benefit is not yet a prospective possibility. Until that happens, scales including CDS will continue to be useful in analysis rather than in patient selection and treatment planning; these latter roles need to be more clearly delineated before a truly transformative status designation can be conferred. -SK
[Black Square] PERSONALIZED ACTIVITY INTELLIGENCE (PAI) FOR PREVENTION OF CARDIOVASCULAR DISEASE AND PROMOTION OF PHYSICAL ACTIVITY
Nes BM, Gutvik CR, Lavie CJ, Nauman J, Wisloff U
Am J Med. Published online first October 28, 2016, doi: 10.1016/j.amjmed.2016.09.031.
Purpose: To derive and validate a single metric of activity tracking that associates with lower risk of cardiovascular disease mortality.
Methods: We derived an algorithm, Personalized Activity Intelligence (PAI), using the HUNT Fitness Study (n = 4631), and validated it in the general HUNT population (n = 39,298) aged 20-74 years. The PAI was divided into three sex-specific groups (<=50, 51-99 and >=100), and the inactive group (0 PAI) was used as the referent. Hazard ratios for all-cause and cardiovascular disease mortality were estimated using Cox proportional hazard regressions.
Results: After >1 million person-years of observations during a mean follow-up time of 26.2 (SD, 5.9) years, there were 10,062 deaths, including 3867 deaths (2207 men and 1660 women) from cardiovascular disease. Men and women with a PAI-level >=100 had 17% (95% confidence interval [CI], 7-27%), and 23% (95% CI, 4-38%) reduced risk of cardiovascular disease mortality compared to the inactive groups, respectively. Obtaining >=100 PAI was associated with significantly lower risk for cardiovascular disease mortality in all pre- specified age-groups, and in participants with known cardiovascular disease risk factors (all P-trends <0.01). Participants who did not obtain >=100 PAI had increased risk of dying regardless of meeting the physical activity recommendations.
Conclusion: PAI may have a huge potential to motivate people to become and stay physically active, as it is an easily understandable and scientifically proven metric that could inform potential users of how much physical activity is needed to reduce the risk of premature cardiovascular disease death.
Editor's Comment: This study describes the development of a novel physical activity "metric" that uses heart rate data to personalize the amount of exercise needed to reduce the risk of death from cardiovascular disease (CVD). Most professional guidelines advise that adults should do 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week, or a combination of moderate or vigorous exercise that approximate the same total energy expenditure. However, some new research suggests that some people may still be at risk for CVD mortality despite following these recommendations.
This new metric called Personal Activity Intelligence (PAI) translates heart rate data from any physical activity (ie, walking, swimming, dancing, cycling) and personal information (ie, age, gender, resting and maximum heart rate) into 1 simple score. To develop PAI, the researchers used data from 4637 individuals from the HUNT Fitness Study. An algorithm was derived based on measured heart rate during a fitness test, detailed questions relating to frequency, duration and intensity of physical activity, and cardiovascular health status (ie, BMI, blood pressure, cholesterol) as outcome measures. The algorithm was then validated in 39 298 healthy Norwegian men and women from the Hunt Study. Participants were divided into 4 groups according to their weekly PAI score (0, 1-50, 51-99, >=100). A score of 0 was considered inactive and used as the reference group for comparison. After a median follow-up of 287 years, there were 10 062 deaths, including 3867 deaths from CVD. Men and women with a PAI level >=100 had about 20% reduced risk of CVD mortality compared to the inactive group. The corresponding risk reduction for all-cause mortality was about 15%. PAI level >=100 was associated with similar reductions in all-cause and CVD mortality regardless of age and in those with risk factors such as smoking, hypertension, overweight, or obesity.
The PAI may be a more relevant approach to quantifying the total "dose" as it considers intensity, duration, and frequency of all activities, including structured exercise as well as lifestyle physical activity. The concept of PAI suggests that if you prefer to walk at a relatively low intensity for hours, or rather perform more high intensity work for shorter periods over the week, you can have the same reduction in risk as long as a PAI >=100 per week is achieved. This study has several limitations that may dampen the excitement of new approach. First, the physical activity data in the validation cohort was obtained at only 1 time-point which is inherently prone to classification bias. Second, the HUNT population is very homogeneous (ie, same ethnicity, race, and generally healthy) so generalizing these findings to ethnically diverse populations needs further study. Despite these limitations there is great potential for incorporating this algorithm into the various physical activity self-monitoring devices, which have become widely available, making it very easy for individuals to know their PAI. While the PAI approach is very intriguing, it's too soon to tell if this metric will ever become a widely embraced method for prescribing and promoting physical activity. -PHB
[Black Square] PHYSICAL ACTIVITY AND ANGER OR EMOTIONAL UPSET AS TRIGGERS OF ACUTE MYOCARDIAL INFARCTION: THE INTERHEART STUDY
Smyth A, O'Donnell M, Lamelas P, Teo K, Rangarajan S, Yusuf S. On behalf of the INTERHEART Investigators
Circulation. 2016;134:1059-1067.
Background: Physical exertion, anger, and emotional upset are reported to trigger acute myocardial infarction (AMI). In the INTERHEART study, we explored the triggering association of acute physical activity and anger or emotional upset with AMI to quantify the importance of these potential triggers in a large, international population.
Methods: INTERHEART was a case-control study of first AMI in 52 countries. In this analysis, we included only cases of AMI and used a case- crossover approach to estimate odds ratios for AMI occurring within 1 hour of triggers.
Results: Of 12 461 cases of AMI 13.6% (n = 1650) engaged in physical activity and 14.4% (n = 1752) were angry or emotionally upset in the case period (1 hour before symptom onset). Physical activity in the case period was associated with increased odds of AMI (odds ratio, 2.31; 99% confidence interval [CI], 1.96-2.72) with a population-attributable risk of 7.7% (99% CI, 6.3-8.8). Anger or emotional upset in the case period was associated with an increased odds of AMI (odds ratio, 2.44; 99% CI, 2.06-2.89) with a population-attributable risk of 8.5% (99% CI, 7.0-9.6). There was no effect modification by geographical region, prior cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time of day or day of onset of AMI. Both physical activity and anger or emotional upset in the case period were associated with a further increase in the odds of AMI (odds ratio, 3.05; 99% CI, 2.29-4.07; P for interaction <0.001).
Conclusions: Physical exertion and anger or emotional upset are triggers associated with first AMI in all regions of the world, in men and women, and in all age groups, with no significant effect modifiers.
Editor's Comment: Several observational studies have identified potential external triggers for acute myocardial infarction (AMI), including physical exertion and anger or emotional upset. However these studies had small sample sizes (n < 2,000) and were completed primarily in 1 country or geographical region (predominantly Western countries). Consequently, large, international studies using standardized methodology are required to determine whether there are variations in the importance of triggering risk factors and to determine other factors that may modify the association. The INTERHEART study provided an opportunity to study the association between these potential external triggers of AMI and effect modifiers in a large, international population.
The INTERHEART study was a case-control study of first AMI completed in 262 centers across 52 countries. Consecutive cases with first AMI (defined by characteristic symptoms and ischemic ECG changes) were recruited, in addition to at least 1 age- and sex-matched control without a history of heart disease or exertional chest pain. In primary analyses, only the cases of AMI, because the exposure to potential triggers was collected systematically in cases and not in controls, were included. Physical exertion was reported by 13.6% (n = 1650) of participants during the case period and 9.1% (n = 1111) during the control period. There were no significant differences between those who reported physical exertion in the case period and those who did not. Compared with the control period, the adjusted odds of AMI associated with physical exertion occurring during the case period was 2.31 (99% CI, 1.96-2.72) with a population-attributable risk of 7.7% (99% CI, 6.3-8.8). There was no statistically significant effect modification on analyses stratified by age group, sex, smoking, diabetes mellitus, hypertension, obesity, angina, stroke INTERHEART risk score, or baseline physical activity. Anger or emotional upset was reported by 14.4% (n = 1746) of participants during the case period and 9.9% (n = 1210) during the control period. There were no significant differences between those who reported anger or emotional upset in the case period and those who did not for all. Compared with the control period, the adjusted odds of AMI associated with anger or emotional upset occurring during the case period was 2.44 (99% CI, 2.06-2.89) with a population-attributable risk of 8.5% (99% CI, 7.0-9.6). There was no statistically significant effect modification on analyses stratified by age group, sex, smoking, diabetes mellitus, hypertension, obesity, angina, stroke, INTERHEART risk score, levels of stress, depression, or level of education. Compared with exposure to neither trigger during the control period, the adjusted odds of AMI associated with exposure to both physical exertion and anger or emotional upset occurring during the case period was 3.05 (99% CI, 2.29-4.07).
These findings from the INTERHEART study confirm previous reports that heavy physical exertion and anger or emotional upset may act as triggers of first AMI but also extend these findings to all regions of the world. This study also revealed an interaction between heavy physical exertion and anger or emotional upset with an additive association in participants with exposure to both in the 1 hour before AMI. These observations were not modified by previous cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time and day of onset of symptoms. In light of these findings, clinicians should advise patients to minimize exposure to extremes of anger or emotional upset because of the potential risk of triggering AMI and that heavy or vigorous physical exertion (but not all physical activity) may trigger a myocardial infarction. Finally, given the established benefits of regular physical activity over the long term, clinicians should continue to advise patients about the many benefits of exercise. -PHB