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The benefits of regular exercise for prevention of cardiovascular disease (CVD) are well known. However, most of the evidence is derived from population-based studies of relatively healthy patients; data on exercise after a cardiovascular event is less robust, particularly in older patients. Kang and colleagues1 hypothesised that regular exercise in older adults with CVD would be associated with lower morbidity and mortality. In a series of 6076 older adults (age at least 60 years with a mean age of 72 years, 51% men) with a new diagnosis of CVD in the Korean National Health Insurance Senior database, levels of physical activity were assessed by a validated questionnaire completed within 2 years before and after the cardiovascular event. Over a median follow-up of 3.8 years, the incidence rate (IR) for overall mortality was lower in patients who exercised regularly both before and after the incident event (IR 2.9, HR 0.53, 95% CI 0.38 to 0.73) and in those who began exercise after the event (IR 3.5, HR 0.73, 95% CI 0.58 to 0.91) compared with non-exercisers (IR 4.8 per 100 person-years) (figure 1). Although the magnitude was attenuated, benefit still was seen in patients age 75 and older, compared with those age 60–75 years.
Graphical abstract summarising the principal findings of this study. The risks of all-cause, cardiovascular and non-cardiovascular death are reduced with more virtuous exercise trajectories in older adults with newly diagnosed cardiovascular (CV) disease.
In the accompanying editorial, Barbiellini Amidei2 discuss how physical activity trajectories in early to mid-life and then late in life might modulate the interaction of cardiovascular risk factors with socioeconomic, genetic and biological factors that contribute to CVD risk. Mechanisms of benefit of physical activity might include ‘improved endothelial function and anti-atherosclerotic effects. Endothelial dysfunction results in impaired nitric oxide production, abnormal vasoconstriction, inflammation and oxidative stress. Physical activity can promote the production of nitric oxide and consequent vasodilation. Exercise is also associated with reduced atherogenic lipid profiles, lower blood pressure and decreased risk of insulin resistance.’ We hope to see more studies on the relationship between intensity, duration and types of physical activity and CVD risk at different life stages now that it is possible to record objective continuous data using wearable devices.
The role of coronary computed tomographic angiography (CCTA) in patients with a suspected acute coronary syndrome (ACS) remains controversial. In the Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT), 250 patients with suspected ACS, a non-diagnostic ECG and an intermediate high-sensitivity cardiac troponin (hs-cTn) level, were randomised to CCTA versus standard care.3 There was no significant difference in the primary outcome of length of stay in those undergoing immediate CCTA versus standard care (7.53 vs 8.14 hours) with a small different in those found to have <25% coronary stenosis on CCTA (figure 2). At follow-up, there were more outpatient referrals in those treated with standard care but no difference in major adverse cardiac events at 12 months. Thus, the authors conclude that CCTA did not reduce the length or cost of the inpatient stay or change 1 year outcomes.
Trial overview. CAD, coronary artery disease; CCTA, coronary CT angiography; FU, follow-up; hs-cTnT, high-sensitivity cardiac troponin T; MACE, major adverse cardiac event; OP, outpatient.
Greer and colleagues4 interpret this study from a more positive point of view. Instead of showing that CCTA did not reduce costs or length of stay in patients with suspected ACS, the more appropriate conclusion is that CCTA is feasible in low and intermediate risk patients with no increase in costs or length of stay. Potential benefits of CCTA include reassurance when no significant coronary disease is identified, identification of important non-coronary diagnoses that might otherwise be overlooked, and possible long-term cost benefits given the lower rate of outpatient cardiology consultation. As they conclude: ‘We believe this trial complements existing data showing CT to be a safe and effective way to identify coronary artery disease in acute chest pain syndromes. What remains to be determined is the optimal approach to patient selection for CT and the best management strategy for its diagnostic findings.’
Transcatheter closure is an effective approach to treatment of atrial septal defects (ASD) but the potential for persistent valve dysfunction in patients with concurrent significant secondary tricuspid regurgitation (TR) has been a concern. In 252 consecutive patients (mean age 54 years) with an ASD and significant TR, 184 (73%) underwent surgical ASD closure plus tricuspid annuloplasty while 68 (27%) underwent transcatheter ASD closure alone.5 In both groups, TR severity significantly decreased after ASD closure and a propensity matched cohort showed no difference in event rates at 5 years between the transcatheter and surgical approaches (10.3% vs 5.5%, p=0.963).
Donal and Yamada6 discuss the pathophysiology of secondary TR in the setting of right ventricular volume overload due to an ASD with left to right shunting. After ASD closure, right ventricular remodelling often leads to a reduction in TR severity, without an additional tricuspid valve procedure. Predictors of right ventricular remodelling after ASD closure include the ASD size as well as right ventricular volumes, afterload, diastolic dysfunction and atrial arrhythmias. There are many unanswered questions from this retrospective study; ultimately, we need data from a randomised trial comparing transcatheter versus surgical ASD closure in patients with concurrent significant TR.
Two important review articles in this issue of Heart address recommendation for exercise and sports in patients with hypertrophic cardiomyopathy7 and valvular heart disease.8 Instead of conservative exercise recommendations for patients with hypertrophic cardiomyopathy, guidelines now recommend mild to moderate exercise to improve functional capacity and quality of life (figure 3). In addition, regular exercise is associated with lower overall cardiovascular mortality. Similarly, in patients with valvular heart disease, titrating exercise recommendations to the type and severity of valve dysfunction allows patients to benefit from the improved cardiovascular fitness and reduced cardiovascular risk associated with regular exercise (figure 4). We should no longer recommend inactivity in our patients with hypertrophic cardiomyopathy or valvular heart disease.
ESC sports cardiology guidelines for exercise in HCM. BP, blood pressure; ESC, European Society of Cardiology; HCM, hypertrophic cardiomyopathy; LVOT, left ventricular outflow tract; SCD, sudden cardiac death.
Recommendations for participation in sport and exercise in asymptomatic individuals according to the severity of respective valvular heart disease, classified as mild (green circle), moderate (orange circle), severe (red circle). *LVEDD cut-offs: LVEDD <60 mm or 35 mm/m2 in men; 40 mm/m2 in women. BP, blood pressure; LV, left ventricle; LVEDD, left ventricular end diastolic dimension; LVEF, left ventricular ejection fraction; sPAP, systolic pulmonary artery pressure.
The Education in Heart article in this issue9 provides an overview of the importance of frailty as a risk factor for adverse outcomes in patients with CVD. Clinical assessment of frailty enriches prognostic risk stratification, provides insight into defining limits of care, helps in identification of potentially beneficial procedures and treatment, improves selection of patients for cardiac rehabilitation and enhances communication of patient complexity. ‘In the UK, general practices routinely record frailty status in the electronic health record using the electronic Frailty Index (eFI), which is calculated automatically using coded data within the record. The eFI categorises people as fit, or as living with mild, moderate or severe frailty based on the proportion of deficits (symptoms and signs, abnormal laboratory values, disability or disease state) they have from a total of 36 possible deficits.’ Routine inclusion and updating of frailty measures in the medical record for older adults with CVD is needed across healthcare systems.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.