Yan LL, Yang X, Chen L, Lu X. Effects of systematic cardiac rehabilitation training in elderly patients with unstable angina following cardiac stent implantation. World J Clin Cases 2024; 12(20): 4137-4145 [PMID: 39015888 DOI: 10.12998/wjcc.v12.i20.4137]
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Yan LL and Lu X designed the research; Yan LL and Yang X performed the research; Yan LL and Chen L analyzed the data; Yan LL and Lu X wrote the manuscript.
Institutional review board statement: This study was approved by the institutional review board of Liyang People's Hospital.
Informed consent statement: Informed consent has been obtained from each particiant.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data are available from the corresponding author.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Received: April 7, 2024 Revised: May 13, 2024 Accepted: May 21, 2024 Published online: July 16, 2024 Processing time: 84 Days and 16.4 Hours
Abstract
BACKGROUND
Coronary stent implantation is usually used to treat unstable angina to alleviate stenosis or occlusion, promoting blood flow restoration and alleviating symptoms such as myocardial ischemia. And postoperative cardiac rehabilitation is essential for enhancing recovery and prognosis. Nevertheless, conventional rehabilitation lacks specificity, particularly for elderly patients with multiple comorbidities and poor compliance, rendering it less effective.
AIM
To investigate the effects of systematic cardiac rehabilitation training in elderly patients with unstable angina following coronary stenting intervention.
METHODS
A retrospective enrollment was conducted comprising fifty-four elderly patients with unstable angina pectoris who underwent systematic cardiac rehabilitation training after receiving coronary intervention as the rehabilitation group, while fifty-three elderly patients who received basic nursing and rehabilitation guidance measures after coronary intervention were assigned to the control group. Differences in Seattle Angina Questionnaire scores, survival quality (SF-36) scores, cardiopulmonary exercise function assessment index, echocardiographic cardiac function index, and adverse cardiovascular events were compared between the two groups.
RESULTS
After intervention, the rehabilitation group observed greater VO2 Max, maximum metabolic equivalent, eft ventricular ejection fraction, left ventricular end-diastolic diameter and smaller left ventricular end-systolic diameter. And the rehabilitation group observed greater scores of physical activity limitation, stable angina pectoris, treatment satisfaction, and SF-36 score. The incidence of adverse cardiovascular events in the two groups, showed no significant difference.
CONCLUSION
Systematic cardiac rehabilitation following coronary stenting in elderly patients with unstable angina pectoris can enhance cardiac function recovery, consequently enhancing both quality of life and cardiopulmonary exercise tolerance.
Core Tip: This study will explore the application value of systemic cardiac rehabilitation training in elderly patients with unstable angina pectoris after coronary stent interventional surgery, and preliminatively find that systemic cardiac rehabilitation training can promote the recovery of cardiac function, quality of life and improvement of cardiopulmonary exercise tolerance in these patients.
Citation: Yan LL, Yang X, Chen L, Lu X. Effects of systematic cardiac rehabilitation training in elderly patients with unstable angina following cardiac stent implantation. World J Clin Cases 2024; 12(20): 4137-4145
Unstable angina stems from fibrous plaque rupture on coronary artery atheromas, leading to platelet adhesion and acute coronary obstruction exacerbation[1]. Predominantly affecting the elderly, it manifests as severe and prolonged chest pain[2]. Clinical practice frequently employs coronary stent implantation, utilizing a stent delivered via a specialized catheter and guidewire under X-ray fluoroscopy, to alleviate stenosis or occlusion, promoting blood flow restoration and alleviating symptoms such as myocardial ischemia[3]. Nonetheless, postoperative cardiac rehabilitation remains essential for enhancing recovery and prognosis[4]. This rehabilitation comprises multiple interventions, including assessment, exercise training, dietary modification, behavioral adjustments, and adherence strategies, collectively enhancing cardiac function and structure[5]. Evidence suggests that cardiac rehabilitation reduces overall and cardiovascular mortality post-myocardial infarction[6]. Nevertheless, conventional rehabilitation lacks specificity, particularly for elderly patients with multiple comorbidities and poor compliance, rendering it less effective[7]. Therefore, this study investigates the efficacy of systematic cardiac rehabilitation in elderly patients undergoing cardiac stent implantation for unstable angina, aiming to elucidate its impact on postoperative quality of life and health-related behaviors.
MATERIALS AND METHODS
General data
Fifty-four elderly patients with unstable angina pectoris who underwent systemic cardiac rehabilitation training after coronary intervention at our hospital from June 2021 to June 2022 were retrospectively selected as the rehabilitation group. Concurrently, 53 elderly patients with unstable angina pectoris who received only basic nursing and rehabilitation guidance measures after coronary intervention during the same period were selected as the control group. Table 1 presents a comparison of the general data between the two groups.
Table 1 Comparison of baseline data between the two groups.
Group
n
Age (yr)
BMI (kg/m2)
Smoking
Drinking
Hypertension
Diabetes
Gender
Number of implanted stents (each)
Killip grading
Male
Female
Grade I
Grade II
Rehabilitation group
54
73.0 ± 3.7
24.61 ± 2.02
22 (40.74)
26 (48.15)
29 (53.7)
13 (24.07)
34 (62.96)
20 (37.04)
1.43 ± 0.50
16 (29.63)
38 (70.37)
Conventional group
53
72.5 ± 3.4
24.84 ± 1.98
16 (30.19)
20 (37.74)
35 (66.04)
8 (15.09)
27 (50.94)
26 (49.06)
1.51 ± 0.51
21 (39.62)
32 (60.38)
t/χ2
0.727
-0.595
1.300
1.183
1.693
1.367
1.577
-0.819
1.181
P value
0.469
0.553
0.254
0.277
0.193
0.242
0.209
0.414
0.277
The inclusion criteria were as follows: (1) Patients aged 65–80 years old; (2) adherence to the diagnostic criteria of unstable angina[8] established by the European Society of Cardiology in 2015, including presentation with sudden retrosternal compression pain, cramping pain with dyspnea, nausea, syncope, with significant ST-segment depression during angina attacks, occasional T wave inversion, with ST-T returning to baseline post-angina relief; (3) Killip cardiac function classification[9] grade I-II; (4) underwent coronary stent implantation in our hospital, with 1-2 stents implanted 1-2; (5) received approval for enrollment by the ethics committee of our hospital; and (6) patients and their families were informed of the study design and signed the relevant consent documents in advance.
The exclusion criteria were as follows: (1) Cancer; (2) liver and kidney dysfunction; (3) severe pulmonary infection; (4) pulmonary embolism; (5) heart valve disease or myocarditis; and (6) consciousness or communication dysfunction.
Rehabilitation training measures
Conventional group: The postoperative conventional group received standard nursing care and rehabilitation guidance, including health education aimed at enhancing patient comprehension of the disease and ensuring timely medication adherence. Psychological interventions were provided to address patient needs and alleviate psychological distress. Patients were advised on a low-oil, low-salt diet, underwent cardiac function testing, and received rehabilitation training supervised by a qualified physician.
Rehabilitation group: Unstable angina was categorized into three stages using the unstable angina severity grading (Braunwald grading): stage I, severe incipient angina or worsening angina without resting pain; stage II, subacute resting angina (occurring within one month, but no attack within 48 h); and stage III, acute resting angina (attack within 48 h). The cardiac rehabilitation program was individualized based on the stage of unstable angina. Considering the advanced age of the patients, the target heart rate was determined as (220 - age) × (60% - 80%), with exercise intensity adjusted according to individual patient conditions. Rehabilitation programs were customized for each patient, following the principles of gradual progress, perseverance, interest, comprehensiveness, and individualization. Each training session consisted of preparation, training, and concluding activities. Adequate preparation and conclusion activities were deemed essential for preventing training-related accidents. All subsequent rehabilitation activities were conducted within the patient's tolerance and could be adjusted as needed.
Phase I: Within 2-4 wk, the objective was to attain a negative low-level motor test outcome and achieve the ability to walk continuously for 100-200 meters at a normal pace, ascend/descend 1-2 flights of stairs, or become symptom-free. A motor capacity of 2-3 metabolic equivalents (METs) was targeted to facilitate adaptation to familial routines. Following the stabilization of postoperative vital signs and the absence of complications, patients were permitted to engage in tolerable daily activities based on self-assessment. These activities encompassed abdominal breathing, resistance and non-resistance to wrist and ankle movements, knee and elbow movements, eating on their own, washing, sitting on the toilet, sitting or not sitting on the bed, sitting and standing with or without relying on the bedside, walking on the bedside, walking in the corridor, and going up and down stairs.
Phase II: This phase commenced 6–8 wk post-patient discharge to achieve disease stability. The aim was gradual restoration of functional capacity for daily activities, encompassing light housework and leisure pursuits. Attainment of an exercise capacity of 5–6 METs was targeted for enhanced quality of life. Activities include indoor and outdoor walks, medical gymnastics, household chores, cooking, gardening, and shopping in nearby towns.
Phase III: This stage involves late intensive rehabilitation for patients in long-term stable condition or completing phase II. Activities were conducted in community settings or at home over 2–3 months. Objectives encompassed consolidating rehabilitation outcomes, managing risk factors, enhancing physical activity, and cardiovascular function, and restoring pre-illness lifestyle and occupational capabilities. Exercise modalities comprised aerobic training (e.g., pedaling, treadmill, rowing) for at least 30 min daily, strength training (2–3 times weekly, 8–10 repetitions) using elastic bands, dumbbells, and strength exercise machines, and joint mobility and flexibility exercises (5–10 min of static pulling) preceding workouts.
Other rehabilitation methods included: (1) Health education and assessment: Patients received systematic health education through tools and videos to enhance their understanding of the disease, postoperative precautions, and rehabilitation protocols. Clinicians provided accurate guidance on medication usage to enhance compliance. Patients' current conditions were assessed, and tailored rehabilitation training was administered; (2) psychological intervention: Professional psychological assessments were conducted to alleviate patients’ anxiety regarding their postoperative condition. Guided by professional doctors, systematic interventions were implemented based on assessment results; and (3) establishment of patient rehabilitation files: Comprehensive patient rehabilitation files were created, documenting clinical diagnosis, treatment information, and lifestyle habits. Daily rehabilitation activities were recorded, and targeted rehabilitation training was provided according to cardiac function ratings.
Observation indicators
Differences in Seattle Angina Questionnaire (SAQ) and SF-36 scores, cardiopulmonary exercise function assessment indices, echocardiographic cardiac function indices, and adverse cardiovascular events were compared between the two groups.
The SAQ[10] contains five survey dimensions, namely, the limitation of physical activity, stable state of angina, frequency of angina attacks, treatment satisfaction, and disease awareness, involving a total of 19 survey questions. The standard score for each dimension was calculated as (actual score - lowest score for that dimension)/(highest score for that dimension - lowest score for that dimension) × 100%, with higher scores indicating better status after treatment.
The SF-36[11] includes nine dimensions: overall health, mental health, general health, physical function, energy, social function, physical pain, emotional function, and physical function, each scored at 100 points. The total SF-36 score is calculated as the sum of the scores for each dimension and is then averaged, with a higher score indicating better survival.
The following cardiopulmonary exercise function assessment indices were assessed[12]: VO2 Max, AT, and maximal metabolic equivalent; echocardiographic cardiac function indices, including left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), or left ventricular end-systolic diameter (LVESD).
The following echocardiographic cardiac function indicators were assessed[13]: Indices that can diagnose valvular, myocardial, and pericardial diseases, quantify cardiac function and structure, differentiate systolic and diastolic insufficiency, estimate pulmonary artery pressure, and provide objective indices for evaluating therapeutic effects, including LVEF, LVEDD, and LVESD.
The cardiovascular adverse event assessment criteria[14] (CTCAE) included recurrent angina pectoris, arrhythmia, cardiogenic stroke, myocardial infarction, and other adverse events, which are classified into five levels: the higher the level, the more serious the condition.
Statistical methods
Data were processed using SPSS 21.0, and the statistical descriptions of the count data collected in this study which conformed to a normal distribution, including the VO2 Max, AT, maximum metabolic equivalent, LVEF, LVEDD, and LVESD, were described as the (mean ± SD), while the hypothesis test for comparison between the two groups for the above measurement data was an independent sample t-test; count data (personal history, comorbid diseases, adverse cardiovascular events) were described as the n (%), and the χ2 test was used for comparative analysis between groups. Statistical significance was set at P < 0.05.
RESULTS
Comparison of cardiopulmonary exercise function and echocardiographic indexes between the two groups
Before the intervention, the measured values of VO2 Max, AT, maximum metabolic equivalent, LVESD, LVEF, and LVEDD in the two groups showed no significant difference (P > 0.05); however, after the intervention, the measured values of VO2 Max, maximum metabolic equivalent, LVEF, and LVEDD in the rehabilitation group were greater than those in the conventional group (P < 0.05), while the LVESD was lower than that in the conventional group (P < 0.05); see Table 2.
Table 2 Comparison of cardiopulmonary exercise function and echocardiographic indexes between the two groups (mean ± SD).
Before the intervention, there was no statistically significant difference in the limitation of physical activity, stable state of angina, frequency of angina attacks, degree of treatment satisfaction, and awareness of the disease between the two groups (P > 0.05); after the intervention, the degree of limitation of physical activity, stable state of angina, and treatment satisfaction scores of patients in the rehabilitation group were greater than those in the conventional group (P < 0.05); Table 3.
Table 3 Comparison of Seattle Angina Questionnaire scores between the two groups (mean ± SD, points).
Comparison of life quality scale scores between the two groups
There was no significant difference in the quality of survival scale scores between the two groups before the intervention (P > 0.05); the scores of patients in both groups increased after the intervention, and the scores of patients in the rehabilitation group were greater than those in the conventional group after the intervention (P < 0.05); Table 4.
Table 4 Comparison of life quality scale scores between the two groups (mean ± SD, points).
Group
n
Degree of treatment satisfaction
t
P value
Before the intervention
After the intervention
Rehabilitation group
54
75.81 ± 3.48
83.93 ± 5.10
-9.636
0.000
Conventional group
53
77.09 ± 4.21
80.74 ± 4.96
-4.107
0.000
t
-1.716
3.279
P value
0.089
0.001
Comparison of incidence of adverse cardiovascular events between the two groups
After the intervention, both groups were followed up for 1 year, and the incidence of adverse cardiovascular events was 9.26% in the rehabilitation group compared with 18.87% in the conventional group, with no statistically significant difference (P > 0.05); Table 5.
Table 5 Comparison of the incidence of adverse cardiovascular events between the two groups.
Group
n
Recurrent angina pectoris
Arrhythmia
Cardioembolic stroke
Myocardial infarction
Adverse cardiac event (%)
Rehabilitation group
54
3
1
0
1
5 (9.26)
Conventional group
53
5
2
2
1
10 (18.87)
χ2
2.049
P value
0.152
DISCUSSION
Unstable angina is an acute coronary syndrome triggered by the formation of coronary atherosclerotic lesions, which act as an intermediate between stable angina and acute myocardial infarction. Episodic chest pain is the primary clinical manifestation of unstable angina, which is further characterized by a risk of unstable plaque rupture leading to acute myocardial infarction[15-17]. As the primary treatment, coronary stenting surgery can reduce the degree of coronary stenosis and improve myocardial ischemia, thus reducing episodes of angina pectoris[18]. However, postoperative cardiac rehabilitation is particularly important in elderly patients because of the high risk of underlying diseases, such as hypertension and diabetes mellitus. Furthermore, elderly patients tend to be in poor physical condition and commonly show poor compliance with drug therapy[19]. The clinical use of systematic cardiac rehabilitation training can provide systematic and targeted rehabilitation for elderly patients, and improve their postoperative quality of life and health-related behaviors[20-22].
In the present study, we compared the cardiopulmonary exercise function and echocardiographic indices of unstable angina patients treated with systemic cardiac rehabilitation training (rehabilitation group) vs basic nursing and rehabilitation guidance (conventional group) after cardiac intervention. The results showed that after the intervention, the measured values of VO2 Max, maximum metabolic equivalent, LVEF, and LVEDD of the patients in the rehabilitation group were greater than those in the conventional group, whereas the LVESD was smaller, indicating that systematic cardiac rehabilitation training can significantly improve cardiac function in elderly patients. The improvement of these indicators reflects the effective recovery and adjustment of the patient's cardiovascular function and cardiac structure, which helps to prevent or delay the progression of cardiovascular disease. Unstable angina is based on fixed narrowing of the vascular lumen due to coronary atherosclerosis, with plaque rupture, erosion, or ulceration complicated by thrombosis, vasoconstriction, microvascular embolism, and other lesions, resulting in decreased myocardial oxygen supply and producing angina[23,24]. Systematic cardiac rehabilitation can improve the patient’s ability to self-intervene and motivate them to train autonomously through exercise and other means[25]. Indeed, some studies have indicated that exercise can improve endothelial cell function[26]. Rehabilitation exercise training accelerates blood circulation and plaque dissolution, increases intravascular blood flow and oxygen supply to the heart, and achieves oxygen saturation, thus ensuring the structural and functional stability of cardiac function[27]. Rehabilitation training also reduces the amount of fat that accumulates in the body and enhances the physical fitness of elderly patients[28]. Psychological interventions in systematic rehabilitation training can also reduce the effects of mood fluctuations on blood pressure in elderly patients, thus reducing their cardiac load. Therefore, through the implementation of rehabilitation training, medical teams can more targeted help patients restore heart function, improve quality of life, and reduce the incidence of cardiovascular events. In addition, these results emphasize the importance of systematic cardiac rehabilitation in elderly patients with unstable angina pectoris, providing a basis for medical institutions to develop more effective rehabilitation plans.
In the present study, we compared the SAQ scores of the two groups, finding that, after the intervention, the degree of restricted somatic activity, angina pectoris stability status, and treatment satisfaction scores of the patients in the rehabilitation group were greater than those in the conventional group. This indicates that patients in the rehabilitation group have significantly improved their daily activity ability, angina symptoms, and recognition of treatment outcomes. Therefore, medical teams can develop personalized rehabilitation plans for patients after coronary stent intervention surgery based on these findings, with a focus on restoring physical activity and alleviating angina symptoms, in order to improve the overall rehabilitation effect and quality of life of patients. Under systematic cardiac rehabilitation training, health education helped patients to correctly understand their disease, and further drew their attention to its management, which improved training enthusiasm, promoted their degree of somatic activity, strengthened their self-management ability, reduced the frequency of angina attacks, prompted patients to develop good lifestyle habits, and reduced the presence of risk factors such as smoking and alcohol consumption[29-31]. At the same time, the psychological condition of patients can be determined through psychological interventions in daily rehabilitation training, while targeted psychological interventions are carried out through professional psychological assessments to help patients reduce their mood swings. By building patient confidence in this process, a good trust relationship can be established, which improves patient treatment satisfaction. Thus, the quality of life of patients was improved in conjunction with their postoperative treatment outcomes[32-34].
In the recent study, the SF-36 scores of the two groups were compared, with the results showing higher scores in the rehabilitation group after the intervention, indicating that systematic cardiac rehabilitation training can effectively improve the quality of life of elderly patients. The incidence of adverse cardiovascular events was also compared between the two groups, and the results showed no significant difference, indicating that systematic cardiac rehabilitation training did not affect the occurrence of adverse vascular events. These results provide important basis for medical institutions to carry out systematic cardiac rehabilitation and provide more comprehensive rehabilitation services for elderly patients with coronary heart disease. Systematic health education further allows patients to correctly understand their disease, improve compliance with medication, help them form good medication habits, improve their self-intervention behavior, and allow them to actively participate in exercise rehabilitation training to promote blood circulation in patients[35]. Psychologically, patients were calmer and more encouraged to relax, thus stabilizing their blood pressure levels[36]. The patients’ diet was prepared under the guidance of professional recipes to develop a diet with less oil and salt, thus improving their quality of life.
CONCLUSION
In conclusion, the use of systematic cardiac rehabilitation training after coronary stenting interventions for unstable angina can help promote the recovery of cardiac function while improving patient quality of life and cardiopulmonary exercise tolerance.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Rehabilitation
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Kuhendra B, Australia S-Editor: Gong ZM L-Editor: A P-Editor: Wang WB
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