Natural history of INOCA described
Patients with ischaemia with no obstructive coronary artery disease (INOCA) have a strong female predominance compared to patients with obstructive CAD (66% v 26%, p <0.001).
The comparison of 208 INOCA patients with 865 obstructive CAD patients also revealed INOCA patients were younger (63 v 66 years, p= 0.001), and less likely to have diabetes (19% v 33%, p <0.001), a prior MI (2% v 15%, p <0.001), and a current (12% v 16%) or former smoking history (29% v 40%, p=0.001). However INOCA patients were more likely to have depression (19% v 9%, p<0.001).
Angina frequency was similar in both groups at baseline and improved in 43% of INOCA patients despite little change in antianginal medications.
“We found no significant correlation between ischaemia severity on stress echocardiography and angina frequency or overall angina-related health status at enrolment in patients selected for moderate or severe ischaemia, either with INOCA or with obstructive CAD.”
The study said clinicians should focus on symptom management in order to maximise patients’ quality of life.
Rehab programs can work in frail and elderly
Exercise rehabilitation for older patients after a hospital admission for heart failure can improve physical function compared to usual care, according to a study in the NEJM.
An RCT of 349 patients with a mean age of 73 years compared an early, transitional, tailored progressive rehab program focusing on strength, balance, mobility and endurance with usual care which could include physical therapy or standard cardiac rehab.
The intervention started in hospital, included home-based sessions if needed until patients could attend outpatients for 12 weeks, as well as an ongoing home exercise component out to 24 weeks.
The Short Physical Performance Battery showed physical function significantly improved with the intervention after three months however rates of rehospitalisation and deaths at six months were similar in both the intervention and usual care groups.
The study said they addressed an evidence gap as most other trials have excluded frail and elderly patients with multiple comorbidities or those hospitalised within the previous six weeks – a period in which physical function was at its nadir and the risk of clinical events was high.
An editorial said the results “provide a compelling argument for the adoption of exercise rehabilitation as standard care, even for elderly, frail patients with acute heart failure.”
Education intervention fails to improve inpatient glycaemia
The use of decision-support algorithms with education on glycaemia and lipid management in the post-CABG surgery setting does not optimise blood glucose levels in patients with diabetes.
A study of 200 patients from the Fiona Stanley Hospital in WA found the intervention did not improve inpatient glycaemia, increase non-statin lipid lowering prescriptions, or reduce re-admissions to hospital within 30 days of surgery.
However the intervention did reduce the length of stay in the cardiac surgery unit and reliance on endocrinology specialist input.
“The preference for prescribing SGLT2 inhibitor therapy rather than insulin at discharge also required less endocrinology input. In addition, the establishment of an inter-speciality approved management algorithm likely improved clinician confidence in managing diabetes, thereby limiting endocrinology referrals to more complex cases,” it said.
The study also found initiation of SGLT2 inhibitors near the time of hospital discharge was not associated with significant harm.