Cardiac Rehabilitation Protects Against the Expansion of Abdominal Aortic Aneurysm

Atsuko Nakayama, Hiroyuki Morita, Masatoshi Nagayama, Katsuyuki Hoshina, Yukari Uemura, Hitonobu Tomoike, Issei Komuro, Atsuko Nakayama, Hiroyuki Morita, Masatoshi Nagayama, Katsuyuki Hoshina, Yukari Uemura, Hitonobu Tomoike, Issei Komuro

Abstract

Background: Virtually no reports on the effects of exercise in patients with a small abdominal aortic aneurysm (AAA) exist.

Methods and results: We conducted a retrospective cohort study on 1515 patients with a small AAA before surgery at 2 high-volume hospitals in Tokyo, Japan, from April 2004 to September 2015. A carefully modified cardiac rehabilitation program without excessive blood pressure elevation during exercise was prescribed to 50 patients with an AAA. Using propensity score matching, mortality and clinical outcomes, including AAA expansion rate, were compared between 2 groups: rehabilitation group and nonrehabilitation group. The background characteristics of the rehabilitation group (n=49) and the nonrehabilitation group (n=163) were almost identical. The risk for AAA repair was much lower in the rehabilitation group after matching (before matching: hazard ratio, 0.43; 95% confidence interval, 0.25-0.72; P=0.001; and after matching: hazard ratio, 0.19; 95% confidence interval, 0.07-0.50; P<0.001). AAA expansion rate was slower in the rehabilitation group (before matching: rehabilitation versus nonrehabilitation group, 2.3±3.7 versus 3.8±3.4 mm/y [P=0.008]; after matching: rehabilitation versus nonrehabilitation group, 2.1±3.0 versus 4.5±4.0 mm/y [P<0.001]). Elevation of blood pressure during exercise was positively correlated with AAA expansion rate after the rehabilitation program (r=0.569, P<0.001).

Conclusions: Cardiac rehabilitation protects against the expansion of small AAAs and mitigates the risk associated with AAA repair, possibly because of the decreased elevation of blood pressure during exercise.

Clinical trial registration: URL: upload.umin.ac.jp. Unique identifier: UMIN000028237.

Keywords: abdominal aortic aneurysm; cardiac rehabilitation; exercise training; systolic blood pressure.

© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Flow chart of abdominal aortic aneurysm (AAA) patient inclusion and reasons for exclusion. Patients with small AAAs, defined as a maximal diameter of >30 mm and <55 mm, were retrospectively taken into consideration. Of a total 1515 patients, those who underwent AAA repair within 150 days of diagnosis, those with a short follow‐up of <150 days, those who had no follow‐up computed tomographic scan, and those diagnosed as having Marfan syndrome, IgG4‐related disease, saccular aneurysm, infectious aneurysm, traumatic aneurysm, inflammatory aneurysm, or congenital aneurysm were excluded. After these exclusions, 213 patients with small AAAs remained, and of those patients, 49 participated in the cardiac rehabilitation program. Finally, 88 patients remained after propensity score matching.
Figure 2
Figure 2
Explanation of the exercise procedure. Vital signs, including blood pressure and heart rate, were checked, followed by stretches for 10 minutes as a gradual warm‐up before exercise. The duration of continuous exercise (an ergometry with a modified anaerobic threshold [AT] level) was ≈30 minutes without interval, and vital signs were checked by medical staff repeatedly, every 10 minutes. Exercise was discontinued when blood pressure during exercise was >150/100 mm Hg. The duration of the gradual cooling‐down period after exercise was ≈10 minutes. Patients were recommended to consume water, according to their medical status, before checkout.
Figure 3
Figure 3
Degree of exercise stress. The exercise intensity level was set using percentage maximum heart rate (% HR) or the exercise factor from the Karvonen formula. For convenience, the approximate systolic blood pressure (SBP) corresponding to each exercise intensity in our institutes is described. The exercise stress with a modified anaerobic threshold (AT) level was much lower than that of other cardiac rehabilitation programs. Exercise with a modified AT level corresponds to an SBP of <150 mm Hg. AAA indicates abdominal aortic aneurysm.
Figure 4
Figure 4
Risks of abdominal aortic aneurysm (AAA) repair, death by any cause, and major adverse cardiovascular events (MACEs) in patients with small AAAs. The risks of AAA repair, death by any cause, and MACEs in patients with small AAAs were analyzed using the Kaplan‐Meier method. A through C, Comparison between the rehabilitation group (n=49) and the nonrehabilitation group (n=163) before matching. D through F, Comparison between the rehabilitation group (n=44) and the nonrehabilitation group (n=44) after matching. Reha indicates rehabilitation.
Figure 5
Figure 5
Receiver operating characteristic (ROC) curves for the accelerated abdominal aortic aneurysm (AAA) expansion rate. A, Areas under ROC curves for the accelerated AAA expansion rate (>5 mm/y) of the initial high‐sensitivity C‐reactive protein (hsCRP) values, hsCRP values after 1 year, and ΔCRP (hsCRP values after 1 year–initial hsCRP values) (n=213) were 0.475, 0.506, and 0.525, respectively (P=0.581, P=0.416, and P=0.594, respectively). B, After the rehabilitation program (n=49), the areas under the ROC curves for accelerated AAA expansion rate (>5 mm/y) of systolic blood pressure (SBP) at rest, SBP at exercise with a modified anaerobic threshold (AT) level, and ΔSBP during exercise (SBP at exercise with modified AT level–SBP at rest) were 0.483, 0.683, and 0.780, respectively (P=0.855, P=0.055, and P=0.003, respectively).
Figure 6
Figure 6
Correlation between the abdominal aortic aneurysm (AAA) expansion rate and systolic blood pressure (SBP) parameters in the rehabilitation group (n=49). Before the rehabilitation program, the AAA expansion rate had no notable correlation with SBP at rest (A), no correlation with SBP at exercise with a modified anaerobic threshold (AT) level (B), and no ΔSBP during exercise (SBP at exercise with modified AT level–SBP at rest) (C). After the rehabilitation program, the AAA expansion rate was not correlated with SBP at rest (D) but was significantly correlated with SBP at exercise with a modified AT level (E) and ΔSBP during exercise (F).
Figure 7
Figure 7
Risk factors for accelerated abdominal aortic aneurysm (AAA) expansion (>5 mm/y) in the rehabilitation group (n=49). With the logistic univariable regression analysis, change in systolic blood pressure (ΔSBP) during exercise >6.5 mm Hg after the rehabilitation program was correlated with accelerated AAA expansion (>5 mm/y). ACE indicates angiotensin‐converting enzyme; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CRP, C‐reactive protein; EF, ejection fraction; and HR, hazard ratio.

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