Impact of Exercise-based Cardiac Rehabilitation on In-stent Restenosis with Different Generations of Drug Eluting Stent

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Abstract

Objective

To compare the rate of restenosis between a cardiac rehabilitation (CR) group and a control group within three different generations of drug eluting stents (DES).

Method

Patients who received DES due to an acute coronary syndrome were included. They were divided into a CR group and a control group. The CR group received six to eight weeks of early cardiac rehabilitation program in a hospital setting, and sustained a self-exercise program for six months in a community. The control group was instructed to exercise by themselves after leaving the hospital. Nine months after the first onset of disease, we implemented a coronary angiography and compared the two groups. In addition, we divided the patients into three subgroups according to the generation of DES, and compared the rate of restenosis between the CR group and control group within these three subgroups.

Results

At 9 months, in-stent restenosis, measured as an in-segment late luminal loss (LLL) of the stented coronary area, was smaller in the CR group (n=52) 0.16±0.42 mm compared to the control group (n=51) 0.39±0.78 mm (p<0.05). A reduction of LLL in the CR group compared to the control group was consistent among the three different generations of DES.

Conclusion

The CR program is strongly associated with a significant reduction in LLL in the stented coronary segments, regardless of the generation of DES.

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Most cited references 27

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Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.

Ellen Keeley, Judith Boura, Cindy Grines (2003)

Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective. We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data. Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% [n=270] vs 9% [360]; p=0.0002), death excluding the SHOCK trial data (5% [199] vs 7% [276]; p=0.0003), non-fatal reinfarction (3% [80] vs 7% [222]; p<0.0001), stroke (1% [30] vs 2% [64]; p=0.0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442]; p<0.0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA. Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.

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A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization.

Marie-Claude Morice, Patrick W. Serruys, J. Eduardo Sousa … (2002)

The need for repeated treatment of restenosis of a treated vessel remains the main limitation of percutaneous coronary revascularization. Because sirolimus (rapamycin) inhibits the proliferation of lymphocytes and smooth-muscle cells, we compared a sirolimus-eluting stent with a standard uncoated stent in patients with angina pectoris. We performed a randomized, double-blind trial to compare the two types of stents for revascularization of single, primary lesions in native coronary arteries. The trial included 238 patients at 19 medical centers. The primary end point was in-stent late luminal loss (the difference between the minimal luminal diameter immediately after the procedure and the diameter at six months). Secondary end points included the percentage of in-stent stenosis of the luminal diameter and the rate of restenosis (luminal narrowing of 50 percent or more). We also analyzed a composite clinical end point consisting of death, myocardial infarction, and percutaneous or surgical revascularization at 1, 6, and 12 months. At six months, the degree of neointimal proliferation, manifested as the mean (+/-SD) late luminal loss, was significantly lower in the sirolimus-stent group (-0.01+/-0.33 mm) than in the standard-stent group (0.80+/-0.53 mm, P<0.001). None of the patients in the sirolimus-stent group, as compared with 26.6 percent of those in the standard-stent group, had restenosis of 50 percent or more of the luminal diameter (P<0.001). There were no episodes of stent thrombosis. During a follow-up period of up to one year, the overall rate of major cardiac events was 5.8 percent in the sirolimus-stent group and 28.8 percent in the standard-stent group (P<0.001). The difference was due entirely to a higher rate of revascularization of the target vessel in the standard-stent group. As compared with a standard coronary stent, a sirolimus-eluting stent shows considerable promise for the prevention of neointimal proliferation, restenosis, and associated clinical events.

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An overview of randomized trials of rehabilitation with exercise after myocardial infarction.

J Buring, Samuel Z Goldhaber, Marilyn Olmstead … (1989)

Of 22 randomized trials of rehabilitation with exercise after myocardial infarction (MI), one trial had results that achieved conventional statistical significance. To determine whether or not these studies, in the aggregate, show a significant benefit of rehabilitation after myocardial infarction, we performed an overview of all randomized trials, involving 4,554 patients; we evaluated total and cardiovascular mortality, sudden death, and fatal and nonfatal reinfarction. For each endpoint, we calculated an odds ratio (OR) and 95% confidence interval (95% CI) for the trials combined. After an average of 3 years of follow-up, the ORs were significantly lower in the rehabilitation than in the comparison group: specifically, total mortality (OR = 0.80 [0.66, 0.96]), cardiovascular mortality (OR = 0.78 [0.63, 0.96]), and fatal reinfarction (OR = 0.75 [0.59, 0.95]). The OR for sudden death was significantly lower in the rehabilitation than in the comparison group at 1 year (OR = 0.63 [0.41, 0.97]). The data were compatible with a benefit at 2 (OR = 0.76 [0.54, 1.06]) and 3 years (OR = 0.92 [0.69, 1.23]), but these findings were not statistically significant. For nonfatal reinfarction, there were no significant differences between the two groups after 1 (OR = 1.09 [0.76, 1.57]), 2 (OR = 1.10 [0.82, 1.47]), or 3 years (OR = 1.09 [0.88, 1.34]) of follow-up. The observed 20% reduction in overall mortality reflects a decreased risk of cardiovascular mortality and fatal reinfarction throughout at least 3 years and a reduction in sudden death during the 1st year after infarction and possibly for 2-3 years. With respect to the independent effects of the physical exercise component of cardiac rehabilitation, the relatively small number of "exercise only" trials, combined with the possibility that they may have had a formal or informal nonexercise component precludes the possibility of reaching any definitive conclusion. To do so would require a randomized trial of sufficient size to distinguish between no effect and the most plausible effect based on the results of this overview.

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Author and article information

Journal

Journal ID (nlm-ta): Ann Rehabil Med

Journal ID (iso-abbrev): Ann Rehabil Med

Journal ID (publisher-id): ARM

Title: Annals of Rehabilitation Medicine

Publisher: Korean Academy of Rehabilitation Medicine

ISSN (Print): 2234-0645

ISSN (Electronic): 2234-0653

Publication date (Print): April 2012

Publication date (Electronic): 30 April 2012

Volume: 36

Issue: 2

Pages: 254-261

Affiliations

Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 139-707, Korea.

[1 ]Department of Cardiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 139-707, Korea.

Author notes

Corresponding author: Min Ho Lim. Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 761-1, Sangye 7-dong, Nowon-gu, Seoul 139-707, Korea. Tel: +82-2-950-1134, Fax: +82-2-935-3076, ckim@ 123456paik.ac.kr

Article

DOI: 10.5535/arm.2012.36.2.254

PMC ID: 3358683

PubMed ID: 22639751

SO-VID: 54064f04-885f-4db8-884b-83562b8ab3c1

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Impact of Exercise-based Cardiac Rehabilitation on In-stent Restenosis with Different Generations of Drug Eluting Stent

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Abstract

Objective

Method

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Cardiovascular Innovations and Applications

Most cited references 27

Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.

A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization.

An overview of randomized trials of rehabilitation with exercise after myocardial infarction.

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