Exercise Training Intervention After Coronary Angioplasty: The ETICA Trial - ETICA Trial

Description:

Exercise Training Intervention After Coronary Angioplasty: The ETICA Trial

Hypothesis:

Exercise training in coronary disease enhances functional capacity and can reduce angina. This study sought to determine the effects of exercise training (ET) on restenosis rate, outcome, functional capacity and quality of life (QOL) following PTCA with or without coronary stenting (CS).

Study Design

Study Design:

Patients Enrolled: 118

Drug/Procedures Used:

118 men and women with CAD who underwent successful PTCA/CS were randomized to ET or a control group at 11 to 39 days following the procedure. Exercise training consisted of 15 minutes of calisthenics and 40 minutes of stationary biking at 60% of peak V02 three times weekly for 6 months. Controls were told to avoid training and each group reported daily activities. Lipid lowering therapy was not allowed. Baseline and 6-month studies by protocol included a repeat coronary arteriogram, qualitative exercise thallium myocardial perfusion imaging, echocardiogram and cardiopulmonary exercise test. Follow-up events were defined as death, cardiac death, MI and repeat revascularization.

Principal Findings:

There were no between-group differences at baseline regarding average age (57+10 years), gender (80% male), fitness, lipids, history of MI (50%), primary angioplasty for MI (16%), LVEF (50%), smokers (65%), diabetics (18%), number of diseased vessels (about 2/3 > 1 vessel), infarct-related angioplasty (50%), vessel location (65% LAD), lesion type (50% A), stent type and residual diameter stenosis. At 6 months, training was associated with more smoking cessation, reduced systolic BP, total and LDL cholesterol and triglycerides and increased HDL-C. Only trained patients had an improvement in peak V02 (26% compared to baseline), and there was a 26.8% enhanced QOL associated with ET compared to control persisting at least 6 months after training. Angiographic restenosis (average 30%) was unaffected by ET, however residual diameter stenosis was lower in trained patients (29.7% less, p=0.045). Despite angiographic restenosis, thallium uptake improved with ET in 19% of patients and scintigraphy was less capable of detecting restenosis (53% vs. 70%). During an average 33-month follow-up training was associated with a reduction in cardiac event rate (11.9 vs. 32.2%, RR 0.71, p < 0.008), a lower hospital readmission rate (18.6 vs. 46%, RR 0.69, p < 0.001) and a reduced need for further revascularization (10 vs. 27%, RR 0.78 p < 0.03). Reduction in events was not collinear with changes in coronary risk profile and thallium uptake. The only independent predictor of events was exercise training (p=0.008).

Moderate exercise training improves functional capacity and QOL after PTCA/stenting. During follow-up, trained patients had fewer events, less revascularization and a lower hospitalization rate despite no difference in restenosis.

Interpretation:

This is an extraordinarily comprehensive study. Not surprising, the very strong benefits attributable to formal exercise training were independent of angiographic restenosis in this group with relatively severe CAD. Improved lipids, smoking cessation and exercise may each contribute to improving coronary endothelial function. In the US, the duration of formal cardiac rehabilitation is currently 2–12 weeks. This study, however, suggests that 6 months of formal group exercise may increase the likelihood of a long-term commitment to all coronary prevention strategies.

References:

1. Belardinelli R, Paolini I, Cianci G, et al. J Am Coll Cardiol 2001;37:1891-900.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Sports and Exercise Cardiology, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Interventions and Imaging, Angiography, Nuclear Imaging, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Myocardial Perfusion Imaging, Follow-Up Studies, Cholesterol, LDL, Constriction, Pathologic, Angioplasty, Balloon, Coronary, Stents, Coronary Angiography, Quality of Life, Patient Readmission, Thallium, Gymnastics, Triglycerides, Diabetes Mellitus, Smoking Cessation, Exercise Test


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