Likelihood of myocardial infarction during stroke rehabilitation preceded by cardiovascular screening and an exercise tolerance test: the Locomotor Experience Applied Post-Stroke (LEAPS) trial.

Coronary artery disease (CAD) is highly prevalent in patients with stroke. Coronary plaques and coronary stenosis of≥50% were observed in 72.4% and 37.5%, respectively, of patients who underwent autopsy after fatal stroke (1), and in 61.9% and 25.7%, respectively, of patients who underwent coronary angiography after stroke (2). In a meta-analysis of 39 population and randomized controlled trials (RCTs), annual risk of myocardial infarction (MI) was 2.2% (95% CI 1.7–2.7) (3). It may be twice this high in patients with internal carotid artery disease and a history of symptomatic CAD (4). However, because neither routine revascularization (5, 6) nor percutaneous coronary intervention (7, 8) improves major clinical outcomes when compared with intensive medical therapy in patients with stable CAD, and this medical therapy is identical for patients with stroke, this high prevalence of CAD is not, in and of itself, cause for diagnostic inquiry. Further diagnostic evaluation is warranted only if patients are symptomatic or have evidence of ischemia on noninvasive tests. It might also be warranted if patients are to undergo vigorous physical therapy in the course of stroke rehabilitation. This is the focus of the present investigation, which involves a secondary analysis of results of the Locomotor Experience Applied Post-Stroke (LEAPS) trial, a large, multi-center randomized controlled trial (RCT) of rehabilitation interventions for gait impairment after stroke (9, 10). LEAPS employed a cardiovascular screening questionnaire in conjunction with an exercise tolerance test (ETT) involving bicycle ergometry immediately prior to randomization in order to minimize the probability of entering subjects at risk for coronary events during study treatments. Our hypothesis was that such screening would eliminate the risk of therapy-induced MI. We report here the results of this strategy. The LEAPS trial compared two types of rehabilitation interventions provided by physical therapists to improve walking after disabling first stroke. LEAPS targeted adults who had hemiparesis due to a stroke severe enough to require inpatient rehabilitation, followed by discharge home. At the time of randomization, 2-months after stroke, participants were still limited to walking with assistance in the home or to walking short distances in the community. Interventions were: (1) a progressive, task-specific locomotor training program (LTP) that included walking on a treadmill with partial body weight-support and over-ground practice and (2) a progressive strength and balance exercise program delivered in the home (Home Exercise Program, HEP). LTP and HEP were delivered at 2-months (early) post-stroke in addition to usual care. A delayed LTP group received the intervention at 6-months post-stroke. Because the LEAPS protocol involved three 90-minute treatment sessions/week for 12 weeks, subjects were exposed to repeated vigorous exercise over an extended period of time, thereby testing the adequacy of our screening procedure.