Impact of Cardiac Rehabilitation Programs on Left Ventricular Remodeling After Acute Myocardial Infarction - the REHAB Trial

Study Overview
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Brief Summary
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The aim of REHAB trial is to investigate the impact of early mobilization after AMI in reducing left ventricular remodeling, as assessed by cardiac magnetic resonance imaging. At the same time, the study aims to demonstrate the contribution of early mobilization to reduction of: systemic inflammation in the immediate post infarction phase, complication rates and mortality, in patients who had suffered a recent AMI, for a 1 year follow-up period.

Detailed Description
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While the role of early mobilization in the immediate postinfarction period has been well demonstrated, little is known in present about the link between early mobilization and reduction of systemic inflammation. At the same time, the impact of early mobilization on regression of left ventricular remodeling has not been elucidated so far. The study will be a single-center, observational, non-randomized study, which will be carried out in the Center of Advanced Research in Multimodal Cardiac Imaging Cardiomed, including 100 patients with AMI, presenting with either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment elevation AMI (NSTEMI). According to the moment of mobilization after AMI patients will be distributed in two groups: group 1 - patients with early mobilization (<2 days after the onset of symptoms), and group 2 - subjects with delayed mobilization after AMI (>2 days after the onset of symptoms). Each patient will be evaluated in terms of systemic inflammatory status in the immediate postinfarction phase, at baseline and at 7 days after AMI. In order to assess ventricular function and remodeling, extent of myocardial scar and transmurality index, late gadolinium enhancement CMR will be performed for each patient. The study will be conducted over a period of 2 years, in which patients will be examined at baseline, and will be followed-up for 1 year for occurrence of MACE. All patients will sign an informed written consent prior to study enrollment. Study objectives: Primary: to evaluate the impact of early mobilization after AMI on the ventricular remodeling in the post-infarction period, as assessed by CMR imaging. Secondary: to assess the rate of in-hospital mortality and the rate of repeated revascularization or MACE (including cardiovascular death or stroke) in patients with early mobilization as compared to those with delayed mobilization, and the effect of early mobilization on systemic inflammation in the immediate postinfarction phase. Study Timeline: Baseline (day 0): Achieve written informed consent form all patients Check all inclusion/exclusion criteria Record demographic information, medical records, cardiovascular risk factors Perform and record physical examination and 12-lead ECG Laboratory analysis (CBC, routine biochemistry, inflammatory biomarkers, acute adhesion molecules) Transthoracic echocardiography / speckle tracking Visit 1 (day 7 / discharge from the hospital): hs-CRP assessment Visit 2 (month 1): LGE-CMR (myocardial fibrosis/scar, infarct size, transmurality, remodeling) Visit 3,4,5 (month 3,6,9): Record results of physical exam, medical records, ECG Transthoracic echocardiography / speckle tracking Final study visit (month 12): Record results of physical exam, medical records, ECG Transthoracic echocardiography / speckle tracking End-point assessment Study procedures: Medical records, physical exam; Laboratory analysis (complete blood count, biochemistry, serum levels of hs-CRP, MMPs, IL6, NT-pro-BNP); Electrocardiography Transthoracic echocardiography for assessment of left ventricular systolic and diastolic performance, speckle tracking echocardiography, Dobutamine viability test Late gadolinium enhancement CMR for evaluation of ventricular function and remodeling, extent of myocardial scar and transmurality index.

Official Title
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Impact of Cardiac Rehabilitation Programs on Left Ventricular Remodeling After Acute Myocardial Infarction - the REHAB Trial

Conditions
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Acute Myocardial Infarction, Non-ST Elevation Myocardial Infarction, Systemic Inflammation, Ventricular Remodeling, Acute Coronary Syndrome

Intervention / Treatment
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* Diagnostic Test: Cardiac imaging
* Diagnostic Test: Laboratory analysis


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with AMI in the last 12 hours; Successful revascularization of the culprit artery within the first 12 hours after the onset of symptoms in STEMI or within first 48 hours in NSTEMI (according to the risk class); Signed written informed consent. Exclusion Criteria: Patient refusal; Any condition that would contraindicate CMR examination; Women during pregnancy or lactation period; Women able to procreate without any contraceptive usage; Chronic kidney disease (glomerular filtration rate <60ml/min/1.73m2) or acute renal injury that requires hemodialysis; Any type of neoplasia documented in the last 3 years before randomization; Expectation of life < 1 year.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| RHB-SG 01<br>Patients with early mobilization (< 2 days after the onset of symptoms) | Diagnostic Test: Cardiac imaging<br>* Transthoracic echocardiography Late gadolinium enhancement CMR<br>Diagnostic Test: Laboratory analysis<br>* complete blood count biochemistry hs-CRP, MMPs, IL6, NT-pro-BNP<br>|
| RHB-SG 02<br>Patients with delayed mobilization after AMI (>2 days after the onset of symptoms) | Diagnostic Test: Cardiac imaging<br>* Transthoracic echocardiography Late gadolinium enhancement CMR<br>Diagnostic Test: Laboratory analysis<br>* complete blood count biochemistry hs-CRP, MMPs, IL6, NT-pro-BNP<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Ventricular remodeling in the post-infarction period | LGE-CMR evaluation for myocardial fibrosis/scar, infarct size, transmurality, remodeling assessment. | Month 1 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Major adverse cardiovascular events | Rate of MACE at follow-up | 12 months | 
| Systemic inflammation in the immediate postinfarction phase | Inflammatory status evaluation via hs-CRP assessment at baseline and at 7 days from the acute event. | Day 7 |