Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Cardiac Rehabilitation in the Modern Era: Optimizing Recovery and Reducing Recurrence

Cardiovascular diseases (CVDs) continue to be a prominent issue in global health, emphasizing the necessity for efficient cardiac rehabilitation programs. This narrative review provides a detailed analysis of the current state of cardiac rehabilitation, focusing on maximizing recovery and minimizing the likelihood of recurrence. This paper examines the historical progression of cardiac rehabilitation, explores the epidemiological background of cardiovascular disease (CVD), and provides an overview of the many stages of the rehabilitation process. The assessment of patients plays a crucial role in healthcare, serving as a fundamental basis that incorporates medical, psychological, and social aspects. The utilization of risk stratification techniques further enhances this process. The present study investigates exercise training, particularly emphasizing the current recommendations and the mutually beneficial effects of aerobic and resistance regimens. In addition to physical therapies, this study emphasizes the importance of nutrition, lifestyle adjustments, and the significant effects of medication. Psychosocial assistance is a crucial element that addresses the significant psychological effects of cardiac disease and provides comprehensive techniques for overall well-being. Technological advancements are significantly transforming the domain of cardiac rehabilitation, encompassing the integration of wearable technologies and telemedicine solutions. The convergence of artificial intelligence and data analytics can enhance the customization of healthcare services. Through a comprehensive rehabilitation program, patients can achieve an improved quality of life and enhanced functional outcomes. However, it is essential to acknowledge that obstacles still hinder individuals from accessing and completing educational programs. Therefore, it is crucial to engage in a discourse on potential tactics that may be employed to address these issues, considering the various cultural and socioeconomic aspects that contribute to them. The analysis focuses on the economic dimension, examining the cost-effectiveness of rehabilitation programs and their congruence with healthcare policies. In anticipation of future developments, the study provides valuable perspectives on the prospective trajectory of cardiac rehabilitation. It delves into nascent patterns and examines the potential ramifications of precision medicine and genetics for tailoring treatment strategies to individual patients. In brief, this narrative review comprehensively examines the various dimensions of contemporary cardiac rehabilitation. It offers a comprehensive perspective on its significance in enhancing recuperation and mitigating the likelihood of the recurrence of cardiovascular ailments. The significance of this review lies in its ability to enhance patient outcomes, thereby making a valuable contribution to the worldwide endeavor to address the burden of cardiovascular disease.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Safety and Feasibility of Tele-Cardiac Rehabilitation Using Remote Biological Signal Monitoring System: A Pilot Study

BACKGROUND

Cardiac rehabilitation (CR) is categorized as a class I recommendation in the guidelines for the management of patients with cardiovascular disease (CVD). However, the penetration rate of outpatient CR is low in Japan. We designed a pilot study to evaluate the safety and feasibility of tele-CR using a remote biological signal monitoring system.

METHODS

A total of nine patients (median aged 70.0 (66.0 - 76.0) years (male = 6) with CVD who participated in phase II CR for 1 month under the exercise prescription using the cardiopulmonary exercise test (CPET) were analyzed. They participated in the tele-CR program with a remote biological signal monitoring system (Nipro HeartLineTM, Osaka, Japan, and Duranta, Miyagi, Japan) in the CR room and were instructed by the CR staff from a separate room in the hospital. We evaluated the occurrence and degree of remote biological signal monitoring defects as safety evaluation items, i.e., whether the patients could set the remote biological signal monitoring equipment, as a feasibility evaluation item during a 3-month period. We also performed CPET at the baseline and follow-up. Following the 3-month tele-CR program, a total of 122 remote CR programs were performed using the remote biological signal monitoring system.

RESULTS

No patient experienced a lack of remote biological signal monitoring during exercise therapy. Significant improvement was noted in the exercise capacity, as assessed using the cardiopulmonary test (from 19.5 (16.7 - 20.2) mL/kg/min to 21.1 (17.3 - 22.8) mL/kg/min, P = 0.01, age ratio from 86% (75-96%) to 99% (78-104%), P = 0.01). One patient required support using the remote biological signal monitoring system, including information technology literacy.

CONCLUSIONS

This study suggests the safety and feasibility of tele-CR using the remote biological signal monitoring system. However, further investigations are required to explore the suitability, effects, and cost-effectiveness of tele-CR as an alternative to center-based CR in the future.

Validation of Wearable Digital Devices for Heart Rate Measurement During Exercise Test in Patients With Coronary Artery Disease

OBJECTIVE

To assess the accuracy of recently commercialized wearable devices in heart rate (HR) measurement during cardiopulmonary exercise test (CPX) under gradual increase in exercise intensity, while wearable devices with HR monitors are reported to be less accurate in different exercise intensities.

METHODS

CPX was performed for patients with coronary artery disease (CAD). Twelve lead electrocardiograph (ECG) was the gold standard and Apple watch 7 (AW7), Galaxy watch 4 (GW4) and Bio Patch Mobicare 200 (MC200) were applied for comparison. Paired absolute difference (PAD), mean absolute percentage error (MAPE) and intraclass correlation coefficient (ICC) were evaluated for each device.

RESULTS

Forty-four participants with CAD were included. All the devices showed MAPE under 2% and ICC above 0.9 in rest, exercise and recovery phases (MC200=0.999, GW4=0.997, AW7=0.998). When comparing exercise and recovery phase, PAD of MC200 and AW7 in recovery phase were significantly bigger than PAD of exercise phase (p<0.05). Although not significant, PAD of GW4 tended to be bigger in recovery phase, too. Also, when stratified by HR 20, ICC of all the devices were highest under HR of 100, and ICC decreased as HR increased. However, except for ICC of GW4 at HR above 160 (=0.867), all ICCs exceeded 0.9 indicating excellent accuracy.

CONCLUSION

The HR measurement of the devices validated in this study shows a high concordance with the ECG device, so CAD patients may benefit from the devices during high-intensity exercise under conditions where HR is measured reliably.

Global perspectives on heart disease rehabilitation and secondary prevention: a scientific statement from the Association of Cardiovascular Nursing and Allied Professions, European Association of Preventive Cardiology, and International Council of Cardiovascular Prevention and Rehabilitation

Cardiovascular disease is a leading cause of death, morbidity, disability, and reduced health-related quality of life, as well as economic burden worldwide, with some 80% of disease burden occurring in the low- and middle-income country (LMIC) settings. With increasing numbers of people living longer with symptomatic disease, the effectiveness and accessibility of secondary preventative and rehabilitative health services have never been more important. Whilst LMICs experience the highest prevalence and mortality rates, the global approach to secondary prevention and cardiac rehabilitation, which mitigates this burden, has traditionally been driven from clinical guidelines emanating from high-income settings. This state-of-the art review provides a contemporary global perspective on cardiac rehabilitation and secondary prevention, contrasting the challenges of and opportunities for high vs. lower income settings. Actionable solutions to overcome system, clinician, programme, and patient level barriers to cardiac rehabilitation access in LMICs are provided.

Educational Intervention Effects on Depression and Anxiety in Patients after Myocardial Infarction: A Randomized Controlled Trial

Depression and anxiety in cardiovascular disease worsen the prognosis of patients. Treatments for these disorders often provide limited improvement. The present study aimed to test, for the first time, the impact of educational technology on anxiety and depressive symptoms in patients participating in a cardiac rehabilitation program. A 12-month randomized controlled trial was conducted, in which 207 patients were randomly assigned to either the experimental (n = 76) or control (n = 69) groups. The intervention involved a structured patient education program provided by medical students who had undergone specially designed training in cardiac rehabilitation. The primary outcomes were death, hospitalization, heart failure, and recurrent myocardial infarction. The study also assessed anxiety and depression. A year later, the experimental group showed a statistically significant decrease in anxiety and depression on the HADS scale, with reductions of 2.0 and 1.9 points, respectively (p < 0.05). The control group showed reductions of 1.5 and 1.2 points (p < 0.05). The difference in the Hamilton Rating Scale for Depression between the groups at 12 months was -1.29 in favor of the main group (95% CI, -0.7 to -1.88), and the standardized mean difference was 0.36 (95% CI, 0.03 to 0.69). No treatment-related adverse events were observed. The results suggest that educational interventions can have a positive impact on mental health. The study's strengths include a structured intervention, randomization, and long-term follow-up. The limitations include the lack of blinding of study participants and a relatively small sample size.

ehealth technology in cardiac exercise therapeutics for pediatric patients with congenital and acquired heart conditions: a summary of evidence and future directions

Many children and adolescents with congenital and acquired heart disease (CHD) are physically inactive and participate in an insufficient amount of moderate-to-vigorous intensity exercise. Although physical activity (PA) and exercise interventions are effective at improving short- and long-term physiological and psychosocial outcomes in youth with CHD, several barriers including resource limitations, financial costs, and knowledge inhibit widespread implementation and dissemination of these beneficial programs. New and developing eHealth, mHealth, and remote monitoring technologies offer a potentially transformative and cost-effective solution to increase access to PA and exercise programs for youth with CHD, yet little has been written on this topic. In this review, a cardiac exercise therapeutics (CET) model is presented as a systematic approach to PA and exercise, with assessment and testing guiding three sequential PA and exercise intervention approaches of progressive intensity and resource requirements: (1) PA and exercise promotion within a clinical setting; (2) unsupervised exercise prescription; and (3) medically supervised fitness training intervention (i.e., cardiac rehabilitation). Using the CET model, the goal of this review is to summarize the current evidence describing the application of novel technologies within CET in populations of children and adolescents with CHD and introduce potential future applications of these technologies with an emphasis on improving equity and access to patients in low-resource settings and underserved communities.

Cost-effectiveness of home-based cardiac rehabilitation: a systematic review

OBJECTIVE

Centre-based cardiac rehabilitation (CR) is recognised as cost-effective for individuals following a cardiac event. However, home-based alternatives are becoming increasingly popular, especially since COVID-19, which necessitated alternative modes of care delivery. This review aimed to assess whether home-based CR interventions are cost-effective (vs centre-based CR).

METHODS

Using the MEDLINE, Embase and PsycINFO databases, literature searches were conducted in October 2021 to identify full economic evaluations (synthesising costs and effects). Studies were included if they focused on home-based elements of a CR programme or full home-based programmes. Data extraction and critical appraisal were completed using the NHS EED handbook, Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists and were summarised narratively. The protocol was registered on the PROSPERO database (CRD42021286252).

RESULTS

Nine studies were included in the review. Interventions were heterogeneous in terms of delivery, components of care and duration. Most studies were economic evaluations within clinical trials (8/9). All studies reported quality-adjusted life years, with the EQ-5D as the most common measure of health status (6/9 studies). Most studies (7/9 studies) concluded that home-based CR (added to or replacing centre-based CR) was cost-effective compared with centre-based options.

CONCLUSIONS

Evidence suggests that home-based CR options are cost-effective. The limited size of the evidence base and heterogeneity in methods limits external validity. There were further limitations to the evidence base (eg, limited sample sizes) that increase uncertainty. Future research is needed to cover a greater range of home-based designs, including home-based options for psychological care, with greater sample sizes and the potential to acknowledge patient heterogeneity.

Hybrid Cardiac Telerehabilitation After Acute Coronary Syndrome: Self-selection Predictors and Outcomes

Aims

To evaluate the effectiveness of a hybrid cardiac telerehabilitation (HCTR) program after acute coronary syndrome (ACS) on patient quality of life (QoL) and physical activity indices throughout phases 2-3 and establish predictors for hybrid program self-selection.

Methodology

This single-centre longitudinal retrospective study included patients who attended a cardiac rehabilitation program (CRP) between 2018-2021. Patients self-selected between two groups: Group 1 - conventional CRP (CCRP); Group 2 - HCTR. Baseline characteristics were registered. EuroQol-5D (EQ-5D) and International Physical Activity Questionnaire (IPAQ) were applied at three times: T0 - phase 2 onset; T1 - phase 3 onset; T2 - 3 months after T1.

Results

59 patients participated (Group 1 - 27; Group 2 - 32). We found significant between-group differences regarding occupation (p=0.003). Diabetic patients were less likely to self-select into HCTR (OR=0.21; p<0.05). EQ-5D visual analogue scale and IPAQ result significantly improved between T0-T2 only for HCTR (p=0.001; p=0.021).

Conclusions

HCTR was superior to CCRP on physical activity indices and QoL of ACS patients.

Effect of Constant vs. Variable Moderate-Intensity Load on Peak Oxygen Uptake in Outpatient Cardiac Rehabilitation

Background: In outpatient center-based cardiac rehabilitation (O-CBCR), moderate-intensity continuous training (MICT) based on the anaerobic threshold (AT) determined by cardiopulmonary exercise stress testing is recommended. However, it is unclear whether differences in exercise intensity within the MICT domain affect peak oxygen uptake (%peakV̇O2). Methods and Results: We retrospectively evaluated patients who underwent O-CBCR at Japan Community Healthcare Organization Osaka Hospital. Those treated with the constant-load method were designated as Group A (n=38), whereas those treated with the variable-load method were designated as Group B (n=48). Although the change in exercise intensity was significantly greater in Group B by approximately 4.5 W, the change in %peakV̇O2 was not significantly different between groups. Group A had a significantly longer exercise time than Group B (by approximately 4-5 min). No deaths or hospitalizations occurred in either group. The percentage of episodes with exercise cessation was similar between the 2 groups, but the percentage of episodes with load reduction was significantly higher in Group B, mostly because of the increased heart rate. Conclusions: In supervised MICT based on AT, the variable-load method increased exercise intensity more than the constant-load method without severe complications, but did not improve %peakV̇O2.

Artificial intelligence for secondary prevention of myocardial infarction: A qualitative study of patient and health professional perspectives

BACKGROUND

Artificial intelligence (AI) has potential to improve self-management of several chronic conditions. However, the perspective of patients and healthcare professionals regarding AI-enabled health management programs, which are key to successful implementation, remains poorly understood.

PURPOSE

To explore the opinions of people with a history of myocardial infarction (PHMI) and health professionals on the use of AI for secondary prevention of MI.

PROCEDURE

Three rounds of focus groups were conducted via videoconferencing with 38 participants: 22 PHMI and 16 health professionals.

FINDINGS

We identified 21 concepts stemming from participants' views, which we classified into five categories: Trust; Expected Functions; Adoption; Concerns; and Perceived Benefits. Trust covered the credibility of information and safety to believe health advice. Expected Functions covered tailored feedback and personalised advice. Adoption included usability features and overall interest in AI. Concerns originated from previous negative experience with AI. Perceived Benefits included the usefulness of AI to provide advice when regular contact with healthcare services is not feasible. Health professionals were more optimistic than PHMI about the usefulness of AI for improving health behaviour.

CONCLUSIONS

Altogether, our findings provide key insights from end-users to improve the likelihood of successful implementation and adoption of AI-enabled systems in the context of MI, as an exemplar of broader applications in chronic disease management.

Unmet Needs for Cardiac Rehabilitation in Africa: A Perennial Gap in the Management of Individuals with Cardiac Diseases

Cardiac rehabilitation (CR) is a standard model of care, and an established component of comprehensive care that has been proven to reduce mortality and morbidity in patients with cardiac diseases. International clinical practice guidelines routinely recommend that cardiac patients participate in CR programs for comprehensive secondary prevention. However, there is scant guidance on how to deliver these programs in low-resourced settings. This dearth of clinical practice guidelines may be an indication of low emphasis placed on CR as a component of cardiac health services in low-income countries, especially in Africa. Indeed, CR programs are almost non-existent in Africa despite the unmet need for CR in patients with ischemic heart disease in Africa reported to be about one million. This figure represents the highest unmet need of any World Health Organization region, and is colossal given the projected accelerated increases in incidence of cardiovascular diseases (CVD) in the region. This narrative review explored the availability of CR programs, potential barriers to CR and strategies that can mitigate such barriers in Africa.

Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology

Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Association of Home-Based Cardiac Rehabilitation With Lower Mortality in Patients With Cardiovascular Disease: Results From the Veterans Health Administration Healthy Heart Program

Background Home-based cardiac rehabilitation (HBCR) and traditional facility-based cardiac rehabilitation (CR) programs have similar effects on mortality in clinical trials and meta-analyses. However, the effect of HBCR on mortality in clinical practice settings is less clear. Therefore, we sought to compare mortality rates in HBCR participants versus nonparticipants. Methods and Results We evaluated all patients who were referred to and eligible for outpatient CR between 2013 and 2018 at the San Francisco Veterans Health Administration. Patients who chose to attend facility-based CR and those who died within 30 days of hospitalization were excluded. Patients who chose to participate in HBCR received up to 9 telephonic coaching and motivational interviewing sessions over 12 weeks. All patients were followed through June 30, 2021. We used Cox proportional hazards regression models with inverse probability treatment weighting to compare mortality in HBCR participants versus nonparticipants. Of the 1120 patients (mean age 68, 98% male, 76% White) who were referred and eligible, 490 (44%) participated in HBCR. During a median follow-up of 4.2 years, 185 patients (17%) died. Mortality was lower among the 490 HBCR participants versus the 630 nonparticipants (12% versus 20%; P<0.01). In an inverse probability weighted Cox regression analysis adjusted for patient demographics and comorbid conditions, the hazard of mortality remained 36% lower among HBCR participants versus nonparticipants (hazard ratio, 0.64 [95% CI, 0.45-0.90], P=0.01). Conclusions Among patients eligible for CR, participation in HBCR was associated with 36% lower hazard of mortality. Although unmeasured confounding can never be eliminated in an observational study, our findings suggest that HBCR may benefit patients who cannot attend traditional CR programs.

The impacts of the combination service model of cardiac rehabilitation on patient outcomes: evidence from a hospital experience

This research is to test whether the combination model (CM) (combining cardiac rehabilitation (CR) with other cardiovascular medical services) impact patients' readmissions, physical and psychological outcomes. We found that CM significantly enhances patients' exercise ability and psychological condition and reduces readmission rates after discharged from the hospital, compared to patients that are admitted to non-CM. Departments' physical resources weaken the impact of CM on patients' physical outcomes and readmission rates while increasing patients' psychological conditions. Human resources strengthen the impact of CM on patients' readmission rates while reducing the impact on patients' physical outcomes. Our results provide empirical evidence for hospital resource constraints puzzle and reallocation. These results provide a possibility of introducing CM as a way to deal with CR implementing challenges.

Effects of home-based cardiac telerehabilitation programs in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

Recent advances in telecommunications technology have raised the possibility of telehealth intervention delivering cardiac telerehabilitation, which may provide the efficacy of health services in patients after percutaneous coronary intervention (PCI). This study aimed to investigate the effects of home-based cardiac telerehabilitation (HBCTR) in patients undergoing PCI.

METHODS

We performed a comprehensive search of the following electronic databases: PubMed, Cochrane Central, Web of Science, Embase, CNKI, and WANFANG. For the prespecified outcomes, the primary outcomes were results of physical function (the six-minute walking test, 6MWT) and quality of life (QoL) of the participants. The secondary outcomes were results of (1) blood pressure; (2) full lipid profile (3) reliable assessment of anxiety and depression in patients.

RESULTS

All studies were conducted between 2013 and 2022, and a total of 5 articles could be included in the quantitative meta-analysis. The results showed that there was a statistically significant difference between the HBCTR intervention group and the control group in 6WMT (MD 16.59, 95%CI 7.13 to 26.06, P = 0.0006), but there was no difference in QoL (SMD  - 0.25, 95%CI  - 1.63 to 1.13, P = 0.73). According to the fixed effects model, there was a statistically significant difference between the HBCTR group versus the control group (MD - 2.88, 95%CI - 5.19 to - 0.57, P = 0.01), but not in diastolic blood pressure. Likewise, significant improvements of triglycerides and in low-density lipoprotein cholesterol were observed in HBTCR groups, but no significant differences were observed regarding total cholesterol and high-density lipoprotein cholesterol.

CONCLUSION

This systematic review and meta-analysis have proven that the HBCTR is one of the promisingly effective cardiac rehabilitation strategies that improve cardiorespiratory fitness and reduce cardiovascular disease risk factors. With the continuous improvement of the telerehabilitation network, it is expected to serve in clinical.

Assessing the Efficacy of a Virtual Assistant in the Remote Cardiac Rehabilitation of Heart Failure and Ischemic Heart Disease Patients: Case-Control Study of Romanian Adult Patients

Cardiovascular diseases (CVDs) are the leading cause of mortality in Europe, with potentially more than 60 million deaths per year, with an age-standardized rate of morbidity-mortality higher in men than women, exceeding deaths from cancer. Heart attacks and strokes account for more than four out of every five CVD fatalities globally. After a patient overcomes an acute cardiovascular event, they are referred for rehabilitation to help them to restore most of their normal cardiac functions. One effective way to provide this activity regimen is via virtual models or telerehabilitation, where the patient can avail themselves of the rehabilitation services from the comfort of their homes at designated timings. Under the funding of the European Union's Horizon 2020 Research and Innovation program, grant no 769807, a virtual rehabilitation assistant has been designed for elderly patients (vCare), with the overall objective of supporting recovery and an active life at home, enhancing patients' quality of life, lowering disease-specific risk factors, and ensuring better adherence to a home rehabilitation program. In the vCare project, the Carol Davila University of Bucharest (UMFCD) was in charge of the heart failure (HF) and ischemic heart disease (IHD) groups of patients. By creating a digital environment at patients' homes, the vCare system's effectiveness, use, and feasibility was evaluated. A total of 30 heart failure patients and 20 ischemic heart disease patients were included in the study. Despite the COVID-19 restrictions and a few technical difficulties, HF and IHD patients who performed cardiac rehabilitation using the vCare system had similar results compared to the ambulatory group, and better results compared to the control group.

Remotely Delivered Cardiac Rehabilitation Exercise for Coronary Heart Disease: Nonrandomized Feasibility Study

BACKGROUND

Exercise-based cardiac rehabilitation (CR) is recommended for coronary heart disease (CHD). However, poor uptake of and poor adherence to CR exercise programs have been reported globally. Delivering CR exercise classes remotely may remove some of the barriers associated with traditional hospital- or center-based CR.

OBJECTIVE

We have developed a bespoke platform, Eastern Corridor Medical Engineering Centre-Cardiac Rehabilitation (ECME-CR), to support remotely delivered CR exercise. This pilot trial sought to test the ECME-CR platform and examine the efficacy and feasibility of a remote CR exercise program compared to a traditional center-based program.

METHODS

In all, 21 participants with CHD were recruited and assigned to either the intervention or control group. Both groups performed the same 8-week exercise program. Participants in the intervention group took part in web-based exercise classes and used the ECME-CR platform during the intervention period, whereas participants in the control group attended in-person classes. Outcomes were assessed at baseline and following the 8-week intervention period. The primary outcome measure was exercise capacity, assessed using a 6-minute walk test (6MWT). Secondary outcomes included measurement of grip strength, self-reported quality of life, heart rate, blood pressure, and body composition. A series of mixed between-within subjects ANOVA were conducted to examine the mean differences in study outcomes between and within groups. Participant adherence to the exercise program was also analyzed.

RESULTS

In all, 8 participants (male: n=5; age: mean 69.7, SD 7.2 years; height: mean 163.9, SD 5.4 cm; weight: mean 81.6, SD 14.1 kg) in the intervention group and 9 participants (male: n=9; age: mean 69.8, SD 8.2 years; height: mean 173.8, SD 5.2 cm; weight: mean 94.4, SD 18.0 kg) in the control group completed the exercise program. Although improvements in 6MWT distance were observed from baseline to follow-up in both the intervention (mean 490.1, SD 80.2 m to mean 504.5, SD 93.7 m) and control (mean 510.2, SD 48.3 m to mean 520.6, SD 49.4 m) group, no significant interaction effect (F_1,14=.026; P=.87) nor effect for time (F_1,14=2.51; P=.14) were observed. No significant effects emerged for any of the other secondary end points (all P>.0275). Adherence to the exercise program was high in both the intervention (14.25/16, 89.1%) and control (14.33/16, 89.6%) group. No adverse events or safety issues were reported in either group during the study.

CONCLUSIONS

This pilot trial did not show evidence of significant positive effect for either the remotely delivered or center-based program. The 6MWT may not have been sufficiently sensitive to identify a change in this cohort of participants with stable CHD. This trial does provide evidence that remote CR exercise, supported with digital self-monitoring, is feasible and may be considered for individuals less likely to participate in traditional center-based programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31855.

Challenges in Cardiovascular Evaluation and Management of Obese Patients: JACC State-of-the-Art Review

Many unique clinical challenges accompany the diagnosis and treatment of cardiovascular disease (CVD) in people living with overweight/obesity. Similarly, physicians encounter numerous complicating factors when managing obesity among people with CVD. Diagnostic accuracy in CVD medicine can be hampered by the presence of obesity, and pharmacological treatments or cardiac procedures require careful adjustment to optimize efficacy. The obesity paradox concept remains a source of confusion within the clinical community that may cause important risk factors to go unaddressed, and body mass index is a misleading measure that cannot account for body composition (eg, lean mass). Lifestyle modifications that support weight loss require long-term commitment, but cardiac rehabilitation programs represent a potential opportunity for structured interventions, and bariatric surgery may reduce CVD risk factors in obesity and CVD. This review examines the key issues and considerations for physicians involved in the management of concurrent obesity and CVD.

Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle-income setting: A randomized controlled trial protocol

Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower-resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart-health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle-income country. Following a pilot study, a single-center, single-blinded, 2 parallel-arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre-intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6-month intervention comprises an app, website, SMS texts with generic heart-health management advice, and bi-weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent-to-treat. If results of this novel trial of women-focused eCR in a middle-income country demonstrate clinically-significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.

Online neuropilates classes in chronic stroke patients: Protocol for a randomised controlled feasibility study

Introduction

Stroke survivors often demonstrate low physical activity levels and experience barriers to physical exercise including embarrassment, low self-efficacy and a shortage of tailored community exercise programmes. Access to physical activity programmes for stroke survivors could be improved by providing tailored, online programmes, although little is known about the safety and feasibility of online exercise classes for stroke survivors. One such programme of exercise which has received little attention in the literature is neuropilates. Neuropilates is the practice of a modified pilates programme in those with neurological conditions and is theorised to have beneficial effects on strength, balance and proprioception in stroke survivors. No previous study has been conducted to investigate online, remotely supervised neuropilates exercise classes in the stroke survivors.

Method and Analysis

This single assessor blinded randomised controlled feasibility study will compare a 6-week online, remotely instructed neuropilates programme to a 6-week online, remotely instructed generalised exercise programme and a 6-week unsupervised generalised home exercise programme in chronic stroke patients. Twenty adults, at least 6 months post stroke, and finished their formal rehabilitation will be recruited to the study. Primary feasibility outcome measures will include patient tolerance of the programme, adherence rates, adverse events, recruitment and retention. Secondary clinical outcomes will include; balance, gait, tone and quality of life. Assessments will be completed at baseline, on programme completion and 3 months post completion by a Physiotherapist blinded to the group allocation.

Ethics and dissemination

This study has received ethical approval from the Sligo University Hospital Ethics committee and ATU ethics board. Results will be published in peer-reviewed journals and presented at national and international conferences.The trial has been registered on clinicaltrials.gov (Identifier: NCT04491279).

A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities

Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.

Comparing Virtual and Center-Based Cardiac Rehabilitation on Changes in Frailty

Many patients with cardiovascular disease (CVD) are frail. Center-based cardiac rehabilitation (CR) can improve frailty; however, whether virtual CR provides similar frailty improvements has not been examined. To answer this question, we (1) compared the effect of virtual and accelerated center-based CR on frailty and (2) determined if admission frailty affected frailty change and CVD biomarkers. The virtual and accelerated center-based CR programs provided exercise and education on nutrition, medication, exercise safety, and CVD. Frailty was measured with a 65-item frailty index. The primary outcome, frailty change, was analyzed with a two-way mixed ANOVA. Simple slopes analysis determined whether admission frailty affected frailty and CVD biomarker change by CR model type. Our results showed that admission frailty was higher in center-based versus virtual participants. However, we observed no main effect of CR model on frailty change. Results also revealed that participants who were frailer at CR admission observed greater frailty improvements and reductions in triglyceride and cholesterol levels when completing virtual versus accelerated center-based CR. Even though both program models did not change frailty, higher admission frailty was associated with greater frailty reductions and change to some CVD biomarkers in virtual CR.

Home-based exercise program in the indeterminate form of Chagas disease (PEDI-CHAGAS study): A study protocol for a randomized clinical trial

Background

Chagas disease (CD) is a neglected endemic disease with worldwide impact due to migration. Approximately 50-70% of individuals in the chronic phase of CD present the indeterminate form, characterized by parasitological and/or serological evidence of Trypanosoma cruzi infection, but without clinical signs and symptoms. Subclinical abnormalities have been reported in indeterminate form of CD, including pro-inflammatory states and alterations in cardiac function, biomarkers and autonomic modulation. Moreover, individuals with CD are usually impacted on their personal and professional life, making social insertion difficult and impacting their mental health and quality of life (QoL). Physical exercise has been acknowledged as an important strategy to prevent and control numerous chronic-degenerative diseases, but unexplored in individuals with the indeterminate form of CD. The PEDI-CHAGAS study (which stands for "Home-Based Exercise Program in the Indeterminate Form of Chagas Disease" in Portuguese) aims to evaluate the effects of a home-based exercise program on physical and mental health outcomes in individuals with indeterminate form of CD.

Methods and design

The PEDI-CHAGAS is a two-arm (exercise and control) phase 3 superiority randomized clinical trial including patients with indeterminate form of CD. The exclusion criteria are <18 years old, evidence of non-Chagasic cardiomyopathy, musculoskeletal or cognitive limitations that preclude the realization of exercise protocol, clinical contraindication for regular exercise, and regular physical exercise (≥1 × per week). Participants will be assessed at baseline, and after three and 6 months of follow-up. The primary outcome will be QoL. Secondary outcomes will include blood pressure, physical fitness components, nutritional status, fatigability, autonomic modulation, cardiac morphology and function, low back pain, depression and anxiety, stress, sleep quality, medication use and adherence, and biochemical, inflammatory and cardiac biomarkers. Participants in the intervention group will undergo a home-based exercise program whilst those in the control group will receive only general information regarding the benefits of physical activity. Both groups will receive the same general nutritional counseling consisting of general orientations about healthy diets.

Conclusion

The findings from the present study may support public health intervention strategies to improve physical and mental health parameters to be implemented more effectively in this population.

Clinical trial registration

[https://ensaiosclinicos.gov.br/rg/RBR-10yxgcr9/], identifier [U1111-1263-0153].

Remote maintenance cardiac rehabilitation (MAINTAIN): A protocol for a randomised feasibility study

Background

Long-term adherence to exercise is often poor for people with coronary heart disease (CHD) who have completed supervised, centre-based cardiac rehabilitation. The aim of this study is to assess the feasibility of a remotely prescribed, delivered and monitored cardiac rehabilitation intervention using a wearable device to support long-term adherence to exercise and physical activity during maintenance of cardiac rehabilitation.

Methods

After completing cardiac rehabilitation, 30 participants with CHD, will be randomised (1:1) to an intervention (n = 15) or a usual care group (n = 15) in a 12-month feasibility randomised controlled trial (RCT). The intervention will comprise of an exercise consultation, personalised exercise prescription delivered via a wearable activity monitor using biometric feedback, regular monitoring via check-ins, and feedback text-messages for 6-months. Participants will be assessed at baseline (following completion of cardiac rehabilitation) and at three-, six-, and 12-months post-randomisation. The primary outcome will be feasibility, including assessment of eligibility, recruitment, adherence, and acceptability. Secondary outcomes will include exercise capacity, physical activity behaviours, cardiovascular disease risk and quality of life. Semi-structured interviews will be conducted at three-, six-, and 12-months post-randomisation (and with those who drop-out) to explore the acceptability of the study intervention and procedures. A questionnaire will be offered to those who decline participation.

Discussion

The MAINTAIN study will evaluate the feasibility of conducting a future definitive multi-centre RCT testing a remotely prescribed and monitored long-term mHealth maintenance exercise programme, versus usual care, for people with CHD who have completed cardiac rehabilitation.

Trial registration number

ClinicalTrials.gov, NCT05292287. Registered on 22/03/2022.

Effect of Home-Based Cardiac Rehabilitation Program on Self-Efficacy of Patients With Implantable Cardioverter Defibrillator

Introduction

For more effective control and treatment of cardiac dysrhythmias caused by diseases, ischemia, or other causes, an implantable cardioverter defibrillator (ICD) is used. One of the effective ways for secondary prevention is the home-based cardiac rehabilitation (HBCR) which nurses have an effective role in its implementation.

Objective

The study aimed to investigate the effect of implementing HBCR programs on the self-efficacy of patients with ICD.

Methods

This is a semi-experimental study conducted on 70 patients who received ICD in Shahid Chamran Heart Center of Isfahan University of Medical Sciences (IUMS) in 2021. The patients were randomly assigned to intervention and control groups and were introduced to the practical concepts of HBCR during four training sessions. In the following, 3-month follow-up and trainings were continued by home visits, telephone follow-up, and use of social messaging networks due to the conditions of coronavirus disease 2019 (COVID-19) pandemic. The data were analyzed with SPSS/21.

Results

The findings showed that performing HBCR programs was effective in improving the self-efficacy of patients with ICDs. A significant trend in the implementation of the HBCR programs in two groups was shown using chi-square test and independent t-test and variance with repeated measurements (p < .001). There was no significant difference in self-efficacy score in both groups at the beginning of the study (p < .056).

Conclusion

Considering the effectiveness of HBCR programs on improving the self-efficacy of patients with ICDs, it can be used in the educational care programs of healthcare workers and in the strategic policies of health care services.

The impact of dietary education and counselling with a smartphone application on secondary prevention of coronary artery disease: A randomised controlled study (the TeleDiet study)

Objective: In a secondary prevention of coronary artery disease (CAD), nutritional management is an integral part of lifestyle optimisation. However, few studies have investigated the potential of remote nutritional follow-up using digital solutions. This study investigates the effectiveness of a smartphone application for nutrition education and feedback with pictures of meals by a dietitian for patients with CAD. Methods: Sixty participants with CAD were randomised to either a TeleDiet group or a control group. Participants in the TeleDiet group participated in dietary education using a messaging application. The primary outcome was the change of the Mediterranean diet score (MedDietScore). The Nutrition-Score, a modification of the MedDietScore, blood tests (blood lipids, blood glucose and kidney function), body mass index, self-efficacy, medication adherence and health-related quality of life during the observation period were analysed as secondary outcomes. Results: Sixty participants participated in the study. The difference in the MedDietScore in the TeleDiet group was greater than in the control group, but not significant (2.0 [-1.0, 4.0] vs. 0.0 [-3.0, 1.5], p = 0.066). The difference in the Nutrition-Score in the TeleDiet group was significantly greater than in the control group (3.0 [1.0, 3.5] vs. 0.0 [-3.0, 2.0], p = 0.029). Nutrition knowledge of the TeleDiet group improved significantly compared to the control group (1.9 ± 1.7 vs. 0.8 ± 2.1, p = 0.048). Conclusions: A feedback system using a simple messaging application that allows patients with CAD to simply send a picture of their food has a positive effect on nutrition knowledge. It could be a hint for the implementation of the Mediterranean diet.

Effects of traditional mind-body movement therapy on chronic cardiopulmonary dyspnoea: a systematic review and meta-analysis

PURPOSE

To evaluate whether traditional mind-body movement therapy (TMBM) can be used as a complementary or alternative therapy for exercise-based cardiopulmonary rehabilitation (EBCR) on chronic cardiopulmonary dyspnoea.

METHODS

PubMed, Embase, Scopus, Web of Science and China National Knowledge Infrastructure were searched from their inception to 2 July 2021. Randomised clinical trials evaluating the effectiveness of TMBM versus EBCR, and TMBM +EBCR versus TMBM in the treatment of chronic cardiopulmonary dyspnoea were selected. The outcomes were exercise capacity (6 min walk distance, 6MWD) and quality of life (QoL).

RESULTS

Thirty-four randomised clinical trials with 2456 patients were included. For TMBM vs EBCR alone, statistically significant improvements in the 6MWD favoured the TMBM for chronic obstructive pulmonary disease (COPD) (mean difference(MD)=12.22 m; 95% CI 5.94 to 18.50; I²=56%) and heart failure (HF) patients (MD=43.65 m; 95% CI 7.91 to 79.38; I²=0%). Statistically significant improvements in QoL also favoured TMBM over EBCR for patients with HF(MD=-9.19; 95% CI -11.05 to -7.32; I²=0%) but non-significant trend for COPD (standardised mean difference (SMD)=-0.31; 95% CI -0.62 to 0.01; I²=78%). Comparisons of TMBM +EBCR versus EBCR alone revealed significant improvements in the QoL for COPD (SMD=-0.52; 95% CI -0.94 to -0.10; I²=86%) and patients with HF (MD=-2.82; 95% CI -4.99 to -0.64; I²=0%). The 6MWD results favoured the TMBM +EBCR for patients with COPD (MD=16.76 m; 95% CI 10.24 to 23.29; I²=0%), but only showed a slight trend towards additional benefits of TMBM +EBCR in the HF studies (MD=13.77 m; 95% CI -1.01 to 28.54; I2=65%) .

CONCLUSIONS

TMBM has positive effects on patients' 6MWD and QoL, with similar or even better effects than EBCR. It may be beneficial to use TMBM as a supplementary or alternative strategy for EBCR in treatment plans.

PROSPERO REGISTRATION NUMBER

CRD42021241181.

Cost-effectiveness analysis of digital therapeutics for home-based cardiac rehabilitation for patients with atrial fibrillation after catheter ablation

Background

In recent years, numerous guidelines and expert consensuses have recommended that digital technologies and products, such as digital therapeutics (DTx), be incorporated into cardiac rehabilitation (CR).

Objective

The study aims to compare the cost-effectiveness of DTx for home-based CR (HBCR) with that of the conventional HBCR for patients with atrial fibrillation (AF) after catheter ablation in a real-world clinical setting.

Methods

Based on a single-center, prospective, blinded, randomized, parallel controlled trial of DTx-based HBCR for AF patients after catheter ablation, 100 AF patients undergoing catheter ablation were selected and randomized at a 1:1 ratio into a UC group (conventional HBCR) and DT group (DTx-based HBCR). The intervention lasted for 12 weeks. Medical cost data and clinical efficacy data (VO2max) were acquired from trial data. Effect data (QALYs, anxiety and depression status, health beliefs related to cardiovascular disease, and exercise self-efficacy) were obtained from a patient questionnaire. The cost-effectiveness analysis was conducted to assess the economic benefits of DTx-based HBCR versus conventional HBCR, and the robustness of the results was verified by sensitivity analysis.

Results

In the DT group (n = 49), the mean QALYs increased 0.119 ± 0.09, VO2max increased 9.3 ± 8.0 mL/(min*kg), anxiety, depression, health belief, and exercise self-efficacy had improved, and the total medical cost was 75,080.55 ± 19,746.62 CNY. In the UC group (n = 48), the mean QALYs increased 0.077 ± 0.06, VO2max increased 4.9 ± 6.6 mL/(min*kg), anxiety, depression, health belief, and exercise self-efficacy had improved, and the total medical cost was 73,972.66 ± 16,582.04 CNY. The difference in the medical cost was 1107.89 CNY, and the incremental cost-effectiveness ratio was 33,572.42 CNY/QALY, which was lower than the willingness-to-pay threshold of 85,698 CNY (China's per capita GDP in 2022).

Conclusion

DTx-based HBCR is more effective and cost-effective than conventional HBCR.

Development of an integrated cardiac rehabilitation program to improve the adaptation level of patients after acute myocardial infarction

Background

Individual's adaptation following acute myocardial infarction (AMI) and low attendance of whole-course cardiac rehabilitation (CR) are significant issues. For optimal health post AMI, an integrated CR program aiming at individual's adaptive behaviors is imperative for improving the CR efficiency and patients' outcomes. This study aims to develop theory-guided interventions to increase CR attendance and adaptation level of patients post-AMI.

Methods

This study was conducted in a tertiary hospital from July 2021 to September 2022 in Shanghai China. Guided by the theory of adaptation to chronic illness (ACI theory), the study followed the Intervention mapping (IM) framework to develop the interventions for CR program. Four phases included: (1) needs assessment of patients and facilitators using a cross-sectional study and semi-structured, in-depth interviews, (2) identification of implementation outcomes and performance objectives, (3) selection of theoretical methods to explain the mechanism of patients' adaptive behaviors and to use for behavior change, and (4) development of implementation protocol from the results of the previous phases.

Results

A total of 226 AMI patient-caregivers paired samples were eligible for the data analysis, 30 AMI patients participated in the qualitative inquiry, 16 experts in the CR field evaluated the implementation protocol, and 8 AMI patients commented on the practical interventions. Following the IM framework, an integrated cardiac rehabilitation program using mHealth strategies was developed for AMI patients to facilitate CR attendance and completion, to improve their adaptation level and health outcomes.

Conclusion

Using the IM framework and ACI theory, an integrated CR program was developed to help guide the behavior change and improve adaptation among AMI patients. The preliminary findings suggest that further intervention in enhancing the combination of three-stage CR is required. A feasibility study will be conducted to assess the acceptability and effectiveness of this generated CR intervention.

Reference Equation of a New Incremental Step Test to Assess Exercise Capacity in the Portuguese Adult Population

Step tests are important in community- and home-based rehabilitation programs to assess patients' exercise capacity. A new incremental step test was developed for this purpose, but its clinical interpretability is currently limited. This study aimed to establish a reference equation for this new incremental step test (IST) for the Portuguese adult population. A cross-sectional study was conducted on people without disabilities. Sociodemographic (age and sex), anthropometric (weight, height, and body mass index), smoking status, and physical activity (using the brief physical activity assessment tool) data were collected. Participants performed two repetitions of the IST and the best test was used to establish the reference equation with a forward stepwise multiple regression. An analysis comparing the results from the reference equation with the actual values was conducted with the Wilcoxon test. A total of 155 adult volunteers were recruited (60.6% female, 47.8 ± 19.7 years), and the reference equation was as follows: steps in IST = 475.52 - (4.68 × age years) + (30.5 × sex), where male = 1 and female = 0, and r² = 60%. No significant differences were observed between the values performed and those obtained by the equation (p = 0.984). The established equation demonstrated that age and sex were the determinant variables for the variability of the results.

National, regional, and urban-rural patterns in fixed-terrestrial broadband internet access and cardiac rehabilitation utilization in the United States

Objective

Sparse patterns in fixed-terrestrial broadband internet access are predominantly observed among older adults and low income areas, which are interrelated factors also associated with low center-based cardiac rehabilitation (CR) utilization in the United States (US). Telehealth CR is proposed to increase CR utilization under an assumption that fixed-terrestrial broadband internet access is readily available nationwide and parallels CR utilization demand. We aimed to characterize national, geographical, and urban-rural patterns in fixed-terrestrial broadband internet access, CR eligibility rates, and center-based utilization throughout the US.

Methods

Centers for Disease Control data were used to estimate CR eligibility rates and center-based utilization for 2017-2018 among Medicare fee-for-service beneficiaries aged ≥65 years. Census Bureau data for 2018 were used to estimate fixed-terrestrial broadband internet access among households of adults aged ≥65 years.

Results

Southern states exhibited the highest percentage of households without broadband internet [median (IQR): 32% (24-39)] coupled with the highest CR eligibility rates [per 1,000 beneficiaries, median (IQR): 18 (15-21)] and lowest participation rates [percentage completing ≥1 session, median (IQR): 25% (17-33)]. Compared with urban areas, rural areas demonstrated significantly higher eligibility rates [15.5 (13.2-18.4) vs. 17.4 (14.5-21.0)], participation rates [30.6% (22.0-39.4) vs. 34.6% (22.6-48.3)], and percentage of households without broadband internet [23.8% (18.1-29.2) vs. 31.6% (26.5-37.6)], respectively.

Conclusion

Overlapping patterns in fixed-terrestrial broadband internet access and CR eligibility rates and center-based utilization suggest telehealth CR policies need to account for the possibility that lack of broadband-quality internet access could be a barrier to accessing telehealth CR delivery models.

Telerehabilitation Approaches for People with Chronic Heart Failure: A Systematic Review and Meta-Analysis

INTRODUCTION

Telerehabilitation (TR) for chronic heart failure (CHF) allows for overcoming distance barriers and reducing exacerbations. However, little is known about TR descriptors, components, and efficacy in CHF.

METHODS

This work systematically reviewed the TR strategies of randomized controlled trials in people with CHF. A meta-analysis was run to test its effect on exercise capacity and quality of life compared to no rehabilitation (NI) and conventional intervention (CI).

RESULTS

Out of 6168 studies, 11 were eligible for the systematic review, and 8 for the meta-analysis. TR intervention was individual and multidimensional, with a frequency varying from 2 to 5 times per 8-12 weeks. The TR components mainly included an asynchronous model, monitoring/assessment, decision, and offline feedback. A few studies provided a comprehensive technological kit. Minimal adverse events and high adherence were reported. A large effect of TR compared to NI and a non-inferiority effect compared to CI was registered on exercise capacity, but no effects of TR compared to NI and CI on quality of life were observed.

CONCLUSIONS

TR for people with CHF adopted established effective strategies. Future interventions may identify the precise TR dose for CHF, technological requirements, and engagement components affecting the patient's quality of life.

Effectiveness of Unsupervised Exercise Therapy After Endovascular Treatment for an Iliac Occlusive Lesion

Objective

Exercise therapy has acceptable outcomes for patients with intermittent claudication (IC), but there are few reports on the results of continuous unsupervised exercise therapy after endovascular treatment (EVT) for an iliac lesion. The aim of this study is to analyze the long-term outcomes of unsupervised exercise therapy for patients after EVT.

Material and Methods

A retrospective analysis was performed in 76 patients (93 limbs) with IC who underwent iliac EVT from 2012 to 2020 at our hospital. Maintenance of unsupervised exercise therapy was evaluated at 6 months after EVT. Long-term outcomes such as primary patency, clinically driven target lesion revascularization (CD-TLR), survival, and major adverse cardiovascular events (MACE) were compared between patients who continued (cET group) or discontinued (dET group) unsupervised exercise therapy.

Results

A total of 28 patients (37%) continued unsupervised exercise therapy until 6 months after EVT for an iliac lesion. There were no differences in patient background and procedural details between the cET and dET groups. The follow-up rate was 96% in a median follow-up period of 35 [25 – 42] months. The mean exercise time in the cET group was 52 ± 18 minutes daily, with a mean frequency of 5.8 ± 1.1 days per week. The median step count in the cET group was 5559 ± 2908 steps daily. At 3 years, the cET group had significantly higher rates for primary patency (97% vs 71%, P = .002), and freedom from CD-TLR (97% vs 79%, P = .007); and a tendency for higher survival (100% vs 94%, P = .074), and higher freedom from MACE (89% vs 73%, P = .12).

Conclusion

The findings of this study suggested superior long-term outcomes, including primary patency, freedom from CD-TLR, survival, and freedom from MACE, in patients who maintained continuous unsupervised exercise therapy after EVT.

Home-based cardiac rehabilitation: A review of bibliometric studies and visual analysis of CiteSpace (2012-2021)

Home-based cardiac rehabilitation has been a major area in cardiac rehabilitation research for a long time. However, there are few systematic studies in this field using bibliometric analysis. We collected articles and reviews for home-based cardiac rehabilitation from the Web of Science Core Collection. Our objectives were to perform a bibliometric analysis and visualization study to determine hotspots and trends of home-based cardiac rehabilitation, identify collaboration and influence among authors, countries, institutions, and journals, and assess the knowledge base to develop clinical research in the future. This study will provide a valuable reference for researchers concerned with HBCR.

A systematic review of economic analyses of home-based telerehabilitation

PURPOSE

Telerehabilitation, or the delivery of rehabilitation using information and communication technologies, may improve timely and equitable access to rehabilitation services at home. A systematic literature review was conducted of studies that formally documented the costs and effects of home-based telerehabilitation versus in-person rehabilitation across all health conditions.

MATERIALS AND METHODS

Six electronic databases were searched from inception to 13 July 2021 (APA, PsycInfo, CINAHL, Embase, EmCare, Medline (Ovid), and PubMed) using a protocol developed by a medical librarian. A quality appraisal of full economic evaluation studies was conducted using the Drummond 10-point quality checklist.

RESULTS

Thirty-five studies were included in this review covering various rehabilitation types and diverse populations. The majority were published in the last six years. Available evidence suggests that telerehabilitation may result in similar or lower costs as compared to in-person rehabilitation for the health care system and for patients. However, the impact of telerehabilitation on long-term clinical outcomes and health-related quality of life remains unclear.

CONCLUSIONS

More high quality and robust economic evaluations exploring the short- and long-term costs and other impacts of telerehabilitation on patients, caregivers, and health care systems across all types of patient populations are still required.Implications for rehabilitationHome-based telerehabilitation may reduce barriers in access to care for individuals living in the community.Economic analyses can inform health care system decision-making by evaluating the costs and effects associated with telerehabilitation.This study found that telerehabilitation may result in similar or lower costs as in-person rehabilitation; however, its impact on health-related quality of life is unclear.

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.

Cardiac Rehabilitation and the COVID-19 Pandemic: Persistent Declines in Cardiac Rehabilitation Participation and Access Among US Medicare Beneficiaries

BACKGROUND

The impact of the COVID-19 pandemic on participation in and availability of cardiac rehabilitation (CR) is unknown.

METHODS

Among eligible Medicare fee-for-service beneficiaries, we evaluated, by month, the number of CR sessions attended per 100 000 beneficiaries, individuals eligible to initiate CR, and centers offering in-person CR between January 2019 and December 2021. We compared these outcomes between 2 periods: December 1, 2019 through February 28, 2020 (period 1, before declaration of the pandemic-related national emergency) and October 1, 2021 through December 31, 2021 (period 2, the latest period for which data are currently available).

RESULTS

In period 1, Medicare beneficiaries participated in (mean±SD) 895±84 CR sessions per 100 000 beneficiaries each month. After the national emergency was declared, CR participation sharply declined to 56 CR sessions per 100 000 beneficiaries in April 2020. CR participation recovered gradually through December 2021 but remained lower than prepandemic levels (period 2: 698±29 CR sessions per month per 100 000 beneficiaries, P=0.02). Declines in CR participation were most marked among dual Medicare and Medicaid enrollees and patients residing in rural areas or socially vulnerable communities. There was no statistically significant change in CR eligibility between the 2 periods. Compared with 2618±5 CR centers in period 1, there were 2464±7 in period 2 (P<0.01). Compared with CR centers that survived the pandemic, 220 CR centers that closed were more likely to be affiliated with public hospitals, located in rural areas, and serve the most socially vulnerable communities.

CONCLUSIONS

The COVID-19 pandemic was associated with a persistent decline in CR participation and the closure of CR centers, which disproportionately affected rural and low-income patients and the most socially vulnerable communities. Innovation in CR financing and delivery is urgently needed to equitably enhance CR participation among Medicare beneficiaries.

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE): A randomized trial to improve post myocardial infarction management

OBJECTIVE

We evaluated the impact of a low intensity web-based and intensive nurse-administered intervention to reduce systolic blood pressure (SBP) among patients with prior MI.

METHODS

Secondary Prevention Risk Interventions via Telemedicine and Tailored Patient Education (SPRITE) was a three-arm trial. Patients were randomized to 1) post-MI education-only; 2) nurse-administered telephone program; or 3) web-based interactive tool. The study was conducted 2009-2013.

RESULTS

Participants (n = 415) had a mean age of 61 years (standard deviation [SD], 11). Relative to the education-only group, the 12-month differential improvement in SBP was - 3.97 and - 3.27 mmHg for nurse-administered telephone and web-based groups, respectively. Neither were statistically significant. Post hoc exploratory subgroup analyses found participants who received a higher dose (>12 encounters) in the nurse-administered telephone intervention (n = 60; 46%) had an 8.8 mmHg (95% CI, 0.69, 16.89; p = 0.03) differential SBP improvement versus low dose (<11 encounters; n = 71; 54%). For the web-based intervention, those who had higher dose (n = 73; 53%; >1 web encounter) experienced a 2.3 mmHg (95% CI, -10.74, 6.14; p = 0.59) differential SBP improvement versus low dose (n = 65; 47%).

CONCLUSIONS

The main effects were not statistically significant.

PRACTICAL IMPLICATIONS

Completing the full dose of the intervention may be essential to experience the intervention effect.

CLINICAL TRIAL REGISTRATION

The unique identifier is NCT00901277 (http://www.

CLINICALTRIALS

gov/ct2/show/NCT00901277?term=NCT00901277&rank=1).

Effectiveness of home-rehabilitation in patients after an acute coronary syndrome and myocardial revascularization

Physical activity is a mainstay (class IA) of rehabilitation programme after an acute coronary syndrome, but less than 40% of patients is physically active at one year. Home-rehabilitation, initially designed to manage the increasing number of patients in rehabilitation programmes, could result in a better strategy to increase adherence and persistence to physical activity.

Objectives

To test such hypothesis, At Cardiac Rehabilitation Centre (Institute of Physical Medicine and Rehabilitation, Udine, Italy), physical activity adherence was compared between patients treated with a standard in-office rehabilitation programme and a cohort where home rehabilitation programme was added.

Methods

From February 2017 to February 2019, 372 patients after an acute coronary syndrome (72 were excluded according to study criteria) were included, 193 patients in standard rehabilitation and 179 in home rehabilitation. At the end of follow-up, patients of both groups were called on the telephone to collect physical activity items according to a standardized questionnaire.

Results

At a medium follow-up of 30.1 months, there are more physically active patients in home rehabilitation than in standard, respectively 139 vs 108 patients (77,1% vs. 56%, p < 0,0001).At multivariate analysis, including age, gender, and rehabilitation model, the probability to be fully physically active at the end of the rehabilitation programme, is 3 times higher (OR 3.0 CI 1,9-6,0 p < 0,0001) for home rehabilitation programme compared to standard one.

Conclusions

Home rehabilitation, when applied to selected populations, resulted in a feasible and effective strategy to promote long term physical activity in secondary prevention after an acute coronary syndrome.

Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease

IMPORTANCE

Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking.

OBJECTIVE

To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022.

EXPOSURES

Participation in 1 or more HBCR or CBCR sessions.

MAIN OUTCOMES AND MEASURES

The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics.

RESULTS

Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR.

CONCLUSIONS AND RELEVANCE

These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

Digital health in older adults for the prevention and management of cardiovascular diseases and frailty. A clinical consensus statement from the ESC Council for Cardiology Practice/Taskforce on Geriatric Cardiology, the ESC Digital Health Committee and the ESC Working Group on e-Cardiology

Digital health technology is receiving increasing attention in cardiology. The rise of accessibility of digital health tools including wearable technologies and smart phone applications used in medical practice has created a new era in healthcare. The coronavirus pandemic has provided a new impetus for changes in delivering medical assistance across the world. This Consensus document discusses the potential implementation of digital health technology in older adults, suggesting a practical approach to general cardiologists working in an ambulatory outpatient clinic, highlighting the potential benefit and challenges of digital health in older patients with, or at risk of, cardiovascular disease. Advancing age may lead to a progressive loss of independence, to frailty, and to increasing degrees of disability. In geriatric cardiology, digital health technology may serve as an additional tool both in cardiovascular prevention and treatment that may help by (i) supporting self-caring patients with cardiovascular disease to maintain their independence and improve the management of their cardiovascular disease and (ii) improving the prevention, detection, and management of frailty and supporting collaboration with caregivers. Digital health technology has the potential to be useful for every field of cardiology, but notably in an office-based setting with frequent contact with ambulatory older adults who may be pre-frail or frail but who are still able to live at home. Cardiologists and other healthcare professionals should increase their digital health skills and learn how best to apply and integrate new technologies into daily practice and how to engage older people and their caregivers in a tailored programme of care.

COVID-19 and Cardiometabolic Health: Lessons Gleaned from the Pandemic and Insights for the Next Wave

Purpose of Review

To review the current evidence regarding the impact of the coronavirus disease 2019 (COVID-19) pandemic on cardiometabolic health, with a focus on strategies to help mitigate adverse effects on population health.

Recent Findings

Individuals with cardiometabolic disease are particularly vulnerable to worse outcomes with COVID-19 infection. In addition, the pandemic itself has had significant deleterious impact on the cardiometabolic health of the population, including declines in physical activity, increases in smoking and alcohol use, worsening blood pressure and glycemic control, and detrimental effects on mental health. Targeted interventions at the patient and community level will be needed to mitigate the long-term consequences of the COVID-19 pandemic on population cardiometabolic health.

Summary

The COVID-19 pandemic has worsened cardiometabolic health, but there are several opportunities and enhanced tools available to counteract these changes.