Alternative models of cardiac rehabilitation: a systematic review

Nurse mentor perceptions in the delivery of a home-based cardiac rehabilitation program to support patients living in rural areas: An interpretive study

Home-based cardiac rehabilitation (CR) programs improve health outcomes for people diagnosed with heart disease. Mentoring of patients by nurses trained in CR has been proposed as an innovative model of cardiac care. Little is known however, about the experience of mentors facilitating such programs and adapting to this new role. The aim of this qualitative study was to explore nurse mentor perceptions of their role in the delivery of a home-based CR program for rural patients unable to attend a hospital or outpatient CR program. Seven nurses mentored patients by telephone providing patients with education, psychosocial support and lifestyle advice during their recovery. An open-ended survey was administered to mentors by email and findings revealed mentors perceived their role to be integral to the success of the program. Nurses were satisfied with the development of their new role as patient mentors. They believed their collaborative skills, knowledge and experience in coronary care, timely support and guidance of patients during their recovery and use of innovative audiovisual resources improved the health outcomes of patients not able to attend traditional programs. Cardiac nurses in this study perceived that they were able to successfully transition from their normal work practices in hospital to mentoring patients in their homes.

Effectiveness and safety of a home-based cardiac rehabilitation programme of mixed surveillance in patients with ischemic heart disease at moderate cardiovascular risk: A randomised, controlled clinical trial

BACKGROUND

Previous studies have documented the feasibility of home-based cardiac rehabilitation programmes in low-risk patients with ischemic heart disease, but a similar solution needs to be found for patients at moderate cardiovascular risk. The objective of this study was to analyse the effectiveness and safety of a home-based cardiac rehabilitation programme of mixed surveillance in patients with ischemic cardiopathology at moderate cardiovascular risk.

METHODS

A randomised, controlled clinical trial was designed wherein 28 patients with stable coronary artery disease at moderate cardiovascular risk, who met the selection criteria for this study, participated. Of these, 14 were assigned to the group undergoing traditional cardiac rehabilitation in hospital (control group) and 14 were assigned to the home-based mixed surveillance programme (experimental group). The patients in the experimental group went to the cardiac rehabilitation unit once a week and exercised at home, which was monitored with a remote electrocardiographic monitoring device (NUUBO®). The in-home exercises comprised of walking at 70% of heart rate reserve during the first month, and 80% during the second month, for 1 h per day at a frequency of 5 to 7 days per week. A two-way repeated measures analysis of variance (ANOVA) was performed to evaluate the effects of time (before and after intervention) and time-group interaction regarding exercise capacity, risk profile, cardiovascular complications, and quality of life.

RESULTS

No significant differences were observed between the traditional cardiac rehabilitation group and the home-based with mixed surveillance group for exercise time and METS achieved during the exertion test, and the recovery rate in the first minute (which increased in both groups after the intervention). The only difference between the two groups was for quality of life scores (10.93 [IC95%: 17.251, 3.334, p = 0.007] vs -4.314 [IC95%: -11.414, 2.787; p = 0.206]). No serious heart-related complications were recorded during the cardiac rehabilitation programme.

CONCLUSIONS

The home-based cardiac rehabilitation programme with mixed surveillance appears to be as effective and safe as the traditional model in patients with ischemic heart disease who are at moderate cardiovascular risk. However, the cardiac rehabilitation programmes carried out in hospital seems to have better results in improving the quality of life.

TRIAL REGISTRATION

Retrospectively registered NCT02796404 (May 23, 2016).

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

Effects of cardiac telerehabilitation in patients with coronary artery disease using a personalised patient-centred web application: protocol for the SmartCare-CAD randomised controlled trial

Background

Cardiac rehabilitation has beneficial effects on morbidity and mortality in patients with coronary artery disease, but is vastly underutilised and short-term improvements are often not sustained. Telerehabilitation has the potential to overcome these barriers, but its superiority has not been convincingly demonstrated yet. This may be due to insufficient focus on behavioural change and development of patients’ self-management skills. Moreover, potentially beneficial communication methods, such as internet and video consultation, are rarely used. We hypothesise that, when compared to centre-based cardiac rehabilitation, cardiac telerehabilitation using evidence-based behavioural change strategies, modern communication methods and on-demand coaching will result in improved self-management skills and sustainable behavioural change, which translates to higher physical activity levels in a cost-effective way.

Methods

This randomised controlled trial compares cardiac telerehabilitation with centre-based cardiac rehabilitation in patients with coronary artery disease. We randomise 300 patients entering cardiac rehabilitation to centre-based cardiac rehabilitation (control group) or cardiac telerehabilitation (intervention group). The core component of the intervention is a patient-centred web application, which enables patients to adjust rehabilitation goals, inspect training and physical activity data, share data with other caregivers and to use video consultation. After six supervised training sessions, the intervention group continues exercise training at home, wearing an accelerometer and heart rate monitor. In addition, physical activity levels are assessed by the accelerometer for four days per week. Patients upload training and physical activity data weekly and receive feedback through video consultation once a week. After completion of the rehabilitation programme, on-demand coaching is performed when training adherence or physical activity levels decline with 50% or more. The primary outcome measure is physical activity level, assessed at baseline, three months and twelve months, and is calculated from accelerometer and heart rate data. Secondary outcome measures include physical fitness, quality of life, anxiety and depression, patient empowerment, patient satisfaction and cost-effectiveness.

Discussion

This study is one of the first studies evaluating effects and costs of a cardiac telerehabilitation intervention comprising a combination of modern technology and evidence-based behavioural change strategies including relapse prevention. We hypothesise that this intervention has superior effects on exercise behaviour without exceeding the costs of a traditional centre-based intervention.

Trial registration

Netherlands Trial Register NTR5156. Registered 22 April 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0477-6) contains supplementary material, which is available to authorized users.

Patients' preference for exercise setting and its influence on the health benefits gained from exercise-based cardiac rehabilitation

OBJECTIVE

To assess patient preference for exercise setting and examine if choice of setting influences the long-term health benefit of exercise-based cardiac rehabilitation.

METHODS

Patients participating in a randomised controlled trial following either heart valve surgery, or radiofrequency ablation for atrial fibrillation were given the choice to perform a 12-week exercise programme in either a supervised centre-based, or a self-management home-based setting. Exercise capacity and physical and mental health outcomes were assessed for up to 24months after hospital discharge. Outcomes between settings were compared using a time×setting interaction using a mixed effects regression model.

RESULTS

Across the 158 included patients, an equivalent proportion preferred to undertake exercise rehabilitation in a centre-based setting (55%, 95% CI: 45% to 63%) compared to a home-based setting (45%, 95% CI: 37% to 53%, p=0.233). At baseline, those who preferred a home-based setting reported better physical health (mean difference in physical component score: 5.0, 95% CI 2.3 to 7.4; p=0.001) and higher exercise capacity (mean between group difference 15.9watts, 95% CI 3.7 to 28.1; p=0.011). With the exception of the depression score in the Hospital Anxiety and Depression Score (F(3.65), p=0.004), there was no evidence of a significant difference in outcomes between settings.

CONCLUSION

The preference of patients to participate in home-based and centre-based exercise programmes appears to be equivalent and provides similar health benefits. Whilst these findings support that patients should be given the choice between exercise-settings when initiating cardiac rehabilitation, further confirmatory evidence is needed.

Kinect system in home-based cardiovascular rehabilitation

Cardiovascular diseases lead to a high consumption of financial resources. An important part of the recovery process is the cardiovascular rehabilitation. This study aimed to present a new cardiovascular rehabilitation system to 11 outpatients with coronary artery disease from a Hospital in Porto, Portugal, later collecting their opinions. This system is based on a virtual reality game system, using the Kinect sensor while performing an exercise protocol which is integrated in a home-based cardiovascular rehabilitation programme, with a duration of 6 months and at the maintenance phase. The participants responded to a questionnaire asking for their opinion about the system. The results demonstrated that 91% of the participants (n = 10) enjoyed the artwork, while 100% (n = 11) agreed on the importance and usefulness of the automatic counting of the number of repetitions, moreover 64% (n = 7) reported motivation to continue performing the programme after the end of the study, and 100% (n = 11) recognized Kinect as an instrument with potential to be an asset in cardiovascular rehabilitation. Criticisms included limitations in motion capture and gesture recognition, 91% (n = 10), and the lack of home space, 27% (n = 3). According to the participants’ opinions, the Kinect has the potential to be used in cardiovascular rehabilitation; however, several technical details require improvement, particularly regarding the motion capture and gesture recognition.

The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review

Telehealth, the delivery of health care services at a distance using information and communications technology, is one means of redressing inequalities in cardiovascular outcomes for disadvantaged groups in Australia. This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.

Patient and provider acceptance of telecoaching in type 2 diabetes: a mixed-method study embedded in a randomised clinical trial

Background

Despite advances in diagnosis and treatment of type 2 diabetes, suboptimal metabolic control persists. Patient education in diabetes has been proved to enhance self-efficacy and guideline-driven treatment, however many people with type 2 diabetes do not have access to or do not participate in self-management support programmes. Tele-education and telecoaching have the potential to improve accessibility and efficiency of care, but there is a slow uptake in Europe. Patient and provider acceptance in a local context is an important pre-condition for implementation. The aim of the study was to explore the perceptions of patients, nurses and general practitioners (GPs) regarding telecoaching in type 2 diabetes.

Methods

Mixed-method study embedded in a clinical trial, in which a nurse-led target-driven telecoaching programme consisting of 5 monthly telephone sessions of +/− 30 min was offered to 287 people with type 2 diabetes in Belgian primary care. Intervention attendance and satisfaction about the programme were analysed along with qualitative data obtained during post-trial semi-structured interviews with a purposive sample of patients, general practitioners (GPs) and nurses. The perceptions of patients and care providers about the intervention were coded and the themes interpreted as barriers or facilitators for adoption.

Results

Of 252 patients available for a follow-up analysis, 97.5 % reported being satisfied. Interviews were held with 16 patients, 17 general practitioners (GPs) and all nurses involved (n = 6). Themes associated with adoption facilitation were: 1) improved diabetes control; 2) need for more tailored patient education programmes offered from the moment of diagnosis; 3) comfort and flexibility; 4) evidence-based nature of the programme; 5) established cooperation between GPs and diabetes educators; and 6) efficiency gains. Most potential barriers were derived from the provider views: 1) poor patient motivation and suboptimal compliance with “faceless” advice; 2) GPs’ reluctance in the area of patient referral and information sharing; 3) lack of legal, organisational and financial framework for telecare.

Conclusions

Nurse-led telecoaching of people with type 2 diabetes was well-accepted by patients and providers, with providers being in general more critical in their reflections. With increasing patient demand for mobile and remote services in healthcare, the findings of this study should support professionals involved in healthcare policy and innovation.

Trial registration

NCT01612520, registered prior to recruitment on 4th June 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0383-3) contains supplementary material, which is available to authorized users.

Audit of a tertiary heart failure outpatient service to assess compliance with NICE guidelines

The National Institute for Health and Care Excellence (NICE) updated its guidelines for chronic heart failure (HF) in 2010. This re-audit assessed interim improvement as compared with an audit in 2011. Patients with HF (preserved and reduced ejection fraction) attending a tertiary cardiac centre over a 2-year period (January 2013-December 2014) were audited. The data collected included demographics, HF aetiology, medications, clinical parameters and cardiac rehabilitation. In total, 513 patients were audited. Compared with 2011, male preponderance (71%) and age (68±14 years, (Mean ± SD)) were similar. 73% of patients lived outside of London. HF aetiologies included ischaemic heart disease (37% versus 40% in 2011), dilated cardiomyopathy (26% versus 20%) primary valve disease (13% versus 12%). For patients with left ventricular systolic dysfunction (n=434, 85% of patients audited) 89% were taking beta-blockers (compared with 77% in 2011), 91% an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (86% in 2011) and 56% a mineralocorticoid receptor antagonist (44% in 2011); 6% were prescribed ivabradine. All patients were reviewed at least 6-monthly. Although 100% of patients were educated about exercise, only 21 (4%) enrolled in a supervised exercise programme. This audit demonstrated high rates of documentation, follow-up and compliance with guideline-based medical therapies. A consistent finding was poor access to cardiac rehabilitation.

Findings from a clinical audit in regional general practice of management of patients following acute coronary syndrome

Patients with acute coronary syndrome (ACS) require ongoing treatment and support from their primary care provider to modify cardiovascular risk factors (including diet, exercise and mood), to receive evidence-based pharmacotherapies and be properly monitored and to ensure their take-up and completion of cardiac rehabilitation (CR). This study assesses adherence to National Heart Foundation guidelines for ACS in primary care in a regional centre in Western Australia. Patients discharged from hospital after a coronary event (unstable angina or myocardial infarction) or a coronary procedure (stent or coronary artery bypass graft) were identified through general practice electronic medical records. Patient data was extracted using a data form based on National Heart Foundation guidelines. Summary statistics were calculated and reported. Our study included 22 GPs and 44 patients in a regional centre. In total, 90% (n=39) of discharge summaries recorded medications. Assessment of pharmacological management showed that 53% (n=23) of patients received four or more classes of pharmacotherapy and that GPs often augmented medication beyond that prescribed at discharge. Of 15 smokers, 13 (87%) had advice to quit documented. Minimal advice for other risk-factor modification was documented in care plans. Patients with type 2 diabetes (n=20) were 70% more likely to receive allied health referral (P=0.02) and 60% more likely to receive advice regarding diet and exercise (P=0.007). However, overall, only 30% (n=13) of those eligible were referred to a dietician, and only 25% were referred to CR (n=10) with six completing CR. Although most GPs did not use standardised tools for mood assessment, 18 (41%) patients were diagnosed as depressed, of which 88% (n=16) were started on antidepressants and 28% (n=6) were referred to a psychologist. Although pharmacotherapy, mood management and smoking cessation management generally followed recommended guidelines, risk factor management relating to diet and exercise by GPs require improvement. Detailed care plans and referral to CR and allied health staff for patient support is recommended.

A Home-Based Rehabilitation Intervention for Adults Living With HIV: A Randomized Controlled Trial

A randomized controlled trial was conducted to investigate the effects of a 16-week home-based rehabilitation (HBR) intervention on the quality of life, functional mobility, and functional capacity of adult people living with HIV (PLWH) on antiretroviral therapy in KwaZulu-Natal, South Africa. The intervention was carried out by community health care workers under the supervision of a qualified physical therapist. Participants in the control group received the standard of care as well as written health advice. While participants in the intervention group showed greater improvements across all outcome measures, between-group differences were nonsignificant. HBR for PLWH is a safe means of addressing the functional deficits experienced by PLWH and appears likely to improve quality of life. A task-shifting approach may be a feasible method of meeting the varied needs of PLWH, while at the same time potentially minimizing costs to already overburdened health care systems.

Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement

Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.

Cardiac patients show high interest in technology enabled cardiovascular rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) can slow or reverse the progression of cardiovascular disease (CVD). However, uptake of community-based CR is very low. E-cardiology, e-health and technology solutions for physical activity uptake and monitoring have evolved rapidly and have potential in CVD management. However, it is unclear what the current technology usage is of CVD patients, and their needs and interests for technology enabled CR.

METHODS

A technology usage questionnaire was developed and completed by patients from a supervised ambulatory CR program and an adult congenital heart disease clinic and from two community-based CR programs. Results were described and related with age, gender and educational level by Spearman correlations.

RESULTS

Of 310 patients, 298 patients (77 % male; mean age 61,7 ± 14,5 years) completed at least 25 questions of the survey and were included in the analysis (completion rate 96 %). Most (97 %) patients had a mobile phone and used the internet (91 %). Heart rate monitors were used by 35 % and 68 % reported to find heart rate monitoring important when exercising at home. Physical activity monitoring was reported by 12 % of the respondents. Respondents were interested in CR support through internet (77 %) and mobile phone (68 %). Many patients reported interest in game-based CR (67 %) and virtual rehabilitation (58 %). At least medium interest in technology enabled CR was reported by 75 % of the patients. Interest decreased with increasing age (r = -0.16; p = 0.005).

CONCLUSIONS

CVD patients show interest for technology enabled home-based CR. Our results could guide the design of a technology-based, virtual CR intervention.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people.

METHODS

Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people.

RESULTS

Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services.

CONCLUSION

The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.

Ensuring Cardiac Rehabilitation Access for the Majority of Those in Need: A Call to Action for Canada

Cardiac rehabilitation (CR) is a proven model of secondary prevention. Indicated cardiac conditions for CR are well established, and participation of these patients results in significantly lower mortality and morbidity when compared with usual care. There are approximately 170 CR programs in Canada, which varies widely by province. There is a grossly insufficient capacity to treat all patients with cardiac indications in Canada and beyond. The density of CR services is about half that in the United States, at 1 program per 208,823 inhabitants or 1 program per 7779 patients with cardiac disease. Despite the Canadian Cardiovascular Society's target of 85% referral for CR for cardiac inpatients with the appropriate indications, significantly fewer patients are referred for CR. Moreover, certain patient groups-such as women, ethnocultural minorities, and those of low socioeconomic status-are less likely to access CR, despite greater need because of poorer outcomes. CR appears to be reaching a healthier population that is perhaps more adherent to secondary prevention recommendations and hence in less need of the limited CR spots available. The reasons for CR underuse are well established and include factors at patient, referring provider, CR program, and health system levels. A Cochrane review has established some effective interventions to increase CR use, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must reallocate our CR resources to patients with the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely available, lower-cost, and effective alternative model of CR.

Effectiveness of person-centred care after acute coronary syndrome in relation to educational level: Subgroup analysis of a two-armed randomised controlled trial

AIM

The aim of this study was to evaluate the effects of person-centred care (PCC) after acute coronary syndrome (ACS) in relation to educational level of participants.

METHOD

199 Patients <75years with ACS were randomised to PCC plus usual care or usual care alone and followed for 6months from hospital to outpatient care and primary care. For the PCC group, patients and health care professionals co-created a PCC health plan reflecting both perspectives, which induced a continued collaboration in person-centred teams at each health care level. A composite score of changes that included general self-efficacy assessment, return to work or previous activity level, re-hospitalisation or death was used as outcome measure.

RESULTS

In the group of patients without postsecondary education (n=90) the composite score showed a significant improvement in favour of the PCC intervention (n=40) vs. usual care (n=50) at six months (35.0%, n=14 vs. 16.0%, n=8; odds ratio (OR)=2.8, 95% confidence interval (CI): 1.0-7.7, P=0.041). In patients with postsecondary education (n=109), a non-significant difference in favour of the PCC intervention (n=54) vs. usual care (n=55) was observed in the composite score (13.0%, n=7 vs 3.6%, n=2; OR=3.9, 95% CI: 0.8-19.9, P=0.097).

CONCLUSION

A PCC approach, which stresses the necessity of a patient-health care professional partnership, is beneficial in patients with low education after an ACS event. Because these patients have been identified as a vulnerable group in cardiac rehabilitation, we suggest that PCC can be integrated into conventional cardiac rehabilitation programmes to improve both equity in uptake and health outcomes.

TRIAL REGISTRATION

Swedish registry, Researchweb.org, ID NR 65 791.

A review of guidelines for cardiac rehabilitation exercise programmes: Is there an international consensus?

BACKGROUND

Cardiac rehabilitation is an important component in the continuum of care for individuals with cardiovascular disease, providing a multidisciplinary education and exercise programme to improve morbidity and mortality risk. Internationally, cardiac rehabilitation programmes are implemented through various models. This review compared cardiac rehabilitation guidelines in order to identify any differences and/or consensus in exercise testing, prescription and monitoring.

METHODS

Guidelines, position statements and policy documents for cardiac rehabilitation, available internationally in the English language, were identified through a search of electronic databases and government and cardiology society websites. Information about programme delivery, exercise testing, prescription and monitoring were extracted and compared.

RESULTS

Leading cardiac rehabilitation societies in North America and Europe recommend that patients progress from moderate- to vigorous-intensity aerobic endurance exercise over the course of the programme, with resistance training included as an important adjunct, for maintaining independence and quality of life. North American and European guidelines also recommend electrocardiograph-monitored exercise stress tests. Guidelines for South America and individual European nations typically include similar recommendations; however, those in the United Kingdom, Australia and New Zealand specify lower-intensity exercise and less technical assessment of functional capacity.

CONCLUSION

Higher-intensity aerobic training programmes, supplemented by resistance training, have been recommended and deemed safe for cardiac rehabilitation patients by many authorities. Based on research evidence, this may also provide superior outcomes for patients and should therefore be considered when developing an international consensus for exercise prescription in cardiac rehabilitation.

Cardiac rehabilitation delivery model for low-resource settings

Objective

Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries.

Methods

A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not.

Results

Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings.

Conclusions

Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.

Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis

OBJECTIVE

Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD).

METHODS

CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre-based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence.

RESULTS

11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low-density lipoprotein cholesterol. Telehealth and centre-based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors.

CONCLUSIONS

Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.

An eHealth Diary and Symptom-Tracking Tool Combined With Person-Centered Care for Improving Self-Efficacy After a Diagnosis of Acute Coronary Syndrome: A Substudy of a Randomized Controlled Trial

Background

Patients with cardiovascular diseases managed by a person-centered care (PCC) approach have been observed to have better treatment outcomes and satisfaction than with traditional care. eHealth may facilitate the often slow transition to more person-centered health care by increasing patients’ beliefs in their own capacities (self-efficacy) to manage their care trajectory. eHealth is being increasingly used, but most studies continue to focus on health care professionals’ logic of care. Knowledge is lacking regarding the effects of an eHealth tool on self-efficacy when combined with PCC for patients with chronic heart diseases.

Objective

The objective of our study was to investigate the effect of an eHealth diary and symptom-tracking tool in combination with PCC for patients with acute coronary syndrome (ACS).

Methods

This was a substudy of a randomized controlled trial investigating the effects of PCC in patients hospitalized with ACS. In total, 199 patients with ACS aged <75 years were randomly assigned to a PCC intervention (n=94) or standard treatment (control group, n=105) and were followed up for 6 months. Patients in the intervention arm could choose to use a Web-based or mobile-based eHealth tool, or both, for at least 2 months after hospital discharge. The primary end point was a composite score of changes in general self-efficacy, return to work or prior activity level, and rehospitalization or death 6 months after discharge.

Results

Of the 94 patients in the intervention arm, 37 (39%) used the eHealth tool at least once after the index hospitalization. Most of these (24/37, 65%) used the mobile app and not the Web-based app as the primary source of daily self-rating input. Patients used the eHealth tool a mean of 38 times during the first 8 weeks (range 1–118, SD 33) and 64 times over a 6-month period (range 1–597, SD 104). Patients who used the eHealth tool in combination with the PCC intervention had a 4-fold improvement in the primary end point compared with the control group (odds ratio 4.0, 95% CI 1.5–10.5; P=.005). This improvement was driven by a significant increase in general self-efficacy compared with the control group (P=.011). Patients in the PCC group who did not use the eHealth tool (n=57) showed a nonsignificant composite score improvement compared with those in the control group (n=105) (odds ratio 2.0, 95% CI 0.8–5.2; P=.14).

Conclusions

We found a significant effect on improved general self-efficacy and the composite score for patients using an eHealth diary and symptom-tracking tool in combination with PCC compared with traditional care.

Trial Registration

Swedish registry, Researchweb.org, ID NR 65 791.

Exercise training characteristics in cardiac rehabilitation programmes: a cross-sectional survey of Australian practice

Introduction

Exercise training is a core component of cardiac rehabilitation (CR), however, little information exists regarding the specific exercise interventions currently provided for coronary heart disease in Australian practice. We aimed to analyse the current status of exercise-based CR services across Australia.

Design

Cross-sectional survey.

Methods

Australian sites offering exercise-based CR were identified from publically available directories. All sites were invited by email to participate in an online Survey Monkey questionnaire between October 2014 and March 2015, with reminders via email and phone follow-up. Questions investigated the demographics and format of individual programmes, as well as specific exercise training characteristics.

Results

297 eligible programmes were identified, with an 82% response rate. Most sites (82%) were based at hospital or outpatient centres, with home (15%), community (18%) or gym-based options (5%) less common. While CR was most often offered in a comprehensive format (72% of sites), the level of exercise intervention varied greatly among programmes. Most frequently, exercise was prescribed 1–2 times per week for 60 min over 7 weeks. Almost one-quarter (24%) had a sole practitioner supervising exercise, although the majority used a nurse/physiotherapist combination. Low to moderate exercise intensities were used in 60% of programmes, however, higher intensity prescriptions were not uncommon. Few sites (<6%) made use of technology, such as mobile phones or the internet, to deliver or support exercise training.

Conclusions

While advances have been made towards providing flexible and accessible exercise-based CR, much of Australia's service remains within traditional models of care. A continuing focus on service improvement and evidence-based care should, therefore, be considered a core aim of those providing exercise for CR in order to improve health service delivery and optimise outcomes for patients.

Home-based rehabilitation interventions for adults living with HIV: a scoping review

Home-based rehabilitation (HBR) has been shown to improve the lives of people living with a wide range of chronic diseases in resource-rich settings. This may also be a particularly effective strategy in resource-poor settings, where access to institution-based rehabilitation is limited. This review aimed to summarise and discuss the evidence related to the effectiveness of home-based rehabilitation (HBR) interventions designed specifically for adults living with HIV. A scoping review methodology was employed, involving systematic search techniques and appraisal of appropriate evidence. English-language journal articles that assessed the quality of life or functional ability outcomes of HBR interventions for adults living with HIV were considered for this review. Out of an initial 1 135 publications retrieved from the search of databases, six articles met this review's inclusion criteria. While this review highlights the scarcity of empirical evidence related to HBR interventions for adults living with HIV, the findings of these six articles are that HBR is a safe management option that may confer a number of physical and psychological benefits for this population. Future research on HBR interventions should include a wider range of assessment measures, including cost-benefit analyses and specific tools designed to assess the functional ability and participation in activities of daily living of participants involved in these programmes. In particular, more research on HBR is required in resource-poor environments, such as sub-Saharan Africa where HIV is endemic, to assess whether this is a feasible strategy that is both effective and practical in the areas that may need it most.

Effects of Exercise Training on Exercise Capacity in Pulmonary Arterial Hypertension: A Systematic Review of Clinical Trials

BACKGROUND

Pulmonary arterial hypertension (PAH) causes profound functional limitations and poor quality of life. Yet, there is only a limited literature available on the role of exercise training. This paper systematically reviews the effects of exercise training on exercise capacity in PAH.

METHODS

A systematic search of databases (PubMed, CINAHL, CENTRAL, Web of Science and PEDRo) was undertaken for English language articles published between 1(st) January 1980 and 31(st) March 2015. Quality rating for all articles was done using the Downs and Black scoring system.

RESULTS

Fifteen articles of good (n=4), moderate (n=6) and poor (n=5) quality were included in the review. Exercise interventions included aerobic, resistance, inspiratory muscle training or a combination, for 6-18 weeks. Improvements were seen in exercise capacity (six minute walk distance (6MWD) and peak VO2) by 17-96m and 1.1-2.1ml/Kg/min, functional class by one class and quality of life, with minimal adverse events.

CONCLUSIONS

There is evidence to recommend the use of exercise training as an adjunct to medical treatment in PAH. More clinical trials and research are required to assess the effects of different types of exercise programs in patients with PAH, while focussing on strong exercise endpoints to quantify the improvements seen with exercise training.

Temporal Trends and Factors Associated With Cardiac Rehabilitation Referral Among Patients Hospitalized With Heart Failure: Findings From Get With The Guidelines-Heart Failure Registry

BACKGROUND

Current guidelines recommend cardiac rehabilitation (CR) in medically stable outpatients with heart failure (HF); however, temporal trends and factors associated with CR referral among these patients in real-world practice are not entirely known.

OBJECTIVES

The purpose of this study was to assess proportional use, temporal trends, and factors associated with CR referral at discharge among patients admitted with decompensated HF.

METHODS

Using data from a national Get With the Guidelines-Heart Failure registry, we assessed the temporal trends in CR referral among eligible patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) at discharge after HF hospitalization between 2005 and 2014. On multivariable analysis, we also assessed patient- and hospital-level characteristics that are associated with CR referral.

RESULTS

Among 105,619 HF patients (48% with HFrEF, 52% with HFpEF), 10.4% (12.2% with HFrEF, 8.8% with HFpEF) received CR referral at discharge. A significant increase in CR referral rates was observed among both HFpEF and HFrEF patients over the study period (ptrend <0.0001 for HFrEF, HFpEF, and overall). Compared with patients discharged without CR referral, patients referred for CR were younger, predominantly men, and more likely to receive evidence-based HF therapies at discharge. On multivariable analysis, younger age, fewer comorbid conditions, and in-hospital procedures such as coronary artery bypass grafting, percutaneous coronary intervention, and cardiac valve surgery were most strongly associated with CR referral.

CONCLUSIONS

Only one-tenth of eligible HF patients received CR referral at discharge after hospitalization for HF. The proportional use of CR referral is increasing over time among both HFrEF and HFpEF patients. Further strategies to improve physician and patient awareness in regard to the benefit of CR should be used to increase CR referral among patients with HF.

A home-based rehabilitation intervention for people living with HIV and disability in a resource-poor community, KwaZulu-Natal: study protocol for a randomised controlled trial

Background

In the era of highly active antiretroviral therapy HIV is now viewed as a chronic disease. Although people living with HIV are living longer lives, they are prone to a number of disabilities. Home-based rehabilitation has been shown to be an effective means of improving quality of life and function for people with a wide range of chronic diseases. There is a dearth of evidence, however, related to home-based rehabilitation interventions for people living with HIV, particularly in sub-Saharan Africa — the region with the highest global prevalence of HIV.

Methods

A randomised controlled trial design will be employed. Adults living with HIV who have been on antiretroviral therapy for at least six months and with defined limited mobility will be randomly allocated to either an intervention group or the control group. Pre and post-intervention testing will be conducted at a public hospital in KwaZulu-Natal, South Africa in order to assess the participants’ quality of life, perceived level of disability, functional ability and endurance. Individuals randomly allocated to the intervention group will participate in a four-month home-based rehabilitation programme, conducted once a week in their homes. This programme will be implemented by community workers who will be trained and supervised by a qualified physiotherapist. The participants in the control group will continue with the standard clinic management offered to them. On completion of the intervention, all participants will be re-assessed using the same outcome measures. Analysis of results will be carried out on intention-to-treat basis in order to identify any changes between intervention and control groups.

Discussion

The researchers aim to employ a novel task shifting approach to implement a needs-based home-based rehabilitation programme for people living with HIV in order to improve their quality of life and functional ability. It is hoped that this study will provide rehabilitation professionals and researchers with evidence that can be utilised to improve existing rehabilitation interventions for people living with HIV.

Trial registration

South African National Clinical Trials Register: NHREC#4094 (Date of registration: 21 July 2015).

Patient perceptions of nurse mentors facilitating the Aussie Heart Guide: A home-based cardiac rehabilitation programme for rural patients

AIM

To explore and describe long-term thoughts and perceptions of the Aussie Heart Guide Programme including the role of the mentor, held by patients recovering from myocardial infarction.

DESIGN

A qualitative design.

METHODS

Thirteen patients recovering from myocardial infarction who were unable to attend a hospital-based or affiliated outpatient cardiac rehabilitation programme were interviewed by telephone at the completion of the programme and asked to describe the relationship with their assigned nurse mentor and their perception of the audiovisual used in the programme.

RESULTS

Three themes emerged; assisting me to cope, supporting me and my family and tailoring the programme to my needs. Patients were satisfied with the programme and appreciative of the supportive and caring relationships provided by mentors during their hospitalization through to their discharge from the programme.

Impacts of intensive follow-up on the long-term prognosis of percutaneous coronary intervention in acute coronary syndrome patients - a single center prospective randomized controlled study in a Chinese population

OBJECTIVES

To investigate the impact of cardiologist-coordinated intensive follow-up on the long-term prognosis of percutaneous coronary intervention in Chinese patients.

METHODS

We recruited 964 patients who had acute coronary syndrome and underwent successful percutaneous coronary intervention in the First Hospital Affiliated to Henan University of Science and Technology, China. Participants were randomly assigned into the intensive follow-up (n = 479) and usual follow-up group (control group, n = 485). They received secondary prevention education during hospitalization and telephone follow-ups after discharge. The control group received telephone calls from nurses, while the intensive follow-up group received telephone calls and medical consultations from cardiologists. Both groups were followed up for 36 months.

RESULTS

(1) At 36 months, the proportions of all-cause death, cardiac death and cumulative major adverse cardiovascular events (MACEs) were 5.3%, 4.4% and 18.6% in the intensive follow-up group. These events were significantly lower than in the control group (10.1%, 9.3 % and 28.8% (p = 0.004, p = 0.003 and p < 0.001). (2) Multivariable Cox regression analysis identified intensive follow-up as an independent predictor of survival, cardiac death-free survival and MACE-free survival. (hazard ratio (HR) = 0.487, 95% confidence interval (CI) 0.298-0.797, p = 0.004; HR = 0.466, 95% CI 0.274-0.793, p = 0.005; HR = 0.614, 95% CI 0.464-0.811, p = 0.001). Kaplan-Meier analysis revealed that patients in the intensive follow-up groups had longer survival (log rank = 8.565, p = 0.003), cardiac death-free survival (log rank = 8.769, p = 0.003) and MACE-free survival (log rank = 15.928, p < 0.001). (3) The average medical cost was significantly less in the intensive follow-up group, especially the cost for re-hospitalization (US$582.74 ± 1753.20 vs. US$999.32 ± 2434.57, p = 0.003). The bleeding events were similar. (4) Patients in the intensive follow-up group had significantly better controls of cardiovascular risk factors and medication adherence.

CONCLUSIONS

A cardiologist-coordinated intensive follow-up program markedly decreased cardiovascular risk factors, reduced medical costs, promoted medication adherence and improved the long-term prognosis of patients after percutaneous coronary intervention in the Chinese population.

Economic and Social Impact of Increasing Uptake of Cardiac Rehabilitation Services--A Cost Benefit Analysis

BACKGROUND

Cardiac rehabilitation can reduce mortality, improve cardiac risk factor profile and reduce readmissions; yet uptake remains low at 30%. This research aims to investigate the social and economic impact of increasing the uptake of cardiac rehabilitation in Victoria, Australia using cost benefit analysis (CBA).

METHODS

Cost benefit analysis has been undertaken over a 10-year period to analyse three scenarios: (1) Base Case: 30% uptake; (2) Scenario 1: 50% uptake; and (3) Scenario 2: 65% uptake. Impacts considered include cardiac rehabilitation program costs, direct inpatient costs, other healthcare costs, burden of disease, productivity losses, informal care costs and net deadweight loss.

RESULTS

There is a net financial saving of $46.7-$86.7 million under the scenarios. Compared to the Base Case, an additional net benefit of $138.9-$227.2 million is expected. This results in a Benefit Cost Ratio of 5.6 and 6.8 for Scenarios 1 and 2 respectively. Disability Adjusted Life Years were 21,117-37,565 years lower than the Base Case.

CONCLUSIONS

Greater uptake of cardiac rehabilitation can reduce the burden of disease, directly translating to benefits for society and the economy. This research supports the need for greater promotion, routine referral to be made standard practice and implementation of reforms to boost uptake.

Heart Failure as a Newly Approved Diagnosis for Cardiac Rehabilitation: Challenges and Opportunities

Many see the broadened eligibility of cardiac rehabilitation (CR) to include heart failure with reduced ejection fraction (HFrEF) as a likely catalyst to high CR enrollment and improved care. However, such expectation contrasts with the reality that CR enrollment of eligible coronary heart disease patients has remained low for decades. In this review, entrenched obstacles impeding utilization of CR are considered, particularly in relation to potential HFrEF management. The strengths and limitations of the HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise Training) trial to advance precepts of CR are considered, as well as gaps that this trial failed to address, such as the utility of CR for patients with heart failure with preserved ejection fraction and the conundrum of poor patient adherence.

Cardiac rehabilitation in low- and middle-income countries: a review on cost and cost-effectiveness

BACKGROUND

By 2030, more than 80% of cardiovascular disease-related deaths and disability-adjusted life years will occur in the 139 low- and middle-income (LMIC) countries. Cardiac rehabilitation (CR) has been demonstrated to be effective and cost-effective mainly based on data from high-income countries. The purpose of this paper was to review the literature for cost and cost-effectiveness data on CR in LMICs.

METHODS

MEDLINE (Ovid) and EMBASE (Ovid) electronic databases were searched for CR 'cost' and 'cost-effectiveness' data in LMICs.

RESULTS

Five CR publications with cost and cost-effectiveness data from middle-income countries were identified with none from low-income countries. Studies from Brazil demonstrated mean monthly savings of US$190 for CR, with a US$48 increase in a control group with mean costs of US$503 for a 3-month CR program. Mean costs to the public health care system of US$360 and US$540 when paid out-of-pocket were reported for a 3-month CR program in seven Latin American middle-income countries. Cardiac rehabilitation is reported to be cost-effective in both Brazil and Colombia.

CONCLUSIONS

Cardiac rehabilitation for patients with heart failure in Brazil and Colombia was estimated to be cost-effective. However, given the limited health care budgets in many LMICs, affordable CR models will need to be developed for LMICs, particularly for low-income countries.

Telerehab III: a multi-center randomized, controlled trial investigating the long-term effectiveness of a comprehensive cardiac telerehabilitation program--rationale and study design

BACKGROUND

Telerehabilitation has been proposed as an adjunct/alternative to standard center-based cardiac rehabilitation. Two recent systematic reviews showed non-inferiority and/or superiority of this remote approach for cardiac rehabilitation. However, these trials focused only on one core component of cardiac rehabilitation and telemonitoring, rather than implementing a more comprehensive approach. The aim of Telerehab III is to investigate the long-term effectiveness of the addition of a patient-tailored, internet-based telerehabilitation program implementing multiple cardiac rehabilitation core components and using both telemonitoring and telecoaching strategies to standard cardiac rehabilitation.

METHODS/DESIGN

In this prospective, multi-center randomized, controlled trial 140 patients with coronary artery disease and/or chronic heart failure patients will be recruited between February 2013 and February 2015. Patients will be randomized 1:1 to an intervention group (receiving an internet-based telerehabilitation program in addition to standard cardiac rehabilitation) or to standard cardiac rehabilitation alone. The mean follow-up is at least 6 months. The primary endpoint is peak oxygen consumption (VO2 peak). Secondary endpoints include measured and self-reported daily physical activity, cardiovascular risk factor control, health-related quality of life, days lost due to (non)cardiovascular rehospitalizations and time to first (non)cardiovascular rehospitalization. A clinical event committee blinded to treatment allocation assesses causes of rehospitalizations.

DISCUSSION

Telerehab III will be one of the first studies to examine the added value of a more comprehensive cardiac telerehabilitation program, focusing on multiple cardiac rehabilitation core components. It has the potential to augment current standard center-based cardiac rehabilitation practices and to be used as a model for other disease prevention programs.

TRIAL REGISTRATION

Current controlled trials ISRCTN29243064. Registration date 21 January 2015.

Technology-assisted congestive heart failure care

The interface between eHealth technologies and disease management in chronic conditions such as chronic heart failure (CHF) has advanced beyond the research domain. The substantial morbidity, mortality, health resource utilization and costs imposed by chronic disease, accompanied by increasing prevalence, complex comorbidities and changing client and health staff demographics, have pushed the boundaries of eHealth to alleviate costs whilst maintaining services. Whilst the intentions are laudable and the technology is appealing, this nonetheless requires careful scrutiny. This review aims to describe this technology and explore the current evidence and measures to enhance its implementation.

Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based recommendation for patients with coronary artery disease (CAD). However, CR is dramatically underutilized. Telehealth interventions have the potential to overcome barriers and may be an innovative model of delivering CR. This review aimed to determine the effectiveness of telehealth intervention delivered CR compared with center-based supervised CR.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library and the Chinese BioMedical Literature Database (CBM), were searched to April 2014, without language restriction. Existing randomized controlled trials, reviews, relevant conference lists and gray literature were checked. Randomized controlled trials that compared telehealth intervention delivered CR with traditional center-based supervised CR in adults with CAD were included. Two reviewers selected studies and extracted data independently. Main clinical outcomes including clinical events, modifiable risk factors or other endpoints were measured.

RESULTS

Fifteen articles reporting nine trials were reviewed, most of which recruited patients with myocardial infarction or revascularization. No statistically significant difference was found between telehealth interventions delivered and center-based supervised CR in exercise capacity (standardized mean difference (SMD) -0.01; 95% confidence interval (CI) -0.12-0.10), weight (SMD -0.13; 95% CI -0.30-0.05), systolic and diastolic blood pressure (mean difference (MD) -1.27; 95% CI -3.67-1.13 and MD 1.00; 95% CI -0.42-2.43, respectively), lipid profile, smoking (risk ratio (RR) 1.03; 95% CI 0.78-1.38), mortality (RR 1.15; 95% CI 0.61-2.19), quality of life and psychosocial state.

CONCLUSIONS

Telehealth intervention delivered cardiac rehabilitation does not have significantly inferior outcomes compared to center-based supervised program in low to moderate risk CAD patients. Telehealth intervention offers an alternative deliver model of CR for individuals less able to access center-based cardiac rehabilitation. Choices should reflect preferences, anticipation, risk profile, funding, and accessibility to health service.

Global availability of cardiac rehabilitation

Cardiovascular disease (CVD) is the most-prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low-income and middle-income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost-effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient's functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under-used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high-income and 23% of LMICs (8.3% for low-income and 28.2% for middle-income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.

Update in cardiology: vascular risk and cardiac rehabilitation

Cardiovascular disease develops in a slow and subclinical manner over decades, only to manifest suddenly and unexpectedly. The role of prevention is crucial, both before and after clinical appearance, and there is ample evidence of the effectiveness and usefulness of the early detection of at-risk individuals and lifestyle modifications or pharmacological approaches. However, these approaches require time, perseverance, and continuous development. The present article reviews the developments in 2013 in epidemiological aspects related to prevention, includes relevant contributions in areas such as diet, weight control methods (obesity is now considered a disease), and physical activity recommendations (with warnings about the risk of strenuous exercise), deals with habit-related psychosocial factors such as smoking, provides an update on emerging issues such as genetics, addresses the links between cardiovascular disease and other pathologies such as kidney disease, summarizes the contributions of new, updated guidelines (3 of which have recently been released on topics of considerable clinical importance: hypertension, diabetes mellitus, and chronic kidney disease), analyzes the pharmacological advances (largely mediocre except for promising lipid-related results), and finishes by outlining developments in the oft-neglected field of cardiac rehabilitation. This article provides a briefing on controversial issues, presents interesting and somewhat surprising developments, updates established knowledge with undoubted application in clinical practice, and sheds light on potential future contributions.