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Ravindhran B, Lim AJM, Kurian T, Walshaw J, Hitchman LH, Lathan R, Smith GE, Carradice D, Chetter IC, Pymer S. Supervised Exercise Therapy for Intermittent Claudication: A Propensity Score Matched Analysis of Retrospective Data on Long Term Cardiovascular Outcomes. Eur J Vasc Endovasc Surg 2024; 67:480-488. [PMID: 38040103 DOI: 10.1016/j.ejvs.2023.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/18/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE This study aimed to explore the long term outcomes of patients with intermittent claudication (IC) who completed supervised exercise therapy (SET) vs. those who declined or prematurely discontinued SET, focusing on the incidence of chronic limb threatening ischaemia (CLTI), revascularisation, major adverse limb events (MALE), and major adverse cardiovascular events (MACE). METHODS A retrospective registry analysis of consecutive patients with IC who were referred for SET between March 2015 and August 2016 and followed up for a minimum of five years. Serial univariable analysis and logistic regression were performed to identify the statistically significant clinical variables that were independent predictors of each outcome measure. The resulting statistically significant variables were used to guide 1:1 propensity score matching (PSM) using the nearest neighbour method with a calliper of 0.2. Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the association between SET and the outcomes of interest. RESULTS Two hundred and sixty-six patients were referred to SET between March 2015 and August 2016. Of these, 64 patients completed SET and 202 patients did not. After PSM, 49 patients were analysed in each cohort. The Cox proportional hazards analysis revealed a significant association between completion of SET and revascularisation requirement (HR 0.46 95% CI 0.25 - 0.84; p = .011), completion of SET and progression to CLTI (HR 0.091, 95% CI 0.04 - 0.24; p < .001), completion of SET and MACE (HR 0.52; 95% CI 0.28 - 0.99; p = .05) and completion of SET and MALE (HR 0.28, 95% CI 0.13 - 0.65; p = .003). The Harrell's C index for all of these models was greater than 0.75, indicating good predictive accuracy. CONCLUSION Completion of SET is associated with better outcomes in patients who completed SET compared with patients who declined or discontinued SET with respect to clinically important cardiovascular outcomes over seven years.
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Affiliation(s)
- Bharadhwaj Ravindhran
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK.
| | - Arthur J M Lim
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Thomas Kurian
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Josephine Walshaw
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Louise H Hitchman
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Ross Lathan
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
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Elfghi M, Dunne D, Jones J, Gibson I, Flaherty G, McEvoy JW, Sultan S, Jordan F, Tawfick W. Mobile health technologies to improve walking distance in people with intermittent claudication. Cochrane Database Syst Rev 2024; 2:CD014717. [PMID: 38353263 PMCID: PMC10865447 DOI: 10.1002/14651858.cd014717.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is the obstruction or narrowing of the large arteries of the lower limbs, which can result in impaired oxygen supply to the muscle and other tissues during exercise, or even at rest in more severe cases. PAD is classified into five categories (Fontaine classification). It may be asymptomatic or various levels of claudication pain may be present; at a later stage, there may be ulceration or gangrene of the limb, with amputation occasionally being required. About 20% of people with PAD suffer from intermittent claudication (IC), which is muscular discomfort in the lower extremities induced by exertion and relieved by rest within 10 minutes; IC causes restriction of movement in daily life. Treatment for people with IC involves addressing lifestyle risk factors. Exercise is an important part of treatment, but supervised exercise programmes for individuals with IC have low engagement levels and high attrition rates. The use of mobile technologies has been suggested as a new way to engage people with IC in walking exercise interventions. The novelty of the intervention, low cost for the user, automation, and ease of access are some of the advantages mobile health (mhealth) technologies provide that give them the potential to be effective in boosting physical activity in adults. OBJECTIVES To assess the benefits and harms of mobile health (mhealth) technologies to improve walking distance in people with intermittent claudication. SEARCH METHODS The Cochrane Vascular Information Specialist conducted systematic searches of the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL, and also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. The most recent searches were carried out on 19 December 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in people aged 18 years or over with symptomatic PAD and a clinical diagnosis of IC. We included RCTs comparing mhealth interventions to improve walking distance versus usual care (no intervention or non-exercise advice), exercise advice, or supervised exercise programmes. We excluded people with chronic limb-threatening ischaemia (Fontaine III and IV). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were change in absolute walking distance from baseline, change in claudication distance from baseline, amputation-free survival, revascularisation-free survival. Our secondary outcomes were major adverse cardiovascular events, major adverse limb events, above-ankle amputation, quality of life, and adverse events. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included four RCTs involving a total of 614 participants with a clinical diagnosis of IC. The duration of intervention of the four included RCTs ranged from 3 to 12 months. Participants were randomised to either mhealth or control (usual care or supervised exercise programme). All four studies had an unclear or high risk of bias in one or several domains. The most prevalent risk of bias was in the area of performance bias, which was rated high risk as it is not possible to blind participants and personnel in this type of trial. Based on GRADE criteria, we downgraded the certainty of the evidence to low, due to concerns about risk of bias, imprecision, and clinical inconsistency. Comparing mhealth with usual care, there was no clear evidence of an effect on absolute walking distance (mean difference 9.99 metres, 95% confidence interval (CI) -27.96 to 47.93; 2 studies, 503 participants; low-certainty evidence). None of the included studies reported on change in claudication walking distance, amputation-free survival, or revascularisation-free survival. Only one study reported on major adverse cardiovascular events (MACE) and found no clear difference between groups (risk ratio 1.37, 95% CI 0.07 to 28.17; 1 study, 305 participants; low-certainty evidence). None of the included studies reported on major adverse limb events (MALE) or above-ankle amputations. AUTHORS' CONCLUSIONS Mobile health technologies can be used to provide lifestyle interventions for people with chronic conditions, such as IC. We identified a limited number of studies that met our inclusion criteria. We found no clear difference between mhealth and usual care in improving absolute walking distance in people with IC; however, we judged the evidence to be low certainty. Larger, well-designed RCTs are needed to provide adequate statistical power to reliably evaluate the effects of mhealth technologies on walking distance in people with IC.
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Affiliation(s)
- Marah Elfghi
- School of Medicine, University of Galway, Galway, Ireland
| | - Denise Dunne
- National Institute for Prevention and Cardiovascular Health, Croí Heart and Stroke Centre, Newcastle, Galway, Ireland
- Croí Heart and Stroke Centre, Newcastle, Galway, Ireland
| | - Jennifer Jones
- Croí, The West of Ireland Cardiac Foundation, Galway, Ireland
| | - Irene Gibson
- Croí, The West of Ireland Cardiac Foundation, Galway, Ireland
| | | | | | - Sherif Sultan
- Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, University of Galway, Galway, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital, Galway, Ireland
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Bashir AZ. Exploring telehealth interventions to monitor rehabilitation in patients with peripheral artery disease. SAGE Open Med 2023; 11:20503121231175542. [PMID: 37223670 PMCID: PMC10201137 DOI: 10.1177/20503121231175542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/26/2023] [Indexed: 05/25/2023] Open
Abstract
Peripheral artery disease is a manifestation of systemic atherosclerosis, and these patients often have claudication pain in the legs during activity. This leads to generally adopting an inactive lifestyle; hence, even small changes in physical activity could reduce the risk of an adverse cardiovascular event. For patients with peripheral artery disease compliance with non-invasive interventions like assistive devices and long-term exercise therapy is important for improved health outcomes. Benefits to patients can only be measured if patients with peripheral artery disease adhere to the intervention and barriers are identified with improved solutions. The effect of mobile health including pedometers and smartphone technological applications in motivating the patient to continue adhering to the intervention and persist in physical activity is a new venture to be explored.
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Affiliation(s)
- Ayisha Z Bashir
- Department of Cardiology, the University of Nebraska
Medical Center, Child Health Research Institute, Children’s Hospital and Medical Center,
Omaha, NE, USA
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Kim M, Kim Y, Choi M. Mobile health platform based on user-centered design to promote exercise for patients with peripheral artery disease. BMC Med Inform Decis Mak 2022; 22:206. [PMID: 35918702 PMCID: PMC9347067 DOI: 10.1186/s12911-022-01945-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Peripheral artery disease (PAD) is a cardiovascular disease that can be improved by risk factor modification. Mobile health (mHealth) intervention is an effective method of healthcare delivery to promote behavior changes. An mHealth platform can encourage consistent involvement of participants and healthcare providers for health promotion. This study aimed to develop an mHealth platform consisting of a smartphone application (app) synchronized with a wearable activity tracker and a web-based portal to support exercise intervention in patients with PAD. Methods This study was conducted based on an iterative development process, including analysis, design, and implementation. In the analysis phase, a literature review and needs assessment through semi-structured interviews (n = 15) and a questionnaire-based survey (n = 138) were performed. The initial prototype design and contents were developed based on the users’ requirements. In the implementation phase, multidisciplinary experts (n = 4) evaluated the heuristics, following which the mHealth platform was revised. User evaluation of the usability was performed by nurses (n = 4) and patients with PAD (n = 3). Results Through the development process, the functional requirements of the platform were represented through visual display, reminder, education, self-monitoring, goal setting, goal attainment, feedback, and recording. In-app videos of exercise and PAD management were produced to provide information and in-app automatic text messages were developed for user motivation. The final version of the platform was rated 67.86 out of 100, which indicated “good” usability. Conclusions The mHealth platform was designed and developed for patients with PAD and their healthcare providers. This platform can be used to educate and promote individualized exercise among patients with PAD.
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Affiliation(s)
- Mihui Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yesol Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Mona Choi
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Veiga C, Pedras S, Oliveira R, Paredes H, Silva I. A Systematic Review on Smartphone Use for Activity Monitoring During Exercise Therapy in Intermittent Claudication. J Vasc Surg 2022; 76:1734-1741. [PMID: 35709859 DOI: 10.1016/j.jvs.2022.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/01/2022] [Accepted: 04/15/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Supervised exercise therapy (SET) is recommended as first line in the management of intermittent claudication (IC). Its use is often limited by accessibility, compliance and cost. Home-based exercise therapy (HBET) programs emerged as an alternative solution, but have shown inferior results. Employment of structured monitoring with the use of external wearable activity monitors (WAM) has been shown to improve outcomes. Mobile applications can make use of built-in accelerometers of modern smartphones and become an alternative solution for monitoring patients during HBET, potentially providing wider accessibility. This review aims to assess current use of smartphone technology (i.e., mobile apps) for monitoring or tracking patients' activity in exercise therapy for peripheral arterial disease (PAD). METHODS The PubMed database was searched from January 2011 to September 2021. Eligible articles had to include a population of patients with PAD, conduct a mobile-health (m-health) exercise intervention and use smartphone technology for monitoring or tracking patients' activity. Randomized control trials (RCTs), prospective studies, and study protocols were included. RESULTS A total of seven articles met the selection criteria. These described six different studies and five different mobile applications. Three were fitness apps (FitBit, Nike+ FuelBand and Garmin Connect) that synchronized with commercially available WAMs to provide users with feedback. Two were PAD-specific apps (TrackPAD and Movn) developed specifically to assess patients' activity during exercise therapy. PAD-specific apps also incorporated coaching and educational elements such as weekly goal setting, claudication reminders, messaging, gamification, training advice and PAD education. CONCLUSION Current HBET programs use smartphone applications mainly via commercially available fitness apps that synchronize with WAM devices to register and access data. PAD-specific apps are scarce but show promising features that can be used to monitor, train, coach, and educate patients during HBET programs. Larger studies combining these elements into HBET programs should provide future direction.
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Affiliation(s)
- Carlos Veiga
- Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto (ICBAS UP), Porto, Portugal.
| | - Susana Pedras
- Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal
| | - Rafaela Oliveira
- Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal
| | - Hugo Paredes
- Instituto de Engenharia de Sistemas e Computadores, Tecnologia e Ciência (INESC TEC), Porto, Portugal; Universidade de Trás-os-Montes e Alto Douro (UTAD), Vila Real, Portugal
| | - Ivone Silva
- Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal; Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto (ICBAS UP), Porto, Portugal
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Elfghi M, Dunne D, Jones J, Gibson I, Flaherty G, McEvoy JW, Sultan S, Jordan F, Tawfick W. Mobile health technologies to improve walking distance in people with intermittent claudication. Hippokratia 2021. [DOI: 10.1002/14651858.cd014717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Marah Elfghi
- College of Medicine; National University of Ireland Galway; Galway Ireland
| | - Denise Dunne
- National Institute for Prevention and Cardiovascular Health; Croí Heart and Stroke Centre; Newcastle, Galway Ireland
- Croí Heart and Stroke Centre; Newcastle, Galway Ireland
| | - Jennifer Jones
- Croí, The West of Ireland Cardiac Foundation; Galway Ireland
| | - Irene Gibson
- Croí, The West of Ireland Cardiac Foundation; Galway Ireland
| | - Gerard Flaherty
- School of Medicine; National University of Ireland; Galway Ireland
| | | | - Sherif Sultan
- Vascular Surgery; Galway University Hospital; Galway Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery; National University of Ireland Galway; Galway Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery; Western Vascular Institute, University College Hospital; Galway Ireland
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Kim M, Kim C, Kim E, Choi M. Effectiveness of Mobile Health-Based Exercise Interventions for Patients with Peripheral Artery Disease: Systematic Review and Meta-Analysis. JMIR Mhealth Uhealth 2021; 9:e24080. [PMID: 33587042 PMCID: PMC7920758 DOI: 10.2196/24080] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/14/2022] Open
Abstract
Background Peripheral artery disease (PAD) affects over 236 million people worldwide, and exercise interventions are commonly used to alleviate symptoms of this condition. However, no previous systematic review has evaluated the effects of mobile health (mHealth)–based exercise interventions for patients with PAD. Objective This study aimed to assess the effect of mHealth-based exercise interventions on walking performance, functional status, and quality of life in patients with PAD. Methods A systematic review and meta-analysis were conducted. We searched in seven databases to identify randomized controlled trials of patients with PAD published in English up to December 4, 2020. Studies were included if patients participated in mHealth-based exercise interventions and were assessed for walking performance. We analyzed pooled effect size on walking performance, functional status, and quality of life based on the standardized mean differences between groups. Results A total of seven studies were selected for the systematic review, and six studies were included in the meta-analysis. The duration of interventions in the included studies was 12 to 48 weeks. In the pooled analysis, when compared with the control groups, the mHealth-based exercise intervention groups were associated with significant improvements in pain-free walking (95% CI 0.13-0.88), maximal walking (95% CI 0.03-0.87), 6-minute walk test (6MWT) distance (95% CI 0.59-1.24), and walking distance (95% CI 0.02-0.49). However, benefits of the interventions on walking speed, stair-climbing ability, and quality of life were not observed. Conclusions mHealth-based exercise interventions for patients with PAD were beneficial for improving pain-free walking, maximal walking, and 6MWT distance. We found that exercise interventions using mHealth are an important strategy for improving the exercise effectiveness and adherence rate of patients with PAD. Future studies should consider the use of various and suitable functions of mHealth that can increase the adherence rates and improve the effectiveness of exercise.
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Affiliation(s)
- Mihui Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea
| | - Changhwan Kim
- Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
| | - Eunkyo Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea
| | - Mona Choi
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea.,Yonsei Evidence Based Nursing Centre of Korea, A JBI Affiliated Group, Seoul, Republic of Korea
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Harzand A, Vakili AA, Alrohaibani A, Abdelhamid SM, Gordon NF, Thiel J, Benarroch‐Gampel J, Teodorescu VJ, Minton K, Wenger NK, Rajani RR, Shah AJ. Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial. Clin Cardiol 2020; 43:537-545. [PMID: 32324307 PMCID: PMC7298994 DOI: 10.1002/clc.23362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown. METHODS Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year. RESULTS A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants. CONCLUSIONS The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.
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Affiliation(s)
- Arash Harzand
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
| | | | - Alaaeddin Alrohaibani
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
| | - Smah M. Abdelhamid
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
| | - Neil F. Gordon
- INTERVENT InternationalSavannahGeorgiaUSA
- Centre for Exercise Science and Sports Medicine, School of Therapeutic SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - John Thiel
- INTERVENT InternationalSavannahGeorgiaUSA
| | - Jaime Benarroch‐Gampel
- Division of Vascular Surgery, Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | - Victoria J. Teodorescu
- Division of Vascular Surgery, Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | | | - Nanette K. Wenger
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | - Ravi R. Rajani
- Division of Vascular Surgery, Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | - Amit J. Shah
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
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