A prospective examination of patterns and correlates of exercise maintenance in coronary artery disease patients

The effects of maintenance cardiac rehabilitation: A systematic review and Meta-analysis, with a focus on sex

Phase III/IV cardiac rehabilitation (CR) is recommended to promote maintenance of benefits achieved during Phase II; there has been no meta-analysis to test this to date. This study determined the effects of maintenance CR on any outcome, with consideration of sex. Seven databases were searched from inception-January 2020. Randomized controlled trials on the effects of maintenance CR in cardiovascular disease patients who had graduated from CR were included. Level of evidence was evaluated with GRADEPro. 819 citations were identified, with 10 trials (21 papers) included (5238 participants; 859 [16.4%] female). Maintenance CR resulted in lower low-density lipoprotein (mean difference [MD]=-0.58; 95% confidence interval [CI]=-1.06--0.10, n = 392) and greater quality of life (MD = 0.28, 95% CI = 0.05-0.52, n = 118) when compared to usual care only. Outcomes for women and sex differences were mixed. In conclusion, maintenance programs appear to sustain patient's quality of life, but more focus on women's outcomes is needed.

The Effectiveness of Interventions to Maintain Exercise and Physical Activity in Post-Cardiac Rehabilitation Populations: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

PURPOSE

Cardiac rehabilitation is a medically supervised program addressing health behavior changes and promoting self-management among individuals with heart disease. This includes initiation of regular physical activity. However, long-term physical activity after cardiac rehabilitation among this population remains a challenge.

METHODS

This study was a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials were identified by searching multiple databases and were selected if they evaluated an intervention with a physical activity or exercise component among individuals who completed cardiac rehabilitation. A descriptive synthesis was performed for all studies and means and standard deviations were used for meta-analysis when possible. Risk of bias, heterogeneity, and publication bias were assessed.

RESULTS

Twenty-five studies met the inclusion criteria and 19 were included in the meta-analysis. The mean age of participants across studies was 60 yr and 80% were male. Descriptive synthesis of the studies combined with meta-analysis results provided evidence of increased physical activity among intervention groups compared with control groups at follow-up.

CONCLUSION

There is evidence to support the effectiveness of interventions aimed at maintaining physical activity and exercise among adults who have completed cardiac rehabilitation.

Association Between Patient Cost Sharing and Cardiac Rehabilitation Adherence

OBJECTIVE

To determine the association between cost sharing and adherence to cardiac rehabilitation (CR).

PATIENTS AND METHODS

We collected detailed cost-sharing information for patients enrolled in CR at Baystate Medical Center in Springfield, Massachusetts, including the presence (or absence) and amounts of co-pays and deductibles. We evaluated the association between cost sharing and the total number of CR sessions attended as well as the influence of household income on CR attendance.

RESULTS

In 2015, 603 patients enrolled in CR had complete cost-sharing information. In total, 235 (39%) had some form of cost sharing. Of these, 192 (82%) had co-pays (median co-pay, $20; interquartile range [IQR], $10-$32) and 79 (34%) had an unmet deductible (median, $500; IQR, $250-$1800). The presence of any amount or form of cost sharing was associated with 6 fewer sessions of CR (16; IQR, 4-36 vs 10; IQR, 4-27; P<.001). Patients hospitalized in November or December with deductibles that renewed in January attended 4.5 fewer sessions of CR (8.5; IQR, 3.25-12.50 vs 13; IQR, 5.25-36.00; P=.049). After adjustment for differences in baseline characteristics, every $10 increase in co-pay was associated with 1.5 (95% CI, -2.3 to -0.7) fewer sessions of CR (P<.001). Household income did not moderate these relationships.

CONCLUSION

Cost sharing was associated with lower CR attendance and exhibited a dose-response relationship such that higher cost sharing was associated with lower CR attendance. Given that CR is cost-effective and underutilized, insurance companies and other payers should reevaluate their cost-sharing policies for CR.

A cohort study examining the factors influencing changes in physical activity levels following an acute coronary syndrome event

Background:

Low physical activity has long been identified as a risk factor for coronary heart disease.

Aims:

The aim of this study was to determine the factors that influence changes in the physical activity of patients following an acute coronary syndrome event.

Methods:

The prospective, inferential cohort design recruited patients admitted to hospital following an acute coronary syndrome event across five research sites. Physical activity was assessed using the short form international physical activity questionnaire.

Results:

Data were collected at baseline and 3 months on 380 patients. The sample profile was: 21% women; body mass index 28 ± 4.6; unstable angina 36%; ST-segment elevation myocardial infarction 25%; non-ST-segment elevation myocardial infarction 39% and a mean age of 63 ± 11.8. There was a significant improvement in physical activity at 3 months ( n=380, t=−3.704, P≤0.001). All regression models, baseline, 3 months and change in physical activity were significant ( p≤0.001). Low physical activity was associated with: at baseline not having health insurance, older age and depression; at 3 months not having health insurance, not in employment and low baseline physical activity; and improvement in physical activity was associated with low physical activity at baseline and not being in employment.

Conclusions:

While physical activity improved significantly, 45% did not reach guideline recommendation levels at 3 months post-event. Physical activity change was little influenced by sociodemographic, clinical, psychological and behavioural factors, suggesting the need to look elsewhere such as behavioural change and improved processes across the care divide to improve physical activity in this at-risk population.

Exercise barriers and the relationship to self-efficacy for exercise over 12 months of a lifestyle-change program for people with heart disease and/or diabetes

BACKGROUND

Barriers to exercise are common in people with coronary heart disease (CHD) and/or diabetes mellitus (DM), and may influence self-efficacy for exercise.

PURPOSE

The purpose of this study was to describe the exercise barriers experienced by people who have CHD and/or DM participating in the Healthy Eating and Exercise Lifestyle Program and to determine whether these barriers influence self-efficacy.

METHODS

Participants ( n = 134) identified their barriers to exercise and completed the self-efficacy for exercise survey at baseline, at 4 months (following structured and supervised exercise) and at 12 months (following home-based exercise with three follow-up calls).

RESULTS

The sample mean age was 63.6 years (SD 8.5) and 58% were male. Barriers to exercise were reported by 88% at baseline, 76% at 4 months, and 47% at 12 months. The most common barriers were lack of motivation (40.3%), lack of time overall (30.6%), and lack of time due to family commitments (17.2%). Only motivation changed significantly over time from baseline (40%) to 4 months (23%, p = 0.040). Lower self-efficacy for exercise was associated with lack of motivation at 12 months only, more depressive symptoms at baseline and 4 months, and a CHD diagnosis and higher body mass index at 12 months. In contrast, male gender and having higher self-efficacy at baseline were associated with higher self-efficacy for exercise at 4 and 12 months.

CONCLUSION

Patients identified many exercise barriers despite participating in a lifestyle-change program. Lack of motivation negatively influenced self-efficacy for exercise at 12 months. Other factors needing attention include baseline self-efficacy, depressive symptoms, being female, being more overweight, and having CHD.

Can illness beliefs, from the common-sense model, prospectively predict adherence to self-management behaviours? A systematic review and meta-analysis

OBJECTIVE

To determine whether people's beliefs about their illness, conceptualised by the common sense model (CSM), can prospectively predict adherence to self-management behaviours (including, attendance, medication, diet and exercise) in adults with acute and chronic physical illnesses.

DESIGN AND MAIN OUTCOME MEASURES

Electronic databases were searched in September 2014, for papers specifying the use of the 'CSM' in relation to 'self-management', 'rehabilitation' and 'adherence' in the context of physical illness. Six hundred abstracts emerged. Data from 52 relevant studies were extracted. Twenty-one studies were meta-analysed, using correlation coefficients in random effects models. The remainder were descriptively synthesised.

RESULTS

The effect sizes for individual illness belief domains and adherence to self-management behaviours ranged from .04 to .13, indicating very weak, predictive relationships. Further analysis revealed that predictive relationships did not differ by the: type of self-management behaviour; acute or chronic illness; or duration of follow-up.

CONCLUSION

Individual illness belief domains, outlined by the CSM, did not predict adherence to self-management behaviours in adults with physical illnesses. Prospective relationships, controlling for past behaviour, also did not emerge. Other factors, including patients' treatment beliefs and inter-relationships between individual illness beliefs domains, may have influenced potential associations with adherence to self-management behaviours.

Validation of Fitbit-Flex as a measure of free-living physical activity in a community-based phase III cardiac rehabilitation population

BACKGROUND

Accurate physical activity monitoring is important for cardiac patients. Novel activity monitoring devices may enable precise measurement of physical activity. This study aimed to validate Fitbit-Flex against Actigraph accelerometer for monitoring physical activity.

DESIGN

A validation study with a comparative design.

METHODS

Cardiac patients and family members participating in community-based exercise programs wore Fitbit-Flex and Actigraph simultaneously over four days to monitor daily step counts and minutes of moderate to vigorous physical activity (MVPA).

RESULTS

Participants (N = 48) comprised 52.1% males, with a mean age of 65.6 ± 6.9 years and 58.9% had a cardiac diagnosis. Fitbit-Flex and Actigraph were significantly correlated in males, females, total participants and cardiac patients for step counts (r = .96; r = .95; r = .95; r = .95), though less so for MVPA (r = .81; r = .65, r = .74; r = .71). As step counts increased the differences between Fitbit-Flex and Actigraph also increased. Fitbit-Flex over-estimated step counts in females (556 steps/day), males (1462 steps/day) and total participants (1038 steps/day) as well as for minutes of MVPA in females (4 min/day), males (15 min/day) and total participants (10 min/day). Fitbit-Flex had high sensitivity and specificity in classifying participants who achieved the recommended physical activity guidelines.

CONCLUSION

Fitbit-Flex is accurate in assessing attainment of physical activity guideline recommendations and is useful for monitoring physical activity in cardiac patients. The device does, however, slightly over-estimate step counts and MVPA.

Correlates of objectively measured physical activity in cardiac patients

Cardiac patients would benefit from increasing their physical activity (PA) levels. Understanding of factors that influence cardiac patients' PA participation would benefit the development of effective interventions. Therefore, the purpose of this study was to determine correlates of objectively-measured PA in cardiac patients. Participants were 65 cardiac patients (74% male, 95% white), age 58.6±10.6 years. The amount of time spent in PA was measured by ActiGraph GT3X accelerometers for 7 days prior to joining cardiac rehabilitation programs (CRP). A total of 25 potential determinants of PA across multiple domains (demographic, clinical, psychosocial, and behavioral) were measured via self-reported questionnaire and clinical examinations. Backward elimination model selection procedures were performed to examine associations of potential determinants with total PA (min/day) and moderate-to-vigorous PA (MVPA) (min/day). Patients spent 153.8±62.8 and 8.4±8.1 min/day in total PA and MVPA, respectively. Across four domains, ten and five potential correlates were found to be significant in univariate analyses for MVPA and total PA, respectively. In the final model, functional capacity, PA readiness, and participation in regular exercise were positively associated with MVPA (R(2) =26.6%). Functional capacity and PA readiness were also positively associated with total PA (R(2) =15.9%). Future initiatives to increase PA levels in cardiac patients could be improved by considering patients' functional capacity, PA readiness, and exercise history in designing interventions.

Long-term outcomes from Healthy Eating and Exercise Lifestyle Program for overweight people with heart disease and diabetes

BACKGROUND

The benefits of exercise and weight reduction for overweight or obese people with coronary heart disease and/or diabetes mellitus are well recognised. The Healthy Eating and Exercise Lifestyle Program demonstrated these outcomes at 4 months, but longer-term outcomes are not yet reported.

AIM

To determine whether positive weight, body mass index, waist and exercise duration outcomes were sustained in the long term (12 months) and to identify the independent predictors of these outcomes at 4 and 12 months.

METHODS

Longitudinal design, combining data of all Healthy Eating and Exercise Lifestyle Program participants (intervention and wait-list control, n = 134). Participants had a body mass index between 27 and 39 kg/m(2) and had completed cardiac rehabilitation and/or diabetes education programmes. Healthy Eating and Exercise Lifestyle Program intervention included an active phase of two 1-hour group-based supervised structured exercise sessions every week for 4 months and four 90-minute group information and support sessions. The maintenance phase included one 90-minute group-based booster information session and three 15-minute goal-focused telephone follow-up calls over 8 months.

RESULTS

Participants had statistically significant reductions from baseline in weight, body mass index and waist circumference and improvements in exercise duration and capacity at 4 and 12 months. Time, self-efficacy, depressive symptoms and male gender were independent predictors for body mass index, waist and/or exercise duration (p < 0.05).

CONCLUSION

The Healthy Eating and Exercise Lifestyle Program was an effective programme to achieve and sustain weight loss and increase exercise participation over 1 year.

Physical inactivity at leisure and work: a 12-month study of cardiac patients

PURPOSE

Physical inactivity has been identified as a distinct health risk. However, little is known about how this can vary at leisure and work in cardiac patients. The aim of this study was to examine the prevalence and predictors of inactivity during leisure and work in the 12 months following a cardiac event in Australian cardiac patients.

METHODS

A total of 346 patients consecutively admitted to hospital with acute coronary syndrome or to undergo coronary artery bypass graft surgery were interviewed in hospital, and 4 and 12 months later. Leisure and occupational physical activity was measured using the Stanford Brief Activity Survey. Sociodemographic, psychosocial, and clinical data were also collected.

RESULTS

The prevalence of leisure-time physical inactivity declined over time, with 52% inactive preevent and 29% inactive at 12 months. Approximately 50% of participants were physically inactive in their work, regardless of whether this was measured before or after the cardiac event. Logistic regression revealed that the significant predictors of leisure-time physical inactivity at 12 months were non-home ownership (OR = 2.19; P = .007) and physical inactivity in leisure-time prior to the event (OR = 2.44; P = .001). The significant predictors of occupational physical inactivity at 12 months were white-collar occupation (OR = 3.10; P < .001) and physical inactivity at work prior to the event (OR = 12.99; P < .001).

CONCLUSIONS

Preevent physical inactivity, socioeconomic, and clinical factors predicted both leisure and work inactivity after an acute cardiac event. Effective interventions could be designed and implemented to target those most at risk of being physically inactive at work or leisure.

Effect of continuous care model on lifestyle of patients with myocardial infarction

BACKGROUND

Myocardial infarction (MI) is a life threatening disease that influences the physical, psychological and social dimensions of the individual. Improper lifestyle is one of the causes of this disease. The use of nursing models could be one of the important and fundamental steps in changing the risk factors associated with MI. This study was carried out to evaluate the effect of continuous care model on the lifestyle of patients with MI.

METHODS

This randomized clinical trial was carried out on 70 patients with MI in coronary care units of hospitals affiliated to Shiraz University of Medical Sciences. Enrolled patients were randomly assigned to intervention or control groups using a randomization list (random permutated blocks with length 4). The continuous care model was used for 35 patients in the intervention group for a period of 3 months and in the control group, the usual cares were applied for 35 patients. Data were collected through lifestyle questionnaire before the intervention and 3 months after. The data were analyzed using chi-square, independent t-test and paired t-test.

RESULTS

Patients in the intervention group showed significant improvements in lifestyle (125.6 ± 15.4 vs. 180.1 ± 19.9). Moreover, the lifestyle score of intervention group was significantly better than that of the control group (117.9 ± 22.0 vs. 180.1 ± 19.9; P < 0.001) after three months.

CONCLUSION

Applying a continuous care model had positive effects on the lifestyle of patients with Myocardial Infarction. In order to reduce the risk factors and improve the lifestyle of patients with MI, nurses could use this model to create an effective change.

Sense of coherence predicts post-myocardial infarction trajectory of leisure time physical activity: a prospective cohort study

Background

Physical activity confers a survival advantage after myocardial infarction (MI), yet the majority of post-MI patients are not regularly active. Since sense of coherence (SOC) has been associated with health outcomes and some health behaviours, we investigated whether it plays a role in post-MI physical activity.

We examined the predictive role of SOC in the long-term trajectory of leisure time physical activity (LTPA) after MI using a prospective cohort design.

Methods

A cohort of 643 patients aged ≤ 65 years admitted to hospital in central Israel with incident MI between February 1992 and February 1993 were followed up for 13 years. Socioeconomic, clinical and psychological factors, including SOC, were assessed at baseline, and LTPA was self-reported on 5 separate occasions during follow-up. The predictive role of SOC in long-term trajectory of LTPA was assessed using generalized estimating equations.

Results

SOC was consistently associated with engagement in LTPA throughout follow-up. Patients in the lowest SOC tertile had almost twice the odds (odds ratio,1.99; 95% confidence interval,1.52-2.60) of decreasing their engagement in LTPA as those in the highest tertile. A strong association remained after controlling for disease severity, depression, sociodemographic and clinical factors.

Conclusion

Our evidence suggests that SOC predicts LTPA trajectory post-MI. Assessment of SOC can help identify high-risk MI survivors, who may require additional help in following secondary prevention recommendations which can dramatically improve prognosis.

Physical activity patterns in older men and women in Germany: a cross-sectional study

Background

Data on physical activity in older adults in Germany is scarce. The aim of this study was to analyze physical activity patterns and to explore factors associated with physical activity in different domains, i.e. sporting activities (SA) and domestic activities (DA), in older men and women.

Methods

As part of the 7-year follow-up telephone interviews of the getABI cohort (community-dwelling older adults in Germany), the PRISCUS-PAQ was used to survey participants about their everyday physical activity patterns. Time per week (hh:mm) spent in SA and DA (heavy housework, gardening) was analyzed for men and women. Multivariate logistic regression analyses were performed in order to assess the odds of participating in SA and DA for at least 2.5 hours/week in association with sociodemographic factors, a broad range of physical health-related factors and interview date (season of the year).

Results

A total of 1,610 primary health care patients (51.6% women) with a median age of 77 (range 72-93) years were included in the analyses. Men engaged in SA more often than women (01:45 vs. 01:10), whereas women did more DA per week than men (04:00 vs. 03:00).

Being interviewed in spring or summer was associated with increased performance of DA in both sexes. Participation in these activities was reduced in more highly educated men and women. Living alone increased the odds of sports participation in women, but not in men. Most physical health-related factors were only selectively associated with either SA or DA, in men or women, respectively. The need for a walking aid was the only factor that consistently lowered the odds of being active in both activity domains and sexes.

Conclusions

This exploratory study delivers reliable and relevant data on the participation in and correlates of sporting and domestic activities of community-dwelling older adults for whom there had previously been only limited information at a population level in Germany. Findings are discussed and implications for epidemiological research and health promotion practice are provided.

Influence of an early recovery telehealth intervention on physical activity and functioning after coronary artery bypass surgery among older adults with high disease burden

OBJECTIVE

Older adults with poor functioning preoperatively are at risk for delayed recovery and more impaired outcomes after coronary artery bypass surgery (CABS). The study objective was to determine whether a 6-week early recovery telehealth intervention, designed to improve self-efficacy and management related to symptoms after CABS, was effective in improving outcomes (physical activity, physiologic, and psychologic functioning) for older adults (aged > 65 years) with higher disease burden.

METHODS

A descriptive, repeated-measures experimental design was used. Follow-up data were collected at 3 and 6 weeks and 3 months after CABS. Subjects were drawn from a larger randomized clinical trial. Parent study subjects who had high disease burden preoperatively (physical component score of < 50 on the Medical Outcome Study Short Form-36 and RISKO score of > 6) were included (N = 55), with 23 subjects in the early recovery intervention group and 31 subjects in the usual care group (n = 31). Subjects ranged in age from 65 to 85 years (M = 71.6 + 5.1 years).

RESULTS

There was a significant main effect by group (F[1,209] = 4.66, P < .05). The intervention group had a least square means of 27.9 kcal/kg/d of energy expenditure compared with the usual care group of 26.6 kcal/kg/d per the RT3 accelerometer (Stayhealthy, Inc, Monrovia, CA). Both groups had significantly improved physical (F[2,171] = 3.26, P < .05) and role-physical (F[2,171] = 6.64, P < .005) functioning over time.

CONCLUSION

The subgroup of subjects undergoing CABS with high disease burden were responsive to an early recovery telehealth intervention. Improving patients' physical activity and functioning can reduce morbidity and mortality associated with poor functioning after cardiac events.