Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials

Molecular insights of exercise therapy in disease prevention and treatment

Despite substantial evidence emphasizing the pleiotropic benefits of exercise for the prevention and treatment of various diseases, the underlying biological mechanisms have not been fully elucidated. Several exercise benefits have been attributed to signaling molecules that are released in response to exercise by different tissues such as skeletal muscle, cardiac muscle, adipose, and liver tissue. These signaling molecules, which are collectively termed exerkines, form a heterogenous group of bioactive substances, mediating inter-organ crosstalk as well as structural and functional tissue adaption. Numerous scientific endeavors have focused on identifying and characterizing new biological mediators with such properties. Additionally, some investigations have focused on the molecular targets of exerkines and the cellular signaling cascades that trigger adaption processes. A detailed understanding of the tissue-specific downstream effects of exerkines is crucial to harness the health-related benefits mediated by exercise and improve targeted exercise programs in health and disease. Herein, we review the current in vivo evidence on exerkine-induced signal transduction across multiple target tissues and highlight the preventive and therapeutic value of exerkine signaling in various diseases. By emphasizing different aspects of exerkine research, we provide a comprehensive overview of (i) the molecular underpinnings of exerkine secretion, (ii) the receptor-dependent and receptor-independent signaling cascades mediating tissue adaption, and (iii) the clinical implications of these mechanisms in disease prevention and treatment.

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

Integrating Cardiac Rehabilitation in Stroke Recovery

Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.

Intrinsic and Extrinsic Contributors to the Cardiac Benefits of Exercise

Among its many cardiovascular benefits, exercise training improves heart function and protects the heart against age-related decline, pathological stress, and injury. Here, we focus on cardiac benefits with an emphasis on more recent updates to our understanding. While the cardiomyocyte continues to play a central role as both a target and effector of exercise's benefits, there is a growing recognition of the important roles of other, noncardiomyocyte lineages and pathways, including some that lie outside the heart itself. We review what is known about mediators of exercise's benefits-both those intrinsic to the heart (at the level of cardiomyocytes, fibroblasts, or vascular cells) and those that are systemic (including metabolism, inflammation, the microbiome, and aging)-highlighting what is known about the molecular mechanisms responsible.

Exercise-based cardiac rehabilitation for patients with coronary heart disease: a systematic review and evidence mapping study

INTRODUCTION

Exercise-based cardiac rehabilitation (CR) plays a critical role in coronary heart disease (CHD) management. There is a heritage in the effect of exercise-based CR with different exercise programs or intervention settings. This study developed an evidence matrix that systematically assesses, organizes, and presents the available evidence regarding exercise-based CR in CHD management.

EVIDENCE ACQUISITION

A comprehensive literature search was conducted across six databases. Two reviewers screened the identified literature, extracted relevant data, and assessed the quality of the studies. An evidence-mapping framework was established to present the findings in a structured manner. Bubble charts were used to represent the included systematic reviews (SRs). The charts incorporated information, exercise prescriptions, outcome indicators, associated P values, research quality, and the number of original studies. A descriptive analysis summarized the types of CR, intervention settings, influential factors, and adverse events.

EVIDENCE SYNTHESIS

Sixty-two SRs were included in this analysis, focusing on six exercise types in addition to assessing major adverse cardiovascular events (MACE), cost and rehabilitation outcomes. The most commonly studied exercise types were unspecified (28 studies, 45.2%) and aerobic (11 studies, 17.7%) exercises. All-cause mortality was the most frequently reported MACE outcome (22 studies). Rehabilitation outcomes primarily centered around changes in cardiac function (135 outcomes from 39 SRs). Only 8 (12.9%) studies were rated as "high quality." No significant adverse events were observed in the intervention group. Despite some variations among the included studies, most SRs demonstrated the benefits of exercise in improving one or more MACE or rehabilitation outcomes among CHD patients.

CONCLUSIONS

The proportion of high-quality evidence remains relatively low. Limited evidence is available regarding the effectiveness of specific exercise types and specific populations, necessitating further evaluation.

[Cardiac rehabilitation after acute coronary syndrome]

Cardiac rehabilitation is a fundamental part of treatment after acute coronary syndrome and should be followed within the first 14 days of the acute inpatient stay. The prognostic value in terms of improving quality of life, reducing both re-hospitalizations and cardiovascular mortality has been shown in numerous studies in recent years. The multimodal, interdisciplinary cardiac rehabilitation aims to maintain and restore the patients' ability to cope with everyday life. The characteristic of cardiac rehabilitation is the combination of sports and physiotherapy, psychosocial care, nutritional therapy, medical diagnostics, and therapy adjustment as well as aftercare recommendations within the framework of a 3-4 week stay in specialized rehabilitation facilities. Participation in exercise-based, multidisciplinary cardiac rehabilitation after acute coronary syndrome reduces cardiovascular mortality and is recommended with Class I, Level A evidence.

Kinesophobia and its related factors in patients after percutaneous coronary intervention: A cross-sectional study

OBJECTIVES

To explore the postoperative kinesophobia of patients after percutaneous coronary intervention (PCI) and its related factors.

BACKGROUND

Percutaneous coronary intervention is an effective method to treat coronary heart disease (CHD), and cardiac rehabilitation is an important auxiliary method after PCI. However, the compliance of patients with cardiac rehabilitation after PCI is not good, among which kinesophobia is an important influencing factor.

DESIGN

A descriptive cross-sectional design was implemented, and the high-quality reporting of the study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology Statement.

METHODS

In total, 351 inpatients who underwent PCI in three tertiary grade-A hospitals in China were selected by convenient sampling method. We use one-way ANOVA and multiple linear regression analysis to determine the relevant related factors.

RESULTS

The kinesophobia of patients after PCI was negatively correlated with chronic illness resource utilization and sense of personal mastery, and positively correlated with illness perception. Education level, clinical classification of CHD, exercise habits, chronic illness resource utilization, illness perception and sense of personal mastery entered the regression equation, which could explain 78.1% of the total variation.

CONCLUSION

The level of kinesiophobia of patients after PCI is high. Education level, clinical classification of CHD, exercise habits, chronic illness resource utilization, illness perception and sense of personal mastery are the related factors of kinesiophobia of patients after PCI.

RELEVANCE TO CLINICAL PRACTICE

By reducing the level of exercise fear of patients after PCI, patients are more likely to accept and adhere to the cardiac rehabilitation plan, thus improving their prognosis and improving their quality of life.

PATIENT OR PUBLIC CONTRIBUTION

The patient underwent PCI in the research hospital. Researchers screen them according to the inclusion criteria and invite them to participate in this study. If they meet the requirements, participants will answer the research questionnaire face to face after signing the informed consent form.

A Detailed Analysis of Cardiac Rehabilitation on 180-Day All-Cause Hospital Readmission and Mortality

PURPOSE

Cardiac rehabilitation (CR) is endorsed for coronary artery disease (CAD), but studies report inconsistent findings regarding efficacy. The objective of this study was to determine whether confounding factors, potentially contributing to these heterogeneous findings, impact the effect of CR on all-cause readmission and mortality.

METHODS

Patients (n = 2641) with CAD, CR eligible, and physically able were identified. Electronic medical records were inspected individually for each patient to extract demographic, clinical characteristic, readmission, and mortality information. Patients (n = 214) attended ≥1 CR session (CR group). Survival was considered free from: all-cause readmission; or composite outcome of all-cause readmission or death. Cox proportional hazards models, adjusting for demographics, comorbidities, and discharge criteria, were used to determine HR with 95% CI and to compare 180-d survival rates between the CR and no-CR groups.

RESULTS

During 180 d of follow-up, 12.1% and 18.7% of the CR and non-CR patients were readmitted to the hospital. There was one death (0.5%) in the CR group, while 98 deaths (4.0%) occurred in the non-CR group. After adjustment for age, sex, race, depression, anxiety, dyslipidemia, hypertension, obesity, smoking, type 2 diabetes, and discharge criteria, the final model revealed a significant 42.7% reduction in readmission or mortality risk for patients who attended CR (HR = 0.57: 95% CI, 0.33-0.98; P = .043).

CONCLUSIONS

Regardless of demographic characteristics, comorbidities, and cardiovascular discharge criteria, the risk of 180-d all-cause readmission or death was markedly decreased in patients who attended CR compared with those who did not.

Cardiac Rehabilitation Programs: Content, Effectiveness, Limitations, and Gaps in Knowledge

Cardiac rehabilitation (CR) constitutes a valuable therapeutic approach for patients with a broad spectrum of cardiovascular diseases facilitating the development and maintenance of a desirable level of physical, social, and psychological functioning following the onset of cardiovascular disease. Nowadays, cardiac rehabilitation programs emphasize the use of a multidisciplinary approach. The current review aims at presenting the state-of-the-art knowledge on the indications of patients entering cardiac rehabilitation programs, including their core components, duration, and effectiveness. Following a careful review of the international literature, we conclude that there are significant differences between the most commonly cited international CR guidelines as well as additional limitations and gaps in knowledge. Despite the benefits associated with CR and despite their widespread acceptance, CR referrals and program attendance remains low, while many questions have not been so far addressed through scientific research. Overall, the findings of our study suggest a critical need for the development of robust and evidence-based standardized CR interventions to increase their use and effectiveness throughout the world.

Development and application of a home-based exercise program for patients with cardiovascular disease: a feasibility study

BACKGROUND

Cardiac rehabilitation (CR) is recommended for patients with cardiovascular disease. However, the participation and completion rates for hospital-based CR are low, and home-based CR has been suggested as an alternative. This study aimed to develop a home-based CR program and assess the feasibility of the program over a 6-week period in patients with left ventricular dysfunction or a history of myocardial infarction.

METHODS

This feasibility study consisted of two phases. The initial phase (Study 1) focused on developing the home-based exercise protocol. Systematic approaches to developing evidence-based home-based exercise intervention were implemented including systematic review, patient surveys, and expert consensus. Study 2 aimed to evaluate the feasibility of a 6-week home-based CR program that was based on the results of Study 1. Study 2 included two exercise education sessions and four telephone counseling sessions. During this stage of the exercise program, the participants exercised on two separate days and their experiences while performing the aerobic and resistance exercises were surveyed. Eight participants participated in Study 1 and 16 participated in Study 2.

RESULTS

Participants expressed overall satisfaction with the exercise program in Study 1. Heart rate increased in response to exercise, but this did not correspond with perceived exertion. The aim of the home-based CR exercise program was for participants to achieve exercise goals (≥150 min/week of aerobic type exercises as well as at least twice weekly resistance exercise using own body weights). We aimed to increase compliance and adherence to the home-based CR program. In Study 2, 13 out of 16 participants (81.3%) completed the 6-week home-based CR program, with a participation rate of 100% in both exercise education and phone counseling sessions. Adherence to the home-based exercise protocol was 83.1% and no serious adverse events were observed. At the beginning of the study, only three out of 13 participants (23.1%) met the requirements for both aerobic and resistance exercises, but at the end of the 6-week program, 10 out of 13 participants (76.9%) fulfilled the requirements.

CONCLUSION

The exercise program developed in this study was safe and feasible, and the 6-week home-based CR program was feasible for patients with cardiovascular disease without any reported adverse effects.

The impact of a neuromuscular rehabilitation programme on the quality of life of patients with acute coronary syndrome and its relationship with sexual dysfunction: a randomised controlled trial

PURPOSE

Many patients with acute coronary syndrome experience problematic or altered sexual function. This aspect of the disease is frequently ignored or overlooked by the healthcare community even though it can strongly influence health-related patient quality of life (HRQoL). Thus, the aim of this study was to compare the effects of a specific cardiac rehabilitation programme focused on aerobic and neuromuscular strength-resistance training to those of a classic rehabilitation programme, both in terms of HRQoL and erectile dysfunction in patients with acute coronary syndrome.

METHODS

This study reports both secondary and unregistered outcomes from a double-blinded, randomised, and controlled clinical trial. The proposed intervention was based on the completion of a 20-session (10-week) cardiac rehabilitation programme for patients with cardiovascular disease. The patient cohort had been diagnosed with acute coronary syndrome and was recruited at the Cardiology Service of a private tertiary hospital. The outcomes assessed in this study were HRQoL and erectile disfunction assessed at baseline, after the intervention, and at a 6-month follow-up.

RESULTS

A total of 30 participants were randomly allocated to each study arm. The results of the two-way mixed ANOVAs showed significant group × time interactions for all the outcome measures (EQ-5D_index, p = 0.004; EQ-5D_VAS, p = 0.017; QLMI-Q, p ≤ 0.001; and IIEF-5, p = 0.001).

CONCLUSION

The neuromuscular strength training programme was more effective than the classic strength training programme in terms of increasing the HRQoL and improving erectile dysfunction in patients following acute coronary syndrome, with differences still remaining between these groups at the 6-month follow-up.

Cardiorespiratory Fitness Benefits of Long-Term Maintenance-Phase Cardiac Rehabilitation in Males and Females: A Retrospective Cohort Study

Purpose

This study investigated if associations exist between enrolment delay and VO2peak over five years of maintenance-phase cardiac rehabilitation (CR) in males and females.

Method

Data were extracted from the records of participants who had enrolled for ≥ 1 year in CR and completed ≥ 2 cardiopulmonary exercise tests. Mixed model analyses examined VO2peak trajectories for up to five years of enrolment. Interactions between enrolment delay × enrolment duration, baseline age × enrolment duration, and baseline VO2peak × enrolment duration were explored for inclusion in the model.

Results

The charts of 151 males (aged 63.9 ± 9.4 y) and 32 females (aged 65.3 ± 9.0 y) were included in the analyses. The enrolment delay following a cardiovascular event was 1.8 ± 3.0 years for males and 1.3 ± 1.7 years for females. No associations were found between enrolment delay × enrolment duration on VO2peak in males (β[SEj, 0.07[0.05]; 95% CI -0.02, 0.16, p = 0.12) or in females (β[SE], 0.07[0.13j; 95% CI -0.18, 0.33, p = 0.57), but predicted trajectories suggest clinically significantly improvements in VO2 peak (range, 1.3 to 1.6 mL/kg/min).

Conclusions

Early enrolment in CR is recommended and encouraged, but the benefits of long-term CR are possible despite delays.

Exercise-based cardiac rehabilitation after acute myocardial infarction in Sweden - standards, costs, and adherence to European guidelines (The Perfect-CR study)

AIMS

Information on standards including structure- and process-based metrics and how exercise-based cardiac rehabilitation (EBCR) is delivered in relation to guidelines is lacking. The aims of the study were to evaluate standards and adherence to guidelines at Swedish CR centers and to conduct a cost analysis of the physiotherapy-related activities of EBCR.

METHODS AND RESULTS

EBCR standards at all 78 CR centers in Sweden in 2016 were surveyed. The questions were based on guideline-recommended core components of EBCR for patients after a myocardial infarction (MI). The cost analysis included the identification, quantification, and valuation of EBCR-related cost items. Patients were offered a pre-discharge consultation with a physiotherapist at n = 61, 78% of the centers. A pre-exercise screening visit was routinely offered at n = 64, 82% of the centers, at which a test of aerobic capacity was offered in n = 58, 91% of cases, most often as a cycle ergometer exercise test n = 55, 86%. A post-exercise assessment was offered at n = 44, 56% of the centers, with a functional test performed at n = 30, 68%. Almost all the centers n = 76, 97% offered supervised EBCR programs. The total cost of delivering physiotherapy-related activities of EBCR according to guidelines was approximately 437 euro (4,371 SEK) per patient. Delivering EBCR to one MI patient required 11.25 hours of physiotherapy time.

CONCLUSION

While the overall quality of EBCR programs in Sweden is high, there are several areas of potential improvement to reach the recommended European standards across all centers. To improve the quality of EBCR, further compliance with guidelines is warranted.

Preventive Cardiology 2024: State of Problem Perspectives of Development

This article presents the current relevance of preventive cardiology, substantiates the increasing importance of the prevention of cardiovascular diseases (CVD) to reduce mortality and the burden of CVD, including in the era of widespread use of modern high-tech methods and effective drug therapy for treating CVD in clinical practice. The article also addresses effectiveness of secondary prevention of CVD and approaches to its improvement. Particular attention is paid to the high importance of introducing into practice comprehensive programs for secondary prevention of CVD and cardiac rehabilitation. The principles of organizing such programs and their most important components are presented in detail.

Rationale and Design of the mTECH-Rehab Randomized Controlled Trial: Impact of a Mobile Technology Enabled Corrie Cardiac Rehabilitation Program on Functional Status and Cardiovascular Health

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based, guideline-recommended intervention for patients recovering from a cardiac event, surgery or procedure that improves morbidity, mortality, and functional status. CR is traditionally provided in-center, which limits access and engagement, most notably among underrepresented racial and ethnic groups due to barriers including cost, scheduling, and transportation access. This study is designed to evaluate the Corrie Hybrid CR, a technology-based, multicomponent health equity-focused intervention as an alternative to traditional in-center CR among patients recovering from a cardiac event, surgery, or procedure compared with usual care alone.

METHODS

The mTECH-Rehab (Impact of a Mobile Technology Enabled Corrie CR Program) trial will randomize 200 patients who either have diagnosis of myocardial infarction or who undergo coronary artery bypass grafting surgery, percutaneous coronary intervention, heart valve repair, or replacement presenting to 4 hospitals in a large academic health system in Maryland, United States, to the Corrie Hybrid CR program combined with usual care CR (intervention group) or usual care CR alone (control group) in a parallel arm, randomized controlled trial. The Corrie Hybrid CR program leverages 5 components: (1) a patient-facing mobile application that encourages behavior change, patient empowerment, and engagement with guideline-directed therapy; (2) Food and Drug Administration-approved smart devices that collect health metrics; (3) 2 upfront in-center CR sessions to facilitate personalization, self-efficacy, and evaluation for the safety of home exercise, followed by a combination of in-center and home-based sessions per participant preference; (4) a clinician dashboard to track health data; and (5) weekly virtual coaching sessions delivered over 12 weeks for education, encouragement, and risk factor modification. The primary outcome is the mean difference between the intervention versus control groups in distance walked on the 6-minute walk test (ie, functional capacity) at 12 weeks post randomization. Key secondary and exploratory outcomes include improvement in a composite cardiovascular health metric, CR engagement, quality of life, health factors (including low-density lipoprotein-cholesterol, hemoglobin A1c, weight, diet, smoking cessation, blood pressure), and psychosocial factors. Approval for the study was granted by the local institutional review board. Results of the trial will be published once data collection and analysis have been completed.

CONCLUSIONS

The Corrie Hybrid CR program has the potential to improve functional status, cardiovascular health, and CR engagement and advance equity in access to cardiac rehabilitation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05238103.

The impact of the time factors on the exercise-based cardiac rehabilitation outcomes of the patients with acute myocardial infarction after percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Cardiac rehabilitation (CR) has been demonstrated to improve outcomes in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). However, the optimal CR initiation time and duration remain to be determined. This study aimed to explore the impact of the time factors on the CR outcomes in AMI patients who received PCI by the method of meta-regression analysis.

METHODS

We searched five databases (PubMed, Embase, Cochrane Library, Web of Science and Google scholar) up to October 31, 2023. Meta-regression analysis was utilized to explore the impact of the time factors on the effect sizes. Subgroups with more than 3 studies were used for meta-regression analysis.

RESULTS

Our analysis included 16 studies and a total of 1810 patients. The meta-regression analysis revealed that the initiation time and duration of CR had no significant impact on the occurrence of arrhythmia, coronary artery restenosis and angina pectoris. The initiation time and duration of CR also had no significant impact on the changes in left ventricular ejection fraction (LVEF, starting time: estimate = 0.160, p = 0.130; intervention time: estimate = 0.017, p = 0.149), left ventricular end-diastolic volume (LVEDV, starting time: estimate = - 0.191, p = 0.732; intervention time: estimate = - 0.033, p = 0.160), left ventricular end-systolic volume (LVESV, starting time: estimate = - 0.301, p = 0.464; intervention time: estimate = 0.015, p = 0.368) and 6-minute walk test (6MWT, starting time: estimate = - 0.108, p = 0.467; intervention time: estimate = 0.019, p = 0.116).

CONCLUSION

Implementation of CR following PCI in patients with AMI is beneficial. However, in AMI patients, there is no significant difference in the improvement of CR outcomes based on different CR starting times within 1 month after PCI or different durations of the CR programs. It indicates that it is feasible for patients with AMI to commence CR within 1 month after PCI and continue long-term CR, but the time factors which impact CR are intricate and further clinical research is still needed to determine the optimal initiation time and duration of CR.

Physical activity, exercise and adverse cardiovascular outcomes in individuals with pre-existing cardiovascular disease: a narrative review

INTRODUCTION

The evidence supporting the cardiovascular health benefits of physical activity and/or exercise training is well-established. While the role of physical activity in primary prevention is unequivocal, its significance in secondary prevention (among those with preexisting cardiovascular disease) is less definitive. Though guidelines universally recommend physical activity as part of the secondary preventive strategy, the empirical evidence underpinning these recommendations is not as robust as that for primary prevention.

AREAS COVERED

This review distills the body of available observational and interventional evidence on the relationship between physical activity, exercise, and adverse cardiovascular outcomes among those with preexisting cardiovascular disease. The postulated biologic mechanisms underlying the relationships, areas of prevailing uncertainty, and potential public health implications are also discussed.

EXPERT OPINION

A physical activity level of 500 MET-min/week (equivalent to 150 min of moderate-intensity physical activity or 75 min of vigorous-intensity physical activity or an equivalent combination) may be a minimum requirement for patients with preexisting CVD. However, to reap the maximum benefits of physical activity and also minimize adverse effects, physical activity and/or exercise regimens should be tailored to unique factors such as individual's baseline physical activity habits, cardiovascular health status and the specific nature of their cardiovascular disease.

Effects of exercise training after acute coronary syndromes in octogenarians - prospective 12-month evaluation

OBJECTIVE

Aim: To demonstrate the impact of individual exercise training on the course of the disease, exercise tolerance and quality of life (QoL) in patients over 75 years after acute coronary syndrome (ACS).

PATIENTS AND METHODS

Materials and methods: Study included octogenarians after ACS randomly assigned into two groups: a training group (ExT) subjected to individualized physical training and a control group (CG) with standard recommendations for activity. Patients underwent exercise tolerance test (ETT), 6-minute walk test (6-MWT), NHP and QoL questionnaires evaluation, lab tests, ECG, echocardiographic examination at the beginning and after 2, 6 and 12 months.

RESULTS

Results: Study included 51 patients, mean age 80 years, 50% men, all patients completed the study. Initial physical capacity was comparable in both groups. After 2-month training the average ETT exercise time increased by 12.5% (p=0.0004), the load increased by 13% (p=0.0005) and the 6-MWT results improved by 8.3% (p=0.0114). Among CG these changes were not significant. But 6 and 12 months after training cessation 6-MWT results returned to the initial values (p=0.069, p=0.062 respecitvely). Average ETT exercise time and average load decreased significantly after 12 months (p=0.0009, p=0.0006). Level of pain was significantly lower at the end of the training in ExT group (p=0.007), but it returned to initial 12 months later (p=0.48). QoL deteriorated significantly in the ExT group 12 months after training cessation (p=0.04).

CONCLUSION

Conclusions: Cardiac rehabilitation in octogenarians after ACS was safe and improved physical performance in a short period of time. Cessation of training resulted in a loss of achieved effects and deterioration of the QoL.

Research trends and hotspots in exercise rehabilitation for coronary heart disease: A bibliometric analysis

Exercise rehabilitation can improve the prognosis of patients with coronary heart disease. However, a bibliometric analysis of the global exercise rehabilitation for coronary heart disease (CHD) research topic is lacking. This study investigated the development trends and research hotspots in the field of coronary heart disease and exercise rehabilitation. CiteSpace software was used to analyze the literature on exercise therapy for CHD in the Web of Science Core Collection database. We analyzed the data of countries/institutions, journals, authors, keywords, and cited references. A total of 3485 peer-reviewed papers were found, and the number of publications on the topic has steadily increased. The most productive country is the USA (1125), followed by China (477) and England (399). The top 3 active academic institutions are Research Libraries UK (RLUK) (236), Harvard University (152), and the University of California System (118). The most commonly cited journals are Circulation (2596), The most commonly cited references are "Exercise-based cardiac rehabilitation for coronary heart disease" (75), Lavie CJ had published the most papers (48). World Health Organization was the most influential author (334 citations). The research frontier trends in this field are body composition, participation, and function. Research on the effects of physical activity or exercise on patients with CHD is a focus of continuous exploration in this field. This study provides a new scientific perspective for exercise rehabilitation and CHD research and gives researchers valuable information for detecting the current research status, hotspots, and emerging trends for further research.

The effect of home-based cardiac rehabilitation on arterial stiffness and peak oxygen consumption in patients with myocardial infarction

Objectives

This study aims to investigate the effectiveness of home-based cardiac rehabilitation (CR) on arterial stiffness in patients with acute myocardial infarction (AMI).

Patients and methods

Between January 2015 and December 2017, a total of 135 patients (120 males, 15 females; mean age: 58.8±11.1 years) with AMI who were referred for CR were included. Home-based CR was prescribed based on a cardiopulmonary exercise test (CPET) for at least six months. All patients completed three consecutive CPETs and brachial-ankle pulse wave velocity (baPWV) measurements at one, four, and seven months after onset.

Results

After six months of CR, there was an improvement in peak oxygen consumption (pVO2) (Month 1, 28.7±6.4 mL/kg/min; Month 4, 31.6±6.3 mL/kg/min; Month 7, 31.2±7.1 mL/kg/min, p<0.001) and a reduction in baPWV (Month 1, left, 1546.0±311.2 cm/sec, right 1545.5±301.5 cm/sec; Month 4, left, 1374.9±282.5 cm/sec, right 1371.6±287.5 cm/sec; Month 7, left, 1362.9±287.0 cm/sec, right 1365.5±281.1 cm/sec, p<0.001).

Conclusion

In patients with AMI, arterial stiffness and aerobic capacity improved after six months of home-based CR, particularly in the early stages of rehabilitation. These results suggest that changes in baPWV are useful in determining the effectiveness of CR and pVO2 in the initial stages of CR.

Keeping the Heart Healthy: The Role of Exercise in Cardiac Repair and Regeneration

Significance: Heart failure is often accompanied by a decrease in the number of cardiomyocytes. Although the adult mammalian hearts have limited regenerative capacity, the rate of regeneration is extremely low and decreases with age. Exercise is an effective means to improve cardiovascular function and prevent cardiovascular diseases. However, the molecular mechanisms of how exercise acts on cardiomyocytes are still not fully elucidated. Therefore, it is important to explore the role of exercise in cardiomyocytes and cardiac regeneration. Recent Advances: Recent advances have shown that the effects of exercise on cardiomyocytes are critical for cardiac repair and regeneration. Exercise can induce cardiomyocyte growth by increasing the size and number. It can induce physiological cardiomyocyte hypertrophy, inhibit cardiomyocyte apoptosis, and promote cardiomyocyte proliferation. In this review, we have discussed the molecular mechanisms and recent studies of exercise-induced cardiac regeneration, with a focus on its effects on cardiomyocytes. Critical Issues: There is no effective way to promote cardiac regeneration. Moderate exercise can keep the heart healthy by encouraging adult cardiomyocytes to survive and regenerate. Therefore, exercise could be a promising tool for stimulating the regenerative capability of the heart and keeping the heart healthy. Future Directions: Although exercise is an important measure to promote cardiomyocyte growth and subsequent cardiac regeneration, more studies are needed on how to do beneficial exercise and what factors are involved in cardiac repair and regeneration. Thus, it is important to clarify the mechanisms, pathways, and other critical factors involved in the exercise-mediated cardiac repair and regeneration. Antioxid. Redox Signal. 39, 1088-1107.

Effectiveness of Cardiac Rehabilitation Services in Low- and Middle-Income Countries: A Systematic Review

Cardiac rehabilitation (CR) is a cost-effective intervention that can reduce cardiovascular disease (CVD) morbidity and mortality by 20%. Despite the clear benefits of CR, it remains unavailable and underutilized. This study aimed to assess the effectiveness of different CR models in reducing CVD-related morbidity and mortality in low-and middle-income countries. We conducted a systematic review of studies conducted in low- and middle-income countries that assessed at least one of the three phases of CR (inpatient rehabilitation, outpatient rehabilitation in a hospital, or community setting and maintenance). The primary outcomes of interest were mortality (all-cause and CVD-specific), CVD-related morbidity, functional capacity, risk factor reduction, and quality of life (QoL). The electronic search retrieved 1,102 studies, of which 22 were retrieved and included in the review. These studies were conducted between 2011 and 2022 and the majority (18) were conducted in Asia. All studies except one were randomized controlled trials (RCTs), and all except one were conducted at a single site. The target population in most studies (16) included patients with coronary artery disease (CAD). Seven studies have incorporated digital technology. Only one study has reported a significant reduction in all-cause mortality. Thirteen studies reported data on functional capacity, and 16 on quality of life (QoL), showing statistically significant improvements. Data on risk factors, anxiety, and depression have shown mixed results. CR is effective in low- and middle-income countries, and strategies to scale it up using locally available resources tailored to the patient population should be adopted.

Self-Reported Executive Function in Hospitalized Cardiac Patients and Associations With Patient Characteristics and Cardiac Rehabilitation Attendance

PURPOSE

Executive function (ExF), the ability to do complex cognitive tasks like planning and refraining from impulsive behavior, is associated with compliance with medical recommendations. The present study identified associations between self-reported ExF and demographics of patients with cardiac disease as well as with cardiac rehabilitation (CR) attendance.

METHODS

Self-reported ExF impairment was measured using the Behavior Rating Inventory of Executive Function (BRIEF) on 316 individuals hospitalized for CR-qualifying cardiac events. Scores were calculated for a global measure (Global Executive Composite [GEC]) and the two BRIEF indices: Behavioral Regulation Index and Metacognition Index (MCI). Participants were followed up post-discharge to determine CR attendance. Univariate logistic regressions between ExF measures and demographic variables were conducted, as were multiple logistic regressions to identify significant, independent predictors. Analyses were conducted using clinical (T scores ≥ 65) and subclinical (T scores ≥ 60) criteria for significant ExF impairment as outcomes. One-way analyses of variance were performed between ExF impairment and CR attendance.

RESULTS

Self-reported ExF deficits were relatively rare; 8.9% had at least subclinical scores on the GEC. Using the subclinical criterion for the MCI, having diabetes mellitus (DM) and being male were significant, independent predictors of MCI impairment. No significant relationship was found between ExF and CR attendance.

CONCLUSION

Using the subclinical criterion only, individuals with DM and males were significantly more likely to have MCI impairment. No significant effect of ExF impairment on CR attendance was found, suggesting that self-reported ExF measured in the hospital may not be an appropriate measure for predicting behavioral outcomes.

The State of Cardiac Rehabilitation in Saudi Arabia: Barriers, Facilitators, and Policy Implications

Cardiovascular disease (CVD) is a critical public health issue in Saudi Arabia, where it is the leading cause of death. The economic burden of CVD in the country is expected to triple by 2035, reaching $9.8 billion. This paper provides an overview of CVD in Saudi Arabia and its risk factors, impact on healthcare, and effects on patients' quality of life. The review emphasizes the potential of cardiac rehabilitation (CR) programs in addressing the CVD epidemic. CR programs have been shown to reduce morbidity, mortality, and hospital readmissions while improving patients' cardiovascular health and overall well-being. However, these programs are underutilized and inaccessible in Saudi Arabia. The paper highlights the urgent need for CR programs in the country and suggests key strategies for implementation. These include increasing patient referrals, tailoring programs to individual needs, enhancing patient education, and making CR accessible through home-based options. Fostering multidisciplinary collaboration and developing tailored guidelines for Arab countries can further enhance the impact of CR programs. In conclusion, this review underscores the vital importance of comprehensive CR programs in Saudi Arabia to combat the rising CVD burden, improve patient quality of life, and align with the goals of the Saudi 2030 Vision for a healthier society.

The Effects of Cardiac Rehabilitation including Nordic Walking in Patients with Chronic Coronary Syndromes after Percutaneous Coronary Interventions in Elective Mode

Background: Percutaneous coronary intervention (PCI) in patients with chronic coronary syndrome (CCS) is a worldwide method of coronary revascularisation. The aim of this study was to assess the immediate and long-term effects of Nordic Walking (NW) training added to a standard cardiac rehabilitation programme on physical activity (PA) and capacity and life quality, as well as selected proatherogenic risk factors. Methods: The studied group comprised 50 patients (considering exclusion criteria, 40 patients), aged 56-70, with CCS after elective PCI qualified them for a 6-weeks-long cardiac rehabilitation. The follow-up period lasted 4 months, and control visits occurred at 2 and 4 months. The studied patients were randomly divided into two groups: control group-standard cardiac rehabilitation programme and experimental group-standard cardiac rehabilitation programme additionally combined with NW training. Results: The cardiac rehabilitation programme in the experimental, compared to the control group, increased intense PA (from 731.43 ± 909.9 to 2740 ± 2875.96 vs. from 211.43 ± 259.43 to 582.86 ± 1289.74 MET min/week) and aerobic efficiency-VO2peak (from 8.67 ± 0.88 to 9.96 ± 1.35 vs. from 7.39 ± 2 to 7.41 ± 2.46 METs), as well as quality of life according to the WHOQOL-BREF questionnaire (from 3.57 ± 0.51 to 4.14 ± 0.36 vs. from 3.29 ± 0.47 to 3.57 ± 0.51 points). The walking distance assessed with the 6-min walk test did not differ between the groups before the beginning of the rehabilitation programme. Both at the I follow-up and II follow-up time points, a significant increase in the walking distance was noted in the control and experimental groups compared to baseline, and the difference between both groups was significant at the end of follow-up (378.57 ± 71.35 vs. 469.29 ± 58.07, p = 0.003). Moreover, NW had a positive effect on the modulation within selected biochemical risk factors of atherosclerosis, as well as subjective quality of life and well-being. Conclusions: Introducing NW training into the cardiac rehabilitation process proved to be a more effective form of therapy in patients with CCS treated via PCI, as compared to the standard cardiac rehabilitation programme alone.

Difference of cardiac rehabilitation in the morning or evening on indexes of left ventricular and N-terminal pro-brain natriuretic peptide: a randomized controlled trial

The present study aimed to evaluate the effects a cardiac rehabilitation program (CRP) performed in the morning or evening on left ventricular (LV) filling indices and the level of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) in patients undergoing percutaneous coronary angioplasty during the COVID-19 pandemic.

Methods

This was a randomized controlled single-blinded clinical trial. Ninety-six patients (mean age: 50.2 ± 8.1 years, 36 women and 44 men) with percutaneous coronary angioplasty were divided into two groups of intervention and control. In each group, the CRP was performed in either morning or evening. The CRP included walking and performing push-ups and sit-ups for 8 weeks. The participants of the control groups received routine care. The functional indices of LV, including LV ejection fraction, systolic function, and diastolic function (i.e. the transmitral flow), the E/e' to left atrium peak strain ratio (as an estimation for LA stiffness), and NT-proBNP level were measured in all participants before starting and at the end of the CRP.

Results

In the intervention group, the individuals performing the CRP in the evening had significantly higher E-wave (0.76±0.02 vs. 0.75±0.03; P=0.008), ejection fraction (52.5±5.64 vs. 55.5±3.59; P=0.011), and diastolic function velocity (E/A ratio, 1.03±0.06 vs. 1.05±0.03; P=0.014) and significantly lower A-wave (0.72±0.02 vs. 0.71±0.01; P=0.041), E/e' ratio (6.74±0.29 vs. 6.51±0.38; P=0.038), and NT-proBNP level (2007.9±214.24 vs. 1933.9±253.13; P=0.045) compared with those performing the program in the morning.

Conclusions

A supervised CRP performed in the evening compared with morning was more effective in improving LV functional indices. Therefore, such home-based interventions are recommended to be performed in the evening during the COVID-19 pandemic.

Physical Activity and Mortality in Patients with Coronary Artery Disease

PURPOSE OF REVIEW

Coronary artery disease (CAD) accounts for half of heart-related mortalities. Secondary prevention measures are aimed at enhancing the probability of survival in acute and chronic heart diseases. Physical activity (PA) has been shown to effectively reduce all-cause and cardiovascular (CV) mortality rates. This article reviews the relationship between PA and mortality in patients with CAD. Additionally, we discuss the process of vascular changes that contributes to survival benefits in physically active CAD patients, along with exercise dosing and guideline recommendations.

RECENT FINDINGS

Recent studies have shown that physical inactivity poses a modifiable risk factor that impedes favorable vasculature remodeling, unlike active individuals. Recent meta-analyses provide strong evidence of the multifaceted advantages of PA in lowering mortality rates in patients with CAD, as opposed to physically inactive participants. In summary, substantial evidence indicates that PA is significantly associated with reduction in all-cause and CV mortality in CAD patients, with a dose-response relationship.

Clinical Management of Patients With Stable Ischemic Heart Disease

Ischemic heart disease is considered stable, if patients are asymptomatic or have well controlled symptoms. Based on the pretest probability, noninvasive imaging tests are performed to rule out the disease, and coronary computed tomography angiography being the first line. Invasive coronary angiography remains the gold standard method for diagnosing coronary artery disease. In patients with stable coronary artery disease, comorbidities such as hyperlipidemia, hypertension, and diabetes should be optimized. For patients with persistent anginal symptoms even with optimized medical therapy, coronary revascularization with percutaneous coronary intervention can be considered. Coronary artery bypass grafting may be more beneficial for patients who has stable coronary artery disease with left main disease and/or left ventricular dysfunction and/or multivessel disease; however, treatment should be individualized to the overall clinical picture.

Cardiology and lifestyle medicine

Poor lifestyle habits, such as physical inactivity and poor diets, are highly prevalent within society and even more so among patients with chronic disease. The need to stem poor lifestyle habits has led to the development of a new field of Lifestyle Medicine, whose mission is to prevent, treat, and even reverse chronic diseases through lifestyle interventions. Three fields within Cardiology relate to this mission: Cardiac Rehabilitation, Preventive Cardiology, and Behavioral Cardiology. Each of these three fields have contributed substantially to the reduction of cardiovascular disease (CVD) morbidity and mortality. The historic contributions of these three cardiac fields are reviewed as well as the challenges each of these fields has faced in optimizing the application of lifestyle medicine practices. A shared agenda between Cardiology and the American College of Lifestyle Medicine could further the utilization of behavioral interventions. This review suggests seven steps that could be shared by these organizations and other medical societies. First, there is a need to develop and promulgate the assessment of lifestyle factors as "vital signs" during patient visits. Second, developing a strong partnership between the fields of Cardiology and Physiatry could improve important aspects of cardiac care, including a potential redesign of cardiac stress testing. Third, behavioral evaluations should be optimized at patients' entrée points into medical care since these may be considered "windows of opportunity". Fourth, there is a need to broaden cardiac rehabilitation into inexpensive programs and make this program eligible for patients with risk factors but no known CVD. Fifth, lifestyle medicine education should be integrated into the core competencies for relevant specialties. Sixth, there is a need for inter-societal advocacy to promote lifestyle medicine practices. Seventh, the well-being effects of healthy lifestyle behaviors, such as their impact on one's sense of vitality, should be emphasized.

A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation

BACKGROUND

Cardiovascular disease (CVD) is a predominant cause of mortality. Pharmacists play an important role in secondary prevention of CVD, however, their role in cardiac rehabilitation is under-reported and services are under-utilised.

AIM

To explore the role of pharmacists in cardiac rehabilitation, the impact of their interventions on patient outcomes, and prospects of future role development.

METHOD

Databases searched were PubMed, Embase, Medline, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO from January 2006 to October 2021. Randomised and non-randomised controlled trials were selected if they assessed the role of pharmacists in cardiac rehabilitation. Cochrane risk of bias tool, Joanna Briggs Institute (JBI) Critical Appraisal Tool for Quasi-Experimental Studies and the National Heart, Lung and Blood Institute (NIH) quality assessment tool, were used to assess quality and a narrative synthesis was conducted.

RESULTS

The search yielded 786 studies, only five met the inclusion criteria. The pharmacist-led interventions included patient education, medication review and reconciliation, and medication adherence encouragement. Four out of the five studies showed that pharmacist-led interventions in cardiac rehabilitation significantly improved patient clinical and non-clinical outcomes. One study showed a statistically significant reduction in low density lipoprotein-cholesterol (LDL-C) levels to optimal target of < 70 mg/dL (80% vs 60%, p = 0.0084). Two studies reported better medication adherence, and two studies showed greater improvement in all domains of health-related quality of life observed in the intervention group.

CONCLUSION

Pharmacist-led interventions in cardiac rehabilitation could lower CVD risk factors and hence recurrence. Although these findings support pharmacists' involvement in cardiac rehabilitation, larger intervention studies are needed to evaluate the feasibility of pharmacist-led interventions and their impact on hospital admissions and mortality risk.

Effectiveness of a behavioral medicine intervention in physical therapy on secondary psychological outcomes and health-related quality of life in exercise-based cardiac rehabilitation: a randomized, controlled trial

BACKGROUND

Interventions promoting adherence to exercise-based cardiac rehabilitation (exCR) are important to achieve positive physical and psychological outcomes, but knowledge of the added value of behavioral medicine interventions for these measures is limited. The aim of the study was to investigate the added value of a behavioral medicine intervention in physical therapy (BMIP) in routine exCR on psychological outcomes and health-related quality of life (HRQoL) versus routine exCR alone (RC).

METHODS

A total of 170 patients with coronary artery disease (136 men), mean age 62.3 ± 7.9 years, were randomized at a Swedish university hospital to a BMIP plus routine exCR or to RC for four months. The outcome assessments included HRQoL (SF-36, EQ-5D), anxiety and depression (HADS), patient enablement and self-efficacy and was performed at baseline, four and 12 months. Between-group differences were tested with an independent samples t-test and, for comparisons within groups, a paired t-test was used. An intention-to-treat and a per-protocol analysis were performed.

RESULTS

No significant differences in outcomes between the groups were shown between baseline and four months or between four and 12 months. Both groups improved in most SF-36 domains, EQ-VAS and HADS anxiety at the four-month follow-up and sufficient enablement remained at the 12-months follow-up.

CONCLUSION

A BMIP added to routine exCR care had no significant effect on psychological outcomes and HRQoL compared with RC, but significant improvements in several measures were shown in both groups at the four-month follow-up. Since recruited participants showed a better psychological profile than the general coronary artery disease population, further studies on BMIP in exCR, tailored to meet individual needs in broader patient groups, are needed. Trial registration number NCT02895451, 09/09/2016, retrospectively registered.

A Comprehensive Secondary Prevention Benchmark (2PBM) Score Identifying Differences in Secondary Prevention Care in Patients After Acute Coronary Syndrome

PURPOSE

The objective of this study was to quantify secondary prevention care by creating a secondary prevention benchmark (2PBM) score for patients undergoing ambulatory cardiac rehabilitation (CR) after acute coronary syndrome (ACS).

METHODS

In this observational cohort study, 472 consecutive ACS patients who completed the ambulatory CR program between 2017 and 2019 were included. Benchmarks for secondary prevention medication and clinical and lifestyle targets were predefined and combined in the comprehensive 2PBM score with maximum 10 points. The association of patient characteristics and achievement rates of components and the 2PBM were assessed using multivariable logistic regression analysis.

RESULTS

Patients were on average 62 ± 11 yr of age and predominantly male (n = 406; 86%). The types of ACS were ST-elevation myocardial infarction (STEMI) in 241 patients (51%) and non-ST-elevation myocardial infarction in 216 patients (46%). Achievement rates for components of the 2PBM were 71% for medication, 35% for clinical benchmark, and 61% for lifestyle benchmark. Achievement of medication benchmark was associated with younger age (OR = 0.979: 95% CI, 0.959-0.996, P = .021), STEMI (OR = 2.05: 95% CI, 1.35-3.12, P = .001), and clinical benchmark (OR = 1.80: 95% CI, 1.15-2.88, P = .011). Overall ≥8 of 10 points were reached by 77% and complete 2PBM by 16%, which was independently associated with STEMI (OR = 1.79: 95% CI, 1.06-3.08, P = .032).

CONCLUSIONS

Benchmarking with 2PBM identifies gaps and achievements in secondary prevention care. ST-elevation myocardial infarction was associated with the highest 2PBM scores, suggesting best secondary prevention care in patients after ST-elevation myocardial infarction.

Cardiac electrophysiological remodeling associated with enhanced arrhythmia susceptibility in a canine model of elite exercise

The health benefits of regular physical exercise are well known. Even so, there is increasing evidence that the exercise regimes of elite athletes can evoke cardiac arrhythmias including ventricular fibrillation and even sudden cardiac death (SCD). The mechanism of exercise-induced arrhythmia and SCD is poorly understood. Here, we show that chronic training in a canine model (12 sedentary and 12 trained dogs) that mimics the regime of elite athletes induces electrophysiological remodeling (measured by ECG, patch-clamp, and immunocytochemical techniques) resulting in increases of both the trigger and the substrate for ventricular arrhythmias. Thus, 4 months sustained training lengthened ventricular repolarization (QTc: 237.1±3.4 ms vs. 213.6±2.8 ms, n=12; APD90: 472.8±29.6 ms vs. 370.1±32.7 ms, n=29 vs. 25), decreased transient outward potassium current (6.4±0.5 pA/pF vs. 8.8±0.9 pA/pF at 50 mV, n=54 vs. 42), and increased the short-term variability of repolarization (29.5±3.8 ms vs. 17.5±4.0 ms, n=27 vs. 18). Left ventricular fibrosis and HCN4 protein expression were also enhanced. These changes were associated with enhanced ectopic activity (number of escape beats from 0/hr to 29.7±20.3/hr) in vivo and arrhythmia susceptibility (elicited ventricular fibrillation: 3 of 10 sedentary dogs vs. 6 of 10 trained dogs). Our findings provide in vivo, cellular electrophysiological and molecular biological evidence for the enhanced susceptibility to ventricular arrhythmia in an experimental large animal model of endurance training.

Impact of obesity, lifestyle factors and health interventions on breast cancer survivors

The incidences of both breast cancer and obesity are rising in the UK. Obesity increases the risk of developing breast cancer in the postmenopausal population and leads to worse outcomes in those of all ages treated for early-stage breast cancer. In this review we explore the multifactorial reasons behind this association and the clinical trial evidence for the benefits of physical activity and dietary interventions in the early and metastatic patient groups. As more people with breast cancer are cured, and those with metastatic disease are living longer, cancer survivorship is becoming increasingly important. Therefore, ensuring the long-term implications of cancer and cancer treatment are addressed is vital. Although there remains a lack of definitive evidence that deliberate weight loss after a diagnosis of breast cancer reduces disease recurrence, a number of studies have reported benefits of weight loss and of physical activity. However, the limited data currently available mean that clinicians remain unclear on the optimal lifestyle advice to give their patients. Further high-quality research is needed to provide this evidence base, which will be required to optimise clinical care and for the commissioning of lifestyle interventions in the UK in breast cancer survivors.

Top 50 cited articles on cardiac rehabilitation: A bibliometric and altmetric analysis study

Background/Aim: Cardiovascular disease (CVD) is the leading cause of death globally, with an estimated 18.6 million deaths each year. Cardiac rehabilitation (CR) has positive effects on reducing the mortality and morbidity of CVD, so there is a growing interest in this field. The aim of this study was to analyze the top 50 cited articles in the field of CR. Methods: The Web of Science (WoS) database was searched for articles published between 1986 and 2021. A record was made of the following information for the bibliometric analysis: article title, year of publication, number of authors and their names, number of citations, citation index, journal of publication, impact factor, type of article, and source of funding. The altmetric attention score (AAS) was recorded using automatic software calculation. Results: The majority of articles were published in the journal “Circulation” (n=14) and the “Journal of the American College of Cardiology” (n=8). The country with the highest number of articles was the US (n=27), and the most cited author was P.A. Ades. Studies evaluating exercise-based rehabilitation, key components of CR, and secondary prevention were among the top cited articles. In terms of AAS, in addition to the titles mentioned, mobile health services that rely on communication technologies have also received attention. Conclusion: This study provides useful information for researchers interested in CR, including trends, topics of interest in the field, and potential research collaborations. It is intended to guide future, more comprehensive, and in-depth studies on CR.

User-centered design of a telehealth-enhanced hybrid cardiac rehabilitation program as hospital quality improvement

Background Innovative program designs and strategies are needed to support the widespread uptake of cardiac rehabilitation (CR) programs in the post-COVID19 era. We combined user-centered design (UCD) and implementation science (ImS) principles to design a novel telehealth-enhanced hybrid (home and clinic-based) CR (THCR) program. Methods As part of a New York Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we designed a THCR program using an iterative 3 step UCD process informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research to: 1) identify user and contextual barriers to CR uptake (stakeholder interviews), 2) design an intervention prototype (design workshops and journey mapping), and 3) refine the prototype (usability testing). The process was optimized for usability and implementation outcomes. Results Step 1: Semi-structured interviews with stakeholders (n = 9) at 3 geographically diverse academic medical centers revealed behavioral (e.g., self-efficacy, knowledge) and contextual (e.g., social distancing guidelines, physical space, staffing, reimbursement) barriers to uptake. Step 2: Design workshops (n = 20) and journey-mapping sessions (n = 3) with multi-disciplinary NYPH stakeholders (e.g., digital health team, CR clinicians, creative director) yielded a THCR prototype that leveraged NYPH's investment in their remote patient monitoring (RPM) platform to optimize feasibility of home-based CR sessions. Step 3: Usability testing with CR clinicians (n = 2) administering and CR patients (n = 3) participating in home-based sessions revealed usability challenges (e.g., RPM devices/exercise equipment usability; Wi-Fi/Bluetooth connectivity/syncing; patient safety/knowledge and protocol flexibility). Design workshops (n = 24) and journey-mapping sessions (n = 3) yielded design solutions (e.g., onboarding sessions, safety surveys, fully supervised remote sessions) and a refined THCR prototype. Conclusion Combining UCD and ImS methods while engaging multi-disciplinary stakeholders in an iterative process yielded a theory-informed telehealth-enhanced hybrid CR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process, and guidance for incorporating UCD and ImS methods in early-stage intervention development. THCR may shrink the evidence-to-practice gap in CR implementation. A future hybrid type I effectiveness-implementation trial will determine its feasibility, acceptability, and effectiveness.

The proGnostic role of caRdiac rehAbilitation in patients with left ventriCular anEurysm formation after anterior myocardial infarction (the GRACE study): Study rationale and design of a prospective randomized controlled trial

Background

Cardiac rehabilitation (CR) is an essential intervention after acute myocardial infarction (MI). However, it is still unclear whether patients with left ventricular aneurysm (LVA) formation after anterior MI would benefit from CR programs. This clinical trial is designed to assess the role of CR in patients with LVA formation after anterior MI.

Trial design

The GRACE study is a single-center, single-blind, prospective, randomized controlled clinical trial in China. 100 subjects aged 18-75 years with LVA formation after anterior MI will be recruited and randomized 1:1 to the CR or control group. Both groups will receive standard drug treatment and routine health education according to the guidelines. Participants in the CR group will additionally receive tailored CR programs delivered over a period of 36 sessions. These participants will then be followed up for 1-year. The primary outcome is peak oxygen uptake measured by cardiopulmonary exercise testing after CR programs. The secondary outcomes are cardiac function and EuroQol 5-Dimension-3 Level index scores after CR program and 1-year and major adverse cardiac cerebrovascular events, a composite of cardiovascular mortality, non-fatal MI, non-fatal stroke, malignant arrhythmia or hospitalization for heart failure during the follow-up period.

Conclusions

This single-center, single-blind, prospective, randomized controlled clinical trial will determine whether CR improves physical capacity and clinical outcomes in patients with LVA formation after anterior MI.

Trial registration

Chinese Clinical Trial Registry ChiCTR2200058852. Registered on 18 April 2022.

Efficacy of a supervised exercise training program on five-year readmission rates in patients with acute coronary syndrome. A randomised controlled trial

INTRODUCTION AND OBJECTIVES

Exercise-based cardiac rehabilitation programmes can reduce mortality but their effects on readmission rates are unclear. The primary aim was to evaluate the efficacy of a supervised exercise-based cardiac rehabilitation programme on cardiac readmissions in patients with acute coronary syndrome at five years.

METHODS

We conducted an open, controlled, randomized, hospital-based clinical trial. Patients were assigned either to the control group (CG) who received standard care or to the intervention group (IG) who participated in a supervised exercise programme (3h per week of supervised exercise training for 10 weeks). Patients were evaluated at 5 years.

RESULTS

Seventy-six patients [41 CG, 35 IG, mean age 59.2 (SD 10.4), 82.9% men] were included. Cardiac readmission rates at 5 years were 24% in the CG compared to 9% in the IG (p=0.068), and readmission rates for all causes were 42% in the CG and 23% in the IG (p=0.085). Emergency care for cardiac disease was required more frequently in the CG (17% vs 11%, p=0.486). IG patients performed more regular and intensive exercise (62% vs. 33%, p=0.088). In both groups there were significant deterioration in systolic and diastolic blood pressure, body mass index, waist circumference, HbAc1, triglycerides, LDL and diet, and a significant increase in HDL.

CONCLUSIONS

Patients who participated in the supervised exercise training programme were readmitted less often than controls for cardiac disease and for all causes at 5 years, the reduction was clinically meaningful although not statistically significant. Control of cardiovascular risk factors deteriorated in both groups.

[Cardiac rehabilitation: investigation of efficacy, results, perspectives]

Previous research experience on cardiac rehabilitation programs as a part of general health care system has shown that they are an important part of the management of cardiovascular patients. Improving quality of life, reducing the severity of risk factors, increasing physical performance, slowing disease progression, decrease in morbidity and mortality indicate the clinical efficacy of cardiac rehabilitation and make it an integral part of therapeutic interventions. Heart rehabilitation is a 1st class recommendation in the majority of modern cardiovascular guidelines around the world.

The feasibility of smartphone-based application on cardiac rehabilitation for Chinese patients with percutaneous coronary intervention in Macau: a qualitative evaluation

Background

To improve cardiovascular risk factors modification and effects of cardiac rehabilitation (CR), electronic applications on CR are suggested in the literature for patients after percutaneous coronary intervention (PCI).

Methods

A sequential qualitative study, embedded in a quantitative experimental trial for mHealth application on CR (mCR) study evaluation, was conducted to understand the usability and satisfaction of mCR study. Purposive sampling were used until achieving data saturation. Individually semi-structured interviews were conducted. The textual narration from interview transcriptions were analysed by content analysis.

Results

Ten participants were interviewed for qualitative evaluation. Findings presented the perceptive and experience of the mCR app users. Results were captured by four themes: 1. feasibility of mCR app, including practicality, acceptability and convenience, and barriers to use; 2. benefits from mCR app, explaining the effectiveness of mCR study; 3. advocator for better hospital care, disclosing an extension of healthcare and promoting patient-healthcarer relationship; and 4. recommendation for mCR app improvement.

Conclusion

Findings provided insights for cardiac healthcare providers to understand the feasibility of mHealth application on phase II CR in Macau. The mCR app facilitated CR engagement which contributed to health and well-being by promoting CHD and CR knowledge, and cardiac healthy lifestyle modification.

[What imaging and what tools for modern cardiac rehabilitation ?]

Conventional Cardiovascular Rehabilitation (RCV) is a global approach; it integrates reconditioning with personalized effort, physical activity (PA), therapeutic education, dietary management, smoking cessation, medication compliance. It requires a multidisciplinary approach with interventions by cardiologists, paramedics, physiotherapists, teachers of adapted physical activity (APA), dieticians, addictologists, and a specialized technical platform for evaluation and reconditioning at the 'effort. The benefit of cardiovascular rehabilitation is supported by numerous studies, it is strongly recommended class IA [1], but the supply of care is insufficient. It is therefore necessary to develop a modality of care in RCV at home, subject to the same requirements as the programs in the center, thanks to the contributions of new technology and connected objects. Technological innovations have made it technically possible to treat and monitor patients remotely [14]. Telerehabilitation is an example of the application of technology-based care. It can be defined as the provision of Secondary Prevention at a distance. It consists of remote monitoring of patient physiological data, remote coaching, e-learning and social interaction [10]. From a theoretical point of view, cardiac telerehabilitation has the potential to go beyond traditional rehabilitation; it removes the barriers that prevent patients with ischemic heart disease from participating in rehabilitation programs in conventional centers. Several studies show that telerehabilitation represents an alternative, less expensive, effective, and profitable, it could, in addition to existing services, improve access to rehabilitation [15]. Increasing participation rates in cardiac rehabilitation can reduce disease burden. The study of the economic and social impact of increasing the use of cardiac rehabilitation and cardiac telerehabilitation shows that and the resulting benefits exceed its costs. Mots-clés: Réadaptation en centre; réadaptation à domicile; téléréadaptation.

FGF21-Sirtuin 3 Axis Confers the Protective Effects of Exercise Against Diabetic Cardiomyopathy by Governing Mitochondrial Integrity

BACKGROUND

Exercise is an effective nonpharmacological strategy to alleviate diabetic cardiomyopathy (DCM) through poorly defined mechanisms. FGF21 (fibroblast growth factor 21), a peptide hormone with pleiotropic benefits on cardiometabolic homeostasis, has been identified as an exercise responsive factor. This study aims to investigate whether FGF21 signaling mediates the benefits of exercise on DCM, and if so, to elucidate the underlying mechanisms.

METHODS

The global or hepatocyte-specific FGF21 knockout mice, cardiomyocyte-selective β-klotho (the obligatory co-receptor for FGF21) knockout mice, and their wild-type littermates were subjected to high-fat diet feeding and injection of streptozotocin to induce DCM, followed by a 6-week exercise intervention and assessment of cardiac functions. Cardiac mitochondrial structure and function were assessed by electron microscopy, enzymatic assays, and measurements of fatty acid oxidation and ATP production. Human induced pluripotent stem cell-derived cardiomyocytes were used to investigate the receptor and postreceptor signaling pathways conferring the protective effects of FGF21 against toxic lipids-induced mitochondrial dysfunction.

RESULTS

Treadmill exercise markedly induced cardiac expression of β-klotho and significantly attenuated diabetes-induced cardiac dysfunction in wild-type mice, accompanied by reduced mitochondrial damage and increased activities of mitochondrial enzymes in hearts. However, such cardioprotective benefits of exercise were largely abrogated in mice with global or hepatocyte-selective ablation of FGF21, or cardiomyocyte-specific deletion of β-klotho. Mechanistically, exercise enhanced the cardiac actions of FGF21 to induce the expression of the mitochondrial deacetylase SIRT3 by AMPK-evoked phosphorylation of FOXO3, thereby reversing diabetes-induced hyperacetylation and functional impairments of a cluster of mitochondrial enzymes. FGF21 prevented toxic lipids-induced mitochondrial dysfunction and oxidative stress by induction of the AMPK/FOXO3/SIRT3 signaling axis in human induced pluripotent stem cell-derived cardiomyocytes. Adeno-associated virus-mediated restoration of cardiac SIRT3 expression was sufficient to restore the responsiveness of diabetic FGF21 knockout mice to exercise in amelioration of mitochondrial dysfunction and DCM.

CONCLUSIONS

The FGF21-SIRT3 axis mediates the protective effects of exercise against DCM by preserving mitochondrial integrity and represents a potential therapeutic target for DCM.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03240978.

Benefits of the First Pritikin Outpatient Intensive Cardiac Rehabilitation Program

PURPOSE

Intensive cardiac rehabilitation (ICR) is a comprehensive, medically supervised exercise treatment program covered by Medicare for patients with approved cardiac diagnoses. The aim of this study was to determine the benefits of the first Pritikin outpatient ICR program.

METHODS

This retrospective analysis included patients referred to ICR or traditional cardiac rehabilitation (CR) during the first 7 yr (2013-2019) at the first facility to implement Pritikin ICR. Intensive cardiac rehabilitation is composed of 36 education sessions on nutrition, exercise, and a healthy mindset, in addition to 36 monitored exercise sessions that comprise traditional CR. Assessments included anthropometrics (weight, body mass index, and waist circumference), dietary patterns, physical function (6-min walk test, [6MWT] Short Physical Performance Battery [SPPB: balance, 4-m walk, chair rise], handgrip strength), and health-related quality of life (Dartmouth COOP, 36-item Short Form Survey). Baseline and follow-up measures were compared within and between groups.

RESULTS

A total of 1963 patients enrolled (1507 ICR, 456 CR, 66.1 ± 11.4 yr, 68% male, 82% overweight or obese); 1141 completed the program (58%). The ICR patients completed 22 exercise and 18 education sessions in 9.6 wk; CR patients completed 19 exercise sessions in 10.3 wk. ICR resulted in improvements ( P &lt; .001 pre vs post) in all anthropometric measures, dietary patterns, 6MWT distance, all SPPB components, grip strength, and health-related quality of life. The improvements in anthropometrics and dietary patterns were greater in ICR than in CR.

CONCLUSIONS

The Pritikin outpatient ICR program promoted improvements in several cardiovascular health indices. Critical next steps are to assess long-term health outcomes after ICR, including cardiac events and mortality.

Individualized exercise prescription and cardiac rehabilitation following a spontaneous coronary artery dissection or aortic dissection

Aims

Prescribed aerobic-based exercise training is a low-risk fundamental component of cardiac rehabilitation (CR). Secondary prevention therapeutic strategies following a spontaneous coronary artery dissection (SCAD) or aortic dissection (AD) should include CR. Current exercise guidance for post-dissection patients recommends fundamental training components including target heart rate zones are not warranted. Omitting fundamental elements from exercise prescriptions risks safety and makes it challenging for both clinicians and patients to understand and implement recommendations in real-world practice. We review the principles of exercise prescription for CR, focusing on translating guidelines and evidence from well-studied high-risk CR populations to support the recommendation that exercise testing and individualized exercise prescription are important for patients following a dissection.

Methods and results

When patients self-perceive exercise intensity there is a tendency to underestimate intensities within metabolic domains that should be strictly avoided during routine exercise training following a dissection. However, exercise testing associated with CR enrolment has gained support and has not been linked to adverse events in optimally medicated post-dissection patients. Graded heart rate and blood pressure responses recorded throughout exercise testing provide key information for developing an exercise prescription. An exercise prescription that is reflective of medical history, medications, and cardiorespiratory fitness optimizes patient safety and yields improvements in blood pressure control and cardiorespiratory fitness, among other benefits.

Conclusion

This clinical practice and education article demonstrates how to develop and manage a CR exercise prescription for post-acute dissection patients that can be safe and effective for maintaining blood pressure control and improving cardiorespiratory fitness pre-post CR.

Effectiveness of activity-monitoring devices in patients with cardiovascular disease participating in cardiac rehabilitation programs: an umbrella review protocol

OBJECTIVE

The objective of the review is to investigate the effect of activity-monitoring devices and mobile applications on physical activity and health outcomes of patients with cardiovascular disease who are participating in cardiac rehabilitation programs.

INTRODUCTION

Supporting patients with cardiovascular conditions to achieve and maintain healthy physical activity levels is the cornerstone of cardiac rehabilitation programs. The effectiveness of activity-monitoring devices and mobile applications (such as physical activity interventions) utilizing consumer-grade monitoring devices and applications to support patients to improve exercise levels during and after program completion has been investigated. Several systematic reviews evaluating the effectiveness of monitoring devices and applications have indicated varying clinical impact, depending on patient characteristics, stage of rehabilitation, and type of intervention.

INCLUSION CRITERIA

This review will consider systematic reviews and/or meta-analyses of randomized controlled trials of patients who participated in cardiac rehabilitation programs that included a physical activity intervention that incorporated activity monitoring using electronic devices and/or mobile applications and reported activity and patient health outcomes.

METHODS

MEDLINE, Embase, Sport Discus, the Cochrane Database of Systematic Reviews, Scopus, CINAHL, the International Network of Agencies for Health Technology Assessment database, Epistemonikos, and Web of Science will be searched from inception to the present. PROSPERO will be searched for unpublished reviews. Articles will be screened by two independent reviewers for inclusion, and methodological quality will be assessed using a JBI critical appraisal tool. Data will be extracted from systematic reviews and a data synthesis of findings will be presented. The certainty will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022298877.

The motivation for physical activity is a predictor of VO2peak and is a useful parameter when determining the need for cardiac rehabilitation in an elderly cardiac population

Background

Exercise-based cardiac rehabilitation (CR) is an essential contributor to a successful recovery for elderly cardiac patients. The motivation for physical activity is a psychological parameter seldom described in secondary prevention, and it is plausible that motivation contributes to the differential effect of CR.

Purpose

To investigate if motivation, measured using the behavioural regulation in an exercise questionnaire (BREQ-2), predicts VO2peak in elderly cardiac patients before and after CR.

Methods

A prospective cohort study of elderly ischemic cardiac patients and patients with valvular disease participating in cardiac rehabilitation was used. Motivation was measured using BREQ-2, which measures five constructs of motivation and a summed score—the relative autonomy index (RAI). VO2peak was measured before and after CR using a cardiopulmonary exercise test (CPET).

Results

Two hundred and three patients performed the baseline tests and initiated CR. One hundred and eighty-two completed CR and comprised the follow-up group. The mean VO2peak was 18 ml/kg/min (SD±5.1). VO2peak increased significantly with increasing motivation, 1.02 (.41–1.62) ml/kg/min pr. SD. Mean improvement from CR was 2.3 ml/kg/min (SD±4.3), the equivalent of a 12% increase. A change in VO2peak after CR was likewise positively associated with increased motivation, .74 (.31–1.17) pr. SD.

Conclusion

The level of motivation predicts VO2peak before CR, and is also able to predict changes in VO2peak following CR. Motivation measured with the BREQ-2 questionnaire can be applied as a screening tool for elderly cardiac patients before they initiate CR to identify patients with need of specific attention.

Disparities in Geographic Access to Cardiac Rehabilitation in Los Angeles County

Background Exercise-based cardiac rehabilitation (CR) is known to reduce morbidity and mortality for patients with cardiac conditions. Sociodemographic disparities in accessing CR persist and could be related to the distance between where patients live and where CR facilities are located. Our objective is to determine the association between sociodemographic characteristics and geographic proximity to CR facilities. Methods and Results We identified actively operating CR facilities across Los Angeles County and used multivariable Poisson regression to examine the association between sociodemographic characteristics of residential proximity to the nearest CR facility. We also calculated the proportion of residents per area lacking geographic proximity to CR facilities across sociodemographic characteristics, from which we calculated prevalence ratios. We found that racial and ethnic minorities, compared with non-Hispanic White individuals, more frequently live ≥5 miles from a CR facility. The greatest geographic disparity was seen for non-Hispanic Black individuals, with a 2.73 (95% CI, 2.66-2.79) prevalence ratio of living at least 5 miles from a CR facility. Notably, the municipal region with the largest proportion of census tracts comprising mostly non-White residents (those identifying as Hispanic or a race other than White), with median annual household income <$60 000, contained no CR facilities despite ranking among the county's highest in population density. Conclusions Racial, ethnic, and socioeconomic characteristics are significantly associated with lack of geographic proximity to a CR facility. Interventions targeting geographic as well as nongeographic factors may be needed to reduce disparities in access to exercise-based CR programs. Such interventions could increase the potential of CR to benefit patients at high risk for developing adverse cardiovascular outcomes.

Association of device-measured physical activity and sedentary behaviour with cardiovascular risk factors, health-related quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees with coronary heart disease

Background

Few studies have considered the relationship between risk factors, physical activity and sedentary behaviour in people with heart disease. Here we examine the independent relationship of device-measured physical activity and sedentary behaviour on risk factors, quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees.

Methods

Hospital-based phase II cardiac rehabilitation participants with coronary heart disease were assessed at the start and end of cardiac rehabilitation (6-weeks), 6 and 12-months. Physical activity (moderate-to-vigorous (MVPA), light-intensity (LIPA); min/day) and sedentary behaviour (min/day, bouts, breaks) were measured using an ActiGraph accelerometer. Risk factors included waist circumference, body mass index, systolic blood pressure (SBP), fasting blood lipid and glucose levels, anxiety and depression. Quality-of-life and exercise capacity were also collected. Associations were assessed with Generalized Estimating Equation modeling.

Results

Sixty-seven participants were included (mean age = 64 (SD 9) years; 81% male). An association was found between higher MVPA and lower high density lipoprotein (p ≤ 0.001). No significant (p ≤ 0.001) associations were found between sedentary behaviour variables and other outcomes. At p < 0.05 several associations were significant. Increased MVPA and LIPA were associated with decreased total cholesterol. Higher MVPA was associated with decreased SBP, whereas higher LIPA was associated with decreased waist circumference and body mass index. Higher sedentary behaviour bouts and breaks were associated with increased total cholesterol, anxiety and depression, and decreased SBP over time.

Conclusions

Any intensity of physical activity was associated with decreased total cholesterol. Increased LIPA was associated with improved measures of adiposity, while breaking up sedentary behaviour and increasing MVPA may decrease SBP over time. Further investigation of MVPA, LIPA and the distribution of sedentary behaviour is indicated in cardiac rehabilitation attendees to explore their relationship with risk factors.

Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx. Registered 22 September 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00562-7.

Prediction parameters of left ventricular diastolic dysfunction improvement in patients after acute coronary syndrome

OBJECTIVES

The aim of this study was to examine the effects of comprehensive cardiac rehabilitation (CCR) in patients after acute coronary syndrome (ACS) resolved by percutaneous coronary intervention (PCI) on left ventricular diastolic dysfunction (LVDD) and to extract the parameters that have the greatest influence on LVDD improvement.

METHODS

The study included 85 subjects who were divided into intervention (N = 56) and control (N = 29) groups depending on CCR attendance. Initially and after 12 weeks, patients of both groups were subjected to echocardiography to assess LVDD, as well as CPET to assess improvement in functional capacity.

RESULTS

The study showed that 23 patients (27.1%) of both groups demonstrated the improvement of LVDD degree. The improvement of the LVDD degree in the intervention group was significant, whereas in the control group, it did not change (a one-degree improvement in 22 (39.3%) patients of the intervention group (p < 0.001) and only 1 (3.4%) (p > 0.05) in the control group). Multivariate binary logistic regression showed that key parameters in LVDD improvement were participation in the CCR, E/A ratio and haemoglobin value. We created a model, for prediction of LVDF improvement, with a cut-off value of 33 (area = 0.9, p < 0.0005), a sensitivity of 87.0% and a specificity of 85.5%.

CONCLUSIONS

CCR can be used as an effective non-pharmacological measure to improve LVDD and functional capacity in patients after ACS. The statistical model may have practical application in prediction of clinical benefit in such a group of patients.