A home-based maintenance exercise program after center-based cardiac rehabilitation: effects on blood lipids, body composition, and functional capacity

Systematic Review of Interventions Designed to Maintain or Increase Physical Activity Post-Cardiac Rehabilitation Phase II

Background:

Cardiovascular disease (CVD) continues to be the No. 1 cause of death in the United States and globally, and individuals with a history of a cardiac event are at increased risk for a repeat event. Physical inactivity creates health problems for individuals with chronic heart disease. Evidence shows that physical activity (PA), as a central component of cardiac rehabilitation phase II (CRII), decreases hospital readmission and mortality. Yet, individual adherence to PA tends to decline several months following CRII completion.

Objective:

The purpose of this review was to evaluate current literature for interventions designed to assist individuals diagnosed with myocardial infarction (MI), coronary artery bypass graft (CABG), coronary artery disease (CAD), and percutaneous coronary intervention (PCI) to maintain or increase PA post-CRII.

Methods:

A systematic search of 5 electronic databases including hand-searched articles between 2000 and 2019. Key Medical Subject Headings (MeSH) search terms included cardiac rehabilitation, intervention, exercise or PA, outcomes, compliance, adherence, or maintenance. Only interventions implemented following CRII program completion were included for review.

Results:

Based on the inclusion criteria, the search yielded 19 randomized control trials retained for descriptive analysis. Interventions were categorized into 3 domains. The intervention designs varied widely in terms of duration of the intervention and the length of time to outcome measurement. Most interventions were short-term with only 2 studies offering a long-term intervention of greater than 1 year. Interventions using a theoretical approach most often included a cognitive-behavioral model.

Conclusions:

Interventions offered shortly after completion of CRII may help cardiac patients maintain PA and reduce the risk of experiencing additional cardiac events; however, more quality research is needed. Additional research to examine PA maintenance in older adults (70 years and older) would be valuable based on the increase in average lifespan. Studies with larger and more diverse samples, and less variation in methods and outcomes would greatly increase the ability to conduct a high-quality meta-analysis.

A novel model of home-based, patient-tailored and mobile application-guided cardiac telerehabilitation in patients with atrial fibrillation: A randomised controlled trial

OBJECTIVE

To assess the effectiveness of tele-monitored cardiac rehabilitation in patients who have undergone ablation for atrial fibrillation.

DESIGN

Single-centre, prospective, assessment-blinded, randomised controlled trial.

SETTING

Domiciliary rehabilitation with support from a tertiary care hospital.

SUBJECTS

One hundred patients who underwent ablation for atrial fibrillation were recruited.

INTERVENTIONS

Participants were randomly allocated to a 12-week standard rehabilitation treatment (control group) or a comprehensive, domiciliary, mobile application-guided and tele-monitored cardiac rehabilitation program (intervention group) in a 1:1 fashion.

MAIN OUTCOME MEASURES

The primary endpoint was the improvement in V_O2peak. The secondary outcomes included adherence, physical activity, beliefs related to cardiovascular disease and exercise self-efficacy.

RESULTS

Ninety-seven patients completed follow-up. The mean V_O2peak increased significantly in both the intervention group (n = 49) (baseline vs 12 weeks: 19.1 ± 4.7 vs 27.3 ± 5.6 ml/(min kg), P < 0.01) and the control group (n = 48) (baseline vs 12 weeks: 18.7 ± 4.9 vs 22.9 ± 6.3 ml/(min kg), P < 0.01). The results of the between-group analysis of aerobic capacity were significantly in favour of the intervention group. During the 12-week program, patients in the intervention group exhibited better adherence than those in the control group. Moreover, self-reported physical activity improved more in the intervention group than in the control group, as did the beliefs related to cardiovascular disease and exercise self-efficacy (all P < 0.01).

CONCLUSIONS

Our domiciliary, mobile application-guided and tele-monitored cardiac rehabilitation program could lead to a more significant improvements in physical fitness, adherence and health beliefs than standard cardiac rehabilitation in patients who have undergone ablation for atrial fibrillation.

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.

Prediction of the Adherence to a Home-Based Cardiac Rehabilitation Program

The incidence and prevalence of cardiovascular diseases (CVD) is increasing which is partly due to an increase in unhealthy lifestyles, including lack of physical activity. Therefore, following a cardiovascular event, patients are encouraged to participate in a supervised exercise-based cardiac rehabilitation (CR) program. However, uptake rates of these programs are low and compliance to adequate volumes of physical activity after the completion of such programs are even lower. An approach that has been proposed towards the increase of patient adherence to exercise, is the incorporation of technology-enabled solutions which are applied at patient's homes. However, different factors may affect patient engagement with such alternative solutions. In this work, we use diverse types of data, including baseline characteristics of the patient (i.e. physiological, behavioral, demographical data) as well as usage data of a tele-rehabilitation solution during a 4-week familiarization period, in order to predict the compliance of patients with CVD to a technology-supported physical activity intervention after completion of a supervised exercise program. Patients were clustered based on their use of a technology intervention during a previously conducted study. Following a feature selection approach, a support vector machine was trained to classify patients as adherent or non-adherent to the intervention. The performance of the classifier was assessed by means of the receiving operator curve (ROC). Bio-psycho-social baseline variables predicted adherence with a ROC of 0.86, but adding usage data of the platform during a 4-week familiarization period increased the ROC up to 0.94. Furthermore, the high sensitivity values (83.8% and 95.5% respectively) support the strength of the models to identify those patients with CVD that will be adherent to a technology-enabled, home-based CR program.

Home-based exercise with telemonitoring guidance in patients with coronary artery disease: Does it improve long-term physical fitness?

BACKGROUND

Home-based interventions might facilitate the lifelong uptake of a physically active lifestyle following completion of a supervised phase II exercise-based cardiac rehabilitation. Yet, data on the long-term effectiveness of home-based exercise training on physical activity and exercise capacity are scarce.

OBJECTIVE

The purpose of the TeleRehabilitation in Coronary Heart disease (TRiCH) study was to compare the long-term effects of a short home-based phase III exercise programme with telemonitoring guidance to a prolonged centre-based phase III programme in coronary artery disease patients. The primary outcome was exercise capacity. Secondary outcomes included physical activity behaviour, cardiovascular risk profile and health-related quality of life.

METHODS

Ninety coronary artery disease patients (80 men) were randomly assigned to 3 months of home-based (30), centre-based (30) or a control group (30) on a 1:1:1 basis after completion of their phase II ambulatory cardiac rehabilitation programme. Outcome measures were assessed at discharge of the phase II programme and after one year.

RESULTS

Eighty patients (72 (91%) men; mean age 62.6 years) completed the one-year follow-up measurements. Exercise capacity and secondary outcomes were preserved in all three groups (P_time > 0.05 for all), irrespective of the intervention (P_interaction > 0.05 for all). Eighty-five per cent of patients met the international guidelines for physical activity (P_time < 0.05). No interaction effect was found for physical activity.

CONCLUSION

Overall, exercise capacity remained stable during one year following phase II cardiac rehabilitation. Our home-based exercise intervention was as effective as centre-based and did not result in higher levels of exercise capacity and physical activity compared to the other two interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02047942. https://clinicaltrials.gov/ct2/show/NCT02047942.

Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis

BACKGROUND

Coronary heart disease (CHD) is a major cause of death worldwide. Cardiac rehabilitation, an evidence-based CHD secondary prevention programme, remains underutilized. Telehealth may offer an innovative solution to overcome barriers to cardiac rehabilitation attendance. We aimed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and/or usual care for patients with CHD.

METHODS

Relevant randomized controlled trials evaluating telehealth interventions in CHD patients with at least three months' follow-up compared with cardiac rehabilitation and/or usual care were identified by searching electronic databases. We checked reference lists, relevant conference lists, grey literature and keyword searching of the Internet. Main outcomes included all-cause mortality, rehospitalization/cardiac events and modifiable risk factors. (PROSPERO registration number 77507.).

RESULTS

In total, 32 papers reporting 30 unique trials were identified. Telehealth was not significant associated with a lower all-cause mortality than cardiac rehabilitation and/or usual care (risk ratio (RR)=0.60, 95% confidence interval (CI)=0.86 to 1.24, p=0.42). Telehealth was significantly associated with lower rehospitalization or cardiac events (RR=0.56, 95% CI=0.39 to 0.81, p<0.0001) compared with non-intervention groups. There was a significantly lower weighted mean difference (WMD) at medium to long-term follow-up than comparison groups for total cholesterol (WMD= -0.26 mmol/l, 95% CI= -0.4 to -0.11, p <0.001), low-density lipoprotein (WMD= -0.28, 95% CI = -0.50 to -0.05, p=0.02) and smoking status (RR=0.77, 95% CI =0.59 to 0.99, p=0.04].

CONCLUSIONS

Telehealth interventions with a range of delivery modes could be offered to patients who cannot attend cardiac rehabilitation, or as an adjunct to cardiac rehabilitation for effective secondary prevention.

Home-Based Rehabilitation With Telemonitoring Guidance for Patients With Coronary Artery Disease (Short-Term Results of the TRiCH Study): Randomized Controlled Trial

Background

Cardiac rehabilitation (CR) is an essential part of contemporary coronary heart disease management. However, patients exiting a center-based CR program have difficulty retaining its benefits.

Objective

We aimed to evaluate the added benefit of a home-based CR program with telemonitoring guidance on physical fitness in patients with coronary artery disease (CAD) completing a phase II ambulatory CR program and to compare the effectiveness of this program in a prolonged center-based CR intervention by means of a randomized controlled trial.

Methods

Between February 2014 and August 2016, 90 CAD patients (unblinded, mean age 61.2 years, SD 7.6; 80/90, 89.0% males; mean height 1.73 m, SD 0.7; mean weight 82.9 kg, SD 13; mean body mass index 27.5 kg/m², SD 3.4) who successfully completed a 3-month ambulatory CR program were randomly allocated to one of three groups: home-based (30), center-based (30), or control group (30) on a 1:1:1 basis. Home-based patients received a home-based exercise intervention with telemonitoring guidance consisting of weekly emails or phone calls; center-based patients continued the standard in-hospital CR, and control group patients received the usual care including the advice to remain physically active. All the patients underwent cardiopulmonary exercise testing for assessment of their peak oxygen uptake (VO₂ P) at baseline and after a 12-week intervention period. Secondary outcomes included physical activity behavior, anthropometric characteristics, traditional cardiovascular risk factors, and quality of life.

Results

Following 12 weeks of intervention, the increase in VO₂ P was larger in the center-based (P=.03) and home-based (P=.04) groups than in the control group. In addition, oxygen uptake at the first (P-interaction=.03) and second (P-interaction=.03) ventilatory thresholds increased significantly more in the home-based group than in the center-based group. No significant changes were observed in the secondary outcomes.

Conclusions

Adding a home-based exercise program with telemonitoring guidance following completion of a phase II ambulatory CR program results in further improvement of physical fitness and is equally as effective as prolonging a center-based CR in patients with CAD.

Trial Registration

ClinicalTrials.gov NCT02047942; https://clinicaltrials.gov/ct2/show/NCT02047942 (Archived by WebCite at http://www.webcitation.org/70CBkSURj)

Strategic Moments: IDENTIFYING OPPORTUNITIES TO ENGAGE CLIENTS IN ATTENDING CARDIAC REHABILITATION AND MAINTAINING LIFESTYLE CHANGES

PURPOSE

There has been extensive investigation of attendance rates at cardiac rehabilitation (CR) but little attention to client reasoning around attendance. This study explored decision-making drivers for attendance or nonattendance at CR programs in rural Victoria, Australia.

METHODS

All new patients referred to the CR programs at either the local hospital or community health service over a 6-month period were invited to participate and were interviewed before, after, and at 6 months post-CR. Content analysis was used to identify and group common themes that emerged from the semistructured interviews.

RESULTS

Eighty-four of the 114 patients referred agreed to participate in the study. Multiple barriers or facilitators affected the decisions of all clients. Three themes were identified that reflected the participant decision-making experience: (1) invitation and information about participation in CR; (2) person-centered approach to CR provision; and (3) ongoing support needs. Significant decision-making points identified were after the cardiac event; before and after hospital-based CR; before and after community-based CR; and at 6 months after the cardiac event. At any time there is a risk that the client can become lost or disengaged in the service system, but providing contact at these points can allow them to reengage.

CONCLUSIONS

This study provided the opportunity to hear participant voices, describing their decisions around CR attendance after a cardiac event. They highlighted the complexity of issues confronting them and suggested improvements to optimize their attendance and to maintain lifestyle changes.

A Systematic Review of the Effects of Telerehabilitation in Patients With Cardiopulmonary Diseases

PURPOSE

To examine the effects of telerehabilitation compared with other delivery models for improving physical or functional outcomes in patients with cardiopulmonary diseases.

METHODS

A search was completed for English language publications from 1990 to August 2013 across 4 electronic databases and gray literature. Inclusion criteria were: (1) home-based telerehabilitation as a core component; (2) at least 2 exercise sessions; (3) randomized controlled trials; and (4) reporting of physical or functional outcome measures in adult patients with coronary heart disease, chronic heart failure, and chronic respiratory disease. Studies were independently screened by 2 reviewers and graded by a reviewer according to the Downs and Black checklist. A narrative synthesis of the included studies was undertaken.

RESULTS

Eleven studies were analyzed. It appears that telerehabilitation is no different to other delivery models for patients with cardiopulmonary diseases, in terms of exercise capacity expressed as distance on the 6-minute walk test and peak oxygen consumption and quality of life. Telerehabilitation appears to have higher adherence rates compared with center-based exercise. There has been similar or no adverse events reported in telerehabilitation compared with center-based exercise.

CONCLUSIONS

Although telerehabilitation shows promise in patients with cardiopulmonary diseases, compelling evidence is still limited. There is a need for more detailed, high-quality studies and for studies on the use of video-based telerehabilitation.

Effect of an exercise consultation on maintenance of physical activity after completion of phase III exercise-based cardiac rehabilitation

BACKGROUND

Many patients do not maintain physical activity levels after completion of phase III exercise-based cardiac rehabilitation.

DESIGN

This study determined the effect of an exercise consultation on maintenance of physical activity and cardiorespiratory fitness 12 months after completion of a phase III exercise programme. Seventy cardiac patients were randomized to the experimental (exercise consultation and exercise information) or control groups (exercise information only).

METHODS

Outcomes recorded at baseline, 6 and 12 months were: physical activity (stage of change, 7-day recall, accelerometer), cardiorespiratory fitness, lipids, quality of life, anxiety and depression.

RESULTS

Both groups were regularly active at baseline. The between-group difference for the change in total activity (min/week) assessed by the 7-day recall was significant from baseline to 12 months [98% confidence interval (CI) -295, -20]. Total activity was maintained in the experimental group (98% CI -63, 154) and significantly decreased in the control group (115 min/week; 98% CI -228, -28) from baseline to 12 months. The between-group difference for the change in accelerometer counts/week was not significant from baseline to 6 (98% CI -1 143 720, 607 430) or 12 months (98% CI -1 131 128, 366 473). A comparable, significant decrease in peak oxygen uptake occurred from baseline to 12 months in experimental (1.8 ml/kg per min; 98% CI -3.2, -0.3) and control participants (2.3 ml/kg per min; -3.8, -0.8). Lipids, quality of life, anxiety and depression were normal at baseline and did not significantly change in either group over time.

CONCLUSION

Exercise consultation was effective in maintaining self-reported physical activity, but not peak oxygen uptake, for 12 months after completion of phase III.

Discharge Planning After Myocardial Revascularization: Differences in Opinions From Patients and Health Experts

BACKGROUND

In-hospital education and discharge planning contribute to recovery after coronary artery bypass graft surgery (CABG).

OBJECTIVE

The objective of this study was to identify differences in perception of the importance of discharge instructions between a sample of adult patients after CABG and health experts responsible for their care.

METHODS

Thirty-five first-time CABG adult patients and 8 multidisciplinary experts rated a 46-item questionnaire of discharge education themes on a 3-point scale. Items were classified as most important if rated as "very important" by more than 85% of the participants in each group.

RESULTS

Of the 31 items considered most important (reaching the 85% approval criteria), agreement between groups was reached for 15 (48%), whereas 11 (35%) items were selected only by the patients and 5 (16%) were selected only by the experts.

CONCLUSIONS

The authors of this study demonstrate a difference in perception between patients and health experts regarding the importance of various discharge instructions. Better understanding areas of patient concern may improve discharge routines.

An Internet- and mobile-based tailored intervention to enhance maintenance of physical activity after cardiac rehabilitation: short-term results of a randomized controlled trial

Background

An increase in physical activity for secondary prevention of cardiovascular disease and cardiac rehabilitation has multiple therapeutic benefits, including decreased mortality. Internet- and mobile-based interventions for physical activity have shown promising results in helping users increase or maintain their level of physical activity in general and specifically in secondary prevention of cardiovascular diseases and cardiac rehabilitation. One component related to the efficacy of these interventions is tailoring of the content to the individual.

Objective

Our trial assessed the effect of a longitudinally tailored Internet- and mobile-based intervention for physical activity as an extension of a face-to-face cardiac rehabilitation stay. We hypothesized that users of the tailored intervention would maintain their physical activity level better than users of the nontailored version.

Methods

The study population included adult participants of a cardiac rehabilitation program in Norway with home Internet access and a mobile phone. The participants were randomized in monthly clusters to a tailored or nontailored (control) intervention group. All participants had access to a website with information regarding cardiac rehabilitation, an online discussion forum, and an online activity calendar. Those using the tailored intervention received tailored content based on models of health behavior via the website and mobile fully automated text messages. The main outcome was self-reported level of physical activity, which was obtained using an online international physical activity questionnaire at baseline, at discharge, and at 1 month and 3 months after discharge from the cardiac rehabilitation program.

Results

Included in the study were 69 participants. One month after discharge, the tailored intervention group (n=10) had a higher median level of overall physical activity (median 2737.5, IQR 4200.2) than the control group (n=14, median 1650.0, IQR 2443.5), but the difference was not significant (Kolmogorov-Smirnov Z=0.823, P=.38, r=.17). At 3 months after discharge, the tailored intervention group (n=7) had a significantly higher median level of overall physical activity (median 5613.0, IQR 2828.0) than the control group (n=12, median 1356.0, IQR 2937.0; Kolmogorov-Smirnov Z=1.397, P=.02, r=.33). The median adherence was 45.0 (95% CI 0.0-169.8) days for the tailored group and 111.0 (95% CI 45.1-176.9) days for the control group; however, the difference was not significant (P=.39). There were no statistically significant differences between the 2 groups in stage of change, self-efficacy, social support, perceived tailoring, anxiety, or depression.

Conclusions

Because of the small sample size and the high attrition rate at the follow-up visits, we cannot make conclusions regarding the efficacy of our approach, but the results indicate that the tailored version of the intervention may have contributed to the long-term higher physical activity maintained after cardiac rehabilitation by participants receiving the tailored intervention compared with those receiving the nontailored intervention.

Trial Registration

ClinicalTrials.gov: NCT01223170; http://clinicaltrials.gov/show/NCT01223170 (Archived by WebCite at http://www.webcitation.org/6Nch4ldcL).

Self-reported versus objectively assessed exercise adherence

OBJECTIVE. We examined agreement of data between self-reported and objectively assessed exercise adherence among women with systemic lupus erythematosus. METHOD. Eleven participants completed weekly exercise logs on date and duration of exercise during a 10-wk Wii Fit™ home-based program. Afterward, exercise data from the log were compared with those recorded in the Wii console. RESULTS. Of the paired data, the mean duration of exercise recorded in the Wii was 29.5 min and that recorded in the log was 33.3 min. The composite intraclass correlation for exercise duration between exercise log and the Wii Fit was 0.4. The 95% limits of agreement indicated large between-subjects variability. CONCLUSION. Exercise logs exhibit a marginally acceptable agreement with Wii estimation of exercise duration at a group level. However, caution should be applied when using the exercise log as a measure of a person's exercise behavior because of the tendency to overreport.

Body fat responses to a 1-year combined exercise training program in male coronary artery disease patients

OBJECTIVE

To analyze the body fat (BF) content and distribution modifications in coronary artery disease (CAD) patients in response to a 1-year combined aerobic and resistance exercise training (CET) program.

DESIGN AND METHODS

We followed two groups of CAD male patients for 12 months. One group consisted of 17 subjects (57 ± 12 years) who engaged in a CET program (CET group) and the other was a age-matched control group of 10 subjects (58 ± 11 years). BF content and distribution were measured through dual energy X-ray absorptiometry (DXA) at baseline and follow-up.

RESULTS

We found no differences on body mass and BMI between baseline and end of follow-up in both groups but, in CET group, we found significant reductions in all analyzed BF depots, including total BF (21.60 ± 6.00 vs. 20.32 ± 5.89 kg, P < 0.01), % total BF (27.8 ± 5.5 vs. 26.4 ± 5.4%, P < 0.05), trunk fat (12.54 ± 3.99 vs. 11.77 ± 4.01 kg, P < 0.05), % trunk fat (31.1 ± 6.9 and 29.2 ± 7.1%, P < 0.05), appendicular fat (8.22 ± 2.08 vs. 7.72 ± 2.037 kg, P < 0.01), % appendicular fat (25.7 ± 4.9 and 24.5 ± 4.9%, P < 0.05), and abdominal fat (2.95 ± 1.06 vs. 2.75 ± 1.10 kg, P < 0.05). Control group showed significant increase in appendicular fat (7.63 ± 1.92 vs. 8.10 ± 2.12 kg, P < 0.05).

CONCLUSIONS

These results confirm the positive effect of CET on body composition of CAD patients, despite no changes in body mass or BMI. In this study, we observed no alterations on BF distribution meaning similar rate of fat loss in all analyzed BF depots. These results also alert for the limitations of BMI for tracking body composition changes.

Beyond resolutions? A randomized controlled trial of a self-regulation lifestyle programme for post-cardiac rehabilitation patients

BACKGROUND

As lifestyle adherence and risk factor management following completion of cardiac rehabilitation (CR) have been shown to be problematic, we developed a brief self-regulation lifestyle programme for post-CR patients.

DESIGN

Randomized-controlled trial.

METHODS

Following completion of CR 210 patients were randomized to receive either a lifestyle maintenance programme (n = 112) or standard care (n = 98). The programme was based on self-regulation principles and consisted of a motivational interview, seven group sessions, and home assignments. Risk factors and health behaviours were assessed at baseline (end of CR) and 6 months thereafter.

RESULTS

ANCOVAs showed a significant effect of the lifestyle programme after 6 months on blood pressure, waist circumference, and exercise behaviour.

CONCLUSION

This trial indicates that a relatively brief intervention based on self-regulation theory is capable of instigating and maintaining beneficial changes in lifestyle and risk factors after CR.

Systematic review of physical activity intervention studies after cardiac rehabilitation

Coronary heart disease significantly impacts the morbidity, mortality, and health care economy of our population. Enrollment into cardiac rehabilitation (CR) after cardiac events improves patient outcomes; however, physical activity (PA) behavior decreases significantly in the years following completion of CR. This article reviews the literature regarding interventions to maintain or increase PA after CR. Fourteen interventions studies from North America, Europe, Asia, and Australia used variations of cognitive and/or behavioral strategies. Women and older adults were underrepresented in the reviewed studies. Measurement of PA varied between studies and included self-report, objective pedometer or accelerometer data, or questionnaire format. Common cognitive interventions included self-efficacy enhancement measures, barrier management, and problem solving. Behavioral interventions included self-monitoring, prompting, goal setting, and feedback. Cognitive intervention studies reported inconsistent results, whereas behavioral studies and studies that used combinations of interventions reported more consistent, positive findings. More intervention studies, using rigorous designs and reliable measures of PA on larger, more diverse populations, are needed to improve the understanding of PA-related behavior change after completion of CR.

Service organisation for the secondary prevention of ischaemic heart disease in primary care

BACKGROUND

Ischaemic heart disease (IHD) is a major cause of mortality and morbidity and its prevalence is set to increase. Secondary prevention aims to prevent subsequent acute events in people with established IHD. While the benefits of individual medical and lifestyle interventions is established, the effectiveness of interventions which seek to improve the way secondary preventive care is delivered in primary care or community settings is less so.

OBJECTIVES

To assess the effectiveness of service organisation interventions, identifying which types and elements of service change are associated with most improvement in clinician and patient adherence to secondary prevention recommendations relating to risk factor levels and monitoring (blood pressure, cholesterol and lifestyle factors such as diet, exercise, smoking and obesity) and appropriate prophylactic medication.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 4), MEDLINE (1966 to Feb 2008), EMBASE (1980 to Feb 2008), and CINAHL (1981 to Feb 2008). Bibliographies were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of service organisation interventions in primary care or community settings in populations with established IHD.

DATA COLLECTION AND ANALYSIS

Analyses were conducted according to Cochrane recommendations and Odds Ratios (with 95% confidence intervals) reported for dichotomous outcomes, mean differences (with 95% CIs) for continuous outcomes.

MAIN RESULTS

Eleven studies involving 12,074 people with IHD were included. Increased proportions of patients with total cholesterol levels within recommended levels at 12 months, OR 1.90 (1.04 to 3.48), were associated with interventions that included regular planned appointments, patient education and structured monitoring of medication and risk factors, but significant heterogeneity was apparent. Results relating to blood pressure within target levels bordered on statistical significance. There were no significant effects of interventions on mean blood pressure or cholesterol levels, prescribing, smoking status or body mass index. Few data were available on the effect on diet. There was some suggestion of a "ceiling effect" whereby interventions have a diminishing beneficial effect once certain levels of risk factor management are reached.

AUTHORS' CONCLUSIONS

There is weak evidence that regular planned recall of patients for appointments, structured monitoring of risk factors and prescribing, and education for patients can be effective in increasing the proportions of patients within target levels for cholesterol control and blood pressure. Further research in this area would benefit from greater standardisation of the outcomes measured.

How much do the benefits cost? Effects of a home-based training programme on cardiovascular fitness, quality of life, programme cost and adherence for patients with coronary disease

Objective: To evaluate cost, adherence and effects on cardiovascular function and quality of life of a home-based cardiac rehabilitation programme for patients with coronary disease.

Design: A randomized, prospective controlled trial.

Setting: Department of Rehabilitation, University Hospital, Brazil.

Subjects: Thirty-nine low-risk patients were assigned to a home exercise training group (n = 19) or a control group (n = 20).

Interventions: The home group performed home-based training for three months with biweekly telephone monitoring.

Main outcome measures: The aerobic capacity and the quality of life (Medical Outcomes Study 36-Item Short Form Survey (SF-36)) of all patients were evaluated before and after the three-month period. Adherence was evaluated weekly. Programme cost was estimated using the Brazilian Classification of Medical Procedures.

Results: After training, the home group had higher peak Vo2 from 28.8 (6.4) to 31.7 (8.1) mL/kg per minute, peak heart rate from 135 (22) to 143 (20) bpm, work rate from 4780 (2021) to 7103 (3057) kpm/min and exercise time from 11.5 (1.9) to 13.6 (2.3) minutes (P ≤ 0.05). The control group showed reduction in peak Vo2 from 28.6 (6.6) to 26.8 (7.2) mL/kg per minute, peak Vo2 pulse from 15.5 (3.9) to 14.3 (3.8) mL/bpm and exercise time from 11.5 (2.3) to 11.4 (2.7) minutes (P ≤ 0.05). The home group reported improvements in all domains of SF-36. The control group showed improvement in only three domains of SF-36. In the home group the average cost per patient was US$502.71 and the adherence achieved 100%.

Conclusion: The programme seems to provide an efficient low-cost approach to cardiac rehabilitation in low-risk patients.

Hypertension in aging: physical activity as primary prevention

In most physiologic systems, there is considerable evidence that the normal aging processes do not result in significant impairment or dysfunction in the absence of pathology and under resting conditions. However, in response to a stress, the age-related reduction in physiologic reserves causes a loss of regulatory or homeostatic balance. This happens before an individual notices that something is wrong. An additional consequence of age-related changes is an increased perception of effort associated with submaximal work. Thus, a vicious cycle is set up, leading to decreasing exercise capacity, resulting in an elevated perception of effort, subsequently causing avoidance of activity, and finally feeding back to exacerbation of the age-related declines secondary to disuse. Sedentary behavior is an important risk factor for chronic disease morbidity and mortality in aging. However, there is a limited amount of information on the type and amount of activity needed to promote optimal health and function in older people [19]. The purpose of this review is to discuss the important role of exercise training as a primary prevention tool to hypertension. In addition, this review will address the topic of the recommended amount of physical activity required for health promotion along with the current exercise guidelines.

Outcomes at One-Year Follow-up of Women and Men With Coronary Artery Disease Discharged From Cardiac Rehabilitation

INTRODUCTION

Little is known about which benefits achieved during cardiac rehabilitation (CR) are maintained 1 year after CR discharge and whether there are any gender-specific differences.

METHODS

One-year follow-up data were available in 244/533 (46%; mean age 62 +/- 11 years, 30% women, 30% nonwhite) patients with coronary artery disease discharged from CR between 1996 and 2005. We compared changes in clinical, behavioral, and health status variables from baseline to CR completion, CR completion to 1-year follow-up, and baseline to 1-year follow-up for the group overall and separately for men and women.

RESULTS

At CR completion, statistically significant improvements from baseline were seen in all measures except for high-density lipoprotein cholesterol and smoking. Compared with baseline, these improvements were sustained at 1 year, albeit with some attrition compared with the benefits achieved at CR completion. Long-term benefits were generally similar in women and men, although women appeared to have better long-term retention and implementation of dietary advice.

CONCLUSION

Improvements in most measures attained during CR were still Vera evident at 1 year in both men and women. Whether reinforcement CR Cardiovascular sessions or other strategies to enhance long-term adherence to lifestyle changes could attenuate the observed attrition in benefits needs further study. Gender-specific strategies may best address the needs of men and women.

The Extensive Lifestyle Management Intervention (ELMI) after cardiac rehabilitation: a 4-year randomized controlled trial

BACKGROUND

Previous reports indicate risk factors and lifestyle behaviors may deteriorate early after completion of a cardiac rehabilitation program (CRP). We hypothesized that a modest risk factor and lifestyle management intervention after a CRP would significantly reduce overall cardiovascular risk using the Framingham risk score compared with usual care after 4 years.

METHODS

Patients with ischemic heart disease (n = 302) were randomized after a CRP to either usual care or intervention (exercise sessions, telephone follow-ups, counseling sessions, and reports to the participants' family physicians). The Framingham risk score, risk factors, and lifestyle behaviors were compared after 4 years.

RESULTS

Data were available for 130 intervention and 119 usual care participants. The intervention resulted in 15.5 hours of direct participant contact. Framingham score, total cholesterol, low-density lipoprotein cholesterol, and systolic blood pressure were significantly improved in the intervention group after adjusting for baseline factors. There were no significant differences with respect to lifestyle factors between the groups.

CONCLUSIONS

A modest risk factor and lifestyle management intervention resulted in a significant reduction to global risk compared with usual care and should be considered after CRP.

Effectiveness of follow-up booster sessions in improving physical status after cardiac rehabilitation: health, behavioral, and clinical outcomes

There is limited research on booster interventions designed to maintain/improve health outcomes following cardiac rehabilitation (CR). The purpose of this study was to examine the effects of a booster intervention on health, behavioral, and clinical physical status outcomes among CR graduates randomly assigned to one of three groups: structured educational/counseling sessions by telephone ( n = 24), clinic ( n = 20), or usual care ( n = 20). The sessions were provided at 3 and 9 weeks following Phase II CR. A repeated measures experimental design was used to examine outcomes at baseline (completion of CR) and at 3 and 6 months. Although the effects of the booster interventions were not significant, there was evidence to suggest that a booster intervention, compared with usual care, had a positive effect on patients' physical functioning, adherence to the exercise program, frequency of exercise, heart rate, and blood pressure.

Impact of program duration and contact frequency on efficacy and cost of cardiac rehabilitation: results of a randomized trial

BACKGROUND

Secondary prevention through cardiac rehabilitation (CR) has been recommended for most patients with coronary artery disease (CAD). Although generally reimbursed for 3 months, to date, optimal CR program duration and frequency of patient contact has yet to be identified. This study compared standard (33 sessions for 3 months) versus distributed (33 sessions for 12 months) CR for effects on exercise variables, risk factors, health-related quality of life (HRQL), depressive symptoms, and direct costs to the cardiac health care system.

METHODS

We randomly assigned 392 patients to either standard CR (n = 196) or distributed CR (n = 196). Outcomes were cardiorespiratory fitness, daily physical activity, coronary risk factors, generic and heart disease HRQL, and depressive symptoms, measured 12 and 24 months after program intake. Secondary outcomes included these variables measured after 3 months. Costs to the cardiac health care system were determined 2 years after program initiation.

RESULTS

Both groups showed improvements over time in cardiorespiratory fitness, daily physical activity, low-density lipoprotein cholesterol, generic and heart disease HRQL, and depressive symptoms. Over time, blood pressure and body mass index values worsened. Smoking status, high-density lipoprotein cholesterol, and triglyceride levels remained unchanged. There were no clinically meaningful or statistically significant between group differences for outcomes at 12 or 24 months. The costs of the programs to the cardiac health care system were not different.

CONCLUSIONS

From a clinical standpoint, this study indicates that both standard and distributed program formats serve patients with CAD equally well over the longer term. Programs could use either program delivery model (standard or distributed) depending on patient or program needs. Costs to the cardiac health care system are similar.

Home versus center based physical activity programs in older adults

BACKGROUND

Physical inactivity is a leading cause of preventable death and morbidity in developed countries. In addition physical activity can potentially be an effective treatment for various medical conditions (e.g. cardiovascular disease, osteoarthritis). Many types of physical activity programs exist ranging from simple home exercise programs to intense highly supervised hospital (center) based programs.

OBJECTIVES

To assess the effectiveness of 'home based' versus 'center based' physical activity programs on the health of older adults.

SEARCH STRATEGY

The reviewers searched the Cochrane Central Register of Controlled Trials (CENTRAL) (1991-present), MEDLINE (1966-Sept 2002), EMBASE (1988 to Sept 2002), CINAHL (1982-Sept 2002), Health Star (1975-Sept 2002), Dissertation Abstracts (1980 to Sept 2002), Sport Discus (1975-Sept 2002) and Science Citation Index (1975-Sept 2002), reference lists of relevant articles and contacted principal authors where possible.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of different physical activity interventions in older adults (50 years or older) comparing a 'home based' to a 'center based' exercise program. Study participants had to have either a recognised cardiovascular risk factor, or existing cardiovascular disease, or chronic obstructive airways disease (COPD) or osteoarthritis. Cardiac and post-operative programs within one year of the event were excluded.

DATA COLLECTION AND ANALYSIS

Three reviewers selected and appraised the identified studies independently. Data from studies that then met the inclusion/exclusion criteria were extracted by two additional reviewers.

MAIN RESULTS

Six trials including 224 participants who received a 'home based' exercise program and 148 who received a 'center based' exercise program were included in this review. Five studies were of medium quality and one poor. A meta-analysis was not undertaken given the heterogeneity of these studies. CARDIOVASCULAR. The largest trial (accounting for approximately 60% of the participants) looked at sedentary older adults. Three trials looked at patients with peripheral vascular disease (intermittent claudication). In patients with peripheral vascular disease center based programs were superior to home at improving distance walked and time to claudication pain at up to 6 months. However the risk of a training effect may be high. There are no longer term studies in this population. Notably home based programs appeared to have a significantly higher adherence rate than center based programs. However this was based primarily on the one study (with the highest quality rating of the studies found) of sedentary older adults. This showed an adherence rate of 68% in the home based program at two year follow-up compared with a 36% adherence in the center based group. There was essentially no difference in terms of treadmill performance or cardiovascular risk factors between groups. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). Two trials looked at older adults with COPD. In patients with COPD the evidence is conflicting. One study showed similar changes in various physiological measures at 3 months that persisted in the home based group up to 18 months but not in the center based group. The other study showed significantly better improvements in physiological measures in the center based group after 8 weeks but again the possibility of a training effect is high. OSTEOARTHRITIS. No studies were found. None of the studies dealt with measures of cost, or health service utilization.

AUTHORS' CONCLUSIONS

In the short-term, center based programs are superior to home based programs in patients with PVD. There is a high possibility of a training effect however as the center based groups were trained primarily on treadmills (and the home based were not) and the outcome measures were treadmill based. There is conflicting evidence which is better in patients with COPD. Home based programs appear to be superior to center based programs in terms of the adherence to exercise (especially in the long-term).

Home-based resistance training is not sufficient to maintain improved glycemic control following supervised training in older individuals with type 2 diabetes

OBJECTIVE

To examine whether improvements in glycemic control and body composition resulting from 6 months of supervised high-intensity progressive resistance training could be maintained after an additional 6 months of home-based resistance training.

RESEARCH DESIGN AND METHODS

We performed a 12-month randomized controlled trial in 36 sedentary, overweight men and women with type 2 diabetes (aged 60-80 years) who were randomly assigned to moderate weight loss plus high-intensity progressive resistance training (RT&WL group) or moderate weight loss plus a control program (WL group). Supervised gymnasium-based training for 6 months was followed by an additional 6 months of home-based training. Glycemic control (HbA1c), body composition, muscle strength, and metabolic syndrome abnormalities were assessed at 0, 3, 6, 9, and 12 months.

RESULTS

Compared with the WL group, HbA1c decreased significantly more in the RT&WL group (-0.8%) during 6 months of supervised gymnasium-based training; however, this effect was not maintained after an additional 6 months of home-based training. In contrast, the greater increase in lean body mass (LBM) observed in the RT&WL group compared with the WL group (0.9 kg, P < 0.05) after the gymnasium-based training tended to be maintained after the home-based training (0.8 kg, P = 0.08). Similarly, the gymnasium-based increases in upper body and lower body muscle strength in the RT&WL group were maintained over the 12 months (P < 0.001). There were no between-group differences for changes in body weight, fat mass, fasting glucose, or insulin at 6 or 12 months.

CONCLUSIONS

In older adults with type 2 diabetes, home-based progressive resistance training was effective for maintaining the gymnasium-based improvements in muscle strength and LBM but not glycemic control. Reductions in adherence and exercise training volume and intensity seem to impede the effectiveness of home-based training for maintaining improved glycemic control.

Effects of a tailored follow-up intervention on health behaviors, beliefs, and attitudes

BACKGROUND

The high rates of relapse that tend to occur after short-term behavioral interventions indicate the need for maintenance programs that promote long-term adherence to new behavior patterns. Computer-tailored health messages that are mailed to participants or given in brief telephone calls offer an innovative and time-efficient alternative to ongoing face-to-face contact with healthcare providers.

METHODS

Following a 1-year behavior change program, 22 North Carolina health departments were randomly assigned to a follow-up intervention or control condition. Data were collected from 1999 to 2001 by telephone-administered surveys at preintervention and postintervention for 511 low-income, midlife adult women enrolled in the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program at local North Carolina health departments. During the year after the behavior change program, intervention participants were mailed six sets of computer-tailored health messages and received two computer-tailored telephone counseling sessions. Main outcomes of dietary and physical activity behaviors, beliefs, and attitudes were measured.

RESULTS

Intervention participants were more likely to move forward into more advanced stages of physical activity change (p = 0.02); control participants were more likely to increase their level of dietary social support at follow-up (p = 0.05). Both groups maintained low levels of reported saturated fat and cholesterol intake at follow-up. No changes were seen in physical activity in either group.

CONCLUSIONS

Mailed computer-tailored health messages and telephone counseling calls favorably modified forward physical activity stage movement but did not appreciably affect any other psychosocial or behavioral outcomes.

Automatic referral to cardiac rehabilitation

OBJECTIVES

Cardiac rehabilitation (CR) remains underused and inconsistently accessed, particularly for women and minorities. This study examined the factors associated with CR enrollment within the context of an automatic referral system through a retrospective chart review plus survey. Through the Behavioral Model of Health Services Utilization, it was postulated that enabling and perceived need factors, but not predisposing factors, would significantly predict patient enrollment.

SUBJECTS

A random sample of all atherosclerotic heart disease (AHD) patients treated at a tertiary care center (Trillium Health Centre, Ontario, Canada) from April 2001 to May 2002 (n = 501) were mailed a survey using a modified Dillman method (71% response rate).

MEASURES

Predisposing measures consisted of sociodemographics such as age, sex, ethnocultural background, work status, level of education, and income. Enabling factors consisted of barriers and facilitators to CR attendance, exercise benefits and barriers (EBBS), and social support (MOS). Perceived need factors consisted of illness perceptions (IPQ) and body mass index.

RESULTS

Of the 272 participants, 199 (73.2%) attended a CR assessment. Lower denial/minimization, fewer logistical barriers to CR (eg, distance, cost), and lower perceptions of AHD as cyclical or episodic reliably predicted CR enrollment among cardiac patients who were automatically referred.

CONCLUSION

Because none of the predisposing factors were significant in the final model, this suggests that factors associated with CR enrollment within the context of an automatic referral model relate to enabling factors and perceived need. A prospective controlled evaluation of automatic referral is warranted.

Older adults with chronic disease: benefits of group-mediated counseling in the promotion of physically active lifestyles

In this 12-month trial standard exercise training was compared with a group-mediated cognitive-behavioral (GMCB) intervention with respect to effects on long-term adherence and change in physical function of older adults who were either at risk for or had cardiovascular disease. Participants (147 older men and women) were randomized to the 2 treatments. Outcomes included self-reportedphysical activity, fitness, and self-efficacy. The GMCB treatment produced greater improvements on all outcomes than did standard exercise therapy. Regardless of treatment assignment, men had more favorable change on the study outcomes than did women. Analysis of a self-regulatory process measure in the GMCB group revealed that change in barriers efficacy was related to change in physical activity and fitness. Results suggest that teaching older adults to integrate physical activity into their lives via GMCB leads to better long-term outcomes than standardized exercise therapy.

Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial

BACKGROUND

Whether cardiac rehabilitation (CR) is effective in patients older than 75 years, who have been excluded from most trials, remains unclear. We enrolled patients 46 to 86 years old in a randomized trial and assessed the effects of 2 months of post-myocardial infarction (MI) CR on total work capacity (TWC, in kilograms per meter) and health-related quality of life (HRQL).

METHODS AND RESULTS

Of 773 screened patients, 270 without cardiac failure, dementia, disability, or contraindications to exercise were randomized to outpatient, hospital-based CR (Hosp-CR), home-based CR (Home-CR), or no CR within 3 predefined age groups (middle-aged, 45 to 65 years; old, 66 to 75 years; and very old, >75 years) of 90 patients each. TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline, after CR, and 6 and 12 months later. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in middle-aged and old persons but smaller, although still significant, in very old patients. TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR. HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients. Complications were similar across treatment and age groups. Costs were lower for Home-CR than for Hosp-CR.

CONCLUSIONS

Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients.

Program participation and physical activity maintenance after cardiac rehabilitation

This study examined exercise maintenance among patients after completing cardiac rehabilitation. Subjects were men and women who had completed a Phase II Cardiac Rehabilitation Program approximately 12 months previously. Subjects were classified according to whether they had (a) never participated in a Phase III program (G-I) (N = 37), (b) enrolled and completed a Phase III program (G-II) (N = 30), or (c) were currently enrolled in a Phase III maintenance program (G-III) (N = 33). Subjects were significantly more likely to be participating in regular exercise if they had participated in a Phase III program (p < .05). Individuals in G-II and G-III engaged in more minutes of physical activity per week and were more likely to meet recommended levels of physical activity compared to G-1 subjects. G-1 individuals who had longer Phase II programs were more likely to maintain their exercise habits following graduation (p < .05). Results suggest that Phase III maintenance programs and longer Phase II participation improved exercise maintenance following rehabilitation.

A controlled trial of hospital versus home-based exercise in cardiac patients

BACKGROUND

Large numbers of patients who stand to benefit from the exercise training component of cardiac rehabilitation are not being served due to access issues. Home-based exercise training may be a potentially useful alternative to training in institutional environments.

PURPOSE

The purpose of this study was to examine the benefit of 6 months of hospital-based exercise training versus 6 months of monitored, home-based exercise training with respect to physical, quality of life, and social support outcomes in patients after coronary artery bypass graft (CABG) surgery.

METHODS

Randomized controlled trial of "direct-to-home" (Home; = 120) versus "direct-to-hospital" (Hosp; = 122) exercise training, 35-49 d post CABG surgery. The primary outcome was peak exercise capacity, measured by peak oxygen consumption (VO(2)) on a symptom-limited cycle ergometer exercise test. Secondary outcomes were health-related quality of life (measured by the SF-36) and social support (measured by the ISEL). Measurements were taken at baseline and after 3 and 6 months of exercise training.

RESULTS

The study groups had similar demographic and health profiles at baseline. Peak VO(2) improved significantly in both groups after 6 months of exercise training; 36% in the Hosp group (1,222.1 +/- 269.0 mL x min(-1) to 1,497.2 +/- 594.3 mL x min(-1); < 0.0001) and 31% in the Home group (1,260.3 +/- 306.5 mL x min(-1) to 1,433.4 +/- 589.7 mL x min(-1); < 0.05). The Home group reported greater total social support than the Hosp group at 3 (36.2 +/- 4.5 vs 34.0 +/- 6.7; < 0.0001) and 6 months (36.0 +/- 4.9 vs 34.6 +/- 6.4; = 0.05). The Home group demonstrated a greater improvement in health-related quality of life (physical) by 6 months in comparison to the Hosp patients (51.2 +/- 6.4 vs 48.6 +/- 7.1; = 0.004).

CONCLUSION

This study suggests that low-risk CABG surgery patients may be served as well or better with a monitored, home-based exercise program than with an institution-based program.

A randomized controlled trial of an extensive lifestyle management intervention (ELMI) following cardiac rehabilitation: study design and baseline data

BACKGROUND

Cardiac rehabilitation programs (CRP) represent comprehensive interventions that are typically limited to four months. Following completion of CRP, it appears that risk factors and lifestyle behaviours may deteriorate. The Extensive Lifestyle Management Intervention (ELMI) Following Cardiac Rehabilitation trial will investigate the benefits of a randomized intervention to prevent these adverse changes.

METHODS

Patients with ischemic heart disease (IHD) were randomized following a standard CRP to the ELMI or to usual care. The ELMI program is a case-managed intervention aimed at individualizing risk factor and lifestyle management based on current treatment guidelines. The program consists of cardiac rehabilitation sessions, telephone follow-up and risk factor and lifestyle counselling sessions. Health professionals work with participants using behavioural counselling and communications with participants' family physicians. Usual care participants return to their family physicians' care, and come to the study clinic only to undergo annual outcomes assessment. The primary outcome is change in IHD global risk after four years. Secondary outcomes include combined cardiovascular events, health care utilization, lifestyle adherence, quality of life and risk factors.

RESULTS

Over 28 months, 302 men and women were randomized. This represented 29% of the total population screened. The average age of study participants is 64 years, 18% are women, 53% have had a previous myocardial infarction, 73% have undergone previous revascularization and 20% have diabetes mellitus. Ischemic heart disease risk factors for the entire cohort improved significantly after subjects had gone through previous CRPs. Baseline risk factors, lifestyle behaviours and medications were similar between the groups.

CONCLUSIONS

This study population is representative of patients completing a standard CRP. Results of the ELMI trial will provide valuable information for the future design of CRPs.

Cardiac rehabilitation: a comprehensive review

Cardiac rehabilitation (CR) is a commonly used treatment for men and women with cardiovascular disease. To date, no single study has conclusively demonstrated a comprehensive benefit of CR. Numerous individual studies, however, have demonstrated beneficial effects such as improved risk-factor profile, slower disease progression, decreased morbidity, and decreased mortality. This paper will review the evidence for the use of CR and discuss the implications and limitations of these studies. The safety, relevance to special populations, challenges, and future directions of CR will also be reviewed.