Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY

Machine Learning-Based Prediction Models for Healthcare Outcomes in Patients Participating in Cardiac Rehabilitation: A Systematic Review

PURPOSE

Cardiac rehabilitation (CR) has been proven to reduce mortality and morbidity in patients with cardiovascular disease. Machine learning (ML) techniques are increasingly used to predict healthcare outcomes in various fields of medicine including CR. This systemic review aims to perform critical appraisal of existing ML-based prognosis predictive model within CR and identify key research gaps in this area.

REVIEW METHODS

A systematic literature search was conducted in Scopus, PubMed, Web of Science, and Google Scholar from the inception of each database to January 28, 2024. The data extracted included clinical features, predicted outcomes, model development, and validation as well as model performance metrics. Included studies underwent quality assessments using the IJMEDI and Prediction Model Risk of Bias Assessment Tool checklist.

SUMMARY

A total of 22 ML-based clinical models from 7 studies across multiple phases of CR were included. Most models were developed using smaller patient cohorts from 41 to 227, with one exception involving 2280 patients. The prediction objectives ranged from patient intention to initiate CR to graduate from outpatient CR along with interval physiological and psychological progression in CR. The best-performing ML models reported area under the receiver operating characteristics curve between 0.82 and 0.91, with sensitivity from 0.77 to 0.95, indicating good prediction capabilities. However, none of them underwent calibration or external validation. Most studies raised concerns about bias. Readiness of these models for implementation into practice is questionable. External validation of existing models and development of new models with robust methodology based on larger populations and targeting diverse clinical outcomes in CR are needed.

Volume of Aerobic Exercise to Optimize Outcomes in Cardiac Rehabilitation: An Official Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation

Exercise training is a core component of cardiac rehabilitation (CR) programming. Exercise and, more broadly, physical activity are critical elements to secondary prevention of cardiovascular disease. The central components of the exercise prescription are well-defined and include frequency (how many bouts of exercise per week), intensity (how hard to exercise), time (duration of exercise session), type (modality of exercise), and progression (rate of increase in the dose of exercise). Specific targets for the volume (total amount) of exercise, however, are less well-defined. This Position Statement provides a general overview of the specific goals for the volume of aerobic exercise to optimize long-term outcomes for participants in CR. Additionally, examples are provided to illustrate how to integrate the various aspects of the exercise.

Home-based transitional cardiac telerehabilitation in older adults post coronary artery bypass grafting: A randomized controlled trial

This randomized controlled trial evaluated the effectiveness of a 12-week home-based transitional cardiac telerehabilitation (Hb-T-CTR) program on health-related quality-of-life and therapeutic self-care in older adults' post-Coronary Artery Bypass Grafting (CABG). The intervention group (n = 57) underwent Hb-T-CTR, incorporating preoperative counseling, postoperative education, a culturally adapted video, home visits, and telephone counseling, while the control group (n = 61) received standard care. Using the Coronary Revascularization Outcome Questionnaire and the Sidani Doran Therapeutic Self-Care Measure, data were collected at three time points. Results showed significant improvements in overall scores for both health-related quality of life (t1=3.386, P = 0.001; t2=4.224, P < 0.001) and therapeutic self-care (t1=7.104, P < 0.001; t2=4.242, P < 0.001) in the intervention group compared to controls. This telehealth approach provides convenient and accessible rehabilitation services for older adults' post-CABG and highlights the importance of integrating Hb-T-CTR into routine care for personalized rehabilitation. This study underscores the potential of telehealth tools in overcoming barriers and enhancing patient-centered interventions.

Geographic access to cardiac rehabilitation and cardiovascular disease outcomes: A study of rural United States counties

Prior studies have examined rural-urban disparities in access to cardiac rehabilitation (CR). However, few have examined the relationship between disparate access to CR and cardiovascular disease outcomes in rural areas. In this analysis of 1975 nonmetro United States counties, we investigated the relationship between number of hospitals with CR and Medicare-population hospitalization rates (per 1000 adults ≥65 years) and county-population mortality rates (per 100,000 adults ≥18 years) due to coronary heart disease (CHD), heart failure (HF), or stroke, using multivariable linear-regression-modeling adjusting for socio-demographic and comorbid conditions. Median CHD hospitalization (13.0 vs. 12.2), HF hospitalization (16.1 vs. 13.3), HF death (114.2 vs. 110.9), stroke hospitalization (12.0 vs. 10.9), and stroke death (39.6 vs. 37.1) rates were higher in nonmetro counties without versus with a CR facility (p-values< 0.001). There were inverse correlations between number of hospitals with CR and CHD (r= -0.161), HF (r= -0.261) and stroke (r= -0.237) hospitalization rates, and stroke mortality (r= -0.144) rates (p-values< 0.001). After adjustment, as the number of hospitals with CR increased, there were decreases in hospitalization rates of 1.78 for CHD, 7.20 for HF, and 2.43 for stroke, per 1000 in the population (p-values < 0.001) and decreases in stroke deaths of 9.17 per 100,000 in the population (p= 0.02). Access to hospitals with CR in US nonmetro counties is inversely related to CHD, HF, and stroke hospitalization, and stroke mortality. Our findings call for reducing barriers to CR in nonmetro communities and further exploring the relationship between CR and stroke outcomes.

Moderating Effect of Sex on the Relationship Between Physical Activity and Quality of Life in Coronary Heart Disease Patients in China

PURPOSE

The aim of this study was to investigate the moderating effect of sex on the relationship between physical activity (PA) and quality of life (QoL) in Chinese patients with coronary heart disease (CHD) not participating in cardiac rehabilitation.

METHODS

Chinese patients with CHD (aged 18-80 yr) were selected 12 mo after discharge from three Hebei Province tertiary hospitals. The International Physical Activity Questionnaire was used to assess PA in metabolic equivalents of energy (METs) and the Chinese Questionnaire of Quality of Life in Patients With Cardiovascular Disease was used to assess QoL. Data were analyzed using Student's t test and the χ 2 test, multivariant and hierarchical regression analysis, and simple slope analysis.

RESULTS

Among 1162 patients with CHD studied between July 1 and November 30, 2017, female patients reported poorer QoL and lower total METs in weekly PA compared with male patients. Walking ( β= .297), moderate-intensity PA ( β= .165), and vigorous-intensity PA ( β= .076) positively predicted QoL. Hierarchical regression analysis showed that sex moderates the relationship between walking ( β= .195) and moderate-intensity PA ( β= .164) and QoL, but not between vigorous-intensity PA ( β= -.127) and QoL. Simple slope analysis revealed the standardized coefficients of walking on QoL were 0.397 (female t  = 8.210) and 0.338 (male t = 10.142); the standardized coefficients of moderate-intensity PA on QoL were 0.346 (female, t  = 7.000) and 0.175 (male, t = 5.033).

CONCLUSIONS

Sex moderated the relationship between PA and QoL among patients with CHD in China. There was a greater difference in QoL for female patients reporting higher time versus those with lower time for both walking and moderate-intensity PA than for male patients.

Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands

PURPOSE

Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components.

METHODS

Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components.

RESULTS

In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization.

CONCLUSIONS

CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

A Mobile Health Behavior Change Intervention for Women With Coronary Heart Disease: A RANDOMIZED CONTROLLED PILOT STUDY

PURPOSE

The aim of this study was to evaluate the effects of a mobile health (mHealth) intervention, HerBeat, compared with educational usual care (E-UC) for improving exercise capacity (EC) and other patient-reported outcomes at 3 mo among women with coronary heart disease.

METHODS

Women were randomized to the HerBeat group (n = 23), a behavior change mHealth intervention with a smartphone, smartwatch, and health coach or to the E-UC group (n = 24) who received a standardized cardiac rehabilitation workbook. The primary endpoint was EC measured with the 6-min walk test (6MWT). Secondary outcomes included cardiovascular disease risk factors and psychosocial well-being.

RESULTS

A total of 47 women (age 61.2 ± 9.1 yr) underwent randomization. The HerBeat group significantly improved on the 6MWT from baseline to 3 mo ( P = .016, d = .558) while the E-UC group did not ( P = .894, d =-0.030). The between-group difference of 38 m at 3 mo was not statistically significant. From baseline to 3 mo, the HerBeat group improved in anxiety ( P = .021), eating habits confidence ( P = .028), self-efficacy for managing chronic disease ( P = .001), diastolic blood pressure ( P = .03), general health perceptions ( P = .047), perceived bodily pain ( P = .02), and waist circumference ( P = .008) while the E-UC group showed no improvement on any outcomes.

CONCLUSIONS

The mHealth intervention led to improvements in EC and several secondary outcomes from baseline to 3 mo while the E-UC intervention did not. A larger study is required to detect small differences between groups. The implementation and outcomes evaluation of the HerBeat intervention was feasible and acceptable with minimal attrition.

Effectiveness of home-based cardiac telerehabilitation in patients with heart failure: A systematic review and meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

To evaluate the effectiveness of home-based cardiac telerehabilitation in patients with heart failure.

DESIGN

This systematic review and meta-analysis of randomised controlled trials were designed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Two researchers independently screened eligible studies. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias within the included studies. A fixed- or random-effects meta-analysis model was used to determine the mean difference, based on the results of the heterogeneity test.

DATA SOURCES

A librarian-designed search of the Cochrane Library, PubMed, Web of Science, EMBASE, CINAHL, CBM, CNKI and Wanfang databases was conducted to identify studies in English or Chinese on randomised controlled trials up to 15 August 2022.

RESULTS

A total of 2291 studies were screened. The meta-analysis included data from 16 studies representing 4557 participants. The results indicated that home-based cardiac telerehabilitation could improve heart rate, VO2 peak, 6-minute walk distance, quality of life and reduce readmission rates. No significant differences were observed in the left ventricular ejection fraction percentages between the home-based cardiac telerehabilitation and usual care groups. Compared with centre-based cardiac rehabilitation, home-based cardiac telerehabilitation showed no significant improvement in outcome indicators.

CONCLUSION

Patients with heart failure benefit from home-based cardiac telerehabilitation intervention. With the rapid development of information and communication technology, home-based cardiac telerehabilitation has great potential and may be used as an adjunct or substitute for centre-based cardiac rehabilitation.

IMPACT

This systematic review and meta-analysis found that patients with heart failure would benefit from home-based cardiac telerehabilitation intervention in terms of cardiac function, functional capacity, quality-of-life management and readmission rate. Future clinical interventions should consider home-based cardiac telerehabilitation as an alternative to conventional cardiac rehabilitation in patients with heart failure to improve their quality of life.

NO PATIENT OR PUBLIC CONTRIBUTION

Our paper is a systematic review and meta-analysis, and such details do not apply to our work.

Main Mechanisms of Remote Monitoring Programs for Cardiac Rehabilitation and Secondary Prevention: A SYSTEMATIC REVIEW

PURPOSE

The objective of this report was to identify the main mechanisms of home-based remote monitoring programs for cardiac rehabilitation (RM CR) and examine how these mechanisms vary by context.

METHODS

This was a systematic review using realist synthesis. To be included, articles had to be published in English between 2010 and November 2020 and contain specific data related to mechanisms of effect of programs. MEDLINE All (1946-) via Ovid, Embase (1974-) via Ovid, APA PsycINFO (1806-), CINAHL via EBSCO, Scopus databases, and gray literature were searched.

RESULTS

From 13 747 citations, 91 focused on cardiac conditions, with 23 reports including patients in CR. Effective RM CR programs more successfully adapted to different patient home settings and broader lives, incorporated individualized patient health data, and had content designed specifically for patients in cardiac rehabilitation. Relatively minor but common technical issues could significantly reduce perceived benefits. Patients and families were highly receptive to the programs and viewed themselves as fortunate to receive such services. The RM CR programs could be improved via incorporating more connectivity to other patients. No clear negative effects on perceived utility or outcomes occurred by patient age, ethnicity, or sex. Overall, the programs were seen to best suit highly motivated patients and consolidated rather than harmed existing relationships with health care professionals and teams.

CONCLUSIONS

Remote monitoring CR programs are perceived by patients to be beneficial and attractive. Future RM CR programs should consider adaptability to different home settings, incorporate individualized health data, and contain content specific to patient needs.

Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization

BACKGROUND

Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes.

METHODS

A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization.

RESULTS

A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles.

CONCLUSIONS

Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.

Identifying Factors for Low-Risk Participation in Alternative Cardiac Rehabilitation Models for Patients with Coronary Heart Disease Using MI'S SCOREPAD

Introduction

Although a recent joint society scientific statement (the American Association of Cardiovascular Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology) suggests home-based cardiac rehab (CR) is appropriate for low- and moderate-risk patients, there are no paradigms to define such individuals with coronary heart disease.

Methods

We reviewed a decade of data from all patients with coronary heart disease enrolled in a single CR center (University of Michigan) to identify the prevalence of low-risk factors, which may inform on consideration for participation in alternative models of CR. Low-risk factors included not having any of the following: metabolic syndrome, presence of implantable cardioverter defibrillator or permanent pacemaker, active smoking, prior stroke, congestive heart failure, obesity, advanced renal disease, poor exercise capacity, peripheral arterial disease, angina, or clinical depression (MI'S SCOREPAD). We report on the proportion of participants with these risk factors and the proportion with all of these low-risk factors.

Results

The mean age of CR participants (n = 1984) was 63 years; 25% were women, and 82% were non-Hispanic White. The mean number of low-risk factors was 8.5, which was similar in the 2011-2012 and 2018-2019 cohorts (8.5 vs. 8.3, respectively, P = 0.08). Additionally, 9.3% of the 2011-2012 cohort and 7.6% of the 2018-2019 cohort had all 11 of the low-risk factors.

Conclusion

In this observational study, we provide a first paradigm of identifying factors among coronary heart disease patients that may be considered low-risk and likely high-gain for participation in alternative models of CR. Further work is needed to track clinical outcomes in patients with these factors to determine thresholds for enrolling participants in alternative forms of CR.

Personalized smart voice-based electronic prescription for remote at-home feedback management in cardiovascular disease rehabilitation: a multi-center randomized controlled trial

Objective

To investigate the quality and efficacy of remote at-home rehabilitation for patients with cardiovascular disease (CVD) using personalized smart voice-based electronic prescription, and further explore the standardized health management mode of remote family cardiac rehabilitation. Trial design: A multicenter, randomized (1:1), non-blind, parallel controlled study.

Methods

A total of 171 patients with CVD who were admitted to 18 medical institutions in China from April 2021 to October 2022 were randomly divided into a treatment group (86 cases) and a control group (85 cases) in a non-blinded experiment, based on the sequence of enrollment. The control group received routine at-home rehabilitation training, and the treatment group received remote feedback-based at-home cardiac rehabilitation management based on routine at-home rehabilitation training. The primary outcome was the difference in VO2peak (mL/min/kg) after 12 weeks. A linear mixed model was developed with follow-up as the dependent variable. Age and baseline data were utilized as covariates, whereas hospital and patient characteristics were adjusted as random-effect variables. As the linear mixed model can accommodate missing data under the assumption of random missing data, there was no substitute missing value for quantitative data.

Results

A total of 171 participants, with 86 in the experimental group and 85 in the control group, were included in the main analysis. The analysis, which used linear mixing model, revealed significant differences in cardiopulmonary function indexes (VO2/kg peak, VO2peak, AT, METs, and maximum resistance) at different follow-up time (0, 4, and 12 weeks) in the experimental group (p < 0.05). In the control group, there was no significant difference in cardiopulmonary values at different follow-up time (0, 4, and 12 weeks; p > 0.05). VO2/kg peak (LS mean 1.49, 95%CI 0.09-2.89, p = 0.037) and other indicators of cardiopulmonary function (p < 0.05) were significantly different between the experimental group and the control group at week 12. The results were comparable in the complete case analysis.

Conclusion

The remote home cardiac rehabilitation management mode using personalized smart voice-based electronic prescription provides several benefits to patients, including improvements in muscle strength, endurance, cardiopulmonary function, and aerobic metabolism. It also helps reduce risk factors for cardiovascular disease and enhances patients' self-management abilities and treatment compliance.Clinical trial registration: http://www.chictr.org.cn, identifier ChiCTR2100044063.

Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program

The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies had shown safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR. A multidisciplinary team reviewed various alternative models for delivery and decided to implement a hybrid CRP2 exercise programme (HCRP2-EP) to ensure continuation of our patient care. Our aim was to enrol in the HCRP2-EP 70% of all eligible patients by 30 September 2020. Institute for Health Care Improvement's collaborative model was adopted. Multiple plan-do-study-act cycles were used to test change ideas. The outcomes of the project were analysed using standard run chart rules to detect the changes in outcomes over time. This project was implemented from March 2020, and the male patients enrolled between August 2020 and April 2021, with sustained monthly median enrolment above target of 70% throughout. As for our secondary outcome, 75.8% of the male patients who completed HCRP2-EP showed a meaningful change in peak exercise capacity of ≥10% (mean change 17%±6%). There were no major adverse events reported, and the median Patient Satisfaction Score was 96% well above the institutional target of 90%. This shows a well-designed quality improvement programme is an appropriate strategy for implementing HCRP2-EP in a clinical setting, and HCRP2-EP is a feasible, effective and safe intervention in eligible male patients with cardiovascular disease.

Participation and Prognostic Impact of Cardiac Rehabilitation After Acute Coronary Syndrome: Big-Data Study of the Korean National Health Insurance Service

BACKGROUND

To investigate the actual rate and quality of cardiac rehabilitation (CR) participation in South Korea and its short-term impact on clinical outcomes after acute coronary syndrome (ACS).

METHODS

Data, including confirmed ACS diagnosis, socio-demographics, comorbidities, clinical outcomes, and CR claim codes, were collected from the Korean National Health Insurance Service claims database and compared between the CR and non-CR groups.

RESULTS

Overall, 102,544 patients were included in the study, of which only 5.8% attended CR. Regarding testing, 83.6% of CR patients performed the cardiopulmonary exercise test, but follow-up testing was infrequently performed; in addition, 53.1% of them participated in an electrocardiogram monitoring exercise, but over half participated in only one session. After 1:1 propensity score matching, post-ACS cardiovascular events were significantly lower in the CR group than in the non-CR group. The cumulative 3-year hazard ratio for all-cause death was 0.612 (95% confidence interval [CI], 0.495-0.756), recurrent ACS was 0.92 (95% CI, 0.853-0.993), CR readmission was 0.817 (95% CI, 0.768-0.868), and major adverse cardiovascular events (MACE) was 0.827 (95% CI, 0.781-0.874) in the CR group. CR was associated with a significant dose-response effect on MACE, with a reduction in incidence from 0.854 to 0.711.

CONCLUSION

The actual rate of CR participation in South Korea remains low, and participation quality was not outstanding despite National Health Insurance coverage. Nevertheless, the impact of CR on cardiovascular outcomes after ACS was significantly superior. Efforts to increase CR participation should be increased by establishing new CR facilities and strategies to resolve associated barriers.

Benefits, Facilitators, and Barriers of Alternative Models of Cardiac Rehabilitation: A QUALITATIVE SYSTEMATIC REVIEW

PURPOSE

Cardiac rehabilitation (CR) improves health outcomes and quality of life for patients with cardiovascular disease, yet only a quarter of eligible patients enroll. A myriad of CR models that use either an alternative location (ie, home-based) and/or an alternative exercise have been developed to overcome known attendance and physical limitation barriers; however, patient experiences with these models have not been systematically reviewed. Our aim is to review patient experiences with these models of CR.

REVIEW METHODS

We conducted a systematic review and thematic analysis of qualitative studies published between 2009 and January of 2022 from CINAHL, PubMed, Web of Science, and PsycINFO.

SUMMARY

Twenty-five studies were included, representing the perspectives of 487 individuals who participated in an alternative model of CR. Exercises included walking, tai chi, yoga, aquatic exercise, exergaming, chair-based exercises, aerobics, physical activity trackers, and individualized exercise plans. Nineteen of 25 studies used home-based models and two used live video. Twelve studies included patients with heart failure. Patient perspectives comprised three central themes: exercise benefits, exercise facilitators, and participation barriers. Some thematic categories were reported variably by particular model/study design (eg, home-based) than by others. All alternative models of CR were found to be physically, psychologically, and/or socially beneficial to patients. Participants described facilitators and barriers that were influential in the decision to initiate or continue exercise. These patient insights are critical for innovative delivery of CR that is appealing, accommodates physical limitations, and broadens access to improve health equity.

Hybrid and Traditional Cardiac Rehabilitation in a Rural Area: A RETROSPECTIVE STUDY

PURPOSE

Cardiac rehabilitation is a prescribed exercise intervention that reduces cardiovascular mortality, secondary events, and hospitalizations. Hybrid cardiac rehabilitation (HBCR) is an alternative method that overcomes barriers to participation, such as travel distance and transportation issues. To date, comparisons of HBCR and traditional cardiac rehabilitation (TCR) are limited to randomized controlled trials, which may influence outcomes due to supervision associated with clinical research. Coincidental to the COVID-19 pandemic, we investigated HBCR effectiveness (peak metabolic equivalents [peak METs]), resting heart rate (RHR), resting systolic (SBP) and diastolic blood pressure (DBP), body mass index (BMI), and depression outcomes (Patient Health Questionnaire-9 [PHQ-9]).

METHODS

Via retrospective analysis, TCR and HBCR were examined during the COVID-19 pandemic (October 1, 2020, and March 31, 2022). Key dependent variables were quantified at baseline (pre) and discharge (post). Completion was determined by participation in 18 monitored TCR exercise sessions and four monitored HBCR exercise sessions.

RESULTS

Peak METs increased at post-TCR and HBCR (P < .001); however, TCR resulted in greater improvements (P = .034). The PHQ-9 scores were decreased in all groups (P < .001), while post-SBP and BMI did not improve (SBP: P = .185, BMI: P = .355). Post-DBP and RHR increased (DBP: P = .003, RHR: P = .032), although associations between intervention and program completion were not observed (P = .172).

CONCLUSIONS

Peak METs and depression metric outcomes (PHQ-9) improved with TCR and HBCR. Improvements in exercise capacity were greater with TCR; however, HBCR did not produce inferior results by comparison, an outcome that may have been essential during the first 18 mo of the COVID-19 pandemic.

A Community-Informed Virtual World-Based Cardiac Rehabilitation Program as an Extension of Center-Based Cardiac Rehabilitation: MIXED-METHODS ANALYSIS OF A MULTICENTER PILOT STUDY

PURPOSE

Innovative methods for delivering cardiac rehabilitation (CR) that provide strategies to circumvent the mounting barriers to traditional CR have the potential to widen access to a well-established secondary prevention strategy. Our study assesses the feasibility and acceptability of a novel virtual world-based CR (VWCR) program, Destination Rehab , as an extension of a conventional center-based CR program.

METHODS

Adult cardiac patients hospitalized at Mayo Clinic hospitals with a diagnosis for CR and ≥1 modifiable, lifestyle risk factor target-sedentary lifestyle (<3 hr physical activity/wk), unhealthy diet (<5 servings fruits and vegetables/d), or current smoking (>1 yr)-were recruited. Patients participated in an 8-wk health education program using a virtual world (VW) platform from a prior proof-of-concept study and a post-intervention focus group. Primary outcome measures included feasibility and acceptability. Secondary outcome measures included changes from baseline to post-intervention in cardiovascular (CV) health behaviors and biometrics, CV health knowledge, and psychosocial factors.

RESULTS

Of the 30 enrolled patients (age 59.1 ± 9.7 yr; 50% women), 93% attended ≥1 session and 71% attended ≥75% of sessions. The overall VWCR experience received an 8 rating (scale 0-10) and had high acceptability. Clinically relevant trends were noted in CV health behaviors and biometrics, although not statistically significant.

CONCLUSIONS

The VWCR program is a feasible, highly acceptable, and innovative platform to potentially influence health behaviors and CV risk and may increase accessibility to disadvantaged populations with higher CV disease burdens.

Physical and Psychological Outcomes of Patients Undergoing Traditional Cardiac Rehabilitation and Intensive Cardiac Rehabilitation

PURPOSE

Both traditional cardiac rehabilitation (TCR) and intensive cardiac rehabilitation (ICR) have proven benefits for patients with cardiovascular disease. The aim of this study was to compare ICR versus TCR on cardiac rehabilitation (CR) outcomes in patients with cardiovascular disease.

METHODS

In a retrospective cohort study of 970 patients (n = 251, ICR; n = 719, TCR) who were referred for CR between January 2018 and December 2019, 693 (71.4%) patients completed it. The TCR sessions were 90 min (60-min exercise) three times/wk for 12 wk, while ICR sessions were 4 hr (60-min exercise) two times/wk for 9 wk. Primary endpoints were change in cardiorespiratory fitness (CRF) (by difference in exercise prescription metabolic equivalents [METs] between the last session and the average of the second and third sessions), anxiety (Generalized Anxiety Disorder-7) scores, percent depression (Patient Health Questionnaire-9 or Center for Epidemiologic Studies Depression Scale) scores, and health status (36-item Short Form Health Survey physical and mental composite scores). Linear regression adjusted for imbalanced baseline characteristics (age, race, and diagnosis of angina).

RESULTS

Of the 693 patients who completed CR (ICR = 204/251 [81%] vs TCR = 489/719 [68%], P < .01), mean age was 66 yr and 31% were female. Patients in TCR had a higher improvement in CRF (CR session METs: ICR +1.5 ± 1.2 vs TCR +1.9 ± 1.5, P < .01) but no difference in health status scores. Conversely, patients in ICR had more reduction in anxiety scores (-2 ± 4 vs -1 ± 3, P < .01) and percent reduction in depression scores (-8.3 ± 13.7% vs -5.0 ± 11.7%, P < .01) than patients in TCR.

CONCLUSIONS

Patients in TCR had higher improvement in CRF while patients in ICR had higher improvement in anxiety and depression scores.

[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.

Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK

PURPOSE

Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation.

METHODS

Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement.

RESULTS

A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers.

CONCLUSIONS

This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.

Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT

OBJECTIVE

The aim of this review was to summarize literature examining the prevalence, impact, and trajectories of sleep disturbance in cardiac rehabilitation (CR) patients and discuss how CR programs may incorporate targeted evaluation and interventions to promote sleep health.

REVIEW METHODS

A narrative review of literature allowed for an examination of the prevalence of sleep disturbance in CR patients, the effects of sleep disturbance on CR outcomes, and trajectories of sleep disturbance in CR.

SUMMARY

Sleep disturbance is prevalent in CR patient populations and is related to clinical and functional outcomes. Sleep may be an important biobehavioral process to target in CR to improve important patient outcomes and achieve secondary prevention goals.

Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation

PURPOSE

Cardiac rehabilitation (CR) is evolving to include both in-person and virtual delivery. Our objective was to compare, in CR patients, the association of in-person, hybrid, and virtual CR with change in performance on the 6-min walk test (6MWT) between enrollment and completion.

METHODS

Patients enrolled in CR between October 22, 2019, and May 10, 2021, were categorized into in-person, hybrid, or virtual groups by number of in-person and virtual visits. All patients received individualized exercise training and health behavior counseling. Cardiac rehabilitation was delivered to patients in the hybrid and virtual cohorts using synchronous video exercise and/or asynchronous telephone visits. Measurements at CR enrollment and completion included the 6MWT, blood pressure (BP), depression, anxiety, waist-to-hip ratio, and cardiac self-efficacy.

RESULTS

Of 187 CR patients, 37/97 (38.1%) were in-person patients and 58/90 (64.4%) were hybrid/virtual patients ( P = .001). Compared to in-person (51.5 ± 59.4 m) improvement in the 6MWT was similar in hybrid (63.4 ± 55.6; P = .46) and virtual (63.2 ± 59.6; P = .55) compared with in-person (51.5 ± 59.4). Hybrid and virtual patients experienced similar improvements in BP control and anxiety. Virtual patients experienced less improvement in depression symptoms. There were no statistically significant changes in waist-to-hip ratio or cardiac self-efficacy. Qualitative themes included the adaptability of virtual CR, importance of relationships between patients and CR staff, and need for training and organizational adjustments to adopt virtual CR.

CONCLUSIONS

Hybrid and virtual CR were associated with similar improvements in functional capacity to in-person. Virtual and hybrid CR have the potential to expand availability without compromising outcomes.

Heart Failure in Cardiac Rehabilitation: A REVIEW AND PRACTICAL CONSIDERATIONS

PURPOSE

Exercise cardiac rehabilitation (CR) represents an evidence-based therapy for patients with heart failure with reduced ejection fraction (HFrEF) and this article provides a concise review of the relevant exercise testing and CR literature, including aspects unique to their care.

CLINICAL CONSIDERATIONS

A hallmark feature of HFrEF is exercise intolerance (eg, early-onset fatigue). Drug therapies for HFrEF target neurohormonal pathways to blunt negative remodeling of the cardiac architecture and restore favorable loading conditions. Guideline drug therapy includes β-adrenergic blocking agents; blockade of the renin-angiotensin system; aldosterone antagonism; sodium-glucose cotransport inhibition; and diuretics, as needed.

EXERCISE TESTING AND TRAINING

Various assessments are used to quantify exercise capacity in patients with HFrEF, including peak oxygen uptake measured during an exercise test and 6-min walk distance. The mechanisms responsible for the exercise intolerance include abnormalities in ( a ) central transport (chronotropic response, stroke volume) and ( b ) the diffusion/utilization of oxygen in skeletal muscles. Cardiac rehabilitation improves exercise capacity, intermediate physiologic measures (eg, endothelial function and sympathetic nervous system activity), health-related quality of life (HRQoL), and likely clinical outcomes. The prescription of exercise in patients with HFrEF is generally similar to that for other patients with cardiovascular disease; however, patients having undergone an advanced surgical therapy do present with features that require attention.

SUMMARY

Few patients with HFrEF enroll in CR and as such, many miss the derived benefits, including improved exercise capacity, a likely reduction in risk for subsequent clinical events (eg, rehospitalization), improved HRQoL, and adoption of disease management strategies.

Safety of home-based cardiac rehabilitation: A systematic review

BACKGROUND

Cardiac rehabilitation is an evidence-based intervention that aims to improve health outcomes in cardiovascular disease patients, but it is largely underutilized. One strategy for improving utilization is home-based cardiac rehabilitation (HBCR). Previous research has shown that HBCR programs are feasible and effective. However, there is a lack of evidence on safety issues in different cardiac populations. This systematic review aimed to provide an evidence-based overview of the safety of HBCR.

OBJECTIVES

To examine the incidence and severity of adverse events of HBCR.

METHODS

The following databases were searched: CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed, Web of Science, Global Health, and Chinese BioMedical Literature Database for randomized controlled trials. The included trials were written in English and analyzed the incidence of adverse events (AEs) as a primary or secondary intervention outcome.

RESULTS

Five studies showed AEs incidence, of which only one study reported severe AE associated with HBCR exercise. The incidence rate of severe AEs from the sample (n = 808) was estimated as 1 per 23,823 patient-hour of HBCR exercise. More than half patients included were stratified into a high-risk group. In the studies were found no deaths or hospitalizations related to HBCR exercise.

CONCLUSION

The risk of AEs during HBCR seems very low. Our results concerning the safety of HBCR should induce cardiac patients to be more active in their environment and practice physical exercise regularly.

Prevalence of US Adults With Cardiovascular Disease Reporting Barriers to Clinician Office Visits: IMPLICATIONS FOR ACCESSIBLE MODELS FOR CARDIAC REHABILITATION

PURPOSE

Despite known health benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), only a quarter of eligible patients attend. Among CR barriers are physical (eg, walking) and in-person attendance limitations. The purpose of this study was to determine the prevalence of difficulty walking and dependence on another person to attend medical appointments among people with and without CVD using national survey data.

METHODS

We compared the prevalence of difficulty walking and difficulty attending medical appointments alone among adults with and without CVD using national survey data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2015-2019. We used logistic regression and Rao-Scott χ2 analysis while controlling for several social determinants of health as covariates.

RESULTS

Of 2 212 973 respondents, 200 087 (9.04%) had CVD. The odds of individuals with CVD experiencing either difficulty walking or difficulty attending medical appointments alone were >3 times greater than the odds for individuals without CVD. In all adults with CVD, 42% reported difficulty walking and 20% reported dependence on another person to attend medical appointments. In all adults with CVD, 46% reported difficulty with one or both difficulties compared with 14% of adults without CVD.

CONCLUSIONS

We estimate that 11.9 million Americans with self-reported CVD have difficulty walking, or are dependent on another person to attend medical appointments, or both. Alternative models of CR that adapt to these limitations are needed to increase attendance of CR so that all adults with CVD can improve their health outcomes.

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

PURPOSE

This study systematically evaluated the quality and functionalities of patient-facing, commercially available mobile health (mHealth) apps for cardiac rehabilitation (CR).

METHODS

We performed our search in two of the most widely used commercial mobile app stores: Apple iTunes Appstore and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: "cardiac rehabilitation," "heart disease and remote therapy," "heart failure exercise," "heart therapy and cardiac recovery," "cardiac recovery," and "heart therapy." App quality was evaluated using the Mobile Application Rating Scale (MARS). App functionality was evaluated using the IQVIA functionality scale, and app content was evaluated against the American Heart Association guidelines for CR. Apps meeting our inclusion criteria were downloaded and evaluated by two to three reviewers, and interclass correlations between reviewers were calculated.

RESULTS

We reviewed 3121 apps and nine apps met our inclusion criteria. On average, the apps scored a 3.0 on the MARS (5-point Likert scale) for overall quality. The two top-ranking mHealth apps for CR for all three quality, functionality, and consistency with evidence-based guidelines were My Cardiac Coach and Love My Heart for Women, both of which scored ≥4.0 for behavior change.

CONCLUSION

Overall, the quality and functionality of free apps for mobile CR was high, with two apps performing the best across all three quality categories. High-quality CR apps are available that can expand access to CR for patients with cardiovascular disease.

Intensive Cardiac Rehabilitation Is Markedly Underutilized by Medicare Beneficiaries: RESULTS FROM A 2012-2016 NATIONAL SAMPLE

PURPOSE

Intensive cardiac rehabilitation (ICR) was developed to enhance traditional cardiac rehabilitation (CR) by adding sessions focused on nutrition, lifestyle behaviors, and stress management. Intensive CR has been Medicare-approved since 2010, yet little is known about national utilization rates of ICR in the Medicare population or characteristics associated with its use.

METHODS

A 5% sample of Medicare claims data from 2012 to 2016 was used to identify beneficiaries with a qualifying indication for ICR/CR and to quantify utilization of ICR or CR within 1 yr of the qualifying diagnosis.

RESULTS

From 2012 to 2015, there were 107 246 patients with a qualifying indication. Overall, only 0.1% of qualifying patients participated in ICR and 16.2% in CR from 2012 to 2016, though utilization rates of both ICR and CR increased during this period (ICR 0.06 to 0.17%, CR 14.3 to 18.2%). The number of ICR centers increased from 15 to 50 over the same period. There were no differences between ICR and CR enrollees with respect to age, sex, race, discharge location, median income, dual enrollment, or number of comorbidities. Compared with eligible beneficiaries who did not attend ICR or CR, those who attended either program were younger, more likely to be male and White, and had higher median income.

CONCLUSIONS

Although ICR and CR have a class 1 indication for the treatment of cardiovascular disease and the number of ICR centers has increased, ICR is not widely available and remains markedly underutilized. Continued research is needed to understand the barriers to program development and patient participation.

A Social-Ecological Perspective of the Perceived Barriers and Facilitators to Virtual Education in Cardiac Rehabilitation: A MIXED-METHODS APPROACH

PURPOSE

This study explored the perceived barriers and facilitators to participation in patients who did and did not attend virtual cardiac rehabilitation (CR) education sessions.

METHODS

A mixed-methods approach was used. Virtual patient education was delivered during the coronavirus-19 pandemic. Phase 1 included a cross-sectional online survey completed by individuals who did and did not participate in these sessions. For phase 2, six virtual focus group sessions were conducted using the social-ecological framework to guide thematic analysis and interpretation of findings.

RESULTS

Overall, 106 online surveys were completed; 60 (57%) attended Cardiac College Learn Online (CCLO) sessions only, one (1%) Women with Heart Online (WwHO) only, 21 (20%) attended both, and 24 (22%) did not attend virtual sessions. Half of the participants who attended virtual sessions viewed between one and four sessions. Most participants were from Canada (95%) and included the Toronto Rehabilitation Institute/Toronto Western Hospital centers (76%). Focus group findings revealed six overarching themes: Intrapersonal (mixed emotions/feelings; personal learning preferences); Interpersonal (desire for warmth of human contact and interaction); Institutional (the importance of external endorsement of sessions); and Environmental (technology; perceived facilitators and barriers).

CONCLUSION

These findings highlight the unprecedented situation that patients and CR programs are facing during the pandemic. Virtual patient education may be more accessible, convenient, and responsive to the complex needs of these CR participants.

Evaluation of Maintained PhysicAl CaPacity 1-yr After Coronary Patient Cardiac Rehabilitation (EMAP): A FRENCH MULTICENTER STUDY

PURPOSE

Data are scarce concerning the sustainable effects of cardiac rehabilitation (CR), on cardiorespiratory fitness (CRF) of patients with coronary artery disease (CAD). This study, carried out using data from a French multicenter study, aimed to clarify the evolution of the CRF of patients with CAD 1 yr after the end of a CR stay.

METHODS

Patients were included after an acute coronary syndrome (77%) and/or coronary revascularization, occurring <3 mo beforehand. All underwent a CR program with CRF evaluation by exercise testing (ET) on a cycle ergometer at the beginning of CR (ET1), at its end (ET2), and 1 yr later (ET3)-all ETs were performed with medication.

RESULTS

Two hundred fifty-nine patients were included (age 60 ± 10 yr, 89% male) in 16 French CR centers. Left ventricular ejection fraction was 55.3 ± 9%. Revascularization was complete (82%). Maximal workloads were 110 ± 37 (ET1), 139 ± 43 (ET2), and 144 ± 46 W (ET3) (P< .001). The estimated metabolic equivalents of the task (METs) were respectively 5.3 ± 1.4, 6.4 ± 1.6 (P< .001), and 6.6 ± 1.7 (P< .002). One year later, 163 patients (63%) improved or maintained their CRF (ET3 ≥ ET2), 73 (28%) decreased (ET1 < ET3 < ET2), and 23 (9%) lost the benefit of CR (ET3 ≤ ET1).

CONCLUSION

Among completers who agreed to enroll in this study, most patients with CAD seem to maintain their CRF 1 yr after CR.

The Impact of and Barriers to Cardiac Rehabilitation Following Cardiac Surgery in the Adult With Congenital Heart Disease

INTRODUCTION

There is a paucity of literature evaluating the impact of and barriers to participation in cardiac rehabilitation (CR) in the adult congenital heart disease population. The aims of this study were to evaluate the impact of CR on physical activity and health-related quality of life, as well as to evaluate the barriers to participation in CR in a post-operative adult congenital heart disease population.

METHODS

Patients ≥18 yr of age seen in the Wisconsin Adult Congenital Heart Disease Program and post-open sternotomy surgery from 2010-2015 were eligible for inclusion. Subjects were mailed a novel physical activity survey and the validated EuroQOL-5D 3L health questionnaire. A retrospective medical record review was performed to extract demographic and clinical data.

RESULTS

One hundred thirty-five patients underwent open sternotomy surgery from 2010-2015. Of these, 22 were excluded because of intellectual disability, three opted out, and three survey packets were returned to the sender. A total of 54 of the remaining 107 patients returned completed surveys. Of these, 47 (87%) were referred to CR. Thirty-five patients completed the entire CR program (74%). Those who completed CR were more likely to develop a home/independent exercise program (P = .027). Barriers to completing CR included insurance coverage, psychiatric disease, and a perception that CR would not be of benefit.

CONCLUSION

Completing CR was associated with developing a home/independent exercise program in post-sternotomy adult patients with congenital heart disease. Barriers to participating in and completing CR in this population could lead to an improved completion rate if modified.

A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE

PURPOSE

This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR.

REVIEW METHODS

To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations.

SUMMARY

A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.

Enhancing participation in cardiac rehabilitation: Focus on underserved populations

Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.

Enrollment and Adherence to Early Outpatient and Maintenance Cardiac Rehabilitation Programs

Early outpatient (ECR) and maintenance cardiac rehabilitation (MCR) programs are essential, evidence-based services that have received unequivocal endorsement by national and international professional organizations. However, the latest data characterizing ECR enrollment and adherence fell well short of what would be expected for a therapy that has accumulated decades of empirical evidence touting the associated physiologic, physical, psychosocial, and financial benefits. Although national participation levels have remained stagnant, a series of recent publications showcase effective strategies that could bolster both ECR enrollment and adherence levels at the institutional level. Unlike ECR, fewer reports on enrollment and adherence rates exist for MCR, partly due to the lack of standardization of this service. In this review, we aim to highlight current data on enrollment and adherence to ECR and MCR and discuss evidence-based programmatic strategies to support utilization of both services.

Cognition and Exercise: GENERAL OVERVIEW AND IMPLICATIONS FOR CARDIAC REHABILITATION

Performance of endurance exercise is associated with a broad range of cognitive benefits, with notable improvements shown across a wide variety of populations including healthy populations as well as those with impaired cognition. By examining the effects of exercise in general populations, as well in populations where cognitive deficits are pronounced, and critical to self-care, we can learn more about using exercise to ameliorate cognitive issues and apply that knowledge to other patient populations, such as those eligible for cardiac rehabilitation (CR). Cognitive challenges are a concern within CR, as management of a chronic disease is cognitively taxing, and, as expected, deficits in cognition predict worse outcomes, including lower attendance at CR. Some subsets of patients within CR may be particularly at high risk for cognitive challenges including those with heart failure with low ejection fraction, recent coronary bypass surgery, multiple chronic conditions, and patients of lower socioeconomic status. Attendance at CR is associated with cognitive gains, likely through the progressive exercise component, with larger amounts of exercise over longer periods having greater benefits. Programs should identify at-risk patients, who could gain the most from completing CR, and provide additional support to keep those patients engaged. While engaged in CR, patients should be encouraged to exercise, at least at moderate intensity, and transitioned to a long-term exercise regimen. Overall, CR programs are well-positioned to support these patients and make significant contributions to their long-term well-being.

Asynchronous and Synchronous Delivery Models for Home-Based Cardiac Rehabilitation: A SCIENTIFIC REVIEW

PURPOSE

To review the principles, advantages, and disadvantages of asynchronous and synchronous delivery models of home-based cardiac rehabilitation (HBCR).

METHODS

We reviewed recently published systematic reviews and other publications of randomized studies of asynchronous and synchronous HBCR to assess principles, outcomes, and limitations of those delivery methods compared with center-based cardiac rehabilitation (CBCR).

SUMMARY

While most studies prior to 2016 involved asynchronous HBCR approaches to care, studies since 2016 have included asynchronous or synchronous delivery models. Both delivery models have been shown to help provide core components of cardiac rehabilitation (CR). Studies using either method have been shown to have similar short-term patient outcomes as CBCR, at least in low- to moderate-risk patients who have been studied. Asynchronous HBCR offers greater flexibility for patients and CR staff, while synchronous HBCR provides greater real-time oversight and feedback to patients.Asynchronous and synchronous HBCR is an option to consider for patients eligible for CR. Additional research is needed for both delivery models, applied separately or in combination, to compare their impact on shorter- and longer-term patient outcomes and to assess their impact in patient subgroups (referral diagnosis, women, elderly, underrepresented racial and ethnic minority groups, patients at a higher cardiovascular disease risk, patients with multiple comorbid conditions, etc).

A Review of Disparities in Cardiac Rehabilitation: EVIDENCE, DRIVERS, AND SOLUTIONS

PURPOSE

Cardiac rehabilitation (CR) has been shown to improve functional status, quality of life, and recurrent cardiovascular disease (CVD) events. Despite its demonstrated compelling benefits and guideline recommendation, CR is underutilized, and there are significant disparities in CR utilization particularly by race, ethnicity, sex, and socioeconomic status. The purpose of this review is to summarize the evidence and drivers of these disparities and recommend potential solutions.

METHODS

In this review, key studies documenting disparities in CR referrals, enrollment, and completion are discussed. Additionally, potential mechanisms for these disparities are summarized and strategies are reviewed for addressing them.

SUMMARY

There is a wealth of literature demonstrating disparities among racial and ethnic minorities, women, those with lower income and education attainment, and those living in rural and dense urban areas. However, there was minimal focus on how the social determinants of health contribute to the observed disparities in CR utilization in many of the studies reviewed. Interventions such as automatic referrals, inpatient liaisons, mitigation of economic barriers, novel delivery mechanisms, community partnerships, and health equity metrics to incentivize health care organizations to reduce care disparities are potential solutions.

Nutrition Intervention in Cardiac Rehabilitation: A REVIEW OF THE LITERATURE AND STRATEGIES FOR THE FUTURE

OBJECTIVE

Despite guideline consensus that quality of nutrition affects most modifiable cardiovascular disease risk factors, the implementation of dietary interventions varies considerably in cardiac rehabilitation (CR) programs. The purpose of this review is to highlight the current existing literature and provide recommendations on best practices for nutrition interventions and future research that support secondary prevention outcomes.

REVIEW METHODS

The review examines original investigations, systematic reviews, and guidelines regarding nutrition intervention in CR.

SUMMARY

Nutrition intervention in CR plays an integral role in the success of patients; however, the literature is limited and standardization of practice is in its infancy. The role of a qualified registered dietician nutritionist, standardization of dietary assessments, individualized and intensive nutrition interventions, and application of specific behavior change techniques are central components in improving diet in CR. This review provides an overview of the evidence-based cardioprotective diets, nutritional interventions and behavioral strategies in CR, and explores areas for best practices and opportunities for innovation in the delivery of nutrition intervention in CR.

Current Status of Cardiac Rehabilitation in the Regional Cardiocerebrovascular Centers in Korea

Regional Cardiocerebrovascular Centers (RCCs)—a Korean government initiative—seek to reduce medical gaps across regions, and their cardiac rehabilitation (CR) programs are expected to model post-acute care for the Korean CR program. Accordingly, this study aimed to evaluate the current status of CR programs in the RCCs. We distributed surveys on the CR condition, activity, and barriers to 12 RCCs in different provinces. The results revealed significant gaps in the annual number of acute myocardial infarction admissions, and CR candidates, capacity, and density across the 12 RCCs. The CR capacity (50–500) and density (0.42–7.36) indicated particularly large gaps. Twelve RCCs had the necessary facilities, equipment and personnel for CR assessments and management, with high CR referral (97%) and patient education (78%) rates. However, the inpatient CR exercise training (56%) participation rate was inadequate, with much lower enrollment (47%) and adherence (17%) rates to the outpatient CR program and large differences across centers. Therefore, this study’s results will provide the evidence required to establish special national health strategies to overcome the CR barriers of patient, doctor/hospital, and policy factors for activating Korean CR programs.

Chinese Home-Based Cardiac Rehabilitation Model Delivered by Smartphone Interaction Improves Clinical Outcomes in Patients With Coronary Heart Disease

Purpose: We evaluated the long-term effect of a smartphone-facilitated home-based cardiac rehabilitation (HBCR) model in revascularized patients with coronary heart disease (CHD) on major adverse cardiac events (MACE), and secondary outcomes, including safety, quality of life, and physical capacity. Methods: It was a prospective observational cohort study including a total of 335 CHD patients after successful percutaneous coronary intervention (PCI) referred to the CR clinic in China between July 23, 2015 and March 1, 2018. Patients were assigned to two groups: HBCR tailored by monitoring and telecommunication via smartphone app (WeChat) (HBCR group, n = 170) or usual care (control group, n = 165), with follow-up for up to 42 months. Propensity score matching was conducted to match patients in the HBCR group with those in the control group. The patients in the HBCR group received educational materials weekly and individualized exercise prescription monthly, and the control group only received 20-min education at baseline in the CR clinic. The primary outcome was MACE, analyzed by Cox regression models. The changes in the secondary outcomes were analyzed by paired t-test among the matched cohort. Results: One hundred thirty-five HBCR patients were matched with the same number of control patients. Compared to the control group, the HBCR group had a much lower incidence of MACE (1.5 vs. 8.9%, p = 0.002), with adjusted HR = 0.21, 95% CI 0.07-0.85, and also had reduced unscheduled readmission (9.7 vs. 23.0%, p = 0.002), improved exercise capacity [maximal METs (6.2 vs. 5.1, p = 0.002)], higher Seattle Angina Questionnaire score, and better control of risk factors. Conclusions: The Chinese HBCR model using smartphone interaction is a safe and effective approach to decrease cardiovascular risks of patients with CHD and improve patients' wellness. Clinical Trial Registration: http://www.chictr.org.cn, identifier: ChiCTR1800015042.

Cognitive decrement in older adults with symptomatic peripheral artery disease

Peripheral artery disease (PAD) is highly prevalent, affecting up to 20% of people over 70 years of age. To test the hypothesis that PAD promotes the pathogenesis of vascular cognitive impairment (VCI), we compared cognitive function in older adults with symptomatic PAD and in participants without PAD who had a burden of comorbid conditions. Furthermore, we compared the cognitive function of these groups after adjusting for demographic and clinical characteristics, comorbid conditions, and cardiovascular risk factors. Participants with PAD (age: 69 ± 8 years; n = 58) and those without PAD (age: 62 ± 8 years; n = 30) were assessed on a battery of eight neuropsychological tests. The tests assessed attention and working memory, verbal memory, non-verbal memory, perceptuo-motor speed, and executive function. Participants were further characterized on demographic and clinical characteristics, comorbid conditions, cardiovascular risk factors, and ankle-brachial index. The PAD group had significantly lower neuropsychological scores than the non-PAD control group on all eight tests (P < .01). After adjusting for covariates, significantly worse scores in the PAD group persisted for verbal memory, measured by tests on logical memory-immediate recall (P = .022), and logical memory-delayed recall (P < .001), and for attention and working memory, measured by tests on digits forward (P < .001), and digits backward (P = .003). Participants with symptomatic PAD have substantially lower levels of performance on tests of attention, working memory, and verbal memory than participants without PAD independent of demographic characteristics and comorbid health burdens. These findings provide additional evidence in support of the concept that generalized accelerated vascular aging manifesting as symptomatic PAD in the peripheral circulation also affects the brain promoting the pathogenesis of VCI. These cognitive difficulties may also negatively impact symptomatic patient's ability to understand and adhere to behavioral and medical therapies, creating a vicious cycle. We speculate that more intensive follow-up may be needed to promote adherence to therapies and monitor cognitive decline that may affect care.

Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis

OBJECTIVES

The objectives of this review were to identify different technology-assisted interventions in cardiac rehabilitation, to explore and examine the effectiveness of technology-assisted cardiac rehabilitation.

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search was performed on six electronic databases: CINALH Complete, Cochrane Library, PubMed, MEDLINE via OvidSP, British Nursing Index and PsycINFO to identify randomised controlled trials from 2010 to 2020. Selection of studies was performed by screening the titles, abstracts and full texts, and two reviewers independently and critically appraised the included studies using the revised Cochrane risk of bias tool for randomized trials (RoB 2).

RESULTS

Nine randomised controlled trials met the inclusion criteria; five studies with some bias concerns related to allocation concealment (n = 2) and measurement of outcome (n = 4), and four studies were of low risk of bias. The pooled effect size showed comparable effectiveness between technology-assisted cardiac rehabilitation and conventional/centre-based cardiac rehabilitation on modifiable coronary risk factors (systolic and diastolic blood pressure, total cholesterol, p>0.05), psychological outcomes (anxiety: SMD 0.25, 95% CI -0.11 to 0.62, p = 0.17 and depression: SMD 0.09, 95% CI -0.16 to 0.35, p = 0.47). Narrative synthesis was performed for adherence to prescribed exercise sessions in cardiac rehabilitation. No significant adverse events occurred. The adverse events that did occur were self-reported, mostly unrelated to the interventions with technology and the number of events was comparable between both groups. Inconsistent results were found across the studies. This review revealed lack of self-efficacy and behaviour change theories/strategies, and educational emphasis among studies.

CONCLUSIONS

The results in the meta-analysis have indicated that technology-assisted cardiac rehabilitation demonstrated comparable results to conventional/centre-based cardiac rehabilitation. Technology-assisted cardiac rehabilitation is a potential alternative not only to remove cardiac rehabilitation barriers but also in the midst of current prolonged pandemic. Future studies on technology-assisted cardiac rehabilitation with the emphasis behavior change theories/strategies and education are required.

Is the Training Intensity in Phase Two Cardiovascular Rehabilitation Different in Telehealth versus Outpatient Rehabilitation?

Telehealth cardiac rehabilitation (CR) is a feasible and effective alternative to conventional outpatient CR. Present evidence is limited on the comparison of exercise intensity adherence in telehealth and outpatient CR. The purpose of the study was to evaluate and compare training intensity adherence through 12-week phase II CR in telehealth and outpatient CR. A sample of 56 patients with coronary artery disease (CAD) with a mean age of 56.7 ± 7.1 entering comprehensive secondary prevention phase II was randomized into telehealth CR (n = 28) and control outpatient CR (n = 28) groups. The primary outcome was a comparison of training intensity adherence in both CR models and heart rate (HR) response from individual CR sessions, expressed by the HR reserve percentage. As a result, the parameter HR reserve percentage as the total average of the training intensity during the telehealth intervention and the outpatient CR did not differ statistically (p = 0.63). There was no death case, and all severe adverse cases required medical admission throughout an exercise training session in study subjects in both groups. This research evidence demonstrated that the telehealth CR model is similar in training intensities to the conventional outpatient CR in CAD patients with low to moderate cardiovascular risk.

Area Deprivation Index and Cardiovascular Events: CAN CARDIAC REHABILITATION MITIGATE THE EFFECTS?

INTRODUCTION

Neighborhood socioeconomic status is associated with health outcomes. Cardiac rehabilitation (CR) provides a cost-effective, multidisciplinary approach to improve outcomes in cardiovascular disease. We aimed to evaluate the association of the Area Deprivation Index (ADI), a marker of neighborhood social composition, with risk of recurrent cardiovascular outcomes and assessed the modifying effect of CR.

METHODS

We identified patients with a primary diagnosis of (1) myocardial infarction or (2) incident heart failure (HF) admitted to a large-sized regional health center during 2010-2018. We derived the ADI from home addresses and categorized it into quartiles (higher quartiles indicating increased deprivation). We obtained number of CR visits and covariates from the health record. We compared rehospitalization (cardiovascular, acute coronary syndrome [ACS], and HF) and mortality rates across ADI quartiles.

RESULTS

We included 6957 patients (age 69.2 ± 13.4 yr, 38% women, 89% White race). After covariate adjustment, the ADI was significantly associated with higher incidence rates (IRs)/100 person-yr of cardiovascular rehospitalization (quartile 1, IR 34.6 [95% CI, 31.2-38.2]; quartile 4, 41.5 [95% CI, 39.1-44.1], P < .001). In addition, the ADI was significantly associated with higher rates of rehospitalization for HF (P < .001), ACS (P < .012), and all-cause mortality (P < .04). These differences in rehospitalization and mortality rates by the ADI were no longer significant in those who attended CR.

CONCLUSIONS

We found the increased ADI was adversely associated with rehospitalizations and mortality. However, in individuals with CR, outcomes were significantly improved compared with those with no CR. Our findings suggest that CR participation has the potential to improve outcomes in disadvantaged neighborhoods.