Cardiac Rehabilitation: A Contemporary Review

Understanding attendance patterns and determinants in cardiac, pulmonary, and ICU rehabilitation/recovery programs: A systematic review and meta-analysis

BACKGROUND

Cardiac, pulmonary, and intensive care unit (ICU) rehabilitation/recovery programs are health promotion interventions designed to improve physical recovery, psychological well-being, and quality of life after acute illness while reducing the risk of adverse events.

OBJECTIVE

Identify the difference in attendance rates for patients invited to a cardiac rehabilitation, pulmonary rehabilitation, or ICU recovery program and factors influencing attendance.

METHODS

We conducted a systematic review and meta-analysis by searching PubMed, EMBASE, CINAHL, Web of Science, and manual reference lists from inception to June 3, 2024. We included studies reporting patient attendance rates in eligible programs following acute illness hospitalization. Two team members independently screened articles and extracted data, with a third member reviewing and achieving consensus when necessary. Our main outcomes focused on the proportion of attendance in eligible programs among patients referred.

RESULTS

Of 3,446 studies screened, 179 studies (N = 4,779,012 patients) were included across cardiac rehabilitation (n = 153 studies), pulmonary rehabilitation (n = 11 studies), and ICU recovery (n = 15 studies) programs. Pooled attendance rates were 53 % (95 % CI: 48-57 %) for cardiac rehabilitation, 56 % (95 % CI: 42-70 %) for pulmonary rehabilitation, and 61 % (95 % CI: 51-70 %) for ICU recovery programs. Significant attendance heterogeneity was present (cardiac I2=100 %, p < 0.001; pulmonary I2=100 %, p < 0.001; ICU I2=94 %, p < 0.01). Barriers to attendance included transportation, distance, work conflicts, and patient factors (e.g., comorbidities, older age). Facilitators included male gender, younger age, higher education, income, provider recommendations, and flexible scheduling. Individual factors represented the primary domain affecting attendance.

CONCLUSIONS

The results indicate comparable attendance rates and factors shaping attendance across acute illness rehabilitation/recovery programs, with ICU recovery programs being the most well-attended on average.

REGISTRATION

PROSPERO CRD42022357261.

Adherence to Cardiac Rehabilitation in Patients with Acute Myocardial Infarction After PCI: A Scoping Review

Purpose

Cardiac rehabilitation (CR) is a multidisciplinary intervention program aimed at enhancing the physical, psychological, and social functioning of patients with cardiovascular disease. Although CR is cost-effective and reduces mortality and readmission rates, and many patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) do not adhere to CR. This review aimed to synthesize the evidence on adherence to CR in patients with AMI after PCI (AMI-PCI).

Patients and Methods

The review was conducted using the methodology proposed by the Joanna Briggs Institute (JBI) to guide reviews and reporting using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extended for Scoping Reviews (PRISMA-ScR). We searched PubMed, Web of Science, CINAHL, Embase, Ovid, and Scopus databases, and two reviewers independently screened the abstracts and full texts of eligible studies against the inclusion and exclusion criteria. Disagreements were resolved in consultation with a third reviewer.

Results

A total of 10 studies were included in the analysis. The results demonstrated that CR reduces the incidence of complications and improves the quality of life of patients with AMI-PCI. However, the CR adherence rate was low, and the factors affecting it are complex and varied, including age, sex, and employment status. Furthermore, interventions to improve adherence in patients with AMI-PCI mainly combined the internet-based interventions, including videoconferencing tele-training, with wearable device monitoring and intelligent management platform follow-up. All these interventions have shown promising results compared with routine care.

Conclusion

Adherence to CR in patients with AMI-PCI is generally low, and CR adherence is affected by many factors; however, relevant research designs are rare and simple. Healthcare professionals should pay more attention to adherence to CR in this population and use a variety of interventions to improve it.

Safety and Feasibility of Tele-Cardiac Rehabilitation Using Remote Biological Signal Monitoring System: A Pilot Study

Background

Cardiac rehabilitation (CR) is categorized as a class I recommendation in the guidelines for the management of patients with cardiovascular disease (CVD). However, the penetration rate of outpatient CR is low in Japan. We designed a pilot study to evaluate the safety and feasibility of tele-CR using a remote biological signal monitoring system.

Methods

A total of nine patients (median aged 70.0 (66.0 - 76.0) years (male = 6) with CVD who participated in phase II CR for 1 month under the exercise prescription using the cardiopulmonary exercise test (CPET) were analyzed. They participated in the tele-CR program with a remote biological signal monitoring system (Nipro HeartLineTM, Osaka, Japan, and Duranta, Miyagi, Japan) in the CR room and were instructed by the CR staff from a separate room in the hospital. We evaluated the occurrence and degree of remote biological signal monitoring defects as safety evaluation items, i.e., whether the patients could set the remote biological signal monitoring equipment, as a feasibility evaluation item during a 3-month period. We also performed CPET at the baseline and follow-up. Following the 3-month tele-CR program, a total of 122 remote CR programs were performed using the remote biological signal monitoring system.

Results

No patient experienced a lack of remote biological signal monitoring during exercise therapy. Significant improvement was noted in the exercise capacity, as assessed using the cardiopulmonary test (from 19.5 (16.7 - 20.2) mL/kg/min to 21.1 (17.3 - 22.8) mL/kg/min, P = 0.01, age ratio from 86% (75-96%) to 99% (78-104%), P = 0.01). One patient required support using the remote biological signal monitoring system, including information technology literacy.

Conclusions

This study suggests the safety and feasibility of tele-CR using the remote biological signal monitoring system. However, further investigations are required to explore the suitability, effects, and cost-effectiveness of tele-CR as an alternative to center-based CR in the future.

Finding benefits in a cardiac event: Direct links with positive affect and healthy dietary behaviors during cardiac rehabilitation

Benefit finding (BF) may be a coping strategy that positively influences outcomes after a stressful event, but previous studies provide an inconsistent pattern of results across several different patient populations. This study aimed to reconcile these inconsistencies by testing whether positive affect related to a cardiac event (PA) mediates the relationship between BF and healthy dietary behaviors, and whether this mediating relationship is stronger for participants high in disease severity. Participants were patients with cardiovascular disease in a cardiac rehabilitation program. Results supported partial mediation, but the interaction was not as predicted: participants low in disease severity showed a stronger relationship between BF and PA than their counterparts high in disease severity. Additionally, the PA/healthy dietary behaviors relationship was negative. Health providers may encourage patients in CR to engage in BF, but also to make thoughtful food decisions when in a positive mood, especially for patients low in disease severity.

Effects of Phase II Comprehensive Cardiac Rehabilitation on Risk Factor Modification and Exercise Capacity in Patients With Acute Coronary Syndrome ― Results From the JACR Registry ―

Background: Cardiac rehabilitation (CR) is categorized as a Class I recommendation in guidelines for the management of patients with acute coronary syndrome (ACS); however, nationwide studies on CR in patients with ACS remain limited in Japan.

Methods and Results: The Japanese Association of Cardiac Rehabilitation (JACR) Registry is a nationwide, real-world database for patients participating in CR. From the JACR Registry database, we analyzed 924 patients participating in Phase II CR in 7 hospitals between September 2014 and December 2016. The mean age of patients was 65.9±12.0 years, and 80% were male. The prevalence of ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina pectoris (UAP) was 58%, 9%, and 33%, respectively. The prevalence of hypertension, diabetes, dyslipidemia, current smoking, and a family history was 55%, 27%, 67%, 21%, and 10%, respectively. Among the entire CR cohort at baseline, 96%, 78%, and 92% were treated with aspirin, β-blockers, and statins, respectively. After CR, the values of body mass index, the lipid profile, and exercise capacity significantly improved in the STEMI, NSTEMI and UAP groups.

Conclusions: In the JACR Registry, a high rate of guideline-recommended medications at baseline and improvements in both coronary risk factors and exercise capacity after CR were observed in patients with ACS.

The effect of a self-help psychoeducation programme for people with coronary heart disease: A randomized controlled trial

AIM

To examine the effect of a self-help psychoeducation program for people with coronary heart disease in Singapore.

BACKGROUND

Cardiac rehabilitation has shown benefits for mitigating many cardiac risk factors and can lead to improvement in health-related quality of life and psychological well-being in people with heart disease. However, traditional hospital-based cardiac rehabilitation faces substantial challenges. A self-management cardiac rehabilitation program offers an avenue to increase uptake and empowers patients to manage their condition at home.

DESIGN

A two-arm, randomized controlled trial.

METHODS

A total of 129 patients with coronary heart disease were recruited from an outpatient clinic in a public hospital in Singapore from April 2015-January 2016. They were randomly assigned to the intervention group or the control group. Participants in the intervention group received the 4-week home-based self-help psychoeducation program. Outcomes were measured at baseline and at 4 weeks and 16 weeks from the baseline.

RESULTS

There were no significant differences in health-related quality of life, psychological status (i.e., perceived stress level, anxiety, and depression levels), or cardiac physiological risk parameters between the intervention and the control groups immediately after the program or at different time points. There was also no significant difference in unplanned health service use at the 16 week posttest point between the two groups.

CONCLUSIONS

This study did not find any significant effect of our program on outpatients with coronary heart disease. Nonetheless, findings on participant characteristics may offer healthcare professionals valuable insights to help facilitate future development of an effective cardiac rehabilitation program catered to outpatients with coronary heart disease.

TRIAL REGISTRATION

The study has been registered with ISRCTN registry. The trial registration number is ISRCTN15839687.

Cardiac rehabilitation for patients having cardiac surgery: a systematic review

INTRODUCTION

Cardiac rehabilitation (CR) is recommended for all cardiac patients including patients after cardiac surgery. Since the effect of CR after cardiac surgery has not been well established yet, we conducted a systematic review on the effects of CR for patients after cardiac surgery compared to treatment as usual.

EVIDENCE ACQUISITION

A systematic review of randomized clinical trials (RCTs), quasi-randomized and prospective observational studies in The Cochrane Library, PubMed/MEDLINE and EMBASE was undertaken until October 18th, 2017. Adults after any kind of cardiac surgery were included. Primary outcome was all-cause mortality, other outcomes were serious adverse events, health-related quality of life, work participation, functioning and costs/cost-effectiveness. Risk of bias was evaluated, and the quality of evidence was assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria.

EVIDENCE SYNTHESIS

Eighteen RCTs and 15 observational studies were included. Low risk of bias was only observed in one observational study. Meta-analysis of RCTs suggested no significant difference of CR compared to control on mortality (random-effects relative risk (RR) 0.93 (95% CI: 0.40-1.81), while observational studies suggested statistically significant beneficial effect associated with CR (random-effects RR=0.49, 95% CI: 0.35 - 0.68). CR did not significantly affect any of the other outcomes. Due to the limited data TSA could not be performed.

CONCLUSIONS

The body of evidence does not allow us to reach any reliable conclusions about the effectiveness of CR following cardiac surgery. Future trials need to be conducted with low risks of bias and clearly defined outcomes.

Cardiac rehabilitation after percutaneous coronary intervention: Results from a nationwide survey

Aim:

The purpose of this study was to estimate the proportion of Norwegian coronary heart disease patients participating in cardiac rehabilitation programmes after percutaneous coronary intervention, and to determine predictors of cardiac rehabilitation participation.

Methods:

Participants were patients enrolled in the Norwegian Coronary Stent Trial. We assessed cardiac rehabilitation participation in 9013 of these patients who had undergone their first percutaneous coronary intervention during 2008–2011. Of these, 7068 patients (82%) completed a self-administered questionnaire on cardiac rehabilitation participation within three years after their percutaneous coronary intervention.

Results:

Twenty-eight per cent of the participants reported engaging in cardiac rehabilitation. Participation rate differed among the four regional health authorities in Norway, varying from 20%–31%. Patients undergoing percutaneous coronary intervention for an acute coronary syndrome were more likely to participate in cardiac rehabilitation than patients with stable angina (odds ratio 3.2; 95% confidence interval 2.74–3.76). A multivariate statistical model revealed that men had a 28% lower probability ( p<0.001) of participating in cardiac rehabilitation, and the odds of attending cardiac rehabilitation decreased with increasing age ( p<0.001). Contributors to higher odds of cardiac rehabilitation participation were educational level >12 years (odds ratio 1.50; 95% confidence interval 1.32–1.71) and body mass index>25 (odds ratio 1.19; 95% confidence interval 1.05–1.36). Prior coronary artery bypass graft was associated with lower odds of cardiac rehabilitation participation (odds ratio 0.47; 95% confidence interval 0.32–0.70)

Conclusion:

The estimated cardiac rehabilitation participation rate among patients undergoing first-time percutaneous coronary intervention is low in Norway. The typical participant is young, overweight, well-educated, and had an acute coronary event. These results varied by geographical region.

Health-Related Quality of Life Improves Similarly in Patients With and Without Type 2 Diabetes After Cardiac Rehabilitation

PURPOSE

Cardiovascular disease is the leading cause of death in the United States and results in substantial healthcare expenditures. Health-related quality of life (HRQoL) is an important aspect in long-term recovery for patients with cardiovascular disease. As such, improvement in HRQoL is a relevant outcome for determining cardiovascular rehabilitation (CR) program efficacy. Increasingly, diabetic patients are participating in CR and face additional challenges to HRQoL, yet there is a lack of research addressing program efficacy in this population. This study tested the hypothesis that CR would effect a favorable change in HRQoL for both diabetic (D; n = 37) and nondiabetic (N-D; n = 58) patients. Furthermore, we tested the hypothesis that the D group would demonstrate a greater overall change compared with the N-D group.

METHODS

In this retrospective study, we reviewed the charts of 95 patients who completed a CR program and collected HRQoL measures using the COOP questionnaire, where lower scores indicate higher HRQoL.

RESULTS

After CR, COOP scores for both the N-D improved (pre: 20.39 ± 0.79 vs post: 16.06 ± 0.75; P < .05) and D (pre: 20.92 ± 0.88 vs post: 15.84 ± 0.80; P < .05). HRQoL was not different between groups at the start of the program (P = .88) or at the end (P = .58), and thus, the improvement in HRQoL was not different between groups (P = .44).

CONCLUSIONS

These results suggest that D and N-D patients do not differ in their HRQoL at the start or end of CR, and that the 2 groups show similar improvements from attending the program. Larger sample studies are needed to confirm these findings.

Shortened questionnaires to assess anxiety and depression during in-hospital rehabilitation: clinical validation and cutoff scores

BACKGROUND

A postacute phase needs reliable routine screening instruments in order to identify the patients to be referred for a clinical interview with a psychologist. The aim of this study was to estimate the clinical cutoff scores of the anxiety and depression questionnaires and their clinical validity using a gold standard.

METHODS

The study involved 177 patients with pulmonary, cardiac, or neurological disease undergoing in-hospital rehabilitation. Receiver operating characteristic curves were used to determine the best concordance between questionnaire's scores and the gold standards.

RESULTS

There was a significant difference (P<0.001) between clinically anxious and depressed patients and nonclinical subjects. The receiver operating characteristic curve for anxiety indicated that the best area under the curve for State Anxiety Inventory is obtained with a cutoff point of 21 for males and 25 for females; for depression scores, the highest area under the curve for Depression Questionnaire-Reduced Form is obtained with a cutoff point of six for males and eight for females.

CONCLUSION

Using appropriate cutoff values, the State Anxiety Inventory and Depression Questionnaire-Reduced Form allow psychologists to optimize early clinical intervention strategies selecting patients with significant needs.

Exercise-induced ischemic preconditioning and the potential application to cardiac rehabilitation: a systematic review

Exercise-induced ischemic preconditioning (IPC) can be assessed by the results of the second of sequential exercise tests. Exercise-induced IPC is quantified by using the time to 1-mm ST-segment depression, the rate-pressure product at 1-mm ST-segment depression, the maximal ST-segment depression, and the rate-pressure product at the peak of exercise. Few studies reported whether exercise-induced IPC could be used in cardiovascular rehabilitation. A systematic review of the literature limited to human studies was performed using electronic databases, and the main key words were ischemic preconditioning, warm-up phenomenon, and exercise. After careful review, 38 articles were included in the systematic review. This review summarizes the molecular pathways of IPC and describes the first window of protection induced by sequential exercise tests, as well as the effect of medication on exercise-induced IPC. A section on the exercise protocol, mode of exercise, and intensity provides understanding as to what is needed for clinicians to induce IPC with sequential stress tests. The final section of the review is a discussion of the potential use of exercise-induced IPC in a cardiovascular rehabilitation setting. Even if exercise-induced IPC is a well-documented phenomenon, additional studies are needed in order to more fully understand its use in rehabilitation.

Effectiveness of motivational interviewing on lifestyle modification and health outcomes of clients at risk or diagnosed with cardiovascular diseases: A systematic review

BACKGROUND AND OBJECTIVE

Clinically, there is an increasing trend in using motivational interviewing as a counseling method to help clients with cardiovascular diseases to modify their unhealthy lifestyle in order to decrease the risk of disease occurrence. As motivational interviewing has gained increased attention, research has been conducted to examine its effectiveness. This review attempts to identify the best available evidence related to the effectiveness of motivational interviewing on lifestyle modification, physiological and psychological outcomes for clients at risk of developing or with established cardiovascular diseases.

DESIGN

Systematic review of studies incorporating motivational interviewing in modifying lifestyles, improving physiological and psychological outcomes for clients at risk of or diagnosed with cardiovascular diseases.

DATA SOURCES

Major English and Chinese electronic databases were searched to identify citations that reported the effectiveness of motivational interviewing. The searched databases included MEDLINE, British Nursing Index, CINAHL Plus, PsycINFO, SCOPUS, CJN, CBM, HyRead, WanFang Data, Digital Dissertation Consortium, and so on.

REVIEW METHOD

Two reviewers independently assessed the relevance of citations based on the inclusion criteria. Full texts of potential citations were retrieved for more detailed review. Critical appraisal was conducted by using the standardized critical appraisal checklist for randomized and quasi-randomized controlled studies from the Joanna Briggs Institute - Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStaRI).

RESULTS

After eligibility screening, 14 articles describing 9 studies satisfied the inclusion criteria and were included in the analysis. Only certain outcomes in certain studies were pooled for meta-analysis because of the large variability of the studies included, other findings were presented in narrative form. For lifestyle modification, the review showed that motivational interviewing could be more effective than usual care on altering smoking habits. For physiological outcomes, the review showed that motivational interviewing positively improved client's systolic and diastolic blood pressures but the result was not significant. For psychological outcomes, the review showed that motivational interviewing might have favorable effect on improving clients' depression. For other outcomes, the review showed that motivational interviewing did not differ from usual care or usual care was even more effective.

CONCLUSIONS

The review showed that motivational interviewing might have favorable effects on changing clients' smoking habits, depression, and three SF-36 domains. For the other outcomes, most of the results were inconclusive. Further studies should be performed to identify the optimal format and frequency of motivational interviewing. Primary research on the effectiveness of motivational interviewing on increasing clients' motivation and their actual changes in healthy behavior is also recommended.

Outpatient cardiac rehabilitation use after coronary bypass surgery in the west of Iran

PURPOSE

Determinants of outpatient cardiac rehabilitation (CR) use in low- and middle-income countries are not well-known. This study analyzed CR use after coronary bypass surgery by gender and geography and effects of systematic referral, program model, and insurance types on CR participation in the west of Iran.

METHODS

This observational study was conducted in Imam-Ali University Hospital in Kermanshah (KSH), the only CR center in the region (2002-2012). There were 2 CR programs: hospital-based and hybrid (combination of home-based and intermittent hospital-based sessions). Patients were divided into groups who lived inside and outside KSH (O-KSH). Referral, participation, and completion rates and program selection were compared by geography, gender, and insurance types. The effects of systematic referral (as of June 2011) were also analyzed.

RESULTS

Of 4735 patients, 44.6% were referred for, 18.7% enrolled in, and 16.5% completed CR. In KSH compared with O-KSH, referral rates were 58.0% versus 30.7% and participation rates were 27.0% versus 10.2%, respectively (P < .001, in both cases). Participation rate in women was lower than that in men (15.6% vs 20.0%, respectively; P = .001). Systematic referral increased participation, especially in women and O-KSH (P < .001, in both cases). The O-KSH patients and those with unfavorable insurance mostly selected the hybrid program (P < .001, in both cases). Among participants, completion rates based on gender and geography were similar.

CONCLUSIONS

Referral and participation rates of coronary bypass surgery patients in CR were low in the west of Iran, especially in women and O-KSH. Systematic referral along with the hybrid program increased them significantly.

Changes in risk factors and exercise capacity after cardiac rehabilitation and its effect on hospital readmission

Background:

Despite the positive outcomes reported with cardiac rehabilitation (CR), its impacts have been reported to be different from a region or country to another, which may be due to the different contents of rehabilitation programs.

Objectives:

To investigate the effect of CR on cardiovascular risk factors.

Patients and Methods:

This is a retrospective cohort study on the data from Imam Ali Cardiac Rehabilitation Center in Kermanshah province, Iran from 2001 to 2008. We used paired t-test to evaluate the effect of CR on cardiovascular risk factors. Logistic regression or t-test (unequal variance) were used to assess the factors influencing re-admission (due to cardiac problems). The relationship between different variables and death was studied using univariate cox proportional hazard. P values < 0.05 were considered significant for all analyses.

Results:

Out of 504 patients who completed rehabilitation, a total of 499 were analyzed. These 499 patients consisted of 383 men and 116 women. All anthropometric measurements, blood lipids (except HDL cholesterol), systolic and diastolic blood pressure, depression, anxiety and exercise capacity improved after rehabilitation (P < 0.05 for all cases). The improvement was observed in both sexes. A total of 39 patients were re-admitted to hospital after rehabilitation. Being female (OR = 2.40; 95%CI: 1.22-4.68) and history of diabetes (OR = 2.04; 95%CI: 1.04-4.02) increased the risk of re-admission significantly. Patients who were readmitted had higher anthropometric measurements at the beginning and the end of the program. Moreover, the initial exercise capacity of readmitted patients was lower than those who were not readmitted. After a maximal follow-up period of 6.3 years (median = 2.99 years), only eight patients expired (survival rate: 97.5%; 95%CI: 94.7-98.8). None of the variables in our study was significantly related to the survival rate.

Conclusions:

The comprehensive CR program in Imam Ali Center efficiently reduces cardiovascular risk factors and improves exercise capacity.

Quantification of perceived exertion during isometric force production with the Borg scale in healthy individuals and patients with chronic stroke

BACKGROUND

The Borg Rating of Perceived Exertion (RPE) scale is widely used for many patient populations, but the ability of patients to accurately report their RPE without visual feedback has not been studied.

OBJECTIVE

The objective was to determine whether the Borg scale could be used as a measure of perceived isometric exertion in healthy subjects and patients with stroke.

METHODS

In experiment 1, young healthy subjects (n = 15) were instructed to perform spontaneous pushes (ie, self-selected effort) without visual feedback and to produce and hold self-determined isometric finger flexion at 5 Borg levels without visual feedback. In experiment 2, subjects with chronic stroke (n = 10) were instructed to produce self-determined isometric elbow flexion at 4 perceptual levels on the impaired and nonimpaired sides.

RESULTS

In experiment 1, young healthy subjects, asked to self-select without visual feedback (spontaneous push), tended to exert at a "somewhat hard" level, about 12% of maximal voluntary contraction (MVC). Self-selection of forces ranged from 2% of MVC (ie, very light) to 39% of MVC (ie, very hard). In experiment 2, subjects with stroke were able to distinguish different levels of perceived exertion among light (19% MVC), somewhat hard (33% MVC), and hard (63% MVC) levels; this ability was not different for the impaired and nonimpaired limbs.

CONCLUSION

Both healthy subjects and subjects with stroke are able to differentiate distinct levels of perceived exertion during isometric force when prompted with the Borg scale. Efforts at lower percentages of MVC are perceived by subjects with stroke as greater-than-normal Borg RPE levels.

Cardiac rehabilitation and outcome in stable outpatients with recent myocardial infarction

OBJECTIVE

To compare the mortality rate and the rate of subsequent ischemic events (myocardial infarction [MI], ischemic stroke, or limb amputation) in patients with recent MI according to the use of cardiac rehabilitation or no rehabilitation.

DESIGN

Longitudinal observational study.

SETTING

Ongoing registry of outpatients.

PARTICIPANTS

Patients (N=1043) with recent acute MI were recruited; of these, 521 (50%) participated in cardiac rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subsequent ischemic events and mortality rates were registered.

RESULTS

Over a mean follow-up of 18 months, 50 patients (4.8%) died and 49 (4.7%) developed 52 subsequent ischemic events (MI: n=43, ischemic stroke: n=6, limb amputation: n=3). Both the mortality rate (.16 vs 5.57 deaths per 100 patient-years; rate ratio=.03; 95% confidence interval [CI], 0.0-0.1]) and the rate of subsequent ischemic events (1.65 vs 4.54 events per 100 patient-years; rate ratio=0.4; 95% CI, 0.2-0.7) were significantly lower in cardiac rehabilitation participants than in nonparticipants. Multivariate analysis confirmed that patients in cardiac rehabilitation had a significantly lower risk of death (hazard ratio=.08; 95% CI, .01-.63; P=.016) and a nonsignificant lower risk of subsequent ischemic events (hazard ratio=.65; 95% CI, .30-1.42).

CONCLUSIONS

The use of cardiac rehabilitation in patients with recent MI was independently associated with a significant decrease in the mortality rate and a nonsignificant decrease in the rate of subsequent ischemic events.

Health-related factors associated with mode of travel to work

Active commuting (AC) to the workplace is a potential strategy for incorporating physical activity into daily life and is associated with health benefits. This study examined the association between health-related factors and mode of travel to the workplace. Methods. A volunteer convenience sample of employed adults completed an online survey regarding demographics, health-related factors, and the number of times/week walking, biking, driving, and using public transit to work (dichotomized as no walk/bike/drive/PT and walk/bike/drive/PT 1 + x/week). Logistic regression was used to predict the likelihood of each mode of transport and meeting PA recommendations from AC according to demographics and health-related factors. Results. The sample (n = 1175) was aged 43.5 ± 11.4 years and was primarily White (92.7%) and female (67.9%). Respondents reported walking (7.3%), biking (14.4%), taking public transit (20.3%), and driving (78.3%) to work at least one time/week. Among those reporting AC, 9.6% met PA recommendations from AC alone. Mode of travel to work was associated with several demographic and health-related factors, including age, number of chronic diseases, weight status, and AC beliefs. Discussion. Mode of transportation to the workplace and health-related factors such as disease or weight status should be considered in future interventions targeting AC.

Self-blame attributions, control appraisals and distress among cardiac rehabilitation patients

This study examined associations between self-blame attributions, control appraisals and distress among cardiovascular disease patients participating in a cardiac rehabilitation (CR) programme. Questionnaire data were collected from 129 patients at the beginning and end of CR. We found little evidence that characterological self-blame (CSB) affects distress symptoms, but behavioural self-blame at the beginning of CR was positively associated with distress symptoms concurrently, and 12 weeks later. Furthermore, diet- and exercise-focused self-blame was only modestly, positively related to control appraisals concurrently, while CSB was negatively associated with control. Prospectively, we found few significant associations between self-blame and control. Results imply that making any type of self-blame attribution during CR does not aid in adjustment or enhanced control appraisals. Our findings suggest that CR staff should encourage patients to recognise their control over reducing risk for recurrence, but should discourage patients from looking backward and ruminating about factors that may have contributed to disease onset.

Nitrates as an integral part of optimal medical therapy and cardiac rehabilitation for stable angina: review of current concepts and therapeutics

The goals of optimal medical therapy in patients with stable angina pectoris are to reduce the risk of cardiovascular mortality and future cardiovascular events, improve exercise capacity, and enhance quality of life. Whereas myocardial revascularization is frequently employed in the management of patients with stable angina, a variety of pharmacologic interventions are recommended as part of optimal medical management. The use of short- and rapidly-acting nitrates (eg, sublingual nitroglycerin spray and tablets) is at the core of the therapeutic armamentarium and should be integrated into optimal medical therapy for stable angina along with exercise therapy. The potential clinical implications from these observations are that prophylactic sublingual nitrates, when combined with cardiac rehabilitation, may allow the patient with angina to exercise to a greater functional capacity than without sublingual nitrates.

Ambulatory surveillance of patients referred for cardiac rehabilitation following cardiac hospitalization: a feasibility study

BACKGROUND

Our purpose was to examine the feasibility of implementing an ambulatory surveillance system for monitoring patients referred to cardiac rehabilitation following cardiac hospitalizations.

METHODS

This study consists of 1208 consecutive referrals to cardiac rehabilitation between October 2007 and April 2008. Patient attendance at cardiac rehabilitation, waiting times for cardiac rehabilitation, and adverse events while waiting for cardiac rehabilitation were tracked by telephone surveillance by a nurse.

RESULTS

Among the 1208 consecutive patients referred, only 44.7% attended cardiac rehabilitation; 36.4% of referred patients were known not to have attended any cardiac rehabilitation, while an additional 18.9% of referred patients were lost to follow-up. Among the 456 referred patients who attended the cardiac rehabilitation program, 19 (4.2%) experienced an adverse event while in the queue (13 of which were for cardiovascular hospitalizations with no deaths), with mean waiting times of 20 days and 24 days among those without and with adverse events, respectively. Among the 440 referred patients who were known not to have attended any cardiac rehabilitation program, 114 (25.9%) had adverse clinical events while in the queue; 46 of these events required cardiac hospitalization and 8 patients died.

CONCLUSIONS

Ambulatory surveillance for cardiac rehabilitation referrals is feasible. The high adverse event rates in the queue, particularly among patients who are referred but who do not attend cardiac rehabilitation programs, underscores the importance of ambulatory referral surveillance systems for cardiac rehabilitation following cardiac hospitalizations.