Telehealth technologies could improve suboptimal rates of participation in cardiac rehabilitation

Home-Based Intervention Tool for Cardiac Telerehabilitation: Protocol for a Controlled Trial

BACKGROUND

Among cardiovascular diseases, adult patients with congenital heart disease represent a population that has been continuously increasing, which is mainly due to improvement of the pathophysiological framing, including the development of surgical and reanimation techniques. However, approximately 20% of these patients will require surgery in adulthood and 40% of these cases will necessitate reintervention for residual defects or sequelae of childhood surgery. In this field, cardiac rehabilitation (CR) in the postsurgical phase has an important impact on the patient by improving psychophysical and clinical recovery in reducing fatigue and dyspnea to ultimately increase survival. In this context, compliance with the rehabilitation program is a key element for the therapeutic benefits of the program. The increase of mobile health care devices and software has greatly extended self-care capabilities across the spectrum of health care activities. Moreover, the possibility of telemonitoring the progress of this self-care provides elements of empowerment and awareness of one's state of health. As a branch of telehealth, CR can be optimized and facilitated using remote telemedicine devices.

OBJECTIVE

The principal goal of the Innovation in Postoperative Rehabilitation Training and Monitoring (IPOTERI) study is to design, realize, and test a composite and integrated system for postsurgical rehabilitation therapies at home specialized for cardiac surgery. The secondary aims are to implement the system in a "real-life" context of postcardiac surgical rehabilitation, and to create a data set and a data collection methodology to prototype data analytics algorithms and artificial intelligence techniques for customizing the rehabilitation pathway.

METHODS

The IPOTERI method consists of a telemonitoring platform that guarantees continuity of postoperative care, an intelligent home station based on an Android app for the patient with a user-friendly interface to record vital signals (electrocardiogram, blood pressure, oxygen saturation, and body weight) and access the planning of rehabilitation activities, and a decision support system that communicates with hospital medical records to transmit alerts and specific support information for the formulation and updating of the treatment and care plan.

RESULTS

The pilot test started in June 2023 (protocol number 20406/2021) including 50 patients who will be monitored for 12-14 weeks using the developed platform, as described in the Procedures subsection of the Methods section.

CONCLUSIONS

The IPOTERI approach, based on the processing of data recorded during the monitoring of telemedicine devices used at home during the postsurgical rehabilitation of a cardiac patient, together with clinical data from the perioperative and postoperative periods could have positive effects on adherence to the rehabilitation program and clinical improvement as well as result in overall improvement of quality of life.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47951.

Comparing the Outcomes of Digital and Traditional Cardiac Rehabilitation Practices: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the effects of digital cardiac rehabilitation (DCR) encompassing application-based telehealth compared to traditional cardiac rehabilitation onmajor adverse cardiovascular events (MACE), rehospitalisation, costs, quality of life (QoL), and physical activity levels in patients with coronary artery disease (CAD). From 2014 to May 2024, a systematic search of the MEDLINE, PubMed, Web of Science, and Scopus databases was conducted using relevant keywords to identify randomised controlled trials (RCTs) or randomised cross-over trials. The methodological quality of the included studies was assessed using the Physiotherapy Evidence Database (PEDro) scale and risk of bias tool. The included articles were then subjected to qualitative synthesis and meta-analysis. Thirteen studies involving 1850 participants were included in the study. Meta-analysis revealed statistically significant improvements in QoL (mean deviation (MD) = 0.10, 95% CI: 0.05-0.15, p = 0.0002). DCR compared with centre-based rehabilitation (CBR). These improvements in QoL likely translated to enhanced daily functioning, such as the increased ability to perform activities of daily living. However, no significant differences were found for physical activity levels (MD = 1.69, 95% CI: 1.49-4.87, p = 0.30), rehospitalisation (relative risk (RR) = 0.86, 95% CI: 0.66-1.11, p = 0.25) or MACE (RR = 0.67, 95% CI: 0.42-1.07, p = 0.09). High heterogeneity was observed in QoL, likely due to variations in DCR modalities, study populations, and intervention content. The results of this study, therefore, must be interpreted with caution. DCR may offer significant benefits in terms of improving the QoL in patients with CAD. While promising trends were observed for rehospitalisation and MACE, further research is needed to confirm these findings. Potential reasons for the observed benefits of DCR over centre-based rehabilitation plausibly include improved accessibility, enhanced patient engagement, and greater flexibility. However, it is important to acknowledge the presence of heterogeneity among the included studies and potential gender imbalances within the study populations, which may have influenced the results. Future research should prioritize long-term outcomes, cost-effectiveness, real-world effectiveness in diverse populations, and the development of standardized DCR protocols.

Effect of a patient health engagement (PHE) model on rehabilitation participation in patients with acute myocardial infarction after PCI: a study protocol for a randomized controlled trial

BACKGROUND

Participation in cardiac rehabilitation is low in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). Although existing rehabilitation methods have achieved certain results, patient participation in exercise rehabilitation is not ideal. The Patient Health Engagement (PHE) model is designed to ensure that patients improve their participation in cognitive, emotional, behavioral, and other aspects in all phases of exercise rehabilitation. The purpose of this study is to confirm whether the rehabilitation method based on the PHE model improves the rate of patient participation and enhances the rehabilitation effect during cardiac rehabilitation in patients with acute myocardial infarction compared with the traditional rehabilitation model.

METHODS/DESIGN

This is a single-center, double-blind, randomized, controlled trial that will enroll 128 patients. Patients with stable acute myocardial infarction after undergoing PCI who received cardiac rehabilitation and postoperative LVEF ≥ 40%, categorized into Killip class I ~ II and with age ≥ 18 years, will be included in the study. Exclusion criteria are mainly malignant arrhythmias, acute heart failure, congestive heart failure, and patients requiring intra-aortic balloon counterpulsation. Patients will be randomized in a 1:1 ratio to the intervention (1) and control (2) groups. Physicians, rehabilitation specialists, patients, and data collectors will be blinded during the study. A rehabilitator and a specialist nurse will conduct the cardiac rehabilitation. The specialist nurse will hand over the sealed bag containing patient information (group 1 or 2) to the physician. Group 1 will undergo cardiac rehabilitation through the PHE model, three times a week for 3 months. The rehabilitation program will be evaluated and adjusted in time from each period of the rehabilitation. Group 2 will be treated with routine cardiac rehabilitation. The rehabilitation participation rate of the two groups will be evaluated before and after 3 months of intervention. The primary outcome will be the level of patient participation in rehabilitation, and the secondary outcome will include general data of patients, postoperative rehabilitation indicators, cardiac rehabilitation knowledge-attitude-practice questionnaire, cardiovascular adverse events, and a brief mood scale.

EXPECTED OUTCOMES

We expect improved cardiac rehabilitation participation rates and rehabilitation outcomes in patients with acute myocardial infarction after undergoing PCI using the PHE model.

DISCUSSION

This approach may increase patient participation in rehabilitation, improve rehabilitation outcomes, and be widely implemented in hospitals and rehabilitation centers.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR2400085276 (Version 2.0 June 04, 2024),  https://www.chictr.org.cn .

TRIAL SPONSOR

Shandong Second Medical university, Weifang, Shandong. Contact name: Dechun Qin, Address: Shandong Second Medical university, Weifang Shandong. Email: 13562666589@163.com.

Effect of Adding a Program of Contextualized, Personalized, Remote Physical Activity Support to Conventional Cardiac Rehabilitation

PURPOSE

The objective of this investigation was to conduct a randomized controlled trial to evaluate whether KiActiv Heart alongside usual care (UC) promotes positive physical activity (PA) change versus UC alone.

METHODS

Patients in cardiac rehabilitation (n = 130) undertook an 8-wk intervention with follow-up at wk 8. Both groups attended UC and wore a PA monitor during the intervention. The intervention group accessed the digital service and received weekly one-to-one remote mentor sessions. The primary outcome was change in PA to achieve the Association of Certified Physiotherapists in Cardiac Rehabilitation (ACPICR) recommendations. The secondary outcome was cardiorespiratory fitness (CRF) change, measured using incremental shuttle walk test (ISWT).

RESULTS

The probability of meeting ACPICR "Daily Activity" recommendation was statistically significantly greater in the intervention group versus control at wk 8 ( P < .05). No statistically significant differences between groups were found for mean ISWT change (intervention 89 ± 116 m; control 44 ± 124 m).

CONCLUSION

Participation in KiActiv Heart alongside UC was associated with statistically significant improvement in probability of meeting ACPICR recommendation and non-statistically significant but potentially clinically important increases in CRF versus UC alone. This builds on existing evidence for effectiveness.

Cardiac telerehabilitation under 5G internet of things monitoring: a randomized pilot study

Owing to issues such as time and cost, patients often show poor acceptance of and adherence to center-based cardiac rehabilitation (CBCR), which impacts the effectiveness of rehabilitation. Therefore, there is growing interest in home-based cardiac rehabilitation and cardiac telerehabilitation (CTR), which entail less time and cost than CBCR. This study aimed to compare the changes in physiological and psychological indicators, compliance, and satisfaction after CTR and CBCR. In this single-blind, randomized, controlled trial, the intervention group received CTR via the 5G Internet of Things platform, while the control group received CBCR. Data from 50 patients (age 66.28 ± 4.01 years) with acute myocardial infarction who underwent percutaneous coronary intervention were analyzed. After an intervention period of three months, the maximal oxygen uptake and metabolic equivalent of task were 5.53 ± 0.12 and 19.32 ± 0.17, respectively, in the intervention group, and 4.15 ± 0.13 and 16.52 ± 0.18, respectively, in the control group. After three months of intervention, there were significant differences between the two groups in all observed indicators (p < 0.05), except for low-density lipoprotein and the incidence of major adverse cardiovascular events (p > 0.05). The use of a 5G Internet of Things platform cardiac rehabilitation model effectively improved outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention. Trials registry: The study protocol was registered at Chinese Clinical Trials Registry (ChiCTR), first trial registration 07/08/2023, identification number ChiCTR2300074435.

Determinants of participation in cardiac telerehabilitation during the first surge of COVID-19

BACKGROUND

Participation rates in cardiac rehabilitation (CR) are low. In multiple trials, telerehabilitation (TR) has been demonstrated to be effective. Still, real-life evidence is scarce. During the first surge of the COVID-19 pandemic our centre deployed a TR programme. This study aimed to characterise the patient population that had, for the first time, the opportunity to participate in cardiac TR and to analyse if there were determining factors for participation or non-participation in TR.

METHODS

All patients enrolled in CR in our centre during the first wave of the COVID-19 pandemic were included in this retrospective cohort study. Data was collected from the hospital electronic records.

RESULTS

369 patients were contacted in the setting of TR. 69 patients could not be reached and were excluded from further analysis. 208 (69%) patients that were contacted agreed to participate in cardiac TR. No significant differences in baseline characteristics were seen between TR participants and TR non-participants. A full model logistic regression did not reveal any significant determinants on participation rate in TR.

CONCLUSION

This study demonstrates that the rate of participation in TR was high (69%). Of the analysed characteristics, none was directly correlated with the willingness to participate in TR. Further research is needed to further assess determinants, barriers and facilitators of TR. Also, research is needed on better delineating digital health literacy and on how to reach also those patients that are less motivated and or less digitally literate.

The Italian Society of Cardiology and Working Group on Telecardiology and Informatics 2023 updated position paper on telemedicine and artificial intelligence in cardiovascular disease

In 2015, the Italian Society of Cardiology and its Working Group on Telemedicine and Informatics issued a position paper on Telecardiology, resuming the most eminent evidence supporting the use of information and communication technology in principal areas of cardiovascular care, ranked by level of evidence. More than 5 years later and after the global shock inflicted by the SARS-CoV-2 pandemic, an update on the topic is warranted. Recent evidence and studies on principal areas of cardiovascular disease will be therefore reported and discussed, with particular focus on telemedicine for cardiovascular care in the COVID-19 context. Novel perspectives and opportunities disclosed by artificial intelligence and its applications in cardiovascular disease will also be discussed. Finally, modalities by which machine learning have realized remote patient monitoring and long-term care in recent years, mainly filtering critical clinical data requiring selective hospital admission, will be provided.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

Willingness to participate in cardiac telerehabilitation: results from semi-structured interviews

Aims

Cardiac rehabilitation (CR) is indicated in patients with cardiovascular disease but participation rates remain low. Telerehabilitation (TR) is often proposed as a solution. While many trials have investigated TR, few have studied participation rates in conventional CR non-participants. The aim of this study was to identify the percentage of patients that would be willing to participate in a TR programme to identify the main perceived barriers and facilitators for participating in TR.

Methods and results

Two groups of patients were recruited: CR non-participants and CR participants. Semi-structured interviews were conducted. Thirty non-participants and 30 participants were interviewed. Of CR non-participants, 33% would participate in TR and 10% would participate in a blended CR programme (combination of centre-based CR and TR). Of CR participants, 60% would participate in TR and 70% would be interested in a blended CR programme. Of those that would participate in TR, 44% would prefer centre-based CR, 33% would prefer a blended CR programme, and 11% would prefer a full TR programme. In both groups, the main facilitating aspect about TR was not needing transport and the main barrier was digital literacy.

Conclusion

For CR non-participants, TR will only partly solve the problem of low participation rates and blended programmes might not offer a solution. Cardiac rehabilitation participants are more prepared to participate in TR and blended CR. Digital literacy was in both groups mentioned as an important barrier, emphasizing the challenges for healthcare and local governments to keep educating all types of patients in digital literacy.

Digital Cardiac Rehabilitation Programs: The Future of Patient-Centered Medicine

Background: The low participation rate in cardiac rehabilitation programs is the major reason for rehospitalization, morbidity, and mortality. Home-based cardiac rehabilitation by technological means is an essential component of a "patient-centered" approach, which is capable of enhancing the participation rate in rehabilitation programs. Introduction: The aim of this research was to examine attitudes, perceptions, and behavioral intentions toward remote digital cardiac rehabilitation (RDCR) with respect to factors such as age, education, smoking, exercise habits, technological illiteracy, and mobile phone behavior. Materials and Methods: This was a cross-sectional study of 200 adult patients discharged from a hospital after an acute coronary syndrome, cardiac surgery, or percutaneous coronary intervention. All patients answered an anonymous Technology Usage Questionnaire, which examined the relationship between their willingness to participate in the RDCR program and various parameters. The surveys were distributed and completed between July 2017 and November 2017 at the Sheba Medical Center in Israel. Results: Overall, 83% of all participants were interested in participating in the RDCR program. Those with heart failure had a greater interest in the program (100%; p < 0.05), whereas patients after coronary bypass surgery had a lesser interest (71.1%; p < 0.05). The level of attitude toward healthy lifestyle was found to be a significant predictor of willingness to participate in RDCR (odds ratio 2.26; p = 0.01). Sociodemographic characteristics, lifestyle, habits, technological knowledge, age, and gender were not found as significant predictors of interest in RDCR. Conclusions: The RDCR program was acceptable to most cardiac patients, including the elderly population, and could be a potential solution for patients who avoid traditional rehabilitation programs in medical centers.

A randomised controlled trial of a facilitated home-based rehabilitation intervention in patients with heart failure with preserved ejection fraction and their caregivers: the REACH-HFpEF Pilot Study

INTRODUCTION

Home-based cardiac rehabilitation may overcome suboptimal rates of participation. The overarching aim of this study was to assess the feasibility and acceptability of the novel Rehabilitation EnAblement in CHronic Hear Failure (REACH-HF) rehabilitation intervention for patients with heart failure with preserved ejection fraction (HFpEF) and their caregivers.

METHODS AND RESULTS

Patients were randomised 1:1 to REACH-HF intervention plus usual care (intervention group) or usual care alone (control group). REACH-HF is a home-based comprehensive self-management rehabilitation programme that comprises patient and carer manuals with supplementary tools, delivered by trained healthcare facilitators over a 12 week period. Patient outcomes were collected by blinded assessors at baseline, 3 months and 6 months postrandomisation and included health-related quality of life (primary) and psychological well-being, exercise capacity, physical activity and HF-related hospitalisation (secondary). Outcomes were also collected in caregivers.We enrolled 50 symptomatic patients with HF from Tayside, Scotland with a left ventricular ejection fraction ≥45% (mean age 73.9 years, 54% female, 100% white British) and 21 caregivers. Study retention (90%) and intervention uptake (92%) were excellent. At 6 months, data from 45 patients showed a potential direction of effect in favour of the intervention group, including the primary outcome of Minnesota Living with Heart Failure Questionnaire total score (between-group mean difference -11.5, 95% CI -22.8 to 0.3). A total of 11 (4 intervention, 7 control) patients experienced a hospital admission over the 6 months of follow-up with 4 (control patients) of these admissions being HF-related. Improvements were seen in a number intervention caregivers' mental health and burden compared with control.

CONCLUSIONS

Our findings support the feasibility and rationale for delivering the REACH-HF facilitated home-based rehabilitation intervention for patients with HFpEF and their caregivers and progression to a full multicentre randomised clinical trial to test its clinical effectiveness and cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN78539530.

Barriers to Outpatient Hospital-Based Cardiac Rehabilitation in Korean Patients With Acute Coronary Syndrome

Objective

To investigate factors associated with enrollment and participation in cardiac rehabilitation (CR) in Korea.

Methods

Patients admitted to four university hospitals with acute coronary syndrome between June 2014 and May 2016 were enrolled. The Cardiac Rehabilitation Barriers Scale (CRBS) made of 21-item questionnaire and divided in four subdomains was administered during admission. CRBS items used a 5-point Likert scale and ≥2.5 was considered as a barrier. Differences between CR non-attender and CR attender, or CR non-enroller and CR enroller in subscale and each items of CRBS were examined using the chi-square test.

Results

The CR participation rate in four hospitals was 31% (170 of the 552). Logistical factors (odds ratio [OR]=7.61; 95% confidence interval [CI], 4.62-12.55) and comorbidities/functional status (OR=6.60; 95% CI, 3.95-11.01) were identified as a barrier to CR enrollment in the subdomain analysis. Among patients who were enrolled (agreed to participate in CR during admission), only work/time conflict was a significant barrier to CR participation (OR=2.17; 95% CI, 1.29-3.66).

Conclusion

Diverse barriers to CR participation were identified in patients with acute coronary syndrome. Providing the tailored model for CR according to the individual patient's barrier could improve the CR utilization. Further multicenter study with large sample size including other CR indication is required.

Rehabilitation Enablement in Chronic Heart Failure-a facilitated self-care rehabilitation intervention in patients with heart failure with preserved ejection fraction (REACH-HFpEF) and their caregivers: rationale and protocol for a single-centre pilot randomised controlled trial

INTRODUCTION

The Rehabilitation EnAblement in CHronic Heart Failure in patients with Heart Failure (HF) with preserved ejection fraction (REACH-HFpEF) pilot trial is part of a research programme designed to develop and evaluate a facilitated, home-based, self-help rehabilitation intervention to improve self-care and quality of life (QoL) in heart failure patients and their caregivers. We will assess the feasibility of a definitive trial of the REACH-HF intervention in patients with HFpEF and their caregivers. The impact of the REACH-HF intervention on echocardiographic outcomes and bloodborne biomarkers will also be assessed.

METHODS AND ANALYSIS

A single-centre parallel two-group randomised controlled trial (RCT) with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention) or usual care alone (control) in 50 HFpEF patients and their caregivers. The REACH-HF intervention comprises a REACH-HF manual with supplementary tools, delivered by trained facilitators over 12 weeks. A mixed methods approach will be used to assess estimation of recruitment and retention rates; fidelity of REACH-HF manual delivery; identification of barriers to participation and adherence to the intervention and study protocol; feasibility of data collection and outcome burden. We will assess the variance in study outcomes to inform a definitive study sample size and assess methods for the collection of resource use and intervention delivery cost data to develop the cost-effectiveness analyses framework for any future trial. Patient outcomes collected at baseline, 4 and 6 months include QoL, psychological well-being, exercise capacity, physical activity and HF-related hospitalisation. Caregiver outcomes will also be assessed, and a substudy will evaluate impact of the REACH-HF manual on resting global cardiovascular function and bloodborne biomarkers in HFpEF patients.

ETHICS AND DISSEMINATION

The study is approved by the East of Scotland Research Ethics Service (Ref: 15/ES/0036). Findings will be disseminated via journals and presentations to clinicians, commissioners and service users.

TRIAL REGISTRATION NUMBER

ISRCTN78539530; Pre-results .