Cardiac rehabilitation 2012: advancing the field through emerging science

From Surviving to Thriving: A Roadmap for Reinventing Cardiac Rehabilitation in Pediatric Congenital Heart Disease

Exercise is an essential component of the cardiac care of children with congenital heart disease (CHD), and safe and effective exercise counselling by the medical team is important early in life to develop positive physical activity and exercise habits. Without it, children are at risk for sedentariness and related comorbidities in childhood and adulthood. Pediatric cardiologists can guide patients to a cycle of positive fitness through exercise counselling, promotion, prescription, and/or supervised exercise training similar to adult cardiac rehabilitation (ACR). ACR has improved exercise capacity, mortality, and quality of life in adults with acquired heart disease. Similar outcomes have been shown in exercise training for adult and pediatric CHD. Exercise training specific to pediatric CHD is not widely available but is expanding in response to growing need and increasing demand. Although ACR provides a framework for structured exercise training, approaches to pediatric exercise training must be individualized and innovated upon to be successful for children. I propose that the ACR model must be reinvented for children with CHD by integrating 6 missing pieces. First, the underlying goal should be to optimize fitness, not rehabilitate to a previous state of health. Second and third are training mental skills and motor skills. Fourth, play-based exercise training is needed to foster a positive relationship with exercise. Fifth, family-focused exercise interventions can address root causes of sedentariness. Finally, building communities in which positive fitness is a priority will be essential to long-term sustainability.

Exercise, cancer, and the cardiovascular system: clinical effects and mechanistic insights

Cardiovascular diseases and cancer are the leading causes of death in the Western world and share common risk factors. Reduced cardiorespiratory fitness (CRF) is a major determinant of cardiovascular morbidity and cancer survival. In this review we discuss cancer- induced disturbances of parenchymal, cellular, and mitochondrial function, which limit CRF and may be antagonized and attenuated through exercise training. We show the impact of CRF on cancer survival and its attenuating effects on cardiotoxicity of cancer-related treatment. Tailored exercise programs are not yet available for each tumor entity as several trials were performed in heterogeneous populations without adequate cardiopulmonary exercise testing (CPET) prior to exercise prescription and with a wide variation of exercise modalities. There is emerging evidence that exercise may be a crucial pillar in cancer treatment and a tool to mitigate cardiotoxic treatment effects. We discuss modalities of aerobic exercise and resistance training and their potential to improve CRF in cancer patients and provide an example of a periodization model for exercise training in cancer.

Effectiveness of cardiac rehabilitation in cancer survivors: A meta-analysis of randomized controlled trials

PURPOSE

This meta-analysis aimed to evaluate available data regarding the potential benefits of cardiac rehabilitation (CR) in cancer survivors.

METHODS

Relevant studies published from inception to April 2024 were retrieved from PubMed, Embase, Web of Science, CENTRAL, CINAHL, PsycINFO, Scopus, CNKI, WanFang, VIP, and CBM databases. Seven randomized controlled trials (RCTs) involving 526 cancer survivors were included in this meta-analysis.

RESULTS

CR increased muscle strength (standardized mean difference (SMD) = 0.39, 95% confidence interval (CI): 0.06 to 0.72, P = 0.020), quality of life (QoL) (SMD = 0.61, 95% CI: 0.40 to 0.82, P < 0.001), and led to a decrease in Body Mass Index (BMI) (mean difference (MD) = -1.11, 95% CI: -2.02 to -0.19, P = 0.020), total cholesterol (TC) (MD = -0.41, 95% CI: -0.69 to -0.14, P = 0.003), triglyceride (TG) (MD = -0.33, 95% CI: -0.63 to -0.03, P = 0.030) and low-density lipoprotein (LDL) (MD = -0.34, 95% CI: -0.57 to -0.12, P = 0.003). The meta-analysis revealed that CR had no statistically significant impact on cardiorespiratory fitness (CRF) and high-density lipoprotein (HDL) levels.

CONCLUSIONS

CR may represent an effective strategy to evaluate cancer survivors because it improves muscle strength and QoL and reduces BMI, TC, TG and LDL levels. Further RCTs with strict study designs and larger sample sizes are required to determine the effects of CR on cancer survivors.

Effect of Cardiac Rehabilitation on Cardiorespiratory Fitness in Patients With Acute Myocardial Infarction: Role of Diabetes Mellitus and Glycated Hemoglobin Level

PURPOSE

Following acute myocardial infarction (AMI), patients with diabetes mellitus (DM) have a poorer prognosis than those without DM. This study aimed to investigate the benefit of cardiac rehabilitation on cardiorespiratory fitness in patients with AMI, examining whether this effect varied depending on DM and glycated hemoglobin (HbA1c) levels.

METHODS

Data were collected from the medical records of 324 patients diagnosed with AMI who were subsequently referred to participate in a supervised exercise-based cardiac rehabilitation program. Cardiorespiratory fitness was assessed using cardiopulmonary exercise testing before and at 3 and 6 mo after the start of cardiac rehabilitation. Linear mixed models were used to evaluate changes in cardiorespiratory fitness between patients with and without DM during the follow-up period.

RESULTS

In total, 106 patients (33%) had DM. Both patients with and without DM showed a significant improvement in cardiorespiratory fitness from baseline to the 6-mo follow-up. However, the improvement was significantly lower in patients with DM than in those without DM (1.9 ± 1.5 vs. 3.7 ± 3.2 mL/kg/min, P < .001). Among patients with DM, those with HbA1c levels < 7% showed a greater improvement in cardiorespiratory fitness than those with HbA1c ≥ 7% (2.7 ± 1.5 vs. 1.1 ± 1.8 mL/kg/min, P < .001) during the follow-up period.

CONCLUSIONS

Improvements in cardiorespiratory fitness following cardiac rehabilitation were significantly lower in patients with AMI and DM. The response to cardiac rehabilitation in patients is influenced by HbA1c levels. These findings suggest potential implications for individualizing cardiac rehabilitation programming and ensuring optimal glycemic control in patients with AMI and DM.

Barriers to cardiac rehabilitation and patient perceptions on the usage of technologies in cardiac rehabilitation: A cross-sectional study

AIMS AND OBJECTIVES

The study aimed to identify factors associated with participation in Phase II cardiac rehabilitation and to assess patient perceptions towards the usage of technologies in cardiac rehabilitation.

BACKGROUND

Despite efforts to promote utilisation of cardiac rehabilitation (CR), participation among patients remains unsatisfactory. Little is known of patient decision to participate Phase II CR in a multi-ethnic country.

DESIGN

A cross-sectional study design.

METHODS

A consecutive sampling of 240 patients with coronary heart disease completed Coronary Artery Disease Education Questionnaire (CADE-Q) II, Hospital Anxiety and Depression Scale (HADS), Multidimensional Scale of Perceived Social Support (MSPSS) and Cardiac Rehabilitation Barriers Scale (CRBS).

RESULTS

Seventy per cent of patients (mean age 60.5 [SD = 10.6] years, 80.8% male) participated in phase II cardiac rehabilitation. Self-driving to cardiac rehabilitation centres, higher barriers in perceived need/health care and logistical factors were significantly associated with decreased odds of participation. Patients with more barriers from comorbidities/functional status, higher perceived social support from friends, and anxiety were more likely to participate. Chinese and Indians were less likely to participate when compared with Malays. More than 80% of patients used both home and mobile broadband internet, and 72.9% of them would accept the usage of technologies, especially educational videos, instant messenger, and video calls to partially replace the face-to-face, centre-based cardiac rehabilitation approach.

CONCLUSION

Several barriers were associated with non-participation in phase II cardiac rehabilitation. With the high perceived acceptance of technology usage in cardiac rehabilitation, home-based and hybrid cardiac rehabilitation may represent potential solutions to improve participation.

RELEVANCE TO CLINICAL PRACTICE

By addressing the barriers to cardiac rehabilitation, patients are more likely to be ready to adopt health behaviour changes and adhere to the cardiac rehabilitation programme. The high perceived acceptance of using technologies in cardiac rehabilitation may provide insights into new delivery models that can improve and overcome barriers to participation.

Acute effects of singing on cardiovascular biomarkers

Background

Singing is a physical activity involving components of the vagal nerves manifested as changes in cardiac autonomic regulation.

Aims

The aim of this pilot study is to investigate the acute effects of singing on biomarkers of cardiovascular health.

Methods

Adult subjects were recruited from cardiology clinics to participate in a single 90-min study visit. Vascular function was measured at the fingertips with peripheral arterial tonometry (PAT) before and after singing to a 14-min video led by a voice expert. Heart rate variability (HRV) was measured with a chest strap sensor at baseline, during, and after singing. PAT measurements were expressed as reactive hyperemia index (RHI) and Framingham reactive hyperemia index (fRHI). Measures of HRV included root mean square of successive RR interval differences (RMSSD) and standard deviation of NN (or RR) intervals (SDNN).

Results

Sixty subjects completed the study (68% female, mean age 61 ±13 years, mean BMI 32 ± 8). There was a significant increase in fRHI (1.88 ± 0.14 to 2.10 ± 0.14, p = 0.02) after singing with no significant change in the RHI (1.99 ± 0.10 to 2.12 ± 0.09, p = 0.22). There was a reduction in HRV during singing (compared to baseline) (RMSSD: 42.0 ± 5 to 32.6 ± 4, p = 0.004 and SDNN: 54 ± 4 to 33.5 ± 3, p = 0.009). HRV measures trended back toward baseline after singing.

Conclusions

A short duration of singing improved vascular function acutely. Improvements were more substantial in subjects with abnormal baseline endothelial function. HRV patterns were similar to that of light-intensity exercise. Future studies should confirm favorable vascular adaptation to more sustained singing interventions.

Clinical trial registration

ClinicalTrials.gov, identifer: NCT03805529.

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.

Supervised Versus Unsupervised Pulmonary Rehabilitation in Patients with Pulmonary Embolism: A Valuable Alternative in COVID Era

The aim of our study was to assess the effect of 8 weeks of pulmonary rehabilitation (PR) in patients with pulmonary embolism (PE) during unsupervised PR (unSPRgroup) versus supervised PR (SPRgroup) on cardiopulmonary exercise testing (CPET) parameters, sleep quality, quality of life and cardiac biomarkers (NT-pro-BNP). Fourteen patients with PE (unSPRgroup, n = 7, vs. SPRgroup, n = 7) were included in our study (age, 50.7 ± 15.1 years; BMI, 30.0 ± 3.3 kg/m2). We recorded anthropometric characteristics and questionnaires (Quality of life (SF-36) and Pittsburg sleep quality index (PSQI)), we performed blood sampling for NT-pro-BNP measurement and underwent CPET until exhausting before and after the PR program. All patients were subjected to transthoracic echocardiography prior to PR. The SPRgroup differed in mean arterial pressure at rest before and after the PR program (87.6 ± 3.3 vs. 95.0 ± 5.5, respectively, p = 0.010). Patients showed increased levels of leg fatigue (rated after CPET) before and after PR (p = 0.043 for SPRgroup, p = 0.047 for unSPRgroup) while the two groups differed between each other (p = 0.006 for post PR score). Both groups showed increased levels in SF-36 scores (general health; p = 0.032 for SPRgroup, p = 0.010 for unSPRgroup; physical health; p = 0.009 for SPRgroup, p = 0.022 for unSPRgroup) and reduced levels in PSQI (cannot get to sleep within 30-min; p = 0.046 for SPRgroup, p = 0.007 for unSPRgroup; keep up enough enthusiasm to get things done; p = 0.005 for SPRgroup, p = 0.010 for unSPRgroup) following the PR program. The ΝT-pro-BNP was not significantly different before and after PR or between groups. PR may present a safe intervention in patients with PE. The PR results are similar in SPRgroup and unSPRgroup.

Applying Mobile Technology to Sustain Physical Activity After Completion of Cardiac Rehabilitation: Acceptability Study

BACKGROUND

Many patients do not meet the recommended levels of physical activity after completing a cardiac rehabilitation (CR) program. Wearable activity trackers and mobile phone apps are promising potential self-management tools for maintaining physical activity after CR completion.

OBJECTIVE

This study aims to evaluate the acceptability of a wearable device, mobile app, and push messages to facilitate physical activity following CR completion.

METHODS

We used semistructured interviews to assess the acceptability of various mobile technologies after participation in a pilot randomized controlled trial. Intervention patients in the randomized controlled trial wore the Fitbit Charge 2, used the Movn mobile app, and received push messages on cardiovascular disease prevention and physical activity for over 2 months. We asked 26 intervention group participants for feedback about their experience with the technology and conducted semistructured individual interviews with 7 representative participants. We used thematic analysis to create the main themes from individual interviews.

RESULTS

Our sample included participants with a mean age of 66.7 (SD 8.6) years; 23% (6/26) were female. Overall, there were varying levels of satisfaction with different technology components. There were 7 participants who completed the satisfaction questionnaires and participated in the interviews. The Fitbit and Movn mobile app received high satisfaction scores of 4.86 and 4.5, respectively, whereas push messages had a score of 3.14 out of 5. We identified four main themes through the interviews: technology use increased motivation to be physically active, technology use served as a reminder to be physically active, recommendations for technology to improve user experience, and desire for personal feedback.

CONCLUSIONS

By applying a wearable activity tracker, mobile phone app, and push messages, our study showed strong potential for the adoption of new technologies by older adults to maintain physical activity after CR completion. Future research should include a larger sample over a longer period using a mixed methods approach to assess the efficacy of technology use for promoting long-term physical activity behavior in older adults.

Efficacy of Lipid-Lowering Therapy during Cardiac Rehabilitation in Patients with Diabetes Mellitus and Coronary Heart Disease

Background: Cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) increases adherence to a healthy lifestyle and to secondary preventive medication. A notable example of such medication is lipid-lowering therapy (LLT). LLT during CR improves quality of life and prognosis, and thus is particularly relevant for patients with diabetes mellitus, which is a major risk factor for CHD. Design: A prospective, multicenter registry study with patients from six rehabilitation centers in Germany. Methods: During CR, 1100 patients with a minimum age of 18 years and CHD documented by coronary angiography were included in a LLT registry. Results: In 369 patients (33.9%), diabetes mellitus was diagnosed. Diabetic patients were older (65.5 ± 9.0 vs. 62.2 ± 10.9 years, p < 0.001) than nondiabetic patients and were more likely to be obese (BMI: 30.2 ± 5.2 kg/m² vs. 27.8 ± 4.2 kg/m², p < 0.001). Analysis indicated that diabetic patients were more likely to show LDL cholesterol levels below 55 mg/dL than patients without diabetes at the start of CR (Odds Ratio (OR) 1.9; 95% CI 1.3 to 2.9) until 3 months of follow-up (OR 1.9; 95% CI 1.2 to 2.9). During 12 months of follow-up, overall and LDL cholesterol levels decreased within the first 3 months and remained at the lower level thereafter (p < 0.001), irrespective of prevalent diabetes. At the end of the follow-up period, LDL cholesterol did not differ significantly between patients with or without diabetes mellitus (p = 0.413). Conclusion: Within 3 months after CR, total and LDL cholesterol were significantly reduced, irrespective of prevalent diabetes mellitus. In addition, CHD patients with diabetes responded faster to LTT than nondiabetic patients, suggesting that diabetic patients benefit more from LLT treatment during CR.

A history of smoking does not reduce long-term benefits of cardiac rehabilitation on cardiorespiratory fitness in men and women with cardiovascular disease

Smoking is an important risk factor for cardiovascular disease and all-cause mortality. Cardiac rehabilitation (CR) is effective for reducing the risk of recurrent cardiac events through improving cardiorespiratory fitness (CRF). Little is known about the influence of smoking on CRF throughout long-term CR. The purpose of this analysis was to compare CRF trajectories among individuals with positive and negative smoking history enrolled in long-term CR. Participants had a positive smoking history if they currently or formerly smoked (Smoke+, n = 55, mean age = 64.9 ± 9.0 years) and had a negative history if they never smoked (Smoke–, n = 34, mean age = 61.4 ± 9.0 years). CRF (peak oxygen uptake) was measured at baseline and annually thereafter for 6 years. The Smoke+ group had lower CRF compared with the Smoke– group over enrollment (β = −3.29 (SE = 1.40), 95% confidence interval (CI) −6.04 to −0.54, p = 0.02), but there was no interaction of smoking history and enrollment (β = 0.35 (SE = 0.21), 95% CI: −0.06 to 0.77, p = 0.10). Moreover, trajectories were not influenced by pack-years (β = 0.01 (SE = 0.01), 95% CI: −0.01 to 0.04, p = 0.23) or time smoke-free (β = −0.002 (SE = 0.01), 95% CI: −0.02 to 0.02, p = 0.80). Although the trajectories of CRF do not appear to be affected by smoking behaviour, individuals without a history of smoking maintained higher CRF throughout enrollment.

Novelty:

The benefits of long-term exercise-based cardiac rehabilitation on cardiorespiratory fitness are similar between those who have smoked and those who have never smoked. Neither the number of pack-years nor the length of time spent smoke-free influence cardiorespiratory fitness trajectories following long-term cardiac rehabilitation.

Establishing a Comprehensive Pediatric Cardiac Fitness and Rehabilitation Program for Congenital Heart Disease

Children and adolescents with congenital heart disease often do not have the opportunity, inclination, or education to participate in safe and effective exercise. The consequences of this behavioral pattern affect not only cardiopulmonary parameters, but also psychosocial factors, especially when lack of participation in peer activities or sports leads to isolation and further sedentary behaviors. Importantly, unlike cardiac rehabilitation programs for adults with atherosclerotic disease, the goal for congenital heart disease patients was less about "rehabilitation" and more about promotion of optimal fitness. We thus developed a comprehensive "Cardiac Fitness Program" at Boston Children's Hospital to promote exercise training, enhanced self-confidence, and motivation for patients with congenital heart disease. Since much of sustained fitness relates to consistency and behavior change, we crafted a progressive, goal-oriented exercise curriculum and augmented it with a self-learning workbook of targeted positive mindset practices to develop self-efficacy, an app for motivation and data collection, and exercise videos to demonstrate mechanics and to reiterate a positive message. We now report our experience including program structure and framework, navigating insurance, curriculum development, and outcome measures. Methods employed and barriers encountered in the initial development and execution of this program are reviewed. Key take-aways and further considerations including virtual and home-based programs are discussed.

Effect of High-Intensity Interval Training Versus Moderate-Intensity Aerobic Continuous Training on Galectin-3 Gene Expression in Postmenopausal Women: A Randomized Controlled Trial

Galectin-3 is a pro-inflammatory biomarker associated with the pathogenesis of heart failure (HF). Physical-activity reduces the risk of heart-failure by modification of inflammation and fibrosis. The purpose of this study was to compare the effects of 8 weeks of high-intensity interval training (HIIT) versus moderate-intensity aerobic continuous training on a predictive factor of HF in postmenopausal women. Thirty sedentary postmenopausal women were randomly assigned to three groups. The first group performed the HIIT program at 60%-90%, and the second group performed an exercise program at 50%-65% of HR reserve. The control group maintained their normal daily regular physical activity level. The gene expressions of galectin-3 and lipid profiles were measured at the baseline and the end of Week 8. The HIIT and moderate-intensity aerobic continuous training attenuated the gene expression of galectin-3, serum low-density lipoprotein, cholesterol, and triglyceride concentrations and enhanced high-density lipoprotein concentrations. These changes were considerably higher in the HIIT group. Our results show that HIIT is superior to moderate-intensity aerobic continuous training in improving the decrease in HF risk in postmenopausal women.

Long-term Cardiac Maintenance Programming: A SINGLE-SITE ANALYSIS OF MORE THAN 200 PARTICIPANTS

PURPOSE

Greater than 65% of all cardiac mortality is related to coronary artery disease (CAD). Cardiac rehabilitation (CR) aims to reduce cardiovascular risk and number of hospital readmissions. Cardiac maintenance programs (CMPs) are designed to sustain or improve health after completing early CR. Although CMPs are supported by most national health guidelines, few long-term studies on these diverse programs have been performed.

METHODS

This was a retrospective repeated-measures analysis with case-controlled subanalysis. Within-subject differences for CMP participants were examined between enrollment and last clinical visit. Assessments included medical history, anthropometry, blood analysis, and cardiopulmonary exercise testing. A subset of 20 CMP participants were compared with 20 patients with CAD who chose not to participate in CMP, matched for age, sex, and follow-up duration.

RESULTS

A total of 207 patients (60 ± 9 yr, 16% female) were included for the primary analyses. Average follow-up was 6.3 ± 4.8 yr (range 4-20 yr). CMP participants reduced peak workload (1.76 ± 0.56 to 1.60 ± 0.58 W/kg; P < .001) and aerobic capacity (26.1 ± 6.2 to 24.6 ± 7.1 mL/kg/min; P = .003). High-density lipoprotein-cholesterol increased significantly (48 ± 12 to 51 ± 14 mg/dL; P < .001), whereas all other metabolic risk factors remained unaffected. Matched controls had higher functional capacity (2.35 ± 0.81 vs 1.56 ± 0.52 W/kg; P < .001) and lower body mass index (25.3 ± 3.6 vs 28.6 ± 3.9 kg/m2) at baseline, but no significant differences with respect to long-term efficacy were observed.

CONCLUSIONS

Long-term participation in CMP did not result in maintaining functional capacity or cardiovascular risk profile in patients with CAD. However, compared with matched nonparticipants, CMP participants (are more deconditioned at baseline) but do not seem to deteriorate as quickly.

Acute Exacerbations of Chronic Lung Disease: Cardiac Considerations

The importance of appropriately recognizing and managing patients with cardiovascular and pulmonary comorbidities is underscored by the poor outcomes described in complex comorbid patients. Patients with chronic obstructive pulmonary disease (COPD) have an increased risk, up to one-third greater than the general population, of cardiovascular comorbidities including hypertension and diabetes [1].

Cardiometabolic responses to cardiac rehabilitation in people with and without diabetes

BACKGROUND

Type 2 diabetes and cardiometabolic comorbidities manifesting as the metabolic syndrome (MetS) are highly prevalent in coronary heart disease (CHD) patients attending cardiac rehabilitation (CR). The study aimed to determine the prevalence of cardiometabolic derangements and MetS, and compare post-CR clinical responses in a large cohort of CHD patients with and without diabetes.

METHODS

Analyses were conducted on 3953 CHD patients [age: 61.1 ± 10.5 years; 741 (18.7%) with diabetes] that completed a representative 12-week CR program. A propensity model was used to match patients with diabetes (n = 731) to those without diabetes (n = 731) on baseline and clinical characteristics.

RESULTS

Diabetic patients experienced smaller improvements in metabolic parameters after completing CR, including abdominal obesity, and lipid profiles (all P ≤ .002), compared to non-diabetic patients. For both groups, there were similar improvement rates in peak metabolic equivalents ([METs]; P < .001); however, peak METs remained lower at 12-weeks in patients with diabetes than without diabetes. At baseline, the combined prevalence of insulin resistance (IR) and diabetes was 57.3%, whereas IR was present in 48.2% of non-diabetic patients, of which rates were reduced to 48.2% and 32.8% after CR, respectively. Accordingly, MetS prevalence decreased from 25.5% to 22.3% in diabetic versus 20.0% to 13.4% in non-diabetic patients (all P ≤ .004).

CONCLUSIONS

Completing CR appears to provide comprehensive risk reduction in cardio-metabolic parameters associated with diabetes and MetS; however, CHD patients with diabetes may require additional and more aggressive attention towards all MetS criteria over the course of CR in order to prevent future cardiovascular events.

See You in 7: improving acute myocardial infarction follow-up care

Acute myocardial infarction (AMI) follow-up care is a crucial part of the AMI recovery process. The American College of Cardiology’s ‘See You in 7 Challenge’ advocates that all patients discharged with a diagnosis of AMI have a cardiac rehabilitation referral made and outpatient cardiac rehabilitation appointment scheduled to occur within 7 days of hospital discharge. A streamlined AMI cardiac rehabilitation referral and appointment scheduling process was not in place at this urban academic medical centre. To develop the streamlined processes, a Six Sigma project was initiated. Four months before the intervention, 1/38 patients with AMI (2.6%) were scheduled to have the initial outpatient cardiac rehabilitation appointment occur within 7 days of hospital discharge, with an average 18.7 days from hospital discharge to the scheduled initial outpatient cardiac rehabilitation appointment. To reduce the time to this initial appointment, availability of outpatient cardiac rehabilitation appointments was increased, additional staff were trained in appointment scheduling and insurance verification processes and appointments were scheduled prior to hospital discharge. After intervention, the number of patients scheduled to attend an outpatient cardiac rehabilitation appointment within 7 days of hospital discharge improved to 72/79 (91.1%) (two-proportion test, p<0.001). Days from hospital discharge to first scheduled outpatient cardiac rehabilitation appointment were reduced from 18.7 days to 6.3 days (a 66.3% reduction) (Mann-Whitney U test, p<0.01). Initial outpatient cardiac rehabilitation attendance within 7 days of hospital discharge increased from 1/38 (2.6%) to 42/79 (53.2%) (a 50.6% increase) (two-proportion test, p<0.001).

Perspectives of cardiac rehabilitation staff on strategies used to assess, monitor and review - a descriptive qualitative study

BACKGROUND

The mechanisms contributing to the success of cardiac rehabilitation (CR) are poorly understood and may include assessment, monitoring and review activities enabled by continuity of care and this is investigated in this study.

OBJECTIVES

To identify active assessment components of CR.

METHODS

A qualitative study using focus groups and individual interviews. CR staff (n = 39) were recruited via professional association email and network contacts and organised into major themes.

RESULTS

CR staff assessment strategies and timely actions undertaken provided a sophisticated post-discharge safety net for patients. Continuity of care enabled detection of adverse health indicators, of which medication issues were prominent. Interventions were timely and personalised and therefore likely to impact outcomes, but seldom documented or reported and thus invisible to audit.

CONCLUSION

CR staff assessment and intervention activities provide an unrecognised safety net of activities enabled by continuity of care, potentially contributing to the effectiveness of CR.

Efficacy of Exercise Therapy on Cardiorespiratory Fitness in Patients With Cancer: A Systematic Review and Meta-Analysis

Purpose To evaluate the effects of exercise therapy on cardiorespiratory fitness (CRF) in randomized controlled trials (RCTs) among patients with adult-onset cancer. Secondary objectives were to evaluate treatment effect modifiers, safety, and fidelity. Methods A systematic search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library was conducted to identify RCTs that compared exercise therapy to a nonexercise control group. The primary end point was change in CRF as evaluated by peak oxygen consumption (VO_2peak; in mL O₂ × kg^-1 × min^-1) from baseline to postintervention. Subgroup analyses evaluated whether treatment effects differed as a function of exercise prescription (ie, modality, schedule, length, supervision), study characteristics (ie, intervention timing, primary cancer site), and publication year. Safety was defined as report of any adverse event (AE); fidelity was evaluated by rates of attendance, adherence, and loss to follow-up. Results Forty-eight unique RCTs that represented 3,632 patients (mean standard deviation age, 55 ± 7.5 years; 68% women); 1,990 (55%) and 1,642 (45%) allocated to exercise therapy and control/usual care groups, respectively, were evaluated. Exercise therapy was associated with a significant increase in CRF (+2.80 mL O₂ × kg^-1 × min^-1) compared with no change (+0.02 mL O₂ × kg^-1 × min^-1) in the control group (weighted mean differences, +2.13 mL O₂ × kg^-1 × min^-1; 95% CI, 1.58 to 2.67; I², 20.6; P < .001). No statistical significant differences were observed on the basis of any treatment effect modifiers. Thirty trials (63%) monitored AEs; a total of 44 AEs were reported. The mean standard deviation loss to follow-up, attendance, and adherence rates were 11% ± 13%, 84% ± 12%, and 88% ± 32%, respectively. Conclusion Exercise therapy is an effective adjunctive therapy to improve CRF in patients with cancer. Our findings support the recommendation of exercise therapy for patients with adult-onset cancer.

Exercise Therapy and Cardiovascular Toxicity in Cancer

Cardio-oncology is an emerging discipline focused predominantly on the detection and management of cancer treatment-induced cardiac dysfunction (cardiotoxicity), which predisposes to development of overt heart failure or coronary artery disease. The direct adverse consequences, as well as those secondary to anticancer therapeutics, extend beyond the heart, however, to affect the entire cardiovascular-skeletal muscle axis (ie, whole-organism cardiovascular toxicity). The global nature of impairment creates a strong rationale for treatment strategies that augment or preserve global cardiovascular reserve capacity. In noncancer clinical populations, exercise training is an established therapy to improve cardiovascular reserve capacity, leading to concomitant reductions in cardiovascular morbidity and its attendant symptoms. Here, we overview the tolerability and efficacy of exercise on cardiovascular toxicity in adult patients with cancer. We also propose a conceptual research framework to facilitate personalized risk assessment and the development of targeted exercise prescriptions to optimally prevent or manage cardiovascular toxicity after a cancer diagnosis.

Cardiopulmonary Exercise Testing in Patients Following Massive and Submassive Pulmonary Embolism

Background

Little data exist regarding the functional capacity of patients following acute pulmonary embolism. We sought to characterize the natural history of symptom burden, right ventricular (RV) structure and function, and exercise capacity among survivors of massive and submassive pulmonary embolism.

Methods and Results

Survivors of submassive or massive pulmonary embolism (n=20, age 57±13.3 years, 8/20 female) underwent clinical evaluation, transthoracic echocardiography, and cardiopulmonary exercise testing at 1 and 6 months following hospital discharge. At 1 month, 9/20 (45%) patients had New York Heart Association II or greater symptoms, 13/20 (65%) demonstrated either persistent RV dilation or systolic dysfunction, and 14/20 (70%) had objective exercise impairment as defined by a peak oxygen consumption (V˙O₂) of <80% of age‐sex predicted maximal values (16.25 [13.4–20.98] mL/kg per minute). At 6 months, no appreciable improvements in symptom severity, RV structure or function, and peak V˙O₂ (17.45 [14.08–22.48] mL/kg per minute, P=NS) were observed. No patients demonstrated an exercise limitation attributable to either RV/pulmonary vascular coupling, as defined by a VE/VCO₂ slope >33, or a pulmonary mechanical limit to exercise at either time point. Similarly, persistent RV dilation or dysfunction was not significantly related to symptom burden or peak V˙O₂ at either time point.

Conclusions

Persistent symptoms, abnormalities of RV structure and function, and objective exercise limitation are common among survivors of massive and submassive pulmonary embolism. Functional impairment appears to be attributable to general deconditioning rather than intrinsic cardiopulmonary limitation, suggesting an important role for prescribed exercise rehabilitation as a means toward improved patient outcomes and quality of life.

Disparities in Cardiac Rehabilitation Participation in the United States: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

Phase 2 cardiac rehabilitation (CR) is a class I recommendation for all patients following an acute cardiac event or cardiac surgery according to the The American Heart Association and the American College of Cardiology Foundation. Studies have shown that there are differences in cardiac rehabilitation participation rates between sociodemographic groups. The purpose of this systematic review and meta-analyses was to synthesize quantitative data on the relationship between outpatient cardiac rehabilitation (OCR) attendance and various sociodemographic factors.

METHODS

We conducted a search of PubMed, PsycINFO, CINAHL, Google Scholar, Dissertations & Theses A&I, and conference abstracts for observational studies conducted in the United States that fit our inclusion criteria. A total of 21 studies were included in our final review and meta-analyses.

RESULTS

Our meta-analyses showed that overall, attenders were younger than nonattenders (mean difference=-3.74 years, 95% CI =-5.87 to -1.61) and the odds of participation were lower among females (OR = 0.59; 95% CI = 0.51-0.69), individuals with a high school degree or less (OR = 0.67; 95% CI = 0.50-0.91), and the uninsured or self-payers (OR = 0.32; 95% CI = 0.14-0.71). Full- or part-time employees were more likely to participate than those not employed (OR = 1.45; 95% CI = 1.08-1.95).

CONCLUSIONS

Our systematic review and meta-analyses showed that there are significant sociodemographic disparities in CR participation. On the basis of this knowledge, clinicians and policy makers should focus on identifying and eliminating barriers to participation.

Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) is underutilized in the United States, with fewer than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but data regarding neighborhood characteristics and CR are sparse. We investigated the association of neighborhood socioeconomic context with CR participation in the SCCS (Southern Community Cohort Study).

METHODS AND RESULTS

The SCCS is a prospective cohort study of 84 569 adults in the southeastern United States from 2002 to 2009, 52 117 of whom have Medicare or Medicaid claims. Using these data, we identified participants with hospitalizations for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery and ascertained their CR utilization. Neighborhood socioeconomic context was assessed using a neighborhood deprivation index derived from 11 census-tract level variables. We analyzed the association of CR utilization with neighborhood deprivation after adjusting for individual socioeconomic status. A total of 4096 SCCS participants (55% female, 57% black) with claims data were eligible for CR. CR utilization was low, with 340 subjects (8%) participating in CR programs. Study participants residing in the most deprived communities (highest quintile of neighborhood deprivation) were less than half as likely to initiate CR (odds ratio 0.42, 95% confidence interval, 0.27-0.66, P<0.001) as those in the lowest quintile. CR participation was inversely associated with all-cause mortality (hazard ratio 0.77, 95% confidence interval, 0.60-0.996, P<0.05).

CONCLUSIONS

Lower neighborhood socioeconomic context was associated with decreased CR participation independent of individual socioeconomic status. These data invite research on interventions to increase CR access in deprived communities.

Chronic Obstructive Pulmonary Disease and Cardiac Diseases. An Urgent Need for Integrated Care

Chronic obstructive pulmonary disease (COPD) is a global health issue with high social and economic costs. Concomitant chronic cardiac disorders are frequent in patients with COPD, likely owing to shared risk factors (e.g., aging, cigarette smoke, inactivity, persistent low-grade pulmonary and systemic inflammation) and add to the overall morbidity and mortality of patients with COPD. The prevalence and incidence of cardiac comorbidities are higher in patients with COPD than in matched control subjects, although estimates of prevalence vary widely. Furthermore, cardiac diseases contribute to disease severity in patients with COPD, being a common cause of hospitalization and a frequent cause of death. The differential diagnosis may be challenging, especially in older and smoking subjects complaining of unspecific symptoms, such as dyspnea and fatigue. The therapeutic management of patients with cardiac and pulmonary comorbidities may be similarly challenging: bronchodilators may have cardiac side effects, and, vice versa, some cardiac medications should be used with caution in patients with lung disease. The aim of this review is to summarize the evidence of the relationship between COPD and the three most frequent and important cardiac comorbidities in patients with COPD: ischemic heart disease, heart failure, and atrial fibrillation. We have chosen a practical approach, first summarizing relevant epidemiological and clinical data, then discussing the diagnostic and screening procedures, and finally evaluating the impact of lung-heart comorbidities on the therapeutic management of patients with COPD and heart diseases.

Accuracy of Heart Rate Measurement Using Smartphones During Treadmill Exercise in Male Patients With Ischemic Heart Disease

OBJECTIVE

To evaluate the accuracy of a smartphone application measuring heart rates (HRs), during an exercise and discussed clinical potential of the smartphone application for cardiac rehabilitation exercise programs.

METHODS

Patients with heart disease (14 with myocardial infarction, 2 with angina pectoris) were recruited. Exercise protocol was comprised of a resting stage, Bruce stage II, Bruce stage III, and a recovery stage. To measure HR, subjects held smartphone in their hands and put the tip of their index finger on the built-in camera for 1 minute at each exercise stage such as resting stage, Bruce stage II, Bruce stage III, and recovery stage. The smartphones recorded photoplethysmography signal and HR was calculated every heart beat. HR data obtained from the smartphone during the exercise protocol was compared with the HR data obtained from a Holter electrocardiography monitor (control).

RESULTS

In each exercise protocol stage (resting stage, Bruce stage II, Bruce stage III, and the recovery stage), the HR averages obtained from a Holter monitor were 76.40±12.73, 113.09±14.52, 115.64±15.15, and 81.53±13.08 bpm, respectively. The simultaneously measured HR averages obtained from a smartphone were 76.41±12.82, 112.38±15.06, 115.83±15.36, and 81.53±13 bpm, respectively. The intraclass correlation coefficient (95% confidence interval) was 1.00 (1.00-1.00), 0.99 (0.98-0.99), 0.94 (0.83-0.98), and 1.00 (0.99-1.00) in resting stage, Bruce stage II, Bruce stage III, and recovery stage, respectively. There was no statistically significant difference between the HRs measured by either device at each stage (p>0.05).

CONCLUSION

The accuracy of measured HR from a smartphone was almost overlapped with the measurement from the Holter monitor in resting stage and recovery stage. However, we observed that the measurement error increased as the exercise intensity increased.

[Cardiac rehabilitation for children and adults with congenital heart disease]

Advances in heart surgery over the past 30 years have significantly improved the prognosis of congenital heart diseases (CHD). Therefore, the epidemiology of CHD has changed dramatically with a shift of mortality from pediatrics to adulthood and an increased prevalence of complex CHD. Today, caregivers and patients focus their interests to new perspectives: improving the quality of life, practicing sports, improving psychosocial care. Cardiac rehabilitation is completely integrated in these new therapeutic strategies. The starting point is the cardiopulmonary exercise test (CPET), with the measurement of oxygen uptake, or "VO2". CPET is now recommended in the follow-up of the adults with CHD. Maximum oxygen uptake correlates to the quality of life of children and adults with CHD. The principles of the rehabilitation in patients with heart failure may usually be applied to CHD patients. Some studies in complex CHD showed improvement of VO2 and quality of life after rehabilitation, without any adverse events. However few physicians have the experience in rehabilitation among CHD patients, especially children. Randomized trials on cardiac rehabilitation in adult and pediatric CHD patients are essential to increase the level of evidence and lead to specific guidelines in this population.

Overcoming research barriers in Chagas disease-designing effective implementation science

Chagas disease is a complex tropical parasitic infection. It affects a significant portion of the population in Latin America, especially in areas of poverty and poor access to health care. It also affects immigrants in high-income countries who lack access to health care due to their legal status. Millions of people are at risk of contracting the disease, and approximately 30 % of chronically infected patients will develop cardiomyopathy. The cost of caring for patients that have been infected is substantial. Basic science research has introduced new concepts and knowledge for the parasite and vector biology as well as better understanding of the pathophysiology of the disease. These research findings nevertheless require effective and timely translation into clinical practice. Likewise, the design of new research projects should account for the multiple system-based barriers. Implementation science facilitates the applicability of research findings and identifies barriers to its execution. Creation of implementation science measures to reach and sustain research programs with greater potential to impact Chagas disease are lacking. This point of view proposes opportunities for implementation science in Chagas disease and strategies for researching effective interventions for preventing and treating the disease.

Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation

PURPOSE

The goal of this study was to determine the prevalence of insulin resistance (IR) and type 2 diabetes mellitus (T2DM) in contemporary cardiac rehabilitation (CR) and to compare clinical responses in CR between these subsets of patients with coronary heart disease (CHD).

METHODS

The study cohort included 818 patients enrolled in CR and separated into 3 groups: (1) individuals with normal hemoglobin A1c (HbA1c) (NoIR: HbA1c < 5.7%); (2) individuals with IR (IR: HbA1c ≥ 5.7 to <6.5%); (3) and individuals with T2DM (HbA1c ≥ 6.5%).

RESULTS

The combined prevalence of IR (44%) and T2DM (23%) was 67%, which paralleled the prevalence of metabolic syndrome (MetSyn), present in 65% of patients. Women had a higher prevalence of IR and MetSyn than men (73% vs 64%, 72% vs. 63%, respectively) and a greater percentage with an elevated waist circumference (71% vs 60%) (all P < .05). All 3 groups experienced decreases in body weight (NoIR = -2.3 ± 4.0, IR = -1.7 ± 4.0, T2DM = -1.0 ± 4.2 kg) and increases in maximal metabolic equivalents (METs) at exercise testing (NoIR = +2.2 ± 2.5 vs IR = +2.1 ± 2.8 vs T2DM = +1.3 ± 2.3) (all P < .05). Individuals with NoIR achieved greater improvements in weight, body mass index, and METs than patients with T2DM (all P < .05). Selected individuals who participated in a 4-session behavioral weight-loss program lost more than twice the weight as nonparticipants.

CONCLUSIONS

The combined prevalence of IR and T2DM in patients with CHD enrolled in CR was remarkably high (67%). To reverse the deleterious consequences of IR and T2DM, targeted interventions involving exercise and weight loss need to be a central focus of CR programming.

Exercise and Risk of Cardiovascular Events in Women With Nonmetastatic Breast Cancer

PURPOSE

Cardiovascular disease (CVD) is a leading cause of death among women with nonmetastatic breast cancer. Whether exercise is associated with reductions in CVD risk in patients with breast cancer with an elevated CVD risk phenotype is not known.

METHODS

Using a prospective design, women (n = 2,973; mean age, 57 years) diagnosed with nonmetastatic breast cancer participating in two registry-based, regional cohort studies, completed a questionnaire that assessed leisure-time recreational physical activity (metabolic equivalent task [MET]-h/wk). The primary end point was the first occurrence of any of the following: new diagnosis of coronary artery disease, heart failure, valve abnormality, arrhythmia, stroke, or CVD death, occurring after study enrollment.

RESULTS

Median follow-up was 8.6 years (range, 0.2 to 14.8 years). In multivariable analysis, the incidence of cardiovascular events decreased across increasing total MET-h/wk categories (Ptrend < .001). Compared with < 2 MET-h/wk, the adjusted hazard ratio was 0.91 (95% CI, 0.76 to 1.09) for 2 to 10.9 MET-h/wk, 0.79 (95% CI, 0.66 to 0.96) for 11 to 24.5 MET-h/wk, and 0.65 (95% CI, 0.53 to 0.80) for ≥ 24.5 MET-h/wk. Similar trends were observed for the incidence of coronary artery disease and heart failure (P values < .05). Adherence to national exercise guidelines for adult patients with cancer (ie, ≥ 9 MET-h/wk) was associated with an adjusted 23% reduction in the risk of cardiovascular events in comparison with not meeting the guidelines (< 9 MET-h/wk; P < .001). The association with exercise did not differ according to age, CVD risk factors, menopausal status, or anticancer treatment.

CONCLUSION

Exercise is associated with substantial, graded reductions in the incidence of cardiovascular events in women with nonmetastatic breast cancer.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

The First Dedicated Cardiac Rehabilitation Program for Patients With Spontaneous Coronary Artery Dissection: Description and Initial Results

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction in women, but the role of rehabilitation after SCAD is unclear.

METHODS

We designed a dedicated SCAD cardiac rehabilitation (SCAD-CR) program for our SCAD survivors at Vancouver General Hospital. This program encompasses a multidisciplinary approach including exercise rehabilitation, psychosocial counselling, dietary and cardiovascular disease education, and peer group support. Exercise and educational classes were scheduled weekly with a targeted participation of 6 months. Psychosocial counselling, mindful living sessions, social worker and psychiatry evaluations, and peer-group support were offered.

RESULTS

We report our first consecutive cohort of 70 SCAD women who joined SCAD-CR from November 2011 to April 2015. The average age was 52.3 ± 8.4 years. Mean participation duration was 12.4 ± 10.5 weeks; 28 completed 6 months, 48 completed ≥ 1 month. At entry, 44 (62.9%) had recurrent chest pains and average metabolic equivalents on exercise treadmill test was 10.1 ± 3.3. At program exit, the proportion with recurrent chest pains was lower (37.1%) and average metabolic equivalents was higher 11.5 ± 3.5 (both P < 0.001). There was a significant improvement in the STOP-D depression questionnaire, with mean scores of 13.0 ± 1.4 before and 8.0 ± 1.7 after the SCAD-CR (P = 0.046). Twenty (28.6%) social worker referrals and 19 (27.1%) psychiatry referrals were made. Mean follow-up was 3.8 ± 2.9 years from the presenting SCAD event, and the major cardiac adverse event rate was 4.3%, lower than our non-SCAD-CR cohort (n = 145; 26.2%; P < 0.001).

CONCLUSIONS

This is the first dedicated SCAD-CR program to address the unique exercise and psychosocial needs of SCAD survivors. Our program appears safe and beneficial in improving chest pain, exercise capacity, psychosocial well-being and cardiovascular events.

Rehabilitation in Patients With Coronary Heart Disease: Participation and Its Effect on Prognosis

BACKGROUND

In Germany, rehabilitation is considered to be indicated after an acute hospital stay for the treatment of a severe cardiac condition. In comparative studies, at least 51% of German hospital patients with coronary heart disease (CHD) who were entitled to rehabilitative measures actually took part n rehabilitation.

METHODS

We examined data on 1910 patients with CHD who took part in two prospective cohort studies at the University Hospital of Halle (Saale) in the years 2007-2011. We contacted these patients again with a questionnaire to determine which ones had undergone rehabilitation. For patients who died before we could contact them, the attempt was made to obtain the dates and causes of death from the local authorities. The primary endpoint of was overall mortality.

RESULTS

The median duration of follow-up was 136 ± 71 weeks. 727 patients (38.1%) had applied for rehabilitation during their acute hospitalization, but only 552 patients (28.9%) actually underwent it. Patients who did not undergo rehabilitation were older than those who did (68.6 ± 10.3 vs. 64.9 ± 10.5 years) and suffered more commonly from diabetes (41.3% vs. 33.7%; p = 0.002), arterial hypertension (89.2% vs. 85.3%; p = 0.017), and peripheral arterial occlusive disease (15.3% vs. 9.8%; p = 0.002). There were more smokers in the rehabilitation group. Kaplan-Meier analysis and multivariate Cox regression analysis both showed that the patients who underwent rehabilitation had lower mortality (hazard ratio 0.067, 95% confidence interval 0.025-0.180, p < 0.001).

CONCLUSION

Rehabilitation for cardiac patients was associated with lower mortality. Fewer patients underwent rehabilitation in this study than in other, comparable studies. Those who did not were older and had a greater burden of accompanying disease.

Utility and efficacy of a smartphone application to enhance the learning and behavior goals of traditional cardiac rehabilitation: a feasibility study

PURPOSE

Most eligible patients do not participate in traditional clinic-based cardiac rehabilitation (CR) despite well-established benefits. Novel approaches to overcome logistic obstacles and increase efficiencies of learning, behavior modification, and exercise surveillance may increase CR participation. In an observational study, the feasibility and utility of a mobile smartphone application for CR, Heart Coach (HC), were assessed as part of standard care. Ultimately, innovative CR models incorporating HC may facilitate better CR usage and value.

METHODS

Twenty-six patients enrolled in CR installed HC. Over the next 30 days, they were prompted by HC to complete a daily "task list" that included medications, walking, education (text and videos), and surveys. Cardiac rehabilitation providers monitored each patient's progress through a HC-based Web dashboard and also sent them personalized feedback and support. Completion of the tasks and feedback (qualitative and quantitative) from patients and clinicians were tracked.

RESULTS

Patients engaged with HC 90% of days during the study period, with uniformly favorable impact on compliance and adherence. Eighty-three percent of patients reported a positive/very positive HC experience. Providers reported that HC enhanced their provision of therapy by improving communication, clinical insight, patient participation, and program efficiency.

CONCLUSIONS

Integrating a mobile care delivery platform into CR was feasible, safe, and agreeable to patients and clinicians. It enhanced patient perceptions of CR care and physician perceptions of the CR caregiving process. Mobile-enabled technologies hold promise to extend the quality and reach of CR, and to better achieve contemporary accountable care goals.

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.

Cardiac rehabilitation completion is associated with reduced mortality in patients with diabetes and coronary artery disease

AIMS

Cardiac rehabilitation (CR) reduces the risks of mortality and hospitalisation in patients with coronary artery disease and without diabetes. It is unknown whether patients with diabetes obtain the same benefits from CR.

METHODS

We retrospectively examined patients referred to a 12 week CR programme between 1996 and 2010. Associations between CR completion vs non-completion and death, hospitalisation rate and cardiac hospitalisation rate were assessed by survival analysis.

RESULTS

Over the study period, 13,158 participants were referred to CR (mean ± SD, age 59.9 ± 11.1 years, 28.9% female, 2,956 [22.5%] with diabetes). Patients with diabetes were less likely to complete CR than those without diabetes (41% vs 56%, p < .0001). Over a median follow-up of 6.6 years, there were 379 deaths in patients with diabetes vs 941 deaths among those without diabetes (12.8% vs 8.9%). Of the non-completers, patients with diabetes had a higher mortality rate compared with those without diabetes (17.7% vs 11.3%). In patients who completed CR, mortality was lower: 11.1% in patients with diabetes vs 7.0% in those without diabetes. In patients with diabetes, CR completion was associated with reduced mortality (HR 0.46 [95% CI 0.37, 0.56]), reduced hospitalisation (HR 0.86 [95% CI 0.76, 0.96]) and reduced cardiac hospitalisation (HR 0.67 [95% CI 0.54, 0.84]). The protective associations were similar to those of patients without diabetes. In multivariable adjusted analyses, all of these associations remained significant.

CONCLUSIONS

Patients with diabetes were less likely to complete CR than those without diabetes. However, patients with diabetes who completed CR derived similar apparent reductions in mortality and hospitalisation to patients without diabetes.

Exercise self-efficacy and symptoms of depression after cardiac rehabilitation: predicting changes over time using a piecewise growth curve analysis

BACKGROUND

Cardiac rehabilitation is often recommended after experiencing a cardiac event and has been shown to significantly improve health outcomes among patients. Several psychosocial variables have been linked with cardiac rehabilitation program success, including exercise self-efficacy. However, little is known about temporal patterns in patients' exercise self-efficacy after program completion.

OBJECTIVE

This study examined changes in exercise self-efficacy among 133 cardiac rehabilitation patients and whether symptoms of depression impacted the rate of change in exercise self-efficacy.

METHOD

Participants completed questionnaires at the beginning and end of cardiac rehabilitation and at 6-month intervals for 2 years.

RESULTS

Growth curve analyses showed that exercise self-efficacy levels were highest at the beginning of cardiac rehabilitation, significantly declined 6 months after cardiac rehabilitation, and leveled off over the next 18 months. Results also showed that baseline depressive symptoms interacted with time: Compared with participants with fewer symptoms, participants high in depressive symptoms began cardiac rehabilitation with lower levels of exercise self-efficacy and evidenced significant declines 6 months after cardiac rehabilitation. At no time were they equal to their counterparts in exercise self-efficacy, and their means were lower 2 years after cardiac rehabilitation than before cardiac rehabilitation.

CONCLUSIONS

Our findings imply that patients show unrealistic optimism surrounding the ease of initiating and maintaining an exercise program and that integrating efficacy-building activities into cardiac rehabilitation, especially for patients who show signs of distress, is advisable.

Resistance training improves hemodynamic function, collagen deposition and inflammatory profiles: experimental model of heart failure

The role of resistance training on collagen deposition, the inflammatory profile and muscle weakness in heart failure remains unclear. Therefore, this study evaluated the influence of a resistance training program on hemodynamic function, maximum strength gain, collagen deposition and inflammatory profile in chronic heart failure rats. Thirty-two male Wistar rats submitted to myocardial infarction by coronary artery ligation or sham surgery were assigned into four groups: sedentary sham (S-Sham, n = 8); trained sham (T-Sham, n = 8); sedentary chronic heart failure (S-CHF, n = 8) and trained chronic heart failure (T-CHF, n = 8). The maximum strength capacity was evaluated by the one maximum repetition test. Trained groups were submitted to an 8-week resistance training program (4 days/week, 4 sets of 10-12 repetitions/session, at 65% to 75% of one maximum repetition). After 8 weeks of the resistance training program, the T-CHF group showed lower left ventricular end diastolic pressure (P<0.001), higher left ventricular systolic pressure (P<0.05), higher systolic blood pressure (P<0.05), an improvement in the maximal positive derivative of ventricular pressure (P<0.05) and maximal negative derivative of ventricular pressure (P<0.05) when compared to the S-CHF group; no differences were observed when compared to Sham groups. In addition, resistance training was able to reduce myocardial hypertrophy (P<0.05), left ventricular total collagen volume fraction (P<0.01), IL-6 (P<0.05), and TNF-α/IL-10 ratio (P<0.05), as well as increasing IL-10 (P<0.05) in chronic heart failure rats when compared to the S-CHF group. Eight weeks of resistance training promotes an improvement of cardiac function, strength gain, collagen deposition and inflammatory profile in chronic heart failure rats.

Effect of a lifestyle therapy program using cardiac rehabilitation resources on metabolic syndrome components

PURPOSE

To assess the effect of a lifestyle therapy program using cardiac rehabilitation (CR) resources for patients at risk for metabolic syndrome (MetS).

METHODS

We designed a cardiometabolic program (CMP) using CR facilities and resources. We compared MetS components of 240 patients classified as either obese (body mass index, ≥30 kg/m) or hyperglycemic (fasting glucose, >100 mg/dL): 58 enrolled and completed the CMP, 59 signed up for the CMP but never attended or dropped out early (control 1) but had followup data, and 123 did not sign up for the CMP (control 2).

RESULTS

The CMP group showed a significant improvement at 6 weeks in waist circumference, body weight, diastolic blood pressure, and total cholesterol. At 6 months, fasting glucose also improved. In contrast, improvements in control 1 and control 2 were modest at best. Comparing the 6-month changes in the CMP group versus control 1 group, those in the CMP had pronounced weight loss (-4.5 ± 5 kg vs. -0.14 ± 6 kg; P < .001), decreased systolic blood pressure (-1.1 ± 17 mm Hg vs. +9.6 ± 20 mm Hg; P = .004), and decreased diastolic blood pressure (-4.6 ± 11 mm Hg vs. +3.4 ± 15 mm Hg; P = .002). Similarly, comparing CMP group versus control 2 group, body weight (-4.5 ± 5 kg vs. -0.9 ± 3 kg; P < .001) and diastolic blood pressure (-4.6 ± 11 mm Hg vs. -0.7 ± 9 mm Hg; P = .02) declined in the CMP group.

CONCLUSION

A lifestyle therapy program using resources of a CR program is effective for individuals who have or are at risk for MetS, although enrollment and completion rates are low.