Relationship between older coronary heart disease patients' phase II cardiac rehabilitation intentions, illness perceptions, and family caregivers' illness perceptions

BACKGROUND

Intention is an important factor in encouraging patients to receive cardiac rehabilitation. Illness perceptions of patients and individuals around them, such as family caregivers, may influence intention. However, no study has explored how family caregivers' illness perceptions enhance older coronary heart disease (CHD) patients' phase II cardiac rehabilitation intentions.

OBJECTIVES

To describe older CHD patients' phase II cardiac rehabilitation intentions and their relationship with family caregivers' illness perceptions and to examine the mediating role of patients' illness perceptions.

METHODS

A descriptive cross-sectional study was conducted among 202 older CHD patient‒family caregiver dyads. The Chinese versions of the Revised Illness Perception Questionnaire, Willingness to Participate in Cardiac Rehabilitation Questionnaire (WPCRQ), and Cardiac Rehabilitation Inventory (CRI) were adopted. Data analysis included descriptive statistics, Pearson correlations, and structural equation modeling. Reporting followed the STROBE checklist.

RESULTS

Patients were 69.81 years and mostly male (64.85 %); family caregivers were 52.58 years and mostly female (55.94 %). Family caregivers' personal control had a direct effect on patients' phase II cardiac rehabilitation intentions (βWPCRQ = -0.217, βCRI = -0.228; P = 0.001). Family caregivers' personal control, treatment control, and timeline acute/chronic had indirect effects on patients' cardiac rehabilitation intentions through patients' corresponding dimensions of illness perceptions (|β|WPCRQ = 0.086∼0.098, |β|CRI = 0.062∼0.097; P < 0.05).

CONCLUSION

Family caregivers' illness perceptions can affect patients' phase II cardiac rehabilitation intentions directly and indirectly through patients' illness perceptions. Interventions targeting illness perceptions in both older CHD patients and their family caregivers could be provided to improve patients' phase II cardiac rehabilitation intentions.

The content and characteristics of face-to-face interventions to encourage patients' enrollment in cardiac rehabilitation; a scoping review

PURPOSE

To provide an overview of the content and characteristics of face-to-face interventions to encourage enrollment in exercise-based cardiac rehabilitation (CR).

METHODS

Following a published protocol describing the methods, six databases were searched. The search was limited to studies published from January 2000 to December 2021. Two reviewers independently performed study selection and data extraction.

RESULTS

5583 studies were identified and 20 studies with a variety of study designs met the inclusion criteria. Eight studies specified important content in face-to-face interventions to be: Education, problem-solving, support of autonomy, exploring reasons for change, emotional and cognitive support while showing understanding. Studies targeting patients' experiences used motivational interviewing and addressed worries and anticipated difficulties. Intention to attend, CR barriers, practical barriers, exercise self-efficacy, and patients asking questions supported enrollment. Reassurance could lead to nonattendance if patients had a high degree of worry and distress.

CONCLUSION

Face-to-face interventions are important to support patients' enrollment in CR and should integrate a person-centered dialogue exploring reasons for change and providing support to overcome barriers. Focus on the patients' perspectives, the mechanisms of change, and the evaluation of the intervention to inform implementation should be further explored.Implications for RehabilitationIn-hospital face-to-face interventions support enrollment in cardiac rehabilitation (CR) in patients with ischemic heart disease.This study suggests that individual worries and barriers toward CR should be jointly explored while considering patients' capacity for making choices as well as their vulnerability.Patients should be encouraged to ask questions.A too strong focus on reassurance and problem-solving can impede enrollment.

Patient characteristics and reasons for discontinuation in a cardiovascular risk management programme in The Netherlands

BACKGROUND

Since 2010, an increasing number of patients have participated in a nurse-led integrated cardiovascular risk management programme in the Netherlands. Because it is important to understand which patients discontinue and why, when evaluating the effectiveness of the care programme, the aim was to identify the reasons for discontinuation.

METHODS

Electronic health records of 3997 patients enrolled in a nurse-led integrated cardiovascular risk management programme that started on April 1st, 2010, were manually scrutinized for reasons for discontinuation between April 1st, 2010, and April 1st, 2018. In addition to death and moving to a diabetes care programme, we describe 7 different reasons why patients discontinued the programme and compared the patient characteristics of those who discontinued the programme without specific reasons with those who remained in the care programme for 8 years.

RESULTS

Between April 1st, 2010, and April 1st, 2018, 1,190 participants (29.8%) discontinued the CVRM care programme, of whom 271 participants died (6.8%) and 195 were transferred to a diabetes care programme (4.9%). The remaining 724 patients (18.1%) participated 5 years before discontinuation. Of these, 67 (9.3%) had a previous cardiovascular event at the start of the programme. In 355 patients, a specific reason for discontinuation was not found. At baseline, these patients less frequently had a history of CVD than those who continued the programme for 8 years (1.7 vs. 22.6%), were younger (62 vs. 67 years), had less registered cardiovascular comorbidity (atrial fibrillation: 1.1 vs. 7.2%; congestive heart failure 0.3 vs. 1.2%; chronic kidney disease 0.0 vs. 4.5%), were more often smokers (13.0% vs. 4.3%) and took blood pressure- and lipid-lowering drugs twice as often.

CONCLUSIONS

In our study we observed that participants who discontinued the nurse-led integrated CVRM care programme between 2010 and 2018 without specific reason or on request were younger, without previous CVD, had less cardiovascular comorbidity and were better adjusted to medication. Exploring the patients' reasons for discontinuation can contribute to an individualized approach to prevent or reduce discontinuation.

Depressive Symptoms After Acute Myocardial Infarction and Its Association With Low Functional Capacity and Physical Activity

PURPOSE

Depressive symptoms after acute myocardial infarction (AMI) are related with adverse health outcomes. However, the risk factors and course of depressive symptoms after AMI have not been widely investigated, especially in Asian populations. We aimed to evaluate changes in the prevalence of depressive symptoms and the associated risk factors at 3 mo after AMI. We also investigated the associations among functional capacity, physical activity (PA), and depressive symptoms.

METHODS

This cross-sectional study was conducted for 1545 patients who were admitted for AMI and referred to cardiac rehabilitation (CR) between August 2015 and March 2019. Of these patients, 626 patients completed the Patient Health Questionnaire-9 (PHQ-9), the Korean Activity Scale Index (KASI), and the International Physical Activity Questionnaire (IPAQ) 3 mo following AMI. A PHQ-9 score of ≥5 was considered to indicate depressive symptoms.

RESULTS

The prevalence of depressive symptoms was 30% at baseline and decreased to 12% at 3 mo after AMI. Depressive symptoms were significantly associated with low functional capacity (OR = 2.20, P = .004) and unemployment status (OR = 1.82, P = .023). After adjusting for variables including functional capacity, depressive symptoms exhibited a significant relationship with low PA after AMI (OR = 1.80, P = .023).

CONCLUSION

Systematic screening and treatment for depressive symptoms and efforts to promote CR may help to improve PA and functional capacity in Korean patients with AMI. Such efforts may aid in reducing the depressive symptoms and related adverse outcomes.

Active Lifestyle Post First Myocardial Infarction: A Comparison between Participants and Non-Participants of a Structured Cardiac Rehabilitation Program

Following myocardial infarction (MI), impaired physical, mental, and cognitive functions can reduce participation in the community and diminish quality of life. This study aims to assess active lifestyle participation and functional performance in patients who were participants and non-participants in cardiac rehabilitation. A total of 71 patients were recruited, 6-10 months after the MI event; 38 chose to participate in a cardiac rehabilitation (CR) program, and 33 did not (NCR). Participation and activity patterns in instrumental activities of daily living, as well as physically demanding leisure activities and social activities, were evaluated using the Activity Card Sort (ACS). Hand grip force and timed up and go (TUG) were tested. A total of 74% of the CR group met physical activity recommendations and only 34% continued to smoke, compared to 39% and 71% in the NCR group, respectively. The CR group, compared to the NCR group, had higher levels of daily activity, social leisure, and physically demanding leisure activities (p ≤ 0.001). Null differences between the NCR and CR groups were observed in grip strength and the TUG tests. The study highlighted community participation after MI. Based on a comparison between the groups, the study implies that patients choosing to participate in CR retained higher community participation levels and had better self-management of cardiovascular risk factors.

Identifying Reasons for Nonattendance and Noncompletion of Cardiac Rehabilitation: INSIGHTS FROM GERMANY AND THE NETHERLANDS

PURPOSE

Despite strong recommendations and beneficial health effects of cardiac rehabilitation (CR), participation rates remain low. Little data are available on reasons beyond quantitative factors in the underutilization of CR. The aim of this study was to identify personal reasons for nonattenders and noncompletions of CR among Dutch and German patients with cardiovascular diseases (CVD) eligible for CR.

METHODS

Between December 2017 and January 2019, a total of 4265 questionnaires were distributed among eligible patients for CR in the bordering area of the eastern Netherlands and western Germany. Patients were eligible if they had an indication for CR according to national guidelines. Questionnaires were used to assess reasons of nonattendance and noncompletion of CR, when applicable.

RESULTS

A total of 1829 patients with CVD completed the questionnaire. Of these, 1278 indicated that they received referral to CR. Despite referral, 192 patients decided not to participate in CR and 88 patients with CVD withdrew from the CR program. The three most reported reasons for nonattendance were as follows: (1) did not need the supervision (56%, n = 108), (2) did not need the CR trajectory (55%, n = 105), and (3) already exercised regularly (39%, n = 74). The most reported reasons for noncompletion were as follows: (1) could no longer participate because of other physical problems (30%, n = 26), (2) did not need the CR trajectory (26%, n = 23), and (3) the CR program was not personal enough (23%, n = 20).

CONCLUSIONS

Most patients had motivational or perceptive reasons for nonattendance or noncompletion to CR. These possible misconceptions as well as perceived shortcomings of traditional CR underline the need for adequate motivation, information, and more personalized solutions (eg, eHealth, home-based CR) to increase the uptake and completion of CR.

Individuals' Intention to Engage in Outpatient Cardiac Rehabilitation Programs: Prediction Based on an Enhanced Model

Motivation is an important factor in encouraging individuals to attend rehabilitation and underpins many approaches to engagement. The aims of this study were to develop an accurate model able to predict individual intention to engage in outpatient cardiac rehabilitation (CR) programs based on the first stage of the Model of Therapeutic Engagement integrated into a socio-environmental context. The cross-sectional study in the cardiology ward of an Australian hospital included a total of 217 individuals referred to outpatient CR. Through an ordinal logistic regression, the effect of random forest (RF)-selected profile features on individual intention to engage in outpatient CR was explored. The RF based on the conditional inference trees predicted the intention to engage in outpatient CR with high accuracy. The findings highlighted the significant roles of individuals' 'willingness to consider the treatment', 'perceived self-efficacy' and 'perceived need for rehabilitation' in their intention, while the involvement of 'barriers to engagement' and 'demographic and medical factors' was not evident.

A Socially Assistive Robot for Long-Term Cardiac Rehabilitation in the Real World

What are the benefits of using a socially assistive robot for long-term cardiac rehabilitation? To answer this question we designed and conducted a real-world long-term study, in collaboration with medical specialists, at the Fundación Cardioinfantil-Instituto de Cardiología clinic (Bogotá, Colombia) lasting 2.5 years. The study took place within the context of the outpatient phase of patients' cardiac rehabilitation programme and aimed to compare the patients' progress and adherence in the conventional cardiac rehabilitation programme (control condition) against rehabilitation supported by a fully autonomous socially assistive robot which continuously monitored the patients during exercise to provide immediate feedback and motivation based on sensory measures (robot condition). The explicit aim of the social robot is to improve patient motivation and increase adherence to the programme to ensure a complete recovery. We recruited 15 patients per condition. The cardiac rehabilitation programme was designed to last 36 sessions (18 weeks) per patient. The findings suggest that robot increases adherence (by 13.3%) and leads to faster completion of the programme. In addition, the patients assisted by the robot had more rapid improvement in their recovery heart rate, better physical activity performance and a higher improvement in cardiovascular functioning, which indicate a successful cardiac rehabilitation programme performance. Moreover, the medical staff and the patients acknowledged that the robot improved the patient motivation and adherence to the programme, supporting its potential in addressing the major challenges in rehabilitation programmes.

African American Women's Perceptions of Cardiovascular Disease After Myocardial Infarction: A Phenomenological Inquiry

BACKGROUND

The primary cause of death among African American women older than 50 years is cardiovascular disease. Cardiovascular disease affects more than 16.8 million Americans and occurs when plaque builds up in the arteries that provide blood to the heart. This often leads to a partial or complete blockage, causing a myocardial infarction (heart attack). There is limited research regarding the lived experiences of African American women before and after a myocardial infarction.

OBJECTIVE

The purpose of this qualitative study was to explore the experiences of African American women living in the southern region of the United States who have experienced a myocardial infarction.

METHODS

A hermeneutic phenomenological framework guided the study. Semistructured, audiotaped interviews were conducted to elicit narratives from 7 participants. Interview data were transcribed verbatim and then coded and analyzed using Colaizzi's phenomenological analysis framework.

RESULTS

The findings revealed 6 major themes: life before myocardial infarction, causes of my myocardial infarction, myocardial infarction warning signs, life after myocardial infarction, cardiac rehabilitation, and family support. Lifestyle changes must be implemented to prevent a second blockage. Attending cardiac rehabilitation and incorporating regular physical exercise are recommended to help prevent further heart damage and to improve quality of life.

An integrative review on facilitators and barriers in delivering and managing injectable therapies in chronic conditions: A part of the ACNAP project 'injectable medicines among patients with cardiovascular conditions'

INTRODUCTION

Although preventive health and therapeutics have benefited from advances in drug development and device innovation, translating these evidence-based treatments into real-world practice remains challenging.

AIM

The current integrative review aims to identify facilitators and barriers and perceptions in delivering and managing injectable therapies from patient perspectives.

METHODS

An integrative review was conducted in the databases of PubMed, CINAHL, PsycINFO and Cochrane. Keywords were used "Injectable therapy", "IV therapy", "SC therapy", "long term injectable therapies", "self-administered injectable therapy", "patients", "caregivers", "family", "carers", "facilitators", "barriers", "perspectives", "needs", "expectations", "chronic disease", "cardiovascular disease" linked with the words "OR" and "AND". The search was limited from January 2000 to July 2019. Inclusion and exclusion criteria were used.

RESULTS

Twenty studies were identified from the literature search. Studies followed qualitative, quantitative methodology and mixed methods. Facilitators included: health improvement, prevention of disease complications, taking control of their disease, effectiveness of the medication and convenience in management. Barriers included: fear of needles, insulin will cause harm, poor perception of the benefits of injectable therapies on their quality of life, inconvenience in self-management, social stigma, impact on daily living, financial barriers, lack of education. Perceptions included: 'treatment of last resort', 'life becomes less flexible', 'injectables were punishment/restriction', 'personal failure of self-management'.

CONCLUSION

Evidence shows how to create effective communication and shared decision-making relationships to provide best possible care to patients who need injectable therapy and support for self-management. Future research might help guide response to the fears and barriers of the patients using patients' perspectives.

Association between attending exercise-based cardiac rehabilitation and cardiovascular risk factors at one-year post myocardial infarction

Background

Randomized trials confirm the benefits of exercise-based cardiac rehabilitation on cardiovascular risk factors. Whether exercise-based cardiac rehabilitation provides the same favourable effects in real-life cardiac rehabilitation settings, in the modern era of myocardial infarction treatment, is less well known. We examined the association between attending exercise-based cardiac rehabilitation and improvements in cardiovascular risk factors at one-year post myocardial infarction in patients included in the Swedish heart disease registry, SWEDEHEART.

Methods

In this retrospective registry-based cohort study, we included 19 136 patients post myocardial infarction (75% men, 62.8±8.7 years) who were registered in SWEDEHEART between 2011 and 2013. The association between attending exercise-based cardiac rehabilitation (43% participation rate) and changes in cardiovascular risk profile between baseline and one-year follow-up was assessed using multivariable regression analysis adjusting for age, comorbidities and medication.

Results

Attenders more often reported to have stopped smoking (men 64% vs 50%; women 64% vs 53%, p<0.001 for both, only smokers at baseline considered), be more physically active (men 3.9±2.5 vs 3.4±2.7 days/week; women 3.8±2.6 vs 3.0±2.8 days/week, p<0.001 for both) and achieved a slightly larger reduction in triglycerides (men -0.2±0.8 vs -0.1±0.9 mmol/L, p = 0.001; women -0.1±0.6 vs 0.0±0.8 mmol/L, p = 0.01) at one-year compared to non-attenders. Male attenders gained less weight (+0.0±5.7 vs +0.3±5.7 kg, p = 0.01) while female attenders achieved better lipid control (total cholesterol -1.2±1.4 vs -0.9±1.4 mmol/L, p<0.001; low-density lipoprotein -1.2±1.2 vs -0.9 ±1.2 mmol/L, p<0.001) compared to non-attenders.

Conclusions

In an unselected registry cohort of patients post myocardial infarction, compared to non-attenders those attending exercise-based cardiac rehabilitation achieved significantly larger improvements in cardiovascular risk factors at one-year after the acute event.

Patient Perception of How Smoking Status Influences Cardiac Rehabilitation Attendance After an Acute Cardiac Hospitalization

PURPOSE

Patients hospitalized with a cardiac condition are less likely to attend cardiac rehabilitation (CR) if they are smokers despite the benefits of doing so. The present study sought to investigate how, if at all, a patient's decision to attend CR was influenced by his or her tobacco use post-discharge.

METHODS

We surveyed smokers during their hospitalization for a cardiac condition. Four to 8 wk after discharge, a follow-up survey assessed self-reported CR attendance, smoking cessation (SC), and patient opinion of how their smoking status influenced CR attendance.

RESULTS

Of the 81 patients who completed the baseline survey (68% male, 57 ± 10 y), 62 (77%) completed the follow-up survey. Consistent with prior findings, there was a substantial correlation between SC and CR attendance (OR: 16.0, P < .001) with 36 (44%) patients attending CR overall and 38 (47%) abstaining from smoking. Patients reported a wide variety of reasons for not attending CR, but most patients (n = 39, 63%) reported that their smoking status did not influence their decision to attend CR. However, 5 patients (8%) reported attending CR because they successfully quit smoking, and 5 (8%) attended CR anticipating support with SC.

CONCLUSION

A strong relationship exists between SC and CR attendance following a cardiac hospitalization; however, most patients did not feel that their smoking status was a factor in their decision to attend CR. Regardless of the reason, it appears that success with one behavior may be related to the other and that both SC and CR attendance should be encouraged.

Web-based cardiac habilitatio alternative for those declining or dropping out of conventional rehabilitation: results of the WREN feasibility randomised controlled trial

Introduction

Cardiac rehabilitation (CR) is typically delivered in hospital-based classes and is recommended to help people reduce their risk of further cardiac events. However, many eligible people are not completing the programme. This study aimed to assess the feasibility of delivering a web-based CR intervention for those who decline/drop out from usual CR.

Intervention

A web-based CR programme for 6 months, facilitated with remote support.

Methods

Two-centre, randomised controlled feasibility trial. Patients were randomly allocated to web-based CR/usual care for 6 months. Data were collected to inform the design of a larger study: recruitment rates, quality of life (MacNew), exercise capacity (incremental shuttle walk test) and mood (Hospital Anxiety and Depression Scale). Feasibility of health utility collection was also evaluated.

Results

60 patients were randomised (90% male, mean age 62±9 years, 26% of those eligible). 82% completed all three assessment visits. 78% of the web group completed the programme. Quality of life improved in the web group by a clinically meaningful amount (0.5±1.1 units vs 0.2±0.7 units: control). Exercise capacity improved in both groups but mood did not change in either group. It was feasible to collect health utility data.

Conclusions

It was feasible to recruit and retention to the end of the study was good. The web group reported important improvements in quality of life. This intervention has the opportunity to increase access to CR for patients who would otherwise not attend. Promising outcomes and recruitment suggest feasibility for a full-scale trial.

Trial registration number

10726798.

Intention, beliefs and mood assessed using electronic diaries predicts attendance at cardiac rehabilitation: An observational study

BACKGROUND

Cardiac rehabilitationis effective in promoting physical/psychological recovery following acute coronary syndrome. Yet, rates of attendance at outpatient cardiac rehabilitation by eligible patients are low.

OBJECTIVES

This study examined the determinants of attendance at outpatient cardiac rehabilitation in acute coronary syndrome patients following discharge until cardiac rehabilitation commencement.

DESIGN

A weekly electronic diary measured cardiac-related cognitions and mood and examined their relation to attendance at outpatient cardiac rehabilitation.

SETTINGS

Three United Kingdom National Health Service secondary care settings in two Health Board areas in Scotland.

PARTICIPANTS

Acute coronary syndrome patients were recruited from March 2012 to June 2013 prior to hospital discharge. Of 488 eligible patients referred for cardiac rehabilitation, 214 consented.

METHODS

Consecutive patients completed a pre-hospital discharge questionnaire targeting age, diagnosis, social class and smoking history. Acute coronary syndrome patients then completed a weekly electronic diary from the first week of discharge until the start of cardiac rehabilitation. Multilevel structural equation models estimated the effects of initial, i.e. baseline and rate of change in cardiac-related cognition and mood on attendance. Intention to attend cardiac rehabilitation was reflected, log transformed, reported thereafter as "do not intend". The role of "do not intend" was explored as a mediator of the relationship between cardiac-related cognition and mood on attendance.

RESULTS

166 participants provided, on average, 5 weeks of diary entries before cardiac rehabilitation commenced. High intention (i.e. low "do not intend") to attend CR and its rate of increase over time predicted attendance. Low negative emotional representation, high perceived necessity, high confidence in maintaining function, low negative affect, and high positive affect following discharge predicted attendance at cardiac rehabilitation. The rate of change in cardiac-related mood and these cognitions was not predictive. Baseline and rate of change in "do not intend" entirely mediated relationships between a) perceived necessity, b) negative affect and attendance at cardiac rehabilitation.

CONCLUSIONS

Negative affect in the first weeks following discharge represents the key challenge to a patient maintaining their intention to attend cardiac rehabilitation. Intervention to improve attendance should focus on improving intention to attend following discharge and during recovery by improving patient understanding of cardiac rehabilitation and reducing negative affect.

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

AIM

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

BACKGROUND

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

DESIGN

A two-arm, randomized controlled trial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Implementing resistance training in the rehabilitation of coronary heart disease: A systematic review and meta-analysis

BACKGROUND

Resistance training has demonstrated efficacy in cardiac rehabilitation programs, but the optimal prescription of resistance training is unknown. This systematic review with meta-analysis compared the effectiveness of cardiac rehabilitation consisting of resistance training either alone (RT) or in combination with aerobic training (CT) with aerobic training only (AT) on outcomes of physical function. Further, resistance training intensity and intervention duration were examined to identify if these factors moderate efficacy.

METHODS

Six electronic databases were searched to identify studies investigating RT, coronary heart disease and physical function. The overall quality of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible and qualitative analysis was performed for the remaining data.

RESULTS

Improvements in peak oxygen uptake (WMD: 0.61, 95% CI: 0.20-1.10), peak work capacity (SMD: 0.38, 95% CI: 0.11-0.64) and muscular strength (SMD: 0.65, 95% CI: 0.43-0.87) significantly favoured CT over AT with moderate quality evidence. There was no evidence of a difference in effect when comparing RT and AT. Shorter duration CT was superior to shorter duration AT for improving peak oxygen uptake and muscular strength (low quality evidence) while longer duration CT was only superior to longer duration AT in improving muscular strength (moderate quality evidence).

CONCLUSIONS

CT is more beneficial than AT alone for improving physical function. Although preliminary findings are promising, more high-quality evidence is required to determine the efficacy of high intensity resistance training. Shorter duration interventions that include resistance training might allow patients to return to their normal activities of daily living earlier.

Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

BACKGROUND

Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation.

METHODS AND RESULTS

Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees, using the Huber-White-sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98-0.99), having a partner (OR 1.31, 95% CI 1.17-1.48), not being employed (OR 0.86, 95% CI 0.77-0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77-0.92), greater anxiety (OR 1.02, 95% CI 1.003-1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42-0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09-2.47).

CONCLUSIONS

CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized.

Relationship between employment and mental health outcomes following Cardiac Rehabilitation: an observational analysis from the National Audit of Cardiac Rehabilitation

BACKGROUND

Employment status has been shown to impact mental health state and intervention outcomes, yet still to be studied in a Cardiac Rehabilitation (CR) population. This observational study investigated the relationship between employment status and mental health outcomes following Cardiac Rehabilitation (CR).

METHODS

All patients with an eligible cardiovascular incident entered into the National Audit of Cardiac Rehabilitation (NACR) 1 January 2013-31st December 2015. Logistic regression comparing the association between employment status and normal mental health categories.

RESULTS

A total of 24,242 CR patients with completed post CR assessments were included and had representative age and gender distribution (mean 65years, 73.2% male). At baseline the unemployed status had a lower proportion of patients in normal healthy categories than other groups (T-test and chi-squared p=<0.05). The regression analyses revealed no significant association between retired and employed groups and outcome. There was significant association between unemployed patients and all mental health outcomes except anxiety; all p values<0.05 and odds ratios between 0.525 and 0.772 showing less likelihood of achieving the normal healthy category.

CONCLUSIONS

This is the first UK study, using routinely collected data, to investigate in coronary heart disease patients the impact of employment status on outcomes. The findings were that when weighted for baseline differences, unemployed patients mostly had poorer outcomes. Teams involved in CR delivery should take particular care when interpreting mental health baseline measures when setting CR goals, especially in relation to unemployed patients, and efforts should be made in providing more patient tailored interventions.

Cognitive Outcomes of Cardiovascular Surgical Procedures in the Old: An Important but Neglected Area

Older individuals can now undergo invasive cardiovascular procedures without serious concern about mortality, and the numbers and proportions of the over 65s and 85s doing so in Australia has been increasing over the last 20 years. There is overwhelming evidence linking cardiovascular conditions to late-life (65 years and over) cognitive impairment and dementia including Alzheimer's Disease, primarily due to impaired cerebrovascularisation and cascading neuropathological processes. Somewhat paradoxically, these cardiovascular interventions, carried out with the primary aim of revascularisation, are not usually associated with short- or long-term improvements in cognitive function in older adults. We discuss factors associated with cognitive outcomes post-cardiovascular surgeries in patients over 65 years of age. There are many opportunities for future research: we know almost nothing about cognitive outcomes following invasive cardiac procedures in the oldest old (85 years and over) nor how to predict the cognitive/delirium outcome using pre-surgical data, and lastly, intervention opportunities exist both pre and postoperatively that have not been tested. As our population ages with increased cardiovascular burden and rates of cardiovascular interventions and surgeries, it is critical that we understand the cognitive consequences of these procedures, who is at greatest risk, and ways to optimise cognition.

Effects of a Phase IV Home-Based Cardiac Rehabilitation Program on Cardiorespiratory Fitness and Physical Activity

BACKGROUND

Cardiovascular diseases are the leading cause of death globally and sedentary lifestyle is one of the main risk factors. Home-based cardiac rehabilitation (CR) programs appear to be effective to improve exercise tolerance. The aim of the study, therefore, was to evaluate the effects of a phase IV (maintenance) home-based CR program on cardiorespiratory fitness and daily physical activity of patients recovering from an acute myocardial infarction.

METHODS

This pilot study, with a sub-group randomised controlled trial, included 32 individuals recovering from a myocardial infarction, randomly divided into the experimental group (EG, n=16) and the control group (CG, n=16). The EG performed an exercise program, three times per week, at home during eight weeks. The two groups received health education sessions. Baseline and final assessments included cardiorespiratory fitness, resting and peak heart rate, blood pressure and rate pressure, heart rate recovery and daily physical activity. (ClinicalTrials.gov: NCT01887080).

RESULTS

At baseline no significant differences were observed between groups. After eight weeks of exercise, the EG significantly increased peak oxygen uptake (p=0.02), test duration (p=0.019), peak rate pressure (p=0.003), peak heart rate (p=0.003) and heart rate recovery (0.025) when compared to the CG. No changes were observed on daily physical activity in both groups.

CONCLUSION

This specific phase IV home-based exercise program seems to improve cardiorespiratory fitness, haemodynamics at peak exercise and heart rate recovery, an indicator of cardiac autonomic function.

Employment Status and Participation in Cardiac Rehabilitation: DOES ENCOURAGING EARLIER ENROLLMENT IMPROVE ATTENDANCE?

PURPOSE

For patients hospitalized for a cardiac event, an earlier appointment to outpatient cardiac rehabilitation (CR) increases participation. However, it is unknown what effect hastening CR enrollment might have among employed patients planning to return to work (RTW).

METHODS

Using 2 complementary data sets from Henry Ford Hospital (HFH) and Mayo Clinic, we assessed when employed patients eligible for CR anticipated a RTW, the impact of an earlier appointment on CR enrollment, and the effect of employment status on the number of CR sessions attended. Patients at HFH attended CR at either 8 or 42 days (through randomization), whereas Mayo Clinic patients attended 10 days after hospital discharge per standard routines.

RESULTS

Among 148 patients at HFH, 65 (44%) were employed and planned to RTW. Of these, 67% desired to RTW within 1 to 2 weeks, whereas 28% anticipated an RTW within 1 to 3 days. Home financial strain predicted nonparticipation in CR (P < .001) and was associated with an earlier planned RTW. Among 1030 patients at Mayo Clinic, 393 (38%) were employed. Employed (vs nonemployed) patients enrolled in CR 3.3 days sooner (P < .001), but attended 1.6 fewer CR sessions (P = .04). In employed patients from both health systems, an earlier (vs later) appointment to CR did not result in additional exercise sessions of CR.

CONCLUSIONS

Employed patients plan to RTW quickly, in part because of home finances. They also enroll earlier into CR than nonemployed patients. Despite these findings, earlier appointments do not seem to favorably impact overall CR participation.

Internet-based interventions for the secondary prevention of coronary heart disease

BACKGROUND

The Internet could provide a means of delivering secondary prevention programmes to people with coronary heart disease (CHD).

OBJECTIVES

To determine the effectiveness of Internet-based interventions targeting lifestyle changes and medicines management for the secondary prevention of CHD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, in December 2014. We also searched six other databases in October 2014, and three trials registers in January 2015 together with reference checking and handsearching to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating Internet-delivered secondary prevention interventions aimed at people with CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data according to the Cochrane Handbook for Systematic Reviews of Interventions. We assessed evidence quality using the GRADE approach and presented this in a 'Summary of findings' table.

MAIN RESULTS

Eighteen trials met our inclusion criteria. Eleven studies are complete (1392 participants), and seven are ongoing. Of the completed studies, seven interventions are broad, targeting the lifestyle management of CHD, and four focused on physical activity promotion. The comparison group in trials was usual care (n = 6), minimal intervention (n = 3), or traditional cardiac rehabilitation (n = 2).We found no effects of Internet-based interventions for all-cause mortality (odds ratio (OR) 0.27, 95% confidence interval (CI) 0.04 to 1.63; participants = 895; studies = 6; low-quality evidence). There was only one case of cardiovascular mortality in a control group (participants = 895; studies = 6). No incidences of non-fatal re-infarction were reported across any of the studies. We found no effects for revascularisation (OR 0.69, 95% CI 0.37 to 1.27; participants = 895; studies = 6; low-quality evidence).We found no effects for total cholesterol (mean difference (MD) 0.00, 95% CI -0.27 to 0.28; participants = 439; studies = 4; low-quality evidence), high-density lipoprotein (HDL) cholesterol (MD 0.01, 95% CI -0.06 to 0.07; participants = 437; studies = 4; low-quality evidence), or triglycerides (MD 0.01, 95% CI -0.17 to 0.19; participants = 439; studies = 4; low-quality evidence). We did not pool the data for low-density lipoprotein (LDL) cholesterol due to considerable heterogeneity. Two out of six trials measuring LDL cholesterol detected favourable intervention effects, and four trials reported no effects. Seven studies measured systolic and diastolic blood pressure; we did not pool the data due to substantial heterogeneity. For systolic blood pressure, two studies showed a reduction with the intervention, but the remaining studies showed no effect. For diastolic blood pressure, two studies showed a reduction with the intervention, one study showed an increase with the intervention, and the remaining four studies showed no effect.Five trials measured health-related quality of life (HRQOL). We could draw no conclusions from one study due to incomplete reporting; one trial reported no effect; two studies reported a short- and medium-term effect respectively; and one study reported both short- and medium-term effects.Five trials assessed dietary outcomes: two reported favourable effects, and three reported no effects. Eight studies assessed physical activity: five of these trials reported no physical activity effects, and three reported effectiveness. Trials are yet to measure the impact of these interventions on compliance with medication.Two studies measured healthcare utilisation: one reported no effects, and the other reported increased usage of healthcare services compared to a control group in the intervention group at nine months' follow-up. Two trials collected cost data: both reported that Internet-delivered interventions are likely to be cost-effective.In terms of the risk of bias, the majority of studies reported appropriate randomisation and appropriate concealment of randomisation processes. A lack of blinding resulted in a risk of performance bias in seven studies, and a risk of detection bias in five trials. Two trials were at risk of attrition bias, and five were at risk for reporting bias.

AUTHORS' CONCLUSIONS

In general, evidence was of low quality due to lack of blinding, loss to follow-up, and uncertainty around the effect size. Few studies measured clinical events, and of those that did, a very small number of events were reported, and therefore no firm conclusions can be made. Similarly, there was no clear evidence of effect for cardiovascular risk factors, although again the number of studies reporting these was small. There was some evidence for beneficial effects on HRQOL, dietary outcomes, and physical activity, although firm conclusions cannot yet be made. The effects on healthcare utilisation and cost-effectiveness are also inconclusive, and trials are yet to measure the impact of Internet interventions on compliance with medication. The comparison groups differed across trials, and there were insufficient studies with usable data for subgroup analyses. We intend to study the intensity of comparison groups in future updates of this review when more evidence is available. The completion of the ongoing trials will add to the evidence base.

Empowered to gain a new foothold in life--A study of the meaning of participating in cardiac rehabilitation to patients afflicted by a minor heart attack

This study aimed to investigate what it means to patients afflicted by a minor heart attack to participate in cardiac rehabilitation (CR). CR is well-established internationally to support patients towards moving forward in satisfying, healthy, and well-functioning lives. Studies indicate that patients achieve improvement in quality of life when participating in CR. However, knowledge of how patients are supported during CR is sparse. Moreover, knowledge of what participating in CR means to patients afflicted by a minor heart attack is lacking. In-depth knowledge in this area is crucial in order to understand these patients' particular gains and needs. In a phenomenological-hermeneutic frame field observations, focus group interviews, and individual interviews were conducted among 11 patients during and after their participation in CR. Field notes and transcribed interviews underwent three-phased interpretation. It was found that patients were supported to gain renewed balance in their lives during CR. Three themes were identified: (1) receiving a helpful but limited caring hand, (2) being supported to find new values in life, and (3) developing responsibility for the remaining time. The patients were carefully guided through a difficult time and supported to continue in healthy everyday lives. They were given hope which enabled them to find themselves a new foothold in life with respect to their own sense of well-being. This guidance and a sense of hopefulness were provided by heart specialists and more seasoned heart patients. In conclusion, patients were empowered to achieve a healthier lifestyle and improve their personal well-being during CR. However, structural barriers in the programme prevented adequate support regarding the patients' total needs. Knowledge of the benefits of CR emphasizes the significance of the programme and highlights the importance of high inclusion. Efforts should be made to develop more flexible and longer lasting programmes and further involvement of relatives must be considered.

Factors Influencing Outpatient Cardiac Rehabilitation Attendance

PURPOSE

In the current health climate, the length of stay of cardiac patients in hospital has been decreasing, and this has significantly reduced the time nurses and colleagues have for providing inpatient cardiac rehabilitation (CR). The purpose of this research was to determine if inpatient CR has an influence on outpatient cardiac rehabilitation attendance for women, Māori, and older people.

METHODS

An audit of patients discharged from hospital between November 2011 and July 2012 with a diagnosis of acute coronary syndrome were sent a postal questionnaire.

FINDINGS

The survey was completed by 143 people: 46% female, 12% Māori, and 70% > 65 years. Only 38% attended outpatient CR on discharge. Reasons for not attending included lack of referral to CR, and 61% understood only some/none of the information given to them while in hospital. The Cardiac Rehabilitation Coordinator most consistently recommended attendance, but this invitation was extended after discharge from hospital.

CONCLUSIONS

Attendance at outpatient CR is low and may increase with an improved individualized plan of care including greater cultural considerations and attention to discharge planning. An automatic referral tool as well as following evidence-based guidelines for inpatient care may increase participation rates for CR.

CLINICAL RELEVANCE

Nursing staff have the majority of contact with patients and it appears that very few nurses are discussing CR programs with their patients. The information to attend CR should be offered by all of the health professionals patients meet during their stay in hospital.

A randomised controlled trial on the effectiveness of a home-based self-management programme for community-dwelling patients with myocardial infarction

AIM

To examine the effectiveness of a four-week home-based self-management rehabilitation programme on health-related quality of life, anxiety and depression levels, cardiac risks and unplanned visits to the health services among community-dwelling patients with myocardial infarction.

METHODS

A randomised controlled trial with repeated measurements was used. A convenience sample of 128 patients with myocardial infarction was recruited from outpatient cardiology clinics at a tertiary hospital in Singapore. Participants were randomly assigned to the intervention group or control group. The outcomes were measured using Short Form 12-item Health Survey Version 2, Myocardial Infarction Dimensional Assessment Scale, and Hospital Anxiety and Depression Scale. The cardiac physiological risk parameters and number of unplanned health service use were also assessed. Data were collected at baseline, and at four weeks and 16 weeks from the baseline.

RESULTS

Over the 16 weeks, the two groups reported significant differences in physical activity (F = 4.23, p = 0.02), dependency (F = 5.16, p = 0.01), concerns over medication (F = 3.47, p = 0.04) on MIDAS, anxiety level (F = 3.41, p = 0.04) and body mass index (F = 3.12, p = 0.04). A significant difference was also found in unplanned cardiac-related emergency room visits (χ(2) = 6.64, p = 0.036) and medical consultation (χ(2) = 9.67, p = 0.046) at the 16-week study point.

CONCLUSION

The study may provide a useful tool to help health care professionals to meet the cardiac rehabilitative care needs of community-dwelling patients with myocardial infarction in Singapore.

Comprehensive cardiac rehabilitation improves outcome for patients with implantable cardioverter defibrillator. Findings from the COPE-ICD randomised clinical trial

AIMS

The aim of this randomised clinical trial was to assess a comprehensive cardiac rehabilitation intervention including exercise training and psycho-education vs 'treatment as usual' in patients treated with an implantable cardioverter defibrillator (ICD).

METHODS

In this study 196 patients with first time ICD implantation (mean age 57.2 (standard deviation (SD)=13.2); 79% men) were randomised (1:1) to comprehensive cardiac rehabilitation vs 'treatment as usual'. Altogether 144 participants completed the 12 month follow-up. The intervention consisted of twelve weeks of exercise training and one year of psycho-educational follow-up focusing on modifiable factors associated with poor outcomes. Two primary outcomes, general health score (Short Form-36 (SF-36)) and peak oxygen uptake (VO₂), were used. Post-hoc analyses included SF-36 and ICD therapy history.

RESULTS

Comprehensive cardiac rehabilitation significantly increased VO2 uptake after exercise training to 23.0 (95% confidence interval (CI) 20.9-22.7) vs 20.8 (95% CI 18.9-22.7) ml/min/kg in the control group (p=0.004 (multiplicity p=0.015)). Comprehensive cardiac rehabilitation significantly increased general health; at three months (mean 62.8 (95% CI 58.1-67.5) vs 64.4 (95% CI: 59.6-69.2)) points; at six months (mean 66.7 (95% CI 61.5-72.0) vs 61.9 (95% CI 56.1-67.7) points); and 12 months (mean 63.5 (95% CI 57.7-69.3) vs 62.1 (95% CI 56.2-68.0)) points (p <0.05). Explorative analyses showed a significant difference between groups in favour of the intervention group. No significant difference was seen in ICD therapy history.

CONCLUSION

Comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves VO₂-uptake and general health. Furthermore, mental health seems improved. No significant difference was found in the number of ICD shocks or anti-tachycardia pacing therapy.