Exercise-Based Telerehabilitation for Heart Failure Patients Declining Outpatient Rehabilitation-A Randomized Controlled Trial

PURPOSE

Cardiac rehabilitation participation rates are low despite strong recommendations, and many chronic heart failure patients remain physically inactive. Rural living, long travel distance, costs, age, and frailty might be factors explaining this. To increase cardiac rehabilitation uptake, we designed an exercise-based randomized controlled telerehabilitation trial enabling chronic heart failure patients unable or unwilling to participate in outpatient cardiac rehabilitation to exercise at home. Aim was to evaluate the long-term effects of telerehabilitation on physical activity levels.

METHODS AND RESULTS

Chronic heart failure patients ( n = 61) with reduced (≤40%), mildly reduced (41%-49%), or preserved ejection fraction (≥50%) were randomized (1:1) to telerehabilitation ( n = 31) with an initial 3-month group-based high-intensity exercise telerehabilitation program or control ( n = 30), with regular follow-up visits over a 2-yr period. All participants attended a "Living with heart failure" course. Outcomes were measures of physical activity, peak oxygen uptake, 6-min walk test distance, quality of life, morbidity, and mortality. We found no significant differences between groups for long-term changes in moderate to vigorous activity (MVPA) or peak oxygen uptake from baseline to the 2-yr follow-up. Nor quality of life differed between groups, but both groups had significant within-group improvements in score on the Minnesota Living with Heart Failure Questionnaire ( P = 0.000) and improvement in EQ-5D visual analog scale score was significant ( P = 0.05) in the telerehabilitation group.

CONCLUSIONS

Telerehabilitation performed as home-based real-time high-intensity exercise sessions provided by videoconferencing for participants unable or unwilling to participate in standard outpatient cardiac rehabilitation did not affect long-term physical activity levels or physical capacity as expected. Still, a positive effect on health-related quality of life was seen in both groups.

The economic burden of ischaemic heart diseases on health systems: a systematic review

INTRODUCTION

There is a dearth of evidence regarding the global economic burden of ischaemic heart diseases (IHDs). This systematic review aims to synthesise national-level studies worldwide quantifying the economic burden of IHDs from a provider's perspective.

METHODS

We searched PubMed, Embase, Cochrane, DARE and EconLit databases from 1 January 2000 to 29 June 2022. We included observational, cost-of-illness and economic modelling studies reporting direct healthcare cost data for IHDs at the national level. At least two reviewers independently screened titles and abstracts and full texts, extracted data and assessed quality using a seven-question assessment tool. We synthesised findings by country, focusing on three key economic estimates: total annual costs of IHDs, costs of managing acute IHD episodes and chronic IHD care. We correlated these costs with country-specific macroeconomic measures and disease burden.

RESULTS

We included 65 national-level studies conducted in 21 countries worldwide, with a majority in high-income countries. The median direct healthcare cost per episode of IHDs was 8062 Int$ 2019 (IQR: 5770-9580), and the median direct healthcare cost of IHDs per patient-year was 10 064 Int$ 2019 (IQR: 7619-14 818). These estimates positively correlated with country-specific macroeconomic and DALY measures.

CONCLUSION

IHDs impose a substantial economic burden on health systems globally. Economic costs in countries exceed per capita public health expenditure, primarily driven by acute episodes. National-level data were available for only 21 countries, and none from low-middle-income and low-income countries. Economic costs of IHDs need to be quantified to inform resource allocation decisions at national and global levels.CRD42022337577.

Advancing translational research in digital cardiac rehabilitation: The preparation phase of the Multiphase Optimization Strategy

While digital cardiac rehabilitation (CR) is an effective alternative to center-based CR, its components and mechanisms of change remain poorly understood. The Multiphase Optimization Strategy (MOST) provides a framework that allows the effects of individual components of complex interventions to be studied. There is limited guidance within MOST on how to develop a conceptual model. This article describes the development of a conceptual model of digital CR. The conceptual model was developed based on several strands of evidence: (i) a systematic review of 25 randomized controlled trials to identify the behavior change techniques in digital CR interventions, (ii) a qualitative study of patients' (n = 11) perceptions of the mechanisms of digital CR, and (iii) a review of international guidelines. Tools and frameworks from behavioral science, including the Behaviour Change Wheel, Capability, Opportunity, Motivation and Behavior model, and Theoretical Domains Framework were used to integrate the findings. An initial conceptual model of digital CR was developed and then refined through discussion. The conceptual model outlines the causal process through which digital CR can enhance outcomes for patients with cardiovascular disease. The model illustrates the key intervention components (e.g. goal setting and self-monitoring, education, exercise training), targeted outcomes (e.g. physical activity, healthy eating, medication adherence), and theorized mediating variables (e.g. knowledge, beliefs about capability). The article provides an example of how behavioral science frameworks and tools can inform the preparation phase of MOST. The developed conceptual model of digital CR will inform guide decision-making in a future optimization trial.

PsicoCare: a pilot randomized controlled trial testing a psychological intervention combining cognitive-behavioral treatment and positive psychology therapy in acute coronary syndrome patients

Background

Although psychological factors play a significant role in the onset and prognosis of acute coronary syndrome (ACS), psychological interventions (PIs) are rarely included in cardiac rehabilitation (CR) programs due to inconclusive evidence regarding specific intervention components and effect sizes. This study aimed to assess the efficacy of a PI based on cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in improving psychological and clinical outcomes in patients with ACS.

Methods

This PsicoCare trial was an open-label randomized controlled trial that compared a combined CBT and PPT-based PI (the PsicoCare program) with a standard CR program (control group). We recruited 87 ACS patients, and psychological outcomes, functional capacity, biochemical and anthropometric measures, and clinical outcomes were assessed at baseline, 2 months, and 9 months after the ACS event.

Results

The PsicoCare group showed significant improvements in depression, anger traits, anger-in, and anger control-out compared to the control group. Additionally, the PsicoCare intervention was associated with the improved maintenance of cognitive function, social support, and spiritual coping styles, while the control group showed deterioration in these areas. Patients experiencing severe ACS showed significant improvement in personal strength and meaning as a result of the PsicoCare intervention. However, no significant effects were observed on anxiety, anger-out, emotion regulation skills, dispositional optimism, other personal strengths, or quality of life. Both groups demonstrated similar improvements in functional capacity and clinical outcomes.

Conclusion

The study suggests that CBT and PPT-based PIs may offer additional benefits for ACS patients, particularly regarding their psychological health. Further larger trials are required to confirm these findings.

Clinical trial registration

identifier, NCT05287061.

Sex and gender specific pitfalls and challenges in cardiac rehabilitation: a working hypothesis towards better inclusivity in cardiac rehabilitation programmes

Notwithstanding its acknowledged pivotal role for cardiovascular prevention, cardiac rehabilitation (CR) is still largely under prescribed, in almost 25% of patients owing an indication for. In addition, when considering differences concerning the two sexes, female individuals are underrepresented in CR programmes with lower referral rates, participation, and completion as compared to male counterpart. This picture becomes even more tangled with reference to gender, a complex socio-cultural construct characterized by four domains (gender identity, relation, role, and institutionalized gender). Indeed, each of them reveals several obstacles that considerably penalize CR adherence for different categories of people, especially those who are not identifiable with a non-binary gender. Aim of the present review is to identify the sex- (i.e. biological) and gender- (i.e. socio-cultural) specific obstacles to CR related to biological sex and sociocultural gender and then envision a likely viable solution through tailored treatments towards patients' well-being.

A Global Perspective on Cardiovascular Risk Factors by Educational Level in CHD Patients: SURF CHD II

BACKGROUND

Clinical guidelines recommend lifestyle modifications and medication use to control cardiovascular risk factors in coronary heart disease (CHD) patients. However, risk factor control remains challenging especially in patients with lower educational level.

OBJECTIVE

To assess inequalities by educational level in the secondary prevention of CHD in the Survey of Risk Factors in Coronary Heart Disease (SURF CHD II).

METHODS

SURF CHD II is a cross-sectional clinical audit on secondary prevention of CHD, conducted during routine clinical visits in 29 countries. The easy-to-perform design of the survey facilitates its implementation in settings with limited resources. We reported risk factor recording, attainment of guideline-defined risk factor targets, and treatment in CHD patients. Differences by educational level in target attainment and treatment were assessed with logistic regression stratified for high- (HIC), upper middle- (UMIC), and lower middle-income (LMIC) countries.

RESULTS

SURF CHD II included 13,884 patients from 2019 to 2022, of which 25.0% were female and 18.6% had achieved only primary school level. Risk factor recording ranged from 22.2% for waist circumference to 95.6% for smoking status, and target attainment from 15.9% for waist circumference to 78.7% for smoking. Most patients used cardioprotective medications and 50.5% attended cardiac rehabilitation.Patients with secondary or tertiary education were more likely to meet targets for smoking, LDL cholesterol and physical activity in HICs and LMICs; for physical activity and triglycerides in UMICs; but less likely to meet targets for blood pressure in HICs and LDL <1.4mmol/L in UMICs. Higher education was positively associated with medication use and cardiac rehabilitation participation.

CONCLUSION

CHD patients generally have poor attainment of risk factor targets, but patients with a higher educational level are generally more likely to participate in cardiac rehabilitation, use medication, and meet targets.

MAIN MESSAGES

Target attainment and participation in cardiac rehabilitation are poor in CHD patients globally.Patients with higher education are more likely to meet risk factor targets, showing health inequities in secondary prevention of CHD.The association between education and risk factor target attainment and treatment varies with country income level.

Cardiac rehabilitation for heart failure: progress and gaps in evidence and policy

PURPOSE OF REVIEW

This review synthesizes recent research on the efficacy, optimal design, and delivery methods of cardiac rehabilitation tailored to heart failure patients. Despite established benefits, cardiac rehabilitation referral and access disparities persist, necessitating elucidation of limitations and solutions.

RECENT FINDINGS

Exercise-based cardiac rehabilitation improves long-term mortality and hospitalization rates but not short-term mortality. cardiac rehabilitation further enhances quality of life and medical therapy adherence. However, cardiac rehabilitation relies on in-person delivery, presenting access barriers exacerbated during COVID-19. Significant geographic disparities exist, with analyses indicating current capacity only serves 45% of eligible US adults even if fully utilized. Referral rates also lag, disproportionately affecting women and minority groups. Research increasingly focuses on home-based and digital therapeutics modalities to expand reach, with evidence demonstrating comparable improvements across settings. Protocols and research center on heart failure with reduced ejection fraction (HFrEF), despite growing heart failure with preserved ejection fraction (HFpEF) prevalence.

SUMMARY

Increasing referrals through standardized procedures and addressing multifactorial geographic, economic, and capacity limitations are imperative to ensure equitable cardiac rehabilitation access. Broadening HFpEF rehabilitation research and care standards also constitutes a critical practice gap requiring alignment with projected epidemiologic shifts. Advancing patient-centered, evidence-based solutions can promote rehabilitation as essential secondary prevention for wider cardiac populations.

VIDEO ABSTRACT

http://links.lww.com/HCO/A97.

Acceptability, Preferred Medium, and Components of Nurse-Led Cardiac Telerehabilitation: A Cross-Sectional Study

Cardiac rehabilitation (CR) is a comprehensive and multidisciplinary secondary prevention care in coronary heart disease (CHD). There are barriers at the patient and health system levels that prevent CR from being utilized. Cardiac telerehabilitation led by nurses (Ne-CTR) can alleviate the obstacles to participation in CR. A patient perspective can improve CR access. This study was the first pre-program investigation to clarify the status of knowledge and participation in CTR. We sought to clarify the acceptability, the reasons for rejection, the desired form, components, and associated factors with the components needed for (Ne-CTR) in patients with CHD. The study aimed to help develop a protocol for Ne-CTR for Chinese patients with CHD. A cross-sectional study was conducted between 2020 and 2021. Hospitals in four provinces in China were included. The participants were 671 patients with CHD in hospitals located in three regions of China. A self-administered questionnaire collected information about demographics, knowledge, and participation in CTR, acceptability, preferred medium, and components of Ne-CTR. Student's t-test, analysis of variance, and multiple linear regression analyzed the factors associated with component needs. All the analyses were conducted using IBM SPSS version 25.0. Most participants (n = 434, 66.77%) had a poor understanding and participation in CTR. In addition, 65.38% (n = 439) of participants were willing to accept the Ne-CTR program, and 43.56% (n = 98) identified safety as reasons for not accepting such a program. In the group accepting Ne-CTR, 35% chose hospital-designed professional applications as a medium for Ne-CTR when offered. Education (4.44 ± 1.056) and drug information (4.44 ± 1.040) had the highest average need score. Education, monthly income, marital status, previous CTR participation, and health insurance were associated with the demand level scores of Ne-CTR. This study demonstrated high levels of need for Ne-CTR among patients with CHD and identified the desired medium, components, and associated factors of Ne-CTR. These findings provide reference information for the construction of a Ne-CTR program.

Exploring patient experiences of participating in digital cardiac rehabilitation: A qualitative study

OBJECTIVE

Digital cardiac rehabilitation (CR) has emerged as a promising alternative to in-person CR. Understanding patients' experiences and perceptions can provide valuable insights into what makes these programmes successful and identify opportunities for improvement. This study aimed to explore patients' experiences of digital CR and to understand the factors that make these programmes successful.

DESIGN

A qualitative approach was taken.

METHODS

From March to August 2022, we conducted semi-structured interviews with patients who were referred to one of two digital CR programmes offered on the island of Ireland. Interviews were audio-recorded, transcribed verbatim and analysed using reflexive thematic analysis. A public and patient involvement panel guided the recruitment strategy and assisted with data analysis.

RESULTS

Eleven patients, predominantly male (82%) and with a mean age of 64 (range 50-75), participated in the study. Five themes were developed: (1) Empowered patients; (2) Controlling the recovery; (3) At home but not alone; (4) The world at your (digital) doorstep and; (5) Challenges of interacting online. Participants reported that digital CR equipped them with the necessary tools and support to modify their lifestyle and effectively manage their recovery. However, the opportunities for social interaction were limited and communicating online was not always straightforward.

CONCLUSIONS

Participants reported that digital CR guided them towards recovery and improved their sense of empowerment and control. However, the limited opportunities for social interaction may represent a challenge for patients seeking social support.

Exercise-based cardiac rehabilitation after acute myocardial infarction in Sweden - standards, costs, and adherence to European guidelines (The Perfect-CR study)

AIMS

Information on standards including structure- and process-based metrics and how exercise-based cardiac rehabilitation (EBCR) is delivered in relation to guidelines is lacking. The aims of the study were to evaluate standards and adherence to guidelines at Swedish CR centers and to conduct a cost analysis of the physiotherapy-related activities of EBCR.

METHODS AND RESULTS

EBCR standards at all 78 CR centers in Sweden in 2016 were surveyed. The questions were based on guideline-recommended core components of EBCR for patients after a myocardial infarction (MI). The cost analysis included the identification, quantification, and valuation of EBCR-related cost items. Patients were offered a pre-discharge consultation with a physiotherapist at n = 61, 78% of the centers. A pre-exercise screening visit was routinely offered at n = 64, 82% of the centers, at which a test of aerobic capacity was offered in n = 58, 91% of cases, most often as a cycle ergometer exercise test n = 55, 86%. A post-exercise assessment was offered at n = 44, 56% of the centers, with a functional test performed at n = 30, 68%. Almost all the centers n = 76, 97% offered supervised EBCR programs. The total cost of delivering physiotherapy-related activities of EBCR according to guidelines was approximately 437 euro (4,371 SEK) per patient. Delivering EBCR to one MI patient required 11.25 hours of physiotherapy time.

CONCLUSION

While the overall quality of EBCR programs in Sweden is high, there are several areas of potential improvement to reach the recommended European standards across all centers. To improve the quality of EBCR, further compliance with guidelines is warranted.

Use of health services and perceived need for information and follow-up after percutaneous coronary intervention

OBJECTIVE

Few patients achieve full control of their coronary artery disease (CAD) risk factors. Follow-up, such as cardiac rehabilitation, is important to increase adherence to lifestyle changes and treatment, to improve the patient's risk profile, and to treat established complications of CAD clinical events. However, the type of follow-up patients receive varies. Therefore, the aim of this research note was to describe and compare patients' self-reported use of health services, the type of follow-up patients reported to prefer, and the type of information patients reported to be important, in two countries with different follow-up practices after PCI.

RESULTS

We included 3417 patients in Norway and Denmark, countries with different follow-up strategies after PCI. The results showed large differences between the countries regarding health services used. In Denmark the most frequently used health services were consultations at outpatient clinics followed by visits to the general practitioner and visits to the fitness centre, whereas in Norway visits to the general practitioner were most common, followed by rehospitalisation and no follow-up used. However, patients found the same type of follow-up and information important in both countries. Patients' perceived need for follow-up and information decreased over time, suggesting a need for early follow-up when the patients are motivated.

TRIAL REGISTRATION

NCT03810612 (18/01/2019).

Assessment of on-site and remote cardiac rehabilitation in Romania

: Introduction: It is well known that cardiovascular diseases are the leading cause of death worldwide. In Romania in 2015, cardiovascular diseases led to 153.953 deaths, representing 59.3% of deaths from all causes. Most people in Romania today have an unhealthy lifestyle, characterised mainly by a poor nutritious diet, low physical activity and a lack of medical screening. Purpose: Considering these deficits of secondary prevention in the treatment line of the Romanian cardiovascular patient, we aimed through this study to assess the current access of the Romanian population to on-site and remote cardiac rehabilitation programs as well as their opinion regarding the telemedicine for future cardiovascular care modelling. Methods: It was a prospective observational study, which was carried out by means of an online questionnaire composed of 26 items. It was dispersed in the online environment, including Social Media platforms, where it was active for ten weeks. Results: Our online evaluation questionnaire had 1115 participants, with a minimum age of 18 years old, a preponderance of female sex and a predominantly urban background. The study participants were from all educational levels, from low to superior. We observed that most participants have an internet connection at home and use at least one form of technology daily, but most have never used a telemedicine service. Conclusions: In conclusion, the access of cardiovascular patients to on-site cardiac rehabilitation services is extremely low and for remote ones, it is almost non-existent. For a middle-income country like Romania with such a high incidence of cardiovascular disease, it is almost mandatory to provide publicly funded cardiac telerehabilitation services also for the future.

Feasibility of telerehabilitation for heart failure patients inaccessible for outpatient rehabilitation

AIMS

Despite strong recommendations, outpatient cardiac rehabilitation is underused in chronic heart failure (CHF) patients. Possible barriers are frailty, accessibility, and rural living, which may be overcome by telerehabilitation. We designed a randomized, controlled trial to evaluate the feasibility of a 3-month real-time, home-based telerehabilitation, high-intensity exercise programme for CHF patients who are either unable or unwilling to participate in standard outpatient cardiac rehabilitation and to explore outcomes of self-efficacy and physical fitness at 3 months post-intervention.

METHODS AND RESULTS

CHF patients with reduced (≤40%), mildly reduced (41-49%), or preserved ejection fraction (≥50%) (n = 61) were randomized 1:1 to telerehabilitation or control in a prospective controlled trial. The telerehabilitation group (n = 31) received real-time, home-based, high-intensity exercise for 3 months. Inclusion criteria were (i) ≥18 years, (ii) New York Heart Association class II-III, stable on optimized medical therapy for >4 weeks, and (iii) N-terminal pro-brain natriuretic peptide >300 ng/L. All participants participated in a 2-day 'Living with heart failure' course. No other intervention beyond standard care was provided for controls. Outcome measures were adherence, adverse events, self-reported outcome measures, the general perceived self-efficacy scale, peak oxygen uptake (VO2peak ) and a 6-min walk test (6MWT). The mean age was 67.6 (11.3) years, and 18% were women. Most of the telerehabilitation group (80%) was adherent or partly adherent. No adverse events were reported during supervised exercise. Ninety-six per cent (26/27) reported that they felt safe during real-time, home-based telerehabilitation, high-intensity exercise, and 96% (24/25) reported that, after the home-based supervised telerehabilitation, they were motivated to participate in further exercise training. More than half the population (15/26) reported minor technical issues with the videoconferencing software. 6MWT distance increased significantly in the telerehabilitation group (19 m, P = 0.02), whereas a significant decrease in VO2peak (-0.72 mL/kg/min, P = 0.03) was observed in the control group. There were no significant differences between the groups in general perceived self-efficacy scale, VO2peak , and 6MWT distance after intervention or at 3 months post-intervention.

CONCLUSIONS

Home-based telerehabilitation was feasible in chronic heart failure patients inaccessible for outpatient cardiac rehabilitation. Most participants were adherent when given more time and felt safe exercising at home under supervision, and no adverse events occurred. The trial suggests that telerehabilitation can increase the use of cardiac rehabilitation, but the clinical benefit of telerehabilitation must be evaluated in larger trials.

Overview of Cardiac Rehabilitation following post-acute myocardial infarction in European Society of Cardiology member countries

AIMS

Cardiovascular disease (CVD) is still a leading cause of death and morbidity in Europe and must be addressed through approaches beyond therapeutic interventions and pharmacological management. Cardiac rehabilitation (CR) is a comprehensive, individualized, and patient-tailored programme, comprising multidisciplinary interventions. Despite its clinical benefits, cost-effectiveness, and existing guidelines, CR uptake in Europe remains suboptimal and detailed information on its current state is lacking. This centralized pan-European study (Overview of Cardiac Rehabilitation-OCRE) aimed to characterize and advance the knowledge about European Society of Cardiology (ESC) affiliated national CR settings.

METHODS AND RESULTS

An online survey about provision and quality indicators from CR was sent to the network of National CVD Prevention Coordinators of ESC member states, whose answers were supported by published evidence and/or national experts. The OCRE study had a high participation rate (82%). Current positive aspects of CR include low dropout rates and short average start time after myocardial infarction, as well as public funding being standard practice. However, the uptake rate and average duration of CR are still suboptimal, and several countries lack CR mandatory rotation in Cardiology training, guidance documents, national accreditation, and electronic database registries. We also found several barriers to CR guideline implementation, at patient, staff, and healthcare levels.

CONCLUSIONS

This study provides a comprehensive characterization of CR in Europe, generating important insight on the current provision and quality of CR in Europe, highlighting its sucesses and shortcomings, and discussing important strategies to overcome current obstacles.

Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis

BACKGROUND

Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context.

METHODS

Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses.

RESULTS

Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective.

CONCLUSION

Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.

The cost-effectiveness of exercise-based cardiac telerehabilitation intervention: a systematic review

INTRODUCTION

Alternatives such as remotely delivered therapy in the home environment or telehealth represent an opportunity to increase overall cardiac rehabilitation (CR) utilization. Implementing alternatives into regular practice is the next step in development; however, the cost aspect is essential for policymakers. Limited economic budgets lead to cost-effectiveness analyses before implementation. They are appropriate in cases where there is evidence that the compared intervention provides a similar health benefit to usual care. This systematic review aimed to compare the cost-effectiveness of exercise-based telehealth CR interventions compared to standard exercise-based CR.

EVIDENCE ACQUISITION

PubMed and Web of Science databases were systematically searched up to August 2022 to identify randomized controlled trials assessing patients undergoing telehealth CR. The intervention was compared to standard CR protocols. The primary intent was to identify the cost-effectiveness. Interventions that met the criteria were home-based telehealth CR interventions delivered by information and communications technology (telephone, computer, internet, or videoconferencing) and included the results of an economic evaluation, comparing interventions in terms of cost-effectiveness, utility, costs and benefits, or cost-minimization analysis. The systematic review protocol was registered in the PROSPERO Registry (CRD42022322531).

EVIDENCE SYNTHESIS

Out of 1525 identified studies, 67 articles were assessed for eligibility, and, at the end of the screening process, 12 studies were included in the present systematic review. Most studies (92%) included in this systematic review found strong evidence that exercise-based telehealth CR is cost-effective. Compared to CBCR, there were no major differences, except for three studies evaluating a significant difference in average cost per patient and intervention costs in favor of telehealth CR.

CONCLUSIONS

Telehealth CR based on exercise is as cost-effective as CBCR interventions. Funding telehealth CR by third-party payers may promote patient participation to increase overall CR utilization. High-quality research is needed to identify the most cost-effective design.

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Greek Version of the Cardiac Rehabilitation Barriers Scale (CRBS-GR): What Are the Barriers in South-East Europe?

Cardiac Rehabilitation (CR) is a secondary prevention intervention proven to improve quality of life, yet with low participation. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess multi-level barriers to participation. This study aimed at the translation, and cross-cultural adaptation of the CRBS into the Greek language (CRBS-GR), followed by psychometric validation. Some 110 post-angioplasty patients with coronary artery disease (88.2% men, age 65.3 ± 10.2 years) answered the CRBS-GR. Factor analysis was performed to obtain the CRBS-GR subscales/factors. The internal consistency and 3-week test-retest reliability was evaluated using Cronbach's alpha (α) and intraclass correlation coefficient (ICC), respectively. Construct validity was tested via convergent and divergent validity. Concurrent validity was assessed with the Hospital Anxiety and Depression Scale (HADS). Translation and adaptation resulted in 21 items similar to the original version. Face validity and acceptability were supported. Construct validity assessment revealed four subscales/factors, with acceptable overall reliability (α = 0.70) and subscale internal consistency for all but one factor (α range = 0.56-0.74). The 3-week test-retest reliability was 0.96. Concurrent validity assessment demonstrated a small to moderate correlation of the CRBS-GR with the HADS. The greatest barriers were the distance from the rehabilitation center, the costs, the lack of information about CR, and already exercising at home. The CRBS-GR is a reliable and valid tool for identifying CR barriers among Greek-speaking patients.

Top 50 cited articles on cardiac rehabilitation: A bibliometric and altmetric analysis study

Background/Aim: Cardiovascular disease (CVD) is the leading cause of death globally, with an estimated 18.6 million deaths each year. Cardiac rehabilitation (CR) has positive effects on reducing the mortality and morbidity of CVD, so there is a growing interest in this field. The aim of this study was to analyze the top 50 cited articles in the field of CR. Methods: The Web of Science (WoS) database was searched for articles published between 1986 and 2021. A record was made of the following information for the bibliometric analysis: article title, year of publication, number of authors and their names, number of citations, citation index, journal of publication, impact factor, type of article, and source of funding. The altmetric attention score (AAS) was recorded using automatic software calculation. Results: The majority of articles were published in the journal “Circulation” (n=14) and the “Journal of the American College of Cardiology” (n=8). The country with the highest number of articles was the US (n=27), and the most cited author was P.A. Ades. Studies evaluating exercise-based rehabilitation, key components of CR, and secondary prevention were among the top cited articles. In terms of AAS, in addition to the titles mentioned, mobile health services that rely on communication technologies have also received attention. Conclusion: This study provides useful information for researchers interested in CR, including trends, topics of interest in the field, and potential research collaborations. It is intended to guide future, more comprehensive, and in-depth studies on CR.

Evaluating the effectiveness of a comprehensive patient education intervention in a hybrid model of cardiac rehabilitation: A pilot study

Objective

To evaluate the effectiveness of a comprehensive educational intervention in a hybrid model of cardiac rehabilitation in Spain during the COVID-19 pandemic.

Methods

In a prospective pretest-posttest pilot study a pooled sample of patients attending hybrid cardiac rehabilitation in Spain received a culturally-adapted education intervention for 6 weeks. Participants completed surveys at pre- and post-rehabilitation assessing disease-related knowledge, health literacy, adherence to the Mediterranean Diet and self-efficacy. Physical activity was measured by number of steps per day using wearable activity tracking devices. Satisfaction with the educational materials was also evaluated by a survey with a 10 point Likert-type scale and yes/no and open-ended questions.

Results

Eighty-one(99%) participants completed both assessments. There was significant improvement in disease-related knowledge(p < 0.001), physical activity(p < 0.001), and adherence to the diet(p = 0.005) post-rehabilitation. The number of participants that were classified as having “high health literacy skills” increased by 17%. Post-rehabilitation knowledge was associated with education level (ß = 0.430; p = 0.001),pre-rehabilitation knowledge (ß = 0.510; p = 0.002), and high health literacy skills (ß = 0.489; p = 0.01). Educational materials were highly satisfactory to participants.

Conclusion

Significant increases in disease-related knowledge and health behaviors in patients attending hybrid models of cardiac rehabilitation are encouraging results that support the value of implementing comprehensive educational initiatives to programs in Spain.

Innovation

This work presents preliminary evidence of the effectiveness of the first comprehensive education intervention that is open access and culturally adapted to people living with cardiovascular disease in Spain.

Adherence to exercise and fitness following exercise-based outpatient cardiac rehabilitation: a cross-sectional survey for Germany

Background

Exercise-based cardiac rehabilitation is safe and effective, evidence-based and implemented in national and international cardiac rehabilitation guidelines. Recent data show a decrease in cardiovascular mortality, reduced hospital admissions and an overall improvement in quality of life. To maintain positive effects and to prevent further cardiovascular events a major goal of cardiac rehabilitation is to induce a long-term health behaviour change and the integration of regular physical activity and exercise training in everyday life. The aim of this study is to evaluate the adherence of cardiac patients to exercise-based programs following rehabilitation phase III.

Methods

A nationwide online cross-sectional survey was conducted. All outpatient aftercare providers who offer sports rehabilitation programs (heart groups) for cardiac patients in Germany were contacted. The questionnaire comprised 15 questions in five subcategories (general information regarding the outpatient aftercare provider, structure of rehabilitation sport programs, membership structure, content of heart groups, adherence to exercise-based programs).

Results

560 of 2447 outpatient aftercare providers participated in the survey (response rate: 23%). On average, rehabilitation sport facilities hosted 2 (IQR 2) heart groups per week, and 23 patients (IQR 30) (61% males; 31% females) per facility completed rehabilitation sport prescription in 2018. Almost all providers offer follow-up programs on a self-payer basis after rehabilitation sport prescription ends. Adherence to follow-up programs was at 54% (IQR 65; 55% males and 50% females). With 60% (IQR 71), patients with a statutory health insurance (mainly pensioners) adhere slightly more often to a follow-up program compared to privately insured persons (mainly population with a high income or civil servants) with 50% and significantly more often compared to persons who were insured by the German pension fund (covering working population) with only 9% (IQR 89) adherence.

Conclusion

Almost all outpatient aftercare providers offer follow-up programs for cardiac rehabilitation patients but only half of them actually participate. Younger people (working population) do not adhere sufficiently to sport and exercise programs following rehabilitation phase III. This seems critical to address in terms of achieving long-term rehabilitation goals.

Correlation of Walking Activity and Cardiac Hospitalizations in Coronary Patients for 1 Year Post Cardiac Rehabilitation: The More Steps, the Better!

Problem

Reducing risk by improving fitness is one of the main objectives of cardiac rehabilitation (CR). To estimate how the number of steps/day post-CR affects coronary patients' prognosis, we analyzed its correlation with the occurrence of death, hospitalizations, and heart complaints, and if and how other variables (ejection fraction (EF), gender, age) relate to those.

Methods

One hundred eleven patients (male = 91, female = 20; average age ± standard deviation (SD): 61 ± 11 years) who had been in CR due to recent coronary revascularization or chronic coronary syndrome could be enrolled. Patients were advised to document their steps (daily), blood pressure (daily), weight (weekly) and occurrences of a cardiac event in a diary for 1 year post-CR. A Cox proportional hazard model was used to examine the influence of steps/day, EF, gender, and age until the occurrence of an event. Kaplan-Meier curves were generated to compare patients' profiles.

Results

Average steps/day of patients post-CR were 7333 (SD 4426). Increased walking activity reduced risk for cardiac hospitalization (constant steps/day: 5000 vs 7500, hazard rate (HR) reduction of 0.43; 10 000 vs 12 500, HR reduction of 0.20) and risk was higher in patients with an EF < 55% versus EF ⩾ 55% (HR increase of 2.88). Median follow-up time post-CR was 218 days. No patient died, 25 were hospitalized.

Discussion

Monitoring the number of steps of coronary patients post CR could be valuable for estimating patients' prognosis.

Efficacy, efficiency and safety of a cardiac telerehabilitation programme using wearable sensors in patients with coronary heart disease: the TELEWEAR-CR study protocol

INTRODUCTION

Exercise-based cardiac rehabilitation (CR) is a beneficial tool for the secondary prevention of cardiovascular diseases with, however, low participation rates. Telerehabilitation, intergrading mobile technologies and wireless sensors may advance the cardiac patients' adherence. This study will investigate the efficacy, efficiency, safety and cost-effectiveness of a telerehabilitation programme based on objective exercise telemonitoring and evaluation of cardiorespiratory fitness.

METHODS AND ANALYSIS

A supervised, parallel-group, single-blind randomised controlled trial will be conducted. A total of 124 patients with coronary disease will be randomised in a 1:1 ratio into two groups: intervention telerehabilitation group (TELE-CR) (n=62) and control centre-based cardiac rehabilitation group (CB-CR) (n=62). Participants will receive a 12-week exercise-based rehabilitation programme, remotely monitored for the TELE-CR group and standard supervised for the CB-CR group. All participants will perform aerobic training at 70% of their maximal heart rate, as obtained from cardiopulmonary exercise testing (CPET) for 20 min plus 20 min for strengthening and balance training, three times per week. The primary outcomes will be the assessment of cardiorespiratory fitness, expressed as peak oxygen uptake assessed by the CPET test and the 6 min walk test. Secondary outcomes will be the physical activity, the safety of the exercise intervention (number of adverse events that may occur during the exercise), the quality of life, the training adherence, the anxiety and depression levels, the nicotine dependence and cost-effectiveness. Assessments will be held at baseline, end of intervention (12 weeks) and follow-up (36 weeks).

ETHICS AND DISSEMINATION

The study protocol has been reviewed and approved by the Ethics Committee of the University of Thessaly (1108/1-12-2021) and by the Ethics Committee of the General University Hospital of Larissa (3780/31-01-2022). The results of this study will be disseminated through manuscript publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05019157.

A motivational interview program for cardiac rehabilitation after acute myocardial infarction: study protocol of a randomized controlled trial in primary healthcare

BACKGROUND

Cardiac rehabilitation after acute myocardial infarction permits recovery of the heart function and enables secondary prevention programs in which changes in lifestyle habits are crucial. Cardiac rehabilitation often takes place in hospitals without coordination with primary healthcare and is not focused on individual patient preferences and goals, which is the core of the motivational interview. The objective of this study was to evaluate the efficacy of a cardiac rehabilitation program with a motivational interview in patients discharged from hospital after acute myocardial infarction.

METHODS/DESIGN

A randomized, non-pharmacological clinical trial in six primary healthcare centers in Barcelona (Spain) will assess whether a tailored cardiac rehabilitation program consisting of four motivational interviews and visits with family physicians, primary healthcare nurses and a cardiologist, coordinated with the reference hospital, results in better cardiac rehabilitation than standard care. A minimum sample of 284 participants requiring cardiac rehabilitation after acute myocardial infarction will be randomized to a cardiac rehabilitation group with a motivational interview program or to standard primary healthcare. The main outcome will be physical function measured by the six-minute walk test, and the secondary outcome will be the effectiveness of secondary prevention: a composite outcome comprising control of blood pressure, cholesterol, diabetes mellitus, smoking and body weight. Results will be evaluated at 1,3 and 6 months.

DISCUSSION

This is the first clinical trial to study the impact of a new primary healthcare cardiac rehabilitation program with motivational interviews for patients discharged from hospital after myocardial infarction. Changes in lifestyles and habits after myocardial infarction are a core element of secondary prevention and require patient-centered care strategies such as motivational interviews. Therefore, this study could clarify the impact of this approach on health indicators, such as functional capacity.

TRIAL REGISTRATION

ClinicalTriasl.gov NCT05285969 registered on March 18, 2022.

[The importance of cardiorehabilitation in the era of modern treatment of cardio-vascular diseases]

Cardiac rehabilitation (CR) has a class IA indication in international and national guidelines as an intervention with proven efficacy for decreasing cardiovascular and all-cause mortality in various categories of cardiological patients. However, CR is one of the least used current technologies for the treatment of patients with cardiovascular diseases worldwide. This article presents the state of the CR problem during the epoch of high-tech treatments of cardiovascular diseases; the prevalence of using CR in various countries; traditional and new methodological approaches, including telemedicine; and clinical and prognostic effects of CR in various categories of patients with cardiovascular diseases.

Exercise-based cardiac rehabilitation programs in the era of COVID-19: a critical review

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide. Increased rates of morbidity and mortality have led to the increased need for the implementation of secondary prevention interventions. Exercise-based cardiac rehabilitation (CR) represents a multifactorial intervention, including elements of physical exercise and activity, education regarding healthy lifestyle habits (smoking cessation, nutritional habits), to improve the physical capacity and psychological status of cardiac patients. However, participation rates in CR programs remain low due to socioeconomic, geographical and personal barriers. Recently the COVID-19 pandemic restrictions have added another barrier to CR programs. Therefore there is an emerging need to further improve the types and methods of implementing CR. Cardiac telerehabilitation, integrating advanced technology for both monitoring and communicating with the cardiac population, appears to be an innovative CR alternative that can overcome some of the barriers preventing CR participation. This review paper aims to describe the background and core components of center-based CR and cardiac telerehabilitation, and discuss their implications for present day clinical practice and their future perspectives.

Current state of cardiac rehabilitation in Portugal: Results of the 2019 national survey

INTRODUCTION

Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal.

OBJECTIVES

This study reports the results of the 2019 survey on CR.

METHODS

In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention.

RESULTS

In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates <25%.

CONCLUSION

The present survey shows an increase in the number of centers and patients undergoing phase II CR, and an increase in the estimated CR coverage after ACS. Despite this, the level of increase means that overall patient representation remained below the optimal range, while the data also showed a decrease in the number of patients in phase III programs. These findings reinforce the importance of optimization of CR entry and maintenance, in order to improve the uptake of this pivotal intervention.

A nationwide survey on participation in cardiac rehabilitation among patients with coronary heart disease using health claims data in Japan

Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017-2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6-10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39-2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.

Efficacy of psychological interventions on psychological outcomes in coronary artery disease: systematic review and meta-analysis

BACKGROUND

The benefits of cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in patients with cardiovascular disease are still not well defined. We assessed the efficacy of CBT and PPT on psychological outcomes in coronary artery disease (CAD) patients.

METHODS

Randomized controlled trials evaluating CBT or PPT in CAD patients published until May 2018 were systematically analyzed. Primary outcomes were depression, stress, anxiety, anger, happiness, and vital satisfaction. Random effects meta-analyses using the inverse variance method were performed. Effects were expressed as standardized mean difference (SMD) or mean differences (MD) with their 95% confidence intervals (CIs); risk of bias was assessed with the Cochrane tool.

RESULTS

Nineteen trials were included (n = 1956); sixteen evaluated CBT (n = 1732), and three PPT (n = 224). Compared with control groups, depressive symptoms (13 trials; SMD -0.80; 95% CI -1.33 to -0.26), and anxiety (11 trials; SMD -1.26; 95% CI -2.11 to -0.41) improved after the PI, and depression (6 trials; SMD -2.08; 95% CI -3.22 to -0.94), anxiety (5 trials; SMD -1.33; 95% CI -2.38 to -0.29), and stress (3 trials; SMD -3.72; 95% CI -5.91 to -1.52) improved at the end of follow-up. Vital satisfaction was significantly increased at follow-up (MD 1.30, 0.27, 2.33). Non-significant effects on secondary outcomes were found. Subgroup analyses were consistent with overall analyses.

CONCLUSION

CBT and PPT improve several psychological outcomes in CAD patients. Depression and anxiety improved immediately after the intervention while stress and vital satisfaction improve in the mid-term. Future research should assess the individual role of CBT and PPT in CAD populations.

Reliability of the Scale of Barriers for Cardiac Rehabilitation in the Colombian Population

Cardiac rehabilitation is supported by the highest level of scientific evidence. However, less than 25% of those eligible to participate in a cardiac rehabilitation program initiate it; and of these, 50% drop out prematurely. A modified Spanish Cardiac Rehabilitation Barriers Scale (CRBS) has been translated, culturally adapted and validated in Colombia, however, the reliability remains to be evaluated. This study aimed to determine the internal consistency and test–retest reliability of the CRBS in a Colombian population. In total, 193 patients (67% men, average age = 65 ± 12 years) completed the scale twice, with an average of eight days between applications. Cronbach’s Alpha and intraclass correlation coefficients (ICC) were calculated. The internal consistency of the Colombian version of the CRBS was acceptable (Cronbach’s alpha = 0.84). The ICC of the CRBS was 0.69 (95% CI 0.61–0.76); 0.78 (95% CI 0.71–0.84) when the CRBS was completed by interview; and 0.47 (95% CI 0.21–0.67) when the CRBS was self-reported. The reliability of the interview version of the CRBS was substantial in the Colombian population; however, the reliability of the self-report version was lower. The use of this scale will allow developing strategies to increase participation and adherence to cardiac rehabilitation programs.

Effectiveness of Home-Based Mobile Guided Cardiac Rehabilitation as Alternative Strategy for Nonparticipation in Clinic-Based Cardiac Rehabilitation Among Elderly Patients in Europe: A Randomized Clinical Trial

Importance

Although nonparticipation in cardiac rehabilitation is known to increase cardiovascular mortality and hospital readmissions, more than half of patients with coronary artery disease in Europe are not participating in cardiac rehabilitation.

Objective

To assess whether a 6-month guided mobile cardiac rehabilitation (MCR) program is an effective therapy for elderly patients who decline participation in cardiac rehabilitation.

Design, Setting, and Participants

Patients were enrolled in this parallel multicenter randomized clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. Researchers assessing primary outcome were masked for group assignment. A total of 4236 patients were identified with a recent diagnosis of acute coronary syndrome, coronary revascularization, or surgical or percutaneous treatment for valvular disease, or documented coronary artery disease, of whom 996 declined to start cardiac rehabilitation. Subsequently, 179 patients who met the inclusion and exclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programmes in the Elderly trial. Data were analyzed from January 21 to October 11, 2019.

Interventions

Six months of home-based cardiac rehabilitation with telemonitoring and coaching based on motivational interviewing was used to stimulate patients to reach exercise goals. Control patients did not receive any form of cardiac rehabilitation throughout the study period.

Main Outcomes and Measures

The primary outcome parameter was peak oxygen uptake (Vo2peak) after 6 months.

Results

Among 179 patients randomized (145 male [81%]; median age, 72 [range, 65-87] years), 159 (89%) were eligible for primary end point analysis. Follow-up at 1 year was completed for 151 patients (84%). Peak oxygen uptake improved in the MCR group (n = 89) at 6 and 12 months (1.6 [95% CI, 0.9-2.4] mL/kg-1/min-1 and 1.2 [95% CI, 0.4-2.0] mL/kg-1/min-1, respectively), whereas there was no improvement in the control group (n = 90) (+0.2 [95% CI, -0.4 to 0.8] mL/kg-1/min-1 and +0.1 [95% CI, -0.5 to 0.7] mL/kg-1/min-1, respectively). Changes in Vo2peak were greater in the MCR vs control groups at 6 months (+1.2 [95% CI, 0.2 to 2.1] mL/kg-1/min-1) and 12 months (+0.9 [95% CI, 0.05 to 1.8] mL/kg-1/min-1). The incidence of adverse events was low and did not differ between the MCR and control groups.

Conclusions and Relevance

These results suggest that a 6-month home-based MCR program for patients 65 years or older with coronary artery disease or a valvular intervention was safe and beneficial in improving Vo2peak when compared with no cardiac rehabilitation.

Trial Registration

trialregister.nl Identifier: NL5168.

Psychosocial Risk Factors in Cardiac Rehabilitation: Time to Screen Beyond Anxiety and Depression

Background

Although it is well acknowledged that psychosocial risk factors (PSRF) such as low socio-economic status, stress, social isolation, negative emotions and negative personality patterns may contribute to the development and adverse outcome of cardiovascular disease (CVD), screening for PSRF in CVD patients is usually limited to anxiety and depression, mainly for feasibility reasons. We therefore aimed to develop a user-friendly screening battery for routine assessment of PSRFs and to evaluate this instrument regarding feasibility of application, PSRF results and attendance of psychological counselling if recommended to cardiac rehabilitation (CR) patients.

Methods

This is a prospective single center cohort study including 609 consecutive CR patients. We first developed a screening instrument based on seven validated scales for the most relevant PSRFs with totally 90 questions presented in a uniform graphical design to facilitate completion called Psychocardiogram® (PCG) and applied the instrument in consecutive patients attending CR. Patients with positive screening results were invited to a psychological counseling session.

Results

Six hundred and nine consecutive patients, aged 34 to 86 years (mean 60.7 years), 85% men, entering the CR program at the Bern University Hospital with ischemic heart failure (CHF), coronary artery disease (CAD) or peripheral artery disease, were included in this study. Eighty-three point three percent of the patients completed the PCG within 40 minutes. Vital exhaustion and Type-D personality were the most prevalent PSRFs (56.9% and 51.1%, respectively), whereas low social support (14.4%) and elevated depressive symptoms (15.9%), were the least prevalent ones. After screening, 120 patients (52.86%) with at least one PSRF made use of psychological counseling.

Conclusions

We found the PCG to be a useful screening tool for PSRF in CR patients with the potential to get new insights into the prevalence of particular PSRF in specific populations and to better study their impact on occurrence and outcome of CVD.

Effect of home-based high-intensity interval training using telerehabilitation among coronary heart disease patients

INTRODUCTION

Cardiovascular diseases are the world's most common causes of morbidity and mortality in the population, including Central Europe. Cardiac rehabilitation (CR) is an effective preventive approach that includes several core components. Physical training is identified as an integral and essential part of CR. Training can positively influence several cardiovascular risk factors in people diagnosed with coronary heart disease and prevent them from clinical events. Our study aims to research the method of high-intensity interval training (HIIT) in a home environment using telerehabilitation. We assume that the HIIT form of telerehabilitation, using a heart rate monitor as a tool for backing up training data, can improve cardiorespiratory fitness and lead to higher peak oxygen uptake than the traditional moderate-intensity continuous training (MICT).

METHODS

This study is designed as a monocentral randomized controlled trial at University Hospital Brno in the Czech Republic. After the coronary heart event, the suitable patients will be randomized (1:1 ratio) and separated into 2 groups: the experimental HIIT group and the control MICT group. Both groups undergo a 12-week telerehabilitation with a 1-year follow-up period. Study participants will be telemonitored during physical training in their home environment via a heart rate monitor and a web platform. Once a week, the patients will give their feedback and motivation by a telephone call.The primary outcome observed will be the effect of intervention expressed by changes in cardiorespiratory fitness. Secondary outcomes will be the health-related quality of life, anxiety, training adherence, body composition, safety, and satisfaction.

DISCUSSION

The HIIT is widely researched predominantly in a center-based supervised form. Our study differs from others by the use of telemedicine and smart technologies in home-based settings. Previous home-based cardiac telerehabilitation studies have focused primarily on MICT, which has demonstrated feasibility, and results have shown similar improvements as center-based CR. There is a presumption that HIIT may be superior to MICT. However, it can be complicated to self-dose the method in the home environment. Investigators expect that HIIT research will provide insight into the possibilities of telemedicine feasibility, effect, and limitations of coronary heart disease patients' use at low to moderate cardiovascular risk.

Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

INTRODUCTION

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

AREAS COVERED

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

EXPERT OPINION

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

Multidisciplinary Cardiac Rehabilitation and Long-Term Prognosis in Patients With Heart Failure

BACKGROUND

Exercise-based cardiac rehabilitation (CR) improves health-related quality of life and exercise capacity in patients with heart failure (HF). However, CR efficacy in patients with HF who are elderly, frail, or have HF with preserved ejection fraction remains unclear. We examined whether participation in multidisciplinary outpatient CR is associated with long-term survival and rehospitalization in patients with HF, with subgroup analysis by age, sex, comorbidities, frailty, and HF with preserved ejection fraction.

METHODS

This multicenter retrospective cohort study was performed in patients hospitalized for acute HF at 15 hospitals in Japan, 2007 to 2016. The primary outcome (composite of all-cause mortality and HF rehospitalization after discharge) and secondary outcomes (all-cause mortality and HF rehospitalization) were analyzed in outpatient CR program participants versus nonparticipants.

RESULTS

Of the 3277 patients, 26% (862) participated in outpatient CR. After propensity matching for potential confounders, 1592 patients were included (n=796 pairs), of which 511 had composite outcomes (223 [14%] all-cause deaths and 392 [25%] HF rehospitalizations, median 2.4-year follow-up). Hazard ratios associated with CR participation were 0.77 (95% CI, 0.65-0.92) for composite outcome, 0.67 (95% CI, 0.51-0.87) for all-cause mortality, and 0.82 (95% CI, 0.67-0.99) for HF-related rehospitalization. CR participation was also associated with numerically lower rates of composite outcome in patients with HF with preserved ejection fraction or frail patients.

CONCLUSIONS

Outpatient CR participation was associated with substantial prognostic benefit in a large HF cohort regardless of age, sex, comorbidities, frailty, and HF with preserved ejection fraction.

Toward a new definition of rehabilitation for research purposes: a comparative analysis of current definitions

There is a need for a common, shared definition of rehabilitation to conduct systematic reviews and identify relevant systematic reviews for knowledge translation purposes, which is an important task of Cochrane Rehabilitation. The present paper aimed to introduce and compare existing health-related definitions of rehabilitation and to propose core aspects that should characterize a new and workable definition of rehabilitation that is able to serve both as the basis for internal communication and identity work and for external communication. We have conducted a PubMed literature search on current definitions that have been published since the launch of WHO's ICF in 2001. Definitions were analyzed by framing questions to which the definitions provide answers. Nine definitions were included in the analysis. Rehabilitation has been defined as a process, as a set or bundle of interventions, and as a health strategy. The main beneficiaries were mainly related to the presence of disability, however, no specific means or interventions in rehabilitation could be identified. The definitions provided varying answers to the questions "by whom…," "where…," and "when…" and additionally identified certain conditions for rehabilitation. The present analysis can serve as a valuable source of information for developing a Cochrane Rehabilitation definition of rehabilitation.

Trends in cardiovascular diseases burden and vascular risk factors in Italy: The Global Burden of Disease study 1990-2017

AIMS

An exhaustive and updated estimation of cardiovascular disease burden and vascular risk factors is still lacking in European countries. This study aims to fill this gap assessing the global Italian cardiovascular disease burden and its changes from 1990 to 2017 and comparing the Italian situation with European countries.

METHODS

All accessible data sources from the 2017 Global Burden of Disease study were used to estimate the cardiovascular disease prevalence, mortality and disability-adjusted life years and cardiovascular disease attributable risk factors burden in Italy from 1990 to 2017. Furthermore, we compared the cardiovascular disease burden within the 28 European Union countries.

RESULTS

Since 1990, we observed a significant decrease of cardiovascular disease burden, particularly in the age-standardised prevalence (-12.7%), mortality rate (-53.8%), and disability-adjusted life years rate (-55.5%). Similar improvements were observed in the majority of European countries. However, we found an increase in all-ages prevalence of cardiovascular diseases from 5.75 m to 7.49 m Italian residents. Cardiovascular diseases still remain the first cause of death (34.8% of total mortality). More than 80% of the cardiovascular disease burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high low density lipoprotein cholesterol, and impaired kidney function.

CONCLUSIONS

Our study shows a decline in cardiovascular mortality and disability-adjusted life years, which reflects the success in reducing disability, premature death and early incidence of cardiovascular diseases. However, the burden of cardiovascular diseases is still high. An approach that includes the cooperation and coordination of all stakeholders of the Italian National Health System is required to further reduce this burden.

Standardization and quality improvement of secondary prevention through cardiovascular rehabilitation programmes in Europe: The avenue towards EAPC accreditation programme: A position statement of the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology (EAPC)

Despite the proven efficacy and cost-effectiveness of contemporary cardiovascular rehabilitation programmes, the referral to/uptake of and adherence to cardiovascular rehabilitation remains inadequate. In addition, heterogeneity persists amongst different cardiovascular rehabilitation centres in Europe, despite the available scientific documents describing the evidence-based rehabilitation format/content. This position statement was elaborated by the Secondary Prevention and Rehabilitation (SP/CR) section of EAPC. It defines the minimal and optimal cardiovascular rehabilitation standards. In addition, it describes the relevant quality indicators of cardiovascular rehabilitation programmes to date. Compliance of European cardiovascular rehabilitation centres with these standards will improve cardiovascular rehabilitation process standardization in Europe and hence increase the quality of cadiovascular rehabilitation programmes.

Systematic review of cardiac rehabilitation guidelines: Quality and scope

Cardiac rehabilitation is a comprehensive model of secondary prevention proven to reduce mortality and morbidity. The World Health Organization is developing a Package of Rehabilitation Interventions for implementation by ministries of health as part of universal healthcare across the continuum. Through a systematic review, we sought to identify the best-quality cardiac rehabilitation guidelines, and extract their recommendations for implementation by member states. A systematic search was undertaken of academic databases and guideline repositories, among other sources, through to April 2019, for English-language cardiac rehabilitation guidelines from the last 10 years, free from conflicts, and with strength of recommendations. Two authors independently considered all citations. Potentially eligible guidelines were rated for quality using the Appraisal of Guidelines for Research and Evaluation tool, and for other characteristics such as being multi-professional, comprehensive and international in perspective; the latter criteria were used to inform selection of 3-5 guidelines meeting inclusion criteria. Equity considerations were also extracted. Altogether, 2076 unique citations were identified. Thirteen passed title and abstract screening, with six guidelines potentially eligible for inclusion in the Package of Rehabilitation Interventions and rated for quality; for two guidelines the Appraisal of Guidelines for Research and Evaluation tool ratings did not meet World Health Organization minimums. Of the four eligible guidelines, three were selected: the International Council of Cardiovascular Prevention and Rehabilitation (2016), National Institute for Health and Care Excellence (#172; 2013) and Scottish Intercollegiate Guideline Network (#150; 2017). Extracted recommendations were comprehensive, but psychosocial recommendations were contradictory and diet recommendations were inconsistent. A development group of the World Health Organization will review and refine the recommendations which will then undergo peer review, before open source dissemination for implementation.

Towards a personalised approach in exercise-based cardiovascular rehabilitation: How can translational research help? A 'call to action' from the Section on Secondary Prevention and Cardiac Rehabilitation of the European Association of Preventive Cardiology

The benefit of regular physical activity and exercise training for the prevention of cardiovascular and metabolic diseases is undisputed. Many molecular mechanisms mediating exercise effects have been deciphered. Personalised exercise prescription can help patients in achieving their individual greatest benefit from an exercise-based cardiovascular rehabilitation programme. Yet, we still struggle to provide truly personalised exercise prescriptions to our patients. In this position paper, we address novel basic and translational research concepts that can help us understand the principles underlying the inter-individual differences in the response to exercise, and identify early on who would most likely benefit from which exercise intervention. This includes hereditary, non-hereditary and sex-specific concepts. Recent insights have helped us to take on a more holistic view, integrating exercise-mediated molecular mechanisms with those influenced by metabolism and immunity. Unfortunately, while the outline is recognisable, many details are still lacking to turn the understanding of a concept into a roadmap ready to be used in clinical routine. This position paper therefore also investigates perspectives on how the advent of 'big data' and the use of animal models could help unravel inter-individual responses to exercise parameters and thus influence hypothesis-building for translational research in exercise-based cardiovascular rehabilitation.