Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology

Association Between Adherence to a 3-Month Cardiac Rehabilitation Program and Long-Term Clinical Outcomes in Japanese Patients With Cardiac Implantable Electronic Devices

PURPOSE

The objective of this study was to evaluate the association between comprehensive cardiac rehabilitation (CCR) completion and long-term clinical outcomes in patients with cardiac implantable electronic devices (CIED).

METHODS

This retrospective cohort study included 834 patients with CIED who participated in CCR, which included a cardiopulmonary exercise test or 6-min walk test. Patients with a left ventricular ejection fraction ≤40%, predicted peak oxygen uptake ≤80%, or B-type natriuretic peptide level ≥80 pg/mL were eligible. The primary outcome was all-cause death.

RESULTS

After excluding 241 patients with duplicate records and 69 who underwent CCR in the outpatient department, the data of 524 patients were analyzed. Mean age was 64 ± 15 yr, 389 (74%) patients were men, left ventricular ejection fraction was 31 ± 15%, and 282 (54%) patients had a history of hospitalization for worsening heart failure.. Of the patients referred for CCR, 294 (56%) completed the program, and an additional 230 patients started but did not complete CCR. Over a 3.7-yr median follow-up period, all-cause deaths occurred in 156 (30%) patients. Completers had lower all-cause death rates than non-completers (log-rank 15.77, P< .001). After adjusting for prognostic baseline characteristics, completers had 58% lower all-cause death risks than non-completers (HR = 0.42; 95% CI, 0.27-0.64, P< .001).

CONCLUSIONS

Three-mo CCR program completion was associated with lower death risks in patients with CIED. New programs or management methods are needed to decrease death risks, especially for those who cannot complete CCR programs.

The psychological well-being index and quality of life after a cardiac rehabilitation program based on aerobic training and psychosocial support

BACKGROUND

This study aimed to investigate the physical and psychological benefits of an alternative cardiac rehabilitation program based on therapeutic groups during physical exercise sessions and to compare the results with those of a conventional cardiac rehabilitation program.

METHOD

The sample included 112 patients from the cardiac rehabilitation unit of a medical center, 91.1 % of whom were male. The control group consisted of 47 subjects, with a mean age of 57.89 ± 12.30 and the experimental group consisted of 65 subjects, with a mean age of M = 58.38 ± 9.86. Quality of life, psychological well-being, health-related quality of life, body mass index, blood pressure, abdominal circumference and resting heart rate were measured before starting and at the end of the cardiac rehabilitation program.

RESULTS

The experimental group improved significantly more than the control group in body mass index, systolic and diastolic blood pressure, abdominal circumference, and resting heart rate (p value < 0.005). In addition, the experimental group had significantly greater improvements in quality of life, psychological well-being, and health-related quality of life than the control group (p-value < 0.001).

CONCLUSIONS

A cardiac rehabilitation program based on simultaneous aerobic training and psychosocial support improved the physical function, health-related quality of life and well-being.

An Investigation of the Sled-Push Exercise Using a Resisted Sled Machine in Apparently Healthy Older Adults: An Exploratory Study

Physical function is regarded as the cornerstone of healthy aging, and exercise is an important determinant of healthy aging. This study examined the feasibility and physiological (heart rate, blood pressure, blood lactate, and rate of perceived exertion) and psychological (enjoyment) response resulting from an acute progressive sled-push (SLP) exercise session using the novel XPO Sled Trainer in older adults and compared that with walking (WKC) condition. The exercise session comprised six exercise bouts at 75%, 85%, 100% (2×), and 125% (2×) of normal velocity with a 2-min rest between bouts. Thirty-six older adults were randomly allocated into either the SLP or WKC conditions. No adverse events were observed during the exercise session, and all participants completed the exercise protocol as prescribed. One-third of the participants in the SLP group reported minimal body discomfort. Significantly higher responses were observed for all physiological variables as the intensity of the exercise increased in the SLP group compared with the WKC group (p < .001). The SLP group presented a decline in enjoyment as the intensity of the exercise increased (during), but similar enjoyment level than the WKC group for the overall exercise session (p = .711). Our findings support the viability and safety of SLP exercise using the XPO Sled Trainer in older adults. Such exercise demonstrated an intensity-driven modality that may have potential to elucidate positive adaptations in the cardiovascular system of older adults with acceptable levels of enjoyment.

The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial

BACKGROUND

Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs.

METHODS

The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation.

DISCUSSION

Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23.

The Clinical Outcome of Cardiac Rehabilitation in Coronary Artery Disease Patients with Regard to the Presence of Left Ventricular Systolic Dysfunction

Background: Despite the use of advanced treatment techniques, coronary artery disease (CAD) still remains the main cause of left ventricular (LV) dysfunction and heart failure. Participation in cardiac rehabilitation (CR) programs can lead to a number of beneficial effects, but some patients do not demonstrate the expected improvement. The aim of this study is to evaluate the impact of CR on changes in exercise capacity with regard to the presence of LV dysfunction. Methods: A group of 428 patients with CAD were consecutively admitted to an outpatient comprehensive cardiac rehabilitation program comprising 24 exercise sessions of interval training on cycle ergometers, three times a week for 45 min, and a health education. The patients were compared in two subgroups, i.e., with LV systolic dysfunction (LVEF < 50%, n = 175) and LVEF ≥ 50% (n = 253). Results: In the LVEF < 50% group, the exercise capacity improved by 1 ± 0.78 MET (median 1.15 MET), and 0.86 ± 0.77 MET (median 1.08 MET) in the LVEF ≥ 50% group. Women with LVEF < 50% demonstrated a significant increase in exercise capacity by 1.2 MET, while those with LVEF ≥ 50% did not display any such increase. All men, regardless of LVEF, exhibited a similar improvement in exercise capacity greater than 1 MET. Conclusions: An outpatient eight-week cardiac rehabilitation program based on 45 min aerobic interval training sessions three times a week appears less effective for women with CAD and EF ≥ 50%. In this group, the proposed training intervention is insufficient in improving exercise capacity to an extent that could indicate a reduction in mortality risk.

A Review of High-Intensity Interval Training in Heart Transplant Recipients: Current Knowledge and Future Perspectives

OBJECTIVE

This review reports how exercise-based rehabilitation strategies have developed over the past decades, and it specifically focuses on the effectiveness, safety, and implementation of high-intensity interval training (HIIT). It provides an overview of the historical progression, main research findings, and considerations surrounding HIIT as the preferred exercise modality for recipients of heart transplant (HTx).

REVIEW METHODS

The review includes a timeline of studies spanning from 1976-2023. The 2017 Cochrane systematic review on exercise-based cardiac rehabilitation in recipients of HTx serves as the main knowledge base (≥2015). Additionally, literature searches in PubMed/Medline and ClinicalTrials.gov have been performed, and all reviews and studies reporting the effects of moderate- to high-intensity exercise in recipients of HTx, published in 2015 or later have been screened.

SUMMARY

High-intensity interval training has gained prominence as an effective exercise intervention for recipients of HTx, demonstrated by an accumulation of performed studies in the past decade, although implementation in clinical practice remains limited. Early restrictions on HIIT in HTx recipients lacked evidence-based support, and recent research challenges these previous restrictions. High-intensity interval training results in greater improvements and benefits compared with moderate-intensity continuous training in the majority of studies. While HIIT is now regarded as generally suitable on a group level, individual assessment is still advised. The impact of HIIT involves reinnervation and central and peripheral adaptations to exercise, with variations in recipent responses, especially between de novo and maintenance recipients, and also between younger and older recipients. Long-term effects and mechanisms behind the HIIT effect warrant further investigation, as well as a focus on optimized HIIT protocols and exercise benefits.

Applying Exercise Capacity and Physical Activity as Single vs Composite Endpoints for Trials of Cardiac Rehabilitation Interventions: Rationale, Use-case, and a Blueprint Method for Sample Size Calculation

OBJECTIVE

To conceptualize a composite primary endpoint for parallel-group RCTs of exercise-based cardiac rehabilitation (CR) interventions and to explore its application and statistical efficiency.

DESIGN

We conducted a statistical exploration of sample size requirements. We combined exercise capacity and physical activity for the composite endpoint (CE), both being directly related to reduced premature mortality in patients with cardiac diseases. Based on smallest detectable and minimal clinically important changes (change in exercise capacity of 15 W and change in physical activity of 10 min/day), the CE combines 2 dichotomous endpoints (achieved/not achieved). To examine statistical efficiency, we compared sample size requirements based on the CE to single endpoints using data from 2 completed CR trials.

SETTING

Cardiac rehabilitation phase III.

PARTICIPANTS

Patients in cardiac rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Exercise capacity (Pmax assessed by incremental cycle ergometry) and physical activity (daily minutes of moderate to vigorous physical activity assessed by accelerometry).

RESULTS

Expecting, for example, a 10% between-group difference and improvement in the clinical outcome, the CE would increase sample size by up to 21% or 61%, depending on the dataset. When expecting a 10% difference and designing an intervention with the aim of non-deterioration, the CE would allow to reduce the sample size by up to 55% or 70%.

CONCLUSIONS

Trialists may consider the utility of the CE for future studies in exercise-based CR to reduce sample size requirements. However, perhaps surprisingly at first, the CE could also lead to an increased sample size needed, depending on the observed baseline proportions in the trial population and the aim of the intervention.

Are exercise prescriptions for patients with cardiovascular disease, made by physiotherapists, in agreement with European recommendations?

AIMS

Physiotherapists often treat patients with (elevated risk for) cardiovascular disease (CVD), and should thus be able to provide evidence-based exercise advice to these patients. This study, therefore, aims to examine whether exercise prescriptions by physiotherapists to patients with CVD are in accordance with European recommendations.

METHODS AND RESULTS

This prospective observational survey included forty-seven Belgian physiotherapists. The participants agreed to prescribe exercise intensity, frequency, session duration, program duration, and exercise type (endurance or strength training) for the same three patient cases. Exercise prescriptions were compared between physiotherapists and relations with their characteristics were studied. The agreement between physiotherapists' exercise prescriptions and those from European recommendations ('agreement score': based on a maximal score of 60/per case) was assessed. A wide inter-clinician variability was noticed for all exercise modalities, leading to a large variance for total peak-effort training minutes (from 461 up to 9000 over the three cases). The exercise frequency was prescribed fully out of range of the recommendations and the prescription of additional exercise modes was generally flawed. Exercise intensity and program duration were prescribed partially correct. The addition of strength exercises and session duration was prescribed correctly. This led to physiotherapist agreement scores of 25.3 ± 9.6, 23.2 ± 9.9, and 27.1 ± 10.6 (all out of 60), for cases one, two, and three, respectively. A greater agreement score was found in younger colleagues and those holding a Ph.D.

CONCLUSION

Exercise prescriptions for CVD patients vary widely among physiotherapists and often disagree with European recommendations.

REGISTRATION

ClinicalTrials.gov NCT05449652.

The longitudinal relationship between fear of movement and physical activity after cardiac hospitalization: A cross lagged panel model

BACKGROUND

Little is known about the association between fear of movement (kinesiophobia) and objectively measured physical activity (PA), the first 12 weeks after cardiac hospitalization.

PURPOSE

To assess the longitudinal association between kinesiophobia and objectively measured PA and to assess the factor structure of kinesiophobia.

METHODS

We performed a longitudinal observational study. PA was continuously measured from hospital discharge to 12 weeks using the Personal Activity Monitor. The PAM measures time spent per day in PA-intensity categories: light, moderate and heavy. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) at four time points (hospital discharge, 3, 6 and 12 weeks). The longitudinal association between PA-intensity and kinesiophobia was studied with a random intercept cross lagged panel model (RI-CLPM). A RI-CLPM estimates effects from kinesiophobia on objectively measured PA and vice versa (cross-over effects), and autoregressive effects (e.g. kinesiophobia from one occasion to the next).

RESULTS

In total, 116 patients (83.6% male) with a median age of 65.5 were included in this study. On no occasion did we find an effect of kinesiophobia on PA and vice versa. Model fit for the original model was poor (X2: = 44.646 P<0.001). Best model fit was found for a model were kinesiophobia was modelled as a stable between factor (latent variable) and PA as autoregressive component (dynamic process) (X2 = 27.541 P<0.12).

CONCLUSION

Kinesiophobia and objectively measured PA are not associated in the first 12 weeks after hospital discharge. This study shows that kinesiophobia remained relatively stable, 12 weeks after hospital discharge, despite fluctuations in light to moderate PA-intensity.

Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

[Treatment of Acute Coronary Syndromes]

Despite significant advances in the detection and rapid management of acute coronary syndromes (ACS), it continues to lead the cause of death statistics and they continuously represent the leading cause of death and living with disabilities, globally. Since ACS combine a spectrum of different diagnoses, a high degree of variability in possible clinical presentation and relevant gender differences, Individualised treatment is not always easy and is constantly changing due to novel evidence from research studies. Therefore, the aim of this article is therefore to explain relevant treatment options and to present the current state of science in the context of clinical patient treatment.

Changes in walking speed 6 months after discharge may be more sensitive to subsequent prognosis than handgrip strength in patients hospitalized for heart failure

BACKGROUND

Despite the prognostic importance of walking speed (WS) and handgrip strength (HGS) in patients with heart failure (HF), no study has reported the prognostic impact of changes in these parameters. This study aimed to examine the association between changes after discharge and the subsequent prognosis.

METHODS

This study included 881 elderly patients hospitalized for HF. WS and HGS were measured at discharge and 6 months after discharge. Based on the presence of slowness (WS <0.98 m/s) or weakness (HGS <30.0 kg for men and < 17.5 kg for women) at both points, patients were divided into four groups (WS: A = -/-, B = -/+, C = +/-, D = +/+; HGS: E = -/-, F = -/+, G = +/-, H = +/+). The study endpoint was a composite of all-cause mortality and HF rehospitalization during the 18 months after 6 months of discharge. The Cox proportional hazards model was used to assess the association between the groups and study outcomes.

RESULTS

Stratified by the WS change patterns, groups B and D showed higher risk of the study outcomes than group A [B: hazard ratio 2.34, 95% confidence interval (CI) 1.29-4.28; D: 2.38, 1.67-3.39], whereas group C was not. When stratified by the HGS change in patterns, only group H was associated with a worse prognosis (HR; 1.85, 95%CI; 1.31-2.60).

CONCLUSION

Changes in WS were related to HF prognosis, suggesting that changes in WS may be more sensitive to further risk stratification than changes in HGS.

Left atrial strain analysis and new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction: A prospective echocardiography study

BACKGROUND

New-onset atrial fibrillation (NOAF) is a well-known complication of ST-segment elevation myocardial infarction (STEMI), probably due to left atrial (LA) remodelling. LA strain (LAS) can predict NOAF in several cardiovascular diseases.

OBJECTIVE

To assess whether LAS predicts NOAF in sinus rhythm patients with STEMI during hospitalization.

METHODS

Adults with a STEMI and transthoracic echocardiography performed within 48hours of admission were included. LAS analysis, performed by automated software, recorded LAS during the reservoir phase (LASr), the conduit phase (LAScd) and the contraction phase (LASct).

RESULTS

From May 2021 to November 2022, 175 patients were included, 21 (12%) of whom developed NOAF. NOAF patients were older (median [Q1-Q3]: 67 [59-80] vs 59 [51-67]years; P=0.006) and had a higher Thrombolysis In Myocardial Infarction scores (4 [2-7] vs 3 [1-4]; P=0.005). All LAS parameters were significantly impaired in NOAF patients, especially LASr (13.0% [10.5-28.4] vs 36.6% [29.0-44.9]; P=0.001). An LASr cut-off of 27% had a sensitivity of 81% and a specificity of 80% to identify patients with NOAF. In a multivariable model, LASr was significantly associated with NOAF (odds ratio 1.18, 95% confidence interval 1.09-1.26; P=0.003). The cumulative risk of NOAF during hospital stay was 30% (18-43 with LASr<27% and 4% [1.5-8.5] with LASr≥27% [P<0.0001]).

CONCLUSION

NOAF is a frequent complication of STEMI. LASr seems helpful for identifying patients at high risk of NOAF during hospitalization.

Cardio-oncology rehabilitation: are we ready?

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation but also a pillar of preventive cardio-oncology. Cardio-oncology rehabilitation is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared with an 'exercise only' programme, comprehensive CORE demonstrates a better outcome. It involves nutritional counselling, psychological support, and cardiovascular (CV) risk assessment, and it is directed to a very demanding population with a heavy burden of CV diseases driven by physical inactivity, cancer therapy-induced metabolic derangements, and cancer therapy-related CV toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (tele-rehabilitation). Not all CORE is created equally: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey. The aim of this paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar population of patients but also for oncologists, primary care providers, patients, and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during, and after cancer treatment, in order to improve quality of life and to fight health inequities.

Translation, cultural adaptation, and psychometric validation of the Provider Attitudes toward Cardiac Rehabilitation and Referral (PACRR-C) Scale in Simplified Chinese

BACKGROUND

The Provider Attitudes toward CR and Referral (PACRR) scale was translated into Simplified Chinese and psychometric validation ensued.

METHODS

Brislin's Translation Model was applied, with two independent forward translations followed by back-translation. Experts assessed the face, content and cross-cultural validity of items, and item analysis followed. For validation, 227 physicians from hospitals in 14 Chinese provinces completed the PACRR-C. Structural validity was assessed through exploratory and confirmatory factor analysis. Internal and split-half reliability were assessed.

RESULTS

Some items were rephrased and one item was deleted. The content validity index for the total scale was 0.965. The correlation coefficients between the 18 items and the total scale ranged between 0.28 and 0.76. Consistent with the English version, four factors were extracted (Cronbach's alpha ranged from 0.671-0.959) through the factor analysis, accounting for 71.21% of the total variance. Split-half reliability was 0.945. The greatest factors impacting physician's CR attitudes were inconvenience of the referral process (3.93 ± 0.65/5); lack of standard referral forms (3.92 ± 0.66), perceiving referral as the responsibility of another clinician (3.89 ± 0.67), and need for support in completing the referral form (3.89 ± 0.64).

CONCLUSIONS/SIGNIFICANCE

The reliability, as well as content, face, cross-cultural, and structural validity of the 18-item, 4-subscale PACRR-C, were supported.

Patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation: a qualitative interview study

Introduction

Despite the well-known benefits of exercise-based cardiac rehabilitation for the secondary prevention of cardiovascular disease, participation in cardiac rehabilitation programmes and adherence to secondary prevention recommendations remain limited. Digital technologies have the potential to address low participation and adherence but attempts at implementing digital health interventions in real-life clinical practice frequently encounter various barriers. Studies about patients' experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting patient-related barriers. This study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology for physical activity and exercise.

Methods

Twenty-five current and former cardiac rehabilitation patients (18 men and 7 women, age range 39 to 83) with various cardiac conditions were recruited from a clinical site in Salzburg, Austria. Semi-structured qualitative interviews were audio-recorded and transcribed verbatim. The analysis followed a descriptive phenomenological approach, applying the framework analysis method.

Results

The sample was diverse, including interviewees who readily used digital devices to support their physical activity, exercise and health monitoring, and interviewees who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements.

Discussion

These findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the preferences and capabilities of the individual patient. Regarding data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technology and digital health interventions.

Effects of Exercise Training Response on Quality of Life and Cardiovascular Risk Factor Profiles in People With Coronary Artery Disease: Insights From the HIIT or MISS UK Trial

OBJECTIVE

To compare the characteristics of responders and nonresponders to 8 weeks of exercise training to determine differences in key cardiovascular disease outcomes in people with coronary artery disease (CAD).

DESIGN

Secondary analysis of data from the HIIT or MISS UK trial.

SETTING

Six outpatient National Health Service cardiac rehabilitation (CR) centers in the UK. In people with CAD attending CR, the HIIT or MISS UK trial reported that short-term, low-volume, high-intensity interval training (HIIT) was more effective than moderate-intensity steady state (MISS) exercise training for improving peak oxygen uptake (V̇o2peak).

PARTICIPANTS

382 participants with CAD (N=382) (mean age: 58.8±9.6y; mean body mass index: 29.0±4.3 kg/m2).

MAIN OUTCOME MEASURES

We identified responders and nonresponders based on a meaningful change in V̇o2peak, using 2 established methods. Key clinical, quality of life (QoL), and cardiopulmonary exercise test (CPET)-derived outcomes were compared between groups.

RESULTS

Responders were more likely to be younger (P<.05), and demonstrate greater improvement in CPET-related outcomes, for example, oxygen uptake efficiency slope, ventilatory efficiency, and peak power output (all comparisons, P<.001). Responders were more likely to observe improvements in QoL (EQ-5D-5L; mean Δ 13.6 vs mean Δ 9.4; P=.045), and high-density lipoprotein cholesterol (HDL-c) (mean Δ 0.09 mmol/L vs mean Δ 0.04 mmol/L; P=.004), compared to nonresponders.

CONCLUSIONS

In people with CAD attending CR, responders to exercise training were more likely to be younger and demonstrate greater improvements in health-related QoL and HDL-c.

What motivates heart transplantation patients to exercise and engage in physical activity? A network analysis

AIMS

After heart transplantation (HTx), increments in physical activity (PA) are strongly recommended. However, participation rates in exercise-based cardiac rehabilitation and engagement in PA are insufficient in many patients. Hence, this study aimed to explore the central factors and the interconnections among distinct types of motivation to exercise, PA, sedentary time, psychosomatic, diet, and activity limitation characteristics in post-HTx patients.

METHODS AND RESULTS

This is a cross-sectional study involving 133 post-HTx patients (79 men, mean age 57 ± 13 years, mean time from transplantation 55 ± 42 months) recruited from an outpatient clinic in Spain. The patients were asked to fill in questionnaires measuring self-reported PA, motivation to exercise, kinesiophobia, musculoskeletal pain, quality of sleep, depression, functional capacity, frailty, sarcopenia risk, and diet quality. Two network structures were estimated: one network including PA and one network including sedentary time as nodes. The relative importance of each node in the network structures was determined using centrality analyses. According to the strength centrality index, functional capacity and identified regulation (subtypes of motivation to exercise) are the two most central nodes of the network (strength: z-score = 1.35-1.51). Strong and direct connections emerged between frailty and PA and between sarcopenia risk and sedentary time.

CONCLUSION

Functional capacity and autonomous motivation to exercise are the most promising targets of interventions to improve PA levels and sedentary time in post-HTx patients. Furthermore, frailty and sarcopenia risk were found to mediate the effects of several other factors on PA and sedentary time.

Training and attitudes concerning cardiac rehabilitation in Portugal: A national survey of physician members of the Portuguese Society of Cardiology

INTRODUCTION AND OBJECTIVES

Cardiac rehabilitation (CR) is a central component in the management of cardiovascular disease. While its potential benefits have been extensively explored and confirmed, its implementation is still suboptimal, due to various possible barriers. This study aimed to assess training and attitudes concerning CR among physicians in a Portuguese setting.

METHODS

An online questionnaire structured in three parts (participant characteristics, training and attitudes concerning CR, and a brief general knowledge assessment) was developed and sent to members of the Portuguese Society of Cardiology. The study population encompassed physicians with a medical specialty or residents from the third year onward of a specialty program.

RESULTS

A total of 97 individuals (57.7% male, 61.9% aged ≤50 years) presented valid answers. CR was available at the workplace of 54.6% of participants. Most of them considered that the time allocated to CR training during residency was inadequate, and thought that more time was needed for this purpose. Most had not dedicated (or intended to dedicate) time for CR training, with lack of time being the most frequently attributed reason. In terms of referral, a substantial proportion of subjects did not refer patients, with lack of CR centers and human resources being the most frequent reasons.

CONCLUSIONS

This survey provides contemporary data on CR training and attitudes, highlighting areas of potential improvement, such as time allocated to training in this area. These results could provide a useful pragmatic framework for optimization of training and awareness in this pivotal field of cardiovascular medicine.

Effects of different rehabilitation modality on cardiopulmonary function in patients with acute coronary syndrome after revascularization

Objective

To investigate the effects of different rehabilitation modalities on cardiopulmonary function in patients with acute coronary syndrome after revascularization.

Methods

Two randomized controlled trials were conducted. All patients were stable for more than 48 h and less than 1 week after revascularization for acute coronary syndrome and were randomly assigned to Group A (home-based rehabilitation group) or Group B (center guided home-based rehabilitation group). The cardiopulmonary exercise test was mainly performed before and 3 months after cardiac rehabilitation (at the end of intervention). The primary endpoints of the study were peak oxygen uptake (VO2peak), and the secondary endpoints were maximum metabolic equivalents (METs), anaerobic threshold exercise load (Load AT), maximal workload (Load max), and anaerobic threshold oxygen uptake (VO2 AT).

Results

A total of 106 patients were included in the study, with 47 patients in Group A (with 6 losses) and 50 patients in Group B (with 3 losses). There were no significant difference between the two groups in terms of age, gender, body mass index (BMI), left ventricular ejection fraction(LVEF), low-density lipoprotein cholesterol(LDL-C),cardiovascular risk factors. In Group A, no significant differences in CPET indices were observed before and after the intervention. In Group B, values of maximum metabolic equivalents (METs), peak heart rate (PHR), anaerobic threshold exercise load (Load AT), maximal workload (Load max), maximum ventilation per minute (VE max), peak oxygen uptake (VO2peak), anaerobic threshold oxygen uptake (VO2 AT) and maximum oxygen pulse (VO2/HRmax) were higher than those before the intervention (P < 0.05). In addition, METs (max), Load AT, Load max, VO2 AT, and VO2peak in Group B were higher than those in group A (P < 0.05). The change rates of VO2peak, METs(max), PHR, Load max, VO2 AT, VE max, VO2/HR(max) in the two groups were significantly different before and after intervention (P <  0.05).

Conclusion

Cardiac exercise rehabilitation is helpful for improving patients' cardiopulmonary endurance and quality of life. Moreover, rehabilitation modalities with regular hospital guidance can improve cardiopulmonary function in a shorter period,which seems to be more effective than a complete home-based rehabilitation model.

Clinical Trial Registration

http://www.chictr.org.cn, identifier (ChiCTR2400081034).

Cardiac rehabilitation and acute aortic dissection: understanding and addressing the evidence GAP a systematic review

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.

Improving adherence to rehabilitation for heart failure patients through immersive virtual reality (VIRTUAL-HF): A protocol for a randomized controlled trial

BACKGROUND

To improve symptoms and reduce poor outcomes related to heart failure (HF), international guidelines recommend cardiac rehabilitation (CR), particularly for those with a reduced ejection fraction. Unfortunately, patient adherence to rehabilitation programs remains suboptimal, with dropouts ranging from 15.4 to 63.3%. An innovative and promising intervention that could improve adherence to rehabilitation is virtual reality (VR). This study aims to evaluate the effects of VR in patients with HF who undergo CR using this technology in terms of adherence (primary outcome), functional capacity, perceived exertion, angina, quality of life, heart rate, oxygen saturation, blood pressure, maximum oxygen uptake, minute ventilation/carbon dioxide production slope, oxygen pulse, blood values of NT-proBNP and HF related rehospitalization rates (secondary outcomes).

METHODS

A randomized controlled trial will be conducted in a sample of 80 patients referred to CR. Participants will be enrolled in a cardiological rehabilitation unit of a large university hospital in Italy and randomized (1:1) to the experimental intervention consisting of CR performed with high-quality immersive VR with PICO 4® Head Mounted Display headset and TREADMILL XR® software (Arm 1) or standard CR (Arm 2). Patients, according to guidelines, will perform 30-min of CR sessions with moderate intensity, twice a week for one month.

RESULTS

Significant improvements in primary and secondary outcomes are expected in patients in the intervention group.

CONCLUSIONS

If proven to be effective, VR could be an innovative, safe, and easy digital health intervention to improve adherence to CR in patients with HF, as well as important clinical outcomes.

Physiological and psychological outcomes of high intensity interval training in patients with heart failure compared to moderate continuous training and usual care: A systematic review with meta analysis

BACKGROUND

An important component of secondary prevention of CVD (including HF) is comprehensive cardiac rehab, including exercise. Novel, individualised approaches are needed to increase uptake and adherence to exercise programmes, one area offering potential is HIIT. HIIT has been shown to be both safe and effective for improving cardiovascular fitness in both coronary artery disease and HF patients.

OBJECTIVES

To provide a current and up to date evaluation of the physiological and psychological outcomes of HIIT in patients with HF compared to MCT and UC. Secondly to perform sub-group analyses comparing short and long HIIT protocols.

METHODS

A systematic review and meta-analysis of randomised controlled trials was undertaken. Medline, Embase, Scopus, CINAHL and SportDISCUS were searched up to July 2022. Trials were included if they carried out a HIIT intervention (defined at intensity ≥ 80% peak HR or ≥ 80% VO2peak) in HF patients (HFpEF or HFrEF) for at least 6 weeks. Comparator group was UC or MCT.

RESULTS

HIIT was shown to be superior to MCT and UC for improving VO2peak (HIIT mean improvement 3.1 mL.kg-1min-1). HITT was superior to MCT and UC for improving LVEF (HIIT mean improvement 5.7%). HIIT was superior to MCT and UC for improving HRQoL, using the MLHFQ (HIIT mean point change of -12.8). Subgroup analysis showed no difference between long and short HIIT.

CONCLUSION

HIIT improves VO2peak, LVEF and HRQoL in patients with HF, the improvements seen in VO2peak and LVEF are superior in HIIT compared to MCT and UC.

Agreement between self-reported and objectively assessed physical activity among out-of-hospital cardiac arrest survivors

BACKGROUND

Low level of physical activity is a risk factor for new cardiac events in out-of-hospital cardiac arrest (OHCA) survivors. Physical activity can be assessed by self-reporting or objectively by accelerometery.

AIM

To investigate the agreement between self-reported and objectively assessed physical activity among OHCA survivors HYPOTHESIS: Self-reported levels of physical activity will show moderate agreement with objectively assessed levels of physical activity.

METHOD

Cross-sectional study including OHCA survivors in Sweden, Denmark, and the United Kingdom. Two questions about moderate and vigorous intensity physical activity during the last week were used as self-reports. Moderate and vigorous intensity physical activity were objectively assessed with accelerometers (ActiGraph GT3X-BT) worn upon the right hip for 7 consecutive days.

RESULTS

Forty-nine of 106 OHCA survivors answered the two questions for self-reporting and had 7 valid days of accelerometer assessment. More physically active days were registered by self-report compared with accelerometery for both moderate intensity (median 5 [3:7] vs. 3 [0:5] days; p < 0.001) and vigorous intensity (1 [0:3] vs. 0 [0:0] days; p < 0.001). Correlations between self-reported and accelerometer assessed physical activity were sufficient (moderate intensity: rs  = 0.336, p = 0.018; vigorous intensity: rs  = 0.375, p = 0.008), and agreements were fair and none to slight (moderate intensity: k = 0.269, p = 0.001; vigorous intensity: k = 0.148, p = 0.015). The categorization of self-reported versus objectively assessed physical activity showed that 26% versus 65% had a low level of physical activity.

CONCLUSION

OHCA survivors reported more physically active days compared with the results of the accelerometer assessment and correlated sufficiently and agreed fairly and none to slightly.

A multi-component intervention increased access to smoking cessation treatment after hospitalization for atherosclerotic cardiovascular disease: a randomized trial

Aims

To evaluate the effects of a multi-component intervention for smokers hospitalized for atherosclerotic cardiovascular disease (ASCVD) on the participation rate in community-based cessation programmes and the use of cessation drugs. Additionally, to explore the impact on the cessation rates at 6 months.

Methods and results

A randomized parallel-group study was conducted at a Norwegian secondary care hospital in 2021. The intervention group was: (i) counselled using motivational interviewing techniques during hospitalization; (ii) given an information leaflet, detailing the cessation programme; and (iii) referred to the community-based smoking cessation treatment including a post-discharge pro-active telephone invitation. The control group received usual care and the same information leaflet containing clear contact details for initiating participation. Data were collected at baseline, 1, 3, and 6 months. Among 99 smokers hospitalized with ASCVD, 40 were excluded. Of 59 randomized patients, 4 were lost to follow-up and 55 completed the study. The mean age was 65.1 (standard deviation 9.3) years, 35% were female, and 88% had smoked >20 years. Co-morbidity was prevalent (mean Charlson score 4.8). The intervention group was more likely to participate in the smoking cessation treatment {48 vs. 7%, difference: 41% [95% confidence interval (CI): 14%, 63%]} and used cessation drugs more frequently [59 vs. 21%, difference: 38% (95% CI: 17%, 59%)]. At the 6 months point prevalence, we observed notable between-group differences in self-reported cessation rate (48 vs. 25%).

Conclusion

The intervention significantly increased the participation rate at community-based smoking cessation programmes and the use of cessation drugs among multi-morbid smokers hospitalized for ASCVD.

An Index for Evaluating Exercise Capacity Improvement After Cardiac Rehabilitation in Patients After Myocardial Infarction

OBJECTIVE

We investigated relationships among predictors of improvement in exercise capacity after cardiac rehabilitation programs in patients after acute myocardial infarction.

METHODS

We carried out a secondary analysis of data from 41 patients with a left ventricular ejection fraction ≥ 40% who underwent cardiac rehabilitation after the first myocardial infarction. Participants were assessed using a cardiopulmonary exercise test and stress echocardiography. A cluster analysis was performed, and the principal components were analyzed.

RESULTS

Two distinct clusters with significantly different ( P = .005) proportions of response to treatment (peak VO 2 ≥ 1 mL/kg/min) were identified among patients. The first principal component explained 28.6% of the variance. We proposed an index composed of the top 5 variables from the first component to represent the improvement in exercise capacity. The index was the average of scaled O 2 uptake and CO 2 output at peak exercise, minute ventilation at peak, load achieved at peak exercise, and exercise time. The optimal cutoff for the improvement index was 0.12, which outperformed the peak VO 2 ≥ 1 mL/kg/min criterion in recognizing the clusters, with a C-statistic of 91.7% and 72.3%, respectively.

CONCLUSION

The assessment of change in exercise capacity after cardiac rehabilitation could be improved using the composite index.

Living Lab Data of Patient Needs and Expectations for eHealth-Based Cardiac Rehabilitation in Germany and Spain From the TIMELY Study: Cross-Sectional Analysis

BACKGROUND

The use of eHealth technology in cardiac rehabilitation (CR) is a promising approach to enhance patient outcomes since adherence to healthy lifestyles and risk factor management during phase III CR maintenance is often poorly supported. However, patients' needs and expectations have not been extensively analyzed to inform the design of such eHealth solutions.

OBJECTIVE

The goal of this study was to provide a detailed patient perspective on the most important functionalities to include in an eHealth solution to assist them in phase III CR maintenance.

METHODS

A guided survey as part of a Living Lab approach was conducted in Germany (n=49) and Spain (n=30) involving women (16/79, 20%) and men (63/79, 80%) with coronary artery disease (mean age 57 years, SD 9 years) participating in a structured center-based CR program. The survey covered patients' perceived importance of different CR components in general, current usage of technology/technical devices, and helpfulness of the potential features of eHealth in CR. Questionnaires were used to identify personality traits (psychological flexibility, optimism/pessimism, positive/negative affect), potentially predisposing patients to acceptance of an app/monitoring devices.

RESULTS

All the patients in this study owned a smartphone, while 30%-40% used smartwatches and fitness trackers. Patients expressed the need for an eHealth platform that is user-friendly, personalized, and easily accessible, and 71% (56/79) of the patients believed that technology could help them to maintain health goals after CR. Among the offered components, support for regular physical exercise, including updated schedules and progress documentation, was rated the highest. In addition, patients rated the availability of information on diagnosis, current medication, test results, and risk scores as (very) useful. Of note, for each item, except smoking cessation, 35%-50% of the patients indicated a high need for support to achieve their long-term health goals, suggesting the need for individualized care. No major differences were detected between Spanish and German patients (all P>.05) and only younger age (P=.03) but not sex, education level, or personality traits (all P>.05) were associated with the acceptance of eHealth components.

CONCLUSIONS

The patient perspectives collected in this study indicate high acceptance of personalized user-friendly eHealth platforms with remote monitoring to improve adherence to healthy lifestyles among patients with coronary artery disease during phase III CR maintenance. The identified patient needs comprise support in physical exercise, including regular updates on personalized training recommendations. Availability of diagnoses, laboratory results, and medications, as part of a mobile electronic health record were also rated as very useful.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05461729; https://clinicaltrials.gov/study/NCT05461729.

Exercise-based cardio-oncology rehabilitation for cardiotoxicity prevention during breast cancer chemotherapy: The ONCORE randomized controlled trial

BACKGROUND

Breast cancer (BC) treatment with anthracyclines and/or anti-human epidermal growth factor receptor-2 (HER2) antibodies is associated with an increased risk of cardiovascular disease complications, including cancer therapy-related cardiac dysfunction (CTRCD). While Cardio-Oncology Rehabilitation (CORe) programs including exercise have emerged to minimize these risks, its role in preventing CTRCD is unclear.

OBJECTIVES

We investigated the effectiveness of an exercise-based CORe program in preventing CTRCD [left ventricular ejection fraction (LVEF) drop ≥10% to a value <53% or a decrease >15% in global longitudinal strain (GLS)]. Secondary outcomes examined changes in cardiac biomarkers, physical performance including peak oxygen consumption, psychometric and lifestyle outcomes. Safety, adherence, and patient satisfaction were also assessed.

METHODS

This is a randomized controlled trial including 122 early-stage BC women receiving anthracyclines and/or anti-HER2 antibodies, randomized to CORe (n = 60) or usual care with exercise recommendation (n = 62). Comprehensive assessments were performed at baseline and after cardiotoxic treatment completion. The average duration of the intervention was 5.8 months.

RESULTS

No cases of CTRCD were identified during the study. LVEF decreased in both groups, but was significantly attenuated in the CORe group [-1.5% (-2.9, -0.1); p = 0.006], with no changes detected in GLS or cardiac biomarkers. The CORe intervention led to significant body mass index (BMI) reduction (p = 0.037), especially in obese patients [3.1 kg/m2 (1.3, 4.8)]. Physical performance and quality-of-life remained stable, while physical activity level increased in both groups. No adverse events were detected.

CONCLUSIONS

This study suggests that CORe programs are safe and may help attenuate LVEF decline in BC women receiving cardiotoxic therapy and reduce BMI in obese patients.

The Translation, Culture-Adaptation and Psychometric Evaluation of the Cardiac Rehabilitation Barriers Scale Among Chinese Older Population

Purpose

This study aimed to translate and cross-culturally adapt the cardiac rehabilitation barriers scale to the Chinese, and examine its reliability and validity among the older population.

Methods

An approach comprising translation, cultural adaptation, reliability, and validity examination in the Chinese version was conducted in two hospitals in Jilin, China. The t-tests were used to compare the sex differences between each item. Participants included Chinese individuals >60 who were eligible for the cardiac rehabilitation program.

Results

In total, 325 participants completed the questionnaire with an average age of 61.23 ± 9.68 years. The item-total correlations were 0.432 to 0.678. Factor analysis of CRBS-C (Kaiser Meyer Olkin = 0.867, Bartlett's test p = 0.000) revealed four factors: logistical factors, comorbidities/functional status, perceived need/healthcare factors, and work/time conflict. The confirmatory factor analysis (CFA) indicated a good model fit (χ2/df = 1.84, RMSEA = 0.051, CFI = 0.953, TLI = 0.945, SRMR=0.046). Cronbach's alpha was 0.88 for the scale, ranging from 0.801 to 0.88 for each item, which indicates the internal reliability was acceptable.

Conclusion

The Chinese version of the CRRS has acceptable reliability and validity in the Chinese elderly population.

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.

Deep learning-based dynamic ventilatory threshold estimation from electrocardiograms

BACKGROUND AND OBJECTIVE

The ventilatory threshold (VT) marks the transition from aerobic to anaerobic metabolism and is used to assess cardiorespiratory endurance. A conventional way to assess VT is cardiopulmonary exercise testing, which requires a gas analyzer. Another method for measuring VT involves calculating the heart rate variability (HRV) from an electrocardiogram (ECG) by computing the variability of heartbeats. However, the HRV method has some limitations. ECGs should be recorded for at least 5 minutes to calculate the HRV, and the result may depend on the utilized ECG preprocessing algorithms.

METHODS

To overcome these problems, we developed a deep learning-based model consisting of long short-term memory (LSTM) and convolutional neural network (CNN) for a lead II ECG. Variables reflecting subjects' physical characteristics, as well as ECG signals, were input into the model to estimate VT. We applied joint optimization to the CNN layers to generate an informative latent space, which was fed to the LSTM layers. The model was trained and evaluated on two datasets, one from the Bruce protocol and the other from a protocol including multiple tasks (MT).

RESULTS

Acceptable performances (mean and 95% CI) were obtained on the datasets from the Bruce protocol (-0.28[-1.91,1.34] ml/min/kg) and the MT protocol (0.07[-3.14,3.28] ml/min/kg) regarding the differences between the predictions and labels. The coefficient of determination, Pearson correlation coefficient, and root mean square error were 0.84, 0.93, and 0.868 for the Bruce protocol and 0.73, 0.97, and 3.373 for the MT protocol, respectively.

CONCLUSIONS

The results indicated that it is possible for the proposed model to simultaneously assess VT with the inputs of successive ECGs. In addition, from ablation studies concerning the physical variables and the joint optimization process, it was demonstrated that their use could boost the VT assessment performance of the model. The proposed model enables dynamic VT estimation with ECGs, which could help with managing cardiorespiratory fitness in daily life and cardiovascular rehabilitation in patients.

Effectiveness of alternative vs traditional exercises on cardiac rehabilitation program utilization in women with or at high risk of cardiovascular disease: a systematic review protocol

OBJECTIVE

This review will evaluate the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization and other outcomes in women with or at high risk of cardiovascular disease.

INTRODUCTION

Exercise-based cardiac rehabilitation programs improve health outcomes in women with or at high risk of cardiovascular disease. However, such programs are underutilized worldwide, particularly among women. Some women perceive traditional gym-based exercise in cardiac rehabilitation programs (eg, typically treadmills, cycle ergometers, traditional resistance training) to be excessively rigorous and unpleasant, resulting in diminished participation and completion. Alternative forms of exercise such as yoga, tai chi, qi gong, or Pilates may be more enjoyable and motivating exercise options for women, enhancing engagement in rehabilitation programs. However, the effectiveness of these alternative exercises in improving program utilization is still inconsistent and needs to be systematically evaluated and synthesized.

INCLUSION CRITERIA

This review will focus on randomized controlled trials of studies measuring the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization as well as clinical, physiological, or patient-reported outcomes in women with or at high risk of cardiovascular disease.

METHODS

The review will follow the JBI methodology for systematic reviews of effectiveness. Databases including MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane CENTRAL, Embase (Ovid), Emcare (Ovid), Scopus, Web of Science, LILACS, and PsycINFO (Ovid) will be searched. Two independent reviewers will screen articles and then extract and synthesize data. Methodological quality will be assessed using JBI's standardized instruments. GRADE will be used to determine the certainty of evidence.

REVIEW REGISTRATION

PROSPERO CRD42022354996.

Cardiac rehabilitation: the gateway for secondary prevention

Cardiac rehabilitation (CR) is a multidisciplinary supervised programme which typically consists of tailored exercise and education on lifestyle management and risk factor modification in cardiac patients. Participation in CR reduces morbidity and mortality, while improving quality of life following major cardiovascular events. Despite the benefits of CR, it is underutilised, generally in the 20%-30% range for eligible patients. Participation and adherence rates are particularly suboptimal in vulnerable populations, such as those of lower socioeconomic status and women. Interventions such as automated referral to CR or hybrid/virtual programmes can increase enrolment to CR. This review summarises the components of CR and provides recommendations for providers regarding participation and adherence. To better engage a larger proportion of CR-eligible patients, CR programmes may need to expand or adjust ways to deliver secondary prevention.

[Exercise-Based Prehabilitation In Orthopaedics, Cardiology And Oncology]

Prehabilitation (prehab) aims to prepare patients for surgery, to reduce perioperative complications and to improve postoperative recovery. Pre-operative interventions depend on the indication and the specific patient characteristics and life circumstances. In orthopaedics, the focus is on preoperative improvement of physical performance, function and muscle strength through specific strength, mobility and sensomotoric training. In cardiology, endurance training and respiratory therapy are used in the preoperative phase, as well as coordination and strengthening exercises and occupational therapy to improve physical fitness and performance and reduce cardiovascular risk factors. In oncology, prehab is used preoperatively and also in addition to chemotherapy or radiotherapy to reduce medical side effects and to increase tolerance to cancer therapies (e. g. surgery, chemotherapy, radiotherapy). Exercise interventions in oncology differ according to the type of cancer (e. g. combined strength and endurance training, respiratory therapy, high-intensity interval training and walking). Study results often show positive effects on health resources using prehab. However, further high-quality clinical intervention studies are needed to confirm the clinical benefits of prehab for implementation in routine care.

Effect of maximal-intensity and high-intensity interval training on exercise capacity and quality of life in patients with acute myocardial infarction: a randomized controlled trial

BACKGROUND

An increase in V̇O2max is important for acute myocardial infarction morbidity, and recurrence rate and intensity have been suggested as important factors in improving V̇O2max.

AIM

The aim of this study was to compare the effects of maximal-intensity interval training (MIIT) and high-intensity interval training (HIIT) on exercise capacity and health-related Quality of Life (HRQoL) in patients with acute myocardial infarction (MI) at low and moderate cardiac risk in cardiac rehabilitation (CR). This study secondarily aimed to compare the effects of hospital-based phase II CR and usual care.

DESIGN

This study is a randomized controlled trial.

SETTING

Outpatient Rehabilitation Setting.

POPULATION

Fifty-nine patients with acute MI were randomly assigned to the MIIT (N.=30) or HIIT (N.=29) group, and 32 to the usual care group.

METHODS

Twice a week, an intervention was conducted for nine weeks in all groups. The maximum oxygen intake (V̇O2max) and MacNew Heart Disease HRQoL were evaluated before and after intervention.

RESULTS

A significant interaction was observed between time and group for V̇O2max (P<0.001). The MIIT group showed greater improvement than those exhibited by the HIIT and usual care groups (P<0.05). Similarly, a significant time and group interaction was observed on the MacNew Global, Physical, and Emotional scales (P<0.05), but not on the social scale (P>0.05).

CONCLUSIONS

Compared to HIIT and usual care, MIIT significantly increased the V̇O2max and was as safe as HIIT in patients with acute MI with low and moderate cardiac risk in CR. Additionally, MIIT and HIIT were superior to usual care in terms of improving the HRQoL.

CLINICAL REHABILITATION IMPACT

Our results suggest that increased intensity in phase II CR could result in better outcomes in terms of V̇O2max increment in patients with acute MI and low and moderate cardiac risk in CR.

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.

Caloric Restriction Rejuvenates Skeletal Muscle Growth in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a major clinical problem, with limited treatments. HFpEF is characterized by a distinct, but poorly understood, skeletal muscle pathology, which could offer an alternative therapeutic target. In a rat model, we identified impaired myonuclear accretion as a mechanism for low myofiber growth in HFpEF following resistance exercise. Acute caloric restriction rescued skeletal muscle pathology in HFpEF, whereas cardiac therapies had no effect. Mechanisms regulating myonuclear accretion were dysregulated in patients with HFpEF. Overall, these findings may have widespread implications in HFpEF, indicating combined dietary with exercise interventions as a beneficial approach to overcome skeletal muscle pathology.

Non-pharmacological rehabilitation interventions for individuals with antiphospholipid syndrome: A scoping review

OBJECTIVE

The objective of this study was to explore what non-pharmacological interventions have been examined for individuals with antiphospholipid syndrome (APS).

METHODS

We conducted a systematic literature search of the databases PubMed, Embase, Scopus, Web of Science, CINAHL, and ClinicalTrials.gov from 1983-Feb. 2023. Our scoping review included studies that examined non-pharmacological interventions for individuals with APS using patient-reported outcome measures. We excluded studies that reported physiological outcomes only.

RESULTS

The review yielded one case study on the safety and efficacy of an exercise program for a 15-year-old male with secondary APS using physiological and patient-reported outcome measures. Despite the lack of evidence of non-pharmacological interventions for individuals with APS, one excluded study reported that individuals with APS want guidance about physical activity and exercise. We also found several types of potentially relevant non-pharmacological interventions for individuals with lupus, a disease that often co-occurs with APS.

CONCLUSIONS

Non-pharmacological interventions may offer a solution for addressing some non-thrombotic or non-obstetric APS symptoms, such as neurological, physical, and cognitive symptoms that are not well-controlled by anticoagulation. Due to the unique risks associated with APS, research is needed to determine the safety and efficacy of non-pharmacological interventions, particularly those involving exercise. Adopting a comprehensive, multidisciplinary approach to managing patients with APS and involving rehabilitation professionals, who are experts in the design and delivery of non-pharmacological interventions, may provide a foundation for developing and testing novel interventions that improve health outcomes while also fulfilling unmet needs reported by patients.

Nurses' knowledge, attitudes, and practices about rehabilitation of patients after heart valve surgery in Namibia

Background

A cardiac rehabilitation programme is a medically supervised intervention to assist patients in recovery after heart surgeries and to prevent potential complications. Nurses should have the knowledge, a positive attitudes, and good practices to improve patient quality of life during the recovery process.

Aim

This study aimed to describe the knowledge, attitudes, and practices of the nurses regarding cardiac rehabilitation for patients after heart valve surgery.

Setting

The study setting was Windhoek Central Hospital, Cardiac Unit, in Windhoek, Namibia.

Methods

A quantitative and descriptive research design was used for convenient non-probability sampling of (N = 23) nurses who consented to participate in the study. Data were collected through self-administered questionnaires and analyzed using SPSS Version 26. Descriptive statistics were used and Fischer's Exact test for associations of variables was performed.

Results

The study results showed a high level of knowledge, good attitudes, and poor to fair practices toward cardiac rehabilitation. However, the respondents demonstrate a lack of knowledge about the indications, and benefits of cardiac rehabilitation, negative attitudes regarding counselling of patients on sexual activities, and poor practice regarding exercises and counseling of patients and caregivers on cardiac rehabilitation. Furthermore, there is a positive relationship between the respondents' older age, senior rank, and having been trained I cardiac conditions and their knowledge, attitudes and practices regarding some core components of cardiac rehabilitation with P-value < 0.050.

Conclusion

There is a need for a cardiac rehabilitation programme to improve nurses' attitudes and practices toward cardiac rehabilitation.

Contribution

Understanding the gap in knowledge, attitudes, and practices among the nurses regarding cardiac rehabilitation would guide the Ministry of Health and Social Services (MoHSS) in the implementation of the cardiac rehabilitation for patients after heart valve surgery.

Acute effects of high intensity interval training versus moderate intensity continuous training on haemostasis in patients with coronary artery disease

Exercise training is associated with an acute net increase in coagulation, which may increase the risk of atherothrombosis in coronary artery disease (CAD) patients. We sought to compare the acute haemostatic effects of a bout of moderate-intensity continuous (MICT) and high-intensity interval training (HIIT) in patients with CAD. Patients after a recent myocardial infarction were randomized into a HIIT or MICT session of exercise training on a stationary bike. Blood was sampled at baseline, after the exercise bout and after a one-hour resting period. We measured overall haemostatic potential (OHP), overall coagulation potential (OCP), fibrinogen, D-dimer and von Willebrand factor (vWF) and calculated overall fibrinolytic potential (OFP). Linear mixed models for repeated measures were constructed to assess the treatment effect. A total of 117 patients were included. OCP, OHP, fibrinogen, D-dimer and vWF significantly increased after exercise and returned to baseline after a one-hour rest, OFP decreased after exercise and returned to baseline levels after a one-hour rest. Linear mixed models showed a significant difference between HIIT and MICT in fibrinogen (p 0.043) and D-dimer (p 0.042). Our study has shown that an exercise bout is associated with a transient procoagulant state in patients with CAD, with similar exercise-induced haemostatic changes for HIIT and MICT.

Cardiac telerehabilitation: current status and future perspectives

Multidisciplinary cardiac rehabilitation (CR) improves the prognosis and quality of life of patients with cardiovascular disease and has therefore received strong recommendations in international guidelines for the treatment of patients with chronic coronary syndromes and chronic heart failure. Aiming to both resolve several barriers that impede participation in CR and to improve the effectiveness of CR, cardiac telerehabilitation (CTR) has emerged as a cost-effective alternative to traditional, centre-based CR. Although the body of evidence for the feasibility and effectiveness of CTR is large and still growing, real-life implementations are scarce, which may be due to insufficient knowledge about CTR interventions and due to the challenges its implementation comes with. Up to now, mainly exercise-related core components of CR and e‑coaching have been investigated in the setting of CTR. Translation of research findings to clinical practice may be hampered by methodological limitations present in most CTR studies, being selection bias of participants, lack of long-term follow-up, heterogeneity of studied interventions and the lack of robust outcome measures. Besides conducting highly needed implementation studies for CTR interventions, their implementation could be facilitated by the development of guideline-based, multidisciplinary and personalised CTR programmes and widespread reimbursement for CTR.

The Exercise aNd hEArt transplant (ENEA) trial - a registry-based randomized controlled trial evaluating the safety and efficacy of cardiac telerehabilitation after heart transplant

BACKGROUND

Heart transplant (HTx) is gold-standard therapy for patients with end-stage heart failure. Cardiac rehabilitation (CR) is a multidisciplinary intervention shown to improve cardiovascular prognosis and quality of life. The aim in this randomized controlled trial is to explore the safety and efficacy of cardiac telerehabilitation after HTx. In addition, biomarkers of rehabilitation outcomes will be identified, as data that will enable treatment to be tailored to patient phenotype.

METHODS

Patients after HTx will be recruited at IRCCS S. Maria Nascente - Fondazione Don Gnocchi, Milan, Italy (n = 40). Consenting participants will be randomly allocated to either of two groups (1:1): an intervention group who will receive on-site CR followed by 12 weeks of telerehabilitation, or a control group who will receive on-site CR followed by standard homecare and exercise programme. Recruitment began on 20th May 2023 and is expected to continue until 20th May 2025. Socio-demographic characteristics, lifestyle, health status, cardiovascular events, cognitive function, anxiety and depression symptoms, and quality of life will be assessed, as well as exercise capacity and muscular endurance. Participants will be evaluated before the intervention, post-CR and after 6 months. In addition, analysis of circulating extracellular vesicles using Surface Plasmon Resonance imaging (SPRi), based on a rehabilomic approach, will be applied to both groups pre- and post-CR.

CONCLUSION

This study will explore the safety and efficacy of cardiac telerehabilitation after HTx. In addition, a rehabilomic approach will be used to investigate biomolecular phenotypization in HTx patients.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05824364.