Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

To contrast and reverse skeletal muscle weakness by Full-Body In-Bed Gym in chronic COVID-19 pandemic syndrome

Mobility-impaired persons, either very old or younger but suffering with systemic neuromuscular disorders or chronic organ failures, spend small amounts of time for daily physical activity, contributing to aggravate their poor mobility by resting muscle atrophy. Sooner or later the limitations to their mobility enforce them to bed and to more frequent hospitalizations. We include among these patients at risk those who are negative for the SARS-COV-2 infection, but suffering with COVID-19 pandemic syndrome. Beside managements of psychological symptoms, it is mandatory to offer to the last group physical rehabilitation approaches easy to learn and self-managed at home. Inspired by the proven capability to recover skeletal muscle contractility and strength by home-based volitional exercises and functional electrical stimulation, we suggest also for chronic COVID-19 pandemic syndrome a 10–20 min long daily routine of easy and safe physical exercises that can activate, and recover from weakness, the main 400 skeletal muscles used for every-day mobility activities. Persons can do many of them in bed (Full-Body in-Bed Gym), and hospitalized patients can learn this light training before leaving the hospital. It is, indeed, an extension of well-established cardiovascular-respiratory rehabilitation training performed after heavy surgical interventions. Blood pressure readings, monitored before and after daily routine, demonstrate a transient decrease in peripheral resistance due to increased blood flow of many muscles. Continued regularly, Full-Body in-Bed Gym may help maintaining independence of frail people, including those suffering with the COVID-19 pandemic syndrome.

Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries: An Interrupted Time Series

BACKGROUND

Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization.

METHODS

From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale.

RESULTS

Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48-2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, -2.4 to -0.12) compared with the prior period. Results were somewhat sensitive to time window variations.

CONCLUSIONS

The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.

Effect of a virtual self-management intervention for atrial fibrillation during the outbreak of COVID-19

BACKGROUND

As the pandemic continues to unfold, effective, technology-based solutions are needed to help patients with atrial fibrillation (AF) maintain their health and well-being during the outbreak of COVID-19.

METHODS

This single-center, pilot study investigated the effects of a 4-week (eight sessions) virtual AF self-management program. Questionnaires were completed at baseline and 1 week after the intervention, and assessed AF knowledge, adherence to self-management behaviors, mental health, physical function, and disease-specific quality of life in patients with AF. Secondary outcomes included knowledge of COVID-19, intervention, acceptability, and satisfaction.

RESULTS

Of 68 patients who completed baseline questionnaires, 57 participated in the intervention and were included in the analysis (mean age of 73.4 ± 10.0 years, 60% male). Adherence to AF self-monitoring behaviors, including monitoring their heart rate (p < .001), heart rhythm (p = .003), and blood pressure (p = .013) were significantly improved at the end of the intervention compared with baseline. Symptom identification (p = .007) and management (p < .001) also improved. Reductions in sleep disturbance (p < .001), anxiety (p = .014), and depression (p = .046) were also observed. Misinformation and inaccurate beliefs about COVID-19 were significantly reduced at the end of the intervention compared with baseline.

CONCLUSIONS

This pilot study suggests that a virtual patient education program could have beneficial effects on adherence to guideline-recommend self-care of AF, emotional wellbeing, physical function, and knowledge of COVID-19 in patients with AF. Future randomized studies in larger samples are needed to determine the clinical benefits of the intervention.

Home-Based Cardiac Rehabilitation: EXPERIENCE FROM THE VETERANS AFFAIRS

PURPOSE

The conceptual utility of home-based cardiac rehabilitation (HBCR) is widely acknowledged. However, data substantiating its effectiveness and safety are limited. This study evaluated effectiveness and safety of the Veterans Affairs (VA) national HBCR program.

METHODS

Veterans completed a 12-wk HBCR program over 18 mo at 25 geographically dispersed VA hospitals. Pre- to post-changes were compared using paired t tests. Patient satisfaction and adverse events were also summarized descriptively.

RESULTS

Of the 923 Veterans with a mean age of 67.3 ± 10.6 yr enrolled in the HBCR program, 572 (62%) completed it. Findings included significant improvements in exercise capacity (6-min walk test distance: 355 vs 398 m; P < .05; Duke Activity Status Index: 27.1 vs 33.5; P < .05; self-reported steps/d: 3150 vs 4166; P < .05); depression measured by Patient Health Questionnaire (6.4 vs 4.9; P < .0001); cardiac self-efficacy (33.1 vs 39.2; P < .0001); body mass index (31.5 vs 31.1 kg/m2; P = .0001); and eating habits measured by Rate Your Plate, Heart (47.2 vs 51.1; P < .05). No safety issues were related to HBCR participation. Participants were highly satisfied.

CONCLUSIONS

The VA HBCR program demonstrates strong evidence of effectiveness and safety to a wide range of patients, including those with high clinical complexity and risk. HBCR provides an adjunct to site-based programs and access to cardiac rehabilitation. Additional research is needed to assess long-term effects, cost-effectiveness, and sustainability of the model.

Current Status and Effect of Outpatient Cardiac Rehabilitation After Percutaneous Coronary Intervention in Japan

Background: Although cardiac rehabilitation (CR) has been reported to be associated with better clinical outcomes in patients with cardiovascular diseases, there are few nationwide studies about CR participation by patients with coronary artery disease in Japan.

Methods and Results: We performed a nationwide retrospective cohort study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan between April 2014 and March 2018. Patients were divided into 2 groups (acute coronary syndrome [ACS] and stable coronary artery disease [sCAD]), and the rates of participation in in- and outpatient CR after percutaneous coronary intervention (PCI) were investigated. Propensity score-matched analysis was performed and the association between outpatient CR participation and all-cause mortality 3 months after PCI was examined. Overall, 616,664 patients (ACS, n=202,853; sCAD, n=413,811) were analyzed. The participation rates of CR increased annually. The participation rate was higher for inpatient than outpatient CR in both the ACS (52% vs. 9%, respectively) and sCAD (15% vs. 3%, respectively) groups. Prognosis was better for patients with than without outpatient CR in both the ACS (hazard ratio [HR] 0.52; 95% confidence interval [CI] 0.47–0.59) and sCAD (HR 0.72; 95% CI 0.65–0.80) groups.

Conclusions: Outpatient CR was associated with a better prognosis in patients with ACS or sCAD. The participation rates of outpatient CR following PCI were extremely low in Japan.

Validation of the Chinese Version of the Coronary Artery Disease Education Questionnaire - Short Version: A Tool to Evaluate Knowledge of Cardiac Rehabilitation Components

Background:

Patient education is the first step in implementing a cardiac rehabilitation (CR) program and a powerful tool for promoting behavioral changes in cardiac patients. In China, the clinical workload is so heavy that a short and reliable tool for assessing disease-related knowledge is needed for targeted patient education.

Objective:

The aim of this study was to translate, adapt and validate the Chinese version of the Coronary Artery Disease Education Questionnaire – Short Version (CADE-Q SV).

Methods:

The CADE-Q SV was translated to simplified Chinese and culturally adapted to the Chinese context. The translated version was reviewed by a committee of seven experts in cardiovascular disease, and the content validity of the questionnaire was established. The psychometric properties of the questionnaire were analyzed considering the responses of 240 CR patients. The Kuder-Richardson-20 (KR-20) coefficient and Cronbach’s alpha were used to assess internal consistency. The intraclass correlation coefficient (ICC) was used to assess test-retest reliability. The criterion-related validity was evaluated by determining whether there were differences in the total scores of patients with different educational levels. Confirmatory factor analysis (CFA) was used to assess the factor structure.

Results:

Three items from the original version were adapted to reflect Chinese culture. The content validity index was 0.94. The KR-20 score was 0.856. All ICC values were > 0.70. The knowledge scores of patients with different educational levels were significantly different, indicating that the criterion-related validity of the Chinese CADE-Q-SV was acceptable. CFA validated the five-factor structure of the Chinese CADE-Q-SV.

Conclusion:

The Chinese CADE-Q SV questionnaire has good reliability and validity. This short, efficient tool can be completed quickly, assess disease-related knowledge in cardiovascular patients and serve as a reference for individualized patient education in China. It can also be used to evaluate the effectiveness of CR-related patient education interventions.

Updated Outpatient Cardiac Rehabilitation Delivery Formats Tailored to the Iranian Population

This article is a Letter to Editor and does not include an Abstract.

Integrating Survivors of Stroke Into Exercise-Based Cardiac Rehabilitation Improves Endurance and Functional Strength

Background

Cardiac rehabilitation (CR) is a structured exercise program prevalent in the United States for people with cardiovascular disease that has been shown to increase cardiovascular endurance and improve quality of life. Despite similar cardiovascular risk factors, stroke is not among the covered diagnoses for CR. The purpose of this study was to examine the participant impact of integrating survivors of stroke into the exercise portion of an existing hospital‐based CR program through measures of physical function and other health impacts and through qualitative evaluation of participant perception.

Methods and Results

Subacute and chronic survivors of stroke were integrated into a standard 12‐week, 3 sessions per week, exercise‐based CR program. A total of 29 began the program, 24 completed the program, and 18 were available for 6‐month follow‐up. Quantitative measures were compared preprogram with postprogram with t‐test or equivalent, and preprogram with postprogram to 6‐month follow‐up with ANOVA or equivalent. Semistructured interviews were completed with 11 participants postprogram. Exercise‐based CR had significant impacts on cardiovascular endurance preprogram to postprogram, with maintenance at 6‐month follow‐up. The participants improved on the 6‐minute walk test on average by 61.92 m(95% CI, 33.99–89.84 m), and maximum metabolic equivalents improved by a median of 3.6 (interquartile range, 2.35). Five times sit to stand (functional strength) improved preprogram to postprogram by a median of 2.85 s (interquartile range, 4.03 s). Qualitative findings highlight additional health improvements. Most participants (83% [15/18]) reported continued exercise at follow‐up.

Conclusions

Exercise‐based CR has the potential to improve cardiovascular endurance, health status, and quality of life for survivors of stroke.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03706105.

Referral Rates for Cardiac Rehabilitation Among Eligible Inpatients After Implementation of a Default Opt-Out Decision Pathway in the Electronic Medical Record

This quality improvement study assesses referral rates for cardiac rehabilitation after a default opt-out option is added to the decision pathway in the electronic medical record.

Social Smoking Environment and Associations With Cardiac Rehabilitation Attendance

PURPOSE

Continued cigarette smoking after a major cardiac event predicts worse health outcomes and leads to reduced participation in cardiac rehabilitation (CR). Understanding which characteristics of current smokers are associated with CR attendance and smoking cessation will help improve care for these high-risk patients. We examined whether smoking among social connections was associated with CR participation and continued smoking in cardiac patients.

METHODS

Participants included 149 patients hospitalized with an acute cardiac event who self-reported smoking prior to the hospitalization and were eligible for outpatient CR. Participants completed a survey on their smoking habits prior to hospitalization and 3 mo later. Participants were dichotomized into two groups by the proportion of friends or family currently smoking ("None-Few" vs "Some-Most"). Sociodemographic, health, secondhand smoke exposure, and smoking measures were compared using t tests and χ2 tests (P < .05). ORs were calculated to compare self-reported rates of CR attendance and smoking cessation at 3-mo follow-up.

RESULTS

Compared with the "None-Few" group, participants in the "Some-Most" group experienced more secondhand smoke exposure (P < .01) and were less likely to attend CR at follow-up (OR = 0.40; 95% CI, 0.17-0.93). Participants in the "Some-Most" group tended to be less likely to quit smoking, but this difference was not statistically significant.

CONCLUSION

Social environments with more smokers predicted worse outpatient CR attendance. Clinicians should consider smoking within the social network of the patient as an important potential barrier to pro-health behavior change.

A Comparison of Exercise Intensity in Hybrid Versus Standard Phase Two Cardiac Rehabilitation

PURPOSE

To compare exercise training intensity during standard cardiac rehabilitation (S-CR) versus hybrid-CR (combined clinic- and remote home-/community-based).

METHODS

The iATTEND (improving ATTENDance to cardiac rehabilitation) trial is currently enrolling subjects and randomizing patients to S-CR versus hybrid-CR. This substudy involves the first 47 subjects who completed ≥18 CR sessions. Patients in S-CR completed all visits in a typical phase II clinic-based setting and patients in hybrid-CR completed up to 17 of their sessions remotely using telehealth (TH). Exercise training intensity in both CR settings is based on heart rate (HR) data from each CR session, expressed as percent HR reserve.

RESULTS

Among patients in both study groups, there were no serious adverse events or falls that required hospitalization during or within 3 hr after completing a CR session. Expressed as a percentage of HR reserve, the overall mean exercise training intensities during both the S-CR sessions and the TH-CR sessions from hybrid-CR were not significantly different at 63 ± 12% and 65 ± 10%, respectively (P = .29).

CONCLUSION

This study showed that hybrid-CR delivered using remote TH results in exercise training intensities that are not significantly different from S-CR.

Increasing Cardiac Rehabilitation Participation Through a "Nearer to Home" Patient Referral Program

PURPOSE

Time to travel to cardiac rehabilitation (CR) centers is a barrier to participation, and tertiary referral centers often care for patients living at a substantial distance. We sought to determine the impact of referring eligible patients to CR centers closer to home or workplace on overall participation rate.

METHODS

An observational review was conducted in patients from a large cardiovascular program who were referred to CR (January 1, 2015, through December 31, 2016). Those declining participation due to distance from their home were identified and provided coordinated referral to a CR program they chose near their home or workplace.

RESULTS

Of the 2912 patients referred to CR, 673 (23%) participated and 1900 declined due to distance. Contact was made in 2017 with 1237 of the 1900 of whom 1083 recalled a discussion of distance referral and completed the phone survey. Participants mean age was 64 yr, predominantly White (88%), male (65%), married (66%), and 70% had ≥ comorbidity. Out of the 1083 referred to a local CR program, 78% reported attending. Of those who attended CR, 55% (469/849) would not have attended had they not been referred to a program closer to their home or workplace. Overall participation increased from 23% to >50% of those referred from our institution.

CONCLUSIONS

Coordinating CR referrals from the discharging facility to facilities closer to home or workplace is an effective means for increasing participation. The very low-cost effort has the potential to have a very meaningful impact on the long-term outcome of cardiovascular patients.

Relevant problems of participation and education of patients in cardiac rehabilitation and secondary prevention programs

The review discusses the participation of patients with coronary artery disease after acute myocardial infarction and revascularization surgeries in cardiac rehabilitation (CR) and secondary prevention programs. The problems of patients not being included in rehabilitation programs and the reasons for low adherence to these programs are considered. The contribution of non-drug therapy to achievement of CR and secondary prevention goals is discussed. Various strategies are proposed for involving and increasing adherence of patients to CR programs.

Quality indicators for cardiac rehabilitation after myocardial infarction in China: a consensus panel and practice test

OBJECTIVES

Cardiac rehabilitation (CR) improves outcomes after myocardial infarction (MI), but it is underused in China. The purpose of this study was to develop a set of quality indicators (QIs) to improve clinical practices and to confirm the measurability and performance of the developed QIs for CR in Chinese patients after MI.

DESIGN AND SETTING

The QIs were developed by a Chinese expert consensus panel during in-person meetings. The five QIs most in need of improvement were selected using a national questionnaire. Finally, the completion rate and feasibility of the QIs were verified in a group of MI survivors at university hospitals in China.

PARTICIPANTS

Seventeen professionals participated in the consensus panel, 89 personnel in the field of CR participated in the national questionnaire and 165 MI survivors participated in the practice test.

RESULTS

A review of 17 eligible articles generated 26 potential QIs, among which 17 were selected by the consensus panel after careful evaluation. The 17 QIs were divided into two domains: (1) improving participation and adherence and (2) CR process standardisation. Nationwide telephone and WeChat surveys identified the five QIs most in need of improvement. A multicenter practice test (n=165) revealed that the mean performance value of the proposed QIs was 43.9% (9.9%-86.1%) according to patients with post-MI.

CONCLUSIONS

The consensus panel identified a comprehensive set of QIs for CR in patients with post-MI. A nationwide questionnaire survey was used to identify the QIs that need immediate attention to improve the quality of CR. Although practice tests confirmed the measurability of the proposed QIs in clinical practice, the implementation of the QIs needs to be improved.

TRIAL REGISTRATION NUMBER

This study is part of a study registered in ClinicalTrials.gov (NCT03528382).

Association between a national public health campaign for physical activity for patients with chronic diseases and the participation in Phase III cardiac rehabilitation in Luxembourg

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National public health campaign may increase participation to Phase III cardiac rehabilitation.

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National public health campaign increases visibility of a website displaying the Phase III cardiac rehabilitation.

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A more integrated and synergized strategic approach may help to sensitize the patients.

Background

A 2-stage national campaign promoting physical activity for patients with chronic diseases (including cardiovascular disease) was implemented in the Grand-Duchy of Luxembourg in 2018. The first stage consisted of national TV and radio advertisements broadcasted from June 15, 2018 to July 29, 2018. The second stage was a promotional mail sent to all medical doctors on September 3, 2018. This study investigated the association between this campaign and the participation of cardiac patients in Phase III cardiac rehabilitation as well as the visibility of a dedicated website (www.sport-sante.lu).

Methods

The daily numbers of participants in the classes of the Phase III cardiac rehabilitation and the visits on www.sport-sante.lu were collected from January 1, 2016 to December 31, 2018. Segmented regression analysis was used to assess the association between the promotional campaign and the participation in the Phase III cardiac rehabilitation as well as the website visibility.

Results

The baseline participation rate, which was 30 participants/day, increased temporarily by 11 (p = 0.0267) and 18 (p = 0.0030) participants/day after the first and second stages of the campaign, respectively. The baseline visit rate on www.sport-sante.lu, which was 12 visits/day, increased temporarily by 20 (p < 0.0001) and 15 (p = 0.0002) visits/day after the first and second stages of the campaign, respectively.

Conclusions

The national public health campaign was associated with a limited increased participation in the Phase III cardiac rehabilitation and the website visibility. However, no conclusion can be drawn about causality due to the long and difficult process from health promotion to patient’s behavior change.

An investigation into whether cardiac risk stratification protocols actually predict complications in cardiac rehabilitation programs?

OBJECTIVES

This study evaluated the capacity of cardiac risk stratification protocols on simple complications that occur during activities of a cardiovascular rehabilitation program.

DESIGN

Observational longitudinal cohort study.

SETTING

Outpatient clinic of cardiovascular rehabilitation.

SUBJECT

Patients diagnosed with cardiovascular disease and/or risk factors.

INTERVENTIONS

Not applicable.

MAIN MEASURES

The relationship between the cardiac risk classes of seven risk stratification protocols and the occurrence of simple complications (such angina, abnormal changes in blood pressure, arrhythmias, fatigue, muscle pain, pallor) was assessed using the chi-square test, and when statistical significance was observed, sensitivity, specificity and accuracy were determined.

RESULTS

About 76 patients were analyzed. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) protocol showed a statistically significant relationship between simple complications and cardiac risk classes (P-value = 0.046), however the results of sensitivity (0.53), specificity (0.52), and accuracy (0.53) were not significant. The other protocols analyzed were not significant: American College of Sports Medicine (P-value = 0.801), Brazilian Society of Cardiology (P-value = 0.734), American Heart Association (P-value = 0.957), Pashkow (P-value = 0.790), Society French Cardiology (P-value = 0.314), and Spanish Society of Cardiology (P-value = 0.078).

CONCLUSION

The AACVPR protocol showed a significant relationship between the risk classes and the occurrence of simple complications, however, the low values obtained for sensitivity, specificity and accuracy show that it is not useful for this purpose.

CLINICAL TRIALS REGISTRATION

NCT03446742.

Factors Influencing the Impact of Depressive Symptoms on Physical Functional Capacity After Cardiac Rehabilitation

PURPOSE

This study aims to determine (1) if depressive symptoms in the year following completion of cardiac rehabilitation impact physical functional capacity and (2) if exercise, perceived benefits and barriers, self-efficacy, and social support moderate this relationship.

DESIGN

This longitudinal correlational secondary data analysis included 379 cardiovascular rehabilitation patients.

METHODS

Participants completed measures of depression and potential moderating variables at baseline, 2 months, 6 months, and 12 months and 6-minute work test at baseline and 12 months and wore heart rate monitors to measure exercise for 12 months.

FINDINGS

Poorer physical functional capacity was predicted by depressed mood score. This relationship was moderated by the percentage of time exercising in target heart rate zone and family support of exercise, but not by perceived benefits and barriers or self-efficacy for exercise.

CONCLUSIONS

Depressive symptoms negatively impact physical functional capacity, and this relationship is moderated by family support and the percentage of time exercising in target heart rate zone.

CLINICAL RELEVANCE

Improving percentage of time exercising in target heart rate zone may be a mechanism by which patients with depressed mood can optimize physical functional capacity.

Toward a Digital Platform for the Self-Management of Noncommunicable Disease: Systematic Review of Platform-Like Interventions

BACKGROUND

Digital interventions are effective for health behavior change, as they enable the self-management of chronic, noncommunicable diseases (NCDs). However, they often fail to facilitate the specific or current needs and preferences of the individual. A proposed alternative is a digital platform that hosts a suite of discrete, already existing digital health interventions. A platform architecture would allow users to explore a range of evidence-based solutions over time to optimize their self-management and health behavior change.

OBJECTIVE

This review aims to identify digital platform-like interventions and examine their potential for supporting self-management of NCDs and health behavior change.

METHODS

A literature search was conducted in January 2020 using EBSCOhost, PubMed, Scopus, and EMBASE. No digital platforms were identified, so criteria were broadened to include digital platform-like interventions. Eligible platform-like interventions offered a suite of discrete, evidence-based health behavior change features to optimize self-management of NCDs in an adult population and provided digitally supported guidance for the user toward the features best suited to their needs and preferences. Data collected on interventions were guided by the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) checklist, including evaluation data on effectiveness and process outcomes. The quality of the included literature was assessed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 7 studies were included for review. Targeted NCDs included cardiovascular diseases (CVD; n=3), diabetes (n=3), and chronic obstructive pulmonary disease (n=1). The mean adherence (based on the number of follow-up responders) was 69% (SD 20%). Of the 7 studies, 4 with the highest adherence rates (80%) were also guided by behavior change theories and took an iterative, user-centered approach to development, optimizing intervention relevance. All 7 interventions presented algorithm-supported user guidance tools, including electronic decision support, smart features that interact with patterns of use, and behavior change stage-matching tools. Of the 7 studies, 6 assessed changes in behavior. Significant effects in moderate-to-vigorous physical activity were reported, but for no other specific health behaviors. However, positive behavior change was observed in studies that focused on comprehensive behavior change measures, such as self-care and self-management, each of which addresses several key lifestyle risk factors (eg, medication adherence). No significant difference was found for psychosocial outcomes (eg, quality of life). Significant changes in clinical outcomes were predominately related to disease-specific, multifaceted measures such as clinical disease control and cardiovascular risk score.

CONCLUSIONS

Iterative, user-centered development of digital platform structures could optimize user engagement with self-management support through existing, evidence-based digital interventions. Offering a palette of interventions with an appropriate degree of guidance has the potential to facilitate disease-specific health behavior change and effective self-management among a myriad of users, conditions, or stages of care.

Effects of the Intensity of Lifestyle Exercise on Changes in Blood Pressure

The purpose of this study was to investigate whether the amount of time participants exercised in the target heart rate zone (THRZ) influenced change in blood pressure (BP) one year following a cardiac event. Lifestyle exercise (habitual, small exercise opportunities) and intensity were objectively measured using portable heart rate monitors. Linear mixed models were used to analyze change in BP among 331 participants. Mean BP at baseline was 118/70 mmHg, and both systolic and diastolic BP increased from baseline to one year-4.79 mmHg (p <.001) and 2.09 mmHg (p =.002), respectively. Overall, participants had a decrease in levels of lifestyle exercise. After controlling for time, age, gender, and study group, SBP change was inversely associated with amount of time in THRZ. Given suboptimal engagement in recommended exercise, the underlying mechanisms of lifestyle exercise effects on the time spent in THRZ to reduce BP warrants further study in this population.

A Gap in Post-Stroke Blood Pressure Target Attainment at Entry to Cardiac Rehabilitation

BACKGROUND

Recurrent events account for approximately one-third of all strokes and are associated with greater disability and mortality than first-time strokes. Blood pressure (BP) is the most important modifiable risk factor. Objectives were to determine the proportion of post-stroke patients enrolled in cardiac rehabilitation (CR) meeting systolic and diastolic BP (SBP/DBP) targets and to determine correlates of meeting these targets.

METHODS

A retrospective study of 1,804 consecutively enrolled post-stroke patients in a CR program was conducted. Baseline data (database records 2006-2017) included demographics, anthropometrics, clinical/medication history, and resting BP. Multivariate analyses determined predictors of achieving BP targets.

RESULTS

Mean age was 64.1 ± 12.7 years, median days from stroke 210 (IQR 392), with most patients being male (70.6%; n = 1273), overweight (66.8%; n = 1196), and 64.2% diagnosed with hypertension (n = 1159), and 11.8% (n = 213) with sleep apnea. A mean of 1.69 ± 1.2 antihypertensives were prescribed, with 26% (n = 469) of patients prescribed 3-4 antihypertensives. SBP target was met by 71% (n = 1281) of patients, 83.3% (n = 1502) met DBP target, and 64.3% (n = 1160) met both targets. Correlates of meeting SBP target were not having diabetes, younger age, fewer prescribed antihypertensives, and more recent program entry. Correlates of meeting DBP target were not having diabetes, older age, fewer prescribed antihypertensives, and more recent stroke.

CONCLUSIONS

Up to one-third of patients were not meeting BP targets. Patients with diabetes, and those prescribed multiple antihypertensives are at greater risk for poorly controlled SBP and DBP. Reasons for poor BP control such as untreated sleep apnea and medication non-adherence need to be investigated.

Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings: OPPORTUNITIES TO REDUCE HEALTH CARE DISPARITIES

Although both cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are recommended by clinical practice guidelines and covered by most insurers, they remain severely underutilized. To address this problem, the National Heart, Lung, and Blood Institute (NHLBI), in collaboration with the National Institute on Aging (NIA), developed Funding Opportunity Announcements (FOAs) in late 2017 to support phase II clinical trials to increase the uptake of CR and PR in traditional and community settings. The objectives of these FOAs were to (1) test strategies that will lead to increased use of CR and PR in the US population who are eligible based on clinical guidelines; (2) test strategies to reduce disparities in the use of CR and PR based on age, gender, race/ethnicity, and socioeconomic status; and (3) test whether increased use of CR and PR, whether by traditional center-based or new models, is accompanied by improvements in relevant clinical and patient-centered outcomes, including exercise capacity, cardiovascular and pulmonary risk factors, and quality of life. Five NHLBI grants and a single NIA grant were funded in the summer of 2018 for this CR/PR collaborative initiative. A brief description of the research to be developed in each grant is provided.

Predictors of cardiac rehabilitation referral, enrolment and completion after acute myocardial infarction: an exploratory study

Background

Despite proven clinical benefits, only a minority of patients complete outpatient cardiac rehabilitation (CR) after acute myocardial infarction (AMI). The main purpose of this study was to evaluate to what extent and at which time patients drop out of CR, and to assess which patient-related characteristics can predict dropout.

Methods

In a retrospective cohort study, we selected patients who had been hospitalised with an AMI in our centre in 2015 or 2016. Patients were selected pseudonymously based on reimbursement codes in the electronic health record. We extracted baseline characteristics and data on CR referral, enrolment and completion for each patient. Multivariable logistic regression was used to assess which characteristics predicted referral and dropout.

Results

The 666 patients included were predominantly male (66%), with a mean age of 69.0 years. Of the 640 eligible patients, 201 (31%) were not referred for CR. Enrolment after referral was 94%. Nonreferral was independently associated with older age, female sex, traveling distance, non-ST-elevation myocardial infarction (NSTEMI; as compared with STEMI), no coronary revascularisation and prior manifestations of coronary artery disease. Of the 414 enrolled patients, 24% did not complete their CR programmes (i.e. dropped out). Older age and worse exercise capacity at baseline were independently associated with dropout. The ability of the multiple regression models to predict nonreferral and noncompletion was good to fair, with an area under the receiver operating characteristic curves of 0.86 and 0.71, respectively.

Conclusion

The main reason for not participating in or not completing CR after AMI was nonreferral. To optimise CR utilisation, improvement of referral rates should be prioritised.

Clinical and Demographic Trends in Cardiac Rehabilitation: 1996-2015

PURPOSE

Clinical interventions in programs such as cardiac rehabilitation (CR) are guided by clinical characteristics of participating patients. This study describes changes in CR participant characteristics over 20 yr.

METHODS

To examine changes in patient characteristics over time, we analyzed data from 1996 to 2015 (n = 5396) garnered from a systematically and prospectively gathered database. Linear, logistic, multinomial logistic or negative binomial regression was used, as appropriate. Effects of sex and index diagnosis were considered both as interactions and as additive effects.

RESULTS

Analyses revealed that mean age increased (from 60.7 to 64.2 yr), enrollment of women increased (from 26.8% to 29.6%), and index diagnosis has shifted; coronary artery bypass surgery decreased (from 37.2% to 21.6%), whereas heart valve repair/replacement increased (from 0% to 10.6%). Risk factors also shifted with increases in body mass index (28.7 vs 29.6 kg/m), obesity (from 33.2% to 39.6%), hypertension (from 51% to 62.5%), type 2 diabetes mellitus (from 17.3% to 21.7%), and those reporting current smoking (from 6.6% to 8.4%). Directly measured peak aerobic capacity remained relatively stable throughout. The proportion of patients on statin therapy increased from 63.6% to 98.9%, coinciding with significant improvements in lipid levels.

CONCLUSIONS

Compared with 1996, participants entering CR in 2015 were older, more overweight, and had a higher prevalence of coronary risk factors. Lipid values improved substantially concurrent with increased statin use. While the percentage of female participants increased, they continue to be underrepresented. Patients with heart valve repair/replacement now constitute 10.6% of the patients enrolled. Clinical programs need to recognize changing characteristics of attendees to best tailor interventions.

Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Impact of ambulatory cardiac rehabilitation on cardiovascular outcomes: a long-term follow-up study

AIMS

To evaluate the long-term clinical impact of the application of cardiac rehabilitation (CR) early after discharge in a real-world population.

METHODS AND RESULTS

We analysed the 5-year incidence of cardiovascular mortality and hospitalization for cardiovascular causes in two populations, attenders vs. non-attenders to an ambulatory CR program which were consecutively discharged from two tertiary hospitals, after ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, coronary artery bypass graft, or planned percutaneous coronary intervention. A primary analysis using multivariable regression model and a secondary analysis using the propensity score approach were performed. Between 1 January 2009 and 31 December 2010, 839 patients attended a CR program planned at discharged, while 441 patients were discharged from Cardiovascular Department without any program of CR. During follow-up, the incidence of cardiovascular mortality was 6% in both groups (P = 0.62). The composite outcome of hospitalizations for cardiovascular causes and cardiovascular mortality were lower in CR group compared to no-CR group (18% vs. 30%, P < 0.001) and was driven by lower hospitalizations for cardiovascular causes (15 vs. 27%, P < 0.001). At multivariable Cox proportional hazard analysis, CR program was independent predictor of lower occurrence of the composite outcome (hazard ratio 0.58, 95% confidence interval 0.43-0.77; P < 0.001), while in the propensity-matched analysis CR group experienced also a lower total mortality (10% vs. 19%, P = 0.002) and cardiovascular mortality (2% vs. 7%, P = 0.008) compared to no-CR group.

CONCLUSION

This study showed, in a real-world population, the positive effects of ambulatory CR program in improving clinical outcomes and highlights the importance of a spread use of CR in order to reduce cardiovascular hospitalizations and cardiovascular mortality during a long-term follow-up.

Exercise testing and cardiac rehabilitation in patients treated for cancer

Cardiovascular disease (CVD) is a major competing cause of morbidity and mortality in patients with cancer. Cancer treatment can have detrimental short- and long-term cardiovascular effects. Moreover, cancer patients may have a significant loss in cardiorespiratory fitness, a key CVD risk factor, during and after cancer treatment. Exercise training has emerged as a potential intervention to improve fitness and reduce the risk of CVD in cancer. In this review, we discuss the role of cardiorespiratory fitness to predict cancer and CVD outcomes, as well as explore the impact of exercise training to improve fitness and other key outcomes in patients with cancer. The role of cardio-oncology rehabilitation will also be highlighted.

Comparison of acute response of cardiac autonomic modulation between virtual reality-based therapy and cardiovascular rehabilitation: a cluster-randomized crossover trial

OBJECTIVE

To assess the acute response of cardiac autonomic modulation (ACAM) during and after a session of virtual reality-based therapy (VRBT) compared to a session of conventional cardiovascular rehabilitation (CR) and to evaluate the effects of 12 weeks of training on this response.

METHODS

We assessed 28 volunteers (63.4 ± 12.5 years). The ACAM was judged by linear indexes of heart rate variability (HRV) in VRBT and CR sessions. Later, patients completed 12 weeks of VRBT+CR and the assessment was repeated at the 12^th week.

RESULTS

Throughout the 1^st VRBT session vagal withdrawal occurred (RMSSD/HFnu); sympathetic nervous system stimulation (LFnu) and progressive decrease of global HRV (SDNN). During the recovery, the SDNN, HFnu, and LFnu improved from the 5^thminute on both therapies. After 12 weeks, the LFnu, HFnu, and the LF/HF-ratio revealed no significant changes in Ex3-Ex4 equated to Rep during VRBT. In recovery, the HFnu and LFnu improved before the 5^thminute on both therapies.

CONCLUSIONS

ACAM during and after the VRBT was comparable to CR, yet, the extents were greater in the VRBT. After 12 weeks of VRBT training, the subjects adapted to the exercises from the 15^thminute and exhibited faster recovery of HFnu and LFnu indexes compared to the 1^st week.

Including Patients With Stroke in Cardiac Rehabilitation: BARRIERS AND FACILITATORS

More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.

The Million Hearts Initiative: CATALYZING UTILIZATION OF CARDIAC REHABILITATION AND ACCELERATING IMPLEMENTATION OF NEW CARE MODELS

Million Hearts and partners have been committed to raising national cardiac rehabilitation participation rates to a goal of 70%. Quality improvement tools, resources, and surveillance models have been developed in support. Efforts to enhance research programs and collaborative initiatives have created momentum to accelerate implementation of new care models.

Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation

Cardiac rehabilitation (CR) is an evidence-based intervention that uses exercise training, health behaviour modification, medication adherence and psychological counselling to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, following coronary intervention, heart failure, or cardiac surgery. These are significantly underused, with only a minority of eligible patients participating in CR in India. Novel delivery strategies and CR endorsement by healthcare organizations are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). Differing from centre-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision. It is provided mostly or entirely outside of the traditional centre-based setting and could be facilitated by the aid of technology and web based applications. The purpose of this appraisal is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR. This appears to hold promise in expanding the use of CR to eligible patients. Additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and people in remote and rural areas. HBCR may be a reasonable option for a selected group of patients and could be a game changer in low- and middle-income countries who are eligible for CR.

Cardiac Rehabilitation Is Associated With Improved Physical Function in Frail Older Adults With Cardiovascular Disease

PURPOSE

Frailty is highly prevalent among older adults with cardiovascular disease (CVD) and is associated with greater than 2-fold risk for morbidity and mortality, independent of age and comorbidities. Many candidates are not referred to cardiac rehabilitation (CR) under the assumption that they are too frail to benefit. We hypothesized that CR is associated with similar benefits for frail adults as for intermediate-frail and nonfrail adults.

METHODS

Retrospective analysis of CVD patients who completed a phase II CR program. Patients classified as frail by meeting ≥2 frailty criteria and intermediate-frail by meeting 1 criterion, including 6-min walk distance (6MWD) <300 m, gait speed ≤0.65 m/sec or 0.76 m/sec normalized to height and sex, tandem stand <10 sec, Timed Up & Go (TUG) <15 sec, and weak hand grip strength per Fried criteria. Changes within and between groups were compared before and after completion of CR.

RESULTS

We evaluated 243 patients; 75 were classified as frail, 70 as intermediate-frail, and 98 as nonfrail. Each group improved in all measures of frailty except for tandem stand. There were no significant differences in pre- to post-CR measures for 6MWD, gait speed, tandem stand, or hand grip strength between groups. Frail patients showed greater improvement in TUG than the other groups (P = .007).

CONCLUSION

Among frail patients, CR was associated with improvements in multiple domains of physical function. Gains achieved by frail adults were similar to or greater than those achieved by intermediate-frail and nonfrail patients. These data provide strong rationale for referring all eligible patients to CR, including frail patients. Those who are most physically impaired may derive gains that have proportionally greater ramifications.

Cardiovascular Protection Variables Based on Exercise Intensity in Stable Coronary Heart Disease Patients After Coronary Stenting: A Comparative Study

Purpose

Our study aimed at determining and comparing the mechanism of cardiovascular protection variables in moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT) in patients with stable coronary heart disease (CHD) after coronary stenting.

Participants and Methods

This experimental study used the same subject and cross-over design, involving eleven stable CHD patients after coronary stenting. These were randomly divided into two groups; MICT for 29 minutes at 50–60% heart rate reserve and HIIT with 4x4 minute intervals at 60–80% heart rate reserve, each followed by three minutes of active recovery at 40–50% heart rate reserve. These were conducted three times a week for two weeks. The participants’ levels of adrenaline, noradrenaline, endothelial nitric oxide synthase (eNOS), extracellular superoxide dismutase (EC-SOD) activity assayed, and flow-mediated dilatation (FMD) were examined before and after treatments were completed.

Results

The HIIT significantly increased the levels of noradrenaline and eNOS compared with MICT (p<0.05). Also, HIIT was better in maintaining EC-SOD activity and FMD compared with MICT (p<0.05). Through the noradrenalin pathway, HIIT had a direct and significant effect on eNOS and FMD (p<0.05) but MICT, through the noradrenaline pathways, had a direct and significant effect on eNOS (p<0.05), and through the EC-SOD activity pathways had a direct and significant effect on FMD (p<0.05). MICT reduced EC-SOD activity and also decreased the FMD value.

Conclusion

HIIT is superior to MICT in increasing cardiovascular protection by increasing the concentrations of noradrenalin and eNOS, maintaining EC-SOD activity, and FMD in stable CHD patients after coronary stenting.

Underutilization of Hospital-based Cardiac Rehabilitation after Acute Myocardial Infarction in Korea

BACKGROUND

Cardiac rehabilitation (CR) after acute myocardial infarction (AMI) is recommended as a mandatory intervention in several national clinical practice guidelines published in America, Europe, and Korea to reduce recurrence and mortality. However, underutilization of CR is an established worldwide issue. In Korea, the promotion of CR is expected due to coverage by National Health Insurance. Nevertheless, the national status of CR use has not been reported. This retrospective cohort study aimed to investigate the current status of CR use in patients with AMI using nationwide data from the National Health Insurance Service of Korea.

METHODS

Patients with AMI admitted with the diagnosis of 'I21' code (from International Classification of Diseases, 10th revision, Clinical Modification) from July 1st, 2017 to June 30th, 2018 were included. CR use was defined as CR treatment or evaluation being performed during an outpatient follow-up period within 6 months after discharge. Participation rate and density were calculated nationally and by administrative division. Logistic regression analysis was performed to identify the influencing factors of CR participation.

RESULTS

Nationally, 1.5% of AMI patients (960/64,982) underwent CR during outpatient treatment after discharge. CR density was approximately 10. Logistic regression analysis revealed that influencing factors included old age, female sex, rural residence, and low Charlson comorbidity index.

CONCLUSION

Hospital-based CR after AMI is underutilized despite its coverage by the National Health Insurance. More CR facilities have to be installed according to the needs of CR in various regions.

Home-Based Functional Electrical Stimulation of Human Permanent Denervated Muscles: A Narrative Review on Diagnostics, Managements, Results and Byproducts Revisited 2020

Spinal cord injury (SCI) produces muscle wasting that is especially severe after complete and permanent damage of lower motor neurons, as can occur in complete conus and cauda equina syndrome. Even in this worst-case scenario, mass and function of permanently denervated quadriceps muscle can be rescued by surface functional electrical stimulation using a purpose designed home-based rehabilitation strategy. Early diagnostics is a key factor in the long-term success of this management. Function of quadriceps muscle was quantitated by force measurements. Muscle gross cross-sections were evaluated by quantitative color computed tomography (CT) and muscle and skin biopsies by quantitative histology, electron microscopy, and immunohistochemistry. Two years of treatment that started earlier than 5 years from SCI produced: (a) an increase in cross-sectional area of stimulated muscles; (b) an increase in muscle fiber mean diameter; (c) improvements in ultrastructural organization; and (d) increased force output during electrical stimulation. Improvements are extended to hamstring muscles and skin. Indeed, the cushioning effect provided by recovered tissues is a major clinical benefit. It is our hope that new trials start soon, providing patients the benefits they need.

Contribution of common chronic conditions to midlife physical function decline: The Study of Women's Health Across the Nation

Background

Chronic conditions are associated with worse physical function and commonly develop during midlife. We tested whether the presence of 8 chronic conditions, or the development of these conditions, is associated with declines in physical function among midlife women as they transition into early late life.

Methods

Participants (N = 2283) were from the Study of Women’s Health Across the Nation. Physical function was assessed at 8 visits starting at the study’s fourth clinic visit in 2000/2001 through follow-up visit 15 (2015/2017) using the Short Form-36 Physical Function subscale. Chronic conditions included diabetes, hypertension, osteoarthritis, osteoporosis, stroke, heart disease, cancer, and depressive symptoms. Repeated-measures Poisson regression modeled associations between 1) prevalent chronic conditions at analytic baseline (visit 4) and longitudinal physical function, and 2) change in physical function associated with developing a new condition. Models were adjusted with the total number of other chronic conditions at visit 4.

Results

In separate fully-adjusted longitudinal models, prevalent heart disease and osteoporosis were associated with 18% (IRR = 0.815, 95% confidence interval [CI]: 0.755–0.876) and 12% (IRR = 0.876, 95% CI: 0.825–0.927) worse initial physical function, respectively. Prevalent osteoarthritis was associated with approximately 6% (IRR = 0.936, 95% CI: 0.913–0.958) worse initial physical function, and a slight additional worsening over time (IRR = 0.995, 95% CI: 0.994–0.996). A 12% (IRR = 0.878, 95% CI: 0.813–0.950) decrease in physical function concurrent with stroke development was evident, as was accelerated decline in physical function concurrent with heart disease development (IRR = 0.991, 95% CI: 0.988–0.995).

Conclusions

Initial prevalent conditions related to the musculoskeletal system were associated with worse initial physical function, with some evidence of accelerated decline in physical function with osteoarthritis. Stroke and heart disease are less common than osteoarthritis in this age group, but the severe effects of these conditions on physical function shows the need for a greater focus on cardiovascular health during midlife. Women who develop chronic conditions during midlife may be at particular risk for poor physical function as they age, warranting disability prevention efforts focused on this population.

Mobile Health Monitoring of Cardiac Status

Cardiovascular diseases (CVDs) are responsible for more deaths than any other cause, with coronary heart disease and stroke accounting for two-thirds of those deaths. Morbidity and mortality due to CVD are largely preventable, through either primary prevention of disease or secondary prevention of cardiac events. Monitoring cardiac status in healthy and diseased cardiovascular systems has the potential to dramatically reduce cardiac illness and injury. Smart technology in concert with mobile health platforms is creating an environment where timely prevention of and response to cardiac events are becoming a reality.

A qualitative exploration of cardiovascular disease patients' views and experiences with an eHealth cardiac rehabilitation intervention: The PATHway Project

The aim of this study is to explore participants' views and experiences of an eHealth phase 3 cardiac rehabilitation (CR) intervention: Physical Activity Towards Health (PATHway). Sixty participants took part in the PATHway intervention. Debriefs were conducted after the six-month intervention. All interviews were audio recorded and transcribed verbatim. Transcripts were analysed with Braun and Clarke's thematic analysis. Forty-four (71%) debriefs were conducted (n = 34 male, mean (SD) age 61 (10) years). Five key themes were identified: (1) Feedback on the components of the PATHway system, (2) Motivation, (3) Barriers to using PATHway, (4) Enablers to using PATHway, and (5) Post programme reflection. There were a number of subthemes within each theme, for example motivation explores participants motivation to take part in PATHway and participants motivation to sustain engagement with PATHway throughout the intervention period. Participant engagement with the components of the PATHway system was variable. Future research should focus on optimising participant familiarisation with eHealth systems and employ an iterative approach to development and evaluation.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Cardiac Rehabilitation in a Rural Setting: OPTIMIZATION OF REFERRAL AND PARTICIPATION RATES

PURPOSE

The cardiac rehabilitation (CR) program at Dartmouth-Hitchcock Medical Center (DHMC) devotes a nurse to the inpatient units in an attempt to optimize the referral process. This report defines the rates of referral and participation at DHMC and explores potential factors that affect participation.

METHODS

Seven hundred ten consecutive patients who underwent percutaneous coronary intervention, coronary artery bypass grafting, or valve surgery from January 1, 2015 to June 30, 2015 were reviewed to determine whether the patient was referred for CR. Participation rates and the effect of time delay and patient-specific factors on participation were examined.

RESULTS

Six hundred ninety-eight (98%) of the 710 post-procedural patients were evaluated by the inpatient rehabilitation nurse. One hundred sixty-seven patients were ineligible for outpatient therapy on the basis of established criteria; the remaining 543 patients were referred to DHMC or regional rehabilitation programs. Of those referred to the on-site program at DHMC, 84% participated. Of those referred to regional programs, 60% participated. There was an inverse correlation (r = -0.82; P = .003) between wait times and participation rates for the various programs.

CONCLUSIONS

Despite its rural location with a large geographic catchment area, DHMC achieves high rates of CR referral and participation. The approach used at DHMC, which includes a CR nurse working with the inpatient cardiac services, a strong level of integration with the physician community, and well-developed relationships with regional rehabilitation programs, may be helpful for those programs wishing to improve referral and participation rates. Shorter wait times between hospital discharge and initiation of rehabilitation may improve participation rates.

The role of cardiopulmonary exercise testing and training in patients with pulmonary hypertension: making the case for this assessment and intervention to be considered a standard of care

Introduction: Pulmonary hypertension (PH) is a broad pathophysiological disorder primarily characterized by increased pulmonary vascular resistance due to multiple possible etiologies. Patients typically present with multiple complaints that worsen as disease severity increases. Although initially discouraged due to safety concerns, exercise interventions for patients with PH have gained wide interest and multiple investigations have established the effective role of exercise training in improving the clinical profile, exercise tolerance, and overall quality of life.Areas covered: In this review, we discuss the pathophysiology of PH during rest and exercise, the role of cardiopulmonary exercise testing (CPX) in the diagnosis and prognosis of PAH, the role of exercise interventions in this patient population, and the expected physiological adaptations to exercise training.Expert opinion: Exercise testing, in particular CPX, provides a wealth of clinically valuable information in the PH population. Moreover, the available evidence strongly supports the safety and efficacy of exercise training as a clinical tool in improving exercise tolerance and quality of life. Although clinical trials investigating the role of exercise in this PH population are relatively few compared to other chronic conditions, current available evidence supports the clinical implementation of exercise training as a safe and effective treatment modality.

Patient Perspectives on Declining to Participate in Home-Based Cardiac Rehabilitation: A MIXED-METHODS STUDY

PURPOSE

A minority of eligible patients participate in cardiac rehabilitation (CR) programs. Availability of home-based CR programs improves participation in CR, yet many continue to decline to enroll. We sought to explore among patients the rationale for declining to participate in CR even when a home-based CR program is available.

METHODS

We conducted a mixed-methods evaluation of reasons for declining to participate in CR. Between August 2015 and August 2017, a total of 630 patients were referred for CR evaluation during index hospitalization (San Francisco VA Medical Center). Three hundred three patients (48%) declined to participate in CR. Of these, 171 completed a 14-item survey and 10 patients also provided qualitative data through semistructured phone interviews.

RESULTS

The most common reason, identified by 61% of patients on the survey, was "I already know what to do for my heart." Interviews helped clarify reasons for nonparticipation and identified system barriers and personal barriers. These interviews further highlighted that declining to participate in CR was often due to competing life priorities, no memory of the initial CR consultation, and inadequate understanding of CR despite referral.

CONCLUSION

We identified that most patients declining to participate in a home-based CR program did not understand the benefits and rationale for CR. This could be related to the timing of the consultation or presentation method. Many patients also indicated that competing life priorities prevented their participation. Modifications in the consultation process and efforts to accommodate personal barriers may improve participation.

Rehabilitation Needs in Cancer Treatment-Related Cardiotoxicity

OBJECTIVES

To examine and summarize current international guidelines regarding cardiovascular risk reduction before and during cancer therapy, and to discuss the emerging role of cardio-oncology as a subspecialty in cancer care and the role of cardio-oncology rehabilitation.

DATA SOURCES

Published articles and guidelines.

CONCLUSION

With improvements in cancer detection and the use of novel adjuvant therapies, an increasing number of individuals now survive a cancer diagnosis. However, for some the cost is high - many survivors are now at higher risk of death from cardiovascular disease than from recurrent cancer. Cardiovascular morbidity and mortality are common and associated with common cancer therapies serially administered in adult oncology care.

IMPLICATIONS FOR NURSING PRACTICE

Timely risk-reduction interventions hold promise in reducing cardiovascular morbidity and mortality. Oncology nurses are the key providers to identify baseline risks, perform necessary referrals, provide individualized teaching, and support the patient within the family and community.