Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands

Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands

PURPOSE

Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components.

METHODS

Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components.

RESULTS

In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization.

CONCLUSIONS

CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

A potential research target for cardiac rehabilitation: brain-derived neurotrophic factor

Cardiovascular diseases pose a major threat to human life, functional activity, and quality of life. Once the disease is present, patients can experience varying degrees of problems or limitations on three levels: physical, psychological, and social. Patients with cardiovascular disease are always at risk for adverse cardiac events, decreased physical activity, psychoemotional disturbances, and limited social participation due to their varying pathologies. Therefore, personalized cardiac rehabilitation is of great significance in improving patients' physical and mental functions, controlling disease progression, and preventing deterioration. There is a consensus on the benefits of cardiac rehabilitation in improving patients' quality of life, enhancing functional activity, and reducing mortality. As an important part of cardiac rehabilitation, Exercise plays an irreplaceable role. Aerobic exercise, resistance training, flexibility training, and other forms of exercise are recommended by many experts. Improvements in exercise tolerance, lipid metabolism, cardiac function, and psychological aspects of the patients were evident with appropriate exercise interventions based on a comprehensive assessment. Further studies have found that brain-derived neurotrophic factor may be an important mediator of exercise's ability to improve cardiovascular health. Brain-derived neurotrophic factor exerts multiple biological effects on the cardiovascular system. This article provides another perspective on the cardiac effects of exercise and further looks at the prospects for the use of brain-derived neurotrophic factor in cardiac rehabilitation. Meanwhile, the new idea that brain-derived neurotrophic factor is a key mediator connecting the brain-cardiac axis is proposed in light of the current research progress, to provide new ideas for clinical rehabilitation and scientific research.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities

BACKGROUND

Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life.

AIMS

To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities.

METHODS

All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified.

RESULTS

In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic.

CONCLUSIONS

Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

Incremental prognostic value of functional impairment assessed by 6-min walking test for the prediction of mortality in heart failure

Natriuretic peptides (NP) are recognized as the most powerful predictors of adverse outcomes in heart failure (HF). We hypothesized that a measure of functional limitation, as assessed by 6-min walking test (6MWT), would improve the accuracy of a prognostic model incorporating a NP. This was a multicenter observational retrospective study. We studied the prognostic value of severe functional impairment (SFI), defined as the inability to perform a 6MWT or a distance walked during a 6MWT < 300 m, in 1696 patients with HF admitted to cardiac rehabilitation. The primary outcome was 1-year all-cause mortality. After adjusting for the baseline multivariable risk model-including age, sex, systolic blood pressure, anemia, renal dysfunction, sodium level, and NT-proBNP-or for the MAGGIC score, SFI had an odds ratio of 2.58 (95% CI 1.72-3.88; p < 0.001) and 3.12 (95% CI 2.16-4.52; p < 0.001), respectively. Adding SFI to the baseline risk model or the MAGGIC score yielded a significant improvement in discrimination and risk classification. Our data suggest that a simple, 6MWT-derived measure of SFI is a strong predictor of death and provide incremental prognostic information over well-established risk markers in HF, including NP, and the MAGGIC score.

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.

Exercise-based cardiac rehabilitation in stable angina pectoris: a narrative review on current evidence and underlying physiological mechanisms

Stable angina pectoris (SAP) is a prevalent condition characterised by a high disease burden. Based on recent evidence, the need for revascularisation in addition to optimal medical treatment to reduce mortality and re-events is heavily debated. These observations may be explained by the fact that revascularisation is targeted at the local flow-limiting coronary artery lesion, while the aetiology of SAP relates to the systemic, inflammatory process of atherosclerosis, causing generalised vascular dysfunction throughout the entire vascular system. Moreover, cardiovascular events are not solely caused by obstructive plaques but are also associated with plaque burden and high-risk plaque features. Therefore, to reduce the risk of cardiovascular events and angina, and thereby improve quality of life, alternative therapeutic approaches to revascularisation should be considered, preferably targeting the cardiovascular system as a whole with a physiological approach. Exercise-based cardiac rehabilitation fits this description and is a promising strategy as a first-line treatment in addition to optimal medical treatment. In this review, we discuss the role of exercise-based cardiac rehabilitation in SAP in relation to the underlying physiological mechanisms, we summarise the existing evidence and highlight future directions.

Effects of DementiaNet's Community Care Network Approach on Admission Rates and Healthcare Costs: A Longitudinal Cohort Analysis

BACKGROUND

People with dementia are increasingly living at home, relying on primary care providers for most healthcare needs. Suboptimal collaboration and communication between providers could cause inefficiencies and worse patient outcomes. Innovative strategies are needed to address this growing disease burden and rising healthcare costs. The DementiaNet programme, a community care network approach targeted at patients with dementia in the Netherlands, has been shown to improve patient's quality of care. However, very little is known about the impact of DementiaNet on admission risks and healthcare costs. This study addresses this knowledge gap.

METHODS

A longitudinal cohort analysis was performed, using medical and long-term care claims data from 38 525 patients between 2015-2019. The primary outcomes were risk of hospital admission and annual total healthcare costs. Mixed-model regression analyses were used to identify changes in outcomes.

RESULTS

Patients who received care from a DementiaNet community care network showed a general trend in lower risk of admission for all types of admissions studied (ie, hospital, emergency ward, intensive care, crisis, and nursing home). Also, the intervention group showed a significant reduction of 12% in nursing days (relative risk [RR] 0.88; 95% CI: 0.77- 0.96). No significant differences were found for total healthcare costs. However, we found effects in two sub-elements of total healthcare costs, being a decrease of 19.7% (95% CI: 7.7%-30.2%) in annual hospital costs and an increase of 10.2% (95% CI: 2.3%-18.6%) in annual primary care costs.

CONCLUSION

Our study indicates that DementiaNet's community care network approach may reduce admission risks for patients with dementia over a long-term period of five years. This is accompanied by a decrease in nursing days and savings in hospital care that exceed increased primary care costs. This improvement in integrated dementia care supports wider scale implementation and evaluation of these networks.

Lyophilized recombinant human brain natriuretic peptide for chronic heart failure: Effects on cardiac function and inflammation

BACKGROUND

Chronic heart failure (CHF) is a serious and prevalent condition characterized by impaired cardiac function and inflammation. Standard therapy for CHF has limitations, prompting the exploration of alternative treatments. Recombinant human brain natriuretic peptide (BNP) has emerged as a potential therapy, with evidence suggesting that it can improve cardiac function and reduce inflammation in patients with CHF. However, further research is required to determine the efficacy and safety of lyophilized recombinant human BNP in CHF patients and its impact on microinflammatory status. This study aimed to investigate the effects of lyophilized recombinant human BNP therapy on CHF patients' cardiac function and microinflammatory status.

AIM

To investigate the effects of freeze-dried recombinant human BNP therapy on cardiac function and microinflammatory status in patients with CHF.

METHODS

In total, 102 CHF patients admitted to our hospital from January 2021 to January 2022 were randomly assigned to control and observation groups (n = 51 patients/group). The control patients were treated with standard HF therapy for 3 d, whereas the observational patients were injected with the recombinant human BNP for 3 d. Clinical efficacy, inflammatory factor levels, myocardial damage, cardiac function before and after the treatment, and adverse reactions during treatment were compared between the two groups.

RESULTS

The overall clinical efficacy was higher in the observation group than in the control group. Compared with baseline, serum hypersensitive C-reactive protein, N-terminal proBNP, and troponin I level, and physical, emotional, social, and economic scores were lower in both groups after treatment, with greater reductions in levels and scores noted in the observation group than in the control group. The overall incidence of adverse reactions in the observation group was not significantly different compared with that in the control group (P > 0.05).

CONCLUSION

Freeze-dried recombinant human BNP therapy can improve heart function and enhance microinflammatory status, thereby improving overall quality of life without any obvious side effects. This therapy is safe and reliable.

A randomized trial of a mobile health intervention to augment cardiac rehabilitation

Mobile health (mHealth) interventions may enhance positive health behaviors, but randomized trials evaluating their efficacy are uncommon. Our goal was to determine if a mHealth intervention augmented and extended benefits of center-based cardiac rehabilitation (CR) for physical activity levels at 6-months. We delivered a randomized clinical trial to low and moderate risk patients with a compatible smartphone enrolled in CR at two health systems. All participants received a compatible smartwatch and usual CR care. Intervention participants received a mHealth intervention that included a just-in-time-adaptive intervention (JITAI) as text messages. The primary outcome was change in remote 6-minute walk distance at 6-months stratified by device type. Here we report the results for 220 participants enrolled in the study (mean [SD]: age 59.6 [10.6] years; 67 [30.5%] women). For our primary outcome at 6 months, there is no significant difference in the change in 6 min walk distance across smartwatch types (Intervention versus control: +31.1 meters Apple Watch, -7.4 meters Fitbit; p = 0.28). Secondary outcomes show no difference in mean step counts between the first and final weeks of the study, but a change in 6 min walk distance at 3 months for Fitbit users. Amongst patients enrolled in center-based CR, a mHealth intervention did not improve 6-month outcomes but suggested differences at 3 months in some users.

A Web-Based Application for Risk Stratification and Optimization in Patients With Cardiovascular Disease: Pilot Study

BACKGROUND

In addition to aspirin, angiotensin-converting enzyme inhibitors, statins, and lifestyle modification interventions, novel pharmacological agents have been shown to reduce morbidity and mortality in atherosclerotic cardiovascular disease patients, including new antithrombotics, antihyperglycemics, and lipid-modulating therapies. Despite their benefits, the uptake of these guideline-directed therapies remains a challenge. There is a need to develop strategies to support knowledge translation for the uptake of secondary prevention therapies.

OBJECTIVE

The goal of this study was to test the feasibility and usability of Stratification and Optimization in Patients With Cardiovascular Disease (STOP-CVD), a point-of-care application that was designed to facilitate knowledge translation by providing individualized risk stratification and optimization guidance.

METHODS

Using the REACH (Reduction of Atherothrombosis for Continued Health) Registry trial and predictive modeling (which included 67,888 patients), we designed a free web-based secondary risk calculator. Based on demographic and comorbidity profiles, the application was used to predict an individual's 20-month risk of cardiovascular events and cardiovascular mortality and provides a comparison to an age-matched control with an optimized cardiovascular risk profile to illustrate the modifiable residual risk. Additionally, the application used the patient's risk profile to provide specific guidance for possible therapeutic interventions based on a novel algorithm. During an initial 3-month adoption phase, 1-time invitations were sent through email and telephone to 240 physicians that refer to a regional cardiovascular clinic. After 3 months, a survey of user experience was sent to all users. Following this, no further marketing of the application was performed. Google Analytics was collected postimplementation from January 2021 to December 2021. These were used to tabulate the total number of distinct users and the total number of monthly uses of the application.

RESULTS

During the 1-year pilot, 47 of the 240 invited clinicians used the application 1573 times, an average of 131 times per month, with sustained usage over time. All 24 postimplementation survey respondents confirmed that the application was functional, easy to use, and useful.

CONCLUSIONS

This pilot suggests that the STOP-CVD application is feasible and usable, with high clinician satisfaction. This tool can be easily scaled to support the uptake of guideline-directed medical therapy, which could improve clinical outcomes. Future research will be focused on evaluating the impact of this tool on clinician management and patient outcomes.

An Overview of Sport Participation and Exercise Prescription in Mitral Valve Disease

The incidence of heart valve disease (HVD) has been rising over the last few decades, mainly due to the increasing average age of the general population, and mitral valve (MV) disease is the second most prevalent HVD after calcific aortic stenosis, but MV disease is a heterogeneous group of different pathophysiological diseases. It is widely proven that regular physical activity reduces all-cause mortality rates, and exercise prescription is part of the medical recommendations for patients affected by cardiovascular diseases. However, changes in hemodynamic balance during physical exercise (including the increase in heart rate, preload, or afterload) could favor the progression of the MV disease and potentially trigger major cardiac events. In young patients with HVD, it is therefore important to define criteria for allowing competitive sport or exercise prescription, balancing the positive effects as well as the potential risks. This review focuses on mitral valve disease pathophysiology, diagnosis, risk stratification, exercise prescription, and competitive sport participation selection, and offers an overview of the principal mitral valve diseases with the aim of encouraging physicians to embody exercise in their daily practice when appropriate.

Physical Activity Over the Lifecourse and Cardiovascular Disease

Despite improvements in cardiovascular care in recent decades, cardiovascular disease (CVD) remains a leading cause of death worldwide. At its core, CVD is a largely preventable disease with diligent risk factor management and early detection. As highlighted in the American Heart Association's Life's Essential 8, physical activity plays a central role in CVD prevention at an individual and population level. Despite pervasive knowledge of the numerous cardiovascular and noncardiovascular health benefits of physical activity, physical activity has steadily decreased over time and unfavorable changes in physical activity occur throughout people's lives. Here, we use a lifecourse framework to examine the evidence reporting on the association of physical activity with CVD. From in utero to older adults, we review and discuss the evidence detailing how physical activity may prevent incident CVD and mitigate CVD-related morbidity and death across all life stages.

Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program

The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies had shown safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR. A multidisciplinary team reviewed various alternative models for delivery and decided to implement a hybrid CRP2 exercise programme (HCRP2-EP) to ensure continuation of our patient care. Our aim was to enrol in the HCRP2-EP 70% of all eligible patients by 30 September 2020. Institute for Health Care Improvement's collaborative model was adopted. Multiple plan-do-study-act cycles were used to test change ideas. The outcomes of the project were analysed using standard run chart rules to detect the changes in outcomes over time. This project was implemented from March 2020, and the male patients enrolled between August 2020 and April 2021, with sustained monthly median enrolment above target of 70% throughout. As for our secondary outcome, 75.8% of the male patients who completed HCRP2-EP showed a meaningful change in peak exercise capacity of ≥10% (mean change 17%±6%). There were no major adverse events reported, and the median Patient Satisfaction Score was 96% well above the institutional target of 90%. This shows a well-designed quality improvement programme is an appropriate strategy for implementing HCRP2-EP in a clinical setting, and HCRP2-EP is a feasible, effective and safe intervention in eligible male patients with cardiovascular disease.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Functional outcome after cardiac rehabilitation and its association with survival in heart failure across the spectrum of ejection fraction

BACKGROUND

There is limited evidence regarding the effects of cardiac rehabilitation (CR) in patients with heart failure and preserved ejection fraction (HFpEF).

METHODS

We studied 1784 patients admitted to inpatient CR. The patients were grouped into HFpEF (EF≥0.50), HF with mildly reduced EF (HFmrEF; EF 41-49), and HF with reduced EF (HFrEF; EF≤0.40). A standardized 6-min walking test was performed at admission and discharge. Measures of functional outcome were: (1) absolute increase in 6-min walking distance (6MWD) from admission to discharge >50 m and (2) increase in 6MWD to ≥300 among the patients who walked <300 m at admission.

RESULTS

After adjustment, the patients with HFpEF or HFmrEF were as likely as those with HFrEF to achieve an increase in 6MWD >50 m (odds ratio 0.95 [95%CI 0.71-1.24; p=0.648] and 1.04 [95%CI 0.77-1.41; p=0.769], respectively) or an increase in 6MWD to ≥300 m (odds ratio 0.79 [95%CI 0.51-1.23; p=0.299] and 0.65 [95%CI 0.38-1.12; p=0.118], respectively). The adjusted hazard ratio of 5-year mortality for patients who achieved an increase in 6MWD >50 m was 0.60 (95%CI 0.51-0.71; p<0.001) and that for patients who achieved an increase in 6MWD at discharge to ≥300 m 0.61 (95%CI 0.48-0.79; p<0.001). In each EF group, both outcomes remained independently associated with improved survival.

CONCLUSIONS

Our data suggest that patients with HFpEF or HFmrEF are as likely as those with HFrEF to benefit from CR in terms of functional improvement. Functional improvement was independently associated with improved long-term survival, regardless of EF.

A Comprehensive Secondary Prevention Benchmark (2PBM) Score Identifying Differences in Secondary Prevention Care in Patients After Acute Coronary Syndrome

PURPOSE

The objective of this study was to quantify secondary prevention care by creating a secondary prevention benchmark (2PBM) score for patients undergoing ambulatory cardiac rehabilitation (CR) after acute coronary syndrome (ACS).

METHODS

In this observational cohort study, 472 consecutive ACS patients who completed the ambulatory CR program between 2017 and 2019 were included. Benchmarks for secondary prevention medication and clinical and lifestyle targets were predefined and combined in the comprehensive 2PBM score with maximum 10 points. The association of patient characteristics and achievement rates of components and the 2PBM were assessed using multivariable logistic regression analysis.

RESULTS

Patients were on average 62 ± 11 yr of age and predominantly male (n = 406; 86%). The types of ACS were ST-elevation myocardial infarction (STEMI) in 241 patients (51%) and non-ST-elevation myocardial infarction in 216 patients (46%). Achievement rates for components of the 2PBM were 71% for medication, 35% for clinical benchmark, and 61% for lifestyle benchmark. Achievement of medication benchmark was associated with younger age (OR = 0.979: 95% CI, 0.959-0.996, P = .021), STEMI (OR = 2.05: 95% CI, 1.35-3.12, P = .001), and clinical benchmark (OR = 1.80: 95% CI, 1.15-2.88, P = .011). Overall ≥8 of 10 points were reached by 77% and complete 2PBM by 16%, which was independently associated with STEMI (OR = 1.79: 95% CI, 1.06-3.08, P = .032).

CONCLUSIONS

Benchmarking with 2PBM identifies gaps and achievements in secondary prevention care. ST-elevation myocardial infarction was associated with the highest 2PBM scores, suggesting best secondary prevention care in patients after ST-elevation myocardial infarction.

Association between postoperative delirium and heart rate variability in the intensive care unit and readmissions and mortality in elderly patients with cardiovascular surgery

This study aimed to investigate the relationship between heart rate variability (HRV), a parameter of the autonomic nervous system activity (ANSA), and postoperative delirium and postoperative events. This retrospective cohort study included elderly patients aged 65 years or older who were admitted to the intensive care unit (ICU) after cardiovascular surgery. ANSA was measured using HRV parameters for 1 h at daytime and 1 h at night-time before ICU discharge. The primary endpoint was the effect of HRV parameters and delirium on mortality and readmission rates within 1 year after discharge, and the secondary endpoint was the association between HRV parameters and delirium. Cox proportional hazards models were used to examine the association between HRV parameters and postoperative events by adjusting for delirium and pre and postoperative information. A total of 71 patients, 39 without delirium and 32 with delirium, met the inclusion criteria. The incidence of death and readmission within 1 year was significantly higher in the delirium group and in the group with higher daytime HF (high frequency power) and r-MSSD (square root of the squared mean of the difference of successive NN intervals), parameters of the parasympathetic nervous system activity (PNSA), than that in other groups. Furthermore, the delirium group had significantly higher HF and r-MSSD than the nondelirium group. Even after adjusting for confounding factors in the multivariate analysis, a trend of higher daytime HF and r-MSSD was observed, indicating a significant effect on the occurrence of combined events within 1 year of discharge. ICU delirium has been associated with higher daytime HF and r-MSSD, parameters of PNSA. ICU delirium was a prognostic factor, and increased daytime PNSA may worsen the prognosis of elderly patients after cardiovascular surgery.

The Association Between a Second Course of Cardiac Rehabilitation and Cardiovascular Outcomes Following Repeat Percutaneous Coronary Intervention Events

PURPOSE

Survivors of coronary artery disease (CAD) events are at risk for repeat events. Although evidence supports cardiac rehabilitation (CR) after an initial CAD event, it is unclear whether a repeat course of CR (CR × 2) is beneficial after a recurrent CAD event. The purpose of this study was to determine the association of CR × 2 with clinical outcomes in persons undergoing repeat percutaneous coronary intervention (PCI).

METHODS

We assessed the prevalence of CR × 2 and its impact on cardiovascular outcomes in individuals who experienced a repeat PCI at the Mayo Clinic hospitals between January 1, 1998, and December 31, 2013. Landmark analyses were used to calculate unadjusted and propensity score adjusted mortality rates and cardiovascular (CV) events rates for patients who underwent CR × 2 compared with those who did not.

RESULTS

Among 240 individuals who had a repeat PCI and who had participated in CR after their first PCI, 97 (40%) participated in CR × 2. Outcomes were assessed for a mean follow-up time of 7.8 yr (IQR 7.1-9.0 yr). Propensity score-based inverse probability weighting analysis revealed that CR × 2 was associated with significantly lower target lesion revascularization (HR = 0.47: 95% CI, 0.26-0.86; P = .014), lower combined end point of CV death, myocardial infarction, and target lesion revascularization (HR = 0.57: 95% CI, 0.36-0.89; P = .014), and lower CV hospitalization (HR = 0.60; 95% CI, 0.43-0.84; P = .003).

CONCLUSION

A second course of CR following repeat PCI is associated with a lower risk of adverse clinical outcomes. These findings support current policies that allow for repeat courses of CR following recurrent CV events.

Updates on obesity and the obesity paradox in cardiovascular diseases

The prevalence of obesity has reached pandemic proportions worldwide and certainly in the United States. Obesity is a well-established independent risk factor for development of many cardiovascular diseases (CVD), including heart failure, coronary heart disease, atrial fibrillation, and hypertension. Therefore, it is logical to expect obesity would have a strong correlation with CVD mortality. However, a substantial body of literature demonstrates a paradox with improved prognosis of overweight and obese patients with established CVD compared to lean patients with the identical CVD. Surprisingly, similar data has also shown that cardiovascular fitness, rather than weight loss alone, influences the relationship between obesity and mortality in those with established CVD. The impact of fitness, exercise, physical activity (PA), and weight loss and their relationship to the obesity paradox are all reviewed here.

Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the ASPC Part I: Bioenergetics, contemporary physical activity recommendations, benefits, risks, extreme exercise regimens, potential maladaptations

Regular moderate-to-vigorous physical activity (PA) and increased levels of cardiorespiratory fitness (CRF) or aerobic capacity are widely promoted as cardioprotective measures in the primary and secondary prevention of atherosclerotic cardiovascular (CV) disease (CVD). Nevertheless, physical inactivity and sedentary behaviors remain a worldwide concern. The continuing coronavirus (COVID-19) pandemic has been especially devastating to patients with known or occult CVD since sitting time and recreational PA have been reported to increase and decrease by 28% and 33%, respectively. Herein, in this first of a 2-part series, we discuss foundational factors in exercise programming, with specific reference to energy metabolism, contemporary PA recommendations, the dose-response relationship of exercise as medicine, the benefits of regular exercise training, including the exercise preconditioning cardioprotective phenotype, as well as the CV risks of PA. Finally, we discuss the 'extreme exercise hypothesis,' specifically the potential maladaptations resulting from high-volume, high-intensity training programs, including accelerated coronary artery calcification and incident atrial fibrillation. The latter is commonly depicted by a reverse J-shaped or U-shaped curve. On the other hand, longevity data argue against this relationship, as elite endurance athletes live 3-6 years longer than the general population.

Cardiac Rehabilitation for Older Women with Heart Failure

Background: the role that sex plays in impacting cardiac rehabilitation (CR) outcomes remains an important gap in knowledge. Methods: we assessed sex differences in clinical and functional outcomes in 2345 older patients with heart failure (HF) admitted to inpatient CR. Three outcomes were considered: (1) the composite outcome of death during the index admission to CR or transfer to acute care; (2) three-year mortality; (3) change in six-minute walking distance (6MWD) from admission to discharge. Sex differences in outcomes were assessed using multivariable Cox or logistic regression models. Results: the hazard ratios of the composite outcome and of three-year mortality for females vs. males were 0.71 (95%CI:0.50−1.00; p = 0.049) and 0.68 (95%CI:0.59−0.79; p < 0.001), respectively. The standardized mean difference in 6MWD increase from admission to discharge between males and females was 0.10. The odds ratio of achieving an increase in 6MWD at discharge to values higher than the optimal sex-specific thresholds for predicting mortality for females vs. males was 2.21 (95%CI:1.53−3.20; p < 0.001). Conclusion: our findings suggest that older females with HF undergoing CR have better prognosis and garner similar improvement in 6MWD compared with their male counterparts. Nonetheless, females were more likely to achieve levels of functional capacity predictive of improved survival.

Cardiac rehabilitation for patients with heart failure: association with readmission and mortality risk

AIMS

To examine the temporal trends and factors associated with national cardiac rehabilitation (CR) referral and compare the risk of hospital readmission and mortality in those referred for CR versus no referral.

METHODS AND RESULTS

This cohort study includes all adult patients alive 120 days from incident heart failure (HF) identified by the Danish Heart Failure Registry (n = 33 257) between 2010 and 2018. Multivariable logistic regression models were used to assess the association between CR referral and patient factors and acute all-cause hospital readmission and mortality at 1 year following HF admission. Overall, 46.7% of HF patients were referred to CR, increasing from 31.7% in 2010 to 52.2% in 2018. Several factors were associated with lower odds of CR referral: male sex [odds ratio (OR): 0.85; 95% confidence interval: 0.80-0.89], older age, unemployment, retirement, living alone, non-Danish ethnic origin, low educational level, New York Heart Association (NYHA) class IV vs. I (OR: 0.75; 0.60-0.95), left ventricular ejection fraction >40%, and comorbidity (stroke, chronic kidney disease, atrial fibrillation/flutter, and diabetes). Myocardial infarction, arthritis, coronary artery bypass grafting, percutaneous coronary intervention, valvular surgery, NYHA class II, and use of angiotensin-converting enzyme inhibitors were associated with higher odds of CR referral. CR referral was associated with lower risk of acute all-cause readmission (OR: 0.92; 0.87-0.97) and all-cause mortality (OR: 0.65; 0.58-0.72).

CONCLUSION

Although increased over time, only one in two HF patients in Denmark were referred to CR in 2018. Strategies are needed to reduce referral disparities, focusing on subgroups of patients at highest risk of non-referral.

Differences in incident and recurrent myocardial infarction among White and Black individuals aged 35 to 84: Findings from the ARIC community surveillance study

BACKGROUND

No previous study has examined racial differences in recurrent acute myocardial infarction (AMI) in a community population. We aimed to examine racial differences in recurrent AMI risk, along with first AMI risk in a community population.

METHODS

The community surveillance of the Atherosclerosis Risk in Communities Study (2005-2014) included 470,000 people 35 to 84 years old in 4 U.S. communities. Hospitalizations for recurrent and first AMI were identified from ICD-9-CM discharge codes. Poisson regression models were used to compare recurrent and first AMI risk ratios between Black and White residents.

RESULTS

Recurrent and first AMI risk per 1,000 persons were 8.8 (95% CI, 8.3-9.2) and 20.7 (95% CI, 20.0-21.4) in Black men, 6.8 (95% CI, 6.5-7.0) and 14.1 (95% CI, 13.8-14.5) in White men, 5.3 (95% CI, 5.0-5.7) and 16.2 (95% CI, 15.6-16.8) in Black women, and 3.1 (95% CI, 3.0-3.3) and 8.8 (95% CI, 8.6-9.0) in White women, respectively. The age-adjusted risk ratios (RR) of recurrent AMI were higher in Black men vs White men (RR, 1.58 95% CI, 1.30-1.92) and Black women vs White women (RR, 2.09 95% CI, 1.64-2.66). The corresponding RRs were slightly lower for first AMI: Black men vs White men, RR, 1.49 (95% CI, 1.30-1.71) and Black women vs White women, RR, 1.65 (95% CI, 1.42-1.92) CONCLUSIONS: Large disparities exist by race for recurrent AMI risk in the community. The magnitude of disparities is stronger for recurrent events than for first events, and particularly among women.

Nurses' perspectives on the barriers to and facilitators of the implementation of secondary prevention for people with coronary heart disease: a qualitative descriptive study

OBJECTIVES

To identify the barriers to and facilitators of secondary prevention among people with coronary heart disease from the perspectives of nurses.

DESIGN

A qualitative descriptive design using face-to-face semistructured interviews.

SETTING

This study was conducted in China from October to November 2021.

PARTICIPANTS

Registered nurses who had experience conducting secondary prevention for coronary heart disease were purposively recruited. Twelve nurses from 10 hospitals participated in this study. The data were analysed using content analysis based on the Theoretical Domains Framework.

RESULTS

Based on the Theoretical Domains Framework, barriers to and facilitators of secondary prevention were identified within four key themes: nurse attributes (eg, knowledge and skills, motivation), patient characteristics (eg, age, education and economic conditions), the environmental context and resources (eg, organisational support, including financial support, clarity of responsibilities) and social influence (eg, economic development level, patient feedback).

CONCLUSIONS

This research highlights the importance of nurses' motivation for delivering preventive care. Organisations should provide adequate support and establish a quality management system to maintain the quality of secondary prevention.

Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease

IMPORTANCE

Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking.

OBJECTIVE

To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022.

EXPOSURES

Participation in 1 or more HBCR or CBCR sessions.

MAIN OUTCOMES AND MEASURES

The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics.

RESULTS

Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR.

CONCLUSIONS AND RELEVANCE

These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

Effects of telecardiac rehabilitation on coronary heart disease: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

We performed a meta-analysis to investigate the effectiveness of telecardiac rehabilitation compared to center-based rehabilitation on cardiorespiratory fitness, blood pressure, blood lipids, body composition, and quality of life in patients with coronary heart disease.

METHODS

We searched the Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase, and Scopus databases and retrieved studies published until October 8, 2021. Randomized controlled trials were included to evaluate cardiorespiratory fitness, blood pressure, blood lipids, body composition, and quality of life after telecardiac rehabilitation and center-based rehabilitation in patients with coronary heart disease. The criteria of the Cochrane Handbook for Systematic Reviews of Interventions were used to evaluate the methodological quality of the studies. Funnel plot analysis and Egger test were performed to confirm the publication bias.

RESULTS

A total of 8 studies, including 750 participants, reported the effectiveness of the telecardiac rehabilitation and center-based rehabilitation included in the analysis. Except for total cholesterol and mental quality of life (P < .05), all parameters were not significantly different between telecardiac rehabilitation and center-based rehabilitation (P > .05).

CONCLUSION

Telecardiac rehabilitation was similar to the effects of center-based rehabilitation. The overall prognosis of patients with coronary heart disease can be improved by increasing patients' participation in cardiac rehabilitation through telerehabilitation.

Racial and Ethnic Differences in Cardiac Rehabilitation Participation: Effect Modification by Household Income

Background

Cardiac rehabilitation (CR) is associated with improved cardiovascular outcomes. Racial and ethnic differences in CR have been identified, but whether income may attenuate these disparities remains unknown. We evaluated (1) racial/ethnic differences in CR participation in a contemporary sample of insured US adults, and (2) assessed how household income modifies associations between race or ethnicity and CR participation.

Methods and Results

We identified 107 199 individuals with a CR‐qualifying diagnosis between January 1, 2016 and December 31, 2018 in Optum’s de‐identified Clinformatics database. We evaluated associations between race or ethnicity and participation in CR, and assessed interaction between race or ethnicity and annual household income. The mean±SD age of all participants was 70.4±11.6 years; 37.4% were female and 76.0% were White race. Overall, 28 443 (26.5%) attended ≥1 CR sessions. After adjustment, compared with White individuals, the probability of attending CR was 31% lower for Asian individuals (95% CI, 27%–36%), 19% lower for Black individuals (95% CI, 16%–22%), and 43% lower for Hispanic individuals (95% CI, 40%–45%), all P<0.0001. The time to CR attendance was also significantly longer for Asian, Black, and Hispanic individuals. Associations between race or ethnicity and attendance at CR differed significantly across household income categories (P interaction=0.0005); however, Asian, Black, and Hispanic individuals were less likely to attend CR at all incomes.

Conclusions

In a geographically and racially diverse cohort, participation in CR was low overall, and was lowest among Asian, Black, and Hispanic candidates. Household income may impact the link between race or ethnicity and attendance at CR, but substantial racial and ethnic disparities exist across incomes.

Cost-effectiveness of an exercise-based cardiovascular rehabilitation program in patients with chronic Chagas cardiomyopathy in Brazil: An analysis from the PEACH study

OBJECTIVES

The present study aimed to perform a cost-effectiveness analysis of an exercise-based cardiovascular rehabilitation (CR) program in patients with chronic Chagas cardiomyopathy (CCC).

METHODS

Cost-effectiveness analysis alongside a randomised clinical trial evaluating the effects of a 6-month exercise-based CR program. The intervention group underwent 3 weekly exercise sessions. The variation of peak oxygen consumption (VO_2peak ) was used as a measurement of clinical outcome. Cost information from all healthcare expenses (examinations, healthcare visits, medication and hospitalisation) were obtained from the medical records in Brazilian reais (R$) and transformed into dollars using the purchasing power parity ($PPP). The longitudinal costs variation was evaluated through linear mixed models, represented by β coefficient, adjusted for the baseline values of the dependent variable. The cost-effectiveness evaluation was determined through an incremental cost-effectiveness ratio using the HEABS package (Stata 15.0).

RESULTS

The intervention group presented higher costs with healthcare visits (β = +3317.3; p < 0.001), hospitalisation (β = +2810.4; p = 0.02) and total cost (β = +6407.9; p < 0.001) after 3 months of follow-up. Costs related to healthcare visits (β = +2455.8; p < 0.001) and total cost (β = +4711.4; p < 0.001) remained higher in the intervention group after 6 months. The CR program showed an incremental cost-effectiveness ratio (ICER) of $PPP 1874.3 for each increase of 1.0 ml kg^-1  min^-1 of VO_2peak .

CONCLUSIONS

The CR program can be considered a cost-effective alternative and should be included as an intervention strategy in the care of patients with CCC.

Understanding Baseline Physical Activity in Cardiac Rehabilitation Enrollees Using Mobile Health Technologies

Background: Baseline physical activity in patients when they initiate cardiac rehabilitation is poorly understood. We used mobile health (mHealth) technology to understand baseline physical activity of patients initiating cardiac rehabilitation within a clinical trial to potentially inform personalized care. Methods: The Virtual AppLication-Supported ENvironment To INcrease Exercise During Cardiac Rehabilitation Study (VALENTINE) Study is a prospective, randomized-controlled, remotely administered trial designed to evaluate an mHealth intervention to supplement cardiac rehabilitation for low and moderate risk patients. All participants receive a smartwatch and usual care. Baseline physical activity was assessed remotely after enrollment and included 1) 6-minute walk distance, 2) daily step count, and 3) daily exercise minutes, both over 7 days and for compliant days, defined by ≥8 hours of watch wear time. Multivariable linear regression identified patient-level features associated with these 3 measures of baseline physical activity. Results: From October 2020 to March 2022, 220 participants enrolled in the study. Participants are mostly White [184 (83.6%)]; 67 (30.5%) are female and 84 (38.2%) are ≥ 65 years old. Most participants enrolled in cardiac rehabilitation after percutaneous coronary intervention [105 (47.7%)] or coronary artery bypass surgery [39 (17.7 %)]. Clinical diagnoses include coronary artery disease (78.6%), heart failure (17.3%), and valve repair or replacement (26.4%). Baseline mean 6-minute walk distance was 489.6 (standard deviation [SD], 143.4) meters, daily step count was 6845 (SD, 3353), and exercise minutes was 37.5 (SD, 33.5). In a multivariable model, 6-minute walk distance was significantly associated with age and sex, but not cardiac rehabilitation indication. Sex but not age or cardiac rehabilitation indication was significantly associated with daily step count and exercise minutes. Conclusions: Baseline physical activity varies substantially in low and moderate risk patients enrolled in cardiac rehabilitation. Future studies are warranted to explore whether personalizing cardiac rehabilitation programs using mHealth technologies could optimize recovery. Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT04587882.

Initial Psychometric Evidence of Physical Inactivity Perceived Experience Scale (Pipes): COVID-19 Pandemic as a Pilot Study

Aims

Our study aimed to develop a two-factor self-administered orthogonal questionnaire to assess the experience of perceived physical inactivity, to test its psychometric properties, to confirm its relationships with fear of COVID-19, and finally, with perceived stress during the pandemic.

Methods

A total of 481 Tunisian subjects collected in several cities, aged from 16 to 67 years with a mean age = 32.48 ± 9.46, and of both sexes participate in our study with (male: 51.8%) and (female: 48.2%), divided according to the level of study into three categories. All subjects voluntarily answered the PIPES questionnaire, the IPAQ scale, the COVID-19 fear scale and the PSS-10 test.

Results

The results of the exploratory and confirmatory factor analysis supported the robustness of the tool measure. In addition, examination of configurational, metric, scalar, and strict invariance supported the equivalence of the structure by gender and educational level. Concurrent validity was established by the positive association of a negative perception of physical inactivity with scores measured by the IPAQ scale and a negative association with scores of COVID-19 fear and perceived stress. Whereas, a positive perception of physical inactivity from the COVID-19 scale was negatively associated with the IPAQ and positively associated with fear of COVID-19 and perceived stress.

Conclusion

The PIPES-10 scale can be used to measure the perception of physical inactivity in different situations.

Prognostic value of functional capacity after transitional rehabilitation in older patients hospitalized for heart failure

Background

Poor functional status is highly prevalent among older patients hospitalized for HF and marks a downward inflection point in functional and prognostic trajectories. We assessed the prognostic value of 6‐min walk test after transitional cardiac rehabilitation in older patients hospitalized for heart failure (HF).

Methods

We studied 759 patients aged ≥60 years who had been transferred to six inpatient rehabilitation facilities (IRF) from acute care hospitals after a hospitalization for acute HF. The primary outcome was 3‐year all‐cause mortality. We used multivariable Cox analysis to determine the association between 6‐min walk distance (6MWD) at discharge from the IRFs and the primary outcome, adjusting for established predictors of death. The optimal cutoff for 6MWD was considered as the one that maximized the chi‐square statistic.

Results

Mean age was 75 ± 8 years. 6MWD significantly increased from admission to discharge (145 to 210 m; p < 0.001). The optimal cutoff for 6MWD was 198 m. After full adjustment, the hazard ratio for each 50 m‐increase in discharge 6MWD was 0.90 (0.87–0.94; p < 0.001) and that for discharge 6MWD dichotomized at the optimal cutoff 0.48 (0.38–0.60; p < 0.001). The incidence rate of death/100 person‐years for the patients who walked >198 m was 13.0 (10.0–15.5) compared with 30.8 (26.9–35.4) for those who walked <198 m. A statistically significant interaction of discharge 6MWD with left ventricular ejection fraction (EF) on the risk of death was observed (p value for interaction 0.047).

Conclusions

A rehabilitation intervention provided in the critical hospital‐to‐home transition period to older patients hospitalized for HF resulted in improved functional capacity. Increasing levels of functional capacity following rehabilitation were closely associated with decreasing risk of death; this association was significantly stronger for the subgroup with preserved EF.

Women Have Lower Mortality Than Men After Attending a Long-Term Medically Supervised Exercise Program

PURPOSE

Medically supervised exercise programs (MSEPs) are equally recommended for men and women with cardiovascular disease (CVD). Aware of the lower CVD mortality in women, we hypothesized that among patients attending a MSEP, women would also have better survival.

METHODS

Data from men and women, who were enrolled in a MSEP between 1994 and 2018, were retrospectively analyzed. Sessions included aerobic, resistance, flexibility and balance exercises, and cardiopulmonary exercise test was performed. Date and underlying cause of death were obtained. Kaplan-Meier methods and Cox proportional hazards regression were used for survival analysis.

RESULTS

A total of 2236 participants (66% men, age range 33-85 yr) attended a median of 52 (18, 172) exercise sessions, and 23% died during 11 (6, 16) yr of follow-up. In both sexes, CVD was the leading cause of death (39%). Overall, women had a more favorable clinical profile and a longer survival compared to men (HR = 0.71: 95% CI, 0.58-0.85; P < .01). When considering those with coronary artery disease and similar clinical profile, although women had a lower percentage of sex- and age-predicted maximal oxygen uptake at baseline than men (58 vs 78%; P < .01), after adjusting for age, women still had a better long-term survival (HR = 0.68: 95% CI, 0.49-0.93; P = .02).

CONCLUSION

Survival after attendance to a long-term MSEP was better among women, despite lower baseline cardiorespiratory fitness. Future studies should address whether men and women would similarly benefit when participating in an MSEP.

Sex Differences in Cardiac Rehabilitation Outcomes

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Cost-Effectiveness of Posthospital Management of Acute Coronary Syndrome: A Real-World Investigation From Italy

OBJECTIVES

This study aimed to assess the cost-effectiveness profile of adherence to recommendations for the community management of patients discharged with a diagnosis of acute coronary syndrome (ACS).

METHODS

The cohort of 50 282 residents in the Lombardy Region (Italy) who were discharged with a diagnosis of ACS during 2011 to 2015 was followed up until 2018. Adherence to selected recommendations including drug therapies (DTs), outpatient controls, and rehabilitation, experienced during the first year after index discharge, was considered. Adherent and nonadherent cohort members were matched on high-dimensional propensity scores. Composite clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and healthcare costs were assessed for a time horizon of 5 years. Cost-effectiveness profile of adherence to recommendations was measured through the incremental cost-effectiveness ratio, that is, the incremental cost for 1 day free from the composite clinical outcome.

RESULTS

Adherence to DTs, outpatient controls, and rehabilitation, respectively, regarded 39%, 81%, and 3% of cohort members. Compared with nonadherent patients, those adherent to DTs, outpatient controls, and rehabilitation had (1) a delay in the occurrence of the composite clinical outcome of 50, 43, and 73 days, respectively, and (2) lower (on average, €199 per year for DTs) and higher costs (€292 and €1024 for outpatient controls and rehabilitation). Cost-effectiveness profiles were better for patients with myocardial infarction than those with angina and for patients with more severe clinical complexity than those with milder conditions.

CONCLUSIONS

Health-related and economic benefits are expected from improving adherence to international guidelines recommendations concerning outpatient treatments and monitoring of patients with ACS.

Current role and future perspectives of cardiac rehabilitation in coronary heart disease

Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

Predictors of non-participation in a cardiac telerehabilitation programme: a prospective analysis

Aims

Current cardiac telerehabilitation (CTR) interventions are insufficiently tailored to the preferences and competences of individual patients, which raises the question whether their implementation will increase overall participation and adherence to cardiac rehabilitation (CR). However, research on patient-specific factors that influence participation and adoption of CTR interventions is scarce. The aim of this study was to evaluate which patient-related characteristics influence participation in a novel CTR intervention in patients with coronary artery disease.

Methods and results

This prospective observational substudy of the SmartCare-CAD randomized controlled trial evaluated patient characteristics of study participants as proxy for participation in a CTR intervention. We compared demographic, geographic, and health-related characteristics between trial participants and non-participants to determine which characteristics influenced trial participation. A total of 699 patients (300 participants and 399 non-participants; 84% male, mean age 64.3 ± 10.5 years) were included. Most of the non-participants refused participation because of insufficient technical skills or lack of interest in digital health (26%), or preferred centre-based CR (21%). Variables independently associated with non-participation included: higher age, lower educational level, shorter travelling distance, smoking, positive family history for cardiovascular disease, having undergone coronary artery bypass grafting; and a higher blood pressure, worse exercise capacity, and higher risk of depression before the start of CR.

Conclusion

Participation in CTR is strongly influenced by demographic and health-related factors such as age, educational level, smoking status, and both physical and mental functioning. Cardiac telerehabilitation interventions should therefore be redesigned with the involvement of these currently underrepresented patient subgroups.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cost-effectiveness of Cardiac Telerehabilitation With Relapse Prevention for the Treatment of Patients With Coronary Artery Disease in the Netherlands

Importance

Cardiac telerehabilitation (CTR) has been found to be a safe and beneficial alternative to traditional center-based cardiac rehabilitation (CR) and might be associated with higher participation rates by reducing barriers to CR use. However, implementation of CTR interventions remains low, which may be owing to a lack of cost-effectiveness analyses of data from large-scale randomized clinical trials.

Objective

To assess the cost-effectiveness of CTR with relapse prevention compared with center-based CR among patients with coronary artery disease.

Design, Setting, and Participants

This economic evaluation performed a cost-utility analysis of data from the SmartCare-CAD (Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform) randomized clinical trial. The cost-effectiveness and utility of 3 months of cardiac telerehabilitation followed by 9 months of relapse prevention were compared with the cost-effectiveness of traditional center-based cardiac rehabilitation. The analysis included 300 patients with stable coronary artery disease who received care at a CR center serving 2 general hospitals in the Netherlands between May 23, 2016, and July 26, 2018. All patients were entering phase 2 of outpatient CR and were followed up for 1 year (until August 14, 2019). Data were analyzed from September 21, 2020, to September 24, 2021.

Intervention

After baseline measurements were obtained, participants were randomly assigned on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group) using computerized block randomization. After 6 supervised center-based training sessions, patients in the intervention group continued training at home using a heart rate monitor and accelerometer. Patients uploaded heart rate and physical activity data and discussed their progress during a weekly video consultation with their physical therapist. After 3 months, weekly coaching was concluded, and on-demand coaching was initiated for relapse prevention; patients were instructed to continue using their wearable sensors and were contacted in cases of nonadherence to the intervention or reduced exercise or physical activity volumes.

Main Outcomes and Measures

Quality-adjusted life-years were assessed using the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS), and cardiac-associated health care costs and non-health care costs were measured by health care consumption, productivity, and informal care questionnaires (the Medical Consumption Questionnaire, the Productivity Cost Questionnaire, and the Valuation of Informal Care Questionnaire) designed by the Institute for Medical Technology Assessment. Costs were converted to 2020 price levels (in euros) using the Dutch consumer price index (to convert to US dollars, euro values were multiplied by 1.142, which was the mean exchange rate in 2020).

Results

Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life among patients receiving CTR vs center-based CR was comparable during the study according to the results of both utility measures (mean difference on EQ-5D-5L: -0.004; P = .82; mean difference on EQ-VAS: -0.001; P = .92). Intervention costs were significantly higher for CTR (mean [SE], €224 [€4] [$256 ($4)]) compared with center-based CR (mean [SE], €156 [€5] [$178 ($6)]; P < .001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], €4787 [€503] [$5467 ($574)] and center-based CR (mean [SE], €5507 [€659] [$6289 ($753)]; P = .36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], €20 495 [€ 2751] [$23 405 ($3142)] vs €24 381 [€3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-€3887 [-$4439]; P = .34).

Conclusions and Relevance

In this economic evaluation, a CTR intervention with relapse prevention was likely to be cost-effective compared with center-based CR, suggesting that CTR maybe used as an alternative intervention for the treatment of patients with coronary artery disease. These results add to the evidence base in favor of CTR and may increase the implementation of CTR interventions in clinical practice.

To what extent are comorbidity profiles associated with referral and uptake to cardiac rehabilitation

INTRODUCTION

Given the high proportion of comorbidities in patients with coronary heart disease (CHD) and low participation rates in cardiac rehabilitation (CR), a better understanding of how comorbidity interacts with the CR pathway is needed. We investigated associations between comorbidity profiles and referral and uptake in everyday clinical CR across UK.

METHOD

Patients (≥18 years) diagnosed with a CHD between 1st of January 2014 and 31st of December 2019 registered in the National Audit of Cardiac Rehabilitation (NACR) database were eligible. Self-reported comorbidities from 15 disease categories were conceptualized into similar or dissimilar based on overall related pathophysiologic profile and care management as CHD. Regression models were conducted with four comorbidity profiles; similar conditions, dissimilar conditions, similar and dissimilar and no comorbidity.

RESULTS

399,348 (61.8%) patients were eligible for referral from 198 programmes. The majority were males (70%), mean age of 67 (±12 SD) years. A non-significant association was found between comorbidity profiles and referral. Odds ratios (OR) for CR uptake were higher in patients with dissimilar (OR = 1.38 (95% CI 1.26-1.54)) and dissimilar and similar comorbidities profiles (OR = 1.35 (95% CI 1.21-1.43)) compared to patients with similar comorbidities. No significant differences in uptake were found between patients with similar comorbidities and those without comorbidities (OR = 0.985 (95% CI 0.854-1.125).

CONCLUSION

Using routine practice data, comorbidity profiles were not significantly associated with CR referral suggesting equality in referral. Dissimilar comorbidity profiles were associated with uptake. To increase the likelihood of starting CR, services should consider developing tailored participation strategies that include comorbidity profiles.

Impact of cardiorespiratory fitness on outcomes in cardiac rehabilitation

Cardiovascular rehabilitation (CR) significantly improves outcomes in patients with cardiovascular diseases (CVD), especially coronary heart disease and heart failure (HF). Although CR is often considered as an exercise training (ET) program for patients following CVD events, CR is more than just ET as it involves education, dietary and psychological counseling, as well as a multi-factorial risk factor modification. However, a major component of ET involves efforts to measure and improve levels of cardiorespiratory fitness (CRF). In this state-of-the-art review, we analyze the data, including from our John Ochsner Heart and Vascular Institute, evaluating CRF and its impact on psychological improvements and major outcomes with CR, especially long-term survival.

Exercise-based cardiac rehabilitation vs. percutaneous coronary intervention for chronic coronary syndrome: impact on morbidity and mortality

AIMS

Accumulating evidence questions the clinical value of percutaneous coronary intervention (PCI) for patients with chronic coronary syndrome (CCS). We therefore compare the impact of exercise-based cardiac rehabilitation (CR) vs. PCI in patients with CCS on 18-month mortality and morbidity, and evaluate the effects of combining PCI with exercise-based CR.

METHODS AND RESULTS

A retrospective cohort study was conducted in March 2021. An online, real-world dataset of CCS patients was acquired, utilizing TriNetX, a global federated health research network. Patients with CCS who received PCI were first compared with patients who were prescribed exercise-based CR. Second, we compared patients who received both CR + PCI vs. CR alone. For both comparisons, patients were propensity-score matched by age, sex, race, comorbidities, medications, and procedures. We ascertained 18-month incidence of all-cause mortality, rehospitalization, and cardiovascular comorbidity [stroke, acute myocardial infarction (AMI), and new-onset heart failure]. The initial cohort consisted of 18 383 CCS patients. Following propensity score matching, exercise-based CR was associated with significantly lower odds of all-cause mortality [0.37 (95% confidence interval (CI): 0.29-0.47)], rehospitalization [0.29 (95% CI: 0.27-0.32)], and cardiovascular morbidities, compared to PCI. Subsequently, patients that received both CR + PCI did not have significantly different odds for all-cause mortality [1.00 (95% CI: 0.63-1.60)], rehospitalization [1.00 (95% CI: 0.82-1.23)], AMI [1.11 (95% CI: 0.68-1.81)], and stroke [0.71 (95% CI: 0.39-1.31)], compared to CR only.

CONCLUSIONS

Compared to PCI, exercise-based CR associated with significantly lower odds of 18-month all-cause mortality, rehospitalization, and cardiovascular morbidity in patients with CCS, whilst combining PCI and exercise-based CR associated with lower incident heart failure only.

Wearable Cardioverter-Defibrillator-Measured Step Count for the Surveillance of Physical Fitness during Cardiac Rehabilitation

Background: The wearable cardioverter–defibrillator (WCD) has a built-in accelerometer, which allows tracking of patients’ physical activity by remote monitoring. It is unclear whether WCD-measured physical activity, step count, and heart rate correlate with established tools for the assessment of cardiopulmonary fitness such as the 6-min walk test (6MWT). Objective: To correlate measurements of patient physical activity through the WCD with a supervised 6MWT during in-patient cardiac rehabilitation (CR) and to allow their use as surrogate parameters of cardiopulmonary fitness in an out-patient setting. Methods: Consecutive patients with a history of WCD use treated at our center and an in-patient CR following an index hospitalization were included. Baseline characteristics, measurements of WCD accelerometer (median daily step count, median daily activity level), median daily heart rate, and clinically supervised 6MWT at admission and discharge of CR were obtained. Results: Forty-one patients with a mean age of 55.5 (±11.5) years were included. Thirty-five patients (85.4%) were male and 28 patients (68%) had a primary prophylactic WCD-indication. The most common underlying heart diseases were ischemic heart disease (24 patients 58.6%) and dilated cardiomyopathy (13 patients, 31.7%). Median CR duration was 20 (IQR 19.75–26.25) days. 6MWT distance increased from a mean of 329 m (±107) to 470 m (±116) during CR (p < 0.0001). The median daily step count and activity level increased significantly, from 5542 steps (IQR 3718–7055) to 8778 (IQR 6229–12,920, p < 0.0001) and median 117 × 10⁶ (IQR 96 × 10⁶–142 × 10⁶) threshold value exceedance (TVE) to 146 × 10⁶ TVE (IQR 110 × 10⁶–169 × 10⁶, p < 0.0001), respectively. The median heart rate was 74.9 bpm (IQR 65.8–84.5) and 70.2 (IQR 64.1–77.3, p = 0.09) at admission and discharge, respectively. Of all three parameters, median daily step count showed the best correlation to the results of the 6MWT at admission and discharge (r = 0.32, p = 0.04 and 0.37, p = 0.02, respectively). Conclusions: Remote monitoring of median daily step count as assessed by the WCD’s accelerometer showed positive correlation with the 6MWT and could serve as a surrogate for cardiopulmonary exercise capacity. Assessment of daily step count and activity level measured remotely by the WCD could help to tailor optimal exercise instruction for patients not attending CR.

Interhospital and interindividual variability in secondary prevention: a comparison of outpatients with a history of chronic coronary syndrome versus outpatients with a history of acute coronary syndrome (the iASPIRE Study)

Background

Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes.

Methods

We studied outpatients who had an index CHD event in the preceding 6–24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods.

Results

Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation.

Conclusions

Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

Cardiac rehabilitation for coronary artery disease: latest updates

PURPOSE OF REVIEW

To summarize recent innovations in cardiac rehabilitation and provide a view towards the future of cardiac rehabilitation as it adjusts to the pressures of a global pandemic.

RECENT FINDINGS

Although cardiac rehabilitation has been shown to result in a mortality benefit, research continues to enumerate the benefits of cardiac rehabilitation to patient function and quality of life in a growing range of cardiovascular diseases. In addition, new methodologies and new models of cardiac rehabilitation have emerged with the goal of increasing patient referral and participation.

SUMMARY

Cardiac rehabilitation continues to evolve and adapt to serve a growing and diversifying number of patients with cardiovascular disease with the goal of both decreasing mortality and improving patient function.

Novel advances in cardiac rehabilitation : Position paper from the Working Group on Preventive Cardiology and Cardiac Rehabilitation of the Netherlands Society of Cardiology

Cardiac rehabilitation (CR) has evolved as an important part of the treatment of patients with cardiovascular disease. However, to date, its full potential is fairly underutilised. This review discusses new developments in CR aimed at improving participation rates and long-term effectiveness in the general cardiac population. It consecutively highlights new or challenging target groups, new delivery modes and new care pathways for CR programmes. These new or challenging target groups include patients with atrial fibrillation, obesity and cardiovascular disease, chronic coronary syndromes, (advanced) chronic heart failure with or without intracardiac devices, women and frail elderly patients. Also, the current evidence regarding cardiac telerehabilitation and loyalty programmes is discussed as new delivery modes for CR. Finally, this paper discusses novel care pathways with the integration of CR in residual risk management and transmural care pathways. These new developments can help to make optimal use of the benefits of CR. Therefore we should seize the opportunities to reshape current CR programmes, broaden their applicability and incorporate them into or combine them with other cardiovascular care programmes/pathways.

Exercise-Based Cardiac Rehabilitation and All-Cause Mortality Among Patients With Atrial Fibrillation

Background

There is limited evidence of long‐term impact of exercise‐based cardiac rehabilitation (CR) on clinical end points for patients with atrial fibrillation (AF). We therefore compared 18‐month all‐cause mortality, hospitalization, stroke, and heart failure in patients with AF and an electronic medical record of exercise‐based CR to matched controls.

Methods and Results

This retrospective cohort study included patient data obtained on February 3, 2021 from a global federated health research network. Patients with AF undergoing exercise‐based CR were propensity‐score matched to patients with AF without exercise‐based CR by age, sex, race, comorbidities, cardiovascular procedures, and cardiovascular medication. We ascertained 18‐month incidence of all‐cause mortality, hospitalization, stroke, and heart failure. Of 1 366 422 patients with AF, 11 947 patients had an electronic medical record of exercise‐based CR within 6‐months of incident AF who were propensity‐score matched with 11 947 patients with AF without CR. Exercise‐based CR was associated with 68% lower odds of all‐cause mortality (odds ratio, 0.32; 95% CI, 0.29–0.35), 44% lower odds of rehospitalization (0.56; 95% CI, 0.53–0.59), and 16% lower odds of incident stroke (0.84; 95% CI, 0.72–0.99) compared with propensity‐score matched controls. No significant associations were shown for incident heart failure (0.93; 95% CI, 0.84–1.04). The beneficial association of exercise‐based CR on all‐cause mortality was independent of sex, older age, comorbidities, and AF subtype.

Conclusions

Exercise‐based CR among patients with incident AF was associated with lower odds of all‐cause mortality, rehospitalization, and incident stroke at 18‐month follow‐up, supporting the provision of exercise‐based CR for patients with AF.