Cardiac rehabilitation: Effective yet underutilized in patients with cardiovascular disease

Position Statement of the Italian Society of Cardiovascular Prevention (SIPREC) and Italian Heart Failure Association (ITAHFA) on Cardiac Rehabilitation and Protection Programs as a Cornerstone of Secondary Prevention after Myocardial Infarction or Revascularization

Despite the remarkable and progressive advances made in the prevention and management of cardiovascular diseases, the recurrence of cardiovascular events remains unacceptably elevated with a notable size of the residual risk. Indeed, in patients who suffered from myocardial infarction or who underwent percutaneous or surgical myocardial revascularization, life-style changes and optimized pharmacological therapy with antiplatelet drugs, lipid lowering agents, beta-blockers, renin angiotensin system inhibitors and antidiabetic drugs, when appropriate, are systematically prescribed but they might be insufficient to protect from further events. In such a context, an increasing body of evidence supports the benefits of cardiac rehabilitation (CR) in the setting of secondary cardiovascular prevention, consisting in the reduction of myocardial oxygen demands, in the inhibition of atherosclerotic plaque progression and in an improvement of exercise performance, quality of life and survival. However, prescription and implementation of CR programs is still not sufficiently considered.The aim of this position paper of the Italian Society of Cardiovascular Prevention (SIPREC) and of the Italian Heart Failure Association (ITAHFA) is to examine the reasons of the insufficient use of this strategy in clinical practice and to propose some feasible solutions to overcome this clinical gap.

Efficacy of the Simulation-Based Education Approach Enhanced by Music on Anxiety, Physical Activity, and Respiratory Outcomes in Patients under Open Heart Surgery: A Randomized Three-Group Clinical Study

Background

Many patients with advanced cardiovascular disease need Coronary Artery Bypass Graft (CABG) surgery, indicating the importance of cardiac rehabilitation. Our study explored the combined efficacy of simulation (using demonstration and return-demonstration approach) with music on post-Open Heart Surgery (OHS) outcomes.

Materials and Methods

This randomized, controlled trial was conducted at Imam Reza Hospital, Mashhad, Iran, on 90 patients awaiting OHS. The participants were allocated to 3 groups: education via simulation, education via simulation enhanced by instrumental music, and conventional instruction. Evaluations were performed pre-education and 2-days post-surgery using the activity measure for post-acute care (AM-PAC) "6-Clicks" Questionnaire, 18-item Nursing Outcomes Classification (NOC) index, and State-Trait Anxiety Inventory (STAI). JASP software (JASP Team, 2023, Version 0.17.3) was employed for statistical analyses, using RM-ANOVA and ANCOVA test.

Results

The results revealed a significant effect in immediate post-intervention and 2-day follow-up periods across all outcome measures (all p < 0.05), except for activity. Post hoc tests demonstrated substantial variations in effect sizes between intervention and control groups. Both intervention groups had significantly greater impact than the control group, particularly the composite group, showing heightened effects in state and trait anxiety and respiratory scores (p < 0.05).

Conclusions

The combined use of the simulation with rhythmic music in phase one cardiac rehabilitation notably improved post-surgical outcomes, outperforming the method without music. This approach shows promise as an effective instructional strategy in cardiac rehabilitation stages.

Increasing Access to Cardiac Rehabilitation Services Among Disadvantaged Populations

The Prince George's County Health Department encountered several challenges to increasing access to cardiac rehabilitation (CR) services among disadvantaged populations. They include excessive patient out-of-pocket costs; requirements that CR orders must be signed by a physician; provider reluctance to refer patients to CR, with most primary care providers preferring to refer clients to cardiologists for the latter to determine whether the patient needs CR referral; limited availability of CR programs; and difficulty identifying patients eligible for CR services. Discussions with other local health departments and public health practitioners indicate that these challenges are not unique to Maryland but are indicative of policy and system barriers that prevent the optimal delivery of cardiovascular health services. This practice report documents the challenges and the Prince George's County Health Department's efforts to resolve them and provides recommendations for decision-makers seeking to make CR programs more accessible to disadvantaged populations.

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

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

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

VIDEO ABSTRACT

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

A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation

OBJECTIVE

The aim of this study was to systematically review the impact and characteristics of interventions with an educational component designed to improve enrollment and participation in cardiac rehabilitation (CR) among patients with cardiovascular disease.

REVIEW METHODS

Five electronic databases were searched from data inception to February 2023. Randomized controlled trials and controlled, cohort, and case-control studies were considered for inclusion. Title, abstract, and full text of records were screened by two independent reviewers. The quality of included studies was rated using the Mixed Methods Assessment Tool. Results were analyzed in accordance with the Synthesis Without Meta-analysis reporting guideline.

RESULTS

From 7601 initial records, 13 studies were included, six of which were randomized controlled trials ("high" quality = 53%). Two studies evaluated interventions with an educational component for health care providers (multidisciplinary team) and 11 evaluated interventions for patient participants (n = 2678). These interventions were delivered in a hybrid (n = 6; 46%), in-person (n = 4; 30%), or virtual (n = 3; 23%) environment, mainly by nurses (n = 4; 30%) via discussion and orientation. Only three studies described the inclusion of printed or electronic materials (eg, pamphlets) to support the education. Eleven of 12 studies reported that patients who participated in interventions with an educational component or were cared for by health care providers who were educated about CR benefits (inhospital and/or after discharge) were more likely to enroll and participate in CR.

CONCLUSION

Interventions with an educational component for patients or health care providers play an important role in increasing CR enrollment and participation and should be pursued. Studies investigating the effects of such interventions in people from ethnic minority groups and living in low-and-middle-income countries, as well as the development of standard educational materials are recommended.

Development and application of a home-based exercise program for patients with cardiovascular disease: a feasibility study

BACKGROUND

Cardiac rehabilitation (CR) is recommended for patients with cardiovascular disease. However, the participation and completion rates for hospital-based CR are low, and home-based CR has been suggested as an alternative. This study aimed to develop a home-based CR program and assess the feasibility of the program over a 6-week period in patients with left ventricular dysfunction or a history of myocardial infarction.

METHODS

This feasibility study consisted of two phases. The initial phase (Study 1) focused on developing the home-based exercise protocol. Systematic approaches to developing evidence-based home-based exercise intervention were implemented including systematic review, patient surveys, and expert consensus. Study 2 aimed to evaluate the feasibility of a 6-week home-based CR program that was based on the results of Study 1. Study 2 included two exercise education sessions and four telephone counseling sessions. During this stage of the exercise program, the participants exercised on two separate days and their experiences while performing the aerobic and resistance exercises were surveyed. Eight participants participated in Study 1 and 16 participated in Study 2.

RESULTS

Participants expressed overall satisfaction with the exercise program in Study 1. Heart rate increased in response to exercise, but this did not correspond with perceived exertion. The aim of the home-based CR exercise program was for participants to achieve exercise goals (≥150 min/week of aerobic type exercises as well as at least twice weekly resistance exercise using own body weights). We aimed to increase compliance and adherence to the home-based CR program. In Study 2, 13 out of 16 participants (81.3%) completed the 6-week home-based CR program, with a participation rate of 100% in both exercise education and phone counseling sessions. Adherence to the home-based exercise protocol was 83.1% and no serious adverse events were observed. At the beginning of the study, only three out of 13 participants (23.1%) met the requirements for both aerobic and resistance exercises, but at the end of the 6-week program, 10 out of 13 participants (76.9%) fulfilled the requirements.

CONCLUSION

The exercise program developed in this study was safe and feasible, and the 6-week home-based CR program was feasible for patients with cardiovascular disease without any reported adverse effects.

Impact of wearable device-based interventions with feedback for increasing daily walking activity and physical capacities in cardiovascular patients: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To systematically review randomised controlled trials (RCTs) using a wearable physical activity monitoring device as an intervention to increase daily walking activity and improve physical capacities in patients with cardiovascular disease (CVD).

DESIGN

Systematic review and meta-analysis of RCTs.

DATA SOURCES

PubMed, Embase and Web of Science from inception to June 2022.

ELIGIBILITY CRITERIA

Randomised controlled studies including patients with CVD over 18 years of age at the end of a cardiac rehabilitation programme comparing an intervention group using a wearable physical activity monitoring device with feedback with usual care or with a control group receiving no feedback on their physical activity and reporting a change in the daily number of steps and/or a change in the distance covered in the 6-minute walk test (6-MWT) or a change in peak oxygen uptake (V̇O2_peak) as endpoints.

RESULTS

Sixteen RCTs were included. The intervention of wearing a physical activity monitoring device with feedback significantly improved daily number of steps compared with controls (standardised mean difference (SMD) 0.85; 95% CI (0.42; 1.27); p<0.01). The effect was greater when the duration of the intervention was less than 3 months (SMD 1.0; 95% CI (0.18; 1.82); p<0.01) than when the duration of the intervention was 3 months or longer (SMD 0.71; 95% CI (0.27; 1.16); p<0.01), but no significant interaction was found between subgroups (p=0.55). 6-MWT distance and V̇O2_peak showed only small effects (SMD 0.34; 95% CI (-0.11; 0.80); p=0.02 and SMD 0.54; 95% CI (0.03; 1.03); p=0.07, respectively).

CONCLUSION

The use of wearable physical activity monitoring devices appears to help patients with CVD to increase their daily walking activity and thus their physical activity, particularly in the short term.

PROSPERO REGISTRATION NUMBER

CRD42022300423.