Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: A systematic review and meta-analysis

Exercise-based cardiac rehabilitation for patients with coronary heart disease: a systematic review and evidence mapping study

INTRODUCTION

Exercise-based cardiac rehabilitation (CR) plays a critical role in coronary heart disease (CHD) management. There is a heritage in the effect of exercise-based CR with different exercise programs or intervention settings. This study developed an evidence matrix that systematically assesses, organizes, and presents the available evidence regarding exercise-based CR in CHD management.

EVIDENCE ACQUISITION

A comprehensive literature search was conducted across six databases. Two reviewers screened the identified literature, extracted relevant data, and assessed the quality of the studies. An evidence-mapping framework was established to present the findings in a structured manner. Bubble charts were used to represent the included systematic reviews (SRs). The charts incorporated information, exercise prescriptions, outcome indicators, associated P values, research quality, and the number of original studies. A descriptive analysis summarized the types of CR, intervention settings, influential factors, and adverse events.

EVIDENCE SYNTHESIS

Sixty-two SRs were included in this analysis, focusing on six exercise types in addition to assessing major adverse cardiovascular events (MACE), cost and rehabilitation outcomes. The most commonly studied exercise types were unspecified (28 studies, 45.2%) and aerobic (11 studies, 17.7%) exercises. All-cause mortality was the most frequently reported MACE outcome (22 studies). Rehabilitation outcomes primarily centered around changes in cardiac function (135 outcomes from 39 SRs). Only 8 (12.9%) studies were rated as "high quality." No significant adverse events were observed in the intervention group. Despite some variations among the included studies, most SRs demonstrated the benefits of exercise in improving one or more MACE or rehabilitation outcomes among CHD patients.

CONCLUSIONS

The proportion of high-quality evidence remains relatively low. Limited evidence is available regarding the effectiveness of specific exercise types and specific populations, necessitating further evaluation.

A behavioural driving model of adherence to home-based cardiac rehabilitation exercise among patients with chronic heart failure: A mixed-methods study

AIMS AND OBJECTIVES

To develop and validate a behavioural driving model for adherence to home-based cardiac rehabilitation exercise in patients with chronic heart failure, and to explain the potential driving mechanism of social support on exercise adherence.

BACKGROUND

Despite the benefits of home-based cardiac rehabilitation exercise, adherence among patients with chronic heart failure remains suboptimal. Several factors contributing to adherence have been confirmed; however, the specific pathway mechanisms by which these factors impact exercise adherence have not been thoroughly explored.

DESIGN

An exploratory sequential mixed-methods study was conducted in this study.

METHODS

A total of 226 patients with chronic heart failure were recruited using convenience sampling. Quantitative data were collected using a series of self-report questionnaires. Hierarchical regression analysis was performed to verify multiple pathways. Subsequently, 12 patients with chronic heart failure were drawn from the quantitative stage. The interview data were thematically analysed. This study followed the Good Reporting of a Mixed Methods Study (GRAMMS) guidelines (Appendix S1).

RESULTS

Perceived social support had a direct positive predictive effect on exercise adherence. Importantly, exercise self-efficacy and exercise fear played a chain-mediating role between perceived social support and exercise adherence. As a result of the qualitative phase, scale, tightness and homogeneity of social support networks emerged as potential drivers of the effectiveness of social support on exercise adherence.

CONCLUSIONS

This study reveals a potential pathway mechanism for social support to improve adherence to home-based cardiac rehabilitation exercises. Social support network plays a crucial role in the effect of social support on exercise adherence.

RELEVANCE TO CLINICAL PRACTICE

To enhance exercise adherence in home-based cardiac rehabilitation for patients with chronic heart failure, establishing a social support network is recommended. This strategy has the potential to promote exercise self-efficacy and alleviate exercise fear.

PATIENT OR PUBLIC CONTRIBUTION

None.

Monitored home-based with or without face-to-face exercise for maternal mental health during the COVID-19 pandemic

INTRODUCTION

Despite the known beneficial effects of exercise, most pregnant women do not exercise regularly. Most studies on exercise have been conducted on supervised exercise and there is limited evidence regarding the adherence and effect of other exercise programs on pregnancy outcomes. Therefore, we aimed to investigate adherence to a face-to-face plus monitored home exercise program versus a monitored home-based exercise program on its own during pregnancy. In addition, effects of these two exercise programs on women's mental health during pregnancy and postpartum (primary outcomes) and on some other maternal and neonatal outcomes (secondary outcomes) will be assessed.

METHODS

In this superiority trial with three parallel arms, 150 women at 12-18 weeks of gestation will be randomised equally into three groups (face-to-face plus monitored home exercise, only monitored home-based exercise, and control). The exercise programs will be performed up to the 38th week of gestation during which participants will be assessed at specific intervals during the pregnancy, and post-partum and followed up until six months after childbirth. The exercise diary will be used to assess the adherence. The Edinburgh Depression Scale and the Positive and Negative Affect Schedule will be used to assess prenatal and postnatal depression and affect, respectively.

DISCUSSION

This study reflects the feasibility and acceptance of two exercise programs for pregnant women and their effects on important outcomes. If these programs are followed properly and effectively, pregnant women's health can be improved using these methods at a lower cost compared to the conventional supervised exercise program.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.

OBJECTIVES

To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

MAIN RESULTS

We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.

Effect of Home-Based Cardiac Rehabilitation Program on Self-Efficacy of Patients With Implantable Cardioverter Defibrillator

Introduction

For more effective control and treatment of cardiac dysrhythmias caused by diseases, ischemia, or other causes, an implantable cardioverter defibrillator (ICD) is used. One of the effective ways for secondary prevention is the home-based cardiac rehabilitation (HBCR) which nurses have an effective role in its implementation.

Objective

The study aimed to investigate the effect of implementing HBCR programs on the self-efficacy of patients with ICD.

Methods

This is a semi-experimental study conducted on 70 patients who received ICD in Shahid Chamran Heart Center of Isfahan University of Medical Sciences (IUMS) in 2021. The patients were randomly assigned to intervention and control groups and were introduced to the practical concepts of HBCR during four training sessions. In the following, 3-month follow-up and trainings were continued by home visits, telephone follow-up, and use of social messaging networks due to the conditions of coronavirus disease 2019 (COVID-19) pandemic. The data were analyzed with SPSS/21.

Results

The findings showed that performing HBCR programs was effective in improving the self-efficacy of patients with ICDs. A significant trend in the implementation of the HBCR programs in two groups was shown using chi-square test and independent t-test and variance with repeated measurements (p < .001). There was no significant difference in self-efficacy score in both groups at the beginning of the study (p < .056).

Conclusion

Considering the effectiveness of HBCR programs on improving the self-efficacy of patients with ICDs, it can be used in the educational care programs of healthcare workers and in the strategic policies of health care services.

The feasibility of smartphone-based application on cardiac rehabilitation for Chinese patients with percutaneous coronary intervention in Macau: a qualitative evaluation

BACKGROUND

To improve cardiovascular risk factors modification and effects of cardiac rehabilitation (CR), electronic applications on CR are suggested in the literature for patients after percutaneous coronary intervention (PCI).

METHODS

A sequential qualitative study, embedded in a quantitative experimental trial for mHealth application on CR (mCR) study evaluation, was conducted to understand the usability and satisfaction of mCR study. Purposive sampling were used until achieving data saturation. Individually semi-structured interviews were conducted. The textual narration from interview transcriptions were analysed by content analysis.

RESULTS

Ten participants were interviewed for qualitative evaluation. Findings presented the perceptive and experience of the mCR app users. Results were captured by four themes: 1. feasibility of mCR app, including practicality, acceptability and convenience, and barriers to use; 2. benefits from mCR app, explaining the effectiveness of mCR study; 3. advocator for better hospital care, disclosing an extension of healthcare and promoting patient-healthcarer relationship; and 4. recommendation for mCR app improvement.

CONCLUSION

Findings provided insights for cardiac healthcare providers to understand the feasibility of mHealth application on phase II CR in Macau. The mCR app facilitated CR engagement which contributed to health and well-being by promoting CHD and CR knowledge, and cardiac healthy lifestyle modification.

The effect of nonsupervised physical activity before and after breast cancer surgery on quality of life: Results from a randomized controlled trial (PhysSURG-B)

Background and objective:

The PhysSURG-B trial of prehabilitation before breast cancer surgery randomized patients to a nonsupervised physical activity or a control group. The effects of the intervention on short- and long-term quality of life (QoL) were examined, with a subgroup analysis of patients receiving adjuvant chemotherapy.

Methods:

Female patients planned for surgery were randomly assigned to either an intervention of 30 min of self-administered physical aerobic activity daily 2 weeks before and 4 weeks after surgery or control. QoL was assessed with questionnaires at baseline, 4 weeks and 12 months postoperatively using the instruments FACT-B, RAND-36, and EQ-VAS.

Results:

Of 354 included participants at 12 months after surgery, 287 were available for analysis. FACT- B scores at 4 weeks and 12 months showed no differences between intervention compared to control, odds ratio (OR) of 0.975 (95% confidence interval (CI) 0.636–1.495) and 0.883 (95% CI 0.581–1.342), respectively. There was no difference in EQ-VAS comparing intervention to control at 4 weeks and 12 months, respectively, OR 1.163 (95% CI 0.760–1.779) and 0.817 (95% CI 0.559–1.300). RAND-36 domains “role limitations due to physical health” and “pain” showed a decrease at 4 weeks in both groups, returning toward baseline at 12 months follow-up. The subgroup who received adjuvant chemotherapy had significantly lower QoL measured using FACT-B at 12 months compared to patients not receiving chemotherapy (OR 0.475; 95% CI 0.300–0.753).

Conclusions:

An intervention of non-supervised physical activity before and after surgery for breast cancer showed no effect on short or long-term QoL, compared to control.

Trial registration:

ClinicalTrials.gov registration number: NCT 02560662.

The Effects of Physical Exercise on the Quality of Life of Healthy Older Adults in China: A Systematic Review

Objective

To systematically evaluate the effects of physical exercise on the quality of life (QOL) of healthy older adults in China.

Methods

Relevant articles published until December 2021 were retrieved from China National Knowledge Infrastructure, Wanfang, China Science and Technology Journal Database, PubMed, EBSCO, Web of Science, and the Library of Congress. Inclusion criteria were studies in which the subjects were healthy Chinese older adults (aged ≥ 60 years), the reported sample size was clear, and the study design was a randomized controlled trial or a research study. In addition, studies were included if they reported the use of at least one QOL questionnaire and investigated at least one form of physical exercise.

Results

In total, 19 studies met the inclusion criteria, which included six studies that used comprehensive physical exercise type as an intervention and 13 studies that used regular physical exercise as an intervention. All 19 studies compared intervention and control groups, of which 12 (63%) were investigative studies and seven (37%) were experimental studies. Of the experimental studies, five used a positive control group and two used a negative control group. All 19 studies reported that physical exercise had varying degrees of positive effects on the QOL in older adults. Body-mind exercise was effective in improving the physical and mental health (MH) of older adults, whereas Xiyangcao only had a positive effect on physical health. Compared with no exercise or other exercise (exercise not used in the intervention group), the exercise group in the survey had a positive effect on the QOL of older adults. Regardless of the type of control group used, the exercise group in the experimental studies showed a positive effect of exercise on the QOL of older adults.

Conclusion

Physical exercise has a positive impact on the QOL of healthy older adults. However, due to the wide and varied scope of the included studies, more randomized controlled trials are needed to examine the effects of different types, intensities, durations, and the frequency of exercise on QOL.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=220115], identifier: [CRD42020220115].

Cardiac rehabilitation for older adults: current evidence and future potential

INTRODUCTION

Growth of the older adult demographic has resulted in an increased number of older patients with cardiovascular disease (CVD) in combination with comorbid diseases and geriatric syndromes. Cardiac rehabilitation (CR) is utilized to promote recovery and improve outcomes, but remains underutilized, particularly by older adults. CR provides an opportunity to address the distinctive needs of older adults, with focus on CVD as well as geriatric domains that often dominate management and outcomes.

AREAS COVERED

Utility of CR for CVD in older adults as well as pertinent geriatric syndromes (e.g. multimorbidity, frailty, polypharmacy, cognitive decline, psychosocial stress, and diminished function) that affect CVD management.

EXPERT OPINION

Mounting data substantiate the importance of CR as part of recovery for older adults with CVD. The application of CR as a standard therapy is especially important as the combination of CVD and geriatric syndromes catalyzes functional decline and can trigger progressive clinical deterioration and dependency. While benefits of CR for older adults with CVD are already evident, further reengineering of CR is necessary to better address the needs of older candidates who may be frail, especially as remote and hybrid formats of CR are becoming more widespread.

Effects of Supervised Cardiac Rehabilitation Programmes on Quality of Life among Myocardial Infarction Patients: A Systematic Review and Meta-Analysis

Coronary heart disease is the leading cause of death and disability worldwide. Traditionally, cardiac rehabilitation programmes are offered after cardiac events to aid recovery, improve quality of life, and reduce adverse events. The objective of this review was to assess the health-related quality of life, after a supervised cardiac rehabilitation programme, of patients who suffered a myocardial infarction. A systematic review was carried out in the CINAHL, Cochrane, LILACS, Medline, Scopus, and SciELO databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomised controlled trials were selected. Meta-analyses were performed for the Short Form Health Survey SF-36, Myocardial Infarction Dimensional Assessment Scale (MIDAS), MacNew Heart Disease-Health-Related Quality of Life (HRQL) questionnaire, and European Quality of Life-Visual Analogue Scale (EuroQol-VAS) with the software Cochrane RevMan Web. Ten articles were found covering a total of 3577 patients. In the meta-analysis, the effect size of the cardiac rehabilitation programme was statistically significant in the intervention group for physical activity, emotional reaction, and dependency dimensions of the MIDAS questionnaire. For the control group, the score improved for SF-36 physical functioning, and body pain dimensions. The mean difference between the control and intervention group was not significant for the remaining dimensions, and neither for the MacNew Heart Disease-HRQL and EuroQol-VAS questionnaires. Supervised cardiac rehabilitation programmes were effective in improving health-related quality of life, however, there was a potential variability in the interventions; therefore, the results should be interpreted with caution. This study supports the importance of providing care and evaluating interventions via the supervision of trained health professionals, and further randomised clinical trials are needed to analyse the positive changes in mental and physical health outcomes.

Efficacy and Safety of Remote Cardiac Rehabilitation in the Recovery Phase of Cardiovascular Diseases: Protocol for a Multicenter, Nonrandomized, Single-Arm, Interventional Trial

Background

Conventional group-based outpatient cardiac rehabilitation through monitoring and center-based approaches for patients in the recovery phase has shown strong evidence for the prevention of cardiovascular diseases. However, there are some cases in which maintaining attendance of center-based cardiac rehabilitation is difficult.

Objective

This study aims to ascertain the safety and efficacy of remote cardiac rehabilitation (RCR) in the recovery phase in patients with cardiovascular disease.

Methods

Patients satisfying the study criteria will be recruited from multiple institutions (approximately 30) across Japan. In total, 75 patients (approximately 2 or 3 patients from each institution) are proposed to be recruited. Patients enrolled in the RCR group will be lent devices necessary for RCR (including calibrated ergometers and tablets). Patients will perform anaerobic exercise at home using ergometer for 30-40 minutes at least 3 times weekly. During exercise, an instructor will monitor the patient in real time (using interactive video tools and monitoring tools for various vital data). Moreover, educational instructions will be given 3 times weekly using e-learning methods.

Results

The primary endpoint is the peak oxygen uptake 2-3 months from the start of exercise or 6-min walk test. The extracted data will be compared between RCR patients and controls without RCR.

Conclusions

The establishment of the system of RCR proposed in this study will lead to the development of more extensive applications, which have been insufficient through conventional interventions.

Trial Registration

University Hospital Medical Information Network—Clinical Trials Registry UMIN–CTR UMIN000042942; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000048983

International Registered Report Identifier (IRRID)

DERR1-10.2196/30725

Effect of Exercise-Based Cardiac Rehabilitation on Left Ventricular Function in Asian Patients with Acute Myocardial Infarction after Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

(1) Background: The effects of exercise-based cardiac rehabilitation (CR) on left ventricular function in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) are important but poorly understood. (2) Purpose: To evaluate the effects of an exercise-based CR program (exercise training alone or combined with psychosocial or educational interventions) compared with usual care on left ventricular function in patients with AMI receiving PCI. (3) Data sources, study selection and data extraction: We searched PubMed, WEB OF SCIENCE, EMBASE, EBSCO, PsycINFO, LILACS and Cochrane Central Register of Controlled Trials databases (CENTRAL) up to 12th June 2021. Article selected were randomized controlled trials and published as a full-text article. Meta-analysis was conducted with the use of the software Review manager 5.4. (4) Data synthesis: Eight trials were included in the meta-analysis, of which three trials were rated as high risk of bias. A significant improvement was seen in the exercise-based CR group compared with the control group regarding left ventricular ejection fraction (LVEF) (std. mean difference = 1.33; 95% CI:0.43 to 2.23; p = 0.004), left ventricular end-diastolic dimension (LVEDD) (std. mean difference = −3.05; 95% CI: −6.00 to −0.09; p = 0.04) and left ventricular end-systolic volume (LVESV) (std. mean difference = −0.40; 95% CI: −0.80 to −0.01; p = 0.04). Although exercise-based CR had no statistical effect in decreasing left ventricular end-systolic dimension (LVESD) and left ventricular end-diastolic volume (LVEDV), it showed a favorable trend in relation to both. (5) Conclusions: Exercise-based CR has beneficial effects on LV function and remodeling in AMI patients treated by PCI.

Symptoms of Depression and Anxiety in Patients With Type 2 Diabetes in a Canadian Outpatient Cardiac Rehabilitation Program

PURPOSE

The objective of this study was to determine whether type 2 diabetes status is associated with an increased likelihood of depressed mood and anxiety in patients attending cardiac rehabilitation (CR) and to explore predictors of depression and anxiety after CR completion in patients with diabetes.

METHODS

A retrospective analysis was conducted in patients who completed a 12-wk CR program between 2002 and 2016. Patients were classified as reporting normal-to-mild or moderate-to-severe symptoms of depression and anxiety using the Hospital Anxiety and Depression Scale (HADS). Logistic regression models were used to compare predictors of depression and anxiety prior to CR enrollment and investigate predictors of post-CR HADS scores among a subset of patients with diabetes.

RESULTS

Data from 6746 patients (mean age 61 ± 11 yr, 18% female, 18% with diabetes) were analyzed. After controlling for known predictors of depression, patients with diabetes were not more likely to report moderate-to-severe levels of depression prior to or after completing CR. In patients with diabetes, younger age predicted moderate-to-severe depression post-CR (OR = 0.95: 95% CI, 0.93-0.98). Patients with diabetes were also more likely to report moderate-to-severe levels of anxiety after completing CR (OR = 1.45: 95% CI, 1.02-2.07). Younger age (OR = 0.93: 95% CI, 0.88-0.97) and smoking status (OR = 3.3: 95% CI, 1.15-7.06) predicted moderate-to-severe post-CR anxiety in patients with diabetes.

CONCLUSIONS

Patients with diabetes, particularly younger patients who currently smoke or recently quit, are more likely to report having anxiety following CR. These patients may therefore require additional management of anxiety symptoms during CR. Larger studies of CR patients with diabetes and more variable depression and anxiety levels are needed.

Home-Based Cardiac Rehabilitation: EXPERIENCE FROM THE VETERANS AFFAIRS

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of e-Health cardiac rehabilitation program on quality of life associated with symptoms of anxiety and depression in moderate-risk patients

Exploring new models of medical care requires evaluating the impact of new care strategies not only on physiological parameters but also on the quality of life of the patient. On the other hand the presence of anxiety together with depression requires further consideration when planning appropriate management strategies. The aim of this study was to examine the effectiveness of a home-based cardiac rehabilitation program incorporating an e-Health technology on health-related quality of life associated with symptoms of anxiety and depression in moderate-risk patients. A multicenter, randomized controlled clinical trial was designed to compare a traditional hospital based cardiac rehabilitation program (n = 38, 35 male) with a mixed home surveillance program where patients exercised at home with a remote electrocardiographic monitoring device (n = 33, 31 male). The Short Form-36 (SF-36) Health Survey and the Goldberg questionnaire were used to evaluate quality of life and the presence of symptoms of anxiety and depression respectively. The results of this study show that the type of cardiac rehabilitation program did not influence the improvement in quality of life (p = 0.854), but the presence of symptoms of anxiety and depression did (p = 0.001). Although both programs achieved a decrease in anxiety and depression symptoms and improved functional capacity (p ≤ 0.001), a significant interaction effect was found between the group with or without anxiety and depression symptoms and the type of program in the bodily pain dimension (p = 0.021). Trial registration: Retrospectively registered NCT02796404 (10/06/2016) in clinialtrials.gov.

Efficacy of Graded Activity with and without Daily-Monitored-Walking on Pain and Back Endurance among Patients with Concomitant Low-Back Pain and Type-2 Diabetes: A Randomized Trial

Background

There is evidence supporting the efficacy of Graded Activity (GA) in managing clinical attributes of patients with Low-Back Pain (LBP) in the general population. However, it is unknown whether GA alone is efficacious in managing these clinical attributes in patients with concomitant LBP and Type-2 Diabetes (T2D) or additional daily-monitored walking will be required.

Methods

A single-blind controlled trial involving 58 patients (mean age: 48.3±9.4 years, 64.7% females) with concomitant LBP and T2D who received treatment twice weekly for twelve weeks was conducted. Participants were randomized into GA or GA with daily-monitored-walking (GAMW) groups. Pain Intensity (PI), Static Back Extensors Endurance (SBEE), Static Abdominal Muscular Endurance (SAME) and Glycaemic Control (GC) were assessed using Visual Analogue Scale, Biering-Sorensen test, flexor endurance test, and in2itTM device respectively at baseline, 4th, 8th and 12th week. Data were analysed using repeated measures ANOVA and Unpaired t-tests at α = 0.05.

Results

There were significant differences in PI, SAME and SBEE among participants in each of GA and GAMW groups respectively (p<0.05). Within-group difference on GC was significant for GAMW (6.3±0.9%, 5.7±0.7%) but not GA (6.3±0.9%, 6.3±0.9%). There was significant difference (p<0.05) between GA and GAMW group participants for SBEE (7.2±0.1 sec, 7.3±0.1 sec) at week 8 of the study and GC (-0.5±0.2%, -0.6±0.5%) at the end of the study. No differences were found between GA and GAMW groups for PI and SAME.

Conclusion

Graded activity with daily-monitored-walking produced positive effects on GC and yielded a better improvement on SAME and SBEE.

Effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery: a systematic review

REVIEW OBJECTIVE

The objective of this review was to investigate the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on patients' health-related quality of life and hospital readmission.

INTRODUCTION

Coronary heart disease is a major cause of death and disability worldwide, putting a great strain on healthcare resources. For the past two decades, population-wide primary prevention and individual healthcare approaches have resulted in a dramatic decline in overall cardiac mortality. Over the intervening years, surgical techniques in cardiology have also improved substantially. As a result, long-term outcomes in patients treated with coronary artery bypass graft surgery have established the treatment's effectiveness and survival benefit. Furthermore, participating in cardiac rehabilitation following coronary artery bypass graft surgery has also demonstrated a significant decrease in all-cause cardiac mortality in these patients.

INCLUSION CRITERIA

This review included studies with participants aged 18 years and over, post coronary artery bypass graft surgery that evaluated nurse-led cardiac rehabilitation (CR) programs compared with usual care or other forms of CR. The outcomes of interest were the health-related quality of life and hospital readmissions following coronary artery bypass graft surgery and measured using validated scales. Randomized controlled trials reported in English between 2000 to June 2017 were considered for inclusion.

METHODS

The search strategy aimed to find both published and unpublished studies using a three-step search strategy. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies including Dissertation Abstracts International, ProQuest Dissertations and Theses, Google Scholar, MedNar and ClinicalTrials.gov. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal tools from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI. No meta-analysis was undertaken due to heterogeneity of the outcome measures. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis.

RESULTS

Three trials involving 329 patients were included in the final review. The trials that investigated the effect of home based cardiac rehabilitation programs compared to usual care at six weeks, three months and six months follow-up demonstrated no statistically significant difference in health-related quality of life at any of the follow-up periods. However, one study demonstrated significantly higher scores related to health-related quality of life among those who received nurse-led home based cardiac rehabilitation (154.93 ± 4.6) compared to those who received usual care (134.20 ± 8.2) at two months follow-up. No trials were identified that compared the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on readmissions to hospital.

CONCLUSION

There is not enough evidence to support or discourage nurse-led cardiac rehabilitation programs on health-related quality of life in patients following coronary artery bypass graft surgery. However, the sparse data available suggests improvements in health-related quality of life at two months follow-up among those who received a nurse-led program. Further large-scale multicenter trials with standardized methodology are needed to determine the effect of nurse-led cardiac rehabilitation programs on health-related quality of life and rates of readmission to hospital following coronary artery bypass graft surgery.

Creating and disseminating a home-based cardiac rehabilitation program: experience from the Veterans Health Administration

BACKGROUND

Cardiac rehabilitation (CR) programs provide significant benefit for people with cardiovascular disease. Despite these benefits, such services are not universally available. We designed and evaluated a national home-based CR (HBCR) program in the Veterans Health Administration (VHA). The primary aim of the study was to examine barriers and facilitators associated with site-level implementation of HBCR.

METHODS

This study used a convergent parallel mixed-methods design with qualitative data to analyze the process of implementation, quantitative data to determine low and high uptake of the HBCR program, and the integration of the two to determine which facilitators and barriers were associated with adoption. Data were drawn from 16 VHA facilities, and included semi-structured interviews with multiple stakeholders, document analysis, and quantitative analysis of CR program attendance codes. Qualitative data were analyzed using the Consolidated Framework for Implementation Research codes including three years of document analysis and 22 interviews.

RESULTS

Comparing high and low uptake programs, readiness for implementation (leadership engagement, available resources, and access to knowledge and information), planning, and engaging champions and opinion leaders were key to success. High uptake sites were more likely to seek information from the external facilitator, compared to low uptake sites. There were few adaptations to the design of the program at individual sites.

CONCLUSION

Consistent and supportive leadership, both clinical and administrative, are critical elements to getting HBCR programs up and running and sustaining programs over time. All sites in this study had external funding to develop their program, but high adopters both made better use of those resources and were able to leverage existing resources in the setting. These data will inform broader policy regarding use of HBCR services.

Comparison of Obesity Related Index and Exercise Capacity Between Center-Based and Home-Based Cardiac Rehabilitation Programs

Objective

To compare a center-based cardiac rehabilitation (CR) program with a home-based CR program in terms of improving obesity related index and cardiopulmonary exercise capacity after the completing a phase II CR program.

Methods

In this study, there were seventy-four patients with acute myocardial infarction after percutaneous coronary intervention who were analyzed. Patients with mild to moderate risk (ejection fraction >40%) were included in the group. The patients underwent an exercise tolerance test by measurement of the modified Bruce protocol at three assessment points. Those in the center-based CR group participated in a 4-week training program with electrocardiography monitoring of the patient’s progress and results, while those patients who were in the home-based CR group underwent self-exercise training. We measured the obesity related indices such as body mass index, fat free mass index (FFMI), and cardiopulmonary exercise capacity including peak oxygen consumption (VO_2max), metabolic equivalents (METs), heart rate, resting systolic blood pressure and the diastolic blood pressure of the participants and noted the results.

Results

Of the 74 patients, 25 and 49 participated in the center-based and home-based CR programs, respectively. Both groups showed significant improvement in VO_2max and METs at 1-month and 6-month follow-up. However, FFMI was significantly improved only in the center-based CR group after 1 month of the phase II CR.

Conclusion

Both groups identified in the study showed significant improvement of VO_2max and METs at 1-month and 6-month follow-up. However, there was no significant difference in the intergroup analysis. A significant improvement of FFMI was seen only in the center-based CR group after phase II CR.

Barriers to participation in center-based cardiac rehabilitation programs and patients' attitude toward home-based cardiac rehabilitation programs

Purpose: The mortality rate of cardiovascular diseases in such developing countries as Iran is on the rise. Despite sufficient evidence pointing to its efficacy, cardiac rehabilitation (CR) approach is only employed to a limited extent. In the present study, barriers to participation in center-based cardiac rehabilitation programs and patients' attitude toward home-based cardiac rehabilitation model were examined. Methods: In this study, 204 eligible patients for CR visiting an academic hospital were examined during the first three months of 2017. Patients had either abandoned rehabilitation programs midway through or had not attended one in the first place. Data about perceived barriers were collected using the modified Cardiac Rehabilitation Barriers Scale. Also, Patients' attitude toward home-based CR was collected using a pre-validated researcher-made questionnaire. Results: The results revealed that the most effective barriers were transportation problems (70%), travel costs (70%), considerable distance to the rehabilitation center (67%), and lack of insurance coverage for rehabilitation costs (64%), respectively. Patients with longer than 30-minute drive time were less likely to attend in training sessions in the center. In addition, the important patient expectations about home-based CR programs included: communication with specialists, training before entering the rehabilitation program, and making periodic visits to maintain motivation and adhere to the home-based CR programs. Conclusions: The results revealed that logistical factors were the major barriers to participation in rehabilitation programs. Alternative models such as home-based CR programs, positively evaluated by the participants, can be used to overcome these barriers.

Evaluating the Impact of the HeartHab App on Motivation, Physical Activity, Quality of Life, and Risk Factors of Coronary Artery Disease Patients: Multidisciplinary Crossover Study

Background

Telerehabilitation approaches have been successful in supporting coronary artery disease (CAD) patients to rehabilitate at home after hospital-based rehabilitation. However, on completing a telerehabilitation program, the effects are not sustained beyond the intervention period because of the lack of lifestyle adaptations. Furthermore, decline in patients’ motivation lead to recurrence of disease and increased rehospitalization rates. We developed HeartHab, using persuasive design principles and personalization, to enable sustenance of rehabilitation effects beyond the intervention period. HeartHab promotes patients’ understanding, motivates them to reach personalized rehabilitation goals, and helps to maintain positive lifestyle adaptations during telerehabilitation.

Objective

This study aimed to investigate the impact of the HeartHab app on patients’ overall motivation, increasing physical activities, reaching exercise targets, quality of life, and modifiable risk factors in patients with CAD during telerehabilitation. The study also investigated carryover effects to determine the maintenance of effects after the conclusion of the intervention.

Methods

A total of 32 CAD patients were randomized on a 1:1 ratio to telerehabilitation or usual care. We conducted a 4-month crossover study with a crossover point at 2 months using a mixed-methods approach for evaluation. We collected qualitative data on users’ motivation, user experience, and quality of life using questionnaires, semistructured interviews and context-based sentiment analysis. Quantitative data on health parameters, exercise capacity, and risk factors were gathered from blood tests and ergo-spirometry tests. Data procured during the app usage phase were compared against baseline values to assess the impact of the app on parameters such as motivation, physical activity, quality of life, and risk factors. Carryover effects were used to gather insights on the maintenance of effects.

Results

The qualitative data showed that 75% (21/28) of patients found the HeartHab app motivating and felt encouraged to achieve their rehabilitation targets. 84% (21/25) of patients either reached or exceeded their prescribed physical activity targets. We found positive significant effects on glycated hemoglobin (P=.01; d=1.03; 95% CI 0.24-1.82) with a mean decrease of 1.5 mg/dL and high-density lipoprotein (HDL) cholesterol (P=.04; d=0.78; 95% CI 0.02-1.55) with a mean increase of 0.61 mg/dL after patients used the HeartHab app. We observed significant carryover effects on weight, HDL cholesterol, and maximal oxygen consumption (VO₂ max), indicating the maintenance of effects.

Conclusions

Persuasive design techniques integrated in HeartHab and tailoring of exercise targets were effective in motivating patients to reach their telerehabilitation targets. This study demonstrated significant effects on glucose and HDL cholesterol and positive carryover effects on weight, HDL cholesterol, and VO₂ max. There was also a perceived improvement in quality of life. A longer-term evaluation with more patients could possibly reveal effectiveness on other risk factors and maintenance of the positive health behavior change.

Trial Registration

ClinicalTrials.gov NCT03102671; https://clinicaltrials.gov/ct2/show/NCT03102671 (Archived by WebCite at http://www.webcitation.org/76gzI9Pvd)

Innovative Application of a Home-Based and Remote Sensing Cardiac Rehabilitation Protocol in Chinese Patients After Percutaneous Coronary Intervention

BACKGROUND

Medical care for the Chinese population has been focused on first-line activities, that is, therapy, but with little follow-up on treated patients. However, efficacy of therapy is highly dependent upon post-therapy recovery. For coronary heart disease (CHD), home-based cardiac telerehabilitation (HBCTR) is an alternative to hospital-based or center-based cardiac rehabilitation, and is an innovative approach to enhance recovery, but the approach is seldom used in China. Our preliminary survey in Shantou, China, indicated that most CHD patients showed a positive attitude toward the HBCTR technology. Our follow-up study was focused on assessing the effect of the HBCTR program in low-risk patients after percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

A two-arm randomized controlled trial was conducted at the First Affiliated Hospital of the Shantou University Medical College, China. The effectiveness of this program was measured by using blood pressure, Six-Minute Walking Test (6MWT), Fagerstrom Test for Nicotine Dependence (FTND), Cardiac Depression Scale (CDS), and SF-36 Health Survey (SF36).

RESULTS

A total of 80 post-PCI patients were recruited and randomly divided into two equal groups. Based upon our effort, the usual care (UC) group received paper-based CHD educational booklets and biweekly outpatient review. The HBCTR group carried out outdoor walking/jogging exercise with real-time physiological monitoring along with CHD education materials. After the 6-week intervention, the 6MWT, SF36 (PCS, MCS), FTND and CDS in both groups were found to have significantly improved compared with baseline. In addition, the improvements in SF36, FTND scores, and 6MWT distance in the HBCTR group were significantly better than those in the UC group (p < 0.05).

CONCLUSION

Our observations indicated that the HBCTR program may be applied successfully in Chinese patients who had very little technical skills and its application may be highly cost-effective.

Gender differences in home-based cardiac rehabilitation of post-percutaneous coronary intervention patients

Cardiac rehabilitation (CR) is a structured program for the prevention of secondary cardiovascular disease (CVD) and related diseases, such as hypertension, diabetes, and obesity. This study aimed to investigate whether there are gender differences after 9 months of home-based cardiac rehabilitation program in post-percutaneous coronary intervention patients. A total of 114 (58.29 ± 10.33 years) men and 30 (60.90 ± 9.32 years) women were enrolled in the CR program. The program included three visits: initial, 4th month (follow-up), and 9th month (final) visits at a CR center. The CR program included exercise and nutrition counseling. In nutrition counseling, a professional nutritionist educated the patients on how to organize the menu, incorporating an optimal caloric, low-salt, and low-cholesterol diet. Exercise was performed 30 min per session for more than 3 days per week with a target heart rate within 40-75% of the peak heart rate-resting heart rate (VO₂ reserve; VO₂R) during intense exercise, which was based on ECG treadmill test. After 9 months, there was no significant difference in terms of dropout rate between men and women (p < 0.05). No significant changes were found in the anthropometric and lipid profiles in women, whereas the HDL-cholesterol (HDL-C) was significantly increased to 6.8% (p = 0.005) in men. The findings of our study showed that there was no difference in the CR participation rate between men and women. Moreover, there was an increase in HDL-C levels and an improvement in cardiorespiratory endurance, strength, and agility in men, whereas no significant difference in most risk factors and fitness variables was found in women. Thus, the 9-month home-based CR program was more effective for fitness in men, but only the HDL-C showed positive improvement among the cardiovascular risk factors. In women, 6-min walk and timed up and go were effective exercises.

Efficacy of Different Types of Exercise-Based Cardiac Rehabilitation on Coronary Heart Disease: a Network Meta-analysis

BACKGROUND

Exercise-based cardiac rehabilitation (CR) has been recognized as an essential component of the treatment for coronary heart disease (CHD). Determining the efficacy of modern alternative treatment methods is the key to developing exercise-based CR programs.

METHODS

Studies published through June 6, 2016, were identified using MEDLINE, EMBASE, and the Cochrane Library. English-language articles regarding the efficacy of different modes of CR in patients with CHD were included in this analysis. Two investigators independently reviewed abstracts and full-text articles and extracted data from the studies. According to the categories described by prior Cochrane reviews, exercise-based CR was classified into center-based CR, home-based CR, tele-based CR, and combined CR for this analysis. Outcomes included all-cause mortality, cardiovascular death, recurrent fatal and/or nonfatal myocardial infarction, recurrent cardiac artery bypass grafting, recurrent percutaneous coronary intervention (PCI), and hospital readmissions.

RESULTS

Sixty randomized clinical trials (n = 19,411) were included in the analysis. Network meta-analysis (NMA) demonstrated that only center-based CR significantly reduced all-cause mortality (center-based: RR = 0.76 [95% CI 0.64-0.90], p = 0.002) compared to usual care. Other modes of CR were not significantly different from usual care with regard to their ability to reduce mortality. Treatment ranking indicated that combined CR exhibited the highest probability (86.9%) of being the most effective mode, but this finding was not statistically significant due to the small sample size (combined: RR = 0.50 [95% CI 0.20-1.27], p = 0.146).

CONCLUSIONS

Current evidence suggests that center-based CR is acceptable for patients with CHD. As home- and tele-based CR can save time, money, effort, and resources and may be preferred by patients, their efficacy should be investigated further in subsequent studies.

Feasibility of a Smartphone-enabled Cardiac Rehabilitation Program in Male Veterans With Previous Clinical Evidence of Coronary Heart Disease

Cardiac rehabilitation (CR) is recommended for patients with coronary heart disease, however, participation among veterans remains poor. Smartphones may facilitate data transfer and communication between patients and providers, among other benefits. We evaluated the feasibility of a smartphone-enabled CR program in a population of veterans. Qualifying veterans were prospectively enrolled in a single-arm, nonrandomized feasibility study of a smartphone-enabled, home-based CR program, featuring an app with daily reminders to exercise, log vitals, and review educational materials. A coach remotely monitored patients through an online dashboard and scheduled telephone visits. Clinical end points were assessed as an exploratory aim. After 21 veterans provided informed consent, 18 were enrolled and successfully completed at least 30days of the program; 13 completed the entire 12-week intervention. Mean (standard deviation) age was 62 (7) years and 96% were male. Program completers logged a mean (standard deviation) of 3.5 (1.4) exercise sessions and 150 (86) exercise minutes per week. The majority (84%) of program completers reported being satisfied overall with the program. Mean functional capacity improved by 1.0 metabolic equivalents (5.3 to 6.3, 95% confidence interval 0.3 to 1.7; p = 0.008) and mean systolic blood pressure at rest improved by 9.6mm Hg (mean difference 9.6, 95% confidence interval -19.0 to -0.7; p = 0.049) among completers. Smartphone-enabled, home-based CR is feasible in veterans with heart disease and is associated with moderate to high levels of engagement and patient satisfaction.

Shared care versus hospital-based cardiac rehabilitation: a cost-utility analysis based on a randomised controlled trial

Background

Changes in the organisation of chronic healthcare, an increased awareness of costs and challenges of low adherence in cardiac rehabilitation (CR) call for the exploration of more flexible CR programmes as alternatives to hospital-based CR (H-CR). A model of shared care cardiac rehabilitation (SC-CR) that included general practitioners and the municipality was developed. The aim of this study was to analyse the cost utility of SC-CR versus H-CR.

Methods

The cost-utility analysis was based on a randomised controlled trial of 212 patients who were allocated to SC-CR or H-CR and followed up for 12 months. A societal cost perspective was applied that included the cost of intervention, informal time, healthcare and productivity loss. Costing was based on a microcosting approach for the intervention and on national administrative registries for the other cost categories. Quality-adjusted life years (QALYs) were based on the EuroQol 5-Dimensions measurements at baseline, after 4 months and after 12 months. Conventional cost-effectiveness methodology was employed to estimate the net benefit of SC-CR.

Results

The average cost of SC-CR was 165.5 kDKK and H-CR 163 kDKK. Productivity loss comprised 74.1kDKK and 65.9 kDKK. SC-CR cost was an additional 2.5 kDKK (95% CI −38.1 to 43.1) ≈ (0.33; −5.1 to 5.8 k€) and a QALY gain of 0.02 (95% CI −0.03 to 0.06). The probability that SC-CR would be cost-effective was 59% for a threshold value of willingness to pay of 300 kDKK (k€40.3).

Conclusion

CR after shared care model and H-CR are comparable and similar in socioeconomic terms.

Trial registration number

NCT01522001; Results.

Music as Medicine: The Therapeutic Potential of Music for Acute Stroke Patients

Nurses caring for patients with acute stroke are likely to administer both music and medication with therapeutic intent. The administration of medication is based on accumulated scientific evidence and tailored to the needs of each patient. However, the therapeutic use of music is generally based on good intentions and anecdotal evidence. This review summarizes and examines the current literature regarding the effectiveness of music in the treatment of critically ill patients and the use of music in neurologically injured patients. The rationale for hypothesis-driven research to explore therapeutic music intervention in acute stroke is compelling.

Yoga-Based Postoperative Cardiac Rehabilitation Program for Improving Quality of Life and Stress Levels: Fifth-Year Follow-up through a Randomized Controlled Trial

Objectives:

This study was aimed to assess the efficacy of yoga-based lifestyle program (YLSP) in improving quality of life (QOL) and stress levels in patients after 5 years of coronary artery bypass graft (CABG).

Methodology:

Three hundred patients posted for elective CABG in Narayana Hrudayalaya Super Speciality Hospital, Bengaluru, were randomized into two groups: YLSP and conventional lifestyle program (CLSP), and follow-up was done for 5 years.

Intervention:

In YLSP group, all practices of integrative approach of yoga therapy such as yama, niyama, asana, pranayama, and meditation were used as an add-on to conventional cardiac rehabilitation. The control group (CLSP) continued conventional cardiac rehabilitation only.

Outcome Measures:

World Health Organization (WHO)-QOL BREF Questionnaire, Perceived Stress Scale, Positive and Negative Affect Scale (PANAS), and Hospital Anxiety and Depression Scale (HADS) were assessed before surgery and at the end of the 5^th year after CABG. As data were not normally distributed, Mann–Whitney U-test was used for between-group comparisons and Wilcoxon's signed-rank test was used for within-group comparisons.

Results:

At the end of 5 years, mental health (P = 0.05), perceived stress (P = 0.01), and negative affect (NA) (P = 0.05) have shown significant improvements. WHO-QOL BREF score has shown improvements in physical health (P = 0.046), environmental health (P = 0.04), perceived stress (P = 0.001), and NA (P = 0.02) in YLSP than CLSP. Positive affect has significantly improved in CLSP than YLSP. Other domains of WHO-QOL-BREF, PANAS, and HADS did not reveal any significant between-group differences.

Conclusion:

Addition of long-term YLSP to conventional cardiac rehabilitation brings better improvements in QOL and reduction in stress levels at the end of 5 years after CABG.

Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery

Background

Evidence suggests that elective cardiac patients are at risk of functional and psychological deterioration in the time preceding surgery. This poses a risk to successful post-operative rehabilitation. This prospective one-group pre-test, post-test evaluation was designed to assess a clinical Pre-operative Rehabilitation (PREHAB) home-based exercise programme, to optimise pre-operative physical function and frailty in patients awaiting elective Coronary Artery By-Pass Graft (CABG) or Valve Surgery.

Method

Consenting patients awaiting cardiac surgery, with wait time ≥ 6 weeks were referred to a Senior Physiotherapist for baseline assessment. Patients were offered PREHAB in the form of functional home-based exercise that was prescribed from baseline physical outcomes. All patients were followed up via telephone to ensure progression of exercise and any problems associated with it. This continued weekly until the patient attended Surgical Pre-assessment clinic, where all outcome measures were re-assessed.

Results

Twenty two patients, out of a total number of 36 patients seen in the surgical clinic between March 2016 and August 2016, participated in the prehab clinical evaluation. Twenty patients completed their prescribed exercises on a weekly basis prior to surgery. No adverse events or cardiac symptoms were reported as a result of the home exercise intervention. Paired t-Test analyses revealed a significant mean difference in clinical frailty score (CFS) of −0.53 ± 0.51 (95% CI [−0.774, −0.279], P = 0.0003). Significant mean difference in six-minute walk test (6MWT) distance of 42.5 ± 27.8 m (95% CI [23.840, 61.251], P = 0.0005), 6MWT walking speed of 0.5 ± 0.4kmh (95% CI, [0.2433, 0.7567], P = 0.001), and short physical performance battery (SPPB) total score of 2.2 ± 1.7, (95% CI [3.066, 1.200], P = 0.0002) were also observed. The change in 6MWT distance was shown to be significantly associated with hospital length of stay (LOS) (r = 0.7; P = 0.03).

Conclusion

This small exploratory evaluation suggests that providing a home-based PREHAB programme for frail patients undergoing CABG or Valve surgery may be able to improve functional ability and reduce hospital length of stay for those patients undergoing cardiac surgery. A frailty score with greater sensitivity may be required to elucidate the influence frailty could have in reducing length of stay. A large randomised controlled study is required to reveal the potential beneficial effects of PREHAB in this patient population.

Digitally enhanced recovery: Investigating the use of digital self-tracking for monitoring leisure time physical activity of cardiovascular disease (CVD) patients undergoing cardiac rehabilitation

Research has shown that physical activity is essential in the prevention and treatment of chronic diseases like cardiovascular disease (CVD). Smart wearables (e.g., smartwatches) are increasingly used to foster and monitor human behaviour, including physical activity. However, despite this increased usage, little evidence is available on the effects of smart wearables in behaviour change. The little research which is available typically focuses on the behaviour of healthy individuals rather than patients. In this study, we investigate the effects of using smart wearables by patients undergoing cardiac rehabilitation. A field experiment involving 29 patients was designed and participants were either assigned to the study group (N = 13 patients who finished the study and used a self-tracking device) or the control group (N = 16 patients who finished the study and did not use a device). For both groups data about physiological performance during cardiac stress test was collected at the beginning (baseline), in the middle (in week 6, at the end of the rehabilitation in the organized rehabilitation setting), and at the end of the study (after 12 weeks, at the end of the rehabilitation, including the organized rehabilitation plus another 6 weeks of self-organized rehabilitation). Comparing the physiological performance of both groups, the data showed significant differences. The participants in the study group not only maintained the same performance level as during the midterm examination in week 6, they improved performance even further during the six weeks that followed. The results presented in this paper provide evidence for positive effects of digital self-tracking by patients undergoing cardiac rehabilitation on performance of the cardiovascular system. In this way, our study provides novel insight about the effects of the use of smart wearables by CVD patients. Our findings have implications for the design of self-management approaches in a patient rehabilitation setting. In essence, the use of smart wearables can prolong the success of the rehabilitation outside of the organized rehabilitation setting.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review previously published in 2009 and 2015.

OBJECTIVES

To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

SEARCH METHODS

We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 21 September 2016. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials, including parallel group, cross-over or quasi-randomised designs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on pre-defined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Quality of evidence was assessed using GRADE principles and a Summary of findings table was created.

MAIN RESULTS

We included six new studies (624 participants) for this update, which now includes a total of 23 trials that randomised a total of 2890 participants undergoing cardiac rehabilitation. Participants had an acute myocardial infarction, revascularisation or heart failure. A number of studies provided insufficient detail to enable assessment of potential risk of bias, in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported.No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in clinical primary outcomes up to 12 months of follow up: total mortality (relative risk (RR) = 1.19, 95% CI 0.65 to 2.16; participants = 1505; studies = 11/comparisons = 13; very low quality evidence), exercise capacity (standardised mean difference (SMD) = -0.13, 95% CI -0.28 to 0.02; participants = 2255; studies = 22/comparisons = 26; low quality evidence), or health-related quality of life up to 24 months (not estimable). Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate quality evidence). However, there was evidence of marginally higher levels of programme completion (RR 1.04, 95% CI 1.00 to 1.08; participants = 2615; studies = 22/comparisons = 26; low quality evidence) by home-based participants.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- and centre-based forms of cardiac rehabilitation seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction or revascularisation, or with heart failure. This finding supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme may reflect local availability and consider the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in the included short-term trials can be confirmed in the longer term and need to consider adequately powered non-inferiority or equivalence study designs.

An m-Health system for education and motivation in cardiac rehabilitation: the experience of HeartCycle guided exercise

Introduction

Home-based programmes for cardiac rehabilitation play a key role in the recovery of patients with coronary artery disease. However, their necessary educational and motivational components have been rarely implemented with the help of modern mobile technologies. We developed a mobile health system designed for motivating patients to adhere to their rehabilitation programme by providing exercise monitoring, guidance, motivational feedback, and educational content.

Methods

Our multi-disciplinary approach is based on mapping “desired behaviours” into specific system’s specifications, borrowing concepts from Fogg’s Persuasive Systems Design principles. A randomised controlled trial was conducted to compare mobile-based rehabilitation (55 patients) versus standard care (63 patients).

Results

Some technical issues related to connectivity, usability and exercise sessions interrupted by safety algorithms affected the trial. For those who completed the rehabilitation (19 of 55), results show high levels of both user acceptance and perceived usefulness. Adherence in terms of started exercise sessions was high, but not in terms of total time of performed exercise or drop-outs. Educational level about heart-related health improved more in the intervention group than the control. Exercise habits at 6 months follow-up also improved, although without statistical significance.

Discussion

Results indicate that the adopted design methodology is promising for creating applications that help improve education and foster better exercise habits, but further studies would be needed to confirm these indications.

Home-based versus centre-based cardiac rehabilitation: abridged Cochrane systematic review and meta-analysis

Objective

To update the Cochrane review comparing the effects of home-based and supervised centre-based cardiac rehabilitation (CR) on mortality and morbidity, quality of life, and modifiable cardiac risk factors in patients with heart disease.

Methods

Systematic review and meta-analysis. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and CINAHL were searched up to October 2014, without language restriction. Randomised trials comparing home-based and centre-based CR programmes in adults with myocardial infarction, angina, heart failure or who had undergone coronary revascularisation were included.

Results

17 studies with 2172 patients were included. No difference was seen between home-based and centre-based CR in terms of: mortality (relative risk (RR) 0.79, 95% CI 0.43 to 1.47); cardiac events; exercise capacity (mean difference (MD) −0.10, −0.29 to 0.08); total cholesterol (MD 0.07 mmol/L, −0.24 to 0.11); low-density lipoprotein cholesterol (MD −0.06 mmol/L, −0.27 to 0.15); triglycerides (MD −0.16 mmol/L, −0.38 to 0.07); systolic blood pressure (MD 0.2 mm Hg, −3.4 to 3.8); smoking (RR 0.98, 0.79 to 1.21); health-related quality of life and healthcare costs. Lower high-density lipoprotein cholesterol (MD −0.07 mmol/L, −0.11 to −0.03, p=0.001) and lower diastolic blood pressure (MD −1.9 mm Hg, −0.8 to −3.0, p=0.009) were observed in centre-based participants. Home-based CR was associated with slightly higher adherence (RR 1.04, 95% CI 1.01 to 1.07).

Conclusions

Home-based and centre-based CR provide similar benefits in terms of clinical and health-related quality of life outcomes at equivalent cost for those with heart failure and following myocardial infarction and revascularisation.

Effects of a Phase IV Home-Based Cardiac Rehabilitation Program on Cardiorespiratory Fitness and Physical Activity

BACKGROUND

Cardiovascular diseases are the leading cause of death globally and sedentary lifestyle is one of the main risk factors. Home-based cardiac rehabilitation (CR) programs appear to be effective to improve exercise tolerance. The aim of the study, therefore, was to evaluate the effects of a phase IV (maintenance) home-based CR program on cardiorespiratory fitness and daily physical activity of patients recovering from an acute myocardial infarction.

METHODS

This pilot study, with a sub-group randomised controlled trial, included 32 individuals recovering from a myocardial infarction, randomly divided into the experimental group (EG, n=16) and the control group (CG, n=16). The EG performed an exercise program, three times per week, at home during eight weeks. The two groups received health education sessions. Baseline and final assessments included cardiorespiratory fitness, resting and peak heart rate, blood pressure and rate pressure, heart rate recovery and daily physical activity. (ClinicalTrials.gov: NCT01887080).

RESULTS

At baseline no significant differences were observed between groups. After eight weeks of exercise, the EG significantly increased peak oxygen uptake (p=0.02), test duration (p=0.019), peak rate pressure (p=0.003), peak heart rate (p=0.003) and heart rate recovery (0.025) when compared to the CG. No changes were observed on daily physical activity in both groups.

CONCLUSION

This specific phase IV home-based exercise program seems to improve cardiorespiratory fitness, haemodynamics at peak exercise and heart rate recovery, an indicator of cardiac autonomic function.

Secondary prevention programmes for coronary heart disease: a meta-regression showing the merits of shorter, generalist, primary care-based interventions

Background

The aim of this study was to determine which programme characteristics influence the effectiveness of secondary prevention programmes for Coronary Heart Disease.

Design

The study follows a meta-regression design.

Methods

We conducted a meta-regression within a systematic review of randomized trials comparing secondary prevention programmes versus usual care. The primary outcome was all-cause mortality. Studies were identified by searching multiple electronic databases, bibliographies of published studies, contact with experts, and references provided by the United States Centers for Medicare and Medicaid Services. Primary authors of all relevant trials were surveyed for detailed information on programme characteristics. Forty-six unique trials were identified (18 821 patients). The pooled all-cause mortality risk ratio (RR) for programmes was 0.87 [95% confidence interval (CI) 0.79-0.97]. Programmes containing less than 10 h of patient contact with health professionals reduced all-cause mortality (RR 0.80, 95% CI 0.68-0.95) as effectively as programmes with more contact time. Programmes provided in general practice settings were effective at reducing all-cause mortality (RR 0.76, 95% CI 0.63-0.92) and compared favourably with the effectiveness of hospital-based programmes. Other characteristics, including specialist versus generalist provision, did not appreciably impact programme effectiveness.

Conclusions

Shorter secondary prevention programmes, those based in general practice, and those staffed by generalists are at least as effective in reducing all cause mortality in patients with coronary heart disease as longer programmes, hospital-based programmes, and programmes staffed by specialists.

Behaviour change techniques in home-based cardiac rehabilitation: a systematic review

Background

Cardiac rehabilitation (CR) programmes offering secondary prevention for cardiovascular disease (CVD) advise healthy lifestyle behaviours, with the behaviour change techniques (BCTs) of goals and planning, feedback and monitoring, and social support recommended. More information is needed about BCT use in home-based CR to support these programmes in practice.

Aim

To identify and describe the use of BCTs in home-based CR programmes.

Design and setting

Randomised controlled trials of home-based CR between 2005 and 2015 were identified by searching MEDLINE^®, Embase, PsycINFO, Web of Science, and Cochrane Database.

Method

Reviewers independently screened titles and abstracts for eligibility. Relevant data, including BCTs, were extracted from included studies. A meta-analysis studied risk factor change in home-based and comparator programmes.

Results

From 2448 studies identified, 11 of good methodological quality (10 on post-myocardial infarction, one on heart failure, 1907 patients) were included. These reported the use of 20 different BCTs. Social support (unspecified) was used in all studies and goal setting (behaviour) in 10. Of the 11 studies, 10 reported effectiveness in reducing CVD risk factors, but one study showed no improvement compared to usual care. This study differed from effective programmes in that it didn’t include BCTs that had instructions on how to perform the behaviour and monitoring, or a credible source.

Conclusion

Social support and goal setting were frequently used BCTs in home-based CR programmes, with the BCTs related to monitoring, instruction on how to perform the behaviour, and credible source being included in effective programmes. Further robust trials are needed to determine the relative value of different BCTs within CR programmes.

Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis

OBJECTIVE

Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD).

METHODS

CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre-based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence.

RESULTS

11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low-density lipoprotein cholesterol. Telehealth and centre-based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors.

CONCLUSIONS

Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.

Adverse events experienced by participants in a back pain walking intervention: A descriptive study

OBJECTIVE

To understand the range and potential severity of adverse events reported by patients with back pain who were participating in a walking intervention.

METHODS

Data were obtained from participants in a randomized trial of a pedometer-based Internet-mediated intervention to promote walking and reduce back pain-related disability (n = 229 participants, 118 usual care, and 111 intervention). Participants reported adverse events throughout the 12-month study period. All reported events were reviewed and classified by system, severity, and study relatedness.

RESULTS

A total of 600 adverse events were reported, 250 by those in usual care and nearly 350 by those in the intervention. After worsening back pain (27%), musculoskeletal events were the most commonly reported events (19%), followed by cardiovascular events (14%), infection (11%), and medical procedures (9%). There were three times as many musculoskeletal events in the intervention compared to the usual care group. Cardiovascular events, which were generally not serious and not walking related, were far less common than musculoskeletal injuries.

CONCLUSIONS

Individuals with chronic back pain can safely engage in a pedometer-based, unsupervised walking program. However, patients may benefit from focused counseling about musculoskeletal risks with specific attention to injury prevention measures such as gradually incrementing activity levels.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review originally published in 2009.

OBJECTIVES

To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

SEARCH METHODS

To update searches from the previous Cochrane review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41), PsycINFO (Ovid, 1806 to October week 2 2014), and CINAHL (EBSCO, to October 2014). We checked reference lists of included trials and recent systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction (MI), angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of the identified trials and data were extracted by a single author and checked by a second. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Seventeen trials included a total of 2172 participants undergoing cardiac rehabilitation following an acute MI or revascularisation, or with heart failure. This update included an additional five trials on 345 patients with heart failure. Authors of a number of included trials failed to give sufficient detail to assess their potential risk of bias, and details of generation and concealment of random allocation sequence were particularly poorly reported. In the main, no difference was seen between home- and centre-based cardiac rehabilitation in outcomes up to 12 months of follow up: mortality (relative risk (RR) = 0.79, 95% confidence interval (CI) 0.43 to 1.47, P = 0.46, fixed-effect), cardiac events (data not poolable), exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.29 to 0.08, P = 0.29, random-effects), modifiable risk factors (total cholesterol: mean difference (MD) = 0.07 mmol/L, 95% CI -0.24 to 0.11, P = 0.47, random-effects; low density lipoprotein cholesterol: MD = -0.06 mmol/L, 95% CI -0.27 to 0.15, P = 0.55, random-effects; systolic blood pressure: mean difference (MD) = 0.19 mmHg, 95% CI -3.37 to 3.75, P = 0.92, random-effects; proportion of smokers at follow up (RR = 0.98, 95% CI 0.79 to 1.21, P = 0.83, fixed-effect), or health-related quality of life (not poolable). Small outcome differences in favour of centre-based participants were seen in high density lipoprotein cholesterol (MD = -0.07 mmol/L, 95% CI -0.11 to -0.03, P = 0.001, fixed-effect), and triglycerides (MD = -0.18 mmol/L, 95% CI -0.34 to -0.02, P = 0.03, fixed-effect, diastolic blood pressure (MD = -1.86 mmHg; 95% CI -0.76 to -2.95, P = 0.0009, fixed-effect). In contrast, in home-based participants, there was evidence of a marginally higher levels of programme completion (RR = 1.04, 95% CI 1.01 to 1.07, P = 0.009, fixed-effect) and adherence to the programme (not poolable). No consistent difference was seen in healthcare costs between the two forms of cardiac rehabilitation.

AUTHORS' CONCLUSIONS

This updated review supports the conclusions of the previous version of this review that home- and centre-based forms of cardiac rehabilitation seem to be equally effective for improving the clinical and health-related quality of life outcomes in low risk patients after MI or revascularisation, or with heart failure. This finding, together with the absence of evidence of important differences in healthcare costs between the two approaches, supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme should reflect the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in these short-term trials can be confirmed in the longer term. A number of studies failed to give sufficient detail to assess their risk of bias.

Assessing the Existing Professional Exercise Recommendations for Hypertension: A Review and Recommendations for Future Research Priorities

The Eighth Joint National Committee guideline on the management of adult hypertension was recently released. Rather than recommending specific lifestyle modifications as in the Seventh Joint National Committee guideline, the Eighth Joint National Committee endorsed the recommendations of the American Heart Association/American College of Cardiology 2013 Lifestyle Work Group. The Lifestyle Work Group report included systematic reviews and meta-analyses of randomized controlled trials or controlled clinical trials from 2001 through 2011 of "fair to good" quality. In total, 11 reviews qualified for inclusion in the report, 6 of which included blood pressure (BP) as the primary outcome. Three reviews did not find significant reductions in BP, and BP status was not reported in 5. When BP was reported, only 22% of the patients had hypertension. Yet, the group concluded with a strength of evidence categorized as "high" that aerobic exercise training reduces BP by 1 to 5 mm Hg in individuals with hypertension and that the most effective exercise interventions on average included aerobic physical activity of moderate to vigorous intensity for at least 12 weeks, 3 to 4 sessions per week lasting 40 minutes per session. The exercise prescription recommendations of the Lifestyle Work Group deviate from those of other professional organizations and committees including the Seventh Joint National Committee, another American Heart Association scientific statement, the American College of Sports Medicine, the European Society of Hypertension/European Society of Cardiology, and the Canadian Health Education Program. The purposes of this review are to present the existing exercise recommendations for hypertension, discuss reasons for differences in these recommendations, discuss gaps in the literature, and address critical future research needs regarding exercise prescription for hypertension.