Effectiveness of technology-assisted cardiac rehabilitation: A systematic review and meta-analysis

Self-care trajectories of patients with coronary heart disease: a longitudinal, observational study

AIMS

To determine if distinct trajectories of coronary heart disease (CHD) self-care behaviours could be identified, linked to differences in quality of life (QoL), and predicted based on baseline characteristics.

METHODS AND RESULTS

A secondary analysis of a prospective, longitudinal, observational study. Patients with CHD answered questionnaires at study enrolment and six months later: Self-Care of Coronary Heart Disease Inventory (three subscales: maintenance, management, and confidence, scored 0-100, higher score = better self-care), Hospital Anxiety and Depression Scale, 12-Item Short Form Survey, 16-Item European Health Literacy Survey Questionnaire, and CHD Education Questionnaire. Latent growth mixture modelling was used to identify distinct self-care trajectories over time. On average, patients (n = 430, mean age 64.3 ± 8.9, 79% male) reported inadequate self-care (maintenance 61.6 ± 15.4, management 53.5 ± 18.5) at enrolment. Two distinct trajectories of self-care behaviours were identified: first, an 'inadequate-and-worsening' (IN-WORSE) trajectory (57.2%), characterized by inadequate self-care, improvement in maintenance (4.0 ± 14.5-point improvement, P < 0.001), and worsening of management over time (6.3 ± 24.4-point worsening, P = 0.005). Second, an 'inadequate-but-maintaining' (IN-MAIN) trajectory (42.8%), characterized by inadequate self-care, improvement in maintenance (5.0 ± 16.2-point improvement, P < 0.001), and stability in management over time (0.8 ± 21.9-point worsening, P = 0.713). In comparison, patients in the IN-WORSE trajectory had less favourable characteristics (including lower health literacy, knowledge, confidence) and significantly lower QoL. Not attending rehabilitation (OR 2.175; CI 1.020-4.637, P = 0.044) and older age (OR 0.959; CI 0.924-0.994, P = 0.024) predicted (IN-WORSE) trajectory inclusion.

CONCLUSION

Two self-care trajectories were identified, both suboptimal. Rehabilitation predicted membership in the more favourable trajectory and some positive characteristics were identified among patients in that group. Therefore, interventions supporting these factors may benefit patients' self-care and QoL.

The Effects of mHealth Interventions on Quality of Life, Anxiety, and Depression in Patients With Coronary Heart Disease: Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death globally. In addition, 20% to 40% of the patients with CHD have comorbid mental health issues such as anxiety or depression, affecting the prognosis and quality of life (QoL). Mobile health (mHealth) interventions have been developed and are widely used; however, the evidence for the effects of mHealth interventions on QoL, anxiety, and depression in patients with CHD is currently ambiguous.

OBJECTIVE

In this study, we aimed to assess the effects of mHealth interventions on QoL, anxiety, and depression in patients with CHD.

METHODS

We searched the Cochrane Library, PubMed, Embase, CINAHL, Web of Science, China National Knowledge Infrastructure, and Wanfang databases from inception to August 12, 2023. Eligible studies were randomized controlled trials that involved patients with CHD who received mHealth interventions and that reported on QoL, anxiety, or depression outcomes. We used the Cochrane risk-of-bias tool for randomized trials to evaluate the risk of bias in the studies, ensuring a rigorous and methodologically sound analysis. Review Manager (desktop version 5.4; The Cochrane Collaboration) and Stata MP (version 17.0; StataCorp LLC) were used to conduct the meta-analysis. The effect size was calculated using the standardized mean difference (SMD) and its 95% CI.

RESULTS

The meta-analysis included 23 studies (5406 participants in total) and showed that mHealth interventions significantly improved QoL in patients with CHD (SMD 0.49, 95% CI 0.25-0.72; Z=4.07; P<.001) as well as relieved their anxiety (SMD -0.46, 95% CI -0.83 to -0.08; Z=2.38; P=.02) and depression (SMD -0.34, 95% CI -0.56 to -0.12; Z=3.00; P=.003) compared to usual care. The subgroup analyses indicated a significant effect favoring the mHealth intervention on reducing anxiety and depressive symptoms compared to usual care, especially when (1) the intervention duration was ≥6 months (P=.04 and P=.001), (2) the mHealth intervention was a simple one (only 1 mHealth intervention was used) (P=.01 and P<.001), (3) it was implemented during the COVID-19 pandemic (P=.04 and P=.01), (4) it was implemented in low- or middle-income countries (P=.01 and P=.02), (5) the intervention focused on mental health (P=.01 and P=.007), and (6) adherence rates were high (≥90%; P=.03 and P=.002). In addition, comparing mHealth interventions to usual care, there was an improvement in QoL when (1) the mHealth intervention was a simple one (P<.001), (2) it was implemented in low- or middle-income countries (P<.001), and (3) the intervention focused on mental health (P<.001).

CONCLUSIONS

On the basis of the existing evidence, mHealth interventions might be effective in improving QoL and reducing anxiety and depression in patients with CHD. However, large sample, high-quality, and rigorously designed randomized controlled trials are needed to provide further evidence.

TRIAL REGISTRATION

PROSPERO CRD42022383858; https://tinyurl.com/3ea2npxf.

Digital health intervention in patients undergoing cardiac rehabilitation: systematic review and meta-analysis

Background

Cardiovascular disease (CVD) continues to be the foremost mortality internationally. Cardiac rehabilitation has proven as an effective program in reducing CVD burden. Participation in cardiac rehabilitation programs is very low. Digital health intervention emerged as an alternative method to deliver Cardiac rehabilitation. This review aimed to investigate the impact of digital health intervention on the outcomes of interest.

Methods

the following databases: PubMed, CINAHL, Scopus, and Cochrane Library have been searched to retrieve randomized controlled trials that examine the impact of digital health intervention on blood pressure, body mass index, lipid profile, blood glucose, Six-Minute Walk Test, and peak oxygen consumption. filters were set to include studies published in English between 2000-2023.

Results

Nineteen studies were included in this review. Six-Minute Walk Test (MD = 16.70; 95% CI: 6.00 to 27.39, p = 0.000) and maximal oxygen consumption (SMD = 0.27; 95% CI: 0.08 to 0.45, p = 0.004) significantly improved following digital health intervention, after employing the sensitivity analysis significant improvement was observed in systolic (MD = -2.54; 95% CI: -4.98 to -0.11, p = 0.04) and diastolic blood pressure (SMD = -2.0182; 95% CI: -3.9436 to -0.0928, p = 0.04) favoring experimental groups. Subgroup analysis revealed significant improvement in quality of life after three months of follow-up (SMD = 0.18; 95% CI: 0.05 to 0.31, p = 0.00), no significant differences have been observed in body mass index, lipid profile, and blood glucose.

Conclusion

The findings emphasize the significant impact of digital vs CBCR or usual care on physical capacity, blood pressure, and quality of life. Despite the non-statistically significant differences in body mass index and lipid profile, the comparable effect between the two methods suggests the superiority of digital over CBCR or usual care due to its convenient nature, accessibility, and cost-effectiveness.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Barriers to cardiac rehabilitation and patient perceptions on the usage of technologies in cardiac rehabilitation: A cross-sectional study

AIMS AND OBJECTIVES

The study aimed to identify factors associated with participation in Phase II cardiac rehabilitation and to assess patient perceptions towards the usage of technologies in cardiac rehabilitation.

BACKGROUND

Despite efforts to promote utilisation of cardiac rehabilitation (CR), participation among patients remains unsatisfactory. Little is known of patient decision to participate Phase II CR in a multi-ethnic country.

DESIGN

A cross-sectional study design.

METHODS

A consecutive sampling of 240 patients with coronary heart disease completed Coronary Artery Disease Education Questionnaire (CADE-Q) II, Hospital Anxiety and Depression Scale (HADS), Multidimensional Scale of Perceived Social Support (MSPSS) and Cardiac Rehabilitation Barriers Scale (CRBS).

RESULTS

Seventy per cent of patients (mean age 60.5 [SD = 10.6] years, 80.8% male) participated in phase II cardiac rehabilitation. Self-driving to cardiac rehabilitation centres, higher barriers in perceived need/health care and logistical factors were significantly associated with decreased odds of participation. Patients with more barriers from comorbidities/functional status, higher perceived social support from friends, and anxiety were more likely to participate. Chinese and Indians were less likely to participate when compared with Malays. More than 80% of patients used both home and mobile broadband internet, and 72.9% of them would accept the usage of technologies, especially educational videos, instant messenger, and video calls to partially replace the face-to-face, centre-based cardiac rehabilitation approach.

CONCLUSION

Several barriers were associated with non-participation in phase II cardiac rehabilitation. With the high perceived acceptance of technology usage in cardiac rehabilitation, home-based and hybrid cardiac rehabilitation may represent potential solutions to improve participation.

RELEVANCE TO CLINICAL PRACTICE

By addressing the barriers to cardiac rehabilitation, patients are more likely to be ready to adopt health behaviour changes and adhere to the cardiac rehabilitation programme. The high perceived acceptance of using technologies in cardiac rehabilitation may provide insights into new delivery models that can improve and overcome barriers to participation.

Patient-reported preferences in eHealth-based cardiac rehabilitation: A qualitative investigation of behavior change techniques, barriers and facilitators

Background

Cardiac rehabilitation (CR) reduces recurrent cardiac events and mortality in patients with cardiovascular diseases (CVD). Innovative eHealth methods can facilitate CR uptake and effectiveness by addressing barriers associated with clinic-based rehabilitation. Tailoring eHealth-based CR to patient preferences is needed to further enhance CR.

Purpose

To identify preferred behavior change techniques (BCTs) as well as barriers and facilitators for the different health behaviors targeted in eHealth-based CR among patients who have been referred to CR.

Methods

Thirty-nine patients were interviewed in nine focus groups in The Netherlands, Germany, and Spain. A thematic analysis, using a combined deductive and inductive approach to coding, was conducted to identify BCTs and barriers and facilitators to behavior change. Behaviors under investigation included physical activity, medication adherence, eating a cardiac healthy-diet, stress reduction and smoking cessation.

Results

The perceived helpfulness of BCTs depended on the specific behavior targeted. Common barriers were negative emotional state and physical limitations. A desire to feel physically or mentally well and having experienced a cardiac life event were the most common facilitators across health behaviors. Specific BCTs, barriers and facilitators were found for each of the health behavior.

Conclusions

Behavior change techniques that patients preferred for each health behavior targeted in eHealth-based CR were identified. A negative emotional state, experiencing a life event, and improving physical functioning are important barriers and facilitators in multiple behaviors targeted in eHealth-based CR programs. Additional tailoring of interventions to patient preferences for BCTs and patient-specific barriers and facilitators per health behavior could lead to further improvement of eHealth-based CR.

Behaviour change techniques and intervention characteristics in digital cardiac rehabilitation: a systematic review and meta-analysis of randomised controlled trials

Evidence suggests that digitally delivered cardiac rehabilitation (CR) is likely to be an effective alternative to centre-based CR. However, there is limited understanding of the behaviour change techniques (BCTs) and intervention characteristics included in digital CR programmes. This systematic review aimed to identify the BCTs and intervention characteristics that have been used in digital CR programmes, and to study those associated with effective programmes. Twenty-five randomised controlled trials were included in the review. Digital CR was associated with significant improvements in daily steps, light physical activity, medication adherence, functional capacity, and low-density lipoprotein-cholesterol when compared to usual care, and produced effects on these outcomes comparable to centre-based CR. The evidence for improved quality of life was mixed. Interventions that were effective at improving behavioural outcomes frequently employed BCTs relating to feedback and monitoring, goals and planning, natural consequences, and social support. Completeness of reporting on the TIDieR checklist across studies ranged from 42% to 92%, with intervention material descriptions being the most poorly reported item. Digital CR appears effective at improving outcomes for patients with cardiovascular disease. The integration of certain BCTs and intervention characteristics may lead to more effective interventions, however better intervention reporting is required.

Effectiveness of Telehealth Cardiac Rehabilitation Programs on Health Outcomes of Patients With Coronary Heart Diseases: An Umbrella Review

PURPOSE

The aim of this study was to conduct an umbrella review summarizing the evidence from existing systematic reviews of telehealth cardiac rehabilitation (CR) on health outcomes of patients with coronary heart disease (CHD).

REVIEW METHODS

An umbrella review of systematic reviews was undertaken in accordance with the PRISMA and JBI guidelines. A systematic search was conducted in Medline, APA PsycINFO, Embase, CINAHL, Web of Science, Cochrane database of systematic reviews, JBI evidence synthesis, Epistemonikos, and PROSPERO, searching for systematic reviews published from 1990 to current and was limited to the language source of English and Chinese. Outcomes of interest were health behaviors and modifiable CHD risk factors, psychosocial outcomes, and other secondary outcomes. Study quality was appraised using the JBI checklist for systematic reviews. A narrative analysis was conducted, and meta-analysis results were synthesized.

SUMMARY

From 1301 identified reviews, 13 systematic reviews (10 meta-analyses) comprised 132 primary studies conducted in 28 countries. All the included reviews have high quality, with scores ranging 73-100%. Findings to the health outcomes remained inconclusive, except solid evidence was found in the significant improvement in physical activity (PA) levels and behaviors from telehealth interventions, exercise capacity from mobile health (m-health) only and web-based only interventions, and medication adherence from m-health interventions. Telehealth CR programs, work adjunct or in addition to traditional CR and standard care, are effective in improving health behaviors and modifiable CHD risk factors, particularly in PA. In addition, it does not increase the incidence in terms of mortality, adverse events, hospital readmission, and revascularization.

The effectiveness of interactive cardiac rehabilitation web applications versus usual care on programme completion in patients with cardiovascular disease: A systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Although available evidence demonstrates positive clinical outcomes for patients attending and completing cardiac rehabilitation, the effectiveness of interactive cardiac rehabilitation web applications on programme completion has not been systematically examined.

METHODS

This JBI systematic review of effects included studies measuring effectiveness of interactive cardiac rehabilitation web applications compared to telephone, and centre-based programmes. Outcome data were pooled under programme completion and clinical outcomes (body mass index, low-density lipoproteins, and blood pressure). Databases including MEDLINE (via Ovid), Cochrane Library, Scopus (via Elsevier) and CINAHL (via EBSCO) published in English were searched. Articles were screened and reviewed by two independent reviewers for inclusion, and the JBI critical appraisal tool and Grading of Recommendations Assessment, Development and Evaluation tool were applied to appraise and assess the certainty of the findings of the included studies. A meta-analysis of the primary and secondary outcomes used random effects models.

RESULTS

In total, nine studies involving 1175 participants who participated in web-based cardiac rehabilitation to usual care were identified. The mean critical appraisal tool score was 76 (standard deviation: 9.7) with all (100%) studies scoring >69%, and the certainty of evidence low. Web-based programmes were 43% more likely to be completed than usual care (risk ratio: 1.43; 95% confidence interval: 0.96, 2.13) There was no difference between groups for clinical outcomes.

DISCUSSION

Despite the relatively small number of studies, high heterogeneity and the limited outcome measures, the results appeared to favour web-based cardiac rehabilitation with regard to programme completion.

Cardiac Rehabilitation in the Modern Era: Optimizing Recovery and Reducing Recurrence

Cardiovascular diseases (CVDs) continue to be a prominent issue in global health, emphasizing the necessity for efficient cardiac rehabilitation programs. This narrative review provides a detailed analysis of the current state of cardiac rehabilitation, focusing on maximizing recovery and minimizing the likelihood of recurrence. This paper examines the historical progression of cardiac rehabilitation, explores the epidemiological background of cardiovascular disease (CVD), and provides an overview of the many stages of the rehabilitation process. The assessment of patients plays a crucial role in healthcare, serving as a fundamental basis that incorporates medical, psychological, and social aspects. The utilization of risk stratification techniques further enhances this process. The present study investigates exercise training, particularly emphasizing the current recommendations and the mutually beneficial effects of aerobic and resistance regimens. In addition to physical therapies, this study emphasizes the importance of nutrition, lifestyle adjustments, and the significant effects of medication. Psychosocial assistance is a crucial element that addresses the significant psychological effects of cardiac disease and provides comprehensive techniques for overall well-being. Technological advancements are significantly transforming the domain of cardiac rehabilitation, encompassing the integration of wearable technologies and telemedicine solutions. The convergence of artificial intelligence and data analytics can enhance the customization of healthcare services. Through a comprehensive rehabilitation program, patients can achieve an improved quality of life and enhanced functional outcomes. However, it is essential to acknowledge that obstacles still hinder individuals from accessing and completing educational programs. Therefore, it is crucial to engage in a discourse on potential tactics that may be employed to address these issues, considering the various cultural and socioeconomic aspects that contribute to them. The analysis focuses on the economic dimension, examining the cost-effectiveness of rehabilitation programs and their congruence with healthcare policies. In anticipation of future developments, the study provides valuable perspectives on the prospective trajectory of cardiac rehabilitation. It delves into nascent patterns and examines the potential ramifications of precision medicine and genetics for tailoring treatment strategies to individual patients. In brief, this narrative review comprehensively examines the various dimensions of contemporary cardiac rehabilitation. It offers a comprehensive perspective on its significance in enhancing recuperation and mitigating the likelihood of the recurrence of cardiovascular ailments. The significance of this review lies in its ability to enhance patient outcomes, thereby making a valuable contribution to the worldwide endeavor to address the burden of cardiovascular disease.

Advances in Technology Promote Patient-Centered Care in Cardiac Rehabilitation

Patient-centered health care (PCC) is a framework of clinical care focused on the patient's individual health care needs. In particular, it emphasizes the development of a partnership between the patient, physician, and healthcare workers to actively involve and empower the patient in their health care decisions. Additionally, PCC goals include ensuring access to care, emotional support, engaging patient support systems, physical comfort, and continuity of care. Technology also provides a platform to engage patients and their families in their care and can be a useful tool to gauge their level of interest, knowledge, and motivations to adequately educate them on the many factors that contribute to their disease, including diet, exercise, medication adherence, psychological support, and early symptom detection. In this article, we summarize the importance of technology in promoting PCC in cardiac rehabilitation and the impact technology may have on the different aspects of patient and physician relationships. Modern technological devices including smartphones, tablets, wearables, and other internet-enabled devices have been shown to help patient-staff communication, cater to patients' individual needs, increase access to health care, and implement aspects of PCC domains.

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

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

Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review

Background

There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies.

Methods

We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers.

Results

In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services.

Conclusions

The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access.

Limitations

Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified.

Future work

High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward.

Funding

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health.

Study registration

The study protocol is registered with PROSPERO [CRD42022309214].

The cost-effectiveness of exercise-based cardiac telerehabilitation intervention: a systematic review

INTRODUCTION

Alternatives such as remotely delivered therapy in the home environment or telehealth represent an opportunity to increase overall cardiac rehabilitation (CR) utilization. Implementing alternatives into regular practice is the next step in development; however, the cost aspect is essential for policymakers. Limited economic budgets lead to cost-effectiveness analyses before implementation. They are appropriate in cases where there is evidence that the compared intervention provides a similar health benefit to usual care. This systematic review aimed to compare the cost-effectiveness of exercise-based telehealth CR interventions compared to standard exercise-based CR.

EVIDENCE ACQUISITION

PubMed and Web of Science databases were systematically searched up to August 2022 to identify randomized controlled trials assessing patients undergoing telehealth CR. The intervention was compared to standard CR protocols. The primary intent was to identify the cost-effectiveness. Interventions that met the criteria were home-based telehealth CR interventions delivered by information and communications technology (telephone, computer, internet, or videoconferencing) and included the results of an economic evaluation, comparing interventions in terms of cost-effectiveness, utility, costs and benefits, or cost-minimization analysis. The systematic review protocol was registered in the PROSPERO Registry (CRD42022322531).

EVIDENCE SYNTHESIS

Out of 1525 identified studies, 67 articles were assessed for eligibility, and, at the end of the screening process, 12 studies were included in the present systematic review. Most studies (92%) included in this systematic review found strong evidence that exercise-based telehealth CR is cost-effective. Compared to CBCR, there were no major differences, except for three studies evaluating a significant difference in average cost per patient and intervention costs in favor of telehealth CR.

CONCLUSIONS

Telehealth CR based on exercise is as cost-effective as CBCR interventions. Funding telehealth CR by third-party payers may promote patient participation to increase overall CR utilization. High-quality research is needed to identify the most cost-effective design.

Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle-income setting: A randomized controlled trial protocol

Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower-resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart-health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle-income country. Following a pilot study, a single-center, single-blinded, 2 parallel-arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre-intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6-month intervention comprises an app, website, SMS texts with generic heart-health management advice, and bi-weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent-to-treat. If results of this novel trial of women-focused eCR in a middle-income country demonstrate clinically-significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.

Physiological and psychological effects of a 12-week home-based telemonitored training in metabolic syndrome

Background

Metabolic Syndrome (MetS) increases the risk of cardiovascular diseases (CVD) and affects around one fourth of the population worldwide. In the prevention and treatment regular exercise trainings are inevitable. Providing personal supervision in out/inpatient care settings for such a large target population challenges the healthcare systems, but using telemonitoring of the home-performed trainings could be a promising and widely available option.

Objectives

The aim of this study was to evaluate the physiological and psychological effects of a 12-week home-based physical training program, telemonitored by widely available fitness devices on parameters of MetS patients.

Methods

A total of 55 MetS patients (mean age 49.19 ± 7.93 years) were involved in the study. They were asked to perform 3-5 sessions of exercise activity (min. 150 min) each week for 12 weeks. Trainings were monitored off-line by heart rate sensors, a fitness application and a cloud-based data transfer system. Physiotherapists supervised, coached, and feedback the trainings through an online coach system. We investigated different anthropometric parameters, maximum exercise and functional capacity levels, laboratory parameters, the level of depression, insomnia, vital exhaustion, and wellbeing as well.

Results

The average weekly training time was 152.0 ± 116.2 min. Out of the 55 participants who completed the program, 22 patients (40%) performed the recommended 150 min or more weekly. Patients showed statistically significant changes in: all the measured waist and hip circumferences; 6-min walk distance (6MWD; from 539.69 ± 78.62 to 569.72 ± 79.96 m, p < 0.001); maximal exercise capacity (11.02 ± 2.6 to 12.14 ± 2 MET, p < 0.001), stress-electrocardiogram duration time (13.74 ± 3.29 to 15.66 ± 2.64 min, p < 0.001); body weight (98.72 ± 21.7 to 97.45 ± 21.76 kg, p = 0.004); high-density lipoprotein cholesterol (n = 45, 1.28 ± 0.31 to 1.68 ± 0.36 mmol/L, p < 0.001); fasting plasma glucose (FPG; n = 47, 6.16 ± 1.26 to 5.44 ± 1.31 mmol/L, p = 0.001); glycated hemoglobin A1c (HbA1c; n = 41, 6.22 ± 0.68 to 5.87 ± 0.78%, p = 0.01). Out of the 55 patients who finished the program 38 patients (70%) completed all the psychological questionnaires. We found statistically significant decrease of the overall scores of the Maastricht Vital Exhaustion Questionnaire, from 3.37 ± 2.97 points to 2.63 ± 2.70 points (p < 0.05) and a significant increase of the overall scores of the WHO Wellbeing Scale from 9.92 ± 2.59 points to 10.61 ± 2.76 points (p < 0.05). We have not found any statistically significant changes in the scores of the Beck Depression Inventory and the Athens Insomnia Scale.

Conclusion

A 12-week home-based telemonitored training supported by an affordable, commonly available device system produces positive, statistically significant changes in many core components in MetS patients. Telemonitoring is a cheap method for coaching and feeding back the home-based interventions.

Effectiveness of Home-Based Cardiac Rehabilitation, Using Wearable Sensors, as a Multicomponent, Cutting-Edge Intervention: A Systematic Review and Meta-Analysis

Exercise-based cardiac rehabilitation is a highly recommended intervention towards the advancement of the cardiovascular disease (CVD) patients’ health profile; though with low participation rates. Although home-based cardiac rehabilitation (HBCR) with the use of wearable sensors is proposed as a feasible alternative rehabilitation model, further investigation is needed. This systematic review and meta-analysis aimed to evaluate the effectiveness of wearable sensors-assisted HBCR in improving the CVD patients’ cardiorespiratory fitness (CRF) and health profile. PubMed, Scopus, Cinahl, Cochrane Library, and PsycINFO were searched from 2010 to January 2022, using relevant keywords. A total of 14 randomized controlled trials, written in English, comparing wearable sensors-assisted HBCR to center-based cardiac rehabilitation (CBCR) or usual care (UC), were included. Wearable sensors-assisted HBCR significantly improved CRF when compared to CBCR (Hedges’ g = 0.22, 95% CI 0.06, 0.39; I2 = 0%; p = 0.01), whilst comparison of HBCR to UC revealed a nonsignificant effect (Hedges’ g = 0.87, 95% CI −0.87, 1.85; I2 = 96.41%; p = 0.08). Effects on physical activity, quality of life, depression levels, modification of cardiovascular risk factors/laboratory parameters, and adherence were synthesized narratively. No significant differences were noted. Technology tools are growing fast in the cardiac rehabilitation era and promote exercise-based interventions into a more home-based setting. Wearable-assisted HBCR presents the potential to act as an adjunct or an alternative to CBCR.

[The importance of cardiorehabilitation in the era of modern treatment of cardio-vascular diseases]

Cardiac rehabilitation (CR) has a class IA indication in international and national guidelines as an intervention with proven efficacy for decreasing cardiovascular and all-cause mortality in various categories of cardiological patients. However, CR is one of the least used current technologies for the treatment of patients with cardiovascular diseases worldwide. This article presents the state of the CR problem during the epoch of high-tech treatments of cardiovascular diseases; the prevalence of using CR in various countries; traditional and new methodological approaches, including telemedicine; and clinical and prognostic effects of CR in various categories of patients with cardiovascular diseases.

Revisiting secondary prevention in coronary heart disease

Secondary prevention in coronary heart disease is the prevention of occurrence of recurrent coronary events after clinical diagnosis. High level of adherence to secondary prevention interventions, especially aggressive lifestyle changes and pharmacotherapy can lead to significant decline in recurrent coronary events. Both international and Indian studies have reported low adherence to such therapies. Evidence-based useful interventions include regular physical activity, yoga, intake of healthy diet, smoking and tobacco use cessation and weight management. Pharmacotherapeutic interventions useful are anti-platelet therapy, target oriented lipid lowering therapy with statins, beta blockers and angiotensin converting enzyme inhibitors in patients with impaired left ventricular function. Hypertension and diabetes management with control to targets is important. Novel strategies include use of anticoagulants, anti-inflammatory drugs, and triglyceride lowering for residual risk. Physician and patient level interventions using multifaceted educational, socioeconomic and technological innovations are important to promote life-long adherence to these strategies.

Preventive Cardiology in the Digital and COVID-19 Era: A Brave New World within the Veterans Health Administration

The past year challenged patients, health care providers, and health systems alike to adapt and recalibrate to meet healthcare needs within pandemic constraints. The coronavirus 2019 (COVID-19) pandemic has radically interfered with the accessibility and delivery of cardiovascular care in the United States. With an emphasis on social distancing and stay-at-home orders in effect, many Americans delayed seeking routine medical care and treatment for acute cardiac symptoms due to fear of contracting the coronavirus. The COVID-19 pandemic compelled a rapid shift toward virtual care solutions across cardiovascular domains. The U.S Department of Veterans Affairs (VA) expanded virtual modalities, notably in specialty care and rehabilitation, which offered secure solutions to maintain treatment continuity. Within the VA and other health systems, virtual cardiac rehabilitation (CR) was embraced as an efficacious alternative to on-site cardiac rehabilitation that enabled patients to receive cardiac care remotely. Leveraging the infrastructure and lessons learned from the pandemic-induced expansion of virtual care carries enormous potential to refine virtual CR and revitalize future treatment paradigms for cardiovascular disease patients.