Feasibility of home-based cardiac rehabilitation using an integrated telerehabilitation platform in elderly patients with heart failure: A pilot study

Effectiveness of home-based cardiac telerehabilitation based on wearable ECG or heart rate monitoring devices in patients with heart disease: A meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of home-based cardiac telerehabilitation based on wearable electrocardiogram or heart rate monitoring devices in patients with heart disease.

METHODS

We searched eight electronic databases under the guidance of Cochrane Handbook and PRISMA recommendations.

RESULTS

The meta-analysis included data from 14 articles (15 RCTs) representing 1314 participants. A significant improvement in left ventricular ejection fraction [MD = 2.12, 95 % CI (1.21, 3.04), P < 0.001], 6-minute walk distance [MD = 40.00, 95 % CI (21.72, 58.29), P < 0.001] and peak oxygen intake [MD = 2.24, 95 % CI (1.38, 3.10), P < 0.001] were observed in the home-based cardiac telerehabilitation group. But it had no difference in anxiety [SMD = -0.83, 95 % CI (-1.65, -0.02), P = 0.05] and depression [SMD = -0.59, 95 % CI (-1.26, 0.09), P = 0.09]. Subgroup analyses revealed that interventions of no less than 3 months improved anxiety [SMD = -1.11, 95 % CI (-2.05, -0.18), P = 0.02] and depression [SMD = -1.01, 95 % CI (-1.93, -0.08), P = 0.03].

CONCLUSION

Home-based cardiac telerehabilitation based on wearable electrocardiogram or heart rate monitoring devices has a positive effect on cardiac function. Long-term (≥ 3 months) cardiac rehabilitation might benefit individuals suffering from anxiety or depression.

Comprehensive Cardiac Rehabilitation Following Acute Myocardial Infarction Improves Clinical Outcomes Regardless of Exercise Capacity

BACKGROUND

Reduced exercise capacity is a prognostic indicator of adverse outcomes in patients with acute myocardial infarction (AMI). However, few studies have evaluated the effectiveness of comprehensive cardiac rehabilitation (CR) in this population. This study aimed to clarify the efficacy of comprehensive CR in patients with AMI and reduced exercise capacity.Methods and Results: This cohort study included 610 patients with AMI who underwent percutaneous coronary intervention. Major adverse cardiovascular events (MACE) were compared between patients who participated in comprehensive outpatient CR for 150 days (CR group; n=430) and those who did not (non-CR group; n=180). During the mean (±SD) follow-up period of 6.1±4.0 years, the CR group exhibited a lower incidence of MACE (log-rank P=0.002). Multivariable analysis revealed that Killip classification, diuretics at discharge, and participation in comprehensive CR were independently associated with MACE. The CR group was further divided into 2 groups, namely reduced exercise capacity (% predicted peak V̇O2<80%; n=241) and preserved exercise capacity (≥80%; n=147), based on the initial cardiopulmonary exercise test. Despite distinct exercise capacities, the incidence of MACE was comparable and physical parameters improved similarly after comprehensive CR in both groups.

CONCLUSIONS

Comprehensive CR in patients with AMI effectively reduced the incidence of MACE regardless of initial exercise capacity. Cardiologists should actively encourage patients with low exercise capacity to participate in comprehensive CR.

Prognostic Value of Objective Social Isolation and Loneliness in Older Patients With Heart Failure: Subanalysis of FRAGILE-HF and Kitasato Cohort

BACKGROUND

Social factors encompass a broad spectrum of nonmedical factors, including objective (social isolation [SI]) and perceived (loneliness) conditions. Although social factors have attracted considerable research attention, information regarding their impact on patients with heart failure is scarce. We aimed to investigate the prognostic impact of objective SI and loneliness in older patients with heart failure.

METHODS AND RESULTS

This study was conducted using the FRAGILE-HF (Prevalence and Prognostic Value of Physical and Social Frailty in Geriatric Patients Hospitalized for Heart Failure; derivation cohort) and Kitasato cohorts (validation cohort), which included hospitalized patients with heart failure aged ≥65 years. Objective SI and loneliness were defined using the Japanese version of Lubben Social Network Scale-6 and diagnosed when the total score for objective and perceived questions on the Lubben Social Network Scale-6 was below the median in the FRAGILE-HF. The primary outcome was 1-year death. Overall, 1232 and 405 patients in the FRAGILE-HF and Kitasato cohorts, respectively, were analyzed. Objective SI and loneliness were observed in 57.8% and 51.4% of patients in the FRAGILE-HF and 55.4% and 46.2% of those in the Kitasato cohort, respectively. During the 1-year follow-up, 149 and 31 patients died in the FRAGILE-HF and Kitasato cohorts, respectively. Cox proportional hazard analysis revealed that objective SI, but not loneliness, was significantly associated with 1-year death after adjustment for conventional risk factors in the FRAGILE-HF. These findings were consistent with the validation cohort.

CONCLUSIONS

Objective SI assessed using the Lubben Social Network Scale-6 may be a prognostic indicator in older patients with heart failure. Given the lack of established SI assessment methods in this population, further research is required to refine such methods.

Telerehabilitation: Exploring the Untapped Potential

Telerehabilitation is a burgeoning field that holds immense promise in revolutionizing the delivery of rehabilitation services. Defined as a branch of telecommunication utilizing technologies such as the internet, it facilitates remote interaction between healthcare providers and patients, transcending geographical barriers. This method proves invaluable in patient assessment, counseling, and treatment across various medical domains, including physical therapy, speech therapy, psychotherapy, and occupational therapy. Particularly beneficial for individuals with disabilities or those unable to access traditional healthcare facilities, telerehabilitation mitigates the constraints of time and cost associated with travel. This paper explores the evolution, types, uses, and research findings in telerehabilitation, shedding light on its transformative potential in health care.

An 8-Week Virtual Exercise Training Program for Pediatric Solid Organ Transplant Recipients

PURPOSE

Musculoskeletal strength can be impaired in pediatric solid organ transplant recipients. Exercise training programs can be beneficial but in-person delivery can be challenging; virtual exercise programs can alleviate some of these challenges. This feasibility study aimed to deliver an 8-week virtual exercise program in pediatric solid organ transplant recipients.

METHOD

Program delivery occurred 3 times per week for 30 minutes. An exercise stress test was completed prior to program start. The Bruininks-Oseretsky Test of Motor Proficiency strength subtest and self-report surveys were used to assess musculoskeletal strength, quality of life, fatigue, and physical activity. Contact was maintained through a text messaging platform. Z scores were calculated using standardized normative data. Medians (interquartile range) are reported for all other data.

RESULTS

Eleven participants completed the program (2 liver, 5 kidney, 4 heart; 58% females; median age = 11.5 [10.3-13.8] y). Six participants attended ≥60% of classes, 5 participants attended <50% of classes. After 8 weeks, strength scores improved (Z score, Pre: -1.0 [-1.65 to -0.60] to Post: -0.2 [-1.30 to 0.40]; P = .007) with no change in other outcome measures.

CONCLUSION

The virtual exercise program was delivered without technical issues and received positive participant feedback. Engagement and costs need to be considered.

Comprehensive home-based telerehabilitation in a morbidly obese male patient with severe obstructive sleep apnea. A case report

BACKGROUND

Rehabilitation may be an effective additional treatment method in patients with obstructive sleep apnea (OSA). Physical exercise, weight reduction, pulmonary rehabilitation, and myofunctional therapy (MT) represent beneficial components of rehabilitation recommended as a possible adjunct to standard OSA treatment.

METHODS AND RESULTS

A 54-year-old man with morbid obesity, long-lasting snoring, breathing pauses, frequent waking, as well as persistent drowsiness and fatigue during the day underwent polysomnography (PSG) to investigate suspected OSA. Severe OSA was confirmed by PSG and a 12-week comprehensive, home-based telerehabilitation program (tele-RHB program) along with continuous positive airway pressure (CPAP) therapy was implemented. The tele-RHB program included regular teleconsultations, aerobic-endurance training, MT, inspiratory and expiratory muscle training, as well as recommendations on proper nutrition, a healthy lifestyle, and behavioral changes. Following the treatment, the patient's quality of life (QoL), exercise capacity, lung function, and OSA severity significantly improved. The patient achieved an overall 19.9 kg reduction in weight, of which 16.2 kg was body fat, and his apnea-hypopnea index decreased by 42.6 episodes/hour.

CONCLUSION

Our case report suggests that the comprehensive home-based tele-RHB program adjunct to CPAP therapy may be a novel approach for improving OSA severity, a patient's QoL, exercise capacity, lung function and body composition. It is important to note that such a program should be optional, however it may be needed to achieve the highest possible overall improvement in a patient's life. Further clinical investigations are needed to determine the therapeutic efficacy and clinical potential of this tele-RHB program.

Remote Cardiac Rehabilitation With Wearable Devices

Although cardiac rehabilitation (CR) has been shown to improve exercise tolerance and prognosis in patients with cardiovascular diseases, there remains low participation in outpatient CR. This may be attributed to the patients' busy schedules and difficulty in visiting the hospital due to distance, cost, avoidance of exercise, and severity of coronary disease. To overcome these challenges, many countries are exploring the possibility of remote CR. Specifically, there is increasing attention on the development of remote CR devices, which allow transmission of vital information to the hospital via a remote CR application linked to a wearable device for telemonitoring by dedicated hospital staff. In addition, remote CR programs can support return to work after hospitalization. Previous studies have demonstrated the effects of remote CR on exercise tolerance. However, the preventive effects of remote CR on cardiac events and mortality remain controversial. Thus, safe and effective remote CR requires exercise risk stratification for each patient, telenursing by skilled staff, and multidisciplinary interventions. Therefore, quality assurance of telenursing and multi-disciplinary interventions will be essential for remote CR. Remote CR may become an important part of cardiac management in the future. However, issues such as cost-effectiveness and insurance coverage still persist.

A scoping review of the feasibility, acceptability, and effects of physiotherapy delivered remotely

PURPOSE

To review the feasibility, acceptability, and effects of physiotherapy when delivered remotely.

MATERIALS AND METHODS

CINAHL, MEDLINE, EBM Reviews, and Cochrane Library databases (January 2015-February 2022) were searched and screened for papers (of any design) investigating remote physiotherapy. Data were extracted by two independent raters. Methodological quality of the identified papers was not assessed. Thematic content analysis drew out the key issues.

RESULTS

Forty-one papers (including nine systemic reviews and six with meta-analyses) were selected involving musculoskeletal, stroke and neurological, pulmonary, and cardiac conditions. The most commonly delivered intervention was remote exercise provision, usually following assessment which was completed in-person. All studies, which assessed it, found that remote physiotherapy was comparably effective to in-person delivery at lower cost. Patient satisfaction was high, they found remote physiotherapy to be more accessible and convenient. It boosted confidence and motivation by reminding patients when and how to exercise but adherence was mixed. No adverse events were reported. Barriers related to access to the technology; technical problems and concerns about therapists' workload.

CONCLUSIONS

Remote physiotherapy is safe, feasible, and acceptable to patients. Its effects are comparable with traditional care at lower cost.IMPLICATIONS FOR REHABILITATIONRemote physiotherapy is safe, feasible, and acceptable to patients with comparable effects to in-person care.Remote delivery increases access to physiotherapy especially for those who cannot travel to a treatment facility whether due to distance or disability.Remote physiotherapy may increase adherence to exercise by reminding patients when and how to exercise.Remote physiotherapy does not suit everyone, thus a hybrid system with both in-person and remote delivery may be most effective.

Disease management using home-based cardiac rehabilitation for patients with heart failure

Home-based cardiac rehabilitation (HBCR) is expected to address the low participation rate in cardiac rehabilitation; however, it is not covered by insurance in Japan, and the optimal method for monitoring a patient's condition during exercise has not been determined. Patients hospitalized for heart failure often deteriorate soon after discharge and require appropriate disease monitoring. In this report, we describe cases in which real-time monitoring of exercise intensity, electrocardiography, and video chat during HBCR was useful in the management of heart failure. Furthermore, the use of HBCR enabled frequent disease monitoring, even during the coronavirus disease 2019 pandemic, and timely medicine adjustment.

Learning objective

Clinicians cannot perform radiography, blood tests, or physical examinations at home during home-based cardiac rehabilitation (HBCR). Therefore, it is particularly important to reconsider the appropriate monitoring indicators for HBCR and apply them to disease management. Our cases suggest that real-time monitoring of the following three indicators is useful for disease management using HBCR: (1) exercise intensity, (2) electrocardiography, and (3) shortness of breath.

Evaluation of the efficacy and safety of an integrated telerehabilitation platform for home-based cardiac REHABilitation in patients with heart failure (E-REHAB): protocol for a randomised controlled trial

INTRODUCTION

Cardiac rehabilitation (CR) is strongly recommended as a medical treatment to improve the prognosis and quality of life of patients with heart failure (HF); however, participation rates in CR are low compared with other evidence-based treatments. One reason for this is the geographical distance between patients' homes and hospitals. To address this issue, we developed an integrated telerehabilitation platform, RH-01, for home-based CR. We hypothesised that using the RH-01 platform for home-based CR would demonstrate non-inferiority compared with traditional centre-based CR.

METHODS AND ANALYSIS

The E-REHAB trial aims to evaluate the efficacy and safety of RH-01 for home-based CR compared with traditional centre-based CR for patients with HF. This clinical trial will be conducted under a prospective, randomised, controlled and non-inferiority design with a primary focus on HF patients. Further, to assess the generalisability of the results in HF to other cardiovascular disease (CVD), the study will also include patients with other CVDs. The trial will enrol 108 patients with HF and 20 patients with other CVD. Eligible HF patients will be randomly assigned to either traditional centre-based CR or home-based CR in a 1:1 fashion. Patients with other CVDs will not be randomised, as safety assessment will be the primary focus. The intervention group will receive a 12-week programme conducted two or three times per week consisting of a remotely supervised home-based CR programme using RH-01, while the control group will receive a traditional centre-based CR programme. The primary endpoint of this trial is change in 6 min walk distance.

ETHICS AND DISSEMINATION

The conduct of the study has been approved by an institutional review board at each participating site, and all patients will provide written informed consent before entry. The report of the study will be disseminated via scientific fora, including peer-reviewed publications and presentations at conferences.

TRIAL REGISTRATION NUMBER

jRCT:2052200064.

Role of wearable devices in cardiac telerehabilitation: A scoping review

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based comprehensive program that includes exercise training, health education, physical activity promotion, and extensive counseling for the management of cardiovascular risk factors. Wearable devices monitor certain physiological functions, providing biometric data such as heart rate, movement, sleep, ECG analysis, blood pressure, energy expenditure, and numerous other parameters. Recent evidence supports wearable devices as a likely relevant component in cardiovascular risk assessment and disease prevention. The purpose of this scoping review is to better understand the role of wearable devices in home-based CR (HBCR) and to characterize the evidence regarding the incorporation of wearable devices in HBCR programs and cardiovascular outcomes.

METHODS & FINDINGS

We created a search strategy for multiple databases, including PubMed, Embase (Elsevier), CINAHL (Ebsco), Cochrane CENTRAL (Wiley), and Scopus (Elsevier). Studies were included if the patients were eligible for CR per Medicare guidelines and >18 years of age and if some type of wearable device was utilized during HBCR. Our search yielded 57 studies meeting all criteria. The studies were classified into 4 groups: patients with coronary heart disease (CHD) without heart failure (HF); patients with HF; patients with heart valve repair or replacement; and patients with exposure to center-based CR. In three groups, there was an upward trend toward improvement in quality of life (QOL) and peak VO2, less sedentary time, and an increase in daily step count in the intervention groups compared to control groups.

CONCLUSIONS

HBCR using wearable devices can be a comparable alternative or adjunct to center-based CR for patients with CHD and HF. More studies are needed to draw conclusions about the comparability of HBCR to center-based CR in patients with heart valve repair or replacement.

Efficacy and Safety of Home-Based Cardiac Telemonitoring Rehabilitation in Patients After Transcatheter Aortic Valve Implantation: Single-Center Usability and Feasibility Study

BACKGROUND

No consensus exists on the efficacy of home-based cardiac rehabilitation (CR) in patients who have undergone transcatheter aortic valve implantation (TAVI). Additionally, there are no reports on home-based cardiac telemonitoring rehabilitation (HBTR) in patients after TAVI.

OBJECTIVE

We aimed to investigate the efficacy of HBTR in patients who have undergone TAVI.

METHODS

This single-center preliminary study introduced HBTR to patients after TAVI, and the efficacy outcomes of the rehabilitation method were compared to that of a historical control cohort. The historical control cohort (control group) consisted of 6 consecutive patients who underwent ordinary outpatient CR after TAVI from February 2016 to March 2020. Patients who participated in the HBTR program were only recruited after the TAVI procedure and before discharge between April 2021 and May 2022. In the first 2 weeks after TAVI, patients underwent outpatient CR and were trained using telemonitoring rehabilitation systems. Thereafter, patients underwent HBTR twice a week for 12 weeks. The control group performed standard outpatient CR at least once a week for 12 to 16 weeks. Efficacy was assessed using peak oxygen uptake (VO₂) prior to and after CR.

RESULTS

Eleven patients were included in the HBTR group. All patients underwent 24 HBTR sessions during the 12-week training period, and no adverse events were observed. The control group participants performed 19 (SD 7) sessions during the training period, and no adverse events were observed. Participants in the HBTR and control groups had a mean age of 80.4 (SD 6.0) years and 79.0 (SD 3.9) years, respectively. In the HBTR group, preintervention and postintervention peak VO₂ values were 12.0 (SD 1.7) mL/min/kg and 14.3 (SD 2.7) mL/min/kg (P=.03), respectively. The peak VO₂ changes in the HBTR and control groups were 2.4 (SD 1.4) mL/min/kg and 1.3 (SD 5.0) mL/min/kg (P=.64), respectively.

CONCLUSIONS

Home-based CR using a telemonitoring system is a safe outpatient rehabilitation method. Its efficacy is not inferior to that of standard CR in patients who have undergone TAVI.

TRIAL REGISTRATION

Japan Registry of Clinical Trials jRCTs032200122; https://jrct.niph.go.jp/latest-detail/jRCTs032200122.

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.

Epidemiology, Pathophysiology, Diagnosis, and Therapy of Heart Failure With Preserved Ejection Fraction in Japan

Heart failure (HF) with preserved ejection fraction (HFpEF) is a global health care problem, with diagnostic difficulty, limited treatment options and high morbidity and mortality rates. The prevalence of HFpEF is increasing because of the aging population and the increasing burden of cardiac and metabolic comorbidities, such as systemic hypertension, diabetes, chronic kidney disease, and obesity. The knowledge base is derived primarily from the United States and Europe, and data from Asian countries, including Japan, remain limited. Given that phenotypic differences may exist between Japanese and Western patients with HFpEF, careful characterization may hold promise to deliver new therapy specific to the Japanese population. In this review, we summarize the current knowledge regarding the epidemiology, pathophysiology and diagnosis of and the potential therapies for HFpEF in Japan.

Current situation of telemedicine research for cardiovascular risk in Japan

Hypertension continues to be a principal risk factor for the occurrence of cardiovascular disorders, stroke, and kidney diseases. Although more than 40 million subjects suffer from hypertension in Japan, its optimal control is achieved only a subpopulation of patients, highlighting the need for novel approaches to manage this disorder. Toward the better control of blood pressure, the Japanese Society of Hypertension has developed the Future Plan, in which the application of the state-of-art information and communication technology, including web-based resources, artificial intelligence, and big data analysis, is considered as one of the promising solutions. In fact, the rapid advance of digital health technologies, as well as ongoing coronavirus disease 2019 pandemic, has triggered the structural changes in the healthcare system globally, increasing demand for the remote delivery of the medical services. Nonetheless, it is not entirely clear what evidence exists that support the widespread use of telemedicine in Japan. Here, we summarize the current status of telemedicine research, particularly in the field of hypertension and other cardiovascular risk factors. We note that there have been very few interventional studies in Japan that clearly showed the superiority or noninferiority of telemedicine over standard care, and that the methods of online consultation considerably varied among studies. Clearly, more evidence is necessary for wide implementation of telemedicine in hypertensive patients in Japan, and also those with other cardiovascular risk factors.

National survey on the secondary preventive measures for coronary artery disease among interventional cardiologists: a report from the Japanese Association of Cardiovascular Intervention and Therapeutics

Insights from recent clinical trial testing revascularization strategies have interested interventional cardiologists in optimal medical therapy and secondary prevention modalities. As no large-scale survey has been recently conducted, this report presents the results of a nationwide survey on interventionists' concerns regarding secondary prevention after percutaneous coronary intervention (PCI) and discusses medical support system needs in Japan. A questionnaire to assess the status and challenges of secondary prevention interventions by interventional cardiologists during outpatient visits was supplied to Cardiovascular Interventional Technology (CVIT)-certificated hospitals. This was answered by representative cardiologists of each hospital and comprised three queries: (1) the necessity of outpatient cardiac rehabilitation to promote post-PCI lifestyle guidance; (2) the feasibility of providing lifestyle guidance; and (3) the barriers to lifestyle guidance, during outpatient visits. Questions 1 and 2 were answered using a 5-point Likert scale. Survey responses were received from 391 hospitals (54.9% of 712 CVIT-certificated facilities). For Question 1, 327 hospitals (84.1%) answered "agree", and 386 hospitals (98.7%) answered "agree" or "somewhat agree". For Question 2, 10% of hospitals answered "agree", and "agree" and "somewhat agree" amounted to less than 50%. For Question 3, 83.5% of the facilities answered lack of time as the major reason). The next reasons included an early reverse referral to family doctors after PCI, and a lack of managerial advantage (60% and 40% of the hospitals, respectively). In conclusion, interventionists are concerned about secondary prevention for their patients. The issues clarified in the survey will be important for developing next-generation secondary prevention systems.

A scoping review of feasibility, cost, access to rehabilitation services and implementation of telerehabilitation: Implications for low- and middle-income countries

Objective

To scope all published information reporting on the feasibility, cost, access to rehabilitation services, implementation processes including barriers and facilitators of telerehabilitation (TR) in low- and middle-income countries (LMICs) and high-income countries (HICs).

Methods

A comprehensive electronic search of PubMed, Scopus, PEDro, Cochrane library, EBSCOhost (Academic search premier, Africa-wide information, CINAHL, Eric, MEDLINE, Health sources - Nursing/Academic edition), Africa online, as well as ProQuest databases were conducted. To maximise the coverage of the literature, the reference lists of included articles identified through the search were also screened. The analysis included both descriptive summary and inductive thematic analysis.

Results

Twenty-nine studies were included. TR was reported to be feasible, cost-saving and improved access to rehabilitation services in both HICs and LMICs settings. Asynchronous methods using different mobile apps (Skype, WhatsApp, Google meet, Facebook messenger, Viber, Face time and Emails) were the most common mode of TR delivery. Barriers to the implementation were identified and categorised in terms of human, organisational, technical and clinical practice related factors. Facilitators for health professionals and patients/caregivers’ dyads were also identified.

Conclusion

TR could be considered a feasible service delivery mode in both HICs and LMICs. However, the mitigation of barriers such as lack of knowledge and technical skills among TR providers and service users, lack of secure platform dedicated for TR, lack of resources and connectivity issues which are particularly prevalent in LMICs will be important to optimise the benefits of TR.

Efficacy and safety of digital therapeutics-based cardiac rehabilitation in heart failure patients: a systematic review

During the coronavirus disease 2019 (COVID-19) pandemic, it has become difficult to provide centre-based cardiac rehabilitation for heart failure patients. Digital therapeutics is a novel concept proposed in recent years that refers to the use of evidence-based therapeutic interventions driven by high-quality software programs to treat, manage, or prevent a medical condition. However, little is known about the use of this technology in heart failure patients. This study aims to explore the safety and efficacy of digital therapeutics-based cardiac rehabilitation in heart failure patients and to provide new insights into a new cardiac rehabilitation model during the COVID-19 era. To identify technologies related to digital therapeutics, such as the use of medical applications, wearable devices, and the Internet, all relevant studies published on PubMed, EMBASE, Cochrane database, and China National Knowledge Internet were searched from the time the database was established until October 2021. The PEDro was used to assess the quality of included studies. We ultimately identified five studies, which included 1119 patients. The mean age was 66.37, the mean BMI was 25.9, and the NYHA classification ranged from I to III (I = 232, II = 157, III = 209). The mean 6-min walk distance was 397.7 m. The PEDro scores included in the study ranged from 4 to 8, with a mean of 5.8. Exercise training was performed in four studies, and psychological interventions were conducted in three studies. No death or serious adverse events were observed. Adherence was reported in three studies, and all exceeded 85%. The results of most studies showed that digital therapeutics-based cardiac rehabilitation significantly increases exercise capacity and quality of life in heart failure patients. Overall, although this study suggests that digital therapeutics-based cardiac rehabilitation may be a viable intervention for heart failure patients during the COVID-19 era, the efficacy of this new model in routine clinical practice needs to be further validated in a large clinical trial.

Practical management of frailty in older patients with heart failure: Statement from a panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology

AIMS

The heart failure (HF) prognosis in older patients remains poor with a high 5-years mortality rate more frequently attributed to noncardiovascular causes. The complex interplay between frailty and heart failure contribute to poor health outcomes of older adults with HF independently of ejection fraction. The aim of this position paper is to propose a practical management of frailty in older patients with heart failure.

METHODS

A panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology conducted a systematic literature search on the interlink between frailty and HF, met to propose an early frailty screening by non-geriatricians and to propose ways to implement management plan of frailty. Statements were agreed by expert consensus.

RESULTS

Clinically relevant aspects of interlink between frailty and HF have been reported to identify the population eligible for screening and the most suitable screening test(s). The frailty screening program proposed focuses on frailty model defined by an accumulation of deficits including geriatric syndromes, comorbidities, for older patients with HF in different settings of care. The management plan of frailty includes optimization of HF pharmacological treatments and non-surgical device treatment as well as optimization of a global patient-centred biopsychosocial blended collaborative care pathway.

CONCLUSION

The current manuscript provides practical recommendations on how to screen and optimize frailty management in older patients with heart failure.

Clinical Implementation of Different Strategies for Exercise-Based Rehabilitation in Kidney and Liver Transplant Recipients: A Pilot Study

Fundamento:

A doença cardiovascular está entre as principais causas de morte entre pacientes transplantados. Embora esses pacientes possam teoricamente se beneficiar de programas de reabilitação baseada em exercícios (RBE), sua implementação ainda é um desafio.

Objetivo:

Apresentamos nossa experiência inicial em diferentes modos de realização de um programa piloto de RBE em receptores de transplante de rim e fígado.

Métodos:

Trinta e dois pacientes transplantados renais ou hepáticos foram convidados para um programa de RBE de 6 meses realizado na academia do hospital, na academia comunitária ou em casa, de acordo com a preferência do paciente. O nível de significância adotado foi de 5%.

Resultados:

Dez pacientes (31%) não completaram o programa. Entre os 22 que completaram, 7 treinaram na academia do hospital, 7 na academia comunitária e 8 em casa. O efeito geral foi um aumento de 11,4% nos METs máximos (tamanho do efeito de Hedges g = 0,39). O grupo de academia hospitalar teve um aumento nos METs de 25,5% (g = 0,58, tamanho de efeito médio) versus 10% (g = 0,25) e 6,5% (g = 0,20) para os grupos de academia comunitária e em casa, respectivamente. Houve efeito benéfico nas pressões arteriais sistólica e diastólica, maior para os grupos academia hospitalar (g= 0,51 e 0,40) e academia comunitária (g= 0,60 e 1,15) do que para os pacientes treinando em casa (g= 0,07 e 0,10). Nenhum evento adverso significativo foi relatado durante o seguimento.

Conclusão:

Programas de RBE em receptores de transplante de rim e fígado devem ser incentivados, mesmo que sejam realizados fora da academia do hospital, pois são seguros com efeitos positivos na capacidade de exercício e nos fatores de risco cardiovascular.

Effectiveness of exercise via telehealth for chronic disease: a systematic review and meta-analysis of exercise interventions delivered via videoconferencing

OBJECTIVE

To investigate the effectiveness of videoconferencing exercise interventions for people with chronic diseases.

DESIGN

Systematic review incorporating meta-analysis.

DATA SOURCES

PubMed, Cinahl, MEDLINE, Web of Science, Embase and Scopus.

ELIGIBILITY CRITERIA

The current literature was searched following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Trials analysing participants with chronic disease undergoing aerobic and/or resistance exercise training over videoconferencing, with exercise capacity and/or quality of life outcomes were included. Meta-analyses were conducted for between-group comparisons of exercise capacity and quality of life. Risk of bias was analysed using the Downs and Black quality checklist and the certainty of evidence with Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Thirty-two trials were included in this review, of which 12 were comparator trials. Small-moderate between-group (videoconferencing vs comparator) effects favouring videoconferencing were seen for studies using a non-exercising comparator for exercise capacity (standardised mean difference (SMD)=0.616, 95% CI 0.278 to 0.954; p=<0.001) and quality of life (SMD=0.400, 95% CI 0.099 to 0.701; p=0.009). Small effects favouring videoconferencing were observed for studies using an exercising comparator for quality of life (SMD=0.271, 95% CI 0.028 to 0.515; p=0.029) and exercise capacity (SMD=0.242, 95% CI 0.059 to 0.426; p=0.009). Moderate risk of bias was identified for included studies (16.3±3.6/28), with GRADE certainty ratings of 'low' (quality of life) and 'moderate' (exercise capacity). Session attendance was 70% and was reported in 23 trials. No serious adverse events relating to videoconferencing were found. Nine trials documented the total number of technical issues that occurred in 17% of the sessions. Positive satisfaction outcomes were associated with ease of access and usefulness of technology.

CONCLUSION

In patients with chronic disease, videoconferencing exercise interventions appear to be feasible and effective for improving exercise capacity and quality of life. More robust methodology is needed in future studies to improve the certainty of the evidence.

PROSPERO REGISTRATION NUMBER

CRD42020191243.

Effects of Cardiac Telerehabilitation During COVID-19 on Cardiorespiratory Capacities in Patients With Coronary Artery Disease

Background

The COVID-19 pandemic led to the closure of most cardiac therapy centers. One of the solutions was to adapt the existing cardiac rehabilitation (CR) program in an institute to a remote approach offered by home-based telerehabilitation. The aim of this study was to measure the cardiorespiratory effects of telerehabilitation compared to conventional center-based CR.

Methods

Patients were assigned to two 3-week CR programs: telerehabilitation and conventional center-based CR. The telerehabilitation group wore a connected watch to monitor heart rate (HR) and gave their perception of effort according to a modified Borg scale. The exercise training (four sessions/week) consisted of 1-h aerobic endurance and strength training session at the target HR zone determined by results based on cardiopulmonary exercise test (CPET) and perception of effort, respectively. The exercise protocol was the same for conventional CR participants except the duration of session that lasted 2 h instead of one. The week before and after the training program, peak oxygen uptake (VO₂ peak), oxygen uptake at first ventilatory threshold (VO₂ at VT₁), peak workload, percent of predicted maximum HR, and the absolute differences in HR and systolic blood pressure between maximum and recovery at 1 and 3 min were measured using a CPET. A two-way ANOVA with one repeated measure and one independent factor was performed.

Results

Fifty-four patients (mean age: 61.5 ± 8.6 years, 10 women) equally split in the two groups were included in this experiment. A significant increase was observed in both groups on VO₂ peak (telerehabilitation: 8.1 ± 7.8% vs. conventional: 10.1 ± 9.7%, p < 0.001), VO₂ at VT₁ (telerehabilitation: 8.8 ± 4.4% vs. conventional: 7.3 ± 19.0%, p = 0.02) and peak workload (telerehabilitation: 16.6 ± 18.9% vs. conventional: 17.2 ± 7.0%, p < 0.001) after the 3-week telerehabilitation and conventional CR, respectively. No significant difference was noticed between both groups.

Conclusion

A 3-week exercise program improved patients’ cardiorespiratory fitness. Telerehabilitation was as effective and represents a safe alternative CR program during the COVID-19 period. In the future, this approach could facilitate the continuity of care for patients unable to participate in center-based CR.

“Staying at Home”: A pivotal trial of telemedicine-based internal medicine hospitalization at a nursing home

Background

In-hospital stay of acutely ill elderlies could be reduced by increasing the availability of community-based hospitalizations. The feasibility of remotely managing these patients by specialized internists, without leaving their nursing homes should be sought. In the current pivotal study, we aimed to evaluate the aforementioned model.

Methods

This was a prospective, open-label study at a tertiary medical center and a nursing home. The study aimed at comparing clinical outcomes of patients hospitalized in each location.

Results

Over a period of 5.5 months, we recruited 18 patients designated for hospitalization, meeting our inclusion criteria to either in-hospital stay or staying in their nursing home and treated by means of telemedicine from our tertiary medical center. The mean age was 85.3 years. Out of 114 hospitalization days, 44 days (48%) were at the nursing home. No significant difference was noted in terms of age, gender, and length of stay between the patients who were hospitalized in either location. In almost all cases, diagnosis changed during hospitalization. Three patients died during the study, all included in the in-hospital group. No safety breaching events happened in the nursing home-hospitalization group.

Conclusions

Remote, telemedicine-based hospitalization of nursing home-dwelling elderlies is safe and feasible, potentially reducing the length of in-hospital stay by almost 50%. Larger studies in this realm are warranted.

Cardiac Telerehabilitation - A Solution for Cardiovascular Care in Japan

Cardiac rehabilitation (CR) is a well-known intervention for the secondary prevention of cardiovascular diseases. However, in Japan, the outpatient CR participation rate is estimated to be very low. Cardiac telerehabilitation (CTR) can be defined as a remote CR program using digital health technology to support it. Evidence regarding the use of CTR has been accumulated, and the COVID-19 pandemic has accelerated the need for CTR. Japan has sufficient potential to benefit from CTR because, nationally, digital literacy is high and the infrastructure for telemedicine is developed. To overcome several barriers, evidence of CTR in Japan, well-educated multidisciplinary CTR teams, a good combination of center-based CR and CTR, and sophisticated systems including social insurance and adequate legislation need to be developed immediately. CTR has the potential to increase the low CR participation rate in Japan. CTR also has many different effects that not only cardiologists, but also paramedics who engage in CTR, have to be aware of.

Safety and feasibility of a telemonitoring-guided exercise program in patients receiving cardiac resynchronization therapy

BACKGROUND

Telerehabilitation is an alternative clinic-based rehabilitation. A remote monitoring (RM) system attached to a cardiac rhythm device can collect physiological data and the device function. This study aimed to evaluate the safety and feasibility of telerehabilitation supervised by an RM in patients receiving cardiac resynchronization therapy (CRT).

METHODS

A single group pre-post exercise program was implemented for 3 months in 18 CRT recipients. The exercise regimen consisted of walking a prescribed number of steps based on a 6-min walk distance (6MWD) achieved at baseline. The patients were asked to exercise 3 to 5 times per week for up to 30 min per session, wearing an accelerometer to document the number of steps taken. The safety was assessed by the heart failure hospitalizations and all-cause death. The feasibility was measured by the improvement in the quality of life (QOL) using the EuroQol 5 dimensions, and daily active time measured by the CRT, 6MWD, B-type natriuretic peptide (BNP) level, and left ventricular ejection fraction (LVEF).

RESULTS

No patients had heart failure hospitalizations or died. No patients had any ventricular tachyarrhythmias. One patient needed to suspend the exercise due to signs of exacerbated heart failure by the RM. Compared to baseline, there were significant improvements in the QOL (-0.037, p < .05), active time (1.12%/day, p < .05), and 6MWD (11 m, p < .001), but not the BNP (-32.4 pg/ml, p = .07) or LVEF (0.28%, p = .55).

CONCLUSIONS

Three months of RM-guided walking exercise in patients with CRT significantly increased the QOL, active time, and exercise capacity without any adverse effects.

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

Frailty in Acute and Chronic Coronary Syndrome Patients Entering Cardiac Rehabilitation

Worldwide population ageing is partly due to advanced standard of care, leading to increased incidence and prevalence of geriatric syndromes such as frailty and disability. Hence, the age at the onset of acute coronary syndromes (ACS) keeps growing as well. Moreover, ageing is a risk factor for both frailty and cardiovascular disease (CVD). Frailty and CVD in the elderly share pathophysiological mechanisms and associated conditions, such as malnutrition, sarcopenia, anemia, polypharmacy and both increased bleeding/thrombotic risk, leading to a negative impact on outcomes. In geriatric populations ACS is associated with an increased frailty degree that has a negative effect on re-hospitalization and mortality outcomes. Frail elderly patients are increasingly referred to cardiac rehabilitation (CR) programs after ACS; however, plans of care must be tailored on individual's clinical complexity in terms of functional capacity, nutritional status and comorbidities, cognitive status, socio-economic support. Completing rehabilitative intervention with a reduced frailty degree, disability prevention, improvement in functional state and quality of life and reduction of re-hospitalization are the goals of CR program. Tools for detecting frailty and guidelines for management of frail elderly patients post-ACS are still debated. This review focused on the need of an early identification of frail patients in elderly with ACS and at elaborating personalized plans of care and secondary prevention in CR setting.