Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial

Moderating Effect of Sex on the Relationship Between Physical Activity and Quality of Life in Coronary Heart Disease Patients in China

PURPOSE

The aim of this study was to investigate the moderating effect of sex on the relationship between physical activity (PA) and quality of life (QoL) in Chinese patients with coronary heart disease (CHD) not participating in cardiac rehabilitation.

METHODS

Chinese patients with CHD (aged 18-80 yr) were selected 12 mo after discharge from three Hebei Province tertiary hospitals. The International Physical Activity Questionnaire was used to assess PA in metabolic equivalents of energy (METs) and the Chinese Questionnaire of Quality of Life in Patients With Cardiovascular Disease was used to assess QoL. Data were analyzed using Student's t test and the χ 2 test, multivariant and hierarchical regression analysis, and simple slope analysis.

RESULTS

Among 1162 patients with CHD studied between July 1 and November 30, 2017, female patients reported poorer QoL and lower total METs in weekly PA compared with male patients. Walking ( β= .297), moderate-intensity PA ( β= .165), and vigorous-intensity PA ( β= .076) positively predicted QoL. Hierarchical regression analysis showed that sex moderates the relationship between walking ( β= .195) and moderate-intensity PA ( β= .164) and QoL, but not between vigorous-intensity PA ( β= -.127) and QoL. Simple slope analysis revealed the standardized coefficients of walking on QoL were 0.397 (female t  = 8.210) and 0.338 (male t = 10.142); the standardized coefficients of moderate-intensity PA on QoL were 0.346 (female, t  = 7.000) and 0.175 (male, t = 5.033).

CONCLUSIONS

Sex moderated the relationship between PA and QoL among patients with CHD in China. There was a greater difference in QoL for female patients reporting higher time versus those with lower time for both walking and moderate-intensity PA than for male patients.

The effectiveness of cardiac telerehabilitation in comparison to centre-based cardiac rehabilitation programmes: A literature review

INTRODUCTION

Cardiac rehabilitation (CR) is an effective, yet under-utilised, form of secondary prevention in cardiac patients. Telemedicine is one method of overcoming barriers to accessing CR. Previous systematic reviews highlight variation in the effectiveness of telerehabilitation programmes and current literature lacks identification of which telemedicine interventions are most effective, despite differences in the results of primary studies. The objectives of this literature review were to: evaluate the effectiveness of cardiac telerehabilitation compared to centre-based programmes for managing cardiac risk factors, satisfaction and adherence in cardiac patients; identify the technologies used to deliver CR; identify the key components of effective interventions.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Scopus. Randomised controlled trials (RCTs) involving an intervention group that received telerehabilitation and a control group that attended a CR centre were included.

RESULTS

Twelve RCTs met the inclusion criteria. There is evidence to suggest that telerehabilitation programmes have similar effectiveness to centre-based CR. Phones were the most commonly used technology. Most studies used a combination of technologies including personal computers and self-monitoring equipment. Phase III telerehabilitation programmes using self-monitoring, motivational feedback and education were more effective than centre-based CR for increasing physical activity and functional capacity.

CONCLUSION

Cardiac telerehabilitation is delivered by a range of technologies and has a similar effectiveness to centre-based programmes. While evidence suggests that additional health benefits are seen in patients who receive a telemedicine intervention in Phase III of CR, further evidence would be required to confidently draw this conclusion.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

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

OBJECTIVES

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Cardiovascular telerehabilitation improves functional capacity, cardiorespiratory fitness and quality of life in older adults: A systematic review and meta-analysis

INTRODUCTION

The aim was to identify whether cardiovascular telerehabilitation programs (CV-T-REHAB) can improve functional capacity, cardiorespiratory fitness and quality of life (QoL) to the same extent of presential rehabilitation (CV-P-REHAB) in older adults, by meta-analysis of previous studies.

METHODS

Literature search was conducted in October 2020 in four databases to select controlled trials of CV-T-REHAB effects on functional capacity (six-minute walk test [6MWT]), cardiorespiratory fitness (maximal oxygen consumption [V ˙ O2max]), and QoL in older adults (> 50 years) and included new articles in April 2022.

RESULTS

CV-T-REHAB improved 6MWT (11.14 m [CI95% = 8.03; 14.26], p < 0.001), V ˙ O2max (1.18 ml/kg/min [CI95% = 0.70; 1.66], p < 0.001), and QoL (standardized mean difference [SMD] = 0.36 [CI95% = 0.05; 0.67], p = 0.02). CV-T-REHAB increased V ˙ O2max to a greater extent than CV-P-REHAB (1.08 ml/kg/min [0.39; 1.76], p = 0.002). Although the 6MWT and V ˙ O2max analyses proved consistent and homogeneous, the QoL analysis showed considerable inconsistency (I2 = 92.90%), suggesting the need for studies exploring the effect of CV-T-REHAB on QoL in this population. Part of the heterogeneity was explained by age differences, as CV-T-REHAB improved QoL in adults >65 years, but not in adults <64 years.

CONCLUSION

CV-T-REHAB improved cardiorespiratory fitness to a level equal to or higher than CV-P-REHAB and improved functional capacity and QoL; being mainly effective for QoL in older adults >65 years. Thus, CV-T-REHAB can be a good alternative, when not the best option and might be considered especially for individuals with limited access to participate in face-to-face programs.

Home-Based Robotic Upper Limbs Cardiac Telerehabilitation System

This article proposes a new, improved home-based cardiac telerehabilitation system enhanced by a robotic and Virtual Reality module for cardiac patients to be used in their rehabilitation program. In this study, a novel strategy was used to integrate existing equipment and applications with newly developed ones, with the aim of reducing the need for technical skills of patients using remote control. Patients with acute or chronic heart diseases require long-term, individualized rehabilitation in order to promote their motor recovery and maintain an active and independent lifestyle. This will be accomplished by creating a system for at-home cardiac telerehabilitation augmented by a VR and cobot systems, which can be used long-term at home by each individual patient. In the pre-feasibility study carried out on healthy volunteers familiar with software applications and robotic systems, we demonstrate that RoboTeleRehab could be technically feasible both hardware and software.

Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost.

METHODS

Medline, PubMed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception through to May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. "Women-focused" CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women's preferences. No studies were excluded on the basis of outcome. Two independent reviewers rated citations for potential inclusion, and one extracted data, including on quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied.

RESULTS

3498 unique citations were identified, of which 28 studies (52 papers) were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with "usual care" comparisons. Compared to "active comparison" group, women-focused CR had no meaningful additional effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence) and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as scores on seven of the eight SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported a favorable economic impact and another reported reduced sick days.

CONCLUSIONS

Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed.

PROSPERO REGISTRATION

CRD42020189760.

Fit, Female or Fifty–Is Cardiac Rehabilitation “Fit” for Purpose for All? A Systematic Review and Meta-Analysis With Meta-Regression

Aims

Cardiac rehabilitation (CR) is an evidence-based intervention promoting risk factor modification following coronary artery disease events but the relative benefits for patient subgroups is not clear. This review synthesizes the available evidence on the effectiveness of modern CR programs and determines outcomes for age, sex and prior level of fitness.

Methods

MEDLINE, CINAHL, and EMBASE were examined for RCT and cohort studies involving exercise prescription or phase II or III CR following Myocardial Infarction (MI), Percutaneous Coronary Intervention (PCI) and cardiac surgery from January 2010 to February 2021. Outcomes assessed included peakVO2max, 6-min walk test and Metabolic Equivalent of Task. Meta-regression was used to determine CR impact for change in fitness and age and sex influences.

Results

The mean age of study participants was 59.5 years and 82.7% were male. Females, younger people and those of average or above cardiorespiratory fitness were substantially under-represented in data and attendance, with 13% of study groups with a mean age &lt;55 years. At entry, 73% were below average for fitness vs. age-matched normative values. Fitness improved across all groups following CR with no evidence of sex or age independently affecting outcomes.

Conclusions

Modest improvements in fitness in all groups were shown, but the benefits of CR can be far greater. A modern, innovative approach to CR will likely lead to more substantial benefits. This may require a “Precision Medicine” model which tailors exercise prescription to different populations to ensure all CR participant's needs are met. This will ensure that CR is more flexible and accessible for all.

Effectiveness of micro-lecture based cardiac rehabilitation education on health status in individuals with coronary artery disease: A randomized clinical trial

OBJECTIVE

To explore the effectiveness of the micro-lecture education on the ability of self-management and lifestyle changes in patients with coronary artery disease.

DESIGN

A randomized control trial with a 12-week follow-up.

SETTING

Cardiology wards of a large Chinese University Hospital.

SUBJECTS

One hundred eligible inpatients with coronary artery disease were recruited.

INTERVENTION

Intervention group received the micro-lecture education, while the control group received the traditional cardiac rehabilitation education.

MAIN MEASURES

Primary outcome of the ability of coronary self-management was assessed by the Coronary self-management scaleat baseline, 12-week after discharge. Secondary outcomes of smoking status, exercise status, and six-minute walk distance were evaluated at the baseline, week4 and week 12 after discharge. The chi-square test,Fisher's exact test, group t-test and the repeated measure variance were used for the data analysis.

RESULTS

Eighty-nine of 100 eligible participants responded, and mean age was 60.2 ± 11.3 years.After the intervention, the mean score of the coronary self-management scale (3.84 ± 0.36) was higher than that in the control group (2.78 ± 0.57).At week 12, the rate of re-smoked in the intervention group (6%) was significantly lower than that in the control group (43%),the frequency of the exercise (85%), and the 6MWD (495.55 ± 85.94) in the intervention group were better than the control group.

CONCLUSION

Micro-lecture education program presented a positive effect on promoting the ability of self-management, and apotential effect on the therapeutic lifestyle changes for the coronary artery disease patients.

The impact of type-2 diabetes mellitus on cardiac rehabilitation outcomes: a meta-analysis

OBJECTIVE

To determine the impact of cardiac rehabilitation (CR) on changes in functional capacity (FC) among patients with CVD and a type-2 diabetes mellitus (T2DM) co-morbidity compared to non-T2DM patients.

DATA SOURCE

A systematic review and meta-analysis of randomized control trials were completed using PubMed, CINAHL, and Web of Science in January 2021.

STUDY SELECTION

Articles were included if they compared CR patients with T2DM to those without T2DM (non-T2DM).

DATA EXTRACTION

The primary outcome variable was FC change from pre to post CR reported as maximal or peak oxygen consumption (VO₂max, VO₂peak), and peak metabolic equivalent (METs). Risk of bias was assessed using the Cochrane risk of bias tool. A random-effects model sub-group meta-analysis was conducted. A diabetes co-morbidity was selected for the subgroup analysis with CVD patients being reported as T2DM or non-T2DM.

DATA SYNTHESIS

Twelve studies with total sample of 15,672 patients were extracted. Average change in peak METs was 1.41±1.76 among non-T2DM and 1.08±1.57 among T2DM patients after CR. Change in FC was significantly lower among T2DM patients (Z-value=2.14; g = -0.42; 95% CI [-0.86 - 0.01]; p=0.03).

CONCLUSION

CVD patients with T2DM experience less robust improvements in FC in response to CR compared to patients with CVD alone. A better understanding of the relationship between T2DM and FC vital step in informing exercise prescription in CR for patients with T2DM and CVD. The lack of understanding the role of T2DM onset and progression is a limitation to this study.

Sex Differences in Cardiac Rehabilitation Outcomes

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

Cardiac rehabilitation in women, challenges and opportunities

Cardiac rehabilitation(CR) has known proven benefits in reducing mortality related to cardiovascular disease (CVD), improving quality of life (QoL), and preventing CVD-related readmissions. Despite these known benefits, CR remains underutilized among women relative to men. Disparities exist at the level of referral, enrollment, and program completion. Much is left to be understood regarding the utility of CR in female-predominant CVD such as postpartum cardiomyopathy and Spontaneous Coronary Artery Dissection. This review identifies the benefits of CR for specific populations of women and elucidates on the barriers to CR. We also describe current recommendations to overcome barriers to CR in women.

Group- plus home-based Tai Chi program improves functional health among patients with coronary heart disease: a randomized controlled trial

AIMS

Tai Chi is a promising exercise option in cardiac rehabilitation to manage coronary heart disease (CHD). Increasing attention was paid on home-based cardiac rehabilitation to improve participation rate, but no study has yet emphasized the effect of home-based Tai Chi. A single-blinded randomized controlled trial is used to examine the effects of a group- plus home-based Tai Chi program on functional health.

METHODS AND RESULTS

Ninety-eight community-dwelling patients with CHD were randomly assigned to the Tai Chi and control groups. Participants in the Tai Chi group attended 6-week group- plus 6-week home-based Tai Chi program. Outcome measures included physical functions, cardiovascular risk factors, and exercise self-efficacy. Data were collected at baseline, 6-week, 12-week, and 24-week. Intervention effects were analysed using the generalized estimating equation model. Compared with changes in the control group, the intervention group achieved significant improvements in aerobic endurance, lower-body strength, agility and dynamic balance, diastolic blood pressure, and exercise self-efficacy over the 24-week study period (all Ps < 0.05). Intervention adherence was high (79.6% of participants attending >75% of all Tai Chi sessions).

CONCLUSIONS

This Tai Chi program significantly improved the functional health of patients with CHD, indicating that Tai Chi could be taught in group sessions and then continued independently as a home exercise routine for health promotion.

Factors Associated with Outpatient Cardiac Rehabilitation Participation in Older Patients: A Population-Based Study Using Claims Data from Two Cities in Japan

BACKGROUND

Although outpatient cardiac rehabilitation has been shown to be effective, the participation status of older cardiac patients is unclear in real-world settings. We investigated the proportion and associated factors of outpatient cardiac rehabilitation participation among older patients with heart diseases after cardiac intervention.

METHODS

We analyzed data from medical and long-term care insurance claims data from two municipalities in Japan. The data coverage period was between April 2014 and March 2019 in City A and between April 2012 and November 2016 in City B. We identified patients aged ≥65 years with post-operative acute myocardial infarction, angina pectoris, or heart valve disease. We estimated the proportion of cardiac rehabilitation participation and conducted logistic regression to identify factors (age, sex, type of cardiac disease, open-heart surgery, Charlson comorbidity index, long-term care need level, catecholamine use, inpatient cardiac rehabilitation, and hospital volume for cardiac rehabilitation) associated with outpatient cardiac rehabilitation participation.

RESULTS

A total of 690 patients were included in this study. The proportion of patients receiving outpatient cardiac rehabilitation was 9.0% overall. Multivariable logistic regression analysis suggested that men (adjusted OR 3.98; 95% CI 1.69-9.37), acute myocardial infarction (adjusted OR 2.76; 95% CI 1.20-6.36; reference angina pectoris), inpatient cardiac rehabilitation (adjusted OR 17.01; 95% CI 5.33-54.24), and "hospital volume" for cardiac rehabilitation (adjusted OR 4.35; 95% CI 1.14-16.57 for high-volume hospitals; reference low-volume hospital) were independently associated with outpatient cardiac rehabilitation.

CONCLUSIONS

The participation rate of outpatient cardiac rehabilitation among older post-operative cardiac patients was suboptimal. Further studies are warranted to examine its generalizability and whether a targeted approach to a group of patients who are less likely to receive outpatient cardiac rehabilitation could improve the participation rate.

Enhancing participation in cardiac rehabilitation: Focus on underserved populations

Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.

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

Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review

Background

Women do not participate in cardiac rehabilitation (CR) to the same degree as men; women-focused CR may address this. This systematic review investigated the: (1) nature, (2) availability, as well as (3a) utilization of, and (b) satisfaction with women-focused CR.

Methods

Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception to May 2020. Primary studies of any design were included. Adult females with any cardiac diseases, participating in women-focused CR (i.e., program or sessions included ≥ 50% females, or was 1-1 and tailored to women’s needs) were considered. Two authors rated citations for inclusion. One extracted data, including study quality rated as per the Mixed-Methods Assessment Tool (MMAT), which was checked independently by a second author. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guideline.

Results

3498 unique citations were identified, with 28 studies (53 papers) included (3697 women; ≥ 10 countries). Globally, women-focused CR is offered by 40.9% of countries that have CR, with 32.1% of programs in those countries offering it. Thirteen (46.4%) studies offered women-focused sessions (vs. full program), 17 (60.7%) were women-only, and 11 (39.3%) had gender-tailoring. Five (17.9%) programs offered alternate forms of exercise, and 17 (60.7%) focused on psychosocial aspects. With regard to utilization, women-focused CR cannot be offered as frequently, so could be less accessible. Adherence may be greater with gender-tailored CR, and completion effects are not known. Satisfaction was assessed in 1 trial, and results were equivocal.

Conclusions

Women-focused CR involves tailoring of content, mode and/or sex composition. Availability is limited. Effects on utilization require further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02267-0.

Sex differences in physical and mental health following high-intensity interval training in adults with cardiovascular disease who completed cardiac rehabilitation

This pre-post study examined sex-differences in peak aerobic power (V̇O2peak) and physical- and mental-health outcomes in adults with cardiovascular disease who completed high-intensity interval training (HIIT)-based cardiac rehabilitation. HIIT consisted of 25 minutes of alternating higher- (4×4 minutes 85-95% heart rate peak (HRpeak)) and lower- (3×3 minutes 60-70% HRpeak) intensity intervals twice weekly for 10 weeks. V̇O2peak estimated from a graded exercise test using the American College of Sports Medicine equation, body mass index (BMI), waist circumference, blood pressure, blood biomarkers and anxiety and depression were assessed at baseline and follow-up. Linear mixed-effects models for repeated measures were performed to examine differences over time between sexes. Of 140 participants (mean ± standard deviation: 58 ± 9 years), 40 were female. Improvements in V̇O2peak did not differ between sexes (interaction: p = 0.273, females: 28.4 ± 6.4 to 30.9 ± 7.6; males: 34.3 ± 6.3 to 37.4 ± 6.0 mL/kg/min). None of the time by sex interactions were significant. Significant main effects of time showed reductions in waist circumference, triglycerides, low-density lipoprotein (LDL), total cholesterol (TC)/high-density lipoprotein (HDL) and anxiety, and increases in V̇O2peak and HDL from baseline to follow-up. Significant main effects of sex revealed smaller V̇O2peak, BMI and waist circumference, and higher LDL, TC and HDL in females than males. HIIT led to similar improvements in estimated V̇O2peak (females: 8.8%, males: 9.0%) and additional health outcomes between sexes. Novelty: HIIT-based cardiac rehabilitation led to similar improvements in estimated V̇O2peak and other physical and mental health outcomes between sexes. The number of sessions attended was high (>70%) and did not differ by sex. Both sexes showed good compliance with the exercise protocol (HR target).

Cardiac Rehabilitation: Under-Utilized Globally

PURPOSE OF REVIEW

Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use.

RECENT FINDINGS

ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.

Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS

PURPOSE

Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR.

REVIEW METHODS

The review examines original studies and meta-analyses regarding women in CR.

SUMMARY

Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR.

Measuring the Feasibility and Effectiveness of an Individualized Exercise Program Delivered Virtually to Cancer Survivors

ABSTRACT

In the spring of 2020, we faced a global pandemic that resulted in social distancing limitations not previously experienced, forcing practitioners to adapt exercise programming to a virtual model. The purpose of this investigation was to measure the effectiveness of a virtual exercise oncology program in 491 participants undergoing antineoplastic therapy between March and June 2020. Each session was completed virtually with a certified exercise oncology trainer. Fitness and psychological parameters were measured preexercise and postexercise intervention. Overall, participants completed 4949 of 5892 prescribed exercise sessions. Patients saw increases in cardiovascular endurance (15.2%, P < 0.05), muscular endurance (18.2%, P < 0.05), flexibility (31.9%, P < 0.05), feelings of support (58.7%, P < 0.05), and quality of life (32.2%, P < 0.05), as well as decreases in loneliness (54%, P < 0.05) and fatigue (48.7%, P < 0.05). In light of our findings, we assert that virtual exercise training is a viable option in circumstances where in-person, individualized exercise training is not possible.

Prognostic effects of cardiovascular rehabilitation: facts and myths

Since CR was introduced, studies have been carried out to discover the effect of CRHPs on cardiovascular morbidity and mortality and on heart-disease patients' quality of life. The first meta-analyses showed improvement in cardiovascular morbidity and mortality, although the studies were conducted in the coronary pre-reperfusion era, before the generalized use in secondary prevention of drugs such as statins, beta-blockers, or renin-angiotensin-system inhibitors, which have produced a decrease in cardiovascular mortality. In Europe, analyzing 25 studies with more than 200,000 patients. It concluded that, in spite of the great heterogeneity of the programs, CR clearly decreases mortality after ACS. Nevertheless, a strategy of CRHP standardization and evaluation is needed. In 2017, a study was carried out in our hospital to evaluate the effectiveness of multidisciplinary CRHP intervention on cardiovascular morbidity and mortality, recurrence of cardiovascular events, the control of RFCV and lifestyle changes in patients after ACS. A total of 442 patients were included who had presented an acute cardiovascular event in the previous six months; 306 patients from the CR group and 136 others with standard cardiology follow-up were used as controls. 405 patients completed follow-up for a median of 60 months. Compared to the usual treatments in cardiology, the patients who underwent CRHPs presented fewer readmissions for cardiovascular reasons (17% vs. 43.38%, P<0.001), fewer major cardiovascular events (11.9% vs. 27.2%, P<0.001) and new revascularizations (9.3% vs. 21.32%, P=0.001), with lower cardiovascular mortality (0 vs. 2.2%, P=0.014). It also led to better control of the RFCV (66% vs. 19.85%, P<0.001) and favored lifestyle changes in these patients (91% vs. 61%, P<0.001). Therefore, in our setting, the performance of CRHPs was shown to be effective in reducing cardiovascular morbidity and mortality and in the secondary prevention of coronary patients.

Enhancing the appeal of cardiac rehabilitation for women: development and pilot testing of a women-only yoga cardiac rehabilitation programme

AIMS

Despite its demonstrated benefits, cardiac rehabilitation (CR) attendance, and completion is suboptimal, particularly in women. The aims of this study were (i) to develop and pilot test a women-only yoga-based CR programme (the Women's Yoga CR Programme; WYCRP); (ii) to investigate programme acceptability; and (iii) to investigate attendance and completion of the WYCRP and continuation to Phase III community-based CR.

METHODS AND RESULTS

Women eligible for CR at a tertiary hospital in Melbourne, Australia were recruited. Over a 6-month period in 2019, they were offered the WYCRP or usual CR. The WYCRP involved attendance at a 1-h yoga session following the usual 1-h mixed-sex education session, over a 7-week period. Participants completed pre- and post-programme questionnaires and attended focus groups to assess programme acceptability. Rates of attendance, completion, and continuation for the WYCRP were recorded and compared to those for the standard CR programme offered in 2018. In total, 27 women were eligible for the study and attended the initial CR assessment. Of those, 22 (81%) attended the WYCRP, 1 (4%) attended usual CR, and 4 (15%) did not attend CR. Ratings of programme acceptability were consistently positive; qualitative comments highlighted both physical and emotional benefits. While attendance at the WYCRP was not significantly higher than for usual CR the previous year (81% vs. 76%; P = 0.40), CR completion, and continuation were (95% vs. 56%; P = 0.02, and 72% vs. 12%; P < 0.001, respectively).

CONCLUSION

This pilot study has demonstrated that women-only yoga-based CR is appealing to women and can improve women's CR completion and continuation. These preliminary findings support further development of women-only and yoga-based CR options.

Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

INTRODUCTION

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

AREAS COVERED

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

EXPERT OPINION

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation

Cardiac rehabilitation (CR) is an evidence-based intervention that uses exercise training, health behaviour modification, medication adherence and psychological counselling to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, following coronary intervention, heart failure, or cardiac surgery. These are significantly underused, with only a minority of eligible patients participating in CR in India. Novel delivery strategies and CR endorsement by healthcare organizations are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). Differing from centre-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision. It is provided mostly or entirely outside of the traditional centre-based setting and could be facilitated by the aid of technology and web based applications. The purpose of this appraisal is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR. This appears to hold promise in expanding the use of CR to eligible patients. Additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and people in remote and rural areas. HBCR may be a reasonable option for a selected group of patients and could be a game changer in low- and middle-income countries who are eligible for CR.

Gender Differences in Healthy Lifestyle Adherence Following Percutaneous Coronary Intervention for Coronary Artery Disease

BACKGROUND

Coronary artery disease (CAD) is the leading cause of mortality in Australian women. We identified gender differences in healthy lifestyle adherence in patients treated with percutaneous coronary intervention (PCI) for CAD.

METHODS

Consecutive patients were prospectively recruited from three Australian institutions (2016-2017). The primary endpoint at 1 year follow-up was healthy lifestyle adherence defined as 3/3 of: a heart-healthy diet, being physically active and not smoking. Secondary endpoints included cardiac rehabilitation attendance, medication use and lipid levels.

RESULTS

From 729 participants (n=192, 26.3% women) 56% were adherent to all three lifestyle measures with no gender difference overall. Compared to men, women were less likely to smoke (7.7% versus 12.2%, p<0.001) to be physically active (61.5% versus 78.2%; p<0.0001), attend cardiac rehabilitation (58.2% versus 66.4%; p<0.045), and take statin therapy (85.4% versus 94.7%; p<0.0001). Female gender independently predicted physical inactivity (OR 2.41, 95% CI 1.57-3.68, p<0.001).

CONCLUSION

Important gender differences exist in patients treated with PCI for CAD, namely, significant lower physical activity, cardiac rehabilitation attendance and statin use in women. These all represent key targets for gender-specific secondary prevention interventions.

How Does Mental Health Impact Women's Heart Health?

From adolescence until old age, women are more vulnerable to common mental disorders (CMDs; depression and anxiety) than men at all stages of the life course. By middle age, women who have clinical depression are at twice the risk of having an incident cardiovascular disease (CVD) than those without. This has important implications for the way we prevent, identify and treat both CMDs and coronary heart disease in women. In this paper, we discuss the various genetic, biological, ethnic/racial, and psychological pathways by which women's vulnerability to CMDs elevate their CVD risk and recovery from a cardiac event. We review the evidence from trials that have, to date, failed to show that treating depression can reduce or delay the onset or recurrence of CVD events, especially for female patients. We discuss the value of lifestyle-based therapies for treating depression, to which women may be more responsive, and finish by discussing how population-based approaches including risk factor assessment could be tailored to consider these factors.

The feasibility of implementing high-intensity interval training in cardiac rehabilitation settings: a retrospective analysis

Background

Cardiovascular disease is the leading cause of death worldwide. Notwithstanding the well-known benefits of cardiac rehabilitation (CR), adherence to CR remains low, particularly in women. High-intensity interval training (HIIT) has received specific attention as an emerging exercise-training paradigm that addresses frequently cited barriers to CR (i.e. lack of motivation/enjoyment and time, perceiving exercise regime as tiring/boring) and improves cardiovascular risk factors. Previous studies have examined the safety of HIIT in CR; there is little evidence on the feasibility of HIIT in CR. The aims of this study were to evaluate the feasibility of HIIT within a CR setting and examine the sex differences regarding the feasibility of such programming.

Methods

Patients attended an on-site HIIT CR program (10-min warm-up, 25 min of interspersed high-intensity [HI - 4 min at 85–95% HRpeak] and lower intensity [LO - 3 min at 60–70% HRpeak] intervals, 10-min cool-down) twice weekly for 10 weeks. Heart rate (HR) and the Borg rating of perceived exertion (RPE) scale (6–20 points) were recorded at each session. Feasibility was assessed by: [1] attendance and compliance: the number of sessions attended and the compliance to the prescribed HI and LO HR ranges; [2] the patient experience: patients’ perceived effort, program difficulty, if the program was challenging and satisfying; and, [3] safety. Descriptive statistics were used to report the means and their variations. Mann-Whitney U tests and Chi-square analyses were performed to examine sex-differences.

Results

A total of 151 patients (33% women, 57.5 ± 9.1 years) attended the HIIT program and completed 16 ± 5 classes with a low attrition rate (11.3%). Most patients met or exceeded the prescribed target HR for the HI (80%) and LO (84%) intervals, respectively. Patients reported a “somewhat hard” RPE for HI (14 ± 2 points) and “very light” for LO (10 ± 2 points) intervals. All patients were satisfied with the program and found it challenging. Most patients found HIIT to be difficult (7 ± 2 points, scale range 0–10 points), yet safe (97%). Three vasovagal episodes occurred and more women dropped-out of the program than men (p < 0.01).

Conclusions

HIIT is a feasible, safe and well-received exercise paradigm in a CR setting.

Women-Only Cardiac Rehabilitation Delivery Around the World

BACKGROUND

Women utilise cardiac rehabilitation (CR) significantly less than men. Gender-tailored CR improves adherence and mental health outcomes when compared to traditional programs. This study ascertained the availability of women-only (W-O) CR classes globally.

METHODS

In this cross-sectional study, an online survey was administered to CR programs globally, assessing delivery of W-O classes, among other program characteristics. Univariate tests were performed to compare provision of W-O CR by program characteristics.

RESULTS

Data were collected in 93/111 countries with CR (83.8% country response rate); 1,082 surveys (32.1% program response rate) were initiated. Globally, 38 (40.9%; range 1.2-100% of programs/country) countries and 110 (11.8%) programs offered W-O CR. Women-Only CR was offered in 55 (7.4%) programs in high-income countries, versus 55 (16.4%) programs in low- and middle-income countries (p<0.001); it was offered most commonly in the Eastern Mediterranean region (n=5, 55.6%; p=0.22). Programs that offered W-O CR were more often located in an academic or tertiary facility, served more patients/year, offered more components, treated more patients/session, offered alternative forms of exercise, had more staff (including cardiologists, dietitians, and administrative assistants, but not mental health care professionals), and perceived space and human resources to be less of a barrier to delivery than programs not offering W-O CR (all p<0.05).

CONCLUSION

Women-Only CR was not commonly offered. Only larger, well-resourced programs seem to have the capacity to offer it, so expanding delivery may require exploiting low-cost, less human resource-intensive approaches such as online peer support.

Maintenance of Gains, Morbidity, and Mortality at 1 Year Following Cardiac Rehabilitation in a Middle-Income Country: A Wait-List Control Crossover Trial

Background

Despite the epidemic of cardiovascular diseases in middle‐income countries, few trials are testing the benefits of cardiac rehabilitation (CR). This trial assessed (1) maintenance of functional capacity, risk factor control, knowledge, and heart‐health behaviors and (2) mortality and morbidity at 6 months following CR in a middle‐income country.

Methods and Results

Eligible Brazilian coronary patients were initially randomized (1:1:1 concealed) to 1 of 3 parallel arms (comprehensive CR [exercise plus education], exercise‐only CR, or wait‐list control). The CR programs were 6 months in duration, at which point follow‐up assessments were performed. Mortality and morbidity were ascertained from chart and patient or family report (blinded). Controls were then offered CR (crossover). Outcomes were again assessed 6 months later (blinded). ANCOVA was performed for each outcome at 12 months. Overall, 115 (88.5%) patients were randomized, and 62 (53.9%) were retained at 1 year. At 6 months, 23 (58.9%) of those 39 initially randomized to the wait‐list control elected to attend CR. Functional capacity, risk factors, knowledge, and heart‐health behaviors were maintained from 6 to 12 months in participants from both CR arms (all P>0.05). At 1 year, knowledge was significantly greater with comprehensive CR at either time point (P<0.001). There were 2 deaths. Hospitalizations (P=0.03), nonfatal myocardial infarctions (P=0.04), and percutaneous coronary interventions (P=0.03) were significantly fewer with CR than control at 6 months.

Conclusions

CR participation is associated with lower morbidity, long‐term maintenance of functional capacity, risk factors, and heart‐health behaviors, as well as with greater cardiovascular knowledge compared with no CR.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02575976.

Early Termination of Cardiac Rehabilitation Is More Common With Heart Failure With Reduced Ejection Fraction Than With Ischemic Heart Disease

PURPOSE

Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF).

METHODS

We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression).

RESULTS

Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31).

CONCLUSIONS

Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea: Recommendations for Cardiac Rehabilitation and Secondary Prevention after Acute Coronary Syndrome

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular (CV) disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea. This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of thirty-three authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified. CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers CV mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Impact of home- and center- based physical training program on cardio-metabolic health and IGF-1 level in elderly women

Background

Data in the literature concerning the effects of physical activity on lipid and IGF-1levels are controversial in postmenopausal women. The aim of the present study was to determine the combined effects of a 12 weeks home-based walking program aiming to achieve 10,000 steps daily and a center- based aerobic exercise training on functional capacity, some important cardio-metabolic parameters, IGF-1 level and psychological items among elderly female patients. Sixty female patients (67.4 ± 5 years) with moderate to high cardiovascular risk were randomly assigned either to an exercise training program for 12 weeks or to the control group.

Results

Our organized training program resulted in a significantly improved daily physical activity (4232 [IQR: 3162–7219] to 8455 [IQR: 6757–11,488]; p < 0.001 ft-steps), functional capacity (MET) (8.17 ± 1.57 to 8.87 ± 1.76) (p = 0.002), metabolic status including total cholesterol (5.17 ± 1.13 to 4.77 ± 1.12 mmol/l), LDL cholesterol (3.37 ± 1.05 to 2.81 ± 0.98 mmol/l), triglyceride (1.68 ± 0.71 to 1.28 ± 0.71 mmol/l) and HgbA1c (6.24 ± 0.67 to 6.06 ± 0.58 mmol/l), as well as IGF-1 (59.68 ± 27.37 to 66.79 ± 22.74 ng/ml) levels (p < 0.05) in the training group. From psychological tests only physical functionality improved significantly (p = 0.03) in the training group. The training group significantly differed from the control group in four parameters including MET (p = 0.003), LDL-cholesterol (p = 0.046), triglyceride (p = 0.001) and IGF-1 levels (p < 0.001) after the intervention.

Conclusion

The applied home-, and- center based training program effectively increased the daily physical activity of the elderly female patients and improved several cardio-metabolic parameters. Further investigations are needed on larger patient population to establish our findings and examine how these positive changes may decrease CV events and mortality.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea

BACKGROUND

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.

METHODS

This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.

RESULTS

CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR.

CONCLUSION

Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea

OBJECTIVE

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and three additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.

METHODS

This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and two general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, three rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.

PRINCIPAL CONCLUSIONS

CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis

Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13⁻1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20⁻0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36⁻0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02⁻1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion.

Interventions to promote patient utilisation of cardiac rehabilitation

BACKGROUND

International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation.

OBJECTIVES

First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations.

SEARCH METHODS

Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics.

MAIN RESULTS

Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.

AUTHORS' CONCLUSIONS

Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

The Effect of Cardiac Rehabilitation in Men With and Without Prostate Cancer: A Retrospective, Comparative Cohort Study

BACKGROUND

Men with prostate cancer (PCa) may be referred to cardiac rehabilitation (CR) following a significant cardiac event, but it is unknown if these men have different effects of CR from men without a history of PCa.

PURPOSE

To compare the effect of CR on cardiorespiratory fitness (VO₂peak), body fat percentage, and body mass index in men with and without a history of PCa.

METHODS

CR participants with PCa were retrospectively compared with a cohort matched on age, clinical indication for CR, and date of referral to the CR program. Participants completed the standardized CR program at the Toronto Rehabilitation Institute, including 1 weekly supervised group session and 4 additional weekly home sessions including aerobic and resistance training for 26 weeks.

RESULTS

Twenty-seven (n = 27) men with PCa were identified and matched 1∶1 with controls. VO₂peak increased in the PCa group (16.9 [5.1]-19.6 [6.2] mL·kg^-1·min^-1; Δ 2.7 mL·kg^-1·min^-1, P < .05) and in the control group (16.4 [4.2]-20.2 [5.8] mL·kg^-1·min^-1; Δ 3.8 mL·kg^-1·min^-1, P < .05) as a result of engaging in CR. There were no significant between-group differences in the postintervention outcomes (P > .05).

CONCLUSIONS

Men with and without PCa experience comparable benefits following CR completion.

Optimal Gender-Specific Strategies for the Secondary Prevention of Heart Disease in Women: A SYSTEMATIC REVIEW

BACKGROUND

There is a paucity of evidence on gender-specific, individually tailored secondary prevention (cardiac rehabilitation [CR]) services for women with heart disease. Women participate less in CR programs, thus increasing their risk of further cardiac events. This review aims to (1) determine the effectiveness of gender-specific interventions specifically designed for women with heart disease, delivered in outpatient CR settings; and (2) classify key elements of effective CR strategies/models for women with heart disease.

METHODS

Using the PRISMA guidelines, this is a systematic review of CR models tailored to women to improve cardiovascular risk. Four databases were searched for randomized controlled trials (RCTs) between January 1974 and July 2017 published in peer-reviewed English language journals.

RESULTS

Three RCTs comprising 725 women of gender-specific CR strategies were identified. Significant improvements were found in one-third (1 study) of the included multicomponent CR strategies for outcomes including general health, social functioning, vitality, mental health, depression, and quality of life.

CONCLUSION

Further large-scale RCTs are required to replicate positive findings and accurately assess the capacity for gender-specific multicomponent CR programs that incorporate participant-driven collaborative models to moderate psychological risk and improve functional capacity and quality of life for women with heart disease.