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Gaalema DE, Allencherril J, Khadanga S, Klemperer E. Differential effects of cigarette smoking on cardiovascular disease in females: A narrative review and call to action. Prev Med 2024:108013. [PMID: 38815766 DOI: 10.1016/j.ypmed.2024.108013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/23/2024] [Accepted: 05/26/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE Cigarette smoking continues to be a major driver in the incidence and progression of cardiovascular disease (CVD). As females become an increasingly larger fraction of those who smoke it is imperative that the sex-specific effects of smoking be further explored and acted upon. METHODS This narrative review describes current evidence on the differential effects of smoking on CVD in females and the need to improve treatment. RESULTS Evidence to date suggests that smoking has disproportionately negative effects on the cardiovascular (CV) system in females, especially in those who are younger. Usually, the onset of CVD is later in females than males, but smoking decreases or eliminates this gap. Females are also more likely to develop types of CVD closely tied to smoking, such as ST-elevated myocardial infarctions, with even higher rates among those who are younger. Possible mechanisms for these worse outcomes in females include a complex interplay between nicotine, other products of combusted cigarettes, and hormones. Sex differences also exist in treatment for smoking. In females, Varenicline appears more effective than either Bupropion or nicotine replacement therapy while in males, all three therapies show similar efficacy. Disparities in smoking are also apparent in secondary prevention settings. Females and males are entering secondary prevention with equal rates of smoking, with potentially higher levels of exposure to the byproducts of smoking in females. CONCLUSIONS These disproportionately negative outcomes for females who smoke require additional research and these persisting rates of smoking suggest a need for female-specific approaches for treating smoking.
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2
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Rouleau CR, Chirico D, Wilton SB, MacDonald MK, Tao T, Arena R, Campbell T, Aggarwal S. Mortality Benefits of Cardiac Rehabilitation in Coronary Artery Disease Are Mediated by Comprehensive Risk Factor Modification: A Retrospective Cohort Study. J Am Heart Assoc 2024; 13:e033568. [PMID: 38761079 PMCID: PMC11179828 DOI: 10.1161/jaha.123.033568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/04/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is a multicomponent intervention to reduce adverse outcomes from coronary artery disease, but its mechanisms are not fully understood. The aims of this study were to examine the impact of CR on survival and cardiovascular risk factors, and to determine potential mediators between CR attendance and reduced mortality. METHODS AND RESULTS A retrospective mediation analysis was conducted among 11 196 patients referred to a 12-week CR program following an acute coronary syndrome event between 2009 and 2019. A panel of cardiovascular risk factors was assessed at a CR intake visit and repeated on CR completion. All-cause and cardiovascular mortality were ascertained via health care administrative data sets at mean 4.2-year follow-up (SD, 2.81 years). CR completion was associated with reduced all-cause (adjusted hazard ratio [HR], 0.67 [95% CI, 0.54-0.83]) and cardiovascular (adjusted HR, 0.57 [95% CI, 0.40-0.81]) mortality, as well as improved cardiorespiratory fitness, lipid profile, body composition, psychological distress, and smoking rates (P<0.001). CR attendance had an indirect effect on all-cause mortality via improved cardiorespiratory fitness (ab=-0.006 [95% CI, -0.008 to -0.003]) and via low-density lipoprotein cholesterol (ab=-0.002 [95% CI, -0.003 to -0.0003]) and had an indirect effect on cardiovascular mortality via cardiorespiratory fitness (ab=-0.007 [95% CI, -0.012 to -0.003]). CONCLUSIONS Cardiorespiratory fitness and lipid control partly explain the mortality benefits of CR and represent important secondary prevention targets.
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Affiliation(s)
- Codie R Rouleau
- TotalCardiology Research Network Calgary Alberta Canada
- Department of Psychology University of Calgary Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
| | | | - Stephen B Wilton
- TotalCardiology Research Network Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
| | | | - Tianqi Tao
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
| | - Ross Arena
- TotalCardiology Research Network Calgary Alberta Canada
- Department of Physical Therapy, College of Applied Health Sciences University of Illinois Chicago IL
| | - Tavis Campbell
- TotalCardiology Research Network Calgary Alberta Canada
- Department of Psychology University of Calgary Calgary Alberta Canada
| | - Sandeep Aggarwal
- TotalCardiology Research Network Calgary Alberta Canada
- Libin Cardiovascular Institute University of Calgary Calgary Alberta Canada
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Taylor MA, Berkowitz JL, Chen K, DeAngelis J, Wu WC. Impact of Prior COVID-19 Infections on Cardiac Rehabilitation Completion Rates and Outcomes. J Cardiopulm Rehabil Prev 2024; 44:157-161. [PMID: 38669342 DOI: 10.1097/hcr.0000000000000841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
PURPOSE This is a retrospective cohort study designed to evaluate the impact of having a prior COVID-19 infection on cardiac rehabilitation (CR) completion rates and outcomes. METHODS Participants enrolled into the CR program from June 1, 2020, to March 30, 2022. They completed both physical and mental health assessments prior to enrollment and upon completion of the program. The cohort was divided into (-) COVID and (+) COVID based on whether they self-reported a prior COVID-19 infection. Outcome measures included General Anxiety Disorder-7, Patient Health Questionnaire-9, Mental Composite Score (Short Form Health Survey-36), Physical Composite Score (Short Form Health Survey-36), and exercise capacity (reported in METs). Program completion rates and outcome measures were compared between (-) COVID and (+) COVID cohorts. RESULTS A total of 806 participants were enrolled in the study. Program completion rates were 58.7% in the (-) COVID group and 67.2% in the (+) COVID group ( P = .072). African Americans ( P = .017), diabetics ( P = .017), and current smokers ( P = .003) were less likely to complete the program. Both (-) COVID and (+) COVID groups showed significant improvement in all outcome measures after completing the CR program. However, there was no difference in outcomes between groups. CONCLUSIONS Having a prior COVID-19 infection did not negatively impact the mental and physical health benefits obtained by completing the CR program, regardless of the American Association of Cardiovascular and Pulmonary Rehabilitation risk category.
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Affiliation(s)
- Matthew A Taylor
- Author Affiliations: Department of Medicine, Rhode Island Hospital, Providence (Drs Taylor and Berkowitz); The Warren Alpert Medical School, Brown University, Providence, Rhode Island (Drs Taylor, Berkowitz, and Wu and Mr Chen); Division of Cardiology, Department of Medicine, VA Medical Center, Providence, Rhode Island (Dr Wu); and Center for Cardiac Fitness, The Miriam Hospital, Providence, Rhode Island (Ms DeAngelis and Dr Wu)
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Park YS, Song IS, Jang S, Nam CM, Park E. Impact of Cardiac Rehabilitation Health Insurance Coverage on Cardiac Rehabilitation Use in Korea Using an Interrupted Time Series. J Am Heart Assoc 2024; 13:e031395. [PMID: 38293924 PMCID: PMC11056114 DOI: 10.1161/jaha.123.031395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/17/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Since 2017, the cardiac rehabilitation (CR) program in Korea has been included in the coverage provided by the National Health Insurance to alleviate financial burden. Our study aimed to identify changes in the CR program use according to the implementation of CR coverage. METHODS AND RESULTS We obtained data from the electronic medical records of a tertiary hospital in Seoul, Korea from January 2014 to February 2020. Data from 2988 patients with acute coronary syndrome who underwent percutaneous coronary intervention were included. To examine the CR use trend among patients undergoing percutaneous coronary intervention, the electronic medical records data of the patients were aggregated quarterly, resulting in a maximum of 24 repeated measures for each patient. Segmented regression is often used to estimate the effects of interventions in an interrupted time series. Policy implementation led to a prompt increase in the probability of CR use (odds ratio [OR], 3.99 [95% CI, 2.89-5.51]). After the implementation of CR coverage, no significant change in CR use (OR, 0.97 [95% CI, 0.92-1.01]) was observed. After percutaneous coronary intervention, more patients opted for CR, especially those receiving education compared with exercise (education: OR, 87.44 [95% CI, 36.79-207.83] versus exercise: OR, 1.99 [95% CI, 1.43-2.76]). CONCLUSIONS The implementation of CR coverage resulted in a rapid increase in the probability of CR use. Use of the educational program was higher than that of the exercise program. Given the persistently low use of CR, it is imperative to stimulate its adoption by increasing its availability.
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Affiliation(s)
- Yu Shin Park
- Department of Public HealthGraduate School, Yonsei UniversitySeoulRepublic of Korea
- Institute of Health Services ResearchYonsei UniversitySeoulRepublic of Korea
| | - In Sun Song
- Department of Health PolicyGraduate School of Public Health, Yonsei UniversitySeoulSouth Korea
| | - Suk‐Yong Jang
- Institute of Health Services ResearchYonsei UniversitySeoulRepublic of Korea
- Department of Healthcare ManagementGraduate School of Public Health, Yonsei UniversitySeoulSouth Korea
| | - Chung Mo Nam
- Department of Public HealthGraduate School, Yonsei UniversitySeoulRepublic of Korea
- Department of Preventive MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Eun‐Cheol Park
- Institute of Health Services ResearchYonsei UniversitySeoulRepublic of Korea
- Department of Preventive MedicineYonsei University College of MedicineSeoulRepublic of Korea
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5
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Nguyen CH, Marzolini S. Pre-participation Withdrawal and Noncompletion of Cardiac Rehabilitation in Peripheral Artery Disease: MATCHED COMPARISONS TO CORONARY ARTERY DISEASE. J Cardiopulm Rehabil Prev 2024; 44:55-63. [PMID: 37624048 DOI: 10.1097/hcr.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE Despite the mortality benefit of cardiac rehabilitation (CR) participation, as well as its cost-effectiveness for people with peripheral artery disease (PAD), there are limited data on adherence and completion of CR in those with and without concomitant coronary artery disease (CAD). The objective of this study was to compare CR pre-participation withdrawal and noncompletion between patients with PAD and concomitant PAD and CAD (PAD/CAD) versus matched and unmatched patients with CAD (uCAD). METHODS Consecutively referred patients between 2006-2017 with PAD (n = 271) and PAD/CAD (n = 610) were matched to CAD by age, sex, diabetes, smoking status, and referral year. The uCAD (n = 14 487) group was included for comparison. Reasons for withdrawal were ascertained by interview. RESULTS There were no significant differences in pre-participation withdrawal between PAD and matched CAD (46 vs 43%, P = .49), nor in noncompletion (22 vs 18%, P = .28). Results were similar for PAD/CAD and matched CAD (withdrawal: 36 vs 34%, P = .37) and (noncompletion: 25 vs 23%, P = .46). A smaller proportion of patients with uCAD withdrew (28%) than patients with PAD ( P < .001) and PAD/CAD ( P < .001), with no difference in noncompletion ( P > .40, both). There were no differences between PAD and PAD/CAD and their matched counterparts for medical and nonmedical reasons for withdrawal and noncompletion ( P ≥ .25, all). CONCLUSION Pre-participation withdrawal rates were similar between patients with PAD, PAD/CAD, and their matched cohorts but greater than patients with uCAD. Once patients started CR, there were similar completion rates among all groups. Reports that patients with PAD are less likely to start CR may be related to their complex medical profile rather than PAD alone. Strategies to improve participation among patients with PAD should focus on the immediate post-referral period.
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Affiliation(s)
- Cindy H Nguyen
- Michael DeGroote School of Medicine, McMaster University-Niagara Regional Campus, St Catharines, Ontario, Canada (Dr Nguyen); KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada (Drs Nguyen and Marzolini); Department of Exercise Sciences, Faculty of Kinesiology and Physical Education (Dr Marzolini), and Rehabilitation Sciences Institute, Temerty Faculty of Medicine (Dr Marzolini), University of Toronto, Toronto, Ontario, Canada; and Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Toronto, Ontario, Canada (Dr Marzolini)
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Khadanga S, Savage PD, Ades PA, Yant B, Anair B, Kromer L, Gaalema DE. Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2024; 44:26-32. [PMID: 37820180 PMCID: PMC10843557 DOI: 10.1097/hcr.0000000000000826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention. METHODS Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance. RESULTS The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A 1c , with more abnormal lipid profiles (all P s < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both P s < .001). CONCLUSION Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.
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Affiliation(s)
| | | | | | | | - Bradley Anair
- University of Vermont Medical Center, Burlington, VT
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Eichner NZM, Zhu QM, Granados A, Berry NC, Saha SK. Factors that predict compliance in a virtual cardiac rehabilitation program. Int J Cardiol 2023; 393:131364. [PMID: 37722456 DOI: 10.1016/j.ijcard.2023.131364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/06/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Despite the well-established benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), participation in CR remain low. Virtual CR programs present a unique opportunity to promote utilization. To date, few virtual CR cohorts have been analyzed for compliance. This study aims to determine factors that predict compliance within a large virtual CR program in the United States. METHODS We analyzed 1409 patients enrolled in the Kaiser Permanente Mid-Atlantic States Virtual CR program that consists of 12 CR sessions via telephone. Demographic characteristics, as well as body weight, blood pressure, HbA1c level, and smoking status were collected at admission. Patients were further classified by CVD diagnosis codes. Compliance was defined as at least 75% (9/12 sessions) attendance. Data was analyzed using simple and multiple regression models with significance defined as P < 0.05. RESULTS Age was the single strongest predictor for virtual CR compliance (adjusted R2 = 0.58; P < 0.001), and non-compliant patients were younger. HbA1C level, CVD diagnosis codes, and smoking status each moderately predicted compliance (adjusted R2 = 0.48, 0.42, and 0.31, respectively; P < 0.001). Smoking and HbA1C level combined in a multiple regression model significantly improved prediction of compliance (adjusted R2 = 0.79, P < 0.01). Sex, baseline weight or hypertension were not significant predictors of CR compliance. CONCLUSIONS Age, diabetes, CVD diagnoses, smoking status at admission are independent predictors of compliance in a large virtual CR program. Targeted intervention could be designed accordingly to improve CR compliance.
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Affiliation(s)
| | - Qiuyu Martin Zhu
- Kaiser Permanente Mid-Atlantic States Internal Medicine Residency Program, Gaithersburg, MD 20879, USA
| | - Adelita Granados
- Kaiser Permanente of the Mid-Atlantic States, Rockville, MD 20852, USA
| | - Natalia C Berry
- Mid-Atlantic Permanente Medical Group, McLean, VA 22102, USA.
| | - Sudip K Saha
- Mid-Atlantic Permanente Medical Group, McLean, VA 22102, USA
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Wang L, Liu J, Fang H, Wang X. Factors associated with participation in cardiac rehabilitation in patients with acute myocardial infarction: A systematic review and meta-analysis. Clin Cardiol 2023; 46:1450-1457. [PMID: 37594292 PMCID: PMC10642335 DOI: 10.1002/clc.24130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) is effective in reducing morbidity and mortality in patients with acute myocardial infarction (AMI), but the participation rate is low and its influencing factors vary. Our study aimed to systematically review the literature and investigate the participation rates and influencing factors of CR in patients with AMI. METHODS We searched 10 databases, including PubMed, Web of Science, Cochrane Library, and so forth. A systematic review and meta-analysis were conducted on the studies on the factors affecting CR participation in AMI. The Q tests and the I2 tests were used to assess heterogeneity between studies. The combined effect size and odds ratio (OR) and their respective 95% confidence interval (CI) for CR participation rate and its influences are expressed, respectively. Stata 17.0 software was used for statistical analysis. RESULTS We included 14 studies with 114 542 participants. Current evidence indicates a CR participation rate of 34% (95% CI: 21%-46%) in patients with AMI. The pooled OR values and CI of each influencing factor are as follows: over 60 years old (OR = 0.865; 95% CI: 0.772-0.969), male (OR = 1.690; 95% CI: 1.276-2.239), college education or above (OR = 2.526; 95% CI: 1.117-5.711), ST-segment elevation myocardial infarction (OR = 4.257; 95% CI: 2.004-9.045), decrease in left ventricular ejection fraction (OR = 0.918; 95% CI: 0.868-0.971), higher economic level (OR = 1.282; 95% CI: 1.108-1.483), history of coronary heart disease(OR = 0.667; 95% CI: 0.509-0.875), smoking (OR = 0.665; 95% CI: 0.550-0.805), combined hypertension (OR = 0.638; 95% CI: 0.562-0.723), and combined hyperlipidemia (OR = 0.577; 95% CI: 0.512-0.651). CONCLUSIONS The overall participation rate of CR in AMI patients is low, and various factors affect the participation rate. Specialist medical staff are needed to further promote CR rehabilitation concepts and scientific knowledge, and take appropriate measures to address the influencing factors to increase CR utilization and improve patient prognosis.
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Affiliation(s)
- Lingyu Wang
- Nursing SchoolAnhui University of Chinese MedicineHefeiAnhuiChina
| | - Jingyu Liu
- Nursing SchoolAnhui University of Chinese MedicineHefeiAnhuiChina
| | - Haiyan Fang
- Nursing SchoolAnhui University of Chinese MedicineHefeiAnhuiChina
| | - Xiang Wang
- Nursing SchoolAnhui University of Chinese MedicineHefeiAnhuiChina
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Gaalema DE, Khadanga S, Pack QR. Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking. Expert Rev Cardiovasc Ther 2023; 21:733-745. [PMID: 37938825 DOI: 10.1080/14779072.2023.2282026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease. AREAS COVERED This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention. EXPERT OPINION Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.
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Affiliation(s)
- Diann E Gaalema
- Department of Psychiatry, University of Vermont, Burlington, VT, United States of America
| | - Sherrie Khadanga
- Cardiac Rehabilitation and Prevention, University of Vermont Medical Center, South Burlington, VT, United States of America
| | - Quinn R Pack
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, United States of America
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Yant B, Kromer L, Savage PD, Khadanga S, Ades PA, Gaalema DE. Financial incentives and case management to improve cardiac rehabilitation participation among patients with lower socio-economic status: Rationale and protocol for a randomized controlled trial. Contemp Clin Trials 2023; 129:107174. [PMID: 37019181 PMCID: PMC10225326 DOI: 10.1016/j.cct.2023.107174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Participation in phase 2 cardiac rehabilitation (CR) is associated with significant decreases in morbidity and mortality. Unfortunately, attendance at CR is not optimal and certain populations, such as those with lower-socioeconomic status (SES), are less likely to participate. In order to remedy this disparity we have designed a trial to examine the efficacy of early case management and/or financial incentives for increasing CR participation among lower-SES patients. METHODS We will employ a randomized controlled trial with a sample goal of 209 patients who will be randomized 2:3:3:3 to either a usual care control, to receive a case manager starting in-hospital, to receive financial incentives for completing CR sessions, or to receive both interventions. RESULTS Treatment conditions will be compared on attendance at CR and end-of-intervention (four months) improvements in cardiorespiratory fitness, executive function, and health-related quality of life. The primary outcome measures for this project will be number of CR sessions completed and the percentage who complete ≥30 sessions. Secondary outcomes will include improvements in health outcomes by condition, as well as the cost-effectiveness of the intervention with a focus on potential reductions in emergency department visits and hospitalizations. We hypothesize that either intervention will perform better than the control and that the combination of interventions will perform better than either alone. CONCLUSIONS This systematic examination of interventions will allow us to test the efficacy and cost-effectiveness of approaches that have the potential to increase CR participation substantially and significantly improve health outcomes among patients with lower-SES.
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Affiliation(s)
- Blair Yant
- University of Vermont, United States of America
| | - Lisa Kromer
- University of Vermont, United States of America
| | | | - Sherrie Khadanga
- University of Vermont, United States of America; University of Vermont Medical Center, United States of America
| | - Philip A Ades
- University of Vermont, United States of America; University of Vermont Medical Center, United States of America
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Beatty AL, Beckie TM, Dodson J, Goldstein CM, Hughes JW, Kraus WE, Martin SS, Olson TP, Pack QR, Stolp H, Thomas RJ, Wu WC, Franklin BA. A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities. Circulation 2023; 147:254-266. [PMID: 36649394 PMCID: PMC9988237 DOI: 10.1161/circulationaha.122.061046] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.
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Affiliation(s)
- Alexis L Beatty
- Department of Epidemiology and Biostatistics (A.L.B.), University of California, San Francisco.,Department of Medicine, Division of Cardiology (A.L.B.), University of California, San Francisco
| | - Theresa M Beckie
- College of Nursing (T.M.B.), University of South Florida, Tampa.,College of Medicine, Division of Cardiovascular Sciences (T.M.B.), University of South Florida, Tampa
| | - John Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine (J.D.), New York University School of Medicine, New York.,Department of Population Health (J.D.), New York University School of Medicine, New York
| | - Carly M Goldstein
- The Weight Control and Diabetes Research Center, the Miriam Hospital, Providence, RI (C.M.G.).,Department of Psychiatry and Human Behavior, The Warren Alpert Medical School (C.M.G.), Brown University, Providence, RI
| | - Joel W Hughes
- Department of Psychological Sciences, Kent State University, OH (J.W.H.)
| | - William E Kraus
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC (W.E.K.)
| | - Seth S Martin
- Department of Medicine, Division of Cardiology, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (S.S.M.)
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic, Rochester, MN (T.P.O., R.J.T.)
| | - Quinn R Pack
- Department of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield (Q.R.P.)
| | - Haley Stolp
- ASRT, Inc, Atlanta, GA (H.S.).,Centers for Disease Control and Prevention, Atlanta, GA (H.S.)
| | - Randal J Thomas
- Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic, Rochester, MN (T.P.O., R.J.T.)
| | - Wen-Chih Wu
- Lifespan Cardiovascular Institute (W.-C.W.), Brown University, Providence, RI.,Division of Cardiology, Providence VA Medical Center, RI (W.-C.W.)
| | - Barry A Franklin
- William Beaumont Hospital, Royal Oak, MI (B.A.F.).,Oakland University William Beaumont School of Medicine, Rochester, MI (B.A.F.)
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Gaalema DE, Yant B, Khadanga S, Savage PD, Rengo JL, Ades PA. Carbon monoxide monitoring to objectively measure smoking status in cardiac rehabilitation. Health Psychol 2022; 41:733-739. [PMID: 35389691 PMCID: PMC9481659 DOI: 10.1037/hea0001178] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Participation in cardiac rehabilitation (CR) is associated with reduced morbidity and mortality. However, most programs rely on self-report measures when assessing the critical risk factor of smoking. This study examined smoking status using self-report versus objective measurement using expired carbon monoxide (CO) and compared patient characteristics by CO level. METHOD Patients were screened for smoking status when entering CR by self-report and by objectively measured CO. Measures of aerobic fitness, educational attainment, depressive symptoms, and self-reported physical function were also collected. The discrepancy between smoking status based on self-report and objective measurement was examined and patient characteristics by CO measurement were compared. RESULTS Of the 853 patients screened, 62 self-reported current smoking and 112 had a CO of ≥ 4 ppm. Using a cut-off of ≥ 4 ppm encompassed almost all self-reported smokers (specificity: 98.5%) and identified 61 patients (not reporting current smoking) needing further screening. Further questioning yielded an additional 21 patients with combusted use (tobacco/cannabis), six nonsmoking patients with environmental CO exposure, and 34 where the reason for elevated CO was unknown. CO ≥ 4 ppm patients were younger (62.2 vs. 67.7, p < .01), had higher depression scores (5.6 vs. 3.7, Patient Health Questionairre-9, p < .01), had lower educational attainment (59.0% ≤ high school vs. 31.3%, p < .01), had lower levels of fitness (after controlling for clinical characteristics, p < .01), and completed fewer CR sessions (18 vs. 22, p < .01). CONCLUSIONS A substantial number of patients who are actively smoking may be misclassified by relying on patient report alone. CO monitoring provides a simple and objective method of systematically screening patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | - Blair Yant
- Department of Psychiatry, University of Vermont
| | | | | | - Jason L. Rengo
- Division of Cardiology, University of Vermont Medical Center
| | - Philip A. Ades
- Division of Cardiology, University of Vermont Medical Center
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Middleton WA, Savage PD, Khadanga S, Rengo JL, Ades PA, Gaalema DE. Benchmarking Depressive Symptoms in Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2022; 42:163-171. [PMID: 34840245 PMCID: PMC9058142 DOI: 10.1097/hcr.0000000000000657] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both. METHODS Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified. RESULTS Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P< .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P< .05). CONCLUSION Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.
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Affiliation(s)
- William A Middleton
- Vermont Center on Behavior and Health, Burlington (Mr Middleton and Drs Ades and Gaalema); Departments of Psychiatry (Dr Gaalema) and Psychology (Mr Middleton and Dr Gaalema), University of Vermont, Burlington; and Division of Cardiology, University of Vermont College of Medicine, Burlington (Messrs Savage and Rengo and Drs Khadanga and Ades)
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Abstract
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.
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Affiliation(s)
- Joshua R. Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Randal J. Thomas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Shane M. Hammer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thomas P. Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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15
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Ades PA, Khadanga S, Savage PD, Gaalema DE. Enhancing participation in cardiac rehabilitation: Focus on underserved populations. Prog Cardiovasc Dis 2022; 70:102-110. [PMID: 35108567 PMCID: PMC9119375 DOI: 10.1016/j.pcad.2022.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Philip A Ades
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America.
| | - Sherrie Khadanga
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| | - Patrick D Savage
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| | - Diann E Gaalema
- Department of Psychiatry, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
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Lovatt S, Wong CW, Holroyd E, Butler R, Phan T, Patwala A, Loke YK, Mallen CD, Kwok CS. Smoking cessation after acute coronary syndrome: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e14894. [PMID: 34541754 DOI: 10.1111/ijcp.14894] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/02/2021] [Accepted: 09/17/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Smoking cessation is an effective secondary prevention measure after acute coronary syndrome (ACS). We conducted a systematic review with the aim to better understand which patients have a greater propensity to quit smoking and the risk factors for continued smoking after ACS. METHODS We searched MEDLINE and EMBASE for studies that evaluated smoking cessation after ACS. The pooled rate of smoking cessation across included studies was performed. Random effects meta-analysis for different variables and their association with smoking cessation was conducted. RESULTS A total of 39 studies with 11 228 patients were included in this review. The pooled rate of smoking cessation following ACS across 38 studies was 45.0%. Factors associated with greater likelihood of smoking cessation were attendance at cardiac rehabilitation (OR 1.90 95% CI 1.44-2.51), married/not alone (OR 1.68 95% CI 1.32-2.13), intention/attempt to quit smoking (OR 1.27 95% CI 1.11-1.46), diabetes mellitus (OR 1.24 95% CI 1.03-1.51) and hospitalised duration (OR 1.09 95% CI 1.02-1.15). Variables associated with a lower likelihood of smoking cessation were depression (OR 0.57 95% CI 0.43-0.75), chronic obstructive pulmonary disease/lung disease (OR 0.73 95% CI 0.57-0.93), previous admission with acute myocardial infarction/cardiac admission (OR 0.61 95% CI 0.47-0.80), cerebrovascular disease/transient ischaemic attack (OR 0.42 95% CI 0.30-0.58) and unemployment (OR 0.37 95% CI 0.17-0.80). CONCLUSIONS The majority of smokers with an ACS continue to smoke after admission. Patients attending cardiac rehabilitation show increased odds of quitting while people who are depressed and those with chronic lung disease were less likely to quit smoking and should be targeted for intensive smoking cessation interventions.
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Affiliation(s)
- Saul Lovatt
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Chun Wai Wong
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Eric Holroyd
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Rob Butler
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Thanh Phan
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Ashish Patwala
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Chun Shing Kwok
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
- School of Medicine, Keele University, Stoke-on-Trent, UK
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17
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Ozemek C, Squires RW. Enrollment and Adherence to Early Outpatient and Maintenance Cardiac Rehabilitation Programs. J Cardiopulm Rehabil Prev 2021; 41:367-374. [PMID: 34727555 DOI: 10.1097/hcr.0000000000000645] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early outpatient (ECR) and maintenance cardiac rehabilitation (MCR) programs are essential, evidence-based services that have received unequivocal endorsement by national and international professional organizations. However, the latest data characterizing ECR enrollment and adherence fell well short of what would be expected for a therapy that has accumulated decades of empirical evidence touting the associated physiologic, physical, psychosocial, and financial benefits. Although national participation levels have remained stagnant, a series of recent publications showcase effective strategies that could bolster both ECR enrollment and adherence levels at the institutional level. Unlike ECR, fewer reports on enrollment and adherence rates exist for MCR, partly due to the lack of standardization of this service. In this review, we aim to highlight current data on enrollment and adherence to ECR and MCR and discuss evidence-based programmatic strategies to support utilization of both services.
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Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago (Dr Ozemek); and Department of Cardiovascular Medicine, Division of Preventive Cardiology, Mayo Clinic and Foundation, Rochester, Minnesota (Dr Squires)
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18
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Khadanga S, Gaalema DE, Savage P, Ades PA. Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS. J Cardiopulm Rehabil Prev 2021; 41:207-213. [PMID: 34158454 PMCID: PMC8243714 DOI: 10.1097/hcr.0000000000000629] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Sherrie Khadanga
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington, VT
- Departments of Psychiatry and Psychology, University of Vermont, Burlington, VT
| | - Diann E. Gaalema
- Departments of Psychiatry and Psychology, University of Vermont, Burlington, VT
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
| | - Patrick Savage
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington, VT
| | - Philip A. Ades
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington, VT
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
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19
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Alqahtani MM, Alanazi AMM, Yohannes AM, Smith CE, Goodfellow LT. The Effectiveness of Cardiopulmonary Rehabilitation Programs on Psychosocial Factors in Patients With Pulmonary and Cardiac Disease. J Cardiopulm Rehabil Prev 2021; 41:271-276. [PMID: 33758152 DOI: 10.1097/hcr.0000000000000599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs. METHODS The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation. RESULTS There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores. CONCLUSION These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.
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Affiliation(s)
- Mohammed M Alqahtani
- Department of Respiratroy Care, King Saud Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia (Messers Alqahtani and Alanazi); Department of Physical Therapy, The University of Alabama at Birmingham (Messrs Alqahtani and Alanazi); Department of Physical Therapy, School of Behavioral and Applied Sciences, Azusa Pacific University, Azusa, California (Dr Yohannes); Department of Psychology, Oklahoma State University, Stillwater (Ms Smith); and Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta (Dr Goodfellow)
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20
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Pack QR, Visintainer P, Farah M, LaValley G, Szalai H, Lindenauer PK, Lagu T. Development of a Simple Clinical Tool for Predicting Early Dropout in Cardiac Rehabilitation: A SINGLE-CENTER RISK MODEL. J Cardiopulm Rehabil Prev 2021; 41:159-165. [PMID: 32947327 PMCID: PMC8147728 DOI: 10.1097/hcr.0000000000000541] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nonadherence to cardiac rehabilitation (CR) is common despite the benefits of completing a full program. Adherence might be improved if patients at risk of early dropout were identified and received an intervention. METHODS Using records from patients who completed ≥1 CR session in 2016 (derivation cohort), we employed multivariable logistic regression to identify independent patient-level characteristics associated with attending <12 sessions of CR in a predictive model. We then evaluated model discrimination and validity among patients who enrolled in 2017 (validation cohort). RESULTS Of the 657 patients in our derivation cohort, 318 (48%) completed <12 sessions. Independent risk factors for not attending ≥12 sessions were age <55 yr (OR = 0.23, P < .001), age 55 to 64 yr (OR = 0.35, P < .001), age ≥75 yr (OR = 0.64, P = .06), smoker within 30 d of CR enrollment (OR = 0.40, P = .001), low risk for exercise adverse events (OR = 0.54, P = .03), and nonsurgical referral diagnosis (OR = 0.66, P = .02). Our model predicted nonadherence risk from 23-90%, had acceptable discrimination and calibration (C-statistics = 0.70, Harrell's E50 and E90 2.0 and 3.6, respectively) but had fair validity among 542 patients in the validation cohort (C-statistic = 0.62, Harrell's E50 and E90 2.1 and 11.3, respectively). CONCLUSION We developed and evaluated a single-center simple risk model to predict nonadherence to CR. Although the model has limitations, this tool may help clinicians identify patients at risk of early dropout and guide intervention efforts to improve adherence so that the full benefits of CR can be realized for all patients.
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Affiliation(s)
- Quinn R Pack
- Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, Massachusetts (Drs Pack and LaValley and Ms Szalai); Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield (Drs Pack, Visintainer, Lindenauer, and Lagu); Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield (Drs Pack, Farah, Lindenauer, and Lagu); and Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (Dr Lindenauer)
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21
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Noguchi KS, Pryzbek M, Moncion K, McQuarrie A, MacDonald MJ, Tang A. A history of smoking does not reduce long-term benefits of cardiac rehabilitation on cardiorespiratory fitness in men and women with cardiovascular disease. Appl Physiol Nutr Metab 2021; 46:155-160. [DOI: 10.1139/apnm-2020-0349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Smoking is an important risk factor for cardiovascular disease and all-cause mortality. Cardiac rehabilitation (CR) is effective for reducing the risk of recurrent cardiac events through improving cardiorespiratory fitness (CRF). Little is known about the influence of smoking on CRF throughout long-term CR. The purpose of this analysis was to compare CRF trajectories among individuals with positive and negative smoking history enrolled in long-term CR. Participants had a positive smoking history if they currently or formerly smoked (Smoke+, n = 55, mean age = 64.9 ± 9.0 years) and had a negative history if they never smoked (Smoke–, n = 34, mean age = 61.4 ± 9.0 years). CRF (peak oxygen uptake) was measured at baseline and annually thereafter for 6 years. The Smoke+ group had lower CRF compared with the Smoke– group over enrollment (β = −3.29 (SE = 1.40), 95% confidence interval (CI) −6.04 to −0.54, p = 0.02), but there was no interaction of smoking history and enrollment (β = 0.35 (SE = 0.21), 95% CI: −0.06 to 0.77, p = 0.10). Moreover, trajectories were not influenced by pack-years (β = 0.01 (SE = 0.01), 95% CI: −0.01 to 0.04, p = 0.23) or time smoke-free (β = −0.002 (SE = 0.01), 95% CI: −0.02 to 0.02, p = 0.80). Although the trajectories of CRF do not appear to be affected by smoking behaviour, individuals without a history of smoking maintained higher CRF throughout enrollment. Novelty: The benefits of long-term exercise-based cardiac rehabilitation on cardiorespiratory fitness are similar between those who have smoked and those who have never smoked. Neither the number of pack-years nor the length of time spent smoke-free influence cardiorespiratory fitness trajectories following long-term cardiac rehabilitation.
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Affiliation(s)
| | - Mike Pryzbek
- School of Rehabilitation Science, McMaster University, Hamilton, ON L8S 1C7, Canada
| | - Kevin Moncion
- School of Rehabilitation Science, McMaster University, Hamilton, ON L8S 1C7, Canada
| | - Angelica McQuarrie
- Physical Activity Centre for Excellence, McMaster University, Hamilton, ON L8S 4L8, Canada
| | | | - Ada Tang
- School of Rehabilitation Science, McMaster University, Hamilton, ON L8S 1C7, Canada
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22
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Factors Affecting Health-Promoting Behaviors in Patients with Cardiovascular Disease. Healthcare (Basel) 2021; 9:healthcare9010060. [PMID: 33435583 PMCID: PMC7827905 DOI: 10.3390/healthcare9010060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 11/29/2022] Open
Abstract
Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.
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23
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Bolívar HA, Elliott RJ, Middleton W, Yoon JH, Okoli CTC, Haliwa I, Miller CC, Ades PA, Gaalema DE. Social Smoking Environment and Associations With Cardiac Rehabilitation Attendance. J Cardiopulm Rehabil Prev 2021; 41:46-51. [PMID: 32925296 PMCID: PMC7755730 DOI: 10.1097/hcr.0000000000000518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Continued cigarette smoking after a major cardiac event predicts worse health outcomes and leads to reduced participation in cardiac rehabilitation (CR). Understanding which characteristics of current smokers are associated with CR attendance and smoking cessation will help improve care for these high-risk patients. We examined whether smoking among social connections was associated with CR participation and continued smoking in cardiac patients. METHODS Participants included 149 patients hospitalized with an acute cardiac event who self-reported smoking prior to the hospitalization and were eligible for outpatient CR. Participants completed a survey on their smoking habits prior to hospitalization and 3 mo later. Participants were dichotomized into two groups by the proportion of friends or family currently smoking ("None-Few" vs "Some-Most"). Sociodemographic, health, secondhand smoke exposure, and smoking measures were compared using t tests and χ2 tests (P < .05). ORs were calculated to compare self-reported rates of CR attendance and smoking cessation at 3-mo follow-up. RESULTS Compared with the "None-Few" group, participants in the "Some-Most" group experienced more secondhand smoke exposure (P < .01) and were less likely to attend CR at follow-up (OR = 0.40; 95% CI, 0.17-0.93). Participants in the "Some-Most" group tended to be less likely to quit smoking, but this difference was not statistically significant. CONCLUSION Social environments with more smokers predicted worse outpatient CR attendance. Clinicians should consider smoking within the social network of the patient as an important potential barrier to pro-health behavior change.
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Affiliation(s)
- Hypatia A Bolívar
- Vermont Center on Behavior and Health (Drs Bolívar, Ades, and Gaalema, Ms Elliott, and Mr Middleton) and Departments of Psychiatry (Drs Bolívar and Gaalema and Ms Elliott) and Psychology (Mr Middleton and Dr Gaalema), University of Vermont, Burlington; Departments of Psychiatry and Behavioural Sciences (Dr Yoon and Ms Haliwa) and Cardiothoracic and Vascular Surgery (Dr Miller), University of Texas Health Science at Houston; College of Nursing, University of Kentucky, Lexington (Dr Okoli); and Division of Cardiology, University of Vermont College of Medicine, Burlington (Dr Ades)
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Halling T, Akkermann S, Löffler F, Groh A, Heitland I, Haefeli WE, Bauersachs J, Kahl KG, Westhoff-Bleck M. Factors That Influence Adherence to Medication in Adults With Congenital Heart Disease (ACHD). Front Psychiatry 2021; 12:788013. [PMID: 34899440 PMCID: PMC8660073 DOI: 10.3389/fpsyt.2021.788013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Innovative operative and interventional procedures have improved survival in congenital heart disease (CHD), and today more than 90% of these children reach adulthood. Consequently, adherence and psychosocial issues are becoming increasingly important because non-adherence to treatment recommendations worsens morbidity and mortality. This study aimed to identify factors modifying adherence to medication in adult congenital heart disease (ACHD). Methods: This cross-sectional study included 451 outpatients (female 47.9%, average age ± SD: 37.9 ± 12 years) from the ACHD department, who completed a questionnaire assessing medication non-adherence and individual barriers to treatment. Further assessments included psychological well-being (Hospital Anxiety and Depression scale; HADS), childhood traumatization, sociodemographic, and clinical data. Binary logistic regression analysis calculated the impact of these factors on drug adherence. Results: Of the 451 patients 162 participants (35.9%) reported to be non-adherent. In univariate analysis non-adherence to treatment was associated with smoking (P = < 0.001) and internet addiction (P = 0.005). Further factors negatively influencing adherence were the presence of depressive symptoms (P = 0.002), anxiety (P = 0.004), and childhood traumatization (p = 0.002). Factors positively associated with adherence were older age (P = 0.003) and more advanced heart disease as indicated by NYHA class (P = 0.01), elevated NT-proBNP (P = 0.02), device therapy (P = 0.002) and intermittent arrhythmias (P = 0.01). In multivariate analysis especially psychopathological factors such as depression (P = 0.009), anxiety (P = 0.032) and childhood traumatization (P = 0.006) predicted non-adherence. Conclusion: Adherence is a critical issue in the long-term management of ACHD. Identifying modifiable factors that worsen adherence offers the opportunity for targeted interventions. Depressive symptoms, anxiety, and adverse childhood experiences are amenable to psychosocial interventions, as well as cigarette smoking. Our study suggests that a multimodal and interdisciplinary treatment concept for the long-term management of adults with congenital heart disease could be beneficial. Whether it will further improve morbidity and mortality, should be assessed in prospective interventions.
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Affiliation(s)
- Tim Halling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Steffen Akkermann
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Friederike Löffler
- Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany
| | - Adrian Groh
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Ivo Heitland
- Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany
| | - Kai G Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
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Gaalema DE, Bolívar HA, Khadanga S, Priest JS, Higgins ST, Ades PA. Current smoking as a marker of a high-risk behavioral profile after myocardial infarction. Prev Med 2020; 140:106245. [PMID: 32910931 PMCID: PMC7680426 DOI: 10.1016/j.ypmed.2020.106245] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 11/28/2022]
Abstract
Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.
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Affiliation(s)
- Diann E Gaalema
- Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States.
| | - Hypatia A Bolívar
- Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States
| | - Sherrie Khadanga
- Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States; University of Vermont Medical Center, Burlington, VT, United States
| | - Jeffrey S Priest
- Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States
| | - Philip A Ades
- Vermont Center on Behavior and Health, United States; University of Vermont, Burlington, VT, United States; University of Vermont Medical Center, Burlington, VT, United States
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Sadeghi M, Shabib G, Masoumi G, Amerizadeh A, Shahabi J, Heidari R, Roohafza H. A Systematic Review and Meta-analysis on the Prevalence of Smoking Cessation in Cardiovascular Patients After Participating in Cardiac Rehabilitation. Curr Probl Cardiol 2020; 46:100719. [PMID: 33160685 DOI: 10.1016/j.cpcardiol.2020.100719] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/19/2020] [Indexed: 12/18/2022]
Abstract
Smoking is the most important modifiable cardiovascular risk factor causes around approximately one of every 4 cardiovascular-related deaths worldwide. Cardiac rehabilitation (CR) is the standard way of management of heart diseases after myocardial infraction. This study aimed to determine the prevalence of cardiovascular patients' quit smoking after participation in CR. PubMed, EMBASE, Web of Science, Scopus, and google scholar were searched systematically. In total, 18 studies were analyzed. Results showed that the mean age of smokers' were 54.80 (52.06, 57.55), and of them 53 % (22%, 83%) quit smoking after participating in CR. Subgroup analysis showed that among type of CR the most effective one was the educational along with physical exercise (comprehensive CR) cause 99% (98%, 100%) smoking cessation (SC). Group-based methods with76% (57%, 94%) of quitters showed to be more effective than individual-based. It can be concluded that CR has been effective in terms of smoking cessation.
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Affiliation(s)
- Masoumeh Sadeghi
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Ghadir Shabib
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholamreza Masoumi
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atefeh Amerizadeh
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Javad Shahabi
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ramin Heidari
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamdreza Roohafza
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Sex- and Gender-Related Factors Associated With Cardiac Rehabilitation Enrollment: A SECONDARY ANALYSIS AMONG SYSTEMATICALLY REFERRED PATIENTS. J Cardiopulm Rehabil Prev 2020; 39:259-265. [PMID: 30252783 DOI: 10.1097/hcr.0000000000000364] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To assess sex- and gender-related factors associated with cardiac rehabilitation (CR) enrollment following acute coronary syndrome among systematically referred patients. METHODS This secondary analysis of a randomized controlled trial used an exploratory approach to examine the TRANSITion process for patients between the coronary care unit and CR (TRANSIT-UC). The present analysis examined the relationship between sex- and gender-related factors and CR enrollment in systematically referred women (n = 35) and men (n = 207). We performed χ and logistic regression analyses to identify statistically significant results. Using the Bonferroni method, a P value of .002 or less was considered a significant statistical result. A raw difference of 15% or more between enrolled and nonenrolled participants was considered a difference worthy of further investigation. RESULTS Men who were regularly engaged in physical activity prior to their hospitalization and who lived near the CR center showed a statistically higher CR enrollment rate. In women and men, a radial entry site for percutaneous coronary intervention resulted in a clinically significant difference in favor of CR enrollment. In women, 3 sex-related and 9 gender-related variables were associated with a difference of 15% or more between enrolled and nonenrolled participants. CONCLUSION Factors related to CR enrollment in women and men are suggested. As women keep showing a lower rate of CR enrolment, the investigation of these factors in a larger sample of patients may hold valuable insights to improve CR enrolment.
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Sunamura M, Ter Hoeve N, van den Berg-Emons RJG, Boersma E, Geleijnse ML, van Domburg RT. Patients who do not complete cardiac rehabilitation have an increased risk of cardiovascular events during long-term follow-up. Neth Heart J 2020; 28:460-466. [PMID: 32198644 PMCID: PMC7431499 DOI: 10.1007/s12471-020-01413-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Cardiac rehabilitation (CR) has favourable effects on cardiovascular mortality and morbidity. Therefore, it might reasonable to expect that incomplete CR participation will result in suboptimal patient outcomes. Methods We studied the 914 post-acute coronary syndrome patients who participated in the OPTImal CArdiac REhabilitation (OPTICARE) trial. They all started a ‘standard’ CR programme, with physical exercises (group sessions) twice a week for 12 weeks. Incomplete CR was defined as participation in <75% of the scheduled exercise sessions. Patients were followed-up for 2.7 years, and the incidence of cardiac events was recorded. Major adverse cardiac events (MACE) included all-cause mortality, non-fatal myocardial infarction and coronary revascularisation. Results A total of 142 (16%) patients had incomplete CR. They had a higher incidence of MACE than their counterparts who completed CR (11.3% versus 3.8%, adjusted hazard ratio [aHR] 2.86 and 95% confidence interval [CI] 1.47–5.26). Furthermore, the incidence of any cardiac event, including MACE and coronary revascularisation, was higher (20.4% versus 11.0%, aHR 1.54; 95% CI 0.98–2.44). Patients with incomplete CR were more often persistent smokers than those who completed CR (31.7% versus 11.5%), but clinical characteristics were similar otherwise. Conclusion Post-ACS patients who did not complete a ‘standard’ 12-week CR programme had a higher incidence of adverse cardiac events during long-term follow-up than those who completed the programme. Since CR is proven beneficial, further research is needed to understand the reasons why patients terminate prematurely.
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Affiliation(s)
- M Sunamura
- Capri Cardiac Rehabilitation, Rotterdam, The Netherlands
| | - N Ter Hoeve
- Capri Cardiac Rehabilitation, Rotterdam, The Netherlands.,Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - R J G van den Berg-Emons
- Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E Boersma
- Department of Cardiology, Thorax center, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M L Geleijnse
- Department of Cardiology, Thorax center, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - R T van Domburg
- Department of Cardiology, Thorax center, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Abstract
BACKGROUND Inpatient cardiac rehabilitation (ICR) programs provide important services to hospitalized patients by delivering risk factor education, daily ambulation, and facilitation of referral to outpatient cardiac rehabilitation. However, little is known about ICR utilization or practice patterns. METHODS We examined the use of ICR, between January 2007 and June 2011, in a geographically and structurally diverse sample of US hospitals (Premier, Inc). RESULTS Among 458 hospitals, there were 1 343 537 admissions with a qualifying diagnosis for outpatient cardiac rehabilitation. Formal ICR was available at 223 (49%) of these hospitals. Overall, patient utilization of ICR was low (21.2%) and varied by indication. Utilization was highest in those undergoing cardiac surgery (43.3%) and lowest in patients with medically managed myocardial infarction (15.6%) or heart failure (10.6%). A larger bed count, the presence of cardiac interventional services, and Midwest location were associated with increased likelihood of a hospital having an ICR program. In multivariable hierarchical analysis adjusting for known hospital characteristics among hospitals that provided ICR, multiple patient factors were associated with a lower likelihood of ICR utilization, including older age, more comorbidities, female sex, and Medicare insurance, but unspecified hospital characteristics explained the vast majority of the variability. CONCLUSIONS We found substantial variation in the delivery of ICR across US hospitals and by patient condition. Overall, only a minority of eligible patients ever received ICR and fewer than half of hospitals treating cardiac patients provided formal ICR services. This substantial gap in the secondary prevention of heart disease warrants further investigation and intervention.
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Nonadherence in Home-Based Pulmonary Rehabilitation Program for COPD Patients. Can Respir J 2020; 2020:5146765. [PMID: 31998425 PMCID: PMC6969984 DOI: 10.1155/2020/5146765] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/15/2019] [Accepted: 10/21/2019] [Indexed: 01/08/2023] Open
Abstract
Background The pulmonary rehabilitation (PR) is beneficial for COPD patients. Due to the poor rate of adherence, we evaluate the factors which will predict the nonadherence of PR. Method We analyzed the data from a retrospective study of COPD patients who were enrolled to attend the PR program. Patients were classified as the adherence group and the nonadherence group according to completion of over 50% sessions during the 8-week PR program. Demographic characteristics, 6-minute walking distance (6MWD), COPD assessment test (CAT), modified Medical Research Council scale (mMRC), and emotional function were compared between two groups. Univariate and multivariable analyses were performed to determine the factors of poor adherence of PR. Results Among 418 patients, 170 patients (40.7%) who completed less than 50% sessions of the PR program were categorized as “nonadherence.” Compared to completers, “nonadherence” patients had more cigarette consumption, higher emotional score, less 6MWD, more exacerbation, using nebulizer frequently, and higher rate of smoking at enrollment. On multivariate analysis, more exacerbation frequency (odds ratio (OR) = 1.434, 95% confidence interval (CI): 1.191∼1.796, P=0.046) and smoking at enrollment (OR = 3.349, 95% CI: 1.194∼6.302, P=0.012) were predict factors associated with nonadherence of PR. Conclusion COPD patients with frequent exacerbation and smoking currently were more likely to be nonadherence during PR.
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Papazisis A, Koreli A, Misouridou E. Heavy Smoking is Associated with Low Depression and Stress: a Smokers' Paradox in Cardiovascular Disease? Mater Sociomed 2019; 31:268-272. [PMID: 32082091 PMCID: PMC7007605 DOI: 10.5455/msm.2019.31.268-272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Smoking, anxiety and depression constitute predisposing factors of coronary artery disease. AIM The aim of this study was to investigate the degree of nicotine dependence in coronary patients and its relationship to anxiety and depression. METHODS The study population consisted of 208 coronary patients, 131 men and 77 women, who were hospitalized in a hospital in Attica and were all smokers. The degree of nicotine dependence was measured by the Fagerstrom scale, while depression and anxiety intensity were assessed with the Zung SDS and SAS scales respectively. RESULTS 158 participants (75.9%) were moderately to highly dependent on nicotine, 108 participants (51.9%) reported moderate to severe depression intensity levels while 91 participants (43.8%) reported moderate to severe anxiety intensity levels. The degree of dependence on nicotine was negatively related to the intensity of anxiety and depression experienced by coronary patients. Additionally, the degree of nicotine dependence, anxiety and depression was associated with various sociodemographic and clinical factors such as educational level, social support, and information on their condition and treatment. CONCLUSION Overall, the findings of this study point to an inverse relationship of nicotine dependence, depression and anxiety. However, this paradoxical association could be a product of shared risk factors or confounding. Nonetheless, the development of individualized educational and supportive interventions to quit smoking in coronary patients should primarily focus on the assessment of depression and stress.
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Effect of Smoking Status on Exercise Perception and Intentions for Cardiac Rehabilitation Enrollment Among Patients Hospitalized With an Acute Cardiac Condition. J Cardiopulm Rehabil Prev 2019; 38:286-290. [PMID: 29120970 DOI: 10.1097/hcr.0000000000000288] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Cardiac rehabilitation (CR) attendance has been associated with higher smoking cessation (SC) rates. However, for unclear reasons, smokers are consistently less likely to enroll in CR than nonsmokers, and it is uncertain what might encourage them to attend. METHODS We surveyed patients eligible for CR who were cigarette smokers at the time of hospital admission. We assessed patient intention to quit smoking, start exercising, and enroll in CR. We also measured anxiety and depression levels. RESULTS Of the 105 patients approached, 81 (77%) completed the survey (69% males, aged 57 ± 10 y, 72% white). Most patients reported interest in SC (80%) and attending CR (78%). Many felt that SC medications (41%), stress management programs (35%), and an exercise program with SC counseling (30%) would increase their likelihood to attend CR; however, 30% stated that they would be less likely to enroll in CR if they continued smoking following discharge. Many patients indicated high levels of anxiety (51%) and depression (27%); many desired to reduce stress following discharge (73%), with 35% stating that stress management programs would increase their likelihood to attend CR. CONCLUSIONS Hospitalized smokers eligible for CR report significant interest in SC, attending CR, and beginning an exercise program. These patients show high levels of anxiety and depression and indicate a strong interest in stress management programs. These results suggest that messages emphasizing the role of CR in the treatment of depression, anxiety, and stress are likely to resonate with smokers, increase their enrollment in CR, and support long-term SC.
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Riley H, Headley S, Lindenauer PK, Goff S, Szalai H, Gaalema DE, Pack QR. Patient Perception of How Smoking Status Influences Cardiac Rehabilitation Attendance After an Acute Cardiac Hospitalization. J Cardiopulm Rehabil Prev 2019; 39:181-186. [PMID: 31022000 PMCID: PMC6492621 DOI: 10.1097/hcr.0000000000000366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Patients hospitalized with a cardiac condition are less likely to attend cardiac rehabilitation (CR) if they are smokers despite the benefits of doing so. The present study sought to investigate how, if at all, a patient's decision to attend CR was influenced by his or her tobacco use post-discharge. METHODS We surveyed smokers during their hospitalization for a cardiac condition. Four to 8 wk after discharge, a follow-up survey assessed self-reported CR attendance, smoking cessation (SC), and patient opinion of how their smoking status influenced CR attendance. RESULTS Of the 81 patients who completed the baseline survey (68% male, 57 ± 10 y), 62 (77%) completed the follow-up survey. Consistent with prior findings, there was a substantial correlation between SC and CR attendance (OR: 16.0, P < .001) with 36 (44%) patients attending CR overall and 38 (47%) abstaining from smoking. Patients reported a wide variety of reasons for not attending CR, but most patients (n = 39, 63%) reported that their smoking status did not influence their decision to attend CR. However, 5 patients (8%) reported attending CR because they successfully quit smoking, and 5 (8%) attended CR anticipating support with SC. CONCLUSION A strong relationship exists between SC and CR attendance following a cardiac hospitalization; however, most patients did not feel that their smoking status was a factor in their decision to attend CR. Regardless of the reason, it appears that success with one behavior may be related to the other and that both SC and CR attendance should be encouraged.
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Affiliation(s)
- Hayden Riley
- Division of Cardiovascular Medicine (Ms Riley and Dr Pack), Institute for Health Care Delivery and Population Science (Drs Lindenauer, Goff, and Pack), Department of Internal Medicine (Dr Lindenauer), and Division of Cardiology (Ms Szalai and Dr Pack), Baystate Medical Center, Springfield, Massachusetts; Department of Exercise Science and Sports Studies, Springfield College, Springfield, Massachusetts (Ms Riley and Dr Headley); Cardiac and Pulmonary Rehabilitation, The Miriam Hospital, Providence, Rhode Island (Ms Riley); University of Massachusetts Medical School at Baystate, Springfield (Drs Lindenauer and Goff); and Department of Psychiatry, The University of Vermont, Burlington (Dr Gaalema)
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Katz DA, Buchanan DM, Weg MWV, Faseru B, Horwitz PA, Jones PG, Spertus JA. Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking? Prev Med 2019; 118:51-58. [PMID: 30316877 PMCID: PMC6322961 DOI: 10.1016/j.ypmed.2018.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/27/2018] [Accepted: 10/10/2018] [Indexed: 12/25/2022]
Abstract
Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20-1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization.
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Affiliation(s)
- David A Katz
- University of Iowa Carver College of Medicine, Iowa City, IA, United States of America; Comprehensive Access & Delivery Research and Evaluation Center, Iowa City VA Medical Center, United States of America.
| | - Donna M Buchanan
- Saint Luke's Mid America Heart Institute, Kansas City, MO, United States of America; University of Missouri at Kansas City, Kansas City, MO, United States of America
| | - Mark W Vander Weg
- University of Iowa Carver College of Medicine, Iowa City, IA, United States of America; Comprehensive Access & Delivery Research and Evaluation Center, Iowa City VA Medical Center, United States of America
| | - Babalola Faseru
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Philip A Horwitz
- University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO, United States of America
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, United States of America; University of Missouri at Kansas City, Kansas City, MO, United States of America
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Resurrección DM, Moreno-Peral P, Gómez-Herranz M, Rubio-Valera M, Pastor L, Caldas de Almeida JM, Motrico E. Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies. Eur J Cardiovasc Nurs 2018; 18:38-47. [PMID: 29909641 DOI: 10.1177/1474515118783157] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although evidence exists for the efficacy of cardiac rehabilitation programmes to reduce morbidity and mortality among patients with cardiovascular disease, cardiac rehabilitation programmes are underused. We aimed systematically to review the evidence from prospective cohort studies on factors associated with non-participation in and/or dropping out from cardiac rehabilitation programmes. METHODS MedLine, Embase, Scopus, Open Grey and Cochrane Database were searched for relevant publications from inception to February 2018. Search terms included (a) coronary heart disease and other cardiac conditions; (b) cardiac rehabilitation and secondary prevention; and (c) non-participation in and/or dropout. Databases were searched following the PRISMA statement. Study selection, data extraction and the assessment of study quality were performed in duplicate. RESULTS We selected 43 studies with a total of 63,425 patients from 10 different countries that met the inclusion criteria. Factors associated with non-participation in and dropout from cardiac rehabilitation were grouped into six broad categories: intrapersonal factors, clinical factors, interpersonal factors, logistical factors, cardiac rehabilitation programme factors and health system factors. We found that clinical factors, logistical factors and health system factors were the main factors assessed for non-participation in cardiac rehabilitation. We also found differences between the factors associated with non-participation and dropout. CONCLUSIONS Several factors were determinant for non-participation in and dropout from cardiac rehabilitation. These findings could be useful to clinicians and policymakers for developing interventions aimed at improving participation and completion of cardiac rehabilitation, such as E-health or home-based delivery programmes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) identifier: CRD42016032973.
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Affiliation(s)
| | - Patricia Moreno-Peral
- 2 SAMSERAP Group, Primary Care Prevention and Health Promotion Research Network (RedIAPP), Spain.,3 SAMSERAP Group, Instituto de Investigación Biomédica de Malaga (IBIMA), Spain
| | | | - Maria Rubio-Valera
- 5 Research and Development Unit, Institut de Recerca Sant Joan de Déu, Spain.,6 Grupo PRISMA, Centro de Investigación Biomédica en Red Epidemiología y Salud Pública, Spain
| | - Luis Pastor
- 7 Unidad Clínica de Cardiología, Hospital Nuestra Señora de Valme, Spain
| | | | - Emma Motrico
- 1 Departamento de Psicología, Universidad Loyola Andalucía, Spain.,2 SAMSERAP Group, Primary Care Prevention and Health Promotion Research Network (RedIAPP), Spain
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Abstract
PURPOSE Cardiac rehabilitation (CR) is a program of structured exercise and interventions for coronary risk factor reduction that reduces morbidity and mortality rates following a major cardiac event. Although a dose-response relationship between the number of CR sessions completed and health outcomes has been demonstrated, adherence with CR is not high. In this study, we examined associations between the number of sessions completed within CR and patient demographics, clinical characteristics, smoking status, and socioeconomic status (SES). METHODS Multiple logistic regression and classification and regression tree (CART) modeling were used to examine associations between participant characteristics measured at CR intake and the number of sessions completed in a prospectively collected CR clinical database (n = 1658). RESULTS Current smoking, lower SES, nonsurgical diagnosis, exercise-limiting comorbidities, and lower age independently predicted fewer sessions completed. The CART analysis illustrates how combinations of these characteristics (ie, risk profiles) predict the number of sessions completed. Those with the highest-risk profile for nonadherence (<65 years old, current smoker, lower SES) completed on average 9 sessions while those with the lowest-risk profile (>72 years old, not current smoker, higher SES, surgical diagnosis) completed 27 sessions on average. CONCLUSIONS Younger individuals, as well as those who report smoking or economic challenges or have a nonsurgical diagnosis, may require additional support to maintain CR session attendance.
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Olsen SJS, Schirmer H, Bønaa KH, Hanssen TA. Cardiac rehabilitation after percutaneous coronary intervention: Results from a nationwide survey. Eur J Cardiovasc Nurs 2017; 17:273-279. [PMID: 29048205 DOI: 10.1177/1474515117737766] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Aim: The purpose of this study was to estimate the proportion of Norwegian coronary heart disease patients participating in cardiac rehabilitation programmes after percutaneous coronary intervention, and to determine predictors of cardiac rehabilitation participation. Methods: Participants were patients enrolled in the Norwegian Coronary Stent Trial. We assessed cardiac rehabilitation participation in 9013 of these patients who had undergone their first percutaneous coronary intervention during 2008–2011. Of these, 7068 patients (82%) completed a self-administered questionnaire on cardiac rehabilitation participation within three years after their percutaneous coronary intervention. Results: Twenty-eight per cent of the participants reported engaging in cardiac rehabilitation. Participation rate differed among the four regional health authorities in Norway, varying from 20%–31%. Patients undergoing percutaneous coronary intervention for an acute coronary syndrome were more likely to participate in cardiac rehabilitation than patients with stable angina (odds ratio 3.2; 95% confidence interval 2.74–3.76). A multivariate statistical model revealed that men had a 28% lower probability ( p<0.001) of participating in cardiac rehabilitation, and the odds of attending cardiac rehabilitation decreased with increasing age ( p<0.001). Contributors to higher odds of cardiac rehabilitation participation were educational level >12 years (odds ratio 1.50; 95% confidence interval 1.32–1.71) and body mass index>25 (odds ratio 1.19; 95% confidence interval 1.05–1.36). Prior coronary artery bypass graft was associated with lower odds of cardiac rehabilitation participation (odds ratio 0.47; 95% confidence interval 0.32–0.70) Conclusion: The estimated cardiac rehabilitation participation rate among patients undergoing first-time percutaneous coronary intervention is low in Norway. The typical participant is young, overweight, well-educated, and had an acute coronary event. These results varied by geographical region.
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Affiliation(s)
- Siv JS Olsen
- Division of Internal Medicine, University Hospital of North Norway, Norway
- Cardiovascular Research Group, The Arctic University of Norway, Norway
| | - Henrik Schirmer
- Cardiovascular Research Group, The Arctic University of Norway, Norway
- Department of Heart Disease, University Hospital of North Norway, Norway
| | - Kaare H Bønaa
- Department of Community Medicine, The Arctic University of Norway, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Norway
- Clinic for Heart Disease, St. Olavs University Hospital, Trondheim, Norway
| | - Tove A Hanssen
- Cardiovascular Research Group, The Arctic University of Norway, Norway
- Department of Heart Disease, University Hospital of North Norway, Norway
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Cardiac rehabilitation in patients who underwent primary percutaneous coronary intervention for acute myocardial infarction: determinants of programme participation and completion. Neth Heart J 2017; 25:618-628. [PMID: 28917025 PMCID: PMC5653538 DOI: 10.1007/s12471-017-1039-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Hospital length of stay after acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (pPCI) has reduced, resulting in more limited patient education during admission. Therefore, systematic participation in cardiac rehabilitation (CR) has become more essential. We aimed to identify patient-related factors that are associated with participation in and completion of a CR programme. Methods We identified 3,871 consecutive AMI patients who underwent pPCI between 2003 and 2011. These patients were linked to the database of Capri CR, which provides dedicated, multi-disciplinary CR. ‘Participation’ was defined as registration at Capri CR within 6 months after pPCI. CR was ‘complete’ if a patient undertook the final exercise test. Results In total, 1,497 patients (39%) were registered at Capri CR. Factors independently associated with CR participation included age (<50 vs. >70 year: odds ratio (OR) 7.0, 95% confidence interval (CI) 5.1–9.6), gender (men vs. women: OR 1.9, 95% CI 1.3–1.8), index diagnosis (ST-elevation myocardial infarction [STEMI] vs. non-ST-elevation myocardial infarction [NSTEMI]: OR 2.4, 95% CI 2.0–2.7) and socio-economic status (high vs. low: OR 2.0, 95% CI 1.6–2.5). The model based on these factors discriminated well (c-index 0.75). CR programme completion was 80% and was inversely related with diabetes, current smoking and previous MI. The discrimination of the model based on these factors was poor (c-index 0.59). Conclusions Only a minority of AMI/pPCI patients participated in a CR programme. Completion rates, however, were better. Increased physician and patient awareness of the benefits of CR are still needed, with focus on the elderly, women and patients with low socio-economic status.
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A Mixed Method Review of Tobacco Cessation for the Cardiopulmonary Rehabilitation Clinician. J Cardiopulm Rehabil Prev 2017; 37:160-174. [PMID: 28448378 DOI: 10.1097/hcr.0000000000000268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To systematically survey the literature, describe the current tobacco science, and perform a mixed method review of randomized control trials of tobacco research in the cardiopulmonary population. METHODS Mixed method review was conducted on major resource databases. Inclusion criteria were English language with a minimum follow-up of 6 months, published between January 1, 2007, and June 30, 2016; adult smokers ≥18 years of age with cardiovascular and/or pulmonary disease; initiation of subject recruitment from hospital or community; tobacco cessation (TC) as the main aim of the study; biometric validation of smoking status; first-line TC medications; and nonpharmacological treatments. RESULTS The pooling of the 10 studies through forest plot analysis revealed the effect of tobacco continuous abstinence rates significant at 3, 6, and 12 months (total OR = 3.73; 95% CI, 2.58-5.38). Also, tobacco point prevalence rates of TC treatments demonstrated overall effects that were significant at the different end points (total OR = 2.63; 95% CI, 1.90-3.64). In both cases, the higher ORs were found in the 3 months end point. Most successful interventions consisted of a combination of pharmacological and nonpharmacological therapy (predominantly counseling). CONCLUSIONS The evidence continues to support the recommended first-line TC pharmacotherapy and nonpharmacological practices published in the 2008 national guidelines. Implications for cardiopulmonary rehabilitation clinicians are discussed.
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Higgins ST, Kurti AN, Redner R, White TJ, Keith DR, Gaalema DE, Sprague BL, Stanton CA, Roberts ME, Doogan NJ, Priest JS. Co-occurring risk factors for current cigarette smoking in a U.S. nationally representative sample. Prev Med 2016; 92:110-117. [PMID: 26902875 PMCID: PMC4992654 DOI: 10.1016/j.ypmed.2016.02.025] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/16/2016] [Accepted: 02/18/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Relatively little has been reported characterizing cumulative risk associated with co-occurring risk factors for cigarette smoking. The purpose of the present study was to address that knowledge gap in a U.S. nationally representative sample. METHODS Data were obtained from 114,426 adults (≥18years) in the U.S. National Survey on Drug Use and Health (years 2011-13). Multiple logistic regression and classification and regression tree (CART) modeling were used to examine risk of current smoking associated with eight co-occurring risk factors (age, gender, race/ethnicity, educational attainment, poverty, drug abuse/dependence, alcohol abuse/dependence, mental illness). RESULTS Each of these eight risk factors was independently associated with significant increases in the odds of smoking when concurrently present in a multiple logistic regression model. Effects of risk-factor combinations were typically summative. Exceptions to that pattern were in the direction of less-than-summative effects when one of the combined risk factors was associated with generally high or low rates of smoking (e.g., drug abuse/dependence, age ≥65). CART modeling identified subpopulation risk profiles wherein smoking prevalence varied from a low of 11% to a high of 74% depending on particular risk factor combinations. Being a college graduate was the strongest independent predictor of smoking status, classifying 30% of the adult population. CONCLUSIONS These results offer strong evidence that the effects associated with common risk factors for cigarette smoking are independent, cumulative, and generally summative. The results also offer potentially useful insights into national population risk profiles around which U.S. tobacco policies can be developed or refined.
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Affiliation(s)
- Stephen T Higgins
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States.
| | - Allison N Kurti
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
| | - Ryan Redner
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
| | - Thomas J White
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
| | - Diana R Keith
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
| | - Diann E Gaalema
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
| | - Brian L Sprague
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
| | | | - Megan E Roberts
- Center of Excellence in Regulatory Tobacco Science, The Ohio State University, United States
| | - Nathan J Doogan
- Center of Excellence in Regulatory Tobacco Science, The Ohio State University, United States
| | - Jeff S Priest
- Vermont Center on Tobacco Regulatory Science, University of Vermont, United States
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Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van 't Hof A, Meindersma E, Bossano Prescott EI, González-Juanatey JR. Participation and adherence to cardiac rehabilitation programs. A systematic review. Int J Cardiol 2016; 223:436-443. [DOI: 10.1016/j.ijcard.2016.08.120] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 08/04/2016] [Accepted: 08/05/2016] [Indexed: 12/14/2022]
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Brown AT, Hitchcock J, Schumann C, Wells JM, Dransfield MT, Bhatt SP. Determinants of successful completion of pulmonary rehabilitation in COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:391-7. [PMID: 26955269 PMCID: PMC4772949 DOI: 10.2147/copd.s100254] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite known benefits, a significant proportion of patients with COPD do not complete pulmonary rehabilitation (PR). Little is known regarding which factors promote successful completion of PR. Methods We analyzed data from a prospectively maintained database of subjects with COPD who attended a PR program at the University of Alabama at Birmingham, from 1996 to 2013. Subjects were categorized as either completers or non-completers, based on successful completion of at least 8 weeks of PR. Demographics and comorbidities were recorded. Short Form 36 Health Survey, Beck Depression Inventory-II, and San Diego Shortness of Breath Questionnaire were administered to all participants at baseline and on completion of PR to assess participants’ perception of their health status, severity of depression, and dyspnea with performance of activities of daily living. Univariate and multivariable analyses were performed to identify predictors of successful completion of PR. Results Four hundred and forty subjects were included, of whom 229 completed PR. Forty-one percent were female, and 17% were African American. Compared with non-completers, completers had greater Short Form 36 Health Survey pain score, lower forced expiratory volume in the first second, and lower Beck Depression Inventory score, and included a lower percentage of current smokers. On multivariate analysis, cigarette smoking at enrollment was associated with lower likelihood of completion of PR (adjusted odds ratio 0.38, 95% confidence interval 0.16–0.90; P=0.02). Conclusion Cigarette smoking was the sole independent predictor of PR dropout, and smoking cessation may warrant greater emphasis prior to enrollment.
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Affiliation(s)
- Angel T Brown
- Division of Pulmonary, Allergy, and Critical Care Medicine, Birmingham, AL, USA
| | - Jason Hitchcock
- Department of Cardiopulmonary Rehabilitation, Birmingham, AL, USA
| | | | - J Michael Wells
- Division of Pulmonary, Allergy, and Critical Care Medicine, Birmingham, AL, USA; UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, Birmingham, AL, USA; UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Birmingham, AL, USA; UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
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Franklin BA, Brinks J. Cardiac Rehabilitation: Underrecognized/Underutilized. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:62. [PMID: 26526338 DOI: 10.1007/s11936-015-0422-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Unfortunately, too many patients continue to rely on costly coronary revascularization procedures, cardioprotective medications, or both, as first-line strategies to stabilize the course of coronary heart disease. However, these palliative therapies do not address the foundational or most proximal risk factors for coronary disease, that is, unhealthy dietary habits, physical inactivity, and cigarette smoking. Because most acute myocardial infarctions evolve from mild-to-moderate coronary artery stenosis (<70 % obstruction), rather than at the more severe obstructions that are commonly treated with coronary revascularization, these findings help explain the inability to demonstrate a reduction in acute cardiac events in most studies examining coronary artery bypass graft surgery and/or percutaneous coronary interventions. The delivery of comprehensive cardiovascular risk reduction, including exercise-based cardiac rehabilitation as an integral component, offers patients a bona fide treatment intervention to prevent recurrent cardiovascular events and the need for repeated revascularization procedures, while simultaneously providing referring physicians with ongoing surveillance data to potentially enhance their medical management.
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Affiliation(s)
- Barry A Franklin
- Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, MI, USA. .,Internal Medicine and Biomedical Engineering, Oakland University William Beaumont School of Medicine, Rochester, MI, USA. .,Beaumont Health Center, Cardiac Rehabilitation, 4949 Coolidge Highway, Royal Oak, MI, 48073, USA.
| | - Jenna Brinks
- Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, MI, USA.,Beaumont Health Center, Cardiac Rehabilitation, 4949 Coolidge Highway, Royal Oak, MI, 48073, USA
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Higgins ST. Editorial: 2nd Special Issue on behavior change, health, and health disparities. Prev Med 2015; 80:1-4. [PMID: 26257372 PMCID: PMC4778247 DOI: 10.1016/j.ypmed.2015.07.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 07/26/2015] [Accepted: 07/28/2015] [Indexed: 11/19/2022]
Abstract
This Special Issue of Preventive Medicine (PM) is the 2nd that we have organized on behavior change, health, and health disparities. This is a topic of fundamental importance to improving population health in the U.S. and other industrialized countries that are trying to more effectively manage chronic health conditions. There is broad scientific consensus that personal behavior patterns such as cigarette smoking, other substance abuse, and physical inactivity/obesity are among the most important modifiable causes of chronic disease and its adverse impacts on population health. As such behavior change needs to be a key component of improving population health. There is also broad agreement that while these problems extend across socioeconomic strata, they are overrepresented among more economically disadvantaged populations and contribute directly to the growing problem of health disparities. Hence, behavior change represents an essential step in curtailing that unsettling problem as well. In this 2nd Special Issue, we devote considerable space to the current U.S. prescription opioid addiction epidemic, a crisis that was not addressed in the prior Special Issue. We also continue to devote attention to the two largest contributors to preventable disease and premature death, cigarette smoking and physical inactivity/obesity as well as risks of co-occurrence of these unhealthy behavior patterns. Across each of these topics we included contributions from highly accomplished policy makers and scientists to acquaint readers with recent accomplishments as well as remaining knowledge gaps and challenges to effectively managing these important chronic health problems.
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Affiliation(s)
- Stephen T Higgins
- Vermont Center on Behavior and Health, Departments of Psychiatry and Psychological Science, University of Vermont, Burlington, VT, USA.
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Blay SL, Schulz AJ, Mentz G. The Relationship of Built Environment to Health-Related Behaviors and Health Outcomes in Elderly Community Residents in a Middle Income Country. J Public Health Res 2015; 4:548. [PMID: 26425497 PMCID: PMC4568426 DOI: 10.4081/jphr.2015.548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 06/03/2015] [Indexed: 11/23/2022] Open
Abstract
Background Few studies have examined the impact of the built environment (BE) on health behaviours and health outcomes in middle income countries. This study examines associations between self-assessed characteristics of the home and neighbourhood environment and health-related behaviours and health outcomes in an elderly population in Brazil Design and methods In a community sample of 6963 community dwellers 60 years old and older living in the state of Rio Grande do Sul, Brazil, associations between self-reported BE conditions and health behaviours and health outcomes were assessed using a structured questionnaire. Multivariate analysis was conducted to investigate these associations while accounting for other relevant characteristics. Results We found significant positive associations between adverse BE conditions and pulmonary, urinary conditions, gastrointestinal, problems, headache and depression. There were mixed associations between adverse BE conditions and musculoskeletal and sensory conditions, inverse associations with metabolic disorders. and no associations with dermatologic problems and cancer. After accounting for health related behaviours, results suggest a modest association between adverse BE conditions and hypertension, with no significant associations with other indicators of cardiovascular conditions (heart problems, stroke, varicose veins). Conclusions The findings in this study suggest links between adverse conditions in the BE and health related behaviours in the hypothesized direction. Associations with the health conditions examined here are mixed. We find the strongest evidence for effects of adverse BE conditions for pulmonary and infectious conditions. Significant associations between the adverse BE indicators and health outcomes persist after accounting for health related behaviours, suggesting that BE conditions are linked to health pathways above and beyond the health related behaviours assessed in this study. Significance for public health The health outcomes for which we found most consistent evidence of associations with the built environment index (BEI) included respiratory conditions (bronchitis, pneumonia), urinary and renal conditions, gastrointestinal problems, headache, visual impairment and stroke. These health outcomes in the elderly may reflect exposures in the household environment associated with inadequate housing, such as mold, dust and damp. They may also be influenced by poor sanitary conditions, reflected in the absence of indoor plumbing and inadequate waste disposal facilities. Poor vision, headache and depression may all be associated with chronic exposure to poverty and stress, for which the measures of the household and neighborhood environmental conditions used in the BEI may be indicators. Assuring that the elderly in Brazil have access to adequate housing located in neighborhoods with access to basic sanitary conditions, water and lighting, will be increasingly important as the average age of Brazilians continues to increase, and increasing proportions of the population experience the adverse health effects associated with these conditions.
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Affiliation(s)
- Sergio L Blay
- Department of Psychiatry, Federal University of São Paulo , Brazi, MI, USA
| | - Amy J Schulz
- Department of Health Behavior and Health Education, University of Michigan School of Public Health , Ann Arbor, MI, USA
| | - Graciela Mentz
- Department of Health Behavior and Health Education, University of Michigan School of Public Health , Ann Arbor, MI, USA
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