Global availability of cardiac rehabilitation

Gender differences in cardiac rehabilitation participation and outcomes: an 18-year retrospective study in Iran

BACKGROUND

Cardiac rehabilitation (CR) is crucial for addressing cardiovascular diseases globally, with a specific emphasis on gender differences. Despite its demonstrated benefits for women, there's limited acceptance globally, especially in low- and middle-income countries. The program aims to optimize risk factors and improve overall patient well-being.

METHODS

A cohort study was performed on those who were candidates for CR programs during 2001-2019. Assessments were performed within one week before and one week after the 8-week CR program. Age, sex, smoking status, clinical data, resting systolic and diastolic blood pressure (SBP and DBP, respectively), echocardiography and laboratory data were obtained. Functional capacity was evaluated using the international physical activity questionnaire, and a treadmill exercise test. Anxiety, depression, general quality of life (QoL), and health-related QoL were selected for psychological status. Then statistical analysis was performed on data.

RESULT

In this study, the number of male patients was 1526 (73.69%). The average age of patients in the female group was higher than that of males (58.66 ± 9.08 vs. 56.18 ± 9.94), according to the crude model results, the changes in emotional, social and physical scores were significant (P-value:0.028, 0.018, 0.030), as well as the differences in Mets and smoking were significant (P-value for both < 0.001) in the adjusted model, the emotional variables and Mets changes were significant in two groups, so that the emotional score in the female group was higher than that of the male group, and the female Mets score was significantly lower than that of the male group.

CONCLUSION

The CR program can improve cardiovascular outcomes, but the greatest impact was on the quality of life, patient METs and smoking behavers. Also the number of female participants in the CR program was less than the number of males.

Barriers to Cardiac Rehabilitation Enrollment and Secondary Prevention Adherence in Patients with Coronary Heart Disease Following Percutaneous Coronary Intervention: A Cross-sectional Survey

Objectives

This study aimed to evaluate adherence to secondary prevention measures and to identify barriers to cardiac rehabilitation enrolment among patients with coronary heart disease after percutaneous coronary intervention.

Methods

An observational cross-sectional survey was conducted through computer-assisted telephone interviews to assess recently treated percutaneous coronary intervention patients at the Prince Sultan Cardiac Center in Saudi Arabia.

Results

Out of 104 surveyed patients with coronary heart disease, 85 (82%) were male, with an average age of 59.5 years. The obesity rate was 28% (n = 29), with a high prevalence of comorbidities: 82 (79%), 63 (61%), and 62 (60%) patients had hyperlipidemia, diabetes, and hypertension, respectively. Despite high medication compliance (97%), adherence to secondary prevention measures was low (21%). Adherence to physical exercise and weight monitoring for fluid body build-up was notably poor at 35% and 9%, respectively. Only 11 (10.6%) patients were referred for cardiac rehabilitation, of whom only four (36.4%) attended. Significant barriers such as a lack of staff contact, insufficient physician support, and distance to cardiac rehabilitation facilities were particularly noted by 69% of rural patients.

Conclusions

This study underscores the significant cardiac risk factors and low adherence to secondary prevention measures among post revascularization patients with coronary heart disease in Saudi Arabia. Low referral and other organizational barriers, as well as the travel distance to hospital-based cardiac rehabilitation, hinder program enrolment. To improve cardiac rehabilitation accessibility, it is crucial to revise the discharge plans, implement automated referral systems, expand the services across all regions, and utilize alternative delivery models.

A Systematic Review of the Completion of Cardiac Rehabilitation Programs for Adults Aged 18-50 Years

OBJECTIVE

To perform a systematic review of completion rates of cardiac rehabilitation (CR) in adults aged 18 to 50 yr and describe how core components were reported, measured, and tailored to those under 50 yr.

REVIEW METHODS

Database search of MEDLINE, Embase, Emcare, PsycINFO, CINAHL, Scopus, and the Cochrane Library based on keywords, including articles from January 1, 1990. The last search was performed on April 21, 2023. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses protocol, eligible articles contained adults (aged between 18 and 50 yr) who had participated in a CR program.

SUMMARY

Out of the articles screened (n = 24,517), 33 reports across 31 independent studies were considered eligible (n = 1958 patients aged ≤50 yr). Cardiac rehabilitation completion rates ranged from 64% to 100%; however, only 5 studies presented a completion rate definition. The length of the program ranged from 7 d to 20 wk, with most (65%) ranging between 6 and 12 wk. While the studies included in this systematic review indicated relatively high rates of completing CR, these are likely to overrepresent the true completion rates as few definitions were provided that could be compared to completion rates used in clinical practice. This systematic review also found that all interventions prescribed exercise (eg, aerobic alone or combined with resistance training or yoga) but had very limited inclusion or description of other integral components of CR (eg, initial assessment and smoking cessation) or how they were assessed and individualized to meet the needs of younger attendees.

Knowledge, Attitude, and Practice of Physiotherapists about Cardiac Rehabilitation Program Adherence among Patients Discharged from the Hospital after Cardiac Surgery in India

Background

In most settings, patients receive phase 1 cardiac rehabilitation in CTVS ICU at the hospital, but there are several barriers to follow-up after patients are discharged from the hospital. Physiotherapists play an important role in the enrolment and continuation of cardiac rehabilitation. Thus, we aim to study the knowledge, attitude, and practice of physiotherapists about CR program adherence among patients discharged from the hospital after cardiac surgery.

Objectives

(i) To study the knowledge of physiotherapists about the importance of cardiac rehabilitation after discharge; (ii) to know the attitude of physiotherapists towards cardiac surgery patients after discharge; and (iii) to know what approach various centres are applying for patients after discharge to ensure adherence to cardiac rehabilitation.

Methods

A questionnaire was developed with reference to the objectives of the study, which was answered by a total of 127 physiotherapists.

Results

The overall response rate was 42.3%; nearly 35.4% of the participants indicated that they knew a lot about CR, while 5.5% said they knew very little. Regarding the program's content, 36.2% of participants reported having a medium degree of awareness of the diverse CR components, while 8.6% reported having very little knowledge of them. Only about one-third, 35.7% stated that CR in India is effective and 95% believed that CR will have an added value for the country. Approximately 80% of respondents thought that it would be challenging for a physiotherapist to recommend patients to a CR in the nation. Nearly 35% of respondents believed that they, "themselves as physios," needed to commence CR, and slightly less than 70% thought that doctors were required to choose and refer the patients when asked who should take the initiative to start this kind of programme in the country. A little over 40% of respondents said that insurance firms are also involved in starting a CR programme.

Conclusion

Physiotherapists have good knowledge of cardiac rehabilitation. However, their attitude and practice towards adherence to exercise protocols are confounded by various clinician- and patient-level factors.

Knowledge, attitudes, and practices of cardiac rehabilitation among physiotherapists in Morocco

Cardiovascular disease is a growing challenge worldwide, and Morocco is no exception. Despite its growing popularity, cardiac rehabilitation is still largely underutilized. In order to improve the provision of cardiac rehabilitation, a study of the knowledge, attitudes, and practices of physiotherapists in Morocco, key players in cardiac rehabilitation, is described. This assessment highlights existing skill gaps and enables the necessary corrective measures to be identified. This cross-sectional study included Moroccan physiotherapists working in different institutions (public and private) in different regions of Morocco. A total of 145 valid questionnaires were collected (33% response rate). The results showed that 72.4% of respondents had a medium level of knowledge of cardiac rehabilitation, 93.8% had a positive attitude, and 73% of physiotherapists said they sometimes practiced cardiac rehabilitation. Subgroup analysis showed that the lower the level of education, the more negative the knowledge and practice of rehabilitation. The results also showed that physiotherapists working in education sector and private clinics had better practice than those working in hospitals.

Cardiac rehabilitation and acute aortic dissection: understanding and addressing the evidence GAP a systematic review

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.

Virtual and augmented reality in cardiovascular care in low and middle income country

The global health sector has witnessed an escalating integration of Virtual Reality (VR) and Augmented Reality (AR) technologies, particularly in high-income countries. The application of these cutting-edge technologies is gradually extending to Low- and Middle-Income Countries (LMICs), notably in the domain of cardiovascular care. AR and VR technologies are revolutionizing cardiovascular care by offering solutions for diagnosis, medical training, and surgical planning. AR and VR provide detailed and immersive visualizations of cardiac structures, aiding in diagnosis and intervention planning. In cardiovascular care, VR reduces patient-reported pain, eases anxiety, and accelerates post-procedural recovery. AR and VR are also valuable for life support training, creating immersive and controlled learning environments. AR and VR have the potential to significantly impact healthcare in low- and middle-income countries with enhanced accessibility and affordability. This review outlines the existing spectrum of VR and AR adoption and its burgeoning utility in the cardiovascular domain within LMICs.

Impact of Cardiac Rehabilitation Health Insurance Coverage on Cardiac Rehabilitation Use in Korea Using an Interrupted Time Series

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.

Exercise-based cardiac rehabilitation after acute myocardial infarction in Sweden - standards, costs, and adherence to European guidelines (The Perfect-CR study)

AIMS

Information on standards including structure- and process-based metrics and how exercise-based cardiac rehabilitation (EBCR) is delivered in relation to guidelines is lacking. The aims of the study were to evaluate standards and adherence to guidelines at Swedish CR centers and to conduct a cost analysis of the physiotherapy-related activities of EBCR.

METHODS AND RESULTS

EBCR standards at all 78 CR centers in Sweden in 2016 were surveyed. The questions were based on guideline-recommended core components of EBCR for patients after a myocardial infarction (MI). The cost analysis included the identification, quantification, and valuation of EBCR-related cost items. Patients were offered a pre-discharge consultation with a physiotherapist at n = 61, 78% of the centers. A pre-exercise screening visit was routinely offered at n = 64, 82% of the centers, at which a test of aerobic capacity was offered in n = 58, 91% of cases, most often as a cycle ergometer exercise test n = 55, 86%. A post-exercise assessment was offered at n = 44, 56% of the centers, with a functional test performed at n = 30, 68%. Almost all the centers n = 76, 97% offered supervised EBCR programs. The total cost of delivering physiotherapy-related activities of EBCR according to guidelines was approximately 437 euro (4,371 SEK) per patient. Delivering EBCR to one MI patient required 11.25 hours of physiotherapy time.

CONCLUSION

While the overall quality of EBCR programs in Sweden is high, there are several areas of potential improvement to reach the recommended European standards across all centers. To improve the quality of EBCR, further compliance with guidelines is warranted.

The effect of cardiac rehabilitation on cardiopulmonary function after coronary artery bypass grafting: A systematic review and meta-analysis

We carried out a meta-analysis on the effect of cardiac rehabilitation (CR) on cardiopulmonary function after coronary artery bypass grafting (CABG). Four databases were searched for studies comparing CR with control. A random-effects model was used to pool mean difference (MD). The meta-analysis showed an increase in peak oxygen consumption (peak VO2) (MD = 1.93 mL/kg/min, p = 0.0006), and 6-min walk distance (6MWD) (MD = 59.21 m, p < 0.00001), and a decrease in resting heart rate (resting HR) (MD = 5.68 bpm, p < 0.0001) in the CR group. The subgroup analysis revealed aerobic exercise could further improve resting HR and peak HR, and physical/combination with aerobic exercise could further increase 6MWD. The improvement of peak VO2, workload, resting HR, peak HR, and 6MWD regarding CR performed within one week after CABG is greater than that one week after CABG. CR after CABG can improve the cardiopulmonary function, which is reflected by the improvement of peak VO2, 6MWD, and resting HR.

Effectiveness of Cardiac Rehabilitation Services in Low- and Middle-Income Countries: A Systematic Review

Cardiac rehabilitation (CR) is a cost-effective intervention that can reduce cardiovascular disease (CVD) morbidity and mortality by 20%. Despite the clear benefits of CR, it remains unavailable and underutilized. This study aimed to assess the effectiveness of different CR models in reducing CVD-related morbidity and mortality in low-and middle-income countries. We conducted a systematic review of studies conducted in low- and middle-income countries that assessed at least one of the three phases of CR (inpatient rehabilitation, outpatient rehabilitation in a hospital, or community setting and maintenance). The primary outcomes of interest were mortality (all-cause and CVD-specific), CVD-related morbidity, functional capacity, risk factor reduction, and quality of life (QoL). The electronic search retrieved 1,102 studies, of which 22 were retrieved and included in the review. These studies were conducted between 2011 and 2022 and the majority (18) were conducted in Asia. All studies except one were randomized controlled trials (RCTs), and all except one were conducted at a single site. The target population in most studies (16) included patients with coronary artery disease (CAD). Seven studies have incorporated digital technology. Only one study has reported a significant reduction in all-cause mortality. Thirteen studies reported data on functional capacity, and 16 on quality of life (QoL), showing statistically significant improvements. Data on risk factors, anxiety, and depression have shown mixed results. CR is effective in low- and middle-income countries, and strategies to scale it up using locally available resources tailored to the patient population should be adopted.

Trends in cardiac rehabilitation rates among patients admitted for acute heart failure in Japan, 2009-2020

OBJECTIVES

To describe inpatient and outpatient cardiac rehabilitation (CR) utilization patterns over time and by subgroups among patients admitted for acute heart failure (AHF) in Japan.

BACKGROUND

Cardiac rehabilitation (CR) is a crucial secondary prevention strategy for patients with heart failure. While the number of older patients with AHF continues to rise, trends in inpatient and outpatient CR participation following AHF in Japan have not been described to date.

METHODS

We conducted a retrospective cohort study of adult patients hospitalized for AHF in Japan between April 2008 and December 2020. Using data from the Medical Data Vision database, we measured trends in inpatient and outpatient CR participation following AHF. Descriptive analyses and summary statistics for AHF patients by CR participation status were reported.

RESULTS

The analytic cohort included 88,052 patients. Among these patients, 37,810 (42.9%) participated in inpatient and/or outpatient CR. Of those, 36,431 (96.4%) participated in inpatient CR only and 1,277 (3.4%) participated in both inpatient and outpatient CR. Rates of inpatient CR rose more than 6-fold over the study period, from 9% in 2009 to 55% in 2020, whereas rates of outpatient CR were consistently low.

CONCLUSIONS

The rate of inpatient CR participation among AHF patients in Japan rose dramatically over a 12-year period, whereas outpatient CR following AHF was vastly underutilized. Further study is needed to assess the clinical effectiveness of inpatient CR and to create infrastructure and incentives to support and encourage outpatient CR.

Impact of cardiac rehabilitation on cardiovascular event in Korea

This study aimed to evaluate the effects of cardiac rehabilitation (CR) on major adverse cardiac events (MACE) among patients who underwent PCI procedure. We used data from the electronic medical records (EMR) of a tertiary hospital in Seoul, Korea, from January 2014 to February 2020. Data from 2988 patients who had experienced their first acute coronary syndrome (ACS) and had undergone percutaneous coronary intervention (PCI) were included during the study period. we classified patients into CR participants and non-participants based on their participation in the cardiac rehabilitation (CR) program within 30 days after discharge. And the outcome was the incidence of myocardial infarction (MI) and stroke within 1 year after discharge. The association between participation in CR and risk of developing MACE was evaluated using the Cox proportional hazards model. Patients who achieved CR after undergoing PCI were at a lower risk of developing MI (HR 0.68, CI 0.53-0.86). There was no significant association between participation in CR and the incidence of stroke. Among patients who had more than three stenotic vessels, the risk of developing MI within 1 year of discharge was reduced in CR users compared to non-users (3 or more stenosis vessels: HR 0.55, CI 0.35-0.86). Among patients who used two and more stents during PCI procedures, the risk of developing MI within 1 year of discharge was reduced in CR users compared to non-users (2 and more stents: HR 0.54, CI 0.35-0.85). Among people diagnosed with ACS and receiving PCI, patients who participated in CR within one month of discharge reduced risk of developing MI. Our study reinforced the current evidence on the effect of CR among patients receiving PCI and presented the expansion and enhancement of the CR program.

Digital Health Programs to Reduce Readmissions in Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

The use of mobile health (mHealth, wireless communication devices, and/or software technologies) in health care delivery has increased rapidly in recent years. Their integration into disease management programs (DMPs) has tremendous potential to improve outcomes for patients with coronary artery disease (CAD), yet a more robust evaluation of the evidence is required.

Objectives

The purpose of this study was to undertake a systematic review and meta-analysis of mHealth-enabled DMPs to determine their effectiveness in reducing readmissions and mortality in patients with CAD.

Methods

We systematically searched English language studies from January 1, 2007, to August 3, 2021, in multiple databases. Studies comparing mHealth-enabled DMPs with standard DMPs without mHealth were included if they had a minimum 30-day follow-up for at least one of all-cause or cardiovascular-related mortality, readmissions, or major adverse cardiovascular events.

Results

Of the 3,411 references from our search, 155 full-text studies were assessed for eligibility, and data were extracted from 18 publications. Pooled findings for all-cause readmissions (10 studies, n = 1,514) and cardiac-related readmissions (9 studies, n = 1,009) indicated that mHealth-enabled DMPs reduced all-cause (RR: 0.68; 95% CI: 0.50-0.91) and cardiac-related hospitalizations (RR: 0.55; 95% CI: 0.44-0.68) and emergency department visits (RR: 0.37; 95% CI: 0.26-0.54) compared to DMPs without mHealth. There was no significant reduction for mortality outcomes (RR: 1.72; 95% CI: 0.64-4.64) or major adverse cardiovascular events (RR: 0.68; 95% CI: 0.40-1.15).

Conclusions

DMPs integrated with mHealth should be considered an effective intervention for better outcomes in patients with CAD.

Presentation, care, and outcomes of patients with NSTEMI according to World Bank country income classification: the ACVC-EAPCI EORP NSTEMI Registry of the European Society of Cardiology

BACKGROUND

The majority of NSTEMI burden resides outside high-income countries (HICs). We describe presentation, care, and outcomes of NSTEMI by country income classification.

METHODS AND RESULTS

Prospective cohort study including 2947 patients with NSTEMI from 287 centres in 59 countries, stratified by World Bank country income classification. Quality of care was evaluated based on 12 guideline-recommended care interventions. The all-or-none scoring composite performance measure was used to define receipt of optimal care. Outcomes included in-hospital acute heart failure, stroke/transient ischaemic attack, and death, and 30-day mortality. Patients admitted with NSTEMI in low to lower-middle-income countries (LLMICs), compared with patients in HICs, were younger, more commonly diabetic, and current smokers, but with a lower burden of other comorbidities, and 76.7% met very high risk criteria for an immediate invasive strategy. Invasive coronary angiography use increased with ascending income classification (LLMICs, 79.2%; upper middle income countries [UMICs], 83.7%; HICs, 91.0%), but overall care quality did not (≥80% of eligible interventions achieved: LLMICS, 64.8%; UMICs 69.6%; HICs 55.1%). Rates of acute heart failure (LLMICS, 21.3%; UMICs, 12.1%; HICs, 6.8%; P < 0.001), stroke/transient ischaemic attack (LLMICS: 2.5%; UMICs: 1.5%; HICs: 0.9%; P = 0.04), in-hospital mortality (LLMICS, 3.6%; UMICs: 2.8%; HICs: 1.0%; P < 0.001) and 30-day mortality (LLMICs, 4.9%; UMICs, 3.9%; HICs, 1.5%; P < 0.001) exhibited an inverse economic gradient.

CONCLUSION

Patients with NSTEMI in LLMICs present with fewer comorbidities but a more advanced stage of acute disease, and have worse outcomes compared with HICs. A cardiovascular health narrative is needed to address this inequity across economic boundaries.

The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990-2019

It has been estimated that in the next decade, IHD prevalence, DALYs and deaths will increase more significantly in EMR than in any other region of the world. This study aims to provide a comprehensive description of the trends in the burden of ischemic heart disease (IHD) across the countries of the Eastern Mediterranean Region (EMR) from 1990 to 2019. Data on IHD prevalence, disability-adjusted life years (DALYs), mortality, DALYs attributable to risk factors, healthcare access and quality index (HAQ), and universal health coverage (UHC) were extracted from the Global Burden of Disease (GBD) database for EMR countries. The data were stratified based on the social demographic index (SDI). Information on cardiac rehabilitation was obtained from publications by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), and additional country-specific data were obtained through advanced search methods. Age standardization was performed using the direct method, applying the estimated age structure of the global population from 2019. Uncertainty intervals were calculated through 1000 iterations, and the 2.5th and 97.5th percentiles were derived from these calculations. The age-standardized prevalence of IHD in the EMR increased from 5.0% to 5.5% between 1990 and 2019, while it decreased at the global level. In the EMR, the age-standardized rates of IHD mortality and DALYs decreased by 11.4% and 15.4%, respectively, during the study period, although both rates remained higher than the global rates. The burden of IHD was found to be higher in males compared to females. Bahrain exhibited the highest decrease in age-standardized prevalence (-3.7%), mortality (-65.0%), and DALYs (-69.1%) rates among the EMR countries. Conversely, Oman experienced the highest increase in prevalence (14.5%), while Pakistan had the greatest increase in mortality (30.0%) and DALYs (32.0%) rates. The top three risk factors contributing to IHD DALYs in the EMR in 2019 were high systolic blood pressure, high low-density lipoprotein cholesterol, and particulate matter pollution. The trend analysis over the 29-year period (1990-2019) revealed that high fasting plasma glucose (64.0%) and high body mass index (23.4%) exhibited increasing trends as attributed risk factors for IHD DALYs in the EMR. Our findings indicate an increasing trend in the prevalence of IHD and a decrease in mortality and DALYs in the EMR. These results emphasize the need for well-planned prevention and treatment strategies to address the risk factors associated with IHD. It is crucial for the countries in this region to prioritize the development and implementation of programs focused on health promotion, education, prevention, and medical care.

The Prevention and Cardiac Rehabilitation Group of the Saudi Heart Association Recommendations Regarding Establishing a Cardiac Rehabilitation Service

Cardiac rehabilitation (CR) is a cornerstone in the secondary prevention of cardiovascular disease (CVD). Comprehensive cardiac rehabilitation has obtained the highest class of recommendation and the level of evidence for the treatment of patients with ST-segment elevation myocardial infarction, after myocardial revascularization, with chronic coronary syndromes, and in patients with heart failure (HF). Comprehensive cardiac rehabilitation should be implemented as soon as possible, be multi-phasic, and adjusted to the individual needs of the patient. CR is still suboptimally used, and many cardiac centers do not have such services (2). The provision of CR services should be based on standards and key performance indicators, and guidelines containing a minimum standard of cardiac rehabilitation utilization should be published to improve the quality of the CR program. This document presents an expert opinion that summarizes the current medical knowledge concerning the goals, target population, organization, clinical indications, and implementation methods of the CR program in the Kingdom of Saudi Arabia.

Outpatient Cardiovascular Rehabilitation Registry in Iran: The First Rehabilitation Registry Experience at EMR

INTRODUCTION

The collected information includes demographic profile, medical history, physical examination, patient risk factors, anthropometric evaluation, medications, echocardiographic results, and exercise testing of all patients who participated in the outpatient cardiac rehabilitation program in Cardiac Rehabilitation Department since 1996 until now. Each patient was assigned an electronic code by which the patient's information could be identified. Subsequently, standard questionnaires were used, such as International physical activity questionnaire (IPAQ) to assess physical activity, MAC NEW to assess the quality of life, Spielberg to measure anxiety, Beck to assess depression, and nutritional questionnaires.

RESULTS

The findings were recorded, and the data were analyzed by the web and SPSS software. For all patients, the forms were filled based on a number of variables including backgrounds, registration components, type of referral, diagnosis of underlying heart disease, methods of data collection and entry, details of the educational program, return to work, psychiatric condition, drug regimen, clinical condition, echocardiography findings, functional capacity and exercise test response, smoking status, nutritional habits, and finally their 5-year follow-up for events and re-hospitalization.

CONCLUSION

It is necessary for the authors to establish a cardiac rehabilitation registration that can properly display care quality indicators and collect and report standard data from different nations to improve the quality of cardiac rehabilitation services and identify weaknesses.

Risk factors in cardiovascular patients: Challenges and opportunities to improve secondary prevention

BACKGROUND

Effective management of major cardiovascular risk factors is of great importance to reduce mortality from cardiovascular disease (CVD). The Survey of Risk Factors in Coronary Heart Disease (SURF CHD) II study is a clinical audit of the recording and management of CHD risk factors. It was developed in collaboration with the European Association of Preventive Cardiology and the European Society of Cardiology (ESC). Previous studies have shown that control of major cardiovascular risk factors in patients with established atherosclerotic CVD is generally inadequate. Azerbaijan is a country in the South Caucasus, a region at a very high risk for CVD.

AIM

To assess adherence to ESC recommendations for secondary prevention of CVD based on the measurement of both modifiable major risk factors and their therapeutic management in patients with confirmed CHD at different hospitals in Baku (Azerbaijan).

METHODS

Six tertiary health care centers participated in the SURF CHD II study between 2019 and 2021. Information on demographics, risk factors, physical and laboratory data, and medications was collected using a standard questionnaire in consecutive patients aged ≥ 18 years with established CHD during outpatient visits. Data from 687 patients (mean age 59.6 ± 9.58 years; 24.9% female) were included in the study.

RESULTS

Only 15.1% of participants were involved in cardiac rehabilitation programs. The rate of uncontrolled risk factors was high: Systolic blood pressure (BP) (SBP) (54.6%), low-density lipoprotein cholesterol (LDL-C) (86.8%), diabetes mellitus (DM) (60.6%), as well as overweight (66.6%) and obesity (25%). In addition, significant differences in the prevalence and control of some risk factors [smoking, body mass index (BMI), waist circumference, blood glucose (BG), and SBP] between female and male participants were found. The cardiovascular health index score (CHIS) was calculated from the six risk factors: Non- or ex-smoker, BMI < 25 kg/m2, moderate/vigorous physical activity, controlled BP (< 140/90 mmHg; 140/80 mmHg for patients with DM), controlled LDL-C (< 70 mg/dL), and controlled BG (glycohemoglobin < 7% or BG < 126 mg/dL). Good, intermediate, and poor categories of CHIS were identified in 6%, 58.3%, and 35.7% of patients, respectively (without statistical differences between female and male patients).

CONCLUSION

Implementation of the current ESC recommendations for CHD secondary prevention and, in particular, the control rate of BP, are insufficient. Given the fact that patients with different comorbid pathologies are at a very high risk, this is of great importance in the management of such patients. This should be taken into account by healthcare organizers when planning secondary prevention activities and public health protection measures, especially in the regions at a high risk for CVD. A wide range of educational products based on the Clinical Practice Guidelines should be used to improve the adherence of healthcare professionals and patients to the management of CVD risk factors.

Remote cardiac rehabilitation program during the COVID-19 pandemic for patients with stable coronary artery disease after percutaneous coronary intervention: a prospective cohort study

OBJECTIVE

The coronavirus disease-19 (COVID-19) pandemic restricts rapid implementation of in-person delivery of cardiac rehabilitation (CR) at the center for coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI), thus enabling a cohort comparison of in-person vs. remote CR program. This study aims to investigate outcomes of exercise capacity, health-related quality of life (HRQL), mental health, and family burden of stable CAD patients undergoing PCI in low-to-moderate risk after different delivery models of CR program.

METHODS

The study included a cohort of stable CAD patients undergoing PCI who had experienced two naturally occurring modes of CR program after hospital discharge at two time periods, January 2019 to December 2019 (in-person CR program) and May 2020 to May 2021 (remote CR program). The exercise capacity was assessed by means of 6-min walk test (6MWT), maximal oxygen uptake (VO₂max) and the respiratory anaerobic threshold (VO_2AT) before discharge, at the end of the 8-week and 12-week in-person or remote CR program after discharge.

RESULTS

No adverse events occurred during the CR period. CAD patients had a longer distance walked in 6 min with a higher VO_2max after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The distance walked in 6 min was longer and the maximal oxygen uptake (VO₂max) was higher at the end of the 12-week in-person or remote CR program than 8-week in-person or remote CR program (p < 0.05). The respiratory anaerobic threshold (VO_2AT) of CAD patients was decreased after 8-week CR program whether in-person or remote model (p < 0.05). CAD patients receiving remote CR program exhibited higher HRQL scores in domains of vitality (p = 0.048), role emotional (p = 0.039), mental health (p = 0.014), and the summary score of the mental composite (p = 0.048) compared to in-person CR program after 8 weeks. The anxiety and depression scores of CAD patients undergoing PCI were decreased after 8-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote delivery showed lower anxiety and depression scores compared to those receiving in-person delivery at the end of the 8-week CR program (p < 0.05). It was found that the family burden scores of CAD patients undergoing PCI were reduced after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote CR program showed lower family burden scores than those receiving in-person CR program after whether 8 weeks or 12 weeks (p < 0.05).

CONCLUSION

These data indicate that a properly designed and monitored remote delivery represents a feasible and safe model for low-to-moderate-risk, stable CAD patients undergoing PCI inaccessible to in-person CR during the COVID-19 pandemic.

Improving long-term care and outcomes of congenital heart disease: fulfilling the promise of a healthy life

Advances in the prevention, diagnosis, and treatment for congenital heart disease (CHD), the most common birth defect in China, have drastically improved survival for individuals with the disease. However, China's current health system is not well prepared to manage the growing population of people with CHD and their complex medical needs, which range from early detection of the condition and intervention for physical, neurodevelopmental, and psychosocial impairment, to long-term management of major complications and chronic health problems. Health disparities caused by long-standing regional differences in access to care pose challenges when major complications such as pulmonary hypertension arise, and when individuals with complex CHD become pregnant and give birth. Currently, no data sources track neonates, children, adolescents, and adults with CHD in China and delineate their clinical characteristics and use of health resources. This scarcity of data should warrant attention from the Chinese Government and relevant specialists in the field. In the third paper of the Series on CHD in China, we summarise key literature and current data to identify knowledge gaps and call for concerted efforts by the government, hospitals, clinicians, industries, and charitable organisations to develop an actionable, lifelong framework of congenital cardiac care that is accessible and affordable for all individuals with CHD. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Unmet Needs for Cardiac Rehabilitation in Africa: A Perennial Gap in the Management of Individuals with Cardiac Diseases

Cardiac rehabilitation (CR) is a standard model of care, and an established component of comprehensive care that has been proven to reduce mortality and morbidity in patients with cardiac diseases. International clinical practice guidelines routinely recommend that cardiac patients participate in CR programs for comprehensive secondary prevention. However, there is scant guidance on how to deliver these programs in low-resourced settings. This dearth of clinical practice guidelines may be an indication of low emphasis placed on CR as a component of cardiac health services in low-income countries, especially in Africa. Indeed, CR programs are almost non-existent in Africa despite the unmet need for CR in patients with ischemic heart disease in Africa reported to be about one million. This figure represents the highest unmet need of any World Health Organization region, and is colossal given the projected accelerated increases in incidence of cardiovascular diseases (CVD) in the region. This narrative review explored the availability of CR programs, potential barriers to CR and strategies that can mitigate such barriers in Africa.

Financial InceNtives for cArdiac rehabilitatioN ComplEtion (FINANCE) (single blind pragmatic RCT)

INTRODUCTION

Cardiac rehabilitation (CR) is strongly indicated in patients with acute myocardial infarction (MI), and has been proven to reduce mortality and recurrence and improve patients quality of life. Although clinical guidelines for CR have already been developed domestically and internationally, hospital-based CR remains underutilized. Currently, studies exploring strategies to improve CR participation in South Korea and Asia are limited.

OBJECTIVES

This study aims to compare the effect of providing CR financial incentives to post-MI patients referred for outpatient CR and to confirm the effect of increasing CR participation and completion rates.

METHODS

This single-blind, pragmatic, randomized controlled trial will be conducted at 2 tertiary hospitals for CR after acute MI. The control and experimental groups will be randomized, with each group consisting of 24 participants (total of 48 participants) assigned in a 1:1 ratio. The experimental group will receive 4, 7, and 11 USD per completed session of CR during the 1st to 12th, 13 to 24th, and 25th to 36th sessions of CR, respectively, for 3 months after enrollment. Participants who completed the 36 sessions will receive 260 USD incentives. The primary outcomes at 3 months will be used to assess the CR participation rate, as the number of CR sessions completed, and CR completion, as attendance of sessions greater than 50%, thus completion of ≥18 sessions. The outcomes will be used to compare changes in cardiorespiratory function (VO2 max, VO2 at anabolic threshold), the Korean activity scale index, EuroQol 5 dimensions, and the patient health questionnaire at 3 months after discharge and 6 and 12 months after baseline.

DISCUSSION

Providing financial incentives may confirm the effect of increasing CR on participation and completion rates.

Traditional Baduanjin exercise through the eyes of patients with chronic heart failure: A qualitative content analysis study

Objective

Baduanjin (eight silken movements) is a traditional Chinese exercise that can be used as cardiac rehabilitation therapy for patients with chronic heart failure (CHF) especially when other forms of rehabilitation are scarce or unaffordable. This study explores the experiences of Chinese patients with CHF who undertook Baduanjin exercise at home as part of a pilot trial in Guangzhou, China.

Methods

We conducted seven qualitative interviews with participants who had participated in the intervention arm of a pilot randomized controlled trial (RCT) (n = 8). For data collection, we used a semi-structured interview guide with both open-ended, and follow-up questions. We audio recorded the interviews, transcribed them verbatim, and then analyzed them with content analysis.

Results

Participants' experiences of doing Baduanjin were classified into three categories: (1) improving practice (2) factors facilitating good exercise adherence, and (3) feeling good. Participants reported that the exercises were easy but that the correct Baduanjin execution and coordination between the mind, movements, and breathing were only achievable through practice. In addition, the training benefits which they perceived were the predominant motivation for patients to keep practicing. Finally, trust in Baduanjin, personal attitudes toward health, flexibility in practice times, as well as social support helped the participants to achieve good adherence to home-based training.

Conclusion

This study's findings indicate that Baduanjin could be a cardiac rehabilitation exercise modality for patients with CHF in China, especially in a home-based setting.

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

Introduction

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

Objective

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

Methods

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

Results

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

Conclusion

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

Nurses’ Beliefs and Barriers of Delivering Cardiopulmonary Rehabilitation for Heart Failure Patients in Saudi Arabia: A Cross-Sectional Study

Background: Patients with heart failure (HF) may benefit greatly from cardiopulmonary rehabilitation (CR), which is provided by a team of healthcare professionals that often includes nurses. There has been no research on how nurses perceive providing CR or the hurdles that may affect referrals. Methods: All registered nurses in Saudi Arabia’s Eastern Province were given access to a cross-sectional online survey consisting of nine multiple-choice questions that address attitudes, beliefs, and barriers to CR for HF patients in Saudi Arabia. Descriptive statistics were used to characterize the respondents. Results: Altogether, 439 registered nurses participated in the online survey, with men making up 194 (44%) and women 245 (56%). The mean and SD of years of clinical experience in caring for patients with HF were 6 ± 5 years. Out of 439 nurses, 107 (24%) strongly agree, and 255 (58%) agree that CR will enhance the physical fitness of patients. However, 94 (21.1%) strongly agree, and 248 (56.4%) agree that CR might alleviate dyspnea in HF patients. The vast majority of the nurses either strongly agree (90 (20.5%)) or agree (240 (55%)), that CR would help reduce palpitations and fatigue in HF patients. Indeed, 87 (19.81%) strongly agree, and 262 (59.68%) agree that CR would help improve HF patients’ ability to perform daily activities, while 51 (11.6%) strongly agree and 223 (51%) agree that CR would help in reducing hospital readmission. It was shown that 360 (82%) of the 439 nurses favored the delivery of CR programs in hospital-supervised programs, while 368 (83.8%) ranked information on HF disease as the most important aspect of the CR program, followed by information about medications at 305 (69.4%). The availability of CR facilities (36%), the cost of therapy (35%), and the absence of an established standardized referring strategy (34%) were identified as the most significant barriers affecting the referral of patients with HF for CR by nurses. Conclusion: Generally, nurses believed CR helped improve desired clinical outcomes in HF patients. Although a hospital-based program with close supervision is optimal for administering CR, few such options exist. Referrals of patients with HF were hampered by the lack of CR facilities, the cost of intervention, and the lack of a systematic approach to referrals.

Qualitative study of the views of people living with cardiovascular disease, and healthcare professionals, towards the use of a digital platform to support cardiovascular disease self-management

OBJECTIVES

This paper focuses on formative research as part of a broader study to develop and evaluate an innovative digital health platform for the self-management of cardiovascular disease (CVD). The primary objective is to better understand the perceptions of key stakeholders towards the proposed platform (Salvio) and to identify the development considerations they may prioritise based on their own experiences of CVD management.

DESIGN

A qualitative research study using thematic analysis to explore patterns and themes within the various participant contributions.

SETTING

Triangulation of data collection methods were used to generate data, including focus group discussions, semistructured interviews and guided conversations.

PARTICIPANTS

Participants (n=26) were people with a diagnosis of CVD (n=18) and relevant healthcare professionals (n=8).

RESULTS

Findings indicate that the proposed platform would be a beneficial solution for certain groups whose health behaviour change is not currently supported by discrete solutions. Both participant groups perceive the digital health platform more trustworthy than accessing multiple interventions through unsupported digital repositories. Healthcare professionals agreed that they would endorse an evidence-based platform that had been rigorously developed and evaluated. CVD participants prioritised a decision support tool to guide them through the platform, as they perceive an unstructured approach as overly complex. Both participant groups perceived data sharing with certain self-selected individuals (eg, spouse) to be a useful method for gaining support with their health behaviour change.

CONCLUSIONS

A digital health platform offering a variety of existing, evidence-based interventions would provide users with suitable self-management solution(s) based on their own individual needs and preferences. Salvio could be enhanced by providing adequate support to platform users, guiding the diverse CVD population through a host of digital solutions, ensuring that Salvio is endorsed by trusted healthcare professionals and maintaining connections with usual care. Such a platform would augment existing self-management and secondary prevention services.

Regional disparities in cardiac rehabilitation volume throughout Japan based on open data from a National Database of Health Insurance Claims

Objective: This study assessed the regional disparities and the associated factors in the implementation of cardiac rehabilitation in Japan. Materials and Methods: Regional disparities were investigated by comparing the number of cardiac rehabilitation units in each of 47 prefectures in Japan based on the National Database of Health Insurance Claims Open Data published by the Ministry of Health, Labour, and Welfare. The relationships between the numbers of inpatient and outpatient cardiac rehabilitation units and the numbers of registered instructors of cardiac rehabilitation, board-certified physiatrists, and board-certified cardiologists were examined. Results: The region with the highest and lowest numbers of inpatient units showed 11,620.5 and 1,650.2 population-adjusted cardiac rehabilitation units adjusted per 100,000 population, respectively, corresponding to a 7.0-fold difference. Meanwhile, 4,865.3 and 238.6 units were present in the regions with the highest and lowest numbers of outpatient units, respectively, corresponding to a 20.4-fold regional disparity. Our analysis showed that the population-adjusted number of inpatient cardiac rehabilitation units was significantly associated with the population-adjusted numbers of registered instructors of cardiac rehabilitation (r=0.647, P<0.001) and board-certified cardiologists (r=0.445, P=0.002) but only marginally associated with the population-adjusted number of board-certified physiatrists (r=0.329, P=0.024). Moreover, the population-adjusted number of outpatient cardiac rehabilitation units was significantly associated with the population-adjusted numbers of registered instructors of cardiac rehabilitation (r=0.406, P=0.005) and board-certified cardiologists (r=0.450, P=0.002) but not with the population-adjusted number of board-certified physiatrists (r=0.078, P=0.603). Conclusion: Large regional disparities were observed during the implementation of cardiac rehabilitation. Increased numbers of cardiac rehabilitation instructors and cardiac rehabilitation practices are expected to eliminate these regional differences in cardiac rehabilitation practices.

Cluster Analysis to Distinguish Patients Most Likely to Benefit from Outpatient Cardiac Rehabilitation-A Prospective, Multicenter Study

Offering cardiac rehabilitation to people who can benefit most could improve the outcomes in the context of limited availability. We used cluster analysis to distinguish three patient groups based on clinical and laboratory variables and then compared the outcomes of 6-month outpatient cardiac rehabilitation between these groups. The outcomes included blood pressure, blood lipids, fasting blood glucose, and uric acid concertation in serum. Group 1 consisted primarily of men with obesity, increased blood pressure, favourable lipid profiles and increased fasting glucose. Group 2 consisted of men or women with normal weight, normal blood pressure, favourable lipid profiles, and normal fasting glucose. Group 3 consisted primarily of women with overweight, normal blood pressure, unfavourable lipid profiles, and normal fasting glucose. After 6 months of cardiac rehabilitation, blood lipids improved in group 3, whereas blood pressure improved in groups 1 and 3, but the outcomes did not change significantly in group 2. We did not see any effect of cardiac rehabilitation on fasting blood glucose and serum uric acid concentration in any group. Concentrations of glucose and uric acid did not change significantly in any group. In conclusion, an adequate selection of patients should maximise the benefits of cardiac rehabilitation.

A survey of the perceptions of barriers to and facilitators of cardiac rehabilitation in healthcare providers and policy stakeholders

Background

Cardiac rehabilitation (CR) is a prognostic management strategy to help patients with CVD achieve a good quality of life and lower the rates of recurrence, readmission, and premature death from disease. Globally, cardiac rehabilitation is poorly established in hospitals and communities. Hence, this study aimed to investigate the discrepancies in the perceptions of the need for CR programs and relevant health policies between directors of hospitals and health policy personnel in South Korea to shed light on the status and to establish practically superior and effective strategies to promote CR in South Korea.

Methods

We sent a questionnaire to 592 public health policy managers and directors of selected hospitals, 132 of whom returned a completed questionnaire (response rate: 22.3%). The participants were categorized into five types of organizations depending on their practice of PCI (Percutaneous Coronary Intervention), establishment of cardiac rehabilitation, director of hospital, and government's policy makers. Differences in the opinions between directors of hospitals that perform/do not perform PCI, directors of hospitals with/without cardiac rehabilitation, and between hospital directors and health policy makers were analyzed.

Results

Responses about targeting diseases for cardiac rehabilitation, patients’ roles in cardiac rehabilitation, hospitals’ roles in cardiac rehabilitation, and governmental health policies’ roles in cardiac rehabilitation were more positive among hospitals that perform PCI than those that do not. Responses to questions about the effectiveness of cardiac rehabilitation and hospitals’ roles in cardiac rehabilitation tended to be more positive in hospitals with cardiac rehabilitation than in those without. Hospital directors responded more positively to questions about targeting diseases for cardiac rehabilitation and governmental health policies’ roles in cardiac rehabilitation than policy makers, and both hospitals and public organizations provided negative responses to the question about patients’ roles in cardiac rehabilitation. Responses to questions about targeting diseases for cardiac rehabilitation, patients’ roles in cardiac rehabilitation, and governmental health policies’ roles in cardiac rehabilitation were more positive in hospitals that perform PCI than those that do not and public organizations.

Conclusions

Hospitals must ensure timely referral, provide education, and promote the need for cardiac rehabilitation. In addition, governmental socioeconomic support is needed in a varity of aspects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08298-3.

The Prevalence of Activities of Daily Living Impairment in Patients With Heart Failure: A Systematic Review and Meta-Analysis

Objectives

The prevalence of activities of daily living (ADL) in patients with heart failure (HF) reported in current studies were inconsistent, ranging from 11.1 to 70.5%. The purpose of this study is to quantify the prevalence of ADL impairment in HF patients.

Methods

PubMed, Embase, Cochrane, CINAHL, CNKI, SinoMed, VIP, and Wanfang databases were systematically searched for relevant studies (up to March 2, 2022). Cross-sectional, case-control, or cohort studies with detailed descriptions of overall ADL impairment in HF were included. Stata 16.0 was used for statistical analysis. Fixed-effect or random-effect model was adopted according to heterogeneity which was evaluated by Cochran’s Q and I2 values. Sensitivity analysis, subgroup analysis, and meta-regression were performed to investigate the sources of heterogeneity.

Results

A total of 12 studies with 15,795 HF patients were included in the meta-analysis, and the pooled prevalence of ADL impairment in patients with HF was 38.8% (95%CI: 28.2–49.3%; I2 = 99.5%, P &lt; 0.001). No possible sources of heterogeneity were found in subgroup analysis and meta-regression. Funnel plots and Egger’s test showed no publication bias (P = 0.595).

Conclusion

The prevalence of ADL impairment is relatively high in HF patients. Differences in the prevalence of ADL impairment in patients with HF may be influenced by country, region, and assessment time. We suggest that more researchers could focus on the changes of ADL impairment in HF patients during different disease periods in different regions and countries.

Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care

OBJECTIVE

Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease.

DESIGN AND METHODS

Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved.

RESULTS

We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders.

CONCLUSIONS

We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.

Trends and Predictors of Cardiac Rehabilitation Referral Following Percutaneous Coronary Intervention: A Prospective, Multi-Site Study of 41,739 Patients From the Victorian Cardiac Outcomes Registry (2017-2020)

BACKGROUND

Following percutaneous coronary intervention (PCI), outpatient cardiac rehabilitation (CR) is essential for secondary prevention. However uptake of CR is suboptimal, despite strong evidence demonstrating benefits. The aim of this study was to identify contemporary trends and predictors of CR referral of PCI patients in Victoria.

METHODS

A prospective, observational study using data extracted from the Victorian Cardiac Outcomes Registry was undertaken. A total of 41,739 patients were discharged following PCI over the study period (2017-2020) and included for analysis.

RESULTS

Cardiac rehabilitation referral was 85%, with an increasing trend over time (p<0.001). Multivariable modelling identifying the independent predictors of CR referral included hospitals with high volumes of ST-elevation myocardial infarction patients (STEMI) (OR 4.89, 95% CI 4.41-5.20), STEMI diagnosis (OR 1.90, 95% CI 1.69-2.14), or treatment in a private hospital (OR 1.45, 95% CI 1.33-1.57). Predictors of non-referral included cardiogenic shock (OR 0.54, 95% CI 0.41-0.71), aged over 75 years (OR 0.62, 95% CI 0.57-0.68) and previous PCI (OR 0.66, 95% CI 0.62-0.70). Percutaneous coronary intervention patients with an acute coronary syndrome who were referred to CR were also more likely to be prescribed four or more major preventive pharmacotherapies, compared to those who were not referred (90% vs 82.1%, p<0.001).

CONCLUSION

Our contemporary multicentre analysis showed generally high CR referral rates which have increased over time. However, more effort is needed to target patients treated in the public sector, low volume STEMI hospitals or with short lengths of stay.

Predictors of Rehabilitation Referral Among Cardiovascular Surgical Patients

Objective

Cardiovascular disease (CVD) continues to be the leading cause of mortality globally. Cardiac rehabilitation (CR) programs act by modifying the evolution of CVD and mortality; however, CR programs are under-used. The aim was to determine the profile of patients that received rehabilitation after cardiac surgery.

Patients and Methods

A retrospective observational study was conducted from January 2017 to December 2017 at a single center. The study sample was chosen among patients admitted to the Intensive Care Unit of the Hospital Gregorio Marañón/Gregorio Marañón General University Hospital. Socio-demographic and clinical variables were collected.

Results

In the present study, 336 patients underwent cardiac surgery of which 63.8% were men and 87.1% had ≥1 cardiovascular risk factors. Of the total cohort, 24.7% were operated for ischemic heart disease, 47.9% valvulopathy, 11% underwent combined surgery, 3.6% cardiac transplantation, 6.5% aneurysms, and 3.9% congenital disease. In-hospital respiratory rehabilitation was prescribed to all patients. Only 4.8% of the patients received motor rehabilitation and 13.8% were referred to CR. We found higher referral rates among patients with more cardiovascular risk factors, <65 years of age, and those undergoing coronary surgery and heart transplantation. Age, ischemic heart disease, and overweight were independent predictors of CR referral.

Conclusion

The benefit of CR programs after cardiac surgery is widely described; however, the referral rate to CR remains low. It is crucial to optimize referral protocols for these patients.

Historical Context of Cardiac Rehabilitation: Learning From the Past to Move to the Future

Contemporary myocardial infarction (MI) care and management has evolved dramatically since the 1950's; yet outpatient rehabilitation remains underutilized. Deepening our understanding of the origins and history of cardiac rehabilitation highlights a contemporary shift required for policy and practice related to secondary prevention of coronary disease in light of societal changes as well as medical, digital and surgical advancements. Contemporary "cardiac rehabilitation" began when bed rest and physical inactivity was recommended and commonplace for MI survivors. Today, most patients who survive an MI, undergo reperfusion therapy, a short inpatient stay and are discharged with minimal physical morbidity. Despite this, the majority of modern day programs continue to be structured in the same way they have been for the past 50 years and this model has become incongruent with the contemporary context, especially in the COVID-19 era. This review aims to describe the historical foundations of cardiac rehabilitation to inform solutions and meet the demands of contemporary MI management. Delivering health systems reform to address modernization is current healthcare challenge where a united and interdisciplinary effort is needed.

Being Uncertain: Rural-Living Cardiac Patients' Experience of Seeking Health Care

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide. Secondary prevention strategies reduce disease progression to heart failure. Rural cardiac patients typically have less access to health care resources to support them in managing secondary prevention, and services to improve quality of life tend to be lacking in rural settings. The study aim was to examine the process that rural cardiac patients go through to access health care and cardiac rehabilitation (CR) following myocardial infarction (MI). In-depth interviews with 11 post-MI participants using Straussian grounded theory were undertaken. Analysis revealed a linear process from hospital discharge to maintaining health. There were five elements: comfort with health information, relationship with health care providers, social support, taking ownership, and availability of/for CR. The core category was "being uncertain." Findings can be used to identify ways to improve access and address uncertainty stemming from a lack of perceived information and supports following discharge.

Association of participation in Cardiac Rehabilitation with Social Vulnerability Index: The behavioral risk factor surveillance system

OBJECTIVES

To identify whether social vulnerability is associated with low cardiac rehabilitations (CR) use, a Class I recommendation by current treatment guidelines following acute myocardial infarction (AMI).

METHODS

We performed this cross-sectional study using the 2017 Behavioral Risk Factor Surveillance System (BRFSS) survey. The Centers for Disease Control and Prevention Social Vulnerability Index (CDC SVI) was calculated using 15 social risk factors from 4 main themes including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. A higher SVI indicates higher social vulnerability. We used multivariable logistic regression models to evaluate the association of CR use with state-level SVI adjusted for demographic, behavioral, socioeconomic, and comorbidity variables.

RESULTS

A total 2093 participants with history of AMI were included. Out of total, 61.7% were older than 65 years, 42.5% female, 72.5% White, and 42.4% used CR. Participation in CR was lower among females (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.44-0.91), those without a primary care physician (OR, 0.45; 95% CI, 0.23-0.87), and higher with college degree education (OR, 1.95; 95% CI, 1.06-3.59). CR use decreased with increasing SVI tertiles (1st =61%, 2nd =52%, and 3rd =35%). Compared with those residing in states in the 1st tertile, CR use was lower in the 2nd (OR, 0.68; 95% CI, 0.47-0.98) and 3rd (OR, 0.33; 95% CI 0.23-0.48) SVI tertiles.

CONCLUSION

CR use following AMI is low and is associated with social vulnerability. Identifying social risk factors may help improve access to care among vulnerable populations.

Cardiac Rehabilitation Improves Long-Term Prognosis for People with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention: A Propensity Matching Analysis

OBJECTIVES

According to researches, many people with chronic kidney disease (CKD) had the higher incidence rate and mortality rate of coronary artery disease (CAD) after percutaneous coronary intervention than those who did not receive percutaneous coronary intervention, while coronary rehabilitation was beneficial for patients who received percutaneous coronary intervention I. This study aims to analyze whether coronary rehabilitation was beneficial to patients with CKD after percutaneous coronary intervention. Patients and Methods. A retrospective survey was used to collect clinical data of patients undergoing percutaneous coronary intervention due to CAD, and CKD patients were screened for further analysis. According to whether patients had received coronary rehabilitation treatment, research subjects were divided into two groups, the coronary rehabilitation group and the noncoronary rehabilitation group. The baseline characteristics of the propensity score matching between the two groups were compared. Survival analysis used the Cox hazard ratio (HR) model as regression method to compare the relative risk of the endpoints in the coronary rehabilitation group and the noncoronary rehabilitation group.

RESULTS

From January 2007 to January 2012, a total of 246 CKD patients treated with percutaneous coronary intervention were included in this study, and 106 of them obtained coronary rehabilitation after surgery. After propensity score matching, there were 89 pairs of patients in the two groups who had no significant difference in demographic and clinical characteristics (all P > 0.05). CKD patients receiving coronary rehabilitation had a significant reduction in all-cause mortality (HR 0.465, 95% CI 0.233-0.926, P=0.029) and cardiac complications (HR 0.532, 95% CI 0.287-0.984, P=0.044). Survival analysis showed that the survival rate of the coronary rehabilitation group was significantly higher than that of the noncoronary rehabilitation group (P=0.024).

CONCLUSIONS

For CKD patients undergoing percutaneous coronary intervention, receiving cardiac rehabilitation can significantly improve long-term survival and reduce cardiac events.

Feasibility of Cardiac Rehabilitation Models in Kenya

Background:

Heart failure (HF), is a leading cause of cardiovascular morbidity and mortality in Sub-Saharan Africa. Cardiac rehabilitation (CR) is known to improve functional capacity and reduce morbidity associated with HF. Although CR is a low-cost intervention, global access and adherence rates to CR remain poor. In regions such as Western Kenya, CR programs do not exist. We sought to establish the feasibility CR for HF in this region by testing adherence to institution and home-based models of CR.

Methods:

One hundred participants with New York Heart Association (NYHA) class II and III HF symptoms were prospectively enrolled from a tertiary health facility in Western Kenya. Participants were non-randomly assigned to participate in one of two CR models based on their preference. Institution based cardiac rehabilitation (IBCR) comprised 36 facility-based exercise sessions over a period of 12 weeks. Home based cardiac rehabilitation (HBCR) comprised weekly pedometer guided exercise targets over a period of 12 weeks. An observational arm (OA) receiving usual care was also enrolled. The primary endpoint of CR feasibility was assessed based on study participants to adherence to at least 25% of exercise sessions. Secondary outcomes of change in NYHA symptom class, and six-minute walk time distance (6MWTD) were also evaluated. Data were summarized and analyzed as means (SD) and frequencies. Paired t-tests, Chi Square, Fisher’s, and ANOVA tests were used for comparisons.

Findings:

Mean protocol adherence was greater than 25% in both CR models; 46% ± 18 and 29% ± 11 (P < 0.05) among IBCR and HBCR participants respectively. Improvements by at least one NYHA class were observed among 71%, 41%, and 54%, of IBCR, HBCR and OA participants respectively. 6MWTD increased significantly by a mean of 31 ± 65 m, 40 ± 55 m and 38 ± 71 m in the IBCR, HBCR and OA respectively (P < 0.05).

Conclusions:

IBCR and HBCR, are feasible rehabilitation models for HF in Western Kenya. Whereas improvement in functional capacity was observed, effectiveness of CR in this population remains unknown. Future randomized studies evaluating effect size, long term efficacy, and safety of cardiac rehabilitation in low resource settings such as Kenya are recommended.

Knowledge, attitudes, and practices of cardiopulmonary rehabilitation among physiotherapists in Lebanon

Background

Insufficient physical activity is one of the leading mortality risks worldwide for cardiovascular and pulmonary diseases. Physiotherapists (PT) are core healthcare professionals who play a major role in the prevention of disease complications and in inspiring a healthy lifestyle. To identify challenges in the promotion of cardiopulmonary rehabilitation (CR) in Lebanon, a survey was conducted among PT and physiotherapy students. The aim was to assess the knowledge, attitudes, and practices of CR in Lebanon.

Results

The response rate was 46.1% (N = 322). Results show that 24.5% of respondents have good to excellent knowledge about CR. More than 60% of the respondents indicate possible barriers to starting a CR program, and one of two respondents identify the absence of skills as a main barrier. Findings highlight the importance of the role of PT as a mediator to increase a healthy lifestyle among patients and to promote the prevention of cardiovascular diseases and pulmonary diseases in the country.

Conclusions and recommendations

Our results support the evidence and clinical guidelines that PT play a major role by increasing the participation of patients in CR. A cost-effective CR program needs to be covered by the private and public system in Lebanon.

Current status of cardiac rehabilitation among representative hospitals treating acute myocardial infarction in South Korea

Cardiac rehabilitation services are mostly underutilized despite the documentation of substantial morbidity and mortality benefits of cardiac rehabilitation post-acute myocardial infarction. To assess the implementation rate and barriers to cardiac rehabilitation in hospitals dealing with acute myocardial infarction in South Korea, between May and July 2016, questionnaires were emailed to cardiology directors of 93 hospitals in South Korea; all hospitals were certified institutes for coronary interventions. The questionnaires included 16 questions on the hospital type, cardiology practice, and implementation of cardiac rehabilitation. The obtained data were categorized into two groups based on the type of the hospital (secondary or tertiary) and statistically analysed. Of the 72 hospitals that responded (response rate of 77%), 39 (54%) were tertiary medical centers and 33 (46%) were secondary medical centers. All hospitals treated acute myocardial infarction patients and performed emergency percutaneous coronary intervention; 79% (57/72) of the hospitals performed coronary artery bypass grafting. However, the rate of implementation of cardiac rehabilitation was low overall (28%, 20/72 hospitals) and even lower in secondary medical centers (12%, 4/33 hospitals) than in tertiary centers (41%, 16/39 hospitals, p = 0.002). The major barriers to cardiac rehabilitation included the lack of staff (59%) and lack of space (33%). In contrast to the wide availability of acute-phase invasive treatment for AMI, the overall implementation of cardiac rehabilitation is extremely poor in South Korea. Considering the established benefits of cardiac rehabilitation in patients with acute myocardial infarction, more administrative support, such as increasing the fee for cardiac rehabilitation services by an appropriate level of health insurance coverage should be warranted.

A Smartphone App (AnSim) With Various Types and Forms of Messages Using the Transtheoretical Model for Cardiac Rehabilitation in Patients With Coronary Artery Disease: Development and Usability Study

Background

Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce.

Objective

This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI).

Methods

The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed.

Results

The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant.

Conclusions

We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research.

Current state of cardiac rehabilitation in Portugal: Results of the 2019 national survey

INTRODUCTION

Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal.

OBJECTIVES

This study reports the results of the 2019 survey on CR.

METHODS

In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention.

RESULTS

In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates <25%.

CONCLUSION

The present survey shows an increase in the number of centers and patients undergoing phase II CR, and an increase in the estimated CR coverage after ACS. Despite this, the level of increase means that overall patient representation remained below the optimal range, while the data also showed a decrease in the number of patients in phase III programs. These findings reinforce the importance of optimization of CR entry and maintenance, in order to improve the uptake of this pivotal intervention.

Cardiac Rehabilitation Early after Sternotomy Using New Assistive VR-Enhanced Robotic Exoskeleton-Study Protocol for a Randomised Controlled Trial

(1) Background and objective: Cardiac rehabilitation (CR) means delivering health education by structured exercises with the means of risk reduction, in a cost-effective manner. Well-conducted CR improves functional capacity, decreases re-hospitalization, and reduces mortality up to 25%. We bring to attention the protocol of a randomised control trial with the aim of validating the prototype of an assistive upper-body robotic exoskeleton system enhanced with a non-immersive virtual reality exergame (CardioVR-ReTone) in patients who undergone cardiac surgery. (2) Methods: Description of the CardioVR-ReTone system and the technical specification, followed by the group selection, randomization and evaluated variables. (3) Expected results: The primary outcome measurement is the modification of life quality at the end of the CR exercise training program. Secondary outcomes will encompass measurements of sternal stability, muscular activity, cardiac response to exercise, pain level and compliance/adherence to CR. (4) Conclusions: Implementing these novel features of the CardioVR-ReTone system, addressability, and efficacy of CR, so problematic in certain situations and especially in cardiac surgery, will be greatly facilitated, being independent of the skills and availability of the rehabilitation therapist.

Knowledge, attitudes and practices survey of cardiac rehabilitation among cardiologists and cardiac surgeons in Lebanon

Background

Cardiovascular diseases (CVDs) are among the leading causes of morbidity and mortality worldwide. Over three quarters of the cardiovascular deaths take place in low and middle-income countries. Despite the benefits, Cardiac Rehabilitation (CR) is still not routinely and not universally available. Numerous studies have found that barriers to access to CR are correlated with providers, patients and environment characteristics. This first national survey on CR in Lebanon assesses the knowledge, attitudes and practices among physicians. In addition, the study identifies what the main barriers to access to CR are and provides suggestions for the implementation of CR in the country.

Results

The response rate was 41.5% (n = 83). Results show that the cardiologists have medium level of knowledge about CR and its multidisciplinary content. Physicians support the implementation of a comprehensive CR program in the country. 50% of the physicians recommended first to solve the financial issues before implementing a CR program. Supplementary learning about the benefits of CR is highly recommended to enroll more patients with CVD into CR. In addition, the lack of specialists in the field, lack of motivation for patients to enroll to CR and inconvenient location of the rehabilitation centers were identified as major barriers by the respondents.

Conclusions

The role of physicians in promoting patient enrolment should be optimized and exploited in the country. The access barriers identified can help to develop CR programs and to improve CR referral and enrolment rates. Funds from private parties and a budget from the government are needed to launch new CR programs in the country. Further research is needed to provide evidence on the CR benefits in Lebanon and to motivate policy-makers to place priority on the establishment of a comprehensive CR program in the country.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-021-00212-2.

A nationwide survey on participation in cardiac rehabilitation among patients with coronary heart disease using health claims data in Japan

Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017-2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6-10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39-2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

BACKGROUND

As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs.

METHODS AND FINDINGS

We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.

CONCLUSIONS

Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.