Participation in exercise-based cardiac rehabilitation is related to reduced total mortality in both men and women: results from the SWEDEHEART registry

Cardiomegaly: Navigating the uncharted territories of heart failure - A multimodal radiological journey through advanced imaging, pathophysiological landscapes, and innovative therapeutic frontiers

Cardiomegaly is among the disorders categorized by a structural enlargement of the heart by any of the situations including pregnancy, resulting in damage to heart muscles and causing trouble in normal heart functioning. Cardiomegaly can be defined in terms of dilatation with an enlarged heart and decreased left or biventricular contraction. The genetic origin of cardiomegaly is becoming more evident due to extensive genomic research opening up new avenues to ensure the use of precision medicine. Cardiomegaly is usually assessed by using an array of radiological modalities, including computed tomography (CT) scans, chest X-rays, and MRIs. These imaging techniques have provided an important opportunity for the physiology and anatomy of the heart. This review aims to highlight the complexity of cardiomegaly, highlighting the contribution of both ecological and genetic variables to its progression. Moreover, we further highlight the worth of precise clinical diagnosis, which comprises blood biomarkers and electrocardiograms (EKG ECG), demonstrating the significance of distinguishing between numerous basic causes. Finally, the analysis highlights the extensive variation of treatment lines, such as lifestyle modifications, prescription drugs, surgery, and implantable devices, although highlighting the critical need for individualized and personalized care.

The Evaluation of Lipid-Lowering Treatment in Patients with Acute Coronary Syndrome in a Hungarian Invasive Centre in 2015, 2017, and during the COVID-19 Pandemic-The Comparison of the Achieved LDL-Cholesterol Values Calculated with Friedewald and Martin-Hopkins Methods

Background/Objectives: Patients with acute coronary syndrome (ACS) represent a vulnerable population. We aimed to investigate serum lipid levels of patients with ACS upon admission and during one year of the COVID-19 pandemic in a rural county hospital, and compared these findings with the data of patients with ACS in 2015 and 2017. The secondary aim of this paper was the comparison of the LDL-C values calculated with the Friedewald and Martin-Hopkins methods. Methods: A retrospective analysis of lipid-lowering data of patients treated with ACS in 2015, 2017 and in a COVID-19 year (1 April 2020-31 March 2021) was performed; the patient's numbers were 454, 513 and 531, respectively. Results: In the COVID-19 period one year after the index event, only 42% of the patients had lipid values available, while these ratios were 54% and 73% in 2017 and in 2015, respectively. Using the Friedewald formula, in the COVID-19 era the median of LDL cholesterol (LDL-F) was 1.64 (1.09-2.30) mmol/L at six months and 1.60 (1.19-2.27) mmol/L at one year, respectively. These values were 1.92 (1.33-2.27) mmol/L and 1.73 (1.36-2.43) mmol/L using the Martin-Hopkins method (LDL-MH). The LDL-F yielded significantly lower values (15% lower at six months, p = 0.044; and 8% lower at one year, p = 0.014). The LDL-F reached the previous target of 1.8 mmol/L during the COVID-19 pandemic 36% at one year vs. 48% in 2017, and 37% in 2015. The recent target LDL-C level of 1.4 mmol/L was achieved in 22% of cases in the COVID-19 pandemic, 16% in 2015 and 19% in 2017. Conclusions: A significantly lower proportion of patients with ACS had available lipid tests during the COVID-19 pandemic. Besides the lower number of available samples, the proportion of achieved 1.4 mmol/L LDL-C target lipids was stable. More rigorous outpatient care in the follow-up period may help to improve the quality of lipid lowering treatments and subsequent secondary cardiovascular prevention. If direct LDL-C determination is not available, we prefer the LDL calculation with the Martin-Hopkins method.

Two-year prognosis and cardiovascular disease prevention after acute coronary syndrome; the role of cardiac rehabilitation: a French nationwide study

AIMS

To evaluate the impact of cardiac rehabilitation (CR) on optimization of secondary prevention treatments for acute coronary syndrome (ACS), medication persistence, medical follow-up, rehospitalisation, and all-cause mortality.

METHODS

The national health insurance database was used to identify all patients hospitalised for ACS in France in 2019 and those among them who received CR. Patients' characteristics and outcomes were described and compared between CR and non-CR patients. Poisson regression models were used to identify the impact of CR after adjusting for confounders. A Cox model was fitted to identify the variables related to mortality after adjustment for medication persistence and cardiologic follow-up.

RESULTS

In 2019, 22% of 134,846 patients hospitalised for ACS in France received CR within six months of their discharge. After one year, only 60% of patients who did not receive CR were still taking BASI drugs (combination of Beta blockers, Antiplatelets agents, Statins and RAAS Inhibitors). This rate and the medical follow-up rate were higher in patients who received CR. Two years after the ACS event, patients who received CR had better medical follow-up and lower mortality risk, after adjusting for cofounding variables (adjusted HR all-cause mortality = 0.65 [0.61-0.69]). After adjustment for the dispensing of cardiovascular drugs and cardiologic follow-up, the independent effect of CR was not as strong but remained significant (HR = 0.90 [95%CI: 0.84-0.95]).

CONCLUSION

Patients who received CR after hospitalisation for ACS had a better prognosis. Optimization of efficient secondary prevention strategies, improved medication persistence, and enhanced cardiologic follow-up seemed to play a major role.

Comprehensive and personalized approach is a critical area for developing remote cardiac rehabilitation programs

In the evolving landscape of cardiac rehabilitation (CR), adopting digital technologies, including synchronous/real-time digital interventions and smart applications, has emerged as a transformative approach. These technologies offer real-time health data access, continuous vital sign monitoring, and personalized educational enhanced patient self-management and engagement. Despite their potential benefits, challenges and limitations exist, necessitating careful consideration. Synchronous/real-time digital CR involves remote, two-way audiovisual communication, addressing issues of accessibility and promoting home-based interventions. Smart applications extend beyond traditional healthcare, providing real-time health data and fostering patient empowerment. Wearable devices and mobile apps enable continuous monitoring, tracking of rehabilitation outcomes, and facilitate lifestyle modifications crucial for cardiac health maintenance. As digital CR progresses, ensuring patient access, equitable implementation, and addressing the digital divide becomes paramount. Artificial intelligence holds promise in the early detection of cardiac events and tailoring patient-specific CR programs. However, challenges such as digital literacy, data privacy, and security must be addressed to ensure inclusive implementation. Moreover, the shift toward digital CR raises concerns about cost, safety, and potential depersonalization of therapeutic relationships. A transformative shift towards technologically enabled CR necessitates further research, focusing not only on technological advancements but also on customization to meet diverse patient needs. Overcoming challenges related to cost, safety, data security, and potential depersonalization is crucial for the widespread adoption of digital CR. Future studies should explore integrating moral values into digital therapeutic relationships and ensure that digital CR is accessible, equitable, and seamlessly integrated into routine cardiac care. Theoretical frameworks that accommodate the dynamic quality of real-time monitoring and feedback feature of digital CR interventions should be considered to guide intervention development.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities

BACKGROUND

Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life.

AIMS

To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities.

METHODS

All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified.

RESULTS

In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic.

CONCLUSIONS

Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

Hemodynamic Response to Exercise Training in Heart Failure With Reduced Ejection Fraction Patients

Background

Supervised exercise training decreases total and cardiac mortality and increases quality of life of heart failure with reduced ejection fraction (HFrEF) patients. However, response to training is variable from one patient to another and factors responsible for a positive response to training remain unclear. The aims of the study were to compare cardiac hemodynamic changes after an exercise training program in responders (R) versus non-responders (NR) HFrEF patients, and to compare different discriminators used to assess response to training.

Methods

Seventy-six HFrEF patients (86% males, 57 ± 12 years) completed an exercise training program for 4 weeks. Patients underwent cardiopulmonary exercise testing (CPET) on a cycle ergometer before and after training. Cardiac hemodynamics were measured by impedance cardiography during CPET. The R and NR groups were classified using the median change in peak oxygen uptake (V̇O2peak).

Results

There were statistically significant differences in V̇O2peak (+35% vs. -1%, P < 0.0001) and in peaks of ventilation (+30% vs. +2%, P < 0.0001), cardiac output (COpeak) (+25% vs. +4%, P < 0.01), systolic blood pressure (+12% vs. +2%, P < 0.05), diastolic blood pressure (+9% vs. +4%, P < 0.05) and heart rate (+8% vs. +1%, P < 0.01) between R and NR after the training program. V̇O2peak was the best discriminator between R and NR (receiver operating characteristic (ROC) area under the curve (AUC) = 0.83, P < 0.0001), followed by COpeak (ROC AUC = 0.77, P < 0.0001).

Conclusion

V̇O2peak is the best discriminator between HFrEF R and NR patients after the training program. Responders showed improvements in peak hemodynamic parameters. These results pave the way for other studies to determine how the individualization of exercise training programs and peak hemodynamic parameters potentially linked to a better positive response status.

Women's Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation's First Global Assessment

BACKGROUND

Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers in women, and women's greatest barriers according to enrollment status.

METHODS

In this cross-sectional study, the English, Simplified Chinese, Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation Barriers Scale was administered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated.

RESULTS

Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women's barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5).

CONCLUSIONS

CR barriers-men's and women's-vary significantly according to region, necessitating tailored approaches to mitigation. Efforts should be made to mitigate unemployed women's barriers in particular.

Changes in Physical Activity and Incidence of Nonfatal Cardiovascular Events in 47 153 Survivors of Myocardial Infarction

Background The majority of patients survive the acute phase of myocardial infarction (MI) but have an increased risk of recurrent cardiovascular disease (CVD) events. To be regularly physically active or change activity level is associated with a lower risk of all-cause mortality. The objective was to explore to what extent physical activity (PA) levels or change in PA levels during the first year post-MI was associated with any recurrent nonfatal CVD events and specific CVD events (eg, MI, ischemic stroke, and vascular dementia). Methods and Results This cohort study among MI survivors was based on Swedish national registries between 2005 and 2020. PA levels were self-rated at 2 and 12 months post-MI, and patients were classified into remaining physically inactive, increasing, decreasing, or remaining active. A total of 6534 nonfatal CVD events occurred during 6 years of follow-up among the 47 153 included patients. In fully adjusted analyses, the risk of any nonfatal CVD event was lower (P<0.05) among patients remaining active (37%), increasing (22%), or decreasing (18%) PA level compared with remaining inactive. Compared with remaining inactive, the risk of recurring MI and stroke was lower (P>0.05) among remaining active (41% versus 52%, respectively), increasing (20% versus 35%, respectively), or decreasing PA level (24% versus 34%, respectively). For vascular dementia, patients remaining physically active had an 80% lower risk compared with remaining inactive (P<0.05). Conclusions Remaining physically active or change in PA levels during the first year post-MI was associated with a lower risk of recurrent nonfatal CVD events. This emphasizes the importance of supporting patients to continue to be or become physically active.

Physical activity, inactivity and sleep in older patients with coronary artery disease following percutaneous coronary intervention: a longitudinal, observational study

OBJECTIVES

Physical activity presents an important cornerstone in the management and care of coronary artery disease (CAD) patients following percutaneous coronary intervention (PCI) and research in older patients continues to be overlooked. This study evaluated differences in physical activity, inactivity and sleep of CAD patients following PCI for acute coronary syndrome consisting of ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) and elective admission of stable angina patients over 12 months.

METHODS

This was an observational, longitudinal study. Fifty-eight patients were recruited (STEMI, n  = 20, NSTEMI, n  = 18 and stable angina, n  = 20) and completed 7-day monitoring (physical activity, inactivity and sleep) using wrist-worn tri-axial accelerometers (GENEActiv, ActivInsights Ltd, Kimbolton, Cambridgeshire, UK) upon discharge from a tertiary centre and repeated measurements at 3 months ( n  = 43), 6 months ( n  = 40) and 12 months ( n  = 33).

RESULTS

Following PCI, CAD patients showed a general trend of increasing light and moderate-vigorous physical activity over the 12-month follow-up. Time in inactivity remained high but decreased over time. Sleep duration and sleep efficiency remained consistent. NSTEMI patients spent less time asleep, more time inactive and less time in light and moderate-vigorous physical activity in comparison to STEMI and stable angina patients. Differences between the groups over time were minimal.

CONCLUSION

These findings suggest that older patients with CAD spend long periods in inactivity but the increasing trend of both light and moderate-vigorous physical activity over time presents a positive change in behaviour in the year following PCI.

Sex differences in cardiac rehabilitation barriers among non-enrollees in the context of lower gender equality: a cross-sectional study

BACKGROUND

Despite the benefits of cardiac rehabilitation (CR), it remains under-utilized, particularly by women. This study compared CR barriers between non-enrolling men and women in Iran, which has among the lowest gender equality globally.

METHODS

In this cross-sectional study, CR barriers were assessed via phone interview in phase II non-attenders from March 2017 to February 2018 with the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P). T-tests were used to compare scores, with each of 18 barriers scored out of 5, between men and women.

RESULTS

357 (33.9%) of the sample of 1053 were women, and they were older, less educated and less often employed than men. Total mean CRBS scores were significantly greater in women (2.37 ± 0.37) than men (2.29 ± 0.35; effect size[ES] = 0.08, confidence interval[CI]: 0.03-0.13; p < 0.001). The top CR barriers among women were cost (3.35; ES = 0.40, CI:0.23-0.56; P < 0.001), transportation problems (3.24; ES = 0.41, CI:0.25-0.58; P < 0.001), distance (3.21; ES = 0.31, CI:0.15-0.48; P < 0.001), comorbidities (2.97; ES = 0.49, CI:0.34-0.64; P < 0.001), low energy (2.41; ES = 0.29, CI:0.18-0.41; P < 0.001), finding exercise as tiring or painful (2.22; ES = 0.11, CI:0.02-0.21; P = 0.018), and older age (2.27; ES = 0.18, CI:0.07-0.28; P = 0.001). Men rated "already exercise at home or in community" (2.69; ES = 0.23, CI:0.1-0.36; P = 0.001), time constraints (2.18; ES = 0.15, CI:0.07-0.23; P < 0.001) and work responsibilities (2.24; ES = 0.16, CI:0.07-0.25; P = 0.001) as greater CR barriers than women.

CONCLUSION

Women had greater barriers to CR participation than men. CR programs should be modified to address women's needs. Home-based CR tailored to women's exercise needs and preferences should be considered.

Lower All-Cause Mortality Risk in Females and Males with Peripheral Artery Disease following Pain-Free Home-Based Exercise: A 7-Year Observational Study

We evaluated the sex-specific difference in response upon participation in an exercise program with respect to the risk of adverse clinical outcomes among patients with peripheral artery disease (PAD) and claudication. The records of 400 PAD patients were assessed between 2012 and 2015. Two hundred of them were addressed to a walking program prescribed at the hospital and executed at home at symptom-free walking speed (Ex), while the remaining 200 acted as a control group (Co). The number and date of deaths, all-cause hospitalizations, and amputations for a 7-year period were collected from the regional registry. At baseline, no differences were observed (M_EXn = 138; F_EXn = 62; M_COn = 149; F_COn = 51). The 7-year survival rate was significantly higher in F_EX (90%) than in M_EX (82% hazard ratio, HR: 0.542 95% CI 0.331-0.885), F_CO (45%, HR: 0.164 95% CI 0.088-0.305), and M_CO (44%; HR: 0.157 95% CI 0.096-0.256). A significantly lower rate of hospitalization (p < 0.001) and amputations (p = 0.016) was observed for the Ex group compared to the Co group, without differences by sex. In conclusion, in PAD patients, active participation in a home-based pain-free exercise program was associated with a lower rate of death and better long-term clinical outcomes, particularly among women.

An evaluation of the role of the exercise training dose for changes in exercise capacity following a standard cardiac rehabilitation program

BACKGROUND

To retrospectively characterize and compare the dose of exercise training (ET) within a large cohort of patients demonstrating different levels of improvement in exercise capacity following a cardiac rehabilitation (CR) program.

METHODS

A total of 2310 patients who completed a 12-week, center-based, guidelines-informed CR program between January 2018 and December 2019 were included in the analysis. Peak metabolic equivalents (MET_peak) were determined pre- and post-CR during which total duration (ET time) and intensity [percent of heart rate peak (%HR_peak)] of supervised ET were also obtained. Training responsiveness was quantified on the basis of changes in MET_peak from pre- to post-CR. A cluster analysis was performed to identity clusters demonstrating discrete levels of responsiveness (i.e., negative, low, moderate, high, and very-high). These were compared for several baseline and ET-derived variables which were also included in a multivariable linear regression model.

RESULTS

At pre-CR, baseline MET_peak was progressively lower with greater training responsiveness (F_(4,2305) = 44.2, P < 0.01, η²_p = 0.71). Likewise, average training duration (F_(4,2305) = 10.7 P < 0.01, η²_p = 0.02) and %HR_peak (F_(4,2305) = 25.1 P < 0.01, η²_p = 0.042) quantified during onsite ET sessions were progressively greater with greater training responsiveness. The multivariable linear regression model confirmed that baseline MET_peak, training duration and intensity during ET, BMI, and age (P < 0.001) were significant predictors of MET_peak post-CR.

CONCLUSIONS

Along with baseline MET_peak, delta BMI, and age, the dose of ET (i.e., training duration and intensity) predicts MET_peak at the conclusion of CR. A re-evaluation of current approaches for exercise intensity prescription is recommended to extend the benefits of completing CR to all patients.

Remotely Delivered Cardiac Rehabilitation Exercise for Coronary Heart Disease: Nonrandomized Feasibility Study

BACKGROUND

Exercise-based cardiac rehabilitation (CR) is recommended for coronary heart disease (CHD). However, poor uptake of and poor adherence to CR exercise programs have been reported globally. Delivering CR exercise classes remotely may remove some of the barriers associated with traditional hospital- or center-based CR.

OBJECTIVE

We have developed a bespoke platform, Eastern Corridor Medical Engineering Centre-Cardiac Rehabilitation (ECME-CR), to support remotely delivered CR exercise. This pilot trial sought to test the ECME-CR platform and examine the efficacy and feasibility of a remote CR exercise program compared to a traditional center-based program.

METHODS

In all, 21 participants with CHD were recruited and assigned to either the intervention or control group. Both groups performed the same 8-week exercise program. Participants in the intervention group took part in web-based exercise classes and used the ECME-CR platform during the intervention period, whereas participants in the control group attended in-person classes. Outcomes were assessed at baseline and following the 8-week intervention period. The primary outcome measure was exercise capacity, assessed using a 6-minute walk test (6MWT). Secondary outcomes included measurement of grip strength, self-reported quality of life, heart rate, blood pressure, and body composition. A series of mixed between-within subjects ANOVA were conducted to examine the mean differences in study outcomes between and within groups. Participant adherence to the exercise program was also analyzed.

RESULTS

In all, 8 participants (male: n=5; age: mean 69.7, SD 7.2 years; height: mean 163.9, SD 5.4 cm; weight: mean 81.6, SD 14.1 kg) in the intervention group and 9 participants (male: n=9; age: mean 69.8, SD 8.2 years; height: mean 173.8, SD 5.2 cm; weight: mean 94.4, SD 18.0 kg) in the control group completed the exercise program. Although improvements in 6MWT distance were observed from baseline to follow-up in both the intervention (mean 490.1, SD 80.2 m to mean 504.5, SD 93.7 m) and control (mean 510.2, SD 48.3 m to mean 520.6, SD 49.4 m) group, no significant interaction effect (F_1,14=.026; P=.87) nor effect for time (F_1,14=2.51; P=.14) were observed. No significant effects emerged for any of the other secondary end points (all P>.0275). Adherence to the exercise program was high in both the intervention (14.25/16, 89.1%) and control (14.33/16, 89.6%) group. No adverse events or safety issues were reported in either group during the study.

CONCLUSIONS

This pilot trial did not show evidence of significant positive effect for either the remotely delivered or center-based program. The 6MWT may not have been sufficiently sensitive to identify a change in this cohort of participants with stable CHD. This trial does provide evidence that remote CR exercise, supported with digital self-monitoring, is feasible and may be considered for individuals less likely to participate in traditional center-based programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31855.

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

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

Exercise training after myocardial infarction increases survival but does not prevent adverse left ventricle remodeling and dysfunction in high-fat diet fed mice

AIMS

Aerobic exercise is an important component of rehabilitation after cardiovascular injuries including myocardial infarction (MI). In human studies, the beneficial effects of exercise after an MI are blunted in patients who are obese or glucose intolerant. Here, we investigated the effects of exercise on MI-induced cardiac dysfunction and remodeling in mice chronically fed a high-fat diet (HFD).

MAIN METHODS

C57Bl/6 male mice were fed either a standard (Chow; 21% kcal/fat) or HFD (60% kcal/fat) for 36 weeks. After 24 weeks of diet, the HFD mice were randomly subjected to an MI (MI) or a sham surgery (Sham). Following the MI or sham surgery, a subset of mice were subjected to treadmill exercise.

KEY FINDINGS

HFD resulted in obesity and glucose intolerance, and this was not altered by exercise or MI. MI resulted in decreased ejection fraction, increased left ventricle mass, increased end systolic and diastolic diameters, increased cardiac fibrosis, and increased expression of genes involved in cardiac hypertrophy and heart failure in the MI-Sed and MI-Exe mice. Exercise prevented HFD-induced cardiac fibrosis in Sham mice (Sham-Exe) but not in MI-Exe mice. Exercise did, however, reduce post-MI mortality.

SIGNIFICANCE

These data indicate that exercise significantly increased survival after MI in a model of diet-induced obesity independent of effects on cardiac function. These data have important translational ramifications because they demonstrate that environmental interventions, including diet, need to be carefully evaluated and taken into consideration to support the effects of exercise in the cardiac rehabilitation of patients who are obese.

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.

Impact of Sex on Mortality in Patients Undergoing Surgical Aortic Valve Replacement

Aortic stenosis (AS) is the second most common valvular heart disease in the United States. Although the prevalence of AS does not significantly differ between the sexes, there is some controversy on whether sex differences affect the long-term mortality of patients with severe AS undergoing surgical aortic valve replacement (SAVR). Therefore, we retrospectively analyzed the medical records of 917 patients (female, n = 424 [46.2%]) with severe AS who had undergone isolated SAVR at a tertiary care center between January 2005 and December 2018. During a median follow-up of 5.2 years, 74 (15.0%) male patients and 41 (9.7%) female patients died. The Kaplan–Meier analysis revealed that the 10-year mortality rate was significantly higher in male than female patients (24.7% vs. 17.9%, log-rank p = 0.005). In the sequential Cox proportional hazard regression model for assessing long-term mortality up to 10 years post-surgery, the adjusted hazard ratio of male sex for mortality was 1.93 (95% confidence interval, 1.28–2.91; p = 0.002). The association between male sex and postoperative long-term mortality was not significantly diminished by any demographic or clinical factor in subgroup analyses. In conclusion, female sex was significantly associated with better long-term survival in patients with severe AS undergoing SAVR.

Sex Differences in Cardiac Rehabilitation Outcomes

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

Current role and future perspectives of cardiac rehabilitation in coronary heart disease

Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

A randomized controlled clinical trial of cardiac telerehabilitation with a prolonged mobile care monitoring strategy after an acute coronary syndrome

Background

Center‐based cardiac rehabilitation (CBCR) improves health outcomes but has some limitations. We designed and validated a telerehabilitation system to overcome these barriers.

Methods

We included 67 low‐risk acute coronary syndrome patients in a randomized controlled trial allocated 1:1 to a 10‐month cardiac telerehabilitation (CTR) program or an 8‐week CBCR program. Patients underwent ergospirometry, blood tests, anthropometric measurements, IPAQ, PREDIMED, HADS, and EQ‐5D questionnaires at baseline and 10 months. Data collectors were blinded to the treatment groups.

Results

The intention‐to‐treat analysis included 31 patients in the CTR group and 28 patients in the CBCR group. The primary outcome showed increased physical activity according to the IPAQ survey in the CTR group compared to the CBCR group (median increase 1726 METS‐min/week vs. 636, p = .045). Mean VO2max increased 1.62 ml/(kg min) (95% confidence interval [CI]: 0.56–2.69, p < .004) from baseline in the CTR group, and 0.60 mL/(kg min) (p = .40) in the CBCR group. Mean apoB/apoA‐I ratio decreased 0.13 (95% CI: −0.03 to 0.24, p = .017) in the CTR group, with no significant change in the CBCR group (p = .092). The median non‐HDL cholesterol increased by 7.3 mg/dl (IQR: −2.4 to 18.6, p = .021) in the CBCR group, but the increase was not significant in the CTR group (p = .080). Adherence to a Mediterranean diet, psychological distress, and quality of life showed greater improvement in the CTR group than in the CBCR group. Return‐to‐work time was reduced with the telerehabilitation strategy.

Conclusion

This system allows minimal in‐hospital training and prolonged follow‐up. This strategy showed better results than CBCR.