Traditional Versus Hybrid Outpatient Cardiac Rehabilitation: A COMPARISON OF PATIENT OUTCOMES

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Effectiveness and reporting of nutrition interventions in cardiac rehabilitation programmes: a systematic review

AIMS

Dietary modification is essential for the secondary prevention of cardiovascular disease. However, there are limited published evidence syntheses to guide practice in the cardiac rehabilitation (CR) setting. This systematic review's objective was to assess effectiveness and reporting of nutrition interventions to optimize dietary intake in adults attending CR.

METHODS AND RESULTS

Randomized controlled trials (RCTs) of nutrition interventions within CR were eligible for inclusion and had to have measured change in dietary intake. MEDLINE, Embase, Emcare, PsycINFO, CINAHL, Scopus, and The Cochrane Library were searched from 2000 to June 2020, limited to publications in English. Evidence from included RCTs was synthesized descriptively. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. This review is registered on PROSPERO; CRD42020188723. Of 13 048 unique articles identified, 11 were eligible. Randomized controlled trials were conducted in 10 different countries, included 1542 participants, and evaluated 29 distinct dietary intake outcomes. Five studies reported statistically significant changes in diet across 13 outcomes. Most nutrition interventions were not reported in a manner that allowed replication in clinical practice or future research.

CONCLUSION

There is a gap in research testing high-quality nutrition interventions in CR settings. Findings should be interpreted in the light of limitations, given the overall body of evidence was heterogenous across outcomes and study quality; 6 of 11 studies were conducted more than 10 years old. Future research should investigate strategies to optimize and maintain nutrition improvements for patients attending CR.

REGISTRATION

PROSPERO; CRD42020188723.

Comparison of telecardiac rehabilitation with centre-based cardiac rehabilitation and usual care: a protocol for systematic review including a meta-analysis

INTRODUCTION

Cardiac diseases are the leading causes of morbidity and mortality. Cardiac rehabilitation is proven to be beneficial in reducing morbidity, mortality and rehospitalisation rates. Recently, more emphasis is given to home-based telemonitored cardiac rehabilitation due to the recent pandemic of SARS-CoV-2. We plan to perform this systematic review and meta-analysis to compare the differences in functional capacity (FC) (measured in peak oxygen uptake (PVO₂)) and health-related quality of life (hr-QoL) between telecardiac rehabilitation and both centre-based cardiac rehabilitation (CBCR) and usual care (UC) separately. It will showcase the feasibility of using telemonitored cardiac rehabilitation as an alternative to CBCR considering the ease of performance, safety and limiting unnecessary contact.

METHODS AND ANALYSIS

This systematic review and meta-analysis protocol was structured according to the published Preferred Reporting Items for Systematic Review and Meta-analysis-Protocol guidelines. We will devise a search strategy to use online databases to search for the randomised controlled trials (RCTs). Inclusion criteria will include adult population (18 years or older) suffering from at least one cardiac disease referred for cardiac rehabilitation comparing telecardiac rehabilitation with both CBCR and UC. Exclusion criteria will be RCTs in non-English language, hybrid studies, cross-over trials, observational studies and case series. The outcome of interest will be FC measured in PVO₂ and hr-QoL. The articles will be reviewed by two independent reviewers and a third reviewer will be available to adjudicate any conflicts. The bias in the selected studies will be assessed using Cochrane risk-of-bias tool for randomised trials. The overall bias of the studies will be assessed. The selected articles will be reviewed and the data will be collected on Microsoft Excel spreadsheet for analysis. These data will include number of subjects in the intervention arm and the comparator arm (which will either be CBCR or UC), measures of FC and hr-QoL and SD. Subgroup analysis and sensitivity analysis will be considered based on heterogeneity among the study effect estimates and the number of available studies for each outcome. Results of the pooled estimates will be reported as standardised mean difference (and 95% CI) with fixed-effect model, if heterogeneity is not significant (I² <50%). Otherwise, random-effects model will be used for I² >50%. The data of the subjects who completed the rehabilitation programme of the study period will be used to calculate the effect estimates (per-protocol effect). Publication bias in the meta-analysis will be assessed using Egger's test and funnel plot. The strength of body of evidence of the outcomes will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Data analysis will be performed using Stata SE V.15.0 (College Station, Texas, USA).

ETHICS AND DISSEMINATION

There will be no direct involvement of the patient or the public in the conception, design, data collection, and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles.

PROSPERO REGISTRATION NUMBER

CRD42021245461.

Cardiac telerehabilitation in a middle-income country: analysis of adherence, effectiveness and cost through a randomized clinical trial

BACKGROUND

The benefits of cardiac rehabilitation (CR) are already well established; however, such intervention has been underused, mainly in low- and middle-income countries.

AIM

To compare adherence, effectiveness, and cost of a home CR with the traditional CR (TCR) in a middle-income country (MIC).

DESIGN

Single-blind randomized control trial.

SETTING

A university hospital.

POPULATION

Individuals with coronary disease that were eligible were invited to participate. A randomized sample of 51 individuals was selected, where two participants were not included by not meeting inclusion criteria.

METHODS

The home-CR group participated in health education activities, carried out two supervised exercise sessions, and was instructed to carry out 58 sessions at home. Weekly telephone calls were made. The TCR group held 24 supervised exercise sessions and were instructed to carry out 36 sessions at home.

RESULTS

49 individuals (42 male, 56.37±10.35years) participated in the study, 23 in the home-CR group and 26 in the TCR group. After the intervention, adherence in the home-CR and TCR groups was 94.18% and 79.08%, respectively, with no significant difference (P=0.191). Both protocols were effective for the other variables, with no differences. The cost per patient for the service was lower in the home-CR (US$ 59.31) than in the TCR group (US$ 135.05).

CONCLUSIONS

CR performed at home in an MIC demonstrated similar adherence and effectiveness compared to the TCR program, but with a lower cost for the service. The results corroborate the possibility of using home CR programs, even in MICs, after exercise risk stratification and under remote supervision.

CLINICAL REHABILITATION IMPACT

Home-CR can contribute to overcome participants' barriers with compatible cost. Home-CR is effective in improving functional capacity and risk factors control. Perform risk stratification and remote supervision are essential to offer Home-CR.

Clinical Status of Cardiac Rehabilitation Manners and Models

Cardiac rehabilitation, which combines cardiology and preventive medicine, is an important part of treatment for cardiovascular diseases. Systematically, cardiac rehabilitation, including simultaneously inhibiting endothelial injury and promoting endothelial repair, is beneficial for physical and mental recovery and reduces the risks of recurrence and death in patients with cardiovascular diseases. Cardiac rehabilitation has developed rapidly in the last 50 years. A preliminary system for cardiac rehabilitation has been developed in China. The present article mainly focuses on the progress of cardiac rehabilitation from the aspects of goals, measures, and modes of research in the current scenario.

Prevalence of US Adults With Cardiovascular Disease Reporting Barriers to Clinician Office Visits: IMPLICATIONS FOR ACCESSIBLE MODELS FOR CARDIAC REHABILITATION

PURPOSE

Despite known health benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), only a quarter of eligible patients attend. Among CR barriers are physical (eg, walking) and in-person attendance limitations. The purpose of this study was to determine the prevalence of difficulty walking and dependence on another person to attend medical appointments among people with and without CVD using national survey data.

METHODS

We compared the prevalence of difficulty walking and difficulty attending medical appointments alone among adults with and without CVD using national survey data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2015-2019. We used logistic regression and Rao-Scott χ2 analysis while controlling for several social determinants of health as covariates.

RESULTS

Of 2 212 973 respondents, 200 087 (9.04%) had CVD. The odds of individuals with CVD experiencing either difficulty walking or difficulty attending medical appointments alone were >3 times greater than the odds for individuals without CVD. In all adults with CVD, 42% reported difficulty walking and 20% reported dependence on another person to attend medical appointments. In all adults with CVD, 46% reported difficulty with one or both difficulties compared with 14% of adults without CVD.

CONCLUSIONS

We estimate that 11.9 million Americans with self-reported CVD have difficulty walking, or are dependent on another person to attend medical appointments, or both. Alternative models of CR that adapt to these limitations are needed to increase attendance of CR so that all adults with CVD can improve their health outcomes.

Brief Vigorous Stair Climbing Effectively Improves Cardiorespiratory Fitness in Patients With Coronary Artery Disease: A Randomized Trial

Background: Cardiac rehabilitation exercise reduces the risk of secondary cardiovascular disease. Interval training is a time-efficient alternative to traditional cardiac rehabilitation exercise and stair climbing is an accessible means. We aimed to assess the effectiveness of a high-intensity interval stair climbing intervention on improving cardiorespiratory fitness (V˙O2peak) compared to standard cardiac rehabilitation care.

Methods: Twenty participants with coronary artery disease (61 ± 7 years, 18 males, two females) were randomly assigned to either traditional moderate-intensity exercise (TRAD) or high-intensity interval stair climbing (STAIR). V˙O2peak was assessed at baseline, following 4 weeks of six supervised exercise sessions and after 8 weeks of ~24 unsupervised exercise sessions. TRAD involved a minimum of 30 min at 60–80%HR_peak, and STAIR consisted of three bouts of six flights of 12 stairs at a self-selected vigorous intensity (~90 s/bout) separated by recovery periods of walking (~90 s). This study was registered as a clinical trial at clinicaltrials.gov (NCT03235674).

Results: Two participants could not complete the trial due to the time commitment of the testing visits, leaving n = 9 in each group who completed the interventions without any adverse events. V˙O2peak increased after supervised and unsupervised training in comparison to baseline for both TRAD [baseline: 22.9 ± 2.5, 4 weeks (supervised): 25.3 ± 4.4, and 12 weeks (unsupervised): 26.5 ± 4.8 mL/kg/min] and STAIR [baseline: 21.4 ± 4.5, 4 weeks (supervised): 23.4 ± 5.6, and 12 weeks (unsupervised): 25 ± 6.2 mL/kg/min; p (time) = 0.03]. During the first 4 weeks of training (supervised) the STAIR vs. TRAD group had a higher %HR_peak (101 ± 1 vs. 89 ± 1%; p ≤ 0.001), across a shorter total exercise time (7.1 ± 0.1 vs. 36.7 ± 1.1 min; p = 0.009). During the subsequent 8 weeks of unsupervised training, %HR_peak was not different (87 ± 8 vs. 96 ± 8%; p = 0.055, mean ± SD) between groups, however, the STAIR group continued to exercise for less time per session (10.0 ± 3.2 vs. 24.2 ± 17.0 min; p = 0.036).

Conclusions: Both brief, vigorous stair climbing, and traditional moderate-intensity exercise are effective in increasing V˙O2peak, in cardiac rehabilitation exercise programmes.

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

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

Including Patients With Stroke in Cardiac Rehabilitation: BARRIERS AND FACILITATORS

More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.

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

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

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

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