A Review of Disparities in Cardiac Rehabilitation: EVIDENCE, DRIVERS, AND SOLUTIONS

Relationship Between Participation of In-Hospital Cardiac Rehabilitation and Regional Characteristics in Japan - Insight From the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination

Background

The influence of various regional backgrounds on participation in cardiac rehabilitation (CR) remains underexplored. We investigated the regional characteristics that potentially promote CR participation.

Methods and Results

This was a nationwide cross-sectional cohort study using the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination. This study included a cohort of 2.7 million inpatients hospitalized between April 2012 and March 2021. The CR participation rate for each hospital was calculated as the percentage of eligible patients who underwent CR during their admission. Among all hospitals, those that do not perform CR were defined as No-CR hospitals. The remaining hospitals were categorized into High- and Low-CR hospitals based on the median level of the CR participation rate (41.5%). High-CR hospitals had significantly smaller medical service areas (P<0.0001), a higher number of physicians per population (P<0.0001), higher air temperature (P=0.02), and fewer primary industry workers (P=0.005) than the other 2 groups. Logistic regression analyses revealed that a lower consumer price index was a significant regional factor that characterized High-CR hospitals, and a lower population aged ≥65 years was a factor approaching significance that characterized the region where High-CR hospitals are located.

Conclusions

High-CR hospitals were found in regions with a lower consumer price index and a trend towards a lower population aged ≥65 years.

Understanding attendance patterns and determinants in cardiac, pulmonary, and ICU Rehabilitation/Recovery programs: A systematic review and meta-analysis

BACKGROUND

Cardiac, pulmonary, and intensive care unit (ICU) rehabilitation/recovery programs are health promotion interventions designed to improve physical recovery, psychological well-being, and quality of life after acute illness while reducing the risk of adverse events.

OBJECTIVE

Identify the difference in attendance rates for patients invited to a cardiac rehabilitation, pulmonary rehabilitation, or ICU recovery program and factors influencing attendance.

METHODS

We conducted a systematic review and meta-analysis by searching PubMed, EMBASE, CINAHL, Web of Science, and manual reference lists from inception to June 3, 2024. We included studies reporting patient attendance rates in eligible programs following acute illness hospitalization. Two team members independently screened articles and extracted data, with a third member reviewing and achieving consensus when necessary. Our main outcomes focused on the proportion of attendance in eligible programs among patients referred.

RESULTS

Of 3,446 studies screened, 179 studies (N = 4,779,012 patients) were included across cardiac rehabilitation (n = 153 studies), pulmonary rehabilitation (n = 11 studies), and ICU recovery (n = 15 studies) programs. Pooled attendance rates were 53 % (95 % CI: 48-57 %) for cardiac rehabilitation, 56 % (95 % CI: 42-70 %) for pulmonary rehabilitation, and 61 % (95 % CI: 51-70 %) for ICU recovery programs. Significant attendance heterogeneity was present (cardiac I2=100 %, p < 0.001; pulmonary I2=100 %, p < 0.001; ICU I2=94 %, p < 0.01). Barriers to attendance included transportation, distance, work conflicts, and patient factors (e.g., comorbidities, older age). Facilitators included male gender, younger age, higher education, income, provider recommendations, and flexible scheduling. Individual factors represented the primary domain affecting attendance.

CONCLUSIONS

The results indicate comparable attendance rates and factors shaping attendance across acute illness rehabilitation/recovery programs, with ICU recovery programs being the most well-attended on average.

REGISTRATION

PROSPERO CRD42022357261.

Race, Social Determinants of Health, and Comorbidity Patterns Among Participants with Heart Failure in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Background

Among individuals with heart failure (HF), racial differences in comorbidities may be mediated by social determinants of health (SDOH).

Methods

Black and White US community-dwelling participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study aged ≥ 45 years with an adjudicated HF hospitalization between 2003 and 2017 were included in this cross-sectional analysis. We assessed whether higher prevalence of comorbidities in Black participants compared to White participants were mediated by SDOH in socioeconomic, environment/housing, social support, and healthcare access domains, using the inverse odds weighting method.

Results

Black (n = 240) compared to White (n = 293) participants with HF with preserved ejection fraction (HFpEF) had higher prevalence of diabetes [1.38 (95% CI: 1.18 - 1.61)], chronic kidney disease [1.21 (95% CI: 1.01 - 1.45)], and anemia [1.33 (95% CI: 1.02 - 1.75)] and lower prevalence of atrial fibrillation [0.80 (95% CI: (0.65 - 0.98)]. Black (n = 314) compared to White (n = 367) participants with HF with reduced ejection fraction (HFrEF) had higher prevalence of hypertension [1.04 (95% CI: 1.02 - 1.07)] and diabetes [1.26 (95% CI: 1.09 - 1.45)] and lower prevalence of coronary artery disease [0.86 (95% CI: 0.78 - 0.94)] and atrial fibrillation [0.70 (95% CI: 0.58 - 0.83)]. Socioeconomic status explained 14.5%, 26.5% and 40% of excess diabetes, anemia, and chronic kidney disease among Black adults with HFpEF; however; mediation was not statistically significant and no other SDOH substantially mediated differences in comorbidity prevalence.

Conclusions

Socioeconomic status partially mediated excess diabetes, anemia, and chronic kidney disease experienced by Black adults with HFpEF, but differences in other comorbidities were not explained by other SDOH examined.

Challenges and solutions to implementing cardiac rehabilitation in a low- and middle-income country

BACKGROUND

Cardiac rehabilitation (CR) remains greatly underutilized, especially in low- and middle-income countries (LMIC). It is therefore important to explore factors that contribute to this, as perceived by health-care professionals (HCPs).

RESEARCH DESIGN AND METHODS

This was a qualitative study using in-depth interviews that enrolled 18 HCPs (i.e. six each of physicians, physiotherapists, and nurses; mean experience in CR: 17.9 ± 11.8 yrs) working in cardiovascular care, and CR across private and government hospitals (both teaching and non-teaching) in India.

RESULTS

The main challenges were related to lack of referrals, perceived lack of benefit from CR, poor infrastructure within hospitals and health systems, and differences in practice. The perceived inadequacies were lack of competencies in CR, limited task sharing strategies, and ineffective utilization of existing human resources. Devising strategies to improve awareness and competencies, facilitating task sharing, and remodeling holistic care with an active CR component may be beneficial to facilitate greater implementation of CR in India.

CONCLUSIONS

Challenges, inadequacies, and solutions to implementing CR have been explored by involving various HCPs commonly involved in delivering CR across different health systems in a LMIC.

TRIAL REGISTRATION

www.ctri.nic.in with identifier CTRI/2020/07/026807.

Racial and Ethnic Disparities in Peri-and Post-operative Cardiac Surgery

Purpose of Review

Despite efforts to curtail its impact on medical care, race remains a powerful risk factor for morbidity and mortality following cardiac surgery. While patients from racial and ethnic minority groups are underrepresented in cardiac surgery, they experience a disproportionally elevated number of adverse outcomes following various cardiac surgical procedures. This review provides a summary of existing literature highlighting disparities in coronary artery bypass surgery, valvular surgery, cardiac transplantation, and mechanical circulatory support.

Recent Findings

Unfortunately, specific causes of these disparities can be difficult to identify, even in large, multicenter studies, due to the complex relationship between race and post-operative outcomes. Current data suggest that these racial/ethnic disparities can be attributed to a combination of patient, socioeconomic, and hospital setting characteristics.

Summary

Proposed solutions to combat the mechanisms underlying the observed disparate outcomes require deployment of a multidisciplinary team of cardiologists, anesthesiologists, cardiac surgeons, and experts in health care equity and medical ethics. Successful identification of at-risk populations and the implementation of preventive measures are necessary first steps towards dismantling racial/ethnic differences in cardiac surgery outcomes.

Exercise Adherence in Older and Middle-Aged Adults With Coronary Artery Disease Before and During COVID-19

BACKGROUND

Regular exercise is advised for individuals given a diagnosis of cardiovascular disease. COVID-19 presented challenges to exercise adherence.

OBJECTIVE

The objective of this study was to determine long-term exercise adherence and whether individuals with cardiovascular disease adhered to American Heart Association/American College of Cardiology Foundation guidelines before and during the COVID-19 pandemic.

METHODS

This is an observational cross-sectional study in which men (73%) and women discharged from a multiwide hospital system after an acute coronary event were enrolled. Participants completed 3 questionnaires, including the Exercise Adherence Rating Scale.

RESULTS

Five hundred eighty-two individuals (mean [SD] age, 67 [9.8] years) completed the survey. Fifty-three percent of participants met minimum exercise guidelines during COVID-19. Exercise days per week decreased significantly during COVID-19 in women ( P = .013) but not significant for men ( P = .301). Categorized by age, the decrease was significant for middle-aged women ( P = .002), not older women ( P = .336). Men exercised more minutes per session ( P = .034), and had greater exercise adherence ( P = .003) and greater exercise intensity ( P < .001). Overall, women participated less in cardiac rehabilitation ( P = .046) and reported the greatest disparity in exercise adherence and intensity.

CONCLUSION

Exercise after an acute event is beneficial, and the percentage of individuals meeting recommended guidelines should be higher considering the relationship between exercise and the possibility of future cardiac events. On the basis of the many physical and mental benefits of maintaining exercise, healthcare practitioners are encouraged to screen all patients for exercise adherence with a major emphasis on educating women and older adults.

Formative research to adapt a cardiac rehabilitation program to breast cancer survivors: the heart health after cancer treatment (HEART-ACT) study

BACKGROUND

Breast cancer survivors are disproportionately at risk for cardiovascular disease; exercise-based interventions may improve cardiovascular health. The objective of this formative research is to better understand the needs of patients and barriers to participation in an adapted cardiac rehabilitation program for diverse breast cancer survivors in an urban safety net setting.

METHODS

We recruited 30 participants (10 English-speaking, 10 Spanish-speaking, and 10 Cantonese-speaking) who had received treatment with curative intent for breast cancer from an urban safety net hospital between November 9, 2021, to August 30, 2022. Participants completed surveys and interviews about perspectives on health behaviors and participating in an adapted cardiac rehabilitation program. Interviews were qualitatively analyzed using rapid template analysis with pre-selected constructs from the Theory of Planned Behavior, Unified Theory of Acceptance and Use of Technology, and Consolidated Framework for Implementation Research, as well as emergent codes. We developed a Participant User Journey for a program based on responses and conducted human-centered design sessions with 8 participants to iteratively revise the Participant User Journey.

RESULTS

Among 30 participants, mean age was 56.7 years (standard deviation [SD] 10.2) with 100% female sex assigned at birth; 1 participant withdrew before completing study procedures. Most participants had limited health literacy (18/29, 62%). Mean body mass index was 31.4 (SD 8.3), 21/29 (72%) had blood pressure below 140/90 mmHg, and 12/29 (41%) had blood pressure below 130/80. Mean 6-minute walk distance was 384.9 meters (SD 78.3). The desired benefits of a program included healthy living and prevention of cancer recurrence. Barriers to participation included motivation, social support, transportation, and concerns about exercise safety. Participants emphasized the need for practicality, such as fitting physical activity into daily life and nutrition support, including recipes and shopping lists. Trusted experts and cultural and language concordance were viewed as important aspects of the program.

CONCLUSIONS

Through participant interviews and human-centered design sessions, we developed the HEART-ACT program, a 12-week multi-disciplinary program addressing physical activity, nutrition, emotional well-being, cardiovascular risk, survivorship, and other components if indicated (e.g., tobacco cessation). Future research will test the effects of this program on patient-centered outcomes.

Impact of Prior COVID-19 Infections on Cardiac Rehabilitation Completion Rates and Outcomes

PURPOSE

This is a retrospective cohort study designed to evaluate the impact of having a prior COVID-19 infection on cardiac rehabilitation (CR) completion rates and outcomes.

METHODS

Participants enrolled into the CR program from June 1, 2020, to March 30, 2022. They completed both physical and mental health assessments prior to enrollment and upon completion of the program. The cohort was divided into (-) COVID and (+) COVID based on whether they self-reported a prior COVID-19 infection. Outcome measures included General Anxiety Disorder-7, Patient Health Questionnaire-9, Mental Composite Score (Short Form Health Survey-36), Physical Composite Score (Short Form Health Survey-36), and exercise capacity (reported in METs). Program completion rates and outcome measures were compared between (-) COVID and (+) COVID cohorts.

RESULTS

A total of 806 participants were enrolled in the study. Program completion rates were 58.7% in the (-) COVID group and 67.2% in the (+) COVID group ( P = .072). African Americans ( P = .017), diabetics ( P = .017), and current smokers ( P = .003) were less likely to complete the program. Both (-) COVID and (+) COVID groups showed significant improvement in all outcome measures after completing the CR program. However, there was no difference in outcomes between groups.

CONCLUSIONS

Having a prior COVID-19 infection did not negatively impact the mental and physical health benefits obtained by completing the CR program, regardless of the American Association of Cardiovascular and Pulmonary Rehabilitation risk category.

Rationale and Design of the mTECH-Rehab Randomized Controlled Trial: Impact of a Mobile Technology Enabled Corrie Cardiac Rehabilitation Program on Functional Status and Cardiovascular Health

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based, guideline-recommended intervention for patients recovering from a cardiac event, surgery or procedure that improves morbidity, mortality, and functional status. CR is traditionally provided in-center, which limits access and engagement, most notably among underrepresented racial and ethnic groups due to barriers including cost, scheduling, and transportation access. This study is designed to evaluate the Corrie Hybrid CR, a technology-based, multicomponent health equity-focused intervention as an alternative to traditional in-center CR among patients recovering from a cardiac event, surgery, or procedure compared with usual care alone.

METHODS

The mTECH-Rehab (Impact of a Mobile Technology Enabled Corrie CR Program) trial will randomize 200 patients who either have diagnosis of myocardial infarction or who undergo coronary artery bypass grafting surgery, percutaneous coronary intervention, heart valve repair, or replacement presenting to 4 hospitals in a large academic health system in Maryland, United States, to the Corrie Hybrid CR program combined with usual care CR (intervention group) or usual care CR alone (control group) in a parallel arm, randomized controlled trial. The Corrie Hybrid CR program leverages 5 components: (1) a patient-facing mobile application that encourages behavior change, patient empowerment, and engagement with guideline-directed therapy; (2) Food and Drug Administration-approved smart devices that collect health metrics; (3) 2 upfront in-center CR sessions to facilitate personalization, self-efficacy, and evaluation for the safety of home exercise, followed by a combination of in-center and home-based sessions per participant preference; (4) a clinician dashboard to track health data; and (5) weekly virtual coaching sessions delivered over 12 weeks for education, encouragement, and risk factor modification. The primary outcome is the mean difference between the intervention versus control groups in distance walked on the 6-minute walk test (ie, functional capacity) at 12 weeks post randomization. Key secondary and exploratory outcomes include improvement in a composite cardiovascular health metric, CR engagement, quality of life, health factors (including low-density lipoprotein-cholesterol, hemoglobin A1c, weight, diet, smoking cessation, blood pressure), and psychosocial factors. Approval for the study was granted by the local institutional review board. Results of the trial will be published once data collection and analysis have been completed.

CONCLUSIONS

The Corrie Hybrid CR program has the potential to improve functional status, cardiovascular health, and CR engagement and advance equity in access to cardiac rehabilitation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05238103.

A Mobile Health Behavior Change Intervention for Women With Coronary Heart Disease: A RANDOMIZED CONTROLLED PILOT STUDY

PURPOSE

The aim of this study was to evaluate the effects of a mobile health (mHealth) intervention, HerBeat, compared with educational usual care (E-UC) for improving exercise capacity (EC) and other patient-reported outcomes at 3 mo among women with coronary heart disease.

METHODS

Women were randomized to the HerBeat group (n = 23), a behavior change mHealth intervention with a smartphone, smartwatch, and health coach or to the E-UC group (n = 24) who received a standardized cardiac rehabilitation workbook. The primary endpoint was EC measured with the 6-min walk test (6MWT). Secondary outcomes included cardiovascular disease risk factors and psychosocial well-being.

RESULTS

A total of 47 women (age 61.2 ± 9.1 yr) underwent randomization. The HerBeat group significantly improved on the 6MWT from baseline to 3 mo ( P = .016, d = .558) while the E-UC group did not ( P = .894, d =-0.030). The between-group difference of 38 m at 3 mo was not statistically significant. From baseline to 3 mo, the HerBeat group improved in anxiety ( P = .021), eating habits confidence ( P = .028), self-efficacy for managing chronic disease ( P = .001), diastolic blood pressure ( P = .03), general health perceptions ( P = .047), perceived bodily pain ( P = .02), and waist circumference ( P = .008) while the E-UC group showed no improvement on any outcomes.

CONCLUSIONS

The mHealth intervention led to improvements in EC and several secondary outcomes from baseline to 3 mo while the E-UC intervention did not. A larger study is required to detect small differences between groups. The implementation and outcomes evaluation of the HerBeat intervention was feasible and acceptable with minimal attrition.

Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation

PURPOSE

Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention.

METHODS

Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance.

RESULTS

The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A 1c , with more abnormal lipid profiles (all P s < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both P s < .001).

CONCLUSION

Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.

Efficacy and Adherence Rates of a Novel Community-Informed Virtual World-Based Cardiac Rehabilitation Program: Protocol for the Destination Cardiac Rehab Randomized Controlled Trial

BACKGROUND

Innovative restructuring of cardiac rehabilitation (CR) delivery remains critical to reduce barriers and improve access to diverse populations. Destination Cardiac Rehab is a novel virtual world technology-based CR program delivered through the virtual world platform, Second Life, which previously demonstrated high acceptability as an extension of traditional center-based CR. This study aims to evaluate efficacy and adherence of the virtual world-based CR program compared with center-based CR within a community-informed, implementation science framework.

METHODS

Using a noninferiority, hybrid type 1 effectiveness-implementation, randomized controlled trial, 150 patients with an eligible cardiovascular event will be recruited from 6 geographically diverse CR centers across the United States. Participants will be randomized 1:1 to either the 12-week Destination Cardiac Rehab or the center-based CR control groups. The primary efficacy outcome is a composite cardiovascular health score based on the American Heart Association Life's Essential 8 at 3 and 6 months. Adherence outcomes include CR session attendance and participation in exercise sessions. A diverse patient/caregiver/stakeholder advisory board was assembled to guide recruitment, implementation, and dissemination plans and to contextualize study findings. The institutional review board-approved randomized controlled trial will enroll and randomize patients to the intervention (or control group) in 3 consecutive waves/year over 3 years. The results will be published at data collection and analyses completion.

CONCLUSIONS

The Destination Cardiac Rehab randomized controlled trial tests an innovative and potentially scalable model to enhance CR participation and advance health equity. Our findings will inform the use of effective virtual CR programs to expand equitable access to diverse patient populations.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05897710.

Health Disparities, Clinical Trials, and the Digital Divide

In the past few years, there have been rapid advances in technology and the use of digital tools in health care and clinical research. Although these innovations have immense potential to improve health care delivery and outcomes, there are genuine concerns related to inadvertent widening of the digital gap consequentially exacerbating health disparities. As such, it is important that we critically evaluate the impact of expansive digital transformation in medicine and clinical research on health equity. For digital solutions to truly improve the landscape of health care and clinical trial participation for all persons in an equitable way, targeted interventions to address historic injustices, structural racism, and social and digital determinants of health are essential. The urgent need to focus on interventions to promote health equity was made abundantly clear with the coronavirus disease 2019 pandemic, which magnified long-standing social and racial health disparities. Novel digital technologies present a unique opportunity to embed equity ideals into the ecosystem of health care and clinical research. In this review, we examine racial and ethnic diversity in clinical trials, historic instances of unethical research practices in biomedical research and its impact on clinical trial participation, and the digital divide in health care and clinical research, and we propose suggestions to achieve digital health equity in clinical trials. We also highlight key digital health opportunities in cardiovascular medicine and dermatology as exemplars, and we offer future directions for development and adoption of patient-centric interventions aimed at narrowing the digital divide and mitigating health inequities.

Predictors of gain in exercise capacity through cardiac rehabilitation: Sex and age matter

BACKGROUND

Cardiac rehabilitation (CR) is a cornerstone of secondary prevention that improves cardiovascular outcomes. However, the determinants of treatment success are poorly understood.

OBJECTIVES

We investigated the associations of health-related quality of life (HRQoL), sex, age, employment status and housing situation with improvement in exercise capacity throughout CR.

METHODS

We analyzed data from 392 CR outpatients (81% men and 19% women). Exercise capacity at baseline and upon completion of the program was measured with the 6-minute walk distance (6MWD). HRQoL at CR entry was assessed with the Short Form 36 Health Survey (SF-36).

RESULTS

A multivariable regression analysis revealed that both men and women showed significant improvement in exercise capacity (p < .001). Female sex (B = 18.118, 95% CI 0.341 - 36.035, p = .046) and younger age (B = -0.887, 95% CI -1.463 - -0.312, p = .003) emerged as predictors of greater improvement, while HRQoL, employment status, and housing situation were not associated with significant change in exercise capacity. The final model explained 25% of the variance in exercise capacity change (adjusted R2 = 0.25, p < .001).

CONCLUSIONS

Our results indicate that women and younger participants benefit from CR by improving their exercise capacity. Employment status, housing situation and HRQoL showed no effects on CR outcome.

Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization

BACKGROUND

Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes.

METHODS

A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization.

RESULTS

A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles.

CONCLUSIONS

Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Patterns of Referral and Postdischarge Utilization of Cardiac Rehabilitation Among Patients Hospitalized With Heart Failure: An Analysis From the GWTG-HF Registry

BACKGROUND

Coverage for cardiac rehabilitation (CR) for patients with heart failure with reduced ejection fraction was expanded in 2014, but contemporary referral and participation rates remain unknown.

METHODS

Patients hospitalized for heart failure with reduced ejection fraction (≤35%) in the American Heart Association Get With The Guidelines-Heart Failure registry from 2010 to 2020 were included, and CR referral status was described as yes, no, or not captured. Temporal trends in CR referral were assessed in the overall cohort. Patient and hospital-level predictors of CR referral were assessed using multivariable-adjusted logistic regression models. Additionally, CR referral and proportional utilization of CR within 1-year of referral were evaluated among patients aged >65 years with available Medicare administrative claims data who were clinically stable for 6-weeks postdischarge. Finally, the association of CR referral with the risk of 1-year death and readmission was evaluated using multivariable-adjusted Cox models.

RESULTS

Of 69,441 patients with heart failure with reduced ejection fraction who were eligible for CR (median age 67 years; 33% women; 30% Black), 17,076 (24.6%) were referred to CR, and referral rates increased from 8.1% in 2010 to 24.1% in 2020 (Ptrend<0.001). Of 8310 patients with Medicare who remained clinically stable 6-weeks after discharge, the CR referral rate was 25.8%, and utilization of CR among referred patients was 4.1% (mean sessions attended: 6.7). Patients not referred were more likely to be older, of Black race, and with a higher burden of comorbidities. In adjusted analysis, eligible patients with heart failure with reduced ejection fraction who were referred to CR (versus not referred) had a lower risk of 1-year death (hazard ratio, 0.84 [95% CI, 0.70-1.00]; P=0.049) without significant differences in 1-year readmission.

CONCLUSIONS

CR referral rates have increased from 2010 to 2020. However, only 1 in 4 patients are referred to CR. Among eligible patients who received CR referral, participation was low, with <1 of 20 participating in CR.

Exercise Self-efficacy Improvements During Cardiac Rehabilitation: IMPACT OF SOCIAL DISPARITIES

PURPOSE

The objective of this study was to determine exercise self-efficacy improvements during cardiac rehabilitation (CR) and identify predictors of exercise self-efficacy change in CR participants.

METHODS

Patients with coronary heart disease at four metropolitan CR sites completed the Exercise Self-efficacy Scale at entry and completion. A general linear model identified independent predictors of change in exercise self-efficacy.

RESULTS

The mean age of patients (n = 194) was 65.9 ± 10.5 yr, and 81% were males. The majority (80%) were married or partnered, 76% were White, and 24% were from an ethnic minority background. Patients received CR in-person (n = 91, 47%) or remote-delivered (n = 103, 54%). Exercise self-efficacy mean scores improved significantly from 25.2 ± 5.8 at CR entry to 26.2 ± 6.3 points at completion ( P = .025). The majority of patients (59%) improved their self-efficacy scores, 34% worsened, and 7% had no change. Predictors of reduced exercise self-efficacy change were being from an ethnic minority (B =-2.96), not having a spouse/partner (B =-2.42), attending in-person CR (B =1.75), and having higher exercise self-efficacy at entry (B =-0.37) (adjusted R2 = 0.247).

CONCLUSIONS

Confidence for self-directed exercise improves in most, but not all, patients during CR. Those at risk for poor improvement (ethnic minorities, single patients) may need extra or tailored support, and screening for exercise self-efficacy at CR entry and completion is recommended. Differences identified from CR delivery mode need exploration using robust methods to account for complex factors.

Association of Home-Based Cardiac Rehabilitation With Lower Mortality in Patients With Cardiovascular Disease: Results From the Veterans Health Administration Healthy Heart Program

Background Home-based cardiac rehabilitation (HBCR) and traditional facility-based cardiac rehabilitation (CR) programs have similar effects on mortality in clinical trials and meta-analyses. However, the effect of HBCR on mortality in clinical practice settings is less clear. Therefore, we sought to compare mortality rates in HBCR participants versus nonparticipants. Methods and Results We evaluated all patients who were referred to and eligible for outpatient CR between 2013 and 2018 at the San Francisco Veterans Health Administration. Patients who chose to attend facility-based CR and those who died within 30 days of hospitalization were excluded. Patients who chose to participate in HBCR received up to 9 telephonic coaching and motivational interviewing sessions over 12 weeks. All patients were followed through June 30, 2021. We used Cox proportional hazards regression models with inverse probability treatment weighting to compare mortality in HBCR participants versus nonparticipants. Of the 1120 patients (mean age 68, 98% male, 76% White) who were referred and eligible, 490 (44%) participated in HBCR. During a median follow-up of 4.2 years, 185 patients (17%) died. Mortality was lower among the 490 HBCR participants versus the 630 nonparticipants (12% versus 20%; P<0.01). In an inverse probability weighted Cox regression analysis adjusted for patient demographics and comorbid conditions, the hazard of mortality remained 36% lower among HBCR participants versus nonparticipants (hazard ratio, 0.64 [95% CI, 0.45-0.90], P=0.01). Conclusions Among patients eligible for CR, participation in HBCR was associated with 36% lower hazard of mortality. Although unmeasured confounding can never be eliminated in an observational study, our findings suggest that HBCR may benefit patients who cannot attend traditional CR programs.

A Community-Informed Virtual World-Based Cardiac Rehabilitation Program as an Extension of Center-Based Cardiac Rehabilitation: MIXED-METHODS ANALYSIS OF A MULTICENTER PILOT STUDY

PURPOSE

Innovative methods for delivering cardiac rehabilitation (CR) that provide strategies to circumvent the mounting barriers to traditional CR have the potential to widen access to a well-established secondary prevention strategy. Our study assesses the feasibility and acceptability of a novel virtual world-based CR (VWCR) program, Destination Rehab , as an extension of a conventional center-based CR program.

METHODS

Adult cardiac patients hospitalized at Mayo Clinic hospitals with a diagnosis for CR and ≥1 modifiable, lifestyle risk factor target-sedentary lifestyle (<3 hr physical activity/wk), unhealthy diet (<5 servings fruits and vegetables/d), or current smoking (>1 yr)-were recruited. Patients participated in an 8-wk health education program using a virtual world (VW) platform from a prior proof-of-concept study and a post-intervention focus group. Primary outcome measures included feasibility and acceptability. Secondary outcome measures included changes from baseline to post-intervention in cardiovascular (CV) health behaviors and biometrics, CV health knowledge, and psychosocial factors.

RESULTS

Of the 30 enrolled patients (age 59.1 ± 9.7 yr; 50% women), 93% attended ≥1 session and 71% attended ≥75% of sessions. The overall VWCR experience received an 8 rating (scale 0-10) and had high acceptability. Clinically relevant trends were noted in CV health behaviors and biometrics, although not statistically significant.

CONCLUSIONS

The VWCR program is a feasible, highly acceptable, and innovative platform to potentially influence health behaviors and CV risk and may increase accessibility to disadvantaged populations with higher CV disease burdens.

Geographical and Urban-Rural Disparities in Cardiac Rehabilitation Eligibility and Center-Based Use in the US

This cross-sectional study analyzes county-level eligibility, participation, adherence, and completion rates for cardiac rehabilitation services among Medicare beneficiaries.

National, regional, and urban-rural patterns in fixed-terrestrial broadband internet access and cardiac rehabilitation utilization in the United States

Objective

Sparse patterns in fixed-terrestrial broadband internet access are predominantly observed among older adults and low income areas, which are interrelated factors also associated with low center-based cardiac rehabilitation (CR) utilization in the United States (US). Telehealth CR is proposed to increase CR utilization under an assumption that fixed-terrestrial broadband internet access is readily available nationwide and parallels CR utilization demand. We aimed to characterize national, geographical, and urban-rural patterns in fixed-terrestrial broadband internet access, CR eligibility rates, and center-based utilization throughout the US.

Methods

Centers for Disease Control data were used to estimate CR eligibility rates and center-based utilization for 2017-2018 among Medicare fee-for-service beneficiaries aged ≥65 years. Census Bureau data for 2018 were used to estimate fixed-terrestrial broadband internet access among households of adults aged ≥65 years.

Results

Southern states exhibited the highest percentage of households without broadband internet [median (IQR): 32% (24-39)] coupled with the highest CR eligibility rates [per 1,000 beneficiaries, median (IQR): 18 (15-21)] and lowest participation rates [percentage completing ≥1 session, median (IQR): 25% (17-33)]. Compared with urban areas, rural areas demonstrated significantly higher eligibility rates [15.5 (13.2-18.4) vs. 17.4 (14.5-21.0)], participation rates [30.6% (22.0-39.4) vs. 34.6% (22.6-48.3)], and percentage of households without broadband internet [23.8% (18.1-29.2) vs. 31.6% (26.5-37.6)], respectively.

Conclusion

Overlapping patterns in fixed-terrestrial broadband internet access and CR eligibility rates and center-based utilization suggest telehealth CR policies need to account for the possibility that lack of broadband-quality internet access could be a barrier to accessing telehealth CR delivery models.

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.

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.

Disparities in the Use of Cardiac Rehabilitation in African Americans

Purpose of review

Cardiac rehabilitation (CR) is a comprehensive outpatient program that reduces the risk of mortality and recurrent events and improves functional status and quality of life for patients recovering from acute cardiovascular disease (CVD) events. Among individuals with established CVD, African Americans have a higher risk of major cardiac events, which underscores the importance of CR use among African Americans. However, despite their high likelihood of adverse outcomes, CR is poorly utilized in African Americans with CVD. We review data on CR utilization among African Americans, barriers to participation, and the implications for policy and practice.

Recent findings

Although established as a highly effective secondary prevention strategy, CR is underutilized in general, but especially by African Americans. Notwithstanding efforts to increase CR participation among all groups, participation rates remain low for African Americans and other minorities compared to Non-Hispanic Whites. The low CR participation rates by African Americans can be attributed to an array of factors including differential referral patterns, access to care, and socioeconomic factors. There are several promising strategies to improve CR participation which include promoting evidence-based guidelines, reducing barriers to access, novel CR delivery modalities, including more African Americans in CR clinical research, and increasing diversity in the CR workforce.

Summary

African Americans with CVD events are less likely to be referred to, enroll in, and complete CR than Non-Hispanic Whites. There are many factors that impact CR participation by African Americans. Initiatives at the health policy, health system, individual, and community level will be needed to reduce these disparities in CR use.

Exercise Training in Patients with Heart Failure: From Pathophysiology to Exercise Prescription

Heart failure (HF) is a chronic, progressive, and inexorable syndrome affecting worldwide billion of patients (equally distributed among men and women), with prevalence estimate of 1-3% in developed countries. HF leads to enormous direct and indirect costs, and because of ageing population, the total number of HF patients keep rising, approximately 10% in patients > 65 years old. Exercise training (ET) is widely recognized as an evidence-based adjunct treatment modality for patients with HF, and growing evidence is emerging among elderly patients with HF. We used relevant data from literature search (PubMed, Medline, EMBASE) highlighting the epidemiology of HF; focusing on central and peripheral mechanisms underlying the beneficial effect of ET in HF patients; and on frail HF elderly patients undergoing ET. Since many Countries ordered a lockdown in early stages pandemic trying to limit infections, COVID-19 pandemic, and its limitation to exercise-based cardiac rehabilitation operativity was also discussed. ET exerts both central and peripheral adaptations that clinically translate into anti-remodeling effects, increased functional capacity and reduced morbidity and mortality. Ideally, ET programs should be prescribed in a patient-tailored approach, particularly in frail elderly patients with HF. In conclusion, given the complexity of HF syndrome, combining, and tailoring different ET modalities is mandatory. A procedural algorithm according to patient's baseline clinical characteristics [i.e., functional capacity, comorbidity, frailty status (muscle strength, balance, usual daily activities, hearing and vision impairment, sarcopenia, and inability to actively exercise), logistics, individual preferences and goals] has been proposed. Increasing long-term adherence and reaching the frailest patients are challenging goals for future initiatives in the field.

General and Vulnerable Population’s Satisfaction With the Healthcare System in Urban and Rural Areas: Findings From the European Social Survey

Introduction: Access to the healthcare system when patients are vulnerable and living outside metropolitan areas can be challenging. Our objective was to explore healthcare system satisfaction of urban and rural inhabitants depending on financial and health vulnerabilities.

Methods: Repeated cross-sectional data from 353,523 European citizens (2002–2016). Multivariable associations between rural areas, vulnerability factors and satisfaction with the healthcare system were assessed with linear mixed regressions and adjusted with sociodemographic and control factors.

Results: In unadjusted analysis, the people who lived in houses in the countryside and those who lived in the suburbs were the most satisfied with the healthcare system. In the adjusted model, residents living in big cities had the highest satisfaction. Financial and health vulnerabilities were associated with less satisfaction with the healthcare system, with a different effect according to the area of residence: the presence of health vulnerability was more negatively correlated with the healthcare system satisfaction of big city inhabitants, whereas financial vulnerability was more negatively correlated with the satisfaction of those living in countryside homes.

Conclusion: Vulnerable residents, depending on their area of residence, may require special attention to increase their satisfaction with the healthcare system.

Impact of Social Disparities on Cardiovascular Disease and COVID-19 Outcomes: BARRIERS TO CARE AND PREVENTIVE INTERVENTIONS

The COVID-19 pandemic has exposed significant disparities within certain population subsets that manifest through greater disease burden and worse outcomes. In this commentary, we propose specific preventive interventions to address these disparities within the United States.