Predicting cardiac rehabilitation attendance in a gender-tailored randomized clinical trial. J Cardiopulm Rehabil Prev. 2010;30:147-156. [PMID: 20216324 DOI: 10.1097/hcr.0b013e3181d0c2ce]

Engaging women in decision-making about their heart health: a literature review with patients' perspective

Cardiovascular disease (CVD) remains the leading cause of death globally. Although the burden of CVD risk factors tends to be lower in women, they remain at higher risk of developing complications when affected by these risk factors. There is still a lack of awareness surrounding CVD in women, both from a patient's and a clinician's perspective, especially among visible minorities. However, women who are informed about their heart health and who engage in decision-making with their healthcare providers are more likely to modify their lifestyle, and improve their CVD risk. A patient-centered care approach benefits patients' physical and mental health, and is now considered gold-standard for efficient patient care. Engaging women in their heart health will contribute in closing the gap of healthcare disparities between men and women, arising from sociocultural, socioeconomic, and political factors. This comprehensive review of the literature discusses the importance of engaging women in decision-making surrounding their heart health and offers tools for an effective and culturally sensitive patient-provider relationship.

Women-Focused Cardiac Rehabilitation Delivery Around the World and Program Enablers to Support Broader Implementation

Background

Women are less likely than men to use cardiac rehabilitation (CR); thus, women-focused (W-F) CR was developed. Implementation of W-F CR globally was investigated, as well as barriers and enablers to its delivery.

Methods

In this cross-sectional study, a survey was administered to CR programs via Research Electronic Data Capture (REDCap) from May to July, 2023. Potential respondents were identified via the International Council of Cardiovascular Prevention and Rehabilitation's network.

Results

A total of 223 responses were received from 52 of 111 countries (46.8% country response rate) in the world that have any CR, across all 6 World Health Organization regions. Thirty-three programs (14.8%) from 30 countries reported offering any W-F programming. Programs commonly did offer elements preferred by women and recommended, namely, the following: patient choice of session time (n = 151; 70.6%); invitations for informal care providers and/or partners to attend sessions (n = 121; 57.1%); CR staff that have expertise in women and heart diseases (n = 112; 53.3%); separate changerooms for women (n = 38; 52.8%); and discussion of CR referral with patients (n = 112; 52.1%). Main barriers to delivery of W-F exercise were physical resources (n = 33; 14.8%), space (n = 30; 13.5%), and staff time (n = 26; 11.7%) and expertise (n = 33; 10.3%). Main barriers to delivery of W-F education were human resources (n = 114; 51.1%), educational resources (n = 26; 11.7%), and expertise in the content (n = 74; 33.2%). Enablers of W-F education delivery were availability of materials, in multiple modalities, as well as educated staff and financial resources.

Conclusions

Despite the benefits, W-F CR is not commonly offered globally. Considering the barriers and enablers identified, the International Council of Cardiovascular Prevention and Rehabilitation is developing resources to expand delivery.

World Heart Federation Roadmap for Secondary Prevention of Cardiovascular Disease: 2023 Update

Background

Secondary prevention lifestyle and pharmacological treatment of atherosclerotic cardiovascular disease (ASCVD) reduce a high proportion of recurrent events and mortality. However, significant gaps exist between guideline recommendations and usual clinical practice.

Objectives

Describe the state of the art, the roadblocks, and successful strategies to overcome them in ASCVD secondary prevention management.

Methods

A writing group reviewed guidelines and research papers and received inputs from an international committee composed of cardiovascular prevention and health systems experts about the article's structure, content, and draft. Finally, an external expert group reviewed the paper.

Results

Smoking cessation, physical activity, diet and weight management, antiplatelets, statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and cardiac rehabilitation reduce events and mortality. Potential roadblocks may occur at the individual, healthcare provider, and health system levels and include lack of access to healthcare and medicines, clinical inertia, lack of primary care infrastructure or built environments that support preventive cardiovascular health behaviours. Possible solutions include improving health literacy, self-management strategies, national policies to improve lifestyle and access to secondary prevention medication (including fix-dose combination therapy), implementing rehabilitation programs, and incorporating digital health interventions. Digital tools are being examined in a range of settings from enhancing self-management, risk factor control, and cardiac rehab.

Conclusions

Effective strategies for secondary prevention management exist, but there are barriers to their implementation. WHF roadmaps can facilitate the development of a strategic plan to identify and implement local and national level approaches for improving secondary prevention.

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.

Exercise-based cardiac rehabilitation in women with heart failure: a review of enrollment, adherence, and outcomes

Exercise-based cardiac rehabilitation (CR) is an evidence-based recommendation for patients with stable heart failure (HF). Less clear is how effective exercise-based CR is for women with HF. The aim of this review was to synthesize the evidence for the effects of exercise-based CR on mortality, hospitalizations, exercise capacity, and quality of life (QOL) among women with HF. We identified 18 studies comprising 4917 patients, of which 1714 were women. The interventions evaluated consisted of various combinations of supervised in-hospital and out-patient sessions as well as home-based programs that included aerobic (walking, treadmill, bicycle) and resistance training. The interventions ranged from 12 to 54 weeks, with a frequency of 2-7 sessions per week, lasting from 30 to 105 min per session. Because of a paucity of sex-specific analyses of the outcomes, it was not possible to draw conclusions for women. There was limited evidence for mortality benefit for men or women participating in exercise-based CR. There was more substantial evidence for reductions in hospitalizations for the participants. Generally, exercise training improved exercise capacity. The effects of exercise-based CR on QOL were mixed with most studies favoring CR at 3 months but not at 4, 5, and 12 months. Moreover, generally, the physical dimension of QOL but not the mental dimensions improved. Recommendations for future research to reduce the gap in knowledge about the effects of exercise-based CR for women are offered.

Outpatient Attendance in COVID Pandemic Lockdown: An Observational Study

Objectives:

The objectives of this study were to analyze the profile of outpatient department (OPD) attendance of a tertiary care hospital during pre- and post-pandemic lockdown period.

Materials and Methods:

All consecutive patients presenting to OPD from August 1, 2019 to November 23, 2020 were included in the study. The sample was divided into Zone R (Regular domain) and Zone L (Lockdown domain). Zone L was divided into three groups A, B, and C; representing attendance to be <30%, 30–60%, and >60% of previous (i.e., Zone R), respectively. The patient gender, intradepartmental, and inter departmental OPD attendance data were collected and analyzed.

Results:

n = 428,322 patients attended the OPD in the study period. 301,586 patients presented in Zone R and 126,736 presented in Zone L (P = 0.000). Zone L recorded an OPD attendance drop to 42% of Zone R. The least attended an OPD (Group A) was ophthalmology, ENT, dermatology, surgery, and orthopedics versus highest attendance (Group C) was noticed in emergency OPD and oncology with a moderate decline in the rest (P = −0.00, 0.00, and 0.00, respectively). Both male and female attendance in the OPD showed a decline; however, the gender divide was apparent with significantly low women attendance in all the departments (P = 0.00).

Conclusion:

OPD attendance showed a significant reduction in COVID lockdown era hitting the non-emergent medical branches the most. The gender divide significantly widened with less female attendance recorded in most OPDs in pandemic lockdown. Apt administrative measures could prove fruitful by an improved OPD attendance and its psychosocial implications to a society with less disease burden.

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 Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 6: Sex- and Gender-Specific Diagnosis and Treatment

This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed.

Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost.

METHODS

Medline, PubMed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception through to May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. "Women-focused" CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women's preferences. No studies were excluded on the basis of outcome. Two independent reviewers rated citations for potential inclusion, and one extracted data, including on quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied.

RESULTS

3498 unique citations were identified, of which 28 studies (52 papers) were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with "usual care" comparisons. Compared to "active comparison" group, women-focused CR had no meaningful additional effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence) and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as scores on seven of the eight SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported a favorable economic impact and another reported reduced sick days.

CONCLUSIONS

Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed.

PROSPERO REGISTRATION

CRD42020189760.

Benchmarking Depressive Symptoms in Cardiac Rehabilitation

PURPOSE

Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both.

METHODS

Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified.

RESULTS

Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P< .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P< .05).

CONCLUSION

Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.

Factors Associated with Outpatient Cardiac Rehabilitation Participation in Older Patients: A Population-Based Study Using Claims Data from Two Cities in Japan

BACKGROUND

Although outpatient cardiac rehabilitation has been shown to be effective, the participation status of older cardiac patients is unclear in real-world settings. We investigated the proportion and associated factors of outpatient cardiac rehabilitation participation among older patients with heart diseases after cardiac intervention.

METHODS

We analyzed data from medical and long-term care insurance claims data from two municipalities in Japan. The data coverage period was between April 2014 and March 2019 in City A and between April 2012 and November 2016 in City B. We identified patients aged ≥65 years with post-operative acute myocardial infarction, angina pectoris, or heart valve disease. We estimated the proportion of cardiac rehabilitation participation and conducted logistic regression to identify factors (age, sex, type of cardiac disease, open-heart surgery, Charlson comorbidity index, long-term care need level, catecholamine use, inpatient cardiac rehabilitation, and hospital volume for cardiac rehabilitation) associated with outpatient cardiac rehabilitation participation.

RESULTS

A total of 690 patients were included in this study. The proportion of patients receiving outpatient cardiac rehabilitation was 9.0% overall. Multivariable logistic regression analysis suggested that men (adjusted OR 3.98; 95% CI 1.69-9.37), acute myocardial infarction (adjusted OR 2.76; 95% CI 1.20-6.36; reference angina pectoris), inpatient cardiac rehabilitation (adjusted OR 17.01; 95% CI 5.33-54.24), and "hospital volume" for cardiac rehabilitation (adjusted OR 4.35; 95% CI 1.14-16.57 for high-volume hospitals; reference low-volume hospital) were independently associated with outpatient cardiac rehabilitation.

CONCLUSIONS

The participation rate of outpatient cardiac rehabilitation among older post-operative cardiac patients was suboptimal. Further studies are warranted to examine its generalizability and whether a targeted approach to a group of patients who are less likely to receive outpatient cardiac rehabilitation could improve the participation rate.

Enhancing participation in cardiac rehabilitation: Focus on underserved populations

Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.

Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review

Background

Women do not participate in cardiac rehabilitation (CR) to the same degree as men; women-focused CR may address this. This systematic review investigated the: (1) nature, (2) availability, as well as (3a) utilization of, and (b) satisfaction with women-focused CR.

Methods

Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception to May 2020. Primary studies of any design were included. Adult females with any cardiac diseases, participating in women-focused CR (i.e., program or sessions included ≥ 50% females, or was 1-1 and tailored to women’s needs) were considered. Two authors rated citations for inclusion. One extracted data, including study quality rated as per the Mixed-Methods Assessment Tool (MMAT), which was checked independently by a second author. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guideline.

Results

3498 unique citations were identified, with 28 studies (53 papers) included (3697 women; ≥ 10 countries). Globally, women-focused CR is offered by 40.9% of countries that have CR, with 32.1% of programs in those countries offering it. Thirteen (46.4%) studies offered women-focused sessions (vs. full program), 17 (60.7%) were women-only, and 11 (39.3%) had gender-tailoring. Five (17.9%) programs offered alternate forms of exercise, and 17 (60.7%) focused on psychosocial aspects. With regard to utilization, women-focused CR cannot be offered as frequently, so could be less accessible. Adherence may be greater with gender-tailored CR, and completion effects are not known. Satisfaction was assessed in 1 trial, and results were equivocal.

Conclusions

Women-focused CR involves tailoring of content, mode and/or sex composition. Availability is limited. Effects on utilization require further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02267-0.

Underutilization of Cardiac Rehabilitation in Women: BARRIERS AND SOLUTIONS

PURPOSE

Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR.

REVIEW METHODS

The review examines original studies and meta-analyses regarding women in CR.

SUMMARY

Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR.

Cardiac rehabilitation and its essential role in the secondary prevention of cardiovascular diseases

Cardiovascular diseases are the most common causes of mortality worldwide. They are frequently the reasons for patient hospitalization, their incapability for work, and disability. These diseases represent a significant socio-economic burden affecting the medical system as well as patients and their families. It has been demonstrated that the etiopathogenesis of cardiovascular diseases is significantly affected by lifestyle, and so modification of the latter is an essential component of both primary and secondary prevention. Cardiac rehabilitation (CR) represents an efficient secondary prevention model that is especially based on the positive effect of regular physical activity. This review presents an overview of basic information on CR with a focus on current trends, such as the issue of the various training modalities, utilization, and barriers to it or the use of telemedicine technologies. Appropriate attention should be devoted to these domains, as CR continues evolving as an effective and readily available intervention in the future.

Factors Associated With Non-enrollment of Center-Based Cardiovascular Rehabilitation Program Among Transient Ischemic Attack or Mild Stroke Patients: A MIXED-METHOD RETROSPECTIVE STUDY

PURPOSE

Cardiovascular rehabilitation programs (CRPs) are effective in secondary stroke prevention, yet the enrollment rate is suboptimal. This study aims to identify demographic and clinical factors and patient-reported reasons for non-enrollment in a center-based outpatient CRP among patients with transient ischemic attack (TIA) or mild stroke.

METHODS

This mixed-method retrospective chart review was conducted in an outpatient CRP affiliated with a tertiary care hospital in Canada from January 2009 to October 2017. A total of 621 patients with TIA or mild stroke were included. Multiple logistic regression was used to determine the relationship between demographic and clinical predictors with non-enrollment. A thematic analysis of multidisciplinary progress notes was done for the non-enrollment subgroup of patients to understand the patient-reported reasons.

RESULTS

The non-enrollment rate was 42%. Travel distance to CRP (OR = 1.024; 95% CI, 1.010-1.038), age (OR = 1.023; 95% CI, 1.004-1.042), and current smoking status (OR = 1.935; 95% CI, 1.230-3.042) were associated with non-enrollment. The patient-reported reasons for non-enrollment were occurrence of new medical events and comorbidities, their perceptions of health and CRP, transportation, work/time conflict, and distance.

CONCLUSIONS

This study found that patients with TIA or mild stroke who were older, lived farther from the CRP center, or were current smokers were less likely to enroll in a CRP. The present findings may help clinicians identify patients unlikely to enroll in a CRP and allow the implementation of interventions focused on health education and physical activity to improve enrollment. Future research should validate these factors in multiple settings using prospective mixed methods so that interventions can be developed to address non-enrollment in the CRP.

Protein Intake and Physical Activity in Newly Diagnosed Patients with Acute Coronary Syndrome: A 5-Year Longitudinal Study

Cardiovascular disease is one of the most common causes of hospitalization and is associated with high morbidity and mortality rates. Among the most important modifiable and well-known risk factors are an unhealthy diet and sedentary lifestyle. Nevertheless, adherence to healthy lifestyle regimes is poor. The present study examined longitudinal trajectories (pre-event, 6-, 12-, 24-, 36-, and 60-month follow-ups) of protein intake (fish, legumes, red/processed meat) and physical activity in 275 newly-diagnosed patients with acute coronary syndrome. Hierarchical Generalized Linear Models were performed, controlling for demographic and clinical variables, the season in which each assessment was made, and the presence of anxiety and depressive symptoms. Significant changes in protein intake and physical activity were found from pre-event to the six-month follow-up, suggesting the adoption of healthier behaviors. However, soon after the six-month follow-up, patients experienced significant declines in their healthy behaviors. Both physical activity and red/processed meat intake were modulated by the season in which the assessments took place and by anxiety symptoms over time. The negative long-term trajectory of healthy behaviors suggests that tailored interventions are needed that sustain patients’ capabilities to self-regulate their behaviors over time and consider patient preference in function of season.

Heart up! RCT protocol to increase physical activity in cardiac patients who report hopelessness: Amended for the COVID-19 pandemic

Hopelessness is associated with decreased physical activity (PA) and increased adverse events and death in patients with ischemic heart disease (IHD). Rates of PA in patients with IHD continue to be low in both hospital-based cardiac rehabilitation and home settings. While researchers have investigated strategies to increase PA among patients with IHD, interventions to promote PA specifically in IHD patients who report hopelessness are lacking. We describe the protocol for a NIH-funded randomized controlled trial designed to establish the effectiveness of a 6-week intervention (Heart Up!) to promote increased PA in IHD patients who report hopelessness. Participants (n = 225) are randomized to one of three groups: (1) motivational social support (MSS) from a nurse, (2) MSS from a nurse plus significant other support (SOS), or (3) attention control. Aims are to: (1) test the effectiveness of 6 weeks of MSS and MSS with SOS on increasing mean minutes per day of moderate to vigorous PA; (2) determine the effects of change in moderate to vigorous PA on hopelessness; and (3) determine if perceived social support and motivation (exercise self-regulation) mediate the effects of the intervention on PA. A total of 69 participants have been enrolled to date. The protocol has been consistently and accurately used by research personnel. We address the protocol challenges presented by the COVID-19 pandemic and steps taken to maintain fidelity to the intervention. Findings from this study could transform care for IHD patients who report hopelessness by promoting self-management of important PA goals that can contribute to better health outcomes.

A Mobile Health Intervention System for Women With Coronary Heart Disease: Usability Study

Background

Coronary heart disease (CHD) is the leading cause of death and disability among American women. The prevalence of CHD is expected to increase by more than 40% by 2035. In 2015, the estimated cost of caring for patients with CHD was US $182 billion in the United States; hospitalizations accounted for more than half of the costs. Compared with men, women with CHD or those who have undergone coronary revascularization have up to 30% more rehospitalizations within 30 days and up to 1 year. Center-based cardiac rehabilitation is the gold standard of care after an acute coronary event, but few women attend these valuable programs. Effective home-based interventions for improving cardiovascular health among women with CHD are vital for addressing this gap in care.

Objective

The ubiquity of mobile phones has made mobile health (mHealth) behavioral interventions a viable option to improve healthy behaviors of both women and men with CHD. First, this study aimed to examine the usability of a prototypic mHealth intervention designed specifically for women with CHD (herein referred to as HerBeat). Second, we examined the influence of HerBeat on selected health behaviors (self-efficacy for diet, exercise, and managing chronic illness) and psychological (perceived stress and depressive symptoms) characteristics of the participants.

Methods

Using a single-group, pretest, posttest design, 10 women participated in the 12-week usability study. Participants were provided a smartphone and a smartwatch on which the HerBeat app was installed. Using a web portal dashboard, a health coach monitored participants’ ecological momentary assessment data, their behavioral data, and their heart rate and step count. Participants then completed a 12-week follow-up assessment.

Results

All 10 women (age: mean 64.4 years, SD 6.3 years) completed the study. The usability and acceptability of HerBeat were good, with a mean system usability score of 83.60 (SD 16.3). The participants demonstrated statistically significant improvements in waist circumference (P=.048), weight (P=.02), and BMI (P=.01). Furthermore, depressive symptoms, measured with the Patient Health Questionnaire-9, significantly improved from baseline (P=.04).

Conclusions

The mHealth prototype was feasible and usable for women with CHD. Participants provided data that were useful for further development of HerBeat. The mHealth intervention is expected to help women with CHD self-manage their health behaviors. A randomized controlled trial is needed to further verify the findings.

Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement

BACKGROUND

Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its' benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations.

METHODS

The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment.

RESULTS

The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95 ± 0.69 (mean ± standard deviation), 5.33 ± 1.12 and 5.64 ± 1.08, respectively.

CONCLUSIONS

Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis

Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13⁻1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20⁻0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36⁻0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02⁻1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion.

Interventions to promote patient utilisation of cardiac rehabilitation

BACKGROUND

International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation.

OBJECTIVES

First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations.

SEARCH METHODS

Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics.

MAIN RESULTS

Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.

AUTHORS' CONCLUSIONS

Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

Effectiveness of a Tailored Lifestyle Management Program for Middle-Aged Women With Coronary Artery Disease: A Preliminary Study

BACKGROUND

Coronary artery disease (CAD) is a leading cause of death in women. Many of the risk factors for CAD relate to lifestyle and thus may be influenced by lifestyle modification. However, middle-aged women often find it difficult to adjust their lifestyle behaviors. Thus, providing individualized treatment is crucial to reducing the risk and incidence of CAD in this population.

PURPOSE

The aim of this study was to explore the effectiveness of a tailored lifestyle management program (TLMP) for middle-aged women with CAD.

METHODS

An experimental design was employed. Thirty-five middle-aged women with CAD (with stenosis [> 50%] of at least one main artery as determined by cardiac catheterization examination results) were recruited. The 35 women were randomlyassigned to the experimental group (n = 17) or the control group (n = 18). Both groups received regular health education during their hospitalization. After discharge, the experimental group received the 12-week, home-based TLMP. A generalized estimating equation was used to examine the effects of the TLMP on metabolic and biomarker indicators for CAD.

RESULTS

The average age of participants was 56.1 ± 5.6 years. No significant demographic differences were identified between the two groups. Compared with the control group, the experimental group had a significantly higher high-density lipoprotein level (B = 7.83, p < .001), a lower level of total cholesterol (B = -49.21, p = .04), and a lower waist circumference (B = -6.42, p < .001).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This study suggests that using tailored interventions is an effective approach to improving high-density lipoprotein, total cholesterol, and waist circumference in middle-aged women with CAD. This result is expected to have important implications for women's healthcare, particularly in terms of preventing the incidence of CAD.

Intention, beliefs and mood assessed using electronic diaries predicts attendance at cardiac rehabilitation: An observational study

BACKGROUND

Cardiac rehabilitationis effective in promoting physical/psychological recovery following acute coronary syndrome. Yet, rates of attendance at outpatient cardiac rehabilitation by eligible patients are low.

OBJECTIVES

This study examined the determinants of attendance at outpatient cardiac rehabilitation in acute coronary syndrome patients following discharge until cardiac rehabilitation commencement.

DESIGN

A weekly electronic diary measured cardiac-related cognitions and mood and examined their relation to attendance at outpatient cardiac rehabilitation.

SETTINGS

Three United Kingdom National Health Service secondary care settings in two Health Board areas in Scotland.

PARTICIPANTS

Acute coronary syndrome patients were recruited from March 2012 to June 2013 prior to hospital discharge. Of 488 eligible patients referred for cardiac rehabilitation, 214 consented.

METHODS

Consecutive patients completed a pre-hospital discharge questionnaire targeting age, diagnosis, social class and smoking history. Acute coronary syndrome patients then completed a weekly electronic diary from the first week of discharge until the start of cardiac rehabilitation. Multilevel structural equation models estimated the effects of initial, i.e. baseline and rate of change in cardiac-related cognition and mood on attendance. Intention to attend cardiac rehabilitation was reflected, log transformed, reported thereafter as "do not intend". The role of "do not intend" was explored as a mediator of the relationship between cardiac-related cognition and mood on attendance.

RESULTS

166 participants provided, on average, 5 weeks of diary entries before cardiac rehabilitation commenced. High intention (i.e. low "do not intend") to attend CR and its rate of increase over time predicted attendance. Low negative emotional representation, high perceived necessity, high confidence in maintaining function, low negative affect, and high positive affect following discharge predicted attendance at cardiac rehabilitation. The rate of change in cardiac-related mood and these cognitions was not predictive. Baseline and rate of change in "do not intend" entirely mediated relationships between a) perceived necessity, b) negative affect and attendance at cardiac rehabilitation.

CONCLUSIONS

Negative affect in the first weeks following discharge represents the key challenge to a patient maintaining their intention to attend cardiac rehabilitation. Intervention to improve attendance should focus on improving intention to attend following discharge and during recovery by improving patient understanding of cardiac rehabilitation and reducing negative affect.

Optimal Gender-Specific Strategies for the Secondary Prevention of Heart Disease in Women: A SYSTEMATIC REVIEW

BACKGROUND

There is a paucity of evidence on gender-specific, individually tailored secondary prevention (cardiac rehabilitation [CR]) services for women with heart disease. Women participate less in CR programs, thus increasing their risk of further cardiac events. This review aims to (1) determine the effectiveness of gender-specific interventions specifically designed for women with heart disease, delivered in outpatient CR settings; and (2) classify key elements of effective CR strategies/models for women with heart disease.

METHODS

Using the PRISMA guidelines, this is a systematic review of CR models tailored to women to improve cardiovascular risk. Four databases were searched for randomized controlled trials (RCTs) between January 1974 and July 2017 published in peer-reviewed English language journals.

RESULTS

Three RCTs comprising 725 women of gender-specific CR strategies were identified. Significant improvements were found in one-third (1 study) of the included multicomponent CR strategies for outcomes including general health, social functioning, vitality, mental health, depression, and quality of life.

CONCLUSION

Further large-scale RCTs are required to replicate positive findings and accurately assess the capacity for gender-specific multicomponent CR programs that incorporate participant-driven collaborative models to moderate psychological risk and improve functional capacity and quality of life for women with heart disease.

Gender differences in the factors predicting initial engagement at cardiac rehabilitation

Objective

To determine whether there are gender differences in the factors that predict attendance at the initial cardiac rehabilitation baseline assessment (CR engagement) after referral.

Methods

Using data from the National Audit of Cardiac Rehabilitation, we analysed data on 95 638 patients referred to CR following a cardiovascular diagnosis/treatment between 2013 and 2016. Eighteen factors that have been shown in previous research to be important predictors of CR participation were investigated and grouped into four categories: sociodemographic factors, cardiac risk factors, patient medical status and service-level factors. Logistic binary regression models were built for male patients and female patients, assessing the likelihood for CR engagement. Each included predictors such as age, number of comorbidities and social deprivation score.

Results

There were no important differences in the factors that predict the likelihood of CR engagement in men and women. Seven factors associated with a reduced probability of CR engagement, and eight factors associated with increased probability, were identified. Fourteen of the 15 factors identified as predicting the likelihood for engagement/non-engagement were the same for both men and women. Increasing age, being South Asian or non-white ethnicity (other than Black) and being single were all associated with a reduced likelihood of attending an initial CR baseline assessment in both men and women. Male patients with diabetes were 11% less likely to engage with CR; however, there was no significant association in women. Results showed that the overwhelmingly important determinant of CR engagement observed in both men and women was receiving an invitation to attend an assessment session (OR 4.223 men/4.033women; p<0.05).

Conclusions

Consideration of gender differences in predictors of CR uptake should probably be more nuanced and informed by the stage of the patient care pathway.

Disparities in Cardiac Rehabilitation Among Individuals from Racial and Ethnic Groups and Rural Communities-A Systematic Review

PURPOSE

Despite the well-described benefits of cardiac rehabilitation (CR) on long-term health outcomes, CR is a resource that is underutilized by a significant proportion of patients that suffer from cardiovascular diseases. The main purpose of this study was to examine disparities in CR referral and participation rates among individuals from rural communities and racial and ethnic minority groups with coronary heart disease (CHD) when compared to the general population.

METHODS

A systematic search of standard databases including MedlLine, PubMed, and Cochrane databases was conducted using keywords that included cardiac rehabilitation, women, race and ethnicity, disparities, and rural populations. Twenty-eight clinical studies from 1990 to 2017 were selected and included 478,955 patients with CHD.

RESULTS

The majority of available clinical studies showed significantly lower CR referral and participation rates among individuals from rural communities, women, and racial and ethnic groups when compared to the general population. Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs. Patients of lower SES have significantly lower CR referral and participation rates than patients of higher SES.

CONCLUSIONS

Data presented underscores the need for systematic referrals using electronic health records for patients with CHD in order to increase overall CR referral and participation rates of minority populations and other vulnerable groups. Educational programs that target healthcare provider biases towards racial and ethnic groups may help attenuate observed disparities. Alternative modalities such as home-based and internet-based CR programs may also help improve CR participation rates among vulnerable populations.

Stability and change of lifestyle profiles in cardiovascular patients after their first acute coronary event

Background

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality. Lifestyle and health behavior changes play an important role in the primary and secondary prevention of ACS recurrence. Changes in unhealthy lifestyles after an acute coronary event have been analyzed by considering separate behaviors individually, even though research on the healthy population has demonstrated that unhealthy behaviors tend to co-occur.

Purpose

The aim of this study was to identify lifestyle profiles of ACS patients and to explore their pathways of change for one year after their first coronary event by adopting a typological approach.

Methods

Two hundred and twenty-three patients (84% male; mean age = 57.14) completed self-report measures of health-related behaviors at the beginning of cardiac rehabilitation, and six months and twelve months after. At each wave depression, anxiety and heart rate were also evaluated. Cluster analysis was performed to identify lifestyle profiles and to analyze their change over time. Differences in psychological factors and heart rate among clusters were assessed.

Results

Patients' diet, physical activity, and smoking behavior greatly improved six months after their first coronary event. No further improvements were detected after one year. At each wave specific lifestyle profiles were identified, ranging from more maladaptive to healthier clusters. Patients with multiple unhealthy behaviors experience greater difficulties in maintaining a healthier lifestyle over time. Moreover, the results demonstrated the association between lifestyle profiles at twelve months after the acute coronary event and depression measured six months earlier. Finally, the most maladaptive lifestyle profile had many members with elevated heart rate at twelve months after the cardiac rehabilitation.

Conclusions

Current findings may have a strong practical impact in the development and implementation of personalized secondary prevention programs targeting lifestyles of ACS patients.

Cardiac Rehabilitation Following Acute Coronary Syndrome in Women

OPINION STATEMENT

Acute coronary syndrome (ACS) is among the leading burdens of disease among women. It is a significant driver of morbidity and chronically undermines their quality of life. Cardiac rehabilitation (CR) is indicated for ACS patients in clinical practice guidelines, including those specifically for women. CR is a multi-component model of care, proven to reduce mortality and morbidity, including in women. However, women are significantly less likely to be referred to CR by providers, and if they are referred, to enroll and adhere to programs. Reasons include lack of physician encouragement, preference not to feel fatigue and pain, transportation barriers, comorbidities and caregiving obligations. Strategies to mitigate this under-use include systematic early inpatient referral, tailoring programs to meet women's needs and preferences (e.g., offering dance, opportunities for social interaction), and offering non-supervised delivery models. Unfortunately, these strategies are not widely available to women. Given the greater longevity seen in women, the critical role CR plays in augmenting quality of life in this population must be recognized and care providers must do more to facilitate referral to and encourage participating in CR programs.

Between mind and heart: Sex-based cognitive bias in cardiovascular disease treatment

Given that both men and women experience cardiovascular disease (CVD), a common misconception is that they have similar risk factors and clinical presentation, receive comparable treatment, and have equivalent clinical outcomes; in reality differences are observed between men and women for each of these endpoints. Moreover, these differences occur as a function of both gender and sex. A review of the literature reveals widespread bias in the selection of research subjects based on these factors, in addition to implicit patient and provider biases that impede the access of women to recommended primary and secondary CVD management. In this perspective, we identify strategies to eliminate such biases and improve women's access to CVD treatments to ensure their care is consistent with current guidelines.

Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions

Cardiac rehabilitation (CR) services improve various clinical outcomes in patients with cardiovascular disease, but such services are underutilized, particularly in women. The aim of this study was to identify evidence-based barriers and solutions for CR participation in women. A literature search was carried out using PubMed, EMBASE, Cochrane, OVID/Medline, and CINAHL to identify studies that have assessed barriers and/or solutions to CR participation. Titles and abstracts were screened, and then the full-text of articles that met study criteria were reviewed. We identified 24 studies that studied barriers to CR participation in women and 31 studies that assessed the impact of various interventions to improve CR referral, enrollment, and/or completion of CR in women. Patient-level barriers included lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. We found support for the use of automatic referral and assisted enrollment to improve CR participation. A small number of studies suggest that incentive-based strategies, as well as home-based programs, may contribute to improving CR attendance and completion rates. A systematic approach to CR referral, including automatic CR referral, may help overcome barriers to CR referral in women and should be implemented in clinical practice. However, more studies are needed to help identify the best methods to improve CR attendance and completion of CR rates in women.

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial

OBJECTIVE

To compare program adherence and functional capacity between women referred to supervised mixed-sex, supervised women-only, or home-based cardiac rehabilitation (CR).

PATIENTS AND METHODS

Cardiac Rehabilitation for Heart Event Recovery (CR4HER) was a single-blind, 3 parallel-arm, pragmatic randomized controlled trial. The study took place between November 1, 2009, and July 31, 2013. Low-risk patients with coronary artery disease were recruited from 6 hospitals in Ontario, Canada. Consenting participants completed a preprogram survey, and clinical data were extracted from charts. Participants were referred to CR at 1 of 3 sites. After intake assessment, including a graded exercise stress test, eligible patients were randomized to supervised mixed-sex, supervised women-only, or home-based CR. Six months later, CR adherence and exit assessment data were ascertained.

RESULTS

Of the 264 consenting patients, 169 (64.0%) were eligible and randomized. Twenty-seven (16.0%) did not attend, and 43 (25.4%) attended a different model. Program adherence was moderate overall (54.46%±35.14%). Analysis of variance revealed no significant differences based on per-protocol analysis (P=.63), but as-treated, home-based participants attended significantly more than did women-only participants (P<.05). Overall, there was a significant increase in functional capacity preprogram to postprogram (P<.001). Although there were no significant differences in functional capacity by model at CR exit based on per-protocol analysis, there was a significant difference on an as-treated basis, which sustained adjustment. Women attending mixed-sex CR attained significantly higher post-CR functional capacity than did women attending home-based programs (P<.05).

CONCLUSION

Offering women alternative program models may not promote greater CR adherence or functional capacity; however, replication is warranted. Other proven strategies such as action planning and self-monitoring should be applied.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01019135.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Biopsychosocial health disparities among young women enrolled in cardiac rehabilitation

PURPOSE

Our aim was to compare the biopsychosocial characteristics of young women with those of older women who were enrolled in cardiac rehabilitation (CR). The baseline characteristics of women who prematurely terminated CR participation were also explored.

METHODS

Baseline physiological and psychosocial indices of women ≤ 55 years compared with older women eligible for CR were evaluated 1 week before enrolling in either a traditional CR or a gender-specific, motivationally enhanced CR.

RESULTS

A greater proportion of young women (n = 65) compared with their older counterparts (n = 187) were diagnosed with acute myocardial infarction during their index hospitalization. They demonstrated lower high-density lipoprotein cholesterol, higher total cholesterol/high-density lipoprotein cholesterol ratios, and greater body weight compared with older women and were more likely to be active smokers. Young women compared with older women reported significantly worse health perceptions, quality of life, optimism, hope, social support, and stress and significantly more symptoms of depression and anxiety. Women who prematurely terminated CR participation were younger, more obese, with worse quality of life, and greater symptoms of depression and anxiety compared with women completing CR.

CONCLUSIONS

Notable differences in physiological and psychosocial profiles of young women compared with older women enrolled in CR were evident, placing them at high risk for nonadherence to secondary prevention interventions as well as increased risk for disease progression and subsequent cardiac adverse events. Continued existence of these health differentials represents an important public health problem and warrants further research to address these age-related and sex-specific health disparities among women with coronary heart disease.

Smoking and cardiac rehabilitation participation: Associations with referral, attendance and adherence

OBJECTIVE

Continued smoking after a cardiac event greatly increases mortality risk. Smoking cessation and participation in cardiac rehabilitation (CR) are effective in reducing morbidity and mortality. However, these two behaviors may interact; those who smoke may be less likely to access or complete CR. This review explores the association between smoking status and CR referral, attendance, and adherence.

METHODS

A systematic literature search was conducted examining associations between smoking status and CR referral, attendance and completion in peer-reviewed studies published through July 1st, 2014. For inclusion, studies had to report data on outpatient CR referral, attendance or completion rates and smoking status had to be considered as a variable associated with these outcomes.

RESULTS

Fifty-six studies met inclusion criteria. In summary, a history of smoking was associated with an increased likelihood of referral to CR. However, smoking status also predicted not attending CR and was a strong predictor of CR dropout.

CONCLUSION

Continued smoking after a cardiac event predicts lack of attendance in, and completion of CR. The issue of smoking following a coronary event deserves renewed attention.

Transtheoretical Model-based Nursing Intervention on Lifestyle Change: A Review Focused on Intervention Delivery Methods

PURPOSE

The transtheoretical model (TTM) was used to provide tailored nursing for lifestyle management such as diet, physical activity, and smoking cessation. The present study aims to assess the provision of intervention delivery methods, intervention elements, and stage-matched interventions, in order to identify ways in which information technology is used in the TTM-based research.

METHODS

The relevant literature was selected by two researchers using inclusion criteria after searching for "TTM (transtheoretical or stage of change)" and "nursing" from the databases PubMed and CINAHL. The selected studies were categorized in terms of study characteristics, intervention delivery method, intervention element, and use and level of stage-matched intervention.

RESULTS

A total of 35 studies were selected including eight studies that used information communication technology (ICT). Nine different intervention delivery methods were used, of which "face-to-face" was the most common at 24 times. Of the 35 studies, 26 provided stage-matched interventions. Seven different intervention elements were used, of which "counseling" was the most common at 27 times. Of all the intervention elements, tailored feedback used ICT the most at seven instances out of nine, and there was a significant difference in the rate of ICT usage among intervention elements.

CONCLUSIONS

ICT is not yet actively used in the TTM-based nursing interventions. Stage-matched interventions and TTM concepts were shown to be in partial use also in the TTM-based interventions. Therefore, it is necessary to develop a variety of ways to use ICT in tailored nursing interventions and to use TTM frameworks and concepts.

Women's preferences for cardiac rehabilitation program model: a randomized controlled trial

BACKGROUND

Although cardiac rehabilitation (CR) is effective, women often report programs do not meet their needs. Innovative models have been developed that may better suit women. The objectives of the study were to describe: (1) adherence to CR model allocation; (2) satisfaction by model attended; and (3) CR preferences.

DESIGN AND METHODS

Tertiary objectives from a randomized controlled trial of female patients randomized to mixed-sex, women-only, or home-based CR were tested. Patients were recruited from six hospitals. Consenting participants were asked to complete a survey and undertook a CR intake assessment. Eligible patients were randomized. Participants were mailed a follow-up survey six months later. Adherence to model allocation was ascertained from CR charts.

RESULTS

Overall 169 (18.6%) patients were randomized, of which 116 (68.6%) completed the post-test survey. Forty-five (26.6%) participants did not receive the allocated model, with those referred to home-based CR least likely to attend the allocated model (n = 25; 45.4%). Semi-structured interviews revealed participants also often switched from women-only to mixed-sex CR due to time conflicts. Satisfaction was high across all models (mean = 4.23 ± 1.16/5; p = 0.85) but participants in the women-only program felt significantly more comfortable in their workout attire (p = 0.003) and perceived the environment as less competitive (p = 0.02). Patients equally preferred mixed-sex (n = 44, 41.9%) and women-only (n = 44, 41.9%) CR, over home-based (n = 17, 16.2%), with patients preferring the model they attended.

CONCLUSION

Females were highly satisfied regardless of CR model attended but preferred supervised programs most. Patient preference and session timing should be considered in program model allocation decisions.

Improvements in heart rate recovery among women after cardiac rehabilitation completion

BACKGROUND

Heart rate recovery (HRR) after exercise cessation is thought to reflect the rate of reestablishment of parasympathetic tone. Relatively little research has focused on improved HRR in women after completing cardiac rehabilitation (CR) exercise training.

OBJECTIVE

We examined the influence of exercise training on HRR in women completing a traditional CR program and in women completing a CR program tailored for women.

METHODS

A 2-group randomized clinical trial compared HRR between 99 women completing a traditional 12-week CR program and 137 women completing a tailored CR program. Immediately upon completion of a symptom-limited graded exercise test, HRR was measured at 1 through 6 minutes.

RESULTS

Compared with baseline, improvement in 1-minute HRR (HRR1) was similar (P = 0.777) between the tailored (mean [SD], 17.5 [11] to 19.1 [12]) and the traditional CR program (15.7 [9.0] to 16.9 [9.5]). The amount of change in the 2-minute HRR (HRR2) for the tailored (30 [13] to 32.8 [14.6]) and traditional programs (28.3 [12.8] to 31.2 [13.7]) also was not different (P = 0.391). Similar results were observed for HRR at 3 through 6 minutes. Given these comparable improvements of the 2 programs, in the full cohort, the factors independently predictive of post-CR HRR1, in rank order, were baseline HRR1 (part correlation, 0.35; P < 0.001); peak exercise capacity, estimated as metabolic equivalents (METs; 0.24, P < 0.001); anxiety (-0.17, P = 0.001); and age (-0.13, P = 0.016). The factors independently associated with post-CR HRR2 were baseline HRR2 (0.44, P < 0.001), peak METs (0.21, P < 0.001), and insulin use (-0.10, P = 0.041).

CONCLUSIONS

One to 6 minutes after exercise cessation, HRR was significantly improved among the women completing both CR programs. The modifiable factors positively associated with HRR1 included peak METs and lower anxiety, whereas HRR2 was associated with insulin administration and peak METs. Additional research on HRR after exercise training in women is warranted.

Promoting patient uptake and adherence in cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review.

OBJECTIVES

To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation.

SEARCH METHODS

We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions.

SELECTION CRITERIA

Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome.

DATA COLLECTION AND ANALYSIS

At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias.

MAIN RESULTS

The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization.

AUTHORS' CONCLUSIONS

We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed.