Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation

Smartphone-based gamification intervention to increase physical activity participation among patients with coronary heart disease: A randomized controlled trial

INTRODUCTION

Despite proven benefits, patients with coronary heart disease (CHD) typically fail to participate in sufficient physical activity (PA). Effective interventions should be implemented to help patients maintain a healthy lifestyle and modify their present behavior. Gamification is the use of game design features (such as points, leaderboards, and progress bars) to improve motivation and engagement. It shows the potential for encouraging patients to engage in PA. However, empirical evidence on the efficacy of such interventions among patients with CHD is still emerging.

PURPOSE

The aim of the study is to explore whether a smartphone-based gamification intervention could increase PA participation and other physical and psychological outcomes in CHD patients.

METHODS

Participants with CHD were randomly assigned to three groups (control group, individual group, and team group). The individual and team groups received gamified behavior intervention based on behavioral economics. The team group combined gamified intervention with social interaction. The intervention lasted for 12 weeks, and the follow-up was12 weeks. The primary outcomes included the change in daily steps and the proportion of patient days that step goals were achieved. The secondary outcomes included competence, autonomy, relatedness, and autonomous motivation.

RESULTS

For the individual group, smartphone-based gamification intervention significantly increased PA among CHD patients over the 12-week period (step count difference 988; 95% CI 259-1717; p < 0.01) and had a good maintenance effect during the follow-up period (step count difference 819; 95% CI 24-1613; p < 0.01). There are also significant differences in competence, autonomous motivation, body mass index (BMI), and waist circumference in 12 weeks between the control group and individual group. For the team group, gamification intervention with collaboration didn't result in significant increases in PA. But patients in this group had a significant increase in competence, relatedness, and autonomous motivation.

CONCLUSION

A smartphone-based gamification intervention was proven to be an effective way to increase motivation and PA engagement, with a substantial maintenance impact (Chinese Clinical Trial Registry Identifier: ChiCTR2100044879).

Determinants of Sexual Health and Sexual Quality of Life after Cardiovascular Surgeries: An Integrative Review

BACKGROUND AND AIM

Sexual health and sexual quality of life are key components of psychosocial adjustment after cardiac surgeries and are often linked with improving the general quality of life. Reviews have been conducted to highlight the associations between cardiovascular diseases and sexual dysfunctions, but no review reported determinants of sexual health and sexual quality of life in patients after cardiovascular surgeries. We aimed to comprehensively examine the determinants of sexual health and sexual quality of life among individuals with cardiovascular surgeries.

METHODS

Literature was searched within PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 816 records were identified from database searches, 279 records were screened, and 11 empirical studies were included for review. Relevant data were extracted using literature summary tables and synthesised using an inductive approach.

RESULTS

The core determinants of sexual health and sexual quality of life were type of surgery and comorbidities, fears and uncertainties regarding sexual activity, sexual health education and counselling, spousal relationship and communication, and demographic factors such as advanced age and literacy levels. Major surgeries performed were coronary artery bypass grafting (CABG) and heart valve surgeries. The data collection tools used to collect data for sexual health and sexual quality of life were the International Erectile Function Questionnaire (IEFQ), International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), Sexual Knowledge CABG Scale (SKS-CABG), Sexual Quality of Life Questionnaire (SQOL), SKS-Myocardial Infarction Scale (SKS-MI), and Couple Communication Scale (CCS).

CONCLUSIONS

Despite their importance, sexual health and quality of life are frequently overlooked during patient rehabilitation after cardiovascular surgeries. The lack of adequate education and counselling from healthcare professionals frequently leads to increased fear and uncertainties among individuals and their partners. Therefore, more person-centred educational and counselling approaches should be developed to address the sexual concerns of individuals and their partners.

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Combined Exercise and Mindset Training During a Pediatric Cardiac Fitness and Rehabilitation Program Benefits Youth with a Range of Congenital Heart Disease

Pediatric cardiac fitness and rehabilitation programs vary widely in structure and content. The Cardiac Fitness Program (CFP) is built on traditional training pillars of aerobic, strength, and flexibility, and adds a fourth, training a positive mindset. This study assesses whether the systematic and comprehensive framework of the CFP results in broad benefits for a range of patients with congenital heart disease (CHD). Data from participants between 01/2017 and 12/2022 were analyzed. Pre- and post-CFP cardiopulmonary exercise test parameters, strength and flexibility metrics, and mindset survey results were compared overall, and by sex, age, diagnosis, and hemodynamic level. Of 62 participants (median age 15.5 years, range 8 to 23, 50% female), 3% had simple, 37% complex, 24% single ventricle CHD, and 35% arrhythmia, cardiomyopathy, or transplant. Significant improvements were noted in aerobic fitness (mean 9 ± 15% increase in % predicted peak oxygen consumption, p < 0.001). Strength metrics significantly improved (each p < 0.001), as did flexibility (p < 0.001). Patient-reported positive mindset scores did not improve significantly (mean increase 1.8 ± 5.1, p = 0.10, n = 25), whereas parents reported significant improvements (5.9 ± 10.4, p = 0.02, n = 20). Improvements were not significantly different by sex, age, diagnosis, or hemodynamic level. Comprehensive training across four pillars of fitness yields significant improvements in aerobic fitness, strength, flexibility, and parent-reported mindset scores for pediatric CHD patients, regardless of patient characteristics, diagnosis type, or severity of hemodynamic limitation. Further study is warranted into optimal standardization of training and whether a comprehensive approach amplifies individual pillars to create more than the sum of its parts.

Acute Coronary Syndrome in Women: An Update

PURPOSE OF REVIEW

The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS).

RECENT FINDINGS

This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.

Relevance of the Get Active Questionnaire for Pre-Participation Exercise Screening in the General Population in a Tropical Environment

The Get Active Questionnaire (GAQ), developed by the Canadian Society for Exercise Professionals (CSEP), was recently recommended for pre-participation screening of the general population in Singapore before increasing their exercise levels. This literature review examines the evidence behind the GAQ and its relevance to our tropical environment. Searches were carried out via Pubmed, MEDLINE and the Cochrane Central Register of Controlled Trials. Resources referenced by the CSEPs were hand searched. The CSEP was also contacted for further information. The evidence behind each GAQ question was compared to international literature and guidelines, where applicable. Out of 273 studies, 49 were suitable for analysis. Two GAQ studies commissioned by the CSEP showed a high negative predictive value but high false negative rate. Of the nine GAQ questions, those on dizziness, joint pains and chronic diseases appear to be justified. Those on heart disease/stroke, hypertension, breathlessness and concussion require modification. The one on syncope can be amalgamated into the dizziness question. The remaining question may be deleted. No long-term studies were available to validate the use of the GAQ. Heat disorders were not considered in the GAQ. Modification of the GAQ, including the inclusion of environmental factors, may make it more suitable for the general population and should be considered.

Predictors of Health-Related Quality of Life Among Women Participating in an Appointment-Based Cardiac Rehabilitation Program

BACKGROUND

An alternative patient-centered appointment-based cardiac rehabilitation (CR) program has led to significant improvements in health outcomes for patients with cardiovascular disease. However, less is known about the effects of this approach on health-related quality of life (HRQoL), particularly for women.

OBJECTIVE

We examined the effects of a patient-centered appointment-based CR program on HRQoL by sex and examined predictors of HRQoL improvements specifically for women.

METHODS

Data were used from an urban single-center CR program at Yale New Haven Health (2012-2017). We collected information on patient demographics, socioeconomic status, and clinical characteristics. The Outcome Short-Form General Health Survey (SF-36) was used to measure HRQoL. We evaluated sex differences in SF-36 scores using t tests and used a multivariate linear regression model to examine predictors of improvements in HRQoL (total SF-36 score) for women.

RESULTS

A total of 1530 patients with cardiovascular disease (23.7% women, 4.8% Black; mean age, 64 ± 10.8 years) were enrolled in the CR program. Women were more likely to be older, Black, and separated, divorced, or widowed. Although women had lower total SF-36 scores on CR entry, there was no statistically significant difference in CR adherence or total SF-36 score improvements between sexes. Women who were employed and those with chronic obstructive pulmonary disease were more likely to have improvements in total SF-36 scores.

CONCLUSION

Both men and women participating in an appointment-based CR program achieved significant improvements in HRQoL. This approach could be a viable alternative to conventional CR to optimize secondary outcomes for patients.

Cardiac Rehabilitation During the COVID-19 Pandemic and the Potential for Digital Technology to Support Physical Activity Maintenance: Qualitative Study

BACKGROUND

Social distancing from the COVID-19 pandemic may have decreased engagement in cardiac rehabilitation (CR) and may have had possible consequences on post-CR exercise maintenance. The increased use of technology as an adaptation may benefit post-CR participants via wearables and social media. Thus, we sought to explore the possible relationships of both the pandemic and technology on post-CR exercise maintenance.

OBJECTIVE

This study aimed to (1) understand CR participation during the COVID-19 pandemic, (2) identify perceived barriers and facilitators to physical activity after CR completion, and (3) assess willingness to use technology and social media to support physical activity needs among older adults with cardiovascular disease.

METHODS

We recruited participants aged 55 years and older in 3 different CR programs offered at both public and private hospitals in Northern California. We conducted individual interviews on CR experiences, physical activity, and potential for using technology. We used thematic analysis to synthesize the data.

RESULTS

In total, 22 participants (n=9, 41% female participants; mean age 73, SD 8 years) completed in-depth interviews. Themes from participants' feedback included the following: (1) anxiety and frustration about the wait for CR caused by COVID-19 conditions, (2) positive and safe participant experience once in CR during the pandemic, (3) greater attention needed to patients after completion of CR, (4) notable demand for technology during the pandemic and after completion of CR, and (5) social media networking during the CR program considered valuable if training is provided.

CONCLUSIONS

Individuals who completed CR identified shared concerns about continuing physical activity despite having positive experiences during the CR program. There were significant challenges during the pandemic and heightened concerns for safety and health. The idea of providing support by leveraging digital technology (wearable devices and social media for social support) resonated as a potential solution to help bridge the gap from CR to more independent physical activity. More attention is needed to help individuals experience a tailored and safe transition to home to maintain physical activity among those who complete CR.

A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation

OBJECTIVE

The aim of this study was to systematically review the impact and characteristics of interventions with an educational component designed to improve enrollment and participation in cardiac rehabilitation (CR) among patients with cardiovascular disease.

REVIEW METHODS

Five electronic databases were searched from data inception to February 2023. Randomized controlled trials and controlled, cohort, and case-control studies were considered for inclusion. Title, abstract, and full text of records were screened by two independent reviewers. The quality of included studies was rated using the Mixed Methods Assessment Tool. Results were analyzed in accordance with the Synthesis Without Meta-analysis reporting guideline.

RESULTS

From 7601 initial records, 13 studies were included, six of which were randomized controlled trials ("high" quality = 53%). Two studies evaluated interventions with an educational component for health care providers (multidisciplinary team) and 11 evaluated interventions for patient participants (n = 2678). These interventions were delivered in a hybrid (n = 6; 46%), in-person (n = 4; 30%), or virtual (n = 3; 23%) environment, mainly by nurses (n = 4; 30%) via discussion and orientation. Only three studies described the inclusion of printed or electronic materials (eg, pamphlets) to support the education. Eleven of 12 studies reported that patients who participated in interventions with an educational component or were cared for by health care providers who were educated about CR benefits (inhospital and/or after discharge) were more likely to enroll and participate in CR.

CONCLUSION

Interventions with an educational component for patients or health care providers play an important role in increasing CR enrollment and participation and should be pursued. Studies investigating the effects of such interventions in people from ethnic minority groups and living in low-and-middle-income countries, as well as the development of standard educational materials are recommended.

Living Lab Data of Patient Needs and Expectations for eHealth-Based Cardiac Rehabilitation in Germany and Spain From the TIMELY Study: Cross-Sectional Analysis

BACKGROUND

The use of eHealth technology in cardiac rehabilitation (CR) is a promising approach to enhance patient outcomes since adherence to healthy lifestyles and risk factor management during phase III CR maintenance is often poorly supported. However, patients' needs and expectations have not been extensively analyzed to inform the design of such eHealth solutions.

OBJECTIVE

The goal of this study was to provide a detailed patient perspective on the most important functionalities to include in an eHealth solution to assist them in phase III CR maintenance.

METHODS

A guided survey as part of a Living Lab approach was conducted in Germany (n=49) and Spain (n=30) involving women (16/79, 20%) and men (63/79, 80%) with coronary artery disease (mean age 57 years, SD 9 years) participating in a structured center-based CR program. The survey covered patients' perceived importance of different CR components in general, current usage of technology/technical devices, and helpfulness of the potential features of eHealth in CR. Questionnaires were used to identify personality traits (psychological flexibility, optimism/pessimism, positive/negative affect), potentially predisposing patients to acceptance of an app/monitoring devices.

RESULTS

All the patients in this study owned a smartphone, while 30%-40% used smartwatches and fitness trackers. Patients expressed the need for an eHealth platform that is user-friendly, personalized, and easily accessible, and 71% (56/79) of the patients believed that technology could help them to maintain health goals after CR. Among the offered components, support for regular physical exercise, including updated schedules and progress documentation, was rated the highest. In addition, patients rated the availability of information on diagnosis, current medication, test results, and risk scores as (very) useful. Of note, for each item, except smoking cessation, 35%-50% of the patients indicated a high need for support to achieve their long-term health goals, suggesting the need for individualized care. No major differences were detected between Spanish and German patients (all P>.05) and only younger age (P=.03) but not sex, education level, or personality traits (all P>.05) were associated with the acceptance of eHealth components.

CONCLUSIONS

The patient perspectives collected in this study indicate high acceptance of personalized user-friendly eHealth platforms with remote monitoring to improve adherence to healthy lifestyles among patients with coronary artery disease during phase III CR maintenance. The identified patient needs comprise support in physical exercise, including regular updates on personalized training recommendations. Availability of diagnoses, laboratory results, and medications, as part of a mobile electronic health record were also rated as very useful.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05461729; https://clinicaltrials.gov/study/NCT05461729.

Enhancing Behavioural Changes: A Narrative Review on the Effectiveness of a Multifactorial APP-Based Intervention Integrating Physical Activity

The rapid evolution of technologies is a key innovation in the organisation and management of physical activities (PA) and sports. The increase in benefits and opportunities related to the adoption of technologies for both the promotion of a healthy lifestyle and the management of chronic diseases is evident. In the field of telehealth, these devices provide personalised recommendations, workout monitoring and injury prevention. The study aimed to provide an overview of the landscape of technology application to PA organised to promote active lifestyles and improve chronic disease management. This review identified specific areas of focus for the selection of articles: the utilisation of mobile APPs and technological devices for enhancing weight loss, improving cardiovascular health, managing diabetes and cancer and preventing osteoporosis and cognitive decline. A multifactorial intervention delivered via mobile APPs, which integrates PA while managing diet or promoting social interaction, is unquestionably more effective than a singular intervention. The main finding related to promoting PA and a healthy lifestyle through app usage is associated with "behaviour change techniques". Even when individuals stop using the APP, they often maintain the structured or suggested lifestyle habits initially provided by the APP. Various concerns regarding the excessive use of APPs need to be addressed.

Effect of mindfulness-based interventions on people with prehypertension or hypertension: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Hypertension and prehypertension have been widely recognized as the main contributors of global mortality. Evidence shows mindfulness-based interventions may reduce blood pressure and improve mental health. However, the effect of mindfulness-based interventions on blood pressure and mental health has not been fully understood.

METHODS

Potential studies published before May 24th 2023 were identified by searching Embase, Ovid Emcare, PsycINFO, CINAHL, Web of Science, Cochrane, PubMed, China National Knowledge Infrastructure, Wanfang database, and VIP China Science. Additionally, two grey databases were searched: Mednar, WorldWideScience.org. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias Assessment tool. The random-effects meta-analyses were conducted using Review Man 5.4 software and the key outcomes are presented as mean difference or standard mean difference and the 95% confidential interval.

RESULTS

Searches returned 802 studies in total, of which 12 were included (N = 715). The duration of interventions was 8 weeks in 10 trials and 6 weeks in one trial. Pooled effect sizes indicated reductions in systolic blood pressure (MD = - 9.12, 95% CI [- 12.18, - 6.05], p < 0.001), diastolic blood pressure (MD = - 5.66, 95% CI [- 8.88, - 2.43], p < 0.001), anxiety (SMD = - 4.10; 95% CI [- 6.49, - 1.71], p < 0.001), depression (SMD = - 1.70, 95%CI [- 2.95, - 0.44], p < 0.001) and perceived stress (SMD = - 5.91, 95%CI [- 8.74, - 3.09], p < 0.001) at post-intervention. The findings from subgroup analyses are favorable for mindfulness-based interventions regardless of gender and baseline blood pressure with regard to BP reduction, with a more profound effect observed in participants with higher pre-intervention blood pressure.

CONCLUSIONS

The results provide evidence for the positive role of mindfulness-based interventions in hypertension management. More large randomized control trials with sufficient statistical power and long-term follow-up are needed.

TRIAL REGISTRATION

The protocol had been registered with Prospero on October 2nd 2021 (registration NO. CRD42021282504 ).

Research trends and hotspots in exercise rehabilitation for coronary heart disease: A bibliometric analysis

Exercise rehabilitation can improve the prognosis of patients with coronary heart disease. However, a bibliometric analysis of the global exercise rehabilitation for coronary heart disease (CHD) research topic is lacking. This study investigated the development trends and research hotspots in the field of coronary heart disease and exercise rehabilitation. CiteSpace software was used to analyze the literature on exercise therapy for CHD in the Web of Science Core Collection database. We analyzed the data of countries/institutions, journals, authors, keywords, and cited references. A total of 3485 peer-reviewed papers were found, and the number of publications on the topic has steadily increased. The most productive country is the USA (1125), followed by China (477) and England (399). The top 3 active academic institutions are Research Libraries UK (RLUK) (236), Harvard University (152), and the University of California System (118). The most commonly cited journals are Circulation (2596), The most commonly cited references are "Exercise-based cardiac rehabilitation for coronary heart disease" (75), Lavie CJ had published the most papers (48). World Health Organization was the most influential author (334 citations). The research frontier trends in this field are body composition, participation, and function. Research on the effects of physical activity or exercise on patients with CHD is a focus of continuous exploration in this field. This study provides a new scientific perspective for exercise rehabilitation and CHD research and gives researchers valuable information for detecting the current research status, hotspots, and emerging trends for further research.

Impact of cardiac rehabilitation on pre- and post-operative transcatheter aortic valve replacement prognoses

Transcatheter aortic valve replacement (TAVR) is a relatively new treatment method for aortic stenosis (AS) and has been demonstrated to be suitable for patients with varying risk levels. Indeed, among high-risk patients, TAVR outcomes are comparable to, or even better, than that of the traditional surgical aortic valve replacement (SAVR) method. TAVR outcomes, with respect to post-surgical functional capacity and quality of life, have also been found to be improved, especially when combined with cardiac rehabilitation (CR). CR is a multidisciplinary system, which integrates cardiology with other medical disciplines, such as sports, nutritional, mind-body, and behavioral medicine. It entails the development of appropriate medication, exercise, and diet prescriptions, along with providing psychological support, ensuring the cessation of smoking, and developing risk factor management strategies for cardiovascular disease patients. However, even with CR being able to improve TAVR outcomes and reduce post-surgical mortality rates, it still has largely been underutilized in clinical settings. This article reviews the usage of CR during both pre-and postoperative periods for valvular diseases, and the factors involved in influencing subsequent patient prognoses, thereby providing a direction for subsequent research and clinical applications.

Exploring the Promise of Telemedicine Exercise Interventions in Children and Adolescents With Congenital Heart Disease

Youth with congenital heart disease (CHD) have reduced exercise capacity via various physical and psychosocial mechanisms. In addition to limited physiologic exercise capacity, these patients experience lower levels of physical activity, physical activity self-efficacy, health-related quality of life, and endothelial function. The study of exercise interventions and cardiac rehabilitation programs in pediatric CHD populations remains limited, particularly home-based interventions that incorporate real-time physiologic monitoring. Home-based interventions provide improved access and convenience to patients. This is principally important for patients from geographically disperse regions who receive their care at centralized subspecialty centres, as is the case for Canadian pediatric cardiac care. These programs, however, have traditionally not permitted the supervision of safety, technique, and adherence that are afforded by hospital/facility-based programs. As such, telemedicine is an important evolving area that combines the benefits of traditional home and facility-based cardiac rehabilitation. An additional key area lacking study surrounds the types of exercise interventions in youth with CHD. To date, interventions have often centred around moderate-intensity continuous exercise. High-intensity interval training might offer superior cardiorespiratory advantages but remains understudied in the CHD population. In this review, we highlight the existing evidence basis for exercise interventions in youth with CHD, explore the promise of incorporating telemedicine home-based solutions, and highlight key knowledge gaps. To address identified knowledge gaps, we are undertaking a 12-week randomized crossover trial of a home-based telemedicine high-intensity interval training intervention in youth with repaired moderate-severe CHD using a video game-linked cycle ergometer (known as the MedBIKE; https://spaces.facsci.ualberta.ca/ahci/projects/medical-projects/remote-rehab-bike-projects).

A Simple Exercise Program for Patients With End-Stage Kidney Disease to Improve Strength and Quality of Life: Clinical Research Protocol

Background

Most patients with end-stage kidney disease (ESKD) appreciate the importance of exercise and would like to increase their physical activity; however, they report a few key barriers, including (1) lack of physician advice to do so, (2) lack of safe and convenient programs (ie, appropriate for home or neighborhood), and (3) cost. Importantly, patients indicated in a previous survey that they would prefer an exercise program that improves muscle strength and symptoms, and are less interested in cardiovascular disease prevention.

Objective

To test the feasibility of a simple, prescribed exercise program using Nordic walking poles in patients with ESKD treated with dialysis.

Design

Randomized multicenter pilot trial of an exercise intervention that includes Nordic walking poles, personalized physician exercise prescriptions, pedometers, and access to exercise videos, compared with standard of care, in patients being treated with maintenance dialysis.

Setting

Multicenter tertiary care centers in Canada.

Patients

Ambulatory adult patients with ESKD treated with peritoneal dialysis or hemodialysis (HD) for at least 6 months at participating sites are potentially eligible. Inclusion criteria include ability to use Nordic walking poles (either de novo or in place of mobility aid) and to provide informed consent in English or in French. Exclusion criteria include (1) any absolute contraindication to exercise, (2) baseline step count >8000 steps/day, (3) planned living donor kidney transplant, and (4) participation in another interventional trial that may affect the results of this study.

Methods

This is a randomized multicenter pilot trial of an exercise intervention that consists of a prescription to exercise using Nordic walking poles, a pedometer to track activity, and access to exercise videos, with the comparator of standard of care (dialysis unit staff encouragement to exercise) in patients being treated with maintenance dialysis. Randomization is concealed and uses a 1:1 ratio for group assignment. Our specific aims are to determine the feasibility of patient recruitment, adherence to the exercise program (verified by step counts), and efficacy of the intervention on patient-important outcomes that were assessed as a priority by patients in a prior survey-specifically strength, fatigue, and sleep. We record days spent in hospital and loss of independent living to inform sample size calculations for a definitive trial of exercise in patient with ESKD treated with dialysis. Adverse events are closely monitored.

Outcomes

Primary: Our recruitment goal is 90 to 150 patients over 27 months; adherence success will be defined if >75% of randomized patients, excluding those who are transplanted or deceased, achieve >80% of their prescribed steps at 6 and 12 months. Secondary Efficacy Outcomes: (1) strength-hand grip strength and 5 times sit to stand, (2) energy-Short Form (SF)-36 vitality subscale, and (3) sleep-Pittsburg Sleep Quality Index will be assessed at baseline, 6, and 12 months.

Results

Trial recruitment started before the COVID-19 pandemic and the pandemic led to many interruptions and delays. Online exercise Web sites and a tailored video were added to the protocol to encourage activity when participants were unable or reluctant to walk in public places.

Limitations

This trial was designed to include ambulatory patients with ESKD and does not address the burden of disease in patients with very restricted mobility.

Trial Registration

NCT03787589.

Muscle strength adaptation between high-load resistance training versus low-load blood flow restriction training with different cuff pressure characteristics: a systematic review and meta-analysis

Purpose: In this systematic review and meta-analysis, blood flow restriction (BFR) with low-load resistance training (BFR-RT) was compared with high-load resistance training (HL-RT) on muscle strength in healthy adults. The characteristics of cuff pressure suitable for muscle strength gain were also investigated by analyzing the effects of applying different occlusion pressure prescriptions and cuff inflation patterns on muscle strength gain. Methods: Literature search was conducted using PubMed, Ovid Medline, ProQuest, Cochrane Library, Embase, and Scopus databases to identify literature published until May 2023. Studies reporting the effects of BFR-RT interventions on muscle strength gain were compared with those of HL-RT. The risk of bias in the included trials was assessed using the Cochrane tool, followed by a meta-analysis to calculate the combined effect. Subgroup analysis was performed to explore the beneficial variables. Results: Nineteen articles (42 outcomes), with a total of 458 healthy adults, were included in the meta-analysis. The combined effect showed higher muscle strength gain with HL-RT than with BFR-RT (p = 0.03, SMD = -0.16, 95% CI: -0.30 to -0.01). The results of the subgroup analysis showed that the BFR-RT applied with incremental and individualized pressure achieved muscle strength gain similar to the HL-RT (p = 0.8, SMD = -0.05, 95% CI: -0.44 to 0.34; p = 0.68, SMD = -0.04, 95% CI: -0.23 to 0.15), but muscle strength gain obtained via BFR-RT applied with absolute pressure was lower than that of HL-RT (p < 0.05, SMD = -0.45, 95% CI: -0.71 to -0.19). Furthermore, muscle strength gain obtained by BFR-RT applied with intermittent pressure was similar to that obtained by HL-RT (p = 0.88, SMD = -0.02, 95% CI: -0.27 to 0.23), but muscle strength gain for BFR-RT applied with continuous pressure showed a less prominent increase than that for HL-RT (p < 0.05, SMD = -0.3, 95% CI: -0.48 to -0.11). Conclusion: In general, HL-RT produces superior muscle strength gains than BFR-RT. However, the application of individualized, incremental, and intermittent pressure exercise protocols in BFR-RT elicits comparable muscle strength gains to HL-RT. Our findings indicate that cuff pressure characteristics play a significant role in establishing a BFR-RT intervention program for enhancing muscle strength in healthy adults. Clinical Trial Registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails; Identifier: PROSPERO (CRD42022364934).

Advances in Technology Promote Patient-Centered Care in Cardiac Rehabilitation

Patient-centered health care (PCC) is a framework of clinical care focused on the patient's individual health care needs. In particular, it emphasizes the development of a partnership between the patient, physician, and healthcare workers to actively involve and empower the patient in their health care decisions. Additionally, PCC goals include ensuring access to care, emotional support, engaging patient support systems, physical comfort, and continuity of care. Technology also provides a platform to engage patients and their families in their care and can be a useful tool to gauge their level of interest, knowledge, and motivations to adequately educate them on the many factors that contribute to their disease, including diet, exercise, medication adherence, psychological support, and early symptom detection. In this article, we summarize the importance of technology in promoting PCC in cardiac rehabilitation and the impact technology may have on the different aspects of patient and physician relationships. Modern technological devices including smartphones, tablets, wearables, and other internet-enabled devices have been shown to help patient-staff communication, cater to patients' individual needs, increase access to health care, and implement aspects of PCC domains.

Psychological interventions aiming for changing dietary habits in patients with cardiovascular disease: A systematic review and meta-analysis

BACKGROUND

Diet is a critical component of healthy lifestyle, especially in cardiac rehabilitation. Psychological interventions, as well as mix-treatment interventions, such as psychological components, appear promising approaches in the adoption and maintenance of a healthy diet in patients with cardiovascular disease (CVD). Given the variety of clinical intervention programmes available, we aimed to determine whether psychological interventions and interventions that incorporate psychological components provide better lifestyle outcomes than traditional care, specifically targeting dietary outcomes, and what types of psychological or mix-treatment interventions are more likely to benefit patients with CVD.

METHODS

A systematic literature search was performed using MEDLINE (PubMed), Scopus, Cochrane Library and PsycINFO to identify interventional studies, published from 2012 to 2022, written in English, evaluating psychological and mix-treatment intervention programmes for dietary outcomes in patients with CVD. In total, 33 intervention studies (n = 5644 patients) were retrieved and analysed using fixed and random effects models.

RESULTS

No significant effect of the psychological intervention was observed regarding fruit and vegetable intake (Hedge's g = +1.06, p = 0.766), whereas a significant reduction was observed in alcoholic beverage consumption in the intervention group, as compared to the control group (Hedge's g = -7.33, p < 0.001). However, based on both our qualitative and quantitative analyses, psychological and mix-treatment interventions were more effective than traditional models in dietary modification. Also, the majority of effective interventions were psychological over mixed-treatment interventions.

CONCLUSIONS

Findings add to the growing evidence suggesting that specific psychological interventions may be effective approaches in dietary modification for patients with CVD, potentially forming part of public health agenda.

Evaluating a Telemedicine Video Game-Linked High-Intensity Interval Training Exercise Programme in Paediatric Heart Transplant Recipients

Paediatric heart transplant recipients (HTRs) have reduced exercise capacity, physical activity (PA), health-related quality of life (HRQoL), and self-efficacy towards PA. Exercise interventions have demonstrated improvements in exercise capacity and functional status in adult HTRs, with a specific emerging interest in the role of high-intensity interval training (HIIT). Studies of exercise interventions in paediatric HTRs have been limited and nonrandomized to date. HIIT has not yet been evaluated in paediatric HTRs. We thus seek to evaluate the safety and feasibility of a randomized crossover trial of a 12-week, home-based, video game-linked HIIT intervention using a cycle ergometer with telemedicine and remote physiological monitoring capabilities (MedBIKE) in paediatric HTRs. The secondary objective is to evaluate the impact of the intervention on (1) exercise capacity, (2) PA, (3) HRQoL and self-efficacy towards PA, and (4) sustained changes in secondary outcomes at 6 and 12 months after intervention. After a baseline assessment of the secondary outcomes, participants will be randomized to receive the MedBIKE intervention (12 weeks, 36 sessions) or usual care. After the intervention and a repeated assessment, all participants will cross over. Follow-up assessments will be administered at 6 and 12 months after the MedBIKE intervention. We anticipate that the MedBIKE intervention will be feasible and safely yield sustained improvements in exercise capacity, PA, HRQoL, and self-efficacy towards PA in paediatric HTRs. This study will serve as the foundation for a larger, multicentre randomized crossover trial and will help inform exercise rehabilitation programmes for paediatric HTRs.

Core components of a rehabilitation program in pediatric cardiac disease

There is increasing effort in both the inpatient and outpatient setting to improve care, function, and quality of life for children with congenital heart disease, and to decrease complications. As the mortality rates of surgical procedures for congenital heart disease decrease, improvement in perioperative morbidity and quality of life have become key metrics of quality of care. Quality of life and function in patients with congenital heart disease can be affected by multiple factors: the underlying heart condition, cardiac surgery, complications, and medical treatment. Some of the functional areas affected are motor abilities, exercise capacity, feeding, speech, cognition, and psychosocial adjustment. Rehabilitation interventions aim to enhance and restore functional ability and quality of life for those with physical impairments or disabilities. Interventions such as exercise training have been extensively evaluated in adults with acquired heart disease, and rehabilitation interventions for pediatric patients with congenital heart disease have similar potential to improve perioperative morbidity and quality of life. However, literature regarding the pediatric population is limited. We have gathered a multidisciplinary team of experts from major institutions to create evidence- and practice-based guidelines for pediatric cardiac rehabilitation programs in both inpatient and outpatient settings. To improve the quality of life of pediatric patients with congenital heart disease, we propose the use of individualized multidisciplinary rehabilitation programs that include: medical management; neuropsychology; nursing care; rehabilitation equipment; physical, occupational, speech, and feeding therapies; and exercise training.

The Association Between Mobile App Use and Change in Functional Capacity Among Cardiac Rehabilitation Participants: Cohort Study

BACKGROUND

Cardiac rehabilitation (CR) is underused in the United States and globally, with participation disparities across gender, socioeconomic status, race, and ethnicities. The pandemic led to greater adoption of telehealth CR and mobile app use.

OBJECTIVE

Our primary objective was to estimate the association between CR mobile app use and change in functional capacity from enrollment to completion in patients participating in a CR program that offered in-person, hybrid, and telehealth CR. Our secondary objectives were to study the association between mobile app use and changes in blood pressure (BP) or program completion.

METHODS

We conducted a retrospective cohort study of participants enrolled in CR at an urban CR program in the United States. Participants were English speaking, at least 18 years of age, participated in the program between May 22, 2020, and May 21, 2022, and downloaded the CR mobile app. Mobile app use was quantified by number of exercise logs, vitals logs, and education material views. The primary outcome was change in functional capacity, measured by change in 6-minute walk distance (6MWD) from enrollment to completion. The secondary outcome was change in BP from enrollment to completion. We estimated associations using multivariable linear or logistic regression models adjusted for age, sex, race, ethnicity, socioeconomic status by ZIP code, insurance, and primary diagnosis for CR referral.

RESULTS

A total of 107 participants (mean age 62.9, SD 13.02 years; 90/107, 84.1% male; and 57/105, 53.3% self-declared as White Caucasian) used the mobile app and completed the CR program. Participants had a mean 64.0 (SD 54.1) meter increase in 6MWD between enrollment and completion (P<.001). From enrollment to completion, participants with an elevated BP at baseline (≥130/80 mmHg) experienced a significant decrease in BP (systolic BP -11.5 mmHg; P=.002 and diastolic BP -7.7 mmHg; P=.003). We found no significant association between total app interactions and change in 6MWD (coefficient -0.03, 95% CI -0.1 to 0.07; P=.59) or change in BP (systolic coefficient 0.002, 95% CI -0.03 to 0.03; P=.87 and diastolic coefficient -0.005, 95% CI -0.03 to 0.02; P=.65). There was no significant association between total exercise logs and change in 6MWD (coefficient 0.1, 95% CI -0.3 to 0.4; P=.57) or total BP logs and change in BP (systolic coefficient -0.02, 95% CI -0.1 to 0.06; P=.63 and diastolic coefficient -0.02, 95% CI -0.09 to 0.04; P=.50). There was no significant association between total app interactions and completion of CR (adjusted odds ratio 1.00, 95% CI 0.99-1.01; P=.44).

CONCLUSIONS

CR mobile app use as part of an in-person, hybrid, or telehealth CR program was not associated with greater improvement in functional capacity or BP or with program completion.

Effectiveness of Exercise-Based Cardiac Rehabilitation for Heart Transplant Recipients: A Systematic Review and Meta-Analysis

Background

Heart Transplant (HTx) is the ultimate chance of life for end stage Heart Failure (HF). Exercise training has consistently shown the potential to improve functional capacity in various chronic heart diseases. Still, the evidence in HTx recipients is scarcer. This study aims to systematically review the literature to evaluate the effectiveness and safety of Exercise-based Cardiac Rehabilitation (EBCR) in HTx recipients and to identify possible moderators of success.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials on the effect and safety of EBCR in adult HTx recipients. The primary outcome was functional capacity, measured by Peak Oxygen Uptake (pVO2). We searched CENTRAL, MEDLINE, Embase, Scopus, and Web of Knowledge databases until December 2020, reviewed references of relevant articles and contacted experts. Usual care (UC), the different dosages of exercise regimens and alternative settings were allowed as comparators. A quantitative synthesis of evidence was performed using random-effects meta-analyses.

Results

A total of 11 studies with 404 patients were included. Nine studies comprising 306 patients compared EBCR with usual care. They showed that EBCR improved pVO2 compared to usual care (Mean Difference [MD] 3.03 mL/kg/min, 95% CI [2.28-3.77]; I 2 = 32%). In the subgroup analysis, including length of intervention and timing of enrollment after HTx, no significant moderator was found. Two trials, with 98 patients total, compared High Intensity Interval Training (HIIT) and Moderate Intensity Continuous Training (MICT). HIIT attained a significant edge over MICT (MD 2.23 mL/kg/min, 95% CI [1.79-2.67]; I 2 = 0%). No major adverse events associated with EBCR were reported.

Conclusion

We found moderate quality evidence suggesting EBCR has a significant benefit on functional capacity improvement HTx recipients at the short-term. HIIT showed superiority when compared to MICT. Research focusing long term outcomes and standardized protocols are needed to improve evidence on EBCR effectiveness.

Influence of Physical Training after a Myocardial Infarction on Left Ventricular Contraction Mechanics

BACKGROUND

Exercise plays a positive role in the course of the ischemic heart disease, enhancing functional capacity and preventing ventricular remodeling.

OBJECTIVE

To investigate the impact of exercise on left ventricular (LV) contraction mechanics after an uncomplicated acute myocardial infarction (AMI).

METHODS

A total of 53 patients was included, 27 of whom were randomized to a supervised training program (TRAINING group), and 26 to a CONTROL group, who received usual recommendations on physical exercise after AMI. All patients underwent cardiopulmonary stress testing and a speckle tracking echocardiography to measure several parameters of LV contraction mechanics at one month and five months after AMI. A p value < 0.05 was considered statistically significant for the comparisons of the variables.

RESULTS

No significant difference were found in the analysis of LV longitudinal, radial and circumferential strain parameters between groups after the training period. After the training program, analysis of torsional mechanics demonstrated a reduction in the LV basal rotation in the TRAINING group in comparison to the CONTROL group (5.9±2.3 vs. 7.5±2.9o; p=0.03), and in the basal rotational velocity (53.6±18.4 vs.68.8±22.1 º/s; p=0.01), twist velocity (127.4±32.2 vs. 149.9±35.9 º/s; p=0.02) and torsion (2.4±0.4 vs. 2.8±0.8 º/cm; p=0.02).

CONCLUSIONS

Physical activity did not cause a significant improvement in LV longitudinal, radial and circumferential deformation parameters. However, the exercise had a significant impact on the LV torsional mechanics, consisting of a reduction in basal rotation, twist velocity, torsion and torsional velocity which can be interpreted as a ventricular "torsion reserve" in this population.

Experience and Perceptions among Older Outpatients after Myocardial Infarction following an Exercise Intervention: A Qualitative Analysis from the PIpELINe Trial

Traditional cardiac rehabilitation (CR) programs effectively improve physical performance and outcomes after myocardial infarction (MI). However, older patients are less likely to participate in such programs. The aim of this qualitative analysis was to investigate experiences and perceptions of cardiac outpatients enrolled in an innovative and exercise-based CR program and to identify possible barriers to improving adherence and quality of life. Semi-structured interviews were conducted on a sample of 31 patients (84% male; age 76 ± 6 years) from the Physical Activity Intervention in Elderly after Myocardial Infarction (PIpELINe) trial, after about six months of the event. Three main themes were identified: Personal feelings after the event; lifestyle change and perception of barriers; and relationships with familiars. Participants perceived sensations of fear at the time of their diagnosis and showed awareness of the importance of following specific health suggestions. They reported a significative change in previous habits and highlighted the need for periodic controls. Few of them felt insecure in carrying out daily activities or practicing exercise and reported an unnecessary protection from the family members. These findings will provide valuable insights for the development of a more feasible patient-centered CR model of intervention.

Cardiac rehabilitation in coronary artery bypass grafting patients: Effect of eight weeks of moderate-intensity continuous training versus high-intensity interval training

BACKGROUND

Physical training in patients with heart failure can affect hemodynamic, cardiac and angiogenesis parameters.

OBJECTIVE

The aim of the present study was to investigate the effects of traditional moderate-intensity rehabilitation training and interval training on some angiogenesis factors in coronary artery bypass graft (CABG) patients.

METHODS

Thirty CABG patients (mean age±SD, 55±3 years) were randomly assigned to one of three groups: high-intensity interval training (HIIT) or moderate-intensity continuous training (MICT) or the control group. After the initial assessments, eligible patients in the experimental groups (HIIT and MICT) performed exercise training for 8 weeks, while the control group did not. Angiogenesis and angiostatic indices, including pro-adrenomedullin (pro-ADM), basic fibroblast growth factor (bFGF), and endostatin, were then measured.

RESULTS

The results showed no significant difference between pro-ADM in the HIIT and MICT groups (P = 0.99), but a significant difference was found between MICT and the control group and between HIIT and the control group (P = 0.001). There is also no significant difference between the bFGF levels in the HIIT and MICT training groups (P = 1.00), but the changes in this factor between the training groups and the control group were significant (P = 0.001). There was a significant difference between the levels of endostatin in all three groups.

CONCLUSIONS

Two methods of cardiac rehabilitation (HIIT and MICT) may be useful for the recovery of patients with coronary artery bypass grafting. This improvement manifested itself in changes in angiogenesis and angiostatic indices in this study. However, more extensive studies are needed to investigate the effects of these two types of rehabilitation programs on other indicators of angiogenesis and angiostatic.

Promoting patient self-management following cardiac rehabilitation using a web-based application: A pilot study

Background

The use of health-related mobile apps has become an important component of healthcare. Patients can use a range of tools to strengthen their health literacy and promote disease management. The aim of the project was to develop a web-based application for use on smartphones, tablets and computers for patients with cardiovascular diseases (cardio-app).

Methods

A semi-standardized written survey was conducted among rehabilitation patients with cardiovascular diseases (n = 158). The usability of the cardio-app was assessed using the System Usability Scale (SUS). The usage behaviour was conducted with a self-developed questionnaire.

Results

The study enrolled 158 eligible rehabilitation patients. The SUS of the cardio-app determined was 74.4 (SD ± 17.4). For 86%, the menu navigation was self-explanatory and logical. The visual presentation appealed to 92% of respondents. The content of the texts used in the app was understandable for 95%, and 93% found the technical terms used in the glossary well explained. For 57%, the app was helpful in planning their physical activities. 83% of the rehabilitation patients would recommend the app to others. The main criticisms of the app were the lack of synchronization options with other apps. Of those who did not use the app, the following reasons for non-use were most frequently cited: too much effort (43%), lack of time (29%) and pandemic-related reasons (29%).

Conclusions

The cardio-app revealed high agreement values. Whether the use of the app is associated with improved clinical state and outcome would have to be verified in further studies.

Interventions Targeted to Address Social Determinants of Health in Ischemic Heart Disease: A Sex- and Gender-Oriented Scoping Review

The burden of ischemic heart disease (IHD) is a major health problem worldwide. The detrimental effect of gendered (ie, unevenly distributed between female and male) socioeconomic determinants of health (SDOH) on outcomes has been demonstrated, more so in female individuals. Therefore, addressing SDOH is a priority for the care implementation of patients with IHD. We conducted a scoping review to identify the types of SDOH-tailored interventions tested in randomised controlled trials (RCTs) among IHD patients, and whether the reporting of findings was sex-unbiased. We identified 8 SDOH domains: education, physical environment, health care system, economic stability, social support, sexual orientation, culture/language, and systemic racism. A total of 28 RCTs (2 ongoing) were evaluated. Since the 1990s, 26 RCTs have been conducted, mainly in the Middle East and Asia, and addressed only education, physical environment, health care system, and social support. The 77% of studies focused on patient-education interventions, and around 80% on SDOH-based interventions achieved positive effects on a variety of primary outcome(s). Among the limitations of the conducted RCTs, the most relevant were an overall low participation of female and racial/ethnical minority participants, a lack of sex-stratified analyses, and a missing opportunity of tailoring some SDOH interventions relevant for health. The SDOH-tailored interventions tested so far in RCTs, enrolling predominantly male patients and mainly targeting education and health literacy, were effective in improving outcomes among patients with IHD. Future studies should focus on a wider range of SDOH with an adequate representation of female and minority patients who would most benefit from such interventions.

Comparing the Effectiveness of Two Cardiac Rehabilitation Exercise Therapy Programs

Cardiovascular diseases are among the leading causes of morbidity and mortality in Canada, highlighting the critical role of disease prevention and risk reduction programs. Cardiac rehabilitation (CR) is a key component of comprehensive cardiovascular care. Currently, more than 200 CR programs are established across the country, varying in duration, number of in-person supervised exercise sessions, and recommendations for exercise frequency at-home. In an increasingly cost-conscious healthcare environment, the effectiveness of healthcare services must be consistently reevaluated. This study evaluates the impact of 2 CR programs implemented by the Northern Alberta Cardiac Rehabilitation Program, by comparing peak metabolic equivalents achieved by study participants in each program. We hypothesize that our "hybrid" CR program, which is structured as an 8-week program with weekly in-person exercise sessions and a prescribed home exercise program, has patient outcomes similar to those of our "traditional" CR program, which required biweekly in-person exercise sessions over the course of 5 weeks. The results of this study may have implications for evaluating how to minimize barriers to both rehabilitation participation and long-term effectiveness of CR programs. The results may help inform the structuring and funding of future rehabilitation programs.

Defining preventive cardiology: A clinical practice statement from the American Society for Preventive Cardiology

Remarkable transformations in science and healthcare have resulted in declines in mortality from cardiovascular disease over the past several decades, largely driven by progress in prevention and treatment of persons at risk. However, these trends are now beginning to stall, as our county faces increases in cardiovascular risk factors including overweight and obesity, type 2 diabetes mellitus, and metabolic syndrome. Furthermore, poor long-term adherence to a healthy lifestyle and lifesaving pharmacotherapy have exacerbated these trends, with recent data suggesting unprecedented increases in cardiovascular morbidity and mortality. A paradigm shift is needed to improve the cardiovascular health of our nation. Preventive cardiology, a growing subspecialty of cardiovascular medicine, is the practice of primordial, primary, and secondary prevention of all cardiovascular diseases. Preventive cardiologists and preventive cardiology specialists are well equipped with the knowledge and skill-set necessary to reduce deaths related to the growing burden of heart disease and its risk factors. Despite dedicated efforts, cardiovascular disease remains the leading killer of men and women in the United States. Although there is little debate regarding the importance of prevention, many healthcare professionals question the need for preventive cardiology as a distinct subspecialty. Additionally, the field's growth has been hampered by a lack of organization and standardization, and variability of training within programs across the country. The purpose of this document is to delineate the key attributes that define the field of preventive cardiology according to the American Society for Preventive Cardiology.

The effect of vitamin D level on cardiac rehabilitation in patients with Coronary Artery Disease

BACKGROUND

25-hydroxy vitamin D (25OHD) deficiency is associated with cardiovascular disease and poor physical performance.

OBJECTIVE

To assign the effect of 25OHD level on cardiac rehabilitation (CR) in patients with coronary artery disease (CAD).

METHODS

One-hundred-thirty-five patients with CAD who underwent a CR programme were enrolled in this retrospective study. Patients were divided into two-group according to 25OHD level (Group 1: < 20 ng/dl; Group 2: ⩾ 20 ng/dl). All patients received CR for 30 sessions. Each participant performed 40 minutes of aerobic exercise with a cycloergometer followed by muscle strengthening exercises. The patients were evaluated before and after CR by a pulmonary function test (PFT) and a cardiopulmonary exercise test (CPET).

RESULTS

There were 77 (57%) patients in Group 1 and 58 patients (43%) in Group 2. Demographic characteristics between the groups were similar. Pre- and post-rehabilitation CPET parameters were lower in Group 1 (p< 0.05). Both groups had significant improvement in CPET (p< 0.05). Post-rehabilitation PFT parameters (FEV1, FVC) were higher in Group 2 (p< 0.05). There was a positive correlation between the 25OHD-level and the CPET-PFT parameters (p< 0.05).

CONCLUSION

25OHD deficiency in patients with CAD reduces the response to CR. It also affects respiratory function according to the FEV1, FVC parameters. In patients scheduled for CR, 25OHD-levels should be evaluated, and any deficiency corrected.

Efficacy of Early Cardiac Rehabilitation After Cardiac Surgery - Verification Using Japanese Diagnosis Procedure Combination Data

Background: The current status of cardiac rehabilitation (CR) after cardiac surgery and the introduction of early CR (E-CR) in Japan are not fully understood. In this study, the current status of E-CR and its efficacy were investigated by the Academic Committee of the Japanese Association of Cardiac Rehabilitation. Methods and Results: We examined the rate of introduction of E-CR and its effects among 220,122 patients who underwent major cardiac and thoracic vascular surgery, as registered in the Diagnosis Procedure Combination (DPC) classification system, between April 2012 and March 2018. In this study, E-CR was defined as CR starting within 1 day after surgery. Patients with and without E-CR were propensity score matched and analyzed for clinical outcomes. Of all patients participating in CR after surgery, E-CR was initiated in 52.1%, 56.9%, 47.4%, and 54.1% of patients undergoing coronary artery bypass grafting, valve surgery, aortic surgery, and other cardiovascular surgery, respectively. After propensity score matching, outcomes for E-CR were significantly superior to non-E-CR in terms of in-hospital deaths, Barthel Index score at discharge, length of hospital stay, and hospitalization costs. Conclusions: E-CR after cardiac surgery was effective in terms of prognosis, hospital stay, and medical costs. This study is the first report using big data in Japan. The results indicate that further introduction of E-CR needs to be recommended in the future.

FORCE Risk Stratification Tool for Pediatric Cardiac Rehabilitation and Fitness Programs

Risk stratification is required to set an exercise prescription for cardiac rehabilitation, but an optimal scheme for congenital heart disease (CHD) is unknown. We piloted a system based on hemodynamic rather than anatomic factors: function, oxygen level, rhythm, complex/coronary anatomy, and elevated load (FORCE). Feasibility, efficacy, and safety of the FORCE tool were evaluated. Patients < 22 years old participating in the Cardiac Fitness Program at Boston Children's Hospital between 02/2017 and 12/2021 were retrospectively analyzed. Assigned FORCE levels, anatomy, adverse events, fitness and exercise test data were collected. Of 63 attempts at FORCE classification, 62 (98%) were successfully classified while one with restrictive cardiomyopathy was not. Thirty-nine (62%) were FORCE 1, 16 (25%) were FORCE 2, and seven (11%) were FORCE 3. Almost half of FORCE 1 patients had simple or complex CHD and the majority of FORCE 2 patients had single ventricle CHD. FORCE 3 patients were more likely to have serious arrhythmias or cardiomyopathy than those in FORCE 1 or 2 (p < 0.001). Postural orthostatic tachycardia syndrome patients appeared in FORCE 1 only. No adverse events occurred over 958 total sessions. The total number of fitness sessions/participant was similar across FORCE levels. It was feasible to risk stratify patients with CHD using a clinical FORCE tool. The tool was effective in categorizing patients and simple to use. No adverse events occurred with fitness training over nearly 1000 exercise training sessions. Adding diastolic dysfunction to the original model may add utility.

Home-Based Robotic Upper Limbs Cardiac Telerehabilitation System

This article proposes a new, improved home-based cardiac telerehabilitation system enhanced by a robotic and Virtual Reality module for cardiac patients to be used in their rehabilitation program. In this study, a novel strategy was used to integrate existing equipment and applications with newly developed ones, with the aim of reducing the need for technical skills of patients using remote control. Patients with acute or chronic heart diseases require long-term, individualized rehabilitation in order to promote their motor recovery and maintain an active and independent lifestyle. This will be accomplished by creating a system for at-home cardiac telerehabilitation augmented by a VR and cobot systems, which can be used long-term at home by each individual patient. In the pre-feasibility study carried out on healthy volunteers familiar with software applications and robotic systems, we demonstrate that RoboTeleRehab could be technically feasible both hardware and software.

Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation

PURPOSE

Cardiac rehabilitation (CR) is evolving to include both in-person and virtual delivery. Our objective was to compare, in CR patients, the association of in-person, hybrid, and virtual CR with change in performance on the 6-min walk test (6MWT) between enrollment and completion.

METHODS

Patients enrolled in CR between October 22, 2019, and May 10, 2021, were categorized into in-person, hybrid, or virtual groups by number of in-person and virtual visits. All patients received individualized exercise training and health behavior counseling. Cardiac rehabilitation was delivered to patients in the hybrid and virtual cohorts using synchronous video exercise and/or asynchronous telephone visits. Measurements at CR enrollment and completion included the 6MWT, blood pressure (BP), depression, anxiety, waist-to-hip ratio, and cardiac self-efficacy.

RESULTS

Of 187 CR patients, 37/97 (38.1%) were in-person patients and 58/90 (64.4%) were hybrid/virtual patients ( P = .001). Compared to in-person (51.5 ± 59.4 m) improvement in the 6MWT was similar in hybrid (63.4 ± 55.6; P = .46) and virtual (63.2 ± 59.6; P = .55) compared with in-person (51.5 ± 59.4). Hybrid and virtual patients experienced similar improvements in BP control and anxiety. Virtual patients experienced less improvement in depression symptoms. There were no statistically significant changes in waist-to-hip ratio or cardiac self-efficacy. Qualitative themes included the adaptability of virtual CR, importance of relationships between patients and CR staff, and need for training and organizational adjustments to adopt virtual CR.

CONCLUSIONS

Hybrid and virtual CR were associated with similar improvements in functional capacity to in-person. Virtual and hybrid CR have the potential to expand availability without compromising outcomes.

Safety of home-based cardiac rehabilitation: A systematic review

BACKGROUND

Cardiac rehabilitation is an evidence-based intervention that aims to improve health outcomes in cardiovascular disease patients, but it is largely underutilized. One strategy for improving utilization is home-based cardiac rehabilitation (HBCR). Previous research has shown that HBCR programs are feasible and effective. However, there is a lack of evidence on safety issues in different cardiac populations. This systematic review aimed to provide an evidence-based overview of the safety of HBCR.

OBJECTIVES

To examine the incidence and severity of adverse events of HBCR.

METHODS

The following databases were searched: CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed, Web of Science, Global Health, and Chinese BioMedical Literature Database for randomized controlled trials. The included trials were written in English and analyzed the incidence of adverse events (AEs) as a primary or secondary intervention outcome.

RESULTS

Five studies showed AEs incidence, of which only one study reported severe AE associated with HBCR exercise. The incidence rate of severe AEs from the sample (n = 808) was estimated as 1 per 23,823 patient-hour of HBCR exercise. More than half patients included were stratified into a high-risk group. In the studies were found no deaths or hospitalizations related to HBCR exercise.

CONCLUSION

The risk of AEs during HBCR seems very low. Our results concerning the safety of HBCR should induce cardiac patients to be more active in their environment and practice physical exercise regularly.

Physical Activity Level and Perspectives of Participants Transitioning from Onsite to Virtual Cardiac Rehabilitation during the Early COVID-19 Pandemic: A Mixed-Method Study

This mixed-method study aimed to compare physical activity (PA) patterns of a cross-over cardiac rehabilitation (CR) cohort with a center-based CR cohort and to explore barriers and facilitators of participants transitioning and engaging in virtual CR. It included the retrospective self-reported PA of a cross-over CR cohort (n = 75) and a matched center-based CR cohort (n = 75). Some of the participants included in the cross-over cohort (n = 12) attended semi-structured focus group sessions and results were interpreted in the context of the PRECEDE-PROCEED model. Differences between groups were not observed (p > 0.05). The center-based CR cohort increased exercise frequency (p = 0.002), duration (p = 0.007), and MET/minutes (p = 0.007) over time. The cross-over cohort increased exercise duration (p = 0.04) with no significant change in any other parameters. Analysis from focus groups revealed six overarching themes classified under predisposing factors (knowledge), enabling factors (external support, COVID-19 restrictions, mental health, personal reasons/preferences), and reinforcing factors (recommendations). These findings suggest an improvement of the PA levels of center-based CR cohort participants pre-pandemic and mitigated improvement in those who transitioned to a virtual CR early in the pandemic. Improving patients’ exercise-related knowledge, provider endorsements, and the implementation of group videoconferencing sessions could help overcome barriers to participation in virtual CR.

Effectiveness and Approach of Rehabilitation in Patients With Acute Heart Failure: A Review

Acute heart failure is associated with high mortality and frequent rehospitalization, resulting in enormous healthcare costs and declining physical function, activities of daily living, and quality of life. Cardiac rehabilitation has been recommended as one of the non-pharmacologic treatments for patients with heart failure. However, much of the evidence for cardiac rehabilitation interventions reported to date has been limited to chronic heart failure. In recent years, the effectiveness of rehabilitation intervention in patients with acute heart failure has been reported, led by the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial. This review overviews the recent evidence of rehabilitation in patients with acute heart failure.

Relation of a Maximal Exercise Test to Change in Exercise Tolerance During Cardiac Rehabilitation

The purpose of this study was to test the hypothesis that an individualized exercise training target heart rate (HR) based on a maximal graded exercise test (GXT) is associated with greater improvements in exercise tolerance during cardiac rehabilitation (CR) compared with no GXT. In this retrospective study, we identified patients who completed 9 to 36 visits of CR between 2001 and 2016, with a length of stay ≤18 weeks and a visit frequency of 1 to 3 days per week. Patients were grouped based on whether their exercise was guided by a target HR determined from a GXT. To assess the relation between GXT and change in exercise training metabolic equivalents of task (METs), we used generalized linear models adjusted for age, gender, race, referral reason, CR visits, CR frequency, METs at start, CR location, and year of participation. Out of 4,455 patients (37% female, 48% White, median age = 62 years), 53% were prescribed a target HR based on a GXT. Compared with no GXT, a GXT was associated with a significantly greater increase in covariate-adjusted METs during CR and percentage change from start (+0.44 METs [95% confidence interval [CI] 0.38 to 0.51] and +17% [95% CI 14% to 19%], respectively). In a sensitivity analysis limited to patients with 24 to 36 visits at ≥2 days per week (n = 1,319), a GXT was associated with a significantly greater increase in covariate-adjusted exercise training METs (+0.51 [95% CI 0.36 to 0.66]; +19% [95% CI 13% to 24%]). In conclusion, to maximize the potential increase in exercise capacity during CR, patients should undergo a GXT to determine an individualized exercise training target HR.

Sleep behaviour and cardiorespiratory fitness in patients after percutaneous coronary intervention during cardiac rehabilitation: protocol for a longitudinal study

INTRODUCTION

Most patients with coronary heart disease experience sleep disturbances and low cardiorespiratory fitness (CRF), but their relationship during cardiac rehabilitation (CR) is still unclear. This article details a protocol for the study of sleep trajectory in patients with coronary heart disease during CR and the relationship between sleep and CRF. A better understanding of the relationship between sleep and CRF on patient outcomes can improve sleep management strategies.

METHODS AND ANALYSIS

This is a longitudinal study with a recruitment target of 101 patients after percutaneous cardiac intervention from the Seventh People's Hospital of Shanghai, China. Data collection will include demographic characteristics, medical history, physical examination, blood sampling, echocardiography and the results of cardiopulmonary exercise tests. The information provided by a 6-min walk test will be used to supplement the CPET. The Pittsburgh Sleep Quality Index will be used to understand the sleep conditions of the participants in the past month. The Patient Health Questionnaire and General Anxiety Disorder Scale will be used to assess depression and anxiety, respectively. All participants will be required to wear an actigraphy on their wrists for 72 hours to monitor objective sleep conditions. This information will be collected four times within 6 months of CR, and patients will be followed up for 1 year. The growth mixture model will be used to analyse the longitudinal sleep data. The generalised estimating equation will be used to examine the associations between sleep and CRF during CR.

ETHICS AND DISSEMINATION

Ethical approval for this observational longitudinal study was granted by the Shanghai Seventh People's Hospital Ethics Committee on 23 April 2021 (2021-7th-HIRB-012). Study results will be disseminated in peer-reviewed journal articles.

Effects of Phase II Cardiac Rehabilitation on Physical Function and Anxiety Levels in Frail Patients

Background: Frailty is an important prognostic factor in patients with cardiovascular diseases (CVD), and patients with CVD have a high rate of concurrent psycho-emotional stress, as well as depressive mood and anxiety symptoms. Despite this, few reports have examined the effects of the efficacy of Phase II cardiac rehabilitation (CR) in frail patients, including improvements in anxiety levels.

Methods and Results: In all, 137 patients (mean [±SD] age 65.8±13.0 years; 71% male) who participated in Phase II CR and were assessed after CR completion were included in this study. Patients were evaluated using the Kihon Checklist (KCL) form at the beginning of CR and were divided into the 3 groups according to KCL scores: frail (n=34, 25%), pre-frail (n=40, 29%), and non-frail (n=63, 46%). Physical function and anxiety levels were compared among the 3 groups. The pre-frail and frail groups had significantly higher state anxiety and trait anxiety than the non-frail group (P<0.01). At the end of Phase II CR, all 3 groups showed significant improvements in the 6-min walking distance (P<0.05). State anxiety improved significantly in the non-frail and pre-frail groups, whereas trait anxiety only improved in the non-frail group.

Conclusions: Physical function was improved in frail patients who participated in Phase II CR. However, there was no significant improvement in their level of anxiety.

Internal medicine resident education improves cardiac rehabilitation knowledge, attitudes, and referral rates: A pilot study

Background

Referrals to cardiac rehabilitation (CR) remain low despite evidence showing reduction in cardiovascular mortality and hospital readmissions. Resident education and awareness may be an opportunity to address barriers to CR referrals.

Methods

This pilot study involves 20 internal medicine residents rotating at an ambulatory primary care clinic. Voluntary surveys were sent through an online-based survey platform. Following survey completion, residents received a 10-minute scripted lecture and an educational handout outlining CR components, availability, indications, insurance eligibility criteria, and referral process. Surveys were redistributed 2 months post-education to assess changes in mean aggregate knowledge scores and attitude ratings on a 5-point Likert scale. CR referral rates of eligible patients pre- and post-education were obtained through review of electronic medical records.

Results

Sixteen (80%) residents completed both pre and post surveys, and 13 (81%) reported no education on CR in the prior year. There was a significant increase in mean aggregate knowledge scores on CR components (5.1 versus 7.0, P = 0.001), insurance coverage (2.4 versus 5.6, P< 0.001), and eligible diagnoses (7.1 versus 9.9, P = 0.03) following education. Attitudes towards CR also improved following education, particularly in self-reported comfort level with explaining CR to patients (3.69 versus 2.06, P<0.001) and perceived familiarity with CR referral process (4.00 versus 2.18, P<0.001). CR referrals increased from 0% (0 out of 10 eligible patients) to 33% (3 out of 9 eligible patients) over a 2-month period before and after education, respectively (P = 0.09).

Conclusions

Internal medicine resident knowledge and attitudes towards CR significantly improved after formal education. Although there was a modest increase in the rates of CR referrals following resident education, this pilot study was not powered to detect statistical significance.

Intermittent aerobic-resistance interval training versus continues aerobic training: Improvement in cardiac electrophysiologic and anthropometric measures in male patients post myocadiac infarction, a randomized control trial

Purpose

Exercise is a valuable intervention modality for patients post-myocardial infarction (MI). Aerobic and resistance training are both commonly used separately in cardiac rehabilitation. However, the effect of aerobic interval exercise combined with alternating sets of resistance training (super-circuit training, SCT) on cardiac electrophysiologic and anthropometric measures had not been thoroughly investigated.

Aim

The primary objective of this study was to compare the effectiveness of moderate-intensity continuous-aerobic training (CAT) vs. SCT on cardiac electrical measures (resting electrocardiographic, ECG; a nd heart rate variability, HRV) in patients’ post-MI presenting reduced left ventricular function. Second, to examine its effect on anthropometric measures.

Material and methods

Twenty-nine men post-MI with reduced left ventricular function were assigned randomly to either 12 weeks of CAT (n = 15) or SCT (n = 14). CAT group performed moderate-intensity activity. SCT group performed high-intensity exercise, alternating between resistance and aerobic training. Differences between CAT and SCT groups were done using independent t-tests, paired t-tests and effect size (ES).

Results

Participants in both groups improved their HRV measures (increase in HFnu; p < 0.05; ES > 0.51) and ECG (reduction in QT-dispersion; p < 0.05; ES > 0.51). Only the SCT group had significant improvements in waist circumference (p < 0.05).

Conclusion

Exercise improves cardiac electrical measures post-MI. However, in comparison to CAT, SCT may yield greater anthropometric changes. In order to have improvements in cardiac electrical stability, clinicians working with post-MI patients may use both CAT and SCT. However, SCT might result in greater improvements.

Implementation of an Appointment-Based Cardiac Rehabilitation Approach: A Single-Center Experience

Background There has been a focus on alternative cardiac rehabilitation (CR) delivery models aimed at improving CR adherence and completion. We examined pre- and post-CR health outcomes, reasons for discharge, and predictors of completion using a patient-driven appointment-based CR approach that uses center-scheduled class start times. Methods and Results Data were used from an urban single-center CR program at Yale New Haven Health (2012-2017) that enrolled 2135 patients. We evaluated pre- and post-CR outcomes (12 weeks) using paired t tests and used a multivariable logistic regression model to examine predictors of CR completion (≥36 sessions) for the overall cardiovascular disease population. The mean age of participants was 65±12 years, 27.9% were women, and 5.1% were Black patients, and patients completed a median of 30 of 36 sessions. Patients achieved significant improvements in health outcomes, including across age and sex subgroups. The primary reason for discharge was completion of all 36 sessions of CR (46.4%). The final logistic regression model contained 12 predictors: age, sex, Black race, marital status, employment, number of physician-reported risk factors, dietary fat intake >30%, obesity, lack of exercise, benign prostatic hyperplasia, and self-reported stress and physical activity. Conclusions We demonstrated that patients participating in an appointment-based CR program achieved significant improvements in health outcomes and across sex/age subgroups. In addition, older individuals were more likely to complete CR. An appointment-based approach could be a viable alternative CR method to aid in optimizing the dose-response benefit of CR for patients with cardiovascular disease.