Trends and Predictors of Participation in Cardiac Rehabilitation Following Acute Myocardial Infarction: Data From the Behavioral Risk Factor Surveillance System

Exploring the feasibility, acceptability, and safety of a real-time cardiac telerehabilitation and tele coaching programme using wearable devices in people with a recent myocardial infarction

BACKGROUND

Cardiac rehabilitation (CR) constitutes the recommended nonpharmacological approach for cardiac patients with cardiovascular disease such as people following a recent (i.e., < 4 week) myocardial infarction (MI). Recent evidence suggests that cardiac telerehabilitation may be as effective as traditional (i.e., in person) CR in people following a recent MI. Nevertheless, the feasibility, acceptability, and safety of such an exercise programme has yet to be examined.

METHODS

Forty-four (11 women, 33 men) people following a recent MI were randomly allocated into two groups (online home-based and gym-based groups). The groups underwent a 24-week CR programme thrice per week. All patients performed the baseline, and 24 weeks follow up measurements where feasibility, acceptability, and safety were assessed.

RESULTS

Eligibility and recruitment rates were found to be 61.5% and 42%, respectively. Compliance to the thrice weekly, 24-week exercise programme for the online- and gym-based groups were 91.6% and 90.9%, respectively. There were no dropouts during the exercise programmes, however four participants, two from each group, were lost to follow up at 6 months. The average percentage of peak HR (% HRpeak) for the online group was 66.6% ± 4.5 and for the gym-based group was 67.2% ± 5. The average RPE and affect during exercise was for both groups 12 ± 1 ("somewhat hard") and 3 ± 1 ("good"), respectively. During the 6-month exercise intervention period for both groups, the exercise-induced symptoms were minimal to none. The user suitability evaluation questionnaire revealed that the online real time telerehabilitation and tele coaching programme was enjoyable (4.85 ± 0.37) and did not induce general discomfort (1.20 ± 0.41).

CONCLUSION

Our cardiac telerehabilitation programme seems to be feasible, acceptable, safe, and enjoyable for people with a recent MI. Our participants had an overall positive experience and acceptability of the cardiac telerehabilitation and tele coaching using wearable devices.

TRIAL REGISTRATION

ClinicalTrial.gov, ID NCT06071273, 10/02/2023, retrospectively registered.

Adherence to Cardiac Rehabilitation in Patients with Acute Myocardial Infarction After PCI: A Scoping Review

Purpose

Cardiac rehabilitation (CR) is a multidisciplinary intervention program aimed at enhancing the physical, psychological, and social functioning of patients with cardiovascular disease. Although CR is cost-effective and reduces mortality and readmission rates, and many patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) do not adhere to CR. This review aimed to synthesize the evidence on adherence to CR in patients with AMI after PCI (AMI-PCI).

Patients and Methods

The review was conducted using the methodology proposed by the Joanna Briggs Institute (JBI) to guide reviews and reporting using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extended for Scoping Reviews (PRISMA-ScR). We searched PubMed, Web of Science, CINAHL, Embase, Ovid, and Scopus databases, and two reviewers independently screened the abstracts and full texts of eligible studies against the inclusion and exclusion criteria. Disagreements were resolved in consultation with a third reviewer.

Results

A total of 10 studies were included in the analysis. The results demonstrated that CR reduces the incidence of complications and improves the quality of life of patients with AMI-PCI. However, the CR adherence rate was low, and the factors affecting it are complex and varied, including age, sex, and employment status. Furthermore, interventions to improve adherence in patients with AMI-PCI mainly combined the internet-based interventions, including videoconferencing tele-training, with wearable device monitoring and intelligent management platform follow-up. All these interventions have shown promising results compared with routine care.

Conclusion

Adherence to CR in patients with AMI-PCI is generally low, and CR adherence is affected by many factors; however, relevant research designs are rare and simple. Healthcare professionals should pay more attention to adherence to CR in this population and use a variety of interventions to improve it.

Trends in Mortality After Incident Hospitalization for Heart Failure Among Medicare Beneficiaries

Importance

Despite advances in treatment and care quality for patients hospitalized with heart failure (HF), minimal improvement in mortality has been observed after HF hospitalization since 2010.

Objective

To evaluate trends in mortality rates across specific intervals after hospitalization.

Design, Setting, and Participants

This cohort study evaluated a random sample of Medicare fee-for-service beneficiaries with incident HF hospitalization from January 1, 2008, to December 31, 2018. Data were analyzed from February 2023 to May 2024.

Main Outcomes and Measures

Unadjusted mortality rates were calculated by dividing the number of all-cause deaths by the number of patients with incident HF hospitalization for the following periods: in-hospital, 30 days (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Annual unadjusted and risk-adjusted mortality ratios were calculated (using logistic regression to account for differences in patient characteristics), defined as observed mortality divided by expected mortality based on 2008 rates.

Results

A total of 1 256 041 patients (mean [SD] age, 83.0 [7.6] years; 56.0% female; 86.0% White) were hospitalized with incident HF. There was a substantial decrease in the mortality ratio for the in-hospital period (unadjusted ratio, 0.77; 95% CI, 0.67-0.77; risk-adjusted ratio, 0.74; 95% CI, 0.71-0.76). For subsequent periods, mortality ratios increased through 2013 and then decreased through 2018, resulting in no reductions in unadjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.94; 95% CI, 0.82-1.06; short-term mortality ratio, 1.02; 95% CI, 0.87-1.17; intermediate-term mortality ratio, 0.99; 95% CI, 0.79-1.19; and long-term mortality ratio, 0.96; 95% CI, 0.76-1.16) and small reductions in risk-adjusted postdischarge mortality during the full study period (30-day mortality ratio, 0.88; 95% CI, 0.86-0.90; short-term mortality ratio, 0.94; 95% CI, 0.94-0.95; intermediate-term mortality ratio, 0.94; 95% CI, 0.92-0.95; and long-term mortality ratio, 0.95; 95% CI, 0.93-0.96).

Conclusions and Relevance

In this study of Medicare fee-for-service beneficiaries, there was a substantial decrease in in-hospital mortality for patients hospitalized with incident HF from 2008 to 2018, but little to no reduction in mortality for subsequent periods up to 3 years after hospitalization. These results suggest opportunities to improve longitudinal outpatient care for patients with HF after hospital discharge.

Effectiveness and Influencing Factors of Home-Center-Based Cardiac Rehabilitation as a Transitional Strategy for Acute Myocardial Infarction Patients

Currently, providing patients, particularly those with acute myocardial infarction (AMI), with comprehensive cardiac rehabilitation (CR) has been challenging because of the inadequate availability of medical resources in developing countries. To ensure balance between disease instability and early rehabilitation, strategies for facilitating professional and comprehensive CR opportunities for patients with AMI must be explored.A prospective cohort study was carried out on 1,533 patients with AMI who were admitted to a tertiary hospital between July 2018 and October 2019. Following the principle of voluntarism, 286 patients with AMI participated in home-center-based CR (HCB group), whereas 1,247 patients received usual care (UC group). The primary endpoint of this study was the occurrence of cardiovascular events at 30 months after AMI. Moreover, the study analyzed factors that influence participation rate and effectiveness of the CR model.After analysis, a significant difference in the occurrence of cardiovascular endpoints between the HCB group and the UC group was observed (harzard ratio, 0.68 [95%CI, 0.51-0.91], P = 0.008), with participation in home-center-based CR being an independent influencing factor. Multivariate regression analysis revealed age, gender, smoking history, triglyceride levels, and ejection fraction as independent factors that influence participation rate. Female gender, peak oxygen uptake per kilogram body weight, and ventilation/carbon dioxide production slope were identified as factors that affect the effectiveness of the CR model.In the context of developing countries, this study demonstrates that the home-center-based CR model is efficient and analyzes factors that influence participation rate and effectiveness of the model. These findings provide practical insights for further development of CR programs.

Effects of a physical therapist-driven individualized hybrid model of the exercise component of cardiac rehabilitation on patient outcomes: a prospective single group, time-series design

PURPOSE

The aim of this prospective single group, time-series study was to determine the feasibility, adherence, and effectiveness of an individualized physical therapist (PT)-driven hybrid model of the exercise component of cardiac rehabilitation (CR) that uses a novel intensity-recovery progression protocol (IRPP) and cardiac testing template (CTT) to assess achieved heart rate (HR) intensity, HR recovery, and intensity-recovery total to guide treatment.

METHODS

Assessment of a questionnaire, treadmill 6-min walk (6MW), 1-min sit-to-stand (1STS), 1-min step, and 1-min agility square tests were assessed on 100 participants. Compared to traditional CR the 36-visit 1:1 hybrid model was individualized using the IRPP program and CTT.

RESULTS

Adherence was 35% (timely) and 44% (overall) completion. The per-protocol analysis (PPA) and intent-to-treat (ITT) analysis suggest significant improvement in objective assessments baseline to visit 15 (PPA = 11 of 14) (ITT = 13 of 14), baseline to visit 30 (PPA = 12 of 14) (ITT = 12 of 14) and visit 15 to visit 30 (PPA = 9 of 14) (ITT = 10 of 14). Improvement beyond the minimal clinically important difference (MCID) was 94.3% in the 6MW and 91.4% in the 1STS.

CONCLUSIONS

The PT-driven IRPP program was feasible in terms of adherence and safety, showing significant improvement in a majority of assessments. Analysis of HR using the CTT may help clinical decision making for progression in CR.Implications for rehabilitationCardiac rehabilitation (CR) is an underutilized means of improving health for people recovering from cardiac surgery.People recovering from cardiac surgery have complex reasons for why they choose to enroll in, drop out from, or complete a CR program.Reporting of outcomes in CR and progression in intensity is not often individualized.An individualized physical therapist driven CR program using both subjective and objective assessments may be successful at improving adherence and effectiveness in this cohort.

Integrating the quantitative with the qualitative: findings from a mixed methods cardiac rehabilitation exercise trial

Background

Cardiac rehabilitation is a core component of cardiovascular disease management. Eastern Corridor Medical Engineering-Cardiac Rehabilitation is a digital health platform for online cardiac rehabilitation exercise. We conducted a mixed methods pilot trial to evaluate Eastern Corridor Medical Engineering-Cardiac Rehabilitation.

Objective

The study sought to examine the difference between objectively measured outcomes and participant perceptions of benefits and improvements gained from participation in a cardiac rehabilitation exercise program.

Methods

Seventeen participants (14 male, 3 female; 69.5 ± 7.3 years of age) took part and were allocated to 1 of 2 groups; an online exercise group (n = 8), or an in-person exercise (n = 9) group. Due to the COVID-19 pandemic, a pragmatic approach to group allocation was adopted. Objective outcomes were assessed at baseline and repeated following the intervention period, with the primary outcome being 6-minute walk test distance. In addition to clinical outcome measurements, we undertook qualitative interviews with participants.

Results

Only 5 participants demonstrated a clinically meaningful improvement in 6-minute walk test distance, following the 8-week exercise program. The main theme emerging from the qualitative interviews was the valued benefits of the cardiac rehabilitation exercise program. Despite the lack of measurable physical change, participants self-defined a range of benefits they valued and attributed directly to participation in the cardiac rehabilitation exercise program.

Conclusion

The findings from this study may offer a useful starting point for further study of community-based cardiac rehabilitation exercise and also highlight the benefit of adopting a mixed methods approach that considers both the objective outcomes measured as well as the subjective reports obtained from participants.

Comprehensive Cardiac Rehabilitation Following Acute Myocardial Infarction Improves Clinical Outcomes Regardless of Exercise Capacity

BACKGROUND

Reduced exercise capacity is a prognostic indicator of adverse outcomes in patients with acute myocardial infarction (AMI). However, few studies have evaluated the effectiveness of comprehensive cardiac rehabilitation (CR) in this population. This study aimed to clarify the efficacy of comprehensive CR in patients with AMI and reduced exercise capacity.

METHODS AND RESULTS

This cohort study included 610 patients with AMI who underwent percutaneous coronary intervention. Major adverse cardiovascular events (MACE) were compared between patients who participated in comprehensive outpatient CR for 150 days (CR group; n=430) and those who did not (non-CR group; n=180). During the mean (±SD) follow-up period of 6.1±4.0 years, the CR group exhibited a lower incidence of MACE (log-rank P=0.002). Multivariable analysis revealed that Killip classification, diuretics at discharge, and participation in comprehensive CR were independently associated with MACE. The CR group was further divided into 2 groups, namely reduced exercise capacity (% predicted peak V̇O2<80%; n=241) and preserved exercise capacity (≥80%; n=147), based on the initial cardiopulmonary exercise test. Despite distinct exercise capacities, the incidence of MACE was comparable and physical parameters improved similarly after comprehensive CR in both groups.

CONCLUSIONS

Comprehensive CR in patients with AMI effectively reduced the incidence of MACE regardless of initial exercise capacity. Cardiologists should actively encourage patients with low exercise capacity to participate in comprehensive CR.

Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries

OBJECTIVE

Despite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes.

METHODS

This retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use.

RESULTS

Overall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001).

CONCLUSIONS

Identifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

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.

Current Role and Future Perspectives of Cardiac Rehabilitation in Heart Disease

As a comprehensive secondary prevention program, cardiac rehabilitation (CR) is a beneficial and cost-effective intervention for patients with heart disease, but the participation rate of patients in CR is low globally. In recent years, due to the COVID-19 pandemic and scientific and technological advances, an increasing number of alternative CR modes have been developed, such as remote CR, home-based CR, hybrid CR and virtual CR. These alternative CR modes represent changes and new opportunities for patients with heart disease. In this review, we will discuss in detail the impact of CR on patients with different types of heart disease, review the various alternative CR models, and explore some prospects for the future of CR in the field of heart disease.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Better together: Relationship quality and mental health among cardiac patients and spouses

Reductions in marital relationship quality are pervasive post-cardiac event. It is not yet understood how relationship quality is linked to mental health outcomes in couples where one member has established cardiovascular disease (CVD) and the interdependence within dyads is seldom measured. This research is required as psychological distress has been independently linked to CVD incidence, morbidity, and mortality. This study assessed associations of relationship quality with depression and anxiety among patients with CVD and their spouses. Participants completed questionnaires measuring four dimensions of relationship quality and mental health. Data were analyzed using an Actor-Partner Interdependence Model with hierarchical moderation analyses. 181 dyads (N = 362 participants) comprised the study sample. Most patients had coronary artery disease (66.3%) and 25.9% were female. Patients reported higher relationship satisfaction and fewer anxiety symptoms than did spouses. Patients and spouses with high dyadic consensus and affectional expression reported fewer mental health symptoms, but only when the other partner also perceived high levels of consensus and affectional expression in the relationship. Patients and spouses with low dyadic cohesion reported worse mental health symptoms (actor effects), but those effects were no longer significant when both the patient and the spouse appraised the relationship as having high levels of dyadic cohesion. Taken together, relationship quality is linked to mental health symptoms in patients with CVD and their spouses. Longitudinal and experimental studies are now warranted to further substantiate the cross-sectional findings of this study.

Factors associated with participation in cardiac rehabilitation in patients with acute myocardial infarction: A systematic review and meta-analysis

BACKGROUND

Cardiac rehabilitation (CR) is effective in reducing morbidity and mortality in patients with acute myocardial infarction (AMI), but the participation rate is low and its influencing factors vary. Our study aimed to systematically review the literature and investigate the participation rates and influencing factors of CR in patients with AMI.

METHODS

We searched 10 databases, including PubMed, Web of Science, Cochrane Library, and so forth. A systematic review and meta-analysis were conducted on the studies on the factors affecting CR participation in AMI. The Q tests and the I2 tests were used to assess heterogeneity between studies. The combined effect size and odds ratio (OR) and their respective 95% confidence interval (CI) for CR participation rate and its influences are expressed, respectively. Stata 17.0 software was used for statistical analysis.

RESULTS

We included 14 studies with 114 542 participants. Current evidence indicates a CR participation rate of 34% (95% CI: 21%-46%) in patients with AMI. The pooled OR values and CI of each influencing factor are as follows: over 60 years old (OR = 0.865; 95% CI: 0.772-0.969), male (OR = 1.690; 95% CI: 1.276-2.239), college education or above (OR = 2.526; 95% CI: 1.117-5.711), ST-segment elevation myocardial infarction (OR = 4.257; 95% CI: 2.004-9.045), decrease in left ventricular ejection fraction (OR = 0.918; 95% CI: 0.868-0.971), higher economic level (OR = 1.282; 95% CI: 1.108-1.483), history of coronary heart disease(OR = 0.667; 95% CI: 0.509-0.875), smoking (OR = 0.665; 95% CI: 0.550-0.805), combined hypertension (OR = 0.638; 95% CI: 0.562-0.723), and combined hyperlipidemia (OR = 0.577; 95% CI: 0.512-0.651).

CONCLUSIONS

The overall participation rate of CR in AMI patients is low, and various factors affect the participation rate. Specialist medical staff are needed to further promote CR rehabilitation concepts and scientific knowledge, and take appropriate measures to address the influencing factors to increase CR utilization and improve patient prognosis.

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.

Mediation analysis of activities of daily living and kinesiophobia in association between cardiac function and health status of patients with chronic heart failure

AIMS

To explore the mediational effect of activities of daily living (ADL) and kinesiophobia on the cardiac function and health status of patients with chronic heart failure (CHF).

METHODS

From October 2021 to January 2022, a total of 244 CHF patients treated in the Department of Cardiology of general hospitals were recruited by the convenience sampling method. They were investigated with the Tampa Scale for Kinesiophobia Heart (TSK-SV Heart), the Barthel index for assessing ADL, and the EuroQol five-dimensional questionnaire (EQ-5D) for assessing the health status.

RESULTS

The cardiac function and kinesiophobia of CHF patients were both negatively correlated with their health status (r = -.390 and -0.410, respectively, both p < .01). Besides, the ADL of CHF patients was positively correlated with the health status (r = .320, p < .01). The cardiac function of CHF patients was negatively correlated with the ADL (r = -.412, p < .01), but positively correlated with kinesiophobia (r = .180, p < .01). The mediation proportion of ADL plus kinesiophobia between the cardiac function and health status of CHF patients was 43.48%. Both ADL and kinesiophobia partially mediated the effect of cardiac function on health status in CHF patients, but their mediational effects showed no significant difference (p = .777).

CONCLUSION

Both ADL and kinesiophobia exert obvious mediational effects between cardiac function and health status in CHF patients. Individualized cardiac rehabilitation (CR) programs based on the cardiac function, ADL and kinesiophobia of CHF patients may contribute to reduce the medical burden and improve the well-being of affected people.

A prospective, randomized, controlled, multicentre trial for secondary prevention in patients with chronic coronary syndrome using a smartphone application for digital therapy: the CHANGE study protocol

Aims

Coronary artery disease (CAD) remains the leading cause of death worldwide. 'Stable' CAD is a chronic progressive condition, which recent European guidelines recommend referring to as 'chronic coronary syndrome' (CCS). Despite therapeutic advances, morbidity and mortality among patients with CCS remain high. Optimal secondary prevention in patients with CCS includes optimization of modifiable risk factors with behavioural changes and pharmacological therapy. The CHANGE study aims to provide evidence for optimization of secondary prevention in CCS patients by using a smartphone application (app).

Methods and results

The CHANGE study is designed as a prospective, randomized, controlled trial with a 1:1 allocation ratio, which is currently performed in nine centres in Germany in a parallel group design. 210 patients with CCS will be randomly allocated either to the control group (standard-of-care) or to the intervention group, who will be provided the VantisTherapy* app in addition to standard-of-care to incorporate secondary prevention into their daily life. The study will be performed in an open design. Outcomes will be assessed using objective data from three in-person visits (0, 12, and 24 weeks). Primary outcomes will involve adherence to secondary prevention recommendations and quality of life (QoL). The recruitment process started in July 2022.

Conclusion

The CHANGE study will investigate whether a smartphone-guided secondary prevention app, combined with a monitor function compared with standard-of-care, has beneficial effects on overall adherence to secondary prevention guidelines and QoL in patients with CCS.

Trial registration

The study is listed at the German study registry (DRKS) under the registered number DRKS00028081.

Effects of the Strong Hearts program after a major cardiovascular event in patients with cardiovascular disease

CONTEXT

Cardiac rehabilitation (CR) and intensive cardiac rehabilitation (ICR) are secondary prevention interventions for cardiovascular disease (CVD) with a class 1a indication yet suboptimal utilization. To date, there are only three approved ICR programs. Alternative programing should be explored to increase enrollment and adherence in these interventions.

OBJECTIVES

This study aims to evaluate the effectiveness of the Strong Hearts program in cardiovascular patients following a major cardiovascular event.

METHODS

One hundred ninety-seven (n = 197) participants were enrolled in this prospective, nonrandomized study. Patients were eligible for participation if they were referred by a physician after a major cardiovascular event, defined as any of the following: (1) acute myocardial infarction (MI) within the preceding 12 months; (2) current stable or unstable angina pectoris; (3) heart valve procedure; (4) percutaneous intervention of any kind; (5) heart transplant; (6) coronary artery bypass grafting (CABG); or (7) congestive heart failure (CHF) with reduced or preserved ejection fraction. Participants were asked to attend program visits four times per week for 9 weeks. Visits consisted of individualized exercise and intensive healthy lifestyle education. Paired t tests were utilized to compare pre- and postprogram outcome measures.

RESULTS

One hundred twenty-eight (n = 128) participants completed the program within the 9-week time frame and their outcome measures were included in the data analysis. Among this, 35.2% participants were female and 64.8% were male. The mean age was 65 (range, 19-88). Qualifying diagnoses were percutaneous coronary intervention (PCI; 60, 46.9%), CABG (33, 25.8%), angina (24, 18.8%), valve procedures (8, 6.2%), and CHF (3, 2.3%). After implementation of the intervention, statistically significant decreases in weight (P < .001), body mass index (BMI, P < .001), waist circumference (P < .001), triglycerides (P = .01), systolic blood pressure (SBP, P <.001), diastolic blood pressure (DBP, P = .002), total fat mass (P < .001), Dartmouth Quality of Life Index P < .001), and cardiac depression scores (P = .044) were detected. In other instances, there were statistically significant increases across time for the clinical parameters of high-density lipoprotein (HDL, P = .02), Vitamin D (P = .001), metabolic equivalents (METS, P < .001), Duke activity scores (P < .001), and Rate Your Plate nutrition scores (P < .001). There were no significant changes across time for total cholesterol (P = .17), low-density lipoprotein (LDL, P = .21), A1c (P = .27), or dual-energy X-ray absorptiometry (DXA) total lean mass (P = .86).

CONCLUSIONS

The 9-week structured program resulted in significant cardiovascular benefit to patients with CVD by reducing cardiac risk factors, increasing exercise capacity, and improving quality of life.

Effects of home-based cardiac telerehabilitation programs in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

Recent advances in telecommunications technology have raised the possibility of telehealth intervention delivering cardiac telerehabilitation, which may provide the efficacy of health services in patients after percutaneous coronary intervention (PCI). This study aimed to investigate the effects of home-based cardiac telerehabilitation (HBCTR) in patients undergoing PCI.

METHODS

We performed a comprehensive search of the following electronic databases: PubMed, Cochrane Central, Web of Science, Embase, CNKI, and WANFANG. For the prespecified outcomes, the primary outcomes were results of physical function (the six-minute walking test, 6MWT) and quality of life (QoL) of the participants. The secondary outcomes were results of (1) blood pressure; (2) full lipid profile (3) reliable assessment of anxiety and depression in patients.

RESULTS

All studies were conducted between 2013 and 2022, and a total of 5 articles could be included in the quantitative meta-analysis. The results showed that there was a statistically significant difference between the HBCTR intervention group and the control group in 6WMT (MD 16.59, 95%CI 7.13 to 26.06, P = 0.0006), but there was no difference in QoL (SMD  - 0.25, 95%CI  - 1.63 to 1.13, P = 0.73). According to the fixed effects model, there was a statistically significant difference between the HBCTR group versus the control group (MD - 2.88, 95%CI - 5.19 to - 0.57, P = 0.01), but not in diastolic blood pressure. Likewise, significant improvements of triglycerides and in low-density lipoprotein cholesterol were observed in HBTCR groups, but no significant differences were observed regarding total cholesterol and high-density lipoprotein cholesterol.

CONCLUSION

This systematic review and meta-analysis have proven that the HBCTR is one of the promisingly effective cardiac rehabilitation strategies that improve cardiorespiratory fitness and reduce cardiovascular disease risk factors. With the continuous improvement of the telerehabilitation network, it is expected to serve in clinical.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Israel's first national remote cardiac rehabilitation program: A retrospective analysis

Aims

Cardiac rehabilitation is an essential component of secondary prevention consistently unexploited by most eligible patients. Accordingly, the remote cardiac rehabilitation program (RCRP) was developed to create optimal conditions for remote instruction and supervision for patients to enable successful completion of the program.

Methods

This study comprised 306 patients with established coronary heart disease who underwent a 6-month RCRP. RCRP involves regular exercise, monitored by a smartwatch that relays data to the operations center and a mobile application on the patient's smartphone. A stress test was performed immediately before the RCRP and repeated after 3 months. The aims were to determine the effectiveness of the RCRP in improving aerobic capacity, and correlating the program goals and first-month activity, with attaining program goals during the last month.

Results

Participants were mostly male (81.5%), aged 58 ± 11, enrolled in the main after a myocardial infarction or coronary interventions. Patients exercised aerobically for 183 min each week, 101 min (55% of total exercise) at the target heart rate. There was a significant improvement in exercise capacity, assessed by stress tests, metabolic equivalents which increased from 9.5 ± 3 to 11.4 ± 7(p < 0.001). Independent predictors of RCRP goals were older age and more minutes of aerobic exercise during the first program month (p < 0.05).

Conclusion

Participants succeeded in performing guideline recommendations, resulting in a significant improvement in exercise capacity. Older age and increased volume of first month of exercise were significant factors associated with a greater likelihood to attain program goals.

Caregiver Distress and Coronary Artery Disease: Prevalence, Risk, Outcomes, and Management

PURPOSE OF REVIEW

Caregivers of patients with coronary artery disease (CAD) are integral to the health care system and contribute substantially to patients' management. The purpose of this review is to provide a narrative synthesis of existing research on caregiving for patients who experienced an acute coronary syndrome (MI/unstable angina) and/or coronary revascularization (PCI/CABG).

RECENT FINDINGS

Thirty-one articles are included in this review. Overall, caregiver distress is low to moderate, ranging from 6 to 67% of caregivers, and seems to dissipate over time for most caregivers. Interventions have demonstrated success in reducing the distress of caregivers of patients with CAD. Due to the heterogeneity in study samples, measurements used, and timing of assessments and programming, these results are far from definitive. Although evidence is accumulating, further advancement in caregiving science and clinical care is required to adequately understand and respond to the needs of caregivers throughout the patient's illness trajectory.

The effect of a game-based mobile app 'MyHeartMate' to promote lifestyle change in coronary disease patients: a randomized controlled trial

Aims

Secondary prevention reduces coronary heart disease (CHD) progression. Traditional prevention programs including cardiac rehabilitation are under-accessed, which smartphone apps may overcome. To evaluate the effect of a game-based mobile app intervention (MyHeartMate) to improve cardiovascular risk factors and lifestyle behaviours.

Methods and results

Single-blind randomized trial of CHD patients in Sydney, 2017-2021. Intervention group were provided the MyHeartMate app for 6 months. Co-designed features included an avatar of the patient's heart and tokens earned by risk factor work (tracking, challenges, and quizzes). The control group received usual care. Primary outcome was self-reported physical activity [metabolic equivalents (METs), Global Physical Activity Questionnaire] and secondary outcomes included lipid levels, blood pressure (BP), body mass index, and smoking. Pre-specified sample size was achieved (n = 390), age 61.2 ± 11.5 years; 82.5% men and 9.2% current smokers. At 6 months, adjusted for baseline levels, the intervention group achieved more physical activity than control (median difference 329 MET mins/wk), which was not statistically significant (95% CI -37.4, 696; P = 0.064). No differences occurred between groups on secondary outcomes except for lower triglyceride levels in the intervention [mean difference -0.3 (95% CI -0.5, -0.1 mmoL/L, P = 0.004)]. Acceptability was high: 94.8% of intervention participants engaged by tracking exercise or BP and completing missions; 26.8% continued to engage for ≥30 days. Participants (n = 14) reported the app supported tracking behaviours and risk factors, reinforcing and improving self-care confidence, and decreasing anxiety.

Conclusion

A game-based app proved highly acceptable for patients with CHD but did not improve risk factors or lifestyle behaviours other than triglyceride levels.

Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK

PURPOSE

Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation.

METHODS

Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement.

RESULTS

A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers.

CONCLUSIONS

This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.

Disparities in Geographic Access to Cardiac Rehabilitation in Los Angeles County

Background Exercise-based cardiac rehabilitation (CR) is known to reduce morbidity and mortality for patients with cardiac conditions. Sociodemographic disparities in accessing CR persist and could be related to the distance between where patients live and where CR facilities are located. Our objective is to determine the association between sociodemographic characteristics and geographic proximity to CR facilities. Methods and Results We identified actively operating CR facilities across Los Angeles County and used multivariable Poisson regression to examine the association between sociodemographic characteristics of residential proximity to the nearest CR facility. We also calculated the proportion of residents per area lacking geographic proximity to CR facilities across sociodemographic characteristics, from which we calculated prevalence ratios. We found that racial and ethnic minorities, compared with non-Hispanic White individuals, more frequently live ≥5 miles from a CR facility. The greatest geographic disparity was seen for non-Hispanic Black individuals, with a 2.73 (95% CI, 2.66-2.79) prevalence ratio of living at least 5 miles from a CR facility. Notably, the municipal region with the largest proportion of census tracts comprising mostly non-White residents (those identifying as Hispanic or a race other than White), with median annual household income <$60 000, contained no CR facilities despite ranking among the county's highest in population density. Conclusions Racial, ethnic, and socioeconomic characteristics are significantly associated with lack of geographic proximity to a CR facility. Interventions targeting geographic as well as nongeographic factors may be needed to reduce disparities in access to exercise-based CR programs. Such interventions could increase the potential of CR to benefit patients at high risk for developing adverse cardiovascular outcomes.

Attachment insecurities, caregiver burden, and psychological distress among partners of patients with heart disease

Caregiver psychological distress (i.e., depression and anxiety) is harmful to both caregiver and patient. Different affect-regulation strategies associated with attachment orientations may impact a caregiver’s perception of their caregiving role as a burden, thereby contributing to their psychological distress. The aim of the present investigation was to examine the links among attachment orientations, caregiver burden, and psychological distress in a cardiac context. Participants (N = 181, Mage = 61.79, SD = 10.49; males = 24.7%) were romantic partners of patients with heart disease (i.e., informal caregivers) who completed validated questionnaires. The majority of caregivers had partners with coronary artery disease (n = 127, 70. 2%). 66.3% of caregivers reported low burden, 87.6% reported low levels of depression and 89.9% reported low levels of anxiety. The mean anxious attachment score was 2.74 (SD = 1.37) and the mean avoidant attachment score was 2.95 (SD = 1.26). Four mediation analyses were run using PROCESS macro for IBM SPSS (version 26). Statistical models showed that the relationships between attachment anxiety and psychological distress were mediated by caregiver burden [abanxiety= 0.15, 95% C.I. (0.04, 0.29); abdepression = 0.15, 95% C.I. (0.05, 0.28)] and that attachment avoidance was not a significant covariate (cvanxiety = −0.02, p>0.05; cvdepression = 0.40, p>0.05). The relationships between attachment avoidance and psychological distress were also mediated by caregiver burden [abanxiety = 0.23, 95% C.I. (0.10, 0.42); abdepression = 0.21, 95% C.I. (0.09, 0.37]with attachment anxiety as a significant covariate (cvanxiety = 1.09, p<0.001; cvdepression = 1.09, p<0.001). Interventions for caregivers reporting attachment insecurity and burden should be explored to potentially lessen caregiver distress as they support their partners with heart disease.

Association of device-measured physical activity and sedentary behaviour with cardiovascular risk factors, health-related quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees with coronary heart disease

Background

Few studies have considered the relationship between risk factors, physical activity and sedentary behaviour in people with heart disease. Here we examine the independent relationship of device-measured physical activity and sedentary behaviour on risk factors, quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees.

Methods

Hospital-based phase II cardiac rehabilitation participants with coronary heart disease were assessed at the start and end of cardiac rehabilitation (6-weeks), 6 and 12-months. Physical activity (moderate-to-vigorous (MVPA), light-intensity (LIPA); min/day) and sedentary behaviour (min/day, bouts, breaks) were measured using an ActiGraph accelerometer. Risk factors included waist circumference, body mass index, systolic blood pressure (SBP), fasting blood lipid and glucose levels, anxiety and depression. Quality-of-life and exercise capacity were also collected. Associations were assessed with Generalized Estimating Equation modeling.

Results

Sixty-seven participants were included (mean age = 64 (SD 9) years; 81% male). An association was found between higher MVPA and lower high density lipoprotein (p ≤ 0.001). No significant (p ≤ 0.001) associations were found between sedentary behaviour variables and other outcomes. At p < 0.05 several associations were significant. Increased MVPA and LIPA were associated with decreased total cholesterol. Higher MVPA was associated with decreased SBP, whereas higher LIPA was associated with decreased waist circumference and body mass index. Higher sedentary behaviour bouts and breaks were associated with increased total cholesterol, anxiety and depression, and decreased SBP over time.

Conclusions

Any intensity of physical activity was associated with decreased total cholesterol. Increased LIPA was associated with improved measures of adiposity, while breaking up sedentary behaviour and increasing MVPA may decrease SBP over time. Further investigation of MVPA, LIPA and the distribution of sedentary behaviour is indicated in cardiac rehabilitation attendees to explore their relationship with risk factors.

Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx. Registered 22 September 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00562-7.

Cardiac rehabilitation performance predicts 1-year major adverse cardiovascular events

BACKGROUND

Cardiac Rehabilitation is an essential following major adverse cardiovascular events however there is no current data correlating rehab performance to long term outcomes.

HYPOTHESIS

Patient exercise performance during cardiac rehabilitation reliably predicts future cardiovascular events.

METHODS

We conducted a single-center study of 486 consecutive patients who participated in a CR program between January 2018 and August 2021. We assessed patient performance using a novel index, the CR-score, which integrated duration, speed of work, and workload conducted on each training device (TD). We used a binary recursive partition model to determine the optimal thresholds for cumulative CR score. We used Cox regression analysis to assess the mortality rate among patients who developed MACE ("study group") and those who did not ("control group").

RESULTS

Among 486 eligible patients, 1-year MACE occurred in 27 (5.5%) patients and was more common in patients with prior cerebrovascular accident or transient ischemic attack (14.8% vs. 3.5%, p < .001). Age, gender, comorbidities, heart failure, and medical treatment did not significantly affect the outcome. The median cumulative CR score of the study group was significantly lower than the control group (595 ± 185.6 vs. 3500 ± 1104.7, p < .0001). A cumulative CR-score of ≥1132 correlated with the outcome (98.5% sensitivity, 99.6% specificity, 95% CI: 0.985-0.997, area 0.994, p < .0001). Patients older than 55 with a cumulative CR score of <1132 were at particularly high risk (OR: 7.4, 95% CI: 2.84-18.42) for 1-year MACE (log-rank p = .03).

CONCLUSION

Our proposed CR-score accurately identifies patients at high risk for 1-year MACE following the rehabilitation program. Multicenter validation is required.

Effect of social support on illness perception in patients with atrial fibrillation during "Blanking Period": Mediating role of sense of mastery

AIM

To explore whether sense of mastery can mediate the relationship between social support and illness perception in patients with atrial fibrillation (AF) who were at the "Blanking Period."

DESIGN

A cross-sectional design.

METHODS

405 patients with AF who were at the "Blanking Period" in the Affiliated Hospital of Qingdao University were recruited; they completed a set of questionnaires, including the Perceived Social Support Scale, the Personal Mastery Scale and the Brief Illness Perception Questionnaire.

RESULTS

Social support and sense of mastery were both adversely connected to illness perception. The indirect effect of social support on illness perception through sense of mastery was negative, accounting for 86.04% of the total effect.

CONCLUSION

During the "Blanking Period," better social support and sense of mastery contribute to a positive illness perception of AF patients. Social support also can influence patients' illness perception indirectly via the mediator of sense of mastery.

Exercise, Physical Activity, and Cardiometabolic Health: Insights into the Prevention and Treatment of Cardiometabolic Diseases

Physical activity (PA) and exercise are widely recognized as essential components of primary and secondary cardiovascular disease (CVD) prevention efforts and are emphasized in the health promotion guidelines of numerous professional societies and committees. The protean benefits of PA and exercise extend across the spectrum of CVD, and include the improvement and reduction of risk factors and events for atherosclerotic CVD (ASCVD), cardiometabolic disease, heart failure, and atrial fibrillation (AF), respectively. Here, we highlight recent insights into the salutary effects of PA and exercise on the primary and secondary prevention of ASCVD, including their beneficial effects on both traditional and nontraditional risk mediators; exercise "prescriptions" for ASCVD; the role of PA regular exercise in the prevention and treatment of heart failure; and the relationships between, PA, exercise, and AF. While our understanding of the relationship between exercise and CVD has evolved considerably, several key questions remain including the association between extreme volumes of exercise and subclinical ASCVD and its risk; high-intensity exercise and resistance (strength) training as complementary modalities to continuous aerobic exercise; and dose- and intensity-dependent associations between exercise and AF. Recent advances in molecular profiling technologies (ie, genomics, transcriptomics, proteomics, and metabolomics) have begun to shed light on interindividual variation in cardiometabolic responses to PA and exercise and may provide new opportunities for clinical prediction in addition to mechanistic insights.

Tracking Cardiac Rehabilitation Utilization in Medicare Beneficiaries: 2017 UPDATE

PURPOSE

This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence.

METHODS

We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type.

RESULTS

In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate >50% and 23 states falling below the overall rate for the United States.

CONCLUSIONS

The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.

Disparities in the Use of Cardiac Rehabilitation in African Americans

Purpose of review

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

Recent findings

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

Summary

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

Active Lifestyle Post First Myocardial Infarction: A Comparison between Participants and Non-Participants of a Structured Cardiac Rehabilitation Program

Following myocardial infarction (MI), impaired physical, mental, and cognitive functions can reduce participation in the community and diminish quality of life. This study aims to assess active lifestyle participation and functional performance in patients who were participants and non-participants in cardiac rehabilitation. A total of 71 patients were recruited, 6-10 months after the MI event; 38 chose to participate in a cardiac rehabilitation (CR) program, and 33 did not (NCR). Participation and activity patterns in instrumental activities of daily living, as well as physically demanding leisure activities and social activities, were evaluated using the Activity Card Sort (ACS). Hand grip force and timed up and go (TUG) were tested. A total of 74% of the CR group met physical activity recommendations and only 34% continued to smoke, compared to 39% and 71% in the NCR group, respectively. The CR group, compared to the NCR group, had higher levels of daily activity, social leisure, and physically demanding leisure activities (p ≤ 0.001). Null differences between the NCR and CR groups were observed in grip strength and the TUG tests. The study highlighted community participation after MI. Based on a comparison between the groups, the study implies that patients choosing to participate in CR retained higher community participation levels and had better self-management of cardiovascular risk factors.

The role of cardiac rehabilitation in improving cardiovascular outcomes

Cardiac rehabilitation is a complex intervention that seeks to improve the functional capacity, wellbeing and health-related quality of life of patients with heart disease. A substantive evidence base supports cardiac rehabilitation as a clinically effective and cost-effective intervention for patients with acute coronary syndrome or heart failure with reduced ejection fraction and after coronary revascularization. In this Review, we discuss the major contemporary challenges that face cardiac rehabilitation. Despite the strong recommendation in current clinical guidelines for the referral of these patient groups, global access to cardiac rehabilitation remains poor. The COVID-19 pandemic has contributed to a further reduction in access to cardiac rehabilitation. An increasing body of evidence supports home-based and technology-based models of cardiac rehabilitation as alternatives or adjuncts to traditional centre-based programmes, especially in low-income and middle-income countries, in which cardiac rehabilitation services are scarce, and scalable and affordable models are much needed. Future approaches to the delivery of cardiac rehabilitation need to align with the growing multimorbidity of an ageing population and cater to the needs of the increasing numbers of patients with cardiac disease who present with two or more chronic diseases. Future research priorities include strengthening the evidence base for cardiac rehabilitation in other indications, including heart failure with preserved ejection fraction, atrial fibrillation and congenital heart disease and after valve surgery or heart transplantation, and evaluation of the implementation of sustainable and affordable models of delivery that can improve access to cardiac rehabilitation in all income settings.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Sex Differences in Cardiac Rehabilitation Outcomes

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

Exercise training in cardiac rehabilitation: Setting the right intensity for optimal benefit

Cardiac rehabilitation (CR) programs are recommended standard-of-care by all major cardiovascular medicine professional organizations. Exercise training is the cornerstone for CR, with aerobic training being the primary form of training. The benefits of exercise training are multiple; however, improved cardiorespiratory fitness is of utmost importance. Moderate-intensity continuous training, supplemented with resistance training, has traditionally been the most common form of exercise training in CR. This review discusses the role of aerobic exercise training in CR and the importance of effective and personalized exercise prescription for optimized results. We also focus on the benefits and utility of high-intensity interval training across different clinical populations commonly seen in the CR setting.

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.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of exercise-based CR (exercise training alone or in combination with psychosocial or educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.

SEARCH METHODS

We updated searches from the previous Cochrane Review, by searching CENTRAL, MEDLINE, Embase, and two other databases in September 2020. We also searched two clinical trials registers in June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months' follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.

DATA COLLECTION AND ANALYSIS

We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).  MAIN RESULTS: This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years. In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years). At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials;  NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes. At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials). At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials). Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias. There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).

AUTHORS' CONCLUSIONS

This updated Cochrane Review supports the conclusions of the previous version, that exercise-based CR provides important benefits to people with CHD, including reduced risk of MI, a likely small reduction in all-cause mortality, and a large reduction in all-cause hospitalisation, along with associated healthcare costs, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up, benefits may include reductions in cardiovascular mortality and MI. In the last decade, trials were more likely to include females, and be undertaken in LMICs, increasing the generalisability of findings. Well-designed, adequately-reported RCTs of CR in people with CHD more representative of usual clinical practice are still needed. Trials should explicitly report clinical outcomes, including mortality and hospital admissions, and include validated HRQoL outcome measures, especially over longer-term follow-up, and assess costs and cost-effectiveness.

Dyadic effects of anxiety and depression on quality of life among couples facing cardiovascular disease

OBJECTIVE

Anxiety and depression are frequently comorbid in patients with cardiovascular disease (CVD) and a patient's poor mental health may implicate the quality of life (QoL) of a partner. The bidirectional effects of comorbid anxiety and depression on patient and partner outcomes are inadequately understood. The aim of this study was to investigate associations of the combined role of depression and anxiety on patients' and partners' QoL.

METHOD

In this cross-sectional study, patients with CVD and their partners completed questionnaires measuring anxiety, depression, and QoL. Dyadic data was analyzed using the Actor-Partner Interdependence Model and polynomial interaction for examining the synergistic and dysergistic effects of anxiety and depression (i.e., in combination).

RESULTS

181 dyads comprised the study sample (66.3% coronary artery disease; 25.9% female patients). Anxiety and depression, in synergy was associated with poorer QoL in patients and partners (actor effects). Patients that are more anxious than depressed have greater physical QoL whereas partners that are more depressed than anxious have greater emotional QoL (dysergistic actor effects). Patients' more severe symptoms of anxiety and depression, in synergy, was associated with partners' poorer QoL (partner effect).

CONCLUSION

Anxiety and depression are comorbid and associated with poor QoL in patients and their partners. The results may have implications for secondary prevention programming but future longitudinal studies are warranted to substantiate the cross-sectional findings.

Effect of early home-based exercise for cardiac rehabilitation on the prognosis of patients with acute myocardial infarction after percutaneous coronary intervention

OBJECTIVE

To investigate the effect of early home-based cardiac rehabilitation (CR) exercise on the prognosis of patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI).

METHODS

The clinical data of 115 patients with AMI in our hospital were collected retrospectively. All patients underwent PCI and were divided into group A (n=57) and group B (n=58) according to postoperative intervention. Patients in group A only received routine rehabilitation guidance, while those in group B received early home-based CR exercise. The incidence of postoperative complications, cardiac function index, 6-minute walking distance (6MWD), cardiac antioxidant index, exercise endurance index and quality of life score were compared between the two groups before and after intervention.

RESULTS

Compared with those in group B, patients in group A showed a lower incidence of postoperative complications (17.54% vs. 3.45%, P<0.05). After intervention, group A had lower left ventricular ejection fraction (LVEF), left ventricular end systolic diameter (LVESD) and left ventricular end diastolic diameter (LVEDD), longer 6MWD, higher total antioxidant capacity (T-AOC) and superoxide dismutase (SOD), lower malonaldehyde (MAD), higher exercise duration (ED), anaerobic threshold (AT) and VO₂ and higher scores of quality of life than group B (P<0.05).

CONCLUSION

Early home-based CR exercise in patients with AMI after PCI can improve cardiac function, reduce the incidence of postoperative complications as well as enhance cardiac antioxidant capacity, exercise ability and quality of life.

Smartphone-guided secondary prevention for patients with coronary artery disease

Introduction

Coronary artery disease (CAD) is the leading cause of death worldwide. Lifestyle change is a crucial part of secondary prevention. Only 30% of CAD patients follow the corresponding guideline recommendations. The widespread adoption of smartphones offers the opportunity to integrate secondary prevention into the daily routine of CAD patients.

Methods

We developed an app to integrate secondary prevention into CAD patients’ everyday life (smartphone-guided secondary prevention, SGSP). The app provided a daily 15-minute program that included video-guided exercises, video sessions with background information about CAD, and a tool to record blood pressure and heart rate once a day. The SGSP app was tested with the primary outcome of 28-day adherence. The secondary outcome was a composite of (1) self-reported behavioral changes, (2) gain of knowledge about cardiovascular risk factors, and (3) an increase in quality of life.

Results

Of the 66 patients screened, 43 (65%) were included into the study and, of those, 17 (40%) used the app continuously for 28 days. From this group, 14 (82%) were physically more active and ten (59%) improved their dietary habits. Usage of the SGSP app was also associated with a gain of knowledge about cardiovascular risk factors (70% physical activity, 59% healthy diet).

Conclusion

The regular use of a SGSP app appears to support lifestyle changes in patients with CAD.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

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.

Health-related risk behaviors among myocardial infarction survivors in the United States: A propensity score matched study

BACKGROUND

According to the American College of Cardiology/the American Heart Association (ACC/AHA) recommendations, health-related risk behaviors for secondary prevention of myocardial infarction (MI) are critical to determine.

OBJECTIVE

This study aimed to compare health-related risk behaviors between MI survivors and propensity-score-matched non-MI controls using nationally representative data.

METHODS

This cross-sectional, matched case-control study used publicly available Behavioral Risk Factor Surveillance System (BRFSS) 2017 data. Older adults with MI were propensity-score-matched to their non-MI controls. The 10 dependent variables included body mass index (BMI), smoking status, heavy alcohol consumption, influenza vaccine, length of time since last routine and cholesterol checkup, alcohol consumption, fruit and vegetable consumption, and physical activity. Chi-square tests and binomial logistic regression were used to examine the health-related risk behaviors differences between MI survivors and propensity-score-matched non-MI controls.

RESULTS

The final study sample consisted of 18,021 MI survivors and 54,063 non-MI controls after propensity score matching. Multivariable logistic regression analysis showed significant differences between MI survivors and matched non-MI controls in terms of cholesterol checkup, smoking status, and alcohol consumption. For example, multivariate analysis of health-related risk behaviors showed MI survivors were more likely to be smokers (AOR = 1.46, 95% CI: 1.28-1.68).

CONCLUSION

Based on this national survey of adults, MI survivors were more likely to be smokers but less likely to consume alcohol compared to their propensity-score-matched controls. Moreover, MI survivors were more likely to have their cholesterol checkup within the past 2 years compared to matched non-MI controls. Although lower alcohol consumption and greater chances of cholesterol checkups are reassuring health-related behaviors, interventions are needed to minimize the chances of smoking in this population.

Relationship of Cisplatin-Related Adverse Health Outcomes With Disability and Unemployment Among Testicular Cancer Survivors

Background

Few data exist on the relationship of cisplatin-related adverse health outcomes (AHOs) with disability, unemployment, and self-reported health (SRH) among testicular cancer survivors (TCS).

Methods

A total of 1815 TCS at least 1 year postchemotherapy underwent clinical examination and completed questionnaires. Treatment data were abstracted from medical records. A cumulative burden of morbidity score (CBM_Pt) encompassed the number and severity of platinum-related AHOs (peripheral sensory neuropathy [PSN], hearing loss, tinnitus, renal disease). Multivariable regression assessed the association of AHOs and CBM_Pt with employment status and SRH, adjusting for sociodemographic and clinical characteristics. Unemployment was compared with a male normative population of similar age, race, and ethnicity.

Results

Almost 1 in 10 TCS was out of work (2.4%, disability leave; 6.8%, unemployed) at a median age of 37 years (median follow-up = 4 years). PSN (odds ratio [OR] = 2.89, 95% confidence interval [CI] = 1.01 to 8.26, grade 3 vs 0, P = .048), renal dysfunction defined by estimated glomerular filtration rate (OR = 12.1, 95% CI = 2.06 to 70.8, grade 2 vs 0, P = .01), pain (OR = 10.6, 95% CI = 4.40 to 25.40, grade 2 or 3 vs 0, P < .001), and CBM_Pt (OR = 1.46, 95% CI = 1.03 to 2.08, P = .03) were associated with disability leave; pain strongly correlated with PSN (r² = 0.40, P < .001). Statistically significantly higher percentages of TCS were unemployed vs population norms (age-adjusted OR = 2.67, 95% CI = 2.49 to 3.02, P < .001). PSN (OR = 2.44, 95% CI = 1.28 to 4.62, grade 3 vs 0, P = .006), patient-reported hearing loss (OR = 1.82, 95% CI = 1.04 to 3.17, grade 2 or 3 vs 0, P = .04), and pain (OR = 3.75, 95% CI = 2.06 to 6.81, grade 2 or 3 vs 0, P < .001) were associated with unemployment. Increasing severity of most cisplatin-related AHOs and pain were associated with statistically significantly worse SRH.

Conclusions

Our findings have important implications regarding treatment-associated productivity losses and socioeconomic costs in this young population. Survivorship care strategies should include inquiries about disability and unemployment status, with efforts made to assist affected TCS in returning to the workforce.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association Between Patient Cost Sharing and Cardiac Rehabilitation Adherence

OBJECTIVE

To determine the association between cost sharing and adherence to cardiac rehabilitation (CR).

PATIENTS AND METHODS

We collected detailed cost-sharing information for patients enrolled in CR at Baystate Medical Center in Springfield, Massachusetts, including the presence (or absence) and amounts of co-pays and deductibles. We evaluated the association between cost sharing and the total number of CR sessions attended as well as the influence of household income on CR attendance.

RESULTS

In 2015, 603 patients enrolled in CR had complete cost-sharing information. In total, 235 (39%) had some form of cost sharing. Of these, 192 (82%) had co-pays (median co-pay, $20; interquartile range [IQR], $10-$32) and 79 (34%) had an unmet deductible (median, $500; IQR, $250-$1800). The presence of any amount or form of cost sharing was associated with 6 fewer sessions of CR (16; IQR, 4-36 vs 10; IQR, 4-27; P<.001). Patients hospitalized in November or December with deductibles that renewed in January attended 4.5 fewer sessions of CR (8.5; IQR, 3.25-12.50 vs 13; IQR, 5.25-36.00; P=.049). After adjustment for differences in baseline characteristics, every $10 increase in co-pay was associated with 1.5 (95% CI, -2.3 to -0.7) fewer sessions of CR (P<.001). Household income did not moderate these relationships.

CONCLUSION

Cost sharing was associated with lower CR attendance and exhibited a dose-response relationship such that higher cost sharing was associated with lower CR attendance. Given that CR is cost-effective and underutilized, insurance companies and other payers should reevaluate their cost-sharing policies for CR.