Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis

Portable bioimpedance analyzer for remote body composition monitoring: A clinical investigation under controlled conditions

OBJECTIVES

In an era when telemedicine is becoming increasingly essential, the development and validation of miniaturized Bioelectrical Impedance Analysis (BIA) devices for accurate and reliable body composition assessment is crucial. This study investigates the BIA Metadieta, a novel miniaturized BIA device, by comparing its performance with that of standard hospital BIA equipment across a diverse demographic. The aim is to enhance remote health monitoring by integrating compact and efficient technology into routine healthcare practices.

METHODS

A cross-sectional observational study was conducted with 154 participants from the Clinical Nutrition Unit. The study compared resistance (R), reactance (Xc), and phase angle (PhA) measurements obtained from the BIA Metadieta device and a traditional hospital-based BIA device.

RESULTS

Analysis revealed strong positive correlations between the BIA Metadieta and the hospital-based device for R (r = 0.988, P < 0.001), Xc (r = 0.946, P < 0.001), and PhA (r = 0.929, P < 0.001), indicating the miniaturized device's high accuracy and reliability. These correlations were consistent across different genders and BMI categories, demonstrating the device's versatility.

CONCLUSIONS

The BIA Metadieta device, with its miniaturized form factor, represents a significant step forward in the field of remote health monitoring, providing a reliable, accurate, and accessible means for assessing body composition.

Comparative efficacy and adherence of telehealth cardiac rehabilitation interventions for patients with cardiovascular disease: A systematic review and network meta-analysis

BACKGROUND

Traditional center-based cardiac rehabilitation had low adherence rates. With the increasing utilization of digital technology in healthcare services, telehealth can overcome common barriers to improve adherence, and some telehealth interventions have been proven safe and effective. However, it remains unclear which telehealth intervention types can maximize the efficacy and adherence for cardiac rehabilitation.

OBJECTIVE

To compare the effect of different types of telehealth interventions on the efficacy and adherence of patients with cardiovascular disease in cardiac rehabilitation.

DESIGN

Systematic review and network meta-analysis.

METHODS

We systematically searched PubMed, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, ProQuest, Scopus, and Embase databases for randomized controlled trials of telehealth cardiac rehabilitation for cardiovascular disease patients from January 2013 to March 2024. The primary outcomes were peak oxygen uptake (VO2 peak) and adherence. Secondary outcomes included 6-minute walking distance, moderate-to-vigorous intensity physical activity, depression, self-reported quality of life, and patient satisfaction. The study protocol has been registered on PROSPERO (ID: CRD42023459643).

RESULTS

This network meta-analysis included 46 randomized controlled trials. The results indicated that telehealth cardiac rehabilitation improved VO2 peak, 6-minute walking distance, moderate-to-vigorous intensity physical activity, and adherence. The surface under the cumulative ranking curve (SUCRA) results showed that the Wearable Devices + Smartphone Applications (SUCRA = 86.8 %, mean rank = 1.7) was the most effective telehealth intervention for improving VO2 peak. The Smartphone Applications + Instant Communication Tools (SUCRA = 74.2 %, mean rank = 2.6) was the most effective telehealth intervention for promoting adherence.

CONCLUSIONS

Combining two or more types of telehealth interventions was found to be effective. Future efforts should prioritize conducting high-quality randomized controlled trials to identify more effective combinations with traditional cardiac rehabilitation.

Application of telemedicine technology for cardiovascular diseases management during the COVID-19 pandemic: a scoping review

Background

Recently, the use of telemedicine technology has increased due to the Covid-19 pandemic. Cardiovascular diseases management is one of the areas that has benefited from using this technology. This study aimed to identify the applications of telemedicine for cardiovascular diseases management during the Covid-19 pandemic.

Methods

This scoping study was conducted in 2023. Various databases, including PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, CINAHL, ProQuest, and IEEE Xplore along with Google Scholar were searched and all related quantitative, qualitative, and mixed-method studies published in English between 2020 and 2022 were included. Finally, the required data were extracted, and the findings were reported narratively.

Results

A total of 17 articles were included in this study. The results showed that teleconsultation via telephone and videoconferencing were the most common used technologies. Telemedicine helped to improve clinical impacts such as patient health status and quality of care, and reduced hospitalizations and re-admission rates compared to in-person visits. The non-clinical impact included reducing waiting time, in-person visits, and healthcare costs during the Covid-19 pandemic.

Conclusion

The Covid-19 pandemic has led to an increased use of telemedicine technology, especially for patients with cardiovascular diseases. As teleconsultation and telemonitoring are useful for cardiovascular diseases management and regular examinations, future research should investigate how these technologies can be improved and used for a wider population.

Cardiac (tele)rehabilitation in routine clinical practice for patients with coronary artery disease: protocol of the REHAB + trial

Introduction

Cardiac rehabilitation programs face the challenge of suboptimal participation, despite being a level Ia recommendation. Cardiac telerehabilitation, with its potential to engage patients who might otherwise not show interest, necessitates the adaption of existing center-based cardiac rehabilitation programs to facilitate rehabilitation at home. REHAB + is a mobile cardiac telerehabilitation program cocreated with patients and rehabilitation centers, aiming to future-proof cardiac rehabilitation and improve accessibility. The REHAB + application enables users to remotely communicate with their coach, receive on-demand feedback on health goal progression, and reduces the need for frequent in-person meetings at the cardiac rehabilitation center. The REHAB + study seeks to compare patient-related outcomes and characteristics of patients between those offered the option to participate in cardiac telerehabilitation and those attending center-based cardiac rehabilitation over a twelve-month period.

Methods

The REHAB + study is a multicenter, prospective, matched controlled, observational study that includes (N)STEMI patients eligible for cardiac rehabilitation. We aim to enroll 300 participants for cardiac telerehabilitation and 600 for center-based cardiac rehabilitation. Participants opting for cardiac telerehabilitation (REHAB+) will be matched with center-based cardiac rehabilitation participants. Additionally, characteristics of patients unwilling to participate in either center-based rehabilitation or telerehabilitation but are willing to share their demographics will be collected. The primary endpoint is quality of life measured with the SF-36 questionnaire at three and twelve months, with patient-related characteristics driving intervention choice as the most important secondary endpoint. Secondary endpoints include physical activity, modifiable risk factors, and digital health experience. The trial is registered at clinicaltrials.gov with registration number NCT05207072.

Discussion

The REHAB + trial is unique by offering patients freedom to choose between cardiac telerehabilitation and center-based rehabilitation. The integration of digital components into cardiac rehabilitation has the potential to complement behavioral change strategies for specific patient groups. Offering patients the option of cardiac telerehabilitation next to center-based rehabilitation could enhance overall cardiac rehabilitation participation rates.

Efficacy of a Mobile Health App (eMOTIVA) Regarding Compliance With Cardiac Rehabilitation Guidelines in Patients With Coronary Artery Disease: Randomized Controlled Clinical Trial

BACKGROUND

Cardiac rehabilitation is fundamental among patients recovering from a coronary event, and mHealth technology may constitute a useful tool that provides guidelines based on scientific evidence in an entertaining, attractive, and user-friendly format.

OBJECTIVE

This study aimed to compare the efficacy of an mHealth intervention involving the eMOTIVA app and that of usual care regarding compliance with cardiac rehabilitation guidelines in terms of lifestyle, cardiovascular risk factors, and satisfaction among patients with acute coronary syndrome.

METHODS

A randomized controlled clinical trial with a parallel group design was conducted. It included 300 patients (mHealth group, 150; control group, 150) who underwent percutaneous coronary intervention for acute coronary syndrome. Both groups underwent evaluations initially (during hospitalization) and after 3 and 6 months (face-to-face consultations). The eMOTIVA app incorporates a virtual classroom providing audio and video information about a healthy lifestyle, a section for self-recording cardiovascular risk factors, and a section for feedback messages and gamification. The primary outcome variables were (1) adherence to the Mediterranean diet and the frequency of consumption of food; (2) physical activity level, sedentary time, and exercise capacity; (3) smoking cessation and nicotine dependence; (4) level of knowledge about cardiovascular risk factors; and (5) app satisfaction and usability.

RESULTS

The study analyzed 287 patients (mHealth group, 145; control group, 142). Most participants were male (207/300, 69.0%), and the mean age was 62.53 (SD 8.65) years. Significant improvements were observed in the mHealth group compared with the control group at 6 months in terms of (1) adherence to the Mediterranean diet (mean 11.92, SD 1.70 vs 8.92, SD 2.66 points; P<.001) and frequency of eating foods (red meat [≤1/week]: 141/143, 97.9% vs 96/141, 68.1%; industrial pastries [<2/week]: 129/143, 89.6% vs 80/141, 56.8%; oily fish [≥2/week]: 124/143, 86.1% vs 64/141, 41.4%; vegetables [≥2/day]: 130/143, 90.3% vs 78/141, 55.3%; fruit [≥2/day]: 128/143, 88.9% vs 85/141, 60.2%; all P<.001); (2) physical activity (mean 2112.66, SD 1196.67 vs 1372.60, SD 944.62 metabolic equivalents/week; P<.001) and sedentary time (mean 8.38, SD 1.88 vs 9.59, SD 2.09 hours; P<.001); (3) exercise capacity (distance: mean 473.49, SD 102.28 vs 447.25, SD 93.68 meters; P=.04); and (4) level of knowledge (mean 117.85, SD 3.83 vs 111.00, SD 7.11 points; P<.001). App satisfaction was high (mean 42.53, SD 6.38 points), and its usability was excellent (mean 95.60, SD 4.03 points).

CONCLUSIONS

With the eMOTIVA app, favorable results were obtained in the intervention group in terms of adherence to the Mediterranean diet, frequency of eating certain foods, physical activity, sedentary time, exercise capacity, knowledge level, systolic blood pressure, heart rate, and blood sugar level. Furthermore, participants reported high app satisfaction and rated its usability as excellent. Thus, this innovative tool is very promising.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05247606; https://clinicaltrials.gov/study/NCT05247606.

Patient-reported convenience and effectiveness of telehealth for breast cancer management

BACKGROUND

Before the coronavirus disease 2019 (COVID-19) pandemic, telehealth was rarely used for breast cancer management at tertiary care centers. We sought to examine patient satisfaction, experiences, preferences, and perceived effectiveness and technical quality of telehealth visits in follow-up patients receiving routine outpatient care in the breast medical oncology practice at The University of Texas MD Anderson Cancer Center.

METHODS

We administered a survey to 60 follow-up patients for a duration of 9 months (January 5, 2021 to October 27, 2021) who had at least one telehealth consultation during the COVID-19 pandemic, from April 10, 2020 to October 21, 2021. Descriptive statistics were then generated for each question, each domain, and overall survey scores. Subgroup comparisons within patient populations were done using the chi-square or t-test when appropriate.

RESULTS

Among the 60 participants, 49 (82%) were undergoing standard follow-up during active treatment for either early-stage or metastatic breast cancer. Telehealth and in-person office visits were considered equivalent in terms of quality of communication by 43 participants (72%). Most participants (n = 49, 82%) felt equally cared for during telehealth and in-person visits, and 40 participants (67%) reported feeling connected to their healthcare professional during both telehealth and in-person visits. In addition, 28 participants (47%) felt that the duration of telehealth visits was similar to in-person visits, 46 (77%) found both telehealth and in-person visits equally comfortable for discussing sensitive topics, 39 (65%) considered telehealth visits convenient, and 42 (70%) perceived the overall quality of care for telehealth to be similar to that of in-person visits. Participants expressed high satisfaction with telehealth appointments, with 42 (70%) rating their experience as very satisfying. Most participants (n = 44, 73%) expressed a strong likelihood of participating in telehealth appointments for breast cancer follow-up care in the future.

CONCLUSIONS

Our results indicate that telehealth can serve as an effective and satisfactory approach for delivering healthcare services to patients with breast cancer requiring follow-up care. The positive experiences and willingness to continue using telehealth indicate its potential for improving access to care and patient outcomes.

Effectiveness of Telerehabilitation Programs in Elderly with Hip or Knee Arthroplasty: A Systematic Review

Background: Lower limb osteoarthritis (OA) often generates musculoskeletal pain causing functional impairment and decreasing mobility, autonomy, and quality of life. Patients with OA are commonly prescribed specific care for total hip arthroplasty or total knee arthroplasty (THA or TKA), when patients present symptoms that are refractory to nondrug treatments. Currently, when patients are discharged from orthopedic surgery, they are either referred to a rehabilitation department, or sent directly home with assistance such as remote monitoring by teleconsultation or a mobile application. In recent years, there has been an evolution in digital health and in particular telerehabilitation. To determine utility and effectiveness, the aim of this systematic review was to highlight and evaluate different telerehabilitation programs using new information and communication technologies. Methods: Five databases, ScienceDirect, PubMed, Web of Sciences, Scopus, and Google scholar, were searched until 30 June 30, 2023. All studies written in English and meeting our inclusion criteria were included. Databases were screened for "Total Hip Arthroplasty," "Total Knee Arthroplasty," "Total Hip Replacement," "Total Knee Replacement," "Rehabilitation," "Physical Activity," "Physiotherapy," "Telerehabilitation," "Telecommunication*," "Senior*," and "Elderly" in accordance with PRISMA-ScR guideline. Results: Fourteen articles were selected according to inclusion criteria. Telerehabilitation was offered in seven different ways (video call, applications smartphones, website, etc.). Assessments included were mainly quality of life questionnaires, perceived effort after exercises, field surveys on the tool experience, and physical tests to assess motor functions. Conclusion: This review highlights the importance and relevance of evaluating the contributions and limits of new health technologies to improve patient monitoring and thus enable better remote clinical care.

Synchronous Group-Based Online Exercise Programs for Older Adults Living in the Community: A Scoping Review

Older adults are the least physically active group with specific barriers to regular exercise, and online exercise programs could overcome some of those barriers. This scoping review aimed to describe the characteristics of supervised group-based synchronous online exercise programs for older adults living in the community, their feasibility, acceptability, and potential benefits. MEDLINE (Ovid), Embase, SPORTDiscus, and the Cumulative Index to Nursing and Allied Health Literature were searched until November 2022. The included studies met the following criteria: participants aged 50 years and above, a minimum of a 6-week group-based supervised and synchronous intervention, and original articles available in English. Eighteen articles were included, with 1,178 participants (67% female, average age of 71 [57-93] years), most (83%) published in the past 3 years. From the limited reported studies, delivering supervised, synchronous online exercise programs (one to three times/week, between 8 and 32 weeks) for older adults living in the community seems feasible, accepted, and can improve physical function.

The effectiveness of cardiac telerehabilitation in comparison to centre-based cardiac rehabilitation programmes: A literature review

INTRODUCTION

Cardiac rehabilitation (CR) is an effective, yet under-utilised, form of secondary prevention in cardiac patients. Telemedicine is one method of overcoming barriers to accessing CR. Previous systematic reviews highlight variation in the effectiveness of telerehabilitation programmes and current literature lacks identification of which telemedicine interventions are most effective, despite differences in the results of primary studies. The objectives of this literature review were to: evaluate the effectiveness of cardiac telerehabilitation compared to centre-based programmes for managing cardiac risk factors, satisfaction and adherence in cardiac patients; identify the technologies used to deliver CR; identify the key components of effective interventions.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Scopus. Randomised controlled trials (RCTs) involving an intervention group that received telerehabilitation and a control group that attended a CR centre were included.

RESULTS

Twelve RCTs met the inclusion criteria. There is evidence to suggest that telerehabilitation programmes have similar effectiveness to centre-based CR. Phones were the most commonly used technology. Most studies used a combination of technologies including personal computers and self-monitoring equipment. Phase III telerehabilitation programmes using self-monitoring, motivational feedback and education were more effective than centre-based CR for increasing physical activity and functional capacity.

CONCLUSION

Cardiac telerehabilitation is delivered by a range of technologies and has a similar effectiveness to centre-based programmes. While evidence suggests that additional health benefits are seen in patients who receive a telemedicine intervention in Phase III of CR, further evidence would be required to confidently draw this conclusion.

Effectiveness of an Interactive mHealth App (EVITE) in Improving Lifestyle After a Coronary Event: Randomized Controlled Trial

BACKGROUND

Coronary heart disease is one of the leading causes of mortality worldwide. Secondary prevention is essential, as it reduces the risk of further coronary events. Mobile health (mHealth) technology could become a useful tool to improve lifestyles.

OBJECTIVE

This study aimed to evaluate the effect of an mHealth intervention on people with coronary heart disease who received percutaneous coronary intervention. Improvements in lifestyle regarding diet, physical activity, and smoking; level of knowledge of a healthy lifestyle and the control of cardiovascular risk factors (CVRFs); and therapeutic adherence and quality of life were analyzed.

METHODS

This was a randomized controlled trial with a parallel group design assigned 1:1 to either an intervention involving a smartphone app (mHealth group) or to standard health care (control group). The app was used for setting aims, the self-monitoring of lifestyle and CVRFs using measurements and records, educating people with access to information on their screens about healthy lifestyles and adhering to treatment, and giving motivation through feedback about achievements and aspects to improve. Both groups were assessed after 9 months. The primary outcome variables were adherence to the Mediterranean diet, frequency of food consumed, patient-reported physical activity, smoking, knowledge of healthy lifestyles and the control of CVRFs, adherence to treatment, quality of life, well-being, and satisfaction.

RESULTS

The study analyzed 128 patients, 67 in the mHealth group and 61 in the control group; most were male (92/128, 71.9%), with a mean age of 59.49 (SD 8.97) years. Significant improvements were observed in the mHealth group compared with the control group regarding adherence to the Mediterranean diet (mean 11.83, SD 1.74 points vs mean 10.14, SD 2.02 points; P<.001), frequency of food consumption, patient-reported physical activity (mean 619.14, SD 318.21 min/week vs mean 471.70, SD 261.43 min/week; P=.007), giving up smoking (25/67, 75% vs 11/61, 42%; P=.01), level of knowledge of healthy lifestyles and the control of CVRFs (mean 118.70, SD 2.65 points vs mean 111.25, SD 9.05 points; P<.001), and the physical component of the quality of life 12-item Short Form survey (SF-12; mean 45.80, SD 10.79 points vs mean 41.40, SD 10.78 points; P=.02). Overall satisfaction was higher in the mHealth group (mean 48.22, SD 3.89 vs mean 46.00, SD 4.82 points; P=.002) and app satisfaction and usability were high (mean 44.38, SD 6.18 out of 50 points and mean 95.22, SD 7.37 out of 100).

CONCLUSIONS

The EVITE app was effective in improving the lifestyle of patients in terms of adherence to the Mediterranean diet, frequency of healthy food consumption, physical activity, giving up smoking, knowledge of healthy lifestyles and controlling CVRFs, quality of life, and overall satisfaction. The app satisfaction and usability were excellent.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04118504; https://clinicaltrials.gov/study/NCT04118504.

Evaluating a technologically enhanced rehabilitation programme for wound healing in patients with coronary heart disease

Wound healing symptoms in patients with coronary heart disease (CHD) are frequently problematic, potentially resulting in complications. In order to tackle this concern, a state-of-the-art rehabilitation programme was created, which incorporated telehealth, virtual reality and robotics in an effort to optimize wound healing in patients with coronary heart disease. The purpose of this research was to assess the efficacy of a rehabilitation programme that utilized cutting-edge technology in enhancing the outcomes of wound recovery for individuals diagnosed with (CHD). Data from 120 CHD patients who participated in this longitudinal randomized controlled trial of a specialized rehabilitation programme intended to promote wound repair were utilized in a cross-sectional analysis. Anthropometric measurements, sociodemographical factors, exercise capacity and the progression of wound recovery were gathered as data. The research participants were primarily comprised of older males from various socioeconomic backgrounds. Age, gender, BMI, socio-educational orientation, physical activity, identified regulation and identified regulation were all significant determinants of wound healing. The significance of customized strategies in cardiac rehabilitation programmes that aim to achieve favourable wound healing outcomes is underscored by these results. In conclusion, this study emphasized the importance of incorporating unique patient attributes when designing technologically advanced rehabilitation protocols aimed at facilitating wound recovery in patients with coronary heart disease. Personalized interventions that consider these variables could potentially result in improved outcomes for wound healing among this particular group of patients.

Effectiveness of mobile health applications on clinical outcomes and health behaviors in patients with coronary heart disease: A systematic review and meta-analysis

Objective

Mobile health applications (apps) have gained significant popularity and widespread utilization among patients with coronary heart disease (CHD). The objective of this study is to evaluate the effects of mHealth apps on clinical outcomes and health behaviors in patients with CHD.

Methods

Databases were searched from inception until December 2023, including Cochrane Library, PubMed, EMBASE, Web of Science, CINAHL, China National Knowledge Infrastructure (CNKI), Chinese BioMedical Literature Service System (SinoMed), Wanfang Data, China Science and Technology Journal Database (VIP), for randomized controlled trials (RCTs) regarding the effectiveness of mHealth apps in patients with CHD. Two researchers conducted a comprehensive review of the literature, extracting relevant data and evaluating each study's methodological quality separately. The meta-analysis was performed utilizing Review Manager v5.4 software.

Results

A total of 34 RCTs were included, with 5,319 participants. The findings demonstrated that using mHealth apps could decrease the incidence of major adverse cardiac events (RR = 0.68, P = 0.03), readmission rate (RR = 0.56, P < 0.001), total cholesterol (WMD = -0.19, P = 0.03), total triglycerides (WMD = -0.24, P < 0.001), waist circumference (WMD = -1.92, P = 0.01), Self-Rating Anxiety Scale score (WMD = -6.70, P < 0.001), and Self-Rating Depression Scale score (WMD = -7.87, P < 0.001). They can also increase the LVEF (WMD = 6.50, P < 0.001), VO2 max (WMD = 1.89, P < 0.001), 6-min walk distance (6MWD) (WMD = 19.43, P = 0.004), Morisky Medication Adherence Scale-8 score (WMD = 0.96, P = 0.004), and medication adherence rate (RR = 1.24, P = 0.03). Nevertheless, there is no proof that mHealth apps can lower low-density lipoprote in cholesterol, blood pressure, BMI, or other indicator (P > 0.05).

Conclusion

Mobile health apps have the potential to lower the incidence of major adverse cardiac events (MACEs), readmission rates, and blood lipids in patients with CHD. They can also help enhance cardiac function, promote medication adherence, and alleviate symptoms of anxiety and depression. To further corroborate these results, larger-scale, multi-center RCTs with longer follow-up periods are needed.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice on telerehabilitation. The European PRM position (UEMS PRM Section)

INTRODUCTION

The evidence on the utility and effectiveness of rehabilitation interventions delivered via telerehabilitation is growing rapidly. Telerehabilitation is expected to have a key role in rehabilitation in the future.

AIM

The aim of this evidence-based position paper (EBPP) is to improve PRM physicians' professional practice in telerehabilitation to be delivered to improve functioning and to reduce activity limitations and/or participation restrictions in individuals with a variety of disabling health conditions.

METHODS

To produce recommendations for PRM physicians on telerehabilitation, a systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section.

RESULTS

The systematic literature review is reported together with the 32 recommendations resulting from the Delphi procedure.

CONCLUSIONS

It is recommended that PRM physicians deliver rehabilitation services remotely, via digital means or using communication technologies to eligible individuals, whenever required and feasible in a variety of health conditions in favor of the patient and his/her family, based on evidence of effectiveness and in compliance with relevant regulations. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in telerehabilitation.

Hybrid Cardiac Rehabilitation Program in a Low-Resource Setting: A Randomized Clinical Trial

Importance

While effective, cardiovascular rehabilitation (CR) as traditionally delivered is not well implemented in lower-resource settings.

Objective

To test the noninferiority of hybrid CR compared with traditional CR in terms of cardiovascular events.

Design, Setting, and Participants

This pragmatic, multicenter, parallel arm, open-label randomized clinical trial (the Hybrid Cardiac Rehabilitation Trial [HYCARET]) with blinded outcome assessment was conducted at 6 referral centers in Chile. Adults aged 18 years or older who had a cardiovascular event or procedure, no contraindications to exercise, and access to a mobile telephone were eligible and recruited between April 1, 2019, and March 15, 2020, with follow-up until July 29, 2021.

Interventions

Participants were randomized 1:1 in permuted blocks to the experimental arm, which received 10 center-based supervised exercise sessions plus counseling in 4 to 6 weeks and then were supported at home via telephone calls and text messages through weeks 8 to 12, or the control arm, which received the standard CR of 18 to 22 sessions with exercises and education in 8 to 12 weeks.

Main Outcomes and Measures

The primary outcome was cardiovascular events or mortality. Secondary outcomes were quality of life, return to work, and lifestyle behaviors measured with validated questionnaires; muscle strength and functional capacity, measured through physical tests; and program adherence and exercise-related adverse events, assessed using checklists.

Results

A total of 191 participants were included (mean [SD] age, 58.74 [9.80] years; 145 [75.92%] male); 93 were assigned to hybrid CR and 98 to standard CR. At 1 year, events had occurred in 5 unique participants in the hybrid CR group (5.38%) and 9 in the standard CR group (9.18%). In the intention-to-treat analysis, the hybrid CR group had 3.80% (95% CI, -11.13% to 3.52%) fewer cardiovascular events than the standard CR group, and relative risk was 0.59 (95% CI, 0.20-1.68) for the primary outcome. In the per-protocol analysis at different levels of adherence to the intervention, all 95% CIs crossed the noninferiority boundary (eg, 20% adherence: absolute risk difference, -0.35% [95% CI, -7.56% to 6.85%]; 80% adherence: absolute risk difference, 3.30% [95% CI, -3.70% to 10.31%]). No between-group differences were found for secondary outcomes except adherence to supervised CR sessions (79.14% [736 of 930 supervised sessions] in the hybrid CR group vs 61.46% [1201 of 1954 sessions] in the standard CR group).

Conclusions and Relevance

The results suggest that a hybrid CR program is noninferior to standard center-based CR in a low-resource setting, primarily in terms of recurrent cardiovascular events and potentially in terms of intermediate outcomes. Hybrid CR may induce superior adherence to supervised exercise. Clinical factors and patient preferences should inform CR model allocation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03881150.

Effectiveness of Telehealth Cardiac Rehabilitation Programs on Health Outcomes of Patients With Coronary Heart Diseases: An Umbrella Review

PURPOSE

The aim of this study was to conduct an umbrella review summarizing the evidence from existing systematic reviews of telehealth cardiac rehabilitation (CR) on health outcomes of patients with coronary heart disease (CHD).

REVIEW METHODS

An umbrella review of systematic reviews was undertaken in accordance with the PRISMA and JBI guidelines. A systematic search was conducted in Medline, APA PsycINFO, Embase, CINAHL, Web of Science, Cochrane database of systematic reviews, JBI evidence synthesis, Epistemonikos, and PROSPERO, searching for systematic reviews published from 1990 to current and was limited to the language source of English and Chinese. Outcomes of interest were health behaviors and modifiable CHD risk factors, psychosocial outcomes, and other secondary outcomes. Study quality was appraised using the JBI checklist for systematic reviews. A narrative analysis was conducted, and meta-analysis results were synthesized.

SUMMARY

From 1301 identified reviews, 13 systematic reviews (10 meta-analyses) comprised 132 primary studies conducted in 28 countries. All the included reviews have high quality, with scores ranging 73-100%. Findings to the health outcomes remained inconclusive, except solid evidence was found in the significant improvement in physical activity (PA) levels and behaviors from telehealth interventions, exercise capacity from mobile health (m-health) only and web-based only interventions, and medication adherence from m-health interventions. Telehealth CR programs, work adjunct or in addition to traditional CR and standard care, are effective in improving health behaviors and modifiable CHD risk factors, particularly in PA. In addition, it does not increase the incidence in terms of mortality, adverse events, hospital readmission, and revascularization.

Main Mechanisms of Remote Monitoring Programs for Cardiac Rehabilitation and Secondary Prevention: A SYSTEMATIC REVIEW

PURPOSE

The objective of this report was to identify the main mechanisms of home-based remote monitoring programs for cardiac rehabilitation (RM CR) and examine how these mechanisms vary by context.

METHODS

This was a systematic review using realist synthesis. To be included, articles had to be published in English between 2010 and November 2020 and contain specific data related to mechanisms of effect of programs. MEDLINE All (1946-) via Ovid, Embase (1974-) via Ovid, APA PsycINFO (1806-), CINAHL via EBSCO, Scopus databases, and gray literature were searched.

RESULTS

From 13 747 citations, 91 focused on cardiac conditions, with 23 reports including patients in CR. Effective RM CR programs more successfully adapted to different patient home settings and broader lives, incorporated individualized patient health data, and had content designed specifically for patients in cardiac rehabilitation. Relatively minor but common technical issues could significantly reduce perceived benefits. Patients and families were highly receptive to the programs and viewed themselves as fortunate to receive such services. The RM CR programs could be improved via incorporating more connectivity to other patients. No clear negative effects on perceived utility or outcomes occurred by patient age, ethnicity, or sex. Overall, the programs were seen to best suit highly motivated patients and consolidated rather than harmed existing relationships with health care professionals and teams.

CONCLUSIONS

Remote monitoring CR programs are perceived by patients to be beneficial and attractive. Future RM CR programs should consider adaptability to different home settings, incorporate individualized health data, and contain content specific to patient needs.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.

OBJECTIVES

To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

MAIN RESULTS

We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.

Is hybrid cardiac rehabilitation superior to traditional cardiac rehabilitation?

BACKGROUND

The current COVID-19 pandemic imposes changes in the management of cardiac pathologies. Cardiac rehabilitation needs to define new protocols to welcome patients back. In connection with the observations of the European Association of Preventive Cardiology, the choice of cardiac tele-rehabilitation appeared to be unavoidable.

AIM

This retrospective research based on data from the Program for the Medicalisation of Information Systems (PMSI) and the electronic medical record analyzes the effect of Hybrid Cardiac Rehabilitation.

METHODS

One hundred and ninety-two patients (29 females and 163 males) with an average of 56.9 years old (±10.3) were able to benefit from a Hybrid Cardiac Rehabilitation program. The data concerning the Stress Test and the Wall Squat Test were collected.

RESULTS

We have noticed that patients had improved their cardiorespiratory capacity on the initial and final Stress Test 6.6 (±1.8) MET to 8.2 (±1.9) MET (p < 0.0001). We also found that patients improved lower limb muscle strength 75.1 (±44.8) seconds to 105.7 (±49.7) seconds (p < 0.0001).

CONCLUSIONS

Hybrid Cardiac Rehabilitation protocols can be set up in this pandemic situation. The programme effectiveness appears to be comparable to the traditional model. However, additional studies are needed to determine the effectiveness of this programme in the long term.

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

AIM

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

METHODS

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

STRUCTURE

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

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

AIM

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

METHODS

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

STRUCTURE

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

Telemedicine in Heart Failure in the COVID-19 and Post-Pandemic Era: What Have We Learned?

Numerous studies showed that patients with heart failure (HF) and COVID-19 are at high risk of in-hospital complications and long-term mortality. Changes in the organisation of the medical system during the pandemic also worsened access to standard procedures, increasing the general mortality in HF and forcing the systems to be reorganised with the implementation and development of telemedical technologies. The main challenges for HF patients during the pandemic could be solved with new technologies aimed to limit the risk of SARS-CoV-2 transmission, optimise and titrate the therapy, prevent the progression and worsening of HF, and monitor patients with acute HF events in the course of and after COVID-19. Dedicated platforms, phone calls or video conferencing and consultation, and remote non-invasive and invasive cardiac monitoring became potential tools used to meet the aforementioned challenges. These solutions showed to be effective in the model of care for patients with HF and undoubtedly will be developed after the experience of the pandemic. However, the multitude of possibilities requires central coordination and collaboration between institutes with data protection and cost reimbursement to create effective mechanisms in HF management. It is crucial that lessons be learned from the pandemic experience to improve the quality of care for HF patients.

Remote cardiac rehabilitation program during the COVID-19 pandemic for patients with stable coronary artery disease after percutaneous coronary intervention: a prospective cohort study

OBJECTIVE

The coronavirus disease-19 (COVID-19) pandemic restricts rapid implementation of in-person delivery of cardiac rehabilitation (CR) at the center for coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI), thus enabling a cohort comparison of in-person vs. remote CR program. This study aims to investigate outcomes of exercise capacity, health-related quality of life (HRQL), mental health, and family burden of stable CAD patients undergoing PCI in low-to-moderate risk after different delivery models of CR program.

METHODS

The study included a cohort of stable CAD patients undergoing PCI who had experienced two naturally occurring modes of CR program after hospital discharge at two time periods, January 2019 to December 2019 (in-person CR program) and May 2020 to May 2021 (remote CR program). The exercise capacity was assessed by means of 6-min walk test (6MWT), maximal oxygen uptake (VO₂max) and the respiratory anaerobic threshold (VO_2AT) before discharge, at the end of the 8-week and 12-week in-person or remote CR program after discharge.

RESULTS

No adverse events occurred during the CR period. CAD patients had a longer distance walked in 6 min with a higher VO_2max after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The distance walked in 6 min was longer and the maximal oxygen uptake (VO₂max) was higher at the end of the 12-week in-person or remote CR program than 8-week in-person or remote CR program (p < 0.05). The respiratory anaerobic threshold (VO_2AT) of CAD patients was decreased after 8-week CR program whether in-person or remote model (p < 0.05). CAD patients receiving remote CR program exhibited higher HRQL scores in domains of vitality (p = 0.048), role emotional (p = 0.039), mental health (p = 0.014), and the summary score of the mental composite (p = 0.048) compared to in-person CR program after 8 weeks. The anxiety and depression scores of CAD patients undergoing PCI were decreased after 8-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote delivery showed lower anxiety and depression scores compared to those receiving in-person delivery at the end of the 8-week CR program (p < 0.05). It was found that the family burden scores of CAD patients undergoing PCI were reduced after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote CR program showed lower family burden scores than those receiving in-person CR program after whether 8 weeks or 12 weeks (p < 0.05).

CONCLUSION

These data indicate that a properly designed and monitored remote delivery represents a feasible and safe model for low-to-moderate-risk, stable CAD patients undergoing PCI inaccessible to in-person CR during the COVID-19 pandemic.

An evidence map of systematic reviews on models of outpatient care for patients with chronic heart diseases

BACKGROUND

Chronic heart disease affects millions of people worldwide and the prevalence is increasing. By now, there is an extensive literature on outpatient care of people with chronic heart disease. We aimed to systematically identify and map models of outpatient care for people with chronic heart disease in terms of the interventions included and the outcomes measured and reported to determine areas in need of further research.

METHODS

We created an evidence map of published systematic reviews. PubMed, Cochrane Library (Wiley), Web of Science, and Scopus were searched to identify all relevant articles from January 2000 to June 2021 published in English or German language. From each included systematic review, we abstracted search dates, number and type of included studies, objectives, populations, interventions, and outcomes. Models of care were categorised into six approaches: cardiac rehabilitation, chronic disease management, home-based care, outpatient clinic, telemedicine, and transitional care. Intervention categories were developed inductively. Outcomes were mapped onto the taxonomy developed by the COMET initiative.

RESULTS

The systematic literature search identified 8043 potentially relevant publications on models of outpatient care for patients with chronic heart diseases. Finally, 47 systematic reviews met the inclusion criteria, covering 1206 primary studies (including double counting). We identified six different models of care and described which interventions were used and what outcomes were included to measure their effectiveness. Education-related and telemedicine interventions were described in more than 50% of the models of outpatient care. The most frequently used outcome domains were death and life impact.

CONCLUSION

Evidence on outpatient care for people with chronic heart diseases is broad. However, comparability is limited due to differences in interventions and outcome measures. Outpatient care for people with coronary heart disease and atrial fibrillation is a less well-studied area compared to heart failure. Our evidence mapping demonstrates the need for a core outcome set and further studies to examine the effects of models of outpatient care or different interventions with adjusted outcome parameters.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42020166330).

Harnessing digital health to optimise the delivery of guideline-based cardiac rehabilitation during COVID-19: an observational study

BACKGROUND

The COVID-19 pandemic accelerated the uptake of digital health interventions for the delivery of cardiac rehabilitation (CR). However, there is a need to evaluate these interventions.

METHODS

We examined the impact of an evidence-based, digital CR programme on medical, lifestyle and psychosocial outcomes. Delivered by an interdisciplinary team of healthcare professionals, the core components of this 12-week programme included lifestyle modification, medical risk factor management, psychosocial and behavioural change support. To support self-management, patients were provided with a Fitbit, a home blood pressure (BP) monitor and an interactive workbook. Patients received access to a bespoke web-based platform and were invited to attend weekly, online group-based supervised exercise sessions and educational workshops. Outcomes were assessed at baseline, end of programme and at 6-month follow-up.

RESULTS

Over a 3-month period, 105 patients (88% with coronary heart disease) were referred with 74% (n=77) attending initial assessment. Of these, 97% (n=75) enrolled in the programme, with 85% (n=64) completing the programme, 86% (n=55) of completers attended 6-month follow-up. Comparing baseline to end of programme, we observed significant improvements in the proportion of patients meeting guideline-recommended targets for physical activity (+68%, p<0.001), BP (+44%, p<0.001) and low-density lipoprotein cholesterol (+27%, p<0.001). There were significant reductions in mean weight (-2.6 kg, p<0.001). Adherence to the Mediterranean diet score improved from 5.2 to 7.3 (p<0.001). Anxiety and depression levels (Hospital Anxiety and Depression score) both reduced by more than 50% (p<0.001). The majority of these improvements were sustained at 6-month follow-up.

CONCLUSION

Outcomes from this study suggest that interdisciplinary digital CR programmes can be successfully implemented and help patients achieve guideline recommended lifestyle, medical and therapeutic targets.

Telerehabilitation as a Therapeutic Exercise Tool versus Face-to-Face Physiotherapy: A Systematic Review

Digital physiotherapy, often referred to as "Telerehabilitation", consists of applying rehabilitation using telecommunication technologies. The objective is to evaluate the effectiveness of therapeutic exercise when it is telematically prescribed.

METHODS

We searched PubMed, Embase, Scopus, SportDiscus and PEDro (30 December 2022). The results were obtained by entering a combination of MeSH or Emtree terms with keywords related to telerehabilitation and exercise therapy. RCTs on patients over 18 years and two groups were included, one working with therapeutic exercise through telerehabilitation and one working with conventional physiotherapy group.

RESULTS

a total of 779 works were found. However, after applying the inclusion criteria, only 11 were selected. Telerehabilitation is most frequently used to treat musculoskeletal, cardiac and neurological pathologies. The preferred telerehabilitation tools are videoconferencing systems, telemonitoring and online platforms. Exercise programs ranged from 10 to 30 min and were similar in both intervention and control groups. In all the studies, results proved to be similar for telerehabilitation and face-to-face rehabilitation in both groups when measuring functionality, quality of life and satisfaction.

CONCLUSION

this review generally concludes that intervention through telerehabilitation programs is as feasible and efficient as conventional physiotherapy in terms of functionality level and quality of life. In addition, telerehabilitation shows high levels of patients' satisfaction and adherence, being values equivalent to traditional rehabilitation.

Remotely Delivered Cardiac Rehabilitation Exercise for Coronary Heart Disease: Nonrandomized Feasibility Study

BACKGROUND

Exercise-based cardiac rehabilitation (CR) is recommended for coronary heart disease (CHD). However, poor uptake of and poor adherence to CR exercise programs have been reported globally. Delivering CR exercise classes remotely may remove some of the barriers associated with traditional hospital- or center-based CR.

OBJECTIVE

We have developed a bespoke platform, Eastern Corridor Medical Engineering Centre-Cardiac Rehabilitation (ECME-CR), to support remotely delivered CR exercise. This pilot trial sought to test the ECME-CR platform and examine the efficacy and feasibility of a remote CR exercise program compared to a traditional center-based program.

METHODS

In all, 21 participants with CHD were recruited and assigned to either the intervention or control group. Both groups performed the same 8-week exercise program. Participants in the intervention group took part in web-based exercise classes and used the ECME-CR platform during the intervention period, whereas participants in the control group attended in-person classes. Outcomes were assessed at baseline and following the 8-week intervention period. The primary outcome measure was exercise capacity, assessed using a 6-minute walk test (6MWT). Secondary outcomes included measurement of grip strength, self-reported quality of life, heart rate, blood pressure, and body composition. A series of mixed between-within subjects ANOVA were conducted to examine the mean differences in study outcomes between and within groups. Participant adherence to the exercise program was also analyzed.

RESULTS

In all, 8 participants (male: n=5; age: mean 69.7, SD 7.2 years; height: mean 163.9, SD 5.4 cm; weight: mean 81.6, SD 14.1 kg) in the intervention group and 9 participants (male: n=9; age: mean 69.8, SD 8.2 years; height: mean 173.8, SD 5.2 cm; weight: mean 94.4, SD 18.0 kg) in the control group completed the exercise program. Although improvements in 6MWT distance were observed from baseline to follow-up in both the intervention (mean 490.1, SD 80.2 m to mean 504.5, SD 93.7 m) and control (mean 510.2, SD 48.3 m to mean 520.6, SD 49.4 m) group, no significant interaction effect (F_1,14=.026; P=.87) nor effect for time (F_1,14=2.51; P=.14) were observed. No significant effects emerged for any of the other secondary end points (all P>.0275). Adherence to the exercise program was high in both the intervention (14.25/16, 89.1%) and control (14.33/16, 89.6%) group. No adverse events or safety issues were reported in either group during the study.

CONCLUSIONS

This pilot trial did not show evidence of significant positive effect for either the remotely delivered or center-based program. The 6MWT may not have been sufficiently sensitive to identify a change in this cohort of participants with stable CHD. This trial does provide evidence that remote CR exercise, supported with digital self-monitoring, is feasible and may be considered for individuals less likely to participate in traditional center-based programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31855.

Comparing Virtual and Center-Based Cardiac Rehabilitation on Changes in Frailty

Many patients with cardiovascular disease (CVD) are frail. Center-based cardiac rehabilitation (CR) can improve frailty; however, whether virtual CR provides similar frailty improvements has not been examined. To answer this question, we (1) compared the effect of virtual and accelerated center-based CR on frailty and (2) determined if admission frailty affected frailty change and CVD biomarkers. The virtual and accelerated center-based CR programs provided exercise and education on nutrition, medication, exercise safety, and CVD. Frailty was measured with a 65-item frailty index. The primary outcome, frailty change, was analyzed with a two-way mixed ANOVA. Simple slopes analysis determined whether admission frailty affected frailty and CVD biomarker change by CR model type. Our results showed that admission frailty was higher in center-based versus virtual participants. However, we observed no main effect of CR model on frailty change. Results also revealed that participants who were frailer at CR admission observed greater frailty improvements and reductions in triglyceride and cholesterol levels when completing virtual versus accelerated center-based CR. Even though both program models did not change frailty, higher admission frailty was associated with greater frailty reductions and change to some CVD biomarkers in virtual CR.

Physiological and psychological effects of a 12-week home-based telemonitored training in metabolic syndrome

Background

Metabolic Syndrome (MetS) increases the risk of cardiovascular diseases (CVD) and affects around one fourth of the population worldwide. In the prevention and treatment regular exercise trainings are inevitable. Providing personal supervision in out/inpatient care settings for such a large target population challenges the healthcare systems, but using telemonitoring of the home-performed trainings could be a promising and widely available option.

Objectives

The aim of this study was to evaluate the physiological and psychological effects of a 12-week home-based physical training program, telemonitored by widely available fitness devices on parameters of MetS patients.

Methods

A total of 55 MetS patients (mean age 49.19 ± 7.93 years) were involved in the study. They were asked to perform 3-5 sessions of exercise activity (min. 150 min) each week for 12 weeks. Trainings were monitored off-line by heart rate sensors, a fitness application and a cloud-based data transfer system. Physiotherapists supervised, coached, and feedback the trainings through an online coach system. We investigated different anthropometric parameters, maximum exercise and functional capacity levels, laboratory parameters, the level of depression, insomnia, vital exhaustion, and wellbeing as well.

Results

The average weekly training time was 152.0 ± 116.2 min. Out of the 55 participants who completed the program, 22 patients (40%) performed the recommended 150 min or more weekly. Patients showed statistically significant changes in: all the measured waist and hip circumferences; 6-min walk distance (6MWD; from 539.69 ± 78.62 to 569.72 ± 79.96 m, p < 0.001); maximal exercise capacity (11.02 ± 2.6 to 12.14 ± 2 MET, p < 0.001), stress-electrocardiogram duration time (13.74 ± 3.29 to 15.66 ± 2.64 min, p < 0.001); body weight (98.72 ± 21.7 to 97.45 ± 21.76 kg, p = 0.004); high-density lipoprotein cholesterol (n = 45, 1.28 ± 0.31 to 1.68 ± 0.36 mmol/L, p < 0.001); fasting plasma glucose (FPG; n = 47, 6.16 ± 1.26 to 5.44 ± 1.31 mmol/L, p = 0.001); glycated hemoglobin A1c (HbA1c; n = 41, 6.22 ± 0.68 to 5.87 ± 0.78%, p = 0.01). Out of the 55 patients who finished the program 38 patients (70%) completed all the psychological questionnaires. We found statistically significant decrease of the overall scores of the Maastricht Vital Exhaustion Questionnaire, from 3.37 ± 2.97 points to 2.63 ± 2.70 points (p < 0.05) and a significant increase of the overall scores of the WHO Wellbeing Scale from 9.92 ± 2.59 points to 10.61 ± 2.76 points (p < 0.05). We have not found any statistically significant changes in the scores of the Beck Depression Inventory and the Athens Insomnia Scale.

Conclusion

A 12-week home-based telemonitored training supported by an affordable, commonly available device system produces positive, statistically significant changes in many core components in MetS patients. Telemonitoring is a cheap method for coaching and feeding back the home-based interventions.

National survey on the secondary preventive measures for coronary artery disease among interventional cardiologists: a report from the Japanese Association of Cardiovascular Intervention and Therapeutics

Insights from recent clinical trial testing revascularization strategies have interested interventional cardiologists in optimal medical therapy and secondary prevention modalities. As no large-scale survey has been recently conducted, this report presents the results of a nationwide survey on interventionists' concerns regarding secondary prevention after percutaneous coronary intervention (PCI) and discusses medical support system needs in Japan. A questionnaire to assess the status and challenges of secondary prevention interventions by interventional cardiologists during outpatient visits was supplied to Cardiovascular Interventional Technology (CVIT)-certificated hospitals. This was answered by representative cardiologists of each hospital and comprised three queries: (1) the necessity of outpatient cardiac rehabilitation to promote post-PCI lifestyle guidance; (2) the feasibility of providing lifestyle guidance; and (3) the barriers to lifestyle guidance, during outpatient visits. Questions 1 and 2 were answered using a 5-point Likert scale. Survey responses were received from 391 hospitals (54.9% of 712 CVIT-certificated facilities). For Question 1, 327 hospitals (84.1%) answered "agree", and 386 hospitals (98.7%) answered "agree" or "somewhat agree". For Question 2, 10% of hospitals answered "agree", and "agree" and "somewhat agree" amounted to less than 50%. For Question 3, 83.5% of the facilities answered lack of time as the major reason). The next reasons included an early reverse referral to family doctors after PCI, and a lack of managerial advantage (60% and 40% of the hospitals, respectively). In conclusion, interventionists are concerned about secondary prevention for their patients. The issues clarified in the survey will be important for developing next-generation secondary prevention systems.

Developing a group-based virtual education curriculum for cardiac rehabilitation and the associated toolkit to support implementation in Canada and across the globe

BACKGROUND

To overcome the many barriers faced by the long-lasting pandemic, the development of new ways to deliver cardiac rehabilitation (CR)'s components was needed.

OBJECTIVE

This mixed-methods study describes the process to create a virtual education curriculum and assess the level of user engagement and acceptability in CR participants.

METHODS

A 4-phase approach was used to develop the new virtual education curriculum for CR and collect feedback regarding patients' engagement with and acceptability of the curriculum in a convenience sample of 80 CR participants. Data were analyzed using a reflexive thematic analysis approach and mapped to the evidence-based implementation strategies, followed by stakeholder engagement. Considering all information gathered and applying best practices in patient education and curriculum development, a 16-week virtual education curriculum was established.

RESULTS

Five themes were identified on how the current education could be improved: focus on self-management, emphasize emotional wellbeing, improve facilitation, incorporate existing resources, and improve content flow. The recommendations associated with each theme informed the new curriculum and a tailored implementation plan to support the use of virtual education as part of routine care within the program. A toolkit that included a screening tool for comfort with/access to technology, patient-centered manuals with weekly learning plans, and a facilitator's manual was created. Overall, all recommended weekly education was completed by more than 70% of the participants, with greater acceptability.

CONCLUSIONS

The present study offers an example of a collaborative approach to tailoring strategies for the development of a new group-based virtual education model of CR.

Effectiveness of mHealth Interventions in the Control of Lifestyle and Cardiovascular Risk Factors in Patients After a Coronary Event: Systematic Review and Meta-analysis

BACKGROUND

Coronary artery disease is the main cause of death and loss of disability-adjusted life years worldwide. Information and communication technology has become an important part of health care systems, including the innovative cardiac rehabilitation services through mobile phone and mobile health (mHealth) interventions.

OBJECTIVE

In this study, we aimed to determine the effectiveness of different kinds of mHealth programs in changing lifestyle behavior, promoting adherence to treatment, and controlling modifiable cardiovascular risk factors and psychosocial outcomes in patients who have experienced a coronary event.

METHODS

A systematic review of the literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A thorough search of the following biomedical databases was conducted: PubMed, Embase, Web of Science, SciELO, CINAHL, Scopus, The Clinical Trial, and Cochrane. Articles that were randomized clinical trials that involved an intervention consisting of an mHealth program using a mobile app in patients after a coronary event were included. The articles analyzed some of the following variables as outcome variables: changes in lifestyle behavior, cardiovascular risk factors, and anthropometric and psychosocial variables. A meta-analysis of the variables studied was performed with the Cochrane tool. The risk of bias was assessed using the Cochrane Collaboration tool; the quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool; and heterogeneity was measured using the I² test.

RESULTS

A total of 23 articles were included in the review, and 20 (87%) were included in the meta-analysis, with a total sample size of 4535 patients. Exercise capacity measured using the 6-minute walk test (mean difference=21.64, 95% CI 12.72-30.55; P<.001), physical activity (standardized mean difference [SMD]=0.42, 95% CI 0.04-0.81; P=.03), and adherence to treatment (risk difference=0.19, 95% CI 0.11-0.28; P<.001) were significantly superior in the mHealth group. Furthermore, both the physical and mental dimensions of quality of life were better in the mHealth group (SMD=0.26, 95% CI 0.09-0.44; P=.004 and SMD=0.27, 95% CI 0.06-0.47; P=.01, respectively). In addition, hospital readmissions for all causes and cardiovascular causes were statistically higher in the control group than in the mHealth group (SMD=-0.03, 95% CI -0.05 to -0.00; P=.04 vs SMD=-0.04, 95% CI -0.07 to -0.00; P=.05).

CONCLUSIONS

mHealth technology has a positive effect on patients who have experienced a coronary event in terms of their exercise capacity, physical activity, adherence to medication, and physical and mental quality of life, as well as readmissions for all causes and cardiovascular causes.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews) CRD42022299931; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299931.

Digitally enabled cardiac rehabilitation following coronary revascularization: results from a single centre feasibility study

Wearable activity monitors, together with smartphone-based health and fitness applications (apps), are becoming more accessible and their widespread use provides an additional opportunity for the recording of cardiovascular metrics in patients with cardiovascular disease. The use of selected metrics by cardiac rehabilitation (CR) programmes allows the facilitation of individualized and tailored positive lifestyle changes to patients and places the patient at the centre of their recovery programme. To investigate the role of such devices on outcomes with patients on a CR programme, a cohort/case–control study was conducted. Patients post-myocardial infarction who were treated with either percutaneous coronary intervention or surgical coronary revascularisation at a single centre were invited to use a physical activity monitor linked to a customized app at their initial assessment for the rehabilitation programme. Those who accepted were allocated to the treatment group. The control group was selected from a larger pool of 400 historical and concurrent patients. Propensity matching was used to associate each case with their closest control. The changes in self-reported physical activity were similar for both groups at the end of the CR programme (EOP). The digitally monitored group tended to achieve greater METS (metabolic equivalent of task - a measure of exercise intensity) at 12 weeks (P &lt; 0.059); however, no difference was observed in the overall change in METS at EOP (P &lt; 0.333). Although no difference was noted in diastolic blood pressure, a statistically significant drop in the systolic blood pressure in the digitally monitored group (P &lt; 0.004) was detected. In this study, the innovative combination of technology and face-to-face CR showed promising results and assisted the individualization of delivered content. This intervention could easily be replicated and expanded. Challenges are the recruitment of the elderly population, those who may be less engaged with or have less access to technology, and the underrepresentation of women in the study sample.

The effect of telemedicine on secondary prevention of atherosclerotic cardiovascular disease: A systematic review and meta-analysis

Aim

The purpose of this systematic review was to evaluate the efficiency of telemedicine on the secondary level of prevention of patients with arteriosclerotic cardiovascular disease (ASCVD), provide evidence for the application of telemedicine in secondary prevention and promote the development of telemedicine in secondary prevention.

Methods

A computer-based search was conducted in MEDLINE, Embase, Pubmed, EBSCO, CINAHL, the Cochrane Library, and Web of Science. Randomized controlled trials regarding the effect of telemedicine on secondary prevention of ASCVD were included from inception to May, 2022. Meta-analysis was used to compare the results of the included studies by RevMan5.4 software. The Cochrane Collaboration bias risk tool was used to perform risk of bias assessment in this study. Outcomes included risk factors, physical activity and exercise, muscle function, exercise compliance, medication adherence, healthy diet, depression and anxiety, self-efficacy, knowledge score, economy, and safety endpoints. Subgroup analysis was carried out for different main intervention measures included in the literature.

Results

A total of 32 randomized clinical studies (n = 10 997 participants) were included in the meta-analysis. Compared with usual secondary prevention (USP) group, participants in telemedicine of secondary prevention (TOSP) group showed significant improvement in some risk factors including BMI (MD -0.87, p = 0.002), SBP (MD -4.09, p = 0.007) and DBP (MD -2.91, p = 0.0002) when they use the telephone as the intervention. In physical activity and exercise, Patients in TOSP showed an improvement in VO2 Peak (mL⋅kg-1⋅min-1) (OR 1.58, p = 0.02), 6MWT (MD 21.41, p = 0.001), GSLTPA score (MD 2.89, p = 0.005). Effects on medication adherence, exercise compliance, muscle function, healthy diet, economy and self-efficacy were synthesized narratively. Patients in TOSP did not show a reduction in knowledge score, depression, anxiety and safety endpoints.

Conclusion

There is a net benefit of secondary prevention supported by telemedicine (especially when using the telephone as an intervention) in patients with ASCVD in the terms of some risk factors, physical activity and exercise. There are still controversies in the improvement of medication adherence, exercise compliance, muscle function, healthy diet, knowledge score, self-efficacy and economy via telemedicine, which is worth exploring. Larger samples size and longer-term follow-ups are needed in future studies.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=330478], identifier [CRD42022330478].

Effects of telemedicine interventions on essential hypertension: a protocol for a systematic review and meta-analysis

INTRODUCTION

Essential hypertension is a major preventable risk factor for early cardiovascular disease, premature death and disability. It has been reported that telemedicine interventions can provide an innovative solution to essential hypertension to overcome the barriers that exist in traditional treatment or control. Nevertheless, this subject has not been thoroughly investigated. The goal of this study is to systematically evaluate and describe the impact of telemedicine interventions on essential hypertension.

METHODS AND ANALYSIS

To find relevant research, we will conduct a systematic literature search of three databases (PubMed, Embase and Cochrane Library), with no language limitations, in addition to researching grey literature. Two reviewers will extract the data individually, and any disagreements will be resolved by discussion or by a third reviewer. The randomised controlled trials will be chosen based on predetermined inclusion criteria. Primary outcomes will include systolic blood pressure and diastolic blood pressure after the telemedicine intervention. Secondary outcomes will include medication adherence (eg, the Morisky Medication Adherence Questionnaire), quality of life (eg, the MOS item scale of the Health Survey Short Form 36 questionnaire), blood pressure control rate and adverse events (eg, stroke, chronic renal failure, aortic dissection, myocardial infarction and heart failure). The quality of the included studies will be assessed using the Cochrane risk-of-bias method. The data will be analysed using RevMan V.5.3.5 software and STATA V.16.0 software. If heterogeneity testing reveals little or no statistical heterogeneity, a fixed effect model will be used for data synthesis; otherwise, a random effect model would be employed. We will synthesise the available evidence to perform a high-quality meta-analysis.

ETHICS AND DISSEMINATION

This project does not require ethical approval because it will be conducted using publicly available documents. The review's findings will be published in peer-reviewed journals and publications.

PROSPERO REGISTRATION NUMBER

CRD42021293539.

The added value of remote technology in cardiac rehabilitation on physical function, anthropometrics, and quality of life: a cluster randomized controlled trial (Preprint)

BACKGROUND

Cardiovascular diseases (CVDs) cause most deaths globally and can reduce quality of life (QoL) of rehabilitees with cardiac disease. The risk factors of CVDs are physical inactivity and increased BMI. With physical activity, it is possible to prevent CVDs, improve QoL, and help maintain a healthy body mass. Current literature shows the possibilities of digitalization and advanced technology in supporting independent self-rehabilitation. However, the interpretation of the results is complicated owing to the studies' high heterogeneity. In addition, the added value of this technology has not been studied well, especially in cardiac rehabilitation.

OBJECTIVE

We aimed to examine the effectiveness of added remote technology in cardiac rehabilitation on physical function, anthropometrics, and QoL in rehabilitees with CVD compared with conventional rehabilitation.

METHODS

Rehabilitees were cluster randomized into 3 remote technology intervention groups (n=29) and 3 reference groups (n=30). The reference group received conventional cardiac rehabilitation, and the remote technology intervention group received conventional cardiac rehabilitation with added remote technology, namely, the Movendos mCoach app and Fitbit charge accelerometer. The 12 months of rehabilitation consisted of three 5-day in-rehabilitation periods in the rehabilitation center. Between these periods were two 6-month self-rehabilitation periods. Outcome measurements included the 6-minute walk test, body mass, BMI, waist circumference, and World Health Organization QoL-BREF questionnaire at baseline and at 6 and 12 months. Between-group differences were assessed using 2-tailed t tests and Mann-Whitney U test. Within-group differences were analyzed using a paired samples t test or Wilcoxon signed-rank test.

RESULTS

Overall, 59 rehabilitees aged 41 to 66 years (mean age 60, SD 6 years; n=48, 81% men) were included in the study. Decrement in waist circumference (6 months: 1.6 cm; P=.04; 12 months: 3 cm; P<.001) and increment in self-assessed QoL were greater (environmental factors: 0.5; P=.02) in the remote technology intervention group than the reference group. Both groups achieved statistically significant improvements in the 6-minute walk test in both time frames (P=.01-.03). Additionally, the remote technology intervention group achieved statistically significant changes in the environmental domain at 0-6 months (P=.03) and waist circumference at both time frames (P=.01), and reference group achieve statistically significant changes in waist circumference at 0-6 months (P=.02).

CONCLUSIONS

Remote cardiac rehabilitation added value to conventional cardiac rehabilitation in terms of waist circumference and QoL. The results were clinically small, but the findings suggest that adding remote technology to cardiac rehabilitation may increase beneficial health outcomes. There was some level of systematic error during rehabilitation intervention, and the sample size was relatively small. Therefore, care must be taken when generalizing the study results beyond the target population. To confirm assumptions of the added value of remote technology in rehabilitation interventions, more studies involving different rehabilitees with cardiac disease are required.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN61225589; https://www.isrctn.com/ISRCTN61225589.

Safety of home-based cardiac rehabilitation: A systematic review

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Standardization of the assessment process within telerehabilitation in chronic diseases: a scoping meta-review

Background

Telerehabilitation (TR) interventions are receiving increasing attention. They have been evaluated in various scientific areas through systematic reviews. However, there is a lack of data on how to standardize assessment and report on their domains to guide researchers across studies and bring together the best evidence to assess TR for chronic diseases.

Aims and objectives

The aim of this study was to identify domains of assessment in TR and to qualitatively and quantitatively analyze how and when they are examined to gain an overview of assessment in chronic disease.

Methods

A scoping meta-review was carried out on 9 databases and gray literature from 2009 to 2019. The keyword search strategy was based on "telerehabilitation", “evaluation", “chronic disease" and their synonyms. All articles were subjected to qualitative analysis using the Health Technology Assessment (HTA) Core Model prior to further analysis and narrative synthesis.

Results

Among the 7412 identified articles, 80 studies met the inclusion criteria and addressed at least one of the noncommunicable diseases (NCD) categories of cardiovascular disease (cardiovascular accidents), cancer, chronic respiratory disease, diabetes, and obesity. Regarding the domains of assessment, the most frequently occurring were “social aspect” (n = 63, 79%) (e.g., effects on behavioral changes) and “clinical efficacy” (n = 53, 66%), and the least frequently occurring was “safety aspects” (n = 2, 3%). We also identified the phases of TR in which the assessment was conducted and found that it most commonly occurred in the pilot study and randomized trial phases and least commonly occurred in the design, pretest, and post-implementation phases.

Conclusions

Through the HTA model, this scoping meta-review highlighted 10 assessment domains which have not been studied with the same degree of interest in the recent literature. We showed that each of these assessment domains could appear at different phases of TR development and proposed a new cross-disciplinary and comprehensive method for assessing TR interventions. Future studies will benefit from approaches that leverage the best evidence regarding the assessment of TR, and it will be interesting to extend this assessment framework to other chronic diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08370-y.

Comparison of Home-Based vs Center-Based Cardiac Rehabilitation in Hospitalization, Medication Adherence, and Risk Factor Control Among Patients With Cardiovascular Disease

IMPORTANCE

Prior studies have suggested that participation in home-based cardiac rehabilitation (HBCR) vs center-based cardiac rehabilitation (CBCR) results in similar clinical outcomes in patients with low to moderate risk; however, outcome data from demographically diverse populations and patients who are medically complex are lacking.

OBJECTIVE

To compare hospitalizations, medication adherence, and cardiovascular risk factor control between participants in HBCR vs CBCR.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted among patients in Kaiser Permanente Southern California (KPSC), an integrated health care system serving approximately 4.7 million patients, who participated in CR between April 1, 2018, and April 30, 2019, and with follow-up through April 30, 2020. Data were analyzed from January 2021 to January 2022.

EXPOSURES

Participation in 1 or more HBCR or CBCR sessions.

MAIN OUTCOMES AND MEASURES

The primary outcome was 12-month all-cause hospitalization. Secondary outcomes included all-cause hospitalizations at 30 and 90 days; 30-day, 90-day, and 12-month cardiovascular hospitalizations; and medication adherence and cardiovascular risk factor control at 12 months. Logistic regression was used to compare hospitalization, medication adherence, and cardiovascular risk factor control, with inverse probability treatment weighting (IPTW) to adjust for demographic and clinical characteristics.

RESULTS

Of 2556 patients who participated in CR (mean [SD] age, 66.7 [11.2] years; 754 [29.5%] women; 1196 participants [46.8%] with Charlson Comorbidity Index ≥4), there were 289 Asian or Pacific Islander patients (11.3%), 193 Black patients (7.6%), 611 Hispanic patients (23.9%), and 1419 White patients (55.5%). A total of 1241 participants (48.5%) received HBCR and 1315 participants (51.5%) received CBCR. After IPTW, patients who received HBCR had lower odds of hospitalization at 12 months (odds ratio [OR], 0.79; 95% CI, 0.64-0.97) but similar odds of adherence to β-blockers (OR, 1.18; 95% CI, 0.98-1.42) and statins (OR, 1.02; 95% CI, 0.84-1.25) and of control of blood pressure (OR, 0.98; 95% CI, 0.81-1.17), low-density lipoprotein cholesterol (OR, 0.98; 95% CI, 0.81-1.20), and hemoglobin A1c (OR, 0.98; 95% CI, 0.82-1.18) at 12 months compared with patients who received CBCR.

CONCLUSIONS AND RELEVANCE

These findings suggest that HBCR in a demographically diverse population, including patients with high risk who are medically complex, was associated with fewer hospitalizations at 12 months compared with patients who participated in CBCR. This study strengthens the evidence supporting HBCR in previously understudied patient populations.

Perspectives on Participation in a Feasibility Study on Exercise-Based Cardiac Telerehabilitation After Transcatheter Aortic Valve Implantation: Qualitative Interview Study Among Patients and Health Professionals

BACKGROUND

Aortic valve stenosis affects approximately half of people aged ≥85 years, and the recommended surgical treatment for older patients is transcatheter aortic valve implantation (TAVI). Despite strong evidence for its advantages, low attendance rate in cardiac rehabilitation is observed among patients after TAVI. Cardiac telerehabilitation (CTR) has proven comparable with center-based rehabilitation; however, no study has investigated CTR targeting patients after TAVI. On the basis of participatory design, an exercise-based CTR program (TeleTAVI) was developed, which included a web-based session with a cardiac nurse, a tablet containing an informative website, an activity tracker, and supervised home-based exercise sessions that follow the national recommendations for cardiac rehabilitation.

OBJECTIVE

This study aims to explore patients' and health professionals' experiences with using health technologies and participating in the exercise-based CTR program, TeleTAVI.

METHODS

This study is a part of a feasibility study and will only report patients' and health professionals' experiences of being a part of TeleTAVI. A total of 11 qualitative interviews were conducted using a semistructured interview guide (n=7, 64% patients and n=4, 36% health professionals). Patient interviews were conducted after 8 weeks of participation in TeleTAVI, and interviews with health professionals were conducted after the end of the program. The analysis was conducted as inductive content analysis to create a condensed meaning presented as themes.

RESULTS

Reticence toward using the website was evident with reduced curiosity to explore it, and reduced benefit from using the activity tracker was observed, as the patients' technical competencies were challenged. This was also found when using the tablet for web-based training sessions, leading to patients feeling worried before the training, as they anticipated technical problems. Disadvantages of the TeleTAVI program were technical problems and inability to use hands-on guidance with the patients. However, both physiotherapists and patients reported a feeling of improvement in patients' physical fitness. The home training created a feeling of safety, supported adherence, and made individualization possible, which the patients valued. A good relationship and continuity in the contact with health professionals seemed very important for the patients and affected their positive attitude toward the program.

CONCLUSIONS

The home-based nature of the TeleTAVI program seems to provide the opportunity to support individualization, autonomy, independence, and adherence to physical training in addition to improvement in physical capability in older patients. Despite technological challenges, basing the relationship between the health professionals and patients on continuity may be beneficial for patients. Prehabilitation may also be considered, as it may create familiarity toward technology and adherence to the training.

Breast cancer survivors’ physical activity and experiences while transitioning to a virtual cardiovascular rehabilitation program during a pandemic (COVID-19)

Breast cancer accounts for 25% of all cancers among Canadian females. Despite successes of decreased mortality, adverse treatment effects, such as cardiotoxicity, contribute to a sedentary lifestyle and decreased quality of life. Physical activity (PA) is a possible therapy for the late effects; however, COVID-19 restricted access to in-person cardiovascular rehabilitation (CR) programs. The purposes are as follows: (1) compare PA of breast cancer survivors’ in-person CR to virtual CR following a transition during COVID-19 and (2) compare the PA of the pandemic cohort to a matched cohort who had completed the program in 2018/2019; (3) explore survivors’ experiences of transitioning to and engaging in virtual CR. Mixed methods included analysis of CR PA data from a pandemic cohort (n = 18) and a 2018/2019 cohort (n = 18) and semi-structured focus group interviews with the pandemic cohort (n = 9) in the context of the PRECEDE-PROCEED model. After the transition, there were no significant differences in mean activity duration, frequency, and cumulative activity (expressed as MET-minutes) (p > 0.05). However, variation of PA duration doubled following the transition from in-person to virtual (p = 0.029), while for the 2018/2019 cohort, variation remained unchanged. Focus groups revealed that women valued their CR experiences pre-COVID-19 and had feelings of anxiety during the transition. Perceived factors affecting participation were environmental, personal, and behavioural. Recommendations for virtual programs were to increase comradery, technology, and professional guidance. PA experiences during a transition to virtual care prompted by a pandemic vary among breast cancer survivors. Targeting individualised strategies and exercise prescriptions are important for improving PA programs and patient outcomes.

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

PURPOSE

This study systematically evaluated the quality and functionalities of patient-facing, commercially available mobile health (mHealth) apps for cardiac rehabilitation (CR).

METHODS

We performed our search in two of the most widely used commercial mobile app stores: Apple iTunes Appstore and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: "cardiac rehabilitation," "heart disease and remote therapy," "heart failure exercise," "heart therapy and cardiac recovery," "cardiac recovery," and "heart therapy." App quality was evaluated using the Mobile Application Rating Scale (MARS). App functionality was evaluated using the IQVIA functionality scale, and app content was evaluated against the American Heart Association guidelines for CR. Apps meeting our inclusion criteria were downloaded and evaluated by two to three reviewers, and interclass correlations between reviewers were calculated.

RESULTS

We reviewed 3121 apps and nine apps met our inclusion criteria. On average, the apps scored a 3.0 on the MARS (5-point Likert scale) for overall quality. The two top-ranking mHealth apps for CR for all three quality, functionality, and consistency with evidence-based guidelines were My Cardiac Coach and Love My Heart for Women, both of which scored ≥4.0 for behavior change.

CONCLUSION

Overall, the quality and functionality of free apps for mobile CR was high, with two apps performing the best across all three quality categories. High-quality CR apps are available that can expand access to CR for patients with cardiovascular disease.

"Medical Assistance in Contextual Awareness" (AMICO): A Project for a Better Quality of Care for Patients in Cardiac Rehabilitation Unit

The "Medical Assistance in Contextual Awareness" (AMICO) project proposes an infrastructure, called an "instrumented environment", consisting of the home environment and the person, both of which are suitably equipped with sensors, a telemedicine service platform (in the Internet of Things) and a Robot who acts as a mediator/master between the person, the surrounding environment and the external environment. This infrastructure, oriented to the citizen's well-being, can offer both services oriented to the person in his home environment, monitoring their behavior and psycho-physical state, and telemedicine services to support the remote monitoring of citizens affected by a cardiovascular event undergoing rehabilitation therapies from part of doctors or caregiver.

Exercise-Based Real-time Telerehabilitation for Older Adult Patients Recently Discharged After Transcatheter Aortic Valve Implantation: Mixed Methods Feasibility Study

BACKGROUND

The use of telehealth technology to improve functional recovery following transcatheter aortic valve implantation (TAVI) has not been investigated.

OBJECTIVE

In this study, we aimed to examine the feasibility of exercise-based cardiac telerehabilitation after TAVI.

METHODS

This was a single-center, prospective, nonrandomized study using a mixed methods approach. Data collection included testing, researchers' observations, logbooks, and individual patient interviews, which were analyzed using a content analysis approach. The intervention lasted 3 weeks and consisted of home-based web-based exercise training, an activity tracker, a TAVI information website, and 1 web-based session with a nurse.

RESULTS

Of the initially included 13 patients, 5 (40%) completed the study and were interviewed; the median age was 82 (range 74-84) years, and the sample comprised 3 men and 2 women. Easy access to supervised exercise training at home with real-time feedback and use of the activity tracker to count daily steps were emphasized by the patients who completed the intervention. Reasons for patients not completing the program included poor data coverage, participants' limited information technology skills, and a lack of functionality in the systems used. No adverse events were reported.

CONCLUSIONS

Exercise-based telerehabilitation for older people after TAVI, in the population as included in this study, and delivered as a web-based intervention, does not seem feasible, as 60% (8/13) of patients did not complete the study. Those completing the intervention highly appreciated the real-time feedback during the web-based training sessions. Future studies should address aspects that support retention rates and enhance patients' information technology skills.

Efficacy of a 6-Week Home-Based Online Supervised Exercise Program Conducted During COVID-19 in Patients With Post Percutaneous Coronary Intervention: A Single-Blind Randomized Controlled Trial

Objective

The aim of this study was to assess the efficacy of a 6-week cardiac rehabilitation (CR) program designed for patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI) that involved an online supervised exercise program that they could access during COVID-19.

Methods

One hundred patients were randomly allocated into control group (CG) and supervision group (SG). CG accepted conventional health education with a home exercise program booklet delivered before discharge, SG had an additional home-based online supervised exercise program (HOSEP). Questionnaires, motor function and lipid profile were administered at baseline. Questionnaires included the Godin-Shephard Leisure-Time Physical Activity questionnaire (GSLTPAQ) and Bandura's Exercise Self-efficacy (ESE). Motor function included: 6-min walk test (6 MWT), timed up and go test (TUG), 30-s sit to stand (30-s STS), and Hand Grip Strength (HG). Lipid profile included: low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC) and triglycerides (TG). The questionnaires were re-administered after 2-weeks, all tests were re-evaluated after 6-weeks.

Results

the questionnaire results showed that scores on GSLTPAQ and ESE were significantly improved in the SG. The changes in GSLTPAQ scores from baseline to 2- and 6-weeks in the SG were significantly higher than in the CG (2-week: 6.9 ± 13.0 for SG and 0.2 ± 10.2 for CG, p = 0.005; 6-week: 9.4 ± 18.1 for SG and 0.2 ± 11.8 for CG, p = 0.003). in terms of motor function, both the CG and SG improved TUG and 6 MWT performance, with the 6 MWT improvement being significantly greater in the SG than CG (43.7 ± 39.2 m for SG and 16.6 ± 39.1 m for CG, p = 0.001). Improvement in the 30-s STS was significantly greater in the SG than CG (2.4 ± 3.6 repetitions for SG and 0.4 ± 3.5 repetitions for CG, p = 0.007). the lipid profile level significantly improved over baseline in both SG and CG after 6-week intervention, and these changes were not statistically different between groups.

Conclusion

This pilot randomized control study demonstrated that a 6-week HOSEP, when added to education delivered pre-hospital discharge for CAD patients following PCI, was beneficial with respect to exercise self-efficacy, exercise behavior, motor function and lipid profile. Supervised exercise programs delivered online in addition to education providing effective and accessible CR during COVID-19.

Delayed medical care due to transportation barriers among adults with atherosclerotic cardiovascular disease

BACKGROUND

In patients with atherosclerotic cardiovascular disease (ASCVD), barriers related to transportation may impair access to care, with potential implications for prognosis. Although few studies have explored transportation barriers among patients with ASCVD, the correlates of delayed care due to transportation barriers have not been examined in this population. We aimed to examine this in U.S. patients with ASCVD using nationally representative data.

METHODS

Using data from the 2009-2018 National Health Interview Survey, we estimated the self-reported prevalence of delayed medical care due to transportation barriers among adults with ASCVD, overall and by sociodemographic characteristics. Logistic regression was used to examine the association between various sociodemographic characteristics and delayed care due to transportation barriers.

RESULTS

Among adults with ASCVD, 4.5% (95% CI; 4.2, 4.8) or ∼876,000 annually reported delayed care due to transportation barriers. Income (low-income: odds ratio [OR] 4.43, 95% CI [3.04, 6.46]; lowest-income: OR 6.35, 95% CI [4.36, 9.23]) and Medicaid insurance (OR 4.53; 95% CI [3.27, 6.29]) were strongly associated with delayed care due to transportation barriers. Additionally, younger individuals, women, non-Hispanic Black adults, and those from the U.S. South or Midwest, had higher odds of reporting delayed care due to transportation barriers.

CONCLUSIONS

Approximately 5% of adults with ASCVD experience delayed care due to transportation barriers. Vulnerable groups include young adults, women, low-income people, and those with public/no insurance. Future studies should analyze the feasibility and potential benefits of interventions such as use of telehealth, mobile clinics, and provision of transportation among patients with ASCVD in the U.S.

Being Uncertain: Rural-Living Cardiac Patients' Experience of Seeking Health Care

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide. Secondary prevention strategies reduce disease progression to heart failure. Rural cardiac patients typically have less access to health care resources to support them in managing secondary prevention, and services to improve quality of life tend to be lacking in rural settings. The study aim was to examine the process that rural cardiac patients go through to access health care and cardiac rehabilitation (CR) following myocardial infarction (MI). In-depth interviews with 11 post-MI participants using Straussian grounded theory were undertaken. Analysis revealed a linear process from hospital discharge to maintaining health. There were five elements: comfort with health information, relationship with health care providers, social support, taking ownership, and availability of/for CR. The core category was "being uncertain." Findings can be used to identify ways to improve access and address uncertainty stemming from a lack of perceived information and supports following discharge.

What Are We Measuring When We Evaluate Digital Interventions for Improving Lifestyle? A Scoping Meta-Review

Background: Lifestyle Medicine (LM) aims to address six main behavioral domains: diet/nutrition, substance use (SU), physical activity (PA), social relationships, stress management, and sleep. Digital Health Interventions (DHIs) have been used to improve these domains. However, there is no consensus on how to measure lifestyle and its intermediate outcomes aside from measuring each behavior separately. We aimed to describe (1) the most frequent lifestyle domains addressed by DHIs, (2) the most frequent outcomes used to measure lifestyle changes, and (3) the most frequent DHI delivery methods. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) Extension for Scoping Reviews. A literature search was conducted using MEDLINE, Cochrane Library, EMBASE, and Web of Science for publications since 2010. We included systematic reviews and meta-analyses of clinical trials using DHI to promote health, behavioral, or lifestyle change. Results: Overall, 954 records were identified, and 72 systematic reviews were included. Of those, 35 conducted meta-analyses, 58 addressed diet/nutrition, and 60 focused on PA. Only one systematic review evaluated all six lifestyle domains simultaneously; 1 systematic review evaluated five lifestyle domains; 5 systematic reviews evaluated 4 lifestyle domains; 14 systematic reviews evaluated 3 lifestyle domains; and the remaining 52 systematic reviews evaluated only one or two domains. The most frequently evaluated domains were diet/nutrition and PA. The most frequent DHI delivery methods were smartphone apps and websites. Discussion: The concept of lifestyle is still unclear and fragmented, making it hard to evaluate the complex interconnections of unhealthy behaviors, and their impact on health. Clarifying this concept, refining its operationalization, and defining the reporting guidelines should be considered as the current research priorities. DHIs have the potential to improve lifestyle at primary, secondary, and tertiary levels of prevention-but most of them are targeting clinical populations. Although important advances have been made to evaluate DHIs, some of their characteristics, such as the rate at which they become obsolete, will require innovative research designs to evaluate long-term outcomes in health.

OUP accepted manuscript

Aims

Enforced suspension and reduction of in-person cardiac rehabilitation (CR) services during the coronavirus disease-19 (COVID-19) pandemic restrictions required rapid implementation of remote delivery methods, thus enabling a cohort comparison of in-person vs. remote-delivered CR participants. This study aimed to examine the health-related quality of life (HRQL) outcomes and patient experiences comparing these delivery modes.

Methods and results

Participants across four metropolitan CR sites receiving in-person (December 2019 to March 2020) or remote-delivered (April to October 2020) programmes were assessed for HRQL (Short Form-12) at CR entry and completion. A General Linear Model was used to adjust for baseline group differences and qualitative interviews to explore patient experiences. Participants (n = 194) had a mean age of 65.94 (SD 10.45) years, 80.9% males. Diagnoses included elective percutaneous coronary intervention (40.2%), myocardial infarction (33.5%), and coronary artery bypass grafting (26.3%). Remote-delivered CR wait times were shorter than in-person [median 14 (interquartile range, IQR 10–21) vs. 25 (IQR 16–38) days, P < 0.001], but participation by ethnic minorities was lower (13.6% vs. 35.2%, P < 0.001). Remote-delivered CR participants had equivalent benefits to in-person in all HRQL domains but more improvements than in-person in Mental Health, both domain [mean difference (MD) 3.56, 95% confidence interval (CI) 1.28, 5.82] and composite (MD 2.37, 95% CI 0.15, 4.58). From qualitative interviews (n = 16), patients valued in-person CR for direct exercise supervision and group interactions, and remote-delivered for convenience and flexibility (negotiable contact times).

Conclusion

Remote-delivered CR implemented during COVID-19 had equivalent, sometimes better, HRQL outcomes than in-person, and shorter wait times. Participation by minority groups in remote-delivered modes are lower. Further research is needed to evaluate other patient outcomes.