A review of guidelines for cardiac rehabilitation exercise programmes: Is there an international consensus?

Opting out of cardiac rehabilitation in local community healthcare services: Patients' perspectives and reflections

RATIONALE

Despite cardiac rehabilitation and medical treatment being integrated parts of the pathway of patients with cardiovascular disease, as well as the well-establish positive effect, cardiac rehabilitation remains underutilised. In recent years, cardiac rehabilitation has increasingly been moved from the hospitals to the community healthcare services. This transition may be challenging for patients with cardiovascular disease.

AIM

To investigate reflections and perspectives of patients opting out of cardiac rehabilitation in community healthcare services to improve participation and adherence to cardiac rehabilitation in the future.

RESULTS

A total of eight patients opting out of cardiac rehabilitation participated in individual interviews. Opting out of cardiac rehabilitation is defined as never enroled or did not complete cardiac rehabilitation. The Interpretive Description methodology was used in the analysis where two themes and six subthemes were identified: (1) 'Structural and organisational factors' with three subthemes; Being a patient in the healthcare system, Enroling into CR when it is meaningful, and Getting back to work is vital, and (2) 'Patients' internal factors' with three subthemes; Feeling a desire to regain control, Seeing yourself as recovered, and Being aware of own needs. The analysis indicates that patients' decision to opt out of CR was multidimensional and based on a combination of factors.

CONCLUSION

Ensuring that the healthcare professionals in the community have sufficient information regarding the patient and a clear communication plan between the healthcare professionals and the patient may reduce the transition causing confusion and frustrations for patients. Incorporating a vocational element in CR and ensuring that employers understand the importance of CR may hamper returning to work as a challenge to CR. Ensuring timely CR referral and enrolment and a transition coordinator may reduce the challenge of patients not viewing CR as meaningful. However, further studies are needed to fully understand how CR could become meaningful for patients opting out of CR.

Exercise intensity prescription in cardiovascular rehabilitation: bridging the gap between best evidence and clinical practice

Optimizing endurance exercise intensity prescription is crucial to maximize the clinical benefits and minimize complications for individuals at risk for or with cardiovascular disease (CVD). However, standardization remains incomplete due to variations in clinical guidelines. This review provides a practical and updated guide for health professionals on how to prescribe endurance exercise intensity for cardiovascular rehabilitation (CR) populations, addressing international guidelines, practical applicability across diverse clinical settings and resource availabilities. In the context of CR, cardiopulmonary exercise test (CPET) is considered the gold standard assessment, and prescription based on ventilatory thresholds (VTs) is the preferable methodology. In settings where this approach isn't accessible, which is frequently the case in low-resource environments, approximating VTs involves combining objective assessments-ideally, exercise tests without gas exchange analyses, but at least alternative functional tests like the 6-minute walk test-with subjective methods for adjusting prescriptions, such as Borg's ratings of perceived exertion and the Talk Test. Therefore, enhancing exercise intensity prescription and offering personalized physical activity guidance to patients at risk for or with CVD rely on aligning workouts with individual physiological changes. A tailored prescription promotes a consistent and impactful exercise routine for enhancing health outcomes, considering patient preferences and motivations. Consequently, the selection and implementation of the best possible approach should consider available resources, with an ongoing emphasis on strategies to improve the delivery quality of exercise training in the context of FITT-VP prescription model (frequency, intensity, time, type, volume, and progression).

Prevalence and influencing factors of kinesiophobia in patients with heart disease: a meta-analysis and systematic review

This study aims to assess the global prevalence of kinesiophobia and the potential influencing factors among patients with heart disease. A comprehensive search was conducted in PubMed, Embase, Web of Science, PsycINFO, and Scopus databases to identify studies reporting on the prevalence of kinesiophobia and its influencing factors in heart disease patients up to January 2024. A random-effects model was employed to aggregate prevalence rates. Heterogeneity sources were investigated through subgroup analysis, while differences in the prevalence of kinesiophobia across regions, types of heart disease, and gender were evaluated. Additionally, a qualitative analysis of the factors influencing kinesiophobia was performed. This research incorporated 15 studies from six countries, with 14 providing data on the prevalence of kinesiophobia and nine exploring its potential influencing factors. The findings indicated that the overall prevalence of kinesiophobia among heart disease patients was 61.0% (95% CI 49.4-72.6%). Subgroup analysis revealed that the prevalence in upper-middle-income countries was 71.8% (95% CI 66.2-77.4%), while it stands at 49.9% (95% CI 30.2-69.5%) in high-income countries. The prevalence rates among patients with coronary artery disease, heart failure, and atrial fibrillation were 63.2% (95% CI 45.2-81.3%), 69.2% (95% CI 57.6-80.8%), and 71.6% (95% CI 67.1-76.1%), respectively. Gender-wise, no significant difference was observed in the prevalence of kinesiophobia between men and women (52.2% vs. 51.8%). A total of 24 potential influencing factors of kinesiophobia were identified, with education level, monthly income, anxiety, and exercise self-efficacy being the most recognized. The prevalence of kinesiophobia in patients with heart disease is notably high and is influenced by a multitude of factors. Early implementation of targeted preventive measures is imperative to mitigate the incidence of kinesiophobia in this population.

Effect of a new resistance training method on the metaboreflex in cardiac rehabilitation patients: a randomized controlled trial

Patients with cardiac disease exhibit exaggerated sympathoexcitation, pressor, and ventilatory responses to muscle metaboreflex activation (MMA). However, the effects of cardiac rehabilitation (CR) and especially resistance training (RT) modalities on MMA are not well known. This study investigated how CR impacts MMA in such patients, specifically examining the effects of two different resistance training (RT) protocols following 12 weeks of CR. In addition to endurance exercises, 32 patients were randomized into either a 3/7 RT modality (comprising 5 sets of 3-7 repetitions) or a control (CTRL) modality (involving 3 sets of 9 repetitions), with distinct inter-set rest intervals (15 s for 3/7 and 60 s for CTRL). MMA, gauged by blood pressure (BP) and ventilatory (Ve) responses during a handgrip exercise at 40% effort and subsequent post-exercise circulatory occlusion, demonstrated CR's significant impact. Systolic BP, initially at + 28 ± 23% pre-CR, improved to + 11 ± 15% post-CR (P = .011 time effect; P = .131 group effect). Diastolic BP showed a similar trend, from + 27 ± 23% to + 13 ± 15% (P = .099 time effect; P = .087 group effect). Ve, initially at + 60 ± 39%, reduced to + 14 ± 19% post-CR (P < .001 time effect; P = .142 group effect). Critical parameters-maximal oxygen consumption, lean mass, hand grip, and quadriceps strength-exhibited parallel increases in both 3/7 and CTRL groups (P < .05 time effect; P > .3 group effect). Ultimately, CR demonstrated comparable improvements in MMA across both RT modalities, indicating its positive influence on cardiovascular responses and physical performance in individuals with cardiac conditions.

High-intensity interval training is feasible, credible and clinically effective in the early subacute stroke stage in the low-income country of Benin

High-intensity interval training (HIIT) has been shown to benefit stroke patients when implemented three months post-stroke. This study examined HIIT's feasibility and clinical effectiveness in the early post-stroke stage in Benin. This was a prospective interventional study comprising an HIIT programme executed on a recumbent bike, three times/week, 20-30 min/session for 6 weeks, added to a conventional physiotherapy. The primary outcomes were feasibility, credibility and expectancy assessed with credibility and expectancy questionnaire. A maximal exercise test, 6-min walking test (6MWT), 10-m walking test (10mWT), Berg balance scale (BBS) and five repetitions sit-to-stand test (5 R-STS) were performed before and after the training programme. Ten outpatients, with a median age [P25-P75]: 63.5[56.7-71.2] years; time since stroke: 15.0[9.7-21.0] days, started and completed all training sessions without serious adverse events. High scores were observed on the Credibility subscale at admission (27.0[25.7-27.0]), which remained so after intervention (26.5[25.7-27.0]). Expectancy subscale scores were high at admission (25.5[24.0-27.0]) and post-training (25.5[24.5-27.0]). Peak workload (p < 0.001), BBS (p < 0.001), 6MWT (p < 0.001), 10mWT (p < 0.001) and 5 R-STS (p = 0.004) were all improved. HIIT is feasible and safe in the early subacute post-stroke stage and is perceived by patients as highly credible, meeting their expectations of recovery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association Between Adherence to a 3-Month Cardiac Rehabilitation Program and Long-Term Clinical Outcomes in Japanese Patients With Cardiac Implantable Electronic Devices

PURPOSE

The objective of this study was to evaluate the association between comprehensive cardiac rehabilitation (CCR) completion and long-term clinical outcomes in patients with cardiac implantable electronic devices (CIED).

METHODS

This retrospective cohort study included 834 patients with CIED who participated in CCR, which included a cardiopulmonary exercise test or 6-min walk test. Patients with a left ventricular ejection fraction ≤40%, predicted peak oxygen uptake ≤80%, or B-type natriuretic peptide level ≥80 pg/mL were eligible. The primary outcome was all-cause mortality.

RESULTS

After excluding 241 patients with duplicate records and 69 who underwent CCR in the outpatient department, the data of 524 patients were analyzed. Mean age was 64 ± 15 yr, 389 (74%) patients were men, left ventricular ejection fraction was 31 ± 15%, and 282 (54%) patients had a history of hospitalization for worsening heart failure. Of the patients referred for CCR, 294 (56%) completed the program, and an additional 230 patients started but did not complete CCR. Over a 3.7-yr median follow-up period, all-cause mortality occurred in 156 (30%) patients. Completers had lower all-cause mortality rates than non-completers (log-rank 15.77, P < .001). After adjusting for prognostic baseline characteristics, completers had 58% lower all-cause mortality risks than non-completers (HR = 0.42; 95% CI, 0.27-0.64, P < .001).

CONCLUSIONS

Three-mo CCR program completion was associated with lower mortality risks in patients with CIED. New programs or management methods are needed to decrease mortality risks, especially for those who cannot complete CCR programs.

Relationship between metabolic status, physical activity and cardiovascular disease in participants with obesity

OBJECTIVE

We aimed to investigate the independent and joint associations between metabolic status, PA (physical activity) and risk of CVD (cardiovascular disease) in participants with obesity.

METHODS

We included 109,301 adults with obesity free of baseline CVD enrolled from 2006 to 2010 in the UK Biobank cohort (aged 56 ± 7.9 years). Based on metabolic status, obesity was grouped into metabolically healthy obesity (MHO; free of hypertension, hypercholesterolemia and diabetes; n = 26,989; BMI 33 ± 3.3 kg/m2) and metabolically unhealthy obesity (MUO; n = 82,312; BMI 34 ± 4.0 kg/m2). PA was categorized into four groups according to moderate-to-vigorous PA (MVPA): none, low, medium, and high. Multivariable Cox regression models were used for the main analyses adjusting for sociodemographic factors, lifestyles and comorbidities.

RESULTS

There were 8,059 CVD events during a median follow-up of 8.1 years. MHO was associated with a 42% reduced risk of CVD compared with MUO (HR = 0.58, 95% CI: 0.53-0.63). A significant interaction effect between PA and metabolic status on CVD risk was found. Among MUO participants, individuals with PA had significantly decreased CVD risk when compared with no MVPA (HR = 0.87, 95% CI: 0.81-0.94 for low PA; HR = 0.85, 95% CI: 0.78-0.93 for medium PA; and HR = 0.86, 95% CI: 0.80-0.92 for high PA). The lowest CVD risk was observed in MHO & medium PA group when compared with MUO & no MVPA (HR = 0.45, 95% CI: 0.37-0.56).

CONCLUSIONS

Both MHO and any MVPA were associated with reduced risk of CVD in adults with obesity, while PA could modify the relationship between metabolic status and CVD risk.

Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands

PURPOSE

Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components.

METHODS

Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components.

RESULTS

In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization.

CONCLUSIONS

CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

Are exercise prescriptions for patients with cardiovascular disease, made by physiotherapists, in agreement with European recommendations?

AIMS

Physiotherapists often treat patients with (elevated risk for) cardiovascular disease (CVD), and should thus be able to provide evidence-based exercise advice to these patients. This study, therefore, aims to examine whether exercise prescriptions by physiotherapists to patients with CVD are in accordance with European recommendations.

METHODS AND RESULTS

This prospective observational survey included forty-seven Belgian physiotherapists. The participants agreed to prescribe exercise intensity, frequency, session duration, program duration, and exercise type (endurance or strength training) for the same three patient cases. Exercise prescriptions were compared between physiotherapists and relations with their characteristics were studied. The agreement between physiotherapists' exercise prescriptions and those from European recommendations ('agreement score': based on a maximal score of 60/per case) was assessed. A wide inter-clinician variability was noticed for all exercise modalities, leading to a large variance for total peak-effort training minutes (from 461 up to 9000 over the three cases). The exercise frequency was prescribed fully out of range of the recommendations and the prescription of additional exercise modes was generally flawed. Exercise intensity and program duration were prescribed partially correct. The addition of strength exercises and session duration was prescribed correctly. This led to physiotherapist agreement scores of 25.3 ± 9.6, 23.2 ± 9.9, and 27.1 ± 10.6 (all out of 60), for cases one, two, and three, respectively. A greater agreement score was found in younger colleagues and those holding a Ph.D.

CONCLUSION

Exercise prescriptions for CVD patients vary widely among physiotherapists and often disagree with European recommendations.

REGISTRATION

ClinicalTrials.gov NCT05449652.

Cost-effectiveness of High-Intensity Interval Training (HIIT) vs Moderate Intensity Steady-State (MISS) Training in UK Cardiac Rehabilitation

OBJECTIVE

To perform a cost-effectiveness analysis of high-intensity interval training (HIIT) compared with moderate intensity steady-state (MISS) training in people with coronary artery disease (CAD) attending cardiac rehabilitation (CR).

DESIGN

Secondary cost-effectiveness analysis of a prospective, assessor-blind, parallel group, multi-center RCT.

SETTING

Six outpatient National Health Service cardiac rehabilitation centers in England and Wales, UK.

PARTICIPANTS

382 participants with CAD (N=382).

INTERVENTIONS

Participants were randomized to twice-weekly usual care (n=195) or HIIT (n=187) for 8 weeks. Usual care was moderate intensity continuous exercise (60%-80% maximum capacity, MISS), while HIIT consisted of 10 × 1-minute intervals of vigorous exercise (>85% maximum capacity) interspersed with 1-minute periods of recovery.

MAIN OUTCOME MEASURES

We conducted a cost-effectiveness analysis of the HIIT or MISS UK trial. Health related quality of life was measured with the EQ-5D-5L to estimate quality-adjusted life years (QALYs). Costs were estimated with health service resource use and intervention delivery costs. Cost-utility analysis measured the incremental cost-effectiveness ratio (ICER). Bootstrapping assessed the probability of HIIT being cost-effective according to the UK National Institute for Health and Care Excellence (NICE) threshold value (£20,000 per QALY). Missing data were imputed. Uncertainty was estimated using probabilistic sensitivity analysis. Assumptions were tested using univariate/1-way sensitivity analysis.

RESULTS

124 (HIIT, n=59; MISS, n=65) participants completed questionnaires at baseline, 8 weeks, and 12 months. Mean combined health care use and delivery cost was £676 per participant for HIIT, and £653 for MISS. QALY changes were 0.003 and -0.013, respectively. For complete cases, the ICER was £1448 per QALY for HIIT compared with MISS. At a willingness-to-pay threshold of £20,000 per QALY, the probability of HIIT being cost-effective was 96% (95% CI, 0.90 to 0.95).

CONCLUSION

For people with CAD attending CR, HIIT was cost-effective compared with MISS. These findings are important to policy makers, commissioners, and service providers across the health care sector.

'The illness isn't the end of the road'-Patient perspectives on the initiation of and early participation in a multi-disease, community-based exercise programme

BACKGROUND

Exercise is the cornerstone of cardiac rehabilitation (CR). Hospital-based CR exercise programmes are a routine part of clinical care and are typically 6-12 weeks in duration. Following completion, physical activity levels of patients decline. Multi-disease, community-based exercise programmes (MCEP) are an efficient model that could play an important role in the long-term maintenance of positive health behaviours in individuals with cardiovascular disease (CVD) following their medically supervised programme.

AIM

To explore patients experiences of the initiation and early participation in a MCEP programme and the dimensions that facilitate and hinder physical activity engagement.

METHODS

Individuals with established CVD who had completed hospital-based CR were referred to a MCEP. The programme consisted of twice weekly group exercise classes supervised by clinical exercise professionals. Those that completed (n = 31) an initial 10 weeks of the programme were invited to attend a focus group to discuss their experience. Focus groups were transcribed and analysed using reflexive thematic analysis.

RESULTS

Twenty-four (63% male, 65.5±6.12yrs) patients attended one of four focus groups. The main themes identified were 'Moving from fear to confidence', 'Drivers of engagement,' and 'Challenges to keeping it (exercise) up'.

CONCLUSION

Participation in a MCEP by individuals with CVD could be viewed as a double-edged sword. Whilst the programme clearly provided an important transition from the clinical to the community setting, there were signs it may breed dependency and not effectively promote independent exercise. Another novel finding was the use of social comparison that provided favourable valuations of performance and increased exercise confidence.

A Systematic Review of Clinical Practice Guidelines and Consensus Statements for Cardiac Rehabilitation Delivery: Consensus, Divergence, and Important Knowledge Gaps

BACKGROUND

After 2020, clinical practice recommendations have been released to inform cardiac rehabilitation (CR) programs of best practices for post-COVID programming. The objective of this systematic review was to identify and summarize recommendations from clinical practice guidelines (CPGs) and consensus statements for CR delivery postpandemic.

METHODS

Five databases (March 2020 through April 2023), grey literature and Web sites of CR international associations were searched. Inclusion criteria were local, national, and international association-endorsed CPGs, and/or position, expert, and scientific statements related to CR delivery (program models, program elements, and core components). Two researchers independently screened the citations for inclusion. The Appraisal of Guidelines for Research and Evaluation (AGREE) II was used for quality assessment. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guidelines.

RESULTS

Overall, 4890 records were identified; 4 CPGs, 9 position/scientific statements, and 6 expert/Delphi consensus papers were included. All guidelines/statements included information related to program delivery models, with 95% endorsing the use of virtual, hybrid, home-based, and telerehabilitation, especially during the pandemic. Outside of the context of COVID-19, program components including referral, CR indications, CR contraindications, timing, and structure were included in the 4 CPGs and 2 of 15 statements. Recommendations related to CR core components were primarily focused on exercise, with no changes since before the pandemic except for COVID-19 considerations for safety. One guideline was specific to women, and 1 scientific statement to heart failure with preserved ejection fraction.

CONCLUSIONS

Although 19 documents were identified, CR delivery in low resource settings and for culturally and linguistically diverse populations require attention. Additionally, few recommendations on nutrition, psychosocial counselling, and patient education were reported.

An Index for Evaluating Exercise Capacity Improvement After Cardiac Rehabilitation in Patients After Myocardial Infarction

OBJECTIVE

We investigated relationships among predictors of improvement in exercise capacity after cardiac rehabilitation programs in patients after acute myocardial infarction.

METHODS

We carried out a secondary analysis of data from 41 patients with a left ventricular ejection fraction ≥ 40% who underwent cardiac rehabilitation after the first myocardial infarction. Participants were assessed using a cardiopulmonary exercise test and stress echocardiography. A cluster analysis was performed, and the principal components were analyzed.

RESULTS

Two distinct clusters with significantly different ( P = .005) proportions of response to treatment (peak VO 2 ≥ 1 mL/kg/min) were identified among patients. The first principal component explained 28.6% of the variance. We proposed an index composed of the top 5 variables from the first component to represent the improvement in exercise capacity. The index was the average of scaled O 2 uptake and CO 2 output at peak exercise, minute ventilation at peak, load achieved at peak exercise, and exercise time. The optimal cutoff for the improvement index was 0.12, which outperformed the peak VO 2 ≥ 1 mL/kg/min criterion in recognizing the clusters, with a C-statistic of 91.7% and 72.3%, respectively.

CONCLUSION

The assessment of change in exercise capacity after cardiac rehabilitation could be improved using the composite index.

Cardiac rehabilitation after cardiac surgery: An important underutilized treatment strategy

Physical inactivity remains in high levels after cardiac surgery, reaching up to 50%. Patients present a significant loss of functional capacity, with prominent muscle weakness after cardiac surgery due to anesthesia, surgical incision, duration of cardiopulmonary bypass, and mechanical ventilation that affects their quality of life. These complications, along with pulmonary complications after surgery, lead to extended intensive care unit (ICU) and hospital length of stay and significant mortality rates. Despite the well-known beneficial effects of cardiac rehabilitation, this treatment strategy still remains broadly underutilized in patients after cardiac surgery. Prehabilitation and ICU early mobilization have been both showed to be valid methods to improve exercise tolerance and muscle strength. Early mobilization should be adjusted to each patient's functional capacity with progressive exercise training, from passive mobilization to more active range of motion and resistance exercises. Cardiopulmonary exercise testing remains the gold standard for exercise capacity assessment and optimal prescription of aerobic exercise intensity. During the last decade, recent advances in healthcare technology have changed cardiac rehabilitation perspectives, leading to the future of cardiac rehabilitation. By incorporating artificial intelligence, simulation, telemedicine and virtual cardiac rehabilitation, cardiac surgery patients may improve adherence and compliance, targeting to reduced hospital readmissions and decreased healthcare costs.

Development and application of a home-based exercise program for patients with cardiovascular disease: a feasibility study

BACKGROUND

Cardiac rehabilitation (CR) is recommended for patients with cardiovascular disease. However, the participation and completion rates for hospital-based CR are low, and home-based CR has been suggested as an alternative. This study aimed to develop a home-based CR program and assess the feasibility of the program over a 6-week period in patients with left ventricular dysfunction or a history of myocardial infarction.

METHODS

This feasibility study consisted of two phases. The initial phase (Study 1) focused on developing the home-based exercise protocol. Systematic approaches to developing evidence-based home-based exercise intervention were implemented including systematic review, patient surveys, and expert consensus. Study 2 aimed to evaluate the feasibility of a 6-week home-based CR program that was based on the results of Study 1. Study 2 included two exercise education sessions and four telephone counseling sessions. During this stage of the exercise program, the participants exercised on two separate days and their experiences while performing the aerobic and resistance exercises were surveyed. Eight participants participated in Study 1 and 16 participated in Study 2.

RESULTS

Participants expressed overall satisfaction with the exercise program in Study 1. Heart rate increased in response to exercise, but this did not correspond with perceived exertion. The aim of the home-based CR exercise program was for participants to achieve exercise goals (≥150 min/week of aerobic type exercises as well as at least twice weekly resistance exercise using own body weights). We aimed to increase compliance and adherence to the home-based CR program. In Study 2, 13 out of 16 participants (81.3%) completed the 6-week home-based CR program, with a participation rate of 100% in both exercise education and phone counseling sessions. Adherence to the home-based exercise protocol was 83.1% and no serious adverse events were observed. At the beginning of the study, only three out of 13 participants (23.1%) met the requirements for both aerobic and resistance exercises, but at the end of the 6-week program, 10 out of 13 participants (76.9%) fulfilled the requirements.

CONCLUSION

The exercise program developed in this study was safe and feasible, and the 6-week home-based CR program was feasible for patients with cardiovascular disease without any reported adverse effects.

Cardiorespiratory Fitness Benefits of Long-Term Maintenance-Phase Cardiac Rehabilitation in Males and Females: A Retrospective Cohort Study

Purpose

This study investigated if associations exist between enrolment delay and VO2peak over five years of maintenance-phase cardiac rehabilitation (CR) in males and females.

Method

Data were extracted from the records of participants who had enrolled for ≥ 1 year in CR and completed ≥ 2 cardiopulmonary exercise tests. Mixed model analyses examined VO2peak trajectories for up to five years of enrolment. Interactions between enrolment delay × enrolment duration, baseline age × enrolment duration, and baseline VO2peak × enrolment duration were explored for inclusion in the model.

Results

The charts of 151 males (aged 63.9 ± 9.4 y) and 32 females (aged 65.3 ± 9.0 y) were included in the analyses. The enrolment delay following a cardiovascular event was 1.8 ± 3.0 years for males and 1.3 ± 1.7 years for females. No associations were found between enrolment delay × enrolment duration on VO2peak in males (β[SEj, 0.07[0.05]; 95% CI -0.02, 0.16, p = 0.12) or in females (β[SE], 0.07[0.13j; 95% CI -0.18, 0.33, p = 0.57), but predicted trajectories suggest clinically significantly improvements in VO2 peak (range, 1.3 to 1.6 mL/kg/min).

Conclusions

Early enrolment in CR is recommended and encouraged, but the benefits of long-term CR are possible despite delays.

Cardiac rehabilitation: the gateway for secondary prevention

Cardiac rehabilitation (CR) is a multidisciplinary supervised programme which typically consists of tailored exercise and education on lifestyle management and risk factor modification in cardiac patients. Participation in CR reduces morbidity and mortality, while improving quality of life following major cardiovascular events. Despite the benefits of CR, it is underutilised, generally in the 20%-30% range for eligible patients. Participation and adherence rates are particularly suboptimal in vulnerable populations, such as those of lower socioeconomic status and women. Interventions such as automated referral to CR or hybrid/virtual programmes can increase enrolment to CR. This review summarises the components of CR and provides recommendations for providers regarding participation and adherence. To better engage a larger proportion of CR-eligible patients, CR programmes may need to expand or adjust ways to deliver secondary prevention.

A behavioural driving model of adherence to home-based cardiac rehabilitation exercise among patients with chronic heart failure: A mixed-methods study

AIMS AND OBJECTIVES

To develop and validate a behavioural driving model for adherence to home-based cardiac rehabilitation exercise in patients with chronic heart failure, and to explain the potential driving mechanism of social support on exercise adherence.

BACKGROUND

Despite the benefits of home-based cardiac rehabilitation exercise, adherence among patients with chronic heart failure remains suboptimal. Several factors contributing to adherence have been confirmed; however, the specific pathway mechanisms by which these factors impact exercise adherence have not been thoroughly explored.

DESIGN

An exploratory sequential mixed-methods study was conducted in this study.

METHODS

A total of 226 patients with chronic heart failure were recruited using convenience sampling. Quantitative data were collected using a series of self-report questionnaires. Hierarchical regression analysis was performed to verify multiple pathways. Subsequently, 12 patients with chronic heart failure were drawn from the quantitative stage. The interview data were thematically analysed. This study followed the Good Reporting of a Mixed Methods Study (GRAMMS) guidelines (Appendix S1).

RESULTS

Perceived social support had a direct positive predictive effect on exercise adherence. Importantly, exercise self-efficacy and exercise fear played a chain-mediating role between perceived social support and exercise adherence. As a result of the qualitative phase, scale, tightness and homogeneity of social support networks emerged as potential drivers of the effectiveness of social support on exercise adherence.

CONCLUSIONS

This study reveals a potential pathway mechanism for social support to improve adherence to home-based cardiac rehabilitation exercises. Social support network plays a crucial role in the effect of social support on exercise adherence.

RELEVANCE TO CLINICAL PRACTICE

To enhance exercise adherence in home-based cardiac rehabilitation for patients with chronic heart failure, establishing a social support network is recommended. This strategy has the potential to promote exercise self-efficacy and alleviate exercise fear.

PATIENT OR PUBLIC CONTRIBUTION

None.

Nurses' knowledge, attitudes, and practices about rehabilitation of patients after heart valve surgery in Namibia

Background

A cardiac rehabilitation programme is a medically supervised intervention to assist patients in recovery after heart surgeries and to prevent potential complications. Nurses should have the knowledge, a positive attitudes, and good practices to improve patient quality of life during the recovery process.

Aim

This study aimed to describe the knowledge, attitudes, and practices of the nurses regarding cardiac rehabilitation for patients after heart valve surgery.

Setting

The study setting was Windhoek Central Hospital, Cardiac Unit, in Windhoek, Namibia.

Methods

A quantitative and descriptive research design was used for convenient non-probability sampling of (N = 23) nurses who consented to participate in the study. Data were collected through self-administered questionnaires and analyzed using SPSS Version 26. Descriptive statistics were used and Fischer's Exact test for associations of variables was performed.

Results

The study results showed a high level of knowledge, good attitudes, and poor to fair practices toward cardiac rehabilitation. However, the respondents demonstrate a lack of knowledge about the indications, and benefits of cardiac rehabilitation, negative attitudes regarding counselling of patients on sexual activities, and poor practice regarding exercises and counseling of patients and caregivers on cardiac rehabilitation. Furthermore, there is a positive relationship between the respondents' older age, senior rank, and having been trained I cardiac conditions and their knowledge, attitudes and practices regarding some core components of cardiac rehabilitation with P-value < 0.050.

Conclusion

There is a need for a cardiac rehabilitation programme to improve nurses' attitudes and practices toward cardiac rehabilitation.

Contribution

Understanding the gap in knowledge, attitudes, and practices among the nurses regarding cardiac rehabilitation would guide the Ministry of Health and Social Services (MoHSS) in the implementation of the cardiac rehabilitation for patients after heart valve surgery.

Long-Term Follow-Up of HRQoL up to Six Years after Outpatient Phase-II Cardiac Rehabilitation

Background: Low health-related quality of life (HRQoL) is associated with adverse cardiovascular outcomes in coronary heart disease (CHD) patients. Cardiac rehabilitation (CR) improves HRQoL; however, evidence on long-term HRQoL changes after CR, and their predictors, is missing. Methods: A total of 153 patients with complete HRQoL data in the short-form (SF)-36 Health Survey at CR entry, discharge and follow-up were included. Using linear mixed-effects regression models for repeated time measurements, we examined predictors of follow-up HRQoL, including age and clinical characteristics. Results: Both physical (t = -5.66, p < 0.001) and mental (t = -2.06, p = 0.040) HRQoL improved significantly from CR entry to discharge, with improvements remaining stable over a mean follow-up of four years (range 2.4-6.1). Better functional capacity (6MWT) at CR entry predicted better physical HRQoL (t = 5.50, p < 0.001) and, with a trend, better mental HRQoL (t = 1.92, p = 0.056) at follow-up. A psychiatric diagnosis at CR entry predicted better mental HRQoL at follow-up (t = 3.85, p < 0.001). Conclusions: Improvements in HRQoL during CR remain stable during long-term follow-up. Levels of functional capacity appear to be relevant to both physical and mental HRQoL at follow-up.

Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review

BACKGROUND AND PURPOSE

Concern for adverse cardiovascular events and limited guidance regarding how to conduct aerobic exercise (AEx) testing for individuals poststroke are key barriers to implementation by physical therapists in stroke rehabilitation. This study aimed to describe the nature and safety of submaximal AEx testing protocols for people with subacute stroke (PwSS) and the nature of comorbidity of PwSS who underwent submaximal AEx testing.

METHODS

We conducted a scoping review and searched MEDLINE, EMBASE, PsycINFO, CINAHL, and SPORTDiscus from inception to October 29, 2020. Studies involving submaximal AEx testing with PwSS, reporting on participant comorbidity and on adverse events during testing, were eligible. Two reviewers independently conducted title and abstract and full-text screening. One reviewer extracted data; a second reviewer verified data.

RESULTS

Thirteen studies involving 452 participants and 19 submaximal AEx testing protocols (10 field test, 7 incremental, and 2 constant load) were included. Hypertension (41%), diabetes (31%), and dyslipidemia (27%) were the most common comorbidities reported. No protocols resulted in a serious adverse event. The most common test termination criterion was a heart rate (HR) limit (9 protocols); a limit of 85% age-predicted maximal HR (APM-HR) most frequently reported. Average APM-HR achieved, computed using mean age and mean peak HR, ranged from 59% to 88% across 13 protocols.

DISCUSSION AND CONCLUSION

Diverse submaximal AEx testing protocols with conservative test termination criteria can be safely implemented with PwSS. Results can inform clinical practice guidelines and address physical therapists' concerns with the occurrence of serious adverse events during submaximal AEx testing.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A430 ).

Exercise therapy as a digital therapeutic for chronic disease management: consideration for clinical product development

Digital exercise therapies (DET) have the potential to bridge existing care gaps for people living with chronic conditions. Acting as either a standalone, embedded within multi-modal lifestyle therapy, or adjunct to pharmacotherapy or surgery, evidence-based DETs can favorably impact the health of a rapidly growing population. Given the nascent nature of digital therapeutics, the regulatory landscape has yet to mature. As such, in the absence of clear guidelines clinical digital product developers are responsible for ensuring the DET adheres to fundamental principles such as patient risk management and clinical effectiveness. The purpose of this narrative review paper is to discuss key considerations for clinical digital product developers who are striving to build novel digital therapeutic (DTx) solutions and thus contribute towards standardization of product development. We herein draw upon DET as an example, highlighting the need for adherence to existing clinical guidelines, human-centered design and an intervention approach that leverages the Chronic Care Model. Specific topics and recommendations related to the development of innovative and scalable products are discussed which ultimately allow for differentiation from a basic wellness tool and integration to clinical workflows. By embodying a code of ethics, clinical digital product developers can adequately address patients' needs and optimize their own future digital health technology assessments including appropriate evidence of safety and efficacy.

Exercise prescription by physiotherapists to patients with cardiovascular disease is in greater agreement with European recommendations after using the EXPERT training tool

BACKGROUND

Exercise prescriptions by clinicians to patients with cardiovascular disease (CVD) often disagree with recommendations, thus requiring improvement.

AIM

To assess whether exercise prescriptions by physiotherapists to patients with CVD are better in agreement with European (ESC/EAPC) recommendations when the EXPERT (EXercise Prescription in Everyday practice & Rehabilitative Training) Training tool is used for digital educational training.

DESIGN

In a prospective non-randomized intervention study.

METHODS

Twenty-three belgian physiotherapists first prescribed exercise intensity, frequency, session duration, program duration and exercise type (endurance or strength training) for the same three patient cases, from which the agreement with ESC/EAPC recommendations (based on a maximal score of 60/per case: agreement score) was assessed. Next, they completed a one-month digital training by using the EXPERT Training tool and completed 31 ± 13 training cases. The EXPERT tool is a training and decision support system that automatically generates a (personalised) exercise prescription according to the patient's characteristics, thus integrating the exercise prescriptions for different CVDs and risk factors, all based on ESC/EAPC recommendations. Thereafter, the same three patient cases as at entry of study were filled out again, with re-assessment of level of agreement with ESC/EAPC recommendations.

RESULTS

After using the EXPERT Training tool, the physiotherapists prescribed significantly greater exercise frequencies, program durations and total exercise volumes in all three patient cases (p < 0.05). In cases 1, 2 and 3, the agreement score increased from 29 ± 9 (out of 60), 28 ± 9, and 34 ± 7 to 41 ± 9, 41 ± 10, and 45 ± 8, respectively (p < 0.001). Hence, the total agreement score increased from 91 ± 17 (out of 180) to 127 ± 19 (p < 0.001, +44 ± 32%). A lower starting agreement score and younger age correlated with a greater improvement in total agreement score (p < 0.05).

CONCLUSIONS

Exercise prescriptions to patients with CVD, generated by physiotherapists, are significantly better in agreement with European recommendations when the EXPERT Training tool is used, indicating its educational potential.

Effect of different exercise regimens on LVEF and restenosis incidence in patients after PCI: a network meta-analysis and an overview of systematic reviews

Objective

We aimed to evaluate the effects of different exercise rehabilitation (ER) programs on LVEF and the incidence of restenosis in patients after percutaneous coronary intervention (PCI) through a systematic review and an integrated network meta-analysis (NMA) to provide a reference for the clinical formulation of ER programs for PCI patients.

Methods

Meta-analyses of the effects of different types of ER programs on LVEF and the incidence of reinfarction in post-PCI patients were retrieved from 11 domestic and foreign databases. The methodological and reporting quality of the included systematic reviews were evaluated using the AMSTAR 2 and PRISMA statements. The GRADE scoring system was used to evaluate the quality of evidence found in the studies included in the meta-analysis, and studies with high and intermediate-quality evidence were qualitatively analyzed. Stata software (version 16.0) was used to conduct an integrated NMA of the original RCTs with moderate and low risk of bias.

Result

Sixteen meta-analyses were included in this evaluation. The reporting quality of the included meta-analyses was relatively complete, and the methodological quality was low. Seventy RCTs were included in the NMA. The results showed that all types of rehabilitative exercises were safe and effectively increased LVEF and reduced the incidence of coronary restenosis in patients. The comprehensive exercise program was the most likely to improve LVEF, and the comprehensive exercise program, early exercise program, and high-intensity interval exercise were better than aerobic exercise. Comprehensive exercise programs, early exercise programs, and aerobic exercise reduced the incidence of restenosis in patients. However, Chinese Qigong did not reduce the incidence of restenosis in patients, and there was a risk of bias and inconsistency in the quantitative analysis of restenosis incidence.

Conclusion

Comprehensive exercise programs have the greatest therapeutic significance in improving cardiac output and reducing restenosis rates in post-PCI patients. The early exercise program has great potential but requires kinesiologists to work with physicians to structure the program and strengthen out-of-hospital management. Aerobic exercise has the least therapeutic significance, and Chinese Qigong is suitable for promotion based on its better efficacy than aerobic exercise and may be an alternative to aerobic exercise, but more experimental evidence is needed.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO CRD42022374590.

Impact of cardiac rehabilitation on cardiovascular event in Korea

This study aimed to evaluate the effects of cardiac rehabilitation (CR) on major adverse cardiac events (MACE) among patients who underwent PCI procedure. We used data from the electronic medical records (EMR) of a tertiary hospital in Seoul, Korea, from January 2014 to February 2020. Data from 2988 patients who had experienced their first acute coronary syndrome (ACS) and had undergone percutaneous coronary intervention (PCI) were included during the study period. we classified patients into CR participants and non-participants based on their participation in the cardiac rehabilitation (CR) program within 30 days after discharge. And the outcome was the incidence of myocardial infarction (MI) and stroke within 1 year after discharge. The association between participation in CR and risk of developing MACE was evaluated using the Cox proportional hazards model. Patients who achieved CR after undergoing PCI were at a lower risk of developing MI (HR 0.68, CI 0.53-0.86). There was no significant association between participation in CR and the incidence of stroke. Among patients who had more than three stenotic vessels, the risk of developing MI within 1 year of discharge was reduced in CR users compared to non-users (3 or more stenosis vessels: HR 0.55, CI 0.35-0.86). Among patients who used two and more stents during PCI procedures, the risk of developing MI within 1 year of discharge was reduced in CR users compared to non-users (2 and more stents: HR 0.54, CI 0.35-0.85). Among people diagnosed with ACS and receiving PCI, patients who participated in CR within one month of discharge reduced risk of developing MI. Our study reinforced the current evidence on the effect of CR among patients receiving PCI and presented the expansion and enhancement of the CR program.

Among Patients Taking Beta-Adrenergic Blockade Therapy, Use Measured (Not Predicted) Maximal Heart Rate to Calculate a Target Heart Rate for Cardiac Rehabilitation

PURPOSE

Among patients in cardiac rehabilitation (CR) on beta-adrenergic blockade (βB) therapy, this study describes the frequency for which target heart rate (THR) values computed using a predicted maximal heart rate (HR max ), correspond to a THR computed using a measured HR max in the guideline-based heart rate reserve (HR reserve ) method.

METHODS

Before CR, patients completed a cardiopulmonary exercise test to measure HR max , with the data used to determine THR via the HR reserve method. Additionally, predicted HR max was computed for all patients using the 220 - age equation and two disease-specific equations, with the predicted values used to calculate THR via the straight percent and HR reserve methods. The THR was also computed using resting heart rate (HR) +20 and +30 bpm.

RESULTS

Mean predicted HR max using the 220 - age equation (161 ± 11 bpm) and the disease-specific equations (123 ± 9 bpm) differed ( P < .001) from measured HR max (133 ± 21 bpm). Also, THR computed using predicted HR max resulted in values that were infrequently within the guideline-based HR reserve range calculated using measured HR max . Specifically, 0 to ≤61% of patients would have had an exercise training HR that fell within the guideline-based range of 50-80% of measured HR reserve . Use of standing resting HR +20 or +30 bpm would have resulted in 100% and 48%, respectively, of patients exercising below 50% of HR reserve .

CONCLUSIONS

A THR computed using either predicted HR max or resting HR +20 or +30 bpm seldom results in a prescribed exercise intensity that is consistent with guideline recommendations for patients in CR.

Hemodynamic Tolerance of New Resistance Training Methods in Patients With Heart Failure and Coronary Artery Disease: A RANDOMIZED CROSSOVER STUDY

PURPOSE

The purpose of this study was to determine and compare the effectiveness of three different resistance training (RT) methods for cardiac rehabilitation.

METHODS

Individuals with heart failure with reduced ejection fraction (HFrEF, n = 23) or coronary artery disease (CAD, n = 22) and healthy controls (CTRL, n = 29) participated in this randomized crossover trial of RT exercises at 70% of the one-maximal repetition on a leg extension machine. Peak heart rate (HR) and blood pressure (BP) were measured noninvasively. The three RT methods were five sets of increasing repetitions from three to seven (RISE), of decreasing repetitions from seven to three (DROP), and three sets of nine repetitions (USUAL). Interset rest intervals were 15 sec for RISE and DROP and 60 sec for USUAL.

RESULTS

Peak HR differed on average by <4 bpm between methods in the HFrEF and CAD groups ( P < .02). Rises in systolic BP (SBP) in the HFrEF group were comparable across methods. In the CAD group, mean SBP at peak exercise increased more in RISE and DROP than in USUAL ( P < .001), but the increase was ≤10 mm Hg. In the CTRL group, SBP was higher for DROP than for USUAL (152 ± 22 vs 144 ± 24 mm Hg, respectively; P < .01). Peak cardiac output and perceived exertion did not differ between methods.

CONCLUSIONS

The RISE, DROP, and USUAL RT methods induced a similar perception of effort and similar increases in peak HR and BP. The RISE and DROP methods appear more efficient as they allow a comparable training volume in a shorter time than the USUAL method.

Enhancing Cardiovascular Health and Functional Recovery in Stroke Survivors: A Randomized Controlled Trial of Stroke-Specific and Cardiac Rehabilitation Protocols for Optimized Rehabilitation

BACKGROUND

Stroke is a major contributor to disability and mortality globally. It leads to physical impairments, including weakness and cardiovascular deconditioning, posing significant challenges to stroke survivors' quality of life. Exercise-based cardiac rehabilitation has shown promise as a rehabilitation strategy. This study aims to assess and compare the impacts of stroke-specific rehabilitation and individualized cardiac rehabilitation exercises on various health parameters in stroke patients.

METHODS

A randomized controlled trial was conducted, involving 38 stroke patients aged 40-75 years. Group A received stroke-specific rehabilitation, which consisted of a combination of range of motion exercises, strength training for the paralyzed side, balance and coordination training, gait training, functional mobility exercises, neuromuscular reeducation, and breathing exercises. This program was conducted five days per week for 12 weeks. Group B received individually designed cardiac rehabilitation exercises, in addition to stroke-specific rehabilitation. They engaged in this exercise for at least 30-45 min per day, four days per week, and incorporated two days of resistive training over a 12-week period. Baseline and post-intervention assessments included measures of cardiac autonomic function, balance (Berg Balance Scale), mobility (Timed Up and Go Test), cardiovascular fitness indicators, respiratory parameters, exercise efficiency, and perceived exertion.

RESULTS

Group B receiving individualized cardio rehab showed significant improvements in balance and mobility compared to Group A receiving conventional stroke-specific rehab. Moreover, Group B exhibited enhanced cardiovascular fitness, respiratory performance, exercise efficiency, and autonomic function post-intervention. Notably, Group A displayed no significant improvements in these parameters.

CONCLUSIONS

Individualized cardiac rehabilitation exercises demonstrated favorable outcomes in improving certain health parameters, highlighting the potential benefits of individualized rehabilitation strategies for stroke patients.

Cluster Sets to Prescribe Interval Resistance Training: A Potential Method to Optimise Resistance Training Safety, Feasibility and Efficacy in Cardiac Patients

The integration of resistance training for cardiac patients leads to important health outcomes that are not optimally obtained with aerobic exercise; these include an increase in muscle mass, maintenance of bone mineral density, and improvements in muscular fitness parameters. Despite the proliferation of evidence supporting resistance exercise in recent decades, the implementation of resistance training is underutilised, and prescription is often sub-optimal in cardiac patients. This is frequently associated with safety concerns and inadequate methods of practical exercise prescription. This review discusses the potential application of cluster sets to prescribe interval resistance training in cardiac populations. The addition of planned, regular passive intra-set rest periods (cluster sets) in resistance training (i.e., interval resistance training) may be a practical solution for reducing the magnitude of haemodynamic responses observed with traditional resistance training. This interval resistance training approach may be a more suitable option for cardiac patients. Additionally, many cardiac patients present with impaired exercise tolerance; this model of interval resistance training may be a more suitable option to reduce fatigue, increase patient tolerance and enhance performance to these workloads. Practical strategies to implement interval resistance training for cardiac patients are also discussed. Preliminary evidence suggests that interval resistance training may lead to safer acute haemodynamic responses in cardiac patients. Future research is needed to determine the efficacy and feasibility of interval resistance training for health outcomes in this population.

Skeletal muscle atrophy, regeneration, and dysfunction in heart failure: Impact of exercise training

This review highlights some established and some more contemporary mechanisms responsible for heart failure (HF)-induced skeletal muscle wasting and weakness. We first describe the effects of HF on the relationship between protein synthesis and degradation rates, which determine muscle mass, the involvement of the satellite cells for continual muscle regeneration, and changes in myofiber calcium homeostasis linked to contractile dysfunction. We then highlight key mechanistic effects of both aerobic and resistance exercise training on skeletal muscle in HF and outline its application as a beneficial treatment. Overall, HF causes multiple impairments related to autophagy, anabolic-catabolic signaling, satellite cell proliferation, and calcium homeostasis, which together promote fiber atrophy, contractile dysfunction, and impaired regeneration. Although both wasting and weakness are partly rescued by aerobic and resistance exercise training in HF, the effects of satellite cell dynamics remain poorly explored.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Cardiac Rehabilitation in the Modern Era: Optimizing Recovery and Reducing Recurrence

Cardiovascular diseases (CVDs) continue to be a prominent issue in global health, emphasizing the necessity for efficient cardiac rehabilitation programs. This narrative review provides a detailed analysis of the current state of cardiac rehabilitation, focusing on maximizing recovery and minimizing the likelihood of recurrence. This paper examines the historical progression of cardiac rehabilitation, explores the epidemiological background of cardiovascular disease (CVD), and provides an overview of the many stages of the rehabilitation process. The assessment of patients plays a crucial role in healthcare, serving as a fundamental basis that incorporates medical, psychological, and social aspects. The utilization of risk stratification techniques further enhances this process. The present study investigates exercise training, particularly emphasizing the current recommendations and the mutually beneficial effects of aerobic and resistance regimens. In addition to physical therapies, this study emphasizes the importance of nutrition, lifestyle adjustments, and the significant effects of medication. Psychosocial assistance is a crucial element that addresses the significant psychological effects of cardiac disease and provides comprehensive techniques for overall well-being. Technological advancements are significantly transforming the domain of cardiac rehabilitation, encompassing the integration of wearable technologies and telemedicine solutions. The convergence of artificial intelligence and data analytics can enhance the customization of healthcare services. Through a comprehensive rehabilitation program, patients can achieve an improved quality of life and enhanced functional outcomes. However, it is essential to acknowledge that obstacles still hinder individuals from accessing and completing educational programs. Therefore, it is crucial to engage in a discourse on potential tactics that may be employed to address these issues, considering the various cultural and socioeconomic aspects that contribute to them. The analysis focuses on the economic dimension, examining the cost-effectiveness of rehabilitation programs and their congruence with healthcare policies. In anticipation of future developments, the study provides valuable perspectives on the prospective trajectory of cardiac rehabilitation. It delves into nascent patterns and examines the potential ramifications of precision medicine and genetics for tailoring treatment strategies to individual patients. In brief, this narrative review comprehensively examines the various dimensions of contemporary cardiac rehabilitation. It offers a comprehensive perspective on its significance in enhancing recuperation and mitigating the likelihood of the recurrence of cardiovascular ailments. The significance of this review lies in its ability to enhance patient outcomes, thereby making a valuable contribution to the worldwide endeavor to address the burden of cardiovascular disease.

Exercise intensity domains determined by heart rate at the ventilatory thresholds in patients with cardiovascular disease: new insights and comparisons to cardiovascular rehabilitation prescription recommendations

Objectives

To compare the elicited exercise responses at ventilatory thresholds (VTs: VT1 and VT2) identified by cardiopulmonary exercise testing (CPET) in patients with cardiovascular disease (CVD) with the guideline-directed exercise intensity domains; to propose equations to predict heart rate (HR) at VTs; and to compare the accuracy of prescription methods.

Methods

A cross-sectional study was performed with 972 maximal treadmill CPET on patients with CVD. First, VTs were identified and compared with guideline-directed exercise intensity domains. Second, multivariate linear regression analyses were performed to generate prediction equations for HR at VTs. Finally, the accuracy of prescription methods was assessed by the mean absolute percentage error (MAPE).

Results

Significant dispersions of individual responses were found for VTs, with the same relative intensity of exercise corresponding to different guideline-directed exercise intensity domains. A mathematical error inherent to methods based on percentages of peak effort was identified, which may help to explain the dispersions. Tailored multivariable equations yielded r2 of 0.726 for VT1 and 0.901 for VT2. MAPE for the novel VT1 equation was 6.0%, lower than that for guideline-based prescription methods (9.5 to 23.8%). MAPE for the novel VT2 equation was 4.3%, lower than guideline-based methods (5.8%-19.3%).

Conclusion

The guideline-based exercise intensity domains for cardiovascular rehabilitation revealed inconsistencies and heterogeneity, which limits the currently used methods. New multivariable equations for patients with CVD were developed and demonstrated better accuracy, indicating that this methodology may be a valid alternative when CPET is unavailable.

arly u ervised ncremental esistance raining (ESpIRiT) following cardiac surgery via a median sternotomy: a study protocol of a multicentre randomised controlled trial

INTRODUCTION

There is no consistency in current practice pertaining to the prescription and progression of upper limb resistance exercise following cardiac surgery via median sternotomy. The aim of this study is to investigate whether less restrictive sternal precautions with the addition of early-supervised resistance training exercise improves upper limb function and facilitates recovery following median sternotomy.

METHODS AND ANALYSIS

This is double-blind randomised controlled trial, with parallel group, concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. 240 adult participants who had median sternotomy from eight hospitals in Malaysia will be recruited. Sample size calculations were based on the unsupported upper limb test. All participants will be randomised to receive either standard or early supervised incremental resistance training. The primary outcomes are upper limb function and pain. The secondary outcomes will be functional capacity, multidomain recovery (physical and psychological), length of hospital stay, incidence of respiratory complications and quality of life. Descriptive statistics will be used to summarise data. Data will be analysed using the intention-to-treat principle. The primary hypothesis will be examined by evaluating the change from baseline to the 4-week postoperative time point in the intervention arm compared with the usual care arm. For all tests to be conducted, a p value of <0.05 (two tailed) will be considered statistically significant, and CIs will be reported. The trial is currently recruiting participants.

ETHICS AND DISSEMINATION

The study was approved by a central ethical committee as well as the local Research Ethics Boards of the participating sites (UKM:JEP-2019-654; Ministry of Health: NMMR-50763; National Heart Centre: IJNREC/501/2021). Approval to start was given prior to the recruitment of participants commencing at any sites. Process evaluation findings will be published in peer-reviewed journals and presented at relevant academic conferences.

TRIAL REGISTRATION NUMBER

International Standard Randomised Controlled Trials Number (ISRCTN17842822).

Comparison of telehealth and supervised phase III cardiac rehabilitation in regional Australia: protocol for a non-inferiority trial

INTRODUCTION

Exercise-based cardiac rehabilitation programmes (ExCRP) promote recovery and secondary prevention for individuals with cardiovascular disease (CVD). Despite this, enrolment and adherence to ExCRP in rural locations is low. Telehealth programmes provide a convenient, home-based intervention, but concerns remain about compliance to exercise prescription. This paper presents the rationale and protocol design to determine if telehealth delivered ExCRP is not inferior to supervised ExCRP for improving cardiovascular function and exercise fidelity.

METHOD AND ANALYSIS

A non-inferiority, parallel (1:1), single-blinded randomised clinical trial will be conducted. Fifty patients with CVD will be recruited from a rural phase II ExCRP. Participants will be randomly assigned to telehealth or supervised ExCRP and prescribed three weekly exercise sessions for 6 weeks. Exercise sessions will include a 10 min warm up, up to 30 min of continuous aerobic exercise at a workload equivalent to the ventilatory anaerobic threshold and a 10 min cool down. The primary outcome will be change in cardiorespiratory fitness as measured by cardiopulmonary exercise test. Secondary outcome measures will include change in blood lipid profile, heart rate variability, pulse wave velocity, actigraphy measured sleep quality and training fidelity. Non-inferiority will be confirmed if intention-to-treat and per-protocol analyses conclude the same outcome following independent samples t-test with p<0.025.

ETHICS AND DISSEMINATION

Research ethics committees at La Trobe University, St John of God Health Care and Bendigo Health approved the study protocol and informed consent. Findings will be published in peer-reviewed journals and disseminated among stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12622000872730p; pre-results.

High-intensity interval training versus moderate-intensity continuous training in patients with heart failure: a systematic review and meta-analysis

The effects of high-intensity interval training (HIIT) in patients with heart failure (HF) remain controversial. This systematic review and meta-analysis aimed to examine the efficacy of HIIT versus moderate-intensity continuous aerobic training (MCT) on exercise tolerance in patients with HF. We searched for studies published up to 4 March 2022 in Embase, MEDLINE, PubMed, and the Cochrane Library with no limitations on data, language, or publication status. We included randomized controlled trials comparing the efficacy of HIIT and MCT on peak oxygen uptake (VO₂), as a measure of exercise tolerance. We pooled the data on peak VO₂, compared HIIT to MCT, and conducted a sub-analysis if there was heterogeneity in the result. We identified 15 randomized controlled trials with 557 patients. Our meta-analysis showed that participants who underwent HIIT achieved a significantly higher peak VO₂ than those who underwent MCT (mean difference 1.46 ml/kg/min, 95% confidence interval 0.39 to 2.53; participants = 557; studies = 15; I² = 65.7%; very low-quality evidence). The meta-regression analysis, conducted as a sub-analysis to explore possible causes of heterogeneity, revealed that the difference in peak VO₂ between HIIT and MCT was inversely associated with body mass index (r =  - 0.508, p = 0.028, 95% confidence interval - 0.95 to - 0.07). Our systematic review showed that HIIT achieved a higher peak VO₂ than MCT in patients with HF. In addition, HIIT may be more effective in improving exercise tolerance in patients with low body mass index.

Effects of high-intensity interval training on trajectories of gas-exchange measures and blood lactate concentrations during cardiopulmonary exercise tests in cardiac rehabilitation-A randomized controlled trial

BACKGROUND

The optimal allocation of training time to different intensities in cardiac rehabilitation is still under debate. The objective of this study was to explore whether in a 12-week cardiac rehabilitation program, replacement of two of four usual continuous endurance training (CET) sessions per week with energy expenditure-matched high-intensity interval training (HIIT) affects the trajectories of cardiopulmonary exercise test (CPET) variables such as ventilatory equivalents for O₂ (EqO₂ ) and CO₂ (EqCO₂ ), and blood lactate (BLa) during CPET.

METHODS

Eighty-two male patients undergoing outpatient cardiac rehabilitation after an acute coronary syndrome were randomized to CET (age [mean ± SD] 61.7 ± 9.8 years, body mass index [BMI] 28.1 ± 3.4) or HIIT+CET (60.0 ± 9.4 years, BMI 28.5 ± 3.5). CPET was performed at baseline, after 6 and after 12 weeks. HIIT consisted of ten 60-s bouts of cycling at an intensity of 100% of the maximal power output (P_max ) achieved in an incremental test to exhaustion, interspersed with 60 s at 20% P_max . CET was performed at 60% P_max with equal duration. Training intensities were adjusted after 6 weeks to account for the training-induced improvement in cardiorespiratory fitness. The entire functions defining the relationship between EqO₂ , EqCO₂ , and BLa, with power output were modeled using linear mixed models to assess how these trajectories are affected by HIIT.

RESULTS

After 6 and 12 weeks, P_max increased to 112.9% and 117.5% of baseline after CET, and to 113.9% and 124.7% after HIIT+CET (means). Twelve weeks of HIIT+CET elicited greater reductions of EqO₂ and EqCO₂ than CET alone (p < 0.0001 each) in a range above 100% baseline P_max . Specifically, at 100% of baseline P_max , least squares arithmetic mean EqO₂ values of CET and HIIT+CET patients were 36.2 versus 33.5. At 115% and 130% of baseline P_max , EqO₂ values were 41.2 versus 37.1 and 47.2 versus 41.7. Similarly, corresponding EqCO₂ values of CET and HIIT+CET patients were 32.4 versus 31.0, 34.3 versus 32.2, and 37.0 versus 34.0. Conversely, mean BLa levels (mM) were not differently affected (p = 0.64). At 100%, 115%, and 130% of baseline P_max after 12 weeks, BLa levels did not differ to a relevant extent (least squares geometric means, 3.56 vs. 3.63, 5.59 vs. 5.61, 9.27 vs. 9.10).

CONCLUSIONS

While HIIT+CET reduced ventilatory equivalents more effectively than CET alone, specifically when patients were approaching their maximal performance during CPET, both training strategies were equally effective in reducing BLa levels.

Achieving cardiac rehabilitation uptake targets: What is the value case for commissioners? A UK case-study

Cardiac Rehabilitation (CR) has become an established intervention to support patient recovery after a cardiac event, with evidence supporting its effectiveness and cost-effectiveness in improving patient health and reducing future burden on healthcare systems. However, this evidence has focussed on the national value case for CR rather than at the point at which it is commissioned. This analysis uses the UK as a case-study to explore variation in current CR engagement and disassemble the value case from a commissioner perspective. Using data collected by the National Audit of CR (NACR), and an existing model of cost-effectiveness, we present details on the current level of CR uptake by commissioning region (Specialist Clinical Networks) in light of the current UK target of achieving 85% uptake. We then interrogate the value case for achieving the target at a commissioner level, highlighting the expected profile of health benefits and healthcare system costs over the long-term. Importantly we consider where this may differ from the national value case. Each commissioning region has a unique level of CR uptake and sociodemographic profile. Concurrently, the value case for commissioning CR relies on the upfront cost of the service being offset by long-term healthcare savings, and health improvements. The shift in the UK and internationally to more localised commissioning necessitates evidence of cost-effectiveness that better reflects the realities of those decision makers. This paper provides vital additional data to facilitate such commissioners to understand the value case in increasing CR uptake in line with national policy.

Insulin resistance, lipids and body composition in patients with coronary artery disease after combined aerobic training and resistance training: a randomised, controlled trial

BACKGROUND

The effect of resistance training (RT) in cardiac rehabilitation (CR) on insulin resistance remains elusive. We examined whether the addition of high-load (HL) or low loads (LL) RT has any effect on the levels of insulin resistance and lipids versus aerobic training (AT) alone in patients with coronary artery disease (CAD).

METHODS

Seventy-nine CAD patients were randomised to HL-RT [70-80% of one repetition maximum (1-RM)] and AT, LL-RT (35-40% of 1-RM) and AT or AT (50-80% of maximal power output), and 59 patients [75% males, 15% diabetics, age: 61 (8) years, left ventricular ejection fraction: 53 (9) %] completed the study. Plasma levels of glucose, insulin, blood lipids [total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL)] cholesterol and body composition were measured at baseline and post-training (36 training sessions).

RESULTS

Training intervention had only time effect on lean mass (p = 0.002), total and LDL cholesterol levels (both p < 0.001), and no effects on levels of glucose and insulin resistance (homeostatic assessment 2-insulin resistance). Total and LDL cholesterols levels decreased following AT [mean difference (95% confidence interval); total cholesterol: - 0.4 mmol/l (- 0.7 mmol/l, - 0.1 mmol/l), p = 0.013; LDL: - 0.4 mmol/l (- 0.7 mmol/l, - 0.1 mmol/l), p = 0.006] and HL-RT [total cholesterol: - 0.5 mmol/l (- 0.8 mmol/l, - 0.2 mmol/l), p = 0.002; LDL: - 0.5 mol/l (- 0.7 mmol/l, - 0.2 mmol/l), p = 0.002]. No associations were observed between post-training change in body composition and post-training change in blood biomarkers.

CONCLUSIONS

RT when combined with AT had no additional effect beyond AT alone on fasting glucose metabolism, blood lipids and body composition in patients with CAD. Trial registration number NCT04638764.

National survey of Australian cardiac rehabilitation programmes: does current exercise programming adhere to evidence-based guidelines and best practice?

Objectives

The efficacy of exercise-based cardiac rehabilitation (CR) for patient outcomes is well established, with better outcomes when delivery meets recommended guidelines. The aim of this study was to assess how well Australian practice aligns with national CR guidelines for exercise assessment and prescription.

Method

This cross-sectional online survey was distributed to all 475 publicly listed CR services in Australia and consisted of four sections: (1) Programme and client demographics, (2) aerobic exercise characteristics, (3) resistance exercise characteristics and (4) pre-exercise assessment, exercise testing and progression.

Results

In total, 228 (54%) survey responses were received. Only three of five Australian guideline recommendations were consistently reported to be followed in current CR programmes: assessment of physical function prior to exercise (91%), prescription of light-moderate exercise intensity (76%) and review of referring physician results (75%). Remaining guidelines were commonly not implemented. For example, only 58% of services reported an initial assessment of resting ECG/heart rate, and only 58% reported the concurrent prescription of both aerobic and resistance exercise, which may have been influenced by equipment availability (p<0.05). Exercise-specific assessments such as muscular strength (18%) and aerobic fitness (13%) were uncommonly reported, although both were more frequent in metropolitan services (p<0.05) or when an exercise physiologist was present (p<0.05).

Conclusions

Clinically relevant deficits in national CR guideline implementation are common, potentially influenced by location, exercise supervisor and equipment availability. Key deficiencies include the lack of concurrent aerobic and resistance exercise prescription and infrequent assessment of important physiological outcomes including resting heart rate, muscular strength and aerobic fitness.

The Effect and Possible Mechanism of Cardiac Rehabilitation in Partial Revascularization Performed on Multiple Coronary Artery Lesions

Purpose

To observe the effect of cardiac rehabilitation (CR) in patients with partial revascularization performed on multiple coronary artery lesions and explore its possible mechanism.

Patients and Methods

A total of 400 patients with multiple coronary artery lesions were enrolled and randomly divided into a complete revascularization group and a CR group, with 200 cases in each group. Target lesion revascularization was performed radically in the complete revascularization group, while it was partially completed in the CR group, and postoperative CR was performed. All the patients were put under conventional treatment. Left ventricular end diastolic dimension (LVEDD), left ventricular ejection fraction (LVEF), 6-minute walking distance (6-MWD), quality-of-life scores, safety and levels of serum nitric oxide (NO), nitric oxide synthase (NOS), superoxide dismutase (SOD), and vascular endothelial growth factor (VEGF) were evaluated and compared between two groups before and after training.

Results

There was no significant difference in LVEDD, LVEF, 6-MWD, quality-of-life scores, levels of serum NO, NOS, SOD, and VEGF between two groups before training (p>0.05). 1 year later, compared with the complete revascularization group, the occurrence of major adverse events in the CR group declined (p>0.05); the measurements of LVEDD decreased and LVEF increased (p>0.05), 6-MWD increased significantly (p<0.05), quality-of-life scores were higher (p<0.05), the levels of serum NO, NOS, and SOD increased noticeably, and the levels of serum VEGF decreased significantly in the CR group (p<0.05). There were significant differences within the same group, before and after training (p<0.05).

Conclusion

Cardiac rehabilitation training, not increase in the incidence of adverse events, is effective and safe after partial revascularization in patients with multiple coronary artery lesions, which has notable clinical advantages in promoting patients' exercise endurance and quality-of-life by improving the nitric oxide synthase system and antioxidant system and reducing the level of VEGF.

Acceptability of a high-protein Mediterranean-style diet and resistance exercise protocol for cardiac rehabilitation patients: Involving service users in intervention design using a mixed-methods participatory approach

Background

Current cardiac rehabilitation (CR) practices focus on aerobic-style exercise with minimal nutrition advice. This approach may not be optimal for CR patients with reduced muscle mass and elevated fat mass. Higher protein, Mediterranean-style diets combined with resistance exercise (RE) may improve muscle mass and reduce the risk of future cardiovascular events, although such an approach is yet to be trialed in a CR population.

Objective

We explored patient perspectives on the proposed design of a feasibility study. Patients reflected on the acceptability of a proposed high-protein Mediterranean-style diet and RE protocol, emphasizing research methodology and the acceptability of the proposed recipes and exercises.

Design

We applied quantitative and qualitative (mixed methods) approaches. The quantitative approach involved an online questionnaire (n = 40) regarding the proposed study methodology and relevance. A subset of participants (n = 12) received proposed recipe guides and were asked to prepare several dishes and complete an online questionnaire regarding their experience. Another subset (n = 18) received links to videos of the proposed RE and completed a questionnaire regarding their impressions of them. Finally, semi-structured interviews (n = 7) were carried out to explore participants' impressions of the proposed diet and exercise intervention.

Results

Quantitative data indicated a high level of understanding of the intervention protocol and its importance within the context of this research. There was a high degree of willingness to participate in all aspects of the proposed study (>90%). The trialed recipes were enjoyed and found to be easy to make by a majority of participants (79 and 92.1%, respectively). For the proposed exercises 96.5% of responses agreed they would be willing to perform them and, 75.8% of responses agreed they would enjoy them. Qualitative analysis revealed that participants viewed the research proposal, diet, and exercise protocol in a positive light. The research materials were considered appropriate and well explained. Participants suggested practical recommendations for improving recipe guides and requested more individual-focused exercise recommendations, and more information on the specific health benefits of the diet and exercise protocols.

Conclusion

The study methodology and the specific dietary intervention and exercise protocol were found to be generally acceptable with some suggested refinements.

The Intersection of Health Rehabilitation Services with Quality of Life in Saudi Arabia: Current Status and Future Needs

Quality of life (QoL) is essential for maintaining a healthy, balanced lifestyle, especially among individuals with chronic diseases. Saudi Arabia (SA) launched a health sector transformation program as part of the nationwide Vision 2030 initiative to ensure the sustainable development of efficient healthcare services, aiming to improve health by increasing well-being and QoL. More investigation into the current status of health rehabilitation services provided to individuals with chronic diseases and future needs to optimize services and improve QoL is needed. This was narratively discussed by experts from different health rehabilitation services in SA. Comprehensive health rehabilitation services including orthopedic, occupational, cardiac, pulmonary, critical care, perioperative, hearing and speech, substance use disorders, and vocational rehabilitation services were addressed. Health rehabilitation services in SA, as in other countries, are suboptimal for individuals in health rehabilitation programs. To optimize the QoL of individuals with chronic diseases, health rehabilitation services should be tailored based on the unique requirements of each service and its serving patients. The shared need to improve health rehabilitation services includes the adoption of home-based and telehealth services, the integration of multi-governmental sectors, the empowerment and allocation of health rehabilitation specialists, public awareness campaigns, policy legislation and guideline development, and the implementation of a long-term follow-up system. This review is one of the first to address the intersection of health rehabilitation services and QoL in SA; urgent and holistic actions are paramount to address the pressing need to optimize SA's health rehabilitation services. The experts' recommendations in this study may be applicable to other countries' health systems, as health rehabilitation services are not well optimized globally.

Average and Interindividual Effects to a Comprehensive Cardiovascular Rehabilitation Program

Background: To describe the average effects and the interindividual variability after a comprehensive outpatient cardiovascular rehabilitation (CCR) program using concurrent exercise training prescribed according to cardiovascular risk stratification on cardiorespiratory fitness (CRF), anthropometric/body composition, quality of life and emotional health in patients of four cardiovascular disease profiles. Methods: CRF, anthropometric/body composition, quality of life, and emotional health were measured before and after a CCR and analyzed in heart valve surgery (HVS), heart failure with reduced ejection fraction (HFrEF), post-acute myocardial infarction (post-AMI), and in coronary artery disease (CAD) patients. Twenty, twenty-four, and thirty-two exercise sessions were prescribed according to mild, moderate, and severe baseline cardiovascular risk, respectively. In addition to concurrent exercise training, nutritional counseling, psychological support, and lifestyle education programs were performed. Results: The main outcomes by delta changes comparisons (Δ) revealed no significant differences at anthropometric/body composition as ΔBody fat decreases (HVS Δ−1.1, HFrEF Δ−1.0, post-AMI Δ−1.4, CAD Δ−1.2 kg) and ΔSkeletal muscle mass increases (HVS Δ+1.4, HFrEF Δ+0.8, post-AMI Δ+0.9, CAD Δ+0.9 kg), and CRF performance as ΔVO2peak increases (HVS Δ+4.3, HFrEF Δ+4.8, post-AMI Δ+4.1, CAD Δ+5.1 mL/kg/min) outcomes among HVS, HFrEF, post-AMI, and CAD (p > 0.05). Secondary outcomes showed significant pre-post delta changes in METs (HVS Δ+1.8, HFrEF Δ+0.7, post-AMI Δ+1.4, CAD Δ+1.4), and maximal O2pulse (HVS Δ+3.1, post-AMI Δ+2.1, CAD Δ+1.9). In addition, quality of life had a significant improvement in physical functioning (HVS Δ+17.0, HFrEF Δ+12.1, post-AMI Δ+9.8, CAD Δ+11.2), physical role (HVS Δ+28.4, HFrEF Δ+26.8, post-AMI Δ+25.6, CAD Δ+25.3), vitality (HVS Δ+18.4, HFrEF Δ+14.3, post-AMI Δ+14.2, CAD Δ+10.6) and social functioning (HVS Δ+20.4, HFrEF Δ+25.3, post-AMI Δ+20.4, CAD Δ+14.8) in all cardiovascular disease. For anxiety (HVS Δ−3.6, HFrEF Δ−2.3, post-AMI Δ−3.0, CAD Δ−3.1) and depression (HVS Δ−2.8, HFrEF Δ−3.4, post-AMI Δ−3.2, CAD Δ−2.3) significant changes were also observed. Conclusions: A CCR program that prescribes the number of exercise sessions using a cardiovascular risk stratification improves CRF, QoL, and emotional health, and the average results show a wide interindividual variability (~25% of non-responders) in this sample of four CVD profile of patients.

Outpatient cardiac rehabilitation dose after acute coronary syndrome in a nationwide cohort

OBJECTIVE

Cardiac rehabilitation (CR) is effective in patients with acute coronary syndrome (ACS); however, CR programmes have not been fully implemented. This study aimed to reveal the current practice of outpatient CR and the dose-effect relationship of CR in real-world settings.

METHODS

We performed a nationwide retrospective cohort study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients with ACS who underwent percutaneous coronary intervention between April 2014 and March 2018 were included. We analysed the implementation rate and dose of outpatient CR and the association between dose and outcomes.

RESULTS

Out of 202 320 patients who underwent percutaneous coronary intervention for ACS, a total of 20 444 (10%) underwent outpatient CR. The median (IQR) number of total CR sessions was 9 (3-17), and the median (IQR) duration for each session was 60 (42-60) min. Patients were divided into four groups according to the total number of sessions (≤9 times or ≥10 times) and the duration per session (<50 min or ≥50 min). Compared with the low-number/short-duration group, the adjusted HR for all-cause mortality was 1.00 (95% CI 0.80 to 1.24, p=0.97) in the low-number/long-duration group, 0.63 (95% CI 0.46 to 0.87, p=0.005) in the high-number/short-duration group and 0.74 (95% CI 0.60 to 0.92, p=0.008) in the high-number/long-duration group, respectively.

CONCLUSION

We found that the participation rate for outpatient CR after ACS was low and the doses of sessions vary in real-world settings. A higher number of total sessions of outpatient CR is associated with a better prognosis irrespective of the session's duration.