Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN72884263]

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.

Begin Again and Continue With Life: A Qualitative Study on the Experiences of Cardiac Rehabilitation Patients

BACKGROUND

Cardiovascular diseases are a main cause of mortality worldwide. However, new diagnostic techniques and treatments have increased the rate of survival for patients with cardiovascular disease. Cardiac rehabilitation programs aim to maintain and enhance the quality of life of patients and improve the secondary prevention of coronary artery disease. Suboptimal participation in rehabilitation programs, early exit from these programs, and not achieving lasting changes are cardiac rehabilitation challenges that are associated with health issues, including the increased need for medication, repeated hospitalization, failure in the secondary prevention programs, and long waiting lists. Exploring the meaning of behavioral changes in the context of cardiac rehabilitation may facilitate the design of effective interventions that are critical to achieving the goals of cardiac rehabilitation programs.

PURPOSE

This study explored the mechanisms that underlie behavioral changes within cardiac rehabilitation centers.

METHODS

We used a descriptive qualitative approach, which is widely acknowledged as the best approach for eliciting in-depth descriptions of behavioral changes in the context of cardiac rehabilitation centers. Using purposive sampling, 15 men and 8 women with coronary heart disease were referred to the two cardiac rehabilitation centers participating in this study. The inclusion criteria were participation in four cardiac rehabilitation sessions and ability and willingness to participate. The data were collected using semistructured in-depth interviews, and the inductive thematic analysis method was used for analysis.

RESULTS

"Trying to stay alive" and "begin again" arose as the two main themes related to behavioral change. These themes include the changes in cognition and values that lead to improvements in the process of behavioral change as a major outcome of cardiac rehabilitation.

CONCLUSIONS

Using psychosocial interventions such as creating and strengthening hope and meaningful intrinsic motivation in the context of rehabilitation centers often helps deal with these challenges. "Trying to stay alive" may take place before referral to a cardiac rehabilitation center. Therefore, psychosocial nursing interventions such as motivational interviewing are designed to improve a process that may be already underway. Thus, stress and anxiety may be treated based on beliefs and emotions. The primary emphasis in cardiac rehabilitation should include changing the beliefs of the patient and motivating her or him to achieve sustainable behavioral change.

Home-based cardiac rehabilitation improves quality of life, aerobic capacity, and readmission rates in patients with chronic heart failure

BACKGROUND

Exercise tolerance and cardiac output have a major impact on the quality of life (QOL) of patients experiencing heart failure (HF). Home-based cardiac rehabilitation can significantly improve not only exercise tolerance but also peak oxygen uptake ((Equation is included in full-text article.)peak), and the QOL in patients with HF. The aim of this prospective study was to evaluate the beneficial effects of home-based cardiac rehabilitation on the quality of medical care in patients with chronic HF.

METHODS

This study was a randomized prospective trial. HF patients with a left ventricular ejection fraction (LVEF) of less than 50% were included in this study. We randomly assigned patients to the control group (n = 18) and the interventional group (n = 19). Within the interventional group, we arranged individualized rehabilitation programs, including home-based cardiac rehabilitation, diet education, and management of daily activity over a 3-month period. Information such as general data, laboratory data, Cardiopulmonary Exercise Test (CPET) results, Six-minute Walk Test (6MWT) results, and the scores for the Minnesota Living with Heart Failure Questionnaire (MLHFQ) before and after the intervention, was collected from all patients in this study.

RESULTS

Patients enrolled in the home-based cardiac rehabilitation programs displayed statistically significant improvement in (Equation is included in full-text article.)peak (18.2 ± 4.1 vs 20.9 ± 6.6 mL/kg/min, P = .02), maximal 6-Minute Walking Distance (6MWD) (421 ± 90 vs 462 ± 74 m, P = .03), anaerobic threshold (12.4 ± 2.5 vs 13.4 ± 2.6 mL/kg/min, P = .005), and QOL. In summary, patients receiving home-based cardiac rehabilitation experienced a 14.2% increase in (Equation is included in full-text article.)peak, a 37% increase in QOL score, and an improvement of 41 m on the 6MWD test. The 90-day readmission rate for patients reduced to 5% from 14% after receiving cardiac rehabilitation.

CONCLUSION

Home-based cardiac rehabilitation offered the most improved results in functional capacity, QOL, and a reduced the rate of readmission within 90 days.

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 cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review previously published in 2009 and 2015.

OBJECTIVES

To compare the effect of home-based 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 21 September 2016. 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, including parallel group, cross-over or quasi-randomised designs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes 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 pre-defined 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. Quality of evidence was assessed using GRADE principles and a Summary of findings table was created.

MAIN RESULTS

We included six new studies (624 participants) for this update, which now includes a total of 23 trials that randomised a total of 2890 participants undergoing cardiac rehabilitation. Participants had an acute myocardial infarction, revascularisation or heart failure. 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 clinical primary outcomes up to 12 months of follow up: total mortality (relative risk (RR) = 1.19, 95% CI 0.65 to 2.16; participants = 1505; studies = 11/comparisons = 13; very low quality evidence), exercise capacity (standardised mean difference (SMD) = -0.13, 95% CI -0.28 to 0.02; participants = 2255; studies = 22/comparisons = 26; low quality evidence), or health-related quality of life up to 24 months (not estimable). 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 quality evidence). However, there was evidence of marginally higher levels of programme completion (RR 1.04, 95% CI 1.00 to 1.08; participants = 2615; studies = 22/comparisons = 26; low quality evidence) by home-based participants.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- and centre-based forms of cardiac rehabilitation 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 evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme may reflect local availability and consider the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in the included short-term trials can be confirmed in the longer term and need to consider adequately powered non-inferiority or equivalence study designs.

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 cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review originally published in 2009.

OBJECTIVES

To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

SEARCH METHODS

To update searches from the previous Cochrane review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41), PsycINFO (Ovid, 1806 to October week 2 2014), and CINAHL (EBSCO, to October 2014). We checked reference lists of included trials and recent systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction (MI), angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of the identified trials and data were extracted by a single author and checked by a second. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Seventeen trials included a total of 2172 participants undergoing cardiac rehabilitation following an acute MI or revascularisation, or with heart failure. This update included an additional five trials on 345 patients with heart failure. Authors of a number of included trials failed to give sufficient detail to assess their potential risk of bias, and details of generation and concealment of random allocation sequence were particularly poorly reported. In the main, no difference was seen between home- and centre-based cardiac rehabilitation in outcomes up to 12 months of follow up: mortality (relative risk (RR) = 0.79, 95% confidence interval (CI) 0.43 to 1.47, P = 0.46, fixed-effect), cardiac events (data not poolable), exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.29 to 0.08, P = 0.29, random-effects), modifiable risk factors (total cholesterol: mean difference (MD) = 0.07 mmol/L, 95% CI -0.24 to 0.11, P = 0.47, random-effects; low density lipoprotein cholesterol: MD = -0.06 mmol/L, 95% CI -0.27 to 0.15, P = 0.55, random-effects; systolic blood pressure: mean difference (MD) = 0.19 mmHg, 95% CI -3.37 to 3.75, P = 0.92, random-effects; proportion of smokers at follow up (RR = 0.98, 95% CI 0.79 to 1.21, P = 0.83, fixed-effect), or health-related quality of life (not poolable). Small outcome differences in favour of centre-based participants were seen in high density lipoprotein cholesterol (MD = -0.07 mmol/L, 95% CI -0.11 to -0.03, P = 0.001, fixed-effect), and triglycerides (MD = -0.18 mmol/L, 95% CI -0.34 to -0.02, P = 0.03, fixed-effect, diastolic blood pressure (MD = -1.86 mmHg; 95% CI -0.76 to -2.95, P = 0.0009, fixed-effect). In contrast, in home-based participants, there was evidence of a marginally higher levels of programme completion (RR = 1.04, 95% CI 1.01 to 1.07, P = 0.009, fixed-effect) and adherence to the programme (not poolable). No consistent difference was seen in healthcare costs between the two forms of cardiac rehabilitation.

AUTHORS' CONCLUSIONS

This updated review supports the conclusions of the previous version of this review that home- and centre-based forms of cardiac rehabilitation seem to be equally effective for improving the clinical and health-related quality of life outcomes in low risk patients after MI or revascularisation, or with heart failure. This finding, together with the absence of evidence of important differences in healthcare costs between the two approaches, supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme should reflect the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in these short-term trials can be confirmed in the longer term. A number of studies failed to give sufficient detail to assess their risk of bias.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

Fostering autonomous motivation, physical activity and cardiorespiratory fitness in rheumatoid arthritis: protocol and rationale for a randomised control trial

Background

People with rheumatoid arthritis are at greater risk of morbidity and mortality from cardiovascular disease than the general population. Sustained physical activity increases cardio-respiratory fitness and reduces cardiovascular disease risk factors. However, little is known about how we can effectively promote long-term participation in physical activity in patients with rheumatoid arthritis. The literature consistently calls for physical activity interventions, and their implementation, to be theoretically-grounded.

Methods/Design

This paper documents the protocol of a randomised control trial that investigates whether a Self-determination Theory-based intervention fosters the adoption and maintenance of physical activity (3, 6 and 12 months) sufficient to provide sustained cardiovascular and personal well-being benefits in patients with rheumatoid arthritis. The cost effectiveness of the intervention will also be determined. The trial is registered as Current Controlled Trials ISRCTN04121489.

Discussion

Results from this trial will provide guidance regarding key social environmental factors that can be manipulated to support motivational processes conducive to positive health behaviour change and optimal functioning in patients with Rheumatoid Arthritis.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-445) contains supplementary material, which is available to authorized users.

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

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based recommendation for patients with coronary artery disease (CAD). However, CR is dramatically underutilized. Telehealth interventions have the potential to overcome barriers and may be an innovative model of delivering CR. This review aimed to determine the effectiveness of telehealth intervention delivered CR compared with center-based supervised CR.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library and the Chinese BioMedical Literature Database (CBM), were searched to April 2014, without language restriction. Existing randomized controlled trials, reviews, relevant conference lists and gray literature were checked. Randomized controlled trials that compared telehealth intervention delivered CR with traditional center-based supervised CR in adults with CAD were included. Two reviewers selected studies and extracted data independently. Main clinical outcomes including clinical events, modifiable risk factors or other endpoints were measured.

RESULTS

Fifteen articles reporting nine trials were reviewed, most of which recruited patients with myocardial infarction or revascularization. No statistically significant difference was found between telehealth interventions delivered and center-based supervised CR in exercise capacity (standardized mean difference (SMD) -0.01; 95% confidence interval (CI) -0.12-0.10), weight (SMD -0.13; 95% CI -0.30-0.05), systolic and diastolic blood pressure (mean difference (MD) -1.27; 95% CI -3.67-1.13 and MD 1.00; 95% CI -0.42-2.43, respectively), lipid profile, smoking (risk ratio (RR) 1.03; 95% CI 0.78-1.38), mortality (RR 1.15; 95% CI 0.61-2.19), quality of life and psychosocial state.

CONCLUSIONS

Telehealth intervention delivered cardiac rehabilitation does not have significantly inferior outcomes compared to center-based supervised program in low to moderate risk CAD patients. Telehealth intervention offers an alternative deliver model of CR for individuals less able to access center-based cardiac rehabilitation. Choices should reflect preferences, anticipation, risk profile, funding, and accessibility to health service.

Feasibility and effectiveness of remote, telephone-based delivery of cardiac rehabilitation

OBJECTIVES

Cardiac rehabilitation (CR) provides significant benefit for persons with cardiovascular disease. However, access to CR services may be limited by driving distance, costs, need for a driver, time away from work, or being a family primary caregiver. The primary aim of the project was to test the reach (i.e., patient and provider uptake), effectiveness (safety and clinical outcomes), and implementation (time and costs) of a remote telephone-based Phase 2 CR program. A secondary aim was to compare outcomes between patients attending the remote program (home-CR) and those attending an on-site program (comparison group).

SUBJECTS AND METHODS

Subjects were given a choice of the remote or face-to-face program. Remote CR participants (n=48) received education and assessment during 12 weekly by telephone calls. Data were compared with those for face-to-face CR program participants (n=14). Independent t tests and chi-squared tests were used for continuous and categorical variables, respectively. Repeated-measures analysis of covariance models were used to assess differences in outcomes. Costs were analyzed using a cost-minimization analysis.

RESULTS

Of 107 eligible patients, 45 refused participation, 5 dropped out, and 1 died unrelated to the study. Participants had a mean age of 64 (standard deviation 7.5) years. Remote CR participants were highly satisfied with their care and had a higher completion rate (89% of authorized sessions versus 73% of face-to-face). Costs for each program were comparable. There were no significant changes over time in any measured outcome between groups at 12 weeks except medication adherence, which decreased over time in both groups; face-to-face patients reported a greater decrease (p=0.05).

CONCLUSIONS

This is the first study to test a remote CR program in a population of older Veterans. Many hospitals do not provide comprehensive CR services on-site; thus remote CR is a viable alternative to bring services closer to the patient.

Understanding physical activity during home-based cardiac rehabilitation from multiple theoretical perspectives

OBJECTIVE

: Previous studies have shown that moderate-to-vigorous physical activity (MVPA) levels during home-based cardiac rehabilitation (CR) have been problematic. Consequently, the present study examined the utility of the theory of planned behavior, protection motivation theory, and social cognitive theory in explaining physical activity (PA) during a Canadian home-based CR program.

METHODS

: Patients (N = 280, mean age 62.8 years; 95.4% white, 72.5% male, 78.9% married, 52.3% retired, 48.0% income more than $60000; and 33.8% postmyocardial infarction) completed a questionnaire at program onset and a MVPA assessment at 3-month followup.

RESULTS

: Path analyses showed that each theory accounted for 28% to 34% of the variance in PA. The theory of planned behavior showed that perceived behavior control was the key predictor of 3-month MVPA (β = .36), whereas protection motivation theory showed that intention (β = .30) was the key predictor. Finally, barrier self-efficacy (β = .21) and the availability of home PA equipment (β = .15) were the key predictors of 3-month MVPA within social cognitive theory.

CONCLUSION

: All 3 theories appeared to be viable options to inform the development of a MVPA intervention during home-based CR. However, the key constructs to target within each theory varied, suggesting the need to potentially use multiple theories to inform intervention development.

Differences between South Asians and White Europeans in five year outcome following percutaneous coronary intervention

AIMS

The aim of this study was to compare rates of target lesion revascularisation (TLR) and total mortality between South Asians (SAs) and White Europeans (WEs) following percutaneous coronary intervention (PCI).

METHODS

We followed a cohort of 293 SAs and 865 WEs patients admitted for elective or urgent PCI to de novo lesions. For each patient, baseline cardiovascular risk factors and angiographic data were obtained. Patients had long-term follow-up for all-cause mortality and TLR.

RESULTS

Patients were followed up over a median period of 54 months (inter-quartile range: 47-65). SAs were younger (62 ± 12 years vs. 66 ± 11 years; p < 0.0001), with a higher prevalence of diabetes, greater social deprivation [Carstairs score: 10.2 (IQR 6.5-12.1) vs. 3.3 (IQR 0.9-6.5); p < 0.0001] and presented more acutely (urgent PCI procedure). During the follow-up period, a total of 119 deaths and 111 TLR [94 repeat PCI and 17 coronary artery bypass grafting (CABG)] occurred. There was no significant difference in the rate of long-term all-cause mortality between SA and WE [31 (10.6%) vs. 107 (12.4%); OR: 0.84 (0.55-1.28); p = 0.47]. However, SA ethnicity was an independent predictor of long-term TLR, after adjusting for baseline clinical and procedural characteristics [54 (18.4%) vs. 57 (6.6%); OR: 2.83 (1.87-4.29); p < 0.0001].

CONCLUSIONS

South Asian patients were more likely to require re-admission to treat clinical restenosis of the index lesion. There was no significant long-term difference in all-cause mortality between SA and WE patients.

Clinical research in cardiac rehabilitation and secondary prevention: looking back and moving forward

Cardiac rehabilitation/secondary prevention (CR/SP) programs are considered standard of care and provide critically important resources for optimizing the care of cardiac patients. The objective of this article is to briefly review the evolution of CR/SP programs from a singular exercise intervention to its current, more comprehensive multifaceted approach. In addition, we offer perspective on critical concerns and suggest future research considerations to optimize the effectiveness and utilization of CR/SP program interventions.

Cardiac rehabilitation in the Northwest

AIM

To audit the cardiac rehabilitation (CR) service in the Northwest.

METHODS

Patients were identified on the CR Information System. Indications, rate of uptake, demographics and complications were all recorded. Cardiovascular risk factors and exercise capacity before and after CR were compared. Systems for referral and phases I-IV were analysed.

RESULTS

Three hundred ninety-two patients were offered CR in 2006. 151 patients completed phase III. One-fifth attended outreach centres. Mean age was 62.9. 22% were female. No serious adverse events occurred during exercise training. A smoking quit rate of 26% was achieved. Mean blood pressures pre and post CR were 141/76 and 131/73 mmHg, respectively. The mean increase in exercise capacity was 2.85 mets.

CONCLUSIONS

CR in the Northwest provides a modern evolving programme. Enhanced referral rate, reduction in the duration of phase II, increased participation by women and improved accessibility will consolidate its contribution to cardiovascular disease management in this region.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

The burden of cardiovascular disease world-wide is one of great concern to patients and health care agencies alike. Traditionally centre-based cardiac rehabilitation (CR) programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation.

OBJECTIVES

To determine the effectiveness of home-based cardiac rehabilitation programmes compared with supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life and modifiable cardiac risk factors in patients with coronary heart disease.

SEARCH STRATEGY

We updated the search of a previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2007, Issue 4), MEDLINE, EMBASE and CINAHL from 2001 to January 2008. We checked reference lists and sought advice from experts. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes, in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Studies were selected independently by two reviewers, and data extracted by a single reviewer and checked by a second one. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Twelve studies (1,938 participants) met the inclusion criteria. The majority of studies recruited a lower risk patient following an acute myocardial infarction (MI) and revascularisation. There was no difference in outcomes of home- versus centre-based cardiac rehabilitation in mortality risk ratio (RR) was1.31 (95% confidence interval (C) 0.65 to 2.66), cardiac events, exercise capacity standardised mean difference (SMD) -0.11 (95% CI -0.35 to 0.13), as well as in modifiable risk factors (systolic blood pressure; diastolic blood pressure; total cholesterol; HDL-cholesterol; LDL-cholesterol) or proportion of smokers at follow up or health-related quality of life. There was no consistent difference in the healthcare costs of the two forms of cardiac rehabilitation.

AUTHORS' CONCLUSIONS

Home- and centre-based cardiac rehabilitation appear to be equally effective in improving the clinical and health-related quality of life outcomes in acute MI and revascularisation patients. This finding, together with an absence of evidence of difference in healthcare costs between the two approaches, would support the extension of home-based cardiac rehabilitation programmes such as the Heart Manual to give patients a choice in line with their preferences, which may have an impact on uptake of cardiac rehabilitation in the individual case.

Use of complementary and alternative medicine and self-tests by coronary heart disease patients

Background

Coronary heart disease patients have to learn to manage their condition to maximise quality of life and prevent recurrence or deterioration. They may develop their own informal methods of self-management in addition to the advice they receive as part of formal cardiac rehabilitation programmes. This study aimed to explore the use of complementary and alternative medicines and therapies (CAM), self-test kits and attitudes towards health of UK patients one year after referral to cardiac rehabilitation.

Method

Questionnaire given to 463 patients attending an assessment clinic for 12 month follow up in four West Midlands hospitals.

Results

91.1% completed a questionnaire. 29.1% of patients used CAM and/or self-test kits for self-management but few (8.9%) used both methods. CAM was more often used for treating other illnesses than for CHD management. Self-test kit use (77.2%,) was more common than CAM (31.7%,) with BP monitors being the most prevalent (80.0%). Patients obtained self-test kits from a wide range of sources, for the most part (89.5%) purchased entirely on their own initiative. Predictors of self-management were post revascularisation status and higher scores on 'holism', 'rejection of authority' and 'individual responsibility'. Predictors of self-test kit use were higher 'holism' and 'individual responsibility' scores.

Conclusion

Patients are independently using new technologies to monitor their cardiovascular health, a role formerly carried out only by healthcare practitioners. Post-rehabilitation patients reported using CAM for self-management less frequently than they reported using self-test kits. Reports of CAM use were less frequent than in previous surveys of similar patient groups. Automatic assumptions cannot be made by clinicians about which CHD patients are most likely to self-manage. In order to increase trust and compliance it is important for doctors to encourage all CHD patients to disclose their self-management practices and to continue to address this in follow up consultations.

Understanding exercise behaviour during home-based cardiac rehabilitation: a theory of planned behaviour perspectiveThis article is an invited paper from 2007 ICRH Leadership in Science: a Forum for Trainees and New Investigators

Although home-based cardiac rehabilitation (CR) programs have been shown to produce significant increases in exercise capacity, obtaining patient adherence to these programs has been challenging. It is therefore critical to identify key theoretical determinants of exercise during home-based CR in order to inform the development of behavioural interventions that improve adherence. The present study examined the utility of the theory of planned behaviour (TPB) in explaining exercise behaviour during home-based CR. Seventy-six patients who were receiving 6 months of home-based CR completed a TPB questionnaire at the beginning and mid-point of the program and a physical activity scale at the mid-point and end of the program. Path analyses showed that attitude and perceived behavioural control significantly predicted intention for both time intervals (baseline to 3 months, and 3 months to 6 months), whereas subjective norm only predicted intention within the 1st 3 months. Intention significantly predicted implementation intention, which, in turn, significantly predicted exercise for both time intervals. Finally, several underlying accessible beliefs were significantly related to exercise for both time intervals. Therefore, results suggest that the TPB is a potentially useful framework for understanding exercise behaviour during home-based CR.

An exploration of the information needs of spouse/partner following acute myocardial infarction using focus group methodology

This study aimed to explore spouse/partners' experience of the information received and required in the acute myocardial infarction (AMI) in-hospital recovery period. A dearth of information exists that uncovers the information needs of spouse/partners following AMI. Although information needs, emotional reactions, support and information provision are prevalent themes within the literature, there are few studies that specifically address these issues in this population. While survey methods abound, with more recent qualitative interviews apparent, focus group methodology is underused. The study employed a qualitative descriptive design. Using focus group techniques, 15 partners were interviewed. Emerging themes included: reactions to the event, feeling like a burden on the health service, the need for information and pulling apart - pulling together. Spouse/partners play a critical role in helping patients recover from acute cardiac events thus information and support for the latter are crucial. While spouse/partners commonly seek information as a problem-solving coping strategy, in an effort to regain personal control, spouses often lack information. This study identifies spouse/partner isolation and suggests that additional supports need to be in place to adequately deal with the challenges that AMI brings to family life. Suggested support mechanisms to enhance current provision are inclusion of spouse/partner in cardiac rehabilitation programs and hospital-based care, self-help groups supported and attended by professionals and telephone support systems.

Exercise training after coronary angioplasty improves cardiorespiratory function

AIM

The aim of this prospective randomized study was to evaluate the impact of long-term aerobic exercise training on respiratory function, left ventricular systolic function and remodeling in patients with coronary heart disease and ischemic heart failure after successful angioplasty.

DESIGN

Patients (n=185) have undergone Doppler echocardiography and ergospirometry. Ninety-five patients practiced 6 month-term aerobic exercise training, less by 10% to their anaerobic threshold. Ninety patients were studied as controls. They were given only drug treatment without training. Measurements were repeated after 6 and 12 months.

RESULTS

Training group patients after 6 months showed significant (p<0.05) improvement in exercise capacity, oxygen consumption and ventilating equivalents. The Doppler echocardiographic findings revealed significant (p<0.05) improvement in ejection fraction, left ventricular and atria morphometric data. Improved ergospirometric and echocardiographic data were established after 12 months, too.

CONCLUSIONS

Long-term aerobic exercise training is an effective and workable measure improving respiratory efficiency, left ventricular systolic function, attenuating negative remodeling and stopping further progression in patients with coronary heart disease and chronic heart failure after successful angioplasty.

Patient Characteristics, Compliance, and Exercise Outcomes of South Asians Enrolled in Cardiac Rehabilitation

PURPOSE

To compare patient demographics, the presence or absence of traditional cardiovascular risk factors, medications on entry, compliance with cardiac rehabilitation (CR), and exercise outcomes at 6 months among South Asians and whites attending a CR program.

METHODS

A retrospective analysis of South Asian (n = 220) and white (n = 980) patients participating in 2 outpatient, hospital-based CR programs over a 3-year period.

RESULTS

South Asians were younger (56 vs 59 years; P = .004), had lower body mass index (26.8 vs 28.4 kg/m2 P < .0001), had lower rates of hypertension (36% vs 45%; P = .01), were less likely to be smokers (25% vs 50%; P = .00001), and were more likely to have diabetes (36% vs 23%; P = .0001). Compliance with the 6-month CR program was poor in both groups, but South Asians were less likely to complete the entire program (43% vs 51%; P = .04). Over the course of CR, maximum achieved metabolic equivalent during stress testing improved in both groups; however, South Asian patients trended to a greater change and more often reached at least 85% of target heart rate (55% vs 42%; P = .02).

CONCLUSION

South Asians participating in CR are younger, have a different risk factor profile, benefit equally, but are less compliant than whites. Further research is needed to better understand the barriers faced by South Asians in successfully participating in and completing CR programs.

Cross-cultural adaptation into Punjabi of the English version of the Hospital Anxiety and Depression Scale

BACKGROUND

We wanted to use a Punjabi version of the Hospital Anxiety and Depression Scale (HADS) to enable non-English speaking patients to participate in a clinical trial. The aim of the study was to translate and validate the Hospital Anxiety and Depression Scale into Punjabi.

METHODS

The HADS was translated into Punjabi by a multidisciplinary team, verified against the original version, and administered to 73 bilingual patients attending an outpatient clinic.

RESULTS

One sample t-tests and the Bland-Altman plots demonstrated acceptable linguistic agreement between the two versions of the HADS. Spearman's rank-order correlation coefficients (p < 0.0001) demonstrate excellent conceptual agreement between each item and its corresponding subscale score, for both versions. Concordance rates revealed that the Punjabi HADS adequately identified borderline cases of anxiety (80.8%), definite cases of anxiety (91.8%) and depression (91.8%), but was less reliable in identifying borderline cases of depression (65.8%). Cronbach alpha coefficients revealed high levels of internal consistency for both the Punjabi and English versions (0.81 and 0.86 for anxiety and 0.71 and 0.85 for depression, respectively).

CONCLUSION

The Punjabi HADS is an acceptable, reliable and valid measure of anxiety and depression among physically ill Punjabi speaking people in the United Kingdom.

Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms--Cornwall Heart Attack Rehabilitation Management Study (CHARMS)

BACKGROUND

Participation in cardiac rehabilitation after acute myocardial infarction is sub-optimal. Offering home-based rehabilitation may improve uptake. We report the first randomized study of cardiac rehabilitation to include patient preference.

AIM

To compare the clinical effectiveness of a home-based rehabilitation with hospital-based rehabilitation after myocardial infarction and to determine whether patient choice affects clinical outcomes.

DESIGN

Pragmatic randomized controlled trial with patient preference arms.

SETTING

Rural South West England.

METHODS

Patients admitted with uncomplicated myocardial infarction were offered hospital-based rehabilitation classes over 8-10 weeks or a self-help package of six weeks' duration (the Heart Manual) supported by a nurse. Primary outcomes at 9 months were mean depression and anxiety scores on the Hospital Anxiety Depression scale, quality of life after myocardial infarction (MacNew) score and serum total cholesterol.

RESULTS

Of the 230 patients who agreed to participate, 104 (45%) consented to randomization and 126 (55%) chose their rehabilitation programme. Nine month follow-up data were available for 84/104 (81%) randomized and 100/126 (79%) preference patients. At follow-up no difference was seen in the change in mean depression scores between the randomized home and hospital-based groups (mean difference: 0; 95% confidence interval, -1.12 to 1.12) nor mean anxiety score (-0.07; -1.42 to 1.28), mean global MacNew score (0.14; -0.35 to 0.62) and mean total cholesterol levels (-0.18; -0.62 to 0.27). Neither were there any significant differences in outcomes between the preference groups.

CONCLUSIONS

Home-based cardiac rehabilitation with the Heart Manual was as effective as hospital-based rehabilitation for patients after myocardial infarction. Choosing a rehabilitation programme did not significantly affect clinical outcomes.

Correlates of Physical Activity Change in Patients Not Attending Cardiac Rehabilitation

OBJECTIVE

Limited research has identified theoretical correlates of physical activity (PA) change in patients not receiving cardiac rehabilitation. The purpose of the present study was to determine whether changes in self-efficacy, PA intention, perceived severity and susceptibility, and PA benefits/barriers were associated with changes in PA over a 12-month period in these patients.

METHODS

Patients (N = 555) not attending cardiac rehabilitation completed a psychosocial questionnaire in hospital and 6 and 12 months after hospitalization for a cardiac event.

RESULTS

Hierarchical regression analyses showed that the increase in PA from baseline to 6 months was significantly related to an increase in self-efficacy and PA intentions and a decrease in the impact of health-related barriers. Furthermore, the decrease in PA from 6 to 12 months was significantly related to a decrease in health-related benefits and PA intentions and an increase in time and health-related barriers. Finally, the increase in PA from baseline to 12 months was significantly related to an increase in health-related benefits and intentions and a decrease in health-related barriers.

CONCLUSIONS

Changes in PA levels over a 12-month period were associated with changes in various theoretical variables. Interestingly, the associations among these variables with PA varied as a function of time after hospitalization.

Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home

BACKGROUND

It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems.

OBJECTIVES

To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home.

SEARCH STRATEGY

We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed.

MAIN RESULTS

We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU.

AUTHORS' CONCLUSIONS

The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.

Plasma haemostatic markers, endothelial function and ambulatory blood pressure changes with home versus hospital cardiac rehabilitation: the Birmingham Rehabilitation Uptake Maximisation Study

BACKGROUND

Cardiac rehabilitation is an accepted therapeutic intervention in patients after myocardial infarction or coronary revascularisation. The effects of cardiac rehabilitation programmes, whether home based or hospital based, on haemostatic indices (as reflected by fibrinogen, plasma viscosity, fibrin D-dimer (an index of thrombogenesis), von Willebrand factor (vWf, an index of endothelial damage/dysfunction), soluble P-selectin (an index of platelet activation)), vasomotor function (using flow-mediated dilatation (FMD)) and ambulatory blood pressure (ABP) in patients with coronary heart disease are unknown.

METHODS

81 patients (66 men, mean (SD) 59 (11) years) after myocardial infarction or coronary revascularisation were randomised to comprehensive hospital-based (n = 40) or home-based (n = 41) cardiac rehabilitation. Plasma levels of vWf, D-dimer, fibrinogen, soluble P-selectin and plasma viscosity, as well as FMD and 24-h ABP, were measured at baseline and after 3 months of cardiac rehabilitation.

RESULTS

In patients who completed cardiac rehabilitation, levels of vWf, fibrinogen and D-dimer were significantly lower and FMD improved (all p<or=0.001), whereas levels were unchanged in controls. Significant reductions were also observed in 24-h mean systolic blood pressure, diastolic blood pressure and mean aortic pressure after completion of cardiac rehabilitation (all p<0.05). No significant differences were observed between the hospital-based and home-based cardiac rehabilitation programmes on these indices.

CONCLUSIONS

Cardiac rehabilitation improves haemostasis, endothelial function and ABP in patients with coronary heart disease, with no significant differences between home-based and hospital-based cardiac rehabilitation programmes. These effects may contribute to the beneficial effects of cardiac rehabilitation programmes on CV outcomes.

Recruitment of ethnic minority patients to a cardiac rehabilitation trial: the Birmingham Rehabilitation Uptake Maximisation (BRUM) study [ISRCTN72884263]

BACKGROUND

Concerns have been raised about low participation rates of people from minority ethnic groups in clinical trials. However, the evidence is unclear as many studies do not report the ethnicity of participants and there is insufficient information about the reasons for ineligibility by ethnic group. Where there are data, there remains the key question as to whether ethnic minorities more likely to be ineligible (e.g. due to language) or decline to participate. We have addressed these questions in relation to the Birmingham Rehabilitation Uptake Maximisation (BRUM) study, a randomized controlled trial (RCT) comparing a home-based with a hospital-based cardiac rehabilitation programme in a multi-ethnic population in the UK.

METHODS

Analysis of the ethnicity, age and sex of presenting and recruited subjects for a trial of cardiac rehabilitation in the West-Midlands, UK.

PARTICIPANTS

1997 patients presenting post-myocardial infarction, percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery.

DATA COLLECTED

Exclusion rates, reasons for exclusion and reasons for declining to participate in the trial by ethnic group.

RESULTS

Significantly more patients of South Asian ethnicity were excluded (52% of 'South Asian' v 36% 'White European' and 36% 'Other', p < 0.001). This difference in eligibility was primarily due to exclusion on the basis of language (i.e. the inability to speak English or Punjabi). Of those eligible, similar proportions were recruited from the different ethnic groups (white, South Asian and other). There was a marked difference in eligibility between people of Indian, Pakistani or Bangladeshi origin.

CONCLUSION

Once eligible for this trial, people from different ethnic groups were recruited in similar proportions. The reason for ineligibility in the BRUM study was the inability to support the range of minority languages.

Incremental shuttle walking is associated with activation of haemostatic and haemorheological markers in patients with coronary artery disease: the Birmingham rehabilitation uptake maximization study (BRUM)

OBJECTIVE

To test the hypothesis that an incremental shuttle walk test (ISWT) affects plasma indices of endothelial damage and dysfunction (von Willebrand factor (vWf)), platelet activation (soluble P-selectin), thrombogenesis (D-dimer), fibrinogen, and plasma viscosity more adversely in coronary artery disease (CAD) than in health. ISWT is a standardised walking test that provokes maximal performance and correlates strongly with maximum oxygen uptake.

METHODS

Research indices were measured before a practice ISWT and immediately after the second ISWT in 53 patients with CAD (48 men, mean (SD) age 59 (10) years) and in 19 matched healthy controls (16 men, 61 (10) years). Data were analysed before and after ISWT.

RESULTS

Despite no significant difference in total distance walked between patients and controls, vWf (162 (45) before v 170 (48) UI/dl after) and fibrinogen (2.9 (0.7) v 3.1 (0.7) g/l) concentrations, plasma viscosity (1.63 (0.12) v 1.71 (0.14) mPa.s), and D-dimer (0.20 (interquartile range 0.10-0.30) v 0.21 (0.12-0.31 mg/l; all p < 0.05), but not soluble P-selectin, were significantly increased after ISWT in patients with CAD, even after correction for plasma volume change. Only fibrinogen (2.5 (0.7) v 2.7 (0.7 g/l) and plasma viscosity (1.60 (0.08) v 1.64 (0.08) mPa.s; both p < 0.01) increased among controls. The increment of fibrinogen was significantly higher in patients than in controls (p = 0.035) and correlated with total walking distance (r = 0.46, p < 0.001) and peak heart rate (r = 0.28, p = 0.02). The increment of plasma viscosity rise also significantly correlated with total distance walked (r = 0.66, p < 0.001).

CONCLUSIONS

ISWT in patients with CAD appears to increase fibrinogen, vWf, and D-dimer compared with healthy controls.

Recent developments in secondary prevention and cardiac rehabilitation after acute myocardial infarction

Primary care has a key role in improving the health of patients who have had a myocardial infarction