Effects of cardiac telerehabilitation in patients with coronary artery disease using a personalised patient-centred web application: protocol for the SmartCare-CAD randomised controlled trial

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

Introduction

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

Methods

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

Discussion

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

Emerging Technologies and Open-Source Platforms for Remote Physical Exercise: Innovations and Opportunities for Healthy Population-A Narrative Review

The emergence of tele-exercise as a response to the impact of technology on physical activity has opened up new possibilities for promoting physical health. By integrating innovative technologies and open-source platforms, tele-exercise encourages people to stay active. In our latest analysis, we delved into the scientific literature surrounding the use of tele-exercise technologies in training healthy individuals. After conducting an extensive search on the PubMed database using the keywords "tele-exercise" and "physical activity" (from 2020 to 2023), we identified 44 clinical trials that were applicable to tele-exercise, but less than 10% of them were aimed at healthy individuals, precisely 9.09% (four out of forty-four studies analyzed). Our review highlights the potential of tele-exercise to help maintain physical fitness and psychological well-being, especially when traditional fitness facilities are not an option. We also underscore the importance of interoperability, standardization, and the incorporation of biomechanics, exercise physiology, and neuroscience into the development of tele-exercise platforms. Nevertheless, despite these promising benefits, research has shown that there is still a significant gap in the knowledge concerning the definition and evaluation of training parameters for healthy individuals. As a result, we call for further research to establish evidence-based practices for tele-exercise in the healthy population.

Effectiveness of Cardiac Rehabilitation With mHealth Through Smartphone Functionalities: A Systematic Review Protocol

Cardiovascular diseases are the leading cause of mortality worldwide, requiring support to manage symptoms and improve prognosis. Home-based cardiac rehabilitation is a realistic resource for this purpose, but it requires patients' self-management skills in order to change behaviours. Smartphones are considered mHealth technology (mobile technological resources in healthcare) and have the potential to provide modalities for delivery of cardiac rehabilitation. This systematic review aims to examine these modalities and identify those that are most effective for improving exercise capacity, quality of life, and patient compliance. Randomized controlled trials (1994 to 2022) performed with adults with coronary artery disease (post-myocardial infarction, angina, post-coronary artery bypass graft surgery) or heart failure eligible for home-based cardiac rehabilitation (mHealth) will be selected. Studies published in English, Spanish, or Portuguese that compare rehabilitation-specific mobile apps or smartphone-based features with conventional cardiac rehabilitation will be included. Searches will be conducted in MEDLINE, CENTRAL, EMBASE, LILACS, PEDro, grey literature, and ongoing or recently completed studies. Data and risk of bias will be assessed, and if appropriate, a meta-analysis will be carried out.

Efficacy of a cardiac rehabilitation program in a municipal sports center compared to the hospital program: randomized controlled trial eCARCEX

BACKGROUND

This study aimed to analyze the effects of an outpatient cardiac rehabilitation program in a municipal sports center on functional capacity and adherence to physical exercise - among other variables - compared to an in-hospital program.

METHODS

Randomized clinical trial that included two parallel groups of acute coronary syndrome patients who performed a cardiac rehabilitation program that consisted of moderate physical exercise intervals along with learning healthy habits in a municipal sports center (experimental group) and in a tertiary hospital (control group) between September 2019 and June 2020. We collected the following data: compliance, anthropometrical, clinical, psychological variables, diet and tobacco habits, strength and functional capacity from ergospirometry.

RESULTS

Twenty-two patients completed the cardiac rehabilitation program (experimental group=12, control group=10). Significant improvement was observed for cholesterol, the sit-and-stand test, cardiac frequency in VT1 and VT2, and watts in VT1 in the control group, and for HDL-cholesterol, triglycerides, the sit-and-stand test, and frequency, and watts in VT1 in the experimental group. Better achievement was found in the control group for cardiac frequency in VT2 (11.17 vs 2.88 bpm) and in EG for HDL-cholesterol (11.0 vs 0.63 mg/dL).

CONCLUSIONS

We are unable to determine the effectiveness of the out-of-hospital cardiac rehabilitation program due to a lack of power (high number of withdrawals caused by COVID-19 lockdown). However, the experimented group achieved higher HDL-cholesterol levels, while cardiac frequency in VT2 was higher in the control group.

A remote monitoring-enabled home exercise prescription for patients with interstitial lung disease at risk for exercise-induced desaturation

RATIONALE

Alternatives to center-based pulmonary rehabilitation are needed to improve patient access to this important therapy. A critical challenge to overcome is how to maximize safety of unsupervised exercise for at-risk patients. We investigated if a novel remote monitoring-enabled mobile health (mHealth) program is safe, feasible, and effective for patients who experience exercise-induced hemoglobin desaturation.

METHODS

An interstitial lung disease (ILD) commonly associated with pronounced exercise desaturation was investigated - the rare, female-predominant ILD lymphangioleiomyomatosis (LAM). Over a 12-week program, hemoglobin saturation (SpO2) was continuously recorded during all home exercise sessions. Intervention effects were assessed with 6-min walk test (6MWT), maximal cardiopulmonary exercise test (CPET), lower extremity computerized dynamometry, pulmonary function tests, and health-related quality of life (QoL) surveys. Safety was assessed by blood biomarkers of systemic inflammation and cardiac wall stress, and incidence of adverse events.

RESULTS

Fifteen LAM patients enrolled and 14 completed the intervention, with high adherence to aerobic (87 ± 15%) and strength (87 ± 12%) training components. An innovative characterization of exercise training SpO2 revealed that while mild-to-moderate desaturation was common during home workouts, participants were able to self-adjust exercise intensity and supplemental oxygen levels to maintain recommended exercise parameters. Significant improvements included 6MWT distance (+36 ± 34 m, p = 0.003), CPET time (p = 0.04), muscular endurance (p = 0.008), QoL (p = 0.009 to 0.03), and fatigue (p = 0.001 to 0.03). Patient acceptability and satisfaction indicators were high, blood biomarkers remained stable (p > 0.05), and no study-related adverse events occurred.

CONCLUSION

A remote monitoring-enabled home exercise program is a safe, feasible, and effective approach even for patients who experience exercise desaturation.

Does anxiety cause angina recurrence after percutaneous coronary intervention in patients with STEMI?

Background

Statistics show that approximately 70% of patients with acute ST-segment elevation myocardial infarction (STEMI) experience relief from chest pain symptoms within 48 h post-percutaneous coronary intervention (PCI). However, over 30% of these patients still suffer from angina post-PCI during their hospital stay and after discharge. Although the interrelation between cardiovascular diseases and psychological states, notably anxiety and stress, has been extensively studied and acknowledged, the specific influence of anxiety disorders on post-PCI clinical outcomes for STEMI patients, especially the recurrence of angina, remains undefined.

Methods

This study included a total of 324 STEMI patients who underwent PCI treatment due to chest pain in our hospital. Baseline and surgical data for all patients were collected. During their hospital stay, patients' emotional states were assessed using the Hamilton Anxiety Scale, while angina was evaluated using the Seattle Angina Questionnaire. All patients were followed up for 6 months post-discharge to gather clinical data and outcomes, analyzing whether anxiety disorders would affect the recurrence of angina post-PCI in STEMI patients.

Results

Out of the 324 patients, 82 experienced recurrent angina symptoms within 6 months post-PCI discharge. Compared to the non-recurrence group, the recurrence group showed statistically significant differences in anxiety levels. Other differing factors included the spouse's health status, cardiac Killip classification, severity of coronary lesions, and the state of the coronary microcirculation. After utilizing propensity score matching to eliminate inherent biases between the two groups at a 1:1 ratio, the COX regression analysis indicated that a patient's anxiety status is a risk factor for the occurrence of angina post-PCI in STEMI patients (HR = 2.094, 95% CI = 1.248-3.514, P = 0.005).

Conclusion

Anxiety is a significant factor for short-term recurrence of angina post-PCI in STEMI patients. This further confirms the crucial impact of mental health on cardiovascular wellness.

Initial Implementation of the My Heart, My Life Program by the National Heart Foundation of Australia: Pilot Mixed Methods Evaluation Study

BACKGROUND

Coronary heart disease (CHD) remains the leading cause of death in Australia, with a high residual risk of repeat events in survivors. Secondary prevention therapy is crucial for reducing the risk of both death and other major adverse cardiac events. The National Heart Foundation of Australia has developed a consumer-facing support program called My Heart, My Life (MHML) to address the gap in the secondary prevention of CHD in Australia. The MHML pilot program supplies advice and support for both patients and their caregivers, and it was conducted over 8 months from November 2019 to June 2020.

OBJECTIVE

This study aims to describe and examine the implementation of a novel multimodality secondary CHD prevention pilot program called MHML, which was delivered through booklets, text messages, emails, and telephone calls.

METHODS

This pilot study consists of a mixed methods evaluation involving surveys of participants (patients and caregivers) and health professionals, in-depth interviews, and digital communication (SMS text message, electronic direct mail, and call record analytics). This study was performed in people older than 18 years with acute coronary syndrome or angina and their caregivers in 38 Australian hospitals from November 2019 to June 2020 through the National Heart Foundation of Australia web page. The main outcome measures were reach, accessibility, feasibility, barriers, and enablers to implementation of this program.

RESULTS

Of the 1004 participants (838 patients and 164 caregivers; 2 missing), 60.9% (608/1001) were males, 50.7% (491/967) were aged between 45 and 64 years, 27.4% (276/1004) were from disadvantaged areas, 2.5% (24/946) were from Aboriginal or Torres Strait Islander background, and 16.9% (170/1004) reported English as their second language. The participants (patients and their caregivers) and health professionals reported high satisfaction with the MHML program (55/62, 88.7% and 33/38, 87%, respectively). Of the 62 participants who took the survey, 88% (55/62) used the text messaging service and reported a very high level of satisfaction. Approximately 94% (58/62) and 89% (55/62) of the participants were satisfied with the quick guide booklets 1 and 2, respectively; 79% (49/62) were satisfied with the monthly email journey and 71% (44/62) were satisfied with the helpline calls. Most participants reported that the MHML program improved preventive behaviors, that is, 73% (45/62) of them reported that they maintained increased physical activity and 84% (52/62) reported that they maintained a healthy diet even after the MHML program.

CONCLUSIONS

The findings of our pilot study suggest that a multimodal support program, including digital, print, phone, and web-based media, for the secondary prevention of CHD is useful and could be a potential means of providing customized at-scale secondary prevention support for survivors of acute coronary syndrome.

Social network interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease

BACKGROUND

Globally, cardiovascular diseases (CVD, that is, coronary heart (CHD) and circulatory diseases combined) contribute to 31% of all deaths, more than any other cause. In line with guidance in the UK and globally, cardiac rehabilitation programmes are widely offered to people with heart disease, and include psychosocial, educational, health behaviour change, and risk management components. Social support and social network interventions have potential to improve outcomes of these programmes, but whether and how these interventions work is poorly understood.  OBJECTIVES: To assess the effectiveness of social network and social support interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease. The comparator was usual care with no element of social support (i.e. secondary prevention alone or with cardiac rehabilitation).  SEARCH METHODS: We undertook a systematic search of the following databases on 9 August 2022: CENTRAL, MEDLINE, Embase, and the Web of Science. We also searched ClinicalTrials.gov and the WHO ICTRP. We reviewed the reference lists of relevant systematic reviews and included primary studies, and we contacted experts to identify additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of social network or social support interventions for people with heart disease. We included studies regardless of their duration of follow-up, and included those reported as full text, published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened all identified titles. We retrieved full-text study reports and publications marked 'included', and two review authors independently screened these, and conducted data extraction. Two authors independently assessed risk of bias, and assessed the certainty of the evidence using GRADE. Primary outcomes were all-cause mortality, cardiovascular-related mortality, all-cause hospital admission, cardiovascular-related hospital admission, and health-related quality of life (HRQoL) measured at > 12 months follow-up.  MAIN RESULTS: We included 54 RCTs (126 publications) reporting data for a total of 11,445 people with heart disease. The median follow-up was seven months and median sample size was 96 participants. Of included study participants, 6414 (56%) were male, and the mean age ranged from 48.6 to 76.3 years. Studies included heart failure (41%), mixed cardiac disease (31%), post-myocardial infarction (13%), post-revascularisation (7%), CHD (7%), and cardiac X syndrome (1%) patients. The median intervention duration was 12 weeks. We identified notable diversity in social network and social support interventions, across what was delivered, how, and by whom.  We assessed risk of bias (RoB) in primary outcomes at > 12 months follow-up as either 'low' (2/15 studies), 'some concerns' (11/15), or 'high' (2/15). 'Some concerns' or 'high' RoB resulted from insufficient detail on blinding of outcome assessors, data missingness, and absence of pre-agreed statistical analysis plans. In particular, HRQoL outcomes were at high RoB. Using the GRADE method, we assessed the certainty of evidence as low or very low across outcomes. Social network or social support interventions had no clear effect on all-cause mortality (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.49 to 1.13, I2 = 40%) or cardiovascular-related mortality (RR 0.85, 95% CI 0.66 to 1.10, I2 = 0%) at > 12 months follow-up. The evidence suggests that social network or social support interventions for heart disease may result in little to no difference in all-cause hospital admission (RR 1.03, 95% CI 0.86 to 1.22, I2 = 0%), or cardiovascular-related hospital admission (RR 0.92, 95% CI 0.77 to 1.10, I2 = 16%), with a low level of certainty. The evidence was very uncertain regarding the impact of social network interventions on HRQoL at > 12 months follow-up (SF-36 physical component score: mean difference (MD) 31.53, 95% CI -28.65 to 91.71, I2 = 100%, 2 trials/comparisons, 166 participants; mental component score MD 30.62, 95% CI -33.88 to 95.13, I2 = 100%, 2 trials/comparisons, 166 participants).  Regarding secondary outcomes, there may be a decrease in both systolic and diastolic blood pressure with social network or social support interventions. There was no evidence of impact found on psychological well-being, smoking, cholesterol, myocardial infarction, revascularisation, return to work/education, social isolation or connectedness, patient satisfaction, or adverse events.  Results of meta-regression did not suggest that the intervention effect was related to risk of bias, intervention type, duration, setting, and delivery mode, population type, study location, participant age, or percentage of male participants.  AUTHORS' CONCLUSIONS: We found no strong evidence for the effectiveness of such interventions, although modest effects were identified in relation to blood pressure. While the data presented in this review are indicative of potential for positive effects, the review also highlights the lack of sufficient evidence to conclusively support such interventions for people with heart disease. Further high-quality, well-reported RCTs are required to fully explore the potential of social support interventions in this context. Future reporting of social network and social support interventions for people with heart disease needs to be significantly clearer, and more effectively theorised, in order to ascertain causal pathways and effect on outcomes.

Impact of a comprehensive cardiac rehabilitation programme versus coronary revascularisation in patients with stable angina pectoris: study protocol for the PRO-FIT randomised controlled trial

BACKGROUND

Currently, in the majority of patients with stable angina pectoris (SAP) treatment consists of optimal medical treatment, potentially followed by coronary angiography and subsequent coronary revascularisation if necessary". Recent work questioned the effectiveness of these invasive procedures in reducing re-events and improving prognosis. The potential of exercise-based cardiac rehabilitation on clinical outcomes in patients with coronary artery disease is well-known. However, in the modern era, no studies compared the effects of cardiac rehabilitation versus coronary revascularisation in patients with SAP.

METHODS

In this multicentre randomised controlled trial, 216 patients with stable angina pectoris and residual anginal complaints under optimal medical treatment will be randomised to: 1) usual care (i.e., coronary revascularisation), or 2) a 12-month cardiac rehabilitation (CR) programme. CR consists of a multidisciplinary intervention, including education, exercise training, lifestyle coaching and a dietary intervention with a stepped decline in supervision. The primary outcome will be anginal complaints (Seattle Angina Questionnaire-7) following the 12-month intervention. Secondary outcomes include cost-effectiveness, ischemic threshold during exercise, cardiovascular events, exercise capacity, quality of life and psychosocial wellbeing.

DISCUSSION

In this study, we will examine the hypothesis that multidisciplinary CR is at least equally effective in reducing anginal complaints as the contemporary invasive approach at 12-months follow-up for patients with SAP. If proven successful, this study will have significant impact on the treatment of patients with SAP as multidisciplinary CR is a less invasive and potentially less costly and better sustainable treatment than coronary revascularisations.

TRIAL REGISTRATION

Netherlands Trial Register, NL9537. Registered 14 June 2021.

A comparison of physiological intensity and psychological perceptions during three different group exercise formats

Introduction

Past research highlighted that group fitness is an ideal format to meet exercise prescription guidelines. To add, a group enhances exertion, enjoyment, and satisfaction. In the last five years, streaming (live classes on screen with other participants visible) and on demand (pre-recorded classes on screen without other participants visible) formats have grown in popularity. Our goal is to compare the physiological intensity and psychological perceptions of live group, live streaming, and non-live on demand classes. We hypothesize that live classes will have the greatest cardiovascular intensity, enjoyment, and satisfaction followed by streaming and finally on demand.

Methods

Fifty-four adults between 18–63 years, who regularly participate in group fitness classes, recorded their heart rate with a chest transmitter during a mixed-martial arts cardiovascular class on consecutive weeks in random order. We calculated the mean, identified the max, and extracted the top 300 values (5 min) for comparison between conditions.

Results

Following each class, the participants completed an online survey to evaluate their rate of perceived exertion, enjoyment, and satisfaction. Confirming our hypothesis, mean class heart rate and mean heart rate for the five minutes at the highest intensity were 9% greater during the live group format compared to both live streaming and non-live on demand (all values, p < 0.01). However, there was no difference in any heart rate variables between the streaming and on demand formats. Also, rate of perceived exertion, enjoyment, and satisfaction were all significantly greater during the live session compared to the home collections (all values, p < 0.05).

Discussion

Streaming and on demand group fitness formats are viable options for meeting exercise prescription guidelines. But physiological intensity and psychological perceptions were greater during the live class format.

Actual status and future directions of cardiac telerehabilitation

Telerehabilitation (TR) was developed to achieve the same results as would be achieved by the standard rehabilitation process and to overcome potential geographical barriers and staff deficiencies. This is especially relevant in periodic crisis situations, including the recent COVID-19 pandemic. Proper execution of TR strategy requires both well-educated staff and dedicated equipment. Various studies have shown that TR may have similar effects to traditional rehabilitation in terms of clinical outcomes and may also reduce total healthcare costs per participant, including rehospitalization costs. However, as with any method, TR has its advantages and disadvantages, including a lack of direct contact or prerequisite, rudimentary ability of the patients to handle mobile devices, among other competencies. Herein, is a discussion of the current status of TR, focusing primarily on cardiac TR, describing some technical/organizational and legal aspects, highlighting the indications, examining cost-effectiveness, as well as outlining possible future directions.

Levels of depressive symptoms in cardiac patients attending cardiac rehabilitation with a history of depression: pre Covid-19 and Covid-19 period comparison

Background

The large-scale changes in cardiac rehabilitation (CR) programme delivery in response to COVID-19 has led to diminished provision. The influence of these service changes on the depression symptoms of patients in CR programmes is unknown. Our study investigated the extent of depressive symptoms prior to and during the COVID-19 periods in patients with a previous history of depression at the start of CR.

Methods

Use of Registry routine practice data, National Audit of Cardiac Rehabilitation (NACR), from COVID-19 period Feb 2020 and Jan 2021, as well as pre COVID-19 period Feb 2019 and Jan 2020, was extracted. Depressive symptoms were defined according to Hospital Anxiety and Depression Score ≥ 8. Chi-square tests and independent samples t-tests were used to investigate baseline characteristics. Additionally, a binary logistic regression to examine the factors associated with high levels of depressive symptoms.

Results

In total 3661 patients with a history of depression were included in the analysis. Patients attending CR during COVID-19 were found to be 11% more likely to have high levels of acute depressive symptoms compared to patients attending CR prior to COVID-19. Physical inactivity, increased anxiety, a higher total number of comorbidities, increased weight, and living in the most deprived areas were statistically significant factors associated with high levels of acute depressive symptoms at the start of CR following multivariate adjustments.

Conclusion

Our research suggests that following a cardiac event patients with prior history of depression have high levels of acute depressive symptoms at CR baseline assessment. This finding exists in both the pre Covid-19 and Covid-19 periods in patients with a history of depression.

Telerrehabilitación en personas con enfermedad cardiovascular durante el periodo de aislamiento preventivo obligatorio por COVID-19 en Colombia

Introducción

La enfermedad cardiovascular es una de las principales causas de morbimortalidad a nivel mundial. Como resultado de la pandemia de COVID-19, muchos programas de rehabilitación han pasado a modelos de entrega remota. La telerrehabilitación es una forma de realizar rehabilitación cardiaca mientras se reduce el riesgo de transmisión del COVID-19.

Objetivo

Describir los efectos de un programa de ejercicio terapéutico en personas con enfermedad cardiovascular que realizan telerrehabilitación, en el periodo de aislamiento preventivo obligatorio por COVID-19.

Materiales y métodos

Estudio cuasiexperimental, de 6 meses, en personas con enfermedad cardiovascular que ingresaron a un programa de ejercicio terapéutico asistido por tecnología virtual en una clínica de Cali (Colombia).

Resultados

De 31 personas, 21 eran hombres. La edad promedio fue de 60,48 ± 11,21 años. Se encontraron diferencias significativas al inicio y al final del estudio en las variables de fracción de eyección del ventrículo izquierdo, frecuencia cardiaca, presión arterial, frecuencia respiratoria, índice de masa corporal, perímetro de abdomen, porcentaje de grasa, porcentaje de masa muscular, colesterol, estado de depresión, distancia recorrida, consumo de oxígeno e índice metabólico (MET), con p < 0,05.

Conclusión

Un programa de ejercicio terapéutico en personas con enfermedad cardiovascular que realizan telerrehabilitación resulta eficaz, al alcanzar las metas de tratamiento.

Effects of multidisciplinary exercise management on patients after percutaneous coronary intervention: A randomized controlled study

Objectives

To explore the effectiveness of the mobile app-based multidisciplinary exercise management on patients who receive percutaneous coronary intervention (PCI).

Methods

From January to October 2020, 54 patients after PCI were randomly assigned to the intervention group (n = 27) and the control group (n = 27). The intervention group received the mobile app-based multidisciplinary exercise management, whereas the control group received routine care. The patients after PCI began to take intervention one month after the operation, and the intervention lasted for two months. Before and after the intervention, 6-Minute Walking Distance was used to evaluate the patient’s exercise tolerance, and the patient’s exercise compliance was evaluated according to the patient’s exercise status recorded by the mobile app. The cognitive questionnaire on knowledge about PCI treatment for Coronary Heart Disease, the Self-efficacy for Chronic Disease Scale and the Perceived Social Support Scale were used to evaluate patients’ disease-related cognition, self-efficacy and perception of social support. This study was registered on Clinical Trials.gov with registration number ChiCTR2000028930.

Results

Totally 51 patients after PCI who completed this study (25 patients in the intervention group and 26 patients in the control group) were included in the analysis. After 2 months of intervention, the exercise compliance of patients in the intervention group was better than that in the control group. And 6-Minute Walking Distance (469.36 ± 57.48 vs. 432.81 ± 67.09), and the scores of knowledge of PCI treatment for coronary heart disease (52.64 ± 9.82 vs. 42.42 ± 8.54), Self-efficacy for Chronic Disease Scale (42.40 ± 8.04 vs. 36.88 ± 7.73) and Perceived Social Support Scale (74.04 ± 5.73 vs. 66.69 ± 6.86) in the intervention group were higher than those in the control group with statistical significance (P < 0.05).

Conclusions

The multidisciplinary exercise management based on the mobile app can effectively improve exercise tolerance, exercise compliance, disease-related cognition, self-efficacy, and perception of social support during exercise training for patients after PCI.

Smart Home Technology Solutions for Cardiovascular Diseases: A Systematic Review

Cardiovascular diseases (CVD) are the leading cause of mortality globally. Despite improvement in therapies, people with CVD lack support for monitoring and managing their condition at home and out of hospital settings. Smart Home Technologies have potential to monitor health status and support people with CVD in their homes. We explored the Smart Home Technologies available for CVD monitoring and management in people with CVD and acceptance of the available technologies to end-users. We systematically searched four databases, namely Medline, Web of Science, Embase, and IEEE, from 1990 to 2020 (search date 18 March 2020). “Smart-Home” was defined as a system using integrated sensor technologies. We included studies using sensors, such as wearable and non-wearable devices, to capture vital signs relevant to CVD at home settings and to transfer the data using communication systems, including the gateway. We categorised the articles for parameters monitored, communication systems and data sharing, end-user applications, regulations, and user acceptance. The initial search yielded 2462 articles, and the elimination of duplicates resulted in 1760 articles. Of the 36 articles eligible for full-text screening, we selected five Smart Home Technology studies for CVD management with sensor devices connected to a gateway and having a web-based user interface. We observed that the participants of all the studies were people with heart failure. A total of three main categories—Smart Home Technology for CVD management, user acceptance, and the role of regulatory agencies—were developed and discussed. There is an imperative need to monitor CVD patients’ vital parameters regularly. However, limited Smart Home Technology is available to address CVD patients’ needs and monitor health risks. Our review suggests the need to develop and test Smart Home Technology for people with CVD. Our findings provide insights and guidelines into critical issues, including Smart Home Technology for CVD management, user acceptance, and regulatory agency’s role to be followed when designing, developing, and deploying Smart Home Technology for CVD.

Point-of-care heart failure platform: where are we now and where are we going to?

INTRODUCTION

Heart failure (HF) remains a leading cause of cardiovascular (CV) mortality in patients with CV disease. The point-of-care (POC) HF platform seems to be an ideal non-invasive workflow-adapted system for personally adjusted management of patients with HF.

AREAS COVERED

In the present manuscript, we reviewed the literature covering some relevant studies regarding the role of point-of care heart failure platform in the risk stratification, earlier diagnosis and prognostically beneficial treatment of patients with different phenotypes of HF.

EXPERT OPINION

POC HF platform including personal consultation, optimization of the comorbidity treatment, step-by-step HF diagnostic algorithm, single biomarker measurements, has also partially been provided in the current guidelines. Although there are several obstacles to implement POC in routine practice, such as education level, aging, affordability of health care, even partial implementation of POC can also improve clinical outcomes. POC seems to be an evolving model, more research studies are required to clearly see whether it helps to make better decisions with diagnosis and care of HF, as well helps to achieve better clinical outcomes.In summary, the POC HF platform is considered to be a more effective tool than conventional algorithm of HF management.

Predictors of non-participation in a cardiac telerehabilitation programme: a prospective analysis

Aims

Current cardiac telerehabilitation (CTR) interventions are insufficiently tailored to the preferences and competences of individual patients, which raises the question whether their implementation will increase overall participation and adherence to cardiac rehabilitation (CR). However, research on patient-specific factors that influence participation and adoption of CTR interventions is scarce. The aim of this study was to evaluate which patient-related characteristics influence participation in a novel CTR intervention in patients with coronary artery disease.

Methods and results

This prospective observational substudy of the SmartCare-CAD randomized controlled trial evaluated patient characteristics of study participants as proxy for participation in a CTR intervention. We compared demographic, geographic, and health-related characteristics between trial participants and non-participants to determine which characteristics influenced trial participation. A total of 699 patients (300 participants and 399 non-participants; 84% male, mean age 64.3 ± 10.5 years) were included. Most of the non-participants refused participation because of insufficient technical skills or lack of interest in digital health (26%), or preferred centre-based CR (21%). Variables independently associated with non-participation included: higher age, lower educational level, shorter travelling distance, smoking, positive family history for cardiovascular disease, having undergone coronary artery bypass grafting; and a higher blood pressure, worse exercise capacity, and higher risk of depression before the start of CR.

Conclusion

Participation in CTR is strongly influenced by demographic and health-related factors such as age, educational level, smoking status, and both physical and mental functioning. Cardiac telerehabilitation interventions should therefore be redesigned with the involvement of these currently underrepresented patient subgroups.

mHealth Apps for Self-Management of Cardiovascular Diseases: A Scoping Review

The use of mHealth apps for the self-management of cardiovascular diseases (CVDs) is an increasing trend in patient-centered care. In this research, we conduct a scoping review of mHealth apps for CVD self-management within the period 2014 to 2021. Our review revolves around six main aspects of the current status of mHealth apps for CVD self-management: main CVDs managed, main app functionalities, disease stages managed, common approaches used for data extraction, analysis, management, common wearables used for CVD detection, monitoring and/or identification, and major challenges to overcome and future work remarks. Our review is based on Arksey and O'Malley's methodological framework for conducting studies. Similarly, we adopted the PRISMA model for reporting systematic reviews and meta-analyses. Of the 442 works initially retrieved, the review comprised 38 primary studies. According to our results, the most common CVDs include arrhythmia (34%), heart failure (32%), and coronary heart disease (18%). Additionally, we found that the majority mHealth apps for CVD self-management can provide medical recommendations, medical appointments, reminders, and notifications for CVD monitoring. Main challenges in the use of mHealth apps for CVD self-management include overcoming patient reluctance to use the technology and achieving the interoperability of mHealth applications with other systems.

Web Portals for Patients With Chronic Diseases: Scoping Review of the Functional Features and Theoretical Frameworks of Telerehabilitation Platforms

Background

The COVID-19 pandemic has required an increased need for rehabilitation activities applicable to patients with chronic diseases. Telerehabilitation has several advantages, including reducing clinic visits by patients vulnerable to infectious diseases. Digital platforms are often used to assist rehabilitation services for patients in remote settings. Although web portals for medical use have existed for years, the technology in telerehabilitation remains a novel method.

Objective

This scoping review investigated the functional features and theoretical approaches of web portals developed for telerehabilitation in patients with chronic diseases.

Methods

PubMed and Web of Science were reviewed to identify articles associated with telerehabilitation. Of the 477 nonduplicate articles reviewed, 35 involving 14 portals were retrieved for the scoping review. The functional features, targeted diseases, and theoretical approaches of these portals were studied.

Results

The 14 portals targeted patients with chronic obstructive pulmonary disease, cardiovascular, osteoarthritis, multiple sclerosis, cystic fibrosis diseases, and stroke and breast cancer survivors. Monitoring/data tracking and communication functions were the most common, followed by exercise instructions and diary/self-report features. Several theoretical approaches, behavior change techniques, and motivational techniques were found to be utilized.

Conclusions

The web portals could unify and display multiple types of data and effectively provide various types of information. Asynchronous correspondence was more favorable than synchronous, real-time interactions. Data acquisition often required assistance from other digital tools. Various functions with patient-centered principles, behavior change strategies, and motivational techniques were observed for better support shifting to a healthier lifestyle. These findings suggested that web portals for telerehabilitation not only provided entrance into rehabilitation programs but also reinforced participant-centered treatment, adherence to rehabilitation, and lifestyle changes over time.

Digital tools to support the maintenance of physical activity in people with long-term conditions: A scoping review

Objective

This scoping review aimed to bring together and identify digital tools that support people with one or more long-term conditions to maintain physical activity and describe their components and theoretical underpinnings.

Methods

Searches were conducted in Cumulative Index to Nursing and Allied Health Literature, Medline, EMBASE, IEEE Xplore, PsycINFO, Scopus, Google Scholar and clinical trial databases, for studies published between 2009 and 2019, across a range of long-term conditions. Screening and data extraction was undertaken by two independent reviewers and the Preferred Reporting Items for Scoping Reviews guidelines informed the review's conduct and reporting.

Results

A total of 38 results were identified from 34 studies, with the majority randomised controlled trials or protocols, with cardiovascular disease, type 2 diabetes mellitus and obesity the most common long-term conditions. Comorbidities were reported in >50% of studies but did not clearly inform intervention development. Most digital tools were web-browser-based ± wearables/trackers, telerehabilitation tools or gaming devices/components. Mobile device applications and combination short message service/activity trackers/wearables were also identified. Most interventions were supported by a facilitator, often for goal setting/feedback and/or monitoring. Physical activity maintenance outcomes were mostly reported at 9 months or 3 months post-intervention, while theoretical underpinnings were commonly social cognitive theory, the transtheoretical model and the theory of planned behaviour.

Conclusions

This review mapped the literature on a wide range of digital tools and long-term conditions. It identified the increasing use of digital tools, in combination with human support, to help people with long-term conditions, to maintain physical activity, commonly for under a year post-intervention. Clear gaps were the lack of digital tools for multimorbid long-term conditions, longer-term follow-ups, understanding participant's experiences and informs future questions around effectiveness.

Cost-effectiveness of Cardiac Telerehabilitation With Relapse Prevention for the Treatment of Patients With Coronary Artery Disease in the Netherlands

Importance

Cardiac telerehabilitation (CTR) has been found to be a safe and beneficial alternative to traditional center-based cardiac rehabilitation (CR) and might be associated with higher participation rates by reducing barriers to CR use. However, implementation of CTR interventions remains low, which may be owing to a lack of cost-effectiveness analyses of data from large-scale randomized clinical trials.

Objective

To assess the cost-effectiveness of CTR with relapse prevention compared with center-based CR among patients with coronary artery disease.

Design, Setting, and Participants

This economic evaluation performed a cost-utility analysis of data from the SmartCare-CAD (Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform) randomized clinical trial. The cost-effectiveness and utility of 3 months of cardiac telerehabilitation followed by 9 months of relapse prevention were compared with the cost-effectiveness of traditional center-based cardiac rehabilitation. The analysis included 300 patients with stable coronary artery disease who received care at a CR center serving 2 general hospitals in the Netherlands between May 23, 2016, and July 26, 2018. All patients were entering phase 2 of outpatient CR and were followed up for 1 year (until August 14, 2019). Data were analyzed from September 21, 2020, to September 24, 2021.

Intervention

After baseline measurements were obtained, participants were randomly assigned on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group) using computerized block randomization. After 6 supervised center-based training sessions, patients in the intervention group continued training at home using a heart rate monitor and accelerometer. Patients uploaded heart rate and physical activity data and discussed their progress during a weekly video consultation with their physical therapist. After 3 months, weekly coaching was concluded, and on-demand coaching was initiated for relapse prevention; patients were instructed to continue using their wearable sensors and were contacted in cases of nonadherence to the intervention or reduced exercise or physical activity volumes.

Main Outcomes and Measures

Quality-adjusted life-years were assessed using the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS), and cardiac-associated health care costs and non-health care costs were measured by health care consumption, productivity, and informal care questionnaires (the Medical Consumption Questionnaire, the Productivity Cost Questionnaire, and the Valuation of Informal Care Questionnaire) designed by the Institute for Medical Technology Assessment. Costs were converted to 2020 price levels (in euros) using the Dutch consumer price index (to convert to US dollars, euro values were multiplied by 1.142, which was the mean exchange rate in 2020).

Results

Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life among patients receiving CTR vs center-based CR was comparable during the study according to the results of both utility measures (mean difference on EQ-5D-5L: -0.004; P = .82; mean difference on EQ-VAS: -0.001; P = .92). Intervention costs were significantly higher for CTR (mean [SE], €224 [€4] [$256 ($4)]) compared with center-based CR (mean [SE], €156 [€5] [$178 ($6)]; P < .001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], €4787 [€503] [$5467 ($574)] and center-based CR (mean [SE], €5507 [€659] [$6289 ($753)]; P = .36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], €20 495 [€ 2751] [$23 405 ($3142)] vs €24 381 [€3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-€3887 [-$4439]; P = .34).

Conclusions and Relevance

In this economic evaluation, a CTR intervention with relapse prevention was likely to be cost-effective compared with center-based CR, suggesting that CTR maybe used as an alternative intervention for the treatment of patients with coronary artery disease. These results add to the evidence base in favor of CTR and may increase the implementation of CTR interventions in clinical practice.

A DETECTION SYSTEM OF EXERCISE ELECTROCARDIOGRAM

ABSTRACT Introduction: A new exercise electrocardiogram (ECG) detection system was investigated in this study to diagnose and analyze cardiopulmonary function and related diseases in a comprehensive and timely manner and improve the accuracy of diagnosis. Besides, its reliability and clinical applicability were judged. Objective: A new type of exercise ECG detection system was constructed by adding parameters such as respiratory mechanics, carbon dioxide, and oxygen concentration monitoring based on the traditional ECG detection system. Methods: The new system constructed in this study carried out the ECG signal detection, ECG acquisition module, blood pressure and respiratory mechanics detection and conducted a standard conformance test. Results: The heart rate accuracy detected by the exercise ECG system was greatly higher than that of the doctor's manual detection (P < 0.05). The accuracy of the new exercise ECG detection system increased obviously in contrast to that of the manual detection result (P < 0.05). The key technical index input noise and input impedance test results (24.5 μV and 12.4 MΩ) of the exercise ECG detection system conformed to the standard (< 30 μV and > 2.5 MΩ). The common-mode rejection and sampling rate test results (103.5 dB and 515 Hz) of key technical indicators in the exercise ECG detection system were all in line with the standards (≥89 dB and ≥500 Hz). Conclusion: The complete exercise ECG detection system was constructed through the ECG acquisition module, blood pressure detection, and respiratory mechanics detection module. In addition, this system could be applied to detect ECG monitoring indicators with high accuracy and reliability, which could also be extensively adopted in clinical diagnosis. Level of evidence II; Therapeutic studies - investigation of treatment results.

A Digital Health Intervention (SweetGoals) for Young Adults With Type 1 Diabetes: Protocol for a Factorial Randomized Trial

BACKGROUND

Many young adults with type 1 diabetes (T1D) struggle with the complex daily demands of adherence to their medical regimen and fail to achieve target range glycemic control. Few interventions, however, have been developed specifically for this age group.

OBJECTIVE

In this randomized trial, we will provide a mobile app (SweetGoals) to all participants as a "core" intervention. The app prompts participants to upload data from their diabetes devices weekly to a device-agnostic uploader (Glooko), automatically retrieves uploaded data, assesses daily and weekly self-management goals, and generates feedback messages about goal attainment. Further, the trial will test two unique intervention components: (1) incentives to promote consistent daily adherence to goals, and (2) web health coaching to teach effective problem solving focused on personalized barriers to self-management. We will use a novel digital direct-to-patient recruitment method and intervention delivery model that transcends the clinic.

METHODS

A 2x2 factorial randomized trial will be conducted with 300 young adults ages 19-25 with type 1 diabetes and (Hb)A_1c ≥ 8.0%. All participants will receive the SweetGoals app that tracks and provides feedback about two adherence targets: (a) daily glucose monitoring; and (b) mealtime behaviors. Participants will be randomized to the factorial combination of incentives and health coaching. The intervention will last 6 months. The primary outcome will be reduction in A_1c. Secondary outcomes include self-regulation mechanisms in longitudinal mediation models and engagement metrics as a predictor of outcomes. Participants will complete 6- and 12-month follow-up assessments. We hypothesize greater sustained A_1c improvements in participants who receive coaching and who receive incentives compared to those who do not receive those components.

RESULTS

Data collection is expected to be complete by February 2025. Analyses of primary and secondary outcomes are expected by December 2025.

CONCLUSIONS

Successful completion of these aims will support dissemination and effectiveness studies of this intervention that seeks to improve glycemic control in this high-risk and understudied population of young adults with T1D.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04646473; https://clinicaltrials.gov/ct2/show/NCT04646473.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/27109.

Recommendations on the utilization of telemedicine in cardiology

The enormous progress made in recent years in the field of information and communication technology and also in sensor and computer technology has affected numerous fields of medicine and is capable of inducing even radical changes in diagnostic and therapeutic processes. This is particularly true for cardiology, where, for example, telemetric monitoring of cardiac and circulatory functions has been in use for many years. Nevertheless, broad application of newer telemedical processes has not yet been achieved to the extent one would expect from the encouraging results of numerous clinical studies in this field and the state of the art of the underlying technology. In the present paper, the Working Group on Rhythmology of the Austrian Cardiological Society aims to provoke a critical discussion of the digital change in cardiology and to make recommendations for the implementation of those telemedical processes that have been shown to exert positive effects on a wide variety of medical and economic parameters. The greatest benefit of telecardiological applications is certainly to be found in the long-term care of patients with chronic cardiovascular diseases. Accordingly, follow-up care of patients with cardiological rhythm implants, management of chronic heart failure and secondary prevention following an acute cardiac event during rehabilitation are currently the most important fields of application. Telemedicine is intended to enable high-quality and cost-efficient care for an increasing number of patients, whose care poses one of the greatest challenges to our healthcare system. Not least of all, telemedicine should make a decisive contribution to improving the quality of life of this segment of the population by favorably influencing mortality, morbidity and hospitalization as well as the patient's contribution to treatment.

The scientific basis for secondary prevention of coronary artery disease: recent contributions from the Netherlands

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

Effect of Smartphone-Based Telemonitored Exercise Rehabilitation among Patients with Coronary Heart Disease

The aim of this study was to investigate the effects of telemonitored exercise rehabilitation on patients with coronary heart disease (CHD) in China. Ninety-six patients with stable CHD were included and analyzed (48 in telemonitored group and 48 in control group). All patients received routine follow-up, and patients in telemonitored group participated in smartphone-based telemonitored cardiac rehabilitation. Patients' demographic information, medical history, diagnosis and treatment of CHD, and laboratory results were collected. The difference of cardiopulmonary exercise testing (CPET), blood test, and echocardiographic parameters; exercise habits; control rate of blood lipid and blood glucose; and incidence of adverse events between the two groups during 6 months of follow-up was analyzed. After intervention, the subjects in the telemonitored group performed significantly better in VO2peak, exercise compliance, and some other parameters than those in the control group. Telemonitored exercise rehabilitation is an effective rehabilitation mode for CHD patients in China.

Telerehabilitation intervention for type 2 diabetes

Diabetes has become an increasingly important health problem worldwide due to its prevalence. Although effective treatments for diabetes management have been developed, many patients have difficulty in achieving their therapeutic goals. Regular exercise training is suggested to prevent or delay the symptoms and complications of type 2 diabetes along with other medical treatments. It has become necessary to develop new rehabilitation models and practices in order to cope with the changing needs of the population. Treatment models using technology can be effective in disease management. Telerehabilitation may be effective as part of the rehabilitation program in the home environment, especially for patients who are unable to participate in conventional center-based rehabilitation due to transport difficulties or work resumption. Telerehabilitation is defined as the delivery of rehabilitation services via telecommunication technology, including phone, internet, and videoconference communications between the patient and health care provider. It is possible that telerehabilitation may benefit people with type 2 diabetes in similar ways with telemonitoring and interactive health communication systems. Although the applicability of telehealth methods has been proven in previous studies, telerehabi-litation studies in type 2 diabetes are inadequate in the literature. With larger, multi-centered randomized controlled studies, established clinical guidelines can be developed that will ultimately improve patient outcomes.

Wearable devices for remote vital signs monitoring in the outpatient setting: an overview of the field

Early detection of physiological deterioration has been shown to improve patient outcomes. Due to recent improvements in technology, comprehensive outpatient vital signs monitoring is now possible. This is the first review to collate information on all wearable devices on the market for outpatient physiological monitoring.

A scoping review was undertaken. The monitors reviewed were limited to those that can function in the outpatient setting with minimal restrictions on the patient’s normal lifestyle, while measuring any or all of the vital signs: heart rate, ECG, oxygen saturation, respiration rate, blood pressure and temperature.

A total of 270 papers were included in the review. Thirty wearable monitors were examined: 6 patches, 3 clothing-based monitors, 4 chest straps, 2 upper arm bands and 15 wristbands. The monitoring of vital signs in the outpatient setting is a developing field with differing levels of evidence for each monitor. The most common clinical application was heart rate monitoring. Blood pressure and oxygen saturation measurements were the least common applications. There is a need for clinical validation studies in the outpatient setting to prove the potential of many of the monitors identified.

Research in this area is in its infancy. Future research should look at aggregating the results of validity and reliability and patient outcome studies for each monitor and between different devices. This would provide a more holistic overview of the potential for the clinical use of each device.

Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial

AIM

To determine the effect of a tele-rehabilitation (TR) program on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes mellitus (DM).

METHOD

Fifty type 2 DM participants were enrolled in the study and divided randomly into two groups; TR (n = 25, mean age: 52.82 ± 11.86) or control (n = 25, mean age: 53.04 ± 10.45) group. Participants in the TR group performed breathing and callisthenic exercises, three times a week, for 6 weeks, at home by internet based video conferences. Outcome measures including, HbA1c level, 6 min walk testing, physical fitness and muscle strength dynamometer measurement, Beck Depression Inventory were performed before and after the 6 weeks.

RESULTS

HbA1c (p = 0.00), 6 min walking distance (p = 0.00), physical fitness subparameters; sit-up (p = 0.00), sit-and-reach (p = 0.04), back scratch (p = 0.00), lateral flexion right (p = 0.04), left (p = 0.00) and time up go tests (p = 0.00), muscles strength (p = 0.00); deltoideus-anterior, middle, quadriceps femoris and gluteus maximus, and depression levels (p = 0.00) changed significantly (p = 0.00) in TR groups. There were no significant improvements in control group (p > 0.05).

CONCLUSION

Our findings suggest that TR interventions found to be safe and effective, and may be an alternative treatment model for type 2 DM management. In addition to these health benefits, patients and rehabilitation team may save time, labor and treatment costs by using TR.

Accuracy of wearable heart rate monitors in cardiac rehabilitation

Background

To assess the accuracy of four wearable heart rate (HR) monitors in patients with established cardiovascular disease enrolled in phase II or III cardiac rehabilitation (CR).

Methods

Eighty adult patients enrolled in phase II or III CR were monitored during a CR session that included exercise on a treadmill and/or stationary cycle. Participants underwent HR monitoring with standard ECG limb leads, an electrocardiographic (ECG) chest strap monitor (Polar H7), and two randomly assigned wrist-worn HR monitors (Apple Watch, Fitbit Blaze, Garmin Forerunner 235, TomTom Spark Cardio), one on each wrist. HR was recorded at rest and at 3, 5, and 7 minutes of steady-state exercise on the treadmill and stationary cycle.

Results

Across all exercise conditions, the chest strap monitor (Polar H7) had the best agreement with ECG (r_c=0.99) followed by the Apple Watch (r_c=0.80), Fitbit Blaze (r_c=0.78), TomTom Spark (r_c=0.76) and Garmin Forerunner (r_c=0.52). There was variability in accuracy under different exercise conditions. On the treadmill, only the Fitbit Blaze performed well (r_c=0.76), while on the stationary cycle, Apple Watch (r_c=0.89) and TomTom Spark (r_c=0.85) were most accurate.

Conclusions

In cardiac patients, the accuracy of wearable, optically based HR monitors varies, and none of those tested was as accurate as an electrode-containing chest monitor. This observation has implications for in-home CR, as electrode-containing chest monitors should be used when accurate HR measurement is imperative.

Integration of Rehabilitation Activities Into Everyday Life Through Telerehabilitation: Qualitative Study of Cardiac Patients and Their Partners

Background

Implementation of cardiac rehabilitation has not been optimal, with patient participation rates below 50%. Factors that contribute to cardiac patients’ lack of participation in rehabilitation programs are patient motivation, logistical difficulties in getting to the rehabilitation facilities, lack of psychosocial elements, and individualization of activities in the rehabilitation programs. Telerehabilitation has been proposed as a new way to address the challenge of engaging and motivating cardiac patients and their partners to participate in rehabilitation.

Objective

The aim of this study was to explore the experiences of cardiac patients and their partners of participating in the Teledialog Telerehabilitation Program (TTP). The Teledialog program consisted of a digital rehabilitation plan, transmission of health data from patient’s home to hospital and health care center, and an interactive Web portal with information and training videos.

Methods

This case study used a theoretical approach combining the “community of practice” approach and self-determination theory. A triangulation of data collection techniques was used, including documents, participant observation (72 hours), and qualitative interviews with cardiac patients and their partners enrolled in the telerehabilitation group. A total of 14 cardiac patients, 12 patient spouses/partners, and 1 son participated in the study. The participants were interviewed at enrollment in the telerehabilitation program and after 12 weeks of participation in the program. Interview data were analyzed using NVivo 11.0.

Results

Patients and their partners found the Web portal ActiveHeart.dk and the electronic rehabilitation (e-rehabilitation) plan to be helpful tools for health education, coordinating rehabilitation goals, creating an overview of the data, and ensuring continuity in the rehabilitation process. The patients felt that the TTP treated them as individuals, gave them a sense of autonomy, and provided enhanced relatedness to health care professionals and partners and a sense of competence as active participants in their own rehabilitation process. Some patients missed being part of a community of practice with other cardiac patients and did not use the Web forum. Patients’ partners found that the telerehabilitation program gave them a sense of security and helped them balance their involvement as a partner to the patient and not push the patient too hard.

Conclusions

Cardiac patients and their partners found telerehabilitation technologies a useful digital toolbox in the rehabilitation process. Telerehabilitation motivated the patients to integrate rehabilitation activities into their work schedule and everyday life and made them feel like unique individuals. Participating in the Teledialog Telerehabilitation Program might not be a suitable strategy for all cardiac patients. Being a patient’s partner in the telerehabilitation program was associated with a heightened sense of security, navigation between active involvement in the rehabilitation process, being an equal partner, and not pushing the patient too hard.

Telemedicine in Rehabilitation

Telerehabilitation refers to the virtual delivery of rehabilitation services into the patient's home. This methodology has shown to be advantageous when used to enhance or replace conventional therapy to overcome geographic, physical, and cognitive barriers. The exponential growth of technology has led to the development of new applications that enable health care providers to monitor, educate, treat, and support patients in their own environment. Best practices and well-designed Telerehabilitation studies are needed to build and sustain a strong Telerehabilitation system that is integrated in the current health care structure and is cost-effective.

Cardiac Rehabilitees' Technology Experiences Before Remote Rehabilitation: Qualitative Study Using a Grounded Theory Approach

Background

Even though technology is becoming increasingly common in rehabilitation programs, insufficient data are as yet available on rehabilitees’ perceptions and experiences. It is important to understand their abilities when using technology for remote rehabilitation.

Objective

This is a qualitative study on technology experiences of persons affected by cardiovascular disease assessed before remote rehabilitation. The aim of the study was to explore rehabilitees’ experiences and attitudes toward technology before 12 months of remote rehabilitation.

Methods

Qualitative interviews were conducted with 39 rehabilitees in four focus groups. The subjects were aged 34 to 77 years (average age 54.8 years) and 74% (29/39) of them were male. They had been diagnosed with coronary artery disease and were undergoing treatment in a rehabilitation center. The interviews were conducted between September 2015 and November 2016. Data were analyzed using Glaser’s mode of the grounded theory approach.

Results

The result of the study was an “identifying e-usage” experience category, which refers to the rehabilitees’ notions of the use of information and communication technologies (e-usage) in the process of behavior change. The main category comprises four subcategories that define the rehabilitees’ technology experience. These subcategories are “feeling outsider,” “being uninterested,” “reflecting benefit,” and “enthusiastic using.” All rehabilitees expected that technology should be simple, flexible, and easy to use and learn. The results reflecting their technology experience can be used in e-rehabilitation programs. Rehabilitees who feel like outsiders and are not interested in technology need face-to-face communication for the major part of rehabilitation, while rehabilitees who reflect benefit and are enthusiastic about the use of technology need incrementally less face-to-face interaction and feel that Web-based coaching could offer sufficient support for rehabilitation.

Conclusions

The findings show that persons affected by heart disease had different experiences with technology and expectations toward counseling, while all rehabilitees expected technology to be easy to use and their experiences to be smooth and problem-free. The results can be used more widely in different contexts of social and health care for the planning of and training in remote rehabilitation counseling and education.

Trial Registration

ISRCTN Registry ISRCTN61225589; http://www.isrctn.com/ISRCTN61225589 (Archived by WebCite at http://www.webcitation.org/74jmrTXFD)

A prescribed walking regimen plus arginine supplementation improves function and quality of life for patients with pulmonary arterial hypertension: a pilot study

Current evidence suggests that exercise training is beneficial in pulmonary arterial hypertension (PAH). Unfortunately, the standard supervised, hospital-based programs limit patient accessibility to this important intervention. Our proof-of-concept study aimed to provide insight into the usefulness of a prescribed walking regimen along with arginine supplementation to improve outcomes for patients with PAH. Twelve PAH patients (all women) in New York Heart Association (NYHA) functional class (FC) II (n = 7) or III (n = 5) and in stable condition for ≥ 3 months were enrolled. Patients performed home- and fitness-center- based walking at 65-75% heart rate (HR) reserve for 45 min, six sessions/week for 12 weeks. Concomitant L-arginine supplementation (6000 mg/day) was provided to maximize beneficial endothelial training adaptations. Cardiopulmonary exercise testing, 6-min walk testing (6MWT), echocardiography, laboratory studies, and quality of life (QoL) survey (SF-36) were performed at baseline and 12 weeks. Eleven patients completed the study (72 session adherence rate = 96 ± 3%). Objective improvement was demonstrated by the 6MWT distance (increased by 40 ± 13 m, P = 0.01), VO₂max (increased by 2 ± 0.7 mL/kg/min, P = 0.02), time-to-VO₂max (increased by 2.5 ± 0.6 min, P = 0.001), VO₂ at anaerobic threshold (increased by 1.3 ± 0.5 mL/kg/min, P = 0.04), HR recovery (reduced by 68 ± 23% in slope, P = 0.01), and SF-36 subscales of Physical Functioning and Energy/Fatigue (increased by 70 ± 34% and 74 ± 34%, respectively, P < 0.05). No adverse events occurred, and right ventricular function and brain natriuretic peptide levels remained stable, suggesting safety of the intervention. This proof-of-concept study indicates that a simple walking regimen with arginine supplementation is a safe and efficacious intervention for clinically stable PAH patients, with gains in objective function and QoL measures. Further investigation in a randomized controlled trial is warranted.

Cardiac rehabilitation costs

BACKGROUND

Despite the clinical benefits of cardiac rehabilitation (CR) and its cost-effectiveness, it is not widely received. Arguably, capacity could be greatly increased if lower-cost models were implemented. The aims of this review were to describe: the costs associated with CR delivery, approaches to reduce these costs, and associated implications.

METHODS

Upon finalizing the PICO statement, information scientists were enlisted to develop the search strategy of MEDLINE, Embase, CDSR, Google Scholar and Scopus. Citations identified were considered for inclusion by the first author. Extracted cost data were summarized in tabular format and qualitatively synthesized.

RESULTS

There is wide variability in the cost of CR delivery around the world, and patients pay out-of-pocket for some or all of services in 55% of countries. Supervised CR costs in high-income countries ranged from PPP$294 (Purchasing Power Parity; 2016 United States Dollars) in the United Kingdom to PPP$12,409 in Italy, and in middle-income countries ranged from PPP$146 in Venezuela to PPP$1095 in Brazil. Costs relate to facilities, personnel, and session dose. Delivering CR using information and communication technology (mean cost PPP$753/patient/program), lowering the dose and using lower-cost personnel and equipment are important strategies to consider in containing costs, however few explicitly low-cost models are available in the literature.

CONCLUSION

More research is needed regarding the costs to deliver CR in community settings, the cost-effectiveness of CR in most countries, and the economic impact of return-to-work with CR participation. A low-cost model of CR should be standardized and tested for efficacy across multiple healthcare systems.

The effect of a smartphone-based coronary heart disease prevention (SBCHDP) programme on awareness and knowledge of CHD, stress, and cardiac-related lifestyle behaviours among the working population in Singapore: a pilot randomised controlled trial

Background

Coronary heart disease (CHD) is the most prevalent type of cardiac disease among adults worldwide, including those in Singapore. Most of its risk factors, such as smoking, physical inactivity and high blood pressure, are preventable. mHealth has improved in the last decade, showing promising results in chronic disease prevention and health promotion worldwide. Our aim was to develop and examine the effect of a 4-week Smartphone-Based Coronary Heart Disease Prevention (SBCHDP) programme in improving awareness and knowledge of CHD, perceived stress as well as cardiac-related lifestyle behaviours in the working population of Singapore.

Methods

The smartphone app “Care4Heart” was developed as the main component of the programme. App content was reviewed and validated by a panel of experts, including two cardiologists and two experienced cardiology-trained nurses. A pilot randomised controlled trial was conducted. Eighty working people were recruited and randomised to either the intervention group (n = 40) or the control group (n = 40). The intervention group underwent a 4-week SBCHDP programme, whereas the control group were offered health promotion websites only. The participants’ CHD knowledge, perceived stress and behavioural risk factors were measured at baseline and on the 4th week using the Heart Disease Fact Questionnaire-2, Perceived Stress Scale, and Behavioural Risk Factor Surveillance System.

Results

After the SBCHDP programme, participants in the intervention group had a better awareness of CHD being the second leading cause of death in Singapore (X²  = 6.486, p = 0.039), a better overall CHD knowledge level (t = 3.171, p = 0.002), and better behaviour concerning blood cholesterol control (X² = 4.54, p = 0.033) than participants in the control group.

Conclusion

This pilot study partially confirmed the positive effects of the SBCHDP programme in improving awareness and knowledge of CHD among the working population. Due to the small sample size and short follow-up period, this study was underpowered to detect significant differences between groups. A full-scale longitudinal study is required in the future to confirm the effectiveness of the SBCHDP programme.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-017-0623-y) contains supplementary material, which is available to authorized users.