"As du Coeur" study: a randomized controlled trial on quality of life impact and cost effectiveness of a physical activity program in patients with cardiovascular disease

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.

Mediating effect of kinesiophobia between self-efficacy and physical activity levels in post-CABG patients: protocol for a prospective, multicentre, cross-sectional study in China

INTRODUCTION

Physical activity (PA) can improve cardiac function, exercise capacity, and quality of life, in addition to reducing mortality by 20%-30% and preventing the recurrence of adverse cardiovascular events in patients following coronary artery bypass graft (CABG). However, PA levels are low in patients after CABG. This study intends to explore the mediating effect of kinesiophobia between self-efficacy and PA levels in patients following CABG.

METHODS AND ANALYSIS

The proposed study constitutes a prospective, multicentre and cross-sectional study comprising 413 patients. Four teaching hospitals with good reputations in CABG will be included in the study. All of them are located in Beijing, China, and provide medical service to the whole country. This study will assess the following patient-reported outcome measures: demographic information, International Physical Activity Questionnaire-Long, Social Support Rating Scale, Cardiac Exercise Self-Efficacy Instrument, Multidimensional Fatigue Inventory, Hospital Anxiety and Depression Scale, and Tampa Scale for Kinesiophobia Heart.

ETHICS AND DISSEMINATION

This study conforms to the principles of the Declaration of Helsinki and relevant ethical guidelines. Ethical approval has been obtained from the Ethics Committee of The Sixth Medical Centre of PLA General Hospital (approval number: HZKY-PJ-2022-2). All study participants will provide written informed consent. Findings from this study will be published in Chinese or English for widespread dissemination of the results.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Register, ChiCTR2100054098.

How are you doing in the eyes of your spouse? Level of agreement between the self-completed EQ-5D-5L and two proxy perspectives in an orthopaedic population: a randomized agreement study

Objectives

To determine the level of agreement between both proxy versions and the self-completed EQ-5D-5L.

Design

A randomized agreement study.

Setting and participants

We recruited 120 patients (compos mentis) and their proxies at the orthopaedic outpatient clinic. Patients completed the regular EQ-5D-5L and their proxy completed the proxy version of the EQ-5D-5L and rated the patients’ health from their own (proxy-proxy) perspective (i.e. how do you rate the health of the patient), and from the patient’s (proxy-patient) perspective (i.e. how do you think the patient would rate their own health if they were able to).

Measures

The primary outcome was the agreement between patients and their proxy, quantified as the intra class correlation coefficient for the EQ-5D-5L Utility score.

Results

Average Utility scores were 0.65 with the self completed EQ-5D-5L, versus 0.60 with the proxy-patient version and 0.58 with the proxy-proxy version. The ICC was 0.66 (95% CI 0.523, 0.753) for the proxy-patient perspective and 0.58 (95% CI 0.411, 0.697) for the proxy-proxy perspective. The mean gold standard score of the VAS-Health was 69.7 whereas the proxy-proxy perspective was 66.5 and the proxy-patient perspective was 66.3.

Conclusion and implications

The proxy-patient perspective yielded substantial agreement with the self completed EQ-5D-5L, while the agreement with the proxy-proxy perspective was moderate. In this study population of patients without cognitive impairment, proxies tended to underestimate the quality of life of their relative.

Effects of neuromuscular training compared to classic strength-resistance training in patients with acute coronary syndrome: A study protocol for a randomized controlled trial

The aim of the present clinical trial is to evaluate the effectiveness of neuromuscular versus classical strength-resistance training as part of a cardiac rehabilitation programme in patients following acute coronary syndrome. The study is designed as a double-blinded, randomised, and controlled clinical trial. Thirty participants suffering from acute coronary syndrome who meet our inclusion criteria will be recruited by a private tertiary hospital. The intervention group will follow 20 sessions of a cardiac rehabilitation programme divided into two parts: aerobic training and neuromuscular strength-resistance training. The control group will complete the same aerobic training as well as a classical strength-resistance training workout programme. The primary outcome of the study will be the mean difference in change from baseline in the Incremental Shuttle Walking Test. The secondary outcomes will be the cardiorespiratory fitness of the patients (assessed by means of the Chester Step Test), lower-limb performance (assessed with the 30-Second Chair Stand Test and Single-Leg Squat Test), lower-limb strength (hip flexor handheld dynamometry), sexual dysfunction assessment (Sex Health Inventory for Men) and quality of life (EQ-5D-5L). This work will provide evidence for the effectiveness of a neuromuscular versus a classic strength-training programme in terms of cardiorespiratory fitness, lower-limb performance capacities and quality of life, in cardiac patients. The data obtained could lead to more effective and functional workouts which, in turn, may enhance the speed at which these patients can return to their everyday activities of life and improve the efficiency of their movement patterns and heart responses. Furthermore, patients may find neuromuscular workout routines more motivating and engaging, thus encouraging them to adopt healthier lifestyle patterns.