Cardiac rehabilitation via telerehabilitation in COVID-19 pandemic situation

The Accessibility and Effect of Cardiac Rehabilitation in COVID-19 Pandemic Era

OBJECTIVE

To prospectively compare the efficacy of conventional center-based cardiac rehabilitation (CBCR) and home-based cardiac rehabilitation (HBCR) during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Ninety Patients were divided into HBCR and CBCR groups based on cardiovascular risk stratification and individual preference. The CBCR group performed supervised in-hospital exercise training 2-3 times/week and subsequent self-exercise at home. The HBCR group performed self-exercise at home after one or two sessions of exercise education. The cardiopulmonary exercise test results at baseline and those at the 3-, 6-, and 12-month follow-ups were analyzed as primary outcome.

RESULTS

The peak oxygen consumption (peak VO2, mL/kg/min) in the CBCR group was 20.1 and 24.0 at baseline and 12 months, respectively, showing significant improvement (p=0.006). In the HBCR group, it only increased from 24.4 to 25.5, showing suboptimal improvement. A significant increase in the Korean activity scale/index was confirmed only in the CBCR group (p=0.04). The cardiovascular outcome did not differ between the two groups, nor did the dropout rate or demographic factors.

CONCLUSION

During the COVID-19 pandemic, only CBCR was associated with a significant improvement in peak VO2 and physical activity levels, a finding that differs from those of other studies and seems to be affected by COVID-19. Therefore, in situations where the importance of HBCR is emphasized, it is essential to introduce measures to monitor and enhance exercise adherence among participants.

Smartphone application-based rehabilitation in patients with chronic respiratory and cardiovascular diseases

Rehabilitation improves symptoms, quality of life, and survival in patients with chronic respiratory or cardiovascular disease. We evaluated smartphone application-based rehabilitation programs for patients with chronic respiratory or cardiovascular diseases. This was a single-center prospective single arm study. Participants underwent smartphone application-based pulmonary or cardiac rehabilitation for 12 weeks. A total of 93 participants were recruited, and 75 visited after rehabilitation. Their median age was 67.0 (interquartile range, 60.0-70.8) years, and 60 (80.0%) were men. For patients with chronic respiratory disease (n = 41), VO2peak (median 13.7 to 15.4 ml/kg/min, P = 0.049), chronic obstructive pulmonary disease assessment test (median 14 to 6, P < 0.001), Euro-QoL 5-Dimension 5-Level (EQ-5D-5L) index (median 0.795 to 0.862, P = 0.001), and Health-related Quality of Life Instrument with 8 Items (HINT-8) index (median 0.784 to 0.855, P < 0.001) were significantly improved. For patients with chronic cardiovascular disease (n = 34), VO2peak (median 21.8 to 23.3, P = 0.007), EQ-5D-5L index (median 0.871 to 1.000, P = 0.037), and HINT-8 index (median 0.890 to 0.903, P < 0.001) were significantly improved. The smartphone application-based rehabilitation program improved exercise capacity and quality of life in patients with chronic respiratory or cardiovascular disease.Trial registration: https://clinicaltrials.gov/ct2/show/NCT05383950 (20/05/2022).

Relationship Between Number of Cardiac Rehabilitation Exercise Training Sessions, Muscle Mass, and Cardiorespiratory Fitness in Rural Elderly Patients with Coronary Artery Disease

Purpose

This study aimed to compare the effects of a cardiac rehabilitation (CR) exercise program on skeletal muscle index (SMI) and cardiorespiratory fitness (CRF) in patients aged ≥65 years.

Patients and Methods

From January 2012 to December 2021, patients living in rural regions aged ≥65 who underwent percutaneous coronary intervention for acute myocardial infarction (AMI) and at least one CR exercise session were enrolled. We retrospectively reviewed the medical records of the patients who underwent an exercise tolerance test (ETT) at initial and 3-month follow-ups. A total of 36 patients were enrolled who underwent a mean of 6.56 exercise sessions and were divided into groups based on the number of center-based CR (CBCR) sessions: 14 in Group A (≥7 sessions) and 22 in Group B (<7 sessions). In CBCR session, we comprehensively counseled them about their nutrition, smoking cessation et al. Both groups underwent an ETT after 12 weeks. The outcomes were CRF parameters examined by a cardiorespiratory exercise test and the SMI examined by bioimpedance analysis (BIA).

Results

The number of exercise sessions was significantly correlated with the rate of SMI change. Group A showed significant increases in metabolic equivalent of task (MET), maximal oxygen uptake (VO2max), and SMI after 3 months. There were significant differences in the rates of change in MET, VO2max, and SMI between the two groups.

Conclusion

CRF significantly improved in Group A in a short period. Further studies are required to increase long-term CBCR adherence in elderly patients with AMI in rural regions.

Smartphone application-based rehabilitation in patients with chronic respiratory and cardiovascular diseases: a randomised controlled trial study protocol

INTRODUCTION

Rehabilitation is well known to improve clinical symptoms and decrease the risk of mortality in patients with chronic respiratory or cardiovascular diseases. We will evaluate the efficacy of smartphone application-based rehabilitation programmes in patients with chronic respiratory or cardiovascular diseases.

METHODS AND ANALYSIS

This single-centre single-blind randomised controlled trial will recruit a total of 162 participants from Asan Medical Center (81 patients each for pulmonary and cardiac rehabilitation, respectively). Participants will be assigned to the pulmonary or cardiac rehabilitation groups based on their underlying disease. Participants will be allocated randomly into the intervention or control groups at the ratio of 2:1 (54 and 27 patients). The intervention group will be provided with a smartphone application and undergo smartphone application-based rehabilitation for 12 weeks. The control group will receive the usual outpatient medical treatment without rehabilitation. Participants will be evaluated at baseline and at the end of the rehabilitation. The primary outcomes will be exercise capacity, such as maximal oxygen consumption on cardiopulmonary exercise test for both groups, chronic obstructive pulmonary disease assessment test for the pulmonary rehabilitation group, and Health-related Quality of Life Instrument with 8 Items questionnaires for the cardiac rehabilitation group. The secondary outcomes will include quality of life questionnaires, symptom scores, pulmonary function test and limb muscle test.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of Asan Medical Center. Written informed consent will be obtained from all participants prior to inclusion. The findings from this study will be disseminated through peer-reviewed scientific journals and conferences.

TRIAL REGISTRATION NUMBER

NCT05610358.

Difference of cardiac rehabilitation in the morning or evening on indexes of left ventricular and N-terminal pro-brain natriuretic peptide: a randomized controlled trial

The present study aimed to evaluate the effects a cardiac rehabilitation program (CRP) performed in the morning or evening on left ventricular (LV) filling indices and the level of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) in patients undergoing percutaneous coronary angioplasty during the COVID-19 pandemic.

Methods

This was a randomized controlled single-blinded clinical trial. Ninety-six patients (mean age: 50.2 ± 8.1 years, 36 women and 44 men) with percutaneous coronary angioplasty were divided into two groups of intervention and control. In each group, the CRP was performed in either morning or evening. The CRP included walking and performing push-ups and sit-ups for 8 weeks. The participants of the control groups received routine care. The functional indices of LV, including LV ejection fraction, systolic function, and diastolic function (i.e. the transmitral flow), the E/e' to left atrium peak strain ratio (as an estimation for LA stiffness), and NT-proBNP level were measured in all participants before starting and at the end of the CRP.

Results

In the intervention group, the individuals performing the CRP in the evening had significantly higher E-wave (0.76±0.02 vs. 0.75±0.03; P=0.008), ejection fraction (52.5±5.64 vs. 55.5±3.59; P=0.011), and diastolic function velocity (E/A ratio, 1.03±0.06 vs. 1.05±0.03; P=0.014) and significantly lower A-wave (0.72±0.02 vs. 0.71±0.01; P=0.041), E/e' ratio (6.74±0.29 vs. 6.51±0.38; P=0.038), and NT-proBNP level (2007.9±214.24 vs. 1933.9±253.13; P=0.045) compared with those performing the program in the morning.

Conclusions

A supervised CRP performed in the evening compared with morning was more effective in improving LV functional indices. Therefore, such home-based interventions are recommended to be performed in the evening during the COVID-19 pandemic.

ehealth technology in cardiac exercise therapeutics for pediatric patients with congenital and acquired heart conditions: a summary of evidence and future directions

Many children and adolescents with congenital and acquired heart disease (CHD) are physically inactive and participate in an insufficient amount of moderate-to-vigorous intensity exercise. Although physical activity (PA) and exercise interventions are effective at improving short- and long-term physiological and psychosocial outcomes in youth with CHD, several barriers including resource limitations, financial costs, and knowledge inhibit widespread implementation and dissemination of these beneficial programs. New and developing eHealth, mHealth, and remote monitoring technologies offer a potentially transformative and cost-effective solution to increase access to PA and exercise programs for youth with CHD, yet little has been written on this topic. In this review, a cardiac exercise therapeutics (CET) model is presented as a systematic approach to PA and exercise, with assessment and testing guiding three sequential PA and exercise intervention approaches of progressive intensity and resource requirements: (1) PA and exercise promotion within a clinical setting; (2) unsupervised exercise prescription; and (3) medically supervised fitness training intervention (i.e., cardiac rehabilitation). Using the CET model, the goal of this review is to summarize the current evidence describing the application of novel technologies within CET in populations of children and adolescents with CHD and introduce potential future applications of these technologies with an emphasis on improving equity and access to patients in low-resource settings and underserved communities.

Association of Home-Based Cardiac Rehabilitation With Lower Mortality in Patients With Cardiovascular Disease: Results From the Veterans Health Administration Healthy Heart Program

Background Home-based cardiac rehabilitation (HBCR) and traditional facility-based cardiac rehabilitation (CR) programs have similar effects on mortality in clinical trials and meta-analyses. However, the effect of HBCR on mortality in clinical practice settings is less clear. Therefore, we sought to compare mortality rates in HBCR participants versus nonparticipants. Methods and Results We evaluated all patients who were referred to and eligible for outpatient CR between 2013 and 2018 at the San Francisco Veterans Health Administration. Patients who chose to attend facility-based CR and those who died within 30 days of hospitalization were excluded. Patients who chose to participate in HBCR received up to 9 telephonic coaching and motivational interviewing sessions over 12 weeks. All patients were followed through June 30, 2021. We used Cox proportional hazards regression models with inverse probability treatment weighting to compare mortality in HBCR participants versus nonparticipants. Of the 1120 patients (mean age 68, 98% male, 76% White) who were referred and eligible, 490 (44%) participated in HBCR. During a median follow-up of 4.2 years, 185 patients (17%) died. Mortality was lower among the 490 HBCR participants versus the 630 nonparticipants (12% versus 20%; P<0.01). In an inverse probability weighted Cox regression analysis adjusted for patient demographics and comorbid conditions, the hazard of mortality remained 36% lower among HBCR participants versus nonparticipants (hazard ratio, 0.64 [95% CI, 0.45-0.90], P=0.01). Conclusions Among patients eligible for CR, participation in HBCR was associated with 36% lower hazard of mortality. Although unmeasured confounding can never be eliminated in an observational study, our findings suggest that HBCR may benefit patients who cannot attend traditional CR programs.

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Greek Version of the Cardiac Rehabilitation Barriers Scale (CRBS-GR): What Are the Barriers in South-East Europe?

Cardiac Rehabilitation (CR) is a secondary prevention intervention proven to improve quality of life, yet with low participation. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess multi-level barriers to participation. This study aimed at the translation, and cross-cultural adaptation of the CRBS into the Greek language (CRBS-GR), followed by psychometric validation. Some 110 post-angioplasty patients with coronary artery disease (88.2% men, age 65.3 ± 10.2 years) answered the CRBS-GR. Factor analysis was performed to obtain the CRBS-GR subscales/factors. The internal consistency and 3-week test-retest reliability was evaluated using Cronbach's alpha (α) and intraclass correlation coefficient (ICC), respectively. Construct validity was tested via convergent and divergent validity. Concurrent validity was assessed with the Hospital Anxiety and Depression Scale (HADS). Translation and adaptation resulted in 21 items similar to the original version. Face validity and acceptability were supported. Construct validity assessment revealed four subscales/factors, with acceptable overall reliability (α = 0.70) and subscale internal consistency for all but one factor (α range = 0.56-0.74). The 3-week test-retest reliability was 0.96. Concurrent validity assessment demonstrated a small to moderate correlation of the CRBS-GR with the HADS. The greatest barriers were the distance from the rehabilitation center, the costs, the lack of information about CR, and already exercising at home. The CRBS-GR is a reliable and valid tool for identifying CR barriers among Greek-speaking patients.

A Pilot, Virtual Exercise Intervention Improves Health and Fitness during the COVID-19 Pandemic

Physical activity levels are low in individuals with chronic disease (e.g., obesity) and have worsened during the COVID-19 pandemic.

PURPOSE

Our pilot study tested a virtual exercise intervention for rural-dwelling adults with chronic disease from January-April 2021 for changes in mental health, physical fitness, and physical activity and for intervention fidelity.

METHODS

Participants (n = 8 [7 female]; age = 57.5 ± 13.8 years, body mass index = 38.2 ± 8.0 kg/m2) completed an exercise intervention led virtually by collegiate health science majors. Participants attended two 60-minute sessions/week for 12 weeks, completing individually-tailored and progressed aerobic and muscle-strengthening training. A non-randomized control group matched on gender and age continued normal activity during the 12 weeks. Changes in mental health, physical fitness, and physical activity measures were evaluated using a 2×2 (group × time) analysis of covariance.

RESULTS

Both groups improved mental health, but only intervention participants lost weight (3.1 ± 1.0 kg; no change in controls). Step test, arm curls, and chair stands improved by 16.1-20.6% in the intervention and 7.8-12.1% in the control groups. Intervention participants did not increase overall physical activity during or after the intervention. Intervention fidelity was high; participants attended ~73% of sessions and rated the sessions 4.7 ± 0.6 (out of 5). Researcher observations rated exercise sessions as meeting 12.7 ± 0.6 of 16 goals.

CONCLUSIONS

Our virtual exercise program was associated with positive mental health and physical fitness changes. Such programs may provide a method, even beyond the pandemic, to improve fitness in adults with chronic disease.

Efficacy, efficiency and safety of a cardiac telerehabilitation programme using wearable sensors in patients with coronary heart disease: the TELEWEAR-CR study protocol

INTRODUCTION

Exercise-based cardiac rehabilitation (CR) is a beneficial tool for the secondary prevention of cardiovascular diseases with, however, low participation rates. Telerehabilitation, intergrading mobile technologies and wireless sensors may advance the cardiac patients' adherence. This study will investigate the efficacy, efficiency, safety and cost-effectiveness of a telerehabilitation programme based on objective exercise telemonitoring and evaluation of cardiorespiratory fitness.

METHODS AND ANALYSIS

A supervised, parallel-group, single-blind randomised controlled trial will be conducted. A total of 124 patients with coronary disease will be randomised in a 1:1 ratio into two groups: intervention telerehabilitation group (TELE-CR) (n=62) and control centre-based cardiac rehabilitation group (CB-CR) (n=62). Participants will receive a 12-week exercise-based rehabilitation programme, remotely monitored for the TELE-CR group and standard supervised for the CB-CR group. All participants will perform aerobic training at 70% of their maximal heart rate, as obtained from cardiopulmonary exercise testing (CPET) for 20 min plus 20 min for strengthening and balance training, three times per week. The primary outcomes will be the assessment of cardiorespiratory fitness, expressed as peak oxygen uptake assessed by the CPET test and the 6 min walk test. Secondary outcomes will be the physical activity, the safety of the exercise intervention (number of adverse events that may occur during the exercise), the quality of life, the training adherence, the anxiety and depression levels, the nicotine dependence and cost-effectiveness. Assessments will be held at baseline, end of intervention (12 weeks) and follow-up (36 weeks).

ETHICS AND DISSEMINATION

The study protocol has been reviewed and approved by the Ethics Committee of the University of Thessaly (1108/1-12-2021) and by the Ethics Committee of the General University Hospital of Larissa (3780/31-01-2022). The results of this study will be disseminated through manuscript publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05019157.

Cardiac Rehabilitation and Mortality Risk Reduction in Peripheral Artery Disease at 6-Month Outcome

The management of patients with peripheral artery disease (PAD) is integrative and multidisciplinary, in which cardiac rehabilitation (CR) plays a prognostic role in terms of functional status, quality of life, and long-term impact on morbidity and mortality. We conducted a prospective cohort study on 97 patients with PAD admitted to a single tertiary referral center. Based on a prognostic index developed to stratify long-term mortality risk in PAD patients, we divided the cohort into two groups: low and low-intermediate risk group (45 cases) and high-intermediate and high risk group (52 cases). We analyzed demographics, clinical parameters, and paraclinical parameters in the two groups, as well as factors associated with cardiological reassessment prior to the established deadline of 6 months. Obesity (p = 0.048), renal dysfunction (p < 0.001), dyslipidemia (p < 0.001), tobacco use (p = 0.048), and diabetes mellitus (p < 0.001) are comorbidities with long-term prognostic value. Low-density lipoprotein cholesterol (p = 0.002), triglycerides (p = 0.032), fasting glucose (p = 0.011), peak oxygen uptake (p = 0.005), pain-free walking distance (p = 0.011), maximum walking time (p < 0.001), and maximum walking distance (p = 0.002) influence the outcome of PAD patients by being factors associated with clinical improvement at the 6-month follow-up. PAD patients benefit from enrollment in CR programs, improvement of clinical signs, lipid and carbohydrate profile, and weight loss and maintenance of blood pressure profile within normal limits, as well as increased exercise capacity being therapeutic targets.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient Perception When Transitioning from Classic to Remote Assisted Cardiac Rehabilitation

Cardiac rehabilitation is an individualized outpatient program of physical exercises and medical education designed to accelerate recovery and improve health status in heart disease patients. In this study, we aimed for assessment of patients’ perception of the involvement of technology and remote monitoring devices in cardiac recovery. During the Living Lab Phase of the Virtual Coaching Activities for Rehabilitation in Elderly (vCare) project, we evaluated eleven patients (five heart failure patients and six ischemic heart disease patients). Patient admission in the UMFCD cardiology clinical department served as a shared inclusion criterion for both study groups. In addition, the presence of II or III heart failure NYHA stage status was considered an inclusion criterion for the heart failure study group and patients diagnosed with ischemic heart disease for the second one. We conducted a system usability survey to assess the patients’ perception of the system’s technical and medical functions. The survey had excellent preliminary results in the heart failure study group and good results in the ischemic heart disease group. The limited access of patients to cardiac rehabilitation in Romania has led to increased interest and motivation in this study. The final version of the product is designed to adapt to patient needs and necessities; therefore, patient perception is necessary.

Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era

Cardiac rehabilitation (CR) is an integral part of the management of various cardiovascular disease such as coronary artery disease (CAD), peripheral artery disease (PAD), or chronic heart failure (CHF), with proven morbidity and mortality benefits. This article aims to review and summarize the scientific literature related to cardiac rehabilitation programs for patients with PAD and how they were adapted during the COVID-19 pandemic. The implementation of CR programs has been problematic since the COVID-19 pandemic due to social distancing and work-related restrictions. One of the main challenges for physicians and health systems alike has been the management of PAD patients. COVID-19 predisposes to coagulation disorders that can lead to severe thrombotic events. Home-based walking exercises are more accessible and easier to accept than supervised exercise programs. Cycling or other forms of exercise are more entertaining or challenging alternatives to exercise therapy. Besides treadmill exercises, upper- and lower-extremity ergometry also has great functional benefits, especially regarding walking endurance. Supervised exercise therapy has a positive impact on both functional capacity and also on the quality of life of such patients. The most effective manner to acquire this seems to be by combining revascularization therapy and supervised exercise. Rehabilitation programs proved to be a mandatory part of the integrative approach in these cases, increasing quality of life, and decreasing stress levels, depression, and anxiety.