Cardiac Rehabilitation Models around the Globe

The psychological well-being index and quality of life after a cardiac rehabilitation program based on aerobic training and psychosocial support

BACKGROUND

This study aimed to investigate the physical and psychological benefits of an alternative cardiac rehabilitation program based on therapeutic groups during physical exercise sessions and to compare the results with those of a conventional cardiac rehabilitation program.

METHOD

The sample included 112 patients from the cardiac rehabilitation unit of a medical center, 91.1 % of whom were male. The control group consisted of 47 subjects, with a mean age of 57.89 ± 12.30 and the experimental group consisted of 65 subjects, with a mean age of M = 58.38 ± 9.86. Quality of life, psychological well-being, health-related quality of life, body mass index, blood pressure, abdominal circumference and resting heart rate were measured before starting and at the end of the cardiac rehabilitation program.

RESULTS

The experimental group improved significantly more than the control group in body mass index, systolic and diastolic blood pressure, abdominal circumference, and resting heart rate (p value < 0.005). In addition, the experimental group had significantly greater improvements in quality of life, psychological well-being, and health-related quality of life than the control group (p-value < 0.001).

CONCLUSIONS

A cardiac rehabilitation program based on simultaneous aerobic training and psychosocial support improved the physical function, health-related quality of life and well-being.

Patient-reported preferences in eHealth-based cardiac rehabilitation: A qualitative investigation of behavior change techniques, barriers and facilitators

Background

Cardiac rehabilitation (CR) reduces recurrent cardiac events and mortality in patients with cardiovascular diseases (CVD). Innovative eHealth methods can facilitate CR uptake and effectiveness by addressing barriers associated with clinic-based rehabilitation. Tailoring eHealth-based CR to patient preferences is needed to further enhance CR.

Purpose

To identify preferred behavior change techniques (BCTs) as well as barriers and facilitators for the different health behaviors targeted in eHealth-based CR among patients who have been referred to CR.

Methods

Thirty-nine patients were interviewed in nine focus groups in The Netherlands, Germany, and Spain. A thematic analysis, using a combined deductive and inductive approach to coding, was conducted to identify BCTs and barriers and facilitators to behavior change. Behaviors under investigation included physical activity, medication adherence, eating a cardiac healthy-diet, stress reduction and smoking cessation.

Results

The perceived helpfulness of BCTs depended on the specific behavior targeted. Common barriers were negative emotional state and physical limitations. A desire to feel physically or mentally well and having experienced a cardiac life event were the most common facilitators across health behaviors. Specific BCTs, barriers and facilitators were found for each of the health behavior.

Conclusions

Behavior change techniques that patients preferred for each health behavior targeted in eHealth-based CR were identified. A negative emotional state, experiencing a life event, and improving physical functioning are important barriers and facilitators in multiple behaviors targeted in eHealth-based CR programs. Additional tailoring of interventions to patient preferences for BCTs and patient-specific barriers and facilitators per health behavior could lead to further improvement of eHealth-based CR.

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study

BACKGROUND

The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models.

OBJECTIVE

The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic.

METHODS

Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis.

RESULTS

Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation.

CONCLUSIONS

Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

Effectiveness of a virtual vs. in-person group-based education curriculum to increase disease-related knowledge and change health behaviour among cardiac rehabilitation participants

OBJECTIVE

To investigate the effectiveness of a virtual 12-week group-based education curriculum and to compare results with a retrospective cohort that received the same education in-person for 24 weeks.

METHODS

Participants completed online surveys (pre- and post-intervention) assessing disease-related knowledge, adherence to the Mediterranean diet, exercise self-efficacy, and satisfaction. The number of steps taken per day was recorded using a wearable device. Paired t tests and repeated measures ANOVA were used. A Bonferroni correction was applied(p < 0.01).

RESULTS

80 CR participants receiving virtual education completed both assessments. Following virtual education, participants significantly increased knowledge(p < 0.001), adherence to the Mediterranean diet(p < 0.001) and number of daily steps(p = 0.01). These results were similarly observed in the in-person education group(n = 80), with no significant differences between groups. Virtual education participants decreased their self-efficacy post-intervention(p < 0.001); in contrast, participants of the in-person education increased their exercise self-efficacy(p < 0.001). Overall,31% of virtual and 71% of in-person education participants reported being satisfied with the education delivery format.

CONCLUSIONS

A virtual group-based education curriculum was effective at improving knowledge and changing behaviour. Similar results were observed in those that received in-person education. Tailoring virtual education interventions to support exercise self-efficacy is warranted.

PRACTICE IMPLICATION

This study strengthens the evidence supporting virtual education in CR.

Global perspectives on heart disease rehabilitation and secondary prevention: a scientific statement from the Association of Cardiovascular Nursing and Allied Professions, European Association of Preventive Cardiology, and International Council of Cardiovascular Prevention and Rehabilitation

Cardiovascular disease is a leading cause of death, morbidity, disability, and reduced health-related quality of life, as well as economic burden worldwide, with some 80% of disease burden occurring in the low- and middle-income country (LMIC) settings. With increasing numbers of people living longer with symptomatic disease, the effectiveness and accessibility of secondary preventative and rehabilitative health services have never been more important. Whilst LMICs experience the highest prevalence and mortality rates, the global approach to secondary prevention and cardiac rehabilitation, which mitigates this burden, has traditionally been driven from clinical guidelines emanating from high-income settings. This state-of-the art review provides a contemporary global perspective on cardiac rehabilitation and secondary prevention, contrasting the challenges of and opportunities for high vs. lower income settings. Actionable solutions to overcome system, clinician, programme, and patient level barriers to cardiac rehabilitation access in LMICs are provided.

[Effectiveness of tertiary prevention on quality of life and control of risk factors in patients with ischemic coronary heart disease]

Objective

Determine the effectiveness of cardiac rehabilitation (CR) as a tertiary prevention strategy in the quality of life and control of risk factors of patients with ischemic coronary heart disease (ICC) of the National Cardiovascular Institute (INCOR) of EsSalud- Lima during the year 2018.

Materials and methods

A retrospective cohort of 280 patients with a diagnosis of CCI was studied who, after medical, interventional, or surgical treatment, were referred to the INCOR CR program for tertiary prevention (PT) in 2018. The program was developed according to the institutional guide for eight weeks with exercise sessions and educational, psychological, nutritional, and recreational workshops. At the beginning and at the end of this, the QLMI-2 quality of life test was applied, and anthropometric, laboratory, and risk factor control measurements were performed.

Results

Quality of life levels at the end of CR showed a statistically significant improvement in the emotional, social, physical, and global dimensions (p < 0.001). The same behavior was observed for the nutritional variables of weight, abdominal circumference, and BMI (p < 0.001). Physical capacity showed a statistically significant improvement in the aspects of muscle strength (12.2%), physical activity (38.0%), and functional capability (25.4%) (p < 0.001). The result was not homogeneous for the biochemical metabolic variables, where glycosylated hemoglobin, glycemia, and lipid profile did not show significant improvement, except for HDL, which raised its levels statistically significantly (p < 0.001).

Conclusions

CR is effective as a central strategy to perform tertiary prevention in patients with ICC since it notably improves quality of life and coronary risk factors.

Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) for women with cardiovascular disease in a middle-income setting: A randomized controlled trial protocol

Women are underrepresented in cardiac rehabilitation (CR) despite the benefits, and this is exacerbated in lower-resource settings where CR is insufficiently available. In this randomized controlled trial, the effectiveness of the Technology-based Comprehensive Cardiac Rehabilitation Therapy (TaCT) electronic cardiac rehabilitation (eCR) intervention on functional capacity, risk factors, quality of life, heart-health behaviors, symptoms, and morbidity will be tested among women with CVD in a middle-income country. Following a pilot study, a single-center, single-blinded, 2 parallel-arm (1:1 SNOSE) superiority trial comparing an eCR intervention (TaCT) to usual care, with assessments pre-intervention and at 3 and 6 months will be undertaken. One hundred adult women will be recruited. Permuted block (size 10) randomization will be applied. The 6-month intervention comprises an app, website, SMS texts with generic heart-health management advice, and bi-weekly 1:1 telephone calls with a nurse trainee. Individualized exercise prescriptions will be developed based on an Incremental Shuttle Walk Test (primary outcome) and dietary plans based on 24 h dietary recall. A yoga/relaxation video will be provided via WhatsApp, along with tobacco cessation support and a moderated group chat. At 3 months, intervention engagement and acceptability will be assessed. Analyses will be conducted based on intent-to-treat. If results of this novel trial of women-focused eCR in a middle-income country demonstrate clinically-significant increases in functional capacity, this could represent an important development for the field considering this would be an important outcome for women and would translate to lower mortality.

Developing a group-based virtual education curriculum for cardiac rehabilitation and the associated toolkit to support implementation in Canada and across the globe

BACKGROUND

To overcome the many barriers faced by the long-lasting pandemic, the development of new ways to deliver cardiac rehabilitation (CR)'s components was needed.

OBJECTIVE

This mixed-methods study describes the process to create a virtual education curriculum and assess the level of user engagement and acceptability in CR participants.

METHODS

A 4-phase approach was used to develop the new virtual education curriculum for CR and collect feedback regarding patients' engagement with and acceptability of the curriculum in a convenience sample of 80 CR participants. Data were analyzed using a reflexive thematic analysis approach and mapped to the evidence-based implementation strategies, followed by stakeholder engagement. Considering all information gathered and applying best practices in patient education and curriculum development, a 16-week virtual education curriculum was established.

RESULTS

Five themes were identified on how the current education could be improved: focus on self-management, emphasize emotional wellbeing, improve facilitation, incorporate existing resources, and improve content flow. The recommendations associated with each theme informed the new curriculum and a tailored implementation plan to support the use of virtual education as part of routine care within the program. A toolkit that included a screening tool for comfort with/access to technology, patient-centered manuals with weekly learning plans, and a facilitator's manual was created. Overall, all recommended weekly education was completed by more than 70% of the participants, with greater acceptability.

CONCLUSIONS

The present study offers an example of a collaborative approach to tailoring strategies for the development of a new group-based virtual education model of CR.

Competencies required by patients and health professionals regarding telerehabilitation: A scoping review

Background

Telerehabilitation offers patients alternative access to therapy and has become more prominent during the COVID-19 pandemic. Despite the increasing attractiveness of such programs, there are research gaps regarding the required competencies in the demand-oriented technology use in rehabilitative care.

Objective

The study aims at collecting evidence on competencies required by patients and health professionals for using telerehabilitation. We analyse tasks and requirements associated with telerehabilitation and derive and systematise relevant competencies.

Methods

We conducted a scoping review and analysed MEDLINE, Psyndex, EMBASE, Cochrane Library, and Web of Science for empirical studies and grey literature from 2017 to May 2022. Articles had to be in English/German and refer to medical rehabilitation accompanied by health professionals taking place in the patient's home.

Results

One hundred ten articles were included, covering video conferencing systems, applications with video, audio, or visual therapy content, or wearables. Depending on the program, tasks before, during, and after therapy sessions differ, as do whether these are performed by health professionals, patients, or the technology. Users need digital, health-related, social, personal, and health professionals also professional competencies. This comprises telerehabilitation, technical, health-related, and clinical knowledge, a range of physical, cognitive, social-interactive, technical, and clinical skills, a positive attitude towards telerehabilitation and experience. Whether sociodemographic factors promote successful use is unclear.

Conclusions

Telerehabilitation requires a variety of different competencies from patients and health professionals - going beyond the sphere of technical skills. This highlights the need for an evaluation of existing programs for promoting competencies in the use of telerehabilitation and refinement of the programs in line with demands.

Availability and nature of cardiac rehabilitation by province in Iran: A 2018 update of ICCPR's global audit

Background

Cardiac rehabilitation (CR) is scantly available in Iran, although it is the cost-benefit strategy in cardiac patients, It has not been established how CR is delivered within Iran. This study aimed to determine: (a) availability, density and unmet need for CR, and (b) nature of CR services in Iran by province.

Materials and Methods

In this cross-sectional sub-study of the global CR audit, program availability was determined through cardiovascular networks. An online survey was then disseminated to these programs in June 2016-2017 which assessed capacity and characteristics; a paper-based survey was disseminated in 2018 to nonresponding and any new programs. CR density and need was computed based on annual incidence of acute myocardial infarction (AMI) in each province.

Results

Of the 31 provinces, 12 (38.7%) had CR services. There were 30 programs nationally, all in capital cities; of these, programs in 9 (75.0%) provinces, specifically 22 (73.3%) programs, participated. The national CR density is 1 spot per 7 incident AMI patients/year. Unmet need is greatest in Khuzestan, Tehran and west Azerbaijan, with 44,816 more spots needed/year. Most programs assessed cardiovascular risk factors, and offered comprehensive services, delivered by a multi-disciplinary team, comprised chiefly of nurses, dietitians and cardiologists. Median dose is 14 sessions/program in supervised programs. A third of programs offered home-based services.

Conclusion

Where programs do exist in IRAN, they are generally delivered in accordance with guidelines. Therefore, we must increase capacity in CR services in all provinces to improve secondary prevention services.

Physical Activity and Factors Affecting Its Maintenance Among Patients With Coronary Heart Disease Not Undergoing Cardiac Rehabilitation in China

BACKGROUND

The level of physical activity (PA) among patients with coronary heart disease (CHD) living in Chinese communities who do not participate in cardiac rehabilitation programs and the factors contributing to patient maintenance of PA are unclear.

OBJECTIVE

This cross-sectional study, guided by the Transtheoretical Model, evaluated (1) the maintenance of PA in Chinese patients with CHD 12 months after hospital discharge and (2) the demographic, clinical, and psychological characteristics associated with maintenance of PA.

METHODS

A total of 1162 patients completed 6 questionnaires at 12 months posthospitalization to assess their maintenance of PA, stage of change, symptoms of depression and anxiety, and health-related quality of life and sleep.

RESULTS

Only 40% of patients with CHD maintained regular PA 12 months after hospital discharge. Walking was their primary PA. Thirty-seven percent of patients reported no intention of having regular PA. Male sex (odds ratio [OR], 1.69), awareness of PA's cardiac benefit (OR, 4.12), a history of regular PA before the cardiac event (OR, 6.08), history of chronic disease (OR, 1.43), mild depressive symptoms (OR, 1.40), moderate and severe depressive symptoms (OR, 0.41), smoking (OR, 0.54), and years of CHD (OR, 0.96) were related to maintenance of regular PA. Patients with CHD who maintained regular PA had better quality of life and sleep (P < .001) and fewer unplanned clinic visits (P = .001) and cardiac cause readmissions (P = .012) and reported fewer declines in PA capacity (P < .001).

CONCLUSIONS

Walking is the most common form of PA 12 months posthospitalization among patients with CHD in China. Patient education and counseling about the cardiac benefits of PA, taking into account stage of change, are important considerations to improve maintenance of PA.

Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review

Background

Women do not participate in cardiac rehabilitation (CR) to the same degree as men; women-focused CR may address this. This systematic review investigated the: (1) nature, (2) availability, as well as (3a) utilization of, and (b) satisfaction with women-focused CR.

Methods

Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception to May 2020. Primary studies of any design were included. Adult females with any cardiac diseases, participating in women-focused CR (i.e., program or sessions included ≥ 50% females, or was 1-1 and tailored to women’s needs) were considered. Two authors rated citations for inclusion. One extracted data, including study quality rated as per the Mixed-Methods Assessment Tool (MMAT), which was checked independently by a second author. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guideline.

Results

3498 unique citations were identified, with 28 studies (53 papers) included (3697 women; ≥ 10 countries). Globally, women-focused CR is offered by 40.9% of countries that have CR, with 32.1% of programs in those countries offering it. Thirteen (46.4%) studies offered women-focused sessions (vs. full program), 17 (60.7%) were women-only, and 11 (39.3%) had gender-tailoring. Five (17.9%) programs offered alternate forms of exercise, and 17 (60.7%) focused on psychosocial aspects. With regard to utilization, women-focused CR cannot be offered as frequently, so could be less accessible. Adherence may be greater with gender-tailored CR, and completion effects are not known. Satisfaction was assessed in 1 trial, and results were equivocal.

Conclusions

Women-focused CR involves tailoring of content, mode and/or sex composition. Availability is limited. Effects on utilization require further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02267-0.

Establishing a process to translate and adapt health education materials for natives and immigrants: The case of Mandarin adaptations of cardiac rehabilitation education

BACKGROUND

Cardiac rehabilitation (CR) is a proven model of secondary prevention in which patient education is a core component.

OBJECTIVES

to translate and culturally-adapt CR patient education for Mandarin-speaking patients living in China as well as immigrants, and offer recommendation for best practices in adaptation for both.

METHODS

these steps were undertaken in China and Canada: (1) preparation; (2) translation and adaptation; (3) review by healthcare providers based on PEMAT-P; (4) think-aloud review by patients; and (5) finalization.

RESULTS

Two independent Mandarin translations were undertaken using best practices: one domestic (China) and one international (immigrants). Input by 23 experts instigated revisions. Experts rated the language and content as culturally-appropriate, and perceived the materials would benefit their patients. A revised version was then administered to 36 patients, based on which a few edits were made to optimize understandability.

CONCLUSIONS

some important differences emerged between translations adapted for native versus immigrant settings.

Traditional versus extended hybrid cardiac rehabilitation based on the continuous care model for coronary artery bypass surgery patients in a middle-income country: A Randomized Clinical Trial

OBJECTIVE

To compare traditional (1-month supervised) versus hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (CCM; intervention), in coronary artery bypass graft (CABG) patients.

DESIGN

randomized controlled trial, with blinded outcome assessment.

SETTING

A major heart center in a middle-income country.

PARTICIPANTS

Of 107 eligible patients that were referred to CR during the period of study, 88 (82.2%) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). There was 92.0% retention.

INTERVENTION

After CR, participants were given an app and communicated biweekly with the nurse from months 1-4 to control risk factors.

MAIN OUTCOME MEASURES

Quality of life (QoL; SF-36; primary outcome), functional capacity (treadmill test), depression, anxiety and stress (DASS-21) were evaluated pre-CR, after one month, and three months after CR (end of intervention), as well as re-hospitalization.

RESULTS

The analysis of variance interaction effects for the physical and mental component summary scores of QoL were <.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (p-values<.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (p<.001), with a clinically-significant 1.5 MET increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t-tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) re-hospitalizations in the control arm, and none in intervention (p=.049). Intended theoretical mechanisms were also impacted by the intervention.

CONCLUSION

Extending CR in this accessible manner, rendering it more comprehensive, was effective in improving outcomes.

Translation, Cross-Cultural Adaptation, and Psychometric Validation of the Chinese/Mandarin Cardiac Rehabilitation Barriers Scale (CRBS-C/M)

OBJECTIVE

Cardiovascular diseases are among the leading causes of morbidity in China and around the world. Cardiac rehabilitation (CR) effectively mitigates this burden; however, utilization is low. CR barriers in China have not been well characterized; this study sought to translate, cross-culturally adapt, and psychometrically validate the CR Barriers Scale in Chinese/Mandarin (CRBS-C/M).

METHODS

Independent translations of the 21-item CRBS were conducted by two bilingual health professionals, followed by back-translation. A Delphi process was undertaken with five experts to consider the semantics and cross-cultural relevance of the items. Following finalization, 380 cardiac patients from 11 hospitals in Shanghai were administered a validation survey including the translated CRBS. Following exploratory and confirmatory factor analysis, internal consistency was assessed. Validity was tested through assessing the association of the CRBS-C/M with the CR Information Awareness Questionnaire.

RESULTS

Items were refined and finalized. Factor analysis of CRBS-C/M (Kaiser Meyer Olkin = 0.867, Bartlett's test p < 0.001) revealed five factors: perceived CR need, external logistical factors, time conflicts, program and health system-level factors, and comorbidities/lack of vitality; Cronbach's alpha (α) of the subscales ranged from 0.67 to 0.82. The mean total CRBS score was significantly lower in patients who participated in CR compared with those who did not, demonstrating criterion validity (2.35 ± 0.71 vs. 3.08 ± 0.55; p < 0.001). Construct validity was supported by the significant associations between total CRBS scores and CR awareness, sex, living situation, city size, income, diagnosis/procedure, disease severity, and several risk factors (all p < 0.05).

CONCLUSIONS

CRBS-C/M is reliable and valid, so barriers can be identified and mitigated in Mandarin-speaking patients.

Impacts of the COVID-19 Pandemic on Cardiac Rehabilitation Delivery around the World

Background

We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients.

Methods

In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification.

Results

Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption.

Conclusion

Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges.

Highlights

- COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.- In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries.- The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training.- There is also significant psychosocial and economic impact on CR providers.- Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management

AIM

This paper aims to demonstrate how the rationale and delivery of cardiac rehabilitation (CR), in those countries with long term established standards of practice, has changed over the past eight decades.

METHODS

A narrative report based on the evolution of key published guidelines, systematic reviews and medical policies since the 1940s.

RESULTS

Case reports of the value of exercise in cardiac disease can be dated back to 1772. Formative groundwork for exercise-based CR was published between 1940 and 1970. However, it was not until the late 1980s that a large enough data set of controlled trials was available to show significant reductions in premature all-cause and cardiac mortality. Since the mid 1990s, cardiac mortality has been greatly reduced due to enhanced public health, emergency care and more sensitive diagnostic techniques and aggressive treatments. As a result, there appears to be an associated reduced potency of CR to affect mortality. New rationales for why, how and where CR is delivered have emerged including: adapting to a longer surviving ageing multi-morbid population, where healthcare cost savings and quality of life have become increasingly important.

CONCLUSIONS

In light of these results, an emerging focus for CR, and in some cases "pre-habilitation", is that of a chronic disability management programme increasingly delivered in community and home settings. Within this delivery model, the use of remote personalised technologies is now emerging, especially with new needs accelerated by the pandemic of COVID-19.

IMPLICATIONS FOR REHABILITATIONWith continued advances in medical science and better long term survival, the nature of cardiac rehabilitation has evolved over the past eight decades. It was originally an exercise-focused intervention on short term recovery and reducing cardiac and all-cause mortality, to now being one part of a multi-factor lifestyle, behavioural, and medical chronic disease management programme.Throughout history, the important influence of psycho-social well-being and human behaviour has, however, always been of key importance to patients.The location of rehabilitation can now be suited to patient need, both medically and socially, where the same components can be delivered in either a traditional outpatient clinic, community settings, at home and more recently all of these being supported or augmented with the advent of mobile technology.

Performance Measures for Short-Term Cardiac Rehabilitation in Patients of Working Age: Results of the Prospective Observational Multicenter Registry OutCaRe

Objective

To determine immediate performance measures for short-term, multicomponent cardiac rehabilitation (CR) in clinical routine in patients of working age, taking into account cardiovascular risk factors, physical performance, social medicine, and subjective health parameters and to explore the underlying dimensionality.

Design

Prospective observational multicenter register study in 12 rehabilitation centers throughout Germany.

Setting

Comprehensive 3-week CR.

Participants

Patients (N=1586) ≤65 years of age (mean 53.8±7.3y, 77.1% men) in CR (May 2017-May 2018).

Interventions

Not applicable.

Main Outcome Measures

Feasibility, defined by data availability for ≥85% of patients (CR admission and discharge), and modifiability based on pre-post comparison (statistical significance, with P value<.01; standardized effect size≥.35; change by ≥5% points in categorical variables). In addition, latent factors were identified using an exploratory factor analysis (EFA).

Results

Based on feasibility and modifiability criteria, smoking behavior, lifestyle change behavior, blood pressure, endurance training load, depression in Patient Health Questionnaire-9 (PHQ-9), the 5-item World Health Organization Well-Being Index (WHO-5), physical and mental health and pain scale of the indicators of rehabilitation status-24 (IRES-24), and self-assessed health prognosis proved to be suitable performance measures. As a result of the EFA, 2 solid factors were identified: (1) subjective mental health including PHQ-9, WHO-5, mental health (IRES-24), mental quality of life, and anxiety and (2) physical health including physical quality of life, physical health and pain scale of IRES-24, and self-assessed occupational prognosis. A third factor represents the blood pressure.

Conclusions

We provide a small set of performance measures, that are essentially based on 3 latent factors (subjective mental health, physical health, blood pressure). These performance measures can represent immediate success of comprehensive CR and be applied easily in clinical practice.

Factors Predicting the Utilization of Center-Based Cardiac Rehabilitation Program

Although cardiac rehabilitation (CR) is clearly beneficial to improving patients’ physical functioning and reducing heart disease progression, significant proportions of patients do not complete CR programs. To evaluate the prevalence and predictors of completion of a center-based CR program in eligible cardiac patients, existing data collected from electronic medical records were used. To identify the predictors of CR completion, we used principal components analysis (PCA) and an artificial neural network (ANN) module. Among 685 patients, 61.4% (n = 421) completed the program, 31.7% (n = 217) dropped out, and 6.9% (n = 47) were referred but failed to initiate the program. PCA was conducted to consolidate baseline data into three factors—(1) psychosocial factors (depression, anxiety, and quality of life), (2) age, and (3) BMI, which explained 66.8% of the total variance. The ANN model produced similar results as the PCA. Patients who completed CR sessions had greater extremity strength and flexibility, longer six-minute walk distance, more CR knowledge, and a better quality of life. The present study demonstrated that patients who were older, obese, and who had depression, anxiety, or a low quality of life were less likely to complete the CR program.

Feasibility and results of an intensive cardiac rehabilitation program. Insights from the MxM (Más por Menos) randomized trial

INTRODUCTION AND OBJECTIVES

Cardiac rehabilitation programs (CRP) are a set of interventions to improve the prognosis of cardiovascular disease by influencing patients' physical, mental, and social conditions. However, there are no studies evaluating the optimal duration of these programs. We aimed to compare the results of a standard vs a brief intensive CRP in patients after ST-segment elevation and non-ST-segment elevation acute coronary syndrome through the Más por Menos study (More Intensive Cardiac Rehabilitation Programs in Less Time).

METHODS

In this prospective, randomized, open, evaluator-blind for end-point, and multicenter trial (PROBE design), patients were randomly allocated to either standard 8-week CRP or intensive 2-week CRP with booster sessions. A final visit was performed 12 months later, after completion of the program. We assessed adherence to the Mediterranean diet, psychological status, smoking, drug therapy, functional capacity, quality of life, cardiometabolic and anthropometric parameters, cardiovascular events, and all-cause mortality during follow-up.

RESULTS

A total of 497 patients (mean age, 57.8±10.0 years; 87.3% men) were finally assessed (intensive: n=262; standard: n=235). Baseline characteristics were similar between the 2 groups. At 12 months, the results of treadmill ergometry improved by ≥ 1 MET in ≥ 93% of the patients. In addition, adherence to the Mediterranean diet and quality of life were significantly improved by CRP, with no significant differences between the groups. The occurrence of cardiovascular events was similar in the 2 groups.

CONCLUSIONS

Intensive CRP could be as effective as standard CRP in achieving adherence to recommended secondary prevention measures after acute coronary syndrome and could be an alternative for some patients and centers. Registered at ClinicalTrials.gov (Identifier: NCT02619422).

More than a matter of the heart: the concept of intravascular multimorbidity in cardiac rehabilitation

INTRODUCTION

Coronary artery disease (CAD) is the major cause of death of cardiovascular disease. It is initiated by atherosclerosis, which narrows the coronary arteries and limits blood flow and oxygen to the heart. Multiple pathophysiological conditions within the arteries, such as arterial wall thickening, endothelial dysfunction, and arterial stiffening, are associated with the development of atherosclerosis.

AREAS COVERED

We introduce a new concept of 'intravascular multimorbidity,' the presence and integration of multiple pathophysiological conditions within the arteries. We also introduce some measurements of intravascular multimorbidity and discuss how these measurements can be utilized in cardiac rehabilitation (CR).

EXPERT OPINION

We propose that the measures of intravascular multimorbidity in different arteries may provide information on disease severity and serve as unique prognostic 'barometers' to disease progression in patients with CAD. By measuring the underlying disease mechanisms within the arteries and understanding individual variability of disease progression/regression, these measures may also provide a unique prognostic window in CR. The window into intravascular multimorbidity can help guide clinical strategies, for example, assessing progress and appropriate titration of exercise. Intravascular multimorbidity may represent an important opportunity for more researchers and clinical professions to evaluate patients in CR.

Cardiac Rehabilitation in India: Results from the International Council of Cardiovascular Prevention and Rehabilitation's Global Audit of Cardiac Rehabilitation

Background

Cardiac rehabilitation (CR) is recommended in clinical practice guidelines for comprehensive secondary prevention. While India has a high burden of cardiovascular diseases (CVD), availability and nature of services delivered there is unknown. In this study, we undertook secondary analysis of the Indian data from the global CR audit and survey, conducted by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR).

Methods

In this cross-sectional study, an online survey was administered to CR programs, identified in India by CR champions and through snowball sampling. CR density was computed using Global Burden of Disease study ischemic heart disease (IHD) incidence estimates.

Results

Twenty-three centres were identified, of which 18 (78.3%) responded, from 3 southern states. There was only one spot for every 360 IHD patients/year, with 3,304,474 more CR spaces needed each year. Most programs accepted guideline-indicated patients, and most of these patients paid out-of-pocket for services. Programs were delivered by a multidisciplinary team, including physicians, physiotherapists, among others. Programs were very comprehensive. Apart from exercise training, which was offered across all centers, some centers also offered yoga therapy. Top barriers to delivery were lack of patient referral and financial resources.

Conclusions

Of all countries in ICCPR's global audit, the greatest need for CR exists in India, particularly in the North. Programs must be financially supported by government, and healthcare providers trained to deliver it to increase capacity. Where CR did exist, it was generally delivered in accordance with guideline recommendations. Tobacco cessation interventions should be universally offered.

A systematic review and thematic synthesis exploring how a previous experience of physical activity influences engagement with cardiac rehabilitation

BACKGROUND

Exercise-based cardiac rehabilitation is recognised internationally as an effective therapy to improve quality of life and reduce the risk of hospital readmission for individuals diagnosed with acute coronary syndrome. Despite this, half of eligible individuals choose not to engage and the main reason is lack of interest. Furthermore, prior to attending, 40% of eligible individuals report meeting physical activity guidelines. It is unclear whether this influences decisions about engagement.

AIMS

The aim of this review is to examine systematically qualitative evidence describing patients' perceptions and experiences, and synthesise what is known about how a previous experience of physical activity in adults diagnosed with acute coronary syndrome influences engagement with physical activity during cardiac rehabilitation.

METHODS

A systematic review and thematic synthesis was conducted of primary qualitative studies to examine peer-reviewed literature published between1990 and 2017, accessed from database searches of MEDLINE, CINHAL, PsycINFO and Embase.

RESULTS

The initial search produced 486 studies, and of these 12 relevant studies were included in this review. Studies included 388 participants from six countries. For previously active individuals, communication factors, self-perceptions of an exercise identity and experience of cardiac rehabilitation influence engagement in physical activity during cardiac rehabilitation.

CONCLUSION

In adults diagnosed with acute coronary syndrome, communication post event and during cardiac rehabilitation is a source of self-appraisal and creates expectations of cardiac rehabilitation. In addition, perceptions of an exercise identity and experience of exercise-based cardiac rehabilitation influence decisions about engagement. To improve uptake and adherence, health professionals should consider previous physical activity levels and tailor information to optimise physical activity post event.

Social prescribing in cardiology: rediscovering the nature within us

Personalised care is integral to the delivery of the NHS England Long Term Plan. Enabling choice and supporting patients to make decisions predicated on ‘what matters to them’, rather than ‘what is the matter with them’ is a fundamental part of the NHS vision. Social prescribing uses non-medical, asset-based, salutogenic approaches to promote this personalised paradigm, and places the patient central to decision making. This article discusses how personalised care can be used to help people with cardiovascular disease using socially prescribed ‘nature-based’ interventions to support the pre-habilitation and rehabilitation of patients with cardiovascular disease. The concept of personalised care outlined and the significance of salutogenic principles as a complementary approach to the pathogenic model is discussed. The authors argue that this seemingly novel approach to using nature-based interventions can help promote wellbeing for people with cardiovascular disease as part of the wider personalised agenda.

Global Need for Physical Rehabilitation: Systematic Analysis from the Global Burden of Disease Study 2017

Background: To inform global health policies and resources planning, this paper analyzes evolving trends in physical rehabilitation needs, using data on Years Lived with Disability (YLDs) from the Global Burden of Disease Study (GBD) 2017. Methods: Secondary analysis of how YLDs from conditions likely benefiting from physical rehabilitation have evolved from 1990 to 2017, for the world and across countries of varying income levels. Linear regression analyses were used. Results: A 66.2% growth was found in estimated YLD Counts germane to physical rehabilitation: a significant and linear growth of more than 5.1 billion YLDs per year (99% CI: 4.8–5.4; r² = 0.99). Low-income countries more than doubled (111.5% growth) their YLD Counts likely benefiting from physical rehabilitation since 1990. YLD Rates per 100,000 people and the percentage of YLDs likley benefiting from physical rehabilitation also grew significantly over time, across locations (all p > 0.05). Finally, only in high-income countries did Age-standardized YLD Rates significantly decrease (p < 0.01; r² = 0.86). Conclusions: Physical rehabilitation needs have been growing significantly in absolute, per-capita and in percentage of total YLDs. This growth was found globally and across countries of varying income level. In absolute terms, growths were higher in lower income countries, wherein rehabilitation is under-resourced, thereby highlighting important unmet needs.

Determinants of coronary artery disease risk factor management across three world regions

Background

The SUrvey of Risk Factors (SURF) indicated poor control of risk factors in subjects with established coronary heart disease (CHD). The present study aimed to investigate determinants of risk factor management in patients with CHD.

Methods and results

SURF recruited 9987 consecutive patients with CHD from Europe, Asia and the Middle East between 2012 and 2013. Risk factor management was summarised as a Cardiovascular Health Index Score (CHIS) based on six risk factor targets (non-smoker/ex-smoker, body mass index <30, adequate exercise, controlled blood pressure, controlled low-density lipoprotein and controlled glucose). Logistic regression models assessed the associations between determinants (age, sex, family history, cardiac rehabilitation, previous hospital admission and diabetes) and achievement of moderate CHIS (≥3 risk factors controlled). The results are presented as OR with corresponding 95% CI. A moderate CHIS was less likely to be reached by women (OR 0.90, 95% CI 0.69 to 1.00), those aged <55 years old (OR 0.62, 95% CI 0.53 to 0.76) and those with diabetes (OR 0.41, 95% CI 0.37 to 0.46). Attendance in cardiac rehabilitation was associated with better CHIS achievements (OR 1.62, 95% CI 1.42 to 1.87). Younger Asian and European patients had poorer risk factor management, whereas for patients from the Middle East age was not significantly associated with risk factor management. The availability and applicability of cardiac rehabilitation varied by region.

Conclusions

Overall, risk factor management was poorer in women, those younger than 55 years old, those with diabetes and those who did not participate in a cardiac rehabilitation. Determinants of cardiovascular risk factor management differed by region.

Interventions to Promote Patient Utilization of Cardiac Rehabilitation: Cochrane Systematic Review and Meta-Analysis

Too few patients utilize cardiac rehabilitation (CR), despite its benefits. The Cochrane review assessing the effectiveness of interventions to increase CR utilization (enrolment, adherence, and completion) was updated. A search was performed through July 2018 of the Cochrane and MEDLINE (Medical Literature Analysis and Retrieval System Online) databases, among other sources. Randomized controlled trials in adults with myocardial infarction, angina, revascularization, or heart failure were included. Interventions had to aim to increase utilization of comprehensive phase II CR. Two authors independently performed all stages of citation processing. Following the random-effects meta-analysis, meta-regression was undertaken to explore the impact of pre-specified factors. Twenty-six trials with 5299 participants were included (35.8% women). Low-quality evidence showed an effect of interventions in increasing enrolment (risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.13⁻1.42). Meta-regression analyses suggested that the intervention deliverer (nurse or allied healthcare provider, p = 0.02) and delivery format (face-to-face, p = 0.01) were influential in increasing enrolment. There was low-quality evidence that interventions to increase adherence were effective (standardized mean difference (SMD) = 0.38, 95% CI = 0.20⁻0.55), particularly where remotely-offered (SMD = 0.56, 95% CI = 0.36⁻0.76). There was moderate-quality evidence that interventions to increase program completion were effective (RR = 1.13, 95% CI = 1.02⁻1.25). There are effective interventions to increase CR utilization, but more research is needed to establish specific, implementable materials and protocols, particularly for completion.