A Systematic Review of Clinical Practice Guidelines and Consensus Statements for Cardiac Rehabilitation Delivery: Consensus, Divergence, and Important Knowledge Gaps

BACKGROUND

After 2020, clinical practice recommendations have been released to inform cardiac rehabilitation (CR) programs of best practices for post-COVID programming. The objective of this systematic review was to identify and summarize recommendations from clinical practice guidelines (CPGs) and consensus statements for CR delivery postpandemic.

METHODS

Five databases (March 2020 through April 2023), grey literature and Web sites of CR international associations were searched. Inclusion criteria were local, national, and international association-endorsed CPGs, and/or position, expert, and scientific statements related to CR delivery (program models, program elements, and core components). Two researchers independently screened the citations for inclusion. The Appraisal of Guidelines for Research and Evaluation (AGREE) II was used for quality assessment. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guidelines.

RESULTS

Overall, 4890 records were identified; 4 CPGs, 9 position/scientific statements, and 6 expert/Delphi consensus papers were included. All guidelines/statements included information related to program delivery models, with 95% endorsing the use of virtual, hybrid, home-based, and telerehabilitation, especially during the pandemic. Outside of the context of COVID-19, program components including referral, CR indications, CR contraindications, timing, and structure were included in the 4 CPGs and 2 of 15 statements. Recommendations related to CR core components were primarily focused on exercise, with no changes since before the pandemic except for COVID-19 considerations for safety. One guideline was specific to women, and 1 scientific statement to heart failure with preserved ejection fraction.

CONCLUSIONS

Although 19 documents were identified, CR delivery in low resource settings and for culturally and linguistically diverse populations require attention. Additionally, few recommendations on nutrition, psychosocial counselling, and patient education were reported.

Inpatient vs. Outpatient: A Systematic Review of Information Needs throughout the Heart Failure Patient Journey

The objective of this systematic review was to identify and describe information needs for individuals with heart failure (HF) throughout their patient journey. Six databases were searched (APA PsycINFO, CINAHL Ultimate, Embase, Emcare Nursing, Medline ALL, and Web of Science Core Collection) from inception to February 2023. Search strategies were developed utilizing the PICO framework. Potential studies of any methodological design were considered for inclusion through a snowball hand search. Data from the included articles were extracted by a reviewer, and the extraction accuracy was independently cross-checked by another author. Quality appraisal was assessed using the Mixed-Methods Appraisal Tool. A narrative synthesis was used to analyze all the outcomes according to the Synthesis Without Meta-analysis reporting guidelines. Twenty-five studies (15 quantitative and 10 qualitative) were included. Socioeconomic, cultural, and demographic factors influencing information needs were considered. The top three information needs for outpatients included general HF information, signs and symptoms and disease management strategies. For inpatients, medications, risk factors, and general HF were reported as the top needs. These divergent needs emphasize the importance of tailored education at different stages. Additionally, the review identified gaps in global representation, with limited studies from Africa and South America, underscoring the need for inclusive research. The findings caution against overgeneralization due to varied reporting methods. Practical implications call for culturally sensitive interventions to address nuanced HF patients' needs, while future research must prioritize standardized reporting, consider diverse patient journey timepoints, and minimize biases for enhanced reliability and applicability.

Women's Knowledge of Future Cardiovascular Risk Associated With Complications of Pregnancy: A Systematic Review

Background

Several common pregnancy conditions significantly increase a woman's risk of future cardiovascular diseases (CVD). Patient education and interventions aimed at awareness and self-management of cardiovascular risk factors may help modify future cardiovascular risk. The aim of this systematic review was to examine education interventions for cardiovascular risk after pregnancy, clinical measures/scales, and knowledge outcomes in published qualitative and quantitative studies.

Methods

Five databases were searched (from inception to June 2023). Studies including interventions and validated and nonvalidated measures of awareness/knowledge of future cardiovascular risk among women after complications of pregnancy were considered. Quality was rated using the Mixed Methods Appraisal Tool. Results were analyzed using the Synthesis Without Meta-analysis reporting guideline. Characteristics of interventions were reported using the Template for Intervention Description and Replication. Fifteen studies were included; 3 were randomized controlled trials.

Results

In total, 1623 women had a recent or past diagnosis of hypertensive disorders of pregnancy, gestational diabetes mellitus, and/or premature birth. Of the 7 studies that used online surveys or questionnaires, 2 reported assessing psychometric properties of tools. Four studies used diverse educational interventions (pamphlets, information sheets, in-person group sessions, and an online platform with health coaching). Overall, women had a low level of knowledge about their future CVD risk. Interventions were effective in increasing this knowledge.

Conclusions

In conclusion, women have a low level of knowledge of risk of CVD after pregnancy complications. To increase this level of knowledge and self-management, this population has a strong need for psychometrically validated tailored education interventions.

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.

A Social-Ecological Perspective of the Perceived Barriers and Facilitators to Virtual Education in Cardiac Rehabilitation: A MIXED-METHODS APPROACH

PURPOSE

This study explored the perceived barriers and facilitators to participation in patients who did and did not attend virtual cardiac rehabilitation (CR) education sessions.

METHODS

A mixed-methods approach was used. Virtual patient education was delivered during the coronavirus-19 pandemic. Phase 1 included a cross-sectional online survey completed by individuals who did and did not participate in these sessions. For phase 2, six virtual focus group sessions were conducted using the social-ecological framework to guide thematic analysis and interpretation of findings.

RESULTS

Overall, 106 online surveys were completed; 60 (57%) attended Cardiac College Learn Online (CCLO) sessions only, one (1%) Women with Heart Online (WwHO) only, 21 (20%) attended both, and 24 (22%) did not attend virtual sessions. Half of the participants who attended virtual sessions viewed between one and four sessions. Most participants were from Canada (95%) and included the Toronto Rehabilitation Institute/Toronto Western Hospital centers (76%). Focus group findings revealed six overarching themes: Intrapersonal (mixed emotions/feelings; personal learning preferences); Interpersonal (desire for warmth of human contact and interaction); Institutional (the importance of external endorsement of sessions); and Environmental (technology; perceived facilitators and barriers).

CONCLUSION

These findings highlight the unprecedented situation that patients and CR programs are facing during the pandemic. Virtual patient education may be more accessible, convenient, and responsive to the complex needs of these CR participants.

The effects of high-intensity interval training, Nordic walking and moderate-to-vigorous intensity continuous training on functional capacity, depression and quality of life in patients with coronary artery disease enrolled in cardiac rehabilitation: A randomized controlled trial (CRX study)

BACKGROUND

Coronary artery disease (CAD) patients undergoing revascularization procedures often experience ongoing, diminished functional capacity, high rates of depression and markedly low quality of life (QoL). In CAD patients, studies have demonstrated that high-intensity interval training (HIIT) is superior to traditional moderate-to-vigorous intensity continuous training (MICT) for improving functional capacity, whereas no differences between Nordic walking (NW) and MICT have been observed. Mental health is equally as important as physical health, yet few studies have examined the impact of HIIT and NW on depression and QoL. The purpose of this randomized controlled trial (RCT) was to compare the effects of 12 weeks of HIIT, NW and MICT on functional capacity in CAD patients. The effects on depression severity, brain-derived neurotrophic factor (BDNF) and QoL were also examined.

METHODS

CAD patients who underwent coronary revascularization procedures were randomly assigned to: (1) HIIT (4 × 4-min of high-intensity work periods at 85%-95% peak heart rate [HR]), (2) NW (resting HR [RHR] + 20-40 bpm), or (3) MICT (RHR + 20-40 bpm) twice weekly for 12 weeks. Functional capacity (six-min walk test [6MWT]), depression (Beck Depression Inventory-II [BDI-II]), BDNF (from a blood sample), and general (Short-Form 36 [SF-36]) and disease-specific (HeartQoL) QoL were measured at baseline and follow-up. Linear mixed-effects models for repeated measures were used to test the effects of time, group and time × group interactions.

RESULTS

N = 135 CAD patients (aged 61 ± 7 years; male: 85%) participated. A significant time × group interaction (p = 0.042) showed greater increases in 6MWT distance (m) for NW (77.2 ± 60.9) than HIIT (51.4 ± 47.8) and MICT (48.3 ± 47.3). BDI-II significantly improved (HIIT: -1.4 ± 3.7, NW: -1.6 ± 4.0, MICT: -2.3 ± 6.0 points, main effect of time: p < 0.001) whereas BDNF concentrations did not change (HIIT: -2.5 ± 9.6, NW: -0.4 ± 7.7, MICT: -1.2 ± 6.4 ng/mL, main effect of time: p > 0.05). Significant improvements in SF-36 and HeartQoL values were observed (main effects of time: p < 0.05). HIIT, NW and MICT participants attended 17.7 ± 7.5, 18.3 ± 8.0 and 16.1 ± 7.3 of the 24 exercise sessions, respectively (p = 0.387).

CONCLUSIONS

All exercise programmes (HIIT, NW, MICT) were well attended, safe and beneficial in improving physical and mental health for CAD patients. NW was, however, statistically and clinically superior in increasing functional capacity, a predictor of future cardiovascular events.

Submaximal Exercise Testing in Cardiovascular Rehabilitation Settings (BEST Study)

Background

This study compared changes in measured versus predicted peak aerobic power (V̇O_2peak) following cardiovascular rehabilitation (CR). Peak cardiopulmonary exercise testing (CPET) results were compared to four V̇O_2peak estimation methods: the submaximal modified Bruce treadmill, Astrand-Ryhming cycle ergometer, and Chester step tests, and the Duke Activity Status Index (DASI).

Methods

Adults with cardiovascular disease (CVD) who completed a 12-week CR program were assessed at baseline and 12 weeks follow-up. CPET, the DASI and three subsequent submaximal exercise tests were performed in a random order.

Results

Of the 50 adults (age: 57 ± 11 years) who participated, 46 completed the 12-week CR program and exercise tests. At baseline 69, 68, and 38% of the treadmill, step and cycle tests were successfully completed, respectively. At follow-up 67, 80, and 46% of the treadmill, step and cycle tests were successfully completed, respectively. No severe adverse events occurred. Significant improvements in V̇O_2peak were observed with CPET (3.6 ± 5.5 mL^.kg^–1.min^–1, p < 0.001) and the DASI (2.3 ± 4.2 mL^.kg^–1.min^–1, p < 0.001). Bland-Altman plots of the change in V̇O_2peak between CPET and the four V̇O_2peak estimation methods revealed the following: a proportional bias and heteroscedastic 95% limits of agreement (95% LoA) for the treadmill test, and for the cycle and step tests and DASI, mean bias’ and 95% LoA of 1.0 mL^.kg^–1.min^–1 (21.3, −19.3), 1.4 mL^.kg^–1.min^–1 (15.0, −12.3) and 1.0 mL^.kg^–1.min^–1 (13.8, −11.8), respectively.

Conclusion

Given the greater number of successful tests, no serious adverse events and acceptable mean bias, the step test appears to be a valid and safe method for assessing group-level mean changes in V̇O_2peak among patients in CR. The DASI also appears to be a valid and practical questionnaire. Wide limits of agreement, however, limit their use to predict individual-level changes.

The effectiveness of eHealth interventions on physical activity and measures of obesity among working-age women: a systematic review and meta-analysis

Physical inactivity and obesity are modifiable risk factors for cardiovascular disease, particularly in women. eHealth interventions may increase physical activity and improve obesity-related outcomes among women. The objective of this study was to review the evidence of the effectiveness of eHealth interventions to increase moderate-to-vigorous physical activity among working-age women. The secondary objective was to examine their effectiveness on improving obesity-related outcomes. A comprehensive search strategy was developed for eight electronic databases; through July 2016. All studies consisting of >80% women of working-age (18-65 years) in high income countries were included. Multiple unblinded reviewers determined study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Risk of Bias Tool and data quality using the Grading of Recommendations Assessment, Development and Evaluation approach. Data were pooled using a random-effects model. Sixty studies were included in the review of which 20 were in the meta-analysis. The meta-analysis demonstrated eHealth interventions improved moderate-to-vigorous physical activity (standard mean difference = 1.13, 95% confidence interval: 0.58, 1.68, P < 0.0001); an increase of ~25 min week^-1 . No changes were observed in obesity-related outcomes; waist circumference (P = 0.06), body mass (P = 0.05) and body mass index (P = 0.35). eHealth interventions are effective at increasing min week^-1 of moderate-to-vigorous physical activity among working-age women from high income countries.

Impact of Workplace Physical Activity Interventions on Physical Activity and Cardiometabolic Health Among Working-Age Women: A Systematic Review and Meta-Analysis

BACKGROUND

Cardiovascular disease is the leading cause of death among women in high-income Organization for Economic Co-operation and Development countries. Physical activity is protective for cardiovascular disease. The realities of modern life require working-age women to address work-related, family, and social demands. Few working-age women meet current moderate-to-vigorous-intensity physical activity (MVPA) recommendations. Given that working-age women spend a substantial proportion of their waking hours at work, places of employment may be an opportune and a controlled setting to implement programs, improving MVPA levels and enhancing cardiometabolic health.

METHODS AND RESULTS

Eight electronic databases were searched to identify all prospective cohort and experimental studies reporting an MVPA outcome of workplace interventions for working-age women (mean age, 18-65 years) in high-income Organization for Economic Co-operation and Development countries. Risk of bias was assessed using the Cochrane risk of bias tool; quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. A qualitative synthesis was performed for all studies, and meta-analyses were conducted where possible. Twenty-four studies met the inclusion criteria; 20 studies were included in the meta-analyses. Workplace interventions significantly increased minutes per week of metabolic equivalents (4 studies; standardized mean differences, 2.07; 95% confidence interval [CI], 1.44 to 2.69), but not minutes per week of MVPA (13 studies; standardized mean differences, 0.38; 95% CI, -0.15 to 0.92) or metabolic equivalents per week (3 studies; standardized mean differences, 0.11; 95% CI, -0.48 to 0.71). Workplace interventions also significantly decreased body mass (7 studies; mean differences, -0.83 kg; 95% CI, -1.64 to -0.02), body mass index (6 studies; mean differences, -0.35 kg/m²; 95% CI, -0.62 to -0.07), low-density lipoprotein (4 studies; mean differences, -0.11 mmol/L; 95% CI, -0.17 to -0.04), and blood glucose (2 studies; mean differences, -0.18 mmol/L; 95% CI, -0.29 to -0.07). These workplace interventions targeting MVPA levels and known beneficial cardiometabolic health sequelae were of lower quality evidence.

CONCLUSIONS

Workplace interventions variably improve MVPA levels and related cardiometabolic health sequelae of working-age women in high-income Organization for Economic Co-operation and Development countries. Our findings underscore the need for ongoing research in this area but also increased dissemination of the existing programs and knowledge.

Associations between measures of vascular structure and function and systemic circulating blood markers in humans

Examination of relationships between systemic markers and functional measures of arterial structure and function may assist in determining alternative indices of vascular regulation and designing and evaluating interventions to improve arterial structure and function. Twenty young healthy individuals, 20 older healthy men, and 26 individuals with coronary artery disease (CAD), comprising a spectrum of vascular health, participated. Systemic markers of vascular structure and function included: pro‐collagen type I C‐peptide (PIP) – marker of collagen synthesis, C‐telopeptide of type I collagen (CTX) – marker of collagen degradation, endothelin‐1 (ET‐1) ‐ vasoconstrictor, and interleukin‐6 (IL‐6) – inflammatory marker. Functional measures of arterial structure and function included carotid artery distensibility and brachial artery flow‐mediated dilation (FMD). Moderate positive relationships were observed between carotid distensibility and CTX and PIP (r = 0.57, P < 0.0001 and r = 0.47, P < 0.0001). A negative correlation exists between ET‐1 and FMD (r = −0.44, P = 0.0004); however, no relationship was observed between IL‐6 and FMD (P = 0.25). Over a broad range of vascular health, relationships were observed between markers of type I collagen turnover and arterial stiffness and between a marker of vasoconstriction and endothelial function. These results indicate that regulatory links, between the indices examined, exist. Therefore, monitoring systemic markers rather than functional vascular measures, may provide sufficient information about vascular health and should be considered in the design and evaluation of vascular interventions.

Descriptive data on cardiovascular and metabolic risk factors in ambulatory and non-ambulatory adults with cerebral palsy

Forty-two participants with cerebral palsy were recruited for a study examining traditional and novel indicators of cardiovascular risk (McPhee et al., 2015 [1]). Data pertaining to the prevalence of obesity, smoking, hypertension, and metabolic risk are provided. These data are presented along with the scoring methods used in evaluation of the study participants. Percentages are included for comparative purposes with the existing literature.

Citrulline does not enhance blood flow, microvascular circulation, or myofibrillar protein synthesis in elderly men at rest or following exercise

Aging is associated with anabolic resistance, a reduced sensitivity of myofibrillar protein synthesis (MPS) to postprandial hyperaminoacidemia, particularly with low protein doses. Impairments in postprandial skeletal muscle blood flow and/or microvascular perfusion with hyperaminoacidemia and hyperinsulinemia may contribute to anabolic resistance. We examined whether providing citrulline, a precursor for arginine and nitric oxide synthesis, would increase arterial blood flow, skeletal muscle microvascular perfusion, MPS, and signaling through mTORC1. Twenty-one elderly males (65-80 yr) completed acute unilateral resistance exercise prior to being assigned to ingest a high dose (45 g) of whey protein (WHEY) or a low dose (15 g) of whey protein with 10 g of citrulline (WHEY + CIT) or with 10 g of nonessential amino acids (WHEY + NEAA). A primed, continuous infusion of L-[ring-(13)C6] phenylalanine with serial muscle biopsies was used to measure MPS and protein phosphorylation, whereas ultrasound was used to measure microvascular circulation under basal and postprandial conditions in both a rested (FED) and exercised (EX-FED) leg. Argininemia was greater in WHEY + CIT vs. WHEY and WHEY + NEAA from 30 to 300 min postexercise (P < 0.001), but there were no treatment differences in blood flow or microvascular perfusion (all P > 0.05). Phosphorylation of p70S6K-Thr(389) was greater in WHEY vs. WHEY + NEAA (P = 0.02). Postprandial MPS was greater in WHEY vs. WHEY + CIT and WHEY + NEAA under both FED (WHEY: ~128%; WHEY + CIT: ~56%; WHEY + NEAA: ~38%) and EX-FED (WHEY: ~251%; WHEY + CIT: ~124%; WHEY + NEAA: ~108%) conditions (P = 0.003). Citrulline coingestion with a low quantity of protein was ineffective in augmenting the anabolic properties of protein compared with nonessential amino acids.

Resistance exercise order does not determine postexercise delivery of testosterone, growth hormone, and IGF-1 to skeletal muscle

Does resistance exercise order affect hormone availability? Participants performed arm exercise before and after leg exercise. Hormone delivery was estimated by multiplying brachial artery blood flow and hormone concentrations. Blood flow increased after arm (276%) and leg (193%; both p < 0.001) exercise. Testosterone, growth hormone, and insulin-like growth factor 1 showed with distinct delivery patterns between conditions; however (interactions all p < 0.001), net exposure was similar. The anabolic potential of postexercise hormones was not affected by exercise order.