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Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis
... To make CR more attractive to the range of eligible patients, clinical guidelines and experts have underlined the importance of CR being delivered in consideration with patient needs and preferences [3,9]. Hence, a vast amount of tailored CR interventions have been investigated, with increasing focus on new and innovative/virtual home-based modes [10][11][12][13][14]. Many more traditional settings of CR, that are centrebased modes, have also adopted or combined centre and home-based interventions (a hybrid model), which among other benefits, are believed to overcome a number of barriers related to accessibility of health services [8,15]. ...
... Many more traditional settings of CR, that are centrebased modes, have also adopted or combined centre and home-based interventions (a hybrid model), which among other benefits, are believed to overcome a number of barriers related to accessibility of health services [8,15]. An increasing body of evidence supports the effectiveness of these new modes of delivery [10][11][12][13][14] and their inclusion provides a natural addition to the CR menu-based allowing greater scope for tailoring to the needs and preferences of patients [9]. ...
... In the research domain, and to some extent in routine practice, alternative delivery modes in CR (e.g. home-based) are known to demonstrate effectiveness comparable with that of traditional centrebased CR [10][11][12][13][14]27]. The inclusion of home-based modes into routine practice is also viewed as a solution to overcome low attendance rates in CR services [7,8] and provide a better alignment with patients' needs and preferences [9,28]. ...
Aim
To achieve effectiveness and reduce inequality in everyday cardiac rehabilitation, this study aims to compare individual patient characteristics along with completion rates to traditional and evolving modes of delivery in cardiac rehabilitation.
Method
Patients were included from the UK National Audit of Cardiac Rehabilitation (NACR) database. All patients with coronary heart disease (≥18 years) between the 1st of January 2014 to 31st of December 2019 that started core rehabilitation with a recorded mode of cardiac rehabilitation delivery were eligible. Modes of delivery were divided into: centre-based, home-based, and hybrid. Logistic regression models were used to investigate association between modes of delivery and completion adjusting for patient demographics.
Result
In total 182,722 patients had mode of delivery recorded: 72.8% centre-based, 8.3% home-based and 18.9% hybrid. The home-based mode in comparison to hybrid and centre-based had significantly higher rates of females, single, white, and unemployed patients (p < 0.001). There was a higher proportion of cardiovascular risk factors in home-based than the other modes (p < 0.001). There was a reduced likelihood of completing home-based cardiac rehabilitation compared to centre-based with an odds ratio of 0.66, (95% CI: 0.48 to 0.91) but no significant difference between hybrid and centre-based modes (odds ratio, 1.18; 95% CI 0.92 to 1.51).
Conclusions
From large real-world data, home-based modes of delivery appear to have significantly lower levels of completion than centre-based modes. Cardiac rehabilitation programs offering home-based and hybrid delivery modes need to be structured to ensure adequacy of completion.
... [8][9][10] Accordingly, center-based cardiac rehabilitation programs that include medically supervised exercise training have been recommended for patients with HF. 11 However, major barriers such as occupational responsibilities, traveling distance, cost, and geographic isolation are responsible for the current poor participation rates in such programs among eligible patients with HF. 12,13 Several clinical trials have implemented different home-based exercise training interventions and have shown the home to be an effective alternative method to traditional centerbased cardiac rehabilitation with greater participation rates. 14,15 The use of mobile health applications (apps) is suggested as a potentially promising approach to promote HF self-management. [16][17][18][19] Almost all patients have a smartphone, and mobile health apps are freely available or preinstalled in most manufactured smartphones. ...
... With an expectation of 20% attrition based on previous studies, the total number of subjects who were sought for recruitment was 152. 14,15 For this study, a nonprobability convenience sampling design was used. All patients with HF in New York Heart Association functional classes I to III attending outpatient cardiologist clinics located in the 3 biggest cities in central and north Jordan were eligible to participate in this study. ...
... Adherence to prescribed exercise sessions was noted to be higher among patients in center-based cardiac rehabilitation; however, those patients showed a greater risk of dropping out compared with patients in home-based cardiac rehabilitation. 15 Dropouts in our intervention were low, with more than 89% adherence to preset weekly goals and 88% of participants successfully completing all intervention requirements. 14,15 Thus, our study demonstrated that home-based mobile health app interventions are acceptable and feasible for patients with HF. ...
Background:
The use of mobile health applications (apps) is an effective strategy in supporting patients' self-management of heart failure (HF) in home settings, but it remains unclear whether they can be used to reduce sedentary behaviors and increase overall physical activity levels.
Aim:
The aims of this study were to determine the effect of an 8-week home-based mobile health app intervention on physical activity levels and to assess its effects on symptom burden and health-related quality of life.
Method:
In this study, we collected repeated-measures data from 132 participants with HF (60.8 ± 10.47 years) randomized into a usual care group (n = 67) or an 8-week home-based mobile health app intervention group (n = 65). The intervention was tailored to decrease the time spent in sedentary behavior and to increase the time spent in physical activities performed at light or greater intensity levels. Physical activity levels were monitored for 2 weeks before the intervention and during the 8-week intervention using the Samsung mobile health app. Heart failure symptom burden and health-related quality of life were assessed at baseline, 2 weeks from baseline assessment, and immediately post intervention.
Results:
At week 8, all participants in the intervention group demonstrated an increase in the average daily step counts above the preintervention counts (range of increase: 2351-7925 steps/d). Only 29 participants (45%) achieved an average daily step count of 10 000 or higher by week 6 and maintained their achievement to week 8 of the intervention. Repeated-measures analysis of variance showed a significant group-by-time interaction, indicating that the intervention group had a greater improvement in physical activity levels, symptom burden, and health-related quality of life than the usual care group.
Conclusion:
Home-based mobile health app-based interventions can increase physical activity levels and can play an important role in promoting better HF outcomes.
... The home-based program is a feasible solution; it is a CR alternative in a home setting, including exercise, monitoring, control sessions, letters, and telephone calls. Walking is a frequently recommended activity [153,154] . This program's advantages include the possibility of better adaptation to the patient's needs and relatively less time spent because of the patient need and not travel to the rehabilitation site. ...
... Home-based program effectiveness has been demonstrated in patients after myocardial infarction and revascularization [21,153] , and in HF patients [154] . Like the center-based program, this option has a favorable effect on the risk factors, QoL, and risks of death or a cardiac event [21,153] . ...
... Home-based program effectiveness has been demonstrated in patients after myocardial infarction and revascularization [21,153] , and in HF patients [154] . Like the center-based program, this option has a favorable effect on the risk factors, QoL, and risks of death or a cardiac event [21,153] . Compared to the center-based program, the home-based program was associated with a higher adherence and completion rate [153] . ...
Cardiovascular diseases are the most common causes of mortality worldwide. They are frequently the reasons for patient hospitalization, their incapability for work, and disability. These diseases represent a significant socio-economic burden affecting the medical system as well as patients and their families. It has been demonstrated that the etiopathogenesis of cardiovascular diseases is significantly affected by lifestyle, and so modification of the latter is an essential component of both primary and secondary prevention. Cardiac rehabilitation (CR) represents an efficient secondary prevention model that is especially based on the positive effect of regular physical activity. This review presents an overview of basic information on CR with a focus on current trends, such as the issue of the various training modalities, utilization, and barriers to it or the use of telemedicine technologies. Appropriate attention should be devoted to these domains, as CR continues evolving as an effective and readily available intervention in the future.
... According to the results of the meta-analysis by Zwisler et al., 7 the cardiac rehabilitation can be done in either the center-based or home-based rehabilitation. Clinical trials have established the efficacy of center-based rehabilitation on increasing muscle strength and VO 2 peak for patients with HF. 8---11 Center-based rehabilitation programs have good facilities and professional resources but need more time and finances to join the program. ...
... To our knowledge, from 2010 to 2019, four published meta-analyses of randomized controlled trials (RCTs) examine the effect of RT in patients with HF, 7,13---15 but only one meta-analysis had analyzed the effects of RT on home-based rehabilitation compared to center-based rehabilitation. 7 However, that study did not analyze the components of RT exercises and the effects of RT on increasing muscle strength. Likewise, an effective exercise prescription should include the components of exercises including the type of exercise (modality of activity), duration (length of the session or the number of repetitions), frequency (number of days per week), and intensity (moderate or vigorous). ...
... This is because home-based exercises are more flexible in time compared to those center-based programs. 7,12,13 Intensity of exercise This study showed that the intensity of the RT exercise in both rehabilitation programs was moderate-intensity, and both had a similar effect on increasing muscle strength and VO 2 peak for patients with HFrEF. Furthermore, training with moderate-intensity can increase oxidative muscle metabolism and muscle strength in patients with HF. 8,29 In home-based rehabilitation, aerobic, and walking were used in the RT exercises compared to the center-based which used the cycling ergometer to exercise. ...
Objective
To analyze the components of resistance training (RT) exercises and evaluate the effects of RT on improving muscle strength and oxygen consumption (VO2) peak based on either center-based rehabilitation or home-based rehabilitation in patients with heart failure with reduced ejection fraction (HFrEF).
Methods
According to the PRISMA guidelines, articles were searched through five databases, including Embase, MEDLINE, CINAHL, PEDro and Cochrane. RevMan 5.3 software was used to perform the meta-analysis.
Results
Nine randomized controlled trial studies met the study criteria, including a total of 299 respondents. In the center-based respondents (n = 81 for intervention group vs. n = 81 for control group), RT resulted in significant effects on both muscle strength of lower extremity (SDM = 1.46, 95% CI = 0.41–2.50, n = 151) and upper extremity (SDM = 0.46, 95% CI = 0.05–0.87, n = 97) and VO2 peak (MD = 1.45 ml/kg/min, 95% CI = 0.01–2.89, n = 114). In the home-based respondents (n = 71 for intervention group vs. n = 66 for control group), RT resulted in significant effects on muscle strength of both lower extremity (SDM = 0.58, 95% CI: 0.20–0.97, n = 113) and upper extremity (SDM = 0.84, 95% CI: 0.24–1.44, n = 47) and VO2 peak (MD = 5.43 ml/kg/min, 95% CI: 0.23–10.62, n = 89).
Conclusion
The RT exercise could increase muscle strength and VO2 peak at either center-based or home-based rehabilitation and should be considered as a part of the care of patients with HFrEF.
... To date, small number of studies exploring the home-based unsupervised rehabilitation models for patients with CHF have been published with relatively short period of observation and intervention limited mainly to exercise/marching. Available data suggest non-inferiority of home-based rehabilitation compared to centre-based rehabilitation with respect to safety and completion [15]. ...
... Our data of high completion rate is consistent with data from Zwisler et al. metaanalysis [15] showing that the home-based cardiac rehabilitation dedicated to CHF patients was associated with higher levels of trial completion compared to centre-based (relative risk: 1.2, 1.0 to 1.3). ...
Background: Rehabilitation plays an important role in the management of patients with chronic heart failure (CHF). An optimal rehabilitation model for CHF patients consisting of exercise training, breathing exercises and inspiratory muscle training has not yet been established. This prospective interventional pilot study assessed the safety and effectiveness of a 6-month home-based caregiver-supervised rehabilitation program among CHF patients.
Methods: Analysis included a total of 54 CHF patients randomized into two groups: intervention group (28 patients), subjected to a 6-month home-based physical training and respiratory rehabilitation program and control group (26 patients) not included in rehabilitation program. The reference group consisted of 25 healthy individuals. The measurement of 6-min walk test (6MWT), respiratory muscle strength, quality of life assessment (SF-36, Fatigue Severity Scale – FSS) were performed prior to the start of the study and after 6 months. Occurrence of adverse events and adherence to training protocol were also assessed.
Results: As a result of objective problems caused by outbreak of COVID-19 pandemic, the course and final outcome of the study have differed from the original protocol, control group has not been assessed after 6 months. In the intervention group, 6 months physical training statistically significantly improved 6MWT distance by 37,86 m (p = 0.001) and respiratory muscle strength PImax by 20.21 cmH2O, PEmax by 20.75 cmH2O (p < 0.01). Statistically significant improvement was observed after the training period with the use of FSS questionnaire -0.68 (p = 0.029). Adherence to exercise protocol was on average 91.5 ± 15.3%. No serious adverse events were noted.
Conclusions: The home-based rehabilitation program that includes respiratory muscle training in CHF patients is safe and effective. It improves functional parameters and diminishes the level of fatigue.
Trial registration: ClinicalTrials.gov, NCT03780803. Registered 12 December 2018, https://clinicaltrials.gov/ct2/show/NCT03780803
... Multiple studies have demonstrated that home-based and centre-based models of CR are equally effective in improving clinical symptoms, health-related QoL, reducing mortality, and readmission rates in patients with cardiovascular disease. 12,13 Home-based CR has the advantage of being free from traffic and weather limitations, but its safety, compliance, and whether patients are following the exercise prescription are difficult to guarantee. 13 Digital therapeutics (DTx) is a novel intervention proposed in recent years that refers to the use of evidence-based therapeutic interventions driven by high-quality software programs to treat, manage, or prevent a medical condition. ...
... 12,13 Home-based CR has the advantage of being free from traffic and weather limitations, but its safety, compliance, and whether patients are following the exercise prescription are difficult to guarantee. 13 Digital therapeutics (DTx) is a novel intervention proposed in recent years that refers to the use of evidence-based therapeutic interventions driven by high-quality software programs to treat, manage, or prevent a medical condition. 14 A more valuable feature that differentiates DTx from traditional medicine or therapy is the use of artificial intelligence and machine learning systems to monitor and predict information such as individual patient symptom data through digital biomarkers in a clinical feedback loop to provide a precision medicine approach to healthcare. ...
During the coronavirus disease 2019 (COVID‐19) pandemic, it has become difficult to provide centre‐based cardiac rehabilitation for heart failure patients. Digital therapeutics is a novel concept proposed in recent years that refers to the use of evidence‐based therapeutic interventions driven by high‐quality software programs to treat, manage, or prevent a medical condition. However, little is known about the use of this technology in heart failure patients. This study aims to explore the safety and efficacy of digital therapeutics‐based cardiac rehabilitation in heart failure patients and to provide new insights into a new cardiac rehabilitation model during the COVID‐19 era. To identify technologies related to digital therapeutics, such as the use of medical applications, wearable devices, and the Internet, all relevant studies published on PubMed, EMBASE, Cochrane database, and China National Knowledge Internet were searched from the time the database was established until October 2021. The PEDro was used to assess the quality of included studies. We ultimately identified five studies, which included 1119 patients. The mean age was 66.37, the mean BMI was 25.9, and the NYHA classification ranged from I to III (I = 232, II = 157, III = 209). The mean 6‐min walk distance was 397.7 m. The PEDro scores included in the study ranged from 4 to 8, with a mean of 5.8. Exercise training was performed in four studies, and psychological interventions were conducted in three studies. No death or serious adverse events were observed. Adherence was reported in three studies, and all exceeded 85%. The results of most studies showed that digital therapeutics‐based cardiac rehabilitation significantly increases exercise capacity and quality of life in heart failure patients. Overall, although this study suggests that digital therapeutics‐based cardiac rehabilitation may be a viable intervention for heart failure patients during the COVID‐19 era, the efficacy of this new model in routine clinical practice needs to be further validated in a large clinical trial.
... Previous literature-including systematic reviews-have provided evidence on the positive effects of virtual interventions for CVD rehabilitation and management, [10][11][12][13][14][15][16][17] including adherence to prescribed medications, 10,12 improvement in quality of life, [11][12][13]15 decreases in anxiety and depression levels, 16 compliance to behaviour change, 10,12,18 improvement in knowledge, attitudes, and beliefs, 14 reduction of CVD risk factors, [19][20][21] and hospitalization rates. 17 In addition, programme efficiency has also been confirmed, with virtual and centre-based interventions presenting an equivalent effect on functional capacity, physical activity behaviour, quality of life, medication adherence, smoking behaviour, psychological risk factors, depression, and cardiac-related hospitalization. ...
... Previous literature-including systematic reviews-have provided evidence on the positive effects of virtual interventions for CVD rehabilitation and management, [10][11][12][13][14][15][16][17] including adherence to prescribed medications, 10,12 improvement in quality of life, [11][12][13]15 decreases in anxiety and depression levels, 16 compliance to behaviour change, 10,12,18 improvement in knowledge, attitudes, and beliefs, 14 reduction of CVD risk factors, [19][20][21] and hospitalization rates. 17 In addition, programme efficiency has also been confirmed, with virtual and centre-based interventions presenting an equivalent effect on functional capacity, physical activity behaviour, quality of life, medication adherence, smoking behaviour, psychological risk factors, depression, and cardiac-related hospitalization. 21 Despite evidence for clinical effectiveness, participation in virtual programmes remain controversial. ...
Background:
Due to restrictions imposed by the severe acute respiratory syndrome coronavirus 2 pandemic much attention has been given to virtual education in cardiac rehabilitation (CR). Despite growing evidence that virtual education is effective in teaching patients how to better self-manage their conditions, there is very limited evidence on barriers and facilitators of CR patients in the virtual world.
Aims:
To identify barriers and facilitators to virtual education participation and learning in CR.
Methods:
A systematic review of peer-reviewed literature was conducted. Medline, Embase, Emcare, CINAHL, PubMed, and APA PsycInfo were searched from inception through April 2021. Following the PRISMA checklist, only qualitative studies were considered. Theoretical domains framework (TDF) was used to guide thematic analysis. The Critical Appraisal Skills Program was used to assess the quality of the studies.
Results:
Out of 6662 initial citations, 12 qualitative studies were included (58% 'high' quality). A total of five major barriers and facilitators were identified under the determinants of TDF. The most common facilitator was accessibility, followed by empowerment, technology, and social support. Format of the delivered material was the most common barrier. Technology and social support also emerged as barriers.
Conclusion:
This is the first systematic review, to our knowledge, to provide a synthesis of qualitative studies that identify barriers and facilitators to virtual education in CR. Cardiac rehabilitation patients face multiple barriers to virtual education participation and learning. While 12 qualitative studies were found, future research should aim to identify these aspects in low-income countries, as well as during the pandemic, and methods of overcoming the barriers described.
... HF symptoms such as fatigue, dyspnoea and exertion, can make daily activities difficult and intolerable; while aggravation of these symptoms may often lead to anxiety, depression, and reduced QoL (16). Although, current evidence suggests increased number of female patients being recruited in the clinical trials, yet, majority of the CR participants are males (6); and the participation rate is much lower among low-and middle-income populations (17). and exercise capacity at baseline) (19). ...
... Self-motivation of patients, increased family support and active health-related education could be useful strategies in improving the adherence towards HBCR (26). The rate of adherence across HBCR interventions was reportedly high and varied from 110% to 54%, according to a recent meta-analysis (6). ...
Home-based cardiac rehabilitation designs have been introduced in clinical practice to identify the weaknesses in CR services and quantify patients' access and participation. Nonetheless, consistent variations of protocols and its effectiveness in high-risk patients remains sceptical. This narrative review aims to update the current literature on HBCR and highlight its importance in the management of chronic heart failure by addressing: (1) effectiveness of home-based versus centre-based CR; (2) structural components; (3) patient characteristics; (4) health-related factors and outcomes (5) utilisation and cost-effectiveness; (6) prognosis; (7) pros and cons. No evident differences existed in mortality, cardiac events, exercise-capacity, healthcare costs, modifiable risk factors and HRQoL between home-based and centre-based CR; but HBCR had increased programme completion and adherence. HBCR is composed of patient assessment, exercise training, dietary counselling, risk factor management, and psychosocial intervention. Limited evidence of differential effects exists across patient-related outcomes which indicates www.turkjphysiotherrehabil.org 25067 similar improvements, regardless of age, sex, current fitness or disease severity. HBCR programmes are safe, effective and affordable choice for low-to-moderate risk HF patients; yet underutilisation persists. CR provides improved health-related outcomes, reduced cardiovascular events and mortality. Nevertheless, the long-term impact of home-based CR on patients' quality of life and clinical outcomes needs to be further evaluated.
... Home-based cardiac rehabilitation (HBCR) programs were thus introduced to increase access and patient acceptance and are reported to be equally effective as conventional CR in improving physical capacity and cholesterol control (9)(10)(11)(12). HBCR, conducted at non-clinical settings, including home and other community-based facilities, is more accessible to patients and costing less (12). ...
... Consistent with another HBCR study, our study indicated improved exercise capacity for patients, particularly for METs, and oxygen consumption at Anaerobic Threshold (VO 2 AT) ( Table 2). Moreover, our study showed that the improvement persists longer than 2 years (3,9,10). Previous studies have established the connection between exercise capacity and health outcome: each increment of 1 metabolic equivalent (MET) (3.5 ml O 2 kg −1 .min ...
Purpose: We evaluated the long-term effect of a smartphone-facilitated home-based cardiac rehabilitation (HBCR) model in revascularized patients with coronary heart disease (CHD) on major adverse cardiac events (MACE), and secondary outcomes, including safety, quality of life, and physical capacity.
Methods: It was a prospective observational cohort study including a total of 335 CHD patients after successful percutaneous coronary intervention (PCI) referred to the CR clinic in China between July 23, 2015 and March 1, 2018. Patients were assigned to two groups: HBCR tailored by monitoring and telecommunication via smartphone app (WeChat) (HBCR group, n = 170) or usual care (control group, n = 165), with follow-up for up to 42 months. Propensity score matching was conducted to match patients in the HBCR group with those in the control group. The patients in the HBCR group received educational materials weekly and individualized exercise prescription monthly, and the control group only received 20-min education at baseline in the CR clinic. The primary outcome was MACE, analyzed by Cox regression models. The changes in the secondary outcomes were analyzed by paired t -test among the matched cohort.
Results: One hundred thirty-five HBCR patients were matched with the same number of control patients. Compared to the control group, the HBCR group had a much lower incidence of MACE (1.5 vs. 8.9%, p = 0.002), with adjusted HR = 0.21, 95% CI 0.07–0.85, and also had reduced unscheduled readmission (9.7 vs. 23.0%, p = 0.002), improved exercise capacity [maximal METs (6.2 vs. 5.1, p = 0.002)], higher Seattle Angina Questionnaire score, and better control of risk factors.
Conclusions: The Chinese HBCR model using smartphone interaction is a safe and effective approach to decrease cardiovascular risks of patients with CHD and improve patients' wellness.
Clinical Trial Registration: http://www.chictr.org.cn , identifier: ChiCTR1800015042.
... We included five SRs with heart failure and CHD indications for the MoC cardiac rehabilitation [66][67][68][69][70]. All included SRs on MoC reported exercise programs. ...
Background
Chronic heart disease affects millions of people worldwide and the prevalence is increasing. By now, there is an extensive literature on outpatient care of people with chronic heart disease. We aimed to systematically identify and map models of outpatient care for people with chronic heart disease in terms of the interventions included and the outcomes measured and reported to determine areas in need of further research.
Methods
We created an evidence map of published systematic reviews. PubMed, Cochrane Library (Wiley), Web of Science, and Scopus were searched to identify all relevant articles from January 2000 to June 2021 published in English or German language. From each included systematic review, we abstracted search dates, number and type of included studies, objectives, populations, interventions, and outcomes. Models of care were categorised into six approaches: cardiac rehabilitation, chronic disease management, home-based care, outpatient clinic, telemedicine, and transitional care. Intervention categories were developed inductively. Outcomes were mapped onto the taxonomy developed by the COMET initiative.
Results
The systematic literature search identified 8043 potentially relevant publications on models of outpatient care for patients with chronic heart diseases. Finally, 47 systematic reviews met the inclusion criteria, covering 1206 primary studies (including double counting). We identified six different models of care and described which interventions were used and what outcomes were included to measure their effectiveness. Education-related and telemedicine interventions were described in more than 50% of the models of outpatient care. The most frequently used outcome domains were death and life impact.
Conclusion
Evidence on outpatient care for people with chronic heart diseases is broad. However, comparability is limited due to differences in interventions and outcome measures. Outpatient care for people with coronary heart disease and atrial fibrillation is a less well-studied area compared to heart failure. Our evidence mapping demonstrates the need for a core outcome set and further studies to examine the effects of models of outpatient care or different interventions with adjusted outcome parameters.
Systematic review registration
PROSPERO (CRD42020166330).
... 8 Home-based cardiac rehabilitation interventions are considered cost-effective alternatives to traditional centered-based cardiac rehabilitation, with better enrollment rates. 4,9,10 However, it is important to note that, regardless of the type of intervention model attended, less than 50% of patients with HF achieve the recommended exercise regimens. 4À6 Previous studies have reported a wide range of barriers to physical activity among patients with HF who attended cardiac rehabilitation interventions. ...
Background:
Physical activity behavior change is considered one of the most challenging lifestyle modifications in patients with heart failure. Even after participation in a cardiac rehabilitation program, most patients do not engage in the recommended level of physical activity.
Objective:
To determine which baseline demographic, physical activity levels, psychological distress, and clinical variables predicted physical activity behavior change to increasing light-to-vigorous physical activity by 10,000 steps/day following participation in home-based cardiac rehabilitation intervention.
Methods:
A prospective design involving secondary analysis was used to analyze data obtained from 127 patients (mean, 61; range, 45-69 years) enrolled in and completed an 8-week home-based mobile health app intervention. The intervention was designed to encourage health behavior change with regard to decreasing sedentary behavior and increasing physical activities performed at light or greater intensities.
Results:
None of the participants accumulated 10,000 steps or more per day pre-intervention (mean, 1549; range, 318-4915 steps/day). Only 55 participants (43%) achieved an average daily step count of 10,000 or more at week 8 of the intervention (10,674 ± 263). The results of the logistic regression showed that higher pre-intervention physical activity levels and anxiety symptoms and lower depressive symptoms were associated with a higher likelihood of achieving physical activity behavior change (p < .003).
Conclusion:
These data highlight that determining pre-intervention physical activity levels and depressive symptoms can be the key to designing an effective home-based cardiac rehabilitation intervention in patients with heart failure.
... Ours is the first observational study to show a mortality benefit with HBCR. Prior literature has focused on comparing HBCR with CBCR programs in clinical trials [18][19][20]37 Although multiple studies have demonstrated similar mortality in patients undergoing HBCR versus CBCR, efficacy in clinical trials does not always translate to effectiveness in real-world clinical practice. Our pragmatic study showed that patients enrolled in HBCR had lower mortality than those not enrolled in CR. ...
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.
... In a Cochrane systematic review of 23 trials with a total of 2890 individuals, homebased cardiac rehabilitation programs demonstrate comparable effects on mortality, exercise capacity, modifiable risk factors and health-related quality of life compared with centre-based programs in people who have suffered a myocardial infarction, angina, HF or who have undergone revascularisation [11]. Hospitalisations and costs have also been shown to be similar between home-based and centre-based cardiac rehabilitation programs, with higher completion rates in the home-based group [12]. Given this lack of difference in clinical outcomes between models, international guidelines have recommended aligning the choice of centre-based or home-based cardiac rehabilitation services with an individual's needs and preferences [13][14][15]. ...
Given the under-utilisation of cardiac rehabilitation despite its benefits, there has been a shift towards alternative delivery models. The recent coronavirus disease 2019 (COVID-19) pandemic has accelerated this shift, leading to a growing interest in home-based cardiac rehabilitation including telerehabilitation. There is increasing evidence to support cardiac telerehabilitation, with studies generally demonstrating comparable outcomes and potential cost-benefits. This review aims to provide a synopsis of the current evidence on home-based cardiac rehabilitation with a focus on telerehabilitation and practical considerations.
... Similarly, our results also coincide with other reviews that compared "telerehabilitation" with other RCV benefit models in patients with cardiopulmonary diseases [19,20]. Although in the RCV section of the Clinicas Hospital we have incorporated Virtual visits to nutrition and kinesiology, real-time training monitoring with devices is, for the moment, a little accessible reality in our environment [21,22]. ...
... Целью инициативы Million Hearts Cardiac Rehabilitation Collaborative является включение в реабилитационный процесс ≥70% пациентов с кардиологической патологией к 2022г (Ritchey 2020). Мобильные приложения и интегрированные датчики для измерения ЧСС, показателей дыхания и других физиологических парамет ров, как правило, лишены основных ограничений, характерных для традиционных подходов, являются доступными по стоимости и удобными в использовании, и поэтому могут быть более приемлемыми для пациентов с ИБС во многих клинических ситуациях (Zwisler 2016). Контролируемое РКИ эффективности традиционного госпитального этапа реабилитации при дополнительном использовании мобильных технологий продемонстрировало улучшение восприятия врачебных рекомендаций, приверженности к терапии и увеличение количества пациентов, продолжающих реабилитацию в домашних условиях после перенесенного ИМ . ...
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health (“mHealth”) technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
... One potential exercise approach that does not require in-person attendance and can be accessed anytime and anywhere is a telehealth exercise intervention. A telehealth exercise intervention is an effective alternative model of home-based rehabilitation that can possibly produce higher compliance rates and similar efficacy when compared with hospital-based programs [23]. Studies in patients with coronary artery disease [24], and heart failure [25] have shown that a telehealth exercise intervention is equivalent to traditional cardiac rehabilitation in achieving functional improvement, managing risk factors (blood pressure, lipid profile, and body mass index), and improving quality of life, without serious adverse events. ...
Background
Advances in autologous hematopoietic stem cell transplantation (HSCT) and supportive care have led to marked improvements in survival for patients with multiple myeloma. Despite these improvements, patients with multiple myeloma remain at high risk of physical dysfunction and frailty due to HSCT and its associated exposures. Although traditional supervised exercise programs can improve frailty in cancer patients and survivors, rehabilitation facilities are typically far from a patient’s residence, are offered on fixed days/hours, contain uniform activities for everyone, and carry a higher risk of contact cross-infection due to immunosuppression, which can be barriers to exercise participation. Innovative personalized interventions are needed to overcome the limitations of traditional exercise interventions. The purpose of this study is to determine the efficacy and sustainability of a telehealth exercise intervention on physical function and frailty in patients with multiple myeloma treated with HSCT.
Methods
This randomized controlled trial will assess the efficacy of an 8-week telehealth exercise intervention in 60 patients with multiple myeloma who underwent autologous HSCT (30–180 days post-transplant) and are pre-frail or frail. There will be 30 intervention participants and 30 delayed controls. We will administer remote baseline assessments (week 0), followed by an 8-week telehealth intervention (week 1–8), post assessment (week 9), and an additional follow-up assessment (week 17). Our primary endpoint will be improved physical function, as assessed by the Short Physical Performance Battery test. Our secondary endpoint will be a decrease in frailty characteristics such as gait speed, strength, and fatigue. We will also evaluate the sustainability of improved physical function and frailty at week 17. Participants randomized to the intervention group will perform at least 90 min of exercise per week throughout the 8 weeks.
Discussion
This study will help optimize the delivery of safe, low-cost, and scalable telehealth exercise interventions to improve health outcomes in patients with multiple myeloma, an understudied population at high risk for physical dysfunction and frailty. Our study may provide the foundation for sustainable telehealth exercise interventions to improve physical function and frailty for other hematologic cancer patients (e.g., acute leukemia, lymphoma) as well as any other cancer population of interest.
Trial registration
ClinicalTrials.govNCT05142371. This study was retrospectively registered on December 2nd, 2021, and is currently open to accrual.
... The variable importance of this factor across studies is probably dependent on the geographical dispersion of the population served by each hospital. In an attempt to overcome geographical barriers, the delivery of hybrid and homebased CR, as well as the delivery of CR in community health service centers exploiting existing physical infrastructures (community exercise centers), may increase patients' enrollment in the future [2,4,[45][46][47][48][49]. Besides that, patients who were not enrolled in CR reported concomitant medical problems (28%), namely musculoskeletal problems (15%), as a common barrier to CR. ...
Despite cardiac rehabilitation (CR) being a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF), it is still underused. This study investigated the clinical determinants and barriers to enrollment in a CR program for HFrEF patients. We conducted a cohort study using the Cardiac Rehabilitation Barriers Scale (CRBS) to assess the reason for non-enrollment. Of 214 HFrEF patients, 65% had not been enrolled in CR. Patients not enrolled in CR programs were older (63 vs. 58 years; p < 0.01) and were more likely to have chronic obstructive pulmonary disease (COPD) (20% vs. 5%; p < 0.01). Patients enrolled in CR were more likely to be treated with sacubitril/valsartan (34% vs. 19%; p = 0.01), mineralocorticoid receptor antagonists (84% vs. 72%; p = 0.04), an implantable cardioverter defibrillator (ICD) (41% vs. 20%; p < 0.01), and cardiac resynchronization therapy (21% vs. 10%; p = 0.03). Multivariate analysis revealed that age (adjusted OR 1.04; 95% CI 1.01–1.07), higher education level (adjusted OR 3.31; 95% CI 1.63–6.70), stroke (adjusted OR 3.29; 95% CI 1.06–10.27), COPD (adjusted OR 4.82; 95% CI 1.53–15.16), and no ICD status (adjusted OR 2.68; 95% CI 1.36–5.26) were independently associated with CR non-enrollment. The main reasons for not being enrolled in CR were no medical referral (31%), concomitant medical problems (28%), patient refusal (11%), and geographical distance to the hospital (9%). Despite the relatively high proportion (35%) of HFrEF patients who underwent CR, the enrollment rate can be further improved. Innovative multi-level strategies addressing physicians’ awareness, patients’ comorbidities, and geographical issues should be pursued.
... Således er der behov for nye rehabiliteringsmodeller, som imødekommer behov og praeferencer hos den enkelte patient. Et alternativ til den traditionelle model er hjemmebaseret selvtraening, som har vist positive effekter [20][21][22]. ...
An increasing number of Danes are living, and dying, with cardiovascular disease. There is good evidence for the impact of cardiac rehabilitation on coronary heart disease, heart failure and symptomatic peripheral arterial disease. However, more high-quality research is needed into a wider range of cardiac diseases including rehabilitation following cardiac arrest, and palliative care for patients with advanced heart disease. In this review it is discussed how to improve the quality of care and identify the direction of future research and development.
... In this connection, a study conducted by Heran et al. [24] analyzing 47 randomized studies on exercise-based cardiac rehabilitation and usual care found that exercise-based cardiac rehabilitation generally reduced cardiovascular morbidity and mortality (RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87) as well as hospital admission rates (RR 0.69 (95% CI 0.51, 0.93)). Supportive studies also asserted that clinic and home-based forms of cardiac rehabilitation proved effective for clinical and health-related quality of life outcomes with heart failure [25]. Regarding exercise training or physical activity, Pollock et al. [26] attributed to the importance of resistance training in cardiac rehabilitation. ...
Introduction: Currently, the deployment of human–computer interactive technologies to provide personalized care has grown and immensely taken shape in most healthcare settings. With the increasing growth of the internet and technology, personalized health interventions including smartphones, associated apps, and other interventions demonstrate prowess in various health fields, including cardiovascular management. This systematic review thus examines the effectiveness of various human–computer interactions technologies through telehealth (mainly eHealth) towards optimizing the outcomes in cardiovascular treatment. Methods: A comprehensive search of MEDLINE, EMBASE, and CINAHL databases using key terms was conducted from 2000 to November 2021 to identify suitable studies that explored the use of human–computer interaction technologies to provide a personalized care approach to facilitate bolstered outcomes for cardiovascular patients, including the elderly. The included studies were assessed for quality and risk of bias, and the authors undertook a data extraction task. Results: Ten studies describing the use of a mix of personalized health app (mHealth) interventions were identified and included in the study. Among the included studies, nine of them were randomized trials. All of the studies demonstrated the effectiveness of various personalized health interventions in maximizing the benefits of cardiovascular disease treatment. Conclusions: Personalized health application interventions through precision medicine has great potential to boost cardiovascular disease management outcomes, including rehabilitation. Fundamentally, since each intervention’s focus might differ based on the disease and outcome preference, it is recommended that more research be done to tailor the interventions to specific disease and patient outcome expectations.
... 44 and combined lower and upper body strength (SMD: 0.59, 95% CI: 0.22-0.96). 45 Furthermore, previous studies have reported significant improvements in 6 min walking test (6MWT) following resistance 46 [55][56][57][58][59][60][61][62] Conventional, continuous, and high-intensity endurance training may all significantly improve quality of life, which has been also shown to be correlated with peak oxygen uptake, 51,54,63-70 although one study did not report any changes (SMD: 0.5 points out of 105, 95% CI: À4.4 to 5.4). 71 ...
The purpose of this review is to describe the present evidence for exercise and nutritional interventions as potential contributors in the treatment of sarcopenia and frailty (i.e. muscle mass and physical function decline) and the risk of cardiorenal metabolic comorbidity in people with heart failure (HF). Evidence primarily from cross-sectional studies suggests that the prevalence of sarcopenia in people with HF is 37% for men and 33% for women, which contributes to cardiac cachexia, frailty, lower quality of life, and increased mortality rate. We explored the impact of resistance and aerobic exercise, and nutrition on measures of sarcopenia and frailty, and quality of life following the assessment of 35 systematic reviews and meta-analyses. The majority of clinical trials have focused on resistance, aerobic, and concurrent exercise to counteract the progressive loss of muscle mass and strength in people with HF, while promising effects have also been shown via utilization of vitamin D and iron supplementation by reducing tumour necrosis factor-alpha (TNF-a), c-reactive protein (CRP), and interleukin-6 (IL-6) levels. Experimental studies combining the concomitant effect of exercise and nutrition on measures of sarcopenia and frailty in people with HF are scarce. There is a pressing need for further research and well-designed clinical trials incorporating the anabolic and anti-catabolic effects of concurrent exercise and nutrition strategies in people with HF.
... As a cost-effective medical intervention, the variation in cardiac rehabilitation levels may also result in the disparity in the frequency of ADL impairment between different countries (24). Cardiac rehabilitation has been shown in a rising number of studies to enhance physical function and the ability to conduct everyday tasks in HF patients (25,26). It is a pity that cardiac rehabilitation is available in only 17% of countries in Southeast Asia (27). ...
Objectives
The prevalence of activities of daily living (ADL) in patients with heart failure (HF) reported in current studies were inconsistent, ranging from 11.1 to 70.5%. The purpose of this study is to quantify the prevalence of ADL impairment in HF patients.Methods
PubMed, Embase, Cochrane, CINAHL, CNKI, SinoMed, VIP, and Wanfang databases were systematically searched for relevant studies (up to March 2, 2022). Cross-sectional, case-control, or cohort studies with detailed descriptions of overall ADL impairment in HF were included. Stata 16.0 was used for statistical analysis. Fixed-effect or random-effect model was adopted according to heterogeneity which was evaluated by Cochran’s Q and I2 values. Sensitivity analysis, subgroup analysis, and meta-regression were performed to investigate the sources of heterogeneity.ResultsA total of 12 studies with 15,795 HF patients were included in the meta-analysis, and the pooled prevalence of ADL impairment in patients with HF was 38.8% (95%CI: 28.2–49.3%; I2 = 99.5%, P < 0.001). No possible sources of heterogeneity were found in subgroup analysis and meta-regression. Funnel plots and Egger’s test showed no publication bias (P = 0.595).Conclusion
The prevalence of ADL impairment is relatively high in HF patients. Differences in the prevalence of ADL impairment in patients with HF may be influenced by country, region, and assessment time. We suggest that more researchers could focus on the changes of ADL impairment in HF patients during different disease periods in different regions and countries.
... This current systematic review and meta-analysis of the available information has identified a positive effect of the wearable-sensors-assisted HBCR with improvements in patients' CRF, whether the HBCR was used as an adjunct or as an alternative to CBCR. This finding is in accordance with previous systematic reviews that also proclaim the feasibility and effectiveness of digital HBCR in improving the patients' CRF levels [7,24,[45][46][47]. Additionally, the participants' adherence rates appear to be higher in the intervention HBCR groups (Table 2), thus promoting a more profound aerobic training and probably explaining the more beneficial impact of HBCR on CRF levels when compared to the CBCR group outcomes. ...
Abstract: Exercise-based cardiac rehabilitation is a highly recommended intervention towards the advancement of the cardiovascular disease (CVD) patients’ health profile; though with low participation rates. Although home-based cardiac rehabilitation (HBCR) with the use of wearable sensors is proposed as a feasible alternative rehabilitation model, further investigation is needed. This systematic review and meta-analysis aimed to evaluate the effectiveness of wearable sensors-assisted HBCR in improving the CVD patients’ cardiorespiratory fitness (CRF) and health profile. PubMed, Scopus, Cinahl, Cochrane Library, and PsycINFO were searched from 2010 to January 2022, using
relevant keywords. A total of 14 randomized controlled trials, written in English, comparing wearable sensors-assisted HBCR to center-based cardiac rehabilitation (CBCR) or usual care (UC), were included. Wearable sensors-assisted HBCR significantly improved CRF when compared to CBCR ( Hedges’ g = 0.22, 95% CI 0.06, 0.39; I2 = 0%; p = 0.01), whilst comparison of HBCR to UC revealed a nonsignificant effect (Hedges’ g = 0.87, 95% CI −0.87, 1.85; I2 = 96.41%; p = 0.08). Effects on physical activity, quality of life, depression levels, modification of cardiovascular risk factors/laboratory parameters, and adherence were synthesized narratively. No significant differences were noted. Technology tools are growing fast in the cardiac rehabilitation era and promote exercise-based interventions into a more home-based setting. Wearable-assisted HBCR presents the potential to act as an adjunct or an alternative to CBCR.
Keywords: wearable sensors; home-based cardiac rehabilitation; cardiovascular disease;
cardiorespiratory fitness; accelerometer; physical activity
... 11 12 Previous systematic reviews and pairwise meta-analyses reported ExCR has potential health benefits. [9][10][11][12][13][14][15][16] Since standard meta-analytical procedures can only consider pairwise comparisons, there is limited understanding of how all delivery modes compare. Network meta-analysis (NMA) overcomes this limitation by enabling simultaneous comparisons between more than two treatments. ...
Background
This review aimed to compare the relative effectiveness of different exercise-based cardiac rehabilitation (ExCR) delivery modes (centre-based, home-based, hybrid and technology-enabled ExCR) on key heart failure (HF) outcomes: exercise capacity, health-related quality of life (HRQoL), HF-related hospitalisation and HF-related mortality.
Methods and results
Randomised controlled trials (RCTs) published through 20 June 2021 were identified from six databases, and reference lists of included studies. Risk of bias and certainty of evidence were evaluated using the Cochrane tool and Grading of Recommendations Assessment, Development and Evaluation, respectively. Bayesian network meta-analysis was performed using R. Continuous and binary outcomes are reported as mean differences (MD) and ORs, respectively, with 95% credible intervals (95% CrI). One-hundred and thirty-nine RCTs (n=18 670) were included in the analysis. Network meta-analysis demonstrated improvements in VO 2 peak following centre-based (MD (95% CrI)=3.10 (2.56 to 3.65) mL/kg/min), home-based (MD=2.69 (1.67 to 3.70) mL/kg/min) and technology-enabled ExCR (MD=1.76 (0.27 to 3.26) mL/kg/min). Similarly, 6 min walk distance was improved following hybrid (MD=84.78 (31.64 to 138.32) m), centre-based (MD=50.35 (30.15 to 70.56) m) and home-based ExCR (MD=36.77 (12.47 to 61.29) m). Incremental shuttle walk distance did not improve following any ExCR delivery modes. Minnesota living with HF questionnaire improved after centre-based (MD=−10.38 (−14.15 to –6.46)) and home-based ExCR (MD=−8.80 (−13.62 to –4.07)). Kansas City Cardiomyopathy Questionnaire was improved following home-based ExCR (MD=20.61 (4.61 to 36.47)), and Short Form Survey 36 mental component after centre-based ExCR (MD=3.64 (0.30 to 6.14)). HF-related hospitalisation and mortality risks reduced only after centre-based ExCR (OR=0.41 (0.17 to 0.76) and OR=0.42 (0.16 to 0.90), respectively). Mean age of study participants was only associated with changes in VO 2 peak.
Conclusion
ExCR programmes have broader benefits for people with HF and since different delivery modes were comparably effective for improving exercise capacity and HRQoL, the selection of delivery modes should be tailored to individuals’ preferences.
... Decreased responsiveness of the sinus node to catecholamines may also explain the lower maximal heart rate and heart rate reserve of older subjects despite increased plasma norepinephrine. (25) The significant increase in functional capacity in the present study was reflected by the statistically significant increase in duration of exercise from 7.5±1.7 minutes to 14.6 ±2.9 minutes and METS from 5.3±1.1 to 9.3±2.4 after completion of the rehabilitation program (P-value<0.01). Our results are similar to the significant improvement in exercise capacity found by Rebecca et al.,, who retrospectively reviewed data from 458 patients enrolled in CR programs following acute coronary syndrome with cardiac rehabilitation and exercise training. ...
... As an alternate to traditional CR, primarily home-based CR programs have proven to be effective in selected individuals [68,71,103]. Compared to participants in traditional CR programs, individuals enrolled in home-based programs have similar improvements in aerobic capacity and measures of quality of life. ...
Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participant. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.
... In addition, a number of non-pharmacologic interventions have emerged such as multimodal, multidisciplinary cardiac rehabilitation programs [10]. Although trials, observational studies and systematic reviews have shown consistent safety, improvement in exercise capacity and overall quality of life, they have not shown a significant and consistent reduction in mortality [11][12][13][14]. One possible explanation is the heterogeneity of these programmes and the short duration of both the intervention and the follow up period. ...
Background
Heart failure (HF) has become a major cause of morbidity and mortality worldwide. Despite significant improvements in the management of HF, the overall outcomes remain poor. In addition to pharmacotherapy and device therapy, non-pharmacological interventions are needed to mitigate the effects of this illness. The aim of this study was to evaluate the impact of the heart failure outreach program on the rate of mortality, HF hospitalisations and guideline directed medical therapy (GDMT) for HF in South Western Sydney Local Health District (SWSLHD).
Methods
In this observational, registry based study, adult patients diagnosed with Heart failure with reduced ejection fraction (HFrEF) within the South Western Sydney Local Health District (SWSLHD) and invited to participate in the heart failure outreach service between March 2011 and January 2016 were included in the study. The primary outcome was all-cause mortality. In addition, we examined the rate of optimal medical therapy, HF hospitalisations and the total lengths of stay.
Results
A total of 818 patients were included in the study; 470 (57.5%) patients were enrolled and 348 (42.5 %) not enrolled into the program. At the end of the follow up period (median 978 days, interquartile range (IQR) 720-1237), the primary outcome of mortality was observed significantly less in the enrolled group (122 (26%) vs. 133 (38.2%), p<0.001) independently of other variables. In addition, significantly fewer enrolled patients had >3 hospital admissions for HF (16.2% vs. 35.6%, p<0.001) and reduced median admission days (14.5 days [IQR 8-25] vs 22 [IQR 12-37], p <0.001). Patients enrolled into the program were much more likely to be on GDMT (76.6% vs 56.6%, p<0.001).
Conclusions
Enrolment in the heart failure outreach program was associated with a significant reduction in mortality as well as a reduction in the frequency and length of hospital admissions. In addition, the rate of GDMT was significantly higher in the enrolled group. With the high prevalence of heart failure, these programs should be considered in the routine management of patients with HFrEF.
Background
Heart failure (HF) has become a major cause of morbidity and mortality worldwide. Despite significant improvements in the management of HF, the overall outcomes remain poor. In addition to pharmacotherapy and device therapy, non-pharmacological interventions are needed to mitigate the effects of this illness. The aim of this study was to evaluate the impact of the heart failure outreach program on the rate of mortality, HF hospitalisations and guideline directed medical therapy (GDMT) for HF in South Western Sydney Local Health District (SWSLHD).
Methods
In this observational, registry based study, adult patients diagnosed with Heart failure with reduced ejection fraction (HFrEF) within the South Western Sydney Local Health District (SWSLHD) and invited to participate in the heart failure outreach service between March 2011 and January 2016 were included in the study. The primary outcome was all-cause mortality. In addition, we examined the rate of optimal medical therapy, HF hospitalisations and the total lengths of stay.
Results
A total of 818 patients were included in the study; 470 (57.5%) patients were enrolled and 348 (42.5 %) not enrolled into the program. At the end of the follow up period (median 978 days, interquartile range (IQR) 720-1237), the primary outcome of mortality was observed significantly less in the enrolled group (122 (26%) vs. 133 (38.2%), p<0.001) independently of other variables. In addition, significantly fewer enrolled patients had >3 hospital admissions for HF (16.2% vs. 35.6%, p<0.001) and reduced median admission days (14.5 days [IQR 8-25] vs 22 [IQR 12-37], p <0.001). Patients enrolled into the program were much more likely to be on GDMT (76.6% vs 56.6%, p<0.001).
Conclusions
Enrolment in the heart failure outreach program was associated with a significant reduction in mortality as well as a reduction in the frequency and length of hospital admissions. In addition, the rate of GDMT was significantly higher in the enrolled group. With the high prevalence of heart failure, these programs should be considered in the routine management of patients with HFrEF.
... It should be noted, however, that the actual adherence may have been underestimated because we based our findings solely on the number of recorded sessions with the activity tracker, which was experienced as troublesome by some patients. Other studies evaluating home-based CR in patients with CHF generally showed a high mean adherence but with a wide variation ranging from 54% to 110% [21]. In patients with COPD too, adherence to home-based exercise programs was highly variable, ranging from 21% [22] to 93.5% [23]. ...
Background
As chronic cardiac and pulmonary diseases often coexist, there is a need for combined physical home-based rehabilitation programs, specifically addressing older patients with advanced disease stages.
Objective
The primary aim of this study is to evaluate the completion and adherence rates of an 8-week, home-based exercise program for patients with advanced cardiopulmonary disease. The secondary end points include patient satisfaction; adverse events; and program efficacy in terms of change in functional capacity, level of dyspnea, and health-related quality of life.
Methods
The participants received a goal-oriented, home-based exercise program, and they used a wrist-worn activity tracker to record their exercise sessions. Activity tracker data were made visible on a digital platform, which was also equipped with several other features such as short instruction videos on how to perform specific exercises. The participants received weekly coaching by a physiotherapist and an occupational therapist through video communication.
Results
In all, 10 patients with advanced combined cardiopulmonary disease participated (median age 71, IQR 63-75 years), and 50% (5/10) were men. Of the 10 participants, 9 (90%) completed the 8-week program. Median adherence to the exercise prescription was 75% (IQR 37%-88%), but it declined significantly when the program was divided into 2-week periods (first 2 weeks: 86%, IQR 51%-100%, and final 2 weeks: 57%, IQR 8%-75%; P=.03). The participants were highly satisfied with the program (Client Satisfaction Questionnaire: median score 29, IQR 26-32, and Purpose-Designed Questionnaire: median score 103, IQR 92-108); however, of the 9 participants, 4 (44%) experienced technical issues. The Patient-Specific Complaints Instrument scores declined, indicating functional improvement (from median 7.5, IQR 6.1-8.9, to median 5.7, IQR 3.8-6.7; P=.01). Other program efficacy metrics showed a trend toward improvement.
Conclusions
Home-based cardiopulmonary telerehabilitation for patients with severe combined cardiopulmonary disease is feasible in terms of high completion and satisfaction rates. Nevertheless, a decrease in adherence during the program was observed, and some of the participants reported difficulties with the technology, indicating the importance of the integration of behavior change techniques, using appropriate technology.
Trial Registration
Netherlands Trial Register NL9182; https://www.trialregister.nl/trial/9182
... Home-based exercises can empower patients to take responsibility and accountability for their own disease management (6). Most importantly, they increase patients' access to EBCR by confronting the challenge of limited healthcare resources. ...
Aims: The Baduanjin Eight-Silken-Movements wIth Self-Efficacy building for Heart Failure (BESMILE-HF) program is a contextually adapted cardiac rehabilitation program. It uses a traditional Chinese exercise, Baduanjin , to solve the unmet demand of exercise-based cardiac rehabilitation programs due to their scarcity and unaffordability in China. This pilot study assesses BESMILE-HF's feasibility and preliminary effects.
Methods: Eighteen patients with chronic heart failure were included: 8 in a BESMILE-HF group (age: 67 ± 5 years, EF: 40.4 ± 13.6%) and 10 in a control group (age: 70 ± 13 years, EF: 42.9 ± 12.5%). Both received the usual medications, with the intervention group receiving additionally the BESMILE-HF program for 6 weeks. Feasibility was explored by participants' involvement in the intended intervention. Clinical outcome assessments were conducted at baseline and post-intervention, while adverse events were captured throughout the study period.
Results: The BESMILE-HF program was well-received by patients, and adherence to the intervention was good. The intervention group completed all required home exercises and total home-practice time was correlated with baseline self-efficacy ( r = 0.831, p = 0.011). Moreover, after 6 weeks, self-efficacy increased in the BESMILE-HF group ( p = 0.028) and the change was higher than in the control [mean difference (MD): 3.2; 95% confidence interval (CI) 0.6–5.9, p = 0.004]. For the exercise capacity, the control group demonstrated a significant decline in peak oxygen consumption ( p =0.018) whereas, the BESMILE-HF group maintained their exercise capacity ( p = 0.063). Although the between-group difference was not statistically significance, there was clear clinical improvement in the BESMILE-HF group (1.5 mL/kg/min, 95% CI, −0.3 to 3.2 vs. minimal clinically important difference of 1 mL/kg/min). Throughout the study period, no adverse events related to the intervention were captured.
Conclusions: BESMILE-HF is feasible for patients with chronic heart failure in Chinese settings. A larger sample size and a longer follow-up period is needed to confirm its benefit on clinical outcomes.
Clinical Trial Registration: ClinicalTrials.gov : NCT03180320.
... Nevertheless, the 2 most recent studies provided a more detailed analysis of this outcome and longer follow-ups, which may represent a new trend in study designs. 17,38 Patients submitted to TR showed significant better results on functional capacity compared to usual care without exercise prescription. It is also relevant to note that patients under TR showed a significant improvement in both 6MWT and pVO2, which highlights TR validity. ...
Background
Tele-rehabilitation (TR) may be an effective alternative or complement to centre-based cardiac rehabilitation (CBCR) with heart failure (HF) patients, helping overcome accessibility problems to CBCR. The aim of this study is to systematically review the literature in order to assess the clinical effectiveness of TR programs in the management of chronic HF patients, compared to standard of care and standard rehabilitation (CBCR).
Methods and Results
We conducted a systematic review and meta-analysis of randomized controlled trials on the effect and safety of TR programs in HF patients, regarding cardiovascular death, heart failure-related hospitalizations, functional capacity and quality of life. We searched 4 electronic databases up until May 2020, reviewed references of relevant articles and contacted experts. A quantitative synthesis of evidence was performed by means of random-effects meta-analyses. We included 17 primary studies, comprising 2206 patients. Four studies reported the number of hospitalizations (TR: 301; Control: 347). TR showed to be effective in the improvement of HF patients’ functional capacity in the 6 Minute Walk-Test (Mean Difference (MD) 15.86; CI 95% [7.23; 24.49]; I2 = 74%) and in peak oxygen uptake (pVO2) results (MD 1.85; CI 95% [0.16; 3.53]; I ² = 93%). It also improved patients’ quality of life (Minnesota Living with Heart Failure Questionnaire: MD −6.62; CI 95% [−11.40; −1.84]; I ² = 99%). No major adverse events were reported during TR exercise.
Conclusion
TR showed to be superior than UC without CR on functional capacity improvement in HF patients. There is still scarce evidence of TR impact on hospitalization and cv death reduction. Further research and more standardized protocols are needed to improve evidence on TR effectiveness, safety and cost-effectiveness.
... The HBCR is considered safe because there are no reports or evidence of increased hospitalization or death risk. These findings support the HBCR program applied to HF patients as an alternative to conventional hospital-based rehabilitation [10,18,20]. ...
Background
Adherence to medication and lifestyle changes are very important in the secondary prevention of cardiovascular disease. One of the ways is by doing a cardiac rehabilitation program.
Main body of the abstract
Cardiac rehabilitation program is divided into three phases. The cardiac rehabilitation program’s implementation, especially the second phase, center-based cardiac rehabilitation (CBCR), has many barriers not to participate optimally. Therefore, the third phase, known as home-based cardiac rehabilitation (HBCR), can become a substitute or addition to CBCR. On the other hand, this phase is also an essential part of the patients’ functional capacity. During the coronavirus disease-2019 pandemic, HBCR has become the leading solution in the cardiac rehabilitation program’s sustainability. Innovation is needed in its implementation, such as telerehabilitation. So, the cardiac rehabilitation program can be implemented by patients and monitored by health care providers continuously.
Short conclusion
Physicians play an essential role in motivating patients and encouraging their family members to commit to a sustainable CR program with telerehabilitation to facilitate its implementation.
... HOME-BASED CR AND TELEMEDICINE. Home-based CR has been demonstrated to be similar to groupbased CR in terms of outcomes, safety, and cost, with superior adherence (84), and has gained even more importance during the coronavirus disease-2019 pandemic, with a global transition toward virtual care and telemedicine. Nonetheless, it is essential to recognize that although patients at high cardiovascular risk are also at high risk for coronavirus infection, exercise in these higher-risk patients without direct supervision is a daunting prospect, with few data to guide this approach (85). ...
Hematopoietic stem cell transplantation (HSCT) is a standard treatment for several malignancies, and >50,000 HSCT are performed annually worldwide. As survival after HSCT improves, cardiovascular disease and associated risk factors have gained importance as a significant cause of morbidity and mortality in this cohort. In this article, we detail the risk factors for cardiovascular disease and their impact in patients undergoing HSCT. Additionally, we critically review the data on the impact of physical exercise in patients undergoing HSCT. Although limited by significant heterogeneity in methodologies, small sample sizes, attrition, and lack of long-term cardiovascular follow-up, most of these studies reinforce the beneficial effects of physical activity and exercise in this patient population. Cardiac rehabilitation (CR) is a structured exercise and lifestyle modification program that is typically instituted in patients who experience acute cardiovascular events. We review the data on CR in the oncologic and nononcologic populations with an aim of building a framework for use of CR in HSCT patients.
... Further functional recovery and readmission prevention are targeted through continued outpatient rehabilitation. In addition, for patients who find it difficult to visit a hospital, continuation of rehabilitation at home is recommended (50), (51), (52) . Exercise tolerance is a prognostic factor for heart failure. ...
An increase in the number of patients with heart failure is an international health-related problem. In advanced countries, the number of such patients has rapidly increased since the beginning of the 21st century, raising an important issue regarding medical practice and public health. In 2010, the concept of "heart failure pandemic" was proposed, and it has been recognized as a global social/economic issue. In particular, the number of elderly patients with heart failure has increased with the rapid aging of society and a decrease in the number of children in Japan. A rapid increase in the number of heart failure patients increases stress and social disease-related/medical economic burdens on individuals and their families. The prognosis of patients with chronic heart failure is unfavorable, and the quality of life markedly reduces. To improve the prognosis of elderly patients with heart failure and reduce the readmission rate, the innovation of a medical-care-providing system for heart failure is required. In addition to the provision of medical practice based on a potent heart failure disease control program, manifold strategies, such as lifestyle improvements, self-care practice, cardiac rehabilitation, and environmental intervention, are essential. It is necessary to innovate hospital-based medical practice to a regional-care-system-based medical care system. In addition, to efficiently promote future heart failure strategies, an investigational study with disease registration must be conducted. Recently a new basic act on countermeasures to cardiovascular diseases has been established which may help the reform for this purpose.
... The Million Hearts Cardiac Rehabilitation Collaborative aims to increase participation rates to ≥70% by 2022 (Ritchey 2020). 18 Mobile apps and linked sensors to measure HR, respiration rate, and exercise parameters may overcome traditional limitations of availability, cost, and convenience and be more acceptable to some patients (Zwisler 2016). 19 A randomized controlled trial center-based and mobile rehabilitation found improved uptake, adherence, and completion with home-based cardiac rehabilitation in postinfarction patients (Varnfield 2014 20 ; Section 4.2.2). ...
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.
... Collaborative aims to increase participation rates to ≥70% by 2022 (Ritchey 2020). Mobile apps and linked sensors to measure heart rate, respiration rate, and exercise parameters may overcome traditional limitations of availability, cost, and convenience and be more acceptable to some patients (Zwisler 2016). A randomized controlled trial center-based and mobile rehabilitation found improved uptake, adherence, and completion with home-based cardiac rehabilitation in postinfaction patients ...
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mo- bile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and life- style management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of pre- dictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
... The Million Hearts Cardiac Rehabilitation Collaborative aims to increase participation rates to ≥70% by 2022 (Ritchey et al., 2020). Mobile apps and linked sensors to measure heart rate, respiration rate, and exercise parameters may overcome traditional limitations of availability, cost, and convenience and be more acceptable to some patients (Zwisler et al., 2016). A randomized controlled trial center-based and mobile rehabilitation found improved uptake, adherence, and completion with home-based cardiac rehabilitation in postinfarction patients (See also 4.2.2.) ...
This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.
Objective
To investigate the quality and efficacy of remote at-home rehabilitation for patients with cardiovascular disease (CVD) using personalized smart voice-based electronic prescription, and further explore the standardized health management mode of remote family cardiac rehabilitation. Trial design: A multicenter, randomized (1:1), non-blind, parallel controlled study.
Methods
A total of 171 patients with CVD who were admitted to 18 medical institutions in China from April 2021 to October 2022 were randomly divided into a treatment group (86 cases) and a control group (85 cases) in a non-blinded experiment, based on the sequence of enrollment. The control group received routine at-home rehabilitation training, and the treatment group received remote feedback-based at-home cardiac rehabilitation management based on routine at-home rehabilitation training. The primary outcome was the difference in VO 2 peak (mL/min/kg) after 12 weeks. A linear mixed model was developed with follow-up as the dependent variable. Age and baseline data were utilized as covariates, whereas hospital and patient characteristics were adjusted as random-effect variables. As the linear mixed model can accommodate missing data under the assumption of random missing data, there was no substitute missing value for quantitative data.
Results
A total of 171 participants, with 86 in the experimental group and 85 in the control group, were included in the main analysis. The analysis, which used linear mixing model, revealed significant differences in cardiopulmonary function indexes (VO 2 /kg peak, VO 2 peak, AT, METs, and maximum resistance) at different follow-up time (0, 4, and 12 weeks) in the experimental group ( p < 0.05). In the control group, there was no significant difference in cardiopulmonary values at different follow-up time (0, 4, and 12 weeks; p > 0.05). VO 2 /kg peak (LS mean 1.49, 95%CI 0.09–2.89, p = 0.037) and other indicators of cardiopulmonary function ( p < 0.05) were significantly different between the experimental group and the control group at week 12. The results were comparable in the complete case analysis.
Conclusion
The remote home cardiac rehabilitation management mode using personalized smart voice-based electronic prescription provides several benefits to patients, including improvements in muscle strength, endurance, cardiopulmonary function, and aerobic metabolism. It also helps reduce risk factors for cardiovascular disease and enhances patients’ self-management abilities and treatment compliance.
Clinical trial registration: http://www.chictr.org.cn , identifier ChiCTR2100044063.
Background:
Allogeneic blood and marrow transplantation (alloBMT) is a curative treatment for blood cancers associated with various treatment-related adverse events and morbidities. Current rehabilitation programs are limited for patients undergoing alloBMT and research is urgently needed to test the acceptability and effectiveness of these programs. In response, we developed a 6-month multidimensional longitudinal rehabilitation program that spans from pre transplant to 3 months post transplant discharge (CaRE-4-alloBMT).
Methods:
This study is a phase II randomized controlled trial (RCT) conducted at the Princess Margaret Cancer Centre in patients undergoing alloBMT. A total of 80 patients stratified by frailty score will be randomized to receive usual care (n = 40) or CaRE-4-alloBMT plus usual care (n = 40). The CaRE-4-alloBMT program includes individualized exercise prescriptions, access to online education through a dedicated self-management platform, wearable technology for remote monitoring, and remote tailored clinical support. Feasibility will be assessed by examining the recruitment and retention rates and adherence to the intervention. Safety events will be monitored. Acceptability of the intervention will be assessed through qualitative interviews. Secondary clinical outcomes will be collected through questionnaires and physiological assessments at baseline (T0, 2-6 weeks pre-transplant), transplant hospital admission (T1), hospital discharge (T2), and 3 months post-discharge (T3).
Conclusion:
This pilot RCT study will determine the feasibility and acceptability of the intervention and study design and will inform full-scale RCT planning.
Introduction
Falls among older adults are associated with adverse sequelae including fractures, chronic pain and disability, which can lead to loss of independence and increased risks of nursing home admissions. The COVID-19 pandemic has significantly increased the uptake of telehealth, but the effectiveness of virtual, home-based fall prevention programmes is not clearly known. We aim to synthesise the trials on telerehabilitation and home-based falls prevention programmes to determine their effectiveness in reducing falls and adverse outcomes, as well as to describe the safety risks associated with telerehabilitation.
Methods and analysis
This protocol was developed using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Database searches from inception to August 2022 will be conducted without language restrictions of MEDLINE, EMBASE, Ovid HealthSTAR, CINAHL, SPORTDiscus, Physiotherapy EvidenceDatabase (PEDro) and the Cochrane Library. Grey literature including major geriatrics conference proceedings will be reviewed. Using Covidence software, two independent reviewers will in duplicate determine the eligibility of randomised controlled trials (RCTs). Eligible RCTs will compare telerehabilitation and home-based fall prevention programmes to usual care among community-dwelling older adults and will report at least one efficacy outcome: falls, fractures, hospitalisations, mortality or quality of life; or at least one safety outcome: pain, myalgias, dyspnoea, syncope or fatigue. Secondary outcomes include functional performance in activities of daily living, balance and endurance. Risk of bias will be assessed using the Cochrane Collaboration tool. DerSimonian-Laird random effects models will be used for the meta-analysis. Heterogeneity will be assessed using the I ² statistic and Cochran’s Q statistic. We will assess publication bias using the Egger’s test. Prespecified subgroup analyses and univariate meta-regression will be used.
Ethics and dissemination
Ethics approval is not required. The results will be disseminated through peer-reviewed publications and conference presentations.
PROSPERO registration number
CRD42022356759.
Aims and objectives:
To evaluate the effectiveness of home-based cardiac telerehabilitation in patients with heart failure.
Design:
This systematic review and meta-analysis of randomised controlled trials were designed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Methods:
Two researchers independently screened eligible studies. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias within the included studies. A fixed- or random-effects meta-analysis model was used to determine the mean difference, based on the results of the heterogeneity test.
Data sources:
A librarian-designed search of the Cochrane Library, PubMed, Web of Science, EMBASE, CINAHL, CBM, CNKI and Wanfang databases was conducted to identify studies in English or Chinese on randomised controlled trials up to 15 August 2022.
Results:
A total of 2291 studies were screened. The meta-analysis included data from 16 studies representing 4557 participants. The results indicated that home-based cardiac telerehabilitation could improve heart rate, VO2 peak, 6-minute walk distance, quality of life and reduce readmission rates. No significant differences were observed in the left ventricular ejection fraction percentages between the home-based cardiac telerehabilitation and usual care groups. Compared with centre-based cardiac rehabilitation, home-based cardiac telerehabilitation showed no significant improvement in outcome indicators.
Conclusion:
Patients with heart failure benefit from home-based cardiac telerehabilitation intervention. With the rapid development of information and communication technology, home-based cardiac telerehabilitation has great potential and may be used as an adjunct or substitute for centre-based cardiac rehabilitation.
Impact:
This systematic review and meta-analysis found that patients with heart failure would benefit from home-based cardiac telerehabilitation intervention in terms of cardiac function, functional capacity, quality-of-life management and readmission rate. Future clinical interventions should consider home-based cardiac telerehabilitation as an alternative to conventional cardiac rehabilitation in patients with heart failure to improve their quality of life.
No patient or public contribution:
Our paper is a systematic review and meta-analysis, and such details do not apply to our work.
Objective
Baduanjin (eight silken movements) is a traditional Chinese exercise that can be used as cardiac rehabilitation therapy for patients with chronic heart failure (CHF) especially when other forms of rehabilitation are scarce or unaffordable. This study explores the experiences of Chinese patients with CHF who undertook Baduanjin exercise at home as part of a pilot trial in Guangzhou, China.
Methods
We conducted seven qualitative interviews with participants who had participated in the intervention arm of a pilot randomized controlled trial (RCT) ( n = 8). For data collection, we used a semi-structured interview guide with both open-ended, and follow-up questions. We audio recorded the interviews, transcribed them verbatim, and then analyzed them with content analysis.
Results
Participants’ experiences of doing Baduanjin were classified into three categories: (1) improving practice (2) factors facilitating good exercise adherence, and (3) feeling good. Participants reported that the exercises were easy but that the correct Baduanjin execution and coordination between the mind, movements, and breathing were only achievable through practice. In addition, the training benefits which they perceived were the predominant motivation for patients to keep practicing. Finally, trust in Baduanjin , personal attitudes toward health, flexibility in practice times, as well as social support helped the participants to achieve good adherence to home-based training.
Conclusion
This study’s findings indicate that Baduanjin could be a cardiac rehabilitation exercise modality for patients with CHF in China, especially in a home-based setting.
Many people with heart failure do not receive cardiac rehabilitation despite a strong evidence base attesting to its effectiveness, and national and international guideline recommendations. A more holistic approach to heart failure rehabilitation is proposed as an alternative to the predominant focus on exercise, emphasising the important role of education and psychosocial support, and acknowledging that this depends on patient need, choice and preference. An individualised, needs-led approach, exploiting the latest digital technologies when appropriate, may help fill existing gaps, improve access, uptake and completion, and ensure optimal health and wellbeing for people with heart failure and their families. Exercise, education, lifestyle change and psychosocial support should, as core elements, unless contraindicated due to medical reasons, be offered routinely to people with heart failure, but tailored to individual circumstances, such as with regard to age and frailty, and possibly for recipients of cardiac implantable electronic devices or left ventricular assist devices.
Currently there is a rapid progress in the new technologies development that expand the possibilities of home cardiac rehabilitation and telerehabilitation. It seems relevant to use wearable devices to monitor hemodynamic parameters, electrical activity of the heart, physical activity of patients in cardiac rehabilitation. This is especially important when monitoring the condition of elderly people and patients with comorbid conditions. The perspectives of sensors integration for assessment of not only hemodynamic parameters, but also the assessment of sensors that allow to monitor some metabolic indicators, human behavior are extremely important for cardiac patients. The use of digital technologies will significantly speed up the process of integrating cardiac rehabilitation into the general health care system. This will also allow to assess the need of high-quality medical care for the maximum of patients to whom it is indicated.
Resumen
Objetivo
Analizar los componentes de los ejercicios de entrenamiento de resistencia (ER) y evaluar los efectos de los mismos en la mejora de la fuerza muscular y el pico de consumo de oxígeno (VO2), sobre la base de la rehabilitación realizada en centros o domiciliaria en pacientes con reducción de la fracción de eyección por insuficiencia cardiaca (HFrEF).
Métodos
Conforme a las directrices del Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), se realizó una búsqueda de artículos a través de cinco bases de datos, incluyendo Embase, MEDLINE, CINAHL, PEDro y Cochrane. Para realizar el metaanálisis se utilizó el software RevMan 5.3.
Resultados
Los nueve estudios de ensayos controlados aleatorizados cumplieron los criterios del estudio, incluyendo un total de 299 respondedores. En los respondedores de los centros (n = 81 para el grupo de intervención vs. n = 81 para el grupo control), el ER produjo efectos significativos tanto en la fuerza muscular de las piernas (diferencia media estandarizada [DEM] = 1,46, IC del 95%,0,41-2,50, n = 151) como de los brazos (DEM = 0,46, IC del 95%,0,05-0,87, n = 97) y el pico de VO2 (DM = 1,45 mL/kg/min, IC del 95%, 0,01-2,89, n = 114). En los respondedores domiciliarios (n = 71 para el grupo de intervención vs. n = 66 para el grupo control), el ER produjo efectos significativos tanto en la fuerza muscular de las piernas (DEM = 0,58, IC del 95%, 0,20-0,97, n = 113) como de los brazos (DEM = 0,84, IC del 95%, 0,24-1,44, n = 47) y pico de VO2 (DM = 5,43 mL/kg/min, IC del 95%, 0,23-10,62, n = 89).
Conclusión
Los ejercicios de ER podrían incrementar la fuerza muscular y el pico de VO2 tanto en la rehabilitación en centros como domiciliario, y deberían considerarse parte de los cuidados de los pacientes de HFrEF.
Background
Cardiac rehabilitation is an evidence-based intervention that aims to improve health outcomes in cardiovascular disease patients, but it is largely underutilized. One strategy for improving utilization is home-based cardiac rehabilitation (HBCR). Previous research has shown that HBCR programs are feasible and effective. However, there is a lack of evidence on safety issues in different cardiac populations. This systematic review aimed to provide an evidence-based overview of the safety of HBCR.
Objectives
To examine the incidence and severity of adverse events of HBCR.
Methods
The following databases were searched: CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed, Web of Science, Global Health, and Chinese BioMedical Literature Database for randomized controlled trials. The included trials were written in English and analyzed the incidence of adverse events (AEs) as a primary or secondary intervention outcome.
Results
Five studies showed AEs incidence, of which only one study reported severe AE associated with HBCR exercise. The incidence rate of severe AEs from the sample (n = 808) was estimated as 1 per 23,823 patient-hour of HBCR exercise. More than half patients included were stratified into a high-risk group. In the studies were found no deaths or hospitalizations related to HBCR exercise.
Conclusion
The risk of AEs during HBCR seems very low. Our results concerning the safety of HBCR should induce cardiac patients to be more active in their environment and practice physical exercise regularly.
Digital medicine is becoming an essential part of the healthcare system. The intense development of mobile technologies, the global coverage of mobile networks, and the growing attachment in the society to mobile devices have prompted the creation of mobile healthcare (mHealth). At present, mobile healthcare technologies have been tested in various cardiovascular diseases. Among the main tasks set for telemedicine, it is necessary to note improvements of general medical care, monitoring of patients’ condition, accuracy of clinical diagnoses, timely correction of therapy, and improvement of emergency care. Clinical studies are performed in parallel with active work in the field of informational technologies to provide safety of data storage and intellectual processing. Finally, despite the broad public support for the development of this area of medicine, the search continues for methods to improve patients’ compliance with the prescribed therapy. This article presents current information about the use of mHealth in cardiology, study results, prospects of mobile healthcare, and major difficulties in implementing projects in this area.
Abstract
Introduction: Exercise is important for cardiac rehabilitation in heart failure (HF) particularly among
people with ejection fraction less than 40% due to its effects on reducing fatigue from HF pathology and
increasing functional capacity. Consequently, hospital re-admissions and mortality rates decline. However, it
is evident that many people with HF do not exercise regularly resulting from physical limitations and illness
severity causing shortness of breathing. Low perceived exercise self-efficacy was found to be associated
with nonadherence to exercise recommendation among HF patients. This article aims to demonstrate roles of
exercise, Bandura’s self-efficacy theory, nurse’s roles, and an application of exercise self-efficacy promotion
program in a case study of patient with reduced ejection fraction HF (HFrEF) including four components
which are 1) mastery experience 2) vicarious experience 3) verbal persuasion and 4) emotional arousal.
Conclusions: promoting exercise adherence is pivotal among people with HFrEF. Nurses are suggested to
promote exercise self-efficacy and exercise adherence using self-efficacy theory among these patients.
In the spring of 2020, we faced a global pandemic that resulted in social distancing limitations not previously experienced, forcing practitioners to adapt exercise programming to a virtual model. The purpose of this investigation was to measure the effectiveness of a virtual exercise oncology program in 491 participants undergoing antineoplastic therapy between March and June 2020. Each session was completed virtually with a certified exercise oncology trainer. Fitness and psychological parameters were measured preexercise and postexercise intervention. Overall, participants completed 4949 of 5892 prescribed exercise sessions. Patients saw increases in cardiovascular endurance (15.2%, P < 0.05), muscular endurance (18.2%, P < 0.05), flexibility (31.9%, P < 0.05), feelings of support (58.7%, P < 0.05), and quality of life (32.2%, P < 0.05), as well as decreases in loneliness (54%, P < 0.05) and fatigue (48.7%, P < 0.05). In light of our findings, we assert that virtual exercise training is a viable option in circumstances where in-person, individualized exercise training is not possible.
BACKGROUND: The aim of this study was to undertake a comprehensive assessment of the patient, intervention and trial-level factors that may predict exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure.
DESIGN: Meta-analysis and meta-regression analysis.
METHODS: Randomized controlled trials of exercise-based rehabilitation were identified from three published systematic reviews. Exercise capacity was pooled across trials using random effects meta-analysis, and meta-regression used to examine the association between exercise capacity and a range of patient (e.g. age), intervention (e.g. exercise frequency) and trial (e.g. risk of bias) factors.
RESULTS: 55 trials (61 exercise-control comparisons, 7553 patients) were included. Following exercise-based rehabilitation compared to control, overall exercise capacity was on average 0.95 (95% CI: 0.76-1.41) standard deviation units higher, and in trials reporting maximum oxygen uptake (VO2max) was 3.3 ml/kg.min(-1) (95% CI: 2.6-4.0) higher. There was evidence of a high level of statistical heterogeneity across trials (I(2) statistic > 50%). In multivariable meta-regression analysis, only exercise intervention intensity was found to be significantly associated with VO2max (P = 0.04); those trials with the highest average exercise intensity had the largest mean post-rehabilitation VO2max compared to control.
CONCLUSIONS: We found considerable heterogeneity across randomized controlled trials in the magnitude of improvement in exercise capacity following exercise-based rehabilitation compared to control among patients with coronary heart disease or heart failure. Whilst higher exercise intensities were associated with a greater level of post-rehabilitation exercise capacity, there was no strong evidence to support other intervention, patient or trial factors to be predictive.
Introduction:
The Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) trial is part of a research programme designed to develop and evaluate a health professional facilitated, home-based, self-help rehabilitation intervention to improve self-care and health-related quality of life in people with heart failure and their caregivers. The trial will assess the clinical effectiveness and cost-effectiveness of the REACH-HF intervention in patients with systolic heart failure and impact on the outcomes of their caregivers.
Methods and analysis:
A parallel two group randomised controlled trial with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention group) or usual care alone (control group) in 216 patients with systolic heart failure (ejection fraction <45%) and their caregivers. The intervention comprises a self-help manual delivered by specially trained facilitators over a 12-week period. The primary outcome measure is patients' disease-specific health-related quality of life measured using the Minnesota Living with Heart Failure questionnaire at 12 months' follow-up. Secondary outcomes include survival and heart failure related hospitalisation, blood biomarkers, psychological well-being, exercise capacity, physical activity, other measures of quality of life, patient safety and the quality of life, psychological well-being and perceived burden of caregivers at 4, 6 and 12 months' follow-up. A process evaluation will assess fidelity of intervention delivery and explore potential mediators and moderators of changes in health-related quality of life in intervention and control group patients. Qualitative studies will describe patient and caregiver experiences of the intervention. An economic evaluation will estimate the cost-effectiveness of the REACH-HF intervention plus usual care versus usual care alone in patients with systolic heart failure.
Ethics and dissemination:
The study is approved by the North West-Lancaster Research Ethics Committee (ref 14/NW/1351). Findings will be disseminated via journals and presentations to publicise the research to clinicians, commissioners and service users.
Trial registration number:
ISRCTN86234930; Pre-results.
Exercise is known to be beneficial for patients with heart failure (HF), and these patients should therefore be routinely advised to exercise and to be or to become physically active. Despite the beneficial effects of exercise such as improved functional capacity and favourable clinical outcomes, the level of daily physical activity in most patients with HF is low. Exergaming may be a promising new approach to increase the physical activity of patients with HF at home. The aim of this study is to determine the effectiveness of the structured introduction and access to a Wii game computer in patients with HF to improve exercise capacity and level of daily physical activity, to decrease healthcare resource use, and to improve self-care and health-related quality of life.
A multicentre randomized controlled study with two treatment groups will include 600 patients with HF. In each centre, patients will be randomized to either motivational support only (control) or structured access to a Wii game computer (Wii). Patients in the control group will receive advice on physical activity and will be contacted by four telephone calls. Patients in the Wii group also will receive advice on physical activity along with a Wii game computer, with instructions and training. The primary endpoint will be exercise capacity at 3 months as measured by the 6 min walk test. Secondary endpoints include exercise capacity at 6 and 12 months, level of daily physical activity, muscle function, health-related quality of life, and hospitalization or death during the 12 months follow-up.
The HF-Wii study is a randomized study that will evaluate the effect of exergaming in patients with HF. The findings can be useful to healthcare professionals and improve our understanding of the potential role of exergaming in the treatment and management of patients with HF.
NCT01785121.
© 2015 The Authors. European Journal of Heart Failure © 2015 European Society of Cardiology.
Full text of letter at: http://www.bmj.com/content/316/7129/469
Although the concept is useful, the method proposed by Egger et al to detect bias in meta-analyses is itself biased1: it overestimates the occurrence and extent of publication bias. This is easily shown by simulating data for a meta-analysis of a hypothetical intervention that is effective (and therefore has a negative regression coefficient by Egger et al's method) and is free of publication bias (and hence should have an intercept of zero in the regression analysis).
In our simulations, each study was of a treated group and a control group, both of equal size. For each simulated meta-analysis, studies ranging from 100 per group to 1000 per group, in increments of 100, were generated. The observed number of events in each group was generated from a binomial distribution.
Here is one example in which the true event rate is 40% in the control group and 10% in the treatment group. When the true population values (which would not be known in practice) are used to estimate precision, the regression coefficient is −1.7942 (an estimated log odds ratio equivalent to the expected value of 0.1667) and the intercept (0.0380, P=0.1) is close to the expected value of zero, reflecting the lack of publication bias. However, the regression coefficient estimated when the precision is based on the observed values, as would occur using Egger et al's method, is −1.7169. More importantly, the intercept is −0.4492 and significant (P<0.0001), incorrectly suggesting that there has been publication bias. In general, our other simulations suggest that the bias in the estimated intercept is greater the more effective the intervention actually is and the smaller the sample size of the studies.
This problem has several causes. Firstly, the estimates of precision are subject to random error due to sampling variability. This regression-dilution bias causes the regression slope to “tilt” around the mean of the predictor and response variables so that its coefficient is closer to zero; this in turn leads to the intercept becoming negative.2 Secondly, the estimated standardised log odds ratio is correlated with the estimated precision. Thirdly, the precision estimated by the method that we assume Egger et al used3 is a biased estimate of the true precision, with the degree of bias increasing as sample size decreases.4
Clearly, until the causes of the problems we have outlined are better elucidated and solutions developed, one cannot rely on the method proposed by Egger et al to detect publication bias.
ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (CPG Chairperson) (The Netherlands), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Bogdan A. Popescu (Romania), Z. eljko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland). Document Reviewers: Theresa McDonagh (CPG Co-Review Coordinator) (UK), Udo Sechtem (CPG Co-Review Coordinator) (Germany), Luis Almenar Bonet (Spain), Panayiotis Avraamides (Cyprus), Hisham A. Ben Lamin (Libya), Michele Brignole (Italy), Antonio Coca (Spain), Peter Cowburn (UK), Henry Dargie (UK), Perry Elliott (UK), Frank Arnold Flachskampf (Sweden), Guido Francesco Guida (Italy), Suzanna Hardman (UK), Bernard Iung (France), Bela Merkely (Hungary), Christian Mueller (Switzerland), John N. Nanas (Greece), Olav Wendelboe Nielsen (Denmark), Stein Orn (Norway), John T. Parissis (Greece), Piotr Ponikowski (Poland). The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
To determine why so few patients with chronic heart failure in England, Wales and Northern Ireland take part in cardiac rehabilitation.
Two-stage, postal questionnaire-based national survey.
Stage 1: 277 cardiac rehabilitation centres that provided phase 3 cardiac rehabilitation in England, Wales and Northern Ireland registered on the National Audit of Cardiac Rehabilitation register. Stage 2: 35 centres that indicated in stage 1 that they provide a separate cardiac rehabilitation programme for patients with heart failure.
Full data were available for 224/277 (81%) cardiac rehabilitation centres. Only 90/224 (40%) routinely offered phase 3 cardiac rehabilitation to patients with heart failure. Of these 90 centres that offered rehabilitation, 43% did so only when heart failure was secondary to myocardial infarction or revascularisation. Less than half (39%) had a specific rehabilitation programme for heart failure. Of those 134 centres not providing for patients with heart failure, 84% considered a lack of resources and 55% exclusion from commissioning contracts as the reason for not recruiting patients with heart failure. Overall, only 35/224 (16%) centres provided a separate rehabilitation programme for people with heart failure.
Patients with heart failure as a primary diagnosis are excluded from most cardiac rehabilitation programmes in England, Wales and Northern Ireland. A lack of resources and direct exclusion from local commissioning agreements are the main barriers for not offering rehabilitation to patients with heart failure.
Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
Are anxiety and depression correlated with physical function, disability, and quality of life in people with chronic heart failure? Does 8 weeks of home-based exercise improve anxiety, depression, physical function, disability, and quality of life in these patients? Do the changes in these outcomes correlate?
Randomised trial.
51 people with clinically stable chronic heart failure were randomised into an experimental group (n=24) or a control group (n=27).
The experimental group undertook an individualised home-based exercise program, 30 minutes per session, 3 sessions per week for 8 weeks, with regular telephone follow-up and consultations. The control group maintained their usual activity during this period.
The Hospital Anxiety and Depression Scale, six-minute walk test, Groningen Activity Restriction Scale, and Minnesota Living with Heart Failure Questionnaire were administered at baseline and 8 weeks.
At baseline, anxiety and depression were inversely moderately correlated with walking distance, activity, and quality of life. Compared with controls, the experimental group improved significantly more in their walking distance (by 21m, 95% CI 7 to 36) and their quality of life (by 7 points on the 105-point Minnesota score, 95% CI 1 to 12). In the experimental group, the changes in quality of life correlated moderately strongly with changes in anxiety (r=0.539, p=0.01).
Anxiety and depression were associated with physical function, disability, and quality of life in people with chronic heart failure. Home-based exercise improved quality of life and physical function significantly but not psychological status in these patients.
ClinicalTrials.gov: NCT01197313.
In heart failure, reduced physical activity level can adversely affect physical and psychosocial functioning. No previous heart failure research has compared effects of home and hospital-based exercise training upon physical activity level, or has objectively assessed their long-term effects upon physical activity. This study used an activPAL™ monitor to examine immediate and long-term effects of home and hospital-based aerobic exercise training upon physical activity level.
Randomized controlled trial.
Sixty patients with heart failure (mean age 66 years; NYHA class II/III; 51 male/9 female) were randomized to home training, hospital training or control. Both programmes consisted of aerobic circuit training, undertaken twice a week for one hour, for eight weeks. All participants wore the activPAL™ at baseline, and after eight weeks, for one week. Six months after cessation of training, a subgroup of participants from the home and hospital training groups (n = 10 from each group) wore the activPAL™ for a further week.
Hospital-based training significantly increased steps taken per day during 'extra long' (P = 0.04) and 'long' (P = 0.01) walks. Neither programme had any immediate effect upon physical activity level otherwise. Though daily upright duration for the home group significantly improved six months after cessation of training (P = 0.02), generally physical activity level was maintained in the long term for both training groups.
Hospital-based training enabled participants to walk for longer periods. It is clinically important that both training groups maintained physical activity level in the long term, given the potential for heart failure to worsen over this time period.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Despite proven benefits of cardiac rehabilitation (CR), currently proposed CR models are not acceptable for many heart failure (HF) patients. The purpose of this study was to evaluate a new model of home-based telemonitored cardiac rehabilitation (HTCR) using walking training compared with an outpatient-based standard cardiac rehabilitation (SCR) using interval training on a cycle ergometer.
The study included 152 HF patients (aged 58.1 + or - 10.2 years, NYHA class II and III, ejection fraction < or = 40%) who were randomized to HTCR (n = 77) or SCR (n = 75). All patients underwent 8 weeks of CR. Both groups were comparable in terms of demographic and clinical characteristics and medical therapy. The effectiveness of CR was assessed by changes in NYHA class, peak oxygen consumption, 6-min walking test distance, and SF-36 score. Cardiac rehabilitation resulted in a significant improvement of all parameters in both groups. All patients in the HTCR group completed the 8 weeks of CR, whereas 15 patients in the SCR group (20%) discontinued CR.
In patients with HF, HTCR is equally as effective as SCR and provides a similar improvement in quality of life. Adherence to CR seems to be better for HTCR. Home-based telemonitored cardiac rehabilitation may be a useful alternative form of CR in patients with HF.
Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses.
Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews.
Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision.
In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias.
A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.
To determine the effect of exercise training on survival in patients with heart failure due to left ventricular systolic dysfunction.
Collaborative meta-analysis. Inclusion criteria Randomised parallel group controlled trials of exercise training for at least eight weeks with individual patient data on survival for at least three months. Studies reviewed Nine datasets, totalling 801 patients: 395 received exercise training and 406 were controls.
Death from all causes.
During a mean (SD) follow up of 705 (729) days there were 88 (22%) deaths in the exercise arm and 105 (26%) in the control arm. Exercise training significantly reduced mortality (hazard ratio 0.65, 95% confidence interval, 0.46 to 0.92; log rank chi(2) = 5.9; P = 0.015). The secondary end point of death or admission to hospital was also reduced (0.72, 0.56 to 0.93; log rank chi(2) = 6.4; P = 0.011). No statistically significant subgroup specific treatment effect was observed.
Meta-analysis of randomised trials to date gives no evidence that properly supervised medical training programmes for patients with heart failure might be dangerous, and indeed there is clear evidence of an overall reduction in mortality. Further research should focus on optimising exercise programmes and identifying appropriate patient groups to target.
Background
Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review originally published in 2009.
Objectives
To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.
Search methods
To update searches from the previous Cochrane review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 9, 2014), MEDLINE (Ovid, 1946 to October week 1 2014), EMBASE (Ovid, 1980 to 2014 week 41),PsycINFO (Ovid, 1806 to October week 2 2014), and CINAHL (EBSCO, to October 2014). We checked reference lists of included trials and recent systematic reviews. No language restrictions were applied.
Selection criteria
Randomised controlled trials (RCTs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction (MI), angina, heart failure or who had undergone revascularisation.
Data collection and analysis
Two authors independently assessed the eligibility of the identified trials and data were extracted by a single author and checked by a second. Authors were contacted where possible to obtain missing information.
Main results
Seventeen trials included a total of 2172 participants undergoing cardiac rehabilitation following an acute MI or revascularisation, or with heart failure. This update included an additional five trials on 345 patients with hear t failure. Authors of a number of included trials failed to give sufficient detail to assess their potential risk of bias, and details of generation and concealment of random allocation sequence were particularly poorly reported. In the main, no difference was seen between home- and centre-based cardiac rehabilitation in outcomes up to 12 months of follow up: mortality (relative risk (RR) = 0.79, 95% confidence interval (CI) 0.43 to 1.47, P = 0.46, fixed-effect), cardiac events (data not poolable), exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.29 to 0.08,P = 0.29, random-effects), modifiable risk factors (total cholesterol: mean difference (MD) = 0.07 mmol/L, 95% CI -0.24 to 0.11, P= 0.47, random-effects; low density lipoprotein cholesterol: MD = -0.06 mmol/ L, 95% CI -0.27 to 0.15, P = 0.55, random-effects;systolic blood pressure: mean difference (MD) = 0.19 mmHg, 95% CI -3.37 to 3.75, P = 0.92, random-effects; proportion of smokers at follow up (RR = 0.98, 95% CI 0.79 to 1.21, P = 0.83, fixed-effect), or health-related quality of life (not poolable). Small outcome differences in favour of centre-based participants were seen in high density lipoprotein cholesterol (MD = -0.07 mmol/ L, 95% CI -0.11 to -0.03, P = 0.001, fixed-effect), and triglycerides (MD = -0.18 mmol/L, 95% CI -0.34 to -0.02, P = 0.03, fixed-effect, diastolic blood pressure (MD = -1.86 mmHg; 95% CI -0.76 to -2.95, P = 0.0009, fixed-effect). In contrast, in home-based participants, there was evidence of a marginally higher levels of programme completion (RR = 1.04, 95% CI 1.01 to 1.07, P = 0.009, fixed-effect) and adherence to the programme (not poolable). No consistent difference was seen in healthcare costs between the two forms of cardiac rehabilitation.
Authors’ conclusions
This updated review supports the conclusions of the previous version of this review that home- and centre-based forms of cardiac rehabilitation se em to be equally effective for improving the clinical and health-related quality of life outcomes in low risk patients after MI or revascularisation, or with heart failure. This finding, together with the absence of evidence of important differences inhealthcare costs between the two approaches, supports the continued expansion of evidence-based, home-based cardiac rehabilitationprogrammes. The choice of par ticipating in a more traditional and supervised centre-based programme or a home-based pr ogrammeshould reflect the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in these short-term trials can be confirmed in the longer term. A number of studies failed to givesufficient detail to assess their risk of bias.
In heart failure (HF), exercise training programmes (ETPs) are a well-recognized intervention to improve symptoms, but are still poorly implemented. The Heart Failure Association promoted a survey to investigate whether and how cardiac centres in Europe are using ETPs in their HF patients.
The co-ordinators of the HF working groups of the countries affiliated to the European Society of Cardiology (ESC) distributed and promoted the 12-item web-based questionnaire in the key cardiac centres of their countries. Forty-one country co-ordinators out of the 46 contacted replied to our questionnaire (89%). This accounted for 170 cardiac centres, responsible for 77 214 HF patients. The majority of the participating centres (82%) were general cardiology units and the rest were specialized rehabilitation units or local health centres. Sixty-seven (40%) centres [responsible for 36 385 (48%) patients] did not implement an ETP. This was mainly attributed to the lack of resources (25%), largely due to lack of staff or lack of financial provision. The lack of a national or local pathway for such a programme was the reason in 13% of the cases, and in 12% the perceived lack of evidence on safety or benefit was cited. When implemented, an ETP was proposed to all HF patients in only 55% of the centres, with restriction according to severity or aetiology.
With respect to previous surveys, there is evidence of increased availability of ETPs in HF in Europe, although too many patients are still denied a highly recommended therapy, mainly due to lack of resources or logistics.
© 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.
Purpose:
Although strategies exist for improving cardiac rehabilitation (CR) participation rates, it is unclear how frequently these strategies are used and what efforts are being made by CR programs to improve participation rates.
Methods:
We surveyed all CR program directors in the American Association of Cardiovascular and Pulmonary Rehabilitation's database. Data collection included program characteristics, the use of specific referral and recruitment strategies, and self-reported program participation rates.
Results:
Between 2007 and 2012, 49% of programs measured referral of inpatients from the hospital, 21% measured outpatient referral from office/clinic, 71% measured program enrollment, and 74% measured program completion rates. Program-reported participation rates (interquartile range) were 68% (32-90) for hospital referral, 35% (15-60) for office/clinic referral, 70% (46-80) for enrollment, and 75% (62-82) for program completion. The majority of programs utilized a hospital-based systematic referral, liaison-facilitated referral, or inpatient CR program referral (64%, 68%, and 60% of the time, respectively). Early appointments (<2 weeks) were utilized by 35%, and consistent phone call appointment reminders were utilized by 50% of programs. Quality improvement (QI) projects were performed by about half of CR programs. Measurement of participation rates was highly correlated with performing QI projects (P < .0001.)
Conclusions:
: Although programs are aware of participation rate gaps, the monitoring of participation rates is suboptimal, QI initiatives are infrequent, and proven strategies for increasing patient participation are inconsistently utilized. These issues likely contribute to the national CR participation gap and may prove to be useful targets for national QI initiatives.
We conducted a literature review of telerehabilitation interventions on cardiac patients. We searched for studies evaluating some form of telerehabilitation in cardiac patients. A total of 116 publications were screened initially, of which 37 publications were eligible for further review. We assessed study strength, based on the level of evidence and the quality of the intervention. The majority of the articles (70%) represented the highest level of evidence. Most interventions were of good (46%) or fair (51%) quality. Most studies evaluated the efficacy of the telerehabilitation interventions (84%), while 38% reported on feasibility and acceptance. Most studies did not include safety and/or cost-benefit analyses. Most telerehabilitation interventions (90%) employed only one or two core components of cardiac rehabilitation (CR). Of the CR core components, physical activity was most frequently evaluated. Telerehabilitation appears to be a feasible and effective additional and/or alternative form of rehabilitation, compared to conventional in-hospital CR. Evaluations of telerehabilitation programmes taking into account patient safety and health economics are now required.
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Purpose:
Although participation in either center- or home-based cardiac rehabilitation (CR) can improve exercise capacity, the sustainability of this improvement following completion of the CR program is challenging. The purpose of this study was to compare the immediate and 1-year effectiveness of center- versus home-based CR on exercise capacity in cardiac patients who were given the choice of participating in a center-based or home-based CR program.
Methods:
This was a retrospective study, which relied on the database from a large multidisciplinary CR program. A sample of 3488 cardiac patients participated either in center-based (n = 2803) or home-based (n = 685) CR. Participants underwent exercise testing at baseline, after 12 weeks of CR and again 1 year after completion of the CR programs.
Results:
Following CR, exercise capacity (ie, peak metabolic equivalents [METs]) increased significantly in both groups (P < .05). From post-CR to the 1-year followup, exercise capacity remained unchanged in home-based CR participants (P = .183), whereas the center-based CR group demonstrated a decline in exercise capacity (P < .05).
Conclusions:
Although at the 1-year followup exercise capacity decreased in the center-based group, the observed decline did not seem to be clinically significant. The present findings indicate that when the patients were given a choice as to the delivery model (center- vs home-based) used for their CR program, they were relatively successful in retaining the improvement in exercise capacity 1 year post-CR irrespective of the exact location for their exercise training.
Introduction:
We conducted a systematic review to assess the effect of exercise training in patients with heart failure with preserved ejection fraction (HFPEF).
Methods:
A number of electronic databases were searched up to November 2011 to identify comparative studies of exercise training in HFPEF. Where possible, outcome data from included studies were pooled using meta-analysis.
Results:
Three randomised controlled trials, one non-randomised controlled trial and one pre-post study were included, for a total of 228 individuals. The combined duration of exercise programmes and follow-up ranged from 12 to 24 weeks. No deaths, hospital admissions or serious adverse events were observed during or immediately following exercise training. Compared to control, the change in exercise capacity at follow-up was higher with exercise training (between group mean difference: 3.0 ml/kg/min, 95% CI: 2.4 to 2.6). In the four studies, that reported the Minnesota Living with Heart Failure questionnaire, there was evidence of a larger gain in health-related quality of life with exercise training (7.3 units, 3.3 to 11.4). The largest study showed some evidence of improvement in the E/E' ratio with exercise training, but this was not confirmed in the other studies (overall -0.9, -3.8 to 2.0); E/A ratios were not changed.
Conclusions:
Exercise training for patients with HFPEF confers benefit in terms of enhancements in exercise capacity and health-related quality of life and appears to be safe. The impact on diastolic function remains unclear. Further trials should provide data on long term effects, prognostic relevance and cost-effectiveness.