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Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis

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... In patients with HF, point estimates were reported in 12 CR meta-analyses [38][39][40][41][42][43][44][45][46][47][48][49]. The active intervention in 11 of these meta-analyses was EBCR [38][39][40][41][42][43][44][45][46][47][48] and HBCR in one [49]. ...
... In patients with HF, point estimates were reported in 12 CR meta-analyses [38][39][40][41][42][43][44][45][46][47][48][49]. The active intervention in 11 of these meta-analyses was EBCR [38][39][40][41][42][43][44][45][46][47][48] and HBCR in one [49]. ...
... Ten CR meta-analyses reported all-cause mortality as an outcome, four in patients with CHD [10,26,29,30], one in patients with angina [37] and five in patients with HF [39,41,43,46,49]. Two of these ten meta-analyses also reported future science group www.futuremedicine.com ...
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Aim: The aim of the project was to conduct a systematic review of meta-analyses of supervised, home-based or telemedicine-based exercise cardiac rehabilitation (CR) published between July 2011 and April 2018. Materials & methods: Evidence on mortality, hospitalization, peak VO2, exercise capacity, muscle strength and health-related quality of life in patients with coronary heart disease or heart failure referred to CR was obtained by searching six electronic databases. Results: Of the 127 point estimates identified in the 30 CR meta-analyses identified (mortality, n = 12; hospitalization, n = 11; VO2, n = 40; exercise capacity, n = 20; strength, n = 18; health-related quality of life, n = 26), 60% were statistically significant and 35% clinically important. Conclusion: The statistical data are sufficiently robust to promote strategies to improve referral to and participation in CR although evidence for clinical importance needs to be further investigated.
... 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]. ...
Article
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.
... 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] . ...
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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. ...
Article
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.
... 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 ...
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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.
... A study reported 39% of cardiac centers surveyed did not implement exercise rehabilitation for HF patients (Zwisler et al., 2016). Moreover, most severely impaired patients with an New York Heart Association (NYHA) class III/IV have limited physical activity and less adherence to conventional exercise training programs (Smart et al., 2013); for these reasons, home-based IMT programs supervised by nurses and other healthcare professionals have been recommended as a safe, flexible, and adjuvant treatment of pharmacologic interventions in HF patients (Pihl, Cider, Strömberg, Fridlund, & Mårtensson, 2011;Smart et al., 2013). ...
... Moreover, most severely impaired patients with an New York Heart Association (NYHA) class III/IV have limited physical activity and less adherence to conventional exercise training programs (Smart et al., 2013); for these reasons, home-based IMT programs supervised by nurses and other healthcare professionals have been recommended as a safe, flexible, and adjuvant treatment of pharmacologic interventions in HF patients (Pihl, Cider, Strömberg, Fridlund, & Mårtensson, 2011;Smart et al., 2013). Despite its underuse in clinical practice (Montemezzo et al., 2014), IMT therapy may be an alternative treatment modality for patients who cannot engage in center-based exercise training programs (Padula, Yeaw, & Mistry, 2009;Zwisler et al., 2016). ...
Article
Aim: Fatigue and dyspnea are debilitating symptoms in patients with heart failure (HF). The purpose of this study was to evaluate the effects of inspiratory muscle training (IMT) on dyspnea, fatigue and the New York Heart Association (NYHA) functional classification in patients with HF. Methods: In this prospective, randomized, controlled trial, 84 patients with HF (NYHA classes II-III/IV) with a mean age of 56.62 ± 9.56 years were randomly assigned to a 6-week IMT (n = 42) or a sham IMT (n = 42) program. The IMT was performed at 40% of the maximal inspiratory pressure (MIP) in the IMT group and at 10% in the sham group. The main outcomes were assessed at baseline and after the intervention and included dyspnea severity scale (Modified Medical Research Council [MMRC], Fatigue Severity Scale [FSS] and the NYHA functional classification (based on the presenting symptoms). Results: The between-group analysis showed significant improvements in dyspnea, fatigue and the NYHA functional classification in the IMT group compared to the sham group (P < .05). The within-group analysis showed significant improvements in dyspnea (from 2.63 ± 0.79 to 1.38 ± 0.66, P < .001), fatigue (from 43.36 ± 8.5 to 28.95 ± 9.11, P < .001) and the NYHA functional classification (from 2.73 ± 0.5 to 2.1 ± 0.6, P = .001) in the IMT group, while fatigue and dyspnea increased significantly in the sham group. Conclusions: The 6-week home-based IMT was found to be an effective and safe tool for reducing dyspnea and fatigue and improving the NYHA functional classification.
... 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). ...
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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.
... We evaluated the risk of bias in studies by using Cochrane Risk of Bias Tool for RCTs. 19 We reviewed studies for evidence of balance in baseline characteristics of groups. The risk of bias was assessed by each reviewer (M.B. and H.I.) independently (Table S2) for all studies. ...
Article
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Background Center‐based cardiac rehabilitation ( CBCR ) has been shown to improve outcomes in patients with heart failure ( HF ). Home‐based cardiac rehabilitation ( HBCR ) can be an alternative to increase access for patients who cannot participate in CBCR . Hybrid cardiac rehabilitation ( CR ) combines short‐term CBCR with HBCR, potentially allowing both flexibility and rigor. However, recent data comparing these initiatives have not been synthesized. Methods and Results We performed a meta‐analysis to compare functional capacity and health‐related quality of life (hr‐ QOL ) outcomes in HF for (1) HBCR and usual care, (2) hybrid CR and usual care, and (3) HBCR and CBCR . A systematic search in 5 standard databases for randomized controlled trials was performed through January 31, 2019. Summary estimates were pooled using fixed‐ or random‐effects (when I ² >50%) meta‐analyses. Standardized mean differences (95% CI ) were used for distinct hr‐ QOL tools. We identified 31 randomized controlled trials with a total of 1791 HF participants. Among 18 studies that compared HBCR and usual care, participants in HBCR had improvement of peak oxygen uptake (2.39 mL/kg per minute; 95% CI , 0.28–4.49) and hr‐ QOL (16 studies; standardized mean difference: 0.38; 95% CI , 0.19–0.57). Nine RCT s that compared hybrid CR with usual care showed that hybrid CR had greater improvements in peak oxygen uptake (9.72 mL/kg per minute; 95% CI , 5.12–14.33) but not in hr‐ QOL (2 studies; standardized mean difference: 0.67; 95% CI , −0.20 to 1.54). Five studies comparing HBCR with CBCR showed similar improvements in functional capacity (0.0 mL/kg per minute; 95% CI, −1.93 to 1.92) and hr‐ QOL (4 studies; standardized mean difference: 0.11; 95% CI , −0.12 to 0.34). Conclusions HBCR and hybrid CR significantly improved functional capacity, but only HBCR improved hr‐ QOL over usual care. However, both are potential alternatives for patients who are not suitable for CBCR .
... Moreover, patients' adherence to CR programs is not satisfactory. Home-based models have been developed to overcome obstacles such as distance as well as time constraints 29,30,31,32,33,34,35 . Tele-CR has been shown to be as effective as conventional facility-based CR 31,36 .A meta-analysis comparing home-based to facility-based CR, examining exercise capacity, modifiable risk factors (blood pressure, blood lipid concentrations, and smoking), QoL, and cardiac events showed no differences in outcomes for those receiving home-based as opposed to facility-based rehabilitation in either the short term (<12 months) or long term (>12 months) 37 . ...
Article
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Despite the evidence that cardiac rehabilitation (CR) reduces the risk of recurrent cardiac events, only a minority of eligible patients are willing to join existing programs at cardiac rehabilitation centers. The unique remote patient monitoring system presented here enables healthcare providers to monitor CR patients at home in real-time and at low cost. The system combines mobile technology, artificial intelligence, and supportive services, expanding the delivery of medical care to the patient's home. The primary aim of the study is to increase the long-term adherence to physical activity in patients who participate in CR via the addition of a home-based digitally monitored CR component to the standard CR program in patients with ischemic heart disease (IHD), with the idea of forming new habitual health behaviors and increasing the long-term motivation for physical exercise (PE) habits at home. Secondary aims are to assess the program's impact on the physical activity level measured by average steps per day, minutes of exercise per week, blood pressure, metabolic parameters, body mass index, and waist-to-hip ratio, as well as a quality-of-life (QoL) questionnaire.The study has two arms: (1) home-based monitored exercise using a smart digital garment and wristband, in addition to motivation and reinforcement via text messages; (2) standard CR facility-based exercise. The study design is a randomized, controlled trial comparing standard CR to a home-based monitoring and reinforcement program. The study program is designed for 12 weeks.Clinical tests and anthropometric measurements are performed before and after the study, measuring height, weight, waist circumference, visceral fat and body mass index (BMI), blood pressure, and HbA1c and lipid profile. Patients have to complete a baseline survey including socio-demographic characteristics and QoL questionnaire SF-36. At the end of the study, patients complete a survey regarding the use of the smart digital garment's benefits and usability. The study is currently underway.
... 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.) ...
Article
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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.
... 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). ...
Article
Full-text available
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.
... The Million Hearts Cardiac Rehabilitation 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 (See also Section 4.2.2.). ...
Article
Full-text available
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.
... Otro aspecto que tener en cuenta son los programas domiciliarios, actualmente supervisados y dirigidos en muchos casos, con nuevas tecnologías. Estos programas también se han demostrado efectivos en pacientes con IC, aunque todavía hay poca experiencia 22,23 . En los centros donde esté disponible y haya experiencia, los pacientes con IC de bajo riesgo podrán ser incluidos en programas domiciliarios de RC dependientes de unidades de RC estructuradas. ...
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Consenso de expertos en la coordinación de la rehabilitación cardiaca entre cardiología y atención primaria Consenso de expertos en la asistencia multidisciplinaria y el abordaje integral de la insuficiencia cardiaca. Desde el alta hospitalaria hasta la continuidad asistencial con primaria INTRODUCCIÓN La insuficiencia cardiaca (IC) es una enfermedad crónica que, por sus elevadas y crecientes prevalencia e incidencia, se considera una auténtica epidemia de nuestro siglo. Constituye uno de los grandes síndromes cardiovasculares cuya incidencia continúa en aumento debido al progresivo envejecimiento de la población y el mejor pro-nóstico de los pacientes con cardiopatía. Un 2% de la población adulta padece IC, una prevalencia que aumenta enormemente con la edad, pues es < 1% antes de los 50 años y aumenta hasta superar el 16% entre los mayores de 75 años 1. La historia natural de la IC está caracte-rizada por las descompensaciones, que habitualmente requieren hos-pitalización. En España, como en otros países industrializados, la IC es la primera causa de hospitalización de los mayores de 65 años 2. Las defunciones totales con un diagnóstico de IC en España en el año 2016 superaron las 17.000 (quinta causa de mortalidad), de las cuales el 73% se registraron en el hospital. Además, suponen un 15% de las muertes por causas cardiovasculares 3. RESUMEN La insuficiencia cardiaca es una enfermedad que precisa un tratamiento multidisciplinario, dadas la diversidad de causas y entornos clínicos implicados que las tratan y las diferentes estrategias terapéuticas que precisan la participación indispensable de diversas disciplinas. La presencia en los servicios de cardiología de unidades de insuficiencia cardiaca centradas en el tratamiento de los pacientes con esta afección y unidades de rehabilitación cardiaca que, entre sus indicaciones para la reducción de la morbimortalidad, también están implicadas en la atención de esos mismos pacientes puede causar dificultades de coordinación y pérdida de una atención integral centrada en el paciente. Por estos motivos, en el presente documento se plantea una estrategia de coordinación entre las diferentes unidades implicadas en el tratamiento de los pacientes dentro de los servicios de cardiología y la continuidad asistencial con atención primaria, tanto tras haber conseguido la estabilidad como la interrelación para una coordinación posterior más efectiva. Expert consensus on multidisciplinary management and integrated approaches in heart failure. Continuity of care from hospital discharge to primary care ABSTRACT Heart failure is a condition that requires a multidisciplinary approach to treatment because of the wide range of causes and clinical contexts that may be involved and because the diverse treatment strategies used necessitate the participation of multiple disciplines. In cardiology departments, the presence of both heart failure units that focus on the treatment of affected patients and cardiac rehabilitation units that, as well as targeting reductions in morbidity and mortality, are also involved in caring for the same patients can create difficulties for coordination and can result in the loss of comprehensive patient-centered care. For these reasons, this paper presents a strategy for coordinating the different units involved in patient management in cardiology departments and for ensuring continuity of care in primary care, both immediately after achieving stabilization and subsequently, when these interactions are important for effective coordination. Document downloaded from http://www.revespcardiol.org/, day 01/07/
... Home-based interventions were proven to be successful in both cost terms and clinical effectiveness in many long-term conditions, [22,23] especially in the context of resource constrained countries. Patient empowerment models are suggested for effective Control of hypertension in such countries. ...
Article
Aim: To investigate the effect of nurse-led home-based biofeedback intervention on the blood pressure levels among patients with hypertension. Background: Nurse-led interventions are emerging as cost-effective as well as clinically proven in chronic illness management. Hypertension, a leading long-term cardiovascular condition, has autonomic dysregulation and increased sympathetic tone as its pathophysiological background. Complementary interventions evidenced to interplay hypertension pathophysiology. Design: A pretest-posttest design. Materials and methods: Uncomplicated primary hypertension outpatients were randomly assigned as study group (n = 173) and control group (n = 173) at a tertiary care hospital. Sociodemographic, clinical, and outcome variables [the baseline blood pressure and galvanic skin response (GSR)] were collected. Study group patients were given four teaching sessions of abdominal breathing-assisted relaxation facilitated by GSR biofeedback. Daily home practice was encouraged and monitored to measure the effects on blood pressure and GSR at the end of the 1st, 2nd, and 3rd month of intervention. Results: The study group participants showed significant decrease in mean (SD) systolic [140.77 (8.31) to 136.93 (7.96), F = 469.08] and diastolic blood pressure [88.24 (5.42) to 85.77 (4.66), F = 208.21]. In contrast, control group participants had a mild increase in the mean systolic (F = 6.02) and diastolic blood pressure (F = 4.70) values from pretest to posttests. GSR showed a significant increase from 559.63 (226.33) to 615.03 (232.24), (F = 80.21) from pretest to posttest III. Conclusions: Use of home-based biofeedback-centered behavioral interventions enabled BP reduction among hypertensive patients. Further studies should use biochemical markers of sympathetic nervous system activity to endorse this home-based chronic illness intervention.
... However, exercise-based cardiac rehabilitation is an established, safe and effective intervention to improve physical functional performance, muscle strength, and quality of life and is associated with a reduction in heart failure hospitalization in stable heart failure patients [38]. Therefore, following rehabilitation of hip fracture and acquisition of walking ability, it is desirable to connect these patients to home-based cardiac rehabilitation [39]. ...
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Several studies have shown that nutrition and muscle strength were associated with functional recovery in patients with hip fracture. However, the impact of heart failure on the improvement of activity of daily living (ADL) in patients with hip fracture have not been fully investigated. The purpose was investigating the effect of heart failure on the ADL improvement by rehabilitation in patients with hip fracture. A total of 116 patients with hip fracture discharged from our convalescent rehabilitation ward were studied. Heart failure was assessed based on plasma B-type natriuretic peptide (BNP) levels on admission. ADL was assessed based on rehabilitation effectiveness (REs), which was calculated using the FIM instrument. Clinical, demographic, and nutritional variables were measured. Multiple regression analysis was performed with REs as the dependent variable; variables showing significant correlation with REs in univariate analyses were selected as independent variables. Based on plasma BNP levels, we assigned 39 patients to a Low group: 22 (17−25) median (interquartile) pg/mL, 39 to a Middle group: 52 (42−65) pg/mL, and 38 to a High group: 138 (93−209) pg/mL. REs, handgrip strength, Hb, albumin, and GNRI were higher and age was younger in the Low group than High group (each p < 0.01, respectively). Multiple linear regression analysis revealed that age (p < 0.05), sex (p < 0.05), handgrip strength (p < 0.01), FOIS at admission (p < 0.01), rehabilitation time per day (p < 0.01), and BNP (p < 0.05) were significantly associated with REs. The effect of rehabilitation on ADL improvement was significantly blunted in the High group compared to the Low group. In conclusion, these results suggest that heart failure assessed based on plasma BNP levels negatively impacts improvements in ADL achieved through rehabilitation in patients with hip fracture.
... 6 Home-based programs are as effective as center-based programs regarding improvements in quality of life, functional capacity and HF hospitalizations. 7 Recognition of home-based CR as a cost-effective intervention has led to its incorporation into the healthcare systems of several countries, including Australia, Canada, and the UK. Interestingly, the National Audit of Cardiac Rehabilitation Quality and Outcomes Report for 2019 by the British Heart Foundation reported that 10% of patients who attend CR participate in a home-based CR program. ...
... 199 Physiotherapy and occupational therapyled interventions are especially important for non-pharmacological breathlessness management [199][200][201] and the improvement of functional ability. [202][203][204] Occupational therapists have core skills in nonpharmacological fatigue and anxiety management, along with the assessment and provision of equipment to maintain function and optimize QoL. 205 PC provides as well bereavement service to support these who lost a loved one. ...
Article
Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social or spiritual nature. This document encourages the use of validated assessment tools to recognise such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
... 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 ...
Article
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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.
... [45][46][47] The model should facilitate the provision of home or community-based care-potentially bolstered by telehealth and remote monitoring; keeping as much care in the home or the community as possible would be beneficial to all and patient-preferred. [48][49][50] Expanding the use of patient-facing technology, such as through the use of online patient portals that allow for communication with clinicians, would likely be needed to expand access outside of clinic visits. ...
Article
Heart failure (HF) is a leading cause of hospitalizations and readmissions in the United States. Particularly among the elderly, its prevalence and costs continue to rise, making it a significant population health issue. Despite tremendous progress in improving HF care and examples of innovation in care redesign, the quality of HF care varies greatly across the country. One major challenge underpinning these issues is the current payment system, which is largely based on fee-for-service reimbursement, leads to uncoordinated, fragmented, and low-quality HF care. While the payment landscape is changing, with an increasing proportion of all healthcare dollars flowing through value-based payment models, no longitudinal models currently focus on chronic HF care. Episode-based payment models for HF hospitalization have yielded limited success and have little ability to prevent early chronic disease from progressing to later stages. The available literature suggests that primary care-based longitudinal payment models have indirectly improved HF care quality and cardiovascular care costs, but these models are not focused on addressing patients’ longitudinal chronic disease needs. This article describes the efforts and vision of the multi-stakeholder Value-Based Models Learning Collaborative of The Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. The Learning Collaborative developed a framework for a HF value-based payment model with a longitudinal focus on disease management (to reduce adverse clinical outcomes and disease progression among patients with stage C HF) and prevention (an optional track to prevent high-risk stage B pre-HF from progressing to stage C). The model is designed to be compatible with prevalent payment models and reforms being implemented today. Barriers to success and strategies for implementation to aid payers, regulators, clinicians, and others in developing a pilot are discussed.
... The setting of exercise training is not specified in the present key action statement, though home-based training programs are somewhat less studied compared with outpatient, clinic-based settings. However, the 2010 and 2016 reviews by Dalal et al 92 and Zwisler et al, 68 respectively, found no difference in exercise capacity and HRQL outcomes based on setting. In comparing home-based aerobic exercise to usual activity, Chin et al 47 found significant improvements in peak VO2 and 6MWT of a magnitude comparable to those reported in other analyses, but found no difference in HRQL. ...
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Shoemaker MJ, Dias KJ, Lefebvre KM, et al. Physical therapist clinical practice guideline for the management of individuals with heart failure. Phys Ther. 2019;99:1-28.] The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, have commissioned the development of this clinical practice guideline to assist physical therapists in their clinical decision making when treating patients with heart failure. Physical therapists treat patients with varying degrees of impairments and limitations in activity and participation associated with heart failure pathology across the continuum of care. This document will guide physical therapist practice in the examination and treatment of patients with a known diagnosis of heart failure. The development of this clinical practice guideline followed a structured process and resulted in 9 key action statements to guide physical therapist practice. The level and quality of available evidence were graded based on specific criteria to determine the strength of each action statement. Clinical algorithms were developed to guide the physical therapist in appropriate clinical decision making. Physical therapists are encouraged to work collaboratively with other members of the health care team in implementing these action statements to improve the activity, participation, and quality of life in individuals with heart failure and reduce the incidence of heart failure-related re-admissions.
... The setting of exercise training is not specified in the present key action statement, though home-based training programs are somewhat less studied compared with outpatient, clinic-based settings. However, the 2010 and 2016 reviews by Dalal et al 92 and Zwisler et al, 68 respectively, found no difference in exercise capacity and HRQL outcomes based on setting. In comparing home-based aerobic exercise to usual activity, Chin et al 47 found significant improvements in peak VO 2 and 6MWT of a magnitude comparable to those reported in other analyses, but found no difference in HRQL. ...
Article
The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, have commissioned the development of this clinical practice guideline to assist physical therapists in their clinical decision making when managing patients with heart failure. Physical therapists treat patients with varying degrees of impairments and limitations in activity and participation associated with heart failure pathology across the continuum of care. This document will guide physical therapist practice in the examination and treatment of patients with a known diagnosis of heart failure. The development of this clinical practice guideline followed a structured process and resulted in 9 key action statements to guide physical therapist practice. The level and quality of available evidence were graded based on specific criteria to determine the strength of each action statement. Clinical algorithms were developed to guide the physical therapist in appropriate clinical decision making. Physical therapists are encouraged to work collaboratively with other members of the health care team in implementing these action statements to improve the activity, participation, and quality of life in individuals with heart failure and reduce the incidence of heart failure-related re-admissions.
... The benefits of cardiac rehabilitation in chronic heart failure (CHF) have been well documented [1]. Evidencebased clinical guidelines recommend that physical activity is integrated into cardiac rehabilitation as a cornerstone of clinical management of CHF [2]. ...
Article
Full-text available
Purpose: Less than 10% of heart failure patients in the UK participate in cardiac rehabilitation programmes. The present pilot study evaluated feasibility, acceptability and physiological effects of a novel, personalised, home-based physical activity intervention in chronic heart failure. Methods: Twenty patients (68 ± 7 years old, 20% females) with stable chronic heart failure due to reduced left ventricular ejection fraction (31 ± 8 %) participated in a single-group, pilot study assessing the feasibility and acceptability of a 12-week personalised home-based physical activity intervention aiming to increase daily number of steps by 2000 from baseline (Active-at-Home-HF). Patients completed cardiopulmonary exercise testing with non-invasive gas exchange and haemodynamic measurements and quality of life questionnaire pre- and post-intervention. Patients were supported weekly via telephone and average weekly step count data collected using pedometers. Results: Forty-three patients were screened and 20 recruited into the study. Seventeen patients (85%) completed the intervention, and 15 (75%) achieved the target step count. Average step count per day increased significantly from baseline to 3 weeks by 2546 (5108 ± 3064 to 7654 ± 3849, P = 0.03, n = 17) and was maintained until week 12 (9022 ± 3942). Following completion of the intervention, no adverse events were recorded and quality of life improved by 4 points (26 ± 18 vs. 22 ± 19). Peak exercise stroke volume increased by 19% (127 ± 34 vs. 151 ± 34 m/beat, P = 0.05), while cardiac index increased by 12% (6.8 ± 1.5 vs. 7.6 ± 2.0 L/min/m2, P = 0.19). Workload and oxygen consumption at anaerobic threshold also increased by 16% (49 ± 16 vs. 59 ± 14 watts, P = 0.01) and 10% (11.5 ± 2.9 vs. 12.8 ± 2.2 ml/kg/min, P = 0.39). Conclusion: The Active-at-Home-HF intervention is feasible, acceptable and effective for increasing physical activity in CHF. It may lead to improvements in quality of life, exercise tolerance and haemodynamic function. Trial registration: www.clinicaltrials.gov NCT0367727. Retrospectively registered on 17 September 2018.
... Increasingly more tools are being developed to improve the monitoring of patients' PA and the effectiveness of CR [71]. Home-based CR associated with telemonitoring is safe compared with CR performed in a specialized centre, has similar results, is more effective than no ET [57,62,72] and reduces CR costs [62]. Home-based CR is also relevant for patients who are very far from CR centres or whose working hours make it difficult to participate in a centre-based programme. ...
Article
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Physical activity is important in heart failure to improve functional capacity, quality of life and prognosis, and is a class IA recommendation in the European Society of Cardiology guidelines (Ponikowski et al., 2016). The benefits of exercise training are widely recognized. Cardiac rehabilitation centres offer tailored exercise training to patients with heart failure, as part of specialized multidisciplinary care, alongside pharmacological treatment optimization and patient education. After cardiac rehabilitation, maintenance of regular physical activity long term is essential, as the benefits of exercise training vanish within a few weeks. Unfortunately, only 10% of patients benefit from a cardiac rehabilitation programme after hospitalization for acute heart failure, and the majority of patients do not pursue long-term physical activity. In this paper, two Working Groups of the French Society of Cardiology (the heart failure group [Groupe Insuffisance Cardiaque et Cardiomyopathies; GICC] and the cardiac rehabilitation group [Groupe Exercice Réadaptation Sport et Prévention; GERS-P]) discuss the obstacles to broader access to cardiac rehabilitation centres, and propose ways to improve the diffusion of cardiac rehabilitation programmes and encourage long-term adherence to physical activity.
... Otro aspecto que tener en cuenta son los programas domiciliarios, actualmente supervisados y dirigidos en muchos casos, con nuevas tecnologías. Estos programas también se han demostrado efectivos en pacientes con IC, aunque todavía hay poca experiencia 22,23 . En los centros donde esté disponible y haya experiencia, los pacientes con IC de bajo riesgo podrán ser incluidos en programas domiciliarios de RC dependientes de unidades de RC estructuradas. ...
Article
Resumen La insuficiencia cardiaca es una enfermedad que precisa un tratamiento multidisciplinario, dadas la diversidad de causas y entornos clínicos implicados que las tratan y las diferentes estrategias terapéuticas que precisan la participación indispensable de diversas disciplinas. La presencia en los servicios de cardiología de unidades de insuficiencia cardiaca centradas en el tratamiento de los pacientes con esta afección y unidades de rehabilitación cardiaca que, entre sus indicaciones para la reducción de la morbimortalidad, también están implicadas en la atención de esos mismos pacientes puede causar dificultades de coordinación y pérdida de una atención integral centrada en el paciente. Por estos motivos, en el presente documento se plantea una estrategia de coordinación entre las diferentes unidades implicadas en el tratamiento de los pacientes dentro de los servicios de cardiología y la continuidad asistencial con atención primaria, tanto tras haber conseguido la estabilidad como la interrelación para una coordinación posterior más efectiva.
... 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). ...
Article
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.
... 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 ...
Article
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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.
... 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). ...
Article
Full-text available
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.
... 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]. ...
Article
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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.
... 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). ...
Article
Full-text available
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.
... 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. ...
Article
Full-text available
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.
... 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. ...
Article
Full-text available
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. ...
Article
Full-text available
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.
... 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. ...
Article
Full-text available
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.
... 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]. ...
Article
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
... 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. ...
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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.
... 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. ...
Article
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.
... 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. ...
Article
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.
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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.
Article
Cardiac rehabilitation (CR) is a structured exercise and lifestyle program that improves mortality and quality of life in patients with heart failure (HF) with reduced ejection fraction. However, significant gaps remain in optimizing CR for older adults with HF. This review summarizes the state of the science and specific knowledge gaps regarding older adults with HF. The authors discuss the importance of geriatric complexities in the design and implementation of CR, summarize promising future research in this area, and provide a clinical framework for current CR clinicians to follow when considering the specific needs of older adults with HF.
Article
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.
Article
Background: Newer models of cardiac rehabilitation (CR) delivery are promising but depend upon patient participation and ability to use technological media including Internet and smart devices. Aim: To explore the availability of smart devices, current utilization and proficiency of use among older CR program attendees. Methods: Study participants were enrolled from four CR programs in Omaha, Nebraska United States and completed a questionnaire of 28 items. Results: Of 376 participants approached, 169 responded (45%). Mean age was 71.1 (SD ± 10) years. Demographics were 73.5% males, 89.7% Caucasians, 52% with college degree and 56.9%, with income of 40K$ or more. Smart device ownership was 84.5%; desktop computer was the most preferred device. Average Internet use was 1.9 h/d (SD ± 1.7); 54.3% of participants indicating for general usage but only 18.4% pursued health-related purposes. Utilization of other health information modalities was low, 29.8% used mobile health applications and 12.5% used wearable devices. Of all participants, 72% reported no barriers to using Internet. Education and income were associated positively with measures of utilization and with less perceived barriers. Conclusion: Among an older group of subjects attending CR, most have access to smart devices and do not perceive significant barriers to Internet use. Nonetheless, there was low utilization of health-related resources suggesting a need for targeted education in this patient population.
Article
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.
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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.
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Objectives: Clinical guidelines recommend regular physical activity for patients with heart failure to improve functional capacity and symptoms and to reduce hospitalisation. Cardiac rehabilitation programmes have demonstrated success in this regard; however, uptake and adherence are suboptimal. Home-based physical activity programmes have gained popularity to address these issues, although it is acknowledged that their ability to provide personalised support will impact on their effectiveness. This study aimed to identify barriers and facilitators to engagement and adherence to a home-based physical activity programme, and to identify ways in which it could be integrated into the care pathway for patients with heart failure. Design: A qualitative focus group study was conducted. Data were analysed using thematic analysis. Participants: A purposive sample of 16 patients, 82% male, aged 68±7 years, with heart failure duration of 10±9 years were recruited. Intervention: A 12-week behavioural intervention targeting physical activity was delivered once per week by telephone. Results: Ten main themes were generated that provided a comprehensive overview of the active ingredients of the intervention in terms of engagement and adherence. Fear of undertaking physical activity was reported to be a significant barrier to engagement. Influences of family members were both barriers and facilitators to engagement and adherence. Facilitators included endorsement of the intervention by clinicians knowledgeable about physical activity in the context of heart failure; ongoing support and personalised feedback from team members, including tailoring to meet individual needs, overcome barriers and increase confidence. Conclusions: Endorsement of interventions by clinicians to reduce patients' fear of undertaking physical activity and individual tailoring to overcome barriers are necessary for long-term adherence. Encouraging family members to attend consultations to address misconceptions and fear about the contraindications of physical activity in the context of heart failure should be considered for adherence, and peer-support for long-term maintenance. Trial registration number: NCT03677271.
Article
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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
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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.
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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.
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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.
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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. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
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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.
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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.