Article

Participation and adherence to cardiac rehabilitation programs. A systematic review

Authors:
  • Complexo Hospitalario Universitario de Vigo. Hospital Álvaro Cunqueiro.
  • University Hospital Alvaro Cunqueiro, Vigo, Spain
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Abstract

Acute myocardial infarction (AMI) is an important health problem. Cardiac rehabilitation (CR) programs following AMI have shown to be effective in reducing mortality. We aim to systematically review the existing literature that analyzes the factors that affect participation and adherence to cardiac rehabilitation programs. We reviewed Medline, EMBASE and Cochrane databases from 01/01/2004 to June 2016 using predefined inclusion and exclusion criteria. We classified the results into factors affecting participation and factors influencing adherence to CR programs. We included 29 studies, and there was a general agreement in those factors predicting participation and adherence to CR programs. These factors can be classified into person-related factors and aspects related to CR programs. Older participants, women, patients with comorbidities, unemployed and uncoupled persons, less educated people and those with lower income had a lower participation. A similar pattern was observed for CR adherence. Also, those potential participants who live farther from CR facilities, do not have transportation, or do not drive, attended less to CR programs. These factors were very similar when analyzing adherence to CR programs. These aspects were similar in Europe and the USA. These results clearly show that participation in CR programs follows a determined pattern that is very homogeneous in different settings. Health professionals should also be aware of patients reluctant to participate in CR programs and adapt their messages and redesign CR programs, to promote participation and adherence.

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... 15 The rationale is to increase accessibility to rehabilitation by moving the health services closer to patients in an attempt to increase the completion rates and prevent dropout from cardiac rehabilitation. 11,13 In 2007, the responsibility for cardiac rehabilitation services in Denmark shifted from a regional level (responsible for hospital management) to a shared responsibility between regional and local community level (administrative entities called municipalities). 16 Hence, in Denmark, exCR is delivered in all of the 98 municipalities, only specialized services are provided at the hospitals. ...
... 30 Previous literature from traditional cardiac rehabilitation programmes has suggested that factors as easier accessibility and enhancement of social support in local healthcare centres could increase completion rates and lower dropout from exCR. 11,13 However, it has also been hypothesized that the transition phase influences patient care pathways and constitutes a barrier for patients' participation. 31 This has, to our knowledge, never previously been scientifically studied. ...
Article
Aims Investigate the dropout rate during a 12-week transitional exercise-based cardiac rehabilitation (exCR) programme focusing on a halfway transition phase between hospital and the municipality-based cardiac rehabilitation. Secondly, investigate patient characteristics associated with dropout at the transition. Methods and results Patients with coronary heart disease, heart failure, or heart valve surgery referred to exCR were included in a prospective cohort study conducted between 1 March 2018 and 28 February 2019 at Zealand University Hospital. Exercise-based cardiac rehabilitation was initiated at the hospital with a halfway transitional to local healthcare centres in the municipalities. Dropouts were identified every third week through telephone interviews. A Kaplan–Meier time-to-event analysis was used to investigate time to dropout, while multiple logistic regression assessed associations between patient characteristics and dropout at the transition. Of 560 patients eligible for exCR, 279 participated in the study. Fourteen patients were lost to follow-up and 103 dropped out, resulting in a dropout rate of 39% [95% confidence interval (CI) 33–45%]. Of the 103 dropouts, 72 patients (70%) dropped out at the transition. In the adjusted analysis, patients attached to the labour market were associated with dropout at the transition [odds ratio (OR) = 6.31 (95% CI 2.04–19.54)]. Furthermore, odds of dropping out at transition were reduced for each extra exercise session attended [OR = 0.79 (95% CI 0.66–0.94)]. Conclusion The transition phase constitutes a critical dropout period in exCR, in which increased attention on patient adherence is needed. In clinical practice, communication and strategies addressing patient retention across settings could be essential to prevent dropout in transitional exCR. Keywords Cardiac rehabilitation • Cross-sectoral • Adherence • Transition phase • Dropout • Exercise
... Moreover, therapy adherence is frequently lower in patients with transportation difficulties, which applies to this older frail population due to, for example, mobility disabilities. Furthermore, a high number of comorbidities/syndromes, as well as the presence of depressed/ill feelings, may negatively impact the participation rate [29] , which both can be present in frail (CVD) patients [ 5 , 30 ]. Finally, there are indications for a lower participation rate in people living alone [29] , which frequently can be the case in older CVD patients. Second, along with therapy adherence constraints, in-patient CR (phase 2) is limited in time [31] . ...
... Moreover, therapy adherence is frequently lower in patients with transportation difficulties, which applies to this older frail population due to, for example, mobility disabilities. Furthermore, a high number of comorbidities/syndromes, as well as the presence of depressed/ill feelings, may negatively impact the participation rate [29] , which both can be present in frail (CVD) patients [ 5 , 30 ]. Finally, there are indications for a lower participation rate in people living alone [29] , which frequently can be the case in older CVD patients. Second, along with therapy adherence constraints, in-patient CR (phase 2) is limited in time [31] . ...
Article
Due to advances in cardiovascular medicine and preventive cardiology, patients benefit from a better prognosis, even in case of significant disease burden such as acute and chronic coronary syndromes, advanced valvular heart disease and chronic heart failure. These advances have allowed CVD patients to increase their life expectancy, but on the other hand also experience aging-related syndromes such as frailty. Despite being underrecognized, frailty is a critical, common, and co-existent condition among older CVD patients, leading to exercise intolerance and compromised adherence to cardiovascular rehabilitation. Moreover, frail patients need a different approach for CR and are at very high risk for adverse events, but yet are underrepresented in conventional CR. Fortunately, recent advances have been made in technology, allowing remote monitoring, coaching and supervision of CVD patients in secondary prevention programs with promising benefits. Similarly, we hypothesized that such programs should also be implemented to treat frailty in CVD patients. However, considering frail patients’ particular needs and challenges, telerehabilitation interventions should thus be appropriately adapted. Our purpose is to provide, for the first time and based on expert opinions, a framework of how such a cardiac telerehabilitation program could be developed and implemented to manage a prevention and rehabilitation program for CVD patients with frailty.
... Furthermore, the completion rate was 80.4% for the SLC participants compared to previously reported completion rates of 13% to 39%. 38,39 Moreover, patients who attend more than 25 sessions of the CR program are 19% less likely to die after five years compared to those who attend fewer sessions. 40 The median completion rate of 80.4% observed in the present study with SLC patients was therefore an encouraging result. ...
... 43 Lack of motivation, older age, living alone, low socioeconomic status, and lower educational level are known factors for low participation and high dropout rates in CR programs. 12,38,39 Effective PE is associated with better psychological, physiological, and social health. Patients' increased knowledge and awareness of CR can strengthen their motivation to participate, thus contributing to improved adherence. ...
Article
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Sisi Zhang,1 Houjuan Zuo,1 Xiaoping Meng,2 Dayi Hu1,3 1Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China; 2Affiliated Hospital of Changchun Traditional Chinese Medicine, Changchun, People’s Republic of China; 3People’s Hospital of Peking University, Beijing, People’s Republic of ChinaCorrespondence: Xiaoping Meng, Affiliated Hospital of Changchun Traditional Chinese Medicine, Gongnong Avenue No. 1478, Chaoyang District, Changchun, 130000, People’s Republic of China, Tel +86-13180889540, Email xiopingmeng@126.com Dayi Hu, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No. 1095, Qiaokou District, Wuhan, 430000, People’s Republic of China, Tel +86-13901389171, Email hudayihust@126.comAim: To describe a new model, the Support Life Club (SLC), for participants of Phase II cardiac rehabilitation (CR) programs and to evaluate this model for adherence, completion rates, and clinical outcomes.Methods: This retrospective study involved 391 consecutive patients who participated in an outpatient CR program between September 2016 and May 2020. The intervention group (SLC) was comprised of 198 patients who participated in education, WeChat-based group activity as well as outdoor activities, while the control group (non-intervention) was comprised of 193 cases. All patients attended a 12-week supervised outpatient CR program (three sessions per week, each lasting 40min). The intervention and control groups were compared for completion rates, Cardiopulmonary Exercise Test (CPET) results, Six-minute Walk Test (6MWT) distances, and Patient Health Questionnaire-9 (PHQ-9) scores.Results: Patients in the intervention group attended at least 75% of the exercise training sessions more often than those in the control group (72.5% vs 40.41%, adjusted odds ratio (OR): 27.385; 95% CI: 10.2 to 73.6; P = 0.0000). Analysis of variance (2 × 2 ANOVA) revealed a significant group-by-time interaction in PHQ9 and 6MWT test results (p = 0.000).Conclusion: The addition of SLC to a cardiac rehabilitation program resulted in better outcomes for PHQ9 and 6MWT tests and may be a useful strategy to improve exercise adherence.Keywords: cardiac rehabilitation, support life club, adherence, completion rate, WeChat platform
... CR is effective in reducing all-cause mortality, cardiac mortality, myocardial re-infarction, and cardiovascular risk factors and improving physical activity and quality of life in high, low, and middle-income countries [9,10]. Although comprehensive CR is effective in improving the health outcomes of patients with CHD, its availability worldwide is only 38% because of inadequate physical and financial resources [11]. Providing a center-based CR is particularly difficult in South Asia including Sri Lanka because of the lack of human resources, space and equipment, and financial support [11,12]. ...
... Although comprehensive CR is effective in improving the health outcomes of patients with CHD, its availability worldwide is only 38% because of inadequate physical and financial resources [11]. Providing a center-based CR is particularly difficult in South Asia including Sri Lanka because of the lack of human resources, space and equipment, and financial support [11,12]. Therefore, effective strategies for the secondary prevention of CHD are urgently needed. ...
Article
Full-text available
Background: Coronary heart disease (CHD), is the major contributor to cardiac-associated mortality worldwide. Lifestyle modification, including physical activity, is highly recommended for secondary prevention for patients with CHD. However, many people in Sri Lanka with CHD do not engage in adequate physical activity. Objective: To develop a culture-specific, motivated, and action-based intervention and examine its effects on physical activity level, exercise self-efficacy, and cardiovascular risk factors among patients with CHD. Methods and materials: This is an assessor-blinded randomized controlled trial that will recruit 150 patients with CHD from the inpatients cardiac unit of a hospital in Batticaloa, Sri Lanka, and will randomly assign them either to the intervention group or the control group. The participants in the intervention group will receive a culture-specific and motivated, action-based intervention in addition to the usual care, while participants in the control will only receive the usual care. The intervention consists of a face-to-face preparatory session and 12-week motivated, action-based sessions which were developed based on the health action process approach (HAPA) framework. The face-to-face preparatory session will identify the health needs of the participants, develop a goal-oriented patient-centered action plan, and provide knowledge and an overview of the program. The 12-week motivated, action-based sessions consist of three monthly group education and center-based group exercises, followed by three 20-min individualized telephone follow-ups. Outcomes will be assessed immediately after the intervention and at one-month post-intervention. Discussion: This protocol proposes a supervised centered-based group exercise with group education, and individualized telephone follow-ups guided by the HAPA framework to improve the physical activity level, exercise self-efficacy, and cardiovascular risk factors of patients with CHD. Results from this study will inform the effectiveness of a motivated, action-based intervention in a low-resource setting and provide information on the feasibility, barriers, and facilitators for lifestyle modification in Sri Lanka. Trial registration: ClinicalTrial.gov.org PRS: NCT05051774; Date of registration: September 21, 2021.
... Similar to geographic region, socioeconomic status (SES) appears to directly impact the use of CR programs [69]. Similar results have been demonstrated in another systematic review where older participants, women, patients with comorbidities, unemployed and uncoupled persons, less educated people and those lower incomes had lower participation rates [72]. Minorities, notably Black, Hispanic, and Asian patients, were 20%, 36%, and 50% respectively less likely than white patients to obtain referral for CR following a MI, according to a major US-based registry. ...
... Patients with lower income, education, and socioeconomic levels (SES) have displayed lower CR participation rates than those with a higher socioeconomic status. These patients usually have insufficient health insurance coverage and fewer health benefits, thus making CR participation economically non affordable [72]. Patients from lower socioeconomic backgrounds also lack transportation to CR facili- ties, and an even larger factors is lack of appropriate childcare, making enrollment and the participation in CR programs difficult to achieve [73]. ...
Article
Full-text available
Cardiovascular diseases are the leading cause of morbidity and mortality worldwide. Increased rates of morbidity and mortality have led to the increased need for the implementation of secondary prevention interventions. Exercise-based cardiac rehabilitation (CR) represents a multifactorial intervention, including elements of physical exercise and activity, education regarding healthy lifestyle habits (smoking cessation, nutritional habits), to improve the physical capacity and psychological status of cardiac patients. However, participation rates in CR programs remain low due to socioeconomic, geographical and personal barriers. Recently the COVID-19 pandemic restrictions have added another barrier to CR programs. Therefore there is an emerging need to further improve the types and methods of implementing CR. Cardiac telerehabilitation, integrating advanced technology for both monitoring and communicating with the cardiac population, appears to be an innovative CR alternative that can overcome some of the barriers preventing CR participation. This review paper aims to describe the background and core components of center-based CR and cardiac telerehabilitation, and discuss their implications for present day clinical practice and their future perspectives.
... 11 This study supports previous findings indicating the need for enhanced crosssectoral collaboration between the referring hospital and the delivering primary healthcare centre of CR with the objective to promote CR uptake and adherence. 12 29 30 Furthermore, health professionals should communicate to patients that CR is an important part of the secondary prevention and provide comprehensive information regarding the various CR activities. 12 29 30 Future research on interventions to promote CR utilisation among patients with low SES is warranted. ...
... 12 29 30 Furthermore, health professionals should communicate to patients that CR is an important part of the secondary prevention and provide comprehensive information regarding the various CR activities. 12 29 30 Future research on interventions to promote CR utilisation among patients with low SES is warranted. 7 8 Generalisability The annual publication of data from the Danish Cardiac Rehabilitation Database in the primary healthcare setting demonstrated comparable numbers of referred patients for CR with those obtained from this investigation based on referrals registered in the National Patient Registry (hospital-based). ...
Article
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Objectives High socioeconomic status (SES) has been linked to high referral for cardiac rehabilitation (CR). However, the impact of SES on CR utilisation from enrolment to completion is unclear. The objective of this study was to examine whether indicators of SES are associated with not taking up and dropout from CR. Design A population-based, follow-up study. Setting Hospitals and primary healthcare centres in the Central Denmark Region. Participant Patients diagnosed with ischaemic heart disease (IHD) in the hospital and referred for rehabilitation in the primary healthcare setting from 1 September 2017 to 31 August 2018 (n=2018). Variables Four SES indicators (education, disposable family income, occupation and cohabitant status) were selected because of their established association with cardiovascular health and CR utilisation. Patients were followed up regarding no uptake of or dropout from CR in the primary healthcare setting. Statistical methods The associations between the four SES indicators and either no uptake or dropout from CR were analysed using logistic regression with adjustment for age, sex, nationality and comorbidity. Results Overall, 25% (n=507) of the referred patients did not take up CR and 24% (n=377) of the participators dropped out the CR. All adjusted ORs, except one (education/dropout) demonstrated that low SES compared with high are statistically significantly associated with higher odds of not taking up CR and dropout from CR. The ORs ranged from 1.52, 95% CI 1.13 to 2.04 (education/no uptake) to 2.36, 95% CI 1.60 to 3.46 (occupation/dropout). Conclusions This study highlights that indicators of SES are important markers of CR utilisation following hospitalisation for IHD.
... Participation and adherence to CR has been associated with reduced myocardial reinfarction rate, cardiovascular and all-cause mortality [32,33]. Despite such importance, participation in CR is often limited by the lack of transportation to the rehabilitation center [34], which was also one of the main limiting factors for inclusion to our study (31% of the excluded patients). During this study, 20 patients were lost to follow-up, thus, the dropout rate was greater (25%) than previously reported across European CR centers (15%) [35]. ...
... Patients that failed to comply with AE protocol were older with multiple chronic cardiovascular and musculoskeletal comorbidities. The same patients` characteristics were also previously demonstrated to be a limiting for participation and adherence to exercise-based CR [34]. In addition, most of the AE sessions that were not performed in compliance with the protocol were performed during the last part of this study, wherein AE intensity was high (>74% of peak power output) [21]. ...
Article
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Resistance exercise (RE) remains underused in cardiac rehabilitation; therefore, there is insufficient evidence on safety, feasibility, and hemodynamic adaptations to high-load (HL) and low-load (LL) RE in patients with coronary artery disease (CAD). This study aimed to compare the safety, feasibility of HL-RE and LL-RE when combined with aerobic exercise (AE), and hemodynamic adaptations to HL and LL resistance exercise following the intervention. Seventy-nine patients with CAD were randomized either to HL-RE (70-80% of one-repetition maximum [1-RM]) and AE, LL-RE (35-40% of 1-RM) and AE or solely AE (50-80% of maximal power output) as a standard care, and 59 patients completed this study. We assessed safety and feasibility of HL-RE and LL-RE and we measured 1-RM on leg extension machine and hemodynamic response during HL-and LL-RE at baseline and post-training. The training intervention was safe, well tolerated, and completed without any adverse events. Adherence to RE protocols was excellent (100%). LL-RE was better tolerated than HL-RE, especially from the third to the final mesocycle of this study (Borgs' 0-10 scale difference: 1-2 points; p = 0.001-0.048). Improvement in 1-RM was greater following HL-RE (+31%, p < 0.001) and LL-RE (+23%, p < 0.001) compared with AE. Participation in HL-RE and LL-RE resulted in a decreased rating of perceived exertion during post-training HL-and LL-RE, but in the absence of post-training hemodynamic adaptations. The implementation of HL-RE or LL-RE combined with AE was safe, well tolerated and can be applied in the early phase of cardiac rehabilitation for patients with stable CAD.
... Several factors are influential in attending CR, some of which are related to patient characteristics, and others are related to access to cardiac rehabilitation services. [11][12][13][14] Therefore, other strategies to increase participation in the CR program for More than 80% of eligible patients who do not participate in a center-based rehabilitation program should be considered, one of which is home-based cardiac rehabilitation (HBCR). [15] Studies have shown that both center-based cardiac rehabilitation and HBCR have had similar outcomes, yet patients have been more satisfied with HBCR than with center-based CR. ...
Article
Background: Cardiovascular diseases are the leading causes of mortality all around the world. Patients with Ischemic heart disease (IHD) are at an increased risk of ischemic events; therefore, secondary prevention measures should continue for these patients. Although Cardiac rehabilitation (CR) is one of the secondary prevention measures for IHD patients which has favorable clinical outcomes, only 50% of patients are referred and among them, a small percentage attends CR. Therefore, other strategies should be considered, one of which is home-based cardiac rehabilitation. Methods: A multicenter, parallel-group randomized controlled trial has been conducting in three hospitals in Isfahan and patients have been assigned into a 1:1 ratio for the evaluation of the effectiveness of home-based cardiac rehabilitation versus usual care. Psycho-educational consultation based on the Health Action Process Approach including heart-healthy diet, stress management, lifestyle changes, smoking cessation, and physical activity has been performed. Primary outcomes, including the quality of life, psychological and smoking status, body mass index, blood pressure, blood cholesterol level, and physical activity level have been measured at 6 months after the randomization and intervention. One year after the intervention, primary and secondary outcomes, including cardiovascular events, the frequency of hospital admissions, and the death rates due to cardiovascular reasons will be assessed. Conclusion: HBCR program can increase patient accessibility to CR services its implantation can be reduce burden IHD.
... However, there is some evidence suggesting site selection in registries may not lead to considerable bias [50,51]. Moreover, we know there are biases in patient access to CR [52], and hence also patients in the registry may not be representative of the average cardiac patient in these settings. Second, target CR programs may have difficulty participating due the fact that they have few resources, and due to known barriers to CR registry uptake [53,54]. ...
Article
Full-text available
Introduction: The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) is developing a registry (ICRR) specifically for low-resource settings, where the burden of cardiovascular diseases is greatest and the need for program development highest. Herein we describe the development process, including the variable selection process. Method: Following a literature search on registry best practices, a stepwise model for ICRR development was identified. Then, based on recommendations by Core Outcome Set STAndards for Development (COS-STAD), we underwent a process to identify variables. All available CR registries were contacted to request their data dictionaries, reviewed CR quality indicators and guideline recommendations, and searched for common data elements and core outcome sets; 35 unique variables (including patient-reported outcomes) were selected for potential inclusion. Twenty-one purposively-identified stakeholders and experts agreed to serve on a Delphi panel. Panelists rated the variables in an online survey, and suggested potential additional variables; A webcall was held to reach consensus on which to include/exclude. Next, panelists provided input to finalize each variable definition, and rated which associated indicators should be used for benchmarking in registry dashboards and a patient lay summary; a second consensus call was held. A 1-month public comment period ensued. Results: First, registry objectives and governance were approved by ICCPR, including data quality and access policies. The protocol was developed, for public posting. For variable selection, the overall mean rating was 6.1 ± 0.3/7; 12 were excluded, some of which were moved to a program survey, and others were revised. Two variables were added in an annual follow-up, resulting in 13 program and 16 patient-reported variables. Legal advice was sought to finalize ICRR agreements. Ethics approvals were obtained. Usability testing is now being initiated. Conclusion: It is hoped this will serve to harmonize CR assessment internationally and enable quality improvement in CR delivery in low-resource settings.
... Previous studies report that individuals employed at the time of their MI, tend to be enrolled in a CR program earlier to return to work as soon as possible [29,30]. These were not consistent with our results, where 90% of the NCR group returned to work, compared with 69% in the CR group. ...
Article
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Following myocardial infarction (MI), impaired physical, mental, and cognitive functions can reduce participation in the community and diminish quality of life. This study aims to assess active lifestyle participation and functional performance in patients who were participants and non-participants in cardiac rehabilitation. A total of 71 patients were recruited, 6–10 months after the MI event; 38 chose to participate in a cardiac rehabilitation (CR) program, and 33 did not (NCR). Participation and activity patterns in instrumental activities of daily living, as well as physically demanding leisure activities and social activities, were evaluated using the Activity Card Sort (ACS). Hand grip force and timed up and go (TUG) were tested. A total of 74% of the CR group met physical activity recommendations and only 34% continued to smoke, compared to 39% and 71% in the NCR group, respectively. The CR group, compared to the NCR group, had higher levels of daily activity, social leisure, and physically demanding leisure activities (p ≤ 0.001). Null differences between the NCR and CR groups were observed in grip strength and the TUG tests. The study highlighted community participation after MI. Based on a comparison between the groups, the study implies that patients choosing to participate in CR retained higher community participation levels and had better self-management of cardiovascular risk factors.
... Cardiac Rehabilitation (CR) programs are part of secondary prevention and are specifically designed to reduce the progression of CVDs (Piepoli et al., 2014). CR can globally reduce the mortality rate up to 25% in addition to other benefits such as lowering the rehospitalization cost and improving the functional capacity of patients (October and Turk-Adawi, 2014;Ruano-Ravina et al., 2016), but only up to 30% of eligible patients participate in CR programs (Piepoli et al., 2014). The barriers to participation in a centre-based CR program are distance to the centre, lack of time, belief in self-control, and lack of understanding of CR (De Vos et al., 2013;Resurrección et al., 2018). ...
Article
Introduction Patients suffering from coronary heart disease (CHD) are frequently less active. Physical Activity (PA) could be increased through changes in routine travel behaviour. Achieving a certain PA amount is essential in the secondary prevention of CHD patients. Objective This study combines objective monitoring together with an intervention using advanced Information, Communication and Technology means in a framework to improve travel-related PA. This paper aims to describe an integrated research framework and tests the effectiveness of a theory-based (Trans-theoretical Model, TTM) intervention. Methods A pilot Randomised Controlled Trial (70:30) was conducted in Belgium. Participating patients attended a preparatory work session intended to get their demographic information, assess their Stage of Change, and learn using a smartphone app (developed to monitor travel behaviour). After the work session, patients in the experimental group were monitored for three weeks and then received a customized feedback report. After feedback, the patients were monitored for another three weeks; while patients in the control arm were continuously monitored for 6 weeks without an intermediate feedback report. At the end of the study period, both groups received their feedback report. Results The data of 25 patients were used in the trial, of which 18 were in the experimental group. The outcome measure used was the Active Travel Score (ATS), i.e. the PA achieved by walking and cycling trips. A significant ( positive increase in ATS () was observed after the intervention. Multiple pairwise comparisons confirmed that the effect of the intervention lasted for a week, indicating an important short-term effect. Conclusion Objective monitoring and TTM-based interventions can be useful to provide a low-cost solution to achieve an increase in PA in secondary prevention of cardiac patients. Although these results are promising, RCTs with larger sample sizes are required to confirm the current findings.
... Moreover, offering self-help psychological interventions are in line with BACPR recommendations for a more menu-based approach to CR. Self-help psychological interventions can be more flexible and convenient for patients, depending on their circumstances. CR attendance rates are generally lower among those with mobility issues, the poor, women and the BAME community; thus, self-help could increase accessibility (Galdas et al., 2018;National Audit of Cardiac Rehabilitation, 2017;Ruano-Ravina et al., 2016). ...
Article
Background: One in three cardiovascular disease (CVD) patients experience significant anxiety and depression. Current psychological interventions have limited efficacy in reducing such symptoms and are offered as a face-to-face intervention that may be a barrier to accessing treatment. We evaluated the feasibility and acceptability of delivering assisted home-based self-help metacognitive therapy (home-MCT) to cardiac rehabilitation (CR) patients experiencing anxiety and depression. Method: One hundred eight CR patients with elevated anxiety and/or depression were recruited to a single-blind randomized feasibility trial across two United Kingdom National Health Service Trusts and were randomized to usual CR or usual CR plus home-MCT. The feasibility and acceptability of adding home-MCT to CR was based on credibility or expectancy ratings, recruitment rate, drop-outs, number of CR and home-MCT modules completed, and ability of outcome measures to discriminate between patients. The study was used to refine the sample size estimate for a full-scale trial. The quality of telephone support calls delivered by CR staff trained in MCT was assessed. Results: Home-MCT was found to be feasible and acceptable for the current CR patients with anxiety and depression. Recruitment and retention of participants was high, and attendance at CR was similar for both groups. Completion of home-MCT was high, but the quality of telephone support calls delivered was lower than expected. Conclusions: Home-MCT was acceptable and feasible to deliver to CR patients experiencing anxiety and depression, and the feasibility of conducting a full-scale trial of the intervention was established. Home-MCT may provide additional treatment options for cardiac patients experiencing psychological distress. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Many people living in poverty face chronic disadvantages related to transportation and have very few options to meet their basic travel needs [66], which is essential to their health. Lack of transportation has been linked to lack of regular medical care, uncompleted referrals or follow-ups, appointment cancellations, and no-shows [28,37,45,62,63]. Cumulatively, such challenges may result in less use of preventative and rehabilitative healthcare, greater use of emergency rooms, and worse health outcomes for people with chronic conditions [29,54]. ...
Conference Paper
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Millions of Americans forego medical care due to a lack of non-emergency transportation, particularly minorities, older adults, and those who have disabilities or chronic conditions. Our study investigates the potential for using timebanks—community-based voluntary services that encourage exchanges of services for “time dollars” rather than money—in interventions to address healthcare transportation barriers to seed design implications for a future affordable ridesharing platform. In partnership with a timebank and a federally qualified healthcare center (FQHC), 30 participants completed activity packets and 29 of them attended online workshop sessions. Our findings suggest that promoting trust between drivers and riders requires systems that prioritize safety and reliability; yet, there were discrepancies in the ability of the timebank and FQHC to moderate trust. We also found that timebank supports reciprocity, but healthcare transportation requires additional support to ensure balanced reciprocity. We explain these findings drawing from network closure and trust literature. Finally, we contribute design implications for systems that promote trust and facilitate relational over transactional interactions, which help to promote reciprocity and reflect participants’ values.
... In all our three regression models, we found lower completion rates in homebased modes compared to centre-based-modesalso in the fully patient characteristics adjusting model. To some degree, this could be influenced by various definitions of completion across trials and routine practice [14], however, another explanation may be differing professional and organizational factors known to influence participation [36][37][38]. Such factors will typically be controlled or similarly distributed in randomized trials whereas modes in routine care may not meet the standard of that found in randomized trials. ...
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.
... Data suggest that patients complete an average of 72% of prescribed training sessions [12]. Lower adherence has been demonstrated in the elderly [13], patients with comorbidities, the unemployed, and the less educated [14]. ...
Article
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Cardiovascular rehabilitation (CR) is an effective secondary preventive model of care. However, the use of CR is insufficient, and the reasons for this are not well-characterized in East- Central Europe. This prospective observational study psychometrically validated the recently translated Cardiac Rehabilitation Barriers Scale for the Czech language (CRBS-CZE) and identified the main CR barriers. Consecutive cardiac in/out-patients were approached from January 2020 for 18 months, of whom 186 (89.9%) consented. In addition to sociodemographic characteristics, participants completed the 21-item CRBS-CZE (response options 1–5, with higher scores representing greater barriers), and their CR utilization was tracked. Forty-five (24.2%) participants enrolled in CR, of whom 42 completed the CRBS a second time thereafter. Factor analysis revealed four factors, consistent with other CRBS translations. Internal reliability was acceptable for all but one factor (Cronbach’s alpha range = 0.44–0.77). Mean total barrier scores were significantly higher in nonenrollers (p < 0.001), decreased from first and second administration in these enrollers (p < 0.001), and were lower in CR completers (p < 0.001), supporting criterion validity. There were also significant differences in barrier scores by education, geography, tobacco use, among other variables, further supporting validity. The biggest barriers to enrolment were distance, work responsibilities, lack of time, transportation problems, and comorbidities; and the greatest barriers to adherence were distance and travel. Several items were considered irrelevant at first and second administration. Other barriers included wearing a mask during the COVID-19 pandemic. The study demonstrated sufficient validity and reliability of CRBS-CZE, which supports its use in future research.
... Developing new methods to increase attendance at exCR is deemed paramount [5]. Such methods could include telehealth, remote monitoring, or a hybrid approach, to increase accessibility and participation [6]. ...
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Background: Cardiovascular diseases (CVD) have been shown to be the greatest cause of death worldwide and rates continue to increase. It is recommended that CVD patients attend cardiac rehabilitation (CR) following a cardiac event to reduce mortality, improve recovery and positively influence behaviour around CVD risk factors. Despite the recognised benefits and international recommendations for exercise-based CR, uptake and attendance remain suboptimal. A greater understanding of CR barriers and facilitators is required, not least to inform service development. Through understanding current cardiac patients' attitudes and opinions around CR and physical activity (PA) could inform patient-led improvements. Moreover, through understanding aspects of CR and PA that participants like/dislike could provide healthcare providers and policy makers with information around what elements to target in the future. Aim: To investigate participants' attitudes and opinions around CR and PA. Methods: This study employed a cross-sectional survey design on 567 cardiac patients. Cardiac patients who were referred for standard CR classes at a hospital in the Scottish Highlands, from May 2016 to May 2017 were sampled. As part of a larger survey, the current study analysed the free-text responses to 5 open-ended questions included within the wider survey. Questions were related to the participants' experience of CR, reasons for non-attendance, ideas to increase attendance and their opinions on PA. Qualitative data were analysed using a 6-step, reflexive thematic analysis. Results: Two main topic areas were explored: "Cardiac rehabilitation experience" and "physical activity". Self-efficacy was increased as a result of attending CR due to exercising with similar individuals and the safe environment offered. Barriers ranged from age and health to distance and starting times of the classes which increased travel time and costs. Moreover, responses demonstrated a lack of information and communication around the classes. Respondents highlighted that the provision of more classes and classes being held out with working hours, in addition to a greater variety would increase attendance. In terms of PA, respondents viewed this as different to the CR experience. Responses demonstrated increased freedom when conducting PA with regards to the location, time and type of exercise conducted. Conclusion: Changes to the structure of CR may prove important in creating long term behaviour change after completing the rehabilitation programme.
... Particularly women, people older than 70 years, younger people, smokers, people with more comorbidity, people with reduced functioning, people living alone, unemployed people and people who have a lower income are more likely to abstain from participation. 18 Contextual factors such as distance, transportation difficulties, family commitment and opinions of significant others are reported to be barriers for enrolling in CR. 19 Though systematised referral is found to be a key to secure that patients enrol in CR, 18 many patients abstain from participation even when systematised referral is implemented in hospital practices. 9 The combination of systematised referral and discussions between the individual patient and a healthcare professional, the so called 'liaison' strategies, have been found more effective than systematised referral on its own, and the incorporation of these interventions into standard, in-hospital pathways has been recommended. ...
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Introduction Cardiac rehabilitation has become an integral part of secondary treatment of cardiovascular heart disease. Despite evidence demonstrating that cardiac rehabilitation improves prognoses, reduces disease progression and helps patients to find a new foothold in life, many patients do not enrol. Face-to-face interventions can encourage patients to enrol; however, it is unclear which strategies have been developed, how they are structured in a hospital context and whether they target the life-world of the patients. The objective of this scoping review is to map and evaluate the nature and characteristics of studies that have reported on face-to-face interventions to encourage patients to enrol in cardiac rehabilitation. Methods and analysis This review will be guided by the Joanna Briggs Institute Methodology for Scoping Reviews. A search strategy developed in cooperation with a research secretary will be applied in six databases including studies published from 2000 in English, Danish, Norwegian, Swedish and German with no restriction on publication type or study design. Studies involving adult patients with ischaemic heart disease or heart failure will be included. Studies providing the intervention after enrolment in cardiac rehabilitation will be excluded. Study selection will be performed independently by two reviewers. Data will be extracted by two reviewers using predefined data charting forms. The presentation of data will be a narrative summary of the characteristics and key findings to facilitate the integration of diverse evidence, and as we deem appropriate will be supported by a diagrammatic or tabular presentation. Ethics and dissemination This scoping review will use data from existing publications and does not require ethical approval. Results will be reported through publication in a scientific journal and presented on relevant conferences and disseminated as part of future workshops with professionals involved in communication with patients about enrolment in cardiac rehabilitation.
... Cardiac rehabilitation (CR) following acute myocardial infarction (AMI) is a multicomponent program leading to secondary prevention in cardiovascular diseases, reducing physical decline and improving physical capacities (Price et al., 2016;Ruano-Ravina et al., 2016;Poffley et al., 2017;Dibben et al., 2018;Cieza et al., 2021;Taylor et al., 2022). Furthermore, CR decreases hospitalizations and cardiovascular mortality (Antypas and Wangberg, 2012;Grazzi et al., 2016). ...
Article
Cardiac rehabilitation (CR) following acute myocardial infarction (AMI) improves physical capacities and decreases hospitalizations and cardiovascular mortality. L-Arginine is the substrate used by nitric oxide (NO) synthase (NOS) to generate NO and it has been shown to exert its beneficial effects on endothelium driving vasodilatation, reducing inflammation, and ameliorating physical function. We hypothesized that L-Arginine could enhance physical capacities in patients who underwent CR after AMI. We designed a study aimed to assess the effects of L-arginine administration on the physical capacity of patients who underwent coronary revascularization after AMI. The trial was carried out amid the COVID-19 pandemic. Patients were assigned, with a 2:1 ratio, to add to their standard therapy 1 bottle containing 1.66 g of L-arginine or 1 bottle of identical aspect apart from not containing L-arginine, twice a day orally for 3 weeks. Patients performed a 6-minute walking test (6MWT) and were assessed their Borg modified 0-10 rating of perceived exertion (BRPE) before starting and at the end of the treatment. Seventy-five patients receiving L-Arginine, and thirty-five receiving placebo successfully completed the study. The 6MWT distance increased significantly in the L-Arginine group compared to both baseline and placebo (p<0.0001). Additionally, we observed a significant improvement in the BRPE in patients treated with L-arginine but not in the placebo group. Taken together, our data indicate that L-arginine potentiates the response to CR, independently of age, sex, baseline functional capacity, and comorbid conditions. ***Significance Statement. This study shows for the first time that oral supplementation of L-arginine potentiates the response to cardiac rehabilitation after myocardial infarction and cardiac revascularization. Indeed, we observed a significant improvement in two fundamental parameters, namely, the 6-minute walking test and the Borg modified 0-10 rating of perceived exertion. Strikingly, the beneficial effects of L-arginine were independent from age, sex, comorbid conditions, and baseline functional capacity.
... The ÖHV runs activities to enhance cardiorespiratory fi tness, to prevent aff ective and cognitive disorders, to control co-morbidities and to maintain social inclusion. Given that many cardiovascular diseases are chronic medical conditions with multiple pathogenic factors, life-long support, healthy life styles and distinct health awareness are vital and require both individual treatment and the patients' readiness for sustainable adherence (Ruano-Ravina et al., 2016). Broadly speaking, patients should understand the great signifi cance of preventative and rehabilitative measures, and related activities should eventually become second nature to them. ...
... 15 16 Despite global recommendations, patients' participation in CR programmes is low mainly due to insufficient medical referral, travel distance, low self-efficacy, perceived body image and lack of time. [17][18][19] Moreover, during the COVID-19 pandemic, new barriers have arisen, such as the suspension of centre-based CR and in-person sessions, travelling and circulation restrictions. 20 21 Thus, the need to avoid the downgrading of CR is imperative. ...
Article
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Introduction Exercise-based cardiac rehabilitation (CR) is a beneficial tool for the secondary prevention of cardiovascular diseases with, however, low participation rates. Telerehabilitation, intergrading mobile technologies and wireless sensors may advance the cardiac patients’ adherence. This study will investigate the efficacy, efficiency, safety and cost-effectiveness of a telerehabilitation programme based on objective exercise telemonitoring and evaluation of cardiorespiratory fitness. Methods and analysis A supervised, parallel-group, single-blind randomised controlled trial will be conducted. A total of 124 patients with coronary disease will be randomised in a 1:1 ratio into two groups: intervention telerehabilitation group (TELE-CR) (n=62) and control centre-based cardiac rehabilitation group (CB-CR) (n=62). Participants will receive a 12-week exercise-based rehabilitation programme, remotely monitored for the TELE-CR group and standard supervised for the CB-CR group. All participants will perform aerobic training at 70% of their maximal heart rate, as obtained from cardiopulmonary exercise testing (CPET) for 20 min plus 20 min for strengthening and balance training, three times per week. The primary outcomes will be the assessment of cardiorespiratory fitness, expressed as peak oxygen uptake assessed by the CPET test and the 6 min walk test. Secondary outcomes will be the physical activity, the safety of the exercise intervention (number of adverse events that may occur during the exercise), the quality of life, the training adherence, the anxiety and depression levels, the nicotine dependence and cost-effectiveness. Assessments will be held at baseline, end of intervention (12 weeks) and follow-up (36 weeks). Ethics and dissemination The study protocol has been reviewed and approved by the Ethics Committee of the University of Thessaly (1108/1-12-2021) and by the Ethics Committee of the General University Hospital of Larissa (3780/31-01-2022). The results of this study will be disseminated through manuscript publications and conference presentations. Trial registration number NCT05019157.
... Reasons for low rates of use of CR are very diverse among different countries and regions. Barriers to participation in ET are classified as inherent to the patient's characteristics or related to accessibility of the CRP system (Ruano-Ravina et al., 2016). For instance, gender, age, comorbidities, disease perception, social class, education level or accessibility, and proximity to 1 | Baseline characteristics of patients in the cardiac rehabilitation program and in the three groups. ...
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Background and Aims: Exercise training (ET) is a critical component of cardiac rehabilitation (CR), but it remains underused. The aim of this study was to compare clinical outcomes between patients who completed ET (A-T), those who accepted ET but did not complete it (A-NT), and those who did not accept to undergo it (R-NT), and to analyze reasons for rejecting or not completing ET. Methods and Results: A unicenter ambispective observational registry study of 497 patients with acute coronary syndrome (ACS) was carried out in Barcelona, Spain, from 2016 to 2019. The primary endpoint was a composite of all-cause mortality, hospitalization for ACS, or need for revascularization during follow-up. Multivariable analysis was carried out to identify variables independently associated with the primary outcome. Initially, 70% of patients accepted participating in the ET, but only 50.5% completed it. The A-T group were younger and had fewer comorbidities. Baseline characteristics in A-NT and R-NT groups were very similar. The main reason for not undergoing or completing ET was rejection (reason unknown) or work/schedule incompatibility. The median follow-up period was 31 months. Both the composite primary endpoint and mortality were significantly lower in the A-T group compared to the A-NT and R-NT (primary endpoint: 3.6% vs. 23.2% vs. 20.4%, p < 0.001, respectively; mortality: 0.8% vs. 9.1% vs. 8.2%, p < 0.001; respectively). During multivariable analysis, the only variables that remained statistically significant with the composite endpoint were ET completion, previous ACS, and anemia. Conclusion: Completion of ET after ACS was associated with improved prognosis. Only half of the patients completed the ET program, with the leading reasons for not completing it being refusal (reason unknown) and work/schedule incompatibility. These results highlight the need to focus on the needs of patients in order to guarantee that structural barriers to ET no longer exist.
... Cardiovascular disease (CVD) is the leading cause of death and disability, and acute myocardial infarction (AMI) is the leading cause of death from cardiovascular disease in certain age groups [1][2][3]. Survival following AMI is dependent on rapid medical care which is categorized as medication and percutaneous coronary intervention (PCI) and lifestyle changes (diet, smoking, psychosocial factors, physical inactivity), including the promotion of physical exercise [2,4]. ...
Article
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Objective Acute myocardial infarction is the most severe manifestation of coronary artery disease. Cardiac rehabilitation programs following percutaneous coronary intervention (PCI) assist patients to get back to their daily routine and can improve their cardiovascular health. The aim of this study was to evaluate the effect of cardiac rehabilitation in patients after primary PCI on the left and right ventricular function. Methods In this cross-sectional study, patient who underwent primary PCI following myocardial infarction were included. Month after the PCI procedure, 5 sessions of cardiac rehabilitation program were performed based on the patient's symptoms and according to the diagnosis by cardiologist. The duration of each rehabilitation session started from 20 minutes in the first session and reached 60 minutes in the last session. Exercises included walking on a treadmill and pedaling a stationary bike with limbs. Ventricular function was assessed after primary PCI and after the rehabilitation program. Patients were followed up by telephone after one year of the rehabilitation program. Results 30 patients were enrolled in the study, 23 of whom were male (76.7%). Right ventricular function did not change after the cardiac rehabilitation program compared to before (p = 1.00). Left ventricular function significantly increased after rehabilitation (p = 0.003). Increased left ventricular function was significant only in males (p < 0.001). Cardiac rehabilitation program in people over 60 years did not change left ventricular function (p < 0.05). One year after the cardiac rehabilitation program, 3 patients (10%) died. Conclusion The findings of our study showed that the implementation of an exercise-based cardiac rehabilitation program improves left ventricular function in patients with myocardial infarction after primary PCI but does not affect right ventricular function. The findings also showed that cardiac rehabilitation program may be associated with the gender and the age of the patients.
... 15 Factors influencing adherence to treatment are gender, 19 older age, presence of comorbidities, unemployed and unmarried persons, persons with low education and income. 20 Myocardial infarction is a life-threatening form of coronary heart disease. Long-term treatment of patients after myocardial infarction is based on the implementation of a therapeutic plan, including lifestyle changes and pharmacotherapy using various influences. ...
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Background: Patients with myocardial infarction have low adherence to secondary prevention. Patients with acute coronary syndromes usually decide not to take cardiac drugs for 7 days after discharge for various reasons and adherence rates are usually very low. The aim of this scoping review was to identify factors influencing treatment adherence after myocardial infarction and the role of interventions to improve treatment adherence. Methods: Two electronic databases (PubMed and Web of Science) were systematically searched for relevant published reviews of interventions for adherence after myocardial infarction. Inclusion criteria were study design: randomized control trial, systematic reviews; published in English; sample age ≥18 years. The methodological framework proposed by Arksey & O'Malley was used to guide the review process of the study. Results: Thirteen articles met the inclusion/exclusion criteria. Four of the thirteen studies assessed factors influencing patient adherence to therapy after myocardial infarction, the remaining studies examined various interventions increasing adherence to treatment after myocardial infarction. Conclusion: There is a need to improve adherence of patients to treatment after myocardial infarction. Studies show that the use of modern technologies and communication with the patients by phone improve adherence to treatment.
... Despite the clear-cut advantage of rehabilitation, one study (5) found a 56% drop-out rate during exercised-based rehabilitation programs, even with a supportive environment that included multiple contacts and educational methods suggesting that non-adherence is the main challenge to the rehabilitation programs. A systematic review found that comorbidities, advanced age, and accessibility were the main factors resulting in low participation in and adherence to cardiac rehabilitation programs (6). This suggests that diverse groups of people initially engaging in rehabilitation need alternative support and pathways, especially when attendance at the healthcare centres is not an option or not perceived as a necessity for them. ...
Article
Background: eHealth literacy (eHL) may be an important factor in the adoption of telerehabilitation. However, little is known about how telerehabilitation affects patients' eHL. The current study evaluated changes over time in eHL for heart failure (HF) patients in a telerehabilitation program (the Future Patient Program) compared to a traditional rehabilitation program. Methods: As part of a randomized controlled trial comparing telerehabilitation with traditional rehabilitation, 137 HF patients completed the eHealth Literacy Questionnaire (eHLQ) at 6 and 12 months of their respective rehabilitation programs. Results: At 6 months, the telerehabilitation group indicated higher levels of 'using technology to process health information' and 'motivated to engage with digital services'. This difference was consistent over time, and we found no other differences between groups or over time with regard to eHL. Conclusions: Providing a digital toolbox for processing health information to HF patients may aid in increasing their eHL, motivation, and ability to engage with digital services in HF patients. Especially, if the technology is designed to support patient needs in terms of the educational content of the program. Preferably technology should be provided early on in the rehabilitation process to ensure optimal outcome. Trial registration: The study was registered in ClinicalTrials.gov (NCT03388918).
... Furthermore, good hearing or vision and having a family income higher than five minimum wages per month (approximately 1,330 USD) were positively associated with treatment adherence. As reported by Ruano-Ravina et al. (2016), these characteristics naturally allow patients to Note. All regression models were adjusted for the following variables: type of affiliation to the health system, patient's education, and problems because of patient loss of vision or hearing. ...
Article
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Abstract Background Multiple factors affect treatment adherence in individuals with cardiovascular disease. However, information on the relationships among treatment adherence, family functioning, and self-care agency in these patients and their families is limited. Purpose This study was developed to determine the relationships among treatment adherence, family functioning, self-care agency, and sociodemographic variables in patients with cardiovascular disease. Self-care agency, as defined by Orem, is the dynamic process patients use to engage in their own healthcare that involves discerning and addressing factors that allow their making decisions that improve self-care abilities. Methods This cross-sectional, observational–analytical study enrolled 151 adult patients with cardiovascular diseases who had undergone pharmacological and nonpharmacological treatments and 108 family members of these patients who had consented to participate. Measurements were performed using the “Questionnaire for measuring treatment adherence in patients with cardiovascular disease,” the “Family Functioning Assessment Scale,” and the “Self-care Agency Scale.” Results Of the 151 patients, 119 (78.8%) were assessed as having a low risk of nonadherence, 60 (39.7%) as having low family functioning, and 131 (86.8%) as having high self-care agency. Treatment adherence and self-care agency showed a moderate and significant correlation (r = .66, p < .001). Similarly, treatment adherence and family functioning showed a low but significant correlation (r = .35, p < .001). Moreover, significant multivariate associations were found among the variables of interest. Patients with a low risk of nonadherence were found to be more likely to have a secondary or postsecondary education, not to have vision or hearing problems, and to have a contributory affiliation mode with the health system or private health insurance. In addition, participants with moderate or high levels of family functioning were less likely to be workers or to not have hearing or vision problems. Finally, significant differences were noted between patients with low self-care agency and those with high self-care agency in terms of kinship relationship with family members and affiliation mode with the health system. Conclusions/Implications for Practice The results of this research help clarify the issue of treatment adherence in patients with cardiovascular disease. Although family functioning and self-care agency were found to be low to moderately correlated with treatment adherence, relevant information regarding these variables and sociodemographic variables is presented in this study. Nurses may use these results as a reference to design nursing care plans and interventions to address the conditions of their patients more appropriately.
Article
(a) background: Home-based cardiac rehabilitation (CR) is an attractive alternative for frail older patients who are unable to participate in hospital-based CR. Yet, the feasibility of home-based CR provided by primary care physiotherapists (PTs) to these patients remains uncertain. (b) objective: To investigate physiotherapists' (PTs) clinical experience with a guideline-centered, home-based CR protocol for frail older patients. (c) methods: A qualitative study examined the home-based CR protocol of a randomized controlled trial. Observations and interviews of the CR-trained primary care PTs providing home-based CR were conducted until data saturation. Two researchers separately coded the findings according to the theoretical framework of Gurses. (d) results: The enrolled PTs (n = 8) had a median age of 45 years (IQR 27-57), and a median work experience of 20 years (IQR 5-33). Three principal themes were identified that influence protocol-adherence by PTs and the feasibility of protocol-implementation: 1) feasibility of exercise testing and the exercise program; 2) patients' motivation and PTs' motivational techniques; and 3) interdisciplinary collaboration with other healthcare providers in monitoring patients' risks. (e) conclusion: Home-based CR for frail patients seems feasible for PTs. Recommendations on the optimal intensity, use of home-based exercise tests and measurement tools, and interventions to optimize self-regulation are needed to facilitate home-based CR.
Article
Background The positive effects of cardiac rehabilitation are well established. However, it has an inherent challenge, namely the low attendance rate among older vulnerable patients, which illustrates the need for effective interventions. Peer mentoring is a low-cost intervention that has the potential to improve cardiac rehabilitation attendance and improve physical and psychological outcomes among older patients. The aim of this study was to test the feasibility and acceptability of a peer-mentor intervention among older vulnerable myocardial infarction patients referred to cardiac rehabilitation. Methods The study was conducted as a single-arm feasibility study and designed as a mixed methods intervention study. Patients admitted to a university hospital in Denmark between September 2020 and December 2020 received a 24-week peer-mentor intervention. The feasibility of the intervention was evaluated based on five criteria by Orsmond and Cohn: (a) recruitment capability, (b) data-collection procedures, (c) intervention acceptability, (d) available resources, and (e) participant responses to the intervention. Data were collected through self-administrated questionnaires, closed-ended telephone interviews, semi-structured interviews, and document sheets. Results Twenty patients were offered the peer-mentor intervention. The intervention proved feasible, with a low dropout rate and high acceptability. However, the original inclusion criteria only involved vulnerable women, and this proved not to be feasible, and were therefore revised to also include vulnerable male patients. Peer mentors ( n = 17) were monitored during the intervention period, and the findings indicate that their mentoring role did not cause any harm. The peer-mentor intervention showed signs of effectiveness, as a high rate of cardiac rehabilitation attendance was achieved among patients. Quality of life also increased among patients. This was the case for emotional, physical, and global quality of life measures at 24-week follow-up. Conclusion The peer-mentor intervention is a feasible and acceptable intervention that holds the potential to increase both cardiac rehabilitation attendance and quality of life in older vulnerable patients. This finding paves the way for peer-mentor interventions to be tested in randomized controlled trials, with a view toward reducing inequality in cardiac rehabilitation attendance. However, some of the original study procedures were not feasible, and as such was revised. Trial registration The feasibility study was registered at ClinicalTrials.gov ( ClinicalTrials.gov identification number: NCT04507529 ), August 11, 2020.
Article
Background: Cardiac rehabilitation is central in reducing mortality and morbidity after myocardial infarction. However, the fulfillment of guideline-recommended cardiac rehabilitation targets is unsatisfactory. eHealth offers new possibilities to improve clinical care. Objective: This study aims to assess the effect of a web-based application designed to support adherence to lifestyle advice and self-control of risk factors (intervention) in addition to center-based cardiac rehabilitation, compared with cardiac rehabilitation only (usual care). Methods: All 150 patients participated in cardiac rehabilitation. Patients randomized to the intervention group (n=101) received access to the application for 25 weeks where information about lifestyle (eg, diet and physical activity), risk factors (eg, weight and blood pressure [BP]), and symptoms could be registered. The software provided feedback and lifestyle advice. The primary outcome was a change in submaximal exercise capacity (Watts [W]) between follow-up visits. Secondary outcomes included changes in modifiable risk factors between baseline and follow-up visits and uptake and adherence to the application. Regression analysis was used, adjusting for relevant baseline variables. Results: There was a nonsignificant trend toward a larger change in exercise capacity in the intervention group (n=66) compared with the usual care group (n=40; +14.4, SD 19.0 W, vs +10.3, SD 16.1 W; P=.22). Patients in the intervention group achieved significantly larger BP reduction compared with usual care patients at 2 weeks (systolic -27.7 vs -16.4 mm Hg; P=.006) and at 6 to 10 weeks (systolic -25.3 vs -16.4 mm Hg; P=.02, and diastolic -13.4 vs -9.1 mm Hg; P=.05). A healthy diet index score improved significantly more between baseline and the 2-week follow-up in the intervention group (+2.3 vs +1.4 points; P=.05), mostly owing to an increase in the consumption of fish and fruit. At 6 to 10 weeks, 64% (14/22) versus 46% (5/11) of smokers in the intervention versus usual care groups had quit smoking, and at 12 to 14 months, the respective percentages were 55% (12/22) versus 36% (4/11). However, the number of smokers in the study was low (33/149, 21.9%), and the differences were nonsignificant. Attendance in cardiac rehabilitation was high, with 96% (96/100) of patients in the intervention group and 98% (48/49) of patients receiving usual care only attending 12- to 14-month follow-up. Uptake (logging data in the application at least once) was 86.1% (87/101). Adherence (logging data at least twice weekly) was 91% (79/87) in week 1 and 56% (49/87) in week 25. Conclusions: Complementing cardiac rehabilitation with a web-based application improved BP and dietary habits during the first months after myocardial infarction. A nonsignificant tendency toward better exercise capacity and higher smoking cessation rates was observed. Although the study group was small, these positive trends support further development of eHealth in cardiac rehabilitation. Trial registration: ClinicalTrials.gov NCT03260582; https://clinicaltrials.gov/ct2/show/NCT03260582. International registered report identifier (irrid): RR2-10.1186/s13063-018-3118-1.
Article
Introduction: Hypertension is among the main primary factors for the cause of death from cardiovascular diseases. Among the treatments for hypertension, physical exercise has stood out. However, the adherence of patients with hypertension to the practice of physical exercises is low, and thus strategies such as virtual rehabilitation may be beneficial, in addition to increasing adherence. Objective: This study aimed to evaluate the effect of a virtual cardiovascular rehabilitation (VCR) program on arterial blood pressure, physical conditioning and the quality of life of patients with hypertension. Methods: This is a randomized clinical trial with 59 patients with hypertension, divided into three groups: conventional cardiac rehabilitation (CCR), VCR and control (CO). Before and after the intervention period the patients were submitted to anthropometric data (BMI, body mass index), vital data (SBP, systolic blood pressure; DBP, diastolic blood pressure), quality of life (SF-36 questionnaire), respiratory muscle strength (MIP, maximum inspiratory pressure; MEP, maximum expiratory pressure) and functional capacity (6-MWT, six-minute walk test) assessment. Both VCR and CCR groups underwent aerobic training. Results: VCR protocol increased functional capacity (p < 0.001), expiratory muscle strength (p < 0.002), and quality of life in the domains in relation to limitation of physical (p < 0.018), emotional aspects (p < 0.019), social aspects (p < 0.042), and mental health (p < 0.002) when baseline and post-intervention were compared. Conclusion: The VCR program is an effective treatment strategy for improving the physical capacity and quality of life of patients with hypertension.
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La enfermedad cardiovascular (ECV) ha sido la principal causa de muerte entre las personas mayores en los países avanzados. Además, la cardiopatía isquémica ha sido una patología típica de los pacientes ancianos. Si bien la angioplastia con stent se considera un procedimiento eficaz y seguro para los pacientes cardíacos mayores de 65 años, la información sobre el seguimiento clínico a largo plazo de los pacientes ancianos sometidos a angioplastia con stent es escasa. El objetivo de este estudio fue aumentar el conocimiento sobre la evolución a largo plazo de los pacientes mayores de 65 años, que requirieron angioplastia con Stent, mediante el desarrollo de un estudio de cohorte, analítico, observacional y prospectivo. Entre junio de 1991 y junio de 1997, se incluyó en el estudio a un total de 1029 pacientes consecutivos. Los pacientes estaban en dos grupos: mayores de 65 años y menores de 65 años. La incidencia de eventos clínicos a largo plazo (4 años) es similar. Aunque se detecta una mayor tasa de mortalidad (65% más alta) en pacientes ancianos. El estudio permite conocer mejor la evolución a largo plazo de los pacientes mayores de 65 años. Es importante destacar que la angioplastia con stent logra resultados satisfactorios a medio plazo en pacientes de edad avanzada. Palabras Clave: Enfermedades cardiovasculares; Enfermedad coronaria; El síndrome coronario agudo; Infarto agudo del miocardio.
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Purpose: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR. Methods: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate. Results: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables. Conclusions: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.
Article
Purpose: Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both. Methods: Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified. Results: Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P < .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P < .05). Conclusion: Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.
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Digital health in cardiovascular prevention and rehabilitation In recent years, digital health has found its way into clinical practice. In cardiology, there is a shift from providing care in the hospital to providing care at the patient’s home, i.e. a shift from intramural to extramural care. This article offers an overview of the current use of digital health technologies in cardiovascular prevention and rehabilitation. Important steps towards implementation are discussed. Finally, a future vision for digital health within cardiac rehabilitation and secondary prevention is outlined, in which the technology is integrated in a digitally enhanced healthcare system. Through digital technology, a strong network can be built between all lines of care. To overcome personal, technological and legal barriers, technological development must take place in dialogue with patients and healthcare providers. In the future, thanks to digital technology, a high-quality, affordable, personalised healthcare could be delivered in a highly human, patient-centered way.
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Background Socioeconomic inequities in acute coronary syndrome (ACS) epidemiology and care have been reported for at least 30–40 years. However, an up-to-date overview of evidence reflecting current clinical practice is not available. This systematic review aimed to summarize literature published in the last decade, regarding the association between socioeconomic position (SEP), incidence and prevalence of ACS, post-ACS medical care, and mortality. Methods The systematic search was performed in PubMed and Embase restricted to publication year (2009–2021), according to predefined methods (PROSPERO: CRD42020197654). Results were classified according to outcomes and socioeconomic exposures, and the risk of bias was evaluated. Results In total, 181 studies were included, mainly from high-income countries (81%). The majority showed an association between lower SEP (i.e. education, income, occupation, insurance, or composite SEP) and increased ACS incidence (89%)(incidence rate ratios: 1.1–4.7), increased ACS prevalence (88%)(odds ratios (ORs): 1.8–3.9), receiving suboptimal ACS-related medical care (46%)(ORs: 1.1–10.0), or increased post-ACS mortality (71%)(hazard ratios: 1.1–4.13). Studies with a lower risk of bias appeared more likely to describe inequity in favor of higher SEP than studies with a higher risk of bias. Conclusions Across studies from the last decade, lower SEP is associated with higher risks of ACS, subsequent suboptimal medical care, and mortality among the ACS patients, in particular in studies with a lower risk of bias. This indicates considerable socioeconomic inequity among ACS patients internationally, despite low- and middle-low-income countries being inadequately represented. Thus, efforts are warranted to continuously monitor ACS-related socioeconomic inequity.
Article
Introduction: Growth of the older adult demographic has resulted in an increased number of older patients with cardiovascular disease (CVD) in combination with comorbid diseases and geriatric syndromes. Cardiac rehabilitation (CR) is utilized to promote recovery and improve outcomes, but remains underutilized, particularly by older adults. CR provides an opportunity to address the distinctive needs of older adults, with focus on CVD as well as geriatric domains that often dominate management and outcomes. Areas covered: Utility of CR for CVD in older adults as well as pertinent geriatric syndromes (e.g., multimorbidity, frailty, polypharmacy, cognitive decline, psychosocial stress, and diminished function) that affect CVD management. Expert opinion: Mounting data substantiate the importance of CR as part of recovery for older adults with CVD. The application of CR as a standard therapy is especially important as the combination of CVD and geriatric syndromes catalyzes functional decline and can trigger progressive clinical deterioration and dependency. While benefits of CR for older adults with CVD are already evident, further reengineering of CR is necessary to better address the needs of older candidates who may be frail, especially as remote and hybrid formats of CR are becoming more widespread.
Article
Background and purpose: Engagement in physical activity following coronary artery bypass graft (CABG) surgery has many benefits and also many potential barriers, especially during the first few months. It is important to explore current clinical practice before investigating ways to optimally prepare and support people to progressively increase their physical activity post-hospital discharge and to navigate the challenges. The aim of the study was to explore current practice in New Zealand hospital services for preparing and supporting people who have had CABG surgery to engage in physical activity following hospital discharge. Methods: Locality authorisation to participate in the study was sought from all 11 hospitals providing cardiac surgery services in New Zealand. The most senior health professional responsible for preparing people to engage in physical activity following CABG surgery was invited to participate by completing a purpose designed questionnaire on behalf of their hospital service. Respondents were also requested to provide any patient information handouts regarding progressive physical activity engagement following CABG surgery. Results: Responses were received from all nine hospitals that granted locality authorisation. All nine hospitals prepared people to engage in aerobic exercise prior to discharge, predominantly through the provision of a walking schedule. In contrast, no hospitals provided information about engagement in resistance exercise. There was wide variability in both the advice provided regarding sternal precautions and time to return to activities of daily living. Additionally, the facilitation of some elements of self-management for physical activity, in particular problem solving and providing follow up support outside of the cardiac rehabilitation setting was provided infrequently. Discussion: The findings demonstrated variability in service delivery in a number of areas and highlighted potential areas for improvement in light of what is known from the literature. Provision of follow up support for those unable to access outpatient cardiac rehabilitation is a key need.
Article
Purpose: Despite known health benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), only a quarter of eligible patients attend. Among CR barriers are physical (eg, walking) and in-person attendance limitations. The purpose of this study was to determine the prevalence of difficulty walking and dependence on another person to attend medical appointments among people with and without CVD using national survey data. Methods: We compared the prevalence of difficulty walking and difficulty attending medical appointments alone among adults with and without CVD using national survey data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2015-2019. We used logistic regression and Rao-Scott χ2 analysis while controlling for several social determinants of health as covariates. Results: Of 2 212 973 respondents, 200 087 (9.04%) had CVD. The odds of individuals with CVD experiencing either difficulty walking or difficulty attending medical appointments alone were >3 times greater than the odds for individuals without CVD. In all adults with CVD, 42% reported difficulty walking and 20% reported dependence on another person to attend medical appointments. In all adults with CVD, 46% reported difficulty with one or both difficulties compared with 14% of adults without CVD. Conclusions: We estimate that 11.9 million Americans with self-reported CVD have difficulty walking, or are dependent on another person to attend medical appointments, or both. Alternative models of CR that adapt to these limitations are needed to increase attendance of CR so that all adults with CVD can improve their health outcomes.
Article
Background As the number of adults with congenital heart disease increases because of therapeutic advances, cardiac rehabilitation (CR) is increasingly being used in this population after cardiac procedures or for reduced exercise tolerance. We aim to describe the adherence and exercise capacity improvements of patients with adult congenital heart disease (ACHD) in CR. Methods and Results This retrospective study included patients with ACHD in CR at New York University Langone Rusk Rehabilitation from 2013 to 2020. We collected data on patient characteristics, number of sessions attended, and functional testing results. Pre‐CR and post‐CR metabolic equivalent task, exercise time, and maximal oxygen uptake were assessed. In total, 89 patients with ACHD (mean age, 39.0 years; 54.0% women) participated in CR. Referral indications were reduced exercise tolerance for 42.7% and post–cardiac procedure (transcatheter or surgical) for the remainder. Mean number of sessions attended was 24.2, and 42 participants (47.2%) completed all 36 CR sessions. Among participants who completed the program as well as pre‐CR and post‐CR functional testing, metabolic equivalent task increased by 1.3 (95% CI, 0.7–1.9; baseline mean, 8.1), exercise time increased by 66.4 seconds (95% CI, 21.4–111.4 seconds; baseline mean, 536.1 seconds), and maximal oxygen uptake increased by 2.5 mL/kg per minute (95% CI, 0.7–4.2 mL/kg per minute; baseline mean, 20.2 mL/kg per minute). Conclusions On average, patients with ACHD who completed CR experienced improvements in exercise capacity. Efforts to increase adherence would allow more patients with ACHD to benefit.
Article
Over 20% of cardiovascular disease (CVD) patients have a comorbid mental health disorder, resulting in an increased risk of recurring major adverse cardiac events (MACE) and mortality. Despite the higher risk, patients with comorbid depression or anxiety disorders are twice as likely to be non-adherent to secondary prevention. Therefore, better understanding of the adherence experiences of this subgroup is needed to inform service delivery and enhance adherence for this higher risk group. This study aims to explore the perceptions, understandings, and experiences of adherence to secondary prevention amongst 33 cardiac patients with diagnosed depression and/or anxiety disorder. Participants were recruited as part of the Cardiovascular Health in Anxiety or Mood Problems Study. Semi-structured interviews were conducted and data were analysed via inductive thematic analysis. Patient understandings of adherence to secondary prevention were limited, with medication compliance considered the marker of adherence. Further, participants did not perceive unintentional non-adherence to constitute non-adherence, rather an intent to engage was viewed as defining adherence. Participants also reported that a lack of practitioner understanding and management around their mental health negatively impacted the practitioner-patient relationship and their engagement with secondary prevention. Results highlight that unique barriers, especially around management of comorbid mental health exist for this subgroup. Additionally, adherence to secondary prevention might be limited by patients' narrow understandings of adherence as the intent to engage and as medication compliance.
Article
Purpose: The beneficial effects of exercise-based cardiac rehabilitation (CR) after an acute coronary syndrome (ACS) are well known, but patients ≥80 yr have been less studied. The aim was to evaluate the effects of CR on patients with ACS ≥80 yr on peak cardiorespiratory fitness (CRF), physical function, and patient-reported outcome measures (PROMs) compared with a control group. Methods: A total of 26 patients with ACS, median age 82 (81, 84) yr, were randomized to hospital-based CR combined with a home-based exercise program (CR group) or to a control group (C) for 4 mo. Outcomes were assessed at baseline and 4 mo and included the peak CRF (primary outcome), 6-min walk test (6MWT), muscle endurance, Timed Up and Go (TUG), Short Physical Performance Battery (SPPB), one-leg stand test, and PROMs. Results: There were no significant differences between the groups in peak CRF. The CR group improved significantly in terms of the 6MWT (P = .04), isotonic muscle endurance (P < .001), one-leg stand test (P = .001), SPPB total score (P =.03), Activities-specific Balance Confidence (P =.01), and anxiety (P =.03), as compared with C. There were no significant intergroup differences in the TUG, the self-reported health question or depression. Conclusions: Patients with ACS ≥80 yr improved in walking distance, muscle endurance, physical function, and PROMs, but not in peak CRF, by participating in a CR program. These results suggest an increased referral to CR for this growing group of patients to enable preserved mobility and independence in daily living, but this needs to be confirmed in larger studies.
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Cardiac rehabilitation is an individualized outpatient program of physical exercises and medical education designed to accelerate recovery and improve health status in heart disease patients. In this study, we aimed for assessment of patients’ perception of the involvement of technology and remote monitoring devices in cardiac recovery. During the Living Lab Phase of the Virtual Coaching Activities for Rehabilitation in Elderly (vCare) project, we evaluated eleven patients (five heart failure patients and six ischemic heart disease patients). Patient admission in the UMFCD cardiology clinical department served as a shared inclusion criterion for both study groups. In addition, the presence of II or III heart failure NYHA stage status was considered an inclusion criterion for the heart failure study group and patients diagnosed with ischemic heart disease for the second one. We conducted a system usability survey to assess the patients’ perception of the system’s technical and medical functions. The survey had excellent preliminary results in the heart failure study group and good results in the ischemic heart disease group. The limited access of patients to cardiac rehabilitation in Romania has led to increased interest and motivation in this study. The final version of the product is designed to adapt to patient needs and necessities; therefore, patient perception is necessary.
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Introduction Cardiac rehabilitation (CR) is a critical treatment for patients with coronary heart disease after percutaneous coronary intervention. Unfortunately, participation and adherence of CR are unexpectedly poor. This study aims to test whether low-intensity or medium-intensity brisk walking is more helpful in improving early attendance, adherence and physical results. Methods and analysis This randomised controlled study will compare the effects of low-intensity and medium-intensity brisk walking to improve adherence and cardiopulmonary endurance. Participants will be randomly allocated to low-intensity or medium-intensity groups and will be followed-up for 8 weeks. Primary and secondary outcome data will be collected at baseline and at 2, 4 and 8 weeks. Primary outcomes measure changes in oxygen consumption (VO 2 ) peak value (mL/kg/min), as well as adherence. Secondary outcomes include changes in body mass index, oxygen pulse, maximal metabolic equivalent, breathing reserve, vital capacity, ratio of forced expiratory volume in 1 s to forced vital capacity, Δoxygen consumption/Δwork rate (ΔVO 2 /ΔWR), minute ventilation/carbon dioxide production and self-efficacy. Ethics and dissemination Ethical approval and informed consent form have been obtained from the Ethics Committee of Hebei General Hospital (approval number: NA-2021–03). The study background and main objective, as well as potential benefits and risks, will be fully explained to the participants and their families. Findings from this study will be published on academic journals in Chinese or in English for widespread dissemination of the results Trial registration number ChiCTR2100047568.
Article
Aim To examine the efficacy of digital health interventions (DHI) versus standard of care among patients with prior heart failure (HF) hospitalization. Methods An electronic search of MEDLINE, Cochrane, OVID, CINHAL and ERIC, databases was performed through August 2021 for randomized clinical trials that evaluated the outcomes with DHI among patients with HF. Data were pooled using the random-effects model. The primary outcome was all-cause mortality. Results 10 randomized trials were included in our analysis, with a total of 7204 patients and a weighted follow up duration of 15.6 months. Compared with the reference group, patients in the DHI group had lower all-cause mortality (8.5% vs. 10.2%, risk ratio-RR 0.80; 95% confidence interval-CI 0.66 to 0.96; P = 0.02), as well as lower cardiovascular mortality (7.3% vs. 9.6%, RR 0.76; 95% CI 0.62 to 0.94; P = 0.01). There was no significant difference in HF-related hospitalizations (23.4% vs. 26.2%, RR 0.82; 95% CI 0.66 to 1.02; P = 0.07) and all-cause hospitalizations (48.3% vs. 49.9%, RR 0.89; 95% CI 0.77 to 1.03; P = 0.11) in the DHI versus reference groups. Patients in the DHI group had fewer days lost due to HF-related hospitalizations (mean difference-MD: -1.77; 95% CI -3.06,-0.48, p = 0.01; I² = 51), but similar days lost to all-cause hospitalizations (MD: -0.76; 95% CI -3.07,-1.55, p = 0.52; I² = 69) compared with patients in the reference group. Conclusion Compared with usual care, DHI among patients with HF provided significant reduction of all-cause mortality and cardiovascular mortality and had fewer total days lost to HF hospitalizations. There were no differences in all-cause hospitalizations, and HF hospitalizations.
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Background Virtual reality-based therapy (VRBT) has been recently used in rehabilitation programs, as it can improve patient's adherence to treatment. However, patients’ acceptance of VRBT has been scarcely investigated. Objective To qualitatively analyze the perceptions and preferences of patients about the inclusion of VRBT to a conventional cardiovascular rehabilitation program (CRP). Methods Fifteen patients from a randomized clinical trial participated in focus groups for qualitative assessment. Results Patients demonstrated good acceptance and satisfaction of VRBT. Physical and psychosocial benefits were highlighted, and patients reported the perception of higher exercise intensity in VRBT then when doing conventional training. In addition, the frequency of VRBT (once a week), associated with conventional treatment was reported as satisfactory. Cognitive aspects that influenced participation to the new approach were also raised by study participants. Conclusion Patients with cardiac conditions demonstrated satisfaction with the inclusion of VRBT in a conventional CRP, demonstrating that VRBT has the potential to be a new approach for this patient population, allowing training diversification. Benefits perceived by patients include physical, mental, and social aspects. Trial Registered NCT04336306 (https://clinicaltrials.gov/ct2/show/NCT04336306)
Article
The article presents a review of literature data reflecting the relevance and modern views on the effectiveness and expediency of using various options for rehabilitation programs for cardiovascular diseases. The issues of the history of the development of cardiac rehabilitation both abroad and in Russia are consecrated. The article also presents alternative models for conducting cardiac rehabilitation, in particular, using remote and telemedicine technologies. The widespread use of smartphones and high-speed Internet access contributed to the further introduction and use of telemedicine technologies in cardiac rehabilitation. The article discusses the possibilities of telerehabilitation of cardiological patients and shows its comparable effectiveness with traditional cardiac rehabilitation.
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Aim The benefits of cardiac rehabilitation (CR) after acute coronary syndrome (ACS) are well established. However, the relative benefit of CR in those with comorbidities, including diabetes, is not well understood. This systematic review and meta-analysis examined the benefit of CR on exercise capacity and secondary outcomes in ACS patients with a co-diagnosis of diabetes compared to those without. Methods Five databases were searched in May 2021 for randomised controlled trials (RCTs) and observational studies reporting CR outcomes in ACS patients with and without diabetes. The primary outcome of this study was exercise capacity expressed as metabolic equivalents (METs) at the end of CR and ≥ 12-month follow-up. Secondary outcomes included health-related quality of life, cardiovascular- and diabetes-related outcomes, lifestyle-related outcomes, psychological wellbeing, and return to work. If relevant/possible, studies were pooled using random-effects meta-analysis. Results A total of 28 studies were included, of which 20 reported exercise capacity and 18 reported secondary outcomes. Overall, the studies were judged to have a high risk of bias. Meta-analysis of exercise capacity was undertaken based on 18 studies (no RCTs) including 15,288 patients, of whom 3369 had diabetes. This analysis showed a statistically significant smaller difference in the change in METs in ACS patients with diabetes (standardised mean difference (SMD) from baseline to end of CR: − 0.15 (95% CI: − 0.24 to − 0.06); SMD at the ≥ 12-month follow-up: − 0.16 (95% CI: − 0.23 to − 0.10, four studies)). Conclusion The benefit of CR on exercise capacity in ACS patients was lower in those with diabetes than in those without diabetes. Given the small magnitude of this difference and the substantial heterogeneity in the results of the study caused by diverse study designs and methodologies, further research is needed to confirm our findings. Future work should seek to eliminate bias in observational studies and evaluate CR based on comprehensive outcomes.
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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
Article
Purpose: Cardiac rehabilitation (CR) is a key aspect of secondary prevention following acute myocardial infarction (AMI). While there is growing evidence of unique benefits of CR in older adults, it remains underutilized. We aimed to examine specific demographic, clinical, and functional factors associated with utilization of CR among older adults hospitalized with AMI. Methods: Our project used data from the SILVER-AMI study, a nationwide prospective cohort study of patients age ≥75 yr hospitalized with AMI and followed them up for 6 mo after discharge. Extensive baseline data were collected on demographics, clinical and psychosocial factors, and functional and sensory impairments. The utilization of CR was collected by a survey at 6 mo. Backward selection was employed in a multivariable-adjusted logistic regression model to identify independent predictors of CR use. Results: Of the 2003 participants included in this analysis, 779 (39%) reported participating in CR within 6 mo of discharge. Older age, longer length of hospitalization, having ≤12 yr of education, visual impairment, cognitive impairment, and living alone were associated with decreased likelihood of CR participation; receipt of diagnostic and interventional procedures (ie, cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft) was associated with increased likelihood of CR participation. Conclusions: Demographic and clinical factors, as well as select functional and sensory impairments common in aging, were associated with CR participation at 6 mo post-discharge in older AMI patients. These results highlight opportunities to increase CR usage among older adults and identify those at risk for not participating.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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To assess the effects of multi-disciplinary cardiac rehabilitation (CR) on survival in the full population of patients with an acute coronary syndrome (ACS) and patients that underwent coronary revascularization and/or heart valve surgery. Population-based cohort study in the Netherlands using insurance claims database covering ∼22% of the Dutch population (3.3 million persons). All patients with an ACS with or without ST elevation, and patients who underwent coronary revascularization and/or valve surgery in the period 2007-10 were included. Patients were categorized as having received CR when an insurance claim for CR was made within the first 180 days after the cardiac event or revascularization. The primary outcome was survival time from the inclusion date, limited to a total follow-up period of 4 years, with a minimum of 180 days. Propensity score weighting was used to control for confounding by indication. Among 35 919 patients with an ACS and/or coronary revascularization or valve surgery, 11 014 (30.7%) received CR. After propensity score weighting, the adjusted hazard ratio (HR) associated with receiving CR was 0.65 (95% CI 0.56-0.77). The largest benefit was observed for patients who underwent coronary artery bypass grafting (CABG) and/or valve surgery (HR = 0.55, 95% CI 0.42-0.74). In a large and representative community cohort of Dutch patients with an ACS and/or intervention, CR was associated with a substantial survival benefit up to 4 years. This survival benefit was present regardless of age, type of diagnosis, and type of intervention. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.
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Cardiac rehabilitation (CR) reduces the risks of mortality and hospitalisation in patients with coronary artery disease and without diabetes. It is unknown whether patients with diabetes obtain the same benefits from CR. We retrospectively examined patients referred to a 12 week CR programme between 1996 and 2010. Associations between CR completion vs non-completion and death, hospitalisation rate and cardiac hospitalisation rate were assessed by survival analysis. Over the study period, 13,158 participants were referred to CR (mean ± SD, age 59.9 ± 11.1 years, 28.9% female, 2,956 [22.5%] with diabetes). Patients with diabetes were less likely to complete CR than those without diabetes (41% vs 56%, p < 0.0001). Over a median follow-up of 6.6 years, there were 379 deaths in patients with diabetes vs 941 deaths among those without diabetes (12.8% vs 8.9%). Of the non-completers, patients with diabetes had a higher mortality rate compared with those without diabetes (17.7% vs 11.3%). In patients who completed CR, mortality was lower: 11.1% in patients with diabetes vs 7.0% in those without diabetes. In patients with diabetes, CR completion was associated with reduced mortality (HR 0.46 [95% CI 0.37, 0.56]), reduced hospitalisation (HR 0.86 [95% CI 0.76, 0.96]) and reduced cardiac hospitalisation (HR 0.67 [95% CI 0.54, 0.84]). The protective associations were similar to those of patients without diabetes. In multivariable adjusted analyses, all of these associations remained significant. Patients with diabetes were less likely to complete CR than those without diabetes. However, patients with diabetes who completed CR derived similar apparent reductions in mortality and hospitalisation to patients without diabetes.
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Our aim was to compare the biopsychosocial characteristics of young women with those of older women who were enrolled in cardiac rehabilitation (CR). The baseline characteristics of women who prematurely terminated CR participation were also explored. Baseline physiological and psychosocial indices of women ≤ 55 years compared with older women eligible for CR were evaluated 1 week before enrolling in either a traditional CR or a gender-specific, motivationally enhanced CR. A greater proportion of young women (n = 65) compared with their older counterparts (n = 187) were diagnosed with acute myocardial infarction during their index hospitalization. They demonstrated lower high-density lipoprotein cholesterol, higher total cholesterol/high-density lipoprotein cholesterol ratios, and greater body weight compared with older women and were more likely to be active smokers. Young women compared with older women reported significantly worse health perceptions, quality of life, optimism, hope, social support, and stress and significantly more symptoms of depression and anxiety. Women who prematurely terminated CR participation were younger, more obese, with worse quality of life, and greater symptoms of depression and anxiety compared with women completing CR. Notable differences in physiological and psychosocial profiles of young women compared with older women enrolled in CR were evident, placing them at high risk for nonadherence to secondary prevention interventions as well as increased risk for disease progression and subsequent cardiac adverse events. Continued existence of these health differentials represents an important public health problem and warrants further research to address these age-related and sex-specific health disparities among women with coronary heart disease.
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The purpose of this study was to evaluate the effect of a physical activity telemonitoring program on daily physical activity level, oxygen uptake capacity (VO2peak), and cardiovascular risk profile in coronary artery disease (CAD) patients who completed phase II cardiac rehabilitation (CR). Eighty CAD patients who completed phase II CR were randomly assigned to an additional telemonitoring intervention or standard CR. The patients in the intervention group (n = 40) wore a motion sensor continuously for 18 weeks. Each week these patients received a step count goal, with the aim to gradually increase the patients' physical activity level. In the control group (n = 40), the patients wore an unreadable motion sensor for seven days for measurement purposes only (at start of follow-up, and after six and 18 weeks). At start of follow-up and after 18 weeks blood lipid profile, glycemic control, waist circumference and body mass index was assessed. VO2peak was assessed at start of follow-up, and after six and 18 weeks. Re-hospitalisation rate was followed during this timeframe. In the intervention group, VO2peak increased significantly during follow-up (P = 0.001), in the control group it did not (P = 0.273). A significant correlation was found between daily aerobic step count and improvement in VO2peak (P = 0.030, r = 0.47). Kaplan-Meier curve analysis showed a trend towards fewer re-hospitalisations for patients in the telemonitoring group (P = 0.09). The study showed that, to maintain exercise tolerance and lower re-hospitalisation rate after hospital-based CR in CAD patients, a physical activity telemonitoring program might be an effective intervention.
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Despite documented benefits of cardiac rehabilitation, adherence to programs is suboptimal with an average dropout rate of between 24% and 50%. The goal of this study was to identify organizational and patient factors associated with cardiac rehabilitation adherence. Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry Project (N=38) were surveyed and records of 4412 enrolled patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. The results show that organizational factors associated with significantly increased adherence were relaxation training and diet classes (group and individual formats) and group-based psychological counseling, medication counseling, and lifestyle modification, the medical director's presence in the cardiac rehabilitation activity area for ≥15 min/week, assessment of patient satisfaction, adequate space, and adequate equipment. Patient factors associated with significantly increased adherence were aged ≥65 years, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) high-risk category, having received coronary artery bypass grafting, and diabetes disease. Non-white race was negatively associated with adherence. There was no significant gender difference in adherence. None of the baseline patient clinical profiles were associated with adherence including body mass index, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and blood pressure. Factors associated with adherence to cardiac rehabilitation included both organizational and patient factors. Modifiable organizational factors may help directors of cardiac rehabilitation programs improve patient adherence to this beneficial program.
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Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.
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Objective To investigate whether attendance at cardiac rehabilitation (CR) independently predicts all-cause mortality over 14 years and whether there is a dose–response relationship between the proportion of CR sessions attended and long-term mortality. Design Retrospective cohort study. Setting CR programmes in Victoria, Australia Patients The sample comprised 544 men and women eligible for CR following myocardial infarction, coronary artery bypass surgery or percutaneous interventions. Participants were tracked 4 months after hospital discharge to ascertain CR attendance status. Main outcome measures All-cause mortality at 14 years ascertained through linkage to the Australian National Death Index. Results In total, 281 (52%) men and women attended at least one CR session. There were few significant differences between non-attenders and attenders. After adjustment for age, sex, diagnosis, employment, diabetes and family history, the mortality risk for non-attenders was 58% greater than for attenders (HR=1.58, 95% CI 1.16 to 2.15). Participants who attended <25% of sessions had a mortality risk more than twice that of participants attending ≥75% of sessions (OR=2.57, 95% CI 1.04 to 6.38). This association was attenuated after adjusting for current smoking (OR=2.06, 95% CI 0.80 to 5.29). Conclusions This study provides further evidence for the long-term benefits of CR in a contemporary, heterogeneous population. While a dose–response relationship may exist between the number of sessions attended and long-term mortality, this relationship does not occur independently of smoking differences. CR practitioners should encourage smokers to attend CR and provide support for smoking cessation.
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Aims: Despite its documented efficacy, cardiac rehabilitation (CR) is still not well implemented in current clinical practice. The aims of the present study were to assess CR uptake rates in the Netherlands, and to identify factors that determine uptake. Methods: The cohort consisted of persons insured with Achmea Zorg en Gezondheid. Based on insurance claims, we assessed CR uptake rates in 2007 among patients with an acute coronary syndrome (ACS), patients who underwent coronary artery bypass graft surgery, percutaneous coronary intervention (PCI), or valvular surgery, and patients with stable angina pectoris (AP) or chronic heart failure (CHF). In addition, we evaluated the relation between CR uptake and demographic, disease-related, and geographic factors for patients with an ACS and/or intervention. Results: The CR uptake rate in the entire cohort (n = 35,752) was 11.7%. The uptake rate among patients with an ACS and/or intervention (n = 12,201) was 28.5%, as opposed to 3.0% among patients with CHF or stable AP (n = 23,551). The highest CR uptake rate was observed in patients who underwent cardiac surgery (58.7%). Factors associated with lower CR uptake were female gender, older age, elective PCI (as compared to acute PCI), unstable AP (as compared to myocardial infarction), larger distance to the nearest provider of CR, and comorbidity. Conclusion: A minority of Dutch patients eligible for CR received CR. Future implementation strategies should focus on females, elderly patients, patients with unstable AP and/or after elective PCI, patients with long travelling distances to the nearest CR provider, and patients with comorbidities.
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Background: International research indicates that attendance of patients to a proposed cardiac rehabilitation (CR) programme varies between 21% and 75%. Addressing the reasons why cardiac patients are not participating will improve accessibility to CR. The objective of this study was to investigate patient compliance with cardiac rehabilitation and the reasons of refusing or abandoning the programme. Methods: Twenty hospital centres were recruited to participate. Each centre was asked to recruit patients from three patient groups, namely: percutaneous coronary intervention patients, patients that underwent major cardiac surgery, and patients being admitted because of an acute myocardial infarction and not belonging to the other two groups. Patients were asked to fill out a questionnaire during a follow-up outpatient consultation after the cardiac intervention. Results: In total, 226 patients participated in the survey. Most patients were proposed (86%) and accepted (81% out of proposed) to attend a CR programme. Of those who accepted, 77% completed the programme. The main reasons that led to patients' refusal to participate in a CR programme were distance to the CR centre, patients' belief they could handle their own problems, and lack of time. The main three reasons for not completing an initiated CR programme were other physical problems, patients' belief they could handle their own problems, and the cost of rehabilitation. Conclusion: Our findings demonstrate the importance of raising patients' awareness of the benefits of CR. Addressing potential barriers to attend a CR programme should be investigated with patients individually in order to ensure compliance.
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Policies suggest that primary care should be more involved in delivering cardiac rehabilitation. However, there is a lack of information about what is known in primary care regarding patients' invitation or attendance. To determine, within primary care, how many patients are invited to and attend rehabilitation after myocardial infarction (MI), examine sociodemographic factors related to invitation, and compare quality of life between those who do and do not attend. Review of primary care paper and computer records; cross-sectional questionnaire. Northern Ireland general practices (38); stratified sample, based on practice size and health board area. Patients, identified from primary care records, 12-16 weeks after a confirmed diagnosis of MI, were posted questionnaires, including a validated MacNew post-MI quality-of-life questionnaire. Practices returned anonymised data for non-responders. Information about rehabilitation was available for 332 of the 432 patients identified (76.9%): 162 (37.5%) returned questionnaires. Of the total sample, 54.4% (235/432) were invited and 37.0% (160/432) attended; of those invited, 68.1% (160/235) attended. Invited patients were younger than those not invited (mean age 63 years [standard deviation SD 16] versus 68.5 years [SD 16]); mean difference 5.5 years (95% confidence interval [CI] = 1.7 to 9.3). Among questionnaire responders, those who attended were younger and reported better emotional, physical, and social functioning than non-attenders (P = 0.01; mean differences 0.44 (95% CI = 0.11 to 0.77), 0.48 (95% CI = 0.10 to 0.85) and 0.54 (95% CI = 0.15 to 0.94) respectively). Innovative strategies are needed to improve cardiac rehabilitation uptake, integration of hospital and primary care services, and healthcare professionals' awareness of patients' potential for health gain after MI.
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Reduced adherence to medical treatment regimens may help to explain the higher risk of mortality among depressed cardiac patients. Participation in cardiac rehabilitation is a highly recommended part of the medical treatment regimen for cardiac patients. This study examined if elevated depressive symptomology, as measured by the Beck Depression Inventory (BDI), predicted failure to complete a 12-week phase II cardiac rehabilitation program for 600 patients. Logistic regression analysis showed that patients with elevated levels of depressive symptomology (BDI scores > or = 10) were 2.2 times less likely to complete cardiac rehabilitation compared to patients without depression (BDI < 10), after controlling for age, gender, body mass index, and employment. Somatic symptoms predicted non-completion due to medical reasons, whereas younger age predicted failure to complete cardiac rehabilitation due to non-medical reasons. Given the difficulty of reducing mortality by treating depression directly, interventions targeting behavior change to improve medical treatment adherence might be an effective complementary strategy.
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The opportunity to attend a cardiac rehabilitation course is usually offered to patients who have suffered a myocardial infarction. However, despite referral, many patients fail to attend. To elicit patients' beliefs about the role of the cardiac rehabilitation course following myocardial infarction. Qualitative study using in-depth semi-structured interviews. London Teaching Hospital. Thirteen patients were interviewed after discharge from hospital following myocardial infarction, but prior to attendance at cardiac rehabilitation. Patients' beliefs about cardiac rehabilitation that may act as barriers to attendance. Themes identified included: the content of cardiac rehabilitation, perceptions of exercise, benefits of cardiac rehabilitation, explicit barriers to attendance and cardiac knowledge. Whilst some patients viewed cardiac rehabilitation as an important and necessary part of recovery others expressed doubt that it was appropriate for them. Some patients were uncertain of the course content and misunderstood the role of exercise and its perceived effects. Misconceptions with regard to cardiac knowledge were also apparent. The combination of erroneous beliefs about cardiac rehabilitation and cardiac misconceptions seemed to result in doubts regarding attendance. Prior to course attendance some patients hold erroneous beliefs about the course content, especially the exercise component. Co-existent cardiac misconceptions are also apparent. Further research is needed to clarify the extent to which these beliefs may contribute to the decision not to attend cardiac rehabilitation.
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To describe the patterns of use of cardiac rehabilitation in Victoria and to assess whether the survival benefits predicted in clinical trials have been realised in the community. Cohort study based on data linkage. All patients admitted for acute myocardial infarction (AMI), coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in Victoria in 1998 (n = 12821). Attendance at one of 66 participating outpatient cardiac rehabilitation centres in Victoria. Rates of attendance at rehabilitation based on key factors such as diagnosis, age, sex, and comorbidity. Five-year survival for attendees compared with non-attendees. Rates of participation in rehabilitation were 15% for AMI, 37% for CABG, and 14% for PTCA. Rehabilitation attendance rates dropped sharply after 70 years of age. Attendees had a 35% improvement in 5-year survival (hazard ratio for death associated with rehabilitation attendance, 0.65 [95% CI, 0.56-0.75]). Attendance rates at cardiac rehabilitation are suboptimal, even though attendance confers a clinically significant difference in 5-year survival. The elderly, women, and those with comorbid conditions may benefit measurably from increased rates of attendance.
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Despite the established benefits of cardiac rehabilitation, evidence suggests referral to, and subsequent enrollment in, cardiac rehabilitation following a coronary event remains low (10-25%). The aim of this study was to identify predictors of attendance to cardiac rehabilitation intake and subsequent enrollment in rehabilitation after coronary artery bypass graft surgery within the framework of an automatic referral system. We conducted a historic prospective study of patients who underwent coronary artery bypass graft surgery between 1 April 1996 and 31 March 2000 and lived within the geographic referral area of a multi-disciplinary cardiac rehabilitation center in central-south Ontario, Canada. Coronary artery bypass graft surgery patients are automatically referred to cardiac rehabilitation at the time of hospital discharge. Consecutive health records of eligible patients were reviewed for medical history, cardiac risk factor profiles, and evidence of cardiac rehabilitation intake attendance and enrolment. A total of 3536 patients met eligibility criteria. Patients were predominantly male (79.1%), approximately 64 years of age, living with a spouse or a partner, English-speaking, retired and had multiple cardiac risk factors. Of eligible patients, 2121 (60.0%) attended the cardiac rehabilitation intake appointment. Of patients who attended cardiac rehabilitation intake 1463 (69%) enrolled in at least one cardiac rehabilitation service, based on their risk factor profile. Selected cardiac rehabilitation services were exercise training (n=1287; 88%), nutrition counseling (n=571; 39.0%), nursing care (n=546; 37.3%), and psychological intervention (n=223; 15.2%). An institutionalized, physician-endorsed system of automatic referral to cardiac rehabilitation resulted in higher rates of cardiac rehabilitation intake and enrollment following coronary artery bypass graft surgery than previously reported and should be adopted for all cardiac populations.
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Cardiac rehabilitation is an important component of recovery and secondary prevention following urgent primary percutaneous coronary intervention. However, attendance and factors that predict participation by patients admitted with ST-elevation myocardial infarction remain unclear. This Australian study was conducted using a descriptive, comparative design. Consecutive patients (n = 246) at two hospitals were interviewed by telephone at four weeks and six months. Open-ended questions were used to assess cardiac rehabilitation attendance, sociodemographics, modifiable risk factors, clinical outcomes, and post-discharge health support. Post-discharge home visits at four weeks (odds ratio: 2.64, 95% confidence interval: 1.48-4.71) and at six months were associated with better cardiac rehabilitation attendance; more males participated at four weeks and at six months. The results suggest the need to integrate post-discharge health support with cardiac rehabilitation to facilitate recovery after primary percutaneous coronary intervention, particularly for females with ST-elevation myocardial infarction.
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Importance Cardiovascular disease prevention, including lifestyle modification, is important but underutilized. Mobile health strategies could address this gap but lack evidence of therapeutic benefit.Objective To examine the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text message on cardiovascular risk factors.Design and Setting The Tobacco, Exercise and Diet Messages (TEXT ME) trial was a parallel-group, single-blind, randomized clinical trial that recruited 710 patients (mean age, 58 [SD, 9.2] years; 82% men; 53% current smokers) with proven coronary heart disease (prior myocardial infarction or proven angiographically) between September 2011 and November 2013 from a large tertiary hospital in Sydney, Australia.Interventions Patients in the intervention group (n = 352) received 4 text messages per week for 6 months in addition to usual care. Text messages provided advice, motivational reminders, and support to change lifestyle behaviors. Patients in the control group (n=358) received usual care. Messages for each participant were selected from a bank of messages according to baseline characteristics (eg, smoking) and delivered via an automated computerized message management system. The program was not interactive.Main Outcomes and Measures The primary end point was low-density lipoprotein cholesterol (LDL-C) level at 6 months. Secondary end points included systolic blood pressure, body mass index (BMI), physical activity, and smoking status.Results At 6 months, levels of LDL-C were significantly lower in intervention participants (mean difference, −5 mg/dL [95% CI, −9 to 0]; P = .04). There were concurrent reductions in systolic blood pressure (−7.6 mm Hg [95% CI, −9.8 to −5.4]; P < .001) and BMI (−1.3 [95% CI, −1.6 to −0.9]; P < .001), significant increases in physical activity (+293 metabolic equivalent task min/wk [95% CI, 102 to 485]; P = .003), and a significant reduction in smoking (26% vs 44%; relative risk, 0.61 [95% CI, 0.48 to 0.76]; P < .001). The majority reported the text-message program to be useful (91%), easy to understand (97%), and appropriate in frequency (86%).Conclusions and Relevance Among patients with coronary heart disease, the use of a lifestyle-focused text messaging service compared with usual care resulted in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors. The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined.Trial Registration anzctr.org.au Identifier: ACTRN12611000161921
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Background Guidelines recommend cardiac rehabilitation after acute myocardial infarction, yet little is known about the impact of cardiac rehabilitation on medication adherence and clinical outcomes among contemporary older adults. The optimal number of cardiac rehabilitation sessions is not clear. Methods We linked patients 65 years or older enrolled in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from January 2007 to December 2010 to Medicare longitudinal claims data to obtain 1 year follow-up. Results A total of 11,862 patients participated in cardiac rehabilitation after acute myocardial infarction, attending a median number of 26 sessions. Patients attending ≥26 sessions were more likely to be male, had lesser prevalence of comorbid conditions and prior revascularization, and were more likely to present with ST-segment elevation myocardial infarction, compared with patients attending 1 to 25 sessions. Among patients with Medicare Part D prescription coverage, increasing number of cardiac rehabilitation sessions was associated with improvement in adherence to secondary prevention medications such as P2Y12 inhibitors and β-blockers. Each 5-session increase in participation was associated with lower mortality (adjusted hazard ratio [HR] 0.87, 95% CI 0.83-0.92) and lower overall risk of major adverse cardiac event (adjusted HR 0.69, 95% CI 0.65-0.73) and death/readmission (adjusted HR 0.79, 95% CI 0.76-0.83). Conclusions In this older patient population, number of cardiac rehabilitation sessions attended was associated with improved medication adherence and lower downstream cardiovascular risk in a dose-response relationship. This provides support for the continued use of cardiac rehabilitation for older adults and encourages efforts to maximize attendance.
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This analysis of clinical data linked to Medicare claims finds the cardiac rehabilitation rate for older patients after acute myocardial infarction is low in the United States and suggests efforts be made for increasing referrals, and addressing attendance barriers, to rehabilitation sessions. A recent clinical practice guideline strongly supports cardiac rehabilitation for patients after acute myocardial infarction (AMI).¹ Cardiac rehabilitation programs are multifaceted outpatient interventions that include individualized exercise regimens, health education, and structured support focused on cardiovascular risk reduction and medication adherence.² Patients typically attend 2 to 3 sessions weekly for up to 36 sessions. Cardiac rehabilitation improves survival after AMI³ and is associated with improvements in lifestyle, functional capacity, and quality of life for older adults.⁴,5 Despite these benefits, rates of referral and participation have traditionally been low, especially among older adults.⁶,7
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Cardiac rehabilitation (CR) is very effective for secondary prevention of cardiovascular disorders. The objective of this study was to analyze population factors associated with nonenrollment of cardiac patients in these programs. Retrospective study of 756 patients referred to the cardiac rehabilitation program (CRP) of a tertiary referral hospital with a service area population of more than 640 000 from January 2009 to June 2012. We assessed the relationship between population characteristics of these patients and nonenrollment by logistic regression analysis. There were 2386 hospital admissions for an acute coronary syndrome during the study period. Out of the 2355 patients who were alive at discharge, 756 (632 men and 124 women) were referred for CR (32.1% vs 3% state average and vs 51% European average). Of these patients, 20.9% did not enroll. The referral rate was lower among women than among men (P < .001). The characteristics associated with a lower rate of enrollment in the program were age (OR: 1.05; 95% CI: 1.02-1.09), living alone (OR: 4.54; 95% CI: 2.53-8.16), living further than 50 km from the CR unit (OR: 2.90; 95% CI: 1.29-6.41) and, in women, having a history of cardiovascular disease (recurrent myocardial infarction) (OR: 6.35; 95% CI: 2.53-11.81). The rate of referral for CR in our setting is well above the national average but still could be improved. We identified older age, living alone, travel distance to the cardiac rehabilitation unit, and, in women, a history of a previous myocardial infarction as barriers to enrollment in CRPs.
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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 o