Cardiac Rehabilitation Center Research Articles

The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial

Background Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs.MethodsThe study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation.DiscussionOptimizing cardiac rehabilitation centres’ delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI.Trial registrationClinicalTrials.gov. Identifier: NCT05889416. Registered 2023-03-23.

Erectile Dysfunction as an Obesity-Related Condition in Elderly Men with Coronary Artery Disease.

Background: This cross-sectional study aimed to investigate the prevalence of erectile dysfunction (ED) in elderly men with overweight or obesity and coronary artery disease. Methods: Patients recruited in cardiac rehabilitation centers post-myocardial infarction provided demographic and anthropomorphic data. ED was assessed using the abbreviated International Index of Erectile Function 5 (IIEF-5) Questionnaire. Results: The study included 661 men with a mean age of 67.3 ± 5.57 years, a mean BMI of 27.9 ± 3.6 m/kg2, and a mean waist circumference of 98.9 ± 10.23 cm. Over 90% of men experienced ED, with similar proportions across BMI categories. The development of ED in men with a waist circumference of ≥100 cm had 3.74 times higher odds (OR 3.74; 95% CI: 1.0-13.7; p = 0.04) than in men with a waist circumference of <100 cm. Men with obesity and moderate-to-severe and severe ED were older compared to those without these disorders (67.1 ± 5.29 vs. 65.3 ± 4.35; p = 0.23). Conclusions: The prevalence of ED in men with coronary artery disease surpasses 90%. An increased body weight raises the risk of ED, with waist circumference proving to be a more reliable predictor of this risk compared to BMI. Physicians are encouraged to screen elderly patients with cardiovascular disease for ED and address obesity to enhance overall health.

Provision of professional interpreters and Heart School attendance for foreign-born compared with native-born myocardial infarction patients in Sweden

ObjectiveInteractive patient education, referred to as Heart School (HS), is an important part of cardiac rehabilitation (CR) after myocardial infarction (MI), which has been associated with improved outcomes. Little is known about HS attendance among foreign-born patients. The aims were to assess; 1) HS attendance in foreign-born versus native-born patients, 2) the association between the provision of professional interpreters and HS attendance, and 3) secondary prevention goal attainment after MI based on HS attendance. MethodsThe provision of professional interpreters during post-MI follow-up was assessed by a questionnaire sent to all 78 Swedish CR sites. Patient-specific data was retrieved from the SWEDEHEART registry. The association between the provision of professional interpreters and HS attendance was estimated with logistic regression models. HS attendance and attainment of secondary prevention goals by country of birth were investigated. ResultsIn total, 8377 patients < 75 years (78 % male) were included. Foreign-born (19.8 %) had a higher prevalence of cardiovascular risk factors and were less likely to attend HS (33.7 vs 51.3 %, p < 0.001), adjusted odds ratio (OR) 0.59 (95 % confidence interval (CI) 0.52–0.68), compared with native-born patients. CR centers providing professional interpreters had higher HS attendance among foreign-born (adjusted OR 1.55, 95 % CI 1.20–2.01) but not among native-born patients. Attending HS was similarly associated with improved secondary prevention goal attainment in both groups. ConclusionsDespite similar positive association between HS attendance and attainment of secondary prevention goals, foreign-born patients attended HS less often. With the provision of professional interpreters, HS attendance increased in foreign-born patients.

Effects of Exercise Training Response on Quality of Life and Cardiovascular Risk Factor Profiles in People With Coronary Artery Disease: Insights From the HIIT or MISS UK Trial

ObjectiveTo compare the characteristics of responders and nonresponders to 8 weeks of exercise training to determine differences in key cardiovascular disease outcomes in people with coronary artery disease (CAD). DesignSecondary analysis of data from the HIIT or MISS UK trial. SettingSix outpatient National Health Service cardiac rehabilitation (CR) centers in the UK. In people with CAD attending CR, the HIIT or MISS UK trial reported that short-term, low-volume, high-intensity interval training (HIIT) was more effective than moderate-intensity steady state (MISS) exercise training for improving peak oxygen uptake (V̇o2peak). Participants382 participants with CAD (N=382) (mean age: 58.8±9.6y; mean body mass index: 29.0±4.3 kg/m2). Main Outcome MeasuresWe identified responders and nonresponders based on a meaningful change in V̇o2peak, using 2 established methods. Key clinical, quality of life (QoL), and cardiopulmonary exercise test (CPET)–derived outcomes were compared between groups. ResultsResponders were more likely to be younger (P<.05), and demonstrate greater improvement in CPET-related outcomes, for example, oxygen uptake efficiency slope, ventilatory efficiency, and peak power output (all comparisons, P<.001). Responders were more likely to observe improvements in QoL (EQ-5D-5L; mean Δ 13.6 vs mean Δ 9.4; P=.045), and high-density lipoprotein cholesterol (HDL-c) (mean Δ 0.09 mmol/L vs mean Δ 0.04 mmol/L; P=.004), compared to nonresponders. ConclusionsIn people with CAD attending CR, responders to exercise training were more likely to be younger and demonstrate greater improvements in health-related QoL and HDL-c.

Third National Registry of Cardiac Rehabilitation Programs in Mexico (RENAPREC III-2022)

In Mexico, cardiac rehabilitation (CR) as an interdisciplinary intervention with therapeutic impact in patients with heart disease is growing. There is the need to know actual conditions of CR in our country. The objective of this National Registry is to follow-up those existing and new CR units in Mexico through the comparison between the two previous registries, RENAPREC-2009 and RENAPREC II-2015 studies. This is a descriptive study focused on diverse CR activities such as assistance training, and certification of health professionals, barriers, reference, population attended, interdisciplinarity, permanence over time, growth prospects, regulations, post-pandemic condition, integrative characteristics, and scientific research. Data were collected from 45 CR centers in the 32 states, 75.5% are private practice units, 67% are new, 33% were part of RENAPREC II-2015, and 17 have continued since 2009. With a better distribution of CR units along the territory, the median reference of candidates for CR programs is 9% with a significant reduction into tiempo of enrollment to Phase II admission (19 ± 11 days). Regarding to previous registries, the coverance of Phases I, II, and III is 71%, 100%, and 93%, respectively; and a coverance increases in evaluation, risk stratification, and prescription, more comprehensive attendance and prevention strategies. CR in Mexico has grown in the past 7 years. Even there is still low reference and heterogeneity in specific processes, there are strengths such as interdisciplinarity, scientific professionalization of specialists, national diversification, and an official society that are consolidated over time.

Effectiveness of a home-based music-paced physical activity programme on exercise-related outcomes after cardiac rehabilitation: a randomized controlled trial.

A randomized controlled trial was conducted to examine the effects of a home-based music-paced physical activity programme guided by Information-Motivation-Strategy (IMS) model and Self-determination theory on exercise-related outcomes for patients with coronary heart disease (CHD) after cardiac rehabilitation (CR). A total of 130 patients with CHD from a regional CR centre in Hong Kong were recruited and randomly allocated into intervention (n = 65) or control groups (n = 65). The intervention group received theory-guided practical sessions on performing prescribed home-based physical activity with individualized synchronized music, and follow-up telephone calls. The primary outcome was exercise capacity. Secondary outcomes included exercise self-efficacy, physical activity level, and exercise self-determination. Data were collected at baseline, 3 months, and 6 months after study entry. The generalized estimating equations model was used to assess the intervention effects. Patients with CHD in the intervention group demonstrated significantly greater improvements in exercise capacity at 3 months [β = 35.68, 95% confidence interval (CI) 2.69-68.68, P = 0.034] and significantly improved exercise self-efficacy at 6 months (β = 3.72, 95% CI 0.11-7.32, P = 0.043) when compared with the control group. However, no significant group differences were found in physical activity level and exercise self-determination. The study findings provide evidence on an innovation on improving the exercise capacity and exercise self-efficacy of patients with CHD. The music-paced physical activity guided by the IMS model and Self-determination theory requires further investigation on its long-term effects in future studies. ChiCTR-IOR-17011015.

Effects of a Nutrition Education Programme in Stage IV Cardiac Rehabilitation Patients: A 3-Arm Randomised Controlled Trial.

This trial examined the influence of two nutrition intervention programmes on health-related and nutritional intake indices pertinent to cardiovascular disease compared to usual care in stage IV cardiac rehabilitation patients. Sixty-six patients were recruited from the Heartbeat North-West cardiac rehabilitation centre in Preston (United Kingdom). Patients were randomly assigned to Usual care, Biggest loser or Nutrition education arms. Usual care undertook their usual two exercise classes per week without nutritional support, Biggest loser underwent weekly education sessions focussing on weight loss using the themes within the British Heart Foundation 'So You Want to Lose Weight for Good' guidelines, and Nutrition education followed the same themes as Biggest loser but in a more focussed manner informed by patient focus groups. In total, this was a 12-week trial in which patients spent 6 weeks engaged in their allocated intervention arm, after which all participants switched to Usual care. The primary outcome was systolic blood pressure, and secondary measures of anthropometric, blood biomarker, nutritional knowledge (via the Mediterranean Diet Assessment Tool) and nutritional intake indices were measured at baseline, 6 weeks, and 12 weeks (follow-up). Intention-to-treat analyses revealed no significant alterations in the primary outcome (Usual care: baseline = 130.45 mmHg, 6 weeks = 127.83 mmHg, and follow-up = 126.35 mmHg, Biggest loser: baseline = 133.50 mmHg, 6 weeks = 123.06 mmHg, and follow-up = 135.22 mmHg, or Nutrition education: baseline = 135.23 mmHg, 6 weeks = 129.20 mmHg, and follow-up = 126.26 mmHg) between arms. However, at 6 weeks, improvements in triglycerides were significantly greater in Usual care (baseline = 1.61 mmol/L and 6 weeks = 1.43 mmol/L) group compared to Nutrition education (baseline = 1.70 mmol/L and 6 weeks = 2.21 mmol/L). Improvements in nutrition knowledge were significantly greater in Nutrition education (baseline = 8.48, 6 weeks = 9.77, and follow-up = 10.07) compared to Usual care (baseline = 7.71, 6 weeks = 8.00, and follow-up = 8.00) and Biggest loser (baseline = 7.71, 6 weeks = 8.73, and follow-up = 8.36). At 6 weeks, the Biggest loser group (baseline = 4.75 g and 6 weeks = 3.83 g) exhibited significantly greater improvements in salt intake compared to Usual care (baseline = 4.87 g and 6 weeks = 4.28 g) and Nutrition education (baseline = 19.25 g and 6 weeks = 16.78 g) in saturated fatty acids compared to Usual care (baseline = 20.26 g and 6 weeks = 21.34 g). This trial shows the effectiveness of nutritional interventions for improving nutritional knowledge and dietary practices in stage IV cardiac rehabilitation, but the mechanisms and longer-term effects of increased triglyceride levels in the Nutrition education group requires further exploration.

The effects of CPET-guided cardiac rehabilitation on exercise tolerance in older persons with CHD after PCI

Prescribing appropriate exercise is an important means to improve the safety and efficacy of cardiac rehabilitation. Improper exercise may induce an increased cardiovascular risk in older persons with coronary heart disease. Cardiopulmonary exercise testing (CPET)-guided cardiac rehabilitation could be helpful for providing clinical evidence for cardiac rehabilitation therapy in older persons after percutaneous coronary intervention (PCI). We retrospectively included older persons who underwent PCI and cardiac rehabilitation based on CPET at the Cardiac Rehabilitation Center of Peking University Third Hospital from January 2014 to December 2019. Patients’ baseline and follow-up clinical data were collected. A total of 403 older persons after PCI were included in the study. The mean age was 80.5 ± 4.3. The mean follow-up time was 12 ± 2 months. During the follow-up period, no significant exercise-related adverse events occurred, and the peak oxygen uptake (VO2peak) increased compared with baseline (15.5 ± 3.8 ml/min/kg vs. 17.3 ± 4.1 ml/min/kg). Among the 90 patients (22.2%) without exercise habits at baseline who started regular exercise during follow-up, the improvement in VO2peak was most significant, at 3.2 ± 0.4 ml/min/kg. Cardiac rehabilitation based on CPET improved exercise habits and exercise tolerance in older persons with coronary heart disease after PCI.

Abstract 18530: Associations Among Self-Reported and Physiologic Sleep Measurements and Fatigue in Adults Following Major Cardiac Events

Background: Insufficient sleep contributes to fatigue and cardiometabolic disorders. Current sleep measures vary in accuracy, with weak correlations between self-report and physiologic measures. Developing reliably associated self-report and physiologic sleep measures can optimize data collection methods. Purpose: Investigate correlations between self-reported and physiologic sleep measures in cardiac rehabilitation patients and determine associations with fatigue. Methods: Participants (N = 25, 58% male, 89% non-Hispanic white, mean age = 61 years) recruited from cardiac rehabilitation centers participated in a three-arm RCT. Inclusion criteria were experiencing a myocardial infarction or revascularization procedure, enrollment in cardiac rehabilitation, and experiencing depression or anxiety. Participants without complete sleep measures were excluded. Data was collected at baseline, 3-, and 6-months. Sleep was measured over 8 days with an investigator-developed self-report diary and an ActiGraph GT9X Link accelerometer. ActiGraphs collected data with a 30Hz sampling rate and were scored using the autodetected sleep periods to determine total sleep time. Mean daily minutes of sleep were calculated from self-report and ActiGraph data. Participants also completed a demographics survey and Fatigue Severity Scale. Statistical methods included Pearson correlation coefficients with 95% confidence intervals (CI) estimated with Fisher's r-to-z transformation. Results: Results showed self-reported and ActiGraph measured sleep were highly correlated (r = 0.889, [95% CI 0.812, 0.935], p &lt; 0.001). Fatigue was not correlated with self-reported (r = 0.074, [95% CI -0.206, 0.342] p = 0.607) or ActiGraph measured sleep (r = 0.150, [95% CI -0.131, 0.408] p = 0.295). Even though the finding was non-significant, the correlation between fatigue and ActiGraph measured sleep was larger than self-reported sleep. Conclusion: Accurate sleep measures are essential to inform future research and interventions. Unlike past work, this investigator-developed, self-report measure was strongly correlated with the physiologic measure. Researchers should consider reliability when selecting sleep measures.

Barriers to cardiac rehabilitation and patient perceptions on the usage of technologies in cardiac rehabilitation: Across-sectional study.

The study aimed to identify factors associated with participation in Phase II cardiac rehabilitation and to assess patient perceptions towards the usage of technologies in cardiac rehabilitation. Despite efforts to promote utilisation of cardiac rehabilitation (CR), participation among patients remains unsatisfactory. Little is known of patient decision to participate Phase II CR in a multi-ethnic country. A cross-sectional study design. A consecutive sampling of 240 patients with coronary heart disease completed Coronary Artery Disease Education Questionnaire (CADE-Q) II, Hospital Anxiety and Depression Scale (HADS), Multidimensional Scale of Perceived Social Support (MSPSS) and Cardiac Rehabilitation Barriers Scale (CRBS). Seventy per cent of patients (mean age 60.5 [SD = 10.6] years, 80.8% male) participated in phase II cardiac rehabilitation. Self-driving to cardiac rehabilitation centres, higher barriers in perceived need/health care and logistical factors were significantly associated with decreased odds of participation. Patients with more barriers from comorbidities/functional status, higher perceived social support from friends, and anxiety were more likely to participate. Chinese and Indians were less likely to participate when compared with Malays. More than 80% of patients used both home and mobile broadband internet, and 72.9% of them would accept the usage of technologies, especially educational videos, instant messenger, and video calls to partially replace the face-to-face, centre-based cardiac rehabilitation approach. Several barriers were associated with non-participation in phase II cardiac rehabilitation. With the high perceived acceptance of technology usage in cardiac rehabilitation, home-based and hybrid cardiac rehabilitation may represent potential solutions to improve participation. By addressing the barriers to cardiac rehabilitation, patients are more likely to be ready to adopt health behaviour changes and adhere to the cardiac rehabilitation programme. The high perceived acceptance of using technologies in cardiac rehabilitation may provide insights into new delivery models that can improve and overcome barriers to participation.

Very brief intervention for physical activity behaviour change in cardiac rehabilitation: protocol for the ‘Measure It!’ effectiveness–implementation hybrid trial

IntroductionPhysical inactivity is a risk factor for repeat cardiac events and all-cause mortality in coronary heart disease (CHD). Cardiac rehabilitation, a secondary prevention programme, aims to increase physical activity levels...

Screening for - and prevalence of - anxiety and depression in cardiac rehabilitation in the post-COVID era. An observational study

BackgroundApproximately 20–30% of patients with a cardiac disease suffer from anxiety and/or depression, leading to poor health outcomes. To identify this subgroup, clinical guidelines recommend screening for anxiety and depression in cardiac rehabilitation (CR). It is unknown how screening practice is delivered post-COVID. MethodsThis observational study used data from the National Audit of Cardiac Rehabilitation from April 2018–March 2022. Descriptive statistics were used to assess screening rates and prevalence, while a multivariate logistic regression model was performed to analyse determinants for screening for anxiety and depression among patients participating in cardiac rehabilitation. ResultsThe population consisted of 245,705 patients, where 128,643 (52.4%) were screened and 117,062 (47.6%) were not. Patients attending CR during first year of COVID-19 were less likely to be screened. Patients with female gender, living alone, non-white ethnicity, living in the most deprived areas, current smoking, and physical inactivity were less likely to be screened, while patients who were revascularized, having an objective physical fitness test, and attending a certified CR center were more likely to be screened. For patients attending CR during COVID-19, the prevalence of anxiety and depression decreased significantly. For anxiety the prevalence dropped from 34.4% to 15.8%, for depression the prevalence dropped from 33.5% to 16.5%. ConclusionCR service provision was negatively impacted during COVID-19, leading to much lower screening for anxiety and depression in the CR setting. Prevalence of anxiety and depression decreased during COVID-19 for this population, possibly because psychologically affected patients refrained from attending CR.

Cost-effectiveness of High-Intensity Interval Training (HIIT) vs Moderate Intensity Steady-State (MISS) Training in UK Cardiac Rehabilitation

ObjectiveTo perform a cost-effectiveness analysis of high-intensity interval training (HIIT) compared with moderate intensity steady-state (MISS) training in people with coronary artery disease (CAD) attending cardiac rehabilitation (CR). DesignSecondary cost-effectiveness analysis of a prospective, assessor-blind, parallel group, multi-center RCT. SettingSix outpatient National Health Service cardiac rehabilitation centers in England and Wales, UK. Participants382 participants with CAD (N=382). InterventionsParticipants were randomized to twice-weekly usual care (n=195) or HIIT (n=187) for 8 weeks. Usual care was moderate intensity continuous exercise (60%-80% maximum capacity, MISS), while HIIT consisted of 10 × 1-minute intervals of vigorous exercise (>85% maximum capacity) interspersed with 1-minute periods of recovery. Main Outcome MeasuresWe conducted a cost-effectiveness analysis of the HIIT or MISS UK trial. Health related quality of life was measured with the EQ-5D-5L to estimate quality-adjusted life years (QALYs). Costs were estimated with health service resource use and intervention delivery costs. Cost-utility analysis measured the incremental cost-effectiveness ratio (ICER). Bootstrapping assessed the probability of HIIT being cost-effective according to the UK National Institute for Health and Care Excellence (NICE) threshold value (£20,000 per QALY). Missing data were imputed. Uncertainty was estimated using probabilistic sensitivity analysis. Assumptions were tested using univariate/1-way sensitivity analysis. Results124 (HIIT, n=59; MISS, n=65) participants completed questionnaires at baseline, 8 weeks, and 12 months. Mean combined health care use and delivery cost was £676 per participant for HIIT, and £653 for MISS. QALY changes were 0.003 and -0.013, respectively. For complete cases, the ICER was £1448 per QALY for HIIT compared with MISS. At a willingness-to-pay threshold of £20,000 per QALY, the probability of HIIT being cost-effective was 96% (95% CI, 0.90 to 0.95). ConclusionFor people with CAD attending CR, HIIT was cost-effective compared with MISS. These findings are important to policy makers, commissioners, and service providers across the health care sector.

Correlation between high sensitivity C reactive protein (Hs-CRP) and neutrophil-to- lymphocyte ratio (NLR) with functional capacity in post COVID-19 syndrome patients.

Post coronavirus disease 2019 (COVID-19) syndrome is one of the causes of reduced functional capacity and work productivity, in particular for healthcare workers. The pathophysiology of the post COVID-19 syndrome is related to complex and multisystem inflammatory mechanisms, and cardiopulmonary exercise rehabilitation program is one of the efforts to improve the recovery process for patients with post COVID-19 syndrome. The aim of this study was to determine the correlation between the level of high sensitivity C-reactive protein (Hs-CRP) and neutrophil-to-lymphocyte ratio (NLR) with functional capacity (VO2max) in individuals with post-COVID-19 syndrome who received moderate- and high-intensity supervised cardiopulmonary exercise. A prospective cohort study was conducted at the Integrated Cardiac Rehabilitation Center of Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia. The supervised cardiopulmonary exercise was conducted for six weeks according to the participant's baseline VO2max. Spearman's and Pearson's correlation tests were used to assess the correlations. A total of 30 individuals (19 and 11 had moderate and high intensity exercise, respectively) were involved in this study. At moderate intensity exercise, the average Hs-CRP and NLR were 3.3 mg/L and 1.99, respectively; while at high intensity, the values were 3.8 mg/L and 1.79, respectively. No significant correlation between Hs-CRP level and functional capacity in both moderate-intensity and high intensity groups. In contrast, NLR was negatively correlated with functional capacity (r=-0.545, p=0.016) in moderate intensity exercise group. In conclusion, NLR value was negatively correlated with functional capacity in individuals with post-COVID-19 syndrome after receiving moderate intensity supervised cardiopulmonary exercise program. Therefore, moderate intensity of cardiopulmonary exercise maybe be used as a program to accelerate the recovery for those with post COVID-19 syndrome.

Effect of digital tools in outpatient cardiac rehabilitation including home training-results of the EPICURE study.

Cardiovascular diseases are the leading cause of death worldwide and are partly caused by modifiable risk factors. Cardiac rehabilitation addresses several of these modifiable risk factors, such as physical inactivity and reduced exercise capacity. However, despite its proven short-term merits, long-term adherence to healthy lifestyle changes is disappointing. With regards to exercise training, it has been shown that rehabilitation supplemented by a) home-based exercise training and b) supportive digital tools can improve adherence. In our multi-center study (ClincalTrials.gov Identifier: NCT04458727), we analyzed the effect of supportive digital tools like digital diaries and/or wearables such as smart watches, activity trackers, etc. on exercise capacity during cardiac rehabilitation. Patients after completion of phase III out-patient cardiac rehabilitation, which included a 3 to 6-months lasting home-training phase, were recruited in five cardiac rehabilitation centers in Austria. Retrospective rehabilitation data were analyzed, and additional data were generated via patient questionnaires. 107 patients who did not use supportive tools and 50 patients using supportive tools were recruited. Already prior to phase III rehabilitation, patients with supportive tools showed higher exercise capacity (Pmax = 186 ± 53 W) as compared to patients without supportive tools (142 ± 41 W, p < 0.001). Both groups improved their Pmax, significantly during phase III rehabilitation, and despite higher baseline Pmax of patients with supportive tools their Pmax improved significantly more (ΔPmax = 19 ± 18 W) than patients without supportive tools (ΔPmax = 9 ± 17 W, p < 0.005). However, after adjusting for baseline differences, the difference in ΔPmax did no longer reach statistical significance. Therefore, our data did not support the hypothesis that the additional use of digital tools like digital diaries and/or wearables during home training leads to further improvement in Pmax during and after phase III cardiac rehabilitation. Further studies with larger sample size, follow-up examinations and a randomized, controlled design are required to assess merits of digital interventions during cardiac rehabilitation.

Cardiac Rehabilitation in Covid Era: was it equally effective?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation is currently described as a mainstay when it comes to treatment of cardiac patients (pts), mainly ischemic heart disease. Despite this, referral and implementation suffered a decrease amidst covid outbreak. Purpose To describe, in a cardiac rehabilitation center, the real life data regarding programme effects during covid pandemic and after the release of most sanitary measures. Methods Prospective cohort study which included consecutive pts who were participating in a center-based CR program lasting 8-12 weeks from 2019 to 2021. The CR program included initial evaluation by cardiologist and rehabilitation specialist with collection of clinical characteristics, three times weekly supervised exercise sessions, appointment with rehabilitation nurse, nutritionist and psychologist and educational sessions. Lab tests, echocardiogram and CPET were done before and after completion of the program. Results We analyzed 349 patients, mean age 60 ± 11,14 years, 83% male, most of them referred because of ischemic heart disease (83,6%), followed by valvular heart disease (7,0%). Mean ejection fraction was 48,4 ± 12,8 and most patients were in NYHA class II (65,1%). After program completion we noticed a clear benefit regarding functional class (NYHA before and after CRP: NYHA I 25,7% vs 63,7%; NYHA II 65,1% vs 34,5%; NYHA III 9,2% vs 1,9%; p&amp;lt;0.05), although differences in weight and body mass index were non significant. Laboratorial data also showed a favourable and significant improvement: NTproBNP 1068±752 pg/mL vs 498±764 (p&amp;lt;0.001); LDL-c 84±35,4 vs 70,6±30,2 (p=0.001); HDL-c 44,7±12,1mg/dL vs 46,8±10,4mg/dL (p=0.001); Triglycerides 126,9±66,6mg/dL vs 116,9±51,8mg/dL (p=0.34); HbA1c 6,07 vs 6,06 % (p=0.89). The significant differences in cholesterol were seen even after adjusting for statin dosage. Conclusions Despite constraints in CR programs during the pandemic, the long term data shows that maintaining such programs has an important effect when it comes to risk factor control and clinical improvement.

Influence of cardiac rehabilitation on blood pressure in patients with coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction One of the main goals of cardiac rehabilitation is the optimalisation of the cardiovascular risk to prevent the progression of heart disease. Arterial hypertension is one of the most important risk factors that however remains often undertreated. Purpose We analysed the patient data from our cardiac rehabilitation center over the last 3 years to assess the evolution in exercise capacity and blood pressure before and after the rehabilitation program. Methods Patients diagnosed with coronary artery disease (acute coronary syndrome, elective percutaneous coronary intervention or coronary artery bypass graft) between October 2019 and September 2022 were retrospectively included if they followed at least 50% of the total training sessions. Mean blood pressure at the beginning and end of the cardiac revalidation was derived from the mean values of the first 5 sessions and of the last 5 sessions. A change in 5 mmHg was investigated. Results The study enrolled 378 patients, of which 17 % female, with a mean age of 65.3 ± 9.68 years. Every patient followed an average of 42 training sessions (over &amp;lt; 6 months) and 149 patients (41%) had a systolic blood pressure drop of at least 5 mmHg. This decrease was more prevalent in men (133 of 149 (89%) in this group vs. 171 of 218 (78%) in the group with no difference in blood pressure (p &amp;lt;0,05)). These 149 patients had higher systolic blood pressure at the beginning of the sessions (mean systolic blood pressure of 132 ± 9,64 mmHg, p &amp;lt;0,05) and a significant difference in the number of patients who stopped smoking (86 of 129 (58%) vs. 98 of 218 (45%) (p&amp;lt; 0.05)) and were more likely to have no acute coronary syndrome (i.e. more elective procedures) (107 of 149 (72%) vs. 133 of 218 (61%) (p &amp;lt;0,05)). There was no difference in the antihypertensive treatment between the 2 groups at the beginning of the cardiac rehabilitation. The evolution in exercise capacity between the beginning and the end of the rehabilitation sessions showed in both groups together an increase in exercise capacity of 3ml/min/kg in peak VO2 (=18% improvement in peak VO2). In the group with a decrease of 5 mmHg in blood pressure, the exercise capacity improved on average with 1,6 METS (32%) vs. 1,1 METS (19%) in the group with no change in blood pressure. In other words, a positive trend could be observed for a drop in the systolic blood pressure with at least 5 mmHg in relation with an improvement in exercise capacity (p=0,06). The mean systolic blood pressure for all patients at the end of the cardiac rehabilitation was 124 ± 8.36 mmHg. Conclusion Following cardiac rehabilitation in patients with coronary artery disease, a decrease in blood pressure was seen in 41% of the participants. This decrease was mainly seen in males that stopped smoking and had no acute coronary disease. A trend towards a significant relation between improved exercise capacity (in METS) and improved blood pressure was observed.

The WALK HOP program: a French innovative multicentric home-based cardiac rehabilitation initiative

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds pour l'innovation du système de santé (FISS) - France. Background Cardiac rehabilitation (CR) has demonstrated scientific benefits in terms of morbidity and mortality. In France, 2019 national data indicates that only 22,3% of coronary patients benefit from CR. The development of alternative programs to center-based cardiac rehabilitation (CBCR) must be considered as a public health priority and requires a reorganization of ambulatory care pathways. Purpose The objective of the "Walk Hop" program is to demonstrate that home-based cardiac tele-rehabilitation (HBCT) is a complementary and safe approach to CBCR, able to increase the proportion of patients benefiting from a rehabilitation program. Methods This feasibility study started begin of 2022. 3,200 coronary patients will be recruited in 8 participating cardiac rehabilitation centers (CRC). Total duration of the experiment is 42 months. The program is financially supported by the French authorities. The HBCT solution developed for the study is proposed to patients by the CRC cardiologist. A multidisciplinary platform consisting of a secure portal and an application allows bidirectional communication. Patients are equiped with a cycle ergometer and a validated heart rate monitor. The application presents aerobic and muscle strenghtening activities and therapeutic education and collects data from the sessions carried out, adherence to the program, symptoms and quality of life. Results By october 2022, 157 active patients have been included in the program with a large majority of men (86%). Mean age is 53,9 ± 9,0. Hypercholesterolemia is noted in 36,9% of the included patients, smoking in 31%, arterial hypertension in 30,6% and diabetes in 11,1%. Obesity/overweight affects 60% of the population. Mean time from angioplasty to initiation of the rehabilitation is 81 ± 90 days. Mean number of home rehabilitation sessions is 21 and a total of 3342 home sessions have been realized. No cardiovascular event or rehospitalization have been registered since the beginnng. Mean adherence to the prescribed sessions is 80 ± 20% and the mean power gain at the end of the program is 14,6 ± 9,9 %. 94% of the patients expressed satisfaction or high satisfaction at the end of the program. Conclusion(s) The Walk Hop program is evaluating the feasibility and acceptability of HBCT with remote monitoring and digital assistance by smartphone. The preliminary data are encouraging in view of the final expected impact: greater cost-effective access to rehabilitation programs by removing obstacles like distance or resumption of work. It is also expected that HBCT will provide an improvement in the long-term maintenance benefits.

Effect of cardiac telerehabilitation as standard care on quality of life

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EIT Health education grant. Background Cardiac telerehabilitation (CTR) is a continuously developing cardiac rehabilitation (CR) format that might offer a solution to some of the challenges centre-based CR programs face. CR centres continue to face suboptimal participation in their provided CR program. The COVID-19 pandemic encouraged CR centres to implement their own CTR program to tackle practical challenges and to improve participation in CR. Multiple centres have since then developed a CTR program in accordance to (inter)national guidelines. CTR aims to improve the quality of life of patients, therefore analyses of quality of life is essential. Purpose Our study aims to analyse quality of life changes over a period of three months after program initiation for patients choosing to participate in either centre-based CR or CTR. Methods Our study included (N)STEMI patients eligible for CR between November 2021 and November 2022. Patients were invited by the cardiac rehabilitation nurse during intake to participate in CR. Patients were offered the choice between centre-based CR and CTR. The centre-based CR exercise program typically lasted for 6-8 weeks and the CTR program for a total of 48 weeks. CTR offers remote-access, digital platform for patients to interact with their healthcare professionals. The digital platform monitors physical activity and progress, which can be access by both patients and coaches. Coaches provide remote-access feedback. The SF-36 questionnaire was send out right after the CR intake procedure (T0) and three months after the CR intake procedure (T1). We only analysed data from participants who completed both T0 and T1 questionnaires, using the paired sample T-test for both CTR and centre-based CR. Results Until now, 173 patients have been included in the study of which 42 patients (24%) participated in CTR. 143 patients reached T1. 84 (59%) participants completed both T0 and T1 questionnaires, of which 24 (29%) participate in CTR (92% male, mean age 60) and 60 (71%) participate in centre-based CR (80% male, mean age 64). Participants from the centre-based CR program improved on both physical (score: +11,12; p &amp;lt; 0,001) and emotional (score: +9,30; p = 0,028) role functioning over a three month period. Participants in the CTR program improved on physical role functioning (score: +18,75; p = 0,002) and social functioning (score: + 13,54; p = 0,019). Conclusion Our preliminary show that patients were able to improve quality of life in both CTR and centre-based CR. Therefore, CTR can be used as an alternative to centre-based CR as standard care. Future research should focus on long term effects on quality of life.

A living lab approach to define patients needs and expectations for eHealth-based cardiac rehabilitation in Germany and Spain: the TIMELY study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020. Background eHealth solutions may be used for personalized care and to provide assistance for disease control to CAD patients over the compendium of the disease. TIMELY is the first artificial intelligence-driven eHealth approach based on cardiac rehabilitation (CR) components connected with internet of things devices. For usability and acceptance of the TIMELY eHealth solution, patients are actively involved in development through a Living Lab approach. Purpose To define patients’ needs for an eHealth-based self-care support CR maintenance program. Methods The Living Lab used a guided survey among CAD patients at CR centers in Germany and Spain during inpatient or outpatient CR, respectively. Questions referred to use of technology and patients’ opinion on usefulness of suggested eHealth features. Importance/usefulness was rated on a 5-point Likert scale (median score). Results 79 CAD patients (20% female) participated (Spain, n=30; Germany, n=49). Patients’ mean age was 57 years (range 37–79), educational level was 87% ≤high school. All patients owned a smartphone also used for information (76%) and documentation (43%). Patients rated the importance of CR components (diet, stress management, regular exercise, risk factor reduction, smoking cessation) along the continuum of care as "very high" (5/5), with no difference between the two centers. Individual support for regular exercise after structured CR was rated "high" (4/5). Renewal of recommended training intensity (heart rate), evaluation of training progress, and suggestions on activities were rated "useful" (4/5) to "very useful" (5/5). The importance of support for stress management, risk factor management, diet, and medication adherence was rated 3/5. Usefulness of an education platform was rated 4/5, motivational messages scored 3/5. Individual feedback by a person was rated over feedback by a virtual agent (4/5 vs. 3/5). The availability of electronic health records was evaluated as "very useful" (5/5) remote blood pressure management and ECG monitoring were rated as "useful" (4/5). All items ranged between 1-5, indicating large interindividual differences. No differences between nationalities were detected for exercise-/medical-related features. For other CR features, overall progression documentation was significantly rated as more useful by German patients compared to Spanish patients (5/5 vs. 4/5, p&amp;lt;0.001) and German patients rated individual feedback of a real person higher than Spanish patients (5/5 vs. 4/5, p=0.005). No differences existed between women and men. Conclusions Patients expressed a strong need for individual support of physical exercise and updated training recommendations during CR maintenance. The observed inter-individual differences regarding usefulness and acceptance indicate the need for an adaptive system to reduce barriers for eHealth access. Patients from Germany and Spain showed equally high acceptance of eHealth components for the management of CAD.