Comprehensive Cardiac Rehabilitation 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.

The Clinical Outcome of Cardiac Rehabilitation in Coronary Artery Disease Patients with Regard to the Presence of Left Ventricular Systolic Dysfunction.

Background: Despite the use of advanced treatment techniques, coronary artery disease (CAD) still remains the main cause of left ventricular (LV) dysfunction and heart failure. Participation in cardiac rehabilitation (CR) programs can lead to a number of beneficial effects, but some patients do not demonstrate the expected improvement. The aim of this study is to evaluate the impact of CR on changes in exercise capacity with regard to the presence of LV dysfunction. Methods: A group of 428 patients with CAD were consecutively admitted to an outpatient comprehensive cardiac rehabilitation program comprising 24 exercise sessions of interval training on cycle ergometers, three times a week for 45 min, and a health education. The patients were compared in two subgroups, i.e., with LV systolic dysfunction (LVEF < 50%, n = 175) and LVEF ≥ 50% (n = 253). Results: In the LVEF < 50% group, the exercise capacity improved by 1 ± 0.78 MET (median 1.15 MET), and 0.86 ± 0.77 MET (median 1.08 MET) in the LVEF ≥ 50% group. Women with LVEF < 50% demonstrated a significant increase in exercise capacity by 1.2 MET, while those with LVEF ≥ 50% did not display any such increase. All men, regardless of LVEF, exhibited a similar improvement in exercise capacity greater than 1 MET. Conclusions: An outpatient eight-week cardiac rehabilitation program based on 45 min aerobic interval training sessions three times a week appears less effective for women with CAD and EF ≥ 50%. In this group, the proposed training intervention is insufficient in improving exercise capacity to an extent that could indicate a reduction in mortality risk.

Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health.

Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.

Relationship between cachexia and short physical performance battery scores in patients with heart failure attending comprehensive outpatient cardiac rehabilitation.

Heart failure (HF) can cause metabolic imbalances, leading to anabolic resistance and increased energy expenditure, which often results in weight loss and cachexia. Comprehensive cardiac rehabilitation (CR), including exercise, nutritional support, and risk management, is crucial for enhancing the health and quality of life of patients with HF and is expected to play a central role in the prevention and treatment of HF-associated cachexia. However, the prevalence of cachexia in patients with HF undergoing comprehensive outpatient CR is currently unknown, and the detailed characteristics including of motor function of such patients remain undefined. Therefore, this cross-sectional study aimed to investigate the prevalence and characteristics of cachexia and the relationship between cachexia and lower limb motor function in patients with HF undergoing outpatient CR. This study included 115 consecutive patients with HF (43% male; mean age, 78 ± 8years) who underwent comprehensive outpatient CR. The cachexia status was assessed according to the definition proposed by the Asian Working Group on Cachexia in 2023. The Short Physical Performance Battery (SPPB) and Mini Nutritional Assessment Short-Form (MNA-SF) were used to evaluate motor function of the lower limbs and nutritional status, respectively. Multivariate logistic regression analyses were used to examine the potential relationship between cachexia and low SPPB scores (≤ 9 points). The prevalence of cachexia was 30% in this study. Compared with those without cachexia, patients with cachexia were significantly older and showed notable reductions in body mass index, MNA-SF scores, handgrip strength, gait speed, and SPPB scores. A multivariate logistic regression analysis, adjusted for confounders, revealed that both age (odds ratio [OR], 1.129; 95% confidence interval [CI], 1.034-1.248; P = 0.016) and presence of cachexia (OR, 3.783; 95% CI, 1.213-11.796; P = 0.022) were independently associated with low SPPB scores. These findings highlight the importance of focusing on cachexia in patients with HF as part of a comprehensive outpatient CR and may be crucial in developing treatments to improve lower limb motor function in patients with HF who develops cachexia.

Comprehensive Cardiac Rehabilitation for Patients With Myocardial Infarction - Impact on Prognosis in Patients With Low Exercise Capacity.

Comprehensive Cardiac Rehabilitation for Patients With Myocardial Infarction - Impact on Prognosis in Patients With Low Exercise Capacity.

Comprehensive Cardiac Rehabilitation Following Acute Myocardial Infarction Improves Clinical Outcomes Regardless of Exercise Capacity.

Reduced exercise capacity is a prognostic indicator of adverse outcomes in patients with acute myocardial infarction (AMI). However, few studies have evaluated the effectiveness of comprehensive cardiac rehabilitation (CR) in this population. This study aimed to clarify the efficacy of comprehensive CR in patients with AMI and reduced exercise capacity.Methods and Results: This cohort study included 610 patients with AMI who underwent percutaneous coronary intervention. Major adverse cardiovascular events (MACE) were compared between patients who participated in comprehensive outpatient CR for 150 days (CR group; n=430) and those who did not (non-CR group; n=180). During the mean (±SD) follow-up period of 6.1±4.0 years, the CR group exhibited a lower incidence of MACE (log-rank P=0.002). Multivariable analysis revealed that Killip classification, diuretics at discharge, and participation in comprehensive CR were independently associated with MACE. The CR group was further divided into 2 groups, namely reduced exercise capacity (% predicted peak V̇O2<80%; n=241) and preserved exercise capacity (≥80%; n=147), based on the initial cardiopulmonary exercise test. Despite distinct exercise capacities, the incidence of MACE was comparable and physical parameters improved similarly after comprehensive CR in both groups. Comprehensive CR in patients with AMI effectively reduced the incidence of MACE regardless of initial exercise capacity. Cardiologists should actively encourage patients with low exercise capacity to participate in comprehensive CR.

Exercise-based cardiac rehabilitation for adults with heart failure.

People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting. To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure. We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers. We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF. We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence. We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes. This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

Cardiac Rehabilitation After Hospitalization for Acute Coronary Syndrome.

Acute coronary syndrome (ACS) carries a high burden of morbidity and mortality. Cardiac rehabilitation over the past century has developed as an important tool in treating and preventing future myocardial infarction events in this critical group. We summarize the rationale and literature evidence supporting the use of cardiac rehabilitation and its role in ACS patients, with an emphasis on its impact on outcomes following hospitalization. Current literature and large-scale reviews and registry analyses provide conflicting data on the benefits of cardiac rehabilitation after ACS, including its impact on mortality, readmission, and quality of life. Cardiac rehabilitation is an important tool in the management ACS patients. It encompasses not only a graduated exercise regimen but also a holistic approach and is therefore best implemented as a comprehensive cardiac rehabilitation strategy including, in addition to exercise regimen, psychosocial counseling, smoking cessation education, medication adherence, nutrition guidance, and other tools for risk modification. Further trials on the role of cardiac rehabilitation after ACS are needed, especially trials examining different cardiac rehabilitation protocols, time period for its implementation after ACS, and optimal program duration.

Enhancing Quality of Life in Cardiovascular Patients: The Role of Comprehensive Interventions and Cardiac Rehabilitation

Abstract Introduction Cardiac rehabilitation is an established strategy to improve cardiovascular outcomes in patients with Acute Coronary Syndrome (ACS) and Heart Failure (HF). However, not all patients can participate in such programs. Intermediate interventions focused on lifestyle modification may be a potential strategy to improve outcomes. Depression and anxiety are common in patients with CVD and are linked to increased mortality. The Hospital Anxiety and Depression Scale (HADS) is a 14-item tool used to measure anxiety and depression symptoms and has been shown to be useful in assessing the psychological well-being of patients undergoing cardiac rehabilitation. Objective The objective of this retrospective study was to evaluate the impact of different levels of intervention on the quality of life of patients after cardiovascular events - ACS and CHF - in terms of depressive and anxious outcomes. Materials and Methods The study analyzed 56 patients who were previously hospitalized in the Cardiology department within one year: 47 for ACS and 9 for decompensated HF. After discharge, 19 patients attended a cardiac rehabilitation program (group 1), 19 had regular cardiovascular risk appointments and educational sessions conducted by psychiatrists, nutritionists, physiatrists, and cardiologists, but without participating in a physical rehabilitation program (group 2), and 18 patients were selected as controls without any of previous strategies (group 3). The group 1 intervention include also the measures implemented in group 2. All participants signed informed consent and completed the HADS questionnaire. Results The average age of the participants was 54.9 ± 9.9 years, with 29% females, and an average of 2.7 ± 0.6 cardiovascular risk factors. There were no significant differences in the distribution of ACS or decompensated heart failure between the groups. Group 1 predominantly presented a normal pattern of HADS scores (56% vs 40% vs 4%), respectively for group 1, 2 and 3. Conversely, in group 3 compared with group 1 and 2, there was a predominance of the abnormal score, respectively (50% vs 17% vs 33.3%); p &amp;lt;0.01. Conclusion The results suggest that patients who underwent regular appointments/education and cardiac functional rehabilitation exhibited lower levels of anxiety and depressive symptoms. In conclusion, the study indicates that a comprehensive intervention continuum, including cardiac rehabilitation and regular appointments/education, can significantly improve patients' quality of life and reduce their cardiovascular risk. Patients who undergo cardiac rehabilitation may experience the greatest benefits. The findings support the potential value of intermediate interventions focused on lifestyle modification as a strategy to improve outcomes for patients who cannot participate in a rehabilitation program.

Using registry data to determine actual cardiac rehabilitation participation after percutaneous coronary intervention

Abstract Background Comprehensive cardiac rehabilitation (CR) has proven beneficial effects, and is a class 1A recommendation in European Society of Cardiology guidelines. Still, CR is grossly underused globally. In Norway, few studies on CR participation exist, and the extent to which CR is underused is more uncertain. Using data from national quality registries provides an opportunity to estimate actual CR participation, and whether there are some groups that participate less often than others do. Aim To determine actual use of CR, comprehensive or single component, in patients after percutaneous coronary intervention (PCI), with a special attention on women, older people, patients with comorbidities and education level. Methods CONCARDPCI is a prospective multicentre cohort study including 1970 patients after PCI at three Norwegian university hospitals during 2017-2019. Socio-demographic characteristics were self-reported during the index hospitalization for PCI. Clinical data were collected from patients’ medical records and the Norwegian Registry on Invasive Cardiology. Data on CR participation were extracted from the Norwegian Control and Payment of Health Reimbursements Database, and measured at 2-, 6- and 12 months after index hospitalisation. Results One year after PCI, one out of six patients (16%) had received single- or multicomponent CR. At 2 months, 7% had participated in CR, from 2–6 months, 12% participated in CR and from 6–12 months, 2% participated in CR. Most patients were men (78%) with a mean age of 66 years (SD 11, range 20-96 years). At 6 months, fewer women than men had participated in CR (9% vs. 13%, p=0.020). During the 12 month period, 12% of women and 17% of men participated in CR (p=0.019). The patients participating in CR were significantly younger (60 vs. 67, p&amp;lt;0.001) at all measuring points. A sizeable proportion had previous cardiovascular comorbidities including hypertension (52%) and hypercholesterolemia (47%). Patients with hypercholesterolemia participated significantly less than those without at 2 months (6% vs. 8%, p=0.031) and 6 months (9% vs. 14%, p=0.001). Those with hypertension also participated less than those without at 2 months (5% vs. 9%, p=0.002) and 6 months (9% vs. 15%, p&amp;lt;0.001). Further, 26% had previous PCI, and those with a history of PCI participated less than those with no history at 2 months (3% vs. 9%, p&amp;lt;0.001) and 6 months (6% vs. 14%, p&amp;lt;0.001). Finally, those with a lower educational level participated less at 2 months (primary school 4% vs. college/university 10%, p=0.034) and 6 months (primary school 9% vs. college/university 15%, p=0.050). Conclusion Very few patients participated in comprehensive or single component CR. Those with a lower educational level and women participated less often in CR, and the proportion was even lower in patients with comorbidities. New modes of delivery for CR is needed to meet the large group of patients not receiving follow-up according to guidelines.

Abstract 17716: Comprehensive Cardiac Rehabilitation Following Myocardial Infarction Improves Clinical Outcomes Regardless of Exercise Capacity in a Long-Term Follow-Up

Background: Reduced exercise capacity is recognized as a prognostic indicator of adverse outcomes in patients with myocardial infarction (MI). However, there is limited research evaluating the effectiveness of comprehensive cardiac rehabilitation (CR) in this population. Here, we show for the first time that participation in CR can improve the prognosis of MI patients with reduced exercise capacity in a long-term study. Methods: This cohort study included 610 consecutive patients with MI who underwent percutaneous coronary intervention (PCI) between 2008 and 2015. Patients who received supervised CR were divided into two groups according to the duration of CR: the non-CR group (only hospitalization) and the CR group (continued to outpatient-CR). Within the CR group, patients were further divided into a reduced exercise capacity group (% predicted peak VO2 &lt;80%) and a preserved exercise capacity group (≥80%). Comprehensive CR consisted of a 150-day supervised exercise program at the anaerobic threshold (AT) performed in the hospital under the supervision of a multidisciplinary team. Major adverse cardiovascular events (MACE) were compared among groups. Results: Mean follow-up was 6.1 ± 4.0 years. The MI patients were divided into three groups: the non-CR group (n = 180), the CR group with reduced exercise capacity (n = 241, peak VO2: 17.2 ± 3.9 ml/min/kg) and with preserved exercise capacity (n = 147, peak VO2: 23.1 ± 4.6 ml/min/kg). There was no significant difference in the improvement of the lower limb exercise capacity index, AT, peak VO2 and risk of MACE between the CR groups with reduced and preserved exercise capacity. However, the risk of MACE was lower in the CR groups compared with the non-CR group (log-rank p = 0.014). Multivariable Cox regression analysis showed that chronic kidney disease (aHR 1.89, 95% CI 1.19-3.01, p &lt; 0.01), non-Killip class 1 (aHR 1.90, 95% CI 1.01-3.57, p = 0.047) and CR participation (aHR 0.57, 95% CI 0.36-0.90, p = 0.015) were independent predictors of MACE. Conclusions: Comprehensive CR after PCI in patients with MI effectively reduces the occurrence of MACE, regardless of their exercise capacity. We should also actively encourage patients with low exercise capacity to participate in comprehensive CR.

Abstract 17829: Improving Access to Cardiac Rehabilitation for Minorities and Vulnerable Patients With a Multidisciplinary Program in a Large Metropolitan Public Hospital Network

Introduction: Cardiac rehabilitation (CR) improves outcomes after myocardial infarction, cardiac surgery or in chronic heart failure with reduced ejection fraction. However, access to CR is often limited to insured patients or those who can pay out-of-pocket, leaving uninsured or undocumented patients without access to these benefits. Our aim is to describe the implementation and outcomes of a multidisciplinary comprehensive CR program in the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care for minorities. Methods: Our CR program started in March 2021 as a virtual program and opened for in-person care in November 2022. We collected clinical, demographic, socioeconomic, and immigration data as well as data on clinical outcomes such as hospital readmission, mortality, and program completion rates. Results: A total of 202 patients were included (35.6% women, mean age 62), with 83.7% of patients in virtual CR and 16.3 % in in-person CR. The most common ethnic group was Black (41.6%) followed by Hispanic (38.6%). A total of 23.8% were uninsured, 21.3% were undocumented and 52.5% lived below the poverty level reported for New York City. The highest level of education was &lt; 8th grade in 16.8%, high school in 22.8%, at least 2 years of college in 5.5%, &gt; 4 years of college in 7.9% and unknown in 47%. The hospital readmission rate at 6 months was 12.4% and mortality was 1.5%. There were no significant differences in survival or readmission by ethnic group. Of patients completing at least one visit, 72% were active or graduated from virtual CR and 90% were active or graduated for in-person CR (Figure). Conclusions: Our multidisciplinary CR program demonstrates feasibility in providing care to underserved and vulnerable populations, showing excellent results and providing a strategy to decrease healthcare disparities in access to an intervention which improves outcomes across a broad spectrum of cardiac disease.

The State of Cardiac Rehabilitation in Saudi Arabia: Barriers, Facilitators, and Policy Implications.

Cardiovascular disease (CVD) is a critical public health issue in Saudi Arabia, where it is the leading cause of death. The economic burden of CVD in the country is expected to triple by 2035, reaching $9.8 billion. This paper provides an overview of CVD in Saudi Arabia and its risk factors, impact on healthcare, and effects on patients' quality of life. The review emphasizes the potential of cardiac rehabilitation (CR) programs in addressing the CVD epidemic. CR programs have been shown to reduce morbidity, mortality, and hospital readmissions while improving patients' cardiovascular health and overall well-being. However, these programs are underutilized and inaccessible in Saudi Arabia. The paper highlights the urgent need for CR programs in the country and suggests key strategies for implementation. These include increasing patient referrals, tailoring programs to individual needs, enhancing patient education, and making CR accessible through home-based options. Fostering multidisciplinary collaboration and developing tailored guidelines for Arab countries can further enhance the impact of CR programs. In conclusion, this review underscores the vital importance of comprehensive CR programs in Saudi Arabia to combat the rising CVD burden, improve patient quality of life, and align with the goals of the Saudi 2030 Vision for a healthier society.

Factors shaping return to work: a qualitative study among heart failure patients in Denmark

Purpose For people of working-age diagnosed with heart failure, return to work (RTW) is often a significant rehabilitation goal. To inform vocational rehabilitation strategies, we conducted a qualitative study aiming at exploring patient experienced support needs, and barriers and facilitators to RTW. Materials and methods Ten men and eight women with heart failure (48–60 years) were interviewed in Denmark during 2022. A thematic analysis was conducted using the Sherbrooke model as framework. Results Multiple factors operating at different levels shaped participants’ RTW processes. Personal factors included motivation, mental and physical health, social relations, and financial concerns. Factors in the health care system shaping RTW included access to medical treatment, mental health care, and cardiac rehabilitation. Factors in workplace system shaping RTW included job type, employer support, and social relations. Factors in the legislative and insurance system shaping RTW included authorities’ administration of sickness benefits, professional assistance, vocational counselling, and interdisciplinary cooperation. Conclusion Findings illustrate a need to include vocational rehabilitation within comprehensive cardiac rehabilitation programmes, to identify people in need of support, to improve the coordination of care across the health and social care sectors, and to involve employers, health care professionals, and social workers in individualised RTW strategies. IMPLICATIONS FOR REHABILITATION Vocational re-integration is shaped by multiple factors operating at different levels (including personal factors, work-related factors, factors in the health care system, and factors in the legislative and insurance system). To improve return to work following heart failure, there is a need for multi-level initiatives, including policy measures and efforts to enhance continuity and coordination of care. People with heart failure in need of vocational support should be identified early within comprehensive cardiac rehabilitation programmes. Health care professionals should address work-related issues and provide individualised information and clear advice regarding timely and safe return to work. Individualised return-to-work plans should be developed within interdisciplinary teams across health and social care sectors and involve employers to ensure that they are aware of relevant work accommodations.

Effects of Comprehensive Outpatient Cardiac Rehabilitation on Exercise Capacity, Functional Status, and Quality of Life in People with Heart Failure: A Systematic Review and Meta-Analysis.

The purpose of this study was to systematically review and conduct a meta-analysis to examine the impact of comprehensive outpatient cardiac rehabilitation on exercise capacity, functional status, and quality of life in patients with heart failure. PubMed, Embase, and CINAHL were searched using keywords and MeSH terms on heart failure and cardiac rehabilitation. Randomized clinical trials published in English using outpatient exercise-based cardiac rehabilitation in patients with heart failure were included. The Grading of Recommendations Assessment, Development and Evaluation was utilized for quality appraisal. Pooled estimates were computed using standardized mean differences (SMDs) and 95% CIs. Primary outcomes were functional status (6-minute walk distance, quality of life, exercise capacity using peak oxygen consumption, muscle strength, and endurance). Eleven randomized controlled trials including 1523 participants ranging from 45 to 80years old and an intervention duration ranging from 2 to 26weeks were analyzed. Pooled results indicated significant improvements with comprehensive cardiac rehabilitation on 6-minute walk distance (SMD = 0.30; 95% CI = 0.06 to 0.54) and oxygen consumption (SMD = 0.23; 95% CI = 0.06 to 0.40). However, there was no additional benefit for the quality of life beyond that seen in the comparison groups. Results of this study suggest that comprehensive outpatient cardiac rehabilitation is associated with significantly better clinical outcomes than single-component exercise programs in cardiac rehabilitation settings, multicomponent exercise in non-cardiac rehabilitation settings, or no exercise. Heart failure is significantly associated with an increased risk of poor exercise tolerance. Despite the proven benefit of cardiac rehabilitation on exercise tolerance and physical activities from individual randomized clinical trials, questions regarding its impact on clinical outcomes such as exercise capacity, functional status, and quality of life remain inadequate. This systematic review and meta-analysis provides strong evidence supporting comprehensive outpatient cardiac rehabilitation for improving clinical outcomes in heart failure.

The association of serum adiponectin level with activities of daily living in hospitalized elderly patients with heart failure

BackgroundSeveral studies have reported a relationship between elevated serum adiponectin levels and poor outcomes in patients with heart failure (HF). However, data on the activities of daily living (ADL) in elderly patients with HF are limited. MethodsWe evaluated 218 hospitalized elderly (≥65 years) patients with HF who underwent a comprehensive cardiac rehabilitation (CR) program during hospitalization. Serum adiponectin levels were measured before discharge. The Barthel index (BI) score was evaluated at discharge. Low ADL was defined as a BI score < 85. ResultsSerum adiponectin levels were significantly associated with low ADL [p = 0.03; odds ratio (OR), 1.024, per 1.0 μg/mL increase]. In logistic or regression analyses adjusted for age, sex, body mass index, and estimated glomerular filtration rate, high adiponectin levels (≥16.2 μg/mL) were significantly associated with low ADL (p = 0.04; OR, 2.53), malnutrition (p < 0.01; OR, 2.88), and 6-min walk distance (p = 0.04; β = −17.5). In the multivariate analysis adjusted for conventional risk factors of low ADL, high adiponectin levels were also significantly associated with low ADL (p = 0.03; OR, 2.68). In the stepwise forward selection procedure, a high adiponectin level was an independent determinant of low ADL (p = 0.02; R2 = 0.0262). Both net reclassification improvement (0.53; p < 0.01) and integrated discrimination improvement (0.02; p = 0.01) improved significantly after the addition of high adiponectin level to conventional risk factors. In the regression analysis adjusted for age and sex, serum adiponectin levels were significantly (p < 0.0025) negatively associated with abdominal visceral and subcutaneous adipose tissue areas, body weight, body mass index, and serum triglyceride levels. ConclusionsHigh serum adiponectin levels were not only significantly associated with an increased risk of low ADL, but also with an increased risk of malnutrition and low physical activity in elderly patients with HF after the in-hospital CR program.

Cardiac rehabilitation for heart failure and atrial fibrillation: a propensity- matched study

BackgroundAtrial fibrillation (AF) is common in individuals with heart failure (HF). Individuals with HF and AF may have a reduced functional capacity and quality of life (QoL) which leads to...

Do ethnic minorities improve in exercise capacity following cardiac rehabilitation? a secondary analysis

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): SOLVE-CHD NHMRC Grant Background/Introduction Ethnic minorities experience higher rates of cardiovascular disease risks due to a combination of risk factors and socio-cultural influences. While comprehensive cardiac rehabilitation (CR) has well-established benefits for reducing mortality, morbidity, and improving physical fitness, little is known about exercise capacity outcomes for ethnic minorities following CR. Purpose This secondary analysis of data from an observational study aimed to evaluate exercise capacity outcomes of ethnic minorities following CR using 6-minute walk test (6MWT) or metabolic equivalent of task (METs) and to compare it to the majority group. Multiple linear regression models were used to determine if ethnic minority status was an independent predictor of change in 6MWT and METs after adjusting for baseline characteristics (age, sex, diagnosis, smoking, referral site, and wait time). Additionally, a binary logistic regression model was created for completers versus non-completers accounting for baseline variables. Results Participants totalled 2335, of which 326 (14%) were ethnic minorities. The mean age of ethnic minorities was 66.46 (SD 12.12) years, with 228 (70%) males. The most common referral diagnosis was myocardial infarction (27%), angina (25%), other – arrhythmias, cardiac devices, valve diseases/procedures (24%), and cardiac surgery (24%). Ethnic minorities had significantly lower 6MWT scores at baseline compared to the majority (379.9 (SD 118) versus 430.7 (SD 103) meters, p&amp;lt;0.001, but METs were comparable (6.69 (SD 2.73) versus 6.46 (SD 2.28) mg/kg/min, p = 0.69. At CR completion, improvements in 6MWT were equivalent for minority (71.03 (SD 58.57)) and majority (71.37 (SD 61.16)) groups (p = 0.96), as well as METs (minority 3.01 (SD 1.66) versus majority 3.13 (SD 1.74) p = 0.77). Minority status was not an independent predictor of change in 6MWT and METs after accounting for age, sex, diagnosis, smoking, referral site, and wait time. However, participants that were minorities were half as likely to complete (OR 0.49 95% CI 0.38, 0.65). Conclusion Ethnic minorities achieve equivalent improvements in exercise capacity to majority participants following CR. These findings add to the effectiveness evidence of CR, at least for exercise capacity, for diverse populations. However, such benefits would only be gained with adequate participation and CR program completion, which remains poor for ethnic minorities. Improving CR program uptake and completion for ethnic minorities with cardiovascular disease should be prioritised.

Women achieve equivalent health-related quality of life benefits to men from attending cardiac rehabilitation: a matched case-control study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): SOLVE-CHD NHMRC Synergy Grant Background/Introduction Coronary heart disease (CHD) is the leading cause of death in women globally; and women have worse health outcomes from CHD than men, including poorer health-related quality of life (HRQL). Comprehensive cardiac rehabilitation (EBCR) has well-established benefit for patients with CHD in improving HRQL. These benefits have rarely been distinguished separately for women despite known differences to men. Purpose The aim of this study was to compare women and men’s HRQL outcomes after accounting for differences in age, partnership status and diagnosis. Methods A secondary analysis of a larger prospective observational study of CR outcomes using a matched case-control study of women and men. The sample included patients enrolled in four CR programs following admission for CHD (myocardial infarction [MI], percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]). Women were matched to men based on age (within 0-2 years), marital status (single, or partnered), and diagnosis (MI, PCI, or CABG). Sociodemographic data were collected from the participants and clinical information (diagnosis, comorbidities) from the medical record. HRQL was measured using the Short Form-12 Health Survey (SF-12). Results Thirty-seven matched women and men were included in this study at baseline, of whom 27 completed the study (72.9%). There were no significance differences in sociodemographic and clinical characteristics between men and women at baseline. Both women and men improved HRQL substantially from pre-post CR, with no significant differences in change scores in any domain between the sexes despite women having worse scores at baseline in Physical Functioning (mean score 41.59 vs 44.15), Bodily Pain (mean score 47.78 vs 48.71) and overall physical summary score (mean score 44.14 vs 45.29). Women had clinically meaningful improvements in Physical Functioning (MD 6.51, 95% CI 2.59-10.44) and Role Physical (MD 6.42, 95% CI 2.81-10.03), Mental Health (MD 4.35, 95% CI 2.05-6.66) and Bodily Pain (MD 4.97, 95% CI 1.36-8.60) and in the overall physical summary score (MD 5.67, 95% CI 1.98-9.38). Men achieved clinically meaningful improvements in the same domains as women plus Vitality (MD 5.11, 95% CI 0.87-9.36) and Social Function (MD 8.54, 95% CI 3.98-13.09). Conclusion(s) When matched to men for age, partnership status, and diagnosis, women achieve clinically meaningful and equivalent HRQL outcomes following CR. Women significantly improved in overall physical and mental health HRQL, as well as in the majority of HRQL domains. These findings could be used to strengthen advocacy in supporting women with CHD to participate and complete CR programs.

Cardiac rehabilitation patient data management and quality improvement in Australia: A national survey

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council Synergy Grant Background Receipt of guideline-indicated comprehensive cardiac rehabilitation improves patient outcomes. Optimum service delivery and meeting quality standards necessitates accurate standardised data collection and reporting. The methods, processes and systems used for data capture and reporting in cardiac rehabilitation are under-documented, limiting identification of areas needing change and creation of a platform for quality improvement (QI) at national levels. Purpose To describe data capture, management, and reporting and the awareness and use of quality indicators in contemporary Australian CR programs. Methods CR programs (n=396) were identified through professional and national directories, jurisdictional networks, webinars, and direct provider contact. Program coordinators completed an online survey on individual service characteristics, data capture and management systems (paper, electronic, database, integrated platform) including awareness, use and usefulness of the published National Cardiac Rehabilitation Quality toolkit components. Results Respondents totalled 319 (80.5%), from all eight states and territories. Coverage of Metropolitan, rural and remote towns, and regional centres was 46.3%, 45.9% and 7.8%, respectively. Indicative annual patient enrolments were &amp;gt;200 (31.0%), 51-200 (46.4%) and ≤50 (22.6%). Most programs used ≥2 data management systems: paper and electronic 62.6% or multiple e-systems 19.1%, or one system, either paper 20.9% or electronic 16.3%. Use of multiple systems and combinations of systems did not differ by number of patients enrolled. QI systems were infrequently used: QI Platforms 17.2%, QI Databases 10.0%. Supplementary to patient care, data gained was used for reports for management (57.0%), QI (56.1%), funding support (43.2%), required jurisdictional reporting (41.1%) and research (30.7%). Higher volume programs were more likely to be using the data capture for multiple purposes. Independent covariates of services using data for QI were enrolments of &amp;gt;200 (OR 3.83 95% CI 1.76, 8.34) and the state/territory location, such that use of QI was less likely in the states of Victoria (OR 0.24 95% CI 0.08, 0.77), New South Wales (OR 0.25 95% CI 0.08, 0.76) and Western Australia (OR 0.16 95% CI 0.05, 0.57). Conclusions Management of cardiac rehabilitation patient data is highly variable across Australian programs and jurisdictions, often including multiple different systems, with limited use of the data for QI. A national user-friendly, low burden approach to CR data collection incorporated into daily work-flow that is capable of benchmarking and informs QI is essential.