Contemporary Cardiac Rehabilitation Research Articles

Cardiac Rehabilitation in the Modern Era: Optimizing Recovery and Reducing Recurrence.

Cardiovascular diseases (CVDs) continue to be a prominent issue in global health, emphasizing the necessity for efficient cardiac rehabilitation programs. This narrative review provides a detailed analysis of the current state of cardiac rehabilitation, focusing on maximizing recovery and minimizing the likelihood of recurrence. This paper examines the historical progression of cardiac rehabilitation, explores the epidemiological background of cardiovascular disease (CVD), and provides an overview of the many stages of the rehabilitation process. The assessment of patients plays a crucial role in healthcare, serving as a fundamental basis that incorporates medical, psychological, and social aspects. The utilization of risk stratification techniques further enhances this process. The present study investigates exercise training, particularly emphasizing the current recommendations and the mutually beneficial effects of aerobic and resistance regimens. In addition to physical therapies, this study emphasizes the importance of nutrition, lifestyle adjustments, and the significant effects of medication. Psychosocial assistance is a crucial element that addresses the significant psychological effects of cardiac disease and provides comprehensive techniques for overall well-being. Technological advancements are significantly transforming the domain of cardiac rehabilitation, encompassing the integration of wearable technologies and telemedicine solutions. The convergence of artificial intelligence and data analytics can enhance the customization of healthcare services. Through a comprehensive rehabilitation program, patients can achieve an improved quality of life and enhanced functional outcomes. However, it is essential to acknowledge that obstacles still hinder individuals from accessing and completing educational programs. Therefore, it is crucial to engage in a discourse on potential tactics that may be employed to address these issues, considering the various cultural and socioeconomic aspects that contribute to them. The analysis focuses on the economic dimension, examining the cost-effectiveness of rehabilitation programs and their congruence with healthcare policies. In anticipation of future developments, the study provides valuable perspectives on the prospective trajectory of cardiac rehabilitation. It delves into nascent patterns and examines the potential ramifications of precision medicine and genetics for tailoring treatment strategies to individual patients. In brief, this narrative review comprehensively examines the various dimensions of contemporary cardiac rehabilitation. It offers a comprehensive perspective on its significance in enhancing recuperation and mitigating the likelihood of the recurrence of cardiovascular ailments. The significance of this review lies in its ability to enhance patient outcomes, thereby making a valuable contribution to the worldwide endeavor to address the burden of cardiovascular disease.

Long-term outcomes of the Coordinated Care Program in Patients after Myocardial Infarction (KOS-MI).

The Coordinated Care in Myocardial Infarction Program (KOS-MI) was introduced to improve prognosis for patients after myocardial infarction (MI). The program includes complete revascularization followed by unrestricted access to rehabilitation, electrotherapy and cardiac care. The aim of this study was to assess major adverse cardiac and cerebrovascular events (MACCE) of patients enrolled in the KOS-MI at 3-year follow-up. This is a retrospective, multicenter registry of patients treated for MI. Study group (KOS-MI) of 963 patients was compared to the control group (standard of care) of 1009 patients. At 3-year follow-up MACCE including death, MI, stroke and repeated revascularization were reported. Additionally, hospitalization due to heart failure (HF) was analyzed. Propensity score matching (PSM) was utilized for group baseline characteristics adjustment. Patients in the KOS-MI group were younger (65 vs. 68; P < 0.001), mostly men (70% vs. 62.9%; P < 0.001), admitted with ST-elevation myocardial infarction (STEMI) (44.6% vs. 36.2%; P < 0.001). Patients in the control group had more comorbidities and were admitted more often with non ST-elevation myocardial infarction (63.8% vs. 55.4%; P < 0.001) and acute HF (5.1% vs. 2.7%; P = 0.007). Following PSM 530 well matched pairs were selected. At three years (92.3% follow-up completeness), the relative risk reduction was: 25% in MACCE (P = 0.008), 38% in mortality (P = 0.008), 29% in repeated revascularization(P = 0.04) and 28% (P = 0.0496) in hospitalization for HF in the KOS-MI group. The combination of contemporary invasive techniques, complete revascularization, cardiac rehabilitation and ambulatory care included in the KOS-MI Program improves long-term prognosis of patients after MI up to 3-year follow-up.

Effectiveness of an intervention to reduce sedentary behaviour as a personalised secondary prevention strategy for patients with coronary artery disease: main outcomes of the SIT LESS randomised clinical trial

BackgroundA high sedentary time is associated with increased mortality risk. Previous studies indicate that replacement of sedentary time with light- and moderate-to-vigorous physical activity attenuates the risk for adverse outcomes and improves cardiovascular risk factors. Patients with cardiovascular disease are more sedentary compared to the general population, while daily time spent sedentary remains high following contemporary cardiac rehabilitation programmes. This clinical trial investigated the effectiveness of a sedentary behaviour intervention as a personalised secondary prevention strategy (SIT LESS) on changes in sedentary time among patients with coronary artery disease participating in cardiac rehabilitation.MethodsPatients were randomised to usual care (n = 104) or SIT LESS (n = 108). Both groups received a comprehensive 12-week centre-based cardiac rehabilitation programme with face-to-face consultations and supervised exercise sessions, whereas SIT LESS participants additionally received a 12-week, nurse-delivered, hybrid behaviour change intervention in combination with a pocket-worn activity tracker connected to a smartphone application to continuously monitor sedentary time. Primary outcome was the change in device-based sedentary time between pre- to post-rehabilitation. Changes in sedentary time characteristics (prevalence of prolonged sedentary bouts and proportion of patients with sedentary time ≥ 9.5 h/day); time spent in light-intensity and moderate-to-vigorous physical activity; step count; quality of life; competencies for self-management; and cardiovascular risk score were assessed as secondary outcomes.ResultsPatients (77% male) were 63 ± 10 years and primarily diagnosed with myocardial infarction (78%). Sedentary time decreased in SIT LESS (− 1.6 [− 2.1 to − 1.1] hours/day) and controls (− 1.2 [ ─1.7 to − 0.8]), but between group differences did not reach statistical significance (─0.4 [─1.0 to 0.3]) hours/day). The post-rehabilitation proportion of patients with a sedentary time above the upper limit of normal (≥ 9.5 h/day) was significantly lower in SIT LESS versus controls (48% versus 72%, baseline-adjusted odds-ratio 0.4 (0.2–0.8)). No differences were observed in the other predefined secondary outcomes.ConclusionsAmong patients with coronary artery disease participating in cardiac rehabilitation, SIT LESS did not induce significantly greater reductions in sedentary time compared to controls, but delivery was feasible and a reduced odds of a sedentary time ≥ 9.5 h/day was observed.Trial registrationNetherlands Trial Register: NL9263.Graphical Outcomes of the SIT LESS trial: changes in device-based sedentary time from pre-to post-cardiac rehabilitation (control group) and cardiac rehabilitation + SIT LESS (intervention group). SIT LESS reduced the odds of patients having a sedentary time >9.5 hours/day (upper limit of normal), although the absolute decrease in sedentary time did not significantly differ from controls. SIT LESS appears to be feasible, acceptable and potentially beneficial, but a larger cluster randomised trial is warranted to provide a more accurate estimate of its effects on sedentary time and clinical outcomes. CR: cardiac rehabilitation.

Abstract 14404: Variation and Predictors of Referral for Cardiac Rehabilitation Among Patients With Heart Failure Before and After Expansion of Coverage and Association With 1-year Clinical Outcomes

Introduction: The Centers for Medicare and Medicaid Services(CMS) expanded coverage for cardiac rehabilitation(CR) in 2014 for patients with clinically stable heart failure(HF) with reduced ejection fraction. Contemporary CR referral and participation rates among eligible patients with HFrEF are not known. Methods: Patients hospitalized for HF with ejection fraction ≤35% in the American Heart Association Get With The Guidelines®-HF(GWTG-HF) registry from 2010-2020 were included. Trends in rate of referrals and predictors of referral were determined. Among subset of participants with available Medicare-linked data, rate of CR participation was assessed, and 1-year outcomes were compared among patients referred vs. not referred to CR. Results: Of 69,441 HF patients eligible for CR, 17,076(24.6%) were referred to CR. There was substantial variability in referral across GWTG-HF participating centers (range 0-100%, IQR 4%-50%). Of patients with fee-for-service Medicare referred to CR, only 4.2% participated in CR in the year following HF hospitalization (median sessions: 3, range 1-76). Referral rate increased from 2010-2020, with significant increase since 2014 CMS coverage expansion (p trend &lt;0.001). Patients not referred were more likely to be older, of minority race, and with greater burden of comorbidities. Patients admitted to rural hospitals and those in the Northeast were less likely to be referred to CR. Among patients free of HF events within 30 days post-discharge, CR referral was independently associated with lower risk of 1-year all-cause mortality vs. those not referred (HR 0.84, 95% CI (0.73 - 0.98, p = 0.0267), without significant difference in 1-year HF-related or all-cause readmission. Conclusions: Although CR referrals have increased among eligible HF patients since CMS expanded coverage in 2014, absolute referral and participation rates remain low. Age, race, and burden of comorbidities were independently associated with CR referral.

Impact of a COmprehensive cardiac REhabilitation framework among high cardiovascular risk cancer survivors: Protocol for the CORE trial

BackgroundCancer survivors are challenging patients, as they often present increased cardiovascular risk. In this background, cardio-oncology rehabilitation frameworks for specific cancer patients have been proposed. However, optimal program designs, as well as their overall safety and efficacy in different subsets of patients, are not fully ascertained. DesignSingle-center, pragmatic, prospective, randomized controlled trial performed in Portugal aiming to evaluate the impact of a center-based cardiac rehabilitation program, consisting of exercise training, nutritional counselling, psychosocial management and lifestyle behavior change, compared to community-based exercise training, in cancer survivors. MethodsAdult cancer survivors (N = 80) exposed to cardiotoxic cancer treatment and/or with previous cardiovascular disease will be randomized (1:1) to receive either an eight-week cardiac rehabilitation program or community-based exercise training. Primary endpoint is cardiorespiratory fitness; secondary endpoints are physical activity, psychosocial parameters, blood pressure, body composition, lipids and inflammatory parameters. Physical function, quality of life, fatigue, health literacy, and feasibility will be assessed; a cost-effectiveness evaluation will also be performed. Between-group differences at baseline and in the change from baseline to the end of the study will be tested with unpaired t-tests or Mann-Whitney U test. Paired t-tests or Wilcoxon signed-rank test will be performed for within-group comparisons. ConclusionThis trial will address the overall impact of a contemporary cardiac rehabilitation program framework in cancer survivors, as compared to a community-based exercise training. Given the higher cardiovascular risk in several groups of cancer patients, our results could provide novel insights into optimized preventive strategies in this complex patient population.

Changes in smoking status after a cardiac rehabilitation program in Spain: description of a smoker's profile

Abstract Background Cigarette smoking is a major cardiovascular (CV) risk factor and aids to the development and progression of CV disease. Purpose To study the prevalence of smoking in a contemporary Spanish cardiac rehabilitation (CR) cohort, study changes in smoking status over time and define smoker's profile after CR. Methods Single-centre, observational retrospective study from all consecutive patients with ischaemic heart disease (n=1379, 6.6% women, age 65.78±11.02 years) that participated in a CR program from 2015 to 2020. Prevalence of smokers was studied over time, from CV event to 6 months after end of CR, including a stratified description of smokers per age group at CV event. Additionally, a comparative analysis of patient profile for those who continued smoking and patients that quitted smoking after CR, was performed. Results N=516 patients (37.4%) were active smokers at CV event, including 72 women (31% of all women) and 444 men (38.6% of all men). Highest percentage of smokers was distributed among the youngest age groups: with a 72.6% prevalence among those aged &amp;lt;45 years and 57.9% among those aged 45–55 years. Smoking prevalence decreased with age. Also, there were less female than male smokers in all analysed age groups (Figure 1). At the beginning of CR, the global proportion of active smokers decreased significantly (p&amp;lt;0.01) to a 15.3% (n=210) and continued to significantly decrease at end of CR (10%, n=124), maintaining similar levels at 6 months follow-up (9.9%, n=96). 58% of active smokers at CV event quitted smoking by end of CR. Ongoing smokers were significantly more (p&amp;lt;0.05) depressed (n=20, 16.3%); and had significantly worse (p&amp;lt;0.05) HADS scores at beginning of CR (anxiety: 6.49±3.98, depression: 5.41±4.46), Table 1. Conclusions Smoking is nowadays still highly prevalent among CR patients in our setting, especially among young men. Despite a significant fall in the prevalence of smokers after the end of the CR program, there is a non-negligible percentage of patients that keep smoking. Targeted smoking cessation interventions should be aimed at smokers that have more depression and have worse HADS scores at baseline. Funding Acknowledgement Type of funding sources: None.

Sedentary Behaviour Intervention as a Personalised Secondary Prevention Strategy (SIT LESS) for patients with coronary artery disease participating in cardiac rehabilitation: rationale and design of the SIT LESS randomised clinical trial

Patients with coronary artery disease (CAD) are more sedentary compared with the general population, but contemporary cardiac rehabilitation (CR) programmes do not specifically target sedentary behaviour (SB). We developed a...

Facemasks during aerobic exercise: Implications for cardiac rehabilitation programs during the Covid-19 pandemic.

Introduction and objectivesDuring the COVID-19 pandemic, among the safety measures adopted, use of facemasks during exercise training sessions in cardiac rehabilitation programs raised concerns regarding possible detrimental effects on exercise capacity. Our study examined the cardiorespiratory impact of wearing two types of the most common facemasks during treadmill aerobic training.MethodsTwelve healthy health professionals completed three trials of a symptom-limited Bruce treadmill protocol: Without a mask, with a surgical mask and with a respirator. Perceived exertion and dyspnea were evaluated with the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale, respectively. Blood pressure, heart rate and arterial oxygen saturation (SpO2) were measured at each 3-minute stage.ResultsUsing a surgical mask or a respirator resulted in a shorter duration of exercise testing. At peak capacity, using a respirator resulted in higher levels of dyspnea and perceived exertion compared to not wearing a facemask. A significant drop in SpO2 was present at the end of exercise testing only when using a respirator. There were no differences in either chronotropic or blood pressure responses between testing conditions.ConclusionsProfessionals involved in cardiac rehabilitation should be aware of the cardiorespiratory impact of facemasks. Future studies should assess whether exposure to these conditions may impact on the overall results of contemporary cardiac rehabilitation programs.

Facemasks during aerobic exercise: Implications for cardiac rehabilitation programs during the Covid-19 pandemic

Introduction and objectivesDuring the COVID-19 pandemic, among the safety measures adopted, use of facemasks during exercise training sessions in cardiac rehabilitation programs raised concerns regarding possible detrimental effects on exercise capacity. Our study examined the cardiorespiratory impact of wearing two types of the most common facemasks during treadmill aerobic training. MethodsTwelve healthy health professionals completed three trials of a symptom-limited Bruce treadmill protocol: Without a mask, with a surgical mask and with a respirator. Perceived exertion and dyspnea were evaluated with the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale, respectively. Blood pressure, heart rate and arterial oxygen saturation (SpO2) were measured at each 3-minute stage. ResultsUsing a surgical mask or a respirator resulted in a shorter duration of exercise testing. At peak capacity, using a respirator resulted in higher levels of dyspnea and perceived exertion compared to not wearing a facemask. A significant drop in SpO2 was present at the end of exercise testing only when using a respirator. There were no differences in either chronotropic or blood pressure responses between testing conditions. ConclusionsProfessionals involved in cardiac rehabilitation should be aware of the cardiorespiratory impact of facemasks. Future studies should assess whether exposure to these conditions may impact on the overall results of contemporary cardiac rehabilitation programs.

Predictors of physical fitness and health-related quality of life based on anthropometrics characteristics and exercise stress test performance in cardiac rehabilitation

Introduction Sedentary lifestyle and physical inactivity are among the leading modifiable risk factors worldwide for cardiovascular disease and all-cause mortality [1]. Many patients in contemporary cardiac rehabilitation programs are quite deconditioned on entry. Cardiac rehabilitation Program (CRP) provides a cost-effective therapy that aims to accelerate recovery following an acute event and reduce the risk of recurrent events, through structured exercise prescription, education, and risk factor modification [2]. The positive effect of CRP on functional capacity has been known for some years [3]. In this study, we aim to assess the relationship between health-related quality of life (HRQoL), Metabolic Equivalents (METS) spend on exercise stress test, body mass index and waist circumference in patients with cardiovascular disease before beginning a cardiac rehabilitation program. Material and methods We performed an observational study with inclusion of thirteen male patients with coronary heart disease, 53.8 ± 8.2 years old who were admitted to the Department of Cardiology of Hospital Garcia de Orta and referred for CRP. The HRQoL was assessed with the short form‐36 (SF‐36) questionnaire. METS were calculated using the Bruce protocol when patients performed exercise stress test, body mass index (BMI) and waist circumference was measured, at initial physical examination. All subjects signed an informed consent. This study followed all the principles of Helsinki Declaration. Results The mean value for BMI was 28.3 ± 4.0 kg m−2, waist circumference 102.6 ± 14.8 cm and METS 9.99 ± 3.14. There was a positive correlation between BMI and waist circumference (r = 0.87; p = .001); between waist circumference and METS a negative correlation was observed (r = −0.59; p = .040). The domain physical functioning score from SF-36 was positively correlated with METS (r = 0.65; p = .010), and was negatively correlated with waist circumference (r = −0.60; p = .020). The lowest mean values of SF-36 scores observed were vitality (63.1 ± 20.4), and general health (56.8 ± 22.5). Discussion and conclusion As expected subjects with higher BMI had also higher waist circumference. Patients with better perception of physical function were those with lower waist circumference and who had better performance in exercise stress test. These results are in accordance with previous studies [4]. We can conclude that waist circumferences and METS could be good CRP effectiveness predictors on these patients. Once it is expectable to achieve decreases in waist circumferences and increase METS after CRP, with improvements in physical function perception.

Sedentary behaviour in cardiovascular disease patients: Risk group identification and the impact of cardiac rehabilitation

BackgroundSedentary behaviour (SB) is potentially an important target to improve cardiovascular health. This study 1) compared SB between cardiovascular disease (CVD) patients and age-matched controls, 2) identified characteristics associated with high SB levels, and 3) determined the impact of contemporary cardiac rehabilitation (CR) on SB. MethodsFor objective 1, we recruited 131 CVD patients and 117 controls. All participants were asked about their general characteristics and medical history. SB was assessed by an objective accelerometer (activPAL3 micro). For objective 2, 2584 CVD patients were asked to fill in a questionnaire about their general characteristics, lifestyle, medical history and their SB. For objective 3, 131 CVD patients were followed over time and measured, pre-, directly post- and 2 months post-CR. ResultsObjective 1. CVD patients spent 10.4 h/day (Q25 9.5; Q75 11.2) sedentary which was higher compared to healthy controls (9.4 h/day [Q25 8.4; Q75 10.29]). Objective 2. CVD patients being male, single or divorced, employed, physically inactive, reporting high alcohol consumption, living in an urban environment, having comorbidities and cardiac anxiety demonstrated a greater odds for large amounts of SB. Objective 3. The CR program significantly reduced sedentary time (−0.4 h/day [95%CI -0.7; −0.1]), which remained lower at 2-months post-CR (−0.3 h/day [95%CI -0.6; −0.03]). ConclusionsCVD patients had greater amounts of objectively measured sedentary time compared to healthy controls. Sedentarism was associated with personal- and lifestyle characteristics, and comorbidities. Participation in a contemporary CR program slightly reduced sedentary time, but tailored interventions are needed to target SB in CVD patients.

Sedentary behaviour in cardiovascular disease patients: risk factor identification and the impact of cardiac rehabilitation

Abstract Background Cardiovascular disease (CVD) patients typically report low physical activity levels. Therefore sedentary behaviour (SB) is potentially an important target to improve survival and to reduce recurrence risk. However, information about SB in CVD patients is scarce. Purpose In this study, we 1) compared SB between CVD patients and age-matched controls, 2) identified patient- and disease characteristics associated with high SB levels, and 3) determined the impact of contemporary cardiac rehabilitation on SB. Methods For objective 1, we recruited 131 patients and 117 healthy, age-matched individuals. All participants were asked about their general characteristics and medical history. SB was assessed objectively by an accelerometer. For objective 2, 2,584 patients completed a questionnaire about their general characteristics, lifestyle, medical history and their SB. For objective 3, SB was examined before, after and 2 months after cardiac rehabilitation among 131 patients using an accelerometer. Results Objective 1. Patients spent 10.4 hrs/day (Q25 9.5; Q75 11.2) sedentary which was higher compared to healthy controls (9.4 hrs/day [Q25 8.4; Q75 10.29]). Similarly, patients reported more prolonged sedentary bouts (&amp;gt;30 min) compared to controls (5.9 versus 4.8 bouts/day; P&amp;lt;0.001). Objective 2. Patients being male, single or divorced, employed, physically inactive, reporting high alcohol consumption, living in an urban environment, having comorbidities and cardiac anxiety demonstrated a greater odds for large amounts of sedentary time (&amp;gt;8 hrs/day). Objective 3. Cardiac rehabilitation significantly reduced sedentary time (−0.4 hrs/day [95% CI: −0.7; −0.1]), which remained lower at 2 months after cardiac rehabilitation (−0.3 hrs/day [95% CI: −0.6; −0.03]). In addition, prolonged sedentary bouts decreased significantly after cardiac rehabilitation (−0.4 bouts/day [95% CI: −0.7; −0.1]), but this effect diminished within 2 months after the programme (−0.2 bouts/day [95% CI: −0.5; 0.1]). Conclusions CVD patients had greater amounts of objectively measured sedentary time compared to healthy controls, with more frequent engagement in prolonged sedentary bouts. Sedentarism was associated with personal- and lifestyle characteristics, and comorbidities. Participation in a contemporary cardiac rehabilitation programme slightly reduced sedentary time, but tailored interventions are needed to target the high amount of sedentary time in CVD patients. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Dutch Heart Foundation

Enhancing Functional Risk Stratification in Contemporary Cardiac Rehabilitation: RESPONDING TO PATIENTS WHO ARE INCREASINGLY OLDER AND MORE PHYSICALLY IMPAIRED.

Current American Association of Cardiovascular and Pulmonary Rehabilitation guidelines rely primarily on cardiovascular disease (CVD)-centered metrics to stratify risk and guide care. Yet, contemporary CVD patients are often older and are more likely to have risks attributable to rudimentary functional impairments that can have disproportionate bearing on management and prognosis. In this study, we stratified risk using novel indices of physical function as well as traditional indices of CVD in patients enrolling in phase II cardiac rehabilitation (CR). We hypothesized that risk stratification (RS) using functional criteria would be nonconcordant with CVD RS in a significant number of patients, thus inferring the conceptual value of CR management priorities that are better tailored for distinctive functional risks in many patients. This was a retrospective analysis of a comprehensive quality improvement database with 489 patients. Risk stratification using novel functional indices (ie, gait speed, Timed Up and Go, hand grip, sit to stand, tandem stand, and a 6-min walk test) was compared with RS using traditional CVD criteria. Using functional RS, 97 patients were determined to be high risk versus 235 at low risk. Using CVD RS in the same cohort, 227 patients had high risk versus 161 who had low risk. Functional RS was consistent with CVD RS only 42.9% of the time. Functional RS and CVD RS varied in the same patients. Enhanced assessment of functional risks adds important prognostic refinement and greater potential to tailor exercise therapy, nutrition, and other CR caregiving priorities.

Does contemporary exercise-based cardiac rehabilitation improve quality of life for people with coronary artery disease? A systematic review and meta-analysis.

ObjectivesTo determine the effect of contemporary exercise-based cardiac rehabilitation on generic and disease-specific health related quality of life for people with coronary artery disease.DesignSystematic review and meta-analysis.Study eligibility criteriaRandomised controlled trials testing exercise-based cardiac rehabilitation versus no exercise control that recruited after 31 December 1999. On 30 July 2019, we searched the Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), Embase (Ovid) and CINAHL (EBSCO) databases.Study appraisal and synthesisStudies were screened for inclusion by two independent reviewers. Risk of bias was assessed using the Cochrane risk of bias tool. Data were reported as pooled means (95% CI for between-group difference.ResultsWe identified 24 studies (n=4890). We performed meta-analyses for 15 short-term and 9 medium-term outcomes (36-Item Short Form Survey Instrument (SF-36), EuroQol-5D (EQ-5D) and MacNew, a cardiac-specific outcome). Six short-term and five medium-term SF-36 domains statistically favoured exercise-based cardiac rehabilitation. Only for two short-term SF-36 outcomes, ‘physical function’ (mean difference 12.0, 95% CI 4.4 to 19.6) and ‘role physical’ (mean difference 16.9, 95% CI 2.4 to 31.3), did the benefit appear to be clinically important. Meta-analyses of the short-term SF-36 physical and mental component scores, EQ-5D and MacNew and the medium-term SF-36 physical component score, did not show statistically significant benefits. Only two studies had a low risk of bias (n=463 participants).Conclusions and implications of key findingsThere is some evidence of a short-term benefit of contemporary exercise-based cardiac rehabilitation on quality of life for people with coronary artery disease. However, the contemporary data presented in this review are insufficient to support its routine use.

Cardiac Rehabilitation in Frail Older Adults With Cardiovascular Disease: A NEW DIAGNOSTIC AND TREATMENT PARADIGM.

Older adults with cardiovascular disease (CVD) pose challenges to cardiac rehabilitation (CR) clinicians because their disease is often coupled to physical frailty. Older patients with CVD and frailty may be less likely to tolerate conventional CR exercise training due to multidimensional (ie, strength, mobility, and balance) physical impairments. Furthermore, conventional CR typically emphasizes endurance training without addressing the intrinsic skeletal muscle impairments of frail patients that often manifest as deficits in strength, mobility, and balance, undercutting feasibility and any likely benefits. However, if appropriately modified to meet the needs of frail older adults, CR may be a powerful tool for this challenging population. To best serve frail, older adults with CVD, CR programs can incorporate well-validated strategies to assess frailty and physical function that also fit within the workflows and patient populations of individual programs. Such frailty assessments provide opportunities to identify specific targets (eg, weakness) that need to be addressed before a subsequent aerobic training program can be successfully implemented and sustained. The current review focuses on the use of physical frailty measures in older adults with CVD, with practical considerations for their clinical use in contemporary CR, as well as directions for future research.

Cardiac Rehabilitation for Frail Older People.

Comprehensive cardiac rehabilitation programmes include multifactorial components to optimise cardiovascular risk reduction, promote healthy behaviours and an active lifestyle, reduce disability and improve health and wellbeing. There is compelling evidence that older people with certain cardiovascular conditions, such as heart failure, can benefit both physically and mentally from cardiac rehabilitation. This chapter discusses the evolution of cardiac rehabilitation, frailty assessment in cardiac rehabilitation and guideline recommendations in the context of ageing populations. Contemporary cardiac rehabilitation service models are presented along with potential solutions to meeting older people's preferences and improving access to effective treatment for those with frailty. Innovations in catheter-based surgical interventions mean that more people with frailty are undergoing cardiovascular surgery than ever before. Although traditionally, cardiac rehabilitation has been associated with secondary prevention after cardiac diagnoses, events and interventions, new models of preconditioning rehabilitation or 'prehab' are being offered to frail older people before surgery to improve functional outcomes and reduce hospital stay. Individual tailoring of cardiac rehabilitation programme components is a cornerstone of high-quality care. Importantly, participation in core components, such as exercise and nutritional interventions, can impact on both cardiac vascular disease and frailty, providing the potential to change the trajectory of both conditions.

P633Comparative analysis of exercise programmes with aerobic moderate and high-intensity interval training in patients after coronary artery bypass grafting

Abstract Background High-intensity interval training is emerging as a potential time efficient strategy in contemporary cardiac rehabilitation. According to current guidelines 150 minutes of moderate physical activity per week is reduced by half to 75 minutes if the week's activity is done at a vigorous intensity. Objective: The main goal of our study was to assess and compare high-intensity interval training (HIIT) with moderate-intensity continuous training (MICT) within cardiac rehabilitation after coronary artery bypass grafting. Methods Sixty three patients (48 male, 15 female, at the mean age of 57±12 years) after coronary artery bypass grafting were recruited into exercise training program on cycle ergometer. The training course started 2 weeks after surgery, lasted 4 weeks and then continued in an outpatient care after 3–6 months. MICT was considered as 50% to 75% of VO2 max (maximal oxygen consumption) or 50–75% of heart rate reserve, while HIIT was considered as ≥85% of VO2 max or ≥85% of heart rate reserve. Training protocols included constant load and ramp interval programs. Control group comprised 40 patients without exercise training program. The safety of HIIT/MICT was the primary end point in our study. Secondary end-points included body mass index, echo and hemodynamic parameters, NT-proBNP and HbA1c levels along with standard cardiorespiratory fitness indicators. Results Significant increase in anaerobic threshold (by 16.9%), VO2 max (by 18.6%) and tolerance of physical load in MET (by 6.4%) were mentioned in study groups compared to equivalent measurements in control group (9.7%, 7.9% and 5.4% correspondingly). Substantial changes were also observed in following variables compared to control group: body mass index reduced (p=0.0032), end diastolic diameter decreased (p=0.0315), LV ejection fraction improved (p=0.045), NT-proBNP reduced (p=0.0015) and HbA1c improved (p=0.023). While analyzing aerobic capacity alterations due to HIIT versus MICT by standardized mean difference (95% CI), HIIT was significantly superior to MICT. Aerobic capacity covered VO2 max (ml/kg/min), anaerobic threshold (%), work rate (Wt) and EQo2=VE/Vo2. Conclusions High-intensity interval training proved to be as safe as a moderate-intensity training in patients after coronary artery bypass grafting. It appeared to be significantly superior to moderate-intensity continuous training in improving cardiorespiratory fitness. Obtained results allow implementing aerobic interval training individually after open-heart surgery and shorten rehabilitation period.

Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation.

The goal of this study was to determine the prevalence of insulin resistance (IR) and type 2 diabetes mellitus (T2DM) in contemporary cardiac rehabilitation (CR) and to compare clinical responses in CR between these subsets of patients with coronary heart disease (CHD). The study cohort included 818 patients enrolled in CR and separated into 3 groups: (1) individuals with normal hemoglobin A1c (HbA1c) (NoIR: HbA1c < 5.7%); (2) individuals with IR (IR: HbA1c ≥ 5.7 to <6.5%); (3) and individuals with T2DM (HbA1c ≥ 6.5%). The combined prevalence of IR (44%) and T2DM (23%) was 67%, which paralleled the prevalence of metabolic syndrome (MetSyn), present in 65% of patients. Women had a higher prevalence of IR and MetSyn than men (73% vs 64%, 72% vs. 63%, respectively) and a greater percentage with an elevated waist circumference (71% vs 60%) (all P < .05). All 3 groups experienced decreases in body weight (NoIR = -2.3 ± 4.0, IR = -1.7 ± 4.0, T2DM = -1.0 ± 4.2 kg) and increases in maximal metabolic equivalents (METs) at exercise testing (NoIR = +2.2 ± 2.5 vs IR = +2.1 ± 2.8 vs T2DM = +1.3 ± 2.3) (all P < .05). Individuals with NoIR achieved greater improvements in weight, body mass index, and METs than patients with T2DM (all P < .05). Selected individuals who participated in a 4-session behavioral weight-loss program lost more than twice the weight as nonparticipants. The combined prevalence of IR and T2DM in patients with CHD enrolled in CR was remarkably high (67%). To reverse the deleterious consequences of IR and T2DM, targeted interventions involving exercise and weight loss need to be a central focus of CR programming.

Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation.

Symptom-limited (maximal) exercise testing before cardiac rehabilitation (CR) was once an unambiguous standard of care. In particular, it served as an important screen for residual ischemia and instability before initiating a progressive exercise training regimen. However, improved revascularization and therapy for coronary heart disease has led many clinicians to downplay this application of exercise testing, especially because such testing is also a potential encumbrance to CR enrollment (delaying ease and efficiency of enrollment after procedures and hospitalizations) and patient burden (eg, added costs, logistic hassle, and anxiety). Nonetheless, exercise testing has enduring value for CR, especially because it reveals dynamic physiological responses as well as ischemia, arrhythmias, and symptoms pertinent to exercise prescription and training and to overall stability and prognosis. Moreover, as indications for CR have expanded, the value of exercise testing and functional assessment is more relevant than ever in the growing population of eligible patients, including those with heart failure, valvular heart disease, and posttransplantation, especially as current patients also tend to be more clinically complex, with advanced ages, multimorbidity, frailty, and obesity. This review focuses on the appropriate use of exercise testing in the CR setting. Graded exercise tests, cardiopulmonary exercise tests, submaximal walking tests, and other functional assessments (strength, frailty) for CR are discussed.

Changes in BNP and cardiac troponin I after high-intensity interval and endurance exercise in heart failure patients and healthy controls

Exercise training represents a cornerstone of contemporary cardiac rehabilitation. Recently, high-intensity interval training (HIT) has been popularized for heart failure (HF) patients (1) and may serve as a superior mode of exercise compared to traditional endurance exercise training. However, there is controversy regarding the safety (2) and the direct effects of HIT on the heart. Previous studies have demonstrated that an acute bout of exercise leads to an increase in cardiac troponin (cTn), a biomarker for cardiac injury, and B-type natriuretic peptide (BNP), a marker for cardiomyocyte stress (3,4). Exercise-induced elevation in these biomarkers is related to exercise intensity and duration (4,5), and may occur to a larger extend in patients with cardiovascular risk factors (6). To date, no previous study: 1. compared changes in cTn and BNP between endurance exercise and HIT, and 2. explored differences in exercise-induced changes in cTn and BNP between HF patients and controls.