Contemporary Cardiac Rehabilitation Research Articles

MICROALBUMINURIA IN NORMOTENSIVE DIPPERS AND NON-DIPPERS USING 24hr ABPM

of care and increase health system accountability. To date, no published literature exists assessing the utilization of and adherence to CCS QIs for CR. We examine temporal trends of adherence to CCS/CACR QIs for CR and SP at a Canadian CR program. METHODS: The CR QIs were reconciled with retrospective data collected in the Cardiovascular & Pulmonary Health in Motion (CPHM) CR database from 1999-2012, and incorporated data abstracted from the Maritime Heart Centre and Cardiovascular Health Nova Scotia registries. Adherence rates to each of the five published most important QIs were analyzed over time, using mainly descriptive statistics. RESULTS: From 2008 to 2012, 7665 inpatients were identified as having diagnoses deemed eligible for CR, of whom 66.7% were referred to CR. Referral rates annually remained stable. Between 1999 and 2012, 4443 patients enrolled in CR. Wait times over that period were within the 30-day QI recommendation, at a median of 27 days from referral to enrollment. Median wait times increased annually over the first six years, but remained stable thereafter. Almost all CRattending participants (93.5%) received self-management education. Most of the 2566 CR program-completing participants (77.6%) achieved the half metabolic equivalent (MET) increase in exercise capacity from program entry to exit. A documented emergency response strategy exists and 100% of the clinical staff at CPHM have been appropriately qualified. CONCLUSION: This retrospective study assesses the application of cardiac rehabilitation and secondary prevention QIs in a real-world setting, and characterizes the degree to which contemporary cardiac rehabilitation care is consistent with guidelines. The results of this study offer a basis of future internal and external program comparison over time, and will be incorporated into routine quality improvement practices to further improve patients’ cardiovascular health and care.

Cardiovascular Fitness and Mortality After Contemporary Cardiac Rehabilitation

ObjectiveTo assess the association between cardiorespiratory fitness (CRF) and outcomes in a cardiac rehabilitation (CR) cohort. Patients and MethodsWe conducted a retrospective study of 5641 patients (4282 men [76%] and 1359 women [24%]; mean ± SD age, 60.0±10.3 years) with coronary artery disease who participated in CR between July 1, 1996, and February 28, 2009. Based on peak metabolic equivalents (METs), patients were classified as low fitness (LFit) (<5 METs), moderate fitness (5-8 METs), or high fitness (>8 METs). ResultsBaseline fitness predicted long-term mortality: relative to the LFit group, patients with moderate fitness had an adjusted hazard ratio of 0.54 (95% CI, 0.42-0.69), and those with high fitness a hazard ratio of 0.32 (95% CI, 0.24-0.44). Improvement in CRF at 12 weeks was associated with decreased overall mortality, with a 13% point reduction with each MET increase (P<.001) and a 30% point reduction in those who started with LFit. At 1 year, each MET increase in CRF was associated with a 25% point reduction in overall mortality in the whole group (P<.001). ConclusionIn this study of contemporary CR patients, higher baseline fitness predicted lower mortality. The novel finding was that improvement in fitness during a CR program and improvements that persisted at 1 year were also associated with decreased mortality, most strongly in patients who start with LFit.

N060 A Pilot Trial of a Coaching Intervention Desgined to Increase Woman's Attendance at Cardiac Rehabilitation Intake

BACKGROUND/RATIONALE: Cardiovascular disease (CVD) continues to be the leading cause of death of Canadian women and while treatment for CVD has improved dramatically, women typically fare worse than men. Cardiac rehabilitation (CR) is well established as a key intervention in the treatment of coronary artery disease and has been shown to be effective in both men and women. CR remains largely underutilized, especially in women who comprise only 1224% of contemporary CR programs, even though the prevalence of CVD in men and women is similar(American Heart Association, 2009). OBJECTIVES/RESEARCH QUESTIONS: The objectives of this pilot trial were to test the feasibility of all procedures, specifically to determine: 1) an estimate of patient recruitment rates, 2) acceptability and feasibility of the intervention and 3) barriers to CR attendance and resources required. Additionally, exploratory research questions were used to determine the effects of telephone coaching on womens’ attendance at CR intake appointment, self-efficacy for cardiac exercise and self-efficacy to attend CR. METHODS: A RCT design enrolled women with CVD referred for CR at a single site in Ontario. Patients were randomized, stratified for age, to either a usual care group or an intervention group. Participants allocated to usual care received a referral to CR. In addition to usual care, women randomly assigned to the intervention group received individualized telephone coaching, designed to support self-management. RESULTS: Eighty-four patients were approached and 70 consented to participate (usual care n 36, intervention n 34). Participants were highly satisfied with their coaching experience; they found the information provided to be helpful with goal setting, action planning and assisted them in their interactions with their health care providers. Participants received three to five calls prior to CR intake appointment and the telephone calls were generally less than 28 minutes in duration (n 118, 99%). Barriers to attendance identified included transportation, health concerns, timing and lack of physician endorsement. Most common resources identified included problem solving support, assistance with communication with physicians and information concerning CR. Participants in the intervention group were significantly more likely to attend CR intake (p 0.048). SIGNIFICANCE/IMPLICATIONS: The evidence obtained from this pilot trial suggests that a telephone coaching intervention designed to enhance self-management is feasible and may improve attendance at CR intake for women following hospital discharge with a cardiac event. N061 DO ALL TAVI PATIENTS REQUIRE TELEHOME MONITORING FOLLOW-UP AFTER DISCHARGE FROM HOSPITAL?

Referral, Enrollment, and Delivery of Cardiac Rehabilitation for Women

Coronary heart disease is the leading killer of women worldwide. Empirical literature documents substantial morbidity and mortality benefits for cardiac rehabilitation participants. Scientific advances have informed the development of evidence-based guidelines for improving the delivery of cardiac rehabilitation yet persistent themes surrounding the substandard referral and utilization rates by women continue unabated in the literature. This review provides an update of the current status of cardiac rehabilitation for women, including a brief overview of the latest findings regarding the unique presentations of heart disease in women. An innovative secondary prevention program, designed exclusively for women is described, and illustrates an attempt to modify a contemporary traditional cardiac rehabilitation program to improve attendance rates and health outcomes in women. Future research with large, diverse samples of women are essential for guiding gender-appropriate referral strategies, effective modifications to traditional center-based programs, and the efficacy of alternative cardiac rehabilitation care models for women.

Ventricular assist device patients on the horizon of cardiovascular prevention and rehabilitation. Can we convert challenges into opportunities?

The first cardiac rehabilitation (CR) programmes appeared around the 1960s when Turell and Hellerstein advocated comprehensive rehabilitation for patients recovering from acute cardiac events. The focus was on the successful integration of patients back into society, improving recovery times and functional status, and reducing the hospital stay; therapeutic exercise was the core component of CR. Since then, CR has undergone profound changes, with programmes now embracing secondary prevention activities and covering a wide spectrum of cardiovascular conditions. Today, CR and prevention programmes include patients post-percutaneous coronary intervention, after cardiac surgery including heart transplantation (HT), and with chronic heart failure (HF). Hence, the CR revolution has occurred in two directions: the type of interventions offered and type of patients referred. The management of patients with recent ventricular assist device (VAD) implantation represents a natural and legitimate development for contemporary CR and prevention programmes.

134 Cardiovascular fitness and mortality following contemporary cardiac rehabilitation

Exercise capacity has been demonstrated to be predictive of mortality in adults with and without coronary artery disease (CAD). However, the association between exercise capacity and outcomes in contemporary cardiac rehabilitation (CR) programs has not been as thoroughly assessed. Furthermore, the association between improvements in exercise capacity achieved through CR and long-term outcomes remains unexplored. We conducted a retrospective study of 2867 subjects with CAD who participated in CR in Calgary, Canada between 1996 and 2009. All subjects underwent initial treadmill testing, attended a 12 week multi-modality CR program including prescribed medication and exercise, and then underwent repeat treadmill testing. Additionally, 1696 subjects underwent treadmill testing at one year. Based on Metabolic equivalents (METs) calculated from the speed and grade of the last stage of the maximal exercise testing, subjects were classified as ‘low fitness' (<5 METs), ‘moderate fitness' (5-8 METs), or high fitness (>8 METs). Clinical and demographic characteristics were compared across fitness classes. Using Cox proportional hazards models, mortality was compared across fitness classes. Change in fitness at 12 weeks and one year relative to baseline were also assessed as predictors of mortality. Subjects in the lowest fitness category were older and had a higher burden of comorbid illnesses including diabetes and hypertension (all P < 0.0001). A greater portion of low fitness subjects were obese or had an elevated waist circumference (both P < 0.0001). Baseline fitness was predictive of long-Term mortality: relative to the low fitness group, subjects with moderate fitness had a hazard ratio (HR) of 0.43 (95% CI 0.30, 0.62), and those with high fitness a HR of 0.17 (95% CI 0.11, 0.26) (Figure). In adjusted analyses this effect persisted (P < 0.0001). Improvement in exercise capacity in 12 weeks was associated with decreased mortality only in the low fitness group, with a 30% reduction in mortality with each MET increase (P < 0.0001). At one year, each MET increase in exercise capacity was associated with a 22% reduction in mortality in the whole group (P < 0.0001). In this study of contemporary CR patients, higher baseline fitness was predictive of decreased mortality. The novel finding was that improvement in fitness over a CR program was associated with decreased mortality in those with low fitness alone, and improvements at one year were associated with decreased mortality across the entire group. Patients with low fitness at baseline should be targeted to increase their functional capacity in an effort to reduce their mortality.

Four-year follow-up of the Choice of Health Options In prevention of Cardiovascular Events randomized controlled trial

To determine if the improved risk factor profile at 1 year attributed to the Choice of Health Options In prevention of Cardiovascular Events (CHOICE) program was maintained at 4 years. Single-blind randomized controlled trial with post-hoc 476 months follow-up (76% complete). Australian tertiary referral hospital. Two hundred and eight acute coronary syndrome survivors. Acute coronary syndrome survivors not accessing cardiac rehabilitation (CR) were randomized to control (n=72) or CHOICE (n=72) comprising the tailored risk factor reduction packaged as a clinic visit and 3 months phone support. A contemporary CR reference group were also recruited (n=64). Blinded risk assessment occurred at baseline, 1 and 4 years. Total cholesterol, systolic blood pressure, smoking status, physical activity. One year improvements in all the modifiable risk factors achieved in CHOICE were maintained at 4 years. CHOICE and control were well-matched at baseline. At 4 years, there was a trend towards lower total cholesterol in CHOICE compared with controls (mean 4.0±0.1 vs. 4.2±0.1 mmol/l, P=0.05), significantly better systolic blood pressure (mean 132.2±2.1 vs. 136.8±2.0 mmHg, P=0.01), physical activity scores (1200±209 vs. 968±196 metabolic equivalent min/week, P=0.02) and proportion with three or more risk factors above national targets (20 vs. 42%,P=0.02). Participants in CHOICE were at higher baseline risk than CR but at 4 years they had similar risk factor profiles. Participants in CHOICE maintained favorable changes in coronary risk profile at 4 years compared with control, indicating that CHOICE is an effective long-term intervention among those not accessing facility-based CR.

An integrated and coordinated approach to preventing recurrent coronary heart disease events in Australia

Implementing existing knowledge about cardiac rehabilitation (CR) and heart failure management could markedly reduce mortality after acute coronary syndromes and revascularisation therapy. Contemporary CR and secondary prevention programs are cost-effective, safe and beneficial for patients of all ages, leading to improved survival, fewer revascularisation procedures and reduced rehospitalisation. Despite the proven benefits attributed to these secondary prevention interventions, they are not well attended by patients. Modern programs must be flexible, culturally safe, multifaceted and integrated with the patient's primary health care provider to achieve optimal and sustainable benefits for most patients.

Cardiologists' Perception of Secondary Prevention and Cardiac Rehabilitation Referral Patterns

Formal cardiac rehabilitation (CR) programs result in decreased cardiovascular and all-cause mortality. Despite overwhelming evidence for the benefits of contemporary CR, fewer than 20% of patients with coronary artery disease participate in such programs, highlighting the vast underutilization of these services, especially in older adults and women. PURPOSE: To quantify/clarify physician perceptions of formalized secondary prevention initiatives and to evaluate CR referral patterns, with specific reference to physician lifestyle practices. METHODS: A 23-item questionnaire was developed and sent to all Michigan cardiologists (N = 840) registered with the American College of Cardiology. The survey, which included a stamped return envelope, was designed to assess referral patterns, perceived benefits of CR, insurance coverage and personal therapeutic lifestyle practices. RESULTS: Of the surveys mailed (N = 840), 105 (13%) were returned by the requested deadline. Most respondents had practices in urban areas (73%), knew of a hospital-based CR program in close proximity (99%), and referred their patients to CR “routinely” (97%). Whereas 92% of respondents felt that CR decreased morbidity, 63% believed that CR decreased mortality. The majority of cardiologist respondents (64%) referred ? 70% of their eligible patients, independent of gender; however, 35% stated a patient's age influences the rate of referral. An increase in exercise tolerance, serial monitoring, education, and improved patient outcomes were the most commonly cited rationale for referral. Respondents who took a cholesterol-lowering statin each day tended to have higher referral rates of all eligible patients (P ≤ 0.05). Although 65% of respondents participated in personal exercise programs at least 3 days/week for at least 30 min/day, there was no relationship between exercise frequency and the reported referral rate to CR. CONCLUSION: These findings indicate that selected personal lifestyle practices among cardiologists may be associated with their referral rates to CR. Primary rationale for referral to CR include increased exercise tolerance, serial monitoring, education, and improved patient outcomes. These data have relevance to CR program staff in clarifying the utilization of services among referring physicians.

Results of cardiac rehabilitation in patients with diabetes mellitus

To study the prevalence, risk profile, and outcomes of diabetics in cardiac rehabilitation, data on 952 consecutively enrolled patients were evaluated. Diabetics on entry had poor glycemic control, and compared with nondiabetics, had a greater adverse risk profile (body mass index, waist circumference, hypertension, triglycerides, peripheral vascular disease, and lower fitness levels), and a lower program adherence rate. Although exercise capacity significantly improved, it is clear from the outcomes reported in this study that more effective interventions in weight management, lipid lowering, and glycemic control are needed. This study emphasizes the need to identify diabetic patients in contemporary cardiac rehabilitation programs and target them for an aggressive program of risk factor management, including exercise training.

NATIONAL SURVEY OF EXERCISE PRACTICES IN OUTPATIENT CARDIAC REHABILITATION PROGRAMS

Few data are available regarding the compliance of contemporary cardiac rehabilitation programs to national recommendations (core components) for exercise programming, especially in regard to aerobic and resistance training (RT). This study was designed to assess the exercise testing and training methods utilized in these programs throughout the United States. METHODS: Programs listed in the database of the AACVPR (n = 1,100) were mailed a cover letter stating the purpose of the study, a self-addressed, postage paid return envelope, and a questionnaire inquiring about their outpatient exercise testing/training practices. Survey responses were manually entered into an Excel spreadsheet program, using a computerized database, with confidentiality assured. RESULTS: Of the 1,100 facilities surveyed, 546 (50%) responded. Only 40% of phase II (pII) and 36% of phase III (pIII) programs required a graded exercise test (GXT) prior to program entry. For programs not requiring a GXT, 94% of pII and 88% of pIII programs utilized initial training intensities corresponding to 20 to 30 beats/min above resting heart rate, using rating of perceived exertion (RPE) and/or metabolic equivalents (METs) as adjunctive intensity modulators. For programs requiring a GXT, aerobic training intensities (mean ± SD) utilized in pII vs pIII were: 61 ± 10 to 80 ± 6% vs 62 ± 10 to 82 ± 5% of maximal heart rate; 57 ± 8 to 79 ± 6% vs 59 ± 9 to 80 ± 5% of heart rate reserve; and, RPEs (6–20 scale) of 10.5 ± 2.6 to 12.9 ± 2.7 vs 10.7 ± 2.5 to 13.1 ± 2.7, respectively. Most pIII programs (89%) offered RT, using 2.2 ± 1.6 sets per exercise at 7.8 ± 3.1 exercise stations for 14.1 ± 3.9 repetitions per set. CONCLUSION: Most contemporary cardiac rehabilitation programs do not require a GXT prior to pII or pIII entry. Relative to aerobic training, there was little or no difference in prescribed exercise intensities between phases. RT practices were compatible with national recommendations.

The risks of exercise training.

The risks of exercise training.

Clinical profile and outcomes of obese patients in cardiac rehabilitation stratified according to National Heart, Lung, and Blood Institute criteria.

Obesity is a major health problem and must be evaluated and treated in cardiac rehabilitation patients. The purpose of this study was to identify the scope of this problem in an urban-based cardiac rehabilitation program by evaluating the prevalence of obesity, and comparing the clinical and risk factor profiles and outcomes of patients stratified according to National Heart, Lung, and Blood Institute (NHLBI) weight classifications. Four hundred forty-nine consecutive cardiac rehabilitation patients, aged 57 +/- 11 years, were stratified according to the NHLBI criteria as: normal (body mass index [BMI] 18-24.9 kg/m2), overweight (BMI 25-29.9 kg/m2), class I/II obese (BMI 30-39.9 kg/m2), and class III morbidly obese (BMI > or = 40 kg/m2). Baseline cardiac risk factors and dietary habits were identified, and both pre- and postexercise training measurements of exercise tolerance, weight, and lipid profile were obtained. Overweight and obesity (BMI > or = 25 kg/m2) were present in 88% of patients. Compared to normal weight patients, obese patients were younger and had a greater adverse risk profile (higher prevalence of diabetes and hypertension, larger waist circumference, lower exercise capacity, lower high-density lipoprotein cholesterol level) at entry. After 10 weeks, all groups had a significant increase in exercise capacity, and on average obese patients in each category lost weight (Class I/II--4 lbs and Class III--12 lbs). Dropout rates were similar among the groups. Overweight and obesity are highly prevalent in cardiac rehabilitation. Overweight and obese patients had a greater adverse cardiovascular risk profile, including a lower exercise capacity in the latter. Thus, targeted interventions toward weight management in contemporary cardiac rehabilitation programs are important. Although short-term outcomes appear promising, greater efforts to improve these outcomes and to support long-term management are needed.

Contemporary Cardiac Rehabilitation: Patient Characteristics and Temporal Trends Over the Past Decade

Recent and dramatic therapeutic advances, aggressive care of the elderly, and a heightened awareness of secondary prevention have had a significant, albeit incompletely described, impact on cardiac rehabilitation (CR) programs. The authors did a retrospective analysis on 1,848 patients from their phase II CR program that were treated over the past decade. The authors sought to identify and analyze how advances in cardiovascular care might be related to temporal changes in demographics, medical comorbidities, coronary artery disease risk factors, and cardiovascular history among individuals with cardiac disease who have completed the phase II CR program over a 10-year period. Cardiac rehabilitation records were reviewed from 1986 to 1996 at Akron City Hospital. The data were compiled prospectively by nurses and exercise physiologists and were subsequently analyzed. The charts reviewed were from 1,848 patients who completed outpatient phase II CR. The program began in 1986 with 53 patients completing CR and evolved to 309 in 1996. There has been an increase in the number of elderly patients referred to and completing the program. The number of participants older than 65 years of age increased from 28.3% in 1986 to 52.1% in 1996. Cardiac rehabilitation participants reflect the known demographics of patients with clinical coronary artery disease. Men outnumber women and, on average, the female participants are older than the male participants. There has been a statistically significant increase in medical comorbidities over the course of the study. Although the absolute number of patients entering CR after coronary artery bypass graft survey has remained fairly constant, there has been a dramatic increase in the absolute number of patients entering CR after percutaneous tansluminal coronary angioplasty (with the latter recently comprising a majority of CR participants). There is a significant trend in the attendance and completion of CR programs by older individuals, which suggests a greater awareness of patients and their physicians. The growth of the program is fueled by high-risk patients with more comorbidities who potentially are the group of patients able to obtain the greatest absolute benefit from CR.

Myocardial oxygen increases due to physical training in individuals with coronary heart disease (CHD): Rate pressure product (RPP) measurements

Endurance training is used to restore, as much as possible, the functional capabilities of individuals with coronary heart disease (CHD) during phase II of the cardiac rehabilitation program. The functional capabilities of individuals with CHD are a function of the capacity of their cardiovascular system which, in turn, is dependent upon the supply of oxygen to cardiac muscles. The greater the supply of oxygen to cardiac muscles (measured by peak myocardial oxygen consumption, MVO2max), the greater the ability of the circulatory system to meet the demands placed upon it. Rate pressure product (RPP; heart rate × systolic blood pressure) is an easy, reliable, and indirect measure of MVo2max. Therefore, contemporary cardiac rehabilitation programs should focus on enhancing RPPmax. Utilizing data from 210 individuals with CHD, a statistically significant pre-post conditioning effect in RPPmax was observed (p<0.01). In the absence of a control group, it was not possible to attribute increases in RPPmax to endurance training. This study also found no significant differences in RPPmax values among the three cardiac conditions investigated (bypass, angioplasty, and post-MI;p≥0.10). However, there were significant differences between the RPPmax values of men and women (p<0.01). The gender differences in RPPmax values disappeared when the data were normalized with respect to pretraining RPP values. Since a severe decline in MVo2max leads to most heart problems, it is suggested that future studies document the effect of endurance training on enhancing RPPmax. If such a relationship is established, then cardiac rehabilitation training programs should focus on enhancing MVo2max, by way of enhancing RPPmax. Such a focus is likely to result in a greater functional capability (ability to perform work). The discussion indicates how the design of jobs and assignment of individuals (both individuals with CHD and healthy people) to various jobs can be based on RPPmax rather than Vo2max, and how it can provide an objective basis for designing less stressful jobs from a psychological and physical demands perspective.

Contemporary Cardiac Rehabilitation Services

Major changes will be required in the components and delivery of cardiac rehabilitation services in the era of managed care. These include restructuring and amplifying the coronary risk reduction services that are currently provided, and offering group and home-based cardiac rehabilitation services to increase their availability.

Cardiac rehabilitation: potential for ergonomic interventions with special reference to return to work and the Americans with Disabilities Act.

This paper briefly reviews the contemporary cardiac rehabilitation process and highlights its limitations. It argues that, in order to improve return-to-work chances, cardiac rehabilitation should focus on simulating actual work conditions. The role of ergonomics in the cardiac rehabilitation process is also outlined. Finally, the current impediments to early return to work are identified and corrective actions are suggested.