Exercise-based Cardiac Rehabilitation Program Research Articles

A generic logic model for physical activity interventions for the cardiac population using intervention mapping

Abstract Introduction Regular physical activity is important in the secondary prevention of cardiovascular disease. But many cardiac patients have difficulty establishing lifelong physical activity habits, even after completion of an exercise-based cardiac rehabilitation programme. There is a need for effective interventions to support cardiac patients' physical activity. Such interventions are often complex behaviour change interventions whose design should be grounded in programme theory, i.e., a description of how the intervention is expected to lead to its effects and under what conditions. A logic model is often used to communicate programme theory [1]. Purpose The purpose of this work was to describe a generic logic model for behaviour change interventions to increase and maintain physical activity among patients who have had an acute cardiac event. Methods We applied the Intervention Mapping approach [2] to develop a generic logic model that is both data- and theory-driven, i.e. informed by research evidence and behaviour change theory. The at-risk behaviour for the individual cardiac patient was defined as "insufficient independent long-term maintenance of heart-healthy physical activity", compounded by the environmental factor "lack of support provision for long-term independent physical activity" from the healthcare providers and people in the patient’s interpersonal environment. We defined performance objectives by asking the questions: "What do people who had an acute cardiac event need to do to increase and maintain their heart-healthy physical activity?" and "What do the healthcare providers and people in the patient’s interpersonal environment need to do to encourage and support the patient in being physically active?" The performance objectives specify what actions are required of the individuals targeted in the intervention. We selected determinants corresponding to performance objectives based on empirical evidence from systematic reviews and based on behaviour change theory such as the Reasoned Action Approach (RAA) and the Health Action Process Approach (HAPA). Results Central elements of the logic model are presented in table 1. The logic model includes 18 performance objectives and 13 determinants, supported by empirical evidence from 40 scientific publications. Conclusion The generic logic model serves as a collection of current knowledge regarding increasing and maintaining physical activity among the cardiac population and can be used for a number of purposes: as a foundation for developing new interventions; as a blueprint against which to compare and/or solidify the programme theory of existing interventions; as a conceptual framework for designing evaluations of interventions; as a current evidence map from which to identify research gaps; and as a point of reference for reflecting on one’s own health behaviour.Table 1.Elements of the logic model.

EFFECTS OF CARDIAC REHABILITATION IN PATIENTS WITH VENTRICULAR ASSIST DEVICES: A SCOPING REVIEW

Introduction Ventricular assist devices represent a treatment option for patients with advanced heart failure, offering control over various haemodynamic variables. Similarly, the prescription of exercise within a cardiac rehabilitation programme for heart failure patients is recommended to reduce symptoms, hospitalisations, improve cardiorespiratory fitness, and increase exercise tolerance. Therefore, exercise prescription can impact those with ventricular assist devices. Given the limited evidence on exercise-based cardiac rehabilitation programmes for this population, this review aims to describe the most commonly used strategies and their health benefits when physical exercise is included in a cardiac rehabilitation programme for patients with ventricular assist devices. Materials and Methods An exploratory review was conducted through searches in the databases: PubMed, SCOPUS, PeDro, and ScienceDirect. The search was limited to studies published between 2013 and 2023. Filters were applied independently by title, abstract, and full text. The included articles were analysed based on the description of the types of cardiac rehabilitation strategies used in patients with ventricular assist devices. Results Seven articles were included. Each programme employed a cardiopulmonary exercise test before prescribing physical exercise. The most commonly used strategy was aerobic exercise, predominantly high-intensity interval training (HIIT) with intensities close to 90% of peak VO2, followed by continuous moderate-intensity exercise. Limb strength exercises were included in three programmes. Conclusions The analysed literature suggests that cardiac rehabilitation in patients with ventricular assist devices is safe and can provide benefits in cardiorespiratory fitness and exercise tolerance. High-intensity interval training is identified as an appropriate strategy for achieving results, offering short-term improvements.

Health-related quality of life in elderly cardiac patients undergoing cardiac rehabilitation and the association with exercise capacity: The EU-CaRE study.

The ability to be physically active is pivotal to the quality of life in elderly patients. This study aims to describe the association between exercise capacity and health-related quality of life (HRQoL), anxiety, and depression following an exercise-based cardiac rehabilitation (CR) program in elderly cardiac patients. Patients aged ≥65 years with acute and chronic coronary syndrome or heart valve surgery were consecutively included from 8 CR centers in 7 European countries. Exercise capacity (VO2peak(ml/kg/min)) was assessed with a cardiopulmonary exercise test (97%) or a six-minute walk test. Outcome variables included HRQoL (SF-36 physical and mental component scores (PCS and MCS)), anxiety (GAD-7), and depression (PHQ-9). Mixed models were used to address the association between baseline and the development in VO2peak, and outcome variables stratified on sex, and adjusted for baseline values, age, and CR center. A total of 1,633 patients were included (T0), 1,523 (93%) completed end-of-CR assessment (T1), and 1,457 (89%) 1-year follow-up (T2). Women had higher % of predicted VO2peak, but poorer scores in HRQoL, anxiety and depression at all time-points. All scores improved in both sexes at follow-up. We found significant associations between VO2peak at baseline as well as development in VO2peak and all outcome variables at T1 and T2 in men (all p < 0.001). In women, VO2peak was only associated with PCS scores (p < 0.001). Improvements in exercise capacity was strongly associated with improvements in HRQoL and mental health, however with stronger associations in men. The results highlight the importance of physical fitness for HRQol and mental health. The findings from this study might be useful to better target individual CR programs.

Effect of an exercise-based cardiac rehabilitation program on quality of life of patients with chronic Chagas cardiomyopathy: results from the PEACH randomized clinical trial.

To investigate the effect of an exercise-based cardiac rehabilitation program on the quality of life (QoL) of patients with chronic Chagas cardiomyopathy (CCC). PEACH study was a single-center, superiority randomized clinical trial of exercise training versus no exercise (control). The sample comprised Chagas disease patients with CCC, left ventricular ejection fraction < 45%, without or with HF symptoms (CCC stages B2 or C, respectively). QoL was assessed at baseline, after three months, and at the end of six months of follow-up using the SF-36 questionnaire. Patients randomized for the exercise group (n = 15) performed exercise training (aerobic, strength and stretching exercises) for 60min, three times a week, during six months. Patients in the control group (n = 15) were not provided with a formal exercise prescription. Both groups received identical nutritional and pharmaceutical counseling during the study. Longitudinal analysis of the effects of exercise training on QoL, considering the interaction term (group × time) to estimate the rate of changes between groups in the outcomes (represented as beta coefficient), was performed using linear mixed models. Models were fitted adjusting for each respective baseline QoL value. There were significant improvements in physical functioning (β = + 10.7; p = 0.02), role limitations due to physical problems (β = + 25.0; p = 0.01), and social functioning (β = + 19.2; p < 0.01) scales during the first three months in the exercise compared to the control group. No significant differences were observed between groups after six months. Exercise-based cardiac rehabilitation provided short-term improvements in the physical and mental aspects of QoL of patients with CCC.Trial registration: ClinicalTrials.gov Identifier: NCT02517632; August 7, 2015.

Effectiveness of alternative vs traditional exercises on cardiac rehabilitation program utilization in women with or at high risk of cardiovascular disease: a systematic review protocol.

This review will evaluate the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization and other outcomes in women with or at high risk of cardiovascular disease. Exercise-based cardiac rehabilitation programs improve health outcomes in women with or at high risk of cardiovascular disease. However, such programs are underutilized worldwide, particularly among women. Some women perceive traditional gym-based exercise in cardiac rehabilitation programs (eg, typically treadmills, cycle ergometers, traditional resistance training) to be excessively rigorous and unpleasant, resulting in diminished participation and completion. Alternative forms of exercise such as yoga, tai chi, qi gong, or Pilates may be more enjoyable and motivating exercise options for women, enhancing engagement in rehabilitation programs. However, the effectiveness of these alternative exercises in improving program utilization is still inconsistent and needs to be systematically evaluated and synthesized. This review will focus on randomized controlled trials of studies measuring the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization as well as clinical, physiological, or patient-reported outcomes in women with or at high risk of cardiovascular disease. The review will follow the JBI methodology for systematic reviews of effectiveness. Databases including MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane CENTRAL, Embase (Ovid), Emcare (Ovid), Scopus, Web of Science, LILACS, and PsycINFO (Ovid) will be searched. Two independent reviewers will screen articles and then extract and synthesize data. Methodological quality will be assessed using JBI's standardized instruments. GRADE will be used to determine the certainty of evidence. PROSPERO CRD42022354996.

Comparison of the Effects of Two Exercise Programs of High-intensity Interval Training and Moderate-intensity Continuous Training on Physiological Function of Heart Patients after Coronary Artery Bypass Graft Surgery

Background: Exercise-based cardiac rehabilitation(CR) programs increase physiological function. However, it’s not yet clear which feature of exercise is most effective in improving important physiological performance indicators in heart patients. Therefore, the aim of this study was to compare the effects of high-intensity interval training(HIT) and moderate-intensity continuous training(MCT) on metabolic equivalent of tasks(METs), submaximal myocardial oxygen consumption(MVO2submax), and heart rate recovery(HRR) of heart patients after coronary artery bypass graft(CABG) surgery. Methods: Twenty-four post-CABG patients (15 males and 9 females) with a mean age of 60.75±3.16 years and a mean body mass index (BMI) of 28.40±1.09 kg/m2 were randomly divided into three groups of HIT, MCT and control group (CG). The training groups (HIT and MCT) trained for eight-weeks, three-sessions per week, and 45minutes per session. The research variables (METs, MVO2submax and HRR) were measured and compared in two stages before and after eight-weeks of CR programs. Results: After eight-weeks of CR programs, patients in both training groups showed a significant improvement in METs, MVO2submax and HRR (P&lt;0.05), and the HIT group showed significantly greater improvement in METs (P=0.001) and HRR (P=0.001) compared to the MCT group, as well the MCT group showed a significantly more improvement in MVO2submax (P=0.001) than the HIT group. Also, no cardiovascular adverse events related to HIT or MCT occurred during the implementation of the study. Conclusion: According to the results of the present study, HIT seems to be more effective than MCT in improving METs and HRR of post-CABG patients, and is safe as well.

The effect of 12 weeks supervised exercise-based cardiac rehabilitation on resting and exercise blood pressure in males and females

Abstract Background Exercise is key in the prevention and management of hypertension. It remains unclear to what extent sex differences exist with regard to changes in blood pressure (BP) in patients following an exercise-based cardiac rehabilitation (CR) program. Purpose To investigate the effect of a 12 week supervised exercise-based CR program on resting BP (BPrest), peak exercise BP (BPmax) and systolic BP (SBP)/metabolic equivalents (MET)-slope and compare sex differences. Methods Of 2963 patients referred for CR at a singular test centre in Belgium during the years 2010-2019, those with missing BP data or with a submaximal (RER&amp;lt;1.1) cardiopulmonary exercise test (CPET) were excluded. Reasons for referral included post myocardial infarction, percutaneous coronary intervention, coronary artery bypass surgery and valve surgery. Patients underwent a bicycle CPET with BP measured at rest seated on the bike (BPrest) and throughout the test using an automated auscultatory BP machine at baseline and after 12 weeks of CR. BPrest, BPmax, peak oxygen uptake (VO2peak), peak workload (Wattpeak), resting heart rate (HRrest), maximal HR (HRmax) and the SBP/MET-slope were recorded from each test. CR incorporated 3 sessions of supervised aerobic and resistance exercise per week. Results A final sample of 2500 patients (20.4% females) were included for analysis with similar age (62±11 for males vs 61±11years for females, P=0.142). More males were on an ACE-inhibitor (55 vs 46% females, P&amp;lt;0.001) with a comparable prevalence of beta-blocker usage between sexes (75 vs 71% females, P=0.053). At both baseline and 12 weeks, females had a significantly lower body mass index, VO2peak, Wattpeak, BPmax and HRmax compared to males (P&amp;lt;0.001 for all) but a higher HRrest (P&amp;lt;0.001). However, both sexes had similar BPrest and SBP/MET-slope at baseline and 12 weeks. After 12 weeks of CR both males and females had a comparable mean±SD improvement in VO2peak (+4.1±3.2 and +3.1±2.6mL/kg/min), and Wattpeak (+33±22 and +22±15Watts), respectively (P&amp;lt;0.001 for all). This was associated with an increased SBPmax for males (171±30 to 181±30mmHg, P&amp;lt;0.001) and for females (159±29 to 167±30mmHg, P&amp;lt;0.001) from baseline to 12 weeks respectively. No change was seen in SBPrest between baseline and 12 weeks for males (128±20 to 128±19mmHg, P=0.39) and females (129±21 to 128±19mmHg, P=0.21) respectively. The SBP/MET-slope also remained unchanged after 12 weeks CR for males (8.97±5.48 to 9.04±4.81mmHg/MET, P=0.63) and for females (8.68±7.11 to 9.19±6.16mmHg/MET, P=0.13) respectively. Conclusion Twelve weeks of exercise-based CR was associated with an increase in SBPmax, although this was largely proportional to the improvement in exercise capacity demonstrated by the unchanged SBP/MET-slope and this was similar in both sexes. These routine clinical markers require further interrogation as to whether they parallel improvements in vascular health associated with exercise training.

Health outcomes of an ambulatory exercise-based cardiac rehabilitation program across patient risk categories

Abstract Background Exercise-based cardiac rehabilitation is recommended after an ST-segment elevation myocardial infarction (STEMI) to improve prognosis, quality of life and control of cardiovascular risk factors. Ambulatory training has been proposed as an alternative if in-hospital training is unavailable. Purpose To study the health outcomes of an ambulatory exercise-based Cardiac Rehabilitation Program (aCRP) in STEMI patients across different patient risk profiles. Methods A Phase 2 aCRP aimed to STEMI patients was implemented in our hospital in 2022. Conventional or cardiopulmonary exercise testing (C/CPET) was performed, patient risk was stratified as low risk or intermediate/high risk, and a 3-month, individualized aerobic and strength ambulatory training program was provided. C/CPET was repeated at the end of Phase 2 and peak oxygen consumption (peak VO2) was measured. Questionnaires were used to analyse quality of life (SF-36), depression (PHQ-2), anxiety (GAD-2), adherence to Mediterranean diet (PREDIMED) and weekly physical activity (IPAQ). Comparisons were performed between patients at low risk and patients at intermediate/high risk. A p&amp;lt;0.05 was considered statistically significant. Results The cohort comprised 41 patients who completed Phase 2 of aCRP (mean age 60.1±10.2 years, 82.9% male and 53.7% smokers) and were stratified as low risk (n=15, 36.6%) or intermediate/high risk (n=26, 63.4%). Reductions in systolic blood pressure (-7.9±15.7mmHg), LDL cholesterol (-59.5±35mg/dL), weight (-3±6.5kg) and body mass index (BMI, -1±2.2) were attained (all p&amp;lt;0.05). Smoking abstinence was accomplished in 90.9% of smokers and most patients achieved an LDL&amp;lt;55mg/dL target (75.6%). Quality of life improved (+8.4±23.7 points in SF-36, p=0.03) and anxiety symptoms diminished (-0.6±1.8 points in GAD2, p=0.04). A median 4.1±4.7ml/kg/min peak VO2 increase was achieved (+17.9% from baseline, p&amp;lt;0.001) and patients increased their reported weekly physical activity in 2681.1±3385.3 METS/week (+156.2% from baseline, p&amp;lt;0.001). No significant differences were noted between low risk and intermediate/high risk patients, except lower LDL&amp;lt;55mg/dL (65.4% vs. 93.3%, p=0.045) and higher weight loss and BMI reduction (-4.2±7.7 vs. -0.8±3kg, p=0.05 and -0.16±1.1 vs. -1.54±2.5, p=0.02, respectively) in intermediate/high risk patients. No readmissions for cardiovascular causes or complications of ambulatory training were registered. Conclusions In STEMI patients, a Phase 2 ambulatory Cardiac Rehabilitation Program can provide excellent control of cardiovascular risk factors, improve quality of life, and significantly increase functional capacity and reported weekly physical activity. Results are comparable in patients at low risk and intermediate/high risk of cardiac rehabilitation, which could support the inclusion of intermediate/high risk patients in ambulatory exercise-based cardiac rehabilitation programs if in-hospital supervised training is unavailable.Health outcomes of aCRP.

Cardiac Rehabilitation in Abu Dhabi: A Retrospective Investigation of Program Delivery, Participants, and Factors Associated with Program Completion Utilizing a Hospital Registry.

Investigations into the provision of cardiac rehabilitation from the Arabian Gulf countries are rare, despite suffering from an unusually high prevalence of cardiovascular disease. This study reports patient and program characteristics from an exercise-based cardiac rehabilitation program in Abu Dhabi, and factors associated with program completion. Data was drawn from the institution's cardiac rehabilitation registry, populated from the electronic medical record of patients enrolled in the hospital-based cardiac rehabilitation program, from 2015 to 2022. The program was administered by physical therapist and nurse specialists and guided by individualized exercise parameters. Completion of the program was defined as attendance of ten or more sessions. Relationships between program completion and demographic characteristics, quality of life, depression, and physical function were explored statistically. A total of 1774 patients attended at least one session, with a total of 15,563 sessions. The number of patients and sessions trended upward since program inception. The most common referral diagnoses of participants who completed the program were coronary artery bypass grafting, valve surgery, and percutaneous coronary intervention. Among all 1774 attendees, median age was 56, comprised of 61.6% male, and 77.1% residents of Abu Dhabi, and 73.5% Emirati nationals. 527 (29.7%) patients completed the program, and this group was significantly lower in BMI (29.4 vs 30.4 kg/m2), had lower prevalence of moderate to severe depression (9.0 vs 13.0%), were more often Abu Dhabi residents or Emirati nationals (88.2 vs 72.2%, and 76.9 and 72.0%, respectively), and more likely to have completed the 6-min walk test at the first visit (80.5 vs 72.5%). There were no differences between those who did and did not complete cardiac rehabilitation with respect to age, gender, quality of life, or first 6-min walk test distance. There is a growing demand for cardiac rehabilitation in Abu Dhabi, particularly among Emirati nationals and residents of Abu Dhabi. Potential risk factors for non-completion such as higher body-mass index, depression, lower physical function, non-residence in Abu Dhabi, and non-Emirati nationality warrant further exploration.

Home- versus centre-based EXercise InTervention in patients with Heart Failure (EXIT-HF trial): A pragmatic randomized controlled trial

IntroductionThe limited accessibility and the lack of adherence explain, in part, the low proportion of heart failure (HF) patients undergoing exercise-based cardiac rehabilitation (CR) programs. Home-based programs showed to be as effective and less costly than centre-based ones and might address those obstacles. Whether the evidence from international studies can be applied to our population is still unclear. ObjectivesTo compare the clinical and economic impact of a home-based versus centre-based CR intervention in HF patients. MethodsThis is a single-center, single-blind, parallel groups, non-inferiority pragmatic randomized control trial. Adult HF patients (n=120) will be randomized to either a centre-based or home-based CR program. In both groups’ patients will participate in a 12-week combined CR program with 2 sessions per week. Exercise training (ExT) protocol consists of a combination of endurance [(at 60%–80% of peak oxygen uptake (VO2peak)] and resistance training (elastic bands). Those allocated to the home-based program will start with 4–5 supervised ExT sessions to familiarize themselves with the training protocol and then will continue the remaining sessions at home. The primary endpoint is the change in VO2peak at the end of the 12-week program. Secondary outcomes include alterations in circulating biomarkers, physical fitness, physical activity, quality of life, diet, psychological wellbeing, dyspnea, and cost-effectiveness analyses. ResultsPatients are currently being recruited for the study. The study started in November 2019 and data collection is anticipated to be completed by December 2022. This is the first study in Portugal comparing the traditional CR program with a home-based program in HF patients. Our study results will better inform healthcare professionals who care for HF patients regarding CR.

Effect of Cardiac Rehabilitation Program on Right Ventricular Function after Acute Inferior Wall Myocardial infarction

Abstract Aim and objectives To assess the role of cardiac rehabilitation on right ventricular (RV) functional recovery by 2D speckle-tracking echocardiography (STE) in a cohort of patients with successful reperfusion after the first episode of acute inferior myocardial infarction (MI) associated with RV infarction. Patients and Methods Fifty patients who underwent successful percutaneous coronary intervention (PCI) after inferior MI mainly associated with ECG criteria of RV infarction were prospectively included (56.08 ± 10.79 years, 40 Men). Twenty-five patients started an exercisebased cardiac rehabilitation (exCR) program after 2-4 weeks of discharge; another twenty-five patients, who were taken as the control group, received the usual care but didn’t participate in the cardiac rehabilitation program. Both groups received guideline-directed medical therapy (GDMT). Echocardiography (including 2D STE and conventional parameters for assessment of RV systolic function ) was performed at baseline, and after a 3-month follow-up for all patients. High levels of strain impairment were observed in both groups at baseline. All parameters improved at 3-month follow-up compared to baseline. Nevertheless, RV global longitudinal strain (GLS) and free wall strain (FWS) improved significantly for patients who completed the cardiac rehabilitation program compared to the control group. Conclusion Cardiac rehabilitation is effective in improving RV strain parameters in patients who developed acute inferior MI associated with RV infarction. Future studies should directly assess the prognostic significance of STE measures of RV function in this population.

It is like someone holding your hand when you need it – lived experiences of patients with cardiovascular disease participating in a digital health intervention focusing on the maintenance of physical activity after cardiac rehabilitation

Purpose To explore patients with cardiovascular diseases’ lived experiences of the support given by a text message intervention focusing on the maintenance of physical activity after supervised cardiac rehabilitation. Methods In a qualitative study, participants from the feasibility trial FAIR were interviewed individually twice to disclose their lived experiences during and after the trial. Transcribed interviews were analysed based on a phenomenological-hermeneutic method, inspired by Paul Ricoeur’s philosophy on narrative and interpretation. Results Interviews of eight patients with cardiovascular disease (3 females, median age 57 years (range 37 to 74 years)) revealed two themes, The FAIR intervention as a bridge builder in the transition to being physically active in everyday life and Meaningful conditions for maintaining physical activity. Action plans guided physical activity, while text messages facilitated actions and left an impression of still being under supervision. A frame of reference with physical activity, family, being monitored, having to report back, and getting feedback, were incentives for being physically active. Conclusion From a patient perspective, the text message intervention in the feasibility trial FAIR was valuable to support the maintenance of physical activity in the transition from a supervised exercise-based cardiac rehabilitation programme to everyday life on an individual basis. Participants experienced the intervention to hold their hands in changing behaviour and redefining themselves. Yet, there is an extended need for belonging and personal interactions in future interventions.

Feasibility of Integrating MEditatioN inTO heaRt Disease (the MENTOR Study): A Phase II Randomized Controlled Trial.

Comorbid depression and/or anxiety symptoms occur in 25% of patients attending cardiac rehabilitation (CR) programs and are associated with poorer prognosis. There is a need to evaluate psychological interventions, including meditation, that have potential to improve psychological health in CR programs. The aim of this study was to determine the feasibility and acceptability of integrating a meditation intervention into an existing Australian CR program for the reduction of depression and anxiety symptoms. This was a mixed-methods feasibility randomized controlled trial. Thirty-one patients with CVD and, at a minimum, mild depression and/or anxiety symptoms were randomized to meditation and standard CR or to standard CR alone. A 16-minute guided group meditation was delivered face-to-face once a week for 6 weeks, with daily self-guided meditation practice between sessions. Feasibility outcomes included screening, recruitment, and retention. Semistructured interviews of patients' (n = 10) and health professionals' (n = 18) perspectives of intervention participation and delivery were undertaken to assess acceptability. Between-group differences in depression, anxiety, stress, self-efficacy for mindfulness, and health status at 6 and 12 weeks were also assessed. Meditation was considered feasible, with 83% (12/15) of the intervention group completing an average of 3.13 (SD, 2.56) out of 6 group meditation sessions and 5.28 (SD, 8.50) self-guided sessions. Meditation was considered acceptable by patients, clinicians, and health managers. Between-group differences in the number of CR sessions completed favored the intervention group in per-protocol analyses (intervention group vs control group, 12 vs 9 sessions; P = .014), which suggests that meditation may be useful to improve patients' adherence to exercise-based CR program.

Clinical Utility of the Cardiorespiratory Optimal Point in Patients with Heart Failure.

We assessed the cardiorespiratory optimal point (COP)-the minimal V̇E /V̇O 2 in a given minute of an incremental cardiopulmonary exercise test-in patients with heart failure (HF) and aimed to determine 1) its association with patient and disease characteristics, 2) changes after an exercise-based cardiac rehabilitation program (CR), and 3) the association with clinical outcomes. We studied 277 HF patients (67 (58-74) yr, 30% female, 72% HF with restricted ejection fraction) between 2009 and 2018. Patients participated in a 12- to 24-wk CR program, and COP was assessed pre- and post-CR. Patient and disease characteristics and clinical outcomes (mortality and cardiovascular-related hospitalization) were extracted from patient files. The incidence of clinical outcomes was compared across COP tertiles (low, <26.0; moderate, 26.0-30.7; high, >30.7). Median COP was 28.2 (24.9-32.1) and was reached at 51% ± 15% of V̇O 2peak . Lower age, female sex, higher body mass index, the absence of a pacemaker or the absence of chronic obstructive pulmonary disease, and lower N-terminal prohormone brain natriuretic peptide concentrations were associated with a lower COP. Participation in CR reduced COP (-0.8; 95% confidence interval, -1.3 to -0.3). Low COP had a reduced risk (adjusted hazard ratio, 0.53; 95% confidence interval, 0.33-0.84) for adverse clinical outcomes as compared with high COP. Classic cardiovascular risk factors are associated with a higher, more unfavorable, COP. CR-based exercise training reduces COP, whereas a lower COP is associated with a better clinical prognosis. As COP can be established during a submaximal exercise test, this may offer novel risk stratification possibilities for HF care programs.

Sex differences and predictors of completion of a 6-month exercise-based cardiac rehabilitation program in 1,536 people following stroke

ObjectiveTo retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017. Materials/methodsPeople with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately. ResultsThere were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O2peak, smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O2peak, smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP. ConclusionsWhile there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes.

The Role of Exercise-based Cardiac Rehabilitation in Heart Failure.

Exercise-based cardiac rehabilitation (EBCR) is a treatment modality for patients with heart failure (HF) that has withstood the test of time. It has continued to show benefits even in the current era of pharmacotherapeutics for HF. Participation in a multidisciplinary comprehensive EBCR programme reduces mortality and morbidity, has a multitude of physiological benefits, and improves cardiovascular risk factor control and quality of life. Despite this, historical barriers to enrolment and uptake remain. Strategies to overcome these, as well as alternative delivery methods of EBCR in HF patients, are emerging and include telerehabilitation, focus on special groups and emphasis on behavioural change. This review provides oversight on the modalities of exercise training in HF as well as their benefits and gives an overview of barriers to the utilisation of EBCR along with future progress in the field.

Does the Addition of Strength Training to a High-Intensity Interval Training Program Benefit More the Patients with Chronic Heart Failure?

Background: Aerobic exercise, either continuous or high intensity interval training (HIIT), induces important benefits in chronic heart failure (CHF) patients. Resistance training has been also shown to be beneficial in CHF. However, data regarding combined aerobic exercise and muscle strength training is still limited. The aim of this study was to investigate whether adding strength training to a HIIT protocol within a cardiac rehabilitation (CR) program has a cumulative beneficial effect on the functional capacity (FC) and quality of life (QoL) in patients with CHF. Methods: Forty-four consecutive patients [35 males, ejection fraction (EF) &lt;50%] with CHF under medication enrolled in a 36-session CR program and were randomized in two exercise groups; HIIT (HIIT group) or HIIT combined with strength training (high intensity interval training combined with strength training (COM) group). All patients underwent baseline and endpoint outcome measures of a symptom-limited maximal cardiopulmonary exercise testing (CPET), 1 repetition maximum (1RM) test, muscular endurance test, echocardiography, and Minnesota Living with Heart Failure Questionnaire (MLWHFQ). Results: Most of the CPET indices, EF, 1RM test, muscular endurance and QoL were improved after the CR program in each exercise training group (p &lt; 0.05). However, COM group demonstrated a further improvement in chest muscle testing and workload at anaerobic threshold (AT) compared to HIIT group. Conclusions: An exercise-based CR program, consisted of either HIIT or HIIT combined with strength training, improves FC and QoL of patients with CHF. However, the addition of strength training to HIIT seems to have further beneficial effects on chest muscle strength and endurance, as well as workload at AT. Clinical Trial Registration: The study was registered in ClinicalTrials.gov with number NCT02387411.

Exercise-based cardiac rehabilitation adaptation protocol during Covid-19 pandemic achieved similar results as compared to non-pandemic usual practice: a single center experience

During the Covid-19 pandemic, exercise-based cardiac rehabilitation (EBCR) faced challenges. Adaptation protocols were implemented to circumvent these challenges. The study aimed to investigate whether the adaptation protocols of EBCR during Covid-19 period influenced the result of cardiac rehabilitation. This was a retrospective cohort study. The subjects were patients who underwent an EBCR program in Dr. Sardjito General Hospital. Yogyakarta, Indonesia. The registry of cardiac rehabilitation was obtained and divided into two periods: non-Covid-19 period and Covid-19 period. During the non-Covid-19 period, 3 EBCR sessions per wk (10-12 total sessions) were performed. During the Covid-19 period, EBCR was reduced to 2 sessions per wk (10-12 total sessions). The functional capacities were evaluated as metabolic equivalents (METs) and exercise test time (min) by treadmill test. A total of 122 subjects completed the EBCR. There were no significant differences in METs and exercise minute achieved between two time periods. Among subjects with different sessions per wk, namely 2, 3, and 4-5 sessions per wk, there were no significant differences in METs (7.01±1.89; 7.23±1.74; and 7.33±2.13, p=0.813) and minutesachieved (6.72±1.94; 6.96±1.96; and 6.81±1.84, p=0.848) in the end sessions. In conclusion, the adaptation of EBCR protocols during the Covid-19 period by reducing the number of sessions per wk has similar results as compared to the usual regular EBCR practice.

The relationship of exercise-based cardiac rehabilitation and the quality of life of patients after myocardial infarction

Background: The aim of the present review is to identify the relationship of an exercise-based cardiac rehabilitation program (exCR) and quality of life in patients after myocardial infarction. Design: The following databases were searched: Medline databases (via PubMed), and Scopus /Elsevier. Additional relevant research was also identified by direct search in scientific journals available online. The review included studies designed to primary evaluate the quality of life of an exCR program with no limitation about the publication date. Case reports and case series were excluded. Data were extracted by one reviewer and checked by a second reviewer. Results: The results are presented as per the PRISMA reporting guideline. The articles that finally met all the inclusion criteria and were analyzed, after the screening of the title, the summary and the whole text, were 6. A total of 694 patients who received exCR were examined in this review. Discussion: The present review indicates that an exCR program improves the quality of life for the patients with myocardial infarction and that quality of life improvements have a bidirectional relationship with increased physical activity and vocational status.

Hypoxic Conditioning in Rehabilitation and Secondary Prevention Programs in Cardiac Patients with Multimorbidity: a Review

INTORDUCTION. Patients with multiple chronic diseases are at higher risk of premature death, hospitalization, longer hospital stays, and reduced health-related quality of life compared to patients with a single disease. On the other hand, the presence of comorbid conditions limits the enrolment of traditional exercise-based cardiac rehabilitation programs. It is predicted that as life expectancy increases, the level of multimorbidity will increase, making it even more important to find new additional methods and technologies for the rehabilitation of cardiac patients with comorbidities. AIM. To analyze the data from the current publications or to define the validity and effectiveness of using different hypoxic conditioning regimens in cardiac patients with concomitant chronic pathology (arterial hypertension, obesity, diabetes mellitus, and chronic bronchopulmonary diseases) as well as in multimorbid elderly patients. MATERIAL AND METHODS. The search for relevant papers was carried out using the Medline, e-library, and Web of Science Core Collection databases, as well as the following keywords: “hypoxic conditioning”, “hypoxic training”, “hypoxic therapy”, “interval hypoxic therapy”, “intermittent hypoxia”, “hypoxic conditioning”, “interval hypoxia training”, and “hypoxic exposure”. The analysis included publications regarding the use of the hypoxic conditioning method in cardiac and elderly patients with multimorbid pathology, as well as publications on the use of the method in the rehabilitation of patients with certain nosologies to identify potential mechanisms in correcting bronchopulmonary violations and lipid and carbohydrate metabolism disorders. The last search date was April 05, 2022. RESULTS. Most of the analyzed studies proved that the hypoxic conditioning technology in passive interval exposure regimes is an effective method for non-pharmacological correction of cardiometabolic risks in cardiac patients with multimorbid pathology and can increase exercise tolerance, optimize hemodynamic parameters (HR, SBP and DBP), reduce the manifestations of bronchial obstruction and respiratory failure, and improve cognitive function and metabolic indicators. Personalized physical activity doses in oxygen-depleted ambient air appear to be promising, but require additional studies to establish optimal application protocols. CONCLUSION. The data presented may recommend hypoxic conditioning technologies for wider implementation in cardiac rehabilitation programs for patients with multimorbid pathologies.