Cardiac Rehabilitation Guidelines Research Articles

Efficacy of a Mobile Health App (eMOTIVA) Regarding Compliance With Cardiac Rehabilitation Guidelines in Patients With Coronary Artery Disease: Randomized Controlled Clinical Trial.

Cardiac rehabilitation is fundamental among patients recovering from a coronary event, and mHealth technology may constitute a useful tool that provides guidelines based on scientific evidence in an entertaining, attractive, and user-friendly format. This study aimed to compare the efficacy of an mHealth intervention involving the eMOTIVA app and that of usual care regarding compliance with cardiac rehabilitation guidelines in terms of lifestyle, cardiovascular risk factors, and satisfaction among patients with acute coronary syndrome. A randomized controlled clinical trial with a parallel group design was conducted. It included 300 patients (mHealth group, 150; control group, 150) who underwent percutaneous coronary intervention for acute coronary syndrome. Both groups underwent evaluations initially (during hospitalization) and after 3 and 6 months (face-to-face consultations). The eMOTIVA app incorporates a virtual classroom providing audio and video information about a healthy lifestyle, a section for self-recording cardiovascular risk factors, and a section for feedback messages and gamification. The primary outcome variables were (1) adherence to the Mediterranean diet and the frequency of consumption of food; (2) physical activity level, sedentary time, and exercise capacity; (3) smoking cessation and nicotine dependence; (4) level of knowledge about cardiovascular risk factors; and (5) app satisfaction and usability. The study analyzed 287 patients (mHealth group, 145; control group, 142). Most participants were male (207/300, 69.0%), and the mean age was 62.53 (SD 8.65) years. Significant improvements were observed in the mHealth group compared with the control group at 6 months in terms of (1) adherence to the Mediterranean diet (mean 11.92, SD 1.70 vs 8.92, SD 2.66 points; P<.001) and frequency of eating foods (red meat [≤1/week]: 141/143, 97.9% vs 96/141, 68.1%; industrial pastries [<2/week]: 129/143, 89.6% vs 80/141, 56.8%; oily fish [≥2/week]: 124/143, 86.1% vs 64/141, 41.4%; vegetables [≥2/day]: 130/143, 90.3% vs 78/141, 55.3%; fruit [≥2/day]: 128/143, 88.9% vs 85/141, 60.2%; all P<.001); (2) physical activity (mean 2112.66, SD 1196.67 vs 1372.60, SD 944.62 metabolic equivalents/week; P<.001) and sedentary time (mean 8.38, SD 1.88 vs 9.59, SD 2.09 hours; P<.001); (3) exercise capacity (distance: mean 473.49, SD 102.28 vs 447.25, SD 93.68 meters; P=.04); and (4) level of knowledge (mean 117.85, SD 3.83 vs 111.00, SD 7.11 points; P<.001). App satisfaction was high (mean 42.53, SD 6.38 points), and its usability was excellent (mean 95.60, SD 4.03 points). With the eMOTIVA app, favorable results were obtained in the intervention group in terms of adherence to the Mediterranean diet, frequency of eating certain foods, physical activity, sedentary time, exercise capacity, knowledge level, systolic blood pressure, heart rate, and blood sugar level. Furthermore, participants reported high app satisfaction and rated its usability as excellent. Thus, this innovative tool is very promising. ClinicalTrials.gov NCT05247606; https://clinicaltrials.gov/study/NCT05247606.

Impact of mHealth application on adherence to cardiac rehabilitation guidelines after a coronary event: Randomised controlled clinical trial protocol.

Coronary disease is the main cause of death around the world. mHealth technology is considered attractive and promising to promote behavioural changes aimed at healthy lifestyle habits among coronary patients. The purpose of this study is to evaluate the efficacy of an mHealth intervention regarding improved results in secondary prevention in patients after an acute myocardial infarction (AMI) or angina in terms of lifestyle, clinical variables and therapeutic compliance. Randomised clinical trial with 300 patients who underwent a percutaneous coronary intervention (PCI) with stent implant. They will be assigned to either the mHealth group, subject to a self-monitored educational intervention involving an internet application installed on their mobile phone or tablet, or to a control group receiving standard healthcare (150 patients in each arm). The primary outcome variables will be adherence to the Mediterranean diet, physical activity, smoking, therapeutic compliance, knowledge acquired, user-friendliness and satisfaction with the application. Measurements of blood pressure, heart rate, body weight, waist circumference (WC) and the 6-min walk test will be taken. Furthermore, the blood lipid profile, glucose and HbA1c will be evaluated. Clinical interview will be conducted, and validated questionnaires completed. The primary quantitative results will be compared using an analysis of covariance adjusted for age and sex. A multivariate analysis will be performed to examine the association of the intervention with lifestyle habits, the control of cardiovascular risk factors (CDRFs) and the results after the hospital discharge (major adverse events, treatment compliance and lifestyle). The study will provide evidence about the effectiveness of an mHealth intervention at improving the lifestyle of the participants and could be offered to patients with coronary disease to complement existing services. NCT05247606. [https://ClinicalTrials.gov]. 21/02/2022.

Randomised control trial of a novel digital system to provide contextualised data feedback to augment physical activity behaviour change in a free-living environment as part of cardiac rehabilitation

Abstract Background Physical activity (PA) is a core component of cardiac rehabilitation (CR) and is crucial for enhancing cardiovascular (CV) fitness[1]. In the UK, CR programmes involve 1-2 hours of face-to-face contact per week over 6-8 weeks, implying that 98-99% of the intervention period is currently unmonitored and not optimised for potential positive lifestyle interventions. Consequently, CR staff are blind to PA that occurs outside of the clinical setting, which could be of too low or high intensity and/or duration, according to the Association of Certified Physiotherapists in Cardiac Rehabilitation (ACPICR) guidelines[2]. A previous pilot study showed a novel digital system to be feasible, acceptable and effective for CR patients[3], making it a promising intervention to assess in a randomised control trial (RCT). Purpose To conduct a RCT to examine whether contextualised data feedback delivered using a novel digital service, in conjunction with usual care (UC) promotes positive PA behavioural change, with direct comparison to UC alone. Methods This prospective, parallel group, open-label, RCT enrolled 130 patients eligible for CR and consisted of an 8-week intervention period with follow-up at 8-weeks. The intervention group received the novel digital CR service plus UC, with the control group receiving UC alone. The primary outcome was changes in PA to achieve the ACPICR guidelines. Both groups wore a PA monitor to collect minute-level energy expenditure data that underwent processing using a patented method to extract the specific PA metrics required for analysis. The secondary outcome was changes in CV fitness between pre and post assessments, measured using Incremental Shuttle Walk Test (ISWT). Results Patient characteristics are shown in Table 1. Adherence to data collection was good, with an average of 37 complete days (≥768 minutes per day) of PA data per person. Fifty-six intervention group patients and 49 control group patients were analysed for the primary outcome. A significant difference (p&amp;lt;0.025) in the probability of achieving the ACPICR ‘Daily Activity’ guideline was found between groups, with the intervention group more likely to achieve the guideline at week-8 versus control. Despite Covid-19 challenges, pre and post ISWT measurements were obtained for 33 intervention group patients and 37 control group patients. No significant differences between groups were found. However, the average improvement seen in the intervention group, +89 metres (m), exceeded the minimum clinically important difference for the ISWT (+70 m), and was more than double that seen in the control group, +44 m. Conclusion This RCT builds on previous evidence supporting the use of the novel digital service in CR[3]. Engagement with, and completion of, the digital CR service was excellent. Participation was associated with statistically significant improved PA in relation to ACPICR guidelines and clinically important increases in CV fitness versus UC alone.Table 1

Integrating evidence-based interventions in cardiac and pulmonary rehabilitation guidelines

Cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs play a crucial role in optimizing the functional capacity and quality of life of individuals with cardiac and respiratory conditions. These programs are guided by evidence-based interventions that have shown effectiveness in improving clinical outcomes and reducing the burden of disease. Patients with chronic diseases like chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) suffer a disproportionate share of healthcare costs, and many see a decline in their physical and mental abilities as a result. Breathlessness is the first sign of both COPD and cardiovascular disease. Rehabilitation programs (RP) symptoms and improving overall health are two of rehabilitation's demonstrated benefits. Management recommendations for COPD and CVD include participation in a PR and CR program. This study looks at similar evidence-based strategies in rehabilitation guidelines that aim to help patients with COPD and CVD feel less short of breath and better able to function physically and mentally. The results of the show that there was agreement in terms of program structure, setting, healthcare provider teams, pre- and post-program patient assessments, and educational content (with some exceptions related to disease-specific content). Evidence-based recommendations for CR and PR differ from rehabilitation guidelines most noticeably in their emphasis on nutritional screening, inspiratory muscle exercise, and psychological evaluations.

Implementation and Importance of Cardiac Rehabilitation for Cardiac Patients in Saudi Arabia: A Systematic Review.

Cardiac rehabilitation (CR) has progressed over the years from a basic monitoring procedure for a safe return to physical activity to a multidisciplinary strategy that emphasizes patient education, specifically for designed exercise training, risk factor management, and the general health of cardiac patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting was used for this systematic review. The studies included were retrieved via an electronic search of Google Scholar and PubMed using the following terms: cardiac rehabilitation (CR), cardiac diseases, coronary artery bypass graft, heart failure, cardiac rehabilitation guidelines, rehabilitation, recovery of function, cardiac rehabilitation importance, cardiac rehabilitation outcomes, physical therapy modalities, secondary prevention, physical medicine, and cardiac rehabilitation phases. Publications (n=24) that included worldwide standards demonstrating the implementation of CR programs in a variety of scenarios were reviewed. These publications are based on well-defined guidelines that represent best practices from several cardiology societies, which use varying valid programs by comparing those guidelines with CR/secondary prevention programs. Several indications have been used in the development of the CR program, with the goal of regaining autonomy and increasing physical, psychological, and social activities. With the Saudi Vision 2030 initiatives for health national transformation programs, there are targets set to ensure the reduction and prevention of noncommunicable diseases and to reduce cardiovascular disease risks by initiating an accredited CR program and guidelines for Saudi Arabia.

Effectiveness of eHealth Interventions on Moderate-to-Vigorous Intensity Physical Activity Among Patients in Cardiac Rehabilitation: Systematic Review and Meta-analysis

Cardiac rehabilitation is a class IA recommendation for patients with cardiovascular diseases. Physical activity is the core component and core competency of a cardiac rehabilitation program. However, many patients with cardiovascular diseases are failing to meet cardiac rehabilitation guidelines that recommend moderate-to-vigorous intensity physical activity. The major objective of this study was to review the evidence of the effectiveness of eHealth interventions in increasing moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. The secondary objective was to examine the effectiveness of eHealth interventions in improving cardiovascular-related outcomes, that is, cardiorespiratory fitness, waist circumference, and systolic blood pressure. A comprehensive search strategy was developed, and a systematic search of 4 electronic databases (PubMed, Web of Science, Embase, and Cochrane Library) was conducted for papers published from the start of the creation of the database until November 27, 2022. Experimental studies reporting on eHealth interventions designed to increase moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation were included. Multiple unblinded reviewers determined the study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Collaboration Tool for randomized controlled trials and the Cochrane Effective Practice and Organization of Care group methods for nonrandomized controlled trials. A random-effect model was used to provide the summary measures of effect (ie, standardized mean difference and 95% CI). All statistical analyses were performed using Stata 17. We screened 3636 studies, but only 29 studies were included in the final review, of which 18 were included in the meta-analysis. The meta-analysis demonstrated that eHealth interventions improved moderate-to-vigorous intensity physical activity (standardized mean difference=0.18, 95% CI 0.07-0.28; P=.001) and vigorous-intensity physical activity (standardized mean difference=0.2, 95% CI 0.00-0.39; P=.048) but did not improve moderate-intensity physical activity (standardized mean difference=0.19, 95% CI -0.12 to 0.51; P=.23). No changes were observed in the cardiovascular-related outcomes. Post hoc subgroup analyses identified that wearable-based, web-based, and communication-based eHealth intervention delivery methods were effective. eHealth interventions are effective at increasing minutes per week of moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. There was no difference in the effectiveness of the major eHealth intervention delivery methods, thereby providing evidence that in the future, health care professionals and researchers can personalize convenient and affordable interventions tailored to patient characteristics and needs to eliminate the inconvenience of visiting center-based cardiac rehabilitation programs during the COVID-19 pandemic and to provide better support for home-based maintenance of cardiac rehabilitation. PROSPERO International Prospective Register of Systematic Reviews CRD42021278029; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278029.

Left atrial dysfunction can independently predict exercise capacity in patients with chronic heart failure who use beta-blockers

BackgroundBeta-blockers are first-line clinical drugs for the treatment of chronic heart failure (CHF). In the guidelines for cardiac rehabilitation, patients with heart failure who do or do not receive beta-blocker therapy have different reference thresholds for maximal oxygen uptake (VO2max). It has been reported that left atrial (LA) strain can be used to predict VO2max in patients with heart failure, which can be used to assess exercise capacity. However, most existing studies included patients who did not receive beta-blocker therapy, which could have a heterogeneous influence on the conclusions. For the vast majority of CHF patients receiving beta-blockers, the exact relationship between LA strain parameters and exercise capacity is unclear.MethodsThis cross-sectional study enrolled 73 patients with CHF who received beta-blockers. All patients underwent a thorough resting echocardiogram and a cardiopulmonary exercise test to obtain VO2max, which was used to reflect exercise capacity.ResultsLA reservoir strain, LA maximum volume index (LAVImax), LA minimum volume index (LAVImin) (P < 0.0001) and LA booster strain (P < 0.01) were all significantly correlated with VO2max, and LA conduit strain was significantly correlated with VO2max (P < 0.05) after adjusting for sex, age, and body mass index. LA reservoir strain, LAVImax, LAVImin (P < 0.001), and LA booster strain (P < 0.05) were significantly correlated with VO2max after adjusting for left ventricular ejection fraction, the ratio of transmitral E velocity to tissue Doppler mitral annulus e′ velocity (E/e′), and tricuspid annular plane systolic excursion. LA reservoir strain with a cutoff value of 24.9% had a sensitivity of 74% and specificity of 63% for the identification of patients with VO2max < 16 mL/kg/min.ConclusionAmong CHF patients receiving beta-blocker therapy, resting LA strain is linearly correlated with exercise capacity. LA reservoir strain is a robust independent predictor of reduced exercise capacity among all resting echocardiography parameters.Clinical Trial registration: This study is a part of the Baduanjin-Eight-Silken-Movement with Self-efficacy Building for Patients with Chronic Heart Failure (BESMILE-HF) trial NCT03180320 (ClinicalTrials.gov, registration date: 08/06/2017).

Cardiac rehabilitation adherence: A multifaceted approach

Cardiac rehabilitation programs are crucial components of cardiac care, aiming to optimize the recovery of patients after cardiac surgery. Within these programs, physiotherapists play a pivotal role in guiding patients through exercise regimens, lifestyle modifications, and the management of pharmacotherapy. Despite their essential role, there remains a limited exploration of the knowledge, attitude, and practice of physiotherapists concerning cardiac rehabilitation program adherence, with a particular focus on the integration of pharmacotherapy, among patients discharged from Indian hospitals after cardiac surgery. This study conducted a structured analysis to comprehensively assess physiotherapists’ knowledge of cardiac rehabilitation guidelines, their attitudes toward patient adherence, and their practices in promoting adherence, taking into consideration the pharmacotherapeutic aspect. Preliminary findings reveal that a substantial proportion of physiotherapists possess an adequate knowledge of cardiac rehabilitation guidelines, emphasizing the significance of exercise, risk factor management, psychosocial support, and medication management. Attitudes toward patient adherence were predominantly positive, reflecting a strong belief in the program’s efficacy in improving patient outcomes. However, it is noteworthy that certain barriers to adherence, including patient motivation, resource limitations, and cultural factors, were identified. In practice, physiotherapists employ diverse strategies, encompassing patient education, exercise supervision, goal setting, and pharmacotherapeutic guidance, to enhance adherence among discharged patients. This review provides valuable insights into the knowledge, attitude, and practice of physiotherapists concerning cardiac rehabilitation program adherence, emphasizing the integration of pharmacotherapy, among patients following cardiac surgery in India. While physiotherapists exhibit robust knowledge and positive attitudes, challenges related to patient motivation and resource constraints warrant dedicated attention. These findings underscore the imperative need for targeted interventions and resource allocation to enhance adherence to cardiac rehabilitation programs, ultimately contributing to improved postoperative outcomes for cardiac surgery patients in India. Furthermore, further research is essential to explore the patient perspective comprehensively and establish a holistic approach to cardiac rehabilitation adherence that seamlessly incorporates pharmacotherapy.

The effectiveness of eHealth interventions on moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants: a systematic review and meta-analysis

Abstract Background Cardiac rehabilitation is a class IA recommendation for patients with cardiovascular diseases. Physical activity is the core component and core competency of cardiac rehabilitation programs. Cardiac rehabilitation guidelines recommend patients achieve at least thirty minutes of moderate-to-vigorous intensity physical activity five or more days per week. However many patients with cardiovascular diseases are failing to meet recommended daily physical activity levels. eHealth interventions may increase moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants. Objectives The objective of this study was to review the evidence of the effectiveness of eHealth interventions to increase moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants. The secondary objective was to examine the effectiveness of eHealth interventions on improving exercise capacity, cardiovascular risk profile and health-related quality of life. Methods A comprehensive search strategy was developed for four electronic databases (PubMed, Web of Science, Embase and The Cochrane Library); through December 16, 2021. All studies reporting on eHealth interventions designed to increase moderate-to-vigorous physical activity among cardiac rehabilitation participants were included. Multiple not-blind reviewers determined study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Collaboration Tool for randomized controlled trials and using the Effective Practice and Organisation of Care Cochrane Review Group for non-randomized controlled trials. Data quality using the Grading of Recommendations Assessment, Development and Evaluation professional guideline development tool. Data were pooled using a random-effects model. All statistical analyses were performed using Stata 17. Results Twenty-one studies were included in the review which fifteen were in the meta-analysis. The meta-analysis demonstrated eHealth interventions improved moderate-to-vigorous physical activity (standard mean difference = 0.17, 95% confidence interval: 0.07, 0.27, P&amp;lt;0.001). No changes were observed in exercise capacity (P=0.09), cardiovascular risk profile (body mass index, P=0.19; waist circumference, P=0.7; systolic blood pressure, P=0.36; total cholesterol, P=0.72; plasma glucose, P=0.41) and health-related quality of life (P=0.12). Conclusions eHealth interventions are effective at increasing minutes/week of moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants. Future high-quality empirical studies are needed to evaluate the effectiveness of eHealth interventions delivered, with these sub-types (wearable devices, online web portal, smart phone application, messaging services and telephone calls) delivered alone or in combination delivered more conducive to moderate-to-high intensity physical activity. Funding Acknowledgement Type of funding sources: None.

Adherence to exercise and fitness following exercise-based outpatient cardiac rehabilitation: a cross-sectional survey for Germany

BackgroundExercise-based cardiac rehabilitation is safe and effective, evidence-based and implemented in national and international cardiac rehabilitation guidelines. Recent data show a decrease in cardiovascular mortality, reduced hospital admissions and an overall improvement in quality of life. To maintain positive effects and to prevent further cardiovascular events a major goal of cardiac rehabilitation is to induce a long-term health behaviour change and the integration of regular physical activity and exercise training in everyday life. The aim of this study is to evaluate the adherence of cardiac patients to exercise-based programs following rehabilitation phase III.MethodsA nationwide online cross-sectional survey was conducted. All outpatient aftercare providers who offer sports rehabilitation programs (heart groups) for cardiac patients in Germany were contacted. The questionnaire comprised 15 questions in five subcategories (general information regarding the outpatient aftercare provider, structure of rehabilitation sport programs, membership structure, content of heart groups, adherence to exercise-based programs).Results560 of 2447 outpatient aftercare providers participated in the survey (response rate: 23%). On average, rehabilitation sport facilities hosted 2 (IQR 2) heart groups per week, and 23 patients (IQR 30) (61% males; 31% females) per facility completed rehabilitation sport prescription in 2018. Almost all providers offer follow-up programs on a self-payer basis after rehabilitation sport prescription ends. Adherence to follow-up programs was at 54% (IQR 65; 55% males and 50% females). With 60% (IQR 71), patients with a statutory health insurance (mainly pensioners) adhere slightly more often to a follow-up program compared to privately insured persons (mainly population with a high income or civil servants) with 50% and significantly more often compared to persons who were insured by the German pension fund (covering working population) with only 9% (IQR 89) adherence.ConclusionAlmost all outpatient aftercare providers offer follow-up programs for cardiac rehabilitation patients but only half of them actually participate. Younger people (working population) do not adhere sufficiently to sport and exercise programs following rehabilitation phase III. This seems critical to address in terms of achieving long-term rehabilitation goals.

The effectiveness of eHealth interventions on moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants: a systematic review and meta-analysis

Abstract Background Cardiac rehabilitation is a class IA recommendation for patients with cardiovascular diseases. Physical activity is the core component and core competency of cardiac rehabilitation programs. Cardiac rehabilitation guidelines recommend patients achieve at least thirty minutes of moderate-to-vigorous intensity physical activity five or more days per week. However many patients with cardiovascular diseases are failing to meet recommended daily physical activity levels. eHealth interventions may increase moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants. Objectives The objective of this study was to review the evidence of the effectiveness of eHealth interventions to increase moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants. The secondary objective was to examine the effectiveness of eHealth interventions on improving exercise capacity, cardiovascular risk profile and health-related quality of life. Methods A comprehensive search strategy was developed for four electronic databases (PubMed, Web of Science, Embase and The Cochrane Library); through December 16, 2021. All studies reporting on eHealth interventions designed to increase moderate-to-vigorous physical activity among cardiac rehabilitation participants were included. Multiple not-blind reviewers determined study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Collaboration Tool for randomized controlled trials and using the Effective Practice and Organisation of Care Cochrane Review Group for non-randomized controlled trials. Data quality using the Grading of Recommendations Assessment, Development and Evaluation professional guideline development tool. Data were pooled using a random-effects model. All statistical analyses were performed using Stata 17. Results Twenty-one studies were included in the review which fifteen were in the meta-analysis. The meta-analysis demonstrated eHealth interventions improved moderate-to-vigorous physical activity (standard mean difference = 0.17, 95% confidence interval: 0.07, 0.27, P&amp;lt;0.001). No changes were observed in exercise capacity (P=0.09), cardiovascular risk profile (body mass index, P=0.19; waist circumference, P=0.7; systolic blood pressure, P=0.36; total cholesterol, P=0.72; plasma glucose, P=0.41) and health-related quality of life (P=0.12). Conclusions eHealth interventions are effective at increasing minutes/week of moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants. Future high-quality empirical studies are needed to evaluate the effectiveness of eHealth interventions delivered, with these sub-types (wearable devices, online web portal, smart phone application, messaging services and telephone calls) delivered alone or in combination delivered more conducive to moderate-to-high intensity physical activity. Funding Acknowledgement Type of funding sources: None.

Cardiac Rehabilitation Program at CUHK Medical Centre

According to World Health Organization (WHO), heart disease remained the leading cause of death globally during 2000-2019[1]. In Hong Kong, heart diseases have been the third leading cause of mortality since 1960s[2]. According to the statistics on the number of hospital discharges and deaths by heart disease group in Hong Kong in 2019, 21578 cases were of heart failure, which accounted for 25% among all other heart diseases[3]. In order to improve the management for heart failure, cardiac rehabilitation is crucial to help patients to improve functional capacity and quality of life, and most importantly to reduce mortality[4]. Guideline for cardiac rehabilitation in CUHK Medical Centre (CUHKMC), the Hong Kong's first non-profit private teaching hospital, has been developed based on evidence-based practices and international guidelines[5]. The experience of cardiac rehabilitation by the CUHKMC physiotherapy team will be shared in this session. According to World Health Organization (WHO), heart disease remained the leading cause of death globally during 2000-2019[1]. In Hong Kong, heart diseases have been the third leading cause of mortality since 1960s[2]. According to the statistics on the number of hospital discharges and deaths by heart disease group in Hong Kong in 2019, 21578 cases were of heart failure, which accounted for 25% among all other heart diseases[3]. In order to improve the management for heart failure, cardiac rehabilitation is crucial to help patients to improve functional capacity and quality of life, and most importantly to reduce mortality[4]. Guideline for cardiac rehabilitation in CUHK Medical Centre (CUHKMC), the Hong Kong's first non-profit private teaching hospital, has been developed based on evidence-based practices and international guidelines[5]. The experience of cardiac rehabilitation by the CUHKMC physiotherapy team will be shared in this session.

Exercise-Based Cardiac Rehabilitation: Secondary Data Analyses of Mortality and Working Capacity in Germany, 2010\u20132017

BackgroundExercise-based cardiac rehabilitation is safe and implemented in international cardiac rehabilitation guidelines. Evidence for long-term health effects is scarce and rare for health care service research.ObjectiveThe aim of this study is to evaluate the effectiveness of exercise-based phase III cardiac rehabilitation programs in improving mortality and working capacity outcomes.MethodsThe present analyses used claims data of the German pension fund from 2010 to 2017. Overall, 54,163 patients with coronary heart disease (ICD10 I20.–I25.) were included and followed up for exercise-based cardiac rehabilitation participation (mean 4.3 ± 1.9 years). All patients were categorized according to participation duration (long: ≥ 90 days, short: < 90 days, no). The effectiveness of exercise-based rehabilitation was analyzed by calculating adjusted hazard ratios for mortality and reduced working capacity in relation to program participation.ResultsOf all the cardiac patients, 57.6% received medical recommendations for exercise-based phase III rehabilitation, and 16.8% participated in this rehabilitation. In total, 1776 (3.3%) patients died during the study period, and 3050 (5.5%) received reduced earning capacity pensions. Mortality risk was nearly doubled for those who did not participate in exercise-based cardiac rehabilitation compared to those who participated for a long duration (HR 1.97, 95% CI 1.60–2.43) and 44% higher compared to a short participation (HR 1.44, 95% CI 1.03–2.01). Furthermore, the risk of reduced working capacity was higher for those who did not participate compared to those who participated for a short duration (HR 1.24, 95% CI 1.00–1.54).ConclusionExercise-based phase III cardiac rehabilitation is independently associated with reduced mortality and reduced loss in working capacity. Strong efforts should be made to increase participation rates to improve cardiac patients care.

Resistance training in heart failure patients: a systematic review and meta-analysis.

Aerobic training (AT) has been the primary mode of exercise training in cardiac rehabilitation. Historically, the reason for the prescription of AT was that it was speculated that although RT may be beneficial for some clinical outcomes, it may have an adverse effect on ventricular structure and function. However, RT has now made its way into current cardiac rehabilitation guidelines, including those directed towards patients with HF, albeit differences exist across institutions and guidelines. A systematic search of PubMed, EMBASE and Cochrane Trials Register on April 30, 2021, was conducted for exercise-based rehabilitation trials in HF. Randomised and controlled trials that reported on resistance training versus usual care or trials that directly compared RT to an AT intervention were included. Resistance training versus controls improves parameters of lower (SMD 0.76 (95%CI 0.26, 1.25, p = 0.003] and upper extremity muscle strength (SMD 0.85 (95%CI 0.35, 1.35), p = 0.0009], both key parameters of physical function throughout the lifespan. Importantly, RT in isolation, versus control, improves VO2peak [MD: 2.64ml/kg/min (95%CI 1.67, 3.60), p < 0.00001] and 6MWD [MD: 49.94m (95%CI 34.59, 65.29), p < 0.00001], without any detrimental effect on left ventricular parameters. Resistance training in HF patients is safe and improves parameters of physical function and quality of life. Where people with HF are unable to, or are not inclined to, partake in aerobic activity, RT alone is appropriate to elicit meaningful benefit.

Evidence based guideline for cardiac rehabilitation in German speaking countries of Europe

An evidence based clinical guideline for cardiac rehabilitation (CR) has been published in collaboration between the German Association of Cardiac Rehabilitation and Prevention of Cardiovascular Diseases (DGPR) and the working groups of prevention and rehabilitation of the cardiac societies of Austria (ÖKG) and Switzerland (CPRS). This guideline has been consented by relevant medical societies in Germany (cardiologists, cardiac surgeans, sports medicine, psychosomatic medicine, rehabilitation scientists). In addition, patients suffering from cardiovascular diseases were involved to emphasize shared decision making in the recommendations. As return to work is a major goal of CR, German pension insurance (DRV-Bund) was associated in the development of this guideline as well. Evidence of CR was evaluated by systematic review of the literature and new meta-analysis performed and published by the guideline committee for patients with coronary artery disease and systolic heart failure. In addition, psychosocial intervention during CR was evaluated by new meta-analysis as well. Other indications for CR and interventions during CR were evaluated by literature review and were consented between collaborating medical societies. This guideline published on 7th of January 2020 in German language (www.awmf.org).

Is patient-centred care for women a priority for policy-makers? Content analysis of government policies

BackgroundConsiderable research shows that women experience gendered disparities in healthcare access and quality. Patient-centred care (PCC) could reduce inequities by addressing the patient’s clinical and personal needs. Healthcare policies can influence service delivery to optimise patient outcomes. This study assessed whether and how government policies recognise and promote PCC for women (PCCW).MethodsWe analysed the content of English-language policies published in Canada from 2010 to 2018 on depression and cardiac rehabilitation – conditions featuring known gendered inequities – that were identified on government websites. We extracted data and used summary statistics to enumerate mentions of PCC and women’s health.ResultsWe included 30 policies (20 depression, 10 cardiac rehabilitation). Of those, 20 (66.7%) included any content related to PCC (median 1.0, range 0.0 to 5.0), most often exchanging information (14, 46.7%) and making decisions (13, 43.3%). Less frequent domains were enabling self-management (8, 26.7%), addressing emotions (6, 20.0%) and fostering the relationship (4, 13.3%). No policies included content for the domain of managing uncertainty. A higher proportion of cardiac rehabilitation guidelines included PCC content. Among the 30 policies, 7 (23.3%) included content related to at least one women’s health domain (median 0.0, range 0.0 to 3.0). Most frequently included were social determinants of health (4, 13.3%). Fewer policies mentioned any issues to consider for women (2, 28.6%), issues specific to subgroups of women (2, 28.6%) or distinguished care for women from men (2, 28.6%). No policies included mention of abuse or violence, or discrimination or stigma. The policies largely pertained to depression. Despite mention of PCC or women’s health, policies offered brief, vague guidance on how to achieve PCCW; for example, “Patients value being involved in decision-making” and “Women want care that is collaborative, woman- and family-centered, and culturally sensitive.”ConclusionsDespite considerable evidence of need and international recommendations, most policies failed to recognise gendered disparities or promote PCC as a mitigating strategy. These identified gaps represent opportunities by which government policies could be developed or strengthened to support PCCW. Future research should investigate complementary strategies such as equipping policy-makers with the evidence and tools required to develop PCCW-informed policies.

How do and could clinical guidelines support patient-centred care for women: Content analysis of guidelines.

Patient-centred care (PCC) improves multiple patient and health system outcomes. However, many patients do not experience PCC, particularly women, who are faced with disparities in care and outcomes globally. The purpose of this study was to identify if and how guidelines address PCC for women (PCCW). We searched MEDLINE, EMBASE, National Guideline Clearing House, and guideline developer websites for publicly-available, English-language guidelines on depression and cardiac rehabilitation, conditions with known gendered inequities. We used summary statistics to report guideline characteristics, clinical topic, mention of PCC according to McCormack's framework, and mention of women's health considerations. We appraised guideline quality with the AGREE II instrument. A total of 27 guidelines (18 depression, 9 cardiac rehabilitation) were included. All 27 guidelines mentioned at least one PCC domain (median 3, range 1 to 6), most frequently exchanging information (20, 74.1%), making decisions (20, 74.1%), and enabling patient self-management (21, 77.8%). No guidelines fully addressed PCC: 9 (50.0%) of 18 depression guidelines and 3 (33.3%) of 9 cardiac rehabilitation guidelines addressed 4 or more PCC domains. Even when addressed, guidance was minimal and vague. Among 14 (51.9%) guidelines that mentioned women's health, most referred to social determinants of health; none offered guidance on how to support women impacted by these factors, engage women, or tailor care for women. These findings pertained even to women-specific guidelines. Reported use or type of guideline development process/system did not appear to be linked with PCCW content. Based on quality appraisal with AGREE II, guidelines were either not recommended or recommended with modifications. In particular, the stakeholder involvement AGREE II domain was least addressed, but guidelines that scored higher for stakeholder involvement also appeared to better address PCCW. This research identified opportunities to generate guidelines that achieve PCCW. Strategies include employing a PCC framework, considering gender issues, engaging women on guideline-writing panels, and including patient-oriented tools in guidelines. Primary research is needed to establish what constitutes PCCW.

Systematic review of cardiac rehabilitation guidelines: Quality and scope.

Cardiac rehabilitation is a comprehensive model of secondary prevention proven to reduce mortality and morbidity. The World Health Organization is developing a Package of Rehabilitation Interventions for implementation by ministries of health as part of universal healthcare across the continuum. Through a systematic review, we sought to identify the best-quality cardiac rehabilitation guidelines, and extract their recommendations for implementation by member states. A systematic search was undertaken of academic databases and guideline repositories, among other sources, through to April 2019, for English-language cardiac rehabilitation guidelines from the last 10 years, free from conflicts, and with strength of recommendations. Two authors independently considered all citations. Potentially eligible guidelines were rated for quality using the Appraisal of Guidelines for Research and Evaluation tool, and for other characteristics such as being multi-professional, comprehensive and international in perspective; the latter criteria were used to inform selection of 3-5 guidelines meeting inclusion criteria. Equity considerations were also extracted. Altogether, 2076 unique citations were identified. Thirteen passed title and abstract screening, with six guidelines potentially eligible for inclusion in the Package of Rehabilitation Interventions and rated for quality; for two guidelines the Appraisal of Guidelines for Research and Evaluation tool ratings did not meet World Health Organization minimums. Of the four eligible guidelines, three were selected: the International Council of Cardiovascular Prevention and Rehabilitation (2016), National Institute for Health and Care Excellence (#172; 2013) and Scottish Intercollegiate Guideline Network (#150; 2017). Extracted recommendations were comprehensive, but psychosocial recommendations were contradictory and diet recommendations were inconsistent. A development group of the World Health Organization will review and refine the recommendations which will then undergo peer review, before open source dissemination for implementation.

High sedentary behaviour and low physical activity levels at 12 months after cardiac rehabilitation: A prospective cohort study.

International cardiac rehabilitation guidelines recommend that participants meet public health physical activity guidelines. Few studies have objectively measured how much time cardiac rehabilitation participants spend in physical activity and sedentary behaviour, particularly over the long term. The aim of this study was to objectively assess physical activity and sedentary behaviour of cardiac rehabilitation participants over 12 months and determine whether they met the public health physical activity and sedentary behaviour guidelines. Cardiac rehabilitation participants with coronary heart disease were recruited in a prospective cohort study (n=72). Participants wore an ActiGraph ActiSleep accelerometer for 7 consecutive days at baseline, 6 weeks, and 6 and 12 months to assess daily minutes of moderate-to-vigorous physical activity and sedentary behaviour (<100 counts/min). Other outcomes collected were self-reported physical activity and sedentary behaviour, body mass index, waist-to-hip ratio, lipid profile, blood glucose level, quality of life, exercise capacity, anxiety and depression. By intent-to-treat analysis, during the 6-week cardiac rehabilitation program, participants increased their light physical activity (P<0.01), which was maintained up to 12 months. Moderate-to-vigorous physical activity and sedentary behaviour did not change during the 6-week cardiac rehabilitation program but did improve over 6 months (sedentary behaviour decreased [P<0.001], moderate-to-vigorous physical activity increased [P<0.05]), which was maintained up to 1 year. Completion of moderate-to-vigorous physical activity in 10-min bouts did not change over 12 months, nor did the proportion of participants meeting physical activity guidelines (15-21%). Sedentary behaviour remained high throughout (11 hr/day). Most cardiac rehabilitation participants did not meet the physical activity guidelines during and after a 6-week program up to 12 months. Reducing sedentary behaviour may be a more achievable first-line strategy for cardiac patients, moving participants along the energy expenditure continuum, aiming to increase their physical activity levels over the medium to long term. Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea.

BackgroundThough clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.MethodsThis study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors—primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.ResultsCR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR.ConclusionIndividualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.