Hybrid Cardiac Rehabilitation Research Articles

The iATTEND Trial: A Trial Comparing Hybrid Versus Standard Cardiac Rehabilitation

The improving ATTENDance (iATTEND) to cardiac rehabilitation (CR) trial tested the hypotheses that hybrid cardiac rehabilitation (HYCR = combination of virtual and in-facility CR sessions) would result in greater attendance compared to traditional, facility-based only CR (FBCR) and yield equivalent improvements in exercise capacity and health status. Patients were randomized to HYCR (n=142) or FBCR (n=140), stratified by sex and race. Attendance was assessed as number of CR sessions completed within 6 mo (primary end-point) and % patients completing 36 CR sessions. Other end-points (tested for equivalency) included exercise capacity and self-reported health status. HYCR patients completed 1 to 12 sessions in-facility, with the balance completed virtually using synchronized, two-way audiovisual technology. Neither total number of CR sessions completed within 6 mo (29±12 vs 28±12 visits, adjusted P= 0.94) nor % of patients completing 36 sessions (59±4% vs 51±4%, adjusted P=0.32) were significantly different between HYCR and FBCR, respectively. The between group changes for exercise capacity (peak oxygen uptake, 6-minute walk distance) and health status were equivalent. Regarding safety, no sessions required physician involvement, there was 1 major adverse event after a virtual session, and no falls requiring medical attention. In conclusion, although we rejected our primary hypothesis that attendance would be greater with HYCR versus FBCR, we showed that FBCR and HYCR resulted in similar patient attendance patterns and equivalent improvements in exercise capacity and health status. HYCR that incorporates virtually supervised exercise should be considered an acceptable alternative to FBCR.NCT identifier: 03646760; The Improving ATTENDance to Cardiac Rehabilitation Trial - Full Text View - ClinicalTrials.gov; https://classic.clinicaltrials.gov/ct2/show/NCT03646760

Cardiac Rehabilitation Using the Family-Centered Empowerment Model is Effective in Improving Long-term Mortality in Patients with Myocardial Infarction: A 10-year Follow-Up Randomized Clinical Trial.

Cardiac rehabilitation (CR) play a critical role in reducing the risk of future cardiovascular events and enhancing the quality of life for individuals who have survived a heart attack. To assess the mortality rates and stability of the effects in myocardial infarction (MI) survivors after implementing a Family-Centered Empowerment Model (FCEM)-focused hybrid cardiac rehabilitation program. This double-blind randomized controlled clinical trial, conducted at Shariati Hospital, an academic teaching hospital in Tehran, Iran (2012-2023), involved 70 MI patients and their families. Participants were randomly assigned to an FCEM intervention group or standard CR control group. The intervention commenced after the MI patient's safe discharge from the CCU and continued for the entire 10-year follow-up period. Various questionnaires were utilized to collect data on mortality rates and health-related quality of life (HRQoL). The 10-year follow-up period revealed lower mortality rates in the intervention group (5.7%, 11.4%, and 17.1% at 5, 7, and 10 years, respectively) compared to the control group (20%, 37.1%, and 48.9%). After adjusting for age, gender, and BMI, the control group had a four times higher mortality risk (HR: 4.346, 95% CI 1.671-7.307, P = 0.003). The FCEM-focused program demonstrated a significant and sustained positive impact on participants' quality of life for 48 months, with greater improvement compared to the control group. This study highlights the effectiveness of FCEM-based hybrid CR programs in enhancing long-term patient outcomes and reducing mortality rates among MI survivors. Further research is needed to explore the potential benefits in larger samples and diverse populations. This study (Identifier: NCT02402582) was registered in the ClinicalTrials.gov on 03/30/2015.

Hybrid Cardiac Rehabilitation Program in a Low-Resource Setting

While effective, cardiovascular rehabilitation (CR) as traditionally delivered is not well implemented in lower-resource settings. To test the noninferiority of hybrid CR compared with traditional CR in terms of cardiovascular events. This pragmatic, multicenter, parallel arm, open-label randomized clinical trial (the Hybrid Cardiac Rehabilitation Trial [HYCARET]) with blinded outcome assessment was conducted at 6 referral centers in Chile. Adults aged 18 years or older who had a cardiovascular event or procedure, no contraindications to exercise, and access to a mobile telephone were eligible and recruited between April 1, 2019, and March 15, 2020, with follow-up until July 29, 2021. Participants were randomized 1:1 in permuted blocks to the experimental arm, which received 10 center-based supervised exercise sessions plus counseling in 4 to 6 weeks and then were supported at home via telephone calls and text messages through weeks 8 to 12, or the control arm, which received the standard CR of 18 to 22 sessions with exercises and education in 8 to 12 weeks. The primary outcome was cardiovascular events or mortality. Secondary outcomes were quality of life, return to work, and lifestyle behaviors measured with validated questionnaires; muscle strength and functional capacity, measured through physical tests; and program adherence and exercise-related adverse events, assessed using checklists. A total of 191 participants were included (mean [SD] age, 58.74 [9.80] years; 145 [75.92%] male); 93 were assigned to hybrid CR and 98 to standard CR. At 1 year, events had occurred in 5 unique participants in the hybrid CR group (5.38%) and 9 in the standard CR group (9.18%). In the intention-to-treat analysis, the hybrid CR group had 3.80% (95% CI, -11.13% to 3.52%) fewer cardiovascular events than the standard CR group, and relative risk was 0.59 (95% CI, 0.20-1.68) for the primary outcome. In the per-protocol analysis at different levels of adherence to the intervention, all 95% CIs crossed the noninferiority boundary (eg, 20% adherence: absolute risk difference, -0.35% [95% CI, -7.56% to 6.85%]; 80% adherence: absolute risk difference, 3.30% [95% CI, -3.70% to 10.31%]). No between-group differences were found for secondary outcomes except adherence to supervised CR sessions (79.14% [736 of 930 supervised sessions] in the hybrid CR group vs 61.46% [1201 of 1954 sessions] in the standard CR group). The results suggest that a hybrid CR program is noninferior to standard center-based CR in a low-resource setting, primarily in terms of recurrent cardiovascular events and potentially in terms of intermediate outcomes. Hybrid CR may induce superior adherence to supervised exercise. Clinical factors and patient preferences should inform CR model allocation. ClinicalTrials.gov Identifier: NCT03881150.

Abstract 17571: Lessons From Launching a Digital Health Trial for Hybrid Cardiac Rehabilitation

BACKGROUND: Despite the well-established benefits of cardiac rehabilitation (CR) for secondary prevention of cardiovascular disease, participation remains low due to limited supply and access barriers. We built a hybrid CR program that combines in-person and home-based CR (with smartphone app (Corrie Health), smartwatch, Bluetooth blood pressure monitor, and health coaching delivered over 12 weeks). We assessed this novel CR program in a pilot study at Johns Hopkins Hospital and applied the lessons learned to launch a randomized controlled trial (mTECH REHAB; NCT05238103) of hybrid versus traditional CR. METHODS: We examined pilot data from Nov 2022 to Feb 2023 for electronic health record (EHR) screening, bedside enrollment, technology onboarding, access to CR, and weekly health coaching. We identified barriers in the enrollment process which we then used to guide trial design and team organization. RESULTS: EHR screening yielded 1,270 candidates, among which 209 (16.5%) were eligible following chart review. Our team approached 106 (50.7%) at bedside and 20 (9.6%) were enrolled into the pilot study. Ten (50.0%) were lost to follow up, with reasons of: loss of interest (3), post-procedural complication (3), frailty requiring acute CR (1), no insurance coverage (1), follow up in external CR (1), and technology challenges (1). These findings informed trial design as follows: 1) pre-specified filters for cardiovascular procedures/surgeries were added to EHR screening; 2) remote enrollment pathway was added; 3) a 2-week run-in period was added to verify insurance and continued interest following hospital discharge; and 4) standardized workflows and specialized teams were developed for patient recruitment, technology onboarding, and health coaching. The mTECH REHAB trial was launched in Apr 2023. In the first 9 weeks, 851 patients were screened, 157 (18.4%) were eligible, 148 (94.2%) were able to be reached at bedside or via telephone, 41 (27.7%; 16 bedside, 25 remote) were enrolled, and 5 (12.2%) were lost to early follow up because of: loss of interest (3), post-procedural complication (1), and patient relocation (1). CONCLUSIONS: A pilot study can inform and improve the enrollment process in a multi-component digital health trial.

Barriers to cardiac rehabilitation and patient perceptions on the usage of technologies in cardiac rehabilitation: Across-sectional study.

The study aimed to identify factors associated with participation in Phase II cardiac rehabilitation and to assess patient perceptions towards the usage of technologies in cardiac rehabilitation. Despite efforts to promote utilisation of cardiac rehabilitation (CR), participation among patients remains unsatisfactory. Little is known of patient decision to participate Phase II CR in a multi-ethnic country. A cross-sectional study design. A consecutive sampling of 240 patients with coronary heart disease completed Coronary Artery Disease Education Questionnaire (CADE-Q) II, Hospital Anxiety and Depression Scale (HADS), Multidimensional Scale of Perceived Social Support (MSPSS) and Cardiac Rehabilitation Barriers Scale (CRBS). Seventy per cent of patients (mean age 60.5 [SD = 10.6] years, 80.8% male) participated in phase II cardiac rehabilitation. Self-driving to cardiac rehabilitation centres, higher barriers in perceived need/health care and logistical factors were significantly associated with decreased odds of participation. Patients with more barriers from comorbidities/functional status, higher perceived social support from friends, and anxiety were more likely to participate. Chinese and Indians were less likely to participate when compared with Malays. More than 80% of patients used both home and mobile broadband internet, and 72.9% of them would accept the usage of technologies, especially educational videos, instant messenger, and video calls to partially replace the face-to-face, centre-based cardiac rehabilitation approach. Several barriers were associated with non-participation in phase II cardiac rehabilitation. With the high perceived acceptance of technology usage in cardiac rehabilitation, home-based and hybrid cardiac rehabilitation may represent potential solutions to improve participation. By addressing the barriers to cardiac rehabilitation, patients are more likely to be ready to adopt health behaviour changes and adhere to the cardiac rehabilitation programme. The high perceived acceptance of using technologies in cardiac rehabilitation may provide insights into new delivery models that can improve and overcome barriers to participation.

Applying User-Centered Design and Implementation Science to the Early-Stage Development of a Telehealth-Enhanced Hybrid Cardiac Rehabilitation Program: Quality Improvement Study.

Cardiac rehabilitation (CR) is an evidence-based intervention that improves event-free survival in patients with cardiac conditions, yet <27% of all eligible patients use CR in the United States. CR is traditionally delivered in clinic-based settings where implementation barriers abound. Innovative nontraditional program designs and strategies are needed to support widespread CR uptake. This study aimed to demonstrate how user-centered design (UCD) and implementation science (IS) principles and methods can be integrated into the early-stage development of nontraditional CR interventions. As part of a NewYork-Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we combined UCD and IS principles and methods to design a novel home- and clinic-based telehealth-enhanced hybrid CR (THCR) program. We co-designed this program with multilevel stakeholders using an iterative 3-step UCD process to identify user and contextual barriers and facilitators to CR uptake (using semistructured interviews and contextual inquiry [step 1]), design an intervention prototype that targets contextual and user factors and emulates the evidence-based practice (through design workshops and journey mapping [step 2]), and review and refine the prototype (according to real-world usability testing and feedback [step 3]). The UCD process was informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research. At step 1, we conducted semistructured interviews with 9 provider- and system-level stakeholders (female: n=6, 67%) at 3 geographically diverse academic medical centers, which revealed behavioral (eg, self-efficacy and knowledge) and contextual (eg, social distancing guidelines, physical space, staffing, and reimbursement) barriers to uptake; hybrid delivery was a key facilitator. Step 2 involved conducting 20 design workshops and 3 journey-mapping sessions with multidisciplinary NYPH stakeholders (eg, digital health team, CR clinicians, and creative director) where we identified key design elements (eg, mix of clinic- and home-based CR and synchronous remote patient monitoring), yielding an initial THCR prototype that leveraged NYPH's telehealth infrastructure. At step 3, we conducted usability testing with 2 CR clinicians (both female) administering home-based sessions to 3 CR patients (female: n=1, 33%), which revealed usability themes (eg, ease of using remote patient monitoring devices or a telehealth platform, technology disruptions, and confidence in using the telehealth platform to safely monitor patients) and design solutions (eg, onboarding sessions, safety surveys, and fully supervised remote sessions) to be included in the final THCR prototype. Combining UCD and IS methods while engaging multidisciplinary stakeholders in an iterative process yielded a theory-informed THCR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process and guidance for incorporating UCD and IS principles and methods into the early-stage development of a nontraditional CR intervention. The feasibility, acceptability, appropriateness, and usability of the final THCR prototype is being evaluated in an ongoing study.

A Theory-Based, Technology-Assisted Intervention in a Hybrid Cardiac Rehabilitation Program for Patients with Coronary Heart Disease: A Feasibility Study

To assess the feasibility of a technology-assisted intervention in a hybrid cardiac rehabilitation program among patients with coronary heart disease. This study was a two-armparallel randomized controlled trial. Twenty-eight patients with coronary heart disease were randomly assigned to either the intervention group, receiving a 12-week technology-assisted intervention (n=14), or the control group (n=14), receiving usual care. Guided by the Health Belief Model, the intervention group received three center-based, supervised exercise training sessions, a fitness watch that served as a cue to action, six educational videos, and a weekly video call. The Self-efficacy for Exercise, exercise capacity, and Health Promoting Lifestyle Profile II were assessed at baseline and immediately post-intervention (12-weeks). Among the 28 patients who participated in this study, 85.7% completed the program, with a relatively low attrition rate (14.3%). The number of exercise training sessions accomplished by the participants in the intervention group was 51.27±19.41 out of 60 sessions (85.5%) compared to 36.46±23.05 (60.8%) in the control group. No cardiac adverse events or hospitalizations were reported throughout the study. Participants in the intervention group showed greater improvement in health-promoting behaviors when compared with the control group at 12weeks. Within-group effects demonstrated improvement in exercise self-efficacy and exercise capacity among participants in the intervention group. A participant satisfaction survey conducted immediately post-intervention revealed that participants were "very satisfied" (23.1%) and "satisfied" (76.9%) with the technology-assisted intervention. The findings demonstrated that technology-assisted intervention in a hybrid cardiac rehabilitation program was feasible and suggested to be beneficial in improvingexercise self-efficacy, exercise capacity, and health promoting behavior among patients with coronary heart disease. A full-scale study is needed to determine its effectiveness in the long term. ClinicalTrials.gov NCT04862351. https://clinicaltrials.gov/ct2/show/NCT04862351.

Is hybrid cardiac rehabilitation superior to traditional cardiac rehabilitation?

Background The current COVID-19 pandemic imposes changes in the management of cardiac pathologies. Cardiac rehabilitation needs to define new protocols to welcome patients back. In connection with the observations of the European Association of Preventive Cardiology, the choice of cardiac tele-rehabilitation appeared to be unavoidable. Aim This retrospective research based on data from the Program for the Medicalisation of Information Systems (PMSI) and the electronic medical record analyzes the effect of Hybrid Cardiac Rehabilitation. Methods One hundred and ninety-two patients (29 females and 163 males) with an average of 56.9 years old (±10.3) were able to benefit from a Hybrid Cardiac Rehabilitation program. The data concerning the Stress Test and the Wall Squat Test were collected. Results We have noticed that patients had improved their cardiorespiratory capacity on the initial and final Stress Test 6.6 (±1.8) MET to 8.2 (±1.9) MET (p < 0.0001). We also found that patients improved lower limb muscle strength 75.1 (±44.8) seconds to 105.7 (±49.7) seconds (p < 0.0001). Conclusions Hybrid Cardiac Rehabilitation protocols can be set up in this pandemic situation. The programme effectiveness appears to be comparable to the traditional model. However, additional studies are needed to determine the effectiveness of this programme in the long term.

Enrollment Barriers in Hybrid Cardiac Rehabilitation

ABSTRACT Background Hybrid (i.e., combined center-based with home/community-based) cardiac rehabilitation (HYCR) programs using telehealth have gained interest to improve access to care. The purpose of this analysis is to describe reasons patients were either ineligible to participate or declined enrollment in a trial that involved HYCR. Methods This is a sub-study of the improving ATTENDance to cardiac rehabilitation (iATTEND) trial, currently randomizing subjects to traditional center-based cardiac rehabilitation (CBCR) versus HYCR. This analysis used screening data from the first 23 months of this trial. Data from patients excluded or who declined enrollment was used to review enrollment barriers. Results Between March 2019 and January 2021, 3,708 patients were referred to cardiac rehabilitation. Of these, 887 (24%) attended a cardiac rehabilitation orientation at a site in the city of Detroit or at one of 2 suburban locations. Among these, 63% (554/887) were ineligible per study criteria, 3% (29/887) lacked access to a smart device, and 14% (128/887) lacked access to exercise equipment. Overall, 23% (205/887) of referred patients declined participation in the trial, and of these, 12% (103/887) declined because they preferred center-based cardiac rehabilitation over HYCR. Among the 157 patients unable to participate due to lack of a smart phone or exercise equipment, the percentage was not significantly different (P = 0.204) between those attending cardiac rehabilitation orientation within Detroit and the suburban locations. Conclusion Lack of access to a smart device did not represent a meaningful barrier (3%) to participate in a trial involving HYCR. Access to exercise equipment represented a potential barrier (14%).

Effect of hybrid cardiac rehabilitation using a smart device: a randomized controlled trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korea National Institute of Health. Background Although cardiac rehabilitation (CR) has been proven to be effective in secondary prevention for patients with cardiovascular diseases, the actual participation in CR is still unsatisfactory. Because home-based CR provides better access to patients and is as effective as center-based CR, it is considered a promising alternative that can overcome various barriers impeding CR implementation. However, home-based CR has not garnered enough attention due to a lack of proper communication, concerns about unexpected adverse events caused by non-monitored exercises, and the absence of supporting insurance services. Purpose We utilized a smart ring with a photoplethysmography to monitor heart rate. Recorded data were stored on a website where the researchers could remotely access and check the uploaded measurements. This study aims to identify the clinical effects of hybrid CR by weekly telephone counseling based on the patients' actual physical activities obtained from the device. Methods Cardiovascular disease patients were educated on concrete methods of home-based CR, including the type, intensity, and time of exercise as well as precautions. They were also instructed to wear the device during exercise. The patients were randomly enrolled into two groups: intervention and observation groups. The patients of the intervention group were given weekly telephone counseling and encouraged to maintain optimal physical activities. In the observational group, only exercise data were recorded without additional interventions. Before and after three months of training, the results of the symptom-limited cardiopulmonary exercise test between the two groups were compared. Results A total of sixty-four patients were enrolled (thirty-two in each group). The subjects were 59.8 ± 9.0 years old and fifty-three (82.8%) were male. There were no significant differences in diagnosis and results of baseline symptom-limited cardiopulmonary exercise test between the two groups (Table 1). After three months of training, peak oxygen consumption was significantly improved in both groups. However, the improvement was greater in the intervention group compared to the observation group (Table 2). Conclusion Home-based CR using a smart device was effective in improving oxygen consumption. For greater effectiveness, proper monitoring and timely counseling by medical experts are likely to be necessary.

Psychological well-being and illness perception in hypertrophic cardiomyopathy patients undergoing hybrid cardiac rehabilitation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Cardiology. Background Hypertrophic cardiomyopathy (HCM) is a congenital heart disease influencing patients' physical capacity and quality of life and increasing the risk of sudden cardiac death. For many years patients with HCM were advised to avoid physical activity and intense psychological stress. Current studies suggest that cardiac rehabilitation (CR) could be safe and beneficial for somatic and psychological status in HCM patients. Method In the RCT study assessing the efficacy of hybrid CR patients with HCM from rehabilitation (R) and control (C) groups were asked to fill the questionnaires regarding their psychosocial well-being (GHQ-28) and illness perception (Brief IPQ) at every stage of the study (baseline, 3, 6, 9, and 15 months). Results There was a significant improvement in the overall distress level in the R group (p=0,003), but not in the C group (p=0.559). There were no significant differences in the illness perception (p=0.200 for the R group and p=0.090 for the C group), although the R group showed significant short-term improvement after three months (p=0.032). Conclusions Cardiac rehabilitation can enhance the psychological well-being of HCM patients and their adjustment to illness. However, significant improvement is observed only in the first months after the rehabilitation.

Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program

The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies...

Evaluation of counselling materials for hybrid cardiac rehabilitation in a low-resource setting: Perceptions of patients and providers

ObjectiveThis study evaluated the usefulness of a booklet as support material for counseling focused on self-efficacy and therapist interaction in the course of counseling in a hybrid CR program (i.e., supervised and unsupervised sessions) developed for low-resource settings. MethodsCounseling material was developed by a multidisciplinary team, with patient input. Using multi-methods, first input from patients from six centers in Chile was sought through a telephone survey (cross-sectional). Second, input from physiotherapists delivering the intervention at all centres was solicited qualitatively through a focus group on Zoom. Content analysis was performed using a deductive-thematic approach. ResultsSeventy-one patients were included. All (100 %) participants responded that the materials were easy to understand, contained suggestions applicable to daily life, captured their attention and was useful for future questions. The booklet overall was rated 6.7 ± 0.6/7 %, and 98.2 % were satisfied with the counselling. Overall themes from the six deliverers related to the CR intervention (e.g., well manualized protocols for counselling), the deliverer (e.g., expertise to deliver) and patients (e.g., found information useful). ConclusionThe usefulness of the counseling together with the supporting booklet was established by patients and delivering professionals. Practice implicationsThus, with some final refinement, this resource can be disseminated for use by other Spanish CR programs.

Hybrid and Traditional Cardiac Rehabilitation in a Rural Area: A RETROSPECTIVE STUDY.

Cardiac rehabilitation is a prescribed exercise intervention that reduces cardiovascular mortality, secondary events, and hospitalizations. Hybrid cardiac rehabilitation (HBCR) is an alternative method that overcomes barriers to participation, such as travel distance and transportation issues. To date, comparisons of HBCR and traditional cardiac rehabilitation (TCR) are limited to randomized controlled trials, which may influence outcomes due to supervision associated with clinical research. Coincidental to the COVID-19 pandemic, we investigated HBCR effectiveness (peak metabolic equivalents [peak METs]), resting heart rate (RHR), resting systolic (SBP) and diastolic blood pressure (DBP), body mass index (BMI), and depression outcomes (Patient Health Questionnaire-9 [PHQ-9]). Via retrospective analysis, TCR and HBCR were examined during the COVID-19 pandemic (October 1, 2020, and March 31, 2022). Key dependent variables were quantified at baseline (pre) and discharge (post). Completion was determined by participation in 18 monitored TCR exercise sessions and four monitored HBCR exercise sessions. Peak METs increased at post-TCR and HBCR ( P < .001); however, TCR resulted in greater improvements ( P = .034). The PHQ-9 scores were decreased in all groups ( P < .001), while post-SBP and BMI did not improve (SBP: P = .185, BMI: P = .355). Post-DBP and RHR increased (DBP: P = .003, RHR: P = .032), although associations between intervention and program completion were not observed ( P = .172). Peak METs and depression metric outcomes (PHQ-9) improved with TCR and HBCR. Improvements in exercise capacity were greater with TCR; however, HBCR did not produce inferior results by comparison, an outcome that may have been essential during the first 18 mo of the COVID-19 pandemic.

A hybrid exercise-based cardiac rehabilitation program is an effective strategy to improve muscle strength and functional exercise capacity in adults and older people with coronary artery disease.

Coronary heart disease is the most common cause of death worldwide. Standard cardiac rehabilitation (face-to-face sessions) has shown benefits in increasing muscle strength and functional exercise capacity in adults and older people. However, it is unknown whether hybrid cardiac rehabilitation (a first face-to-face phase + a second remote monitoring phase) will have similar benefits in adults versus older subjects. The aim of this study was to compare the effects of a hybrid exercise-based cardiac rehabilitation program on muscle strength and functional exercise capacity in “adult” versus “older” people with coronary artery disease. We hypothesized that a hybrid exercise-based cardiac rehabilitation program would improve muscle strength and functional exercise capacity, but the impact would be smaller in the older group than the adult individuals. This study is part of a larger project (The Hybrid Cardiac Rehabilitation Trial-HYCARET). We subjected 22 adult (<60 y) females and males (ADULT; n = 5/17 (f/m); 52 ± 5 y; 28.9 ± 3.4 kg·m-2) and 20 older (≥60 y) females and males (OLDER; n = 6/14 (f/m); 66 ± 4 y; 27.4 ± 3.9 kg·m-2) with coronary artery disease to 12 weeks of hybrid exercise-based cardiac rehabilitation program. Prior to and after 12 weeks of a hybrid exercise-based cardiac rehabilitation program, grip strength (handgrip), leg strength (chair stand test), and functional exercise capacity (6-minute walk test, 6MWT) were assessed. The hybrid exercise-based cardiac rehabilitation program resulted in a 9.4 ± 14.6% and a 6.2 ± 12.1% grip strength increase, a 14.4 ± 39.4% and a 28.9 ± 48.1% legs strength increase, and a 14.6 ± 26.4% and a 6.8 ± 14.0% functional exercise capacity improvement in ADULT and OLDER, respectively (p < 0.05) with no differences between groups. In conclusion, a hybrid exercise-based cardiac rehabilitation program could increase muscle strength and improve functional exercise capacity in adults and older people with coronary artery disease. More future studies comparing effectiveness among these age groups are needed to strengthen this conclusion.

ANDY’S STORY: HYBRID CARDIAC REHABILITATION USING A DIGITAL HEALTH PLATFORM

BackgroundCardiac rehabilitation (CR) is a cornerstone of secondary cardiovascular prevention but remains underutilized, especially among underrepresented minorities. We developed a 12-week hybrid CR program to improve equitable CR access and participation. The program utilizes an evidenced-based digital health platform, Corrie, that consists of a smartphone app, smartwatch, blood pressure monitor, clinician dashboard, and virtual health coaching. We share a patient’s journey to provide insight into his experience of this novel hybrid CR program.NarrativeAndy is a 63 year-old Black man, retired airline industry worker, with hyperlipidemia, hypertension, and former tobacco smoking. He presented to the Johns Hopkins Hospital due to ongoing chest pain and was found to have obstructive coronary artery disease requiring percutaneous coronary intervention to the left anterior descending artery. Andy was identified as a candidate for hybrid CR via an electronic health record automated report. After receiving attending approval, a Corrie patient navigator met Andy at the bedside to discuss the program and set up the technology. He received in-person tutorials supplemented by video instructions and weekly check-in calls. Andy ranked himself as “low digital health literacy,” but through onboarding and coaching, he tracked his medications with 100% adherence, vitals, and viewed educational materials. After completing two in-person CR sessions for safety, he tracked exercises from home, following goals he discussed with his coach. Through the program, Andy increased his exercise capacity and implemented healthy lifestyle habits that he plans to continue into the maintenance phase of CR, such as riding a bicycle he recently rebuilt.ConclusionAndy's Journey on Hybrid Cardiac Rehabilitation ProgramView Large Image Figure ViewerDownload Hi-res image Download (PPT) BackgroundCardiac rehabilitation (CR) is a cornerstone of secondary cardiovascular prevention but remains underutilized, especially among underrepresented minorities. We developed a 12-week hybrid CR program to improve equitable CR access and participation. The program utilizes an evidenced-based digital health platform, Corrie, that consists of a smartphone app, smartwatch, blood pressure monitor, clinician dashboard, and virtual health coaching. We share a patient’s journey to provide insight into his experience of this novel hybrid CR program. Cardiac rehabilitation (CR) is a cornerstone of secondary cardiovascular prevention but remains underutilized, especially among underrepresented minorities. We developed a 12-week hybrid CR program to improve equitable CR access and participation. The program utilizes an evidenced-based digital health platform, Corrie, that consists of a smartphone app, smartwatch, blood pressure monitor, clinician dashboard, and virtual health coaching. We share a patient’s journey to provide insight into his experience of this novel hybrid CR program. NarrativeAndy is a 63 year-old Black man, retired airline industry worker, with hyperlipidemia, hypertension, and former tobacco smoking. He presented to the Johns Hopkins Hospital due to ongoing chest pain and was found to have obstructive coronary artery disease requiring percutaneous coronary intervention to the left anterior descending artery. Andy was identified as a candidate for hybrid CR via an electronic health record automated report. After receiving attending approval, a Corrie patient navigator met Andy at the bedside to discuss the program and set up the technology. He received in-person tutorials supplemented by video instructions and weekly check-in calls. Andy ranked himself as “low digital health literacy,” but through onboarding and coaching, he tracked his medications with 100% adherence, vitals, and viewed educational materials. After completing two in-person CR sessions for safety, he tracked exercises from home, following goals he discussed with his coach. Through the program, Andy increased his exercise capacity and implemented healthy lifestyle habits that he plans to continue into the maintenance phase of CR, such as riding a bicycle he recently rebuilt. Andy is a 63 year-old Black man, retired airline industry worker, with hyperlipidemia, hypertension, and former tobacco smoking. He presented to the Johns Hopkins Hospital due to ongoing chest pain and was found to have obstructive coronary artery disease requiring percutaneous coronary intervention to the left anterior descending artery. Andy was identified as a candidate for hybrid CR via an electronic health record automated report. After receiving attending approval, a Corrie patient navigator met Andy at the bedside to discuss the program and set up the technology. He received in-person tutorials supplemented by video instructions and weekly check-in calls. Andy ranked himself as “low digital health literacy,” but through onboarding and coaching, he tracked his medications with 100% adherence, vitals, and viewed educational materials. After completing two in-person CR sessions for safety, he tracked exercises from home, following goals he discussed with his coach. Through the program, Andy increased his exercise capacity and implemented healthy lifestyle habits that he plans to continue into the maintenance phase of CR, such as riding a bicycle he recently rebuilt. Conclusion

Evaluating the effectiveness of a comprehensive patient education intervention in a hybrid model of cardiac rehabilitation: A pilot study.

ObjectiveTo evaluate the effectiveness of a comprehensive educational intervention in a hybrid model of cardiac rehabilitation in Spain during the COVID-19 pandemic.MethodsIn a prospective pretest-posttest pilot study a pooled sample of patients attending hybrid cardiac rehabilitation in Spain received a culturally-adapted education intervention for 6 weeks. Participants completed surveys at pre- and post-rehabilitation assessing disease-related knowledge, health literacy, adherence to the Mediterranean Diet and self-efficacy. Physical activity was measured by number of steps per day using wearable activity tracking devices. Satisfaction with the educational materials was also evaluated by a survey with a 10 point Likert-type scale and yes/no and open-ended questions.ResultsEighty-one(99%) participants completed both assessments. There was significant improvement in disease-related knowledge(p < 0.001), physical activity(p < 0.001), and adherence to the diet(p = 0.005) post-rehabilitation. The number of participants that were classified as having “high health literacy skills” increased by 17%. Post-rehabilitation knowledge was associated with education level (ß = 0.430; p = 0.001),pre-rehabilitation knowledge (ß = 0.510; p = 0.002), and high health literacy skills (ß = 0.489; p = 0.01). Educational materials were highly satisfactory to participants.ConclusionSignificant increases in disease-related knowledge and health behaviors in patients attending hybrid models of cardiac rehabilitation are encouraging results that support the value of implementing comprehensive educational initiatives to programs in Spain.InnovationThis work presents preliminary evidence of the effectiveness of the first comprehensive education intervention that is open access and culturally adapted to people living with cardiovascular disease in Spain.

Efficacy and Safety of Hybrid Cardiac Telerehabilitation in Patients with Hypertrophic Cardiomyopathy without Left Ventricular Outflow Tract Obstruction and Preserved Ejection Fraction—A Study Design

Hypertrophic cardiomyopathy (HCM) is the most common congenital disease increasing the risk of sudden cardiac death. For many years, HCM patients were excluded from exercise training. However, there are data showing that patients with HCM undergoing supervised exercise training could improve physical performance without serious adverse events. A project was designed as a randomized clinical trial to assess the effectiveness and safety of hybrid cardiac rehabilitation (HCR)—a combination of hospital-based cardiac rehabilitation (1 month) with a new form of home-based telemonitored cardiac rehabilitation (2 months) in HCM patients without left ventricular (LV) outflow tract obstruction and preserved systolic function. Sixty patients who fulfil the inclusion criteria have been randomly assigned (1:1) to either HCR plus usual care (training group) or usual care only (control group). The primary endpoint is a functional capacity evaluated by peak oxygen uptake (pVO2). Secondary endpoints include workload time during the cardiopulmonary exercise testing, a six-minute walk test distance, NT-pro BNP level, echocardiographic parameters of the left ventricular diastolic function (E/A, E/e’, myocardial strain rate), right ventricular systolic pressure, a gradient in the LV outflow tract, and quality of life. The tertiary analysis includes safety, acceptance and adherence to the HCR program. Our research will provide innovative data on the effectiveness and safety of hybrid cardiac rehabilitation in HCM patients without LV outflow tract obstruction and preserved systolic function. Clinical trials registry: ClinicalTrials.gov Identifier NCT03178357.

Feasibility and preliminary effects of technology-assisted interventions in hybrid cardiac rehabilitation (TecHCR): A pilot randomised controlled trial

Abstract Funding Acknowledgements Type of funding sources: None. Background As COVID-19 pandemic continues, using technologies within cardiac rehabilitation facilitates access to care and reduces the frequency of direct contact with vulnerable cardiac patients. We aimed to assess the feasibility of technology-assisted interventions in hybrid cardiac rehabilitation (TecHCR) and preliminarily evaluate its effects on patients with coronary heart disease (CHD). Methods Between February 2021 to May 2021, a total of 28 patients with CHD were recruited and randomised to receive a 12-week TecHCR programme (n = 14) or a 12-week conventional, centre-based programme (n = 14). The TecHCR group received three center-based, supervised exercise training sessions. Participants were instructed to wear a fitness tracker watch for exercise self-monitoring at home environment, and the exercise data were shared through a web-based application for remote monitoring by the intervener. Participants received six audio-visual educational videos via a messaging application and a weekly video/telephone call follow-up. Self- Efficacy for Exercise (ESE), Health Promoting Lifestyle Profile II (HPLP II), Hospital Anxiety and Depression Scale (HADS), exercise capacity and cardiovascular health outcomes were assessed at baseline and at 12th week on completion of the programme. Generalised estimating equations analysis was conducted to compare the outcomes between groups. Results Out of 28 participants (56.46±12.98 years old; 1 female), 67.9% had percutaneous coronary intervention and 28.6% had coronary bypass grafting surgery. Among 14 participants in the TecHCR group, three dropped out due to: 1) fear to attend face-to-face supervised exercise training during high daily COVID-19 cases; 2) infected with COVID-19 and 3) found a job in overseas. Eleven participants in the TecHCR group attended all video/telephone call sessions, nine participants completed 3 supervised exercise training sessions and nine participants adhered to the weekly exercise recommendations. No treatment-related adverse events were reported. TecHCR was non-inferior to conventional, centre-based program on exercise self-efficacy, exercise capacity and cardiovascular health outcomes. TecHCR group showed significantly greater improvement in health-promoting behavior when compared with the control group (p =0.013) at post-intervention. Conclusion This pilot study demonstrated the feasibility in recruitment and implementation of TecHCR as an alternative delivery mode and could enhance health-promoting behavior among patients with CHD. Implications The TecHCR program provides accessible interventions to patients without frequent visits to the outpatient centre. A full-scale randomised controlled trial is needed to confirm the effectiveness of TecHCR.

Traditional versus extended hybrid cardiac rehabilitation based on the continuous care model for coronary artery bypass surgery patients in a middle-income country: an embedded mixed method

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation (CR) is a proven method to reduce the risk of disease, but unfortunately in low-and middle-income countries (LMICs), it is either unavailable or done in small quantities. Purpose To compare traditional (1-month supervised) vs hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (intervention) in patients who have undergone coronary artery bypass graft (CABG). Methods The embedded method has been used for the conduction of this study in two phases. The first phase of the study was carried out using a randomised clinical trial. Of 107 eligible patients who were referred to CR during the period of study, 82.2% (N=88) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). After CR, participants were given a mobile application and communicated biweekly with the nurse from months 1-4 to control risk factors. Quality of life (QOL, Short Form-36, primary outcome); functional capacity (treadmill test); and the Depression, Anxiety and Stress Scale were evaluated pre-CR, after 1 month, and 3 months after CR (end of intervention), as well as re-hospitalisation. In the second phase, a qualitative study was conducted using the conventional content analysis method. 17 patients from the intervention group and 3 members of their families were interviewed. Results The results of the quantitative stage showed the analysis of variance interaction effects for the physical and mental component summary scores of QOL were &amp;lt;.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (P&amp;lt;.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (P&amp;lt;.001), with a clinically significant 1.5 metabolic equivalent of task increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) re-hospitalisations in the control arm and none in intervention (P=.049). Intended theoretical mechanisms were also affected by the intervention. From the analysis of qualitative data, 20 subcategories, 6 categories, and three themes, including promotion and continuity of self-care, self-efficacy enhancement, belief, and lifestyle modification were extracted. Finally, qualitative findings supported quantitative findings. Conclusions Extending CR in this accessible manner, rendering it more comprehensive was effective in improving outcomes. Therefore, using the CCM can greatly reduce the gap due to cardiac rehabilitation in LMICs.