Maintenance Cardiac Rehabilitation Research Articles

Remote maintenance cardiac rehabilitation (MAINTAIN): A protocol for a randomised feasibility study.

Long-term adherence to exercise is often poor for people with coronary heart disease (CHD) who have completed supervised, centre-based cardiac rehabilitation. The aim of this study is to assess the feasibility of a remotely prescribed, delivered and monitored cardiac rehabilitation intervention using a wearable device to support long-term adherence to exercise and physical activity during maintenance of cardiac rehabilitation. After completing cardiac rehabilitation, 30 participants with CHD, will be randomised (1:1) to an intervention (n = 15) or a usual care group (n = 15) in a 12-month feasibility randomised controlled trial (RCT). The intervention will comprise of an exercise consultation, personalised exercise prescription delivered via a wearable activity monitor using biometric feedback, regular monitoring via check-ins, and feedback text-messages for 6-months. Participants will be assessed at baseline (following completion of cardiac rehabilitation) and at three-, six-, and 12-months post-randomisation. The primary outcome will be feasibility, including assessment of eligibility, recruitment, adherence, and acceptability. Secondary outcomes will include exercise capacity, physical activity behaviours, cardiovascular disease risk and quality of life. Semi-structured interviews will be conducted at three-, six-, and 12-months post-randomisation (and with those who drop-out) to explore the acceptability of the study intervention and procedures. A questionnaire will be offered to those who decline participation. The MAINTAIN study will evaluate the feasibility of conducting a future definitive multi-centre RCT testing a remotely prescribed and monitored long-term mHealth maintenance exercise programme, versus usual care, for people with CHD who have completed cardiac rehabilitation. ClinicalTrials.gov, NCT05292287. Registered on 22/03/2022.

Enrollment and Adherence to Early Outpatient and Maintenance Cardiac Rehabilitation Programs.

Early outpatient (ECR) and maintenance cardiac rehabilitation (MCR) programs are essential, evidence-based services that have received unequivocal endorsement by national and international professional organizations. However, the latest data characterizing ECR enrollment and adherence fell well short of what would be expected for a therapy that has accumulated decades of empirical evidence touting the associated physiologic, physical, psychosocial, and financial benefits. Although national participation levels have remained stagnant, a series of recent publications showcase effective strategies that could bolster both ECR enrollment and adherence levels at the institutional level. Unlike ECR, fewer reports on enrollment and adherence rates exist for MCR, partly due to the lack of standardization of this service. In this review, we aim to highlight current data on enrollment and adherence to ECR and MCR and discuss evidence-based programmatic strategies to support utilization of both services.

A Randomized, Controlled, Crossover Trial of Virtual Reality in Maintenance Cardiovascular Rehabilitation in a Low-Resource Setting: Impact on Adherence, Motivation, and Engagement.

The purpose of this study was to investigate the effects of adding virtual reality (VR) to maintenance cardiac rehabilitation (CR); it was hypothesized VR would increase adherence, motivation, and engagement. This study was a randomized, 1:1 concealed-allocation, single-blinded, 2parallel-arm, crossover trial. Blinded assessments were undertaken at baseline (midprogram), 12weeks, and 24weeks after baseline. The setting was a single CR program of unlimited duration in Brazil. Participants were patients with cardiovascular diseases or risk factors who had been in the program for 3months or longer. The CR program consisted of 3 supervised exercise sessions per week. In the VR arm, participants had 1 VR session of the 3 per week during the initial 12weeks of the trial; this was withdrawn the subsequent 12weeks. Measures were program adherence (% of 3 sessions/week over 12weeks, ascertained in all participants), motivation (Behavioral Regulation in Exercise Questionnaire 3), and engagement (User Engagement Scale, adapted; vigor, dedication, and absorption subscales); all 3 were primary outcomes. Sixty-one (83.6%) patients were randomly assigned (n=30 to CR+VR); 54 (88.5%) were retained at 12 and 24weeks. At baseline, participants had been in CR on average 7years and had high engagement and motivation. CR+VR resulted in a significant increase in adherence at 12weeks (baseline=72.87%; 12weeks=82.80%), with significant reductions at 24weeks when VR was withdrawn (65.48%); in the usual CR care arm, there were no changes over time. There was a significant effect for arm, with significantly higher adherence in the CR+VR arm than usual CR at 12weeks (73.51%). Motivation decreased significantly from baseline to 12weeks (4.32 [SD=0.37] vs 4.02 [SD=0.76]) and significantly increased from 12 to 24weeks in the CR+VR arm (4.37 [SD=0.36]). Absorption was significantly lower at 12weeks in the CR+VR arm (6.79 [SD=0.37] vs 6.20 [SD=1.01]). Although VR increased program adherence, interspersing it with usual CR sessions actually decreased patient motivation and absorption. Supplementing a maintenance CR program with VR using "exergames" resulted in significantly greater adherence (8% increase or 3 of 36 sessions), and this was quite a robust effect given it was extinguished with the removal of VR. However, contrary to the hypotheses, offering 1 session of VR per week and 2 of usual CR exercise was related to lower motivation and absorption, which has implications for how clinicians design programs for this patient population.

The Effects of Maintenance Cardiac Rehabilitation: A SYSTEMATIC REVIEW.

Maintenance cardiac rehabilitation (M-CR) programs aim to preserve the health benefits achieved during phase II cardiac rehabilitation (CR). The aim of this study was to establish the effects of M-CR on functional capacity, quality of life, risk factors, costs, mortality, and morbidity, among other outcomes. Scopus, ISI Web of Science, PubMed, Embase & Embase classic OVID, and Lilacs were searched. Randomized controlled trials, published between 2000 and 2016, on the effects of M-CR in patients with cardiovascular disease, who had graduated from CR, having a control or comparison arm were included. Citations were processed by two authors, independently. Methodological quality was assessed using PEDro, and level of evidence graded with the Scottish scale. Outcomes were qualitatively synthesized. The searches retrieved 1901 studies with 26 articles meeting inclusion criteria (3752 participants). Some trials tested M-CR in nonclinical settings, and others used resistance or high-intensity interval training. The methodological quality of 11 articles was good, with a level of evidence (1+) and a grade B recommendation. Results showed M-CR resulted in increased or maintained functional capacity, quality of life, and physical activity levels, when compared with the control. No adverse events were reported. Few studies assessed rehospitalizations and mortality. Quality of included trials was low because it is not possible to double-blind in M-CR trials and also due to the heterogeneity of M-CR interventions. Understanding, availability, and use of M-CR programs should be increased.

Physical activity, physical function and quality of life in community-based maintenance cardiac rehabilitation

Objective: This study compared physical activity (PA), physical function and quality of life in elderly individuals with coronary artery disease (CAD) and their non-CAD peers participating in community-based, maintenance cardiac rehabilitation (CR). Design: Cross-sectional study. Setting: Community-based maintenance CR programme. Methods: A total of 39 individuals (71.8% women; age 70.5 ± 5.5 years; 13 CAD, 26 non-CAD) wore an accelerometer for 7 days and completed anthropometry, chair stands, handgrip strength, a Short Physical Performance Battery, a PA questionnaire (IPAQ- SF), a quality of life questionnaire (SF-36), a 10-m shuttle walk test and two 6-minute walk tests. Results: Compared with the non-CAD group, the CAD group accumulated more objectively measured moderate-to-vigorous PA per week (329.7 ± 233.3 vs 160.6 ± 149.5 minutes, p = .013), achieved PA guidelines on more days per week (3.8 ± 2.2 vs 2.1 ± 2.6 days/week, p = .042), had a lower proportion of body fat (27.5 ± 8.4% vs 36.5 ± 8.7%, p = .004) and a higher proportion of muscle mass (72.5 ± 8.4% vs 63.0 ± 9.8%, p = .022). Physical function and quality of life were not different between the groups. Conclusion: Elderly CAD patients participating in community-based maintenance CR performed more PA and had more favourable body composition but similar physical function and quality of life compared with their non-CAD peers. Long-term participation in community-based maintenance CR may promote PA in elderly CAD patients and help maintain physical function and quality of life at a level similar to that of their non-CAD peers. However, due to a small sample size, these findings should be interpreted with caution and examined in future larger studies.

The effectiveness of physical activity-based maintenance cardiac rehabilitation on physical activity levels and quality of life: A systematic review

The effectiveness of physical activity-based maintenance cardiac rehabilitation on physical activity levels and quality of life: A systematic review

Long-term effects of cardiac rehabilitation in elderly individuals with stable coronary artery disease

Purpose: To compare exercise capacity and cardiovascular response to exercise in elderly individuals with coronary artery disease (CAD) who attend ongoing community-based maintenance cardiac rehabilitation (CR) versus age- and gender-matched healthy “very active” (HVA; ≥ 2000 kcal/week) and healthy “less active” (HLA; <2000 kcal/week) individuals. Method: Sixty-three participants (age: 72.3 ± 5.1 years; 62% men; n = 21 per group) completed the following assessments: (1) symptom-limited graded exercise test with expired gas analysis and bioimpedance assessment of cardiovascular function during exercise; (2) walking tests; (3) physical function; (4) anthropometry and (5) 12-month physical activity recall. Results: The CR group achieved 98% (range: 73–154%) of age- and gender-predicted peak oxygen consumption for healthy individuals. Peak oxygen consumption was lower in CR compared to HVA but not HLA group (VO2peak: CR: 19.0 ± 4.5, HVA: 23.7 ± 2.9, HLA: 20.7 ± 4.7 ml ·kg−1ċmin−1, p = 0.001 versus HVA; p = 0.390 versus HLA). Peak heart rate was lower in CR compared to both HVA and HLA. Walking test results and cardiovascular and physical function were not different between the groups. Conclusions: Elderly individuals with CAD participating in maintenance CR have similar exercise capacity and cardiorespiratory response to exercise compared to their age- and gender-matched less active healthy peers. The findings support referral of elderly patients to community-based CR.Implications for RehabilitationFitness benefits of long-term maintenance cardiac rehabilitation (CR) programs remain unknown.Elderly individuals with coronary artery disease participating in maintenance CR have exercise capacity and cardiorespiratory response to exercise similar to their less active healthy peers.Maintenance CR may play an important role prolonging independent living in elderly individuals.

Examining Motivations and Barriers for Attending Maintenance Community-Based Cardiac Rehabilitation Using the Health-Belief Model

Reasons for low attendance at maintenance cardiac rehabilitation (CR) programs remain largely unknown. Using the Health Belief Model as a theoretical framework, this study compared the motivations and barriers for attending a community-based CR maintenance program in high attenders (HA), low attenders (LA) and non-attenders (NA) with coronary artery disease (CAD). Forty-four older adults with CAD (70.5% males; age: 72.7±6.9 years; 11 HA, 16 LA and 17 NA) completed questionnaires examining reasons for attending CR: perceived threat (symptoms of CAD; the Revised Illness Perception Questionnaire), perceived benefits (Multi-dimensional Outcomes Expectations for Exercise Scale), perceived barriers (Cardiac Rehabilitation Barriers Scale) and cues to action questionnaire. Sociodemographic characteristics and perceived threat were not different between the groups. Compared to LA and NA, HA perceived greater social and physical (vs NA only) benefits of participation in maintenance CR and had fewer barriers to attending (all p<0.05). The CR program newsletter, personal health concerns and others having heart problems were stronger cues to action for HA versus NA (all p<0.05). Participants perceived greater benefits from attending CR, had fewer barriers and perceived stronger cues to action compared to non-attenders. Promoting CR maintenance programs should emphasise physical and social benefits and provide encouragement.

Patient and Program Characteristics of Early Outpatient Cardiac Rehabilitation Programs in the United States

The purpose of this study was to perform a brief survey to determine the patient and program characteristics associated with early outpatient cardiac rehabilitation (EOCR) in the United States. To assess these characteristics, a brief survey (13 items, some with multiple responses) was sent by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) to all program administrators or directors on the AACVPR mailing list in 2009. Responses were received from 138 program administrators or directors in 44 states, accounting for 19 689 patients who completed at least 1 EOCR exercise session. More men (68%) were enrolled in EOCR programs, and the 3 most prevalent primary diagnoses were percutaneous coronary intervention or stent (31%), coronary artery bypass graft surgery (30%), and myocardial infarction (22%). Seventy-two percent of responding programs were AACVPR certified and had staff trained primarily (66%) in either nursing or exercise physiology. Eighty-four percent of the programs offered an outpatient maintenance cardiac rehabilitation program, and 62% were located in a rural setting. This study provides valuable information on use and patient demographics of EOCR programs in the United States. This information may be beneficial for health care professionals, health care institutions, third-party payers, and regulatory agencies that seek to quantify health care quality.

A pedometer-based physical activity intervention for patients entering a maintenance cardiac rehabilitation program: a pilot study.

To compare the effects of an individualized pedometer-driven physical activity (PA) intervention with the usual time-based PA recommendations given to patients entering a maintenance cardiac rehabilitation (CR) program. A total of 18 subjects entering a maintenance CR program were recruited and completed the study. Subjects were randomized into pedometer feedback [PF: n=10 (2 women), 53.3±8.1 yrs] and usual care [UC: n=8 (2 women), 59.4±9.9 yrs] groups. New Lifestyles NL-1000 pedometers were used to monitor ambulatory PA. Subjects in both groups participated in the same maintenance CR program for a total of 8 weeks and all were encouraged to obtain a minimum of 30-40 min/d of moderate-vigorous-intensity physical activity (MVPA), on days they did not attend CR. Subjects in the PF group were given individualized daily stepcount goals (increase 10% of baseline steps/d each week) for weeks 2-8. Ambulatory PA was measured with pedometers, recording both total number of steps/d and min/d of MVPA. Measures were obtained during the first week of the maintenance CR program and during the 8th week. Data were also compared between days subjects attended and on days they did not attend. By the 8th week of CR, PF subjects increased daily stepcounts by 42% (2,297±1,606 steps/d, P=0.001), with a 36% increase on CR days (2,654±2,089 steps/d, P=0.003) and a 45% increase on days they did not attend CR (1,872±2,026 steps/d, P=0.017). There were no changes observed in the UC group. Providing pedometers with individualized stepcount goals to patients entering a CR program was superior to the usual time-based PA recommendations for increasing PA.

Abstract P178: Pedometer Feedback Intervention Increases Time Spent in Moderate-to-Vigorous Physical Activity in Cardiac Rehabilitation Patients

Introduction: Pedometer feedback with step goals has previously been demonstrated to be effective in increasing daily steps in cardiac rehabilitation patients. These monitors allow the individual to track steps taken during a day, which may influence the frequency or duration of structured physical activity that is intended to achieve a step goal. However, it is not known whether an increase in step counts by pedometer feedback with step goals also increases time spent in recommended intensity levels for improved health, specifically moderate-to vigorous physical activity (MVPA), in cardiac rehabilitation patients. Hypothesis: Pedometer feedback with weekly step goals will increase time spent in MVPA, mediated by an increase in step counts in cardiac rehabilitation patients. Methods: A total of 31 (22 men and 9 women, age 62 ± 9 years) patients participated in a 12-week maintenance cardiac rehabilitation, pedometer based step goal intervention. Prior to the intervention, each subject’s one week baseline average daily step count was measured and 10% of this value was used to increase step goals during the intervention. Each week the step goal was met, the following week’s goal was appropriately increased. However, if the step goal for the week was not achieved, the step goal would not increase until the goal was fulfilled. Additionally, daily step counts and time spent in MVPA and light physical activity were assessed at baseline (without pedometer feedback) and for each intervention week (with pedometer feedback) using a Kenz Lifecorder PLUS monitor (Nagoya, Japan). Average time spent in light physical activity (activity level of 1-2) and MVPA (activity levels ≥3), were determined according to activity intensity level defined by the manufacturer’s analyses program. Results: The average step count for the baseline week was 5546 ± 2679 steps/day which significantly increased to 8348± 3613 steps/day by week 12 (p&lt;0.01). The average time spent in MVPA also significantly increased (p&lt;0.01) from 19 ± 16 min/day at baseline to 38 ± 23 min/day at week 12. In addition, there was a significant increase (p&lt;0.05) in time spent in light physical activity from baseline (42 ± 18 min/day) to week 12 (51 ± 24 min/day). Conclusion: Findings of this study demonstrate that a 12-week pedometer feedback-based intervention was effective in increasing time spent in MVPA in maintenance cardiac rehabilitation patients. Cardiac rehabilitation facilities can utilize pedometer feedback and goal setting to promote increases in time spent in recommended activity levels previously associated with improved health outcomes.

Maintenance Cardiac Rehabilitation Exercise Adherence: Effects of Task and Self-Regulatory Self-Efficacy

The purpose of this study was to examine whether self-efficacy functions as a determinant and outcome of maintenance cardiac rehabilitation exercise adherence. Specifically, the purpose of this prospective observational study was to examine which types of self-efficacy–task or self-regulatory–predicted maintenance exercise attendance. In addition, the relative contribution of self-efficacy to the prediction of perceived exercise intensity was examined. Self-regulatory self-efficacy was operationalized as confidence to schedule and manage exercise sessions, while task self-efficacy concerned confidence to perform aspects of the exercise session and to walk for increasing durations. Sixty-four maintenance cardiac rehabilitation participants completed social cognitive measures and provided attendance data for 4 weeks prior to and 4 weeks following assessment. Results indicated that scheduling and walking self-efficacy significantly predicted cardiac rehabilitation exercise attendance. Task self-efficacy was the best predictor of perceived exercise intensity. Past exercise attendance significantly predicted all 3 dimensions of self-efficacy. Findings are discussed with respect to self-efficacy theory and applications to the maintenance of cardiac rehabilitation exercise adherence.

Leisure time physical activity of patients in maintenance cardiac rehabilitation.

PURPOSE Increasing caloric expenditure through physical activity is associated with reduced mortality. On the basis of observational studies, previous authors have suggested that at least 1000 kcal per week and possibly 1500 kcal per week of physical activity is necessary for health benefits. The authors have previously reported that patients in maintenance cardiac rehabilitation accumulate approximately 230 kcal per exercise session, suggesting that additional activity outside of cardiac rehabilitation is needed to achieve the goal of 1500 kcal per week. The authors estimated the amount of energy expenditure performed each week by patients in cardiac rehabilitation during both program participation and leisure time. METHODS For this study, 104 patients enrolled in a supervised maintenance cardiac rehabilitation program at both tertiary care and community settings for at least 6 months completed a self-administered physical activity questionnaire. Energy expenditure in cardiac rehabilitation and leisure time activity was measured in kilocalories. Total caloric expenditure was determined by adding up the number of kilocalories expended by the patients each week climbing stairs, walking, participating in cardiac rehabilitation, and engaging in sports. RESULTS Patients in cardiac rehabilitation expended weekly, on the average, 1504 +/- 830 kcal in physical activity, 830 +/- 428 kcal in cardiac rehabilitation, and 675 +/- 659 kcal in leisure time activity. There was a significant difference in caloric expenditure between men and women, between those with a body mass index (BMI) less than 30 and those with a BMI of 30 or more, and between those younger than 70 years and those 70 years or older. There was no difference between races. Whereas 43% of the patients accumulated 1500 kcal, 57% did not. CONCLUSIONS The findings showed that 72% of the patients in cardiac rehabilitation accumulated at least 1000 kcal of energy expenditure per week and met public health guidelines. Also, 43% of the patients in cardiac rehabilitation accumulated more than 1500 kcal of energy expenditure per week, a level identified as necessary to reduce all-cause mortality. Women of either race, patients with a BMI of 30 or more, and patients age 70 years or older are the groups least likely to achieve 1500 kcal of energy expenditure per week. The authors recommend incorporating weekly kilocalories of energy expenditure in the exercise prescription of patients to ensure achievement of maximum health benefits.

Caloric expenditure during cardiac rehabilitation.

The purpose of this study was to describe estimated caloric expenditure among patients in a maintenance cardiac rehabilitation program relative to a stated goal of approximately 300 kcal/session or 1,000 kcal/week. Additionally, we assessed the validity of several different methods for estimating caloric expenditure. The caloric expenditure for an exercise session was evaluated in 30 of 65 patients exercising in a maintenance cardiac rehabilitation program. Patients exercised using a treadmill, dual-action ergometer, upright stepper, or reclining stepper. The kilocalorie expenditure was assessed by three different techniques. The first used liquid crystal display (LCD) readings from the equipment (LCD method), the second combined both the American College of Sports Medicine metabolic equations for treadmill walking and the LCD values from the other equipment (Combined method), and the third measured oxygen consumption (VO2 method). The caloric expenditure for the LCD, Combined, and VO2 methods were 247 +/- 83, 245 +/- 80, and 230 +/- 88 kcal, respectively. Agreement between methods using intraclass correlation analysis was r = 0.84 (0.68 to 0.92, 95% confidence intervals) for LCD versus VO2 and r = 0.88 (0.77 to 0.94, 95% confidence intervals) for Combined versus VO2 method. Most patients (83%) in a maintenance cardiac rehabilitation program exercise below 300 kcal per session, a level believed to be necessary to illicit favorable changes in cardiovascular health. Additionally, the Combined method provides a reasonable estimate of kilocalorie expenditure. Use of kilocalorie expenditure should be considered in the cardiac rehabilitation setting as a fourth component in the exercise prescription.