Start Of Cardiac Rehabilitation Research Articles

Effects of a Dedicated Cardiac Rehabilitation Program for Patients With Obesity on Body Weight, Physical Activity, Sedentary Behavior and Physical Fitness: the OPTICARE XL Randomized Controlled Trial.

Previously published results of the OPTICARE XL open label randomized controlled trial showed no added value of OPTICARE XL CR, a dedicated cardiac rehabilitation (CR) program for patients with obesity, with respect to health-related quality of life (primary outcome). This clinical trial studied the effects of OPTICARE XL CR on several secondary outcomes, which included body weight, physical activity, sedentary behavior, and physical fitness. Patients with coronary artery disease or atrial fibrillation and body mass index (BMI) ≥ 30 were randomized to OPTICARE XL CR (n = 102) or standard CR (n = 99). OPTICARE XL CR is a 1-year group intervention, specifically designed for patients with obesity, and included aerobic and strength exercise, behavioral coaching, and an aftercare program. Standard CR consisted of a 6- to 12-week group aerobic exercise program, supplemented with cardiovascular lifestyle education. Study end points included body weight, physical activity, sedentary behavior (accelerometer), and physical fitness (6-Minute Walk Test and handgrip strength), which were evaluated 6months after the end of CR (primary end point) and 3months after the start of CR. Six months after completion of either program, improvements in body weight, physical activity, sedentary behavior, and physical fitness were similar between groups. Three months after CR start, patients randomized to OPTICARE XL CR showed greater weight loss (mean change = -3.6 vs -1.8kg) and a larger improvement in physical activity (+880 vs +481 steps per day) than patients randomized to standard CR. Patients allocated to OPTICARE XL CR lost significantly more body weight and showed promising results with respect to physical activity 3months after the start of CR; however, these short-term results were not expanded or sustained in the longer term. Patients with obesity do not benefit from standard CR programs. The new OPTICARE XL CR program showed its effects in the short term on weight loss and physical activity, and, therefore, redesign of the aftercare phase is recommended.

Prealbumin level is a predictor of activities of daily living at discharge in older patients with heart failure who became ADL-independent after hospitalization: - Acute and early recovery cardiac rehabilitation trials.

To determine the relationship between prealbumin level and activities of daily living (ADL) at discharge in patients with heart failure (HF) and assess the usefulness of prealbumin measurement in predicting discharge Barthel Index (BI) in older patients with HF who become non-independent in ADL after hospital admission. Patients with HF, aged ≥75 years, who were admitted to an acute hospital and underwent acute and early recovery cardiac rehabilitation (CR) were studied retrospectively. The exclusion criteria were non-independent ADL before admission (BI < 85 points) and independent ADL at the start of CR (BI ≥ 85 points). The usefulness of prealbumin level in predicting discharge BI was compared between four models. Albumin and Controlling Nutritional Status (CONUT) were used as comparison variables. The models and independent variables were model 1 (covariates only), model 2 (prealbumin + covariates), model 3 (albumin + covariates), and model 4 (CONUT score + covariates). Adjusted R2, a measure of model fit, was used to compare predictive ability. A total of 152 patients were included in the analysis. Prealbumin level was a significant variable for BI at discharge but not albumin or CONUT. The adjusted R2 was higher in model 2 with the addition of prealbumin than that in model 1 (0.362 vs. 0.347). Prealbumin levels are useful in predicting discharge BI in older patients with HF who become non-independent in ADL after hospitalization.

Levels of depressive symptoms in cardiac patients attending cardiac rehabilitation with a history of depression: pre Covid-19 and Covid-19 period comparison

BackgroundThe large-scale changes in cardiac rehabilitation (CR) programme delivery in response to COVID-19 has led to diminished provision. The influence of these service changes on the depression symptoms of patients in CR programmes is unknown. Our study investigated the extent of depressive symptoms prior to and during the COVID-19 periods in patients with a previous history of depression at the start of CR.MethodsUse of Registry routine practice data, National Audit of Cardiac Rehabilitation (NACR), from COVID-19 period Feb 2020 and Jan 2021, as well as pre COVID-19 period Feb 2019 and Jan 2020, was extracted. Depressive symptoms were defined according to Hospital Anxiety and Depression Score ≥ 8. Chi-square tests and independent samples t-tests were used to investigate baseline characteristics. Additionally, a binary logistic regression to examine the factors associated with high levels of depressive symptoms.ResultsIn total 3661 patients with a history of depression were included in the analysis. Patients attending CR during COVID-19 were found to be 11% more likely to have high levels of acute depressive symptoms compared to patients attending CR prior to COVID-19. Physical inactivity, increased anxiety, a higher total number of comorbidities, increased weight, and living in the most deprived areas were statistically significant factors associated with high levels of acute depressive symptoms at the start of CR following multivariate adjustments.ConclusionOur research suggests that following a cardiac event patients with prior history of depression have high levels of acute depressive symptoms at CR baseline assessment. This finding exists in both the pre Covid-19 and Covid-19 periods in patients with a history of depression.

Short- and Long-Term Effects of High-Intensity Interval Training vs. Moderate-Intensity Continuous Training on Left Ventricular Remodeling in Patients Early After ST-Segment Elevation Myocardial Infarction-The HIIT-EARLY Randomized Controlled Trial.

AimDue to insufficient evidence on the safety and effectiveness of high-intensity interval training (HIIT) in patients early after ST-segment elevation myocardial infarction (STEMI), we aimed to compare short- and long-term effects of randomized HIIT or moderate-intensity continuous training (MICT) on markers of left ventricular (LV) remodeling in STEMI patients receiving optimal guideline-directed medical therapy (GDMT).Materials and MethodsPatients after STEMI (<4 weeks) enrolled in a 12-week cardiac rehabilitation (CR) program were recruited for this randomized controlled trial (NCT02627586). During a 3-week run-in period with three weekly MICT sessions, GDMT was up-titrated. Then, the patients were randomized to HIIT or isocaloric MICT for 9 weeks. Echocardiography and cardiopulmonary exercise tests were performed after run-in (3 weeks), end of CR (12 weeks), and at 1-year follow-up. The primary outcome was LV end-diastolic volume index (LVEDVi) at the end of CR. Secondary outcomes were LV global longitudinal strain (GLS) and cardiopulmonary fitness.ResultsSeventy-three male patients were included, with the time between STEMI and start of CR and randomization being 12.5 ± 6.3 and 45.8 ± 10.8 days, respectively. Mixed models revealed no significant group × time interaction for LVEDVi at the end of CR (p = 0.557). However, there was a significantly smaller improvement in GLS at 1-year follow-up in the HIIT compared to the MICT group (p = 0.031 for group × time interaction). Cardiorespiratory fitness improved significantly from a median value of 26.5 (1st quartile 24.4; 3rd quartile 1.1) ml/kg/min at randomization in the HIIT and 27.7 (23.9; 31.6) ml/kg/min in the MICT group to 29.6 (25.3; 32.2) and 29.9 (26.1; 34.9) ml/kg/min at the end of CR and to 29.0 (26.6; 33.3) and 30.6 (26.0; 33.8) ml/kg/min at 1 year follow-up in HIIT and MICT patients, respectively, with no significant group × time interactions (p = 0.138 and 0.317).ConclusionIn optimally treated patients early after STEMI, HIIT was not different from isocaloric MICT with regard to short-term effects on LVEDVi and cardiorespiratory fitness. The worsening in GLS at 1 year in the HIIT group deserves further investigation, as early HIIT may offset the beneficial effects of GDMT on LV remodeling in the long term.

Design of a Remote Coaching Program to Bridge the Gap From Hospital Discharge to Cardiac Rehabilitation: Intervention Mapping Study.

BackgroundRemote coaching might be suited for providing information and support to patients with coronary artery disease (CAD) in the vulnerable phase between hospital discharge and the start of cardiac rehabilitation (CR).ObjectiveThe goal of the research was to explore and summarize information and support needs of patients with CAD and develop an early remote coaching program providing tailored information and support.MethodsWe used the intervention mapping approach to develop a remote coaching program. Three steps were completed in this study: (1) identification of information and support needs in patients with CAD, using an exploratory literature study and semistructured interviews, (2) definition of program objectives, and (3) selection of theory-based methods and practical intervention strategies.ResultsOur exploratory literature study (n=38) and semistructured interviews (n=17) identified that after hospital discharge, patients with CAD report a need for tailored information and support about CAD itself and the specific treatment procedures, medication and side effects, physical activity, and psychological distress. Based on the preceding steps, we defined the following program objectives: (1) patients gain knowledge on how CAD and revascularization affect their bodies and health, (2) patients gain knowledge about medication and side effects and adhere to their treatment plan, (3) patients know which daily physical activities they can and can’t do safely after hospital discharge and are physically active, and (4) patients know the psychosocial consequences of CAD and know how to discriminate between harmful and harmless body signals. Based on the preceding steps, a remote coaching program was developed with the theory of health behavior change as a theoretical framework with behavioral counseling and video modeling as practical strategies for the program.ConclusionsThis study shows that after (acute) cardiac hospitalization, patients are in need of information and support about CAD and revascularization, medication and side effects, physical activity, and psychological distress. In this study, we present the design of an early remote coaching program based on the needs of patients with CAD. The development of this program constitutes a step in the process of bridging the gap from hospital discharge to start of CR.

Tailor-made cardiac rehabilitation for patients with obesity: results of the OPTICARE-XL randomized controlled trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Organisation for Health Research and Development (ZonMW) and Capri Cardiac Rehabilitation Background More than a third of the patients referred to cardiac rehabilitation (CR) suffers from obesity, and this number is growing. However, in patients with obesity, standard CR is not effective in achieving the recommended physical activity levels and results achieved in weight loss and health related quality of life (HRQOL) are unsatisfactory. Purpose To describe the effectiveness of a new state of the art CR program designed for patients with obesity, OPTICARE XL, on weight, physical activity and HRQOL. Methods A total of 201 patients that were referred to CR after a diagnosis of coronary artery disease (CAD) or atrial fibrillation (AF) and a BMI≥30 were randomized to standard CR (n=99) or OPTICARE XL CR (n=102). Standard CR consists of a 6 till 12 week aerobic exercise program, supplemented with cardiovascular lifestyle education. OPTICARE XL CR is a one-year intervention including aerobic and strength exercise, behavioral coaching on diet and physical activity and an after-care program. Weight was measured with a calibrated weight scale, physical activity (steps/day) was measured with an Actigraph GT3X+, and HRQOL with the MacNew questionnaire. Data was analyzed by means of linear mixed-effect models. Results Included patients had a mean age of 59 years, were predominantly male (73%) and the majority was referred to CR after a CAD (66% CAD, 34% AF). Patients in the OPTICARE XL group showed on average greater weight loss three months after the start of CR (mean change -3.6 kg vs -1.8 kg, respectively, p=0.002). Six months post CR, changes in body weight were equal between groups (-2.5 kg in both groups, p=0.959). No significant between-group differences were seen in improvements in physical activity both three months after the start of CR (+880 steps/day for OPTICARE XL vs +481 steps/day for standard CR, p=0.169) and six months post CR (+331 steps/ day vs +283 steps/day, p=0.919). With regard to HRQOL score, also no significant between groups differences in improvements were seen both three months after the start of CR (+0.6 for OPTICARE XL vs +0.5 for standard CR, p=0.169) and six months post CR (+0.5 for both groups, p=0.907). Conclusion OPTICARE XL had added value on the short-term, but this did not sustain on the long-term. We suggest to re-evaluate the OPTICARE XL program to expand short-term effects.

Sex-specific differences in trimethylamine N-oxide (TMAO) concentrations before and after cardiac rehabilitation in acute myocardial infarction patients.

Trimethylamine N-oxide (TMAO) is a biomarker of cardiovascular risk and may enhance the progression of atherosclerosis. The aim of the study was to determine whether there are sex-specific differences in TMAO concentrations before and after cardiac rehabilitation in acute myocardial infarction (AMI) patients. A total of 56 participants [45/56 (80.4 %) males, 11/56 (19.6 %) females] were drawn from AMI inpatients hospitalized at the Division of Cardiology, Medical University of Graz, Austria. For the assessment of TMAO, serum samples were collected within the first day after hospital admission due to AMI and at the start and end of cardiac rehabilitation. Shortly after hospital admission due to AMI, females had significantly higher TMAO blood concentrations than males. These initially high TMAO levels remained almost unchanged in the female AMI patients until the start of cardiac rehabilitation and only reached the lower TMAO concentrations observed in the male patients after rehabilitation [female patients: TMAO (acute myocardial infarction) = 5.93 μmol/L (SE = 1.835); TMAO (start of rehabilitation) = 5.68 μmol/L (SE = 1.217); TMAO (end of rehabilitation) = 3.89 μmol/L (SE = 0.554); male patients: TMAO (acute myocardial infarction) = 3.02 μmol/L (SE = 0.255), TMAO (start of rehabilitation) = 3.91 μmol/L (SE = 0.346), TMAO (end of rehabilitation) = 4.04 μmol/L (SE = 0.363)]. After AMI, women might be at higher cardiovascular risk due to persistently higher levels of TMAO. High TMAO levels in women might decrease after cardiac rehabilitation due to cardiac rehabilitation-associated lifestyle modifications. These lifestyle modifications after AMI might also prevent increases in TMAO concentrations in men.

Predictors of non-participation in a cardiac telerehabilitation programme: a prospective analysis.

Current cardiac telerehabilitation (CTR) interventions are insufficiently tailored to the preferences and competences of individual patients, which raises the question whether their implementation will increase overall participation and adherence to cardiac rehabilitation (CR). However, research on patient-specific factors that influence participation and adoption of CTR interventions is scarce. The aim of this study was to evaluate which patient-related characteristics influence participation in a novel CTR intervention in patients with coronary artery disease. This prospective observational substudy of the SmartCare-CAD randomized controlled trial evaluated patient characteristics of study participants as proxy for participation in a CTR intervention. We compared demographic, geographic, and health-related characteristics between trial participants and non-participants to determine which characteristics influenced trial participation. A total of 699 patients (300 participants and 399 non-participants; 84% male, mean age 64.3 ± 10.5 years) were included. Most of the non-participants refused participation because of insufficient technical skills or lack of interest in digital health (26%), or preferred centre-based CR (21%). Variables independently associated with non-participation included: higher age, lower educational level, shorter travelling distance, smoking, positive family history for cardiovascular disease, having undergone coronary artery bypass grafting; and a higher blood pressure, worse exercise capacity, and higher risk of depression before the start of CR. Participation in CTR is strongly influenced by demographic and health-related factors such as age, educational level, smoking status, and both physical and mental functioning. Cardiac telerehabilitation interventions should therefore be redesigned with the involvement of these currently underrepresented patient subgroups.

Efficacy of Lipid-Lowering Therapy during Cardiac Rehabilitation in Patients with Diabetes Mellitus and Coronary Heart Disease.

Background: Cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) increases adherence to a healthy lifestyle and to secondary preventive medication. A notable example of such medication is lipid-lowering therapy (LLT). LLT during CR improves quality of life and prognosis, and thus is particularly relevant for patients with diabetes mellitus, which is a major risk factor for CHD. Design: A prospective, multicenter registry study with patients from six rehabilitation centers in Germany. Methods: During CR, 1100 patients with a minimum age of 18 years and CHD documented by coronary angiography were included in a LLT registry. Results: In 369 patients (33.9%), diabetes mellitus was diagnosed. Diabetic patients were older (65.5 ± 9.0 vs. 62.2 ± 10.9 years, p < 0.001) than nondiabetic patients and were more likely to be obese (BMI: 30.2 ± 5.2 kg/m2 vs. 27.8 ± 4.2 kg/m2, p < 0.001). Analysis indicated that diabetic patients were more likely to show LDL cholesterol levels below 55 mg/dL than patients without diabetes at the start of CR (Odds Ratio (OR) 1.9; 95% CI 1.3 to 2.9) until 3 months of follow-up (OR 1.9; 95% CI 1.2 to 2.9). During 12 months of follow-up, overall and LDL cholesterol levels decreased within the first 3 months and remained at the lower level thereafter (p < 0.001), irrespective of prevalent diabetes. At the end of the follow-up period, LDL cholesterol did not differ significantly between patients with or without diabetes mellitus (p = 0.413). Conclusion: Within 3 months after CR, total and LDL cholesterol were significantly reduced, irrespective of prevalent diabetes mellitus. In addition, CHD patients with diabetes responded faster to LTT than nondiabetic patients, suggesting that diabetic patients benefit more from LLT treatment during CR.

Predictors for one-year outcomes of cardiorespiratory fitness and cardiovascular risk factor control after cardiac rehabilitation in elderly patients: The EU-CaRE study.

Studies on effectiveness of cardiac rehabilitation (CR) in elderly cardiovascular disease patients are rare, and it is unknown, which patients benefit most. We aimed to identify predictors for 1-year outcomes of cardiorespiratory fitness and CV risk factor (CVRF) control in patients after completing CR programs offered across seven European countries. Cardiovascular disease patients with minimal age 65 years who participated in comprehensive CR were included in this observational study. Peak oxygen uptake (VO2), body mass index (BMI), resting systolic blood pressure (BPsys), and low-density lipoprotein-cholesterol (LDL-C) were assessed before CR (T0), at termination of CR (T1), and 12 months after start of CR (T2). Predictors for changes were identified by multivariate regression models. Data was available from 1241 out of 1633 EU-CaRE patients. The strongest predictor for improvement in peak VO2 was open chest surgery, with a nearly four-fold increase in surgery compared to non-surgery patients. In patients after surgery, age, female sex, physical inactivity and time from index event to T0 were negative predictors for improvement in peak VO2. In patients without surgery, previous acute coronary syndrome and higher exercise capacity at T0 were the only negative predictors. Neither number of attended training sessions nor duration of CR were significantly associated with change in peak VO2. Non-surgery patients were more likely to achieve risk factor targets (BPsys, LDL-C, BMI) than surgery patients. In a previously understudied population of elderly CR patients, time between index event and start of CR in surgery and disease severity in non-surgery patients were the most important predictors for long-term improvement of peak VO2. Non-surgery patients had better CVRF control.

Anxiety and depression; influence on information needs in patients receiving cardiac rehabilitation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Educational interventions on healthy lifestyle and cardiovascular risk factors are important elements of Cardiac Rehabilitation (CR), and may increase patients’ self-efficacy, satisfaction and health-promoting behaviour. However, these interventions are often not tailored to individual needs of patients, thereby reducing their effectiveness. In order to tailor educational interventions to individuals, it"s important to identify determinants of information needs. Depression and anxiety are highly prevalent in cardiac patients and negatively influence prognosis. Additionally, depression and anxiety may prevent people from seeking information due to lack of initiative and withdrawal from social situations. Little is known on information needs for anxious and depressed patients entering CR. This study evaluated the influence of anxiety and depression on information needs of patients entering CR. Methods Prospective observational study. Patients were asked to complete questionnaires on anxiety and depression and on information needs and information seeking behaviour before start of CR. Primary endpoint was the association between information needs and risk of anxiety and depression. Results We included 259 patients, predominantly male (76%), mean age 64.8 ± 10.4 year. Two thirds of patients were diagnosed with MI (68%), 163 patients underwent PCI (63%), 71 patients underwent CABG (27%) and 22 patients were treated by medication only (9%). At baseline 19 patients were current smokers (8%). Patients with moderate to high risk of anxiety or depression more often had questions on mood than patients with low risk of anxiety and depression. Patients with moderate to high anxiety risk also more often had questions on nutrition than low risk patients. Discussion In patients entering CR, moderate to high risk of anxiety and depression was associated with higher degree of information needs on mood than their low risk counterparts. This indicates that CR programme and educational interventions should be more specifically tailored to patients’ information needs, taking into account anxiety and depression risk. Information needs before start CR Anxiety risk Depression risk Low (HADS score 0-7) Moderate to high (HADS score 8-21) p-value Low (HADS score 0-7) Moderate to high (HADS score 8-21) p-value Questions on physical activity 71 (37%) 25 (44%) 0.34 78 (38%) 17 (39%) 0.96 Questions on nutrition 49 (26%) 26 (45%) 0.02 57 (28%) 18 (40%) 0.28 Questions on mood 29 (15%) 37 (65%) &amp;lt;0.001 43 (21%) 23 (52%) &amp;lt;0.001 Questions on smoking 3 (23%) 4 (50%) 0.35 5 (33%) 2 (33%) 1.00

Improvement in Physical Function After Coronary Artery Bypass Graft Surgery Using a Novel Rehabilitation Intervention: A RANDOMIZED CONTROLLED TRIAL.

Cardiorespiratory and skeletal muscle deconditioning occurs following coronary artery bypass graft surgery and hospitalization. Outpatient, phase 2 cardiac rehabilitation (CR) is designed to remediate this deconditioning but typically does not begin until several weeks following hospital discharge. Although an exercise program between discharge and the start of CR could improve functional recovery, implementation of exercise at this time is complicated by postoperative physical limitations and restrictions. Our objective was to assess the utility of neuromuscular electrical stimulation (NMES) as an adjunct to current rehabilitative care following postsurgical discharge and prior to entry into CR on indices of physical function in patients undergoing coronary artery bypass graft surgery. Patients were randomized to 4 wk of bilateral, NMES (5 d/wk) to their quadriceps muscles or no intervention (control). Physical function testing was performed at hospital discharge and 4 wk post-discharge using the Short Physical Performance Battery and the 6-min walk tests. Data from 37 patients (19 control/18 NMES) who completed the trial were analyzed. The trial was registered at ClinicalTrials.gov (NCT03892460). Physical function measures improved from discharge to 4 wk post-surgery across our entire cohort (P < .001). Patients randomized to NMES, however, showed greater improvements in 6-min walk test distance and power output compared with controls (P < .01). Our results provide evidence supporting the utility of NMES to accelerate recovery of physical function after coronary artery bypass graft surgery.

UK cardiac rehabilitation fit for purpose? A community-based observational cohort study

ObjectivesThis study aimed to characterise the exercise performed in UK cardiac rehabilitation (CR) and explore relationships between exercise dose and changes in physiological variables.DesignObservational cohort study.SettingOutpatient community-based CR in Leeds,...

To what extent is multi-morbidity associated with new onset depression in patients attending cardiac rehabilitation?

BackgroundDepression is associated with increased mortality and poor prognosis in patients with cardiovascular disease (CVD). However, little is known about the patient characteristics associated with new onset post heart event depressive symptoms, specifically medical comorbidities, among cardiac rehabilitation (CR) participants. Therefore, this paper examines the comorbidity profile and characteristics associated with new onset depressive symptoms in patients attending CR.MethodsAn observational study using the routine practice data of British Heart Foundation National Audit of Cardiac Rehabilitation (NACR) from the last six years between April 2012 and March 2018. Patients with new onset post heart event depression and no previous documented history of depression were selected as the study population. An independent samples t-test and chi square tests were used to compare the association between new onset depressive symptoms and patient variables including demographics, clinical measures and comorbidities. A binary logistic regression was conducted to investigate the predictors of new onset depressive symptoms employing log-likelihood ratio statistic.ResultsThe analyses included 109,055 CR patients with new onset depression measured by Hospital Anxiety and Depression Scale (HADS). At baseline assessment, comorbidity measures associated with new onset depressive symptoms were increased total number of comorbidities and a range of comorbidities - including diabetes, angina, arthritis, chronic back problems, asthma, stroke, anxiety, rheumatism, claudication, osteoporosis, chronic bronchitis and emphysema. After multivariate adjustments were done, at the start of CR, the significant predictors of new onset depressive symptoms were physical inactivity, high HADS anxiety score measurement, increased weight, total number of comorbidities, diabetes, stroke, chronic back problems, being from areas with higher levels of social deprivation, being single, and male.ConclusionThe research findings establish new insights into the association between patient demographic and clinical variables across a range of comorbidities in patients with new onset post heart event depressive symptoms. At the start of CR, patients with new onset depressive symptoms need to be assessed skilfully as they tend to have a complex multi-morbid presentation linked to psychosocial risk factors known to hinder CR engagement.

Factors associated with acute depressive symptoms in patients with comorbid depression attending cardiac rehabilitation

BackgroundThe literature suggests that comorbid depression, defined in this paper as a history of depression prior to a cardiovascular event, has an impact on later onset depression as well as constituting increased risk of mortality and adverse cardiac events. However, which factors are associated with depression, specifically in patients with comorbid depression, is unclear. Therefore, this paper investigates the factors associated with depression in patients with comorbid depression attending cardiac rehabilitation (CR).MethodsThis observational study used routinely collected data from the British Heart Foundation National Audit of Cardiac Rehabilitation for the time period between April 2012 and March 2017. CR participants with comorbid depression were selected as the study population. An independent t-test and chi-square test were used to compare the association between acute depression symptoms and baseline characteristics in this population.ResultsA total of 2715 CR patients with comorbid depression were analysed. Characteristics associated with acute depressive symptoms in patients with comorbid depression were found to be: young age (MD: 2.71, 95% CI 1.91, 3.50), increased number of comorbidities (MD: -0.50, 95% CI -0.66, − 0.34), increased weight (MD: -1.94, 95% CI -3.35, − 0.52), high BMI (MD: -1.94, 95% CI -3.35, − 0.52), HADS anxiety (MD: -5.17, 95% CI -5.47, − 4.87), comorbid anxiety (52.4%, p < 0.001), physical inactivity (150 min moderate physical activity a week and 75 min vigorous exercise a week; 27.5%, p < 0.001; 5.6%, p < 0.001 respectively), smoking (12.7%, p < 0.001), and being less likely to be partnered (63.6%, p < 0.001).ConclusionThe study demonstrated the association between a variety of clinical and socio-demographic factors and depression. The findings of the research indicated that, at CR baseline assessment, caution must be taken with patients with comorbid depression, specifically those with higher level depressive symptoms at the start of rehabilitation. Furthermore, their multi-comorbid condition must also be taken into account. Patients with higher depression symptoms and comorbid depression scored five points higher on the HADS anxiety scale in comparison to patients with lower level depression symptoms at the start of CR, which demonstrated that anxiety and depression are interrelated and present together.

Intention, beliefs and mood assessed using electronic diaries predicts attendance at cardiac rehabilitation: An observational study

BackgroundCardiac rehabilitationis effective in promoting physical/psychological recovery following acute coronary syndrome. Yet, rates of attendance at outpatient cardiac rehabilitation by eligible patients are low. ObjectivesThis study examined the determinants of attendance at outpatient cardiac rehabilitation in acute coronary syndrome patients following discharge until cardiac rehabilitation commencement. DesignA weekly electronic diary measured cardiac-related cognitions and mood and examined their relation to attendance at outpatient cardiac rehabilitation. SettingsThree United Kingdom National Health Service secondary care settings in two Health Board areas in Scotland. ParticipantsAcute coronary syndrome patients were recruited from March 2012 to June 2013 prior to hospital discharge. Of 488 eligible patients referred for cardiac rehabilitation, 214 consented. MethodsConsecutive patients completed a pre-hospital discharge questionnaire targeting age, diagnosis, social class and smoking history. Acute coronary syndrome patients then completed a weekly electronic diary from the first week of discharge until the start of cardiac rehabilitation. Multilevel structural equation models estimated the effects of initial, i.e. baseline and rate of change in cardiac-related cognition and mood on attendance. Intention to attend cardiac rehabilitation was reflected, log transformed, reported thereafter as “do not intend”. The role of “do not intend” was explored as a mediator of the relationship between cardiac-related cognition and mood on attendance. Results166 participants provided, on average, 5 weeks of diary entries before cardiac rehabilitation commenced. High intention (i.e. low “do not intend”) to attend CR and its rate of increase over time predicted attendance. Low negative emotional representation, high perceived necessity, high confidence in maintaining function, low negative affect, and high positive affect following discharge predicted attendance at cardiac rehabilitation. The rate of change in cardiac-related mood and these cognitions was not predictive. Baseline and rate of change in “do not intend” entirely mediated relationships between a) perceived necessity, b) negative affect and attendance at cardiac rehabilitation. ConclusionsNegative affect in the first weeks following discharge represents the key challenge to a patient maintaining their intention to attend cardiac rehabilitation. Intervention to improve attendance should focus on improving intention to attend following discharge and during recovery by improving patient understanding of cardiac rehabilitation and reducing negative affect.

Comparison of the Effects of Media-based and Face-to-face Cardiac Rehabilitation Training Programs on Self-efficacy in Patients Undergoing Coronary Artery Bypass Grafting

Background: Several complications may occur in patients after coronary artery bypass grafting (CABG) leading to decreased self-efficacy. Rehabilitation training is the best method for reducing the complications and increasing self-efficacy. Various educational techniques lead to different rehabilitation results and levels of self-efficacy. Improving these measures requires the selection of the most appropriate educational technique. Aim: This study aimed to compare the effect of two media-based and face-to-face cardiac rehabilitation training methods on self-efficacy in patients undergoing CABG. Method: This clinical trial was conducted among 60 patients, who were randomly assigned into two groups, in Imam Reza Hospital, Mashhad, Iran, 2017. Cardiac rehabilitation training program was implemented face-to-face or using a researcher-made multimedia upon admission, discharge, at the start of cardiac rehabilitation, and at the end of the 10th session for half-hour. A researcher-constructed questionnaire on self-efficacy was completed by the participants in the mentioned stages. Data analysis was performed in SPSS software, version 16. Results: The mean ages of the participants in the face-to-face and multimedia groups were 56.0±8.1 and 57.5±7.3 years old, respectively. No significant difference was observed in the self-efficacy scores of the patients upon admission (P=0.36). However, there was a significant difference between the groups at the post-intervention stage (P<0.001). Implications for Practice: Despite the lack of presence of an active teacher, media-based cardiac rehabilitation training improved the self-efficacy of patients undergoing CABG more than face-to-face method.

Exercise Training Workloads Upon Exit From Cardiac Rehabilitation in Men and Women

To describe exercise training workloads, estimated as metabolic equivalents of task (METs) both upon exit from cardiac rehabilitation (CR) and as the change in MET level following CR, stratified by age, sex, initial MET level, number of sessions completed, and qualifying event at entry into CR. A retrospective study involving 8319 (31% female) patients who completed ≥9 exercise training sessions in the early outpatient CR program at Henry Ford Hospital. Exercise training MET levels achieved during CR were estimated on the basis of the speed and grade recorded from a treadmill. Exercise training METs at the start of CR were defined as the average of the second and third sessions, whereas MET level upon exit from CR was determined from the average of the last 2 patient encounters. The overall mean MET level while training just prior to exit from CR was 3.9 ± 1.4 (4.1 ± 1.4 and 3.3 ± 1.0 in men and women, respectively). The mean change in METs after CR was 1.3 ± 1.1 (+45% ± 37%) and 0.9 ± 0.7 (+40% ± 32%) in men and women, respectively. In a large and demographically diverse cohort of patients who participated in CR, increases in mean workload (ie, METs) during exercise training were observed that approximated 45% in men and 40% in women. These data could be considered when establishing benchmarks for program-related performance outcome measures.

0240: Cardiac rehabilitation in diabetic patients

Diabetes mellitus (DM) is increasing in prevalence in France and is now more common in patients entering cardiac rehabilitation (CR). Only a few studies have focused on the effects of cardiac rehabilitation in patients with DM but it is still unclear if they gain the same benefit from a CR program as do non diabetics. The aim of this study was to compare the effects of exercise-based CR on cardiac risk factors and exercise parameters in a series of diabetic and non diabetic individuals. Between 2009 and 2013, 386 patients were consecutively referred to our institution after an acute cardiac event. Our CR program consists of 4 sessions per week for 5 weeks (total of 20 sessions) and includes both exercise and health and nutrition education sessions. Patients were divided into two groups according to their diabetic status. The prevalence of diabetis, in our ambulatory cardiac rehabilitation center was 29% (113 patients). Hypertension, obesity, and dyslipidemia were more common in diabetic vs non diabetic participants (P<0.001 for all). Diabetic patients had increased SBP, triglyceride concentrations, weight and carotid femoral pulse wave velocity (PWV), but decreased HDL concentrations compared with non diabetics at the start of CR (P<0.05 for all). Initial exercise capacity parameters (Wpeak, VO2 peak/kg, 6 minute walk test) were lower in diabetics vs nondiabetics (P<0.001). Both diabetics and non diabetics showed significant improvement in quality of life, SBP, DBP, lipid profile, and exercise capacity after CR. This study emphasizes similar beneficial effects of multidisciplinary CR program on exercice capacity and quality of life in patient with or without type 2 diabetes mellitus. A significant benefit can be seen after 5 weeks (20 sessions) of CR program.

Routine initial exercise stress testing for treatment stratification in comprehensive cardiac rehabilitation

There is evidence of substantial benefit of cardiac rehabilitation (CR) for patients with low exercise capacity at admission. Nevertheless, some patients are not able to perform an initial exercise stress test (EST). We aimed to describe this group using data of 1094 consecutive patients after a cardiac event (71±7 years, 78% men) enrolled in nine centres for inpatient CR. We analysed sociodemographic and clinical variables (e.g. cardiovascular risk factors, comorbidities, complications at admission), amount of therapy (e.g. exercise training, nursing care) and the results of the initial and the final 6-min walking test (6MWT) with respect to the application of an EST. Fifteen per cent of patients did not undergo an EST (non-EST group). In multivariable analysis, the probability of obtaining an EST was higher for men [odds ratio (OR) 1.89, P=0.01], a 6MWT (per 10 m, OR 1.07, P<0.01) and lower for patients with diabetes mellitus (OR 0.48, P<0.01), NYHA-class III/IV (OR 0.27, P<0.01), osteoarthritis (OR 0.39, P<0.01) and a longer hospital stay (per 5 days, OR 0.87, P=0.02). The non-EST group received fewer therapy units of exercise training, but more units of nursing care and physiotherapy than the EST group. However, there were no significant differences between both groups in the increase of the 6MWT during CR (123 vs. 108 m, P=0.122). The present study confirms the feasibility of an EST at the start of CR as an indicator of disease severity. Nevertheless, patients without EST benefit from CR even if exercising less. Thus, there is a justified need for individualized, comprehensive and interdisciplinary CR.