Machine learning models for assessing risk factors affecting health care costs: 12-month exercise-based cardiac rehabilitation.

Introduction: Exercise-based cardiac rehabilitation (ECR) has proven to be effective and cost-effective dominant treatment option in health care. However, the contribution of well-known risk factors for prognosis of coronary artery disease (CAD) to predict health care costs is not well recognized. Since machine learning (ML) applications are rapidly giving new opportunities to assist health care professionals' work, we used selected ML tools to assess the predictive value of defined risk factors for health care costs during 12-month ECR in patients with CAD. Methods: The data for analysis was available from a total of 71 patients referred to Oulu University Hospital, Finland, due to an acute coronary syndrome (ACS) event (75% men, age 61 ± 12 years, BMI 27 ± 4 kg/m2, ejection fraction 62 ± 8, 89% have beta-blocker medication). Risk factors were assessed at the hospital immediately after the cardiac event, and health care costs for all reasons were collected from patient registers over a year. ECR was programmed in accordance with international guidelines. Risk analysis algorithms (cross-decomposition algorithms) were employed to rank risk factors based on variances in their effects. Regression analysis was used to determine the accounting value of risk factors by entering first the risk factor with the highest degree of explanation into the model. After that, the next most potent risk factor explaining costs was added to the model one by one (13 forecast models in total). Results: The ECR group used health care services during the year at an average of 1,624 ± 2,139€ per patient. Diabetes exhibited the strongest correlation with health care expenses (r = 0.406), accounting for 16% of the total costs (p < 0.001). When the next two ranked markers (body mass index; r = 0.171 and systolic blood pressure; r = - 0.162, respectively) were added to the model, the predictive value was 18% for the costs (p = 0.004). The depression scale had the weakest independent explanation rate of all 13 risk factors (explanation value 0.1%, r = 0.029, p = 0.811). Discussion: Presence of diabetes is the primary reason forecasting health care costs in 12-month ECR intervention among ACS patients. The ML tools may help decision-making when planning the optimal allocation of health care resources.

Participation and Prognostic Impact of Cardiac Rehabilitation After Acute Coronary Syndrome: Big-Data Study of the Korean National Health Insurance Service.

BACKGROUND: To investigate the actual rate and quality of cardiac rehabilitation (CR) participation in South Korea and its short-term impact on clinical outcomes after acute coronary syndrome (ACS). METHODS: Data, including confirmed ACS diagnosis, socio-demographics, comorbidities, clinical outcomes, and CR claim codes, were collected from the Korean National Health Insurance Service claims database and compared between the CR and non-CR groups. RESULTS: Overall, 102,544 patients were included in the study, of which only 5.8% attended CR. Regarding testing, 83.6% of CR patients performed the cardiopulmonary exercise test, but follow-up testing was infrequently performed; in addition, 53.1% of them participated in an electrocardiogram monitoring exercise, but over half participated in only one session. After 1:1 propensity score matching, post-ACS cardiovascular events were significantly lower in the CR group than in the non-CR group. The cumulative 3-year hazard ratio for all-cause death was 0.612 (95% confidence interval [CI], 0.495-0.756), recurrent ACS was 0.92 (95% CI, 0.853-0.993), CR readmission was 0.817 (95% CI, 0.768-0.868), and major adverse cardiovascular events (MACE) was 0.827 (95% CI, 0.781-0.874) in the CR group. CR was associated with a significant dose-response effect on MACE, with a reduction in incidence from 0.854 to 0.711. CONCLUSION: The actual rate of CR participation in South Korea remains low, and participation quality was not outstanding despite National Health Insurance coverage. Nevertheless, the impact of CR on cardiovascular outcomes after ACS was significantly superior. Efforts to increase CR participation should be increased by establishing new CR facilities and strategies to resolve associated barriers.

Association of Perceived Health Competence With Cardiac Rehabilitation Initiation.

PURPOSE: Cardiac rehabilitation (CR), a program of supervised exercise and cardiovascular risk management, is widely underutilized. Psychological factors such as perceived health competence, or belief in one's ability to achieve health-related goals, may play a role in CR initiation. The aim of this study was to evaluate the association of perceived health competence with CR initiation among patients hospitalized for acute coronary syndrome (ACS) after adjusting for demographic, clinical, and psychosocial characteristics. METHODS: The Vanderbilt Inpatient Cohort Study (VICS) characterized the effect of psychosocial characteristics on post-discharge outcomes in ACS inpatients hospitalized from 2011 to 2015. The primary outcome for this analysis was participation in an outpatient CR program. The primary predictor was the two-item Perceived Health Competence Scale (PHCS-2), which yields a score from 2 to 10 (higher scores indicate greater perceived health competence). Multiple logistic regression was used to evaluate the relationship between the PHCS-2 and CR initiation. RESULTS: A total of 1809 VICS participants (median age: 61 yr, 39% female) with ACS were studied, of whom 294 (16%) initiated CR. The PHCS-2 was associated with a higher odds of CR initiation (OR = 1.15/point increase: 95% CI, 1.06-1.26, P = .001) after adjusting for covariates. Participants with comorbid heart failure had a lower odds of CR initiation (OR = 0.31: 95% CI, 0.16-0.60, P < .001) as did current smokers (OR = 0.64: 95% CI, 0.43-0.96, P = .030). CONCLUSION: Perceived health competence is associated with outpatient CR initiation in patients hospitalized with ACS. Interventions designed to support perceived health competence may be useful for improving CR participation.

[Anti-smoking intervention in the acute phase of acute coronary syndrome: Is there additional benefit in patients included in a cardiac rehabilitation program?] / Intervención antitabaco en fase aguda del síndrome coronario agudo: ¿existe beneficio adicional en pacientes incluidos en un programa de rehabilitación cardiaca?

BACKGROUND: Smoking is a challenge in secondary prevention after acute coronary syndrome (ACS). The objective was to assess whether the early anti-smoking intervention (ASI), in the acute hospitalization phase, improves the abstinence rate obtained during a cardiac rehabilitation program (CRP). METHODS: Multicenter clinical trial in which smoker patients admitted for ACS were randomized 1:1 to receive or not ASI from the first day of admission. Upon discharge, both groups were referred to the CRP, performing abstinence controls using co-oximetry. Patients lost were considered smokers. RESULTS: 72 patients were included, 58 men (80.5%), mean age 53 ± 8.1 years. They were admitted for ST elevation myocardial infarction 42 (58%), non-ST elevation myocardial infarction 29 (40%) and unstable angina 1 (1.3%). They smoked an average of 22 ± 11.3 cigarettes/day (pack-year index 37 ± 20). They completed the Richmond test (8.8 ± 1.3) and Fagestrom (5.69 ± 2.1). 36 patients (50%) were randomized to ASI, with no differences in the baseline characteristics of both groups. The dropout rate at the time of inclusion in CRP was higher in the ASI group (69 vs. 44%; p 0.034; OR 2.84), without statistical significance at discharge from the CRP (58 vs. 50%; p 0.478; OR 1.4) or at 12 months (58 vs. 44%; p 0.24; OR 1.75). CONCLUSIONS: The ASI during admission significantly improves the smoking cessation rate at the time of inclusion in the CRP. Part of these beneficial effects are reduced in the follow-up losing statistical significance with respect to the control group.

Trends and Factors Associated With Cardiac Rehabilitation Participation　- Data From Japanese Nationwide Databases.

BACKGROUND: Few studies have comprehensively evaluated the trends and factors associated with CR participation across major cardiovascular diseases in Japan.Methods and Results: This study performed a nationwide cross-sectional study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan and the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination database. This study described the nationwide trends and evaluated patient- and hospital-level associated factors of CR participation for patients with acute heart failure (AHF), acute coronary syndrome (ACS), acute aortic dissection (AAD), peripheral artery disease (PAD), and after cardiovascular surgery using mixed-effect logistic regression analysis. Although the annual number of patients who underwent CR has increased during the study period, the total number of patients participating in outpatient CR was lower than that of inpatient CR. The outpatient CR participation rate was lower for patients with AHF (3.5%), AAD (3.2%), and PAD (1.7%), compared with ACS (7.9%) and after surgery (9.4%). Age, sex, body mass index, Barthel index, Charlson comorbidity index, and institutional capacity were identified as significant associated factors of CR participation in inpatient and outpatient settings. CONCLUSIONS: Participation in outpatient CR was still low, and higher age, multi-comorbidity, and low institutional capacity contributed to the lower outpatient CR participation rate. Identification of the associated factors may help cardiologists to increase CR participation.

The impact of a comprehensive pharmaceutical care intervention in addition to cardiac rehabilitation program on outcomes of post-acute coronary syndrome patients: A pilot study.

OBJECTIVE: To test the efficacy of Comprehensive pharmaceutical care intervention added to cardiac rehabilitation program(CR programs) in improving echocardiographic parameters, nutritional status and High sensitivity C-Reactive Protein(hs-CRP), in post-acute coronary syndrome patients. METHODS: A prospective; randomized, controlled study. 40 post-acute coronary syndrome patients, participating in CR program, were randomly allocated to either the control group(n = 20) or the intervention group(n = 20). Pharmaceutical care intervention included face-to-face education about the disease, healthy lifestyle, medication adherence, drug related problems management and goal setting. hs-CRP and cardiac parameters were measured at baseline and after 3 months. RESULTS: After three months,the intervention group showed a significant decrease in left ventricular end systolic volume (p = 0.0026) and left ventricular end diastolic volume (p = 0.0009) compared to the control group. Also, intervention group showed a significant increase in nutritional status (p = 0.037) and the patients' knowledge about the disease and drugs (p = 0.0001). However, there was no significant change in hscrp level between groups. CONCLUSION: Our findings indicate that Comprehensive pharmaceutical care intervention added to CR programs significantly improved cardiac parameters and nutritional status. This is best explained by increasing adherence to cardiovascular medications and to healthier lifestyle and optimizing medication knowledge and doses. PRACTICE IMPLICATIONS: Implementing Comprehensive pharmaceutical care intervention added to CR programs could improve the cardiac function and nutritional status of post-acute coronary syndrome patients.

Cost-Effectiveness of Posthospital Management of Acute Coronary Syndrome: A Real-World Investigation From Italy.

OBJECTIVES: This study aimed to assess the cost-effectiveness profile of adherence to recommendations for the community management of patients discharged with a diagnosis of acute coronary syndrome (ACS). METHODS: The cohort of 50 282 residents in the Lombardy Region (Italy) who were discharged with a diagnosis of ACS during 2011 to 2015 was followed up until 2018. Adherence to selected recommendations including drug therapies (DTs), outpatient controls, and rehabilitation, experienced during the first year after index discharge, was considered. Adherent and nonadherent cohort members were matched on high-dimensional propensity scores. Composite clinical outcomes (cardiovascular hospital admissions and all-cause mortality) and healthcare costs were assessed for a time horizon of 5 years. Cost-effectiveness profile of adherence to recommendations was measured through the incremental cost-effectiveness ratio, that is, the incremental cost for 1 day free from the composite clinical outcome. RESULTS: Adherence to DTs, outpatient controls, and rehabilitation, respectively, regarded 39%, 81%, and 3% of cohort members. Compared with nonadherent patients, those adherent to DTs, outpatient controls, and rehabilitation had (1) a delay in the occurrence of the composite clinical outcome of 50, 43, and 73 days, respectively, and (2) lower (on average, €199 per year for DTs) and higher costs (€292 and €1024 for outpatient controls and rehabilitation). Cost-effectiveness profiles were better for patients with myocardial infarction than those with angina and for patients with more severe clinical complexity than those with milder conditions. CONCLUSIONS: Health-related and economic benefits are expected from improving adherence to international guidelines recommendations concerning outpatient treatments and monitoring of patients with ACS.

Effect of aerobic training on exercise capacity and quality of life in patients older than 75 years with acute coronary syndrome undergoing percutaneous coronary intervention.

BACKGROUND: Limited clinical studies are available on early exercise-based cardiac rehabilitation in elderly acute coronary syndrome (ACS) patients. OBJECTIVE: To evaluate the effect of aerobic exercise on exercise capacity and quality of life (QoL) in such patients. METHODS: Seventy elderly patients with ACS undergoing percutaneous coronary intervention in Zhejiang Hospital during August 2016-June 2017 were randomly divided into the control (n = 35) or cardiac rehabilitation group (CR, n = 35). The control group was treated with standard medical treatments without exercise, whereas the CR group was treated with standard medical treatments and exercise-based cardiac rehabilitation. General information, cardiopulmonary exercise test (CPET) results, responses to QoL and mental health questionnaires, and clinical outcomes and safety were collected. RESULTS: The CR group safely finished CPET and the 12-week exercise-based cardiac rehabilitation. After the 12-week intervention, the CR group showed significant differences in maximal oxygen uptake (VO2max) and greater improvements in VO2max, compared with the control group. The CR group showed statistically significant differences in QoL and mental health compared with the control group. CONCLUSION: CPET-based exercise in cardiac rehabilitation can safely increase exercise capacity and QoL in such patients.

Determinants of Functional Improvement After Cardiac Rehabilitation in Acute Coronary Syndrome.

INTRODUCTION: Cardiac rehabilitation (CR) is an effective tool for secondary prevention after acute coronary syndrome (ACS). AIM: Aim of our study was to find the significant determinants of exercise capacity (evaluated with the six-minute walking test-6-MWT) and functional improvement in patients undergoing CR after an ACS. METHODS: The study group included 298 patients (mean age 61.6 ± 10.2 years; males 80.2%) who, after ACS, were enrolled in CR program at Niguarda Hospital in Milan from 2015 to 2018. For all patients, we collected anamnestic, clinical and instrumental cardiological data. All patients performed a 6-MWT at the beginning (6-MWT-1) and at the end (6-MWT-2) of CR program. Δ meters were used to represent functional improvement. RESULTS: Multiple linear regression models were carried out for 6-MWT-1, 6-MWT-2, Δ meters and % Δ meters. Standardized regression coefficients showed that age (ß = - 0.237; p < 0.001), BMI (ß = - 0.116; p = 0.006) and heart rate (ß = - 0.082; p = 0.040) were determinants of exercise capacity (6MWT-1 and 2), whereas age (ß = -.231; p = 0.004), sex (ß = - 0.187; p = 0.008) and BMI (ß = - 0.164; p = 0.022) were determinants of functional improvement (Δ meters). CONCLUSIONS: Our data showed that functional improvement after CR in ACS patients is mainly related to non-cardiological variables. Instead it is related to intrinsic factors, both modifiable (BMI) and non-modifiable (age, sex).

Interhospital and interindividual variability in secondary prevention: a comparison of outpatients with a history of chronic coronary syndrome versus outpatients with a history of acute coronary syndrome (the iASPIRE Study).

BACKGROUND: Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes. METHODS: We studied outpatients who had an index CHD event in the preceding 6-24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods. RESULTS: Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation. CONCLUSIONS: Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

Comparison of the improvement of flow-mediated dilatation in patients with acute coronary syndrome versus stable angina after six-month cardiac rehabilitation.

BACKGROUND: We investigated whether the improvement in endothelial function, measured using flow-mediated dilatation (FMD), an important predictor of cardiovascular outcomes, was comparable in acute coronary syndrome (ACS) versus stable angina patients after percutaneous coronary intervention (PCI) and a six-month cardiac rehabilitation (CR) programme. METHODS: We analysed the results from 119 patients who completed a six-month CR programme after successful PCI for stable angina (n = 50) and ACS (n = 69). RESULTS: After six months of CR, the results of FMD were significantly improved in both groups. There were no significant between-group differences in the FMD results at the six-month follow up. CONCLUSIONS: After successful PCI and a six-month CR programme, FMD values were equally improved in both stable angina and ACS patients.

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes: a randomized controlled trial.

BACKGROUND: There are well-documented treatment gaps in secondary prevention of coronary heart disease with a lack of clearly defined strategies to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. OBJECTIVES: The primary goal of this study was to assess whether a smartphone-based, early cardiac rehabilitation program improved exercise capacity in patients with ACS. METHODS: A total of 206 patients with ACS across six tertiary Australian hospitals were included in this randomized controlled trial. Participants were randomized to usual care (UC; including referral to traditional cardiac rehabilitation), with or without an adjunctive smartphone-based cardiac rehabilitation program (S-CRP) upon hospital discharge. The primary endpoint was change in exercise capacity, measured by the change in 6-minute walk test distance at 8 weeks when compared to baseline, between groups. Secondary endpoints included uptake and adherence to cardiac rehabilitation, changes in cardiac risk factors, psychological well-being and quality of life status. RESULTS: Of the 168 patients with complete follow-up (age 56 ± 10 years; 16% females), 83 were in the S-CRP. At 8-week follow-up, the S-CRP group had a clinically significant improvement in 6-minute walk test distance (Δ117 ± 76 vs. Δ91 ± 110 m; P = 0.02). Patients in the S-CRP were more likely to participate (87% vs. 51%, P < 0.001) and adhere (72% vs. 22%, P < 0.001) to a cardiac rehabilitation program. Compared to UC, patients receiving S-CRP had similar smoking cessation rates, LDL-cholesterol levels, blood pressure reduction, depression, anxiety and quality of life measures (all P = NS). CONCLUSION: In patients with ACS, a S-CRP, as an adjunct to UC improved exercise capacity at 8 weeks in addition to participation and adherence to cardiac rehabilitation (Australian New Zealand Clinical Trials Registry; ACTRN12616000426482).

Effects of neuromuscular training compared to classic strength-resistance training in patients with acute coronary syndrome: A study protocol for a randomized controlled trial.

The aim of the present clinical trial is to evaluate the effectiveness of neuromuscular versus classical strength-resistance training as part of a cardiac rehabilitation programme in patients following acute coronary syndrome. The study is designed as a double-blinded, randomised, and controlled clinical trial. Thirty participants suffering from acute coronary syndrome who meet our inclusion criteria will be recruited by a private tertiary hospital. The intervention group will follow 20 sessions of a cardiac rehabilitation programme divided into two parts: aerobic training and neuromuscular strength-resistance training. The control group will complete the same aerobic training as well as a classical strength-resistance training workout programme. The primary outcome of the study will be the mean difference in change from baseline in the Incremental Shuttle Walking Test. The secondary outcomes will be the cardiorespiratory fitness of the patients (assessed by means of the Chester Step Test), lower-limb performance (assessed with the 30-Second Chair Stand Test and Single-Leg Squat Test), lower-limb strength (hip flexor handheld dynamometry), sexual dysfunction assessment (Sex Health Inventory for Men) and quality of life (EQ-5D-5L). This work will provide evidence for the effectiveness of a neuromuscular versus a classic strength-training programme in terms of cardiorespiratory fitness, lower-limb performance capacities and quality of life, in cardiac patients. The data obtained could lead to more effective and functional workouts which, in turn, may enhance the speed at which these patients can return to their everyday activities of life and improve the efficiency of their movement patterns and heart responses. Furthermore, patients may find neuromuscular workout routines more motivating and engaging, thus encouraging them to adopt healthier lifestyle patterns.

Cardiac rehabilitation activities during the COVID-19 pandemic in Italy. Position Paper of the AICPR (Italian Association of Clinical Cardiology, Prevention and Rehabilitation).

The COVID-19 outbreak is having a significant impact on both cardiac rehabilitation (CR) inpatient and outpatient healthcare organization. The variety of clinical and care scenarios we are observing in Italy depends on the region, the organization of local services and the hospital involved. Some hospital wards have been closed to make room to dedicated beds or to quarantine the exposed health personnel. In other cases, CR units have been converted or transformed into COVID-19 units.  The present document aims at defining the state of the art of CR during COVID-19 pandemic, through the description of the clinical and management scenarios frequently observed during this period and the exploration of the future frontiers in the management of cardiac rehabilitation programs after the COVID-19 outbreak.

Prevalence of obstructive sleep apnoea in acute coronary syndrome patients: systematic review and meta-analysis.

BACKGROUND: Obstructive Sleep Apnoea (OSA) has been recognised as a risk factor for cardiovascular diseases such as hypertension and cardiovascular events such as acute coronary syndrome (ACS). Since it is also known to reduce exercise tolerance, it is important to establish the prevalence of OSA in ACS patients, particularly in those who are commencing cardiac rehabilitation (CR) programs. METHODS: Using PRISMA guidelines a systematic search was conducted in order to identify studies that objectively measured (using polysomnography or portable monitoring) the prevalence of OSA in ACS patients following hospital admission. A data extraction table was used to summarise study characteristics and the quality of studies were independently assessed using the Joanna Briggs Institute Prevalence Critical Appraisal Tool. Meta-analysis of the selected studies was conducted in order to estimate OSA prevalence as a function of the two main methods of measurement, the severity of OSA, and timing of the OSA assessment following ACS hospital admission. RESULTS: Pooled prevalence estimates of OSA using the "gold standard" polysomnography ranged from 22% for severe OSA to 70% for mild OSA, at any time after hospital admission. Similar prevalence estimates were obtained using portable monitoring, but interpretation of these results are limited by the significant heterogeneity observed among these studies. CONCLUSIONS: Prevalence of OSA following ACS is high and likely to be problematic upon patient entry into CR programs. Routine screening for OSA upon program entry may be necessary to optimise effectiveness of CR for these patients.

Functional Improvement After Outpatient Cardiac Rehabilitation in Acute Coronary Syndrome Patients is Not Related to Improvement in Left Ventricular Ejection Fraction.

INTRODUCTION: Cardiac rehabilitation (CR) improves the functional capacity and the prognosis of patients with coronary artery disease. AIM: Our study was aimed at assessing the relationship between functional improvement (evaluated with 6-min Walk Test-6MWT) and the improvement in left ventricular ejection fraction (LVEF) after CR. METHODS: We collected data from 249 patients (age 66.79 ± 11.06 years; males 81.52%) with a recent history of Acute Coronary Syndrome that performed CR. The functional improvement after CR was expressed as the Δ between distance covered at the final versus the initial 6-min Walking Test (6-MWT), while LVEF was calculated with transthoracic echocardiogram at the beginning and at the end of the CR. RESULTS: Patients were divided accordingly to their pre-rehab LVEF (≥ 55% vs < 55%). With superimposable age and baseline 6MWT distance covered (434.58 vs 405.12 m, p = 0.08), the latter group presented higher Δ meter values at 6MWT (167.93 vs 193.97 m, p = 0.018). However, no statistically significant positive correlation between Δ meters and Δ LVEF was found. Moreover, linear regression analyses found that nor baseline LVEF nor Δ LVEF were significant determinants of Δ meters when considering the whole group, with age, basal 6MWT and peak CK-MB as additional covariates in the model. CONCLUSION: Although it could be expected that an increase in LVEF is related to the functional improvement after CR, no significant correlation was found in our population.

Dose-Response Effect of a Digital Health Intervention During Cardiac Rehabilitation: Subanalysis of Randomized Controlled Trial.

BACKGROUND: Previous data have validated the benefit of digital health interventions (DHIs) on weight loss in patients following acute coronary syndrome entering cardiac rehabilitation (CR). OBJECTIVE: The primary purpose of this study was to test the hypothesis that increased DHI use, as measured by individual log-ins, is associated with improved weight loss. Secondary analyses evaluated the association between log-ins and activity within the platform and exercise, dietary, and medication adherence. METHODS: We obtained DHI data including active days, total log-ins, tasks completed, educational modules reviewed, medication adherence, and nonmonetary incentive points earned in patients undergoing standard CR following acute coronary syndrome. Linear regression followed by multivariable models were used to evaluate associations between DHI log-ins and weight loss or dietary adherence. RESULTS: Participants (n=61) were 79% male (48/61) with mean age of 61.0 (SD 9.7) years. We found a significant positive association of total log-ins during CR with weight loss (r2=.10, P=.03). Educational modules viewed (r2=.11, P=.009) and tasks completed (r2=.10, P=.01) were positively significantly associated with weight loss, yet total log-ins were not significantly associated with differences in dietary adherence (r2=.05, P=.12) or improvements in minutes of exercise per week (r2=.03, P=.36). CONCLUSIONS: These data extend our previous findings and demonstrate increased DHI log-ins portend improved weight loss in patients undergoing CR after acute coronary syndrome. DHI adherence can potentially be monitored and used as a tool to selectively encourage patients to adhere to secondary prevention lifestyle modifications. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01883050); https://clinicaltrials.gov/ct2/show/NCT01883050.

Association Between Exercise Capacity and Health-Related Quality of Life During and After Cardiac Rehabilitation in Acute Coronary Syndrome Patients: A Substudy of the OPTICARE Randomized Controlled Trial.

OBJECTIVE: To examine the strength of the association between exercise capacity and health-related quality of life (HRQOL) during and after cardiac rehabilitation (CR) in patients with acute coronary syndrome (ACS) who completed CR. DESIGN: Prospective cohort study. SETTING: Outpatient CR center. PARTICIPANTS: Patients (N=607) with ACS who completed CR. INTERVENTIONS: Multidisciplinary 12-week exercise-based CR program. MAIN OUTCOME MEASURES: At baseline (pre-CR), the 6-Minute Walk Test (6MWT) was performed to determine exercise capacity, and the MacNew Heart Disease Health-related Quality of Life questionnaire was used to assess HRQOL. Measurements were repeated immediately after completion of CR (post-CR): at 12 months and 18 months follow-up. Multivariable linear regression, including an interaction term for time and exercise capacity, was applied to study the association between exercise capacity and HRQOL at different time points relative to CR, whereas model parameters were estimated by methods that accounted for dependency of repeated observations within individuals. RESULTS: Mean age in years ± SD was 58±8.9 and 82% of participants were male. Baseline mean 6MWT distance in meters ± SD was 563±77 and median (25th-75th percentile) global HRQOL was 5.5 (4.6-6.1) points. Mean 6MWT distance (P<.001) and the global (P<.001), physical (P<.001), emotional (P<.001) and social (P<.001) domains of HRQOL improved significantly during CR and continued to improve during follow-up post-CR. Independent of the timing relative to CR (ie, pre-CR, post-CR, or during follow-up), a difference of 10 m 6MWT distance was associated with a mean difference in the global HRQOL domain of 0.007 (95% confidence interval [CI], 0.001-0.014) points (P=.029) and a mean difference in the physical domain of 0.009 (95% CI, 0.001-0.017) points (P=.023). CONCLUSIONS: Better exercise capacity was significantly associated with higher scores on the global and physical domains of HRQOL, irrespective of the timing relative to CR, albeit these associations were weak. Hence, CR programs in secondary prevention should continue to aim at enhancing both HRQOL and exercise capacity.

Effects of high-intensity interval training on platelet function in cardiac rehabilitation: a randomised controlled trial.

OBJECTIVE: To compare effects of moderate-intensity continuous training (MICT) and high-intensity interval training (HIIT) on platelet function in patients undergoing cardiac rehabilitation, as hyper-reactive platelets are involved in atherogenesis and atherothrombosis. METHODS: In this single-centre parallel group randomised controlled trial, male patients after an acute coronary syndrome under dual antiplatelet therapy performed MICT or HIIT+MICT for 12 weeks. Main outcome was platelet reactivity measured by the half-maximal concentration (EC50) of platelet agonist thrombin receptor-activating peptide-6 (TRAP-6) in terms of P-selectin expression. EC50 was determined at baseline, after 6 and 12 weeks, each time at physical rest and on exertion. RESULTS: 82 patients were randomised to MICT or HIIT+MICT. Mean (95% CI) baseline EC50values at physical rest were 6.7 µM (6.3 µM to 7.0 µM) TRAP-6. After 6/12 weeks, 36/33 MICT and 34/28 HIIT+MICT patients were examined. HIIT+MICT patients had 0.9 µM (0.4 µM to 1.4 µM)/0.5 µM (-0.1 µM to 1.0 µM) higher EC50values than MICT ones, and the propensity of their platelets to form aggregates with monocytes was significantly lower after 12 weeks. Short-term strenuous physical exertion was generally associated with platelet activation and an EC50reduction of 0.7 µM (0.6 µM to 0.8 µM). HIIT+MICT patients tended to be fitter after 12 weeks. No serious harms were observed. CONCLUSIONS: Including HIIT in cardiac rehabilitation seems to confer additional benefits compared with MICT alone, which should be confirmed in clinical trials with hard endpoints. Exertion-induced platelet activation and hyper-reactivity occur despite dual antiplatelet therapy. TRIAL REGISTRATION NUMBER: NCT02930330; Results.

Bridging the intention-behavior gap for cardiac rehabilitation participation: the role of perceived barriers.

Purpose: Patients referred to cardiac rehabilitation after an acute coronary syndrome event commonly report strong intention to attend, but at least one-third do not participate. This study explored whether well-documented cardiac rehabilitation barriers (e.g., comorbidities, logistical/time constraints, and low social support) moderate the association between intention to participate and actual program enrollment and attendance.Method: Following referral but prior to commencing a 12-week outpatient cardiac rehabilitation program, 100 patients with acute coronary syndrome completed measures of intention to attend cardiac rehabilitation, perceived cardiac rehabilitation barriers, and social support. Program enrollment and attendance were determined by chart review.Results: Despite high reported intention to attend (M = 6.08/7.00, SD = 1.80), nearly one-in-five did not enroll. Weaker intention to attend (b = 0.46, SE = 0.16, p = 0.004) and greater cardiac rehabilitation barriers (b= -1.67, SE = 0.70, p = 0.017) corresponded to lower program enrollment. Similarly, weaker intention (b = 2.29, SE = 0.50, p < 0.001) and greater barriers (b =-6.19, SE = 1.55, p < 0.001) predicted poorer attendance. Barriers moderated the association between intention to participate and cardiac rehabilitation enrollment (b=-0.60, SE = 0.29, p = 0.037) and attendance (b = -3.12, SE = 1.02, p = 0.003).Conclusions: Perceived cardiac rehabilitation barriers influence whether patients successfully translate their intention to attend into actual program participation. Enhancing self-efficacy to overcome barriers may represent an important intervention target among prospective cardiac rehabilitation patients.Implications for RehabilitationPatients with acute coronary syndrome report strong intention to attend cardiac rehabilitation upon referral, yet cardiac rehabilitation programs remain underutilized.Assessing and addressing perceived barriers during the transition to cardiac rehabilitation, even when patients present as highly motivated to attend, may be critical to promoting program uptake.Rehabilitation professionals should ask patients about specific barriers to attending cardiac rehabilitation (e.g., financial constraints, transportation problems) and provide individualized solutions (e.g., fee subsidization, home- or web-based programs) to increase participation.