Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Support for diabetes using technology: a pilot study to improve self-management.

Technology may assist people living with type 2 diabetes with self-management. A pilot study that used Apple iPad technology to support diabetes self-management is described.

A program to provide resources and support for clinical associates.

Clinical associates are necessary and valued contributors to nursing education. All those involved in student instruction need to have clearly defined expectations that are aligned with the conceptual framework and program outcomes. Additionally, they must have the necessary resources to facilitate their ability to effectively instruct and evaluate nursing students in the clinical setting. Preparing competent clinical associates to provide effective clinical instruction requires detailed planning and development that includes guided mentoring from faculty. This article describes the development of an orientation course and ongoing resources and support designed to facilitate the transition into a clinical instructor role for registered nurses teaching in a baccalaureate nursing program. The Clinical Associate Resources and Support program was designed to enhance learning experiences for both clinical associates and the recipients of clinical education, nursing students.

Exercise as a treatment for the risk of cardiovascular disease.

OPINION STATEMENT: Regular physical activity decreases the risk of cardiovascular disease and modifies multiple cardiovascular risk factors. The optimum amount of exercise continues to generate debate; however, the general recommendation is that all adults should engage in 30 min of moderate-intensity physical activity on five, and preferably all, days of the week. Despite extensive data and recommendations, a significant proportion of the US adult population remains sedentary. Promoting physical activity at a public level remains a major challenge because of the presence of multiple behavioral, physical, and environmental barriers. Health care providers have an opportunity and a responsibility to include exercise counseling in routine office visits.

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Secondary prevention outcomes among black and white cardiac rehabilitation patients.

BACKGROUND: Disparities in coronary heart disease and related risk factors persist. It is unknown if cardiac rehabilitation (CR) narrows the gap in risk factor control between black and white patients. Thus, we compared baseline characteristics and secondary prevention outcomes between black and white CR patients. METHODS: Data from patient records (n = 616, mean age 62 +/- 10 years, 29% women, 25% black) collected between January 1996 and June 2006 were examined. Comparisons were made between Blacks and Whites for baseline characteristics, changes in secondary prevention measures during CR, and the proportion of patients at treatment goals before and after CR. General linear regression modeling was used to determine the effect of race/ethnicity on outcomes. RESULTS: At baseline, Blacks had more hypertension and diabetes and more adverse measures for blood pressure, low-density lipoprotein and non-high-density lipoprotein cholesterol (non-HDL-C), hemoglobin A1c, 6-minute walk distance, and Short-Form Health Survey (SF-36) physical component score. At CR completion, improvement (P < .05) was achieved among whites in all measures except for HDL-C and systolic blood pressure. Among Blacks, improvement did not reach significance for HDL-C, body mass index, waist circumference, and hemoglobin A1c (when diabetes was present). When adjusting for age, gender, number of sessions attended, and baseline measure, Whites improved more than Blacks in 6-minute walk distance, self-reported physical activity, body mass index, waist circumference, low-density lipoprotein cholesterol, and hemoglobin A1c (all P < .05). CONCLUSION: Blacks entered CR with more adverse risk factor measures compared with Whites. Although both groups gained secondary prevention benefits, the degree of improvement was less for Blacks than Whites, and this was especially evident among black women.

Assessing Physical Activity as a Core Component in Cardiac Rehabilitation: A POSITION STATEMENT OF THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION.

Physical inactivity is a well-established major risk factor for cardiovascular disease. As such, physical activity counseling is 1 of the 10 core components of cardiac rehabilitation/secondary prevention programs recommended by the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). In addition, the ability to perform a physical activity assessment and report outcomes is 1 of the 10 core competencies of cardiac rehabilitation/secondary prevention professionals published by the AACVPR. Unfortunately, standardized procedures for physical activity assessment of cardiac rehabilitation patients have not been developed and published. Thus, the objective of this AACVPR statement is to provide an overview of physical activity assessment concepts and procedures and to provide a recommended approach for performing a standardized assessment of physical activity in all comprehensive cardiac rehabilitation programs following the core components recommendations.

Women in cardiac rehabilitation: outcomes and identifying risk for dropout.

BACKGROUND: Women are underrepresented in cardiac rehabilitation (CR). Few reports describe outcomes and explore factors that may be barriers to CR participation among women. The purposes of this study were to (1) compare baseline characteristics between women who completed and did not complete CR, (2) identify factors associated with women completing CR, and (3) describe outcomes among completers. METHODS: Study sample included women (n = 228) with coronary heart disease enrolled in CR at an academic medical center's program (January 1996-August 2003). Baseline differences between completers and noncompleters were compared; multivariate regression analyses identified factors associated with completers. Outcome measures included lipid levels, 6-minute walk distances, body mass index, Beck Depression Inventory II (BDI-II), self-reports of diet, physical activity, smoking, and perceived health status. RESULTS: Mean age was 62 +/- 11 years, 44% were nonwhite, and 42% were stratified as high risk. Dyslipidemia was the most common risk factor (85%) followed by hypertension (81%), low physical activity (74%), obesity (53%), diabetes (39%), and smoking (18%). BDI-II scores were elevated (> or = 14) in 31% of women. In the adjusted multivariate regression model, completers were less likely to be obese (adjusted odds ratio [AOR] 0.28, CI 0.10-0.76, P = .01) or have elevated BDI-II scores (AOR 0.87, CI 0.81-0.95 P = .001) than noncompleters. Completers achieved significant improvements in all outcome measures (all P < .05) except for high-density lipoprotein. CONCLUSION: Women enrolled in CR had a high risk factor burden and those completing achieved significant benefits. Women not completing CR were more likely to be obese or have depressive symptoms which may serve as barriers to completing CR.

Heart Failure as a Newly Approved Diagnosis for Cardiac Rehabilitation: Challenges and Opportunities.

Many see the broadened eligibility of cardiac rehabilitation (CR) to include heart failure with reduced ejection fraction (HFrEF) as a likely catalyst to high CR enrollment and improved care. However, such expectation contrasts with the reality that CR enrollment of eligible coronary heart disease patients has remained low for decades. In this review, entrenched obstacles impeding utilization of CR are considered, particularly in relation to potential HFrEF management. The strengths and limitations of the HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise Training) trial to advance precepts of CR are considered, as well as gaps that this trial failed to address, such as the utility of CR for patients with heart failure with preserved ejection fraction and the conundrum of poor patient adherence.

Quantitative study of correlates of physical activity in women from diverse racial/ethnic groups: Women's Cardiovascular Health Network Project--introduction and methodology.

BACKGROUND: Physical activity is an important aspect of cardiovascular disease prevention. However, data show a high prevalence of physical inactivity among women and ethnic minority and low-income populations. The purpose of this introduction is to describe the Women's Cardiovascular Health Network Project and implementation of the Women and Physical Activity Survey. The goal of the survey was to identify personal, social environmental, and physical environmental factors that are associated with physical activity status among diverse groups of women. METHODS: Seven universities were funded to study factors that influence physical activity among African-American, Native American, Latina, and white women residing in rural, suburban, and urban living environments. An ecologic model was used to design a quantitative questionnaire that was implemented by telephone or face-to-face interviews in seven sites across the United States. RESULTS: The survey was completed by a total 4122 women, with group totals ranging from 300 to 1000. Results from each site are presented in individual articles in this issue. A summary of results that compare and contrast the groups is presented in an additional report. CONCLUSION: This study provides important information on the assessment of physical activity among women. Results can be used to help improve assessments and to develop more effective policies and interventions for unique groups of women.

Personal, social, and physical environmental correlates of physical activity in rural African-American women in Alabama.

BACKGROUND: Physical inactivity is prevalent among African-American women in rural Alabama. The purpose of this study was to explore personal, social, and physical environmental factors associated with activity to help plan interventions. METHODS: As part of the Women's Cardiovascular Health Network Project, telephone surveys were collected from African-American women residing in three rural counties. The women reported the number of minutes engaged in moderate or vigorous activities and were categorized into the following groups: (1) inactive (no moderate or vigorous activities), (2) insufficient (not meeting recommendations), and (3) meets recommendations (engaged in moderate activity five times per week for at least 30 minutes or vigorous activity three times per week for at least 20 minutes). Logistic regression modeling was used to identify personal, social, and physical environmental factors associated with the more active groups. RESULTS: Among the 567 women who were classified in physical activity groups, 221 (39%) met the recommendations, 260 (46%) were insufficiently active, and 86 (15%) were inactive. In the adjusted model, the social environmental factors associated with women meeting the recommendations (versus inactive) were attending religious services and seeing people exercise in the neighborhood. Attending religious services, knowing people who exercise, and a higher social issue score were associated with women who reported any activity (versus inactive). No physical environmental factors were associated with the more active groups. CONCLUSIONS: Social environmental factors were associated with higher levels of activity and need to be considered when planning interventions. More research is needed to identify associations between specific aspects of the social environment and physical activity behaviors.

Physical activity patterns among women in rural Alabama.

OBJECTIVE: To explore factors associated with physically active women in a rural community. METHODS: Physical activity patterns were assessed in 585 women in rural Alabama. RESULTS: When combining leisure and nonleisure activities, 68% of women reported > or = 150 minutes per week. Active African American women tended to be younger (AOR 0.97), married (AOR 1.75), less likely to report arthritis (AOR 0.58), or give health (AOR 0.30) or motivational reasons (AOR 0.39) for not being more active; active white women were less likely to report lower health perception (AOR 0.51). CONCLUSION: Ethnic differences in factors associated with higher activity levels need to be considered in physical activity interventions.

International Charter on Cardiovascular Prevention and Rehabilitation: a call for action.

Cardiovascular disease remains the leading cause of death in both women and men globally and is a growing epidemic in low- to middle-income countries. Without systematic access to cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and suffer unnecessarily premature death. The 2 aims of this Charter are (1) to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation and (2) to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation. The Global Charter on CR calls to action those responsible for administering patient care to (a) establish CR as an obligatory, not optional service, and (b) to support countries to establish and augment programs of CR to ensure broad access to these proven services. In addition, the Charter calls for CR organizations and associations in high-income countries to collaborate with those in low- to middle-income countries, to support capacity building and provide tangible toolkits for program development and maintenance. The aim of this Charter is to maintain and grow this global consortium through partnerships with international organizations and to consider and communicate ongoing consensus of evidence-based standards for CR worldwide.

Writing for publication: faculty development initiative using social learning theory.

Demonstrating scholarly competency is an expectation for nurse faculty. However, there is hesitancy among some faculty to fully engage in scholarly activities. To strengthen a school of nursing's culture of scholarship, a faculty development writing initiative based on Social Learning Theory was implemented. The authors discuss this initiative to facilitate writing for publication productivity among faculty and the successful outcomes.

Cardiac rehabilitation outcomes: impact of comorbidities and age.

PURPOSE: Medical comorbidities (CM) contribute to cardiac rehabilitation (CR) underutilization. Whether individuals with coronary heart disease and an increased CM burden achieve similar benefits from CR as those with a low CM burden is unknown. METHODS: We analyzed 794 patients with coronary heart disease completing CR from 1/96 to 4/08. Medical CM burden was assessed using a comorbidity index (CMI) previously validated in a CR population. Distance achieved on a 6-minute walk test, body mass index, and the physical and mental component scores on the Medical Outcomes Short Form 36 were measured at baseline and at CR completion. We performed multivariable linear regression to compare changes in these parameters between individuals with a low CM burden (CMI = 0) and those with a moderate (CMI = 1-2) or high (CMI > 2) CM burden by age group (<56, 56-65, and >65 years of age). RESULTS: Mean age was 61.6 ± 10.6 years, 29% were women, 31% nonwhite; 305 individuals had a CMI = 0, 305 had a CMI = 1 to 2, and 184 had a CMI > 2. All subgroups, regardless of age or CMI, demonstrated improvements with CR on virtually all parameters measured. Among individuals younger than 56 years, those with a CMI = 0 had greater improvements in these parameters after multivariable adjustment than those with a CMI of 1 to 2 or more than 2. In contrast, in older age groups, the degree of improvement was similar regardless of CMI. CONCLUSION: All patient groups, regardless of CM burden, benefited from CR. Medical CM burden, especially among older patients, should not discourage referral to CR.

Core competencies for cardiac rehabilitation/secondary prevention professionals: 2010 update: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation.

Cardiac rehabilitation/secondary prevention (CR/SP) services are typically delivered by a multidisciplinary team of health care professionals. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognizes that to provide high-quality services, it is important for these health care professionals to possess certain core competencies. This update to the previous statement identifies 10 areas of core competencies for CR/SP health care professionals and identifies specific knowledge and skills for each core competency. These core competency areas are consistent with the current list of core components for CR/SP programs published by the AACVPR and the American Heart Association and include comprehensive cardiovascular patient assessment; management of blood pressure, lipids, diabetes, tobacco cessation, weight, and psychological issues; exercise training; and counseling for psychosocial, nutritional, and physical activity issues.

Clinical research in cardiac rehabilitation and secondary prevention: looking back and moving forward.

Cardiac rehabilitation/secondary prevention (CR/SP) programs are considered standard of care and provide critically important resources for optimizing the care of cardiac patients. The objective of this article is to briefly review the evolution of CR/SP programs from a singular exercise intervention to its current, more comprehensive multifaceted approach. In addition, we offer perspective on critical concerns and suggest future research considerations to optimize the effectiveness and utilization of CR/SP program interventions.