The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada.

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.

En dépit des avancées importantes de la recherche médicale et des efforts en santé publique, il reste des lacunes dans les connaissances sur la santé cardiaque des femmes sur les plans de l'épidémiologie, du tableau clinique, de la prise en charge, des résultats, de l'éducation, de la recherche et des publications. Du point de vue historique, la cardiopathie a d'abord été perçue comme une maladie qui touchait les hommes et les individus de sexe masculin. De ce fait, la compréhension des risques particuliers et des symptômes qu'éprouvent les femmes est limitée. Ces lacunes dans les connaissances posent particulièrement problème puisqu'à l'échelle mondiale la cardiopathie est la cause principale de décès chez les femmes. Jusqu'à récemment, la recherche en cardiologie, notamment la recherche préclinique et clinique, ne portait pas sur le sexe et le genre. Le recrutement souvent limité aux participants masculins et aux individus dont l'identité de genre correspond au sexe masculin et l'absence d'analyses de données en fonction du sexe ou du genre ont eu pour conséquence un manque de données sur la façon dont les traitements et les interventions nuisent aux patientes féminines et aux individus dont l'identité de genre correspond au sexe féminin, et ce, de façon différente. Cette absence de données a mené à un traitement sous-optimal et à des limites de notre compréhension des mécanismes sous-jacents de la cardiopathie chez les femmes, et est directement reliée à nos connaissances limitées, et à nos lacunes en formation professionnelle et en éducation du public. Le fait que les femmes ne connaissent souvent pas leurs facteurs de risque de maladies du cœur ou les symptômes qu'elles peuvent éprouver entraîne des retards de diagnostic et de traitements. De plus, le fait que les prestataires de soins de santé ne reçoivent pas la formation adéquate pour poser le diagnostic et traiter la cardiopathie chez les femmes les mène à poser un mauvais diagnostic ou à ne pas traiter suffisamment. Pour pallier ces lacunes de connaissances, il faut une approche à plusieurs volets, qui porte notamment sur l'éducation et les changements dans les politiques, et qui repose sur la recherche fondée sur des données probantes. Dans ce chapitre, nous passons en revue l'état actuel de la recherche existante sur les maladies cardiovasculaires au Canada, plus particulièrement chez les femmes.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Women's Knowledge of Future Cardiovascular Risk Associated With Complications of Pregnancy: A Systematic Review.

Background: Several common pregnancy conditions significantly increase a woman's risk of future cardiovascular diseases (CVD). Patient education and interventions aimed at awareness and self-management of cardiovascular risk factors may help modify future cardiovascular risk. The aim of this systematic review was to examine education interventions for cardiovascular risk after pregnancy, clinical measures/scales, and knowledge outcomes in published qualitative and quantitative studies. Methods: Five databases were searched (from inception to June 2023). Studies including interventions and validated and nonvalidated measures of awareness/knowledge of future cardiovascular risk among women after complications of pregnancy were considered. Quality was rated using the Mixed Methods Appraisal Tool. Results were analyzed using the Synthesis Without Meta-analysis reporting guideline. Characteristics of interventions were reported using the Template for Intervention Description and Replication. Fifteen studies were included; 3 were randomized controlled trials. Results: In total, 1623 women had a recent or past diagnosis of hypertensive disorders of pregnancy, gestational diabetes mellitus, and/or premature birth. Of the 7 studies that used online surveys or questionnaires, 2 reported assessing psychometric properties of tools. Four studies used diverse educational interventions (pamphlets, information sheets, in-person group sessions, and an online platform with health coaching). Overall, women had a low level of knowledge about their future CVD risk. Interventions were effective in increasing this knowledge. Conclusions: In conclusion, women have a low level of knowledge of risk of CVD after pregnancy complications. To increase this level of knowledge and self-management, this population has a strong need for psychometrically validated tailored education interventions.

Contexte: Plusieurs problèmes médicaux liés à la grossesse augmentent significativement le risque d'une maladie cardiovasculaire (MCV) ultérieure chez les femmes. L'éducation des patients et les interventions axées sur la sensibilisation aux facteurs de risques cardiovasculaire et sur l'autoprise en charge pourraient aider à limiter le risque de MCV. La présente analyse des études qualitatives et quantitatives publiées visait à examiner les interventions éducatives au sujet des risques cardiovasculaires après la grossesse, les mesures et échelles cliniques qui y sont associées, et les résultats de ces interventions sur le plan des connaissances. Méthodologie: Des recherches ont été réalisées dans cinq bases de données (de leur date de création jusqu'à juin 2023). Les études considérées incluaient des interventions et des mesures validées ou non de la sensibilisation des femmes au sujet des risques de MCV après des complications liées à la grossesse ou de leurs connaissances à ce sujet. La qualité des études a été évaluée avec l'Outil d'évaluation de la qualité méthodologique des études incluses dans une revue mixte, et les résultats ont été évalués à l'aide de la méthodologie Synthesis Without Meta-analysis. Les caractéristiques des interventions ont été relevées selon le modèle Template for Intervention Description and Replication. Quinze études ont été retenues, dont 3 essais contrôlés randomisés. Résultats: Au total, 1623 femmes avaient reçu récemment ou auparavant un diagnostic de trouble hypertensif lié à la grossesse, de diabète gestationnel et/ou de travail prématuré. Parmi les 7 études ayant eu recours à des questionnaires ou des sondages en ligne, 2 mentionnaient l'évaluation des propriétés psychométriques des outils. Dans 4 études, plusieurs interventions éducatives ont été utilisées (dépliants, feuillets informatifs, séances de groupe en personne et plateforme en ligne offrant un accompagnement en matière de santé). De manière générale, le niveau de connaissance des femmes au sujet de leur risque de MCV était faible, mais les interventions se sont révélées efficaces pour améliorer ces connaissances. Conclusions: En conclusion, les femmes ne connaissent pas bien les risques de MCV associés aux complications survenues au cours de la grossesse. Pour améliorer le niveau des connaissances et l'autoprise en charge, des interventions conçues pour cette population et validées sur le plan psychométrique sont indispensables.

Development of an Algorithm to Screen for Frailty Using the Clinical Frailty Scale with Postoperative Patients Entering Cardiac Rehabilitation.

Purpose: Frailty is not commonly assessed on intake to cardiac rehabilitation (CR), but screening could enable targeted interventions and potentially reduce secondary complications. This study aimed to develop and retrospectively examine the feasibility of utilizing a CR-specific algorithm based on the Clinical Frailty Scale (CFS). Our CFS-CR algorithm endeavoured to screen for frailty in older adults (> 65 y) entering CR following cardiac surgery/procedure. Method: The charts of 30 former patients (mean age: 74.0 ± 6.9 y) were examined by a clinician working in CR. Results: The clinician was unable to score any of the patients based on their medical charts using the CFS-CR due to insufficient data. Documentation was typically limited in the areas of instrumental and basic activities of daily living whereas exercise data were readily available. Conclusions: Current intake documentation in CR limited the ability to retrospectively screen for frailty. This finding suggests a need for a frailty-specific tool to support routine clinical screening. Prospective evaluation of the CFS-CR is warranted to further examine the clinical utility of the algorithm during CR intake assessments.

Objectif: la fragilité est peu évaluée à l'admission en réadaptation cardiaque (RC), mais le dépistage pourrait permettre de cibler des interventions et peutêtre de réduire les complications secondaires. La présente étude visait à créer un algorithme de RC d'après l'échelle de fragilité clinique (ÉFC) et à procéder à une analyse rétrospective pour déterminer la faisabilité de l'utiliser. L'algorithme ÉFC-RC était conçu pour dépister la fragilité chez les personnes âgées (de 65 ans ou plus) qui arrivaient en RC après une opération ou une intervention cardiaque. Méthodologie: une clinicienne qui travaillait en RC a examiné les dossiers de 30 anciens patients (âge moyen de 74,0 ± 6,9 ans). Résultats: la clinicienne n'a pu mesurer les résultats d'aucun patient d'après leur dossier médical au moyen de l'ÉFC-RC en raison de données insuffisantes. Les éléments du dossier se limitaient généralement aux activités déterminantes et courantes de la vie quotidienne, tandis que les données sur les exercices étaient facilement accessibles. Conclusions: l'information contenue dans les dossiers d'admission actuels en RC limitait la possibilité de procéder à l'analyse rétrospective de la fragilité. Cette observation laisse croire à la nécessité de concevoir un outil axé sur la fragilité pour contribuer au dépistage clinique systématique. Une évaluation prospective de l'ÉFC-RC s'impose pour mieux analyser l'utilité clinique de l'algorithme lors des évaluations à l'admission en RC.

Artificial intelligence-driven virtual rehabilitation for people living in the community: A scoping review.

Virtual Rehabilitation (VRehab) is a promising approach to improving the physical and mental functioning of patients living in the community. The use of VRehab technology results in the generation of multi-modal datasets collected through various devices. This presents opportunities for the development of Artificial Intelligence (AI) techniques in VRehab, namely the measurement, detection, and prediction of various patients' health outcomes. The objective of this scoping review was to explore the applications and effectiveness of incorporating AI into home-based VRehab programs. PubMed/MEDLINE, Embase, IEEE Xplore, Web of Science databases, and Google Scholar were searched from inception until June 2023 for studies that applied AI for the delivery of VRehab programs to the homes of adult patients. After screening 2172 unique titles and abstracts and 51 full-text studies, 13 studies were included in the review. A variety of AI algorithms were applied to analyze data collected from various sensors and make inferences about patients' health outcomes, most involving evaluating patients' exercise quality and providing feedback to patients. The AI algorithms used in the studies were mostly fuzzy rule-based methods, template matching, and deep neural networks. Despite the growing body of literature on the use of AI in VRehab, very few studies have examined its use in patients' homes. Current research suggests that integrating AI with home-based VRehab can lead to improved rehabilitation outcomes for patients. However, further research is required to fully assess the effectiveness of various forms of AI-driven home-based VRehab, taking into account its unique challenges and using standardized metrics.

Evidence-informed development of women-focused cardiac rehabilitation education.

BACKGROUND: Despite their differential risk factor burden, context and often different forms of heart disease, cardiac rehabilitation (CR) programs generally do not provide women with needed secondary prevention information specific to them. OBJECTIVE: to co-design evidence-informed, theory-based comprehensive women-focused education, building from Health e-University's Cardiac College for CR. METHODS: A multi-disciplinary, multi-stakeholder steering committee (N = 18) oversaw the four-phase development of the women-focused curriculum. Phase 1 involved a literature review on women's CR information needs and preferences, phase 2 a CR program needs assessment, phase 3 content development (including determining content and mode, assigning experts to create the content, plain language review and translation), and phase 4 will comprise evaluation and implementation. In phase 2, a focus group was conducted with Canadian CR providers; it was analyzed using Braun and Clarke's iterative approach. RESULTS: Nineteen providers participated in the focus group, with four themes emerging: current status of education, challenges to delivering women-focused education, delivery modes and topical resources. Results were consistent with those from our related global survey, supporting saturation of themes. Co-designed educational materials included 19 videos. These were organized across 5 webpages in English and French, specific to tests and treatments, exercise, diet, psychosocial well-being, and self-management. Twelve corresponding session slide decks with notes for clinicians were created, to support program delivery in CR flexibly. CONCLUSION: While further evaluation is underway, these open-access CR education resources will be disseminated for implementation, to support women in reducing their risk of cardiovascular sequelae.

Conceptualization of frailty in rehabilitation interventions with adults: a scoping review.

Purpose: We aimed to synthesize the literature that considered frailty in the evaluation of rehabilitation interventions for adults (aged ≥18) by answering: (1) how is frailty defined in rehabilitation intervention research?; (2) how is frailty operationalized in rehabilitation intervention research?; (3) what are the characteristics of rehabilitation interventions for frail adults and what frailty related outcomes are assessed?Materials and methods: A scoping review was conducted. Data were analyzed using descriptive statistics and qualitative content analysis.Results: 53 articles met the inclusion criteria. Most studies were conducted in Europe and involved randomized control trials. The included studies reported on rehabilitation interventions that only included individuals aged 50 or older. Thirteen studies used Fried's definition of frailty, but most (n = 27) did not use any definition. Many studies did not differentiate between the conceptualization (e.g., definition) and operationalization (e.g., use of inclusion/exclusion criteria, outcome measures) of frailty. Most interventions focused on exercise. Instrumental activities of daily living reported most frequently as outcomes (n = 11).Conclusions: There is an absence of consistent definitions of frailty in rehabilitation interventions and current definitions tend to focus on physical functioning. The authors suggest rehabilitation researchers consider an expanded definition of frailty informed by the International Classification of Functioning, Disability and Health framework.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals should use an expanded definition of frailty, informed by the International Classification of Functioning, Disability and Health framework, should include physical, mental, personal, environmental, and social factors to decrease, delay, or prevent frailty in adults.Rehabilitation professionals should consider a broader operationalization of frailty that is not dependent on age and physical functioning.Rehabilitation professionals that consider a broader conceptualization of frailty should tailor interventions to the specific needs of frail adults.

Use of Digital Health Technology in Heart Failure and Diabetes: a Scoping Review.

Use of digital health technologies (DHT) in chronic disease management is rising. We aim to evaluate the impact of DHT on clinical outcomes from randomized controlled trials (RCTs) of patients with heart failure (HF) and diabetes mellitus (DM). Electronic databases were searched for DHT RCTs in patients with HF and DM until February 2021. Patient characteristics and outcomes were analyzed. One published (N = 519) and 6 registered (N = 3423) eligible studies were identified, with one study exclusively including HF and DM patients. Median DHT monitoring was 12 months, with six studies using mobile platforms as their key exposure. Clinical outcomes included quality-of-life or self-care surveys (n = 1 each), physical activity metrics, changes in biomarkers, and other clinical endpoints (n = 3). Limited data exist on RCTs evaluating DHT in patients with concomitant HF and DM. Further work should define standardized clinical endpoints and platforms that can manage patients with multiple comorbidities.

The impact of facility-based transitional care programs on function and discharge destination for older adults with cognitive impairment: a systematic review.

BACKGROUND: Older adults with cognitive impairment are frequently hospitalized and discharged to facility-based transitional care programs (TCPs). However, it is unknown whether TCPs are effective in improving their functional status and promoting discharge home rather than to long-term care. The aims of this systematic review were to examine the effectiveness of facility-based TCPs on functional status, patient and health services outcomes for older adults (≥ 65 years) with cognitive impairment and to determine what proportion post TCP are discharged home compared to long-term care. METHODS: The Joanna Briggs Institute Critical Appraisal Manual for Evidence Synthesis was used to guide the methodology for this review. The protocol was published in PROSPERO (registration number CRD42021257870). MEDLINE, CINAHL, PsycINFO, the Cochrane Library, and EMBASE databases, and ClinicalTrials.gov and the World Health Organization Trials Registry were searched for English publications. Studies that met the following criteria were included: community-dwelling older adults ≥ 65 years who participated in facility-based TCPs and included functional status and/or discharge destination outcomes. Studies with participants from nursing homes and involved rehabilitation programs or transitional care in the home or in acute care, were excluded. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Results are in narrative form. RESULTS: Twenty-two studies (18 cohort and four cross sectional studies) involving 4,013,935 participants met inclusion criteria. The quality of the studies was mostly moderate to good. Improvement in activities of daily living (ADLs) was reported in eight of 13 studies. Between 24.4%-68% of participants were discharged home, 20-43.9% were hospitalized, and 4.1-40% transitioned to long-term care. Review limitations included the inability to perform meta-analysis due to heterogeneity of outcome measurement tools, measurement times, and patient populations. CONCLUSIONS: Facility-based TCPs are associated with improvements in ADLs and generally result in a greater percentage of participants with cognitive impairment going home rather than to long-term care. However, gains in function were not as great as for those without cognitive impairment. Future research should employ consistent outcome measurement tools to facilitate meta-analyses. The level of evidence is level III-2 according to the National Health and Medical Research Council for cohort and cross-sectional studies.

Peer-support interventions for women with cardiovascular disease: protocol for synthesising the literature using an evidence map.

INTRODUCTION: The leading cause of death for women is cardiovascular disease (CVD), including ischaemic heart disease, stroke and heart failure. Previous literature suggests peer support interventions improve self-reported recovery, hope and empowerment in other patient populations, but the evidence for peer support interventions in women with CVD is unknown. The aim of this study is to describe peer support interventions for women with CVD using an evidence map. Specific objectives are to: (1) provide an overview of peer support interventions used in women with ischaemic heart disease, stroke and heart failure, (2) identify gaps in primary studies where new or better studies are needed and (3) describe knowledge gaps where complete systematic reviews are required. METHODS AND ANALYSIS: We are building on previous experience and expertise in knowledge synthesis using methods described by the Evidence for Policy and Practice Information (EPPI) and the Coordinating Centre at the Institute of Education. Seven databases will be searched from inception: CINAHL, Embase, MEDLINE, APA PsycINFO, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials, and Scopus. We will also conduct grey literature searches for registered clinical trials, dissertations and theses, and conference abstracts. Inclusion and exclusion criteria will be kept broad, and studies will be included if they discuss a peer support intervention and include women, independent of the research design. No date or language limits will be applied to the searches. Qualitative findings will be summarised narratively, and quantitative analyses will be performed using R. ETHICS AND DISSEMINATION: The University of Toronto's Research Ethics Board granted approval on 28 April 2022 (Protocol #42608). Bubble plots (ie, weighted scatter plots), geographical heat/choropleth maps and infographics will be used to illustrate peer support intervention elements by category of CVD. Knowledge dissemination will include publication, presentation/public forums and social media.

Physical Activity Level and Perspectives of Participants Transitioning from Onsite to Virtual Cardiac Rehabilitation during the Early COVID-19 Pandemic: A Mixed-Method Study.

This mixed-method study aimed to compare physical activity (PA) patterns of a cross-over cardiac rehabilitation (CR) cohort with a center-based CR cohort and to explore barriers and facilitators of participants transitioning and engaging in virtual CR. It included the retrospective self-reported PA of a cross-over CR cohort (n = 75) and a matched center-based CR cohort (n = 75). Some of the participants included in the cross-over cohort (n = 12) attended semi-structured focus group sessions and results were interpreted in the context of the PRECEDE-PROCEED model. Differences between groups were not observed (p > 0.05). The center-based CR cohort increased exercise frequency (p = 0.002), duration (p = 0.007), and MET/minutes (p = 0.007) over time. The cross-over cohort increased exercise duration (p = 0.04) with no significant change in any other parameters. Analysis from focus groups revealed six overarching themes classified under predisposing factors (knowledge), enabling factors (external support, COVID-19 restrictions, mental health, personal reasons/preferences), and reinforcing factors (recommendations). These findings suggest an improvement of the PA levels of center-based CR cohort participants pre-pandemic and mitigated improvement in those who transitioned to a virtual CR early in the pandemic. Improving patients' exercise-related knowledge, provider endorsements, and the implementation of group videoconferencing sessions could help overcome barriers to participation in virtual CR.

The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 6: Sex- and Gender-Specific Diagnosis and Treatment.

This chapter summarizes the sex- and gender-specific diagnosis and treatment of acute/unstable presentations and nacute/stable presentations of cardiovascular disease in women. Guidelines, scientific statements, systematic reviews/meta-analyses, and primary research studies related to diagnosis and treatment of coronary artery disease, cerebrovascular disease (stroke), valvular heart disease, and heart failure in women were reviewed. The evidence is summarized as a narrative, and when available, sex- and gender-specific practice and research recommendations are provided. Acute coronary syndrome presentations and emergency department delays are different in women than they are in men. Coronary angiography remains the gold-standard test for diagnosis of obstructive coronary artery disease. Other diagnostic imaging modalities for ischemic heart disease detection (eg, positron emission tomography, echocardiography, single-photon emission computed tomography, cardiovascular magnetic resonance, coronary computed tomography angiography) have been shown to be useful in women, with their selection dependent upon both the goal of the individualized assessment and the testing resources available. Noncontrast computed tomography and computed tomography angiography are used to diagnose stroke in women. Although sex-specific differences appear to exist in the efficacy of standard treatments for diverse presentations of acute coronary syndrome, many cardiovascular drugs and interventions tested in clinical trials were not powered to detect sex-specific differences, and knowledge gaps remain. Similarly, although knowledge is evolving about sex-specific difference in the management of valvular heart disease, and heart failure with both reduced and preserved ejection fraction, current guidelines are lacking in sex-specific recommendations, and more research is needed.

Ce chapitre présente un résumé sur le diagnostic et le traitement des tableaux cliniques aigus/instables et non aigus/stables des maladies cardiovasculaires chez les femmes, et les différences propres à chacun des deux sexes. Les lignes directrices, les énoncés scientifiques, les revues systématiques/méta-analyses et les études de recherche originale sur le diagnostic et le traitement des coronaropathies, des maladies vasculaires cérébrales (AVC), des valvulopathies cardiaques et de l'insuffisance cardiaque chez les femmes ont été examinés. Les données probantes sont résumées sous forme narrative et, lorsqu'elles sont disponibles, des recommandations en matière de pratique et de recherche pour chacun des deux sexes sont présentées. Les tableaux cliniques du syndrome coronarien aigu et les délais d'attente à l'urgence sont différents selon qu'une femme ou un homme en est atteint. L'angiographie coronarienne reste l'examen de référence pour le diagnostic des coronaropathies obstructives. D'autres examens d'imagerie diagnostique (p. ex. la tomographie par émission de positons, l'échocardiographie, la tomographie d'émission à photon unique, la résonance magnétique cardiovasculaire, l'angiographie coronarienne par tomodensitométrie) se sont avérés utiles pour la détection des cardiopathies ischémiques chez les femmes. Le recours à ces modalités dépend de l'objectif de l'évaluation personnalisée et des ressources disponibles. La tomodensitométrie sans agent de contraste et l'angiographie par tomodensitométrie sont utilisées pour le diagnostic des AVC chez les femmes. Malgré les différences entre les sexes quant à l'efficacité des traitements de référence des divers tableaux cliniques du syndrome coronarien aigu, bon nombre des médicaments et des interventions cardiovasculaires qui ont fait l'objet d'essais cliniques n'avaient pas la puissance statistique nécessaire pour détecter des différences selon les sexes, de sorte que les connaissances restent fragmentaires sur ce sujet. De même, malgré l'évolution des connaissances sur les différences sexuelles quant à la prise en charge des valvulopathies cardiaques et de l'insuffisance cardiaque avec fraction d'éjection réduite ou préservée, on ne trouve pas de recommandations pour chaque sexe dans les lignes directrices actuelles, d'où la pertinence d'études supplémentaires portant sur cette question.

Breast cancer survivors' physical activity and experiences while transitioning to a virtual cardiovascular rehabilitation program during a pandemic (COVID-19).

Breast cancer accounts for 25% of all cancers among Canadian females. Despite successes of decreased mortality, adverse treatment effects, such as cardiotoxicity, contribute to a sedentary lifestyle and decreased quality of life. Physical activity (PA) is a possible therapy for the late effects; however, COVID-19 restricted access to in-person cardiovascular rehabilitation (CR) programs. The purposes are as follows: (1) compare PA of breast cancer survivors' in-person CR to virtual CR following a transition during COVID-19 and (2) compare the PA of the pandemic cohort to a matched cohort who had completed the program in 2018/2019; (3) explore survivors' experiences of transitioning to and engaging in virtual CR. Mixed methods included analysis of CR PA data from a pandemic cohort (n = 18) and a 2018/2019 cohort (n = 18) and semi-structured focus group interviews with the pandemic cohort (n = 9) in the context of the PRECEDE-PROCEED model. After the transition, there were no significant differences in mean activity duration, frequency, and cumulative activity (expressed as MET-minutes) (p > 0.05). However, variation of PA duration doubled following the transition from in-person to virtual (p = 0.029), while for the 2018/2019 cohort, variation remained unchanged. Focus groups revealed that women valued their CR experiences pre-COVID-19 and had feelings of anxiety during the transition. Perceived factors affecting participation were environmental, personal, and behavioural. Recommendations for virtual programs were to increase comradery, technology, and professional guidance. PA experiences during a transition to virtual care prompted by a pandemic vary among breast cancer survivors. Targeting individualised strategies and exercise prescriptions are important for improving PA programs and patient outcomes.

A Social-Ecological Perspective of the Perceived Barriers and Facilitators to Virtual Education in Cardiac Rehabilitation: A MIXED-METHODS APPROACH.

PURPOSE: This study explored the perceived barriers and facilitators to participation in patients who did and did not attend virtual cardiac rehabilitation (CR) education sessions. METHODS: A mixed-methods approach was used. Virtual patient education was delivered during the coronavirus-19 pandemic. Phase 1 included a cross-sectional online survey completed by individuals who did and did not participate in these sessions. For phase 2, six virtual focus group sessions were conducted using the social-ecological framework to guide thematic analysis and interpretation of findings. RESULTS: Overall, 106 online surveys were completed; 60 (57%) attended Cardiac College Learn Online (CCLO) sessions only, one (1%) Women with Heart Online (WwHO) only, 21 (20%) attended both, and 24 (22%) did not attend virtual sessions. Half of the participants who attended virtual sessions viewed between one and four sessions. Most participants were from Canada (95%) and included the Toronto Rehabilitation Institute/Toronto Western Hospital centers (76%). Focus group findings revealed six overarching themes: Intrapersonal (mixed emotions/feelings; personal learning preferences); Interpersonal (desire for warmth of human contact and interaction); Institutional (the importance of external endorsement of sessions); and Environmental (technology; perceived facilitators and barriers). CONCLUSION: These findings highlight the unprecedented situation that patients and CR programs are facing during the pandemic. Virtual patient education may be more accessible, convenient, and responsive to the complex needs of these CR participants.

Profile of women choosing mixed-sex, women-only, and home-based cardiac rehabilitation models and impact on utilization.

This study compared characteristics and program utilization in women electing to participate in mixed-sex, women-only, or home-based cardiac rehabilitation (CR). In this retrospective cohort study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017-February 2020 were analyzed. There were 727 women (74.7% mixed, 22.0% women-only, 3.3% home-based) who initiated CR. There were significantly more women who were not working in women-only than mixed-sex (80.4% vs 64.1%; P = .009). Session adherence was significantly greater with mixed-sex (58.8 ± 28.9% sessions attended/25) than women-only (54.3 ± 26.3% sessions attended/25; P = .046); program completion was significantly lower with home-based (33.3%) than either supervised model (59.7%; P = .035). Participation in women-only CR may be less accessible. Further research is needed to investigate offering remote women-focused sessions or peer support.

Exploring the perspectives of outpatient rehabilitation clinicians on the challenges with monitoring patient health, function and activity in the community.

PURPOSE: Rehabilitation clinicians need information about patient activities in the home/community to inform care. Despite active efforts to develop technologies that can meet this need, clinicians' perspectives regarding how information is collected and used in outpatient rehabilitation have not been comprehensively described. Therefore, we aimed to describe: (1) what data pertaining to a patient's health, function and activity in their home/community are currently collected in outpatient rehabilitation, (2) how these data can impact clinical decisions, and (3) what challenges clinicians encounter when they manage the care of outpatients based on this information. MATERIALS AND METHODS: Eight clinicians working in outpatient rehabilitation programs completed qualitative interviews that were analyzed using an inductive thematic analysis. RESULTS: Four themes were identified: "Nature of data about a patient's health, function and activity in the home/community and how it is collected by clinicians," "Value of data from the home/community," "Perceived drawbacks of current data collection methods," and "Improving data collection to understand patient trajectory." CONCLUSIONS: Clinicians described the importance of understanding patient activities in the home/community, but perspectives varied regarding the suitability of current methods. These perceptions may inform the design of solutions to bridge the gap between the clinic and the community in outpatient rehabilitation.Implications for rehabilitationClinical decision-making in outpatient rehabilitation is guided by verbal and written reports about a patient's health and function in the community and adherence to treatment plans.Differing perceptions on the suitability of current data collection methods indicate that the development of new solutions, such as rehabilitation technologies, needs to carefully consider clinician workflows and what data are perceived as meaningful.Potentially impactful directions for new solutions include providing well validated data on adherence, movement quality, or longitudinal progression, presented in formats that match clinical decision criteria.

Capturing the perspectives of women with coronary artery disease regarding interval training or continuous exercise in cardiac rehabilitation.

BACKGROUND: Motivators and barriers to exercise participation in women with coronary artery disease remain poorly understood. With evidence suggesting that women with coronary artery disease are less likely to adhere to exercise during cardiac rehabilitation and are more likely to drop out, it is important to understand these factors in order to optimize cardiac rehabilitation programs for women. METHODS: We contribute to the discussion by presenting findings from a qualitative study using two focus groups with nine women with coronary artery disease sharing their experiences with attending cardiac rehabilitation and exercising in this setting, in addition to their perceived motivators and barriers to performing aerobic interval training. Focus group transcripts were analysed using a deductive thematic approach with Bandura's Social Cognitive Theory as the guiding conceptual framework. RESULTS: Four themes were identified regarding the attitudes and experiences of attending and exercising at cardiac rehabilitation, while five themes capturing the motivators and barriers for these women to perform aerobic interval training were identified for the first time. These novel themes encompassed the daunting nature of it, the physical discomfort associated with it, and conversely, the potential sense of enjoyment and accomplishment that it could bring. CONCLUSION: This study demonstrates the complexity of implementation of aerobic interval training into clinical practice, and suggests that further research is warranted to explore this domain.IMPLICATIONS FOR REHABILITATIONDespite challenges in feasibility of conducting a randomised controlled trial in female patients with coronary artery disease examining the effects of aerobic interval training versus moderate-intensity continuous exercise on aerobic exercise capacity, there was a significant per protocol treatment effect of 0.95 ml·kg-1·min-1 in favour of aerobic interval training.The cardiac rehabilitation environment provides key facilitators and perceived benefits for exercising and attending cardiac rehabilitation for women, and thus emphasises the need for improving referral and enrolment processes specifically for women into cardiac rehabilitation programs.Aerobic interval training may elicit feelings of fear and physical discomfort, or may be precluded by comorbid conditions, therefore, judicious consideration must be taken in examining the suitability of implementation into clinical practice for each female patient.

Women's outcomes following mixed-sex, women-only, and home-based cardiac rehabilitation participation and comparison by sex.

BACKGROUND: Despite women's greater need for cardiac rehabilitation (CR), they are less likely to utilize it. Innovative CR models have been developed to better meet women's needs, yet there is little controlled, comparative data assessing the effects of these models for women. This study compared outcomes in women electing to participate in mixed-sex, women-only, or home-based CR, and a matched sample of men. METHODS: In this retrospective study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017 and July 2019 were analyzed; clinical outcomes comprised cardiorespiratory fitness, risk factors and psychosocial well-being. These were assessed at intake and post-6-month program and analyzed using general linear mixed models. RESULTS: There were 1181 patients (727 women [74.7% mixed, 22.0% women-only, 3.3% home-based]; 454 age and diagnosis-matched men) who initiated CR; Cardiorespiratory fitness among women was higher at initiation of mixed-sex than women-only (METs 5.1 ± 1.5 vs 4.6 ± 1.3; P = .007), but no other outcome differences were observed. 428 (58.9%) women completed the programs, with few women retained in the home-based model limiting comparisons. There were significant improvements in high-density lipoprotein cholesterol (P = .001) and quality of life (P = .001), and lower depressive symptoms (P = .030) as well as waist circumference (P = .001) with mixed-sex only. VO2peak was significantly higher at discharge in mixed-sex than women-only (estimate = 1.67, standard error = 0.63, 95% confidence interval = 0.43-2.91). CONCLUSION: Participation in non-gender-tailored women-only CR was not advantageous as expected. More research is needed, particularly including women participating in home-based programs.

The effect of insulin on post-exercise hypoglycemia in adults with type 2 diabetes participating in outpatient exercise-based cardiac rehabilitation.

PURPOSE: Few studies have reported on self-monitored blood glucose changes following acute exercise, particularly in patients with type 2 diabetes prescribed oral sulfonylureas and insulin medication. This study sought to determine the magnitude of post-exercise blood glucose changes and incidence of hypoglycemia (blood glucose < 4.0 mmol/L) in relation to medication regimen. METHODS: A retrospective chart review was conducted in adults with type 2 diabetes attending a 6-month rehabilitation program. Demographics, medications, exercise prescription and patient-reported pre/post-BG values were collected at program initiation. It was hypothesized that patients with type 2 diabetes will experience a post-exercise capillary blood glucose reduction (ΔcapBG), and that incidents of hypoglycemia (< 4.0 mmol/L) will be strongly associated with insulin or oral secretagogue class of medication. RESULTS: A chart review was conducted (n = 52, 46.2% males, mean age: 62.7 ± 8.3 years, A1c: 7.7 ± 1.6%, body mass index, BMI: 34.4 ± 7.8 kg/m2) in patients with type 2 diabetes (9.0 ± 7.7 years since diagnosis). A greater reduction in BG was related to a greater pre-exercise BG (beta [95% CI]: - 0.46 [- 0.54, - 0.37] mmol, p < 0.0001), independent of BMI and exercise duration. Post-exercise hypoglycemia (< 4.0 mmol) was associated with prescribed insulin use (vs. non-users: 14.5% vs. 3.0%, p < 0.05). Among insulin users, pre-mixed insulin had the highest incidence of hypoglycemia (vs. non-users: 50% vs. 3%, p < 0.0001) and insulin (bolus and basal; vs. non-users: 11.1% vs. 3%, p = 0.04). CONCLUSIONS: These findings may suggest a low post-exercise hypoglycemia occurrence in patients with type 2 diabetes, except when taking insulin. Self-management strategies should be considered, especially for patients on insulin medications.