Sex Differences in Cardiac Rehabilitation Outcomes.

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands.

Importance: Cardiac rehabilitation (CR) is an effective strategy to improve clinical outcomes, but it remains underused in some subgroups of patients with cardiovascular disease (CVD). Objective: To investigate the implications of sex, age, socioeconomic status, CVD diagnosis, cardiothoracic surgery, and comorbidity for the association between CR participation and all-cause mortality. Design, Setting, and Participants: Observational cohort study with patient enrollment between July 1, 2012, and December 31, 2017, and a follow-up to March 19, 2020. The dates of analysis were March to May 2020. This study was performed among Dutch patients with CVD with a multidisciplinary outpatient CR program indication and who were insured at Coöperatie Volksgezondheidszorg, one of the largest health insurance companies in the Netherlands. Among 4.1 million beneficiaries, patients with CVD with an acute coronary event (myocardial infarction or unstable angina pectoris), stable angina pectoris, chronic heart failure, or cardiothoracic surgery (coronary artery bypass grafting, valve replacement, or percutaneous coronary intervention) were identified by inpatient diagnosis codes and included in the study. Main Outcomes and Measures: Cox proportional hazards models were used to evaluate the association between CR participation and all-cause mortality. Stabilized inverse propensity score weighting was used to account for patient and disease characteristics associated with CR participation. Results: Among 83 687 eligible patients with CVD (mean [SD] age, 67 [12] years; 60.4% [n = 50 512] men), only 31.3% (n = 26 171) participated in CR, with large variation across different subgroups (range, 5.1%-73.0%). During a mean (SD) of 4.7 (1.8) years of follow-up, 1966 CR participants (7.5%) and 13 443 CR nonparticipants (23.4%) died. After multivariable adjustment, CR participation was associated with a 32% lower risk of all-cause mortality (adjusted hazard ratio, 0.68; 95% CI, 0.65-0.71) compared with nonparticipation. Sex, age, socioeconomic status, and comorbidity did not alter risk reduction after CR participation, but a statistically significant interaction association was found across categories of CVD diagnosis and cardiothoracic surgery. Larger reductions in risk estimates for all-cause mortality were found after CR participation for STEMI (adjusted HR, 0.59; 95% CI, 0.52-0.68 vs 0.72; 95% CI, 0.65-0.79; P < .001), NSTEMI (adjusted HR, 0.64; 95% CI, 0.58-0.70 vs 0.72; 95% CI, 0.65-0.79; P < .001), and stable AP (adjusted HR, 0.69; 95% CI, 0.63-0.76 vs 0.72; 95% CI, 0.65-0.79; P < .001) compared with patients with chronic heart failure, whereas unstable AP had a smaller risk reduction (adjusted HR, 0.75; 95% CI, 0.67-0.85 vs 0.72; 95% CI, 0.65-0.79; P < .001). Conclusions and Relevance: In this cohort study, CR participation was associated with a 32% risk reduction in all-cause mortality, and this benefit was independent of sex, age, socioeconomic status, and comorbidity. These findings reinforce the importance of CR participation in secondary prevention and highlight the possibility that CR should be prescribed more widely to vulnerable patients with CVD, such as older adults with chronic diseases or multimorbidity.

ASPIRE-3-PREVENT: a cross-sectional survey of preventive care after a coronary event across the UK.

OBJECTIVE: To quantify the implementation of the third Joint British Societies' Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) after coronary event. METHODS: Using a cross-sectional survey design, patients were consecutively identified in 36 specialist and district general hospitals between 6 months and 2 years, after acute coronary syndrome or revascularisation procedure and invited to a research interview. Outcomes included JBS3 lifestyle, risk factor and therapeutic management goals. Data were collected using standardised methods and instruments by trained study nurses. Blood was analysed in a central laboratory and a glucose tolerance test was performed. RESULTS: 3926 eligible patients were invited to participate and 1177 (23.3% women) were interviewed (30% response). 12.5% were from black and minority ethnic groups. 45% were persistent smokers, 36% obese, 52.9% centrally obese, 52% inactive; 30% had a blood pressure >140/90 mm Hg, 54% non-high-density lipoprotein ≥2.5 mmol/L and 44.3% had new dysglycaemia. Prescribing was highest for antiplatelets (94%) and statins (85%). 81% were advised to attend cardiac rehabilitation (86% <60 years vs 79% ≥60 years; 82% men vs 77% women; 93% coronary artery bypass grafting vs 59% unstable angina), 85% attended if advised; 69% attended overall. Attenders were significantly younger (p=0.03) and women were less likely to attend (p=0.03). CONCLUSIONS: Patients with coronary heart disease (CHD) are not being adequately managed after event with preventive measures. They require a structured preventive cardiology programme addressing lifestyle, risk factor management and adherence to cardioprotective medications to achieve the standards set by the British Association for Cardiovascular Prevention and Rehabilitation and JBS3 guidelines.

Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative.

BACKGROUND: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. METHODS AND RESULTS: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. CONCLUSIONS: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.

Digital Cardiac Rehabilitation Programs: The Future of Patient-Centered Medicine.

Background: The low participation rate in cardiac rehabilitation programs is the major reason for rehospitalization, morbidity, and mortality. Home-based cardiac rehabilitation by technological means is an essential component of a "patient-centered" approach, which is capable of enhancing the participation rate in rehabilitation programs. Introduction: The aim of this research was to examine attitudes, perceptions, and behavioral intentions toward remote digital cardiac rehabilitation (RDCR) with respect to factors such as age, education, smoking, exercise habits, technological illiteracy, and mobile phone behavior. Materials and Methods: This was a cross-sectional study of 200 adult patients discharged from a hospital after an acute coronary syndrome, cardiac surgery, or percutaneous coronary intervention. All patients answered an anonymous Technology Usage Questionnaire, which examined the relationship between their willingness to participate in the RDCR program and various parameters. The surveys were distributed and completed between July 2017 and November 2017 at the Sheba Medical Center in Israel. Results: Overall, 83% of all participants were interested in participating in the RDCR program. Those with heart failure had a greater interest in the program (100%; p < 0.05), whereas patients after coronary bypass surgery had a lesser interest (71.1%; p < 0.05). The level of attitude toward healthy lifestyle was found to be a significant predictor of willingness to participate in RDCR (odds ratio 2.26; p = 0.01). Sociodemographic characteristics, lifestyle, habits, technological knowledge, age, and gender were not found as significant predictors of interest in RDCR. Conclusions: The RDCR program was acceptable to most cardiac patients, including the elderly population, and could be a potential solution for patients who avoid traditional rehabilitation programs in medical centers.

Setenta y cinco años de rehabilitación cardiovascular en México / Seventy-five years of cardiovascular rehabilitation in Mexico

Resumen Los pacientes que sufren una enfermedad cardiovascular requieren de atención médica integral que involucre las terapias y procedimientos necesarios para reintegrarlos de forma óptima a su vida personal, familiar, laboral y social. Las intervenciones dirigidas a alcanzar dichas metas se incluyen en los programas de rehabilitación cardiaca. Estos programas son diseáados para limitar los efectos dañinos tanto fisiológicos como psicológicos de las cardiopatías, reducir el riesgo de muerte súbita o reinfarto, controlar la sintomatología cardiovascular, estabilizar o revertir el proceso de aterosclerosis y mejorar el estado psicosocial y vocacional de los pacientes. Dichos programas existen en México desde la década de 1940 y han evolucionado a lo largo de los años, adaptándose a las condiciones de enfermedad presentes en nuestro país, desde su inicio con terapias para tratar a pacientes cardiopatía reumática hasta la aplicación del ejercicio físico en pacientes con insuficiencia cardiaca, cardiopatías congénitas complejas o hipertensión arterial pulmonar. Estas actividades son de índole transdisciplinaria e implica la integración de cardiólogos, fisioterapeutas, psicólogos y nutriólogos, entre otros. Actualmente, estos programas se han extendido a lo largo de la República Mexicana gracias a cardiólogos rehabilitadores egresados de las principales instituciones de salud del país, como son los Institutos de Salud, el IMSS (Instituto Mexicano del Seguro Social) y el ISSSTE (Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado). En este documento se expondrán los orígenes de la rehabilitación, desde la época prehispánica hasta la actual, destacando las contribuciones en docencia e investigación de los médicos que han ejercido en esta área en las instituciones previamente mencionadas.

Abstract Patients suffering from cardiovascular disease require comprehensive medical attention that involves therapies and procedures necessary to reintegrate them optimally to their personal, family, work and social life. Interventions aimed at achieving these goals are included in cardiac rehabilitation programs. These programs are designed to limit the harmful physiological and psychological effects of heart disease, reduce the risk of sudden death or reinfarction, control cardiovascular symptoms, stabilize or reverse the atherosclerosis process and improve the psychosocial and vocational status of patients. These programs have existed in Mexico since the 1940's and have evolved over the years, adapting to the disease conditions present in our country, starting with therapies to treat patients with rheumatic heart disease until the application of physical exercise in patients with heart failure, complex congenital heart disease or pulmonary arterial hypertension. These activities are of a transdisciplinary nature and involve the integration of cardiologists, physiotherapists, psychologists, and nutritionists among others. Currently, these programs have spread throughout the Mexican Republic thanks to rehabilitation cardiologists graduating from the main health institutions in the country such as Health Institutes, Mexican Social Security Institute and Institute of Security and Social Services of State Workers. In this document, the origins of rehabilitation from the pre-Hispanic era to the present will be discussed, highlighting the contributions in teaching and research of the physicians who have practiced in this area in the aforementioned institutions.

Clinical and Demographic Trends in Cardiac Rehabilitation: 1996-2015.

PURPOSE: Clinical interventions in programs such as cardiac rehabilitation (CR) are guided by clinical characteristics of participating patients. This study describes changes in CR participant characteristics over 20 yr. METHODS: To examine changes in patient characteristics over time, we analyzed data from 1996 to 2015 (n = 5396) garnered from a systematically and prospectively gathered database. Linear, logistic, multinomial logistic or negative binomial regression was used, as appropriate. Effects of sex and index diagnosis were considered both as interactions and as additive effects. RESULTS: Analyses revealed that mean age increased (from 60.7 to 64.2 yr), enrollment of women increased (from 26.8% to 29.6%), and index diagnosis has shifted; coronary artery bypass surgery decreased (from 37.2% to 21.6%), whereas heart valve repair/replacement increased (from 0% to 10.6%). Risk factors also shifted with increases in body mass index (28.7 vs 29.6 kg/m), obesity (from 33.2% to 39.6%), hypertension (from 51% to 62.5%), type 2 diabetes mellitus (from 17.3% to 21.7%), and those reporting current smoking (from 6.6% to 8.4%). Directly measured peak aerobic capacity remained relatively stable throughout. The proportion of patients on statin therapy increased from 63.6% to 98.9%, coinciding with significant improvements in lipid levels. CONCLUSIONS: Compared with 1996, participants entering CR in 2015 were older, more overweight, and had a higher prevalence of coronary risk factors. Lipid values improved substantially concurrent with increased statin use. While the percentage of female participants increased, they continue to be underrepresented. Patients with heart valve repair/replacement now constitute 10.6% of the patients enrolled. Clinical programs need to recognize changing characteristics of attendees to best tailor interventions.

Effectiveness and cost-effectiveness of a Yoga-based Cardiac Rehabilitation (Yoga-CaRe) program following acute myocardial infarction: Study rationale and design of a multi-center randomized controlled trial.

BACKGROUND: Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. METHODS: This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18-80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. CONCLUSION: This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings.

Referral for cardiac rehabilitation after acute myocardial infarction: Insights from nationwide AMIS Plus registry 2005-2017.

BACKGROUND: Referral rates for cardiac rehabilitation (CR) after an acute myocardial infarction (AMI) are low despite a Class I recommendation in the present guidelines. Therefore, we aimed to identify predictors for referral and patient characteristics from the national Swiss AMIS Plus registry. DESIGN AND METHODS: Data were extracted from the Swiss AMIS Plus registry between 2005 and 2017, which included patients with ST-elevation myocardial infarction (STEMI) and Non-ST-elevation myocardial infarction (NSTEMI). For 32,416 patient (93.2%) data about destination at discharge were available with 10,940 (33.7%) having a recommendation for CR while 12,282 (37.9%) went home. 9194 (28.4%) were transferred to another hospital after index hospitalisation and were excluded. RESULTS: Patients referred to CR were younger (62.6 vs. 68.2 years) and had a higher prevalence of obesity (22.0% vs. 20.4%). Except for smoking (44.0% vs 34.9%), they had less risk factors such as dyslipidemia (55.0% vs. 60.1%), hypertension (55.6% vs. 65.3%) and diabetes (16.7% vs. 21.5%). Patients with in-hospital complications were more likely being referred for CR. Furthermore, STEMI (OR 1.61; CI 1.52-1.71), performed PCI (OR 2.65; CI 2.42-2.90) and Killip class >2 (OR 1.58; CI 1.36-1.84) favoured referral for CR, while age > 65 years, previous myocardial infarction, cerebrovascular disease or peripheral artery disease had a negative impact on referral for CR. CONCLUSIONS: Our data from 23,222 patients after AMI demonstrate that in Switzerland patients referred for CR are younger, more obese with more STEMI. In-hospital complications were strong predictors for CR recommendation. Unlike anticipated, other risk factors were less present in CR patients.

Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement.

BACKGROUND: Cardiac rehabilitation is strongly recommended after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery, but it is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States. METHODS: From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used International Classification of Diseases, 9th Revision codes to identify patients hospitalized for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery from 2007 to 2011. After excluding patients who died in ≤30 days of hospitalization, we calculated the percentage of patients who participated in ≥1 outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models. RESULTS: Overall, participation in cardiac rehabilitation was 16.3% (23 403/143 756) in Medicare and 10.3% (9123/88 826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, whereas those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% versus 10.6%) and VA (16.6% versus 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3% to 75% in Medicare and 1% to 43% in VA. CONCLUSIONS: Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, remarkably similar regional variation exists, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower performing hospitals and regions.

Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery: Data From the Clinical Outcomes Assessment Program.

BACKGROUND: Despite guideline recommendations that patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass surgery, or valve surgery be referred to cardiac rehabilitation, cardiac rehabilitation is underused. The objective of this study was to examine hospital-level variation in cardiac rehabilitation referral after PCI, coronary artery bypass surgery, and valve surgery. METHODS AND RESULTS: We analyzed data from the Clinical Outcomes Assessment Program, a registry of all nonfederal hospitals performing PCI and cardiac surgery in Washington State. We included eligible PCI, coronary artery bypass surgery, and valve surgery patients from 2010 to 2015. We analyzed PCI and cardiac surgery separately by performing multivariable hierarchical logistic regression for the outcome of cardiac rehabilitation referral at discharge, clustered by hospital. Patient-level covariates included age, sex, race/ethnicity, comorbidities, and procedure indication/status. Cardiac rehabilitation referral was reported in 48% (34 047/71 556) of PCI patients and 91% (21 831/23 972) of cardiac surgery patients. The hospital performing the procedure was a stronger predictor of referral than any individual patient characteristic for PCI (hospital referral range 3%-97%; median odds ratio, 5.94; 95% confidence interval, 4.10-9.49) and cardiac surgery (range 54%-100%; median odds ratio, 7.09; 95% confidence interval, 3.79-17.80). Hospitals having an outpatient cardiac rehabilitation program explained only 10% of PCI variation and 0% of cardiac surgery variation. CONCLUSIONS: Cardiac rehabilitation referral at discharge was less prevalent after PCI than cardiac surgery. The strongest predictor of cardiac rehabilitation referral was the hospital performing the procedure. Efforts to improve cardiac rehabilitation referral should focus on increasing referral after PCI, especially in low referral hospitals.