Cardiac rehabilitation in women; comparison of enrollment, adherence and outcomes between heart failure and coronary artery disease.

BACKGROUND: There is paucity of data on cardiac rehabilitation (CR) enrollment and outcomes in women with heart failure (HF). METHODS: In this retrospective analysis, we compared enrollment, adherence and outcomes between women with HF versus coronary artery disease (CAD)-related indications referred to a university-affiliated CR program from June 2014-July 2018. A multivariate regression analysis was performed to adjust for imbalanced variables at baseline and baseline value of each outcome to compare change in outcomes between HF and CAD groups RESULTS: A total of 538 women (HF=63 vs CAD=475) were included in the study. At baseline, women with HF were younger, had lower attendance to CR intake and worse perceived health, higher AACVPR risk category and lower exercise capacity but had similar enrollment, weight and dieatry habits when compared to women with CAD. Adjusted analyses showed that almost all cardiac rehabilitation outcomes except for positive affect (anxiety, depression symptoms, negative affect, dietary habits, perceived physical and mental health summary scores, exercise duration and capacity) improved significantly from baseline and in a similar fashion in both groups. Weight loss was significantly greater for women with CAD versus those with HF (CAD: Δ -1.12 ± 2.23 kg versus HF: Δ -0.66 ± 2.78 kg, p = 0.03). CONCLUSION: Despite a lower attendance to CR intake, lower perceived physical health and higher baseline AACVPR risk in women with HF, they have similar CR enrollment, adherence and completion rates compared to women with CAD. Both groups showed significant but similar improvements from baseline in almost all cardiac rehabilitation outcomes. These findings should alert cardiology providers to help overcome obstacles for women with HF to attend CR intake.

Transition to Home-Based Treatment Plans for Center-Based Cardiac, Pulmonary, and Vascular Rehabilitation during COVID-19.

BACKGROUND: Traditional rehabilitation services, whether they are cardiac, pulmonary, or vascular, consist of 6-36 center-based, supervised sessions; however, due to COVID-19, in-person visits were suspended. This study sought to implement a transitional home-based treatment plan (HBTP) to patients. METHOD: Patients enrolled in a rehabilitation service at the Miriam Hospital during the time of temporary closure were provided with a HBTP that was individualized to their needs and multi-disciplinary in nature. Patients were called weekly for continual guidance and support. RESULTS: Of the 129 patients that received a HBTP, 115 (89%) participated in follow-up correspondence (63±12 years, 83% white, 66% male, 81% enrolled in cardiac rehab). Nearly 70% of patients continued to participate in regular exercise and upon re-opening, 69 (60%) of patients returned to center-based care. Psychosocial factors appeared to inhibit treatment adherence. CONCLUSIONS: Patients are receptive to an HBTP and subsequent follow-up throughout temporary closure of rehabilitation services.

Examination of clinical and psychosocial determinants of exercise capacity change in cardiac rehabilitation.

PURPOSE: Most cardiac rehabilitation (CR) completers improve in multiple functional and psychosocial domains. However, not all demonstrate uniform improvement in functional indicators such as exercise capacity. This study examined baseline predictors and correlates of change in exercise capacity from CR intake to completion. METHODS: CR participants (n = 488) completed assessment of metabolic equivalents (METs) via treadmill stress test, depressive symptoms, quality of life, and social support at intake and discharge. Associations between demographic, clinical, and psychosocial factors and MET changes was tested with linear regression. RESULTS: METs increased from intake to discharge (1.91 ± 1.48, p < .001). Younger age (p < .001), lower BMI (p < .001), and lower weight (p < .01) were associated with greater MET change. Greater percentage weight loss (p < .05), and self-reported improvements in physical functioning (p < .001) and bodily pain (p < .01) were concurrently related to MET change. CONCLUSIONS: Older CR attendees and those with higher baseline BMI may benefit from tailored intervention to ensure maximum benefit in exercise capacity.

Improvements in Depressive Symptoms and Affect During Cardiac Rehabilitation: PREDICTORS AND POTENTIAL MECHANISMS.

PURPOSE: Depression is indicative of poor prognosis in cardiac patients. Reductions in depression have been observed following cardiac rehabilitation (CR). Whether similar improvements in positive and negative affect occur is unknown. Greater understanding of depressive symptom and affect change is needed to enhance facilitators of emotional improvement after a cardiac event. METHODS: Cardiac rehabilitation attendees (n = 637) completed measures of depressive symptoms, affect, health status, and social support at CR intake and discharge. Body mass index, metabolic equivalents, and blood pressure were also measured. Relationships between changes in psychosocial and physical health indicators and depressive symptoms, positive affect, and negative affect were examined. RESULTS: From intake to discharge, depressive symptoms (d = 0.40, P < .001) and negative affect (d = 0.26, P < .001) decreased. Positive affect increased (d = 0.34, P < .001). In multivariate regression, predictors of depressive symptom reduction were increased vitality (ß = -.26) and decreased bodily pain (ß = -.08). Predictors of positive affect increase were increased vitality (ß = .25), social support (ß = .16), and physical role functioning (ß = .09). Predictors of negative affect reduction were increased vitality (ß = -.23) and social support (ß = -.10). Changes in indicators of physical health were not related to depressive symptom or affect change. CONCLUSIONS: Depressive symptom and affect improvements following CR were observed and most strongly associated with improvements in vitality and social support. Future research should explore how enhancement of these mechanisms may further improve depressive symptom and affect during CR.

Anxiety and Fear of Exercise in Cardiopulmonary Rehabilitation: PATIENT AND PRACTITIONER PERSPECTIVES.

PURPOSE: One unexplored mechanism for poor outcomes in cardiovascular and pulmonary rehabilitation (CVPR) is fear about aerobic exercise. Patients in CVPR may tend to avoid aerobic exercise because of the fear of physical sensations associated with exertion. This study examined fear about exercise in patients enrolled in outpatient CVPR and practitioner beliefs and behaviors related to fear associated with exercise. METHODS: Survey data were collected from patients (n = 117) enrolled in cardiac rehabilitation (n = 69) and pulmonary rehabilitation (n = 48) and practitioners (n = 16) who were exercise physiologists and nurses working in CVPR. RESULTS: Fears about exercise and avoidance behaviors were common among patients. In pulmonary rehabilitation, fears and avoidance of exercise were correlated with higher levels of anxiety and depression (r values = 0.27-0.54), lower forced expiratory volume in the first second of expiration/forced vital capacity (r values = -0.13 to -0.39), lower health-related quality of life (r values = -0.13 to -0.62), and stronger beliefs about utility of anxiety treatment (r values = 0.21-0.36). In cardiac rehabilitation, fears about exercise were correlated with higher levels of anxiety (r values = 0.19-0.38), lower mental health quality of life (r values = -0.25 to -0.27), and stronger beliefs about utility of anxiety treatment (r values = 0.30-0.40), and avoidance of exercise was correlated with lower exercise tolerance and poorer physical health quality of life (r values = -0.22 to -0.24). Practitioners estimated that an average of 47 ± 20% of patients experience fear associated with exercise and reported low feelings of preparedness to address patient anxiety and fear. CONCLUSIONS: It may be beneficial to provide practitioners with skills to recognize and address anxiety and fear in their patients as it relates to exercise.

Safety and Outcomes of Cardiac Rehabilitation for Patients with Spontaneous Coronary Artery Dissection.

OBJECTIVE: To evaluate the safety and outcomes of aerobic and resistance training in patients undergoing cardiac rehabilitation after spontaneous coronary artery dissection. METHODS: Eleven patients with spontaneous coronary artery dissection at 2 academic centres were studied retrospectively during cardiac rehabilitation from July 2013 to September 2017. Patients underwent maximal effort exercise testing at enrollment and discharge per institutional protocol. Patients were prescribed individualized exercise regimens based on stress test results, stress management with a behavioural psychologist, and diet counselling with a nutritionist. Resistance training was introduced during weeks 3-5 with close blood pressure monitoring. RESULTS: Ten patients who completed cardiac rehabilitation showed improvements in aerobic exercise capacity and exercise duration. For resistance training, patients increased the total number of resistance exercise modalities, repetitions, or both. After cardiac rehabilitation, significant improvements were found in exercise capacity, Mental Composite Score, Physical Composite Score, anxiety measured by Generalied Anxiety Disorders (GAD-7), and positive affect. During a mean followup of 14 months, no patients had any recurrent dissection or major adverse cardiac events. CONCLUSION: Cardiac rehabilitation is safe and improves functional status, anxiety, positive affect and quality of life in patients with spontaneous coronary artery dissection. Future studies should explore ways to further improve the psychosocial and functional status of these patients.

Effect of Case Management With Goal-Setting on Diet Scores and Weight Loss in Cardiac Rehabilitation Patients.

PURPOSE: The impact of cognitive-behavioral strategies and clinical factors on diet change during cardiac rehabilitation (CR) is not well studied. The purpose of this study was to examine the effects of collaborative goal-setting and clinical predictors on diet scores and weight loss in a case management model of CR. METHODS: We retrospectively examined the effects of clinical factors and goal-setting facilitated by case managers on diet scores and weight loss in 629 consecutive patients with atherosclerotic cardiovascular disease enrolled in our CR program between 2014 and 2016. The Rate Your Plate (RYP) diet score was used to measure diet quality at baseline and discharge. Logistic regression modeling was used to identify predictors of diet score change in a subsample with goal-setting data (n = 615). Analysis of variance was conducted in the subset with complete weight data (n = 584) to compare weight loss between those who improved their RYP scores versus those who did not. RESULTS: Participants were 27.9% female, with a mean age of 63.4 ± 11.5 y. The average body mass index at baseline was 30.3 ± 6.8, and 51.7% reported diet change and/or weight loss as a goal. After an average of 33 CR sessions, 27.3% improved their RYP scores by at least 1 risk category (mean score, 54.0 ± 9.0 vs 58.2 ± 7.3, P < .001) and the average weight loss was 1.5 ± 2.9 kg (P < .001). After logistic regression modeling, dietary goal-setting was significantly associated with improvement in diet scores and with greater weight loss (2.2 ± 3.1 kg vs 0.84 ± 2.6 kg, P < .001). CONCLUSIONS: A case management model that incorporates dietary goal-setting is associated with improved measures of diet quality and weight loss during CR.

Comparison of phase 2 cardiac rehabilitation outcomes between patients after transcatheter versus surgical aortic valve replacement.

Background Referral rates and outcomes of cardiac rehabilitation have not been evaluated in patients with transcatheter aortic valve replacement or compared with surgical aortic valve replacement. Method A retrospective cohort study was conducted in 488 patients who underwent transcatheter aortic valve replacement ( n = 199) and surgical aortic valve replacement ( n = 289) from a university-based statewide transcatheter aortic valve replacement/surgical aortic valve replacement program during 2015-2017. Cardiac rehabilitation consisted of supervised exercise, diet education, and stress and depression management. We compared changes from baseline in exercise duration and intensity during cardiac rehabilitation sessions, quality-of-life (36-Item Short-Form Health Survey), and psychosocial measures (anxiety, depression, mood, social support, and diet) between transcatheter aortic valve replacement and surgical aortic valve replacement patients using t-test and chi-square analyses. Results Of 488 patients, cardiac rehabilitation referral rates were similar at 41% (transcatheter aortic valve replacement 81/199 versus surgical aortic valve replacement 117/289), but enrollment rates were lower in transcatheter aortic valve replacement (27/199, 14%) versus surgical aortic valve replacement (102/289, 35%, p < 0.01). Among eligible patients, cardiac rehabilitation completion rates were lower in transcatheter aortic valve replacement (12%) than surgical aortic valve replacement (32%). Exercise intensity during cardiac rehabilitation improved in both groups in a similar fashion (transcatheter aortic valve replacement 1.03 ± 1.09 versus surgical aortic valve replacement 1.34 ± 1.15 metabolic equivalents), but increase in exercise duration was higher in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients (14.52 ± 6.42 versus 10.67 ± 8.38 min, p = 0.02). Improvement in physical composite score was higher in surgical aortic valve replacement versus transcatheter aortic valve replacement (8.72 ± 7.87 versus 2.36 ± 7.6, p = 0.02) while improvement in mental composite score was higher in transcatheter aortic valve replacement (8.19 ± 8.50) versus surgical aortic valve replacement (1.18 ± 7.23, p = 0.02). There was no significant difference between the two groups in improvement in psychosocial measures. Conclusion Cardiac rehabilitation enrollment was low in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients despite similar referral rates. Improvement in functional and quality-of-life performance was achieved in both transcatheter aortic valve replacement and surgical aortic valve replacement. Future studies should address obstacles for enrollment of transcatheter aortic valve replacement patients.

Supervised exercise training versus usual care in ambulatory patients with left ventricular assist devices: A systematic review.

Implantation of left ventricular assist devices (LVAD) has increased because of improved safety profile and limited availability of heart transplantation. Although supervised exercise training (ET) programs are known to improve exercise capacity and quality of life (QoL) in heart failure (HF) patients, similar data is inconclusive in LVAD patients. Thus, we performed a systematic review on studies that incorporated supervised ET and measured peak oxygen uptake in LVAD patients. A total of 150 patients in exercise and 55 patients in control groups were included from 8 studies selected from our predefined criteria. Our systematic review suggests supervised ET has an inconsistent effect on exercise capacity and QoL when compared to control groups undergoing usual care. A quantitative sub-analysis was performed with 4 studies that provided enough data to compare peak oxygen uptake and QoL at baseline and at follow-up. After at least 6 weeks of training, LVAD patients undergoing supervised ET demonstrated significant improvement in exercise capacity (standardized mean difference [SMD] = 0.735, 95% Confidence Interval-[CI], 0.31-1.15 units of the standard deviation, P = 0.001) and QoL scores (SMD = 1.58, 95% CI 0.97-2.20 units of the standard deviation, P <0.001) when compared to the usual care group, with no serious adverse events with exercise. These results suggest that supervised ET is safe and can improve patient outcomes in LVAD patients when compared to the usual care.

Design and methods of the Gentle Cardiac Rehabilitation Study--A behavioral study of tai chi exercise for patients not attending cardiac rehabilitation.

INTRODUCTION: Cardiac rehabilitation (CR) programs reduce overall and cardiovascular mortality in patients with a history of acute coronary events or revascularization procedures, but only 30% of patients enroll in CR and attrition rates reach up to 60%. Tai chi, a mind-body practice based on light/moderate aerobic exercise accompanied by meditative components could be a possible exercise option for patients who do not attend CR. METHODS/DESIGN: Sixty patients will be randomized to a "LITE" condition (one tai chi session twice weekly for 12 weeks) or to a "PLUS" condition (one tai chi session 3 times weekly for 12 weeks, followed by maintenance classes 1-2 times weekly for an additional 12 weeks). Measurements will be conducted at baseline, 3-, 6-, and 9 months after enrollment. The primary outcome is to determine the feasibility, acceptability and safety of each dose. Secondary outcomes include estimates of effect size of each dose on accelerometry-assessed physical activity; the proportion of patients meeting current recommendations for physical activity; and measures of fitness, quality of life, body weight, and sleep. In addition, we will collect exploratory information on possible mediators (exercise self-efficacy, perceived social support, resilience, mindfulness, and depression). CONCLUSIONS: Findings from this pilot study will provide preliminary indications about the usefulness of tai chi as an exercise option for patients not attending traditional CR programs. Results will also shed light on the possible mechanisms by which tai chi practice may improve overall physical activity among patients with atherosclerotic coronary heart disease.