Contribution of individual and cumulative frailty-related health deficits on cardiac rehabilitation completion.

BACKGROUND: Despite the high burden of frailty among cardiac rehabilitation (CR) participants, it is unclear which frailty-related deficits are related to program completion. METHODS: Data from a single-centre exercise- and education-based CR program were included. A frailty index (FI) based on 25 health deficits was constructed. Logistic regression was used to estimate the odds of CR completion based on the presence of individual FI items. The odds of completion for cumulative deficits related to biomarkers, body composition, quality of life, as well as a composite of traditional and non-traditional cardiovascular risk factor domains were examined. RESULTS: A total of 3,756 individuals were included in analyses. Eight of 25 FI variables were positively associated with program completion while 8 others were negatively associated with completion. The variable with the strongest positive association was the food frequency questionnaire score (OR 1.27 (95% CI 1.14, 1.41), whereas the deficit with strongest negative association was a decline in health over the last year (OR 0.74 (95% CI 0.58, 0.93). An increased number of cardiovascular deficits were associated with an increased odds of CR completion (OR per 1 deficit increase 1.16 (95% CI 1.11, 1.22)). A higher number of traditional CR deficits were predictive of CR completion (OR 1.22 (95% CI 1.16, 1.29)), but non-traditional measures predicted non-completion (OR 0.95 (95% CI 0.92, 0.97)). CONCLUSION: A greater number of non-traditional cardiovascular deficits was associated with non-completion. These data should be used to implement intervention to patients who are most vulnerable to drop out to maximize retention.

Reliability and Validity of the 6-Minute Step Test for Clinical Assessment of Cardiorespiratory Fitness in People at Risk of Cardiovascular Disease.

Giacomantonio, N, Morrison, P, Rasmussen, R, and MacKay-Lyons, MJ. Reliability and validity of the 6-minute step test for clinical assessment of cardiorespiratory fitness in people at risk of cardiovascular disease. J Strength Cond Res 34(5): 1376-1382, 2020-The purpose of this study was to determine the test-retest reliability and validity of the 6-minute step test (6MST) as a potential assessment of cardiorespiratory fitness (CRF) of people at risk of cardiovascular disease (CVD). A prospective, cross-sectional, correlational study design was used. A single cohort of 30 adults with 2 or more risk factors for CVD was recruited. Exercise tests were scheduled on 2 days, separated by 1 week. Validity was determined by comparing 6MST results with those obtained in a symptom-limited treadmill test and the 6-minute walk test (6MWT). Main outcome variables were peak heart rate (HRpeak) and peak oxygen consumption (V[Combining Dot Above]O2peak) measured during the 6MST, treadmill test, and 6MWT. Test-retest reliability of HRpeak and V[Combining Dot Above]O2peak during the 6MST was very strong (intraclass correlation coefficient [ICC], 0.92; 95% confidence interval [CI], 0.83-0.97 and ICC, 0.93; 95% CI, 0.84-0.97, respectively). Correlations were also very strong between 6MST and treadmill test HRpeak (r = 0.81) and between 6MST and treadmill test V[Combining Dot Above]O2peak (r = 0.88). Correlations were moderate between 6MST HRpeak and 6MWT steady-state HR (r = 0.57) and strong between 6MST V[Combining Dot Above]O2peak and 6MWT steady-state V[Combining Dot Above]O2 (r = 0.70). The 6MST seems to be a reliable, valid option for assessing CRF of people at risk of CVD in a broad range of clinical settings. Providing practical, accessible tests will help facilitate the goal of establishing CRF as a clinical vital sign. The next step in the development of the 6MST should be to identify the most appropriate 6MST predictor variables to estimate V[Combining Dot Above]O2max.

Cardiac issues of noncardiac drugs: the rising story of avastin in age-related macular degeneration.

Emerging safety data, accompanied with recent demographic trends, point to the need for an in-depth review and consideration of potential consequences that might arise from continuing use of bevacizumab (Avastin®) to treat elderly patients presenting with wet age-related macular degeneration (AMD). Although it is expected that lower doses of Avastin used for intravitreal administration and an intact blood-retina barrier would reduce the systemic exposure of the drug, both animal and human studies suggest that this may not be the case. In addition, emerging real-world and clinical trial data continue to point toward compromises in both cardio- and cerebrovascular safety with Avastin. Thus, clinicians are urged to adopt the highest possible standard of care in the treatment of an already fragile AMD population. Furthermore, postmarketing surveillance and pharmacovigilance with intravitreal anti-VEGF inhibitors should remain a priority.

Cardiac Rehabilitation and Frailty: A systematic review and meta-analysis.

BACKGROUND: Frailty among cardiac rehabilitation (CR) participants is associated with worse health outcomes. However, no literature synthesis has quantified the relationship between frailty and CR outcomes. PURPOSE: Examine frailty prevalence at CR admission, frailty changes during CR, and if frailty is associated with adverse outcomes following CR. METHODS: We searched CINAHL, EMBASE, and MEDLINE for studies published from 2000-2023. Eligible studies included a validated frailty measure, published in English. Two reviewers independently screened articles and abstracted data. Outcome measures included admission frailty prevalence, frailty and physical function changes, and post-CR hospitalization and mortality. RESULTS: Observational and randomized trials were meta-analyzed separately using inverse variance random-effects models. 34 peer reviewed articles (26 observational, 8 randomized trials; 19,360 participants) were included. Admission frailty prevalence was 46% [95% CI 29%, 62%] and 40% [95% CI 28%, 52%] as measured by Frailty Index and Kihon Checklist (14 studies) and Frailty Phenotype (11 studies), respectively. Frailty improved following CR participation (SMD; 0.68, 95% CI 0.37, 0.99; P<.0001; 6 studies). Observational studies meta-analysis revealed higher admission frailty increased participants' risk of all-cause mortality (Hazard ratio: 9.24, 95% CI 2.93, 29.16; P=.0001; 4 studies). Frailer participants at admission had worse physical health outcomes, but improved over the course of CR. CONCLUSIONS: High variability in frailty tools and CR designs was observed, and randomized controlled trials contributions were limited. The prevalence of frailty is high in CR and is associated with greater mortality risk; however, CR improves frailty and physical health outcomes.

Frailty levels are high in cardiac rehabilitation and elevate the risk of adverse health outcomes, however, participating in cardiac rehabilitation may improve prognosis. Key Findings: A large proportion of people in cardiac rehabilitation were frail. Frailty levels were improved by participating in cardiac rehabilitation, especially in those who were frailer at admission.Higher baseline frailty levels were associated with a greater risk of hospitalization and mortality and a reduced likelihood of completing the intervention.

Comparing Virtual and Center-Based Cardiac Rehabilitation on Changes in Frailty.

Many patients with cardiovascular disease (CVD) are frail. Center-based cardiac rehabilitation (CR) can improve frailty; however, whether virtual CR provides similar frailty improvements has not been examined. To answer this question, we (1) compared the effect of virtual and accelerated center-based CR on frailty and (2) determined if admission frailty affected frailty change and CVD biomarkers. The virtual and accelerated center-based CR programs provided exercise and education on nutrition, medication, exercise safety, and CVD. Frailty was measured with a 65-item frailty index. The primary outcome, frailty change, was analyzed with a two-way mixed ANOVA. Simple slopes analysis determined whether admission frailty affected frailty and CVD biomarker change by CR model type. Our results showed that admission frailty was higher in center-based versus virtual participants. However, we observed no main effect of CR model on frailty change. Results also revealed that participants who were frailer at CR admission observed greater frailty improvements and reductions in triglyceride and cholesterol levels when completing virtual versus accelerated center-based CR. Even though both program models did not change frailty, higher admission frailty was associated with greater frailty reductions and change to some CVD biomarkers in virtual CR.

Association of admission frailty and frailty changes during cardiac rehabilitation with 5-year outcomes.

AIMS: Examine the association between (1) admission frailty and (2) frailty changes during cardiac rehabilitation (CR) with 5-year outcomes (i.e. time to mortality, first hospitalization, first emergency department (ED) visit, and number of hospitalizations, hospital days, and ED visits). METHODS AND RESULTS: Data from patients admitted to a 12-week CR programme in Halifax, Nova Scotia, from May 2005 to April 2015 (n = 3371) were analysed. A 25-item frailty index (FI) estimated frailty levels at CR admission and completion. FI improvements were determined by calculating the difference between admission and discharge FI. CR data were linked to administrative health data to examine 5-year outcomes [due to all causes and cardiovascular diseases (CVDs)]. Cox regression, Fine-Gray models, and negative binomial hurdle models were used to determine the association between FI and outcomes. On average, patients were 61.9 (SD: 10.7) years old and 74% were male. Mean admission FI scores were 0.34 (SD: 0.13), which improved by 0.07 (SD: 0.09) by CR completion. Admission FI was associated with time to mortality [HRs/IRRs per 0.01 FI increase: all causes = 1.02(95% CI 1.01,1.04); CVD = 1.03(1.02,1.05)], hospitalization [all causes = 1.02(1.01,1.02); CVD = 1.02(1.01,1.02)], ED visit [all causes = 1.01(1.00,1.01)], and the number of hospitalizations [all causes = 1.02(95% CI 1.01,1.03); CVD = 1.02(1.00,1.04)], hospital days [all causes = 1.01(1.01,1.03)], and ED visits [all causes = 1.02(1.02,1.03)]. FI improvements during CR had a protective effect regarding time to all-cause hospitalization [0.99(0.98,0.99)] but were not associated with other outcomes. CONCLUSION: Frailty status at CR admission was related to long-term adverse outcomes. Frailty improvements during CR were associated with delayed all-cause hospitalization, in which a larger effect was associated with a greater chance of improved outcome.

This work improves our understanding of the relationship between admission frailty and frailty changes with mortality, hospitalization, and emergency department (ED) use in a cardiac rehabilitation (CR) setting. Frailty changes during CR were related with time to hospitalization due to any cause.Higher frailty levels at admission of CR were related to lower time to death, re-hospitalization, and ED visit and to a higher total number of hospitalizations and ED visits due to all causes or due to cardiovascular diseases.Overall, this work underscores the importance of considering the degree of frailty in the CR setting for the purpose of predicting adverse outcomes.

Program of Rehabilitative Exercise and Education to Avert Vascular Events After Non-Disabling Stroke or Transient Ischemic Attack (PREVENT Trial): A Randomized Controlled Trial.

BACKGROUND: Non-disabling stroke (NDS) and transient ischemic attack (TIA) herald the possibility of future, more debilitating vascular events. Evidence is conflicting about potency of exercise and education in reducing risk factors for second stroke. METHODS: Three-site, single-blinded, randomized controlled trial with 184 participants <3 months of NDS or TIA (mean age, 65 years; 66% male) randomized to usual care (UC) or UC + 12-week program of exercise and education (PREVENT). Primary (resting systolic blood pressure) and secondary outcomes (diastolic blood pressure [DBPrest], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], total cholesterol [TC], TC/HDL, triglycerides, fasting glucose, and body mass index) were assessed at baseline, post-intervention, and 6- and 12-month follow-up. Peak oxygen consumption (VO2peak) was measured at baseline, post-intervention, 12-month assessments. RESULTS: Significant between-group differences at post-intervention favored PREVENT group over UC: DBPrest (mean difference [MD]: -3.2 mmHg, 95% confidence interval [CI]: -6.3, -.2, P = .04) and LDL-C (MD: -.31 mmol/L, 95% CI: -.42, -.20, P = .02). Trends of improvement in PREVENT group were noted in several variables between baseline and 6-month follow-up but not sustained at 12-month follow-up. Of note, VO2 peak did not change over time in either group. CONCLUSION: Impact of PREVENT on vascular risk factor reduction was more modest than anticipated, possibly because several outcome variables approximated normative values at baseline and training intensity may have been sub-optimal. Further investigation is warranted to determine when exercise and education programs are viable adjuncts to pharmaceutical management for reduction of risk factors for second stroke.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: #NCT00885456.

The Impact of Exercise on Cardiotoxicity in Pediatric and Adolescent Cancer Survivors: A Scoping Review.

Childhood and adolescent cancer survivors are disproportionately more likely to develop cardiovascular diseases from the late effects of cardiotoxic therapies (e.g., anthracycline-based chemotherapy and chest-directed radiotherapy). Currently, dexrazoxane is the only approved drug for preventing cancer treatment-related cardiac damage. While animal models highlight the beneficial effects of exercise cancer treatment-related cardiac dysfunction, few clinical studies have been conducted. Thus, the objective of this scoping review was to explore the designs and impact of exercise-based interventions for managing cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors. Reviewers used Joanna Briggs Institute's methodology to identify relevant literature. Then, 4616 studies were screened, and three reviewers extracted relevant data from six reports. Reviewers found that exercise interventions to prevent cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors vary regarding frequency, intensity, time, and type of exercise intervention. Further, the review suggests that exercise promotes positive effects on managing cancer treatment-related cardiac dysfunction across numerous indices of heart health. However, the few clinical studies employing exercise interventions for childhood and adolescent cancer survivors highlight the necessity for more research in this area.

Behavioural interventions to increase the physical activity of cardiac patients: a review.

To examine the behaviour change techniques that have been used in physical activity (PA) interventions to increase PA during and after completing cardiac rehabilitation (CR) and for patients who do not attend CR (non-CR). PubMed, PsychINFO, SPORTdiscus, Web of Science, Prowler and Cochrane databases were searched to identify studies that described an intervention delivered to adults in the CR and non-CR contexts that focused solely on promoting PA. Twenty-three studies (14 post-CR and nine non-CR) were included in this review. Findings showed that interventions can increase PA; however, there were notable differences across CR contexts in their purpose, the participant demographics, and some of the behaviour change techniques used. Techniques shown to be most effective in the post-CR context were self-monitoring, setting specific goals, identifying barriers and developing plans for relapse prevention. In the non-CR context, unsupervised home-based interventions were shown to be effective at increasing PA, particularly when accompanied by follow-up prompts, general encouragement, specific goals set by the researcher and self-monitoring. Post-CR and non-CR interventions can result in improved PA outcomes; however, the research in this area is limited. More interventions are needed that target PA-only, particularly in the non-CR context.

Location-Based Sedentary Time and Physical Activity in People Living With Coronary Artery Disease.

PURPOSE: Sedentary time (ST) and lack of physical activity increase the risk of adverse outcomes for those living with coronary artery disease (CAD). Little is known about how much ST, light physical activity (LPA), and moderate to vigorous physical activity (MVPA) that CAD participants not attending cardiac rehabilitation engage in, the locations where they engage in these behaviors, and how far from home the locations are. METHODS: Participants completed a survey and wore an accelerometer and global positioning system receiver for 7 d at baseline and 6 mo later. RESULTS: Accelerometer analyses (n = 318) showed that participants averaged 468.4 ± 102.7 of ST, 316.1 ± 86.5 of LPA, and 32.9 ± 28.9 of MVPA min/d at baseline. ST and LPA remained stable at 6 mo, whereas MVPA significantly declined. The global positioning system (GPS) analyses (n = 315) showed that most of participant ST, LPA, and MVPA time was spent at home followed by other residential, retail/hospitality, and work locations at baseline and 6 mo. When not at home, the average distance to a given location ranged from approximately 9 to 18 km. CONCLUSIONS: Participants with CAD spent the majority of their time being sedentary. Home was the location used the most to engage in ST, LPA, and MVPA. When not home, ST, LPA, and MVPA were distributed across a variety of locations. The average distance from home to a given location suggests that proximity to home may not be a barrier from an intervention perspective.

Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial.

BACKGROUND: Despite lack of outward signs, most individuals after non-disabling stroke (NDS) and transient ischemic attack (TIA) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke, hospitalization for other vascular events, or death. Most have multiple modifiable risk factors (e.g., hypertension, physical inactivity, hyperlipidaemia, diabetes, tobacco consumption, psychological stress). In addition, accelerated rates of depression, cognitive decline, and poor quality of sleep have been reported following TIA, which correlate with poor functional outcomes and reduced quality of life. Thus, NSD and TIA are important warning signs that should not be overlooked. The challenge is not unlike that facing other 'silent' conditions - to identify a model of care that is effective in changing people's current behaviors in order to avert further morbidity. METHODS/DESIGN: A single blind, randomized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA. 250 adults within 90 days of being diagnosed with NDS/TIA will be randomly allocated to a 12-week program of exercise and education (PREVENT) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated (USUAL CARE). Primary outcome measures will include blood pressure, waist circumference, 12-hour fasting lipid profile, and 12-hour fasting glucose/hemoglobin A1c. Secondary measures will include exercise capacity, walking endurance, physical activity, cognitive function, depression, goal attainment and health-related quality of life. Outcome assessment will be conducted at baseline, post-intervention, and 6- and 12-month follow-ups. Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared. Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards. DISCUSSION: Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known. We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention.

Association Between Cardiac Rehabilitation and Frailty.

BACKGROUND: Cardiac rehabilitation is a mainstay treatment for patients experiencing an adverse cardiovascular event. Heart disease is important in frailty, but the impact of cardiac rehabilitation on frailty is unclear. METHODS: Patients were referred to a 12-week group-based exercise and education cardiac rehabilitation program performed twice weekly. Frailty was measured with the use of a 25-item accumulation of deficits frailty index (range 0-1; higher values indicate greater frailty) at cardiac rehabilitation admission and completion. Patients were categorized by the degree of frailty in 0.1 increments. RESULTS: Of the 4004 patients who enrolled, 2322 (58.0%) completed cardiac rehabilitation with complete data at admission and completion. There were 414 (17.8%), 642 (27.6%), 690 (29.7%), 401 (17.3%), and 175 (7.5%) patients with admission frailty levels of < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50, respectively. Frailty levels improved from cardiac rehabilitation admission (mean 0.34 [95% CI 0.32-0.35]) to completion (0.26 [0.25-0.28]) for those who completed the program (P < 0.001). After adjusting for age, sex, and number of exercise sessions attended, frailty improved in all frailty groups by mean differences of 0.03 (0.02-0.03), 0.05 (0.05-0.06), 0.08 (0.08-0.09), 0.10 (0.09-0.11), and 0.11 (0.10-0.13) in the < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50 frailty groups, respectively. The minimal improvement in frailty scores (≥ 0.03 reduction) was achieved by 48%, 65%, 72%, 76%, and 79% of patients in the the 5 frailty groups, respectively. CONCLUSIONS: Although higher frailty levels were associated with cardiac rehabilitation drop-out, finishing the program was related to improving frailty levels, especially in patients who were the frailest.

Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update.

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription-the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012 to 2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. The AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke.

The Effect of Cardiac Rehabilitation and a Specialized Clinic on Outcomes of Patients With Atrial Fibrillation.

BACKGROUND: Cardiac rehabilitation (CR) intervention programs are currently not part of management in patients with atrial fibrillation (AF). We sought to determine the effect of CR compared with a specialized AF clinic (AFC) and usual care on outcomes in patients with AF. METHODS: This was a single-centre retrospective cohort study that was carried out using 3 databases: the Hearts in Motion database (2010-2014), prospectively collected data in an AFC (2011-2014), and a retrospective chart review for patients in usual care (2009-2012). Three care pathways were compared: (1) CR; (2) AFC; and (3) usual specialist-based care. The main outcome was AF-related emergency department visits and cardiovascular hospitalizations. RESULTS: Of 566 patients with newly diagnosed AF, 133 (23.5%) patients underwent CR, 197 patients (34.8%) attended the AFC, whereas the remaining 236 (41.7%) were followed in a usual specialist-based care clinic. At 1 year, AF-related emergency department visits and cardiovascular hospitalization rates occurred in 7.5% in the CR group, 16.8% in the AFC group, and 29.2% in usual care. After a propensity matched analysis, usual care was associated with the highest rate of the main outcome (odds ratio, 4.91; 95% confidence interval, 2.09-11.53) compared with CR, as did the AFC compared with CR (odds ratio, 2.75; 95% confidence interval, 1.14-6.6). CONCLUSIONS: Among patients with AF, CR was associated with a lower risk of AF-related outcomes. These findings support further study of the use of CR in the management of these patients to determine the optimal model of care for AF patients.

Feasibility and usability of an ontology-based mobile intervention for patients with hypertension.

BACKGROUND: Lifestyle changes and the adoption of healthy behaviours are well established recommendations for the management of hypertension-a risk factor for cardiovascular and kidney disease. Mobile health interventions offer unique advantages and novel approaches to helping individuals make and maintain such behaviour changes; however, current interventions often lack theoretical and scientific grounding. OBJECTIVE: The goal of this study is to effectively model the knowledge, concepts and relationships relevant to the management of a chronic illness like hypertension, and to implement this knowledge model within a mobile self-management application that can be used by patients. METHODS: A behaviour modification approach based on COM-B (capability, opportunity, motivation, behaviour) Model and the associated Behaviour Change Wheel was developed. An ontology-based knowledge model was implemented to formally conceptualise relevant knowledge in hypertension clinical practice guidelines, behaviour change models and associated behaviour change strategies. A hypertension management decision support framework was designed and implemented as a proof-of-concept mobile phone application (EmpowerBP) using the aforementioned model. The usability of this pilot application was tested using think-aloud protocol by eight individuals with hypertension while performing predefined tasks. Thematic analysis with inductive thematic coding was performed to identify specific feedback and areas for improvement. RESULTS: The most common positive feedback included participants finding application resources interesting or helpful and liking the user interface. The most common negative feedback was finding the included salt calculator confusing or laborious to use and finding the profile creation questionnaire too long. The derived themes were: features, profile creation, resources, scenario, usability, user interface. CONCLUSIONS: The ontology knowledge model formalises variables, properties, and relationships such that they can be used for problem solving. By integrating and computerising complex knowledge from clinical practice guidelines, behaviour change theories, and associated behaviour change strategies, it is possible to model existing information about the management of hypertension as an ontology. This proof-of-concept application creates clinical and behavioural profiles of a user to provide them with personalised management strategies, rooted in established behaviour change theory, that will engage and empower them to manage their condition. Given the nature of ontological models, this approach can be easily modified to address a variety of chronic illnesses.

The Community Balance and Mobility Scale: A VALID ASSESSMENT TOOL OF BALANCE IN CARDIAC REHABILITATION PATIENTS.

PURPOSE: Many patients participating in cardiac rehabilitation (CR) programs have decreased balance. This is a concern, as it may affect their ability to optimally perform physical exercise in CR and thus decrease CR efficacy. Despite this concern, balance is typically not assessed as part of CR intake. This may be attributable to the fact that a suitable balance assessment tool has not been identified for higher-functioning CR patients. A potential solution to this issue is using the Community Balance and Mobility Scale (CBMS), which has been used to assess balance in higher-functioning clinical populations; however, its use in a CR population has never been investigated. Therefore, the purpose of this study was to determine the reliability and validity of the CBMS for assessing balance in CR patients. METHODS: Fifty-three participants were recruited from local CR programs to perform the CBMS. Dynamic posturography was also measured in a subset of participants (n = 31) using the Limits of Stability (LOS) test. RESULTS: Analysis of CBMS scores revealed that the mean CBMS score was 61.9 ± 16.2 (out of 96) and that no floor or ceiling effects were observed for any participants. CBMS scores were significantly correlated with the LOS results (0.41-0.53). Interrater reliability between novice and expert testers was strong (r = 0.95), with all differences falling within the 95% limits of agreement. CONCLUSION: Overall, these results suggest that the CBMS is a valid tool to measure balance in CR patients and can be reliably administered by health care professionals with minimal training.

High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity.

INTRODUCTION: Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise. Optimal cardiovascular training parameters to maximize recovery in stroke survivors also remains unknown. While stroke rehabilitation recommendations suggest the use of moderate-intensity continuous exercise (MICE) to improve CRF, neither is it routinely implemented in clinical practice, nor is the intensity always sufficient to elicit a training effect. High-intensity interval training (HIIT) has emerged as a potentially effective alternative that encompasses brief high-intensity bursts of exercise interspersed with bouts of recovery, aiming to maximize cardiovascular exercise intensity in a time-efficient manner. HIIT may provide an alternative exercise intervention and invoke more pronounced benefits poststroke. OBJECTIVES: To provide an updated review of HIIT poststroke through ( a) synthesizing current evidence; ( b) proposing preliminary considerations of HIIT parameters to optimize benefit; ( c) discussing potential mechanisms underlying changes in function, cardiovascular health, and neuroplasticity following HIIT; and ( d) discussing clinical implications and directions for future research. RESULTS: Preliminary evidence from 10 studies report HIIT-associated improvements in functional, cardiovascular, and neuroplastic outcomes poststroke; however, optimal HIIT parameters remain unknown. CONCLUSION: Larger randomized controlled trials are necessary to establish ( a) effectiveness, safety, and optimal training parameters within more heterogeneous poststroke populations; (b) potential mechanisms of HIIT-associated improvements; and ( c) adherence and psychosocial outcomes.

Effects of a 12-week cardiovascular rehabilitation programme on systemic inflammation and traditional coronary artery disease risk factors in patients with rheumatoid arthritis (CARDIA trial): a randomised controlled trial.

INTRODUCTION: Patients with systemic inflammatory diseases such as rheumatoid arthritis (RA) have an increased risk of cardiovascular disease (CVD) above the baseline risk attributable to traditional CVD risk factors seen in the general population. Exercise in cardiac rehabilitation (CR) is designed specifically for high-risk primary prevention and those with established CVD. Even though the European League Against Rheumatism guidelines state that exercise is safe for individuals with RA and exercise can reduce CVD risk, patients with RA rarely participate in CR. Thus, little is known about CR's impact on inflammatory and CVD risk in the RA population. The purpose of this trial is to determine the feasibility of a 12-week CR programme for patients with RA and whether it decreases CVD risk without exacerbating RA. METHODS AND ANALYSIS: This is a randomised controlled trial whereby 60 participants with RA will be recruited and randomly assigned to either standard of care (SOC) treatment or SOC plus a 12-week CR programme (60 min of education plus two 60 min aerobic exercise sessions/week). Exercise will be performed at 60%-80% of heart rate reserve. Outcome measures (Framingham Risk Score, resting heart rate, blood pressure, blood lipids, markers of systemic inflammation (ie, interleukin (IL) 6 and tumour necrosis factor-α (TNF-α), Clinical Disease Assessment Index, Disease Activity Score-28, physical activity levels and peak cardiorespiratory fitness) will be assessed preintervention (week-0), postintervention (week-13) and 6 months postintervention. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Nova Scotia Health Authority Research Ethics Board. Results will be submitted for publication in an appropriate peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT01534871; Pre-results.

EXercise to prevent AnthrCycline-based Cardio-Toxicity (EXACT) in individuals with breast or hematological cancers: a feasibility study protocol.

BACKGROUND: Anthracyclines (AC), widely used and effective anticancer agents, are known to induce both acute and chronic declines in cardiovascular health, ranging in severity from asymptomatic, subclinical dysfunction to substantial cardiomyopathy leading to congestive heart failure and death. There is substantial evidence that physical activity, higher levels of cardiorespiratory fitness, and exercise therapy can help prevent cardiovascular disease. Moreover, animal studies have shown that exercise performed concomitantly with AC treatment may attenuate early cardiac damage that results from AC exposure. Our primary objective is to assess the feasibility of a 12-week aerobic exercise training (AET) program in patients receiving AC-based chemotherapy. METHODS/DESIGN: This is a prospective, single-arm (pre-post-test design), feasibility study of a supervised 12-week progressive, light-to-moderate to moderate-to-vigorous intensity AET program for patients (18-65 years) receiving AC chemotherapeutic treatment for a primary/non-recurrent breast cancer or hematological malignancy. Both feasibility (e.g., participant recruitment, program adherence, safety) and intervention outcome (e.g., biological markers of cardiotoxicity, aerobic capacity, quality of life) measures will be collected. The AET program will include two, 45-min community-based exercise sessions (treadmill or cycle) per week for a total of 12 weeks. All exercise sessions will be supervised by trained exercise specialists. DISCUSSION: Data from the EXACT study will be evaluated to determine the need to refine patient recruitment methods and general acceptability of the AET program. Preliminary data on the effects of the AET intervention on pertinent cardiac and health outcomes will also be evaluated and used to inform future studies in terms of the most appropriate outcome measure(s) to adopt and sample size estimation. TRIAL REGISTRATION: ClinicalTrails.gov, NCT02471053.

Protocol for the PREHAB study-Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial.

INTRODUCTION: Frailty is a geriatric syndrome characterised by reductions in muscle mass, strength, endurance and activity level. The frailty syndrome, prevalent in 25-50% of patients undergoing cardiac surgery, is associated with increased rates of mortality and major morbidity as well as function decline postoperatively. This trial will compare a preoperative, interdisciplinary exercise and health promotion intervention to current standard of care (StanC) for elective coronary artery bypass and valvular surgery patients for the purpose of determining if the intervention improves 3-month and 12-month clinical outcomes among a population of frail patients waiting for elective cardiac surgery. METHODS AND ANALYSIS: This is a multicentre, randomised, open end point, controlled trial using assessor blinding and intent-to-treat analysis. Two-hundred and forty-four elective cardiac surgical patients will be recruited and randomised to receive either StanC or StanC plus an 8-week exercise and education intervention at a certified medical fitness facility. Patients will attend two weekly sessions and aerobic exercise will be prescribed at 40-60% of heart rate reserve. Data collection will occur at baseline, 1-2 weeks preoperatively, and at 3 and 12 months postoperatively. The primary outcome of the trial will be the proportion of patients requiring a hospital length of stay greater than 7 days. POTENTIAL IMPACT OF STUDY: The healthcare team is faced with an increasingly complex older adult patient population. As such, this trial aims to provide novel evidence supporting a health intervention to ensure that frail, older adult patients thrive after undergoing cardiac surgery. ETHICS AND DISSEMINATION: Trial results will be published in peer-reviewed journals, and presented at national and international scientific meetings. The University of Manitoba Health Research Ethics Board has approved the study protocol V.1.3, dated 11 August 2014 (H2014:208). TRIAL REGISTRATION NUMBER: The trial has been registered on ClinicalTrials.gov, a registry and results database of privately and publicly funded clinical studies (NCT02219815).