Digital Technologies in Cardiac Rehabilitation: A Science Advisory From the American Heart Association.

Cardiac rehabilitation has strong evidence of benefit across many cardiovascular conditions but is underused. Even for those patients who participate in cardiac rehabilitation, there is the potential to better support them in improving behaviors known to promote optimal cardiovascular health and in sustaining those behaviors over time. Digital technology has the potential to address many of the challenges of traditional center-based cardiac rehabilitation and to augment care delivery. This American Heart Association science advisory was assembled to guide the development and implementation of digital cardiac rehabilitation interventions that can be translated effectively into clinical care, improve health outcomes, and promote health equity. This advisory thus describes the individual digital components that can be delivered in isolation or as part of a larger cardiac rehabilitation telehealth program and highlights challenges and future directions for digital technology generally and when used in cardiac rehabilitation specifically. It is also intended to provide guidance to researchers reporting digital interventions and clinicians implementing these interventions in practice and to advance a framework for equity-centered digital health in cardiac rehabilitation.

Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association.

Patients with lower-extremity peripheral artery disease (PAD) have greater functional impairment, faster functional decline, increased rates of mobility loss, and poorer quality of life than people without PAD. Supervised exercise therapy (SET) improves walking ability, overall functional status, and health-related quality of life in patients with symptomatic PAD. In 2017, the Centers for Medicare & Medicaid Services released a National Coverage Determination (CAG-00449N) for SET programs for patients with symptomatic PAD. This advisory provides a practical guide for delivering SET programs to patients with PAD according to Centers for Medicare & Medicaid Services criteria. It summarizes the Centers for Medicare & Medicaid Services process and requirements for referral and coverage of SET and provides guidance on how to implement SET for patients with PAD, including the SET protocol, options for outcome measurement, and transition to home-based exercise. This advisory is based on the guidelines established by the Centers for Medicare & Medicaid Services for Medicare beneficiaries in the United States and is intended to assist clinicians and administrators who are implementing SET programs for patients with PAD.

Influence of Changes in Sedentary Time on Outcomes of Supervised Exercise Therapy in Individuals with Comorbid Peripheral Artery Disease and Type 2 Diabetes.

BACKGROUND: Although supervised exercise therapy (SET) is effective in improving walking distance among adults with symptomatic peripheral artery disease (PAD), some research suggests that individuals with comorbid PAD and type 2 diabetes mellitus (T2DM) may experience a blunted response to SET. It is unknown whether free-living sedentary time changes during SET, and if increases in sedentary time could, in part, explain poor response to SET. The purposes of this pilot study were to (1) determine if older adults with PAD (with and without T2DM) engaging in SET change their sedentary behavior and (2) examine the relationship between changes in sedentary behavior and SET outcomes. We hypothesized that decreased sedentary time during SET would be associated with greater improvements in six-minute walk test (6MWT) total distance and other key SET outcomes. METHODS: Participants (n = 44) initiating a 12-week SET program completed the 6MWT, Short Physical Performance Battery, Walking Impairment Questionnaire, and accelerometer-assessed sedentary behavior at SET initiation, 6 weeks, and 12 weeks. RESULTS: Participants' mean age was 72.3 (7.1) years, mean ankle-brachial index was 0.71 (0.25), and 47.7% were female. On average, sedentary time did not change after SET, although there was substantial variability (-40% to +38% change in minutes of sedentary time/day). Participants with T2DM experienced greater improvements in claudication onset distance than participants without T2DM (mean = 35 m, P = 0.044, 95% confidence interval = 1.6 to 115.4 m). Neither changes in sedentary time from baseline to 6 weeks (P = 0.419) nor T2DM (P = 0.154) predicted changes in 6MWT total distance from baseline to 12 weeks. CONCLUSIONS: As SET availability increases, further examination of factors that may influence SET outcomes will help maximize benefits of this proven therapy.

Variability in Individual Response to Aerobic Exercise Interventions Among Older Adults.

Although a plethora of evidence supports the benefits of exercise among older adults, a majority of studies have emphasized group differences, while giving little, if any, attention to individual differences. Given the lack of data on variability in response, the present review examined how nonresponse to aerobic exercise has been defined in older adult populations and characteristics associated with nonresponse among older adults. The results of this review suggest that interindividual variability in response of maximal oxygen consumption to aerobic exercise interventions is prevalent among older adults (1.4-63.4%); age, sex, race, and body mass index may not be critical determinants of nonresponse; whereas health status, baseline fitness, and exercise dose appear important. Future intervention studies should evaluate and report the variability in individual response of older adults to exercise; investigators should develop programs that allow for modification of components to assist older adults in achieving optimal benefit from exercise programs.

The Relationship Between Peripheral Artery Disease Symptomatology and Ischemia.

BACKGROUND: Fewer than half of individuals with peripheral artery disease (PAD) experience classic claudication, and the relationships between PAD typical or atypical symptom intensity, location, and description (classic or atypical) with ischemic changes have not previously been reported. OBJECTIVE: The primary purpose of this study was to evaluate the relationship between self-reported PAD symptom intensity and calf tissue ischemia measured using the tissue saturation index (TSI) during treadmill exercise. The location and descriptors of atypical PAD symptoms in the presence of calf tissue ischemia were also identified. METHODS: Adults with PAD with exercise-limiting ischemic symptoms were asked to (a) rate symptom intensity using a numerical rating scale (NRS) from 0 to 5 (0 = no pain, 1 = onset of pain, 5 = maximal pain), (b) provide symptom locations and descriptors, and (c) wear a near-infrared spectroscopy device to obtain calf TSI values during treadmill exercise. Multilevel models with TSI as the outcome variable were estimated during exercise and recovery. Covariates included were exercise time, recovery time, baseline TSI, exercise rating, recovery rating, ankle-brachial index (ABI), age, race, gender, body mass index, diabetes, neuropathy, and smoking. RESULTS: During three successive bouts of treadmill exercise for 40 participants (80% Caucasian men; average age = 68 years, SD = 9.2), the most rapid decline in TSI occurred between the start of exercise and symptom onset (when NRS = 1). The TSI nadir was often reached prior to report of maximum discomfort (when NRS = 5), and changes in TSI were related to exercise time (p < .001), baseline TSI (p < .001), exercise ratings (p < .001), and ABI (p < .05). During recovery, TSI increased steadily for most participants as pain eased. In the recovery model, changes in TSI were associated with recovery ratings (p < .001) and ABI (p < .03). Of 120 treadmill exercise tests, 69.2% were stopped due to discomfort in the calf with classic descriptors reported only half the time (55.4%). DISCUSSION: Exploratory analyses revealed ischemic symptoms extended beyond classic claudication locations and descriptors. Future research should evaluate changes in TSI relative to atypical locations and descriptors to improve understanding of the full range of ischemic symptoms experienced by individuals with PAD.

Characterization of the peripheral artery disease symptom experience.

Claudication is the most commonly recognized peripheral artery disease (PAD) symptom, but not the most prevalent. Only 7.5%-33% of patients report claudication as being part of their symptom experience. However, there is little evidence supporting atypical symptom reporting. The study purpose was to describe the full spectrum of symptoms experienced by older and younger individuals with PAD. Semistructured interviews were conducted with a purposive sample of 38 community-dwelling adults aged 49-83 years; transcripts were analyzed using content analysis. Six themes emerged: symptom descriptors (claudication and atypical), maintaining equilibrium, temporal fluctuations, the role of exercise, perceived impact on quality of life, and disease presence and treatment. Results suggest heavy reliance on claudication can result in mis- or under-diagnosis of PAD. Further research is needed to validate the correspondence of atypical symptoms with ischemic changes during exercise to broaden currently accepted symptom locations and descriptors associated with PAD.

Methods of symptom evaluation and their impact on peripheral artery disease (PAD) symptom prevalence: a review.

Peripheral artery disease (PAD) is a common progressive atherosclerotic occlusive disease that causes insufficient blood flow to the lower extremities. The symptom that health care professionals most often associate with PAD is claudication. However, patient reporting of claudication is highly variable. A structured literature review was conducted to evaluate how PAD symptoms are identified, defined, and categorized. This review focuses on the development and performance characteristics of PAD symptom questionnaires and the identification of a spectrum of leg symptoms beyond classic claudication. Additionally, potential confounders of PAD symptom reporting and strategies for a more comprehensive assessment of PAD symptoms are discussed. Overall, there is a lack of consistency in the utilization of PAD claudication questionnaires which impacts PAD symptom reporting and categorization. Based on this review, atypical symptoms are commonly reported, but poorly understood. Additional research is needed to gain a better understanding of the presentation of atypical symptoms, as well as the role of age, gender, race, and comorbid conditions on the symptom experience of patients with PAD.

Effects of Telephone-Based Brief Motivational Interviewing on Self-Management, Medication Adherence, and Glycemic Control in Patients with Uncontrolled Type 2 Diabetes Mellitus in a Rural Community in Thailand.

Introduction: Owing to the increased prevalence of type 2 diabetes mellitus (T2DM) and the high proportion of patients with uncontrolled T2DM, effective interventions for disease management are needed. Objective: The study aim was to test the effects of brief motivational interviewing (MI) on patients' self-management, medication adherence, and glycemic control. Methods: A single-group repeated measures trial was used to examine the effects of usual care only and usual care plus telephone-based brief MI. Participants were 29 patients with uncontrolled T2DM recruited from a rural primary care setting in Nakhon Sawan, Thailand. Participants received usual care during the first 4 weeks, followed by usual care plus brief MI during weeks 4-8. Outcomes of self-management, medication adherence, fasting blood sugar (FBS) levels, and hemoglobin A1c (HbA1c) levels were assessed at baseline, 4 weeks, and 8 weeks. Data were analyzed using descriptive statistics, one-way repeated measures analysis of variance, and Friedman test. Results: Significant changes in self-management (p < 0.001), medication adherence (p < 0.001), and FBS (p < 0.05) were observed over the 8-week study. In multiple comparisons, self-management was the only parameter significantly different across baseline, 4, and 8 weeks (p <0.05, <0.001, and <0.001, respectively); medication adherence was significantly different between 4 and 8 weeks (p < 0.05), and between baseline and 8 weeks (p < 0.001); and FBS was significantly different between 4 and 8 weeks (p < 0.05). HbA1c declined over the 8-week study, but not significantly. Conclusion: An intervention combining telephone-based brief MI with usual care significantly increased self-management, medication adherence, and glycemic control (ie, FBS) after 4 weeks, whereas usual care only significantly increased self-management. Phone-based brief MI may be an effective way for healthcare providers to remotely enhance patients' self-management and glycemic control, thus reducing barriers related to time and geographic location.

Relation of non-exercise walking activity with exercise performance in patients with peripheral artery disease: NEW activity for PAD.

INTRODUCTION: Community-based structured exercise training (CB-SET) programs are beneficial for patients with peripheral artery disease (PAD). However, the impact of lower levels of walking activity accumulated separately from formal exercise is unclear. The aim of this study was to determine the relation of non-exercise walking (NEW) activity with exercise performance in PAD. METHODS: This was a post hoc analysis from twenty patients with PAD enrolled in a 12 week CB-SET program using diaries and accelerometry. Formal exercise (3 sessions·week-1) was detected using patient-reported diary entries that corresponded with accelerometer step data. NEW activity was characterized as steps completed over five days each week, excluding steps achieved during formal exercise sessions. The primary exercise performance outcome was peak walking time (PWT) assessed on a graded treadmill. Secondary performance outcomes included claudication onset time (COT) from the graded treadmill and peak walking distance (PWD) achieved during the six-minute walk test (6MWT). Partial Pearson correlations evaluated the relation of NEW activity (step·week-1) with exercise performance outcomes using exercise session intensity (step·week-1) and duration (min·week-1) as covariates. RESULTS: NEW activity demonstrated a moderate, positive correlation with change in PWT (r=0.50, p=0.04). Other exercise performance outcomes were not significantly related to NEW activity (COT: r=0.14; 6MWT PWD: r=0.27). CONCLUSIONS: A positive association was demonstrated between NEW activity and PWT following 12 weeks of CB-SET. Interventions to increase physical activity levels outside of formal exercise sessions may be beneficial for patients with PAD.

The PADQOL: development and validation of a PAD-specific quality of life questionnaire.

Understanding the impact of peripheral artery disease (PAD) requires broad evaluation of how functional limitations of PAD affect patients' perceptions of health-related quality of life (HRQL). The objective of this study was to describe the development, testing, and psychometric properties of the PAD Quality of Life Questionnaire (PADQOL). The PADQOL was developed in three steps: (1) interviews of symptomatic PAD patients provided content of the initial questionnaire; (2) co-administration with the SF-36 (a 36-item short-form health survey), Walking Impairment Questionnaire, and Profile of Mood States examined construct validity; and (3) a three-phased factor analysis identified factors and shortened the questionnaire. Data analyses from 297 symptomatic PAD patients resulted in a 38-item questionnaire of five factors: Social relationships and interactions, Self-concept and feelings, Symptoms and limitations in physical functioning, Fear and uncertainty, and Positive adaptation (α = 0.92-0.73) and items related to sexual function, intimate relationships and employment. Between-instrument correlations established construct validity. In conclusion, PADQOL is a validated measure to assess the disease-specific physical, psychosocial and emotional effects of PAD for research and practice.

The Impact of Human Milk on Outcomes for Infants with Congenital Heart Disease: A Systematic Review.

Background: Infants with congenital heart disease (CHD) are at risk for feeding-related morbidity and mortality, with growth failure and oral feeding problems associated with poor outcomes. The benefits of human milk (HM) for preterm infants have been well documented, but evidence on HM for infants with CHD has recently begun to emerge. Objectives: Our primary aim was to examine the impact of HM feeding on outcomes for infants with CHD. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. The quality of each study was assessed using the Joanna Briggs Critical Appraisal Tools. A total of 16 studies were included. Results: There was evidence that an exclusive HM diet reduces the risk of necrotizing enterocolitis (NEC) for infants with CHD. Evidence with a higher risk for bias indicated that a well-managed HM diet may be associated with improved growth, shorter length of stay, and improved postoperative feeding and nutritional outcomes. Chylothorax outcomes were similar between modified HM and medium-chain triglyceride formula. The studies had significant limitations related to power, lack of control for covariates, and inconsistent delineation of feeding groups. Conclusions: Based on the reduced risk for NEC and given the conclusive benefits in other vulnerable populations, we recommend that clinicians and institutions prioritize programs to support HM feeding for infants with CHD. Large high-quality studies are needed to validate these results. Future work should clarify best practices in managing an HM diet to support optimal growth and development for these infants.

Individual Differences in Response to Supervised Exercise Therapy for Peripheral Artery Disease.

Nonresponse to exercise has been extensively examined in young athletes but is seldom reported in studies of aerobic exercise interventions in older adults. This study examined the prevalence of nonresponse and poor response to exercise in functional and quality of life outcomes and response patterns between and among older adults undergoing 12-weeks of supervised exercise therapy for the management of peripheral artery disease (N = 44, mean age 72.3 years, 47.7% female). The prevalence of nonresponse (no change/decline in performance) in walking distance was 31.8%. The prevalence of poor response (lack of a clinically meaningful improvement) was 43.2%. Similar patterns of response were observed in both objective and patient-reported measures of physical function. All participants improved in at least one outcome; only two participants improved in all measured outcomes. Additional research should examine modifiable predictors of response to inform programming and maximize an individual's potential benefit from exercise therapy.

Harnessing Mobile Health Technology for Secondary Cardiovascular Disease Prevention in Older Adults: A Scientific Statement From the American Heart Association.

Secondary prevention of cardiovascular disease (CVD), the leading cause of morbidity and mortality, is critical to improving health outcomes and quality of life in our aging population. As mobile health (mHealth) technology gains universal leverage and popularity, it is becoming more user-friendly for older adults and an adjunct to manage CVD risk and improve overall cardiovascular health. With the rapid advances in mHealth technology and increasing technological engagement of older adults, a comprehensive understanding of the current literature and knowledge of gaps and barriers surrounding the impact of mHealth on secondary CVD prevention is essential. After a systematic review of the literature, 26 studies that used mHealth for secondary CVD prevention focusing on lifestyle behavior change and medication adherence in cohorts with a mean age of ≥60 years were identified. Improvements in health behaviors and medication adherence were observed, particularly when there was a short message service (ie, texting) component involved. Although mobile technologies are becoming more mainstream and are starting to blend more seamlessly with standard health care, there are still distinct barriers that limit implementation particularly in older adults, including affordability, usability, privacy, and security issues. Furthermore, studies on the type of mHealth that is the most effective for older adults with longer study duration are essential as the field continues to grow. As our population ages, identifying and implementing effective, widely accepted, cost-effective, and time-efficient mHealth interventions to improve CVD health in a vulnerable demographic group should be a top health priority.

Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure or Cholesterol: Who, What, and How?: A Scientific Statement From the American Heart Association.

Current guidelines published by the American Heart Association and the American College of Cardiology broadly recommend lifestyle approaches to prevent and treat elevated blood pressure and cholesterol. For patients with mildly or moderately elevated blood pressure and blood cholesterol, lifestyle-only approaches are the first line of therapy. The purpose of this scientific statement is to: (1) highlight the mild-moderate-risk patient groups indicated for lifestyle-only treatment for elevated blood pressure or cholesterol; (2) describe recommendations, average effects, and additional considerations when prescribing lifestyle treatment with physical activity; and (3) provide guidance and resources for clinicians to assess, prescribe, counsel, and refer to support increased physical activity in their patients. An estimated 21% and 28% to 37% of US adults, respectively, have mild-moderate-risk blood pressure and cholesterol and should receive lifestyle-only as first-line treatment. Of the recommended lifestyle changes, increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes. Physical activity assessment and prescription are an excellent lifestyle behavior treatment option for all patients, including for the large population of mild-moderate-risk patients with elevated blood pressure and blood cholesterol.

Adherence and exercise mode in supervised exercise therapy for peripheral artery disease.

Supervised exercise therapy (SET) is a first-line treatment for people with peripheral artery disease (PAD). However, data on patient adherence to SET are limited. In addition, while intermittent treadmill exercise has been widely tested, no studies have investigated recumbent total body stepping (step-ex). We examined whether exercise mode (treadmill walking [n = 17], step-ex [n = 18], or a multimodal approach [n = 18]) affected adherence to a 12-week SET program. We also investigated the potential safety and viability of step-ex for people with PAD by looking at change in exercise training capacity (highest metabolic equivalent of tasks [METs] achieved and highest total MET-minutes achieved per session). The 53 participants comprised 50% female candidates (n = 26) and were (mean [SD]) 74.2 (8.3) years old, with an ankle-brachial index of 0.70 (0.19). Overall adherence to SET was 62%. There was a difference in adherence between groups (P = .022), with the multimodal group (73.6% [21.5%]) higher than the treadmill group (50.2% [28.8%], P = .010). Treadmill participants (n [%]) (8 [47.1%]) dropped out at a higher rate than the multimodal group (3 [16.7%], P = .053). All groups increased the exercise training capacity. The multimodal group achieved greater improvement in total MET-minutes achieved per session (61.5 [45.1]) than the treadmill group (14.7 [44.3]) (P = .008).A multimodal approach to PAD exercise therapy resulted in higher adherence and greater change in exercise training capacity. Step-ex was safe for people with PAD. While further study is warranted, it is appropriate for SET programs to consider a multimodal approach using step-ex, especially given the varied health and physical ability of the PAD population.

A mixed methods study of perceived barriers to physical activity, geriatric syndromes, and physical activity levels among older adults with peripheral artery disease and diabetes.

Previous studies suggest a myriad of factors prevent individuals from engaging in physical activity; however, less is known about barriers faced by individuals with multiple chronic conditions, such as peripheral artery disease (PAD) and type 2 diabetes, and how these barriers may impact engagement in physical activity. To date, there are no studies that integrate simultaneous assessment of perceived barriers to physical activity and engagement in physical activity in older adults with PAD and diabetes. This integration is key to understanding the implications of barriers to physical activity and to developing strategies to address those barriers. Therefore, this study investigated the unique physical activity experiences of older adults with PAD and diabetes. This study used a concurrent mixed methods design. Ten adults aged 65 years and older with PAD and diabetes completed semistructured interviews about experiences with physical activity, self-reported questionnaires assessing quality of life and fear of falling, and measures of physical function (eg, 6-minute walk test, chair stand, gait speed). Physical activity was measured objectively with accelerometry. Inductive content analysis was used to identify themes, and integrated analysis was performed to evaluate patterns among qualitative and quantitative variables. On average, participants were 74 years old and spent 10% of their time in moderate or vigorous physical activity (range: 3%-18%); 80% of participants were men. Barriers to physical activity identified through qualitative interviews included lack of accessibility, lack of enjoyment of activity, lack of motivation, and pain and physical health. Facilitators to physical activity were social support, accessibility and convenience, and enjoyment of the activity. Participants with more sedentary time and less moderate or vigorous physical activity tended to report greater fear of falling and greater barriers to physical activity and achieved lower distances in 6-minute walk tests. This research provides insight into both the nature of perceived barriers to physical activity and engagement in physical activity among older adults with PAD and diabetes. The integration of self-reported measures and objective measures facilitates our understanding of the lived experiences of individuals with these conditions. Study findings can be used to support further investigation into factors that influence engagement in physical activity in individuals with PAD and diabetes and to assist in the development of strategies to address identified barriers.

Effects of fasting on tissue contents of coenzyme A and related intermediates in rats.

Exposure of rats and mice to hyperoxia decreases lung coenzyme A (CoASH) contents, with a decrease of 50% observed in adult male Fischer-344 rats exposed to >95% O(2) for 48 h. Decreases in lung CoASH levels are not accompanied by increases in contents of the mixed glutathione disulfide of CoA, as might be expected of a primary oxidative stress on CoASH status. Animals exposed to hyperoxia exhibit decreased food intake, and the present studies were to test the hypothesis that fasting would decrease lung CoASH contents, thereby suggesting a mechanism for the effects of hyperoxia. Adult male Fischer-344 rats were examined after 0, 24, or 48 h of fasting (n = 5, 6, and 6, respectively). Fasting for 24 or 48 h did not affect lung CoASH levels or lung weights, despite 6 and 12% losses in body weight. Lung glutathione concentrations (nanomoles per gram of tissue) and contents (nanomoles per whole organ) and glutathione disulfide contents were 10 to 20% lower in rats fasted for 48 h than in fed rats. Liver weights and glutathione and glutathione disulfide contents and concentrations were 30 to 70% lower in rats fasted for 24 or 48 h than in fed rats. Hepatic CoASH concentrations increased during fasting, but hepatic contents of CoASH remained remarkably constant. Liver protein contents (milligrams of protein per whole organ) decreased after 24 and 48 h of fasting, but protein concentrations (milligrams of protein per gram of tissue) were higher in rats fasted 48 h than in fed rats. Overall, glutathione, glutathione disulfide, and protein contents in liver and skeletal muscle decreased with fasting, but significant changes in CoASH contents were not observed. Diminished food intake in animals does not explain the effects of hyperoxia on lung CoASH contents. CoASH and derived thioesters participate in many cellular functions, and if depletion of lung CoASH during hyperoxia proves to be relevant to mechanisms of lung injury, support of mechanisms needed to sustain CoA levels could be helpful in prematurely born infants and in adults.