Probing Evidence of Cerebral White Matter Microstructural Disruptions in Ischemic Heart Disease Before and Following Cardiac Rehabilitation: A Diffusion Tensor MR Imaging Study.

BACKGROUND: Ischemic heart disease (IHD) is linked to brain white matter (WM) breakdown but how age or disease effects WM integrity, and whether it is reversible using cardiac rehabilitation (CR), remains unclear. PURPOSE: To assess the effects of brain aging, cardiovascular disease, and CR on WM microstructure in brains of IHD patients following a cardiac event. STUDY TYPE: Retrospective. POPULATION: Thirty-five IHD patients (9 females; mean age = 59 ± 8 years), 21 age-matched healthy controls (10 females; mean age = 59 ± 8 years), and 25 younger controls (14 females; mean age = 26 ± 4 years). FIELD STRENGTH/SEQUENCE: 3 T diffusion-weighted imaging with single-shot echo planar imaging acquired at 3 months and 9 months post-cardiac event. ASSESSMENT: Tract-based spatial statistics (TBSS) and tractometry were used to compare fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) in cerebral WM between: 1) older and younger controls to distinguish age-related from disease-related WM changes; 2) IHD patients at baseline (pre-CR) and age-matched controls to investigate if cardiovascular disease exacerbates age-related WM changes; and 3) IHD patients pre-CR and post-CR to investigate the neuroplastic effect of CR on WM microstructure. STATISTICAL TESTS: Two-sample unpaired t-test (age: older vs. younger controls; IHD: IHD pre-CR vs. age-matched controls). One-sample paired t-test (CR: IHD pre- vs. post-CR). Statistical threshold: P < 0.05 (FWE-corrected). RESULTS: TBSS and tractometry revealed widespread WM changes in older controls compared to younger controls while WM clusters of decreased FA in the fornix and increased MD in body of corpus callosum were observed in IHD patients pre-CR compared to age-matched controls. Robust WM improvements (increased FA, increased AD) were observed in IHD patients post-CR. DATA CONCLUSION: In IHD, both brain aging and cardiovascular disease may contribute to WM disruptions. IHD-related WM disruptions may be favorably modified by CR. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

The impact of 6 months of exercise-based cardiac rehabilitation on sympathetic neural recruitment during apneic stress.

The current study evaluated the hypothesis that 6 mo of exercise-based cardiac rehabilitation (CR) would improve sympathetic neural recruitment in patients with ischemic heart disease (IHD). Microneurography was used to evaluate action potential (AP) discharge patterns within bursts of muscle sympathetic nerve activity (MSNA), in 11 patients with IHD (1 female; 61 ± 9 yr) pre (pre-CR) and post (post-CR) 6 mo of aerobic and resistance training-based CR. Measures were made at baseline and during maximal voluntary end-inspiratory (EI-APN) and end-expiratory apneas (EE-APN). Data were analyzed during 1 min of baseline and the second half of apneas. At baseline, overall sympathetic activity was less post-CR (all P < 0.01). During EI-APN, AP recruitment was not observed pre-CR (all P > 0.05), but increases in both within-burst AP firing frequency (Δpre-CR: 2 ± 3 AP spikes/burst vs. Δpost-CR: 4 ± 3 AP spikes/burst; P = 0.02) and AP cluster recruitment (Δpre-CR: -1 ± 2 vs. Δpost-CR: 2 ± 2; P < 0.01) were observed in post-CR tests. In contrast, during EE-APN, AP firing frequency was not different post-CR compared with pre-CR tests (Δpre-CR: 269 ± 202 spikes/min vs. Δpost-CR: 232 ± 225 spikes/min; P = 0.54), and CR did not modify the recruitment of new AP clusters (Δpre-CR: -1 ± 3 vs. Δpost-CR: 0 ± 1; P = 0.39), or within-burst firing frequency (Δpre-CR: 3 ± 3 AP spikes/burst vs. Δpost-CR: 2 ± 2 AP spikes/burst; P = 0.21). These data indicate that CR improves some of the sympathetic nervous system dysregulation associated with cardiovascular disease, primarily via a reduction in resting sympathetic activation. However, the benefits of CR on sympathetic neural recruitment may depend upon the magnitude of initial impairment.

Does vascular stiffness predict white matter hyperintensity burden in ischemic heart disease with preserved ejection fraction?

The survival rate of patients with ischemic heart disease (IHD) is increasing. However, survivors experience increased risk for neurological complications. The mechanisms for this increased risk are unknown. We tested the hypothesis that patients with IHD have greater carotid and cerebrovascular stiffness, and these indexes predict white matter small vessel disease. Fifty participants (age, 40-78 yr), 30 with IHD with preserved ejection fraction and 20 healthy age-matched controls, were studied using ultrasound imaging of the common carotid artery (CCA) and middle cerebral artery (MCA), as well as magnetic resonance imaging (T1, T2-FLAIR), to measure white matter lesion volume (WMLv). Carotid ß-stiffness provided the primary measure of peripheral vascular stiffness. Carotid-cerebral pulse wave transit time (ccPWTT) provided a marker of cerebrovascular stiffness. Pulsatility index (PI) and resistive index (RI) of the MCA were calculated as measures of downstream cerebrovascular resistance. When compared with controls, patients with IHD exhibited greater ß-stiffness [8.5 ± 3.3 vs. 6.8 ± 2.2 arbitrary units (AU); P = 0.04], MCA PI (1.1 ± 0.20 vs. 0.98 ± 0.18 AU; P = 0.02), and MCA RI (0.66 ± 0.06 vs. 0.62 ± 0.07 AU; P = 0.04). There was no difference in WMLv between IHD and control groups (0.95 ± 1.2 vs. 0.86 ± 1.4 mL; P = 0.81). In pooled patient data, WMLv correlated with both ß-stiffness (R = 0.34, P = 0.02) and cerebrovascular ccPWTT (R = -0.43, P = 0.02); however, ß-stiffness and ccPWTT were not associated (P = 0.13). In multivariate analysis, WMLv remained independently associated with ccPWTT (P = 0.02) and carotid ß-stiffness (P = 0.04). Patients with IHD expressed greater ß-stiffness and cerebral microvascular resistance. However, IHD did not increase risk of WMLv or cerebrovascular stiffness. Nonetheless, pooled data indicate that both carotid and cerebrovascular stiffness are independently associated with WMLv.NEW & NOTEWORTHY This study found that patients with ischemic heart disease (IHD) with preserved ejection fraction and normal blood pressures exhibit greater carotid ß-stiffness, as well as middle cerebral artery pulsatility and resistive indexes, than controls. White matter lesion volume (WMLv) was not different between vascular pathology groups. Cerebrovascular pulse wave transit time (ccPWTT) and carotid ß-stiffness independently associate with WMLv in pooled participant data, suggesting that regardless of heart disease history, ccPWTT and ß-stiffness are associated with structural white matter damage.

Implementing recommendations for inpatient healthcare provider encouragement of cardiac rehabilitation participation: development and evaluation of an online course.

BACKGROUND: A policy statement recommending that healthcare providers (HCPs) encourage cardiac patients to enroll in cardiac rehabilitation (CR) was recently endorsed by 23 medical societies. This study describes the development and evaluation of a guideline implementation tool. METHODS: A stepwise multiple-method study was conducted. Inpatient cardiac HCPs were recruited between September 2018-May 2019 from two academic hospitals in Toronto, Canada. First, HCPs were observed during discharge discussions with patients to determine needs. Results informed selection and development of the tool by the multidisciplinary planning committee, namely an online course. It was pilot-tested with target users through a think-aloud protocol with subsequent semi-structured interviews, until saturation was achieved. Results informed refinement before launching the course. Finally, to evaluate impact, HCPs were surveyed to test whether knowledge, attitudes, self-efficacy and practice changed from before watching the course, through to post-course and 1 month later. RESULTS: Seven nurses (71.4% female) were observed. Five (62.5%) initiated dialogue about CR, which lasted on average 12 s. Patients asked questions, which HCPs could not answer. The planning committee decided to develop an online course to reach inpatient cardiac HCPs, to educate them on how to encourage patients to participate in CR at the bedside. The course was pilot-tested with 5 HCPs (60.0% nurse-practitioners). Revisions included providing evidence of CR benefits and clarification regarding pre-CR stress test screening. HCPs did not remember the key points to convey, so a downloadable handout was embedded for the point-of-care. The course was launched, with the surveys. Twenty-four HCPs (83.3% nurses) completed the pre-course survey, 21 (87.5%) post, and 9 (37.5%) 1 month later. CR knowledge increased from pre (mean = 2.71 ± 0.95/5) to post-course (mean = 4.10 ± 0.62; p ≤ .001), as did self-efficacy in answering patient CR questions (mean = 2.29 ± 0.95/5 pre and 3.67 ± 0.58 post; p ≤ 0.001). CR attitudes were significantly more positive post-course (mean = 4.13 ± 0.95/5 pre and 4.62 ± 0.59 post; p ≤ 0.05). With regard to practice, 8 (33.3%) HCPs reported providing patients CR handouts pre-course at least sometimes or more, and 6 (66.7%) 1 month later. CONCLUSIONS: Preliminary results support broader dissemination, and hence a genericized version has been created ( http://learnonthego.ca/Courses/promoting_patient_participation_in_CR_2020/promoting_patient_participation_in_CR_2020EN/story_html5.html ). Continuing education credits have been secured.

Effects of aging and coronary artery disease on sympathetic neural recruitment strategies during end-inspiratory and end-expiratory apnea.

In response to acute physiological stress, the sympathetic nervous system modifies neural outflow through increased firing frequency of lower-threshold axons, recruitment of latent subpopulations of higher-threshold axons, and/or acute modifications of synaptic delays. Aging and coronary artery disease (CAD) often modify efferent muscle sympathetic nerve activity (MSNA). Therefore, we investigated whether CAD (n = 14; 61 ± 10 yr) and/or healthy aging without CAD (OH; n = 14; 59 ± 9 yr) modified these recruitment strategies that normally are observed in young healthy (YH; n = 14; 25 ± 3 yr) individuals. MSNA (microneurography) was measured at baseline and during maximal voluntary end-inspiratory (EI) and end-expiratory (EE) apneas. Action potential (AP) patterns were studied using a novel AP analysis technique. AP frequency increased in all groups during both EI- and EE-apnea (all P < 0.05). The mean AP content per integrated burst increased during EI- and EE-apnea in YH (EI: Δ6 ± 4 APs/burst; EE: Δ10 ± 6 APs/burst; both P < 0.01) and OH (EI: Δ3 ± 3 APs/burst; EE: Δ4 ± 5 APs/burst; both P < 0.01), but not in CAD (EI: Δ1 ± 3 APs/burst; EE: Δ2 ± 3 APs/burst; both P = NS). When APs were binned into "clusters" according to peak-to-peak amplitude, total clusters increased during EI- and EE-apnea in YH (EI: Δ5 ± 2; EE: Δ6 ± 4; both P < 0.01), during EI-apnea only in OH (EI: Δ1 ± 2; P < 0.01; EE: Δ1 ± 2; P = NS), and neither apnea in CAD (EI: Δ -2 ± 2; EE: Δ -1 ± 2; both P = NS). In all groups, the AP cluster size-latency profile was shifted downwards for every corresponding cluster during EI- and EE-apnea (all P < 0.01). As such, inherent dysregulation exists within the central features of apnea-related sympathetic outflow in aging and CAD.

Coronary artery disease affects cortical circuitry associated with brain-heart integration during volitional exercise.

This study tested the hypothesis that coronary artery disease (CAD) alters the cortical circuitry associated with exercise. Observations of changes in heart rate (HR) and in cortical blood oxygenation level-dependent (BOLD) images were made in 23 control subjects [control; 8 women; 63 ± 11 yr; mean arterial pressure (MAP): 90 ± 9 mmHg] (mean ± SD) and 17 similarly aged CAD patients (4 women; 59 ± 9 yr; MAP: 87 ± 10 mmHg). Four repeated bouts each of 30%, 40%, and 50% of maximal voluntary contraction (MVC) force (LAB session), and seven repeated bouts of isometric handgrip (IHG) at 40% MVC force (fMRI session), were performed, with each contraction lasting 20 s and separated by 40 s of rest. There was a main effect of group (P = 0.03) on HR responses across all IHG intensities. Compared with control, CAD demonstrated less task-dependent deactivation in the posterior cingulate cortex and medial prefrontal cortex, and reduced activation in the right anterior insula, bilateral precentral cortex, and occipital lobe (P < 0.05). When correlated with HR, CAD demonstrated reduced activation in the bilateral insula and posterior cingulate cortex, and reduced deactivation in the dorsal anterior cingulate cortex, and bilateral precentral cortex (P < 0.05). The increased variability in expected autonomic regions and decrease in total cortical activation in response to the IHG task are associated with a diminished HR response to volitional effort in CAD. Therefore, relative to similarly aged and healthy individuals, CAD impairs the heart rate response and modifies the cortical patterns associated with cardiovascular control during IHG.

Quantifying Improvement in V˙ o2peak and Exercise Thresholds in Cardiovascular Disease Using Reliable Change Indices.

PURPOSE: Improving aerobic fitness through exercise training is recommended for the treatment of cardiovascular disease (CVD). However, strong justifications for the criteria of assessing improvement in key parameters of aerobic function including estimated lactate threshold (θ LT ), respiratory compensation point (RCP), and peak oxygen uptake (V˙ o2peak ) at the individual level are not established. We applied reliable change index (RCI) statistics to determine minimal meaningful change (MMC RCI ) cutoffs of θ LT , RCP, and V˙ o2peak for individual patients with CVD. METHODS: Sixty-six stable patients post-cardiac event performed three exhaustive treadmill-based incremental exercise tests (modified Bruce) ∼1 wk apart (T1-T3). Breath-by-breath gas exchange and ventilatory variables were measured by metabolic cart and used to identify θ LT , RCP, and V˙ o2peak . Using test-retest reliability and mean difference scores to estimate error and test practice/exposure, respectively, MMC RCI values were calculated for V˙ o2 (mL·min -1. kg -1 ) at θ LT , RCP, and V˙ o2peak . RESULTS: There were no significant between-trial differences in V˙ o2 at θ LT ( P = .78), RCP ( P = .08), or V˙ o2peak ( P = .74) and each variable exhibited excellent test-retest variability (intraclass correlation: 0.97, 0.98, and 0.99; coefficient of variation: 6.5, 5.4, and 4.9% for θ LT , RCP, and V˙ o2peak , respectively). Derived from comparing T1-T2, T1-T3, and T2-T3, the MMC RCI for θ LT were 3.91, 3.56, and 2.64 mL·min -1. kg -1 ; 4.01, 2.80, and 2.79 mL·min -1. kg -1 for RCP; and 3.61, 3.83, and 2.81 mL·min -1. kg -1 for V˙ o2peak . For each variable, MMC RCI scores were lowest for T2-T3 comparisons. CONCLUSION: These MMC RCI scores may be used to establish cutoff criteria for determining meaningful changes for interventions designed to improve aerobic function in individuals with CVD.

A standardized approach to evaluate effectiveness of aerobic exercise training interventions in cardiovascular disease at the individual level.

BACKGROUND: Reliable change indices can determine pre-post intervention changes at an individual level that are greater than chance or practice effect. We applied previously developed minimal meaningful change (MMCRCI) scores for oxygen uptake (V̇O2) values associated with estimated lactate threshold (θLT), respiratory compensation point (RCP), and peak oxygen uptake (V̇O2peak) to evaluate the effectiveness of exercise training in cardiovascular disease patients. METHODS: 303 patients (65 ± 11 yrs.; 27% female) that completed a symptom-limited cardiopulmonary exercise test (CPET) before and after 6-months of guideline-recommended exercise training were assessed to determine absolute and relative V̇O2 at θLT, RCP, and V̇O2peak. Using MMCRCI ∆V̇O2 scores of ±3.9 mL·kg-1·min-1, ±4.0 mL·kg-1·min-1, and ± 3.6 mL·kg-1·min-1 for θLT, RCP, and V̇O2peak, respectively, patients were classified as "positive" (ΔθLT, ΔRCP, and/or ΔV̇O2peak ≥ +MMCRCI), "non-" (between ±MMCRCI), or "negative" responders (≤ -MMCRCI). RESULTS: Mean RCP (n = 86) and V̇O2peak (n = 303) increased (p < 0.05) from 19.4 ± 3.6 mL·kg-1·min-1 and 18.0 ± 6.3 mL·kg-1·min-1 to 20.1 ± 3.8 mL·kg-1·min-1 and 19.2 ± 7.0 mL·kg-1·min-1 at exit, respectively, whereas θLT (n = 140) did not change (15.5 ± 3.4 mL·kg-1·min-1 versus 15.7 ± 3.8 mL·kg-1·min-1, p = 0.324). For changes in θLT, 6% were classified as "positive" responders, 90% as "non-responders", and 4% as "negative" responders. For RCP, 10% exhibited "positive" changes, 87% were "non-responders", and 2% were "negative" responders. For ΔV̇O2peak, 57 patients (19%) were classified as "positive" responders, 229 (76%) as "non-responders", and 17 (6%) as "negative" responders. CONCLUSION: Most patients that completed the exercise training program did not achieve reliable improvements greater than that of chance or practice at an individual level in θLT, RCP and V̇O2peak.

Virtual care during COVID-19: The perspectives of older adults and their healthcare providers in a cardiac rehabilitation setting.

The present study aimed to explore the perspectives of older adults and health providers on cardiac rehabilitation care provided virtually during COVID-19. A qualitative exploratory methodology was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Five themes emerged from the data: (1) Lack of emotional intimacy when receiving virtual care, (2) Inadequacy of virtual platforms, (3) Saving time with virtual care, (4) Virtual care facilitated accessibility, and (5) Loss of connections with patients and colleagues. Given that virtual care continues to be implemented, and in some instances touted as an optimal option for the delivery of cardiac rehabilitation, it is critical to address the needs of older adults living with cardiovascular disease and their healthcare providers. This is particularly crucial related to issues accessing and using technology, as well as older adults' need to build trust and emotional connection with their providers.

One, two and three-dimensional ultrasound measurements of carotid atherosclerosis before and after cardiac rehabilitation: preliminary results of a randomized controlled trial.

BACKGROUND: It is still not known how patients who are post-transient ischemic attack (TIA) or post-stroke might benefit from prospectively planned comprehensive cardiac rehabilitation (CCR). In this pilot evaluation of a larger ongoing randomized-controlled-trial, we evaluated ultrasound (US) measurements of carotid atherosclerosis in subjects following TIA or mild non-disabling stroke and their relationship with risk factors before and after 6-months of CCR. METHODS: Carotid ultrasound (US) measurements of one-dimensional intima-media-thickness (IMT), two-dimensional total-plaque-area (TPA), three-dimensional total-plaque-volume (TPV) and vessel-wall-volume (VWV) were acquired before and after 6-months CCR for 39 subjects who had previously experienced a TIA and provided written informed consent to participate in this randomized controlled trial. We maintained blinding for this ongoing study by representing treatment and control groups as A or B, although we did not identify which of A or B was treatment or control. Carotid IMT, TPA, TPV and VWV were measured before and after CCR as were changes in body mass index (BMI), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), systolic blood pressure (SBP) and diastolic blood pressure (DBP). RESULTS: There were no significant differences in US measurements or risk factors between groups A and B. There was no significant change in carotid ultrasound measurements for group A (IMT, p = .728; TPA, p = .629; TPV, p = .674; VWV, p = .507) or B (IMT, p = .054; TPA, p = .567; TPV, p = .773; VWV, p = .431) at the end of CCR. There were significant but weak-to-moderate correlations between IMT and VWV (r = 0.25, p = .01), IMT and TPV (r = 0.21, p = .01), TPV and TPA (r = 0.60, p < .0001) and VWV and TPV (r = 0.22, p = .02). Subjects with improved TC/HDL ratios showed improved carotid VWV although, this was not statistically significant. CONCLUSION: In this preliminary evaluation, there were no significant differences in carotid US measurements in the control or CCR group; a larger sample size and/or longer duration is required to detect significant changes in US or other risk factor measurements.

Impact of ischemic heart disease and cardiac rehabilitation on cerebrovascular compliance.

We aimed to determine the influence of ischemic heart disease (IHD) and cardiac rehabilitation (CR) on cerebrovascular compliance index (Ci). Eleven (one female) patients with IHD (mean[SD]: 61[11] yr, 29[4] kg/m2) underwent 6 mo of CR, which consisted of ≥3 sessions/wk of aerobic and resistance training (20-60 min each). Ten (three female) similarly aged controls (CON) were tested at baseline as a comparator group. Middle cerebral artery velocity (MCAv) and mean arterial pressure were monitored continuously using transcranial Doppler ultrasound and finger photoplethysmography, respectively, during a rapid sit-to-stand maneuver. A Windkessel model was used to estimate cerebrovascular Ci every five cardiac cycles for a duration of 30 s. Cerebrovascular resistance was calculated as the quotient of MAP and MCAv. Two-way ANOVAs were used to determine whether cerebrovascular variables differ during postural transitions between groups and after CR. Baseline MCAv was higher in CON versus IHD (P = 0.014) and a time × group interaction was observed (P = 0.045) where MCAv decreased more in CON after standing. Compared with the precondition, CR had no effect on MCAv (condition P = 0.950) but a main effect of time indicated that MCAv decreased from the seated position in both conditions (time P = 0.013). Baseline cerebrovascular Ci was greater in IHD versus CON (P = 0.049) and the peak cerebrovascular Ci during the transition to standing was significantly higher in IHD compared with CON (interaction P = 0.047). CR did not affect cerebrovascular compliance (P = 0.452) and no time-by-condition interaction upon standing was present (P = 0.174). Baseline cerebrovascular Ci is higher in IHD at baseline compared with CON, but 6 mo of CR did not modify the transient increase in cerebrovascular Ci during sit-to-stand maneuvers.NEW & NOTEWORTHY Post-cardiac event cognitive impairment is common and exercise-based rehabilitation may be an effective intervention to mitigate cognitive decline. Microvascular damage due to high blood pressure pulsatility entering the brain is the putative mechanism of vascular dementia. Whether patients with ischemic heart disease exhibit lower cerebrovascular compliance, and if cardiac rehabilitation can improve cerebrovascular compliance is unknown. We observed that patients with ischemic heart disease have paradoxically higher cerebrovascular compliance, which is not affected by cardiac rehabilitation.

Do Clinical Exercise Tests Permit Exercise Threshold Identification in Patients Referred to Cardiac Rehabilitation?

BACKGROUND: To evaluate the feasibility of "threshold-based" aerobic exercise prescription in cardiovascular disease, we aimed to quantify the proportion of patients whose clinical cardiopulmonary exercise test (CPET) permit identification of estimated lactate threshold (θLT) and respiratory compensation point (RCP) and to characterize the variability at which these thresholds occur. METHODS: Breath-by-breath CPET data of 1102 patients (65 ± 12 years) referred to cardiac rehabilitation were analyzed to identify peak O2 uptake (V˙O2peak; mL·min-1 and mL·kg-1·min-1) and θLT and RCP (reported as V˙O2, %V˙O2peak, and %peak heart rate [%HRpeak]). Patients were grouped by the presence or absence of thresholds: group 0: neither θLT nor RCP; group 1: θLT only; and group 2: both θLT and RCP. RESULTS: Mean V˙O2peak was 1523 ± 627 mL·min-1 (range: 315-3789 mL·min-1) or 18.0 ± 6.5 mL·kg-1·min-1 (5.2-46.5 mL·kg-1·min-1) and HRpeak was 123 ± 24 beats per minute (bpm) (52 bpm-207 bpm). There were 556 patients (50%) in group 0, 196 (18%) in group 1, and 350 (32%) in group 2. In group 1, mean θLT was 1240 ± 410 mL·min-1 (580-2560 mL·min-1), 75% ± 8%V˙O2peak (52%-92%V˙O2peak), or 84% ± 6%HRpeak (64%-96%HRpeak). In group 2, θLT was 1390 ± 360 mL·min-1 (640-2430 mL·min-1), 70% ± 8%V˙O2peak (41%-88%V˙O2peak), or 78% ± 7%HRpeak (52%-96%HRpeak), and RCP was 1680 ± 440 mL·min-1 (730-3090 mL·min-1), 84% ± 7%V˙O2peak (54%-99%V˙O2peak), or 87% ± 6%HRpeak (59%-99%HRpeak). Compared with group 1, θLT in group 2 occurred at a higher V˙O2 but lower %V˙O2peak and %HRpeak (P < 0.05). CONCLUSIONS: Only 32% of CPETs exhibited both θLT and RCP despite flexibility in protocol options. Commonly used step-based protocols are suboptimal for "threshold-based" exercise prescription.

Transitional Care from Hospital to Cardiac Rehabilitation During COVID-19: The Perspectives of Older Adults and Their Healthcare Providers.

Transitional care to cardiac rehabilitation during the pandemic was a complex process for older adults, with additional challenges for decision-making and participation. This study aimed to explore the perspectives of older adults and health providers on transitional care from the hospital to cardiac rehabilitation, focusing on patient participation in decision-making. A qualitative exploratory design was used. Semi-structured interviews were conducted with 15 older adults and 6 healthcare providers. Document analysis and reflexive journaling were used to support triangulation of findings. Six themes emerged from the data, related to insufficient follow-up from providers, the importance of patients' emotional and psychological health and the support provided by family members, the need for information tailored to patients' needs and spaces for participation in decision-making, as well as challenges during COVID-19, including delayed medical procedures, rushed discharge and isolating hospital stays. The findings of this study indicated a number of potential gaps in the provision of transitional care services as reported by older adults who had a cardiovascular event, often during the first few weeks post hospital discharge.

Perceptions of cardiac rehabilitation patients, specialists and rehabilitation programs regarding cardiac rehabilitation wait times.

BACKGROUND: In 2006, the Canadian Cardiovascular Society (CCS) Access to Care Working Group recommended a 30-day wait time benchmark for cardiac rehabilitation (CR). The objectives of the current study were to: (1) describe cardiac patient perceptions of actual and ideal CR wait times, (2) describe and compare cardiac specialist and CR program perceptions of wait times, as well as whether the recommendations are appropriate and feasible, and (3) investigate actual wait times and factors that CR programs perceive to affect these wait times. METHODS: Postal and online surveys to assess perceptions of CR wait times were administered to CR enrollees at intake into 1 of 8 programs, all CCS member cardiac specialists treating patients indicated for CR, and all CR programs listed in Canadian directories. Actual wait times were ascertained from the Canadian Cardiac Rehabilitation Registry. The design was cross-sectional. Responses were described and compared. RESULTS: Responses were received from 163 CR enrollees, 71 cardiac specialists (9.3% response rate), and 92 CR programs (61.7% response rate). Patients reported that their wait time from hospital discharge to CR initiation was 65.6 ± 88.4 days (median, 42 days), while their ideal median wait time was 28 days. Most patients (91.5%) considered their wait to be acceptable, but ideal wait times varied significantly by the type of cardiac indication for CR. There were significant differences between specialist and program perceptions of the appropriate number of days to wait by most indications, with CR programs perceiving shorter waits as appropriate (p < 0.05). CR programs reported that feasible wait times were significantly longer than what was appropriate for all indications (p < 0.05). They perceived that patient travel and staff capacity were the main factors negatively affecting waits. The median wait time from referral to program initiation was 64 days (mean, 80.0 ± 62.8 days), with no difference in wait by indication. CONCLUSIONS: Wait times following access to cardiac rehabilitation are prolonged compared with consensus recommendations, and yet are generally acceptable to most patients. Wait times following percutaneous coronary intervention in particular may need to be shortened. Future research is required to provide an evidence base for wait time benchmarks.

The relationship between anxiety sensitivity and clinical outcomes in cardiac rehabilitation: A scoping review.

Background: Despite well-established efficacy for patients with a cardiovascular diagnosis or event, exercise-based cardiac rehabilitation program participation and completion has remained alarmingly low due to both system-level barriers and patient-level factors. Patient mental health, particularly depression, is now recognized as significantly associated with reduced enrollment, participation, attendance, and completion of a cardiac rehabilitation program. More recently, anxiety sensitivity has emerged as an independent construct, related to but distinct from both depression and anxiety. Anxiety sensitivity has been reported to be adversely associated with participation in exercise and, thus, may be important for patients in cardiac rehabilitation. Accordingly, the objective of this study was to conduct a scoping review to summarize the evidence for associations between anxiety sensitivity and cardiovascular disease risk factors, exercise, and clinical outcomes in cardiac rehabilitation. Methods: A formal scoping review, following PRISMA-ScR guidelines, was undertaken. Searches of MEDLINE, Web of Science, CINAHL, PSYCINFO, and Scopus databases were conducted, supplemented by hand searches; studies published through December of 2020 were included. The initial screening was based on titles and abstracts and the second stage of screening was based on full text examination. Results: The final search results included 28 studies. Studies reported statistically significant associations between anxiety sensitivity and exercise, cardiovascular disease, and participation in cardiac rehabilitation. Many studies, however, were conducted in non-clinical, community-based populations; there were few studies conducted in cardiovascular disease and cardiac rehabilitation clinical patient populations. Additionally, significant gaps remain in our understanding of the sex-based differences in the complex relationships between anxiety sensitivity, exercise and cardiac rehabilitation. Conclusion: More research is needed to understand specific associations between anxiety sensitivity and clinical outcomes among clinical cardiovascular disease patients and participants in cardiac rehabilitation programs. Treatment of anxiety sensitivity to optimize clinical outcomes in cardiac rehabilitation programs should be investigated in future studies.

The Physical Activity Levels and Sitting Time of Adults Living With Atrial Fibrillation: The CHAMPLAIN-AF Study.

Background: The primary goal of this study was to determine the time spent completing moderate-to-vigorous intensity physical activity (MVPA) among adults with atrial fibrillation (AF). Secondary aims examined MVPA and sitting time (ST) by AF subtypes (ie, paroxysmal, persistent, long-standing persistent, and permanent) and associations between MVPA or ST and knowledge, task self-efficacy, and outcome expectations. Methods: An observational study was conducted in the Champlain region of Ontario, Canada. AF patients completed a survey to determine MVPA and ST using the Short-Form International Physical Activity Questionnaire. Results: A total of 619 patients (66% male; median age 65 years [95% CI 64-67 years]) completed the survey. Median MVPA and ST were 100 (60-120) min/wk and 6 (5-6) h/d; 56% of patients were not meeting the Canadian 24H Movement Guidelines. Most patients (54%) did not know/were unsure of the MVPA recommendations, yet 72% thought physical activity should be part of AF management. Positive correlations were found between higher MVPA levels and the following: (i) speaking to a healthcare professional about engaging in physical activity for managing AF (ρ = 0.108, P = 0.017); (ii) greater confidence regarding ability to perform physical activity and muscle-strengthening exercise (ρ = 0.421, P < 0.01); and (iii) patient agreement that AF would be better managed if they were active (ρ = 0.205, P < 0.01). Conclusions: Many AF patients do not meet the MVPA recommendations, which may be due to lack of physical activity knowledge. Exercise professionals may help educate patients on the benefits of physical activity, improve task-self efficacy, and integrate MVPA into patient lifestyles.

Introduction: Le principal objectif de la présente étude était de déterminer le temps consacré à faire de l'activité physique modérée à vigoureuse (APMV) chez les adultes atteints de fibrillation auriculaire (FA). Les objectifs secondaires visaient à examiner l'APMV et le temps en position assise (TA) selon les sous-types de FA (c.-à-d. paroxystique, persistante, persistante de longue durée et permanente) et les associations entre l'APMV ou le TA et les connaissances, le sentiment d'auto-efficacité et les attentes de résultats. Méthodes: Nous avons réalisé une étude observationnelle dans la région de Champlain, en Ontario, au Canada. Les patients atteints de FA ont rempli une enquête pour déterminer l'APMV et le TA à l'aide du questionnaire court International Physical Activity Questionnaire (IPAQ). Résultats: Un total de 619 patients (66 % d'hommes; âge médian de 65 ans [IC à 95 % 64-67 ans]) a rempli l'enquête. L'APMV et le TPA médians étaient de 100 (60-120) min/sem et de 6 (5-6) h/j; 56 % des patients ne répondaient pas aux Directives canadiennes en matière de mouvement sur 24 heures. La plupart des patients (54 %) ne connaissaient pas les recommandations d'APMV ou n'étaient pas certains de les connaître, mais 72 % pensaient que l'activité physique devrait faire partie de la prise en charge de la FA. Nous avons observé des corrélations positives entre les degrés plus élevés d'APMV et ce qui suit : (i) le fait de parler à un professionnel de la santé de la pratique de l'activité physique pour prendre en charge la FA (ρ = 0,108, P = 0,017); (ii) la confiance accrue quant à la capacité de faire de l'activité physique et les exercices de renforcement musculaire (ρ = 0,421, P < 0,01); (iii) l'accord du patient sur le fait que la pratique de l'activité physique contribuerait à une meilleure prise en charge de la FA (ρ = 0,205, P < 0,01). Conclusions: Plusieurs patients atteints de FA ne répondaient pas aux recommandations d'APMV, possiblement en raison du manque de connaissances concernant l'activité physique. Les professionnels de l'activité physique peuvent contribuer à l'éducation des patients afin de leur faire connaître les avantages de l'activité physique, améliorer leur auto-efficacité et intégrer l'APMV à leur mode de vie.

Comprehensive cardiac rehabilitation for secondary prevention after transient ischemic attack or mild stroke: I: feasibility and risk factors.

BACKGROUND AND PURPOSE: Comprehensive cardiac rehabilitation (CCR), which integrates structured lifestyle interventions and medications, reduces morbidity and mortality among cardiac patients. CCR has not typically been used with cerebrovascular populations, despite important commonalities with heart patients. We tested feasibility and effectiveness of 6-month outpatient CCR for secondary prevention after transient ischemic attack or mild, nondisabling stroke. This article presents risk factors. A future article will discuss psychological outcomes. METHODS: Consecutive consenting subjects having sustained a transient ischemic attack or mild, nondisabling stroke within the previous 12 months (mean, 11.5 weeks; event-to-CCR entry) with ≥1 vascular risk factor, were recruited from a stroke prevention clinic providing usual care. We measured 6-month CCR outcomes following a prospective cohort design. RESULTS: Of 110 subjects recruited from January 2005 to April 2006, 100 subjects (mean age, 64.9 years; 46 women) entered and 80 subjects completed CCR. We obtained favorable, significant intake-to-exit changes in: aerobic capacity (+31.4%; P<0.001), total cholesterol (-0.30 mmol/L; P=0.008), total cholesterol/high-density lipoprotein (-11.6%; P<0.001), triglycerides (-0.27 mmol/L; P=0.003), waist circumference (-2.44 cm; P<0.001), body mass index (-0.53 kg/m(2); P=0.003), and body weight (-1.43 kg; P=0.001). Low-density lipoprotein (-0.24 mmol/L), high-density lipoprotein (+0.06 mmol/L), systolic (-3.21 mm Hg) and diastolic (-2.34 mm Hg) blood pressure changed favorably, but nonsignificantly. A significant shift toward nonsmoking occurred (P=0.008). Compared with intake, 11 more individuals (25.6% increase) finished CCR in the lowest-mortality risk category of the Duke Treadmill Score (P<0.001). CONCLUSIONS: CCR is feasible and effective for secondary prevention after transient ischemic attack or mild, nondisabling stroke, offering a promising model for vascular protection across chronic disease entities. We know of no similar previous investigation, and are now conducting a randomized trial.

Primary care provider perceptions of intake transition records and shared care with outpatient cardiac rehabilitation programs.

BACKGROUND: While it is recommended that records are kept between primary care providers (PCPs) and specialists during patient transitions from hospital to community care, this communication is not currently standardized. We aimed to assess the transmission of cardiac rehabilitation (CR) program intake transition records to PCPs and to explore PCPs' needs in communication with CR programs and for intake transition record content. METHOD: 144 PCPs of consenting enrollees from 8 regional and urban Ontario CR programs participated in this cross-sectional study. Intake transition records were tracked from the CR program to the PCP's office. Sixty-six PCPs participated in structured telephone interviews. RESULTS: Sixty-eight (47.6%) PCPs received a CR intake transition record. Fifty-eight (87.9%) PCPs desired intake transition records, with most wanting it transmitted via fax (n = 52, 78.8%). On a 5-point Likert scale, PCPs strongly agreed that the CR transition record met their needs for providing patient care (4.32 ± 0.61), with 48 (76.2%) reporting that it improved their management of patients' cardiac risk. PCPs rated the following elements as most important to include in an intake transition record: clinical status (4.67 ± 0.64), exercise test results (4.61 ± 0.52), and the proposed patient care plan (4.59 ± 0.71). CONCLUSIONS: Less than half of intake transition records are reaching PCPs, revealing a large gap in continuity of patient care. PCP responses should be used to develop an evidence-based intake transition record, and procedures should be implemented to ensure high-quality transitional care.

Measuring True Change in Individual Patients: Reliable Change Indices of Cardiac Rehabilitation Outcomes, and Implications for Quality Indicators.

BACKGROUND: Mediated by outcomes such as improved exercise capacity, cardiac rehabilitation (CR) reduces morbidity and mortality. For accuracy, an individual CR patient's change must be measured reliably, an issue not typically considered in practice. Drawing from psychometric theory, we calculated reliable change indices (RCIs), to measure individual CR patients' true clinical change, apart from that from error and test practice/exposure, in exercise capacity, anxiety, and depression. METHODS: Indirectly calculated exercise capacity (peak metabolic equivalents [METs]) and psychological symptoms were each measured twice, 1 week apart, by administering treadmill tests or the Hospital Anxiety and Depression Scale (HADS) to separate samples of 35 (mean age: 59.0 years; 6 women) and 96 (mean age: 64.4 years; 32 women) CR patients, respectively. Using test-retest reliability and mean difference scores from these samples to estimate error and practice/exposure effects, we calculated RCIs for a separate cohort (n = 2066; mean age: 62.0 years; 533 women) who completed 6-month CR, and compared change distributions (worsened/unchanged/improved) based on critical RCIs, mean and percent changes, cut-off scores, and standard deviations. RESULTS: Practice/exposure effects were nonsignificant, except the mean HADS anxiety score decreased significantly (P ≤ 0.013; d = 0.17, small effect). Test-retest reliabilities were high (METs r = 0.934; HADS anxiety score r = 0.912; HADS depression score r = 0.90; P < 0.001). Among 2066 CR patients, RCI distributions differed (P < 0.001) from those of most other change criteria. CONCLUSIONS: Change ascertainment depends on criterion choice. A Canadian Cardiovascular Society CR quality indicator of increase by 0.5 MET may be too small to assess individuals' functional capacity change. RCIs offer a pragmatic approach to benchmarking reliable change frequency, and pending further validation, could be used for feedback to individual patients.

CONTEXTE: Grâce à des résultats tels que l'amélioration de la capacité d'exercice, la réadaptation cardiaque (RC) réduit la morbidité et la mortalité. Pour être précis, le changement de RC d'un patient doit être mesuré de manière fiable, un aspect qui n'est généralement pas pris en compte dans la pratique. En nous inspirant de la théorie psychométrique, nous avons déterminé des indices de changement fiables afin de mesurer le véritable changement clinique individuel des patients en RC en lien avec la capacité d'entraînement, l'anxiété et la dépression et indépendamment des erreurs et de la pratique du test/l'exposition au test. MÉTHODOLOGIE: La capacité d'entraînement calculée indirectement (l'équivalent métabolique maximum [MET]) et les symptômes psychologiques ont été mesurés deux fois, à une semaine d'intervalle, par le biais de tests sur tapis roulant ou de l'échelle de l'évaluation de l'anxiété et de la dépression en milieu hospitalier (HADS), auxquels ont respectivement été soumis des échantillons de 35 personnes en RC (âge moyen : 59,0 ans; 6 femmes) et de 96 personnes en RC (âge moyen : 64,4 ans; 32 femmes). En recourant à la fiabilité test-retest et aux écarts moyens dans les scores de ces échantillons pour faire une approximation des effets d'erreur et de pratique/exposition, nous avons déterminé des indices de changement fiables pour une cohorte distincte (n = 2 066; âge moyen : 62,0 ans; 533 femmes) qui a terminé une RC de six mois, et comparé la répartition des changements (aggravé/inchangé/amélioré) sur la base des indices de changement fiables critiques, des changements moyens et en pourcentage, des scores-seuils et des écarts types. RÉSULTATS: Les effets de la pratique/exposition étaient peu significatifs, sauf une diminution du score moyen de l'anxiété sur l'échelle HADS (p ≤ 0,013; d = 0,17, petit effet). La fiabilité test-retest était élevée (MET, r = 0,934; score de l'anxiété sur l'échelle HADS, r = 0,912; score de la dépression sur l'échelle HADS, r = 0,90; p < 0,001). Parmi les 2 066 patients en RC, la répartition des indices de changement fiables différait (p < 0,001) de celle de la plupart des autres critères de changement. CONCLUSIONS: Le constat du changement dépend du choix du critère. Une augmentation de 0,5 MET selon l'indicateur de qualité en RC de la Société canadienne de cardiologie est peut-être trop faible pour évaluer le changement de capacité fonctionnelle des individus. Les indices de changement fiables offrent une approche pragmatique pour comparer la fréquence du changement fiable et, en attendant une vérification plus poussée, ils pourraient être utilisés comme rétroaction fournie individuellement aux patients.

Cardiac Rehabilitation Component Attendance and Impact of Intervening Clinical Events, as Well as Disease Severity and Risk Factor Burden.

PURPOSE: To examine: (1) the rate of clinical events precluding cardiac rehabilitation (CR) continuation, (2) CR attendance by component in those without events, and (3) the association between disease severity (eg, tobacco use, diabetes, and depression) and component attendance (eg, exercise, diet, stress management, and tobacco cessation). METHODS: Retrospective analysis of electronic records of the CR program in London, Ontario, from 1999 to 2017. Patients in the supervised program are offered exercise sessions 2 times/wk with a minimum of 48 prescribed sessions tailored to patient need. Patients attending ≥1 session without major factors that would limit their exercise ability were included. Intervening events were recorded, as was component attendance. RESULTS: Of 5508 enrolled, supervised patients, 3696 did not have a condition that could preclude exercise. Of those enrolled, one-sixth (n = 912) had an intervening event; these patients were less likely to work, more likely to have medical risk factors, had more severe angina and depression, and lower functional capacity. The remaining cohort attended a mean of 26.5 ± 21.3 sessions overall (median = 27; 19% attending ≥48 sessions), including 20.5 ± 17.4 exercise sessions (median = 21). After exercise, the most common components attended were individual dietary and psychological counseling. Patients with more severe angina and depressive symptoms as well as tobacco users attended significantly fewer total sessions, but more of some specific components. CONCLUSIONS: In one-sixth of patients, CR attendance and completion are impacted by clinical factors beyond their control. Many patients are taking advantage of components specific to their risk factors, buttressing the value of individually tailored, menu-based programming.