Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association.

Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.

Current smoking as a marker of a high-risk behavioral profile after myocardial infarction.

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.

The effect of executive function on adherence with a cardiac secondary prevention program and its interaction with an incentive-based intervention.

Participation in secondary prevention programs such as cardiac rehabilitation (CR) reduces morbidity, mortality, and hospitalizations while improving quality of life. Executive function (EF) is a complex set of cognitive abilities that control and regulate behavior. EF predicts many health-related behaviors, but how EF interacts with interventions to improve treatment adherence is not well understood. The objective of this study is to examine if EF predicts CR treatment adherence and how EF interacts with an intervention to improve adherence. Data were collected from 2013 to 2018 in Vermont, USA. 130 Medicaid-enrolled individuals who had experienced a qualifying cardiac event were enrolled in a controlled clinical trial and randomized 1:1 to receive financial incentives for completing secondary prevention sessions or to usual care. In this secondary analysis, effects of EF on CR adherence (defined as completing ≥30/36 sessions) were examined in 112 participants (57 usual care, 55 intervention) who completed an EF battery. Delay-discounting, a measure of impulsivity, predicted CR adherence (p = 0.01) and interacted with the incentive intervention, such that those who exhibited greater discounting of future rewards benefitted more from the intervention than those who discounted less (F(1, 104) = 5.23, p = 0.02). Better cognitive flexibility, measured with the trail-making-task, also predicted CR adherence (p = 0.02). While EF has been associated with adherence to a variety of treatment regimens, this interaction between an incentive-based intervention to promote treatment adherence and EF is novel. This work illustrates the value of considering individual differences in EF when designing and implementing interventions to promote health-related behavior change.

Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products.

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.

Tobacco use in cardiac patients: Perceptions, use, and changes after a recent myocardial infarction among US adults in the PATH study (2013-2015).

Smoking status following cardiac events strongly predicts future morbidity and mortality. Using a nationally representative sample of United States adults, aims of this study were (1) to estimate use of, and attitudes towards, tobacco products as a function of level of cardiac risk, and (2) to explore changes in attitudes and tobacco use among adults experiencing a recent myocardial infarction (MI). Data were obtained from the first and second waves of the Population Assessment of Tobacco and Health (PATH) study. Use and attitudes towards tobacco products were examined at Wave 1 among adults with no chronic health condition (n = 18,026), those with risk factors for heart disease (n = 4593), and those who reported ever having had an MI (n = 643). Changes in perceived risk of tobacco and use between the two waves and having an MI in the last 12 months (n = 240) were also examined. Those who reported lifetime MI were more likely to believe that smoking/using tobacco was causing/worsening a health problem. Having had a recent MI event increased perceived tobacco-related risk and attempts at reduction/quitting, but did not significantly impact combusted tobacco cessation/reduction or uptake of non-combusted tobacco products. Sociodemographic characteristics and use of other tobacco products were associated with change in use of tobacco products. Those who have an MI are sensitized to the harm of continued smoking. Nonetheless, having an MI does not predict quitting combusted tobacco use or switching to potentially reduced harm products. Intense intervention is necessary to reduce combusted use in this high-risk population.

Obesity in coronary heart disease: An unaddressed behavioral risk factor.

Obesity is an independent risk factor for the development and progression of coronary heart disease (CHD). Over 80% of patients with CHD are overweight or obese. While obesity is often considered a relatively "minor" CHD risk factor, weight loss is a broadly effective risk-factor intervention. Weight loss can profoundly influence a number of "major" risk factors including: hypertension, dyslipidemia and insulin resistance/type 2 diabetes mellitus. Despite its prominence as a risk factor most cardiac rehabilitation (CR) programs do not have a specific, targeted intervention to assist patients with weight loss. Consequently, the weight loss that occurs during CR is quite small and unlikely to appreciably alter risk factors. Relying on CR associated exercise as a sole intervention is an ineffective strategy to promote weight loss. There is evidence, however, that behavioral weight loss (BWL) interventions can be effectively employed in the CR setting. In contrast to programs that do not offer a targeted intervention, studies show that participants in CR-related BWL programs lose significantly more weight. The additional weight loss from the BWL intervention is associated with greater improvements in insulin sensitivity and other components of the metabolic syndrome such as hypertension and lipid abnormalities. As a means of maximizing CHD risk factor reduction CR programs need to incorporate BWL programs as a standard programming for overweight/obese patients.

Exercise interventions for individuals with advanced cancer: A systematic review.

Despite improvements in therapy a large proportion of individuals with cancer will have a shortened life expectancy because of advanced or metastatic disease. Advances in therapy have however, extended life in those with advanced cancer thus heightening the importance of living well and preventing decline. The burdens of disease and cancer therapy impair aerobic fitness, strength, physical function and quality of life (QOL). Fatigue, the most common side effect of cancer and cancer therapy can further deteriorate QOL. Exercise has the potential to improve aerobic fitness, physical function, control fatigue and enhance QOL. However, exercise interventions are not routinely provided to those with advanced cancer. We present a systematic literature review of outcomes from interventions that include exercise for patients with advanced cancer. Studies were reviewed if they included an advanced cancer population and an intervention with a component of exercise. Overall, exercise containing interventions resulted in improvements in measures of aerobic capacity (14 of 19 studies) strength (11 of 12 studies), and components of physical function (9 of 9 studies). Fatigue and QOL were identified to improve in slightly over half of all evaluated studies (11 of 19 studies and 10 of 19 studies for fatigue and QOL respectively). The numbers of total participants reporting improvements in QOL (60%) were greater than fatigue (45%). Exercise provided to individuals with advanced cancer maintains or improves fitness and physical function and may diminish fatigue and enhance QOL and should be considered as an intervention to prevent further health complications.

Skeletal muscle ultrastructure and function in statin-tolerant individuals.

INTRODUCTION: Statins have well-known benefits on cardiovascular mortality, though up to 15% of patients experience side effects. With guidelines from the American Heart Association, American College of Cardiology, and American Diabetes Association expected to double the number of statin users, the overall incidence of myalgia and myopathy will increase. METHODS: We evaluated skeletal muscle structure and contractile function at the molecular, cellular, and whole tissue levels in 12 statin tolerant and 12 control subjects. RESULTS: Myosin isoform expression, fiber type distributions, single fiber maximal Ca(2+) -activated tension, and whole muscle contractile force were similar between groups. No differences were observed in myosin-actin cross-bridge kinetics in myosin heavy chain I or IIA fibers. CONCLUSIONS: We found no evidence for statin-induced changes in muscle morphology at the molecular, cellular, or whole tissue levels. Collectively, our data show that chronic statin therapy in healthy asymptomatic individuals does not promote deleterious myofilament structural or functional adaptations.

Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients.

PURPOSE: Cardiac rehabilitation (CR) improves medical outcomes after myocardial infarction or coronary revascularization. Lower socioeconomic status (SES) patients are less likely to participate in and complete CR. The aim of this study was to test whether financial incentives may increase participation and adherence to CR among lower-SES patients. METHODS: Patients eligible to participate in CR with Medicaid insurance coverage were approached for inclusion. Patients were placed on an escalating incentive schedule of financial incentives contingent upon CR attendance. CR participation was compared to a usual care group of 101 Medicaid patients eligible for CR in the 18months prior to the study. Attendance (participating in ≥one CR sessions) and adherence (sessions completed out of 36) were compared between groups. The study was conducted in Vermont, USA, 2013-2015. RESULTS: Of 13 patients approached to be in the study and receive incentives, 10 (77%) agreed to participate. All 10 patients completed at least one session of CR, significantly greater than the 25/101 (25%) in the control condition (p<0.001). Of patients in both groups who attended at least one session of CR, adherence was higher in the intervention group (average of 31.1 sessions completed vs. 13.6 in the control group, p<0.001). CR completion rates were also higher during the intervention with 8 of 10 (80%) intervention patients completing all 36 sessions compared to only 2 of 25 (8%) control patients (p<0.001). CONCLUSIONS: Financial incentives may be an efficacious strategy for increasing CR participation and adherence among Medicaid patients.

Molecular determinants of force production in human skeletal muscle fibers: effects of myosin isoform expression and cross-sectional area.

Skeletal muscle contractile performance is governed by the properties of its constituent fibers, which are, in turn, determined by the molecular interactions of the myofilament proteins. To define the molecular determinants of contractile function in humans, we measured myofilament mechanics during maximal Ca(2+)-activated and passive isometric conditions in single muscle fibers with homogenous (I and IIA) and mixed (I/IIA and IIA/X) myosin heavy chain (MHC) isoforms from healthy, young adult male (n = 5) and female (n = 7) volunteers. Fibers containing only MHC II isoforms (IIA and IIA/X) produced higher maximal Ca(2+)-activated forces over the range of cross-sectional areas (CSAs) examined than MHC I fibers, resulting in higher (24-42%) specific forces. The number and/or stiffness of the strongly bound myosin-actin cross bridges increased in the higher force-producing MHC II isoforms and, in all isoforms, better predicted force than CSA. In men and women, cross-bridge kinetics, in terms of myosin attachment time and rate of myosin force production, were independent of CSA, although women had faster (7-15%) kinetics. The relative proportion of cross bridges and/or their stiffness was reduced as fiber size increased, causing a decline in specific force. Results from our examination of molecular mechanisms across the range of physiological CSAs explain the variation in specific force among the different fiber types in human skeletal muscle, which may have relevance to understanding how various physiological and pathophysiological conditions modulate single-fiber and whole muscle contractility.

Chronic disuse and skeletal muscle structure in older adults: sex-specific differences and relationships to contractile function.

In older adults, we examined the effect of chronic muscle disuse on skeletal muscle structure at the tissue, cellular, organellar, and molecular levels and its relationship to muscle function. Volunteers with advanced-stage knee osteoarthritis (OA, n = 16) were recruited to reflect the effects of chronic lower extremity muscle disuse and compared with recreationally active controls (n = 15) without knee OA but similar in age, sex, and health status. In the OA group, quadriceps muscle and single-fiber cross-sectional area were reduced, with the largest reduction in myosin heavy chain IIA fibers. Myosin heavy chain IIAX fibers were more prevalent in the OA group, and their atrophy was sex-specific: men showed a reduction in cross-sectional area, and women showed no differences. Myofibrillar ultrastructure, myonuclear content, and mitochondrial content and morphology generally did not differ between groups, with the exception of sex-specific adaptations in subsarcolemmal (SS) mitochondria, which were driven by lower values in OA women. SS mitochondrial content was also differently related to cellular and molecular functional parameters by sex: greater SS mitochondrial content was associated with improved contractility in women but reduced function in men. Collectively, these results demonstrate sex-specific structural phenotypes at the cellular and organellar levels with chronic disuse in older adults, with novel associations between energetic and contractile systems.

A lifestyle program of exercise and weight loss is effective in preventing and treating type 2 diabetes mellitus: Why are programs not more available?

There is substantial evidence that type 2 diabetes mellitus (T2DM) can be prevented in high-risk individuals by a lifestyle program of regular exercise and weight reduction. Additionally, there is emerging evidence that new onset T2DM (<1year) can go into remission after weight loss and exercise in a majority of motivated individuals, obviating a need for glucose lowering medications. Yet, lifestyle programs to support such behavior change are not widely available. Moreover, health care insurance companies generally do not provide coverage for behavioral weight loss programs to prevent or treat T2DM. Consequently, physicians caring for individuals with T2DM may find it much easier to start a chronic glucose lowering medication rather than attempting to motivate and support patients through long-term behavior change. The cardiac rehabilitation model of disease management, with a network of over 2000 programs in the U.S., is well suited to deliver medically-supervised lifestyle programs. National organizations such as the American Diabetes Association and the American Association of Cardiovascular and Pulmonary Rehabilitation should support greater availability and use of lifestyle programs for T2DM treatment and prevention.

Smoking and cardiac rehabilitation participation: Associations with referral, attendance and adherence.

OBJECTIVE: Continued smoking after a cardiac event greatly increases mortality risk. Smoking cessation and participation in cardiac rehabilitation (CR) are effective in reducing morbidity and mortality. However, these two behaviors may interact; those who smoke may be less likely to access or complete CR. This review explores the association between smoking status and CR referral, attendance, and adherence. METHODS: A systematic literature search was conducted examining associations between smoking status and CR referral, attendance and completion in peer-reviewed studies published through July 1st, 2014. For inclusion, studies had to report data on outpatient CR referral, attendance or completion rates and smoking status had to be considered as a variable associated with these outcomes. RESULTS: Fifty-six studies met inclusion criteria. In summary, a history of smoking was associated with an increased likelihood of referral to CR. However, smoking status also predicted not attending CR and was a strong predictor of CR dropout. CONCLUSION: Continued smoking after a cardiac event predicts lack of attendance in, and completion of CR. The issue of smoking following a coronary event deserves renewed attention.

Muscle disuse alters skeletal muscle contractile function at the molecular and cellular levels in older adult humans in a sex-specific manner.

Physical inactivity that accompanies ageing and disease may hasten disability by reducing skeletal muscle contractility. To characterize skeletal muscle functional adaptations to muscle disuse, we compared contractile performance at the molecular, cellular and whole­muscle levels in healthy active older men and women (n = 15) and inactive older men and women with advanced­stage, symptomatic knee osteoarthritis (OA) (n = 16). OA patients showed reduced (P < 0.01) knee extensor function. At the cellular level, single muscle fibre force production was reduced in OA patients in myosin heavy chain (MHC) I and IIA fibres (both P < 0.05) and differences in IIA fibres persisted after adjustments for fibre cross­sectional area (P < 0.05). Although no group differences in contractile velocity or power output were found for any fibre type, sex was found to modify the effect of OA, with a reduction in MHC IIA power output and a trend towards reduced shortening velocity in women, but increases in both variables in men (P < 0.05 and P = 0.07, respectively). At the molecular level, these adaptations in MHC IIA fibre function were explained by sex­specific differences (P ≤ 0.05) in myosin­actin cross­bridge kinetics. Additionally, cross­bridge kinetics were slowed in MHC I fibres in OA patients (P < 0.01), attributable entirely to reductions in women with knee OA (P < 0.05), a phenotype that could be reproduced in vitro by chemical modification of protein thiol residues. Our results identify molecular and cellular functional adaptations in skeletal muscle that may contribute to reduced physical function with knee OA­associated muscle disuse, with sex­specific differences that may explain a greater disposition towards disability in women.

Cost-Effectiveness of Cardiac Rehabilitation in Older Adults With Coronary Heart Disease.

PURPOSE: While cardiac rehabilitation (CR) is recommended and effective following acute cardiac events, it remains underutilized, particularly in older adults. A study of 601 099 Medicare beneficiaries ≥65 yr hospitalized for coronary heart disease compared 5-yr mortality in users and nonusers of CR. Using instrumental variables (IV), CR improved mortality by 8.0% ( P < .001). A validation analysis based on 70 040 propensity-based (PB) matched pairs gave a similar gain (8.3%, P < .0001). The present cost-effectiveness analysis builds on these mortality results. METHODS: Using the framework of the Second Panel on Cost-Effectiveness Analysis, we calculated the incremental cost-effectiveness ratio (ICER) gained due to CR. We accessed the costs from this cohort, inflated to 2022 prices, and assessed the relationship of quality-adjusted life years (QALY) to life years from a systematic review. We estimated the ICER of CR by modeling lifetime costs and QALY from national life tables using IV and PB. RESULTS: Using IV, CR added 1.344 QALY (95% CI, 0.543-2.144) and $40 472 in costs over the remaining lifetimes of participants. The ICER was $30 188 (95% CI, $18 175-$74 484)/QALY over their lifetimes. Using the PB analysis, the corresponding lifetime values were 2.018 (95% CI, 1.001-3.035) QALY, $66 590, and an ICER of $32 996 (95% CI, $21 942-$66 494)/QALY. CONCLUSIONS: Cardiac rehabilitation was highly cost-effective using guidelines established by the World Health Organization and the US Department of Health and Human Services. The favorable clinical effectiveness and cost-effectiveness of CR, along with low use by Medicare beneficiaries, support the need to increase CR use.

Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation.

PURPOSE: Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention. METHODS: Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance. RESULTS: The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A 1c , with more abnormal lipid profiles (all P s < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both P s < .001). CONCLUSION: Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.

Anxiety Predicts Worse Cardiorespiratory Fitness Outcomes in Cardiac Rehabilitation for Lower Socioeconomic Status Patients.

PURPOSE: The purpose of this study was to show that patients in cardiac rehabilitation (CR) with lower socioeconomic status (SES) have worse clinical profiles and higher rates of psychiatric difficulties and they have lower cardiorespiratory fitness (CRF) improvements from CR than their counterparts with higher SES. Improvement in CRF during CR predicts better long-term health outcomes. Research suggests that higher anxiety impairs CRF in structured exercise regimes and is overrepresented among patients with lower SES. However, no study has determined whether this relationship holds true in CR. METHODS: This study is a secondary analysis of a randomized controlled trial to improve CR attendance among patients with lower SES. Anxiety (ASEBA ASR; Achenbach System of Empirically Based Assessment, Adult Self Report) and CRF measures (metabolic equivalent tasks [METs peak ]) were collected prior to CR enrollment and 4 mo later. Regression was used to examine the association of anxiety with CRF at 4 mo while controlling for other demographic and clinical characteristics. RESULTS: Eight-eight participants were included in the analyses, 31% of whom had clinically significant levels of anxiety ( T ≥ 63). Higher anxiety significantly predicted lower exit CRF when controlling for baseline CRF, age, sex, qualifying diagnosis, and number of CR sessions attended ( ß =-.05, P = .04). Patients with clinically significant levels of anxiety could be expected to lose >0.65 METs peak in improvement. CONCLUSIONS: The results from this study suggest that anxiety, which is overrepresented in populations with lower SES, is associated with less CRF improvement across the duration of CR. The effect size was clinically meaningful and calls for future research on addressing psychological factor in CR.

Financial incentives and case management to improve cardiac rehabilitation participation among patients with lower socio-economic status: Rationale and protocol for a randomized controlled trial.

BACKGROUND: Participation in phase 2 cardiac rehabilitation (CR) is associated with significant decreases in morbidity and mortality. Unfortunately, attendance at CR is not optimal and certain populations, such as those with lower-socioeconomic status (SES), are less likely to participate. In order to remedy this disparity we have designed a trial to examine the efficacy of early case management and/or financial incentives for increasing CR participation among lower-SES patients. METHODS: We will employ a randomized controlled trial with a sample goal of 209 patients who will be randomized 2:3:3:3 to either a usual care control, to receive a case manager starting in-hospital, to receive financial incentives for completing CR sessions, or to receive both interventions. RESULTS: Treatment conditions will be compared on attendance at CR and end-of-intervention (four months) improvements in cardiorespiratory fitness, executive function, and health-related quality of life. The primary outcome measures for this project will be number of CR sessions completed and the percentage who complete ≥30 sessions. Secondary outcomes will include improvements in health outcomes by condition, as well as the cost-effectiveness of the intervention with a focus on potential reductions in emergency department visits and hospitalizations. We hypothesize that either intervention will perform better than the control and that the combination of interventions will perform better than either alone. CONCLUSIONS: This systematic examination of interventions will allow us to test the efficacy and cost-effectiveness of approaches that have the potential to increase CR participation substantially and significantly improve health outcomes among patients with lower-SES.

Self-Reported Executive Function in Hospitalized Cardiac Patients and Associations With Patient Characteristics and Cardiac Rehabilitation Attendance.

PURPOSE: Executive function (ExF), the ability to do complex cognitive tasks like planning and refraining from impulsive behavior, is associated with compliance with medical recommendations. The present study identified associations between self-reported ExF and demographics of patients with cardiac disease as well as with cardiac rehabilitation (CR) attendance. METHODS: Self-reported ExF impairment was measured using the Behavior Rating Inventory of Executive Function (BRIEF) on 316 individuals hospitalized for CR-qualifying cardiac events. Scores were calculated for a global measure (Global Executive Composite [GEC]) and the two BRIEF indices: Behavioral Regulation Index and Metacognition Index (MCI). Participants were followed up post-discharge to determine CR attendance. Univariate logistic regressions between ExF measures and demographic variables were conducted, as were multiple logistic regressions to identify significant, independent predictors. Analyses were conducted using clinical (T scores ≥ 65) and subclinical (T scores ≥ 60) criteria for significant ExF impairment as outcomes. One-way analyses of variance were performed between ExF impairment and CR attendance. RESULTS: Self-reported ExF deficits were relatively rare; 8.9% had at least subclinical scores on the GEC. Using the subclinical criterion for the MCI, having diabetes mellitus (DM) and being male were significant, independent predictors of MCI impairment. No significant relationship was found between ExF and CR attendance. CONCLUSION: Using the subclinical criterion only, individuals with DM and males were significantly more likely to have MCI impairment. No significant effect of ExF impairment on CR attendance was found, suggesting that self-reported ExF measured in the hospital may not be an appropriate measure for predicting behavioral outcomes.