Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands.

PURPOSE: Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components. METHODS: Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components. RESULTS: In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization. CONCLUSIONS: CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

Sex Differences in Cardiac Rehabilitation Outcomes.

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Serum Angiopoietin-Like Protein 2 and NT-Pro BNP Levels and Their Associated Factors in Patients with Chronic Heart Failure Participating in a Phase III Cardiac Rehabilitation Program.

Angiopoietin-like protein 2 (ANGPTL2) promotes chronic inflammation and plays a key role in the pathogenesis of heart failure. Cardiac rehabilitation (CR) is an integral component of heart failure management and has been shown to have anti-inflammatory effects. However, ANGPTL2 concentration in chronic heart failure patients undergoing CR has not been evaluated. This study aimed to investigate serum ANGPTL2 levels and their associated factors and compare the results with those of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with chronic heart failure undergoing phase III CR.A total of 56 patients were enrolled. Clinical characteristics including body composition, grip strength, exercise tolerance, duration of CR, blood counts and biochemistry, and echocardiographic parameters were evaluated for their association with serum ANGPTL2 and NT-proBNP levels.The median (first and third quartiles) value of ANGPTL2 was 4.05 (2.70-5.57) ng/mL. Clinical parameters that correlated with serum ANGPTL2 levels were body weight, body mass index, body fat mass, body fat percentage, anaerobic threshold (AT), C-reactive protein, and total protein (TP), which were mostly distinct from those that correlated with serum NT-proBNP levels. A multivariate analysis revealed that AT and TP were independent factors related to ANGPTL2 levels, whereas age, left ventricular ejection fraction, and left atrial dimension were independently related to NT-proBNP levels.These observations suggest that CR increases the exercise tolerance and exhibits anti-inflammatory effects simultaneously, and this situation is reflected by decreased serum ANGPLT2 and TP levels. ANGPTL2 may be a useful marker of inflammation and impaired exercise tolerance in patients with chronic heart failure.

Impact of COVID-19 Pandemic on Physical Activity in Patients With Implantable Cardioverter-Defibrillators.

PURPOSE: The coronavirus disease-2019 (COVID-19) pandemic has been spreading rapidly worldwide since late January 2020. The strict lockdown strategy prompted by the Italian government, to hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) spreading, has reduced the possibility of performing either outdoor or gym physical activity (PA). This study investigated and quantified the reduction of PA in patients with automatic implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden death. METHODS: Daily PA of 24 patients was estimated by processing recorded data from ICD-embedded accelerometric sensors used by the rate-responsive pacing systems. RESULTS: During the forced 40-d in-home confinement, a mean 25% reduction of PA was observed as compared with the 40-d confinement-free period (1.2 ± 0.3 vs 1.6 ± 0.5 hr/d, respectively, P = .0001). CONCLUSIONS: This objective quantification of the impact of the COVID-19 pandemic on PA determined by an ICD device showed an abrupt and statistically significant reduction of PA in primary prevention ICD patients, during the in-home confinement quarantine. To counteract the deleterious effects of physical inactivity during the COVID-19 outbreak, patients should be encouraged to perform indoor exercise-based personalized rehabilitative programs.

Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands.

Importance: Cardiac rehabilitation (CR) is an effective strategy to improve clinical outcomes, but it remains underused in some subgroups of patients with cardiovascular disease (CVD). Objective: To investigate the implications of sex, age, socioeconomic status, CVD diagnosis, cardiothoracic surgery, and comorbidity for the association between CR participation and all-cause mortality. Design, Setting, and Participants: Observational cohort study with patient enrollment between July 1, 2012, and December 31, 2017, and a follow-up to March 19, 2020. The dates of analysis were March to May 2020. This study was performed among Dutch patients with CVD with a multidisciplinary outpatient CR program indication and who were insured at Coöperatie Volksgezondheidszorg, one of the largest health insurance companies in the Netherlands. Among 4.1 million beneficiaries, patients with CVD with an acute coronary event (myocardial infarction or unstable angina pectoris), stable angina pectoris, chronic heart failure, or cardiothoracic surgery (coronary artery bypass grafting, valve replacement, or percutaneous coronary intervention) were identified by inpatient diagnosis codes and included in the study. Main Outcomes and Measures: Cox proportional hazards models were used to evaluate the association between CR participation and all-cause mortality. Stabilized inverse propensity score weighting was used to account for patient and disease characteristics associated with CR participation. Results: Among 83 687 eligible patients with CVD (mean [SD] age, 67 [12] years; 60.4% [n = 50 512] men), only 31.3% (n = 26 171) participated in CR, with large variation across different subgroups (range, 5.1%-73.0%). During a mean (SD) of 4.7 (1.8) years of follow-up, 1966 CR participants (7.5%) and 13 443 CR nonparticipants (23.4%) died. After multivariable adjustment, CR participation was associated with a 32% lower risk of all-cause mortality (adjusted hazard ratio, 0.68; 95% CI, 0.65-0.71) compared with nonparticipation. Sex, age, socioeconomic status, and comorbidity did not alter risk reduction after CR participation, but a statistically significant interaction association was found across categories of CVD diagnosis and cardiothoracic surgery. Larger reductions in risk estimates for all-cause mortality were found after CR participation for STEMI (adjusted HR, 0.59; 95% CI, 0.52-0.68 vs 0.72; 95% CI, 0.65-0.79; P < .001), NSTEMI (adjusted HR, 0.64; 95% CI, 0.58-0.70 vs 0.72; 95% CI, 0.65-0.79; P < .001), and stable AP (adjusted HR, 0.69; 95% CI, 0.63-0.76 vs 0.72; 95% CI, 0.65-0.79; P < .001) compared with patients with chronic heart failure, whereas unstable AP had a smaller risk reduction (adjusted HR, 0.75; 95% CI, 0.67-0.85 vs 0.72; 95% CI, 0.65-0.79; P < .001). Conclusions and Relevance: In this cohort study, CR participation was associated with a 32% risk reduction in all-cause mortality, and this benefit was independent of sex, age, socioeconomic status, and comorbidity. These findings reinforce the importance of CR participation in secondary prevention and highlight the possibility that CR should be prescribed more widely to vulnerable patients with CVD, such as older adults with chronic diseases or multimorbidity.

Optimising Secondary Prevention and Cardiac Rehabilitation for Atherosclerotic Cardiovascular Disease During the COVID-19 Pandemic: A Position Statement From the Cardiac Society of Australia and New Zealand (CSANZ).

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has introduced a major disruption to the delivery of routine health care across the world. This provides challenges for the use of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). The aim of this Position Statement is to review the implications for effective delivery of secondary prevention strategies during the COVID-19 pandemic. CHALLENGES: The COVID-19 pandemic has introduced limitations for many patients to access standard health services such as visits to health care professionals, medications, imaging and blood tests as well as attendance at cardiac rehabilitation. In addition, the pandemic is having an impact on lifestyle habits and mental health. Taken together, this has the potential to adversely impact the ability of practitioners and patients to adhere to treatment guidelines for the prevention of recurrent cardiovascular events. RECOMMENDATIONS: Every effort should be made to deliver safe, ongoing access to health care professionals and the use of evidenced based therapies in individuals with CVD. An increase in use of a range of electronic health platforms has the potential to transform secondary prevention. Integrating research programs that evaluate the utility of these approaches may provide important insights into how to develop more optimal approaches to secondary prevention beyond the pandemic.

Cardiac Rehabilitation During the COVID-19 Era: Guidance on Implementing Virtual Care.

Cardiac rehabilitation programs across Canada have suspended in-person services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. Virtual cardiac rehabilitation (VCR) offers an alternate mechanism of care delivery, capable of providing similar patient outcomes and safety profiles compared with centre-based programs. To minimize care gaps, all centres should consider developing and implementing a VCR program. The process of this rapid implementation, however, can be daunting. Centres should initially focus on the collation, utilization, and repurposing of existing resources, equipment, and technology. Once established, programs should then focus on ensuring that quality indicators are met and care processes are protocolized. This should be followed by the development of sustainable VCR solutions to account for care gaps that existed before COVID-19, and to improve cardiac rehabilitation delivery, moving forward. This article reviews the potential challenges and obstacles of this process and aims to provide pragmatic guidance to aid clinicians and administrators during this challenging time.

Aplicabilidad de los consensos de expertos de unidades de insuficiencia cardiaca/rehabilitación cardiaca y RehaCtivAP con respecto a la COVID-19 / Applicability of the consensus of experts from heart failure/cardiac rehabilitation units and RehaCtivAP regarding the COVID-19

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ASPIRE-3-PREVENT: a cross-sectional survey of preventive care after a coronary event across the UK.

OBJECTIVE: To quantify the implementation of the third Joint British Societies' Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) after coronary event. METHODS: Using a cross-sectional survey design, patients were consecutively identified in 36 specialist and district general hospitals between 6 months and 2 years, after acute coronary syndrome or revascularisation procedure and invited to a research interview. Outcomes included JBS3 lifestyle, risk factor and therapeutic management goals. Data were collected using standardised methods and instruments by trained study nurses. Blood was analysed in a central laboratory and a glucose tolerance test was performed. RESULTS: 3926 eligible patients were invited to participate and 1177 (23.3% women) were interviewed (30% response). 12.5% were from black and minority ethnic groups. 45% were persistent smokers, 36% obese, 52.9% centrally obese, 52% inactive; 30% had a blood pressure >140/90 mm Hg, 54% non-high-density lipoprotein ≥2.5 mmol/L and 44.3% had new dysglycaemia. Prescribing was highest for antiplatelets (94%) and statins (85%). 81% were advised to attend cardiac rehabilitation (86% <60 years vs 79% ≥60 years; 82% men vs 77% women; 93% coronary artery bypass grafting vs 59% unstable angina), 85% attended if advised; 69% attended overall. Attenders were significantly younger (p=0.03) and women were less likely to attend (p=0.03). CONCLUSIONS: Patients with coronary heart disease (CHD) are not being adequately managed after event with preventive measures. They require a structured preventive cardiology programme addressing lifestyle, risk factor management and adherence to cardioprotective medications to achieve the standards set by the British Association for Cardiovascular Prevention and Rehabilitation and JBS3 guidelines.

One-year follow-up of heart transplant recipient with cardiac rehabilitation: A case report.

INTRODUCTION: Heart transplantation (HT) is known to be the final therapy for patients with advanced heart failure; however, the exercise capacity of these patients remains under the aged-predicted value after HT. Many studies have described the effectiveness and safety of cardiac rehabilitation (CR) in HT recipients. Nevertheless, long-term follow-up data of HT recipients undergoing CR are insufficient, and there is a lack of evidence on the long-term effects of CR. In this case report, we present the long-term benefits of CR in an HT recipient, including serial follow-up clinical data over 1 year. PATIENT CONCERNS: A 48-year-old female patient underwent HT because of advanced dilated cardiomyopathy. DIAGNOSIS: Cardiopulmonary exercise test showed reduced exercise capacity and pulmonary function. The grip power and quadriceps muscle strength were also decreased after HT. INTERVENTIONS: The patient underwent a phase I CR program for 3 months, followed by a phase III CR program for 7 months. In the beginning, moderate-intensity continuous training was conducted. Thereafter, high-intensity interval training was implemented after a period of adjustment for interval training. OUTCOMES: The exercise capacity, 6-min walk distance, muscle strength, and vital capacity were improved after CR. CONCLUSION: CR in HT recipients may improve muscle strength and pulmonary function as well as exercise capacity, without serious cardiovascular complications. Phase III CR may help maintain exercise capacity in these patients.

Optimum nutritional strategies for cardiovascular disease prevention and rehabilitation (BACPR).

Nutrition has a central role in both primary and secondary prevention of cardiovascular disease yet only relatively recently has food been regarded as a treatment, rather than as an adjunct to established medical and pharmacotherapy. As a field of research, nutrition science is constantly evolving making it difficult for patients and practitioners to ascertain best practice. This is compounded further by the inherent difficulties in performing double-blind randomised controlled trials. This paper covers dietary patterns that are associated with improved cardiovascular outcomes, including the Mediterranean Diet but also low-carbohydrate diets and the potential issues encountered with their implementation. We suggest there must be a refocus away from macronutrients and consideration of whole foods when advising individuals. This approach is fundamental to practice, as clinical guidelines have focused on macronutrients without necessarily considering their source, and ultimately people consume foods containing multiple nutrients. The inclusion of food-based recommendations aids the practitioner to help the patient make genuine and meaningful changes in their diet. We advocate that the cardioprotective diet constructed around the traditional Mediterranean eating pattern (based around vegetables and fruits, nuts, legumes, and unrefined cereals, with modest amounts of fish and shellfish, and fermented dairy products) is still important. However, there are other approaches that can be tried, including low-carbohydrate diets. We encourage practitioners to adopt a flexible dietary approach, being mindful of patient preferences and other comorbidities that may necessitate deviations away from established advice, and advocate for more dietitians in this field to guide the multi-professional team.

Cardiac Rehabilitation Dose Around the World: Variation and Correlates.

BACKGROUND: Cardiac rehabilitation (CR) is recommended in clinical practice guidelines, but dose prescribed varies highly by country. This study characterized the dose offered in supervised CR programs and alternative models worldwide and their potential correlates. METHODS AND RESULTS: In this cross-sectional study, an online survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Countries were classified based on region and income categories. Dose was operationalized as program duration×sessions per week. Generalized linear mixed models were performed to assess correlates. Of 203 countries in the world, 111 (54.7%) offered CR; data were collected in 93 (83.8% country response rate; n=1082 surveys, 32.1% program response rate). Globally, supervised CR programs were a median of 24 sessions (n=619, 57.3% programs ≥12 sessions); home-based and community-based programs offered 6 and 20 sessions, respectively. There was significant variation in supervised CR dose by region (P≤0.001), with the Americas (median, 36 sessions) offering a significantly greater dose than several other regions; there was also a trend for variation by country income classification. There was no difference in home-based dose by region (P=0.43) but there was for community-based programs (P<0.05; Americas offering greater dose). There was a significant dose variation in both home- and community-based programs by income classification (P=0.002 and P<0.001, respectively), with higher doses offered by upper-middle-income than high-income countries. Correlates of supervised CR dose included more involvement of physicians (P=0.026), proximity to other programs (P=0.002), and accepting patients with noncardiac indications (P=0.037). CONCLUSIONS: CR programs in many countries may need to increase their dose, which could be supported through physician champions.

Cardiac Rehabilitation in Frail Older Adults With Cardiovascular Disease: A NEW DIAGNOSTIC AND TREATMENT PARADIGM.

Older adults with cardiovascular disease (CVD) pose challenges to cardiac rehabilitation (CR) clinicians because their disease is often coupled to physical frailty. Older patients with CVD and frailty may be less likely to tolerate conventional CR exercise training due to multidimensional (ie, strength, mobility, and balance) physical impairments. Furthermore, conventional CR typically emphasizes endurance training without addressing the intrinsic skeletal muscle impairments of frail patients that often manifest as deficits in strength, mobility, and balance, undercutting feasibility and any likely benefits. However, if appropriately modified to meet the needs of frail older adults, CR may be a powerful tool for this challenging population. To best serve frail, older adults with CVD, CR programs can incorporate well-validated strategies to assess frailty and physical function that also fit within the workflows and patient populations of individual programs. Such frailty assessments provide opportunities to identify specific targets (eg, weakness) that need to be addressed before a subsequent aerobic training program can be successfully implemented and sustained. The current review focuses on the use of physical frailty measures in older adults with CVD, with practical considerations for their clinical use in contemporary CR, as well as directions for future research.

Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative.

BACKGROUND: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization. METHODS AND RESULTS: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography. CONCLUSIONS: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.

Digital Cardiac Rehabilitation Programs: The Future of Patient-Centered Medicine.

Background: The low participation rate in cardiac rehabilitation programs is the major reason for rehospitalization, morbidity, and mortality. Home-based cardiac rehabilitation by technological means is an essential component of a "patient-centered" approach, which is capable of enhancing the participation rate in rehabilitation programs. Introduction: The aim of this research was to examine attitudes, perceptions, and behavioral intentions toward remote digital cardiac rehabilitation (RDCR) with respect to factors such as age, education, smoking, exercise habits, technological illiteracy, and mobile phone behavior. Materials and Methods: This was a cross-sectional study of 200 adult patients discharged from a hospital after an acute coronary syndrome, cardiac surgery, or percutaneous coronary intervention. All patients answered an anonymous Technology Usage Questionnaire, which examined the relationship between their willingness to participate in the RDCR program and various parameters. The surveys were distributed and completed between July 2017 and November 2017 at the Sheba Medical Center in Israel. Results: Overall, 83% of all participants were interested in participating in the RDCR program. Those with heart failure had a greater interest in the program (100%; p < 0.05), whereas patients after coronary bypass surgery had a lesser interest (71.1%; p < 0.05). The level of attitude toward healthy lifestyle was found to be a significant predictor of willingness to participate in RDCR (odds ratio 2.26; p = 0.01). Sociodemographic characteristics, lifestyle, habits, technological knowledge, age, and gender were not found as significant predictors of interest in RDCR. Conclusions: The RDCR program was acceptable to most cardiac patients, including the elderly population, and could be a potential solution for patients who avoid traditional rehabilitation programs in medical centers.

Promoting patient utilization of outpatient cardiac rehabilitation: A joint International Council and Canadian Association of Cardiovascular Prevention and Rehabilitation position statement.

BACKGROUND: Cardiac Rehabilitation (CR) is a recommendation in international clinical practice guidelines given its' benefits, however use is suboptimal. The purpose of this position statement was to translate evidence on interventions that increase CR enrolment and adherence into implementable recommendations. METHODS: The writing panel was constituted by representatives of societies internationally concerned with preventive cardiology, and included disciplines that would be implementing the recommendations. Patient partners served, as well as policy-makers. The statement was developed in accordance with AGREE II, among other guideline checklists. Recommendations were based on our update of the Cochrane review on interventions to promote patient utilization of CR. These were circulated to panel members, who were asked to rate each on a 7-point Likert scale in terms of scientific acceptability, actionability, and feasibility of assessment. A web call was convened to achieve consensus and confirm strength of the recommendations (based on GRADE). The draft underwent external review and public comment. RESULTS: The 3 drafted recommendations were that to increase enrolment, healthcare providers, particularly nurses (strong), should promote CR to patients face-to-face (strong), and that to increase adherence part of CR could be delivered remotely (weak). Ratings for the 3 recommendations were 5.95 ±â€¯0.69 (mean ±â€¯standard deviation), 5.33 ±â€¯1.12 and 5.64 ±â€¯1.08, respectively. CONCLUSIONS: Interventions can significantly increase utilization of CR, and hence should be widely applied. We call upon cardiac care institutions to implement these strategies to augment CR utilization, and to ensure CR programs are adequately resourced to serve enrolling patients and support them to complete programs.