Cardiac rehabilitation availability and characteristics in Latin America and the Caribbean: A Global Comparison.

BACKGROUND: This study aimed to establish availability and characteristics of cardiac rehabilitation (CR) in Latin America and the Caribbean (LAC), where cardiovascular disease is highly prevalent. METHODS: In this cross-sectional sub-analysis focusing on the 35 LAC countries, local cardiovascular societies identified CR programs globally. An online survey was administered to identified programs, assessing capacity and characteristics. CR need was computed relative to ischemic heart disease (IHD) incidence from the Global Burden of Disease study. RESULTS: ≥1 CR program was identified in 24 LAC countries (68.5% availability; median = 3 programs/country). Data were collected in 20/24 countries (83.3%); 139/255 programs responded (54.5%), and compared to responses from 1082 programs in 111 countries. LAC density was 1 CR spot per 24 IHD patients/year (vs 18 globally). Greatest need was observed in Brazil, Dominican Republic and Mexico (all with >150,000 spots needed/year). In 62.8% (vs 37.2% globally P < .001) of CR programs, patients pay out-of-pocket for some or all of CR. CR teams were comprised of a mean of 5.0 ± 2.3 staff (vs 6.0 ± 2.8 globally; P < .001); Social workers, dietitians, kinesiologists, and nurses were significantly less common on CR teams than globally. Median number of core components offered was 8 (vs 9 globally; P < .001). Median dose of CR was 36 sessions (vs 24 globally; P < .001). Only 27 (20.9%) programs offered alternative CR models (vs 31.1% globally; P < .01). CONCLUSION: In LAC countries, there is very limited CR capacity in relation to need. CR dose is high, but comprehensiveness low, which could be rectified with a more multidisciplinary team.

Nature of Cardiac Rehabilitation Around the Globe.

BACKGROUND: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. METHODS: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. FINDINGS: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ±â€¯2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ±â€¯1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). INTERPRETATION: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes.

Cardiac Rehabilitation Availability and Density around the Globe.

BACKGROUND: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. METHODS: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. FINDINGS: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35-1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04-1.06), and significantly lower with private (OR = .92, 95%CI = .91-.93) or public (OR = .83, 95%CI = .82-84) funding compared to hybrid sources.Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150-390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. INTERPRETATION: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.

Severity of Depressive Symptoms Pre- and Postcardiac Rehabilitation: A COMPARISON AMONG PATIENTS IN BRAZIL, CANADA, COLOMBIA, THE UNITED STATES, AND VENEZUELA.

PURPOSE: Depression is 3 times more prevalent in the cardiac than the general population in high-income countries and is particularly high in middle-income countries. Comorbid depression is associated with twice the mortality after a cardiovascular event. The objectives of this study were to describe and compare depressive symptoms pre- and postcardiac rehabilitation (CR) among patients in high-income countries and middle-income countries in the Americas. METHODS: The study design was prospective and observational. A convenience sample of CR participants completed the Patient Health Questionnaire-9 (PHQ-9) at CR intake and again at program discharge. Clinical data were extracted from medical charts. RESULTS: There were 779 participants: 45 Brazilian (5.8% of sample), 214 Canadian (27.5%), 126 Colombian (16.2%), 309 American (39.7%), and 85 Venezuelan (10.9%). Pre-CR depressive symptoms significantly differed between countries (P < .05), with Colombian participants reporting higher scores than Canadians and Venezuelans. Total PHQ-9 scores significantly decreased during CR in Colombia (mean change =-2.33; P < .001), the United States (mean change =-1.12; P < .001), and Venezuela (mean change =-2.14; P < .001), but not in Brazil (where less psychosocial intervention was offered) or Canada (where pre-CR scores were low). Among the 102 (13.1%) participants with scores in the elevated range pre-CR, the mean change in PHQ-9 scores was -6.57 ± 1.09 and 40 (39.2%) participants no longer had elevated symptoms postprogram. CONCLUSIONS: Depressive symptoms are variable among patients with CR in South and North American countries. CR programs incorporating psychosocial components can reduce these symptoms.

Cardiac rehabilitation in Latin America.

This article provides a description of the status of cardiovascular (CV) rehabilitation (CVR) in Latin America (LA) and the potential impact on CV disease in the region. We discuss the insufficient number of CVR programs in the region and describe the components of CVR that are more commonly available, like exercise interventions, medical assessment and patient education. Additionally, we discuss the heterogeneity in other components, like the evaluation of depression, sleep apnea, and smoking cessation programs. Lastly, we provide a brief review on the main characteristics of the health systems of each country regarding access to CVR programs and compare the average cost of CV procedures and treatments with CVR.