Mobile Technology Improves Adherence to Cardiac Rehabilitation: A Propensity Score-Matched Study.

Background Despite its established effectiveness, adherence to cardiac rehabilitation remains suboptimal. The purpose of our study is to examine whether mobile technology improves adherence to cardiac rehabilitation and other outcomes. Methods and Results We identified all enrollees of the cardiac rehabilitation program at Boston Medical Center from 2016 to 2019 (n=830). Some enrollees used a mobile technology application that provided a customized list of educational content in a progressive manner, used the patient's smartphone accelerometer to provide daily step counts, and served as a 2-way messaging system between the patient and program staff. Adherence to cardiac rehabilitation was defined as the number of attended sessions and completion of the program. Enrollees had a mean age of 59 years; 32% were women, and 42% were Black. Using 3:1 propensity matching for age, sex, race/ethnicity, education, smoking status, transportation time, diagnosis, and baseline depression survey score, we evaluated change in exercise capacity, weight, functional capacity, and nutrition scores. Those in the mobile technology group (n=114) attended a higher number of prescribed sessions (mean 28 versus 22; relative risk, 1.17; 95% CI, 1.04-1.32; P=0.009), were 1.8 times more likely to complete the cardiac rehabilitation program (P=0.01), and had a slightly greater weight loss (pounds) following rehabilitation (-1.71; 95% CI, -0.30 to -3.11; P=0.02) as compared with those in the standard group (n=213); other outcomes were similar between the groups. Conclusions In a propensity-matched, racially diverse population, we found that adjunctive use of mobile technology is significantly associated with improved adherence to cardiac rehabilitation and number of attended sessions.

Diagnostic and prognostic testing to evaluate coronary artery disease in patients with diabetes mellitus.

Coronary artery disease (CAD) continues to be the most common cause of morbidity and mortality in patients with diabetes mellitus (DM). In recent years, the strategies for treatment of CAD in DM have undergone much evolution. Currently, all patients with DM, regardless of symptoms or diagnosed CAD, are treated aggressively for CAD risk factor reduction. In this clinical climate, the ability to specifically identify patients with disease that will benefit from more aggressive and invasive therapies remains a challenge. In this article we review the current literature on diagnostic and prognostic utility of conventional non-invasive modalities for assessment of CAD in patients with DM, as well as on novel and emerging methods for CAD risk stratification.

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in the Evolution of Cardiac Rehabilitation.

The maturing of a clinical discipline necessitates the ability to document scientific advancements and state-of-the-art reviews with a focus on clinical practice. Such was the case for the field of cardiac rehabilitation in 1981. Whereas a growing body of literature was demonstrating benefits of exercise in cardiac patients with regard to clinical, psychologic, and quality-of-life outcomes,, there were still concerns about the safety of exercise and whether it could be widely adapted in clinical care. Since this was a time period when searches of online databases such as PubMed had not yet been established (began in 1996), there was a great value of concentrating much of the cardiac rehabilitation literature in a single journal.This commentary describes the conceptualization and implementation of the Journal of Cardiopulmonary Rehabilitation and Prevention from 1981 to the present and its acceptance as the official journal of the American Association of Cardiovascular and Pulmonary Rehabilitation and later the Canadian Association of Cardiac Rehabilitation. The commentary also highlights the journal's inclusion in Index Medicus in 1995, its receipt of an impact factor from International Scientific Indexing in 2007, and its publication of many important scientific statements, often in collaboration with major scientific organizations such as the American Heart Association and the American College of Cardiology.

Pre-operative stress testing in the evaluation of patients undergoing non-cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Pre-operative stress testing is widely used to evaluate patients for non-cardiac surgeries. However, its value in predicting peri-operative mortality is uncertain. The objective of this study is to assess the type and quality of available evidence in a comprehensive and statistically rigorous evaluation regarding the effectiveness of pre-operative stress testing in reducing 30-day post -operative mortality following non -cardiac surgery. METHODS: The databases of MEDLINE, EMBASE, and CENTRAL databases (from inception to January 27, 2016) were searched for all studies in English. We included studies with pre-operative stress testing prior to 10 different non-cardiac surgery among adults and excluded studies with sample size<15. The data on study characteristics, methodology and outcomes were extracted independently by two observers and checked by two other observers. The primary outcome was 30-day mortality. We performed random effects meta-analysis to estimate relative risk (RR) and 95% confidence intervals (95% CI) in two-group comparison and pooled the rates for stress test alone. Heterogeneity was assessed using I2 and methodological quality of studies using Newcastle-Ottawa Quality Assessment Scale. The predefined protocol was registered in PROSPERO #CRD42016049212. RESULTS: From 1807 abstracts, 79 studies were eligible (297,534 patients): 40 had information on 30-day mortality, of which 6 studies compared stress test versus no stress test. The risk of 30-day mortality was not significant in the comparison of stress testing versus none (RR: 0.79, 95% CI = 0.35-1.80) along with weak evidence for heterogeneity. For the studies that evaluated stress testing without a comparison group, the pooled rates are 1.98% (95% CI = 1.25-2.85) with a high heterogeneity. There was evidence of potential publication bias and small study effects. CONCLUSIONS: Despite substantial interest and research over the past 40 years to predict 30-day mortality risk among patients undergoing non-cardiac surgery, the current body of evidence is insufficient to derive a definitive conclusion as to whether stress testing leads to reduced peri-operative mortality.

Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.

The American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation recognize that all cardiac rehabilitation/secondary prevention programs should contain specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and compliance to these behaviors, reduce disability, and promote an active lifestyle for patients with cardiovascular disease. This update to the previous statement presents current information on the evaluation, interventions, and expected outcomes in each of the core components of cardiac rehabilitation/secondary prevention programs, in agreement with the 2006 update of the American Heart Association/American College of Cardiology Secondary Prevention Guidelines, including baseline patient assessment, nutritional counseling, risk factor management (lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counseling and exercise training.

Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology.

Habitual physical activity reduces coronary heart disease events, but vigorous activity can also acutely and transiently increase the risk of sudden cardiac death and acute myocardial infarction in susceptible persons. This scientific statement discusses the potential cardiovascular complications of exercise, their pathological substrate, and their incidence and suggests strategies to reduce these complications. Exercise-associated acute cardiac events generally occur in individuals with structural cardiac disease. Hereditary or congenital cardiovascular abnormalities are predominantly responsible for cardiac events among young individuals, whereas atherosclerotic disease is primarily responsible for these events in adults. The absolute rate of exercise-related sudden cardiac death varies with the prevalence of disease in the study population. The incidence of both acute myocardial infarction and sudden death is greatest in the habitually least physically active individuals. No strategies have been adequately studied to evaluate their ability to reduce exercise-related acute cardiovascular events. Maintaining physical fitness through regular physical activity may help to reduce events because a disproportionate number of events occur in least physically active subjects performing unaccustomed physical activity. Other strategies, such as screening patients before participation in exercise, excluding high-risk patients from certain activities, promptly evaluating possible prodromal symptoms, training fitness personnel for emergencies, and encouraging patients to avoid high-risk activities, appear prudent but have not been systematically evaluated.

Effect of an American Heart Association Get With the Guidelines program-based clinical pathway on referral and enrollment into cardiac rehabilitation after acute myocardial infarction.

Cardiac rehabilitation (CR)/secondary prevention programs are an important part of patient care after acute myocardial infarction (AMI). However, only 10% to 15% of eligible patients enroll in such programs. The purpose of this study was to evaluate the effect of an American Heart Association Get With the Guidelines (GWTG)-based clinical pathway on referral and enrollment into CR after AMI. Patients (n = 780) admitted to a single center during an 18-month period with AMI and discharged to home were evaluated retrospectively for referral and enrollment into CR programs. A total of 714 patients (92%) were on the GWTG pathway; 392 (55%) were referred and 135 (19%) were enrolled into CR. Higher referral was associated with pathway use (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1 to 4.9, p = 0.03), percutaneous coronary intervention (OR 3.1, 95% CI 1.9 to 5.2, p <0.0001), and in-patient physical therapy consultation (OR 13, 95% CI 8.2 to 20.5, p <0.0001). Ethnicity did not affect referral, but was the only variable associated with lower enrollment. Hispanic and black patients had 92% (OR 0.08, 95% CI 0.01 to 0.55, p = 0.02) and 57% (OR 0.43, 95% CI 0.19 to 1.05, p = 0.06) lower odds to enroll compared with white patients, respectively. In conclusion, use of the American Heart Association GWTG pathway showed a significantly higher referral rate to CR after AMI than previously reported in the literature. Nonetheless, most referred patients did not enroll. Strategies to bridge the gap between referral and enrollment in CR should be incorporated into AMI clinical pathways, with special emphasis on increasing enrollment in ethnic minorities.

Effect of exercise training in supervised cardiac rehabilitation programs on prognostic variables from the exercise tolerance test.

Meta-analyses showed that exercise training decreased mortality in patients after myocardial infarction, but no single adequately powered trial has shown this benefit. The purpose of this study was to evaluate the effect of cardiac rehabilitative exercise training on prognostic variables derived from the exercise tolerance test and whether these changes had an effect on predicted cardiovascular and all-cause mortality using externally validated risk scores. Two hundred ten consecutive patients who completed a 12-week cardiac rehabilitation program were analyzed. Peak MET level, heart rate recovery, chronotropic index, Duke prognostic score, and Cleveland Clinic Foundation risk score obtained at program entry and exit were compared. All prognostic variables and risk score-derived predicted 5-year mortality rates improved significantly after cardiac rehabilitation. Exercise capacity increased by 32% (6.6 +/- 2.7 to 8.7 +/- 2.9 METS; p <0.0001), heart rate recovery increased by 20% (15 +/- 9 to 18 +/- 10 beats/min; p <0.0001), and chronotropic index increased by 11% (56 +/- 22% to 62 +/- 22%; p <0.0001). Duke prognostic score 5-year predicted cardiovascular mortality rate decreased by 33% (6 +/- 4% to 4 +/- 2%; p <0.0001), and Cleveland Clinic Foundation risk score 5-year predicted total mortality rate decreased by 40% (5 +/- 7% to 3 +/- 5%; p <0.0001). These improvements remained significant in high-risk subgroups. When controlled for age, gender, diabetes, MET level achieved, ejection fraction, and beta-blocker use, changes remained significant (p <0.0001) for each outcome measure. In conclusion, exercise training in supervised cardiac rehabilitation programs significantly improved exercise capacity, measures of chronotropic dynamics, and prognostic risk scores. These differences translate into a decrease in predicted mortality.

Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation.

This article updates the 1994 American Heart Association scientific statement on cardiac rehabilitation. It provides a review of recommended components for an effective cardiac rehabilitation/secondary prevention program, alternative ways to deliver these services, recommended future research directions, and the rationale for each component of the rehabilitation/secondary prevention program, with emphasis on the exercise training component.