Interventions to promote patient utilisation of cardiac rehabilitation.

BACKGROUND: International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation. OBJECTIVES: First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations. SEARCH METHODS: Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics. MAIN RESULTS: Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. AUTHORS' CONCLUSIONS: Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

Promoting patient uptake and adherence in cardiac rehabilitation.

BACKGROUND: Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review. OBJECTIVES: To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation. SEARCH METHODS: We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions. SELECTION CRITERIA: Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome. DATA COLLECTION AND ANALYSIS: At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias. MAIN RESULTS: The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization. AUTHORS' CONCLUSIONS: We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed. 

A web-based program improves physical activity outcomes in a primary care angina population: randomized controlled trial.

BACKGROUND: Angina affects more than 50 million people worldwide. Secondary prevention interventions such as cardiac rehabilitation are not widely available for this population. An Internet-based version could offer a feasible alternative. OBJECTIVE: Our aim was to examine the effectiveness of a Web-based cardiac rehabilitation program for those with angina. METHODS: We conducted a randomized controlled trial, recruiting those diagnosed with angina from general practitioners (GPs) in primary care to an intervention or control group. Intervention group participants were offered a 6-week Web-based rehabilitation program ("ActivateYourHeart"). The program was introduced during a face-to-face appointment and then delivered via the Internet (no further face-to-face contact). The program contained information about the secondary prevention of coronary heart disease (CHD) and set each user goals around physical activity, diet, managing emotions, and smoking. Performance against goals was reviewed throughout the program and goals were then reset/modified. Participants completed an online exercise diary and communicated with rehabilitation specialists through an email link/synchronized chat room. Participants in the control group continued with GP treatment as usual, which consisted of being placed on a CHD register and attending an annual review. Outcomes were measured at 6-week and 6-month follow-ups during face-to-face assessments. The primary outcome measure was change in daily steps at 6 weeks, measured using an accelerometer. Secondary outcome measures were energy expenditure (EE), duration of sedentary activity (DSA), duration of moderate activity (DMA), weight, diastolic/systolic blood pressure, and body fat percentage. Self-assessed questionnaire outcomes included fat/fiber intake, anxiety/depression, self-efficacy, and quality of life (QOL). RESULTS: A total of 94 participants were recruited and randomized to the intervention (n=48) or the usual care (n=46) group; 84 and 73 participants completed the 6-week and 6-month follow-ups, respectively. The mean number of log-ins to the program was 18.68 (SD 13.13, range 1-51), an average of 3 log-ins per week per participant. Change in daily steps walked at the 6-week follow-up was +497 (SD 2171) in the intervention group and -861 (SD 2534) in the control group (95% CI 263-2451, P=.02). Significant intervention effects were observed at the 6-week follow-up in EE (+43.94 kcal, 95% CI 43.93-309.98, P=.01), DSA (-7.79 minutes, 95% CI -55.01 to -7.01, P=.01), DMA (+6.31 minutes, 95% CI 6.01-51.20, P=.01), weight (-0.56 kg, 95% CI -1.78 to -0.15, P=.02), self-efficacy (95% CI 0.30-4.79, P=.03), emotional QOL score (95% CI 0.01-0.54, P=.04), and angina frequency (95% CI 8.57-35.05, P=.002). Significant benefits in angina frequency (95% CI 1.89-29.41, P=.02) and social QOL score (95% CI 0.05-0.54, P=.02) were also observed at the 6-month follow-up. CONCLUSIONS: An Internet-based secondary prevention intervention could be offered to those with angina. A larger pragmatic trial is required to provide definitive evidence of effectiveness and cost-effectiveness. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 90110503; http://www.controlled-trials.com/ISRCTN90110503/ISRCTN90110503 (Archived by WebCite at http://www.webcitation.org/6RYVOQFKM).

Cardiac rehabilitation to improve physical functioning in refractory angina: a pilot study.

OBJECTIVES: Refractory angina patients suffer debilitating chest pain despite optimal medical therapy and previous cardiovascular intervention. Cardiac rehabilitation is often not prescribed due to a lack of evidence regarding potential efficacy and patient suitability. A randomised controlled study was undertaken to explore the impact of cardiac rehabilitation on cardiovascular risk factors, physical ability, quality of life and psychological morbidity among refractory angina sufferers. METHODS: Forty-two refractory angina patients (65.1 ± 7.3 years) were randomly assigned to an 8-week Phase III cardiac rehabilitation program or symptom diary control. Physical assessment, Progressive Shuttle Walk test, Hospital Anxiety and Depression Scale, Health Anxiety Questionnaire, the York Angina Beliefs scale, ENRICHD Social Support Instrument and SF-36 were completed before and after intervention and at 8-week follow-up. RESULTS: Following cardiac rehabilitation, patients demonstrated improved physical ability compared with controls in Progressive Shuttle Walk level attainment (p = 0.005) and total distance covered (p = 0.015). Angina frequency and severity remained unchanged in both groups, with the control demonstrating worsening SF-36 pain scale (63.43 ± 22.28 vs. 55.46 ± 23.98, p = 0.025). Cardiac rehabilitation participants showed improved Health Anxiety Questionnaire reassurance (1.71 ± 1.72 vs. 1.14 ± 1.23, p = 0.026) and York Beliefs anginal threat perception (12.42 ± 4.58 vs. 14.35 ± 4.73, p = 0.05) after cardiac rehabilitation. Physical measures were broadly unaffected. CONCLUSIONS: Cardiac rehabilitation can be prescribed to improve physical ability without affecting angina frequency or severity among patients with refractory angina.

Randomized controlled trial of a lay-facilitated angina management programme.

AIMS: This article reports a randomized controlled trial of lay-facilitated angina management (registered trial acronym: LAMP). BACKGROUND: Previously, a nurse-facilitated angina programme was shown to reduce angina while increasing physical activity, however most people with angina do not receive a cardiac rehabilitation or self-management programme. Lay people are increasingly being trained to facilitate self-management programmes. DESIGN: A randomized controlled trial comparing a lay-facilitated angina management programme with routine care from an angina nurse specialist. METHODS: Participants with new stable angina were randomized to the angina management programme (intervention: 70 participants) or advice from an angina nurse specialist (control: 72 participants). Primary outcome was angina frequency at 6 months; secondary outcomes at 3 and 6 months included: risk factors, physical functioning, anxiety, depression, angina misconceptions and cost utility. Follow-up was complete in March 2009. Analysis was by intention-to-treat; blind to group allocation. RESULTS: There was no important difference in angina frequency at 6 months. Secondary outcomes, assessed by either linear or logistic regression models, demonstrated important differences favouring the intervention group, at 3 months for: Anxiety, angina misconceptions and for exercise report; and at 6 months for: anxiety; depression; and angina misconceptions. The intervention was considered cost-effective. CONCLUSION: The angina management programme produced some superior benefits when compared to advice from a specialist nurse.

[Application of physical factors for the hospital-based rehabilitation of patients with combined cardiovascular and bronchopulmonary diseases].

The hospital-based rehabilitative treatment was given to 36 patients presenting with combined cardiopulmonary pathology. It included electrophoresis of the the salt sediment from Amurskaya-2 mineral water and the assessment of its efficacy in clinical, functional, and laboratory studies. It was shown that this therapeutic modality had positive influence on lipid metabolism and improved the functional state of myocardium. Overall, the rehabilitative potential of the treatment increased.

Promoting patient uptake and adherence in cardiac rehabilitation.

BACKGROUND: Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programmes are below the recommended levels. This aim is to update a previous non-Cochrane systematic review which examined interventions that may potentially improve cardiac patient uptake and adherence in rehabilitation or its components and concluded that there is insufficient evidence to make specific recommendations. OBJECTIVES: To determine the effects of interventions to increase patient uptake of, and adherence to, cardiac rehabilitation. SEARCH STRATEGY: A previous systematic review identified studies published prior to June 2001. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4 2007), MEDLINE (2001 to January 2008), EMBASE (2001 to January 2008), CINAHL (2001 to January 2008), PsycINFO (2001 to January 2008), Web of Science: ISI Proceedings (2001 to April 2008), and NHS Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) from 2001 to January 2008. Reference lists of identified systematic reviews and randomised control trials (RCTs) were also checked for additional studies. SELECTION CRITERIA: Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and randomised or quasi-randomised trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. Only studies reporting a measure of adherence were included. DATA COLLECTION AND ANALYSIS: Titles and abstracts of all identified references were screened for eligibility by two reviewers independently and full papers of potentially relevant trials were obtained and checked. Included studies were assessed for risk of bias by two reviewers. MAIN RESULTS: Ten studies were identified, three of interventions to improve uptake of cardiac rehabilitation and seven of interventions to increase adherence. Meta-analysis was not possible due to multiple sources of heterogeneity. All three interventions targeting uptake of cardiac rehabilitation were effective. Two of seven studies intended to increase adherence had a significant effect. Only one study reported the non-significant effects of the intervention on cardiovascular risk factors and no studies reported data on mortality, morbidities, costs or health care resource utilisation. AUTHORS' CONCLUSIONS: There is some evidence to suggest that interventions to increase the uptake of cardiac rehabilitation can be effective. Few practice recommendations for increasing adherence to cardiac rehabilitation can be made at this time. Interventions targeting patient identified barriers may increase the likelihood of success. Further high quality research is needed.

Response shift in the assessment of quality of life among people attending cardiac rehabilitation.

OBJECTIVES: To examine whether any response shift in quality of life (QoL) assessment over the course of a cardiac rehabilitation (CR) programme could be explained by changes in individuals' internal standards (recalibration), values (reprioritization), and/or conceptualization of QoL and the extent to which any response shift could be explained by health locus of control, optimism, and coping strategy. DESIGN: Longitudinal survey design. METHODS: The schedule for evaluation of individual QoL-direct weighting (SEIQoL-DW) was administered at the beginning and end of a CR programme. At the end of the programme, the SEIQoL-DW then-test was also administered to measure response shift. A total of 57 participants completed these measures and other measures to assess health locus of control, optimism, and coping. RESULTS: Response shift effects were observed in this population mainly due to recalibration. When response shift was incorporated into the analysis of QoL a larger treatment effect was observed. Active coping as a mechanism in the response shift model was found to have a significant positive correlation with response shift. CONCLUSION: This study showed that response shift occurs during CR. The occurrence of response shift in QoL ratings over time for this population could have implications for the estimation of the effectiveness of the intervention.

[The scope and algorithm of instrumental physiotherapy programs at the hospital stage of rehabilitation of patients with stable angina pectoris].

Optimization of the list of physiotherapeutic methods for rehabilitation of patients with stable angina of effort provided a basis for the rationale and the development of an algorithm of instrumental physiotherapy programs. The algorithm permits to avoid negative effect of environmental physical factors on the human body.

[Comparative efficiency of a course of multi-factor physiotherapeutic treatment and a complex of instrumental physiotherapy technics for medical rehabilitation of patients with stable angina pectoris].

Examination of comparable groups of patients with angina of efforts has demonstrated identical clinical efficiency of multi-factor therapeutic modalities and methods of instrumental physiotherapy for medical rehabilitation of patients with stable angina of effort. The results of this study suggest the possibility to avoid polypragmasia when prescribing physiotherapeutic treatment.

Does health status differ between men and women in early recovery after myocardial infarction?

BACKGROUND: Although much attention has been given to survival after myocardial infarction (MI), little is known about sex differences in health status (symptoms, function, and quality of life). A particularly critical moment to assess health status following an MI is early after discharge when patients have resumed routine activities and when additional treatments may be offered to those with residual angina or quality of life limitations. METHODS: We used multivariable Poisson and linear regression models to examine differences in 30-day health status by sex in a cohort of 2096 MI patients enrolled in a 19-center Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER). RESULTS: Women (32% of the cohort) were older and less likely to be white, married, or treated with coronary revascularization. They were more likely to have had a non-ST segment elevation MI, diabetes, hypertension, heart failure, chronic lung disease, and worse health status at admission. Risk-adjusted multivariable models suggest women were slightly more likely to have angina (RR 1.06, 95% CI 1.0, 1.14, p = 0.06), worse quality of life (difference in SAQ score = -4.36 points, 95% CI -5.44, -3.27 points, p = <0.001) and poorer physical functioning (difference in SF-12 PCS = -2.55 points, 95%CI = -3.62, -1.48 points, p = <0.001) at 30 days than men. CONCLUSIONS: One in four patients experienced angina 1 month after their MI, and women had a slightly greater prevalence than men. The physical function and quality of life of women 30 days after an MI is similar to or worse than that of men.

Impact of depressive mood on lifestyle changes in patients with coronary artery disease.

OBJECTIVE: The aims of this study were to investigate the time-course of depressive mood in patients with coronary artery disease during a secondary prevention rehabilitation program, and to analyse how different pre-treatment levels of depressive mood during a treatment phase were related to the degree of lifestyle change at 36 months follow-up. SUBJECTS: The study group comprised 109 of the original 183 consecutive coronary artery disease patients (91 male and 18 female) of whom 48 recently had experienced an acute myocardial infarction, 36 had been treated with coronary bypass surgery, 13 with percutaneous transluminal coronary angioplasty, and 12 had angina pectoris that had not been invasively treated. The subjects were divided into 3 subgroups based on their pre-treatment level of depressive mood. METHODS: Depressive mood was assessed at baseline, after 4 weeks and 12 months, using the depression subscale of the Hospital Anxiety and Depression scale. Lifestyle changes analysed included diet, smoking, relaxation (stress management) and exercise. RESULTS: Overall depressive mood ratings were significantly lower, both at the 4-week and 12-month assessments, compared with baseline, with the greatest improvements in patients with higher Hospital Anxiety and Depression measured depression. Original levels of depressive mood were not found to influence change of lifestyle habits during a 36-month follow-up period. CONCLUSION: Depressive mood might not be an obstacle to lifestyle changes when participating in a behaviourally oriented rehabilitation program including exercise-training, which might be a component important for improved depressive mood.

Metabolic syndrome and related dietary intervention among patients with coronary and peripheral arterial disease attending cardiovascular rehabilitation programs.

AIM OF THE STUDY: To provide estimates of the prevalence of metabolic syndrome (MS) among patients with coronary artery disease (CAD) or peripheral arterial obstructive disease (PAOD) attending cardiac rehabilitation (CR) programs, as well as related dietary needs targeted on the single core components of the syndrome. METHODS: Observational study enrolling 209 patients (males 75%, mean age 65 +/- 8 yrs.) referred to a CR facility because of silent ischemia (11%), chronic stable angina (28%), acute coronary syndrome (41%), or peripheral arterial disease (20%). The MS was diagnosed according to the 2005-modified NCEP ATP III criteria. Dietary regimens were classified into four areas of intervention (weight control, lipid control, glycaemic control, and blood pressure control) and compared in patients with and without MS. RESULTS: MS accounted for 26% of all patients, with the highest prevalence (31%) among those admitted after acute coronary syndromes. All four dietary regimens were significantly more prescribed (p < 0.001) among patients with MS as compared to controls, with low sodium (95%) and low fat (90%) diets as the most represented patterns. All patients with MS were prescribed multiple dietary patterns, with adoption of a comprehensive low energy, low fat, and low glucose diet in up to one fifth of cases. CONCLUSION: Patients with CAD or PAOD referred to CR programs often display an high cardiometabolic risk and need a broad regimen of dietary modification.

Clinical evidence for a health benefit from cardiac rehabilitation: an update.

The recent decision by the Centers for Medicare and Medicaid Services to expand the indications for cardiac rehabilitation (CR) provides an opportunity to review the clinical evidence of the efficacy of exercise in the CR setting for patients who have experienced an acute myocardial infarction, coronary artery bypass graft surgery, stable angina, percutaneous coronary intervention, chronic heart failure, cardiac transplant, or cardiac valve repair/replacement. Evidence shows that physician-directed, exercise-based CR positively affects the basic pathophysiology of coronary artery disease, the extent of disability and level of quality of life, and the ability to potentially impact events of both morbidity and mortality. The role of CR, including regular exercise, lifestyle modification, and appropriate medical therapy, is effective in younger and older men and women with cardiac diagnoses. The efficacy of this important therapeutic modality warrants its more widespread application.

Effect of enhanced external counterpulsation on resting oxygen uptake in patients having previous coronary revascularization and in healthy volunteers.

This study analyzed the acute effects of enhanced external counterpulsation (EECP) on oxygen uptake (VO2) at rest in adults with symptomatic coronary artery disease (CAD) compared with healthy volunteers. EECP therapy increases exercise tolerance in patients with refractory angina pectoris. This may be attributed, at least in part, to a training effect, but measurement of VO2 during an EECP treatment session has not been previously reported. We measured VO2 continuously in 20 adults during a single treatment session of EECP, including 10 subjects with previous coronary revascularization who were referred for EECP therapy for refractory angina, and 10 healthy, sedentary volunteers. VO2 was measured for 10 minutes before EECP, during a 30-minute EECP treatment session, and for 10 minutes after cessation of EECP treatment. Patients with CAD were older (65.9 +/- 12 vs 38.5 +/- 7 years, p = 0.002) and had a higher body mass index (32.0 +/- 10.0 vs 25.5 +/- 3.0 kg/m2, p = 0.027) and percent body fat (37 +/- 7% vs 21+/-9%, p = 0.006). VO2 at rest, although slightly lower in the CAD group, was not significantly different (2.75 +/- 0.54 vs 3.19 +/- 0.51 ml/kg/min, p = 0.09). The 2 groups demonstrated a small, sustained increase in VO2 during EECP treatment (CAD +0.66 +/- 0.56 ml/kg/min, p < 0.005; healthy +0.72 +/- 0.40 ml/kg/min, p < 0.001; CAD vs healthy, p = 0.13), which returned to baseline levels during recovery. In conclusion, VO2 at rest is increased to the same degree during an EECP treatment session in healthy subjects and symptomatic patients with CAD. This effect may contribute to the increased exercise tolerance of patients with refractory angina after receiving EECP therapy.

Modular prevention of heart disease following acute coronary syndrome (ACS) [ISRCTN42984084].

BACKGROUND: Coronary heart disease (CHD) is a major cause of morbidity and mortality in Australia and it is recommended that all persons with unstable angina (UA) or myocardial infarction (MI) participate in secondary prevention as offered in cardiac rehabilitation (CR) programs. However, the majority of patients do not access standard CR and have higher baseline coronary risk and poorer knowledge of CHD than those persons due to commence CR. The objective of this study is to investigate whether a modular guided self-choice approach to secondary prevention improves coronary risk profile and knowledge in patients who do not access standard CR. METHODS/DESIGN: This randomised controlled trial with one year follow-up will be conducted at a tertiary referral hospital. Participants eligible for but not accessing standard CR will be randomly allocated to either a modular or conventional care group. Modular care will involve participation in individualised modules that involve choice, goal-setting and coaching. Conventional care will involve ongoing heart disease management as directed by the participant's doctors. Both modular and conventional groups will be compared with a contemporary reference group of patients attending CR. Outcomes include measured modifiable risk factors, relative heart disease risk and knowledge of risk factors. DISCUSSION: We present the rationale and design of a randomised controlled trial testing a modular approach for the secondary prevention of coronary heart disease following acute coronary syndrome.

"The Heart Game": Using Gamification as Part of a Telerehabilitation Program for Heart Patients.

OBJECTIVE: The aim of this article is to describe the development and testing of a prototype application ("The Heart Game") using gamification principles to assist heart patients in their telerehabilitation process in the Teledialog project. MATERIALS AND METHODS: A prototype game was developed via user-driven innovation and tested on 10 patients 48-89 years of age and their relatives for a period of 2 weeks. The application consisted of a series of daily challenges given to the patients and relatives and was based on several gamification principles. A triangulation of data collection techniques (interviews, participant observations, focus group interviews, and workshop) was used. Interviews with three healthcare professionals and 10 patients were carried out over a period of 2 weeks in order to evaluate the use of the prototype. RESULTS: The heart patients reported the application to be a useful tool as a part of their telerehabilitation process in everyday life. Gamification and gameful design principles such as leaderboards, relationships, and achievements engaged the patients and relatives. The inclusion of a close relative in the game motivated the patients to perform rehabilitation activities. CONCLUSIONS: "The Heart Game" concept presents a new way to motivate heart patients by using technology as a social and active approach to telerehabilitation. The findings show the potential of using gamification for heart patients as part of a telerehabilitation program. The evaluation indicated that the inclusion of the patient's spouse in the rehabilitation activities could be an effective strategy. A major challenge in using gamification for heart patients is avoiding a sense of defeat while still adjusting the level of difficulty to the individual patient.

When the Topic Turns to Sex: CASE SCENARIOS IN SEXUAL COUNSELING AND CARDIOVASCULAR DISEASE.

Patients with cardiovascular disease and their partners frequently have concerns about sexual intimacy, and sexual counseling is needed across health care settings to ensure that patients receive information to safely resume sexual activity. The purpose of this review is to provide practical, evidence-based approaches to enable health care providers to discuss sexual counseling, illustrated by several case scenarios. Evidence shows that patients expect health care providers to initiate sexual activity discussions, although providers may be hesitant and often rely on patients to ask questions. Although some providers cite lack of knowledge or confidence in their ability to provide sexual counseling, others mention time pressures in the clinical setting. Although such barriers exist, sexual counseling can be individualized to the cardiac condition of a patient with a few select questions. The representative examples of patients with angina pectoris, myocardial infarction, coronary artery bypass surgery, heart failure, and implantable cardioverter defibrillator are used to illustrate key points and provide a model for sexual counseling in practice.