Showing papers in "Journal of Cardiopulmonary Rehabilitation and Prevention in 2020"

Muscular Strength and Cardiovascular Disease: AN UPDATED STATE-OF-THE-ART NARRATIVE REVIEW

Abstract: This review discusses the associations of muscular strength (MusS) with cardiovascular disease (CVD), CVD-related death, and all-cause mortality, as well as CVD risk factors, such as metabolic syndrome, diabetes, obesity, and hypertension. We then briefly review the role of resistance exercise training in modulating CVD risk factors and incident CVD.The role of MusS has been investigated over the years, as it relates to the risk to develop CVD and CVD risk factors. Reduced MusS, also known as dynapenia, has been associated with increased risk for CVD, CVD-related mortality, and all-cause mortality. Moreover, reduced MusS is associated with increased cardiometabolic risk. The majority of the studies investigating the role of MusS with cardiometabolic risk, however, are observational studies, not allowing to ultimately determine association versus causation. Importantly, MusS is also essential for the identification of nutritional status and body composition abnormalities, such as frailty and sarcopenia, which are major risk factors for CVD.

The Million Hearts Initiative: CATALYZING UTILIZATION OF CARDIAC REHABILITATION AND ACCELERATING IMPLEMENTATION OF NEW CARE MODELS.

Abstract: Million Hearts and partners have been committed to raising national cardiac rehabilitation participation rates to a goal of 70%. Quality improvement tools, resources, and surveillance models have been developed in support. Efforts to enhance research programs and collaborative initiatives have created momentum to accelerate implementation of new care models.

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

Abstract: 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.

Importance of Lifestyle Modification on Cardiovascular Risk Reduction: COUNSELING STRATEGIES TO MAXIMIZE PATIENT OUTCOMES.

Abstract: This commentary builds on the unhealthy lifestyle habits, population health, risk factors as harbingers of cardiovascular disease, current provider counseling practices, assessing patient readiness to change, and research-based interventions to facilitate behavior change (eg, the 5A's, motivational interviewing, and overcoming inertia with downscaled goals).

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 Years and Its Role in Promoting Lifestyle Medicine for Prevention of Cardiovascular Diseases: PART 1.

Abstract: Risk to individuals for cardiovascular events are invariably tied to their exposure to major coronary risk factors. This risk can be substantially mitigated by lifestyle behaviors. This first part of this Commentary focuses on the important role both adopting healthful dietary patterns and regularly obtaining adequate physical activity have as preventative therapies for cardiovascular diseases.

Response to Exercise Training During Cardiac Rehabilitation Differs by Sex.

Abstract: PURPOSE Directly measured peak aerobic capacity or oxygen uptake is a powerful predictor of prognosis in individuals with cardiovascular disease. Women enter phase 2 cardiac rehabilitation (CR) with lower and their response to training, compared with men, is equivocal. We analyzed at entry and exit in patients participating in CR and improvements by diagnosis to assess training response. We also identified sex differences that may influence change in . METHODS The cohort included consecutive patients enrolled in CR between January 1996 and December 2015 who performed entry exercise tolerance tests. Data collected included demographics, index diagnosis, , and exercise training response. RESULTS The cohort consisted of 3925 patients (24% female). There was a significant interaction between baseline and diagnosis (P < .001), with percutaneous coronary intervention and myocardial infarction greater than other diagnoses. Surgical patients demonstrated greater improvement in than nonsurgical diagnoses (n = 1789; P < .001). Women had lower than men for all diagnoses (P < .02) and demonstrated less improvement (13 vs 17%, P < .001). Percent improvement using estimated metabolic equivalents of task (METs) were similar for women and men (33 vs 31%, P = NS). Despite overall increases in , 18% of patients (24% women, 16% men) failed to demonstrate any improvement (exit ≤ entry ). CONCLUSIONS While there were no differences in training effect estimated by METs, directly measured showed a significantly lower training response for women despite adjusting for covariates. In addition, 18% of patients did not see any improvement in . Alternatives to traditional CR exercise programming need to be considered.

Cardiac Rehabilitation Is Associated With Improved Physical Function in Frail Older Adults With Cardiovascular Disease.

Abstract: PURPOSE Frailty is highly prevalent among older adults with cardiovascular disease (CVD) and is associated with greater than 2-fold risk for morbidity and mortality, independent of age and comorbidities Many candidates are not referred to cardiac rehabilitation (CR) under the assumption that they are too frail to benefit We hypothesized that CR is associated with similar benefits for frail adults as for intermediate-frail and nonfrail adults METHODS Retrospective analysis of CVD patients who completed a phase II CR program Patients classified as frail by meeting ≥2 frailty criteria and intermediate-frail by meeting 1 criterion, including 6-min walk distance (6MWD) <300 m, gait speed ≤065 m/sec or 076 m/sec normalized to height and sex, tandem stand <10 sec, Timed Up & Go (TUG) <15 sec, and weak hand grip strength per Fried criteria Changes within and between groups were compared before and after completion of CR RESULTS We evaluated 243 patients; 75 were classified as frail, 70 as intermediate-frail, and 98 as nonfrail Each group improved in all measures of frailty except for tandem stand There were no significant differences in pre- to post-CR measures for 6MWD, gait speed, tandem stand, or hand grip strength between groups Frail patients showed greater improvement in TUG than the other groups (P = 007) CONCLUSION Among frail patients, CR was associated with improvements in multiple domains of physical function Gains achieved by frail adults were similar to or greater than those achieved by intermediate-frail and nonfrail patients These data provide strong rationale for referring all eligible patients to CR, including frail patients Those who are most physically impaired may derive gains that have proportionally greater ramifications

Pathophysiology of Exercise Intolerance and Its Treatment With Exercise-Based Cardiac Rehabilitation in Heart Failure With Preserved Ejection Fraction

Abstract: Heart failure with preserved ejection fraction (HFpEF) is the fastest growing form of heart failure in the United States. The cardinal feature of HFpEF is reduced exercise tolerance (peak oxygen uptake, (Equation is included in full-text article.)O2peak) secondary to impaired cardiac, vascular, and skeletal muscle function. There are currently no evidence-based drug therapies to improve clinical outcomes in patients with HFpEF. In contrast, exercise training is a proven effective intervention for improving (Equation is included in full-text article.)O2peak, aerobic endurance, and quality of life in HFpEF patients. This brief review discusses the pathophysiology of exercise intolerance and the role of exercise training to improve (Equation is included in full-text article.)O2peak in clinically stable HFpEF patients. It also discusses the mechanisms responsible for the exercise training-mediated improvements in (Equation is included in full-text article.)O2peak in HFpEF. Finally, it provides evidence-based exercise prescription guidelines for cardiac rehabilitation specialists to assist them with safely implementing exercise-based cardiac rehabilitation programs for HFpEF patients.

The Urgent Need to Sit Less and Move More During the COVID-19 Pandemic.

Abstract: The coronavirus disease-2019 (COVID-19) pandemic containment and mitigation strategies may lead to excessive physical inactivity and sedentary behavior, drastically impacting cardiorespiratory fitness and overall health. It is urgent to safely find ways to sit less and move more.

Feasibility and Efficacy of the Pulmonary Rehabilitation Program in a Rehabilitation Center: CASE REPORT OF A YOUNG PATIENT DEVELOPING SEVERE COVID-19 ACUTE RESPIRATORY DISTRESS SYNDROME.

Abstract: DETAILS OF THE CLINICAL CASE: A 51-yr-old man underwent a respiratory rehabilitation program (RRP), after being tracheostomized and ventilated due to acute respiratory distress syndrome (ARDS) from coronavirus disease-2019 (COVID-19) infection Respiratory care, early mobilization, and neuromuscular electrical stimulation were started in the ad hoc isolation ward of our rehabilitation center At baseline, muscle function was consistent with intensive care unit-acquired weakness and the patient still needed mechanical ventilation (MV) and oxygen support During the first week of RRP in isolation, the patient was successfully weaned from MV, the tracheal cannula was removed, and the walking capacity was recovered At the end of the RRP, continued in a standard department, respiratory muscles strength increased by 7% and muscle function improved as indicated by the quadriceps size enlargement of 13% and the change of the Medical Research Council sum score from 48/60 to 58/60 DISCUSSION: Providing RRP in patients with severe COVID-19 ARDS involves risks for operators and organizational difficulties, especially in rehabilitation centers; nevertheless, its continuity is important to prevent the development of permanent disabilities in previously healthy subjects Limited to the experience of only one patient, we were able to carry out a safe RRP during the COVID-19 pandemic, promoting the complete functional recovery of a COVID-19 young patient SUMMARY: Most patients who develop serious consequences of COVID-19 infection risk a reduction in their quality of life However, by organizing and directing specialized resources, subacute rehabilitation facilities could ensure the continuity of the RRPs even during the COVID-19 pandemic

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

Abstract: 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.

Cardiopulmonary exercise testing following open repair for a proximal thoracic aortic aneurysm or dissection

Abstract: Purpose: There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, Vo), and blood pressure. Methods: Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection. Results: Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured Vo was <36% predicted normative values (19.2 mL·kgmin vs 29.3 mL·kg·min, P <.0001); the most marked impairment in Vo was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P <.05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups. Conclusions: We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. Vo was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.

Exercise Training Effects on the Relationship of Physical Function and Health-Related Quality of Life Among Older Heart Failure Patients With Preserved Ejection Fraction.

Abstract: Purpose Although exercise training (ET) has been shown to improve both physical function and health-related quality of life (HRQOL) in older patients with heart failure and preserved ejection fraction (HFpEF), the relationship between changes in these important patient-centered outcome measures has not been adequately investigated. Methods Patients (n = 116) with HFpEF (from 2 previous randomized controlled trials) were assigned to either 16 wk of endurance ET or attention control (CON). The ET in both trials consisted of ≤ 60 min of moderate-intensity endurance ET 3 time/wk. Peak exercise oxygen uptake (V˙o2peak) and other exercise capacity measures were obtained from a cardiopulmonary exercise test on an electronically braked cycle ergometer and 6-min walk test (6MWT). HRQOL was assessed using the Minnesota Living with Heart Failure (MLHF) Questionnaire and the 36-item Short Form Health Survey (SF-36). Results Compared with CON, the ET group demonstrated significant improvement in measures of physical function (V˙o2peak and 6MWT) at 16 wk of follow-up. There were no significant differences observed between the groups for MLHF scores, but the ET group showed significant improvements on the SF-36. There were no significant correlations between change in any of the physical function and HRQOL measures in the ET group. Conclusions While endurance ET improved both physical function and some domains of HRQOL, the lack of significant correlations between changes in these measures suggests the effects of ET on physical function and HRQOL are largely independent of one another. Since these measures assess important and unique patient-centered outcomes in HFpEF patients, both physical function and HRQOL should be assessed in exercise-based programs and clinical trials.

Telemedicine Home-Based Cardiac Rehabilitation: A CASE SERIES.

Abstract: Details of the clinical case In this case series report, we review 2 patients who were among the first to participate in the Henry Ford telemedicine home-based cardiac rehabilitation (TM-HBCR) program. These patients had barriers to full participation in a facility-based cardiac rehabilitation (CR) program due to return to work and access to transportation. However, they were willing and able to participate in the TM-HBCR program. Discussion The two cases discussed herein are examples of individuals who likely would not have fully participated in CR if the only option available was a facility-based program. While HBCR is not an option for all patients, it does address several barriers that are known to limit participation in facility-based CR for some individuals. Summary Technology has made it possible to provide the key components of a facility-based CR program through a TM-HBCR model using a secure connection to the patients via their personal mobile device.

Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings: OPPORTUNITIES TO REDUCE HEALTH CARE DISPARITIES.

Abstract: Although both cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are recommended by clinical practice guidelines and covered by most insurers, they remain severely underutilized. To address this problem, the National Heart, Lung, and Blood Institute (NHLBI), in collaboration with the National Institute on Aging (NIA), developed Funding Opportunity Announcements (FOAs) in late 2017 to support phase II clinical trials to increase the uptake of CR and PR in traditional and community settings. The objectives of these FOAs were to (1) test strategies that will lead to increased use of CR and PR in the US population who are eligible based on clinical guidelines; (2) test strategies to reduce disparities in the use of CR and PR based on age, gender, race/ethnicity, and socioeconomic status; and (3) test whether increased use of CR and PR, whether by traditional center-based or new models, is accompanied by improvements in relevant clinical and patient-centered outcomes, including exercise capacity, cardiovascular and pulmonary risk factors, and quality of life. Five NHLBI grants and a single NIA grant were funded in the summer of 2018 for this CR/PR collaborative initiative. A brief description of the research to be developed in each grant is provided.

Low-Volume High-Intensity Aerobic Interval Training Is an Efficient Method to Improve Cardiorespiratory Fitness After Myocardial Infarction: PILOT STUDY FROM THE INTERFARCT PROJECT.

Abstract: PURPOSE To analyze the changes in cardiorespiratory fitness (CRF) and body composition following 2 different (low-volume vs high-volume) high-intensity aerobic interval training (HIIT) programs with Mediterranean diet (Mediet) recommendations in individuals after myocardial infarction (MI) and compared with an attention control group (AC). METHODS Body composition and CRF were assessed before and after a 16-wk intervention in 70 participants (58.4 ± 8.5 yr) diagnosed with MI. All participants received Mediet recommendations and were randomly assigned to the AC group (physical activity recommendations, n = 14) or one of the 2 supervised aerobic exercise groups (2 d/wk training): high-volume (40 min) HIIT (n = 28) and low-volume (20 min) HIIT (n = 28). RESULTS Following the intervention, no significant changes were seen in the AC group and no differences between HIIT groups were found in any of the studied variables. Only HIIT groups showed reductions in waist circumference (low-volume HIIT, Δ = -4%, P < .05; high-volume HIIT, Δ = -2%, P < .001) and improvements in CRF (low-volume HIIT, Δ = 15%, P < .01; high-volume HIIT, Δ = 22%; P < .001) with significant between-group differences (attention control vs HIIT groups). CONCLUSIONS Results suggest that a 16-wk intervention (2 d/wk) of different HIIT volumes with Mediet recommendations could equally improve CRF and waist circumference after MI. Low-volume HIIT may be a potent and time-efficient exercise training strategy to improve functional capacity.

Aortic Aneurysm: DIAGNOSIS, MANAGEMENT, EXERCISE TESTING, AND TRAINING.

Abstract: BACKGROUND Some patients who participate in cardiac rehabilitation have aortic abnormalities, including abdominal and thoracic aneurysm (AAA and TAA, respectively) There is scant guidance on implementing exercise training in these individuals This article reviews the epidemiology, diagnostic process, medical issues, and the available exercise training literature, and provides recommendations for performing regular exercise CLINICAL CONSIDERATIONS Patients with aortic abnormalities are at risk for enlargement, aneurysm development, dissection, and rupture During exercise, individuals with large aneurysms may be at greater risk of an adverse event The available literature suggests little increased risk of complications when training at low and moderate intensities in those with an AAA, and exercise may be protective for aneurysm expansion There is little exercise data for TAA, but the available literature suggests training at lower intensities and avoidance of excessive increases of blood pressure EXERCISE TESTING AND TRAINING When exercise testing and training are performed, the intensity should be controlled to avoid complications It is prudent to keep systolic blood pressure <180 mm Hg in most patients and <160 mm Hg in those at greater risk of dissection or rupture (eg, women and larger sized aneurysm) during aerobic training During resistance training, patients should avoid sudden excessive blood pressure increases (ie, avoid the Valsalva maneuver), and keep intensity below 40-50% of the 1-repetition maximum Existing data suggest these patients may improve functional capacity and reduce the rate of aneurysm expansion SUMMARY Most patients with AAA can safely perform exercise training when conservative guidelines are followed Additional research is needed to fully determine whether exercise is protective against aneurysm expansion, and the effects of exercise in those who have had surgical repair More research is necessary to provide specific recommendations for those with a TAA

Comprehensive Cardiac Rehabilitation Effectiveness in a Middle-Income Setting: A RANDOMIZED CONTROLLED TRIAL.

Abstract: PURPOSE The impact of comprehensive cardiac rehabilitation (CCR) in Latin America is not well known. Herein, the pre-specified tertiary outcomes of a cardiac rehabilitation (CR) trial are reported: disease-related knowledge, depressive symptoms, and heart-health behaviors (exercise, diet, and smoking). METHODS This was a single-blinded, single-center (Brazil) randomized trial with three parallel arms: CCR (exercise + education) versus exercise-only CR versus wait-list control. Eligible patients were randomized in blocks of four with 1:1:1 concealed allocation. The CR program was 6 mo long. Participants randomized to exercise-only CR received 36 exercise classes; the CCR group also received 24 educational sessions, including a workbook. All outcomes were assessed at pre-test and 6-mo later (blinded). Analysis of covariance was performed by intention-to-treat (ITT) and per-protocol (PP). RESULTS A total of 115 (89%) patients were randomized; 93 (81%) were retained. There were significant improvements in knowledge with CCR (ITT [51.2 ± 11.9 pre and 60.8 ± 13.2 post] and PP; P < .01), with significantly greater knowledge with CCR versus control (ITT mean difference [MD] = 9.5, 95% CI, 2.3-16.8) and CCR vs exercise-only CR at post-test (ITT MD = 6.8, 95% CI, 0.3-14.0). There were also significant improvements in self-reported exercise with CCR (ITT [13.7 ± 15.8 pre and 32.1 ± 2 5.7 post] and PP; P < .001), with significantly greater exercise with CCR versus control at post-test (ITT MD = 7.6, 95% CI, 3.8-11.4). Also, there were significant improvements in diet with CCR (PP: 3.4 ± 7.5 pre and 8.0 ± 7.0 post; P < .05). CONCLUSIONS In this first-ever randomized trial of CR for coronary artery disease in Latin America, the benefits of CCR have been supported.

Patient Perspectives on Declining to Participate in Home-Based Cardiac Rehabilitation: A MIXED-METHODS STUDY.

Abstract: Purpose A minority of eligible patients participate in cardiac rehabilitation (CR) programs. Availability of home-based CR programs improves participation in CR, yet many continue to decline to enroll. We sought to explore among patients the rationale for declining to participate in CR even when a home-based CR program is available. Methods We conducted a mixed-methods evaluation of reasons for declining to participate in CR. Between August 2015 and August 2017, a total of 630 patients were referred for CR evaluation during index hospitalization (San Francisco VA Medical Center). Three hundred three patients (48%) declined to participate in CR. Of these, 171 completed a 14-item survey and 10 patients also provided qualitative data through semistructured phone interviews. Results The most common reason, identified by 61% of patients on the survey, was "I already know what to do for my heart." Interviews helped clarify reasons for nonparticipation and identified system barriers and personal barriers. These interviews further highlighted that declining to participate in CR was often due to competing life priorities, no memory of the initial CR consultation, and inadequate understanding of CR despite referral. Conclusion We identified that most patients declining to participate in a home-based CR program did not understand the benefits and rationale for CR. This could be related to the timing of the consultation or presentation method. Many patients also indicated that competing life priorities prevented their participation. Modifications in the consultation process and efforts to accommodate personal barriers may improve participation.

The Journal of Cardiopulmonary Rehabilitation and Prevention at 40 yr and Its Role in Promoting Preventive Cardiology: Part 2.

Abstract: Aggressive risk factor modification, including smoking cessation, blood pressure management, and more intensive efforts to control hyperlipidemia, as well as stress management training, are associated with improved cardiovascular outcomes and impressive mortality reductions. This commentary addresses these topics, with specific reference to lifestyle modification and complementary cardioprotective medications.

Cardiac Rehabilitation for Adults and Adolescents With Congenital Heart Disease: EXTENDING BEYOND THE TYPICAL PATIENT POPULATION.

Abstract: Purpose:Cardiac rehabilitation (CR) effectively decreases morbidity and mortality in adults after cardiovascular events. Cardiac rehabilitation has been underutilized for patients with congenital heart disease (CHD). The primary objective was to evaluate the inclusion of adolescents and adults with

Promoting Patient Utilization of Outpatient Cardiac Rehabilitation: A JOINT INTERNATIONAL COUNCIL AND CANADIAN ASSOCIATION OF CARDIOVASCULAR PREVENTION AND REHABILITATION POSITION STATEMENT.

Abstract: Purpose 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 enrollment 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 patients' 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 Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review and public comment. Results The 3 drafted recommendations were that to increase enrollment, health care 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 (mean ± SD) for the 3 recommendations were 5.95 ± 0.69, 5.33 ± 1.12, and 5.64 ± 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 that CR programs are adequately resourced to serve enrolling patients and support them to complete programs.

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

Abstract: 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.

The Effects of Maintenance Cardiac Rehabilitation: A SYSTEMATIC REVIEW.

Abstract: PURPOSE Maintenance cardiac rehabilitation (M-CR) programs aim to preserve the health benefits achieved during phase II cardiac rehabilitation (CR) The aim of this study was to establish the effects of M-CR on functional capacity, quality of life, risk factors, costs, mortality, and morbidity, among other outcomes METHODS Scopus, ISI Web of Science, PubMed, Embase & Embase classic OVID, and Lilacs were searched Randomized controlled trials, published between 2000 and 2016, on the effects of M-CR in patients with cardiovascular disease, who had graduated from CR, having a control or comparison arm were included Citations were processed by two authors, independently Methodological quality was assessed using PEDro, and level of evidence graded with the Scottish scale Outcomes were qualitatively synthesized RESULTS The searches retrieved 1901 studies with 26 articles meeting inclusion criteria (3752 participants) Some trials tested M-CR in nonclinical settings, and others used resistance or high-intensity interval training The methodological quality of 11 articles was good, with a level of evidence (1+) and a grade B recommendation Results showed M-CR resulted in increased or maintained functional capacity, quality of life, and physical activity levels, when compared with the control No adverse events were reported Few studies assessed rehospitalizations and mortality CONCLUSION Quality of included trials was low because it is not possible to double-blind in M-CR trials and also due to the heterogeneity of M-CR interventions Understanding, availability, and use of M-CR programs should be increased

Effects of Exercise-Based Interventions on Fall Risk and Balance in Patients With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW.

Abstract: Purpose Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease characterized by airflow limitation and is associated with decreased balance and increased fall risk. Since falls are related to increased mortality, interventions targeting balance and fall risk could reduce morbidity and mortality. The objective of this review was to systematically assess the effects of exercise-based interventions on fall risk and balance in patients with COPD. Methods PubMed, Web of Science, EMBASE, and CINAHL were screened for randomized controlled trails and within-group studies evaluating effects of exercise-based interventions on fall risk or balance in patients with COPD. Data were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results Fifteen studies were identified, 6 randomized controlled trails and 9 within-group studies. All interventions reported positive effects on balance outcomes. No studies reported fall risk. Taking current recommendations of balance outcome measures in patients with COPD into account, pulmonary rehabilitation combined with balance training had the highest effect size. Nine papers had concerns regarding bias, mostly due to the lack of blinding outcome assessors. Conclusions Exercise-based interventions have a positive effect on balance in patients with COPD. Pulmonary rehabilitation with balance training seems to have the most beneficial effect on balance. The effects on fall risk, as well as the long-term intervention effects remain unclear. A standardized balance assessment and research on long-term effects and fall risk are recommended.

Effects of Behavioral Weight Loss and Weight Loss Goal Setting in Cardiac Rehabilitation.

Abstract: PURPOSE Obesity is prevalent among participants in cardiac rehabilitation (CR). Establishing a weight loss goal is an important strategy for promoting weight loss. We evaluate the association between a pre-program weight loss goal and change in weight during CR. METHODS Body weight was measured at CR entry and at exit from CR. Overweight/obese participants were categorized as having: (1) established a weight loss goal and attended behavioral weight loss sessions (G + BWL); (2) set a weight loss goal but did not attend BWL (G); (3) and neither set a weight loss goal nor attended BWL (NoG). RESULTS The cohort consisted of 317 overweight/obese participants; 52 of whom set a weight loss goal and attended BWL, 227 patients set a goal but did not attend BWL, and 38 did neither. The G + BWL group lost more weight than the G group (-6.8 + 4.3 vs -1.1 + 3.5) (P < .0001). Both groups that established a weight loss goal lost more weight than the NoG group. CONCLUSIONS For overweight/obese individuals in CR, participating in BWL classes and setting a weight loss goal leads to more weight loss than G alone. Setting a weight loss goal alone leads to greater weight loss than not setting a weight loss goal.

Effect of Home-Based Cardiac Rehabilitation in a Lower-Middle Income Country: RESULTS FROM A CONTROLLED TRIAL.

Abstract: Purpose Cardiovascular disease is the leading cause of mortality and morbidity in lower-middle income countries (LMICs), including Bangladesh. Cardiac rehabilitation (CR) as part of secondary prevention of cardiovascular disease has been shown to reduce mortality and morbidity and improve quality of life and exercise capacity. However, to date, very few controlled trials of CR have been conducted in LMICs. Methods A quasi-randomized controlled trial comparing home-based CR plus usual care with usual care alone was undertaken with patients following coronary artery bypass graft surgery. Participants in the CR group received an in-hospital CR class and were introduced to a locally developed educational booklet with details of a home-based exercise program and then received monthly telephone calls for 12 mo. Primary outcomes were coronary heart disease (CHD) risk factors, health-related quality of life (HRQOL), and mental well-being. Maximal oxygen uptake as a measure of exercise capacity was a secondary outcome. Results In total, 142 of 148 eligible participants took part in the trial (96%); 71 in each group. At 12-mo follow-up, 61 patients (86%) in the CR group and 40 (56%) in the usual care group provided complete outcome data. Greater reductions in CHD risk factors and improvements in HRQOL, mental well-being, and exercise capacity were seen for the CR group compared with the usual care group. Conclusions In the context of a single-center LMIC setting, this study demonstrated the feasibility of home-based CR programs and offers a model of service delivery that could be replicated on a larger scale.

Including Patients With Stroke in Cardiac Rehabilitation: BARRIERS AND FACILITATORS.

Abstract: More than 13 million cases of stroke are occurring annually worldwide. Approximately a quarter of these strokes are recurrent strokes, and there is compelling evidence of the benefit of supervised exercise and risk factor modification programming in the secondary prevention of these strokes. However, there is insufficient time in inpatient and outpatient stroke rehabilitation for focused exercise interventions. General lifestyle interventions on their own, without guidance and supervision, are insufficient for improving physical activity levels. Cardiac rehabilitation (CR) is a setting where cardiac patients, and increasingly stroke patients, receive comprehensive secondary prevention programming, including structured exercise. Unfortunately, not all CR programs accept referrals for people following a stroke and for those that do, only a few patients participate. Therefore, the purpose of this review is to report the barriers and facilitators to improving linkage between health services, with a focus on increasing access to CR. In the next two decades, it is projected that there will be a marked increase in stroke prevalence globally. Therefore, there is an urgent need to create cross-program collaborations between hospitals, outpatient stroke rehabilitation, CR, and community programs. Improving access and removing disparities in access to evidence-based exercise treatments would positively affect the lives of millions of people recovering from stroke.

Pedometer Feedback Interventions Increase Daily Physical Activity in Phase III Cardiac Rehabilitation Participants.

Abstract: PURPOSE To determine the effects of individually tailored interventions designed to increase physical activity (PA) in cardiac patients. METHODS A total of 99 (77 men and 22 women, 61.5 ± 10.7 yr) patients entering a phase III cardiac rehabilitation program completed a 12-wk PA intervention. Patients were randomized to usual care (UC, time-based recommendation), pedometer feedback (PF), newsletter-based motivational messaging (MM), or PF + MM. Both PF groups were given a goal of increasing steps/d by 10% of individual baseline value each week. If the goal for the week was not reached, the same goal was used for the next week. Physical activity was assessed for 7 d before beginning and after completing the program. The change in steps/d, moderate to vigorous intensity PA minutes, and sedentary time were compared among intervention groups. RESULTS Average change in steps/d was found to be significantly greater (P < .01) in the PF (2957 ± 3185) and the PF + MM (3150 ± 3007) compared with UC (264 ± 2065) and MM (718 ± 2415) groups. No group experienced changes in moderate to vigorous intensity PA time and only the PF intervention group decreased sedentary time (baseline 470.2 ± 77.1 to postintervention 447.8 ± 74.9 min/d, P = .01). CONCLUSION The findings from this study demonstrate that using PF was superior to the usual time-based PA recommendations and to newsletter-based MM in patients starting a phase III CR program. Cardiac rehabilitation programs are encouraged to implement PA feedback with individualized PA goals in order to support the increase in PA.

Exercise-Based Cardiac Rehabilitation Improves Cognitive Function Among Patients With Cardiovascular Disease.

Abstract: Purpose To investigate the effects of cardiac rehabilitation (CR) exercise training on cognitive performance and whether the changes are associated with alterations in prefrontal cortex (PFC) oxygenation among patients with cardiovascular disease. Methods Twenty (men: n = 15; women: n = 5) participants from an outpatient CR program were enrolled in the study. Each participant completed a cognitive performance test battery and a submaximal graded treadmill evaluation on separate occasions prior to and again upon completion of 18 individualized CR sessions. A functional near-infrared spectroscopy (fNIRS) device was used to measure left and right prefrontal cortex (LPFC and RPFC) oxygenation parameters (oxyhemoglobin [O2Hb], deoxyhemoglobin [HHb], total hemoglobin [tHb], and oxyhemoglobin difference [Hbdiff]) during the cognitive test battery. Results Patients showed improvements in cardiorespiratory fitness (+1.4 metabolic equivalents [METs]) and various cognitive constructs. A significant increase in PFC oxygenation, primarily in the LPFC region, occurred at post-CR testing. Negative associations between changes in cognition (executive function [LPFC O2Hb: r = -0.45, P = .049; LPFC tHb: r = -0.49, P = .030] and fluid composite score [RPFC Hbdiff: r = -0.47, P = .038; LPFC Hbdiff: r = -0.45, P = .048]) and PFC changes were detected. The change in cardiorespiratory fitness was positively associated with the change in working memory score (r = 0.55, P = .016). Conclusion Cardiovascular disease patients enrolled in CR showed significant improvements in multiple cognitive domains along with increased cortical activation. The negative associations between cognitive functioning and PFC oxygenation suggest an improved neural efficiency.