Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients

Background: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a lowresource setting. Methods: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Results: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). Conclusions: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed. Keywords: Health care services, Cardiac rehabilitation, Cardiac care facilities, Attitude of health personnelYork University Librarie

Identification of anaerobic threshold using heart rate response during dynamic exercise

The objective of the present study was to characterize the heart rate (HR) patterns of healthy males using the autoregressive integrated moving average (ARIMA) model over a power range assumed to correspond to the anaerobic threshold (AT) during discontinuous dynamic exercise tests (DDET). Nine young (22.3 ± 1.57 years) and 9 middle-aged (MA) volunteers (43.2 ± 3.53 years) performed three DDET on a cycle ergometer. Protocol I: DDET in steps with progressive power increases of 10 W; protocol II: DDET using the same power values as protocol 1, but applied randomly; protocol III: continuous dynamic exercise protocol with ventilatory and metabolic measurements (10 W/min ramp power), for the measurement of ventilatory AT. HR was recorded and stored beat-to-beat during DDET, and analyzed using the ARIMA (protocols I and II). The DDET experiments showed that the median physical exercise workloads at which AT occurred were similar for protocols I and II, i.e., AT occurred between 75 W (116 bpm) and 85 W (116 bpm) for the young group and between 60 W (96 bpm) and 75 W (107 bpm) for group MA in protocols I and II, respectively; in two MA volunteers the ventilatory AT occurred at 90 W (108 bpm) and 95 W (111 bpm). This corresponded to the same power values of the positive trend in HR responses. The change in HR response using ARIMA models at submaximal dynamic exercise powers proved to be a promising approach for detecting AT in normal volunteers

AUTONOMIC MODULATION AND FUNCTIONAL CAPACITY IN DIABETES MELLITUS TYPE 1 AND 2 SUBJECTS

Objetivos: avaliar a variabilidade da frequência cardíaca (VFC) durante testes autonômicos cardiovasculares e a capacidade funcional de indivíduos com DM tipos 1 e 2. Método: foram avaliados 15 indivíduos com DM e 12 indivíduos saudáveis, durante a realização de testes autonômicos cardiovasculares de manobra de acentuação da arritmia sinusal respiratória (ASR), handgrip e valsalva. Além disso, foi aplicado o teste submáximo de Paschoal para avaliação da capacidade funcional. Durante a realização dos testes autonômicos foi coletada a variabilidade da frequência cardíaca (VFC), por meio do registro dos intervalos RR, considerando-se os índices no domínio do tempo (RMSSD e pNN50) e da freqüência, como baixa e alta freqüência (BF e AF) e a relação entre os mesmos (BF/AF). Além da análise da VFC, foi registrado a distância percorrida durante o Teste de Paschoal e a glicemia capilar Resultados: Os valores referentes à glicemia foram significativamente maiores (p &lt; 0,05) no grupo DM1 e DM2 comparados aos controles. Os valores de pNN50 para o DM1, em todos os testes realizados, foram menores em relação ao CDM1. Nenhuma diferença estatística foi encontrada quando comparados DM2 com o CDM2. A distância percorrida no teste de Paschoal foi similar entre os grupos de indivíduos com DM e seus respectivos controles. Conclusão: A variável pNN50 foi menor nos indivíduos com DM1, sugerindo redução da atividade parassimpática nesses indivíduos, porém sem alteração da capacidade funcional, avaliada pelo teste de Paschoal quando comparados ao grupo controle. Objectives: Evaluation of heart rate variability (HRV) during cardiovascular autonomic tests and functional capacity of patients with type 1 and type 2 DM.Methods: Fifteen individuals with DM and twelve healthy ones were evaluated  during cardiovascular autonomic tests of maneuver enhancement of respiratory sinus arrhythmia (RSA), handgrip and Valsalva. In addition, the Paschoal test was applied to evaluate submaximal functional capacity. During the tests, autonomic heart rate variability (HRV) was collected by recording the RR intervals, considering the rates in the time domain (RMSSD and pNN50) and frequency domain, as low and high frequency (LF and HF) and the relationship between them (LF / HF). Besides the analysis of HRV and capillary glucose, the distance traveled during Paschoal test was also recorded. Results: The values related to blood glucose levels were significantly higher (p &lt;0.05) in DM1 and DM2 groups compared to controls. PNN50 values for DM1 in all tests were lower compared to CDM1. No statistical difference was found when compared DM2 with CDM2. The distance of Paschoal test was similar between groups of individuals with diabetes and their respective controls. Conclusion:  The variable pNN50 was lower in individuals with DM1, suggesting reduced of the parasympathetic activity in these individuals, but no change in functional capacity, as measured by Paschoal test when compared to the control group

Prevalence of self-reported frailty in awake and alert critically ill patients

Critically ill subjects admitted to intensive care units (ICU) might experience physical and cognitive reserves losses that increase their vulnerability to adverse events –characterizing frailty syndrome. This study aimed to delineate the prevalence of self-reported frailty in awake and alert critically ill patients admitted to the ICU of a teaching hospital. We included adult subjects (≥18 years old), admitted for at least 48 hours in the ICU of a teaching hospital in the city of Uberaba, state of Minas Gerais (MG), Brazil, who were alertat the time of the assessment. Subjects were encouraged to report their level of frailty using the Clinical Frailty Scale (CFS). Subjects with a CFS of 1 to 3 were considered non-fragile, 4 vulnerable, and greater than 5 frail. 50 subjects aged 44 to 78 years, mostly males, were evaluated. The prevalence offrail subjects was null, one subject was considered vulnerable and the others were considered non-frail, in which category 3 prevailed in 64% of the population. When analyzing thedemographic and clinical data in the different CFS scores, no statistically significant difference was observed between gender and age in the analyzed categories. The functionalcomorbidity index was increasing in the analyzed categories, (p=0.05). The prevalence of self-reported frailty was null in critically ill patients admitted to this teaching hospital in Uberaba-MG. Self-reported frailty assessment scales may be inaccurate to identify frail subjects.Los individuos críticamente enfermos que ingresan en unidades de cuidados intensivos (UCI) pueden presentar pérdidas de reservas físicas y  cognitivas, que aumentan su vulnerabilidad ante eventos adversos y caracterizan el síndrome de fragilidad. El objetivo de este estudio fue delimitar la prevalencia de fragilidad  autodeclarada en pacientes  críticamente enfermos despiertos y alertas hospitalizados en UCI de un hospital escuela. Participaron individuos adultos (≥18 años), hospitalizados por al menos 48 horas en las UCI de un hospital escuela de Uberaba (Minas Gerais, Brasil), que estaban alertas en el momento de laevaluación. Se estimuló al individuo a informar su nivel de fragilidad utilizando la Escala de Fragilidad Clínica (EFC). Los niveles de 1 a 3 de EFC evaluaban a los individuos como no frágiles; 4 como vulnerables; y superior a 5 como frágiles. Participaron 50 individuos de los 44 años a los 78 años, predominantemente hombres. La prevalencia de individuos frágiles fue nula, 1 individuo se evaluó como vulnerable, y los demás como no  frágiles, con un predominio de la categoría 3 en el 64% de la población. Al evaluar los datos demográficos y clínicos en las diferentes puntuaciones de EFC no se encontró diferencias estadísticamente significativas entre sexo y edad entre las categorías  analizadas. El índice de comorbilidad funcional tuvo un aumento en las categorías analizadas (p=0,05). La prevalencia de fragilidad autodeclarada fue nula en pacientes críticamente enfermos ingresados en un hospital escuela en Uberaba (Minas Gerais). Las escalas autodeclaradas para evaluar la fragilidad no parecen ser útiles para  identificar con exactitud a los individuos frágiles.Indivíduos criticamente enfermos internados em unidades de terapia intensiva (UTI) podem apresentarperdas de reservas físicas e cognitivas que aumentam a vulnerabilidade frente a eventos adversos, caracterizandoa síndrome da fragilidade. O objetivo do estudo foi delinear a prevalência de fragilidade autorreferida em pacientescriticamente enfermos acordados e alertas internados na UTI de um hospital escola. Foram incluídos indivíduos adultos (≥18 anos), internados por, pelo menos 48 horas nas UTI de um hospital escola de Uberaba-MG, que encontravamse alertas no momento da avaliação. O indivíduo foi estimulado a referir seu nível de fragilidade utilizando a Escala de Fragilidade Clínica (EFC). Indivíduos com EFC de 1 a 3 foram considerados não frágeis, 4 vulneráveis e maior que 5, frágeis. Foram incluídos 50  indivíduos com idade entre 44 e 78 anos com predominância do sexo masculino. A prevalência de indivíduos frágeis foi nula, 1 indivíduo foi considerado vulnerável e os demais foram considerados não frágeis com predominância da categoria 3, com 64% da população. Ao analisar os dados demográficos e clínicos nas diferentes pontuações da EFC não foi observado diferença estatisticamente significante entre sexo e idade entre as categorias analisadas. O índice de comorbidade funcional foi crescente nas categorias analisadas, (p=0,05).A prevalência de fragilidade  autorreferida foi nula em pacientes criticamente enfermos internados em um hospital escola de Uberaba-MG. Escalas autorreferidas para avaliação de fragilidade podem ser incapazes de identificar acuradamente indivíduos frágeis