Maintenance of Gains, Morbidity, and Mortality at 1 Year Following Cardiac Rehabilitation in a Middle‐Income Country: A Wait‐List Control Crossover Trial

Background-—Despite the epidemic of cardiovascular diseases in middle-income countries, few trials are testing the benefits of cardiac rehabilitation (CR). This trial assessed (1) maintenance of functional capacity, risk factor control, knowledge, and hearthealth behaviors and (2) mortality and morbidity at 6 months following CR in a middle-income country. Methods and Results-—Eligible Brazilian coronary patients were initially randomized (1:1:1 concealed) to 1 of 3 parallel arms (comprehensive CR [exercise plus education], exercise-only CR, or wait-list control). The CR programs were 6 months in duration, at which point follow-up assessments were performed. Mortality and morbidity were ascertained from chart and patient or family report (blinded). Controls were then offered CR (crossover). Outcomes were again assessed 6 months later (blinded). ANCOVA was performed for each outcome at 12 months. Overall, 115 (88.5%) patients were randomized, and 62 (53.9%) were retained at 1 year. At 6 months, 23 (58.9%) of those 39 initially randomized to the wait-list control elected to attend CR. Functional capacity, risk factors, knowledge, and heart-health behaviors were maintained from 6 to 12 months in participants from both CR arms (all P>0.05). At 1 year, knowledge was significantly greater with comprehensive CR at either time point (P<0.001). There were 2 deaths. Hospitalizations (P=0.03), nonfatal myocardial infarctions (P=0.04), and percutaneous coronary interventions (P=0.03) were significantly fewer with CR than control at 6 months. Conclusions-—CR participation is associated with lower morbidity, long-term maintenance of functional capacity, risk factors, and heart-health behaviors, as well as with greater cardiovascular knowledge compared with no CR. Clinical Trial Registration-—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02575976. (J Am Heart Assoc. 2019;8: e011228. DOI: 10.1161/JAHA.118.011228.) Key Words: cardiac rehabilitation • coronary disease • morbidity/mortality • rehabilitation • risk factorYork University Librarie

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

Cardiac Rehabilitation Models around the Globe.

Alternative models of cardiac rehabilitation (CR) delivery, such as home or community-based programs, have been developed to overcome underutilization. However, their availability and characteristics have never been assessed globally. In this cross-sectional study, a piloted survey was administered online to CR programs globally. CR was available in 111/203 (54.7%) countries globally; data were collected in 93 (83.8% country response rate). 1082 surveys (32.1% program response rate) were initiated. Globally, 85 (76.6%) countries with CR offered supervised programs, and 51 (45.9%; or 25.1% of all countries) offered some alternative model. Thirty-eight (34.2%) countries with CR offered home-based programs, with 106 (63.9%) programs offering some form of electronic CR (eCR). Twenty-five (22.5%) countries with CR offered community-based programs. Where available, programs served a mean of 21.4% ± 22.8% of their patients in home-based programs. The median dose for home-based CR was 3 sessions (Q25-Q75 = 1.0⁻4.0) and for community-based programs was 20 (Q25⁻Q75 = 9.6⁻36.0). Seventy-eight (47.0%) respondents did not perceive they had sufficient capacity to meet demand in their home-based program, for reasons including funding and insufficient staff. Where alternative CR models are offered, capacity is insufficient half the time. Home-based CR dose is insufficient to achieve health benefits. Allocation to program model should be evidence-based

Information about secondary prevention in coronary patients: a comparison between Italian and Brazilian Application of MICRO-Q Questionnaire

Background: The MICRO-Q (MaugerI CaRdiac preventiOn Questionnaire) is a self-administered questionnaire addressed to the evaluation of information regarding secondary prevention in patients with coronary heart disease (CHD). The aim of this study was to compare the results from Italian and Brazilian application of MICRO-Q. Methods: the instrument was administered to 500 coronary patients (250 Italian and 250 Brazilian), 117 female and 383 male, aged on average 61.16 years (SD=9.74; range: 33-86), participants of cardiac rehabilitation programs. The Italian MICRO-Q has 26 items, 18 true statements and 8 false, with responses true, false and ‘don’t know’, with three separate scores: correct, uncorrect and uncertain. The Brazilian MICRO-Q has 25 items, 18 true statements and 7 false, with the same responses and scores. To verify and compare results we used Independent-Sample T Test, ANOVA and Bonferroni Post-hoc. Results: The analysis of mean total scores of Italian and Brazilian applications showed statistically significant differences for correct answers (p<0.001) and for ‘don’t know’ answers (p<0.001). 18 statements had significant (p<0.005) differences between applications in the two countries. Conclusion: Despite differences between Italy and Brazil, the analysis of MICRO-Q applications showed a similar mean score percent of correct answers, indicating enough knowledge about secondary prevention of CHD

Cardiac rehabilitation a global perspective on where we have come and where we must go

No abstract available

ICCPR Guideline: Women-Focused CR

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and may result in better quality-of-life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary healthcare providers, a policy-maker, and patient partners. The guideline was developed in accordance with AGREE II and RIGHT. Initial recommendations were based on a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR’s audit; N=76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A webcall was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (GRADE). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing) and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but one recommendation, ≥75% voted to include; implementability ratings were <5/7 for 4 recommendations, but only one for impact. Ultimately one recommendation was excluded, one separated into two and all revised (two substantively); one recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming

The impact of ICCPR's Global Audit of Cardiac Rehabilitation: where are we now and where do we need to go?

Despite the global epidemic of cardiovascular disease and the well-established mitigating benefits of cardiovascular rehabilitation (CR), availability is known to be grossly insufficient, and little was known about the nature of services delivered in resource-poor settings where it is needed most. Indeed, this had not been quantified before the International Council of Cardiovascular Prevention and Rehabilitation's (ICCPR) 2017 Global Audit, published in volume 13 of eClinicalMedicine.1,2 This commentary will: (1) summarize the key findings of the Global Audit, (2) actions taken to address identified issues, (3) what is known about current CR availability and the nature of delivered services globally, and finally (4) consider open questions and future directions to achieve change. There were two main parts to the Audit. First, ICCPR's many members Associations (i.e., 43) and friends (https://globalcardiacrehab.com/Members) confirmed any program availability in every country globally (including number of programs in the country, where applicable). Second, they facilitated administration of an online survey to identified CR programs. This assessed program capacity and quality of services.There was no funding for this commentary. We have not been paid to write this article by a pharmaceutical company or other agency.Scopu