Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: COMPARISON BETWEEN MEN AND WOMEN Purpose: To compare functional and cardiovascular variables of men and women with peripheral artery disease (PAD). Methods: This observational, cross-sectional study included 67 women and 144 men (age 66 ± 9 and 67 ± 10 yr, respectively) with PAD. Patients were submitted to a clinical evaluation, 6-min walk test (6MWT) and cardiovascular evaluation, including blood pressure, arterial stiffness variables, and heart rate variability. Results: Women had lower claudication onset distance (P = .033) and 6MWT distance (P < .001), and similar percentage of the predicted 6MWT distance (P > .05). Women had higher pulse pressure (P = .002), augmentation index (P < .001), augmentation index corrected by 75 bpm (P < .001), and brachial and central systolic blood pressure (P = .041 and P = .029). Diastolic blood pressure, pulse wave velocity, and heart rate variability were similar between sexes (P > .05). Conclusion: Although predicted 6MWT performance was similar between sexes, women had higher blood pressure and wave reflection variables compared with men. Interventions to reduce blood pressure and wave reflection should be emphasized in women with PAD. Correspondence: Raphael M. Ritti-Dias, PhD, Universidade Nove de Julho, São Paulo, SP, Brazil (raphaelritti@gmail.com) The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Adherence to Pulmonary Rehabilitation in COPD: A QUALITATIVE EXPLORATION OF PATIENT PERSPECTIVES ON BARRIERS AND FACILITATORS Purpose: Adherence to pulmonary rehabilitation (PR) is low. This qualitative study used the PRECEDE model to identify predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors acting as barriers or facilitators of adherence to PR, and elicit recommendations for solutions from patients with chronic obstructive pulmonary disease (COPD). Methods: Focus groups with COPD patients who had attended PR in the past year were conducted. Sessions were recorded, transcribed verbatim, and coded independently by 2 coders, who then jointly decided on the final coding scheme. Data were summarized across groups, and analysis was used a thematic approach with constant comparative method to generate categories. Results: Five focus groups with 24 participants each were conducted. Participants (mean age 62 yr) were 54% male, and 67% black. More than half had annual income less than $20 000, 17% were current smokers, and 54% had low adherence (less than 35% of prescribed PR sessions). The most prominent barriers included physical ailments and lack of motivation (intrapersonal), no support system (interpersonal), transportation difficulties, and financial burden (structural). The most prominent facilitators included health improvement, personal determination (intrapersonal), support from peers, family, and friends (interpersonal), and program features such as friendly staff and educational component of sessions (structural). Proposed solutions included incentives to maintain motivation, tobacco cessation support (intrapersonal), educating the entire family (interpersonal), transportation assistance, flexible program scheduling, and financial assistance (structural). Conclusion: Health limitations, social support, transportation and financial difficulties, and program features impact ability of patients to attend PR. Interventions addressing these interpersonal, intrapersonal, and structural barriers are needed to facilitate adherence to PR. Correspondence: Gabriela R. Oates, PhD, 1600 7th Ave South, ACC 620, Birmingham, AL 35233 (goates@uab.edu). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Motivational Telephone Intervention to Reduce Early Dropouts in Cardiac Rehabilitation: A FEASIBILITY PILOT STUDY Purpose: Cardiac rehabilitation (CR) improves outcomes, yet early dropout is common. The purpose of the study was to determine whether a motivational telephone intervention among patients at risk for nonadherence would reduce early dropouts. Methods: We performed a randomized double-blind pilot study with the intervention group receiving the telephone intervention 1 to 3 d after outpatient CR orientation. The control group received the standard of care, which did not routinely monitor attendance until 2 wk after orientation. The primary outcome was the percentage of patients who attended their second exercise session as scheduled. Secondary outcomes included attendance at the second CR session at any point and total number of sessions attended. Because not everyone randomized to the intervention was able to be contacted, we also conducted a per-protocol analysis. Results: One hundred patients were randomized to 2 groups (age 62 ± 15 yr, 46% male, 40% with myocardial infarction) with 49 in the intervention group. Patients who received the intervention were more likely to attend their second session as scheduled compared with the standard of care (80% vs 49%; relative risk = 1.62; 95% CI, 1.18-2.22). Although there was no difference in total number of sessions between groups, there was a statistically significant improvement in overall return rate among the per-protocol group (87% vs 66%; relative risk = 1.31; 95% CI, 1.05-1.63). Conclusions: A nursing-based telephone intervention targeted to patients at risk for early dropout shortly after their CR orientation improved both on-time and eventual return rates. This straightforward strategy represents an attractive adjunct to improve adherence to outpatient CR. Correspondence: Grace LaValley, DNP, AGACNP-BC, Baystate Health Systems, 759 Chestnut Street, Springfield, MA 01199 (grace.lavalley@baystatehealth.org). The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria, participation in speakers' bureaus, memberships, employment, stock ownership, or other equity interest) or nonfinancial interest (such as personal or professional relationships affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript. Dr Quinn R. Pack was partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (award number: KL2TR001063). The content is solely the responsibility of the authors and does not represent the official views of the NIH. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Patient-Reported Psychological Distress After Spontaneous Coronary Artery Dissection: EVIDENCE FOR POST-TRAUMATIC STRESS Purpose: High rates of depression and anxiety are reported among patients who have experienced spontaneous coronary artery dissection (SCAD) but the incidence of post-traumatic stress disorder (PTSD) is unknown. The purpose of this study was to investigate symptoms of PTSD in women who have experienced SCAD. Methods: This cross-sectional pilot study included 14 female SCAD patients, mean age of 51 yr, who responded to standardized psychosocial questionnaires at a median of 35 mo post-SCAD. Patients were identified by cardiologists as having had a SCAD event and were concurrently invited to participate in a psychosocial group for SCAD survivors. Results: Participants reported current symptoms of stress (93%), insomnia (57%), anxiety (71%), depression (36%), and PTSD (43%). Eight of the 11 women who reported having a mental health history (72.7%) indicated that their symptoms were related to having experienced SCAD. Health-related quality of life and social support were comparable with other all-female cardiac samples. Patterns of perceived control were more similar to those of patients with cancer than other cardiac patients in that SCAD patients ranked “chance” as more likely than “self-control” to impact medical outcomes. Conclusions: The prevalence of PTSD symptoms in this first-known assessment of post-traumatic stress among SCAD patients is concerning. The unexpected nature of SCAD and lack of known treatment options may play a role in patient distress. Future research is needed to accurately estimate rates of PTSD after SCAD and assess the benefits of treatment. Correspondence: Katharine S. Edwards, PhD, Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Rm H2103, Stanford, CA 94305 (ksedwards@stanford.edu). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Training in Adults With Congenital Heart Disease: A SYSTEMATIC REVIEW AND META-ANALYSIS Background: Evidence from many studies demonstrates that regular exercise has a favorable effect on cardiovascular disease, but it is still unclear whether adults with congenital heart disease (ACHD) benefit from exercise training. The aim of this study was to assess the effects of exercise training on ACHD. Methods: PubMed, EMBASE, the Cochrane Library, Cumulative Index to Nursing and Allied Health, and Web of Science databases were searched. Differences were expressed using mean difference (MD) with 95% CI. The statistical analysis was performed using Review Manager (RevMan 5.3). Outcomes, including cardiorespiratory fitness, neurohumoral activation (NT-proBNP levels), rating of perceived exertion (Borg scale), and safety status, were investigated. Results: Nine trials with 403 ACHD were included. The following outcomes were statistically significant: peak (MD = 1.96, 95% CI, 0.70-3.23; P = .002); maximal workload (MD = 11.46, 95% CI, 7.06-15.87; P < .00001); and maximal exercise duration (MD = 2.04, 95% CI, 1.00-3.07; P = .0001). But no significant decrease was reported regarding neurohumoral activation or the rating of perceived exertion. Furthermore, no major adverse events were reported. The overall quality of evidence ranged from moderate to very low. Conclusions: Evidence was underpowered to suggest that exercise training is effective in the management of ACHD. Future studies with longer follow-up are needed. Correspondence: Qing Du, PhD, Department of Rehabilitation, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, 1665 Kongjiang Rd, Shanghai 200092, China (duqing@xinhuamed.com.cn). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). PROSPERO registration number: CRD42018085990 (available at: http://www.crd.york.ac.uk/prospero/). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Wearable Cardioverter Defibrillator–Guided 6-Min Walk Test Performed at Home Is Accurate and Reliable: RESULTS OF THE TRENDS STUDY Purpose: The 6-min walk test (6MWT) is broadly used to evaluate the functional ability of patients with heart failure (HF). The purpose of this study was to evaluate the accuracy and reliability of the wearable cardioverter defibrillator (WCD)–guided 6MWT performed at home by patients with HF versus in-clinic testing. Methods: Patients (n = 197) with HF and a low ejection fraction prescribed a WCD were randomized to 2 groups. Group 1 completed an in-clinic clinician-guided 6MWT while wearing the WCD; results were recorded by the clinician. Group 2 completed a WCD-guided 6MWT, also performed in the clinic; results were recorded by the WCD accelerometer. Both groups performed weekly unsupervised WCD-guided 6MWTs at home, with results recorded by the WCD. Results: The initial in-clinic 6MWT showed no significant group difference in distance walked (group 1 = 306 m; group 2 = 297 m). For patients in group 2 who completed at least one 6MWT at home, there was a 15-step decrease between the in-clinic WCD-guided 6MWT and the first at-home 6MWT, 558 and 543 median steps (P = .001), respectively. Among patients with at least 8 weekly home WCD-guided 6MWTs (n = 70), there was no significant difference in the number of steps walked during the 6MWT from week to week. Conclusions: Results of the in-clinic 6MWT are similar between clinician-guided and WCD-guided patients across objective distances. Distances walked with a WCD-guided walk test were consistent whether conducted in the clinic or at home and were reliable over time. Correspondence: Ashley E. Burch, PhD, Department of Psychology, East Carolina University, 104 Rawl Bldg, Greenville, NC 27858 (burchas15@ecu.edu). Ashley E. Burch, PhD: research grants: Medtronic, ZOLL Medical. All funds are directed to East Carolina University. Andreas J. Rieth, MD: research grants: Pfizer, directed to Kerckhoff-Klinik Forschungs GmbH; Biotest, directed to Kerckhoff Herzforschungsinstitut; speaker fees and/or honoraria: St Jude Medical, Actelion, Novartis, and Orion Pharma. Nicole R. Bianco, PhD, Employee, ZOLL Medical. Samuel F. Sears, PhD: honoraria/consulting fees: Medtronic, Boston Scientific, St Jude Medical, ZOLL Medical; research grants: Medtronic, ZOLL Medical. All funds are directed to East Carolina University. The rest of the authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effects of Different Rehabilitation Protocols in Inpatient Cardiac Rehabilitation After Coronary Artery Bypass Graft Surgery: A RANDOMIZED CLINICAL TRIAL Purpose: Patients undergoing coronary artery bypass graft (CABG) surgery typically experience loss of cardiopulmonary capacity in the post-operative period. The purpose of this study was to evaluate the effects of different rehabilitation protocols used in inpatient cardiac rehabilitation on functional capacity and pulmonary function in patient status post-CABG surgery. Methods: This was a single-blind randomized controlled trial. The primary endpoint of functional capacity and secondary endpoints of lung capacity and respiratory muscle function were assessed in patients scheduled to undergo CABG. After surgery, 40 patients were randomly assigned across 1 of 4 inpatient cardiac rehabilitation groups: G1, inspiratory muscle training, active upper limb and lower limb exercise training, and early ambulation; G2, same protocol as G1 without inspiratory muscle training; G3, inspiratory muscle training alone; and G4, control. All groups received chest physical therapy and expiratory positive airway pressure. Patients were reassessed on post-operative day 6 and post-discharge day 30 (including cardiopulmonary exercise testing). Results: The 6-min walk distance on post-operative day 6 was significantly higher in groups that included exercise training (G1 and G2), remaining higher at 30 d post-discharge (P < .001 between groups). Peak oxygen uptake on day 30 was also higher in G1 and G2 (P = .005). All groups achieved similar recovery of lung function. Conclusion: Protocols G1 and G2, which included a systematic plan for early ambulation and upper and lower limb exercise, attenuated fitness losses while in the hospital and significantly enhanced recovery 1 mo after CABG. Correspondence: Maurice Zanini, ScD, PT, Exercise Cardiology Research Group, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Térreo (Serviço de Fisiatria e Reabilitação) 90035-007, Porto Alegre, RS, Brazil (mauricezanini@gmail.com). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Interval Endurance and Resistance Training as Part of a Community-Based Secondary Prevention Program for Patients With Diabetes Mellitus and Coronary Artery Disease Purpose: High-intensity interval training (HIIT) has been observed to improve health and fitness in patients with cardiovascular disease. High-intensity interval training may not be appropriate in community-based settings. Moderate-intensity interval training (MIIT) and resistance training (RT) are emerging as effective alternatives to HIIT. These have not been well investigated in a community-based cardiac maintenance program. Methods: Patients with coronary artery disease and/or diabetes mellitus participated in clinical examinations and a 6-mo exercise program. Center-based MIIT and home-based moderate continuous intensity exercise were performed for 3-5 d/wk for 30-40 min/session. RT, nutritional counseling, coping, and behavioral change strategies were offered to all patients. Within-group changes in clinical metrics and exercise performance were assessed on a per-protocol basis after 6 mo. Results: Two hundred ninety-two patients (74%) concluded the 6-mo program. There were no serious adverse events. The peak oxygen uptake and peak workload increased significantly, 21.8 ± 6.1 to 22.8 ± 6.3 mL/kg/min and 128 ± 39 to 138 ± 43 W, respectively (both P < .001). Submaximal exercise performance increased from 68 ± 19 to 73 ± 22 W (P < .001). Glycated hemoglobin decreased from 6.57 ± 0.93% to 6.43 ± 0.12%, (P = .023). Daily injected insulin dosage was reduced from 42 IU (interquartile range: 19.0, 60.0) to 26 IU (interquartile range: 0, 40.3, P < .001). Conclusions: MIIT and RT were feasible and effective in a community-based cardiac maintenance program for patients with cardiovascular disease, improving exercise performance, and blood glucose control. Correspondence: Jeffrey W. Christle, PhD, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Falk Cardiovascular Research Building, 870 Quarry Road Ext, Palo Alto, CA 94304 (christle@stanford.edu). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Higher Anxiety and Will to Live Are Associated With Poorer Adherence to Cardiac Rehabilitation Purpose: Cardiac rehabilitation (CR) session attendance and rates of completion remain suboptimal. Greater distress (ie, depression and anxiety) has been associated with both better and poorer adherence. Will to live (ie, desire, determination and effort to survive) has been associated with survival among cardiac patients and thus may be relevant for CR adherence. It was hypothesized that depression and anxiety would be negatively associated with adherence, and that will to live would moderate these relationships. Methods: Sixty patients (mean age = 56.9 ± 10.8 yr; 38 males) entering outpatient CR completed self-report measures of will to live (Wish to Prolong Life Questionnaire) and distress (Hospital Anxiety and Depression Scale). Hierarchical regression analyses were performed to predict CR session attendance (%) and program completion (yes/no) from depression and anxiety, as well as the interaction of those variables with will to live. Results: Neither depression nor anxiety was associated with CR adherence (Ps > .33). However, there was a significant interaction of will to live with anxiety in predicting attendance (β = −0.31, P = .03, Model R2 = .19, P = .01), reflecting that anxiety predicted lower attendance only among patients reporting greater will to live. Conclusions: These data help clarify the complex relationship between distress and CR adherence. Findings suggest that higher anxiety is associated with poorer adherence, but only in combination with greater motivation for living. Patients higher in anxiety and will to live may benefit from additional strategies to make actionable behavioral change in the context of CR. Correspondence: Charles F. Emery, PhD, Department of Psychology, The Ohio State University, 1835 Neil Ave, Columbus, OH 43210 (emery.33@osu.edu). All authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

“Let's Boogie”: FEASIBILITY OF A DANCE INTERVENTION IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE Purpose: Exercise is an effective treatment for individuals with chronic obstructive pulmonary disease (COPD); however, lack of adherence to exercise programs is a common barrier. Innovative approaches to exercise are needed to increase patient engagement and adherence. Dance has been shown to benefit populations with neurological conditions. The aim of our study was to investigate the feasibility of a dance intervention in individuals with COPD. Methods: Twenty individuals with COPD participated in a 1-hr dance class delivered twice a week for 8 wk. The primary outcome measure of the study was the feasibility determined by enrollment rate, attendance rate, adverse events, and participant satisfaction. Secondary outcomes included functional capacity, balance, anxiety and depression, steps count, and health-related quality of life. Results: Of the 47 individuals approached, 37 (79%) were interested in the program and 23 (49%) consented to participate and 20 completed the program with no adverse events and a mean attendance rate of 78%. The mean age ± SD of the participants was 73.4 ± 7.6 yr and 70% were females. Participant satisfaction with the program was high and significant improvements were achieved in the 6-min walk test (P = .03), Balance Evaluation Systems Test (BESTest) (P < .01), Chronic Respiratory Disease Questionnaire (P = .001), and the Activities-specific Balance Confidence scale (P = .007). Conclusion: Dance is an enjoyable, safe, and feasible way to exercise for those with COPD. This pilot study will inform the design of a larger randomized controlled trial to determine effectiveness of dance on exercise capacity, balance, and quality of life for people with COPD. Correspondence: Adnan Wshah, PhD (C), Rehabilitation Sciences Institute, University of Toronto, 160-500 University Ave, Toronto, Ontario, M5G 1V7, Canada (adnan.wshah@mail.utoronto.ca). Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.