Home-Based Cardiac Rehabilitation: A SCIENTIFIC STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN COLLEGE OF CARDIOLOGY Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Cardiac Rehabilitation Quality Improvement: A NARRATIVE REVIEW Purpose: Despite evidence of the effectiveness of cardiac rehabilitation (CR), there is wide variability in programs, which may impact their quality. The objectives of this review were to (1) evaluate the ways in which we measure CR quality internationally; (2) summarize what we know about CR quality and quality improvement; and (3) recommend potential ways to improve quality. Methods: For this narrative review, the literature was searched for CR quality indicators (QIs) available internationally and experts were also consulted. For the second objective, literature on CR quality was reviewed and data on available QIs were obtained from the Canadian Cardiac Rehabilitation Registry (CCRR). For the last objective, literature on health care quality improvement strategies that might apply in CR settings was reviewed. Results: CR QIs have been developed by American, Canadian, European, Australian, and Japanese CR associations. CR quality has only been audited across the United Kingdom, the Netherlands, and Canada. Twenty-seven QIs are assessed in the CCRR. CR quality was high for the following indicators: promoting physical activity post-program, assessing blood pressure, and communicating with primary care. Areas of low quality included provision of stress management, smoking cessation, incorporating the recommended elements in discharge summaries, and assessment of blood glucose. Recommended approaches to improve quality include patient and provider education, reminder systems, organizational change, and advocacy for improved CR reimbursement. An audit and feedback strategy alone is not successful. Conclusions: Although not a lot is known about CR quality, gaps were identified. The quality improvement initiatives recommended herein require testing to ascertain whether quality can be improved.

What Is the Optimal Exercise Prescription for Patients With Dilated Cardiomyopathy in Cardiac Rehabilitation? A SYSTEMATIC REVIEW Purpose: Dilated cardiomyopathy (DCM) is 1 of the major causes of advanced heart failure. However, relatively little is known about the effects of exercise specifically in patients with DCM. This purpose of this literature review was to identify optimal exercise training programming for patients with DCM. Methods: A systematic review was conducted by 3 clinical specialists and the level of evidence of each study was rated using Sackett's levels of evidence. Multiple databases (PubMed Central, EMBASE, and EBSCO) were searched with the inclusion criteria of articles published in English. Results: A total of 4544 studies were identified using the search strategy, of which 4 were included in our systematic review. The exercise frequency of the reviewed studies ranged from 3 to 5 times/wk, and exercise intensity was prescribed within a range from 50% to 80% of oxygen uptake reserve. Exercise time was as high as 45 min by the final month of the exercise prescription. Exercise type was mainly aerobic exercise and resistance training. The average improvement of exercise capacity was 19.5% in reviewed articles. Quality of life also improved after intervention. Conclusions: According to this systematic review of the literature, data related to exercise therapy specifically for patients with DCM are scarce and exercise interventions in articles reviewed were prescribed differently using the FITT (frequency, intensity, time, and type) principle. Exercise intensity tailored to individual exercise capacity should be used for optimal exercise prescriptions that are safe and efficacious in patients with DCM.

Muscle Dysfunction in Smokers and Patients With Mild COPD: A SYSTEMATIC REVIEW Purpose: To describe and discuss the available evidence in the literature concerning muscle function and the association between smoking and muscle dysfunction in smokers and patients with mild chronic obstructive pulmonary disease (COPD). Methods: The literature search involved the following databases: PubMed, Pedro, CINAHL, Cochrane Library, Lilacs, and EMBASE. Studies were included if they investigated muscle strength and/or endurance and/or cross-sectional area (CSA) in smokers and/or patients with COPD classified as Global Initiative for Obstructive Lung Disease (GOLD) I and without lung cancer. Two authors screened and identified the studies for inclusion. Results: Eighteen studies were identified. Some studies found lower values in a variety of muscle strength variables in smokers compared with nonsmoking controls, whereas others found similar values between these groups. When comparing patients with COPD classified as GOLD I with smokers, COPD patients showed lower muscle strength. Two studies found no differences in muscle CSA between smokers compared with nonsmoking controls. Some preliminary evidence also shows that patients with COPD classified as GOLD I had lower CSA in comparison with smokers. Conclusion: Results concerning muscle dysfunction in smokers are divergent, since some studies have shown worse results in a variety of muscle strength variables in smokers compared with nonsmoking controls, whereas other studies have not. Moreover, there is rather preliminary evidence indicating worse muscle dysfunction and lower CSA in patients with mild COPD in comparison with healthy (or non-COPD) smokers.

A Cross-Sectional Study of Return to Work Rate Following Heart Transplantation and the Contributing Role of Illness Perceptions Background: Social rehabilitation, including return to work (RTW), is a key indicator of transplant success. However, little is known regarding the RTW rate following heart transplantation or the factors influencing this. The objective of this study was to examine RTW among heart transplant recipients and identify associated predictors. Methods: Attendees of the post–heart transplant clinic based at the Golden Jubilee National Hospital, Scotland, were invited to respond to a mailed survey comprising a demographic form, an employment history questionnaire, and a modified Brief Illness Perception Questionnaire. Frequency distributions, χ2 test, and stepwise regression were used to examine employment history and associated factors. Results: Sixty percent of transplant recipients reported working 12 mo prior to transplant compared with 50% of recipients at 1-y post-transplant. Forty-four percent of all working-age recipients were currently employed, a relatively median rate compared with those found in previous studies. Univariate analysis revealed “receipt of benefits,” “time off work pre–heart transplant,” “employment 12 mo pre–heart transplant,” “employment at listing,” “perceived work ability,” “discharge age,” “illness consequences,” “illness concern,” and “emotional representation” as predictors of RTW. Logistic regression modeling revealed “time off work pre–heart transplant” and “perceived work ability” to have the most significant influence on RTW, explaining 62% of the variance in outcome. Conclusions: Psychological and demographic variables influence RTW after heart transplant. Knowledge and understanding of these variables facilitate the design of interventions and services to help promote RTW and social rehabilitation. Study limitations are discussed, and suggestions for similar research and the outpatient clinic are provided.

Sex- and Gender-Related Factors Associated With Cardiac Rehabilitation Enrollment: A SECONDARY ANALYSIS AMONG SYSTEMATICALLY REFERRED PATIENTS Purpose: To assess sex- and gender-related factors associated with cardiac rehabilitation (CR) enrollment following acute coronary syndrome among systematically referred patients. Methods: This secondary analysis of a randomized controlled trial used an exploratory approach to examine the TRANSITion process for patients between the coronary care unit and CR (TRANSIT-UC). The present analysis examined the relationship between sex- and gender-related factors and CR enrollment in systematically referred women (n = 35) and men (n = 207). We performed χ2 and logistic regression analyses to identify statistically significant results. Using the Bonferroni method, a P value of .002 or less was considered a significant statistical result. A raw difference of 15% or more between enrolled and nonenrolled participants was considered a difference worthy of further investigation. Results: Men who were regularly engaged in physical activity prior to their hospitalization and who lived near the CR center showed a statistically higher CR enrollment rate. In women and men, a radial entry site for percutaneous coronary intervention resulted in a clinically significant difference in favor of CR enrollment. In women, 3 sex-related and 9 gender-related variables were associated with a difference of 15% or more between enrolled and nonenrolled participants. Conclusion: Factors related to CR enrollment in women and men are suggested. As women keep showing a lower rate of CR enrolment, the investigation of these factors in a larger sample of patients may hold valuable insights to improve CR enrolment.

Clinical and Demographic Trends in Cardiac Rehabilitation: 1996-2015 Purpose: Clinical interventions in programs such as cardiac rehabilitation (CR) are guided by clinical characteristics of participating patients. This study describes changes in CR participant characteristics over 20 yr. Methods: To examine changes in patient characteristics over time, we analyzed data from 1996 to 2015 (n = 5396) garnered from a systematically and prospectively gathered database. Linear, logistic, multinomial logistic or negative binomial regression was used, as appropriate. Effects of sex and index diagnosis were considered both as interactions and as additive effects. Results: Analyses revealed that mean age increased (from 60.7 to 64.2 yr), enrollment of women increased (from 26.8% to 29.6%), and index diagnosis has shifted; coronary artery bypass surgery decreased (from 37.2% to 21.6%), whereas heart valve repair/replacement increased (from 0% to 10.6%). Risk factors also shifted with increases in body mass index (28.7 vs 29.6 kg/m2), obesity (from 33.2% to 39.6%), hypertension (from 51% to 62.5%), type 2 diabetes mellitus (from 17.3% to 21.7%), and those reporting current smoking (from 6.6% to 8.4%). Directly measured peak aerobic capacity remained relatively stable throughout. The proportion of patients on statin therapy increased from 63.6% to 98.9%, coinciding with significant improvements in lipid levels. Conclusions: Compared with 1996, participants entering CR in 2015 were older, more overweight, and had a higher prevalence of coronary risk factors. Lipid values improved substantially concurrent with increased statin use. While the percentage of female participants increased, they continue to be underrepresented. Patients with heart valve repair/replacement now constitute 10.6% of the patients enrolled. Clinical programs need to recognize changing characteristics of attendees to best tailor interventions.

Do London Chest Activity of Daily Living Scale and St George's Respiratory Questionnaire Reflect Limitations During Activities of Daily Living in Patients With COPD? Purpose: It is unclear whether activities of daily living (ADL) and quality-of-life scales reflect real ADL limitations. The aim of the study was to assess the limitation during ADL simulation and to identify whether the London Chest Activity of Daily Living (LCADL) Scale and St George's Respiratory Questionnaire (SGRQ) are able to reflect the patient's real limitations during ADL simulation. Methods: Forty-eight patients with chronic obstructive pulmonary disease (age = 69 ± 8 y; forced expiratory volume in the first second of expiration [FEV1] = 1.37 ± 0.49 L) were assessed by SGRQ and LCADL Scale. Activities of daily living simulations were performed: showering (ADL1); lifting and lowering containers above the shoulder girdle (ADL2); and raising and lowering pots below the pelvic girdle (ADL3). Results: SpO2 and ΔSpO2 in ADL2 were statistically lower than in ADL3. Ventilatory demand was statistically higher in ADL2 and ADL3 than in ADL1. Metabolic equivalent values were similar between the ADLs with values above 3.6. Oxygen desaturation was present in 41.7% (ADL1) and 33.3% (ADL2) of the patients. The LCADL% showed a moderate positive correlation with dyspnea in ADL3 and metabolic demand in ADL1. The SGRQ score presented a moderate positive correlation with dyspnea in all ADL simulations and metabolic demand in ADL1 and ADL3. Dyspnea in ADL3 and metabolic demand in ADL1 explained 33% of the variability in LCADL%. The dyspnea and metabolic demand in ADL3 explained 67% of the variability in SGRQ. Conclusion: Activities of daily living lead to oxygen desaturation and high ventilatory demand. London Chest Activity of Daily Living Scale reflected 33% and SGRQ reflected 67% of the functional limitation during ADL simulation, such as dyspnea and the metabolic demand during ADL.

Home-Based Pulmonary Rehabilitation for Patients With Idiopathic Pulmonary Fibrosis: A PILOT STUDY Purpose: To evaluate the adherence and effectiveness of a home-based exergame program for patients with idiopathic pulmonary fibrosis (IPF). Method: Patients with IPF were randomly assigned to a relatively unsupervised Wii Fit exergame intervention group or Wii video game control group (with no active whole-body movement involved). Participants in both groups were instructed to play their respective games 30 min/d, 3 d/wk for 12 wk. In addition, they were asked to perform their usual exercise/physical activities. Outcome measures were 6-min walk distance (6MWD), exercise-related dyspnea, and St George's Respiratory Questionnaire (SGRQ). Results: The 20 participants differed significantly between intervention and control groups in baseline characteristics (forced vital capacity = 2.0 ± 0.5 vs 3.1 ± 0.7 L; forced expiratory volume in 1 sec = 1.7 ± 0.4 vs 2.5 ± 0.6 L, respectively). Participant adherence rate to the exergame program was very low (20%). There was no significant improvement in the outcome measures in either group. In fact, both the intervention and control groups had a deterioration in 6MWD (−22 ± 56 m vs −60 ± 111 m), respectively and SGRQ scores (3 ± 9 vs 1 ± 11), respectively. Conclusions: The home-based exergame intervention for patients with IPF did not show improvement in functional performance, dyspnea, or health-related quality of life at the completion of the 12-wk program in our 2 heterogeneous groups. In addition to the low adherence rate, insufficient frequencies and durations of exergaming may contribute to the lack of improvement. A lack of effectiveness of home-based pulmonary rehabilitation using exergaming for patients with IPF appears consistent with prior observational studies that used more traditional modes of home-based exercise.