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UK cardiac rehabilitation fit for purpose? A community-based observational cohort study.

ABSTRACT: OBJECTIVES:This study aimed to characterise the exercise performed in UK cardiac rehabilitation (CR) and explore relationships between exercise dose and changes in physiological variables. DESIGN:Observational cohort study. SETTING:Outpatient community-based CR in Leeds, UK. Rehabilitation sessions were provided twice per week for 6?weeks. PARTICIPANTS:Sixty patients (45 male/15 female 33-86 years) were recruited following referral to local outpatient CR. OUTCOME MEASURES:The primary outcome was heart rate achieved during exercise sessions. Secondary outcomes were measured before and after CR and included incremental shuttle walk test (ISWT) distance and speed, blood pressure, brachial artery flow-mediated dilatation, carotid arterial stiffness and accelerometer-derived habitual physical activity behaviours. RESULTS:The mean % of heart rate reserve patients exercised at was low and variable at the start of CR (42%±16 %) and did not progress by the middle (48%±17 %) or end (48%±16 %) of the programme. ISWT performance increased following CR (440±150?m vs 633±217?m, p<0.001); however, blood pressure, body weight, endothelial function, arterial stiffness and habitual physical activity behaviours were unchanged following 6?weeks of CR (p>0.05). CONCLUSION:Patients in a UK CR cohort exercise at intensities that are variable but generally low. The exercise dose achieved using this CR format appears inadequate to impact markers of health. Attending CR had no effect on physical activity behaviours. Strategies to increase the dose of exercise patients achieve during CR and influence habitual physical activity behaviours may enhance the effectiveness of UK CR.

SUBMITTER: Ibeggazene S

PROVIDER: S-EPMC7549464 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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UK cardiac rehabilitation fit for purpose? A community-based observational cohort study.

Ibeggazene Saïd S Moore Chelsea C Tsakirides Costas C Swainson Michelle M Ispoglou Theocharis T Birch Karen K

BMJ open 20201010 10

<h4>Objectives</h4>This study aimed to characterise the exercise performed in UK cardiac rehabilitation (CR) and explore relationships between exercise dose and changes in physiological variables.<h4>Design</h4>Observational cohort study.<h4>Setting</h4>Outpatient community-based CR in Leeds, UK. Rehabilitation sessions were provided twice per week for 6 weeks.<h4>Participants</h4>Sixty patients (45 male/15 female 33-86 years) were recruited following referral to local outpatient CR.<h4>Outcome ...[more]

PMID: 33040006

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Project description:Aim Although cardiac rehabilitation improves physical fitness after a cardiac event, many eligible patients do not participate in cardiac rehabilitation and the beneficial effects of cardiac rehabilitation are often not maintained over time. Home-based training with telemonitoring guidance could improve participation rates and enhance long-term effectiveness. Methods and results We randomised 90 low-to-moderate cardiac risk patients entering cardiac rehabilitation to three months of either home-based training with telemonitoring guidance or centre-based training. Although training adherence was similar between groups, satisfaction was higher in the home-based group ( p?=?0.02). Physical fitness improved at discharge ( p?<?0.01) and at one-year follow-up ( p?<?0.01) in both groups, without differences between groups (home-based p?=?0.31 and centre-based p?=?0.87). Physical activity levels did not change during the one-year study period (centre-based p?=?0.38, home-based p?=?0.80). Healthcare costs were statistically non-significantly lower in the home-based group (€437 per patient, 95% confidence interval -562 to 1436, p?=?0.39). From a societal perspective, a statistically non-significant difference of €3160 per patient in favour of the home-based group was found (95% confidence interval -460 to 6780, p?=?0.09) and the probability that it was more cost-effective varied between 97% and 75% (willingness-to-pay of €0 and €100,000 per quality-adjusted life-years, respectively). Conclusion We found no differences between home-based training with telemonitoring guidance and centre-based training on physical fitness, physical activity level or health-related quality of life. However, home-based training was associated with a higher patient satisfaction and appears to be more cost-effective than centre-based training. We conclude that home-based training with telemonitoring guidance can be used as an alternative to centre-based training for low-to-moderate cardiac risk patients entering cardiac rehabilitation.

Project description:BACKGROUND:Wearable technology is finding its way into clinical practice. Physical activity describes patients' functional status after cardiac surgery and can be monitored remotely by using dedicated trackers. OBJECTIVE:The aim of this study was to compare the progress of physical activity in cardiac rehabilitation by using wearable fitness trackers in patients undergoing coronary artery bypass surgery by either the conventional off-pump coronary artery bypass (OPCAB) or the robotically assisted minimally invasive coronary artery bypass (RA-MIDCAB). We hypothesized faster recovery of physical activity after RA-MIDCAB in the first weeks after discharge as compared to OPCAB. METHODS:Patients undergoing RA-MIDCAB or OPCAB were included in the study. Each patient received a Fitbit Charge HR (Fitbit Inc, San Francisco, CA) physical activity tracker following discharge. Rehabilitation progress was assessed by measuring the number of steps and physical activity level daily. The physical activity level was calculated as energy expenditure divided by the basic metabolic rate. RESULTS:A total of 10 RA-MIDCAB patients with a median age of 68 (min, 55; max, 83) years and 12 OPCAB patients with a median age of 69 (min, 50; max, 82) years were included. Baseline characteristics were comparable except for body mass index (RA-MIDCAB: 26 kg/m²; min, 22; max, 28 versus OPCAB: 29 kg/m²; min, 27; max, 33; P<.001). Intubation time (P<.05) was significantly lower in the RA-MIDCAB group. A clear trend, although not statistically significant, was observed towards a higher number of steps in RA-MIDCAB patients in the first week following discharge. CONCLUSIONS:RA-MIDCAB patients have an advantage in recovery in the first weeks of revalidation, which is reflected by the number of steps and physical activity level measured by the Fitbit Charge HR, as compared to OPCAB patients. However, unsupervised assessment of daily physical activity varied widely and could have consequences with regard to the use of these trackers as research tools.

Project description:Exosomes are defined as submicron (30-150 nm), lipid bilayer-enclosed extracellular vesicles (EVs), specifically generated by the late endosomal compartment through fusion of multivesicular bodies with the plasma membrane. Produced by almost all cells, exosomes were originally considered to represent just a mechanism for jettisoning unwanted cellular moieties. Although this may be a major function in most cells, evolution has recruited the endosomal membrane-sorting pathway to duties beyond mere garbage disposal, one of the most notable examples being its cooption by retroviruses for the generation of Trojan virions. It is, therefore, tempting to speculate that certain cell types have evolved an exosome subclass active in intracellular communication. We term this EV subclass "signalosomes" and define them as exosomes that are produced by the "signaling" cells upon specific physiological or environmental cues and harbor cargo capable of modulating the programming of recipient cells. Our recent studies have established that signalosomes released by mesenchymal stem/stromal cells (MSCs) represent the main vector of MSC immunomodulation and therapeutic action in animal models of lung disease. The efficacy of MSC-exosome treatments in a number of preclinical models of cardiovascular and pulmonary disease supports the promise of application of exosome-based therapeutics across a wide range of pathologies within the near future. However, the full realization of exosome therapeutic potential has been hampered by the absence of standardization in EV isolation, and procedures for purification of signalosomes from the main exosome population. This is mainly due to immature methodologies for exosome isolation and characterization and our incomplete understanding of the specific characteristics and molecular composition of signalosomes. In addition, difficulties in defining metrics for potency of exosome preparations and the challenges of industrial scale-up and good manufacturing practice compliance have complicated smooth and timely transition to clinical development. In this manuscript, we focus on cell culture conditions, exosome harvesting, dosage, and exosome potency, providing some empirical guidance and perspectives on the challenges in bringing exosome-based therapies to clinic.

Project description:BACKGROUND:Cardiac rehabilitation (CR) is known for its beneficial effects on functional capacity and is a key component within current cardiovascular disease management strategies. In addition, a larger increase in functional capacity is accompanied by better clinical outcomes. However, not all patients respond in a similar way to CR. Therefore, a patient-tailored approach to CR could open up the possibility to achieve an optimal increase in functional capacity in every patient. Before treatment can be optimized, the differences in response of patients in terms of cardiac adaptation to exercise should first be understood. In addition, digital biomarkers to steer CR need to be identified. OBJECTIVE:The aim of the study was to investigate the difference in cardiac response between patients characterized by a clear improvement in functional capacity and patients showing only a minor improvement following CR therapy. METHODS:A total of 129 patients in CR performed a 6-minute walking test (6MWT) at baseline and during four consecutive short-term follow-up tests while being equipped with a wearable electrocardiogram (ECG) device. The 6MWTs were used to evaluate functional capacity. Patients were divided into high- and low-response groups, based on the improvement in functional capacity during the CR program. Commonly used heart rate parameters and cardiac digital biomarkers representative of the heart rate behavior during the 6MWT and their evolution over time were investigated. RESULTS:All participating patients improved in functional capacity throughout the CR program (P<.001). The heart rate parameters, which are commonly used in practice, evolved differently for both groups throughout CR. The peak heart rate (HRpeak) from patients in the high-response group increased significantly throughout CR, while no change was observed in the low-response group (F4,92=8.321, P<.001). Similar results were obtained for the recovery heart rate (HRrec) values, which increased significantly over time during every minute of recuperation, for the high-response group (HRrec1: P<.001, HRrec2: P<.001, HRrec3: P<.001, HRrec4: P<.001, and HRrec5: P=.02). The other digital biomarkers showed that the evolution of heart rate behavior during a standardized activity test differed throughout CR between both groups. These digital biomarkers, derived from the continuous measurements, contribute to more in-depth insight into the progression of patients' cardiac responses. CONCLUSIONS:This study showed that when using wearable sensor technology, the differences in response of patients to CR can be characterized by means of commonly used heart rate parameters and digital biomarkers that are representative of cardiac response to exercise. These digital biomarkers, derived by innovative analysis techniques, allow for more in-depth insights into the cardiac response of cardiac patients during standardized activity. These results open up the possibility to optimized and more patient-tailored treatment strategies and to potentially improve CR outcome.

Project description:INTRODUCTION:Cardiac rehabilitation (CR) reduces all-cause and cardiovascular mortality in patients with coronary heart disease (CHD). Much of this improvement has been attributed to the beneficial effects of structured exercise training. However, UK-based studies have not confirmed this. Improvements in survival and cardiovascular health are associated with concurrent improvements in cardiorespiratory fitness (CRF). It is therefore concerning that estimated CRF improvements resulting from UK-based CR are approximately one-third of those reported in international literature. Modest improvements in CRF suggest that UK CR exercise training programmes may require optimisation if long-term survival is to be improved. However, contemporary UK studies lack control data or use estimates of CRF change. Cardiovascular and cardiorespiratory Adaptations to Routine Exercise-based CR is a longitudinal, observational, controlled study designed to assess the short-term and long-term effect of CR on CRF, as well cardiovascular and cardiometabolic health. METHODS AND ANALYSIS:Patients will be recruited following referral to their local CR programme and will either participate in a routine, low-to-moderate intensity, 8-week (16 sessions) exercise-based CR programme or freely abstain from supervised exercise. Initial assessment will be conducted prior to exercise training, or approximately 2?weeks after referral to CR if exercise training is declined. Reassessment will coincide with completion of exercise training or 10 weeks after initial assessment for control participants. Participants will receive a final follow-up 12 months after recruitment. The primary outcome will be peak oxygen consumption determined using maximal cardiopulmonary exercise testing. Secondary outcomes will include changes in subclinical atherosclerosis (carotid intima-media thickness and plaque characteristics), body composition (dual X-ray absorptiometry) and cardiometabolic biomarkers. ETHICS AND DISSEMINATION:Ethical approval for this non-randomised controlled study has been obtained from the Humber Bridge NHS Research Ethics Committee-Yorkshire and the Humber on the 27th September 2013, (12/YH/0278). Results will be presented at national conferences and published in peer-reviewed journals.

Project description:Physical training has beneficial effects on exercise capacity, quality of life and mortality in patients after a cardiac event or intervention and is therefore a core component of cardiac rehabilitation. However, cardiac rehabilitation uptake is low and effects tend to decrease after the initial rehabilitation period. Home-based training has the potential to increase cardiac rehabilitation uptake, and was shown to be safe and effective in improving short-term exercise capacity. Long-term effects on physical fitness and activity, however, are disappointing. Therefore, we propose a novel strategy using telemonitoring guidance based on objective training data acquired during exercise at home. In this way, we aim to improve self-management skills like self-efficacy and action planning for independent exercise and, consequently, improve long-term effectiveness with respect to physical fitness and physical activity. In addition, we aim to compare costs of this strategy with centre-based cardiac rehabilitation.This randomized controlled trial compares a 12-week telemonitoring guided home-based training program with a regular, 12-week centre-based training program of equal duration and training intensity in low to moderate risk patients entering cardiac rehabilitation after an acute coronary syndrome or cardiac intervention. The home-based group receives three supervised training sessions before they commence training with a heart rate monitor in their home environment. Participants are instructed to train at 70-85% of their maximal heart rate for 45-60 minutes, twice a week. Patients receive individual coaching by telephone once a week, based on measured heart rate data that are shared through the internet. Primary endpoints are physical fitness and physical activity, assessed at baseline, after 12 weeks and after one year. Physical fitness is expressed as peak oxygen uptake, assessed by symptom limited exercise testing with gas exchange analysis; physical activity is expressed as physical activity energy expenditure, assessed by tri-axial accelerometry and heart rate measurements. Secondary endpoints are training adherence, quality of life, patient satisfaction and cost-effectiveness.This study will increase insight in long-term effectiveness and costs of home-based cardiac rehabilitation with telemonitoring guidance. This strategy is in line with the trend to shift non-complex healthcare services towards patients' home environments.Dutch Trial Register: NTR3780. Clinicaltrials.gov register: NCT01732419.

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UK cardiac rehabilitation fit for purpose? A community-based observational cohort study.

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UK cardiac rehabilitation fit for purpose? A community-based observational cohort study.

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